The Great Debate

Published on 27/02/2015 by admin

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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?

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