Authentic Learning of Clinical Skills Through AIMST University Model of Ambulatory Care and In-patient Care Simulation.

AIMST University, Malaysia

The lockdown in Malaysia since 18th March 2020 has created a sudden vacuum in the face to face learning opportunity of clinical skills. We had to design and deliver authentic learning of clinical-skills in a simulated environment in the faculty of Medicine, AIMST University, for the under-grad medical students studying in the MBBS program. This is a gist of the principles we have followed to achieve that to the best of the collective ability of the faculty. Guiding Principles in Brief: Structuring of Clinical Teaching-Learning (through years 3 to 5 of MBBS) has been done by adopting RIME framework. We have been following the RIME model since 2019. Briefly, it is to teach and learn, — recording (R) clinical history and physical examination in year-3; — interpreting (I) the clinical case details and the investigation reports in year-4; and — planning management (M) of the case; — how to give follow up advice by patient education (E) in year-5 of the MBBS course. Choice of the Mode of Teaching-Learning: This has been based on the predominant domain as per the revised Bloom’s taxonomy and Miller’s prism/pyramid. Academic freedom was given to each clinical unit to base their choice of the level of clinical experience based on availability of resources, feasibility and priorities. The guiding principle for the choice of learning experience was Dale’s cone of experience. For example, the clinical units with access to real ambulatory cases arranged to get the cases to the simulated bedside discussions. Other units, used hybrid models to the extent possible combining, i) standardized patients, who could give clinical history in a consistent manner, ii) normal volunteers for the students to practice physical examination, and iii) high fidelity simulators to learn perceptual skills of visual, auditory and tactile senses. Ambulatory Care Simulation: Ambulatory (outpatient) care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. The goal is to learn the skills of focused case assessment and advising the patient on home based management of the problem. It is feasible to use some of the clinical students to play the roles of ambulatory cases with a bit of guidance and coaching on key features of the case scenario. The others would then interact with them in layperson’s language to elicit the case history. Several symptoms do not have any abnormal physical findings and are diagnosed based on history alone. These are easy to begin the program of ambulatory care simulation. “AIMST University Model” of simulated In-patient environment: Cognitive realism is more important than physical realism in creating authentic learning environment. Therefore, each clinical unit has planned sustainable and practicable in-patient simulation based on the principles of design stated earlier. We have created a 4 bedded in-patient cubicle to create a realistic milieu. On day-0, the briefing is done on the objectives of the in-patient simulation exercises, which would spread over 3 to 5 days. The students who play the roles of in-patient cases will be initially coached on case details. From day-1, they would plan to narrate their daily progress until they are discharged. The clinical conditions are chosen from the common diseases prevalent in Malaysia. On day-1, the rest of the students are allotted a new patient for clerking. Appropriate Mannequins or videos will be supplemented to present the physical findings of the patient allotted. After an hour of clerking, the clinical instructor will take ward rounds and analyze each case presentation in detail, especially focusing on differential diagnosis, further investigations and initial treatment plan. On day-2, the daily progress report, and the lab reports & images will be the basis for discussions. The focus will be narrowing the diagnostic possibilities, planning further work up if needed, and modifying treatment plan based on test results. This may go on for a day or two more as planned by the unit. On the final day of the simulation exercise, the students will discuss discharge plans and instructions to the patients. Evaluation of the Ambulatory and In-patient simulation: Evaluation of the learning outcomes are assessed daily, using the RIME evaluation format already available with the major clinical units. In addition, feedback has been obtained from the students, from the role-players and from the clinical instructors on the usefulness of the simulated clinical environment in achieving the expected outcomes. The encouraging feedback has consolidated our efforts to persist with the AIMST-model during 2021, the second year of pandemic-associated disruption in face-to-face learning in real-life clinical settings. In conclusion, to the best of our knowledge, our model of longitudinal clinical-clerkship simulation over 4 to 5 days, is an original contribution to Medical Education.

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