Saint of Circumstance: David Gaba on simulation in healthcare

Willem van Meurs
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In a conversation with Willem van Meurs, David Gaba, the leading pioneer in healthcare simulation, traces his path from biomedical engineering to anesthesiology, highlighting his desire to merge engineering with medical practice. He shares with us elements of the history of simulation, detailing the development of an anesthesia simulator at VA Palo Alto, and how he was selected as the inaugural Editor-in-Chief of the journal Simulation in Healthcare. Currently, Dr. Gaba concentrates on supporting others in healthcare simulation research. In this interview he tells about the people who have inspired and supported him, first and foremost his wife Deanna. Sharing his lasting admiration for the Grateful Dead, he is keen to point out that his incredible career is not yet over.

We could not fail to invite David Gaba to be part of the SIM Face, given his key role in the development of healthcare simulation. He talked with Willem van Meurs, our assistant editor. Engineer first, then anesthesiologist, he has significantly influenced anesthesia and critical care through his invention of a modern full-body patient simulator. David imaginatively adapted Crew Resource Management from aviation to healthcare and has been instrumental in developing cognitive aids and Emergency Manuals. An acclaimed author and educator, he has received numerous awards for his contributions to medical education and patient safety. Outside work, he enjoys reading, physics, outdoor activities, and various sports, reflecting his diverse interests. And we found out which is his favorite rock group.

Willem van Meurs: What a privilege for SIMZINE and a pleasure for me having this talk with you. I know your undergraduate degree was in biomedical engineering. Can you tell us a bit more about that, and how did that shape your decision to enter medicine and anesthesiology?

David Gaba: Thank you! I did my undergraduate at Northwestern University already planning to go to medical school after graduation – I was interested in engineering (my father was an Electrical Engineering grad). I had hoped to combine my engineering with medicine, at first thinking that I might get a PhD in Biomed Engineering; but I quickly found out that my interest in medicine overwhelmed my interest in engineering itself. Ultimately, I succeeded in combining both from the standpoint of an anesthesiologist. The technical aspects of anesthesiology were substantial and the “dynamic” aspects of it vs. most other branches of medicine (things happened in seconds, minutes, hours not in days, weeks, months, or years) greatly appealed to me.

WvM: In the early nineties, we saw each other frequently when you were promoting your own anesthesia simulator, developed by a combined team from Stanford and Harvard. Could you detail the collaboration and the simulator?

DG: To be clear, the “simulator” was not developed by a combined team from Stanford and Harvard – but rather was completed at VA Palo Alto by me (Stanford faculty) and medical student research associates (Abe DeAnda and John Williams). Jeff Cooper saw the importance of our simulator and Anesthesia Crisis Resource Management (ACRM) curriculum for Patient Safety and brought me (on sabbatical for 3 months) plus Abe, John, and Steve Howard for a few days – along with our 2nd generation simulator – to the Harvard-affiliated hospitals’ anesthesia departments where we taught about 10 anesthesia faculty to conduct the ACRM. In 1995 John and I negotiated an agreement with CAE Link to acquire our technology to develop a commercial patient simulator. We had created our own math model of the cardiovascular system in the first versions of this simulator. CAE Link later licensed the model developed by Howard Schwid from the University of Washington. I believe that the consortium of the Anesthesia Departments was the first to purchase a CAE Link Patient Simulator, and they then established the Boston Anesthesia Simulation Center (BASC)

WvM: You are the – very much appreciated – founding Editor-in-Chief of the first and still leading scientific journal in our field: Simulation in Healthcare. I had the pleasure of serving on the initial editorial board for that and in 2006 my group in Porto published the very first paper in the journal. Can you tell us a bit more about the journal’s inception? And has it fulfilled your vision?

DG: Initially Dan Raemer spearheaded the call for the creation of a professional society for simulation, and the Society for Simulation in Healthcare was launched. It was clear the SSH needed to create a full-blown PubMed listed scientific journal. I was one of 2 candidates for Editor-in-Chief; ultimately I was selected. Starting a journal “from scratch” was fascinating. Dan and others selected the publisher, settling on (then) Wolters Kluwer. Beverley Anderson (may she rest in peace) became the first Managing Editor. The SSH selected an Editorial Board, while I selected the first group of Associate Editors. We received our listing in PubMed on our 2nd try. I served as EIC for 12 years, handing off to Professor Mark Scerbo. The scope and rigor of the Journal expanded continuously – now approaching 20 years of publication. Certainly, among the other journals in healthcare simulation available to date, this one distinctly stands out as the leading publication in healthcare simulation, surpassing all my expectations!

WvM: What current projects are you leading in healthcare simulation?

DG: Since I am 45 years old (hexadecimal notation; 69 in decimal notation) and have been a tenured professor at Stanford for nearly 30 years, a lot of what I do is not “leading” per se, but rather helping others as individuals or groups to accomplish their goals and activities. I am proud and pleased that a major thread of my research – to study the dynamic decision making of anesthesiology professionals – has continued steadily from our initial studies in the late 1980s through the present time. In the last 10 years I have been a senior player in two large projects on this topic with my colleague Matt Weinger as the Principal Investigator and many others of long-time collaboration with me heavily involved. I hope that this thread of research continues for a long time. We still don’t know enough about how anesthesiologists think, and perform, in difficult situations.

WvM: You’ve worked with Nik Gravenstein (1925-2009), another simulation pioneer. Could you reflect on the influence of those interactions?

Nik was indeed a giant of anesthesiology and patient safety. I was honored to serve with him as a Board Member of the APSF, and that was my major connection with him. In the development of patient simulators for anesthesiology he and his team, that included you, Willem, Mike Good, Sem Lampotang, and Ron Carovano were sometimes friendly rivals. And in anesthesiology and patient safety I was the brash newcomer. Fortunately, over the years all of this smoothed out to the mutual benefit of all of us as individuals and to the expansion of patient simulation for teaching, research, and the improvement of patient outcome and patient safety in a host of arenas of healthcare. 

WvM: Along the way, you have met many other people and worked with various simulationists. Were there people who inspired you? Did anyone specifically change the way you thought about simulation?

DG: For starters, I have to say that my wife Deanna Man was a key inspiration in my entire simulation endeavor. Jeff Cooper has been a constant mentor and friend for over 30 years. He was surely my inspiration about patient safety, and I introduced him to mannequin-based simulation and the CRM-based approach to understanding and training both medical/technical and non-technical aspects of patient care in anesthesiology and otherwise. Jeff played a huge role in boosting simulation and with his Boston colleagues creating all sorts of novel things. He is also the most “ethical” person I know. We continue to be in regular contact, exchanging thoughts, ideas, and advice. Of course, my work at VA Palo Alto and Stanford has provided a host of colleagues – especially Steve Howard, Ruth Fanning, Sara Goldhaber Fiebert, and Naola Austin – who have served as important sources of ideas and advice. The scope of simulation, even just in anesthesiology, is huge and I have many colleagues and friends with whom my long-term relationships have also provided new insights. These include my close colleague Matt Weinger, Lisa Sins, Amanda Burden, and my partner at the Stanford Center for Immersive and Simulation-based Learning, Susan Eller. The list of all other influences(ers) is too long and sadly I must leave out many important people…

WvM: Do you have an idea about how virtual reality, artificial intelligence, and ChatGPT may change the way simulation is done?

DG: About 20 years ago I wrote that, by 2020 or 2025, VR would completely take over from physical (i.e. mannequin-based) simulation. This has not happened yet, and it may not happen by 2025. One barrier has been the inability for a participant to interact with “completely believable” computer-generated patients or (critically) believable co-workers (e.g. surgeons, nurses, other anesthesia professionals). The onset of Large Language Models and their implementation in commercial software applications (ChatGPT and others) may greatly accelerate the development of VR capabilities. However, as long as the actual conduct of health care is done by real human beings – often in teams – ON real human beings, it is unclear whether physical presence IS needed to fully recreate the complexities of dynamic patient care. That aside I have a large list of other useful applications of generative AI to many aspects of the spectrum of simulation.

WvM: Are the Grateful Dead still on your playlist, David?

DG: Ha ha! Yes indeed. Not only do I listen to the Dead on my playlist for my bike rides (using only one ear!), but they are frequent appearances on the playlist in the simulation OR at Stanford. No OR is complete without music. And, of course, Steve Howard is also a Dead Head, and when I took him to a Dead show at the Stanford Frost Amphitheater when he was a resident many years ago it cemented his becoming a fellow in my simulation “lab” – and the rest is history!

WvM: Anything else you would like to share with our readers?

DG: One thing is a way to think about the spirit that drives all of us in our simulation activities. I often end my lectures with a saying which appears in different forms in both the Hebrew Talmud and the Muslim Quran: “Whoever saves the life of one person it is as if they have saved the life of all mankind”. Although positive proof that simulation saves lives is hard to establish, we have substantial reason to believe that our simulation activities have contributed strongly to the saving of hearts, brains, and lives.

Our goal in simulation is to improve the quality and safety of patient care for all people, everywhere.   

I would also suggest that while the expansion of the full spectrum of simulation modalities and applications is encouraging, we have only scratched the surface of what needs to be accomplished. We can be proud of what we have accomplished but we need to have the long view, pushing continually to promote our lofty goals regardless of the difficulties.

WvM: We normally close these interviews by a question that is a bit outside of the box. You have been a keynote speaker at many prestigious conferences. Is there a conference where you wish they had invited you?

DG: Hmm…. interesting question. Maybe not so much as to “conferences” but I never got to provide testimony to Congress in pursuit of the goals stated above; nor have I been asked to do a TED Talk.  Hmm… perhaps my style isn’t well suited to either? I would also love to talk about the role of simulation in preparing personnel for dynamic clinical management in outer space. Of course, I’ve not retired yet and continue in both of my positions as Associate Dean for Immersive and Simulation-based Learning at Stanford School of Medicine, and Founder, and Senior Advisor of the Simulation Center at VA Palo Alto Health Care System. So, who knows these wishes might still be granted!

WvM: Thank you again David. I am looking forward to, one day, seeing a fully organized account of your path through simulation, but not as much as I am looking forward to the other contributions you will still undoubtedly make!

DG: Thanks so much for the invitation and your patience!!


Willem van Meurs

Willem van Meurs

Consultant in simulations (self-employed), Lahitte-Toupière, France View all Posts

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