American College of Physicians: Internal Medicine — Doctors for Adults ®

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High-tech tools provide hands-on training without the risks

Next generation options are interactive and current, but can virtual patients teach doctors real-life lessons?

From the January-February ACP Observer, copyright 2006 by the American College of Physicians.

By Bonnie Darves

Last June, internal medicine residents at Michigan State University in East Lansing began inserting a central line and performing a lumbar puncture without watching the clock or sweating as they fumbled to identify the right spot. That's because they were working on simulated patients in the university's new learning and assessment center, a multipurpose facility for physicians, nurses and veterinarians in training.

And at the University of Oklahoma College of Medicine in Tulsa, residents are turning on their computer to bone up on physician-patient communication and professionalism. The online program, called "doc.com," provides narrative education as well as expert clinician communicators demonstrating skills with "live" patients.

It's a far cry from the traditional textbook treatment on two notoriously difficult-to-teach subjects, said Ronald B. Saizow, FACP, the Oklahoma program's co-director and one of the editors of the doc.com series, which was developed by the American Academy on Physician and Patient and Drexel University College of Medicine, with grant support from the Arthur Vining Davis Foundations.


In many training programs, online modules are beginning to replace some traditional lectures and textbook assignments.



"Among the many things that are surprising us is that the learners are coming prepared for the [Friday conference] discussion and skills practice vs. when they were asked to read a book chapter," Dr. Saizow said. "They're engaged at a much higher level, often having tried new skills that they learned about and saw demonstrated on doc.com."

While this new breed of learning products is popular among the next generation of tech-savvy physicians, many educators are also embracing them. The products, after all, fill the growing demand for well-designed, up-to-date content to supplement traditional training venues.

But the new educational services also raise concerns among educators. How, they ask, can working with a machine teach young physicians the skills they need to treat patients?

More active learning?

Proponents of so-called "alternative education"—a term that covers everything from Web-based curriculum and interactive software to patient simulators and technology-enhanced grand rounds videos—hardly expect such products to replace the traditional lectures and textbook chapter assignments. But programs trying to meet increasingly stringent requirements for better ambulatory education and demonstrated competencies are turning to nontraditional curricula.

The residency program at the University of Connecticut Health Center in Farmington, Conn., for instance, did away with its traditional noon conference lecture more than a year ago.

The replacement? An Internet learning portal called Blackboard, with online curriculum covering 150 traditional core inpatient and outpatient medicine topics as well as interpretive skills for electrocardiograms and chest X-rays. (See "Online resources.")

"As interactive as we tried to make those [noon] lectures, they were very much examples of passive learning," recalled program director Steven V. Angus, ACP Member, who is also a member of the Governor's Council of the ACP Connecticut Chapter. "The residents were not prepared to discuss the topic—often times they only figured out what the topic was by the title slide. We have gone to a more active form of learning that allows our residents to decide when it is best for them to learn. As a result, they come better prepared for—and take away more from—the conferences we hold."

Residents at the University of Oklahoma-Tulsa, in addition to the doc.com programs, are using a series of modules developed by the Johns Hopkins Medicine Internet Learning Center to work through their ambulatory care rotation, with topics including community-acquired pneumonia and menopause. Residents complete pre- and post-tests, linking to related guidelines and recent literature in what is primarily case-focused content written by recognized experts.

Oklahoma-Tulsa's associate program director Erik A. Wallace, ACP Member, said the program turned to the modules as part of a bigger effort to retool its ambulatory education offerings.

"We revamped our ambulatory morning report and that worked well," said Dr. Wallace, who is a member of ACP's Council of Young Physicians. "But we realized that as medical education evolves, the Internet can be a good resource."

Residents now arrive for the weekly Friday conference better prepared and ready to engage in more targeted discussion of specific issues. "We use the conference to not only reinforce what they've learned but to build upon that," Dr. Wallace explained. "It's been a great addition."

Residents say they can fit in module sessions whenever their schedules allow, noted Sameer Badlani, ACP Associate Member, a third-year chief resident. He completed a medical informatics fellowship before starting his residency in Tulsa, and is a member of ACP's Council of Associates.

"There is a big convenience factor and a major standardization factor," Dr. Badlani said. "Instead of having attendings teaching different aspects of one topic based on personal preferences, you have a standardized pre-set module." Although it's hard for module authors to clarify material that may be confusing, he said, "the pre-test and post-test [design] allows you to take remedial action right then and there."

New options

Although use of such non-traditional education remains in its infancy, it is fast gaining ground, according to John P. Fitzgibbons, FACP, past president of the Association of Program Directors in Internal Medicine and a new member of the internal medicine residency review committee.

"If people go out there fishing for [alternative] curricula, they will find a lot of options," said Dr. Fitzgibbons, citing his recent Google search on cardiology curricula that uncovered dozens of options from leading academic institutions and health care organizations such as Kaiser Permanente. "There are a lot of resources people can go to rather than reinventing the wheel."

The Hopkins modules, for example, which were officially launched in 2001 and now include 26 modules, are being used by 69 internal medicine training programs. Stephen D. Sisson, ACP Member, director of ambulatory care for the Hopkins internal medicine residency program and a co-developer of the curriculum, noted that Hopkins "only advertised once" when it decided to offer the modules outside its own program. "The growth has been mostly word of mouth," he said.

The Hopkins curriculum can be tailored to individual programs, which accounts for the wide variation in how programs use it. "Some include a certain number of modules as a required part of their block experience," Dr. Sisson said. "Others use it similarly to the way we do—two modules a month throughout the year."

Increasingly, training programs are also eyeing such resources as a means of "benchmarking" themselves by "checking what they're doing internally," noted Dr. Fitzgibbons, who is also ACP Governor for the Pennsylvania Eastern Chapter. "There is more sharing of curricula occurring now and there are more dedicated list servers, so you can readily see what is happening."

The simulator debate

While Web-based curricula appear to be moving into the mainstream, the use of patient simulators may evolve more slowly, largely because of practical, financial and philosophical concerns. Michigan State's simulator facilities cost $1.8 million, for example, and space is hard to come by at many institutions. And some educators say that using "mannequin" patients doesn't make for a valid learning experience.

Davoren Chick, FACP, Michigan State's internal medicine residency program director, noted that simulators can serve a valuable purpose early in residency.

"The main benefit of simulators is that they allow teaching of the very fundamental approaches of a procedure—the pre- and post-procedure care—and allow residents to do the procedure in a less time-delineated fashion," Dr. Chick said. That takes the pressure off residents to just get the procedure done quickly. "They can stop to ask questions or fiddle with a guide-wire without being afraid of losing it in a patient's circulatory system."

For educators, the chief benefit is the ability to "stop" the procedure at any time to redirect and teach the resident, she added, and discuss errors in a blame-free environment. Still, Dr. Chick allowed that simulators have definite downsides: The tissue doesn't have the "variability" of the real stuff, as residents who eventually graduate to performing the procedure on actual patients will find.

Kristofer M. Dosh, ACP Associate Member, chief resident at Michigan State, also gave the simulator experience—especially the sessions on invasive procedures—a thumbs-up. He said he wishes he'd had exposure to the simulator before he performed his first invasive procedures.

"It's helpful to actually see the open [central line] kit in front of you, learn about its components and then use them—with guidance from an experienced person—on a simulated patient you can't actually harm," Dr. Dosh said. "All of the residents I spoke to afterward said it was a good experience."

Loss of human interaction

Supporters of the technological alternatives admit the tools are no substitute for hands-on, physician-patient and trainee-attending learning that forms the crux of the residency experience. But some educators worry what lessons these tools are teaching physicians.

Faith T. Fitzgerald, MACP, professor of medicine and assistant dean of the humanities and bioethics program at the University of California, Davis, worries that simulators and Web-based curriculum are "severely limited in their ability to reveal the full kaleidoscope of human illness."

"True patient care, with all the nuances and subtleties, can be learned only by direct and expertly directed interaction with as many patients as possible," she said. "With [the] limitation of resident hours and rapidity of patient 'throughput'—an iniquitous term—in both hospital and clinic, to take residents away from patients to teach them about patients becomes increasingly hazardous."

The message tacitly sent to students, she added, "is that real patients, whether 'classic' or atypical in their presentations, are not the most valuable teachers about themselves."

Further, Dr. Fitzgerald voiced concerns that using certain alternative teaching methods for the sake of efficiency implies "a false economy." Such experiences, she pointed out, aren't likely to enrich the resident's understanding of real patients.

At UC-Davis, the residency program's associate director Craig R. Keenan, ACP Member, said he is not at all opposed to alternative methods such as online teaching modules—which have been used more with medical students than with residents. Patient simulators are used to practice procedures and codes, Dr. Keenan said, but only as a supplement to actual clinical teaching.

However, "we have looked at some Web-based curricula for outpatient medicine but have decided against it," he said. "The content is great, but we felt that the one-on-one interaction with the computer could not replace the interactions in our small group of residents and faculty at our weekly case-based pre-clinic conference."

Even educators and residents who favor the use of alternative teaching methods or resources are careful to state that such modes don't—and shouldn't—replace resident-faculty and resident-patient interactions.

"Medicine is an art," said Dr. Chick from Michigan State, "and it's a human-to-human interaction and complex decision-making issue. The simulator and Web curriculum are very specifically intended to supplement that fundamental baseline knowledge and skill set."

She also acknowledged that alternative teaching methods don't always accommodate the complexity and subtlety of medical decision-making.

"For that you really still need the physician-resident, small-group interactions," she said. That's why internal medicine residents at Michigan State use a hybrid approach: For procedures, the simulator training experience is one learning opportunity that supplements supervised procedures performed by residents on actual patients.

And for their ambulatory training, residents must complete two of the online modules created by Johns Hopkins. However, they also attend targeted lectures by faculty or outside speakers, and they have interactive teaching during precepted clinics.

According to Dr. Chick, the Web modules can be a better learning tool than targeted lectures. "To me," she said, "the lecture format is one of the least effective ways to teach people anything—medicine or any other discipline."

As long as training programs make the distinction between what's considered core curriculum—medical knowledge, clinical skills and direct patient care—then supplemental, alternative modes can be safely and effectively employed, Dr. Fitzgibbons suggested.

"Everybody can use the [alternative] curriculum to confirm the medical knowledge piece," he said. "What you can't use it for, I think, is to deal with the clinical experience. It's up to individual programs to figure out how to deliver that."

Bonnie Darves is a freelance writer in Lake Oswego, Ore.

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