![1
From Primitive Cultures to
Modern Day: Has Clinical
Education Really Changed?
G. Allan Shemanko 1.1 Chance-based Hunter-Gatherer Culture 3
1.2 Intended/Predictable/Deliberate Agriculture Model 4
1.2.1 Where Do We Go From Here? • 1.2.2 How Do We Get There?
1.3 Conclusion 6
1.4 Favorite Problem Solvers 7
References 7
1.1 Chance-based Hunter-Gatherer
Culture
Reviewing the roots of clinical care before looking at the future
of simulation is an integral step on the journey to learn where
we are going by looking at where we have been. Through
the process of reviewing the past, we effectively change per-
spective in navigating our path to the future. My inspiration
for this line of thinking came from a very unlikely source –
a department coffee-table book stored in my office. The His-
tory of Medicine: An Illustrated History follows the history of
medicine from ancient times of the hunter-gatherer cultures
of humankind, progressing through the ages to our present era
of technology, complex medical diagnostic, and interventional
wizardry that we call modern medicine [1]. It struck me that
medicine has not really progressed from primitive times.
In ancient times, there were four specific requirements for
any therapy to be effective: magic, ceremony, superstition,
and the patient’s belief that the therapy will work [1]. These
requirements have not changed! In a modern day, hospital
patients present themselves to a registration desk where the
ceremony begins. Paperwork, commonly followed by blood-
letting and other ceremonial rituals disguised as assessments
create the perfect environment for a truly mystical experience.
The patient is drawn further and further into the belief that
the surgery they are about to undergo will cure them. To
appease the superstition, patients will wear their “lucky slip-
pers,” remove all forms of adornment (lest they offend the
diagnostic imagers), put on the ceremonial hair cover, and
then lay on a stretcher ready for the long journey to the oper-
ating room. Here the anesthetist, appropriately garbed in the
ceremonial scrub costume replete with a colorful cap and sur-
gical mask that dangles from his neck, inserts an intravenous
catheter in order to administer his favorite secret induction
potion. The anesthetist then proceeds to administer his concoc-
tion, reassuring the patient that when they awake, they will be
cured because the surgical magic will have already happened.
The patient awakens completely ignorant of the intraopera-
tive proceedings; the postoperative surgical pain is a crude
reminder that the magic experienced in their drug-induced
slumber was indeed manifest. Now, the disease is completely
cured – truly a miracle!
Our clinical professions require hard evidence that
medicines and other interventional therapeutics work – hence
the randomized control trial ritual is known as the gold stan-
dard. Although there are indeed other methods of proving or
disproving what I refer to as the pharmacomagic benefit of any
given drug, there is still the little issue of the “placebo effect.”
Physicians attend to their loyal patients and prescribe medica-
tions to the sick. Very few patients understand why or even care
how these medications work, relying on the simple pharma-
comagic properties of the drug to make them better. Patients
dutifully consume these concoctions, fully expecting they will
work. For those people enrolled in randomized control trials,
there will be some who will respond positively even though
they were taking a placebo sugar pill. Their belief that they are
Copyright © 2008 by Elsevier Inc.
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![4 I Why Simulate?
truly receiving the experimental medication and that the drug
will cure them is so strong that their symptoms and even their
disease process will disappear. This is a perfect example of true
pharmacomagic.
Even in the education of health care providers, there is a
certain amount of ceremony involved. Ritualistic registration
proceedings followed by the massing of students in classrooms
establish the required environment for learning. Our belief that
the education system will provide us with the very best learn-
ing environment is evident. The “sage of the stage” enters in
an appropriate costume complete with lab coat and begins to
addresstheminions.Althoughweseemtohavetheenvironmen-
tal creation ceremony and individuals willing to submit them-
selves to the rituals of clinical and allied health care education,
are we providing the best learning environment that we can?
Our ancestors used to follow the migrating herds of animals
because they were dependent upon these creatures for their
food, clothing, and shelter. Indeed, they were ensuring their
very survival; however, this was not the most efficient model to
ensure the progression of a population. When humans changed
their approach to a more intentional and predictable agricul-
ture model, they certainly became more efficient. Now they
began to grow their own food, fenced in their animals, and
provided better, more permanent shelters. Without having to
spend so much of their day simply surviving, they began to
better themselves. They began to plan for the future, and so
must we. In planning for our next future, we need to move
from the hunter-gatherer model, where education happens in a
rather chaotic environment, to a more predictable, intentional
agriculture model.
1.2 Intended/Predictable/Deliberate
Agriculture Model
If we are to progress past primitive magic as a tool to learn
the practice of medicine, we need to change our ceremony in
the classroom. There are many examples of medical residents,
respiratory therapists, nurses, and other health care practition-
ers who learn at the mercy of the gods. They wait for the
rare but critical condition in a patient in order to learn. They
wait for the likely but critical events to happen. They wait for
the definite and critical. They wait to be chosen to perform
the ceremonial intubation in the operating room, assuming
they don’t have to fight for the privilege of passing an air-
way on a patient. Instead, the anesthetist believes that this
is a difficult airway and that only they should perform the
intubation. How is an anesthetic resident, nurse practitioner,
respiratory therapist, or paramedic supposed to learn difficult
airway management if they are not allowed to manage a diffi-
cult airway? A true apprentice needs to be taught, guided, and
afforded full access to the patient, for every patient is different,
thereby creating an environment of critical thinking. Lave and
Wenger [2] remark on this very subject when contemplating
the work of Becker and his concerns regarding full access for
apprentices:
He recognizes the disastrous possibilities that struc-
tural constraints in work organizations may curtail
or extinguish apprentices’ access to the full range of
activities of the job, and hence to possibilities for
learning what they need to know to master a trade.
(p. 86)
Certainly, one way of providing full access to the patient is to
provide a synthetic model. This could take the form of basic,
high-fidelity, or even virtual reality simulators now widely
available, depending on the task at hand. Technology always
expands to fill the need. We are not technology limited, but
we are ceremony limited.
We need to move away from the Guttenberg era of ever
greater amounts of noninteractive media as the panacea for
clinical education! We need to change the way students inter-
act. We need to better understand the processes of teaching
and learning in order to adapt technological tools and cur-
ricula to make sure they fit our needs and the needs of our
patients. We must ensure that that we are engaging in the
perpetual scholarship that provides for reproducible results in
all health care education programing.
How often does a pneumothorax strike a mechanically ven-
tilated patient? If this experience does not happen very often
even to those professionals working 12-hour rotating shifts,
how are these individuals going to learn to recognize the prob-
lem and provide the treatment in a timely and safe manner?
Unfortunately, this learning and teaching scenario either does
not happen or if it does, it often occurs during a crisis event,
the least likely moment to allow for the inexperienced to gain
competence. Although this form of random, situated learning
has important learning potential, “baptism by fire” cannot and
should not be our basis for clinical education [2]. We need
to plan ahead for the crisis instead of waiting for the crisis to
come to us. We need to be more predictable in what and how
we teach to health care providers in order to provide the best
care for the patient. This is the reason many of us are in the
profession of health care in the first place.
Teaching and learning should be planned and reproducible
if we are to move past the random hunter-gatherer stage of
old and move into the intended, more predictable agriculture
model of the future. In one sense, we are well on our way with
our current apprenticeship model of health care education.
However, in moving from the unique to the ubiquitous in
health care education, we need to map the impact of health
care education:
• from enrolment to engagement,
• from the classroom to the real world,
• from the text to critical thinking,](https://image.slidesharecdn.com/2204633-250603063455-99bb6472/85/Clinical-Simulation-Operations-Engineering-And-Management-Richard-R-Kyle-24-320.jpg)
![1 From Primitive Cultures to Modern Day: Has Clinical Education Really Changed? 5
• from exposure to mastery,
• from the procedure to understanding the process.
In order to make this leap, there are many educators and
practitioners who would be against change for the sake of
change. Dr W. Edwards Deming once said “In God we trust.
All others bring data.” He believed that a scientific approach,
combined with systems thinking and data analysis, will allow
us to understand how to create processes that will consistently
deliver what our students need.
1.2.1 Where Do We Go From Here?
Students need to attain familiarization through simulation
before going into a clinical rotation and treating live patients.
We can predict what and how health care providers, includ-
ing physicians, are going to learn using simulation. We can
require these learners to practice and demonstrate their skills
on simulators rather than on real patients. The feedback that
can be provided through high-fidelity simulation can be much
more comprehensive to the learner than an instructor saying
“good job.” Students can see changes in blood pressure and
oxygen saturation – this is the profound feedback that they
would receive from a real patient. Through simulation, learners
are immersed in learning rather than being bystanders. “The
effectiveness of the circulation of information among peers
suggests, to the contrary, that engaging in practice, rather than
being its object, may well be a condition for the effectiveness
of learning [2].” Students will still be afforded the opportu-
nity to be involved in the care of patients who develop the
rare but critical event during a clinical rotation. The only dif-
ference is that their learning will not be dependent upon the
development of such a scenario; it will be complimented by it.
Their simulation experiences will also prime them to gain the
maximum value from their live patient experiences.
With the population around the world aging, there may be
a shortage of all health care professionals including respiratory
therapists, nurses, physicians, and others. This could require
the delegation of authority for nonphysicians to perform cer-
tain skill sets that have traditionally fallen under the authority
of physicians and others in independent practice. Governments
are currently planning for a worldwide influenza pandemic.
It is anticipated that 15–35% of all health care practitioners
could succumb to the flu if a vaccine is not available, effectively
removing them from providing health care to the sick and
injured [3]. Cross-training of health practitioners will be part
of the contingency plan used to address the anticipated impact
on human resources. This requires planning for effective edu-
cation if these individuals are going to provide safe health care
in this environment. Simulation could certainly help fill the
training gap in teaching the practitioners these additional (new
to them) skills as our population ages or should a pandemic
scenario come to fruition. There is already talk of using den-
tists for triage in mass casualty events. A good application of
resource management indeed, but when and how are these
dentists to gain familiarity in the additional clinical and team-
work skills required? Through simulation.
1.2.2 How Do We Get There?
From the perspective of students, they are now becoming
much savvier in choosing their educational institutions! Not
only are they asking how many hours of didactic versus lab-
oratory the school will provide, they are also now beginning
to ask about simulation and whether this form of education is
provided. The policy makers need to take heed – simulation
is here. Education must dictate policy rather than the reverse.
The development of sound education policies needs to include
the best that simulation has to offer, and curricula need to
reflect developing and reinforcing the lifetime-of-learning cul-
tural needs of learners. We need to change the behavior of our
policy makers and our educators similar to the ways advertisers
change behaviors of their customers. We have the attitude and
we have simulation as the approach to implement solutions.
With the ever-increasing need to practice the critical but
infrequent scenarios such as recognizing and treating malig-
nant hyperthermia or tension pneumothorax, simulation can
be a lifesaver. There are many examples of the increasing need
to practice the likely but critical events that are likely to come
across our paths depending on where we work. For example,
providing hemodialysis will certainly put the nurse or other
health care provider in the way of critical events. These events
have been cataloged, and as such becomes a curriculum for
these health care providers. Why would we not want to pre-
pare these individuals as much as possible in order to set them
up for success in treating their patients?
Even more important than the perennially low frequency,
high-acuity events is the fact that for each clinical student, at
one time, each and every procedure, process, diagnostic deci-
sion, and treatment event is their first time – by definition the
lowest frequency event they can possibly experience. Simula-
tion can address this very real “fear factor” – not by wishing it
way, but by augmenting a curriculum that acknowledges and
respects this fundamental law of learning.
Research and product development will eventually produce
haptics (“sense of touch”) of sufficient performance at an
affordable price in order to provide yet another dimension to
the apprenticeship model of clinical education. Imagine the
surgical resident never having cut into flesh before, praying
he/she could have the experience of the surgeon. Now imag-
ine the ability of the resident to stand in the surgeon’s virtual
shoes, seeing what the surgeon is seeing, and feeling what the
surgeon is feeling through the use of virtual reality. Taking
that one step even further, imagine the surgeon now being
able to feel or sense how hard the resident is pressing on the
flesh about to be incised. By placing the resident in the same
orientation as the surgeon (please feel free to insert any clin-
ical relationship here) and using tactile feedback afforded by](https://image.slidesharecdn.com/2204633-250603063455-99bb6472/85/Clinical-Simulation-Operations-Engineering-And-Management-Richard-R-Kyle-25-320.jpg)
![6 I Why Simulate?
virtual reality tools, desired learning is occurring at a much
faster and more efficient rate than was ever before possible.
Similarly, the crisis management in anesthesiology program
can also help provide the tools necessary to care for patients.
There are similar curricula for perfusionists and heart–lung
bypass crisis diagnosis and intervention practice. Simulation
is commonplace where there is a need to practice the definite
and critical, with complex surgeries being but one example.
Simulation can also help us learn to work together bet-
ter using crisis resource management (CRM) principles with
a simulator, with standardized patients, or a combina-
tion of the two. Standardized patients can help us with
patient/physician/health care worker interaction. Perhaps the
first time a new health care professional comes in contact with
a patient should actually be a simulated event. We can learn
how to interact with patients more compassionately and com-
bine skilled interview techniques with standardized patients to
help us elucidate the problems.
Standardized patients can also help us with interprofessional
communication, cooperation, and collaboration. We have all
met and have had to deal with an individual who had less than
the best bedside or professional manner. Standardized patients
can be used to modify inappropriate behaviors so that the
student is better prepared for the outside world. Standardized
patients can be used to help teach everything from conducting
a patient interview to learning to perform a pelvic or rectal
examination. When we are dealing with such private areas
of the body, it would be prudent to have the student well
prepared in conducting these examinations. And, when the
practicing is first done on a device simulator, we can use these
standardized patients to test competencies. Clinical schooling
is difficult – why not set up our future doctors, respiratory
therapists, nurses, and other critical health care providers for
success rather than failure? If we fail to appropriately use all
of the tools that we have at our disposal, then we are guilty
of setting up students for failure. If we are truly setting our
students up for failure, then we have only succeeded in failing
ourselves, for we are all aging and will be at the mercy of those
who we have taught.
There are many people out there who may wish to be a
health care provider, but just do not have what it takes to be
one. To my knowledge, there is really no good tool out there
that is sensitive enough to predict the future clinical perfor-
mance of a student in any health profession. Why not use
simulation to develop assessment tools to predict successful
or not-so-successful outcomes? A significant portion of attri-
tion in health care-related professions can be attributable to
a change of career that “may be related to inadequate knowl-
edge of those fields or due to misconceptions regarding them
[4].” Simulation could certainly be used as part of a career
investigation. Without simulation, how does a nonhealth care
professional really know what it is like to touch a patient,
or learn what the job is like? With simulation, an interested
person could touch a “patient” and perform some therapeutic
intervention to save a life! Learning that you faint at the sight
of blood during your first suturing experience or phlebotomy
laboratory is probably not the best time. This learning example
is known as the null curriculum. Learning that you faint at
the sight of blood was not the intended goal of the suturing
experience, yet learning has still occurred. Simulation can pro-
vide the directed, predictable learning that needs to happen,
whether or not it is part of the curriculum.
1.3 Conclusion
How do we use simulation to provide the very best of clinical
education to help us provide the very best of clinical care? How
do we move from the hunter-gatherers of clinical education to
the much more intended and predictable agriculture model?
Can we keep the magic and ceremony of medicine without
affecting our need to move forward? We need to be proactive
instead of reactive. This means we need to plan ahead for crisis
instead of waiting for the crisis to come to us. We need to
ensure that our clinical apprentices, no matter the field, are
afforded complete access to and responsibility for their patients
in order to set them up for learning success. We need to look
at the data that has been already collected, and we need to
move forward.
Imagine a time where patients are not exposed to medical
residents who have to spend 36 hours on-call simply to gain
experience with what may or may not happen. Imagine a
time where all health care providers take calls in a simulated
clinical setting where directed learning can be anticipated and
patients die only when it furthers the education of our students.
Imagine a future where a resident, on their first time ever, is
given permission and the time to attend a dying patient, hold
their hand and grieve for the loss without also having to attend
to another patient. Imagine a future where health care students
are allowed to make a mistake and see the consequences of
their actions without causing injury or death to a real patient.
We no longer have to imagine this future – we can have this
right now if we make the decision. We just need to make the
decision and then follow through with action.
Learning the art of medicine does not need to be haphaz-
ard anymore. We have the tools, the magic, the ceremony,
and a patient’s belief that we can make them better. Now
we also have the tools, the magic, the ceremony, and the
learner’s belief that we can make better health care practi-
tioners. As our population ages along with the masters of our
clinical professions, I can only believe that our very survival
could become dependent upon our clinical culture moving
from the hunter-gatherer approach to education more toward
the intentional, more predictable agriculture model. For, as
the population ages, so do our masters of clinical education.
I would rather not risk the education of our future health care
providers to chance – I prefer better odds than that.](https://image.slidesharecdn.com/2204633-250603063455-99bb6472/85/Clinical-Simulation-Operations-Engineering-And-Management-Richard-R-Kyle-26-320.jpg)
![2
Undergraduate Medical
Education is NOT Rocket
Science: But that Does NOT
Mean it’s Easy!
Mark R. Adelman 2.1 The Big Picture 9
2.2 Successful Applicants Becoming Successful Graduates: Modifying Attitudes 10
2.3 Words Matter 12
2.4 Make the Verbal-Visual Link 12
2.5 The Four Questions Algorithm 12
2.6 Analysis and Diagnosis 13
2.7 Probability and Uncertainty 13
2.8 Short-term and Long-term Views 14
2.9 Test-taking Strategies and Educational Value of Tests 14
2.10 Studying Hard Versus Studying Smart 15
2.11 Broader Perspective 16
2.12 Conclusion 16
Reference 16
2.1 The Big Picture
If you want to know what this chapter is doing in this book,
ask the editors. They believe (and I agree) that simulation
includes more than just a full-sized simulator. If you want
to know why this chapter might be worth reading (or maybe
not), look at the reference, which is the only reference in what
is nevertheless a very scholarly article [1].
What follows are a series of opinions of a basic science
medical educator who has been trying to help students learn
for over 35 years. They are opinions shared by many others
who have been working at the same task. And have come to
similar conclusions. So it is a sort of status report on an ongo-
ing longitudinal study (with no control group). It is based on
extensive observations of thousands of subjects, selected read-
ings of scholarly and lay texts, and a healthy dose of common
sense. My goal is to convince you of what you already know.
To leave you with the conclusion that everything I said is (and
was) obvious, and that you already knew it before we began.
My goal is to have you forget that you even read this chapter,
and that you ever even heard of me. But also to modify the
way you approach medical education, so that you will be more
effective and will reach your “ultimate” goal with less effort
than you might have otherwise. That is the “big picture,” as
I’ve been saying to first year medical students for a long time.
It might be informative to interject here that the first
draft of this chapter was written without any idea of the
contents of the rest of the book (other than that the overall
goal of this book is to help those interested in improving
clinical education), and that I have essentially no first-hand
experience with the use of simulators (especially high-fidelity
ones) in clinical education. After completing the first draft,
I requested that the editors send me a provisional table of
contents. Having skimmed the table of contents, I asked to
see draft versions of several of the chapters in the sections
on Purposes and Philosophies of Operations, Engineering and
Management and Lessons already learned from other disciplines.
On the basis of that reading, I felt it worthwhile to insert this
Copyright © 2008 by Elsevier Inc.
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![4
Basing a Clinician’s Career on
Simulation: Development
of a Critical Care Expert into
a Clinical Simulation Expert
Lorena Beeman 4.1 New Path to Perennial Goal 31
4.2 Health Sciences Center Demographics 32
4.3 Simulation Capabilities 32
4.4 Topics of Study 37
4.4.1 Magnet Recognition • 4.4.2 The Reality
4.5 An Overview of Benner’s Novice to Expert 37
4.6 Development of a Tiered Critical Care Education Program 38
4.7 Tier One: Advanced Beginner to Competent 38
4.7.1 Cardiac Simulation Laboratory • 4.7.2 Pulmonary Simulation Laboratory •
4.7.3 Neuroscience Simulation Laboratory • 4.7.4 Multisystem Simulation Laboratory •
4.7.5 Incorporating the Family • 4.7.6 Lessons Learned • 4.7.7 Lessons Learned by the Clinical
Educators • 4.7.8 Evolving Uses for the Essentials of Critical Care Orientation Simulation Labs
4.8 Tier Two: Competent to Proficient 47
4.8.1 Lessons Learned
4.9 Tier Three: Proficient to Expert 49
4.9.1 Lessons Learned
4.10 Conclusion 50
References 50
Appendix: Tables 4A.1–4A.28 (see Companion Site)
4.1 New Path to Perennial Goal
At the University of New Mexico Health Sciences Center,
Albuquerque, New Mexico, U.S.A., our Clinical Education and
Human Simulation programs employ the philosophy of the
educational theorist Patricia Benner and her phenomenological
model of Novice to Expert [1]. The rationale for this decision
was multifold, as will be discussed.
This chapter will present how we created a critical care
nurse clinician education curriculum utilizing human simula-
tion technology for evaluation that addresses five levels of a
professional clinician’s career. Curriculum design will accom-
pany this discussion, along with lessons learned and those still
being learned. A functional overview of an education model
will be presented so that the reader can better appreciate our
curriculum design and the use of simulation for documenting
the progression of a clinician’s professional career.
Historically, in acute care hospitals, the majority of educa-
tional time is spent on introductory or core curricula that are
mandatory for the area in which the clinician will be practicing.
Traditionally, once this introductory phase is completed, edu-
cational offerings beyond this level are scarce. What offerings
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![32 II What’s In It For Me
are presented are most commonly associated with establishing
and maintaining clinician competency or current concepts in
the area of practice.
At our teaching hospital, we decided to establish and develop
educational offerings to complement this traditional, mainly
lecture-based format, focusing on initiatives to improve patient
outcomes, while at the same time providing learning oppor-
tunities for clinicians to expand their knowledge and experi-
ential base.
4.2 Health Sciences Center
Demographics
The Center is the only Level I trauma center in the state of
New Mexico, with an approximate population of 1,819,046
(U.S. Census data 2000). The Center has just over 300 staffed
beds at the present time. We have three adult critical care units,
one pediatric critical care unit, and one newborn intensive
care unit. (The adult units will be the focus of this discus-
sion as the curriculum development and use of simulation to
evaluate the clinical learner is adult-focused.) The medical-
cardiovascular critical care unit has 15 beds and employs 50
nurses (full- and part-time). The neuroscience critical care unit
has 10 beds and employs 30 nurses (full- and part-time). The
trauma-surgical critical care unit has 18 beds and employs 36
nurses (full- and part-time).
The center is in the process of constructing a new pavilion
that will house these critical care units. It is expected to be
completed in 2007, and will take each of these critical care units
to 24 beds. Obviously, the impact on staffing and educational
needs, specifically simulation training, will be dramatic.
Additionally, we have five adult subacute care units. While
all of these units have a predominant specific type of patient
population focus, all must be able to take patient overflow for
each other. One of these units focuses on the cardiovascular
patient. It has 20 beds (all with telemetry monitoring), and a
staffing goal of approximately 42 full-time nurses. The second
unit focuses on the trauma-surgical patient. It has 20 beds as
well, all with telemetry monitoring and also has a staffing goal
of 42 full-time nurses.
The other three subacute care units were originally medical-
surgical units. Owing to the high patient acuity and the con-
comitant need for telemetry beds, our hospital has gradually
brought these units to the subacute level. One of the units
focuses on renal patients. It has 20 beds, all of which are now
hardwired with monitors. It is staffed with 34 employees (full-
and part-time) at present. The fourth focuses on oncology
and clinical research inpatients. It has 16 beds, six of which
have telemetry monitoring. The unit is staffed for 25 full-time
nurses. The fifth subacute care unit is the smallest, and focuses
on neuroscience patients. It has six beds (increasing to 10)
with telemetry monitoring collectively housed as an old-style
ward, within a larger 27-bed unit. All nurses in that unit are
expected to be able to staff the subacute care unit as needed.
4.3 Simulation Capabilities
The simulation and virtual experience opportunities at our
center are referred to as the B.A.T.C.A.V.E. It is both a descrip-
tive mnemonic, a physical location, as well as a cost center.
The mnemonic stands for Basic Advanced Trauma Computer
Assisted Virtual Experience, and is cofunded by our center
and the University of New Mexico School of Medicine.
Our center has three high-fidelity patient simulators, two
adults and one pediatric. At the present time, only one of our
high-fidelity simulators is housed in a setting that has piped-
in gases (nitrogen, carbon dioxide, and oxygen) and live wall
suction (Figure 4.1). It has a control booth with a one-way
viewing window, audiovisual capability allowing for recording
(Figure 4.2), and audio/video reproduction of the room and its
events into a separate breakout room (that can hold 10 clinical
learners), or onto a large screen in the main, multipurpose
room (Figure 4.3), with space for up to 30 clinical learners.
The other two high-fidelity simulators are currently housed
in separate rooms. However, they do not have piped-in gases,
live suction, nor a control booth at this time. These simula-
tors require their own air compressors, which are quite noisy
(Figure 4.4 and 4.5). (Remodeling is expected to begin for
these rooms in the near future, and that, hopefully, will permit
the creation of control booths, piped-in gases, and live wall
suction.)
We have three mid-fidelity patient simulators that are trans-
portable. One is an adult, one is capable of simulating labor
and delivery (Figure 4.6), and one is a neonate (Figure 4.7).
We also have one mid-fidelity heart and breath sound sim-
ulator (Figure 4.8) that generates signals with the assistance
of a computer-based model, and is interactive with multi-
ple, simultaneous clinical learners. We have also recently pur-
chased a high-fidelity cardiac auscultation software package
(UMedic
) [2].
We have numerous low-fidelity mannequins that are utilized
for skill development (as with intubation technique) or as
environmental props in the setting of mid- or high-fidelity
simulations for embedded learning opportunities. In addition,
numerous partial-task simulators and their attendant clinical
devices greatly extend the range of clinical skills experienced
prior to first attempts on live patients. These devices are housed
within four breakout rooms. These rooms have the space for
up to 10 clinical learners each.
Located in separate sites, our center has several high-fidelity,
virtual reality simulators. These simulators permit the clinical
learner to develop bronchoscopy, endoscopy, colonoscopy, and
surgical suturing techniques prior to these procedures being
performed on a live patient.](https://image.slidesharecdn.com/2204633-250603063455-99bb6472/85/Clinical-Simulation-Operations-Engineering-And-Management-Richard-R-Kyle-49-320.jpg)
![4 Basing a Clinician’s Career on Simulation 37
4.4 Topics of Study
Educators and clinical learners who benefit from this technol-
ogy at our center are multidisciplinary in health care back-
ground, educational experience, and professional experience.
Currently, we provide educational opportunities to students
from the University of New Mexico Schools of Medicine, Nurs-
ing (undergraduate, graduate nursing including family and
acute care nurse practitioners), Physician Assistant, and Phar-
macy. Additionally, we provide educational opportunities to
physical therapy, paramedic, and respiratory therapy students.
Educational opportunities involving simulation are also
offered to medical residents, nurses, nurse technicians, respira-
tory therapists, pharmacists, and paramedics working within the
health care sciences center, for the purposes of establishing and
maintaining competency, and/or professional development.
4.4.1 Magnet Recognition
Adoption of a new educational philosophy was also congru-
ent with the center’s drive toward its application to the Magnet
RecognitionProgram
establishedbytheAmericanNursesCre-
dentialing Center (a subsidiary of the American Nurses Associ-
ation) [3], and concomitantly serves as an excellent recruitment
and retention tool. This is especially apropos in light of the cur-
rent professional health care personnel shortage (The Magnet
Recognition Program
is described in Table 4A.1).
4.4.2 The Reality
While all of this sounds quite appealing and laudatory in its
goals, it quickly presented the clinical educators with numerous
challenges:
• Using the Benner educational model at a practical level
for the bedside clinician.
• Clarity with the use of terminology and appropriate
definitions (e.g., Competent as a Benner level versus
competency).
• Educating the educator in relation to constructing learn-
ing objectives and validation criteria appropriate for the
identified Benner level.
• Educating the educator about evaluation roles necessary
to achieve learner outcomes (mentor, coach, evaluator).
• Appropriate selection of the level of simulation and envi-
ronmental fidelity.
The first four of these challenges are referent to the process
involved with the adoption and application of the Benner
model. The last challenge is referent to the space and fiscal
constraints of the B.A.T.C.A.V.E. Because of these constraints,
our center’s focus is on “sufficient” fidelity to achieve
the educational goals, and not “perfect” fidelity just for
its own sake.
4.5 An Overview of Benner’s Novice
to Expert
In the early 1980s, Patricia Benner described a skill acquisition
model for critical care nurses founded upon clinical experi-
ences acquired over time in conjunction with development of
critical thinking in relation to the patient and clinical setting.
She described five levels that all clinical learners are expected
to progress to over time:
• Novice
• Advanced Beginner
• Competent
• Proficient
• Clinical Expert
Distinctions between the levels are related to how the clinical
learner applies six aspects of clinical judgment and skill acquisi-
tion (Table 4A.2). How the clinical learner demonstrates these
aspects of clinical judgment and skill acquisition within a given
level are referred to as milestones (Table 4A.3) [1, 4, 5].
The first aspect is performing reasoning-in-transition. This
is the ability of the clinician to recognize and reason about
changes in the patient’s baseline physiological, psychological,
and/or emotional status and act upon it (thinking in action).
The second aspect is applying skilled know-how. Essentially,
this is the capability of knowing what to do for the patient,
and when to do it in the context of the immediate critical care
environment (situational relevancy).
The third aspect is demonstrating response-based prac-
tice. It is one thing to read about clinical manifestations of
pathophysiology or responses to medications and successfully
complete a written examination, and another to take that
knowledge and simultaneously apply it and respond to the
patient within the immediacy of the situation at hand (crisis
management).
The fourth aspect is presenting agency. This involves improv-
ing the clinician’s engagement with the patient, acceptance of
responsibility, and becoming a valued member of the health
care team.
The fifth aspect is developing perceptual acuity and skill of
involvement. In order to problem solve, the clinician must
first identify the problem by defining and framing it. This
requires perception, and perception requires engagement with
the problem, the patient, and the critical care environment.
The sixth aspect is linking ethical and clinical reasoning. Good
clinical judgments and clinical practice, and optimal patient
outcomes must be considered in relation to what the patient or
family views as such. It involves the balance between the ethi-
cal concepts of beneficence and nonmalfeasance during times
when the patient and family are most distressed and vulnerable.
Thus, as one transitions from novice to expert, the clinician
will change from a rule-based approach and concrete thinking
to the application of abstract principles and evidence-based](https://image.slidesharecdn.com/2204633-250603063455-99bb6472/85/Clinical-Simulation-Operations-Engineering-And-Management-Richard-R-Kyle-54-320.jpg)
![This ebook is for the use of anyone anywhere in the United States
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under the terms of the Project Gutenberg License included with this
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you are located before using this eBook.
Title: L'Illustration, No. 0055, 16 Mars 1844
Author: Various
Release date: October 16, 2013 [eBook #43964]
Most recently updated: October 23, 2024
Language: French
Credits: Produced by Rénald Lévesque
*** START OF THE PROJECT GUTENBERG EBOOK L'ILLUSTRATION, NO.
0055, 16 MARS 1844 ***](https://image.slidesharecdn.com/2204633-250603063455-99bb6472/85/Clinical-Simulation-Operations-Engineering-And-Management-Richard-R-Kyle-60-320.jpg)
Clinical Simulation Operations Engineering And Management Richard R Kyle
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- 5. Epigraph All the world’s a stage, And all the men and women merely players. They have their exits and their entrances; And one man in his time plays many parts William Shakespeare (1564–1616), “As You Like It,” Act 2, Scene 7.
- 6. Biographies Richard R. Kyle, Jr., BSE, MS Formally educated in fluid mechanics and physical chemistry, his lifetime fascinations with engineering, theatrical produc- tion, and biomedical investigation found the perfect storm in clinical simulation. In 1997, co-founded the Patient Simula- tion Laboratory, Uniformed Services University, Bethesda MD, with one class-one topic to teach using one clinical instructor, one CAE-Eagle patient simulator, a foot-pumped OR bed, and an empty room 15 × 20 feet. Since then, he’s ridden the waves of ever increasing simulation program and facility creation. In doing so he’s meet new friends and collaborated on expanding simulation-based learning at home and around the globe. Now he wonders how much more the fundamental characteristics of simulation (intentional, deliberate, and scheduled) can reduce harmful novelty in clinical care and clinical education, and at what scales. W. Bosseau Murray, MBChB, FFA(RCS)(Lon), MD(Anaes) (Stell) Formally educated in medicine and anesthesia, his interests include physics, statistics, mathematics, and common sense as applied in the Health Care Sciences. His aim is to learn how to better be able to teach these essential concepts using inno- vative educational modalities. Associate Director of the Sim- ulation Development and Cognitive Science Laboratory (also known as the “Simulation Lab”), Professor of Anesthesiology at Pennsylvania State University College of Medicine at the Milton S Hershey Medical Center in Hershey, Pennsylvania, U.S.A. Alice L. Acker, MPA, CHE Civilian and military health care management: a passion for start-ups, technology, and e-based learning; longtime inter- ests in acting, playwriting and moulage. Adjunct Professor of Master of Healthcare Administration. 2005, Program Manager, Institute for Surgical and Interventional Simulation (ISIS), University of Washington, Seattle, U.S.A. J. Lance Acree, BMechEng, MSEng, MSAeroEng First encountered simulation in U.S. Air Force pilot train- ing; served as instructor pilot in the Defense Department’s school for the C-130 aircraft, learned that instructing in sim- ulation is different from, more challenging and more pow- erful than instructing in “the real thing.” Pentagon budget boy; commanded the C-17 training squadron; earned Boeing 737 type rating through simulation. Senior Executive Consul- tant for Aviation Training Consulting, LLC (www.atc-hq.com). Severna Park, Maryland, U.S.A. Mark R. Adelman, PhD BA in Biology (Princeton, 1963), then realized he would prob- ably make a poor medical doctor, switched paths, earned a PhD in Biophysics (University of Chicago, 1969), and has taught undergraduate medical students and graduate students since 1971, but has never taught a course that he has for- mally taken as a student. Always educated by his failures but has still not succeeded in getting students to accept failures as learning experiences. Department of Anatomy, Physiology and Genetics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, U.S.A. Amy Guillet Agrawal, MD Areas of clinical specialization: Critical Care Medicine and Infectious Diseases. Research: Clinical trials on West Nile virus. Physician and clinical researcher in the Critical Care Medicine Department at the National Institutes of Health Clinical Center. 2004: Founder and Director of the Clinical Simulation Service at the National Institutes of Health Clinical Center, Bethesda, Maryland, U.S.A. Riva R. Akerman, MD Recently an Assistant Professor of Anesthesiology in the pedia- tric anesthesia division at the University of Miami Miller School of Medicine, Miami, Florida. Very involved in the sim- ulation program at their Center for Patient Safety. Now an Assistant Professor of Anesthesiology and associate program director of the pediatric anesthesia fellowship in the pedi- atric anesthesia division at Columbia University, New York, New York, USA. Guillaume Alinier, DUT, MPhys (Hons), PGCE, CPhys, MInstP, ILTM Formal education in Physics. Research in ultra- sound altimetry, fish deterrence systems, medical technology. Teaches “Medical Design and Technology” and “Simulation Facilitator Training.” University Teaching Fellow to the Center for the Enhancement of Learning and Teaching in 2005. Elected Secretary for the Society in Europe for Simulation Applied to Medicine, SESAM, for 2005–2006. Awarded National Teaching Fellowship from Higher Educa- tion Academy of Great Britain in 2006. Simulation Center Manager, University of Hertfordshire, U.K. John J. Anton, BA, MS, Chief Technology Officer and Vice President, Engineering, Government Systems and Education Training. Medical Edu- cation Technologies Inc. Sarasota, Florida, U.S.A. xi
- 7. xii Biographies Craig Balbalian Prehospital and tactical care training program coordinator, US Army Medical Command, Walter Reed Army Medical Center, Washington DC, U.S.A. Lorena Beeman, RN, MS, CCVT Twenty-five years as a critical care nurse; 14 years as a critical care nurse educator; Cardiovascular and pulmonary patho- physiology critical care and education. In 2001, her retired pharmacist husband became a simulation coordinator at the hospital at which she worked. Motivated to learn not just the scripting, but the setup and mechanics, and organization of the whole simulation process. University of New Mexico Health Sciences Center Clinical Education Department, Albu- querque, New Mexico, U.S.A. Thomas E. Belda, RRT, BA A decade as respiratory therapist with pediatric and neonatal patients and their families, interests in computers and tech- nology, degree in Information Technology and web-based software development. Learned concepts and technologies of high-fidelity simulation in aerospace simulation projects. Con- tributes to the big health care machine with the promise of improving patient safety and new methodologies for teach- ing and training in medical education. Network Systems Engineer – Mayo Clinic Multidisciplinary Simulation Center, Rochester, Minnesota, U.S.A. Betsy Bencken, MS Formally studied human anatomy with a focus on neuro- anatomy and gross anatomy. Twenty-five years of University experience in medical research, education and administration. 2002, Codeveloper of the Center for Virtual Care, University of California at Davis. Expanded this simulation program to encompass students of prehospital care all the way through advanced practitioners. Active in clinical instruction as well as Center management. Davis, California, U.S.A. Haim Berkenstadt, MD Graduate of the Hebrew University medical school in Jerusalem, served as a military physician at the Israeli Defense Forces Medical Corps, and trained as anesthesiologist at Sheba Medical Center, Tel Hashomer. Practices neuroanesthesia and clinical research in hemodynamic monitoring, serves on the Israeli Board of Anesthesia, and a clinical senior lecturer of anesthesiology at the Tel Aviv University Medical School. A founding member and now Deputy Director of MSR – the Israel Center for Medical Simulation, Tel Hashomer, Israel. Anthony Brand, LCH, BSc, MA, PhD, DUniv, MARH Studied Physics and first encountered simulation approaches and techniques as an undergrad in the late 1960s; later, as part of his Doctorate, this was extended using a Monte Carlo tech- nique. Currently his simulation work includes collaborating with a variety of clinical practitioners – nurses, osteopaths, homoeopaths, and pharmacists. Anglia Ruskin University, Cambridge, England, U.K. Cathleen K. Brannen, MBA Thirty years in higher education administration, including 7 years as CFO of a nursing school. Charter and current member of the HealthPartners Simulation Center Oversight Committee. Experienced consumer of health care services. Gardener, woodworker, photographer. Vice President, Finance and Administration, Metropolitan State University, St. Paul, Minnesota, U.S.A. Brian C. Brost, MD, FACOG, FACS Formal education in chemistry and medicine, appointments as various types of Medical Student, OB/Gyn Residency and Maternal Fetal Medicine Fellowship director, started develop- ing in his garage low-cost but tactilely accurate training models and simulators, work at Mayo Multidisciplinary Simulation Center, Rochester, Minnesota, U.S.A. Ronald G. Carovano, Jr., BSEE, MBA Formal education in Electrical Engineering, Management and Finance; Researcher with the Department of Anesthesiology at the University of Florida College of Medicine; Co-Inventor and U.S. Patent-holder of Human Patient Simulator (HPS™) technology developed at the University of Florida and licensed to Medical Education Technologies, Inc. (METI). Fan of the University of Florida Fightin’ Gators and U.S. National Soccer Teams. 1989, Director of Development with Medical Education Technologies, Inc., Sarasota, Florida, U.S.A. Daniel Castillo, MD Cardio-Thoracic Anesthesia and Critical Care Medicine. Medical Director for Simulation Center for Patient Safety, Department of Anesthesiology University of Miami Miller School of Medicine. Miami, Florida, U.S.A. Chris Chin, MBBS, MRCP, FRCA Consultant Anesthetist, Guy’s and St Thomas NHS Founda- tion Trust. Associate Director, Barts and the London Medical Simulator. After qualifying as a doctor, several years in inter- nal medicine and intensive care before training in Anesthesia in London, U.K. and Toronto, Canada. Subsequently specializing in Pediatric and Cardiac Anesthesia. 2001, Started instructing in the newly opened Barts and the London Simulator Center and in 2003, appointed as Associate Director. London, England, U.K. Roger E. Chow, RT Formal education in Fine Arts and in Respiratory Therapy. A lifelong hope to be a full-time artist, but I can’t be creative when I’m hungry. Started simulating in 2000, currently the Simulation Coordinator at St. Michael’s Hospital and Trauma Center, Toronto, Canada.
- 8. Biographies xiii Larry A. Cobb, RN, BSN, CEN, EMT-P Has enjoyed a varied Nursing/EMS career. From Sports– Medicine, to Neurosurgery, to Orthopedics, to Emergency Medicine – always an educator. He’s utilized a portion of his hobby, resin casting, to produce detailed “props” for train- ing/teaching purposes. Currently a Nurse Educator with the University of New Mexico Health Sciences – B.A.T.C.A.V.E. simulation lab, Albuquerque, New Mexico, U.S.A. Neil Coker, BS, EMT-P Emergency medical services education program director at Amarillo College, Texas Tech University Health Sciences Center, and Temple College. Texas State Emergency Medi- cal Services Training Coordinator. EMS program specialist for City of Dallas and Texas Department of Health. 2004, Director of Simulation Teaching, Assessment, and Research Programs, Temple College, Temple, Texas, U.S.A. Edmundo P. Cortez, MD Medical Student Clerkship Director/PICU Resident Education Director Assistant Professor of Pediatrics. Medical Director of Pediatric ICU North. Assistant Pediatric Clerkship Director, Rush Children’s Hospital, Chicago Illinois, U.S.A. Robert C. Cox, BS First encountered simulation in U.S. Air Force pilot training; served as instructor pilot and evaluator pilot in the formal school for the C-141 aircraft. Later served as director of the training systems for the C-17, C-5, C-141, and the T-1A air- craft, where he learned to reduce training costs by applying the systems approach to training and good business sense. Over 2000 hours instructing in aircraft simulators. President and CEO of Aviation Training Consulting, LLC (www.atc-hq.com), Altus, Oklahoma, U.S.A. Ian Curran, BSc, AKC, MBBS, FRCA, Pg Dip Med Ed Enduring passion for undergraduate and postgraduate clinical education, teaching faculty development, professional behav- iors, and assessment. The greatest challenge facing educators: creating effective learning. The greatest danger we face as edu- cators is being seduced by the activity of teaching! Consultant in Pain Medicine and Anesthesia, Clinical Tutor and Assoc. Director of Medical Education, St Bartholomew’s and The Royal London Hospitals, Assoc. Chair “Anesthetists as Educa- tor” Program, Royal College of Anaesthetists, United Kingdom. Director, Barts and the London Medical Simulation Center, London, England, U.K. Sharon M. Denning, MS, RN, CNA Majority of nursing career spent in critical care, with more than 20 years as nurse manager and director. Strong interest in education, patient safety, and helping staff to develop clinical expertise. Director of HealthPartners Simulation Center for Patient Safety at Metropolitan State University in St. Paul, Minnesota, U.S.A. Peter Dieckmann, PhD Psychologist, inspired by Kurt Lewin’s formula: B = fPE, with a focus on safety and simulation; became involved with simula- tion by taking part in an experiment. Now researching human error using simulators, training of simulator instructors, and incident reporting/analysis at the Center for Patient Safety and Simulation (TuPASS), Tuebingen, Germany. Harold K. Doerr, MD Bachelor of Arts in 1979 from Rutgers University; MD from University of Texas Health Science Center in 1987; Resi- dency in Anesthesiology; fellowships in Cardiac Anesthesiology and Cardiology-Ultrasound; principal investigator for Medical Operations Support Team to use patient simulation for medi- cal training in space; created Anesthesia protocol for astronauts following landing; developed a technique for intubating in zero gravity. Houston, Texas, U.S.A. Thomas J. Doyle, MSN, RN Over 25 years of experience as a registered nurse, hospi- tal administrator, and nurse educator; 4 years as Patient Simulation Program Coordinator; guides integrating patient simulation-based curriculum into clinical education programs. Medical Education Technologies, Inc. Sarasota, Florida, U.S.A. Bonnie Driggers, R.N., M.S., M.P.A. Served as Director of Clinical Teaching Systems and Programs for the OHSU School of Nursing and Co-Director of the OHSU Simulation and Clinical Learning Center. A founding member and the past chair of the Oregon Simulation Alliance, serves on the Governing Council of the Simulation Alliance. Co- authored the “Oregon Simulation Readiness Report” which presented a comprehensive look at desire and readiness for simulation education in Oregon. Served as Co-Director of the OCNE Clinical Education Model Project focused on the redesign of clinical education in nursing for the consortium. The model includes the use of simulation as one of several clinical learning activities as an adjunct to clinical experiences that support the competencies required for healthcare practi- tioners. Currently provides statewide simulation education and consults throughout the United States, Canada and overseas in the area of simulation education, program development and implementation. Professor Emeritus at the Oregon Health Science University (OHSU) Schools of Nursing and Medicine. William F. Dunn, MD 2008, President, Society for Simulation in Healthcare; Asso- ciate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Past Director of Mayo Multidisciplinary Criti- cal Care Fellowship, Mayo Clinic, Rochester, Minnesota, U.S.A.
- 9. xiv Biographies David Erez, EMT-P, MSc BSc in Sport and Exercise Science, MSc in Cardiac Reha- bilitation from University of Auckland, Diploma as Mobile Intensive Care Paramedic from Magen David Adom in Israel. Assisted establishing Divisional High Fidelity Simula- tion Education Center at Auckland University of Technol- ogy; supervised and tutored students in Bachelor in Health Science – Paramedic Program, AUT. Developed educational program for patients at the Auckland Cardiac Rehab Clinic. Instructor and course developer at Israel Center for Medical Simulation, Tel Hashomer, Israel. Mark E. A. Escott, BMBS, MPH, LP Founded an Emergency Medical Service at Rice University in Houston, Texas, and an EMS training program in Department of Human Performance and Health Sciences as an Adjunct Professor. Involved in paramedic education and simulation at Rice, further developed skills as a medical student at Flinders University (Adelaide, Australia). Aided design of simulation- based medical student curriculum in Emergency Medicine, and did research involving cricoid pressure trainers. Experience with high-tech simulators during Space Medicine Clerkship at NASA/Baylor College of Medicine, Houston, Texas where he designed scenarios for the training of astronauts/flight sur- geons for emergency situations. Currently a consultant to Rice University and a resident in Emergency Medicine, PennState- MS Hershey Medical Center, Hershey, Pennsylvania, U.S.A. Margaret Faut-Callahan, CRNA, DNSc, FAAN Initial interest in clinical simulation related to the enhanced learning opportunities for students in a nonthreatening but clinically relevant environment. She is also interested in the way we educate health professionals, increasing patient safety across many practice settings. As a founding member of our simulation faculty, the dramatic impact on our students has been rewarding. Chair, Adult Health Nursing and Director, Nurse Anesthesia Program, Rush University Medical Center, Chicago, Illinois, U.S.A. Valerie Follows, RN Registered nurse with Intensive Care diploma and experience in acute care nursing since 1975. Began in Simulation, edu- cating nurses in Canada, expanded the process with Professor Harry Owen, establishing the Simulation Unit at Flinders Uni- versity in 2001. Now lectures, plans simulations and teaching sessionsforthemedicalstudentsinFlindersUniversityGraduate Entry program; also assists other educators in using our facility. Coordinator of the Clinical Simulation Unit and Associate Lec- turer in Simulation at Flinders University, Adelaide, Australia. Michael C. Foss, MA, RDMS, RVT Formal education in Diagnostic Medical Sonography (ultra- sound), teacher education, educational administration, and leadership. Currently Dean, School of Health housing 16 health programs. Have always dabbled in electronics, photography, woodworking, and trying to make things work. Remain fasci- nated by how Walter Elias Disney could create an environment that suspended disbelief. He will do whatever it takes to help students learn how to provide high-quality health care. Inte- grates patient simulation into the health curriculum, with the expectation of improved patient care. After all, everything we do is for the patient. Springfield Technical Community College in Springfield, Massachusetts, U.S.A. Flight Lieutenant Denis B. French, RAAFSR BSN, BNursPrac(Aviation), GradDipNursing(Perioperative), RN Ex-full-time RAAF Nursing Officer with operational expe- rience in East Timor and Iraq as an OR and recovery room nurse. Now part-time ICU nurse and part-time desk officer coordinating health simulation policy, doctrine and implemen- tation across the Australian Defence Force. 2005, Staff Officer Grade 2 Health Simulation, Defence Health Services Division, Australian Defence Force. Canberra, Australia. Christopher J. Gallagher, MD Anesthesiologist who has practiced in Sweden, North Carolina, California, Florida, and New York. (He keeps getting run out of town on a rail.) Played with dolls as a young man and found this the highlight of my existence. The leap to simulators was a cinch. Simulation Center for Patient Safety, University of Miami Miller School of Medicine. Miami, Florida, U.S.A. John Gillespie, CAT Retired from USAirways as a Flight Attendant, taught as a Flight Attendant Instructor and performed Certification for the FAA, a crash site investigator for the NTSB; worked at the University of Louisville-School of Medicine, OR Anesthesia Technician at the University of Louisville Hospital; certified as a National Disaster Life Support Foundation Instructor; coor- dinated the Education and Training Department at Medical Education Technologies Inc.; now the Simulation Center Coor- dinator at the Medical College of Georgia, Augusta, Georgia, U.S.A. Ronnie J. Glavin, MB, ChB, MPhil, FRCA Became very interested in medical education during anesthetic training and embarked upon some formal training – A one year Certificate in Medical Education from the University of Glas- gow (1989), received a Master of Philosophy degree in Educa- tional Studies (1993). He saw simulation as a way of extending the possibilities of training and of studying how anesthetists really work. Clinical anesthetist in Glasgow, Scotland. Michael S. Goodrow, BS, MEng Formal education is in engineering mathematics. Used various simulation techniques to analyze weapon system effectiveness for 10 years, and used discrete event simulation to analyze industrial engineering processes for five years. 2001: Joined
- 10. Biographies xv the University to operate the Medical School’s clinical simu- lation center. Doctoral candidate in physiology. University of Louisville, Louisville Kentucky, U.S.A. Wolfgang Heinrichs, MD, PhD Professor of Anesthesiology, staff member and co-director of the department of anesthesia and intensive care at university hospital Mainz (Johannes Gutenberg University Mainz, Medi- cal School). Founder and director of the academic simulation center at Mainz from 1996. Founder and director of the private simulation center Mainz at AQAI. Special interests: Modeling pharmacology, complex models, interfaces and add-on devices to simulation. Mainz, Germany. Charles W. Hilton, MD Formal education in Endocrinology; served as Program Direc- tor in Internal Medicine; lifelong interest in trying to improve educational processes; employs active involvement in learning through immediate feedback and practice makes perfect. Asso- ciate Dean for Academic Affairs at Louisiana State Univeristy School of Medicine, New Orleans, Louisiana, U.S.A. Steven K. Howard, MD Undergraduate training at University of California, Santa Barbara in pharmacology and pursued postgraduate training in anesthesiology at Stanford after medical school. He was exposed to simulation very early in his residency and was captivated by its potential to make us better clinicians. 1989: Director, Patient Safety Center of Inquiry, VA Palo Alto Health Care System, Palo Alto, California, U.S.A. Judith C.F. Hwang, MD, MBA Studied Biomedical Sciences and English. Formal training in anesthesiology and critical care medicine. Associate Professor in Anesthesiology at University of California, Davis. Interested in fostering team work, communication, and adult learning. 2002, Faculty and Faculty Coordinator at the Center for Virtual Care, University of California, Davis Medical Center, Sacra- mento, California, U.S.A. Constance M. Jewett Johnson, MPH, BS, RN Formal education in nursing and health care administra- tion. Experienced health care administrator with experience in the full continuum of care (clinic, hospital, home care, nursing home, senior housing). Experienced in design and building clinical spaces. Knowledgeable about the real world of care delivery and the needs of providers. Director, Cen- ter for Continuing Professional Development, HealthPartners Institute for Medical Education. Charter and current mem- ber of the HealthPartners Simulation Center Oversight Com- mittee, Metropolitan State University in St. Paul, Minnesota, U.S.A. Dan Johnson, MA, PT Formal education includes BS in Physical Therapy with mas- ters and doctoral work in education. Teaching experience at the community college level with academic leadership roles as associate and acting academic dean. Currently working within a large health care system in clinical education program devel- opment related to staff development and care improvement. Served as Project Manager for development of the Health- Partners Simulation Center for Patient Safety at Metropoli- tan State University and founding member, Center Oversight Committee, Metropolitan State University in St. Paul, Min- nesota, U.S.A. Linn Jones, RRT Formal education in Respiratory Therapy. Instructor for the Respiratory Therapy program at NAIT and respiratory ther- apist at the Royal Alexandra Hospital in the Adult Intensive Care unit, professional passion is teaching in adult education. Owner and mother to two Labrador Retrievers Emmy and Ozzy. Seeking a smoother transition from the classroom to the clinical setting for our students, ease some of the pressures fit- ting students into clinical rotations. Northern Alberta Institute of Technology in Edmonton, Alberta, Canada. Alan D. Kaye, MD, PhD, DABPM Bachelors of Science degrees in biology and psychology, PhD in pharmacology, Chairman and Program Director in the Department of Anesthesiology, Professor of Pharmacology; devoted to educating medical students and residents. Louisiana State University School of Medicine, New Orleans, Louisiana, U.S.A. Lawrence E. Kass, MD, FACEP, FAAEM Vice Chair for Education and Director of Residency Training in the Department of Emergency Medicine. Penn State Hershey Medical Center, Hershey, Pennsylvania, U.S.A. Valeriy V. Kozmenko, MD Formal training in Anesthesiology, Emergency Medicine, Crit- ical Care, Normal Psychology and Abnormal Psychology. 2002, Director of the Human Patient Simulation Lab at Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A. Jane E. Kramer, MD Pediatric Residency Program Director. Director, Pediatric Emergency Medicine. Rush University Medical Center, Chicago, Illinois, U.S.A. Mary Katherine Krause, MS, CHE 15-year career in field of physician relations and medical education. Associate Vice President for Medical Affairs Admin- istration at Rush University Medical Center, Chicago, Illinois. Assistant Professor of Health Systems Management, Rush
- 11. xvi Biographies University. 2004, Administrative leadership liaison to the Rush University Simulation Laboratory. Rush University Medical Center, Chicago, Illinois, U.S.A. Derek J. LeBlanc, BA, MA 12 years of paramedic practice and EMS program design and facilitation prior to becoming in 2001 the Program Manager of the Emergency Health Services Atlantic Health Training and Simulation Center in Halifax, Nova Scotia, Canada. Howard Levine, B.Sc Formally educated at University of Michigan, developed tech- nology used for an advanced medical simulation and training program involving real time teleconferencing and remote con- trol of human patient simulators. Developing new methods in simulation-based distance medical education and platforms suitable for use in the Third World and in technologically impoverished regions of the globe. Currently Executive Vice President and Director of Operations at Digital Realm, Inc, Ann Arbor, Michigan, U.S.A. William E. Lewandowski, BA, MS Served as an U.S. Army Officer and later worked as an Instruc- tional Designer and Corporate Manager. Eighteen years of experience using, designing, and managing simulation devices and simulation centers, in the military and commercial aviation, priortomovingintoclinicalsimulationin2000.Owner,William E. Lewandowski Consulting, Daytona Beach, Florida, U.S.A. Marilyn Loen, PhD, RN Experience in a variety of nursing staff positions, teaching, and leadership in baccalaureate and graduate nursing education. Cofounder of HealthPartners Simulation Center. Professor and Executive Director of Metropolitan State University’s School of Nursing, St. Paul, Minnesota, U.S.A. Dag K. J. E. von Lubitz Combines tools and concepts from once thought to be disparate domains like simulation, telemedicine and global clinical training into new solutions to previously intractable problems. Chairman and Chief Scientist at MedSMART, Inc, Ann Arbor, Michigan and adjunct professor at HG Dow College of Health Sciences at Central Michigan University, Mt Pleasant, Michigan, U.S.A. Christina M. Matadial, MBBS, MD, Diplomate, American Board of Anesthesiology Undergraduate Education – Physics and biochemistry – Uni- versity of the West Indies, Psychology – Broward Community College, University of Miami – Jackson Memorial Hospital, Miami, Florida. Interests: amateur photography. Now with the Simulation Center for Patient Safety, University of Miami Miller School of Medicine. Miami, Florida, U.S.A. William C. McGaghie, PhD Formal education in educational and social psychology, research methods, and educational measurement; professional researcher in medical education and preventive medicine. Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A. Christopher A. McNeal, BS, EMTP Simulation Laboratory Coordinator, Rush University Simu- lation Laboratory, Rush University Medical Center, Chicago, Illinois, U.S.A. Andreas H Meier, MD, FAAP, FACS Pediatric surgeon with interest in computer technology, simu- lation and surgical education; started with simulation in 1999 while at the Center for Advanced Technology in Surgery at Stanford (CATSS) with Tom Krummel. 2002, participating faculty at the Cognitive Science and Simulation Laboratory at Penn State University, Hershey, Pennsylvania, U.S.A. Jane Lindsay Miller, MA, PhD Formal education in anthropology and education, medical anthropologist with the United Nations Development Pro- gram in maternal-child health and infectious disease, edu- cational researcher in learner outcomes and effectiveness of performance-based teaching and assessment. Endless fascina- tion with human behavior and advocate for health care reform. Minneapolis, Minnesota, U.S.A. Stefan Mönk, MD, DEAA 1992–1998, Specialist training in Anesthesia and Intensive Care Medicine; 1997, Cofounder of the Mainz Simulation Center; 1998, Coauthor of the German requirements for Simulation in Anesthesia of the German Anesthesia Society; 1998, Spe- cialist in Anesthesia and Intensive Care Medicine; 1999, Euro- pean Diploma in Anaesthesiology and Intensive Care (DEAA); 2000, Specialist for Emergency Medicine; 2000, Host of the SESAM Annual Conference in Mainz, Germany (Simulation in Europe Applied to Medicine); 2000–2006, Chief Emergency Physician of the city of Mainz, Germany; 2003, Consultant in Anesthesia at the Mainz Medical School; 2001–2003, Secre- tary of SESAM; 2003–2005, President of SESAM; 2003–2005, Program Manager for the DGAI-project; 2003, Abstract Chair, International Meeting on Medical Simulation, IMMS; 2004, Workshop Chair, International Meeting on Medical Simula- tion, IMMS; 2005, left University to become Vice President Production, Research and Development at AQAI Mainz Simu- lation center; 2005, Member of METI modeling consortium; 2005, Cohost of HPSN (Human Patient Simulator Network) Europe; 2006, Cohost of HPSN Europe. Barbara Morgan, MD 1973, graduate of Louisiana State University School of Medicine in New Orleans; 1976, completed anesthesiology
- 12. Biographies xvii residency at Baylor College of Medicine in Houston, Texas, and later Chair of Anesthesiology Departments of two hos- pitals; After Hurricane Katrina in 2005, she responded to an urgent plea for physicians and was assigned my own 30–40 bed unit within the Louisiana State University athletic facil- ity for several days until the federal government responded. Currently, an Associate Clinical Professor in Anesthesiology at LSU Medical School in New Orleans in charge of preoperative evaluation and screening of surgical patients. She assists Dr Kozmenko with his research and work in Human Simulation at LSU Medical School, New Orleans, Louisiana, U.S.A. Viren N. Naik, MD, MEd, FRCPC Graduate studies and research in health professional education and evaluation. Many years of instruction (swimming, tennis, sailing, medicine). 2002, Medical Director of the Patient Simu- lation Center, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada. Harry Owen, MBBCh (Bristol), MD, FRCA (UK), FANZCA Supervises a busy program using simulation to improve med- ical student learning of important technical and nontechnical skills used in caring for very sick and injured patients. Uses cycling for health maintenance, stress relief, and reducing car- bon emissions from transport. Trained in the U.K and moved to Australia 20 years ago. Director of the Flinders Clinical Skills and Simulation Unit and Professor of Anesthesia and Pain medicine at Flinders University, Adelaide, Australia. Alfredo Guillermo Pacheco, MD Ten years as ICU Physician, 10 years as ICU ambulance physician, 5 years as Medical Coordinator and in charge of education and training of emergency staff of Air and Land Transport of Critical Patients at the Integral Emergency Ser- vice of the Ministry of Health of the Province of Buenos Aires, Argentina. David Patterson, BSE Fourteen years in the office of medical education doing edu- cational support and every sort of simulation lab done at the school. Director, Human Simulation Center, Kirksville Col- lege of Osteopathic Medicine, A.T. Still University, Kirksville Missouri, U.S.A. Carl Patow, MD, MPH, FACS Executive Director of an educational institute in a nonprofit health system, including CME, GME, medical library, simu- lation, online learning, allied health and nursing education. Head and neck surgeon, experienced in managed care leader- ship. Cellist, sculptor, tree farmer. 2003, Cofounder, Health- Partners Simulation Center for Patient Safety at Metropolitan State University, St. Paul, Minnesota, U.S.A. Frédéric Patricelli, BSEE, MSEE At Telecom Italia’s Corporate University (SSGRR) since 1986 researching Database Technology applied to Telecommuni- cations. Invited speaker at Academy of Sciences (Moscow), Ecole Supérieure des Télécommunications (Paris) and VTT Electonics/Nokia (Helsinki). Led the International Education Business Unit at SSGRR until 2004. Founded ICTEK World- wide, an international education consulting company on ICT, and served as guest professor at university of L’Aquila, Italy. Worked at Motorola’s Satellite Communications Divi- sion (Phoenix), and currently serves as Training Manager at Mobile Telecommunications Co. (Kuwait City). Leonard Pott, MBBCh Trained as an anesthesiologist in South Africa, and currently working in the U.S.A. Been interested in simulation and assess- ment since 1992, particularly airway management and deci- sion making. Currently: Assistant Professor of Anesthesiology; Director, Advanced Airway Management; Director, Medical Student Education; Director, Educational Research; Penn State College of Medicine at the Milton S. Hershey Medical Center, Hershey, Pennsylvania, U.S.A. Ramiro Pozzo, Biomedical Engineer Formal education in: bioengineering/health and social security systems/computer programing; Experience in: maintenance of biomedical equipment in hospital critical areas (ICU, OR), magnetic resonance image processing, disaster area volunteer for United Nations, member of anesthesia equipment stan- dards commission. Integral Emergency Service of the Ministry of Health of the Province of Buenos Aires, Argentina. Carla M. Pugh, MD, PhD, FACS 2001, Assistant Professor of Surgery with a PhD in educa- tion; Inventor and U.S. Patent holder for METI’s (Medical Education Technologies, Inc.) “Touch Sensitive®” simulation technology. Broad research interests in the use of technol- ogy for medical and surgical education and assessment. 2003, Associate Director of Center for Advanced Surgical Educa- tion, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A. Commander Fabian E. Purcell, RANR, MB BS, FANZCA Graduate Monash University Medical School and Fellow Australian New Zealand College Anaesthetists. Commissioned Royal Australian Navy Reserve 1988. Currently Reserve Direct- ing Staff at the Australian Command and Staff College. Senior Instructor at St. Vincents Simulation Center, Melbourne, Australia. Marcus Rall, MD Studied medicine in Tuebingen, Cologne and Wurzburg, Germany, with rotations at Harvard Medical School
- 13. xviii Biographies (Endocrinology, Emergency Medicine (MGH) and Cardiology (BWH)) and at University of Michigan (Emergency Medicine’s St. Joseph Mercy Hospital, Ann Arbor). Firefighter and Paramedic before and during medical school. Always wondered, “why one was never told how to prevent errors, only how stupid other people are?” 1998, Translated and adapted David Gaba’s book: “Crisis Management in Anes- thesia” into German. Married with a wonderful wife and 2 kids (trying to practice CRM also at home ). Since 1994, anesthesiologist and prehospital emergency physician and clin- ical lecturer at the University of Tuebingen Medical School, Department of Anesthesiology and Intensive Care Medicine. Founder and director of the Center for Patient Safety and Simulation Tuebingen (TuPASS), Germany. Silke Reddersen, MD Anesthetist at Tuebingen University Hospital, Germany, gained experience in the operating theater as well as on intensive care unit. Came in contact with simulation in 2000 by taking part in a research project. Working as an instructor with an emphasis on mobile training and incident reporting. Center for Patient Safety and Simulation Tuebingen (TuPASS), Germany. Simon Richir, MEng, PhD His domains of education and research include technological innovation, innovative projects driving and engineering design of Virtual reality systems. Simon is scientific chair of Laval Virtual international conference. Professor at ENSAM, high French engineers school, and Director of “Presence innova- tion” research lab, France. Jill Steiner Sanko, CRNP Bachelors degrees in nursing and anthropology, Masters degree in nursing; an acute care nurse practitioner; interested in teaching critical thinking during crisis events and applying anthropology to examine the cultural differences among vari- ous health care disciplines. Clinical Center, National Institutes of Health, Rockville, Maryland, U.S.A. Diane C. Seibert, BSN, MS, PhD, CRNP Wide array of nursing experiences including: ICU, Orthopedics, ENT/Eye, Multiservice Unit, Outpatient Care, Labor Delivery, Newborn Nursery, Postpartum. Certifications as a Women’s Health NP, Adult NP, Lamaze Educator and Menopause Clinician. The “go to” person in the Graduate School of Nurs- ing for all things technology. Program Director Family Nurse Practitioner Program. USUHS, Bethesda, Maryland, U.S.A. Michael Seropian, MD, FRCPC Pediatric anesthesiologist, started with simulation in 1995 and has designed and helped implement multiple programs. He sits as a member of both the board of the Society for Simulation in Healthcare and the Oregon Simulation Alliance. He is the founder and past director of the OHSU Simulation Center. He has a background in computer programing; has always been entrepreneurial and interested in creating things that work; strong background in electronics, project management, and collaboration. Has worked a great deal with nursing and con- siders himself discipline agnostic when it comes to simulation. Oregon Health Sciences University, Portland Oregon, U.S.A. Paul N. Severin, MD, FAAP BS (Biology); Research Assistant (College of St Francis; State University New York Downstate; Illinois State Police Crime Laboratory); Laboratory research (sepsis); PALS Course Codi- rector. Rush University Medical Center and John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, U.S.A. 2003, Member, Rush University Simulation Laboratory Steering Committee and Assistant Director, Affiliated Programs. Rush University Medical Center, Chicago, Illinois, U.S.A. Ilya Shekhter, MS, MBA Studied biomedical engineering/signal processing and con- structed mathematical models of the auditory system; taught signal and system analysis to engineering students at Boston University. 1997–2004, Simulation Engineer, Rochester Center for Medical Simulation, University of Rochester Medical Cen- ter, Rochester, NY, USA. From 2004 till date, Technical Director of Medical Simulation, Center for Patient Safety, University of Miami, Jackson Memorial Hospital, Miami, FL, U.S.A. G. Allan Shemanko, MA, RRT Very diverse past including ambulance attendant, live the- ater technician, worked in a large inner-city hospital ICU and ER as a respiratory therapist, instructed in the Northern Alberta Institute of Technology Respiratory Therapy Program for 6 years, and completed a graduate degree in distributed learning. He enjoys opera and live theater, foreign travel, dogs (especially basset hounds – they help me learn patience). 2004, Assistant Manager, Respiratory Services, Royal Alexandra Hos- pital, Edmonton, Alberta, Canada. Cynthia H. Shields, MD Participated in behind-the-scene theater arts in high school and college. Physical therapy technician and EMT. Came to simulation after 9 years as a clinical anesthesiologist in 2001. Desired a more effective way to teach critical attitudes, skills, and thought processes to clinicians. Director of Anesthesi- ology Simulation, Uniformed Services University, Bethesda, Maryland, U.S.A. N. Ty Smith, MD NIH Career Development award: 1966–1971. Interests have included computers, cardiovascular physiology and pharma- cology, EEG analysis and display, closed-loop control, drug interactions, physiologic and pharmacologic mathematical
- 14. Biographies xix modeling, simulation, noninvasive monitoring, the human pharmacology of inhaled anesthetic agents, and auto- mated record keeping, including voice recognition. First microcomputer in medicine. Founded Journal of Clinical Monitoring, Society for Technology in Anesthesia (which spawned the SSH) and the ASA EMIT Committee. During this long time, managed to put together about 400 publications. Most importantly, has been blessed to work with some incredi- blybrightandcreativepeople.Hismostsatisfyingachievementis founding PACEM, the Pacific Academy of Ecclesiastical Music, a nonprofit organization whose goal is to advance and pre- serve church music. 1970: Started physiologic/pharmacologic modeling, on an analog/hybrid computer. 1985: Our first digital simulator, “Sleeper” (Sigmagraphics Iris 2300, with two parallel processors). San Diego, California, U.S.A. David H. Stern, MSEE, MD Studied Physics and Electrical and Biomedical Engineering. Background in electronics repair, video production, photogra- phy, computer programing. Clinical research in hemodynam- ics. Trained in cardiac anesthesia and echocardiography. 1994, Assoc. Prof. of Anesthesiology and Director of the U of R Cen- ter for Medical Simulation, University of Rochester Medical Center, Rochester, NY, U.S.A. Kristina Lee Stillsmoking, RN, BSN, M.ED., CNOR PeriOperative Registered Nurse, Hospital Educator, served in the Gulf and Iraqi Wars; various life experiences provide cre- ativity in managing the simulation training for a variety of specialties and mentorship of new educators in the field of simulation. Two years as Simulation Education Facilitator- GME/Nursing, Charles A. Andersen Simulation Center, Madi- gan Army Medical Center, Ft. Lewis, Washington, U.S.A. Eric Stricker, M.Sc. Studied biomedical-engineering; is working in simulation since 2004, research on different types of training with a sim- ulator, and incident reporting/analysis. Currently employed in the Center for Patient Safety and Simulation (TuPASS), Tuebingen, Germany. Claudia Sun, BSME BS in Mechanical Engineering (University of New Mexico). Studied artificial muscles, medical imaging, and medical equipment design. Worked as Vehicle Design Engineer at Ford Motor Company. 2003, Simulation Center Manager/Engineer, VA Palo Alto/Stanford Simulation Center, Palo Alto, California, U.S.A. Kay M.B. Thiemann, BS, MBA Studied business finance and communications at undergradu- ate and graduate levels. Planned and implemented the Mayo Multidisciplinary Simulation Center, Mayo Clinic. Teach ele- ments of business planning, strategic planning, and process improvement. Education Administrator, Mayo Clinic College of Medicine; Clinical Operations Administrator, Mayo Clinic, Jacksonville, Florida, U.S.A. Carol I. Vandrey, RN, BSN, MS, CCRN Degrees include Bachelor of Science in Nursing, University of Wisconsin and Master of Science, University of Maryland. Vast experience scrounging teaching materials from dumpsters and anactiveimaginationthatincorporatesfoundarticlesintoteach- ingscenariosthatreplicateactualpatientscenarioswithuncanny accuracy. Over 30 years of clinical experience in coronary, medi- cal, surgical, thoracic, and pediatric intensive care. Twenty years experience as Deputy Director of the Department of the Army’s graduate level Critical Care Nursing Course. Five years of expe- rience with the Patient Simulation Laboratory, Uniformed Ser- vices University. Director of the Advanced Cardiac Life Support Program and the Trauma Nursing Core Course programs for Walter Reed Army Medical Center, Washington DC, U.S.A. Jochen Vollmer, Dipl. Math. Formal education in maths, computer science, and physics. Main interests in education, ergonomics, and physiologic modeling. Founding member of Simulationszentrum Mainz in 1997, since 2003 manager of METI International Customer Support and 2005 Vice President Technics and Support of AQAI Simulationszentrum Mainz, Germany. Diane Bronstein Wayne, MD Director of large training program in internal medicine, research interest in medical education; Current interests: devel- oping rigorous training programs for physicians, assessment of these programs and linking their use to quality improvement on the clinical service; Board-certified internist and Program Director, Internal Medicine Residency Northwestern Univer- sity Feinberg School of Medicine. Chicago, Illinois, U.S.A. Eileen R. Wiley, BS, MS BS in Psychology and MS in Urban and Policy Sciences earned simultaneously at State University of New York at Stony Brook in 1981. 26 years of experience in all aspects of facilities plan- ning, design and construction. 21 years at academic medical centers. Last 16 years at Penn State College of Medicine at Milton S. Hershey Medical Center. Currently, Assistant Direc- tor of Facilities Planning and Construction. Main responsibil- ity is space planning and analysis, and facility planning with emphasis on educational facilities, research laboratories, offices and outpatient clinics. Paul Williamson, BEngMech(Hons) MBA Qualified in mechanical engineering in manufacturing and computer systems engineering plus an advanced MBA from Adelaide, Australia. Moved through engineering and IT project management to start-up business development and venture capital. Travel too much for amateur theater these days, but
- 15. xx Biographies it was a good influence along with paramedic experience and pitching to venture capitalists – you see more blood in venture capital. Currently building and commercializing simulators and courseware under the master of engineering at Flinders University, Adelaide, Australia. Jörg Zieger, MD Started clinical anesthesiology in 1995 (University Hospital Tuebingen/Germany), instructor in simulation courses, special interest in mobile simulation, working in simulation since 2001 in Tuebingen Center for Patient Safety and Simulation (TUPASS, Marcus Rall), Tuebingen, Germany. Amitai Ziv, MD, MHA, A veteran combat pilot and instructor in the Israeli Air Force; trained as a Pediatrician in Israel (Hebrew University – Hadassah Medical Center) with subspecialties in Adolescent Medicine (University of Pennsylvania, USA) and in Medical Management, and a Masters degree (Tel-Aviv University) in Health Administration; on the editorial board of the Journal of the Society for Simulation in Healthcare and chair of the Cre- dentialing, Accreditation, Technology, and Standards (CATS) Committee; a clinical senior lecturer at the Department of Behavioral Sciences of the Tel Aviv University Medical School, and Adjunct Associate Professor of Pediatrics at Case Western Reserve University. Responsible for Risk Management, Quality Assurance and Medical Education; founder and Director of MSR – the Israel Center for Medical Simulation and Deputy Director of the Sheba Medical Center at Tel Hashomer, Israel. Glossary of Degrees and Awards AKC Associateship of King’s College BA Bachelor of Arts BEngMech Bachelor of Mechanical Engineering BMBS Bachelor of Medicine, Bachelor of Surgery (Medical Doctor, Australia) BMechEng Bachelor of Mechanical Engineering BNursPrac (Aviation) Bachelor of Nursing Practice (Aviation) BS Bachelor Surgery BS Bachelor of Science BSc Bachelor of Science BSE Bachelor of Science, Education BSE Bachelor of Science, Engineering BSN Bachelor of Science, Nursing BSEE Bachelor of Science, Electrical Engineering BSME Bachelor of Science, Mechanical Engineering CAT Certified Anesthesia Technologist CCRN Critical Care Registered Nurse CCVT Certified Cardiovascular Technologist CEN Certified Emergency Nurse ChB “Chirurgiae Baccalaureus” Bachelor of Surgery CHE Certified Healthcare Executive CNA Certified Nurse Anesthetist CNOR Certified PeriOperative Nurse CPhys Chartered Physicist CRNA Certified Registered Nurse Anesthetist CRNP Certified Registered Nurse Practitioner DABPM Diplomate, American Board of Pain Medicine DEAA European Diploma in Anaesthesiology and Intensive Care Dipl. Math. Diplomate, Mathematics DNSc Doctor of Nursing Science DUniv Doctor of the University DUT University Technical Diploma EMT-P Emergency Medical Technician-Paramedic FAAEM Fellow of the American Academy of Emergency Medicine FAAN Fellow of American Academy of Nursing FAAP Fellow of American Academy of Pediatrics FACEP Fellow of American College of Emergency Physicians FACOG Fellow of American College of Obstetricians and Gynecologists FACS Fellow of American College of Surgeons FANZCA Fellow of Australian New Zealand College Anaesthetists FCA(SA) Fellow of the College of Anesthesiologists (South Africa) FFA(RCS)(Lon) Fellow of the Faculty of Anaesthetists, Royal College of Surgeons (London) FLTLT Flight Lieutenant FRCA Fellow of Royal College of Anaesthetists FRCPC Fellow of Royal College of Physicians of Canada GradDipNursing (Perioperative) Graduate Diploma of Nursing (Perioperative) ILTM Member, Institute of Learning and Teaching (UK Higher Education Academy) LCH Licentiate of the College of Homeopathy LP Licensed Paramedic MA Master of Arts MARH Member of the Association of Registered Homeopaths
- 16. Biographies xxi MB Bachelor of Medicine MBA Master of Business Administration MBBCh Bachelor of Medicine/Bachelor of Surgery MBBS Bachelor of Medicine and Bachelor Surgery (Doctor of Medicine, UK) MBChB Bachelor of Medicine/Bachelor of Surgery MD Doctor of Medicine MD(Anaes)(Stell) Doctor of Medicine, Anaesthesia Stellenbosch MD(Sc) Doctor of Medicine, Science MEd Master of Education MEng Master of Engineering MInstP Member of the Institute of Physics MPA Master of Public Administration MPH Master of Public Health MPhil Master of Philosophy MPhys Master of Physics MRCP Member, Royal College of Physicians MS Master of Science MSEE Master of Science in Electrical Engineering MSEng Master of Science, Engineering MSAeroEng Master of Science, Aerospace Engineering MSN Master of Science in Nursing PGCE Postgraduate Certificate in Education Pg Dip Med Ed Postgraduate Diploma in Medical Education PhD Doctor of Philosophy PPS Plenipotentiary for Patient Simulation PT Physical Therapist RAAFSR Royal Australian Air Force Specialist Reserve RANR Royal Australian Naval Reserve RDMS Registered Diagnostic Medical Sonographer RN Registered Nurse RRT Registered Respiratory Therapist RT Respiratory Therapist RVT Registered Vascular Technologist
- 17. Foreword This monograph “Clinical Simulation: Operations, Engineering and Management” by Richard Kyle and Bosseau Murray fills a rapidly growing need as the science of sim- ulation achieves acceptance by the health care field as an important medical educational tool. This acceptance has been very slow to come, especially considering that aviation and other industries have used simulation for over 50 years. And looking at the history of medical education, it is clear that such an opportunity, in fact a revolution, only occurs once every century or so – our last great medical education revolution was with the Flexner Report in 1910. Whatever will be developed during the coming decade may well be the foundation until the 22nd century. Just as important is the timeliness of the book. The Res- idency Review Committee of the Accreditation Council on Graduate Medical Education has begun requiring residency programs to have simulation as an integral part of their train- ing programs. The American College of Surgeons (ACS) has also recognized this transformation, and has taken the bold step to certify training centers to ensure the quality of the training that will be provided – other societies and credential- ing bodies are sure to follow. A natural by-product of this will be that curricula will become more standardized, the measures of success more uniform, and the overall quality of education will take a giant step forward. Most important is the fact that students can be trained in a safe environment – an environ- ment in which they have “permission to fail” and in which they will be taught via errors, how to recognize them and to avoid or repair them. And all this without jeopardy to a patient. It has also been recognized, and repeatedly emphasized in these chapters, that this will require that the training be both multispecialty and interprofessional, including not only all spe- cialties of physicians and medical students, but also nurses and other allied health professionals. The ACS application for certification requires that at least three different categories of students be taught by the simulation center. Deans of med- ical schools and nursing schools are under pressure; now is the time when all levels of medical education are searching for advice on how to establish their own simulation centers, and many of the answers have been succinctly provided by the contributing authors. Rather than an academic dissertation on the changes in the educational process and the subsequent impact on the training of students, the authors have chosen a practical approach and address critical issues that lead to successful implementation of simulation into a training program and propose pragmatic solutions to transitioning to clinical utilization. Certainly, the theory and philosophy of education are touched upon, but mainly to illustrate a practical point or provide a theoretical basis or provide an underlying structure. The practical focus is critical, and the authors have identified the salient features that epitomize the value added by simulation: the importance of objective assessment using a benchmark performance criterion, and then training students to the criterion rather than continue to use the traditional time-based training. The setting of metrics to be achieved and the reporting of outcomes that are fed back to the student, form a critical tool for both the educator and students – emphasizing the value of the debriefing. However, some of the most valuable information will be that which addresses the day-to-day decisions needed to establish and then maintain a busy simulation center. With resources scarce and expensive, the experience of the contributors is invaluable in sorting through the numerous options in facility design, curricula development, simulator purchasing, schedul- ing, etc. The treatment of these important issues is compre- hensive and illuminating. The chapters are laced with vignettes and lessons learned to help those charged with starting a new simulation center. Just as simulation provides an opportunity to make mistakes on a simulator before operating on a patient, so too does this book let the reader learn the many mistakes before striking out on their own endeavors. The authors are to be commended for recognizing a critical need and then provid- ing such an eminently practical solution for all levels of readers. Richard Satava, MD 2007 xxii
- 18. How to use this book “Experience is a hard teacher because she gives the test first, the lesson afterwards.” Vernon Sanders This book consists of 82 chapters from 99 contributors, arranged in 22 topics on the What and the How of clinical simulation. Integrated throughout these works are messages on the Why. These topics are arranged in an order that we like to use in all our teachings: starting at the widest view then zooming inward for examination of numerous fine details. These details are like the stones of a structure: useful to the extent that they link with their neighbors, valuable in how each contributes the overall purpose of the structure. For any topic, we encourage you to first read through all of it looking for the larger perspective, and then return for a closer examination of the finer details. For those topics with more than one chapter, each chapter approaches the common theme from a different vantage point. Thus, one chapter may address issues left unre- solved for you by the other chapters, or may present it in a way that is more accessible to you than by the others. On purpose, our topic introductions are framed as our half of a dialog with you; what we might say in conversation about the value a given topic contributes to a successful clinical simulation program. We assumed that questions and curiosity would be your motivation to open this book, and thus, like any good instructor, we attempted to anticipate your primary question: “what will I gain from investing my time and atten- tion upon this topic?” To the extent that these introductions do not mislead you, we were successful in anticipating your needs. To the extent that the authors’ contents enlighten you, they were successful in their efforts to communicate the lessons they learned from their experiences. To the extent that you employ their lessons or that they catalyze your own inven- tiveness, all of us will have reached our goal of helping you become better at helping others become better clinicians. Note that the book chapters’ content are printed and bound, while the chapters’ appendices are provided via a web site created and hosted by Elsevier, and accessed through this one common URL: www.books.elsevier.com/9780123725318/ companions Even though the Appendices are only on the web site, we believe that this structure of the book will help you, the reader, rapidly find the Why, the What, and How of clinical simulation needed to enhance the learning of your trainees. xxiii
- 19. Introduction “How many things are looked upon as quite impossible until they have been actually effected?” Pliney the Elder While the words “simulation” and “simulators” may be new for many of us in clinical education, they are not new phe- nomena in our own personal history of learning, in the history of clinical education, in the history of human learning. At the smallest individual scale, from birth each of us used simulation as a way to master speech, walking, and attaining individual autonomy. One could argue that each of us used simulation in imagining what our lives would be like after we graduated from the schools we applied to, that we and the admissions inter- viewers used simulation to estimate how compatible we might be. At the largest social scale, from inception all societies used simulation to convey its beliefs to attain group consistency. All culturalization processes engage in active audience partic- ipation. All use role models of desired outcomes. All include punishments and rewards for failure and successes. All employ repetition. All consist of many small ingestible bits of new- ness that once digested, become incorporated into amazing capabilities. All require a person dedicated to helping others become better. You, the clinical educator, are that person for your clinical students. You are reading this book to become a better clinical teacher to help your students become better clinicians to help their patients become better. Your goal is to become so proficient with simulation that your students can’t see your effort – only the results. This invisibility is the acme of the professional. In a word, you appear a “magician”. Consider this book to be a “how to” guide in your efforts to become a better magician. Clinical simulation is pretend for the purpose of improving behaviors for someone else’s benefit. Clinical simulation is not fakery, not a con game where the purpose is to fool others for one’s own benefit. Clinical simulation is clinical theatrics with full contact audience participation. Today, entire schools and their libraries are devoted to teaching the arts and crafts of live theater. Courses address writing, dialog, acting, music, props, sound effects, lighting, costumes, stage design, theater construction, finances, patronage, publicity, location, person- nel and personalities. The essence that makes theatrical story telling universally accessible to the audience and infinitely mal- leable in their forms is the very same used in successful clinical simulation. All theatrical productions require competent pro- ducers, directors, actors, writers, prop masters, personnel and facility managers. You, in your effort to become a competent simulation professional, must become knowledgeable with all, and expert in many of these trades. Those of us staging clinical simulations face the same issues and challenges perennial to all live performances: present a compelling event for the audience to fully engage in, while displaying adaptability given the unpredictable. Since all clin- ical simulations include under-scripted students at the center of the action, the risks and uncertainties to the outcomes are greater than in any other form of live production. Yet, this reality echoes all clinical care, where under-scripted patients are the center of the action. As educators, our task is done when the only source of novelty that our students face is their next patient, not their environment, not their equipment, not their own knowledge, skills, or attitudes Technology can be defined as “the way we do things” more than just “with what we do”. Technologies, like electric lights and amplified sounds, have reduced many of the limitations to theatrical production. Such technologies are used to make accessibility easier for the audience to experience staged events. The better stage professionals understand that some new tech- nologies can be used to improve their theatrical presentations. The best stage professionals have mastered the use of any technology for the purpose of pulling their audiences’ con- sciousness out of their seats and fully engage them in the action on the stage. Yet, technological advances have done little to change the purpose of most theater or the value of the stories told to most audiences. Usually, if the audience is captivated by the production technology employed, let alone even notices it at all, then the intended story-telling purpose of the theatrical event has been lost. Clinical simulation has recently employed new technolo- gies like robotics and physio-pharmacological computational models. Such technologies are used to make it easier for the student to experience staged clinical events. The better clin- ical instructors thoughtfully use only those technologies that improve their teachings. The best clinical instructors have mas- tered the use of any technology for the purpose of making their students’ fully engaged in clinical care. Yet, technological advances have done nothing to change the purpose of clini- cal education or the value of it to students. Always, if clinical students are distracted by the technology employed in their simulated clinical learning experience, then the educational purpose of the class is lost. A note about manufactured simulators. These are the most recent kind of simulators to join human actors, human cadav- ers and non-human animals employed by clinical educators. The most distinct feature of manufactured simulators, and also their most significant added value, is their greater predictabil- ity. To the extent that the market place offers features you desire, you can select just what you need at the time of placing your order. As your needs mature, so will the commercial xxiv
- 20. Introduction xxv offerings. No cadaver, animal or human actor can offer such feature specificity combined with boundless reproducibility and ease of access. However, such extraordinary capability brings extraordinary expectations. Users all too easily come to expect engineering and marketing miracles from the makers and vendors. The payers all too easily come to demand validation and documentation of performance (like we have learned to expect when buying an automobile) unlike they have ever demanded of non-manufactured clinical simulators. This tension pulls both ways. For the first time ever, we all can legitimately challenge ourselves with two fundamental questions: “just what is valid clinical education?” and “how can we craft and provide valid clinical education?” This book is an attempt to help you create answers to these what and how questions. Let’s imagine that we are already on the mountaintop, which is the best vantage point from which to consider paths to get there. Clinical education is behavior modification: chang- ing knowledge, skills and attitudes. Books, libraries and other repositories of vetted information provide access to facts and figures. Laboratories, with and without the presence of real patients, provide practice opportunities to gain functional apti- tude. Instructor qualities such as honesty and respect provide context within which content is ingested and integrated. Classical clinical education management structure is based upon individualism. Individuals in isolation are accepted indi- vidually into a clinical education program. They form a crowd of individuals, each individually rewarded and punished in iso- lation from one another. The reward and punishment reinforce the role of external motivation, to the detriment of internal motivation. Upon completion, each of the graduates indepen- dently joins the next crowd. But clinical care is a team sport: the team is often seen as consisting of just two members, a clinician and a patient. Yet like an iceberg, most of the other members are much less visible but play equally critical roles in achieving success. Patients seek clinical care for their own benefit, not for that of the clinicians. Success, from the patients’ point of view, is mostly within themselves, the patient. Herein lies the rub: if clinicians actually function as mem- bers of a team with the team goal of satisfying the needs of the patient, then how can we expect such a result from any educational process based upon individuals, each receiving iso- lated reinforcement for self-promotion? If the motivations are all external, how will we ever see clinicians who are inter- nally motivated to perform beyond the currently acceptable minimum? In other words, the current education process rein- forces attitudes (“individualism”) diametrically opposed to the desired end product (“teams”). Back to behavior modification. Training systems, both familiar and emerging, employ simulation to train attitudes as well as skills. Simulation is a tool, and like all tools, produces results no better than the ability and intent of its wielder. Sim- ulation, by its very nature a schedulable event, provides clinical educators a unique tool: an obstacle course/treasure hunt as well matched to the students’ needs as the educator can make it, and provided at a time and location far more driven by a deliberate curriculum than real patients can ever be. To date, most clinical simulation has been employed within the classical education model, including when the goals of the teachers and students directly address teamwork. Yet, even in this application, almost all of the students’ rewards and punishments are individualized. Using this new tool in such an old way is not an inherent limitation of the tool itself. Simulation can build and reinforce the team-centric atti- tudes and behaviors that correlate directly with the desired end performance. It can also reinforce the internal motiva- tion mechanisms in the clinician. Simulation has, can, and will, provide utility within the classical clinical education model. It just may be the lever to shift the world of clinical education. While reading one single book cannot substitute for a life- time of learning, our goal is to bring together pragmatic descriptions of the broad range of topics essential to success in many forms of clinical simulation. We chose these topics based upon what we learned from our experiences in creat- ing clinical simulations. We chose these topics’ authors based upon their ability to convey their learning experiences. We requested that the authors address perennial issues, challenges and concepts, and only reference today’s products as illustra- tions. For example, recording and replaying sights and sounds of clinical simulation sessions will always be a key contributor, yet the audio and video tools and technologies available have never been in such a flux as we are currently experiencing. Thus, the challenge to the authors was in crafting lessons in which the fundamental principles are elucidated in ways that are both universal and specific enough to be accessible and usable for a broad audience. Throughout the book you will happen upon terms like “better”, “improvement” and “successful”. The repetition is intentional. We have no delusions that of us knows the per- fect solutions to all clinical education issues as well as ways to perfectly convey these solutions to you. Yet, each and every suggestion offered here is based upon lessons learned by others in their real life as clinical educators in using simulation to help them be better at their task. To the extent that the experiences of others can teach the teachable, we offer them here. Richard R. Kyle Jr., and W. Bosseau Murray
- 21. I Why Simulate? 1 From Primitive Cultures to Modern Day: Has Clinical Education Really Changed? G. Allan Shemanko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 Undergraduate Medical Education is NOT Rocket Science: But that Does NOT Mean it’s Easy! Mark R. Adelman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 3 Guidance for the Leader-Manager Robert C. Cox and J. Lance Acree . . . . . . . . . . . . . . . . . . . 19 It isn’t that they can’t see the solution. It is that they can’t see the problem. G. K. Chesterton J ust as the lessons learned from any clinical simulation experience do not exist in isolation, neither does the use of simulation within clinical education. In fact, the greater that simulation is absorbed into the very fabric of clinical curricula, the more successful it will have become. These three chapters are distinct, wide-angle perspectives providing big-picture context for understanding where and how this tool we call simulation can contribute to your students’ learning. Each in their own way share the premise that clinical care is information application, thus clinical education should prepare future clinicians to be very competent information appliers. Also, each shares the premise that clinical care is always a collaborative event, thus clinical education should prepare future clinicians to be very competent collaborators. If you agree with these two premises, then you may also agree that the current execution of clinical education should be changed to improve the performance of our future clinicians. For any one person at any one time, changing oneself into a clinician is a significant challenge; yet, changing today’s ways in which we provide clinical education may seem far more challenging given the far greater number of participants, each with their own vested interests. However, in both cases, the only way the desired change is possible is through deliberate, intentional practice. Simulation as a teaching method has a rich and successful history as a tool to safely practice change and explore the consequences of change. Participants in activities like aviation and nuclear power turned themselves into high-reliability organizations through simulation. In doing so, they made many of the pioneering developments in simulation-based learning. No one today would ever accuse clinical care or clinical education as being prime examples of high reliability. However, if we want to make it so, many of the principles, if not also the tools already developed and refined by nonclinicians, are well suited for adoption by clinicians. Thus, you can apply well-founded simulation approaches not only to help your clinical students attain your current educational goals, but also to evaluate your teaching methods, as well as investigate alternatives to the very goals and methods themselves. Allan Shemanko describes today’s traditions-based clinical education as in the preagricultural age, best characterized for a time when day-to-day survival depended upon whatever could be found or caught. While massive effort could and did overcome this unpredictability and allowed our ancestors’ survival in small tribes, the uncertainty was still too large to allow the development and expansion of civilization and all its rich benefits. Mark Adelman describes the transformation that we intend to generate in our 1
- 22. 2 I Why Simulate? clinical students during their brief exposure in our schools and to us. All clinical simulation programs will succeed or fail to the extent that they help or hinder this change. Robert Cox and Lance Acree describe how simulation contributed to the transformation of a comparable high risk/low reliability enterprise into a high risk/high reliability one. They show which parts of this transformative activity are common with clinical care, which learning methods are suitable for transplantation, and which wheels we don’t need to reinvent.
- 23. 1 From Primitive Cultures to Modern Day: Has Clinical Education Really Changed? G. Allan Shemanko 1.1 Chance-based Hunter-Gatherer Culture 3 1.2 Intended/Predictable/Deliberate Agriculture Model 4 1.2.1 Where Do We Go From Here? • 1.2.2 How Do We Get There? 1.3 Conclusion 6 1.4 Favorite Problem Solvers 7 References 7 1.1 Chance-based Hunter-Gatherer Culture Reviewing the roots of clinical care before looking at the future of simulation is an integral step on the journey to learn where we are going by looking at where we have been. Through the process of reviewing the past, we effectively change per- spective in navigating our path to the future. My inspiration for this line of thinking came from a very unlikely source – a department coffee-table book stored in my office. The His- tory of Medicine: An Illustrated History follows the history of medicine from ancient times of the hunter-gatherer cultures of humankind, progressing through the ages to our present era of technology, complex medical diagnostic, and interventional wizardry that we call modern medicine [1]. It struck me that medicine has not really progressed from primitive times. In ancient times, there were four specific requirements for any therapy to be effective: magic, ceremony, superstition, and the patient’s belief that the therapy will work [1]. These requirements have not changed! In a modern day, hospital patients present themselves to a registration desk where the ceremony begins. Paperwork, commonly followed by blood- letting and other ceremonial rituals disguised as assessments create the perfect environment for a truly mystical experience. The patient is drawn further and further into the belief that the surgery they are about to undergo will cure them. To appease the superstition, patients will wear their “lucky slip- pers,” remove all forms of adornment (lest they offend the diagnostic imagers), put on the ceremonial hair cover, and then lay on a stretcher ready for the long journey to the oper- ating room. Here the anesthetist, appropriately garbed in the ceremonial scrub costume replete with a colorful cap and sur- gical mask that dangles from his neck, inserts an intravenous catheter in order to administer his favorite secret induction potion. The anesthetist then proceeds to administer his concoc- tion, reassuring the patient that when they awake, they will be cured because the surgical magic will have already happened. The patient awakens completely ignorant of the intraopera- tive proceedings; the postoperative surgical pain is a crude reminder that the magic experienced in their drug-induced slumber was indeed manifest. Now, the disease is completely cured – truly a miracle! Our clinical professions require hard evidence that medicines and other interventional therapeutics work – hence the randomized control trial ritual is known as the gold stan- dard. Although there are indeed other methods of proving or disproving what I refer to as the pharmacomagic benefit of any given drug, there is still the little issue of the “placebo effect.” Physicians attend to their loyal patients and prescribe medica- tions to the sick. Very few patients understand why or even care how these medications work, relying on the simple pharma- comagic properties of the drug to make them better. Patients dutifully consume these concoctions, fully expecting they will work. For those people enrolled in randomized control trials, there will be some who will respond positively even though they were taking a placebo sugar pill. Their belief that they are Copyright © 2008 by Elsevier Inc. All rights of reproduction in any form reserved 3
- 24. 4 I Why Simulate? truly receiving the experimental medication and that the drug will cure them is so strong that their symptoms and even their disease process will disappear. This is a perfect example of true pharmacomagic. Even in the education of health care providers, there is a certain amount of ceremony involved. Ritualistic registration proceedings followed by the massing of students in classrooms establish the required environment for learning. Our belief that the education system will provide us with the very best learn- ing environment is evident. The “sage of the stage” enters in an appropriate costume complete with lab coat and begins to addresstheminions.Althoughweseemtohavetheenvironmen- tal creation ceremony and individuals willing to submit them- selves to the rituals of clinical and allied health care education, are we providing the best learning environment that we can? Our ancestors used to follow the migrating herds of animals because they were dependent upon these creatures for their food, clothing, and shelter. Indeed, they were ensuring their very survival; however, this was not the most efficient model to ensure the progression of a population. When humans changed their approach to a more intentional and predictable agricul- ture model, they certainly became more efficient. Now they began to grow their own food, fenced in their animals, and provided better, more permanent shelters. Without having to spend so much of their day simply surviving, they began to better themselves. They began to plan for the future, and so must we. In planning for our next future, we need to move from the hunter-gatherer model, where education happens in a rather chaotic environment, to a more predictable, intentional agriculture model. 1.2 Intended/Predictable/Deliberate Agriculture Model If we are to progress past primitive magic as a tool to learn the practice of medicine, we need to change our ceremony in the classroom. There are many examples of medical residents, respiratory therapists, nurses, and other health care practition- ers who learn at the mercy of the gods. They wait for the rare but critical condition in a patient in order to learn. They wait for the likely but critical events to happen. They wait for the definite and critical. They wait to be chosen to perform the ceremonial intubation in the operating room, assuming they don’t have to fight for the privilege of passing an air- way on a patient. Instead, the anesthetist believes that this is a difficult airway and that only they should perform the intubation. How is an anesthetic resident, nurse practitioner, respiratory therapist, or paramedic supposed to learn difficult airway management if they are not allowed to manage a diffi- cult airway? A true apprentice needs to be taught, guided, and afforded full access to the patient, for every patient is different, thereby creating an environment of critical thinking. Lave and Wenger [2] remark on this very subject when contemplating the work of Becker and his concerns regarding full access for apprentices: He recognizes the disastrous possibilities that struc- tural constraints in work organizations may curtail or extinguish apprentices’ access to the full range of activities of the job, and hence to possibilities for learning what they need to know to master a trade. (p. 86) Certainly, one way of providing full access to the patient is to provide a synthetic model. This could take the form of basic, high-fidelity, or even virtual reality simulators now widely available, depending on the task at hand. Technology always expands to fill the need. We are not technology limited, but we are ceremony limited. We need to move away from the Guttenberg era of ever greater amounts of noninteractive media as the panacea for clinical education! We need to change the way students inter- act. We need to better understand the processes of teaching and learning in order to adapt technological tools and cur- ricula to make sure they fit our needs and the needs of our patients. We must ensure that that we are engaging in the perpetual scholarship that provides for reproducible results in all health care education programing. How often does a pneumothorax strike a mechanically ven- tilated patient? If this experience does not happen very often even to those professionals working 12-hour rotating shifts, how are these individuals going to learn to recognize the prob- lem and provide the treatment in a timely and safe manner? Unfortunately, this learning and teaching scenario either does not happen or if it does, it often occurs during a crisis event, the least likely moment to allow for the inexperienced to gain competence. Although this form of random, situated learning has important learning potential, “baptism by fire” cannot and should not be our basis for clinical education [2]. We need to plan ahead for the crisis instead of waiting for the crisis to come to us. We need to be more predictable in what and how we teach to health care providers in order to provide the best care for the patient. This is the reason many of us are in the profession of health care in the first place. Teaching and learning should be planned and reproducible if we are to move past the random hunter-gatherer stage of old and move into the intended, more predictable agriculture model of the future. In one sense, we are well on our way with our current apprenticeship model of health care education. However, in moving from the unique to the ubiquitous in health care education, we need to map the impact of health care education: • from enrolment to engagement, • from the classroom to the real world, • from the text to critical thinking,
- 25. 1 From Primitive Cultures to Modern Day: Has Clinical Education Really Changed? 5 • from exposure to mastery, • from the procedure to understanding the process. In order to make this leap, there are many educators and practitioners who would be against change for the sake of change. Dr W. Edwards Deming once said “In God we trust. All others bring data.” He believed that a scientific approach, combined with systems thinking and data analysis, will allow us to understand how to create processes that will consistently deliver what our students need. 1.2.1 Where Do We Go From Here? Students need to attain familiarization through simulation before going into a clinical rotation and treating live patients. We can predict what and how health care providers, includ- ing physicians, are going to learn using simulation. We can require these learners to practice and demonstrate their skills on simulators rather than on real patients. The feedback that can be provided through high-fidelity simulation can be much more comprehensive to the learner than an instructor saying “good job.” Students can see changes in blood pressure and oxygen saturation – this is the profound feedback that they would receive from a real patient. Through simulation, learners are immersed in learning rather than being bystanders. “The effectiveness of the circulation of information among peers suggests, to the contrary, that engaging in practice, rather than being its object, may well be a condition for the effectiveness of learning [2].” Students will still be afforded the opportu- nity to be involved in the care of patients who develop the rare but critical event during a clinical rotation. The only dif- ference is that their learning will not be dependent upon the development of such a scenario; it will be complimented by it. Their simulation experiences will also prime them to gain the maximum value from their live patient experiences. With the population around the world aging, there may be a shortage of all health care professionals including respiratory therapists, nurses, physicians, and others. This could require the delegation of authority for nonphysicians to perform cer- tain skill sets that have traditionally fallen under the authority of physicians and others in independent practice. Governments are currently planning for a worldwide influenza pandemic. It is anticipated that 15–35% of all health care practitioners could succumb to the flu if a vaccine is not available, effectively removing them from providing health care to the sick and injured [3]. Cross-training of health practitioners will be part of the contingency plan used to address the anticipated impact on human resources. This requires planning for effective edu- cation if these individuals are going to provide safe health care in this environment. Simulation could certainly help fill the training gap in teaching the practitioners these additional (new to them) skills as our population ages or should a pandemic scenario come to fruition. There is already talk of using den- tists for triage in mass casualty events. A good application of resource management indeed, but when and how are these dentists to gain familiarity in the additional clinical and team- work skills required? Through simulation. 1.2.2 How Do We Get There? From the perspective of students, they are now becoming much savvier in choosing their educational institutions! Not only are they asking how many hours of didactic versus lab- oratory the school will provide, they are also now beginning to ask about simulation and whether this form of education is provided. The policy makers need to take heed – simulation is here. Education must dictate policy rather than the reverse. The development of sound education policies needs to include the best that simulation has to offer, and curricula need to reflect developing and reinforcing the lifetime-of-learning cul- tural needs of learners. We need to change the behavior of our policy makers and our educators similar to the ways advertisers change behaviors of their customers. We have the attitude and we have simulation as the approach to implement solutions. With the ever-increasing need to practice the critical but infrequent scenarios such as recognizing and treating malig- nant hyperthermia or tension pneumothorax, simulation can be a lifesaver. There are many examples of the increasing need to practice the likely but critical events that are likely to come across our paths depending on where we work. For example, providing hemodialysis will certainly put the nurse or other health care provider in the way of critical events. These events have been cataloged, and as such becomes a curriculum for these health care providers. Why would we not want to pre- pare these individuals as much as possible in order to set them up for success in treating their patients? Even more important than the perennially low frequency, high-acuity events is the fact that for each clinical student, at one time, each and every procedure, process, diagnostic deci- sion, and treatment event is their first time – by definition the lowest frequency event they can possibly experience. Simula- tion can address this very real “fear factor” – not by wishing it way, but by augmenting a curriculum that acknowledges and respects this fundamental law of learning. Research and product development will eventually produce haptics (“sense of touch”) of sufficient performance at an affordable price in order to provide yet another dimension to the apprenticeship model of clinical education. Imagine the surgical resident never having cut into flesh before, praying he/she could have the experience of the surgeon. Now imag- ine the ability of the resident to stand in the surgeon’s virtual shoes, seeing what the surgeon is seeing, and feeling what the surgeon is feeling through the use of virtual reality. Taking that one step even further, imagine the surgeon now being able to feel or sense how hard the resident is pressing on the flesh about to be incised. By placing the resident in the same orientation as the surgeon (please feel free to insert any clin- ical relationship here) and using tactile feedback afforded by
- 26. 6 I Why Simulate? virtual reality tools, desired learning is occurring at a much faster and more efficient rate than was ever before possible. Similarly, the crisis management in anesthesiology program can also help provide the tools necessary to care for patients. There are similar curricula for perfusionists and heart–lung bypass crisis diagnosis and intervention practice. Simulation is commonplace where there is a need to practice the definite and critical, with complex surgeries being but one example. Simulation can also help us learn to work together bet- ter using crisis resource management (CRM) principles with a simulator, with standardized patients, or a combina- tion of the two. Standardized patients can help us with patient/physician/health care worker interaction. Perhaps the first time a new health care professional comes in contact with a patient should actually be a simulated event. We can learn how to interact with patients more compassionately and com- bine skilled interview techniques with standardized patients to help us elucidate the problems. Standardized patients can also help us with interprofessional communication, cooperation, and collaboration. We have all met and have had to deal with an individual who had less than the best bedside or professional manner. Standardized patients can be used to modify inappropriate behaviors so that the student is better prepared for the outside world. Standardized patients can be used to help teach everything from conducting a patient interview to learning to perform a pelvic or rectal examination. When we are dealing with such private areas of the body, it would be prudent to have the student well prepared in conducting these examinations. And, when the practicing is first done on a device simulator, we can use these standardized patients to test competencies. Clinical schooling is difficult – why not set up our future doctors, respiratory therapists, nurses, and other critical health care providers for success rather than failure? If we fail to appropriately use all of the tools that we have at our disposal, then we are guilty of setting up students for failure. If we are truly setting our students up for failure, then we have only succeeded in failing ourselves, for we are all aging and will be at the mercy of those who we have taught. There are many people out there who may wish to be a health care provider, but just do not have what it takes to be one. To my knowledge, there is really no good tool out there that is sensitive enough to predict the future clinical perfor- mance of a student in any health profession. Why not use simulation to develop assessment tools to predict successful or not-so-successful outcomes? A significant portion of attri- tion in health care-related professions can be attributable to a change of career that “may be related to inadequate knowl- edge of those fields or due to misconceptions regarding them [4].” Simulation could certainly be used as part of a career investigation. Without simulation, how does a nonhealth care professional really know what it is like to touch a patient, or learn what the job is like? With simulation, an interested person could touch a “patient” and perform some therapeutic intervention to save a life! Learning that you faint at the sight of blood during your first suturing experience or phlebotomy laboratory is probably not the best time. This learning example is known as the null curriculum. Learning that you faint at the sight of blood was not the intended goal of the suturing experience, yet learning has still occurred. Simulation can pro- vide the directed, predictable learning that needs to happen, whether or not it is part of the curriculum. 1.3 Conclusion How do we use simulation to provide the very best of clinical education to help us provide the very best of clinical care? How do we move from the hunter-gatherers of clinical education to the much more intended and predictable agriculture model? Can we keep the magic and ceremony of medicine without affecting our need to move forward? We need to be proactive instead of reactive. This means we need to plan ahead for crisis instead of waiting for the crisis to come to us. We need to ensure that our clinical apprentices, no matter the field, are afforded complete access to and responsibility for their patients in order to set them up for learning success. We need to look at the data that has been already collected, and we need to move forward. Imagine a time where patients are not exposed to medical residents who have to spend 36 hours on-call simply to gain experience with what may or may not happen. Imagine a time where all health care providers take calls in a simulated clinical setting where directed learning can be anticipated and patients die only when it furthers the education of our students. Imagine a future where a resident, on their first time ever, is given permission and the time to attend a dying patient, hold their hand and grieve for the loss without also having to attend to another patient. Imagine a future where health care students are allowed to make a mistake and see the consequences of their actions without causing injury or death to a real patient. We no longer have to imagine this future – we can have this right now if we make the decision. We just need to make the decision and then follow through with action. Learning the art of medicine does not need to be haphaz- ard anymore. We have the tools, the magic, the ceremony, and a patient’s belief that we can make them better. Now we also have the tools, the magic, the ceremony, and the learner’s belief that we can make better health care practi- tioners. As our population ages along with the masters of our clinical professions, I can only believe that our very survival could become dependent upon our clinical culture moving from the hunter-gatherer approach to education more toward the intentional, more predictable agriculture model. For, as the population ages, so do our masters of clinical education. I would rather not risk the education of our future health care providers to chance – I prefer better odds than that.
- 27. 1 From Primitive Cultures to Modern Day: Has Clinical Education Really Changed? 7 1.4 Favorite Problem Solvers 1. The Society for Simulation in Healthcare (http:// www.ssih.org/), specifically the listserv and the “Ask the Wizards” section has provided us with several key work- arounds that have helped make our simulation experi- ences more realistic. 2. Association for Standardized Patient Educators (http:// www.aspeducators.org/) helped us to identify how stan- dardized patients could help enhance our program and student success. 3. Loyd, G. E., Lake, C. L., and Greenberg, R. Practical Health Care Simulations. Elsevier, Philadelphia, 2004. This book provided us with several answers to questions related to planning and setting up our simulation centre – a good all-round reference book suitable for all sizes of simula- tion centres. 4. Monsters, Inc. (movie). The initial 3 minutes of this movie is a simulation that provided us with a great exam- ple of how NOT to conduct a debriefing session! 5. The Institute for Medical Simulation’s “Comprehenisve Workshop in Medical Simulation.” This intensive workshop helped me to understand the importance of embracing qualities of emotional intelligence while learning and practicing a variety of debriefing techniques for my facilitation “toolbox.” 6. Bates, A. W., and Poole, G. Effective Teaching with Technology in Higher Education: Foundations for Success. Jossey-Bass, San Francisco, 2003. From this book we learned the best way to successfully incorporate new tech- nology into the workplace. References 1. Lyons, A. S. and Petrucelli, R. J. Medicine: An Illustrated History. Abradale Press, New York, 1987. 2. Lave, J. and Wenger, E. Situated Learning: Legitimate Periph- eral Participation. Cambridge University Press, New York, 2002. 3. Government of Alberta. Alberta’s Plan for Pandemic Influenza. Retrieved March 20, 2006, from http://www. health.gov.ab.ca/influenza/Pandemic_plan.pdf, 2003. 4. Douce, F. H. and Coates, M. A. Attrition in respiratory therapy education: Causes and relationship to admissions criteria. Respiratory Care 29(8), 823–828 (1984).
- 28. 2 Undergraduate Medical Education is NOT Rocket Science: But that Does NOT Mean it’s Easy! Mark R. Adelman 2.1 The Big Picture 9 2.2 Successful Applicants Becoming Successful Graduates: Modifying Attitudes 10 2.3 Words Matter 12 2.4 Make the Verbal-Visual Link 12 2.5 The Four Questions Algorithm 12 2.6 Analysis and Diagnosis 13 2.7 Probability and Uncertainty 13 2.8 Short-term and Long-term Views 14 2.9 Test-taking Strategies and Educational Value of Tests 14 2.10 Studying Hard Versus Studying Smart 15 2.11 Broader Perspective 16 2.12 Conclusion 16 Reference 16 2.1 The Big Picture If you want to know what this chapter is doing in this book, ask the editors. They believe (and I agree) that simulation includes more than just a full-sized simulator. If you want to know why this chapter might be worth reading (or maybe not), look at the reference, which is the only reference in what is nevertheless a very scholarly article [1]. What follows are a series of opinions of a basic science medical educator who has been trying to help students learn for over 35 years. They are opinions shared by many others who have been working at the same task. And have come to similar conclusions. So it is a sort of status report on an ongo- ing longitudinal study (with no control group). It is based on extensive observations of thousands of subjects, selected read- ings of scholarly and lay texts, and a healthy dose of common sense. My goal is to convince you of what you already know. To leave you with the conclusion that everything I said is (and was) obvious, and that you already knew it before we began. My goal is to have you forget that you even read this chapter, and that you ever even heard of me. But also to modify the way you approach medical education, so that you will be more effective and will reach your “ultimate” goal with less effort than you might have otherwise. That is the “big picture,” as I’ve been saying to first year medical students for a long time. It might be informative to interject here that the first draft of this chapter was written without any idea of the contents of the rest of the book (other than that the overall goal of this book is to help those interested in improving clinical education), and that I have essentially no first-hand experience with the use of simulators (especially high-fidelity ones) in clinical education. After completing the first draft, I requested that the editors send me a provisional table of contents. Having skimmed the table of contents, I asked to see draft versions of several of the chapters in the sections on Purposes and Philosophies of Operations, Engineering and Management and Lessons already learned from other disciplines. On the basis of that reading, I felt it worthwhile to insert this Copyright © 2008 by Elsevier Inc. All rights of reproduction in any form reserved 9
- 29. 10 I Why Simulate? very brief paragraph, to call attention to two points that are woven through my chapter, which – except for this insertion – is otherwise largely unchanged from the draft version. First, it is my assertion that undergraduate medical students – at least in their early years – are not the sort of “adult learners” who are prepared to derive maximal benefit from high-quality simulation centers. Secondly, it is our job as educators to help our students to transition from those comfortable with “other- directed” to those now performing “self-directed” learning, and we should be doing so using a variety of techniques, including a continuum of “simulation experiences.” It would be wonderful if I could proceed with a prioritized list of key “things” or “concepts” or “teaching tips.” But you wouldn’t buy it any more than the “typical” first year medical student. We all know there is no “free lunch,” just as we all know there is no such thing as a typical medical student. Those are two big picture items and both belong on any short list of key items. But what would be the first? Always step back so you can get a better view of the big picture, because the answer is very rarely in the details, and because the answer can almost never be understood in terms of details unless the big picture is kept in mind. Obvious, right? Most people who do not teach first year medical students cannot understand how difficult it is to get first year medical students to recognize, let alone use that obvious principle. Another obvious fact is that medical school is not conceptu- ally difficult, it’s just that there is so much to learn. While that fact is largely true, it is also largely irrelevant to the challenge facing undergraduate medical educators. Especially those of us who meet the first year medical students as they enter the front door, but also those who treat them in their clinical rota- tions. Because much of what follows is from the perspective of a “basic science educator,” rather than the perspective of a “clinical science educator,” I think it is extremely important to state the obvious: education is a continuum. We all start with the student who comes in the front door and we must have respect for (but realistic expectations and evaluations of) what is/is not achieved by those educators who precede us and those who follow us. As an educator of first year medical stu- dents, I frequently work clinical correlations into my teaching. And occasionally, I invite clinicians to give such correlations. I am usually struck by how much more skillfully clinicians can do such a presentation. And how often clinicians do not remember what they knew, as first year medical students, at that particular point in the process. A student in May (near the end of their first year) is very different than the same one in September (near the beginning of their first year). Obvious, right? All of it is obvious, but we must keep it constantly in mind as we work our craft. As a pathologist colleague (who teaches second year medical students) and I worked together on gaps in the curriculum, we rediscovered that when second year medical students report that they were not taught anything about macrophages, this does not necessarily mean that the histologists who taught the students as “first years” neglected to cover the topic. And the fact that a surgeon can teach much (maybe even all) of gross anatomy does not necessarily mean that the surgeon has the skills (or desire) to help first year medical students take the necessary steps toward becoming a self-directed learner. We all have a job to do; we are all part of the process. It is perhaps worth noting at this point that while the use of complex simulations has been most common in the clinical years of undergraduate medical education, there is growing awareness of the value of simulators in the preclinical arena. I would argue that it is vitally important for all of us to stress the value of simulations of varying kinds in the continuum of medical education. We need to make students aware that much of what they learn is in the framework of an environment that is not the reality of everyday medical practice and that learn- ing in a simulated environment is the norm (rather than the exception), ranging from looking at histology slides (very far removed from reality), to virtual microscopy, to demonstrat- ing complex physiological processes as computer models, to practicing complex diagnostic and surgical techniques on ever- more-realistic simulation devices. Knowing very little about the most current (and complex) simulation devices, I would presume to include them in a continuum of tools that allow us to help our students learn in a relatively safe way, how tricky (yet fascinating) it is to deal with a “real” patient, how easy it is to make mistakes, how necessary and useful it is to make such mistakes (and to learn from them), and how gradual the spec- trum is from simulation to reality, both in terms of devices and in terms of practices. I look forward to the day when first year medical students not only enjoy learning from an amazingly realistic patient simulator but also intuitively understand the value of actively learning by simulating reality and challenging themselves: by pretesting themselves, not simply to maximize the chance of passing an examination but to reduce the num- ber of mistakes that they will inevitably make as they practice medicine on the living. 2.2 Successful Applicants Becoming Successful Graduates: Modifying Attitudes First year medical students are developing medical profession- als. Essentially, all of them matriculate at medical school as very successful young adults and nearly all of them will graduate from medical school as even more successful young physicians, ready for still more development. However, they are a rather heterogeneous group of learners when they enter and they travel diverse paths as they proceed. We all know that there are multiple modes of learning; actually, when we say this, most of us are thinking of multiple modes of acquiring knowl- edge. Remember the old trilogy: KSA = Knowledge, Skills, and Attitudes? Over the years, I have come to understand that
- 30. 2 Undergraduate Medical Education is NOT Rocket Science: But that Does NOT Mean it’s Easy! 11 our students arrive with lots of knowledge (and the ability to assimilate much more), numerous skills (and they develop many more), but a number of attitudes that are not optimal for the kind of self-directed learning that we expect life-long learners to have – or to acquire. That is not surprising, given that they are among the most successful graduates of primary, secondary, and postsecondary education systems which are based upon “other-directed” rewards and punishments. That last statement about attitudes could well be the basis for an entirely separate chapter, but I want to expand it briefly here, so as to provide context for the specific comments that follow, regarding most (but not necessarily all) entering medical students. Because of the ways in which our society views education (mostly as some sort of commodity), and the processes by which the students who enter medical school have been taught and tested, we matriculate some very capable students who – for the most part – have some deficits for which neither they nor we are responsible. But these are deficits of which we must be aware and must help them work to overcome. The most immediate challenge is to get students to recognize that although they have been very successful, i.e., have passed a lot of tests, passing tests is a very small part of what they must do as successful medical students, and as successful clinicians. And that the most important tests will be administered long after they graduate – by their patients. We need to convince them that they can multitask (they’ve been doing it for many years) and that time management and having confidence in their own ability to make “educated guesses” are neither new skills nor ones that they are likely to perfect any time soon. That grades in courses matter, but only a little, and that their patients (for the most part) will not care how much they know, only how well they use what they know. That no one has “the truth” hidden in some secret Personal Digital Assistant (PDA) (or whatever technological wonder is currently threatening to replace textbooks). And so on. All obvious, but all concepts and principles that we must keep in mind as we work with the medical students who enter our schools and proceed through the process. First year medical students are not – with rare exceptions – “adult” (i.e., self-directed) learners. If we who work with them do our job correctly, those who teach our students later in the process will be teaching students who are closer to being adult learners; but the process is surprisingly slow and variable. Like a meandering stream that almost always gets to the ocean, even- tually. Consider the following facts about first year medical stu- dents, but please do not regard these as criticisms. I have a very high regard for the vast majority of the students with whom I interact. They are hardworking, intelligent, decent people who have an intense desire to become very good doctors – and for very noble reasons. Please consider all of what follows as schol- arly critique, rather than petulant criticism. My comments are meant to apply to most students. I guesstimate that some 10– 20% figure all of this out for themselves, so long as we do not “mess them up.” About 10% do not get it during the first year; I can only hope that things improve later on. Hence I’m talking about let’s say 70% of the entering first year medical students. 1. Very few of them have thought about how they think and learn. Call it meta-cognition if you wish; it is a for- eign concept. Can one be a successful self-directed learner without engaging in some meta-cognition? Possibly (per- haps even probably), but that will make the overall task much less efficient. 2. Because they have been so successful, and because most are not used to analyzing how they think (never had to), they are ill-prepared to deal with the new challenges of medical school. They are not inclined to accept the free- dom (and its flip side, responsibility) of being in charge of their own education. Nor are they inclined to try different strategies; why change what has always worked? Nor do they regard the faculty as people who are there to help them (not even those of us who really are there to help!). 3. A surprisingly large number not only do not seek out our help (except immediately before an examination, or after a series of disastrous examination results), they also seem to reject the notion that we want to, and can, help them. Faculty are often regarded as “the enemy”: people who write trick questions, focus on obscure and irrelevant details, and/or are so involved in research that they regard students as an annoyance. It seems to take many students an exceedingly long time to sort out those faculty who fit one or more of the above categories from those who do not. Even when those faculty who do not fit any of the above undesirable categories try repeatedly to make their availability (to help) quite clear, they are still “not accepted” by some first year medical students. 4. While most students recognize the value of reasoning by analogy, very few actually use analogies in their pro- fessional lives (as developing doctors). And when they “finally” seek help from professional educators, such stu- dents are usually astounded at what they can learn about their learning styles by thinking in terms of analogies to everyday life. 5. Once they make the decision to take control of the learn- ing process, most are very quick to recognize how they have been making things harder for themselves and how easy it is to fix things. But what is even more revealing is the number of students who, in those quiet moments when educator and student can relate as human beings, will freely (often with a wry grin or a self-deprecating remark) acknowledge that what they are doing doesn’t really make sense, and that they would give the same advice (that the educator has been giving) to a friend or to their own children. So the most important challenge, in dealing with first year medical students (and this probably applies to all would-be clinicians in all their student years – to varying degrees), is the
- 31. 12 I Why Simulate? challenge of modifying a number of attitudes. And doing so in a manner that leads the student to appropriate the altered attitude as the logical, reasonable, and obvious one to apply if the student is to make the journey with minimal stress and maximal effectiveness. The task is not a simple one. The goal is not easily reached. But most medical students “get it” and they must get it on their own (with our help) so that they own it. And, as they begin to own it, a number of specific points can be made. I have listed a number of points in what follows, but they are not listed in any priority order, for a number of reasons. Not all students absorb these points in the same way and in the same sequence. Each real learning encounter with each student is in essence a new teaching session and cannot be taught using PowerPoint or any other technological tool (although such tools may prove useful). And many of the points seem so simple (because they are), that students may reject them because they know there is no such thing as “free lunch” and must develop – for themselves – such concepts as “what is hard work,” “what is big picture and what is detail,” or “what is an important fact to me.” 2.3 Words Matter It is not surprising that so many students find it difficult to deal with all the “jargon” of medical school. They are the prod- ucts of an educational process that does not value precision in language and does not understand the relationship between precise use of words and true understanding of concepts. Our students are the product of a social process that fills the public discourse with “y’ know,” regards proper grammar as anti- quated (or is it antique?), insists that correct spelling is the responsibility of the computer, and operates on the principle that even the most nuanced argument must be presented in a 30-second sound bite. Very few know any foreign language and many function as though their native language (especially if it is English) is a foreign language. So we cannot be surprised that, in addition to not knowing Greek or Latin, they do not see the value of being informed that the stem “reticul” is used in so many words: reticular fiber, reticular cell, endoplasmic reticulum, and so on; and that knowing this simple stem makes it much easier to keep track of so many seemingly mysterious words and terms. They know that words are used to transmit information, know that certain words are condensations of entire sentences, know that acronyms are abbreviations that are immensely useful (but must be used in the appropriate context), but bristle at having to learn a bunch of new words, not to mention being expected to spell them correctly and use them in complete sentences! I routinely tell our students that the medical dictionary they are issued when classes begin is an immensely valuable book. They often look at me as though I was speaking a foreign language. They all know how to “google” something, yet rarely do so when the something is a word that is a stumbling block to their understanding of such a trivial distinction as the difference between an intralobular duct and an interlobular one, and do not seem to believe me when I repeat for the Nth time that the terms are just used to convey a sense of where the duct is found. Much of my work with individual students involves helping them understand, by using examples and making analogies, how often the proper use of a particular word has big-picture implications on how and what they learn. 2.4 Make the Verbal-Visual Link One of the notions we try to stress in our teaching of Histology and Cell Biology is the need to “make the verbal-visual link.” Students are aware of the old saying about a picture being worth a thousand words. And they understand, almost imme- diately that “if you can’t picture it, you don’t understand it,” but most have very little practice in converting words to pic- tures or in extracting words from pictures. It takes some time to convince them that this is a valuable skill; one that they need to develop not just to pass our tests (and those in pathology, radiology, etc.) but also in order to “read charts,” make a first level diagnosis from a physical exam, etc. What is even more challenging is the task of getting them to commit to practic- ing “making the verbal-visual link” as much as is needed to develop the skill of doing it rapidly, effectively, and usefully. As a concrete example, many students balk at “wasting time” looking at glass microscope slides, trying to find “stuff” that an instructor could show them in just a few seconds. Many of us have put lots of wonderful images on websites and are invest- ing tremendous resources in developing “virtual microscopy” so that students do not have to spend too much time with old-fashioned microscopes and loan slide sets. It is absolutely true that most of them will rarely (if ever) use a microscope after they have left medical school. But the skill of observing and converting the observations to words that can transmit information to others is such a vital skill for any physician, that we must convince the students of the value of the attitude that this skill must be developed, even if it isn’t easy, takes a lot of time, and – in the context of a first year Histology course – seems very far from relevant to medical practice. It may be useful to explain an algorithm (one of many) I often trot out in helping students (who have finally sought help) use the microscope as a learning tool. The algorithm (call it four questions) is based on the premise that most students do not understand that the best way to learn and prepare for a test is to test oneself (and/or one’s peers) repeatedly. 2.5 The Four Questions Algorithm The “four questions” algorithm goes something like this: Place any loan slide on the stage of your microscope. Make sure that
- 32. 2 Undergraduate Medical Education is NOT Rocket Science: But that Does NOT Mean it’s Easy! 13 light is going through the specimen, and that the specimen is in focus with either the 10× objective or the 40× objective. Then switch objectives (to/from 10 or 40), and without looking in the oculars, move the stage slightly, but not so far that the specimen is no longer in the light path. Then look in the oculars and, with reference to the pointer (or crosshairs or reticule – all our loan microscopes have one), ask yourself the following questions: 1. What is at the tip of the pointer? 2. What does it do? 3. How does it do that? 4. So what? (that is, what is the significance of its normal function?) Obviously, the use of this algorithm requires some questions and answers (such as an explanation of my assertion that all students have a built-in “my answer is bull-shit” meter). It is in fact the framework for a lot of discussion and education, both by the educator and by the self-directed learner. And this leads into the next “item.” 2.6 Analysis and Diagnosis All first year medical students know that they will be mak- ing diagnoses as part of their professional career. Some even understand the notion of a differential diagnosis. But very few recognize that any diagnosis is, in essence, an analysis leading to an “educated guess.” (See following section on probability and uncertainty.) Even fewer have had much practice analyz- ing the implications of observations – for example, looking at a picture, describing the elements present, making a tentative conclusion as to what the facts imply, and acting on that edu- cated guess. We spend a lot of time explaining to our students that we test them with practical exams (at the microscope), for multiple purposes, including the desire to determine if they have developed the knowledge of what an organ looks like in the microscope (and how that relates to the function(s) of the organ), the skill of observing the visual manifestation of the structure and converting the information to a verbal equivalent, and the attitude of a professional who understands that solving many different puzzles is the only way to develop the ability to solve new puzzles. Medical students are – as I’ve said – quite intelligent and industrious, but it is often a hard sell on that last point. They seem to think – as do many computer junkies – that skilled diagnosis can be reduced to a list of choices and a simple algorithm, both of which can be rapidly learned and voila! We all know that “gifted” diag- nosticians get there by working hard and thinking about what they are doing. Pattern recognition (whether it is of histology slides or clinical scenarios) is developed over time and is best applied by someone who understands when certain patterns are truly diagnostic and when they must be used cautiously in a complex process of differential diagnosis and feedback evaluation of the analysis. 2.7 Probability and Uncertainty Perhaps the most difficult attitudinal issue for first year med- ical students is the notion that so many things in medicine are not certain and that so many decisions must be based on probabilities. It is my perception that students arrive hav- ing learned about probabilities as a mathematical subject, but have not actually recognized how much it plays a role in their everyday lives. And the part of their everyday lives that has been centered on education has not provided them with the attitude that dealing with probabilities is the reality. Instead, most arrive firmly convinced that medicine is a set of true facts that, if applied, will lead to success. Of course they recognize the reality that medicine frequently fails, but there seems to be a fundamental disconnect between what they understand as the reality in one context (life) and the reality they expect in their education as physicians. Here I am not claiming to know what the average student thinks; I doubt that anyone really knows what anyone else thinks. I am simply observing how they behave when confronted with uncertainty: they are unwilling to accept and deal with it. Students behave as though the faculty member who does not give them a simple yes/no answer must be deliberately hiding some essential fact from them. And this attitude is extremely difficult to modify. Every colleague with whom I have spoken about this tells me essen- tially the same story. Student X asks for an identification of a particular cell. The educator tries to help the student figure it out, using various elements of verbal-visual linkage, analysis, etc. And brings the student to the point of accepting that the cell is, e.g., a fibroblast. Or rather is probably a fibroblast. But could be a macrophage. But, given the available information and the probabilities, it is most likely a fibroblast. The observed reality is that the “average” student is extremely unsatisfied. How will they be sure that, on the examination, they will be able to identify the cell at the pointer? The truthful answer is that they cannot be certain; but they can increase the prob- ability of reaching the most likely choice if they practice the analytical approach we are trying to teach. The educator must be prepared to go through the process a very large number of times, repeatedly pointing out to the student that they rou- tinely make probabilistic decisions in everyday life and are usually right, but – in those cases where they are wrong – they deal with the consequences and move on to the next decision. Again, in those rare moments when student and educator talk as equals – caring human beings – the students understand and admit that their behavior (demanding certainty) is unrealistic and does not make sense. But modifying attitudes ingrained by the educational system that helped them gain admission to medical school is neither easy, nor rapidly achieved.
- 33. 14 I Why Simulate? 2.8 Short-term and Long-term Views Students have become so used to studying for one exam, because that exam is crucial, that they have not developed the attitude of constantly thinking about the long-term goals of building knowledge, skills, and attitudes that they will use as practicing physicians. It requires considerable effort to get them to stop studying just for the test. Equally difficult is the task of getting them to appropriate the reality that some skills are learned in stages, only the last of which is the desired level of skill, but that all the stages must be not only mastered but also retained. Repeated examples (clinical scenarios, experi- ences with simulations, analogies from everyday life, likely test questions from a second-year course exam – or the United States Medical Licensing Examination) must be presented and employed not to show them how much they do not know, but rather how what they have learned (or are learning) has relevance to all the upcoming hurdles. They understand this “intellectually,” but find it very difficult to modify the behav- iors that got them to medical school. If there is one single thing I could do to improve the education our students receive before they walk in the front door of our medical schools, it would be to stop the obsessive focus on testing and the resultant delivery of the message that passing specific-staged tests is the single most important thing students must do to become educated!! 2.9 Test-taking Strategies and Educational Value of Tests First year medical students bring with them an astonishing number of learned test-taking strategies, many of which don’t help them do well on our examinations, or – more impor- tantly – are not useful strategies for the daily tests that are presented in the practice of medicine. Many of the strate- gies “work” in the context of “standard” exams. For example, knowing (i) that the longest answer is probably wrong (or right) or (ii) that words like “never” and “always” are red-flags. Such facts may be useful in the game of test-taking, but are not very useful in the game of practicing medicine. Perhaps most astonishing to me (and others) is the number of students who do not understand the value of going over an examination after it is done (whether they did well or poorly) so as to learn from the examination. Mentioning the notion that doctors do in fact learn from mistakes resonates with many students, but they do not seem to see the obvious implications for how to analyze their mistakes so as to learn from them. A few examples (from the long list that any experienced educator can supply): 1. Students often dismiss an answer option because it is “too easy.” Working with each student as an individual, one can help them decide which particular fallacy in thinking (or flawed assumption) made them reject the obvious. It may be the old theme of not looking for zebras when one hears hooves. Or it may be the notion that teachers are not necessarily trying to trick them – and that it is impossible to guess what trick such an evil teacher would be using anyway! Or it may be that the student, having experienced crushing defeat (a “C”!!!) on an examination, is now convinced that he/she doesn’t know anything and thus must distrust what seems like the obvious answer. 2. Perhaps related to the above, but also a reflection of the “lack of big-picture syndrome,” is the fact that many students, after being shown that the “correct” answer was not just obvious, but was also one that they probably would have chosen before they came to medical school, still refuse to accept that reading any question from the perspective of general information will often lead them to sorting out the correct answer from amongst a number of choices that seem confusingly equally likely, because the student is ignoring an obvious element of the correct answer that has been obscured by all the “distractors.” 3. Returning briefly to the theme of simulations, I note that most students do not recognize the immense value of simulating the test situation by posing questions to themselves (and small groups of their peers), as a means of studying the material on which they will be tested. (Recall the four questions algorithm.) At our institution, it has long been a practice for the second year medical students to set up a “practice practical” for the first year medical students. This is usually done just before our first examination and is very useful in exposing the students to the mechanics of a practical examination. However, despite multiple discussions with students about how our practical exams are constructed (and why), I have yet to be successful in conveying to them the multiple levels at which such examinations are in fact simulations of the various testing elements to which they will routinely be subjected throughout their careers. The analogies are transparent and obvious, and this perhaps explains why students do not think though the useful implications. (I am working on an article on this, tentatively entitled The Anatomy of a Practical Exam: Rationale and Logistics of a Simulation Experience.) 4. Returning to the themes of words and analysis, I am often struck by the way in which students categorize their mis- takes on an examination in response to my suggestion that they go over the examination and try to sort out what sorts of mistakes they made. One of the most com- mon terms they use is “that was just a dumb mistake.” It takes a lot of effort to convince them that the word “dumb” in this context is usually not only inaccurate, but also judgmental (self-deprecating), and – even worse – a “cop-out,” because if a mistake is “dumb,” one is off the hook since there is little one can do about being “dumb” except to work harder. Which brings me to the last of my “points.”
- 34. 2 Undergraduate Medical Education is NOT Rocket Science: But that Does NOT Mean it’s Easy! 15 2.10 Studying Hard Versus Studying Smart For many first year medical students who have problems with the material they encounter at the start of undergraduate med- ical education, their inclination is to assume that they are not working hard enough and to spend more time studying. In my experience, most students in fact spend ample time (per- haps even too much time) studying, but do not understand how to study in a more efficient fashion. Many fall back on time-proven techniques of rereading texts, highlighting notes, making lists of “important” stuff, studying examinations from previous iterations of the course, etc. Despite having been urged to outline big-picture concepts, identify only a limited number of things to memorize, and to work on trying to decide what is most useful for them to learn, students persist in trying to memorize minutiae first, then major topics later. I choose to finish this last major “point” section by listing a few of the concepts that students need to own in order to make the transition to the self-directed learning style that they will in fact achieve if we all do our job and they do theirs. Unfor- tunately, many of these concepts are neither subtle nor easy to sell. 1. Students overestimate the value of detailed factual knowl- edge and underestimate the value of simple information, common sense, etc. If you ask the average student whether they expect future patients to care how much they (as physicians) know, and suggest that future patients are much more likely to care about how well the physician can use whatever they know, every student (even those who have never been patients) will immediately under- stand that all the detailed knowledge is worthless if they do not have it in some sort of accessible toolkit and can actually use it. But when you stress the value of restricting memorization to the most useful things (like a list of all the organs in the body and a 25-word definition of what each does), they will balk at the absurdity of this being a useful exercise. And will probably still do so after you point out that the reason they misidentified a section of parathyroid for one of parotid was that they forgot about the existence of the parathyroid. (Trust me – I have col- lected a long list of such “common errors” that are only understandable in the context of a student who has lost sight of the big picture.) Another example might be help- ful. We routinely stress that there are four basic tissues in the body (epithelium, connective tissue, muscle, and nerve) and that one can identify (and begin to understand the function of) any organ by observing, identifying the tissues present, describing the amounts and arrangements of those tissues, etc. And that one should not attempt to memorize details like the types of collagen present in, nor the substances produced by, a particular organ (say a gland), until one can state a very brief description of the specific versions of the four basic tissue types that make up that organ. Yet, I can assure you it is much easier to find a first year medical student in June (at the end of the first year) who can name the type of collagen in a specific connective tissue of an organ than to find one who can quickly name the four basic tissue types. One very interesting consequence of all this is that students in fact spend more time memorizing than we want them to, do not memorize the most useful things, and then – when examination questions seem harder than they in fact are – the students complain that we were testing on picky little details. 2. Students lack a number of fundamental organizational skills – as applied to studying – that most of us would like to assume they bring in the front door. They do not understand (or display skill in) outlining a topic, nor the value (to them) of starting from the major points and working down into the details. They do not recog- nize that putting material down on paper “from their memory” is an excellent way of combining learning, and reviewing, and self-testing. If you suggest a chart as a way of reviewing material, be sure to suggest the rows and columns but do not fill in the chart, because they are more likely to try to memorize its contents than under- stand the logic of its construction. If you suggest that they make a sketch of something and label it as a means of reviewing material, be sure you do not label your sketch and be sure to urge them to discard the labeled dia- gram immediately after they have prepared it. And do not be surprised if a student asks how they can be sure that they have included “everything” in the chart or cor- rectly labeled the diagram – and seems nonplussed if you respond by suggesting that they look at similar charts and diagrams (in the texts you have assigned) for con- firmation or corrections. The current mantra is for us as educators to integrate what we are teaching and avoid wasting student time by redundant presentations. Do not buy this! Because many students have not learned and thus do not understand that the only meaningful integra- tion that occurs is what they do in their own minds. And that time is only wasted with redundancy if students who have already learned something keep reading about it (or attending optional lectures) because they are unwilling to test out the premise that they have learned the mate- rial, by simulating reality and learning from any mistakes they make. 3. We devote a great deal of effort to gathering student evaluations of our courses – as we should. Not because they are our customers, but because they are our students and every educator knows there is much to be learned from students. But not necessarily what is the best way to teach. Because most students do not spend enough time analyzing how they think and learn. Because we know,
- 35. 16 I Why Simulate? better than they are likely to, that there is no best way to teach all students and that while “popularity” may be a very useful indicator of effective teaching, it is not an infallible guideline. In fact, for many students, the most effective teacher will be the one they least enjoy. And for most students, there is immense value in being taught the same things by many different educators, because the most important things we are likely to teach them are the things that are so obvious that there is no way of predicting which iteration will be the charmed one, from which they “get it.” 4. Related to the above, I would like to comment on the notion (growing in popularity) that we must give the stu- dents more time to study and learn on their own. To the extent that we see the problem as excessive reliance on didactic teaching (lectures and the like) and not enough on experiential learning (small group discussions, discov- ery at the microscope or in the library, experience at a simulator, or with a mock patient), we must correct the imbalance – and are doing so. But anyone who thinks that giving first year medical students more free time and a list of tasks to do, problems to solve or methods to master, without taking pains to make sure they have the skills and attitudes necessary – that educator is flirting with disaster. Work with all students until your are fairly sure that each is indeed an independent learner, with all that entails, and meet with them often so you can be reasonably certain that they are testing themselves and neither kidding themselves nor you about what they are learning. 2.11 Broader Perspective OK ENOUGH! I’ll close with a redundant reference to the importance of the big picture. Redundant because we all know of the danger of losing sight of the forest for the trees. But we all tend to forget that while it is easy to see the forest from the outside, it is exceedingly difficult to have an overall view of it from the inside. So one last example from my own experience. In countless instances, I have had a student call me over to a microscope and with utter frustration point to the scope and ask me “what is that thing at the pointer and how on earth would I be expected to know that?” And in most such cases, I simply switch the objective lens from 40× (where the student almost always is) to 10× (as an approximation to the bigger picture) and ask him/her to describe what they now see. And – if necessary – work them through the verbal-visual tasking until they have described what is there. And usually (but not always, because it takes time), the student will say something like “You mean its just a ?” And I respond, more or less: “Seems likely to me.” 2.12 Conclusion The approach of helping the student see the bigger picture and figure it out for themselves has always seemed – to me – the obvious way to go. And I know it works in many areas. Having had no experience in teaching clinical sciences with space age simulators, I certainly cannot be sure about this. But the next time a student is peering at some display, or strip chart output, or listening intently to some sound produced by a simulation device – and the student seems totally befuddled and is try- ing to look closer or listen more carefully – ask the student to step back and describe where they are and what they are doing. What is the overall reality of what they are analyzing so intently? Are they trying to deduce something about cardiovas- cular function from an EKG? Are they trying to figure out what is wrong with a respiratory system by listening with a stetho- scope? Is the goal to understand why the simulated patient isn’t responding as expected to an anesthetic? Looking closer or thinking smaller may get them to an answer, but maybe not. Stepping back may not always make things more obvious. But it frequently will and, even if it doesn’t make the answer to the specific question obvious, it will allow the student to recast the question so they see it from a broader perspective and have a better chance of “seeing” what is obvious even when it is not quite as obvious as we would like to think it will be. Reference 1. Mark R. Adelman is an Associate Professor of Anatomy, Physiology and Genetics at the Uniformed Services University of the Health Sciences (USUHS), 4301 Jones Bridge Road, Bethesda, MD, 20814-4799. He can be reached at adelman@educationalassistance.org. After receiving a undergraduate Bachelor of Arts degree in Biology (as a pre-medical student) in 1963 from Princeton, and realiz- ing that he would probably make a rotten medical doctor, he switched paths, attended the University of Chicago (for graduate studies) and received a PhD in Biophysics (1969). He then did post-doctoral research in Cell Biology at the Rockefeller University. He has taught undergraduate med- ical students since 1971, first at Duke University, more recently at USUHS. He has also taught graduate students and undergraduates at Duke, USUHS, and other schools. Most of his teaching has been of Histology and Cell Biol- ogy, working with first year medical students; hence most of his ‘examples’ are based on those experiences. But he has taught many other subjects and there is one common thread to all of his educational efforts: he has NEVER taught a course that he has formally taken as a student. He does not believe ANY of the materials he has presented to students are all that hard, he fails often and is always educated by his failures, tries to get his students to accept that this is the
- 36. 2 Undergraduate Medical Education is NOT Rocket Science: But that Does NOT Mean it’s Easy! 17 way it is; but has STILL not succeeded in getting students to accept failures as learning experiences. He recognizes that most of his comments are based on data derived from stu- dents and colleagues in the United States. But, given his discussions with other members of IAMSE (International Association of Medical Science Educators), he suspects that much of this chapter will resonate with educators from other countries.
- 37. 3 Guidance for the Leader-Manager Robert C. Cox J. Lance Acree 3.1 You as the Reader 19 3.2 You as the Leader 19 3.3 The Clash of the Titans 20 3.4 The Aviation Analogy: Is it Valid? 21 3.5 The Systems Approach to Training 22 3.6 Defining the Performance Requirement 22 3.7 Cost Versus Value Added 24 3.8 Operations Cost 24 3.9 Standardization: What is it, and who Wants it? 25 3.10 Patients as Training Conditions 25 3.11 Equipment as Training Conditions 26 3.12 Increase in Training System Cost 26 3.13 You as the Leader-Manager 27 3.14 Conclusion 27 Endnotes 27 3.1 You as the Reader Our purpose in writing this chapter was to help the decision maker understand some of the factors we have come across in our experience designing and implementing training systems that employ simulations.1 3.2 You as the Leader Integrating simulation into a training program is more than an academic exercise – it can be a major culture change adventure. Culture change is not a job for administrators; it requires leaders. The commitment of a few leaders to bring- ing constructive change over the long-term will be essential to success in building an integrated and comprehensive train- ing system. Your ability to communicate the purpose and philosophy of this change will be the most critical ingredi- ent in providing leadership throughout the culture change. Since many of the concepts you will be attempting to com- municate are somewhat abstract, the following discussion will introduce some specific terminology that you as a leader might find helpful. Leaders recognize and wrestle with the “trade space” of cost, performance, and risk; they seek to maximize performance output for the least cost and risk input (Figure 3.1). You and your fellow leaders will develop a vision and define goals for your training, so that you can begin the communication work to spread the vision and shape the expectations for the rest of the organization. Prepare yourself to face and overcome the natural organic resistance to change. If the apprentice- training (“Halsted”2 ) model is the only model people have known, they will have difficulty imagining how anything else will work. So you might start by imagining, for yourself, what it would be like to have a world-class performance-driven training system that uses courseware, simulation, and “the real thing” to reduce overall cost and risk while boosting graduate performance. You may want to write down what you imagine this would look like, especially in terms of the finished product. For exam- ple, you might envision your graduates, on graduation day, being proficient with the latest technology and techniques, Copyright © 2008 by Elsevier Inc. All rights of reproduction in any form reserved 19
- 38. 20 I Why Simulate? Performance Risk Cost FIGURE 3.1 The dynamic challenge facing the leader-manager: balancing cost and risk to gain performance. proficient with your institution’s information systems and processes, proficient at teamwork under stress, and so forth. Imagine them having practiced repeatedly in simulations, and having proven their skill against objective standards, so that their first interaction with a real patient is a low-stress event for everyone. Your imagination is going to get a workout in this chapter, so you might as well start stretching out and limbering up. Leadership is also “the art of the possible.” You and your allies will need to identify a feasible starting solution – something not too big to accomplish within a year, requiring TABLE 3.1 Two pilot programs Examples: starting small but feasible a. Some eye surgeons we work with selected the procedure “peel an epiretinal membrane” for a starting point; this surgical task has distinct beginning and end points, and some simulation is available to help train it. Using a microcosm of a comprehensive training system, we were able to perform experiments to demonstrate quantifiable performance gains in retinal surgery. Of particular interest was the participants’ response to the task analysis–based courseware (residents through attending physicians); the case group response was both positive (difference in means 20%) and statistically significant (p value less than 0.05) as compared to the control group response. Appendix 70A.1 contains some of the quantitative results from this example. b. A different community (anesthesiologists) selected a more general, whole-body emergency procedure as a prototype for revising their graduate medical education program. The procedure is known as COVERABCD-A Swift Check, and includes over 20 subalgorithms to address a corresponding number of top life-threatening complications. Starting with this procedure and one of its subalgorithms will enable them to prove the principle; their goal is to expand the program sequentially to the full procedure (all algorithms) while gathering performance gain and cost data. maybe 25–50% more resources than you have on hand, to prove to the powers-that-be that the concept works, and begin a spiral development cycle. Perhaps focusing on one or two critical procedures or skills will do the trick (Table 3.1). This will stretch you as you hold on, with one part of your brain, to the ideal grand vision you imagined in the paragraph above, while simultaneously working on a practical first step with some other part of your melon. Chances are, if you are reading this chapter, you are a visionary. If so, you may have real difficulty identifying a truly feasible starting solution; pick friendly colleagues who are naturally skeptical. Make them help you determine what is feasible. Keep these pragmatists in your inner circle to balance out your idealism; they will force you to think practically. 3.3 The Clash of the Titans If you haven’t yet run into the traditional training philosophy in your organization, it won’t be long before you do. You must not be surprised when “expert opinion” deems simulation inadequate for training, either because “it’s not the real thing” or because “it will hinder training in dealing with real patients” or some similar reaction. Editors’ Note: Most of today’s allopathic medical school curriculum is “not the real thing” compared to the daily behaviors and responsibilities of real clinicians treating real patients. The basic science years are just a continuation of a typical undergraduate science curriculum, with con- tent assumed essential for subsequent learning of clinical thought. The following clinical years, at best, prepare the students to make informed choices in selecting a specific residency topic and program. The residency years trans- form these extensively prepared individuals into actually functional clinicians. Then come fellowships to master the most rare and arcane specialized skills and abilities. Finally, after 10 years in clinical practice, the former clinical school applicant is now a master craftsman, doing “the real thing.” You are now facing a classic collision between training philosophies, and you will come out better (clothed and in your right mind) if you label this conflict as such every time you encounter it. By proper use of the word philosophy, you are grasping a distinct and powerful cognitive tool for achieving lasting culture change. (In contrast, the word attitude points to the affective or emotional domain, and culture is too broad a term to steer with.) This statesman approach helps keep the collision from degenerating into personality-driven argumentation.3
- 39. 3 Guidance for the Leader-Manager 21 Training philosophies are built on assumptions. To help make allies out of adversaries, you might list the underlying assumptions of the competing philosophies (Table 3.2). You might recognize the last entry in the table under tradi- tional philosophy, where performance is assumed if sufficient TABLE 3.2 Training philosophies and their underlying assump- tions Traditional training philosophy Performance-driven training philosophy You can’t replace “the real thing.” Simulation augments “the real thing.” (By the way, what’s your definition of “the real thing?”) Unless the simulation is exactly like “the real thing,” no real training can be accomplished. Simulation does not have to be exactly like “the real thing” in order to boost the trainee’s performance while reducing overall cost and risk. The trainee should be developing judgment, and that can only be learned when facing the ambiguities of real situations. Properly constructed simulations include a wide variety of scenarios, some of which are ambiguous, to push the trainee to develop competent judgment. A “war/sea story” told = Lesson Learned. It’s not a Lesson Learned until it’s in a lesson. (We’ll discuss later how you can be certain the lesson has actually been learned.) Probabilistic, random, ad hoc: The trainees might be trained to perform actual tasks X, Y, and Z to the satisfaction of an expert, during the training period T, if the right patient mix appears during T. Deterministic: The trainees must perform training tasks x, y, and z in period T, under select conditions and to appropriate training standards; they can then be expected to perform actual tasks X through Z.a Only expert clinicians can determine what should be trained and how it should be trained. Subject matter experts determine what is to be trained; training system experts help competent authority to determine how it is best trained. Curriculum is a list of medical conditions and procedures; it’s a general list I keep in my head. Curriculum is the blueprint that guides and controls the entire training system; it’s highly detailed and kept in a database. Personality-driven Trainee performance-driven Time spent with a master = performance. Only performance = performance. a We’re using upper and lower case Xs, Ys, and Zs to distinguish between actual tasks (upper case) and training tasks (lower case). time has passed. The aviation version is “Fly with an instructor pilot for x hours; come back alive and don’t crash too many aircraft.” The academic version is “Sit in the instructor’s class for x hours; come out sober and don’t flunk too many quizzes.” The medical version is “Operate with an attending surgeon for x years; come out sane and don’t kill too many patients.” As the smoking wreckage of many an airplane will attest, time spent with a master certainly aids performance, but it is highly unre- liable as a guarantee of performance. The surviving passengers were the first to complain, followed closely by the people who paid for the airplanes. Eventually, even the pilots recognized that any crash is one crash too many, and aviation adopted an integrated, performance-driven training philosophy. That led aviation to investigate a new approach to training. 3.4 The Aviation Analogy: Is it Valid? We occasionally encounter the argument that since engineers design planes, but they don’t design humans, treating the patient as if they were an airplane (and the clinicians as if they were flight crew members) does not hold up. But this is a mis- perception; the aviation analogy, when properly articulated, does not place the patient in the role of the airplane. It is more correct to say that the engineers design aircraft to function as the interface between the aircrew and the atmosphere. We can see this by looking at the mission of the aircrew, which is not the simplistic “fly the airplane.” This would make a mere device the goal of the activity, which it is not. Likewise, we would not make “operate clinical gadget X” the mission statement of a clinician. Properly stated, the mission of the aircrew is to deliver something through the atmosphere. This statement keeps the aircraft and other gadgets in their proper place; they are merely the means to the end. It also identifies the main challenge to be overcome by the aircrew, and that’s not the airplane – it’s the atmosphere. Figure 3.2 illustrates why this approach makes the aviation analogy work for clinicians. In this illustration, the airplane functions in the same way as the syringe in the clinician’s hand; they both serve merely as interfaces with the primary challenge. Of course, the modern airplane is more complicated than a syringe – and so is the Patient Display Display s s s s s s Atmosphere FIGURE 3.2 The aviation analogy (art courtesy of R. Kyle).
- 40. 22 I Why Simulate? da Vinci Surgical System®. But in the early days, airplanes were simple and crude; take a look at a modern hang glider. These early airplanes and their modern counterparts have hardly any systems, displays, or sensors – no altimeter, no airspeed indicator. Note that these two sensors measure and display atmospheric behavior, not airplane system behavior. These sen- sors were added early on to assist the aircrew in understanding their primary challenge – the atmosphere. Pilots needed to know the airspeed, for example, with greater precision when the mission demanded that the gadget (airplane) be operated close to the edge of its atmospheric behavior limits, such as the stall speed. Stalling is atmospheric behavior, not airplane system behavior. The behavior of the atmosphere challenges the aircrew in many other ways: drag, low visibility, wing tip vortices, icing, turbulence, crosswind, tire friction loss. And aeronautical engineers don’t design atmospheric behavior. These challenges are highly variable and unpredictable. (How far do you trust the weather forecast?) In contrast, the system behavior of the airplane is well understood and thoroughly documented, mainly through systematic engineering and flight-test pro- grams. You will not find a hydraulic system, or a fuel system, or any other kind of system inside a properly certified airplane that does not have reams of charts describing its behavior in excruciating detail. Sometimes, a system failure (such as adding the wrong kind of hydraulic fluid, the equivalent of a drug-delivery error) complicates the mission, and while these complications are serious, they are not the primary challenge. As we move to the outside of the aircraft, we begin to encounter things we can’t see and don’t thoroughly understand, from boundary layer separations to microbursts. Seen this way, the patient functions like the atmosphere, not like the airplane; the patient generates most of the variability and unpredictability that challenge the clinician. In aircrew training curriculum, you would expect to see air- planesystemsimulations(thatemulatepredictablehydraulicsys- tem behavior, for example), but you would also find a variety of unpredictable atmospheric conditions. It is these conditions that call for simulations of dangerous crosswind, turbulence, fog, icing, etc. – things that do not emanate from the air- plane itself but from the atmosphere. In its quest to control risk and cost, aviation discovered a reliable way to methodi- cally identify and force these hazardous conditions (and their corresponding simulations) into its training systems. The end resultisreliablehumanperformanceat acceptable cost and risk. 3.5 The Systems Approach to Training It is a common mistake to start out campaigning for adding simulation to existing training when that is only one part of the solution to risk, performance, and cost. Simulation, whether Entry-level performance Field-ready performance level Curriculum Training load Textbooks Classroom instruction Part-task simulation Full simulation The real thing Mentoring Training system FIGURE 3.3 The training system and the training load. adopted in whole or piecemeal, will ultimately fail to deliver on its promises unless it is understood to be only one element in your training system. Unless having a simulation museum is your goal, it would be a mistake to procure simulators and construct simulation facilities without first defining, in a systematic way, what you expect the simulation to help you accomplish. This may sound daunting, but there already exists a process for this; you are going to apply the systems engineer- ing process to the whole training equation. This is called the Systems Approach to Training, and, like systems engineering, it begins with analyzing the training requirement, as opposed to beginning with analyzing glossy sales brochures. Training exists to build human performance; it seeks to guarantee a minimum level of performance at an acceptable level of risk and at an acceptable cost (see Chapter 8). If we start with the goal of minimum risk, or with the goal of mini- mum cost, either way we will rapidly conclude that the solution is zero training (= zero risk and zero cost) and consequently zero performance gain. Therefore, we begin by carefully defin- ing that minimum performance level required of the graduate in the field, and then work backward toward the entry-level performance, methodically managing risk and cost as we go. It may help to visualize the training required to achieve the min- imum performance requirement as a weight, or training load, that the training system must lift, or help each trainee learn to lift. The different elements in the training system – the text- books, the classroom, the lab, the simulation, the instructors, and “the real thing” – all carry part of the training load, and are organized into a system by the curriculum. Figure 3.3 shows the training load as an increasing performance requirement, lifted by the various elements of training as they are organized into a system by the curriculum. 3.6 Defining the Performance Requirement World-class human performance, the kind that requires (and deserves) a world-class training system, is quite complex and must be described in multiple variables. This gets at one of the primary arguments used against simulation: “You can’t
- 41. 3 Guidance for the Leader-Manager 23 FIGURE 3.4 The tent analogy, showing a typical tent, held in place by stakes, poles, and ropes. define the real performance requirement with a simulator.” Before we address this charge, we need to examine how to define complex performance requirements in general. Think of a tent, held in position by a collection of points: the peaks and corners (Figure 3.4). Without these peaks and corners, the tent collapses; we might say the tent is defined by these points. Simple tents have only a few; elaborate tents have many. But we don’t set up tents just for the fun of pounding stakes – we set them up to get what is inside, the nice dry living space that exists between the peaks and corners. We could say that the living space inside is also defined by these points. If one of these points moves, as when a tent rope slips, the living space inside changes, so an experienced camper pays a lot of attention to the peaks and corner points. You might also have noticed that the concept of living space we are using includes not only spatial dimensions but also dampness conditions and probably temperature and ventilation conditions, as well. Now imagine that your tent is made of a revolutionary fabric that stretches freely in all directions without limit. You can create quite a complex living space by simply adding points. But as you add points to your tent, and the complexity of the living space increases, you will find that at some point you have enough rooms and halls in the tent to meet your needs. You or your significant other will say, “That’s good enough – that’s all the living space I think we’ll need, at least for the near future.” By defining the corners and peaks, you will have achieved your target living space requirement. The analogy we’re driving at is this: the living space in the tent is like the performance target our training system is supposed to produce. For the rest of this discussion, we will call this complex performance requirement the target perfor- mance space. This is not the geometric use of the word space, which uses only three dimensions. We’re talking about multi- ple dimensions and variables – procedures, time, instruments, patient status, blood pressure, heart rate. It’s closer to the more abstract Operations Research use of the word, as in solution space. Operations researchers use this term to describe solu- tions – in all sorts of combined, nonspatial measures, such as degree-days, ton-miles, unit-cost, and man-hours – that make up the abstract volume of feasible combinations. Recall that our living space concept included temperature, ventilation, and dampness characteristics in addition to length, width, and height. Someone might object that performance space is too abstract to work with, but we already work with abstract concepts with- out batting an eyelash (try explaining to a child, in words, what the dollar and energy are; not what they do – what they are). Once you become familiar with defining points, the cor- ners and peaks, you will find the performance space concept quite powerful and even familiar. Consider the following fairly familiar example of one defining point in a target performance space: Given a typical car and a 6 by 25 parallel parking space, perform parallel parking, without striking the parking space markers, and placing the curbside tires within 12 inches of the curb in less than 3 minutes. Many other key points are required to define the “corner points” of the performance space for driving a car, such as the one for merging with heavy expressway traffic, but the parallel parking “corner” has the advantage of evoking painful memories of the driving test. It also is written above as a “Terminal Learning Objective”, complete with task (“perform parallel parking”), condition (car, 6 by 25 ft. parking space), and standard (3 minutes, no crashing, 12 inches from the curb). A collection of terminal learning objectives, written in a form similar to this one, would define all the “corners” of the target performance space for driving a car. Remember your tent – the target performance space – held in position by a collection of points, peaks, and corners – the defining terminal learning objectives. If a trainee performs up to standard at each of the terminal learning objectives, you can be reasonably assured that the trainee will perform acceptably at all points in between. If you think the driving example is too simple to apply to the medical community, remember that we use it to train teenagers – millions of them – to operate potentially dangerous machines in ambiguous and potentially deadly situations, and you still get on the highway with them. The risk has been balanced against the cost and the performance requirement. You might well wonder how someone came up with 3 min- utes, or 12 inches, since no one hacks a stopwatch or whips out a ruler for parking “the real thing.” Teenagers certainly wonder, out loud and with enthusiasm. The answer is that these were selected by a competent authority for training purposes only. The competent authority knew full well that these metrics are artificial and even arbitrary, but the authority also knew that without them neither the instructors nor the trainees would know what performance goal they should attempt during train- ing. Nor would they know if they had achieved success. In the absence of a well-defined terminal learning objective, paral- lel parking training would become randomized across a wide
- 42. 24 I Why Simulate? range of time and distance, bounded only by human imagina- tion. The phrase for training purposes only should become part of your hip pocket vocabulary, along with task, condition, and standards. Once the key terminal learning objectives for the target per- formance space are defined, it is a much simpler task for a manufacturer to build a simulation for it, if the technology is cost-effective. This helps harness the power of market eco- nomics to your training goals. In order to minimize risk and cost, the training system designer will first help the competent authority move as much training load as possible out of “the real thing” and into high-fidelity simulation. Then, since high- fidelity simulation is not cheap, the designer begins attempting to move as much training load as possible out of high-fidelity simulation and into some other lower-cost media, such as benchtop models and interactive computer-based training. This systematic method, in contrast to the traditional ad hoc method, will help you manage risk and cost while ensuring that the required performance is achieved consistently. As to the original charge (“You can’t define the real performance requirement with a simulator”), you have sidestepped this logic conundrum by defining the training performance requirement in great detail, as close to the real performance requirement as possible. Where simulation helps demonstrate this perfor- mance, and/or reduces cost and risk, it has been included in the training system along with experience in “the real thing.” And you now have a baseline from which to begin updating the entire training system as “the real thing” shifts and changes shape. 3.7 Cost Versus Value Added One of the first questions facing you as a leader contemplat- ing or advocating a simulation-rich training system is how to communicate the cost versus the value added. It is not enough to say that simulation and task analysis are good for training; how good, and how much investment is required to bring that good about need to be quantified as much as possible, so that people will embrace the effort. In a high-level tally, you might spell it out as in Table 3.3. The arguments summarized in Table 3.3 have the disadvan- tage of being intuitive and difficult to measure. Measurable increases and decreases will be needed to justify investments of specific man-hours and funds. But for starters, this is not a bad summary; most people easily recognize that the patient is safer if the trainee first practices on a mannequin or some other simulation before attempting to handle their first real case (Figure 3.5). Likewise, they will probably see the intu- itive linkage between increasing patient safety and cutting the litigation and settlement costs while improving public image. The “decrease in realism” in the cost column should be kept opposite the increase in patient safety, because while we all TABLE 3.3 Conceptual tally of value added versus cost Value added Cost Increase in patient safety Increase in spectrum of case experience Increase in standardization Decrease in operations cost Decrease in insurance cost Decrease in litigation cost Decrease in out-of-court settlement cost Increase in public image Increase in esprit de corps Decrease in realism during training Increase in training system support cost Increase in standardization Time in surgical training Time in surgical training Trainee surgical performance Risk to patient Halsted method Halsted Systems approach Actual surgery Actual surgery Systems approach FIGURE 3.5 Notional performance and risk-to-patient curves for both the Halsted (traditional) method and the Systems Approach to Training. Note that the systems approach introduces simulation well before the start of actual surgery experience, and continues its use as appropriate afterward. want the perfect training fidelity that comes from learning on live patients, the patient’s best interest must be kept in mind at all times. 3.8 Operations Cost What people may not see, and what you as the leader must con- tinue to highlight, is the potential to reduce overall operations cost. Without an integrated training system, training load tends to migrate surreptitiously into the most costly and highest-risk arena – the “real thing.” Training that currently occurs in the Operating Room, at hundreds of dollars per minute operating cost, can be transferred into simulation at tens of dollars per minute. Most hospital administrators are examining Operating Room costs, and some have begun to pressure surgeons whose operations take longer than average. But this relatively crude approach to cost reduction does not consider how training
- 43. 3 Guidance for the Leader-Manager 25 strongly influences time in the Operating Room. There is the direct time cost of training, as when one clinician takes extra time to show a trainee how to do something. But there is also the indirect cost, as when inefficiency, or avoidable mistakes that should have been caught and corrected during simulation turn short procedures in the Operating Room or Emergency Room (OR/ER) into much longer ones, or worse. How often this happens, and the resulting unplanned costs, are usually hidden from view. Another indirect cost strongly influenced by training is the cost of turnover. The greater the turnover, the bigger the drain on your resources. Each new person added to the team requires some kind of training, even if it is distributed (and hidden from view) as informal on-the-job training. This training is not free – no matter how informal it is, someone has to take extra time to show the trainees how things are done. Throughout their orientation and on-the-job training, newcomers are not fully productive on their own, and they are a steady drain on those who are productive on their own. It might be argued that on-the-job training occurs mainly during “dead time” not used for productive work, but that argument is normally based on data-free analysis. And by the way, doesn’t all that “dead time” cost something? It is highly probable that the most valuable on-the-job train- ing occurs when the instructor is doing productive work, slowed down on purpose to allow the trainee to absorb the knowledge; this is followed by the trainee attempting to do the same procedure under the eye of the instructor, again in slow motion, to allow the instructor to control the risk to the actual patient. But how much does all this “slowing down” cost the institution, if we could sum it all up? More importantly, how well are all the trainees performing? Can anyone describe their performance in objective terms? What on-the-job training have they completed and when? Is their training qualitatively equal? Are they fully productive? What is all this on-the-job training costing us, and can we reduce that cost? The honest answer in most institutions that depend largely on informal, ad hoc on-the-job training is we don’t know. We know that we have intrinsic training costs, but we can’t manage them because we can’t measure them. The Systems Approach to Training will improve visibility into all of these issues. One of the intangible benefits of replacing as much as possi- ble of the ad hoc, probabilistic, and personality-driven training method with a world-class, curriculum-driven training sys- tem will appear as esprit de corps. Both the trainees and their instructors, seeing the tangible investment in training, sense that the institution really values their quality performance, and people tend to interpret that as the institution leaders think I’m important. This effect internally spurs them on to help you keep the training system strong, and improve it where possi- ble. They will be reluctant to leave an institution where leaders invest so much in their people, and this reduction in turnover will be visible. This attitude percolates beyond the institu- tion and into the community as an increasingly strong public image. Since world-class training systems focus on reducing human error, you can reasonably expect a decrease in the tan- gible costs associated with human error: insurance premiums, litigation, out-of-court settlements, and negative publicity. As a leader, you will need to keep reminding people about these costs and how a performance-driven training system will help reduce them while building up the morale of your work force. 3.9 Standardization: What is it, and who Wants it? You probably noticed that “increase in standardization” appears in both the “value added” and “cost” columns in Table 3.3. This is not an error; it points out that standardiza- tion is viewed by some as value added, while the free spirits among us view it with disdain and possibly horror. Frequently, people associate standardization with regimentation or even a complete loss of creative freedom. Your challenge will be to assure them that an increase in standardization does not mean pervasive regimentation; we still expect instructors to tell their war/sea stories and to pass on their personal techniques and pet peeves. These personal touches have great value, but they do not replace the curriculum. In fact, a well-designed cur- riculum will make room in the schedule for storytelling and personal technique propagation. You’re trying to standardize what you can so that it takes less time to build a core com- petency – this means the instructors will have more time for building higher-level skills like adapting and innovating. What people may not have contemplated is how simulation allows a training system to provide both a wide spectrum of cases and a standardized set of cases and treatments, so that the graduate’s performance is a known quantity. As we discussed earlier, the trainee will be trained to handle a representative set of problems (terminal learning objectives) that have been carefully selected to frame the target performance space. Since the condition part of the task-condition-standard formula is partly defined by the spectrum of patients, who are in turn described in terms of a large and complex array of variables, it may be appropriate to speak of the patient space. 3.10 Patients as Training Conditions In aviation training, conditions described in the terminal learn- ing objectives are frequently weather conditions – the highly variable and somewhat unpredictable challenge of operating in the atmospheric media. In the world of clinician training, the patients may provide the majority of this function all by them- selves. Examining the patient is somewhat akin to looking out the windscreen at the weather you’re about to fly through. One goal in a systems approach is to avoid artificially limiting the
- 44. 26 I Why Simulate? trainee’s experience to the random distribution of real patients that appear during his or her clinical training, when a guar- anteed distribution of simulated patients can provide uniform experience across a broader sample of the patient space. As we pointed out earlier, this is “fixed” or “deterministic” training as opposed to the traditional ad hoc or “probabilistic” training. Trainees who are struggling can be made to repeat well-defined simulations until their performance is acceptable: they must meet objective performance standards in an objec- tively defined core competency. The actual patient cases then add real (but highly variable and unpredictable) conditions on which to apply the core competency developed during sim- ulation. In a well-designed curriculum, trainees continually alternate between simulations and “the real thing” so that a powerful coupling effect emerges: real experience internally motivates the trainees to learn as much as they can from sim- ulation, so that they can be confident and self-assured in the next real experience. By way of example, military aviation seeks to build adapta- tion/innovation skills for a highly variable and unpredictable spectrum of future combat conditions by first establishing a fixed core competency in the target performance space. Then, the training system adds realistically ambiguous scenarios to help develop adaptation and innovation skills. Military avi- ators deploying to “the real thing” can then begin from a known starting point, the fixed core competency, and use their adaptation and innovation skills when they encounter their unpredictable adversary on an unfamiliar battlefield. 3.11 Equipment as Training Conditions Another pesky component of the training condition, with its own annoyingly complex set of multiple variables, might be called the equipment space. This is the increasingly large array of pharmaceuticals and the hardware and software configura- tions that plague modern clinical equipment, all of which act together to create a large and growing training load. We’re willing to bet you have equipment in your hospital that has untapped capability because of a lack of training. We’d also bet you have equipment in your hospital that no one knows how to use, except as a coat rack; someone used to know, but they forgot or left your institution. This untapped equip- ment capability costs the institution something. Even for the equipment your people are trained on, the equipment con- figurations change over time as parts and software “morph” (change) under your feet, and this only increases the already formidable training load. You might also include the train- ing load due to the ever-increasing rate of introducing new pharmaceuticals and their interactions in this “equipment” category. Your training system must evolve with an evolving equipment space. 3.12 Increase in Training System Cost This is where you will brazenly come out in the open with a tangible investment plan for your training system, to challenge the hidden training costs (and costly risks) of the traditional method. As we have seen, the goal of standardizing a core com- petency translates into a requirement for a process to define that competency (in terms of terminal learning objectives), and define it to a degree of granularity not encountered in the traditional probabilistic model. This new process, curriculum development, will require a tangible investment of time and expense. Once this detailed and comprehensive view of compe- tency has been built, it will pay quantifiable dividends to keep it current as equipment, software, procedures, and techniques continue to change. These gains come only with some investment of time, energy, and funds; because this cost element is fuzzy, most people assume that the investment will be more than the reduc- tion in operation costs. This is especially true if the actual operating costs are unknown or are obscured by the random on-the-job training, the convoluted billing processes of the typically Byzantine clinical bureaucracy, and the human ten- dency to hide the true cost of human error. Until an algebraic cost/return model can be built that can project the return on investment, it may suffice to point out that, intuitively, training performed in the OR/ER costs in the hundreds of dollars per minute, while simulation training costs in the tens of dollars per minute. Of course, some training must be accomplished with the real thing, in the highest-cost, highest-risk arena – “on the floor” and on real patients. But extensive and sys- tematic use of simulation means that this live training can be focused on final polishing, because the basic skills and sup- porting knowledge have been learned and demonstrated in the lower-cost, zero-risk simulations. The instructor talent (and cost) can be distributed along the training system according to the performance level required; early (basic) training may be performed by general instructors, saving the more specialized instructors for the final, refined training. Closely connected to this concept is the need to train the instructors, especially since the media and meth- ods of simulation-based teaching is significantly different from the media and methods of actual patient-based teaching. The instruction methods traditionally employed to train in the OR/ER will not leverage all the capability of the simulation; simulation instruction has its own skill set. In fact, the desired results of all teaching – the performance gains in the trainee – are strongly constrained by the instructing performance of the instructor. The strong and well-deserved urge of the instruc- tor to protect the live patient from the less-than-competent student is a huge handicap when teaching with simulation. So also is the tendency to mimic the pedagogical instruc- tion techniques from one’s past experiences in the traditional method, when the adult learning model is much more effective.
- 45. 3 Guidance for the Leader-Manager 27 The simulation instructor skill set should therefore be defined with its own terminal learning objectives and trained in its own unique training program. The cost of change is another element that is usually disguised by Byzantine billing processes. New equipment, new pharmaceuticals, new software and protocols, and new techniques have a way of appearing suddenly and with little training support, and this translates into inefficient use of the highest priced/greatest risk clinical care environment. Estimates range widely, but medical knowledge probably doubles in less than 10 years; this means that demand for skills is also doubling. With proper support processes, simulation can help keep skills up-to-date despite rapid changes in the real world. This leads us to the need to categorize and manage training system support costs. 3.13 You as the Leader-Manager Once your pilot project is beginning to take shape, it will be important to develop the supporting processes and manage them well. This may include (in no particular order): • Methodically expanding the curriculum development beyond the pilot project. • Budgeting for expansion beyond the pilot project. • Procuring courseware specified by the Systems Approach to Training curriculum. • Procuring training devices (mannequins, benchtop sim- ulators, etc.) specified by the curriculum. • Building increased use of simulation into future training plans. • Building a real estate plan – rooms and floor space – to support the training system. • Developing training for simulation instructors. • Developing training for terminal learning objectives that require teamwork. • Developing feedback mechanisms for students and instructors. • Developing processes to analyze aggregated trainee per- formance metrics. • Building a financial model to determine the Return On Investment (ROI) and refining it as you go. • Developing a system to track clinical equipment config- urations and who has been trained to use them. • Developing change management processes to keep your training system current. • Soliciting feedback from the field, where your training system graduates end up. This list represents a sizable effort that will involve some cost to sustain. But all these processes contribute to helping you manage a world-class training system, and will help you under- stand, quantify, and manage the cost of training for your institution. In the process, you will be materially reducing risk and its costs. But if all this is too daunting, feel free to call in some training system experts. 3.14 Conclusion Transitioning from the ad hoc apprentice training model to a true performance-driven training system is not just a manage- ment change – it is a cultural change. That requires leader- ship and persistence on your part. It requires a good blueprint, a curriculum built on defined training targets. It requires your best communication skill and determination. Expect peo- ple to react to culture change; more importantly, expect to win them over, one at a time, with your persistent focus on the value added. And when all the risks and costs are added up, the bottom line is patient safety. It’s the right thing to do. Endnotes 1. Robert Cox is the CEO of Aviation Training Consult- ing, LLC (ATC), and Lance Acree is the Senior Executive Consultant. The company provides strategic and opera- tional consulting service and curriculum development for aviation and medical clients. ATC corporate headquar- ters is located in Altus Oklahoma; the mailing address is: P.O. Box 754, Altus, OK 73522. Phone: (580) 477-1767; Fax: (580) 477-1886; www.atc-hq.com. 2. William Stewart Halsted (1852–1922), usually credited with starting the first formal surgical apprenticeship training pro- gram in the United States, as well as initiating the American tradition of requiring junior doctors to stay on the wards around the clock. Hence the term “resident.” 3. You may want to obtain a copy of the Virtual Patient Research Roadmap from www.FAS.org. This summary is a superb reference document; it cites numerous sources and studies over the years that have examined the value of simulation.
- 46. II What’s In It For Me 4 Basing a Clinician’s Career on Simulation: Development of a Critical Care Expert into a Clinical Simulation Expert Lorena Beeman . . . . . . . . . . . . . . . . . . . . . . . . 31 5 Basing a Non-clinician’s Career upon Simulation: The Personal Experience of a Physicist Guillaume Alinier. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 6 Overcoming Operational Challenges: An Administrator’s Perspective Alice L. Acker . . . . . 59 Progress always involves risk; you can’t steal second base and keep your foot on first base. Frederick Wilcox N ot until we believe that rewards for us might outweigh risks to us will we engage ourselves and employ our resources toward a new end. Clinical education has three primary job categories: those that provide the face-to-face clinical labor alongside the students, those that provide supporting educational labor, and those who provide program management. The many tasks required in clinical simulation fall under at least one of three roles: the foreground clinical instructor, the background clinical professional, and the academic administrator. The role of the foreground clinical instructor is the most easily imagined, but the one most often miscast, if not just misperformed of the three. The students must accept the legitimacy of each and every person that they encounter during each and every one of their simulation sessions. Content competency is a necessary but insufficient requirement for these foreground instructors; just as knowing the dialog is a necessary but insufficient requirement for any stage performer. Like any educator, they must not only be competent in conveying ideas, abilities, and attitudes to their students, but also strive to improve how they do so in using simulation. Yet, unlike during real patient clinical teaching, when using simulation, they must redirect their focus from that of their patients’ safety to that of their students’ betterment. This essential point is often not obvious, even to those who already grasp that using simulation may improve patient safety. For the near future, most foreground instructors will follow the traditional path of developing their teaching using real patients, and only later ever doing so with simulated ones. Many of the learned habits conducive to good patient care and safety actually hinder good teaching. Such habits are hard to change. Lorena Beeman describes the transformation of a competent patient’s bedside clinical instructor into an accomplished simulator foreground instructor. The role of the background instructor is the most unfamiliar of the three, thus is the most difficult to hire or develop with confidence. As manufactured simulators first appear as just another gadget and simulation facilities’ technological budgets are noticeable, this role is too often given the job title of simulation technician; yet this title is beyond inadequate, it is incorrect. Everyone directly involved in any clinical simulation production is first and foremost a teacher, a professional occupation. Every thought and action they take should clearly support the students’ learning. Thus, a better job title is “Simulation Professional.” One necessary characteristic of any successful background instructor is the desire and 29
- 47. 30 II What’s In It For Me ability to create and use new tools and new methods. A second necessary characteristic is zero desire to actually perform patient care – clinically trained individuals can become background instructors, but they must forego all responsibility for live patient care, because producing simulated patient care is a full-time activity. Despite their commonality of purpose, the contributions of the background and foreground instructors complement each other. Like our right and left feet, they share the load for the common good, but are neither interchangeable nor individually sufficient for optimal performance. To further this analogy, while we are familiar with stating a given foot is preferred when performing a movement like striking a ball, the other foot is engaged in an equally important task of sustaining a nonmoving link to the ground. Both feet moving to strike a ball at the same time is almost as ineffective as both feet immobile at the same time. During scenario development, the background instructor is focused upon the “how to present” while the foreground instructor is focused upon the “what to present.” During scenario presentation, the background instructor is focused upon the proper execution of everything under their influence, while the foreground instructor is focused upon the clinical performance of the student. Few enough individuals are masters of either domain; very few are masters of both. Assigning both full-time responsibilities to one single person or several who are all either foreground or all background instructors has never been documented as a recipe for success. Guillaume Alinier shares his adventure in first creating a successful career for himself as a scientist and instructor in a well-defined basic science subject and then taking on the challenge of changing himself into a gifted simulation professional. His successes in his current endeavor are well supported by the professional level of his previous creative accomplishments. There is a notion that the definition of a good manager is one who can mange any activity in any organization without actually being a subject matter expert in that activity, they just need to know how to manage. While this may be a laudable concept, all good managers first seem to have become experts in managing themselves and then experts in the subject of their organizations’ primary activity long before they became expert managers of others. Simulation is very disruptive to clinical education, and most organizations are purposely designed to minimize disruptions. Also, there is little or no “spare” time, people, money, beliefs, or floor space in any clinical education program just waiting for employment. Simulation resources all have to be created out of purposeful enthusiasm or taken away from others. The good simulation manager will go far beyond mere acceptance of these fundamental conditions, making use of whatever resources are available to support the activities of the foreground and background simulation instructors. Alice Acker presents those challenges and their practical solutions common to managing a new clinical simulation program inserted into a well-established, traditional clinical academic ecology.
- 48. 4 Basing a Clinician’s Career on Simulation: Development of a Critical Care Expert into a Clinical Simulation Expert Lorena Beeman 4.1 New Path to Perennial Goal 31 4.2 Health Sciences Center Demographics 32 4.3 Simulation Capabilities 32 4.4 Topics of Study 37 4.4.1 Magnet Recognition • 4.4.2 The Reality 4.5 An Overview of Benner’s Novice to Expert 37 4.6 Development of a Tiered Critical Care Education Program 38 4.7 Tier One: Advanced Beginner to Competent 38 4.7.1 Cardiac Simulation Laboratory • 4.7.2 Pulmonary Simulation Laboratory • 4.7.3 Neuroscience Simulation Laboratory • 4.7.4 Multisystem Simulation Laboratory • 4.7.5 Incorporating the Family • 4.7.6 Lessons Learned • 4.7.7 Lessons Learned by the Clinical Educators • 4.7.8 Evolving Uses for the Essentials of Critical Care Orientation Simulation Labs 4.8 Tier Two: Competent to Proficient 47 4.8.1 Lessons Learned 4.9 Tier Three: Proficient to Expert 49 4.9.1 Lessons Learned 4.10 Conclusion 50 References 50 Appendix: Tables 4A.1–4A.28 (see Companion Site) 4.1 New Path to Perennial Goal At the University of New Mexico Health Sciences Center, Albuquerque, New Mexico, U.S.A., our Clinical Education and Human Simulation programs employ the philosophy of the educational theorist Patricia Benner and her phenomenological model of Novice to Expert [1]. The rationale for this decision was multifold, as will be discussed. This chapter will present how we created a critical care nurse clinician education curriculum utilizing human simula- tion technology for evaluation that addresses five levels of a professional clinician’s career. Curriculum design will accom- pany this discussion, along with lessons learned and those still being learned. A functional overview of an education model will be presented so that the reader can better appreciate our curriculum design and the use of simulation for documenting the progression of a clinician’s professional career. Historically, in acute care hospitals, the majority of educa- tional time is spent on introductory or core curricula that are mandatory for the area in which the clinician will be practicing. Traditionally, once this introductory phase is completed, edu- cational offerings beyond this level are scarce. What offerings Copyright © 2008 by Elsevier Inc. All rights of reproduction in any form reserved 31
- 49. 32 II What’s In It For Me are presented are most commonly associated with establishing and maintaining clinician competency or current concepts in the area of practice. At our teaching hospital, we decided to establish and develop educational offerings to complement this traditional, mainly lecture-based format, focusing on initiatives to improve patient outcomes, while at the same time providing learning oppor- tunities for clinicians to expand their knowledge and experi- ential base. 4.2 Health Sciences Center Demographics The Center is the only Level I trauma center in the state of New Mexico, with an approximate population of 1,819,046 (U.S. Census data 2000). The Center has just over 300 staffed beds at the present time. We have three adult critical care units, one pediatric critical care unit, and one newborn intensive care unit. (The adult units will be the focus of this discus- sion as the curriculum development and use of simulation to evaluate the clinical learner is adult-focused.) The medical- cardiovascular critical care unit has 15 beds and employs 50 nurses (full- and part-time). The neuroscience critical care unit has 10 beds and employs 30 nurses (full- and part-time). The trauma-surgical critical care unit has 18 beds and employs 36 nurses (full- and part-time). The center is in the process of constructing a new pavilion that will house these critical care units. It is expected to be completed in 2007, and will take each of these critical care units to 24 beds. Obviously, the impact on staffing and educational needs, specifically simulation training, will be dramatic. Additionally, we have five adult subacute care units. While all of these units have a predominant specific type of patient population focus, all must be able to take patient overflow for each other. One of these units focuses on the cardiovascular patient. It has 20 beds (all with telemetry monitoring), and a staffing goal of approximately 42 full-time nurses. The second unit focuses on the trauma-surgical patient. It has 20 beds as well, all with telemetry monitoring and also has a staffing goal of 42 full-time nurses. The other three subacute care units were originally medical- surgical units. Owing to the high patient acuity and the con- comitant need for telemetry beds, our hospital has gradually brought these units to the subacute level. One of the units focuses on renal patients. It has 20 beds, all of which are now hardwired with monitors. It is staffed with 34 employees (full- and part-time) at present. The fourth focuses on oncology and clinical research inpatients. It has 16 beds, six of which have telemetry monitoring. The unit is staffed for 25 full-time nurses. The fifth subacute care unit is the smallest, and focuses on neuroscience patients. It has six beds (increasing to 10) with telemetry monitoring collectively housed as an old-style ward, within a larger 27-bed unit. All nurses in that unit are expected to be able to staff the subacute care unit as needed. 4.3 Simulation Capabilities The simulation and virtual experience opportunities at our center are referred to as the B.A.T.C.A.V.E. It is both a descrip- tive mnemonic, a physical location, as well as a cost center. The mnemonic stands for Basic Advanced Trauma Computer Assisted Virtual Experience, and is cofunded by our center and the University of New Mexico School of Medicine. Our center has three high-fidelity patient simulators, two adults and one pediatric. At the present time, only one of our high-fidelity simulators is housed in a setting that has piped- in gases (nitrogen, carbon dioxide, and oxygen) and live wall suction (Figure 4.1). It has a control booth with a one-way viewing window, audiovisual capability allowing for recording (Figure 4.2), and audio/video reproduction of the room and its events into a separate breakout room (that can hold 10 clinical learners), or onto a large screen in the main, multipurpose room (Figure 4.3), with space for up to 30 clinical learners. The other two high-fidelity simulators are currently housed in separate rooms. However, they do not have piped-in gases, live suction, nor a control booth at this time. These simula- tors require their own air compressors, which are quite noisy (Figure 4.4 and 4.5). (Remodeling is expected to begin for these rooms in the near future, and that, hopefully, will permit the creation of control booths, piped-in gases, and live wall suction.) We have three mid-fidelity patient simulators that are trans- portable. One is an adult, one is capable of simulating labor and delivery (Figure 4.6), and one is a neonate (Figure 4.7). We also have one mid-fidelity heart and breath sound sim- ulator (Figure 4.8) that generates signals with the assistance of a computer-based model, and is interactive with multi- ple, simultaneous clinical learners. We have also recently pur- chased a high-fidelity cardiac auscultation software package (UMedic ) [2]. We have numerous low-fidelity mannequins that are utilized for skill development (as with intubation technique) or as environmental props in the setting of mid- or high-fidelity simulations for embedded learning opportunities. In addition, numerous partial-task simulators and their attendant clinical devices greatly extend the range of clinical skills experienced prior to first attempts on live patients. These devices are housed within four breakout rooms. These rooms have the space for up to 10 clinical learners each. Located in separate sites, our center has several high-fidelity, virtual reality simulators. These simulators permit the clinical learner to develop bronchoscopy, endoscopy, colonoscopy, and surgical suturing techniques prior to these procedures being performed on a live patient.
- 50. 4 Basing a Clinician’s Career on Simulation 33 FIGURE 4.1 High-fidelity patient simulation room with piped-in gases. FIGURE 4.2 Control booth for the high-fidelity patient simulator referenced in Figure 4.1.
- 51. 34 II What’s In It For Me FIGURE 4.3 Main room of the B.A.T.C.A.V.E. FIGURE 4.4 Second high-fidelity patient simulator (same as in Figure 4.1 but run by compressor).
- 52. 4 Basing a Clinician’s Career on Simulation 35 FIGURE 4.5 High-fidelity pediatric patient simulator run by compressors. FIGURE 4.6 Mid-fidelity patient simulator and laboratory for labor and delivery.
- 53. 36 II What’s In It For Me FIGURE 4.7 Mid-fidelity neonatal patient simulator laboratory. FIGURE 4.8 Mid-fidelity cardiac and breath sound auscultation simulator.
- 54. 4 Basing a Clinician’s Career on Simulation 37 4.4 Topics of Study Educators and clinical learners who benefit from this technol- ogy at our center are multidisciplinary in health care back- ground, educational experience, and professional experience. Currently, we provide educational opportunities to students from the University of New Mexico Schools of Medicine, Nurs- ing (undergraduate, graduate nursing including family and acute care nurse practitioners), Physician Assistant, and Phar- macy. Additionally, we provide educational opportunities to physical therapy, paramedic, and respiratory therapy students. Educational opportunities involving simulation are also offered to medical residents, nurses, nurse technicians, respira- tory therapists, pharmacists, and paramedics working within the health care sciences center, for the purposes of establishing and maintaining competency, and/or professional development. 4.4.1 Magnet Recognition Adoption of a new educational philosophy was also congru- ent with the center’s drive toward its application to the Magnet RecognitionProgram establishedbytheAmericanNursesCre- dentialing Center (a subsidiary of the American Nurses Associ- ation) [3], and concomitantly serves as an excellent recruitment and retention tool. This is especially apropos in light of the cur- rent professional health care personnel shortage (The Magnet Recognition Program is described in Table 4A.1). 4.4.2 The Reality While all of this sounds quite appealing and laudatory in its goals, it quickly presented the clinical educators with numerous challenges: • Using the Benner educational model at a practical level for the bedside clinician. • Clarity with the use of terminology and appropriate definitions (e.g., Competent as a Benner level versus competency). • Educating the educator in relation to constructing learn- ing objectives and validation criteria appropriate for the identified Benner level. • Educating the educator about evaluation roles necessary to achieve learner outcomes (mentor, coach, evaluator). • Appropriate selection of the level of simulation and envi- ronmental fidelity. The first four of these challenges are referent to the process involved with the adoption and application of the Benner model. The last challenge is referent to the space and fiscal constraints of the B.A.T.C.A.V.E. Because of these constraints, our center’s focus is on “sufficient” fidelity to achieve the educational goals, and not “perfect” fidelity just for its own sake. 4.5 An Overview of Benner’s Novice to Expert In the early 1980s, Patricia Benner described a skill acquisition model for critical care nurses founded upon clinical experi- ences acquired over time in conjunction with development of critical thinking in relation to the patient and clinical setting. She described five levels that all clinical learners are expected to progress to over time: • Novice • Advanced Beginner • Competent • Proficient • Clinical Expert Distinctions between the levels are related to how the clinical learner applies six aspects of clinical judgment and skill acquisi- tion (Table 4A.2). How the clinical learner demonstrates these aspects of clinical judgment and skill acquisition within a given level are referred to as milestones (Table 4A.3) [1, 4, 5]. The first aspect is performing reasoning-in-transition. This is the ability of the clinician to recognize and reason about changes in the patient’s baseline physiological, psychological, and/or emotional status and act upon it (thinking in action). The second aspect is applying skilled know-how. Essentially, this is the capability of knowing what to do for the patient, and when to do it in the context of the immediate critical care environment (situational relevancy). The third aspect is demonstrating response-based prac- tice. It is one thing to read about clinical manifestations of pathophysiology or responses to medications and successfully complete a written examination, and another to take that knowledge and simultaneously apply it and respond to the patient within the immediacy of the situation at hand (crisis management). The fourth aspect is presenting agency. This involves improv- ing the clinician’s engagement with the patient, acceptance of responsibility, and becoming a valued member of the health care team. The fifth aspect is developing perceptual acuity and skill of involvement. In order to problem solve, the clinician must first identify the problem by defining and framing it. This requires perception, and perception requires engagement with the problem, the patient, and the critical care environment. The sixth aspect is linking ethical and clinical reasoning. Good clinical judgments and clinical practice, and optimal patient outcomes must be considered in relation to what the patient or family views as such. It involves the balance between the ethi- cal concepts of beneficence and nonmalfeasance during times when the patient and family are most distressed and vulnerable. Thus, as one transitions from novice to expert, the clinician will change from a rule-based approach and concrete thinking to the application of abstract principles and evidence-based
- 55. Another Random Document on Scribd Without Any Related Topics
- 59. The Project Gutenberg eBook of L'Illustration, No. 0055, 16 Mars 1844
- 60. This ebook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this ebook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook. Title: L'Illustration, No. 0055, 16 Mars 1844 Author: Various Release date: October 16, 2013 [eBook #43964] Most recently updated: October 23, 2024 Language: French Credits: Produced by Rénald Lévesque *** START OF THE PROJECT GUTENBERG EBOOK L'ILLUSTRATION, NO. 0055, 16 MARS 1844 ***
- 61. Ab. pour Paris.--3 mois, 8 fr.--6 mois, 16 fr.--Un an, 30 fr. Prix de chaque No. 75 c.--La collection mensuelle br., 2 fr. 75. Ab. pour les Dép.--3 mois, 9 fr.--6 mois, 17 fr.--Un an, 32 fr. pour l'Étranger. -- 10 -- 20 -- 40 Nº 55 Vol. III.--SAMEDI 16 MARS 1844. Réimprimé.--Bureaux, rue Richelieu, 60.
- 62. Sommaire. Histoire de la Semaine. Rupture d'une digue.--Chronique musicale. Corrado d'Altamura; I Puritani; l'Orphéon; Oreste et Pylade.--Salon de 1844 (1er article). L'Incendie de Sodome, par M. Corot; les Laveuses à la Fontaine, par M. A. Leleux; Une bohémienne, par M. Eugène Tourneux; Mosquée, par M. Dauzats; Sainte Famille, par M. Decaisne; Un prisonnier, par M. de Lemud.--Romanciers contemporains. Charles Dickens. (Suite.) Eden en perspective et Eden en réalité. Vue de l'Eden.-- Courrier de Paris. Matinée d'Enfants costumés; la Procession des Blanchisseuses.--Une Vocation. Nouvelle, par P. de K. Amélioration des Voies Publiques, à Paris. Plan.--Nouvelles Recherches sur un petit Animal très-curieux. (1er article.) Vingt-quatre gravures.-- Bulletin bibliographique.--Modes. Travestissements. Deux Gravures.- -Danse de la Polka. Caricature par Cham.--Amusements des Sciences.--Rébus.
- 63. Histoire la Semaine. Les éléments conjurés ont, cette semaine, fait une rude guerre à la mature et lutté avec avantage contre la politique en lui disputant, par leurs sinistres bulletins, les colonnes des journaux. Les feuilles des départements sont remplies de tableaux de mines, de récits de désastres. Ici, quand on est allé voir l'inondation assez innocente de Bercy, de la Gare ou de la plaine d'Asnières, les fossés pleins d'eau de la place Louis XV, et les cuisines envahies des Tuileries, on est au courant de tous les méfaits de la Seine parisienne; mais nos fleuves, nos rivières, en font malheureusement bien d'autres dans les départements. Dans celui de la Gironde, le service des malles-postes a été interrompu, et il a fallu recourir, pour y suppléer, à des bateaux à vapeur. Dans celui de la Sarthe, cette rivière ayant également couvert les chaussées et forcé les populations à communiquer en bateaux, de nombreux événements sont venus jeter la désolation dans ces contrées. Près du pont de Châteaueuf, une barque montée par six personnes, dont un enfant, a été submergée: l'enfant seul, retenu par un arbre, a été miraculeusement sauvé. La Moselle et le Rup-de-Mad ont, de concert, envahi le pays qu'ils traversent. Le village d'Arnaville a été encore plus complètement inondé que les autres, et des nacelles, montées par des hommes courageux, sillonnaient en tous sens cette triste Venise improvisée, et apportaient l'eau et le pain nécessaires aux habitants captifs et désespérés. Dans le département de Maine-et-Loire, la Loire a causé des malheurs et exercé des ravages plus déplorables encore. Cette route, qui sert de digue à ce fleuve, et que tous les voyageurs qui ont parcouru ce pays si pittoresque connaissent sous le nom de la levée, a été rompue en plusieurs endroits, et a ainsi fourni passage à des torrents qui sont allés renverser des constructions et couvrir de sables les champs si fertiles de cette immense vallée. C'est là que les désastres ont été les plus pittoresques, et c'est une des scènes qui se sont produites au pied des coteaux de la Loire, et en présence des ruines historiques qui les couronnent, que nos artistes ont cru devoir préalablement retracer.
- 64. Rupture d'une Digue. Si de ces tristes tempêtes nous passons aux orages politiques, nous aurons la satisfaction de dire que, cette semaine, M. Sauzet n'en a pas eu de bien furieux à maîtriser. --La chambre des députés, qui avait accumulé dans son ordre du jour de samedi dernier à la suite de la discussion du rapport sur les pétitions relatives aux fortifications de Paris et la discussion de la proposition de M. Cimbarel de Leyvil sur le vote par division, prévenue que les opérations du collège électoral de Louviers lui seraient soumises dans cette même séance, a sagement renvoyé au 16 le débat sur la prise en considération de la modification qu'on lui propose d'introduire dais son règlement. Évidemment, il était aisé de prévoir qu'il y aurait largement de quoi remplir une séance dans la vérification des pouvoirs de M. Charles Laffitte et dans la nouvelle discussion à laquelle devait donner lieu le rapport de M. Allard. Il est même plus que probable que cette dernière question eût, à elle seule, absorbé plus de temps qu'on ne lui en avait assigné par avance, si le savant orateur qu'on a entendu eût, comme les autres membres de l'opposition qui l'avaient précédé à la tribune, soutenu uniquement les pétitions qui demandaient que le ministère fût tenu de se renfermer, pour la fortification de Paris, dans les limites de la loi de 1841. Mais M. Arago, sans se préoccuper
- 65. probablement beaucoup du succès, et plus désireux de dire avec sa logique vigoureuse et sa forme incisive son fait au rapporteur que de faire avancer la question, a, avec la spirituelle abondance qu'on lui connaît, lancé ses arguments par-dessus le débat, tel qu'il avait été précédemment posé, pour aller atteindre plusieurs dispositions essentielles de la loi de 1841 et M. Allard en personne. Il a discuté l'inconvénient, le danger, selon lui, des forts votés par les chambres; il a refait, avec un esprit toujours nouveau les discours qu'il avait précédemment prononcés et les brochures qu'il avait plus récemment publiées. La Chambre l'a écouté, pendant plus d'une heure et demie, avec l'attention que commande un mérite éminent; mais, après une réplique de M. Allard, elle a voulu passer au vote. Sur la proposition de M. Dupin aîné, elle a écarté par l'ordre du jour toutes les pétitions qui ne tenaient aucun compte de la loi de 1841, et demandaient que ce que cette loi avait ordonné d'édifier fût détruit. Quant aux pétitions qui avaient protesté seulement contre l'extension illégale, selon elles et selon MM. de Tocqueville, Lherbette et de Lamartine, entendus dans la séance du 2, donnée par le ministère aux prescriptions de la loi, on a seulement voté la question préalable, réservant ainsi celle qu'elles soulèvent pour le moment où l'on aura à discuter les crédits demandés par le ministère pour ces travaux attaqués. Pour être historien fidèle, ou du moins chronologiste exact, avant de rapporter le débat en quelque sorte épisodique qui a assez froidement terminé la séance, nous aurions dû rendre compte du débat animé qui l'avait ouverte. M. Lebobe, comme rapporteur du bureau qui avait été chargé de la vérification des pouvoirs de M. Charles Laffitte, nommé une seconde fois à Louviers, était venu rendre compte des opérations du collège de cet arrondissement et conclure à l'admission de son élu. On savait qu'une minorité assez forte avait dans le bureau combattu ces conclusions, et l'on était curieux de savoir par quelles preuves nouvelles la majorité avait été déterminée à proposer à la chambre de revenir sur sa première décision, de se déjuger. On s'accordait à penser que, pour que la chambre fût amenée à une pareille et si nouvelle résolution, il fallait qu'on eût des témoignages bien différents de ceux qu'on avait précédemment recueillis et admis, des témoignages bien irrécusables. L'étonnement a été assez grand quand on a vu que M. le rapporteur n'avait absolument aucune preuve pour infirmer la première décision, et
- 66. que toute son argumentation, comme celle d'un autre membre du bureau qui lui a succédé à la tribune, M. Agénor de Gasparin, consistait à dire que s'il y avait eu corruption à la première élection, comme la chambre l'avait à la presque unanimité reconnu, une seconde élection couvrait tout, et que la chambre n'avait point à se croire liée par sa première décision, que le collège électoral, dans son omnipotence souveraine, avait cassée. Cette absence de preuves, cette théorie plus neuve que morale, ont porté malheur aux conclusions du bureau et à l'élu qu'il avait pris sous sa protection. M. Grandin, avec une netteté et une loyauté parfaites, a de nouveau et plus complètement encore démontré l'existence du marché qui a fait sortir de l'urne électorale le nom du soumissionnaire de l'embranchement de Louviers. M. Odilon Barrot, en repoussant le sophisme politique de M. A. de Gasparin, a été merveilleusement inspiré. Il a trouvé dans son respect sincère pour les droits du pays, dans sa sollicitude pour la dignité de la Chambre et dans la probité de son âme des accents qui ont été entendus. «Est-ce qu'il s'agit ici, s'est-il écrié, de la personne ou des opinions? Non; il s'agit de l'acte: c'est l'acte seul que vous avez à juger. On met en avant, a-t-il ajouté, la souveraineté des électeurs; oui, certes, les électeurs sont souverains dans l'exercice légitime et honnête de leur droit, pour donner librement leur vote suivant leurs sympathies, suivant leurs opinions, mais non pour le vendre. Là s'arrête le pouvoir souverain que je reconnais aux électeurs; là commence le vôtre... Le plus noble, le plus grand de tous les droits, celui de donner des législateurs à son pays n'est pas une de ces propriétés personnelles dont on puisse trafiquer; ce droit, c'est une fonction qu'ils exercent au nom de tous; il n'est pas plus permis aux électeurs de vendre leur vote qu'il ne le serait à un jury de trafiquer de son verdict.»--La Chambre après avoir applaudi à ces paroles éloquentes, à ces sentiments si nobles et si vrais, a invalidé la nouvelle élection de M. Charles Laffitte. On ne peut attribuer à ce débat d'avoir donné naissance à la proposition qu'ont déposée MM. Gustave de Beaumont, Lacrosse et Leyrand, pour mieux préciser le cas de corruption électorale et en fixer la pénalité. L'enquête à laquelle la Chambre actuelle s'est livrée, à la suite de la vérification générale des pouvoirs, le vœu exprimé par des conseils généraux, notamment par celui du département de la Creuse, que M. Leyrand représente, enfin le désir de conserver à l'élection sa sincérité,
- 67. et sa dignité à notre chambre élective, ont inspiré cette motion, qui ne doit à l'épisode de Louviers que son à-propos, tous les bureaux en ont admis la lecture; elle n'a rencontré que de rares contradicteurs, parmi lesquels ne s'est pas trouvé un seul député ministre. La Chambre aura en conséquence à voter, le 18, sur la prise en considération de cette proposition, dont la pensée est excellente, et dont les dispositions pourront encore être améliorées.--C'est également à l'ordre du jour du 18 qu'a été remise la discussion du projet relatif aux fonds secrets. M. Viger, au nom de la commission, a donné à la Chambre lecture d'un rapport qui conclut à l'admission pure et simple du projet. La Chambre a nommé ses commissions et pour le projet de loi relatif aux chemins de fer du Nord et de Vierzon, et pour celui du chemin de fer de Montpellier à Nîmes. Les projets de M. Dumon comptent une majorité assez forte; quelques commissaires penchent même pour la confection entière de tous les chemins par l'État. Ainsi les intérêts publics, que nous regardons comme déjà garantis par les projets du ministre, ne pourraient être que mieux servis encore s'il y était apporté des changements. La loi sur les patentes est arrivée à fin. On a vu, par ce que nous en avions cité précédemment, qu'elle ne fait guère que reproduire ce qui existait dans la législation précédente, et que les rares changements qu'elle a sanctionnés ne sont pas tous heureux. La patente reste un impôt de quotité. Un droit proportionnel continuera à être perçu sur l'habitation personnelle du patenté; enfin, avec les deux anciennes classifications très-nettes, très-tranchées, et par conséquent très-faciles à établir de marchands en gros et de marchands en détail, nous allons avoir le moyen terme, la classe amphibie des marchands en demi-gros, à laquelle on pourra faire élever un marchand en détail peu protégé, ou descendre un marchand en gros mieux vu de son contrôleur. Si cette dernière mesure n'avait d'autre effet que de rendre modestes tous les épiciers de nos coins de rue qui mettent sur leurs enseignes: Commerce de demi-gros, nous nous en réjouirions pour les peintres en bâtiment, qui vont, avoir bien de la besogne d'ici à la formation du rôle de 1845. Mais nous avons dit son danger, et les plaintes auxquelles elle donnera lieu ne tarderont pas à en faire sentir l'inconvénient à l'administration des contributions elle-même. Les dispositions de la nouvelle loi, qui ont le mérite de fixer des points de législation jusqu'ici incertains ou contestés,
- 68. sont celles qui établissent la part que le maire est appelé à prendre au recensement et son droit de faire consigner ses observations sur les procès-verbaux. La ville de Paris, dont les maires n'étaient jusqu'ici que des officiers purs et simples de l'état civil, est, à cette occasion, rentrée dans le droit commun, et a vu attribuer aux élus de ses douze arrondissements des pouvoirs analogues à ceux des maires des autres villes. C'est un premier pas vers une organisation municipale dont la capitale ne peut être privée longtemps encore. La chambre des pairs a voté la prise en considération d'une proposition de M. le comte Beugnot et de M. le président Boullet, relative à la surveillance des condamnés libérés, et ayant pour objet de conférer au gouvernement le droit de déterminer le lieu où les libérés mis en surveillance devront résider après l'expiration de leur peine, tandis qu'aux termes de l'article 44 du code pénal actuel, le gouvernement a seulement aujourd'hui la faculté d'interdire la résidence dans certains lieux qu'il détermine à son gré. Le Mémoire au roi des évêques de la province de Paris, que nous avons mentionné dans notre dernier bulletin, a motivé une lettre de M. le garde des sceaux adressée à M. l'archevêque et insérée au Moniteur, dans laquelle le ministre déclare cette démarche illégale, non pas seulement parce que ce Mémoire jette un blâme général sur les établissements d'instruction publique fondés par l'État, sur le personnel du corps enseignant tout entier, et dirige des insinuations offensantes contre M. le ministre de l'instruction publique, mais parce que la loi du 18 germinal au X interdit toute délibération dans une réunion d'évêques non autorisée, et qu'une correspondance collective n'est qu'un moyen d'éluder cette prohibition, en établissant le concert et opérant la délibération sans qu'il y ait assemblée. On a remarqué que postérieurement à la remise de ce Mémoire, un des signataires, M. l'évêque de Versailles, avait été élevé à la dignité d'archevêque de Rouen. Cette circonstance a rendu difficile à comprendre le blâme très-vif infligé tardivement à une démarche qui n'avait pas empêché la faveur ministérielle de se porter sur un de ses auteurs. Du reste, en réponse à la note du Moniteur, on lit dans l'Univers: «On assure que déjà plusieurs membres de l'épiscopat ont envoyé leur adhésion au mémoire des évêques de la province de Paris. C'est là, ce nous semble, la réponse la plus convenable qui puisse être
- 69. faite à M. Martin (du Nord). Monseigneur l'archevêque de Paris trouvera ainsi dans ces sympathies la consolante et glorieuse réparation de ce nouvel et impuissant outrage.» On annonce aussi que M. l'archevêque de Reims vient de rédiger un mémoire sur la question de l'enseignement, qu'ont signé avec lui M. l'archevêque de Cambrai, M. le cardinal-evêque d'Arras. MM. les évêques de Soissons, de Beauvais, de Châlons et d'Amiens. Ce nouveau mémoire est surtout dirigé contre le troisième article du projet de loi sur l'instruction secondaire, aux termes duquel nul ne peut être autorisé à ouvrir une école secondaire sans avoir préalablement déposé entre les mains du recteur de l'Académie l'affirmation par écrit et signée du déclarant, de n'appartenir à aucune association ni congrégation religieuse non légalement établie en France. Ce mémoire est adressé, non plus au roi, mais à M. le ministre des cultes. L'idée si utile de faire instituer, sous le patronage de l'État, une caisse de retraite pour les travailleurs des deux sexes, vient de faire un progrès, et le ministère se trouve en quelque sorte aujourd'hui mis en demeure de la faire arriver à réalisation. Une commission, présidée par M. le comte Molé, et composée en grande partie d'hommes politiques et d'industriels distingués, après s'être livrée à de longs travaux, à une étude approfondie de la législation anglaise de 1833, et à une enquête sur les améliorations dont l'expérience doit conseiller l'adoption, a formulé un projet de loi et un exposé de motifs, et est allée les présenter à M. le ministre des finances, qui a promis d'entreprendre sans retard l'étude de cette question et l'examen de ce travail. Les principales dispositions de ce projet sont celles-ci: Toute personne âgée de 21 ans au moins pour les hommes, de 18 pour les femmes, et de 15 au plus pour les deux sexes, est admise à faire le versement d'une prime annuelle pour obtenir de l'État une pension de retraite, calculée sur une mortalité moyenne entre la table de Duvillard et celle de Deparcieux. La femme mariée aura le droit de se constituer une pension, et d'en percevoir les arrérages; en cas de refus d'autorisation du mari, le juge de paix y suppléera. Le minimum de la pension sera de 60 fr., et le maximum de 480 fr. La pension partira de l'âge de 50, 55, 60 ou 65 ans, au choix des contractants, mais à la condition que l'entrée en jouissance sera séparée de l'époque du premier versement par 20 ans au moins. Au décès du contractant, soit avant, soit après l'ouverture de la pension, il sera payé
- 70. une somme égale à une année de la pension, savoir: au conjoint survivant; à son défaut, aux descendants légitimes; à leur défaut, aux ascendants légitimes. Le montant de ces paiements ne pourra excéder celui des primes versées; toutefois il sera prélevé et payé, dans tous les cas, une somme de 30 francs pour servir aux frais funéraires;» Nous ne saurions assez applaudir à un projet qui rendra à la classe ouvrière un service immense, et qui, en même temps, que l'État ne le perde pas de vue, pourra servir à conjurer le danger auquel il s'est exposé en se rendant dépositaire des fonds des caisses d'épargne. La plupart de ces dépôts seront convertis en primes annuelles pour servir à la constitution des pensions; il pourra ainsi faire passer une grande partie des sommes qu'il a entre les mains du compte toujours exigible des caisses d'épargne au grand-livre de la dette publique viagère et non remboursable. Cette institution nouvelle sera donc le salutaire complément et le correctif fort bien entendu des caisses d'épargne telles que les a faites une imprévoyante disposition. L'Angleterre poursuit, elle aussi, la réduction de l'intérêt de sa dette. Le 3 12 sera converti en 3 00; l'accueil qui a été fait à ce projet ne permet pas de douter que prochainement il ne devienne loi.--La sympathie des Anglais pour l'Irlande se manifeste avec une expansion et une énergie qui doivent embarrasser le ministère Peel et lui donner à réfléchir. On prépare à Londres, pour O'Connell, un banquet monstre qui rappellera les plus nombreux meetings d'Irlande, mais ce sera un meeting où l'appétit des assistants trouvera son compte comme leur patriotisme. On dit que plusieurs membres de la chambre des lords assisteront à ce banquet, où l'on est sûr de voir du moins un grand nombre de membres de la chambre des communes. En attendant, le libérateur a assisté à Birmingham à un grand meeting pour le suffrage universel, et a remercié avec effusion les Anglais libéraux de leurs sentiments envers l'Irlande. «Maintenant, a-t-il dit, je suis sûr que ma patrie sera libre, et qu'il y aura union véritable entre l'Irlande, l'Écosse et l'Angleterre.» Les troupes d'Isabelle ont occupé Alicante, dont la garnison s'est rendue après rembarquement de Bonet. D'autres correspondances disent que ce chef d'insurgés est tombé au pouvoir des forces royales, et qu'il a été immédiatement passé par les armes. Mais le spectacle sur lequel on veut en ce moment attirer tous les yeux en Espagne, c'est la marche rendue
- 71. triomphale de Marie-Christine à travers la Catalogue. Tous les journaux de cette province, ceux du moins auxquels il est permis de paraître, sont, à l'occasion de la rentrée de la reine-mère, imprimés sur papier de couleur, en signe de fête, remplis de vers élogieux et illustrés de gravures. Dans une de ces compositions nous avons vu l'ex-régente, conduite par une divinité, s'avancer au milieu d'une population empressée et fouler à ses pieds l'hydre des révolutions sous les traits d'Espartero. L'Académie française, dans sa séance du 14, a procédé à des élections pour le remplacement de MM. Casimir Delavigne et Ch. Nodier. On se rappelle que la désignation du successeur du premier avait déjà amené une lutte que n'avaient pu terminer sept tours consécutifs de scrutin. Les membres votants étaient au nombre de 36; la majorité était donc de 19. M. Sainte-Beuve est, cette fois, venu beaucoup plus facilement à bout de son compétiteur. Dès le premier tour de scrutin il avait compté 17 voix en sa faveur; il en a réuni 21 au second. L'Académie a prononcé ensuite sur la succession de M. Ch. Nodier. Au premier tour de scrutin les voix se sont partagées entre MM. Mérimée, 10; Casimir Bonjour, 7; Aimé Martin, 7; Vatout, 5; Alfred de Vigny, 4; Émile Deschamps, 2; Onésime Leroy, 1. Il a fallu sept tours de scrutin pour donner enfin la majorité à M. Mérimée. L'Académie a donc fait deux choix que l'opinion publique s'empressera de ratifier. Nous avons, dans notre numéro du 13 janvier dernier, rendu hommage à la vie si bien remplie de Mathieu de Dombasle, à sa mémoire si digne de vénération. Aujourd'hui nous avons à annoncer qu'un digne tribut va lui être payé. Une souscription, qui a bien le droit de s'intituler nationale, est ouverte, dans les bureaux du Cultivateur, rue Tanume, n° 10, pour l'érection à Nanci d'un monument en l'honneur de l'illustre fondateur de Roville. Une commission, qui sera composée de pairs de France, de députés, de membres de l'Institut et de nos principales illustrations agronomiques, sera chargée des soins que réclamera l'accomplissement de ce projet.--Une autre souscription remplit aussi les colonnes du National, qui le premier en a eu l'idée, et de la plupart des journaux des départements. Elle a pour but d'offir une épée d'honneur au contre- amiral Dupetit-Thouars. Bien qu'un maximum bien bas ait été fixé pour chaque offrande, le chiffre de cinquante centimes, une somme
- 72. considérable se trouve déjà réalisée par suite de l'influence des innombrables citoyens qui sont allés se faire inscrire. Le modèle du tombeau de Napoléon est terminé; voici en quoi consiste ce spécimen. Il se compose de douze pilastres ayant entre chacun d'eux un entre-colonnement à jour bordé d'une galerie circulaire. Cette galerie communique à deux escaliers dont l'issue aura lieu par le souterrain qui doit communiquer de l'église (près du chœur) à la crypte. Douze figures de Victoires, tenant chacune une couronne à la main, décorent le pourtour de celle-ci. Ces statues, d'une proportion gigantesque, sont adossées contre les pilastres. Au-dessus règne une large frise décorée d'allégories et de bas-reliefs. Le sarcophage qui doit renfermer le cercueil impérial ne dépasse pas le niveau du sol. Cette mesure a été adoptée, afin de ne rien ôter de l'harmonie générale de l'architecture du dôme, et de lui conserver tout le cachet historique de l'époque de Louis XIV. A la hauteur du sol, et tout autour de la crypte, est établie une enceinte bordée d'une balustrade à hauteur d'appui, d'où le public pourra voir tout l'ensemble du monument. Il n'a été fait sur ce modèle aucune inscription. La commission a décidé qu'on y graverait seulement le nom de Napoléon, Enfin, on a décidé que l'épée de l'empereur, ainsi que son chapeau, la couronne impériale, la couronne de fer et la décoration de l'ordre de la Légion d'honneur, qu'il a instituée et qu'il portait à Sainte- Hélène, seraient déposés sur sa tombe. M. de Sausm, évêque de Blois et doyen de l'épiscopat français, vient de mourir au chef-lieu de son diocèse, il était né le 11 février 1756. C'était un proche parent de Condorcet. Après avoir été grand vicaire de Valence, il fut nommé évêque de Blois lors du rétablissement de ce siège épiscopal en 1822. Nommé plus tard à l'archevêché d'Avignon, il refusa. Il refusa également la croix d'honneur: «J'ai assez, dit-il, de ma croix d'evêque.» Vivant trés-modestement, il employait ses revenus à des actes de bienfaisance.--Monseigneur l'évêque de Blois rendait le dernier soupir le 6; le 7, M. de Tournefort, évêque de Limoges, succombait à une longue et douloureuse maladie, dans sa quatre-vingt-troisième année. Son testament, déposé au greffe du tribunal, établit que ce prélat meurt dans un état de pauvreté complète, et ne laisse pas de quoi pourvoir aux frais de son inhumation.
- 74. Chronique musicale. THÉATRE-ITALIEN: Corrado d'Altamura; I Puritani.--L'ORPHÉON.-- THÉATRE DE L'OPERA COMIQUE: Oreste et Pylade. Vraiment le Théâtre-Italien est d'une activité merveilleuse et qui devrait faire rougir de honte nos deux théâtres lyriques français. En six mois, il fait autant ou plus de besogne que ses deux concurrents n'en font dans toute une année. Nous avons déjà rendu compte de Belisario, de Maria di Rohan, du Fantasma, sans compter les reprises d'ouvrages anciens, auxquels des chanteurs nouveaux donnaient un vif attrait. Voici une dernière reprise et un dernier opéra inconnu jusqu'ici en France, qui vont clore dignement une saison si bien employée. L'opéra nouveau est intitulé: Corrado d'Altamura. Il a trois actes, on plutôt deux actes, dont le premier est divisé en deux parties, pour ménager l'attention des auditeurs. Il est de M. Frédéric Ricci, jeune compositeur italien qui a fait tout exprès le voyage pour le faire représenter et assister aux répétitions. On n'exigera pas de nous de grands détails sur le libretto que M. Frédéric Ricci a mis en musique. Corrado n'est pas un géant comme le sont d'ordinaire les héros d'opéra: c'est un père, un père tendre, qui adore sa fille et n'entend pas raillerie sur les mauvais tours qu'on lui joue. C'est ce qu'un certain chevalier félon, appelé Roger, apprend bientôt à ses dépens. Roger s'est fait aimer par la belle Delizia, fille de Corrado, ou Conrad. Il lui a promis mariage; il porte à son doigt l'anneau des fiançailles, gage de leur foi mutuelle. Il doit l'épouser après la campagne. Mais le drôle est ambitieux. Le grand chancelier de Sicile, qui ne sait rien des engagements de Roger, lui offre sa fille, et Roger accepte sans se faire prier. La fille d'un chancelier est bonne à prendre. Mais Bonello ne laissera pas le crime s'accomplir.
- 75. Bonello est un brave jeune homme, assez joli garçon, bien que sa poitrine étale un embonpoint un peu trop féminin, qui nourrit en secret pour Delizia une affection délicate. Il a vent de ce qui se passe, et il en avise le papa Conrad, qui se met dans une grande colère. Tous deux, et avec eux Delizia, se mettant en route pour Palerme, et arrivent chez le chancelier au moment même de la célébration du mariage. Delizia parait la première et montre son anneau; Conrad et Bonello disent à Roger une foule de choses désagréables, auxquelles celui-ci n'a rien à répondre. Jugez de l'indignation du chancelier! Le mariage est rompu, et le maraud, débouté, va cacher on ne sait où sa honte, sa jolie figure et ses cheveux en tire-bouchon. Car ce drôle était coiffé tout justement comme un roi d'Assyrie ou comme une vieille Anglaise, et, nous l'avouons, il nous est difficile de pardonner à Delizia un attachement si vif pour un homme aussi ridiculement accommodé. Nous le demandons à toute femme qui a du sens, voudrait-elle d'un amant coiffé en tire-bouchon? Delizia finit par être tout à fait de notre avis. Elle ne se pardonne pas à elle-même d'avoir eu si peu de discernement; elle se met au couvent pour expier son erreur. Le moyen le plus sûr de réparer un mauvais choix serait pourtant d'en faire un meilleur: c'est notre opinion, du moins, et celle de Bonello, et aussi celle de Conrad; mais Delizia est en train de faire des sottises. Bonello jure de se venger sur son rival. Quant à Conrad, il ne jure rien; mais Roger venant tout à coup se présenter à lui, il profite de l'occasion, il provoque son ennemi, le force à se battre, et lui perce la poitrine d'un grand coup d'épce. Quand il a le poumon gauche ainsi coupé en deux, Roger revient chanter un duo avec Delizia, puis un quatuor avec la même, Conrad et Bonello; et nous déclarons que jamais il n'a eu la voix si fraîche, si pure et si retentissante. Voilà sans contredit une admirable recette, et nous la recommandons à M. Léon Pillet, qui cherche partout des ténors. Au lieu d'aller en Italie, que ne fait-il ouvrir la poitrine à M. Marié? Ce libretto est, comme on le voit, aussi innocent que tout autre. Voilà les fleurs poétiques que produit aujourd'hui la terre qui porta jadis Métastase, Casti et Da Ponte. Heureusement la partition vaut un peu mieux que le livret. Non pas que nous la donnions pour un chef-d'œuvre, l'Italie n'enfante plus de chefs-d'œuvre; et des deux côtés des Alpes il
- 76. semble que pour le moment, l'art se repose, comme un champ que trop du culture a épuisé. M. Ricci n'a fait qu'une œuvre éphémère comme tant d'autres... raison du plus pour que nous soyons indulgents à l'égard de ce compositeur. Ne faisons pas à son amour-propre des blessures que la postérité ne guérira pas. A tout prendre, sa partition n'est point ennuyeuse; on l'écoute sans fatigue, et quelquefois on l'entend avec plaisir. M. Ricci est mélodiste, comme tous les Italiens, et même ses mélodies ont de temps en temps une apparence d'originalité qui ne déplaît pas. Il s'attache à varier ses mouvements et ses rhythmes, et l'on n'est pas tenté de prendre son opéra pour un seul morceau infiniment trop prolongé. Ce qui lui manque surtout, c'est ce qu'on acquiert avec de l'étude et de l'expérience, nous voulons dire l'art des préparations et des développements, l'art de coordonner les différentes parties d'un morceau, et de lui donner une forme convenable. Il n'est pas grand harmoniste, et module parfois assez maladroitement; mais enfin il a des idées, ce qui est une grande qualité par le temps qui court. On a remarqué la cavatine assez gracieuse de Delizia, au premier acte, le début de son duo avec Roger, l'air de Conrad, fort bien chanté par M. Ronconi,--bien qu'avec un peu trop de violence peut-être,--et des couplets que l'auteur a mis dans la bouche de Delizia, couplets dont la fin est gauche et péniblement contournée, mais dont le début est franc et original. Nous ne parlons pas de la charmante cavatine de Bonello, que madame Brambilla exécute avec tant de charme: c'est un emprunt que M. Ricci a fait à son frère aîné. Luigi Ricci, auteur de Scaramuccia, de Chiaradi Rosenberg et de plusieurs autres ouvrages connus. Le final du second acte produit assez d'effet; il en ferait plus encore s'il était moins long. Il y a des qualités dans le duo du troisième, entre Roger et Delizia, lequel se termine en quatuor et termine la pièce; mais toutes ces qualités sont perdues pour être employées mal à propos. Il est trop absurde de faire exécuter un crescendo à un homme blessé à mort, et qui n'attend que la cadence finale pour expirer.
- 77. Le meilleur morceau de l'ouvrage est un petit trio par où débute le troisième acte: il est fort bien fait; il s'élève de beaucoup au-dessus du niveau commun; il ne mérite aucun des reproches que nous avons adressé au reste de l'ouvrage. Que M. Ricci nous donne un nouvel opéra dont tous les morceaux aient autant de valeur que le petit trio dont nous parlons, et il peut compter sur nous pour proclamer son génie et pour célébrer sa gloire. --Les Puritains n'avaient pas été représentés une seule fois l'an passé; on les a repris lundi dernier avec un grand éclat. La salle était pleine, littéralement. Du parterre aux quatrièmes loges, on eût cherché vainement une place pour un spectateur du plus. L'œuvre de Bellini a été accueillie d'un bout à l'autre avec un enthousiasme inexprimable; elle était, il faut le dire, dignement exécutée: madame Grisi et Lablache y ont eu les plus belles inspirations. Jamais la voix de Mario n'avait paru plus énergique ni plus touchante. M. Ronconi, qui remplaçait Tamburini, a été un peu faible au premier acte; mais il a pris au second une éclatante revanche, et le célébré duo Suoni la tromba intrepida a été applaudi et redemandé avec fureur. Hélas! toute cette admiration et tout ce bruit nous rendront-ils cet aimable et malheureux jeune homme à qui le ciel avait donné tant de génie, et que la mort est venue arrêter tout à coup au début d'une carrière qui devait être si brillante? --Nous avons donné l'année dernière sur l'Orphéon et les écoles publiques de chant organisées par D. Wilhem, et dirigées aujourd'hui par son digne successeur, M. Hubert, des détails assez étendus pour que nous n'ayons pas besoin d'y revenir. Deux réunions solennelles ont eu lieu tout récemment dans la grande salle de la Sorbonne; il n'y avait là ni artistes ni chanteurs de profession, mais de laborieux et modestes ouvriers (l'élite, il est vrai, des bons ouvriers de Paris), de jeunes enfants de tous les quartiers, pour qui le chant n'est qu'une étude accessoire, une noble et morale récréation, des amateurs, en un mot, des amateurs pris dans les derniers rangs de la société parisienne. Il faut, dit le proverbe, se défier des concerts d'amateurs. En général, le proverbe a raison; mais, relativement aux amateurs de l'Orphéon, il a tort. Cette armée chantante, si nombreuse et si bien disciplinée, a fait entendre successivement plusieurs morceaux des plus grands maîtres, qui ont été dits avec une justesse et un ensemble, souvent même avec une pureté,
- 78. un goût et une délicatesse de nuances qui ont excité, à plusieurs reprises, l'attendrissement et l'admiration de l'auditoire. --Oreste et Pylade, ouvrage représenté dernièrement à l'Opéra-Comique, n'est qu'un vieux vaudeville joué aux Variétés vers l'an 1820. Le compositeur, M. Thys, voyant qu'au lieu d'un poème on ne lui donnait qu'un vaudeville, a jugé à propos de rendre à M. Scribe la monnaie de sa pièce; au lieu d'une partition d'opéra, il n'a fait qu'un album de chansonnettes. La revanche a été complète et éclatante. M. Thys et M. Scribe sont évidemment deux hommes d'égale force; ils se sont moqués l'un de l'autre avec beaucoup d'esprit, et un succès égal. C'est la fable du renard et de la cigogne qu'ils ont mise en action; mais, dans cette affaire, M. Scribe a été le renard. Les concerts se succèdent presque sans interruption. Dans un prochain numéro nous apprécierons le talent des artistes les plus remarquables et les plus remarqués cette année.
- 79. Salon de 1844. (PREMIER ARTICLE.) Vendredi soir, 15 mars. Nous sommes encore tout meurtri; malgré la foule qui assiégeait les portes du Musée, nous avons pu entrer dans le sanctuaire. Mais notre coup d'œil a été rapide, et nos impressions sont encore vagues. Dans d'autres articles, nous essaierons de faire connaître et d'apprécier les ouvrages les plus remarquables du salon de 1844. Aujourd'hui nous ne pouvons que mentionner à la hâte sept à huit tableaux qui nous ont particulièrement frappé, et donner quelques détails encore incomplets sur ceux que nos dessinateurs ont déjà pu reproduire. Nous mettons en pratique les principes sur l'art que M. le baron Taylor exposait, il y a quelques années, dans un ouvrage remarquable sur le Salon. «Notre premier but, disait-il, a été d'encourager les artistes par la publicité que nous offrons à leurs œuvres. Nous ne renonçons point, ni au désir, ni au droit de les éclairer de nos conseils; mais notre critique, à nous, sera toujours amicale et bienveillante, et elle s'efforcera surtout d'être utile par des renseignements non moins réfléchis que désintéressés.» Ne semble-t-il pas que ces lignes aient été écrites pour l'Illustration, dont le but, ici, est de populariser les œuvres les plus remarquables? Nous marchons au hasard, sans chercher tel ou tel peintre, sans établir du catégories, sans même nous préoccuper des noms plus ou moins célèbres qui honorent la peinture française; et cependant nous aimons à signaler de grandes œuvres. Le Salon de 1844 n'est pas aussi faible que bien des gens se plaisent à le dire; des talents nouveau se sont manifestés, et nous le constatons avec plaisir; nous leur rendrons la justice qui leur est due. M. Adrien Guignet a fait un pas de géant; son Salvator Rosa chez les brigands est une de ces compositions où tout se trouve; l'effet, la couleur et l'ensemble. Ces montagnes sauvages, ces routes impraticables, voilà
- 80. bien la nature qu'aimait et étudiait Salvator Rosa! Son talent se retrempait au milieu de ces sites âpres et grandioses. M. Adrien Guignet a bien compris son sujet, et, ce qui était plus difficile, il l'a parfaitement rendu. Salvator Rosa est comme une introduction à la Mêlée, non pas imitée de ce maître, mais peinte dans son style, la Mêlée est une immense composition, si l'on considère la multitude de personnages qui agissent dans les différents groupes du tableau. Le mouvement est remarquable; la bataille est arrivée à son apogée: Soldats, fantassins et cohortes, Tombaient comme des branches mortes Qui se tordent dans le brasier, a dit le poète. Nous avons parlé de l'effet du tableau. La couleur en est vigoureuse, mais, à notre avis, un peu trop bistreuse. L'ensemble, principalement, fait de cette toile une grande œuvre. Il ne manque à M. Adrien Guignet que la réputation; mais, patience, la réputation est encore plus facile à acquérir que le talent, son paysage et ses dessins ne le cèdent qu'en importance à Salvator Rosa et à la Mêlée. M. Guignet aîné a exposé plusieurs portraits. Cette fois, la critique ne pourra, sans injustice, lui être hostile, et reconnaître les brillantes qualités qui le distinguent. Le style sévère dont cet artiste ne s'écarte jamais le maintiendra dans une bonne route, et il vaut mieux le voir sobre de tons, que visant à ce que nous appellerons le papillotage. Son portrait en pied de madame la comtesse de *** est en tous points hors ligne. Une dignité aristocratique, un maintien noble, et l'expression des figures de la comtesse et de sa jeune fille, font de ce portrait une œuvre à la hauteur de celles des maîtres; jamais M. Guignet aîné n'avait traité les accessoires avec plus de conscience, jamais non plus il n'était arrivé à une ressemblance aussi exacte, aussi poétique, ajouterons-nous. Son portrait de madame Laetitia Bonaparte est fort beau, et va de pair avec celui de madame la comtesse de ***. Nous en avons remarqué un autre qui, dès l'abord, ne nous a point paru être sorti de l'atelier de M. Guignet aîné, tant la nuance était différente de celle qu'il a adoptée. Dans cette toile, M. Guignet aîné a abandonné le style sévère, et s'est mis à la portée de tout le monde. Devons nous le dire, nous qui, par
- 81. notre profession de critique, pouvons prétendre avoir de justes notions sur l'art? ce portrait nous plaît infiniment, quoiqu'il soit moins irréprochable que les autres du même peintre. M. Guignet aîné et M. Adrien Guignet sont frères, comme MM. Adolphe et Armand Leleux. La fraternité, à ce qu'il paraît, est heureuse aux peintres. M. Hippolyte Flandrin, ainsi que nous l'avions annoncé, n'a point exposé, occupé qu'il est de travaux importants pour l'église Saint-Germain-des- Prés; son frère, M. Paul Flandrin, a voulu dignement soutenir l'honneur de sa famille. Ses portraits, sans être à la hauteur de ceux de M. Hippolyte, méritent cependant nos éloges; ils se distinguent par une pureté de dessin remarquable. M. Paul Flandrin aussi est portraitiste; mais, avant tout, il est paysagiste. C'est là qu'il faut le voir à l'œuvre, et qu'il faut le juger. Nous avons remarqué avec plaisir que sa manière se modifiait un peu; les paysages qu'il a exposés cette année n'ont pas cette froideur qu'on reprochait avec raison à ses productions dernières. Sa Vue de Tivoli a de belles lignes; elle est bien choisie, les collines boisées qui s'étendent autour du château ont une grande fraîcheur. Ses Deux jeunes Filles auprès de la fontaine sont comme une miniature à l'huile. Charmant petit tableau, scène antique, inspirée par les églogues de Virgile. Les Bords du Rhône (environs d'Avignon) sont peints d'après nature; le site est agréable; la campagne, chaude comme elle l'est dans le midi de la France, est rafraîchie à certaines distances par des alluvions du fleuve. Ce paysage peut s'appeler étude terminée. Là encore, ce qu'il faut remarquer avant tout, c'est la pureté des lignes et le choix du point de vue. M. Paul Mandrin fera bien de se préoccuper des accessoires, qui ne nuisent jamais au principal dans un tableau, et dont l'absence, au contraire, a souvent rendu une toile incomplète. Lors de notre visite dans les ateliers, nous vous annoncions que le jury d'admission serait moins sévère que par le passé; nous espérions qu'il serait juste. Il a fait acte de justice en se montrant moins hostile envers M. Corot.
- 82. L'Incendie de Sodome, par M. Corot, est une belle et large composition, pleine d'effet, et où se trouvent réunies toutes les excellentes qualités qui distinguent son talent. Qui pourrait croire qu'un pareil tableau ait été refusé l'année dernière, et que le célèbre paysagiste ait été obligé d'en rappeler, comme on dit à la Correctionnelle? M. Corot est bien vengé par ses œuvres elles-mêmes; elles protestent éloquemment contre l'exclusion brutale dont elles avaient été frappées. L'incendie de Sodome, tableau par M. Corot. La Sainte Elisabeth de M. Glaise est une œuvre estimable, et par là nous voulons dire un de ces tableaux bien faits, mais peu saillants, où il est presque impossible de signaler des défauts, mais où, en revanche, les qualités n'abondent pas. M. Glaize, plein d'avenir et de talent, nous remet à l'année prochaine sans doute. Sa Sainte Elisabeth est bien peinte; la tête a un admirable caractère de piété. M. Auguste Charpentier nous donne une Adoration des Bergers, sujet fréquemment traité, où un grand nombre de peintres ont échoué. M. Auguste Charpentier s'en est tiré à son honneur, et il y a vraiment lieu à le féliciter. La composition de son tableau est savamment ordonnée; les
- 83. groupes sont habilement disposés; mais pourquoi la couleur n'est-elle pas plus harmonieuse, et surtout plus vigoureuse? M. Auguste Charpentier possède un talent de dessinateur si remarquable que nous lui souhaitons un vrai talent de coloriste. Ses autres ouvrages accusent tous un incontestable mérite, et les portraits qu'il a exposés rappellent ceux qui l'ont tout d'abord placé au premier rang parmi nos portraitistes. Un jeune peintre, M. Baudron, a droit à nos éloges pour son Annonciation de la Vierge, purement dessinée, de couleur assez brillante, et où nous avons distingué quelques inexpériences de composition. M. Baudron appartient à l'école ingriste; son tableau nous porte à croire qu'il s'est un peu affranchi des règles du maître quant à la couleur. M. Adolphe Leleux a déjà fait ses preuves; il a exposé de délicieuses scènes bretonnes qui l'ont mis du premier coup au nombre des peintres de genre les plus distingués. Ses Paysans picards sont des portraits véritables. Rien de plus naïf et de plus naturel, M. Adolphe Leleux a rencontré ces paysans-là, et nous-mêmes, il nous semble les reconnaître. Les Cantonniers navarrais sont l'œuvre capitale du peintre. Ici M. Adolphe Leleux a agrandi le cercle ordinaire de ses compositions; il a placé la scène au milieu des montagnes de la Navarre, où la nature est à la fois vigoureuse comme en Normandie, et chaude comme en Espagne. L'ensemble du tableau est parfait; les personnages sont gracieusement et naturellement posés; les montagnes sont d'une couleur excellente;--et combien leur vue est douce à celui qui les a traversées! Mais, se demande-t-on, M. Adolphe Leleux aurait-il abandonné la Bretagne pour la Navarre? Il y aurait chez lui ingratitude; nous aimions tant ses premiers tableaux bretons! Répondons aux mécontents que M. Leleux illustre la Bretagne en ce moment, et que, l'année prochaine, il exposera des Faneuses bretonnes: il n'a pas, d'ailleurs, jeté exclusivement ses vues sur cette province de la France. Que M. Adolphe Leleux voyage en Bretagne, ou en Navarre, ou dans les Alpes, il rapportera toujours de ses excursions de gracieux tableaux. Ne soyons donc pas exclusifs à son égard, et ne lui imposons pas de limites.
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