Teaching Versus Learning and the Role of Simulation-Based Training in Pediatrics
Article Outline
Teach: To impart knowledge of or skill in; give instruction in.1
Those of us in academic medicine carry a great responsibility, that of preparing the next generation of health care professionals to care for their future patients. Consequently, we take great pride in our skill as teachers; indeed, our employment is directly tied to this skill. But is it possible that our focus on teaching is misplaced?
Learn: To acquire knowledge of or skill in by study, instruction, or experience.1
What is the difference between teaching and learning? It is clear from the foregoing definitions that teaching is something that is done to trainees (consequently, a passive exercise from their viewpoint) while learning is something that trainees (actively) do themselves. Acknowledgement of this difference mandates a reexamination of how we think about education and training. In other words:
| Do not ask? | Instead, ask: |
|---|---|
| Whom do we teach? | Who are the learners? |
| What do we teach? | What can be learned? |
| How do we teach? | How is learning best facilitated? |
It is important to appreciate the fact that not everything that is taught is necessarily learned. Consequently, our focus should be on the learning environment rather than on the teaching environment. Let us briefly examine these important questions.
Who are the Learners?
Today’s learners are independent, self-directed, internally motivated adults who seek immediate applications of their knowledge.2 They are professionals for whom acquisition, recall, and application of content knowledge, while providing an essential foundation for delivering care to their patients, nevertheless is inadequate preparation for the complexity of their real-life practice of medicine. They want tomorrow’s information today, delivered to them in a format that can be accessed at their convenience and in a language that they can understand. They are connected with cell phones, MP3 players, and laptop computers with wireless internet access and Firewire ports for rapid downloads of digital data. The typical medical student graduating in 2007 was born 12 years after man first walked on the moon, has never used a manual typewriter or rotary dial phone, and has never existed in a world without the internet. These learners are unlike previous generations in many ways.
What Can Be Learned?
There are 3 “skill sets” that may be acquired and refined: (1) what we know in our brains (cognitive skills, or content knowledge), (2) what we do with our hands (technical skills), and (3) what we do to use the first 2 skill sets while caring for patients while working under realistic time pressure (behavioral skills). Content knowledge is the skill set most familiar to and most frequently assessed by (through written or online tests) in learners. Technical skills are more important for some pediatric subspecialties than others and are most commonly evaluated by subjective assessment of performance of such skills at practice stations (isolated from the pressures of the real environment) or while caring for real patients. Behavioral skills, such as leadership and effective communication, are critically important to successful patient outcomes.3 Unfortunately, these important skills are rarely specifically addressed during the training of health care professionals.
How is Learning Best Facilitated?
For the most part, the current paradigm of training consists of reading about patients and their diseases, observing senior colleagues caring for patients, and finally assuming graduated responsibility for direct patient care. It is presumed that completion of a training period implies competence; yet, competence is more a life-long journey rather than an end destination. The limitations to this paradigm are obvious. Many current training strategies do not take into account that learners have different strengths, weaknesses, and life experiences; that they learn best by doing rather than observing; and that they acquire and retain different skills at different rates. Despite the fact that training periods are most frequently defined by time, there are little objective data concerning the length of time necessary for the initial acquisition of skills and the frequency and intensity of ongoing practice required for the maintenance of those same skills. Although current training strategies focus primarily on the individual learner, much health care is delivered in collaboration with a multidisciplinary team rather than by individual practitioners. Finally, training that relies almost solely on the accumulation of actual clinical experiences is subject to the “education by random opportunity” that occurs when learning objectives are limited by the diseases that come through the door of the hospital or clinic (personal communication, Thomas Krummel, MD, Jan 16, 2003). Such a training strategy provides inadequate preparation for those rare but potentially devastating events that we all face if we practice medicine long enough. Learning is best facilitated when the training is tailored to meet the needs of trainees as adult learners. This means that it must be dominated by active rather than passive learning activities; integrate cognitive, technical, and behavioral skills; be based on achievement of skills rather than on time; and incorporate aspects of team performance.
So, what does this mean for those of us who are “teachers”? We must facilitate rather than dominate the learning process. We must use technology to optimize rather than overwhelm the educational experience while meeting the expectations of the learners. We must appreciate that time with learners should be spent in active rather than passive learning opportunities and provide relevant and challenging immersive experiences in training environments that have high fidelity to the real environment.
But how can this be done? Successful examples exist in numerous other domains where the risk to human life is high. Simulation-based training is defined as a methodology for realistically recreating the key visual, auditory, and tactile cues of actual situations to provide training experiences that closely mimic the conditions encountered when working in the real environment. Simulation-based training is standard in commercial aviation, aerospace, nuclear power, and the military and is now being used increasingly in health care as well.
Simulation-based training provides many advantages over traditional methodologies. Because patient simulators replace humans, there is no risk to patients; invasive procedures can be practiced without fear of patient harm or medical liability. Simulator experiences can be scheduled at convenient times and structured so that specific learning objectives are consistently achieved. Simulation-based training is an ideal methodology for allowing learners to incorporate and practice all 3 of the skill sets described earlier, and it easily accommodates multidisciplinary teams. Because it can be scaled in intensity to meet the needs of learners at all levels of experience, it can be used to foster both the acquisition and maintenance of skills. Faculty efforts to facilitate learning are more easily prioritized and documented in the simulator than in the clinic or ward, where multiple other responsibilities must be met. Although little supporting data currently exist, it can be hypothesized that learners who participate in simulation-based exercises likely will be better prepared and will need less supervision when entering the real clinical domain, resulting in improved patient safety and faculty productivity.
Challenges exist in bringing simulation into the mainstream of pediatric training. Metrics capable of assessing all 3 skill sets must be developed, validated, and implemented. Although the objective assessment of content knowledge has long been achieved through written and oral responses to multiple-choice and open-ended questions, the evaluation of technical and behavioral skills has proven more elusive. For example, the technical skill of intubation may be broken down into multiple elements and evaluated as such, yet in the end what matters the most is whether the patient is intubated successfully and safely, not the summary of the trainee’s scores on each individual step of the procedure. Similar problems exist in assessing behavioral skills: How does one define and score skills such as leadership and communication? An evidence-based approach to skill assessment will require collaboration with professionals in other domains and usher in a field of empirical investigation that is relatively new to pediatrics.
Analysis of the costs and benefits of simulation-based and traditional training are needed to determine where simulation offers the optimal learning experience. Departments and schools must recognize that the nature of higher-fidelity, hands-on, simulation-based training mandates smaller groups of learners and a higher teacher-to-learner ratio (compared with more passive activities, such as lectures) and reallocate resources accordingly. Faculty must be reprogrammed to cede more control of and responsibility for the learning process to the learners. For learners to better appreciate their strengths and weaknesses, they must be given the key visual, auditory, and tactile cues so that they can display authentic skills when working in the simulated environment. These cues come from the patient simulators, people, and equipment in the training environment. Pediatric patient simulators are becoming more realistic and cost-effective, but their development needs to be driven and guided by pediatric professionals, not their adult counterparts. A successful example of such an effort is exemplified in a document published online by the American Academy of Pediatrics that spells out the characteristics of a neonatal patient simulator necessary to achieve the learning objectives of the Neonatal Resuscitation Program.4 Although standardized patients have been used for both training and high-stakes examinations in health care, such actors are not able to realistically portray the anatomic and physiological changes seen in a critically ill patient, and it is not ethical to practice invasive and/or risky procedures on them. Therefore, the development of suitable neonatal and pediatric patient simulators is an important step in achieving sustained success in this area. Finally, if simulation is ever to be used for high-stakes evaluation, then appropriate assessment tools must be developed and validated.
Although no one wants to “practice” on real patients, we have even less desire to do so when that patient is someone’s child, especially in situations in which a wrong move may result in harm or even death. Higher-fidelity simulation-based training in health care began in the adult domains of anesthesiology and critical care. One of the first such efforts in pediatrics began in neonatal-perinatal medicine a decade ago.5 Simulation-based training is revolutionizing health care; current draft legislation (the SIMULATION Act of 2007), if passed into law, will establish simulation as the standard for training in health care just as it is in other high-risk domains (see the Advanced Initiatives in Medical Simulation [AIMS] home page at http://www.medsim.org).
As pediatricians dedicated to the health and well-being of children, we not only need to be a part of this revolution, but also need to lead it by actively incorporating simulation-based methodologies into graduate and continuing medical education activities. In doing so, we should partner with our colleagues in obstetrics and maternal-fetal medicine in recognition of the fact that for a certain period, we share responsibility for the same patient—the fetus to become newborn—while working together in the delivery room. Now is the time for action and collaboration.
References
- The Random House Dictionary of the English Language, Unabridged. 2nd edition. New York: Random House; 1987;
- . Andragogy in Action: Applying Modern Principles of Adult Education. San Francisco, CA: Jossey-Bass; 1984;
- The Joint Commission. Sentinel event alert: Preventing infant death and injury during delivery. Available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_30.htm. Accessed June 25, 2007.
- American Academy of Pediatrics. Desired features for industry for the development of a realistic neonatal human patient simulator. Available at http://www.aap.org/nrp/pdf/patientsimulator.pdf. Accessed June 25, 2007.
- Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics. 2000;106:e45
PII: S0022-3476(07)00586-0
doi:10.1016/j.jpeds.2007.06.012
© 2007 Mosby, Inc. All rights reserved.