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Using the Zone 01 Proximal Development As a Conceptual Framework to Create a Unique High-Fidelity Simulation… Applegarth, Oliver Aug 31, 2009

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   Using the Zone 01 Proximal Development As a Conceptual Framework to Create a Unique High-Fidelity Simulation Program in Undergraduate Anesthesia Education     Oliver Applegarth      Submitted to Dr. Dan Pratt, Professor Dept of Educational Studies University of British Columbia          Adult Education - ADHE 590            August 2009 Table of Contents Acknowledgement ....................................................................................................... 3 Summary ..................................................................................................................... 4 High-Fidelity Patient Simulation: Defining the Landscape? ........................................... 5 The Role of Simulation in Undergraduate Medical Education ..... ; ................................. 6 Deconstructing the Constructivist Basis of High-Fidelity Simulation in Undergraduate Anesthesia Education ................................................................................................. 10 The Zone of Proximal Development and HPS ............................................................. 12 Vygotsky's Zone of Proximal Development ................................................................ 13 Re-conceptualizing Simulation in a Vygotskian Fashion .............................................. 16 Freeze-Action Simulation and Situational Awareness ................................................. 18 Collaboration in "Freeze-Action" Simulation .............................................................. 20 Re-Defining "Ownership" of Knowledge in "Freeze-Action" Simulation ...................... 21 "Freeze-Action" Simulation in a Practical Light ........................................................... 23 Discussion and Future Directions ............................................................................... 25 References ................................................................................................................. 28 Acknowledgement I want to thank Dr. Dan Pratt for all his guidance and assistance with this Paper. Many of the ideas herein could not have been properly developed without the direction he offered along the way. Summary High-Fidelity Patient Simulation (HPS) has become an important component of medical education, and its role in undergraduate anesthesia education in no exception. While there is an ever-increasing body of work looking at its uses and the outcomes it creates, little analysis exists examining at the epistemological assumptions that drive this powerful learning tool. We have attempted to re-consider the pedagogical foundation upon which simulation is utilized at the undergraduate level and have asked ourselves whether there exists some current educational theories that could better inform HPS . To this end we have drawn on the work of Lev Vygotsky, specifically with respect to the zone of proximal development (ZPD). From these conceptual ideas has grown a unique style of simulation that is not rigid in its delivery, but rather one that becomes adaptable to the needs of the individual student and can support the individualized level of development that each student brings to the simulator. Collaborative development in this environment is a key. It is one thing to theorize, but we have attempted to move from the conceptual into reality. One key element we have incorporated arises from work looking at situational awareness in a simulated environment, in which the simulator can be frozen. We have termed our program "freeze-action" simulation, a unique simulation environment for delivery to the undergraduate anesthesia clerkship at the University of British Columbia. This program utilizes "freeze-Action" simulation initiated by the learners themselves. The freezes are thought of as individual moments of potential learning initiated at the discretion of the learner and they are used to explore educational opportunities surrounding the "freeze" based on the needs of each student. We have aligned the medical student with a peer learner, an "expert" anesthesia resident and adjuvant learning materials to help navigate this novice learner through perioperative resuscitative scenarios that are designed to operate above their current developmental level. It is hoped that ultimately through researching this unique environment we can obtain data on all students individual zone of proximal development, the role that the "expert" plays in expanding this ZPD, and how this environment can be harnessed to maximize the educational efficiency on HPS. Understanding the ZPD could lead to modifications to medical curriculum that improve development and alter all student's ZPD in a positive fashion. It is believed that our "freeze-action" simulation environment could be a major contributor to this developmental process. High-Fidelity Patient Simulation: Defining the Landscape? Simulation is in essence an artificial environment designed to "simulate" or represent a "real-life" scenario or environment. A simulated experience can be something as simple as practicing IV insertion on an orange, or as complicated as a mock code orange involving an entire hospital or municipality. For a thorough analysis of the typology of simulators, see Meller (1997). A high fidelity patient simulator (HPS) is, in simple terms, a mannequin placed within a room that has been designed to resemble an operating room. The room is complete with an OR table (on which the mannequin is placed), a monitor outlining the mannequin's vital signs, intravenous lines, medications, airway equipment etc. The mannequin is connected to a control cable and powered by a laptop computer. The power of high-fidelity simulation (as the reference to fidelity implies) is that the mannequin and environment are interactive and attempts to mimic the clinical changes of a genuine clinical scenario. It has arterial pulses, lungs and a heart that creates sound. It has an airway that can accept an endotracheal tube and can be altered to be either easy to intubate or difficult. The computer can alter the clinical scenario by altering the feedback from the mannequin or by altering the display on the anesthesia machine (heart rate, blood pressure, and many other variables) to mimic the occurrence of a life-threatening event. The scenario can be completely interactive and the outcome can be altered "on the fly", based on the simulated injection of medications or alterations made on the Anesthesia machine. There are many clinical events that can be programmed and then simulated; massive blood loss, an airway too difficult to secure with an endotracheal tube (such a patient may suffer brain damage within minutes), or a malignant heart rhythm (set off perhaps by our anesthetic medications), to name a few. The Role of Simulation in Undergraduate Medical Education There are many forces within medical education driving the move to incorporate HPS into undergraduate anesthesia education. Standardization of curriculum is important, and HPS aides in removing the "randomness" of anesthesia education in which the average student may never experience these scenarios within the operating room, and will therefore not derive experiential education based around that experience. It also offers a safe (though sometimes stressful) environment in which to learn, make mistakes and be de-briefed (debriefing being the feedback classically offered at the end of a simulator session). The use of simulation in medical education may seem commonplace now, but it was not always so. In fact, it could be argued that its incorporation into medical education came after its importance was recognized in other fields. The use of simulation has been a facet of warfare for centuries, jousting being a prime example. The aviation industry has embraced simulation, with the presence of government agencies overseeing its implementation and requiring it for continuation of certification (Federal Aviation Administration, 2009). Within medicine, high fidelity patient simulation did not appear in the literature until 1969, when the use of the first simulator known as SimOne was described (Abrahamson, 1969). The widespread use of SimOne was not quick in coming, though. This may have been partly due to the low-fidelity eco-validity of the simulator, and maybe also due to operational cost. A large part, though, could relate to the slow acceptance by the medical establishment that anything other than the classic mode of teaching was necessary. This mode, which could be described as "see one, do one, teach one - on living patients" permeated medical training, and persists today. The traditional method of medical education has been best described as a 2 X 2 system in which the first two years of training encompass principles of basic medicine and the last two clinical years looking after patients (Cuban, 1997, p.86). Cuban states that this method of teaching traces its roots well back into the 19th century. The new reality of "Western" medical practice, however, has placed pressures on medical schools to ensure the adequacy of their students training. Healthcare has become more fragmented, with specialized care delivered at facilities focused on certain disease states or certain patient populations. This distribution of care has made it difficult to allow medical students to observe and learn on patients in a continuous fashion. The financial reality of medicine is such that it has become more cost-effective to pursue many treatments in an outpatient, or ambulatory fashion. Once again, this trend has diminished the medical student's exposure to useful clinical cases. This has resulted in the loss of clinical acumen. A recent study documented the fact that house officers have difficulty picking up cardiac findings. The authors suggested that strategies must improve clinical education, and they suggested that simulation be a part of this (Mangione & Nieman, 1997). Simulation is also proving to be a valuable tool to address the drive to improve patient safety and decrease medical errors. A thorough analYSis of patient safety and how simulation becomes a key player in this discussion is beyond the scope of this article (for a thorough discussion see Nishisaki, Keren, & Nadkarni, 2007). Still, it is clear that alongside the recent proliferation in our understanding of simulation has been a recent proliferation in the identification of factors that lead to medical errors and factors that place patient safety in question. Classically medical education has existed within a difficult quagmire in this area. Learning must occur and must occur on "live" patients at some point. Mistakes will be made and experience can be a major contributor to overall knowledge base and competency. The challenge for the medical school is to properly balance to what degree a medical student be allowed to interact with a patient, and how to maintain the autonomous safety of that patient. Undoubtedly simulation offers a unique environment in which to "practice" skills and obtain knowledge before interaction with "real" patients. In 2000 the Institute of Medicine published "To Err is Human" in which they attempted to outline the causes of many medical errors and suggest solutions. Simulation was noted to be an important contributor in improving patient safety (Kohn, 2000). While the reality remains that there is not a great deal of data proving that simulation makes a better doctor or a safer patient, the association between patient safety and simulation has made it the "cause celebre" in political circles, with an inertia to advance that is coming from the politicians and not the educators. Congressman J. Randy Forbes (R-VA) has recently created the Congressional Modeling and Simulation Caucus and has introduced the Enhancing SIMULATION Act of 2007 to fund advancement of simulation in health care. In his words, "if we have the opportunity to significantly decrease the number of medical errors and increase training time - to save lives and reduce health care costs - wouldn't we take it?" (Forbes, J.R., 2008). This new reality about who mandates advancement in simulation is unfortunate because it becomes based as much upon hype and hearsay as much as it is upon facts and outcomes. In this regard, though, the use of simulation in medicine is simply following its progression in other industries such as aviation and defense, in which there are huge political factors at play alongside issues of safety. Deconstructing the Constructivist Basis of High-Fidelity Simulation in Undergraduate Anesthesia Education There is no doubt that simulation is a revolutionary educational tool, and that it has had profound effects on the delivery of medical education. Within the realm of undergraduate anesthesia education, clinical teachers will suggest that the standard delivery of HPS serves a practical role, in disseminating knowledge and skills, and that it is soundly based in educational theory. With respect to this theoretical aspect, educators have attempted to tie simulation to numerous epistemologies informing this technology, suggesting that it is this pedagogical basis that gives simulation much of its strength. Included in these ideas are theories of experiential learning, collaborative learning, theories of expertise formation, and for the sake of this discussion, social constructivism. It is this last angle that perhaps deserves further analysis. Before considering social constructivism, though, I should briefly describe what I mean by the "standard" delivery of HPS in anesthesia education. This standard use of simulation will see a group of learners (medical students) descend on a high-fidelity simulator and carry out a number of simulated scenarios from start to finish. They are able to offer treatments, administer drugs through an intravenous delivery system, and can initiate procedures. At every step the student can alter their management based on feedback from the mannequin. A debriefing session classically follows, allowing students to critique their own performance, and in some cases watch a taped version of their session, in order to refine their future approach. With that description in place, let's move to consider the constructivist basis on which standard HPS is based. Loosely considered, constructivism suggests that students construct their own basis for learning information and that the method of learning takes the unique perspectives of the student into account in its delivery. Constructivism embraces meaning-making, stating that education is derived from contextual situations that require independent "construction". Driscoll (2005, in Lathrop, Winningham, & Vandevusse, 2007) outlines the optimal conditions for constructivist learning. They are seen as being 1. Embedding learning in complex, realistic, and relevant environments 2. Supporting multiple perspectives and multiple modes of learning 3. Providing for social negotiation and an integral part of learning 4. Encouraging learners self-awareness of knowledge construction processes Lathrop et al. (2007) therefore states that HPS is consistent with constructivist principles by "removing learners from the classroom and placing them in a ... dynamic scenario." That is all fine, but with that framework in place we should move to critically examine the constructivist basis of HPS in anesthesia undergraduate medical education. Standard HPS is based on one clinical algorithm delivered at a time, in a rigid, fast paced and anxiety-provoking environment. Students do receive feedback from the treatments they initiate, but even that feedback is limited in its scope. The scenarios encompass ideas and situations that have rarely been previously encountered by the students. This limited knowledge/experience base is not incorporated into the delivery of the scenario. Previous experience is a key player in constructivist educational theory. As Juhary (2006) states, "students bring prior knowledge to a learning situation in which they must critically assess and re-evaluate their understanding of new information". To align with constructivist theory the limited experience of the students must be an integral factor in the delivery of education. Jonassen (1999) states this emphatically What students lack most are experiences. This lack is especially critical when trying to solve problems. So, it is important that CLEs (constructivist learning environments) provide access to a set of related experiences to which novice students can refer. (p.223) In simpler terms then, it is HPS (in its traditional form within anesthesia undergraduate education) that forces the medical student to adapt to it, not the other way around. The previous experience of the student, which is limited at best, is not incorporated into the teaching style. Cognitive flexibility and individualism of learning is lost. With respect to Driscoll's criteria for constructivist learning and HPS, I would suggest that the standard delivery may very well be a social Endeavour, but it does not efficiently draw from the relevant experiences of the students, it does not adequately support multiple modes of learning, and it occurs far too quickly to allow for self-awareness of knowledge construction. Can we therefore conclude that an undergraduate anesthesia simulation program, in its standard form, is adequately constructivist? The Zone of Proximal Development and HPS It should be understood that I am not emphatically stating that HPS is not informed by social constructivist theories of learning in any way. Undoubtedly HPS can be said so roughly align with almost any modern educational theory, for simulation is a dynamic environment and can be delivered in countless styles. The question should not be to what degree we can fit simulation into an educational pedagogy, but whether we can alter simulation to better fit these theories. Perhaps we have attempted to make HPS loosely fit into the epistemologies we examine, instead of deconstructing simulation in order to re-build it in the eyes of the theories we seek to use. If one was to do carry out this deconstruction/reconstruction process, what effect may this have on the learning that occurs in that environment? It was this idea that challenged us as we set out to create a simulation program for the undergraduate anesthesia clerkship at UBC. Could we create a simulation environment using a contextual framework of education that may offer an interesting vision? In doing so could we suggest that our program may be able to more efficiently harness the constructivist ideals on which simulation claims to be drawn? The ideas of Lev Vygotsky and the zone of proximal development offer one perspective on this issue. We chose these theories and attempted to harness them to transform HPS into a unique learning experience. The theories were brought into reality, and a simulation program was set up. The initial pilot sessions offered very positive feedback. Vygotsky's Zone of Proximal Development Before outlining how our simulation program was informed by the ZPD, it may be of some benefit to outline our interpretation of the theories of Vygotsky. This will ensure congruency of thought between the reader and myself and explain how our simulator program was conceptualized. The zone of proximal development is considered one ofVygotsky's most utilized theory. It is generally accepted that the theory was Vygotsky's way of attempting to understand the interaction between collaborative instruction and development (Chaiklin, 1999). In his own words, the zone of proximal development .. .Is the distance between the actual development level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance, or in collaboration with more capable peers. (Vygotsky, 1978, p.86) What is important about Vygotsky's theory is that the words used are chosen carefully. It is a theory of development, not learning. Vygotsky was clear that there is a difference between learning and development, but they are intimately connected, in so far as the "learning creates ... the zone of proximal development (Vygotsky, 1978, p.90). The goal of programs operating in a ZPD is to enhance the development of individuals only within the levels that they are comfortable with, or ready to achieve. This also relates to the idea that the zone is proximal. The development occurs in a forward fashion within these comfort zones. The theory does not attempt to offer insight into the presentation of new concepts or foreign developmental stages, for these are not considered proximal. The fact that Vygotsky refers to his theory as operating in a zone is important. Vygotsky envisioned instruction within the ZPD as a quantifiable entity. The role of the "capable peer" is to identify the maturing features ofthe learner that are visible but are inadequate for independent function. The collaborative environment created therefore improves the end-stage development of the pupil in a quantifiable way. To Vygotsky it should be possible to identify a zone of proximal development and create curriculum designed to harness the proper developmental level of the student to enhance outcome. It is important to understand that Vygotsky's ZPD places the source of education at the feet of the student and not the instructor. It is learning theories such as scaffolding, a theory similar to, but not synonymous with, the ZPD, which are more instructor-centred. The ZPD is a characteristic intrinsic to the student, best thought of as that beginning state that the student brings to the table. It cannot be altered before instruction begins, it simply has to be appreciated for existing at the level it does. Instruction within a ZPD places an onus not only on the instructor to understand the developmental level of the student, but also on the student, who must have the understanding that he/she has the freedom to take advantage ofthe collaboration offered to them in order to develop the faculties that intrinsically exist within them. Instruction within a ZPD should be collaborative, individualized and adaptive to the developmental level of all students. The goal to be achieved is that instruction within a ZPD can enhance development in a way superior to instruction not cognoscente of these ideas. Vygotsky himself viewed the ZPD as a measurable entity. If one is able to properly identify a pupil's entry point into the ZPD and can properly align this with useful collaboration, then there will be an increase in what can soon be accomplished without help. Re-conceptualizing Simulation in a Vygotskian Fashion By analyzing the classical delivery of HPS to senior medical students through the lens ofVygotsky's ideas, one can suggest a few deficiencies associated with the traditional delivery of HPS. Once again, by using the term traditional, it should be understood that we are describing the navigation of a clinical scenario in a simulator from its beginning to end, with treatments initiated thereof, but the scenario run to its conclusion. The theoretical deficiencies with this technique have been introduced above, but are summarized here, with some suggestion as to how the ZPD could address them Senior medical students have little previous knowledge upon which to draw when they enter a simulated environment that focuses on critical care or perioperative crises. They may have some background knowledge, but few if any have hands-on experience upon which to refer. Classical HPS delivery argues that it is the simulator that is there to offer this experience, but in a Vygotskian sense the simulated crises will unfold at a level that far exceeds the developmental level of most students. The developmental level of senior medical students is highly variable, much more so than that of resident physicians (a group also offered exposure to HPS). A Vygotskian approach would suggest that these differing levels must be appreciated. The learning must adapt to these individual levels to ensure that development of students occurs in a proximal zone, not within a parallel zone not relevant to the student in question. With traditional HPS involving a single scenario run front-to-back, with the student expected to offer a finite set of interactions and treatments. Failure to offer these results in deterioration of the patient. Even the proper treatment may only temporize the situation before deterioration still occurs. In this way HPS is in no way adaptable to the student. Traditional HPS fails to properly utilize collaboration in a manner consistent with the ZPD. Certainly medical students can find themselves in groups within a simulator and must work together to navigate the scenario. Certainly practitioners of HPS would suggest that this is a strength of classical HPS, and it is. But this use of collaboration approaches the ideas of Vygotsky without fully realizing the power of collaboration. Why? Once again, the scenario is occurring to fast to properly utilize collaboration. Anxiety is a major factor in classical HPS and therefore the ideas raised through collaboration may go missed. Most importantly, though, classical HPS fails to insert an "expert peer" into the environment. This expert peer has the potential to improve development by harnessing the individualized level of each student. With these criticisms in mind, we set out to create a simulation program aimed at senior medical students who are rotating through their anesthesia clerkship at the University of British Columbia. We attempted to create this program informed by the ideas of the ZPD. The goal was to find a solution to what we perceived to be problems with classical delivery of HPS, as outlined above. We focused on the following guiding principles The program had to be adaptable The medical student must have the ability to individualize the program to meet their individual educational needs Collaboration with "expert peers" must occur in real-time within the environment, not simply through lectures of de-briefing Freeze-Action Simulation and Situational Awareness The key ingredient to our simulation program is our modification of the "freeze-action - answer probe" technique. In name this is not a concept we created. Rather, it is one derived from literature analyzing the role of situational awareness in anesthesia. Situational awareness is one human factor considered in the analysis of non-technical skills utilized during crisis resource management. Endsley (1988) defines situational awareness as "the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future." A thorough description of situational awareness and the research there of is not directly relevant to this discussion. What is, though, is one technique used to measure it. Within a simulated scenario designed to assess one's situational awareness, the environment will be literally frozen in time in order for inquiry to be made about surrounding variables. Referred to as the "freeze-action - answer probe" technique, it is one technique utilized to study situational awareness in a simulated environment (Small, 2002). Zhang (2002) explains the concept by saying, "This technique consists of pausing the simulation to query the person with a questionnaire about the status of the variables displayed on the monitor." Endsley (1995) has suggested that compared to other techniques, the freeze technique provides the most powerful measure of the subject's situational awareness. Though utilized in this field of study, the idea of "freeze-action" as a simulation technique utilized outside of situational awareness is non-existent, as far as I have been able to surmise from a through review of the literature. The concept of borrowing and incorporating the "freeze-action" technique as an educational adjuvant to simulation seemed intriguing. In brainstorming the use of this technique, the "freeze-action" moments were conceptualized as important points within the scenario in which further learning could take place, points could be clarified, or a "break in the action" could ensue, simply to relieve anxiety. The "freeze-action" concept seemed sound, but the major modification that we chose to make was to empower the medical student with the action of freezing the simulator. This is in direct comparison to its use the study of situational awareness, in which the programmer controlled the freezes. To us, the act of freezing needed to be placed into the hands of the students to individualize the environment. Empowerment of the student is needed in order to bring our program into alignment with the theoretical framework ofVygotsky's ZPD. In this manner simulation becomes less about students understanding the environment they are placed in, and more about students directing their educational development based on their needs, at a level of comfort for them. Collaboration in "Freeze-Action" Simulation Having attempted to alter simulation to make it adaptable to the individual's developmental level, we moved to create an environment that harnessed the power of collaboration. Vygotsky's ZPD does not limit collaboration to that of an "expert peer", but it is the example classically discussed in connection to his theory. Traditional simulation delivery certainly has some degree of collaborative learning through teamwork, but the degree of interaction is hampered by the speed of the scenario, the anxiety associated with leading a simulated scenario, and the inability for the individual learner to choose those moments best suited for further dialogue. Collaboration in socially construcitivist envinroments must take a central role. Applefield, Huber and Moallem (Dec2000/Jan2001) outline the important role of collaborative learning in social constructivist learning, stating Dialogue is the catalyst for knowledge acquisition. Understanding is facilitated by exchanges that occur through social interaction, through questioning and explaining, challenging and offering timely support and feedback. (p.38) We chose to continue with embrace these principles, understanding that the interaction between inexperienced peers in a crisis scenario can be educationally fruitful and certainly operates at the boundaries of a ZPD. To fully harness the power of the ZPD that we were striving for, though, we felt that collaboration with a more experienced individual was necessary. We chose to enlist the help of anesthesia residents, "buddying" them up with the medical students in the simulated environment. The purpose of the resident was not to perpetuate the hierarchal learning environment of resident-student. Rather, the interaction was seen as being one of aided development. The resident becomes a resource on which to draw during "freeze-action" opportunities, thus expanding the ZPD. To us this distinction was important, especially in order to create a program informed by the ZPD. It was the student who chose the moment of "freeze-action", deciding based on their own developmental level, and what their learning needs were. Once the student had recognized those needs, though, there was an "expert" available to help sharpen knowledge, guide thought process, offer assistance and suggest improvement. In this way the resident has been used as a bridge to access the "related experiences" referred to in Jonassen's outline of creating constructivist learning environments. The residents are able to draw out ideas surrounding the limited previous experience of the students and aide in the organization of that information. They can also tap into their own experiences to relay them to the students, as the scenario proceeds. Re-Defining "Ownership" of Knowledge in "Freeze-Action" Simulation The dynamic, individualized environment established within our "freeze-action" simulation program has some interesting consequences with respect to the flow of information, knowledge, and learning. The adaptability of the environment creates a learning situation that is unique to the individual student. The learning goals not easily pre-determined, and are instead are initiated by that student, based not only on predetermined goals, but goals that may form at instantaneous moments in the simulation. Likewise, the collaborative process between the lead student, the supportive student and the resident is also unique. Finally, the methods that are utilized to achieve the educational goals are also unique to the situation at any given moment. The decision to draw on the learning from a fellow student, a resident, or the adjuvant learning materials, will be a moment-to-moment decision on the part of the lead student. The resulting educational environment is therefore one in which knowledge is quickly transmitted from numerous sources, based on a fluid interplay between participants. The "ownership" of the knowledge is therefore not a trait intrinsic to the medical student; rather it is a nebulous entity present in the room. To some degree the knowledge (which aides the development of the student within the ZPD) takes on a life of its own, leading in different directions each time the identical scenario is undertaken. This aspect to our simulation program has both advantages and disadvantages. On the one hand, the exciting, unique situation established therein certainly seems to be more consistent with the ideas of social constructivism, and more specifically with the goals of a program based upon the ZPD. On the other hand it makes the establishment of strict objectives and the documentation of outcomes very difficult. We will have to be very careful as we move forward with studies of "freeze-action" simulation, that we strike a balance between the need to study a definable educational outcome and the need to maintain the free-flowing environment that is the backbone of this unique program. "Freeze-Action" Simulation in a Practical Light Having established the theoretical basis for our unique simulation environment, it may be beneficial to explain how it functions in a practical sense. In other words, how does "freeze-action" simulation really work? Let us consider an example of a simulated scenario in which a patient has an anesthetic induction that includes antibiotics. The hemodynamics of the patient begin to alter, with the blood pressure decreasing, the heart rate increasing and the airway pressure increasing. An anaphylactic reaction is underway. Within this environment is one medical student "leader", one medical student in the background who can be called in to assist, and an anesthesia resident, available when a "freeze-action" moment occurs. The "leader" is free to navigate the scenario in whatever way he/she feels appropriate or comfortable. They may chose to initiate a treatment, and if one is taken the scenario can be manipulated appropriately. On the other hand the student has been pre-briefed to the idea that they can stop the simulation at any time. Let's say that the student decides to call a freeze once the hemodynamics change. This is a unique decision on the part of that student, and it may be at a moment entirely different to that of the next student who will lead. The reason for the stoppage will also be unique to the student. It may be that patient variables were changing too fast to allow the student to react. It may be that the student wants to know more about the differential diagnosis of hypotension under anesthesia. Or, it may be that the student has recognized this as potentially being an anaphylactic reaction, but wants to take some time to review the treatment options pertaining to anaphylaxis before proceeding. This point here is that the timing of the freeze is as unique as the reason for the freeze, each representing the individual developmental characteristics of the student. Once the freeze is initiated the student has the freedom to decide what resources they need to optimize their development. They can draw from the assistance of their fellow medical student, simply think through the problem themselves, or draw from the resident, their "expert". By initiating interaction with the resident, the two can then collectively examine the reason for the freeze, and decide what information or help is needed before continuing through the scenario. Just as the reason for freezing the scenario and the timing of the freeze are characteristics unique to the medical student, there is also uniqueness in the interaction between student and "expert" resident. This uniqueness, however, in contrast to those previously mentioned, is not individual but collective. Together, the expert and the student must examine what is required to further develop the student. It may be that a skill is needed and that the "expert" can facilitate by guiding the student through the skill. If knowledge acquisition is required, the resident can use open ended questions or write down ideas on a whiteboard, all designed to stimulate thought and fill in gaps at the current knowledge-level of the student. The practical topography of "freeze-action" simulation is an extension of the theoretical base on which it is built. Through this style of simulation the environment is changed from the traditional method to one that is far more organic and fluid, altering at every step to meet the unique needs of the student. Development is enhanced by the presence of the "expert", whose role it is to collaborate at the point of "freeze-action", guiding thought process and facilitating skills acquisition. Through our simulator program the power ofVygotsky's zone of proximal development is unleashed into undergraduate anesthesia education. Discussion and Future Directions This paper outlines the theoretical basis for a new, and unique, high-fidelity patient simulation program to be utilized as a core component of anesthesia undergraduate education at the University of British Columbia. Creation has flowed from an attempt to critically examine the epistemological basis of HPS, focusing in on the constructivist foundation some will claim informs HPS. By deconstructing HPS and reconstructing it to better suit ideas of constructivism, we have created what is termed "freeze-action" simulation. Our program borrows heavily from the ideas of Lev Vygotsky and the ZPD. "Freeze-action" simulation places learning and development at the feet of the student. They can navigate this environment in an individualized fashion, deciding when to freeze and re-start the simulator at their will. Once frozen, they can decide what knowledge or skills they require to improve their developmental level, utilizing multiple educational strategies. In this way we feel our program is consistent with the major ideas of the ZPD. By individualizing the simulated scenario, development occurs at a level consistent with the student's current abilities. We have also incorporated an "expert-peer" in the form of an anesthesia resident, who can guide learning and widen the ZPD. The unique nature of this environment will most certainly require further investigation in order to establish educational validity. At this point there is no gold standard upon which to compare our "freeze-action" program. Having now outlined our program, we can return to the ideas of Driscoll presented earlier to re-explore to what degree our program conforms to the goals of constructivist programs. Once again, they are 1. Embedding learning in complex, realistic, and relevant environments 2. Supporting multiple perspectives and multiple modes of learning 3. Providing for social negotiation and an integral part of learning 4. Encouraging learners self-awareness of knowledge construction processes I would suggest that "freeze-action" simulation has a greater degree of conformation with these principles. To what degree does our program align itself with the best evidence in medical education literature? There is not a lot of information about how educational epistemology improves HPS. However, a recent BEME systematic J Review (Iseenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005) has reviewed the literature on the effective use of high fidelity medical simulation, and has drawn some categorical descriptions for what aspects facilitate effective learning. The authors note the following features Providing feedback Repetitive practice Curriculum integration Range of difficulty level Multiple learning strategies Capture clinical variation Controlled environment Individualized learning Defined outcomes Simulator validity It is clear that our program is accurately captured in many of these categories, most notably the controlled, individualized learning, multiple learning strategies, curriculum integration, the offering of feedback and the ability to alter the range of difficulty. While this alignment is in no way meant to imply that the validity of our program is proven, it does suggest that what we have created roughly conforms in principle, to the best evidence available at this time. I would suggest that we are on a solid path. Our goal in the future, then, is to more closely examine and study "freeze-action" simulation, to ascertain the positive effects on HPS that we think Vygotsky's ZPD confers. References Applefield, J.M., Huber, R, & Moallem, M. (Dec200/Jan2001). Constructivism in theory and practice: toward a better understanding. The High Schooljournal, 84(2), 35-53. Cuban, L. (1997). Change without reform: The case of Stanford University School of Medicine 1908-1990. Medical Education Research Journal, 34(1),83-122. Driscoll, M.P. (2005). Psychology of Learning for Instruction, 3 rd ed. Boston: Allyn & Bacon. Endsley, M.R (1988). Design and evaluation for situation awareness enhancement. Proceedings of the human factors society. Santa Monica, Ca. Human Factors Society. Pp. 97-101. Ensley, M.R (1995). Measurement of situation awareness in dynamic systems. Human Factors, 37, 65-84. Federal Aviation Administration (June 5, 2009). National Simulator Program: Simulation Quality Management System (SQMS). Retrieved from _ http://www.faa.gov laboutlinitiatives Insp/ Forbes, J.R (2008, May 30). Bringing Health Care into the 21st Century. Retrieved July 29 2008 from http:///www.house.gov/forbes/newsroom/enewsletter/2008/05302008.ht m Issenberg, S.8., McGaghie, W.C., Petrusa, E.R, Gordon, D.L., & Scalese, RJ. (2005). Features and uses of high-fidelity simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27(1), 10-28. Jonassen, D. (1999). Designing constructivist learning environments. In C.M. Reigeluth (ed.), Instructional design theories and models, volume II: A new paradigm of instructional theory (pp.215-239). Mahwah, New Jersey: Lawrence Erlbaum Associates, Publishers. Juhary, J.W. (2006). Simulation Technologies and Learning Theories. Accessed online June 10, 2009 at www.siaa.asn.au/get/2423621845.pdf Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (eds.). (2000). To err is human: building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine. Washington, D.C.: National Academy Press. Lathrop, A., Winningham, B., & Vandevusse, L. (2007). Simulation-based learning for midwives: background and pilot implementation. Journal ofmidwifery & Women's Health. 52(5),492-498. Mangione, S., & Nieman, L.Z. (1997). Cardiac auscultatory skills of internal medicine and family practice residents: a comparison of diagnostic proficiency. Journal of the American Medical Association. 278(9), 717-22. Meller, G. (1997). A typology of simulators for medical education. Journal of Digital Imaging, 10(3, supp 1), 194-196. Nishisaki, A., Keren, R., & Nadkarni, V. (2007). Does simulation improve patient safety? Self-efficacy, competence, operational performance and patient safety. Anesthesiology Clinics, 25, 225-236. Small, S.D. (2007). Simulation applications for human factors and systems evaluation. Anesthesiology CliniCS, 25: 237-259. Vygotsky, L.S. (1978). Interaction between learning and development (M. Lopez-Morillas, trans.)' In M. Cole, V. John-Steiner, S. Scribner, & E. Souberman (eds.), Mind in society: The development of higher psychological processes (pp. 79-91). Cambridge, MA: Harvard University Press. Zhang, Y., Drews, F.A., Westenskow, D.R., Foresti, S., Agutter, J., Bermudez, J.c., Blike, G., and Loeb, R. (2002). Effects of integrated graphical displays on situation awareness in anaesthesiology. Cognition, Technology & Work, 4:82-90. 

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