A N e w A p p r o a c h to T e a c h i n g N o r m a l H u m a n G r o w t h and D e v e l o p m e n t The Role of Clinical Simulations as a Teaching and Evaluation Device for Preclinical Medical Students Drora Selinger, MD, Sabina Cohen, PhD, and Anna Schiffmann, MD Hebrew University--Hadassah Medical School

ABSTRACT: A new approach to teaching Normal Growth and Development to preclinical medical students is described. By using specially constructed multidisciplinary clinical simulations as training and evaluation devices, students were gradually and simultaneously exposed to: (1) subject matter; (2) the concept of multidisciplinary health care delivery; and (3) the objectives, strategies, and techniques of problem solving and diagnostic reasoning that characterize experienced physicians. The course, designed by a child psychiatrist and medical educators, was taught by a multidisciplinary teaching team drawn from faculty and health care representatives. Student evaluations of the course were favorable.

Expert physician performance is characterized by subject matter competence, diagnostic reasoning (including early provisional hypothesis generation), [ 1 ] an understanding of doctor-patient interaction, and technical proficiency. Though their relative importance may vary from one medical discipline to another and, indeed, from one patient to another, the role of these components, whatever additional ones may yet be identified, seems firmly established. If we accept that one of the goals of undergraduate medical education is to train students so that their performance, at all stages, will resemble as closely as possible that of the expert physician, then medical school curricula should include gradual and graded training in each of the components and their integration into the desired professional performance pattern. Requests for reprints may be sent to Dr. Drora Selinger at the Office for Research and Development in Medical Education, Hebrew University-Hadassah Medical School, Jerusalem, Israel. The authors are grateful to Miss L. Karp for her help in the preparation of the manuscript. Child Psychiatry and H u m a n Development, Vol. 8(4), Fall 1978 0009-398X/78/1400-0239500.95 9 H u m a n Sciences Press



Child Psychiatry and Human Development

It may be assumed that medical diagnostic reasoning is a specialized application of the more general process of problem solving. [2] l~cent research has shown that problem solving skills cannot be demonstrated or taught without some medical subject matter content, and that knowledge of specific disease entities, alone, does not account for differences in problem solving performance. [3] The revised experimental course in Normal Human Growth and Development (G and D) described in this article was based on the simultaneous teaching of subject matter, some of the initial steps of the problem solving process, and the fundamentals of doctor-patient interaction. The course was taught during the 1975-76 academic year to second year medical students for w h o m it was the first clinically oriented instructional setting at the preclinical stage of the six years undergraduate curriculum at the Hebrew University Hadassah Medical School (HUHMS). Description of the Course

Organization G and D was allotted 72 curricular hours (36 two-hour teaching sessions). In addition, an instructor serving as a tutor-consultant was available in the library two hours a week for individual consultations in conjunction with the required readings and the preparation of weekly exercises. Student


The entire class of second year medical and dental students (124) participated in the course.

Teaching Staff Academic and administrative responsibility for course construction and implementation were assigned to a child psychiatrist who is a member of the HUHMS' Department of Medical Education. Senior and junior teaching staff included the then a~ting chairman of the Department of A n a t o m y (an anatomist/pediatrician specialist in teratology), a pediatrician who is a member of the HUHMS Department of Social Medicine and works in the Hadassah University Hospital Well Baby Clinics, four child psychiatrists, and a clinical psychologist from the Department of Pediatrics and Child Care.

Selinger, Cohen, and Schiffmann


The choice of a child psychiatrist from the Department of Medical Education to design and direct the course, the disciplines represented by the teaching team and the orientation of the participating guest lecturers, all reflected a conception of medicine which may be summarized as follows: 1) At every stage of his medical training, the student must be made aware that the physician, whether a pediatrician or other specialist, deals with a human being--a body-mind complex in ceaseless interaction who must be considered in his entire social, environmental, psychological, and medical context when problems are defined and a course of therapy planned; 2) Every physician, whatever his specialty, should be capable of providing psycho-social first aid with equal comfort, skill and satisfaction as medical or surgical treatment;[4] 3) The study of growth and development must be firmly anchored in an understanding of the normal which, in turn, must serve as the point of reference for an ever increasing awareness of and ability to detect, define, and deal with the abnormal; 4) Every physician must develop the skills necessary to communicate with representatives of other medical specialties and allied health professions in order to create effective and meaningful teamwork.

Objectives o f the Course The objectives of the course were to: 1) Introduce the processes of normal growth and development; 2) Enable students to recognize and identify deviations from normal growth and development; 3) Train students to analyze behavior as an expression of developmental stage(s) and personality in a given situation; 4) Develop students' awareness of the multiple causes, both physical and mental, of signs and s y m p t o m s and the interaction(s) of these causes; 5) Train students to use the initial steps of the problem solving process (cue detection, grouping, analysis and problem formulation) and to provide them with opportunities to practice their application to diagnostic reasoning and recording;[2] and 6) Train students to identify problems b e y o n d their area of competence or present interest, and to design an appropriate and practical plan for dealing with them, i.e., consultation, referral or collab-


Child Psychiatry and Human Development

oration with representatives of other medical specialties and health professions. Subject Matter Physical growth and motor, cognitive, language, affective (psychosexual), and psycho-social development during early childhood, school age, adolescence, adulthood, and old age comprised the subject matter of the course, with a major emphasis on the first three stages. Methods and Materials Self-learning based on the use of four paper and pencil clinical simulations designed especially for second year medical students (Developed in the HUHMS Department of Medical Education, supported by Grant No. 169 from the U.S. Israel Binational Science Foundation.) readings in normal growth and development, instructor moderated group discussions, and frontal lectures were the main teaching methods. A general description of the course objectives, the simulations accompanied by detailed instructions for their use, and a list of required and suggested supplementary readings bound together in w o r k b o o k form were distributed to students at the beginning of the course. The first four lecture hours were devoted to an explanation of the course objectives, an outline of the areas in normal growth and development viewed as dynamic interactions of many factors, and an introduction to the first steps of the problem solving process and their application to medical recording using the Problem Oriented Record (POR). Each of the clinical simulations represented a patient with a growth and development problem(s) and was based on the records of the Growth and Development Evaluation Unit of the Hadassah University Hospital. Some or all of the following were included in each simulation: (1) Data base (physical and psychological); (a) subjective; (b) objective; (2) Information on previous medical consultation; (3) Results of previous medical and psychological examinations; (4) Patient's past history; (5) Family history; and (6) Description of patient's and, when appropriate, family members' behavior in the presence of the physician (during interview/examination). Each simulation centered on one stage of the Growth and Development process and was used for several exercises, each of which focused on a specific area of the stage. For each area, students were asked to read the'

Selinger, Cohen, and Schiffmann


simulation and the relevant literature listed in the w o r k b o o k , and to complete three tasks. Task I

1. Identify and list all of the problem cues dealing with the specific area, e.g., motor development. 2. Categorize these problem cues as subjective or objective data. 3. Identify and list all cues suggesting deviations from the normal (absolute, pathological abnormalities, developmental lag). Task H

1. Group the problem cues listed in Task I(3) which suggest deviations from the normal according to their c o m m o n cause (origin) and a relationship among them as expressed by the specific sign or symptom. 2. Analyze the interactions among the problem cues reflected in the described signs and s y m p t o m s data. Task III

Formulate the problem, i.e., generate a provisional hypothesis. Students' early problem formulations (hypotheses) and the reasoning underlying them were then defended, revised, or discarded during the weekly group discussions devoted to the influence of the particular area being studied on the course of normal growth and development. The topic of each group discussion was announced one week in advance. For each session, students were divided into groups of six. Instructor designated group representatives were responsible for presenting the general consensus of their groups based o n each member's individual reading and completion of the required simulation based exercise at each general gro.up discussion. Each group discussion was summarized by the instructor who also presented an analysis of the same problem emphasizing behavior as an expression of ego development. The weekly lectures were delivered by a multidisciplinary team of guest lecturers representing the various health professions (e.g., medical specialists, clinical psychologist, special education consultant, speech therapist, dietician, physical and occupational therapists, and social workers). Each lecturer presented a general description of his specialty, an introduction to its language and basic diagnostic tools,


Child Psychiatry and Human Development

and examples of their use in the evaluation of normal growth and development and in interdisciplinary diagnosis and treatment. Evaluation

The final examination consisted of three parts, each covering a different chronological stage in the process of h u m a n growth and development. Parts one and two were required of all students and consisted of a simulation exercise on the subject matter of early childhood and a multiple choice section on the subject matter of school age and adolescence. In part three, students were given a choice of simulation, multiple choice questions, or short answer essays on adulthood and old age. Thirty-six of the 124 students chose the simulation. The simulation exercise on early childhood was an open book examination requiring the same three tasks that the students had practiced during the course. Task one, cue detection, called mainly for lower level skills of recognition and recall of information, while tasks two and three, problem formulation, called for the higher level cognitive skills of analysis and synthesis in the formulation of patient problems. Prior to the examination, two physicians who had served as teachers during the course were asked to complete the exercises. Eighty percent of the average of the combined number of cues t h e y detected was set as the m a x i m u m (100%) to be expected from students. The same procedure was used for determining the standard for problem formulation. Extra credit was given in cases where a student presented an especially clear, accurate and inclusive analysis of the data. Students were given two scores for their performance on the simulation, a score for task one, cue detection, and another combined score for tasks two and three, problem formulation, which required mainly synthesis, a higher level skill. The overall class mean performance on cue detection was 68.7% (S..D. = 15.5), while the mean for problem formulation was 71.0% (S.D. = 12.3). A t test showed that these means were n o t significantly different from each other (t = = 1.59, nonsignificant), giving the impression that students performed similarly on these two types of skills. A more in depth analysis of student performance, however, revealed a low, though statistically significant, correlation between the two sets of scores (r = .37, p ~ .01), indicating that there were m a n y students who performed differentially on the two tasks of the simulation. This group is of particular interest because the current approach to clinical studies emphasizes higher level skills. We found that a great

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Table I R a n g e of D i f f e r e n c e S c o r e s b e t w e e n S t u d e n t P e r f o r m a n c e


T w o P a r t s of t h e S i m u l a t i o n E x a m i n a t i o n R a n g e of D i f f e r e n c e in S c o r e s

N u m b e r of Students


0 - 3



16.1 )

4 - 7



24.2 )

8 - 12 p o i n t s


17.7 )

13 - 16 p o i n t s


12.9 )

17 - 20 p o i n t s


8.9 )

21 - 24 p o i n t s


5.6 )

25 a n d e v e r

18 Total



14.5 )



many students in the class performed substantially higher or lower on cue detection than on problem formulation. Table 1 shows that 42% of the class (52 of the 124 students) had a difference in their two scores greater than the mean difference of 12.5 points. Of the 52 students with the large differences in their subscores, 21 performed better on cue detection and 31 performed better on problem formulation. Since clinical simulation exercises had previously n o t been used during the second preclinical year at HUHMS, we wished to analyze

T a b l e II Student Ratings on Examinations Responding


Question: W e r e t h e e x a m i n a t i o n s a s u i t a b l e m e a s u r e of the c o n t e n t a n d s k i l l s y o u a c q u i r e d d u r i n g t h e course?

( n = 41) Yes


Simulation Exercise



Multiple Choice Q u e s t i o n s




Child Psychiatry and Human Development

student attitudes towards this teaching and evaluation device. At the end of the course, 65 students volunteered to fill in a special evaluation questionnaire anonymously. Students rated the relevance of the course to medicine quite highly (mean of 7.4 on a scale of 9 points). On another part of the questionnaire, 41 of the students rated the simulation versus the multiple choice examination as measures of the subject matter content and skills acquired during the course (see Table 2). The fact that 80.5% of the students who responded to this part of the questionnaire felt that the simulation exercise on Early Childhood was a fair indicator of the subject matter content and skills they had acquired during the course, while only 46.5% thought so for the conventional multiple choice examination, augurs well for the use of simulations in future examinations. Discussion The second year of the HUHMS curriculum is a crucial one because after a year of premedical studies on another campus, it is the student's first contact with the medical school-teaching hospital environment. To it he brings his ideals, expectations, demands, anxieties, and conceptions or misconceptions of his chosen profession and the studies upon which he has embarked. Mixed with their feelings of superiority at having been granted admission to a restricted, carefully selected elite, students are often uneasy, unsure of what to expect, of what will be expected of them and whether they will be capable of meeting these demands. Several of the difficulties that arose early in the course seemed to originate, at least in part, from these conflicting feelings of superiority and anxiety. Students often complained that what was being taught "wasn't medicine," "wasn't relevant to medicine," "wasn't enough," or "was superfluous" because it had already been "covered" during another course, e.g., Introduction to Psychology. On the other hand, some students expressed anger at being presented with demands, i.e., assigned tasks, which they feared they couldn't perform. This was most apparent in relation to problem formulation, medical recording, and the physician-patient relationship. Sometimes it seemed that students felt that they were expected to be capable of performing, and had forgotten that they had come to learn and their teachers to teach. A partial solution to these problems was to repeatedly refer to the course objectives during the group discussions, to enlarge upon them in relation to the specific student complaints and the task demands, and to explain that the course was designed to provide many oppor-

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tunities for the practice and gradual mastery of specific skills (learn, ing by doing). The subject matter studied, the required exercises, and the choice of multidisciplinary guest lecturers and the material they presented, were discussed in the light of their relevance to medical practice. The fact that those who completed the a n o n y m o u s evaluation questionnaire rated the relevance of the course as high (mean of 7.4 on a scale of 9 points) is interesting n o t only in itself b u t in view of the fact that during the previous year's G and D course which covered the same subject matter but did not include simulation exercises, students had complained about t h e lack of relevance for the practice of medicine, and the class representatives had even asked that the course be eliminated from the curriculum. The importance of acquiring the skills necessary for locating, organizing, and integrating information on a given topic was reinforced by pointing out that in this way it is possible for a physician to follow up an area of special interest or to acquire sufficient knowledge to function adequately, or to make an appropriate referral to, or to collaborate with others in an area b e y o n d his competence. Self learning was selected as a major instructional approach for t w o reasons: (a) the belief that it is necessary in the development of the future seeker-learner at every level of medical training and practice; and (b) research findings which have demonstrated that when appropriately planned and directed, it can save time for additional subject matter and/or more in depth study [5] and practice. At the beginning of the course, however, t w o problems arose in this area. The first, c o m m o n to many countries where much of the scientific literature is in a second language (in our case English), was that many students needed considerably more time for reading the material than had originally been thought and sometimes found parts of it difficult, if n o t incomprehensible. Moreover, many students had n o t had sufficient opportunities to acquire the skills necessary for combining selflearning with tutor-consultant aid. They were not always able to pinpoint their individual difficulties (e.g., subject matter, language), frame their questions, integrate tutorial assistance into their study schedules and habits, and organize and use the material that they had read in connection with the required exercises and group discussions. Because of these difficulties, subject matter acquisition was slower than had b e e n originally anticipated, some of the group discussion and lecture time had to be devoted to a review of basic material. Second year students do not y e t have the skills necessary for collecting a data base (the first step of the problem solving process) which can only be acquired by supervised interviewing and examination of


Child Psychiatry and Human Development

real patients or trained actors. Simulations based on actual case records provide this data without exposing students to real patients which, in some cases, may be detrimental, or at least uncomfortable, for both, and allow the learner to start with cue detection, the second step of the problem solving process. The use of simulations also makes it possible to control the quantity, type(s) and level of difficulty of data to be included or excluded in relation to course objectives, thus allowing students to concentrate on a gradually increasing number of aspects and the interaction(s) among them. If we hope to train future physicians to see each patient as a total human being, a body-mind complex functioning in a given environment, and to understand normal and abnormal behavior as an expression of a developmental stage, personality, and situation, so that they can analyze and effectively interact with patients in order to collect and interpret a diversity of data and make appropriate management decisions, there is little need to belabor the necessity for psychiatry, the academic-medical representative of the mind c o m p o n e n t to accept a larger role in nonspecialist, undergraduate medical education. Teaching undergraduate medical students about the contributions of other health and associated professions and disciplines to medical care is still a matter of controversy. By inviting a broad spectrum of guest lecturers to explain and demonstrate their professions' contributions to the diagnosis and treatment of growth and development problems at the same time that students are studying these problems, we hoped to create an early and natural exposure to the concept of patient centered interdisciplinary health care based on consultation, referral, and collaboration. How much of this orientation students will carry with them into their clinical studies remains to be seen. Growing awareness of patient centered medical care as a team operation helped students to appreciate the importance of standardized medical records to be used in all medical settings by all of the medical specialties and allied professions and of learning how to use them. At present, the POR is the most practical and well developed standardized medical audit. This was one of the reasons, albeit n o t the major one, why we selected it. For us, POR was more important because it provides the most practical instrument for the systematic application of the problem solving m e t h o d to health care and health care record-keeping and "can be the teacher's basic tool because it is the single repository which documents the reliability, thoroughness, critical analysis ability, and efficiency of the student relative to the objective presented before him."[4] Only partial evaluation of this course was possible--the degree of


Selinger, Cohen, and Sehiffmann

subject matter acquisition and the ability to use the first steps of the problem solving process. The degree to which students will be able to use and develop these skills in other medical settings, e.g., the 3rd year Introduction to Clinical Medicine course and later rotating clinical clerkships, will have to be carefully examined. Therefore, we have designed a longitudinal study which will follow students from the beginning of their second year through the completion of their undergraduate medical school training and into their professional career patterns. References 1, Elstein AS, Kagan N, Shulman LS, et al: Methods and theory in the study of medical inquiry. J Med Educ 47:85, 1972. 2. Weed LL: Medical Records, Medical Education and Patient Care. Chicago, Year Book Medical Publishers Inc, 1969. 3. Berner ES, Bligh TJ: How content specific is medical problem-solving? In University of Illinois College of Medicine, Center for Educational Development, Report to the Faculty 1974, pp 16-21. 4. Grant RL: The Problem-Oriented Record--A tool for teaching and evaluation o f learning in the new psychiatric curriculum. Presented at the conference on Evaluation of Learning in Psychiatry, Chicago, 1972. 5. Mager RF, McCann J: Learner Controlled Instruction. Varian Associates, 1962.

A new approach to teaching normal human growth and development. The role of clinical simulations as a teaching and evaluation device for preclinical medical students.

A N e w A p p r o a c h to T e a c h i n g N o r m a l H u m a n G r o w t h and D e v e l o p m e n t The Role of Clinical Simulations as a Teaching...
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