Though clean-cut and scholarly in bearing, James Gordon, MD, MPA, is an agitator of sorts. As director of the MGH Learning Laboratory, the veteran emergency-medicine physician is in the forefront of an effort to fundamentally change the way medicine is practiced and taught at Massachusetts General Hospital, an institution mindful of its reputation for world-class care and education.
The cause is simulation, a form of learning that doesn’t involve encounters with real patients, long the centerpiece of medical education. Simulation aims to replicate such experiences with computerized mannequins, interactive video devices and intensive role playing. Dr. Gordon and like-minded colleagues envision medical and nursing students using it to learn basic skills and have their first experiences with typical scenarios. They hope experienced caregivers will regularly use the same tools to pick up new skills and stay sharp on those they know. “We’re trying to catalyze a transformation in culture,” Dr. Gordon says.
Advocates of simulation maintain it can improve patient safety, bolster the quality of care and enhance the consistency and efficiency of medical education. They also say it can help ratchet down the cost of care.
See One, Do One, Teach One
But one big challenge is persuading medical institutions already grappling with a host of economic and regulatory pressures to tackle such an overhaul. Another is convincing busy caregivers to buy in. Practice drills aren’t part of the typical work week for experienced doctors and nurses. Moreover, the conventional way of learning medical procedures has been to see one, do one and then teach one — all with live patients. “But there have been a whole variety of things that have pushed us toward reconsidering the best approaches to medical education,” Dr. Gordon says. “In part, we simply don’t have the luxury of as many real-time teaching encounters as we used to.”
Indeed, treatment innovations and tighter insurance restrictions have reduced the time patients spend in hospitals. Medical interns and residents are there less often as well thanks to new limits on their workweeks. Meanwhile, concerns about patient safety have been heightened by a host of factors including a 1999 Institute of Medicine study indicating that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors.
Opened in April, 2011, the MGH Learning Laboratory underscores Mass General’s recognition of this fast-changing medical landscape as well as its determination to make simulation a key element of its response. “It’s a big statement that the hospital leadership recognizes the current and future importance of simulation both for healthcare education and patient safety,” says simulation pioneer Jeffrey Cooper, PhD, a senior biomedical engineer for the MGH Department of Anesthesia, Critical Care and Pain Medicine. Dr. Cooper is also founder and executive director of the Cambridge-based Center for Medical Simulation, launched in 1993 to provide related programs to Mass General and other Harvard-affiliated hospitals.
Manipulated Vital Signs
Medical mannequins have evolved dramatically since the early 1960s, when a relatively simple model was introduced for teaching cardiopulmonary resuscitation. Today’s mannequins can breathe, bleed and speak. Fluids can pump through their blood vessels and, with a few computer keystrokes, their vital signs can be manipulated to replicate heart attacks and other critical events.
With many training exercises, designed to improve communication and teamwork skills, the technological capability of the mannequin is less important. In other situations, there is no mannequin at all. Surgeons can, for instance, practice their laparoscopic techniques using virtual reality trainers featuring surgical instruments connected to a computer monitor.
Nationwide, some institutions have consolidated their simulation offerings in newly built virtual training centers, often set apart from real hospital facilities. In contrast, Mass General aims to broaden the acceptance and use of simulation by providing both central and distributed resources in the heart of its campus. The Learning Lab is part of a flexible hub-and-spoke strategy designed to build upon the progress already made by a variety of specialized simulation initiatives.
Since 2001, for instance, MGH anesthesiologists completing their department’s simulation program have received a break on insurance premiums. Meanwhile, the Knight Simulation Program, within the MGH Institute for Patient Care, offers programs for nurses and interdisciplinary teams that include nurses, physicians, pharmacists, respiratory therapists, chaplains and other medical professionals. “In my mind, it has really revolutionized the way clinicians are taught,” says Brian French, RN, manager of the Knight program.
High-Tech Mannequin Drills
Critical care specialists at MassGeneral Hospital for Children regularly drill with high-tech mannequins in the same rooms where, at other times, they treat real children. Phoebe Yager, MD, program director, says staff members learn from mistakes and practice team responses to specific medical situations, some of which are rare in real life. “You can do it again, and do it again and do it again, safely,” she says.
The Learning Lab was also established to complement, connect and support more specialized programs at the departmental level, explains Britain Nicholson, MD, senior vice president and chief medical officer, who serves as the Learning Lab’s executive sponsor. “My experience has been that the more ownership there is at the local level, the greater the utilization of the programs and the more innovative the programs are,” Dr. Nicholson says.
The lab is housed on the second floor of the Treadwell Library, a place where Mass General medical trainees and providers have gone for over a hundred years to gain knowledge. “How people acquire information has changed over the years — from print books and journals to dynamic online learning resources,” says Elizabeth Schneider, Treadwell’s director.
Designed for maximum flexibility, the laboratory’s simulation ward can be reconfigured to portray a variety of environments. One recent morning, a military-clad mannequin with a gaping leg wound was awaiting demonstration in one bay. The adjacent one was set up to look like an emergency department.
A Cradle of the Simulation Movement
On the other side of the ward, third year Harvard medical students based at MGH for the year were performing basic tasks at stations manned by surgeons. At one, the students practiced sutures on a training block made of flesh-colored plastic and microfiber. At another, Emily Morell, of Oakland, Calif., used an ultrasound device to find the internal jugular of a medical mannequin in preparation for the insertion of a type of deep intravenous catheter. “I’ve never operated an ultrasound before,” said Ms. Morell, who described the simulation experience as “a wonderful opportunity for us to practice in a non-threatening atmosphere.”
Mass General is a cradle of the simulation movement. For more than 20 years, MGH faculty members have been introducing their peers to such training and developing tools to teach it. They have lobbied Congress for supportive legislation and helped other institutions launch their own programs.
MGH trailblazers include Dr. Cooper, the biomedical engineer, whose 1978 study of anesthesia-related errors sparked a nationwide effort to strengthen training and safety in the field of anesthesiology, an early adopter of simulation. In the 1980s, he created a program that helped fund efforts nationwide to develop more lifelike mannequins.
Steven Dawson, MD, an interventional radiologist, has been a simulation leader at MGH and the Center for Integration of Medicine & Innovative Technology (CIMIT), a consortium of Boston-area teaching hospitals and universities. During the 1990s, his team helped to develop a cardiac catheterization simulator now used worldwide. More recently, he and his group invented a fully portable, battery-operated synthetic human designed to provide combat medics with advanced training in the treatment of traumatic injuries such as penetrating wounds, traumatic amputations and life-threatening hemorrhage. No technician is needed to operate it.
Rudimentary Teaching Devices
When Dinesh G. Patel, MD, chief of Arthroscopic Surgery, was a medical student, knee surgery typically involved cutting through the skin and tissue surrounding the joint. The advent of arthroscopic surgery in the 1970s promised less invasive procedures but there were few tools to teach the new technique. Among other things, it required surgeons to develop the hand-eye coordination to watch a video monitor while performing delicate surgical maneuvers that they couldn’t see directly.
After fashioning rudimentary teaching devices using bovine knees and common hardware, Dr. Patel persuaded manufacturers to develop more sophisticated simulation trainers and found space for Mass General students and doctors to use them. Such orthopaedic training has been going on at Mass General since 1983. These days, medical students, residents and fellows at Mass General can develop their arthroscopic skills, improve their hand-eye coordination and learn newer techniques on simulation models of different joints at the Dr. Dinesh G. Patel Arthroscopy Learning Laboratory. To eliminate medical errors and reduce costs, simulation “is the single most important thing that healthcare people can do,” Dr. Patel says.
Dr. Gordon was unimpressed with the basic training mannequins he encountered while volunteering as an emergency medical technician as an undergraduate history major at Princeton. His perspective changed later while he was taking a continuing education course at the Harvard-Macy Institute in Boston. One day, he and some classmates were assigned to treat a more sophisticated mannequin, housed at the Center for Medical Simulation. It talked, blinked and had a heartbeat. “I knew this thing was plastic but I really felt like I was taking care of somebody,” Dr. Gordon recalls.
The goal with simulation is to create enough realism, stress and challenge to leave participants with an indelible memory. Dr. Gordon maintains that, if pilots, firefighters and other high-risk professionals accept simulation practice as routine, doctors, nurses and other caregivers should be able to as well. If they do, Mass General will have to find the resources to keep up with increasing space and technology requirements and provide backup for staff taking part in simulation training. Philanthropic supporters can play a crucial role. “They can help make Mass General the first hospital in the world to fully incorporate routine simulation practice into its daily workings, on an unprecedented scale,” Dr. Gordon says.
“Doc. You’re Not Listening to Me!”
In the meantime, the Mass General Learning Lab is already having an impact on the likes of Andrew Bishara, a Harvard medical student who recently took part in a week of simulated surgical training. For one exercise, groups of three medical students were assigned to handle a series of emergencies.
Played out in a faux emergency-room bay, the scenarios were controlled by Marc de Moya, MD, a Mass General trauma surgeon who is also director of both the MGH Surgical Clerkship and the Surgical Simulation Program. Equipped with a microphone and a laptop, he sat behind a dark glass screen calling in lab results and providing the voices for simulated patients. They included a young man who had been shot twice and an elderly woman weary from a night of vomiting. Dr. de Moya provided students with analysis and advice after each scenario.
Mr. Bishara was in charge of treating “Harold,” a 65-year-old bleeding from a head wound after falling from a ladder. With one eye on the vital signs fluctuating on the overhead monitor, Mr. Bishara asked his injured patient a few questions about how he was feeling. Harold interrupted him repeatedly by loudly recounting precisely how the ladder had slipped.
“Doc, you’re not listening to me! Doc! Doc!”
Advised later that such confused repetition is not uncommon with head injuries, the medical student said he was grateful the learning experience had involved a mannequin. Not that he planned to forget it. “There is so much emotion involved,” Mr. Bishara said. “You’ll remember it for the rest of your life.”