I begin many of my talks with a quote by George Bernard Shaw–“All great truths begin as blasphemies.” For better or worse, this quote suits me. I am both an academic risk taker and a contrarian–not afraid to challenge the status quo--and not afraid to leave my comfort zone for unique or promising pursuits. My interests and pursuits often live at the bleeding edge-their power, innovation, and impact often not appreciated until many years later.
Some might find the time to adoption frustrating- I don’t let it bother me. I have one of the best jobs in healthcare. Throughout my career as an undergraduate, medical student, resident, fellow, and faculty I have combined my love of technology with my interest and passion for human biology and medicine into a career that's uniquely my own.
Healthcare is a conservative profession-- not always receptive to change—many discoveries take 15 years or more to reach widespread adoption. Despite these difficulties, I have been single-minded in my pursuits. As Assistant Dean for Educational Technology for the School of Medicine and as Director of the Human Simulation and Patient Safety Center, I have been able to meld my passion—technology— with my core strengths of innovation and creativity—in an attempt to make healthcare safer for our patients and more enjoyable and efficient for its practitioners.
As I learned from great innovative companies like Apple Computer, innovation often comes by bridging two (or more) disparate fields. Many of my most successful projects have used this philosophy. Many of my projects have been “firsts”—initially ignored or even scorned, but later adopted or copied into commercial offerings. Many have won awards, been cited as a “best practice,” or have been made commercially available --all affirmations of my early hard work. Some of my most promising work (e.g. the use of digital games-based learning and the use of simulation to enhance the safety and efficiency of clinical trials) are only now coming to fruition.
Education and Clinical
I credit Julian Biebuyck, the Chair of the Penn State University Department of Anesthesiology, with catalyzing my career. I interviewed at many of the top anesthesiology programs in the country. My second interview was at Penn State. It was with Dr. Biebuyck I shared my interests, passions, and dreams of melding technology, healthcare, and education. He embraced my vision and offered me unique opportunities as a resident--one that gave me enough flexibility to achieve my goals. As I interviewed around the country my thoughts returned to Penn State. No other program, including those in my native California, were a better match for me. I matched and matriculated to Penn State in 1991 to begin post-graduate training.
Dr. Biebuyck’s support bore fruit —while still a resident, I won several awards both individually and with collaborators as a member of the Penn State Cognitive Science Laboratory (e.g. first place in the Scientific Exhibits at the Annual American Society of Anesthesiologists Meeting). The Cognitive Science Laboratory was one of the first simulation centers in the country. At Penn State, I served as Chief Resident and was was appointed to my first national committee, The Electronic Media and Information Technology (EMIT) Committee of the ASA--where I served for the next 10 years.
During my residency, I developed multi-media and web-based programs with another close mentor, Dr. Kirk Shelley. Several of my projects won awards and gained international recognition, especially those leveraging the newly emerging internet.
My fellowship training was in neuroanesthesiology with an emphasis on neural monitoring. My clinical mentor, Garry Russell, launched a successful perioperative neural monitoring service where we monitored close to 800 patients per year. In addition to mastering neural monitoring, I continued to expand my interests in the technology of learning. Although my research interests moved away from clinical medicine, my love of neurosurgery bleeds over into my teaching–being one of my preferred subjects to discuss with the residents rotating through the operating rooms and the focus of several of our simulation initiatives.
In 1999 I was recruited to Duke University as a member of the neuroanesthesiology group and became the Director of Informatics Education for the Department.
Rather than pursuing bench research, I chose simulation and technology as my academic pursuits. I viewed simulation as an opportunity to leverage my passions for technology and healthcare while getting involved in a rapidly emerging area. While still a resident, I worked primarily on non-simulation technology involving the World Wide Web, but I appreciated the potential of simulation--both for its growing impact in healthcare and as an opportunity to leverage my innate strengths.
In 2001 I was asked to direct the Duke University Human Simulation and Patient Safety Center. I positioned our laboratory to both deliver education and to take advantage of the emerging emphasis on patient safety. I wrote a proposal, in 2003, to launch a new patient safety research program at Duke. The program was approved and was initiated with the hiring a full-time human factors engineer. Our research program currently focuses on both theoretical and applied patient safety and quality issues. The model I implemented at Duke-having clinicians and human factors engineers work side-by-side, has been emulated by many and been cited as a model for healthcare patient safety for the 21st century.
Most of my personal work has been in the realm of serious games and virtual environments. I currently am the programatic lead on a multimillion dollar project named Immersive Learning Environments @ Duke (ILE@D) to build a virtual learning platform for healthcare. Although the platform is based within the School of Medicine, the impact of our work will be felt throughout the healthcare continuum. I plan to use this platform to focus on the emerging trends / needs of continuous professional development, global health and assessment.
In addition to winning first place in the Scientific Exhibits at the American Society of Anesthesiologists Meeting in 1994, my work has won many other awards. I was the recipient of a research award for scientific abstracts at the 2003 International Meeting on Medical Simulation for my work on online simulation case repositories. I co-authored a paper that won a “Simmy Award” for the Most Innovative Educational Strategy at the 2011 International Meeting on Simulation in Healthcare. Most recently, I received the International Anesthesia Research Society's 2013 Teaching Innovation Award for my work with games-based learning / simulation.
I have been continuously extramurally funded for almost a decade. The majority of my funding has been for novel uses of simulation to enhance the quality and safety of healthcare. The unifying theme of my research efforts centers around the use of technology—both in education and patient safety and typically bridges the domains of informatics, educational technology, and simulation. The combinations of these interests leads to unique projects and opportunities. My funding has come from from the military, foundations, industry and the NIH. I believe my long track record of funding points to my ability to identify and position myself early in emerging areas. My proposals consistently receive high marks for innovation and potential impact. I am particularly proud of the fact that my first R01 (focusing on learning curves in clinical trials) was funded on the very first submission.
I have participated in national panels of peer-review for grants for the Agency for Healthcare Research and Quality, including Clinical Informatics to Promote Patient Safety Special Emphasis Panel (HS-01-006), Transforming Healthcare Quality Through Information Technology (THQIT), (HS-04-010), and Healthcare Quality and Effectiveness Research (HCQER).
Science of Achievement
I am an avid reader. As I investigated the feasibility of games-based learning in healthcare, I came across the field of Positive Psychology. This emerging domain, pioneered by Martin Seligman at University of Pennsylvania, has since profoundly influenced my views on achievement, success, and mentorship.
I discovered Positive Psychology after asking myself what makes a commercial video games so addictive (and wondering if the same dynamics might be leveraged in education). By exploring this interest, I learned of Flow (a pleasant state of concentration so profound that nothing else seems to matter). As I read more widely in the domain, I became convinced Positive Psychology will have a profound influence on learning. Games-based learning, more than any other pedagogy, satisfies the requirements laid forth in Positive Psychology as well as aligning with traditional learning theory. As I realized this, my commitment to the concept of games-based learning in education and assessment deepened. Concepts such as intrinsic motivation (Angela Duckworth), Flow (Mihaly Csikszentmihalyi), and the development of expertise (K. Anders Ericsson) all speak deeply to me and have greatly influenced my work.
As an example, consider Ericsson's concept of Deliberate Practice--the development of truly (measurable) expert performance requires thousands of hours of practice and intense self-reflection. Lectures are passive and don't offer the opportunity to act and then reflect. Mannequin-based simulators offer opportunities for deliberate practice, but scalability is hampered by their high cost, limited learner throughput, and need for highly trained facilitators–there simply are not enough simulators or facilitators to handle the sheer number of hours required. What is needed is a robust, scalable, easily accessible, personal, interactive learning platform that enables learners to practice new skills, make mistakes, receive immediate feedback, and reflect on how they might improve—a scalable platform for deliberate practice. I believe serious games and virtual environments fit this niche.
Administrative and Service
At Duke, I serve on numerous committees in the medical school and the University--primarily focusing on education, technology, and innovation. Departmentally, I serve on the Residency Evaluation Committee and the Senior Education Council. I have served on Chair evaluation committees and was a member of our national search committee for residency director of our department.
Nationally, I was an inaugural member of the American Society of Anesthesiologists’s Committee on Simulation Education. I was honored to be one of the founding board members and one of the three inaugural elected officers of the **Society for Simulation in Healthcare**. I directed and moderated the Society's electronic communication during the early days--the listserv I developed and maintained, MedicalSim-L , became the official communication channel of the Society. Because of my efforts, Duke is recognized as one of only six Founding Sponsors of the Society for Simulation in Healthcare—a Society that has shown explosive growth over the last 10 years. During my tenure on the Board of the Society, we launched the peer-reviewed journal, Simulation in Healthcare ( indexed by Indicus Medicus). I remained on the Editorial Board of Simulation in Healthcare until last year.
As a SSH grew and mannequin-based simulation became more commonplace in healthcare, I turned my focus to the emerging area of virtual environments and serious games. I founded and co-Chaired the Society's special interest group on virtual environment/serious games through 2014.
My domains of interest–healthcare education, technology and quality are not the prototypical bench science pursuits. Those with traditional academic careers (e.g. bench scientists) have a hard time understanding what it is I do. In fact, it has been difficult to find traditional academic mentors due to the uniqueness of my niche.
Time has reinforced the true importance of mentorship. I am forever thankful to the mentors I had thus far in my career-several took an interest in me even though they didn't fully understand my passion. It has been challenging given my interest in cutting / bleeding edge technologies to find mentors at the faculty level—there simply aren’t others that do what I do. Despite this, I have had a modicum of success despite this shortcoming by seeking strong mentors that although they do not understand my domain, do excel excel at mentoring.
It is my hope, by assembling an outstanding, passionate and productive team, we will help change the definition of a 'traditional' academic career.
More importantly, I’ve tried to pass the mentoring I've received forward—and have found I especially enjoy mentoring certain types of individuals—those that have intrinsic motivation andpassion for success—qualities Angela Duckworth (another positive psychology researcher) refers to as “Grit.” Gritty individuals, in my experience, are much more likely to find success in their academic endeavors. One of my mentees, Ryan Fink, is investigating the correlation of Grit with academic success.
I’ve found an ever-expanding number of residents, nurses, fellows and young faculty are interested in developing simulation and patient safety as the focus of their academic pursuits. I receive supreme satisfaction in helping talented individuals realize their potential. I plan to expand my circle of interprofessional mentees in the next phase of my career, supporting and mentoring them .
My vision for the future of healthcare education includes evidence-based, technology driven pedagogy that relies heavily on self-directed, self-paced learning and peer-to-peer interaction. Learning modules based upon gaming technology maintain a great deal of the interactivity of mannequin-based simulation with the added benefits of scalability, distributability, and personalization. In addition games-based learning allows us to augment reality (e.g. speed up or slow down time, add visual cues in the environment, etc.) as well as collect and analyze every choice, action, or interaction made in the computerized environment. Analysis of the data sets generated by each learner or aggregates of learners, through an emerging field called learning analytics, will allow us to focus limited resources on those that truly need help. Through real-time dashboards, learners who are struggling can be redirected to their peers who "get it" (much like Khan Academy) or be targeted for direct facilitator tutoring--a much more scalable and efficient solution than anything available today.
Resource intensive methods of teaching (e.g. mannequin-based learning, or team-based learning) will not be eliminated, but instead will be reserved for critical times (such as capstone exercises, psychomotor, or "soft" skills). Ultimately, learners will participate in blended learning--optimized for efficiency and efficacy through the lens of learning analytics.
As I approach the next phase of my career, I plan to continue my professional growth. I will continue to develop, study, and publish on how games-based learning fits into the continuum of healthcare. I am particularly interested in the potential role of games-based learning in high-stakes assessment. Along the way, I will continue to mentor the next generation of academic physicians interested in learning–only accepting those that are passionate (or as Angela Duckworth says, "gritty") about their work. Ultimately I hope to have an impact on the engagement, efficiency, and the safety of medicine in the 21st Century.