Gained in translation

Spring 2007 Interaction

Courtesy of School of Medicine

The Learning and Knowledge Center, seen here in an artist's rendering, will form part of the School of Medicine's new "front door."

The School of Medicine gets awards and honors for just about everything. But not architectural planning. At least not yet.

"Right now, over there, there's one of everything," said campus architect David Lenox, including buildings that date back to the school's move from San Francisco to the Farm nearly 50 years ago.

L.A. Cicero
Maggie Saunders is project manager of the Learning and Knowledge Center.

School and university officials had been talking about a redesign for years, but it was the arrival of Dean Philip Pizzo in 2001 that kicked the plans into gear. Many of the building projects on campus are attempts to revitalize Stanford's original east-west quad arrangement, but given the potpourri of buildings at the medical school, another scheme had to be devised.

So the school will be at the intersection of two coherent walkways. The clinical, or "Discovery," walk will link the school in one direction to the hospitals, in the other to the two science and engineering quads, SEQ1 and SEQ2; the research walk will run east-west from the school buildings past the Clark Center to the biology and chemistry buildings. The paths will formally integrate the off-campus community with the schools of Medicine, Engineering and Humanities and Sciences.

At the heart of all this — the nexus of research and education and health care — is the Learning and Knowledge Center (LKC), which will occupy the site of Fairchild Auditorium. Construction will start in late spring 2008. The project was designed by the architectural firm NBBJ. (The building's stunning website is

"The Discovery Walk underlies our mission of translational medicine," said LKC project manager Maggie Saunders. "This building is the first step in the translation process, because without teaching, there is no translation."

"A human process"

L.A. Cicero
Dr. David Gaba, associate dean for immersion and simulation-based learning.

The planning process began with meetings among all the players, including faculty members. One faculty member who from the start assumed a leading role was Dr. David Gaba, associate dean for immersion and simulation-based learning.

"The most important part of the process is bringing together faculty from different parts of medical education," Gaba said. "That was the secret."

Gaba was on a similar building committee at the Palo Alto VA Hospital after the 1989 Loma Prieta earthquake. Technology has changed since then; designers can portray things graphically far better than before. "But frankly," he said, "the process is a human process, and that hasn't changed."

Gaba is an anesthesiologist.

"Anesthesia has always been at the forefront of mannequin-based simulation because it is dangerous and it is not therapeutic in and of itself," he said. "Anesthesiologists are very worried about safety, very risk-adverse, so they were the leaders of the patient-safety movement."

Those concerns led him 20 years ago to adapt techniques used in cockpits by aviators, who have to make the same type of split-second decisions as anesthesiologists.

Simulation-based learning will be one of the most outstanding pedagogical features of the LKC. One common feature of all building planning processes is the fight over window space; happily, that was not the case here, as virtual reality (VR) and simulation labs are light-averse. So the simulation component, the largest in the building, will be in the basement.

All in one place

It will comprise several parts. The school and hospitals today have four simulation labs; most or all of them will now be together, incorporating all modalities of simulation: clinic rooms with standardized-patient actors or mannequins, VR labs, rooms for task-trainer machines and what amount to movie sets, where clinical sites such as operating rooms or roadside accidents can be recreated. There may also be hybrids between VR and physical simulation, along with high-resolution power-wall displays and telepresence capability.

Courtesy of David Gaba
Medical residents "treat" a mannequin in one of the simulation laboratories.

"In a one-dimensional simulation — like an actor portraying someone in pain — students can't very well practice treatment, "said Dr. Clarence Braddock, Gaba's colleague in the planning process. "But in a multidimensional situation, students can experience more complex scenarios. The simulations will be much more rich."

The basement will also contain a large project classroom (the "wet-dry" room), with benches for messy exercises. Faculty members will be able to observe many of the activities with monitors or one-way mirrors. Actors will have an area for lockers and a break room.

The mannequins won't have a break room, but they will have names. One of Gaba's many virtues is that of being an unrepentant Deadhead, so the simulated patients have been honored with names such as Jack Straw, John B. Goode and August West.

"The exact design of the basement is still under consideration," Gaba said. "We need space with flexibility for the future. We know there will be new developments out there, but nobody knows yet what they are."

He envisions a large role for Stanford University Medical Media and Information Technologies (SUMMIT), led by Parvati Dev, who earned a Ph.D. in electrical engineering from Stanford. SUMMIT develops and shares medical informatics, be they simulation devices for teaching surgical techniques, anatomical images broadcast around the world or virtual environments for teaching medical emergency management.

The group originally was focused on anatomy and curricular development, and many of its projects enable medical students in distant places to follow along. But increasingly it has turned its attention to surgery and gaming, changing its emphasis as the imaging technology has advanced.

"What's refreshing about Stanford is that everyone has a keen curiosity and willingness to learn," said Pat Youngblood, SUMMIT's associate director for evaluation. Youngblood, who has Ph.D. in education and has worked for two decades in educational technology, makes sure the technology actually helps medical students learn.

"People don't wear blinders," at Stanford, she said, "they don't say, no, that's not my field. I work with surgeons, and we share a common commitment to teaching and learning. Surgeons want to learn from me."

The notion that medical education must be grounded in practice is fundamental to Pizzo's vision for the school, Saunders said. "He knows that innovation happens by doing."

Flexible classrooms

If that is true in the basement, it will be true on the LKC's other floors as well. For instance, designers and faculty spent many months developing a prototype of the classroom of the future.

"Because the clinics pay most of the salaries of many of our faculty," Saunders said, "there might be an incentive on the part of faculty not to innovate with teaching. So we have to supply spaces and opportunities so they can see the advantages. The building will be a step ahead of where the faculty are; it will move them."

Courtesy of David Gaba
Pediatric nurses
Pediatric nurses at Lucile Packard Children's Hospital engage in an exercise using a mannequin-based simulator.

Prototypes are "expensive but essential," Saunders said. With a relatively small faculty, the medical school aims for highly flexible studio classrooms that can accommodate several small groups at a time. Renderings look a bit like a second-grade class at a Montessori school, with groups of students clustered around various large tables. Furniture and whiteboards will be on casters. Projection technology will be adaptable.

Braddock, who teaches general internal medicine and has won a long list of teaching awards, worked with architects and other faculty members in developing the classrooms with team-based learning in mind.

"In health care, people are calling for interdisciplinary teamwork among physicians, nurses, pharmacists, etc. As an instructional method, this lets learners apply knowledge to real-life case studies and work effectively in high-performance teams," he said. "The instructor's role is to prepare students to enter into very active application exercises and work collaboratively."

A second-floor conference center will enable the medical school to host important national and international gatherings and, Saunders said, "maintain a better conversation with the rest of the university." Bereft of an adequate conference center, the school today holds most of its major meetings off-campus. Like the classroom space and lecture halls, the center will be highly flexible, allowing for tiered or flat seating, small or large groups.

The dean's office will be on the third floor. So, too, will a suite of classrooms, the point being to ensure that the school's administration, faculty and students have opportunities to bump into one another, as they do in the neighboring Clark Center, the path-breaker in enlightened design on campus.

But you won't bump into students on the fourth floor of the LKC, because you can't get there from here. With the best view in the house, the top floor is a students-only space.

Medical students, Ph.D. students and post-docs will have a study area, fitness center, computer labs and kitchen all to themselves. During the planning meetings, it became clear that medical students were not happy with this mix, fearing they would not be able to have frank conversations about patients if there were researchers on the adjacent treadmills. So they will have a small place to themselves, though the gym and kitchen will be mixed.

Inspiration from the top

All this does not come cheap, of course. The estimated cost of the initial LKC building (there will be a second one) is around $90 million.

But in the minds of the school's leaders, there is no other way, no better way, of training physicians and medical researchers. As Pizzo likes to say, the school must teach students not just what to think, but how to think.

"Looking ahead," Gaba said, "immersive learning will be embedded in the fabric of what we do in professional education at every stage, in individual and group learning, throughout one's whole career."

Philip Pizzo

As the project moves closer to groundbreaking day, the school is looking ahead with excitement and trepidation. "Controlled chaos" is on the agenda, the dean warned the school in a recent open letter, addressing the frightening prospect of fewer parking spaces. But innovation never comes easy.

"I'm not aware of any school that has gone as far in promoting team-based learning," Braddock said. "Our whole second-year curriculum is based on teams. We're doing research on the method to see how it affects learner ratings and educational outcomes."

"It starts at the top," he added, asked to explain Stanford's efforts. "Dean Pizzo has created an environment where there's more support for trying to enhance and seek excellence in education."

"The dean has never wavered," Saunders agreed. "He gives us inspired leadership."

It's been a long process, Braddock said. "I've accumulated lots of frequent flyer miles," he said, referring to the planners' road trips to leading medical schools around the country to see what works and how. "But this is a very important building for Stanford, and for it to work we need to have faculty input. So I felt the obligation to provide that. It's really exciting now, looking at how it's turning out."