the intersection of ethics, education, and simulation...

TheIntersectionofEthics,Education,andSimulation:ExploringDifficult

Issues

AaronW.Calhoun,MDChair,SSIHResearchCommitteeAssociateEditor,SimulationinHealthcareDirector,SPARCProgram

AnInvitationtoaNerdFight…

Outline

• EmergingEthicalIssuesinSimulation• DeathofaSimulator:HelporHindrancetoLearning

• DeceptionasanEducationalMethodology:IsItAlways(orEver)Wrong?

Disclosures

• AaronW.Calhoun- Co-investigatoronHealthResourcesandServicesAdministration(HRSA)targetedissuesgrant

EthicalIssuesinSimulation

• “Insimulation,yougettoplaywithpeople’smindsforagoodcause…”– Aretherelimits?–Whatarethey?– Howdowemakegooddecisions?

• Currentlyfacingseveralethicalissueswithoutclearanswer

EthicalIssuesinSimulation

• DeathinSimulation?– Isitappropriate?– Ifso,whenandwithwhom?

• DeceptioninSimulation?– Isitappropriate?– Ifso,whenandwithwhom?

• Thesequestionsarecurrentlygeneratingagreatdealofdiscussioninthesimulationcommunity

VS

DeathinSimulation,anOngoingDebate

WhatisDeath,Exactly?

• Soundslikeanoddquestion,buttherearemanywaysamannequincandie…

• Leighton’sTaxonomy– ExpectedDeath-Bothfacilitatorsandlearnersareawarethemannequinwilldie

– UnexpectedDeath - Facilitatorsknowbutlearnersdonot

– DeathduetoActionorInaction-Completelyunplanned.Facilitatorsdecidetoletmannequindiebasedonlearneractions

LeightonK:Deathofasimulator.ClinicalSimulationinNursing2009;5(2):e59-62

WhatisDeath,Exactly?

• Soundslikeanoddquestion,buttherearemanywaysamannequincandie.

• Leighton’sTaxonomy– ExpectedDeath-Bothfacilitatorsandlearnersareawarethemannequinwilldie

– UnexpectedDeath - Facilitatorsknowbutlearnersdonot

– DeathduetoActionorInaction-Completelyunplanned.Facilitatorsdecidetoletmannequindiebasedonlearneractions

LeightonK:Deathofasimulator.ClinicalSimulationinNursing2009;5(2):e59-62

SimulatedDeath:WhatWeKnow

• AddingEmotionalStressorstoTraininginSimulatedCardiopulmonaryArrestEnhancesParticipantPerformance.– 25studentvolunteersrandomlyassignedtocontrolvsintervention

– Actorsscriptedtoaddstresstocardiacarrestscenariofor“intervention”group

– Addingemotionalstressorstosimulationenhancedlearneranxiety(measuredbymaxheartrate[120vs95]andStateAnxietyInventoryscores[35vs28],toolrange20-80)

– Addedstressalsoimprovedpracticalcompetencyscores(32.5/40vs25/40)sixmonthslater

DeMaria S,etalAddingEmotionalStressorstoTraininginSimulatedCardiopulmonaryArrestEnhancesParticipantPerformance.MedicalEducation.44(10):1006-1015


• TheImpactofSimulatedPatientDeathonMedicalStudents’StressResponseandLearningofACLS– 26studentsparticipatinginanAHAACLScourse– Studentsthenengagedinahigh-fidelitysimulationscenariorandomizedtodeathvssurvivalconditions

– 6monthfollow-upsimulationinwhichACLSskillswereassessed

– Allparticipantshadhigherheartrate(32bpmdiff),DHEA(97pg/mldiff),andsalivarycortisol(0.115ug/mldiff)

– Heartratesignificantlyhigherindeathgroup(29.2bpmdiff)– Nodifferenceinskillat6months

DeMaria S,etalTheImpactofSimulatedPatientDeathonMedicalStudent’sStressResponseandLearningofACLS.MedTeach2016Jul;38(7):730-737


• DeathDuringSimulationTraining:FeedbackfromTrainees– 63physiciansand175airmedicalteammemberscompletedQIsurveysregardingtheirperceptionsofdeathinthesimulatedenvironment

– Participantsinsimulationswithunexpecteddeathdidnotfinditdistracting

– Participantsexpectedthesimulatortodieifthiswasanappropriateoutcome

– Participantsstronglydisagreedthatstudentsshouldbeexemptfromsimulateddeath

– Participantsdidnotfeelthatitwouldgeneratereluctancetoengageinfutureactivities

Phrampus P,etalDeathDuringSimulationTraining:FeedbackFromTrainees[abstract].In:InternationalMeetingonMedicalSimulation:2005;Miami(FL)SocietyforTechnologyinAnesthesia:2005p95,Abstractsnr16.


• TraineePerspectivesonManikinDeathDuringMockCodes– 62pediatrictraineessurveyedregardingmockcodeparticipation

– 59(95%)surveyreturnrate,42%ofwhichhadwitnessedadeathduringasimulation

– Traineesfounditrareandunexpectedwhenthemannequindied,equatingitwithinadequateresuscitation

– Traineesfoundmannequindeathtobeasignificantstressor,butthoughtitbeneficial

– Traineesdidnotthinka“deathdisclosure”priortothesimasneeded

Lizotte MH.TraineePerspectivesonManikinDeathDuringMockCodes.Pediatrics.July2015;136(1):e93-e98


• DeathofaManikin:AdverseEffectonLearningandMechanisms– Prospectiveinterventionon116medicalstudents– Randomallocationto“death”or“nodeath”groups– Moreemotionalstressandsadnessmeasuredimmediatelyafterthesession

– Highercognitiveloadmeasuredimmediatelyafterthesession(7.63/9vs7.25/9)

– 3monthslater,studentsinthe“death”groupwerelesslikelytonavigateasimilarsituationsuccessfully(70.9%vs86.9%

FraserK,etalDeathofaManikin:adverseEffectonLearningandMechanisms[Abstract].In:Chest2011;140(4)


• TheEmotionalandCognitiveImpactofUnexpectedSimulatedPatientDeath– Furtherdataderivedfromsamestudy– Oddsratioof0.37(95%CI,0.14-0.95)ofbeingrated“competent”atthefollow-upsimulationforthoseexposedtomannequindeath

FraserK,etalTheEmotionalandCognitiveImpactofUnexpectedSimulatedPatientDeath:ARandomizedControlledTrial.Chest.May2014;145(5):958-963

SimulatedDeath:Whatweknow

• First,DoNoHarm:UsingSimulatedPatientDeathtoEnhanceLearning– LettertotheeditorregardingDeMaria study– Concernedthatsomeofthedatafromthatstudy(particularlycommentsfromnursesreferringblameforthe“death”tothephysicians)indicatederosionofthecollaborativeenvironment

– Expressesconcernthatsimulateddeathisoftennotgroundedinsoundethicalprinciplesthatpromotenon-punitiveeducationalculturesandinter-professionalcollaboration

– Advisedthatsimulateddeathonlyoccurwhenitisanexplicitpartofthelearninggoals

Bruppacher HR,etalFirst,DoNoHarm:UsingSimulatedPatientDeathtoEnhanceLearning.MedEduc 45(3):317-318

SimulatedDeath

• Studiesaddressdifferent(perhapsunrelated)questions

• Resultsnoteasytocorrelate

• Whatneedstobedonetounifyourapproach?

TheImportanceofTheoreticalFrameworks

• Notonlyistherelimiteddata,thereisnouniformlyacceptedwaytoapproachtheissue

• Theoreticalframeworkshelpusorganizeourdataandourquestionsaboutthedata,allowingustoarriveatmoreconsistentanswers

AQualitativeResearchStudy…

Focusgroupscomposedoffellows,residents,and

nursesthathadexperiencedsimulated

death

Transcriptswereanalyzedby3coders

Triangulatedusingagroundedtheory

approachtogeneratealistofrelevantthemes

Themesorganizedintoaframeworkdepicting

relationships

Surveywasgeneratedusingframework

Surveyelectronicallydistributedtoallfellows,residents,nurses,andRTs

Surveyanalyzedusingmixedmethodsapproach

Resultsusedtomodifythetheoreticalframework

ThemesfromOurLearners

1. Learnerpreparationandsuspensionofdisbeliefduringsimulation

2. Differencesinemotionalresponsebetweenrealandsimulateddeath

3. Effectsofsimulateddeathonfutureemotionalengagementwithlearningactivities

4. Learnerself-perceptionandperceptionbyteamregardingdeficits

5. Impactofdebriefingonemotiveresponsetothesimulation

6. Impactofdebriefingonlearnerknowledgeandskills7. Knowledgeretentionandpracticechangescausedby

mannequindeath

1:LearnerPreparation

andSuspensionofDisbelief

MannequinDeath

2:DifferencesinEmotionalResponse

betweenRealandSimulated

Death

3:EffectofSimulatedDeath

onFutureEmotional

EngagementinLearningActivities

4:LearnerSelf-perceptionandPerceptionbyTeamRegardingKnowledgeandSkillDeficits

5:ImpactofDebriefingon

EmotiveResponsetotheSimulation

6:ImpactofDebriefingtheKnowledgeandSkillsLearnedDuringtheSimulation

7:EffectofMannequinDeathonKnowledge

RetentionandPracticeChange

APilotModeloftheEffectofMannequinDeathDuetoLearnerActionorInactionontheLearner’sEducationalExperience

LearnerReactiontoSubsequentSimulationSessions

LearnerExperience

andKnowledge

fromPreviousSimulationSessions

Tripathy S,etal.WhentheMannequinDies:CreationandExplorationofaTheoreticalFrameworkUsingaMixedMethodsApproach.SimulationinHealthcare.June2016;11(3):149-156

Theme: Study:2:DifferencesinEmotionalResponseBetweenRealandSimulatedDeath

• NickersonM,etal.SimulationPhilosophyandPractice:SimulatorPatientDeathvs Survival

3:EffectsofSimulatedDeathonFutureEmotionalEngagementinLearningActivities

7:PerceivedEffectofMannequinDeathinKnowledgeRetentionandPracticeChanges

• Phrampus P,etal.DeathDuringSimulationTraining:FeedbackFromTrainees

• Phrampus P,etal.PerceptionsofExperiencingSimulatedDeath

5:ImpactofDebriefingonEmotiveResponsetotheSimulation


• FraserK,etal.DeathofaManikin:AdverseEffectonLearningandMechanisms

• Lizotte MH.TraineePerspectivesonManikinDeathDuringMockCodes

6:ImpactofDebriefingonKnowledgeandSkillsLearned


• DeMariaS,etal.Addingemotionalstressorstotraininginsimulatedcardiopulmonaryarrestenhancesparticipantperformance

• FraserK,etal.TheEmotionalandCognitiveImpactofUnexpectedSimulatedPatientDeath:ARandomizedControlledTrial

• Lizotte MH.TraineePerspectivesonManikinDeathDuringMockCodes

ExternalExperienceandValidation

• ParallelstudyconductedatLurieChildren’sHospital

• Educationalphilosophyexcludingmannequindeathduetoactionorinaction

• Externalrescueprovidedinallcaseswherethisotherwisewouldoccur

• Afterafriendlydebateatthesimulationconference…

AParallelStudy

• Similarqualitativemethodology• 3physicianand3nursefocusgroups• Essentiallyconfirmedthemes• Additionalthemenoted…– Effectofactionsusedtomitigatedeathonperceptionsoffidelity

• Thisthemecouldonlyhavearisenatacenterwheremannequindeathisprevented

• Modelmodifiedtoincludeadditionalthemeaswellasimplieddecisionpoint

1:LearnerPreparation

andSuspensionofDisbelief

MannequinDeath?

2:DifferencesinEmotionalResponse

betweenRealandSimulated

Death

3:EffectofSimulatedDeath

onFutureEmotional

EngagementinLearningActivities

4A:LearnerSelf-perceptionandPerceptionbyTeamRegardingKnowledgeandSkillDeficits

5:ImpactofDebriefingon

EmotiveResponsetotheSimulation

6:ImpactofDebriefingtheKnowledgeandSkillsLearnedDuringtheSimulation

7:EffectofMannequinDeathonKnowledge

RetentionandPracticeChange

FinalModeloftheEffectofMannequinDeathDuetoLearnerActionorInactionontheLearner’sEducationalExperience

LearnerReactiontoSubsequentSimulationSessions

LearnerExperience

andKnowledge

fromPreviousSimulationSessions

4B:EffectofActionsUsedtoMitigateDeathonPerceptions

ofFidelity

Yes

No

MannequinDeath:ContributingFactors

• Effectofstressonlearning• Effectoffidelityonlearning• Effectoffidelityonfutureexpectations• Roleoflearnerexperience

Stress:TheYerkes-DoddRelationship

LowStress HighStress

HighPerformance

LowPerformance

LowComplexityActivities

HighComplexityActivities

Yerkesetal.TheRelationofStrengthofStimulustoRapidityofHabitFormation.JournalofComparativeNeurologyandPsychology.18:459–482

Fidelity

NoCasesEndinDeath

AllCasesEndinDeath

HighPerformance

LowPerformance

1:1CorrelationwithLearnerAction

EffectonFutureExpectations

• Inpractice,ouractions(evenwhentechnicallycorrect) donotalwaysresultinsurvival

• Doesa1:1correlationbetweenstudentactionsandsurvivalgiveafalseimpressiontostudents?

• Doesa1:1correlationaugmentfuturepsychologicalstressbycausinglearnerstoinvariablyequatedeathandfailure?

Lizotte MH.TraineePerspectivesonManikinDeathDuringMockCodes.Pediatrics.July2015;136(1):e93-e98

SomeCurrentData

• SPARCSimulationProgramroutinelyallowsformannequindeathduetoactionorinaction

• InternationalSimulationDataRegistry(ISDR)queriedforallSPARCProgramdeaths

• 41/242(17%)simulatedcardiacarrestsinSPARCProgramendindeath

• 30%averagerateofdeathduringpediatricresuscitation(1.7xgreater)

Bhanjietal.SurvivalRatesFollowingPediatricIn-HospitalCardiacArrestsDuringNightsandWeekends.JAMAPediatrics.2017.171(1):39-45

EffectonFutureExpectations

NoCasesEndinDeath

AllCasesEndinDeath

HighPerformance

LowPerformance


Isamore“realistic”deathratebetterlongterm?

VS

EffectofExperience

• Experiencelevelofthelearner/learnergroupmayhaveoppositeeffect

• Whilethedataismixed,manysuggestthatdeathduetoactionorinactionshouldbeavoidedattheundergraduatelevel

CalhounAW,Pian-SmithMC,Truog RD,Gaba DM,MeyerEC.DeceptionandSimulationEducation:Issues,Concepts,andCommentary.SimulationinHealthcare.June2015;10(3):163-169.

EffectofExperience

NoCasesEndinDeath

AllCasesEndinDeath

HighPerformance

LowPerformance


Isamore“forgiving”approachneededforthelessexperienced?VS

TheFinalEquation…

(Stress)+∫(Experience)(Fidelity)=?–Intheend,thedecisionisacomplexrelationalcalculus–Likesomanythingsinmedicine,thecorrectanswerisprobably“itdepends…”

PracticalImplications

• Learnerexperienceandpotentialpsychologicalafter-effectsmatterwhenapproachingemotionallydifficultsimulations

• Learnersalsoseemtowanttoexperiencetheoutcomeoftheiractions,especiallyinasafeenvironment

• FutureQuestions:– Whatleveloftrainingisappropriateforcertainexperiences?

– Isourcurrentglobaleducationalculturetooprotective?

– Whatarethelong-termpositiveandnegativeeffectsofdifferenttypesofmannequindeath

Deception:IsitAlwaysWrong?

DeceptionandScience

• LaserInterferometerGravitationalWaveObservatory(LIGO)

• Thegoal:Todetectevidenceofgravitationalwaves

• “Falsepositive”signalsroutinelyinsertedintosystemtotestinstrumentandscientists

• Donetomitigatethebiastowardconfirmingapositivesignal

• Scientistsbeing“deceived”…CollinsH.Gravity’s Kiss. MITPress 2017

DeceptionandSociety

• LasVegasPoliceinvestigationofthekillingof2homelessmen

• Mannequinplacedatlocationofmurdersasdecoy

• Feb23at3am:Suspectapproachedthesceneandstruckmannequin’sheadrepeatedlywithahammerconcealedwithinapizzabox

• Subsequentlyarrestedforcarryingaconcealedweapon

• Cannot,ofcourse,makemurderaccusation

http://ktla.com/2017/03/07/to-catch-thrill-killer-vegas-cops-set-up-sleeping-mannequin/

DeceptioninSimulation,ACaseStudy…

• Asimulated sixyearoldpatientwithahistoryofrenalfailurebythenameofRodneySmithisadmittedtotheICUforfrequentPVC’s

• HewasinitiallybroughttotheEDwithanewcomplaintofchestpainand“racingheart”thatbeganfourhoursago

• Accordingtothefamilyhehasmissedhislastseveralperitonealdialysispassesduetoequipmentmalfunction

• SuddenlythepatientdevelopspulselessventriculartachycardiaandCPRisinitiated

• CallfromEDtolearnergroupimmediatelythereafterrevealingaserumpotassiumof12

TheConfederate

• Dr.MarkMcDonaldarrives• Intensivist,NortonChildren’sHospitalMedicalDirector

• Doubleagent!• Dr.McDonaldordersapotassiumphosphatebolus

• Residentandnurseconfirmandadministerit

• Patientbecomesasystolic…

=?TheDoubleAgent…

TheMastermind…

IsThisUnethical?

• Goalofthecaselaudable:teachinghowtoappropriatelychallengehierarchy

• Alegitimateclinicalissue• Thedeceptionwasneededtocreaterealism

• Butwasitreally?• Thoughthismayseemself-evident,somemedicalethicistsdisagree

• Currentlythefocusofanongoingdebateinthesimulationcommunity

WhatConstitutesDeception?

ExamplesofDeceptioninSimulation

Aconfederatefromoutsidethelearnergroup joinstheteamduringasimulationandintentionallymakesinappropriatemedicaldecisionsduringthecase

Simulationfacultyintentionallyplacefaultyequipmentwithin thesimulatedenvironmentinawaythatwouldbeunexpectedtolearners

Theoutcomeofthesimulated caseisintentionallydecoupledfromtheactionsofthelearnergroup inawaythatisinconsistentwiththegroundrulesofthecase.

NestedSpectraofDeception…

Aconfederatefromoutsidethelearnergroup joinstheteamduringasimulationandintentionallymakesinappropriatemedicaldecisionsduringthecase

Simulationfacultyintentionallyplacefaultyequipmentwithin thesimulatedenvironmentinawaythatwouldbeunexpectedtolearners

Theoutcomeofthesimulated caseisintentionallydecoupledfromtheactionsofthelearnergroup inawaythatisinconsistentwiththegroundrulesofthecase

NotDeceptive

HighlyDeceptive

NotDeceptive

NotDeceptive

HighlyDeceptive

HighlyDeceptive

DeceptioninSimulation:WhatDoWeKnow?

DeceptioninSimulation:WhatDoWeKnow?

• Verylittleliteraturearisingfromthemedicaleducationcommunity

• Mostvaluableinformationcomesfromthefieldofpsychology

• Significantfocusontherolethatdeceptionhasplayedinpastpsychologicalresearch– The“infamous”MilgramExperiment– TheStanfordPrisonExperiment

TheMilgramExperiment

• 1961- YalepsychologistStanleyMilgram begana“study”oftheeffectsofpainonmemory

• Recruitedvolunteerswhothenwereaskedtoadministerelectricshockstolearnerswhentoldbyaproctor

• Shocksquicklyescalatedbyproctortopotentiallylethalvoltages

• Inreality,Milgramwasstudyingvolunteerobedience…

PerryG.BehindtheShockMachine.TheNewPress2012

DistinctionsinDeception

• Deception“Within”vsDeception“About

DeceptionWithin

MutuallyAcceptableEducationalPurpose

Another,UndisclosedPurpose

DeceptionAbout

Kelman HC.HumanUseofHumanSubjects:TheProblemofDeceptioninSocialPsychological Experiments.PsychologicalBulletin1967;67(1):1-11.

DistinctionsinDeception

• Deception“Within”vsDeception“About

DeceptionWithin

MutuallyAcceptableEducationalPurpose

Another,UndisclosedPurpose

DeceptionAbout

Kelman HC.HumanUseofHumanSubjects:TheProblemofDeceptionInSocialPsychological Experiments.PsychologicalBulletin1967;67(1):1-11.

AnApproach…

• Answertothequestionismultifactorial

• Learner,Faculty,EducationalMaterial,andInstitutionalEnvironmentareallpotentialfactors

• Perhapsmoresignificantly,therelationshipbetweenthesefactorsisalsoimportant…

AnExample

• Aresidentlearnerentersasimulationinwhichdeceptionisemployed

• Boththeresidentandthesessionfacultyhaveadequateexperiencetoengageintheemotionallychallengingsituation

• But…theresidentandfacultyalsojusthadaparticularlynegativeinteractiononroundsthatmorning

• Theuseofdeceptionmaynotbewiseinthiscircumstance

AFrameworkForEmotionallyDifficultSimulations

InstitutionalEnvironment

ScenarioStructure

SessionGoal

FacultyBackground

LearnerBackground

EducationalIntent

CalhounAW,Pian-SmithMC,Truog RD,Gaba DM,MeyerEC.DeceptionandSimulationEducation:Issues,Concepts,andCommentary.SimulationinHealthcare.June2015;10(3):163-9.

PracticalImplications

• Again,learnerexperiencematters,asdothepotentialpsychologicalafter-effects

• Nomanorwomanisanisland• Educationisfundamentallyrelational,andourrelationshipswithourlearnersisasignificantfactorintheeffectivenessofourtraining

• Theultimateansweronthequestionofdeception’slegitimacyislikelytobe“itdepends”

IntotheFuture…

• Currentlydesigningamixedmethodsstudyintendedtoexploretheusageofdeceptionwithinthesimulationcommunity– Rangeofdefinitions– Spectrumofapproaches– Decisionmakingprocessregardinguse

• Ultimategoalistocreateamorerobustfoundationforfutureresearch

Summary

• MannequinDeathduetoActionorInactionandtheroleofdeceptivetechniquesarecurrentareasofethicaldebateinthesimulationcommunity

• Whilesomedataexistsregardingmannequindeath,thereislittlepublishedregardingdeception

• Answerswillnotbesimple,andlikelydependonindividuallearnerandfacultyexperienceandrelationships

• Moreworkisneeded…

Questions

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