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									Michael W. Brands, PhD
 Department of Physiology
 Medical College of Georgia

     Augusta, Georgia




  Active learning strategies to
   teach renal-cardiovascular
        integration with
  high student : teacher ratios
                              Research Support from HL56259
How do you employ active learning
methods, in a meaningful way,
with 190 students per class?




MCG Photos Credit: Mr. Phil Jones
How do you employ active learning
methods, in a meaningful way,
with 190 students per class?



Effective Approaches:
  •   Audience response systems ("clickers")
  •   Exercises in anesthetized animals
  •   Computer simulations
  •   Small-group problem solving
  •   Worksheets + classroom discussion
How do you employ active learning
methods, in a meaningful way,
with 190 students per class?



Potential Limitations:
  •       Audience response systems ("clickers")
      •     needs good "rehearsal" to prevent lag
      •     if points are awarded, attendance battle
            may arise
      •     effectiveness is tied to individual lecturer's
            presentation skills
How do you employ active learning
methods, in a meaningful way,
with 190 students per class?



Potential Limitations:
  •       Exercises in anesthetized animals
      •     cost
      •     continual struggle with animal rights
            issues
      •     heavily dependent on skilled laboratory
            leaders, space, equipment, etc.
How do you employ active learning
methods, in a meaningful way,
with 190 students per class?



Potential Limitations:
  •       Computer simulations
      •     potential perception as "busy work"
      •     risk of boredom and apathy
      •     requirement for knowledgeable faculty
            (physiology AND the simulation software)
            to act as facilitators.
How do you employ active learning
methods, in a meaningful way,
with 190 students per class?



Potential Limitations:
  •       Small-group problem solving
      •     requirement for knowledgeable faculty to
            act as facilitators.
How do you employ active learning
methods, in a meaningful way,
with 190 students per class?



Potential Limitations:
  •       Worksheets + classroom discussion
      •     challenge to tie it to material that students
            believe they need to know and avoid "busy
            work" perception
Combined Approach
to employ active learning
methods with 190 students

             In the 1st year
Medical Physiology course:
 •       Patient simulator exercise (hemorrhage)
 •       Small-group problem solving with
         computer simulation (hemorrhage)
 •       Worksheets + classroom discussion
         (heart failure)
     •     integrates acute and chronic CV & renal
Combined Approach
to employ active learning
methods with 190 students

             In the 1st year
Medical Physiology course:
 •       Patient simulator exercise (hemorrhage)
                 These simulators are not
 •       Small-group problem solving with
                 good tools for teaching
         computer simulation (hemorrhage)
                 renal physiology as a
                 stand-alone system.
 •       Worksheets + classroom discussion
         (heart failure)
     •     integrates acute CV with chronic renal
Patient Simulator
     Exercise

       How the
    project began:
School of Medicine Administration facilitated my introduction
to the director of the Simulation Center, a teaching center in
the School of Nursing that had not yet been employed for
teaching by any course in the School of Medicine.


Lori Schumacher, PhD, RN, CCRN
Medical College of Georgia
Associate Dean for Simulated Learning Innovations
Director of the Interdisciplinary Simulation Center
Patient Simulator
     Exercise


Challenges
•       Make it relevant to the course and to
        clinical practice ... capitalize on excitement
•       Balance rigor with simplicity *
    •     * the patient simulators actually can bleed and
          receive iv fluid replacement ... how practical?

•       Time: how to fit it into a packed schedule
                            The "Wow!" factor cannot be
Patient Simulator           overlooked or overestimated.

     Exercise               Letting students get excited about
                            looking forward to the patient-care
                            aspect of their medical education is
                            important.

Challenges                  Every student group continues to be
                            thrilled just to explore the simulator.

•       Make it relevant to the course and to
        clinical practice ... capitalize on excitement
•       Balance rigor with simplicity *
    •     * the patient simulators actually can bleed and
          receive iv fluid replacement ... how practical?

•       Time: how to fit it into a packed schedule
                               Our initial plans were to have a bleeding
Patient Simulator              patient and require the students to find
                               and stop the bleeder.
     Exercise
                               The ability to clean up and reset the
                               room for the next group was a concern.

                               Other major concern was the potential
Challenges                     for mechanical failures: Students have
                               zero tolerance for failed demos.

•       Make it relevant to the course and to
                             We opted for a very simple exercise.

        clinical practice ... capitalize on excitement
•       Balance rigor with simplicity *
    •      * the patient simulators actually can bleed and
           receive iv fluid replacement ... how practical?

•       Time: how to fit it into a packed schedule
                            The curriculum already is packed.
Patient Simulator
                            Only time available was afternoon, and
     Exercise               we had to schedule around ECM
                            afternoon sessions.

                            First year was completely voluntary,
                            with zero points awarded and assurance
Challenges                  that no test questions would be taken
                            from the simulator exercise.

•       Make it relevant to the course and to
        clinical practice ... capitalize on excitement
•       Balance rigor with simplicity *
    •     * the patient simulators actually can bleed and
          receive iv fluid replacement ... how practical?

•       Time: how to fit it into a packed schedule
Patient Simulator
     Exercise


Design
•       Students are broken into groups of 4
•       3 groups run simultaneously per session
    •     1 hr session (patient + computer session)

•       2-4 sessions per day (1-5 p.m.) for 5 days
•       17 contact hours total that I moderate
Patient Simulator
     Exercise


Design
•   Case: Hemorrhage of 1800 ml over 30 min
•   Patient Data Gathered: blood pressure (BP), heart rate,
    ventilation rate, blood O2 saturation (SbO2), hematocrit,
    and peripheral pulses
•   explore patient & collect baseline data (~ 10 min)
•   10 min bleeding simulated in 2 min; pause to collect
    data after each 10 min period (rather than real-time)
•   500 ml saline given after 30 minutes of bleeding
Patient Simulator
     Exercise


Results
•       The simplicity of the measurements continues NOT to
        detract from the students' enthusiasm for the exercise.
    •      contrary to my initial and continued fear
•       The total time to complete the exercise is ~ 30 min or
        less. Students always ask if they'll do more of this later.
•       Hanging the saline bag and setting the stopcock are a
        highlight for most; it is their first "real" exposure to
        these basic clinical tools. BP measurement also is fun.
Combined Approach
to employ active learning
methods with 190 students

             In the 1st year
Medical Physiology course:
 •       Patient simulator exercise (hemorrhage)
 •       Small-group problem solving with
         computer simulation (hemorrhage)
 •       Worksheets + classroom discussion
         (heart failure)
     •     integrates acute and chronic CV & renal
Small-group
simulation session


Purpose
•       enable more detailed analysis of the
        physiologic response to hemorrhage
    •     tie the clinical scenario and the physiology
          together

•       provide a framework for small-group
        problem solving
Small-group
simulation session


Design
•   use Quantitative Circulatory Physiology (QCP;
    Physiology, Univ. Mississippi Med. Ctr.)
•   set up a patient (Mr. McG) for the same
    hemorrhage rate as the patient simulator model
•   have 3 laptops set up in a study room; each
    group of 4 moves here after the patient phase
•   a worksheet is given to each student
We Used this
    www.umc.edu
Physiology & Biophysics
                        Adjustments had to be made to make
Small-group             sure that the results from both
                        simulations were ~ equal.
simulation session
                        Worksheet was designed so a student
                        who had never before seen QCP could
                        start and run the exercise.

Design                  Trial runs were made with 2nd year med
                        student volunteers; many revisions.

•   use Quantitative Circulatory Physiology (QCP;
    Physiology, Univ. Mississippi Med. Ctr.)
•   set up a patient (Mr. McG) for the same
    hemorrhage rate as the patient simulator model
•   have 3 laptops set up in a study room; each
    group of 4 moves here after the patient phase
•   a worksheet is given to each student
                          4-student groups work together to
Small-group               move through the worksheet.

simulation session There are data gathering and study
                          problem aspects to the worksheet.

                          Students keep the worksheet; they can
                          do the study problems later if they
Design                    choose, or work on them together.

                         Multiple revisions were made so that
 •   use Quantitative    this could Physiology 30 min.
                      Circulatorybe completed in ~(QCP;
     Physiology, Univ. Mississippi Med. Ctr.)
 •   set up a patient (Mr. McG) for the same
     hemorrhage rate as the patient simulator model
 •   have 3 laptops set up in a study room; each
     group of 4 moves here after the patient phase
 •   a worksheet is given to each student
Page 1
of
QCP
  Page 1 of
  Worksheet



The students initiate the
30-min hemorrhage and
collect data.
Example of one of the data windows.
Page 2 of
Worksheet




Additional data that
are collected.
Page 3 of
Worksheet




The students give 500 ml
saline just as they did
with the patient
simulator, and then
answer questions about
it.
Page 4 of
Worksheet



The role of the SNS is
tested by repeating the
hemorrhage with alpha
receptor blockade.

ACE inhibition and beta
blockade were included
initially, but it added too
much time to the
exercise.
Small-group
simulation session


Results
•   I remain shocked that the vast majority of students stay to
    complete the study problems.
•   I also remain surprised that there is not a noticeable grumbling
    that "the simulator is great, but the other part $*!%& (is not great)"
•   Most students want to try and answer the problems before asking
    me; good follow-up dialogue occurs.
•   Good open discussion among the students.
•   It is critical that you do not try to do too much with this portion in
    terms of data collection, and 30 minutes is the upper limit.
Combined Approach
to employ active learning
methods with 190 students

             In the 1st year
Medical Physiology course:
 •    Patient simulator exercise (hemorrhage)
 •    Small-group problem solving with
      computer simulation (hemorrhage)
Summary
 •    - Combined session classroom discussion
      Worksheets +takes ~ 1 hr per group and is very popular.
      - The first year, with it voluntary, only 6 people did not show up.
              - failure)
      (hearteven the Friday 4:00 p.m. session had full attendance
      - Currently, 10 points are given just for attending the session.
     • integrates acute and chronic CV & renal
             - zero no-shows this year, and one last year.
      - The SOM is exploring ways to add more simulations.
Combined Approach
to employ active learning
methods with 190 students

             In the 1st year
Medical Physiology course:
 •       Patient simulator exercise (hemorrhage)
 •       Small-group problem solving with
         computer simulation (hemorrhage)
 •       Worksheets + classroom discussion
         (heart failure)
     •     integrates acute and chronic CV & renal
Heart Failure Worksheet &
Classroom Review


Goals
•       Tie CV and renal together
•       Try and get the students to think about
        this before discussing it in class
    •     no guarantee, but those who want to test
          themselves have the opportunity to
          complete the worksheet before we review it
Heart Failure Worksheet &
Classroom Review


Design
•   The hemorrhage exercise
    came in the middle of the CV lectures
•   This comes after CV and renal have been
    completed AND tested over.
•   Students get 10 points for completing the
    worksheet (given out one week prior).
Page 1 of
Worksheet

QCP is used again.

BUT !!!! Now the
students are given all
the data.

I tried this having them
run the simulations and
they revolted.

Once, as part of the
hemorrhage exercise,
was enough.
Page 2 of
Worksheet

Circulatory and cardiac
function data
Page 3 of
Worksheet

Renal function data
Page 4 of
Worksheet


  Renal function
  questions
Page 5 of
Worksheet


  Treatment
  (more questions
  follow on p 6)
Heart Failure Worksheet &
Classroom Review


Results
•   Jury is still out
•   Response was better now that the data
    are provided
•   Challenge is trying to add a clinical
    component, or clinical questions based
    on these data
Division of Hypertension
Worksheet & Discussion
Division of Hypertension
Worksheet & Discussion
Division of Hypertension
Worksheet & Discussion
Division of Hypertension
Worksheet & Discussion
Division of Hypertension
Worksheet & Discussion


Results
•       Urine collection is a hit
•       Dilemma for questions again is trying to
        balance the physiology and clinical context
    •     Many students appreciate the value in integrating the
          physiological concepts, but without revisiting this
          directly in years 2-4, hard to show clinical relevance.
          Potential solution is to work with clinician to develop
          clinical vignettes as additional questions.
Combined Approach
to employ active learning
methods with 190 students


Summary
•   Patient simulator exercise
•   Small-group problem solving with computer
    simulation
•   Worksheets + classroom discussion

•   Each works with large class size; variety
    and combination of approaches is
    feasible & may enhance effectiveness.

								
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