Professor Amitai Ziv, a pediatrician and an ex-Air Force pilot, is helping transform the way medical and other community service professionals (from healthcare professionals and social workers to secondary educators) are trained and evaluated, in order to enhance the social and professional skill sets of these professions. Amitai, a leader in simulation-based medical education (SBME) is bringing about a “safety revolution”—offering a significant step forward in improving patient care, reducing medical error, and embedding a systemic and transparent quality improvement process into often old and conservative training regimes, thus contributing to a deep change in patient safety culture of today’s healthcare systems.
The New Idea
Amitai and the Israel Center for Medical Simulation (MSR), which he founded in 2001, employs a host of pedagogical and methodological approaches to mitigate medical error for the sake of improving and increasing worldwide patient safety. By creating a safe environment in which professionals are invited to practice, make mistakes, reflect on and learn from their errors, Amitai and his team at MSR work to improve the quality of medical staff and ultimately, of healthcare systems.
In spite of notable improvements in access to medical information and connectivity among healthcare professionals around the world, there still remains a worrying dilemma: Far too many mistakes are made unintentionally by health professionals and many of them are mistakes that could be avoided, or at least mitigated, with proper training. Amitai is addressing this problem by combining the medical skills he acquired as a physician with the simulation experiences he received as an Air Force pilot. The result of this synergy of skills and experiences is a comprehensive and widely applicable model for medical simulation, which has already begun to be implemented among other community service professions and by medical institutions outside of Israel. Aside from providing procedural simulation that integrates interdisciplinary teams of medical, nursing, paramedic, and other professions, MSR trains for a wide variety of conventional and unconventional emergency preparedness situations, including chemical, biological, and nuclear warfare as well as putting much focus on simulating challenging and difficult emotional scenarios in medicine to improve the humane approach and communication skills of healthcare providers.
As a result of this high degree of comprehensiveness and applicability, those parties interested in the link between patient safety and simulation-based training come to MSR for guidance. These include parties such as medical simulation centers, medical center and healthcare institutions, health professional schools as well as medical device and pharmaceutical companies. Other professional bodies in service fields such as welfare (e.g. social workers), education (e.g. schools’ teachers and principals) or even the commercial world (e.g. cellular phone costumer service supporters)—seek advice and training in order to better serve their mission and clients.
To illustrate the gravity of the high rate of medical errors, a study published in the U.S. in 1999 (To Err is Human) claimed that in the U.S. alone, 100,000 patients die in hospitals every year due to medical errors. According to Amitai, these deaths are analogous to “a jumbo Boeing 747 crashing in the U.S. hospitals every day.” The World Health Organization estimates that “medical errors and healthcare related adverse events” occur in about 10 percent of hospitalizations worldwide. These staggering figures are evidence that the current protocol for decreasing the rate of medical errors—lectures, workshops, and other forms of non-praxis-oriented training—are failing to serve the medical profession.
This is perhaps one of the biggest paradoxes of Western medicine: It has highly-trained professionals, advanced technologies, a health expenditure of 6 to 18 percent of GNP, and unparalleled investment in biomedical research, and yet has unreliable health systems with high rates of error—most of which are preventable.
This safety deficiency is seen by some experts in the field as a systems failure—a combination of deficient communication and handover skills, inadequate practical training, lack of cultural competences, and the need for patient empowerment. In particular, such high numbers of errors stem primarily from a lack of awareness, real practice and teamwork—as well as due to inadequate training, assessment and accreditation in ‘soft skills’ such as communication, humility, and empathy. Miscalculations and poor administration of dosages, poor post-surgical protocol, and surgical mistakes are common medical errors that can be prevented or reduced.
By creating an almost real-life environment in which one learns from his/her own practical successes and failures and improves his/her teamwork and communication skills, MSR is enabling healthcare professionals and other community-serving professionals to perfect the intricacies of their professions.
Amitai’s medical simulation work is based on the belief that exposing health professionals to challenging and extreme encounters where they can err without endangering real patients improves outcomes while dramatically reducing medical errors that result in needless deaths or harm to patients. Similarly, this mistake- and assessment-driven experiential education adds essential non-technical skills and professional behaviors to the knowledge base of the trainee. Ultimately, educational simulated experiences—including the realistic enactments of complex medical situations and the use of high-tech mannequins in learning about human reactions to medical interventions—have the power to save many lives.
MSR’s approach creates a safe environment in which trainees can make mistakes in a proactive and controlled educational environment—a system in which the process is as important as the outcome and feedback and debriefing are as central as the practice itself.
MSR trains medical staff in ‘softer’ skills as well: How to tell a family about the loss of their loved one; how to apologize for a mistake you did, how to deal with an aggressive, shy or silent patient; how to improve communication within the medical team around the patient’s bed; and, how to ensure that the information arising in this process is being registered and taken into account. When MSR offers similar services and opportunities to other social professions, one can describe Amitai’s model as a real vehicle to cultural change, offering a broad spectrum of simulation modalities and heralding a paradigm shift in the training and evaluation of professionals.
MSR’s curricula reach and train over 10,000 professionals in over sixty courses per year, all of which include hands-on practice. In total, MSR has trained and assessed more than 120,000 professionals over the last ten years. Based in a virtual hospital established on the Chaim Sheba Medical Center campus, which is one of the largest and most comprehensive hospitals in the Middle East, the center has over 100 simulators or models and employs over 150 professional actors for its courses (“simulated patients” from all cultural backgrounds with ages ranging from 16- to 80-years-old). The center is a not for-profit organization that achieves sustainability via a fee-for-service model and employs over thirty full-time staff members. To address more context/geographic-specific problems in medicine, MSR has also developed a variety of educational programs specifically designed for international groups, such as AIDS management for teams in Ethiopia and trauma management for doctors in the West Bank and Gaza.
MSR has become a standard across Israel—all medical student candidates, interns, paramedics, anesthesiologists and all advanced specialty nurses are trained and/or tested for competencies at MSR as part of their educational process. At a global scale, MSR has approached the problem of medical error by implementing its model at medical institutions around the world. The list of international medical institutions with which MSR is currently collaborating includes Case Western Reserve in Cleveland, McGill University in Montreal, Albert Einstein Medical Center in Sao Paolo, Mayo Clinic in Minnesota and New York Presbyterian Hospital and Columbia University in New York.
Amitai’s life has never strayed too far from two passions: Simulation-based education and improving the world. Even while in the for-profit high-tech world in the field of medicine, these passions were never absent from his life.
Amitai’s drive to help people stemmed from the socialist educational doctrine of his parents who came to Jerusalem from the kibbutz life and from witnessing the horrors and misfortunes of war throughout his Air Force career in the Israeli army. This experience opened up Amitai’s eyes to a new world of human suffering, a sense of social rights and social values. His experience with war also brought about the realization that he wanted to transition from the killing industry to the healing industry.
Amitai realized his passion and talent for simulation during his time with the Israeli Air Force. Integral to the aviation profession, Amitai fell in love with the simulation involved in training because it was not fighting; but instead was showing people to learn how to teach better. He witnessed how much the training changed his student pilot’s capabilities and from then on, he began to appreciate the art of debriefing as well as diagnosing and analyzing human error.
Feeling the pull of social service at the end of his time in the Air Force, Amitai decided to become a pediatrician. After experiencing a fellow student commit suicide two hours after that student failed a test for a class in medical school, Amitai decided that the testing system—both to get into medical school and to become a licensed physician—was incomplete. It failed to assess the human side of being a physician—a side that is perhaps as important as the cognitive side. Stirred by this revelation, Amitai completed his MD dissertation on peer evaluation.
Amitai ultimately turned his dissertation into a program that certified foreign immigrant doctors applying to U.S. medical schools. With the desire to show that the business of helping others can also be lucrative, he decided to join a U.S.-based medical simulation company that his Israeli Air Force friends had started. However, the business failed to attract venture capital at the end of the 1990s, in great part due to the fact that the field had yet to be recognized as a valid field in the business and medical worlds.
In the aftershocks of this entrepreneurial failure, Amitai received an offer from the Sheba Medical Center in Israel to be its vice president, in charge of patient safety, risk management and medical education in 2000. He accepted the offer on the condition of creating the Israel Center for Medical Simulation, in order to spread his approach.
In 2007 Amitai won the Charles Bronfman Prize (a humanitarian award that celebrates the vision and endeavor of an individual or team less than 50 years of age, whose humanitarian work has contributed significantly to the betterment of the world) for “establishing the pre-eminent medical simulation center, which serves as a model for such centers throughout the world. Amitai has made his mark not only in Israel, but worldwide, revolutionizing the health community’s views on medical simulation as well as how it is implemented in disciplines as diverse as preparation for mass casualty, military medical preparedness, and sexual abuse.”