Hands-on learning hard to replace in health sciences


There’s no virtual substitute for practicing surgery or the detailed hand skills of dentistry in person, so Pitt’s schools of the health sciences are finding innovative ways to adapt to the delay in clinical opportunities and laboratory access.

They are moving up didactic work — lectures and literature reviews, for instance — to earlier months and pushing hands-on experiences later in semesters. They’re also creating more chances to work with sophisticated simulations for learning other skills.

The School of Medicine, for one, has suspended its clinical rotations. Inpatient sites don’t have enough personal protective equipment to cover them, and patient volumes at outpatient facilities “have decreased significantly,” said Jason Rosenstock, interim associate dean for Medical Education and associate professor of psychiatry. “It made it not really educationally viable” to continue rotations.

While New York State, for instance, has instituted emergency licensure to allow those nearly ready to graduate to help in their overwhelmed health facilities, Pennsylvania hasn’t seen the need to do so yet. “Our UPMC residencies have said that they can’t start early,” Rosenstock added — and UPMC takes a third of Pitt medicine graduates, he said.

The school is now hoping they’ll get the go-ahead to restart clinical rotations in June. In the meantime, medical students are learning other important skills: they are using simulations to perform patient physical exams, reviewing video virtual cases and practicing telemedicine.

The first two years of the school’s curriculum is now entirely online, as are the didactic curricula of the other health sciences schools, using Panopto video, real-time lectures, large group discussions and small-group work on Zoom. Medicine’s hundreds of third- and fourth-year students have moved out of hospitals and clinics and into month-long remote electives, such as the 58 who are now in the online course Pandemic in Medicine and Society. Rosenstock describes it as “a mix of medical humanities and science,” including the history of medicine in plagues and epidemics, involving microbiology and pharmacology.

Medical students conduct research across all four years, and “every student is developing a backup plan” for their projects, he said, such as focusing for the moment on data analysis and literature reviews. “They’re all working with their mentors to see what that might look like.”

NURSING: Accelerated programs offer greatest challenge

Similarly, School of Nursing students have been prevented from undertaking clinical experiences in outpatient settings, physician practices, the Allegheny County Health Department, Pittsburgh Public Schools, daycare facilities (for children, older adults and those with disabilities), and home-care settings.

Instead, said Jacqueline Dunbar-Jacob, dean and distinguished service professor of nursing, faculty members have employed case studies, discussion boards and online simulations that let students make choices and virtually handle equipment to continue to receive clinical learning, so that “no one has to take an incomplete.”

There have been some speedbumps, “but for the most part, faculty have been working successfully with online delivery and we have not had complaints from students,” she said. “They are anxious to be back on site.”

One challenge comes from nursing’s accelerated three-semester program toward a nursing bachelor’s degree, for those adding to a previous non-nursing bachelor’s degree. These students must fulfill a state board-approved curriculum with hands-on clinical experiences. Dunbar-Jacob said the school is hoping for the chance to re-up clinical instruction at the end of June but realizes such instruction may have to wait until the fall. The school’s master’s and doctor of nursing practice students are awaiting a similar decision.

 “The one thing that we’re seeing in all areas of health care delivery,” she said, “is this incredible mounting of telehealth interactions.” For instance, pediatric nurse practitioner students are doing online visits with children and their family members in community service programs. The “birth of telehealth services,” she said, “is probably going to be here to stay in many instances.”

DENTAL MEDICINE: Degree completions still on track

The School of Dental Medicine didn’t have an extra week to adapt its classes to online-only, said

Melanie Reyes, the school’s curriculum development administrator for academic affairs. They had a weekend, she said, but the transition “was relatively smooth.”

Most seniors due to graduate “had a significant portion of patient experiences completed,” Reyes said, and had already passed regional licensure exams and national board exams required for entry-level practice. School faculty members have developed a virtual clinical curriculum customized to individual student needs, which allows students to finish an experience in, say, endodontics that hadn’t quite been completed. “Their critical thinking and clinical skills are still being challenged in a virtual environment,” she said.

 “The area that’s been most challenging for us is the pre-clinical environment” — the simulation laboratories where dental medicine and dental hygiene students develop the hand skills and fine motor movements needed for their professions.

“We can’t really offer that from a distance; there is no substitute,” she said. But to allow students to practice by themselves, faculty are posting demonstration videos for review. “We are going to have a lot of students” needing to make up experiences, she added, and are already discussing the eventual restart of the “sim labs” with socially distanced simulations — maybe breaking students into smaller groups and spreading individuals apart physically.

But dental students are still practicing their communications skills — active listening, empathy, motivational interviewing — with people who are role-playing patient types. But they’re doing it via Zoom, instead of in-person, with their faculty facilitator observing virtually. Senior case presentations, usually presented to a faculty panel that quizzes the student about their evidence-based treatment rationale, are done on the same platform.

“It’s been challenging,” Reyes said, “but honestly it’s been — I hate to say the word ‘rewarding,’ because I know there’s been so much devastation going on with the pandemic — but given what we’ve faced we’ve had to come up with innovative ways to present things.”

HEALTH AND REHABILITATION SCIENCES: Creative alternatives for more than two dozen programs

The School of Health and Rehabilitation Sciences has developed “creative alternatives … to clinical skills labs, competency assessments and clinical fieldwork,” said Debora L. Miller, the school’s vice dean and faculty member, as “traditional on-campus skills labs and clinical fieldwork placements have been suspended.” 

Each of the school’s 27 degree programs has different field work or clinical placements, and different clinical competency skills that need to be assessed. And their laboratories specialize in teaching people skills.

Students in the prosthetics and orthotics program, for instance, normally use their clinics to learn to make these devices, practicing how to cut and fabricate them alongside representatives from manufacturing companies. Sports medicine students usually work with student athletes, and physical therapy students need to learn manual therapy skills based on individual patient needs.

So, while “there are clinical field placements that are going to have to wait” for hospitals and nursing facilities to re-open to students, this school also is employing simulations. “Each of the accrediting bodies has been fluid in responding to COVID-19,” Miller said.

The doctor of occupational therapy program, for example, has partnered with a practice in rural Pennsylvania — Capable Kids pediatric rehabilitation clinic in Hermitage — pairing OT students with patients and their family members for telehealth visits “where patients are underserved and where patients maybe don’t have access” to visit physicians personally in the best of times, Miller said. This provides “an avenue for continuity of care” for these patients “and an opportunity for students to accomplish fieldwork requirements with a novel skill.”

In the masters of science in physician assistant studies, one usual assessment measure — preceptor evaluations — has moved to Zoom and been modified to let students evaluate virtual patients. Practicing physician assistants play the roles of patients with common disease cases, and students are asked to develop ways to educate such patients about their individual conditions.

The doctor of audiology program also uses commercially available Simucase software as well as computer-based virtual patients developed by the school’s clinical instructors, based on patient data from UPMC audiology clinics.

The school has created a template to allow these instructors to “present patient data, a bit at a time,” Miller say, “prompting dynamic student interactions like completing case history questions, planning evaluation methods, interpreting results, planning treatments, evaluating outcomes, (and) completing documentation.” This allows students to continue working with their previously assigned field faculty members as well.

And for the bachelor of science in emergency medicine program, faculty members are conducting Zoom cardiology labs, with ECG strips converted to PowerPoint slides. They then use an online rhythm generator to hear each strip’s rhythm, then learn to run a monitor defibrillator that helps them judge whether a cardiac event is happening and manage each particular simulated cardiology station.

“Our number one commitment,” Miller said, “is to ensure the high-quality education programs and clinical experiences for our students, despite the COVID-19 crisis.”

Marty Levine is a staff writer for the University Times. Reach him at martyl@pitt.edu or 412-758-4859.


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