Medical Education

#FOAMPubMed 3: Type I Error

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First things first, no piece of research is perfect.  Every study will have its limitations. 

One way we try to make research better is through understanding error.  

If we find that the new drug works when it doesn’t that’s called a false positive.  We can’t eliminate false positives; some patients will get better even if given placebo.  But too many false positives and we will find an effect when one doesn’t actually exist. We will wrongly reject our null hypothesis.  

Type I Error comes about when we wrongly reject our null hypothesis. 

This will mean that we will find our new drug is better than the standard treatment (or placebo) when it actually isn't.

Type I Error is also called alpha

A way I like to look at Type I Error is the influence of chance on your study. Some patients will get better just through chance. You need to reduce the impact of chance on your study.

For instance, I may want to investigate how psychic I am. My null hypothesis would be ‘I am not psychic.’

I toss a coin once. I guess tails. I’m right. I therefore reject my null hypothesis and conclude I’m psychic.

You don’t need to be an expert in research to see how open to chance that study is and how one coin toss can’t be enough proof. We’d need at least hundreds of coin tosses to see if I could predict each one.

You see how understanding Type I Error influences how you design your study, including your sample size

More of that later. The next blog will look at how we actually statistically show that we’ve reduced Type I Error in our study.

#FOAMPubMed 2: The null hypothesis

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When we do research in Medicine it’s usually to test whether a new treatment works (by testing it against placebo) or better than the established treatment we’re already using.


At the beginning of our study we have to come up with a null hypothesis (denoted as H0).


The null hypothesis is a statement that assumes no measurable difference between whatever you’re studying.  


The null hypothesis is therefore usually something along the lines of: 

‘Drug A won’t be better than Drug B at treating this condition.’  

We then set out to test this null hypothesis.  If we find Drug A is better than B then we reject the null hypothesis and conclude Drug A is the superior treatment. If Drug A is found to be no better (i.e. the same or worse) than Drug B then we accept our null hypothesis and conclude that Drug A is non-superior (or inferior).


Error comes when we either wrongly reject or wrongly accept the null hypothesis.

Error means we come to the wrong conclusion. There are two types of error, the next blog will look at the first, Type I Error.

Going Mobile: A review of mobile learning in medical education

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Next month will mark the 50th anniversary of mankind’s greatest accomplishment; landing human beings on the Moon. Yet today the vast majority of our learners each carry in their bag or packet a device with millions of times the computing power than the machines we used to meet this achievement. This is why one of my passions as an educator is mobile learning and the opportunities our unprecedented age now offers. I’ve enjoyed learning how to create resources such as a podcast and a smartphone application and how these have innovated the way I teach.

The Higher Education Academy defines mobile learning as “the use of mobile devices to enhance personal learning across multiple contexts.” Mobile learning itself is a subset of TEL or ‘Technology Enhanced Learning.’ There’s repetition of a key word: enhance/enhanced. We’ll come back to that word later.

This musing looks at some of the current evidence of mobile learning use in medical education and tries to pinpoint some themes and things we still need to iron out if we’re going to make the most out of mobile learning.

From Del Boy to Web 2.0

It’s safe to safe that mobile phones have come a long way since being used as a cumbersome prop in Only Fools and Horses. They are now a key part of everyday life.

More than 4 billion people, over half the world’s population, now have access to the internet, with two thirds using a mobile phone; more than half of which are smartphones.  By 2020 66% of new global connections between people will occur via a smartphone. We are now in the era of the internet of things such as touchscreen phones and tablets as well as smart wearables such as glasses or watches. Humans have been described as “technology equipped mobile creatures that are using applications, devices and networks as a platform for enhancing their learning in both formal and informal settings.”  It’s been argued that as society is now heavily characterised by the widespread use of mobile devices and the connectivity they afford there is a need to re-conceptualise the idea of learning in the digital age.

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A key development in the potential of mobile learning was the development of Web 2.0. The first iterations of the internet were themselves as clunky as Del Boy’s mobile, fixed, un-editable and open to a select few. Web 2.0 is known as the ‘participatory web’; blogs, podcasts and wikis. It is now possible for people with no computing background whatsoever to produce and share learning resources with massive success such as Geeky Medics.

Another aspect interlinked with these social and technological changes has been the shortening of the half-life of knowledge. By 2017 the half-life of medical knowledge was estimated at 18-24 months.  It is estimated that by 2021 it will be only 73 days. It’s therefore fairly easy to envisage a world where libraries of books will be out of date. Students will instead be their own librarian accessing knowledge on the go via their mobile device.

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In education when we look at professionals collaborating we think of a community of practice. Thanks to Web 2.0 the collaboration of professionals, patients and students in medicine has been given the epithet of ‘Medicine 2.0’. This represents a new community of practice and how technology links all of us in healthcare. Health Education England argue that digital skills and knowledge should be “a core component” of healthcare staff education. In order to reflect the new world of Medicine 2.0 medical schools in the US and Hungary have set up courses aimed at familiarising students with social media. A Best Evidence Medical Education review showed that mobile resources help with the transition from student to professional.

Towards collaboration

The general movement in mobile learning is towards collaboration. The unique features of mobile devices, in particular their portability, social connectivity and a sense of individuality mean they make online collaboration more likely as opposed to desktop computers that don’t have those features. A meta-analysis of 48 peer-reviewed journal articles and doctoral dissertations from 2000 to 2015 revealed that mobile technology has produced meaningful improvements to collaborative learning. The focus is on bringing people together via their mobile devices to share learning and practice.

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Perhaps the extreme of mobile learning and collaboration has been the advent of massive open online courses (MOOCs) since 2008.  These are courses without any fees or prerequisites beyond technological access. Some MOOCs are delivered to tens of thousands of learners. As a result along with mobile learning in general MOOCs have been credited with democratising education.  MOOCs have been suggested as best augmenting traditional teaching methods in the ‘flipped classroom’ approach. In the flipped classroom students are introduced to learning material before the classroom session with that time being used to deepen understanding.  In general the HEA credits mobile and online resources as providing an accessible toolkit for delivering flipped learning.

Medical students and mobile learning

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The tradition has been to divide students into digital natives (those who grew up with technology) and digital immigrants (those for whom technology arrived later on in life). This distinction assumes that younger people have innate skills with and a preference of technology. However, more recent evidence suggests that this distinction doesn’t exist and is unhelpful. Learners whose age falls within the category of being a digital native still need and benefit from teaching aimed at digital literacy. The notion of digital natives belongs in the same file as learning styles; they just don’t exist.

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Research into medical students use of mobile learning focuses on evaluating a specific intervention. These include Facebook, a novel Wiki platform, a MOOC and a tailor made smartphone application. While that has a use I’d argue that most students will appreciate any new learning intervention. As a result we’re still in the early days of understanding how students use mobile resources. That said, the evidence suggests that students quickly find a preferred way of using Web 2.0 resources. Whilst it’s been suggested that male students are less likely to ask questions via a Web 2.0 resource students overall seem to find them a safe environment and more comfortable than clinical teaching. It’s been suggested that mobile learning resource usage is linked to a student’s intrinsic motivation. The more motivated a student is the more likely they are to use a mobile resource. Medical students themselves report concerns regarding privacy and professional behaviour when using social media in education.

A 2013 systematic review of social media use in medical education found an association with improving knowledge, attitudes and skills.  The most often reported benefits were in learner engagement, feedback, collaboration and professional development. The most commonly cited challenges were technical difficulties, unpredictable learner participation and privacy/security concerns.  A systemic review the following year however reviewed only publications that included randomisation, reviews and meta-analyses and concluded despite the wide use of social media there were no significant improvements in the learning process and that some novel mobile learning resources don’t result in better student outcomes.   

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A recent review of literature on mobile learning use in medical education suggests that it remains a supplement only.  There still is not a consensus on the most efficient use of mobile learning resources in medical education but the ever changing nature of resources means this is probably inevitable. There’s that word enhance again. Is this is limit of mobile learning in medical education? To enhance more traditional teaching and not replace?

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There’s also the issue of whether students want more mobile resources. The most recent student survey by the Higher Education Policy Institute found that students prefer direct contact time with educators over other learning events.  44% of students rating their course as poor or very poor value for money included a lack of contact hours as part of their complaint.  Only tuition fees and teaching quality were reported more often as a reason for rating their course as poor or very poor value for money. More students (19%) were dissatisfied with their contact time than neutral (17%); an increase on the previous year. However, the survey did not explore mobile resources either as a contact time alternative or how students viewed their educators creating resources for them. 62% of Medicine and Dentistry students reported that they felt they had value for money for their tuition fees; this was the highest reported value for money of any subject.

According to the HEPI students in the UK are conservative in their preferred learning methods and this means any innovation takes time to become embedded in a curriculum. The HEPI recommend engaging with students and involving them in the development of any resource as well as building technology into curriculum design and for a nationwide evidence and knowledge base to be developed on what works.

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This is being done. Case studies in the UK show that the success of mobile learning in higher education has involved some degree of student inclusion alongside educators during design.  But there’s no evidence of this being done in UK medical schools. One example was published from Vanderbilt University, Nashville; a committee formed of administrators, educators and selectively recruited students.  This committee serves four functions: to liaise between students and administration; advising development of institutional educational technologies; developing, piloting, and assessing new student-led educational technologies; and promoting biomedical and educational informatics within the school community. The authors report benefits from rapid improvements to educational technologies that meet students’ needs and enhance learning opportunities as well as fostering a campus culture of awareness and innovation in informatics and medical education.

An example from a European medical school was found from the Faculty of Medicine of Universität Leipzig, Germany.  Rather than a physical committee their E-learning and New Media Working Group established an online portal for discussion with students over mobile resources as well as expanding the university’s presence across social media to help disseminate information.

The HEPI have also recommended that the UK higher education sector develop an:

“evidence and knowledge base on what works in technology-enhanced learning to help universities, faculties and course teams make informed decisions. Mechanisms to share, discuss and disseminate these insights to the rest of the sector will also be required.”

Medical educators and mobile learning

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Teachers’ attitudes toward and ability with mobile resources are a major influence on students deciding to use them. It’s been suggested that Web 2.0 offers opportunities for educator innovation. However, it has been shown that teachers may be less engaged than their students in utilising Web 2.0 resources especially in accessing materials outside of the classroom.

I’ve not been able to find any research in the literature looking at the perceptions of UK medical educators toward mobile learning. However, a recent online survey of 284 medical educators in Germany did show some interesting findings.  Respondents valued interactive patient cases, podcasts and subject-specific apps as the more constructive teaching tools while Facebook and Twitter were considered unsuitable as platforms for medical education.  There was no relationship found between an educator’s demographics and their use of mobile learning resources.

* * *

It’s obvious that mobile learning offers great opportunities for medical students and educators. I hope this review has shown some of the trends in our current understanding of mobile learning in medical education: that the future seems to be collaboration, digital natives don’t exist and students need tuition in how to use mobile resources, research is currently limited to studying interventions, students value contact time and need to be included to make the most of resources and need to know more about what teachers think.

This is a time for leadership, for educators to start to fill these gaps in knowledge and expand on these trends. In September 1962 President Kennedy challenged his country to got to the Moon by the end of the decade. To say this was ambitious is an understatement; American’s had only got into space barely a year earlier. Yet the country rose to the challenge and on 20th July 1969 man walked on the Moon. I like how he said it. “We CHOOSE to go to the Moon.” Challenges are there to be met. We can meet the challenges of mobile learning in medical education if we choose to. We can choose to use mobile learning and help shape it. Or not. That choice is ours.

Don't Just Sit There: Audience Participation in Simulation

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In my last blog I talked a bit about setting the audience up for a simulation. In this blog I wanted to explore this more. Students who volunteer first to simulate are often in the minority but it’s important that the audience don’t feel like it’s an easy ride and just sit there.

The standard lay out when I run a simulation session is like this:

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One of the audience members becomes the scribe, recording the clinical history and the story as in unfolds. This provides a point of reference for the students in the simulation as well as helping discussion during debrief. As these example show it also lets students be a bit creative:

We’ve often given students in the audience a checklist and asked them to record proceedings as well as part of student to student feedback.

If you’re giving the students in the simulation information such as an ECG or blood gas, make sure the audience can either see it or get a copy too to involve them. Later on reflect on their conclusions: are they different from those in the simulation?

In the previous blog I mentioned lifelines such as ‘Ask the Audience’. I find reminding the audience that at any moment the students in the simulation might turn round and ask your opinion inspires them to keep paying attention!"

‘Tag Team Simulation’ is something I’ve thought about but not done yet but would be another way to keep the audience engaged - I’d be interested to hear how this works if anyone has done it.

Managing audience members is a key part of the simulation session. If nothing else their engagement is a sign of respect for the students actually doing the simulation and helps create a positive learning atmosphere for everyone.

Thanks for reading

- Jamie

Setting the Stage: The Pre-Brief

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Simulation is an indelible part of medical education as well as the training of other healthcare professionals. At DREEAM I’m lucky to be able to work with the great cohort of simulated patients trained by my colleague Ali Whitfield. Working with real human beings rather than mannequins adds another layer of realism and has become a firm fixture in the training we offer at DREEAM.

However, being ‘on stage’ in a simulation remains a very divisive issue for learners. From my experience half of students will feed back how much they love simulation and want more with the other half hating every moment. That’s usually due to previous bad experiences or pre-conceived notions.

As I’ve worked more with simulation as a facilitator I’ve put more emphasis at the beginning; the pre-brief or ‘setting the stage’ partly due to these pre-conceived notions but also as not every student has the same experiences with simulation. Much as an actor wouldn’t expect to just walk onto a stage so a novice student shouldn’t be expected to just perform without some clear guidance.

My pre-briefs usually follow the same pattern:

  • Introduce the session and why we are using simulation - it’s not being arbitrarily used to scare but instead with very clear objectives with definite relevance

  • The setting (ward, A&E, GP practice whatever) their role (you’re a student/doctor/nurse) and the expectations of the behaviours expected - act as you would as a doctor, treat the simulated patient as a real patient etc. How do referrals work in this scenario? Also, what is expected from the audience? I regularly get one member to act as a scribe on a flip-chart for the learners in the simulation to refer to. Encourage the audience to be active observers

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  • Orientate the students around the environment and the equipment. Highlight any potential sources of confusion such as differences between the patient’s palpable pulse rate and what is on the monitor. Will there be blood results available? Are we running in real time? This helps keep the scenarios running later on

  • Acknowledge simulation can be challenging and where possible allay fears - if you’ve set the scenario up so that any mistakes made will be corrected and death is not an outcome then tell them! In my experience the biggest apprehension toward simulation from students is that we’re trying to catch them out and they’ll kill the patient. If that won’t happen let them know. If it might happen then also let them know and reassure that it’s a safe environment allowing for these mistakes

  • Lifelines - the timeout is a common theme in any simulation and it’s important to reassure students about this. I go further and add lifelines similar to ‘Who Wants to be a Millionaire?’ Students can ‘Ask the Audience’ - turn to the learner watching and ask their opinion or ‘Phone a Friend’ - ask the facilitator a closed, focused question; “I think it’s aortic dissection what’s the best imaging for this?” If it’s not going great we can always time-out and take a break; this is fine and should be used if needed

  • Is there a specific aspect of simulation they’d like you to look out for? Giving useful feedback can be challenging. Students may have apprehensions about one particular skill or part of simulation such as cannulation or delivering a useful referral based on previous experiences. If they can tell you this beforehand it helps observation and providing feedback the student can use

  • Give them appropriate information beforehand. Most of the simulations I do with students are based in the Emergency Department. One is with a patient presenting with chest pain who turns out to have a pulmonary embolus. In real life there would be an ECG. I provide this ECG and give them a moment to read it. I ask what the students are thinking and why. They usually say Acute Coronary Syndrome. At the end after diagnosing PE during the feedback I then ask them to take us through the process of how they ended up changing their mind from ACS to PE (usually because the patient complains of calf pain). I reinforce how important it is to always consider ACS but also what aspects should make us think PE (yes calf pain is important but the patient had oxygen saturations of 90% with no lung history, a clear chest and her ECG shows AF.) - this shows the nature of a true ‘working diagnosis’ as well as helping us understanding each others thought processes

Ultimately the pre-brief is about you and your learners finding out about each other. Standardise as much as you can. Students who go first may resent being ‘the example’ so think about making a video to show everyone what is expected at the beginning. This is then easier for you later on. I think pre-brief is an investment in your simulation sessions. The more and better you do at the beginning the bigger and more rewarding your session will be.

Thanks for reading

Jamie

Pitch Perfect: Delivering a Short Talk

Earlier this year I submitted an abstract to the Association for Simulated Practice in Healthcare (ASPiH) conference about my work on the application for medical students in the Emergency Department.

On 3rd August I received an email back informing me I’d been accepted for a poster presentation. Joy was then met with not a small amount of trepidation as I read further “You should plan to speak for 3 minutes with an additional 2 minutes for questions.”

3 minutes?

180 tiny seconds of time to talk about my project, my baby?

I’d presented for 10 minutes before but this was something else in terms of brevity. So I tried to have a process. This is my process, I’m not saying it’s perfect and there’s still things I’d want to change but it’s an example of how to approach the problem of getting your message across in a short period of time.

The idea of any talk is to engage, inspire and inform, That ratio can be changed around; the longer your talk you more you can inform about at the risk of losing engagement and inspiration. Obviously with only 3 minutes I was going to have to cut on the informing and focus on engagement and inspiring. I needed another way of informing the audience.

So, I wrote a blog. This step helped me know the subject and clarify the key points along the way. What’s the killer and what’s filler? What is nice to know but what is absolutely essential about your message? By doing this I realised I had three (always a good number) key points I wanted to highlight: the app was easy to make, it flipped the classroom and blended learning and that students value opportunities to practice digital literacy in simulation.

My talk would therefore be used to get those three points across and hopefully inspire my audience to look for the blog to read more.

Once the blog was written (and that took a long time) and I’d realised what the purpose of my talk would be I decided to see this as an ‘elevator pitch’ similar to those used in business as a format of engaging potential employers/investors in your project. Essentially you imagine you’re in the lift with the person you want to impress and you’ve got the time it takes to go from the ground floor to the top to sell yourself or your product.

With that in my mind I did a few Google searches to find what advice is our there to create an elevator pitch. Unsurprisingly, they’ve made an industry out of this so there’s a lot of information but very little I found useful without needing to pay money. However, I found this blog very useful by Alyssa Gregory. She breaks the process down into stages:

  1. Define who you are are

  2. Describe what you do

  3. Identify ideal audience

  4. Explain what’s unique and different about you

  5. State what you want to happen next

  6. Create an attention-grabbing hook

  7. Put it all together (start with 6)

So I did this. I wrote it out.

And I read it out loud. Slowly and clearly. It came in at 2 minutes 45 seconds. Great! But on reading it out loud it felt flat. And weird. I realised while it was a useful tactic to plan a bit like an elevator pitch the key difference was I wasn’t selling anything. So I did the next step. I practised. With an audience.

This seems perfunctory but it’s key. Only on performing in front of colleagues who I knew would be productive in their criticism did I start to get a sense of what it was like to hear about the application. They could tell me about the ebb and flow and how easy it was to follow my three key messages. There was a rewrite. And another.

Finally, I was lucky in that my poster was on the third day of ASPiH so on the second I was able to watch a poster session and get a feel for the room and see what works and what doesn’t. Clear, slow speech was vital. A bit of humour if possible. Don’t distract with your body language. Look at the audience and not your poster.

There was another slight rewrite and then a lot more practising.

This is what I came up with.

As I said before it’s not perfect but I was happy with it and it seemed to be well received.

I hope this is useful to you and helps if you’ve got a very short presentation to make. Any of your own tips? Anything you don’t agree with? Let me know!

Medical Education - There's An App For That

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Third year medical students at the University of Nottingham on clinical attachment at the Queens Medical Centre spend one week with us in DREEAM and the Emergency Department. Emergency Medicine can be daunting for experienced students let alone those right at the beginning of the clinical phase of the course. Also, as students arrive in the spring their week is often shortened due to Bank Holidays and other commitments such as core teaching. I wanted to find a way to give the students as much information as possible about the working of the department and its protocols as well as a way of increasing contact time to make the most of their attachment. A smartphone application seemed a practical solution.

IT’S EASY

The thought of creating an application might bring to mind Matrix-style screens of numbers and formulas indecipherable to anyone except hackers and programmers. The truth is it has never been easier to create your own application thanks to a number of websites which require no coding experience. A simple Google search reveals just what a crowded market the app building industry has become so I recommend a bit of research to find the platform that works best for you. Most of them work along the lines of choosing a template and then picking functionality such as social media links to add literally in a ‘drag and drop’ style. I chose AppMakr due to its ease of use and because the app also works as a website allowing students to access it on their computers and laptops as well.

The whole process is based on simply picking what functionality you want (say a calendar) and dragging it across. Each function is based on an RSS feed so you link your calendar to a Google calendar or your podcast icon to a SoundCloud feed. In order for the app to have our department’s Initial Assessment Tools (IATs) I created a Google Drive folder containing the guidelines as PDF files and used the shareable link. This meant clicking on the IATs button opened the IATs up for the students to use.

Backgrounds can be played around with. I tried importing pictures but found the resolution and sizes difficult; I think this had more to do with the images I was trying to bring in rather than the website itself.

You can pay to create your app and submit it to iTunes for consideration (it will need to be very good to get approved) or AppMakr will create a mobile website for free. The mobile website for this application can be found here. All students need to do is set the website to the home screen of their mobile or tablet and there, instant application. It was that simple.


Simply pressing on the green cross brings up the list of functions. The green cross acts as a kind of home button.

Using Google Drive links the presentation buttons bring up the slides for each session. The IATs function works the same. The calendar links to a Google Calendar account created especially for this application.

External resources were linked to the application as well. Certain Free Open Access Medical Education (FOAM) resources were linked as well as dedicated Social Media, Podcast and YouTube resources to help the students during the attachment. Unlike other apps this worked without internet connection which helps in the concrete basement of our Emergency Department!

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Finally, a forum was created into which students and educators could log in and communicate. This helped share resources and further discussions. This brings me on to my next point:

FLIPS THE CLASSROOM AND BLENDS YOUR CURRICULUM

The flipped classroom describes students being given learning resources before a teaching session. The teaching session is then used to explore the material in greater detail (Heacademy.ac.uk, 2018). The role of the teacher in the flipped classroom has been described as a facilitator and coach or ‘guide on the side’ (Baker 2000). This notion resonates within suggested theories in medical education regarding the exponential growth as well as the shortening half life of knowledge such as connectivism (Siemens 2005) or navigationism (Brown 2006). The growth of Web 2.0 resources such as blogs and podcasts further facilitates this.

Using the application it was possible via the forum and word of mouth to point the students to a particular resource (say a podcast on Abdominal Pain) and advise them to listen to it before their session on Abdominal Pain. By flipping the classroom we can establish a set level of prior knowledge the traditional session can then build on. This maximises the time together. There’s a number of resources aimed at helping educators set up a flipped classroom programme such as this one from the Flipped Learning Network.


The forum allowed further discussions around cases (anonymised) or other subjects that couldn’t be covered in the timetabled sessions. These discussions were held between 1700-1900 in the evening and all students were encouraged to participate. This use of online resources alongside traditional sessions is called blended learning (Heacademy.ac.uk, 2018). The point was that the sessions would lead onto online discussion which would then be referred back to in the next face-to-face session which takes some time to get used to but is rewarding. The Higher Education Academy has a great page on blended learning here.

REAL LIFE PRACTICE IN SIMULATION

In all 18 students ‘downloaded’ the application. There was an orientation session at the beginning as well as clear guidance on professional online behaviour; so called ‘netiquette’ (Webroot.com, 2018).

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All sessions were designed to integrate the application either through guideline reference in simulation or signposted online resources during seminar sessions. All students used the application in at least one session with 11 students (61%) using the application in every session.

The forum transcription was analysed for any emergent themes. As I already discussed the forum was a key part of the ‘flipped classroom’ and improving communication before educators and students. This resulted in logistical messages communicating session changes or short term information such as interesting patients:

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There was signposting to resources to consolidate sessions or for prior learning before teaching:

There were also online discussions instigated around investigations or clinical questions:

The reason(s) for students using the application during simulation was assessed. By far and away the most common reason was to look up departmental guidelines (13) followed by looking up national guidelines (4), looking up free open access resources (2) and to look back on a presentation (1).

Students were asked to rate the application on a Likert scale. All students rated the application positively (4 or 5) with 14 (78%) rating the application 5/5.

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Finally, students were given a free text box for further feedback. As the diagram below shows this feedback focused on themes of reference and reflecting real life practice:

This suggests that medical students appreciate the role of guidelines and technology in clinical practice. The importance of digital literacy and navigating resources for expedient care is well documented with the Royal College of Nursing and Health Education England launching programmes to improve and formalise skills in this area (The Royal College of Nursing, 2018 and Health Education England, 2018). Studies have looked at promoting digital literacy amongst medical students (Mesko, Győrffy and Kollár, 2015). Perhaps with the rise of connectivism and/or navigationism as a learning paradigm we will see even more work into this area with digital literacy becoming a key skill alongside clinical acumen. Anecdotally speaking to the students the biggest barrier to using the application was familiarity. Once this was overcome they felt comfortable using it and contributing on the forum.

Students value innovation from educators but this requires careful design of the curriculum and resources to ensure feasibility and compatibility.  The project suggests that application design is feasible for educators with limited coding experience and the results indicate that students engage well with a blended curriculum.  Engagement with the application was related to student confidence and perceived relevance.  Mobile learning tailored with simulation offers students a realistic experience.  Resource design may become a crucial part of educator development.  Students require guidance with new resources when presented to them.

Reference

Baker, J. W. (2000) The “Classroom Flip”: Using Web Course Management Tools to Become the Guide on the Side. In: the 11th International Conference on College Teaching and Learning: Jacksonville, Florida.

Brown, T. (2006) "Beyond constructivism: navigationism in the knowledge era", On the Horizon, Vol. 14 Issue: 3, pp.108-120, https://doi.org/10.1108/10748120610690681

Flipped Learning Network (FLN). (2014) The Four Pillars of F-L-I-P™

Heacademy.ac.uk. (2018). Blended learning | Higher Education Academy. [online] Available at: https://www.heacademy.ac.uk/knowledge-hub/blended-learning-0 [Accessed 19 Oct. 2018].

Heacademy.ac.uk. (2018). Flipped learning | Higher Education Academy. [online] Available at: https://www.heacademy.ac.uk/knowledge-hub/flipped-learning-0 [Accessed 19 Oct. 2018].

Health Education England. (2018). Digital literacy. [online] Available at: https://www.hee.nhs.uk/our-work/digital-literacy [Accessed 29 Oct. 2018].

Mesko, B., Győrffy, Z. and Kollár, J. (2015). Digital Literacy in the Medical Curriculum: A Course With Social Media Tools and Gamification. JMIR Medical Education, 1(2), p.e6.

Siemens, G. (2005). Connectivism: A learning theory for the digital age.International Journal of Instructional Technology and Distance Learning2(1), 3-10.

The Royal College of Nursing. (2018). Improving Digital Literacy | Royal College of Nursing. [online] Available at: https://www.rcn.org.uk/professional-development/publications/pub-006129 [Accessed 29 Oct. 2018].

Webroot.com. (2018). What is Netiquette? A Guide to Online. [online] Available at: https://www.webroot.com/hk/en/resources/tips-articles/netiquette-and-online-ethics-what-are-they [Accessed 29 Oct. 2018].

Heart or Head - Can We Teach Empathy?

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First, I want you to read the descriptions of these four patients and imagine, really imagine, them in front of you as if this is their triage and you're just about to see them:

  • A teenager with leukaemia on chemotherapy who's presenting with a fever, shortness of breath and a productive cough

  • An elderly lady who has tripped on the pavement whilst collecting for charity and is presenting with right hip pain and shortening and external rotation of her right leg

  • An intravenous drug user who presents with left groin pain and swelling with fever two days after injecting there

  • A middle aged man in police custody after being arrested at a far right rally for smashing a window brought to you with a laceration to his right arm who's being racially abusive

You're probably already making working diagnoses based on these statements: possible neutropenic sepsis, right neck of femur fracture, groin abscess, laceration needing sutures.  But how do you feel reading them?  Sure, you're going to do your best and you'll be professional but how would you be inside as you see these hypothetical patients?  Would you feel compassion? Sympathy?  How about empathy?

Empathy has been an important factor in the reflections all healthcare professionals underwent following the Mid Staffs scandal:

“food and drinks were left out of reach of patients…the standards of hygiene were at times awful with families forced to remove used bandages and dressings from public areas…people…suffered horrific experiences that will haunt them and their loved ones for the rest of their lives” (Campbell, 2018).

The Francis Report identified empathy as one of the main professional attributes that enable compassionate care (Webarchive.nationalarchives.gov.uk, 2018). The Department of Health and NHS Commissioning Board 2012 recommended that, “care is given through relationships based on empathy, respect and dignity” (Webarchive.nationalarchives.gov.uk, 2018). This leads us to the obvious question:

WHAT IS EMPATHY?

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I think it's fair to say that empathy's meaning can get lost in translation.  A straw poll of colleagues on a certain shift led to a number of different suggestions, "it's when you feel sorry for someone", "it's when you show you care", "it's when you can put yourself in their shoes".

Empathy is defined by Merriam-webster.com (2018) as:

  1. the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also the capacity for this

  2. the imaginative projection of a subjective state into an object so that the object appears to be infused with it

I like this line from Harper Lee's 'To Kill a Mockingbird' - 

"You never really understand another person until you consider things from his point of view - until you climb inside of his skin and walk around in it."

First things first: empathy is not about feeling sorry - that's sympathy.  But let's look at the above definition from Merriam-Webster.  "Understanding, being aware of, being sensitive to" - all sound very appropriate for the caring professional.  But "vicariously experiencing the feelings, thought and experience of another...the capacity for the imaginative projection" - is this necessary?  Is it healthy for healthcare professionals exposed to challenging environments every day to be put through such an emotional wringer?

THE BIOLOGY OF EMPATHY

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We certainly know that empathy has a biological framework. Empathy has a proven genetic basis (Knafo, 2008) acting as an evolutionary advantage by promoting altruism and other prosocial behaviours (de Waal, 2008). Displaying empathy is linked to known neuronal pathways such as those involved in facial mimicry (Sonnby-Borgstrom et al, 2003) and imitation (Field et al, 1982 and Fornan et al, 2004) as well as the mirror neuron (Iacoboni, 2008) and limbic systems (Carr el al, 2003, Iacoboni and Dapretto, 2006 and Preston and de Waal, 2002). In contrast deficits in empathy are particularly evident after focal prefrontal cortex damage with poor empathic development seen in children with early damage to their frontal lobes (Eslinger, 1998). Further evidence of the innateness of empathy has been reproduced in several studies showing how children as young as 18-hours-old are distressed at other’s crying (Martin and Clark, 1982, Sagi and Hoffmann, 1976 and Simner, 1971).

Behavioural psychologists have hypothesised that everyone falls somewhere on a spectrum of emphasising and tendency towards system creation (empathy-systemising theory) (Baron-Cohen, 2009). 

EMPATHY AS BEHAVIOUR - THE CHECKLIST APPROACH

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If we accept empathy as behaviour we can focus on the prosocial behaviours in a simulated environment with our students. Kahn’s Etiquette Based Medicine (EBM) (Kahn, 2008) is an interesting development in this area.  He looked at clinical checklists such as Pronovost’s checklist for inserting central lines (Thelancet.com, 2018) and used the same principle for empathetic behaviour in a potentially simulated environment giving the following example:

1. Ask permission to enter the room; wait for an answer.

2. Introduce yourself, showing ID badge.

3. Shake hands (wear glove if needed).

4. Sit down. Smile if appropriate.

5. Briefly explain your role on the team.

6. Ask the patient how he or she is feeling about being in the hospital.

Let’s imagine designing a simulation where this could be assessed.  Our students could cycle through simulated patients with a variety of different diagnosis: a patient in pain, a patient with substance abuse, a patient with mental health issues.  The simulation could also look at the standard A-E and diagnostic approach but also include this empathic assessment just as prominently.  The simulated patient would be very useful  in feedback:

“When I mentioned that my husband had died it was nice that you held my hand.”

or

“You didn’t always look me in the eye which made me feel like you were talking over me sometimes.”

Those observing the simulation can also give similar feedback based on their third person observations in a purely objective format: we saw or heard this therefore it appeared as this.  It would be useful to include fellow students as part of this audience to help learn from each other. Further studies have expanded on Kahn's initial checklist to include suggestions for a second meeting with a patient (Castelnuovo, 2013).

Kahn accepts the pedagogical limitations here; this is behaviour not feeling.  But he argues that this is a useful first step for students to start to develop empathy.  This reminds me of the ‘Hello my name is...’ campaign, an incredibly successful movement based on a very simple premise.  As Kahn himself argues, it is easier to change behaviour than attitude.

We already use simulation and observed exercises as the basis of teaching and assessing communication skills.  A student could in theory pass without issue on a station marked communication skills when they know that is being assessed before forgetting communication skills when it comes to further stations.  The current move towards more holistic and OSCE assessment partially recognises this possibility; a station is no longer marked for one particular topic but instead assesses focused examination, investigation interpretation and communication skills.  We have to make sure that empathy is consider in all observed real and simulated patient encounters both assessed and not.

EMPATHY - REFLECTING AND REPORTING

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Experiential attempts to foster empathy in students have focused on immersion and realism such as ageing simulation (Through Their Eyes Project, 2018) and reflection and simulation (Counseling.org, 2018).  These are time and resource heavy. The Jefferson Scale of Physician Empathy offers a psychometric assessment of students and practitioners and has a growing evidence base (Tavakol, Dennick and Tavakol, 2011). The JSPE is based on self-reporting via a questionnaire. This suggests that a reflective model can be encouraged either via simulation and immersion or through qualitative questioning of subjects. This obviously relies on resources and honesty.

So can empathy be taught? The truth is this depends on how you view empathy, as a skill or a behaviour. Even then, some of the greats of education have been unable to agree and have changed their minds.

In 1951 humanist Carl Rogers wrote that empathy was a skill that can be taught (Rogers, 1951) but by 1975 changed his opinion and argued that it wasn’t a skill but behaviour that had to be willingly displayed (Rogers, 1975). This definition sounds closer to behaviourism but still includes the element of free will. Fellow humanist Martin Buber disagreed arguing that feeling empathy was a passive event that had to be allowed to happen (Buber, 1955).

However, some have argued that empathy cannot be taught. The philosopher Edith Stein repeated Buber’s idea of empathy only being noticed ‘post-event’. However she disagreed with Rogers arguing that what they called empathy was in fact ‘self-transposal’ – a person actively listening to another – and that empathy was only achieved after crossing-over to the other’s viewpoint before returning back. She believed that empathy was a ‘happening’ not behaviour and as such was impossible to teach (Stein, 1970). Davis agreed with Stein believing that self-transposal could be taught as it is cognitive process but as a behaviour empathy cannot be taught as a skill (Davis, 1990). She did however argue that through experiential learning, humanism and reflection empathy could be facilitated (Davis, 1989).

So we have a dictionary definition of empathy and we know there are checklists and questionnaires we can use as well as immersive simulation to help foster, if not teach, empathy in our students even if we can’t agree if that is a skill or a behaviour we are fostering. This brings me to my next question: Is empathy even that useful? Could it even be harmful?

Although some authors have concluded that empathy makes for better clinicians (Quince et al, 2016) the evidence and models used to make these conclusions is sketchy at the best.  One study Quince (2016) referred to concluded that clinicians can improve their ability to recognise emphatic moments in clinic not that it made them better at their job (Levinson, 2000).  I can think of medical students so caught up in feeling for patients they'd seen in a trauma call they reported not concentrating well afterwards to the detriment of their studies.  Previous studies have shown how empathy actually declines with experience until a "minimum level of empathy" is found which is all that's needed "to benefit from the positive aspects of professional quality of life in medicine" (Gleichgerrcht and Decety, 2014). 

EMPATHY AND DECISION MAKING

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Paul Bloom wrote a very interesting article in the New Yorker called The Baby in the Well (Bloom et al., 2018) explaining how individuals actually make bad assessments of situations based on empathy.  He cites several studies where empathy skews our emotional response and decision making disproportionately.  In one such study participants were given the choice between donating to save the life of one named individual with a photograph and back story or a group of 8 nameless individuals.  Participants consistently gave more money to save that one individual whose name they knew and who they could empathise to even though money to the other group would have saved more lives (Kogut and Ritov, 2005).

This means we could be liable to make bad decisions for the patients we feel more empathetic toward. Never mind the potential risks of counter-transference that inexperienced practitioner or student may not be aware of when they first encounter patients. So if empathy might be risky what else should we encourage?

EMPATHY OR COMPASSION?

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According to Singer and Klimecki (2014) whenever we meet a person in distress we are inspired to feel either compassion or empathic distress. The two pathways have two distinct basis in neurobiology. First, the empathy training activated motion in the insula (linked to emotion and self-awareness) and motion in the anterior cingulate cortex (linked to emotion and consciousness), as well as pain registering). The compassion group, however, stimulated activity in the medial orbitofrontal cortex (connected to learning and reward in decision making) as well as activity in the ventral striatum (also connected to the reward system). The two types of training led to very different emotions and attitudes toward action. The empathy-trained group actually found empathy uncomfortable and troublesome. The compassion group, on the other hand, created positivity in the minds of the group members. The compassion group ended up feeling kinder and more eager to help others than those in the empathy group.

From Singer and Klimecki (2014)

This suggests there is an importance to encourage healthcare workers towards the positive outcomes and to encourage compassion rather than empathy. The Loving Kindness Meditation model of mindfulness has been shown to foster positive emotions (Fredrickson et al., 2008).

In debating whether empathy testing could be introduced to medical school applications Schwartzstein (2015) suggested the following four stage model for supporting compassion development at medical school:

APPROACHES TO SUSTAINING COMPASSION AND COMMUNICATION SKILLS IN MEDICAL SCHOOL

  • Implement curricular changes that support students' idealism, kindness, and focus on patients, such as providing earlier clinical experiences or requiring participation in student-directed clinics.

  • Select clinical faculty for their ability to support the desired values.

  • Refine measures and instruments for assessing interpersonal skills, support faculty in completing these assessments, and prohibit students deficient in the necessary skills from advancing in their training.

  • Advocate for financial and logistic systems that enable doctors to spend more time with patients.

I find this model fascinating as it suggests a complete overhaul of a medical education facility based purely on compassion and communication. Would it work? It’s too early to tell and it will be interesting to see if it gets any mileage.

Back to our hypothetical patients.  Would attempting to place ourselves in the shoes of a fascist be helpful?  Obviously we have to be professional and ignore fundamental-attribution bias but what about empathy? Empathy has been shown to motivate an individual to help another person based purely on altruism - the 'empathy-altruism hypothesis' - rather than any gain to the individual (Batson et al, 1991).  If a healthcare professional is doing their best for their patient does it matter if it is empathy or professional duty motivating their actions?  Is it better to teach our students the behaviours and values of treating our patients with compassion and respect rather than obsessing about empathy?  Use feedback from patients both real and simulated to reflect on clinical behaviour and encourage the actions which make others feel respected and listened to regardless of motivation.  Make students aware they are entering an emotionally challenging profession and that they should expect complex feelings.  Encourage them to reflect and support them if they don't feel empathy, support them if they do and support them if they feel too much.

This is obviously a massive topic and it’s impossible to cover everything. Let me know what you think, I’d love to continue this debate.

- Jamie (@mcdreeamie)

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