Conference on Cybernetic Modeling of Biological Systems 2021

End of May 2021 DID-ACT partners participated in the International Conference on Cybernetic Modeling of Biological Systems (MSCB), a conference hosted by Jagiellonian University in Kraków, Poland in hybrid mode. Online participation was facilitated via MS Teams. MCSB is a series of international conferences that has been hosted in Krakow, Poland since 1978 and are repeated usually around each fifth year. The conference planned in 2020 had to be rescheduled due to the COVID-19 pandemic outbreak. Finally, the conference was held 28-30 May 2021 and had more than 170 registered participants and 69 presentations. The MCSB meetings are organized by Jagiellonian University Medical College and AGH University of Science and Technology – two large universities in Krakow with differing history and profile. The goal of the MCSB events is to bring together researchers from biomedical sciences and technology to work together and present joint projects. The initial scope of the series of meetings was cybernetic modeling of biological systems. This covers for instance how computers can simulate the way a human ear functions, model behaviour of a robo-dog or development of a beehive. Through the years the themes discussed at the conference have expanded and include now also computer modeling for the purpose of medical education or eHealth. The variety of topics is visible in the MCSB 2021 conference program. Computer modeling of clinical reasoning for the purpose of training in health professions fits well into the current scope of the conference.

The presentation Clinical reasoning learning analytics – How to visualise and measure the invisible? by DID-ACT project members Andrzej Kononowicz, Martin Adler, Ada Frankowska and Inga Hege started by presenting a clinical reasoning model by Bernard Charlin and colleagues. This model inspired development of a clinical reasoning tool based on concept maps led by Inga Hege and is in use internationall). The scope of the speech was on how to summarise using learning analytics methods (numeric metrics and graphical presentation in form of dashboards) the process of clinical reasoning learning by students for the purpose of feedback and deliberate practice. Examples were presented from the virtual patient platform CASUS. This presentation was a good opportunity to disseminate the outcomes reported in the DID-ACT project D5.1 deliverable on developing a set of evaluation and learning analytics tools for the student curriculum and the train-the-trainer course.

The second presentation related to DID-ACT presented that day was by Ada Frankowska. The focus of her work was to analyse students’ perspectives on how navigation through the content of interactive patients is perceived. The common methods are linear, branched and template-based models. The students expressed their preference for branched models, but the results were tight and delivered many pros and cons of each approach. Interesting was to see how themes like attitudes towards personal errors, opportunities for reflection and feeling of authenticity emerged from the data. These findings are important from the perspectives of research as they give insight into how students use virtual patients, what they see as valuable affordances and what they still miss. We can learn from that how to design DID-ACT curriculum learning units to make them attractive and helpful for students.The MCSB 2021 conference abstracts including DID-ACT presentations will be available in a special issue of the Bio-Algorithm and Med-Systems journal published by De Gruyters which has a similar profile as the conference. The next MCSB conference is planned for May 2025.

Participants: Medical educators

Learning units: Person-centered approach and the role of patients
Level: Teacher

Description: Offered as part of the faculty development to faculty educators.
Mode: Part to the faculty development program with emphasize on the educational potential of clinical reasoning teaching techniques

Technical Integration: Access to the DID-ACT Moodle, synchronous sessions were held via the virtual platform NewRow.

Tips & Tricks:

Participants: Multi-professional educators (nurses, physicians, paramedics)

Learning units: What is Clinical Reasoning and Models
Level: Teacher

Description: Offered as additional faculty development opportunity to staff members of the Medical Education Department.
Mode: Option / additional part to the faculty development program with emphasize on the educational potential of clinical reasoning teaching techniques

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face.

Tips & Tricks: Give participants time to familiarize themselves with the learning material between the sessions. Do not put too much in one day - better to meet twice for shorter sessions. Face-to-face sessions lead to more productive discussions than Zoom meetings. Focus on discussion with the audience and on examples from practical teaching to illustrate the learning objectives.

Participants: Multi-professional educators

Learning units: Differences and similarities in clinical reasoning among health professions
Level: Teacher

Description: Offered as part of the faculty development program, it was held as a blended learning course with the synchronous phase online.
Mode: Part of the faculty development program with certificate

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held online via Zoom.

Tips & Tricks: Give good practical information how Moodle works and how the participants can find and work with the different assigments of the learning unit. Emphasize the importance to the participants to work with the different individual tasks, as the discussions will be more interesting and fruitful. Also important that all the participants from different occupations feel comfortable to meet and that they all are a part of the discussion. This is an important and maybe the primary task for the facilitator!

Participants: Multi-professional and international educators

Learning units: Clinical Reasoning teaching and assessment & What is Clinical Reasoning and Models
Level: Teacher

Description: Offered as optional learning unit for participants of the Master of Medical Education (MME) program in Bern/Switzerland.
Mode: Part of the faculty development program with certificate

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face.

Tips & Tricks: To foster a valuable learning experience it is indispensible to provide good case examples that are tailored to the needs and experiences of the participants, so that they can relate to their prior knowledge. Thus, the provided examples in this learning units might need some adaptations for your target group of educators.

Participants: Multi-professional educators across German-speaking coutries

Learning units: Differences and similarities in clinical reasoning among health professions
Level: Teacher

Description: Offered as part of the faculty development program at the University of Augsburg, but open to participants from Germany, Austria, and Switzerland. It was held as a blended learning course with the synchronous phase online. Participants were eager to exchange their experience and disucss their views across institutions and professions.
Mode: Part of the faculty development program with certificate

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held online via Zoom.

Tips & Tricks: To foster a valuable interprofessional experience the participants should represent a balanced mix of professions and also ideally the facilitators should at least represent two different professions. This allows a good discussion and also guarantees that the small groups can work interprofessionally. Our experience with a less-balanced group composition was that the over-represented profession dominates the discussions and it was quite difficult to counter-balance this.

Target group: Medical students in year 2

Learning units: Person-centered approach to clinical reasoning
Level: Novice

Description:The Learning Unit was run as an extra-curricular session as a virtual class. The facilitators were trained on this topic by attending the Train-the-trainer learning unit on "Person-centered approach and the role of patients".
Mode: Extracurricular activity

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held online via NewRow.

Tips & Tricks: Learning objective cross-referencing with the existing curriculum helps identify the level of integration. Encouraging and helping students to get familiar with Moodle before the session facilitates a smooth integration of the asynchronous phases.

Target group: Medical students in year 4 and 5

Learning units: Generating differential diagnoses and deciding about final diagnoses
Level: Novice

Description: The learning unit was integrated into a pediatric emergency department clerkship with a relation to virtual patients already used in this clerkship. Facilitators were trained by attending the train-the-trainer unit on "Information gathering, Generating differential diagnoses, Decision making, and Treatment planning".
Mode: Part of a regular curricular activity

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face.

Tips & Tricks: Integration into clerkships works well, especially with a relation to already used content.

Target group: Medical students in year 1-6

Learning units: All 25 learning units of the DID-ACT curriculum
Level: Novice - Advanced

Description:
Longitudinal integration of the DID-ACT learning units into a clinical skills & communication course with the following suggested distribution across years:
Year 1: What is Clinical Reasoning, Person-centered approach to clinical reasoning, Health profession roles in clinical reasoning, and Biomedical Knowledge & Clinical Reasoning. (Required time in curriculum ca. 5 hours / semester)
Year 2: Dual Process Theory, Illness scripts, Collect and prioritize key clinical findings/problems, and What is clinical reasoning and How can theories be put into practice (Intermediate). (Required time in curriculum: ca. 4 1/2 hours/semester)
Year 3: Generating differential diagnoses and deciding about final diagnosis, Biases and cognitive errors - an Introduction, Analyzing and avoiding errors. (Required time in curriculum: ca. 4 1/2 hours/semester)
Year 4: Using the Outcome Present State Test Model, Developing a treatment plan, Metacognition, reflection and models for reflection, Collaboration of health professions in Clinical Reasoning (Intermediate). (Required time in curriculum: ca. 6 hours/semester)
Year 5: All remaining intermediate learning units: Shared Decision Making in Clinical Reasoning, Decision Support Systems, Ethical aspects - patient management and treatment, Uncertainty. (Required time in curriculum: ca. 5 hours/semester)
Year 6: All 6 advanced learning units: Collaborate with others in clinical reasoning, Decision Support Systems, Biases and cognitive errors, Uncertainty, Metacognition, reflection and models for reflection, Analyzing and avoiding errors.
(Required time: ca. 6 hours / semester. Final year students often have a day/week off from clinical work so these days could be used for DID-ACT learning units and optional participation in the train-the-trainer units)
Years 1-5: Virtual Patients (VPs) as additional deliberate practice activities in increasing number and complexity (e.g. starting with 5 VPs (=ca. 1.5 hours)/semester) in Year 1 and increasing to 10 VPs/semester) in Year 3-5.
Mode: Integrated into a clinical longitudinal course that runs from year 1 to 6 resulting in a total of 2.4 ECTS.

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions face-to-face or online.

Tips & Tricks:
Alining a longitudinal curriculum with curricula of other health professions remains a challenge and requires careful and early planning, but the asynchronous phases might be a good starting point for interprofessional teaching sessions. The VPs can be quite easily aligned with other curricular courses e.g., based on key symptoms.

Target group: Medical students in year 3

Learning units: Person-centered approach to clinical reasoning
Level: Novice

Description: The learning unit was integrated into the Laboratory Training of Clinical Skills. This course consists of six face-to-face meetings for groups of around 10 students. Within the meetings the students discuss various topics related to communication skills and person-centered approach. The fifth of the six meetings of the course was replaced by the DID-ACT learning unit. Students could then refer back to this learning unit during final session of the course.
Mode: Part of a regular curricular activity

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face. If possible, a uniform technology to provide access to the online resources in the class (using university tablets in our case) and support of the technical staff on-site was helpful to lower the technical barrier.

Tips & Tricks: Changing of the standard format of classes is interesting and motivating for the students. Virtual patients are a tool to present authentic clinical scenarios which are appreciated by the students. A blend of role-play and virtual patients allows students to take advantages of the two methods to reach the learning objectives.

Target group: Medical students in year 2 and nursing students in year 3 across Europe

Learning units: Collaboration of Health Professions in Clinical Reasoning
Level: Intermediate

Description:
This learning unit was implemented with , aside from clinical reasoning, tow additional objectives: 1) providing internationalization experience for students without traveling. 2) Deepening the knowledge of one's own professional roles and responsibilities and knowledge of another profession .
Mode: Extra-curricular interprofessional learning session with international participants

Technical Integration: Self-registration on DID-ACT Moodle, synchronous sessions via zoom.

Tips & Tricks: Facilitators running this course and supporting the discussions should be careful about supporting and encouraging all the participating professions' perspectives.

Target group: Medical students in year 1 and 2 (preclinical) across Europe

Learning units: Introduction into Clinical Reasoning & Health profession roles in clinical reasoning
Level: Novice

Description: The course was offered as a blended learning module to students from different medical schools in Europe as an international elective. Synchronous phases were held online via Zoom. The international aspect was very motivating for students and they learnt a lot from each other by exchanging their perspectives and how they are taught clinical reasoning vaspects. This teaching mode could also be implemented as an activity to welcome or prepare new Erasmus students. Facilitairs were trained by attending the train-the-trainer learning unit on "Differences and similarities in clinical reasoning among health professions".
Mode: Elective course

Technical Integration: Self-registration on DID-ACT Moodle, synchronous sessions via zoom and use of Padlet for interactivities.

Tips & Tricks: The organization with the registration of students was a bit complex, so, we suggest just setting dates and let students book. Allow enough (more time) for discussion and introduction rounds as participants do not know each other and are eager to hear and learn from peers at other schools and countries. Ideally, this session could also be held interprofessionally, however, it makes the finding of suitable dates even more complex.

How to teach synchronously in a virtual setting

  • You need a reliable camera, microphone, and virtual platform and be familiar with its features, such as whiteboard, chat, polling, breakout rooms, etc.
  • At the beginning establish communication rules, e.g. whether participants should raise their (virtual) hand, use the chat, and/or just speak. Also, we recommend asking participants to turn on their camera
  • For small group work break out rooms work very well, just be clear about the tasks the groups should work on prior to dividing them into the groups.
  • For collaboration the use of integrated virtual whiteboards or other platforms such as Padlet are very useful. Just make sure prior to the session that you have everything setup and the links at hand, e.g. to post them in the chat.
  • Allow a bit more time for starting the session and the group works as there might be participants who are not familiar with the platform or technical problems might occur.

How to motivate unprepared participants

  • Make clear that the asynchronous assignments are a core part of the course and that its content will not be repeated. Even if it is difficult, stick to that when starting the synchronous teaching session.
  • If you expect unprepared participants, you can start the session with a student-centered group exercise mixing prepared and unprepared students to increase peer-pressure and make them realize that being unprepared does not feel good.  
  • Use the introductory or closing quizzes / tests so that participants can self- assess whether they have the required knowledge and you as a facilitator can see the level of knowledge and preparation of your participants.

Further recommended reading:

How to involve participants with different levels of experience

  • To account for such different levels, we recommend making use of the asynchronous preparatory phases which also include introductory quizzes in which participants can self-assess their prior knowledge and you as a facilitator can assess the differences within your group. Participants with less prior experience can also be guided to additional preparatory resources.
  • Encourage participants to work in pairs or small groups when preparing so that they can help and learn from each other. You could even facilitate this by dividing them into groups with different levels of experience.
  • Similarly, during the synchronous phases, we recommend forming groups with participants different levels of experience and emphasize the peer support aspects of such group activities.
  • We also recommend starting with rather smaller groups and allow more time than stated in the course outlines, if you expect a heterogenous level of experience. This way you can better manage this challenge.
  • Encourage your participants to ask questions, emphasizing that nobody knows everything and that it is important for learning to ask questions.  
  • Especially in the train-the-trainer course you might have to deal with over-confident participants, who especially in an interprofessional setting can dominate the group. This is a complex cultural challenge, but you could try to establish (and follow) communication rules at the beginning of a session.  

How to address potential overlaps or redundancies

  • Identify what is already included and what is missing in your curriculum related to clinical reasoning outcomes and compare it to the DID-ACT blueprint. Prioritize learning outcomes that are not yet covered but regarded as important.
  • Identify activities, resources, or teaching sessions with similar learning outcomes that might be in need for change anyway because of low evaluation results, teachers or students struggle with it. These could be suitable for adding or replacing parts with DID-ACT activities.
  • Ask teachers and students about overlaps and gaps they see in their teaching / learning of clinical reasoning and where they struggle. This could also be done by a reflection round after related teaching activities in the curriculum
  • Although ideally a longitudinal integration is aimed at, we recommend to starting small with a pilot implementation to gain experience and develop a show case.

How to teach in an interprofessional setting

  • Allow for enough time prior to the teaching for the organization and motivation / encouragement of stakeholders and participants
  • Allow for enough time and guidance during the course so that the participants from the different professions can get to know each other and their professions and discuss their different perspectives. This might mean that you need to calculate some extra time in addition to the suggested duration of the learning unit.
  • There may be a different understanding of clinical reasoning in the different health professions, so we recommend making participants aware of this. You could for example use and adapt activities from the learning units on the health profession roles to facilitate this.
  • Courses in an interprofessional setting should not come too early in the curriculum (not before professions have formed their own professional identity - however, this also depends on the aim of the course). 
  • Make sure you have enough participants from different professions. If possible, the facilitator could divide the participants in smaller groups with an equal distribution of professions. 
  • Similarly, you need an equal distribution of facilitators / facilitators from different professions.
  • Develop customized learning materials considering the different professions. If needed you can adapt the material and activities provided in the DID-ACT curriculum.

Further recommended reading:

van Diggele, C., Roberts, C., Burgess, A. et al. Interprofessional education: tips for design and implementation. BMC Med Educ 20, 455 (2020). (Link)

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