An unsimulated success

Israel's Dr. Amitai Ziv has been awarded the Bronfman Prize for his work in risk-free medical education.

battlefield simulation (photo credit: Sheba Medical Center)
battlefield simulation
(photo credit: Sheba Medical Center)
People are not born doctors, nurses, paramedics, social workers or fighter pilots. In professions where lives are at stake, it's best to use simulation to determine whether someone's suited for the profession, and even after they pass this hurdle, they should be trained and tested by simulation. It was for innovation in the field of medical simulation - simulation which can be adapted to other professions - that Dr. Amitai Ziv, an Israel Air Force combat pilot who became a pediatrician and then a medical administrator, recently received the $100,000 Charles Bronfman Prize. Some 30,000 people have passed through MSR ( - a Hebrew acronym for the Israel Center for Medical Simulation - that he founded at Sheba Medical Center in Tel Hashomer six years ago as a non-profit organization, saving countless lives and improving professionals' clinical skills. Some of its 30 unconventional classrooms look like Hollywood sets of battlefields, surgical theaters or delivery rooms. "There are no lectures, only hands-on learning," he declared in an interview with The Jerusalem Post. The 48-year-old MSR head and deputy director of Sheba in charge of risk management and patient safety was honored at the Israel Museum in Jerusalem two weeks ago, after receiving the prize in New York in May. Instead of applicants to medical school being chosen solely according to their matriculation and psychometric scores, thus letting in people who aren't suited, actors playing patients are used to test communications skills and empathy. Unsuitable applicants are thereby filtered out. And after graduation, instead of "practicing" on patients before internship or after passing through various stages of specialization, doctors perform "invasive procedures" and interact with the actors and their "families" to see how they cope and learn from their mistakes. THE 550 INTERNS who graduate each year from Israeli medical schools take a five-day course at MSR before they start working. Situations involving "drunk" patients, relatives whose loved one has just died and other high-pressure scenarios are simulated. All sessions are videotaped from several angles and followed by debriefings with a physician. "Amitai Ziv was a fighter pilot who applied the lessons learned in flight simulation to that of his chosen profession of medicine. His pioneering effort in the education of young doctors is the kind of creative breakthrough that my children sought to identify and honor when they established the prize," said Charles Bronfman, the Canadian philanthropist for whom the prize was named and endowed by his son Stephen, daughter Ellen Bronfman Hauptman and Claudine Blondin Bronfman in honor of his 70th birthday. The previous two winners were Jay Feinberg, founder and director of the Gift of Life Bone Marrow Foundation in the US, and Dr. Alon Tal, an Israeli environmentalist and founder of the Arava Institute for Environmental Studies. The prize celebrates the vision and talent of an individual or team under 50 whose humanitarian work has contributed to the betterment of the world. Ziv was chosen from among a large number of nominees by a panel of judges comprised of former justice minister Dan Meridor, former World Bank president James Wolfenson and Rosalie Silberman Abella, a Supreme Court justice from Canada. "He embodies the very qualities that have guided our father throughout his lifetime," said Stephen Bronfman at the ceremony, "and represents the best of the young generation's values, commitment, creativity and energy. His insightful and innovative work responds to the imminent need for reshaping the way medical care is delivered." Simulation has been used unsystematically since the early days of medical practice. In the 16th century, mannequins (called "phantoms") were developed to teach obstetrical skills and cut high maternal and infant mortality rates. Today, said Ziv, it's common for medical students to do their first injections on an orange, practice suturing on pieces of cloth, rehearse medical interviews while role playing, or practice physical exams on actors. SUCH SIMULATION-BASED medical education (SBME) began many years ago in various parts of the world, acknowledges Ziv, who was born in Israel to parents who came from Canada. But abroad it was unstructured. "MSR is unique in that it was the first to build a national simulation center that integrates all the medical, nursing, paramedic and other professions," he explained. Applicants for the Technion's Rappaport Medical Faculty and Tel Aviv University Medical Faculty are all sent for half a day through MSR to face actors at a variety of "stations" and see how they function. The Hebrew University Medical Faculty and Ben-Gurion University's Health Science Faculty do not yet use MSR to sift out unsuitable applicants, but do use the center for later stages in doctors' training. Newly minted physicians, for example, work on hi-tech mannequins that cost as much as $200,000 and bleed, present symptoms, have vital signs such as a beating "heart" and blood pressure that rises or falls. They can go into "convulsions" or suddenly suffer a "heart attack." More veteran doctors learn to perform laparoscopy (keyhole surgery), angioplasty (insertion of tiny video cameras, catheters or supportive stents inside clogged and weakened coronary arteries), deliver babies and do a wide variety of other procedures without first trying them out on real people. Deputy directors of hospitals who are responsible for patient safety and risk management also come to learn. MSR also trains the trainers, and some 800 have passed through MSR, which is not budgeted by the government but receives institutional fees for services. Emergency room doctors and operating room and other advanced nurses practice procedures and teamwork at the center. "Most medical errors," added Ziv, "come from a lack of teamwork. These can be prevented with simulation." Emergency room teams learn to work in a coordinated fashion, as do child abuse and domestic violence detection and treatment teams, Israel Defense Forces and Magen David Adom medics and others. "At MSR, one is allowed to make mistakes. Medical professionals are busy with defensive medicine, to protect themselves from lawsuits. Simulation lets them make mistakes and learn from them," Ziv said. He noted that a study at the US National Institutes of Health found that about 100,000 Americans a year die due to medical errors. "That's as if a jumbo Boeing 747 crashed into the ocean every day," he said. The corresponding estimated figure of Israelis is 2,000 per year - four times the number of road accident victims. During the Second War in Lebanon last summer, IDF medical teams on the battlefield had been trained at MSR, and said the training helped them save lives. Soldier mannequins come in blood-stained uniforms, and virtual-reality computers produce the noise of helicopters. Rockets and mortars sound as if they are falling nearby, making the scene seem real. MSR's 40 staff members consist of physicians, nurses, social workers, paramedics, psychologists, educational workers and technology and logistics; they work together with some 150 specially trained freelance actors. SINCE ITS founding in 2001, MSR has become a model at medical institutions around the world, including the famed Mayo Clinic in Minnesota, Case Western Reserve in Cleveland and McGill University in Montreal. As an Israeli center cannot hope to serve as a model in Arab countries, Mayo Clinic staffers were trained by MSR and are now helping Saudi Arabia develop SBME. In addition, Amharic-speaking Israeli actors recently helped a visiting group of Ethiopian physicians take part in role-playing scenarios connected to the treatment of HIV/AIDS patients. "Methods developed and implemented by MSR are revolutionizing the manner in which physicians and allied health personnel are trained," said Dr. William Dunn, medical director of the Mayo Multidisciplinary Simulation Center. Ziv's impact and accomplishments "are unsurpassed by any other physician dedicated to medical education. His tireless efforts have given birth to the pre-eminent center in medical education, utilizing the revolutionary and powerful means of experiential education. He has established a facility unlike any in the world. He's had an incalculable worldwide impact," Dunn continued. Professionals from Britain's National Health Service, the World Health Organization, the International Committee of the Red Cross, the US Centers for Disease Control and Prevention and other institutions abroad have also come to see what MSR does. "We don't do active marketing. They come to us," Ziv noted. He was officially nominated for the Charles Bronfman Prize by Sheba director-general Dr. Zev Rothstein, who has supported his venture from the beginning. Prof. Shimon Glick, former dean of BGU's medical school and currently the Health Ministry's ombudsman who deals with claims of medical negligence, has known and admired Ziv for years, and was one of those who recommended him for the award. "His doctoral thesis on peer evaluation of medical students was not only awarded a prize for excellence, but also exemplified the unusually high stature that [he] had among his classmates," said Glick. "Gradually he became one of the world's authorities on the use of simulators in medicine." Ziv founded the first medical simulation center in Philadelphia, conducted major research and outcome studies with leading US medical schools, and then left behind many opportunities to return home in the hope that he could change the culture of medical training not just in Israel but around the world. And he did. His skill, continued Glick, "is so vital in an era where super-specialists' views are often narrow and limited in scope... This ability combined with Amitai's unusual leadership ability enables him to organize and activate teams to produce major innovations." The first thing one learns in medical school is the Latin phrase Primum non nocere (First Do No Harm)," Ziv concluded at the reception in the Israel Museum's sculpture garden. "But you also need a human touch, transparency, honesty and modesty. You have to learn from your errors. That is the message of MSR."