Working on Communication Skills in the Simulator

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CHAPTER 4 Working on Communication Skills in the Simulator

“Speech finely framed delighteth the ears.”

2 Maccabees II:39

Picture yourself sitting in front of a person with a doctorate in education (EdD) from Harvard. This professor now holds joint appointments at MIT and Harvard.

The professor is not the Marquis de Sade or the Grand Inquisitor peppering you with rapid fire, trip-you-up, “where were you on the night of the 15th”? questions. This professor does not have you on the rack, is not holding a cat o’nine tails. No light is shining in your eyes. This professor is not standing over you, does not have you in a shorter chair, has not deprived you of sleep. This professor has not made you take a blood oath of allegiance to the Boston Red Sox. This professor has done nothing whatsoever to intimidate you; on the contrary, this professor has shown nothing but kindness to you.

You ask a question about the behavioral aspects of Simulation training.

“You know, I’ve studied all about the clinical end for years, the heart attacks and codes and stuff. But this behavioral business, how do I go about learning that?”

“Well”, the professor with ties to MIT and Harvard says, “you have to read.”

And the professor looks at you.

“Oh,” you say, “yeah.” And you squeak out a forced/embarrassed/moronic giggle. “Yeah, I guess, to learn something, it does, sort of, make sense that, you know, you, or me, that is, I would be, um, well advised to, uh, actually open a book and look at the words written in the book, which is what constitutes the act of, well, reading.”

“Yes,” the person with a doctorate in learning from the most hallowed institutions of learning in the world says, “reading in order to learn has a long track record.”

Who are we to argue with that?

You can’t just instantly know how to teach the behavioral part—or you could call it the “communication” part—of the Simulation experience. You need to study it, to read about it, just like you had to read about cardiac physiology or the autonomic nervous system.

An initial reaction might be, “Ah, to hell with that psycho-babble. I’m training people in the clinical arena! Codes! Shock! STAT! That’s the ticket. The Simulator was never meant to be a marijuana-laced, Haight-Ashbury-esque, harmonic convergence love fest. Nor is the Simulator meant to teach us how to talk ‘administrative-ese’ like a bunch of CPAs. So let’s skip the ‘getting in touch with our feelings’ and the ‘prioritization of goal-oriented intermediary assessment protocols.’ That’s all sissy stuff.”

BOX 4-1 How to Learn About Behavior

• Read
• Read
• Read

You think to yourself, “Why should I read about this fluff at all? Real clinicians don’t give a *#! about that hooey anyway. Skip the ‘talk’ books, let’s put that Simulator into V-fib and freak out some students. Now that’s REAL learning!”

And, truth to tell, when you start to drift into this behavioral sea, you do hit some suspiciously “administrato-speak” sounding icebergs.

CRISIS RESOURCE MANAGEMENT

What’s this? Crisis and management in the same phrase? “Crisis,” which evokes images of the Hindenburg bursting into flames, bodies falling from the sky, people, still smoking, staggering out of the wreckage. “Oh the humanity!” And you couple that with “management”?

Management. Double entry ledgers. Setting minimum the wage. Breaking up the gang around the water cooler with a gruff, “Time is money.”

Crisis is a can of Coke that you shake up, then pop open all at once.

Management is a can of Coke you left sitting open in the fridge for 3 days.

Conceptualizing

Six syllables, in one word?

Spare me.

But the kicker in this is—this behavioral stuff really does matter. These phrases, although they come across as bloodless and limp, make a big difference in the crunch. And the more you read about behavioral psychology, negotiating under stress, working in teams, the more you realize we do need to know this stuff. When you see it all unfold in the Simulator, you become a true believer.

The Professor was right: “You have to read.”

Hmm. Where to now? Here are the questions:

• What should I read?
• How do I make this reading “meaty”? How do I turn “flat cans of Coke” into “exploding cans of Coke”?

Here is the answer to the first question: What should I read?

• The 7 Habits of Highly Effective People. Steven R. Covey. [I listened to the audio tape in my car.]
• Getting to Yes: Negotiating Agreement without Giving In. Roger Fisher, William Ury, Bruce Patton
• Difficult Conversations. Douglas Stone, Bruce Patton, Sheila Heen
• Notes from the Center for Medical Simulation’s “Teach the Teacher” meeting
• Learning from Accidents. Trevor Kletz
• Innovative Simulations for Assessing Professional Competence. Ara Tekian, Christine H. McGuire, William C. McGaghie
• Simulators in Anesthesiology Education. Edited by Lindsey C. Henson and Andrew C. Lee
• Anger and Other Emotions in Adverse Event and Error Disclosure [two-DVD set]. Robert Buckman [can order by telephone 1-800 488-8234; e-mail: cinemedic@bellnet.ca; web site: www.cinemedic.com]
• Boulet J, Murray D, Kras J, Woodhouse J, McAllister J, Ziv A. Reliability and validity of a simulation-based acute care skills assessment for medical students and residents. Anesthesiology 2003;99:1270–1280 [great bibliography; gets you up to date on all the latest “Simulato-think”]
• Gordon JA [one of the teachers at the “Teach the Teacher” course], Oriol NE, Cooper JB. Bringing good teaching cases “to life”: a simulator-based medical education service. Acad Med 2004;79(1): 23–27 [Dr. Gordon is major cool, and this article reflects it.]
• LaCombe DM, Gordon DL, Issenberg SB, Vega AI. The use of standardized simulated patients in teaching and evaluating prehospital care providers. Am J Anesthesiol 2000;4:201–204 [how paramedics work into a Simulator program]
• Issenberg SB, et al. Simulation technology for health care professional skills training and asssessment. JAMA 1999;282:861–866 [This article sort of “lays out the debate” in the general way that JAMA articles do.]
• Issenberg SB [can you tell he’s a Kahuna?], et al. Effectiveness of a cardiology review course for internal medicine residents using simulation technology and deliberate practice. Teaching Learn Med 2002;14:223–228 (Simulators are groovy for all specialties!)
• Gordon MS, Issenberg SB [who else?] Mayer JW, Felner JM. Developments in the use of simulators and multimedia computer systems in medical education. Med Teacher 1999;21:32–36

Here is an answer to the second question, “How do I make this reading ‘meaty’?”

Make the administrato-speak (crisis resource management, conceptualization) more vibrant. Put pure learning theory into something you can hold, bite, rend, dismember, eviscerate. Toward that lofty goal, here goes with a “Primer on Behavioral Stuff Writ Gritty for Medical Folk.”

Apologies to many and sundry great educators. Lifetimes of learning and entire careers went into all this cerebration. I bastardize, warp, distill, and distort all their fine work into a few punchy lessons. Their brilliant discourse morphs into so many sound bites.

image image

FIGURE 4-1 Educational theory and, for that matter, education in general, can drift into an endless blah-blah-blah of lectures, recitations, and stultifying boredom. The simulator, actually doing something, can put some teeth into the educational experience—can give it a real bite.

Filet mignon covered in ketchup and served as a happy meal.

COMMUNICATION AND BEHAVIORAL STUFF WRIT GRITTY FOR MEDICAL FOLK

Learning

John Dewey, a great educator in the early 20th century, looked at the importance of experience in learning. A good way to learn is “trying to do something and having the thing perceptibly do something in return.” That is the siren song of the Simulator! You give epinephrine to the Simulator, and the Simulator responds with a jump in blood pressure and heart rate. John Dewey would love this stuff.

BOX 4-2 John Dewey Paraphrased

“To learn, do something and have something happen back.”

“The first stage of contact with any new material … must inevitably be of the trial and error sort.”

—Vintage John Dewey

Bingo! Go into the Simulator, try to intubate a swollen airway, change the head position, try a different blade…. No go? Eventually you “trial and error” your way all the way to a surgical airway, placing a catheter into the Simulator’s cricothyroid membrane and starting jet ventilation.

image

FIGURE 4-2 In simulation scenarios, you have to play your cards right. You’re given a certain hand—say, a patient with a bad airway—and you have to learn to “play the hand you’re given.” In the case of the bad airway, for example, you may opt for an awake intubation. This is the same “deal” that you get in real life.

Dewey said, “What is [needed is] an actual empirical situation as the initiating phase of thought.”

You want an empirical situation? How about a mannequin, generating breath sounds on his right side, no breath sounds on his left side, and, through a speaker, gasping and saying, “I can’t take a deep … breath … it’s … so hard to … I … just … can’t.” And up on the wall is a chest X-ray showing a pneumothorax and across the room is a computer-generated chart detailing the “patient’s” car wreck and rib fractures.

That’s a 4+ empirical situation for learning.

Again, Dewey: “No one has ever explained why children are so full of questions outside of the school … and the conspicuous absence of display of curiosity about the subject matter of school lessons.”

Link to the Simulator? Listen to people chattering away as they walk down the hall after a Simulator scenario.

“Oh man! I’m thinking vagal, then V tach!”

“Did you catch the temp rising?”

“How come you got the tube in—his mouth was like a rock!”

Compare that with your average “regular” lesson, a lecture.

“Any questions?”, the lecturer asks, looking around at a sea of glazed eyes and partially obstructed airways. “No? Sure? Anyone?”

BOX 4-3 Simulation Dilemmas

• Clinical
• Behavioral
• Ethical

“A difficulty is an indispensable stimulus to thinking,” Dewey wrote in 1916. Each Simulation scenario has just that—a diagnostic dilemma (is this asthma or CHF?), a treatment headache (do we go right to dantrolene, or do we see if malignant hyperthermia is really happening?), or an ethical problem (his saturation is dropping but he’s refusing intubation). And Simulator centers crank out difficulties by the boatload. The Harvard people describe 200 different scenarios. Duke’s Simulation center has a ton. Stanford, Houston, Tampa—all across the fruited plain—Simulation centers tap their evil genius to come up with new puzzlers for their students. And these Simulation centers share their wicked twists on their web sites, so Simulator learning metastasizes like a well vascularized malignancy.

You want difficulties?

We got difficulties.

image

FIGURE 4-3 The famous educator John Dewey said you need an “actual situation” to do your best learning. That is what the simulator gives you, an actual situation to work through. No tennis player learns to play tennis by reading a book. You need that “actual situation”—a real tennis court, real tennis balls, real racquets, a real opponent—to learn the craft. Here our intrepid instructor learns that perhaps it is time to take up golf.

“When an activity is continued into the undergoing of consequences, when the change made by an action is reflected back into the change in us, the mere flux is loaded with significance. We learn something.”

Democracy and Education: An Introduction to the Philosophy of Education (Macmillan, New York, 1916, p. 163)

—John Dewey

Simulato-people dig their scenarios and jazz them up big time. They want to make Dewey’s “flux” memorable. And they don’t just ham it up, they breathe life into those scenarios.

“What the hell’s going on around here”, the medical attending bellows, “I didn’t want this guy intubated!”

“My head hurts so bad,” the voice from the Simulator says, “this is the worst headache in my life. Am I going to die, doctor? Is this a stroke?”

The more you read Dewey, the more you love the Simulator.

Another angle on learning: Draw an “emotional circle,” with low level emotions below—hanging out at Borders on a Saturday afternoon—and high level emotions above—hanging out at Hillary’s Step, (a steep rock incline about a thousand feet from Mount Everest’s summit) with your oxygen running low and a blizzard blowing in.

Most education is attained via reading and lectures. Plowing through a book or somnambulating through a lecture creates the “Borders” emotional state.

When you go into the Simulator, you get your dander up. You get pumped. Your emotions amp. Red zone. Hillary’s Step.

You remember your “Hillary’s Step” lessons. You tend to forget your “Borders” lessons.

How About Medical Education?

“Hang around long enough, and you’ll see what you need to see,” goes the traditional thinking.

• Keep the surgeon in the hospital 95 hours per week for 5 years, and he or she will take care of the requisite number of appendectomies, bowel obstructions, and tumors.
• Sure, malignant hyperthermia is a 1/35,000 event; but if you do enough anesthesia, you’ll see it.
• Didn’t see Cushing’s triad of increased intracranial pressure, hypertension, and bradycardia? Well, do another year of fellowship. It’ll pop up. Maybe.

Scripture addressed this aspect of education long ago: “Time and chance happeneth to them all.” That is, medical education has traditionally been a crap shoot. Maybe you’ll see epiglottitis; but then again if you happen to be on vacation when the one case comes in, well, you won’t. Maybe you’ll see an inferior MI with bradycardia, but then, maybe not.

Enter the Simulator

The Simulator slays time and chance. The Simulator can make sure you see the rare things and can make sure you get practice with, well, whatever your teachers want you to know.

An internal medicine professor wants to make sure all his residents see status asthmaticus progress all the way to respiratory failure. Shazam, the Simulator makes it happen.

An anesthesiology instructor wants to walk his residents through the much-dreaded “can’t intubate, can’t ventilate” sequence. Voila! Done.

An ER team wants to go through a terrorist attack drill with multiple codes happening at once. No problem.

And best of all, the Simulator can go through these scenarios at no risk to any patient. No one had to “allow” asthma to progress to respiratory failure. No one had to “fake” a lost airway and put an anesthetized patient at risk. And no zealous instructor had to go shoot up a crowd to get his mass casualties.

You kill the Simulator? Press the reset button, and Lazarus comes right back at you none the worse for wear.

BOX 4-4 Traditional Education

• Time
• Chance
• Maybe

BOX 4-5 Simulator

• Time not a problem
• Chance not a problem
• Maybe not a problem

And when you look at it from another angle, it makes sense that we practice on un-killable Simulators. With a Simulator, we are doing our first learning on a pretend person. We are doing our first drive in a pretend car, our first flight in a pretend plane.

As medical folk, sooner or later we have to learn by practicing. And because our job involves working on people, it means that, gulp, we learn by practicing on real people.

That’s a tough sell to the public.

The public doesn’t mind that you learn by practicing on real people. So long as it’s other real people. Not me real people. And no matter how you look at it, everyone is me people. So it makes sense that we practice on the only non-me people out there—the Simulator.

Errors

To prevent screw-ups, you have to study screw-ups. And don’t just limit yourself to medical ones. Study all sorts of cool stuff. You can always draw some thin thread of relevance to the field of medical education and Simulation.

(Or better yet, just sit back and enjoy. These stories rock!)

So put on your “medical education” cap and follow along. The questions you ask yourself are:

• How did this error “evolve”?
• How could such an “error evolution” occur in medicine?
• How could a Simulator fit in here and “save the day”?

If you’re not in the learning mode but are just in this for voyeuristic thrills, ask yourself:

Just how cool is this?
Oh man, isn’t it great this didn’t happen to me?
When are they going to show this stuff on The Learning Channel?

BOX 4-6 Errors

• Evolve
• Several events coincide
• System fails

Show Me the Money

A psychologist named Lia DiBello, working with the National Science Foundation, took the idea of “business simulation” to three floundering companies: a biotech firm, a foundry, and a nuclear fuel producer. First, DiBello pegged what was going on—she nailed the “error.”

At the biotech firm, half the people thought the company was a research firm, and the other half thought it was a commercial enterprise. The left hand didn’t know what the right hand was doing.

The foundry had inefficient molds and generated too much scrap. Bosses in the office didn’t know what was going on the “floor” of the factory. Floor workers didn’t realize the impact of these inefficiencies on the company’s profits. The left hand didn’t care what the right hand was doing.

In the nuclear fuel company (God Almighty, I hope they get it right!), managers from various departments feuded and sniped at each other. The left hand was beating the hell out of the right hand.

Now go to the three questions.

1. How did the error evolve? Over time all the companies “pulled apart,” and no one was working together.
2. How could such an error evolve in medicine? Think of the departments at your hospital. Do they work together, or do they set up separate bailiwicks, each looking after its own interest? Think of the subdivisions in your departments. Just how much do they talk with each other?
3. How could a Simulator “save the day”? Psychologist DiBello went to work. (her company, in San Diego, is called Workforce Transformation Research and Innovation—www.wtri.com; e-mail: contactWTRI@wtri.com; telephone: 619-232-8054.) She set up intense business simulations where everyone had to work together. Like it or not, the right hand and the left hand had to cooperate.

The biotech firm had to do a Simulation exercise designed by the fine people of WTRI. Research and development had to pay attention to financial realities and design something that would actually sell. Then they had to get the goods out on time, assess whether the product was selling, and dump the unprofitable junk. Now everyone, even the research people, were working toward a profit. Guess what? After the exercise, the company started making a real, not a simulated, profit.

At the foundry, the floor workers had to do a Simulation where they designed more efficient molds. Voila! They generated less scrap, saved money, and took this lesson back to the factory. And now the foundry is in the black. Uh, as in black ink, not black soot.

In nuclear-ville, DiBello’s Simulation forced the various managers to work together. They had to, well, perform the managerial equivalent of a fusion reaction. No explosion occurred, thank goodness, and the company went on to enjoy financial success.

Well hot diggity dog, the Simulator did come to the rescue!

Could a Medical Simulator work similar magic?

Hell yes! Medical Simulators are the greatest thing since pizza delivery. Medical Simulators walk on water, and the water doesn’t have to be frozen when they do it.

Well, perhaps I’m given over to a modicum of hyperbole, but a medical Simulator could certainly help.

• Mass casualty exercise where surgeons, anesthesiologists, intensivists, and nursing staff work together.
• End of life exercise where a dying patient is in severe respiratory distress. Ethicists, clergy, and doctors could work out this difficult scenario together.
• Radiologists, radiology techs, engineers, and anesthesiologists could work together on the problem of the anesthetized patient in a new radiology device.

Workforce Transformation Research and Innovation has identified and solved big, expensive problems in industry. By getting disparate elements to work together in a Simulation, they have succeeded in the prime dictum of business: “Take care of the bottom line.”

Time for us to take the hint. We should use the Simulator to make our disparate medical elements work together. That way we can succeed in the prime dictum of medicine: “Take care of the patient.”

A Samovar with Attitude

The Soviet take on nuclear safety should raise an eyebrow or two. One manager of a nuclear reactor said, “A nuclear reactor is just a samovar.” (An ornate kind of teapot used in Russia.)

On April 26, 1986, the samovar at Chernobyl served up a nasty brew. The managers decided to do a safety test that day (note the irony). During the safety test, a series of glitches occurred. The engineers:

• Cut off power to the water-cooling system.
• Didn’t insert enough of the radioactive rods into a graphite “absorber.”
• Disconnected a safety switch that would have dropped the radioactive rods into the graphite “absorber.”

And the design of the reactor itself had a basic design flaw: As the reactor overheated, the nuclear reaction sped up. That is, there was no feedback loop to stop a runaway reaction.

A 9-foot thick concrete shield on top of the reactor blew off and fell to the ground with, one assumes, a loud sound. A total of 45 people died right then or over the next few months, and thousands would likely die from cancer from the released radiation.

Children in that area of the Ukraine have to look at painted pictures of trees on the walls in their schools because they are not allowed to walk in the woods. Too much radiation out there.

To this day.

How Did this Error “Evolve”?

It is easy with this “mother of all disasters” to fall into the trap of error analysis—assign blame to the lowest level engineers, the last guys to press the buttons.

“They blew it” (literally).
“They should have known.”
“They’re ultimately responsible, so pin it on them.”

And when you jump into this “blame game,” you can’t help but feel good. Something terrible happened. You have someone at whom you can point your finger. Maybe sue them, fire them, imprison them. Maybe some irate relative will even whack them. Hey, great, we killed the bad guys, just like in some Clint Eastwood movie.

So everything’s OK now, right?

Well, no.

It’s satisfying to nail it all on that last poor jerk, but it doesn’t do any good. A flawed system brought about this “tempest in a samovar” and only a system analysis can fix it. So go back as far as you can, find every element that contributed to the blow-out, and work your fix from there.

• Design of the reactor itself—build in a feedback loop that doesn’t allow a runaway reaction.
• Make sure management and technicians know you have to keep sufficient power going to the water coolant system.
• Instill “safety” in the workplace, so no one would ever think to disconnect the crucial safety switch. Better yet, design in a redundant safety switch as a backup.

So rather than a simple “he did it,” look at the evolution of the error and say, “let’s make sure we can never do it again.”

How Could Such an Error Evolve in Medicine?

A medical pipeline crossover unfolds just like a mini-Chernobyl. And, just like Chernobyl, the solution lies in a system review. Find out how the system made it happen and fix the system. Don’t just take one poor fellow out and hang him from the yardarm.

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