Medical Safety Podcast

Ep 5 - Simulation in Medicine with Dr. Jesse Guscott

• Dr. Adam Shehata & Dr. Amir Hamid • Episode 5

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Show notes

  • How to make simulation effective
    • Although equipment is expensive and may seem like a barrier to establishing a simulation program, the emphasis of a simulation focused on CRM principles should be communication and having skilled debriefers who can facilitate skills development
    • Using simulation to have someone experience a crisis and reflecting on why things didn’t go well, with the help of a skilled debriefer/facilitator is key in identifying systems we can put in place to mitigate these issues when the occur in reality
    • “Simulation without goals is just playing”
    • When designing a good simulation experience, it is important to keep the learning goals at the forefront; this may mean that the simulation is not the highest fidelity, but sometimes they don’t need to be
    • When designing a simulation for learning, you have to make a safe environment and make it clear to the participants there is no evaluation component; learning is the single priority
      • It is hard to have the dual role of coach and assessor and may make the environment challenging for learning
  • Why simulation is important
    • As we have seen with the episodes focused on the airline industry, rarely are the catastrophic events due to a technical proficiency, catastrophic mechanical failure or knowledge issue; they are more often caused by failures in communication or decision making
    • When we analyze issues in medicine we can see similar trends
    • The evidence shows that simulation improves confidence of participants. It is very hard to measure competence; there is anecdotal support from bystanders, simulation facilitators, allied health that it makes people better, but there are no RCTs to demonstrate this as it is inherently a difficult thing to measure
    • For physicians who are at risk of leaving high acuity fields (IE: rural physicians working emergency medicine or hospitalist medicine), increasing their confidence may help with retention, which is pivotal in some of these communities. This may also encourage junior physicians to practice at full scope, especially in underserved communities where it is traditionally hard to hire physicians
    • Simulation directly works on team dynamics; improving team dynamics may improve the work environment and improve retention
  • Different kinds of simulation
    • There is a specific kind of simulation focused on logistics and ergonomics
    • Although some Simulation focused on CRM principles may bring this out, there is a dedicated form of simulation meant to test this
      • This can be implemented locally without a lot of equipment or cost by a hospital “code committee” to solely look at implementation in a site or system
    • Rapid cycle deliberate practice is a tool you can use to work on specific technical skills in a short time frame without needing a full theatre simulation experience
  • Can we use simulation as an evaluation tool for competency?
    • In medicine, we are rarely given the opportunities to practice what we learn in simulation, or real life scenarios reflective of what we see in simulation, so there are not many opportunities to practice these events prior to being evaluated on them
    • If we build a training system that the skillsets of CRM are taught well, and people have the opportunity to practice those skills, in training and in independent practice, with a very low barrier to entry, we may have the foundations for using simulation as a competency assessment tool, like they have in aviation
    • There are some residency programs that make simulation a mandatory part of their program and use it as a formal assessment tool during their licensing 
  • Some key CRM themes
    • Fixation vs focus:
      • Fixation is when you devote your attention and mental resources to the wrong thing in a crisis situation
      • Focus when you devote your attention and mental resources to the correct thing in a crisis
      • If you are maintaining your situational awareness (an accurate mental model of what is occurring and what the priorities are) then you are not fixated.
      • The issue is that our attention narrows when performing complex tasks and we lose our situational awareness (e.g. when intubating, we momentarily lose sight of the bigger picture).
      • Either delegate such tasks (IV access, intubation, chest tube insertion, etc) or have someone else run the rest of the resuscitation and then inform you of what occurred while you were performing that task.
    • If our system is built around the infallibility of a single person, or a few key people, our system will inevitably fail because no one can be perfect 100% of the time
    • Crisis resource management is fundamentally moving from a theoretical solution to a problem in crisis, to a practical solution to this problem
  • Ways to improve your performance in crisis
    • Think about the resources you have available that can help you; sometimes this is a colleague, or a more experienced member of the team. You may also lean on support outside of your immediate institution
    • Use a whiteboard or other visible task board to help maintain situational awareness in crisis and manage priorities
    • Develop and practice communication, situational awareness, leadership and communication, even if it is in a low fidelity sessions like table rounds, similar to journal clubs you may already have


Safety intervention worth mentioning

  • Cognitive aids, such as the Stanford Emergency Manual (there is also a phone app)
  • Buy a whiteboard and put it in the resuscitation area


Resources mentioned in the episode


Random recommendations


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SPEAKER_02

This is my commitment to Mr. Brahmali. No one is ever gonna die of a can't intubate, can't oxygenate scenario in the room that I'm in without us having access to that airway through the front of the neck.

SPEAKER_03

Welcome back to the medical safety podcast. I'm Adam Shahada.

SPEAKER_04

I'm your Hammond.

SPEAKER_03

And in this podcast, we discuss how to improve the safety of our healthcare system through the integration of human factors into system safety, including medical investigation and proactive safety measures. In the first episode, we discussed the Elaine Bromley case, where a healthy 37-year-old woman underwent attempted elective sinus surgery and died after a can't intubate, can't oxygenate situation, where the medical team were unable to establish an airway for over 20 minutes. Her husband, Martin Bromley, a UK airline pilot, commissioned, anonymized, and published a report of the circumstances of her death so that others could learn from it. In particular, he called out the fact that the human factors, which are widely taught and used in the analysis of aviation accidents, are not being sufficiently discussed in medicine. Later we heard from Captain Mike Schuster, a Canadian airline captain and aviation safety expert. He discussed how crew resource management was the genesis in aviation and its development to date. More recently, we interviewed Dr. Katie Lynn, a critical care transport physician, stroke attending, and emergency physician from Calgary. She provided insight into the escalation of language where there is a safety concern during resuscitation, which was the focus of her Master's of Public Health, which she earned from Harvard. In today's episode, we have the privilege of speaking with Dr. Jesse Guscott, who is a simulation expert in the field of medicine.

Dedication to Air Canada Jazz Pilots who died in a recent aviation accident

SPEAKER_03

Before we get to Dr. Jesse Guscott, we just wanted to dedicate this episode to the two Air Canada pilots who recently lost their lives in an aviation accident that occurred when they were landing their CRJ at LaGuardia Airport and they collided with a fire truck that was crossing the active runway. And that only happened a short while ago. We'll probably be publishing this when much more is known. Captain Antoine Forrest, who was age 30 from Cote du Lac, Quebec, and First Officer Mackenzie Gunter, who was age 24, who also graduated from Seneca College's aviation program as I did, but he graduated a lot more recently in 2023 and died when they collided with the fire truck. It's a reminder that we all need to be more vigilant and that safety isn't static. It changes from year to year. It changes from moment to moment on an actual flight, or for those of you in medicine in the clinic or in the OR or in the trauma bay, regardless of our professions and the environment in which we work, we work in an imperfect system. It's not some amorphous system that keeps us safe. It is the practitioners from pilots, flight attendants, air traffic controllers, airport personnel, and of course everyone in the medical context understands that as well. While we're on the subject of air traffic controllers, I wanted to point out that while much attention has been placed on an individual air traffic controller that cleared the fire truck across the active runway, it takes the failure of several defenses in depth for such an accident to occur, and we never place hundreds of lives in any one individual's hands. This is a sentiment that I've heard from actual Air Canada jazz pilots over the radio that they expressed to LaGuardia in the days after the accident.

SPEAKER_00

I just wanted to say uh our thoughts are with your uh colleague that was working that day. We're all uh hoping he's okay.

SPEAKER_01

You know, the planet community.

SPEAKER_00

Yes, sir. All right, thanks for that. And uh thanks.

SPEAKER_03

Yeah, I really appreciate you guys meeting a lot. It's just a reminder that we're all working towards safety and we can all learn from each other. And so with that, Amir, maybe I'll turn it over to you and you can introduce

Introducing Dr. Jesse Guscott

SPEAKER_03

us to Dr. Jesse Guscan.

SPEAKER_04

Thanks, Adam. I have the privilege of introducing Dr. Jesse Guscon, who is a rural generalist in Collingwood, Ontario. His ever-evolving clinical practice has included anesthesia, emergency medicine, and hospitalist medicine. A passionate award-winning educator, he has leadership roles in medical education and simulation with the Northern Ontario School of Medicine, McMaster, and the University of Toronto. He also teaches a number of CME programs for practicing clinicians, including his own interdisciplinary simulation course, SCORE. He loves all things airway, resuscitation, and crisis research management. He was my program director in my anesthesia training and continues to be a valuable mentor. So thank you, Jesse, for joining us today. How did you become interested in medicine? Could you talk about how your career led you to the field in general?

SPEAKER_02

Yeah,

Jesse's Journey to and through medicine

SPEAKER_02

when I was in high school, I was not a super high achieving student. I was a pretty social kid in high school and spent a bit of time actually living on my own without parental supervision. So I would say I was not your prototypical super high achieving high school student, but I but I had a sense that I could I could do some things when I when I finally found the time to apply myself. And then when I went to undergrad, I was pretty keen to do well. I had initially thought I might be interested in something like forensic science. I liked the concept of sciences and that application appeal to me. And then when I got into my undergrad, I figured out pretty quickly that I wasn't much of a laboratory scientist. I just wasn't what I was good at. I was also interested in humanities and I was actually started out as I was a biochemistry English major minor and then switched into microbiology and history and ended up sort of finishing my undergrad as a as a microbiome major and I did a minor in post-colonial history. And what I found when I was an undergrad was I really loved the intersection between science and and and humanities and humanness and communication and relationship. And so that was sort of what pushed me towards medicine, is I felt like that was going to be the best application of science stuff for me, was figuring out how to also draw in relationship and communication. So I did some medical school at McMaster, which was an excellent fit for me. I did a family medicine residency in the rural program at McMaster. So training to become a rural generalist. I was really inspired by some mentors that I had worked with along the lines who were doing that kind of medicine. And when I was training in the city, I didn't really even know that that was a possibility, but I worked with some cool people who were doing family medicine and emergency medicine and anesthesia and OB, and just thought that that's amazing. And if I do that, I don't have to, I don't have to switch. I don't have to choose one over the other. So that's how I ended up in in rural family medicine. And then I did the family practice anesthesia fellowship, largely initially for skill set. I was really interested in emergency medicine, thought that would be an excellent skill set for me. And again, had a had a great mentor in anesthesia who said, Well, don't you think about doing anesthesia instead of emergency and you'll still be able to practice emergency medicine, but you'll have this other skill set that people, you know, really value in emergency medicine. You'll be good at all the things that scare emerge talks, which is why. And uh yeah, I thought that that makes good sense. So that's how kind of how I ended up in general practice with a focus in emergency medicine or sorry, a focus in anesthesia. I did practice emergency medicine for around 13, 14 years. And then I've always had things going on in the side clinically. Very early in my medicine career, I got interested in education and started out like everyone else, just you know, teaching medical students on electives, then teaching residents on elective, and then ended up in taking on the role of program director for the failing practice anesthesia program for McMaster. And somewhere along the lines, really decided I want education to be more than just a hobby, more than just a side gig of what I do clinically. I want to be a professional, I want to be a really great educator, I want to teach for a living, I want that to be part of what I do. So focused my attentions on on just trying to be better, to get had to get better first. And so just wanted to be a great educator, focused on on how we can improve, got some mentorship, worked, collaborated with some other people who are like-minded who wanted to be excellent educators too, and have sort of a peer group of of people who give each other feedback, bounce ideas off of.

SPEAKER_04

You mentioned your kind of transitioning to a more formalized education role, but can you talk about how you got started in medical simulation?

SPEAKER_02

Yeah, it's funny. When you answer the question of like, how did you end up here? It's crazy, all of the little fortuitous things that kind of add up to make these things happen. You know, I think, you know, I'll just if I can just digress for one second, you know. I just think about how my high school experience set me up for my undergrad experience, having been a bit of a truant high school student and being in an era where we did grade 13, you know, I went through the OEC program, and then showing up at university, kind of a little older and having sort of done that exploratory phase in high school that actually set

How Jesse got involved in Simulation

SPEAKER_02

me up perfectly for undergrad to do really well. I was ready to do that. So, kind of the same thing with simulation. How did I end up there? Totally fortuitous. It was just like the stars all aligned on a particular day. So I was the program director for McMaster's family practice anesthesia residency program. I got an email from a guy I had never met or heard of named Rob Anderson. And Rob was at the time the program director for Nawsom's family practice anesthesia program. And he said, we've put together this little simulation program for family practice anesthesia residents. We ran it for our own residents last year and we're looking to expand. I would like to invite your residents to come if you think that would be something that would be helpful for them. I had never done SIM, like SIM was not part of my educational experience when I was a medical learner, but thought, yeah, hey, that sounds good. And then follow-up email from Rob was like, also, if any of the program directors want to come and hang out and see what we do and maybe even chip in, you're welcome. And it was the first one we did was in in August. I happened to have a couple days there where I was free. I was doing some work at a children's camp, like not actually not that far. So I thought, yeah, sure, like I'll go poke around. And so I went. And that was like absolutely a life-changing experience where you know, the I I went and saw it and just instantly was in love. Just thought this is the most fun thing ever. The Nossum group is unbelievable. They the the commitment to fidelity is just is so great. And the perspectives that they were bringing on why we're doing what we're doing just was really, really fun. And I got right into it, thought it was great, and basically dove headfirst into that pool. So started getting involved that first week in doing a little bit of debriefing. And it turned out it was a thing that again sort of meets the intersection of what excites me in medicine and in life. I cats the call, the intersection between, you know, science and humanities, the intersection between, you know, the things we know and and how we actually do those things, why people perform the way they perform in in high pressure situations. That stuff all was super exciting for me. And I love that the you know, the heart of the teaching is in communication. So that it just aligned with all the things that I love that I didn't even know I loved at the time, you know, in that way. I didn't know that that was a thing. I just got really excited about that. So yeah, so so did a boot camp with Nonsam. And I would say for the first bunch of years, that was the heart of my simulation experience. It was once a year going to Sudbury and doing a week of pretty intensive stuff. We'd kind of do, you know, 60 hours of sim over the course of week. And then after four or five years, I started looking for other opportunities to do that. So started integrating it into my own residency program. And then in in my home hospital in Collingwood, there was a group that was doing some very, very like low fidelity, I would call it almost like walkthroughs, not even really simulations, but little like walkthroughs looking at code responses. And when I sort of found out that was happening, I was like, hey, uh, there's this other whole world that's like amazing. Can I introduce you to this the world of like high fidelity of simulation? And um got a couple of them excited about that. And what I emphasized to them was just like the importance of the skill debriefer. Um, and and that I felt like that was really the fundamental skill with which we build a program and basically built built our programs out from there. Next step was to go to find some money because this the equipment is very expensive. And and my pitch is to stakeholders and donors was always that our emphasis was going to be on the people. The equipment is merely a tool. And when we think about or observe programs that are not successful, I think it's an over-emphasis on the technology and an under-emphasis on the people. I think um putting a mannequin in front of five people doesn't make them get better. Um, I think it's the person in the room that's going to facilitate those discussions, the person in the room who has an understanding and has the observational skills to see what's happening and help to process those things. So that's always been the emphasis of our program. We we love the fidelity. Don't get me wrong, the theatra is fun, that uh makes believability and uh stimulates breath responses in the way that we want. Um, but at the end of the day, our program really centers on those communication aspects. So we built a local program with um some really generous funding from our hospital foundation to buy a mannequin and start to put some stuff together. And over the decade or so, um, that's just grown exponentially. So we've taken on um teaching simulation for some residency programs, particularly the McMaster Rural Program. We also do some teaching for Toronto and then start branching this program out as sort of an outreach, you know, trying to reach clinicians who practice outside of our narrow circle. Um so we have this program called SCORE, which is a simulation program for other healthcare professionals. Sometimes we run courses in Collingwood where physicians can come. And uh, sometimes we take our show on the road to hospitals that are looking for simulation programs. We also pass along what we know about uh debriefing and communication with other people. So we have a train the trainer program where if hospitals are trying to get their own simulation programs going, we can go in and support that with some skills around um educational planning, simulation planning, um, and debriefing. And that's sort of where we land right now. Um, programs running super strong in in a bunch of different ways and both teaching clinicians, teaching um learners, teaching in-house, did a big SIMD yesterday for OR nurses, uh, and then also um getting out into the community and hopefully spreading the word and uh helping to empower other people to take on this work and and in their own environments.

SPEAKER_04

Me and Adam are like super red-pilled into this. Like we buy sim. You don't have to convince us that this is a good thing, you don't have to convince us that this is worth doing, but maybe for some of our listeners, can you just clarify why simulation in medicine? What is the actual through line that connects the two and why is it super

Why simulation is a good fit for medicine

SPEAKER_04

applicable in our field of work?

SPEAKER_02

I love where you're positioning me amongst your speakers. If you'll indulge me for a second, I'll just draw on some of the things that you've been been talking about in your previous sessions. I just want to start with with Martin Bromley. When I was a resident in what would have been 2005, and that was around the time that the Bromley story got put into some video and became a patient safety campaign. And I remember watching that video as a family practice anesthesia resident and just being like absolutely stunned, absolutely floored, uh terrified, but also inspired. I remember saying to myself, that will never happen in a room that I'm in. This is my commitment to Mr. Bromily, is the work that he's doing, the work that he's done to put his story out there in such a progressive and proactive way to try to help others, like it's landed for me, and I will commit to no one is ever gonna die of a can't intubate, can't oxygenate scenario in the room that I'm in without us having access that airway through the front of the neck. That was my commitment. So for me, simulation, you know, why simulation? Why is it important? I mean, it started from from thinking about how does a room full of people now who are smart perform suboptimally in such a horrible way and have such a horrible outcome? How can that happen? It can't be because people are dumb, it can't be because people just can't do it. There have to be some other pieces. Or I think some art can inherently respond to crises better than others, but nobody performs perfectly in crisis, nobody performs optimally in crisis. And so simulation is a way to try to improve our responses in crisis by being able to put ourselves in stressful situations and then deconstructing them and saying, How did my brain operate in crisis? Why did I perform so optimally? What are the ways that I can and need to get better? You know, the the basic assumption we talk about when I when I teach a course, the first thing we do is we do a little pre-brief session where we talk about what we're trying to do in the assumptions. And the very first assumption that I share with people is you are all smart and capable. And there is nothing that you can do today to convince me that you are not smart and capable. My second assumption is that smart, capable people perform suboptimally in crisis. I just think that that's a fact. I think you could get that. But when I was in medical training, we never talked about any of this stuff. When you want to manage you can't intubate, can't oxygenate. Here's the piece of paper that describes the four steps that you're going to do. That was how we learned. We learned on paper. You know, how do you respond to a cardiac arrest? Well, here's the algorithm. And the algorithm will have 12 steps in a row. You walk into a room in a code at a rural hospital, you know, at two in the morning with one nurse standing next to you, and you ask for the 12-step that you memorized in medical school. I don't need to tell you that that's not gonna go well. When I first started practicing, that was my approach in emergency medicine is okay, I know sepsis. There's like there's 36 things I want to do in the next four minutes, and I'm gonna ask for them all right now because that's how I learned. I learned in batches, I learned in lists. And trying to translate those lists into real world action requires a complete rethinking about how you're going to do things.

SPEAKER_03

I think what I really like about having you on, Jesse, is that you are a rural generalist. I mean, we've had people who come from big academic centers and they have a team of nurses that are there. Sometimes you just have that one nurse and you're in that rural hospital, and it might be you and you might be the emerge doc, or you might be it might be you and an emerge doc. You know, I've I've been at where it's anesthesia and an intensivist in the ICU uh at two o'clock in the morning, um, and we're trying to get lines and all these other things and so on. It's funny how you said, you know, 20 years ago, you kind of came to this idea that how do people who are otherwise smart, caring, motivated, et cetera, uh perform suboptimally. And they had this similar revolution in aviation. The difference was it was public, right? And we we saw in in previous episodes how we had in the 70s a few different crashes where there was not some major malfunction like an engine failure, engine fire, things like that, that brought down a whole airliner full of people. It was a landing gear malfunction. And obviously these people were extremely well experienced and uh caring and motivated and smart and all of those things, and yet they all died. And so that became very public. And then they said, okay, well, how are we going to do things? And it's not that simulation was new. So it's interesting, but the way they use the simulator, going back to the idea of it's not the technology, it's a tool on how you use it. It was, well, okay, well, we at least have cockpit voice recorders and we have flight data recorders, and we can see how this chain of events has happened. Now let's look at it and talk about team performance and the interaction of humans and technology and so on. And so, as we've seen in other episodes, oh, this is how this airplane ran out of fuel, even though there were people in the cockpit that were trying to tell the captain what was going on, or this is how this ended up happening instead of that. As Captain Mike Schuster had mentioned, the newest generation is not just general guidance and things that are in the industry, it's company specific. So we might one day see hospital specific. And so it's interesting that we seem to be having this revolution in medicine. And yes, it's talked a lot more in, especially residency programs, many of which have incorporated simulation to some degree. But it doesn't seem to be something that necessarily always translates. Like I'm wondering one day if we're not going to see some of the courses that you run, for example, as part of a requirement if you work in an acute care specialty, or if you're a hospitalist, or if you want to get into being a hospitalist after doing family medicine for a while, or if you want to go into the eMERGE, where that's part of the sort of proficiency you require to do these things, at least demonstrate some competency, or at least in terms of the many ways in which we can complete our continuing medical education.

SPEAKER_02

But when I talk about crisis resource management, I have a talk that I give on principle like my proles of CRM. And the introduction to that talk is to talk about how we ended up here and it draws from exactly what you talked about, which is the airline industry's recognition that almost never is it a catastrophic mechanical failure, that that there was no way to solve it. Those were the big themes, which almost always sorry, failures of communication, failures of decision making, failures of leadership. And I would say medicine in many ways is analogous. The most obvious analogy I would say is anesthesia. I would say anesthesia is much like aviation in that there's a heavy reliance on technology. There's an interaction with data systems that are in front of you that are shouting numbers and alarming at you. The captain, I put that in quotation marks, um, you know, is also coordinating a team. So I would say that was like the most logical foray into simulation in medicine, um, lends itself very well. And then I think what we're seeing is is that expanding out into the different specialties, recognizing um that these skills are are crucial across the board. I use the example that you're that you're talking about landing gear. So United Airlines flight 173, um, landing gear is the issue. Plane runs out of fuel, it's totally analogous to a situation like a failed airway. This United Airlines flight 173 crashed ultimately.

Fixation Vs focus

SPEAKER_02

Um, because of the failure to recognize what the actual problem was. The problem was we needed to land the plane. The fixation was why is this light not working? Or why am I not getting this data point that I'm expecting? Um, and in fixating on trying to solve that problem, we lost the track of the real problem, which is altitude. We are thinking we are now going to lose altitude. The way I define the differences, focus is you've chosen the right thing to focus on. And we call fixation when you've chosen the wrong thing to focus on. You won't know until after the fact. Um, same thing in a can't intubate, can't oxygenate scenario where the fixation becomes on how do I get a plastic thing below the vocal cords to ventilate instead of what the real problem is. The altitude is the oxygenation. That's the only thing that really matters. It doesn't matter how you get it in or out. It doesn't matter if you land that plane with a landing year or not, or a landing year gauge or not. Um, the altitude is the issue.

SPEAKER_03

I can't remember if this was you or not, but but somebody told me, and I'm gonna attribute it to you because I can't remember if it was somebody else, but it was people don't die from uh a lack of plastic in their trachea. They they die because of a lack of oxygen, and it's a it's the manner in which you get it there.

SPEAKER_02

Absolutely. What my joke, Adam, as you've heard me say before, is the things that I say over and over, I would get tattooed on my arm or on my chest. Uh, and that's definitely one of my tattoos because nobody dies for a lack of plastic below the trachea. Um, we got to figure out a way to get in that. But this is a perfect example of how the human brain fails in crisis, is we lose track of what our what our real problem is. We lose situational awareness around what the problem we actually are trying to solve is because we are so used to I'm gonna get a tube and I'm gonna get the two below cords. That's the thing I'm gonna do. That we think that's the problem we have to solve is how am I gonna get this tube below cords? The problem is really how am I gonna maintain altitude and my oxygen saturations? How am I gonna keep this patient alive? Um, and that's a thing you have to learn and practice. Um, and when you you fail, when the quote unquote captain or the quote unquote team lead, you know, fails to maintain that situational awareness, how can we have a system to protect us from our own shortcomings? In the introduction, you talked about how if a system cannot depend on one controller being perfect every single day. That can't be the system. If that is our system, our system will fail. It's the same thing in medicine. In the generations prior to mine, if the system is, the doctor will know all the answers. The doctor will get it right a hundred percent of the time, the doctor will lead us to salvation. Our system will fail. Our system is is is doomed from the start.

SPEAKER_03

Even when I was a flight instructor, and this is one of my one of my first real jobs as a pilot and so on, and it was a manager of mine. Um, actually, it was Captain Mike Schuster who we had on here. He gave me my very first job. And his philosophy of running the flight school was if you get hit by that proverbial boss, we want to make sure that we can pick up that pilot training record and you put all your notes in there, and we can pick up this pilot and continue training them and so on. The idea is somebody else should be able to pick up your work and go on there. And I think it only gets more acute, this idea of redundancy and backups and things like that, the more critical your role is.

The connection between CRM and Simulation

SPEAKER_04

And Jesse, I like what you were saying about the fixation versus focus and all that stuff, but I'd I'd ask you to draw a fine point between that whole concept, something we agree with, and simulation. How do you bridge those two? Like, what is the through line between them? And how does simulation actually get us there?

SPEAKER_02

How do we get from a theoretical understanding of solving a problem to actually solving a problem? That's what crisis resource management fundamentally is. And so I think the through line is you have to see it, you have to experience it, you have to observe it, and then you have to reflect on it. I think it's the reflection is the through line. I think it's the reflection as a team, the reflection with a with a skilled facilitator. What I want to be able to show someone is they're gonna come out of a simulation and they're gonna say, Why did I do this, or why didn't I do this, or how did I miss this data point? I want to be able to show people that that is the norm. You know, that is that is how these things go. What I what I like to tell people is like if you get 90% of the management and approaches perfect, like that's great. 90% is great, but we're missing 10%. We need a system that protects us, even in essentially an optimal performance. We still need a system to catch that other 10%. So I think the through line is a reflection on that, a normalization that 90% is amazing, 80% is still really good, 70% is adequate. We need to fill in the other 30%. We need to fill in the gaps. And that comes from reimagining our systems and/or reformulating our systems. One of my very favorite simulation debriefs when we do interdisciplinary work is to just talk about the other resources in the room. Talk about who else knew what or saw what at any given time. And one of the very common themes in interdisciplinary simulation is I know there's a nurse in the back of the room and I can see it in her eyes. She knows the answer. She knows what we need next, and it's not coming forward to the team lead. And that was the that was the lesson of United Airlines Flight 173 is people in the cockpit knew we were low on fuel that was not getting transmitted forward. So um that's the same.

SPEAKER_03

And Martin Bromley, right? And Martin, like I mean, in the Martin Bromley case, the nurses brought the trait kit in. They brought the kid in. And and very similar to, I mean, you use we use the United 173 as well as the same sort of thing where people tried to say, hey, this is it. And we've talked about one of the reasons we talked to Dr. Katie Lynn was because she did her master's public health in the language of concern during resuscitation.

The Evidence supporting simulation

SPEAKER_03

And you know, this is not specific to medicine, this is not specific to any industry. How do we know the intervention of simulation works?

SPEAKER_02

Great question and complicated answer. So simple answer is what do we have good evidence for? We have good evidence that simulation improves the confidence of the participants. So good evidence that if you come out of a sim, you feel better, you feel rejuvenated, reassured, you feel like you've learned, you feel like you've done better. I think that that's a very evidence-based result of the intervention. In and of itself, that is important. Particularly in the populations that I work with, which is rural generalists, there's a fundamental need to have the confidence to keep doing what you do. Rural generalists always have an out to say, yeah, you know what? Hospitalist is just getting too hard. Uh, I'm gonna do family medicine, I'm gonna do walking clinic, I'm gonna do something that doesn't have the high acuity risk of the current work that I'm doing.

SPEAKER_03

So physicians as a resource for the community, physicians as a resource for the community, avoiding burnout, physicians as a resource for for everybody. I uh cosign, as people say these days, cosign 100%.

SPEAKER_02

Is that what the kids are saying these days? I gotta probably let me write that down. I mean like incorporate that into my I got that from Amir. They keep me cool. They let me they teach me the the cool words when you're looking at um either encouraging new grads or young physicians into a field, like I encouraged Amir to practice emergency medicine or some other primary care after his anesthesia. If I can make him more confident, he's more likely to do that. And our country needs that. Our healthcare system needs generalists to serve rural communities.

SPEAKER_03

I definitely wanted to highlight the idea that just because it's subjective does not mean that it is not actually important, right? This idea that, well, it makes people feel good. Well, that doesn't matter. No, it it matters very much for the reasons that you said. So absolutely, yeah.

SPEAKER_02

Very much. Yeah, so that's been the current iteration of what I've been doing with interdisciplinary SIMs outside of my own facility. It's encouraging new physicians um to practice high acuity medicine and to try to retain end-of-career physicians in high acuity medicine because those are the groups that keep the healthcare system together. And without those groups, uh, we can't staff our rural emergency rooms, we can't staff our hospital inpatient units. So um, so I think confidence is absolutely an outcome that's of importance.

SPEAKER_03

So when we say one of the benefits of simulation and CRM and all these things is to have a better functioning team, we also inevitably have a better functioning work environment. And that actually translates to better care. That better work environment means that we're going to retain people, as you said, senior physicians and senior nurses and things like that.

SPEAKER_02

Yesterday, I ring simulation day for my hospital. One of my expressed goals for that session was confidence. But like you said, we shouldn't talk about that just because it's subjective. We shouldn't talk about that like it's a flippant goal. It's it's a crucial goal. On the issue of competence, uh, competence is very hard to measure. And time and time again, you're going to hear that it's hard to measure performance from a simulation point of view. You can't simulate every scenario. And you're trying to derive some skills that apply in all kinds of different situations, which then makes it hard to have the control. You know, it's hard to say, it's hard to measure, you know, did I get better? You know, do the same sim six months later. Did I get better? I'm gonna perform better because I saw that sim six months ago. The objective measurements of performance are much harder to show in the literature. I'll get asked that question typically by people who are contemplating paying for these things. Does it make people better? People will tell you it made them better for sure. There's no question about that in the literature. Do I think it makes them better? Yeah, absolutely. When I see the difference between um the residency programs, we work with their performance at the end of two years versus at the beginning, like light and day. And when I see those graduates versus graduates from programs that have not had simulation training, it's very clear. I can go to someone afterwards and say, Hey, where did you do your sim? You know, and they're like, Oh, I did it here or I did it there. You know, like I know they've done sim because no one uses that language, no one brings those skills to the table that hasn't trained in that. There are no great randomized control trials that I can point to that say, This, this training definitely improves your skills in X, Y, and Z. Can I tell you, having watched thousands of hours of simulation, that these skills are acquired and demonstrated and reproducible over time? 100% yes, all day, um, every day, and we see it. I'll have nurses often in my sim program be like, Oh, was he one of our residents? Because he said X, Y, or Z, and it's like, it's exactly how we teach her, exactly how we do it. One of the things that I really focus on, Adam, when I'm when I'm teaching is I'm not there to evaluate performance. I'm not there to judge performance, I'm there to make you a little bit better than you were when you showed up at eight o'clock this morning.

SPEAKER_03

It's been sticking in my mind that those two Air Canada pilots that that died at the Guardia, we're gonna see millions of dollars spent in the investigation as it should be. Um, and we're probably gonna see all kinds of changes, changes to physical systems, maybe that truck was gonna have a transponder. We're gonna see probably changes to the air traffic control system, we're gonna see perhaps changes in the aircraft, we're gonna see perhaps changes in pilots. We're not entirely sure. And those are two people that died, and and those lives obviously matter. We wouldn't have dedicated this podcast episode to them if they didn't. But in the grand scheme of a large airplane accident, those are a few number of fatalities. We know that in the medical system, there have been people that more than two people, of course, that have died, perhaps even this year, that may not necessarily have needed to had they taken these kinds of courses and had they had these kinds of interventions and so on. And what's interesting to me is it's very public. And within hours of that accident happening at LaGuardia, the president of the United States commented on it, the Prime Minister of Canada commented on it, the CEOs of of all kinds of organizations commented on it, there was an outpouring. I think in medicine, part of the problem is these things happen behind closed doors. They don't necessarily get identified as having been the antecedents of those issues. And so sometimes the interventions aren't necessarily put forward or the investigation isn't necessarily there. And I think you answer the question as best you can. And the reality is, do we really need an RCT? You don't need any RCT to prove that parachute works. We know that it has the benefit that it has. Do we need to quantify it? Perhaps, perhaps not.

SPEAKER_02

You might be seguing into a question that I'm going to answer anyways, but let me just punctuate that thought. We talk about simulation as a resource-intensive intervention because by education standards, it is resource intensive. If we talk about it in terms of the resources that go into a hospital or a system, we're talking trivial, trivial, trivial dollars, right? We're talking about a thousand or two thousand dollars for a physician, you know, to come and take a course, which for a physician out of pocket, you know, feels like a lot of money in the moment. And it is, it's not a trivial amount of money, but when we compare it to the cost of like running an OR for a for a day.

SPEAKER_03

Like it's, I mean, the dollars are there. I I know Amirov and I have had this conversation. The dollars are there, right? When we say something is expensive, first of all, it's often put in the cart before the course. We need to determine as a society, as a healthcare system, what is the safety standard? Is the standard that we do recurrent training like aviation does? Is the standard that we require this for continuing professional development? Is the standard whatever it happens to be? Do we need this monitor, for example? Do we need this piece of surgical equipment, whatever the standard happens to be, and then decide how to pay for it? It's not it's not the other way around. I know it's a public system, it's just a matter of what are we going to pay for, how do we justify it, all of these sorts of things. Amir, sorry, go ahead.

Simulation for ergonomics

SPEAKER_04

I'd like Jesse for you to talk about the utility of not just simulation as a whole or as an educational endeavor, but like when you bring this high fidelity simulation to other sites where you can actually test their systems, like if you go to a rural hospital somewhere else and you run a high fidelity sim there and they start troubleshooting, hey, this piece of equipment was not available or was available, or we don't really know how to use that. Can you can you speak to that a bit?

SPEAKER_02

I'll start out by saying is there are people who do this work specifically, you know, who do sim purely for testing, you know, ergonomics and logistics. And I think that that is a really valuable thing. Most of the time that I'm asked to come and teach a STEM course outside of my hospital, that's not exactly what they're looking for. My group hasn't been asked to do a lot of that. I think the focus of most of the teams that have asked us to come in has been really more about the communication pieces, the leadership pieces, some clinical medicine. Obviously, clinical medicine and resuscitation is a thing that people tend to want a lot of. I think that there are some groups who are focused really on the logistic pieces, the ergonomic pieces. I think that that is also super valuable. So when we are in the simulation program for my own hospital, a lot of what we do is really centered around our local responses to things. So we have, for example, a code committee for our hospital. And our code committee will look at different versions of codes and let's make this new code omega or whatever. And here are the people who are going to come to that. We will then simulate that code. We will then run that resuscitation in our hospital to look at how that system responds, how that system works. Yesterday, we were in a simulation day in the operating room for our massive hemorrhage protocol. This is a really lovely example of the difference between how something looks on paper and how something actually happens. Back in the mid-2000s, we had a pediatric traumatic death from the skee hill. At that stage of my career, anytime I had a case that really ate me up for a long time, whether clinically applicable or not, I wanted to make a change as a tribute to that patient. So this child died not because of the massive hemorrhage protocol or the absence of and didn't die of hemorrhage, but the confusion and the challenges around logistics of the massive hemorrhage protocol inspired me to make that sort of my dedication to that child. So I designed a massive hemorrhage protocol. I designed a thing on paper. And then when you try to execute that thing on paper, it doesn't look the same when you get into practice. And we've had many iterations over the years. But yesterday was again a testing of our massive hemorrhage protocol in a specific context, which is in the operating room, which looks different than the ICU and looks different than the emergency room. And when we get into those, invariably there are challenges around nurses who were saying, Well, how do I have to enter this piece into the computer before the blood shows up? But I'm the only nurse here. We got an arterial bleed on the table, and you're asking me to go over to a computer to type in, you know, like my pin to release another unit of blood or whatever. It wasn't quite that dramatic. But you know, these logistic challenges that when we're drawing up these protocols, we don't anticipate. So a lot of our in-house simulation results in the kinds of things that you're talking about, which is a re-examination of your protocols, no matter how good they look on paper, until you actually have real blood or simulated blood falling on your feet. You don't know how the system can respond around you. And that's an opportunity to test your plans. Once we went to EMR, we required the patient to have a chart in EMR. I can get a page from EMF saying this fellow is missing an arm and has an arterial bleed out of his arm socket. And I'm thinking, okay, let's get some blood here. Well, you can't get blood because you don't have an EMR chart. And so we had to revamp our EMR responses to say, well, what about in this clinical scenario? How can we go ahead and initiate blood without that version of a charge? Better to figure that out in testing your systems than to figure that out on the day that you want, you know, eight units of blood and and before the patient even gets

The evolution of Jesse's Simulation Delivery over his career

SPEAKER_02

there.

SPEAKER_04

Jesse, can you speak about how your simulation has evolved over your career or your training? You painted a beautiful narrative of how is one step to the next, to the next, to the next. But can you maybe refine that a little bit more and specifically talk about how your delivery of sim, how sim training has evolved over time?

SPEAKER_02

I would say the biggest way that my teaching or my approach to simulation has evolved over the last decade and a half or so is getting way better at designing simulation activities or designing educational activities for a specific goal. I think early on in my exposure to STIM was in what we call theater simulation. So you design a case, fidelity is of paramount concern. That case runs for 15 or 20 minutes, and then you debrief it for 40 minutes. That was the initial model to which I came to simulation. And I loved it, and it's fun. And I would say it's still my favorite model. It's the most fun model to work. Just presenting that case doesn't necessarily get to all of the specific objectives you you might want out of that case. So what I have gotten way better at over time is reflecting on how am I going to design this simulation to get at the learning objectives that I'm setting forth for myself. We've talked about different examples like expressing concern or having allied health professionals develop the confidence, the language to express concern in crisis. So if that was my goal for a simulation in can't intubate, can't auctionate, I would design that case in a very specific way. I would design that case with the physician as a confederate, meaning the physician is a person on the simulation team, because I want to control the way they respond to the nursing staff, the allied health professionals to draw out the behaviors that I'm trying to work on with the Allied Health people. If I want to do a simulation whose primary objective is to figure out is our difficult airway cart in the right place? Does it have the right things on it? I'm going to design a very different simulation. I'm going to put real people, none of whom know the scenario, into their normal environment, let it run, and then see how the ergonomics of that case unfold. If I want to focus on accessing through the front of the neck, I'm going to take us out of the theater. I'm going to go to a place where I can do 20 reps of scalpel to skin in 20 minutes. I've gotten way better at figuring out how to adapt the educational activity to really focus on specific goals. I can't remember if I came up with this or if I stole this from someone else. Usually when I stole the same thing, it's from Rob Anderson. So I'm going to credit this to Rob Anderson, even if I made it up. Simulation without goals or objectives is playing. You're just playing if you don't actually have a goal. It's fun and good things might happen. But if you're not coming in with very specific objectives and you haven't designed your simulation to meet very specific objectives, you will lose efficiency and you may or may not get at your objectives. So I would say that's the biggest way that my approach has evolved. For example, if we're trying to teach the skills of code blues, we actually don't do that as a theater simulation. A theater simulation is essentially one rep. You're going to get one ghost through, and then at the end of it, you're going to talk about ways that you could improve, but you're not actually going to try them. You're not actually going to improve them. You're not actually going to reinforce them until your next activity, which might be six months or six years later. The way that our group teaches ACLS is we do what's called rapid cycle deliberate practice, where we really are only interested in about three minutes of that resuscitation. How quick do you get the pads on? How good are your compressions? And what are your compression to ventilation ratios? How quickly do you get the defibrillator on? You know, do you get the right drugs and the right doses? Those are all things that kind of can happen in the first four minutes of resuscitation. So we'll just rep that out over and over. We'll spend an hour. As soon as we deviate, especially when there's something that has standards like an ACLS protocol or an NRP protocol, we'll just rep that out. And as soon as we deviate from the standard, we'll stop and we'll say, okay, Adam, I noticed that your compression depth is a little shallow there and your rate is a little bit quick. So what we're going to do is we're going to rewind 30 seconds, we're going to start again. And I want you to focus. Your compression depth and your rate. And Amir, I want you to coach Adam on his on his depth and his rate. And they're going to wreck that out. And every time there's a deviation, we're going to stop and we're going to get better at those pieces. That means that's a completely different simulation modality from going into a sim where we do a code blue, and at the end of it, we say, well, Adam, you're I noticed during the case your compressions were not great. So I would say that's been the evolution for me is just getting more creative, more precise around matching educational opportunities to objectives. I like to think my debriefing has evolved over the years. You've never seen all of the possibilities that can go in a sim, but I've seen so many sims that I know the themes. I tend to know why people have done what they've done in a scenario. And I think I can match that up with language that I think is helpful. So I like to think I've gotten better over the years, also just that the debriefing and execution piece of those.

SPEAKER_03

That's great. And it really ties back to some of the themes we talked about earlier. You know, the idea that, well, in the past in aviation, for example, they would absolutely use the same and they, okay, you'd mess this this part up of the engine fire drill, let's just reset it and go back. And there is a place for that in medicine, as we've talked about. There is the place for the high reps, as you said, especially for those high acuity, low opportunity, or halo or whatever you want to call those kind of scenarios. Absolutely. And there is a place for muscle memory and skill acquisition and skill maintenance and all of that. And then there is also this idea that, well, let's fail the landing gear indicator light and let's make sure that they don't get into this. And I had uh a situation like that only a few days ago, where we get a patient in the room just for just a colonoscopy, which is usually where the troubles sent tend to start to arise. And we didn't realize that because the nursing note was was late and I didn't have access with the EMR, I didn't have access to the surgeon's note and so on. We get the patient in the room and realize, oh, well, she's actually BMI 55. And I realized, oh, well, the airway is a significant concern here, and I'm gonna change my anesthetic plan considerably. And I literally just said to the nurses and everyone, I said, the patients in the room, we're we're going to go ahead, but we're gonna go ahead when I'm ready. And that means I'm gonna get a bunch of airway equipment out, I'm gonna have some extra help around, I'm gonna use different medications to maintain spontaneous, all of these sorts of things. And then that's the we can still potentially do this, but we need to maintain that margin of safety, and we're gonna do this in a different way, as opposed to just blasting ahead and hoping everything sort of works out or or getting into a tight spot that maybe through good skill I could have, you know, prevented this or that. But it's the judgment that hopefully prevents the

Simulation as a requirement for credentialing or its role in continuing medical education

SPEAKER_03

use of the that necessary skill and all of those sorts of things.

SPEAKER_04

I like the framing of this in terms of design and having intention with the simulation. I want to go back to something you had teased earlier, Jesse, because I think it's a point that that is very applicable to our audience, and that is the role of simulation in CME education, whether or not it should be a requirement, the floor is yours.

SPEAKER_02

Awesome. You got about two hours to talk about this stuff, okay? Let me clear the rest of my day. So, simulation and CME. I mean, this is this is what I love. This is the thing I like to do. Amazing opportunities and also some significant challenges. When we talk about making things mandatory, uh it changes the face of what what you do. If you talk about things like performance assessments or demonstrating competency, it changes the way that you would design the activity, it changes the goals of the activity. In the current iteration of what I do most days, my goal is to create an environment that feels very safe for learners, that feels very comfortable for learners, that makes them feel like they can come in and perform suboptimally and get better. And that that's the only goal of the activity. That is really liberating for me because I get to just focus on creating a safe environment to make people better, and that is my goal. There are people who do great work on simulation for performance assessment in residency programs and and for sure in other industries. And Adam's alluded to the airline industry and simulation as demonstration of competence. We don't currently have that in medicine. And when that topic comes up for me around performance assessments for learners, I take a little bit of pause, only because it's not what I've historically done. My emphasis has always been on explicitly the opposite. I'm not watching with the lens of like, do you know a lot or do you not know a lot? I'm watching with a lens of if this emergency happened to you today, how could we do better at this? You know what you know today. You were gonna draw on that, and you're gonna draw on your other resources. My tattoo around safety is if you make that something safe and you make it fun, people will come back. If they come back, they can learn some more. If you make it intimidating or scary, or the feedback is received partially, people won't come back. And if they don't come back, you can't teach them anymore. You asked a question earlier about how my teaching has evolved. As you can probably tell saying those of you who know me, I tend to talk fast, I tend to talk in huge volumes. I'm enthusiastic about what I do. And early in my career, I could not resist the urge to add more learning and more teaching. And my Sims would go like 10 minutes over. You guys would both remember from DoCamp, you know, getting the knock on the door, like you've gone over time because I just want to get all of it out there. And one of the things that I learned from a safety point of view is sometimes you just have to back off. Sometimes there's a thing that you really would like someone to take away, but you can see in their body language, in their responses, that they're not going to be receptive to a particular piece of feedback or to a particular suggestion. And early in my career, I generally struggled to resist that urge. Now I recognize that my number one goal is for you to learn, get a little bit better, and also have an experience that's pleasant enough and rewarding enough that you'll come back. And I'll catch you the next time. We'll get at this point, you know, in another iteration. So that's what I've been doing. Um, challenges, um, challenges around competency assessment is now you're changing the game. Now you're changing the objective. And that is going to increase pressure. I think if it's like relatively voluntary, people will shy away from like getting report cards. I think most people don't actually want that, especially on these kinds of topics of high pressure situations. I think that the training and the opportunities to develop skills are so limited for people. It would be unfair to say every five years you're going to show up. And I'm going to give you the scariest possible emergency you can imagine, and now you better solve it. We're not going to give you any training opportunities in the next five years, but five years from now, you better show up knowing how to run a pediatric massive average protocol. That feels unfair. And then we've talked about the challenge of cost. I think cost on the individual is significant. If you're looking to do a SIM course every year, you're looking at a couple thousand dollars every year. Grand scheme of things, not the end of the world, but that does add up and it feels like a lot in the moment for systems. If you're in a rural community and you say, hey, I had like $40,000 to run a SIM program for the next year. That number feels big to administrators who are trying to figure out how to balance their budget. Grand scheme of things, $40,000 is probably two days in a tertiary care ICU. If we could save two days, for sure, we would like to think a sim program would save us two days in an ICU somewhere. So we can make all kinds of cost equivalence arguments, but I would say having people recognize, appreciate the value, and monetize that value is a huge challenge. So I would say before we get to a place where we can use mandatory simulation performance assessments, we would need to offer the world of medicine relatively ubiquitous opportunities to practice and train and learn. Once that's there, then I think you could start to talk about this is a maintenance of competence certification or whatever. Like literally, I teach 60-year-old physicians who have never been in a sim before. It was not part of their training. They've worked in in small community hospitals, they've never had the opportunity, they've never talked about leadership, they've never talked about closed-loop communication, they've never talked about macrodelegation, all the things that are like, you know, my bread and butter vernacular, my bread and butter vocabulary, it's novel to people who trained in 1990, you know, or 1995, you know, let alone 1975. So I would say um at this point, it would be it would be premature to start to make those things mandatory. I think first we have to build a system where that training, that skill set is taught really well and people have access to learning and practicing those skills, and then it can come down the road. I have good friends who do work in simulation for competency assessment in residency, and I think that that it's there and and can be done, but from a systems point of view, for practicing clinicians, it's a waste of shit.

SPEAKER_04

I echo your thoughts and feelings very strongly about this, Jesse. I I think in one of the previous conversations Adam and I had on this podcast, we talked about the fact that when you're a physician, let alone an FRCP or a family physician being trained, there isn't really an assessment about how well you do leadership, or at least not formally. There is more now. There are more programs that are actually incorporating SIM as a formal assessment of their ability to graduate and be competent. But I don't think, at least historically, there was ever a question of whether or not you were an appropriate leader in a neurosurgical operating room, or if you're an I am attending on the floor as to how you can lead a team. It was more related to your textbook knowledge of medicine, your more and medical facts. And Adam brought up the point that no, no, no, in aviation, this is actually a skill that you have to have to practice and graduate. Like we assess you for your ability to have like leadership skills and things like that. And so, you know, I hear your points that simulation isn't there as an assessment tool as of yet in the big scheme of things. But I wonder if you can comment on the fact that some of these skills that we pull out in sim should be part of our medical training, should be part of the physicians we graduate. How do we incorporate that? And if your answer is just do more sim early on in your training, fine, I buy it. But I'd love for you to expand on that thought if you could.

SPEAKER_03

I'll just supplement with the aviation side of things. So, in you cannot get your private pilot license in Canada and I think most of the world these days, unless at some point on the flight test, you've had your pilot decision making and task management. So this is a single pilot operation in the day in good weather. So you have had some at some point you'll have to divert the aircraft to an unintended destination, prioritize things, land the airplane, et cetera. And incorporated in that is your task management. You know, did you get task saturated? Did you get fixated? Did you, et cetera, et cetera? But also your decision making. So at some point, there is at least some attempt to evaluate, even at the private pilot level, the pilot's decision making. And then, of course, when we get up to multi-crew aircraft, there is the idea of crew coordination and resource management. So at some point in there, we're testing not just can you perform the engine fire drill correctly and can you land and save everyone on the airplane, but at some point we are assessing these other things. And somewhere in there is an element of leadership, but really it's decision making, it's resource management, it's task management. So just to frame that there, just in the context of Amir's question.

SPEAKER_02

I think at the residency level, we're ready for that. I think we're there and ready to start testing and evaluating and requiring a demonstration of competence. I think that's exactly kind of the phase we're at. Let me add that that is not the work that I have historically done and partly intentionally, and maybe I'll come back to that. But a colleague of mine, Andrew Hole, has done lots of work with the Royal College around simulation for performance assessment. The Royal College Anesthesia Program has part of that as their examination where they do have a simulation component. I think it's excellent. And I think it's the only logical way. What people generations before would have said is like, oh, well, of course that's part of what we do. That's part of your IDER for your internal medicine rotation, is like, could you run a code? The truth is nobody actually ever observed you run a code because you were the SMR and you went and you did that on your own. The truth is if I'm your preceptor and I'm standing next to you, I'm not going to stand there and watch you run a resuscitation on your own if I'm worried, you know, like I'm going to intervene. And as you know, I'm a control enthusiast, so I'm probably going to intervene a lot. You know, that's the way it's going to go in real life. So, so if we want to assess someone's ability to lead in crisis, you have to simulate that. I think that that needs to be done. Specifically on my role, I tried hard to make people feel safe in simulation. And I've I've enjoyed the distance, the intentional distance or the intentional boundary between being a coach and being an evaluator. And so, particularly for my own learners, my own residents, or my own colleagues, I would way rather be a coach than be an evaluator. And I think it's really hard to be both of those things at the same time. I think that if you want someone to be an evaluator, that should be their job. And they should have that, people should perceive them in that way. I think if I'm going to be a coach and a mentor, it puts an undue pressure if also one day I'm going to take that hat off and give you a report card. And that report card might have an F on it. But then tomorrow I'm going to go back to being your coach and try to pump your tires and try to help build your confidence. Not that I couldn't do the role of being an assessor, but I've really enjoyed the separation of focusing on the coaching piece.

SPEAKER_03

It is funny. In preparation for this podcast, I just was reviewing the flight test guide. And in Transport Canada, they will put out a very specific this is the private pilot flight test guide. You are required to show the examiner, which you will take up in the air, these exercises to this standard, et cetera. And it may not be in this necessarily order and so on, but this is what you're being evaluated on and how to succeed and those sorts of things. They also have a separate flight test examiner manual where they actually, again, you can look this up, it's all public, where they give instruction to the examiner as to how to fairly examine and so on. And they have a very they have a section specifically on what if you are examining your own students, which does in special rural areas happens from time to time, right? You can sort of switch that hat, but they're very aware of it's a bit of a precarious situation. There may be a conflict, there's all kinds of things that go into that.

SPEAKER_02

In keeping that separation between the two roles, it also allows me to be a little more demanding. I can be demanding of my learners, I can put very high standards, I can give very honest feedback that's that sometimes can sting a little bit because at the end of the day, my learners know my only goal is to make them better. And I think that you you have to change the way you give feedback if the learner knows that your goal is to assess them, is to give them a passing or failing grade. That feedback looks very different. Amir and I worked together for over a year. You know, I don't I don't need to mince my words with Amir. You know, I can give feedback that's very directive because he trusts me, he had to build that relationship and earn that over time. But we got to a point where I don't need to worry about him coming back tomorrow because I know he's gonna, and I can give feedback that's directive and honest. And I think if you're coming from a different perspective, if you have different goals for your feedback, it has to look differently. I could adapt to another role, but I like the role that I have right now.

SPEAKER_03

It's a great point. It's a great point that they also make in these manuals that I mentioned. They talk about the Transport Canada gives feedback as to examiners as to how to, for example, handle a failed flight test. The nature of your relationship is different when you are the instructor, for example, as opposed to the examiner. How the feedback is received is different, no matter how it's worded, is just completely different. And so, and as you say, the objective is different. And I think that what you can accomplish is also different due to the fact that you have that relationship. That's great. I think Amir wants to say something.

SPEAKER_04

We can we can talk forever about the educational journey I've

Outros

SPEAKER_04

had in the context of Jesse's mentoring. It is a very unique relationship when you have someone that you can trust to educate you. Like, I think that the way the program is structured on McMaster is that yes, at the end of the day, like you're signing all my forms that say like I'm competent to graduate, but because of the uh design of the program and the people who are teaching me day to day, like you actually do get to separate that role very well. And it's it's weird, one of these mixed things because like you can never really separate it when you're in the moment. But I actually think you you you hit up the point correctly whereby like you have to build a relationship of trust and understand that even if you are writing the note of you know, incompetent failure, whatever word you want to use, like there's an understanding there. It's never blindsided, it never feels like it's coming from a uh from an unfamiliar place.

SPEAKER_03

We'll just move to sort of our our our outro here. We we just do usually three things. You know, one's a safety intervention worth mentioning, and then we talk about sort of who can do what tomorrow, and then we we get into some fun suggestions. So the safety intervention worth mentioning, we're just gonna briefly talk about some cognitive aids. And the one that I'm most familiar with is the Stanford Emergency Manual, which is just essentially it's it's meant to be a checklist of sort of an anesthesia style checklist of emergency-specific checklists, such as, oh, this is malignant hyperthermia, this is hemorrhage, this is hypoxia, used during a crisis as a checklist is supposed to be used. And we're gonna have to have another episode on how checklists and cognitive aids are actually used. It's not an instruction manual, obviously. No one's learning for the first time, oh, we should call the MH hotline and do these things and so on. It's more that it is a cognitive aid where it's you've probably done half the things on the list already, but let's not forget about these other things. And also the person who's doing it is probably not the one running the resuscitation, it's more somebody else who is there. And there's a manner in which you use the aid, but the fact is that the aid exists and some people may not be familiar with it, some people will be familiar with it. I know that they recently went to for the Stanford Emergency Manual an app that I put on my phone. I still have the PDF in a Dropbox saved on my phone just in case. And I do try and pull them out every once in a while when I have one of these just as a backup to find these things out. But as I say, we're gonna have to have a whole episode on those sorts of things.

SPEAKER_02

Safety interventions that you can do tomorrow. Go to Giant Tiger and buy a whiteboard and carry it with you or put it put it in a resuscitation space that you like and then go to a committee and try to get it approved. But first, you just go buy your whiteboard, uh, put it in your in your resuscitation space. Number two is figure out a way to practice communication, situational awareness, leadership, communication, you know, decision making and crisis. And whether that's signing up for a course, whether that's bringing a course to your hospital, whether that's getting together with, you know, four of your colleagues and just running a tabletop Zoom, have some education plan for how you're going to develop and or maintain these fundamental skills in the same way that you would read a headline, you know, gym article or a headline CMAJ article.

SPEAKER_03

So I don't know if a lot of people know this, but I'm sure many people are familiar with the idea of Top Gun. Top gun, by the way, was for instructors. It was not for the best fighter pilots, it was for flight instructors. It was for the fighter pilots who would then go back to their squadrons and teach other people. You had to be a good instructor. It was an instructor-trainer idea. And so that's something that could happen where you have program directors that implement high fidelity simulation, but you could also have chiefs of staff, department heads of hospitals could implement, you know, proficiency training or train the trainer or things like that. And of course, we all know that on an individual practitioner basis, you can go and try and take some of these courses with the idea that as Dr. Guscott mentioned, the objective is really important. It's not just to go there and have fun and this and that. What are the one to three things that you're gonna learn that you're gonna make your practice different? And it you may not know them going in, but if you listen to that debrief and if you think of it at the end and say, Oh, I learned about this, I hadn't even thought about this. I am going to try to implement that next time. We're gonna move on to some random recommendations. This is in the vein of Accrack, which is an anesthesia podcast that we all like here. Mine is gonna be the movie called Fakam Hall, which is for those of you I like Downtown Abbey, which is a very sort of old school, you know, this sort of thing. But it's a naked gun version of Downtown Abbey. It's very, very slapstick and has a bunch of rude jokes in there, but it made me laugh. So I figured I would I would go with that. Amir, do you have anything for this?

SPEAKER_04

I do. I would say take more photos, especially of the people you love and the times you're having. Me and my wife just got back from vacation. We realized how few photos we took of each other. We took a lot of mountains, we took a lot of like the beautiful scenery, but I'm like, where are the moments that we were enjoying, and we did not take enough photos of us? So going forward, just take more photos of yourselves and the people you love because uh years from now, you'll care less about the mountains and you'll care more about the experiences you had and what you look like.

SPEAKER_03

I co-sign that.

SPEAKER_02

Any thoughts, Jesse? My random recommendation that one of my rec room, one of my current residents is going to Tanzania reminded me of my favorite book ever, which I bought from on Amazon, which is called The Shadow of the Sun by Richard Kapuczynski. And it's just a beautiful book about mostly about Sub-Saharan Africa, and I love it so much. That every couple of years, when I find out that someone is going to East Africa or Sub-Saharan Africa, I say, Oh, you have to read this book. My my uncle, who's an English professor, bought it for me when I went to East Africa the first time. And so anybody who's traveling to that part of the world, I recommend that book.

SPEAKER_03

When you're next on, I need to hear more about this uh humanities that you did. I can't remember what. It sounds uh sounds amazing. I need to hear uh yeah, I need to hear more.

SPEAKER_02

I'm an old man now, and I I barely remember that.

SPEAKER_03

I don't see a lot of gray in that beard. That's it for this episode of the Medical Safety Podcast for our guest, Dr. Jesse Guscott. I'm Adam Shahada.

SPEAKER_04

Uh I'm Amir Hammud. And as one Thomas.

SPEAKER_05

And as one TV doctor said, No, I don't want to say it this time. All right, go ahead, go ahead. As one TV doctor said what? You have to say it.

SPEAKER_00

Beautiful day to say bye.

SPEAKER_03

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