Opening Plenary – Rachel H. Ellaway, Economies of Presence and Standardized Patient Education

By Petra DuncanRachel Ellaway

Rachel Helen Ellaway, PhD, is the Assistant Dean for Curriculum and Planning, Director of Simulation, and an Associate Professor for Education Informatics at the Northern Ontario School of Medicine in Canada.  Her academic work, widely published in the field of medical education, concentrates on online learning, simulation and the use of new technologies for teaching and assessment in and around health professional education.  Further information on Dr. Ellaway’s achievements is in the ASPE Conference program.

Dr. Ellaway began her presentation with a trip down memory lane to the 1960’s, describing presence as a concept.  Pop tarts, cassette tapes, Dr. Who and lava lamps were all born during this time, not to forget SPs. Dr. Ellaway presented these beautiful memories as an example of presence – the experience or the perception of being there.

We are all about the presence.  The ASPE conference is about presence: being here, now, with everyone else.  As Dr. Ellaway put it, “Wherever you are, you are always there,”  adding that presence is desired, valued and even misunderstood.

Presence has three meanings:

  1. Proximity between entities in time and space
  2. Experience of being here and now
  3. Experience of the personal bearing of others.

Presence never used to be an issue: you were either here or there.  However, today’s technology has complicated what “here” and “there” really mean to us.  We cannot be sure that when someone is in one place that they are not simultaneously elsewhere.  In today’s busy life style, we have become concerned with the idea of presence: what presence is, what form presence takes, how presence affects us and how can we use presence effectively.  As this writer thought about the speaker’s words, I became more aware of presence and its many different interesting aspects. I realized that everyone thinks about presence all the time either consciously or subconsciously, and that Dr. Ellaway was really making a lot of sense.  Educational presence can be described as cognitive, social and teaching.  So, then the question was asked: is face-to-face the best form of presence?  Does the face-to-face Oxbridge tutorial trump on-line every time?  We know that the one-on-one patient and trainee or preceptor and trainee experiences in Medicine are more favourable.  The highest value is given to that which is “authentic,” i.e., being here and now.

However, there are many situations where the economics of face-to-face presence make other forms useful and necessary.  For example, distance, location, scheduling, and resource allocation often make the face-to-face experience too costly.  Dr. Ellaway therefore introduced the idea of remote presence systems with a quote from Witmer and Singer (1998): “the subjective experience of being in one place or environment even when one is physically situated in another.” Imagine being in hospital and having a robot roll up to your bed with a doctor’s voice speaking to you from somewhere else through a computer screen.  How would you feel about attending ASPE Conference sessions using telepresence?  Would you try presenting or taking part in a workshop using this style of equipment?  How would this change things?  Would you rather be here, now?

In the use of patients in clinical examinations there are three approaches to consider:

  1. Real Patients: as in medical practice
  2. Simulated or Standardized Patients
  3. Patient Substitutes: video or sound representations; plastic or other models; computer simulations, such as second life

Regarding the latter, there has been much experimentation with second life and virtual patients, leading to many forms of avatar creations.

However, a question for you to ponder, over your afternoon tea is: Does automation drive us further away from what we want to achieve, rather than closer?  We can all list a million reasons why simulated and standardized patients are an advantage over patient substitutes in many settings.  It is the age old argument: you cannot replace humans with machines.  However, there will always be challenges concerning costs and the most effective methods for each program or skills practise.  For instance, Skype can be used for some skills training, but distance can be a problem with certain types of scenarios, where smell, texture, emotion and a physical presence become important.  It is difficult to be a caregiver online to someone in need of emotional attention.  Dr. Ellaway spoke about alternatives to SPs and their benefits.  For human interaction the real, simulated or standardized patient is essential and for the abstracted or algorithmic interaction, substitutes such as video or computer simulations could be used.

Standardized Patients are agents of presence.  How do we think about different kinds of presence in SP activities?  What kind of presence is appropriate in a variety of settings?  As Dr. Ellaway outlined the different types of presence, she discussed economies of presence, i.e., the cost/benefit ratio for each type of presence, both physical and digital.  Context matters as our options regarding location and setting broaden: “The power of place will prevail. As traditional locational imperatives weaken, we will gravitate to settings that offer particular cultural, scenic, and climatic attractions together with those face-to-face interactions we care most about.”[1] Place is incredibly important as demonstrated in the slide presentation.
Dr. Ellaway also talked about ‘Ethics of Inconvenience’, suggesting that we need to have those inconveniences and difficulties in life, such as pauses and silences.  Rather than trying to seek convenience, we should seek out and treasure what the possible inconvenience of embodied interactions can teach us because they are so much more nuanced than abstracted digital forms. This is one of the strengths that SPs can bring very naturally into any setting.

The subject of patient presence is huge and has so many different avenues to explore.  The simulated and standardized patient is at the very heart of medical education, and, Dr. Ellaway pointed out, all activities in health professional education is simulation of some sort. Every part of health professional education includes some form of abstracted patients or practitioners.  This led to a discussion on dimensions of simulation, the designing of SP activities, and most notably that presence in SP activities is about perception. Finally Dr. Ellaway tied the concept of presence to our business as SP educators as being all about what learning is retained, what is transformed, and what value is added to the education process with the different forms of presence.  As SPeds, we are all becoming quite sophisticated negotiating the use of SPs and the economies of presence.

Dr. Ellaway’s plenary generated a lot of enthusiasm and colorful discussion both after the presentation and throughout the duration of the conference. I found it fun to listen to folks chatting about presence and associating different moments with Dr. Ellaway’s topic. I must say that in that one hour, I felt like I had done a whole day’s work!  I was thinking that I would like to sit outside in the sun for a while, but wondered if anyone would miss my presence.


[1] Mitchell, WJ. E-topia. Cambridge, MA: MIT Press, 2000

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