The Great Debate

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CHAPTER 7 The Great Debate

“I beg to differ.”

A common expression

Yin. Yang.

Red state. Blue state.

Men—Mars; Women—Venus.

Dr. Jekyll. Mr. Hyde.

What is it about opposites that so fascinates us?

Eastern philosophy hinges on the interweaving and interplay of Yin (moon, woman) and Yang (sun, man).

Fox News pounds the red state (Nascar dad, NRA)/blue state (polo dad, bean sprout) divide into our skulls every night.

Men and women? Beyond the scope of this book. Beyond the scope of any book, if you think about it.

And finally Robert Louis Stevenson’s cautionary tale of “what lies within.” Dr. Jekyll—doctor, healer, scientist, kind soul—finds out that he too has a darker side. After the magic potion goes to work, Mr. Hyde comes out—sadist, lecher, killer. Dr. Jekyll seemed too good to be true. Who, after all, is perfect in every way? Mr. Hyde seemed too bad to be true. Who, after all, is evil in every way?

The truth lies somewhere in between.

Which brings us to our cautionary tale about Simulators. Are Simulators Dr. Jekyll, as some would maintain, or are they Mr. Hyde, as others would maintain? The truth, of course, lies somewhere in between. But let’s look at this debate the way Robert Louis Stevenson would. Let’s argue about the Simulator by creating our own Dr. Jekyll and Mr. Hyde story.

MONEY

Dr. Jekyll—Simulators are worth the money.

Who are we kidding, anything in medicine is pricey. This is a high-rent district, and education in medicine is no exception. Plus, the money we are laying down is going to save lives and prevent medical catastrophes. You’re fretting a couple hundred thousand to set up a safety center? How much did you pay the last time your hospital was sued?

Chipped tooth—$25,000.

Successful lawsuit from the hospital’s point of view (no judgment for the plaintiff)—$50,000, and that’s if everything went perfectly and appeals don’t drag out. And 50 thou is a low estimate.

Unsuccessful lawsuit—well, you pick whatever number you want. The jury surely will.

If simulator training, with its emphasis on safety, can prevent one adverse event, it has paid for itself in spades.

“But this is all speculative!” the cynic says.

No, there are some dollars and cents savings that result directly from Simulator training. And these savings come from the malpractice insurance companies themselves. Talk about hard-nosed business people!

Harvard and MIT worked together to create a Simulator center. Practitioners who come for Simulator training there get a reduction in their malpractice premiums!

BOX 7-1 Are Simulators Worth It?

• Cost
• Proven benefit?
• Speculative?
• Better alternatives?

An insurance company asking for less money. When was the last time you heard of that? The insurance companies are saying, in a concrete way, “Simulator training is a worthy financial investment.”

Hmm. Hard to argue with that.

Look at this a different way. OK, Simulators are an expensive, new, technologically cutting-edge “toy” for the hospital and the medical school. Looked at any of the other toys the hospital picks up? PET scanner? Brain simulator for neurosurgery used to ablate certain pathways in patients with Parkinson’s disease? Three-dimensional CT scanners capable of doing “virtual facial reconstruction” before the surgeon starts cutting?

How much do those puppies cost? Has anyone “proven beyond a shadow of a doubt” that each and every one of them is worth every penny spent on them?

No!

Medicine is a business yet it’s not exactly a business. We push the envelope of technology to get the next thing, the next breakthrough, the next procedure that may benefit our patients. And that means “jumping out into the financial unknown” sometimes.

• Yes, the PET scanner is expensive, and before you have “paid it off” a newer, slicker imaging technique may come along (quark scanner?). But for now, the detailed images provided by the PET scanner seem the best thing for our patients, so let’s embrace this new expensive technology.
• Yes, the neuroablative techniques to treat Parkinson’s patients require tremendously expensive equipment and procedures. And tomorrow or next month or next year some new technique may make this procedure obsolete (gene therapy? some new pharmacologic breakthrough?). But right now this neurosurgical approach seems like the best thing for our patients, so let’s use it.
• Yes, the three-dimensional CT scanners … the list goes on, and the argument stays the same. So long as the medical community believes that a procedure or technique or technology is the best thing for our patients, we’ll use it, even if it’s expensive.

So it doesn’t take a 28-foot Olympic leap of faith to apply the same reasoning to the Simulator. Yes, the Simulator mannequins are expensive. Yes, technical help is expensive. Yes, pulling anesthesiologists from clinical duties is expensive. But training in a Simulator seems like the best thing for our patients. So let’s bring it on.

Unconvinced?

Look at things from an amortization point of view. “Amortization” comes from the Latin for “a financial term that hardly anyone understands.” You lay a lot of money down initially for a Simulator center, but you don’t have to keep laying down all that money. You still need upkeep and staffing costs—not small sums by any stretch—but after you buy the main things, you, well, have them! You don’t need to “buy them again” each year.

That’s the “Dummies Guide to Amortization.”

Still unconvinced?

Fine, look at this from a different point of view. Put on your Harvard Business School cap and look at the numbers. The Simulator can actually make money for the hospital or medical school.

What! No way!

Yes, way.

The Simulator center can provide valuable training for all kinds of professionals—emergency medical technicians, fire-rescue personnel, military medics. Nursing schools may benefit by sending their students to the Simulator center. Other physicians can come to your center for training—office-based oral surgeons, office-based plastic surgeons, community anesthesiologists who want some “crisis training.” A Simulator center can become a “little red schoolhouse.” And, like schoolhouses everywhere, you can charge tuition.

This book is about “Simulators in anesthesia,” so we won’t go into training those other professionals. But if you want to set up a Simulator center, and you are fretting how you will pay for it, try this business plan out.

Monday—Train your residents.
Tuesday—Train your medical students.
Wednesday—Rent the place out for training EMTs.
Thursday—Rent the place out for training office-based physicians.
Friday—Rent the place out for training military personnel.
Saturday—Put up a mirror ball, dress the dummies in polyester leisure suits, play disco music through the mannequin’s speakers, and rent the place out for a retro 70s party.

image

FIGURE 7-1 Trouble making ends meet in the Simulator? Rent it out to some latter-day John Travolta on “Saturday Night Simulator” night. Don’t charge those paddles or you may zap your dance partner.

Didn’t make enough money on the 70s party?

Simulator centers can pick up additional money from educational grants, pharmacology company sponsorship, you name it. Do what all the stadiums do, sell the naming rights to your Simulation center!

The Enron Simulation Center.

Who knows? You are limited only by your imagination.

So from a variety of financial angles, Simulators are worth the money. Simulators are a financial Dr. Jekyll.

Mr. Hyde—Simulators are not worth the money.

No “Simulator champion” ever looks at what else you could do with all that money.

Let’s pull a number out of the air—a million dollars—and see what we could buy with that, from an educational point of view.

Take the million dollars you would have spent on Simulator mannequins, technicians, space, upkeep, and lost income (attending anesthesiologists working in the Simulator and not billing for cases). Scour the country and hire three full-time academic anesthesiologists and two educational PhDs and have them do nothing but teach. They can wander the ORs and ICUs looking for “teaching opportunities.” They have all the time in the world to prepare lectures, set up web-based learning (aided by the educational PhDs, who understand the learning process), creating “scenarios” on the fly, sitting down with lagging residents, making sure there are “no children left behind.” This battery of educational specialists, freed of any clinical duties, will never be tired, will never show up late for lectures, will never be too busy/harried/exhausted to focus on education for the anesthesia residents and fellows.

OK, fine, you say, but what about all that money we were going to make in the Simulator?

These full-time education specialists can write papers, get grants, obtain pharmacology company and governmental support for their worthy projects. You can get a lot of “bang for your buck” from these people. Better to hire these five people than pour a ton of money into a Simulator center.

Unconvinced? Mr. Hyde has other financial arguments against Simulators.

Go around the country, go to all the anesthesia programs that have Simulator centers. How many of those Simulator centers still have a pulse? You might be surprised how many programs laid down a ton of money for Simulator mannequins, and the mannequins are gathering dust in some back room.

It takes an ongoing champion, an ongoing river of money, time, and scheduling to keep the Simulator centers going. They may open with great fanfare, but the grind of “getting residents out of the OR and to the Simulator” takes a toll. Inertia is a damned powerful force (it has its own named physical principle, for God’s sake), and inertia is forever wanting to kill these programs.

Technician leaves? Who takes his place? Who will pay for the technician? The hospital? No, they’ve lost their enthusiasm. The anesthesia department? No, their “Simulator guru” went into private practice last year, and no one else is interested.

Call it inertia, call it gravity, whatever it is, there is a powerful downward drag on Simulator centers after their initial sheen wears off. You plunk down a boatload of cash for a Simulator center, and after a while all it supports is cobwebs.

So, from a variety of financial angles, Simulators are not worth the money. Simulators are a financial Mr. Hyde.

EDUCATION

Dr. Jekyll—Simulators are the way to educate.

Educational theory shows that Simulators are the way to go in education. Most learning occurs in the dull and dreary confines of the lecture hall or the library. The student gets no emotional attachment to the lesson, so the learning goes in one ear (or eye) and out the other.

“The treatment for symptomatic bradycardia is atropine.” Whether you read that on page 458 of a textbook or whether you hear it in hour 7 of your pharmacology series, the result is the same. The lesson is learned in a “low emotional state,” so there’s no reason to “brand it into your memory.”

Now, give that same lesson in the Simulator and put an emotional tag on the lesson.

“You are treating a 65-year-old man for a hernia repair. You have placed a spinal and it’s working fine. The surgeon is now dissecting around and pulling on the spermatic cord.”

The Simulator suddenly drops the heart rate to the 20s. Through the speakers in the mannequin, a voice says, “I feel funny”; then the sound of retching occurs. The pulse is weak and it’s clear the patient is in trouble. The surgeon yells at you, “What the hell’s the matter up there!”

The student reaches for atropine, forgets to tell the surgeon to “quit tugging on the spermatic cord!” By mistake the student grabs succinylcholine and gives a full syringe of it, then at the “last cc” the student says, “Oh wait, I didn’t want to give that!”

AAG!

Lesson learned? Atropine is the treatment for symptomatic bradycardia. The same lesson as on page 458 of the textbook or hour 7 of the pharmacology series. But this lesson is branded onto the student’s brain. This lesson has a monster emotional tag associated with it, so the student will remember this lesson forever more.

Another lesson gleaned from the educational experts?

Education in the clinical arena is subject to the vagaries of time and chance. For example, any anesthesia resident should know how to recognize and treat a pneumothorax. Pneumothorax can kill in minutes. This is not a condition where you can “stand there like a deer in the headlights” and hope the badness goes away. You have to diagnose it now and treat it now!

But in the 4 years of anesthesia training, a resident may never see a pneumothorax. A pneumothorax occurred in the ER last night, but he wasn’t on call last night. A pneumothorax occurred during line placement in OR 12 today, but the resident was in OR 11 today. Every time a lung drops here, the resident is there.

How can you solve this problem from an educational standpoint? You can always keep the resident in training for 10 years, figuring that sooner or later, time and chance will line up and finally “hand him a pneumothorax.” But that isn’t practical.

Enter the Simulator. The Simulator can hand residents anything you want to throw at them. You can, for example, make sure that each and every resident goes through the Simulator and sees a pneumothorax. They’ll have to make the diagnosis, place the needle in the chest, and satisfy the Simulator teacher that they know how to handle this dangerous condition.

How about other, rarer conditions, such as malignant hyperthermia or thyroid storm?

Bingo, the Simulator can provide those—no problem. No need to wait for years to see this condition. The Simulator can deliver these conditions piping hot (forgive the pun) anytime you want.

How about the less exotic conditions? The basic problems that plague anesthesia everyday?

Again, the Simulator can provide the perfect educational setting for these conditions too, placing no patient at risk. Right mainstem intubation? Hypoxemia? Hypotension from a spinal anesthetic? These are not bizarre weirdoes that appear once in a blue moon. They happen every day. What better place to teach them than in the Simulator. Plus, because no patient is at risk, because no one is actually hypoxemic, you can do “stop-action” teaching, pausing the scenario as you explain the mechanisms of hypoxemia to your heart’s content, taking as long as you want to make sure the resident “gets it.” You don’t have that kind of time in a real case.

Back to broader educational theory.

The Simulator experience and the traditional experience may both “end up” at the same place. But the Simulator can accelerate learning—the higher line on the graph below.

Now look at the learning graph and ask this question—What happens in the “area between” the lines. What is going on there?

That represents an area where the Simulator people know what they are doing and the non-Simulator people don’t know yet what they are doing. Who gets hurt in there?

Patients.

Take a concrete example to clarify the issue.

About halfway through residency, a difficult central line is being placed. The Simulator person has been trained about pneumothorax recognition and treatment. The non-Simulator person has not.

Pop! The lung gets hit and goes down.

By the time the non-Simulator person sees it and recognizes it, the patient has gone onto a tension pneumothorax and is in big trouble, going on to arrest. The Simulator person sees it a little earlier, reacts a little faster, avoids the tension pneumothorax and the arrest.

image

FIGURE 7-2 A. Educational theory, predigested. Learning over time may get you to the same endpoint, but it may get you there via different pathways. Slow learning is on the lower curve. Accelerated learning is on the upper curve. Traditional medical teaching follows the slow curve: If you stick around the hospital long enough, you eventually see everything you need to see and learn everything you need to learn. Accelerated learning with a Simulator puts you on the fast, upper curve. You don’t just “hang around forever” and learn stuff; we target what you need to learn and make sure you learn it in the Simulator. If this all sounds theoretical and hard to prove, you’re right! B. If you buy this whole paradigm (not everyone does, but I do), the area between traditional, slow learning and accelerated, fast learning represents something. What is that something? Patients getting hurt as you “learn through mistakes.” Ouch. Makes a good argument for speeding up the learning process. Makes a good argument for the Simulator.

By the end of their residence, both residents know about pneumothoraces. But the patient who arrested “paid the price.” The patient who arrested occupied that dangerous shaded area.

From a bunch of angles, Simulation is an educational yes. Simulation is an educational Dr. Jekyll.

Mr. Hyde—Simulators are not the way to educate.

Hooey! All this educational theory and all these educational graphs are hooey! The vaporous musings of people with too much time on their hands.

That educational circle with “emotional tags” on the lessons? Sounds sort of plausible, but that’s all—plausible. Where’s the proof for all these ruminations? And the graph showing learning over time with the deadly “Bermuda Triangle” in the middle where patients are dying like flies? Once again, great stuff to ponder in some journal of educational theory, but the real thing?

I doubt it.

Traditional medical teaching—2 years of preclinical work, 2 years of clinical work, followed by an apprentice-like residency—has given us a great medical system. We produce fine doctors and specialists this way. We don’t need some “new teaching with Simulators” to fix a system that is not broken.

And traditional teaching isn’t stuck in the Middle Ages. By all means web-based learning, supplemental lectures, assigned reading, small group discussions. This works just fine.

And every time you yank an anesthesia resident from the OR, from the pain clinic, from the PACU, from the ICU, you are replacing flesh-and-blood teaching with latex-and-computer-program teaching. And that mannequin, no matter how good its proponents say it is, is just not the same as taking care of a real patient.

Danger to patients, you say? Of course there is danger to patients, but that is why you have your attending right there, closely supervising, watching the residents like a hawk. The ACGME has laid down guidelines to ensure that residents get adequate rest, sleep, and time off. We have a safe system! Perfect, no—no system is—but pretty good. And no simulator maven can convince me that the system is more perfect with Simulators in the curriculum.

No, Simulators are not the way to teach. From an educational standpoint, the Simulator is a Mr. Hyde.

ACCREDITATION

Dr. Jekyll—We should make board certification a “Simulator event.”

United Airlines does not let their pilots grab the stick on that 747 until they prove their mettle in a flight simulator. Hundreds of lives in the air, and possibly hundreds more on the ground, hinge on this pilot’s ability. And if the hydraulic system fails (you can simulate that in the safety of the simulator), wind shear occurs (you can simulate that too), the landing gear doesn’t come down, one engine flames out—you name it—then the pilot must prove his or her stuff. Once he has shown that he can do the job, he gets the green light.

This has such unavoidable logic you just can’t argue with it. This is called “face validity.” It just plain (or, plane in this case) makes sense.

image

FIGURE 7-3 During the debriefing session, you can reconstruct and illustrate disasters. Here, the models demonstrate the catastrophe in Tenerife, when two 747s collided on a runway, killing more than 500 people. Communication between the pilot and the tower broke down, fog obscured the runway, and then—disaster. In a tight OR situation, communication can also break down, “fog” can obscure your thinking, and disaster can occur. Draw lessons from aviation, from history, from current events and apply it to the medical scene. The more variety and interest you inject into the lesson, the better.

BOX 7-2 Simulator Accreditation a Good Idea?

• Airlines do it.
• Other countries do it.
• Wave of the future?

Shouldn’t you prove this? Have half the pilots prove themselves in the simulator, which leaves a control, untested group. Then, to ensure scientific validity, do this with thousands of pilots, and make sure enough people die so the statistics are clean. Once that tenth 747 plunges out of the sky into a packed baseball stadium, you should be able to draw a superb scientific conclusion with a P value of less than 0.05!

Uh, most folks would prefer we take the face validity and keep testing the pilots. Let’s just agree that this is a good idea, avoid rigorous statistics, and keep those 747s up in the air and out of section A of Wrigley Field.

So why not do this in anesthesia too?

Forget proof, look at the logic. Wouldn’t you want your anesthesiologist to have proven that he or she can handle anesthetic emergencies? Just as pilots prove themselves capable of handling engine failure, shouldn’t anesthesiologists prove themselves capable of handling anesthesia machine failure? Is it so much to ask that anesthesiologists prove, before an examiner, that they can handle the things that all anesthesiologists encounter?

Hypoxemia
Hypercarbia
Hypotension
Hypertension
Dysrhythmias
Myocardial ischemia
Difficult or lost airway
Allergic reaction
Light anesthesia

We already “sort of” do this in our oral board exams. Why not do the exam in a simulated operating room? Call it an “oral board on steroids.” Instead of just saying, “I would hand-ventilate, listen to both sides of the chest, and suction the endotracheal tube,” have the examinee actually hand-ventilate, listen to both sides of the chest, and suction the endotracheal tube.

image

FIGURE 7-4 Certification. Hmm. Should we use the Simulator to certify practitioners? Would that make the certificates on your office wall more meaningful? Would the patient find that more comforting? Would you? Would anyone? Is this inevitable, or are we tinkering with a system that doesn’t need additional certification? Hmm.

Not in theory, actually do it!

This is not such a stretch, by any means.

Look at this accreditation from two angles: the patient’s and the American Board of Anesthesiology’s.

Patient: “Wow, when I see that paper on the wall saying ‘Board Certified Anesthesiologist’, I know that this doctor has really proven him- or herself. In an actual OR, with the same stuff they use on me, this doctor proved worthy of certification. I feel so much more comfortable knowing this.”

American Board of Anesthesiology: “Before we give our imprimatur, our seal of approval, we really put them through the mill. Not just a written exam (the world is full of geniuses who can memorize facts but can’t do anything) but a real-live practical exam. We look at them in action and make sure they know what they’re doing. We are a dandy certification body, amen, amen.”

The Simulator as accreditation mechanism is a Dr. Jekyll all the way.

Mr. Hyde: We should not make board certification a “Simulator event.”

What, our current system isn’t good enough? Who says so? Before someone can even sit for their written exam, they have to pass three steps of the written medical boards, then they have to go through an ACGME-approved internship, then an ACGME-approved residency. And no one is evaluating their ability to handle hypoxemia, hypercarbia, light anesthesia, or dysrhythmias during all these years of training? Please!

BOX 7-3 Arguments Against Simulator Certification

• Not real
• Stage fright
• Other certifications have a track record

Any ACGME-approved residency has to jump through a lot of flaming hoops, making sure that their residents see a wide variety of cases, perform a plethora of procedures, and all the time being evaluated by board-certified anesthesiologists. Now that the six core clinical competencies are mandatory, residents are not learning just technical skills but interactive skills as well, such as professionalism, communication, and how to work in a medical system.

The idea that you have to use a Simulator to “make sure they know what to do” is an insult to residencies everywhere! These residencies have proven it—otherwise they wouldn’t be residencies.

The final step of current board certification, the oral board examination, has a long track record. For decades, this has served as a fine “final stamp of approval.” Look at mortality statistics from the 70s versus mortality statistics today. Yes, it could be the pulse oximeter, it could be the end-tidal CO2 monitors, it could be the more rigorous training. Whatever it is, the system does seem to be working, so why change it?

The mechanics of the oral boards seems to work pretty well too. For a week, examiners and examinees meet somewhere, the exams proceed, grades go out, and another round of certification is done.

Now let’s throw a Simulator into the deal. Oh, that should go swimmingly!

Simulator breakdown? Now what? Computer glitch? Um, come back next week? Examinees talk to each other, so will it be easier to “find out what they’re asking” and pass at the end of the week versus the beginning? One resident comes from a “heavy Simulator training” residency, another comes from a “we don’t have a Simulator yet” residency. Is this fair?

Now let’s look at the examiners themselves. Just how much do they know about the Simulator? Do we need to “certify the certifiers”? That opens a new can of worms. Do we videotape the exam and review it, just like they “review the films” in football? Who looks at them? What if there is a disagreement on the “call”; do we get someone else to look at the film too?

The logistics start to go super-nova.

Oh, where do we do the exam? Boston’s Simulation center? Pittsburgh’s? Miami’s? Do we need the same mannequin, or a whole bunch of them (there are 19 in Pittsburgh)?

Forget the logistical and administrative nightmare for a while, pretend it doesn’t exist. Let’s look at the Simulator itself.

No matter how you look at it, the Simulator is not a person. No matter how you look at it, the Simulator cannot do what a patient does. Simulators don’t blush or flush. Simulators can vomit, sort of, but Simulator centers rarely do that because clean-up is a monster, and you’re always afraid the fake emesis will leak into something and screw up your expensive computer system. Simulators can’t buck. They can’t reach up (one no-longer-available model could lift one forearm).

Simulators require a nervous technical person to keep a close eye on them (“don’t stick the needle there, you’ll break the speaker!”).

Simulators do have a limited repertoire, and they are slaves to computer input. They are also slaves to computer and technical mishaps.

And upon this rock, you build your certification church?

Forget the Simulator itself, pretend it is absolutely perfect in every way. Now look at the idea of a “Simulator exam.”

The Simulator is theater, and some people get stage fright. Other people thrive in the limelight and do quite well “on stage.” Should your ability to “act” determine your worthiness as a doctor?

It’s easy to imagine a perfectly capable practitioner “choking” during the simulation, particularly if he or she had little practice with the Simulator.

On the flip side, it’s easy to imagine a poor practitioner in the “real world” doing quite well in the Simulator, particularly if he or she had a lot of practice with it. Stretch your imagination a little and picture this—to make absolutely sure I pass my Simulator exam, I’ll take off 3 months, never do any cases, and just “practice in the Simulator until I have it all down pat.”

I myself would not want this person taking care of my child.

No matter how you look at a “Simulator as accreditation” model, it stinks. The Simulator as accreditor is a Mr. Hyde.

AND SO IT GOES

And so it goes with the great debate about the Simulator. From finances to education to accreditation, you can argue that the Simulator is great, or you can argue that the Simulator is horrible.

No one of us is all Dr. Jekyll. No one of us is all Mr. Hyde. We are all, each of us, a little of both.

So too with the Simulator.

Related posts:

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