Dr. Richard Judge, renowned cardiologist and pioneer in the development of the pacemaker, originally began his career at the University of Michigan Medical School in 1951. During the latter half of the twentieth century, he directed the course in Physical Diagnosis, and many medical schools throughout the world adopted his book on the subject. When computers became available he realized that this technology could provide students with a means of practicing their observational skills with immediate faculty feedback. He seized the opportunity to marry his interest in technology with his passion for education, and created what is now known as The Professional Skill Builder (PSB), available on the Open.Michigan website.
Editor’s note: This article was co-authored by Dr. Judge and Stephanie Dascola, Publishing and Communications Editor for Learning Design and Publishing, a unit of Medical School Information Services. You may also be interested in this companion interview,“Building enduring clinical skills: An interview with Dr. Rajesh S. Mangrulkar.”
What is the Professional Skill Builder (PSB)?
The PSB is a computer-based series of tutorials, which provide learners with an opportunity to practice the cognitive skills required for the examination of patients with cardiac and pulmonary disorders. Like a batting cage in baseball it allows the learner to practice with the help of a coach. A skill by definition is learned only by practice with guidance. The PSB provides both.
It requires no classroom time and can be accessed by the learner anywhere any time. All of the simulated case problems in the PSB are authentic and thanks to video, they are realistically presented. The mentors are all academic cardiologists and pulmonologists.
The PSB focuses on four primary skills: accurate observation, correct description, correct interpretation, and the best method of verification. Two secondary skills, the integration of observations and clinical judgment, are also included.
You mentioned three levels of complexity. Would you explain this?
The PSB is now divided into three levels, each with increasing degrees of complexity.
The first level is designed to augment the introductory course in clinical skills. It focuses mostly on listening to the heart and imprinting the eight basic cardiac sound cadences by means of repetition. This is where we use the Heart Sound Challenge. Correct identification of twenty four cadences in a row.
You can try it too! Heart Sounds Challenge (headphones required)
Second level cases are five to ten minutes in length and are designed to augment the cardiac and pulmonary lectures later in the curriculum. The idea is to give students access to clinical examples of what is described in their lectures. “Bring the patient into the classroom,” so to speak.
Third level cases are longer and more complicated, like being assigned a patient on the medical service or in the outpatient. They provide the learner with one-on-one contact with a series of important cardiac and pulmonary problems, which they might not have been able to work up and examine during their clinical rotations. Each case has a faculty mentor who provides immediate feedback with regard to the accuracy of the learner’s observations and decisions.
How did you come to be involved with PSB?
As Assistant Dean for Student Programs I interviewed many senior students prior to graduation, and I noticed that many of them were not having the opportunity to examine and study patients with some very common heart and lung diseases like community acquired pneumonia or mitral valve prolapse. It occurred to me that we might be able to use computer technology to fill in the gaps.
In 1990, I was 70 years old, and I was leaving private practice to devote all my time to the U-M Medical School as Assistant Dean for Student Programs. I was excited to embark on this new stage of my career. I teamed up with Chris Chapman who is now an Assistant Director for Education with the Medical School Information Services department’s Learning Design & Publishing group, to develop a short series of computer-based heart cases entitled CARDIAX. It was popular with the third-year students and they considered it a valuable adjunct to their clinical experience; and so Chris and I continued to expand it year by year.
In 1997, Dr. Rajesh S. Mangrulkar joined us and with his input, the software was upgraded so we were web-compatible and the content broadened to three levels of complexity for use in all four years of the curriculum. A dozen pulmonary case problems were added along with sections on ECG and chest x-ray. And finally proficiency assessments were created.
What are your favorite aspects of the PSB?
One of the uniquely valuable aspects of the PSB is that the learner receives immediate feedback from a faculty expert for each observation. This feedback loop is vital for the development or improvement of any skill. Unfortunately it is often not available on a busy clinical service.
Another valuable feature is its availability online to learners everywhere whenever they have the time and the interest use it.
So what is the Professional Skill Builder like now?
There are now over sixty long and short case problems as well as exercises in the PSB. There are also basic science correlations, a “tool box” which provides the learner with “Just-in-Time” factual information and several levels of self-assessment.
What else is new with the PSB?
PSB is now available on different platforms including the Mac, PC, iOS, as well as on the web, as a mobile app, and Raspberry Pi. More content has been added to the pulmonary medicine modules, and both a Course Director’s Guide and a User’s Guide have been created.
We applied a Creative Commons license, CC BY-SA 4.0, making it available for remixing and/or local hosting via GitHub and it’s available on the Open.Michigan website. And because of the Creative Commons license, the PSB is being used by Khan Academy, a popular online educational platform.
The Creative Commons license will also aid in our plan to distribute to medical schools, schools of nursing including nurse practitioners and clinical nurse specialist programs, and schools for physician assistants. We’re developing continuing medical education (CME) programs, and plan to make it available on MedEdPORTAL. These are all very important and valuable dimensions to the PSB’s use.
What’s next for the PSB?
We are currently evaluating how long the Level Three cases should be for the modern student. We feel that the proper length depends on the complexity of the case. The more complicated problems require time, and all medical students are short on time. One answer might be to divide each case into several shorter units. But there is no quick fix in learning a cognitive skill. It takes time and practice, just as it does to improve your golf swing or to play the guitar.
I thought it was important to have this available, and I made the time and put in the effort to make it happen. I saw a need in Africa, China, and other institutions that have small medical schools with limited faculty or those without as many resources as U-M. Even programs closer to home could benefit.
What keeps you motivated?
I’ve long been interested in pairing technology with learning as well as finding ways to integrate technology into the classroom. The Medical School has given us the tools and technical support to develop something which could benefit learners, not just at the University of Michigan, but nationally and internationally; and not just medical students and physicians, but also clinical nurse specialists, physician assistants, and the like. For this I am grateful.
How was it working with Chris Chapman?
We have worked together since 1990. We’re very close. Many of the innovations that make the PSB especially attractive were not created by me or Dr. Mangrulkar, or any other faculty member for that matter, but by Chris. His contribution has been profound. For example, the Heart Sounds Challenge in Level 1 was Chris’ idea—to make it like a game; and 92% of students get 24 in a row. He’s an expert on using computer technology for education. His designs have been excellent. He applied learning techniques that balanced the project.
Give it a try! Heart Sounds Challenge (headphones required)
What advice would you offer to colleagues who may be interested in using technology in an innovative way?
In order to use educational technology properly, it is going to take time and commitment. Before you start, decide whether the technology is going to provide substantial improvement in what you are teaching. If the answer is “yes,” then give it all you’ve got. But it isn’t like putting together a PowerPoint presentation. To create good, freestanding, online instructional media, you have to really be committed and invest substantial effort and time.
You might also be interested in the journal articles where Dr. Judge, et al., showed that students who used ‘Cardiacs’ showed profound knowledge retention:
- Mangrulkar RS, Judge RD, Chapman C, Watt J, Stern DT. The Effect of a CD-ROM Multimedia Tool on the Cardiac Auscultation Ability of Internal Medicine Residents. The Society for General Internal Medicine Annual Meeting, San Diego CA. May 5, 2001. Proceedings of the 24th SGIM Meeting. Journal of General Internal Medicine, 16 (Suppl. 1): 103, April 2001.
- Stern DT, Mangrulkar RS, Gruppen LD, Lang AL, Chapman CM, and Judge RD. Using a Multimedia Tool to Improve Cardiac Auscultation Knowledge and Skills. Journal Gen Int Med, 2001; 16(11): 763-9.
You may enjoy reading these UMHS Headlines articles, “Mobile app makes learning heart sounds easier” and “The Professional Skill Builder: A virtual coach for cardiology and pulmonary medicine.”
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