Clinical learning from a distance
Welcome to the osmosis webinar on Clinical Learning from a Distance. I'm Catherine Johnson, Senior Director of Institutional Engagement at osmosis.
Uh Our agenda for today will be to go through. Welcome and introductions which we've started now, we'll do a quick uh recap of how we got to this place now with COVID-19.
Um And then we'll walk through some approaches to distance learning, including uh simulation and tle clerkships or Tle Cinical.
Today's presenters are Doctor Amin Azam, who is a psychiatrist and associate professor at UC SF Berkeley, um and Doctor Sean Tackett who's an associate professor at Hopkins.
Hello, everyone. Um I'm broadcasting live from outside of Baltimore.
Uh I've got a three year, three year old and seven year old boys downstairs. Uh just to kind of show you how we're doing it.
Uh social distancing, that's theodore's little desk. That's our first grader.
That's where he's doing his homeschooling. I kicked them out of the room so that I could speak to you.
Uh So that, but I, you know, if you hear any noise or anything like crashing or breaking, that's them, it's probably them.
Um So just to put uh you know, So, like I said, I, I'm, I'm a general internist. Um I'm, I know a lot about medical education and medical schools do recognize that a lot of you uh who are joining us may not be from medicine.
Um A and you know, II think a lot of the principles that we're gonna share with you will uh will apply to your own educational work.
Um But, you know, at the same time, we want this to be interactive. We want everybody to be sharing their own experiences because frankly, you know, nobody's an expert uh in what to do with our current circumstance.
Um And so the more we, you guys can share with us and with each other, I think the, the more everybody will get out of the session.
Um So I'd like to just begin by putting things into context. Um So on New Year's Eve, whenever uh many of us were probably having a good time and were carefree.
Uh That, that was the day that the wh O was informed of a so-called pneumonia of unknown cause from Wuhan China. And in January, it's, it started to spread, you can see that Thailand was the first case outside of China.
It was in the US as early as January 19th in Seattle. Um And then things kind of conflicted from there uh in terms of a public health emergency, uh global pandemic and then by Saint Patrick's Day, the US accrediting authorities for both allopathic and osteopathic medicine.
Sent out declarations essentially saying all students should stay at home, regardless of whether you were in a clerkship setting or uh or in a preclerkship or non clerkship setting, you gotta just stay home.
So that presented big challenges for medical schools in terms of how do we keep students learning clinically um whenever they can't be in the clinic.
Um So where we are today, this, this impacts approximately, you know, 30 to 50,000 medical schools in the US alone, we surveyed so called osmosis medical Education fellows.
Uh So this is 67 students who are in a program of osmosis administers. Uh They come from 55 schools across 18 countries.
And we asked them how their schools were adapting to Coronavirus and social distancing. And uh every one of the students except the single student who is from uh a school in Samoa, which is an island that actually at the time we sent the survey on March 20th, I didn't have any COVID cases diagnosed one of the few places in the world um that everybody else though had their schools have told them to stay home and that there, there was no more uh student presence in the clinic on a for, for learning purposes.
Um So again, this has not ever happened before. II think, you know, today, one thing we can reflect on is that if it ever were to happen, this is about as good of a time as any were to happen.
Given the technology and opportunities we have to keep students going. Um Despite the fact that again, they can't have a physical presence in the clinic.
Um so that I started thinking about just generically and broadly approaches to clinical learning at a distance. Um The way it made sense to me to think about it was there are sort of simulated learning experiences and then there are sort of true learning experiences that are done at a distance.
So phrasing these as tec clerkship or tele cinical kind of experiences. So in the big category of simulated clinical learning, um you can actually do quite a lot.
Uh So there are resources out there for help to help students clinical reasoning. Um There are plenty of like simulated clinical cases that students can work their way through um to hone their in their thought processes.
Um There are resources out there for diagnostic skills like visual DX is a popular one, but there are like dermatology specific ones and other specialty specific ones to um improve student skills and visual diagnosis in particular.
Um There are dedicated curricula for communication skills. Um and this can also be simulated in, in fancier ways.
And I mean, I speak a bit in terms of how you can sort of remote into a a simulated patient experience. Um And then you can even go as far as to assess some physical exam skills at a distance.
Um So the virtual OS is something that is being picked up more and more out of necessity um during COVID times in medical schools.
So these are all simulated. Um So again, there's no real patients here.
These are, these are sort of out of the box kind of solutions or, you know. Um So that's sim clinical, the, the talent clerkship is I think something new and not being done a lot and not being done enough from, from my own perspective.
Um And so again, the, the categories, they made sense to me where there's sort of participating in true telehealth practice.
Um So, you know, like telera, there are plenty of current radiologists who currently work from home or, or work on a, on a boat or wherever they are and, and have a, a nice lifestyle and they're doing the exact same work and, and billing them the same way that a radiologist would if they were stationed in a hospital and similar to telepathology, you know, their billing practices in particular, they're, they, they're able to um look at a slide anywhere and it's the same billing code.
And so it's essentially, again, they don't, they don't need to be at a, a given location. Um The telemedicine visits for in the ambulatory setting have, have been in place now for, for quite some time.
Um And so these are actual patient visits and students can participate in those. Um And then there's a, a several categories of provider to provider consultations.
And that's what this uh chart depicts in a way uh on the right. And so, um and so these come in again, different shapes and sizes.
And so, so this is when like a provider might ask for a second opinion on radiology or pathology specimen, or they might ask for a written uh second opinion that where they send documents in a so called store and forward manner.
Um And then the specialist provider writes a report to answer their clinical questions. Um Even something like teles stroke, which is more emergent is a type of sort of provider to provider telemedicine modality.
So that's just what I mean. Um when, whenever I mention that, and again, I think students can participate in these in a similar way that they can participate in clinical consultative electives.
Um I think some, the place where a lot of schools are trying to innovate more is, is in. Uh well, I'm I'm terming here tele rounding.
And so there, there are examples um that from Hopkins is actually uh where, you know, the students can round in the ICU remotely with.
Um you know, there's a, there's a video you can look it up online where there's a Hopkins critical care doctor, he puts uh an iphone strapped over top of his COVID sort of face mask and then he kind of walks around and the students can sort of see through his lens what's going on on rounds and they can also participate.
Um And then I'll, I'll share one example of uh awards elective for internal medicine uh where students are, are similar lately trying to pre round on their patients uh rounding with the team and then doing follow up work from home.
And then so something I haven't seen, but II would imagine it feasible is teles scrubbing. So, you know, 11 challenge is the, what do you do with when you don't have access to an operating room?
Um or, or some other, if you're in a procedure based kind of clinical learning experience, how, how do you keep learning?
Um because it would seem like you really need to be there for the hands on part of it. Um But you know, it, uh again, my surgeon friends tell me that routinely at, at surgery conferences, they have sort of live streaming of surgeons describing what they're doing, um which would not be that much different in my mind from like a medical student or, or some other students standing in the, or looking over the the surgeon's shoulder as they mostly do now.
Uh and kind of asking questions or being pimped, uh you know, and uh to, to enhance their understanding of anatomy and the procedure.
So these are just to provide you like a with a, a framework, like a manageable way to kind of think about how we can deal with this, a simulated clinical learning and then so called tele clerkship tele cinical.
So we'll just talk through a few examples and then we're gonna, I think pass it on to the, to the group to share their examples.
So this is the one that I'm most familiar with. This is literally just got off and running in the last week.
Um So the pilot was over the last week and then they're gonna formalize it into an elective. So the students who participate are people have already done their general medicine uh clerkship and then uh would be sort of eli eligible for an advanced clerkship or a sub.
Uh And so the, the, the people's faces here, this is a pa and this is so they're the people who are actually uh making this work in, in the hospital or Johns Hopkins Hospital and John Hopkins baby medical center.
So the what is a student can expect and what they, what they've done over the last week is they, you know, they get up and roll out of bed and sit in front of their computer and they, they pre round.
Um And so this, this is similar to what they would do. Um If they're sitting in the workroom, they look at epic, um they can actually call the patient and speak and take a, a brief history.
Um You know, some, if they are able to manage it, they can synchronize with the intern and be there when the interns present and do some sort of physical exam.
Uh and then check in with the intern before rounds about what the plan for the day would be. Um Then they participate in rounds, they just do it remotely through zoom and so they can present on their own patient as they would.
Um And then also kind of listen to what's going on with the other patients, ask questions, you ask questions and keep learning that way.
Um If it's, if it's an admitting day, um then they are eligible to admit a patient again via uh Zoom. Um and then they can even put in admission orders into epic because they have remote access there and they can be cosigned by uh the resident or um and then, uh and then if, if there's no admitting, then, you know, they would just do their general tasks as, as they normally would.
Again, this can be calling the patient checking with the family, checking with outpatient providers, doing an extra, extra effort with medica medication, reconciliation, extra education for the patient.
Um You know, they can, they can do literature reviews to teach the team and provide sort of the pearls that a lot of it is common for um work rooms in the afternoon.
Um So the, it's, again, it's, it's pretty much thinking about whatever they were doing before and how much of it can they do.
And when you, when we thought about it and started working on it. You can actually do almost everything.
Um So that's, yeah, so that's tele tele clerkship on the words. Um And I'll just pass it to me and talk through several examples from UCSF and uh Berkeley.
Before we start with Doctor Azam, can we had a question from the audience? Uh Sean, which is, is there a um tele rounding uh resource for students to view or is it, or are you seeing that done more locally?
Uh Do you mean like a how to tell around? Um, not now, I mean, we don't know yet.
We're, we're figuring it out ourselves but um uh uh and I can, I can also speak to. So there is, you know, John John to Bay View, it's like a 500 some bed um hospital and then there's John Hospital, which is like 1000 plus bed hospital and they're like three miles apart, but they might as well be in different universes.
Uh uh more, I guess, you know, different Galaxies, right? It can only be one universe.
Um But you know, so what, what I, what I've been told is that at, at Bayview, um they, the technology work relatively well where they've been able to get into the room with the patient without a lot of difficulty at Hawkins Hospital.
There have been more, there's been more difficulty sort of connecting with the patient um through the phone. So, you know, So, II think we're, we're actively troubleshooting a lot of the tech issues on this.
Um And um and so, you know, so wherever you are, you know, we can provide advice and a framework but ultimately, like the, your tech may be different and you know, there'll probably be like a, a pilot and iteration kind of days to, to work through.
Thank you one more quick question before we move on to a mean, which is uh uh uh about HIPAA and FPA um compliance. So how do you keep that patient information secure in a, in a telehealth setting?
Yeah. So, so now um in Hopkins, um it even in the inpatient setting, it's become routine in, in the COVID era strictly because of COVID, it's become routine for patients to sign like a telemedicine waiver.
Um And so they, they've consented to participating in telemedicine. And this is, this is, this is because um again, whenever I II did my first, I saw my first COVID patients and you know, we, we actually see them, we speak with them remotely before we walk in the room.
And, and I think even going forward, there's gonna be um like for uh hospitalists or internists in inside the hospital are going to be um be able to see patients follow up patients remotely.
So there actually may not be any, any physician who goes in and sees the patient on on a certain day. Um So just to brace for that reality, patients are now getting all patients are signing up for like a a telemedicine waiver.
Um So they consented to that. Um And then, and then each of the modalities that we're using is uh is sort of vetted for HIPAA compliance.
So, Zoom for, from Hopkins perspective is um HIPAA compliant. Um and you know, telephone has been um anything where you're doing through the is compliant.
So, so yeah, it's, we've thought about it and that, that's how we've done with it. All right.
Um I think Catherine, I'll go ahead and um move ahead to other examples and we'll do some more Q and A. So um so I am, my name is Amin Azam.
As Catherine said, I am a psychiatrist by training at heart and educator. I've been on faculty at UCSF in the School of Medicine at, at UC Berkeley UCSF in the joint medical program in the School of Public Health and at Samuel Merit University in the simulation center where my focus is interprofessional education.
Uh First, I'll just sort of do the same disclosure Shawn did. I'm also working from home and sort of uh the same kind of deal where, you know, you work from wherever, whatever space you have.
So I've got this like space that's been converted into a clinical space where my wife and I both practice our clinical care uh when we can from home.
So, um just to address some of the things that were already discussed in in Shawn's comments. UCSF has has definitely moved to telepsychiatry or telehealth as well like the Johns Hopkins patients, my patients sign uh waivers or consents to participate in in uh remote clinical uh providing care.
And um in my case, I run psychotherapy groups for patients living with chronic medical conditions. So we also have to make sure the waivers ensure that uh patients in groups are also not in public places where there might be accidental disclosure of patients, private HIPAA information.
In any case, that's the clinical side. I'm gonna now share with you some examples from my various educator hats from my different universities to get you thinking about the educator side.
So at S Mart University, we run Interprofessional education simulations um with uh with our SIM Center. So we have these all set up to go before COVID-19 and the COVID-19 hit in the middle of our curriculum.
So um we had already planned to design the simulation with students actually working with standardized patient actors in the SIM Center.
And when that became impossible, we moved towards a virtual remote simulation. So what I'm showing you here is an example of, of uh a subsection of the timeline of the simulation in which what we did was use historical footage that we had from last year students with the same virtual scenario, the same uh standardized patient.
Um And then what we did with this year students on the zoom meeting was we literally said, all right, we're now gonna advance the clock and you are going to be the change of shift that's taking care of the same patient.
So you had the privilege of watching last shifts uh team. Um You got better sign out than you would have otherwise because you actually got to watch their care rather than hear them discuss their care.
And now we'd like you to proceed with your care by doing a hallway huddle and how you as an interprofessional team are gonna care for this patient.
So you can see that the SIM technology specialist had some specific uh instructions about muting and unmute the actors videos.
And we discovered that Zoom has an ability to hide all nonvideo participants. So we actually literally uh it effectively like pushing the observer students and faculty out of the room so that you maximize the viewer uh experience of feeling like all of those students and those actors were actually in a conference room together uh rather than the Zoom artificiality of everybody being at home.
So uh we made it work. Uh we ran uh over 100 students through the simulation over about seven different sessions across all of the universities and students.
And yes, they were technical hiccups and yes, we struggled with some of those. But like all simulations you learn as you go and you get better as you go.
That's one very uh specific example of a success doing um inter uh institutional interprofessional remote simulation based zoom uh education.
OK. Second example, this is from my uh Berkley hat um UC Berkeley UCSF joint medical program, medical students in their pre clerkship years of medical school.
Um And in this case, they are also uh developing a remote ay I know that Sean hinted at that. There's definitely a lot of discussion around that with some of the uh educator list serves.
Um So this is an example of a standardized patient um uh uh script for the actors, just a sub part of that screen. And what I wanted to draw your attention to is uh the um simulation itself.
I in the SP script, we're basically describing uh where are we simulating and we're basically gonna be simulating a telehealth visit.
And so the patient would be calling from home. The medical student is going to pretend that they're either calling from home just like Sha has described in the real uh tele rounds um or they can pretend that they're in a hospital setting.
Uh uh Some people are aware that Zoom has these simulated backgrounds or you can pretend to be in a different room. I we're not asking students to do that at this point, but the point is uh students can pretend to be doing a telehealth visit with an actor who is uh playing the role of a patient calling in from home.
Um and this one is gonna um we're using the learning management system that Berkeley subscribes to the the canvas course site.
And so I wanted to just give you a hint at, at the, as the, the educator team is developed in rapid fire ability to have students practice zoom on their home device before their actual encounter with the actors.
And so this is a chance to work out all of those technical logistics uh upstream of the actual event. Um And so it really kudos to the be my Berkeley teammates who have done a really amazing job developing this as Sean described with Hopkins on very rapid timeline, timeline to make sure that it works.
Um And this gives us students a chance to still engage in the clinical reasoning and history taking interview component without the physical exam component, I would offer that um for your programs um as is always been done long before COVID-19.
If a student wants to perform a portion of a physical exam with a standardized patient actor that is invasive. Um Long ago, um simulation said you could tell the actor I would now like to perform a pelvic exam and the actor would say the results are in the drawer or the here's the piece of paper with the results.
So there's no reason you can't continue those kinds of simulated activities even though you are now remote from the actor and not in the same room.
OK. Third example.
Um This is now my CSF hat. So we've been running a Wikipedia editing course for med school credit uh for a number of years now.
And this is offered to the Wiki Education Foundation. This is their equivalent of a learning management system.
So this is a screenshot of my most recent cycle of my course in March of 2020. Um And you can see uh the, the course dashboard allows people to track the students contributions to Wikipedia.
Um And so I had seven students enrolled in my course, they were senior final year medical students and they, the seven students made 287 edits to uh to a adding a 12,700 words to Wikipedia and 100 and 22 references.
And those pages that they worked on those seven pages viewed 75,900 times just during the month, my students were working on it.
The, the course dashboard has a lots of uh abilities to track and monitor your students. So these were the pages that my students worked on this last month and on that far second of right far most column there is that little tool that looks like a a piece of paper.
And if you click on that, it allows you to track and sort of highlight back, highlight the edits that your students actually make.
So this is one of my students who worked on the central venous catheter Wikipedia page and you can see that he made quite a few edits.
Um uh So that's another possibility is having students engage in remote um care of virtual if you will real patients, real people are reading on Wikipedia but not actually doing clinical care.
Uh Fourth example comes from Oregon Health Science University. Um This I discovered through the Doctor Ed Listserve, there's lots of different educator uh communities I mentioned there's another one called Dox which is uh directors of Clinical Skills courses in Medical School.
The Society for Simulation and Health Care has a lot of list serves related to different types of health professionals using simulation.
I'm sure some of, you know, some other list serves. You'll tell us about in the discussion course.
And uh Oregon Health Sciences University runs a course on biomedical and health informatics. They've been running this long before COVID-19.
What I thought was really wonderful about this example and I wanted I highlighted for you here. It was basically they opened up their course to students globally and they said, dear beloved faculty at other schools, you manage your students, we'll run the course, you work out an academic credit at your institution.
We'll just, we'll have you run it. I mean, we'll have you participate in it and then you work out all the aca details.
And what I really love about this example is they're opening up their arms to other students uh without opening up their uh administrative team to the headaches of having non Oregon students enrolled in the course.
But I love the example of um sharing resources across institutions. OK.
Um All right. I think from here I'm gonna hand it back to Catherine.
I'll stop sharing Shawn's screen and Catherine take it away. Wonderful.
Thank you. So, now we are at the uh discussion portion.
So before we get started, we just wanted to provide some guiding questions which you're seeing here as initial questions to ponder.
These are things that we certainly discussed prior to this presentation, um especially surrounding what does it mean to do clinical education in in this scenario?
Um and more broadly, how, how do we set the bar for that? Um How do we know that what we're assessing what's appropriate to assess?
Um So we would love to hear from you. Um Please feel free to ask questions in the chat and I can unmute you if you would like to share a story.
Um uh I will just answer in in greater detail. There was a question a Panelist asked me about whether we got permission from the historical students video footage to share it with your peers.
We did and we only used one set of five students rather than getting a whole bunch of different historical footage. It was a lot easier and simpler to just get permission from those five students.
Excellent. We do have a question which is the challenge in South Africa is to reduce synchronous online teaching to the minimum uh due to bandwidth and access challenges for some students.
Um Yes, we're aware of that. So are there particular examples of clinical online teaching that don't require uh people being online at the same time using up that bandwidth, Sean?
You can go ahead and I I'll answer first and then pass it to you. So in uh in your simulation land, there's definitely lots of examples of that.
So there are different vendors or uh co curricular content creators that have um example cases online that students can work through on their own schedule and then individual universities can assign students for example, reflections on those activities that the students submit to their clinical faculty of record.
So it doesn't require the clinician or the educator to be simultaneously or concurrently going through the online case scenario with the student.
That would be an example where you're um doing the entire simulation asynchronously. Um uh I know that there are examples of that in nursing education uh in physical therapy education and some of the other health professions I've worked with.
Um It all depends on what um co curricular content creators you have access to. If you have example cases in your own local institution, you could easily share that within your local uh arch technology architecture.
And I think the key is for the educators to be writing some specific requests of the students that they reflect on what they did, that proves the students did it, that proves the students are thinking and then the faculty can respond to the student reflection.
Excellent. There is a classroom uh a question about uh youtube for videos or do you have suggestions of what they can watch?
Um such as videos? Are there videos being filmed at Hopkins that are, are being shared out?
One thing I can tell you is that there has been an uh incredible increase in the amount of resources that are available for learning at home.
Um II know the double AMC has tried to correlate those there, there's a website, we can maybe share it out after this. Um I think it's like I collaborative but there's, and that as I've watched that website since it was launched, it's, it's been growing in, in the amount of uh resources that it's, it's, it's sharing, I can share it.
Yeah, while you pull that up, I'll just answer some of the other questions that were asking me. Um So one about the, the challenges of of training sp actors, um we've been using Zoom to train our actors.
Um And so you definitely wanna have an upstream training with the actors. We used to do those trainings in person.
Now we do them on zoom. So it's a simulation educator with the actor without students.
If you have a simulation center that has the luxury of simulation technology specialists, then working with them also to train up the actors on Zoom or the video conference platform you'll use.
Second question was around challenges with hiring actors. Um I know again, my Simulation Simulation Center has already a, a mechanism in place to hire and pay actors.
I would offer that a lot of actors are out of work right now because a lot of those their other do day jobs have gone dark.
And so actors are actually really eager to do this kind of work. Um So I would imagine there might be a mechanism for you to find the actors uh in terms of the paying payment structure.
I it would depend on your local context of how much uh actors are normally paid uh for doing this kind of standardized patient work.
Um The cost was not trickled down to the students at all. The cost was borne by the institution that is hiring the actors.
Um There was a question about sys and I'll answer this and then pass it back to Sean to go over the i collaborative resource.
Um So there's been a lot of discussion on the Doctor Ed Lister about Ay and how institutions are converting to remote acies and to secure and how to make sure that they're secure.
I've followed some of that discussion, I would just say that a lot of the different elements are very much up for renegotiations in this era.
So we've seen examples of aus that have reduced the number of stations uh uh to make, to reduce the complexity and ay that have reduced the security issues.
Um Ay that have designed a ways in which students are um participating remotely. But still with a, if you will Proctor, a faculty proctor who's watching in live real time.
So you can tell the student if, if the student were to try to take screenshots or to try to step off screen. So there are lots of creative ways people are doing to address uh AK uh while still trying to run something like what used to be an Ay uh Sean to you.
Yeah. So I'll just show, you know, some of the websites again, there's just been too many that you shake a stick at, but these are like some nice ations.
Um So I collaborative and the way they've organized it are around like the A C GME competencies. So this is for personal communication, medical knowledge is a lot um patient care, so so called patient care resources practice based on improvement, professionalism, based practice.
And there's overlap. So, um you know, some of these are in multiple different categories but um but you know, spending some time snooping through these uh could, could give you some ideas.
This is, this is the one I was referring to about the ICU uh like tele ICU rounding. So there, there's a video in here that describes how this being done at Hopkins.
Um and then this is a weird but good. Uh This is a Google doc that people have kind of created.
Um And, and so it gives kind of like, it has a lot of information related to student volunteering. But um and then also talks about student learning and the like, like on the wards and other like clinical kind of uh learning.
And II found this one again, this is my internal medicine world. Um The Alliance for academic internal Medicine has, has put together uh this list of COVID specific sites from these different organizations.
So just clicking through here, I found ACP stuff to be really helpful and it's free. Um and pretty, you know, pretty comprehensive.
So these are just other and ama is doing a good job with this. So, um you know, these are other resources that you could uh spend some time with.
There's one question in the chat about sort of uh um uh distance uh manual procedure based uh uh simulations or activities.
And uh from Stacey Hunt, I wanted to just encourage Stacey to think creatively here. I'll share, for example, as a, as a nonclinical example, my kids are being homeschooled, of course, like a lot of other kids.
And, you know, my kid has a music class and so the teachers produced a video of her um performing on a ukulele and she's asked all the students to find some sort of musical instrument at home that they can play along with or drum along with.
And she said very clearly, if you don't have an instrument, you know, a pot little work just fine be creative with what you have.
Why do I use that example? You talked about medication reconstitution, I completely get that.
You can't expect students to have the ability to do that manual dexterity task at home. Um On the other hand, there's probably resources that are low fidelity ways to simulate medication reconstitution at home where the students might even be able to video themselves with their low quality stuff.
Um To demonstrate to you that they've tried some manual dexterity task that you could then see that they're trying to simulate.
And then if you actually invite the students to figure out tasks, the ways that they're doing this task, they will build the fidelity together as they improve the sort of particular things that are necessary for the task.
Um So that might be an example of ways in which you can leverage your students creativity in designing scenarios or manual dexterity tasks uh from home Catherine.
I don't know if there's other questions you want us to address in the chat. Thank you for moderating the chat.
Zakia demasi asked a question which I did attempt to answer about using um managing simulations or, or clerkship experiences when the bulk of what we're seeing right now is COVID-19 related.
Um My sense is that we always see a seasonality um in flu or, or, or gunshot trauma, there's a seasonality to how things show up in the emergency department and practice.
But I wonder if you could speak to ways to mitigate that in learning again. I'll answer first and then Sean feel free to chime in.
Um So to really agree with Catherine's point, even pre COVID-19, there was always seasonal variation in the demographics of, of inpatient or, or other sort of uh disease uh presentations.
So, you know, the argument here is students get it over time across the longitudinal arc of their curricular experiences.
Um Certainly, um there have been a um a a strong desire to minimize inpatient care of, of diseases other than COVID-19 to create space for the surge of cases of clinical COVID-19.
So, you know, some health institutions and some uh crediting bodies and some organizations are reducing the the expectation of the volume of clinical activity that students should be expected to see.
Obviously, we need to make sure we have a minimum bar of what students must see. Um And so those accrediting bodies de determine that the minimum bar, they may be lowering it a bit but not way down.
And, and so there may be some wiggle room in terms of allowing students to have a lower diversity of clinical experience and yet still complete their training.
Um uh I also think that um uh when not if, but when we get past this global pandemic um whenever that happens, those accrediting bodies will likely look for examples in which students can downstream make up some of the missed stuff.
Sean. Yeah.
And I, like, like you, like everybody said, you know, you can have simulated cases to make up for things you actually don't see.
Um And, and the accrediting authorities tend to be pretty uh flexible with exactly how, you know, the, the, the spectrum of, of different clinical scenarios are, are addressed by schools.
Uh again from a, from a medicine side, but this is probably true of almost any specialty. Um You know, a a patient with COVID do doesn't just have COVID in, in the vast majority of cases.
So they're gonna have comorbidities and you're gonna have to manage, not just the COVID, but there are other comorbidities.
Um And so, you know, so even if it's not a cheap complaint of heart failure, um you may have to manage heart failure and, and so, you know, just logging those conditions.
Um So you, you find you find that students actually have e even even if um chief complaint, I guess is, is COVID for, for a disproportionate number of patients.
Um You end up managing quite a wide spectrum of, of illnesses. I think we are caught up on questions.
Um Peter off says stop touching your face, son. I'm uh you know, I'm not touching over here or here.
Thank you, Peter for teasing us. Um uh You know, II wanted to acknowledge uh that um uh there are a lot of resources out there.
Um We have deliberately not been promoting the osmosis resources specifically because we wanted to be uh platform or a agnostic.
If you will, you know, we're wearing our academic hats. Today.
We are both as you saw in those uh sort of title slides affiliated with OSMOSIS. Um I would just add that um there is a resource for educators on the, the osmosis has a landing page for resources for educators that are osmosis produced.
But just like you've seen in the chat feature, lots of you are sharing other resources that are aggregates of different uh high quality resources.
Like all consumers of information, we as health educators need to be a aware of the sources that we're uh seeking and we need to make our own independent judgments of how reliable we think those sources are.
So, you know, as, as you all start to look for shop for either content that you wanna use in your local context and or uh resources that are co produced or uh what is called co curricular content from uh individual producers of content that are not other universities.
Um Just remind you to uh think carefully and deliberately about what your learning objectives are, what you're trying to achieve and whether that that resource, those resources meet your needs.
Thank you. I mean, we have some questions through the question and answer feature.
Uh So, Mits Scott and asked if we have any creative suggestions for students to practice physical examination skills. Um I'm home with a 17 year old and a thirteen-year-old.
So um II could certainly practice uh pediatric and adolescent medicine, physical examination, uh Catherine. Uh I'll take a stab with that too.
Um So, uh when my kids were younger, I did used to bring them uh uh without their permission to my medical students to teach to sort of like developmental milestones.
And so obviously, one gets creative and uh in your educator hats. Um I um long before we had c patients, long before we had mannequins and simulation students would practice their physical exam skills on each other.
I know there are risks associated with that. And so I acknowledge you need to be very careful about that.
Um As long as you ensure the safety of your students or you do your best to ensure the safety of students, you can get very creative with physical exam skill techniques uh that are non invasive um for places that are allowing simulations to occur or simulation centers to continue, then you still have the advantage of mannequins and spa patients.
Yeah. And even if you're by yourself, I mean, if you have access to somebody who is with somebody else, you can guide, talk them through a physical exam maneuver.
So the only thing you're missing is that tactile aspect of it. So you you can do again, almost everything, remotely great suggestion.
Um So uh Laura Weisbrod asked, Lana, was Weisbrod asked in nursing ed, what percentage of face to face uh with patients, clinical learning hours is acceptable to transform to the virtual and distance learning approach.
And have we seen any guidelines from the literature? I can tackle this one.
So um it was Samuel Merritt. Uh It's a nursing school here in San Francisco Bay area.
Uh The California Board of Nursing is responsible for declaring what fraction of simulation is acceptable for clinicals prior to COVID-19, that fraction was set.
Uh The it's 75% of the clinicals need the actual clinical encounters. Um And then um the California Board of Nursing has lowered that bar to 50%.
So that means then therefore that up to 50% of clinicals can now be uh um replaced with simulation. Um different health professions have different bars on that.
I know that physical therapy has a different bar and you can see some other uh uh participants sharing their experiences and their local.
So thank you, Martha about Mains being 50%. So, so I think that there isn't to my knowledge any literature about that, I haven't personally looked for the literature on that.
Um And even if there is literature, it's all pre COVID-19. And so I think the COVID-19 pandemic is, is uh appropriately asking accrediting bodies and licensing agencies to reassess their prior bars.
And so I think that that those institutions are generally conservative and they may move slowly and a global pandemic is a challenging time to move quickly.
But I would suspect and anticipate that a lot of their accrediting bodies are going to modify their bars to allow for flexibility as each institution and each uh health profession designs uh created ways to address clinicals.
Wonderful. We got another great question.
Um uh More of a comment that uh emergency online teaching um which uh we're now starting to call E RT emergency remote teaching uh is causing anxiety for students and teachers and that many of us aren't um aren't comfortable teaching remotely.
Um So I think that that nods to a really important question about, are we doing distance learning or are we doing emergency remote teaching uh as an instructional designer.
Um and, and educator, I would say the answer is we're, we're not doing by and large, very good uh distance learning yet because we are learning right?
When we do something quickly, we just don't often have the infrastructure in place to line up those assessments. Um Sean, do you, how many times?
I think it's a lot of it's a lot of time to be nervous about failing, you know. Um, I think just, uh, nobody's, nobody's gonna judge you.
I II, well, my, my, my personal point of view is that we shouldn't be focusing on what, uh, the, the judgments other people might be passing on us at a time like this.
We should just be doing the best we can and, you know, come what may and, and, you know, and so II think I, II think that's where this, this, this, I'm scratching my nose.
Sorry. Um, but I think that's, that's where this, uh, this tension between like, is it emergency remote teaching versus, is it online learning?
I mean, it's online learning, right. Um, it is, but it, the, it's very bizarre and hastily, uh, put together online learning.
So it's not the best of online learning. It's online learning though.
And I think if, as long as we just recognize that there's a nuance there, um, then people will, will be ok with it. But, uh, you know, again, II think everybody's nervous, um, about everything these days.
Um, and all we can really do is, is sort of take things day by day and do the best that we can with, with the role that each of us has.
And, um, and, and II think, you know, to the extent we can also forgive others if, if we think that maybe they're not doing as well as, you know, again, II just think, I think it is hard and II think that um do the best you can and don't worry so much about the judgment other people are gonna pass as, as long as you know.
Yeah, just because this is, this is hard. So totally, totally agree with you.
I'll make three points first in terms of our own wellbeing as educators, I did produce an osmosis video that's uh free on our youtube channel about taking care of ourselves.
So we can take care of our students and some suggestions on how to do that. Um A as to that sort of um uh what do we call it, the sort of imposter syndrome or fear of failure.
So um I remember years ago learning what, what I was taught was called the 70% rule in medical education. I think this applies in other health professionals education.
If you get an innovation up to 70% of what you want it to be, go ahead and launch it because thankfully in health professions, education and when we make mistakes, it's not life or death because it's not real patients thankfully.
And so, and the other good news is that we get to iterate and improve our innovations for the next cycle of students. So we will improve it.
And if we waited until we got it to 100% that last 30% would take so long we wouldn't innovate. Um And again, um we can, uh Sean is right, like our students get that this is unheard of.
None of us have done this before. None of us have lived through a global pandemic before.
So I think being permissive of yourself to try and stumble and um we say in simulation, I think this is true in all of our work.
Um When we make mistakes in simulation, they are not crimes to be punished, they're puzzles to be solved. And the same could be said for all of our innovations in emergency remote teaching or in online or flip classroom or converting what we used to do to what we're doing.
Now, I really a part of our goal here in, in giving lots of space and time uh to the participants was to hear your examples.
So we can all let those creative juices uh flow from this discussion, right? I think we are caught up on um on questions unless uh um unless Tracy, um mckay uh be would like to uh would like to talk.
And if so I'll figure out how to unmute you Tracy. Um There was a question about uh how, how nursing programs are approaching this and she said that they're using Zoom to work through online simulated experience uh for nursing experiences.
Um and having the students create teaching videos to demonstrate skills on what they have available themselves, their Children, dolls, stuffed animals, etcetera.
Did, uh, did you wanna add some more color to that? Tracy?
I think that's lovely. I put you on this.
Can you hear me? Yes.
Wonderful. Hi.
Hi. Um, so I'm, um, a nurse educator from Saskatoon, Saskatchewan, Canada.
And, um, of course, we did a lot of this on the fly. But, um, again doing the best with what you've got and um, the finding out how many amazing resources are actually available um out there and even just tweaking them um to meet your, to meet your own needs.
So, um, I wasn't exactly, mm, wasn't exactly 100% on board with potentially some of the resources that um, our uh university chose to utilize.
Um, because I felt that there were better resources out there that I could utilize, but I did um take what was what we were allowed to use and then tweaked it um to meet our own needs.
So there was some great simulation um events that we used that could simulate a number of things. So for instance, in nursing, uh one example that I'll just speak to was um a child with, I teach pediatrics.
So, uh a child with meningitis that a medication error was made on and then the whole process of reporting a medication error and um, and working through, of course, an assessment of a child with a neurological um disease.
And so II just created kind of using the simulation and the premise of the simulation to um create a, like a powerpoint with visual cues to help my students, you know, work through a, a neurological exam to look at the safety of the setting when they walked in.
Um So, of course, I found a picture um that had a child in a bed, had a ton of toys and no seizure precautions um in place.
So they had to pick up on the fact that there were no sec seizure precautions in place, what things they would be looking for.
Um And then we went on and, and it was actually amazing, almost all of the students made the medication error um because they didn't look at the medication label that had was put up on the screen to do their, their three checks.
They all explained to me that they would do their three checks and all the, you know, different moments of right medication.
But they all made the error because when they were looking at the screen, they didn't pick up on the fact that it was the wrong antibiotic, which was really valuable for me.
And I think an amazing lesson for them. Um Not to assume that the medication that is being given is the correct.
We're also dependent on technology and not looking sometimes at the the obvious. And that is the picture that's right in front of your face.
Um So there was some great learning experiences that came out of that. Um And then the creation of assignments where, and I was amazed because my students are all at a distance, um how they collaborated and worked together to create a teaching video um for Children based on their different growth and developmental needs.
So they had to take that knowledge of, you know, how would you speak to a adolescent versus a preschooler child? Um to teach the very same specific um entity kind of thing.
And so uh they created these amazing, amazing videos or like a puppet show um for a preschooler and school age Children um to teach them about germs and washing your hands like it, it was actually uh um amazing uh at where the students went with things and then there were some other opportunities where they could potentially look at creating policy um which they never get the opportunity to, but we teach them that they need to do it.
So, yeah, there was lots of and, and then that's only the tip of the iceberg. Thank you for sharing that lovely story.
Um Amin, did you want to respond? And then we'll, we'll do a wrap up as we are at the top of our hour.
Sure. Uh Tracy again, thank you.
Um um One comment um you hinted at um it as individual faculty, you have like individual resources, you might recommend then of course ones that you are subscribed to or your institution subscribed to and what your resources your institution endorses versus allows.
And so obviously, there are layers of that but uh I think innovative faculty can seek resources. There's this joke in medical student education in the United States that every med school suffers from the NIH syndrome are not invented here.
And the problem is we've all been teaching and working in isolation and the more we distribute and collaborate, the better and the more we share resources, the better.
Um Catherine has asked me, I put my email in the chat. Uh II wanted to let you all know that we do have an osmosis list serve that we curate of educators at, at institutions.
And so if you'd like to join that, we may be able to use that to continue to share stories with each other of, of best practices and innovations and lessons learned in our own innovations.
So I think uh Catherine, you had uh we're gonna turn it back to wrap up and I forgot exactly what we're doing with wrap up, but I know you remember.
So let me pass it back to you. Excellent.
Um So Sean, if you'll bring us to the next slide. Uh So first, thank you.
Thank you everyone for joining. Uh We hope that you'll join us next week.
We'll be uh we'll be talking on Friday about uh raising the line academic productivity and personal wellbeing um for educators during COVID-19.
So we would love to, to have you back. Uh If you have any questions, uh if you want to join the list of Martha, I see your comment.
Um Please email me Catherine on the next slide. Sorry, Catherine at osmosis.org.
We wish you health. And um thank you again for more info.
Visit our medical educator page at osmosis.org/educators.
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