- Email: [email protected]
Simulation of integrative physiology for medical education
Morphologie (2019) 103, 187—193
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
Simulation of integrative physiology for medical education Simulation de la physiologie intégrative à l’appui de l’éducation médicale R.L. Hester a,b,∗, W. Pruett a,b, J. Clemmer a,b, A. Ruckdeschel b a b
Department of physiology, University of Mississippi Medical Center, Jackson, MS, USA Center for computational medicine, University of Mississippi Medical Center, Jackson, MS, USA
Available online 25 September 2019
KEYWORDS VPH; Simulation; Physiology; Healthcare; Electronic health record
Summary Medical education is founded on the understanding of physiology. While lecture materials and reading contribute to the learning of physiology, the richness and complexity of the subject suggest that more active learning methods may provide a richer introduction to the science as it applies to the practice of medicine. Simulation has been previously used in basic science to better understand the interaction of physiological systems. In the current context, simulation generally refers to interactive case studies performed with a manikin or anatomic device. More recently, simulation has grown to encompass computational simulation: virtual models of physiology and pathophysiology where students can see in a mechanistic setting how tissues and organs interact with one another to respond to changes in their environment. In this manuscript, we discuss how simulation fits into the overall history of medical education, and detail two computational simulation products designed for medical education. The first of these is an acute simulator, JustPhysiology, which reduces the scope of a large model, HumMod, down to a more focused interface. The second is Sycamore, an electronic health record-delivered, real time simulator of patients designed to teach chronic patient care to students. These products represent a new type of tool for medical and allied health students to encourage active learning and integration of basic science knowledge into clinical situations. © 2019 Elsevier Masson SAS. All rights reserved.
∗ Corresponding author at: University of Mississippi Medical Center, Department of Physiology, 2500 N. State Street, Jackson, MS 39216-4505, USA. E-mail address: [email protected] (R.L. Hester).
https://doi.org/10.1016/j.morpho.2019.09.004 1286-0115/© 2019 Elsevier Masson SAS. All rights reserved.
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R.L. Hester et al. Résumé L’étude de la médecine est fondée entre autres sur la compréhension de la physiologie. Bien que l’apprentissage de la physiologie puisse se faire au moyen de cours magistraux et la lecture de contenus spécialisés, la richesse et la complexité du sujet laissent supposer que des méthodes d’apprentissage plus interactives puissent susciter une initiation plus élaborée de cette science et de son application à la pratique de la médecine. La simulation a précédemment été appliquée aux sciences fondamentales afin de mieux comprendre l’interaction entre systèmes physiologiques. Dans le contexte actuel, la simulation réfère en général à des études de cas interactives réalisées à l’aide d’un mannequin ou tout autre modèle anatomique. Plus récemment, la simulation s’est étendue à la simulation informatique incluant des modèles virtuels de physiologie et de physiopathologie à partir desquels les étudiants peuvent apprécier dans un contexte mécanistique comment les tissus et organes interagissent dans leur réponse à tout changement environnemental. Dans cet article nous présentons comment la simulation s’intègre dans l’histoire de l’éducation de la médecine et détaillons deux modèles de simulation informatique adaptés à l’éducation médicale. Le premier modèle, JustPhysiology, est un simulateur de courte durée qui réduit le champ d’action d’un simulateur plus complexe, HumMod, à une interface plus spécialisée. Le second outil est Sycamore, un dossier de santé électronique généré en temps réel et conc ¸u pour un apprentissage de la pratique de soins médicaux en continu. Ces simulateurs informatiques représentent un nouvel outil pour les étudiants en médecine et autres professions de santé afin d’encourager un apprentissage actif et l’intégration de concepts scientifiques fondamentaux aux conditions cliniques. © 2019 Elsevier Masson SAS. Tous droits r´ eserv´ es.
In order to provide safe, evidence-based, and competent patient care, medical education should involve understanding the underlying physiology and pathophysiology and then applying this understanding in a complex clinical setting. Medical education before the 1600s in Europe, and through the mid-1700s in America, was largely apprenticeship based, with a highly varied outcome that depended strongly on the skill of the master and the range of patients seen by the student. With the advancement of scientific theory and the concentration of people in the great cities of Leyden, Edinburgh, Paris, and London, a pairing of experiment and lecture appeared, marking the beginning of modern medical education. Thomas Bond, the founder of the Pennsylvania Hospital, which became the clinical partner to the first modern medical school in the United States, recognized, however, that the student ‘‘must join examples with study before he can be sufficiently qualified to prescribe for the sick, for language and books alone can never give him adequate ideas of diseases and the best methods of treating them’’ [1]. Implicit in this statement is the idea that more examples are better than fewer, and that examples should exhibit didactic properties that encourage a type of thinking to develop in the physician-trainee. The same concept translates equally well to nurses and other students in the medical/patient care field. As technology has changed, these didactic methods have changed as well. We can sort them into three basic classes, in increasing order of generality and accessibility: patient interactions, case studies, and simulation. Patient interactions are restricted to the population available to the student, and the responses seen are specific to the intervention, and therefore to the level of care given by the teacher [2]. In this way, they suffer the same limitations of inconsistency at the system level that apprenticeship style education found. On the other hand, the student is assured
that patients are responding to their treatment in realistic ways, a level of credibility that other didactic methods may lack. Case studies tend to be static, providing a brief history and vital signs of a patient. In these cases, students are not able to determine if a selected or planned treatment would be effective. Case studies also suffer from the tendency of students to ‘‘diagnose first, prove later’’ model, which requires some measure of unlearning and can lead to a lack of clarity following a learning session [3]. Medical simulation is the final didactic method, which may be separated into two functional subsets. The first, physical simulation, routinely addresses acute conditions such as hemorrhage, heart attack, or pneumothorax, and focuses on crisis response as well as team building exercises. These simulations help students learn the correct practice for well understood mechanistic disorders, improving consistency and timeliness of therapy, but they neglect physiological and management issues that arise during chronic diseases and long-term care. As cases, they resemble case studies with limited outcomes, and these outcomes are typically proscribed by how well the students follow a script. In well-understood clinical situations, which are at least a plurality of the type of clinical situations physicians will find themselves in, this type of simulation can be a useful tool to improve outcomes. This kind of simulation also includes actor encounters, where students have to bridge the gap between their knowledge and their ability to communicate effectively with their patients. The second type of simulation is computational simulation. In this type of simulation, the system responds dynamically to student interaction. This type of simulation goes from simple models included onboard manikins to complex surgical simulators with virtual reality and haptics. Currently, we are unaware of any product in the medical education/simulation industry that addresses the management of chronic health conditions.
Simulation of integrative physiology for medical education The practice of modern medicine requires more than a deep knowledge of physiology and pathophysiology: it also requires significant investment in the technology of medicine. While each specialty has specific tools used in patient care, utilization of health information technology is common to all disciplines, and currently, a knowledge gap also exists between health information technology education and professional practice. Medical information and technology systems aid in evidence-based practice and clinical decision-making [4]. Thousands of patients die in U.S. hospitals each year due to preventable medical errors. Hinojosa-Amaya et al. [5] estimates the number of preventable deaths each year is between 44,000 and 98,000. Millions of life-threatening medical errors occur each year, with many of these errors made by newly graduated physicians [6]. These errors cost hospitals approximately $46 million per day, accounting for 16% of patient care costs [7]. According to the CMS, an electronic health record (EHR) ‘‘can improve patient care by reducing the incidence of medical error by improving the accuracy and clarity of medical records’’ [8]. They accomplish this goal by improving critical thinking and clinical reasoning in new graduates [9]. EHR systems have the capacity to alert health care professionals to potential patient care conflicts as well as provide resources for referencing diagnoses and medications. These built-in safety mechanisms aid health care professionals in reducing errors leading to improving patient outcomes [10]. The rapid proliferation of technologies to access, utilize, store, and communicate critical health care information and the demonstration that such technologies improve clinical outcomes have resulted in health care employers expecting new graduates to be competent in the use of an EHR [10]. This transformation in health care has created a profound need for students to be competent in information technology and, in particular, the use of the EHR [9]. In order to meet this need, education must be transformed. By increasing EHR knowledge, competency, and skill level, students will better understand health information systems used in the practice environment, making them more mindful, which could prevent medication errors. The Joint Commission addressed safe use of health information technology, with actions centering on safety culture and process improvement [11]. We use the physiology engine, HumMod (http://hummod. org), a time-dependent physiologic simulation engine developed to simulate normal and pathophysiologic processes across different organ systems. HumMod is the result of over 45 years of development in the Department of Physiology at the University of Mississippi Medical Center [12—16]. Drs. Guyton, Coleman, and Granger published the initial mathematical model of integrated human physiology in 1972. Dr. Coleman continued the development of additional simulation software and developed HumMod along with the co-authors of this paper. HumMod currently contains a series of mathematical equations and > 10,000 variables and parameters that describe cardiovascular, renal, respiratory, endocrine, and neural physiology as well as metabolism, exercise, and environmental factors. Additionally, HumMod can simulate chronic diseases, such as hypertension, congestive heart failure, and numerous endocrine disorders (e.g., diabetes mellitus or diabetes insipidus). The HumMod software is efficient; depending on the disease state, a month simulation takes less than 5 minutes. Fig. 1 provides the
189 results of a two-week HumMod simulation of essential hypertension. Antihypertensive treatment was simulated with an angiotensin converting inhibitor as well as a beta blocker, which both resulted in a fall in blood pressure (Fig. 1). In order to teach basic physiology to undergraduate and postgraduate students, JustPhysiology, a cloud-based physiological simulator based on the HumMod model was developed. The HumMod user interface was found to be too complex for medical education; users must navigate multiple menu items to find single values. This forced students to expend working memory on the interface, rather than the physiology. To alleviate this problem a new interface was developed and deployed from http://justphysiology.com, by HC Simulation, LLC. Users interact with HumMod though a web browser that provides introductory material, variables, and controllers for a specific simulation or concept. In addition to basic physiological simulations, JustPhysiology has a series of virtual patients that students have the ability to diagnosis and treat, either correctly or hazardously. For example, Ms. Paile has orthostatic hypotension whose blood pressure falls upon standing (see Fig. 2). Other virtual patient examples include Mr. Alden who has hypertension associated with sleep apnea and Ms. Nance who has congestive heart failure. In all of these cases, the simulations run faster than real time and provide physiological variables, such as cardiovascular hemodynamics and function or level of pulmonary edema. Additionally, students can treat the underlying pathology with drugs, such as alpha/beta blockers, blockers of the renin angiotensin system, diuretics, sympathomimetics, or exogenous insulin.
Sycamore Long-term care software simulations must address three goals: • long-term care and responsibility; • patient-centered problem solving skills (not fixed responses or predetermined outcomes); • interdisciplinary communication skills. The following describes a software project, known as ‘‘Sycamore’’, which is currently under development and addresses these goals. Once developed, modeled, and refined, this educational program can be packaged and utilized by any medical training program including undergraduate and graduate studies. Further, the simulation will include patient migration, requiring students to practice transfers and hand-offs. These transfers and hand-offs could potentially be between other disciplines or providers, including multiple academic institutions. A visual representation of the student interaction with Sycamore is shown in Fig. 3. We are unaware of any training environments that provide an integrated system allowing a longitudinal care experience for health care students at all levels. For Sycamore, we are linking HumMod with EPIC, the EHR system used by most academic health centers across the U.S. This system will operate in real-time, so that health care students will follow patients over months or years. This program is designed as a cross-disciplinary training
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R.L. Hester et al.
Figure 1 Demonstration of a HumMod simulation of a patient with hypertension due to sleep apnea and resultant treatments with a Converting Enzyme Inhibitor, first fall in pressure (arrow), followed by a second fall in pressure due to treatment with a beta blocker.
Figure 2 Demonstration in JustPhysiology of a patient with orthostatic hypertension. Note the fall in blood pressure, and reflex increase in blood pressure, at 10 minutes when the patient stood.
Simulation of integrative physiology for medical education
Figure 3
191
A visual representation of the student interaction with Sycamore. Note the interaction takes place in real time.
environment, including medical, nursing, and pharmacy students. Sycamore will utilize simulated patients with chronic illnesses such as hypertension, diabetes, progressive heart failure, and kidney disease, isolated or occurring in tandem, along with more acute disorders, to train students in safe, timely, and efficient health care. We will also implement socio-economic complications into treatment strategies. For example, irregular prescription use due to apathy, forgetfulness, or economic insufficiency can complicate long-term patient management. Recognition of non-compliance is a critical role for the vigilant health care professional. Sycamore will assess medical knowledge, professionalism, practice-based learning and improvement, ethics, and systems-based practice. This is accomplished by monitoring patient health outcomes, student responsiveness to patients’ needs, resource utilization, and student identification of system dysfunctions, which are known to impede real patient care. This education and training will be performed in an environment where medical physiology is science-based rather than running on an operator’s idea of what might happen, thus allowing students a nonthreatening, yet rigorous and realistic learning environment. We believe that this type of educational training will also improve health care, diagnoses, record keeping, and minimizing the ordering of inappropriate medical tests. Sycamore will require four parts for implementation: • a physiological engine that provides realistic simulation of chronic conditions over time; • a controller program to develop ‘‘patients’’ for the end users;
• an EHR front end, and; • an assessment suite. Together, these parts ensure a self-contained, robust learning environment that will vigorously challenge medical students.
Controller The controller will generate patients and interface between the HumMod engine and the user interface in the form of an EHR. It will provide random patients, including history and physical data for the relevant pathological condition to each student. Real-life patient responses to pathologies and their treatments are highly variable. Equation-based physiological simulations are traditionally deterministic, with simulation outcomes always being the same unless initial conditions change. To overcome this issue, we developed a novel technique to generate robust populations of individuals with specific disorders, where the individuals may have different underlying physiology for the same pathology. This process will furnish different patients to each student without relying on a template for each disease state. Matching patients to an integrative physiological model rather than a predetermined script provides students with an open-ended tool designed for inquisitive exploration more applicable to clinical practice rather than directed linearity. As such, it represents a disruptive breakthrough in the medical education paradigm, bridging the gap between education and technology driven health care practices.
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User Interface Students will interface with patients in two ways: • through an EHR; • through real-time communication paradigms (e.g., text, email, and calendar) to alert the student to acute changes in patient status. We will use existing EHRs to provide the most realistic simulation of patient care possible. When students enter a request for patient values, such as complete blood counts or plasma hormone levels, the controller will request the data from HumMod and the controller will then populate the EHR. Conversely, when the student prescribes a treatment the controller will provide that treatment information to HumMod, which will then simulate the results of the treatment. The HumMod engine can provide continual data; however, the controller will only provide data to the EHR when requested by the student, with delays mimicking a hospital’s data collection pace. Patients will be ‘seen and evaluated’ by a virtual appointment. Since Sycamore is real-time, students may need appointment reminders to prepare for the patient encounter. Low wait-times make for happier patients, which improves outcomes. In addition, students will need to respond to the urgent or emergent problems for a select number of their patients. Response time and intervention will be tracked via the program. Finally, a select number of patients for each student will have significant physiologic changes requiring intervention. These changes will result from chronic disease processes, superimposed major physiologic stressors, and system dysfunction. Instructors will be able to introduce specific perturbations to reinforce lessons. Students will be able to assess their patients and implement care plans. Physician communication ranks as one of the highest, if not the highest, source of preventable medical mistakes. The largest source of communication errors is in transfer of care. Sycamore will allow multiple modalities to transfer care, including hand-offs, transfers, and walk-ins (e.g.: people on vacation that become ill). In these cases, the medical record plus direct communication must suffice to pass all relevant information to the new provider. This type of transfer is a learned skill that must be taught and trained. For example, an ‘‘on-call’’ physician signs-out new patients to other providers, essentially functioning as an information conduit. Similarly, if a patient ‘‘moves’’ or changes physician, a summary of care must be made to smooth the transition. For each case, appointments between providers can be made within the system and a phone call scheduled for the communication. The other modality to consider is that of a traveling patient who becomes ill or injured. Since the nearest physician will not be their primary physician, the patient would present with little information. The treating physician can contact the primary physician to gather pertinent information; however, the response depends on the primary physician, although an appointment or phone conversation may not be feasible. In this case, the record and a brief note may have to suffice. Sycamore’s design will allow individuals to practice interdisciplinary team
R.L. Hester et al. management by working with the same patient, allowing teamwork between physician-trainees and nurse-trainees, for example, to take place seamlessly. Furthermore, handoffs and communication could be practiced more effectively.
Utilization For undergraduate medical education, we propose that Sycamore be integrated as a required longitudinal project throughout the second to fourth year. During the second year, students are introduced to their Sycamore patients. During the first half of the third year and coinciding with the traditional transition to a clinical curriculum, students will review and utilize appropriate practice guidelines for patient care. During the second half of the third year, students will manage their patients’ complications, which coincides with students receiving increased responsibility for patient care in the clinical setting. During the fourth year, students assume full ownership for patient care and must utilize best practices and self-assess patient care. At project completion, each student will receive a summative performance assessment covering application of medical knowledge, professionalism, practice-based learning and improvement, and systems-based practice.
Conclusion In summary, these two products represent new tools for medical and health education to encourage active learning and integration of basic scientific knowledge into clinical applications and situations. JustPhysiology currently provides a browser-based environment for students to explore basic physiology and to understand physiology within virtual patients with pathological conditions. Sycamore will provide a unique training opportunity for medical students, nursing students, residents, and other health care professionals. It will offer directed learning, while avoiding the linearity of directed acute simulations. It will assess medical knowledge, professionalism, practice-based learning and improvement, ethics, and systems-based practice by monitoring patient health outcomes, student responsiveness to patients’ needs, resource utilization, and system dysfunctions that impede patient care.
Funding This work was supported by grants from the American Heart Association (AHA 17POST33661071), the National Institute of General Medical Sciences (P20 GM104357), the National Science Foundation (NSF EPS 0903787) and the National Heart, Lung, and Blood Institute (P01 HL051971).
Disclosure of interest HumMod is licensed by the University of Mississippi Medical Center to HC Simulation, LLC. Dr. Robert Hester is CEO and Owner of HC Simulation, LLC. William Andrew Pruett is Chief Science Officer of HC Simulation, LLC. Sycamore is a joint project between the University of Mississippi Medical Center and HC Simulation, LLC.
Simulation of integrative physiology for medical education The other authors declare that they have no competing interest.
References [1] Bridenbaugh C. Dr. Thomas Bond’s essay on the utility of clinical lectures. J Hist med Allied Sci 1947;2(1):10—9. [2] Bokken L, Rethans JJ, Scherpbier AJ, van der Vleuten CP. Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: a review. Simul Healthc 2008;3(3):161—9. [3] Ghosh S. Combination of didactic lectures and case-oriented problem-solving tutorials toward better learning: perceptions of students from a conventional medical curriculum. Adv Physiol Educ 2007;31(2):193—7. [4] Healthcare Information and Management Systems Society (2010). Technology Informatics Guiding Educational Reform. Retrieved from https://www.himss.org/informaticscompetencies. [5] Hinojosa-Amaya JM, Rodriguez-Garcia FG, Yeverino-Castro SG, Sanchez-Cardenas M, Villarreal-Alarcon MA, Galarza-Delgado DA. Medication errors: electronic vs. paper-based prescribing. Experience at a tertiary care university hospital. J Eval Clin Pract 2016;22(5):751—4. [6] Saintsing D, Gibson LM, Pennington AW. The novice nurse and clinical decision-making: how to avoid errors. J Nurs Manag 2011;19(3):354—9. [7] Zimmerman DM, House P. Medication safety: simulation education for new RNs promises an excellent return on investment. Nurs Econ 2016;34(1):49—51.
193 [8] Centers for Medicare and Medicaid Services (2012). Electronic health records. Retrieved from https://www.cms.gov/ medicare/e-health/ehealthrecords/index.html. [9] Pilarski T. Where is nursing informatics in undergraduate nursing education. CJNI: Can J Nurs Informat 2010:5. [10] Health Information Technology. Health IT and health information exchange basics. Retrieved from https://www.healthit. gov/topic/health-it-and-health-information-exchangebasics/health-it-and-health-information-exchange. 2014. [11] Joint Commission (2015). Safe use of health information technology. Sentinel Event Alert, 54. Retrieved from http://www.jointcommission.org/assets/1/18/SEA 54.pdf. [12] Clemmer JS, Pruett WA, Hester RL, Iliescu R, Lohmeier TE. Role of the heart in blood pressure lowering during chronic baroreflex activation: insight from an in silico analysis. Am J Physiol Heart Circ Physiol 2018. [13] Pruett WA, Clemmer JS, Hester RL. Validation of an integrative mathematical model of dehydration and rehydration in virtual humans. Physiol Rep 2016;4(22.). [14] Hester RL, Brown AJ, Husband L, Iliescu R, Pruett D, Summers R, et al. HumMod: a modeling environment for the simulation of integrative human physiology. Front Physiol 2011;2: 12. [15] Guyton AC, Coleman TG, Manning Jr RD, Hall JE. Some problems and solutions for modeling overall cardiovascular regulation. Mathemat Biosci 1984;72(2):141—55. [16] Summers RL, Coleman TG. Computer systems analysis of the cardiovascular mechanisms of reentry orthostasis in astronauts. Comput Cardiol 2002;29:521—4.
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
Simulation of integrative physiology for medical education Simulation de la physiologie intégrative à l’appui de l’éducation médicale R.L. Hester a,b,∗, W. Pruett a,b, J. Clemmer a,b, A. Ruckdeschel b a b
Department of physiology, University of Mississippi Medical Center, Jackson, MS, USA Center for computational medicine, University of Mississippi Medical Center, Jackson, MS, USA
Available online 25 September 2019
KEYWORDS VPH; Simulation; Physiology; Healthcare; Electronic health record
Summary Medical education is founded on the understanding of physiology. While lecture materials and reading contribute to the learning of physiology, the richness and complexity of the subject suggest that more active learning methods may provide a richer introduction to the science as it applies to the practice of medicine. Simulation has been previously used in basic science to better understand the interaction of physiological systems. In the current context, simulation generally refers to interactive case studies performed with a manikin or anatomic device. More recently, simulation has grown to encompass computational simulation: virtual models of physiology and pathophysiology where students can see in a mechanistic setting how tissues and organs interact with one another to respond to changes in their environment. In this manuscript, we discuss how simulation fits into the overall history of medical education, and detail two computational simulation products designed for medical education. The first of these is an acute simulator, JustPhysiology, which reduces the scope of a large model, HumMod, down to a more focused interface. The second is Sycamore, an electronic health record-delivered, real time simulator of patients designed to teach chronic patient care to students. These products represent a new type of tool for medical and allied health students to encourage active learning and integration of basic science knowledge into clinical situations. © 2019 Elsevier Masson SAS. All rights reserved.
∗ Corresponding author at: University of Mississippi Medical Center, Department of Physiology, 2500 N. State Street, Jackson, MS 39216-4505, USA. E-mail address: [email protected] (R.L. Hester).
https://doi.org/10.1016/j.morpho.2019.09.004 1286-0115/© 2019 Elsevier Masson SAS. All rights reserved.
188
R.L. Hester et al. Résumé L’étude de la médecine est fondée entre autres sur la compréhension de la physiologie. Bien que l’apprentissage de la physiologie puisse se faire au moyen de cours magistraux et la lecture de contenus spécialisés, la richesse et la complexité du sujet laissent supposer que des méthodes d’apprentissage plus interactives puissent susciter une initiation plus élaborée de cette science et de son application à la pratique de la médecine. La simulation a précédemment été appliquée aux sciences fondamentales afin de mieux comprendre l’interaction entre systèmes physiologiques. Dans le contexte actuel, la simulation réfère en général à des études de cas interactives réalisées à l’aide d’un mannequin ou tout autre modèle anatomique. Plus récemment, la simulation s’est étendue à la simulation informatique incluant des modèles virtuels de physiologie et de physiopathologie à partir desquels les étudiants peuvent apprécier dans un contexte mécanistique comment les tissus et organes interagissent dans leur réponse à tout changement environnemental. Dans cet article nous présentons comment la simulation s’intègre dans l’histoire de l’éducation de la médecine et détaillons deux modèles de simulation informatique adaptés à l’éducation médicale. Le premier modèle, JustPhysiology, est un simulateur de courte durée qui réduit le champ d’action d’un simulateur plus complexe, HumMod, à une interface plus spécialisée. Le second outil est Sycamore, un dossier de santé électronique généré en temps réel et conc ¸u pour un apprentissage de la pratique de soins médicaux en continu. Ces simulateurs informatiques représentent un nouvel outil pour les étudiants en médecine et autres professions de santé afin d’encourager un apprentissage actif et l’intégration de concepts scientifiques fondamentaux aux conditions cliniques. © 2019 Elsevier Masson SAS. Tous droits r´ eserv´ es.
In order to provide safe, evidence-based, and competent patient care, medical education should involve understanding the underlying physiology and pathophysiology and then applying this understanding in a complex clinical setting. Medical education before the 1600s in Europe, and through the mid-1700s in America, was largely apprenticeship based, with a highly varied outcome that depended strongly on the skill of the master and the range of patients seen by the student. With the advancement of scientific theory and the concentration of people in the great cities of Leyden, Edinburgh, Paris, and London, a pairing of experiment and lecture appeared, marking the beginning of modern medical education. Thomas Bond, the founder of the Pennsylvania Hospital, which became the clinical partner to the first modern medical school in the United States, recognized, however, that the student ‘‘must join examples with study before he can be sufficiently qualified to prescribe for the sick, for language and books alone can never give him adequate ideas of diseases and the best methods of treating them’’ [1]. Implicit in this statement is the idea that more examples are better than fewer, and that examples should exhibit didactic properties that encourage a type of thinking to develop in the physician-trainee. The same concept translates equally well to nurses and other students in the medical/patient care field. As technology has changed, these didactic methods have changed as well. We can sort them into three basic classes, in increasing order of generality and accessibility: patient interactions, case studies, and simulation. Patient interactions are restricted to the population available to the student, and the responses seen are specific to the intervention, and therefore to the level of care given by the teacher [2]. In this way, they suffer the same limitations of inconsistency at the system level that apprenticeship style education found. On the other hand, the student is assured
that patients are responding to their treatment in realistic ways, a level of credibility that other didactic methods may lack. Case studies tend to be static, providing a brief history and vital signs of a patient. In these cases, students are not able to determine if a selected or planned treatment would be effective. Case studies also suffer from the tendency of students to ‘‘diagnose first, prove later’’ model, which requires some measure of unlearning and can lead to a lack of clarity following a learning session [3]. Medical simulation is the final didactic method, which may be separated into two functional subsets. The first, physical simulation, routinely addresses acute conditions such as hemorrhage, heart attack, or pneumothorax, and focuses on crisis response as well as team building exercises. These simulations help students learn the correct practice for well understood mechanistic disorders, improving consistency and timeliness of therapy, but they neglect physiological and management issues that arise during chronic diseases and long-term care. As cases, they resemble case studies with limited outcomes, and these outcomes are typically proscribed by how well the students follow a script. In well-understood clinical situations, which are at least a plurality of the type of clinical situations physicians will find themselves in, this type of simulation can be a useful tool to improve outcomes. This kind of simulation also includes actor encounters, where students have to bridge the gap between their knowledge and their ability to communicate effectively with their patients. The second type of simulation is computational simulation. In this type of simulation, the system responds dynamically to student interaction. This type of simulation goes from simple models included onboard manikins to complex surgical simulators with virtual reality and haptics. Currently, we are unaware of any product in the medical education/simulation industry that addresses the management of chronic health conditions.
Simulation of integrative physiology for medical education The practice of modern medicine requires more than a deep knowledge of physiology and pathophysiology: it also requires significant investment in the technology of medicine. While each specialty has specific tools used in patient care, utilization of health information technology is common to all disciplines, and currently, a knowledge gap also exists between health information technology education and professional practice. Medical information and technology systems aid in evidence-based practice and clinical decision-making [4]. Thousands of patients die in U.S. hospitals each year due to preventable medical errors. Hinojosa-Amaya et al. [5] estimates the number of preventable deaths each year is between 44,000 and 98,000. Millions of life-threatening medical errors occur each year, with many of these errors made by newly graduated physicians [6]. These errors cost hospitals approximately $46 million per day, accounting for 16% of patient care costs [7]. According to the CMS, an electronic health record (EHR) ‘‘can improve patient care by reducing the incidence of medical error by improving the accuracy and clarity of medical records’’ [8]. They accomplish this goal by improving critical thinking and clinical reasoning in new graduates [9]. EHR systems have the capacity to alert health care professionals to potential patient care conflicts as well as provide resources for referencing diagnoses and medications. These built-in safety mechanisms aid health care professionals in reducing errors leading to improving patient outcomes [10]. The rapid proliferation of technologies to access, utilize, store, and communicate critical health care information and the demonstration that such technologies improve clinical outcomes have resulted in health care employers expecting new graduates to be competent in the use of an EHR [10]. This transformation in health care has created a profound need for students to be competent in information technology and, in particular, the use of the EHR [9]. In order to meet this need, education must be transformed. By increasing EHR knowledge, competency, and skill level, students will better understand health information systems used in the practice environment, making them more mindful, which could prevent medication errors. The Joint Commission addressed safe use of health information technology, with actions centering on safety culture and process improvement [11]. We use the physiology engine, HumMod (http://hummod. org), a time-dependent physiologic simulation engine developed to simulate normal and pathophysiologic processes across different organ systems. HumMod is the result of over 45 years of development in the Department of Physiology at the University of Mississippi Medical Center [12—16]. Drs. Guyton, Coleman, and Granger published the initial mathematical model of integrated human physiology in 1972. Dr. Coleman continued the development of additional simulation software and developed HumMod along with the co-authors of this paper. HumMod currently contains a series of mathematical equations and > 10,000 variables and parameters that describe cardiovascular, renal, respiratory, endocrine, and neural physiology as well as metabolism, exercise, and environmental factors. Additionally, HumMod can simulate chronic diseases, such as hypertension, congestive heart failure, and numerous endocrine disorders (e.g., diabetes mellitus or diabetes insipidus). The HumMod software is efficient; depending on the disease state, a month simulation takes less than 5 minutes. Fig. 1 provides the
189 results of a two-week HumMod simulation of essential hypertension. Antihypertensive treatment was simulated with an angiotensin converting inhibitor as well as a beta blocker, which both resulted in a fall in blood pressure (Fig. 1). In order to teach basic physiology to undergraduate and postgraduate students, JustPhysiology, a cloud-based physiological simulator based on the HumMod model was developed. The HumMod user interface was found to be too complex for medical education; users must navigate multiple menu items to find single values. This forced students to expend working memory on the interface, rather than the physiology. To alleviate this problem a new interface was developed and deployed from http://justphysiology.com, by HC Simulation, LLC. Users interact with HumMod though a web browser that provides introductory material, variables, and controllers for a specific simulation or concept. In addition to basic physiological simulations, JustPhysiology has a series of virtual patients that students have the ability to diagnosis and treat, either correctly or hazardously. For example, Ms. Paile has orthostatic hypotension whose blood pressure falls upon standing (see Fig. 2). Other virtual patient examples include Mr. Alden who has hypertension associated with sleep apnea and Ms. Nance who has congestive heart failure. In all of these cases, the simulations run faster than real time and provide physiological variables, such as cardiovascular hemodynamics and function or level of pulmonary edema. Additionally, students can treat the underlying pathology with drugs, such as alpha/beta blockers, blockers of the renin angiotensin system, diuretics, sympathomimetics, or exogenous insulin.
Sycamore Long-term care software simulations must address three goals: • long-term care and responsibility; • patient-centered problem solving skills (not fixed responses or predetermined outcomes); • interdisciplinary communication skills. The following describes a software project, known as ‘‘Sycamore’’, which is currently under development and addresses these goals. Once developed, modeled, and refined, this educational program can be packaged and utilized by any medical training program including undergraduate and graduate studies. Further, the simulation will include patient migration, requiring students to practice transfers and hand-offs. These transfers and hand-offs could potentially be between other disciplines or providers, including multiple academic institutions. A visual representation of the student interaction with Sycamore is shown in Fig. 3. We are unaware of any training environments that provide an integrated system allowing a longitudinal care experience for health care students at all levels. For Sycamore, we are linking HumMod with EPIC, the EHR system used by most academic health centers across the U.S. This system will operate in real-time, so that health care students will follow patients over months or years. This program is designed as a cross-disciplinary training
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Figure 1 Demonstration of a HumMod simulation of a patient with hypertension due to sleep apnea and resultant treatments with a Converting Enzyme Inhibitor, first fall in pressure (arrow), followed by a second fall in pressure due to treatment with a beta blocker.
Figure 2 Demonstration in JustPhysiology of a patient with orthostatic hypertension. Note the fall in blood pressure, and reflex increase in blood pressure, at 10 minutes when the patient stood.
Simulation of integrative physiology for medical education
Figure 3
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A visual representation of the student interaction with Sycamore. Note the interaction takes place in real time.
environment, including medical, nursing, and pharmacy students. Sycamore will utilize simulated patients with chronic illnesses such as hypertension, diabetes, progressive heart failure, and kidney disease, isolated or occurring in tandem, along with more acute disorders, to train students in safe, timely, and efficient health care. We will also implement socio-economic complications into treatment strategies. For example, irregular prescription use due to apathy, forgetfulness, or economic insufficiency can complicate long-term patient management. Recognition of non-compliance is a critical role for the vigilant health care professional. Sycamore will assess medical knowledge, professionalism, practice-based learning and improvement, ethics, and systems-based practice. This is accomplished by monitoring patient health outcomes, student responsiveness to patients’ needs, resource utilization, and student identification of system dysfunctions, which are known to impede real patient care. This education and training will be performed in an environment where medical physiology is science-based rather than running on an operator’s idea of what might happen, thus allowing students a nonthreatening, yet rigorous and realistic learning environment. We believe that this type of educational training will also improve health care, diagnoses, record keeping, and minimizing the ordering of inappropriate medical tests. Sycamore will require four parts for implementation: • a physiological engine that provides realistic simulation of chronic conditions over time; • a controller program to develop ‘‘patients’’ for the end users;
• an EHR front end, and; • an assessment suite. Together, these parts ensure a self-contained, robust learning environment that will vigorously challenge medical students.
Controller The controller will generate patients and interface between the HumMod engine and the user interface in the form of an EHR. It will provide random patients, including history and physical data for the relevant pathological condition to each student. Real-life patient responses to pathologies and their treatments are highly variable. Equation-based physiological simulations are traditionally deterministic, with simulation outcomes always being the same unless initial conditions change. To overcome this issue, we developed a novel technique to generate robust populations of individuals with specific disorders, where the individuals may have different underlying physiology for the same pathology. This process will furnish different patients to each student without relying on a template for each disease state. Matching patients to an integrative physiological model rather than a predetermined script provides students with an open-ended tool designed for inquisitive exploration more applicable to clinical practice rather than directed linearity. As such, it represents a disruptive breakthrough in the medical education paradigm, bridging the gap between education and technology driven health care practices.
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User Interface Students will interface with patients in two ways: • through an EHR; • through real-time communication paradigms (e.g., text, email, and calendar) to alert the student to acute changes in patient status. We will use existing EHRs to provide the most realistic simulation of patient care possible. When students enter a request for patient values, such as complete blood counts or plasma hormone levels, the controller will request the data from HumMod and the controller will then populate the EHR. Conversely, when the student prescribes a treatment the controller will provide that treatment information to HumMod, which will then simulate the results of the treatment. The HumMod engine can provide continual data; however, the controller will only provide data to the EHR when requested by the student, with delays mimicking a hospital’s data collection pace. Patients will be ‘seen and evaluated’ by a virtual appointment. Since Sycamore is real-time, students may need appointment reminders to prepare for the patient encounter. Low wait-times make for happier patients, which improves outcomes. In addition, students will need to respond to the urgent or emergent problems for a select number of their patients. Response time and intervention will be tracked via the program. Finally, a select number of patients for each student will have significant physiologic changes requiring intervention. These changes will result from chronic disease processes, superimposed major physiologic stressors, and system dysfunction. Instructors will be able to introduce specific perturbations to reinforce lessons. Students will be able to assess their patients and implement care plans. Physician communication ranks as one of the highest, if not the highest, source of preventable medical mistakes. The largest source of communication errors is in transfer of care. Sycamore will allow multiple modalities to transfer care, including hand-offs, transfers, and walk-ins (e.g.: people on vacation that become ill). In these cases, the medical record plus direct communication must suffice to pass all relevant information to the new provider. This type of transfer is a learned skill that must be taught and trained. For example, an ‘‘on-call’’ physician signs-out new patients to other providers, essentially functioning as an information conduit. Similarly, if a patient ‘‘moves’’ or changes physician, a summary of care must be made to smooth the transition. For each case, appointments between providers can be made within the system and a phone call scheduled for the communication. The other modality to consider is that of a traveling patient who becomes ill or injured. Since the nearest physician will not be their primary physician, the patient would present with little information. The treating physician can contact the primary physician to gather pertinent information; however, the response depends on the primary physician, although an appointment or phone conversation may not be feasible. In this case, the record and a brief note may have to suffice. Sycamore’s design will allow individuals to practice interdisciplinary team
R.L. Hester et al. management by working with the same patient, allowing teamwork between physician-trainees and nurse-trainees, for example, to take place seamlessly. Furthermore, handoffs and communication could be practiced more effectively.
Utilization For undergraduate medical education, we propose that Sycamore be integrated as a required longitudinal project throughout the second to fourth year. During the second year, students are introduced to their Sycamore patients. During the first half of the third year and coinciding with the traditional transition to a clinical curriculum, students will review and utilize appropriate practice guidelines for patient care. During the second half of the third year, students will manage their patients’ complications, which coincides with students receiving increased responsibility for patient care in the clinical setting. During the fourth year, students assume full ownership for patient care and must utilize best practices and self-assess patient care. At project completion, each student will receive a summative performance assessment covering application of medical knowledge, professionalism, practice-based learning and improvement, and systems-based practice.
Conclusion In summary, these two products represent new tools for medical and health education to encourage active learning and integration of basic scientific knowledge into clinical applications and situations. JustPhysiology currently provides a browser-based environment for students to explore basic physiology and to understand physiology within virtual patients with pathological conditions. Sycamore will provide a unique training opportunity for medical students, nursing students, residents, and other health care professionals. It will offer directed learning, while avoiding the linearity of directed acute simulations. It will assess medical knowledge, professionalism, practice-based learning and improvement, ethics, and systems-based practice by monitoring patient health outcomes, student responsiveness to patients’ needs, resource utilization, and system dysfunctions that impede patient care.
Funding This work was supported by grants from the American Heart Association (AHA 17POST33661071), the National Institute of General Medical Sciences (P20 GM104357), the National Science Foundation (NSF EPS 0903787) and the National Heart, Lung, and Blood Institute (P01 HL051971).
Disclosure of interest HumMod is licensed by the University of Mississippi Medical Center to HC Simulation, LLC. Dr. Robert Hester is CEO and Owner of HC Simulation, LLC. William Andrew Pruett is Chief Science Officer of HC Simulation, LLC. Sycamore is a joint project between the University of Mississippi Medical Center and HC Simulation, LLC.
Simulation of integrative physiology for medical education The other authors declare that they have no competing interest.
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