This year was the 200th anniversary of the battle of Waterloo, famous for being the final conflict of Napoleon Bonaparte, one of history’s greatest generals. At this battle the resurgent grand Napoleonic army was defeated against the odds by Allied forces; the decisive weapon at the battle being the British foot soldier. As a bit of a military history geek I have always known that there was something special about the way that our troops were trained however I only realised this week that there was a lesson to be learned from this for medical training.
I have been practicing medicine for about 20 years now. During that time I have seen a transition from the “see one, do one, teach one” attitude to a complex system of portfolios, competencies and assessments. Doctors are now trained in an environment which has a completely different set of rules. Training has improved in many ways and one of the major improvements has been the use of simulation as a learning tool.
Simulation is a teaching method allowing an individual, or a team, to role-play a scenario with a subsequent learning conversation about what has occured. One of the strengths of simulation is the ability to incorporate infrequently encountered events. For example, we could simulate an encounter with a patient who may have Ebola. I’ve never seen this scenario myself and simulation would be a good way to get me to put into practice what I know only in theory. With the right facilitator I would get feedback that would prepare me well for the real thing.
Another of the strengths about simulation is that it is a relatively non-threatening learning environment. If I make a mistake with my Ebola manikin, there is a lot less paperwork to fill out afterwards and, although I might feel embarrassed, I don’t need to feel guilty. Most importantly no-one has been harmed. However, I sometimes feel that we make simulation too nice and try to sanitise it.
This brings me back to the 1815 British Redcoat infantryman. These soldiers proved themselves in battle over and over against armies such as Napoleon’s. Napoleon’s army was larger in sheer size, as well as infantry and cavalry. Napoleon had far more cannons and his army was unified.
What swung the odds back in favour of the British soldiers was their training. While other armies were practicing the complex process of loading and firing a musket by role playing, the redcoats of Wellington’s army trained with actual ammunition in their guns. That meant that their training was as close to the real thing as possible. This was not pleasant. Firing a musket was deafening, it jarred your shoulder and filled your mouth with salty gunpowder (as each cartridge was opened by biting into it). Training with ammunition in your gun for a soldier of that era would have been gruelling and probably caused many injuries. But it made all the difference when battle came.
There is a possibility in simulation training that clinicians are be learning in comfort what they need to perform in a crisis. This may be a dangerous precedent. As is frequently quoted (from an anonymous special forces navy seal):
“Under pressure, you don’t rise to the occasion, you sink to the level of your training,”
That was proved over and over when these two armies met, with the British Infantry consistently outperforming their enemies. Later, at the battle of Gettysburg, muskets were found which had been loaded 12 times and never fired. Was this due to being trained without ever learning to fire actual ammunition?
This year an article was published in the journal Pediatrics titled “Trainee Perspectives on Manikin Death During Mock Codes” exploring the issue of simulation that includes what I would call ‘mess‘. Medicine is messy and in high stress situations things go wrong. Sometimes despite all the best efforts children die.
There can be a reluctance to create stressful simulation with impossible tasks. What this means in practice is that we are failing to train our clinicians for the most important situation of all – the ‘no win” situation. I have had a significant part in the development of the Children’s Advanced Trauma (CAT) course and I am sometimes asked whether there is educational value in situations where there is too much to manage or where the situation is pre-determined to have a bad outcome. I believe that there is.
I would like trainers and learners to embrace the idea that failures are more valuable learning experiences than successes. As long as we are sensitive to the effect that these situations have on the learner I believe that the more mess you have in simulation the better. It is also important to have enough time set aside for the discussion afterwards.
There are other ways to look at this attitude towards medical training, which is to treat the most stressful experiences in day-to-day medical practice as learning opportunities. It takes a skilled person to do this well but when things do get messy, there is usually so much to learn that it is a shame to miss out on it. Medicine is messy. Perhaps as we train for the worst that acute clinical medicine has to throw at us we should include a few loud bangs in our learning?
What have you learnt this week? #WILTW
Consultant Paediatrician specialising in Paediatric Emergency Medicine (Sheffield Children’s Hospital)