By Christina Frangou
Salt Lake City—As a young combat pilot in the Israeli Air Force, Amitai Ziv practiced on a simulator for every nightmare scenario his trainers could come up with: ejecting from airplanes, landing planes overcome with flames, managing all sorts of equipment malfunctions.
When he started medical school after leaving the air force, he was astonished that medical trainees honed their skills not on simulators, but on real patients.
“We expect both health care and aviation to have very low tolerance for errors. But in health care, we are very much behind aviation in that respect,” Dr. Ziv said in a lecture at the 2014 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting.
“Our health care training, despite the simulation movement, is still by and large the old model: See one, teach one, do one, kill one. … The patients are the ones who pay the price,” said Dr. Ziv, chair of medical education, Sackler School of Medicine, Tel Aviv University.
Amitai Ziv, MD, believes personality traits should count more when evaluating medical students and physicians.
Dr. Ziv, a pediatrician, has spent the past 20 years trying to adapt the lessons of flight simulation training to the field of medical training.
According to his bio, this idea came to him in medical school when a fellow student committed suicide hours after failing a test. The future Dr. Ziv decided then that the testing system, both to get into medical school and to become a licensed physician, was inadequate. It focused purely on a student’s cognition. The system failed to assess the human side of being a physician.
Driven by this realization, Dr. Ziv completed his MD dissertation on peer evaluation. Later, he worked with the Educational Commission for Foreign Medical Graduates on a simulation-based program that certifies foreign immigrant doctors applying to work in the United States.
In 2001, Dr. Ziv returned to Israel and founded the Israel Center for Medical Simulation (MSR), now “arguably one of the most effective and influential simulation centers in the world,” said Gerald Fried, MD, immediate past president of SAGES and chair of surgery at McGill University, in Montreal, Canada.
Housed in a virtual hospital on the massive Chaim Sheba Medical Center campus just outside Tel Aviv, MSR is home to more than 100 different kinds of simulators and employs more than 150 professional actors for its courses. The nonprofit center, which operates on a fee-for-service model, trains more than 10,000 health professionals in more than 60 courses annually.
Almost all health care practitioners in Israel have undergone some training at MSR. The student body ranges from medical school applicants to hospital CEOs. Among the trainees are pharmacists who learn communication skills that can help with angry patients and reduce errors; surgeons who rehearse complex procedures in a high-tech operating room simulator; and surgical residents who practice on virtual-reality simulators. MSR instructors watch everything through one-way mirrors and conduct extensive aviation-style debriefs. Even the country’s medical clowns refine their skills through courses at MSR.
MSR trains health care workers for run-of-the-mill scenarios but also for the catastrophic “unimaginable” ones. Israel is known for its extensive mass casualty preparedness; much of that training is conducted at MSR. Notably, the training extends also to Palestinians; MSR uses simulation to provide trauma training for Palestinian physicians and paramedics through an affiliation with Physicians for Human Rights.
MSR’s simulation model can be used around the world to improve safety and medical training, Dr. Fried said. “This can reshape the way medical care is delivered around the world.”
The center is founded on the principle that simulation-based medical training and assessment can revolutionize the safety culture in medicine. For too long, medicine has accepted suboptimal levels of safety, said Dr. Ziv, deputy director of Sheba Medical Center, responsible for patient safety, risk management and medical education.
He likes to compare medicine to aviation. If the deaths attributed to medical errors are put into aviation terms, they amount to four Boeing 747 crashes daily, Dr. Ziv said, citing a recent controversial study in the Journal of Patient Safety (2013;9:122-128).
Medical errors disproportionately affect women, children and older patients, he added. “This is not something intentional, but these are groups, perhaps, that we do not communicate as effectively with.”
Simulation, which ranges from expensive high-tech simulators to low-tech role-playing with actors, provides an environment for people to learn by hands-on practice but without putting patients’ lives at risk, Dr. Ziv said. “This is a very powerful way of teaching.”
Dr. Ziv pointed to data collected by the American nonprofit behavioral psychology center, the National Training Laboratory, which showed that learners who are taught by hands-on practice retain around 75% of information. In contrast, students remember about 5% of what they hear in lectures, 10% of what they read and 30% of what they see.
A key advantage of simulation is that it can teach skills needed in emergency situations, the medical equivalents of trying to land a plane with a fire in the cockpit, Dr. Ziv said. These are low-frequency but high-stakes scenarios.
MSR runs programs to teach trainees and practicing physicians how to respond in so-called “nightmare scenarios.” There is even a module known as the “nightmare course,” a mandatory five-day program for Israeli interns about to begin their first hospital rotations. They are challenged with a series of stressful situations such as finding themselves in an elevator alone at night with a patient who stops breathing.
“Or it could be the nightmare on the emotional front: telling a family that we have erred and we gave their father the wrong blood, that we are responsible for the loss of a loved one,” Dr. Ziv said.
“It’s through this kind of proactive learning, rather than [a] reactive one with our apprentice one, [that] we can enact nightmares.”
Dr. Ziv asserted that medical errors occur because of malfunctions built into the health care system from the moment applicants are evaluated as candidates for medical school. At most medical schools, the application committee considers grades and extracurricular activities, but places little emphasis on personality traits.
But medical schools need to consider personality traits, Dr. Ziv said. And so, MSR, together with Israeli medical schools and Israel’s National Institute for Testing and Evaluation, developed an assessment program—known as MOR, a Hebrew acronym for “selection for medicine”—to measure candidates’ judgment and decision-making skills. Candidates complete a series of behavioral stations, including encounters with simulated patients and group tasks, an autobiographical questionnaire, and a judgment and decision-making questionnaire. They are evaluated on interpersonal communication skills, ability to handle stress, initiative and responsibility, and self-awareness.
This program resulted in a change of about 20% in the cohort of accepted students compared with previous admission criteria (Med Educ 2008;42:991-998). The investigators found very low correlation between the candidates’ MOR scores and cognitive scores.
“MOR conveys the importance of maintaining humanistic characteristics in the medical profession to students and faculty staff,” Dr. Ziv noted.
He would like to see similarly thorough assessments of physicians throughout their career. Physicians should be evaluated on all aspects of the care they provide, from their ability to deal with high-stress situations to their operative skill, he said.
“Surgeons can be operating with Parkinson’s and nobody can ground that surgeon. That’s true today around the world and it is not right.”
Dr. Ziv hoped that simulation-based medical education will spark a revolution in medicine.
“We will have to change course. We have some barriers but they are not as high as we think. The end of it, there’s the humility message that if we meet our errors in the simulation environment, we will be better off in the real world,” he said.