Sunday morning, 2am, I’m staring at the hospital ceiling. I’m too hot and I don’t understand why I’m here. The nurse and the doctor both seem new; they wouldn’t let me take my clothes off to cool down. I’m confused by the doctor’s questions and no one brings me the water they’ve promised. So much for a good night out after a stressful week.
My current state was caused by David Gaba, an anaesthetist and a pilot. Simulators had been used since 1929 to train pilots; Gaba wondered why they weren’t used to train doctors. Atul Gawande has describe the conflict “between the imperative to give patients the best care and the need to provide novices with experience” (Complications, p. 24). Simulation offers a way around this, and has become more popular alongside increasing concern for patient safety, decreasing faith in doctors and fewer hours practice to become a consultant.
At Homerton Hospital, simulation exercises knowledge and skill, but focuses on behaviour. Simulated ‘Crisis Resource Management’ provides experience and insights which can’t be gained any other way, in teamwork and communications, decision making and task prioritisation and in managing stress. Simulation allows risk-free, realistic practice under pressure.
Increasingly, Val Dimmock, the centre manager at Homerton, has moved to training ‘in situ’. Instead of bringing practitioners to the Simulation Centre, the simulator (a monitor, an actor or a sophisticated dummy) is taken to a spare bed. A scenario can be completed in an hour, with two or three ‘candidates’ – perhaps a nurse, a junior doctor and a senior doctor – receiving a briefing, a twenty-minute simulation and a twenty-minute debriefing. In situ training is realistic, fits into the working day and identifies ‘latent errors’, like problems of building layout, missing equipment or confusing drug-packaging. Having begun with acute cases, the team now practise anything that is difficult: in situ training has been conducted in every ward in the hospital, from outpatients to elderly care; the video below offers one example:
Planning a scenario during a ‘train the trainers’ course, we sought something realistic, feasible and worthwhile. While my ‘overdose’ derived from the experience of a doctor in our group, scenarios also come from national reports, the training curriculum and challenges identified by the hospital, such as the need for greater clarity in emergency calls. Our goal was a scenario which would push each of our three candidates; so we planned each step, identifying how I would respond and what readings the monitor would show for pulse, breathing and blood pressure. A range of alternative plans reflect the range of possible responses from candidates.
As a patient I passed from confusion to distraction to unconsciousness; I was passed from medical student to junior doctor to consultant. None of it was meant to be a trick, so when I passed out I did so clearly. The nurse keeping my clothes on was a fellow trainer, able to help candidates – passing them equipment or highlighting symptoms – so they could focus on making decisions. A third trainer managed the scenario (changing the readings on the electronic simulator, stating my responses to treatment, deciding what happened next), a fourth observed and prepared for the debriefing.
Afterwards, we tried to help candidates think through what had happened, why, and what they could learn. We asked them to describe each step and each decision, then to analyse what had worked well and then to apply what they had learned. Where a candidate needed additional technical knowledge it was explained, but the focus was on decisions and behaviour. Candidates were humble and self-critical, although I was somewhat wary of their assertion that they would have stepped back and thought through the scenario more carefully had they not been in the Simulation Centre. Haresh, the lead instructor, encouraged us to elicit discussion of similar cases as a powerful way for candidates to share expertise. The doctor who had treated ‘my’ case, for example, explained how a bad batch of ecstasy had affected festival-goers and his hospital had received three over three nights. This capacity to trigger memories of previous experiences seemed a powerful way to ensure what had been learned was passed on.
Simulation seemed to have a powerful effect: one candidate, a medical student, had now dealt with an overdose independently, while her two colleagues had been reminded to step back and think strategically. Haresh described practice giving candidates a bank of experiences to draw upon and confidence in what they did. He also mentioned the usefulness of practising cases anaesthetists see once a decade (like anaphylaxis) or once a career (like the need to create an emergency airway). The team has also seen significant improvement in removing specific latent errors in the hospital.
Simulation is no panacea. It demands time and resource – no one throws anything away in the hospital without checking first if Val can use it. Nor can simulation fix every latent error or teach every skill. I wondered whether medical simulation would benefit from more modelling of good practice [LINK], and asking candidates to commit more clearly to specific changes. But simulation does offer a safe, powerful way to practise and improve, and a tool to identify latent errors. Val described an ongoing stream of examples of the usefulness of simulation from her colleagues, and the struggle to quantify this. No one has run a Randomised-Controlled Trial on simulation; David Gaba argues that:
“…no industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation (or CRM) before embracing it… Neither should anesthesiology (health care)”
Lessons for teacher development?
1) A culture of practice: Val describes the acceptance of practice-based training within medicine: all but the oldest consultants have experienced it in training. I hope we can embrace the centrality of practice to teacher-development (particularly given that we don’t need expensive technical resources).
2) More complicated practice? The most effective practice-based training [LINK – Uncommon] I’ve seen has been in ‘simple’ teaching skills. This makes sense: ensuring trainees master individual skills is crucial, the skills are hard enough, and ‘practice’ beats ‘scrimmage’ which simply teaches trainees that teaching is hard. Homerton’s approach makes me wonder whether we can go further, practising more complicated endemic scenarios: ‘the projector fails thirty seconds before your lesson starts’, ‘three students need urgent attention simultaneously’, ‘a student wanders in from another lesson’. More complicated scenarios risk taking us beyond ‘practising perfect’, but might increase the power of practice, especially for skilled teachers.
3) In situ training? I’m struck by the realism and convenience of in situ training. We know the value of distributed practice over one-off training and that what we learn in context we remember better in that context. What if we spent half a free period practising a scenario with colleagues? (The closest thing I’ve seen to this has been morning CPD at Dixons Trinity Academy, which allows teachers to put what they have learned into practice the same day).
4) Debriefings. I have spent some time prioritising practice over reflection as rarer and more valuable. With Teach for Sweden this summer, I hope to retain the focus on practice but better exploit the power of the debriefing to share experiences and ‘lock in’ learning.
5) I’m struck by the links between all of this and Deborah Ball’s idea of ‘laboratory schools’: a longer-term aspiration for teaching schools perhaps?
I was privileged to receive appropriate treatment for my overdose; the candidates were privileged to learn from their colleague’s experience of similar cases; I hope they will be better doctors for it. I hope to be able to make similar statements about educational training one day.
With thanks to Val and Haresh.