'I did the training, got the T-shirt, but are you willing to be your life on me?' The Medical simulation revolution

Attended a fantastic lecture by Mark Bowyer an ex trauma and combat surgeon, now professor of surgery at Uniformed University (where American Army doctors study medicine). 

The lecture was all about the different types and benefits of medical simulators available, particularly in surgery and combat medicine. 

Dr Bowyer started off by talking about the current state of medical training, a world where most medical students learn from books and lectures and are expected to perform without mistakes on real patients when they start work. Does written performance translate to technical performance? He showed a video of a fifth year medical student who had passed all the life support courses and written exams and in a practical exam on intubation put the laryngoscope in the mouth of the simulation doll the wrong way round.  The old mantra of 'see one do one teach one' that I myself have heard many times on the surgical ward is outdated and even dangerous. In fact healthcare itself is one of the most dangerous professions, up there with bungee jumping and mountain climbing. He jokes 'I did the training got the T-shirt are you willing to be your life on me?' Surgeons have to know around 120 procedures to pass their board exams and be described as proficient. 60 of these procedures surgeons practice on average less than 1 time per year.  We all want doctors that are safe, competent and proficient. Many doctors will only get the opportunity to 'practise' on patients themselves and with stats like those above they may not even get that opportunity often. In fact these days there is less tolerance for errors and on top of that training times have shortened, what's the solution? Dr Bowyer believes the answer is medical simulation.
An important thing about simulation is that you can allow people to fail, because well like it or not, it does happen. You can repeat interventions as many times as you like, develop goal orientated practise and use it as a teaching tool. These days most methods are expensive, (medical education is expensive in general though) but as the industry grows, hopefully we will be seeing more of it. It's a powerful tool and we are probably just entering a new age of medical education as it grows. Dr Bowyer spent the second half of the presentation describing the various methods of solution available and their pros and cons. Before starting medical school I was a simulated patient for the UK OSCE exams, I had to pretend to have various symptoms like hearing loss, blindness and at one point some respiratory condition. Simulated patients provide an optimum human experience; history taking, physical exams and re-enacted disaster scenes, you can't get much more real than dealing with a living breathing human being. Dr Bowyer had a volunteer simulated patient who had already lost his legs in battle enacting a scene that his legs were blown off with fake blood on the ends, a powerful image for new army doctors. How do you prepare someone for the 'image' of trauma.? Part task trainers is another method of simulation for example peritoneal lavage (simPL) simulation. Students can puncture a synthetic membrane (made to look like abdomen, with umbilicus etc) with a needle that is tracked on a computer screen in front, the simulator mimics the pop of crossing the fascia and the peritoneum. Another way this technique can be trained is on a pig. Animals however do not have human anatomy and a small study comparing the computerised synthetic membrane to pig for peritoneal lavage showed better site selection and seldinger technique with the synthetic model. Working with the gaming industry and virtual reality technology, there is an expanding market of surgery simulation games. Some less professional like the very entertaining Surgeon Simulator 2013 but some more more didactic and professional as Touch surgery.

Dr Bowyer showed some incredible examples of 'virtual environments', another new medium for medical simulation. In these virtual environments you can simulate sounds, smells, scenery, noise, smoke, gun fire and much more (air cannons were used to simulate bombs going off nearby). One such environment had a helicopter platform that tipped and rolled just like a real helicopter, where the soldier could simulate getting a patient aboard and then treating him/her while the helicopter 'flew'. Just check out this WAVE (wide area virtual environment) simulator: https://www.youtube.com/watch?v=ineGH9Smce0

With the enrolment of multiple actors and simulated patients, you can simulate mass casualties and disaster zone situations using this technology.

When it comes to surgery, there are already simulators available for laparascopic and robotic surgery but the real challenge is open surgery simulation. A model of open surgery needs to act like human tissue, be anatomically correct and bleed in a realistic fashion. There has already been some success with visco-elastic foam models. One such model was used to teach doctors going out to Irag the correct procedure for fasciotomies and will have saved many legs from amputation. wouldn't you rather train on a simulator before performing an amputation tomorrow?

Now there are even simulators in development for teaching c-sections to third world countries.

Medical simulation is the new revolution in medical education! hopefully we will see one day a standardized curricula based on physical models that is consensus driven, validated, proficiency-based, offers remediation strategies and assessable to all. 

Cricothyroidotomy training simulator

Medice Cura Te Ipsum

Today I attended a really interesting talk by sociologist Dr Jonathan Imber and his good friend Dr Lorenzo Berra, a professor of Anaesthesia at Harvard medical school. The talk was titled 'medice cura te ipsum', a latin phrase taken from the bible which is best translated as 'Physician, Heal thyself'. The phrase is best understood as 'counsel to your defects before you counsel the defects of others', an important message in complicated field of medicine.  

Jonathan Imber specializes in the sociology of medicine and its historical and religious dimensions, while Dr Berra works in the intensive care unit at Massachusetts general hospital. Imber published in 2008 the book Trusting Doctors: the decline of moral authority in american medicine, a topic I'm sure many doctors particularly older ones can relate to. 

The talk started as simple discussion about the origins of their friendship, in the shadowing experience of Imber's son who had some doubts about pursing a career in medicine. Dr Imber went on to highlight the importance of experience with people being a key factor in deciding whether to pursue a career in medicine. Medicine after all is about dealing with people, people who are in fact often suffering and at their most vunerable. Medical education itself is lacking in this aspect of teaching students about real suffering. Dr Berra described how he didn't actually learn about suffering until well after graduation when dealing with one of his own family members suffering with a terminal cancer. 

Dr Berra was very personable and delved into great detail about the personal experiences that shaped his medical career. He really pushed the importance of a good mentor, someone to share the experience of becoming a doctor, not someone who just teaches things now and there but someone who you can develop a real friendship with and can relate to your own experiences.

Two of Dr Berra's stories stood out (I have changed many of the facts, but the idea is the same). When he was just an intern only on his second rotation he was on a late shift and a young guy came in with gastroenteritis, flu-like symtoms, unable to walk. The patient became hypotensive and the decision was made with the team to give fluids, but the patients BP kept falling. Eventually the patient crashed and they had to give CPR for over an hour, and unfortunately the patient passed away. Later they found out that the chap had a viral myocarditis and perhaps fluids wasnt the best shout. 

The second story, a young guy came in after a horrendous crash after a snowmobile jump. the guy had landed flat on his back with the snowmobile on top of him. Almost every bone was broken, contusions everywhere and the spine was severed at C7. While looking at the CT with the radiologist and the team, the radiologist openly said theres no hope, what can we do, such a young guy paralysed for life. Dr Berra stood up and said lets at least try, come on. Later the father of the young guy thanked Dr Berra, he had infact been their with the team as they looked at the CT with the radiologist. The patient is now ok, many years on and able to move his hands despite the lack of sensation and mobility in his legs. 

The entire hospital was sued for the first case, many doctors became very defensive with their medicine after that. Medicine now is all about performance. People forget doctors are human and can make mistakes, and sometimes that mistake is just an inability to predict some outcomes in the future. Defensive medicine is an expensive way to deal with patients, both economically and in terms of suffering. Doctors need to also trust their own patients. A good doctor needs to do decision making without fear and in the best interests of the patients.

Dr Imber told a great story about how the editor of the NEJM (New England Journal of Medicine) became really quite ill once, needing to spend many days stuck in a hospital bed. The editor having been a doctor for many many years, only then realised how important nurses were to the patient experience. There is more to the patients experience than just the doctor-patient relationship. The patient deals with nurses, other healthcare staff, his/her own suffering and of course family and friends. 

I guess I've ranted on a bit now. In summary:

• If you are considering medicine, be around people. Try to gain experience in the human experience of suffering. Care homes for example are an ideal place to start.
• A good mentor is important
• Trust yourself and your decisions
• Never stop studying, even when you are well qualified
• There is much more happening outside the doctor-patient relationship in hospital for the patient
• Take your time with patient to take a full history and gain a complete understanding of their illness experience (10-15 minutes assigned time is a ridiculous concept). 

(Dr Joanthan Imber and Dr Lorenzo Berra, Humanitas Hospital Rozzano 2016)