Experiences with development and use of simulation-based module for teaching family study skills to undergraduate medical students in coronavirus disease epoch

INTRODUCTION

The competency-based medical education (CBME) curriculum has envisaged the acquiring of certain competencies through the community medicine curriculum, which contributes to instilling in knowledge, skills, and attitude in a budding doctor.^[1] From the beginning, the separate study block for community medicine has been used for creating balance between clinical medicine, basic science, and community medicine in curriculum. Clinical social medicine, as seen in primary health care, cannot be taught in another setting as it does not exist elsewhere.^[2]

The teaching-learning methodologies of these competencies are mostly based in the field practice area. Field experience and community learning are indispensable for building a foundation into a competent IMG. The teaching of these skills has been done through the Family study methodology adopted by almost all the colleges throughout the country since long. Teaching family-centered health care is an important facet of medical education. Families are being used as faculty to teach first-person family-centered care.^[3] Community-based teaching through family visits is the core of medical graduates’ training.^[4]

The 4 weeks of clinical posting in 3^rd, 4^th, and 6^th Semester have been used for field training through allotment of families. The departments have been using clinico-psycho-social case studies or family presentations to focus on this clinical training. These are typical clinical case presentations with an added description of family members, socioeconomic status, dietary history, and household environment.

Adapting the framework of the Commission of Social Determinants of Health, a family study should: ^[5]

1. Identify the composite determinants of health affecting the particular family

2. Show how the major determinants relate to each other

3. Clarify the mechanisms by which these determinants act to decrease health

4. Provide a framework for evaluating which of these are the most important to address and map specific interventions for improvement of the health of the family.

Just like an index case (patient) is an entry point into a family, a family is an entry point into the community. Therefore, we also use the family study to gain insight into the larger health issues in the community. The appreciation of the economic, social, environmental, and emotional aspects in the medical problems should result in a change in their attitude and approach to patients. The end-point of a family study is a presentation made to faculty members. Usually, the focus of presentation and questioning is on the method of data collection, especially on clinical methods and dietary history. Evaluation of a family study includes equal weightage to the aspects of data collection, making diagnoses, web of interaction, and management.^[6]

For more than a decade, medical schools have been working to transform pedagogy by eliminating/reducing lectures; using technology to replace/enhance anatomy and laboratories; implementing team-facilitated, active, and self-directed learning; and promoting individualized and interprofessional education.^[7]

With the coronavirus disease 2019 (COVID-19) pandemic and its resultant concerns of social distancing, teaching family study skills became a big problem for the Department of Community Medicine. Even today, when we are at a decrease in the absolute numbers, the free interaction of students into community remains a challenge. Due to this alternative way of delivering these learning experiences became the need of the hour. The use of simulation was one answer.

Although simulation in medicine has been in vogue since the 9^th century when Madame du Coudray used mannequin pelvis and babies to train midwives for childbirth, its use became more rampant with the introduction of versatile human simulators by the late 1990s and early 2000s. Simulation has been used in training for the Departments of Anesthesia, Pharmacology, Physiology, Surgery, and Pediatrics to name a few for quite some time,^[8,9] but their use in Community Medicine to replace actual field experience has never been tried. Few studies on using simulation in public health have developed pre-analysis framework for network-based epidemic simulations for purposes of training students and novice researchers and gave framework reduction and extension examples in terms of collected geographic and demographic data.^[10]

Simulation is an educational strategy in which a particular set of conditions is created or replicated to resemble authentic situations that are possible in real life. Simulation can incorporate one or more modalities to promote, improve, or validate a participant’s performance.^[11] Simulation if properly planned has been studied to address the educational needs and domains as represented in the following Figure 1.^[11]

Close

Figure 1:

Domains addressed by Simulation models

Export to PPT

Simulation-based experience(s) are a broad array of structured activities that represent actual or potential situations in education, practice, and research. These activities allow participants to develop or enhance knowledge, skills, and/or attitudes and provide an opportunity to analyze and respond to realistic situations in a simulated environment.^[11] One way of simulation is use of standardized patient (also known as simulated patient). He is a person trained to consistently portray a patient or other individual in a scripted scenario for the purposes of instruction, practice, or evaluation.^[11]

Some guidelines are crucial while developing any simulation-based learning sessions. These include: – Performing a need assessment, developing learning objectives, structure the format, designing a case scenario of the context, create realism, facilitate the participant, pre-briefing, debriefing, evaluation of all involved and feedback session, provide resource and preparation material, and finally pilot test.^[12]

While online teaching has taken up most of the current learning platform, the teaching of these family skills cannot be compromised and has to continue even in the current scenario. There might arise a need to continue similar methodologies of training in the few years to follow. With this background in mind, the present study was planned for training undergraduate students of our medical institution to expose the students to community learning.

MATERIALS AND METHODS

RESULTS

The validation of the module was established by the internal experts on face and content validity parameters. The face validity was established based on the format and presentation of the module. The face validity was reported to be satisfactory (>70% on all items). The content validity was measured on various sub-criteria using individual items. The overall module content validation index (CVI) was found to be 0.95 and universal agreement (CVI-UA) was 0.75.

Various TL methods and resources used

Observation and report preparation of the video, followed by presentation by the students, recording the data and submission, case- based learning, PPT, simulated video on community walk, recorded video interviews with the health workers, Pro forma – Community Profile (Family Record Book), paper based case scenario, interactive session, briefing regarding various types of socio-economic scales and their uses, observation and report preparation from the videos, checklist pro forma, self-exercise to calculate socio-economic status of one’s own biological family, recorded video interview with family + Pro forma – family bio data and socio-economic status of the family (family record book), simulated patient interview by students using breakout rooms, interactive lecture, brainstorming, DOAP (role play), building a sketch map, SGD, AV aids, Video links, simulation exercise, simulated role play, simulated family, One’s own biological family, maids families, simulated mother of an under 5 child, case scenarios discussion, Chalk and Board, Zoom breakout rooms, printed case exercises, allotment of topic to groups, and simulated patient and case taking.

The various assessment methods used were: evaluation and feedback for the submitted case sheet, assessment of the environmental reports prepared by students, case presentation-nutritional assessment and diagnosis, including counseling and nutritional education, case based scenario, and simulated case presentations.

The sessions were held consequently using the module through the online mode and feedback of the students was obtained on Likert scale (ranging from 1 to 5). This is depicted as in [Table 1].

Table 1: Satisfaction level of students for family study sessions.

Topics	Median	IQR
Community diagnosis	4	3–4
Family biodata and socio-economic status	4	4–5
Environmental assessment	4	3–5
Nutritional assessment	4	4–5
KAP and family planning study	4	3–5
Immunization	4	4–5
Clinicosocial case discussion	4	3–5
Overall satisfaction	4	3–4

IQR: Interquartile range

[Table 1] shows that the median of satisfaction level of participants for all attended family study sessions is 4 (highly satisfactory) and interquartile range for most of the sessions lies between 3 and 5.

The satisfaction percentages of students with various sessions as well as overall satisfaction are shown as in [Figures 2 and 3].

Close

Figure 2:

Satisfaction percentage of students.

Export to PPT

Close

Figure 3:

Overall satisfaction of students.

Export to PPT

Thus, the overall satisfaction level was high in majority of students.

[Table 2] shows that the median of rating of students on various variables of the sessions is 4 (highly satisfactory) and interquartile range for most of them lies between 3 and 4.

Table 2: Rating of whole block of family study by students.

Variables	Median	Inter Quartile Range
Learning objectives	4	3-4
Scientific content and resource material	4	3-4
Teaching leaning methodology and assessment used	4	3-4
Guidance/facilitation provided by faculty	4	4-5
Overall learning experience	4	3-5

Figure 4 shows that overall learning experience of the participants for the whole block of the family study was good.

Close

Figure 4:

Overall learning experience of students.

Export to PPT

Similarly, feedback was obtained from faculty on Likert scale on the variables to rate the teaching block.

[Table 3] shows that the median of rating level by the faculty members for family study sessions is 4 and interquartile range lies between 4 and 4. About 100% faculty was satisfied with the overall teaching experience.

Table 3: Rating of whole block of family study sessions by faculty members.

Variables	Median	Inter quartile range
Learning objectives	5	5–5
Scientific content and resource material	4	4–5
Teaching leaning methodology and assessment used	4	4–4
Student participation	3	2–4
Overall teaching experience	4	4–4

Thematic analysis was done for the open-ended questions. Themes generated on qualitative analysis of the student and faculty feedback is depicted as in [Figures 5 and 6] for students and faculty, respectively.

Close

Figure 5:

Themes generated after qualitative analysis of feedback provided by students.

Export to PPT

Close

Figure 6:

Themes generated after qualitative analysis of feedback provided by faculty.

Export to PPT

The students were assessed on a global rating scale after the training. About 87.5% students were able to satisfactorily perform in the assessment conducted by the faculty after 2 weeks. The performance is shown in [Figure 7].

Close

Figure 7:

Pie diagram showing performance of students.

Export to PPT

Out of total 144 students, 18 (12.5%) scored unsatisfactory, 121 (84%) scored satisfactory, and 5 (3.5%) students excelled with excellent scoring.

DISCUSSION

A structuring approach to teach family study skills has been tried by authors in the past. Around 11 domains were identified by a study conducted by Krishnan et al. in 2017.^[6] In our study, we identified 7 domains under which the sessions were delivered and the final assessment approach was similar as in the referred study. The seven subtopics were structured with substituting the field visits by the various teaching-learning methodologies. The students were asked to work on their own personal families as a simulated family and generate all the relevant data related to them. The students worked on family demographic structure, socio-economic status, environmental assessment, nutritional assessment of family, and then all members, conducting KAP sessions on their family members with detailed communication recordings and immunization workouts. This was followed by the generation of clinic-social diagnosis and then generating an action plan. The teaching training methods used for simulation exercises were simulated patients/standardized patients, role plays, virtual tours, pre-recorded interviews with families/patients/ health workers, etc., and case-based learning exercises.

In the scenario of complete absence of field visits to families in the COVID situation, the student teaching training program was continued with the creation of the best possible alternatives to simulate the community setting experiences. Although the actual experience cannot be replaced, the students were largely satisfied with the efforts made by the faculty to teach family study. About 74% students were satisfied with more satisfaction being accorded to the teaching of immunization sessions, followed by biodata, socio-economic status, environmental, and nutritional sessions. The lowest satisfaction was reported for clinic-social cases as expected since we know that the actual case-taking experience is difficult to be replicated in controlled settings.

The overall satisfaction with the learning experience was about 70 % and around 30 % was average. Only 0.93% were not satisfied. The students reported satisfaction to clearly defined learning objectives, resource material provided, TL methods used, and assessment and were completely satisfied with the guidance provided by the faculty.

The teachers were 100% satisfied and had put maximum effort to achieve high-quality learning environment for students. However, they reported student participation to below.

The thematic analysis of the students and faculty responses to open questions was done. The positive aspects of the initiative were brought about nicely by the students and faculty. The problem areas were also identified, however at the same time, suggestions were made to overcome them. Some of the verbatims of the faculty are:

“the skills taught this way can help them for their actual interaction with community…”

“develop more videos for showing interaction with community…”

“…. help in communication skill development…”

“formative assessment and feedback improve students’ active participation and learning…”

The final crux that emerged was that simulated family study teaching was the only option of preventing the academic loss to the students in the COVID epoch. The use of technology and structuring of lessons by the faculty was the landmark innovation which worked successfully and was feasible and acceptable to both the teacher and the learner.

The profound effects of COVID-19 may forever change how future physicians are educated.^[7] The module is here to stay in case of any such future needs and can also be taken up for priming the students before taking up actual field sessions in the future. More and more resource generation can be done by collaborating with other departments/colleges and universities for validating this further.

CONCLUSION

A structured validated module using simulation-based teaching-learning methods was developed to impart family study skills to undergraduate students through online mode. The module was pilot tested and students and faculty were satisfied with the teaching using the developed module

The simulation-based technology can be used for online teaching in the subject of Community Medicine during difficult times to supplement the physical teaching sessions.