Many are not aware that almost 30 years ago the Veterans Health Administration (VHA) was on the leading edge of innovation with the introduction of the Veterans Information Systems and Technology Architecture (VistA). It was one of the first electronic health record (EHR) systems and is used throughout the United States, linking all the VHA’s 1,200-plus healthcare sites.
VistA enables a veteran who has been treated in Minneapolis, but has a medical need while visiting Florida to have complete access to their records. A concept that, three decades later, the private sector still has not been able to master. It was such an extraordinary innovation that it garnered the Computer World Smithsonian Award back in 1995.
Perhaps the next quantum leap in clinical training and patient outcomes could come out of the same institution. In fact, it is being developed at the VHA SimLEARN
(Simulation Learning, Education and Research Network) National Simulation Center, headquartered at the new Orlando VA Medical Center at Lake Nona.
To describe SimLEARN’s center as “state- of-the-art” is an understatement. Every part of the facility is designed as a teaching opportunity — from admission and waiting room experiences, to exam rooms and fully equipped surgical suites. The range of learning settings is like being on a movie sound stage, and the experience is closer to that than you might imagine.
Fixing What is Broken
Why is it so revolutionary? “The current model of healthcare education, which continues to rely heavily on the ‘see one, do one, teach one’ paradigm, is extremely outdated and not patient care-focused,” Dr. Yasuharu (Haru) Okuda, the national medical director of SimLEARN, explained. The engaging young doctor is considered not only a thought leader, but an early adopter and trendsetter in the use of simulation in clinical training. “In an era that strives to reduce errors in medicine, it’s no longer appropriate to be ‘practicing’ on patients,” he observed.
Having trained as a concert violinist, Okuda knows something about the necessity of practice to develop and retain skills. “Whether you’re playing the violin or playing golf, practice is what hones your expertise. Regrettably, we intensely train healthcare personnel, particularly physicians, and once they’re finished with medical school and residency they’re expected to be gameday ready for life. Imagine a player making it to the NFL, but only playing on Sunday in games and never practicing. We would consider that absurd.”
Okuda has taken a page out of the training methods used for airline pilots and flight attendants. “We put our personnel in immersive simulation scenarios to rehearse in a safe environment to not only learn skills but learn to make what could be life- or-death decisions. Our purpose isn’t to simply identify weakness, but to create an instructional environment that produces self-discovery and team cohesiveness.”
Some mannequins are so sophisticated they breathe in oxygen and exhale carbon dioxide, move and converse with the people in the scenario. When given an injection, they actually react like a patient does to an overdose or to wrong medicines.
It is not just what goes on in the simulation scenario that is so instructive, it is the debrief, where trainees watch and break down the experience, which has been digitally recorded from a variety of angles, that produces the “ah-ha” moments. “One insight, we often observe, is we may think we’re communicating with a patient or a team member, but we only thought it, we didn’t say it. These debriefs afterwards are where these realizations occur,” Okuda shared.
But do not assume everyone is on board for this new model. Convincing traditionalists of the value of the sim concept can be an uphill battle; some even refer to it as “Simulation Wars.” Dr. James Gordon of Harvard Medical School, director of a sim center at Massachusetts General Hospital, who has collaborated with Okuda, was quoted as saying, “Haru doesn’t come to the table assuming everyone will agree with him. He is able to engage people in thoughtful conversations and debate.”
“STAR TREK ACADEMY” FOR MEDICAL PERSONNEL
From experiences to refine skills in the most advanced robotic surgical techniques, including eye and heart surgery, performing colonoscopies or root canals, to how to conduct a patient interview, the breadth of the training is surprisingly diverse.
Okuda guides trainees and visitors through the facility, which he helped design, like a museum curator. “Many medical mistakes happen during transfers, like from the ambulance to the hospital,” he explains as he shows the back and interior of a typical ambulance, permanently mounted in one of the rooms. Down the hall is an elevator door, which he opens to reveal a standard hospital-size elevator. Only, this building is just one story. “Things happen when you move patients in a hospital; we want to prepare our staff for those situations. This is how we move the dial not only in training outcomes, but patient outcomes.”
SimLEARN’s goal is to improve veteran health care outcomes, and one of the high priorities for Dr. Okuda and his team is working to adapt simulation training to suicide prevention.
Of course, the real simulation experience happens when doctors, nurses or hospital staff are interfacing with the SimLEARN patients. These lifelike mannequins or, more accurately, “high fidelity simulators” have evolved from the Resusci Anne (also called Resuscitator Annie), like dial telephones have advanced into the newest smartphone. Life size, and dare we call them “dolls,” they were first introduced in the early 1960s to train medical and non-medical personnel in the recently discovered technique of mouth-to-mouth resuscitation.
Medical mannequins like Resuscitator Annie cost several hundred dollars; the ones used at SimLEARN can cost more than $250,000. In most of the simulated hospital surgical or exam rooms, there is a one-way mirror, behind which are not only observation teams, but technicians who operate the mannequins. Some mannequins are so sophisticated they breathe in oxygen and exhale carbon dioxide, move and converse with the people in the scenario. When given an injection, they actually react like a patient does to an overdose or to wrong medicines, and can be used to practice some of the most intricate of medical procedures.
Perhaps the most important medical technique they are used to simulate is the patient/doctor interface; an area of expertise modern medicine realizes is fundamental to desired results.
PLAYING A DIFFERENT TUNE
Okuda, who came to this country when he was four, describes his family, with great qualification, as being “almost un- Japanese.” His grandfather was an opera singer, who traveled the world and trained in Italy, which gave his own father a kind of wanderlust. His father’s mastery of English and love for books brought him to the United States to study at the University of Illinois and upon graduation, landed him a job with Time-Life books, where he worked his entire professional career. In talking with Okuda, it is obvious that family and paternal bonds were vital to him, as they are with his twin daughters and his Korean/American wife.
Though trained in violin and rising to the highest levels by the time he was 14, Okuda realized the prodigies coming up behind him were so formidable and his own interests too varied to focus exclusively on mastery of the violin. Equally passionate about science and serving a greater good, medicine was an easy choice.
However, once into this pursuit, he carried a sort of Renaissance Man perspective, which seems to have formed his career and his willingness to think outside the structured box of how training can and should be done. Perhaps drawn to emergency medicine because of the diversity and pace of the ER, he admits to a variety of interests, a skillset essential in running a cutting-edge training center.
Okuda attended Brown University, where he also served as a concert master, and then New York Medical College. He was later chosen, at 37, to direct the Institute for Medical Simulation and Advanced learning for the New York City Health and Hospitals Corporation, a $10 million medical simulation training center located in the Bronx.
One of his friends, Dr. Ernest Wang, said about him in an interview, “Haru is quietly driven, detail-oriented, and wants to make a difference. Add to that his vision of what simulation can be for medical education, and you can see how he brought sim wars to a national stage and successfully executed its production.”
When one malpractice case can easily cost more than $1 million and one mistake can cost a human life, it is a challenge Okuda is determined to conquer. ◆