Contributors: Prof. Dr. Michael Punt, Dr. Jacqui Knight, Dr. Daniel Korn, Nicolas Peres

Supported by: Arts – Health Collaboration Fund. Faculty of Arts, Humanities and Business (FoAHB), University of Plymouth. The Plymouth Institute of Health and Care Research (PIHR)

Introduction and aim of research

This project scopes the viability of using VR production for virtual elective programmes in primary care. It also considers the design of a film production toolkit to enable clinicians as content creators. The project develops some of the synergies between Daniel Korn’s VR Patient journey to GP practice and Transtechnology Research’s collaboration with the digital education unit at Torbay and South Devon NHS Trust (TAaCT project) and Nick Peres work with immersive technologies in healthcare and education. In particular we were interested to scope the possible and appropriate use of 360 video, VR and AR technologies to support the acquisition of soft skills in virtual elective training (VR in healthcare and E-medicine). It was also recognised that materials produced would be useful for predeparture training, recruitment and raising digital literacy amongst the workforces.   

In the later stages of the project we were invited to sit in on a pilot virtual elective program for UK and Rwandan medical students. It became evident through student feedback that the most engaging exchanges were social and cultural insights shared through music, recipes and traditions using candid photography and informal discussion. There was an immediate realisation that high technological solutions were not altogether necessary for enriching cross cultural exchanges, though they might be more appropriate for recruitment purposes or tours of the hospital environment.  

This insight led to rethinking the technological intervention in a more vibrant and accessible way. The use of photography and video as a reflexive or discursive tool to exchange first person perspectives and experiences in the workplace or sharing some aspect of their culture, seemed far more appropriate. Choosing a low-tech solution is more accessible, inclusive, and crucial if we hope that students and clinicians are to become creators of their own content, choosing the subjects that speak to them. In addition, it was recognised that a video ethnographic toolkit would be a good way to build competencies in digital and visual literacy towards the use of more sophisticated content creation using VR immersive technologies.

Problem outline

Typically, medical electives give student doctors the opportunity to work alongside local medical professionals to gain first-hand experience of the health care system in a developing country. This exposure develops medical student’s practice by confronting different illnesses and treatments, discovering new techniques and methods and observing how teams work together in often resource stretched settings. Electives are typically organised by the students themselves to explore areas of interest and often takes place during the penultimate or final year of the degree.

Before the Covid-19 pandemic there were already many challenges facing students who undertook medical elective placements. They include; health and safety issues when students are asked to work outside of their comfort zone, qualification level or expertise; safeguarding issues for themselves and others and the expense of travel and placement

The Covid-19 pandemic presented an opportunity for medical education by necessitating the need for an alternative model of medical electives. Various institutions started offering virtual elective programs in many different forms but always using video conferencing tools such as Zoom. One of the challenges, however, of creating a virtual medical curriculum is transforming sessions or courses that have active learning associated with it and preserving that active engagement in a virtual environment.

Problem statement – How might we use digital media for cross-cultural exchange that preserves the active engagement in a virtual environment.

Outline of the research undertaken  

This project began by scoping the market to see who was already running virtual elective programmes and the format that they take. Virtual electives had become an established form of training prior to Covid-19 but gained significant momentum during the pandemic. Typical pedagogical approaches behind work placements are experiential learning, situated and authentic learning, and social-based learning.

The UK Medical Schools Elective Council has identified the sub-set of global health learning outcomes which are best achieved through undertaking a medical elective:

1. Recognise that health systems are structured and function differently (across the globe). 
2. Describe how the environment and health interact (at the global level).
3. Discuss communicable and non-communicable diseases (at the global level).
4. Demonstrate awareness that climate change will become an increasing threat to global health in the twenty-first century. 

As highlighted by Rahim et al’s systematic review, there is a core set of ethical skills that medical students need to develop to face ethical issues during international health electives. These are:

1. Self-awareness/introspection
2. Humility
3. Critical reflection
4. Cultural competence
5. Dealing appropriately with conflict
6. Consulting appropriately in decision making
7. Willingness to listen and learn
8. Commitment to addressing social injustice

Virtual elective programmes range from peer-to-peer training modules delivered as powerpoint documents (Doctors of the World) to virtual one-week work experience placements (Red Cross) to browser-based virtual simulated placements (HEE). Many of these virtual placement programmes use pre-recorded footage and virtual “clickers” (audience response systems that allow students to submit answers to questions posted in real-time by instructors). Another organisation, Medic Mentor provides an open-access virtual live work experience programme that includes a Q&A feature.

One notable organisation, Feinberg School of Medicine, recognised the need to preserve active engagement in a virtual environment. They organised online boot camps for clinical skills training for graduating fourth-year students in obstetrics and gynaecology. Students were mailed suture knot tying kits (to practice suturing and knot-tying under the virtual supervision of faculty and residents), small aspirators and papaya (to learn how to do endometrial biopsies), and water balloons and amnihooks (to practice artificial rupture of membranes). In other clinical skills training, colleagues serve as virtual avatars for students to instruct.

Several trends in the e-learning sector have emerged in recent years, most of which are related to large-scale increases in Internet speed and accessibility, and changes in the ways technology is used. E-learning is available through computers, on mobile devices such as smartphones and tablets (often referred to as m-learning or mobile learning), and through open online courses and social media channels, and is facilitated through open education resources. Other common sources of online learning include videos and educational materials offered through the websites of healthcare service providers, public-private partnerships and health-care-related associations and organisations.

Frameworks for developing virtual elective programmes.

Several notable organisations had written frameworks for developing virtual placement programmes:

Scenarios for virtual and virtually supported work placements (Rintala and Schrader, 2011) is a document developed in the framework of the EU-VIP (Enterprise-University Virtual Placements) project. It includes cross-border collaboration with people from different backgrounds and cultures working and studying together. The initial framework introduced in this document was tested through 18 pilot projects. It provides definition and benefits of virtual and virtually supported work placements, description of organisational, pedagogical and technological foundations of virtual and virtually supported placements, support for developing validated scenarios for these types of work placements.

The Toolkit for a Sustainable Health Workforce in the WHO European Region (2018) includes a section on e-learning using a case study that describes the use of Multilingual virtual simulated patients (MVSP) that aids medical education across Europe under the European Commission’s lifelong learning programme. MVSP is designed to provide patient simulations in primary care settings and is available in Bulgarian, English, German, Hungarian, Italian, Portuguese, and Spanish. A further benefit of MVSP is the ability to provide cultural communication education, as patient simulations can simulate a patient not native to the country, representing migrant populations or other patients speaking in a second language.

Connect Health is a community services healthcare provider for occupational health physiotherapy services. They provide an eight-point guide to setting up virtual student placements to enable students to take part from their home countries, keeping the pipeline of physios flowing during Covid-19 and beyond.

Practical and ethical considerations

During a discussion about how we might use digital media for cross-cultural exchange that preserves the active engagement in a virtual environment several practical and ethical considerations became evident

• Are the aims of each exchange organisation the same?
• Where are the key areas where exchange programmes fail?
• Ethical/cultural/social implications
• Power and representation: mirror misrecognition and the role it plays in forming identities
• Effective use of technology – do we need to use 360 or a range of cameras?
• Who will do the filming? How is time paid for?
• How will the programme be delivered (via zoom?)

Collaboration and consultation across diverse cultures

One of the issues that was raised – how do we approach collaboration and consultation across diverse cultures for more inclusive and equitable outcomes? This led to a survey of existing facilitation frameworks for cross-cultural collaboration.

• Global Citizenship Education Framework (Oxfam, 2021)  lays out a ladder of participation, being actively involved in decision-making and taking action on issues relevant to them.

• Enterprise facilitation – Ernesto Sirolli of Sirolli Institute an international non-profit organisation that teaches community leaders how to establish and maintain Enterprise Facilitation projects in their community.

• The Center for Nonviolent Communication (CNVC) https://www.cnvc.org/ is a global organization that supports the learning and sharing of Nonviolent Communication (NVC), and helps people peacefully and effectively resolve conflicts in personal, organizational, and political settings. Rosenburg, M. (2015) Nonviolent Communication — A Language of Life: Life-Changing Tools for Healthy Relationships.

• Co-design processes in which key components are; Intentionally involving target users in designing solutions; postponing design decisions until after gathering feedback; Synthesizing feedback from target users into insights; Developing solutions based on feedback.

A typology of digital communication tools and their use.

The issue of resources was raised as a key concern for the development of the filmmaking toolkit for use in virtual elective programmes. Assuming video conferencing tools such as Zoom will be as the common platform what other digital and non-digital tools might be used to exchange audio/visual experiences. 

We developed a typology of tools and their uses.

1. Synchronous tools (facilitating communication between users at the same time), e.g. Zoom, Teams, videoconferencing tools
2. Asynchronous tools (facilitating communication between users independent of time), e.g. email, online discussion forums, e-portfolio
3. reflective tools (e-portfolio, weblog),
4. noninteractive tools (streaming media, podcasts, videos, websites)
5. collaborative tools (wiki, group blog, discussion forums),
6. communication tools (email, chat, video, audio and web conferencing)
7. social networking tools (social networking, shared media, social bookmarking). (Op de Beeck et al., 2008)

Observations and insights from a pilot virtual elective programme between UK and Rwandan medical students.

 As Daniel and I discussed, more complex ideas such as 360 videos and VR production just isn’t feasible with limited resources, without buy out on staff time, technical/ digital literacy etc. In the first instance, it’d be good to scope what audio/visual tools are already being used? ie. are clinicians already recording and sharing practices on their smartphones (even informally)? this would indicate how much of a leap we’d be making to send 360 cameras and expect the footage to be stitched and edited with sound etc. There are so many uses for this kind of tech – some of which I tried to explain through previous projects ie like this one between Torbay Hospital and HEE https://hee-vr360.azurewebsites.net/   It’s a bit of a chicken and egg situation though for students or new users – you need to have some experience of using various video technologies to be able to think about what problems you can apply it to and how.  

There are parallels here with another project in which we’re developing a framework for an online CPD module on video ethnographic reflexive methods to sensitise trainee dentists to influences and cues of patient anxiety. In this project, we are using video in a more formalised way – to collect qualitative data for research and training purposes. Because this is not a typical part of dentist curricula we have had to think through a step by step programme –  the first steps are to teach basic filmmaking techniques and sharing a basic filmmaking tool kit, then to teach visual literacy (how to decode video, what it can say and what it can’t tell us) and then use the videos a reflexive /discursive tool in debriefing sessions. 

I was thinking, having now had a bit of insight into your programme, perhaps it might be appropriate to set up a series of film exchange exercises ie. pairing students from each partner country, letting each decide on an area of their practice/ an interaction / a cultural insight / or a problem that they could film and then present back to the group in an open discursive forum (perhaps, in fact, you’re already doing this informally?).

Video ethnographic approaches emphasise practical, in the field, lived experience. They ‘show rather than tell’. This is also a technique used in screenwriting to allow the reader to experience the story through action, words, thoughts, senses, and feelings rather than exclusively through the author’s summarisation and description. Techniques such as these provoke an experiential/ sensorial engagement for the viewer which helps to overcome some of the loss in online learning.  As we discussed last night, students should be the creators of their own content and choose the subjects /problems that speak to them. This would be a good way to build competencies in digital and visual literacy towards bigger projects using 360 cameras and VR to exchange a view of hospital environments, share practice knowledge, observe how teams work together to support pre-departure planning and exchange cultural experiences.

There is a clear cross over between both these projects. Although video ethnographic methods are used often in social science, I can’t see (after a very quick scan) any evidence of it being used more formally in a virtual elective programme. I see Standford, in the wake of the pandemic, are now looking at how to practice ethnography research remotely using certain analogue and digital tools https://iriss.stanford.edu/doing-ethnography-remotely So maybe taking the idea back a notch and building a video ethnographic virtual elective programme might be an idea for a way forward? 

Problem statement – How might we develop a framework for an online module that uses video ethnographic methods for cross-cultural exchange within virtual elective programmes? How might we develop more mutually beneficial collaborative virtual elective programmes?

Summary of findings

Having scoped different models of practice-based learning in global health, observed interactions in the virtual elective pilot which trialled and evaluated alternatives to face-to-face placements, it is clear that technological interventions and solutions are context contingent. The field of virtual placement programmes is broad and needs a focussed approach, from needs analysis through to evaluation tools to help educators identify and focus on the challenges worth pursuing, develop interventions that will actually work, and create equitable learning solutions that provide real impact. As Hamilton and Hattie, (2021) argue in their paper Not All That Glitters Is Gold, although technology has long promised to revitalise education, evidence suggests that we still haven’t figured out the most effective ways to use technology for the biggest impact.

We should start thinking about this problem in terms of a hybrid of technologies instead of a single technological platform. There is an illusion that technological solutions or platforms (like Zoom) create a unifying experience.  Whilst in our Zoom culture there is a tenancy to see a single platform as being attractive and manageable there are cultural, technological and ecological reasons why that may not be possible. Secondly, we need to prepare the future workforce for practical skills in dealing with images and raising visually literacy – the ability to interpret, negotiate, and make meaning from information presented in the form of an image.

The problem is one of broader communication skills, rather than thinking that technology is going to solve the problem. In our solutions to this, we need to be responsive and agile in relation to local circumstances. Although, in many ways the problem of managing technology in global and local communities are similar – unstable internet connections, user confidence etc. we still need digital literacy programmes and co-design solutions that work for different groups regionally and locally according to their competencies and curiosities. The apparent ubiquity and uniformity of the platform is an idealisation and not a given and this really highlights differences between contexts/ countries.

Recommendations for further research

This report is evidence that more work is justified on the initial question and approach.  In particular:

• A SWOT analysis of the existing frameworks for developing virtual placement programmes
• Further investigation of facilitation frameworks for cross cultural collaboration
• Further investigation of mix modality digital solutions that will respond to local and global circumstances.
• Further exploration of methods to encourage wider engagement with the technology in this context.

Legacy of this project in terms of collaboration

As we suspected at the outset there is a continuity between this project and the Arts – Health Collaboration with the Peninsula Dental School and the Digital Literacy project with Torbay and South Devon NHS Trust. All three collaborative projects draw on interdisciplinary expertise from speculative design, filmmaking, simulation, medical education and training, robotics, and the humanities in the cross-pollination of ideas to generate new ways of thinking by sharing knowledge.

 The summary findings here will be drawn into the digital literacy project with Torbay NHS

 in which we aim to draft a project design and feasibility for large scale funded research.

References

Hastings A, Dowell J, Eliasz MK. Medical student electives and learning outcomes for global health: A commentary on behalf of the UK Medical Schools Elective Council. Med Teach. 2014 Apr;36(4):355–7.

Oxfam (2021). GLOBAL CITIZENSHIP EDUCATION FRAMEWORK. [online] Available at: https://www.sfyouth.eu/images/toolkit/global_citizenship_education/GlobalCitizenshipEducationFramework.pdf.

Rahim A, Knights (Née Jones) F, Fyfe M, Alagarajah J, Baraitser P. Preparing students for the ethical challenges on international health electives: A systematic review of the literature on educational interventions. Med Teach. 2016 Sep 1;38(9):911–20.

Rintala, U. and Schrader, C. (2011) Scenarios for virtual and virtually supported work placements. [online] Available at: https://www.eurashe.eu/library/modernising-phe/mobility/virtual/WG4%20R%20euvip%20annex12.pdf [Accessed 18 Oct. 2021].

Rosenburg, M. (2015) Nonviolent Communication — A Language of Life: Life-Changing Tools for Healthy Relationships.

Stoller. P. (2014) The Taste of Ethnographic Things: The Senses in Anthropology

WHO. (2018). The toolkit for a sustainable health workforce in the WHO European Region. [online] Available at: https://www.euro.who.int/__data/assets/pdf_file/0004/375547/WH11_TK_text_AW-2.pdf.