A Disorienting Orientation to Simulation

Inside Abraham Lincoln’s tomb; photo by Anna Bartosik

My training and education is weighted heavily towards language learning and teaching; specifically, learning and teaching English as an additional language.

My research focuses on self-directed language teacher development in digital landscapes.

I am reasonably confident about my abilities in these two realms; on a good day, I think I am not a bad teacher in a classroom environment.

None of this was adequate experience for my trial by fire last week.

I had a disorienting orientation in the world of medical simulation.

In Springfield Illinois, home of Abraham Lincoln and the Dana Thomas Frank Lloyd Wright house, the Southern Illinois University School of Medicine offers standardized patient training for teaching and assessment. Within the first hour on Monday, I was knocking on the door of an examination room. On the other side sat Mrs. Reynolds, a 70+ year old who had come to the clinic because of her recent falls. Before entering the room, I had approximately 30 seconds to read the chart on the door with her vitals and instructions for the encounter. I assumed her temperature, listed in Fahrenheit, was normal, but I stopped dead when I read I was expected to do a complete history and physical diagnosis in twenty minutes. A lack of clinical experience, apparently, was dismissed as a poor excuse when I tried to back out. The facilitator smiled and pushed me through the door.

“In you go.”

Simulation Room; photo by Anna Bartosik

Mrs. Reynolds sat in a typical examination room next to a table filled with gauze and tongue depressors. Polished, petite, and polite, she greeted me with a smile when I came in. Thankfully I managed to remember her name and asked her if I might sit down across from her. At that moment, I wasn’t sure if the session was being recorded, even though I saw motion cameras in the room. I looked at the two-way mirror. Someone was likely watching.

Ignoring the pounding in my chest, I started by asking Mrs. Reynolds why she had come to the clinic that day.

“A fall. I had a fall.” She offered this information to me confidently.

“Where did you fall?”

“I fell. In my apartment.”

“You fell in your apartment? Did you fall in the bathroom—I mean– restroom?” Suddenly hyperaware of my Canadian English, I panicked. Is it a bathroom at home and a restroom in a public space? Best not to think about it.

“Yes, in my apartment.”

I have played Twenty Questions with my students, which helped me strategize my questions. I found my first clue. My second clue was Mrs. Reynolds’ socks. They didn’t match.

“Can you tell me about the last time you fell in your apartment? Can you describe what happened?”

Mrs. Reynolds looked at me blankly for a moment, then replied, “I fell. I fell in my apartment.” More confident now, I targeted my questions to complete Mrs. Reynolds’ history.

My questions from that point prodded about memory and cognitive tests such as recalling everyday items I had recently recited to Mrs. Reynolds. I also asked Mrs. Reynolds to draw a clock. It is ridiculously depressing how much information you know how to collect when you have a personal family history of dementia and Alzheimer’s.

The knock on the door telling me that the 20 minutes was up came sooner than I thought. I was led to a debriefing room with a trainer and asked about my perspective on the session. The trainer also shared with me the case history for Mrs. Reynolds, as well as the diagnosis and differential diagnoses. More relief that I had correctly diagnosed her.

Immediately after the debrief I saw my next patient. He had just been diagnosed with HIV/AIDS after a routine blood donation. I’ll share more about this emotional experience in my next post.

All ten of us participating in this training had encountered the same two scenarios, played by four standardized patients (SPs). We all met together afterwards to receive collective feedback from the SPs. It provided us an opportunity to quiz the SPs about their approaches to playing cases. Their level of professionalism and investment in contributing to medical education impressed all of us.

Finding connections between medical education and language teaching is rarely successful for me; the past year in my job has been an immersive learning experience. This time, however, the connection was clear.

Simulation in medical education is the best kind of task-based learning I’ve ever seen. Medical students have to encounter 12 different types of cases before graduation at the school I trained at. These simulations and SPs ensure students will receive the appropriate exposure and training before encountering real patients. In fact, the students encounter both real and standardized patients concurrently at later stages of their education. The diagnosis is not the goal of the encounters; it’s the process, communication, and the building of empathy which is paramount. Research shows that medical students’ communication skills deteriorate over time (Junod Perron et al, 2015), and this type of regular simulation helps students maintain higher levels of empathy and communication. All simulations are recorded and students can access them to review at any point during their education. This is the standard for simulation everywhere. Medical students encounter SPs at least once a week in Illinois; residents encounter them weekly as well, in addition to seeing real patients. I wish pre-service language teachers had access to this kind of scenario training in their education. I recall with embarrassment the missteps I made in my early years of teaching. Working through difficult scenarios not directly related to teaching content would have been invaluable. One of the medical students, when questioned how seriously he treats SP encounters, said:

“I’d rather have the chance to make a fool out of myself and have a bad memory of negotiating an emotional or difficult encounter in a low-stake setting. At least I’ll have something to draw on if I encounter a patient in similar conditions.”

In the next few days I built scenarios with medical professionals that these standardized patients ran through with us. I trained SPs to mimic physical symptoms of various illnesses. I played an SP. I learned some make up tricks. I also took the lead on one of these scenarios.

Out of my comfort level? It’s worse than the first settlement English class I taught.

Interesting? I wish language teacher training and education focused on task-based learning to this extent.

Relevance to other teaching contexts? The Bulimia scenario one team developed was designed to run alternatively with a male and then a female patient, to see if interns treat and diagnose patients differently. The domestic violence case accommodated SPs playing both same sex and opposite sex partners. One scenario included a transitioning patient, but it’s just a detail in the scenario – the patient is experiencing back pain – it’s not the focus of the scenario. Communication and empathy in simulations account for 50 percent of the mark. I took this training in the Midwest, and no one said “Oh, no, I can’t do this scenario with my students. They come from [insert name of conservative place] and will be too [insert adjective] to make this work.”

I saw so many unmined opportunities for simulations (task-based learning) for pre-service language teachers in language teacher education programs. I know task-based learning makes an appearance in language teacher education programs, in varying degrees, but its focus is on language teaching, not language teachers. A practicum doesn’t match this experience. It’s not a simulation – you’re already teaching real “patients” on your first try. The experiential learning process of simulation – run the simulation, debrief as a group, teach according to gaps in knowledge, run the simulation again, reflect – this process would be more effective in language teacher programs than a sole practicum experience. Training “standardized language learners” and utilizing them in case-based scenarios, providing feedback to the teacher, giving pre-service teachers a “do-over”, having pre-service teachers reflect on the process…invaluable.

I think nursing programs and medical schools are getting it right. We trust medical professionals for advice, and their competency-driven/simulation education approach is the rule, not the exception. Why can’t we augment strategy-based language teacher training with experiences language teachers will most likely encounter?

More to come.

References:

Junod Perron, N., Sommer, J., Louis-Simonet, M., & Nendaz, M. (2015). Teaching communication skills : Beyond wishful thinking. Swiss Medical Weekly, 145(0708).