Building enduring clinical skills: An interview with Dr. Rajesh S. Mangrulkar

Photo by Aki Yao. Copyright 2011 The Regents of the University of Michigan. Licensed under a CC-BY 3.0 license.

Dr. Mangrulkar is the Marguerite S. Roll Professor of Medical Education, the Associate Dean for Medical Student Education, Associate Professor of Internal Medicine, and Associate Professor of Learning Health Sciences.

He was kind enough to take time out of his busy day to talk us about the Professional Skill Builder (PSB). Developed collaboratively between faculty of the U-M Medical School and Medical School Information Services, the PSB is an engaging, safe environment for learners to enrich pulmonary and cardiac clinical skills.

Dr. Mangrulkar joined the team growing the PSB in 1997; it was, and continues to be, an evolutionary project that combines his passion for education, training in medicine, and background in computer science.

You may also be interested in this companion interview,“Technology that ‘coaches’ learners: An interview with cardiologist Dr. Richard Judge.”

How did you come to be involved with PSB?  

I knew rather early in my internal medicine residency training that I wanted to be an academician. In my fourth year, when I was serving as chief resident, I realized that what I really wanted to do with my career was to dive in-depth into the scholarship of learning and teaching.

One of my mentors, David Stern, said, “I’d like you to meet some people…Dr. Richard Judge and Chris Chapman.” They were working on the PSB, which was called ‘Cardiax’ back then. I felt like I had found my kindred spirits! They were developing something that was really exciting.

The focus of the project was on education and heart sounds using a CD-ROM that was inserted into the computer; there was no internet-based portal or any of the platforms we have today. My goal became to determine if there was a transferability that could result in better clinical skills by physicians, residents, and students.

We are confident about the quality. There’s a lot of attention to detail. This is part of the reason for engaging Jasna Markovac and her MSIS Learning Design and Publishing team – to address how we can promote it more so that we can have more use and then we’ll learn more from it. It’s not much different than what we had before; it’s just on a different scale.

The pacing of PSB is a little more deliberate. We made it a slower process, which is helpful with the imprinting, especially for the fundamental foundational skills. There must be this intentional pace. You have to think about what’s the right feedback and when to give it. It’s more helpful in the long run, especially for skills that you need to come back to. If it’s about getting new pieces of knowledge, if you’ve got good scaffolding, then you can instantly get it. The knowledge is also transient. Knowledge changes, but the skills are enduring. That really is an important part. The skills of talking to patients, asking the right questions, listening to their heart…those aren’t going to go away. They may change in how they are done, but they’re not going to go away.

Try it! “Aortic regurgitation due to a bicuspid aortic valve (headphones required)

Many universities develop online content and tools that they make available publicly but under strict terms of use licenses (e.g. All Rights Reserved). Why did you choose to apply an open, Creative Commons (CC) license?

Our team believes that the natural default should be that everything is open. We’re at a university that supports this value, so it’s hard for me to think about not using a CC license. Some people will disagree, but if you return to our goal which was to get it out there for people to use, then the license makes perfect sense. If you restrict the content, then you’re really not congruent with that goal. Our motivation is the developing student; our motivation is better learning; our motivation is getting it out there; all of which can be done under a CC license.

How do current learning trends and needs compare with those when the PSB was first conceived?

Originally we were concerned about how students were learning and retaining fundamental clinical skills. But I would say that 20 years later we still have a profound need for building those basic skills. The clinical environment has gotten much more complex than ever; some people would say that it has become less supportive because of the pressures in the healthcare environment. The time to teach, the time to go to the bedside, the amount of time to spend with the patient, has gotten increasingly disrupted. It’s become very work-focused, but there still needs to be learning in that environment. The necessity for tools like the Professional Skill Builder is even greater than it was before.

IT capability has also changed and grown. When I first started, the PSB was on a CD-ROM. This was when the Internet was starting to really expand, and I pushed the idea of putting it on the Internet. Now it’s about platform neutrality, apps, and opencourseware. Technology has changed the way that students fundamentally learn. They’re not buying books; they’re using digital information in an on-demand style.

Our challenge with the PSB is to continue lay a good foundation but acknowledge and embrace those other ways that students learn, including the on-demand model. This format allows students to easily access information in a less disruptive way which becomes the bridge between learning and patient care. How we capitalize on that is a significant trend in education.

What is your favorite aspect of PSB?

One of my favorite components of the PSB is the Heart Sounds Challenge. I love that game. You have to get a certain number of correct identifications correct in a row, and the moment you get one wrong you have to start over.

Try it! The Heart Sounds & Murmur Library (headphones required)

The PSB was developed to be a balance between authenticity and in-depth learning and assessment. You can make things really in-depth and complicated, but then it loses the authentic feel. Or you can make things extraordinarily authentic but then you are just skimming the surface and not capturing the real learning that is going on. We’re always walking that balance whenever we’re doing any of these designs. It’s a fun puzzle.

I also like the coaching aspect of the PSB. It’s critical, really. The faculty used to be those coaches, but it’s more difficult to do that now. We need these virtual coaches now more than ever because of the challenging clinical learning environment, and we need to be able to use the technology to transmit feedback. A coach can provide corrective information, and is focused on performance, and helping you achieves your goals. The virtual coach of the PSB is always watching and providing feedback just at the right moment it is needed, but not in an overwhelming way. The tool allows the learner to try again, to practice it again, like a player in the batting cage or the football stadium or the hockey rink. That’s what they do in the athletic domain, and that’s how the PSB is built. It gives the learner a safe place to try again and a safe space to fail.

What keeps you motivated?

There are two things that keep me motivated. The first is the students—seeing the students use the PSB, listening to how they use it, understanding how it improves their skills. If we’re not doing this for students or learners, then I’m not really interested. From the beginning it’s always been about how can we change the way students think, and how can we change the way that they believe about fundamental skills and build their confidence.

The other thing that keeps me motivated is the team. This is a phenomenal team! My relationship with Dr. Judge is longstanding and deep and professional, but also personal. Same with Chris Chapman. Both of them are remarkable people, and being able to interact with them and the other wonderful members of the team like Marc, John, Jason and Aki, is a true privilege for me. Tracing each other’s journey in education and educational leadership has been fascinating and inspirational.

What advice would you offer to colleagues who may be interested in using technology in an innovative way?

Having been now in this field for nearly 20 years, where technology has been the centerpiece of my academic development, the most important lesson is this: technology is not the answer. Technology is the facilitating factor in education and learning.

We have to think about the wrapper, the delivery method, to maximize its learning impact. Thinking about the wrapper around the tool is really important from an educational principle. Tools are always implemented in a context, whether it be a lecture, small group session, a new case, or technology. If we are just developing a tool because it’s the coolest new technology or the hottest new trend, then we will distract ourselves and lose the focus on learning.

What potential do you see for the PSB?

There are many opportunities for the PSB including research, international use, expanding to other health professions such as nursing, as well as other medical and health professions schools across the country.

Additionally, mobile apps are the future of medical education, and we need to embrace the mobile platform to bring education to the bedside. This is what really keeps me interested: how can technology advance to facilitate better learning? When I hear the students’ positive feedback like, “The PSB really helped me because I had a patient and heard something that I remembered from a particular module, and I was able to help my patient.” That is really motivating for me personally. I see the technology being able to augment that experience.

We can help other schools–not just globally, but other schools across the United States, especially through MedEdPORTAL. The teacher’s manual is designed to help other schools use the tool. We had a great experience with Dartmouth, when Dr. Judge was over there. I think other schools could use it. I’d love to see how they do. The Heart Murmur Library is used within lectures on Khan Academy. And the course materials are available on Open.Michigan, which has an international audience. That’s pretty amazing.

What is the future of the PSB?

We want to continue to set the goals of keeping students motivated about the fundamental clinical skills. I think we’ve flipped as a profession. We’re less about talking and observing, and more about diagnostic testing; I fundamentally disagree with that. Tools like the PSB can help us keep that goal of dialog and observation. When I see students embracing that, getting jazzed about that, I feel like we’re making really good progress there. When I see faculty really enjoying creating new modules, it becomes fun for everyone. That’s honestly what this should be. Returning to the connection between the care provider and the patient without the interference of a technology interface. There are ways to design the interface that actually promote the connection.

The future is going to the on-demand model, which will be mediated by mobility including platforms that are open. We have to figure out a way to bring the learning to the patient, and then connecting the patient and the physician together. More modules that will be available on demand as well, with an eye for an easier way to search for things that you need, like a reference book in your pocket. This would be for both practicing physicians and students. For example, if I’m in clinic and I hear a heart sound I don’t recognize, can we use technology to match what I’m listening to with the answer?

I have so many ideas based on this concept of the PSB. For example, maybe we’ll create a heart device that would feed the patient’s heart sound into the app and match it to the module that has the particular heart sound. All these things that a mobile device has that we haven’t even thought about yet.

That kind of mobility for education is the next frontier. I think the tools haven’t caught up, not embraced that part of the technology as much. Neither have we. We’ve only created a couple of different apps. I think we need to do more, and patients have to be part of that. They’re going to have access to this information anyway, thanks to the Internet. The technology could help patient monitor their own condition, collect data and share with the doctor. There are so many games that are available for patients to manage their own health, especially those who have diabetes or hypertension. I don’t think there’s any reason why patients can’t have games around their heart disease or their symptoms. I’m not sure the PSB is the right platform for it, but it’s definitely a trend globally in education: how patients can be engaged using that.

I personally have always wanted to see how much impact it would have on actual learning in the clinical setting. It’s just really hard to do those research studies. I’m hopeful that part of this publicity outreach will be to get people who are interested in studying its impact into the team as well.

More Information

You might also be interested in the journal articles where Dr. Mangrulkar, et al., showed that students who used ‘CARDIAX’ demonstrated knowledge retention:

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.”

Learn how to share your content under a Creative Commons license.

Contact MSIS Learning Design and Publishing and Open.Michigan for assistance with publishing, educational projects, and Creative Commons licenses.  The article was written by Stephanie Dascola, Publishing & Communications Editor, Medical School Information Services Learning Design and Publishing, and, except where otherwise noted, is published under a Creative Commons Attribution 4.0 license.

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