Training the Modern Workforce Live is a weekly show discussing training and talent development solutions and best practices. Hosted by Allogy CEO Colin Forward, each episode features an informative conversation with a prominent guest in the training world.
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About Dr. Kevin Chung, Professor of Medicine and Surgery Chair, Uniformed Services University School of Medicine
Army Col. Dr. Kevin Chung is a graduate of the United States Military Academy at West Point and Georgetown University School of Medicine. After finishing a fellowship in critical care medicine at Walter Reed Army Medical Center, Dr. Chung was assigned to the U.S. Army Institute of Surgical Research where he has served in the capacity of Medical Director of the Burn Intensive Care Unit, Task Area Manager of Clinical Trials and Burns and Trauma, and the Director of Research over the last 12 years. He is currently Chair of the Department of Medicine at the Uniform Services University of the Health Sciences. Dr. Chung also holds academic appointments at USU as Professor of Medicine and Professor of Surgery. In his career, Dr. Chung has authored more than 180 manuscripts in peer-reviewed journals, authored 13 book chapters, and has been an invited speaker for over 85 lectures internationally. His research interests include burn resuscitation, critical care, and organ failure.
Episode Transcript
Adam Wagner: Hello, everyone, and welcome back to Allogy’s podcast, Training the Modern Workforce Live, the weekly show discussing training and talent development solutions and best practices. Each episode, we’ll talk about a different training topic, and make sure to keep an eye out for special guests and interviews from top training professionals.
With me, as always, I have Colin Forward, CEO of Allogy. For the last decade, Colin has provided major U.S. hospitals and federal agencies with distance learning solutions. He studied mobile technology under Dr. David Metcalf while earning a degree in computer science and his MBA.
And joining Colin this week is Army Colonel, Dr. Kevin Chung. Dr. Chung is a graduate of the United States Military Academy at West Point and Georgetown University School of Medicine. After finishing a fellowship in critical care medicine at Walter Reed Army Medical Center, Dr. Chung was assigned to the U.S. Army Institute of Surgical Research where he has served in the capacity of Medical Director of the Burn Intensive Care Unit, Task Area Manager of Clinical Trials and Burns and Trauma, and the Director of Research over the last 12 years. He is currently Chair of the Department of Medicine at the Uniform Services University of the Health Sciences. Dr. Chung also holds academic appointments at USU as Professor of Medicine and Professor of Surgery. In his career, Dr. Chung has authored more than 180 manuscripts in peer-reviewed journals, authored 13 book chapters, and has been an invited speaker for over 85 lectures internationally. His research interests include burn resuscitation, critical care, and organ failure.
This week, we’re going to be talking about training during an emergency response. We’ve got some great questions on deck already, but feel free to ask any questions that may come up in the chat, and we’ll get to as many as we can. Alright, Colin, over to you.
Colin Forward: Great. Thanks, Adam. And, thank you, Dr. Chung, for joining us. We’ve had conversations on this show about all different kinds of training already. We’ve had military guests; we’ve had conversations about healthcare. But COVID is a really unique situation in that there are so many training challenges around COVID itself. And then, also, just the way that it’s changed the way that we have to do things day to day—even training for how we do our regular jobs.
So, we really appreciate you joining us today to shed some light on how you’ve been handling the situation. So, we’ll jump right in. And I think the best thing to do to set the stage for the conversation is if you could help us understand:
How Did the U.S. Military Respond to the COVID-19 Pandemic?
Dr. Kevin Chung: So, great. Adam, thank you for the kind introduction, and Colin, thanks for the question. Just a little bit about me, aside from that introduction: for the past year as the chair of medicine, my role has been amplified, as you could imagine, given the fact that this disease is an internal medicine problem.
I also happen to be, as Adam said, an intensivist. And so, I have training in critical care, and as you all know, this is a critical care disease for the most severe patients. And so as the critical care consultant for the Army—which I had been previously; I gave that up this summer—it was really my job to sort of get everybody ready to take care of critically ill COVID patients as we were hearing about what was going on in China and, more dramatically, what was going on in Italy. And so when all that happened, given the fact that I have a background in burns and trauma, I’ve been deployed a couple of times, and the whole time I was taking care of trauma patients.
And so, the military has been uber-focused on taking care of combat casualties. Yes, there are categories of injury or illness categorized as disease, non-battle injury on the battlefield, and we are, based on our specialty, skilled and trained to take care of patients who have illnesses, infectious disease illnesses, and whatnot when we’re deployed. But, in general, our training program and all our efforts have been focused on dealing with the scenario of massive casualties from trauma.
And so, when this happened, it was the most unexpected thing. I mean, we sort of always heard about the possibility of pandemics, and there was a lot of attention paid to researching emerging diseases. We learned a lot of lessons from H1N1. We learned a lot of lessons from Ebola. That’s the last time that the Army—and the military, in general—was really all in with regards to preparedness. So when COVID hit the way it did, it shook everybody, and the military had to very quickly pivot towards a national, whole government response and playing a major role in that.
And so, there are many, many ways that the military stood by in terms of being ready to take care of any requests that would come down. And so, you may know that in order for the military to be involved, number one, there’s gotta be a national emergency declared. So that was done immediately. But within each state, the federal government can’t just go into a state and help out without being solicited, without the governor asking for it.
And so, when New York was overwhelmed, when Washington was beginning to have signals that they were going to be overwhelmed, our combat support hospitals, the way they were structured then—and what I mean by that is geared entirely for trauma and combat casualties, not for pandemic response, mind you. So we took those footprints and placed them in the two areas: one at Javits Center, another in Seattle. The Seattle combat support hospital was not utilized whatsoever. They didn’t see a single patient because, although there were specific hospitals that were overwhelmed, the other hospitals were not, so they could distribute the patients rather well, and they didn’t have a need for the military. So that was a wasted effort.
The Javits Center deployment—you may have heard of the Comfort ship that was deployed by the Navy. And then, there was a National Guard presence as well. So multi-service response to New York.
Initially, there was a lot of confusion as to what their role was going to be because they didn’t understand or really appreciate what the hospitals needed. And so, initially, the mission was we’re going to support and take care of patients that don’t have COVID. And so, that’s the mentality that they took with them.
Pretty quickly, we realized that the hospitals don’t want to give up their non-COVID patients, particularly the surgical patients. So they had no patients for the first week or so. There were some negative press and a few articles that came out saying that Comfort has a thousand-bed capacity and none of them are being used, for example. Well, the Military’s good at one thing, and that’s continuous improvement. We identify gaps, and we know when we’re not doing well in a certain area, and we pivot, and we improve.
That’s ingrained into our mindset, you know? Always look for things that we’re not doing well, and let’s improve and get better. And so, slowly — I think within two weeks, actually, it wasn’t that slow. I mean, it seemed like an eternity back then, but looking back, I mean, it was rather quick. They changed their rules of engagement to allow COVID patients and very rapidly filled up the hospital to capacity for the personnel they had.
Now, you kept on hearing reports about, “Oh, the hospital ship has the capacity for X number of beds, and they’re only using 230.” Well, what’s the point of having the bed if you don’t have a nurse to take care of that patient. And so, for the personnel that was deployed, they were pretty maxed out for probably a six-week period.
And this is both on the Comfort as well as the Javits Center. And so, if you talk to anybody who practiced in any of the hospitals in New York City, particularly the ones that were overwhelmed, the feedback that we received was very positive. They were able to play a major role in offloading and helping provide relief for the hospitals that were overloaded.
Now, was that the perfect solution? No, it wasn’t because, even still, despite them acting like a pop-off valve, many of the hospitals were reluctant to give up their patients, and that’s something we did not put into the equation as an organization. We thought, “Oh, there’s a pandemic. There’s disaster. It’s crisis. Everybody’s going to send us patients.” Well, that didn’t happen.
Colin Forward: I think you’ve set the stage really well for a topic that I want to dig into. So we work with New York Presbyterian, and we were hearing day to day how they were needing to retrain employees to do new jobs because, like you were saying, of course the logistics are fluid and things are changing as we better understand what needs to actually be done at a tactical level. But when it comes to helping the people—you know, the boots on the ground—do the job, the expectations were changing.
I know I’ve actually listened to some of your briefs on Deployed Medicine, and some of the information that you were providing would change week to week or month to month.
What Training Challenges Did COVID-19 Present and How Did You Overcome Them?
Here, what was happening is our rate limiting step was our ICU capacity. And so, very quickly we learned that the ICU beds were overflowing. And now, you saturate all the ICU beds, and where do the patients go? They have to go to another ICU. So now you’re taking medical ICU patients and putting them in a surgical ICU, and then putting them in a burn ICU. Typically, any average-sized hospital will have 60 to 70 ICU beds. Well, they have 150 ICU patients; where do they put them all? So they would have to basically open up the ER rooms that had all the connections necessary to run ventilators, oxygen, and all that stuff to make it an ICU bed—convert all those beds into ICU beds.
The ward beds. So regular standard hospital rooms were converted to ICU beds. And so, there was a surge of patients that were being taken care of on wards by nurses, techs, and docs not used to taking care of ventilators, pressors, all that stuff, not used to taking care of critically ill patients.
So there was immediate need for on-demand or just-in-time training. And so, that’s just setting the stage. So what did we do? Well, fortunately, we had some information that we received from Italy that this was a possibility. And so, to a certain degree, for those hospitals that were overwhelmed, I’m sure they’re going to say they felt underprepared. But the hospitals that weren’t, we trained and trained and trained and trained, and the patients never came. This happened in many hospitals around the country.
And so how do we train? Sometime in March, we produced within USU—this was for the military, but it generalized just very quickly—these short instructional videos on how to manage the ventilator if you are not an intensivist, how to manage pressors if you’re not an intensivist, how to titrate sedation if you’re not in an intensivist. From a nursing perspective, how to set up these infusions, how to calculate all the drug dosages, how to tweak all that, how to insert IVs—all of these instructional videos specific to the nurses. We had other videos on how to handle and adjust ventilators, separate video. So probably 12 videos, 15 videos, that we produced in a span of three or four weeks that we just put out there.
Now, we got our hands slapped for it because it was not an official DoD-approved video. But we didn’t have time to get it approved by the hospital, then the National Capital Region, and then DHA. And we just didn’t have time to go through all those steps necessary to get them approved. These were medical instructional videos, so we put it up.
Colin Forward: Sure. Let me stop you there real quick because I’m sure we’re going to come back to just-in-time learning and on-demand learning. But I’m really curious about this sort of like change management aspect in a disaster environment or response. So can you expand a little bit on what kind of internal communication challenges you faced when it came to trying to be nimble and trying to be responsive and supportive but also trying to just stay in your lane, so to speak?
Dr. Kevin Chung: Yeah. I think, like any organization, we have a process through which we have to go through if we want to have any content that’s external facing. And during that very critical time where we perceived that there was a crisis going on, we took it upon ourselves, a few of us, to just put content out there and ignore the rules.
You know, I think if I were to do it again, I’d still do it the same way because we got the information out there within the first 24 hours. The “How to Manage the Ventilator If You’re a Non-Intensivist” video had like 200,000 views from like 50 different countries. And so, we had content that was highly valuable to people. I mean, medical videos don’t get 200,000 views in a day. Let’s just say.
Colin Forward: Yeah, we’ve seen it with the Deployed Medicine.
Dr. Kevin Chung: I know. It’s just, that is extreme. And so, when it went “viral” like that, it turned some heads and people started asking questions. Well, was this approved? And I’m looking at them, like, “Do you understand what kind of situation we’re in right now?” And we butted heads.
I mean, yes, I should have gotten this video approved. My colleagues and I should have gone through the process. That would have taken us a week, but we didn’t have a week. And so we made a decision.
Colin Forward: You know, one thing we’ve seen a lot is that there’s kind of two ways that people respond to a crisis. They either try and respond directly to that crisis and fix the things that they weren’t prepared for. And then, by the time that’s done, the crisis is over, and the momentum to keep that practice going is gone.
But you actually mentioned Ebola, and I keep mentioning Deployed Medicine, but Ebola was really the motivation for Deployed Medicine. Everyone was attaching PowerPoints about donning and doffing PPE, and there wasn’t really a centralized resource or a way to provide canonical information. So the Defense Health Agency stood this up for combat medicine.
And I don’t know all of the internal conversations that led to having, for example, your COVID briefings going out on Deployed Medicine. I imagine that there was some relationship there, but that leads me to ask, what do you think are the preparations for, again, this kind of change management that can help us prepare for the next one?
The approach that we’re taking with Deployed Medicine is equipping the subject matter experts—in that case, primarily the Joint Trauma System—to provide their combat casualty care and all the other domains of information that they’re responsible for. But in this case, when we’re talking about this kind of ad hoc response, whether it’s a pandemic or anything else, are the lessons learned around having a clear authority, an authoritative source on this information, or is there some other lesson learned that we can take into the acquisition cycle, the training, the preparation for next time?
What Lessons Has the COVID-19 Pandemic Provided on Emergency Preparedness?
Dr. Kevin Chung: Yeah. I mean, you can plan all you want and be the best planner strategically on the face of the earth. But when something hits the fan, all those plans go by the wayside and you’re dealing with something else that you didn’t prepare for. That’s always the case.
And so, I think, more important than planning for as many scenarios as possible is maybe having policies in place whereby when a crisis hits and somebody hits the emergency button, some of these things are allowed and we’re not so tied up with IT security. Yes, we don’t want our adversaries to claim our videos or steal our videos and infiltrate. Yes, I totally get that. I’m all about cybersecurity. But in a situation like this, there’s gotta be a way to bend the rules, and to a certain degree, we had some of that.
Like, for example, immediately, we had to go from face-to-face patient care interactions to video—VTC, video teleconference. And so, these virtual visits needed any platform that worked, and the platforms that the military had at that time were clunky and needed 15 different passwords, and they just didn’t work. And so what did DoD do?
They allowed for any of the platforms, like four or five that were available that met the minimal cybersecurity standards, and they didn’t meet every standard, but they released them and put out a statement saying anybody can use them now—open them up, remove the firewalls. So that kind of action was very helpful.
So, I think, from an education standpoint, we need to knock down those barriers similarly. If we’re trying to communicate, and there are these cumbersome rules in place that impede our response, they need to just go away. And if that rule hasn’t gone away, somebody hasn’t thought of it. We need to have leadership that’s able to critically think and say, “How is this really going to impact our security? And is it going to negatively impact it or positively impact it? And is that content useful?” And just allow some rules.
Colin Forward: Right. So I get some interesting questions from time to time about data rights or media rights, and like you said, “What if our enemies get hands on this?” And sometimes, my response is, “Well, maybe they’ll save more lives.”
But the question, I think, still remains about the importance of formal training versus self-directed, on-demand, just-in-time training. And I have to imagine that in this case, you’ve been relying almost entirely on a gentle push, and then people looking for the information that they needed at the time. Is that true, or are you still taking a more traditional military approach and looking for credentials and certification?
During the COVID response, did you focus more on formal training or self-directed, on-demand resources?
Dr. Kevin Chung: Oh, no, no. So we had a process to streamline all that stuff. We had, sort of, policies in place where we were ready for the surge and contingency standards of care and crisis standards of care and what would happen if we got overwhelmed. Fortunately, we had some of that already made for other scenarios.
With regards to your point on how you get information out there: I mean, the video is just one example, and that’s something that the participant has to seek. The first thing that has to happen when a crisis occurs or you’re about to enter into a crisis situation is you gotta set up comms. You’ve gotta be able to communicate. I mean, that’s the first thing that has to happen because if you’re not communicating and you’re not over-communicating, then nobody knows what’s going on and there’s chaos.
And so, for the military, the fastest way to do this is to take a non-DoD-approved platform, WhatsApp. And we created a WhatsApp group, and immediately, we had 200 people that we connected with. These are all intensivists across all the MTS. We have 50 hospitals, 200-something clinics around the globe. About 30 of those hospitals have ICUs, and we were able to connect with all of them. And as they were receiving patients, I’d see it on my WhatsApp channel, and we’d be texting back and forth, and we would release anytime we had new memos instantly would go out on WhatsApp.
That was the best way to communicate. It was so effective, so effective. And we’ve done AARs after disasters. For example, somewhere in the Southeast, maybe India, there was a big fire with 500 casualties, and they did an AAR that asked, “What was the best thing that you did to respond to this mass-casualty situation?” They mentioned WhatsApp as the primary communication tool. It was so quick. You can share files, and you can connect immediately.
Colin Forward: Yeah. I mean, on one hand, I could see that being the group chat from hell; on the other hand, in a pinch, that makes a lot of sense. That gets the information out. But it leaves me to wonder, now that we’re a year into this, do you feel like there are ways in which you could have benefited from better insight into how people were accessing and leveraging your training? Because WhatsApp probably doesn’t provide a whole lot of that.
How Do You Gather New Information and Ensure It’s Trusted and Authoritative?
Dr. Kevin Chung: No, not at all. And so I think you need a multimodal strategy. I think, for us, we didn’t know what we didn’t know. So we put out as much information as we could with regards to what we thought people needed to know. But you have to have a system where you’re always sensing what the needs are, and you’re able to turn around product very rapidly. And for us, that sensing mechanism was a weekly case conference.
It seems simple, but we learned that weekly case conference from the Joint Trauma System, which had the system up and running when we were receiving casualties from Iraq and Afghanistan from like 20 different combat support hospitals. I mean, how do you keep track of all those patients as they move through like three or four handoffs during the global evacuation.
And so, at that time, the most effective tool to sense problems and to, sort of, disseminate information and training materials and all that was just to get on a call—and at that time it was a telephone call. We then turned it into a virtual conference for COVID, but we did that once a week.
You have all the recordings on Deployed Medicine, and this is where the providers were invited to talk. Initially, it was just going around the horn. And then, eventually, that morphed into instructional content that was dedicated and geared towards our participants who are our audience who called in to get information and to learn about the different types of things that they had to learn and where. And we instructed them on how they can get that information or delivered the material right there and then. For example, new guidelines for the therapies, pharmacotherapies, that were released, and so on and so forth.
So that, I think, helped. We also talked earlier about who is the authority when this kind of thing—
Colin Forward: That was my next question.
Dr. Kevin Chung: Yeah. How do you know who to trust, what source you direct people to? Well, it’s great for any other disaster because there are all sorts of materials and places that we can point to and say, “This is the authority we’re going with—these guidelines.” For COVID, we didn’t have any guidelines. Zero. And so, for DoD, over a weekend, we wrote up like a 40-page guideline draft. We thought of the idea on Thursday; by Monday, we had it distributed throughout DoD to all the providers.
And again, here’s a process issue. The JTS has 60 clinical practice guidelines. Clinical practice guidelines, by definition, have to go through like a 15-step approval process. And so, my first document that we wrote, we had the title “Clinical Practice Guidelines for COVID” for DoD, preliminary or whatever. That got axed right away. They were like, “You can’t call this a clinical practice guideline.” We’re going to be exposed because it didn’t go through the 15 steps.
I’m like, “Kidding me?” And so, we had to change the name to practice management guide. Yeah, it got down to that. It was that incredible. And so, we changed the title, and that was okay with everyone. Since it wasn’t a CPG, it didn’t have to go through all the 15 steps. We just got it signed off by the head of DHA, and boom, it went out. We are now on the seventh version in 10 months.
How Do You Maintain an Authoritative Voice When Information is Rapidly Changing?
Colin Forward: Okay, so you answered one of my questions about the CPGs. I guess the reason that they’re so strict about using that verbiage is because that designation carries some weight. That implies that it is authoritative. It is a standard. And we’ve seen this with everything from whether or not people should wear masks or what medications are effective or how long you should be isolating.
Dr. Kevin Chung: Yeah, and this is still happening. Things are changing—not on a daily basis anymore, probably more like a weekly to monthly basis scale. But we have to really, really be careful not to fall into, as clinicians, practicing based on the latest paper that just came out. I don’t base my practice on the last New England Journal study, even though New England Journal is pretty impactful. But—
Colin Forward: Or the Lancet.
Dr. Kevin Chung: Yeah, not until you have reproducible evidence suggesting definitive benefit do you change your practice on a global scale, like consistently as a practice. We still practice medicine, and it’s called practice because it’s the art of medicine. And so, we have the flexibility to be able to provide a therapeutic off-label. In fact, 90% of what I do in the ICU is off-label, to a certain degree, that’s not backed by randomized control trials. And many of the drugs I use, I’m using not for the indication it was approved for but for another indication. That’s just the basic practice of medicine.
And so, how do you practice in that environment? There was a presentation this week in Society Critical Care Medicine that medicine during the time of COVID, in terms of practice variation, was completely crazy. Wide practice variation when you compare the United States versus international, when you compare rural versus urban, when you compare East Coast versus West Coast, when you compare January/March last year to December? I mean, wide practice variation? And that’s expected.
And so, in order to minimize that as much as possible, you have to very quickly develop that authoritative, true clinical practice guidelines. Yeah, it’s going to take some time. And so we produced the practice management guide. That was a guide. We said, “These are all the suggested therapies. You can use them if you want. We’re not saying one thing or the other. These are the mechanisms. These are the studies that have been out. Okay. You make the decision as a provider.”
We didn’t provide any rating, like strong recommendation, moderate recommendation, we do not recommend. We didn’t recommend anything. And so, we just provided information.
The NIH, however, by May were able to get together a group, and over the course of like a month—which is extremely fast, okay; usually, clinical practice guidelines take a year—they put out the NIH treatment guidelines, and that changes every month or two or three, and they have a variety of different therapeutics. Pretty much, they cover all the therapeutics that are out there. And that, for us, varies quickly. As soon as that came out, the practice management guide just deferred to that authoritative source. But it takes time to get everybody on the same page, and we’re still not on the same page to a large degree.
Colin Forward: Right, and we’re just talking here mostly about the sort of discreet instruction that you would give someone to perform a specific type of task. But even, you mentioned, something like 90% of what you’re doing is off-label. And then, we had Aric Gray in the audience today say it’s medicine, it’s not something you want to control every aspect.
From a training perspective, are there things that you can do either beforehand or in the moment to empower your learning audience to make the right decisions?
Dr. Kevin Chung: I think you can. But what do you focus on? It’s a challenge. I think, for us, in the ICU, there are always drills that we perform during quiet times where we practice how to go through a cardiac arrest. We call it code drills—code blue drills. And it becomes part of your practice where every month you’re going to do this when things are quiet.
I haven’t done a code drill in a year. Why? Because we’re doing the real thing, unfortunately, all the time. And so what do you drill? What do you teach? It’s really, I think, participant- and learner-specific independent, and you’ve got to have a platform that’s flexible enough and self-driven enough and self-paced enough that they’re able to fill their own gaps where necessary.
Now, that takes a motivated individual to have the insight to know what they don’t know. Most people don’t know what they don’t know. They just jump in and do whatever they need to do. And half the time, they’re just not realizing they don’t know something. And so that’s another thing that we’re dealing with.
In the military, for the purposes of combat casualty care, we have something called the KSAs: knowledge, skills, and abilities or attributes, depending on what you read. But we’re trying to line up what we think people should know to be competent in that environment with what they have and the knowledge they have. And then, how do we fill those gaps on an individualized basis?
I think you could do something like that for everybody; everybody in the hospital has some type of credentialing folder with a checklist of things that they need to be competent on to be effective on that floor. And every nurse that first shows up in an ICU gets those things checked off one by one, and it takes eight weeks, for example, to get oriented to a unit because somebody has to observe you do that procedure to make sure that you’re competent and you’re able to do that on your own. In a crisis, man, that is very, very hard to do.
Colin Forward: It’s tough to evaluate someone for competency in decision-making.
Dr. Kevin Chung: Yup. It is. It is. If you solve that very complex problem, I think you’ve got something—you’ve got a winner.
Colin Forward: Well, I mean, have you seen any best practices? I mean, from our perspective, Allogy is a training company. We’re introducing things like branching scenarios, chatbots, things that require interaction and force someone to deal with the consequences of their decisions. Maybe they end up at a suboptimal outcome, and it’s not the best, and it’s not failure. But that’s just one approach, and that’s something that we’re looking at. I’m curious what you think might be some of the best approaches you’ve seen to that kind of thing.
What Are Some Best Practices for Being Prepared for an Emergency Response?
Dr. Kevin Chung: I think we take a lot in healthcare from the airline industry with regards to high reliability. And so, the principles of high reliability are pretty much everywhere now, but one of the hallmarks of that mindset is just acknowledging and continuously evaluating where your gaps are, in general.
And so, it always seems like the military is messing up, but it’s not because we’re messing up more than we would otherwise; it’s because we’re highlighting those mistakes. We’re able to highlight those mistakes because we know that we’re going to learn from them, and we own our mistakes. And so, you need to have an environment, whatever the environment, where that’s okay—that failure is seen as a learning opportunity, not you’re fired. You know what I mean?
And so, really, it’s about the mindset more than anything else when you’re entering into this kind of situation. If you have that mindset of we have multiple redundancies in place whereby failure is accepted to a certain degree and it’s just something that you learn from. You don’t let it affect the patient because you have these redundancies in place.
Sometimes, when you’re spread too thin, those redundancies go away, and failure could lead to bad patient outcomes. And this is where mortality doubles. When you’re talking about a normal ICU with a normal census compared to crisis standards when they’re full and overfull, mortality doubles. And it’s because that redundancy goes away.
Colin Forward: Wow. I mean, I think what you’re talking about here about people being allowed to fail and that being okay. I mean, that cuts across every industry. Pretty much every training environment that we could possibly try and apply it to. I would imagine—you can tell me if I’m wrong here—that the tolerance for that kind of thing is way higher, as you’ve mentioned, in this kind of response environment. But what does the process look like for feeding those lessons learned back into training and preparation?
How does learning from failure feed back into future training and preparation?
Dr. Kevin Chung: It’s gotta be done at the local level, and it’s gotta be part of that culture. And you hope that that culture becomes infectious for every other group—
Colin Forward: No pun intended.
Dr. Kevin Chung: —and across many different organizations across the country. And so, it starts with that local culture where they take whatever has happened, an event—and in the hospital, we can call it a sentinel event or whatever—and we do a conference, and we evaluate, we go through it. And the person presenting—and this is amongst physicians—oftentimes is the person that made that mistake, and they’ll present what their thought process was. They’ll get beat up, and they’ll get asked questions. Have you thought of this? Did you think of this? And then, they’ll be responsible for presenting what we could have done better and then presenting what we’re going to do from here on out.
And that’s part of high reliability. I mean, you need to have that within an organization and every hospital—that process in order for you to be considered a good hospital.
And I know, I’ve evaluated burn centers. I was a part of the verification committee for burn centers around the country. So I traveled from burn center to burn center, and I didn’t care if they were terrible knowledge-wise, I just cared about whether or not they had that process, that QA process. Because if they told me that they had never had a bad event in the last five years and told me everything’s perfect, they’re not passing because they don’t have that process. They may be good now, but you know what? They’re going to be terrible in a year if they don’t have that continuous learning environment.
Colin Forward: That makes perfect sense. I mean, that really highlights even in, say, a corporate environment having that sort of collaborative process with your instructional designers, making sure that your subject matter experts in every domain can feed back into content development and the continuous improvement process that you’re talking about.
Dr. Kevin Chung: Yeah, and you’re not gonna hit a home run and have a 100-percent solution right away. You may have a 51-percent solution, and then you troubleshoot and have a 55-percent solution, and then a 60-percent solution, and then 70 percent. It’s iterative, but you’ll never reach 100 percent.
Colin Forward: And so, you’re saying it has to be done at a local level. How do you manage the difference between that canonical source, that authoritative source of information, and then that local wisdom and making sure that those two can work together and one isn’t necessarily trying to overcome the other?
How do you reconcile authoritative sources with local experience when information. israpidly changing?
Dr. Kevin Chung: It’s been hard to do this past year because everybody’s been so busy and worried about their local process. We just hope that that process was in place at every local hospital and that in every unit it’s triggering continuous improvement. But you’re right. I mean, there could be variability in quality, and we don’t know. How do we solve that?
First, you’ve got to figure out if that exists. Like, right now we’re flying blind, aren’t we? We’re not visiting the units like we’re doing with the burn centers. I’m verifying every single one of them. I don’t think JCHAO has been around, for example, to visit hospitals. Have they? I don’t know. I’ve not heard of a hospital being subjected to JCHAO inspection, but it’s the standardized care and processes from around the country.
And so, how do you get everybody on the same page? You say this is the standard, and then you’ve got to have some type of evaluation process. Right now, that is lacking. That is lacking, and we’re trying to get there. We’re trying to look at metrics, certain metrics. How do you compare somebody against a metric when you’re just making up that metric? It’s so unfair. Like, we’re making up the rules as we go. We’re making up where the goalposts are going to be as we go.
And so, that’s been the challenge. It’s hard to say X percentage of patients need to be on this therapy. Well, there are huge disagreements on every therapy. Maybe one has the least amount of disagreement, and that’s steroids. But how do you assess when to know that there’s a gap? That’s a big challenge right now.
Colin Forward: Do you have any examples of metrics that you think are going to survive in this situation? What people are going to end up looking back and evaluating their performance on?
Why Are the Basic Principles of Critical Care Important During an Emergency Response?
Dr. Kevin Chung: I think what we’ve learned over the past year is critical—speaking from my lens from in the critical care community. We’ve had the swings of, like, “Oh, we need to start intubating everybody now. And as soon as they come in and they hiccup, you’ve got to intubate them,” to, “Oh, we don’t have to intubate them until they’re completely exhausted and on BiPAP.” Well, that may not be the right answer.
I think at the end of the day, what we’ve all learned is that the principles of basic critical care—if they’re applied correctly—are not going to change over time. Applying good, critical care means, sort of, holding onto some principles like wanting to minimize the medications as much as possible. You don’t want to do a procedure if they don’t absolutely need it—those kinds of things. You want to support them, and sometimes less is more. That’s a critical care principle.
I keep on hearing from the critical care community, “Hey, we’re just practicing basic critical care. All your fancy discovered-yesterday drugs may be beneficial, but we’re having pretty good outcomes with just straight critical care—basic critical care.” You know, resuscitate them when they need to, don’t over resuscitate, provide them with mechanical ventilator support when they need to, monitor them very closely, don’t do anything too extreme, do the things that have been proven, and stick to those principles.
Colin Forward: What I’m hearing is the folks who are on the front lines should feel confident, then, that they can fall back on the same methods that they’re used to being evaluated on. But I’m still left wondering if there is some method by which you might evaluate how well someone was able to respond to the changing situation, outside of just their fundamentals.
How are you evaluating someone’s ability to be flexible and responsive to the situation?
Dr. Kevin Chung: Yeah. That’s a really good question. And that really depends on who’s doing the judging and what standards that they’re being judged against. And so, without there being a consensus for that, it’s hard to impose.
In terms of assessing agility and flexibility, I’ve not found a tool that’s been helpful. It’s something that when you observe somebody practicing, it’s not necessarily outcome-based. It can be. If they keep on having bad outcomes, then you’ve got to question, “Well, why is that?” But sometimes it doesn’t lead to bad outcomes, necessarily, in terms of more morbidity and mortality. It’s just bad care in general.
It’s hard to assess, and you really need to be in that unit, and you’ve got to have objective, sort of, referees making those evaluations on a standardized, agreed-upon template that everybody agrees should be the standard and should be the benchmarks. And so, that’s going to be hard to do for assessing something as soft as agility and flexibility. You’re either very flexible and agile, or you’re not. You just see it when you see it.
Colin Forward: Well, I guess this kind of sheds some light on why there is so much focus in the military research community right now. Things like the STE, the Synthetic Training Environment. We’ve talked to folks like Dr. Ben Goldberg that’s doing a lot of work on coaching in that environment—on adaptive coaching and understanding people’s competencies and using that to try and help teams develop good decision-making processes.
Do you see that continuing to be a focus, or where do you think we are on the timeline of being able to really roll out comprehensive training programs that are targeting flexibility, decision-making, and critical thinking?
What Is One of the Most Important Skills in Medical Training?
Dr. Kevin Chung: Yeah, I think improving the outcomes of patients, in general, is not that different than what’s important in training—an infantry unit and training leaders and whatnot. You depend on subordinate leaders to be competent. And you’ve got to have the leader on top of that have trust in those leaders that they’re going to do their jobs because they’re not going to be everywhere.
And so, you’ve got to train those individuals to a certain standard to be able to make critical decisions. For us, in the medical field, those may be the fellows or those may be the attendings that need to have that skill. And that skill is not something that you develop overnight.
It starts in medical school, and this is what we focus on at USU. When I assess a student, it’s not about knowledge. I don’t care if they know X, Y, and Z because you can Google that stuff. I care about how they process information, how they take 100 data points of complex information and distill it down to the top three things they’re going to do for that patient. That’s what I value. And in medical education, it’s sort of transforming into that. It’s not about knowledge and knowing the steps. It’s about critical thinking and knowing how to process information.
And it takes four years of medical school to take them through all the necessary didactics and real-life scenarios to train them, to get them ready to be an intern. And then, it takes the entire internship year to specialize in what they’re going to go into. And then, it takes two to three years of a residency—for us in internal medicine, it’s two years after internship. And then, it takes another two to three years of critical care to become a competent intensivist.
And so, all along those steps, you need to have a scenario where you’re constantly evaluated and given feedback on how you think. And we have a culture within intensive care where everybody’s sort of on the same page to a certain degree with regards to what’s important—and that’s critical thinking.
Colin Forward: And it seems like that is a great way to demonstrate the necessity for a career-long or lifelong learning as well. So you’re talking about this starting in med school, but I think one of the issues that a lot of careers, a lot of industries, are facing right now is that there’s not necessarily a coherent record for one person and how they’re carrying these skills and these training with them into the workforce. Do you see any kind of developments or any sort of like bright lights in that area? I mean, I know there’s a lot of work being done on the total learning architecture, trying to bring more consistency and interoperability to the military training ecosystem. But what’s that look like from your perspective?
How is military medicine bringing more consistency and interoperability to their training?
Dr. Kevin Chung: Yeah, skills degrade over time. You may go through training and be optimally skilled when you graduate from fellowship and know pretty much how to handle everything. Well, if you stop learning there, that skill is going to degrade.
I’m sure it’s like that in every organization and every discipline. So, for medicine, the way we keep up the competency is by continuing education. And it’s a voluntary thing to a certain degree, but it’s also not. Like, in order to get re-credentialed and relicensed as an intensivist, every 10 years, you’ve gotta recertify, and that certification process requires a test and requires evidence of continuous education—like a hundred hours of continuous education. It’s like this in law.
And so, I think for every organization to be operational—especially those dependent on high-level skills, technical skills—you need to have some sort of continuing education built-in. Otherwise, people that have been there 10 years, of course, they’re going to have that experience. They’re going to have the insight and the wisdom. But the technical knowledge, they’re going to be depending on the people that just came out of school because everything is always changing. And so, if you don’t have continuous education built into your psyche, you are going to be a learner for the rest of your life, that’s a problem. And this is true in medicine, and I’m sure it’s true everywhere else.
Colin Forward: Definitely. Yeah, we’re seeing it become more of a focus in everything from corporate environments to law enforcement. And so the show is called Training the Modern Workforce. I think you’ve done a great job of explaining how you’ve been working through the challenges of supporting the workforce that you’re responsible for that’s looking to you for information. But in the little bit of time we have left, we haven’t really talked about patients, and that’s one of the biggest education problems that we’ve faced over the last year.
So, I mean, for some of our listeners that might be somewhat analogous to customer education. But in this case, the outcomes are definitely affected by how well we’re able to prepare patients and the general public to respond to the challenges that they’re facing day to day. So what have those training and communication challenges looked like for you?
How Do You Train Patients (or Customers) for Better Outcomes?
Dr. Kevin Chung: So it’s not difficult to any degree to educate and help train individuals who are seeking that knowledge. For example, if you have a patient discharged, they’re going to be asking a hundred questions because they want to know how to prevent themselves from getting back to the hospital.
If you’re talking about educating the public to prevent admission, now that’s very, very tricky. And I think it requires a multi-pronged approach that leverages everything that we have at our disposal to spread knowledge—to include social media, multimedia, the news, political leaders. I mean, the messaging has to be perfect. And so, if you’re talking about, sort of, training your customers, I think you have to identify what they’re seeking. You have to know and understand what they’re looking for.
For example, I remember I was the medical director of the burn unit, and a new fancy machine came to be. It was a dialysis machine, and the person came in, brought the machine, and they were going to give me an education session. And so, the person starts talking, and they’re talking about the basic physiology of acute kidney injury, which I give lectures about. And so, within a minute into this talk, I said, “I know. I’m sorry, You know, excuse me for being rude, but can we just talk about the machine?”
So you can have a bunch of educators out there educating the customer, but if they’re talking about stuff that the customers already know, then that’s a problem. Their eyes are glazed over. It doesn’t matter how much pizza you have, they’re not going to pay attention. You’ve got to focus on what they’re missing and what they’re seeking, the knowledge they’re seeking. And you’ve gotta have people who are trainers who have that insight and are able to identify where those gaps are and are flexible enough to change their 50-slide set presentation and just hone in on the three critical slides for it.
Colin Forward: Not that we want to endorse 50-slide sets. Well, so, I think that’s an important point about patients or any audience really needing to be receptive to training. But is there any way that you can maybe establish the urgency and the importance of the information that you need to get to that audience? Is there any way that you’ve been able to overcome some of that with public education?
Dr. Kevin Chung: Yeah. It starts, again, with that multimedia campaign to declare a problem or declare a knowledge gap or declare that that knowledge gap is connected to bad outcomes, and there’s an urgency to the information that you’re about to receive for you to learn it. Without establishing that, you’re going to get very few takers because it’s not going to register in their brain that, “Oh, this is important. I need to pay attention.” Even if they log on, they’re not going to pay attention because it’s worthless.
You’ve got to have information that’s valuable to them. And how do you establish that value? It’s filling in the gaps, like I said. But how do you fill in the gaps when you don’t know the gaps? That’s the challenge.
Colin Forward: Well, it seems like it’s been a really challenging year. But I appreciate you sharing everything that you’ve learned with us over the year and just helping us better understand some of the challenges that you face. Like you said, I mean, there’s been good press, there’s been bad press, and it really helps to get this firsthand perspective about what kind of training you’ve had to deliver and how you’ve had to adjust as the situation evolves. So we’re pretty much out of time here. I just wanted to say thank you and see if there’s anything else that you wanted to offer to the audience while we have you.
Dr. Kevin Chung: Well, I feel really bad that there were a number of questions that we didn’t get to. Can we answer a few of them? Do we have time to do that?
Colin Forward: Sure. I did see a couple come in. Adam, did you have any specific questions that you pin.
Dr. Kevin Chung: It may have been comments.
Colin Forward: Yeah. There was definitely some good conversation going on. I saw that.
Adam Wagner: Yeah, I didn’t get any specific questions in there. It was mainly just people reacting to what you were saying, Dr. Chung.
Colin Forward: Yeah, I mean, there’s a lot of people reinforcing what you were saying. I want to thank Aric and Kimberly for their responses. Caleb also kind of backed up what you were saying about being able to fail. Mentioned the Office Space example of having eight bosses come in to complain about you doing something wrong and that being a big disincentive, kind of going against the culture of failure being okay.
So I do want to thank those folks who participated. That was helpful when you were referencing that as we went. And also, just to let everyone know, this was recorded. We have this episode and all of our other episodes up on the Allogy website. And, actually, I should just turn it over to Adam. He’s got a better idea of where everyone should go to find this if they want to reference back to it after the fact.
Adam Wagner: Yeah. Thanks, Colin. This was Training the Modern Workforce Live, presented by Allogy. Join us next Friday for a conversation about emerging technologies in training and simulation with UCF’s Dr. David Metcalf.
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