AUC Academic Conference 'From Virtual to Reality' The University of Queensland 1996

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Paper Title:

Patients in the Virtual Teaching Hospital

Presenter:

Dr. Edward Hettiaratchi, The University of Sydney

Authors:

Dr. Edward Hettiaratchi, Senior Lecturer, Mrs. May Wong, Lecturer,
Dr Hoang Tran-Dinh, Senior Lecturer,
Faculty of Health Sciences,
Elizabeth Post, Senior Lecturer,
Department of Animal Science,
The University of Sydney.

Ms Christine Anne Brown, PhD student,
Faculty of Education,
University of Wollongong.

(contact details)

Keywords: Multimedia, Teaching

Faculty area: Health Sciences

Introduction and Rationale

The Faculty of Health Sciences at The University of Sydney trains allied health professionals such as Physiotherapists, Speech Therapists, and Occupational Therapists. A large part of the time in the first two years of the curriculum is devoted to the study of the basic sciences (Anatomy, Physiology, Chemistry, Physics and Microbiology) with the clinical subjects being taught mainly in the later years. This approach is based on the syllogism that skilled clinicians use the knowledge of the basic sciences in solving patient problems, that these sciences are basic and therefore students must be exposed to these subjects prior to being allowed to come to grips with the knowledge base of their chosen profession. As a result, students have a poor perception of the relevance of the basic sciences and hence an early loss of motivation to learn. Within the current curriculum the presentation of complex knowledge in a linear hierarchical fashion makes it decontexualised and purely academic. The lack of robustness in the knowledge acquired in these early years through such traditional teaching methods has been a source of frustration for those of us who are engaged in teaching the basic sciences and in this respect we are in agreement with the views of Brown, Collins and Duguid (1989).

Spiro and Jehng (1990) have pointed out that with advanced knowledge acquisition, content becomes complex and application of the knowledge to different situations become more irregular. Under such conditions, linear, compartmentalised, hierarchical and rigidly pre-packaged entities are not suitable. We therefore decided to adopt a constructivist model within which to present the knowledge in basic sciences. The constructivist view of learners places them in an active, purposive mode, taking responsibility for their own learning (Driver & Oldham, 1986). Black et al (1994) have identified six principles of constructivist design, viz.

(1) allowing students to generate their own knowledge where possible in a learning situation;

(2) anchoring the knowledge in authentic situations;

(3) using cognitive apprenticeship where the teacher initially provides the model and then gradually withdraws support until the students can think independently;

(4) situating the knowledge in multiple contexts to facilitate transfer to new contexts;

(5) creating cognitive flexibility with the use of multiple perspectives.

(6) using student collaboration in knowledge construction.

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Case studies provide the context and activity so vital to situated learning. Each case study, however, is also unique, so cognitive flexibility is required to be able to spontaneously restructure one's knowledge, in many ways, in adaptive response to changing demands both within one case and also across different cases. Students are led from simple rote learning and rule-following to a more complex approach which involves integration and application of knowledge and skills from a number of discipline areas to different situations.

The multimedia capabilities of the computer allow us to provide learning materials for students in a form that enables them to actively explore and experience multiple perspectives of a field of knowledge. They can draw on a variety of analogies, observe different dimensions of analysis and tap into the social, emotional and contextual aspects of the cases.

The multimedia presentation of case studies has been used to facilitate learning within a framework of constructivism. While staff have expertise in clinical and basic sciences, teaching, and support for case-based learning, they do not have sufficient programming skills or awareness of recent applications of information technology to learning. Therefore we decided to develop a computer software template, to provide a mechanism for staff to produce learning modules - the Virtual Teaching Hospital (VTH)

The Design Process

The Macintosh platform was chosen because of its superior graphic capabilities and ease of use. The design team opted to prototype the browser interface and template in HyperCard. As the case study material was compiled, the structure of its presentation unfolded. The patient was the prime focus, therefore, it was decided to make the central theme a patient profile. Since the patient was presented within a hospital environment, the profile was made up of critical patient events represented on a time line. Provision was also made for the presentation of numerous views of the patient by a range of different health professionals dealing with the case. This would provide the students with a range of perspectives on the one set of patient data.

As the initial case of a stroke patient profile was being compiled by a clinician, the basis for the clinical decisions was not clear to other team members who lacked expertise in this field. Active discussion of these difficulties led us to realise that the team members were in a position equivalent to that of students who would use the program . This prompted the inclusion of the expert's thought processes in the patient profile so as to explain why certain questions were asked or tests ordered and what the appropriate responses were to patient answers and test results. (refer to (1)"pre-thoughts" and (4)"post-thoughts" in Figure 1). The exposition of these thought processes is an unique feature of the patient profile and provides a means for tapping into the process of hypothesis formulation and self-questioning which is often automatic but not generally shared by experts in such situations as clinical rounds. Teams of health professionals frequently work on cases, but it is not common for one health professional to have access to the thought processes of another. By exposing this process, the relevance and scope of the required content knowledge to formulate such hypotheses is naturally shown.

Figure 1 : Patient Profile

An important feature of the patient profile is a series of student challenges which are used to reveal the basic sciences underlying the clinical reasoning processes as shown in the pre-thoughts and post-thoughts. These student challenges are in the form of questions. Throughout the profile, the feedback to these questions has been adopted as a major learning tool as well as a mechanism of illustrating the relevance of the basic sciences to clinical decision making.

Where it is thought that students can profit from more extensive study of the topic under discussion, references are made to appropriate material accessible through the program or to other resources as indicated by "background information" in the patient profile.

Use of the Patient Profile by Students

Once a patient profile is selected, the students are able to follow the events in the daily hospital life of that patient, including interviews, physical examinations, tests ordered, test results and consultations. Selection of any event enables the student to select one of three levels of presentation of the data. Of these, the most comprehensive level provides access to a detailed analysis of the information, including the pre- and post-thoughts of the health professional dealing with the patient. Student challenges at this analysis level show the basis for the process of hypothesis formulation by the expert and give the student a chance to see the relevance of the subject-based content they are learning, from the perspectives of a range of health professionals. It also enables the students to observe the processes by which a health problem is tackled and the limitations and constraints inherent in these processes. By presenting the necessary complexity of situations across a range of cases some of the requirements for constructivist learning are met.

The case study profiles do not place the learner in a simulation situation. They present the time frame of the case in a retrospective fashion. The student is not selecting the interview question or test they wish performed. This program does not aim to replace the real case with an extremely complex simulation nor is it an attempt to teach diagnostic skills. The students can, however, explore the case at their own pace as often as they like with or without visualising the clinician's thought processes . The specific questions that an author of a case study may like the students to address with respect to that particular case are made available through the notebook icon that appears on the side of the patient profile interface (see "8" in Figure 1) and can be accessed at any time. Students within one health profession are able to gain insight into the way other colleagues may approach the patient, and why certain pieces of information are vital to fellow health professionals. The opportunity is also there to involve the family of the patient, and to let health professionals consider the emotions and thoughts of patient, family and friends.

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Use of the Template by the Academic Staff

In the authoring mode, the template permits the members of staff to construct the patient profile as they wish through the provision of simple palettes, the instructions for the use of which are simple and can be easily taught. This means that the academic staff using the program need have no programming skills.

To complement the application of a complex network of knowledge within a case study, content resources are needed within the VTH for students to pursue material they perceive as clinically important. Here the browser nature of the general hospital interface provides the anchors for many types of content. For instance various rooms within the hospital can provide logical venues to seek out certain kinds of information. By selecting various objects in this graphic environment, students can get more information about various pieces of equipment or learn about various procedures. Such an informative hospital walk has great potential for development which has not as yet been fully exploited. More recent programs such as QuickTime VR will make the simulations more realistic in the future. The library within the VTH provides a central resource for the student. From the library the student is able to access any of the patient profiles in the VTH or other resources internal to the VTH such as a glossary and eventually to resources accessible through the Internet. Recently, a classroom structure has been linked to the library in the VTH to serve as a logical place to find certain subject-based content chunks, the presentation of which conforms to constructivist principles. As befits the evolving nature of the VTH, it is anticipated that interface graphics will continue to change in response to staff-driven design needs.

Challenges to Staff

Staff within the faculty would be provided with the opportunity to develop material related either to a case study, or their content speciality. Staff using the template can enter the multimedia construction process either at a familiar spot - presenting the content of their expertise, or they could tackle the more difficult task of re-structuring material in a way relevant to specific cases. The browser also offers the opportunity to link content software already produced by other learning institutions.

The design of the VTH acknowledges the importance of the teaching staff not only in the production of learning material, but also in the support of this material when it is used with students. Process is the important keyword here, not product. This is an evolving design process within the Faculty, aimed at including staff in the technological innovations, rather than imposing change without consultation. It is envisaged that the nature of the student tasks which drive them through the many resources of the Virtual Teaching Hospital will be determined and developed by staff members. Some of these tasks may be presented on computer, while other staff members may use case material as a stimulus for discussion, or content packages linked in the hospital as resource material for assignments. The wealth of possibilities will be unfolded through use and creative staff initiatives.

Future directions

A courseware browser for use by different schools within the Faculty of Health Sciences has been realised, but this is just the beginning of a very long term process which seeks initially to skill and involve academic staff in the construction and use of information technology for learning. What many staff have yet to realise is the difficulty in presenting material from the varied perspectives of clinical relevance. We believe that the desire to highly structure content and merely map that to the learner's mind has to be overcome, and constructivist principles of learning acknowledged.

In the development and maintenance of a courseware browser and its many associated resource links, staff will come to appreciate the crucial role of resource management - not only its organisation, but also its coding for appropriate use. By experiencing this process, they will share what the student must experience as they seek to build their own personal information system to deal with the complex and ill-structured professional domain they have selected. Hopefully, academic staff will come to appreciate the multiplicity of solutions to the wonderful process of learning, and thus create a range of learning task tools to support students in their difficult journey from novice to expert.

An alternative learning strategy that can be explored is to offer the template to the students to generate their own patient profiles and supporting contents. This would be an even more powerful method of applying the constructivist principles of learning.

The VTH design experience has already provided the Faculty of Health Sciences at the University of Sydney with a considerable challenge - to invest the effort required to move to a situated model of learning which capitalises on the new developments in information technology.

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References

Brown, J. S., Collins, A., & Duguid, P. (1989). Situated Cognition and the Culture of Learning. Educational Researcher, 18(1), 32-41.

Black, J. B., Thalheimer, W., Wilder, H., de Soto, D., & Picard, P. (1994). Constructivist Design of Graphic Computer Simulations. In M. R. Simonson, N. Maushak, & K. Abu-Omar (Ed.), 1994 Convention of the Association for Educational Communications and Technology, (pp. 63-67). Nashville, TN: Iowa State University.

Driver, R., & Oldham, V. (1986). A Constructivist Approach to Curriculum Development in Science. Studies in Science Education, 13, 105-122.

Spiro, R., & Jehng, J. (1990). Cognitive Flexibility and Hypertext: Theory and Technology for the Nonlinear and Multidimensional Traversal of Complex Subject Matter. In D. Nix & R. Spiro (Eds.), Cognition, Education, and Multimedia: Exploring Ideas in High Technology (pp. 163-205). Hillsdale: Lawrence Erlbaum Associates.

Acknowledgements

The Virtual Teaching Project was supported with funds and equipment from :

The project team wishes to acknowledge contributions made by:

Mr Jayachandran, Higher Education Officer, Department of Biomedical Sciences, Faculty of Health Sciences, The University of Sydney.

Ms Nancy Tam, Higher Education Officer, Department of Biomedical Sciences, Faculty of Health Sciences, The University of Sydney.

Ms Marlene Knight, Cockatoo Graphics

Contact Details

Dr. Edward Hettiaratchi, Senior Lecturer,
Department of Biomedical Sciences,
Faculty of Health Sciences
The University of Sydney
P.O. Box 170
LIDCOMBE NSW 2141

Phone: (02) 6466326
Fax: (02) 6466520

e-mail: E.Hettiaratchi@cchs.su.edu.au

Mrs. May Wong, Lecturer, Department of Biomedical Sciences, Faculty of Health Sciences, The University of Sydney.

Ms Christine Anne Brown, PhD student, Faculty of Education, University of Wollongong, Northfields Avenue, Wollongong NSW 2522 Australia

Elizabeth Post, Senior Lecturer, Department of Animal Science The University of Sydney,

Dr Hoang Tran-Dinh, Senior Lecturer, Department of Biomedical Sciences, Faculty of Health Sciences, The University of Sydney.

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