Collaborative learning in Medical Education - Where is the Patient?

For a while now I have been muddling over a few thoughts in my head. These were prompted by

1. Medicine's incredible success at treating acute problems and thus bringing chronic problems to the forefront e.g. patient survives a stroke but is left with bed sores, incontinence OR survives an acute heart attack and is left with congestive heart failure. A William Schwab put it at a recent grand rounds, "Success brings failure" and thus our success in treating acute problems has brought us an excess of chronic problems.
   
2. Increasing popularity of social media tools like Facebook, Twitter and Second Life. A recent study that I discussed earlier showing students were more likely to use Facebook for a course discussion than the University's learning management system.
   
3. Medical education moving from a traditional "talking to the boards" model to a small group collaborative problem solving model - can we use this momentum for including patients into the learning "group"? This thought was resurrected by a post I read by Anne Marie Cunningham.
   

It seems that learning how to treat an acute problem is something we can do well in our current model of education which has minimal involvement of the patient (in most schools). As our population ages, has more chronic problems, a model that does not involve the patient in the learning process is not going to succeed.

Thus we know what an obese patient with poorly controlled diabetes needs to do to bring his/her condition under control and maintain it there. Patient also often knows this. Still optimal outcome occurs only rarely and if it does, it is not sustained.

In managing chronic conditions, the patient has to learn to take control of his/her condition and the physician is only a part of the solution to make this happen. Our medical students learning is designed to occur either in classrooms or in hospitals - both of which are perfect for acute condition management. The exposure to outpatient chronic condition management where they can interact with the same few patients longitudinally does not occur in most schools.

The reasons for this are mostly logistic. Scheduling students to be in the clinic the same time as specific patients is a logistic nightmare. How about a model using social media?

Can we have students create limited, private accounts in a social media site like Facebook or create a specific site using Ning and invite consenting patients to be their "friends". We could have a list of patients with different conditions and abilities to use these social media tools. The sites would not be accessible except to invitees. The students would collaborate with a set of patients over their entire medical school experience. The patients would post/tweet about their symptoms, office visits, hospitalizations, test results and the students would learn/read up about these and explain these to the patients. In addition, they would work on skills like motivational interviewing, negotiated goal setting to help the patients take better control of their conditions.

This model will allow students to learn the role they have to play in management of chronic conditions and prepare them for the future!

3 Apps I love for capturing what's on the screen

For years I had taught people how to do screen captures with the Print Screen button and continued to be mildly surprised when people who get excited when they learned that there was actually a purpose for tha button on the keyboard! I still use that when I am not at my own computer.
Since I have to do some faculty development sessions, training medical educators on use of technology in education, I had to find some tools that were easier to use. So here is my very short list of 3 applications that I find very useful.

1. Jing - This is a great tool for capturing a portion of the screen and annotating it with arrows and text. While it does do screencasting, the free version has limits on time of a single movie and it puts its logo prominently at the end of the movie. It also allows to upload the captured image to its online repository. I do not use that much as I need to save and reuse the images for other purposes.

2. Wink - After a lot of trials and errors, I have settled on Wink for screencasting. It creates a flash movie from a window that you select on your screen. You select the number of frames/sec and it will capture these faithfully. It has a builtin annotation tool for adding callouts, textboxes etc. Also automatically adds pauses to the movie and you can add navigation buttons for the user so they can read the text and then proceed with the movie. You can delete unnecessary frames and thus keep the movie short and sweet. The only problem I had was deciding on the resolution. I used the Firefox window resizer add-on and captured at 800X600 so I could put the flash file in a frame or otherwise have room left on either side.

3. FRAPS - this is the only one of the 3 that I spent money on (35 dollars). I use Second Life for various educational purposes and FRAPS allows me to record the machinima in SL - both audio and video. It is very easy to use and has a hot key to start, stop the recording. The only thing to keep in mind is the incredibly HUGE file size. For one 20 minute recording it used up 10 GB of space on my HD. The solution is to use Virtual Dub to compress this to MPEG4 and the same file become close to 400 MB.

So that's it! Jing, Wink and FRAPS.

Second Life and virtual patient interviews

So today was a special day. The study that we were working on for the past 3 months finally got underway - "Feasibility of using Second Life to train medical Students on patient interviewing skills".
So how does this work?
A medical student interviews a patient - both are in Second Life sitting face to face in an exam room. They "talk" to each other using headsets with microphones. They use lip-synching so when they talk, their lips move. They also use speech gestures so when they talk their hands and arms move around like most people in real life. The patient also has a number of pre-programmed gestures - crying, laughing, frowning, wringing ones hands, etc.
So why is this a good idea? Can't they just meet in some place in real life and do this? Can't they just talk over the phone?

They can meet in real life but that can be inconvenient. With S/L the 2 people can be poles apart! In addition, with S/L they are anonymous - the patient can be controlled by a physician without the student being aware of who it is. Also it can be less intimidating for a student than being face to face.

Does S/L add anything over and above a phone encounter? I sure hope so. There is good data that being in a MUVE affects spatial behavior. In addition the Social Identity model of Deindividuation Effects (SIDE) has shown that anonymity can have profound effects on group interactions. Does it make the encounter appear more real? We are interviewing the students to find out.

There are other advantages:

1. The encounter can be captured digitally using software like FRAPS.


2. The encounter can be viewed by anyone later - student or faculty. The faculty member can provide feedback to the student. Would be great to use VoiceThread for this.


3. There are few geographic barriers. This could be offered as a service run by retired clinicians to train medical and nursing students in patient interviewing skills - a little bit like outsourcing your OSCE's.

As I was viewing the macinima of the first 2 patient interviews, I could recognize several teaching moments. What if we give this recording to a clinician educator not involved with the study, have them record their comments as annotations on the video (like VoiceThread) and then share with the student or even with other students?

The possibilities are numerous. I cannot post the machinima without student consent. Will write more about this once we get some feedback!

Does emotion help learning? Duh!

Educators have always known that getting emotions attached to learning material helps memorizing it. Did you ever doubt it?

Say you were trying to teach the lyrics of a song "I dreamed a dream" or you wanted to teach a group of kids (all adults) not to judge a book by its cover, you could show this video (which half the world seems to have seen already).

See the first 5 minutes and then if you disagree post a comment.

I rest my case. Go Susan Boyle. (My heart keeps telling my cynical side that this was not staged by the marketing gurus at "Britain has got talent").

If after watching the video, you want the lyrics, here they are:


Lyrics | Fantine - I Dreamed a Dream lyrics

Chemistry of Facebook

Innovate has an interesting article (Have to go through free registration to read the full article) on use of Facebook to create an online community for students enrolled in an Organic Chemistry Lab at Iowa State University. The authors (Jacob Schroeder and Thomas Greenbowe)compared the use of WebCT and Facebook for discussions regarding the course material. While all 128 students were required to use WebCT (e.g. to get their grades), the use of Facebook was optional.

The main finding in this exploratory study was that while only about 40% of students used the Facebook discussion board, they used it in richer ways (posting photos of molecule structures, links etc) and for a longer period. The discussion group on WebCT was not used much and quickly petered out.

We don't know from the available data whether students who used Facebook were already using it socially? The authors were also not able to survey the students regarding the reasons why they used or did not use a specific tool. Thus we are left to wonder...

One guess is that if you are already using Facebook, clicking over to your Organic Chemistry Group to check something out or put in a comment would be quick and easy. Problem is getting the other 60% of students to also use this tool. Would love to know if it was their learning style, attitude towards technology, use of other social networking sites, or some other reason that prevented them from joining this discussion board. Is it even important to get them to join? What if only 10% of students had joined? What is the critical mass for something like this to be meaningful? The activity required instructor time to moderate the group. If a number of students were using another site like MySpace, would it be possible to moderate 2 groups? What about 3?

What if WebCT had a facebook widget or the other way around so both the WebCT and Facebook users could participate without having to log in some where else?

Practical model for using the Information Processing Theory to stay current with (medical) literature

The Information Processing Theory compares the human brain to a computer and suggests that just like we can make a computer work better by changing the processor, motherboard or RAM and the programming, the human can also become more sophisticated thinkers with appropriate strategies, sensory inputs and rules.

While I don't know how well validated this theory is, it does describe an interesting flow of information from the sensory register to short term memory to long term memory.
The wikipedia describes it thus

Sensory register: the mental processing unit that receives information from the environment and stores it fleetingly.
Short-term memory: the mental processing unit in which information may be stored temporarily; the work space of the mind, where a decision must be made to discard information or to transfer it to permanent storage, in long-term memory.
Long-term memory: the encyclopedic mental processing unit in which information may be stored permanently and from which it may be later retrieved.

The way I understand it, Constructivism works great for understanding how we can facilitate learning of new concepts e.g. medical students learning anatomy in their first year. Active learning, Problem based small group discussions, etc.

When we think about how to help a practicing physician keep up with medical updates in his or her specialty, it is a different setting. The person already knows the subject, is busy and probably does not have much time for collaborative learning in small groups. The constructs have already been formed during medical school, residency and subsequent experiences. It seems self directed learning using the principles of the Information Processing Theory would very helpful to help the physician refine these constructs on a longitudinal basis. Let me show you a model of how this would work.

Software needed:

1. Google Reader This is a free web application and all it requires is a free Google account.
2. Zotero I have referred to Zotero in a previous post. It is a free bibliography and citation tool that works as an add on to Firefox.

Screen shots of the Model:

Overview of Google Reader



Google Reader Detail:



Zotero Overview:


Zotero Details:


Retrieval from Zotero:

Steps in the Model:

1. Set up RSS subscriptions to your specialty medical journals in Google Reader
2. This allows abstracts of articles flow into your Reader automatically and allows you to view these in one place
3. This is equivalent to the sensory register mentioned above. When you browse through the RSS feeds, you "receive the information from the environment and store it fleetingly"
4. As you scan through the abstracts, you can in Google Reader mark the ones that seem significant and relevant with a star. The Google Reader automatically tracks the ones you have browsed and removes them from the "home screen".
5. You have thus gone through the process of determining whether the abstracts are to be discarded or to be processed for storage in long term memory. This is similar to the short term memory proposed in the Information Processing Theory.
6. When you have more time and inclination, you return to the Google Reader using Firefox that has the Zotero plug-in installed.
7. You click on the hyperlink to the abstract and from there to the full text article if you have access. You read the abstract and determine that it is worth "storing". Zotero allows you to take a "Snapshot" of the article and annotate it with notes, keywords and highlights. The bibiliography information of the article along with the annotated snapshot and notes and keywords are all stored in your Zotero library
8. Zotero allows each reference item to be included in several collections. Thus as an Internist, I have collections for all subspecialties of medicine - e.g. Cardiology, Pulmonary etc.
9. This process of analysing the article, annotating it and adding keywords, notes and sorting into collections is similiar to encoding that is described in Constructivism and helps move the information into a more permanent long-term storage.
10. The entire Zotero library is searchable and allows for easy retreival of previously processed information. As information is recalled and applied more often, it is more likely to become true knowledge.

Try it out, you have nothing to lose and possibly a lot to gain!

Creating from Scratch!

Scratch is a great way to get way to create interactions, animations and games. It is extremely easy to learn. Almost anyone can learn to use this and be up and running in a few minutes. Once you spend a few minutes learning Scratch, you create games like this one which was my first attempt.
GOAL: Get the cat to chase and catch the red ball of wool. Have to get the mouse pointer exactly over the red ball. I forgot to de-link the mouse pointer from the cat so you have to click on the red stop sign to stop the script. Hey you live and you learn right?

Learn more about this project

After you spend more than a few minutes working on Scratch, you can create something like this:
Learn more about this project
Key features
1. Free programming tool with a terrific user interface from http://scratch.mit.edu
2. Requires JAVA
3. Free hosting service on Scratch servers
4. You can download and examine the code for all uploaded projects
5. Code is "written" by stacking blocks on each other!
6. Once uploaded to Scratch servers, you can embed the "game" into your blog or web page like I just did.

So how can you use this?
1. Teach logic
2. Teach the concepts of programming
3. Create educational games - that teach medical concepts e.g. A red blood cell moves through the circulation and you have to click on the appropriate valve in appropriate sequence to get it through from the vena cava to the Right Atrium to Right ventricle to Lungs to Left Atrium to Left Ventricle to Aorta. Or you could allow them to click on a valve to create a state of Stenosis or regurgitation and show what happens.
4. You could embed this into a LMS or Assessment tool or even PowerPoint to help make for more active learning!