September 27, 2010 - By Jonathan Rabinovitz
As associate dean for immersive and simulation-based learning, David Gaba, MD, has played a major role in the development of the Hon Mai and Joseph Goodman Center for Simulation and Immersive Learning — a virtual hospital floor on the ground level of the Li Ka Shing Center for Learning and Knowledge and one of the world’s largest medical simulation facilities. An internationally-renowned expert in this type of experiential, hands-on learning, Gaba, professor of anesthesiology, recently discussed the history of the field and how it would be practiced in the LKSC with communications office executive director Paul Costello. A podcast of their conversation, part of the medical school’s “1:2:1” program, is available at http://med.stanford.edu/121/2010/gaba.html. Here’s an excerpt adapted from that interview.
Q: More than 20 years ago, you created the first patient simulators. Can you talk about that invention?
Gaba: Actually, there had been a patient simulator in the late 1960s, but they didn’t really know what to do with it so it died out before the mid ’70s. In fact, I’d never heard of it when we realized, in the mid ’80s, that we needed a simulator.
Initially, our idea was to have the simulator as a device to support our research into the thinking of anesthesiologists and other kinds of clinicians in handling challenging and possibly lethal, critical situations that would develop in surgery or in other settings. We realized we needed a systematic way to probe and study how they would respond.
Looking at other industries, like aviation, space flight and nuclear power, we saw that they all used simulators for those kinds of purposes as well as for training. And we said, “Well, we need a simulator.” Given that I’m an engineer by my original training, and the medical student working in my lab at the time was also a Stanford electrical engineering graduate, we said, well, maybe we could make one. And we did.
Now, about 25 years after our pioneering work, simulation is widespread in medical schools, teaching hospitals and even non-teaching hospitals. We’re now in a phase where simulation is starting to become embedded in the fabric of health care. We’re past the point where it was a novelty. But we’re just at the beginning of the phase in which we really apply this on an everyday basis, not only to medical students and other early learners, but also to everybody in the field and for all the things that it can do.
The term “simulation” is actually very broad. We consider simulation everything from non-technological simulations — such as narrative storytelling, verbal-simulation role play, up through the use of standardized patient actors who play the role of patients in interacting with students and others — to the technological simulators like the computerized mannequins that my lab pioneered, and then to things like partial-task surgical and procedural trainers which may involve virtual reality, and ultimately to full-blown virtual reality itself.
Q: The aviation industry learned a lot when it looked at airline crashes: They recognized that they had not only structural issues, but also communications issues. I understand that part of what you teach is not only the technical aspects of medicine, but also the significance of communication in medical settings.
Gaba: I think my lab can be credited with two major discoveries. One was the independent reinvention of the mannequin-based simulation technology. The second is the adaptation into health care of the paradigm from commercial aviation that was originally called “cockpit resource management” and then got the name “crew resource management.”
In the case of aviation, the “stick-and-rudder” skills — the skills of flying the plane — were important, but they didn’t account for the bulk of crashes and mishaps. Most of those were traced to systematic issues and to the interaction of the crewmembers, and with the other components of air travel, like air-traffic control and the cabin crew in the back of the plane. So they instituted new training paradigms in which these behavioral issues were as, or more, important than the technical issues.
We brought that into health care, first in anesthesiology, because there are good cognitive parallels between what happens on the flight deck of an airliner and the anesthesiologist’s work with the surgical team in an operating room. We realized that many of our mishaps and poor outcomes could be traced not to people not knowing technically what to do but to issues of, on the one hand, dynamic decision-making, in matters of seconds and minutes, and on the other hand, in team-management kinds of issues: leadership, followership, communication and distribution of workload.
Using the simulator, we were able to not only bring the theory of crew resource management into health care, but to create mechanisms for people to learn these skills abstractly, and then practice them.
Q: Let’s talk about the LKSC, which is bringing together some of the newest, most exciting, immersive training of any medical school in the country.
Gaba: The Goodman Immersive Learning Center, which occupies the entire ground floor of the LKSC is about a 28,000-square-foot immersive learning center. That makes it one of the biggest in the world. It’s also one of the very few that brings together all the modalities of simulation into one place. We have the mannequin-based simulators, where the computerized mannequin stands in for the patient. We have an extensive clinic for standardized-patient actors to interact with medical students and others in an ambulatory-care-like situation: Where all you’re going to do is interview the patient and maybe do some elements of the physical examination, there is no better simulator for a human being than another human being. We have a number of rooms for deployment of partial-task and surgical trainers, where you can learn the actual, hands-on psychomotor procedures of doing medical procedures and surgical procedures. And then we have a number of facilities for various kinds of virtual reality. We have a room for the use of on-the-computer-screen kinds of simulators, and virtual worlds, which are worlds on the computer in which you control an avatar, and your avatar interacts with other avatars. You can talk to them. All the teenagers play “World of Warcraft” on the computer. Well, these virtual worlds are like that, except, instead of killing monsters and whatnot, you’re working on healing people.
And ultimately, we have 1,000 square feet reserved for the development of things in virtual reality and mixed reality. Imagine the Star Trek holodeck, where you can have virtual experiences indistinguishable from real life. We’re not there yet, but we’re hoping to be able to deploy some things in the coming years that start to approach that kind of virtual reality.
This new facility is the culmination of years of work. We’ve had a dedicated simulation center here at Stanford as part of my lab’s work at the VA hospital in Palo Alto since 1995. So we’ve been pioneering all the techniques and, bit by bit, the various technologies that were needed not only in simulation but also on the audio-visual side in terms of capturing the performance of people, capturing these simulations so that we can do an intensive debriefing of the learners after the experience. And there have been additional simulation centers that have opened at Stanford in recent years. On the standardized-patient actor side, we’ve had a standardized-patient clinic for many years in which that kind of simulation has been done. So we’ve had pioneers and practitioners of all the various forms of simulation here at Stanford for many years. But we’ve been waiting for a long time for a world-class facility.
Q: How much does it cost to have this great technology available to students in medical school?
Gaba: Again, because the modalities of simulation run the gamut from non-technological to technological, some things can be done very cheaply. Our cardiac surgeons learn to do coronary-bypass grafts by suturing those grafts in pig hearts or beef hearts we get from the butcher shop. The role-playing and those non-technological sorts of simulation are pretty cheap in themselves. It turns out the most expensive part of this whole endeavor is the time of the experienced personnel to run these activities. A simulator, whether it’s technological or non-technological, is just a tool for somebody who knows what they’re doing and how to teach about it. Those people are not so easy to come by. So the biggest expense is the teachers, not the technologies.
Now, for the technologies, mannequin-based simulators can be as cheap as $30,000 or so. The ones that we’re buying primarily for the Immersive Learning Center cost about $70,000, and some go up to about $200,000. Similarly, the task trainers for procedures and for surgery can be in the order of $30,000 to $60,000, but the most expensive ones are over $100,000.
Then there’s the amount of audio-visual technology that we’ve put into the immersive learning center as well as into the building as a whole to support all the learning modalities in the building. We have one of the most technologically advanced buildings on the Stanford campus for sure. I understand there’s a mile and a half of fiber optic cable, and the CAT6 cable in the building would run from here to Sacramento. We have video from anywhere toanywhere in the building, meaning we can take camera feeds from anywhere and put them up in a display anywhere in the building.
We can record just about everything. We record all our lectures and many of our symposia. We record many of our simulation activities and, as I say, we can debrief on them immediately after in our debriefing rooms, bringing up the audio and video of what just transpired in the simulation.
And all that audio-visual technology is a number of millions of dollars to put it all together, but it’s going to be one of the most spectacular places of its kind in the world.
Q: How does this advance medical education for students and physicians?
Gaba: This closes the gap between understanding something in a book sense, or from osmosis by being a member of a team and observing and watching role models, to actually being able to do it, and to do it under not only routine conditions but under conditions that are really unusual or very critical. Historically, the only way to learn these skills was an apprenticeship model, in which you would have increasing levels of responsibility, from being an observer, which is a lot of what we do as medical students, to then being interns and residents and doing these things yourself but under very close supervision by faculty. Yet, at some point, the young doctor has to go from being under supervision to being “it.” Well, how do you make that transition from being an observer to a doer, from being a doer under supervision to the doer of final accountability?
Historically, we as patients have been the simulators for people to learn those skills. And yet no other industry in which human lives depend on the skilled performance of the professionals depends on learning it only with actual activities. They all use simulation to close that gap between the talking about it, the knowing about it, the observing it to being able to do it — and then to being able to do it as the final authority. We’re glad that we can close that gap using simulation and that makes it applicable not only to the early learners, like medical students, but also throughout the entire career of health-care professionals.
We have some technological advances still to make, especially in the realm of virtual reality. But a lot of the progress we need to make is more on the organizational side. Even though simulation is now extensively used for our student population, there are more parts of their experiences that can benefit from simulation. In addition, if you look at the more experienced populations of the practicing physicians, practicing nurses and so forth, the number of them who’ve been through a really cogent and credible simulation experience, nationwide, is quite small. It’s only probably a few percent. If we want to follow the model of other industries, like aviation, these activities have to be something that all people in health care do on a regular basis. The vision we have is that professionals in health care will cycle through different kinds of modalities of simulation — sometimes as individuals, sometimes in teams — and do different things in different ways throughout an entire career. And I like to say the only way that someone in health care would stop doing these simulation activities is either if they retire or they die.
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