Simulated Client workshop, Canberra, 16.8.17 – Keynote, Debra Nestel

by Paul Maharg on 16/08/2017

I’m back at ANU, Canberra, giving a series of workshops and seminars over three days, which I’ll liveblog or try to summarise in this and subsequent posts – part of my duties as an Honorary Prof at the ANU College of Law (I’m now with Osgoode Hall Law School).

First up is an all-day workshop that is the second in the series of workshops on simulation and simulated clients (SCs).  The first was held in London, in June, and this one is being held at University House (and there will be a third, probably next year, at Osgoode Hall Law School, in Toronto).  All resources, including slides, will be up on the SCI site, LH column.

First up and giving the keynote is Debra Nestel, Professor of Surgical Education and Professor of Simulation in Healthcare at Monash University. I met with Debra soon after I first arrived in Canberra in 2013, for I’d followed her amazing work on simulation, and it was clear she was the one keynote I had to have for this workshop – her research is outstanding in the field, both in quality and quantity.

Debra opened with some provoking ideas about simulation and identity, and the idea that rather than think of SPs as Simulated Patients, she preferred to think about Simulated Participants – an idea I like a lot, and put into practice in some of what we do in the training of SCs.  She addressed the drivers for simulation in healthcare – the ethical imperative, trainee numbers, safer working hours, quality and safety movement, increased rigour in assessments, and technology developments.

She set out simulation modalities – low-tech simulators to much higher spec simulators in healthcare, eg the Da Vinci robot on which people can be trained and certified to use the simulator (there’s an idea for raising the standard of sims in legal education…).  She showed SPs who were pregnant, and described how the SPs were trained not just to be physically adaptive to their condition but to take affect into account also; wound surgery sims, eg a sleeve with bleeding vessels, and moulage.  She showed videos of portable simulated clinical spaces, and compared the surgical theatre to a literal theatre space, where the sim space, set up as a sort of pop-up structure in a public building, can be an educational space for the general public – a brilliant, interdisciplinary, educational idea.  And it brings to the fore the concept of focus in simulation – what do we simulate and why?  We only need to simulate those aspects of an act, a space, or a resource within the act or space, that are at the centre of the circle of focus; we don’t need to simulate the realia on the periphery of the sim.  (This so reminded me of Ardcalloch, and the design of a fictional town on the web, and the decisions we had to take designing: which aspects of a SimCity-type approach did we need for legal sims, and which could we just sketch in roughly as backdrop.)

She cited the avatars of Mark Sagar (Lab for Animate Technologies) — he’s creating live computational models of the face and brain, combining bioengineering, computational and theoretical neuroscience, AI and interactive computer graphics.  The images on Debra’s slides were remarkable – go to the SCI site and view them.  Wide Area Virtual Environments (WAVE) is another example of high-tech high authenticity.

Applications?  In training, clinical practice and research.  Can sims replace part of clinical time?  Two parallel randomised controlled trials showed that one year on graduation and one after there were no significant differences between two groups, one trained on clinical time, the other with time in sim training.  Debra pointed out how influential such studies have been for policymakers, for whom cost of healthcare training is a consideration amongst many other factors.

Faculty development is essential, she pointed out, as is educational design.  Sim activity is important but so also is briefing and debriefing.  See for a map of simulation phases.  Also the US Association of Standardized Patient Educators (ASPE), and their published Standards of Best Practice.  See also the journals: Simulation in Healthcare, Journal of the Society for Simulation in Healthcare, Simulation and Gaming, BMJ Simulation & Technology Enhanced Learning.  (And good god, how poor by comparison with healthcare education we are in legal education infrastructure, financing, research methodologies, and sheer practice heft.)

Debra noted that patient-centred care was at the core of what she and her colleagues did.  Teaching can sometimes be ‘a mirror for the teachers’ preconceptions’  (Nestel and Kneebone) rather than what the authentic patient encounter is about.  Seeing through patients’ eyes is often what the many absorbing accounts doctors give of their own illnesses focus upon – and these are valuable accounts for that reason because (my extrapolation) doctors were forced to shift from thinking and acting as expert to being patient.  SPs, she noted, were often proxies for clinicians, not for patients, paradoxically, and this is a danger in the whole sim technique.  To counteract such inauthenticity Debra advised early ‘medical conversations’ for students involving lay people, on last visit to a GP, ‘patient’s’ perceptions, etc., the point of such conversations being to break down barriers and preconceptions of patient care that are constructed by and for experts.  Profound point.

Fascinating summary of the huge field of sims in healthcare, and with many points of contact for legal education.  And a hugely stimulating glimpse by Debra into how healthcare has developed the whole field of simulation.



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