 Well and one of the ways we can get them more comfortable is because it's a simulation and the patient is either a mannequin patient or an actor patient who's not going to be harmed or hurt by what's done or not done is we could literally and we do come in in the middle of that situation we literally press pause we're like pause patient's not going to get any better not going to get any worse let's just think this through what are the signs and symptoms you're concerned about what are the signs and symptoms you're concerned about yes how are you thinking about moving forward how are you thinking about moving forward so they can hear each other's plans they can calm down a little bit talk it out and then we literally rewind a minute or two start it back up so it's sort of like a live video game yes and they can reorganize themselves boom what's up everyone welcome to simulation i'm your host on sake and very excited we are in boston massachusetts we are going to be talking about healthcare simulation we are at the center for medical simulation we are sitting down with dr jenny rudolf hello good to meet you alan thank you so much for coming on the show and it's great that matthew your brother ended up introducing us and i'm very excited to talk to you i just had an incredible experience here at your center for medical simulation where i experienced one myself and it was very inspiring for me and we'll have some videos embedded that will show people what this is like we're going to be breaking this down for those that don't know jenny's background she's the executive director at the center for medical simulation where she creates learning oriented cultures in healthcare she's also on the faculty at massachusetts general hospital in the department of anesthesia critical care and pain medicine as well as in the department of anesthesia at harvard medical school and you can find the link in the bio to harvardmedsim.org as well as jenny's linkedin her twitter and the medical simulation twitter account as well all right so let's start things off with our one of our favorite ways to start things off which is we love asking our guests we find ourselves as stewards of earth what is your current take on the state of humanity i'd say my biggest concern for us right now is certainty too many of us are certain we're right and are not curious enough about other people's perspectives and i think that gets us in a whole where it's really hard for us to understand what other people care about and therefore much harder for us to bridge from our point of view to somebody else's and so i think as my mom susanne hober Rudolph wrote about that can cause people in different countries to get very solid views of each other that are very hard to move they can cause people within our own country to get very rigid ways of viewing each other it makes it very hard for us to come to compromise invent new policies that might help with global warming or with income inequality et cetera and i think if we can learn to be curious about each other's point of view hold each other in high regard those kinds of things could be bridged better and Jenny has this really cool acronym wtf which instead of what the she has is what the frame what's the frame and that's great because then it gets people to think behind the other person's perspective what is their frame what is their perspective why do they potentially think the way they do and i like how you said certainty when we see things as a probability curve we see a lot of people saying i'm a hundred percent certain that this is the right way and then they can't have discourse about about things and so if you think that hey maybe i can be humble i can be curious i can say i don't know everything and that we can maybe tackle some of these challenging issues of wealth and quality climate change global cohesion on these complex exponential technologies that are occurring that was a wonderful answer Jenny let's jump into your journey so you're born here in the boston area and then you find yourself getting into uh excited about medicine at university chicago then at harvard and then now here as the executive director doing some professorship along the way teach us about this journey and how you picked up your interests sure so it really came from being i think a lifelong athlete i played basketball in college i played basketball in high school and i rode crew on the us team one day when i was watching the 34th video of myself rowing down the charles river something occurred to me i was like wow only we could practice and watch videos and rehearse on things that really matter like healthcare or any complex technology or industry and so uh not long after that i was doing a phd in organizational behavior and i thought wow is there anywhere any places where people are practicing and of course there are a lot in maritime uh shipping in aviation and nuclear power and in healthcare so i thought how can i get to play basically for a living and i think simulating practicing trying doing it over video is a form of play which i also think is very generative for us adults who tend to take ourselves too seriously so that was kind of how i got into it yeah this is a cool story because you you know you're we when you're in boston you see this charles river and you see these the teams of of rowing they're you know in their long what do you call the boat shells they're in their long shells and there's seven eight of them yeah so they vary there's eights fours twos eight four twos and you see like eight of them really like you know rowing and they're moving quite fast yeah and you were on the us team which of the us crew for rowing which is really interesting and then when you're doing that you like you said this 34th replay of watching yourself and you're like let's apply this to to real world ways of of becoming better in you know healthcare simulation in aviation simulation is already happening and so we're now seeing this in engineering software we're seeing this in manufacturing simulation of designing certain parts of aviation all these all these different fields of aerospace engineering it's in biotechnology it's now getting more and more popular you know the show is called simulation and it's becoming more and more popular for us to figure out what is the highest greatest fit for in a case and in your case it was how do we how do we maximize the the experience of of of the patient and the practitioners the physicians the nurses that are working on the patient and there's so much nuance and complexity that we'll get into i'm really happy that that the story makes so much cool sense on you getting involved in this and then so now tell us about this um this trajectory for you once you saw it how did you envision implementing it so in my phd program i got really interested in industrial safety and a particularly perhaps because of my athletics background i was really interested in what we're called high hazard industries sometimes called high reliability industry depending on your point of view so high hazard industries are generally ones where things are tightly coupled and somewhat complex so you've got processes that have to go just perfectly for everything to line up and everybody to stay safe for example in nuclear power or chemical processing and i realized that without mindfulness and awareness it was really easy to make mistakes because vigilance is almost impossible to maintain so i was interested in the systems part of that you can't maintain vigilance it's basically impossible there's research on quote unquote normal accidents that they will happen sometimes regardless of all of our best planning because things line up in unexpected ways but i was really interested in the human performance part of it and so i started looking around for where could i study that what could i do with that and i started by learning about how do we prevent and learn from accident and error in these high hazard industries during that period um um my partner was pregnant with our first baby and i thought i need something to study that's nearby and close here in moston and so that got me interested in the simulation healthcare simulation world and i stumbled upon the center for medical simulation here uh and thought this would be a great place to do my doctoral dissertation because uh medical error healthcare error is actually quite rare and i'd have to watch a lot of healthcare provision to find a few small mistakes but here at the center for medical simulation and a lot of other simulation centers we push people to work at the edge of their expertise so it's common that they zig when they wish they had zagged almost every single day and so i could study what was happening in that context yeah the i love you know you're using this like at the edge cases or or in the these error cases that we follow a procedure a lot we follow like an algorithm for a certain procedure in nuclear or in or in manufacturing or in even when we're doing a sport we're following certain algorithms and especially when you're a physician you're you know you're following algorithms and and so what happens when you get a curveball that's thrown at you when you have an edge case an error how can we know how to um which which line of trajectory do we transition to that has the highest rate of efficacy of you know making sure that the patient is safe and healthy and um and the procedure goes as as well as possible and um and i i really like envisioning it as as as a sport because you know that totally makes sense the connection between your sport profession as well as your medical simulation uh and then okay so then the implementation of it so then um you like um using you told me as this is like this goal better outcomes for our patients and helping clinicians feel mastery and there's an there's a massive exponential growth of this that's happening you said over the last 15 years it's just been hockey sticking up you have people from around the world even today yeah you know visiting so yeah so tell us about this goal and and how it's happening here so i think i'll talk about this alan in terms of how do you create simulations and how do you educate people to be really good simulation educators so let's imagine that i've got a resident who's in emergency medicine and he or she has a young kid who's come to the emergency department and they've been in an accident and they're in shock and they need more volume whether it's blood volume or uh more just more fluid in their body to maintain their their blood pressure one of the ways that that can get done when you need to get a lot of fluid in all at once or if there's if you're having difficulty getting it in via normal IVs is you put in something called an intraosseous line and that is something that you basically put in through the uh skin into the bone itself so it's a little bit of a scary procedure for people to learn for the first time and so what we think about is what are the different things you would have to be able to master to put in an i o line and one is actually putting in the line itself the procedure but the second is imagine an anxious mom or dad standing there seeing you with this giant thing that you're about to put into their kid's leg and they start freaking out so there's several things that you have to master as that resident one is the procedure one is managing the anxious parent one may be managing your internal self so when you made the analogy to sports one of the connections is this process of mastery learning or deliberate practice where you practice get feedback try it again try it again so we break that process up into different pieces for people so one might be practicing the procedure just getting your hands and feet in the right place and putting it in the right place in the patient the other might be the difficult conversation with the parent so mom you know bear with me here uh and how you would talk with the parent or you would assign someone to talk with the parent yeah yeah this is this is you're really hitting on it from a way you know we try our best to help on the show make it clear about the nuance and the complexity of our of our world and when you take a procedure and you start explaining that hey it's not just uh you know it's not just roses uh that it's all gonna just be completely smooth every single time there's so many variables at play so so not only do we have to get good at building the mastery at the actual procedure itself the physical um eradication of an issue or the amelioration of the health an augmentation of the health in in any way but also we have to deal with a potentially a parent that is concerned we also have to deal with something another variable that's happening in the procedure that like we had a hypotension issue uh earlier that we'll we'll get to so if something like that happens how does the team react to that so there's all these cool ways that you're that you're running simulations and just for for everyone to get an idea of of you know what this actually looks like uh you can see this video that we're you know embedding right now that you know there are these you have these you have the actual simulation rooms where there's an actual patient and a practicing table with all the instruments you know you see the heart rate and you see the blood pressure levels and then you also there's a there's a room outside of that which is kind of like the control center where you're viewing what's happening you can hear the physicians and nurses describing what's occurring in their procedures you're videotaping that so that they can then debrief on what happened in so yeah so teach us about this because that was so fascinating for us to learn sure so one way to think about this is practice uh if anybody who's watching this practice learned an instrument or uh worked on their free throw shots in basketball or hit tennis shots as we know you have to hit thousands of tennis balls to be able to hit a good top spin in a game the clinicians who come to our center practice hundreds of hours every year thousands of hours every year in their discipline but they rarely have the opportunity to practice step back observe and think about their thinking so we really break this down into three parts we think about what are the clinical results or psychosocial results so think about that example did the kid get the volume did the kid get the blood into them they needed did the mom get uh talked to in a compassionate way so the result would be the mom would be calm the kid would be stabilized uh uh hemodynamically the actions that the clinicians take that's the second thing we think about what are they doing or not doing saying or not saying so we can help them learn different steps of conversations or different clinical procedures or whatever the third piece though is what we really focus on so there's clinical results there's actions taken or not taken but then there's the thinking or the frames of the clinicians when they're doing things so most of us humans to do an expert procedure or whether it's play a musical instrument or take care of a patient we have a whole complex routine of thoughts and feelings and expertise that we're blending all together to produce those actions so what we do in simulation is you can practice the actions but then you get to press pause and either go into a debriefing and take some time and reflect on your thinking by talking about it with other colleagues or you can literally press pause in the middle of the simulation and sort of like a video game live die repeat you're just gonna that it's not actually a real patient it's a mannequin patient or an actor patient who's not going to be harmed or hurt by anything we're doing so you can pause think about what you're doing wind the situation back a few minutes and try it again so it's all about the deliberate practice of getting better at whatever you're doing yes yes yeah as as you're explaining that to I was I was thinking about as these simulations become so indistinguishable from reality that it'll also be powerful because then people could really not have that going on in their head that oh this is just a simulation so I may not have to treat this seriously as I should be so there's almost a very strange dynamic that will occur when it becomes so you know indistinguishable but I love may I may I build on what you said yeah please yeah so that will be wonderful and that may happen but part of the art of good healthcare simulation or any simulation is we try to create something called a fiction contract which is this idea that I've made it real enough physiologically emotionally and experientially and conceptually such that like if the blood pressure drops and you give a medication that should raise the blood pressure the blood pressure will come back up so the world is functioning the way you expect even if the mannequin is a plastic mannequin that looks sort of real not that real what we find is people are very able to buy in and participate with their heart and mind if we make it real enough and importantly we make it psychologically safe enough so your professional skills are on display like let's say we were doing a simulation of an interview and then we paused it we debriefed to do that you'd want to feel like hey you know people care about me here they're here to help me become a better interviewer or maybe I'm doing media training they're here to help me be a better interview week it can't be a kind of gotcha environment so we can get people to be act as if it's real with a surprisingly low level of fidelity or realism yeah yeah the the the trust that it has to be built into the environment that people can feel like you were like you describe that it's so crucial for them to feel like they can voice how they feel because it's almost as though we have to become more and more comfortable with the dynamically shifting patient care environment to say how we think the next part of the procedure should go and if we feel comfortable voicing it then in practice then we will in the in the actual environment and so building that sort of a culture between physicians and nurses when all these different things are shifting with with parents or family as well as the actual physical procedure and all the variables that are being tweaked along the way let's let's give let's give the actual example that that that we had okay we were watching an appendectomy so there was just about a little over an hour there was a simulation occurring where the physicians and nurses on the operating table were working on a patient the simulated patient with with with the the process was to remove the appendix and there was this is very interesting we you know I called it a curve ball and I'll we'll let you explain but the general idea is that you threw anaphylaxis at the team and the the anaphylaxis caused it caused a hypotension it caused a rash it caused a bunch of things that then they had to dynamically adjust to so this was very fascinating for me watching it and seeing a simulated environment of it because now they know what to do when this edge case happens in the real world and they can be prepared to to to save the patient and there was even the epinephrine drip that was occurring and how much of it you needed to give in order to kick the you know the body into action to fight the anaphylaxis so yes please explain this it was so cool watching it and then in the control room there was you know there were people you know we were listening to them watching them and it was so interesting yeah and well let me uh I'll do my best to explain it with the caveat that I'm an organizational behavior scholar not a clinician so I'm going to explain it somewhat conceptually but with a few clinical examples so what we would like to do in healthcare simulation is prepare people for things that they are going to face so if they if that was your mom on the table or your dad on the table you would like them to be very comfortable with anaphylaxis happening in the middle of an operation that one of your loved ones was having and be able to quickly know what were the medications they need to give and so on we try to help people in our simulation center there's lots of different kinds of simulations but here we tend to help people work at the edge of their expertise we have advanced practitioners who are already capable of managing fairly complex challenges so in this case an appendectomy is a pretty bread and butter surgery even a minimally invasive one which was what was happening and anaphylaxis is pretty bread and butter problem for many people in the textbook so it's possible for you to go through 10 years of practice and you know all about the signs and symptoms of anaphylaxis but you have never actually treated it yourself wow you and the other thing is the textbook presentation of anaphylaxis which is an allergic reaction could be hypotension which is a drop in blood pressure a rash wheezing a variety of other things but what my clinical colleagues in this course and others have told me is anaphylaxis doesn't always present in the textbook manner and so what we're trying to prepare people for is their own autonomic nervous system reaction their own stress which can kind of shut down how their brain actually thinks just like any other person so you've got to calm yourself down rethink what's going on assess the signs and symptoms and figure out how to manage the patient sometimes with additional complexities in the presentation of the patient themselves so it might be a bread and butter anaphylaxis it might be a bread and butter appendectomy but maybe there's something complex about the patient that makes it extra difficult and so we're looking for people to be able to apply the knowledge they have in a situation that's new for them yeah yeah there's a couple things there one of the things was the physicians and nurses we typically don't think need to be a good practitioners of meditation or mindfulness like one's ability to to see you know a stressful situation and not you know necessarily panic but maybe you know take a deep breath realize okay what do we need to do to best handle this right now and then take it from a very you know logical procedural perspective and then also the I love how you keep describing this state of of of flow it's almost as though yeah you're challenging people right at their expertise level it's not too easy but it's not yeah too hard and then they're they're right in that state of their optimal cognitive challenge and then by doing that that's how they keep becoming a master in what they're what they're working on may I build on that for a second yes so one of the things that's important is simulation is expensive it's expensive in time it's expensive in space it's expensive in equipment so anybody can study what are the signs and symptoms of anaphylaxis what are the first line treatments I could you could study that and I could give you a test of that tomorrow and you could probably answer a lot of questions correctly what we're trying to do is create this context where people where it's valuable to work at the edge of your expertise or sorry to to take the value of all this expensive input and help people at the edge of their expertise if we're just about the knowledge they don't need simulation if we're just about the experience which they get every single day they don't need simulation it's the unique combination of practice plus debriefing plus reflection that helps you get in that sort of deliberate practice improvement loop yeah that's very very well put and there's actually um you know like Achille interactive one of the really great um progress is that we've made in digital medicine kind of takes people to their optimal level of of of a cognitive challenge with with increasing certain areas of their of their cognitive processing maybe working memory or their just attention all these focus right so so it's as though you've created a similar you know closed loop feedback system with people being at their optimal level of cognitive challenge in an experiential environment versus a textbook environment like you're indicating earlier which just has um you know we're seeing today with the advent of like spatial computing in the 3d virtual reality augments reality spaces it's just when you envision an actual biological system in the 3d space and you can tweak it it's much greater level of of of remembering uh and uh and under learning then it is on a 2d page um so you have the experiential environment then you go into the debriefing side of things which then you're having discourse amongst your peers about what was what you could what you learned what you could do better and then um you go into another one it's just this is a very very beautiful um process that you've that you built here and okay so then it it's also interesting that um you have this process I want to talk about the the actual um debriefing and uh dash the assessment please teach us about that sure um so we were approached a number of years ago by a colleague who was involved with the american heart association adam chang who was really interested in how do we get novice educators to be better at the very very important task of helping people be better in managing cardiac arrest and he had some different ideas about how to do that and he came to me and my colleague robert simon and he said I'd like to be able to assess the quality of the debriefing after they practice doing a code resuscitation what is the impact of the debriefing on the learning can you give me can what's your assessment tool and we said um we don't have one but we thought hmm challenge so robert simon is a psychometrician I'm a organizational behavior psychologist with an interest in conversation and cognition and we got busy with our simulation colleague uh dan reymer and working with a variety of colleagues all over the world we created an instrument to assess the quality of debriefing so that doesn't sound all that interesting but what's really cool about it is it gives a common language a common set of standards a common parlance that we can all use then to create a community of people who knows how to have this technical conversation better better better so the dash has been translated into about six different languages it's about to come out in mandarin it's uh arabic translation is underway and what's neat about that is simulation programs in riyadh or in beijing or in santander spain get together work on giving each other feedback on their debriefing again who cares the reason I care and the reason I think it's really important is debriefing is a stylized way to practice having difficult conversations all of us humans hate the awkwardness of critiquing another person we would just rather do you know have a root canal practically instead of that but what the dash or debriefing getting better debriefing helps you do is learn how you can be curious and assume the best of the other person which solves this horrible dilemma of having to basically cover over my feelings and lie to you about the critique and just hope that you're going to guess why you did it wrong so what we focus on is I can be straight with you about the critique because you're intelligent capable trying to bet do your best and want to improve I'm thinking that about you which reduces my anxiety and social awkwardness and lets me tell you the truth in a kindly way yes and so the dash helps build communities that can do that better you you know this this behavior science side of things the perspective that you take there about building out the environments that make it people comfortable with having a growth mindset and a comfortable with critique feedback integration and then further practice is being translated into Mandarin and Arabic that's huge it's billions of people that's awesome and I love that you know the debriefing side is such a critical you know you guys will have a video here embedded as well where you can see the sitting around the table having discussion watching the video replay of what happened in the medical simulation with the patient and with everyone moving and you know being able to pause it being able to rewind it fast forward it jump to the different highlighted annotation points was really cool yeah yeah that part was very interesting as well like when the actual allergic reaction happened you can kind of like find that area and go to it exactly right yeah that's that's very cool and then you can rewatch how people yeah behave at that moment so what we've been talking about this individual skill development and and cognition improvement and self-management improvement you could think about that as the core of an onion of performance improvement but I'd like to just mention a couple other ways that that's spreading out in the simulation world especially related to some of the other technological developments you mentioned so for example with 3d printing our colleagues at the boston children's hospital peter weinstock and others have worked with their surgical colleagues to create a con a process whereby if there's a child coming in for neurosurgery they use the ct scan of that child's brain produce a 3d model of that child's brain and then the neurosurgeons can practice what's the route to get into for example a tumor before the child is even on the operating table greatly reducing the amount of time that the kid needs to be under anesthesia and in reducing some of the uncertainty of a very complex procedure so that is happening around the world we need to do that interview too yes let's make that one happen too that'll be fascinating yeah well so we can actually yeah we can model the actual patients biological systems and then go and practice on their exact biological systems like tumor whatever the ailment is and then practice on on removing that and and get mastery on it and then actually do it on the patient holy cow that's great yeah yeah so and then another application that's happening again using kind of simulation to look at the systems of care is a colleague in Australia named Victoria brazil and team at the gold coast university hospital have been using simulation to map out the patient journey but also build interprofessional knowledge and trust so let me tell you what all those terms mean so imagine that you want to get the patient from who's having a some kind of a heart attack a STEMI from the door of the emergency department to the cath lab for definitive treatment they have to come from the ambulance and the pre-hospital providers through the emergency department transported through the hospital up to the cath lab nobody really understands what each other's roles are there they're sometimes misunderstandings even conflict between this and we can set up a situation where people can wear go pros and see each other's part of the process and Victoria and team debrief 40 50 people all together who can see that entire process and so they learn about each other's roles and build trust among each other so it's very easy to focus on the technology but what simulation really is an excuse to do is understand each other's thinking better so going back to the very beginning of the interview what I'm passionate about is how do we build how do we come to each other from sort of a stance of curiosity and respect when we do these interprofessional simulations people get more curiosity and more respect about each other's roles yeah yeah similarly I just want to quickly build on that one too it was so cool all the way to the actual EMTs that are sitting in that ambulance yeah and having that GoPro so that you know the physicians and nurses and staff at hospital can see what they're experiencing with the patient while they're being transported all the way to like you said just all of the complexity that actually occurs at the hospital being able to get behind with the curious curiosity behind the eyes of every single one of those people along the way you're building that trust it's it is such an interdisciplinary field and to be able to to take care of the patient oh yeah give us more of these examples okay well there's another one that I think is really interesting and important which is testing out whether architectural designs actually work for patient safety and patient care so colleagues at the modern health services in Brisbane Australia that team at Boston Children's that I mentioned earlier the team at Texas Children's team at all Johns Hopkins all children's in Florida all of them have different ways of bringing simulation to a building basically bring a patient bring the people so for imagine that you're building a pediatric intensive care unit or let's say regular intensive care unit you build a room that has a bed and a sink and all these different things it looks great but what you hadn't thought about is if that kid all of a sudden crashes and needs to be on something called ECMO or you need to bring a defibrillator in there or you need to bring ECMO in there and the defibrillator was already in there and the 10 people that go with all that equipment and all the plugs and all the cords and all the noise and all whoa all of a sudden all those things don't actually fit in that room yeah and you can't take care of the child so simulation is being used to help plan to do mid-course testing on architectural designs and then to test after the design is done so huge cost savings but also important safety advances yeah so architecturally speaking can the room where the patient is being operated on fit the anomaly case equipment that needs to be brought into the room how noisy will it be can it be plugged in all this yeah all these how many more staff members are going to be in the room to do that part of it do they how will they know the patient's data you had this you know love that look this an image embedded here where you actually have a whiteboard in the in the operating room with the the the data on the patient there you know their date of birth there they're like they're if they have any allergies if they have the their actual health record number yeah itself but Alan let me just I hasten to say I think a lot of my colleagues would really love it if we could go back to having whiteboards everywhere many of my colleagues are now working with an electronic medical record or an integrated electronic medical record which is supposed to make life easier totally but if you imagine that now you have all these doctors nurses respiratory therapists other allied health who are supposed to be looking at the patient and each other are now also on top of that basically having to do data entry data entry on top and so the into the electronic medical record it adds a level of complexity that we're also trying to understand using simulation because it completely changes the relationships in the room not only with the patient but with each other yeah when we had Dr Robert Lustig on the show he made it very clear that he and a lot of the other physicians around the world have found it to be quite difficult to you know you're the doctor and I'm the patient and you're spending you know a part of the time looking at me and empathizing with me and then part of the time looking at a device and entering data into a device and then that whole process is it takes you longer and it's a and it's also very important that that electronic medical or health record can then also be read by the other that the data can very easily move around that I can retain some ownership of the data there's all these can that data then be used for further medical research do I have control that there's so many of these questions and it makes a lot of sense to to find the most frictionless process of being able to potentially capture what the physicians and nurses are saying by voice and then find the key phrases parse for the key phrases enter that in to the electronic record that'd be fantastic go hopefully the the algorithms that we're working on will be able to get us to that point there's I mean there's so many so much else that that we can talk about with the examples I think this is an interesting one since this was this was just happening we had we had one of the midwifery nurses visiting for physicians visiting from Belgium yeah so we had and this was just was again just happening a little over an hour ago you know people from around the world usually have about four or so like let's say anesthesiologists that come in and that they're training they're from mass gen mass use a general hospital and they're in their training on on how to become a better anesthesiologist with these simulations but then you can also have people from around the world like from Belgium coming to visit and so usually what the midwives doing is working with the mother that's about to birth a child and there can be complications that occur like you were explaining the shoulder could get you you know stuck in the canal and then they're and then what so how do you so then they quite these are the things is how do you prepare the midwife to be able to handle a situation like that through simulation there could be some nerve damage that occurs how do you talk to the the the family after that so this is very beautiful you were starting to teach me about this and then so maybe walk us through some more of these you know you have people visiting from around the world and they've they're in different fields and you have different simulations for them and then they take it back and teach their part of the world about it yeah so just to set this context here and then maybe pick an example that would illustrate it so we have simulation fellows that join us for three months to 12 months who come from whether it's Germany or Spain or Saudi Arabia or Belgium or wherever and they are working on improving their simulation programs whether they are skill based or system based or these different kinds of applications that we've discussed a lot of what we specialize in is interprofessional communication so how do people from different professions which often amounts to slightly different cultures because how professions are trained can be quite different in what your expectations are and your assumptions are work together so let's take the labor and delivery example that you gave so one of the things that we sometimes practice here is a mother who comes in let's say she's had a motor vehicle accident or some other kind of situation or condition where she's deteriorating maybe she's heading toward a heart attack maybe she has some kind of a cardiac arrhythmia at the same time the baby maybe is having some fetal distress so the problem is we've got to take care of the mom and we've got to take care of the baby and the people who are focused on stabilizing the mom often the anesthesiologist and the people are focused on caring for the baby often the OBGYNs or the midwives or the nurses have slightly competing objectives there are certain things that need to be done for the baby there are certain things that need to be done for the mom and they have to quickly negotiate that in maybe minutes or 90 seconds they have to clarify what each other's goals are and if they haven't been in that situation quickly grasp that and find a way to make a decision for example sometimes it's going to be in the interest of both mom and baby to do an emergency cesarean section and get the baby out but to do that requires certain preparations and certain kinds of things for the mom sometimes it might be better to do something for the mom first and wait before we deliver the baby imagine just trying to figure that all out as the blood pressure is going down and the heart rate is going up and fetal monitors looking non-reassuring these are things that we try to help people practice here and so returning to some of the themes we've discussed that involve self-management how do I calm myself down so my colleague Rebecca Meinhardt who's an anesthesiologist and an OB anesthesiologist has been doing a study in one of our courses on how do the clinicians perceive a crisis what is a crisis to them what is it externally what is it internally in terms of what they feel and she's trying to understand that so we can better build that into our courses and prepare that help people be prepared for self-management then there's organizing the team so for example that anesthesiologist might need to name the things that are happening help people claim roles and then aim the team with the intervention so we have a algorithm as you've called it before that's name claim aim that helps people organize the team so those are some of the different things that we might do in that interprofessional way and Jennifer Joris who's the midwife visiting us from Belgium that you met is really interested in that sort of interprofessional coordination and collaboration under stress and time pressure wow that example in 90 seconds let's say uh they have to logically talk about the protocol the next step um that's so crazy yeah and wow the blood pressure is dropping like what yeah and so these are you know let's get behind the eyes of of of more people you know everything from people that are still um using jerry can gallons to go and get water from wells all the way to um people that are uh working in the restaurants that we're eating and customers at all the way to the nurses and physicians that are working on on our loved ones and the more that we can do that and realize the complexity of what their work is and um and even potentially you know do the simulations that get people a more comfortable uh in those environments uh with more mastery in those environments well and one of the ways we can get the more comfortable is because it's a simulation and the patient is either a mannequin patient or an actor patient who's not going to be harmed or hurt by what's done or not done is we could literally and we do come in in the middle of that situation we literally press pause we're like pause patient's not going to get any better not going to get any worse let's just think this through what are the signs and symptoms you're concerned about what are the signs and symptoms you're concerned about yes how are you thinking about moving forward how are you thinking about moving forward so they can hear each other's plans they can calm down a little bit talk it out and then we literally rewind a minute or two start it back up so it's sort of like a live video game yes and they can reorganize themselves it's so cool yeah when you you know when you you know in many ways well this is this is a game civilization the human experiment earth is a game and so you know it would be fascinating to actually be able to pause our game earth and go how do we you know geopolitically handle artificial intelligence let's take a break yeah oh that would be so wonderful if you stop the world i want to get off i need to think about how can we slow down global warming here yeah yeah because the fact that the economy is just roaring at unprecedented speeds and um causing us in many ways to not be able to press the pause button it just keeps us going every single day and that's why we experience a lot of the miscommunications and issues that we do and we have no space for oops moments yeah with the scale of errors that could potentially be occurring yeah okay this has been this has been so fascinating and i want to ask you about where you see all of this going with the future of healthcare the future of medical simulations healthcare simulations where do you see this moving to in the in the future so i think there's kind of two or three big trends that i think are important and likely to get more important so one is AR augmented reality virtual reality and we're working with a group called e-real who is synthesizing work from a bunch of universities around Italy to bring AR and VR to healthcare and i can talk more about AR and VR one is integration of simulation so we've learned into the healthcare system and the third is using it more for just in time type training so we've already alluded to all three of those so the AR VR is an area where there's a number of companies that are already trying to help us visualize for example 3d models of things and be actually in them and we know a lot about the transfer from 3d to 2d that is already showing for example in mammography that we can have greater accuracy and better prevention of adverse outcomes with better visualization this is not my area of expertise but i believe it's something that's going to be important uh the second is this integration so i'm a simulationista as they say but what i'm really keen to do is how do we bring debriefing more and more into just real clinical spaces we don't need simulation we have hundreds of cases every day thousands of cases every day at at massachusetts general hospital or other could we have a mini micro debrief of that are there ways that we we're not going to practice on our patients but there's a lot of what we do that we could learn from if we could have some little moments of reflection but the other is to build it into the context such that we are testing our systems while building our skills so we're actually in situ there's a lot of in situ simulation happening and i believe that's going to expand in some ways in situ in situ so right in the situation yep in the city yeah so using that what's that latin word yeah so in the clinic in the home in the real clinic in the real home in the in the uh intensive care unit in the operating room itself so people are using their own equipment their own environment their own electronic medical record and those kinds of things allow us to learn a lot more about the intersection of our skills in our systems challenge there as it's very expensive to be in any real clinical space i can potentially take uh the my own um electronic health record and uh and run like my own biometrics and potentially run a simulation on what it would be like if i um if i took the antibiotic that i needed to combat something or that i need um if i maybe needed uh some sort of a a if i would desired a genetic engineering procedure of some sort and just see what it would do to meet potentially and that that's interesting then of course like uh um taking and you leveraging the power of of computation and all the permutations that um really powerful computing can do um in the actual operating room and be able to simulate out if we made this decision and you know in just 90 seconds i'll hear all the decisions the highest efficacy is this one and you know to be able to see which protocols best and then of course like you said debriefings around the world if i was thinking about it would be great if there were you know two teams tackling and that way the team that tackles the surgery can then go debrief for half an hour while the other team goes and does the next one so that it's not um having to go from one to the next to the next to the next there's no debriefing time in between that was interesting and then of course yeah we have some great um connections for you we'll love to connect you to infinite retina who we just had on the show on um the uh spatial computing and augmented reality uh and they already um work with so many um uh healthcare organizations that are using the technology to be able to um have that augmentation that three-dimensional augmentation of the patient experience to to make sure it's of greater levels of of efficacy um awesome conversation in just so mind-expanding i feel so much more enlightened i want to ask you just two questions that we typically ask our guests on the way out of the show first questions of course funny in the given the context we're in uh are we in a simulation uh well you and i did a little bit of a debriefing we thought a little bit about what we would want to do here and theoretically we could pause at any time and rewind redo in fact we should have done that that would have been kind of fun um i try to approach my life as a little bit of a deliberately developmental opportunity so or action inquiry and i give myself as much slack as i can to rewind and redo so even if we're not going to immediately redo this um you know if this had been a real life would we be doing this differently or is life a simulation i like to think about being able to practice and get better though as you say it's a game with real consequences so um i will say parts of life are a simulation yeah yeah it's a constant uh leveling up and um and knowing that it is uh building our own our own skill sets and helping contribute at the level of our family community world is just so critical brings us most meaning in life and uh and that's what i think drives so much of our existence is so i'd like to just ask you a question about simulation so i noticed that the podcast is called simulation and i was thinking wow ellen must be into rehearsal practice something why does he call it simulation so why is your show called simulation it's called simulation for so many reasons um you know it's so funny that you know we are here center for medical simulation and i think that um when you take uh simulations and healthcare simulations and engineering software to find the right fit for aerospace or for automotive or for whatever industry on an engineering software side of things or there's um there's simulations used for um for how to uh calculate the you know the trajectory of of the rockets that need to go to the international space station you know there's the there's simulations for for biology the central dogma of biology and how that actually works um when you uh when you drop in um you know the above like pharmaceuticals into the biological system how that affects it i mean it's endless where simulations are actually applied already in in real life and so you know that's you know one of the reasons of course another one of the reasons is because this the question of if we are in a simulation is very interesting and it also um speaks greatly to in the next couple of decades hopefully within 50 years we'll be running our own um simulations and we'll be able to do things like look back at um at how humans actually evolved from you know from the big bang to the development of the earth orbiting the star to the development of of of life uh all the way up to um civilization flourishing and we can actually finally look at all the artifacts the archaeology of the anthropology of the evolution and we can not have to play the guessing game we can actually watch how uh language was invented how fire was invented how the wheel was invented um and so anyway that's you know these are the these are the reasons why so you are really attracted to these abilities to kind of predict and and play out and that's why you named it simulation or yeah yeah that and I would also say that um it's just a lot of the show is about um also asking really thought-provoking questions the leaders at the edge of their fields and inspiring and engaging other people to get to the edge and work at the edge and build the future and so um you know the thought-provoking question you know are we in a simulation what is consciousness are we alone in the cosmos the last question we like to ask our guess is what is the most beautiful thing in the world empathy compassion attunement being together really those are those are really raw yeah yeah yeah and I I hope that um one of the things for millennials and for gen z is really hear what Jenny just said you know really the empathy the attunement the ability to get behind the other's eyes and to be there with the presence with the heart and the energy the spirit right here you know is uh so so crucial um so to say that we're you know with our friends when we're FaceTiming around the devices is you know much much different um so yeah yeah thank you so much this is such a great interview good to meet you great to spend some time together yes I love you and I love your work so much thank you thank you for all that you're doing for all that the Center for Medical Simulation is doing um please check out the links below all again the links are harvardmedsim.org also uh Jenny's link to her LinkedIn profile the med simulation on twitter as well as get curious now um Jenny's twitter check out those links below everyone let us know your thoughts about the episode as well so share the thoughts around medical simulation healthcare simulation with your friends your families online with your co-workers let's get more talking about this let's get behind the eyes of the physicians and the caretakers the nurses that are helping us live healthy um lives and all the complicated protocols that they go through and uh also support the artists and entrepreneurs and the organizations that you believe in around the world simulations links are below as well support us help us scale help us grow help us continue come to cool places like Boston to do interviews like this and go and build the future everyone manifest your dreams into the world we love you very much thank you for tuning in and we will see you soon peace