Human Factors Science in the Undergraduate Medicine Curriculum at Dundee

1. Human Factors Science in the Undergraduate Medicine Curriculum at Dundee Dr Evridiki (Evie) Fioratou Lecturer Medical School Lead for Behavioural & Social Science Human Factors Workshop, 2G12 Dalhousie, 18.12.2013

2. Outline • Teaching Agenda • Progress • Challenges • Strategic Vision

3. Teaching Agenda

4. Teaching Agenda • Development of Human Factors Science in the undergraduate medical curriculum • Integration of teaching and research • Critical thinking development

5. GMC’s Tomorrow’s Doctors (2009) Outcomes To be Addressed by Human Factors Science Teaching

6. Ensuring GMC’s Tomorrow’s Doctors (2009) Outcomes

7. Outcomes 1The doctor as a scholar & a scientist 9 Apply psychological principles, method & knowledge to medical practice • Explain normal human behaviour at an individual level 12 Apply scientific method & approaches to medical research (b) Formulate simple relevant research question in … psychosocial science … and design appropriate studies or experiments to address the questions

8. Outcomes 3 The doctor as a professional 21 Reflect, learn & teach others (c) Continually & systematically reflect on practice … (e) Recognise own personal & professional limits … 22 Learn & work effectively within a multi-professional team (b) Understand the contribution that effective interdisciplinary teamworking makes to the delivery of safe & high-quality care (d) Demonstrate ability to build team capacity & positive working relationships & undertake various team roles … 23 Protect patients & improve care • Place patients’ needs & safety at the centre of the care process • Deal effectively with uncertainty & change • Promote, monitor & maintain health & safety in the clinical setting, understanding how errors can happen in practice, applying the principles of quality assurance, clinical governance & risk management to medical practice, & understanding responsibilities within the current systems for raising concerns about safety & quality

9. Human Factors Science: Design & Delivery An interactive and continuously evolving process

10. Planning I • Agreement on key Human Factors topics for undergraduate medicine* • Clinical colleagues’ needs assessment* • Identification of Human Factors topics within the extant curriculum • Students’ needs assessment • Environmental needs assessment • SSCs

11. Planning II Teaching Delivery Methods • Lectures and workshops • Individual and Group projects (teaching–research link is mutually beneficial) Assessment Tools • In line with the Medical School: e.g., formative/summative, written reports, verbal presentations, reflective portfolios, as well as integrated assessment within OSCE, DOPS, mini-CEX and CBD

12. Developing • Define learning outcomes for: whole Human Factors programme, SiP and PiP phases, SSCs • Identify relevant diverse resource materials for the study guides and the teaching sessions • Develop case scenarios from different medical areas with the help of clinical colleagues to instill HF practice and relevance and to ensure seamless integration (cf. TDGs: Patey, Fioratou, Friar, & Flin, 2011: AME) • Develop diverse research opportunities for transfer of learning from the lab to the medical world (cf. Fioratou, Flin & Glavin, 2010: Anaesthesia)

13. Implementing (albeit fragmentarily at the moment!)

14. Fundamental Characteristics of Human Factors • It takes a systems approach • It is design driven • It focuses on two closely related outcomes: performance and well-being Dul et al. (2012; Ergonomics)

15. Progress

16. Year 1 • Principles Block Systems thinking [Clinical human factors skills & IPL] • Respiratory Block Integration of systems thinking and clinical human factors skills • GI Block (in preparation) Application of systems thinking and clinical human factors skills

17. Principles Lecture

18. Learning Objectives • Define Human Factors Science • Develop an understanding of systems thinking & its applicability • Explain the relevance of Human Factors Science to clinical practice

19. Human Factors/Ergonomics Definition Ergonomics (or human factors) is the scientific discipline concerned with the understanding of the interactions among humans and other elements of a system, and the profession that applies theoretical principles, data and methods to design in order to optimize human well being and overall system performance. ~ International Ergonomics Association ~

20. Definition – Reinforced “… the theoretical and fundamental understanding of human behaviour and performance in purposeful interacting socio-technical systems, and the application of that understanding to design of interactions in the context of real settings” ~ Wilson (2000) ~ Wilson JR. Fundamentals of ergonomics in theory and practice. Applied Ergonomics 2000; 31: 557–67.

21. Systems Engineering Initiative for Patient Safety (SEIPS) Model Carayon P, Hundt AS, Karsh BT, Gurses AP, Alvarado CJ, Smith M, et al. Work system design for patient safety: The SEIPS model. Quality & Safety in Health Care 2006; 15: i50–i58

22. The Wayne Jowett Case • Identify the SEIPS elements involved in this case http://www.smd.qmul.ac.uk/risk/videos.html#

23. Interacting SEIPS Elements in the Wayne Jowett Case SPACE TIME

24. Recognise that interactions are central to the care you provide within a particular complex sociotechnical system • Explore the interactions of different components of the complex sociotechnical system in which you find yourself • Acknowledge not only the psychosocial components of your system but also its physical and organisational components and examine how they impact your patient care • Embrace complexity & uncertainty How do you apply SEIPS Systems Thinking in practice?

26. Respiratory Lecture

27. Learning Objectives • Integrate Human Factors Principles: systems thinking & clinical human factors skills • Explore problem solving in action • Develop an understanding of problem solving theory • Explore problem solving in a patient case • Develop an appreciation of problem solving theory applicability to clinical practice

28. Integrating Systems Thinking & Clinical Human Factors Skills Decision making Managing stress Coping with fatigue Communication Team working Situation awareness Leadership

29. Problem Solving in Action

30. Try to solve the following problem in groups of no more than 3 people. You have 5 minutes! • You are given 4 chains of 3 links each as shown below • It costs £2 to open a link and £3 to close a link • Your goal is to connect all chains, as shown below, at a cost of no more than £15

31. The Solution to the Cheap Necklace Problem(Silveira, 1971; Fioratou& Cowley, 2009) Fioratou, E., & Cowley, S. J. (2009). Insightful thinking: cognitive dynamics and material artifacts. Pragmatics & Cognition, 17, 549-72

32. Systems Thinking in Problem Solving Problem solving behaviour emerged from the interaction of your team members, your task, your tools, your environment & our organisation How can we improve the interaction of our system elements to solve the CNP?

33. Application to clinical practice

34. The Elaine Bromiley Case http://www.risky-business.com/talk-89-just-a-routine-operation.html Working in groups of no more than 3 people, discuss the following for this case: • What System Elements (from SEIPS) can you identify? • What Clinical Human Factors Skills were involved? • What problem solving aspects can you identify that led to the unsuccessful management of this patient?

35. Linking the Bromiley case to the CNP problem solving performance In the CNP In the Bromiley case Expertise is necessary but not sufficient for successful case management Persevering with intubation leads to fixation and ultimately to patient death • Knowledge is necessary but not sufficient for problem solving success • Persevering with the hill-climbing leads to fixation and ultimately to failure to solve the problem Failure to escape fixation by capitalising on cues in the environment

36. Suggested Actions from an Independent Review (2005) • Obtain and display a set of the latest DAS guidelines in each anaesthetic room • Develop a protocol to ensure that when any emergency event occurs, be it in the anaesthetic room or the operating theatre, there is someone designated to keep full contemporaneous records of the event and to provide an elapsed time prompt. • Ensure an atmosphere of good communication in the operating theatre such that any member of staff feels comfortable to make suggestions on treatment. • Organise a study day on airway management with particular reference to equipment not regularly used and any peculiarities

38. Strategies to Minimise Cognitive Errors

39. Summary • By exploring problem solving in action, we experienced how heuristics may sometimes lead us to fixation and failure to solve simple problems • The applicability of problem solving concepts in clinical practice can help us appreciate the limitations of our cognitive powers and prepare us for future fixation recovery • By exploring problem solving in the Elaine Bromiley case, we experienced how clinical human factors skills may interact with the particular system elements leading to fixation and ultimately to patient harm • We need to start learning and adopting strategies to minimise our cognitive limitations

40. GI Workshops(in preparation)

41. Year 2 • Dermatology Block • Child & Family Block (in preparation)

42. Dermatology Online Module

43. Learning objectives • Understand the complexity of the dermatology consultation from a Human Factors Science approach • Explore the affective component of clinical work and understand the fundamental attribution error • Reflect on your own emotions and develop strategies against potential fundamental attribution error

44. Child & Family Workshops(in preparation)

45. Year 4Transition Block 2 Workshops

46. Learning Objectives • Introduction to Systems Thinking within Human Factors Science • Problem solving in action – introduction to Systems Thinking in the lab & experimental methodology • Real patient cases – application of Systems thinking in healthcare & naturalistic methodology

47. Evaluating • Feedback from students* • Feedback from clinical teachers • Learn from the feedback and improve the programme accordingly…

48. Challenges

49. Integrating Human Factors principles in clinical training and practice • Human Factors information provided before it becomes clinically relevant • Dissonance between the Human Factors & biomedical cultures • Linking with other teaching (e.g., core clinical problems, clinical skills centre, patient journey, clerking) • Inconsistent modelling of Human Factors principles in the clinical setting • My role and development as a non-clinical lecturer…

50. Solutions? Human Factors integration throughout the spiral curriculum Co-ordination with clinical colleagues but also acceptance of individual differences & contextual issues Cultural change via leadership