e‐Learning and transfusion medicine

Audits of clinical transfusion practice have consistently demonstrated deficiencies in knowledge and practice that impact on patient safety and in some cases result in death. These deficiencies include transfusion being prescribed inappropriately, administration of blood components using poor processes, documentation deficiencies and inadequate identification of potential transfusion recipients. Improvement needs to be driven by a multifaceted approach that includes robust systems and mechanisms to ensure compliance combined with education of staff. However, education of medical, nursing and other staff involved in the transfusion chain can be difficult. Large numbers of staff, shiftwork, varying levels of background knowledge and limited resources create significant challenges. Consideration of these problems and informal needs analysis defined a web‐based or on‐line learning tool (e‐learning) as being a suitable mechanism to assist hospitals to increase knowledge of staff. An effective e‐learning tool must be engaging, replicate an authentic learning environment, cater for various learning styles and engage the learner in the learning process. This requires knowledge of on‐line learning best‐practice, learner profiles, learning styles and the learning environment, as well as consideration of interface design, motivational tools and knowledge retention strategies. Funding was provided by the South Australian Department of Health, under the BloodSafe programme, to develop an e‐learning tool. This has resulted in a multimedia‐rich programme utilizing video, audio, animations, and case studies and didactic instruction in order to create an authentic learning environment. Learning content includes expert and peer education, case studies, interactive games and puzzles and modelling of best‐practice processes. A flexible learning pathway gives learners control over learning sequence, content viewed and assessment. Learner demographics, progress and assessment tools and records are stored in an SQL database. This tool is available for use by hospitals and healthcare institutions and professionals. Initial use has demonstrated a high degree of acceptance with participants providing strong feedback on the content, learning pathway and ease of use. Further development is being undertaken to add additional modules offering advanced content and/or a broader audience base. The initial implementation of this e‐learning tool is directed at an Australian audience, however, the content is relevant to the wider transfusion scene in the Asia‐Pacific region (and beyond) as a mechanism for educating staff involved in all steps of the transfusion chain.     

Empowerment of patients and communication with health care professionals through an electronic health record

Objective: The aim of this project was to design and develop a personal electronic health record (EHR) in order to support patient empowerment and additionally to enhance their communication and information exchange with health professionals through this EHR. Method: The functionality of a personal Electronic Healthcare Record (EHR) may vary from a simple web-based interface for interactive data entry and data review up to a much more powerful system additionally supporting electronic data/document communication between clinical information systems of primary care practitioners or hospitals and even reminder based support for the empowered citizen, to actively take care of his health, based on relevant disease management programs. It is one means to support patient empowerment, additionally supported by tools for building a patient community. Since storage and communication of data in an EHR comprises sensible personal health data, each of those functions needs specific security and access management requirements to be considered and implemented. Result: Clinical pilot projects are already done or under development.     

Copability,coping, and learning as focal concepts in the evaluation of computerised diabetes disease management

Introduction: Within diabetes care, the majority of health decisions are in the hands of the patient. Therefore, the concepts of disease management and self-care represent inescapable challenges for both patient and healthcare professionals, entailing a considerable amount of learning. Thus, a computerised diabetes disease management systems (CDDM) is to be seen not merely as tools for the medical treatment, but also as pedagogical tools to enhance patient competence. Hypothesis: The unfortunate lack of success for most knowledge-based systems might be related to the problem of finding an adequate way of evaluating the systems from their development through the implementation phase to the daily clinical practice. The following presents the initial methodological considerations for evaluating the usefulness of a CDDM system called DiasNet, which is being implemented as a learning tool for patients. The evaluation of usefulness of a CDDM, we claim, entails clinical assessment taking into account the challenges and pitfalls in diabetes disease management. Results: Drawing on activity theory, we suggest the concept of copability as a supplement to ‘usability’ and ‘utility’ when determining ‘usefulness’. We maintain that it is necessary to ask how well the user copes with the new situation using the system. As ways to measure copability of DiasNet the concepts of coping and learning are discussed, as well as ways this methodology might inform systems development, implementation, and daily clinical practice.     

Virtual biomedical universities and e-learning

In this special issue on virtual biomedical universities and e-learning we will make a survey on the principal existing teaching applications of ICT used in medical Schools around the world. In the following we identify five types of research and experiments in this field of medical e-learning and virtual medical universities. The topics of this special issue goes from educational computer program to create and simulate virtual patients with a wide variety of medical conditions in different clinical settings and over different time frames to using distance learning in developed and developing countries program training medical informatics of clinicians. We also present the necessity of good indexing and research tools for training resources together with workflows to manage the multiple source content of virtual campus or universities and the virtual digital video resources. A special attention is given to training new generations of clinicians in ICT tools and methods to be used in clinical settings as well as in medical schools.     

The diagnosis related groups enhanced electronic medical record

Problem. The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data like diagnosis and procedure codes. In order to enhance physicians’ coding compliance, an easy-to-use interface integrating coding tasks seamlessly into clinical routine had to be developed. A generic approach should access coding and clinical guidelines from different information sources. Methods. Within the Electronic Medical Record (EMR) a user interface (‘DRG Control Center’) for all DRG relevant clinical and administrative data has been built. A comprehensive DRG-related web site gives online access to DRG grouping software and an electronic coding expert. Both components are linked together using an application supporting bi-directional communication. Other web based services like a guideline search engine can be integrated as well. Results. With the proposed method, the clinician gains quick access to context sensitive clinical guidelines for appropriate treatment of his/her patient and administrative guidelines for the adequate coding of the diagnoses and procedures. This paper describes the design and current implementation and discusses our experiences.     

Using n-gram method in the decomposition of compound medical diagnoses

Objective: Our goal in this study was to find an easy to implement method to detect compound medical diagnosis in Hungarian medical language and decompose them into expressions referring to a single disease. Methods: A corpus of clinical diagnoses extracted form discharge reports (3079 expressions, each of them referring to only one disease) was represented in an n-gram tree (a series of n consecutive word). A matching algorithm was implemented in a software, which is able to identify sensible n-grams existing both in test expressions and in the n-gram tree. A test sample of another 92 diagnoses was decomposed by two independent humans and by the software. The decompositions were compared with measure the recall and the precision of the method. Results: There was not full agreement between the decompositions of the humans, (which underlines the relevance of the problem). A consensus was arrived in all disagreed point by a third opinion and open discussion. The resulting decomposition was used as a gold standard and compared with the decomposition produced by the computer. The recall was 82.6% the precision 37.2%. After correction of spelling errors in the test sample the recall increased to 88.6% while the precision slightly decreased to 36.7%. Conclusion: The proposed method seems to be useful in decomposition of compound diagnostic expressions and can improve quality of diagnostic coding of clinical cases. Other statistical methods (like vector space methods or neural networks) usually offer a ranked list of candidate codes either for single or compound expressions, and do not warn the user how many codes should be chosen. We propose our method especially in a situation where formal NLP techniques are not available, as it is the case with scarcely spoken languages like Hungarian.     

Do we need dissection in an integrated problem-based learning medical course? Perceptions of first- and second-year students

BACKGROUND: The introduction of a problem-based learning (PBL) curriculum at the School of Medicine of the University of Melbourne has necessitated a reduction in the number of lectures and limited the use of dissection in teaching anatomy. In the new curriculum, students learn the anatomy of different body systems using PBL tutorials, practical classes, pre-dissected specimens, computer-aided learning multimedia and a few dissection classes. The aims of this study are: (1) to assess the views of first- and second-year medical students on the importance of dissection in learning about the anatomy, (2) to assess if students' views have been affected by demographic variables such as gender, academic background and being a local or an international student, and (3) to assess which educational tools helped them most in learning the anatomy and whether dissection sessions have helped them in better understanding anatomy. METHODS: First- and second-year students enrolled in the medical course participated in this study. Students were asked to fill out a 5-point Likert scale questionnaire. Data was analysed using Mann-Whitney's U test, Wilcoxon's signed-ranks or the calculation of the Chi-square value. RESULTS: The response rates were 89% for both first- and second-year students. Compared to second-year students, first-year students perceived dissection to be important for deep understanding of anatomy (P < 0.001), making learning interesting (P < 0.001) and introducing them to emergency procedures (P < 0.001). Further, they preferred dissection over any other approach (P < 0.001). First-year students ranked dissection (44%), textbooks (23%), computer-aided learning (CAL), multimedia (10%), self-directed learning (6%) and lectures (5%) as the most valuable resources for learning anatomy, whereas second-year students found textbooks (38%), dissection (18%), pre-dissected specimens (11%), self-directed learning (9%), lectures (7%) and CAL programs (7%) as most useful. Neither of the groups showed a significant preference for pre-dissected specimens, CAL multimedia or lectures over dissection. CONCLUSIONS: Both first- and second-year students, regardless of their gender, academic background, or citizenship felt that the time devoted to dissection classes were not adequate. Students agreed that dissection deepened their understanding of anatomical structures, provided them with a three-dimensional perspective of structures and helped them recall what they learnt. Although their perception about the importance of dissection changed as they progressed in the course, good anatomy textbooks were perceived as an excellent resource for learning anatomy. Interestingly, innovations used in teaching anatomy, such as interactive multimedia resources, have not replaced students' perceptions about the importance of dissection.     

The Group Objective Structured Clinical Experience: Building communication skills in the clinical reasoning context

Objective

Students are rarely taught communication skills in the context of clinical reasoning training. The purpose of this project was to combine the teaching of communication skills using SPs with clinical reasoning exercises in a Group Objective Structured Clinical Experience (GOSCE) to study feasibility of the approach, the effect on learners’ self-efficacy and attitude toward learning communication skills, and the effect of providing multiple sources of immediate, collaborative feedback.

Methods

GOSCE sessions were piloted in Pediatrics and Medicine clerkships with students assessing their own performance and receiving formative feedback on communication skills from peers, standardized patients (SPs), and faculty. The sessions were evaluated using a retrospective pre/post-training questionnaire rating changes in self-efficacy and attitudes, and the value of the feedback.

Results

Results indicate a positive impact on attitudes toward learning communication skills and self-efficacy regarding communication in the clinical setting. Also, learners considered feedback by peers, SPs, and faculty valuable in each GOSCE.

Conclusion

The GOSCE is an efficient and learner-centered method to attend to multiple goals of teaching communication skills, clinical reasoning, self-assessment, and giving feedback in a formative setting.

Practice implications

The GOSCE is a low-resource, feasible strategy for experiential learning in communication skills and clinical reasoning.     

Evaluation of Racial Microaggressions Experienced During Medical School Training and the Effect on Medical Student Education and Burnout: A Validation Study

IntroductionMicroaggressions in the learning environment have been documented at various levels of medical training. However, there is lack of data detailing the prevalence and effects of racial microaggressions in medical school. This limits interventions that might improve the learning environment for underrepresented minority medical students (URMMS). This study describes the creation and validation of a survey instrument characterizing the experience of microaggressions in medical school and their impact on medical student education and burnout.MethodsAn anonymous survey instrument was adapted for medical students from the validated Racial and Ethnic Microaggressions Scale (REMS) and distributed to the national listservs of the Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), and the Asian Pacific American Medical Student Association. Responses were categorized into two cohorts: under-represented minority (URM) and non-URM based on self-reported race or ethnicity.ResultsA total of 217 responses were collected from medical students across the United States, with 148 (68.2%) students identifying as URM. URM respondents were significantly (p < 0.05) more likely to report experiencing race-related microaggressions during medical school (55% vs 31%), and to report that these microaggressions contributed to feelings of burnout (62% vs 29%) and compromised learning (64% vs 49%). URM students were significantly less likely to feel that adequate resources were available to address microaggressions (26% vs 39%, p < 0.05).ConclusionsOur results suggest that microaggressions experienced by URMMS can be evaluated using an adapted REMS. Additionally, the experience of microaggressions negatively impact the learning environment, and students feel the availability of sufficient resources to address microaggressions and their effects are lacking. Further research is needed to evaluate microaggressions and their impact on a larger scale. This should be followed by interventions to minimize the frequency and impact of these microaggressions.     

Problem-based learning in medical informatics for undergraduate medical students: an experiment in two medical schools

PURPOSE: The objective of this work was to assess problem-based learning (PBL) as a method for teaching information and communication technology in medical informatics (MI) courses. A study was conducted in the Schools of Medicine of Rennes and Rouen (France) with third-year medical students. METHODS: The "PBL-in-MI" sessions included a first tutorial group meeting, then personal work, followed by a second tutorial group meeting. A problem that simulated practice and was focused on information technology was discussed. In Rouen, the students were familiar with PBL, and they enrolled on a voluntary basis, while in Rennes, the students were first-ever participants in PBL courses, and the program was mandatory. One hundred and seventy-seven students participated in the PBL-in-MI sessions and were given a questionnaire in order to evaluate qualitatively the sessions. RESULTS AND DISCUSSION: The response rate was 92.1%. The overall opinion of the students was good. 69.8% responded positively to the program. In Rouen, where the students participated in PBL-in-MI sessions on a voluntary basis, the students were significantly more enthusiastic about PBL-in-MI. Moreover, attitudes and opinions of students are plausibly related to differences in previous PBL skills. The fact that the na?ve group had two tutors, one trained and one na?ve as the students, has been investigated. Teacher naivety was an explanatory factor for the differences between Rennes and Rouen.     

Learning outcomes in medical informatics: comparison of a WebCT course with ordinary web site learning material

OBJECTIVE: The purpose of this study is to compare whether students' learning outcomes would be better in a designed learning environment (WebCT) than in a conventional web site (WWW) with similar course material but without special learning tools. CONTEXT: Third-year medical students in an introductory course on medical informatics at the University of Helsinki, Finland. METHODS: Students were randomly assigned to a WebCT group (n=39) and a WWW group (n=46). The students in the WebCT group utilized the course material in general discussion groups, special discussions about lectures, quizzes and students' own notes. The WWW group had access only to the course material. The learning outcome was assessed by administering an on-line examination and the learning experience of the students was assessed by an on-line quiz. RESULTS: The course grade was significantly higher in the WebCT group as compared to the WWW group. This finding was more prominent among females. The students of the WebCT group also experienced significantly more improvement in collaboration with the use of computers than the students in the WWW group. CONCLUSIONS: Based on our results, web-based learning seems to be more effective when students are provided with specially designed learning tools.     

Evaluating the knowledge acquisition of lower limb anatomy among medical students during the post-acute COVID-19 era

Anatomy is the foundation of many medical and surgical specialties yet knowledge acquisition and retention among medical students is questionable. Over the years the anatomy teaching environment and teaching modalities have changed, even more so with the onset of the COVID-19 pandemic and the shift to a virtual environment. The aim of this study was to evaluate the knowledge acquisition of applied musculoskeletal lower limb clinical anatomy among first year medical students in Malta following the transition back to face-to-face lectures. The Kahoot online game-based quiz platform was used through a best out of four multiple-choice setting across four sessions. Scores generated by the platform along with frequencies of correctly answered questions were utilized to measure knowledge acquisition. The average scores for each question across sessions were statistically analyzed using ANOVA and student's t-test accordingly. Across the four sessions, the positive percentage response for clinical based questions remained higher than for pure anatomy questions. Anatomy knowledge acquisition appears to be subjective to clinical based knowledge rather than pure anatomy. There may be a plethora of reasons as to this outcome including the misconception that anatomy is not essential for clinical practice as well as the potential aftermath of the COVID-induced virtual learning environment. Further research is merit to ensure that students are provided with the best tools to enhance their knowledge acquisition, both as students and as future doctors.     

A Bayesian approach to generating tutorial hints in a collaborative medical problem-based learning system

OBJECTIVES: Today a great many medical schools have turned to a problem-based learning (PBL) approach to teaching. While PBL has many strengths, effective PBL requires the tutor to provide a high degree of personal attention to the students, which is difficult in the current academic environment of increasing demands on faculty time. This paper describes intelligent tutoring in a collaborative medical tutor for PBL. The main contribution of our work is the development of representational techniques and algorithms for generating tutoring hints in PBL group problem solving, as well as the implementation of these techniques in a collaborative intelligent tutoring system, COMET. The system combines concepts from computer-supported collaborative learning with those from intelligent tutoring systems. METHODS AND MATERIALS: The system uses Bayesian networks to model individual student clinical reasoning, as well as that of the group. The prototype system incorporates substantial domain knowledge in the areas of head injury, stroke and heart attack. Tutoring in PBL is particularly challenging since the tutor should provide as little guidance as possible while at the same time not allowing the students to get lost. From studies of PBL sessions at a local medical school, we have identified and implemented eight commonly used hinting strategies. In order to evaluate the appropriateness and quality of the hints generated by our system, we compared the tutoring hints generated by COMET with those of experienced human tutors. We also compared the focus of group activity chosen by COMET with that chosen by human tutors. RESULTS: On average, 74.17% of the human tutors used the same hint as COMET. The most similar human tutor agreed with COMET 83% of the time and the least similar tutor agreed 62% of the time. Our results show that COMET's hints agree with the hints of the majority of the human tutors with a high degree of statistical agreement (McNemar test, p=0.652, kappa=0.773). The focus of group activity chosen by COMET agrees with that chosen by the majority of the human tutors with a high degree of statistical agreement (McNemar test, p=0.774, kappa=0.823). CONCLUSION: Bayesian network clinical reasoning models can be combined with generic tutoring strategies to successfully emulate human tutor hints in group medical PBL.     

Which clinical decisions benefit from automation? A task complexity approach

Objective: To describe a model for analysing complex medical decision making tasks and for evaluating their suitability for automation. Method: Assessment of a decision task's complexity in terms of the number of elementary information processes (EIPs) and the potential for cognitive effort reduction through EIP minimisation using an automated decision aid. Results: The model consists of five steps: (1) selection of the domain and relevant tasks; (2) evaluation of the knowledge complexity for tasks selected; (3) identification of cognitively demanding tasks; (4) assessment of unaided and aided effort requirements for this task accomplishment; and (5) selection of computational tools to achieve this complexity reduction. The model is applied to the task of antibiotic prescribing in critical care and the most complex components of the task identified. Decision aids to support these components can provide a significant reduction of cognitive effort suggesting this is a decision task worth automating. Conclusion: We view the role of decision support for complex decision to be one of task complexity reduction, and the model described allows for task automation without lowering decision quality and can assist decision support systems developers.     

Resource implications of a knee referral

Introduction: The latest government targets state that by the end of 2005 the maximum waiting time for an outpatient appointment will be 3 months. These recommendations will not only increase the size of the outpatient clinics, but also the resources required thereafter. The purpose of this study was to analyse the outcome of new patient referrals to one knee outpatient service in order to quantify the resources required to investigate and treat these patients. Method: All new patients attending one consultant's knee outpatient service in the time period January 1st 1997 to December 31st 1997 were prospectively entered into a database recording patient details, source of referral and diagnosis. Eighteen months after the time period a cohort of 200 patients was randomly selected and the case notes were analysed. The number of outpatient appointment episodes, MRI scans, physiotherapy referrals and surgical episodes generated were recorded for each patient. Results: Analysis of the initial database records show that a total of 662 new knee referrals were seen in 1997. Fifty-two percent (341) were made up of the five most common diagnoses, these being osteoarthritis, anterior knee pain, anterior cruciate ligament injury, medial ligament injury and medial meniscus injury. Retrospective analysis of the 200 patient notes revealed that these patients required a total of 499 outpatient episodes, 43 MRI scans, 180 courses of physiotherapy and 93 surgical episodes (53 elective and 40 emergency). These figures can be used to predict the resources that would be required by all new patients seen in an outpatient knee service in a year. Discussion: Each new patient that enters the cycle of investigation followed by treatment must be met by extra resources. If this does not occur the net result will be that although government targets may be met, the time taken to complete each patient episode will become longer. It is imperative that before an agreement is made to see new patients the resources required to manage them are in place.     

Study of some of the mechanisms involved in the prevention against Salmonella enteritidis serovar Typhimurium infection by lactic acid bacteria

The possible mechanism exerted by different lactic acid bacteria (LAB) in the protection against Salmonella enteritidis serovar Typhimurium (S. typhimurium) infection was determined. LAB was administered to BALB/c mice, and the animals were subsequently challenged with S. typhimurium. The inhibition of the translocation of S. typhimurium in the liver was correlated with a decrease in cellular apoptosis determined in slices from the small intestine of mice. The microbiocidal activity of peritoneal macrophages was increased by Lactobacillus delbrueckii subsp. bulgaricus and Streptococcus thermophilus, but not for the probiotic strain L. casei CRL 431. The levels of IFNγ and Bcl-2 positive cells in the small intestine of mice fed with the LAB were also determined by immunofluorescence. Using in vivo studies, we demonstrated that the biological and immune mechanisms induced by the LAB studied were different for each bacterium and were mediated by anti-S. typhimurium S-IgA microbiocidal activity and/or cellular apoptosis inhibition of infected immune cells.     

Cognitive simulators for medical education and training

Simulators for honing procedural skills (such as surgical skills and central venous catheter placement) have proven to be valuable tools for medical educators and students. While such simulations represent an effective paradigm in surgical education, there is an opportunity to add a layer of cognitive exercises to these basic simulations that can facilitate robust skill learning in residents. This paper describes a controlled methodology, inspired by neuropsychological assessment tasks and embodied cognition, to develop cognitive simulators for laparoscopic surgery. These simulators provide psychomotor skill training and offer the additional challenge of accomplishing cognitive tasks in realistic environments. A generic framework for design, development and evaluation of such simulators is described. The presented framework is generalizable and can be applied to different task domains. It is independent of the types of sensors, simulation environment and feedback mechanisms that the simulators use. A proof of concept of the framework is provided through developing a simulator that includes cognitive variations to a basic psychomotor task. The results of two pilot studies are presented that show the validity of the methodology in providing an effective evaluation and learning environments for surgeons.     

Integration of internet-based genetic databases into the medical school pre-clinical and clinical curriculum.

Over the past several years, the field of medical genetics has continued to expand and is now impacting a broad range of medical care, mainly due to rapid advances in genetic technology and information generated by the Human Genome Project. Physicians from multiple disciplines will need to become familiar with genetic principles, and the availability of genetic databases on the internet is a valuable resource for medical students and physicians.To integrate these tools into medical student training, the University of Chicago Pritzker School of Medicine set out to develop multiple, interactive, case-based, educational sessions in the pre-clinical and clinical curriculum, designed to reinforce basic principles taught in the pre-clinical genetics class and demonstrate the usefulness of genetic information accessible via the internet in the clinical setting.Two interactive sessions and a self-assessment exercise were developed. The sessions took place in a computer classroom where each student had access to the internet and could work independently. The sessions used case-based scenarios to help students become familiar with internet based resources and demonstrate how genetic information can affect medical care.The sessions were well received by the student participants with 99% agreeing that the material was useful and important to clinical medicine. In a follow-up questionnaire 1/3 of the students reported using the databases presented during class in a clinical setting.