Clinical Innovators: Charles Pozner, MD, A Pioneer in Medical Simulation

Over the past decade, there has been an increasing recognition that medical simulation can improve quality of care in low-frequency, high-risk situations. This recognition has accelerated as simulator technology has grown in his realism. Medical simulation is on the path towards becoming ubiquitous among medical schools and hospital centers.

CardioSource WorldNews spoke recently with Charles Pozner, MD, an associate professor of medicine at Harvard Medical School in Boston, and the director of the Neil and Elise Wallace STRATUS Center for Medical Simulation, about his path towards a career in medical simulation, the history of the field, and its future.

How did you become interested in medical simulation?

My first use of medical simulation was as a paramedic student in the early 1980s. At that time there were only task trainers (e.g., CPR, defibrillation, airway, IV arms). We would put together bodies that looked like they were from a science fiction movie: two heads, two chests, and an arm! My next use of simulation was in the late 1990s as chair of the resuscitation committee of an academic medical center. We were getting nowhere with traditional methods to improve response to codes. I purchased a basic simulator, put it in the board room in ventricular fibrillation, and called a code blue. I videotaped it, and as expected, it was a disaster; taking 16 minutes to defibrillate! I pointed out to hospital administration the "patient" would have received more timely care if they had had their cardiac arrest on the sidewalk! I kept my job and implemented formalized code team training. Upon arriving at Brigham and Women’s Hospital (BWH), I was asked if I was interested in developing a simulation program. I jumped at the opportunity, and medical education and simulation have become an important focus of my career.

How is medical simulation being used to enhance patient care and training at Brigham and Women’s Hospital?

STRATUS contributes to education, patient safety, and research at BWH. In an era of "reduced work hours," simulation has become an essential adjunct to bedside teaching. It takes the "chance" out of chance encounters. Learning with the simulator reduces risk to learners and patients. It eliminates the negative impact that the patient's presence and hospital throughput have on the learning process. We went from "See one, do one, teach one," to "Learn, master, then perform." A fitting analogy is Tiger Woods learning to play golf. He didn’t learn at high-stakes tournaments. Unfortunately, clinicians have been required to learn and practice at the "tournament." There will always be the first time a procedure is performed on a patient, but it should be after attaining a minimum level of competence in the simulated environment.

STRATUS is an essential element of education programs at BWH. The residencies in medicine, anesthesia, surgery, OB/GYN, and emergency medicine each use STRATUS on a regular basis. Emergency medicine has substituted lectures with small group learning using simulation. Other disciplines and providers are using STRATUS' computer-based simulation, skills training, virtual reality-based training, and full-scale human patient simulation. There are also a variety of interdisciplinary team training programs including: Code Team, Trauma Team, Labor and Delivery Team, Operative Team, and Emergency Department Team. Various disciplines have begun to employ STRATUS for assessment of clinical skills. Emergency Medicine has residents demonstrate a variety of skills in the simulator before promotion. This process has facilitated earlier identification of clinical deficiencies enabling directed remediation.

STRATUS is also a component of BWH's patient safety efforts. Sentinel events are scrutinized using simulation. Simulation is used to improve processes, even before there is a bad outcome. STRATUS conducts unannounced "mock" codes throughout the hospital. Local caregivers must respond, initiate care, and summon the code team. These 10- to 15-minute scenarios conclude with a short debriefing. An after-action analysis is done in which performance is benchmarked against accepted standards. A report is sent to the local team and identified deficiencies must be addressed. We have been able to make changes to a number of systemic deficiencies resulting in better and safer care for our patients.

We are actively involved in research at STRATUS. One example is an AHRQ-supported study examining the impact of the use of checklists on the outcomes of operative emergencies. Many studies are also being conducted to validate the effectiveness of simulation in both education and the assessment of competence.

What are the outcomes that demonstrate medical simulation works?

In the early stages of medical simulation, studies used qualitative metrics like learner satisfaction and confidence to measure effectiveness. Because of the associated costs of simulation, these studies were inadequate to demonstrate return on investment. As with many other health care interventions, tying simulation to patient outcomes has been difficult. Surrogate indicators of effectiveness continue to be identified so that simulation can be validated as a useful modality for both education and assessment. There are a growing number of studies, from a variety of disciplines, that have demonstrated the value of simulation as a means of decreasing errors and procedural duration. One elegant study showed that the introduction of simulation-based training resulted in a reduction in central-line infections as compared to matched controls. In this study, the investigators reported a 7:1 return on investment measured as reduction in both length-of-stay and cost (Cohen ER, et al. Simul Healthc. 2010;5(2):98-102). 

One may extrapolate the value of simulation as a result of several organizations that have adopted simulation. For more than 10 years, the Controlled Risk Insurance Company (CRICO), the self-funded insurer of Harvard-affiliated hospitals, has been providing premium discounts to anesthesiologists who have attended simulation programs emphasizing teamwork and the principles of crisis resource management. CRICO extended this program to obstetrics and surgery. Although they have not released specific data, it is clear that CRICO's actuaries see the value of simulation. Further evidence comes from the American Board of Surgery, which requires applicants to pass a laparoscopic skills assessment on a simulator as a prerequisite to taking their certifying examination. The American Board of Anesthesiology has recently added medical simulation to their lifelong learning requirements.

Medical simulation is still seen as "new" and "innovative." What will it take for it to go mainstream? What are the obstacles you face in proceeding along these lines?

I believe that medical simulation is already in the mainstream. In 2004, when STRATUS first opened, few people had any concept of medical simulation. Now, medical students and residents expect that selected subjects will be presented in a simulated format. Although growth is limited by the slow evolution of the technology, there are institutional obstacles that hinder simulation's penetration: money, technology, and resistance to change.

Because simulation requires an investment of resources, one must find administrators who support it both financially and philosophically. After an initial investment of money and space, an institution must have a strategy for ongoing support. Philanthropy and grants help, but are not sustainable models. Internal fee for service is limited because those who control budgets are usually not the users of simulation. Revenue from extra-institutional users may contribute, but will not fully support the enterprise. BWH employs a shared-funding model. The hospital and the physician’s organization support the operating budget. This model supports use without concerning internal users with how it will be paid for.

Operating the technology requires a level of acumen and time that our busy (and expensive) faculty find unacceptable. STRATUS employs technicians who prepare, operate, program, and maintain the equipment, enabling faculty to focus on curriculum development and teaching. Besides collaborating with content experts on curriculum development, our education specialist reduces the anxiety created when traditional "PowerPoint jockeys" are asked to develop simulation curricula.

What’s the future of medical simulation?

The future of simulation seems limitless. Simulation is being used in ways that I never would have dreamed of when I started on this journey! Technology will certainly be a limiting factor in the pace of simulation’s growth; however, the increasing number of users ensures never-ending development of new and imaginative approaches. In the near future, besides teaching and learning, I see simulation having a central role in competence assessment, process improvement, and technology development.

In the past, clinical competence was assumed if a trainee spent enough time on the wards, made no or few critical mistakes, didn’t "piss people off," and could pass a written (and sometimes oral) examination at the end of training. We can no longer rely on time and chance to ensure that our trainees (or attendings for that matter) have an opportunity to competently care for patients with specific presentations. I am certain that we will see assessment of clinical competence under validated simulation-based conditions.

Health care is undergoing dramatic change necessitated by both an unsustainable funding model, as well as a growing intolerance of clinical inefficiency and variability. At BWH, we have already used simulation as a tool in process improvement. As national health care reform necessitates development of new care models, I am certain that simulation will contribute to the process by enabling change agents to analyze new delivery models in a simulated environment, speeding both their development and their implementation. 

Industry is already beginning to reap the benefits of simulation. In the past, device prototypes would be shown to focus groups whose opinions would be brought by engineers back to their laboratories to implement changes. This process would be repeated until a mature device was ready to be tested in the clinical setting. At BWH, we have worked with industry to streamline the process by having clinicians utilize prototypes in simulated scenarios with engineers observing the process. It is easy to see how this could accelerate the development cycle.

Disclaimer: Dr. Jain recently accepted a position as chief medical information officer at Merck. This column was written and submitted prior to his accepting this position. The fact that this column is published in CardioSource WorldNews is not meant to imply endorsement or approval of Merck products or initiatives by the ACC, the ACCF or the editors of CardioSource WorldNews.

Keywords: Patient Care, Health Care Reform, Patient Simulation, Emergency Medicine, Ventricular Fibrillation, Patient Safety

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