Visions of the future

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Recently a colloquium was held regarding the future of medical education, in particular clinical skills training. The issue of sustainability in the face of rising student numbers, diminishing practical experiences in the traditional hospital setting and the reduction of clinical teachers were the key issues on the agenda. Whilst I originally thought that the use of technology could be used to enhance the learning experience, it was clear from the discussion that technology was necessary, given the current constraints, to provide an adequate education.

The medical profession appears to be polarized at both ends of the technology continuum. Surgery is using cutting edge technology to improve outcomes for patients, but medical education typically is many years behind adopting modern teaching practices and tools. There are isolated examples of forward thinking, but the majority of clinicians and educators are still focused on their experiences as a students and do not see the need to change.

The real vision of the future for medical education in Australia lies in a changing culture of teachers. The changes that need to occur is in the realization and acceptance of the following:

• To be a competent clinician, it is impossible to be a luddite
• That the word ‘doctor’ derives from the word ‘teacher’ and that education is a mandatory part of medical training
• That it is impossible to know everything and that knowing how to ‘find out‘ will be a critical skill for a doctor
• That team approaches to patient management is in the patient’s best interest.

There are also changes in the student population’s expectations of their education and their practicing life.

On line learning in medical education in the current political climate in Australia will soon rely heavily on technology filling the gaps where real experiences are unable to be provided. The future in medical education IS elearning, because there is no other alternative within the parameters defined by the government, the students and the community.

Person	Description
Gian	A new student
Jackie	A 3rd year student
Rachel	An academic
Todd	An administrator
Indira	A student on a clinical / professional placement

Gian is a year 1 student. He graduated from a degree in Optometry a couple of years ago. He has worked with staff from Medicine Sans Frontiers and realized that his real calling was medicine.

This is the beginning of his first year and is about to attend the first Information Age Medicine week. It is expected to be an exciting but possibly daunting programme as it will show students how to mine the resources of the internet, to critically assess the information and to apply it to a clinical situation. Gian is well aware that new doctors will be faced with a well educated public who will, in all likelihood, be more aware of current developments in particular areas than he will be.

As part of his preparation for this week, Gian has tapped into the curriculum for the course. This is also a new strategy that the school has invested in and already seems to be paying off. The School has taken a leaf out of the open source curriculum but added their own flavour to it by using a wiki to produce a collaboration on learning materials similar to wiki textbooks (Anderson, 2006). Other students were a little cynical about the whole idea, saying that the School was trying to get out of writing all their own learning materials, but others looked forward to the possibility of contributing themselves.


URinvited2 (tell all or part of this story or give some suggestions as to what might happen for this student.I would like to introduce him to Second Life - what do you think would be the best way?

A university campus in could be created in Second Life and be used as a 3D learning environment for teaching and student interaction. 3D tools, available as part of Second Life, are used to design interactive objects that can be edited and used in simulations. Lecturers perform classes and assessment in simulated activities rather than using "live" subjects and by linking to robotic devices could interact in the "real" world as well.

An example of a university using this technology now is http://www.nmc.org/sl/NMC. - Andrew.

Check out how Harvard are using second life in their law school here - Yasmin

Please lean closer to your Web Cam, sorry your resolution it not sufficient, do you have you DV camera handy? please lean closer, Ahhhh hold still, Click Snap, .... scanning ... result. - it seems from your eye scan you appear to be suffering from the following.... - check here for more information regarding you liver ... . - Roly

Jackie is a 3rd year medical student and she is about to start her Paediatrics rotation at the Royal Childrens hospital. She is really excited about this rotation as it is her desire to reduce the suffering of children that was her reason to go into medicine. Still, she was nervous. Jackie had viewed the online material and signed up for the Paeds online community and had read the précis of comments by the previous students. Once her PDA was checked and the GPS clipped in, her microvision glasses in her pocket, Jackie left for the Hospital.

URinvited2 (to suggest some other devices that Jackie may take with her.



When she arrived, Jackie checked her mobile phone to see if Andrew and Joy-Lin had arrived. They had and her phone alerted her friends of her arrival as well as the student co-ordinator.

After the initial information sessions, she and Andrew were paired up and told to familiarise themselves with the Paediatric ward, the equipment and the ward policies and procedures. Jackie switched her PDA onto ‘induction’ mode. As she walked around the ward, the induction program informed her of the key staff, the history of the ward and where the toilets were located. Walking past each area resulted in information about the people in the ward, the equipment and other administrative activities.

Along with a number of other students, Jackie was to attend a grand round that afternoon. Before hand, she had put on her microvision glasses. The clinician in charge had notified them via sms that he would be late to meet him in the ward reception area. The microvision glasses were fabulous as they could overlay each patient with the details of the particular problem. The first child that they were introduced to had a full cast on the right leg. The glasses showed where the injury was and the history of the patient. Jackie found this very useful as she could consider how she would have managed the patient and then compare it to the actual management plan.

After the grand round, Jackie was left to her own devices. As it was an unusually quiet day and the clinician was busy with private work, Jackie decided not to waste her time and to check into the Virtual Medical School. She went to the library at the hospital, found a free study pod and entered the VMS Emergency room. This was not the first time that Jackie had participated in the VMS ER – she loved the pace in there as well as the camaraderie of the other participants. Jackie’s avatar - Dr Zhivago (her mother had loved that movie!) donned her coat and was immediately allocated a trauma patient – a car accident victim – this certainly ran her through her paces. Jackie knows that she is improving not only from the feedback from the others around her, but also her response time and performance is improving. She can even beat Joy-Lin! Jackie gets more live patients as outcomes which is always a good sign.

URinvited2 (to comment whether you think a medical student would really take such a simulation game seriously as an eduational tool?

Although this simulation game may seem like just a bit of competetive fun for Jackie and her fellow students, the literature supports this media as a learning tool. However, whether students like Jackie are able to transfer that knowledge to a real-life situation is probably a more important consideration. Much of the literature relates to anecdotal reports of students' perception of increased knowledge and confidence. I have not yet found any research results that quantify the transference of knowledge gained in simulation to the ability to deal effectively with a real-life medical situation. From a personal perspective, having learned Advanced Life Support in simulation, I found that when faced with a real-life scenario (cardiac arrest) I go into "training mode" and just do it. If I stopped to think about the reality, I may not have been able to perform with the confidence, calm, and skill necessary for positive patient outcomes. I think that as long as the simulation is as near as possible to a realistic scenario and the patient management protocols and standards in the simulation game are consistent with local standards, real learning does occur. For example, drug names are different in the USA and Australia, and management protocols can be different. Jillean

There seems to be so much that we have to learn about teaching in Virtual Worlds. One of the things that I was wanting to convey is that maybe VWs can be used to provide a place where students can practice what they have learned. I liken it to learning your multiplication tables. You repeat them over and over again and eventually they embed in your brain. If the students had the ability to apply their skills learnt in real life in a VW many times, then maybe, like you, a student could go into "training mode" when faced with a real patient. I also saw it as a confidence developer and an opportunity to interact with real (virtual) people in medical situations. This also opens up a can of worms in regard to ethics - what information should medical students provide in virtual worlds to people they interact with? Could a participant take a students advice? If an adverse result occurs, what liability would the student have?
- Yasmin

Her reverie is broken by her mobile phone which notifies her that a child has been brought in. Her PDA picks up that a respirator is also being brought to the ward. Reasonably, it surmises that the child has some respiratory issues and located and presents some learning resources to Jackie for her to refer to if necessary. She picks the one on respirator operation as she has not had much to do with them and puts on her microvision glasses which display a graphic representation of an operating respirator. By the time the child has entered the ward, Jackie feels comfortable that she can contribute to the management plan of the child even in a limited way.

After a long first day, and feeling pretty comfortable with how it has gone, she participates in an online debriefing session and then reviews her day. The portable devices she carries download their data to Jackie’s laptop and allow her to review the activities of her day. She highlights some of the importance experiences, notes her major performance indicators which are then migrated into her learning portfolio.

Enough for today – time to go for a game of squash with Joy-Lin.

Rachael is a senior academic in the Medical School. She is a GP and most of her teaching occurs in Year 2 or the pre-clinical years and she is feeling a little miffed.

Over the past 5 years, Rachael has been expected to teach on line. Early on, she was a bit wary of this as she didn’t have a technical background and her only on line experience was email and searching library catalogues. Some time after her initial attempts into the online learning world, she found support in a colleague who had luckily had some experience in the online environment and introduced her to an online forum for academics from all over the world. Through her interaction with others, Rachael was able to learn techniques others had already used and was able to vent her frustrations to a sympathetic group when things went wrong. Her online teaching had really improved to such and extent that she felt that there might be some papers for Medical Teacher in the future.

One of the resources that really helped her was the team of staff that the School had employed to support teachers. This team was skilled in online design, simulations, communications and software. They looked after the sourcing/constructing of any leaning activities that needed to be undertaken. Rachael even had them help construct a tool to help her manage the hundreds of daily emails.

Rachael had also started to contribute academically to a couple of on line fora. This is why she is feeling a bit annoyed. Despite the changes that had been occurring in higher education over the past years, it has never been recognised at her performance appraisal! The were still only to recognise papers presented in traditional journals
Even though she is annoyed at the sluggish progression of the university’s bureaucracy, she is still aware that it is the start of the academic year and there is still so much preparation required. Rachael is concerned that there are not enough tutors/clinical staff on board. It is always easy to recruit for the Virtual Medical School as it is seen as a fun way to contribute to teaching (3 of her current VMS clinicians are Dr Strangelove, Dr Who and Dr Evil!). Getting real staff is much more difficult.

The VMS has been a real bonus. Recently Rachael had to schedule a symposium for 550 students. Nowhere around town was it possible to organise a physical location for this many. Luckily, she was able to get admin to organise the symposium in VMS. Scheduling activities in the VMS has caused some problems with the uni student administration. They had to be lobbied extensively to include details on the timetabling system to include the attributes ‘world’ and ‘avatar’.

Rachael remembers that this is the first day of 3rd year rotations and wants to see how last years Year 2’s were going. She checks her laptop for their details and smiles when she sees that not all students arrived on times. Even with all the technology available to them, students still can’t get to class on time! Rachael is able to see that all students had checked in with the ward sister and had familiarised themselves with the ward. Some of the students had looked at the learning resources provided some good feedback on them.

One of last years students, Jackie, had even checked into the ER (emergency) simulation in VMS. Rachael was particularly pleased to see this as she had been a little worried about Jackie who wasn’t feeling very confident about her abilities and was concerned about her performance in a clinical environment. Rachael thought that some time in VMS ER would build up her experience and therefore confidence levels. Jackie had done really well and Rachael was able to track her progress. Jackie’s response times and critical performance indicators showed substantial improvement.

Satisfied with her students performance, Rachael decides to call it a day.

Yes, you are right about it being unrealistic that Rachael has been able to develop all these skills. I had hoped that the team of staff I suggested that the School had provided would provide most of the initial set up for Rachael and that there had been enough development of the technology to allow it to disappear.

The most profound technologies are those that disappear. They weave themselves into the fabric of everyday life until they are indistinguishable from it. (Windham, 2005, p.94)

In regard to your other questions about what the VMS is like, I would think that there would be real clinicians involved in the simulations as well as students and members of the public. How this would all work is not something that I have resolved. As I am not a teacher and not involved with the teaching process, I do not have an indepth knowledge of how clinical teaching would work although I can see real challenges in the hands on activites!

Again your questions about monitoring students progress is an area where more research into teaching in Virtual Worlds. Not only do we need to know how to collect the information, but also what information should we collect based on the types of teaching and learning that occurs in VWs.

Do you have any ideas? - Yasmin

Second Life Andrew Weppner. I have really been quite affected by the Virtual World - Second Life and have built Second Life into my scenarios.

Games and Education Jo Foster

Augmented Reality Jean Clayton

e-Simulations Paul Penfold

Clinical Skills Simulation in the Training of Health Care Professionals Jillean Martyn

U.S. Deans Outline Vision for Improving Medical Education
The Future of Education VISIONS 2020

23 October 2006: A new site for "Learning Futures" just announced by Elliot Maisie as a project of LEARNING 2006 http://www.learningfutures.com/

LearningLinks will be a peer rated, free, non-commercial site that will allow any learning professional around the globe to add, use, rate, and
review learning links. Our goal is thousands of links submitted by our colleagues.

Should be interesting to keep an eye on developments of this site. They have included many of the issues/topics covered in this subject. Jo F