Clinical training without the clinic

A School of Medicine program switched its in-person patient contact modules to a telemedicine format. And the director of the School of Nursing and Health Studies’ simulation lab brought two high-tech manikins home with her, so students could still use them to learn, albeit remotely.

As a result, half a dozen medical and nursing classes logged clinical training online, just in the first week after break, and that pace will pick up in weeks to come.

Education on the line

On April 2 and 3, 95 students in the UMKC nurse practitioner program interviewed and assessed 10 patients with varying health conditions, all without risking any contamination.

That’s because all the interviews were done by video conference — telemedicine style — rather than in person. And their “patients” were from the School of Medicine’s Standardized Patient Program, which has 60 people trained as medical actors to present dozens of possible conditions to student learners.

“Several training events had to be canceled in the immediate aftermath of the COVID-19 closures,” said Courtney McCain, the program coordinator. “Faculty members and I hurriedly emailed, phoned and Zoomed to come up with alternatives for our April events.”

As a result, the students in the nursing school’s nurse practitioner program had video conferences with their “patients.” Then they were rated on how well they interviewed them and took their medical histories, and on how well they communicated with them.

“Our standardized patients also are trained in constructively assessing how well the students communicate, which they will do after running through their scenario so the students can learn from these experiences,” McCain said. “Ordinarily, this exercise would have included a hands-on, physical exam. But we have modified its objectives to emphasize students’ ability to take a competent patient history and to communicate professionally.”

There were some first-week glitches, as bandwidth bottlenecks and software quirks were discovered. But five students who submitted comments were all positive about the exercise, which let them see their patient’s chart well in advance, so they could be prepared for the examination.

Two students, Tiffany Arnold and Abby Martens, said they had handled real telemedicine appointments shortly before campus shut down. The exercise “was very accurate, with no real difference from the visits I was doing in the last month,” Arnold said. Martens added, “I thought it was realistic. I worked with a physician one day a couple of weeks ago who did telehealth all day, and it was pretty similar.”

Another classmate, Catharine Cooper, said, “My actor was fantastic as a patient and really seemed like patients that I have seen in clinic, when I was at clinic.”

“This experience is helping us realize how much more we can do in a telemedicine setting. We’re growing our repertoire of simulations and possibilities.”
— Courtney McCain

McCain said some tweaks had been made after the first sessions, so things should go even better for the next large group of nurse-practitioner students who have a similar exercise. The first students for a revamped exercise in the School of Medicine program just happened to be from the nursing school, she said.

The program is overseen by Emily Hillman, M.D., director of simulation for the UMKC Clinical Training Facility. Hillman, an assistant professor, earned her M.D. and a recent master’s in medical education from UMKC. Now she and other faculty are devising the online versions of fourth- and fifth-year medical students’ clinical experiences in family medicine, pediatrics, surgery and in-patient hospital visits and treatment.

McCain has been with the Standardized Patient Program since 2011 and has seen the number of training scenarios it presents grow 450 percent. Now, as challenging as it is to shift all clinical training online, she sees an opportunity for more growth and creativity. A recent international webinar with other directors of standardized patient programs also gave her some more ideas and troubleshooting tips.

“It’s been a crash-course in new technology, along with everything else. We are rapidly making lemonade,” McCain said. “This experience is helping us realize how much more we can do in a telemedicine setting. We’re growing our repertoire of simulations and possibilities, so if the COVID-19 closures continue, we’ll be in a good position to continue delivering scenarios to students so they’ll have minimal interruption in this portion of their studies.”

Smart use of dummies

Christine Zimmerman’s house recently added a couple of occupants, but she didn’t have to put them on her Census form. Her guests, one adult and one child, are manikins from the nursing school’s simulation lab.

Nursing students normally spend hours in the school’s high-fidelity simulation lab, managing patients with complex clinical issues while practicing assessment and communication skills. When Zimmerman heard that access to campus buildings would be greatly restricted, she got the idea to set up a smaller version of the lab in her basement.

“We have nine manikins, but I can adapt most simulations with these two,” said Zimmerman, who has a master’s in nursing education and a Ph.D. in nursing from UMKC, in addition to her R.N. “They breathe; they blink. They’re computer controlled. You can monitor their heartbeat and other vital signs.”

Students can’t come to her house, but groups of around eight meet online and can see and guide Zimmerman’s assessment of the patients. Other simulation staff members are online, too, and can speak for the manikin as the students ask questions.

The class members can discuss the case among themselves, but they have to be tactful about what they say in “earshot” of the patient. And if they decide medicines are needed in a particular scenario, they can make a virtual stop by a “meds station” Zimmerman has set up. There she can hold labels up to the camera so a student can verify that the right pharmaceutical is being dispensed.

Zimmerman started the lab sessions the Tuesday after spring break and is running four or five a week, as she usually does when she has access to the full lab.

“The sessions run either four hours or eight hours,” she said. “We cover a lot of ground, and I’m pleasantly surprised with how successful this transition has been.”

Students agreed. Madison Putnam, a senior nursing student, said, “I am grateful UMKC and Dr. Zimmerman have found ways to continue to provide us nursing students as much ‘hands on’ education as possible.”

Natalie Patton, a junior said, “Dr. Zimmerman’s recreation of SIM lab was amazing. And it was wonderful to work with more of my classmates than an in-person simulation would have provided. Though we had to take turns talking, the online format did not impede our communication at all, and we were able to efficiently work together and save the patient in crisis.”

Zimmerman also said it was a bonus for her to have a whole group of students online so she can hear their discussion of cases, something she can’t normally do when a class huddles up out of her earshot.

“If anything, they are more focused on the critical thinking and clinical evaluations they have to do,” Zimmerman said. “Of course, I’m sorry for the situation that makes all this necessary, but I enjoy the challenge and the need to take a creative approach to these challenges.”