HPS in Medical Education 1
EFFECTS ON LEARNING USING HUMAN PATIENT SIMULATION
IN MEDICAL EDUCATION
______
A Dissertation Proposal
Presented to
The Faculty of the CurrySchool of Education
University of Virginia
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In Partial Fulfillment
of the Requirements for the Degree
Doctor of Philosophy
______
by
Sue Oliver Kell
July, 2006
CHAPTER I
INTRODUCTION
Patient safety is of utmost concern to anyone currently seeking or providing health care services. “First, do no harm,” or a similar oath, is taken by all physicians when obtaining alicense topractice medicine. In the last decade, theprevalence of health care provider mistakes and their effect on patient safety has led to changes in medical education, including the use of human patient simulation. Human patient simulators are computer-driven, life-sized mannequins, programmed to respond to medical situations and procedures, giving students a chance to perform and learn in close-to-real-life scenarios. Simulators provide a risk-free environment that can be standardized and reviewed. Many medical teaching institutions are purchasing human patient simulators (HPS) to enhance the clinical and emergency response skills of health care students.
Because of the many perceived advantages associated with HPS, the number of educational centers using HPS worldwide has grown exponentially since the mid-1990’s. In 1994, there were 9 simulation centers worldwide. In 2005, there were 557 simulation centers worldwide, with 356 being in the United States(Worldwide simulation sites, 2005).
The expense of HPS is a significant factor when looking at the cost-to-benefit ratio of this educational format. Each high-fidelity mannequin costs an average of $200,000 and it takesapproximately one million dollars to open a simulation center (Jha, Duncan, & Bates, 2001). A simulation center is a facility containing the simulation equipment, instructors, and support personnel needed to conduct training of healthcare students and workers.
Simulation in High Risk Occupations
Many high risk occupations use forms of simulation for training purposes in hopes of increasing safety (Jha et al., 2001). The aviation industry was the first to widely employ simulation for educational purposes. Flying skills and management of flight emergencies are two areas where simulation education has been developed. Since the late 1920’s, flight simulators have been shown to be so effective for pilot training that certification for pilots can occur by demonstrating competence on a flight simulator. Studies from the 1980’s found that safety has been linked to the crew’s ability to manage resources effectively. In response, aviation education experts use activities, such as full-mission simulations and debriefings, termed Crew Resource Management (CRM), which is required training used to improve crew performance(Gaba, Howard, Fish, Smith, & Sowb, 2001).
Anesthesia was the first of the medical fields to find parallels to aviation’s educational needs. As a high risk occupation where 80% of all adverse anesthesia incidents are due to human error (Jha et al., 2001), it has been thought that simulation experiences might improve patient outcomes. The first anesthesia simulator was developed in 1969, but it was not until the mid-1980’s that educators began routinely utilizing simulation in anesthesia training (Gaba et al., 2001).
Many other medical disciplines, including emergency medicine, cardiology, radiology and pharmacology are now beginning to incorporate simulation in the education of health care professionals(Gaba et al., 2001). Pharmacology, the science of drugs and their effects on the human body, is an area ripe for simulation development. Management of medication interactions, overdoses, and side effects are common requirements for patients in emergency medicine settings. Similar to anesthesiology, pharmacology scenarios using a human patient simulator are relatively user-friendly to program. A broad range of HPS pharmacology scenarios could provide experiences for medical students and residents who may not otherwise encounter these challenges in early practice.
Patient Safety
Patient safety is one of the driving forces behind the use of human patient simulation. In 1999, the Institute of Medicine (IOM) investigated the incidence and reasons for the startling number of medical errors leading to death and disability, and made recommendations for solutions, including the use of simulators in healthcare training (Kohn, 1999). The latest IOM report on medication mistakes claims an average of one error per hospitalized patient per day, costing $3.5 billion to treat the related patient injuries due to error {{59 Aspden, P. 2006; }}. Simulators inspire hope for patient safety gains because students can see the simulated patient response to their clinical decisions and actions at no risk to a real patient. A study by Peignet found that doctors trained with a simulator performed retinal photocoagulation as well as those trained with patients (Peugnet, Dubois, Rouland, 1998). Despite this study and others, there is no solid evidence that simulation-based training improves patient outcomes. Cohort studies examining outcomes would be difficult to perform because of the sheer number of patients and physicians that would be required and a host of confounding factors to be considered (Jha et al., 2001).
HPS Replaces Dog Laboratories
The discontinuation of dog laboratories in medical universities is becoming a reality in the United States. As of 2003, of the 125 schools, 100 have replaced their dog labs with other methods of teaching anatomy, including human patient simulation. Arguments concerning the ethical treatment of animals in medical institutions have been a hot issue for students, faculty and animal activists,for years. As HPS has become more sophisticated, their ability to teach students is highly regarded by groups such as the Physicians Committee for Responsible Medicine. Medical advisor for the group, John Pippin, a Dallas cardiologist says,
“Human simulators can be programmed by an instructor to show a variety of responses. You can program it to be critically ill or stable. To show an allergic response versus a normal response. They can be programmed to respond to 55 different drugs.” (March 12, 2006 editions of the Milwaukee Journal Sentinel)
Pippin feels the real advantage of HPS is the ability to repeat procedures, which is not possible in the dog laboratory.
"You can't do that with a dog," Pippin said. "Medical students learn at different rates. Of the five students working on that dog, some will get it and some won't. And those who don't are going to have to do it over and over again. The live dog lab doesn't give them that opportunity." (March 12, 2006 editions of the Milwaukee Journal Sentinel)
Medical Students
Becoming a medical student is a highly selective process. Students are chosen based on performance in academics, Medical College Admissions Test (MCAT) scores, motivation and commitment to medicine, and personal characteristics linked to physician success. Students must complete 90 undergraduate credit hours which include Biology, General Chemistry, Organic Chemistry and Physics{{58 Anonymous 2006; }}.
At the University of Virginia, approximately 500 interviews are granted every year out of approximately 3,500 applicants. Only 141 students are selected from the total pool of interviewees each year{{58 Anonymous 2006; }}.
MedicalSchool Curriculum
Medical students at the University of Virginia are enrolled in a four year program of medical training where learning in the presence of patients is one of the valued components of the school’s educational philosophy. Knowledge, management and understanding are also components of the education philosophy and are combinedin a curriculum termed the‘practice and science of medicine.’ First year medical students engage inthe basic knowledge acquisition of physiology, histology, genetics, biochemistry, anatomy, and neuroscience.This first year of knowledge building is a critical step in knowledge construction upon which all future layers of learning are applied. This scientific knowledge is used to discuss clinical applications in small groups with faculty, called the Practice of Medicine(POM). In the first year of medical school at UVA, students learn to obtain patient histories through patient interviews, andconduct physical exams on patients. Two of the five sections of Pharmacology, General Principals and Endocrinology, are taught at the end of the first year of medical school{{51 Anonymous 2005; }}.
Pharmacologyand pathology are the primary foci for second year medical students. This coursework is dovetailed with clinical observations and the furthering of patient examination skills though a curriculum organized by organ systems--pulmonary, gastrointestinal, cardiovascular, renal, neurological, infectious disease, endocrinology. Second year medical students receive preceptorship assignments, where students work in a community medical practice with a physician for one week{{51 Anonymous 2005; }}.
Third year medical students devote much of their time to clinical training. Clerkship assignments occur at UVA and surrounding hospitals and are arranged by medical department, such as internal medicine, surgery, pediatrics, and the like, and involve direct patient contact. Students learn during patient rounds with practicing physicians, and in seminars with faculty{{51 Anonymous 2005; }}.
Fourth year students select electives to further their education in their own areas of interest, by selecting clinical rotations under their advisors’ guidance. Students also participate in an intensive study of neurology{{51 Anonymous 2005; }}.
After completion of the four years of medical school, graduates apply for admission to a three year accredited Residency program in their chosen specialty area. The majority of applicantsare selected by one of their three program institution choices. In the first year, these graduates are called interns, and thereafter first and second year residents. Progression through the three years of residency leads to greater independence in treating patients. Interns and first and second year residents focus on their chosen specialty area, but are also required to rotate through most, if not all, of the clinical specialties.
Pharmacology Curriculum
Pharmacology principles are taught primarily by lecture, using PowerPoint slides, and by observation in clinical settings. There is a website of practice exam questions available to students as well as small discussion groups with faculty and a Pharmacology Course Newsgroup website for course information, resources and the posting of pharmacology questions.
“The three goals of the course are, in the order of importance, to learn the basic mechanisms of action of the major drug classes, to learn the fundamentals of their therapeutic use, and to memorize the major representative drugs of each class.”{{57 Cruetz, C. E. 2006; }}
Five sections of Pharmacology are covered in medical school, including General Principles, Endocrinology, Pharmacology, Autonomic and GI Drugs, and Introduction to Central Nervous System Drugs (CNS), CNS and Cardivascular Drugs, and Antimicrobial and Antineoplastic Drugs{{57 Cruetz, C. E. 2006; }}.
Simulation in Pharmacology
Limited reference to the use of human patient simulation is found in the literature regarding the application of this technology in pharmacology. However, information aboutuse of HPS in anesthesiology is more readily available and does have parallels with pharmacology in that administration of medications is a key function within the discipline. The National University of Singapore describes the application of human patient simulation in Anesthesiology training as follows:
“Specifically, simulator training will be very useful in:
- Teaching basic skills to medical students.
- Training trainee doctors in basic anaesthesia skills before they administer anaesthesia to real patients.
- Crisis management for experienced doctors, nurses and paramedics, particularly those who work in intensive care, emergency departments and operating theatres.
- Demonstration of new drug and new equipment by pharmaceutical and medical equipment companies.
Teaching and training with a patient simulator will render current medical school teaching more complete, realistic and systematic. All students can be trained to a required practical standard in a controlled, safe and even enjoyable environment.” {{49 Anonymous Undated; }}
Experts think that HSP is particularly important in learning medical practice in this domain, because administration of medications on real patients for training purposes is considered to be ethically unacceptabledue to inherent patient safety risks. With HPS, students can either participate in hands-on activities with HPS, or observe how experienced clinicians manage predetermined scenarios involving pharmacology.
More than ever, schools of medicine and nursing are expected to produce clinicians who have a comprehensive knowledge base and skill set. During their training, students may experience treating only a limited number of patient conditions. This occurs because students depend on learning from the live patients who present at their medical universities. Not every student on a toxicology rotation will treat a patient who has ingested jimson seeds, or seen fasciculations from a rattlesnake bite. Simulation can fill in the ‘gaps’ by providing a broad range of patient conditions. HPS scenarios can be standardized, evaluated and reviewed as needed (Gaba, 2000).
I plan to take advantage of fourth year medical students’ and interns’ limited skill set in this dissertation study. Treatment of venomous snakebites is a topic not typically covered during medical school or internship. At the University of Virginia, treatment of venomous snakebites only occurs if the fourth year student or resident chooses the Toxicology Rotation through the Division of Medical Toxicology or if they happen to be present when a patient presents with a snakebite in the emergency room.
The UVA Department of Emergency Medicine treats approximately two dozen venomous snakebite victims each year, usually in the warmer months. Bites most commonly occur from Copperhead snakes, and at most one or two Timber Rattlesnake bite victimsare treated per year. Since Timber Rattlesnake bite victims are a rarity, most of my participants will not have any experience treating this condition. I plan to use treatment of Timber Rattlesnake patients as the educational topic for my study and control groups.
Research Questions
Research demonstrating the educational benefits of using HPS over traditional teaching methods is lacking. There is limited research showing the effectiveness of HPS in any educational modality including knowledge, application, retention or performance.
This dissertation will describe two pilot studies and a final study, which all evaluate the effectiveness of HPS as a teaching tool. The underlying question in these studies is, “What is the role of HPS in improving learning in pharmacology?”
My dissertation research will investigate the use of HPS in a specific learning situation, the treatment of a Timber Rattlesnake victim. The question for this research follows: “How does a learning experience with HPS effect medical resident treatment and evaluation of a standardized patient who is the victim of a snakebite?”
Important Definitions:
human patient simulation- a form of multimedia learning which replicates patient conditions with sufficient realism to practice diagnosis and treatment
standardized patient- someone trained to perform like a patient with a certain medical condition
multimedia learning- building mental representations with words and pictures
knowledge- presence of factual information
application- use of knowledge to interpret a given circumstance
retention- ability to recall knowledge and application after two weeks have lapsed.
performance- interventions in patient care to improve patient condition
In summary, the effectiveness of using human patient simulation in medical education safety needs to be analyzed. Many educators think HPS has the potential to improve patient care and safety by giving students a more hands-on approach to learning about a wide variety of patient conditions in a safe environment. Little is known about the true educational benefits of using human patient simulation. So, I will ask what benefits occur using HPS in the educational modalities of knowledge acquisition, application and retention of knowledge, and performance.
CHAPTER II
REVIEW OF LITERATURE
A review of the literature found many relevant topics concerning medical education as it relates to learning theory, human patient simulation, pharmacology, and multimedia. This evidence provides an important foundation upon which I build my case to study the role of human patient simulation in teaching medical residents pharmacology principles. In order to defend the instructional design used in this experiment, I will present information on learning theory for use in this application. I will explain the practice of medical education as it currently exists, including the different types of learning that must take place, characteristics of the medical school curriculum, and the learning challenges involved. Last, I will provide a discussion of the research outcomes relative to this line of inquiry.
Learning Theory
Learning implies change, demonstrated change leads to theory generation, and theory informs practice. In the last sixty years educational theorists have described three basic philosophies of learning: behaviorism, cognitivism and constructivism. Simply stated, behaviorism is based on changing behavior patterns through repetitive learning tasks involving memory, cognitivism is based on the thought processes leading to and measured by behavior changes resulting from mental models, and constructivism is making sense of the world, in an individual way, by using past learning experiences to create a set of rules or mental models to explain how things are understood. Learning is a search for meaning whichbuilds upon previously formed attitudes and beliefs which are used to solve problems in new situations. Examples of each, in order, might include, Pavlov’s classical conditioning with stimulus and response thereby creating memory, imitation of behavior in social contexts which creates new behavior patterns, and learning through experience to react accurately in novel situations. It is difficult to completely separate each approach in education because many educational teaching strategies incorporate aspects of all three approaches(Jonassen & McAleese, Undated).
We see this blending of learning theory in medical education where medical students are challenged to make learning gains in scientific knowledge, demonstration of skills, and through expressing empathy and problem-solving. These learning domains represent a wide range of expected ability in practitioners, from the objective to subjective areas of activity.
David Jonassen, a professor in Instructional Systems at PennsylvaniaStateUniversity, states that constructivist learning strategies are “most effective for an advanced knowledge acquisition stage of learning” and are practiced universally on the undergraduate and graduate levels. Constructivist learning requires a more open-ended approach, is learner controlled, and is more difficult to measure. Constructivist learning strategies provide learners with a representation of reality, authentic tasks, case-based learning environments, reflective practice, context- and content-dependent knowledge construction, and collaborative construction of knowledge(Jonassen & McAleese, Undated).