Medical Teacher
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Teaching Procedural Skills - An Overview J. R. Marshall To cite this article: J. R. Marshall (1979) Teaching Procedural Skills - An Overview, Medical Teacher, 1:4, 190-194 To link to this article: http://dx.doi.org/10.3109/01421597909012599
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 45
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [University of California, San Diego]
Date: 06 November 2015, At: 18:47
SPECIAL ARTICLE
Teaching Procedural Skills - An Overview J. R. MARSHALL
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
J. R . Marshall,
MB, B.Ch, FRACGP, & Assistant Director of Education, Family Medicine Programme, The Royal Australian College of General Practitioners, 15 Gover Street, North Adelaide, South Australia 5006.
This paper provides a n overview of various methods that have been developed to help students learn procedural skills. Future issues of Medical Teacher will describe each of the methods in depth. During their training medical students have traditionally acquired fundamental skills by practising on animals and human cadavers. For example, they have been required to practise and later to show proficiency in such procedures as dissection of the earthworm, the frog and the rabbit; perfusion of the isolated frog’s heart in physiology; and dissection of cadavers in anatomy. Assessment of their ability to perform these tasks has contributed to their final mark in the subjects concerned. Such procedures have not involved live patients for obvious reasons. In dealing with patients, training in procedural skills has been by means of apprenticeship, the students learning by observation. Subjective assessments may be made by supervisors during the training period, but to date few objective tests of ability to perform procedural tasks involving patients have been designed or utilized. Generally speaking, assessment has been confined to the ‘clinical’ examination, where candidates traditionally elicit a history, detect abnormal physical signs and make a differential diagnosis. Treatment is discussed, but no opportunity is afforded to assess manual dexterity in relation to treatment -whether this requires the application of eyedrops or the removal of a pituitary tumour. Frequently, the manner in which abnormal signs are tested for is not observed. A further disadvantage of assessment in the clinical examination is the shortage of time, which permits only a small number of areas to be tested. As examiners have not, on the whole, been trained to observe the particular ‘domains’ being assessed, it is doubtful whether the tests are reliable. In recent years, considerable effort has been directed at producing programmes that help students to learn procedural skills. As manual skills involve predominantly the psychomotor domain, most teaching methods involve the use of demonstration and various audiovisual aids, such as videotape, motion pictures and closed circuit TV. 190
Such media are more suitable than printed text, audiotapes or formal lectures which lend themselves more readily to teaching in the cognitive or content area. However, no matter how sophisticated the audiovisual simulation, one cannot be sure whether at the end students will be competent to, say, anaesthetize a patient. It is in helping students to acquire such complex skills that the computerized patient simulator is proving to be so useful. This paper provides an overview of various methods that have been developed to help students learn procedural skills. Further issues of Medical Teacher will describe each of these methods in depth. Choice of Method The complexity and cost of the method used will vary with the complexity of the skills to be taught. Thus, it is relatively simple and cheap to teach someone how to put in eyedrops, for example, but it is complicated and expensive to devise a method to teach the skills required of a competent anaesthetist. Before embarking on the production of any educational package to teach procedural skills, the objectives must be determined. Lists of what skills are to be taught and how they will be assessed in order to maintain objectivity will be necessary. To facilitate assessment, detailed rating forms are helpful. These provide check lists which can be utilized to ensure that all aspects have been covered as well as to maintain objectivity. Methods of Teaching Procedural Skills
A udiovisual A ids Simple audiovisual aids (e.g. tape slides) can be used to help teach such basic skills as putting in sutures, removing a cyst, packing a nose or applying eyedrops. Here, the only equipment required is a slide projector and a tape recorder, preferably with cueing facilities whereby a signal is put on the tape so that slides are
Medical Teacher Vol 1 No 4 1979
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
advanced automatically. Other skills which require continuity of motion, such as removing an appendix, are better suited to motion picture formats like videotape and 16 mm film. The advantages of videotapes are that they are light, easy to transport and require a minimum of skill to operate. The only problem is ensuring that the videotape is compatible with the playback unit. Tape slides have been used as part of programmed instruction packages to help students learn more complex skills. For example, at the University of Southern California, Los Angeles, staff at the Division of Research in Medical Education have produced a series of six tape slide presentations providing approximately eight hours of teaching on ‘Anaesthesia Gas Systems and Machines’. These presentations show the various stages of anaesthesia, the complications that may occur, etc. An accompanying overview of the course, exercises and selftest are included in the package. There is also a follow-up discussion for students, with an instructor present to answer questions and demonstrate equipment. The advantages of this programme are that students can work at their own pace; removal of the learning process from the operating room reduces the risk to patients caused by distraction of the teacher during surgery, and fewer demands are placed on teaching staff in supervision.
Simulation Models Considerable work has been carried out in the USA in developing models or simulators which simulate various parts of the body and help students to familiarize themselves with various pathological conditions (Sajid et al. 1970). Examples include the Heart and Breath Sound Simulators, the Lymph Node/Breast Simulator, the Ear Model and Laryngeal Model developed by the University of Illinois at the Medical Centre. Other models have been developed commercially and include the Ophthalmoscopy Manikin (Figure l), Glaucoma Test Head Model, Infant Intubation Simulator, Injectable Training Arm, Keeler Eye Model, Prostate Palpation Simulator, Spinal Tap Simulator and Strabismus Cover-Uncover Test Demonstrator (Figure 2). At Indiana University School of Medicine a family of infant simulators has been developed for use in the paediatric education programme (Schreiner et al. 1979). These include a ‘soft model baby’ with different, easily palpated abdominal masses; ‘Hippy’, a model of the lower torso and lower limbs of a term-sized newborn infant, for teaching the diagnosis of congential hip dislocations; simulators for learning radial artery puncture and umbilical vessel catheterization; and a head model for scalp vein infusion. Models have been developed as part of modular instructional programmes -for example the OMNI programme developed at the University of Southern California, Los Angeles, in cooperation with the Ortho Pharmaceutical Corporation. This consists of a number of learning modules comprising models, textbooks, slides and films. The models include the ‘Gynny’ Pelvic Teaching Model (Figure 3). the ‘Betsi’ Breast Teaching
Medical Teacher Vol 1 No 4 1979
Figure 1. Colenbrander ophthalmoscopy manikin. This simulated model helps to familiarize students with the use of the ophthalmoscope and with various pathological conditions of the eye. Interchangeable slides of the pathology of the fundus are provided f o r insertion, to be viewed through the ‘cornea’ using an ophthalmoscope. ‘Corneal’and ‘lens’opacities are also provided.
Figure 2 . Strabismus cover-uncover test demonstrator. The simulated face has moveable eyes, which enables students to practise the cover-uncover test for various types of strabismus.
Model, the ‘Adam’ Male Model and the ‘Patti’ model of a pregnant woman. Such models are very expensive to develop and are sometimes easily damaged. However, with international usage, the products can be purchased at fairly reasonable cost. Their main advantage lies in the 191
fact that standardized problems can be presented without the inconvenience of utilizing a single patient repeatedly for the same purpose. If assessment is to take place following training, this will be more objective if standard rating forms are used.
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
Programmed Simulation Models The most sophisticated model for the teaching of procedural skills-a computer controlled patient simulator -has been developed at the University of Southern California, L a Angela. Sim One (Figure 4) is a computer controlled manikin for learning the skill of endotracheal intubation and for training anaesthetists. The simulated patient looks like a living person, ‘breathes’ with chest and abdomen, has carotid and temporal pulses synchronous with an audible heartbeat, and can be ventilated by bag and mask or through an endotracheal airway (Denson and Abrahamson 1979). The model allows the intravenous ‘injection’ of drugs, produces pupil dilation or constriction, and can produce inhalation of vomitus as well as muscle fasciculation and a variety of cardiac arrhythmias. The model can even ‘die’, being restored ‘to life’ by pushing the appropriate button. A computer print-out (Figure 5) records all the actions taken by the student, with the effects produced. It also records the time intervals between events. The model enables students to learn to cope with all anaesthetic emergencies likely to be encountered without posing any risk to real patients. The major drawback of such models is that they are extremely expensive.
Figure 3. The ‘Gynny’ pelvic teaching model. Many gynaecological procedures such as abdominal palpation, catheterization and evaluation of the sacral curvature can be practised using this model, which is accompanied by a set of 16 interchangeable parts. Also available are four filmed interviews with patients with a gynaecological problem. The ‘Gynny’ models can be programmed to correspond with each patient’s problem. Students view the patient’s presentation, examine the simulated patient, and, after a group discussion of the problem, return t o the f i l m f o r a summary of the case.
Figure 4. This programmed simulation model (SIMONE) enables students to practaie endotracheal intubation. It t i also w e d f o r training anaesthetists. (Photo by courtesy of the World Health Organization.) Training with Sim One showed that students achieved pre-established levels of competence with a significantly smaller investment of faculty and/or student time than is required by conventionally trained students (Hoffman 1974).
Battery-powered Simulation Manikin Resusci Anne is a simulation manikin developed in Sweden as an aid in teaching cardiopulmonary resuscitation. It features an automatic corrective feedback system which tells the user if mistakes are being made (Figures 6 and 7). The manikin can also be used to teach students to check for carotid pulse and pupil dilation.
Simulated Patients A pioneer in the use of simulated patients to teach procedural skills is Dr H0ward.S. Barrows, a neurologist Figure 5. Reproduction of a SIM-ONE computer printout showing the various clinical conditions which can be simulated during anaesthesia. (‘Bucking’= attempt to ‘cough’out the endotracheal airway.) ANESTHESIOLOGY -PATIENT TRAINER RECORD STUDENT: TIME 01 :29 01 :31 01 :32 01 :33 03:31 03:32 03:35 03:36 03:38 03:39 HOLD
192
INSTRUCTOR: EVENT LEFT BRONCHUS BLOCK-ON LEFT BRONCHUS BLOCK-OFF RIGHT BRONCHUS BLOCK-ON RIGHT BRONCHUS BLOCK-OFF BUCKINGON BUCKING-OFF. LARYNGOSPASM-ON LARYNGOSPASM-OFF ARRHYTHMIA-ON , ARRHYTHMIA-OFF
DATE:
TIME:
REMARKS
05
Medical Teacher Vol 1 No 4 1979
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
at McMaster University. Healthy volunteers are trained to simulate various patient problems in the areas of neurology, surgery, obstetrics/gynaecology, psychiatry, family medicine and orthopaedics. In the neurological examination, for example, volunteers are trained to simulate abnormal physical signs, including exaggerated reflexes, extensor plantar responses and areas of sensory deficit. The advantages of simulated patients are that they offer great flexibility in dealing with real problems; there is no risk (but some discomfort) to the patient: there is no embarrassment to the student and the student is relieved of the constraints of time. Training new volunteers takes about three hours, but once familiar with the concept, an experienced simulator may need less than an hour’s training for a new simulation. Over a period, using simulated patients will undoubtedly be more expensive than simulation models if the simulated patients have to be paid for each visit. In addition, because they become bored with performing only one role or because they may not be available at the required time, more than one volunteer per medical problem may be necessary. Figure 6. Resusci Anne. The manikin is fitted with a control box where a series of coloured lights flash to indicate how the resuscitation is progressing. The control box incorporates a metronome. A n instrument in the manikin’s abdomen records and divulges the computer printout of ventilation and cardiac compression.
Instructor-Patients Competition for access to appropriate hospitalized patients has also led to the use of non-hospitalized patients to teach physical examination techniques. The instructor patients are trained to provide appropriate
Figure 7. Resusci Anne computer printout. The recording shows q t h e force was sufficient to depress the sternum about 1 . 5 inch (the lower printed end of the curve should reach down into the narrow segment marked ‘Compression?; the force was excessive (the pointed lower end of the curve would extend beyond the segment marked ‘Compression?; the pressure against the sternum was released completely between each compression (the top of the curve should go back to its base line); rhythm and frequency were correct; the ratio between ventilations and compressions was correct (2 ventilations: 15 compressions); the ventilations were performed quickly enough so that the interruptions in compressions did not exceed 5 or 6 seconds; the tempo of heart compressions was correct (80 per minute); minute volume f o r ventilation was sufficient; the number of heart compressions per minute was sufficient (average 60 per minute); the rescuer did not start heart compressions until he had recognized pulselessness; penodic c h e c k were made during resuscitation to determine the effectiveness of the resuscitation. (Pupil check to determine whether oxygen supply to the brain had been re-established. Carotid pulse check to determine whether the heart had started to beat spontaneously. r f so, heart compressions should be stopped and ventilation continued, but the pulse should still be checked frequently.)
Pulse
L
Incorrect pressure point
Medical Teacher Vol 1 No 4 1979
Incorrect pressure point
Incorrect pressure point
193
feedback to students regarding technique and patientexaminer communication. Training time averages six hours. Results to date show that the use of instructorpatients in this way is a feasible endeavour (Anderson and Meyer 1978).
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
Recent Developments i n Australia With the setting up of a vocational training programme for general practice some five years ago, it became apparent that training was deficient at undergraduate level in many areas, including procedural skills. Attempts to rectify this situation through the Family Medicine Programme of the Royal Australian College of General Practitioners has to take account of the fact that many new graduates are required to practise in remote areas, often several hundred miles from fellow practitioners. At the same time, many established practitioners work in isolation and may require refresher courses and contact with their peers.
Refresher Courses A pilot scheme was developed in Queensland, where locums from city areas were recruited to relieve practitioners working in isolated areas to allow them to attend refresher courses, particularly in surgery and obstetrics. Such exchanges have proved very popular, not only for the remote practitioner but for the locums involved, especially where these have been recruited from the specialist ranks. Where possible, private aircraft have been used in the exchanges. Considerable cooperation has been obtained from the teaching hospitals concerned, as they are now willing to set aside short term posts in such specialties as surgery, obstetrics, orthopaedics and psychiatry for the postgraduate training of general practitioners.
Video Production Over the past year the Family Medicine Programme of the RACGP has devoted considerable time to producing videotapes related to procedural skills in general practice. Where material was already available and permission obtained, copies have been made. Such material includes tapes on normal delivery, breech delivery, multiple births, repair of episiotomy, scalp vein monitoring, insertion of IUDs, etc. , As we have our own studio at the RACGP, it has proved a relatively inexpensive exercise to develop videotapes not readily available. The cooperation of expert resource persons, often at no cost other than a copy of the completed programme, has allowed considerable developmental work. Programmes produced so far include appendectomy, breast examination, developmental screening, tonsillectomy, joint examination, reduction of the fractured nose, as well as a series on ophthalmology, one of which utilizes a simulation model (strabismus) (see Figure 2). In a typical programme, such as ‘the use of the ophthalmoscope’, there is a brief description of the optics 194
of the eye utilizing charts and slides laid into the video. There is also an outline of the mechanism of the ophthalmoscope -light source, lenses, depth of penetration, beam controls and field of view. The incorporation of a series of slides of pathological conditions allows brief coverage of commonly presenting abnormalities involving the cornea, anterior and posterior chamber, lens and retina.
Simulation A novel method of providing motivation has been used during the past two years when candidates presenting for the College examination for fellowship have been informed that one of the tests in the ‘physical examination’ section would be cardiopulmonary resuscitation. While some examiners initially were unhappy with supplying such information to candidates, they later conceded that this development could lead to meaningful learning. Resusci Anne (Figure S), the simulation manikin developed in Sweden, was demonstrated to candidates in all States well in advance of the examination and candidates were given adequate time to practise. Few candidates failed to score highly in the examination, while many had performed inadequately during rehearsals. Assessment utilized the recording strip (Figure 7), which provides a continuous record of the adequacy of depth and frequency of both ventilation and compression, thus ensuring that assessment would be as objective as possible. Conclusion While still in the early years, the use of videotape and the development of simulation models appear to hold considerable promise in the teaching of procedural skills. Communication and co-operation will be necessary to ensure that techniques developed can be shared at an international level. References Anderson. K. K. and Meyer, T. C . , The use of instructor-patients to teach physical examination techniques, Journal of Medical Education, 1978, 53,831-836. Denson, J. S. and Abrahamson, S . , A computer controlled patient simulator, Journal of the American Medical Association, 1969, 208, 504. Hoffman. Kaaren, The Effectiveness of the Use of a Simulator in Training for Certain Health-Care Tasks. Paper presented at AAMC’s 13th Annual Conference, Chicago. Ill. November 12-13, 1974. Sajid, A. et al.. A simulation laboratory for medical education,Journal of Medical Education, 1975,50,970. Schreiner, R. L. et al., Simulators to teach paediatric skills, Journal of Medical Education, 1979,54,242-243.
Further Reading Barrows, H. S., Simulated Patients, Charles C. Thomas, Springfield, Ill., 1971.
Medical Teacher Vol1 No 4 1979
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Teaching Procedural Skills - An Overview J. R. Marshall To cite this article: J. R. Marshall (1979) Teaching Procedural Skills - An Overview, Medical Teacher, 1:4, 190-194 To link to this article: http://dx.doi.org/10.3109/01421597909012599
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 45
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [University of California, San Diego]
Date: 06 November 2015, At: 18:47
SPECIAL ARTICLE
Teaching Procedural Skills - An Overview J. R. MARSHALL
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
J. R . Marshall,
MB, B.Ch, FRACGP, & Assistant Director of Education, Family Medicine Programme, The Royal Australian College of General Practitioners, 15 Gover Street, North Adelaide, South Australia 5006.
This paper provides a n overview of various methods that have been developed to help students learn procedural skills. Future issues of Medical Teacher will describe each of the methods in depth. During their training medical students have traditionally acquired fundamental skills by practising on animals and human cadavers. For example, they have been required to practise and later to show proficiency in such procedures as dissection of the earthworm, the frog and the rabbit; perfusion of the isolated frog’s heart in physiology; and dissection of cadavers in anatomy. Assessment of their ability to perform these tasks has contributed to their final mark in the subjects concerned. Such procedures have not involved live patients for obvious reasons. In dealing with patients, training in procedural skills has been by means of apprenticeship, the students learning by observation. Subjective assessments may be made by supervisors during the training period, but to date few objective tests of ability to perform procedural tasks involving patients have been designed or utilized. Generally speaking, assessment has been confined to the ‘clinical’ examination, where candidates traditionally elicit a history, detect abnormal physical signs and make a differential diagnosis. Treatment is discussed, but no opportunity is afforded to assess manual dexterity in relation to treatment -whether this requires the application of eyedrops or the removal of a pituitary tumour. Frequently, the manner in which abnormal signs are tested for is not observed. A further disadvantage of assessment in the clinical examination is the shortage of time, which permits only a small number of areas to be tested. As examiners have not, on the whole, been trained to observe the particular ‘domains’ being assessed, it is doubtful whether the tests are reliable. In recent years, considerable effort has been directed at producing programmes that help students to learn procedural skills. As manual skills involve predominantly the psychomotor domain, most teaching methods involve the use of demonstration and various audiovisual aids, such as videotape, motion pictures and closed circuit TV. 190
Such media are more suitable than printed text, audiotapes or formal lectures which lend themselves more readily to teaching in the cognitive or content area. However, no matter how sophisticated the audiovisual simulation, one cannot be sure whether at the end students will be competent to, say, anaesthetize a patient. It is in helping students to acquire such complex skills that the computerized patient simulator is proving to be so useful. This paper provides an overview of various methods that have been developed to help students learn procedural skills. Further issues of Medical Teacher will describe each of these methods in depth. Choice of Method The complexity and cost of the method used will vary with the complexity of the skills to be taught. Thus, it is relatively simple and cheap to teach someone how to put in eyedrops, for example, but it is complicated and expensive to devise a method to teach the skills required of a competent anaesthetist. Before embarking on the production of any educational package to teach procedural skills, the objectives must be determined. Lists of what skills are to be taught and how they will be assessed in order to maintain objectivity will be necessary. To facilitate assessment, detailed rating forms are helpful. These provide check lists which can be utilized to ensure that all aspects have been covered as well as to maintain objectivity. Methods of Teaching Procedural Skills
A udiovisual A ids Simple audiovisual aids (e.g. tape slides) can be used to help teach such basic skills as putting in sutures, removing a cyst, packing a nose or applying eyedrops. Here, the only equipment required is a slide projector and a tape recorder, preferably with cueing facilities whereby a signal is put on the tape so that slides are
Medical Teacher Vol 1 No 4 1979
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
advanced automatically. Other skills which require continuity of motion, such as removing an appendix, are better suited to motion picture formats like videotape and 16 mm film. The advantages of videotapes are that they are light, easy to transport and require a minimum of skill to operate. The only problem is ensuring that the videotape is compatible with the playback unit. Tape slides have been used as part of programmed instruction packages to help students learn more complex skills. For example, at the University of Southern California, Los Angeles, staff at the Division of Research in Medical Education have produced a series of six tape slide presentations providing approximately eight hours of teaching on ‘Anaesthesia Gas Systems and Machines’. These presentations show the various stages of anaesthesia, the complications that may occur, etc. An accompanying overview of the course, exercises and selftest are included in the package. There is also a follow-up discussion for students, with an instructor present to answer questions and demonstrate equipment. The advantages of this programme are that students can work at their own pace; removal of the learning process from the operating room reduces the risk to patients caused by distraction of the teacher during surgery, and fewer demands are placed on teaching staff in supervision.
Simulation Models Considerable work has been carried out in the USA in developing models or simulators which simulate various parts of the body and help students to familiarize themselves with various pathological conditions (Sajid et al. 1970). Examples include the Heart and Breath Sound Simulators, the Lymph Node/Breast Simulator, the Ear Model and Laryngeal Model developed by the University of Illinois at the Medical Centre. Other models have been developed commercially and include the Ophthalmoscopy Manikin (Figure l), Glaucoma Test Head Model, Infant Intubation Simulator, Injectable Training Arm, Keeler Eye Model, Prostate Palpation Simulator, Spinal Tap Simulator and Strabismus Cover-Uncover Test Demonstrator (Figure 2). At Indiana University School of Medicine a family of infant simulators has been developed for use in the paediatric education programme (Schreiner et al. 1979). These include a ‘soft model baby’ with different, easily palpated abdominal masses; ‘Hippy’, a model of the lower torso and lower limbs of a term-sized newborn infant, for teaching the diagnosis of congential hip dislocations; simulators for learning radial artery puncture and umbilical vessel catheterization; and a head model for scalp vein infusion. Models have been developed as part of modular instructional programmes -for example the OMNI programme developed at the University of Southern California, Los Angeles, in cooperation with the Ortho Pharmaceutical Corporation. This consists of a number of learning modules comprising models, textbooks, slides and films. The models include the ‘Gynny’ Pelvic Teaching Model (Figure 3). the ‘Betsi’ Breast Teaching
Medical Teacher Vol 1 No 4 1979
Figure 1. Colenbrander ophthalmoscopy manikin. This simulated model helps to familiarize students with the use of the ophthalmoscope and with various pathological conditions of the eye. Interchangeable slides of the pathology of the fundus are provided f o r insertion, to be viewed through the ‘cornea’ using an ophthalmoscope. ‘Corneal’and ‘lens’opacities are also provided.
Figure 2 . Strabismus cover-uncover test demonstrator. The simulated face has moveable eyes, which enables students to practise the cover-uncover test for various types of strabismus.
Model, the ‘Adam’ Male Model and the ‘Patti’ model of a pregnant woman. Such models are very expensive to develop and are sometimes easily damaged. However, with international usage, the products can be purchased at fairly reasonable cost. Their main advantage lies in the 191
fact that standardized problems can be presented without the inconvenience of utilizing a single patient repeatedly for the same purpose. If assessment is to take place following training, this will be more objective if standard rating forms are used.
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
Programmed Simulation Models The most sophisticated model for the teaching of procedural skills-a computer controlled patient simulator -has been developed at the University of Southern California, L a Angela. Sim One (Figure 4) is a computer controlled manikin for learning the skill of endotracheal intubation and for training anaesthetists. The simulated patient looks like a living person, ‘breathes’ with chest and abdomen, has carotid and temporal pulses synchronous with an audible heartbeat, and can be ventilated by bag and mask or through an endotracheal airway (Denson and Abrahamson 1979). The model allows the intravenous ‘injection’ of drugs, produces pupil dilation or constriction, and can produce inhalation of vomitus as well as muscle fasciculation and a variety of cardiac arrhythmias. The model can even ‘die’, being restored ‘to life’ by pushing the appropriate button. A computer print-out (Figure 5) records all the actions taken by the student, with the effects produced. It also records the time intervals between events. The model enables students to learn to cope with all anaesthetic emergencies likely to be encountered without posing any risk to real patients. The major drawback of such models is that they are extremely expensive.
Figure 3. The ‘Gynny’ pelvic teaching model. Many gynaecological procedures such as abdominal palpation, catheterization and evaluation of the sacral curvature can be practised using this model, which is accompanied by a set of 16 interchangeable parts. Also available are four filmed interviews with patients with a gynaecological problem. The ‘Gynny’ models can be programmed to correspond with each patient’s problem. Students view the patient’s presentation, examine the simulated patient, and, after a group discussion of the problem, return t o the f i l m f o r a summary of the case.
Figure 4. This programmed simulation model (SIMONE) enables students to practaie endotracheal intubation. It t i also w e d f o r training anaesthetists. (Photo by courtesy of the World Health Organization.) Training with Sim One showed that students achieved pre-established levels of competence with a significantly smaller investment of faculty and/or student time than is required by conventionally trained students (Hoffman 1974).
Battery-powered Simulation Manikin Resusci Anne is a simulation manikin developed in Sweden as an aid in teaching cardiopulmonary resuscitation. It features an automatic corrective feedback system which tells the user if mistakes are being made (Figures 6 and 7). The manikin can also be used to teach students to check for carotid pulse and pupil dilation.
Simulated Patients A pioneer in the use of simulated patients to teach procedural skills is Dr H0ward.S. Barrows, a neurologist Figure 5. Reproduction of a SIM-ONE computer printout showing the various clinical conditions which can be simulated during anaesthesia. (‘Bucking’= attempt to ‘cough’out the endotracheal airway.) ANESTHESIOLOGY -PATIENT TRAINER RECORD STUDENT: TIME 01 :29 01 :31 01 :32 01 :33 03:31 03:32 03:35 03:36 03:38 03:39 HOLD
192
INSTRUCTOR: EVENT LEFT BRONCHUS BLOCK-ON LEFT BRONCHUS BLOCK-OFF RIGHT BRONCHUS BLOCK-ON RIGHT BRONCHUS BLOCK-OFF BUCKINGON BUCKING-OFF. LARYNGOSPASM-ON LARYNGOSPASM-OFF ARRHYTHMIA-ON , ARRHYTHMIA-OFF
DATE:
TIME:
REMARKS
05
Medical Teacher Vol 1 No 4 1979
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
at McMaster University. Healthy volunteers are trained to simulate various patient problems in the areas of neurology, surgery, obstetrics/gynaecology, psychiatry, family medicine and orthopaedics. In the neurological examination, for example, volunteers are trained to simulate abnormal physical signs, including exaggerated reflexes, extensor plantar responses and areas of sensory deficit. The advantages of simulated patients are that they offer great flexibility in dealing with real problems; there is no risk (but some discomfort) to the patient: there is no embarrassment to the student and the student is relieved of the constraints of time. Training new volunteers takes about three hours, but once familiar with the concept, an experienced simulator may need less than an hour’s training for a new simulation. Over a period, using simulated patients will undoubtedly be more expensive than simulation models if the simulated patients have to be paid for each visit. In addition, because they become bored with performing only one role or because they may not be available at the required time, more than one volunteer per medical problem may be necessary. Figure 6. Resusci Anne. The manikin is fitted with a control box where a series of coloured lights flash to indicate how the resuscitation is progressing. The control box incorporates a metronome. A n instrument in the manikin’s abdomen records and divulges the computer printout of ventilation and cardiac compression.
Instructor-Patients Competition for access to appropriate hospitalized patients has also led to the use of non-hospitalized patients to teach physical examination techniques. The instructor patients are trained to provide appropriate
Figure 7. Resusci Anne computer printout. The recording shows q t h e force was sufficient to depress the sternum about 1 . 5 inch (the lower printed end of the curve should reach down into the narrow segment marked ‘Compression?; the force was excessive (the pointed lower end of the curve would extend beyond the segment marked ‘Compression?; the pressure against the sternum was released completely between each compression (the top of the curve should go back to its base line); rhythm and frequency were correct; the ratio between ventilations and compressions was correct (2 ventilations: 15 compressions); the ventilations were performed quickly enough so that the interruptions in compressions did not exceed 5 or 6 seconds; the tempo of heart compressions was correct (80 per minute); minute volume f o r ventilation was sufficient; the number of heart compressions per minute was sufficient (average 60 per minute); the rescuer did not start heart compressions until he had recognized pulselessness; penodic c h e c k were made during resuscitation to determine the effectiveness of the resuscitation. (Pupil check to determine whether oxygen supply to the brain had been re-established. Carotid pulse check to determine whether the heart had started to beat spontaneously. r f so, heart compressions should be stopped and ventilation continued, but the pulse should still be checked frequently.)
Pulse
L
Incorrect pressure point
Medical Teacher Vol 1 No 4 1979
Incorrect pressure point
Incorrect pressure point
193
feedback to students regarding technique and patientexaminer communication. Training time averages six hours. Results to date show that the use of instructorpatients in this way is a feasible endeavour (Anderson and Meyer 1978).
Downloaded by [University of California, San Diego] at 18:47 06 November 2015
Recent Developments i n Australia With the setting up of a vocational training programme for general practice some five years ago, it became apparent that training was deficient at undergraduate level in many areas, including procedural skills. Attempts to rectify this situation through the Family Medicine Programme of the Royal Australian College of General Practitioners has to take account of the fact that many new graduates are required to practise in remote areas, often several hundred miles from fellow practitioners. At the same time, many established practitioners work in isolation and may require refresher courses and contact with their peers.
Refresher Courses A pilot scheme was developed in Queensland, where locums from city areas were recruited to relieve practitioners working in isolated areas to allow them to attend refresher courses, particularly in surgery and obstetrics. Such exchanges have proved very popular, not only for the remote practitioner but for the locums involved, especially where these have been recruited from the specialist ranks. Where possible, private aircraft have been used in the exchanges. Considerable cooperation has been obtained from the teaching hospitals concerned, as they are now willing to set aside short term posts in such specialties as surgery, obstetrics, orthopaedics and psychiatry for the postgraduate training of general practitioners.
Video Production Over the past year the Family Medicine Programme of the RACGP has devoted considerable time to producing videotapes related to procedural skills in general practice. Where material was already available and permission obtained, copies have been made. Such material includes tapes on normal delivery, breech delivery, multiple births, repair of episiotomy, scalp vein monitoring, insertion of IUDs, etc. , As we have our own studio at the RACGP, it has proved a relatively inexpensive exercise to develop videotapes not readily available. The cooperation of expert resource persons, often at no cost other than a copy of the completed programme, has allowed considerable developmental work. Programmes produced so far include appendectomy, breast examination, developmental screening, tonsillectomy, joint examination, reduction of the fractured nose, as well as a series on ophthalmology, one of which utilizes a simulation model (strabismus) (see Figure 2). In a typical programme, such as ‘the use of the ophthalmoscope’, there is a brief description of the optics 194
of the eye utilizing charts and slides laid into the video. There is also an outline of the mechanism of the ophthalmoscope -light source, lenses, depth of penetration, beam controls and field of view. The incorporation of a series of slides of pathological conditions allows brief coverage of commonly presenting abnormalities involving the cornea, anterior and posterior chamber, lens and retina.
Simulation A novel method of providing motivation has been used during the past two years when candidates presenting for the College examination for fellowship have been informed that one of the tests in the ‘physical examination’ section would be cardiopulmonary resuscitation. While some examiners initially were unhappy with supplying such information to candidates, they later conceded that this development could lead to meaningful learning. Resusci Anne (Figure S), the simulation manikin developed in Sweden, was demonstrated to candidates in all States well in advance of the examination and candidates were given adequate time to practise. Few candidates failed to score highly in the examination, while many had performed inadequately during rehearsals. Assessment utilized the recording strip (Figure 7), which provides a continuous record of the adequacy of depth and frequency of both ventilation and compression, thus ensuring that assessment would be as objective as possible. Conclusion While still in the early years, the use of videotape and the development of simulation models appear to hold considerable promise in the teaching of procedural skills. Communication and co-operation will be necessary to ensure that techniques developed can be shared at an international level. References Anderson. K. K. and Meyer, T. C . , The use of instructor-patients to teach physical examination techniques, Journal of Medical Education, 1978, 53,831-836. Denson, J. S. and Abrahamson, S . , A computer controlled patient simulator, Journal of the American Medical Association, 1969, 208, 504. Hoffman. Kaaren, The Effectiveness of the Use of a Simulator in Training for Certain Health-Care Tasks. Paper presented at AAMC’s 13th Annual Conference, Chicago. Ill. November 12-13, 1974. Sajid, A. et al.. A simulation laboratory for medical education,Journal of Medical Education, 1975,50,970. Schreiner, R. L. et al., Simulators to teach paediatric skills, Journal of Medical Education, 1979,54,242-243.
Further Reading Barrows, H. S., Simulated Patients, Charles C. Thomas, Springfield, Ill., 1971.
Medical Teacher Vol1 No 4 1979
