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Clinical simulations on a microcomputer
Comput. Educ. Vol. 8, No. 4. pp. 397-399, 1984 Printed in Great Britain
0360-1315/84$3.00+ 0.00 Pergamon Press Ltd
CLINICAL SIMULATIONS MICROCOMPUTER
Department
ON A
M. C. BLANCHAFXR of Biochemistry, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada R3E 0W3
This paper deals with the design of interactive microcomputer-based clinical case simulations for use in a first year medical basic science course[l]. Although case simulations have been used for over 20 years in medical education these have been implemented mostly on main-frame systems or minicomputers. Also, such materials have been aimed primarily at testing and reinforcing the diagnostic skills of senior students and graduate physicians. The simulations to be described were designed to address a problem of increasing concern in the education of undergraduate health science professionals. It has arisen from a gradual encroachment by an ever-growing mass of new information on the time formerly devoted to the learning of problem solving skills. This phenomenon has been especially striking in basic science courses presented during the earlier years of professional education. Some 9 years ago we attempted to address this problem by introducing into a first year Biochemistry course patient-management exercises that require students to commit themselves to a series of decisions, each based on the evidence available at the time. The instructor’s response to each decision is hidden in a latent image on paper until the student’s choice is made[2]. Although these materials remain popular with students and improve retention of both factual material and problem solving skills, they are mechanically cumbersome to produce. A more serious defect is that they offer cues as to the possibly correct answer(s) because the choices must be offered in multiple choice format. Since health professionals rarely encounter clinical situations in which decisions to be made present themselves in that format, it would seem more realistic to expect the users of these exercises to generate and “write in” the most appropriate response. Although the potential of the computer in this regard was attractive, frequent difficulties in telephone communication at that time with a remote main-frame machine alienated our students. Some 3 years ago the increasing availability of microcomputers with graphic capabilities led to a reconsideration of computer use for the present purposes. The choice of microcomputer system was influenced by several considerations. Firstly, experience with simulations in the latent image format had indicated the desirability of including in the case studies graphics that respond dynamically to student input. Secondly, at a more mundane level, the microcomputer system chosen would need to accommodate the limited patience and the computer naivitt of the author. The third consideration was the expected cost: benefit ratio, this was assessed as follows. It appeared probable that each simulation generated would require at least 400-500 h of designing and programming per hour of user time. Since these materials would have a maximum world audience of 2000 students yearly it seemed the author’s time commitment could be justified only if broad access were assured by programming for a simple, widely available machine. Consideration of the various microcomputers available at the time narrowed the choice to the Apple II Plus. Aside from the usually mentioned features of this machine, the final decision was greatly influenced by the availability of the recently released Apple version of the high-level PILOT authoring language, which featured easily generated graphics. (An improved version, Apple SuperPILOT, has become available since.) To date eight simulations have been written with this system. While designed primarily for our students, some 80 copies of these programmes have been purchased by eleven health science faculties in North America, Europe, Africa and Australia. DESIGN
CONSIDERATIONS
The aim of these clinical case studies is to afford students, relatively early in their professional schooling, an opportunity to apply their recently acquired knowledge of the basic sciences to the identification of the physiologic, metabolic or anatomical abnormality underlying a specific CAE“‘4 F
397
398
M. C. BLANCHAER
patient’s clinical signs and symptoms. The principal objective in designing the exercises had been, through a series of challenging interactions with the programme, to engage the users’ commitment to solving a diagnostic problem and to deciding upon the appropriate treatment, all in a clinical setting consistent with the students’ anticipated future professional role. Real-life problems the health professional is called upon to solve are invariably multifactorial. Therefore, in these simulations the overt expression of the underlying organic disturbance in signs and symptoms is shown to be inthtenced by the patient’s psychosocial circumstances. Thus, in one case study the student is, as subtly as possible, guided to request and interpret the parents’ story of the untoward turn in their child’s initially minor illness. Sooner or later, depending on her/his acuity, the student uncovers the essential clue, viz. that “It took quite a bit of aspirin to bring down Sydney’s temperature”. This in turn leads to laboratory confirmation of aspirin poisoning as the problem. In other simulations information is available, if requested by the (student) “practitioner”, from “colleagues” who may provide important diagnostic clues. By these and other devices, problem solving has been broadened to include problem detection, identification, evaluation and finally, management. As a result such simulations seem realistic to beginning students with no clinical experience. However, they are at best quasi-clinical, since the sensorial cues and interpersonal exchanges that play important roles in diagnosis and management are absent. Nevertheless, these exercises elicit a desire to learn basic science material that otherwise often seems dry and abstract. Apart from the obvious “relevance” of the material, the students’ personal success in using such facts and concepts in a professional situation with which they can identify is also strongly motivating. The programmes are structured so as to encourage users to follow the diagnostic approach actually practised by competent health professionals. Rather than requiring an exhaustive’ gathering-of information initially, students-are encouraged by the programme structure to think of various causal hypotheses quite early. These can then be explored in a series of information gathering steps that stimulate continual revision of the hypothesis list as the users progress through the simulation. Eventually the list is reduced to the single most probable “cause” to which the “practitioners” are then required to show their commitment by using it as the basis of their “treatment” of the patient’s problem. Therapeutic mistakes are shown to aggravate the “illness” and in two simulations, threaten the patient’s life. Because of the exigencies of the computer medium, such as the limited attention span of most users (20-30 min), considerable simplification of complex situations often is necessary, resulting in an exercise that may resemble a game more than a true life experience. Also, areas in which there are still unresolved conflicts may need to be glossed over. This is usually balanced by an opportunity to test at least one doubtful hypothesis by procedures that might not be permissible in clinical practice. Care is taken to ensure such semi-fictional elements do not interfere with the overall validity of the information provided or with the problem solving methods being illustrated. This type of experience has been shown by others to lead to a greater facility in problem solving in similar situations encountered at a later time[3]. Also, although considered of secondary importance to the acquisition of improved problem solving skills, our students show on formal examinations that they do retain the basic science facts and concepts encountered. Again, this is most marked when such material has been recalled by the student during the simulation and employed successfully in decision making. To further reinforce this outcome, users are allowed as much as possible, control over the speed and sequence in which the specific diagnostic approaches are chosen. These measures tend to give a (partially illusory) feeling of freedom and make the novice more comfortable in difficult and sometimes threatening situations. That a simulation might be threatening to students some years before they actually encounter However, efforts are made throughout the clinical responsibilities may seem an exaggeration. exercises to have the student self-identify as the protagonist who is to solve and manage a specific patient’s problem. This begins early in the “Opening Scene ” with a statement such as “You have completed your training and are now in practice in Nubile, Saskatchewan”. Other devices employed to maintain interest and commitment include the programme expressing approval of correct choices and yet providing progressively more explicit and helpful information after each incorrect response, especially at diagnostically important points.
Clinical
simulations
on a microcomputer
399
It also has proved important to include questions at intervals during the simulation to test the student’s understanding of what has gone before. This is necessary because the linear nature of the computer medium makes it difficult for some students, unless stimulated to do SO, to integrate new information as it is encountered with previously learned knowledge, and especially with information discovered earlier in the exercise. The process of integration also can be helped by asking the student to recall and use earlier findings, the implications of which may not have been fully appreciated at the time. To minimize interference with the problem solving task the programmes are made self starting, requiring only insertion of a diskette into a drive and turning on one switch. To mitigate initial fears of dealing with this new learning medium, the first response requested is “Touch any key to continue”. Next, when offered the comforting option of a “review”, only a “yes” or “no” followed by a RETURN is required. The idea of a review arose from student requests for hints early in the exercise to help them orient themselves towards the problem(s) to be encountered in that particular “patient”. Some of course would prefer a preview of the case at this point. However, others merely wished to be “pointed in the right direction” or even to be required to recall the facts, concepts and interrelationships that might be useful in the simulation. Perusal of the education research literature showed that such an orienting device, known as an “advance organizer”, is effective in situations similar to the present case studies[4]. Consequently, a number of orientating and informational screen loads are inserted as an advance organizer, followed by a series of multiple choice questions. Although, as explained above, multiple choice questions are not totally suited for the present learning materials, they are employed in the early stages of the simulations since this is the questioning format with which the users are most comfortable and thus does not distract them from the substantive content of the enquiry. However, once most of the basic facts and concepts needed to begin understanding the patient’s condition have been encountered, the type of questioning changes. The user is now expected to type in a word or phrase, without the help of the cues inherent in the multiple choice format. Somewhat disconcerting initially, the “Type in your answer” now being requested requires students to recall appropriate information from their long term memory into the working memory. There it can be integrated with the incoming information to solve the immediate problem raised by the programme’s question. Research in medical problem solving indicates this is the way physicians operate in real-life problem solving situations[3]. Space limitations preclude detailed discussion of a number of design features including the formatting of text on the screen, use of the colloquial idiom and choice of wording and phraseology to suit specific situations in the exercises. In any case, their utility usually is apparent only when the programme is run with a detailed flowchart to hand.
CONCLUSION
Apart from their apparent success in student self-instruction, these materials have proved to have the real but less obvious value of being a stimulating learning experience for the instructor-asauthor. Because of this a student has been employed recently to participate in the design and programming of new simulations. The resulting interaction between the student and instructors knowledgeable in the various subject fields involved in the simulation being prepared has been mutually beneficial. It has resulted in products attuned to the students’ interests and the instructors’ educational objectives. Expansion of this unanticipated adventure in mutual education should benefit both students and instructors. REFERENCES 1. Blanchaer M. C., Microcomputer-based learning in a medical biochemistry course. Biochem. Educ. 10, 107 (1982). 2. Blanchaer M. C., Simulated clinical problems in a medical biochemistry course. Biochem. Educ. 3, 71 (1975). 3. Elstein A. S. et al., Medical Problem Solving: An Analysis of Clinical Reasoning. Harvard University Press, Cambridge, MA (1978). 4. Mayer R. E., Can advance organizers influence meaningful learning? Rev. Educ. Res. 49, 371 (1979).
0360-1315/84$3.00+ 0.00 Pergamon Press Ltd
CLINICAL SIMULATIONS MICROCOMPUTER
Department
ON A
M. C. BLANCHAFXR of Biochemistry, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada R3E 0W3
This paper deals with the design of interactive microcomputer-based clinical case simulations for use in a first year medical basic science course[l]. Although case simulations have been used for over 20 years in medical education these have been implemented mostly on main-frame systems or minicomputers. Also, such materials have been aimed primarily at testing and reinforcing the diagnostic skills of senior students and graduate physicians. The simulations to be described were designed to address a problem of increasing concern in the education of undergraduate health science professionals. It has arisen from a gradual encroachment by an ever-growing mass of new information on the time formerly devoted to the learning of problem solving skills. This phenomenon has been especially striking in basic science courses presented during the earlier years of professional education. Some 9 years ago we attempted to address this problem by introducing into a first year Biochemistry course patient-management exercises that require students to commit themselves to a series of decisions, each based on the evidence available at the time. The instructor’s response to each decision is hidden in a latent image on paper until the student’s choice is made[2]. Although these materials remain popular with students and improve retention of both factual material and problem solving skills, they are mechanically cumbersome to produce. A more serious defect is that they offer cues as to the possibly correct answer(s) because the choices must be offered in multiple choice format. Since health professionals rarely encounter clinical situations in which decisions to be made present themselves in that format, it would seem more realistic to expect the users of these exercises to generate and “write in” the most appropriate response. Although the potential of the computer in this regard was attractive, frequent difficulties in telephone communication at that time with a remote main-frame machine alienated our students. Some 3 years ago the increasing availability of microcomputers with graphic capabilities led to a reconsideration of computer use for the present purposes. The choice of microcomputer system was influenced by several considerations. Firstly, experience with simulations in the latent image format had indicated the desirability of including in the case studies graphics that respond dynamically to student input. Secondly, at a more mundane level, the microcomputer system chosen would need to accommodate the limited patience and the computer naivitt of the author. The third consideration was the expected cost: benefit ratio, this was assessed as follows. It appeared probable that each simulation generated would require at least 400-500 h of designing and programming per hour of user time. Since these materials would have a maximum world audience of 2000 students yearly it seemed the author’s time commitment could be justified only if broad access were assured by programming for a simple, widely available machine. Consideration of the various microcomputers available at the time narrowed the choice to the Apple II Plus. Aside from the usually mentioned features of this machine, the final decision was greatly influenced by the availability of the recently released Apple version of the high-level PILOT authoring language, which featured easily generated graphics. (An improved version, Apple SuperPILOT, has become available since.) To date eight simulations have been written with this system. While designed primarily for our students, some 80 copies of these programmes have been purchased by eleven health science faculties in North America, Europe, Africa and Australia. DESIGN
CONSIDERATIONS
The aim of these clinical case studies is to afford students, relatively early in their professional schooling, an opportunity to apply their recently acquired knowledge of the basic sciences to the identification of the physiologic, metabolic or anatomical abnormality underlying a specific CAE“‘4 F
397
398
M. C. BLANCHAER
patient’s clinical signs and symptoms. The principal objective in designing the exercises had been, through a series of challenging interactions with the programme, to engage the users’ commitment to solving a diagnostic problem and to deciding upon the appropriate treatment, all in a clinical setting consistent with the students’ anticipated future professional role. Real-life problems the health professional is called upon to solve are invariably multifactorial. Therefore, in these simulations the overt expression of the underlying organic disturbance in signs and symptoms is shown to be inthtenced by the patient’s psychosocial circumstances. Thus, in one case study the student is, as subtly as possible, guided to request and interpret the parents’ story of the untoward turn in their child’s initially minor illness. Sooner or later, depending on her/his acuity, the student uncovers the essential clue, viz. that “It took quite a bit of aspirin to bring down Sydney’s temperature”. This in turn leads to laboratory confirmation of aspirin poisoning as the problem. In other simulations information is available, if requested by the (student) “practitioner”, from “colleagues” who may provide important diagnostic clues. By these and other devices, problem solving has been broadened to include problem detection, identification, evaluation and finally, management. As a result such simulations seem realistic to beginning students with no clinical experience. However, they are at best quasi-clinical, since the sensorial cues and interpersonal exchanges that play important roles in diagnosis and management are absent. Nevertheless, these exercises elicit a desire to learn basic science material that otherwise often seems dry and abstract. Apart from the obvious “relevance” of the material, the students’ personal success in using such facts and concepts in a professional situation with which they can identify is also strongly motivating. The programmes are structured so as to encourage users to follow the diagnostic approach actually practised by competent health professionals. Rather than requiring an exhaustive’ gathering-of information initially, students-are encouraged by the programme structure to think of various causal hypotheses quite early. These can then be explored in a series of information gathering steps that stimulate continual revision of the hypothesis list as the users progress through the simulation. Eventually the list is reduced to the single most probable “cause” to which the “practitioners” are then required to show their commitment by using it as the basis of their “treatment” of the patient’s problem. Therapeutic mistakes are shown to aggravate the “illness” and in two simulations, threaten the patient’s life. Because of the exigencies of the computer medium, such as the limited attention span of most users (20-30 min), considerable simplification of complex situations often is necessary, resulting in an exercise that may resemble a game more than a true life experience. Also, areas in which there are still unresolved conflicts may need to be glossed over. This is usually balanced by an opportunity to test at least one doubtful hypothesis by procedures that might not be permissible in clinical practice. Care is taken to ensure such semi-fictional elements do not interfere with the overall validity of the information provided or with the problem solving methods being illustrated. This type of experience has been shown by others to lead to a greater facility in problem solving in similar situations encountered at a later time[3]. Also, although considered of secondary importance to the acquisition of improved problem solving skills, our students show on formal examinations that they do retain the basic science facts and concepts encountered. Again, this is most marked when such material has been recalled by the student during the simulation and employed successfully in decision making. To further reinforce this outcome, users are allowed as much as possible, control over the speed and sequence in which the specific diagnostic approaches are chosen. These measures tend to give a (partially illusory) feeling of freedom and make the novice more comfortable in difficult and sometimes threatening situations. That a simulation might be threatening to students some years before they actually encounter However, efforts are made throughout the clinical responsibilities may seem an exaggeration. exercises to have the student self-identify as the protagonist who is to solve and manage a specific patient’s problem. This begins early in the “Opening Scene ” with a statement such as “You have completed your training and are now in practice in Nubile, Saskatchewan”. Other devices employed to maintain interest and commitment include the programme expressing approval of correct choices and yet providing progressively more explicit and helpful information after each incorrect response, especially at diagnostically important points.
Clinical
simulations
on a microcomputer
399
It also has proved important to include questions at intervals during the simulation to test the student’s understanding of what has gone before. This is necessary because the linear nature of the computer medium makes it difficult for some students, unless stimulated to do SO, to integrate new information as it is encountered with previously learned knowledge, and especially with information discovered earlier in the exercise. The process of integration also can be helped by asking the student to recall and use earlier findings, the implications of which may not have been fully appreciated at the time. To minimize interference with the problem solving task the programmes are made self starting, requiring only insertion of a diskette into a drive and turning on one switch. To mitigate initial fears of dealing with this new learning medium, the first response requested is “Touch any key to continue”. Next, when offered the comforting option of a “review”, only a “yes” or “no” followed by a RETURN is required. The idea of a review arose from student requests for hints early in the exercise to help them orient themselves towards the problem(s) to be encountered in that particular “patient”. Some of course would prefer a preview of the case at this point. However, others merely wished to be “pointed in the right direction” or even to be required to recall the facts, concepts and interrelationships that might be useful in the simulation. Perusal of the education research literature showed that such an orienting device, known as an “advance organizer”, is effective in situations similar to the present case studies[4]. Consequently, a number of orientating and informational screen loads are inserted as an advance organizer, followed by a series of multiple choice questions. Although, as explained above, multiple choice questions are not totally suited for the present learning materials, they are employed in the early stages of the simulations since this is the questioning format with which the users are most comfortable and thus does not distract them from the substantive content of the enquiry. However, once most of the basic facts and concepts needed to begin understanding the patient’s condition have been encountered, the type of questioning changes. The user is now expected to type in a word or phrase, without the help of the cues inherent in the multiple choice format. Somewhat disconcerting initially, the “Type in your answer” now being requested requires students to recall appropriate information from their long term memory into the working memory. There it can be integrated with the incoming information to solve the immediate problem raised by the programme’s question. Research in medical problem solving indicates this is the way physicians operate in real-life problem solving situations[3]. Space limitations preclude detailed discussion of a number of design features including the formatting of text on the screen, use of the colloquial idiom and choice of wording and phraseology to suit specific situations in the exercises. In any case, their utility usually is apparent only when the programme is run with a detailed flowchart to hand.
CONCLUSION
Apart from their apparent success in student self-instruction, these materials have proved to have the real but less obvious value of being a stimulating learning experience for the instructor-asauthor. Because of this a student has been employed recently to participate in the design and programming of new simulations. The resulting interaction between the student and instructors knowledgeable in the various subject fields involved in the simulation being prepared has been mutually beneficial. It has resulted in products attuned to the students’ interests and the instructors’ educational objectives. Expansion of this unanticipated adventure in mutual education should benefit both students and instructors. REFERENCES 1. Blanchaer M. C., Microcomputer-based learning in a medical biochemistry course. Biochem. Educ. 10, 107 (1982). 2. Blanchaer M. C., Simulated clinical problems in a medical biochemistry course. Biochem. Educ. 3, 71 (1975). 3. Elstein A. S. et al., Medical Problem Solving: An Analysis of Clinical Reasoning. Harvard University Press, Cambridge, MA (1978). 4. Mayer R. E., Can advance organizers influence meaningful learning? Rev. Educ. Res. 49, 371 (1979).