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What a Difference an M.D. Makes

Your on-call pager goes off in the middle of the night. A voice on the other end of the line asks: “Doctor, What’s the next step?”


Graduating students are getting ready to transition to the responsibilities that come with being a hospital intern. The Update Course’s simulation workshops help them prepare to put four years of learning to work.

For four years they have lived in the role of a medical student. Their knowledge, understanding and problem–solving was frequently tested. But ultimately, someone else was on hand to make the final call.

At graduation, they will add an M.D. to their name and soon after will have the responsibilities that come with being a hospital intern. When their pager goes off in the middle of the night, they’ll need to assimilate all the learning of the past four years to make judgments, diagnoses and decisions.

To help them make that transition, an Update Course held in early May gave students the chance to confront common patient situations. For example, how do you begin to make a diagnosis when your patient arrives at the emergency room unconscious? Or authoritatively direct resuscitation efforts—known as “running a code” in medicine’s in–house lingo—when a patient has been found not breathing and with no pulse?

The students met in the Center for Human Simulation and Patient Safety, a safe setting where hesitation, questions and mistakes are teaching moments, not life–and–death crises.

This workshop on inserting a central line uses the torso of a mannequin. If blue fluid is drawn through the catheter they know they have placed it correctly, but red fluid indicates the wrong vessel was breached. Other workshops reviewed technical skills like suturing and placing central venous catheters, as well as communication approaches for delivering life-changing news.

In one room, faculty familiarize students with situations that arise in the emergency department. Doug Franzen, M.D., M.Ed., walks five students through the initial steps of a resuscitation.

“There’s no need to do television CPR,” he calls to the students when he sees them delivering ineffective chest compressions on the life–size human patient simulator. “You can do real CPR. Lock your elbows; the motion is in your hips. You know you’re doing good CPR if you feel it in your stomach.”

Franzen, the director of medical education for the Department of Emergency Medicine, reminds them that quality CPR can save more lives than the new cardiac drugs and Advanced Cardiac Life Support protocols. He also challenges them to try to match the rhythm of their chest compressions to the disco hit “Staying Alive,” as was recommended in a 2008 study. One advantage of the human patient simulator is its realism encourages students to interact with it just as they would a real patient, which in this case meant doing real CPR.

“White on right, smoke over fire,” was Franzen’s chant as he attached the EKG’s white, black and red wires to the requisite spots on the simulatorís chest.

The students discuss and debate their patient’s condition and decide a three–lead EKG could provide important information on what’s going on with the heart.

As Franzen guides the students in reviewing the things they know but perhaps have never put into practice, he assesses their performance: “There’s a time when you need to act. Your current reflex is to ask permission, but now you’re the resident. You knew what was going on, knew the right treatment, but you were afraid to act.”

In the next room, the Department of Anesthesiology’s Michael Czekajlo, M.D., Ph.D., groups the students into teams of three. He’s going to run them through some common scenarios: allergic reactions, a confused patient who no longer realizes that he’s in the hospital, a construction worker whose legs were crushed when a wall fell.

Unknown to the students, each of the patients is headed to a cardiac arrest. Along the way, they get Czekajlo’s advice, based on his personal experience, on what lab tests will deliver the fastest results and which drugs are best to use in real-life situations.

Often, he asks them to recall lessons from their first–year physiology course to explain the patients’ changing medical conditions. “If you know the why behind the physical findings, youíll know what your options and next step should be.”

It’s only a simulation, but the tension mounts as the students struggle to discover what went wrong and how to help the patient. One of the watching students mutters: “This is terrifying. Way too realistic.”

Just as important as becoming comfortable being in charge, says Czekajlo, is learning what their boundaries are and when to call for help. “The danger is they don’t know what they don’t know.”

Transforming the Curriculum

Faculty share their personal experience with the students, from how to get the fastest results from a drug or lab test, to which heart murmurs have a musical quality or sound like machine gun fire.

The third–year students also got a turn in the Simulation Center. During their Workshop Week, as it’s called, the Class of 2010’s Sarah Stuppy was a fan of the emergency department simulations.

Since before entering medical school, Stuppy has known she wants to go into emergency medicine. But it’s not included in the third–year’s rotation through seven specialties. Instead, whenever she had the chance on rotations like pediatrics and psychiatry, she would volunteer to evaluate a patient waiting in the emergency department for admission to the hospital.

But she still appreciates the simulation workshops. “It”s great to have this exposure at this stage in our education,” she says, especially when she and her fellow classmates are making choices about the specialties they are likely to pursue. She would like to see more of this kind of training.

And that, in fact, is exactly what Alan Dow, M.D., M.S.H.A., has in mind. As assistant dean for medical education, Dow is part of a team at work designing a new curriculum and developing the programming for the medical school’s new education building that will open in 2013. “As we plan, we are finding opportunities to make changes to our current student’s education,” says Dow. “And one of those updates is to incorporate more simulation experiences.”

Dow, himself, led a session that takes simulation in a different direction. Instead of life–size mannequins that use computers and software to re–create medical crises, Dow asked his students to consider how they would communicate with patients in the aftermath of those situations.

He has teamed up with the Department of Theatre’s Aaron Anderson, M.F.A., Ph.D., to teach the students how to share bad news with patients or their families. They’ve modified a model that cancer specialists developed to help them communicate well in difficult situations. “I want to you to be as good as oncologists at delivering bad news,’ says Dow.

Dow and Anderson have modified a communication model to help medical students consider how to deliver bad news. The original model, known as SPIKES, was published in 2000 in the journal The Oncologist.
pre Prepare and plan, from choosing your location, to who is available to support the patient when the conversation is over
S Choose your Setting and be mindful of body language
P Learn about your patient’s Perception, what they know about their condition or think is going on as well as the values that they bring to the conversation
I Invite them to indicate how much they want to know
K Share your Knowledge, being as clear and direct as possible
E Communicate empathy non–verbally, including a rule of thumb to give a patient 10 seconds to absorb the news
S Have a Support system ready to step in. Learning your patientís values, for example, will give you a head start on knowing who they will want to turn to, whether itís their family or the chaplainís office

He then asks for a volunteer and sets up the scenario: a young woman collapsed while running a marathon. Rushed to the hospital, she died in the emergency room. Her distraught husband has just arrived.

The time will come when these current students have to deliver bad news to a patient. Dr. Alan Dow’s goal is to equip them with a set of communication skills they are confident in.

“You need to tell him what’s happened,” Dow challenges the student, who quickly jumps into the role play with Anderson. “The leading cause of Post–Traumatic Stress Disorder in the United States is the sudden death of a loved one,” he cautions. “You can’t make it better, but you can make it worse.”

Next comes delivering the news of a HIV diagnosis.

Then explaining that an error has been made with a patient’s medications.

And finally a fatal diagnosis. One by one, the students take their turns in the hot seat, with Anderson convincingly morphing from shock to anger to devastation as the scenarios change.

This isn’t a patient’s hospital room, or even a hospital hallway (which is not a recommended setting for an important conversation, says Dow). But the interactions and conversations feel real as the students struggle for the right words and approach. “Body language communicates five times what words do,” reminds Anderson as he helps students think through the mental barrier created by a chart, crossed arms or a confrontational stance.

On the whole, the week reminds the students that they are about to enter a new phase of their training. They’ll be expected to draw from all the skills and knowledge they’ve accumulated over four years.

The simulation weeks, says Dow have given the students “complex situations they have to navigate. It engages them, forces them to think it through. These are very bright, very motivated people. If you put a challenge in front of them, they take it on with a real passion and a real vigor.”

See for yourself: watch a video from Workshop Week.

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