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I recently had a great opportunity to do bedside teaching in the REAL Emergency Department of Wan Fang Hospital, which is one of the major teaching hospitals of Taipei Medical University in Taipei, Taiwan where I hold an appointment as a Visiting Professor.

It is amazing to realize the similarities between bedside teaching usual actual patients and the learning that can be facilitated through effective structured communications that encourage reflective learning. Yes, indeed those of you not so subtly reading between the lines recognize I am saying that I was implementing classic debriefing methods to help facilitate learning critical thought process while utilizing the experience of real patients.

We did case discussions of two actual patients with junior and senior level medical students. We reviewed case details, patient examination, hypothesis testing, clinical testing and diagnosis. During the two hour sessions I was relying upon the structured and supporting debriefing model (GAS Model) to facilitate the discussion.

The GAS model is one of the most common methods of simulation used throughout the world and was created by my Colleague Dr. John O’Donnell of WISER and University of Pittsburgh School of Nursing, Chair of the Department of Nurse Anesthesia in conjunction with the American Heart Association. 

In recent years John, I, and others have discovered the advantages of using “simulation style” structured debriefing used in the clinical teaching setting. The model encourages active reflection and self discovery through a structured model supported by supplemental learning materials and focusing on the participants readiness to learn.

Implementing the GAS Model during this exciting, but challenging opportunity to actualize bedside clinical teaching in an environment with participants who do not speak English as a primary language was hugely successful for the students judging by the feedback that I have received.

The model of debriefing can be expanded and contracting for varying levels of complexity and molded to support any learning encounters that benefit from active reflection with a goal of prompted discovery. It is easily learned through structured education sessions and workshops.

All of the discussion on the Sim Connect Community networking site of the SSH inspired me to expound a little on the topic of death during simulation.

A number of years ago we had a poster at IMSH reporting our results of a survey given to 224 professionals (Emergency Physicians, Flight Paramedics and Flight Nurses) who attended courses that had some scenarios that ended in death depending on how the cases were managed. Overall 48% of them had experienced death during the courses. These were courses that did not include objectives on death, family/patient communications or teamwork. Thus, there was no focus on the death during the debriefing.   PDF of Poster

They were asked a series of questions about experiencing death during the simulations. The four main conclusions that we reported were: 1) Participants disagreed that simulated death was distracting to the learning environment; 2) Participants strongly disagreed that students in their respective fields should be exempted from simulated death; 3) Participants strongly disagreed that experiencing simulated death would create a reluctance to participate in further simulation training; 4) Participants disagreed that a separate disclosure about the possibility of simulated death was necessary. On further analysis there was no difference in the perceptions of those who experienced simulated death and those who had not.

Bear in mind these are all practicing professionals and all from a high-acuity emergency profession. But, none the less this was their collective opinion. So maybe at times we should slow down and ask the participants their impression. I think many people take the phrase “safe learning environment” to extremes and try to make absolute rules that are very broad sweeping and thus become rate limiting steps in creating effective education.

Do I think that death in simulation is appropriate for all learners? Absolutely not! In the case of the learners participating in the courses we studied, it was the collective opinion of the subject matter experts involved in the design of the courses that it was appropriate. But importantly, it was a deliberate decision as part of the course design.

While there is significant passion, emotions, urban myths and beliefs surrounding this topic, like most things in simulation I think there is no one correct answer. I believe that those who profess to know “THE” way to do simulation and are unyielding in there methodology or offerings should be viewed with skepticism and doubt.

When programs carefully evaluate who their learners are, make realistic expectations, understand what is needed of the learner to provide the best patient care possible, remains attentive to the general emotional well being of the participants, and deliver the learning with well trained facilitators, I believe they are providing PATIENT CENTRIC SIMULATION. A concept which I believe is the most useful of all to the global healthcare community and will result in higher quality patient care.

While of course we want to be nice to everyone who interfaces with the health care education community in reality we must allocate priorities to how we direct our resources. Many times when I am speaking in front of large group of simulation colleagues I ask the question “who is the ultimate customer of simulation program?” Often times, the audience will quickly convey to me that it is the students of the simulation program.

I share a slightly different view. While I believe that it is the patient’s AND students who are the ultimate beneficiaries of the simulation services it is actually the faculty members and those who create simulation programs that are the true “main” customers of simulation center. I come at this from a perspective of being the director of a multidisciplinary, academic simulation program that functions in a unique collaborative model in which the staff of the simulation center partner with faculty member content experts to create successful simulation based education programs that are taught by clinical faculty educators. Those educators come from various domains such as the school of medicine, the school of nursing, and various educational units of hospital systems and so on.

I remind the staff on the regular basis that the true customer is faculty who come to our facility to create learning programs, and then subsequently teach them. I believe they are the customers that our system should be designed to offer the most support to assist them in achieving their goals. At our center we continuously strive to develop tools, pathways and process, as well as new innovative ideas on collaborative opportunities to lower the barrier of participation and increase the success of the people that are here trying to create and conduct programs of education for health care providers. In the model that I have described our content experts come from a variety of backgrounds and professional domains, and most of them are not full-time simulation based educators. In fact that would be rare in our system.

Whether it is standardizing the curriculum development process, or just finding ways to assist them in the administrative needs, or perhaps assisting with the technical aspects of simulation, we stand ready to support that faculty member. Similarly, we believe that supporting the faculty members during the actual conduct of the simulation course is critically important. Being able to troubleshoot glitches, handle the “super technical” aspects that may be outside the wheelhouse of expertise of the faculty member, give the faculty member confidence in their ability to achieve her goals through simulation based education. In addition to trying to remove the workload, part of our customer service strategy is to minimize the stress of the faculty members.  

It is my belief that this extra attention of customer service effort dedicated to our faculty members and course directors directly contributes to the success of the programs that are conducted at our center. Further, it also increases the ability of faculty members to participate in continued to go the extra mile to engage students with innovative learning that includes simulation.

The net result is a proliferation of very successful programs that give great education to the participant, which is ultimately benefiting the patient’s that we here to provide care. So while the students, or participants are certainly important, the main customer is the faculty who are creating and teaching the programs.  

My First Simulator – Good Enough?

In 1972 I was eight years old, in the third grade, and vividly remember my first encounter with what I would call my first medical simulator at the YMCA during swimming practice. Today most would call this a partial task trainer; however I argue that that is part of simulation in the way the start of today.

I built a replica of this simulator a few years back to present at a lecture and it appears in the picture in this post. The original was built by some clever swimming instructors who were teaching fourth graders how to do mouth-to-mouth resuscitation to save a life associated with drowning, and near drowning incidents.

It is simply a Clorox bottle with a hole cut in it, feeding into a plastic bag that would force the back of a clipboard up and down in response to ventilation’s being provided via the mouth of the Clorox bottle. See it in action here.

Crude? Perhaps. Effective? Undoubtedly! At least in my case.  High fidelity? Yep. When I breath air into the Clorox bottle, the “chest” goes up and down just like when I do ventilations on a real patient.

I keep this simulator prominently displayed in my office to serve as a continuous reminder that we are about achieving outcomes through innovative education as opposed to that of evangelism for sake of technology. While all of it has its place, I love high tech stuff as much as anybody else, there are times when simplistic models combined with enthusiastic instructors and aptly defined curriculum and learning outcomes will prevail. Prevail is a sense of sustainability and achieving long term outcomes.

This is part of the educational strategies I use join faculty development programs. The important thing is to focus on learning outcomes first, then adapt to the reality of available equipment, budget, finance and lastly scalability.

If low-tech simple solutions are the answer, then perhaps, yes they are good enough.