the amedd’s central simulation committee (csc) robert m. rush, jr,. md, facs chief of surgery...
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The AMEDD’s Central Simulation Committee (CSC)
Robert M. Rush, Jr,. MD, FACSChief of Surgery
Madigan Healthcare SystemSpecialty Advisor in Surgery to the
CSC
Vital Statistics
Inception: 2007 11 Army Medical Centers (to
include the Uniformed Services University)
Total square footage: – 30,645 (range 585 – 8,000)
Learners: 108,869 (thru CY 2011) Hours trained: 555,633 Budget: $10s of millions
CSC Focus Graduate Medical Education Allied Health Education FORSCOM medical educational
support Needs and gap assessments Standardized curricula Centralized simulator
procurement Research in education The “Silos” meet at CSC Sim
Centers
The 3 ARMS of Army Medical Training AMEDD Center and School –
policy and official POIs Medical Simulation Training
Centers – MSTC – 68W sustainment training
CSC simulation centers – platforms for all medical personnel to train and perform research in education
Each CSC Site – falls under the DME (Director of Graduate Medical Education)
Medical Director Administrative officer
IT technician Nurse educator
Department advisors and/or lead users
Educational Platform…minus the “live human patient”
“Going Under the Knife? Ask Your Surgeon How Much He Drank Last Night”
Or maybe “how long has it been since you last did the type of surgery you are proposing to do on me?”
Deployments Maternity
leave/OA Re-integration
plan Metrics Is there a
decrement for a seasoned provider?
What is a seasoned provider?
Moto and Mission
US Army Medical Command: “Conserve the Fighting Strength”
What does this mean?
Go and do “trauma care” care in support of our of our armed
forces…
…in the most austere places…
…in the most dangerous environments and extreme weather conditions…
…and “trauma” care also means taking care of civilians and children – for non-traumatic illnesses…
…and set up a developing country’s medical infrastructure…
…and you will only get a handful of people to do it…
…and because you don’t have that many people, you all have 10 jobs
Problem defined – what next?
What are the implied tasks of doing all this?
They are enormous, numerous, detailed and cross all possible venues:– Force Protection– Logistics – medical and necessities for life– Individual trauma care– Team trauma care– Evacuation– And more
Individual Tasks – the Cycle Provide healthcare to service
members and families at home Prepare to deploy Deploy – provide health care to
service members “down range” Redeploy Provide healthcare to service
members and families at home REPEAT
Individual Tasks – the Cycle Provide healthcare to service
members and families at home Get ready to deploy Deploy – provide health care to
service members “down range” Redeploy Provide healthcare to service
members and families at home REPEAT
Where and how do we intervene in the cycle? Pre-deployment?
During deployment?
At the end of the deployment?
Perceived Effects of Deployment on Surgeon and Physician Skills in the Army Medical Department
Robert M. Rush, Jr., MD, FACSChief of Surgery, Madigan Army Medical Center Shad H. Deering, MD, FACOGRichard N. Lesperance, MDBernard J. Roth, MD, FAAP
The Andersen Simulation CenterAMEDD Central Simulation Committee Madigan Army Medical Center
Background Afghanistan, Iraq, and other
GWOT deployments have stressed the military medical system
Most physicians are deployed in 6-12 month increments, many multiple times
Skill sets and practice vary greatly between deployment & home duties
A “needs assessment”
250 FST Data - OEF1
Command-initiated survey sent to 1500 eligible staff physicians
Questions developed by consensus from the Army Central Simulation Committee (CSC) leadership
Specialty, length of deployment(s), and skill utilization / deterioration.
Descriptive and statistical analysis performed
Methods
Survey Questions Topics covered in surgery:
– Specialty and deployed assignment– Years out of training and board
certification– Time away from clinical practice and
type of practice while deployed– Perceived skills degradation or
improvement in trauma and at-home specialty
Clinical skills = cognitive skills Surgical skills = technical skills
Results
673 responses (45% response rate)
Respondents:– 7 surgical specialties – 16 non-surgical specialties
Most respondents were non-surgeons
Non-surgeons
Surgeons
0 100 200 300 400 500 600
Respondents (Surgeon vs other)
Respondents by Specialty
Internal MedicineFamily Medicine
Emergency medicinePediatrics
General SurgeryAnesthesia
OB/GYNPsychiatry
Preventive MedicineRadiology
OphthalmologyAerospace medicine
UrologyDermatology
Occupational MedicineOrthopedic Surgery
NeurologistOtolaryngology
none (internship only)Pathology
Physical Medicine and RehabilitationNeurosurgery
Radiation Oncology
0 20 40 60 80 100 120 140 160
Number Responding
Respondents by Specialty
Internal MedicineFamily Medicine
Emergency medicinePediatrics
General SurgeryAnesthesia
OB/GYNPsychiatry
Preventive MedicineRadiology
OphthalmologyAerospace medicine
UrologyDermatology
Occupational MedicineOrthopedic Surgery
NeurologistOtolaryngology
none (internship only)Pathology
Physical Medicine and RehabilitationNeurosurgery
Radiation Oncology
0 20 40 60 80 100 120 140 160
Number Responding
0-1 YEARS
1-2 YRS
2-3 YRS
3-4 YRS
4-5 YRS
> 5 YRS
0 20 40 60 80 100 120 140 160 180
Years out of Residency
SurgeonsNon-surgeons
Surgical Sub-Specialties
Years out from
residencyGS OB/GYN Optho U OS ENT NS
Total
(n=130)
0-1 20 7 0 3 4 2 036(28%
)
1-2 8 5 3 3 0 1 020(15%
)
2-3 4 4 5 3 1 1 018(14%
)
3-4 6 0 0 1 0 0 0 7(5%)
4-5 1 4 3 1 0 0 0 9(7%)
> 5 17 12 6 4 2 3 140(31%
)
yes
10%
16%
Did deployment delay board certi-fication?
SurgeonsNon-surgeons
(p = 0.023)
0-1 MONTHS
1-6 MONTHS
6-12 MONTHS
12-18 MONTHS
> 18 MONTHS
0 50 100 150 200 250
Length of Deployment
SurgeonsNon-surgeons
(p=0.003)
Bn Surg CSH Other FST0
50
100
150
200
250
Deployment Assignment
Non-SurgeonsSurgeons
(p<0.005)
0-1 MONTHS
1-6 MONTHS
6-12 MONTHS
12-18 MONTHS
>18 MONTHS
0 50 100 150 200 250
Time away from clinical practice
SurgeonsNon-surgeons
(p=0.003)
0 1 2 3 4 5 6 70
5
10
15
20
25
30
35
40
45
50
Comparison of Surgeons' Trauma Skills Pre- and Post- deployment
PrePost
(p<0.005)
worse skills better skills
0%
20%
40%
60%
80%
100%
0 20 40 60 80 100 120 140 160 180
Percentage of clinical practice while deployed
SurgeonsNon-surgeons
(p>0.05)
0 1 2 3 4 5 6 70
10
20
30
40
50
60
Comparison of Surgeons' Clinical Skills Pre and Post-deployment
PrePost
(p<0.005)
worse skills better skills
Percentage of time spent practicing in
specialty while deployed
Number of GS respondents
Number who consider themselves
subspecialists (% of total)
0-20% 11 (21%) 7 (31%)40-60% 12 (23%) 7 (31%)80-100% 28 (54%) 8 (36%)
Pertaining to GS only: % time while deployed spent in specialty/61J sub-specialty
1-3 months
3-6 months
6-9 months
9-12 months
>12 months
0 20 40 60 80 100 120 140 160 180
Estimated Time to Regain Clinical Skill Level
SurgeonsNon-surgeons
(p=0.02)
1-3 months
3-6 months
6-9 months
9-12 months
>12 months
0 50 100 150 200 250 300
Longest Deployment without Losing Clin-ical Skills
Surgeons Non-surgeons
(p=NS)
Questions not asked: “Is there any type of re-
deployment training that you would need/prefer?”
Options:– Mentored cases (“Assist on a few
cases then have partner on standby”)
– Early case selection– CME review courses
Technical Cognitive
– Mini-fellowship– Fellowship
The Lethal Triad of the Military Surgeon/Physician/Nurse/Medic/Corpsman
DeployedVariable clinical experience
No family time
Working hard at homeMaking up for degraded skills
Limited family time
Train-up for deploymentVariable valueNo family time
(usually done at remote sites)
4 2
1 Individual Trauma Training
TeamTraining
Individual
RefresherTraining
3
Skills Maintenanc
e
The Lethal Triad of the Military Surgeon/Physician/Nurse/Medic/Corpsman
DeployedVariable clinical experience
No family time
Working hard at homeMaking up for degraded skills
Limited family time
Train-up for deploymentVariable valueNo family time
(usually done at remote sites)
4 2
1 Individual Trauma Training
TeamTraining
Individual
RefresherTraining
3
Skills Maintenanc
e
Options Centralized refresher training
– More time away from home MEDCEN vs Community Hospital
– MEDCEN can absorb more– Local university program mentor
Is there a substitute for experience and doing the work?– VR platforms for distributive practice– Live tissue vs inanimate trainers– Better curricula for all of the above– Make it mobile/regional
What we don’t know Is there a measurable skill degradation
in physicians returning from war? Or, is this perception a decline in
confidence? Are deployments associated with worse
outcomes upon return? Study currently underway
– Logistically difficult– Multiple sets of physicians/surgeons:
Medical Center Community hospital Reserve and National Guard component
Conclusion Operational deployments are
causing significant changes in military physician practices
Surgeons and non-surgeons report a significant decrease in their skills due to deployments
Longer deployments were associated with longer delays in regaining both Clinical and Surgical skills
Suggested maximum deployment time: 6 months
“Training Today Saves
Lives Tomorrow”
Andersen Simulation Center