EXECUTIVE SUMMARY

Results of recent research show a direct correlation between simulator training for OB/GYNs and a reduction in medical malpractice claim rates.

  • Claim rates declined from 11.2 claims per 100 physician coverage years before simulation training to 5.7 claims.
  • Similar effectiveness can be expected from simulation training in other areas of medicine.
  • A simulation training program should accommodate the emotional needs of participants because the scenarios can be so realistic.

Using medical simulators for obstetrics training can lower the incidence of medical malpractice claims, according to recent research from CRICO/Risk Management Foundation of the Harvard Medical Institutions, Brigham and Women’s Hospital, Harvard Medical School, and the Center for Medical Simulation.

OB/GYNs who participated in medical simulation training experienced fewer claims in the retrospective analysis. The researchers compared malpractice claim rates for 292 OB/GYNs who were insured by the same company and attended at least one simulation training session over 17 years.

The malpractice claim rate was 11.2 claims per 100 physician coverage years before simulation training. After training, that number fell to 5.7 claims per 100 physician coverage years. Looking specifically at two-year periods before and after simulation training, claim rates fell from 9.2 claims per 100 physician coverage years before training to 5.4 claims per 100 physician coverage years after simulation training.

The simulation training in the study focused on teamwork and crisis management, says lead author Adam C. Schaffer, MD, MPH, of Brigham and Women’s Hospital. Other OB/GYN simulation training focuses on more technical skills of delivery, such as responding to shoulder dystocia.

“It was a low-frequency, high-acuity training scenario, addressing situations such as a mother going into cardiac arrest around the time of birth due to severe postpartum bleeding,” he says. “The simulation focuses on how the team works together, how to have a functional hierarchy so that everyone works well together to provide effective, coordinated care.”

Schaffer suggests the reduction in malpractice claim rates probably can be tied to the simulation training addressing two of the most common factors that contribute to adverse events in obstetrics: poor communication and a dysfunctional hierarchy.

The research also revealed a dose response relationship. The more simulation training a physician participated in, the more that physician’s claim rate dropped afterward. That supported the conclusion that the simulation training was responsible for the drop in claims, Schaffer says.

For a risk manager seeking a robust simulation training program, Schaffer advises starting with a risk assessment.

“Consult with your clinical leaders to find out what are the scenarios that keep them up at night. Then, you can tailor your simulation program to the needs of your clinician workforce,” he explains. “Part of the challenge is getting people to participate in the simulation training. Even though people often are enthusiastic about it, as a practicing physician there are many demands on your time. By tailoring the simulation to what your clinicians are most concerned about, you can encourage participation.”

Risk managers also might consider other incentives for participation, such as protected time off from a scheduled clinical shift, rather than asking physicians to add the training on top of their regular duties.

“In our research, the malpractice insurer offered a premium reduction to clinicians who participated in the simulation training. That creates a financial incentive that motivates people to participate,” Schaffer says.

A good outcome of the study would be for medical malpractice insurers to offer more incentives for participation in simulation training, suggests Ziad Rouag, CEO of Biomodex, a medical simulator company in Quincy, MA. Insurers offer discounts for organizations and individual practitioners who demonstrate adherence to best practices and participation in advanced education. Rouag suggests a similar certification could be developed for simulation training.

“We think the technology could be used in the same fashion, because the insurance companies benefit from the reduction in claims that was demonstrated in this research,” he says. “There is value there.”

Address Emotional Effect

One factor to consider is the emotional effect of simulation training. Administrators should be prepared to offer emotional support to participants, Schaffer says, because the training can be realistic enough to generate the same kind of stress that comes from treating real patients in high-risk scenarios.

“That’s part of the point of simulation training. It feels real in every regard and the simulation is designed to immerse the practitioner in a way that feels very realistic,” he says. “It can be intense and emotionally draining, even for those who are just observing.”

It is important for training programs to incorporate a post-course briefing that serves two functions. First, it allows a discussion of what went well and what did not, allowing participants to learn from their mistakes in a safe way.

“But it also is important to let people talk about their experience, to share their reactions and some of their emotions related to the intensity of the clinical situation,” Schaffer says. “I observed one session in which the participants weren’t able to figure out what went wrong, and the simulated patient died. That’s a very emotional experience. One objective of the post-simulation briefing is to give people a chance to talk about their reactions.”

Can Alleviate Physician Stress

Researchers confirmed the importance of simulation training for OB/GYNs in particular, says Laura Fortner, MD, an OB/GYN and life coach in Newark, OH, who counsels physicians involved in medical malpractice cases. She notes other research shows that by the age of 45, 36% of doctors in low-risk specialties and 88% of those in high-risk specialties have been subjected to a malpractice claim.

By the age of 65, those numbers jump to 75% for low-risk and 99% for high-risk specialties. OB/GYN is in the high-risk category.

“Unfortunately, when a physician gets sued, even if it does not have any merit, emotional injury is real. Ninety-five percent of physicians will go through litigation stress, and they report feelings of isolation, anger, shame, negative self-image, self-doubt, and fear for the future,” she says.

The effects of litigation stress range from burnout, poor patient communication and care, increase in medical errors, defensive medicine, divorce, family problems, and suicide.

“If simulators do, in fact, cut down on medical malpractice lawsuits, they literally could save not only patients’ lives but physicians’ as well,” Fortner says. “We should incorporate simulators as a must in the training process.”

Medical simulators could improve the safety of healthcare in general, especially patient safety, Fortner says. They allow healthcare practitioners to acquire valuable experience, in a variety of clinical settings, without putting patients at risk.

“The more physicians practice, the more competent they become. This especially is beneficial at the resident or fellow level,” she says. “With the time restrictions in resident training programs across this country, the number of patients they see and evaluate is less than in the years past. Simulators would definitely enhance their skills and help with competency to combat this issue.”

The best way to optimize the benefits of simulation is to incorporate it at the beginning of medical school. “If we started at this level, we could truly see the impact of lowering medical malpractice claims, lowering medical errors, increasing patient safety, and increasing physician well-being, and possibly decreasing physician suicide,” Fortner says.

Proven Effectiveness

Research has proven the effectiveness of simulation training, says James Archetto, vice president of U.S. direct sales for Gaumard Scientific, a medical simulator company in Miami. A study published by the National Council of State Boards of Nursing (NCSBN) revealed training nursing students with simulation is as effective as clinical training with a patient. NCSBN concluded up to 50% of the students’ clinical time could be performed via simulator in an optimally designed simulation training program.

This latest research showing the direct linkage to a reduction in claims is consistent with the previous research on effectiveness, Archetto says. He notes the use of simulation training for high-risk, low-frequency scenarios in medicine is similar to what the airline industry uses with pilots who train in simulators for potentially deadly situations that rarely occur.

“Malpractice claims are the byproduct of medical errors. The objective in simulation is to reduce errors, to ensure that the healthcare practitioner is skilled and has the ability to perform these very important procedures that they may encounter very infrequently,” he says.

While the most recent research focused on OB/GYNs, Archetto says the effect on reducing errors and claims is seen in other areas of medicine just as strongly. For example, simulation training is highly effective in practicing intubation because it is a challenging procedure that is difficult to practice on real patients.

The use of simulation training has increased significantly in recent years, and will continue to grow as research shows the effectiveness and linkage to reduced claim rates, Archetto says.

The simulation industry is growing due to the evidence of its effectiveness, says Eric Gantwerker, MD, MMSc, FACS, vice president and medical director at Level Ex, a company in Chicago that provides medical training games for physicians. The fact malpractice insurance carriers often fund these programs is a testament to their efficacy, he says, and CRICO has been leading the way in this arena.

“There is mounting evidence that skills learned during simulation training can be transferred to the clinical realm. However, the effect of these improved skills on patient outcomes has historically been very difficult to demonstrate due to countless confounding variables and, often, the time delay from education to patient care,” Gantwerker says. “Studies like this go a long way to show that patient care improves when healthcare practitioners train on simulators, validating long-held beliefs that we have always had problems proving.”

Gantwerker says all aspects of simulation, from physical task trainers to software-based simulation, can produce similar effects. Video games, although they are not always simulative in the truest sense, also can help physicians learn a variety of skills using similar methods to simulation.

“There is strong evidence that video game skills can be transferred to the real world in a variety of domains, including medicine. A well-designed program can utilize all these types of solutions, in addition to traditional experiential learning,” Gantwerker says. “Stronger evidence will lead to more funding for these programs and ultimately improve patient safety, patient outcomes, and, hopefully, reduce costs.”

Many types of simulators exist, including physical simulators, task-trainers, and software-based solutions.

Virtual reality and augmented reality (VR/AR) have been the subject of a lot of hype and significant funding increases, but Gantwerker says it has not yet proven its worth.

“Unfortunately, VR/AR implementations often are solutions looking for problems to solve, and the development of technology for technology’s sake,” Gantwerker says. “Best practice continues to require evidence that these solutions can do what they say they do. Existing proof shows that people enjoy them more than traditional learning only go so far. We need better evidence that these programs actually improve healthcare practitioners’ cognitive, affective, and psychomotor skills, that those skills transfer to the patient bedside, and that, ultimately, they improve patient outcomes.”

SOURCES

  • James Archetto, Vice President, U.S. Direct Sales, Gaumard Scientific, Miami. Phone: (800) 882-6655. Email: jamesa@gaumard.com.
  • Laura Fortner, MD, The Med Mal Coach, Newark, OH. Email: themedmalcoach@gmail.com.
  • Eric Gantwerker, MD, MMSc, FACS, Vice President and Medical Director, Level Ex, Chicago.
  • Ziad Rouag, CEO, Biomodex, Quincy, MA. Email: ziadrouag@biomodex.com.
  • Adam C. Schaffer, MD, MPH, Brigham and Women’s Hospital, Boston. Email: aschaffer@bwh.harvard.edu.