Attendance and Scheduling Issues

Published on 27/02/2015 by admin

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CHAPTER 5 Attendance and Scheduling Issues

“Half of life is showing up.”

Anonymous

Yea verily, hear these words, as they are the lament of simulator people from sea to shining sea. From Boston’s storied Ether Dome down to hurricane-battered Miami, across the fruited plain, up over the Rockies to LA’s smog, San Fran’s fog, and Seattle’s drizzle, the problem with simulators is always the same.

It’s not the scenarios—there are tons of them. They’re available on the Internet, they’re well described in articles, and the next great scenario is percolating in the imagination of an instructor somewhere in Chicago or Pittsburgh or Atlanta. Scenarios aren’t the problem.

It’s not the simulators themselves—the simulator “universe” has had years of experience with them. We know how to make them “do their thing.” Simulators are getting more and more clever, more and more user-friendly; and in the way of all things computeresque, they’re getting less expensive. Laerdal and METI honor their service agreements and keep their simulators humming pretty well. Simulators aren’t the problem.

It’s not the instructors—there are a lot of people who like to teach. Teach the teachers courses abound, but even without “official training” a good teacher put in a simulator can create a good learning experience.

So if it’s not the scenarios, if it’s not the simulators, and if it’s not the instructors, then what is the problem?

Moving the meat
Getting the residents in there
The lowest tech element in this high-tech world of computerized wizardry—scheduling the residents out of the OR and into the simulation lab

From the “Simulator guru’s” point of view, this is nothing short of maddening, but it is the biggest problem with simulator education. You can debate whether the simulator is a checklist or theater; you can argue whether simulators are valid teaching methods; you can hash and rehash the “Simulator as certification” question. But if you can’t get the residents to darken the doorstep of the simulation center, there is nothing to debate! The issue is decided. If no one ever goes to the Simulator center, then by definition simulation is a big, fat zero.

Simulator centers tend to open with great fanfare. Wow! Zowie! This is new, this is the latest, this is the way to go, now we’ve arrived, now we’re “keeping up with the Joneses” (who also have a Simulator). But the nitty gritty of making sure residents rotate through the simulator becomes a real headache, and it’s too easy to fall back into this response, “Oh, yeah, the simulator, um, we have one, but no one has gone there for the past year. We got a little short-staffed, and, you know, with the 80 hour rule it’s hard to, you know, make them go, and CRNA’s cost a pretty penny, and …”

BOX 5-1 Scheduling The Simulator

• Pull from OR?
• Evening?
• Weekend?
• Who pays?
• Voluntary?

So the Simulator sits there, becoming a cobweb magnet in a dark room. A hundred scenarios, a thousand lessons huddle within the Simulator’s latex chest, but there they sit and there they stay, waiting for someone to rediscover them.

The obstacles to scheduling are quite daunting, involving two nontrivial components—time and money!

MONEY HEADACHES WITH SIMULATION SCHEDULING

• Say your program has CRNAs. If, at 7:30 on a Wednesday you are going to pull three residents out of the OR and send them to the simulator, by mathematical analysis, fast Fourrier transformation, quantitative numerometricologic integrative triangulatory derivativations, you will have to send, just a second, let me count on my fingers.

Uh, you’ll have to send three CRNAs into the rooms to relieve your residents. So you must have three extra CRNAs that day. Three more than those needed for breaks, lunches, call-in-sicks, and having people to cover regular rooms and be ready for that ruptured aneurysm or stat C-section.

Three extra CRNAs? In today’s climate of CRNA shortages? Plus, what does a CRNA cost? I don’t have enough fingers to count that high.

• Say your program is an “all-resident” program. Let’s fire up that computer again and see what we’ll need to do if we pull three residents out of the OR at 7:30 on a Wednesday. Miracle of miracles, that same number keeps appearing—three!

So now your program needs to have three extra residents. And we still need to provide breaks—residents get a break every 2 hours, get a lunch break every 4 hours. (Ours is a vigilance task, you can’t just make the remaining residents “tough it out” while their pals are in the simulator.) And “all-resident” programs are not immune from people calling in sick, nor are they immune from the need to provide for the emergency aneurysm or C-section.

• Say you flesh out your program with AAs (anesthesia assistants). Forget, if you can, the firestorm of controversy about this issue. You still can’t get around the physical reality that pulling three residents means you have to “create three replacements.”

And replacements mean more money.

image

FIGURE 5-1 Time is, well, for lack of a better term, money. And scheduling people in the simulator boils down to time and money. Pulling people out of the OR costs money. Expecting people to come in after hours or on weekends costs time—time people may want to spend otherwise. And residents are under the “80-hour rule”—you can’t violate that. Scheduling is the problem once you get a simulation center up and running.

TIME HEADACHES WITH SIMULATION SCHEDULING

• Forget pulling the residents who were going to be in rooms. Let’s do this post-call. Aha, the perfect answer! No need to replace them, they were going home anyway! Suddenly, 7:30 on a Wednesday seems like the perfect time.

OK, sure. Now, the ACGME says that, technically, you can do this. After 24 hours on call, a resident can be allowed to stay for an additional 6 hours, so long as he or she is not giving an anesthetic or is not accepting new patients into the ICU. So, yes, you are adhering to the letter of the law.

And even if they are exhausted, you could weave this argument, “Good, most mistakes are made when you are tired, so what better time to put them through the simulator than when they are tired!”

Unfortunately, the weave on that argument unravels in the glare of reality. Anyone who’s done, say, a busy night on OB or a shoot-‘em-dead night on trauma knows that by dawn the lights are going out on your brain. Keeping a beat-up resident around for another 3 to 4 hours in the simulation lab seems foolish. Plus, forget for a moment patient safety, think about resident safety. Interns deprived of sleep have more car wrecks on their way home. So now we’re going to keep them awake another few hours then put them on the road? Not a good idea.

• Pulling residents during the day is just too tough; let’s make this a nights/weekend deal. ACGME rules once again rear their administrative head. Residents must have at least 10 hours off between clinical duties one day and clinical duties the next day. The 80-hour rule applies, and 3 to 4 hours of required time in the simulation lab is part of that 80-hour formula. Residents must have at least one 24-hour period where they have no clinical or educational duties each week. Add this all up, and you do have to pay careful attention to just how many nights and weekends you can “eat into.”

Plus, the residents might not take this lying down—“I’m already here late enough nights!” “I only get one really good weekend a month, now this! Now I have no time to myself or my family!” For religious reasons, Friday nights and Saturday days may be off limits for certain residents as well, limiting your weekend options.

• Wave the magic wand—let’s make this whole thing voluntary! This opens a different can of worms. It comes as no surprise that the worst residents have the least insight into their problems. They don’t take criticism well, and “suggestions for improvement” fall on deaf ears. Superb residents are always looking for ways to improve themselves (that’s how they got so good).

So what happens if the Simulator becomes voluntary?

The best residents would sign up, would find a way to get there, would put in the time and effort to get the most out of their Simulator experience. Good for them! At the other end of the spectrum, the worst residents would not sign up, would find every excuse not to get there, and would not put forth the time and effort to benefit from the Simulator experience. That’s fine if you just want to write off your lower-achieving residents. But that’s not what a residency is about. It’s our job as teachers to do our best for all the residents, not just the shining stars.

So gee whiz, time and money don’t seem to be on our side in our “Simulator quest.” What to do? Give up? Did we buy this Porsche of a Simulator just to let it “sit in the garage all day,” as a lot of people do? In this battle of Scheduling Monster versus Simulatorzilla, will the Scheduling Monster prove victorious?

Never!

Here are a few approaches to slaying the Scheduling Monster. Your weapons are limited only by your creativity and by the vagaries of your program.

• Bring residents in pre-call.

Some programs have night shifts, either a 3 p.m. to 7 a.m. or sometimes a 3 p.m. to 11 p.m. shift. Have the residents come in a little earlier, say, at noon. They have a simulation session while they’re still “awake and alert”; then they go to their call assignment.

• Find residents you can “free up” for a few hours.

Pain clinic, preop clinic, PACU, ICU, OB—all these rotations can sometimes “survive for a while” without a resident. Yes, sometimes things get stretched a little, and there may be times when you have to “rush someone out” of the Simulator (OB gets two stat sections at once, codes are pouring in, ICU patients are all going sour). But a little flexibility on their part and a little on your part can usually accommodate everybody.

Don’t aim for a perfect system, just a pretty good one.

• Study your OR schedule. Thursday is a big ortho day, tons of artificial joints, plus the hand surgeons are busy as bees all day. Friday tends to be a little lighter. So make Friday the day for the Simulator. Most ORs and most programs don’t go flat out 110%, 110% of the time. Look for a crease in that schedule.

BOX 5-2 Simulator Innovations

• Pre-call
• Simulator call team
• Cracks in the schedule

• Schedule medical students and CRNA students on busy OR days. Students are easier to schedule because you don’t have to “find a replacement” for them. So if your Simulator center takes in students, schedule them on the days when it’s impossible to schedule residents (such as Thursdays in the preceding example).
• Have a “Simulator call” team. By definition, medical care and medical timing are hit and miss. One day the cardiac room is bursting at the seams, the next day there is nothing on the schedule. Consider a “Simulator opportunity” to be the same as an “emergency case.” All of a sudden, three residents are drifting rudderless, their cases canceled, the surgeon broke his leg and can’t operate for a while, who knows. Beep the Simulator call team (we have code teams, liver transplant teams, peds specialists on call, why not a Simulator call team?), fire up the Simulator, and go! Might not work all the time (what, after all, does?), but even if it works a few times that’s a few more residents who benefited from the Simulator.
• Go ahead and hire the extra people to cover for those residents! OK, easier said than done. But there are creative ways around financing, and there’s no reason you can’t be clever in your Simulator financing as well. If your Simulator center receives grant support from industry or for a study, part of that money should be earmarked for “salary support in the OR.” Not every penny spent for a Simulator has to be spent in the Simulator. Part of that money is justifiably spent back in the OR making sure that residents can get to the Simulator.

So there are some ideas for steering your young charges into the Simulator. But do people want to make the Simulator happen? Do people believe in the Simulator? If they don’t, then no amount of clever scheduling will matter.

No one will come.

BOX 5-3 Simulator of Dreams

“If you champion it, they will come.”

If you do believe in the Simulator, then no amount of obstacles will keep them from coming.

You gotta believe!

Here’s a few approaches to keeping the faith.

• Champion. Someone in the upper echelon has to champion the cause of the Simulator. Program chairman, program director, educational director, clinical competence chairman, somebody. Inertia is a powerful force; and if no energy jolts the simulator system from above, the program will “go to its lowest energy level”—the unplugged, unused Simulator sitting in a dark room. “Lack of a champion” is the most frequent cause of a Simulator program dying.
• Residents themselves. The Simulator experience has been likened to sex—even when it’s not great, it’s still pretty good. I have done simulations in a crummy old decrepit OR, equipment malfunctioning (I drew pictures of the EKG and taped them to the monitors), Simulator sputtering, airway leaking, and the tech was sick that day. A worse simulation you could not imagine.

The residents loved it and wanted to come back for more!

Most residents enjoy their time in the Simulator, no matter how bad (technically) the thing goes. Just being taught, being singled out for the sole purpose of education, seems to resonate with them. They’re not just “stuck in a room with an attending who splits and never teaches anything anyway.” They are there only to be taught. There is no “sitting there while the attending is out drinking coffee or whatever the hell an attending does.” The attending is just there for them, to teach!

So to generate interest in a Simulator program, just find a way, any way, to get the residents in there for a session or two. They will ask for more; they will demand more.

Then give them what they want.

Scheduling is a killer.

Scheduling is the killer of Simulators.

But where there’s a will … you know the rest.

Kill the Scheduling Monster before it kills you.

Related posts:

Bibliography What Is a Simulator–a Clinical Checklist or a Theater? With What Other Disciplines Should We Work? The Great Debate Working on Communication Skills in the Simulator Simulation Scenarios and Clinical Lessons Learned