Manoj K Patel*_{MD (Hom)}¹_, ,
Devangini Broker, _{MD (Hom)}²
Prashant Tamboli, _{MD (Hom)}³

ABSTRACT

INTRODUCTION

The MLD Trust has been conducting the M. D. (Hom.) Course in 6 subjects since 2005-2006. Though the students bifurcate into their own subjects later on, there are a lot of mind-sets and skills that they have to develop right since the outset. The teaching faculty has thought that these must be boosted early on, so that their perceptivity improves. A project was taken up to bring about this change. Multimedia technology was utilized, in keeping with this techno-savvy age. This Paper brings to you this experiment and an analysis of the results.

AIM

To bring innovation in the M.D.(Hom.) course curriculum planning and teaching methodology for Part I students to enhance the skills of observations for better Homeopathic case-taking.

OBJECTIVES

To create the module using multimedia aids to teach Observation skills to postgraduate students. evaluating the changes in the observation skills learning at the end of the module

METHODOLOGY

The project was implemented in four categories: five sessions. All four categories travelled from gross to finer observations and, finally, to complex observations pertaining to the internal observer. Every stage was designed to increase different complexities of observation and documentation. Different aspects of multimedia like audio, video of life situations of patients, visuals of painting and clinical situations with didactic sessions – dramatic representation of doctor-patient relationship – and discussion on cases and history were used. Nineteen (16 female,3 male) MD Part I students were enrolled in the study. Evaluation was conducted after each session.

RESULTS

Significant changes were seen in various competencies, viz., identifying gross observations (p 0.00014), observations during the interview process (p 0.00014), observations regarding doctor–patient relationships (p 0.0002) and observing one’s own internal state (p 0.0002).

CONCLUSION

The module of observation skills produced significant changes in the above-mentioned skills of the post-graduate students. Multimedia technology was effective in imparting observation skills to the students. However, even when students are self-motivated, periodic supervision is essential to assess long-term benefits.

KEYWORDS

Multimedia technology, Postgraduate Homoeopathy, Observation skills, Internal Observer, Clinical Evaluation form, Transactional Record Analysis Form

¹ Prof and HOD, Department of Psychiatry and Director, Community Health

 ² Lecturer, Department of Repertory and Senior Research Fellow, Department of Research

³  Reader, Department of Repertory and Head, Department of Research,

Dr. M. L. Dhawale Memorial Homoeopathic Institute (MLDMHI)

*Address of correspondence: Dr Manoj Patel

Email: drpatelmanoj@gmail.com

How to cite this article:

Patel MK, Broker DR, Tamboli PP. Using multimedia for enhancing the observational skills of homoeopathic post-graduate students during case taking. Journal of Integrated Standardized Homoeopathy (JISH) 2018;01(01):1-11.

Received on: August 07, 2018

Accepted for Publication: September 20, 2018

 

INTRODUCTION:

Homoeopathy is a holistic health science based on the concept of Individualization. Dr. Samuel Hahnemann describes in Aphorisms 83 and 84 the qualities needed by the physician for Ideal Case Taking in Homoeopathy,¹emphasizing unprejudiced observation as the most important skill, which demands both refined sensitivity and balanced sensibility to receive suffering or pathos empathetically. Further, he emphasizes documenting even all that is silently observed.Traditionally, these skills are taught during clinical training in the outpatient department (OPD), the clinical exposure contributing to acquiring them. However, the restricted time frame of the OPD makes it difficult to acquire different observational skills and to apply theoretical learning. This era of technology allows the use of multimedia software combining video, slides, graphics, voice, and text with computer–assisted instruction. Although multimedia technology has been used to teach these techniques for various disciplines in medicine, the effectiveness of these technologies has not yet been established.This study focuses on the use of multimedia technology in teaching observation skills and improving the case-taking process in post-graduate students.

NEED FOR THE STUDY

In our Institute, post-graduate students are directly involved in patient care within a few weeks of their admission. Often, they cannot be closely supervised due to the magnitude of hospital workload. Comprehensive and effective training of the physician as observer is therefore essential. Case-based Learning (CBL) using multimedia presentation can enhance students’ skills of observation and reflection in a short time, the student acquiring gross and fine observation skills with minimum expenditure of resources. The other purpose of this study was to establish the utility of multimedia and CBL teaching methods in teaching observation skills to Homoeopathic post-graduate students.

REVIEW OF LITERATURE:

“Observation is the close watching of someone or something. It is the ability to notice important details”.⁸Theobservation process focuses on observing the attitudes and phenomena by using one or more senses. Hahnemann states in Aphorism 83 that observation and communication skills are important in case taking to obtain a complete picture of the diseased individual. The requisite qualities are: the physician must be free from prejudices, be possessed of sound senses, be able to correct and completely observe facts and phenomena, and perform a faithful recording of facts without any omission. If these requisites are followed, only then is the physician in a position to grasp the complete picture of the diseased individual. Humans in general tend to confuse observation with perception or interpretation; perception being influenced by an individual’s culture, past experiences, and previous knowledge. Hence, it is important to teach students the difference between observation and perception so that they can become better observers. Studies have shown that teaching of observation skills and their refinement along with effective feedback and evaluation improves communication skills, judgment, and decision-making in the clinical set-up.

Berger (1980) explained the hierarchy levels of clinical observations. The whole person (behavior, attire of the person); part of person (specific features of the person); context – personal (e.g., clothing, jewelry) environmental (room); behavior and interactions (interpersonal and intimate objects such as pets); the impression created on emotional and aesthetic planes and the medium. Boudreau et al identified eight core principles of clinical observations as follows:

1. have a sensory perspective and a cognitive component;
2. are distinct from inference;

• are made concrete through description;

1. occur at different levels;
2. are goal-oriented;
3. occur over a period;

• are powerful cultural determinants and
• carry ethical obligations

These principles are useful in teaching observation skills in medical practice based on the principle of differentiation between observation and perception. The use of multimedia technique – showing visual examples – can make students aware of the difference between their observations and inferences. These techniques actively help the student to focus on the whole person with an illness rather than just a disease or a part of the person.⁹Thus, it fulfils Dr. Hahnemann’s requisites in developing the physician as a healer.

Multimedia uses a combination of different content forms such as text, audio, images, animation, video and interactive content. Learning theory has expanded significantly after the introduction of multimedia in education technology enabled the use of tools such as computers, electronic devices, digital media such as videos and portraits, images and texts. It enhances the problem-solving and feedback opportunities.¹⁶Naghshineh S.et al., conducted a study on 34 students; they arranged 8 paired sessions of observation exercise with didactics that integrated the fine arts – Pictures and Music concepts – with the physical diagnosis topics. This method significantly improved the participants’ visual literacy skills by developing the habits of active looking and unbiased inspection.¹¹Several research studies have shown that the use of multimedia is effective in teaching and enhancing observation skills, further improving accuracy in recording.^9-14

OBJECTIVES

1. To create a module using multimedia aids for teaching observation skills to the students of MD Part I
2. At the end of the module, to evaluate the observation skills learnt

MATERIALS AND METHODS 

Design:

The study was planned as a prospective non-randomized experimental design with pre-and post-study evaluations. Data were collected as per the evaluation parameters in the ordinal scale to assess the impact of the Observation Skill Module on Post-graduate (MD Part I) students.

Sample:

In 2016-17, all the Post-graduate MD part I students who had taken admission in the academic year 2016-17 completed 3 months of training at MLDMHI. The study included 16 female and 3 male Part I students who had undergone theoretical and practical training of aphorisms 83 and 84 at the Under-graduate level. The Institutional ethics committee approved of the study.

Intervention:

The training for the observation skills was a 5-week orientation module consisting of 4 hours of didactic sessions per week with multimedia visual art techniques. (Text Box 1)

Text Box 1: Description of the Observation Exercise Concepts and Multimedia techniques

Observation Focus and Stage	Didactics	Multimedia used	Clinical Training
Gross Observations Stage 1	Gross Observations: Concept, definition, Importance in case-taking A Case of Pott’s Spine	Observing the Photos: Identifying the Artifacts A video: Moon-walking bear* http://www.youtube.com/watch?v=KB_lTKZm1Ts	Identifying Gross Observation in 2 clinical cases at the OPD level
Observations during interview process Stage 2	Discussion of identifying the changes occurring in scenes / epochs of life in stipulated time	A Life Revealed: Read the 1985 Story: Photographer Steve McCurry Tells the Story of His Search Magician tricks videos** Whodunit http://www.youtube.com/watch?v=ubNF9QNEQLA	Submission of Transaction Record Analysis12 (TRA) of one clinical case at the OPD level
Observing intricacy of interview: Doctor-patient relationship Stage 3	Role playing: Dramatic presentation of case of a woman with extra-marital affair Discussion on Observations and their impact on problem definition and interview planning. Requisite of Observer in Clinical Interview	Painting by Tayeb Mehta – (falling bird) Video of father with dementia and daughter: Heart-touching short film Momentos	Clinical Session Evaluation Form12 (CSEF) and TRA12 of one clinical case at the OPD level
Observing Internal state, I Stage 4A	Discussion of Self-evaluation of previous 3 sessions Demonstrating the difference between “Observation” and “Perception”	Meditation followed by Musical Note (Payalki Jhankar Raste Raste) from old film (Mere Lal 1964)	—
Observing Internal State II Stage 4 B	Discussion of Obsessive-Compulsive Disorder (OCD) Experience sharing of previous 4 sessions	Video of OCD patient	—
Feedback Session	Receiving a constructive feedback of 5 sessions. Awareness of change from Simple Observer to Complex Observer

 

Text Box 2: Tabular representation of the description of artistic concepts and it’s correlation with clinical interview:

Multimedia Technique	Observer in Clinical Interview
Identifying the artifacts, as many as possible, from the given Picture Video: Moon-Walking Bear: Where the viewer’s attention is drawn by counting the passes made while playing basketball. In-between the bear comes and goes.	In the clinical Interview while doing Homoeopathic case-taking Gross observations like punctuality, appearance, conduct of patient in waiting area, relatives of patients, gait and posture of patients, verbal, para-verbal, and non-verbal expressions as well as behavior of the patients are recorded
A Life Revealed: Read the 1985 Story: Photographer Steve McCurry tells the Story of his Search: Students were asked to write the story based on their imaginations Magician tricks videos** Whodunit	Homoeopathic case histories consist of an in-depth life interview; while narrating there are constant changes in facial expressions, attire, and posture at a finer level. In real time, a physician needs to observe these changes while conducting an interview or observing another physician in interview
Painting by Tayeb Mehta (Falling Bird) A Modern art – abstract painting  Video of father with dementia and daughter: Heart touching short film Momentos	During the case interview at times the physician too vibrates with the pathos of patient. Here, perception influences the observation process. Awareness of self-perception; the internal state is important to observe the patient in his pain.
Meditation Pranayama (breathing control) Musical Note (Payalki Jhankar Raste Raste) from old film (Mere Lal 1964)	During receiving the patient with pathos, physician, being observer, should be aware of the internal state of mind caused by listening to the real emotions. Knowing these emotions is important in perceiving the patients
Video of OCD Patient	Improving the documentation of clinical observations in real time

 

The observation exercises were facilitated by a Homoeopathic physician who is an expert in case-taking. The students individually recorded all the identified observations during the demonstration of didactic and multimedia paintings and videos. Group discussion methodology was used for sharing observations with colleagues in large groups and finally standard observations were evolved to identify the gaps between one’s ability of observation and that of the evolved standard. The students were helped to identify these gaps, thus helping in spotting various blocks. At the end of every session, new insights were documented through evaluation reports followed by an evaluation meeting prior to the next session. Students were trained to document their observations on the given formats. The faculty members of MLDMHI and the respective OPD supervisors explored the application of various artistic concepts to specific components of observation in Homoeopathic clinical interview by filling TRA and CSEF forms.

The competency of the internal observer was facilitated by the expert Homoeopathic physician who evaluated the session reports of all the five sessions. The major cost of the module was faculty and supervisor time, which amounted to a total of 35 hours (half an hour individual training + 2 * 5 session hours’ preparation + 3 * 5 session hours).

Outcome Measures:

1. Baseline assessment of observations was done prior to introducing the module.
2. Subsequently, after each case presentation, assessment was done by supervisors from the written work as well as evaluation reports.
3. At the end, inputs were once again taken from the supervisors regarding the progress made by the student in making and recording significant observations.
4. Assessment was done on the following parameters:
   1. Number of observations identified
   2. Number of significant observations missed
   3. Number of observations accurately documented
   4. Logical reasoning behind the observation process

Peer group members had evaluated the working done by each participant, recording the changes and improvement in colleagues as the session progressed. The whole experience gave glimpses of self-directed learning. Finally, students presented their learning to all supervisors and teachers in a large group. It was observed that growth of learning was directly proportional to the ability of documentation.

RESULTS:

Statistical analysis of changes at four levels – gross observation, observation of interview process, observation of the doctor-patient relationship, and observing the internal state – were performed using non-parametric test Wilcoxon matched signed – ranks. The statistical analyses were performed with IBM SPSS (Statistical Package for the social sciences) version 24.0. All the tests were two-sided with an alpha of 0.05.

The collective result of the entire group was evaluated before the project and changes were observed, noted and verified after the project.

Figure 1: Comparative box plot representing the effect of the training module on the competency of Gross level observations:

The Wilcoxon matched signed-ranks applied on median score of gross observation skills; the result is significant at p ≤ 0.05 (z = -3.823, p = 0.00014)

Figure 2: Comparative Box plot representing the effect of the training module on observation process during the interview

The Wilcoxon matched signed-ranks applied on median score of gross observation skills; the result is significant at p ≤ 0.05. (z = -3.823, p = 0.00014)

Figure 3: Comparative Box plot representing the effect of training module on Observation skills

The Wilcoxon matched signed-ranks applied on median score of gross observation skills; the result is significant at p ≤ 0.05. (z = -3.7236, p = 0.0002)

Figure 4: Comparative Box plot representing the effect of training module on the Internal Self Observation skills

The Wilcoxon matched signed-ranks applied on median score of observation skills of self internal state; the result is significant at p ≤ 0.05 (z = -3.7236, p = 0.0002)

DISCUSSION:

Homeopathic case-taking is a very complex phenomenon. Knowing the patient as a person is essential for successful Homoeopathic prescribing.¹This inquiry demands mastery over observation skills and communication skills. Competency of finer observation evolves over time since the very complex task, that of observing all three components – patient, physician, and one’s own inner mechanisms of prejudices – is very challenging for a young professional. The purpose of this module was to enhance the observation skills by training the mind to observe and record. The module also differentiated observation and perception using Multimedia techniques.⁹ The methodology used the artistic concepts and core concepts of observation skills.^9,11 The sessions and evaluations were facilitated by expert Homoeopathic physicians and supervisors.

The students were taught Gross Observation skills by showing them different pictures. Naghshineh et al. conducted a similar experiment to enhance observation skills in medical students; they found that it was quite effective.⁹ Further, in this module, a case of Pott’s spine and the video of the moon-walking bear was used the purpose being to teach how one misses observations when adequate attention is not paid. The learning then extended to help the student to observe punctuality, appearance, conduct of patients in the waiting area, relatives of patients, gait and posture of patients, and the verbal, para-verbal, and non-verbal expressions and behavior of the patients. The statistical calculation indicates significant improvement in Gross Observation skills (Figure 1).

The multimedia technique of identifying changes occurring in a fraction of a minute in whodunit videos of the Sherlock Holmes series was considered to demonstrate the need to note changes occurred in verbal, para-verbal, and non-verbal gestures in the clinical interview. These were useful to cultivate the habits of mindfulness and to notice the smallest details. The story-writing was based on the observations made from the two different portraits of the Afghan lady. Bardes et al. found that discussing painted portraits and patient faces resulted in improved observation skills to notice the smallest details and awareness of emotions in human facial expressions.¹⁴ The pilot experiment of creative writing demonstrated self-reflection due to the generated emotions.¹⁶ After the clinical interview, the physician writes the story of the patient’s life in his words. The practice helps to improve the observation skills thereby reducing the perceptions in perceiving the patients. The technique has shown significant results in improving the observation skills during the interview process (Figure 2).

Statistically significant improvement (Figure 3) was seen in observations and accurate recording of observations made during the clinical interview or in assessing the dynamic relationship between patient and doctor. The portrait shown was a modern abstract. Decoding the portrait at an abstract level helped refine inductive logic-particular observations to generalization. The observations need to be generalized for refined understanding of the problem definition of the patient and understanding of the pathos. The practice to see beyond the specific content areas stimulates the imagination resulting in improvement of visual literacy skills.⁹ Our results are consistent with those of prior educational research.

 

To understand the difference between observations and perceptions, the CSEF and TRA tools were used. These tools give the learner an opportunity to re-experience the interview from the locations of physician, patient, and observer. At the end of the analysis or while reflecting, the observer discovers his own perceptions and sensitivity. In the current study, the tools helped to make the participants more aware about their internal state and we could see significant results in the students’ ability to observe their own internal state (figure 4). The last session studied an OCD patient to enhance the communication skills of narrating observations verbally and in writing.

Our study has significant strengths. The phenomenal result of our study was not only due to the planned module on artistic and multimedia concepts but also due to active engagement of students in the learning circumstance, group discussion, writing self-evaluation reports, and their analysis of their own working, all of which allowed them to see what they knew as well as what they did not.

Our study also has certain limitations. First, the study was conducted without a control. Ideally, the control would have been the traditional teaching of observation skills and comparison of its results with those of the newer techniques of multimedia technology. Second, a major confounding variable was the interest of the student to learn and apply in the clinical set-up. As we know, Homoeopathic case-taking differs from one Homoeopath to another; some favor the Hahnemannian learning using in–depth interviews, where as some give importance to clinical observations at a level. This might interfere with the learning and application process of this module in the clinical set up. Third, the students were exposed to different under-graduate training methods, which might have influenced the prior scoring and learning from this module. A controlled randomized study would be desirable to validate these findings so that this module can be incorporated in the teaching.

CONCLUSIONS:

The methodology of multimedia including portraits, videos, music, and role-playing has enhanced observational skills. The use of tools such as CSEF and TRA enhance self-reflection i.e. observing one’s own internal state during the clinical interview. The demonstrable skill set of learning by doing under close supervision of the faculty members is the only way to enable the evolution of young students into empathetic, sensible, insightful, and competent Homoeopathic Physicians.

ACKNOWLEDGEMENTS

The journey of achieving this objective would not have been possible without the support of my mentors, Dr. Kumar Dhawale sir and Dr. N. L. Tiwari sir; I thank them for their constant encouragement. I thank Dr. Kavita Jadhav and my niece, Brina, for analysis, Dr. Sunita Nikumbh for looking into the niceties of department as acting HOD, Dr. Vidya Arunachalam for assessment of student data, and Dr. Gayatri at the home front for being the best half. Finally, many thanks to the students who were participants in this teaching module.

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