Holding an ultrasound probe steady with his left hand and inserting a needle at a precise angle with his right, Joseph Frye threads a catheter into his patient’s neck. There’s little margin for error. A slip of the needle could puncture the carotid artery; failing to scrub up sufficiently could introduce a deadly infection into Mr. Jones’s bloodstream.
Lucky for the young doctor, Mr. Jones is a mannequin—an upper torso, really—and just the subject for a fresh-out-of-medical-school doctor who is still learning his way around the human body.
“I would freak out if I had to do it on a real patient first,” says Dr. Frye, a first-year resident in physical and rehabilitation medicine at the University of South Florida. Using a mannequin, “I’m starting to feel a lot more comfortable with this.”
Downstairs, an operating theater designed to train Army medics is equipped with sounds of explosions and whirring helicopters, 106-degree temperature, and an enlarged backdrop of a desert landscape. With a few flipped switches, the room can be transformed into an urban hospital or a natural-disaster setting.
These are just a few of the activities taking place at the University of South Florida’s Center for Advanced Medical Learning and Simulation, a $38-million, 90,000-square-foot facility that opened in March.
The sleek, three-story building sprawls over a city block in downtown Tampa and features 39 surgical stations, which offer training in robotic, computer-assisted, and image-guided surgeries, along with sophisticated equipment such as a 64-slice CT scanner that allows doctors to peer into blood vessels to detect clots.
The Tampa facility, which also includes a virtual pharmacy and an interdisciplinary research center, may be the most ambitious example of a growing trend in medical education and training. Simulation centers are springing up at more and more medical schools as pressure to reduce medical errors mounts, and as the technology becomes both cheaper and more sophisticated.
In 2006, more than 187,000 people died in the United States as a result of medical mistakes, says the National Center for Policy Analysis, a nonprofit think tank. Actuaries estimated that in 2008, the total cost of medical errors was $17.1-billion. according to a report published in the journal Health Affairs.
“All of this has created a perfect storm for simulation,” says Paul E. Phrampus, president-elect of the Society for Simulation in Healthcare. “It’s not just a toy for the kids to fool around with anymore.”
Among medical schools with major simulation centers are those at the Johns Hopkins University, the University of Miami, the University of Minnesota, Stanford University, and the Mayo Clinic. Nursing students at the University of Texas campuses at Arlington and El Paso, too, train in simulated hospitals.
Dr. Phrampus, who directs a multidisciplinary simulation center at the University of Pittsburgh’s School of Medicine, describes the Florida center as “enormous and well thought-out.” The University of South Florida calls it the largest free-standing medical-simulation center in the world.
Only a Test
Simulation exercises play an increasingly important role in training and testing surgeons, not only because of the obvious danger a slip of the knife can pose to a real, breathing patient, but also because of restrictions in the number of hours such trainees are permitted to work.
Surgery residents, who sometimes used to clock 100 or more hours a week, are now limited in most cases to an 80-hour work week (averaged over four weeks). The change was made in all medical disciplines in 2003 to cut down on deadly mistakes by sleep-deprived trainees. Some surgery-residency directors, however, complained that the shorter hours were depriving their residents of something else: hands-on practice.
Part of the reason for requiring marathon work schedules was to make sure that surgical residents encountered enough patients with specific, complex problems to practice on. With simulation, trainees can step in to a room anytime their schedules permit and practice a technique over and over until they have it down.
New doctors aren’t the only ones who stand to benefit from simulation centers, says Stephen K. Klasko, dean of the University of South Florida’s College of Medicine. As the physician work force ages, surgeons who continue to operate into their 70s and 80s might not have the fine motor skills, or mental acuity, that they had earlier in their careers.
If a pilot makes his second bumpy landing in a month, he might get a note from his airline telling him to get his technical competence tested on a flight simulator. If the test showed that he had early signs of, say, Parkinson’s disease, the airline could assess whether he was still capable of flying with appropriate medication.
But what about a doctor whose skills are becoming equally shaky? He could go on practicing for years without anyone pulling him aside and testing his skills, Dr. Klasko says.
If, instead, a physician, or a medical team, that has had a couple of bad outcomes were sent to a simulation center, he could progress through a series of exercises programmed to replicate the problematic ones. Individual or teams could practice while their technical, cognitive, and group-communication skills were being assessed. A printed report would evaluate their skills at the beginning and end of the session.
“In the past, we have trained health professionals as individuals, not as teams,” says John Armstrong, the South Florida center’s chief medical officer."If you look at medical errors, you can trace many of them back to issues of communication.”
Team Players
Communication issues are front and center on a recent afternoon, when first-year residents at the University of South Florida are acting out a series of role-playing exercises in a simulated delivery room.
Faculty members watch from behind a one-way mirror as a half-dozen residents, in blue scrubs and masks, hunch over a mannequin baby that has just been delivered by emergency Caesarean section. The baby is struggling to breathe and has started to turn blue when one of the residents delivers gentle chest compressions to its tiny chest. The doctor, obviously flustered, fumbles with the count as she continues the compressions.
Darren Adderly, a first-year resident assigned the role of team leader, steps in, stops his colleague for a moment and calmly steers her counting and compressions back on track.
Later, sitting in a circle in a classroom, the team and its professor rehashed the experience and talked about what it was like to apply what they had learned in the classroom.
“Resuscitating a newborn is pretty intense,” Dr. Adderly says, describing how he had to collect his thoughts and apply his knowledge in a high-stress environment.
More trouble awaits the next student team, whose artificial newborn has inhaled amniotic fluid and is struggling to breathe. From their control room, three faculty members glance from their monitors to the window as the team tries suctioning and then delivering chest compressions before deciding to intubate the infant. The split computer screens show close-ups of the residents, as well as monitors displaying the baby’s vital signs.
The team will need to work on finding surgical instruments faster, the evaluators say, but the young residents get praise for sending an emissary over to update the hysterical mom.
They will have a lot of time to practice their people skills, interacting with some of the 240 actors the medical school has hired part time to play the roles of patients in a variety of scenarios at the simulation center.
Out-of-Towners Welcome
Darrell G. Kirch, president of the Association of American Medical Colleges, says the Tampa center reflects the trend toward evaluating health-care professionals on the basis of the clinical skills and competencies they have acquired. “Simulation training and assessment are among the most important tools we have in the move toward competency-based training,” he says.
While almost every medical school today has some kind of simulated teaching experience, whether with robots, surgical-skills labs, or actors posing as patients, the Tampa center’s is the most ambitious he’s seen. “The technology is dazzling,” he says.
The University of South Florida put $3-million toward the center’s $38-million price tag. Most of the rest was covered by bonds and lease arrangements that will be paid for with the fees charged to other groups to use the facility.
The center is expected to be self-sustaining, with a tiered price structure for groups that train there, says its chief executive officer, Deborah Sutherland. (Nonprofit groups will pay less than industry groups.)
In addition to serving its own students, the university hopes the center will attract as many as 30,000 health professionals from around the world each year to train in advanced surgical techniques and have their skills evaluated.
The center has signed contracts to deliver continuing-education programs for groups including the American College of Obstetrics and Gynecology, the American College of Cardiology, and the American Urological Association.
The center also hopes to open its doors to residency programs from other medical schools.
“Any surgical resident will tell you about the ‘See one, do one, teach one’” model, in which residents learn by practicing on real patients, says Dr. Klasko, of South Florida’s medical school, referring to the longtime teaching model of medical education. “But why should that model exist in 2012, when there are so many tools you could use before you put a patient at risk?”
