Presentation by Lucas Opitz at the International conference on Simulation-based training in medicine (Kyiv, Ukraine, March 19-20, 2015) http://motherandchild.org.ua/eng/SimConf-2015

1. Medical simulation and emotions
Dr Lucas Opitz
CHU Nice, France

2. What are emotions?
emotion (n.) 1570
- "a (social) moving, stirring, agitation," from middle French
Emotion (16c.), old French emouvoir "stir up" (12c.), latin
emovere "move out, remove, agitate"
- assimilated form of ex- "out" + movere "to move" = MOVE
OUT = Sense of "strong feeling" deriving from one’s
circumstances, mood, or relationship with others
- first recorded 1650s; extended to any feeling by 1808

3. What are emotions?
- James’s (1884): still unanswered (but interminably asked) question…
- Brain modes, actions or action tendencies, reflexes, instincts, attitudes,
cognitive structures, motives, sensations, feelings?
- Biologically fixed modules (and hence reducible to biology)
- Socially constructed roles (and reducible to sociology)?
- Discrete categories or bipolar dimensions?
- Cognitive, precognitive, or postcognitive?
- Mental states or mental-behavioural processes?
- Same class as sensations, beliefs and desires

4. Emotions
Behavioural reactions
Emotional regulations
Extrinsic reactions
interactions
Management

5. Emotions during simulation exercises
• Anxiety: unknown: DANGER
• Pressure:
– Performance
– External observers
– Discussions, analyses - critics?
• Relief
Changed from: Dis Mon 2011;57:700-705
Stress

6. Stress
• Definition: Appears to arise whenever there is a departure
from optimum conditions which the organism is unable, or
not easily able, to correct
• Imbalance between demand and the organism’s capacities
• Importance of failure: the demand must be considered as
important by the concerned person: performance, social
(Stress and performance, A. T. Welford, Ergonomics 1973, vol 16 n°5 567 - 580)
Capacities
Demands
Environment
Social situation

7. Physiological reactions to stress
Emotive-cognitive:
• Sensation of impotence
• Panic, anxiety
• Angriness, irritability
• Confusion
• Sadness
• Sensation of guilt
• Sensation of being vulnerable
• Loss of interest

8. Physiological reactions to stress
Difficult to control:
– Blushing
– Bloc respiration
– Trembling
– Cold hands
– Face expressions

9. How does the the trainee feel?
• “What do they want from me?” incertitude
• “Am I able to respond to their expectations?” performance
• “I don’t like them watching me!”
• “How can I avoid to show them I do not know all of it?”
• “I should have read the latest recommendations. Still, I must prove I
am a good professional”
• “This here is just not real, reality is completely different”
• “I have always worked in my way and never had any problems”
• Protection or vulnerability according to team
• After more than some hours, days: getting more relaxed
• At the end: relieved: no further damage has been inflicted…

10. The trainee: Possible attitudes:
• Withdrawal, abandon
• Aggressivity
• Mockery (situation, self)
• Playing the game
• Missunderstanding the signals
• Wanting to be recognized
PROTECTION

11. Trainees prototypes, or parallel communication
• Dominant
• “Recessive” = timid,
• Indifferent
• Aggressive
• Enthusiastic
• Manipulative

12. - Simple or well-learned tasks:
- linear relationship
- improvements in performance as arousal increases
- Complex, unfamiliar, or difficult tasks:
- relationship between arousal and performance becomes
inverse
- declines in performance as arousal increases
Emotions and performance
Neural Plast. 2007;2007:60803.The temporal dynamics model of emotional memory processing: a synthesis
on the neurobiological basis of stress-induced amnesia, flashbulb and traumatic memories, and the Yerkes-Dodson
law. Diamond DM1, Campbell AM, Park CR, Halonen J, Zoladz PR

13. Yerkes-Dodson law (1908):
- Performance increases with physiological or mental
arousal, but only up to a certain point
- When levels of arousal become too high, performance
decreases.
Emotions and performance

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15. The trainer’s emotions
• “Do I cover all the possible events?”
• “Do I know/master all the possible clinical events?”
• “No technical incident?”
• “We had this teaching goal but now they focus on
something else, irrelevant..”
• Confrontation with some trainee
• “Why does the trainee always justifies himself?”

16. Defense mechanisms
Fragility Resources
Denial
Cleavage
Projection
Aggressiveness
Cancellation
Denial
Justification
Rationalization
Obsessions
Isolation
Sublimation
Creativity

17. Theory of adaptation
STRESS
balance
imbalance Resource mobilization

18. Resource mobilization
• Not equal for everybody
• Adaptation:
– Time
– Individual
• Need to be enhanced, emphazised, coached

19. Effects of simulation on real-life stress
• Medical simulation decreases the physiological and psychological
effects of stress experienced by participants
• Diminishes its effects on decision making and skill degradation and
improves overall medical performance to a simulated anesthesia
emergency
• Jeffrey A. PhD, CRNA; Hogan, Gerard T. DNSc., CRNA Medical Decision Making Under Stress-Evaluating the Impact of Medical
Simulation Instruction on Affective LearningGroom, Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare:
Summer 2006 - Volume 1 - Issue 2 - p 99
• Impacts on BP, HR
• ScenarioMorris Kharasch, MD, FACEP, Pam Aitchison, RN, Christopher Pettineo, BA, Laura Pettineo, MA,
Ernest E. Wang, MD, FACEP: Physiological Stress Responses of Emergency Medicine Residents During an
Immersive Medical Simulation Scenario Disease-A-Month, November 2011 Volume 57, Issue 11, Pages 700-705

20. Stress in simulation to help to lower stress in real-life
• Medical staff reported that error is important but difficult to discuss
and not handled well in their hospital
• Barriers to discussing error:
– denying the effect of stress and fatigue on performance
– differing perceptions of teamwork among team members
– reluctance of senior theatre staff to accept input from junior members
• But: Research in aviation shows that individuals can be trained to recognise stress as an
error inducer
• BMJ. Mar 18, 2000; 320(7237): 745ñ749.PMCID: PMC27316Error, stress, and teamwork in medicine and
aviation: cross sectional surveysJ Bryan Sexton, doctoral candidate,a
Eric J Thomas, assistant professor,b
and Robert
L Helmreich, professora

21. Psychology of communication
- Signals that we give one to another contain several
concurrent messages, which can be of very different weight
- Explicit - implicit
- Non-verbal messages
- Sender and receiver believe different messages of the signal
to be the most important for them

22. Psychology of communication
• 4-ears-model
• Which ear are you talking to?
• With which ear are you listening?

23. Psychology of communication
1. Factual information (which I am informing about) blue
2. A self-statement (what I show of myself) green
3. A relationship indicator (what I think of you and how
I relate to you) yellow
4. An appeal (what I want you to do) red

24. QuickTime™ et un
décompresseur
sont requis pour visionner cette image.

25. Psychology of communication
• Sender and receiver: not the same package
• The knowledge that each signal contains various
messages, as well as the ability to receive signals
with 4 ears, are the best guarantee that
misunderstandings can be minimized in
communication between people

26. Psychology of communication
If a problem in communication has arisen, the
receiver should go through the following
check-list:
1. What are the messages in the signal?
2. Which was the main message?
3. Does the signal also contain implicit messages?
4. Was the signal congruent or incongruent?
5. What was expressed on the level of
metacommunication? (the "that-is-what-is-
meant" part of the signal)
6. Have I picked up the signal with 4 ears or with
only one?
Linus Geisler: Doctor and patient - a partnership through dialogue†† © Pharma Verlag Frankfurt
http://www.linus-geisler.de/dp/dp06_speech.html

27. Psychology of communication: example
• “This baby breathes badly”
– Factual:
• SaO2 83% at room air
• Expiratory moaning
– I made the diagnosis before anybody else
• (see I am a good clinician)
– You should have realized earlier
• (I have a moral authority on you)
– You should put him under CPAP
• (I am ther leader, your boss)

28. “This baby breathes badly”: reactions
– I know, I have realized as well
– Why do you say this in this tone, do you think you are
better than me?
– Do not tell me what I should have done because I know
what to do, but I wanted to check other parameters first
– Do not give me orders, you are not my superior

29. “This baby breathes badly”: reactions
– Yes, she/he is right
– She/he will help me in this difficult moment, she/he
knows what to do (submission)
– I realize I have insufficient capacities (anxiety is
raising)
– Tell me what I should do so I shall not be blamed
(abandon of proper initiative)

30. “This baby breathes badly”: reactions
The question of…
- Leadership
- “Fighting” for leadership in a group
- Switching leader
- Search for recognition
- Abandon/submission
- Silence
- Inactivity
- Loss of initiatives

31. Metacommunication
• "When I send a signal, I also send (whether I want to or
not) a message about how this signal is meant to be
received" (F. Schulz von Thun)
• "We shall be pleased to see you”:
Tolstoi's "Anna Karenina" dismisses the young Ljewin in a
cool and dry tone to the words: is experienced as a
classical example of implicit metacommunication.
• A message always contains means of interpretation:
– Non-verbal: attitudes, movements, mimics
– Verbal: reformulations, oratory precautions, tone of the
voice etc.

32. Signal,
Metacommunication
Interpretation according to receiver’s sensitivity
Neutral position when you elaborate
About signals
Hearing the signal
Neutral position when you receive
Neutral feed back
excessive insufficient

33. Sender-receiver
• Thought is not said
• Said is not heard
• Heard is not understood
• Understood is not wanted
• Wanted is not being able
• Being able and wanted is not done
• Done is not memorized
(Paul Watzlawick)

34. Sender-receiver: catalysing debriefing Hebel
• Thought is not said
• Said is not heard
• Heard is not understood
• Understood is not wanted
• Wanted is not being able
• Being able and wanted is
not done
• Done is not memorized
Make them speak out
Be able to listen with the right ear
Make sure everybody understands
(double-check)
“Play it again!”
Subtle advocacy

35. Debriefing
• Relationship of confidence: coaching, facilitating
• Feedback or not feedback, and how much?
– Positive: yes
– Negative: no, but…
– Neutral: promote self-assessment
• Feedback through questioning
• Express your thoughts when asked
• Facilitator’s task:
– Give hints
– But: Monopolizing: the other(s) will disconnect, be subordinated
to the speaker and therefore enter in phase of (relative) passivity

36. Debriefing
• Students learn better in a safe supportive learning
environment, one which is challenging but not intimidating
(WHO/IER/PSP/2009.3S)
• Errors in health care: focus on learning and fixing errors
instead of blaming those involved
(Leape 1994)

37. The essentials
• Simulation deals a lot with human psychology and
communication
• Understanding feelings and stress means being able to
anticipate them and to create constructive dynamics
• Parallel ways of communication exist and should be taken
into account:
– Promotion of free expressions
– Neutral, positive kindness
– “Nourishing feedback”