SIMULATION- BASED MEDICAL EDUCATION (SBME) IN HOMOEOPATHY

HOMOEOPATHY

1 2

Dr.SmithaMadhavan,Dr.SanilKumar.M.C

1DepartmentofOrganonofMedicine,Govt:HomoeopathicMedicalCollege,Kozhikode,Kerala,India.

2DepartmentofForensicMedicineandToxicology,Govt:HomoeopathicMedicalCollege,Kozhikode,Kerala,India.

ABSTRACT

Simulationbasedmedicaleducationisaninnovativeteachingandlearningmethodology Simulationisagenerictermthatreferstoanartificialrepresentationofarealworld process to achieve educational goals through experiential learning. Simulation based medical education is defined as any educational activity that utilizes simulationaidestoreplicateclinicalscenarios.Itenhancesknowledge,skill,andbehavioralaspectsofthestudentstoalargeextend.TraininginSBMEisprovided mainlywiththeaidofsimulators,rangingfromlowtohighfidelityandthetrainingcanbegiventostudentsinarisk-freeenvironment.

CurriculumofHomoeopathicmedicalgraduationcourseinsiststoteachalltheaspectsofbasicmedicalsciencealongwithspecificHomoeopathicsubjects.SBMEis notareplacementtootherteachingmethodologies,insteaditactsasanadditionalaid.NationalcommissionforHomoeopathyhastakenanewinscriptiontoinclude skilllabtrainingasapartofundergraduatecurriculumintheirrecentlyreleasedsyllabusdraft.EnhancementofProficiencyamongthescholarscanbeassuredthrough acquisition of both knowledge and clinical skills. Difficulty in application of theoretical knowledge to management of patients is the main problem faced by undergraduates.Inthiscontextitisworthtobuildupclinicalcompetencybyprovidingexperientiallearninginacontrolledsafeenvironmentthroughsimulationbased medicaleducation.It will maketheclinicaltrainingmore standardizedand to achievethis goal, allthe facultiesneedto be trainedand equippedwith alllevelsof simulationtechnologiesinmedicaleducation.

KEYWORDS:Simulation,medicaleducation,experientiallearning,Homoeopathy,clinicalscenario,virtualreality

INTRODUCTION:

Theentireworldisdisruptedbytheemergenceofthepandemic-covid19andits negativeimpactiscreatingproblemsineveryaspectofhumanlife.Themedical educationsystemistheonewhichisbadlyhitbytheemergenceofCovid-19,asit failedtoagreatextendinimpartingpatient-orientedtrainingtomedicalgraduatesandpostgraduates. Thepresentscenariocompelledustorethinkaboutthe conventional methodologies of teaching and learning and consequently educational systems are transformed from a state of institutional education to digital platform. Medical education is also shifted towards experiential ('hands-on') medicallearning;however,applyingthisconcepttorealpatientsislessacceptable to society and is subject to legal and ethical issues. Currently we have immensesourcestoacquiretheoreticalknowledgeabouteverythingwithinseconds through worldwide connectivity, so also in health-related issues. Simulationbasedmedicaleducationisapartofsuchtechnology,whichisemergingas aninnovativeteachingandevaluationmethodology Itisrecommendedthatthe technology-enhanced simulation training in health professional education improvesknowledge,skill,andbehavioralaspectstoalargeextendandmoderateeffectsforpatient-relatedoutcomes.(1)Thisarticleisdescribingthefundamentalsoftheabovesaidteachingmethodology,andtheaimistomakeallthe health science faculty aware of the concept of simulation-based teaching and learningtoimparteffectivetraininginHomoeopathicmedicaleducation.

DISCUSSION:

Experiential learning is the key element of Simulation to achieve educational goalsusingsimulators.Therearedifferenttypesofsimulatorsaccordingtothe degreeoftheirresemblancetothereality,or'fidelity',fromlowfidelitytohigh fidelitysimulators(2).Thisresearchprovenmethodprovideshandsontraining andthestudentortraineerequiredtorespondtotheproblemsassheorhewould undernaturalcircumstances.

This Complementary teaching method in medical education is not meant for replacingtraditionalmethodsofteaching,buttoaddto”.AdvancedSBMEcan providerealisticrepresentationsofcomplexclinicalenvironmentsandalloweducators to alter patient reactions and responses in ways unattainable with actual patients.(3)

CurriculumofHomoeopathicgraduationcourseinsisttoteachalltheaspectsof basic medical science and specific Homoeopathic subjects and majority of the teaching faculties are following conventional teaching aids for teaching and learning. Simulation methodologies are not gained overhype in Homoeopathic medical education as it is not made mandatory by the central council for Homoeopathy.EventhensomeoftheHomoeopathicmedicalcollegesarerunningskilllabseffectively EnhancementofProficiencyamongthescholarscan beassuredthroughacquisitionofboththeoreticalknowledgeandclinicalskills. Difficultyinapplicationoftheoreticalknowledgetomanagementofpatientsis themainproblemfacedbyundergraduates(2).Inthiscontextitisworthtobuild up clinical competency by providing experiential learning in a controlled safe

environmentthroughsimulationbasedmedicaleducation.(4)

Experiential learning is an active process during which the learner constructs knowledge by linking new information and new experiences with previous knowledge and understanding (5). Development of clinical competency leads thelistofadvantagesofmedicalsimulation.Therebyimprovespatientsafetyand reducehealthcarecoststhroughtheimprovementofthemedicalprovider'scompetencies. Clinical competency refines the ability of communication skill, historytaking,professionalattitude,awarenessofethicalbasisofhealthcare,physical examination, therapeutic skill, resuscitation skill, clinical laboratory skills, diagnostic skills, critical thinking, clinical reasoning, problem solving, team work,organizationalskill,andmanagementskills(5).Thesearetheareastobe givenprimeimportanceinHomoeopathicmedicaleducationtoo.Thefaculties are to be well equipped for offering such an effective training for the budding Homoeopathsforensuringpatientsafety

Itpromotesfacultyimprovementandteam-basedlearning(6)andcanbeusedfor evaluation and assessment of students more accurately (5) Interprofessional approaches to learning and health care can be promoted through this emerging methodology (7).

Thepresentscenarioofmedicaleducationwithrealpatient-orientedtrainingis creatingbiasinprovidingequalchancesforlearningtoeverystudentsespecially incaseofrarediseasesandinunexpectedemergencies.(7)

Teaching and learning through Clinical scenarios, use of simulation manikins, trainingwithstandardized/simulatedpatientsandvirtualsimulatorsarenowin use under SBME.All these modalities may be incorporated in Homoeopathic medicaleducationforenhancingclinicalcompetencyespeciallyinindividualizingthepatientthroughcasetaking,developingskillsininvestigationsanddiagnosisandmanagementofthecase.Wecandesignclinicalscenariosorsetsimulated patients to teach different approaches of Homoeopathic interventions in managementofcasesaccordingtodifferenttypesofdisease.Elicitingcharacteristic symptoms, case analysis and evaluation and totality construction are the otherareaswherestudentsfinddifficultyinpractice.Repeatedtrainingthrough clinicalscenariosofferproficiencyintheseaspects.

Virtual reality systems are emerging technologies that have drawn scientists' attentiontoitspotentialbenefitforrehabilitation.(8)

Terminologiesinsimulation: Clinicalscenario:

Aftersettingthelearningobjectives,asituationiscreatedwhichisthereplicaof therealone,mostlycarriedoutbyateaminasimulatedenvironment.Itcanbe videotaped for immediate feedback to participants during debriefing sessions. Debriefing initiates discussions and make sure that all the learning objectives werecovered.(2)

Debriefing: Canfocus botharoundthecognitiveprocess involvedintherecognitionof the problem, the implementation of the management guidelines and the technical levelatwhichtheabilityofthelearnertoapplyrulesandappropriateresponsesin astressfulsituationisevaluated.(2)

Simulators: High fidelity simulators – can respond, blink, eye movement eg: METI human patientsimulator,Noelle(obstetricsimulator)

Medium fidelity simulator – Harvey (cardiology simulator) can hear sound, pulse,breathingsound

Lowfidelitysimulator–itisstatictoteachbasicsoftechnicalskills,eg:IVtrainer

Virtual reality – advancedhumancomputerinteractionusedinthecaseofhaptic feedbacktoproducefeelingofresistancewhenusinginstrumentsinsimulation environment.

Eg:endoscopic,laparoscopictrainers

Simulatedandstandardizedpatients(2): They are usually, but not necessarily, lay people who are trained to portray a patientwithaspecificconditioninarealisticway,sometimesinastandardized way(wheretheygiveaconsistentpresentationwhichdoesnotvaryfromstudent tostudent).SPscanbeusedforteachingandassessmentofconsultationandclinical/physical examination skills, in simulated teaching environments or in situ.(9)

VirtualReality(VR):

VRistheuseofsoftwaretocreateanimmersive(feelingofbeingthere)simulated environment. Virtual reality is best described as a concept of advanced human-computerinteraction(2).Theyarecommerciallyavailable,soaresimple tosetup,anddesignedforeaseandsafetyofuse.ManyVRsystemsworkwithno faculty required. Learners can go to theVRsystem and take part in simulation whenevertheylike(9)

Eg:ToolsforGeneralAnatomy

YOUisareal-timesimulationofthehumanbodywhichexploreorgansandsystemsinafullyimmersive3Denvironmentinvirtualreality,displaydiseasesin varyingstatesofseverity,andaddtreatmentstovisualizeandunderstandmedicaloptions.(10)

It allows studying any structure of the human body by placing the user inside each one. By allowing virtual immersion in a body structure such as the interior of the cranium, stereoscopic vision goggles make these innovative teaching technologies a powerful tool for training in all areas of health sciences(11)

th September17 isobservedasworldpatientsafetyday ItisreportedthatGlobally,asmanyas4in10patientsareharmedinprimaryandoutpatienthealthcare. Upto80%ofharmispreventable.Themostdetrimentalerrorsarerelatedtodiagnosis,prescriptionandtheuseofmedicines(12)

CONCLUSION:

It is a best standard for education and evaluation. It touches all three domains namelycognition,motorskillsandattitudeofthestudents.Clinicalcompetency hasbeenfoundtobeenhancedthroughmedicalsimulationattheundergraduate andpostgraduatelevels.Experientiallearningthroughsimulationcanplayavery significantrole,notonlyinhospitalsettingsbutalsoincommunitycontextshelpfulincommunityeducationindiseaseprevention,safehealthpractices,nutrition andwellnessthroughsettingupsimulatedruralcommunityvillage.

Teaching should not be simply based on imparting theoretical knowledge and assessment,butshouldbepracticaloriented.SBMEcanbeconsideredasanadditiontoconventionalmethodofteaching.Simulated/standardizedpatients,clinicalscenariosandroleplay,virtualsimulatorsetc.Canbeeffectivelyutilizedto developskillintheareaofperception,systematiccaseanalysisandevaluation, totalityconstructionandindividualizationinHomoeopathictraining.Procedural skills like intra venous infusion, catheterization, IM injections, suturing techniquesetccanbegiventoenhancetheskills.Allthefacultiesmustbesensitized inthisregardthroughworkshopsasaninitialstep.

IngeneralQualityandquantityofresearchinthisareaislimitedandneedmore researchtoconfirmtheeffectiveness(7)

ExampleForASimulationScenarioOfCardiopulmoraryResuscitationIn Adults:

ConductedatGovt.HomoeopathicMedicalCollege,Kozhikodeamongagroup of10postgraduatestudents.

Target: Post graduate students, Govt: Homoeopathic Medical College, Kozhikode

Introduction: Cardiopulmonary resuscitation is a life saving intervention, if it is done in an effectiveway Rateofpatient'ssurvivaldependsonrateandqualityofchestcompressionandventilation. Soitisourdutyashealthcareproviderstomakeourstudents competent to provide effective CPR in emergency This aim may not be achievedthroughpassivelecturingalone.Nowmedicalsimulationhasemerged asateachingandassessmentmethodwhichallowsthelearnertopracticepatient careawayfrombedsideinacontrolledandsafeenvironment.Toensureskillat an expert level the deliberate practice of hands-on training is necessary So we madeanattempttoteachCPRtopostgraduatestudentsofGovt. Homoeopathic Medical College, Kozhikode with the help of a hybrid simulation modality involvingCPRmanikinandroleplay

Background:ThestudywasplannedtomakethestudentcompetentinperformingeffectiveCPRwiththehelpofhybridsimulationmodalityandaimedtoevaluatetheimpactofthissessionthroughpreandposttest Thestudypopulationwasagroupof10postgraduatestudentsfromdifferentdiscipline.

Venue: The simulation scenario was conducted at the simulation lab of Govt. HomoeopathicMedicalCollege,Kozhikode Overview

Title: Simulationscenarioofcardiopulmonaryresuscitationinadults

Author:Dr SmithaMadhavan

Purpose:ToteachthestudentsabouttheeffectivewayofgivingCPR

Date:5.9.2019

Timeschedule: Setup : 20mts Runsimulation : 30mts Debriefing : 10mts Total : 1hr

Targetlearners: Postgraduatestudents

Learningobjectives: Attheendofthesessionthestudentsshouldbeableto:

1. TolearnthealgorhythmofdoingCPR

2. Togiveeffectivechestcompressionandventilation

Clinicalcontext: Anil,aged52years,felldownunconsciouslyontheroadwhilejoggingwithhis wife.Hewashypertensive.Assumethatthepersonwasunresponsive.Nopulse andrespirationonexamination.

Knowledge,skill,attitude: Knowledge: FollowedcorrectsequenceofthealgorhythmofdoingCPR

Skill: Gave effective chest compression which was verified by hearing a click sound while doing it on the manikin and provided effective rescue breathing notedbychestriseinthemanikin.

Event/trigger: Wifewasaskingdistractingquestions.

Patientprofile: Name:Anil

Age:52years

Gender:Male

Vitalsigns:Norespirationandcarotidpulse

Currentmedication:Takingantihypertensivemedicine

Modality:Hybrid(CPRmanikinandroleplay)

Scenariocastmembers:2learners,oneinstructor,andonepatient

Confederate: patient'swife,crowd Equipmentpreparation:CPRmanikin,sheetforsupportofknee

Debriefing:10minutesdebriefingwasdoneafterthescenario.Duringthissessionthestudentscouldbeabletopointouttheirmistakes(scenesafetywasnot checked) and the entire participants opinioned that, simulation provides better and effective learning experience. The candidate who acted in the student role wassohappytoexpresshersatisfactoryfeeling,asshedidagreatjobtosavethe life of a person.All the participants demanded to learn other procedural skills throughthisway

Pretestandposttest:

Pre test and post test were conducted before and after the simulation scenario respectively, to evaluate the theoretical knowledge of the participants by using thesamequestionnaire.ThequestionnaireconsistsoftenmultiplechoicequestionsbasedonthedifferentaspectsofCPR.

Analysisofpreandposttest: Masterchart:

TableshowingPretestresults

Averagescoresecuredbyparticipantsinpretest=4.9

TableshowingPosttestresults

Thefirstquestionwasaboutthe'CAB'ofCPR. Inthepre-test5outof10students(50%)gotitcorrect.Inthepost-test10outof10(100%)gavethecorrect response.

ThesecondquestionwasaboutDepthofchestcompressioninadultswhiledoing CPR.Inthepre-testonly1outof10(10%)gavethecorrectanswer Inthepost–testanalysis,10outof10(100%)gotitcorrect.

The third question wasregardingthepulsewhichwesupposetocheckinadults duringCPR.Inthepre-testanalysis,9outof10(90%)wereabletogivethecorrectresponse.10outof10(100%)gavecorrectresponseinpost–test

ThefourthquestionwasabouttheCompressiontoventilationratioinadultCPR. Inthepre-testanalysis,8outof10(80%)gavethecorrectresponse.10outof10 (100%)gavetherightanswerinpost-test

The fifth question wasaboutRateofchestcompressioninCPR.Inthepre-test,4 outof10(40%)gavethecorrectanswer Inthepost–test,90%gotitcorrect.

The sixth question was about the duration of assessment of the carotid pulse? Only5outof10candidates(50%)gotitrightinthepre-testandalltheparticipants(100%)gotitrightinthepost–test

The seventh question wasabouttheinitialsteptobeginCPR.Outof10,5candidates(50%)gavecorrectresponseinpre–test.Duringpost–test10outof10 (100%)gotitright.

The eight question wasaboutthenumberofcyclesofCPRshouldbegivenin2 minutes. 2outof10(20%)gavecorrectresponseinthepre-test.Duringpost–test,6outof10(60%)gavecorrectanswer

Theninthquestionwasaboutthefullformof AED.9outof10(100%)gavecorrectresponseinpre-test.Inthepost–test,10outof10(100%)gotitrightinthe post–test.

Thetenthquestionwasabouttherecoveryposition.Onlyonecandidategavecorrectanswerinthepretestandintheposttestallthecandidatesgotitcorrect.

Thisconfirmedthateachindividualiteminthepretestsecuredanimprovedscore intheposttest.

RESULTSANDDISCUSSION:

Averagescoresecuredbycandidatesinposttestinposttest=9.5

ANALYSISOFRESULTS:

Theaveragemarksscoredinthepre-testbythe10candidateswere4.9marksout ofamaximum10marks.Inthepost-test,theaveragemarksscoredbythecandidateswere9.5outofamaximum10marks.

Inthepre-testanalysis,atotalof2studentssecured2marks,1studentscored4 marks, 3 students scored 5 marks, 2 students scored 6 marks, and 2 students scored7marks.

In the post test analysis, 5 students scored 9 marks, and 5 students scored 10 marks. The analysis showed significant improvement in the mean score of the participantsafterthesimulationscenario.

Comparisonbetweenpreandposttest

Significant improvement was noted in the average score secured by the candidatesintheposttest,whencomparedtopretest.Thisshowedthatthedomainof knowledgecanbeenhancedthroughsimulationbasedlearning.Competencycan beensuredindoingeffectivechestcompressionandmouthventilation.Student's feeling of being valued among the society and their feeling of self-esteem can generateasparkofmotivation.

This study is intendedto give trainingin cardiopulmonaryresuscitationas, the studentsfromHomoeopathicmedicalinstitutionsareusuallygettinglessexposuretoemergencysituations.

Apartfromteachingtheprocedural skills andbasicmedicalsciencestothestudents, simulation based medical education especially simulated/ standardized patientsand role play, can be effectivelyutilized to develop skill in the vital areasofHomoeopathysuchastheareaofcasetaking, systematiccaseanalysis andindividualization.

Thesetypesofinteractivesessionsaremoreeffectivethanregulartext-bookorientededucation

Allthe10studentsinthelearnersgroupwereprovidedhandsontrainingwiththe CPR manikin after demonstration. Then simulation scenario was conducted. Assessmentwasdone withthechecklistshownbelow

CHECKLIST:

8810.1001/jama.2011.1234(pubmed)

AugDoi:10.1097/SIH.06013e318229f550Pubmed.ncbi.nlm.nih.gov

III. Abdulmohsen H Al-Elq Simulation based medical teaching and learning PMID:22022669 J Family community medicine2010 Jan-Apr; 17(1): 35–40 doi: 10.4103/1319-1683.68787(PMC)

IV PaulBradleg.MedEduc.2006MarMedEduc.2006 March40(3):254-62Thehistoryof simulation in medical education and possible future directions Doi:10.1111/j.13652929.2006.02394XPMID:16483328

V Simulation based team training in health care WalterEppic et al. SimulHealthc. 2011AugDoi:10.1097/SIH.06013e318229f550Pubmed.ncbi.nlm.nih.gov

VI. SylvainBoetetal.MedTeach.2014Oct,Twelvetipsforasuccessfulinterprofessional teambasedhighfidelitysimulationeducationsession(Pubmed)

VII. BurhanuddinAliAkber,Simulatedlearninginruralcommunityenvironment:pushing the boundary Adv Simul 6, 5 (2021). https://doi.org/10.1186/s41077-021-00155-3 (Openaccess)

VIII.SantiagoGonzálezIzardVirtualRealityEducationalToolforHumanAnatomyPMID: 28326490 DOI: 10.1007/s10916-017-0723-6 (pubmed) J Med Syst. 2017 May; 41(5):76.

IX. JackPottleVirtualrealityandthetransformationofmedicaleducationFutureHealthc J.2019Oct;6(3):181–185.doi:10.7861/fhj.2019-0036,https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC6798020//

X. RashmiDattaSimulationanditsroleinmedicaleducation,MedJArmedForcesIndia 2012 Apr; 68(2):167-72. doi: 10.1016/S0377-1237(12)60040-9. Epub 2012 Apr 21, PMID:24623932PMCID:PMC3862660DOI:10.1016/S0377-1237(12)60040-9

XI. https://www.who.int/news-room/fact-sheets/detail/patient-safetyPatientSafety

XII. Jennifer A Cleland The use of simulated patients in medical education https://pubmed.ncbi.nlm.nih.gov/19811162/ Med Teach. 2009 Jun; 31(6):477-86. PMID:19811162DOI:10.1080/01421590903002821