Simulation-based learning in competency-based medical education: The Indian context: Dr Dinesh Badyal

Simulations are being used in the airline industry for training, re-training and certification. For the airline industry, safety is of paramount importance. Medical services also look at safety as a very important parameter. Risk reduction strategies are being used in these two areas. Medical education curricula have been trying to use simulation-based learning (SBL) for years. Simulations are presently being used for skill acquisition and assessment. However, the following dilemmas remain: what to use in simulations, why to use simulations and how to use simulations for learning.

In India, we have two contrasting scenarios related to availability of clinical material for learning in medical colleges. In some well-established colleges there are large number of patients, while in other colleges, there are a smaller number of patients or patients refuse examination by students. Simulations and simulation-based teaching can be useful in these scenarios. The use of skills and simulation labs have become mandatory in India for undergraduate medical education from 2019 as per the new competency-based curriculum.

Due to the above reasons, medical colleges are trying to set up simulation labs and start simulation-based teaching. However, unfortunately most colleges buy mannikins and fill their simulation labs with a variety of plastic material without realizing their need or without having any teaching-learning relevance. In a way they invest heavily in plastic mannikins but not in training their stakeholders in how to develop and implement simulation-based teaching-learning.

Simulation laboratories can be used to learn technical or non-technical skills. Non-technical skills including communication, team-based learning etc. can be very effectively taught in simulated scenarios. In technical skills, techniques like intravenous injections, lumbar puncture can be done repeatedly and improvements can be done. It is not always possible to learn these skills in real encounters. Therefore, simulation encounters using various simulations e.g. mannikins, standardised patients, or hybrid models can help a lot to improve student learning and patient safety. The confidence of learners improve and they can practice multiple times on simulations and also take remedial actions. Otherwise, a learner cannot poke a patient multiple times to learn intramuscular injections.

The development of low-resource intensive simulations and simulated  environments can contribute to better skills learning and improved patient safety. It is reported to improve patient outcomes too. The use of low-fidelity simulation can be also very useful if appropriate teaching learning methods are employed. The educational material in a simulation module can include learning objectives, methods, material needed, logistics  about space, time, practice time, faculty training tips and assessment strategies e.g. checklists, OSAT (Objective structured assessment of technical skills), OSCE (Objective structured clinical examination), OSPE (Objective structured practical examination). The possibility of using hybrids i.e. video/computer simulation/ real patients should be explored as in India at number of places ample number of patients are available. Hybrid models can be used for intramuscular injection by using actual subject for palpation of bony landmarks and marking site of injection followed by actual administration into simulated arm.

All stakeholders should make appropriate efforts and invest time & money in equipping faculty with skills to develop educational material for the simulation-based learning and train more and more faculty in using simulations in learning.

(Dr Dinesh Badyal is Professor, Dept of Pharmacology & Professor, Dept of Medical Education, Christian Medical College, Ludhiana. He is a FAIMER Institute Fellow, an IFME Fellow, and a CMCL-FAIMER Fellow. He is Director of the CMCL-FAIMER Regional Institute and Convener, MCI Nodal Centre for Faculty Development.)

Is it time to shift to flipped classrooms?: Dr Anshu

One oft-heard complaint from teachers in medical schools in India is that students don’t attend lectures. The woes of low attendance in theory classes are a repeated refrain from administrators. And this isn’t a problem just restricted to India. Worldwide, schools are beginning to realize that even the best lecturers are not always successful in attracting students to lectures. Clearly, the traditional lecture isn’t doing too much to engage students. Teachers need to think of newer ways to capture the attention of this digital generation of learners. Is it time then to shift to flipped classrooms?

In a traditional model, teachers deliver didactic content to students in the classroom, and give them homework to hone their skills. The flipped classroom reverses the manner in which time is spent inside and outside the classroom. The flipped classroom is an educational model where students are assigned didactic study content before a class, and the classroom time is utilized for more engaging and active learning strategies. With the availability of technology, such asynchronous and distributed learning formats are possible in our settings. To give you an example, teaching videos or assigned readings are uploaded on an online platform before the scheduled class. Students are expected to study and come prepared. Once students are in the classroom, they are given a short quiz or assessment to ensure that they are ready with the basics. This helps in ensuring that unprepared students will not distract learning of other prepared students during the group exercises. Students then work in teams to apply their knowledge to assigned tasks.

The concept of the flipped classroom comes from time-tested educational theories. Teaching and learning do not occur in closed systems. Learning often happens outside the formal boundaries of time and space, and learners need meaningful enriching experiences. In the flipped classroom format, students can metacognitively manage the pace of their own learning, identify their learning gaps, and formulate their plans of moving ahead with the guidance of their teachers. The role of classroom activities is to scaffold student learning and facilitate learner-centred collaborative environments.

How can you design flipped classrooms in your setting?

The key to designing flipped classrooms is organizing how you will teach. The first step is to have a look at your learning outcomes and plan backwards. Make learning outcomes explicitly clear to learners. Think about the assessment and learning activities that your students must undertake actively to achieve those outcomes. Write down a clear schedule of what you expect learners to do and share it with them. Remember to sort the material based on difficulty level. Difficult and advanced concepts need to be taught in class, while easier instructional material that might be easy to assimilate by learners can be given as pre-reading assignments. While doing this, do not forget the cognitive load on the learners, and estimate the time they will require to study on their own. In the classroom, develop small formative assessments to determine the learning gaps. You can also use technological advances like audience response systems or online assessments to determine learning gaps. Use active learning strategies like group work and hands-on skill training.

Clearly, using the flipped classroom approach needs organizational changes such as altered arrangements of the classrooms, and availability of resources such as books, audio-visual aids, computers and the internet. This also requires much more preparation from faculty than the traditional lecture, due to the unpredictability of what learners may need. Creation of web-based content like online lectures, videos and assessment may take time to prepare, but once done, they can be re-used easily for future batches of learners. Learning material must be easy to access. Proper sequencing of tasks from easy to difficult is essential. Flipped classrooms can free up time for interactive activities and hands-on training. Collaborative strategies such as brainstorming, concept-mapping, team-based learning and problem-based learning are suitable for medical students. The role of the teacher will be to facilitate learning as subject experts by moderating discussions, resolving doubts, providing feedback and ensuring that learning objectives are met.

How do flipped classrooms help?

Flipped classrooms make students responsible for their own learning. They can use the face-to-face time to interact with teachers and peers, ask specific questions, obtain guidance, receive feedback, and apply their newly learnt knowledge to real-life scenarios. Students seem to love this kind of active learning as it allows them the freedom to think and discover things for themselves. Use of formative assessments helps students in identifying their own learning gaps. This format takes students to a deeper level of learning instead of merely cramming the subject.

In a systematic review, Chen et al (2017) have shown that the flipped classroom is a promising approach to improve learner motivation and engagement. They were found to be at least as effective as traditional lectures. There is not enough evidence yet to suggest that this method helps in better knowledge retention or transfer of knowledge to professional practice.

As with any other major curricular change, transitions to flipped classrooms will require drastic alterations in organizational culture. It is important to create an environment of inquiry and open questioning. This transition must be facilitated by good administrative coordination and communication between faculty and students. Additionally, technological support will be critical to sustaining this model. Faculty training is essential to understand how redesigning of face-to-face classroom time can be best done. If used well, the flipped classroom model allows efficient use of time and technology. Watching student enthusiasm towards learning can be very fulfilling.

(Dr Anshu is Secretary, AHPE. She is Professor in the Department of Pathology at the Mahatma Gandhi Institute of Medical Sciences Sevagram, Maharashtra)

The different shades of social obligation and medical colleges in India: Dr Sucheta Dandekar

The ultimate goal of medical colleges in India or anywhere else in the world is to improve the health of people, be it physical, mental or social. This is invariably attempted by juggling the three-pronged approach of educating the future health professionals; conducting relevant clinical research; and delivering comprehensive patient care. To make this possible, amalgamation of the social determinants such as behaviour, environment and social conditions and the values associated with social obligation (quality, equity, relevance and effectiveness) need to be adhered to.

Quality in health care has the community in mind and where treatment is person- and situation-specific and should be coordinated to serve the complete needs of a patient or a citizen. Equity implies that all persons from the community have equal access to the health services. Relevance is adhered to, when the most important health problem is identified and treated on priority such that the person, groups, society and community benefits. Effectiveness is achieved when all the available resources and infrastructure are put to optimal use to benefit individuals and the population. Establishing these values are the key towards social accountability.

It is nearly 22 years since WHO defined social accountability of medical schools as, “the obligation of medical schools to direct their education, research and service activities towards addressing the priority health needs of the community, region, and/or nation they have a mandate to serve. The priority health needs are to be identified jointly by stakeholders namely, governments, healthcare organizations, health administrators, health professionals and the public” (Boelen and Heck, 1995).

The terms ‘social obligation’, ‘social responsibility’, ‘social responsiveness’, and ‘social accountability’ are often used interchangeably.  At the moment, students from our medical schools are ‘being taught’ ‘social responsibility’ by sending them to the rural health centres and making them work as per the Medical Council of India (MCI) norms. When some of our students take part in blood donation camps, when they visit the community during floods, when they respond to the epidemics, they are being ‘socially responsive’. Most of the times, this is tackled on a voluntary basis. The more the students from a medical school come forward, the more it is a reflection of the effectiveness of our teaching. However, how prepared are we for all the principles to be tested remains debatable. This shall lead us to becoming ‘socially accountable’, when we are ready for an evaluation and accreditation process. Sensitizing of the stakeholders regarding issues of social accountability and accreditation is important. This, perhaps, shall be the much-needed step in making a positive impact on the society.

Medical educationists have acknowledged the challenges faced by Indian medical schools and suggested that if progress has to be made, it should be based on contextual planning of the curriculum, such that it incorporates the health needs of the community and encourages sound educational research, with the governmental agencies also seeing eye-to-eye. Researchers have suggested the identification of current and prospective social needs and challenges, adaptation of education programs to meet these needs and, evaluation to show that the society has benefitted from the interventions.

We realize that there is a need to work collaboratively by advocating changes to the health system. Faculty of our medical schools have a large responsibility of inculcating this into the system by taking into confidence the governing bodies, community, institutional administrators and students. The understanding of the importance of this symbiotic relationship cannot be denied. Some medical schools are no doubt, closer to implementing a model of social obligation as compared to others.

 

(Dr Sucheta Dandekar is a FAIMER Institute Fellow (2010) and an IFME Fellow (2014). She has completed her MHPE from the University of Keele in 2018. She is Professor and Head of the Dept. of Biochemistry & Clinical Nutrition at Seth GS Medical College & KEM Hospital, Mumbai)