When Amitai Ziv was a medical student at the Hebrew University in Jerusalem, he was put in front of an anesthetized patient, handed a scalpel, and told to cut.
He really didn’t want to. He really didn’t think he should. He knew he wasn’t ready. He cut anyway.
Dr. Ziv had been a fighter pilot in the Israel Defense Forces. He’d learned to fly on simulators, and was only allowed to take the controls on a real airplane, taking off into the actual air, after he’d logged many hours in a pretend cockpit.
So why should he cut into a real living human being without having practiced on a fake one? Why should the time-honored if cringe-making medical school mantra — see one, teach one, do one — not be challenged?
Maybe it’s because medical students, men and women alike, have to prove their inherent machismo as they work toward demigod status, but IDF pilots already have reached that status. Perhaps they just have less to prove.
Whatever the reason, Dr. Ziv decided that he was going to find a way to keep inexperienced medical students from cutting into human flesh. He established the Israel Center for Medical Simulation in 2001.
In 2013, a team from Holy Name Medical Center in Teaneck, inspired by a similar trip that Angelica Berrie of Englewood — the philanthropist who is the president of the Russell Berrie Foundation, which funds projects both locally and in Israel — and Michael Maron, Holy Name’s president and CEO, made together, went to Israel to learn about simulation. The team returned to Teaneck, “started construction immediately after we returned, and opened our doors in December 2013,” Cedar Wang, the medical center’s director of simulation education, said.
In 2014, the center received a grant from the Berrie Foundation.
There are not many programs like it in the country, and none in the area. Holy Name has applied for accreditation from the Society for Simulation in Healthcare, and expects to be accredited in 2018. “We will be the first accredited program in New Jersey,” Ms. Wang said.
The simulation center is a mix of mannequins and actors. The mannequins — there are nine of them — range from what Ms. Wang called high-fidelity — they breathe, blink, scream, cry, and shed actual liquid tears — to the lo-fi versions that owe their voices to behind-the-scenes actors.
Most of the simulations — scenarios, as they are called — involve a mix of mannequins and actors, and the participants act either as the doctors and health-care workers they are, or as family members. (When they are playing patients, the actors are called simulated patients, a term of art that evolved from the earlier one, standardized patients.) One of the simulations, the low-tech dementia room, is even more interactive; in that room, through ingenious mechanical interventions, participants learn a tiny bit of what it feels like to have Alzheimers.
Once the scenarios are complete, the participants and observers debrief; they discuss what worked well, what could be improved, and how to improve it. The actors sometimes participate as well, reporting on what they felt, because although they are not experiencing anything firsthand — they’re actors! They act! — still their emotions are in play.
All of the simulations exist to help caregivers become more compassionate, or at least more fully to engage the sense of compassion and empathy that they might have pushed down behind their professional façade. It’s to help caregivers reassert their humanity, and their patients’, not at the expense of the technology that fuels so much of their work, but alongside it.
“It’s about the intersection of emotion, science, and behavior,” Ms. Wang said.
Mr. Maron likes telling a story about a simulation he saw on that trip to Israel. It involved a distraught man — an actor — in a bed. Soon, the man was on the floor, in pain, in a panic, weeping, as the American visitors watched.
A housekeeper walked into the room. It was a regular bed in a regular room, and it was a regular housekeeper. She was not part of the simulation, and she had no idea that she was walking into a play rather than real life; for that matter, it’s not at all clear that the actor knew that she was not part of the scenario.
So she reacted like a real person. She sat down with the patient and consoled him, acting out of human warmth, empathy, and goodness. She modeled exactly the behavior the model was meant to teach, and the observers were able to watch it and discuss it afterward.
Everyone who watched that interaction and discussed it learned from it, Mr. Maron said.
Everyone who comes to work at Holy Name goes through the simulation program, and every registered nurse and every patient care technician — aka nurse’s aide — repeats it again annually. Many physicians do as well.
The annual simulations are changed every year, “and tailored to the caregivers’ departments,” Ms. Wang said. “We throw in things that are low in incidence but high risk, and we also throw in more routine things.”
Another part of the annual simulation is “that you have to talk to a patient for five minutes, about anything other than illness,” she added. “It’s all to develop empathy and compassion.”
All of this seems entirely obvious, but, like the wheel — which made perfect sense once someone thought of it, but until someone thought of it no one ever thought of it — someone had to think of it.
That’s because, as Ms. Wang said, “We have worried so much about our skills and expertise that we have lost our ability to see people as human beings. Technology is vitally important, but it cannot replace human beings. “We have worked so much about our skills and expertise that we have lost our ability to see people as human beings.”
Yes, technology is important, she said, but “technology will only grow exponentially. We have to be intentional about maintaining a human approach.”
What we need, she continued, is a combination of the old-time family doctor, the GP who made house calls and sat at the foot of the bed and made reassuring noises — but had absolutely no way to cure anybody of anything — and the high-tech world that can fix many physical problems but cannot touch anyone’s heart, much less his or her soul.
To train caregivers in both technique and compassion, the mannequins on which they work include a pregnant woman, teeth bared horse-like in unrelievable pain, who labors in a number of different, terrifying adverse conditions, as well as a lower-tech child and baby.
The actors who work with the mannequins, sometimes behind the scenes, providing them with voices, and more often in full view, playing patients or caregivers or family members, come from a range of backgrounds.
They represent a wide range of ages and ethnicities, and they are as diverse in every way as the population in this wildly diverse area. Many of them — there are eight on call — are would-be stage actors, who fill the time between auditions and gigs and waiting tables with this work. “Sometimes someone is gone for a few months, working on cruises,” Ms. Wang said. Some of them put together a patchwork of simulation jobs — just straight-ahead acting, used in medical-school simulations, isn’t nearly as uncommon as the version at Holy Name — so they work nearly full time.
To play their parts, the actors must know a great deal about the diseases from which their characters suffer, and they must be able to reproduce the symptoms accurately. They rarely work from a script, except at the start of a scenario, but instead are expected to improvise using the information they have learned. The conditions they enact can be either physical or psychological, or both.
Some of Holy Name’s simulation work is in end-of-life discussions, where actors mingle with health care providers to work through those difficult talks, and then debrief together afterward. These scenarios are increasingly important, because the number of older people has grown.
According to the United Nations, the world’s population of old people — defined as 80 or older — is the fastest-growing demographic group. In 2050, demographers estimate, the number of old people will triple from what it is now. Part of that is because people live longer, and part of it is because the so-called silver tsunami — the oldest slice of the baby boomers — is nowhere near 80 yet but eventually, sooner than they would like to admit, they’ll get there.
Assisted living and nursing homes are working with Holy Name’s simulation programs to train their caregivers, Ms. Wang said.
Perhaps the lowest-tech simulation technique in Holy Name’s arsenal is the most effective.
It’s the dementia room.
It’s the one place where the health care provider does not provide care to an actor or to a dummy, but instead puts her or himself in the intensely vulnerable position of someone desperately needing care, and even more desperately needing compassion and understanding.
Most of the sensations evoked by this powerful simulation are caused by mechanical devices. Nothing is high-tech.
The dementia room is kept dim; it’s possible for the person undergoing the simulation — let’s call her the participant — to turn the lights on, but almost no one ever thinks of that, Ms. Wang said.
The participant puts inserts in her shoes to simulate neuropathy, a physical condition that is not part of Alzheimers but is common to elderly people, including most dementia patients. The inserts are mildly painful, and make it impossible to stride. Instead, you shuffle.
She also is given thick-ish gloves, cutting way down on her manual dexterity. Sometimes, her fingers are taped together, to simulate arthritis.
She is given glasses with yellowish lenses, to mimic the color that most elderly people’s own lenses become; the lenses have a blob in their center that makes it hard to see straight ahead, in an effect that mimics macular degeneration, and they are fuzzy around the outside, to mimic the way elderly people’s eye muscles grow weak with age. That means that the participant can see only a sort of constricted yellow halo.
She is given headphones with distracting background noises, because elderly people tend to have compromised hearing, and sounds often distract rather than inform them.
She is given instructions before she enters the room, but after she is suited up. Those instructions, a complicated list of orders, are hard to remember, but they are written up and posted on the wall. But they’re posted in a jumble of letters, with vowels missing and proper spelling optional. Someone sitting in a well-lit room, with her eyes and ears functioning properly, would have little trouble reading the list — but the participant does.
People with dementia often wander; let loose in the dementia room, so do participants. They know that they have tasks to do, Ms. Wang said, and they want to do them — but they can’t remember what those tasks are, they can’t see where they are, they can’t clear the hum out of their heads so they can think more clearly.
And then there is the self-consciousness.
The dementia room participants know that they’re being watched. It’s not paranoia — a control room overlooks the dementia room, and the onlookers can see everything. There’s recording equipment as well, sophisticated machinery that allows simulation educators to tag moments they will want to replay and discuss during the debriefing as they happen.
People with dementia know that they’re being watched, Ms. Wang said, and they suffer embarrassment. It’s humiliating. It’s particularly acute during the early stages, when they know what’s happening to them, although it fades as their own sense of self leaves them.
The dementia room — which is based on the Virtual Dementia Tour, a product of a nonprofit called Second Wind Dreams — can be so powerful that it can leave participants shaken, she said; it is particularly difficult for people whose parents suffer from the condition. And sometimes people full-on refuse to do it. Watching it is hard enough.
In this scenario, as in so many others, the debriefing can be emotional. The facilitators who work at the simulation center are trained to deal with emotion and to direct it properly, Ms. Wang said.
The goal is to increase caregivers’ empathy, and with it their compassion.
To be practical, insurance companies like simulation training, because it makes doctors not only more compassionate but also more adept; they’ve learned responses to difficult but rare situations by doing them on dummies, not people. It’s an approach that’s increasingly in demand, and Holy Name administrators are glad to be able to provide the training, and proud to be the first in the area to have it.
Cutting medical errors is extremely important, Angelica Berrie said two years ago, when the center was ramping up.
“There are 100,000 completely avoidable deaths that are the result of medical errors in the United States every year,” Ms. Berrie said. “How do you train people to lower that incidence? That’s how Dr. Ziv thought about it. He wanted to give people hands-on experience, so they would be competent.”
But it is far more wide-reaching even than that.
“We are trying to shape and craft the experience for everyone involved,” Ms. Wang said. “That is the art.” And yes, she added, this is art. “If there is an emotional art form, this is it.”