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When See One, Do One, Teach One Just Doesn't Cut It Anymore

March 1, 2017

Plato said, “necessity is the mother of invention.” Isn’t that always the starting point for innovation — a problem, frustration or a way of doing something that isn’t efficient or effective? The BAYADA Award for Technological Innovation in Health Care Education and Practice recognizes and celebrates people who see a healthcare need and figure out a way to satisfy it. That’s what Joshua D. Lenchus, DO, FACP, SFHM, associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine did when he realized that the apprenticeship method, “see one, do one, teach one,” for teaching specific procedures just wasn’t working. 
Q: What need did you see that led you to come up with the simulation-based curriculum in invasive bedside procedural instruction?
A: The apprenticeship model, the same model I went through during training, is predicated on the fact that people get out of medical school and they have this requisite knowledge to which we build upon in residency years in this apprenticeship method. The fact is that that foundational knowledge is simply not there. I don’t know if anybody ever thought that there was. Maybe they thought that procedures were easy to pick up on if you just sort of watch what I’m doing, but medical students don’t go through formal curriculum on how to do these procedures. In fact, when I think back to when I was in medical school, there was no mention really of how to perform the procedure at all. A lumbar puncture for example, we knew we did that for meningitis, and for other indications of course, but that was the extent of what we heard about a lumbar puncture. 
I enjoyed doing these procedures while in training, but after I got out I solicited feedback from a number of institutions from around the country in an effort to figure out if someone else had tried to tackle this issue and found that the vast majority of people had not. I thought, there’s got to be a better way to do it.
We created the curriculum, biting off a pretty fair-sized bite, to tackle the four or five procedures we would be doing routinely in medicine. We started off training medical students and residents, but when other people heard about it, it quickly expanded. We have invaded the nursing realm and the medical realm both here and outside of our own institution. And now we train people who, frankly, in the past would have scoffed at the idea of somebody in internal medicine training them to do a procedure that’s sort of their bread and butter.
Q: Do you think the technology which is available now lends itself better to this kind of development than what was previously available?
A: Technology plays a pivotal role in our ability to train people on how to do this. If you look at other things that are currently available, alternatives to buying very expensive manikins, using ballistic gel to build their own model or using non-human tissue models (a store-bought rack of ribs, chicken breasts or pig’s feet that you used to practice suturing on) are some common options. There are live animals, which many people are steering away from, and cadaver labs. We don’t have much outside the manikin realm to do something repetitively with good results that are standard or don’t require a lot of other regulations, so simulation plays an incredible role. The manikins now on the market are durable, anatomically representative and fluid filled. Ultrasound can be done on them —this crucial in our ability to teach people how to do this.
Most people, when you mention manikins, think of the 30 or 40 year old ALS or BLS Annie model that you used to throw on the floor and do compressions — to do a particular task. There were things you could and couldn’t do on that old Annie model.  This is the same thing in the procedures we teach. We have a model specific for a central line, a model specific for a lumbar puncture, et cetera, so we’re not buying $100,000 human patient simulators. In fact, there’s another name for the manikins we use — task trainer — it trains you how to do a particular task.
Q: What have you noticed since implementing this kind of instruction? What have the outcomes been for patients and students?
 A: I expected we would blend a great educational experience for medical, nursing, physician assistant students, whoever was learning, with providing a service to the hospital. Almost ten years later, that’s exactly what happened. We’ve had universally positive feedback for people who we train, regardless of the specialty, designation or years of training including those who’ve been outside practicing on their own for a number of years.  
From a service perspective, the hospital is absolutely floored by what we’ve been able to do. Traditionally, we’d send a patient somewhere or wait for a surgeon to come put a central line in. That created an inordinate delay in patient care. You thought you were speeding things up by offloading this work to someone else, but it became a complete standstill for that patient moving through the system. Now, we are the mobile ones. I joke with people saying if we can get a kit and the ultrasound out to a parking lot, we can do this in the patient’s car. They don’t even need to come to the emergency room. We’re the mobile part of the procedure which serves as an incredible opportunity in reducing healthcare expenditures for the whole system and improving patient throughput.
Think about a patient who may be in septic shock, has TB and is intubated in the ICU. It’s a whole production to get that patient out of the intensive care unit to the radiology suite where they are going to do a procedure that may take a half an hour. It may take an hour and a half just to coordinate that and the team of people who have to go with the patient. Now, the same patient stays right where they are, in the intensive care unit, where they’re monitored and the requisite equipment is if something goes wrong. We don’t need to rely on transportation or on someone else’s schedule. We’ve drastically improved the throughput because we can do the procedure at the bedside. 
We go to the emergency room to take fluid out for a para or thoracentesis and then patients can go home instead of being admitted. We’ve been called about 11,000 times to do procedures in the almost ten years and have data showing that the rate of complications, inherent to some of the procedures like infections for a central line or a collapse in a lung in a thoracentesis, are actually decreasing compared to the rest of this hospital and compared to other national metrics that are out there from us doing those procedures instead of people who haven’t been through the program.
Q: What have you done since then and what did you do with the prize money?
A: We’ve continued to grow the team and the program. Certainly the recognition from BAYADA has been tremendous. It’s one thing for the local area, the hospital, the people you teach, other departments and divisions in the hospital to come give you a pat on the back. But external recognition of a program you’re doing is incredibly important. It shows that other people have recognized what you’ve done as important.
We are building upon a metastatic model, if you will, where we go out and train others so they can do it in their own institution. Between the BAYADA award last May and now, I went to Virginia Commonwealth University in Richmond where, in July, they launched their program on the heels of that weeklong visit where I conducted training and did grand rounds. It’s been running now for eight months; the feedback I’ve been getting back from them has been incredibly positive. Now I’m going to Georgia and South Dakota to train.
While the external recognition of the award lets us say we have a program, a proven method, the ability to go places to do the same thing, and we’re recognized as a leader in the field, the prize money helped us purchase a handheld ultrasound device. It actually fits in your pocket. The clarity of the image could be better on the smaller screen, but the tradeoff is portability and technology to improve image quality is being looked at.
A: The most obvious thing is that there is absolutely no downside to applying. That would be number one. Number two, is if somebody thinks they have a really fantastic innovation, it behooves them to apply for their own recognition, but also to help get the word out about what they’re doing. The recognition piece is not just that it gives external legitimacy to your program locally, but it’s also a megaphone which really helps build an incredible network. People at Drexel and BAYADA now know about my program who otherwise may not have known until we published 23 other articles. There were other people at the award ceremony who were not part of Drexel that heard the presentation. The people on the review committee certainly know people who are outside that circle. It’s sort of that ripple effect, it really builds tremendous impact.
The award is an incredible philanthropic effort by the Baiadas who gave back to do this, of course, but then to foster this kind of technological innovation in healthcare and education, I think, is a fantastic platform from which you can sort of brag about your product and innovation.