The Impact of Experiential Learning, Operation Bushmaster, on Medical Student Decision-Making Compared to Directed Learning

To the editor,

The last two decades have seen a dramatic transformation in medical education moving from a primary apprenticeship model to directed focus individual education. Following the Institute of Medicine’s two published reports drawing attention to widespread problems with quality, safety, and cost, there has been a shift in the health care system. The Accreditation Council for Graduate Medical Education applied system models moving from the exclusive physician–patient relationship to a more adaptive system. Lacking systematic review and challenge, system-based practice is difficult to define, operationalize, and measure effectiveness.

Physicians serving in the military are confronted with operational challenges not addressed by standard medical school curriculums. Concern has been expressed by many medical educators, noting that the implemented restrictions on work hours, less direct responsibility of the student for patient care management, and decreased assimilation into the patient care team have been detrimental. The degradation of responsibility in the clinical realm has resulted in medical students, interns, and residents lacking in hardiness, resiliency, and emotional intelligence. To address these concerns, medical educators have implemented experiential learning into the medical education curriculum. The complexity and cost associated with providing real-life experience, constructed knowledge and meaning to medical education, requires educators to critically evaluate the effectiveness of experiential learning for medical students.

In the article, “The impact of Operational Bushmaster on medical student decision making in a high-stress, operational environment,” Dr Cole and colleagues add to the growing significant literature addressing the benefits of experiential learning in medical education. The important aspect of their investigation is the focus on the environment of operational medicine with the expressed outcome measure of medical decision-making while under stress. The population for this analysis is a small cohort of fourth-year students attending Uniformed Services University. Previous reports have described the impact of experiential learning utilizing hyperrealistic^tm full-emersion training for medical students in the Health Professional Scholarship Program. The article by Cole et al. is meaningful but only applicable to students within their institution and potentially extrapolatable to other students who will serve as medical officers in the uniformed services, such as students receiving Health Professional Scholarship Program.

To explore the impact of experiential learning associated with a high-fidelity military medical field practicum (MFP), the authors investigated a cohort consisting of a convenient sample of 4th-year medical students. The control group for this analysis was students undergoing a 5-day full immersion MFP, “Operation Bushmaster.” The experimental group consisted of students assigned to asynchronous online directed learning. The outcome of interest was medical decision-making performance measured by a rubric derived by a panel of board-certified emergency medicine physicians utilizing a modified Delphi technique.

To a critical reader, there are several methodological concerns regarding design, assumptions, and analysis leading to the conclusions drawn from this small cohort analysis. Although the limitations of this study will be briefly described, they should not dissuade the reader from embracing the important concepts illustrated by the study.

For this cohort analysis, the authors attribute comparability between groups, as all are from the same class attending Uniformed Services University of the Health Sciences. Descriptive statistics are not provided regarding group characteristics to justify comparability of groups. The sample sizes are small and unmatched. Review of age, sex, and ethnicity provided in the manuscript does not appear to be equally distributed between the control and intervention groups. The literature attests that learning has a dependency on these confounding variables.

The authors chose to develop the outcome measure with board-certified emergency physicians, as experts, using the systematic, qualitative Delphi technique. Structured qualitative measures have value and innately seem reasonable but lack the rigors of quantitative analysis, reproducibility, and validation. Inherently, the outcome of interest, measured by pre- and post-intervention measures, is subject to the risk of systematic discrepancy with the introduction of observer bias. Regardless of the potential biased outcome measure, the difference in findings of the control group, attended MFP, pre vs. post P-value < .01, compared to the intervention group, online directed learning, pre vs. post P = .554, is meaningful and should not be ignored.

The report by Cole et al. is notable. The authors chose the interventional group as the asynchronous online directed learning group. The control group students attended an experiential immersive 5-day military MFP that included live actors and high-fidelity simulation. The insightful aspect of the report is that experiential learning is considered the norm, control. Education of physicians changed markedly following the Institute of Health’s critique of U.S. health care. This article speaks to the core of medical education in the current environment, where the introduction of directed personal learning has resulted in limiting the extent that the historic apprenticeship model is utilized. The disappointing performance of the individual online directed learning is not surprising. Directed learning is by its nature lacking the critical component of direct patient interaction, whether real or simulated, a critical shortcoming well illustrated by this analysis.

The reported findings by Cole et al. call into question the assumed value of directed personal learning when compared to the experiential learning of clerkships, internships, and residencies with the full emersion in patient care and team integration. Furthermore, the report supports full-emersion high-fidelity simulation to create experiential learning environments, justifying the high cost and high personnel utilization required. Joint operations with simultaneous training of various elements (combat, logistics, field care, and patient transport) can provide a more cost-effective experiential educational experience for multiple elements.

Teaching institutions should assure that students engage in experiential learning to promote medical student professional development. Medical education should have less emphasis on structured, directed self-learning, such as online modules, which limits the student’s ability to transfer skills to the operational setting. Opportunities to participate in experiential learning, Operational Bushmaster, that is based on experience, collaboration, reflection, and the development of critical-thinking skills are imperative for the development of student’s hardiness, emotional intelligence, and resilience. The authors are to be congratulated and encouraged to further explore the findings of this pilot study, including the role of stress inoculation and utilization in more generalizable operational environments and civilian medical training.

FUNDING

None declared.

CONFLICT OF INTEREST STATEMENT

The author has no financial conflict to disclose. The views expressed are those of the author and do not represent the views of Rocky Vista University.