The patient in Room 2 has splitting headaches, and Johnny Costello needs to find out why. He needs to get to the bottom of the case in Room 5, too, where the woman who has achy joints in her hands and wrists sits waiting. And there’s the middle-aged guy in Room 8, who wonders whether the chest pains he’s having will end up as the fatal stroke his mother suffered, or lead to the coronary bypass surgery his brother had to endure.
A second-year student at the School of Medicine, Costello spends 15 minutes in a perfect mock-up of an examining room with each of them (and, eventually, nine others) to gather some basic information, take vitals, and discuss with them how their conditions manifested themselves. Then, he tells his patients, he’ll report to “the medical team” and come back with some recommendations.
Costello isn’t a real doctor yet, but that’s OK. The people he sees aren’t really sick, either. Called “standardized patients” (or “SPs”), they are trained actors who mimic a set of conditions that test a resident’s listening skills, medical knowledge, and time management capabilities—the tools he or she will need to practice out in the real world.
Costello’s encounters with the SPs can be monitored by instructors on the other side of the one-way mirrors in each exam room. And since the young student’s interactions are also being videotaped, they’ll be able to replay—and critique—his performance on the 32-inch LCD screens in each room, or via a bank of video monitors in a central hallway.
Down the hall in what looks like a semi-private room in a pediatric ward, other residents will try to save a baby named Molly over and over again, hour after hour. Because she is made of plastic, Molly—a “SimBaby”—has amazing powers of resuscitation. “SimMan,” a simulated human that is made of the same stuff as Molly, lies on a gurney in an immaculate operating room awaiting intubation, ventilation, a colonoscopy, or whatever else might be called for.
Molly, SimMan, the gleaming video monitors, and well-equipped operating rooms are all part of the new Johns Hopkins Simulation Center: a state-of-the-art concoction of the fake, the plastic, and the phony.
The center, which opened in March on the 8th floor of the Outpatient Center, is seen by leaders at the School of Medicine and Johns Hopkins University as a leap forward in medical education: The two institutions have poured $5 million into making the center as technologically forward-looking as possible. Through the use of cutting-edge electronics, interactive simulations, and the hands-on rehearsing of emergency codes and procedures, Hopkins educators hope to better prepare the next generation of doctors. At the same time, the center provides an environment where practicing professionals in medicine, nursing, and various types of therapy can upgrade their skills.
Early reviews are promising. “It’s really good because they’re not replacing contact with patients, but augmenting it,” says Costello, the 23-year-old student from Neenah, a paper mill town in Wisconsin. Costello, who plans on becoming a pediatrician, scans the shiny new center and adds: “They made it look like the real deal.”
The product of seven years of research, fundraising, modeling, and construction, the Simulation Center trains medical students daily in the fine art of patient care—often substituting plastic for flesh.
“We want the younger generation of medical students to know that this is a safe place where you can make mistakes,” says Elizabeth “Betsy” Hunt, director of the Simulation Center, as well as an assistant professor in anesthesiology and critical care here. (A “pediatric intensivist” by trade, Hunt also recently completed a PhD in public health at the Bloomberg School.) “Instead of teaching people in classrooms, which isn’t how adults learn best anyway, we have them get in there and practice on plastic. Showing what real situations look like is a great way to get them to visualize, as well as to teach them how to work together in teams,” says Hunt, who holds the Doctors David S. and Marilyn Zamierowski Directorship.
Even the most basic facets of medical practice will be taught more completely, Hunt says. For example, new surgeons are frequently dressed down by older colleagues for not properly washing their hands. The presence of a real operating room—outfitted with a genuine operating-room sink—will help change that, Hunt says, particularly after she points out hand-washing shortcomings from behind a viewing mirror: “I get to watch every move like a hawk.”
Sweating the details is an integral part of a resident’s learning experience, agrees Charles M. Wiener, director of the Osler Residency Training Program, whose residents will begin using the center in June. “It helps to learn how to use even the most simple things—screw caps, syringes—before you get out in the clinic,” he says.
Although machine-based simulations have taken place around the world since the 1960s, it took 30 years for most medical institutions to catch up with them. “It was prohibitively expensive early on,” says Beverlee Anderson, executive director of the Society for Simulation in Health Care, a membership group headquartered in Santa Fe, N.M. made up primarily of 2,000 community colleges, medical schools, and nursing schools. The group’s membership has exploded since 2005, when it encompassed just 120 institutions. “Initially, mannequins might cost $100,000 or more. (Now, a typical one costs $35,000.) It was hard to convince people that they should invest dollars in simulation. The movement stayed in the closet for a good while because of that,” she says.
Hopkins started practicing simulations in earnest in 1994, when SimMan and other pieces of plastic took up residence at the Clinical Education Center on the 4th floor of the Blalock building. Although the Clinical Education Center was the eventual birthplace for several award-winning developments of simulation methods—the hospital has been recognized at five of the last six International Meetings on Simulation and Health Care—it was short of space, with only nine examining rooms. Since medical students have to successfully handle 12 cases in a day, the tight quarters hardly proved ideal.
“You were right in the middle of a working ward,” says Costello, who recalls his experience as a first-year student. “Sometimes, you’d be working on something and they’d push an actual patient down the hallway, which would disrupt students and make things less than ideal for patients in terms of privacy.”
Recognizing the need to expand both in terms of mission and space, leaders from the hospital, the Bloomberg School of Public Health, and the School of Medicine—along with several medical specialists from the faculty—put together a white paper in 2001 on the value and possibilities of simulation.
By 2004, the university and the school were ready to move forward on the paper’s recommendation: to establish a state-of-the-art simulation center that would benefit students and faculty alike. “I think we got ahead of the hue and cry over this and the results of that are bearing themselves out,” says David Nichols, vice dean for education. “The extent to which real things can be simulated has just been explosive in the last five years.”
The need for a top-of-the-line center had become even more critical when the Accreditation Council for Graduate Medical Education (ACGME)—prompted by concerns about patient and resident safety—cut weekly hospital hours for residents from 120 to 80. The change meant that residents spend less time on the hospital floor experiencing the situations they’ll face on the wards.
Simulations, the collective thinking went, could help fill the void, says Hunt, who was hired to head the center in 2004. She had developed a strong reputation for researching emergency code responses in hospitals while serving as an assistant professor here. “She seemed like a perfect choice. Her research has led to better CPR outcomes in the hospital and she understands the technology,” Nichols says.
Following up on visits by an earlier Hopkins team to the University of Pittsburgh, Stanford, the University of Toronto, and other teaching hospitals, Hunt paid her own way to conferences in Denmark, Portugal, and Sweden, picking up ideas from top-notch European simulation centers that predated those in the United States. And she took courses on simulation techniques at some stateside schools, such as Harvard, that had already built centers.
“One of the key things I learned is to make each room as flexible as possible,” says Hunt. “You’d think you’d want something to look like the cardiac OR all the time, but you can’t do that. The reality is that the cardiac cath team isn’t going to be here but once or twice a year. In the meantime, I’ve got to get the room ready for a team from obstetrics.”
To make sure that students’ hands-on learning links up with their class studies, the Simulation Center has integrated its operations with the school’s new “Genes to Society” curriculum (now being phased in before a full launch next year). The curriculum focuses on the effects of genes on the development of disease.
“Students will learn how to ask questions that will help them treat people with a predisposition to heart disease, for example: How do you do an EKG on them? and, How do you write in their chart?” says Hunt. The Sim Center’s new resources will also make it possible for Hopkins medical students to begin getting clinical skills in the first year, instead of exclusively in the second year, she notes.
For residents, the center will be useful in preparing them for the six core competencies mandated by the ACGME. These include medical knowledge, patient care, and professionalism.
The newness of the center affords Hunt several advantages. For one, she no longer has to play make-believe to keep students on their toes. “In the past, we had to pretend some things, like whether someone had hooked up oxygen to a mannequin or not,” Hunt says. “I’ve always had to throw an imaginary monkey wrench in there—‘How am I going to screw things up for them today?’”
Now she can manipulate the functions of mannequins and monitor their vital signs through computers she commands as students practice on the other side of the one-way mirror. “All I have to do is very carefully watch them. If someone has made a mistake with oxygen, then I can show them by making SimBaby turn blue.”
Hunt and her crew of seven—a simulation engineer, a simulation specialist, an information technologist, an SP trainer, two managers, and a receptionist—will run courses on site on transitioning to residency for fourth-year students. “People were going into wards totally lost,” says Hunt. “We’re hoping to change that.”
Now that simulations have become established as desirable teaching tools, many groups that accredit physicians are ramping up plans to test practicing surgeons and other professionals at certain intervals to make sure they are maintaining old skills while developing new ones. The American Board of Internal Medicine, for example, is considering changing from a test performed on a computer to one that is done using simulation.
“It hasn’t happened yet, but many more boards are thinking of making doctors show hands-on competence,” says Hunt. Safety staff, respiratory therapists, and nurses are among those professionals who will also benefit from training courses at the center, she says. And as virtual reality systems come online, surgeons and other professionals will likely make a beeline here to sharpen their techniques.
Hopkins’ leaders expect the Simulation Center to have a strong impact on medical care. “It gives us the opportunity to teach very real scenarios that can help learners develop judgment and wisdom that otherwise only comes from years of practice,” says Deborah Schwengel, director of the anesthesiology residency program and an assistant professor of anesthesiology, critical care medicine, and pediatrics. “It’s also a kind of fun way to learn. You’re with other people and that makes it more enjoyable.”
“Our hope is that simulations will lead to patients who are safer and happier, and that it lowers the cost of care,” says Nichols. He adds that, under Hunt, there will be more research performed at the center on code responses and simulation teaching methods.
For Hunt, the task is to challenge medical students and residents to take chances. She cites a study that found that elite figure skaters who fall down on the ice more often outperform others because they are more likely to take risks. “They got to be the best because they pushed themselves,” Hunt says. “I tell people who come in here, ‘What are you learning if you get things right all the time?’ I want them to be able to have a sense of achievement, but I want to throw a lot of different situations at them.”
And, she adds with a smile, “I want them to know that it’s OK to fail here.”