the amedd’s central simulation committee (csc)

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 DepartmentRobert 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 0 36(28%)

1-2 8 5 3 3 0 1 0 20(15%)

2-3 4 4 5 3 1 1 0 18(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 1 40(31%)

yes

10%

16%

Did deployment delay board certification?

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 6 705

101520253035404550

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