The Education Cycle

The notion that broad concepts of the process of learning can be described as a cycle is not new. Pattinson and Matthews⁵⁸ recently applied it to wilderness medicine while planning a mountain medicine curriculum. As depicted in Figure 105-3, the program director first makes an assessment of the needs of the learners; he or she gets to know the audience. Next is the often-underestimated task of establishing tailored and focused learning objectives. The educator then selects teaching methods and settings that best accomplish the objectives while meeting the needs and expectations of the learners. Finally, after the experience, the educator makes an assessment to ascertain whether learning has occurred. This final step may be the most difficult and least attended of all. These elements will be addressed later.

FIGURE 105-3 The education cycle.

Experience-Based Learning

Kolb’s model⁴¹ of learning is based on how individuals internalize and process learning experiences. Learners perform an action, referred to as a “concrete experience.” They then process the new information by “reflective observation.” Next they consider how the new information can be applied to their unique circumstances by “abstract conceptualization.” Having internalized the experience, they try it by “actively experimenting” with what they have learned to apply it in new and unique ways. This model is reflected in several of the teaching and assessment techniques discussed later, especially those that address concrete skills.

Education and the Human Organism

Setting the conditions for learning can be conceptualized by using Maslow’s famous explanation⁴⁸ of how humans address fundamental needs. Vella’s work^71,73 in popular education extends these ideas to the realm of education in the social context but still deals with the rudiments of human nature.

Unmet physiologic needs, such as warmth and hunger, tend to impair learning as the human organism prioritizes toward survival. Unfulfilled security needs, which Vella⁷¹ refers to as safety, distract from any process that does not pose an immediate threat. In adult education, safety issues may be subtle. Students who do not feel free to voice opinions or reveal a deficiency may be said to lack a safe learning environment. Identification with a group of learners addresses the need for belonging that is used by organized team sports and the military. The need for self-esteem may be met by recognition for academic achievement in front of one’s peers. Finally, the highest level of Maslow’s concept, self-actualization, is represented by satisfied expectations on the part of the learner. By expanding these concepts and directly addressing each in the classical hierarchical fashion, a program director can remove many obstacles to learning during the planning phase of the educational experience. A learning event that accounts for them will have a high likelihood of success and impact the student’s life well beyond the experience.

Learner Sophistication

Another powerful tool available to teachers is the identification of the level of understanding, or “sophistication,” of the learner. Neal Whitman proposed four levels that learners traverse as they acquire new knowledge and skills. Correctly matching teaching methods to these will improve the overall experience by saving time and increase the likelihood of fully meeting expectations.⁷⁵

Most people begin the education journey at the level of being “unconsciously incompetent” and do not know enough about the material to know what they do not know. After a time, they become “consciously incompetent” as they gain an appreciation for the amount and nature of the information they will have to master. Next they become “consciously competent,” in that they know how to perform the skill or can use the information but not yet with efficiency or at the level of mastery. The final stage, that of the teacher, is becoming “unconsciously competent.” At this level the learner becomes so practiced at the skill and the understanding is so well internalized that it can be performed to standard without consciously focusing on process. The learner simply knows what to do.

Principles of Androgogy

There have been numerous efforts to roll learning theories together into a concise package of tools for health care education. To this end, the work of Malcolm Knowles is widely read and often cited by education academics. He put structure to the concept of helping adults learn and called it “androgogy.” He suggested that through the principles of androgogy, adult learners are most successful when they are assisted in the process rather than directed through it.³⁹ Knowles made five basic assumptions about adult learners from which he derived his principles. They can be summarized as follows: (1) Adults tend to have internally and not externally focused motivations for learning; (2) The learning process should be related to solving real-life problems; (3) Existing knowledge and experience greatly influence learning; (4) Self-direction improves the learning experience; and (5) Adults learn best with problem-based rather than subject-based methods. Knowles’ seven principles of androgogy are summarized in Box 105-1.

Learner-Centered Education

Jane Vella has applied learning theory in unique ways to the social context across different cultures. She recognized that education lay at the heart of many social issues. The teacher’s message is often lost in the delivery because of avoidable cross-cultural and interpersonal obstacles. She maintains that the key to adult learning is clear dialogue between the teacher and learner.^71–72 Educators too often fail to establish productive dialogue and hence select ineffective teaching approaches. Vella suggested that traditional hierarchical teacher-student roles be discouraged. Teachers become facilitators. Barriers to dialogue are “addressed and eradicated.” She offered to popular education a paradigm that places the learner at the center of the educational universe. Her principles link theory to practical use in a way that enables learning in challenging circumstances. Vella’s principles are summarized in Box 105-2.

Learning-Oriented Teaching Model

Cate and associates⁹ recently published their notion of a model of teaching based on concepts from educational psychology. Their proposals are meant to influence all aspects of adult education, especially those of curriculum design, teaching techniques, and teacher assessment. An attractive feature is a method to “inventory” and match teaching and learning styles to improve outcomes. The authors build a model around what they identify as the “components of learning” and the “amount of guidance” that learners require to navigate the experience. Their premise is that, because education seeks to enable people to “function independently,” the process should foster self-regulation of learning. In the model, learners mature from “externally guided” learning through “shared guidance” to self-guided or “internally guided” learning. This applies to both cognitive (what to learn) and affective (why to learn) components of learning.

Putting It All Together

Theories and models are meaningless without practical application. Directly applying ideas from theorists with diverse backgrounds and agendas into the realm of wilderness medicine education is difficult. Kaufman³⁸ recently reviewed several adult education theories in the context of health care education. He examined them for key areas of commonality and offered simple principles to “guide” medical educators as they think about and plan educational experiences (Box 105-3). Wilderness medicine educators can easily adopt these.

Lecture

Lecture is the most often used educational technique. It offers several important advantages. Large amounts of information can be delivered in relatively short periods of time. Planning is generally easier for the lecture format. It requires little logistic support and only one teacher. It works well for highly technical information that the learner will most likely have to study again in order to internalize. Lectures can be easily enhanced with audiovisual aids. All of this adds up to a degree of efficiency that is highly attractive to the resource-limited educator. In one small but interesting study, Reed⁶² illustrated that, despite the availability of highly technical and resource-intensive teaching methods, a simple “low-cost, low-tech” lecture approach can offer rewards in terms of improved skill performance (Figure 105-4, online).

FIGURE 105-4 Despite limitations, lecture remains a valuable method of teaching because of the flexibility and efficiency it offers.

(Courtesy James R. Liffrig.)

The lecture technique has several equally important disadvantages. Learning is highly dependent on the delivery skill of the teacher. Because it is passive, many adult learners do not respond as well to this approach. It is generally accepted that levels of retention of material presented by pure lecture are lower than more active teaching techniques.⁶⁷ There is generally limited opportunity for hands-on applications and practice. Thus the usefulness is limited in some areas of wilderness medicine that are largely skills oriented. The more restricted the opportunity for student questioning and dialogue, the less effective this technique becomes. Students can often more effectively learn by themselves information to be presented by lecture. Brookfield⁸ discussed methods to enhance the lecture as a means to communicate information (Box 105-4).

Problem-Based Learning

A highly effective trend in health care education is the use of problem-based learning (PBL). PBL can take various forms, but generally learners are presented with a problem and are guided through a structured discussion that leads to a preestablished solution. This learner-centered approach has proven popular among students and demonstrates comparable outcomes when compared with other, more traditional formats. An interesting aspect to PBL is that student-led experiences tend to be more highly favored among participants than those facilitated by faculty, yet the outcomes remain at least comparable in terms of satisfaction and examination scores.^29,66

PBL offers great versatility to the curriculum planner. It can be used whether the focus is on acquiring pure fact-based knowledge or practical skills. It is most often applied in the small-group setting and therefore may pose logistic challenges in some space and resource-limited settings. It complements the strengths of small-group learning in that it reinforces communication and problem-solving skills, teamwork, individual responsibility for learning, and the need to share knowledge.⁷⁷ It tends to give the best results when it is structured and forces learners to use critical thinking skills. It fosters the process of analysis, organized problem solving, and decision making using group discussion to direct and reinforce learning. The general format for PBL is presented in Box 105-5.⁵

Case-Based Learning

Case-based learning (CBL) is a subtype of PBL that is extremely useful in wilderness medicine education. It makes use of several powerful aspects of theory to solidify learning. This method improves outcomes over pure lecture for certain types of material. Many of the skills-oriented topics in wilderness medicine can be easily presented through scenarios and cases. The teacher can easily modify case scenarios to suit various learner levels, styles, and objectives. It can be modified for learning experiences in the field setting because, if properly planned, it requires minimal logistic support.

This technique motivates the learner because it is directly relevant to the reasons for which they sought the experience. It offers an automatic sequence and information source for presentation, because cases flow in accordance with actual or simulated events. The teacher generally facilitates discussion and assists the students with understanding and methods to organize information. Clinical problem-solving styles can easily be demonstrated.

Scenarios and Role-Play

Scenario-based and role-play training is familiar to prehospital emergency care educators but less widely used in traditional medical education. It maximizes many of the strengths of newer approaches to adult education because it guides self-motivated students through a process of “discovery” of the information.⁴⁵ The main role for teachers in this format is to facilitate, not direct, the learning process.³⁰ Being an expert in the clinical details of each case is less important than understanding how to apply problem-based learning. This method is often scripted and makes use of actors, props, and moulage to simulate real-life situations. The logistics of carrying out this aggressive training technique may be prohibitive to some programs, but the investment is worth the effort in terms of improved outcomes and retention of knowledge by learners. Nearly all organizations that train prehospital wilderness medicine practitioners use some form of complex case- or scenario-based learning program. The use of role-play has benefits beyond the teaching and development of technical skills. One recent randomized controlled trial confirmed the utility of using role-play when teaching technical skills in the area of communication. The authors of this small study of 36 medical students randomized to learn a skill with and without role-playing concluded that, although there were no differences in technical performance between groups, the introduction of role-play as a training method enhanced the realism of technical skills training and led to better patient-physician communication⁵³ (Figure 105-5).

FIGURE 105-5 Wilderness medicine education provides many opportunities for scenario-based training using role-playing.

(Courtesy Fred Baty.)

Subject-Based Learning

The term subject-based learning (SBL) is a euphemism for traditional teacher-centered techniques of presenting information. The student in an SBL setting is the passive recipient of instruction rather than an active participant in the learning process. SBL methods typically present information by broad topic in a mainly lecture-based format. Health care curricula designed around SBL tend to be redundant, because broad topics may deal with the same or similar types of information. For example, a traditional medical school first-year basic science curriculum will have a series of lectures on pharmacology, biochemistry, pathology, and microanatomy. Each will incorporate specific material on diabetes presented by different departments. The student may have to wait a year to receive a session that focuses on diabetes that incorporates elements of pharmacology, biochemistry, pathology, and microanatomy.

Although SBL has a role, most health care educators have incorporated more learner-centered techniques, such as PBL, into their curricula. The main drawback of SBL is that by favoring efficient delivery and lengthy, complex curricula, it often fails to take advantage of features in adult learning theory that are known to lead to higher rates of retention and deeper learning.

Discussion

The technique of discussion is a versatile and highly effective teaching tool that is rooted in behavioral science. People learn better when the information is presented in ways that challenge them to process it in more than one way. Although not as efficient as lecture in terms of the quantity of information that can be delivered, it offers advantages to the wilderness medicine educator when teaching problem-solving skills and broad concepts that can be applied to many types of scenarios. Students readily internalize material because they have to intellectually manipulate it in various ways. The information is introduced, processed, and discussed. Students modify their own notions and then formulate solutions based on their new internal constructs of the problem. Learning is guided by the facilitator-teacher and reinforced by the group, which is all going through the same process and adopting a similar problem-solving skill set.

There are two basic modes of discussion-based learning.⁴³ The Socratic questioning method challenges students to identify the most important features of a specific problem and then reconstruct it using general principles that are the true focus of the discussion. Developmental discussion approaches the problem in parts. It keeps all students focused on one part at a time and takes advantage of the group setting to ensure that teaching points are addressed.

Teacher-facilitators may highlight the discussion with the powerful tools of analogy, discovery, and induction to stimulate learning and ensure retention.¹⁶ Analogy illustrates concepts by asking students to visualize using examples with which they are already familiar. The process of discovery leads students through a sequence of steps from the most basic to the more complex to guide them to the final goal of deeper understanding of the principal learning objective. Induction asks students to take general lessons from specific examples or experiences, make comparisons, and draw new conclusions relevant to the learning objective. These three techniques can be applied in any setting that involves learner interaction with the teacher.

Small-Group Learning

The selection of a teaching method is highly influenced by class size and quantity of information that must be learned. Large classes that must digest substantial amounts of information tend to push faculty into selecting passive modes of teaching. The traditional CME conference at which hundreds of attendees review highly technical material is an example of this. However, passive, lecture-based methods are not the most effective and often not the most efficient for all types of learning, especially in wilderness medicine. It is now widely accepted that skills-based learning presented in a small-group setting is a better way to teach practical skills⁴⁴ (Figure 105-6, online).

FIGURE 105-6 Education conducted in small groups may enhance learning in many areas of wilderness medicine because it is an active process in which all learners participate.

(Courtesy James R. Liffrig.)

The problems inherent in teaching large groups can often be overcome by adopting a combined approach. In this strategy, the information is delivered in parts to the entire group. Learners are then broken into small groups to conduct activities that allow them to discuss it, use it, and solidify learning. There is usually a more favorable teacher-to-learner ratio and greater self-direction of learning by the group.

Wilderness medicine offers ample opportunity to use the combined approach and the pure small-group venue for teaching. Both rely upon the process and mechanics of group experiences. The simple act of breaking a large group into smaller groups does not constitute small-group teaching. This method requires skill and experience with group processes on the part of the educator to avoid pitfalls that detract from learning. When done well, small-group learners take away solid lessons and the strong relationships that they had to build to get them. If done poorly, learners walk away dissatisfied with negative attitudes toward learning, the setting, and the discipline.

To understand group learning is to understand how the individuals within the group interact.

Bruce Tuckman’s original concept of the developmental sequence of small groups should greatly influence how teachers plan and conduct these activities.^26,36,69,70 The general strategy for teachers is to become familiar with the stages, recognize their manifestations, and use a planned approach that gradually releases control of the teaching process to the group as members become more able to direct their own learning.

Group members get acquainted and become oriented to the setting during the forming stage. Student anxiety may hinder learning as interpersonal dynamics take shape. Students tend to adopt a passive mode of learning. They respond best during this stage to a more directive teaching style with clearly defined expectations and structured events.

During the storming stage, the group’s identity begins to take shape among some members, while others continue to seek individual goals over those of the group. Dissent may be voiced about leader- or teacher-directed tasks. Teachers should demonstrate strong but patient leadership to move through this stage without alienating group members. They should openly encourage support for group-generated goals.

The group identity solidifies during the norming stage. Individual ownership of group goals and a greater affinity for teamwork are hallmarks. As they gain a sense of safety, members in their interactions with other participants display genuineness. Leadership tasks should be directed to group members. Learning activities, such as role-play and case discussions, become most useful.

During the performing stage, the teacher acts only as a resource for the group that has developed to a point of relative autonomy. The group is able to plan and conduct its own activities, as well as make self-assessments in an organized and productive fashion. Energy is spent on learning rather than on the interpersonal mechanics of the process.

The role of the teacher in a small-group setting should be oriented toward facilitation of learning rather than direct delivery of material. However, the teacher remains accountable and cannot take a completely hands-off approach and expect that objectives will be met. By attending to the details of process, the teacher ensures that the learners do not have to perform this task. The teacher creates the proper learning environment and keeps the process on track. Some common mistakes made by small-group “facilitators” include the following: the teacher presents a lecture; the teacher talks too much; students do not participate unless prompted or directly questioned; the students lack preparation for the session (e.g., prereading); there are overbearing, domineering students; and participants want to be provided a quick and simple solution to the problem rather than engage in the process of group discovery.³⁵

Despite not being part of the learner group, the teacher has great influence over the process and the outcomes. A poorly prepared teacher ignores the internal dynamics of the group and sets up the experience for failure. Some techniques available to avoid these problems include: agreed-upon rules for the conduct of sessions; clearly stated tasks and objectives; use of the rhetorical method of questioning to stimulate thinking; taking a lengthy pause after posing a question, allowing students to answer; not offering immediate solutions or guidance unless participants appear to be taking the wrong path; attending to body language and mannerisms of all participants, both when they are speaking and when they are listening; addressing the entire group, rather than a single student, with mannerisms and eye contact.³⁵

The general steps in preparing for and conducting small-group teaching are summarized as follows:

Small-group learning is a rewarding and highly effective method of teaching. It requires preparation and experience. The characteristics of small-group learning make it the teaching method of choice for many wilderness medicine educational activities, especially when combined with other techniques such as simulation, scenarios, and case presentations.

Distance Learning

Distance learning, traditionally provided via correspondence courses, has taken an entirely new direction. With proliferation of the Internet, more people than ever find it possible to further their education without physically entering the classroom. A little-used tool in wilderness medicine education is web-based distance learning. It has found widespread application in other academic areas such that health care educators have embraced many of the benefits of this rapidly evolving tool.

The advantages that the Internet offers to medical educators are many. Even courses that are not offered as complete web-based packages can be supported by limited Internet applications such as e-mail, distribution of materials, enrollment, needs assessments, and testing. To this can be added videoconferencing, discussion boards, live topic-specific chat rooms, and presentation of live events via video streaming. Nearly any software application that can be used on a home computer can be offered in some fashion over the Internet. With the advent of high-speed connectivity and constantly changing security programs, obstacles to efficiency and learner security have been minimized. Virtual learning environment software enables all of these applications to be managed efficiently while keeping the focus on the learner and not the technology.³²

The ability to hyperlink from any web page brings an entire world of web-based information to the learner with a few clicks. The speed and degree of access that modern learners have to information create implications for adult education that theorists never imagined.

For all of its attraction, the Internet is not a panacea for wilderness medicine education. There are two main disadvantages. First is the need for learners to posses sufficient computing power to allow for rapid and efficient downloading and presentation of course materials. This is made worse when they travel to remote locations. Perhaps the biggest drawback to web-based learning in wilderness medicine is its dependence on technology and the support that goes with it. Large organizations that offer this approach find it necessary to hire full-time support staff to provide a comprehensive and reliable product. Many wilderness medicine educators find it difficult to dedicate the resources necessary to bring it to full implementation. However, even small organizations find great usefulness in some applications.

For many wilderness medicine topics, passive approaches to learning, such as distance learning online, suffice to deliver information. It is up to the student to embrace the style and internalize the material. Basic science and clinical topics that can also be taught in lecture format with audiovisual aids work well when presented online. However, much of the body of wilderness medicine knowledge, especially that dealing with the prehospital phase of care, is largely experiential and requires direct interaction with other people.

There are numerous ways that education can be delivered online. The two broad categories are pure distance learning and the hybrid web-based course. In a completely web-based program, all course work, materials, sessions, and assessments are transmitted via the Internet; even assistance from teachers occurs by e-mail or live message applications. This method is a true virtual learning experience. Alternatively, many organizations offer hybrid online courses in which students use Internet applications as an additional tool to complete portions of the course but are required to participate in periodic face-to-face sessions.

Many health care practitioners involve themselves in wilderness medicine because of the fellowship with other uniquely qualified and experienced professionals. As web-based applications become more widely used in wilderness medicine, educators will be increasingly challenged to ensure that learners do not feel isolated from their wilderness medicine peers and role models. The learner, not the technology, must remain at the center of the effort. Internet applications must be selected for how they enhance the learning experience, not because they are high-tech and progressive.

Field Experiences

Medical schools and residencies are following the lead of commercial WPHEC programs and moving learners out of the classroom and into the field.⁴⁵ Rotations and electives that include field-training experiences of various lengths are now highly sought after. These have the effect of maintaining high levels of student interest and satisfaction. They offer direct relevance and immediate application of newly learned skills. When coupled with effective group process and feedback, the benefits of field training make this a powerful venue for skills-oriented education. These experiences are most often part of an overall curriculum that incorporates other techniques, such as lecture and problem-based learning, in a didactic setting (Figure 105-7).

FIGURE 105-7 Learning conducted in the field under genuine conditions is a vital component of any comprehensive wilderness medicine course. This method enhances skills development for individuals and teams and facilitates several aspects of the 360-degree summative evaluation of learners.

(Courtesy Fred Baty.)

Concerns include safety and security of participants as well as liability issues for the sponsoring organization. The logistic support package can be expensive and complex. The quality of the experience is greatly influenced by uncontrollable factors such as weather and climate. Proper screening and selection of participants are critical to success, especially in programs that are conducted in remote locations or in physically demanding environments. Multiple techniques, such as scenarios and hands-on practical exercise, can be applied simultaneously to maximize the learning experience. Field training affords an opportunity to introduce nonmedical skills such as leadership, wilderness survival, and land navigation.⁴⁵ This not only generates interest but also creates well-prepared learners and an overall lower level of risk.

Audiovisual

Audio and visual aids may take many forms limited only by the creativity of the teacher. The most basic may be a sand-covered stone upon which simple diagrams are drawn that communicate simple ideas and relationships. The most complex may be a multimedia presentation that incorporates diagrams, video, audio, and a computer-based interactive application to enhance learning by appealing to multiple senses. Despite the obvious advantages afforded by technology in preparing appealing and effective learning activities, pitfalls exist. These are not often represented by the lack of visual aids, but rather by the overbearing, confusing, or complex nature of those that are used.

The basic roles of visual aids are to illustrate the organization of a topic as it develops, to reinforce or highlight key material, and to provide an organizational “anchor” for the group that allows members to take notes, think, pose questions, and keep pace with the session.¹⁷

Examples of simple low-tech aids include terrain models, sand tables, chalkboards, paper charts, maps, and butcher-block flip charts. These offer significant advantages to wilderness medicine teachers in that they are inexpensive and retain their usefulness in austere settings. The disadvantages of these dependable visual aids include the time required to prepare them, the fact that many are good for a single use or a single topic, and their limited flexibility if changes in teaching direction are made. Perhaps the most detracting feature to some is that faculty cannot easily hide a lack of preparation behind these simple devices.

High-tech audio and visual aids include overhead projectors, video machines, 35-mm slide projectors, and computer software–driven and projected presentations. These all have the advantages of flexibility and appeal to multiple senses. If used properly and in the right setting, they enhance learning and provide a professional look to a degree that is unattainable with simple devices.

The obvious disadvantages of the high-tech methods to the wilderness medicine educator include expense and their reliance on additional technology such as electricity, lightbulbs, software, power cords, connectors, remote controls, and computers. Not only must faculty be comfortable with their subject, they must be facile with computers and software packages. Many “high-powered” presentations have been aborted because of lack of a simple piece of equipment, an incompatible software program, or a non–technically prepared speaker.

A mistake when preparing computer-based presentations is the tendency to want to use all of the “bells and whistles.” There is a wide selection of graphics, animations, and interactive tools available to the educator with even the most basic familiarity with standard software. The trick to preparing good presentations is to resist the temptation to use them. Anything that distracts learners from the main message of the graphic should be avoided. This includes sound effects, animated characters, moving text, and “wild and crazy” fonts. Some background colors and patterns work best with certain colors and fonts of text and large versus small room and screen sizes. Although there are some limited conventions in this regard, the best advice is to keep it simple and personally test any presentation in the place where it will be used.

Textbooks

Like any tool, textbooks are designed for specific purposes. It is important to address this issue before selecting a book to support an educational activity. The most important factor when selecting a textbook is to choose the right tool for the job. Some are intended to be encyclopedic and used mostly for reference. These tend to be larger and cover topics from a theoretical and evidence-based perspective. Although they act as good references and study resources, they may be unwieldy for use in wilderness medicine courses that focus on skills or are conducted in remote locations. They generally have greater application in the areas of wilderness medicine that cover theoretical and highly technical topics such as infectious disease and tropical, aerospace, and dive medicine.

Some smaller texts are intended for use as summaries of larger works. These can even be condensed into quick-reference pocket versions. The disadvantage of these is the amount of information and important detail that is lost with each “condensation.” They are seldom used as primary texts for courses; rather, they are adjuncts for rapid access to information already available elsewhere.

A third type of textbook is designed for use as a practical study guide. These come in various forms, but all appeal to the more practical areas of wilderness medicine that focus on prehospital care and acquisition of hands-on skills. Course planners may organize an entire curriculum around these highly flexible texts, or they may use certain sections to support an existing program of instruction.

Formats for modern textbooks include hard copy, electronic (CD-ROM), and fully Internet based. Publishers are now integrating their hard-copy texts with web-based tools that offer advanced features such as updates, searches, and downloading of graphics and additional information.

Syllabus Material and Handouts

The main purpose of providing handouts is to supplement material provided in texts or presented in class. They are often used when faculty want to either summarize or reorganize information into a format that more closely matches learning objectives. Handouts may be used to provide background information when more superficial treatments of material are offered in texts designed for skills- or case-based learning. Other roles for handouts may be to provide a resource for the conduct of projects or self-examination and to update information presented in published texts (e.g., clinical guidelines and procedural protocols).

Handouts that are meant for preclass preparation should be provided before the session. Those meant to recap or summarize may be best provided after the session to avoid distraction.¹⁷ Some syllabus materials are meant to save students’ time in note taking by providing key points with spaces provided to fill in additional information. This serves the dual purpose of keeping students engaged and making them think about the information before summarizing it in their own words. This technique carries a risk that important information may be misquoted or missed entirely.

Handouts are sometimes intended for use as comprehensive study and preparation resources, much like a textbook. Settings where this may be most beneficial are resource-constricted courses held in remote locations that are not able to provide standard texts for all students to use.

A modern approach to the use of handouts is that of providing course materials either on a CD-ROM or in a web-based, downloadable version. This presents challenges to the wilderness medicine educator in that many activities are conducted at locations where the Internet is inaccessible and students may not want to bring computers.

Whatever approach is used, a poorly prepared handout detracts from learning as much as does a badly conducted session or an inadequate teacher. No matter how well prepared and presented the learning activity, students will feel frustrated if they must navigate a disorganized, error-ridden syllabus.

Simulations

Among the most thorough treatments of the history and perspectives of the use of simulation in medical education is offered by Gardner and Raemer, who describe the use of this educational tool in obstetrics and gynecology training. They point out that among all the techniques available for the transfer of medical skills and knowledge, “simulation is a practical and safe approach to the acquisition and maintenance of task-oriented and behavioral skills across the spectrum of medical specialties. It is a means to augment didactic instruction, providing an out-of-the-chair and hands-on experience in a safe environment without harming real patients.” The notion that nonhuman objects could be used to train medical practitioners is not new and is being used across many disciplines.^6,56,68,74 As a model of complex skill training using a simulation-based mastery learning program to increase learner skills, Barsuk⁷ recently used simulated central venous catheter insertion to demonstrate improved performance that decreased complications related to central venous catheter insertions in actual patient care.

The incorporation of modern, computer-based technology across the spectrum of industries did not escape health care. Most medical schools and graduate medical education programs incorporate some form of simulation in their curricula.^7,27 Computer-based simulation technology has evolved to the point of offering virtual world individual and team-based scenarios using preprogrammed patients to expand the breadth and depth of options available for medical education.^57,64 Expectations for increased quality of medical training and the improved outcomes that result seem to contradict the decreased time allotted and increased resources required to conduct this training, as well as the associated expense. Training on virtual patients using interactive, computer-based clinical scenarios offers a potential solution¹¹ (Figure 105-10).

FIGURE 105-10 The use of simulation technology in wilderness medicine education often involves simple, low-tech models to enhance learning.

(Courtesy Fred Baty.)

Simulation technology is being used increasingly in medical training settings to enhance team training. As with any team-based vocation, medical teams that frequently practice their interactions are more effective and efficient. Teams that use simulation tools along with scenario-based role-play will benefit greatly. This is particularly useful in first responder and many types of hands-on wilderness medicine training courses. The learning and reinforcing of basic teamwork principles are greatly facilitated by using scenario- and simulation-based training. These include leadership, followership, situational awareness, closed loop communication, critical language, standardized responses, assertive communication, adaptive behaviors, workload management, and debriefing^31,54 (Figure 105-11).

FIGURE 105-11 Medical simulation with scenario-based role-play training is being used increasingly in medical education to enhance team-based learning.

(Courtesy Fred Baty.)

The use of simulation with computer-based mannequins and live patient role-play adds a dimension to skills-based training in wilderness medicine not available to more theoretical areas. Although this tool limits the quantity of information that can be covered and is resource intensive, it is a highly effective means to solidify learning and conduct reliable and valid assessments of hands-on skills. Except for the important teaching paradigms of austerity, limited treatment resources, and improvisation, its use in wilderness medicine is fundamentally no different than how it is employed in other areas of health care education.

Important factors to consider when planning training using patient simulation are the setting, the scene, acting, evaluation, and makeup (moulage).⁴⁷ The setting can be either indoors or outdoors as long as the proper clues are available to the learners. Highly realistic indoor settings call for elaborate surroundings and are often unnecessary. The basic function is to allow learners to familiarize quickly with the details of the scenario and make treatment and resource allocation decisions based on that information. Outdoor settings add more realism and use fewer resources but are subject to limitations imposed by weather and terrain. Even though prehospital courses in wilderness medicine orient their curricula toward anticipating, recognizing, and managing clinical syndromes using limited, often improvised equipment, the use of prefabricated and prepositioned props may make the training more efficient and the assessments more reliable.

The ability of learners to mentally immerse themselves in experiences using simulations seems to be directly related to the quality of the learning experience.²⁷ No matter the quality and high degree of fidelity of the simulation device used, the willingness of participants to “act the part” as though the situation were real for the duration of the training event facilitates the quality of their learning (Figure 105-12).

FIGURE 105-12 No matter the quality and high degree of fidelity of the simulation device used, the willingness of participants to “act the part” as though the situation were real for the duration of the training event facilitates the quality of their learning.

(Courtesy Fred Baty.)

Managing the acting can be challenging. Much of what role-players will be asked to do will seem unnatural. Some will simply not have the personality or behavioral repertoire to make good role-players. This results in either overacting or underacting, both of which hinder learning and assessment. Thorough briefings about training goals and setting ground rules for role-players are crucial. Having role-players that are thoroughly familiar with the script ensures that training objectives are met and skills assessments remain reliable. Students within the group can be used for training and derive additional learning benefit from this experience. Outside role-players should generally be used as victims for skills testing. The variation in quality of role-players can be partly overcome by having experienced and thoroughly briefed faculty and examiners at each station.

When available, makeup devices enhance learning by adding a high degree of realism. Makeup may consist of inexpensive improvised items or costly, anatomically correct moulage kits designed specifically for this purpose. The overriding concern when improvising or selecting moulage is whether it enhances or detracts from achieving the learning objectives of the scenario. If it directly supports the clinical syndrome being portrayed, then it is a good choice. If it does not, then it may confuse learners by causing them to make faulty assumptions. This has the overall effect of incorrectly learning material and leads to unreliable and invalid assessments (Figure 105-13).

FIGURE 105-13 Simple moulage strategies can be combined with other inexpensive props to add realism to a clinical wilderness medicine scenario.

(Courtesy Fred Baty.)

Time spent in developing a fair and valid assessment process using patient simulation will pay off. As previously mentioned, this is impacted by many factors, such as the quality and preparation of role-players and faculty, as well as environmental issues that are often beyond the control of the course director.

The notion of computer-simulated training dates back to the 1960s. Modern applications are taking the concept to a new level in the field of health care education. Patient simulation is particularly well suited for skills-oriented basic and advanced life support training in wilderness prehospital courses.⁴⁵ This tool merges computer technology with fundamental behavior-based adult learning principles to deliver effective teaching. Students are both challenged and stimulated to high levels of performance. Information is delivered in a tangible, practical fashion with immediate reinforcement. Learners may repeat scenarios, make on-the-spot corrections of wrong decisions, and see immediate results. Simulation at this level is more efficient than both problem- and scenario-based teaching largely due to the high quality of feedback that learners receive as they observe the immediate consequences of their interventions.⁴⁵

Life-sized mannequins are used that have complex analog to digital computer interfaces and run algorithm-based software designed to deliver a response to anything the learner does, including doing nothing. Software can be programmed to demonstrate any number of minor to life-threatening clinical presentations that are interpreted by the student as physiologic changes that would be expected in a real patient with a similar history and status. Interventions such as cardiopulmonary resuscitation, intravenous fluid administration, injectable medications, and intubations can be made that, if done properly and in the correct sequence, will result in the expected clinical improvement.

An additional feature offered by this tool is that of assessment of learning. In relation to traditional forms of written testing, computer patient simulation using scenarios is one of the most effective learning assessment methods. To this already superb tool can be added computer-generated reports and video of the interaction that can be viewed individually or in groups to reinforce teaching points and make corrections.

Method of Evaluation

There are three basic methods available: individual interview, open discussion, and questionnaire-survey. Interview and discussion have limited roles in the overall, long-term process-improvement of most wilderness medicine courses but have great usefulness in making short-term, on-the-spot adjustments. Questionnaires and surveys have the greatest applicability and will be discussed further.

Fairness and Confidentiality

All participants must be afforded the opportunity to evaluate the educational experience. Although it may not be feasible to make it mandatory, it should be highly encouraged. Questions should be constructed so that they do not unintentionally bias the results toward one group of learners over another (e.g., physicians versus EMTs). Most instruments are provided in a confidential fashion, whether or not names are provided on each questionnaire. The issue of anonymity has two schools of thought. One advocates anonymity to reduce the impact of bias and to make sure respondents feel free to offer honest critique without fear of reprisal. The other requires students to provide their name but takes steps to guard against unintended disclosure and reprisal. This provides for responsible commentary and allows for further clarification by individual students if needed. A reasonable compromise is to make it optional to provide names.

Usefulness of the Results

Like any other assessment, the ideal evaluation is reliable, valid, acceptable, and inexpensive.⁵¹ A violation of any of these will decrease the usefulness of the instrument. A poorly designed or administered critique wastes valuable resources and time for both respondents and faculty. This lack of respect will transform the process into a meaningless exercise. So how does one ensure that the results will be useful? The most important aspect is the actual construction of the instrument itself (see later discussion). Next is to make students feel vested in the course so that thoughtful assessment has a purpose and comes naturally. This must be nurtured in the course design and should have already occurred before the critique forms are handed out on the last day. Attend to the principle of proximity. For lengthy courses, ensure that there is time scheduled and reminders given each day to fill out critique forms for each session. A short, overall evaluation of the course can be done at the end. Students may be in a hurry to depart after academic activities are over and evaluations are being completed. A common technique to ensure that each student completes an evaluation is to require that he or she turns in a form before receiving a graduation or training certificate.

What to Evaluate

Participants may be queried about anything that is relevant to the conduct of the course. However, consideration must be given to the actual usefulness of the information and the time it takes to complete the form. At a minimum, students should be given the opportunity to rate and add additional commentary on the following components:¹⁵

Format of the Evaluation Instrument

Selection of the proper format of the evaluation is critical. An improperly designed instrument with poorly worded questions may lead to meaningless results or faulty assumptions that lead to inappropriate modification of course design. A good instrument respects students’ time. They will not fill it out properly if it is too lengthy or complicated. It should minimize potential for error and confusion by reducing the amount of work and thought that goes into filling out the form. Provide as much unique identifying course-related information for them as possible on the form. The fewer pages the better. One page is best. Instructions must be brief and clear.

Written commentary format gives immediate comprehensible feedback to the faculty that can be either positive or negative. However, it may be superficial and limited in scope. Comments may be difficult to translate into actionable information that leads to course improvements. Evaluations that use this method exclusively have limited reliability and validity.

The multiple-choice format facilitates tabulation and objective comparison. The choice of responses must be broad enough to avoid bias toward either end of the scale. In general, simple good-bad descriptors are less helpful than those that address the function and effectiveness of the item in question. Descriptive adjectives should be selected that match the component being evaluated. For example, adjectives describing helpfulness and effectiveness may be most appropriate when asking questions about class materials or procedures. A space for commentary should be provided after each question. Scaled forms on which the student must fill in a circle or cross off a number to rate the specific features of the course take less time to complete and are helpful in managing the results. A quick reminder about the nature of the item being rated may accompany these questions. Rating scales can be from 1 to 5 or 1 to 10 and may correspond to various forms of descriptors.

No matter what format is chosen, it is a good idea to leave room for several open-ended questions that address the most and least valuable portions of the course as well as what improvements the respondent recommends. Responses to these tend to be highly contextual based on the background and personality of the student. However, multiple responses from a single class that focus on the same issue or several that are similar across multiple courses may indicate need for change.

Provide the Results

Course directors should provide tabulated and summarized results of the evaluations to all faculty members. Both group and individual sessions with instructors may be beneficial to discuss the results and select process improvement strategies. Faculty members should see specific comments only about themselves and not those made about other instructors. There should also be some way to inform the students about the results of the evaluations and the resulting actions that were taken.

Evaluation of teaching is a critical component to the overall process of educating adults in any discipline. Learners and teachers at all levels expect this and often look forward to it. With some effort in planning and design work, the practice can become one of the most valuable tools available to wilderness medicine educators.

Desired Outcomes

Outcomes are addressed on two levels: the overall course goals or objectives and specific learning objectives for each session or activity. As the name implies, course goals describe the overall purpose for students attending the course. This may include a job- or skill-related certification or simply advancement of their general fund of knowledge. It addresses what they should be able to do or know after completing the entire program. All activities related to the formal curriculum should contribute in some way to these goals. This is similar to a large corporation that does institution-level analysis of mission, vision, goals, and objectives. Any action resulting from this strategic planning that does not contribute in some way to the mission of the organization is at best distracting and possibly a hindrance. Individual learning objectives can be viewed in this context. Accomplishment of the course goals depends on them.

Two sources, or stakeholders, should be queried to determine outcomes at both levels. Potential learners may be asked using various methods (polling, focus groups, and questionnaires) what they think is important and what they would most like to learn. Organizations that hire or interface with potential graduates of the course may be asked for their input on what skills, knowledge, and qualities the graduates should possess. The goals and objectives should be formalized, written, and distributed to anyone involved with curriculum design. They serve as a compass to guide all planning and design efforts.

The set of general educational objectives for the WPHEC curriculum proposed in 1991 by the Wilderness Medical Society (summarized later) offers an example of how to organize course objectives for this type of program.⁷⁶ A learning needs assessment of the intended audience allows these to be rewritten in a more active tense using appropriate verbs to make them suitable for use as outcomes in any setting. Courses designed to provide certification or registration would address this requirement as well in the course objectives.

Some wilderness medicine courses focus on specific environments such as dive, tropical, aerospace, or desert medicine. Course objectives for these should reflect the unique requirements of each and be tailored to the needs of the anticipated audience.

Determine the Content

After the course objectives are established, they are used as a basis to begin selecting major content divisions or sections. There is no “best” method of dividing the information, but sections should be easy to support with effective teaching and assessment methods based on sound learning theory (e.g., problem based versus lecture based, small-group discussion versus hands-on practical exercise). The organization of the WMS WPHEC objectives suggests sections devoted to basic science, clinical science, EMS and evacuation procedures and equipment, field craft, and prevention. The major sections are further broken down into subsections or topics. The basic science section might be divided by topic-specific reviews of anatomic or physiologic systems. The field-craft section might be broken down into land navigation and wilderness survival. Land navigation may be further divided into sessions on map reading, compass use, celestial navigation, and use of Global Positioning System (GPS). It is this final level for which specific learning objectives are written. There are no absolutely right or wrong answers to selecting the specific content of a course. As long as the basic steps are followed, a suitable solution will reveal itself.

Select Teaching Methods

Methods to deliver the information should be selected after the course content has been established. Course planners should make use of several techniques and, if possible, vary them daily to maintain student interest. An entire day of hands-on practical exercise in frigid temperatures may distract from learning as much as 10 hours of back-to-back lectures. Intermixing the techniques by spending 2 hours outside, and 2 hours indoors in small-group work, followed by 2 more hours outside, capped off with an hour or two of lecture at the end of the day is an example of this type of variation. Planners should make maximum use of the various forms of problem-based instruction and small-group work. Lectures should be limited to introductions and those topics that absolutely do not lend themselves to the aforementioned techniques.

Of the steps in curriculum design, the selection of teaching methods may be most influenced by the physical setting of the course. This includes climate, terrain, and accommodations for teaching and lodging, as well as available support. There is no best time in the curriculum design process to finalize the setting. It will sometimes be preestablished, forcing accommodations in design work. At other times, the curriculum may be set pending the outcome of a suitable location at which to conduct the course.

Select Learning Assessment Instruments

The assessment of learning derives directly from the course objectives that are supported by the learning objectives. Written testing will allow assessment of both. Some questions may be intended to evaluate knowledge of facts addressed by learning objectives from individual sessions. Others address the synthesis of information drawn from multiple sessions and in different sections. Written tests or quizzes can be used for formative assessment, whereas hands-on skills testing using scenarios and role-players may be used in practice, formative, and summative (end-of-course) roles. For some courses, skills-based assessments may be out of place, forcing planners to be skilled at constructing written exams. The main concept in constructing assessment tools is to develop them based on well-written session and course objectives.

Medical Students

Opportunities for medical student education have increased tremendously. Although students are free to pursue WFA and WFR courses as described later, many seek formal electives for educational credit through medical schools. These electives continue to grow, typically require a 2- to 4-week commitment in the third or fourth year, and may result in WFR or other certification. The majority of these experiences incorporate classroom instruction with some form of outdoor experience with problem- or case-based learning. Several of these electives are based in urban locations and transition to backcountry or resource-poor settings for experience-based teaching and simulation. The WMS has a well-established month-long course in the Great Smoky Mountains National Park in association with the Uniformed Services University of the Health Sciences. In addition, the WMS sponsors student interest groups to help foster educational activities and events. Although students are free to attend CME events in wilderness medicine, several conferences exist specifically for medical students. Box 105-10 lists some well-established programs with links to their websites.

Residents

Several organizations offer elective time to residents, primarily in family and emergency medicine (Box 105-11). These electives incorporate a variety of EMS, search and rescue training, and international experiences and typically require a 2- to 4-week commitment. Many elective experiences integrate learners from all disciplines and levels of medical education.