00:02.65

Zahra Massicotte

Welcome back to Tech in EdTech, the show where we dig into the realities of learning and technology advancements. I'm your host, Zahra, and today we're going somewhere I've actually been genuinely excited to explore: healthcare simulation and workforce training. My guest today is Francisco Castelblanco. Francisco is a DNP, a registered nurse, and the MAHEC director and chair of Continuing Professional Development at the Mountain Area Education Center in Asheville, North Carolina. Francisco oversees more than a thousand educational programs a year, reaching roughly ten thousand health professionals across the state. He's a cardiac nurse by training, an adjunct professor at UNC School of Nursing, and someone who's spent a career sitting at the intersection of clinical education and health equity. He's also been recognized for that work, including receiving the Martin Luther King Jr. Emerging Leader Award at MAHEC. There's a lot to get into today around simulation, modality choices, rural training challenges, and how we build the healthcare pipeline earlier. Francisco, welcome to the show. It's so great to have you here today.

01:20.44

Francisco Castelblanco

It is a pleasure to be here. Thank you very much.

01:22.46

Zahra Massicotte

Yes, absolutely. So Francisco, clearly you wear a lot of hats. To start, can you tell us a little bit more about yourself, and when someone asks you what you actually do at MAHEC, how would you describe it?

01:37.46

Francisco Castelblanco

Sure, absolutely. So, so MAHEC is part of the North Carolina AHEC system. And the AHEC system is a nationwide program that started about fifty-five years ago in order to fund rural training right across the country. And the North Carolina system is one of the most developed ones in the country. And MAHEC is the largest single AHEC in the country. And so we're located here in Western North Carolina, in Asheville in particular. And we train residents, we train medical students, we have clinics. And my area is continuing professional development. And so we do a lot of programs for not only the learners- residents, medical students, nursing students- but also healthcare professionals. So current nurses, physicians, allied health, pharmacy professionals that are needing to continue their education and stay updated with the latest modalities, with the latest guidelines. And that is basically what a thousand programs a year can constitute.

02:49.62

Zahra Massicotte

Amazing. Thank you for that. So the center's mission is tied very closely to recruiting, training, retaining healthcare providers in Western North Carolina, as you mentioned. When or how do you think it was recognized that there was a gap in learning that, like a lecture, online module, or traditional clinical rotation couldn't fully address?

03:16.46

Francisco Castelblanco

Yeah, absolutely. So I would say probably about thirty-ish years ago, different healthcare organizations and even academic institutions recognized that PowerPoints and lectures were not enough, right? We've all been in those classrooms in those settings where you have death by PowerPoint, where the provider or whoever is lecturing, and you'll retain anywhere between 25 and maybe even up to 40% of a lecture in a classroom setting. Online modules may even be less depending on how they're set up. And so the idea behind simulation is how do you reinforce not only the knowledge, but some of those very practical skills. So it has to do with kinesthetic learning, right? And like actually going through, because your brain will remember a little bit more than it would by doing something, right? By practicing something. And it develops that muscle memory, which is incredibly important in healthcare, right? And you learn so much more from mistakes. We all do. We all remember mistakes that we made. And so, simulation really addresses that in a very safe environment, right? Simulation is about suspension of disbelief. And we make sure that these individuals are in a safe place that we go over with them, saying, “It's going to be okay. Don't worry. This isn't anything that can harm you.” But the simulations can get very realistic and, you know, you go into that fight or flight mode as a provider of like, “Okay, what do I do? What do I do?” And so, the simulation helps to train them and train that muscle memory and connect them with the knowledge and the practical hands-on learning. And so, simulation has been part of healthcare education now for a number of years, and it's continuing to evolve, right? It's no longer the simple mannequins and like pretending that like they're breathing or they're doing this or that. Mannequins now can blink. They can, you know, have tears coming out of their eyes; their pupils can dilate; you can hear heart sounds, lung sounds, and they're continuing to evolve into other modalities such as virtual reality. And different technology, that is really something that is exciting, right? Because these younger learners grew up with this technology, right? And so they're used to it. They understand it, and they react to it, and they learn better.

06:00.50

Zahra Massicotte

Really important points that you brought up there. And I like how you how you frame that with the practice. And, you know, we learn better when we make mistakes. So I really love how you framed that. And it's amazing. And we'll dive into how in-depth some of these simulations have gotten. And, you know, in healthcare, some of these situations are very high stakes, right? So you're giving the students an opportunity to have a lower risk environment. But for some of those stakes that are very high, how would you decide that a scenario actually needs simulation time, you know, where practicing in the real life would be too risky or rare or just not available?

06:45.72

Francisco Castelblanco

Oh, absolutely. So we have curriculum design instructors who actually sit with, say, the residency director who comes to us and he says, “OK, I want my surgery residents to have this kind of experience.” And so we will sit with them, and we will develop the type of simulation that best fits that group. And sometimes we have learners that are middle school, high school students that are coming in, and so very different level that we also develop very specialized training for them so that they can get the best experience out of it. I'll give you one example in both. One, for say, surgery residents. When they have the ability to practice on different kinds of technology. So we have something called a laparoscopic mentor, which is a machine where they can come in and practice laparoscopic surgery. So they are holding the same equipment that they would be holding in an operating room, and they're looking through a screen, and the screen is simulating gallbladder surgery, for example. And so, as they're moving their hands and manipulating what would be the extension of the equipment inside an individual's body, it is haptic. And haptic means that it is feeling very real. So it's pushing, it's gliding easier, it's… it's harder. It's pushing against what it is showing you on the camera, could be a different organ or a different part of the gallbladder. And so they're getting that feel, right? That sense of what it actually is like to do this surgery, but not on a real person yet, right? So they might be very first year, you know, couple of months into their surgery residency where they develop that skill, they develop what it feels like and understanding some of the implications of things that could happen, because you can set up the lap mentor to be like, okay, this is going to happen now. And the resident doesn't see or know that. And then when they're in surgery, and they're actually doing the surgery on real patients, they've already had experience doing this, right? They've already had that feel of what it feels like to move the equipment around, to tie sutures, right? Because they practice tying sutures in the same manner way before they touch a patient. And so, it gives them that complete experience and gets them better at it without touching a patient yet. And then I'll give you another example. We have middle school students that are interested in health careers, and we bring them here in the summer and during the year, and we will do a pig heart dissection. So we have pig hearts that you can get, and the students are then taught a little bit about cardiovascular, and I make them jump up and down, and I love teaching. This is one of the favorite ones that I teach.

10:13.61

Zahra Massicotte

Sounds like a fun task.

10:14.86

Francisco Castelblanco

I have them jump up and down, and like, okay, you're going to measure your heartbeat now, and then you're going to sit, you’re going to relax, and then we're going to talk about, does anybody in your family have this kind of experience? And we talk about heart attacks. We talk about cardiac arrest. We talk about what to do in emergency situations. And meanwhile, there's a pig heart in front of them. And they're wearing gloves, and they're smelling this pig heart and looking at it. And they build up that excitement to touch these pig hearts and to get in there. And so then for the last part of the class, then we start talking about the different components of the heart. And I have them find, “Here's the valve. Here's this artery. Here's that artery.” And pig hearts are very similar to human hearts, so it's a beautiful setup for it. And then they understand not only what the body does, in terms of all of, you know, the different functions of the heart, but they've touched it, they've felt it. And then I talk about being a nurse in the OR. I talk about being a surgeon in the OR. Talk about being a cardiologist; about being a rehab technician. So then we're connecting careers.

11:27.26

Zahra Massicotte

Mm-hmm

11:27.32

Francisco Castelblanco

And I say, this is what these jobs can make. This is the type of schooling that you need. And so, it puts that idea in their head. And once again, they go home, they're excited. It's like, “Oh, maybe I want to do this. Maybe I want to do that.” Some of them may never want to do anything like that. And so then they at least get an idea of it. And so that's the exciting part about simulation.

11:54.62

Zahra Massicotte

Right, they come back with that knowledge. And it's good to know. I don't think I can do that for a living even though, you know, they might have an idea of what it's like to be a doctor or nurse or whatever, but then when they're in that scenario, they really get that feel. So that's… that's amazing. Both of those examples were great, and how amazing and advanced technology is getting, and how life-like these simulations are. So thank you so much for describing that. And it made me think of a couple of questions. And one, you kind of answered, and it sounds like you customize it quite a bit for whether it's someone, you know, like in middle school or high school, a first year on healthcare student, or, you know, someone coming back for their continuing learning that the design of the simulation is going to change a little bit or the way you approach it, certainly.

12:45.08

Francisco Castelblanco

Yes, absolutely. And so one of the frameworks that they use is called Schön's. And Schön's framework is all about learning and adapting to the type of learning and make sure that the outcomes answer that so what. Yes, you were exposed to the information, you had an experience, but did it change the knowledge? Did it change that competence? And that is the ultimate goal, right? With education in general. And I think it's, you know, making sure that we are adapting whatever type of scenario to the types of learners, and you develop objectives and you measure them and you try to make it, especially in simulation, as realistic as possible, right? But at the same time, maintaining that safety for the learner. And it's particularly important for the younger learners. We've had students who are in middle school delivering babies, right? Because we have the mannequins that deliver the babies. And there were a couple of objections to that, right? That, you know, a parent wrote in like, “I didn't know that my son would be delivering a baby, right?” Or exposed to that.

14:00.88

Zahra Massicotte

Yeah, sure.

14:01.79

Francisco Castelblanco

And, you know, this is not a sex ed class that we teach. You know, we're literally showing them, like, "This is how a baby comes out," right? And this is what you would do as a nurse; as an OBGYN. And so, you got to be careful, right, with some of these.

14:20.44

Zahra Massicotte

Yeah.

14:20.90

Francisco Castelblanco

And we've learned our lessons in that regard. But at the same time, we've also instilled in some of these people, like, “That's what I want to do.” Like, and they're so excited about that. And, you know, people are empowered to become something because now they have a better idea, right? They've seen it, they've experienced it. And, in some cases, talking to some of the different healthcare professionals, because we do have physicians of all different specialties in our sim center who do help with education, even the education for middle school students because they love teaching and they love inspiring that generation. So that's, I think, one of the greatest parts of MAHEC in that. We have so many learners, and our faculty are just passionate about teaching and making sure that they're preparing students all across those pipelines and pathways, right? Going back to middle school, not just the residents, not just medical students, but all across that spectrum.

15:26.04

Zahra Massicotte

That's really great. It must feel really good to be in the room when you see that student have that moment of like, “This is so cool. I want to do this. Like this is what I want to do.” I want to go back to a couple of things you brought up about, you know, still tying this back to learning objectives and competencies. So simulations, obviously, they're so realistic now. Is there a point that you think- and I think probably, I mean, generally my argument has been - and in most simulations that I talk about, the more real, the better. But do you think that's always true? Is there any point where it stops helping or can get in the way of learning? 

16:08.31

Francisco Castelblanco

So we make sure that before any simulation, whether it's with middle school students all the way up through residents or even fellows, right, who graduated residency, that we sit with them and we let them know, “hey, this is a safe environment. We will put all these different kinds of situations in front of you, and you will be debriefed afterward.” And so making sure that they understand that their mental and emotional safety is a priority for us and that it is going to be okay, because you can quickly forget. And I'll give you one example of something that we do that our team developed here. We do codes, right? And code training for mock codes, meaning that, like, a patient's heart went into a rhythm that is either not life-sustaining or just completely stopped, right? They had a cardiac arrest and stopped. And so this is something that all hospitals do. And how systems and all different kinds of sim centers do in terms of training. But we added a different component. We blindfold the lead for this mock code. In other words, we walk in and like say, “Hey, this is your patient, Mr. Smith.” And, you know, we are going to blindfold you now and let you know what is happening with Mr. Smith. And so they get blindfolded, and they're standing or sitting at the edge of the bed, right? In a chair or just standing right at the edge of the bed. And then we say, “Ok, Mr. Smith is not breathing. What would you like to do?” And we walk them through that scenario. And at first it starts slowly. It's like, okay, he's still not breathing. What would you suggest that we do? And being blindfolded gives you a whole different experience because now you're going through in your brain, “Okay, what is that algorithm? What do I do?” But you're not relying on the visuals. You're having to rely on what you're hearing. And you're like, “Ok, put oxygen. Give them oxygen.” And then we don't say a whole lot more on purpose, right? We want them to start asking questions, right? And one of the main questions that we're looking for right in the very beginning is, is there a heartbeat? Right? Can you feel a pulse? Right? And so to start guiding them into it, and if they don't ask that right away, after about two or three minutes, we're like, okay, the patient is turning blue, right? Even though we're giving them oxygen, we haven't done anything more, right? And like they're going through all these things. It's like, “Well, what medication did they take?” You know. “Did we do some kind of procedure or anything?” And like we're answering all the questions, but really the patient's heart just went into this rhythm, and they're like, “Oh yeah, get a monitor on, start doing CPR.” And so then, “Okay, here's nurse Jackie, and Jackie is here for you. What would you like her to do?” And he's like, “Okay, nurse Jackie, start compressions,” right? Because if their pulse isn't, you know, you can't feel it, then you have to get that compression going so that that heart is now pumping blood to the rest of the body. And the most important part is the brain. And then we keep walking them through. But it is an incredible experience that, to your question, can be scary, right? Because you're not quite sure what's happening and you're blindfolded. It's like a scary movie at times in one of, you know, a challenging situation that happens in medicine, which is a code. So you've just made it even harder. But the outcomes and the evaluations are spectacular. Because then these students, and most of them are medicine residents, so internal medicine, hospitalists program, they are the ones who are running codes in the hospital. And so then they are now going in much better prepared, right? And I mean, there's code teams in the hospital, but they always defer back to the residents to help run the codes because that's how they train them. But it used to be kind of like sink or swim, and it was never pretty… never pretty. And so we made an initiative of ours because we do have that internal medicine residency to make sure that these residents are trained much better and really develop that confidence in running these codes. And so, it's exciting work. I love that the simulation center came up with that blindfolded code idea.

20:55.22

Zahra Massicotte

I love that.

20:55.38

Francisco Castelblanco

And I hope others do too.

20:57.24

Zahra Massicotte

What a great approach. That's a really, really, really great example. Thank you for sharing. So I want to switch gears a little bit. You talked a little bit about modality. And so, say you've decided on a scenario worthy of a simulation, but the next question is, what's the best tool for learning? So let's dive into how you would think about that. And the first one being VR, you know, which I've talked about in a recent episode of this podcast as well. But VR is getting a lot of tension, and specifically, in healthcare education and workforce training. In healthcare simulation today, where do you think VR earns its place, and where does a mannequin or simple task trainers, or, you know, some of the other things that you're doing work better? Or, you know, maybe there's just different scenarios for different tools.

21:48.25

Francisco Castelblanco

Yeah, absolutely. There's very different scenarios and different equipment. And a lot of it goes back to that initial meeting with whoever, right? Whether it's a school or whether it's a nursing program or residency program. And we ask them, what is the objective? What do you want them to walk away with, right? And then what types of learners are there, right? And understanding that there are different modalities that could achieve different results. So, some are very much task-oriented, meaning you got to develop a good competency for such and such, right? If you're tying sutures and it's a matter of doing it, not only using the physical trainers, and by physical trainers, we have boxes, and it's literally a box, and it has, you know, what they would use in laparoscopic surgery, but it's very simple. It doesn't have the haptic part of it. And they practice tying sutures on fruits, right?

22:57.34

Francisco Castelblanco

Like we will cut open an apple, will cut open a lime, will cut open any different types of skin on a fruit. And sometimes we even use pig pieces, right? In terms of we use pig hearts obviously for some of those. But they'll use different pig components that will also help to simulate different types of skin or different conditions. And so, having them practice, you know, that hands-on can achieve that results. Now, if it is a simulation, or something that they want to achieve that combines things, that is much more of the critical thinking component, then we pull in our curriculum designer. And the curriculum designer has a lot of ideas of like, “Okay, what about using this and making it a combination of different equipment that we have?” Where can you can use VR, right? And or you can actually have people in the room, physically in the room, and they're also talking to you, right? They're also answering some of the questions. And so, it is a way of utilizing the really high-tech components of VR, but also having that feel and that sound and like, okay, you can touch them through the VR in theory, but you could also touch your patient. And the standardized patients that we have are the actors, right? And these are the actors who are like, “Yes, I'm having chest pain.” And, you know, they're simulating it at the same time. And in that part, to me, compounds the experience. It gives it just such a strong, strong sense of reality because they're seeing it, they're hearing it, and they're touching it, you know. And so, you have all of those components at the same time happening. And so, I do think that the future of VR, the future of some of this technology is, number one, using it in the right setting, right? Depending upon those objectives, making sure that you're really asking the right questions before you develop anything.

25:12.98

Francisco Castelblanco

You know. And then number two, constantly improving, have to get better. Learners of this generation are learning very, very quicker than we did, right? They're developing these skills at a higher pace, and medicine needs them to, right? Patients are sicker; they're older, they have so many more complex chronic conditions that, you know, the patient doesn't just come in with one thing. No, they have three or four, and they're 92 years old, right? And they're on 27 medicines, and you got to figure out all of these different things. So, the scenarios are getting more complex on purpose, because we want these students, particularly the residents and med students and nursing students, to develop those critical thinking skills. And so, it's utilization of all of the tools at times, some in combination, some for different specific types of training and objectives. But it's really making sure that we design them for those learners and the objectives.

26:25.78

Zahra Massicotte

Yeah, I love that, how you're tying it back to the specific learner. What, you know, how did they learn best? And what's that goal? What's that objective? You're not just using a simulation to use it when you know a piece of fruit will work just fine. You don't need the expensive equipment. Like things like that are really great examples. So something that sets MAHEC apart from simulations that not only happen in your great state-of-the-art center, but you bring it out to the field and communities. And it sounds like you're very well connected to what's going on in the community, and how you're working together. Can you tell me a little bit about what changes when you're making that simulation happen on the… or you're still trying to have that learning impact when you're on the road? You're in someone else's environment versus, you know, having that dedicated center and equipment?

27:21.57

Francisco Castelblanco

Sure. I can give you a couple of recent examples. One, we went out to a camp, and we taught a wilderness first aid course. So it's in a camp setting, and you're teaching wilderness first aid. So, you know, what better setting can you do this in? And really, making sure that, like, okay, this individual- we bring a patient actor out there and a mannequin; we'll bring both, right? This individual just got stung by whatever. We don't know exactly what it is, but they're slowly going into respiratory distress and/or, bam, what do you do, right? They collapse down on the ground. And, you know, so we've practiced with very hands-on scenarios. Also, individuals who had a leg injury, who broke a leg, who, you know, maybe suffered some kind of, you know, injury while, like, chopping wood with a chainsaw or whatever the scenario is, and then look around. What do you have out here that you can use to make a splint to carry this individual out to be able to respond to them, right? In those emergency situations, being in those settings is priceless. It is priceless. We have a campus here, and we're fortunate in that we have some woods around us, and so we will do that on campus to a certain extent. We practice bear attacks because we actually have bears that come through Asheville, our campus, all the time.

28:57.91

Zahra Massicotte

Yeah.

29:00.47

Francisco Castelblanco

Like they'll walk through the parking lot. And they're, you know, at the moment, pretty harmless. Like they don't want to mess with humans. You know, they just walk through because, right now, the berries are not in yet.

29:10.04

Zahra Massicotte

Yeah

29:13.98

Francisco Castelblanco

And so we've seen a few bears these past couple of weeks, and they're just looking for food, right? Because we're really close to the parkway, and so we have those simulations of what to do if a bear attacks here on campus, you know. If somebody gets, you know, attacked by a bear. And so, we do train individuals in those situations. And then, a second example, this is something that we did a little while ago. We went out to a regional hospital for the Cherokee Nation, so a Native American tribe. It's about an hour and 15 minutes away. And we worked with them on how to improve a lot of different areas. So one of those were the respiratory emergencies that they have in terms of, like, how do you intubate? Which is one of those skills that is really important when a person stops breathing, right? And you have to try to intubate. It is not an easy thing to do, right. And so, we worked with them on, you know, rapid sequence intubation is what it's called, and making sure that their staff were comfortable and that they were trained, that… that we trained an individual to do this training right for future vigils there. And then another thing that we did with them, because they had a challenge with codes, we went in, and we did mock codes with them that were unannounced. In other words, we would show up one time at like four o'clock in the morning, one time at like six o'clock at night, you know, during those times where you don't have everybody ready to go, right? Where you're not expecting it, and you call a code and then you, literally, just essentially are watching what they do, how they do it, and then you debrief with them. It's like, “Okay, this is our suggestion, right? This is, you know, what we think could have gone better. What do you think could have gone better?” And we hear from them. And a lot of the times, they make these improvements because they realize, like, “Hey, this is something that we can change the location of, you know, the equipment here.” Or who responds to the code, or where's the respiratory therapist, right? At 4 o'clock in the morning, if the emergency medicine physician is not available at that moment because he's taking care of some other emergency, to intubate a patient. And so those are the things that I think are invaluable to some of these organizations and different settings, in that we can take it out to rural communities and make sure that individuals develop that training. And whenever we go out, one of our strong, strong suggestions is that they develop a trainer, right? And so, we do that Train the Trainer program with almost everything that we do, because you can buy a mannequin, right? And like here's, you know, a $100,000 mannequin that can do all the things. But, if you don't have somebody who is skilled in providing that education, who understands some of the components that we're talking about today in terms of learning modalities and communication and teamwork, all these different facets that go into it, when you're training with simulation equipment, then that mannequin is not going to be any any more useful than anything else that they have, right? So that part is a key to taking training on the road.

32:58.14

Zahra Massicotte

Yeah. And it's very clear that you're focused solely on that objective and like really creating the most realistic scenarios possible for these learners, whether that's in your simulation center, out in the physical wild. You know, you're creating all these files just like any, like, yeah, ER or any other scenario could come up. And, you know, certainly you're referencing some specific rural examples, you know. A  bear attack, you know, other wilderness-type injuries. But those are still transferable skills, even in the city. Or, you know, you could come across, and then you would know how to, you know, it sounds like, to adapt. And you're talking a lot about the critical thinking. So, it's not even necessarily like what it is, but the reaction to it and how you're thinking on your feet type of training.

33:53.75

Francisco Castelblanco

Absolutely.

33:55.03

Zahra Massicotte

So, I want to talk a little bit about how you would give like advice to other facilities trying to launch something similar. So, say there's, for example, an institution that has the equipment, but they're not quite sure; they haven't figured out how to the implementation piece, how to launch the program. If you're advising one of these programs, what do you think? What capability would you tell them to build first?

34:25.78

Francisco Castelblanco

Oh, the training staff. 

34:28.25

Zahra Massicotte

Yeah. Mm-hmm.

34:29.40

Francisco Castelblanco

That is the most, I think, that is our greatest asset in the Sim Center that we have. We have millions of dollars' worth of equipment in there. But that equipment is pointless without the staff who know how to apply it, to know how to apply the right types of modalities and the right types of equipment and develop the right kind of scenarios so that the student outcomes and the learning outcomes are actually achieved; that is gold, right? And simulation educators, it is a great career. It is an excellent career. It pays really well. And you have the ability to work at some of the top centers across the country, and so they are invaluable. Training that staff is probably the greatest asset that we have. Because you can get, you know, the fancy mannequins and the different mentor tools and VR tools and everything, but if you don't have the right staff to be able to go forward, you're never going to be able to get the best student outcomes. And so we focus on training our staff, entertaining our staff, probably as like our number one priority in the SIM Center.

35:50.34

Zahra Massicotte

Such a really important point. And do you think there is an implementation cost, and maybe this is it, that organizations underestimate in the simulation-based training?

36:03.03

Francisco Castelblanco

So the different components of your program, and we have the experience of starting it from scratch, right? When we started our SIM program, we were developing a surgery residency, right? And so, if you have a surgery residency program, where you're training these residents, you have to have a simulation center. That's part of the requirements. And so that's really the impetus why we started this. And then, I mean, from there, it just went forward of like, okay, we can do so many different simulations with so many different learners, not just surgery. But initially, we didn't know what equipment to buy, not buy, what they would use, not use. And, you know, we consulted with different simulation centers. We traveled around. And we bought most of the right equipment, but there were a couple of pieces that we didn't need, right? A couple of expensive tools that we didn't have, and this equipment was not used that much, right? So, you know, my recommendation is to understand what are the goals of your program, you know, whether you're an academic health center, you know, or a surgery program, or even a nursing education center where it's primarily nursing, what are the valuable components of it? And once again, I have to stress, it is the educators. It is those individuals that are doing that, because they can combine low-modality trainers, right? Meaning they're not high-fidelity mannequins or VR. And VR is even getting less expensive. And so, you don't need all the bells and whistles, right? You just need the right program with the right people to meet those needs that you're trying to meet locally.

38:07.83

Zahra Massicotte

Yeah, and equipment is very expensive. And so, there's this pressure a lot of institutions face with, well, we just invested, we got to use it, we got to make the best use out of it. So, I like all that thoughtfulness in your approach. And, you know, it could take a little bit of time and, you know, sharing your knowledge. And, you know, it needs to be a community, so folks can help you. We all have the same mission of making sure these learners are ready for the workforce. I noticed, shifting gears a little bit, I noticed there seems to be some debate on debriefing. So let's shift from, you know, the learner did the simulation, and now it's time to really make sure the learning sticks, right? How to make that learning sticky from that experience. What are the elements of a post-simulation debrief that can actually really change behavior and make it a little bit more impactful?

39:14.91

Francisco Castelblanco

Yes, that's a great question. Have you ever watched yourself on video, right? If somebody records you doing something?

39:23.67

Zahra Massicotte

Yeah, it's like cringeworthy.

39:25.50

Francisco Castelblanco

It is, right? And so, in these scenarios, right, where we do have cameras and in all our SIM rooms, right? And so we record the majority of simulations. And what we do is we build in time in that debrief so that we play, usually a good part of that video, right? And like, our, you know, our educators are once again highly trained and like, okay, here's a good piece, here's a good piece, you know, and so they mark it as they're going along. And so when we play that back for them, and you know, we set it up so that this isn't punitive, right? We want to learn. We want to figure out how we can do this better and what you need more practice in or what you think you can do better in the future, you know. And so, we set it up with that premise, and they watch the video, and then we ask them, “So what do you think?” You know. “What are your thoughts on that?” And they come up with way more things than we would have come up with, right? Because, you know, as human beings, we're so highly critical of ourselves, and especially watching the video of it.

40:28.82

Zahra Massicotte

Yeah. Right.

40:30.71

Francisco Castelblanco

You're like, oh, I did that. Oh, I could have done this or that, you know. Or like, I forgot to do this. And when you forget to do something, we had one doctor who forgot to tell the nurse to do chest compressions.

40:36.47

Zahra Massicotte

Yeah.

40:45.68

Francisco Castelblanco

And we didn't remind them. We didn't say anything. We just let the code go on. And no chest compressions were done during this code. And, like, the doctor was mortified; beside themselves. They're like, “I cannot believe that. I cannot believe that.” And like, you know, we told them they weren't the first, right, that this has happened before because it has.

41:08.12

Zahra Massicotte

Yeah.

41:08.98

Francisco Castelblanco

But I guarantee you that provider will never go into a code again and forget to, like, make sure that somebody's doing chest compressions because it's such a basic component, but it's something that we take for granted that, like, oh no, somebody's doing it automatically.

41:14.01

Zahra Massicotte

Oh, absolutely.

41:25.37

Francisco Castelblanco

But if you didn't order it and like, you don't say it, it's not happening. And then, you know, we ask them to sometimes write it up, you know, because then that reinforces things that they can do better, right? Like what would you do differently next time? Like we don't ask them to write their mistakes; we just say, what would you do differently?

41:30.81

Zahra Massicotte

Yeah.

41:46.33

Francisco Castelblanco

You know, so that it's framed in a positive way. Because, once again, that mental safety is so important for these learners. We want them to experience it, learn from it, and come back, right? And not be afraid of it. Not be afraid of like, “Oh, I'm going to be videotaped this next time.” You know, and the stakes are… It's a mannequin. So, you know, the patient's going to live, essentially. But in real-world scenarios, we want them to, like, remember, “Hey, I could do this better.”

42:21.09

Zahra Massicotte

Yeah. Well, in that video, almost, it adds a little bit of nervousness probably too. But that's almost good, right? Because it brings another element that is a little bit more life-like as well.

42:34.62

Francisco Castelblanco

Absolutely.

42:35.51

Zahra Massicotte

And, you know, you mentioned what I, you know, some of the things you're talking about, bringing up kind of teamwork a little bit, and that healthcare is very team-based, you know, nurses and many different specialists are working hand-in-hand with doctors, for example. But the education piece can often be siloed; you're on your specific track to your program. So what kind of gaps can be revealed during these simulations that, you know, are getting missed out on for lectures or other single-discipline trainings?

43:11.16

Francisco Castelblanco

So part of the impetus for us to start doing the blind codes came from the goal that we saw overall with many different scenarios, that one of the objectives was how do you improve communication, right? How do you make sure that there's communication among doctor to nurse, doctor to respiratory therapist, nurse to nurse aide? And it was a theme that became very clearly apparent to us that we needed to include communication aspects in almost every kind of simulation that we were doing. And so that is something that we try to embed as a primary or secondary goal for everything is understanding that healthcare now is so team-based, and it has to be, because everybody's practicing up to their higher scope of practice, right? They have to. Healthcare is not easy. There's not enough of any role. In healthcare, whether it's hospital or primary care settings, you have to do the max. And, to be able to do the max, you have to be able to have good communication of, like, okay, I'm going to do this, this, and that. I need you to do this. And making sure that like those teams are in close communication with each other. I'm going to give you one example of interprofessional education that I think is really, really the future of how we do this and how we do this a little bit better. We had scenarios where we had in the room a medical student, a nursing student, a social work student, and a pharmacy student. So there were four different disciplines in the room, and we had a standardized patient. So this was a live actor. And the scenarios had to do around substance use and care for this individual. And it was both in hospital settings and in outpatient primary care settings. And so, you had the team develop, “Okay, this is our patient, this is what they're experiencing.” Kind of develop that plan beforehand. And who's going to say what? What are we going to ask them? And then they go in, they do the scenario, and then they step out of the room, and then they debrief amongst themselves. And we're obviously observing this piece here, seeing how they communicate, what they would go forward with, and then they go back into the room, and they finish up the simulation. And that, to me, was one of the huge, huge eye-opening things for these students to be able to understand the value of all of those team members and what they brought to that patient care and ultimately patient outcome. And so, to me, that is part of the future of simulation and healthcare education in general is more of the team-based care because, as healthcare continues to evolve, we're going to need a lot more of that. And making sure that they're not only learning together, but learning to work together well, and even bringing them back after they're all professionals practicing to do some of these scenarios. So, that's one of those outcomes that I think about, you know. How do you improve that, and what do you look for that can really develop a higher level of competence?

47:06.08

Zahra Massicotte

Yeah, extremely important piece. Thank you so much for that example. So Francisco, we've made it to the lightning round here. I'm just going to ask you a question and just a quick answer, whatever comes to mind, if that sounds OK.

47:21.43

Francisco Castelblanco

Sure.

47:22.36

Zahra Massicotte

Great. OK, so one simulation modality that gets overhyped.

47:28.66

Francisco Castelblanco

That gets overhyped. I would say depending on technology, right? It's the basics that really pull in technology. And so, understanding and practicing those basic communication skills is what comes to mind. Without that, any tool is not going to be as useful as you think it would be.

47:51.42

Zahra Massicotte

Great answer. Thanks. One low-tech element that makes high-tech simulations work better? 

47:58.36

Francisco Castelblanco

Debriefing, by far. Making sure that those debriefs are honest and that they're learning opportunities.

48:10.52

Zahra Massicotte

Okay. One rural healthcare training challenge that works nationwide.

48:16.66

Francisco Castelblanco

To me, it is developing better programs based upon the types of students, right? So, in other words, if you're training or trying to teach middle school kids, high school kids versus fellows, it's making sure that the curriculum designer is integrated in developing those outcomes.

48:41.74

Zahra Massicotte

Wonderful. And is there a metric that you trust more than the number of people trained?

48:49.18

Francisco Castelblanco

Oh, absolutely. So patient outcomes, right? And there's many different ways to track this, you know, in health systems, in inpatient and outpatient settings, where is the patient better off, right? Are those, whatever it is that you're measuring, whether it's survival rate from a code or improved blood pressure numbers or diabetes, whatever it is that the goal was, that you tie it back to those patient outcomes, the most important thing that we can do.

49:23.43

Zahra Massicotte

Perfect. So coming to a close, just a couple quick questions here. So, for the healthcare education leaders in our audience who are trying to improve their simulation-based training this year, but you know they don't have a million-dollar budget. What do you think is the smartest move they can make first?

49:43.61

Francisco Castelblanco

Without question, training your staff.

49:45.82

Zahra Massicotte

Training, yeah.

49:46.23

Francisco Castelblanco

And, you know, you have that old adage of like, you know, what if you train them and they leave? And I always think of what a professional told me once, like, well, what if you don't train them and they stay? You know, because these individuals are affecting so many lives. You train a medical student, a resident; think about how many patients they're going to take care of in their lifetime. Nursing, you know, respiratory, pharmacy, all of these areas, right? So if you can instill in them great habits, and great skills and competencies, my goodness, incredible investment. But you've got to train staff.

50:29.75

Zahra Massicotte

Great. So finally, where can listeners learn more about MAHEC's work and the simulation training your team is doing?

50:35.80

Francisco Castelblanco

Absolutely. So we're always happy to consult with anybody and share. You know, we want organizations to do better. And so, you know, our website is the best place to start, mahec.net. And then if you look under, just you can put in the search bar “simulation center”, you'll see a bunch of the things that we're doing there. But I'm always happy if you want to reach out to myself, or the center director; we are happy to get on the phone with you and just share things that have worked and things that haven't. You know, we learn from each other, and ultimately better patient outcomes is what we all want.

51:12.76

Zahra Massicotte

Absolutely. Well, it's such a pleasure chatting with you today, Francisco. Thank you so much for being here and sharing your insights and your amazing stories. What great knowledge. I really enjoyed our conversation today. So that's a wrap for today's episode of Tech in EdTech. If you found today's episode useful, please share it with some of your network who is building healthcare or other workforce training programs. And we'll see you next time on Tech in EdTech.