Innovative, realistic experiences without risk to patients
Simulations are common training tools in myriad industries, but it’s not easy to simulate the tactile elements of heart surgery using a computer alone.
Meanwhile, cardiology faculty face the challenge of teaching more than ever in shorter time periods.
“It once was common for residents to work 120 or more hours per week,” says Nahush Mokadam, MD, G.S. Kakos, MD and T.E. Williams, Jr., MD, PhD Endowed Professor in Cardiac Surgery, professor and director of the Ohio State Division of Cardiac Surgery and the program director for Ohio State’s Cardiothoracic Surgery Fellowship.
“Residency programs are mandated to keep it below 80 hours. Simultaneously, there’s been a huge increase in knowledge. We needed to create a way that they could still get the experience they need to be prepared for anything.”
That’s why Ohio State became one of a small handful of schools to integrate KindHeart simulation into its cardiothoracic surgery program.
It uses an exhaustive, innovative curriculum, written by Dr. Mokadam and other specialists, centered around the simulator, which uses a pig’s heart attached to balloons to keep it beating, filled with stage blood to simulate bleeding.
“It’s an important complementary process—what we can do in the simulation lab, we can’t do on real patients,” Dr. Mokadam says. “We can operate until they get it right and work through adverse events.
“In the real world, if something goes wrong, the attending takes over completely. In the simulation lab, I make things go wrong, and I let them sweat.”
The simulation doesn’t completely replace experiences with human patients for Ohio State residents. But Dr. Mokadam says it can create an environment of more deliberate practice and repetition to develop those muscle-memory skills necessary for excellent surgeons. It also gives him the ability to coach and provide formative feedback.
“In the OR, my focus is on the patient. But in the sim lab, the priority is the resident. I can say, ‘Try this,’ or troubleshoot with them, or badger them to induce stress and help them learn how to operate in a high-pressure situation.”
“Take a world-class pitcher in the bottom of the ninth with two outs and the bases loaded. He had to learn how to throw the perfect pitch with and without that pressure. It’s the same concept, being able to restart a heart when someone’s life is on the line.”
Experiences to enhance understanding of inequities
Trainees and practicing clinicians alike are learning how to provide better care for their most vulnerable patients through virtual reality (VR)-based simulations created in partnership with the Ohio Department of Medicaid and the Ohio Colleges of Medicine Government Resource Center.
The goal of the training programs isn’t just to increase knowledge, but to increase understanding and empathy among care providers, says Sheryl Pfeil, MD, medical director of the Ohio State College of Medicine’s Clinical Skills Center.
“It imparts not so much how to be a dentist, or how to treat back pain, but it’s teaching us how to provide better, more culturally sensitive care for patients in all sorts of circumstances,” Dr. Pfeil says. “Frankly, it’s what we must strive to do as physicians.”
Four Ohio State-developed Medicaid Equity Simulations are funded by an Ohio Medicaid Technical Assistance and Policy Program (MEDTAPP) grant:
- Building Empathy in Care of Patients With Dementia
- Developed at Ohio State’s Advanced Computing Center for the Arts and Design, this training highlights the effects of short-term memory loss and time-and-place disorientation—common dementia symptoms—for patients and caregivers through a VR experience.
- Simulated Patient With Limited English Proficiency
- Learners interact with an avatar that’s a virtual simulated patient who has limited English proficiency. Learners conduct a virtual health care visit, honing their communication skills and leading the encounter with cultural competency.
- Virtual and Augmented Reality Implicit Association Training (VARIAT)
- Developed in partnership with Nationwide Children’s Hospital, this mobile app (available to the public) takes learners through gamified modules designed to reveal and emphasize how biases and social determinants of health can lead to inequitable care. The training exercises are linked with educational content to help learners develop strategies to minimize disparities.
- Access to Dental Care for Immigrant Families/MPATHI
- Wearing a VR headset, the participant assumes the role of a parent seeking dental care for their child in an environment where they don’t speak the native language, highlighting cultural, language and literacy barriers, and best practices when working with interpretive services.
“These trainings are very compelling,” Dr. Pfeil says. “On days that so much is required of physicians, it can seem like a challenge to have a patient with added needs, such as someone who’s not English-speaking. It’s tempting not to take the appropriate extra steps to help them understand.
“This helps us see what a negative experience we can give our patients. After you’re wearing that headset in the role of a patient, you think, ‘I never want to be that provider who’s impatient and annoyed.’”
The programs are available to providers throughout Ohio and so far have reached about 500 participants in 2020.
Vital new training in women’s health
Ohio State is filling training gaps for Ohio health care providers with two projects designed by experts in maternal fetal medicine and emergency medicine working with the Ohio State College of Medicine’s Clinical Skills Education and Assessments Center. Both projects are free for providers and funded through the Ohio Department of Health (ODH).
A Virtual Telehealth Delivery Training for Women’s Health Providers seeks to help providers give better care to patients who can’t easily access early prenatal and specialty care.
“Before COVID-19, 92% of obstetric providers in Ohio hadn’t used telehealth, but now, at least 77% of them use it regularly,” says Cynthia Shellhaas, MD, MPH, a maternal fetal medicine specialist who helped design both training programs. “This training helps them lead those encounters effectively.”
Three modules, which began sessions in September 2020, take women’s health providers through simulations to learn efficient workflow management, co-management, virtual patient assessment and other fundamentals of telehealth.
“The scenarios are varied provider-to-patient encounters that use standardized patients, or actors,” Dr. Shellhaas says. “They include a patient with limited English proficiency working through an interpreter, and a patient who’s in the country illegally.”
Two other simulation modules are provider-to-provider communication trainings—one for specialists using video-consult services to work with non-specialists and referring physicians; the second designed for the reverse, teaching referring physicians to use telehealth for patient care and engaging specialists.
A second ODH-funded program, Obstetric Emergency Simulation Training for Emergency Medicine Providers, is designed for emergency medicine (EM) physicians, physician assistants, nurse practitioners, nurses and EMT/EMS.
“Emergency departments see a lot of pregnant and postpartum patients,” Dr. Shellhaas says. “While 98% of Ohio hospitals have reported conducting simulation drills for obstetric emergencies, 100% of those drills involved labor and delivery or postpartum staff—but only 30% involved emergency department staff.
“Considering that some Ohio hospitals don’t even have maternity units, that leaves EM providers unprepared.”
The program, which began its first trainings in August 2020, puts participants through virtual simulations to improve recognition, treatment and management of obstetric emergencies including hypertensive emergencies, postpartum hemorrhage and cardiomyopathy.
One session involves the simulations themselves, but two other trainings offer EM physicians and nurse educators the tools to facilitate their own low-cost obstetric emergency simulations at their home hospitals.
Because of COVID-19, all trainings are currently being held virtually.