War Games!

One of the problems with medical education is that while you are intellectually trained to deal with medical problems and emergencies, actual experience with how to respond to emergent clinical situations is difficult to teach and usually only comes with experience. Further, real clinical experts make medical decisions almost by reflex. You see this in medical school that while you as a medical student have to actively think about what is going on in any given situation, medical experts act more by pattern recognition and have an instant reflexive response to clinical situations. And how do you teach reflexes?

Here at UVA, Jeff Young, a trauma surgeon and researcher in clinical decision making has published on a new strategy of assessing and improving the response of doctors in training to high-risk medical situations. His strategy is rather than stressing cognitive experience, which much of medical school and resident training emphasizes, the goal is to build reflexive responses to critical situations. In an emergency, the ability to generate differential diagnoses and recall complex information is secondary to knowing how to acutely assess patients, resuscitate and stabilize them. Clinical experts do this without even thinking about it. Young’s goal is to train medical students, interns and residents by simulation of critical care situations so that when they end up involved in charge of a critical patient they will reflexively perform the correct actions to resuscitate and stabilize patients. After all, practice makes perfect.

The result is what Dr. Young calls “War Games” – simulations in which students and residents are drilled in their responses to medical emergencies. By putting students under some stress and making them think fast about critical care, reflexive responses to emergent situations are drilled into the subjects, and hopefully when the situations are encountered in real life they’ll know what to do without even thinking about it.

So enough talking about it. Here’s what one looks like – me being drilled by the chief resident on a patient presenting with hypotension.

You notice that rather than going for diagnosis the goal is to start with the basics. First you evaluate the airway, breathing, and circulatory status, resuscitate the patient as necessary, gain IV access, get basic vitals and check tests. Only after you’ve stabilized a patient should you start thinking about what the exact diagnosis is, whether you need to operate etc. It also emphasizes things you don’t necessarily learn in class, like the need to call the attending when some disaster has occurred. It seems like things like this should be obvious (they probably are to EMTs and paramedics), but the reality is that these kinds of practical skills are difficult to relate in a classroom setting. You also quickly realize that when you are under pressure, it’s completely different from all those sessions you remember from 2nd year where you sat around thinking about differential diagnosis with 5 other people in the room. I clearly screw up a few times during the simulation, but hey, that’s why I’m in training and why I appreciate these sessions.

This also demonstrates something I think we can appreciate about evidence-based medicine. Not only do we emphasize a scientific basis for the treatments we use, but we also actively use science to figure out the best ways to train doctors to be better clinicians. I found this strategy to be incredibly useful, and I hope other medical schools around the country also adopt War Games to help train their students to be better docs.