NHS UK is faced with shortage of teachers and patients as most patients are treated in community outside hospitals- Dr. Vikram Jha


Proceedings of Simulations conference organized by UHS Lahore

NHS UK is faced with shortage of teachers
and patients as most patients are treated in
community outside hospitals-Dr.Vikram Jha

We must learn the art and science of medicine and
use real patients which are many-Mowadat H. Rana

Cost effective simulation material including
Manikins can be produced locally-Prof.Tariq Mufti

LAHORE: The first plenary session during the Simulations conference held at University of Health Sciences from November 20-22nd had four speakers. Dr. Vikram Jha from University of Liverpool was the first speaker who spoke on involving real patients in health professional’s education.  He talked about patient narrative to promote patent safety, awareness, active patients units in the educational process, patient’s involvement in education policy and patient safety.  Patients feel that nothing should be done about them without telling them. In the National Health Service these days there is a teacher’s shortage and patients shortage. Majority of the patients are now treated in the community out of hospital. He also referred to the financial problems as it is run on business model. Role of patients in medical education is referred to by the British Medical Associaton as well as the General Medical Council. He also talked about the rational of patients’ involvement.

Vice Chancellor UHS Prof. Maj. Gen. Mohammad Aslam presenting
mementoes to Dr. Gohar Wajid and Dr. Usman Mahboob during
the Simulations conference.

Research evidence refers to the notion of experts, enhanced knowledge and self management.  Satisfaction is the major advantage for the patient. Patient’s exposure is enhanced and at times student do not seem to be interested in patients impact. Patients learning are a journey working in partnership. He emphasized the importance of developing objectives of teaching sessions. He also referred to the dramatizing theory, patient’s centeredness, and patient’s story triggering emotional response. We must learn from discussion and restore patient’s faith in the doctors, he added.

Prof. Tariq Mufti from Rehman Medical Institute was the next speaker whose presentation was on “Bridge between basic medical sciences training and clinical practice. He gave details of a cost effective clinical skill center which they have developed at Rehman Medical Institute. He was of the view that there is a misconception that there is nothing which the West can learn from developing countries. He also talked about the safety of patients and trainees, standardization of training.  We have trained students in clinical skills on simulations. He then showed the urethral catheterization, developing skin sheets and production of cost effective Manikins locally.

Prof. Amar Zaman Khan Prof. of surgery at  FJMC presenting mementoes to Prof. Vikram Jha,
Dr. David  Taylor,Dr. Gominda, Prof. Khalid Masood Gondal and Prof. Mowadat H.Rana
during the Simulations conference organized by UHS at Lahore last month.

Dr. K. Mohana from Keele University School of Medicine was the next speaker who made a presentation on Simulation in global world. She discussed the use of simulation in assessment which was a case study. Clinical Skills assessment was used for the exam of Royal College of General Practitioners. The pass percentage of UK graduates was 90.3% whereas the pass percentage of International Medical Graduates was just 34.7%. She further stated that at least one third of UK doctors are trained overseas and almost 13% of residents were born outside UK. We are now moving towards globalized education, she remarked.


Dr. Asad Zaheer Registrar UHS presenting a mementoe to one of
the guest speakers at the Simulations conference.

Dr. David Taylor also from Liverpool highlighted the importance of adult learning theory to simulation. Clinical teaching, he said are essential but there are real considerations. Simulation mirrors and augments actual practice. Simulation, he opined has a place in teaching and training and so has the patients. Simulated patients play roles while Manikins are complete simulations.  Ethics and education are drivers and it is an effective method of education. He also talked about rehersal of skills, rehersal  of situations. Feed back, he felt, was extremely important in using simulation. Give the students regular feed back and find solution to the problems so as to do better next time. Speaking about the elements of simulation he mentioned perfection, briefing, encounter, de-briefing, feed back, reflection and evaluation.  Learning by doing is better. He then mentioned about reliberating practice and building up professional identity.

During the discussion the importance of patient friendly learning environment, cost effective patient simulation and learning friendly simulation were discussed in detail. It was felt that we can learn from our mistakes and move forward. Globalization of curriculum and localization practice also came under discussion. One of the participant said that one can learn invasive procedures which  can be practiced better on simulation but diagnostic procedures like palpation are not possible. Simulation has got some constraints. Prof. Tariq Mufti’s efforts to produce indigenous Manikins and simulation material were commended and it was stressed that we should plan for local manufacture of Manikins which will be must cost effective.

Prof. I.A. Naveed along with Maj. Gen. Hannan presenting a mementoe to one of the guest speakers
at the Simulations conference held at UHS recently. On right the picture shows Maj. Gen. M. Aslam
VC UHS, Prof. Humayoun Maqsood Principal FMDC and Mr. Shaukat Ali Jawaid Chief Editor Pulse International.

In the afternoon session Dr. Gominda Ponnamperuma from Sri Lanka talked about role of simulation in assessment. He was of the view that in the long run one long case and one short case will not be enough for assessment. For those simulations comes in.  We need to assess application of knowledge. Use many assessors, many situations, patients and simulations repeatedly.  Achieve objectivity and standardization. We must use real life situations in assessment. He also discussed the standard safety methods. If you talk to the candidates after the examination, some will say I failed because I was not up to the mark, some will say that everything I knew was not in the examination. Examinations are good for bookworms because they are too theoretical. We need to lay emphasis on assessment of application of knowledge. Some students may say he got difficult patient in the examination.  We need to assess taking more time and using overtime. Some students might complain that the exam was too difficult as compared to the last year. That is why we should aim at replication of comparable situations, he remarked.

Prof. Khalid Masood Gondal Regional Director of CPSP Lahore gave details of e log system which the CPSP is using in monitoring of the residency programme.  He pointed out that at present there are 19,251 trainees being trained by 208 supervisors and video conferencing facility is used for monitoring. The residents are now inducted only twice a year and it has been streamlined, curriculum has been structured, training is competency based and e log system is used for evaluation. It is also more helpful in data collection and research. About 20-30% trainees do have some problems with the e log book but this is a feasible authentic option for developing countries, he remarked.

Prof. Mowadat H. Rana talked about challenges and opportunities in Pakistan as regards simulated patients. He started his presentation with a quotation from Caliph Hazrat Ali that “sources of our pain and pleasures are the same”.  He then talked about learning by trial and error method and also referred to See one and Do one philosophy. He also referred to the strength and weakness of simulated patients, limitations of simulation. We have some medical colleges with no teaching hospitals. No patient, hence simulation is going to come and it will happen. There will be no patient who will be thankful as the contract with the patient won’t be there. We will have actors to play the role of schizophrenia patient.

Picture on left shows Dr.David Taylor, Prof. Musarrat and Dr.Amina Ahmad during the Simulations conference
while on left Dr. David Taylor is presenting certificates to the workshop participants.

Continuing Prof. Mowadat H. Rana remarked that if we look into the reality, we have no dearth of patients. Public hospitals have long list of patients waiting for the doctor to examine them.  He wondered why the private medical colleges cannot be involved in looking after this pool of patients. Public and private medical colleges can join hand and share the patient. In return the private medical colleges should pay some percentage of the student fee to the public medical college hospitals. We must learn the art and science of medicine and use real patients which are many, he remarked. It was generally felt that though simulated patients have a great role to play but how to use them in Pakistan needs to be looked into. Replacement of real patients is an important concern.  Simulated patients will no doubt minimize harm. We must try to reduce trauma to the patient. Simulations, it was felt, was inevitable in obstetric and gynaecology.

On Day Two of the conference Dr. Slumpff was the first speaker who talked about use of virtual labs in teaching of physiology. She discussed in detail teaching physiology, building problem solving skills, training of students in use of technical equipment, practicing mathematical skills and data evaluation, inventing new approaches in diagnosis and treatment to educate scientifically minded doctors. She then demonstrated how they divide one hundred eighty students in fifteen groups and there is one instructor per group.  Ten different units are in each group. For experiment the students are supposed to read the manual and come prepared for the experiment. It is essential that students pass all ten units but those who miss a unit, they must repeat it.  It is a real life experiments which provide hands on experience but it requires trained staff and special expensive equipment. All these experiments are computer based, she added.

Dr. Gohar Wajid from Dammam Saudi Arabia was the next speaker. His presentation was on DEEP approach: Building team based team assessment.  He first referred to Knowledge, Skills and Attitudes for novice to experiment. He also talked about inter professional education and collaboration and how to assess a team. Miller Pyramid was also discussed to assess the individuals. For assessment of a team, technical skills, critical thinking, inter professional skills are important. He also talked about delegation, collaboration, leadership and respect for the team members. DEEP he said stands for Delegation, Elastic, Establish and Procedures.  Simulations can be used in different variety of team assessment. It can be used for staff training in management of mass casualties. A combination of various simulations can be used to assess team performance but it does require deeper understanding, he remarked.

Prof. Maria Andredes from Aga Khan University made a presentation on Development of a Bank of standardized patients. She was of the view that patient safety becomes a problem as patients are reluctant to be used for teaching purposes. There is a change in diseases from acute to chronic. Hence the standardized patients are carefully coached to simulate as actual patients. They are used for teaching communication skills, teaching clinical skills. It does have some disadvantages as it may become an ideal text book. It is expensive and leads to medicalization of standardized patients. It is important that they are trained in an efficient way and their retention is also important for question answer session. She then showed how these standardized patients are used for MRCGP Examination in South Asia. This exam is held in four countries in Asia including   Sri Lanka, Pakistan and India. They have trained eighty standardized patients of which thirty three are in Pakistan and forty seven in Sri Lanka. This bank of standardized patients does not have any paediatric simulated patient. De-briefing of the SPs is done routinely.  We provide regular feed back to the SPs.  They are afraid of their own health and they feel uncomfortable in intimate relationship. There is a demand and recognition of standardized patients. To decrease the cost of examination one should get SPs and they can also be used to evaluate curriculum, she added. The examiners provide feed back regularly. SPs are tried in later part of the examination and the case is made simple by adding few lines.  She concluded her presentation by stating that development of a bank of standardized patients will go a long way in ensuring validity and reliability of training and assessment.

Dr. Usman Mahboob from Khyber Medical University spoke on teaching professionalism. He was of the view that we can use simulations for teaching and we need to use professionals to improve patient safety. For this we use simulated patients. He then referred to the attributes of a professional doctor like how he deals with the patients, how to deal with colleagues, working in a team, dealing with other healthcare professionals. Knowing one’s limitations, dealing with conflicts. We must include sufficient time for delivering while using simulated patients. Simulation, he opined, has a role in medical education but it cannot replace real patients. He further stated that in debriefing, real learning takes place. These days the teacher’s role is more of a facilitator rather than instructor. Simulations can be used in assessment programmes in medical education in Pakistan, he stated.

Summing up the deliberations Major Gen. Hannan who was chairing this session said that Army has always used simulations for wars. We always used simulation in labs. However, simulation will remain simulation and it will never achieve the status of reality of near reality. We must remember our first and foremost objective should be doing no harm to the patient. We must always keep this in mind. We must look at our appliances, look at their maintenance and make best use of them. He also emphasized the importance of judicious use of simulation and said that simulation should be safe for the patient but it can be dangerous if you do not know your equipment well, he remarked. 

Lt. Gen. Afzal Ahmad Principal CMH Medical College Lahore was the first speaker in the second session. He pointed out that Skills Labs are available in most of the medical colleges and with the passage of time all the facilities will improve. The question arises why to go for Simulation and the answer is to avoid errors. In highly developed countries like United States a study had revealed that thousands of medical errors take place in healthcare facilities and some of them prove to be fatal but in Pakistan we do not have any such data and the situation could be very depressing. By adopting simulations, patients benefits as they are not exposed to un-necessary errors. Physician is more competent and is not involved in any litigation. There is also a great potential for the industry to come forward and join hands with professionals which will also create lot of jobs. Prof. Tariq Mufti from Peshawar has shown that it is feasible and practical and we can produce indigenous simulation material. We will have a better product and it will also be cost effective. It is essential that we have trained manpower. He also advised the authorities to remove taxes and duties on the import of Manikins while local industry should be encouraged to produce Manikins and improve their standards.

The teaching by Simulation should be incorporated in our teaching methods and assessment. He suggested that a Task Force may be constituted which should look into ethics and its professionalism in our healthcare workers. A curriculum has to be worked our  for Simulations and this Task Force can come up for guidelines in this regard, he added.

Prof. Noshad Sheikh VC Liaquat University of Medical and Health Sciences was the next speaker who gave a Third World perspective as regards Simulated and Standardized patients in Health Professionals Education. He pointed out that there can be low tech and high tech simulators. For use of Manikins we need skilled trainers. The standardized patients are carefully coached to pose as real patients. However to enhance our knowledge and skill, attitude we have to use live patients. Otherwise the students may be good theoretically but they won’t know the skills. Deaths on the operating tables, amputations are reality hence we need simulators to teach skills.

At times you may come across a patient who does not want four to five medical students to do his PR examination. How can you let them learn on someone’s child? One also comes across a situation when the patient says they do not want to be operated by junior surgeons. There is a very thin line between training of learners and protecting rights of the patients. It is an ethical dilemma. Aviation industry, military and Nuclear power have been using simulations for long time. Healthcare has lagged behind in adopting simulations.  We at LUMHS have established medical skills labs, dental skills lab, nursing skills lab, Endo trainer are available in the Laparoscopy Training Center. We have Lap mentors for training of surgeons. Speaking about the challenges he mentioned shortage of human resources, resistance to change, redesigning the curriculum, train the trainers, validation, funding, legislation and endorsement by the PM&DC.

Dr. Masood Jawaid Assistant Professor of Surgery conducted a workshop on Gamification using
PowerPoint at SIMS Lahore during the Simulations Conference organized by UHS recently.
Picture shows  Gen.Aslam, Mr. Shaukat Ali Jawaid and Prof. Hamid Butt Principal SIMS at the
workshop while on extreme left is Dr. Masood Jawaid the workshop facilitator.

Dr. Rukhsana Ansari talked about overcoming pitfalls in assessment in OSCE using simulated patients. She started his presentation quoting Sir Osler who once said that “Good Physicians treat Disease but Great Physicians treat the Patient.” She pointed out that there has been a significant increase in the use of simulators in teaching. Simulators are now easily available any time. We need to improve the standard of our General Practice by combining expertise with knowledge. Using simulators there was a 47.92 pass percentage in OSCE. Some of the problems which were encountered were the limited number of cases. Now we have developed standard OSCE Bank. Interested motivated doctors were included in the pool of faculty. Twenty four applied of which nine were taken on Board. We train the standardized patients; have daily debriefing of these SPs. It ensures improvement in communication skills and also improves practice. It has gone a long way in improving the image of the FPs, Family Physicians scientific esteem has increased and their knowledge about women health has increased than before. The take home message she said was evaluate, implement changes, adhere to develop procedures and embrace change in positive way.

The next presentation was by Iqbal Khan and Saeed Shafi from Azad Kashmir Medical College, Muzzafar Abad Azad Kashmir. They pointed out that they have been using simulated patients and integrated curriculum from the very first day. Clinical training is started form the very first day of medical school. However, patient safety is our main concern. Simulated patients are used widely.  A survey conducted among student showed that 92% felt, simulated patients are useful for clinical training and 95% agreed to continue this programme. The advantage is that it avoids patient’s exposure to un-necessary risks. However, one needs strong institutional leadership to implement it in resource constrained countries. Establishment of Skills Labs should be mandatory but it will not replace the real patients. Hence, both simulated patients and real patients should run side by side,

During the discussion judicious use of resources was emphasized since these simulators and Manikins are very expensive. Some participants suggested that since the patient in public teaching hospital gets free treatment, they should be asked to serve as teaching material. One must treat patients with dignity and self respect. Either one can go for cost effective simulators or use standardized patients was the other option.

Later in the concluding session Dr. David Taylor remarked that while we should use this new technology but we should always keep in mind its limitations. Mr. Shaukat Ali Jawaid Chief Editor Pulse International said that many important issues have been discussed during the two days conference.  He was glad to note that the speakers while highlighting the usefulness of simulation have also talked about their disadvantages and limitations. It was also gratifying to note that patient safety, judicious use of resources and Do No Harm to patient’s figured in the deliberations. All these are extremely important issues as regards ethical medical practice. He further stated that a sub-committee of Health Care Ethics Committee of National Bioethics Committee headed by Prof. Farhat Moazam has almost finalized the draft of the Bioethics Curriculum to be taught to undergraduate medical and dental students. Once it is approved by the NBC it will be forwarded to the Pakistan Medical & Dental Council for implementation.

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