140
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL.
[7] F. A. Anderson, Jr., R. A. Peura, B. C. Penney, H. B. Wheeler, and A. H. Hoffman, "Simultaneous Mechanical and Electrical Impedance Plethysmography." 2nd Annual New England Bioengineering Conference Proceedings, March, 1974 (in press). (8] B. C. Penney, R. A. Peura, L. M. Narducci, F. A. Anderson, Jr., and H. B. Wheeler, "Electric Field Model Applied to Im-
A
Clinically
NO.
2, MARCH 1975
pedance Plethysmography," 2nd Annual New England Bioengineering Conference Proceedings, March, 1974 (in press). [9] W. R. Grogan, J. S. Demetry, R. A. Peura, and K. E. Scott, "The WPI Plan: A Comprehensive Historical Report." 1974, Frontiers in Education Conference Proceedings, pp. 91-94, July, 1974.
Oriented Bioengineering for Undergraduates
JOHN S. DETWILER,
BME-22,
Program
ARTHUR C. SANDERSON, RAN VAS, MEMBER, IEEE
MEMBER, IEEE,
MEMBER, IEEE, AND
Abstract-The well-documented emergence of Bioengineering from independent research into clinical problem-solving has influenced the development of Bioengineering education at CarnegieMellon. Offered as an option to undergraduates, Bioengineering supplements the basic curriculum of an Engineering department with courses in the life sciences, clinical and instrumentation laboratories, and a hospital internship. These laboratories and internship, which are described here in detail, have as their purpose to provide the student with a familiarity with engineering applications in the medical field and to encourage the ability to work cooperatively in the clinical environment. These specific skills are to be added to the general engineering excellence and ability for independent growth which are the goals of the basic departmental curricula. Two years from its introduction, enrollment in the option has grown to a total of 49 undergraduates for the current academic year.
I. INTRODUCTION THE DIRECTION OF Biomedical Engineering education is changing. The assumed potential demand for engineers in the delivery of health care, and the visible softness of demand in research, has inspired many efforts to train "clinical engineers." These have varied from associate-degree programs comparable to those in medical laboratory technology, to the "aerospace retread" programs to turn high-level technology into what are hoped to be more productive channels. Although health care and clinical are the jargon of the day, the engineer's place in medicine is still not obvious, as can be seen in the simultaneous educational assault on the system at all levels from instrument repair to national resource allocation planning. Both the graduates and the faculty of any training program, therefore, assume considerable risk in Manuscript received June 28, 1974; revised October 15, 1974. J. S. Detwiler is with the Veterans Administration Hospital, Pittsburgh, Pa. 15240, and the Biotechnology Program, CarnegieMellon University, Pittsburgh, Pa. A. C. Sanderson and R. Vas are with the Biotechnology Program, Carnegie-Mellon University, Pittsburgh, Pa.
attempting to aim too closely at a specific job-model. Not only is the reality of clinical demand unproven (and maybe unprovable), but the entire health system is a target moving more rapidly than any other in the economy, and in an unpredictable direction. At Carnegie-Mellon University, we have begun a program of undergraduate education in clinical engineering as an outgrowth of our well-established graduate research activities. In doing so, we have attempted to prepare the baccalaureate engineer to work in the clinical environment as a professional, by providing a background in life sciences and practical experience with both medical instruments and medical institutions. At the same time, we have retained the principle that the bioengineer's most valuable asset will continue to be his excellence in engineering. The undergraduate bioengineering curriculum has been established, therefore, as an option-to be completed in conjunction with a degree program in one of the more traditional engineering disciplines-which supplements rather than replaces education in more established engineering disciplines. Making bioengineering an augmentation (rather than a substitution) to a more ordinary engineering degree has the dubious advantage that the graduate can always claim to be, for example, an Electrical Engineer, should he fail to find work in a biomedical field. That is not our purpose. We have retained the basic curriculum because it includes elements which are essential to all branches of engineering: the ability to identify, organize, and solve problems, and to respond flexibly and creatively to new situations. This "art of engineering" is even more important for the Clinical Engineer, who will most likely be working in a non-engineering environment and almost certainly be supervised, if at all, by a non-engineer. A second anchor of the curriculum is the encouragement of professional growth, to continue to learn throughout one's career. Again, while
DETWILER et al.: CLINICALLY ORIENTED PROGRAM
necessary for any professional in today's fast-changing technology, this capacity for growth and evolution is absolutely vital for the bioengineer. The capability for self-directed and continuous growth is the appropriate skill in an unpredictable employment market, not specialized training which is tied tightly to an assumed market demand. The whole of the undergraduate curriculum in engineering and science at CM{U is now being reorganized to further emphasize this ability for growth. At its core is a sequence of courses treating Analysis, Synthesis and Evaluation in the conitext of particular engineering problems. Our existing undergraduate bioengineering option meshes well with this new curriculum: problems with a biomedical content will be seen in several of the Analysis, Synthesis, and Evaluation courses for all undergraduates. Further, the specific bioengineering course offerings (to be described) are presented in this larger context of problem solving in the engineering curriculum. In addition to these fundamental skills, the bioengineer must develop his experience, language, background knowledge and organizational skills to work in a very special, non-engineering environment. Our approach to filling these needs has grown out of our experience with graduate education and research, as well as through cooperation with those immersed in the clinical setting. The graduate program offers Ph.D. and M.S. degrees in Bioengineering, either alone or jointly with a particular engineering or science department. This entire graduate curriculum has recently been revised to be more coherent in focus, comprehensive in scope, aind clinical in orientation. In this report we have chosen to describe the new undergraduate program rather than the ongoing graduate program. The undergraduate option represents our response to changing conditions in the biomedical professions. The philosophy of supplementing the basic engineering curriculum at the undergraduate level-and the means by which we have implemented this program in courses, laboratory, and internship-may offer a valuable contrast to other, more single-purpose approaches.
II. EVOLUTION OF THE UNDERGRADUATE OPTION Biomedical engineering education began at CMU in the early 1960's, much as in other institutions, as an informal outgrowth of faculty research activity. Graduate students became involved in bioengineering research projects as members of a particular engineering department. In 1966, the "Biotechnology Program" was fortnally established as an interdisciplinary program within the university. At that time the establishment of such a program rather than a formal department was based on the nature of bioengineering as a collage of people from many different disciplines. The key advantage of the interdepartmental structure remains its flexibility. While the original interdisciplinary membership of the program consisted primarily of faculty from different engineering departments, the current faculty of the program also includes engineers with specific areas of clinical experience, a physiologist, a
141
physician, and members with formal joint appointments with local hospitals. As the faculty formed and strengthened its associations with clinical activities, we were made aware of the potential value of technically sophisticated engineers participating directly in health care and, at the same time, the
limitations of our research-centered graduate study (with its emphasis on novelty) in developing the necessary qualifications for such work. Simultaneously, medical costs began to come under less sympathetic scrutiny, with two important implications for our prospects in "Clinical Engineering." First, we could expect that engineers would be welcomed by hospital administrators to the extent that they contributed to efficiency and reduction of waste in an increasingly technical industry. Second, that the career advancement needs of researchers and physician specialists were, rightly or wrongly, suspected of adding costs disproportionate to their immediate value in patient care. On both counts, the job market would call not for novelty or research, but for pragmatism and reduction to practice. We were, of course, not alone in drawing the conclusion that Clinical Engineers might encounter easier entry into hospitals at the B.S. or M.S. level than with the Ph.D. [1], [2]. But we preferred to introduce the practical "training" in Bioengineering in a way which would not detract from engineering "education" or unnecessarily narrow the opportunities of our graduates. The development and implementation of an effective educational program in'bioengineering required the careful definition of goals. The diversity of the bioengineering field, as a whole, as well as the multiple avenues which are open to a graduate of such a program suggested that a wide variety of needs must be satisfied by the educational program. After consideration of these possibilities, one may be tempted to set objectives for the program which are impossibly broad and multi-faceted. The implementation of the bioengineering option at CMIU has involved the refinement of such broad goals into a set of concrete objectives determined first by the educational needs of a large number, but certainly not all, of interested students.and second by the resource constraints of the program itself and the associated cooperating departments. Perhaps the most important step in identifying concretely the objectives of the undergraduate bioengineering option was to first explore the variety of job opportunities among which our graduates may choose upon leaving the university. The main categories of activities open to the bioengineering graduate at the bachelor's level are: 1) biomedical-related position in hospital, 2) biomedical-related position in industry, 3) graduate study in bioengineering leading either to Master's degree or Ph.D. degree, 4) medical school, 5) non-bioengineering graduate study, and 6) non-bioengineering position in industry. The variety of skills, of experience, and of professional attitudes which are required to fulfill these different posi-
142
tions makes it extremely unlikely that any program will prepare students equally well for all of these areas. While total flexibility in the design of the program and unconstrained individual planning of curricula is one obvious response to this multiplicity of goals, such a system does not serve the typical undergraduate who has not yet defined his career goals. In such an instance the burden of designing a program which best serves the student's ultimate needs falls upon the advisor, with the result that the curriculum, intended to be tailored to the individual student's needs, dissolves into a group of unconnected sub-programs. In establishing the undergraduate bioengineering option, our intention was to introduce a structure which could be taken as a whole and did not require the student or his advisor to synthesize its parts into a coherent design. The freedom to tailor one's own curriculum still exists, of course, regardless of the form chosen for the Bioengineering option. A student whose unequivocal plan is for medical school may enroll in an engineering department and use his course electives to satisfy medical school admission requirements. In contrast, the curriculum of the Bioengineering option provides not a haphazard exposure to the elements of engineering and the life sciences, but a focused activity leading to a level of accomplishment recognizable in any of the fields of endeavor above. The guiding principle on which subsequent decisions were based was to require existing courses from other university departments for the necessary background of engineering and sciences while we contributed a small number of carefully placed courses and other activities which would focus this preparation into the clinical applicat;ion of Bioengineering. The decision to adopt a clinical focus in the undergraduate option was influenced by several recent developments. First, we perceived that a job market for bioengineers with specific skills was developing both in hospitals and industry and that many and perhaps most of the positions could be filled by bachelors- and masters-level students, rather than by Ph.D. holders. The first concrete objective which was laid down in restructuring the option then was to identify the specific skills which would be useful in clinical bioengineering positions and to develop the teaching resources to convey them to our students. This approach contrasts with the earlier philosophy that exposing an engineer to biology and chemistry courses is sufficient preparation at the undergraduate level. The identification of specific skills such as those outlined in the description of our undergraduate clinical laboratory is an important step and one which has come only with the maturation of bioengineering as a profession and the accompanying increase in acceptance of bioengineers in the medical environment. The second specific objective which was formulated in the restructuring of the bioengineering option was to prepare students to function comfortably and efficiently in the medical environment. This preparation has now been embodied in our hospital internship program. This second objective evolved as a result of our observation that the medical environment is, indeed, foreign to the layman; therefore it is extremely valuable for a student preparing
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, MARCH
1975
for a career in that environment to be exposed to the functional organization, the personnel, and the mode of operation of the hospital as early as possible. The third major objective of the undergraduate option (that the undergraduate bioengineer should be first of all a well-trained engineer) has been retained since its inception. The achievement of this objective is the essence of the option structure which supplements, rather than supplants the departmental engineering curricula. III. BIOENGINEERING COURSES AND LABORATORIES The result of the three simultaneous objectives above is the following undergraduate program. The student registers in an engineering or science department and has a four-year schedule: (1) to satisfy all requirements of an engineering depart-
ment,'
(2) to utilize available technical electives in order to satisfy: (a) a series of additional science courses including biology, chemistry, and physiology, (b) a limited number of undergraduate biomedical engineering courses offered by the Biotechnology Program, including three mandatory courses (see below), (c) a choice between a clinical internship or a graduate level biomedical engineering course from a specialized area. Of the three courses specified as mandatory, the first is a survey course intended for freshmen or sophomores to introduce the applications of technology to medicine and biology and the range of activities being pursued within the program faculty. Under the Freshman-Sophomore Elective system at CMU, this course is frequently taken before the student decides on the Bioengineering option or for that matter, a major department. A course in physiology provides the background necessary for the problems addressed in the final required course, Engineering in Biology and Medicine. The combination of lecture and laboratory material presented in this final course, along with the clinical internship to follow, are offered to the junior and seniior students to synthesize these preceding years of study into the practical application of Bioengineering. As the most novel course of the option curriculum, it will be described here in some detail. Its purpose is to teach both the technical aspects of medical instrumentation and the measurement of clinically significant parameters on human subjects. A. Lectures In two one-hour lectures per week, Program faculty and guest speakers practicing at the medicine-technology interface relate the student's engineering training to quantitative aspects of clinical practice and measurement in several major areas. The lecture material covers the design con1 Students are also admitted to the option from Science and mathematics departments provided that special provision is made to satisfy several key engineering requirements.
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DETWILER et al.: CLINICALLY ORIENTED PROGRAM
siderations, underlying theory, physiological bases, maintenance principles and evaluation of a wide range of hospital instruments including artificial organs, laboratory analyzers, diagnostic ultrasonic and radiological equipment and physiological monitors. Arrangements have been made with local hospitals for demonstrations of the use of these devices and the brief loan of some of them for technical evaluation. The remainder of the course consists of a two-hour clinical measurement laboratory and a two-hour instrumentation laboratory per week which, as a whole, focus on a set of instruments which measure a variety of clinically useful parameters. The two-hour instrumentation section concerns itself with the theory underlying the measuring device, as well as the pragmatic aspects of its construction and maintenance. The clinical measurement section is oriented toward the measurement itself, the technique and its interpretation in a limited range of pathology, using actual patient data. B. The Instrumentation Laboratory An agreement reached with one of the hospitals makes it possible for a student to actually get his "hands on" various pieces of instrumentation of the same type as that to be used in the Clinical Measurement Laboratory (below) which are either out of use or damaged and are brought to the Program for repair. Not only are there a variety of instruments involved which are continually updated, but the defects are real products of the applications environment. Each student, or perhaps a pair team, chooses one such instrument and as a project will develop an operations manual, maintenance protocol, and troubleshooting guide for the device. The aim here is to acknowledge that a hospital-based bioengineer will almost surely have some responsibility for instrument maintenance and safety. At the same time we have tried to instill a professional, supervisory attitude toward this function.
C. The Clinical Measurement Laboratory In the third part of this course the interactions between physiology and instrumentation are explored. Measurenent techniques and interpretations of data are studied. The choice of the measurements to be performed has been made to include a variety of physiological phenomena, consistent with an undergraduate-level physiological background. We have chosen to accent non-invasive techniques in the cardiovascular, muscular, and neurological systems for several reasons. The electrical phenomena of the heart (ECG), muscle (EMG) and brain (EEG) are representative of electrical phenomena in the body. The recording of heart movements (apexcardiography) involves the kinematics of tissue. Phonocardiography serves well to demonstrate acoustical phenomena appearing in the human body. We have incorporated, in addition, other measurements which, simply because of wide or rapidly growing use, demand attention. For example, a simple ultrasonic measurement will be made. Perhaps as important as the technical knowledge and proficiency to be achieved in this course is the simple experience of approaching the living human subject for the
purpose of making measurements. By the taking of such a role with other students, we hope to give the student greater confidence to undertake such activities in the hospital. Although such confidence-building is unusual in engineering education, it is made necessary here by the much greater independence wvhich the clinical engineer must assume immediately upon taking a hospital position. Finally, the analysis of data from such measurements makes the student aware of the greater variability in physiological over physical data and the different approach to the data which it necessitates. Having first applied his skills to physiological measurements in the laboratory, the student then has the opportunity, in the hospital internship, to continue into the clinical environment itself.
IV. HOSPITAL INTERNSHIP The Hospital Internship has evolved continuously throughout the life of the Biotechnology Program at Carnegie-Mellon, beginning as a catch-all course designation and arriving at the present, more tightly organized, clinical experience. We now approach the internship in the medical sense of a putting into practice of professional training. Early "Hospital Internships" were single long-term projects or technician-apprenticeships under a hospital physician, and some of these were extremely good. (One student went so far as to attach himself to a medical intern, accumulating a great deal of hospital experience, although from a somewhat limited vantage point.) The present internship consists of an organized orientation to the hospital environment, followed by a carefully chosen project assignment which is more critically evaluated than those in the past. The internship is offered to senior undergraduates and to graduate students in Bioengineering whose research work is not clinically oriented. It is now required for the designation "Bioengineering option" on the undergraduate degree. For the undergraduate it forms the climax of his association with the program, in which he puts his classroom training to work as well as experiencing the stimulating environment of clinical medicine. Because of some concern that the course would prov-e too attractive to senior engineering students, we have limited enrollment to those who have fulfilled, or are fulfilling, the other requirements of the option for clinical engineering. We also require an interview with the course instructor. The educational goals of clinical internships are many, and the priorities among them are not unanimously agreed upon. We feel that it is most important to foster the ability to communicate with both health professionals and patients. This requires not only factual knowledge of the kind which is not easily taught in engineering laboratories, but also a sympathy for medical traditions and a selisitivity to patients' dignity and vulnerability. We expect each student to spend some time in clinical services. He should have some idea of what is done, what equipment and techniques predominate, what the concerns are. Second, the internship provides support for the engineer in this difficult period of adjustment. Once on the job, the
144
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, MARCH
new graduate will assume an unusual degree of independent responsibility in the absence of sympathetic coworkers who have experienced similar disorientation. Thus, the period of the internship includes weekly sessions at which all students come together to share their experiences and compare their approaches. Third, the internship, through a project, attempts to demonstrate the practical constraints on applied engineering in hospitals, and it aims to temper the students' enthusiasm for purely technological solutions. Students see the wide variation in technical sophistication among users of medical equipment. (Not incidentally, the project also serves to repay our clinical associates for their investment in student supervision, and to foster interest in Biomedical Engineering among the hospital staffs.) Finally, we would hope to give the students an appreciation of the hospital as an enterprise: where resources come from, where they are spent, and how they are managed. In the past academic year the faculty participating in this internship program included two practicing clinical engineers (one in the V.A. Hospital affiliated with the University of Pittsburgh School of Medicine, the other in a local private hospital), both on the program faculty. The students were four engineering seniors, three electrical and one mechanical engineer. The course was scheduled for six hours in the Spring Semester. It began with supervised visits to clinical services: the intensive care unit, open heart surgery, central supply, cardiac catheterization laboratory, hemodialysis, obstetrics, and diagnostic ultrasound, as well as lectures by hospital physicians and administrators. About four weeks into the semester, students began work on independent projects under the supervision of hospital staff. This year the projects included a study of outpatient service operations, analysis of open heart "pump reports," instrumentation for a pacemaker clinic, and an evaluation of a prototype fetal monitor. The results of the internship have been, from the students' point of view, quite rewarding. The students performed well in the hospital environment, and we have found no complaints from the hospital personnel or significant problems in student-clinical cooperation. The students were generally enthusiastic about their experience, although (as we had expected) each was somewhat disappointed in the progress he had made in his project. Following our evaluation of the past year's program, we have made some revisions in our plans for following years. First, the scheduled time will be spread over two semesters, with a single semester hour in the Fall during which all supervised hospital visits and lectures will be included, and five semester hours in the Spring devoted exclusively to independent project work. We also intend to expand to non-teaching city and suburban hospitals as well as those in the University Health Center complex. V. CONCLUSIONS
Interest in the undergraduate Bioengineering option has grown in the short period since its origin. Enrollment is summarized in Table I. Students enroll in the option at the
1975
TABLE I ENROLLMENT OF STUDENTS IN UNDERGRADUATE, BIOTECHNOLOGY OPTION Number of Students
Graduating Class in
No. of Students
1974 1975 1976 1977
5 14 13 22
TABLE II DISTRIBUTION OF STUDENTS AMONG DEPARTMENTS FOR ACADEMIC YEAR 1973-1974 Chemistry Chemical Engineering
Electrical Engineering Mathematics Mechanical Engineering Metallurgy and Materials Science Total
1 7 15 I 6 2 32
beginning of the sophomore year, so that total enrollment normally includes students from three graduating classes. The total enrollment for 1973-1974 was 32 students; for 1974-1975 this has increased to 49 students. The distribution of students enrolled in 1973-1974 is shown in Table II. While the largest constituency is from Electrical Engineering, representation from other departments is increasing. Average enrollment in the three undergraduate courses presently averages 25 students a semester per course and includes many students who are not enrolled in the option but who elect these courses. How has the change in structure of the undergraduate option affected the quality of the student graduate, and how well do these changes prepare the student for the variety of situations which he may encounter on graduation? The definitive answer to this question will come only after several years, when graduates in the program have had an opportunity to function in these areas for some time. However, it is important to recognize that a commitment has been made to training bioengineers for bioengineering positions and that our success in the program must be measured by how many graduates successfully pursue careers in the biomedically related professions either in industry, or in the hospital environment, or in the university, and not by their achievements in the engineering profession. We feel that the existence of the bioengineering program as an undergraduate option remains the most efficient organizational medium and provides a compromise between the individualized curriculum and the highly structured department. The flexibilitv inherent in the organization of the option has served us well in the restructuring of the program and in the implementation of our revised objectives for an undergraduate bioengineering curriculum. REFERENCES [1] "The Future of Training in Biomedical Engineering," Engineering in Biology and Medicine Training Committee of N.I.H., IEEE Trans. BAIE, Vol. 19, p. 148, 1972. [21 Plonsey, R., "New Directions for Biomedical Engineering," Engineering Education, Dec. 1973, pp. 177-179.
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL.
[7] F. A. Anderson, Jr., R. A. Peura, B. C. Penney, H. B. Wheeler, and A. H. Hoffman, "Simultaneous Mechanical and Electrical Impedance Plethysmography." 2nd Annual New England Bioengineering Conference Proceedings, March, 1974 (in press). (8] B. C. Penney, R. A. Peura, L. M. Narducci, F. A. Anderson, Jr., and H. B. Wheeler, "Electric Field Model Applied to Im-
A
Clinically
NO.
2, MARCH 1975
pedance Plethysmography," 2nd Annual New England Bioengineering Conference Proceedings, March, 1974 (in press). [9] W. R. Grogan, J. S. Demetry, R. A. Peura, and K. E. Scott, "The WPI Plan: A Comprehensive Historical Report." 1974, Frontiers in Education Conference Proceedings, pp. 91-94, July, 1974.
Oriented Bioengineering for Undergraduates
JOHN S. DETWILER,
BME-22,
Program
ARTHUR C. SANDERSON, RAN VAS, MEMBER, IEEE
MEMBER, IEEE,
MEMBER, IEEE, AND
Abstract-The well-documented emergence of Bioengineering from independent research into clinical problem-solving has influenced the development of Bioengineering education at CarnegieMellon. Offered as an option to undergraduates, Bioengineering supplements the basic curriculum of an Engineering department with courses in the life sciences, clinical and instrumentation laboratories, and a hospital internship. These laboratories and internship, which are described here in detail, have as their purpose to provide the student with a familiarity with engineering applications in the medical field and to encourage the ability to work cooperatively in the clinical environment. These specific skills are to be added to the general engineering excellence and ability for independent growth which are the goals of the basic departmental curricula. Two years from its introduction, enrollment in the option has grown to a total of 49 undergraduates for the current academic year.
I. INTRODUCTION THE DIRECTION OF Biomedical Engineering education is changing. The assumed potential demand for engineers in the delivery of health care, and the visible softness of demand in research, has inspired many efforts to train "clinical engineers." These have varied from associate-degree programs comparable to those in medical laboratory technology, to the "aerospace retread" programs to turn high-level technology into what are hoped to be more productive channels. Although health care and clinical are the jargon of the day, the engineer's place in medicine is still not obvious, as can be seen in the simultaneous educational assault on the system at all levels from instrument repair to national resource allocation planning. Both the graduates and the faculty of any training program, therefore, assume considerable risk in Manuscript received June 28, 1974; revised October 15, 1974. J. S. Detwiler is with the Veterans Administration Hospital, Pittsburgh, Pa. 15240, and the Biotechnology Program, CarnegieMellon University, Pittsburgh, Pa. A. C. Sanderson and R. Vas are with the Biotechnology Program, Carnegie-Mellon University, Pittsburgh, Pa.
attempting to aim too closely at a specific job-model. Not only is the reality of clinical demand unproven (and maybe unprovable), but the entire health system is a target moving more rapidly than any other in the economy, and in an unpredictable direction. At Carnegie-Mellon University, we have begun a program of undergraduate education in clinical engineering as an outgrowth of our well-established graduate research activities. In doing so, we have attempted to prepare the baccalaureate engineer to work in the clinical environment as a professional, by providing a background in life sciences and practical experience with both medical instruments and medical institutions. At the same time, we have retained the principle that the bioengineer's most valuable asset will continue to be his excellence in engineering. The undergraduate bioengineering curriculum has been established, therefore, as an option-to be completed in conjunction with a degree program in one of the more traditional engineering disciplines-which supplements rather than replaces education in more established engineering disciplines. Making bioengineering an augmentation (rather than a substitution) to a more ordinary engineering degree has the dubious advantage that the graduate can always claim to be, for example, an Electrical Engineer, should he fail to find work in a biomedical field. That is not our purpose. We have retained the basic curriculum because it includes elements which are essential to all branches of engineering: the ability to identify, organize, and solve problems, and to respond flexibly and creatively to new situations. This "art of engineering" is even more important for the Clinical Engineer, who will most likely be working in a non-engineering environment and almost certainly be supervised, if at all, by a non-engineer. A second anchor of the curriculum is the encouragement of professional growth, to continue to learn throughout one's career. Again, while
DETWILER et al.: CLINICALLY ORIENTED PROGRAM
necessary for any professional in today's fast-changing technology, this capacity for growth and evolution is absolutely vital for the bioengineer. The capability for self-directed and continuous growth is the appropriate skill in an unpredictable employment market, not specialized training which is tied tightly to an assumed market demand. The whole of the undergraduate curriculum in engineering and science at CM{U is now being reorganized to further emphasize this ability for growth. At its core is a sequence of courses treating Analysis, Synthesis and Evaluation in the conitext of particular engineering problems. Our existing undergraduate bioengineering option meshes well with this new curriculum: problems with a biomedical content will be seen in several of the Analysis, Synthesis, and Evaluation courses for all undergraduates. Further, the specific bioengineering course offerings (to be described) are presented in this larger context of problem solving in the engineering curriculum. In addition to these fundamental skills, the bioengineer must develop his experience, language, background knowledge and organizational skills to work in a very special, non-engineering environment. Our approach to filling these needs has grown out of our experience with graduate education and research, as well as through cooperation with those immersed in the clinical setting. The graduate program offers Ph.D. and M.S. degrees in Bioengineering, either alone or jointly with a particular engineering or science department. This entire graduate curriculum has recently been revised to be more coherent in focus, comprehensive in scope, aind clinical in orientation. In this report we have chosen to describe the new undergraduate program rather than the ongoing graduate program. The undergraduate option represents our response to changing conditions in the biomedical professions. The philosophy of supplementing the basic engineering curriculum at the undergraduate level-and the means by which we have implemented this program in courses, laboratory, and internship-may offer a valuable contrast to other, more single-purpose approaches.
II. EVOLUTION OF THE UNDERGRADUATE OPTION Biomedical engineering education began at CMU in the early 1960's, much as in other institutions, as an informal outgrowth of faculty research activity. Graduate students became involved in bioengineering research projects as members of a particular engineering department. In 1966, the "Biotechnology Program" was fortnally established as an interdisciplinary program within the university. At that time the establishment of such a program rather than a formal department was based on the nature of bioengineering as a collage of people from many different disciplines. The key advantage of the interdepartmental structure remains its flexibility. While the original interdisciplinary membership of the program consisted primarily of faculty from different engineering departments, the current faculty of the program also includes engineers with specific areas of clinical experience, a physiologist, a
141
physician, and members with formal joint appointments with local hospitals. As the faculty formed and strengthened its associations with clinical activities, we were made aware of the potential value of technically sophisticated engineers participating directly in health care and, at the same time, the
limitations of our research-centered graduate study (with its emphasis on novelty) in developing the necessary qualifications for such work. Simultaneously, medical costs began to come under less sympathetic scrutiny, with two important implications for our prospects in "Clinical Engineering." First, we could expect that engineers would be welcomed by hospital administrators to the extent that they contributed to efficiency and reduction of waste in an increasingly technical industry. Second, that the career advancement needs of researchers and physician specialists were, rightly or wrongly, suspected of adding costs disproportionate to their immediate value in patient care. On both counts, the job market would call not for novelty or research, but for pragmatism and reduction to practice. We were, of course, not alone in drawing the conclusion that Clinical Engineers might encounter easier entry into hospitals at the B.S. or M.S. level than with the Ph.D. [1], [2]. But we preferred to introduce the practical "training" in Bioengineering in a way which would not detract from engineering "education" or unnecessarily narrow the opportunities of our graduates. The development and implementation of an effective educational program in'bioengineering required the careful definition of goals. The diversity of the bioengineering field, as a whole, as well as the multiple avenues which are open to a graduate of such a program suggested that a wide variety of needs must be satisfied by the educational program. After consideration of these possibilities, one may be tempted to set objectives for the program which are impossibly broad and multi-faceted. The implementation of the bioengineering option at CMIU has involved the refinement of such broad goals into a set of concrete objectives determined first by the educational needs of a large number, but certainly not all, of interested students.and second by the resource constraints of the program itself and the associated cooperating departments. Perhaps the most important step in identifying concretely the objectives of the undergraduate bioengineering option was to first explore the variety of job opportunities among which our graduates may choose upon leaving the university. The main categories of activities open to the bioengineering graduate at the bachelor's level are: 1) biomedical-related position in hospital, 2) biomedical-related position in industry, 3) graduate study in bioengineering leading either to Master's degree or Ph.D. degree, 4) medical school, 5) non-bioengineering graduate study, and 6) non-bioengineering position in industry. The variety of skills, of experience, and of professional attitudes which are required to fulfill these different posi-
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tions makes it extremely unlikely that any program will prepare students equally well for all of these areas. While total flexibility in the design of the program and unconstrained individual planning of curricula is one obvious response to this multiplicity of goals, such a system does not serve the typical undergraduate who has not yet defined his career goals. In such an instance the burden of designing a program which best serves the student's ultimate needs falls upon the advisor, with the result that the curriculum, intended to be tailored to the individual student's needs, dissolves into a group of unconnected sub-programs. In establishing the undergraduate bioengineering option, our intention was to introduce a structure which could be taken as a whole and did not require the student or his advisor to synthesize its parts into a coherent design. The freedom to tailor one's own curriculum still exists, of course, regardless of the form chosen for the Bioengineering option. A student whose unequivocal plan is for medical school may enroll in an engineering department and use his course electives to satisfy medical school admission requirements. In contrast, the curriculum of the Bioengineering option provides not a haphazard exposure to the elements of engineering and the life sciences, but a focused activity leading to a level of accomplishment recognizable in any of the fields of endeavor above. The guiding principle on which subsequent decisions were based was to require existing courses from other university departments for the necessary background of engineering and sciences while we contributed a small number of carefully placed courses and other activities which would focus this preparation into the clinical applicat;ion of Bioengineering. The decision to adopt a clinical focus in the undergraduate option was influenced by several recent developments. First, we perceived that a job market for bioengineers with specific skills was developing both in hospitals and industry and that many and perhaps most of the positions could be filled by bachelors- and masters-level students, rather than by Ph.D. holders. The first concrete objective which was laid down in restructuring the option then was to identify the specific skills which would be useful in clinical bioengineering positions and to develop the teaching resources to convey them to our students. This approach contrasts with the earlier philosophy that exposing an engineer to biology and chemistry courses is sufficient preparation at the undergraduate level. The identification of specific skills such as those outlined in the description of our undergraduate clinical laboratory is an important step and one which has come only with the maturation of bioengineering as a profession and the accompanying increase in acceptance of bioengineers in the medical environment. The second specific objective which was formulated in the restructuring of the bioengineering option was to prepare students to function comfortably and efficiently in the medical environment. This preparation has now been embodied in our hospital internship program. This second objective evolved as a result of our observation that the medical environment is, indeed, foreign to the layman; therefore it is extremely valuable for a student preparing
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, MARCH
1975
for a career in that environment to be exposed to the functional organization, the personnel, and the mode of operation of the hospital as early as possible. The third major objective of the undergraduate option (that the undergraduate bioengineer should be first of all a well-trained engineer) has been retained since its inception. The achievement of this objective is the essence of the option structure which supplements, rather than supplants the departmental engineering curricula. III. BIOENGINEERING COURSES AND LABORATORIES The result of the three simultaneous objectives above is the following undergraduate program. The student registers in an engineering or science department and has a four-year schedule: (1) to satisfy all requirements of an engineering depart-
ment,'
(2) to utilize available technical electives in order to satisfy: (a) a series of additional science courses including biology, chemistry, and physiology, (b) a limited number of undergraduate biomedical engineering courses offered by the Biotechnology Program, including three mandatory courses (see below), (c) a choice between a clinical internship or a graduate level biomedical engineering course from a specialized area. Of the three courses specified as mandatory, the first is a survey course intended for freshmen or sophomores to introduce the applications of technology to medicine and biology and the range of activities being pursued within the program faculty. Under the Freshman-Sophomore Elective system at CMU, this course is frequently taken before the student decides on the Bioengineering option or for that matter, a major department. A course in physiology provides the background necessary for the problems addressed in the final required course, Engineering in Biology and Medicine. The combination of lecture and laboratory material presented in this final course, along with the clinical internship to follow, are offered to the junior and seniior students to synthesize these preceding years of study into the practical application of Bioengineering. As the most novel course of the option curriculum, it will be described here in some detail. Its purpose is to teach both the technical aspects of medical instrumentation and the measurement of clinically significant parameters on human subjects. A. Lectures In two one-hour lectures per week, Program faculty and guest speakers practicing at the medicine-technology interface relate the student's engineering training to quantitative aspects of clinical practice and measurement in several major areas. The lecture material covers the design con1 Students are also admitted to the option from Science and mathematics departments provided that special provision is made to satisfy several key engineering requirements.
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DETWILER et al.: CLINICALLY ORIENTED PROGRAM
siderations, underlying theory, physiological bases, maintenance principles and evaluation of a wide range of hospital instruments including artificial organs, laboratory analyzers, diagnostic ultrasonic and radiological equipment and physiological monitors. Arrangements have been made with local hospitals for demonstrations of the use of these devices and the brief loan of some of them for technical evaluation. The remainder of the course consists of a two-hour clinical measurement laboratory and a two-hour instrumentation laboratory per week which, as a whole, focus on a set of instruments which measure a variety of clinically useful parameters. The two-hour instrumentation section concerns itself with the theory underlying the measuring device, as well as the pragmatic aspects of its construction and maintenance. The clinical measurement section is oriented toward the measurement itself, the technique and its interpretation in a limited range of pathology, using actual patient data. B. The Instrumentation Laboratory An agreement reached with one of the hospitals makes it possible for a student to actually get his "hands on" various pieces of instrumentation of the same type as that to be used in the Clinical Measurement Laboratory (below) which are either out of use or damaged and are brought to the Program for repair. Not only are there a variety of instruments involved which are continually updated, but the defects are real products of the applications environment. Each student, or perhaps a pair team, chooses one such instrument and as a project will develop an operations manual, maintenance protocol, and troubleshooting guide for the device. The aim here is to acknowledge that a hospital-based bioengineer will almost surely have some responsibility for instrument maintenance and safety. At the same time we have tried to instill a professional, supervisory attitude toward this function.
C. The Clinical Measurement Laboratory In the third part of this course the interactions between physiology and instrumentation are explored. Measurenent techniques and interpretations of data are studied. The choice of the measurements to be performed has been made to include a variety of physiological phenomena, consistent with an undergraduate-level physiological background. We have chosen to accent non-invasive techniques in the cardiovascular, muscular, and neurological systems for several reasons. The electrical phenomena of the heart (ECG), muscle (EMG) and brain (EEG) are representative of electrical phenomena in the body. The recording of heart movements (apexcardiography) involves the kinematics of tissue. Phonocardiography serves well to demonstrate acoustical phenomena appearing in the human body. We have incorporated, in addition, other measurements which, simply because of wide or rapidly growing use, demand attention. For example, a simple ultrasonic measurement will be made. Perhaps as important as the technical knowledge and proficiency to be achieved in this course is the simple experience of approaching the living human subject for the
purpose of making measurements. By the taking of such a role with other students, we hope to give the student greater confidence to undertake such activities in the hospital. Although such confidence-building is unusual in engineering education, it is made necessary here by the much greater independence wvhich the clinical engineer must assume immediately upon taking a hospital position. Finally, the analysis of data from such measurements makes the student aware of the greater variability in physiological over physical data and the different approach to the data which it necessitates. Having first applied his skills to physiological measurements in the laboratory, the student then has the opportunity, in the hospital internship, to continue into the clinical environment itself.
IV. HOSPITAL INTERNSHIP The Hospital Internship has evolved continuously throughout the life of the Biotechnology Program at Carnegie-Mellon, beginning as a catch-all course designation and arriving at the present, more tightly organized, clinical experience. We now approach the internship in the medical sense of a putting into practice of professional training. Early "Hospital Internships" were single long-term projects or technician-apprenticeships under a hospital physician, and some of these were extremely good. (One student went so far as to attach himself to a medical intern, accumulating a great deal of hospital experience, although from a somewhat limited vantage point.) The present internship consists of an organized orientation to the hospital environment, followed by a carefully chosen project assignment which is more critically evaluated than those in the past. The internship is offered to senior undergraduates and to graduate students in Bioengineering whose research work is not clinically oriented. It is now required for the designation "Bioengineering option" on the undergraduate degree. For the undergraduate it forms the climax of his association with the program, in which he puts his classroom training to work as well as experiencing the stimulating environment of clinical medicine. Because of some concern that the course would prov-e too attractive to senior engineering students, we have limited enrollment to those who have fulfilled, or are fulfilling, the other requirements of the option for clinical engineering. We also require an interview with the course instructor. The educational goals of clinical internships are many, and the priorities among them are not unanimously agreed upon. We feel that it is most important to foster the ability to communicate with both health professionals and patients. This requires not only factual knowledge of the kind which is not easily taught in engineering laboratories, but also a sympathy for medical traditions and a selisitivity to patients' dignity and vulnerability. We expect each student to spend some time in clinical services. He should have some idea of what is done, what equipment and techniques predominate, what the concerns are. Second, the internship provides support for the engineer in this difficult period of adjustment. Once on the job, the
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IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, MARCH
new graduate will assume an unusual degree of independent responsibility in the absence of sympathetic coworkers who have experienced similar disorientation. Thus, the period of the internship includes weekly sessions at which all students come together to share their experiences and compare their approaches. Third, the internship, through a project, attempts to demonstrate the practical constraints on applied engineering in hospitals, and it aims to temper the students' enthusiasm for purely technological solutions. Students see the wide variation in technical sophistication among users of medical equipment. (Not incidentally, the project also serves to repay our clinical associates for their investment in student supervision, and to foster interest in Biomedical Engineering among the hospital staffs.) Finally, we would hope to give the students an appreciation of the hospital as an enterprise: where resources come from, where they are spent, and how they are managed. In the past academic year the faculty participating in this internship program included two practicing clinical engineers (one in the V.A. Hospital affiliated with the University of Pittsburgh School of Medicine, the other in a local private hospital), both on the program faculty. The students were four engineering seniors, three electrical and one mechanical engineer. The course was scheduled for six hours in the Spring Semester. It began with supervised visits to clinical services: the intensive care unit, open heart surgery, central supply, cardiac catheterization laboratory, hemodialysis, obstetrics, and diagnostic ultrasound, as well as lectures by hospital physicians and administrators. About four weeks into the semester, students began work on independent projects under the supervision of hospital staff. This year the projects included a study of outpatient service operations, analysis of open heart "pump reports," instrumentation for a pacemaker clinic, and an evaluation of a prototype fetal monitor. The results of the internship have been, from the students' point of view, quite rewarding. The students performed well in the hospital environment, and we have found no complaints from the hospital personnel or significant problems in student-clinical cooperation. The students were generally enthusiastic about their experience, although (as we had expected) each was somewhat disappointed in the progress he had made in his project. Following our evaluation of the past year's program, we have made some revisions in our plans for following years. First, the scheduled time will be spread over two semesters, with a single semester hour in the Fall during which all supervised hospital visits and lectures will be included, and five semester hours in the Spring devoted exclusively to independent project work. We also intend to expand to non-teaching city and suburban hospitals as well as those in the University Health Center complex. V. CONCLUSIONS
Interest in the undergraduate Bioengineering option has grown in the short period since its origin. Enrollment is summarized in Table I. Students enroll in the option at the
1975
TABLE I ENROLLMENT OF STUDENTS IN UNDERGRADUATE, BIOTECHNOLOGY OPTION Number of Students
Graduating Class in
No. of Students
1974 1975 1976 1977
5 14 13 22
TABLE II DISTRIBUTION OF STUDENTS AMONG DEPARTMENTS FOR ACADEMIC YEAR 1973-1974 Chemistry Chemical Engineering
Electrical Engineering Mathematics Mechanical Engineering Metallurgy and Materials Science Total
1 7 15 I 6 2 32
beginning of the sophomore year, so that total enrollment normally includes students from three graduating classes. The total enrollment for 1973-1974 was 32 students; for 1974-1975 this has increased to 49 students. The distribution of students enrolled in 1973-1974 is shown in Table II. While the largest constituency is from Electrical Engineering, representation from other departments is increasing. Average enrollment in the three undergraduate courses presently averages 25 students a semester per course and includes many students who are not enrolled in the option but who elect these courses. How has the change in structure of the undergraduate option affected the quality of the student graduate, and how well do these changes prepare the student for the variety of situations which he may encounter on graduation? The definitive answer to this question will come only after several years, when graduates in the program have had an opportunity to function in these areas for some time. However, it is important to recognize that a commitment has been made to training bioengineers for bioengineering positions and that our success in the program must be measured by how many graduates successfully pursue careers in the biomedically related professions either in industry, or in the hospital environment, or in the university, and not by their achievements in the engineering profession. We feel that the existence of the bioengineering program as an undergraduate option remains the most efficient organizational medium and provides a compromise between the individualized curriculum and the highly structured department. The flexibilitv inherent in the organization of the option has served us well in the restructuring of the program and in the implementation of our revised objectives for an undergraduate bioengineering curriculum. REFERENCES [1] "The Future of Training in Biomedical Engineering," Engineering in Biology and Medicine Training Committee of N.I.H., IEEE Trans. BAIE, Vol. 19, p. 148, 1972. [21 Plonsey, R., "New Directions for Biomedical Engineering," Engineering Education, Dec. 1973, pp. 177-179.
