OVERDUE FINES ARE 25¢ PER DAY PER ITEM Return to book drop to remove this checkout from your record. © Capyright by THOMAS CHARLES WINTERS 1978 A CHRONOLOGICAL STUDY or INTERPERSONAL ASCENDANT SIMULATION AS A VEHICLE OF INSTRUCTIONAL DEVELOPMENT IN MEDICAL EDUCATION BY Thomas Charles Winters A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Secondary Education and Curriculum 1978 ABSTRACT A CHRONOLOGICAL STUDY OF INTERPERSONAL ASCENDANT SIMULATION AS A VEHICLE OF INSTRUCTIONAL DEVELOPMENT IN MEDICAL EDUCATION BY Thomas Charles Winters The Problem In medical education patient availability, rising enrollments and decreasing effective budgets have caused and are continuing to cause an increasing demand for instructional accountability. This study examines the potential of interpersonal ascendant simulation as one instructional strategy which may assist in increasing accountability or maximizing cost/benefits of medical learn- ing systems. By answering the eight following questions, this historical study attempts to provide an exposition of media and interpersonal ascendant simulation which could assist decision makers in their analysis, utilization and assessment of this strategy: 1. What are the critical events that have occurred in the evolution of media ascendant simulation in the Eastern and Western cultures to the present? 2. What are the critical events that have occurred in the evolution of interpersonal ascendant Thomas Charles Winters simulation in the Eastern and Western cultures to the present? 3. What are the student learning benefits in terms of evaluation, feedback and transfer which have been derived through media ascendant simulation? 4. What are the student learning benefits in terms of evaluation, feedback and transfer which have been derived through interpersonal ascendant simulation? 5. How does media ascendant simulation compare to alternative instructional strategies in terms of resource requirements affecting costs? 6. How does interpersonal ascendant simulation com- pare to alternative instructional strategies in terms of resource requirements affecting costs? 7. What are the effects of the evolution of the media ascendant on the evolution of interpersonal ascendant simulation in medical education? 8. What is the present state-of-the-art in terms of learning benefits and costs for interpersonal ascendant simulation in medical education? 212% Primary research sources were obtained via a National Institute of Health Bibliography on Simulation performed at Michigan State University. Primary and additional material were gathered and written as a time line. The information in the time line was selected and subjected to analysis by the Selection and Evaluative Criteria equivalent to external and internal criticisms in historical studies. The eight research questions are answered in terms of the researcher's judgemental value of external and internal data obtained as degrees of available evidence. Thomas Charles Winters Results From the possible 223 sources used, the evidence ranged from marginally sufficient to more than sufficient to qualify the various answers for each of the eight research questions. Marginally sufficient evidence has indicated that there has been critical changes which has taken place in media and interpersonal ascendant simulation from three thousand years before Christ until the present. Marginally sufficient to sufficient evidence indi- cates that both media and interpersonal ascendant simula- tion has contributed as viable strategies to learning bene- fits in terms of evaluation, feedback and transfer. As continued utilization of these strategies progresses, a more comprehensive understanding of the effects of these strategies to evaluation, feedback and transfer is unfold- ing. Marginally sufficient to sufficient evidence indi- cates that both media and interpersonal ascendant simula- tion has contributed as viable strategies in terms of resources requirements to lower costs as compared to alter— native methodologies. As continued utilization of these strategies progresses, a more comprehensive understanding of their effects to the potential to lower instructional costs is taking place. Sufficient evidence indicates that media ascendant simulation has had a marked effect on the progress of Thomas Charles Winters interpersonal simulation. Progress in both electronic and mechanical technology by business is a prime example of providing processing agents to help execute the scenario of interpersonal ascendant simulation. Sufficient evidence indicates that the present state-of-the-art of interpersonal ascendant simulation in medical education in terms of learning benefits and costs is that the strategy has been used in select situations with success. As continued utilization of interpersonal simulation progresses, especially with more institutional involvement, a deeper and fuller understanding of strategy design and implication will evolve. DEDICATED To Tommie, our little boy, who at the tender year of five, has exhibited a motivation and enthusiasm about life, which I admire, especially to Jean, my wife, whose sensitivity and understanding was endless during the entire educa- tional undertaking. iii ACKNOWLEDGMENTS A collection and synthesis of writings of such a magnitude obviously reflects the aspirations of its writer and those who have assisted him. To these individuals, I wish to recognize their support. To my wife, Jean, and son, Tommie, who were sym- pathetic of my goals and aspirations by the positive rein- forcement of the ongoing activities and accepting the neg- lect, while pursuing the program. To Dr. James R. Nord, guidance committee chair- person and major advisor, who demonstrated a keen interest in this writer as an individual and a student, while pro- gressing through the course of the doctoral program. To Dr. Castelle G. Gentry, committee member, for his expertise which I have sought during numerous occasions within the entire doctoral program. To Dr. Donald C. Tavano, cognate advisor and com- mittee member, who was responsible for the meaningful input from Medical Education, where this work will hOpe to bene- fit. iv To Dr. Stephen L. Yelon, committee member, who has given of his untiring insights and encouragement during the evolution of this document. To Dr. Jack L. Maatsch, Professor, Office of Medical Education Research and Development, for giving of his time during those discussions to stimulate the interest. To Dr. J. Dennis Hoban, now with the University of Cincinnati School of Medicine, for the opportunity to work as a researcher to study the state-of-the-art of simulation under a grant from the National Library of Medicine. To Dr. Paul W. F. Witt, Professor Emeritus, now with the University of Florida, who gave so unselfishly of his time and experience, both in and out of the class- room, with this writer and his family, which have been enlightening, rewarding and most beneficial. This writer came in contact with interpersonal ascendant simulation, as used in medical education, in the classrooms of Drs. Jack L. Maatsch and Gerald B. Holtzman. While there had been considerable contact with the method- ology during active military duty and in the Michigan Air National Guard, the real implications of this strategy came through exposure to medical education. As a result of classwork with these excellent professionals, this researcher became highly motivated to more closely examine this powerful tool. This study reflects one of several personal end pro- ducts from that classroom setting, that is to learn as much as possible about the strategy and former uses of it within medical education. Obviously, to evoke such an understanding, past considerations of other simulation areas had to be introduced to place all in perspective. This study has enabled this researcher to gain for himself some understanding of the undertakings of past accomplish- ments. As a consequence, the writer feels more confident and knowing about what has transpired in order to go about the task of contributing to the accumulation of expertise about interpersonal ascendant simulation as vehicle of instructional develOpment in medical education. To all singly and collectively, an appreciative thank you. vi LIST OF LIST OF Chapter I. II. III. TABLE OF CONTENTS TABLES O I O O O O O O O O FIGURES O O O O O O O O O C THE PROBLEM. . . . . . . . . Background and Rationale. . . . Purpose of the Study . . Research Questions . . . . . Need and Importance of the Study . Limitations and Scope of the Study Definition of Terms . . . . . Overview . . . . . . . . . THE METHODOLOGY . . . . . . . Research Design of the Study . . Bibliographical Development-Collections Selection Criteria . . . . . Evaluative Criteria. . . . . Criteria Results. . . . . . Evidence Summation . . . . . smary O O O O O O O O 0 REVIEW OF THE HISTORICAL LITERATURE. Development of Media Ascendant Simulation China and Japan . Europe . . . . United Kingdom . United States. . vii Page xi Chapter Military . . . . Business . . . . Education. . . . Medical Education . DeveIOpment of Interpersonal Ascendant Simulation . . . . . . . . . China and Japan Europe . . . United Kingdom. United States . Military . . . . Business . . . . Education. . . . Medical Education . Summary. . . . . . . . . . . IV. ANALYSIS OF THE HISTORICAL LITERATURE . Selection Criteria . Evaluative Criteria. Analysis Procedure . Analysis Data. . . Summary. . . . . V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS Purpose of the Study . . . . . . Research Design of the Study. . . . Summary. . . . . . . . . . China and Japan Eur0pe . . . United Kingdom. United States . Military . . . Business . . . Education. . . Medical Education Conclusions . . . . . . . . . Research Question No. l. . . . . Research Question No. 2. . . . . Research Question No. 3. . . . . viii 138 139 141 144 149 149 154 156 168 193 195 196 196 199 201 245 247 247 249 250 250 251 252 255 256 258 260 263 267 268 270 274 Chapter Page Research.Question No. 4 . . . . . . . 275 Research Question No. S . . . . . . . 277 Research Question No. 6 . . . . . . . 278 Research Question No. 7 . . . . . . . 280 Research Question No. 8 . . . . . . . 281 Recommendations . . . . . . . . . . 284 Recommendations for Further Study. . . . 28S LIST OF REFERENCES . . . . . . . . . . . . 287 APPENDIX A STUDY OF SIMULATION TECHNOLOGY IN MEDICAL EDUCATION . . . . . . . . 308 ix Table 1. 2. Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Data Data Data Data Data Data Data Data LIST OF TABLES for for for for for for for for Research Research Research Research Research Research Research Research Question Question Question Question QuestiOn Question Question Question Page 202 213 219 223 226 230 233 240 LIST OF FIGURES Figure Page 1. Topical Superimposition of Chapter III on a Timeline 0 O O O O O O O O O O O 4 7 2. Prussian Role Play War Game . . . . . . 142 3. Critical Events Trace in the Evolution of Interpersonal and Media Ascendant Simulation 0 O O O O O O O O O O 273 xi CHAPTER I THE PROBLEM In medical education patient availability, rising enrollments and decreasing effective budgets are causing an increasing demand for instructional accountability. This study examines the potential of interpersonal ascendant simulation as one instructional strategy which may assist in the increasing of accountability or maximizing the cost/ benefits of medical learning systems. Presently lacking, however, is a clear exposition of the evolutionary develop- ment of media and interpersonal ascendant simulation, which would assist decision makers in the analysis and utili- zation of this strategy. Background and Rationale In the United States today most educational insti- tutions are experiencing some sort of financial strain. This may be attributed, generally, to the ever present inflation and state budgets which have failed to keep pace. Increasing enrollments frequently compound the problem.1 1H. R. Bower, "Financial Needs of the Campus," The Corporation and the Campus, ed. by Robert H. Conney, Pro- ceedings of the Academy of Political Science, 1970. l Within institutions there are additional difficulties of an instructional nature with current staffing, teaching and instructional methods.2 These stress, coupled with the continued problems of labor intensive organizations exist- ing in a capital intensive socio-economy, have imposed on many institutions, especially state schools, a real need and concern for expenditure accountability. Academic insti- tutions have been and may continue to be basically labor intensive.3 Baumol and Bowen4 define a labor intensive organization as a group which cannot or will not resort to technological improvement to increase productivity. This researcher offers that such establishments as education, medical facilities, fine arts and selected one-person or small business or consultant establishments, i.e., sales persons, are often labor intensive. Baumol and also Kiesling continue to prOpose that a capital intensive facility as an entity which increase its productivity by investing in technological improvement. 2J. G. Gaff, Toward Faculty Review (San Francisco: Jossey-Bass Publishers, Inc., 1975). ' 3H. J. Kiesling, "On the Economic Analysis of Edu- cational Technology," To Improve Learning, ed. by Sidney G. Tickton (New York: R. R. Bowker Company, 1971). 4W. J. Baumol and W. G. Bowen, Performing Arts, the Economic Dilemma; a Study of Problems Common to Theater, Opera, Music and Dance (Cambridge: Massachusetts Institute of Technology Press, 1968). While the capital intensive sector continues to increase its production and profits, a commensurate adjust- ment of each worker's wages and production quotas is real- ized. Baumol and Kiesling.point out that the society operates as a single whole, therefore justifying that the wage and salary requirements of those employees of labor intensive organizations must also rise at the same commen- surate rate for their survival. It is the single level which wages must achieve over time which imposes a financial hardship on the labor intensive facility. Thus the labor intensive segment, i.e., education, has only two recourses. The first recourse would be to increase its monitary demand for Operation or second to substitute, in part, a tech- nological component to maintain and/or increase productivity. The tradition of adding staff to accommodate increasing enrollments has not and continues not to be pOpular with the tax providers (many of whom are members of the capital intensive sector). While Kiesling and Baumol suggest that increased prices in the labor intensive sector will force consumers of either sector to buy products and services evolving from situations where productivity has kept pace (by increasing production per person), these con- sumers (tax payers) can only place pressure threatening or effecting available funds through tax regulation. As a result, educational institutions must, if they are to sur- vive, undertake efforts to improve instructional techniques in terms of learning cost and efficiency through the use of added or increased technology.5 This technique of sub- stituting capital improvements for labor to enhance pro- ductivity of the educational institution and reduce economic pressure could offer the potential to incorporate simula- tion as a strategy. With the application of state funding to private medical schools to match tax support to state-owned medical facilities, medical educators are facing the same criti- cism. They are facing difficulties in providing new approaches to the education of student physicians. Tra- ditionally, the educational programs at most medical schools have been free of serious scrutiny. Unlike the nonmedical schools these institutions have enjoyed almost unlimited funds and program freedom.6 With added costs per pupil to Operate a medical program, the tax providers increasingly demand more accountability. Authors in the medical pro- fession have initiated feasibility studies to determine whether the accountability practices of other educational 5G. L. Wilkinson, "Cost Evaluation of Instructional Strategies," AV Communications Review, 21(1) (Spring, 1973), pp. 29-30. 6H. Jason, "Some High Priority Needs in Medical Education," World Medical Journal 5 (May, 1970), p. 107. programs can be incorporated and actually work in the once closed society of physicians.7 One important condition, patient availability for medical education has become a logistical and human rela- tions dilemma. This is due in part to (l) the implications of the passage of the 1974 Privacy Act, (2) the growing opinion that medical personnel should allow a patient to convalesce with dignity and privacy, (3) the belief that patients will recover at a more rapid rate without external interruption, (4) the fact that patients are less willing to grant permission to be used as "instructional models," and (5) the fact that primary care facilities will not pay patients to serve as pathological examples as it is cost prohibitiVe and not ethically apprOpriate.8 It is there- fore, becoming increasingly difficult to maintain a satis- factory source of patients exhibiting pathologies consistent with those indicated in the course objectives. In establishing the most recent medical schools, the lack of patient availability has been further compounded by the decision not to build resident hospitals on the 7H. Jason, "Instructional Accountability: Is It Desirable or Feasible?", Journal of Medical Education, 49(5) (May, 1974), PP. 460-461. 8J. L. Maatsch, "The Role of Simulation in Training," a handout given as part of the class note package given during the course entitled, "Simulation and Clinical Instruction," offered during the Winter Term, 1976, Michigan State University, College of Human Medicine. campus. For example, Michigan State University and New York College of Osteopathic Medicine have no resident hos- pitals. Medical colleges can no longer afford to build them during the initial years of Operation. In addition, empty beds in existing hospitals restricts new construction. For patient contact students in those medical colleges without resident hospitals, must be transported to outside medical facilities. Such transportation costs both instructional time and money.9 Medical education is attempting to respond to demands for greater instructional accountability by initiating programs which foster learning while simultaneously effecting cost savings. Instructional development techniques have been slowly diffused among medical educators who have found them relevant. Because of the traditional characteristics of the medical community as indicated by Menzel and Katz 10 and Rourke and Brooks, selected diffusion innovation 9F. C. Tinning, Simulation in Medical Education (East Lansing: Michigan State University, College of Osteopathic Medicine, Office of Medical Education, Research, and Development, 1975). loH. Menzel and E. Katz, "Social Relations and Innovation in the Medical Profession: The Epidermology of a New Drug," Public Opinion Quarterly (Winter, 1955-1956), p. 339; and F. E. Rourke and G. E. Brooks, "The 'Managerial Revolution' in Higher Education," Administrative Science Quarterly, 9(2) (September, 1964), pp. 154-181. studies have used a cross-cultural diffusion model.11 Rogers' and Shoemaker's model has been serving as a map to study diffusion characteristics in the medical community and the applicability of the model.12 Alignments and realignments of the social structures in a medical organization and the importance of pressures on the collegial, bureaucratic, and political segments of the academic community, cannot be underestimated. Communi- cations analysts who study the multiplicity of factors exerting stress on the academic unit from outside agencies have been asked to extend administrative decision to their 13 Administrative analyses to the medical community. decision and its interplay with instance of top-down and/ or bottom-up diffusion have opened up the once traditional, 11E. M. Rogers and F. F. Shoemaker, Communications of Innovations (New York: Collier-MacMillan, Ltd., 1971), p. 38 and Communication of Innovations: A Cross-Cultural Approach, 2nd edition (New York: The Free Press, 1971). 12E. M. Rogers, Research on the Diffusion of Innovations Applicability to the DiffusIOn of Medical Technology in the Health Field (East Lansing: Michigan State University, Department of Communications, unpublished research findings, September 24, 1972), pp. 1-22. 13M. Weber, The Theory of Social and Econamig Organization (New York: The New York Free Press, 1947); J. V. Baldridge, Power and Conflict in the University New York: John Wiley and Son, Inc., 1971); and W. Bennis, The Learning Ivory Tower (Washington, D.C.: Jossey-Bass Publishers, 1973). closed, medical academic community to investigations by outside competent authorities.14 Medical schools have been responding to the con- tinued cry for accountability. Programs have been announced and faculty growth acknowledged and justified by means of strategies, analyzations and appropriateness.15 Likewise, faculty have generated new methods of evaluation, academic and otherwise, to determine new ways to introduce and use new technologies, simulation being one. Intro- ducing this technology has, in part, led to curricula modifications and, more importantly, is increasing learning efficiency through improving instruction.16 Specific studies suggesting improved instruction within medical education are being disseminated to the tax providers. One such study described a comparative examination of the effectiveness of the audiotutorial and lecture methods.17 l4E. Erickson and H. Gandhi, Truth: On the Origins of Militant Nonviolence (New York: W. w. Norton Company, 1969). 15J. F. Wergin et al., "The Practice of Faculty Development,“ Journal of Higher Education, 57(3) (May/June, 1976), PP. 289-335. 16W. Bergquist and S. R. Phillips, "Components of an Effective Faculty Development Program," Journal of Higher Education, 46(2) (March/April, 1975), pp. 177-211. 17Report to the Faculty (Urbana: University of Illinois, College of Medicine, Center for Educational Development Bulletin, 1972-1973. (Mimeographed.) A more recent study assessed effects of interpersonal ascendant simulation versus clinical training for osteo- pathic students within a specific setting.18 Curricula modifications have also been important during recent attempts to comply with accountability demands by the medical community. A curriculum modification at the University of Illinois, soliciting student input, has been coupled with appropriate measures of faculty education 19 during the transition. Management analysis, an accepted part of instructional develOpment, has been used as a sys- 20 tematic strategy to improve a curriculum. It is believed that this strategy will eventually provide principles of order to the discipline. The use of this strategy has necessitated the develOpment of specific tasks and rules and their apprOpriate identifications.21 _‘ 18F. C. Tinning, An Experimental Study Invgsti- gating the Effects of Realvand Simulated Clinical Training on Psychomotor, Affective, and ngnitive Variables During Real Clinical Performance of First Year Osteopathic Medical Students (East Lansing: Michigan State University, Depart- ment of Counseling, Personnel Services, and Educational Psychology, 1973). 19L. P. Tremonti, “Curriculum Development," Journal of Medical Education, 49(5) (May, 1974), pp. 444-446. 20A. S. Golden, Development ofpa Curriculum for Health Practitioners (Baltimore: The John HOkans Univer- sity, 1973). 21Ibid. and G. L. Rowse et al., “Role Based Curriculum DeveIOpment in Higher Education," Education Technology (July, 1975), PP. 13-22. 10 To satisfy the demands for accountability many methods from other disciplines have been employed. An area, which has contributed heavily, has been methematics, particularly statistics. Through statistics, many logical research sequences have been devised to handle the data necessary to prove or disprove various hypotheses. Like- wise, logical patterns have, within limitations, led to consistent evaluative techniques for teaching effectiveness. The state-of-the-art has been refined. Wotruba and Wright22 have been one of many groups to present research methods for develOping a rating instrument for teaching effectiveness. Their instrument incorporates mechanisms to collect data reflecting the Opinions, knowledge and concerns of faculty, administrators, students, or other groups. Within these) designs a major concern has been the reliability and validity (internal and external) of the instruments in assessing the data pertaining to the precise relationships between the faculty and the students. Assessment criteria are subject to clarification and have been constantly 23 revamped and revised. In an evaluative setting, 22T. R. Wotruba and P. L. Wright, "How to Develop a Teacher-Rating Instrument: A Research Approach," Journal of Higher Education, 46(6) (November/December, 1975), pp. 653-663. 23W. C. McGaghie, "Student and Faculty Ratings of Instruction: Another Look,” Journal of Medical Education 50(4) (April, 1975). pp. 387-389. 11 instruments have been formulated to satisfy the objectives of medical and professional health students in specific settings such as clinical environments and one-to-one 24 The advent of relationships through perceptorships. computers is well documented for assisting in performing evaluations and as a data bank for accountability infor- mation.25 Evaluative measures coupled with systems analysis have been instrumental in planning and developing medical education facilities. The use of systems analysis in medicine has been incorporated from other areas of edu- cation.26 This descriptive and conceptual analysis has been used to determine a process for planning and develop- ing clinical facilities. While this application of manage- ment science principles and techniques to the planning process originated at the Georgia Institute of Technology, 24C. A. Johnson and R. S. Hurley, "Design and Use " of an Instrument to Evaluate Students' Clinical Performance, Journal of the American Dietetic Association, 68(5) (May, 1968), PP. 450-453; and J. L. DeMers et al., "Standard- izing, Monitoring, and Evaluating Preceptorships: A Model for Decentralized Medical Education," Journal of Medical Education, 50(5) (May, 1975), pp. 471-473. 25C. Stefanu et al., "A Computerized Student Evalu- ation Information Retrieval System," Journal of Medical Education, 50(2) (February, 1975), pp. 201-203. 26J. E. Hill, How Schools Can Apply Systems Analy- sis (Indiana: The Phi Delta Kappa Educational Foundation, I972). 12 its concept and purpose were designed for a medical user.27 Management science techniques and principles for instruc- tional systems and facilities develOpment have also been employed as resources in improving teaching competencies, both for faculty develOpment and for the student.28 Embedded in accountability efforts have been a general call for direction. Direction in the form of new or revised educational programs for all professional health personnel (both pre-professional and in-service). Needs exist for up-to-date models of patient care, efficient delivery systems, and there is a continuing call for com- munity involvement. To meet all Of the needs for direction much experimental work has been done by individuals and learned societies, affiliated with or interested in the medical profession. The University of Illinois School of Medicine29 presented a study which focused on the health needs of society. Their findings impressed readers with the fact that needs can no longer be met by physicians alone, but 27J. B. Mathews, The Planning of Clinical Facili- ties for Medical Education: A Systems Approach YAthens: Georgia Institute of Technology, August, 1970). 28C. Jung, "Instructional Systems for Professional Development," Theory into Practice, 11(5) (December, 1972), pp. 276-284. 29"Continuing Education for the Health Professions," College of Medicine, University of Illinois-Urbana, mimeo, December, 1966. 13 require the attention and efforts of a growing number of related health professions. The Carnegie Commission pro- gressed one step further, exposing readers to a set of interrelated ideas for reforming not only health manpower training, but the whole system of health care delivery in the United States.30 Lastly, a more recent prognosis for medical education's direction may be extracted from a report of a Delphi probe of the perceptions of medical school deans. These perceptions were in regard to changes in medical education and health care systems, which the deans expect to influence during the next twenty years.31 The situations thus far described involve a diverse multiplicity of events indicating many inconsistencies, which tend to undermine the traditionally held beliefs underpinning medical education. This evidence, while not wholly conclusive, suggests that a thorough reinves- tigation of the current programs in medical education is in order. With the push to re-evaluate medical education and accommodate the demands for accountability has come the impetus to employ instructional develOpment. Instructional 3oJ. Walsh, "Medical Education: Carnegie Panel Urges Expansion and Acceleration," Science, 170(3959) (November 13, 1970), pp. 713-714. 31'J. A. Keyes et al., "The Future of Medical Edu- cation: Forecast of the Council of Deans," Journal of Medical Education, 59(4) (April, 1975), pp. 319-372. 14 development, while it may require new or reallocated resources, has been determined the most effective tool available for the effort to shift medical education from a labor intensive to a capital intensive endeavor.32 Simulation, in its varying forms, is a strategy being employed. In general the advantage of using simu- lation is that often the strategy is less expensive and affords greater control by the instructional manager, while still providing an environment where the student can respond as he would in a real situation.33 Simulation is the parent form from which several 34 Within medical education one offspring were derived. widely used differentiation schema of simulation is (1) interpersonal and (2) media ascendant simulation. Non- simulation games (the equivalent to games in Boocock's classification) is mentioned as a tactical alternative.35 In terms of the research examined in this study, simulation, in its varying forms has been used more 32H. Jason, 1974, op. cit. 33F. C. Tinning, 1973, op. cit. 34S. Boocock and E. O. Schilds, Simulation Games in Learning (Beverly Hills, California: Saga Publications, Inc., 1968); and F. C. Tinning, 1973, Op. cit. 35D. R. Cruickshank, Simulation as an Instructional Alternatiye in Teacher Preparation (Washington, D.C.: National Education Association, #8, June, 1971). 15 frequently in nonmedical education, than in medical edu- cation. Considerable research on simulation has been done and is continuing outside the sphere of medical education. The diffusion of simulation into medical education has only recently occurred when compared to other disciplines. Tinning has implied that research, especially evaluative, evolving from the use of simulation in medical education is slow to be disseminated and is distributed in a random fashion. The dispersed condition of simulation information findings makes it difficult for practitioners to obtain facts about the strategy. If more historical and empirical research were made available, then medical educators would have a better information base from which to begin their research. Collected in a single document, it could facilitate dis- semination of the findings. It is ready access to these past findings that form an evolution over time that is useful to the medical educator. It also helps the researcher to determine if his current research is dupli- cating past efforts. Purppse of the Study Medical education is responding to the need for increased accountability by implementing programs employing instructional development strategies. Simulation, as indicated, in its varying forms, is just one such strategy being employed. Simulation, as a strategy, has often led 16 to curricular modifications and a more positive learning . . . 36 . . . experience for instruction. These curricular modifica- tions are now finding their way into medical education.37 The application of different learning situations over time may serve as a historical lesson for future development and use strategies. Use of the information from this study should assist medical programmers in reallocating simu- lation resources and/or develOping simulations that will provide students with a closer approximation of the skills which medical schools are accountable for teaching. By means of investigation and analysis, the purpose of this study is to critically describe the evolutionary trends of media ascendant simulation and interpersonal ascendant simulation as a strategy used by instructional developers in medical education. Research Questions To fulfill this purpose, this study will address the following research questions: 1. What are the critical events that have occurred in the evolution of media ascendant simulation in the Eastern and Western cultures to the present? 2. What are the critical events that have occurred in the evolution of interpersonal ascendant 36Report to the Faculty, 1972, Op. cit; and F. C. Tinning, 1973, op. cit. 37F. C. Tinning, 1973, Op. cit.; and J. Walsh, 1970, op. cit. higher tional 17 simulation in the Eastern and Western cultures to the present? What are the student learning benefits in terms of evaluation, feedback, and transfer which have been derived through media ascendant simulation? What are the student learning benefits in terms of evaluation, feedback, and transfer which have been derived through interpersonal ascendant simulation? How does media ascendant simulation compare to alternative instructional strategies in terms of resource requirements affecting costs? How does interpersonal ascendant simulation com- pare to alternative instructional strategies in terms of resource requirements affecting costs? What are the effects of the evolution of the media ascendant on the evolution of interpersonal ascendant simulation in medical education? What is the present state-of-the-art in terms of learning benefits and costs for interpersonal ascendant simulation in medical education? Need and Importance of the Study_ In the United States today, many institutions of learning are faced with a need for more instruc- accountability. Included within this group are the medical colleges which are experiencing difficulty in solving existing and potential instructional problems. Those responsible for staffing, teaching, and developing instructional methods for medical education are experiencing difficulty in solving the problems of rising enrollments ‘with decreasing effective budgets. 38 38J. G. Gaff, 1975, op. cit. 18 One important condition, patient availability for medical education, has become a logistical and human rela- tions problem. This problem is due in part to (1)-the implications of the passage of the 1974 Privacy Act, (2) the growing acceptance that medical personnel should allow a patient to convalesce with dignity and privacy, (3) the belief that patients will recover at a more rapid rate without external interruption, (4) that patients are less willing to grant permission to be "instructional models," and (5) the fact that primary care facilities will not pay patients to display inherent pathologies as it is cost 39 As mentioned prohibitive and not ethically apprOpriate. earlier it is becoming increasingly difficult to draw from an established pool of patients exhibiting pathologies . which are coincident with those indicated in the course objectives. Earlier it was pointed out that with the establish- ment of new medical schools in recent years, lack of patient availability was further compounded by the absence of resident hospitals on the campus. For example Michigan State University, Ohio University, Wright State University, West Virginia College of Osteopathic Medicine, New England College of OsteOpathic Medicine and New York College of Osteopathic Medicine have no resident hospitals. Medical 39J. L. Maatsch, 1976, Op. cit. 19 colleges can no longer afford to build resident hospitals during the initial years of Operation. In addition, excess beds in existing hospitals restrict new construction. To be provided patient contact, students, in these medical colleges without resident hospitals, must be transported to participating facilities. This transportation costs both instructional and/or student expense and time.40 Developers of medical education are attempting to respond to demands for greater instructional accountability by initiating programs which foster learning benefits while simultaneously effecting costs. Medical schools are now responding to demands for increased accountability by employing instructional devel- Opment programs. Employing instructional develOpment pro- grams causes the application of instructional strategies and their evaluation. Simulation, in its varying forms, is just one such strategy being employed. In general, the advantage of using simulation is that often the strategy is less expen- sive than other alternatives and affords greater control by the instructional manager, while still providing an environment where the student can respond as he would in the real situation.41 40F. C. Tinning, 1975, op. cit. 41F. c. Tinning, 1973, Op. cit. 20 Simulation is the parent form from which several offspring were derived.42 Within medical education one widely used differentiation schema of simulation is (1) interpersonal and (2) media ascendant simulation. Non- simulation games (the equivalent to games in Boocock's classification) is mentioned as a tactical alternative.43 Medical education adopted simulation after it was diffused into the military, business and nonmedical edu- cation. Research in the military, business and education have generated earlier findings. These preceding disci- plines have used and abused the various forms of simu- lation more frequently than medical education. Accordingly, medical education has only recently accepted a modest diffusion of the strategy, when compared to the other dis- ciplines. The research is slow to be disseminated and is being randomly distributed, which is evolving from simu- lation use in medical education. This writer believes those innovators, who would desire past and more immediate findings, are having difficulty obtaining the information. If more historical, descriptive, and empirical research were made available, then interested medical edu- cators would have a better information base from which 428. Boocock and E. O. Schilds, 1968; F. C. Tinning, 1973; and P. A. Twelker, 1967, Op. cit. 43o. R. Cruickshank, 1971, op. cit. 21 their research could be initiated. If this information were collected in a single document, it would facilitate dissemination of the findings. This type of base would enable the researcher to determine if his current research was duplicating efforts of the past. It is ready access to these past findings that forms an evolution or trend over time, which would be useful to the medical educator. The medical educator could use this information to initiate instructional design adaptations or replications to develop programs in response to the need to be accountable. It is this need which this study will attempt to satisfy by providing a comprehensive information base about simulation, with specific attention dedicated to interpersonal ascendant simulation. This study will provide to those interested in the improvement of medical education (1) a body of knowledge about instruc- tional simulation, (2) methods and values as to its success in effectively deriving learning benefits and (3) efficient use of resources that effect costs through alternative strategies. Limitations and Scope of the Study The following points identify the limitations and sc0pe of the study: 1. The study will be concerned with the evolution of interpersonal ascendant simulation and the effect 22 on it by the concurrent evolution of media ascendant simulation. 2. The focus will be on simulation as it may relate to medical education. 3. The study will be concerned with the discussion of learning benefits of interpersonal ascendant simulation in terms of instructional and/or student expense and time. 4. The study will be concerned with the discussion of resource requirements effecting cost savings in terms of instructional and/or student time and expense. Definition of Terms For clarification a variety of terms peculiar to .this chronological study are herewith submitted: Accountability. A state of being responsible, 44 In this study this liable, answerable or explicable. will be interpreted in terms of learning benefits and cost analyses.* Adoption. A decision to utilize the use of an innovation as the best solution through the (1) Awareness, 44J. L. McKechnie (ed.), Webster's New Twentieth Centurprictionary of the English‘Language, Second Edition, Unabridged (Cleveland: The WorId Publishing Company, 1962). *A definition suggested by the researcher of this study. 23 (2) Information, (3) Application, (4) Trial and (5) Adoption Stages.45 Bureaucracy. A network of social groups dedicated to limited goals and organized for maximum efficiency. Regulation of the system is based on the principle of legal rationability.46 Collegium. A community of scholars, who make their decisions on a round table setting. Individuals hold authority based on what they know and can do. Informal regulation is based on friendships, loyalty, or personal allegiance to a charismatic leader.47 Cpgg. An occurrence from a modification of the learning environment, such that students effectively respond to experiences which were assembled in concurrence with an efficient application of resources. Costs are reflected as instructional and/or student eXpense and time.* Critical. A characterization by careful analysis such that the item is important or essential for determining a decisive point in time. A state of occurrence on which 45E. M. Rogers and G. M. Beal, "Importance of Per- sonal Influences in the AdOption of Technical Changes," Social Focus, 36(4) (May, 1958), p. 330. 46M. Weber, 1947, Op. cit., Chapter 8, p. 159. 47J. V. Baldridge, Academic Governace (Berkeley: McGutchan Publishing Corporation, 1971): PP. 5-6. *A definition suggested by the researcher of this study. 24 the issue of things depends. A characterization by careful analysis of the Observations and subsequent knowledge of simulation to determine what is important or essential.48 Describe. The act of delineating or outlining to achieve a verbal picture. To tell or write about as in giving a detailed account of an activity or occurrence.49 Education. For this study, subdisciplines to include the Obvious and dietetics, dentistry, veterinary medicine and nursing have been included within this tOpic.* Fidelity. Usually the preplanned degree to which the simulator has been designed to approximate or relate with the true aspects of reality. The greater the degree of fidelity, the closer the simulator will approach the essence of the aspect of the real situation.* Eggs. A device to organize participants and their interactions so that a winner may evolve to control. Games or gaming causes one to investigate the players, the stakes of the players, their strategies and tactics, the resources available for play, the rules of play to even imply what is fair play, the type of communications among 48J. L. McKechnie, 1962, Op. cit. 49J. L. McKechnie, 1962, Op. cit. *A definition suggested by the researcher of this study. 25 participants and any degree of uncertainty accompanying a! the outcomes.50 Innovation. The perception of an idea, practice, process or object as being new by.an individual or orga- nization.51 Instruction. A process intended to foster and shape learning. Instruction is a broader term encompassing the element of teaching as in self-instruction implying that there is no teacher and hence no teaching per se.52 Instructional Development. A set of processes which causes the appropriate expertise to generate a catalytic environment. The catalytic environment main- tains a systematic application of knowledge and technology for the design, production, and evaluation of learning.53 50C. C. Abt, Serious Gamgg (New York, New York: The Viking Press, 1971), pp. 5-15. 51E. M. Rogers and F. F. Shoemaker, Communication of Innovation, 1971, op. cit., p. 37. 52F. W. F. Witt, "Instructional Development--What? How? Who?," a paper presented for the use of participants in the Symposium on Instructional DevelOpment, Michigan State University, May 3-7, 1971, p. 6. 53T. E. Harries, "Instructional Development: A Definition," a paper presented for the use of participants in the Symposium on Instructional DevelOpment, Michigan State University, May 3-7, 1971, p. 7. *A definition suggested by the researcher of this study. 26 Interpersonal Ascendant Simulation is an instruc- tional strategy which provides learning in a realistic likeness of the real world situation utilizing the use of human living models. The models are characterized by role playing, decision making and player interactions.54 Learning. A change in behavior, which occurs as a result of an individual's interaction with his environment. This includes an interpretation to represent a meaning of behavior as encompassing the totality of a person's actions and reactions, both overt and covert. The encompassment would further include feelings and attitudes (affective component), as well as knowledge (cognitive segment), and 55 skills (psychomotor and cognitive divisions). Learninngenefits. The desired Outcomes of an instructional environment as it contributes to behavioral change in its students.* Live Model. A person who has been trained to relate to the essence of an abnormality employing the use of psychomotor skills with or without the use of inanimate assists. The person may relate to the physical 54F. C. Tinning, 1975. 55p. w. E. Witt, 1971, op. cit., p. 7. *A definition suggested by the researcher of this study. 27 manifestations of a medical abnormality by employing live modeling as an inclusive part of role play. Media Ascendant Simulation. A connotation of a product and a process whereby methods are utilized to relate to the essence of something without all aspects of reality emphasizing the interaction with equipment, machines, films, and other hard and software.56 Medical Education. For this study, subdisciplines to include allopathic and osteopathic medicine have been included within this tOpic.* Non-Simulation Games. A connotation of a process emphasizing the competitive aspects of abstract games to motivate learning of concepts.and principles of a particular discipline or subject matter.57 Patient Games. A simulation, which has been care- fully planned depicting an interesting patient, that has been designed to facilitate the instruction in the clinical knowledge and skills associated with the examination, diag- nosis and management of the specific problems presented. This interaction involves the use of people to play roles of the patient, i.e., the instructor, another student or 56F. C. Tinning, 1975, op. cit., p. 4. 57 op. cit. D. R. Cruickshank, 1971; and F. C. Tinning, 1973, *A definition suggested by the researcher of this study. 28 paid live model. The game has required the use of instruc- tional materials to be utilized in order to achieve a reasonable cost factor and a convenient teaching method. Utilizing extracts from both interpersonal and media ascendant simulations, a game may be designed to accommo- 58 date varying amounts of each of these major types. Political. A fragmented social structure once articulated, power, and influence go through a complex process until the policies are shaped, reshaped and forged from the competing claims of multiple groups.59 Programmed Patient. A person who has been trained to relate to the essence of something without all aspects of reality. The person may relate to the psychological and physical manifestations of an abnormality by employing role play and/or live modeling according to the Operational procedures defined by the scenario.* Role Play. A person who has been trained to relate to the essence of a normality of abnormality relying on a spontaneous performance according to the constraints of the scenario. Role play may require displays of live 58J. L. Maatsch, An Introduction to Patient Games: Some Fundamentals of ClinicaI Instruction TEast Lansing: Michigan State University, Office of Medical Education, Research, and DevelOpment, 1974). p. 7. 59J. v. Baldridge, 1971, op. cit., pp. 8-9. *A definition suggested by the researcher of this study. 29 modeling to achieve the performance. Role play may be an active constituent of a total procedure to be carried out by a programmed or simulated patient in order to relate to the essence of something.* Simuland. The true aspect of reality, whether it be animate or inanimate, which the simulator has been asked to relate or imitate; that situation which is simulated.* Simulated Patient. A person who has been trained to completely simulate a patient or any aspect of a patient's illness depending upon the educational need. The individual may reproduce the psychological, emotional, historical and physical manifestations of a patient on observation, interview and examination. The individual is trained to give constructive feedback (reinforcement).60 61 Simulation (known as "versimilar training" ). An instructional method that seeks to provide learning in a truthful or real likeness of the real world situation in which subsequent, independent performance will occur.62 60H. S. Barrows, Simulated Patients (Springfield, Illinois: Charles C. Thomas, Publisher, 1971). p. v. 61J. L. Maatsch, 1974, op. cit., pp. 1-2. 62J. McLeod, Simulation (Toronto: McGraw-Hill, Incorporated, 1968), p. 6; and F. C. Tinning, Op. cit., p. 4. *A definition suggested by the researcher of this study. 30 Simulation Game. A process emphasizing the com- petitive aspects of games Operating in an environment of truthful or real likeness of a real world situation.63 * Simulator. An animate or inanimate object designed to portray the essence of something with all aspects of reality; that which simulates.* Teaching. A process composed of the actions in which teachers engage. It includes what they say, what they write, what they show, what they demonstrate, what they assign, what they do when they react, what they do when they judge, etc. The purpose of teaching is to bring about learning and to have some influence on the nature and quality of learning. Teachers exert their influence on learning by manipulating, in the most desirable sense of the word--the environment.64 Trend. As used here, is a simultaneous happening or a series of events toward some object, purpose or 65 result of events, discussion or Opinions. Written Simulation. Sometimes called a paper and pencil simulation, an instructional method that seeks to provide learning in a truthful or real likeness of the real 63S. Boocock and E. O. Schild, Simulgpion Games in Learning (Beverly Hills, California: Sage Publications, Inc., 1968): PP. 11-15. 54p. w. Witt, 1971, Op. cit., p. 6. 65Interviews with S. Chojnacki, Graduate Director, East Lansing: Michigan State University, Department of History, counsel was held during August, 1977 and February, 1978. *A definition suggested by the researcher of this study. 31 world situation. The simulation is executed through the means of the student writing by hand all of the responses necessary. Some written simulations are also designed to have the scenario, supplemental data, decision point data and evaluation (feedback) transmitted by the facilitator . . 66 * in the written format. Overview A frame of reference for this chronological study has been developed in Chapter I, The Problem. Included under this heading have been the background and rationale, purpose, need and importance of the study, limitations and sc0pe of the study and definitions of terms. In Chapter II the methodology will be established; this includes the research design, bibliographical develOpment, selection criteria, evaluative criteria, criteria results and evi- dence summation. Chapter III is devoted to a review of the historical literature, encompassing the develOpment of media ascendant and interpersonal ascendant simulation in the Eastern and Western cultures. Chapter IV will detail 66B. J. Andrew, "An Approach to the Construction of Simulated Exercises in Clinical Problem-Solving," Journal 9f Medical Education, 47(12) (December, 1972), p. 953; and C. H. McGuire and D. Babbott, "Simulation Technique in the Measurement of Problem-Solving Skills," Journal of Educa- tional Measurement, 4(1) (Spring, 1967), p. 2. *A definition suggested by the researcher of this study. 32 an exacting analysis of the historical literature to answer concerns of authenticity and worth of each contributor. Chapter V will present the study summary, conclusions and recommendations. CHAPTER II THE METHODOLOGY The procedures used in this study to accomplish the purposes outlined in the first chapter are similar to methods used in other sociological, educational and scien- tific studies. The methodology has been referred to by research groups as historical development, a heritage, a time-based development, a factual development and a chrono- logical study. This method has permitted the researcher to collect factual, relevant information about educational activities centering around the employment of interpersonal ascendant simulation as a device of instructional develOp- ment in medical education. This design does not use hard data as proof of instructional accomplishment for an edu- cational activity in the experimental sense. Instead, descriptive passages have usually been employed to familiar- ize the reader with the historical occurrances, designed to foster further inquiry. The methodology has provided a means to collect descriptive information from existing materials, collate and synthesize it into a chronological display and then inductively develOp apprOpriate analysis according to the subject headings which follow. 33 34 Research Design of the Study This study employs data gathering techniques designed to initiate a "historical inquiry."1 The object of the endeavor is to address the develOpment of simula- tion, primarily the interpersonal type, in order to provide an accurate description of its evolution and current state- Of-the-art. The study will be divided into six chapters as described in the following: Chapter One - The Problem to include the Background and Rationale, Purpose, Need and Importance of the Study, Limitations and Scope of the Study and Definitions of Terms. Chapter Two - The Methodology to include Research Design of the Study with Bibliographical Development, Reference Securing and Selection Criteria. Chapter Three - Historical Literature to include DevelOpment of Media Ascendant Simulation and of Inter- personal Ascendant Simulation. Under each of these primary headings, the evolution will reveal critical activities within Eastern and Western cultures. Within the United States, as a component of the Western culture, the dis- cussion will address the evolution in the military, business, education, and medical education. A timeline will be incorporated within each subheading. This timeline, by 1B. R. Worthen and J. R. Sanders, Educational Evaluation: Theory and Practice (Worthington, Ohio: Charles A. Jones Publishing Company, 1973). 35 choice, will identify concurrent events within those sub- headings which will accommodate time and information inter- faces. Chapter Four - Analysis of the Historical Literature will indicate the analysis procedures, selection criteria, evaluative criteria and analysis data to be used when treat- ing the authenticity and worth of the data of the contribu- tors from the two cultures. Chapter Five - Summary and Conclusions will summar- ize the Purpose and Design of the Study followed by the Summation and Conclusion of the Study. Recommendations will include Recommendations for Further Study and Reflections. Bibliographical Development- Collections An extensive bibliography of simulation will be assembled. The interpersonal ascendant material will be extracted from the main body of information. The bibliog- raphy will be develOped from a number of sources including A Study of Simulation in Medical Education, Volume 4: An Annotated Bibliography. This Annotated Bibliography was assembled by the Office of Medical Education, Research, and DevelOpment (OMERAD), Michigan State University. Further, the Annotated Bibliography was gathered through several computer based search retrievals by the Michigan State University Library employing the Systems DevelOpment 36 Corporation Interactive Retrieval Service of the ERIC retrieval file. All of the material which was used to generate the Bibliography is located within OMERAD and is at the disposal of this researcher. A detailed explanation of the search procedures (Transmittal Sheet) used by OMERAD will be included as the appendix. Additional sources will include materials in the Michigan State University Library as illustrated by the following examples: 4 1. Library Card Catalogue System 2. Dissertation Abstracts 3. Current Index to Journals in Education 4. Reader's Guide Index 5. Research in Education The major anticipated sources of documents are the OMERAD and MSU Libraries. This includes one-of-a-kind and unpublished materials from learned individuals and societies. Selection Criteria The following criteria will be used to research information to answer the previous eight research questions: 1. Does the study contribute to the amount of knowl- edge about media ascendant simulation? 2. Does the study contribute to the amount of knowl- edge about interpersonal ascendant simulation? 37 3. Does the study identify the apprOpriate discipline and time of application? 4. Does the study provide a descriptive briefing of the instructional problem? 5. Does the study provide a descriptive briefing of the simulation application? 6. Does the study provide a descriptive observation on documented fact or evaluation which was derived from it? 7. Does the study provide other contacts and resources for further inquiry and study to help eliminate collection bias of sole-sources? Evaluative Criteria In order to provide a valid and reliable assessment of the historical data, certain evaluative criteria will be used. The following evaluative criteria are recommended for historical research as reported from their literature and concurred by interviews with researchers in the field on this campus:2 2T. E. Felt, Researching, Writing and Publishing Local History (Nashville: American Association of State and Local History, 1976); and interviews with J. C. Moore, East Lansing: Michigan State University, College of Education, Secondary Education and Curriculum, Assistant Chairperson, counsel held during March, 1978; and S. Chojnacki, Graduate Director, East Lansing: Michigan State University, Department of History, counsel was held during August, 1977 and February, 1978. 38 1. Does the contributor(s) speak of the event as being closest to it in time and space, if not an actual observer or participant? 2. Does the contributor(s) demonstrate competence as being most capable of understanding and describing the situation? 3. Does the contributor(s) demonstrate minimal impartiality by disallowing omissions, additions or emotional involvement in the event? 4. Does the contributor(s) present the information objectively? 5. While the use of the written word implies skep- ticism on the part of the reader, does the con- tributor(s) separate the findings from the con- clusions? 6. The researcher must have some faith in the written word by acknowledging a possible threat to the professional reputation of the contributor(s), if he/they were caught within the insecurity of non- truths. In addition the following evaluative criteria are necessary to investigate those descriptive findings from . . . . . 3 sources which incorporate empirical deSIgns: 3Interviews with S. Gitterman, East Lansing: .Michigan State University, College of Education, Office of Research Consultation, Research consultant, counsel 'was held on April 5, 1978. - 39 7. Does the contributor(s) incorporate a design model appropriate for the study to be conducted, i.e., nonequivalent, nesting, crossed, or balanced considerations? 8. Does the contributor(s) incorporate the statistics apprOpriate for the design under consideration, i.e., nonparametric, parametric, univariate or multivariate considerations? 9. Does the contributor(s) incorporate data which is valid for the design chosen, i.e., sampled from right group, populations and done so prOperly? Is the dependent variable indicative of the vari- able of interest? 10. Does the contributor(s) incorporate reliable data as an issue in the study under consideration, i.e., interrater reliability, subject mortality, objec- tive design, and pre-post test relationships and frequency of administration for proper design? The use of all information, wherever derived, will be based on the previous selection and/or evaluative cri- teria. Where possible and practical, primary sources will be used. If the contributions meet the selection and evaluative criteria, they will be entered in the timeline according to the date of publication. Secondary sources Imay be used when the primary contributions exhibit the following attributes: 40 l. Referred to a source for further clarification. 2. Referred to a resource as an alternative of fostering study of possible significance. 3. Was obtained during a time frame when there was a minimum of published information. 4. Primary sources do not exist. Criteria Results The results of this prOposed dissertation may be useful to readers interested in one or both of the areas listed below in order to derive more information about possibilities of employing simulation to improve instruc- tional accountability: l. A sequence of critical changes related to simu- lation within a particular time period or dis- cipline. 2. The overall sequence of events effecting the evolution of simulation. The inclusion of each information source will depend on that source satisfying the selection and/or evaluative (validity and reliability considerations) cri- teria. Negative effects resulting from the application of a simulation strategy will be included, if the selection and/or evaluative criteria are followed. Once the information sources are chosen, according to the selection and/or evaluative criteria, they will be classified by country. Selected information from Eastern 41 and Western cultures will be covered according to the general chronology of the develOpment of simulation. When the evolution is reported within the United States the studies and findings will be presented within these areas of application: Military, Business, Education, and Medical Education, according to chronological order. The treatment of these areas, within the United States, will be reported in continuing chronological order as an extension of those data from other countries of Eastern and Western cultures. While there will be a sincere attempt to maintain a precise chronology of the data, there will be circumstances where reference to an occurrence during another time frame will be necessary to place the topic of immediate discussion in proper perspective. This raw data will provide the information from which trends will be interpolated to respond to each of the eight research questions previously stated. The research questions will focus on: (1) the evolutionary movement of media ascendant simulation and interpersonal ascendant simulation, (2) the evolutionary learning benefits, (3) the evolution of resources effecting cost savings, (4) the evolution of the media ascendant form to that of the interpersonal type, and (5) the state-of- the-art of simulation in medicine. The answer to the questions on learning benefits will specifically consider findings regarding evaluation, feedback and transfer. The answer to the questions on 42 the efficiency of resource allocation effecting cost savings will specifically consider findings regarding instructor and materials costs and instructor and student time. The answer to the question on the specific occur- rences will be reported within the other simulation (media ascendant) which addresses the effect, if any, on the evolution of the interpersonal form. These findings will give reference only to benefit/cost as related to learning and efficient use of resources. All of these data summaries will either descrip- tively support or refute answers to the eight questions previously proposed and how the answers change over time. Furthermore this design, by choice, may enable the reader to see if one development preceded another. Using this plan will allow the researcher to use literature contribu- tions which satisfy the selection criteria and validity and reliability considerations, but may only supply data to answer one of the questions or its subcomponents. Minor occurrences, which may prove to foster a future significant effect, will also be considered. The researcher believes that some readers may be.interested in minor trends, especially if they foster major movements in later years. Evidence Summation The potential, or lack of it, for simulation will depend on its record over time. Organizers (Eastern and 43 Western cultures identified by country and discipline) will be included to provide an additional set of references so that trends can be easily identified to the institutions with which the reader may be familiar. The summation of the evidence will reflect the record, whether positive or negative, occurring over time. This should appeal to the interests of the readers concerned with past applications and results of the simulation in how it answers the pro- posed questions. The evidence summation will retain the design format of the paper. The conclusions, within the "historical inquiry," are devices for pinpointing these trends identified within the data and its analyses. The conclusions will be stated to reflect positive or negative trends and their effect on the answers to the proposed questions. The conclusions must present to the reader a finite overview in sufficient detail so that a basic impression could be drawn. The conclusions could provide a point at which a reader would embark in order to identify other needed information. This information should enable the reader to determine whether these representative past activities of interper- sonal ascendant simulation justify the strategy in terms of accountability as related to medical education. Summary Chapter II Opens with a description of the method- ology employed by this researcher and its relationship to 44 similar methodologies. The research design of the study has been divided into five parts, which are (l) biblio- graphical development, (2) selection criteria, (3) evalu- ative criteria, (4) criteria results, and (5) evidence summation. The major source for much of the findings referred to in this chapter came from the research work of OMERAD entitled, A Study of Simulation Technology in Medical Education, Volume 4: An Annotated Bibliography. The procedures (Transmittal Sheet) for developing that work are described in the appendix. CHAPTER III REVIEW OF THE HISTORICAL LITERATURE The primary concern of this endeavor is to produce a chronological study of interpersonal ascendant simulation as a vehicle of instructional develOpment in medical edu- cation. To achieve this end, Chapter III reflects a literature search, within the constraints previously mentioned, by treating the simulation tOpic in two parts. Part One will be devoted to a literature review revealing many of those activities associated with the evolution of media ascendant simulation. TOpical discus- sions include a chronological treatment within specific areas. The areas are China and Japan, Europe, United Kingdom and United States (to include Canada). In Europe and the United Kingdom, treatments concern early develop- ment in the military and later develOpment in business, education and medical education. In the United States, a treatment is devised to include the subtopical considera- tions for the military, business, education and medical education. It should be remembered that medical education has only included those activities within allopathic and osteopathic medical education; whereas, education consider 45 46 all topics of a general nature including veterinary medicine, dietetics, dentistry and nursing. Part Two has been designed to explore pertinent historical literature with respect to the development of interpersonal ascendant simulation. Similarly, the chrono- logical treatment will be discussed under apprOpriate sub- ject headings. Area headings include China and Japan, EurOpe, United Kingdom and United States. Occasionally, a situation will develOp in which the principal investigator has made contributions in two or possibly more subjective classifications, even in a number of combinations. The findings will be separated into their respective categories as continuity permits. When overlap I is warranted, appropriate inferences will be made to facilitate the transition. However, the implications of these transitions will be included as one of the require- ments of Chapter V, the Summary, Conclusions and Recom- mendations. Figure l, TOpical Superimposition of Chapter III on a Timeline, is designed to assist the reader in under- standing the tOpical organization as it relates to the simulation chronology. The table contains a vertical and horizontal axis. The horizontal axis presents the time- line found in the chronology. This timeline reads from left to right on the broadside page. When reading from left to right, please notice that the timeline is presented 47 mm. on. .ocflaoefle o co HHH noumcco mo coduwmomafiuomsm Hoowmoeuu.a ousmwm ccflacsns Vb. NB. OF. m0. @0- 00. mm. Om. mV. 0V. Om. NH. OOGH Oh. OOmHV. cohucostm Hmoficmz :o«ucosom mmocflmom sutbflawz mmucom tongs: socmcflx tcuucs mmousm comma use onwno coHumHoEHm HOCOmHomuoucH nodumooom Hecate: GOAOOOOUM mmocfimom xumufiawz moumum pouaca 80pmcax ponds: omousm comma can mcwnu QOHUMHDEHW ”HUGS mOHmOB 48 in reverse logarithmic (approximate, that is) order, mean- ing the compression effect is at the left side of the page. This prOportional effect is used to save space in listing the earlier years. The horizontal lines represent, within graphical error, the approximate times of the search covered in Chapter III. The horizontal lines do not show nor take into account any diffusion of simulation between or among disciplines, cultures or countries. The vertical axis lists the topical headings as found on the Table of Con- tents for Chapter III. The order of the headings are listed in order from tOp to the bottom of the broadside page. Figure l, Topical Superimposition of Chapter III on a Time- line, represents the results of the information conforming to the order just described. Development of Media Ascendant Simulation This section focuses on media ascendant simulation whereby the environment to represent reality is mainly produced by technological mechanisms and software, rather than with human participation and models as does inter- personal ascendant simulation. As Part One of Chapter III, the treatment of specific geographic areas (China and Japan, EurOpe, United Kingdom and United States, including Canada) is considered. While the first labeled use of media ascendant simulation in education took place in America as the Jefferson Township Simulation about eighteen years ago, 49 the method is much older and its origin is uncertain. The history reveals a develOpment occurring from an unusual relationship among the military, business and education. In the case of gaming and simulation, education has taken a method from business, which business in turn had borrowed from military training.1 China and Japan Information from selected resources have attributed that the game of chess, coming from the Orient, is the old- est form of simulated game. Chess, being a competitive situation of tactical relevance and associated maneuvers, may be termed an interaction game used in the movement of implied men and equipment in a warring effort.2 Chess required contrived finite rules and tactics evoking con- sequences which could be controlled. The design of the game under such rules also lent itself to the control of the stimuli preceding responses in the environment of play. It is the inherent potential in the game to control the preceding stimulus and evoked consequences which modern day learning theorists suggest provide a means for the players to learn. When the design of the game (chess) 1P. J. Tansey and D. Unwin, Simulation and Gaming in Education (Toronto: Methuen Educatidnai, Ltd., 1969). 2J. L. Taylor and R. Welford, Simulation in the Classroom (Baltimore: Penguin Books, Inc., 1972). 50 fosters an environment which causes learning from the con- trol of the evoked consequences of player behavior, this situation has been labeled Operant learning (conditioning (by B. F. Skinner).3 An added significance of the chess game may be that the design causes an environment whereby there is control of the preceding stimuli initiating or provoking player interactions. In this setting a group of game stimuli will result in the players demonstrating an intended sequence of responses. When the players learn under this form of a stimulus-elicited response relation- ship, it has been labeled respondent learning (condition- ing by B. F. Skinner). When a version of chess was adopted to war simu- lation, the game utilized technicalities of abstraction to enhance the realism of the battlefield situation. Prior to 1800 maps were employed as a device to further the realism. Even then, while it may not have been explicitly stated, these planners, through the emphasis of realism, were striving for a relevance and transfer of learning to 3P. A. Twelker, Instruction Simulation: A Research Development and Dissemination Activit (Corvallis, Oregon: Continuing Education and ERIC Pub ications, 1969; and R. M. Gagne' , The Conditions of Learning (New York: Holt, Rinehart and Winston, 1964). 4J. D. Krumboltz (ed. ), Revolution in Counseling: Im.lications of Behavioral Science (Boston: Houghton MiEfIin Company, Inc., 1966). 51 real combat situations. It is this acknowledgment of realism (fidelity) to some measured degree, which learning theorists such as Gagne' and Twelker have suggested effects the process of the student transferring from the learning situation (Environment) to the real world.5 Europe During the first seventy years of the nineteenth century, two types of games were developed in Prussia. The first was called the rigid war game. It reflected realistic situations responding to an elaborate code of rules. In response to these rules, changing patterns of war play were effected by the probabilities produced by a die or dice. In an attempt to simulate the intricacies of men and equipment in a battlefield configuration, these rigid war games were highly abstract, academic exercises. The rigid war game tended to Operate in an environment fostering competition very similar to that experienced by checker or chess players. Maps, a component of media ascendant simulation, added an element of realism (fidelity) to the resources available for play. As the rigid war game organized the participants and their interactions, consequences were evoked. Modern day learning theorists 5R. M. Gagne', "Simulators," TraininggResearch and Education, ed. by Robert Glasser (Pennsylvania: University of Pittsburgh Press, 1962); and P. A. Twelker, loc. cit. 52 now suggest that these evoked consequences provide a means for the participants to learn. The design of the rigid war game incorporated an environment which caused learning from the consequences of player behavior, which has been called Operant learning. As the game provokes player interaction, this process contributes to learning from the consequences of the many decisions which eventually lead one to win or lose. As the players work in this competitive state, this process creates game conditions which become associated with the behavior of the participants. Learning under these associated behaviors has now been called respondent learning. It is the acknowledgment of the Operant and respondent forces which may foster learning. Furthermore, when learning takes place in a controlled, representative environment, then transfer from a strategic exercise to the real world battlefield may result. The value of these Prussian war games was mainly training in overall military strategy.6 During these same seventy years, the second type of game employed a greater element of reality. The games became less media and more interpersonal ascendant (role play) by the use of large groups of military personnel in situations controlled more or less by umpires. Umpires were necessary to replace a "scoring" mechanism of the 6P. J. Tansey and D. Unwin, Simulation and Gaming in Education (Toronto: Methuen Educational, Ltd., 1969). 53 game which gives feedback in terms of war casualties and advancing or retreating lines of men and equipment on both sides.7 The objective of such simulations was to provide practice without the loss and destriction of valuable men and equipment. Likewise, an extensive employment of mili- tary resources sufficient to create entirely realistic situations might have had political and security overtones, that could have meant additional danger to the country from both internal and external enemies. The activity of the second enlarged game has suggested learning endeavors in alignment with Twelker's8 adaptation of the stimulus- response (S-R) theory of learning. The game seemed to agree in substance with Twelker's assertion that this gaming (instructional) simulation embodied a stimulus situ- ation presented to the strategists (learner), a response which was the observable change in the strategist's (learner's) behavior and an umpire's decision (feedback to reinforce), which subjectively interpreted the consequences of the deployment which took place to satisfy the require- ments of the strategy. While this search seemed to be sketchy on names and specifics, the value of these two Prussian war games was strategic. Since strategy and 7Ibid. 8P. A. Twelker, Instruction Simulation: A Research Development and Dissemination Activity (Corvallis, Oregon: Continuing Education and ERIC Publication, 1969). 54 tactics go hand-in-hand in war, it is apprOpriate to under- stand the concurrent yet parallel developments of the Prussian war games. The activities just discussed spurred use of simu- lation techniques in other parts of the world. Simulation research and develOpment, as an assist to learning, were to flow back to EurOpe in later years from these other parts of the world. The selected literature searches described in Chapter II revealed several classic studies recorded in periodicals. The studies which are to follow are discussed to reveal a representation of work and a lack of stagnation on the part of the EurOpeans. An European influence, J. A. Overstone in 1966, specializing in computer application, in association with the University of Adelaide of Australia, produced a docu- ment recorded in the medical journal of that country, which discussed the possible use of computers in medical education. Discussions centered on the rationale behind a hardware expert's considerations when designing an insti- tutional program. It announced to their medical community that computer assisted instruction using simulation and other formats in medical settings was feasible. Cost analogies, in the form of estimates without specifics, were offered as one of the prominent justifications.9 9J. A. Overtone, "Computer-Assisted Instruction in Undergraduate and Post-Graduate Medicine," Medical Journal of Australia, 19 (September 10, 1966), pp. 78-81. 55 At the University of Bergen, West Germany, media ascendant simulation was integrated into the dental curric- ulum prior to 1972. A model comprising the maxilla and mandible was designed to assist in teaching procedures of oral surgery to dental students. To increase fidelity, tooth anomalies could be identified using the radiograph (x-rays) procedure. After identification and assessment, the learner could practice lifelike restoration techniques on the model. This model simulator enabled students to improve both diagnostic and psychomotor skills. The model was designed to be set up for other oral pathologies and procedures which future course objectives would call.10 A study at the Saint Chad's Queenway in Birmingham, United Kingdom, completed during 1974, was to determine the acquisition of psychomotor skills in conservative dentistry. The study evaluated one aspect of a variety of skills, which are required of a dental surgeon. Skills in use of a dental mirror are necessary to orient a student for work on the maxilla. Models were also used to provide skills in indirect vision work, when students were com- paring cavities in the maxilla. This media ascendant simulation was effective in training students in the coordination of visual and psycholomotor skills. 10E. Hars and S. Hellem, "The Use of a Model for Teaching Oral Surgery," The Journal of Oral Surgery, Anethesia, and Hospital Dental Service, 30 (June, 1972), pp. 410-412. 56 A secondary, yet indirect, function of the inani- mate simulation was to assist students to overcome problems in working by indirect vision. The findings indicated that those students using simulated crainial models, with prepared civities in the maxilliary, early in the program achieved better orientation, usually in less time, than the control group.11 In Finland considerable attention has been given to written simulations. At the University of Oulu a simple and inexpensive method was proposed to assess clinical problem solving skills by using this form of simulation with coded and free answers. Medical school problems in hemotology were written in question and answer form as simulated patients. The cases were based on real patient's studies. A method of scoring using positive (+) marks for correct answers, negative (-) marks for harmful wrong answers and zero (0L marks for wrong, but unharmful answers was employed. A complete empirical result was not avail- able at the 1974 publication since the validity of the testing instrument had not been verified.12 11J. C. G. Jones, "The Acquisition of Dental Skills," British Dental Journal, 137(5) (3 September 1974): pp. 185-188. 12I. P. Palva, "Measuring Clinical Problem Solving," Bripishjgournal of Medical Education, 49(8) (August, 1974), pp. 52-56. 57 United Kingdom A direct progression of events identifying Britain's participation in the transition of war gaming simulation to the west was not easy to discern. Only certain, if not salient, landmarks were identified. In the following dis- cussion, certain activities have been indicated which fall into the definition of interpersonal ascendant simulation. This extension into the second part of Chapter III is necessary at times to benefit organization of the topic. With the war game activity being pursued in Prussia, there was a growing belief that war was rapidly becoming less an art and more a science. Simulation games began to be viewed as an important approach to training.13 The continuing military search for increased efficiency led to greater and more widespread investment in the technique. During the eighteen seventies, the method of these games was incorporated by the British Army. This promoted a military situation which has proved useful through many wars. Prior to and during the First World War, elaborate and extensive war game maneuvers were undertaken by many factions. In 1963 there were over two hundred Operational official war gaming models, excluding many used purely for very basic military training. At that time it was believed that this number was probably being doubled about every 13J. L. Taylor and R. Walford, Simulation in the Classroom (Baltimore: Penguin Books, Inc., 1972). 58 two years.14 In terms of money and energy expended, resources devoted to war gaming in Britain and elsewhere have shown little sign of decreasing. Mathematics, a discipline utilized in the planning and execution of maneuvers, gave birth to another form of simulation. Called "machine" then later "computer" simu- lation, these techniques involved probability theory. This theory (game theory and other associated mathematical techniques and Operations) were used to build chance and random elements into simulated activities. These early versions were processed by machine (calculator or the like), then later processed by electronic calculator or computer. Machine simulation has reached a higher level of complexity, since now the computer is able to handle excessive numbers of variables in a way that was impossible for the human brain. Vinsonhaler15 indicated (see page 74) there has been significant refinements of the electronic technology in computers from 1945 to 1965. The concepts of storage, processing and control were refined and developed. In Britain during this era, the Electronic Delay Storage 14A. Wilson, The Bomb and the Computer (New York: Delacorte Press, 1968). 15 J. F. Vinsonhaler, Com uters in Education and Social Science, Part I, Chapter 5 (East LanSing: Michigan State University, Information System Laboratory, 1972). 59 Automatic Computer (ERSAC) was developed at Cambridge by Dr. M. V. Wilkes. L. Lyons and Company began COOperative work with the Wilkes Laboratory on a commercial machine, the Lyons' Electronic Office (LEO), first used in 1953.16 During the close of the period from 1945 to 1965, the electronic computer was an important tool for most insti- tutions but involved minimum user, i.e., game player, con- tact. As a result of more recent developments of computer hardware miniaturization, computing cost reduction, time sharing, teleprocessing, and the small computer have enabled user groups to initiate apprOpriate simulation designs.17 The computer has usually been employed to expedite the results of a simulation by finding answers. With data chance factors and ultimate factors programmed into the Computer, human participation was limited to the initial develOpment of the program and a response to the final result. Such techniques have been used in simulation to speed the Operationresearch and to utilize probability in certain functions. Horse races, such as runs of the Derby and cricket matches, in which players from differing eras of the sport are represented have been played. In January, 1972, England played Austria in a derby match. Using part 16B. Murrphy, "Towards a European Computer," Science Journal, 6(7) (July, 1970), pp. 82-85. 17J. F. Vinsonhaler, op. cit. 60 of the Monte Carlo effect, the computer was able to simu- late the unpredictability of the sport to the known skills of.the performers. Using similar Monte Carlo probabilities, a commer- cial firm develOped a simulation game to be applied to medical education. The programming procedures and the simulated game were designed to reveal symptoms, with a preestablished probability. Using plus or minus as a fixed percentage, the computerized simulation was used to teach diagnosis skills. Case histories and laboratory test data were integrated with probability of occurrence to arrive at a diagnosis at the command of the student. The computer was assisting in confirming the probability of a disease being true with those given patient infor- mation.18 With miniaturization of computer devices and 17 has specialization to a directed purpose, Crane gp‘ai. been able to apply the technology as an electronic simu- lator. An improved design, the simulator was to be used for study of the distribution of anesthetic agents. This 18A. D. Kirsch, "A Medical Training Game Using a Computer as a Teaching Aid," Methods of Information in Medicine, 2(4) (April, 1963), pp. 138-143. 19R. Crane EE.El-r "An Improved Electronic Simu- lator for the Study of the Distribution of Anaethetic Agents,“ British Journal of AnaethesiologY: 40(12) (December, 1968), pp. 936-942. 61 improved version employed the analogue computing concept to permit measurement of stored charges on gas tension capacitors and incorporates the physiological mechanism involved in intrapulmonary gas exchange. The electronic simulator offers fuller analyzation for greater compre- hension of the factors governing anesthetic management. As computer availability has increased, so has the possibility of taking the busy work out of calculations. Other games and simulations have suggested the utility of computers doing this. The game develOped by the Institute of Chartered Accountants is called the National Management Game. This game uses computer calculations to provide fast feedback to schools after they have made their weekly management decisions concerning a hypothetical firm. The ease with which complex variables are handled assists con- siderably in maintaining the interest of participants.20 Medical education work by DeDombal gp‘ai.,21 at the University of Leeds, Department of Surgery has demon- strated continued use of computer simulations in various 20J. L. Taylor and R. Walford, 1972, op. cit.; and P. J. Tansey and D. Unwin, 1969, op. cit. 21F. T. DeDombal et al., "A Computer-Assisted System for Learning C1iniEEl‘Diagnosis," Lancet, 1 (January, 1969), pp. 145-148; "Teaching Surgical Diagnosis with the Aid of a Computer," British Journal of Surgery, 56(10) (October, 1969), pp. 754-757; and gpyai., "Production of Artificial 'Case Histories' by Using a Small Computer," British Medical Journal, 2 (February, 1971): pp. 578-58l(a). 62 situations. Known as computer assisted learning (CAL), it has been used as a method of teaching clinical diagnosis. A question and answer format with a printout was used and concurrent control of student progress employed throughout the exercise. The advantage claimed is that it allows practice of diagnostic skills with some built-in controls. Certain disadvantages have been declared, such as lack of realism.and information storage, retrieval problems and obtaining a balance between student freedom and control. A subsequent article, written in October, 1969, indicated that the equation between student freedom and control has been stabilized so that the system can capitalize on devel- oping initiative and judgment in surgeons. In 1971, the same authors extended their hardware capability to handle the production of artificial case histories to test the accuracy of diagnosis, effectiveness, and confidence among clinicians, secretaries, technicians, and students. An overview of the findings indicated that all groups usually concurred on the correct diagnosis but the clinicians were less confident. When errors in diagnosis were harshly penalized the clinicians were more effective than other groups. In the United Kingdom, the debut of business enter- prise into simulation was a direct outgrowth of the war games and the initiatives in 1956 of the American Manage- ment Association. The specifics of this innovation are 63 discussed in the second part of the chapter under "United States-Business." Within Britain the interests of business seem to center around two basic aspects of simulation. The first point is gaming, which falls under interpersonal ascendant simulation for this study. Likewise, an extended treatment of the relevant develOpment of gaming has been devoted to the United Kingdom under interpersonal ascendant simulation. A second contribution to simulation by business has been in the area of computer develOpment and its dis- semination. Since at least 1956 the British Broadcasting Company (BBC) has screened a number of management education series using simulation techniques to identify general business problems. Certain firms have had simulation pro- grams developed for their exclusive use such as the British European Airways. Commercial learning institutions, such as Ashridge Management College, have used simulation material within the general scheme of their courses.22 In 1968 the E880 Student's Business Game, a com- mercially developed product, was given its first trials in the classroom. In the next few years several commercial firms grouped together to build a simulation package. These were composite packages; each section was designed by the specialty firm or firm of responsibility. The ESSO 22J. L. Taylor and R. Walford, 1972, Op. cit.; and A. Wilson, 1968, op. cit. 64 Student's Business Game was expanded by the Institute of Chartered Accountants, International Computers, Limited, and the Financial Times, a newspaper. This interschool game was used by two hundred and forty-three schools in England and Wales. In Britain, as in the United States, the develop- ment of war and business games with the production of many by business firms for-themselves or under contract influ- enced the evolution of ideas to other users. This evolu- tion involved, or caused to be involved more commercial establishments. Formalized "think tanks," such as that initiated at the Research and DevelOpment Corporation of America (RAND) and the advances in computer technology (as briefly discussed), Operational research and systems thinking began to influence many new users. It was partly these commercial develOpments which led to feasibility studies and use develOpment by individuals, who had not previously used simulation.23 Following a good deal of unconscious and informal use of simulation techniques, general experimentation in Britain was given a conscious impetus by American initi- atives. The British school system, in such fields as social studies, general studies and historical geography, used media ascendant simulation to the greatest extent 23J. L. Taylor and R. Walford, 1972, op. cit.; and P. J. Tansey and D. Unwin, 1969, op. cit. 65 between the years 1967 and 1972. During that time experi- mentation was fragmented and difficult to document. Many simulation ideas and applications spread from one classroom to another, usually by word of mouth or mimeographed docu- ments. In 1972 no agencies or journals existed in Britain like Abt Enterprises or Project Smile or the Simulation and Gaming Journal in the United States. In 1969 the Society for Academic Gaming in Educa- tion and Training (SAGET) was established at the Berkshire College of Education.24 SAGET acted as a clearing house for many pieces of simulation material and was run as a voluntary and spare time activity by the organizers. The main services were a summer conference, a newsletter and an advisory service. Berkshire College was the seat of some of the first work on simulation as a key to solving classroom problems for student teachers. During this period two researchers were working with simulation on participants 25 at the younger ages. Smith and Cole produced favorable findings employing the use of simulation with very young children. Joined by Beynon25 they then develOped these findings into basic conceptual teaching material and strategies. 24F. J. Tansey and D. Unwin, Simulation and Gaming in Education (Toronto: Methuen Educational, Ltd., 1969). 25G. Smith and J. P. Cole, "Geographical Games," Bulletin of_guantitative Data for Geographers (England: 66 A comparative study was undertaken at the University of Leeds in which multi media simulation modes were used to determine the relationship between a clinician's diag- nostic performance and a preference for the modes. Clinical case studies of varying difficulty were developed in three modes: (1) computer, (2) "Min-Sim" board problem cards and (3) a verbal mode which was information presented in response to verbal questions. The clinicians worked through six cases in each simulation mode. The findings indicate that the verbal mode was preferred for both enjoyment and fidel- ity. The Minisim board seemed to cause the experimenters to select more information than they would in real life. In the computer mode the clinician repeatedly asked the same question sequence regardless of the format or presen- tation of different problems. Surprisingly, the computer was least preferred as these cases had a slightly lower percentage of correct diagnosis. The accuracy of diag- nostic judgment was not significantly different.26 In the United States, research into media ascendant simulation applications was fostered by financial backing University of Nottingham, Department of Geography Bulletin, No. 7, 1967); and J. P. Cole and N. J. Beynon, New Ways in Geography (London: Blackwell Scientific Publications, 1969). 26F. T. DeDombal et al., "Simulation of Clinical Diagnosis--A Comparative Stacy," British Medical Journal, 2 (February, 1971), pp. 575-577(b). 67 from many sources. The United States incorporated the idea from the British Army before the turn of the twentieth century. In this country, the military initially considered the potential of simulation. The next section addresses movements of simulation in the United States from the mili- tary to business, education and medical education. United States Professionals in this country receiving media ascendant simulation through the military, has since taken the strategy and applied it in business, education and 27 This section deals with those devel- medical education. Opments through the consideration of four salient areas: Military, Business, Education and Medical Education. The focus continues to center on media ascendant simulation. As previously indicated, examples of the promulgation of the interpersonal ascendant are included in order to pro- mote continuity. Military.--While there is no straight line in the course of events leading to the use of media ascendant simulation in the United States Military, landmark activ- ities can be identified. With a tactical relevance only associated with chess prior to 1800, the incorporation of print materials (maps) into the games at the turn of the 27P. J. Tansey and D. Unwin, 1969, Op. cit. 68 nineteenth century, and the development of the rigid war game in Prussia during the beginning of the nineteenth century; this possible form of media ascendant simulation could have been adOpted by the British Army. Both forms of the Prussian war games were said to have been success- fully used by that army during the eighteen seventies.28 The relevance of these war games (rigid style with two players is considered media ascendant and rigid style with large groups is called interpersonal ascendant) was instilled in the belief that war had become less of an art and more of a science. For this reason simulation was viewed as an important approach to training implying, in part, efficiency. The continuing search by the military for increased efficiency of troop deployment through simu- lation led to greater and more respected use of the tech- nique. This situation continues to be one of the viable justifications for the use of simulation to this day. The British obviously realized this as they employed simulation in both forms from about 1870 onward.29 While the specific detail of both the British and American involvement with simulation as a training mechan- ism has been sketchy, occasional comments indicate that 28F. J. Tansey and D. Unwin, Simulation and Gaming in Education (Toronto: Methuen Educational, Ltd., 1969). 29J. L. Taylor and R. Walford, 1972, Op. cit.; and P. J. Tansey and D. Unwin, 1969, op. cit. 69 both countries used this instructional design extensively in an elaborate style. Prior to World War I, simulation was used to train trOOps in combat and equipment maneuvers in the Military of both the United Kingdom and the United States. Between the World Wars there seems to be a lull in significant activity in the use of simulation in the military. However, a build-up of the war effort in response to the activities of Germany and Japan, coupled with finan- cial activity to establish viable programs, obviously had an effect On the use of simulation in the military. The develOpment of cockpit simulators, such as the Link Trainer, was a case in point and firmly established the concept of media ascendant simulation. These simulations were basic- ally noncompetitive realistic game designed on a physical model. These situations usually involved only one person, as the pilot in a fighter aircraft setting, but could use more than one person for other aircraft configurations. The design was considered media ascendant simulation, as the competition was changed from man versus man to a situ- ation in which man competed with the environment displayed by the simulator. The highly complex learning activity had to be transferred to the job situation. The pilot(s) was involved with the training and actual physical similar- ity between the training environment (simuland) and real life. These physically modeled (later computer controlled) simulations were developed to depict their counterpart, 70 which was too expensive, in terms of lives and equipment, to risk using for entry training.30 In 1963 it was officially indicated that over two hundred Operational war gaming models, not including many simulator schemes, were in use for very basic military training. A projection by Wilson indicated that the number of simulation projects would be doubled during each two 31 . . . Wilson's estimation was somewhat con— year interval. servative as in 1969 it was estimated that the military had applied over three thousand simulation techniques for instructional develOpment.32 In more recent findings the Air Force Human Reli- ability Laboratory indicated in their technical report that the use of simulation has just as much relevance now as in the past. Even though the Air Force has been working with simulation for a longer period of time than other groups in this country, relevant findings, by business and especially education are noted. In these studies cost effectiveness has been given priority, as implied by the inclusion of 30J. L. Taylor and R. Walford, 1972, op. cit.; P. J. Tansey and D. Unwin, 1969, Op. cit.; J. F. Vinsonhaler, 1972, op. cit.; and A. Wilson, 1968, Op. cit. 31A. Wilson, The Bomb and the Computer (New York: Delacorte Press, 1968). 32F. A. Twelker, Instructional Simulation: A Research DevelOpment and Dissemination Activipy (Corvallis, Oregon: Continuing Education and ERIC Publication, 1969). 71 rules and principles for evaluation. A major finding was that fidelity can be quite low in certain procedural tasks without a significant decrease in performance. This implied that some complex electronic equipment (some or all of which may have been tied into the simuland's computer) can be simulated in simple, relatively inexpensive devices without adverse effects on training. As very few studies have been compiled to validate the rules and principles of simulation develOped many years ago they lack evalu- ation.33 New designs and developments of computers by uni- versity and business sectors has added a program processing capability to some military simulations schemes, especially for media ascendant. While this evolution will be dis- cussed in the business section, the computer intervention in military simulation has kindled work in medical simu- lation training devices to be used both by the military and the private sectors. A case in point is described by the establishment of the Socratic System at Wright- Patterson Air Force Base, Ohio. The Socratic System employed the use of computer assisted instruction (CAI) in diagnosing various medical 33G. G. Miller, Some Considerations in the Desigp and Utilization of Simulators for Technical Training (Lowery Air Force Base, Colorado: Air Training Command, Air Force Human Reliability Laboratory, Technical Train- Division, Training Report (AFHRL-TR) 74-65, August, 1974). 72 problems, fOr example, illustrating a case involving the diagnosis of Pneumococcal (bacterial based) Pneumonia. The problem was presented to demonstrate how clinical prob- lem solving can be taught through computer simulation (CAI). The system was designed to accommodate students who might be hampered by an inability to demonstrate initiative under a relatively restricted procedure.34 The activity of the military and the impetus to develOp computer technology fostered by the government were to generate the inclusion of American businesses as a simu- lation user in 1956. In return, business accelerated the research into workable technology to make available a com- puter which was to continue to add a new dimension to the military, business itself, education and medical education. Business.--Industry and business were faced with the never ending task of maintaining a sufficient number of able persons to fill the supply of management positions becoming available. Attempts to lure these peOple from other firms did not solve the problem. An in-house train- ing program, as a viable alternative, was developed to 34W. Feurzeig et al., "Computer-Aided Teaching in Medical Diagnosis," Jofifp§::of Medical Education, 39(8) (August, 1964), pp. 746-754; and J. A. Swets and W. Feurzeig, "Computer-Aided Instruction," Science, 150 (October, 1965), pp. 572-576. 35J. F. Vinsonhaler, 1972, op. cit.; and J. L. Taylor and R. Walford, 1972, Op. cit. 73 resolve the dilemma. This alternative was proven effective in providing both morale and stability incentives. While the business world had the appropriate funds to carry on such training, the conventional modes, namely, intellectual and on-the-job training activities, were leaving measurable voids. In 1956 the American Management Association spon- sored development of the "TOp Management Decision Simu- lation." This simulation was a training technique which was designed to incorporate the desirable traits of the 36 Almost overnight, the simu- committed training methods. lation received instantaneous recognition. This form of gaming became a pOpular training activity for universities in this field, e.g., Michigan State University Advanced Management Program,37 as well as for industry and commerce. The attractiveness of the technique, coupled with the initiatives of modern business enterprise, has led to the design of over 250 business games.38 The "Top Management Decision Simulation" was a highly competitive device; the participants were able to 36P. J. Tansey and D. Unwin, Simulation and Gaming in Education (Toronto: Methuen Educational, Ltd., 1969). 37Advanced Managemept Program (East Lansing: Michigan State University, Graduate School of Business Administration, Course Announcement, circa, 1977). 38P. A. Twelker, Instructional Simulation: A Research Development and Dissemination Activity iCorvallis, Oregon: Continuing Education and ERIC Publication, 1969). 74 act as executives, make management decisions and then see the effects of those decisions. These games were refined to increase the level of fidelity for decision making and its associated planning, organization and evaluation. A first generation computer, the IBM 650, was used to facili- tate game accomplishment. Computers were used to reduce the game execution time and to keep participants in their roles and interested. Vinsonhaler40 has suggested the evolution of the computer in the United States came about in four (4) stages. 1. Business Machines Industry: 1900-1945. The period was initiated by Hollerith's punched card and termi- nated by Aiken's calculating industry. Large business firms were established, which created potential markets in business, industry, science and government for faster and more automatic calculating devices. The Computing- Tabulating-Recording Company (the forerunner to the Inter- national Business Machines (IBM)) was established and grew into a dominant firm in the highly profitable field of accounting machinery. During this period the wartime (at least World War II) concept of federal funding for research and develOpment helped establish important facilities, 39J. L. Taylor and R. Walford, 1972, op. cit. 40J. F. Vinsonhaler, Computers in Education and Social Sciences, Part I, Chapter 2 (East Lansing: Michigan State University, Information Systems Laboratory, 1972). 75 e.g., Harvard, MIT, and the Rand Corporation, which later figured actively in the evolution of the computer industry. 2. Noncommercial Computing Industry: 1945-1950. During the first five years develOpment of prototype com- puters, the computing industry was essentially noncommer- cial. Each machine was one of a kind and support came primarily from universities and government (military).41 Over three-fourths of all new computer models were built by noncommercial users, such as universities, government 42 This period was the research agencies or laboratories. and development stage, which preceded the active marketing of electronic computers. During this period the required technical developments were completed for commercial com- puters, all in the United States, United Kingdom, and Europe (see page 57). 3. Early Commercial Industry: 1950-1955. Until 1951 the computing industry was mainly dependent upon government (especially military) backing. In the first five years of the fifties, the commercial industry came of age by shifting away from one-Of-a-kind machines to com- mercial models with many copies of the same machine design. In addition to a growing commercial market, vigorous 41W. F. Sharp, The Eopnomics of Computers (Santa Monica, California: The RandSCorporation, 1969). 42K. E. Knight, "Evolving Computer Performance, 1963-1967," Datamation, 1 (January, 1968), pp. 31-35. 76 competition for the lead in computer sales was attributed to the major competitors, Remington Rand and IBM. 4. Modern Commercial Industry: 1955-1965 (and possibly later*). After about 1955 the computing industry began to undergo more stable develOpment-rapid growth and continued dominance by IBM. There has been a tremendous growth in the computer related and computer service indus- tries through component firms, service corporation and academic departments for computer science. In the United States, the principal user of computers is still the govern- ment. Even with the advent of computers, the basic premise of the management simulation games remained the same, that is, to solve the problems of business using methods of science. Management simulations were used to simplify the problems and to extract, from the multitude of variables, those essential features on which a decision must be made. As a result, competitive business games established and used models of a mathematical nature. This particular application of simulation gaming with the advent of computers, spawned similar applications within business, education and medical education in the United States, Europe and the United Kingdom. In Britain, for example, the ESSO Student's Business Game in 1968 was *Suggested by the researcher of this study. 77 the first simulation product (see page 63). In the United States, a political crisis game called Inter-Nation Simu- lation was developed in 1959, then refined as a tool in the teaching of international relations.43 The involvement of the computer industry, as a business entity and a component of media ascendant simu- lation development, continues to be discussed. Computer assistance (CAI) as instituted by IBM, in a clinical setting has encouraged the develOpment of a computer service as an elective portion of the rotating internship at the Kaiser Foundation Hospital in Oakland, California. The IBM Corporation helped to prepare experiences so that class participants receive training in principles, facts and pro- 44 The cedures of electronic data processing techniques. Remington Rand Corporation helped develop the rationale for selecting medical problems from which to build computer simulation models of anti-coagulant drug-clotting factor interactions and management of diabetic ketoacidosis. In 1972 Rand was involved with the first model of FLUIDMOD, a computerized simulation of the electrolyte and fluid 43H. Guetzkow (ed.), Simulation in International Relations (Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1963). 44K. M. Woodrow, "Computer Education for Physicians: A Computer Service in an Internship Program," The Journal of Medical Education, 45(6) (June, 1970), p. 531. 78 45 systems of the body. In an effort to compete, IBM became involved with the research to build a simulation to model the logic patterns physicians used in decision making.46 It can be observed in the literature that computer manufacturing firms are catering to the potential of edu- cation by either participating directly or indirectly in develOping the justification to computerize simulation instructional techniques (see page 74). Cost effectiveness, instructional support, retrieval and counseling were some of the areas evaluated in comparing computing advantages 47 Likewise, these busi- and disadvantages in simulation. nesses have been becoming involved with more empirical studies. IBM provided the hardware and software components in a mediated simulation developed to provide instruction in clinical decision making for the diagnosis and treatment of pulmonary case studies. The empirical study involved statistical treatment of the feedback and performance evaluation, including errors of comission and omission. IBM was instrumental, in part, in having the model designed 45E. C. Deland pp.ai., "FLUIDMOD: A Versatile CIA System for Medical Students," First USA-JAPAN Computer Conference, Sessions 8-5-1 to 8-5-5, 1972, pp. 272-276. 46L. L. Shane et al., "Computer Simulation of Medical Logic in a ClifiicaI Decision Support System,” New York State Journal of Medicine, 72(12) (June 15, 1972), pp. 1636-1644. 47R. D. Tennyson, "Applications of Computers in Education," Physiologist, 16(4) (November, 1973), pp. 600- 608. 79 so well that it may be adapted to the same process in other subject areas. The evaluative criteria were based on stu- dent selection of the appropriate diagnosis and defense of it. Changes in the problems were instituted as a vari- able as the student provided the appropriate management.48 This was a case in point to demonstrate the remarkable input from the computer industry to computerize simulation strategies and then evaluate the findings according to the wishes of the user. In other areas of media simulation, cOmmercial firms have generated measurable input to such areas as sound and visual simulators, mannequins and multi media approaches. The Bell and Howell Company has provided the hardware fer the develOpment of a heart sound simulator. The sounds are recorded on magnetic tape and attached to a card. The sounds may be played back at will to include a description of the sound sequence, textbook references, and graphic equivalences printed on the card.49 Mannequins employing Optical devices for use in both Ophthalmology and neurology have been develOped by 48J. A. Crocco et al., "A Computer Assisted Instruction Course in tHE Diagnosis and Treatment of Respiratory Diseases," American Reviow of Respiratory Disease, 3 (March, 1975), PP. 299-305. 49D. Levinson, "A New Audiovisual Aid to Heart- Sound Instruction," Journal of the American Medical Association, 205 (September 23, 1968), pp. 105-106. 80 firms specializing in Optics and plastics composition. These forms Of media ascendant simulation and their con- tributions by simular business enterprise have enhanced student's diagnostic and psychomotor skills, while main- taining a reasonable degree of fidelity.50 Lastly, within the multi media category, several writings have shown that commercial establishments have actually measured the cost of publishing works accumulated by learned individuals and have underwritten the fees for symposia so that research information on simulation was disseminated. Organized business has contributed to the advance- ment of simulation in the United States. Many of the con- tributions were designed for corporate gain and profit, but this trade-off can and has been accepted for the far reaching benefits that this segment of our society has provided both here and abroad.51 soA. Colenbrander, "Simulation Device for Ophthal- mosc0py," American Journal of Ophthalmology, 74(4) (October, 1972), pp. 738-740; and J. C. Maroon and C. Gosling, "A Head and Neck Trauma Teaching Model," Journal of Trauma, 13(3) (March, 1973): pp. 245-247. 51I. H. Beck, Spme Dimensions of Simulation, a paper presented at the Symposium on Simuiation for the American Educational Research Association (Orange, Cali- fornia: Bruce Monroe and Insgroup, Inc., February, 1969); and J. A. Farquhar pp ai., Application of Advanced Tech- nology to Undergraduate Medical Education (Santa Monica, California: The Rand Corporation, 1970). 81 The EurOpean Research Group on Management (ERGOM), since its inception in 1966, has been a symbol of the rele- vance of simulation in the business world. Headquartered in Barcelona, Spain, and funded by the Ford Foundation, the organization serves as a clearing house for the devel- opment of simulation games and conducts teaching sessions to prepare those who will be conducting such within their own organizations. One of the institutions heavily touched by business enterprise has been education. The next section details some of the salient contributions of education to the evolution of media ascendant simulation. Education.--Since 1960 education has incorporated the techniques of simulation, both in media and interper- sonal ascendant. The transitions have been basically handed over from the military and, more recently, from business. In the beginning the permeation was slow, but over eighteen years spread throughout the discipline. This section traces some of the relevant developments of media ascendant simulation in education. References to concurrent, parallel developments within the interpersonal ascendant scheme have been made to continue establishing meaningful transitory effects and maintain continuity. ‘Within education there have been included the general -developments of that subject including salient activity in dietetics, nursing, veterinary medicine and dentistry. 82 Within the definitions of this study, these disciplines have been mentioned in this section in order not to attenu- ate their relevance in the evolution of simulation. The first formal use of media ascendant simulation in education took place in America about eighteen years ago, as a solution to a need for an effective management strategy for public school principals. This endeavor became a classic published work known as the Jefferson Township School District study. The study was designed and devel- oped to draw conclusions about administrator's performance 52 The simulation and personality traits of participants. utilized both media and interpersonal components to evoke decision making learning behaviors of school principals. It was an outgrowth from administrative training procedures 53 The substance of the simu- common to the business world. lation used a set of exercises as scenarios in tandem with film and tape recordings of situations and conversations. The scenario required the participants to assume a role play of someone else, the principal. In the role of the principal, the participant had the opportunity to practice apprOpriate decision making processes. 52P. J. Tansey and D. Unwin, Simulation and Gaming in Education (Toronto: Methuen Educational, Ltd., 1969). 53J. K. Hemphill 33 al., Administrative Performance eand Personaiity: A Study of the Principal in a Simulated IElementary School (New York:iCBlumbia University,7Teachers College, 1962) . 83 The Jefferson simulation was designed to cause the participants to become involved in role playing activities, a forerunner to the simulated patient in medical education. The participants had to learn from the consequences of their behavior and the conditions that became associated with their decisions through appropriate feedback. This system caused the participants to learn by doing, a critical element of student activity in a chosen learning environ- ment. In 1961 Bersh Y. Kersh employed the mechanisms of management decision making simulation, with modifications, for pre-service teacher training. Utilizing a media ascendant technique, a simulated classroom was built with the apprOpriate audio visual support to make it appear as if the classroom was reacting directly to the student, who was taking part in the simulation. Feedback (reinforce- ment) sequences were shown, which were keyed to the student's decision in order to show the trainee the immediate effect of his decision actions, as in a real classroom. Kersh concluded that the students, who partook of the simulation training, were judged to be ready to assume responsibility for-their classes earlier than students preparing for the same experience via other methods of training.54 54B. Y. Kersh, Classroom Simulation: Further Studies on Dimensions of Realism (Monmouth: Oregon State System of 'Higher Education, Teacher Research Division, NDEA Project No. 5-0848, Title VII, Final Report, 1965). 84 Additional modifications were made in response to a finding that students responded to filmed, simulated experiences, which were projected on a screen which was less (smaller) than life size. In this instance a more positive response was observed initiating from a situation (stimulus), which was reduced in fidelity. There was no significant differ- ence in the final test (post) performance of students, who enact responses from situations on film, equated against those students who describe how they responded. Kersh indicated employing higher fidelity in simulation was important for motivation, but had a negligible affect on 55 In 1964 Kersh experimentally vali- 1earning transfer. dated a study on the effects of variations in the visual display on learning rate and laboratory performance ratings. His results tended to be more in support of the current thinking utilizing verbal mediation as a method of trans- fer.56 At the collegiate level simulation had been utilized prior to 1964 in counseling interviews as a training experi- ence for counselors. This simulated experience provided 558. Y. Kersh, Simulation in TeachingEducation (Monmouth: Oregon State System of Higher Edfication, Teach- ing Research Center, 1962). 563. Y. Kersh, Fidelity in Classroom Simulation: The Effects of Variations in the Visual Display on Learning Rate and Laboratpry Performance Ratings, a paper presented— at the American Educational Research Association Convention, Chicago, February, 1964. 85 the counseling students with discriminating behavior between the cognitive (knowledge) and affective (attitude) elements embedded within client verbalization. Standish cited sig- nificant gains in the counselor's performance in responding to verbalizations in such a way as to facilitate more effec- tive verbalization.57 These management decision simulations were actually requiring their designers to go through some sort of sequence in order to build the game. At the University of Wisconsin the effects of simulation, as a factor in learn- ing and retention, were being enhanced by designing the simulation according to the systems approach. The systems approach implied_the establishment of a simulation taxonomy of synthetic designs chosen in response to the instruc- ' tional objectives. The systems approach, a carry over from the business enterprise, also explicitly required the use of an evaluation scheme. This development acknowledged the role of simu- lation in facilitating transfer of skills from the syn- thesized to the real worlds. Fidelity was accentuated in the need to simulate both the physical and psychological 57J. H. Beaird and J. T. Standish, Audiosimulation in Counselor Training (Monmouth: Oregon State System of Higher Education, Teaching Research Division, 1964). 86 (affective, cognitive and psychomotor) aspects of this real world.58 From 1966 to 1972, Twelker was a major contributor to the research of simulation in education. He concluded that simulation was very appropriate for teaching prin- ciples on how to control and manage a classroom. Learning was further enhanced by the introduction of prompting as an assist to improve learning without measurably reducing the transfer.59 Learning by discovery was an issue in point, but the concern for the increased time, reduced performance and transfer were some of the prime topics of discussion. In 1967 Twelker found that material fidelity in simulation and prompting were not as important as once commonly thought in effecting transfer. Instructor differ- ences and length of training by comparison were indicated 60 to have a more meaningful effect. In recent years, Twelker has become increasingly involved in the systematic 58C. E. Stewart et al., Simulating Intercultural Communication Through Role-Playing (Alexandria, Virginia: George Washington University, Human Resources Research Office, Technical Report No. 69-7, 1969). 59P. A. Twelker, Prompting as an Instructional Variable in Classroom Simulation (Monmouth: Oregon State System of Higher Education, Teaching Research Division, NDEA Project No. 5-0950, Title VII, Grant No. 7-47-9015-276, Final Report, 1966). 60F. A. Twelker, "Classroom Simulation and Teaching Preparation," School Review, 75(2) (February, 1967), Pp. 40-43. 87 planning of simulation and has tried to segment simulation into meaningful parts. He has done this by assigning definitions to certain simulation strategies, e.g., non- simulation games, planning exercises, interpersonal ascen- dant and large system simulation. Comparisons among the four are made by equating them in terms of learning con- texts.61 Concluding in a report of 1967, Wayne State Univer- sity established a program known as Project Pit. The inner city youth of Detroit used as subjects were recipi- ents of the simulation of an industrial setting coupled with a guidance program. The simulation was designed, in part, to convey ocupational information and guidance to. help the subjects see the relevance of a good education, manufacture goods for nonprofit organizations and provide financial means to return to school. These mechanisms embedded within simulation were designed to upgrade the employees goals and help them acquire a sound background in occupations available. While the program was short in duration and their aspirations intangible, a significant shift in educational and occupational aspirations to a 61P. A. Twelker, Instructional Simulation: A Research Development and Dissemination ActiVityiTCorvallis, Oregon: Continuing Education and ERIC Publication, 1969); and P. A. Twelker and K. Layden, Educational Simulation and Gamin (Corvallis, Oregon: Continuing Education and ERIC Pub ication, August, 1972). 88 more realistic and higher level were noted through the use of simulated training.62 Innovative individuals and projects that have been adequately noted in the literature have contributed sub- stantial research in the use of media ascendant simulation in education. Clark C. Abt, an early game developer, founded in 1965 the Abt Associates, Incorporated, a commer- cial organization which has concentrated on building edu- cational and training game systems. This firm was respon- sible for the development of the Agile-Coin game, which was commissioned by the Advanced Research Project Agency in 1964 to find out more about problems of internal revolu- tionary conflict. The projectwas a result of the diffi- culties which the American troops were experiencing in Vietnam. The development of a game for military reasons served as a sound base on which to form the company even before their involvement in the develOpment of classroom simulations began. Many levels of simulation games have been exemplified by Pollution and Neighborhood, a community oriented classroom game designed at the request of the Wellesley, Massachusetts school system. Other games such as Manchester, Virgin Island, and a number of simulations 62Wayne State University, A Summer Industrial Work Experience and Occppapional Guidance Program (Detroit: Author, Department of Industriai Education, 1967). 89 d.63 More for curriculum projects have been develOpe recently, Clark Abt has compiled his expertise into a bound volume discussing simulation games in terms of their background, rationale, uses and advantages. He has employed a systems approach for their design to include formative and summary evaluative procedures to imply cost effective- ness. Finally, Abt reserved space to expound on the future direction of the games.64 Project Simile was a culmination of efforts first financed by the Western Behavioral Science Institute. Located at LaJolla, California, the project was first coordinated by Hall Sprague and Gary Shirts. In recent years Shirts has undertaken complete control of the activ- ity, which is concerned with the design and development of simulations in the field of the humanities. These simulations focus on the way in which the interactions arouse participant interest and change their attitudes. While Shirts has, on occasion, expressed some skepticism about the present claims for the use of simulation, authors 63C. C. Abt, Games for Learning: Social Studies Curriculum Project (Cambridge, Massachusetts: Educational Services, Inc., Paper No. 7, 1966); Serious Games (New York, New York: The Viking Press, 1971); Final Report on the Virgin Island Game (Cambridge, Massachusetts: Abt Associ- ates, Inc., 1968); and "A Game for Planning Education," InventinggEducation for the Future, ed. by Werner Z. Hirsch (San Francisco: Chandler Publishing Company, 1967) 64C. C. Abt, Serious Games (New York, New York: The Viking Press, 1971). 90 have acknowledged the success he has enjoyed in introducing the simulation idea to an extended school audience. One of the better known simulations which evolved from Project Simile was called Starpower. The situational setting of Starpower involved groups of participants who are issued sets of chips to trade. The conditions of trade and their strategies has led to particularly explosive conclusions to the game. The intensely competitive role play under- taken by the participants has led to the notoriety of the game as being one for adventurous and courageous players. The game has the added dynamics of continuing until one or more of the participant conpetitors refuses to continue to play. The adventurous and explosive nature of the game is embedded within the valuable and stimulating considera- tion of the problems of underdevelopment and the under- privileged. The simulation strategy achieved an Oppor- tunity for the players to unconsciously experience the feeling of what it is like to be poor.65 Jerome Bruner, among other educational psycholo- gists, has for some time been eminent among those attempt- ing to satisfactorily describe the learning process and build a theory of instruction. With support from the Ford Foundation, he has directed a Social Studies curriculum 65$. Boocock and E. O. Schild, Simulation Games in Learnin (Beverly Hills, California: Sage Publications, Inc., 968); and R. G. Shirts, "Games Students Play," Saturday Review (May 16, 1970), pp. 81-82. 91 program entitled, "Man: A Course of Study." Within his general writings on education and his own curriculum studies, Bruner has highlighted the academic relevance of simulation ideas and the benefits which they offer. In an attempt to rescue the occurrences of social life from banality and preclude primitive and bizarre overtones, Bruner proposed four techniques. The third of these four techniques suggests participation. To accomplish partici- pation, he suggested use of simulation games to incorporate formal prOperties of the occurrences of social life for which the game serves as an analogue. He admits that, in this sense, the game is like a mathematical model. The model is considered artificial, but often a powerful repre- sentation of reality. He conjectures by saying games can go a long way toward involving children in understanding language, social organization, and the rest. Games intro- duce the idea of theory to these occurrences, while provid- ing an excellent means of getting children to actively participate in the process of learning.66 Alexander in 1967 used a model mediated simulation design to provide exercises in problem solving and decision making for prospective principals. These techniques were incorporated into a cohesive training program. A question- naire was used to identify behavior forms to be analyzed. 66J. S. Bruner, Towards aTheory of Instruction (Cambridge, Massachusetts: Belknap Press of Harvard University, 1966). 92 The analyzation, in part, indicated that the simulation exercises were effective training tools for improving the administrative problem solving and decision making skills of the student principals.67 ‘To determine the optimal difficulty level for selected occupational problems, a simulated vocational problem scheme was designed using 288 male high school subjects; the criterion for successful performance was set at three levels of difficulty. The level of difficulty was not found to produce differences in the measures of expressed interest scores on the information test and inci- dents of information seeking behavior. The simulation design did generate interest and exploration in the spe- cific occupation used in the simulated vocational prob- lems.68 James Coleman, head of the Department of Social Relations at Johns HOpkins University, has been the stimulus for many of the ideas and much of the research on simulation. Boocock and Schild have acknowledged their own debt to him in the preface of their 1968 book. With 67L. T. Alexander ep al., A Demonstration of the Use of Simulation in the Traifiipg of School Administrators (New York: City University of New York, School of Education, Division of Teacher Education, 1967). 68R. G. Johnson, Simulated Occupational Problems in Encouraging Career Exploration, speech text given at a meeting of the American Personnel and Guidance Association, Detroit, Michigan, April, 1968. 93 funds from the Carnegie Foundation, the Center for the Study of Social Organization of Schools at Johns HOpkins has done much to identify problem areas in contemporary education and Opportunities offered by simulation. Academic Gaming Associates (Coleman) has continued to emphasize the functional possibilities of games in schools as distinct from their cognitive and affective influences. Additionally, with the advent of subsequent studies in game simulation by the University of Tennessee in the fiCtitious Munroe School System and the logic simulation studies undertaken by Layman E. Allen at Yale University, d69 to were events that possibly caused Boocock and Schil identify three distinct, but overlapping, phases of devel- Opment. Phase I: 'Acceptance on Faith.‘ During this phase, which lasted until 1962 or 1963, social scientists dis- covered gaming as a technique for the classroom. Boocock and Coleman had developed games at Johns Hopkins University to give experience and training in social living. This phase lacked research supporting the use of simulation. More time was spent on designing the games than on evalu- ating them, and there was a consequent rush of 69S. Boocock and E. O. Schild, Simulation Games in Learning (Beverly Hills, California: Sage Publications, Inc., 1968), pp. 15-18. 94 enthusiastic reports tempered by little hard evidence about the effect of games in the school situation. Phase II: 'Post-Honeymoon Period.‘ During the years from 1963 to 1965, some researchers attempted cOn- trolled experiments with games but produced either nega- tive or inconclusive results. The consensus of opinion seemed to be that simulation games do assist in learning, but why or how this occurred was not known. By not being able to determine the overall effects of these games, no way was available to determine which game design was more fruitful than another design. When Cherryholmes7o syn- thesized a number of reports, he suggested a problem in simulation may center on the construction of a good design. This implied a critical factor in building an explicit theory about the referent (simuland) system. He continued to suggest the incorporation of systems building (design) by referring to subject matter tasks, facts, or conditions representative of the real world with actions and conse- quences of behaviors similar to the real life situation. Lastly, he contended that games do motivate, but that there was insufficient evidence to purport that they teach facts or problem solving skills, or that they induce critical thinking in comparison with other methods of learning. 70C. H. Cherryholmes, "Some Current Research on the Effectiveness of Educational Simulation: Implications for Alternative Strategies," American Behavioral Scientist, 10(2) (February, 1966). 95 During this era observations in participant motivation and interest arousal were foregoing efforts to measure learning directly induced by the games. Phase III: 'Realistic Optimism.‘ From 1964 until, hOpefully, the present, the trend has been directed toward number of these simulation games. This has been expressed by field testing a number of different simulation data on the learning effects of specific games and revision and clarification of theory or claims concerning what games can do in the classroom. The advent of computers, as previously discussed on page 74, has overwhelmingly scored in an attempt to increase learning efficiency through simulation. Announced in 1970, a computerized simulation package was designed to accommodate upper level undergraduate and graduate students in studying pOpulation dynamics. A key feature was that the computers could effectively simulate a population con- stantly changing through variances in fertility and mortal- ity rates. Basic and advanced pOpulation theories based on its formation and continuing evolution were identified by simulating the population fluctuations as a response.71 Twelker's work in studying prompting and its effect on simulation has been extended by a computer simulation 71E. Van De Walle and J. Knodel, "Teaching Popu- lation Dynamics with a Simulation Exercise," Demography, 7(4) (November, 1970), pp. 433-448. 96 which employs graphic displays. To deal with the recorded knowledge involving judgment (decision) situations a simu- lation of diagnostic problems employing Multiple Cue Proba- bilities Learning (decision making) was computerized to include the graphic display. This visual assist has been keyed to enhance learning by permitting comparison between the pictorial representations of the student's decision system and the written properties of the task.72 In describing the software package called CAISYS-B Holm ep‘ai. have disseminated important information to those factions of education including simulation, which could use this programming package for computer assisted instructiOn. The inviting feature of this package lies in the fact that it is adapted to the emerging breed of mini- computers now available and that the teacher or simulation designer can program the unit himself without the assist- ance of a professional programmer, a cost saving factor.73 During the spring of 1972, Dr. Norman T. Bell of Michigan State University used the Formative Evaluation and Heuristic Research (FEHR) in his course of educational research. Michigan State served as an official test site 72K. R. Hammond, "Computer Graphics as an Aid to Learning," Science, 172(3986) (May 28, 1971), pp. 903-908. 73C. Holm et al., "CAISYS-8: A CAI Language Devel- Oped for MinicompuEErsT" Computers in Biology and Medicine, 3 (March, 1973). PP. 281—291. 97 for this computer-based research simulation developed at the University of Michigan. The FEHR practicum was designed to provide an extended range of practical experience in educational research and evaluation without the risks to student subjects and the expense and time commitments inherent in actual research. The computer based research simulation contains a data base of thirteen thousand (13,000) simulated students with 52 standardized test scores as well as demographic data. Dr. Bell's students used FEHR data to provide experience with designing studies and analyzing the resultant data in order to arrive at practical educa- tional decisions and to enjoy the benefit of direct feed- back (reinforcement) regarding the adequacy of their decisions.74 From 1962 to the present the design, rationale and development of multimediated simulations in the field of education have gained prominence. Starting with the advent of Steward's work proposing use of a systems design concept in media simulation to that of Norman I. Kagan in initiating reliability refinements in interpersonal process recall technology, there has been a sizeable body of research concerning this facet of simulation. 74Office of the Educational Development Program, Educational DevelOpment at Michigan State University (East Lansing: Author, No. 7, Spring, 1975), PP. 40-42. 98 Another salient activity employing the use of a mediated simulation has been the ongoing work of Kagan of Michigan State University with the develOpment and use of Interpersonal Process Recall (IPR). IPR is a learning activity to assist professionals to become more effective in interpersonal relations. The technique has been devel- oped from IPR research at Michigan State University. Pro- cedures used confront professional clients with their own reactions to emotional stimuli. Actors simulating affective scenarios or affective films were used before clients to depict an interpersonal relation. Both the client and the film or actor were videotaped during their encounter. The videotape is then played back to the client and trained interrogators help him examine his reaction to the film or role play. The course is set up to expose a series of dis- crete develOpmental tasks that require approximately forty hours: the time divided between large group interaction with twenty to thirty students have reported the effective- ness of IPR in different settings including its reliability in influencing mental health professionals' methods.75 75N. I. Kagan and P. G. Schauble, "Affect Simu- lation in Interpersonal Process Recall," Journal of Counsel- ing Psychology: 16(4) (April, 1969), pp. 309-313; (a) N. I. Kagan ep al., "Interpersonal Process Recall," Journal of Nervous aid Mental Disease, 148(4) (April, 1969), PP. 365- 374; (b) N. I. Kagan, “Can Technology Help Us Toward Reli- ability in Influencing Human Interaction?", Educatipnal Technology: (February, 1973): pp. 44-51; "Teaching Inter- personal Relations for the Practice of Medicine," Lakartidningen, 71(47) (November 20, 1974), pp. 4758-4760; 99 The remaining portion of this Education section will address progress in media ascendant simulation in medical areas which support or are allied with human medicine. Specifically, simulation treatments are considered for dietetics, nursing, veterinary medicine, and dentistry. In dietetics, research has been generated on effects of computer based simulations at Indiana University in 1968. A computer assisted food program was instituted in part to serve as clinical simulation, but the main effort was to key menu compositions to such variables as calorie requirements, food consistency needs and food preferences as directed by the physician, pathology or patient personal wishes.76 The preparation of the DIETETIC COM-PAK has been a more formal representation of the employment of a computerized simulation at the Univer- sity of Missouri-Columbia. The simulation model has been used for teaching dietitians, dietetic students and interns the computer assisted food systems management. This pro- gram serves to confirm the point that Boocock and Schild's 'Realistic Optimism' phase still continues as this program and Office of the Educational Development Program, Educa- tional Development at Michigan State University (East Lansing: Michigan State University, Author, No. 7, Spring, 1975). 76M. J. Winters (Simpson) and other class partici- pants, Computerized Menu Planning (Indianapolis: Indiana University, Department of Dietetics, Internship, September, 1967 to June, 1969). 100 contains an evaluation segment in addition to its other design considerations.77 Within the nursing profession, notable research activity has taken place with written and computerized simulation. At the University of California-San Francisco the National Institute of Health funded the development of a written simulation designed to evaluate the problem solving skills of seniors enrolled as baccalaureate nursing students. The test followed the sequence of a patient's experience from arrival at the emergency room to a period of time after he returned home. Designed in two parts, one called for a free response section by presenting problems for the student to solve. In the second part, called the controlled response section, a set of alter- native actions were listed from which the student chose a preferred action. The evaluation was run from 1966 through 1969. Classes constituting the experimental group reported significantly higher scores on certain criterion measures.78 Utilizing the concept of the Link Trainer with computerized control, another simulation was designed to 77L. W. Hoover and A. N. N. Moore, "Dietetic Com- Pak: An Educational Model Simulation Computer-Assisted Dietetics," Journal of the American Dietetic Association, 64(5) (May, 1974): pp. 500-504. 78H. M. McIntyre pp ai., "A Simulated Clinical Nursing Test," Nursing Research, 21(5) (September-October, 1972), pp. 429-435. 101 teach nurses to diagnose and initiate emergency treatment for the cardiac abnormalities most Often encountered in coronary care units. This computerized simulation has terminals at a number of sites within five hospitals with the capacity to display fourteen arrhythmias including the audio. In the exercise the student nurse is offered courses of action (prompting) from which to choose. If the student's response in any way was delayed in comparison to the average response time, then the electrocardiogram variable changed its reading, thus changing the stimulus.79 . At the University of Illinois-Urbana, instruction time, expense, serviceability and flexibility were some of the advantages cited for employing a computerized simu- lation on the PLATO III for teaching maternity care mater- ials to nursing students. The process was built on simu- lated patient situations which employed interactibility. Using a screen and keyboard, the students show achievement comparable with the conventional method.80 During recent years designers have been applying computerized simulations to both graduate nursing and life long education. In 1972 F. C. Reed and his associated 79R. H. Warner, "A Link Trainer for the Coronary- Care Unit," Computers in Biomedical Research, 2(2) (October, 1968), pp. 135-144. 80M. D. Bitzer and C. Boudreauz, "Using a Computer to Teach Nursing," Nursing Forum, 8(3) (March, 1969), pp. 234-254. 102 recognized the special problems that would have to be anal- yzed in order to use computer assisted simulation instruc- tion for individuals participating in continuing education. Such problems as availability of terminals, flexibility to accommodate day and night shift workers and the type and approach of material to be taught by simulation were con- fronted.81 Within the spectrum of graduate nursing edu- cation, the disciplines of psychiatric and cardiOpulmonary nursing have had certain concepts designed for simulation to have students learn mainly through interaction. A pro- grammed patient (inanimate) serves as one of the interaction pieces for the student. While achievement scores on mid- term and post tests were favorable, problems were encountered with financial and technical management plus the need for greater variety in instructional materials.82 A significant study at the University of Illinois, College of Veterinary Medicine has used computerized simu- lations to teach a portion of animal bacteriology. With financial backing from the Department of Health, Education, 81F. C. Reed et al., "Computer-Assisted Instruction for Continued Learning," American Journal of Nursing, 72 (11) (November, 1972), PP. 2035- 2039. 82M. Kamp and M. Burnside, "Computer-Assisted Learning in Graduate Psychiatric Nursing," Journal of Nursing Education, 13(4) (November, 1974), pp. 18- 25; and E. P. Hoffer et al., "Use of Computer-Aided Instruction in Graduate Nursing Education: A Controlled Trial, " Journal of Emergency Nursipg, (March-Apri1,l975), pp. 27- 29. 103 and Welfare (HEW), a program known as Identification of Bacteriological Unknowns has been set up. The program simulates a laboratory in which the student selects a speci- men, isolates the organism and makes the tests to identify it (much like qualitative chemistry). A multi-media format employing color slides of bacteriological colonies, tests and strains is used. The Computer stores the results for the student and assists (prompts) him in finding the unknown. A definite savings in school facilities, student time and energy, and staff laboratory time, has been achieved by allowing the student to perform qualitative laboratory work, which formerly required weeks, to complete execution within hours.83 In Dentistry sizeable contributions to the litera- ture in computer simulations have been undertaken including several studies which have been reported using the audio visual and mannequin design. A slide tape format was designed to present a battery of simulated endodontic prob- lems to a group of dental students at the University of Kentucky. The empirical study employed the usual experi- mental and control groups which received lecture-discussion presentations of the subject matter. Consideration of endodontics included material to enhance student management 83G. M. Grimes gt‘al., "Identification of Bacterio- logical Unknowns: A Computer-Based Teaching Program," Journal of Medical Education, 47(4) (April, 1972), pp. 289- 292. 104 and diagnostic skills, general education on endodontics and accepted emergency procedures to employ. These tOpics were addressed to-both evaluation groups in the clinical setting. Without particulars, the experimental group performed significantly better in the post-test evaluation diagnosis of endodontic conditions; however, the tape- slide simulation did not significantly aid in increasing the performance of treating endodontic pathologies.84 An inanimate model (mannequin) of the facial skele- ton of a patient was constructed to include all deformities and dental abnormalities as a simulation for oral surgeons prior to the surgery on that patient. Using this mannequin simulation, surgeons were able to plan the surgical pro- cedures and develop obvious alternative procedures just in case there had to be a deviation. Of course, all alter- natives could not be mapped to meet unanticipated obscure problems. Only the more obvious alternatives were con- sidered. Once the mappings were complete the simulated model was available for practice, first by the oral surgeons prior to surgery, and then by those surgeons and students who wanted practice after surgery completion. Those who practiced on the model after the surgery were able to receive feedback to reinforce their strategies in terms 84T. P. Mullaney gt al., ”Programmed Simulation of Clinical Endodontic Problems-,—Tr Journal of Dental Educa- tion, 36(11) (November, 1972), pp. 37-39. 105 of what was really found and what corrective procedures were actually taken. Of course that feedback could be conditioned on post examination and recovery trends of the patient. This simulation scheme was used to develop psycho- motor skills in current students and showed promise as a learning assist in the continuing education program for resident practitioners.85 In dental education, as in other disciplines, there has been a move to reduce instructional time without hinder- ing the quality of instruction, a positive note for account- ability. At the State University of New York-Buffalo, a federal grant was used to build, in part, an electro- mechanical dental simulator designed to simulate a cavity in the mandibular right first molar. Dental students, in cavity preparation, used this model with progressive train- ing to perfect their restorative procedures. The evalu- ation showed basically a substantial reduction in training time for all concerned contrasted against the time required for traditional method of training.86 85R. E. McMahon gt al., "Skeletal Models as an Adjunct to Jaw Surgery," Journal of Oral Surgery, 31(5) (May, 1973). pp. 340-347. 86G. Salvendy 35 31., "Electromechanical Simu- 1ator for Acquisition of Psychomotor Skills in Cavity Preparation," Journal of Dental Education, 37(12) (December, 1973), pp. 32-40. 106 The computer industry, through varied technology, has contributed computerized simulation packages to meet educational requirements in dentistry. Diagnostic studies 87 used computer assisted instruc- by Sokolow and Solberg tional simulation for the temporomandibular joint disorders designed by Gaston88 at Ohio State to employ an interactive sequence leading to a diagnosis for Pyogenic Granuloma, and 89 at the same institution for a simu- by Cassidy gt al., lated diagnostic package to solve a toothache in three major areas. The areas included a toothache with revers- ible pulpal pain, irreversible pulpal pain, and periodontal pain associated with the vital pulps. Other areas of application for computerized simula- tion include curriculum develOpment, statistics appropriate to dentistry and interviewing techniques. Logan and Jacobs90 at the University of Iowa College of Dentistry initiated an 87S. Sokolow and W. Solberg, "Computer-Assisted Instruction in Dental Diagnosis: A Product Development," Journal of Dental Education, 35(6) (June, 1971), PP. 349-355. 88G. W. Gaston, "Computer Assisted Instruction in Dental Education," Journal of Dental Education, 35(5) (May, 1971), pp. 283-288. 89R. Cassidy st 31,, "Computer-Assisted Instruction for Diagnostic Problem Solving of Toothache,” Journal of Dental Education, 36(3) (March, 1972): PP. 46-53} 90N. S. Logan and R. M. Jacobs, "Continuous- Progress Education II: Computer Simulation Model of a Flexible Dental Curriculum,” Journal of Dental Education, 36(12) (December, 1972), pp. 27-32. 107 experimental study to use a computer simulation model of a flexible dental curriculum. On the West coast at the University of Pacific, Saffir and Myers91 placed practice problem solving exercises on a computer in the form of a simulation. This simulation was designed to be used by dental students enrolled in a statistics course tailored to their needs. The format included a ten week course followed by an open-ended practice session doing statistical problems with the computer simulation. A cost savings has been enjoyed in money and time expended for the students, faculty and institution. In the same city, at the University of California, a computer based patient simulation exercise was developed to allow dental students to practice interviewing tech- niques before proceeding to the live patient situation. A rating scale was develOped and used to measure history taking performance of dental students. The empirically derived study indicated this simulation was effective in improving the transition between the didactic and clinical phases of instruction in history taking, as reflected by the higher level performance by the experimental group.92 91A. J. Saffir and H. M. Myers, ”A Modern Statistics Course for Dentists Using a Time-Sharing Computer," Journal of Dental Education, 36(4) (April, 1972), PP. 26-30. 92H. A. Brady et al., "Computer-Based Simulated Patient for Teaching History-Taking," Journal of Dental Education, 37(8) (August, 1973). PP. 27- 31. 108 Effective contributions to instructional problems, using simulation within education, have been many and varied as indicated in this section. Medical education, to include only allopathic and osteopathic disciplines, likewise, has enjoyed these simulation contributions, only beginning at a later date. The following concluding treatment of media ascendant simulation has been coordinated to address some of the contributions of this form of simulation to medical education. Medical Education.--This section has been structured to consider some of the relevant applications of simulation in allopathic and osteOpathic medical education. To observe the tradition of continuity, certain facts implying refer-” ence to interpersonal ascendant simulation have been incor- porated in addition to the inclusion of transitions to other parts of this text. The section has been designed to consider chronological developments within Canada and the United States to include written, audiovisual, mannequins, computerized and multi-media simulations and simulation centers. The Canadian contributions have been grouped together to establish continuity for that country. In Canada the literature has revealed relevant activity from 1967 to the present in multi-media and com- puter simulations. Significant studies have poured forth complimenting development within the United States and else- where. The earliest contribution indicated by this search 109 is represented by the computerized product developed at the University of Manitoba concluding in 1967. This simu- lation consisted of a computer assisted question and answer (linear)_dia1ogue directed toward selected topics in medical pathology. Carefully noted were early and initial attempts to apply simulated, but programmed, instruction. A computer assisted question and answer (linear) dialogue was developed toward selected topics in medical pathology. The clinicopathologic course was com- plimented by the programmed computer to test the students, give rapid feedback on answer correctness, record student cumulative performance and identify immediate or potential flaws in the present instructional methods--a case in point to justify its continued use to derive student learning benefits and effect instructional resource requirements effecting costs. The early and initial attempts to apply simulated, but programmed instruction were reflected in the "Programmed Clinicopathological Conference." The confer- ence consisted of a manual with a selected number of cases which presented signs, laboratory data, symptoms and course of diseases. Mediated laboratory test data and observations followed the written organizers. A series of questions, requiring the students simulate their position as the attending physician and make decisions to answer those questions, were presented. In both settings the computer was programmed to provide remedial loOps into the program. 110 In this instance, instructor contact time was reduced to only one day per week (Mondays), while the branching inherent in the program enabled students to progress at their own rate. At that time the report did not indicate how far or how long this medical simulation would extend.93 Addressed as a contributory effect on the part of Canadian educators, a computer simulation program was designed to compliemtn instruction on acid-base and electrolyte aspects of hemotology. These applications were currently being applied to similar subject matter in the United States during this era. While acknowledgment of typical simu- lation advantages was noted, considerable attention was directed to the technical difficulties encountered when the system was used at the University of Ottawa medical school clinics.94 In 1974 Anderson and Tomlinson95 identified con- crete employment of a systems management program to develOp a computer application course for medical students. Such 93D. H. Bowden, "Computer-Assisted Instruction in Pathology," Canadian Medical Association Journal, 97(12) (September 16, 1967). PP. 739-742. 94D. z. Levine, "Computer-Aided Instruction at the Ottawa General Hospital," Canadian Medical Association Journal, 108(4) (February 17, 1973), pp. 486-492. 95J. Anderson and R. W. S. Tomlinson, "Teaching the Uses of Computers within the Clinical Course," Proceed- in s of the Royal Society of Medicine, 67(9) (September, 9 4): PP. 948-950. 111 considerations included establishing aims (define by iden- tifying problems and analyzing objectives), employing the best teaching methods (detailing the methods and construct- ing the prototype) and testing the results (test prototype, analyze the results and implement and recycle), when pre- paring the computer appreciation course. The Royal College of Physicians and Surgeons, a medical specialty group, commissioned Taylor aE‘al.,96 in 1976 to develop a computerized simulation based on currently accepted practices in patient management problems for certification of pediatricians. Simulated patient manage- ment cases were develOped to accompany the multiple choice questions and oral examination to be given by this Canadian specialty group. The bilingual (English and French) exami- nations have given greater objectivity and saved examiner time. The contributions made to medical education in the United States have been active and full. This literature has disclosed numerous sources which have identified meaningful contributions. In consideration of the number of articles identified within the limits of the primary search, their bibliographies and secondary and tertiary sources a conservative count would probably include well 96W. C. Taylor et al., "The Use of Computerized Patient Management Problems in a Certifying Examination," Medical Education, 10(3) (May, 1976), pp. 179-182. 112 over 250 writings. To address this number of contributions, within the chronological display for the United States, would appropriately surpass the entry criteria for a separate dissertation. Therefore, this researcher has proposed to address, in terms of an overview, the probable contributing factors during the indicated time spans in the aforementioned types of simulation. References will continue to be cited so that the reader may expand his research on an issue. In the United States written simulation has con- tributed to medical education since 1965, as indicated by this search. Nineteen sixty-five has been identified as the year of one of the earlier simulation contributions by Christine McGuire, from the University of Illinois, whose name has been encountered numerous times during the course of this writing. During this year a paper and pencil simu- lation was constructed in order to devise an economical, objective and adequate sampling procedure to evaluate student physicians in dermatology.97 The need to improve upon the instruction process in interview techniques for physicians was apparent in 98 1966 when Froelich identified his paper and pencil 97C. H. McGuire, "Evaluation in Dermatology," Archives of Dermatology, 91 (April, 1965), pp. 303-312. 98R. E. Froelich, "Programmed Medical Interviewing: A Teaching Technic," Southern Medical Journal, 59(3) (March, 1966), PP. 281-283. 113 simulation. Calling them "programmed interviews,” he con- sidered his contribution to be one answer to satisfy the need for means of training physicians to be skilled inter- viewers. In 1967 a written simulation was developed to improve student physician decision-making processes which was built around the patient management problem. An erasable overlay was used to obtain immediate feedback (reinforce- ment) and identify multiple routes to the solution.99 Two 100 continued to refine the evaluation years later McGuire of student's diagnostic and management (decision-making) skills using written simulations with sequenced branching circuits as part of an implied feedback mechanism. The evolution criteria in terms of scoring, reliability and validity have been further refined to utilize a written 101 continued simulation as an instrument. In 1971 McGuire to refine these patient management problems as written simulations. The refinement has culminated in the polished 99W. H. McCarthy and J. S. Gonnella, “The Simulated Patient Management Problem: A Technique for Evaluating and Teaching Clinical Competence," British Journal of Medical Education, 1 (December, 1967), pp. 348-352. 100C. H. McGuire and D. Babbott, "Simulation Tech- nique in the Measurement of Problem-Solving Skills," Journal of Educational Measurement, 4(1) (Spring, 1967), pp. 1-10. 101C. H. McGuire and L. M. Solomon (eds.), Clinical Simulations: Selected Problems in Patient Management (New York, New York: Meredith Corporation, Appleton-Century- Crofts Educational Division, 1971). 114 presentation of a number of medical cases with evaluation and management procedures included. The introduction of a more implied systems approach has been the keynote of work by Andrew.102 The systems identification comes from the fact that written simulations for patient management must be constructed to conform to problem solving processes underlying clinical performance. The identification of cognitive skills and knowledge used in clinical management are used. Reports of audio visual simulations have been noted in this literature beginning in 1968 to the present. During 1968 the audio stimulus was employed as a simulation con- veyance of heart sounds to assist instructional activities. Video taping was used for a simulation "dry run" to con- front students with issues in ethical concerns, decision making concerns and family and patient management problems. The video tape was used to provide prepared situations. In both instances the audio and visual media were used to present simulated stimuli to the students before they encountered the real life situation.103 1028. J. Andrew, "An Approach to the Construction of Simulated Exercises in Clinical Problem-Solving," Journal of Medical Education, 47(12) (December, 1972): pp. 952-958. 103D. Levinson, ”A New Audiovisual Aid to Heart- Sound Instruction," Journal of the American Medical Association, 205 (September 23, 1968): pp. 105-106; and J. W. Ramey, "Teaching Medical Students by Videotape Simu- lation," Journal of Medical Education, 43(1) (January, 1968), PP. 55-59. 115 Two years later videotaping played a vital role in enabling medical students to view a simulated interviewer. The interviewer's behavior had to be observed in order to determine hindering or facilitating features involved in obtaining relevant information from the patient in a reason- able amount of time.104 Color transparencies have been used as a visual simulation of selected pathologies in selected settings. This researcher has been exposed to transparency use within a facial mannequin to portray pathologies of the eye at the Michigan State University Simulation Laboratory. Descrip- tive information on this form of simulation was provided by the New York Medical College in 1974. Identified as the Tutorendoscope, it supports color transparencies, which depict the visual simulation, as a self-contained teaching system. Employed with other proctotrainers, it was used to simulate tumors in the bronchial, colon and gastro- 105 106 intestinal sections of the body. Creech at al., in 104A. J. Enelow 23 al., "Programmed Instruction in Interviewing: An Experiment—in Medical Education," Journal 9£_the Americaa_Medical Association, 212(11) (June 15, 1970): PP. 1843-1846. 1058. S. Bentivegna, Teaching Diagnostic Oncology at New York Medical College Utilizing the Tutorendoscope System fg£_CanceraDetection (New York City: New York Medical College, Department of Surgery, Publication Report, 1974). 106J. C. Creech and G. M. Arsham,"Development, Vali- dation, and Dissemination of Instructional Materials: An Analysis," Medical Education, 10(4) (July, 1976), PP. 274- 278. 116 1976 used the popular video cassette and the slide/tape mode to develOp a self-instructional package in ophthalm- ology. Visual simulations included considerations for red eye, external eye diseases and occular emergencies. The simulation was directed to enhance the student's diagnostic skills and emergency decision-making management. Identified in 1965 under the direction of Arthus S. Elstein, a training model was developed in response to improved procedures and materials for training medical students in patient diagnosis and treatment. Color films were employed to present the first four to six minutes of a doctor-patient encounter as a device to simulate those conditions during the early encounter. To accentuate the process of feedback, duplicate c0pies of the films had thought statements recorded at strategic points to identify the physician's thoughts and timing for those thoughts during the interview and observation of the patient. The nondocumented films were used in soliciting outcome feedback.107 With mannequins a selected set of sources was available to identify certain activities from 1954 until 1974. Possibly the potential of the undertaking by 107Office of the Educational DevelOpment Program, Educational Develooment at Michigan State University (East Lansing: Michigan State University, Author, No. 7, Spring, 1975). 117 108 in 1953 will have relevance to Traugott and Shemesh medical education as a simulation model, if only the appro- .priate connections were made to those activities in the military. Probably proposed as a medical illustration, these designers were producing wax models (simulators which were very real) of pathological specimens. While the article addresses it attention to methods of manufacturing the replicas, the potential of it all still exists as a function in the establishment of the use of inanimate models for simulation as an assist to learning. This literature measures almost fifteen years before any activ- 109 110 each ity was again to unfold. Spivey and Griffiths, were involved (with the collaboration of a commercial firm for Spivey's work) with the development of facial manne- quins at the University of Iowa. Spivey's model was intended for students to produce intraocular surgery, while Griffiths' contribution was designed to be a func- tioning paper model of the larynx and surrounding cervical 108F. Traugott and A. Shemesh, "A Wax Moulage Technique," Medical Biolo ical Illustration, 4(1) (January, 1954), pp. 31-3 . 1093. E. Spivey, "Mannequin for Practice of Tech- niques and Procedures," Ophthalmology, 82 (October, 1969), pp. 487-488. 1100. A. Griffiths, "A Working Paper Model Of the Human Larynx," Medical ang Biological Illustration, 21(1) (January, 1970), pp. 41-47. 118 structures. His paper model was used for an anatomical display during teaching. lll extended the work of During 1972 Colenbrander Spivey by improving the fidelity and capacity of the manne- quin to demonstrate opacitive and refractive errors. The applicability to evaluation had been given additional attention. In both cases a commercial firm, Hansen OphthalmoscoPic Laboratory, was instrumental in the initial develOpment and improvements. With contributions of Arsham 112 in 1973, the potential use of the mannequin had 222-, diffused as an innovative characteristic identifying their Ophthalmology curriculum, as a prototype for curriculum development within the sphere of medical education. The design, especially the construction of mannequins, has been and continues to be quite expensive, especially if there is commercial involvement. Gosling and Maroon113 in 1974 identified this problem rather early and prior to the furor for accountability in medical schools. Their considerations describe construction materials and ll1A. Colenbrander, "Simulation Device for Ophthal- mosc0py," American Journal of Ophthalmology, 74(4) (October, 1972): pp. 738:740. 112G. M. Arsham at al., "A Prototype for Curriculum Development in Medical Education," Journal of Medical Education, 48(1) (January, 1973), pp. 78-84. 113C. G. Gosling and J. C. Maroon, "Patient Simu- lators and Medical Models," Journal of Biocommunications, 1(1) (June, 1974), PP. 17-22. 119 techniques, including certain trade-offs to reduce fidelity without losing the overall effect of the simulation and its effect on the transfer of learning to real world situations. 'Contributions to the use of simulation in medical education prompted by the event of the computer have been enormous. Computer applications in the military, business and education, both in the United States and elsewhere, have provided an extensive base of knowledge from which medical education benefits. The application of computer simulation in medical education is as extensive and varying as there are facets of the body which can be taught. This literature identified some of the contributions from 1963 until the present with the frequency of applications increas- ing almost exponentially during each year, as one nears the present. In 1963 Entwisle and Entwislell4 at the University of Maryland and Johns HOpkins University designed an early form of computer assisted instruction as a simulation to teach differential diagnosis. Students would select a disease solution from a group offered, to satisfy the cause of the symptoms. An interaction took place once a disease was chosen, a form of feedback. The evaluation feature compared correct and incorrect responses. Ironically 114G. Entwisle and D. R. Entwisle, "The Use of a Digital Computer as a Teaching Machine," Journal of Medical Education, 38(10) (October, 1963), pp. 803-812. 120 enough, the authors called it a teaching machine and this activity was being undertaken at the same institution where James Coleman was doing research on the applicability of simulation in education. Three years later computer simulations were being recognized as feasible in information dissemination, indi- vidualized instruction, physician-patient encounters, monitoring of physiological experiments and record keeping (clinical histories). At the University of Wisconsin, a small computer employing a screen (cathode-ray tube-CRT) and a typewriter was used to direct questions pertinent to allergy history collection. When these questions were shown on the screen the patient would respond by pressing the keys of the typewriter. This data could be used for the construction of computerized, simulated patient files for diagnosis and management decision making.115 During 1967 the relevant computer applications of simulation were addressed to diagnosis, management deci- sions, evaluation and interviewing techniques. The Socratic System (see page ) used by the military was the precursor in one study which applied the method to establishing a ‘~_,,,__‘ A-..“ *7» ..._-_. 115E. N. Brandt, Jr., "Electronic Computers in Medical Education of the Future," ed. by J. M. White, "Medical Education and Anesthesia," Clinical Anesthesia, 1 (1966), Chapter 13, pp. 125-136; and W. V. Slack et al., "A Computer-Based Medical History System," New England— Journal of Medicine, 214 (January 29,1966): pp. 194- 198. ”- 121 simulation to assist students in diagnosis and decision making. While Wayne State University was initiating Pro- ject Pit, an industrial occupation simulation for Detroit inner city youth (see page 87), a second computer simu- lation was available to teach diagnostic skills to begin- ning psychiatric residents and to pool case material for didactic requirements.116 117 indicated during a confer- Lysaught and Jason ence in June 1965, that computer simulation requires the input of individuals from other disciplines, not only medicine, to perfect these packages. These specialty inputs are considered necessary in order to use and develop self instructional material. ‘The design of COMPUTEST, a programming language, has permitted users to simulate both the interviewer and the patient behavior within the frame- work of an initial psychiatric interview. Those simulated 116E. W. Fonkalsrud at al., "Computer-Assisted Instruction in Undergraduate Surgical Education," Surgery, 62(1) (July, 1967), PP. 141-147; and J. L. Grisell 33 al., "Teaching Diagnostic Strategies with a Computer," Journal of Medical Education, 42(3) (March, 1967), p. 275. 117J. P. Lysaught and H. Jason (eds.), Self- Instruction in MedigalEducation (New York: University of Rochester, Rochester Clearinghouse of Self-Instructional Materials for Health Care Facilities, Proceedings of the Second Rochester Conference, June 24-26, 1965). 122 interviews have been used for instruction and as validation for certain theories of interviewing.118 From 1968 to 1970, the literature has identified three main areas of computer application in simulation, which were diagnosis, evaluation and continuing (life-long) education (see page 74). With respect to diagnosis, sufficient strides were evident to indicate an improvement in the handling of information and an extension over infor- mation areas which were simulated. A transition has been apparent whereby the computer has been able to be programmed to maintain case histories, offer and execute a choice of diagnostic solutions and to include a battery of numerous laboratory test data. The master program incorporated all of this stored information and combined it with student's responses to provide an evaluation mechanism and expanded feedback feature.119 118J. A. Starkweather, "COMPUTEST: A Computer Language for Individualized Testing, Instruction, and Interviewing," Psycholo ical Reports, 17(1) (July- December, 1965), pp. 22 -237. 119A. Budkin and H. R. Warner, "Computer-Assisted Teaching of Cardiac Arrhythmias," Computers and Biological Research, 2(2) (October, 1968), pp. 145-150; and J. P. Hubbard 22 al., "Computer-Based Evaluation of Clinical Competence,“—ACEP Bulletin, 11(10) (October, 1970), PP. 502-505. 123 Apter120 in 1970 reported a computerized simulation package which was designed for both diagnostic and research use. While serving to compliment the requirement of diag- nostic studies with students, a special research provision was incorporated to help physicians in clinical practice and research to clarify their understanding of a clinical problem. In this vein the computer was able to assimilate information and accepted solutions on a number of con- ditions. Based on the particular contingencies of the research problem, the computer then would project a selected number of probable solutions for researchers to first con- sider. Within continuing education, the University of Oklahoma has described a computer application employing simulation as a tutorial program on emergency resuscitation techniques, as part of the clinical anesthesia sequence. When coupled with instructional television, surveys indi-ated cated student's (continuing) positive perceptions of those modes, as compared to pure programmed instruction.121 120J. T. Apter, "The Analog Computer as a Teaching Aid in Medical Practice and Research," Computers in Biology and Medicine, 1 (January, 1970), pp. 133-140. 121W. G. Harless ag‘al., "Computer Assisted Instruction in Continuing Medical Education," Journal of Medical Education, 44(8) (August, 1969), pp. 670-674; and A. W. Nunnery, 1"Computer-Assisted Instruction of Medical Students," Southern Medical Journal, 62(12) (December, 1969), p. 1542. 124 During 1971 a continuation of diverse applications to medical situations was evident. An attempt to portray a simulation under computer control was announced by Baker.122 In respiratory mechanics the computer had been programmed as a control mechanism to demonstrate properties of the larynx, trachea and bronchea. The problem, being researched at the time of publication, was how to program the computer to effectively simulate the mechanical mbve- ments of each of these sections during well and diseased states. A premise was posed that the transition piece from the computer to effect mechanical movement would involve mathematical relationships. Possibly as an extension and refinement of the work of Apter and as an attempt to better satisfy the desires of continuing education, a package was developed as a consultation assist for physicians and students in managing patients with acid-base and electrolyte dis- orders. In the development of this simulation, a discussion ensued which acknowledged the fact that computers could compliment the human information processing system.123 122A. B. Baker, "Analogs of Respiratory Mechanisms," International Anesthesiology Clinics, 9(2) (February, 1971), pp. 39-640 123H. L. Bleich, "The Computer as a Consultant," New England Journal of Medicine, 284(3) (March, 1971), pp.*14l-l47. 125 Up to this point, little has been said in this search about the fabricator of simulated patient histories by the computer. As a logical step in that direction, Harless ag‘al.,124 in 1971 described the Computer-Aided Simulation of the Clinical Encounter (CASE) system in which enough real patient information had been collected to allow the computer to be programmed and instructed to fabricate new patient histories from the interaction of the vast stores of real patient information. To effect the fabri- cation the CASE system was coupled with the GENESYS, a semi-automatic patient generating system, at the University of Illinois. While the primary purpose of CASE (especially coupled with GENESYS) is to afford the student to play the role of a physician, engaged in decision-making and observ- ing the decision consequences, a cost savings was reflected by allowing the students to access, understand and respond to the program in English. No computer language had to be used by the medical students. Likewise, the medical or sociological background of the simulated patient was revealed to the student in English--not a computerized language intermediary. GENESYS allowed patient CASE his- tory generation by using the vast amount of data available, but in different combinations. The computer made these 124W. G. Harless aglal., "CASE--A National Language Computer Model," Compaters in Biology and Medicine, 48(3) (March, 1973), pp. 227-246. 126 combinations--not requiring complete manual synthesis-- thus reducing the costs for total human manipulation. During the last phase of the regeneration, however, the program did permit any hand tailoring that may be neces- sary. GENESYS and CASE does afford the cost savings of being able for students to study disease management coor- dinated with the objectives of the course through readily available simulated histories. To depend on the natural flow of patients to meet this need would be cost pro- hibitive. The generation of these simulated encounters, according to the authors, has filled the void to provide the apprOpriate evaluation, immediate feedback and trans- fer which may not be available in that students cannot maintain (legally, that is) full responsibility for deliver- ing the complete care with the real patient. Diagnosis implies an interpersonal action which has been considered in the computer program at Stanford known as THERAPY. The package was designed to illustrate psychotherapy interviewing problems in psychiatry. Once the therapist has digested the setting, he then assigns a number to his response and effect of response. Based on the numerical assignment, the computer selects a patient response using probabilities of response and effect as opposed to the usual method of branching, which was felt 127 (a nonempirical finding) to more closely simulate the 125 Even though probability was used interview situation. to determine a patient response, it was still considered a structured response in terms of the student's perceptions of the interactions. At the University of California-San Francisco, a language called PILOT was adapted to accept free responses from students as opposed to a selection from several choices. Diagnostic decision making and evaluative skills were arranged on a student survey. The students were able to enter, in free prose, their questions about history collection and responses as they were their decisions.126 From a comparison of articles, it appears that Bleich in 1972 expanded evaluation flexibility in the computer based consultation program. Originally announced one year earlier as catering to the patient problems, the evaluation package has been expended to include diag- nostic possibilities (branching) therapeutic recommendations and precautionary measures and suggestions.127 125R. G. Hillman, "The Teaching of Psychotherapy Problems by Computer," Archives of General Psychiatry, 25(10) (October, 1971): pp. 324-329. 126M. Kamp, "Evaluating the Operation of Inter- active Free-Response Computer Program," Journal of Bio- medical Systems, 2 (Winter, 1971), pp. 31-44. 127H. L. Bleich, "Computer-Based Consultation," American Journal of Medicine, 53 (September, 1972), pp. 285- 291. 128 An initial treatment of computerized simulation in public health has been developed at Cornell University. The simulations were devised to supplement the teaching of epidemiology to medical students studying public health and epidemic control. The interactive simulations were used to expose students to realistic epidemic situations and permit them to experiment with control strategies. Two of the epidemic packages have been named MEASLES and INFLU.128 During 1973 the literature seemed to abound with findings that computer simulations were very appropriate to a number of applications in medicine. The publications stressed that other educational techniques have not dupli- cated the computers' capabilities and that this form of simulation has been effective in teaching difficult prob- lems and objective skills and filling the void when there is a lack of trained medical education personnel. With these potentials, including a study on the student psycho- logical implications, this indicates that the peripheral effects of computer simulation in medical education have come under study.129 1'28R. Swain et Ll., "Epidemic Simulation for Train- ing in Public Health Management," IEEE Transitions on Bio- Medical Engineering, 19(2) (March, 1972), pp. 120-125. 1296. O. Barnett, "Strategies, Potentials, and Problems of Computerized Assisted Instruction," Physiologist, 16(4) (November, 1973), pp. 621-625; and S. R. Bless and 129 Similar to Warner's study with emergency cardiac simulations for nurses (see page 100), aflcondition change variable has been integrated into a patient-physician encounter simulation at the University of Wisconsin. The added fidelity was induced by the unique capability of this program to change the patient's time, laboratory and phys- ical results. Any one, part, or all of these variables cause the student to reconsider his decisions regarding length of patient stay, cost and/or availability of tests 130 Continued refinements in the simulation and procedures. programs, called CASE and ATS (a tutorial system), were adapted so that free responses in English could be input ' by students. This provision was added on to the CASE sys- tem and the ATS was a separate package developed at the School of Medicine, Cornell University, to be used in con- junction with other diagnostic computerized simulations.131 R. A. Rifkind, "Computer-Assisted Medical Instruction," New York StatapJouaaal of Medicine, 73(18) (September 15, 1973). PP. 2252-2255. 130R. B. Friedman, "A Computer Program for Simu- lating the Patient-Physician Encounter," Journal of Medical Education, 48(1) (January, 1973), pp. 92-97. 131W. D. Hagaman et al., "ATS in Exposition," Computers in Biology and fiEdIEiaa, 3 (March, 1973), PP. 205- 226; and W. G. Harless aE a£., "CASE--A Natural Language Computer Model," Computers in Biology and Medicine, 3 (March, 1973), pp. 227-246. 130 A modified form of free inquiry was announced by McKnown and Barr132 at the University of Illinois. A non- verbal input was available to students through their con- trol of voltage and current levels to the excitable mem- brane simulation of the Hoglin-Huxley model. The main simulation package was PLATO IV by Socratic Dialogue. While it was used in other disciplines, a University of Wisconsin study prepared a bank of evaluation questions to be given to their students in the diagnostic service of the clinic. On command the computer would assist in test construction by formulating a test of over one hundred questions from the bank. While not a simulation in its own right, this related program was used to produce a product (test), which was used in conjunction with other simulation activity.133 134 seems to be one of the forerunners Trzebiatowski in this search who has clearly acknowledged the fact that medical education has come under fire to improve its edu- cation and services. In response to this accountability 132R. McKnown and L. Barr, "Simulation of Excitable Membrane Experiments," Physiologist, 16(4) (November, 1973), pp. 658-668. 133S. E. Sivertson a5 al., "Computerized Test Bank for Clinical Medicine," EducatiEnal Technology, 13 (March, 1973). PP. 38-39. 134G. L. Trzebiatowski and I. C. Ferguson, "Com- puter Technology in Medical Education," Medical Prpgress Through Technology, 1(4) (February, 1973), pp. 178-186. 131 demand, the author has presented documented testimony using the computerized simulation as an example of a tutor, doctor and patient to include other roles. As a tutor the computer has made available advan- tages in preparing instruction, simulating normal human communication instead of computer language as the primary discourse, low cost of system use, i.e., IBM 370/145 avail- ability via one terminal (fifty workspaces) over a lend lease line at a fixed rate of four hundred dollars per month or 55 cents per hour, copy provision for producing material previously entered into memory, editing function to delete, insert or replace words or phrases, fine func- tion for rapid access of needed words and phrases, change command to-correct syntax or spelling errors, student interruption of program sequence to ask questions and a question series format which may be directed to the student for extra insight without manual intervention from the instructor. When the computer is used as a patient, the author identifies the following examples of student learning and resource requirements effecting cost savings: (1) a simu- lation model which aided students to transfer the exposure to a number of situations to the real world before actually experiencing the real situation, (2) immediate feedback to allow the student to evaluate the effects of his decision-making efforts, (3) simulated medical problem 132 encounters which will allow the student to manage it from the very onset, and (4) the reduction of instructor-student contact time, especially during the one-to-one student- simulated patient encounters. Trzebialowski continues to express a justification for using the computer as physician to strengthen the "dual-purpose" concept. The dual purpose refers to this system of approach to satisfy the significant interpretive needs of the licensed physician by supplementing his knowl- edge and to the medical student attempting to learn more of a disease and its ramifications. The author suggests, that in either case, valuable time will be saved due to the computer being able to orderly handle and analyze vast amounts of data into a few concise statements. In many cases by the program suggesting differential lists for decision, physicians and students learn from their input in the computer and/or computer simulation. The program or its simulated program superimposes principles of critical data evaluation through repeated exposure and performance (doing). This activity is an example of the implementation of computer simulators in continuing education and efforts to interface existing retrieval systems with those com- puters handling simulations. Continuing education has to be concerned with unique problems inherent with its clien- tele such as location, hours of access, access to new material, specific requirements and degree of pursuit, to 133 name a few. Educators have been trying to justify the use of computer assisted simulation to meet the exacting needs of these students. One such accommodation has been imple- mented by the Downstate Medical Center of the State Univer- sity of New York and the City University of New York, where certain continuing education requirements are satisfied by the availability of a computer simulation with accompany- ing charts on the diagnosis and treatment of rheumatic diseases. New continuing education students have access to the same complete evaluation packages that accompany the main program. These students enjoy immediate feedback and the correction of errors with explanations all con- ducted in an atmosphere which is conducive to saving (time.135 I 3 Lastly, during this year a proposal was made by Smith136 such that the librarian have the potential to play key roles in the development, monitoring and evaluation of computer assisted simulation programs. Within this context, it has been inferred that the librarian should be 135E. N. Brandt, Jr., "Role of the Computer in Continuing Medical Education," Texas Medicine, 70(1) (January, 1974), pp. 43-48; and H. S. Diamond 23 al., "A Computer-Assisted Instructional Course in Diagnosis and Treatment of the Rheumatic Diseases," Arthritis Rheum, 17(6) (November-December, 1974), pp. 1049-1055. 136L. C. Smith, "The Medical Librarian and Computer- Assisted Instruction," Bulletin of the Medical Library Association, 62(1) (January, 1974), pp. 6-18. 134 instrumental in laying the ground work for the use of com- puter assisted instruction in encouraging the use of on- line bibliographical retrieval systems. From 1975 until the present a persistent trend seems to indicate the expanding use of computers, in part as a provider of simulation strategies for effective learn- ing. This device has been the widest used conveyance of simulation. Likewise, computers provide one well founded solution for accountability. In order to improve the use of the computer even more an internal method of simulation feasibility was presented by Clark 21:. 2.1.: .137 during 1975. In essence the back of successful simulated packages has now become sufficiently large and well defined that this battery of information can be used to compare new simu- lation models for obvious (to the computer, that is) faults. With all of the advantages and disadvantages of most packages stored in memory, in addition to their descriptive and design criteria, a new model (printed, mediated, or inanimate) is immediately verified for any faults within the limits of the information in the memory. In this fashion the accuracy of a model to satisfy its objectives can be determined before implementation. This prototype examination can save the institution many hours 137M. R. Clark a; a£., "Computer Simulation of Biological Models Using the Inners Approach," Computers in Biology and Medicine, 5 (May, 1975). PP. 263-282. 135 of student and faculty energy. The use of terminals, some with their own mini-computers tied in to the main simulator has become more obvious. For example, a recent study was set up to determine the success of a network of terminals in the emergency rooms of five hospitals. Within this setting physicians and other health personnel, under con- tinuing education conditions, could work with computerized simulated patient management cases in order to remain cur- rent with recent practice.138 Having reviewed some of the literature under the multi media heading, it has been found that the increased activity has usually incorporated some type of mannequin (SIMI, GYNNE, HARVEY, Colenbrander Eye Model, Evans Pros- trate Model, HERA, Iowa Eye Model, Bartner Eye Model, and Heart Sound Simulator) or partial mannequin to allow stu- dents to experience a "hands on" situation before encoun- tering real patients. In most cases the evolutionary trend has been to increase the fidelity of these simulations through the use of design and structure considerations, employment of audio and/or visual media or the use of the computer. The evolution has included the incorporation of several of these modes in order to achieve a specific end. The pace of evolution has been parallel to that of the 138E. P. Hoffer, "Computer-Aided Instruction in Community Hospital Emergency Departments: A Pilot Project," Journal of Medical Education, 50(1) (January, 1975): PP. 84-86. 136 audio visual simulations. One consideration should be noted with the range of this literature (1969 to the present). A trend to increase construction and design costs in order to have the inanimate simulator be more responsive to the audio, visual and tactile senses had been evident before 1976. Within the last two years, however, appropriate questions have been posed (some with empirical research) as to whether a fidelity trade-off (with less financial investment in design and construction) could be afforded without a significant decrease in transfer of learning into the real world. Research is needed to resolve this question which may be applicable to the many, many settings available for simulation in medical educa- tion. Simulation centers have been discussed in this literature search since 1971 with contributions from Michigan State University, Queens University and the University of Illinois. Basically, these centers have been designed to provide the following services for the medical student. First, a quiet and orderly place to concentrate on the exercises at hand. Second, a physical layout simu- lating (with some fidelity) the future environment of practice. This has been identified as a potential situ- ation in which foster a learning transfer from the train- ing area to the real world situation. Third, the center provides the environment for educational experiences to be 137 staged and adjusted to meet the readiness, needs and interests of the students. Finally, the center provides a relatively controlled environment in which educational studies can be conducted. At Queens University the center caters to activ- ities in interviewing, history-taking, physical examinations, record keeping, remedial and additional experiences, patient and media interactions, final oral examinations, individual- ized and self instruction and interactions with mannequins. Nursing as well as medical students use the facility.139 At Michigan State University similar activities take place in the simulation laboratory (except final oral examina- tions). Allopathic, OsteOpathic and nursing students gene- rally use the facility. At the University of Illinois, 140 has discussed the Center of Educational Sajid ag‘ai., Development which provides a similar environment to satisfy the purposes discussed above. The researcher identified numerous three dimensional mannequins that the facility houses. A laboratory layout was contrived from the break- down of the simulations into mannequins, electronic and recorded simulations, computer simulations (terminals of 139A. M. Bryans et al., "New Type of Facility in Medical Education: The CTIhiEal Learning Center," Journal of Medical Education, 50(3) (March, 1975), PP. 227-284. 140A. Sajid a; a£., "A Simulation Laboratory for Medical Education," Journal of Medical Education, 50(10) (October, 1975), pp. 790-795. 138 mini computers), self assessment experiences and video interactions. The taxonomy also exists at the simulation laboratories on the campuses in Rockford and Peoria. This concludes review of the evolution of some of the relevant activities within medical education. With the conclusion of this section, the chronological study of media ascendant simulation from the early Prussian war games to that of today is also concluded. The evolution of activities has traced some of the relevant media ascendant simulation of activity from Europe, the United Kingdom and finally the United States and Canada. The second part of this chapter will give attention to the evolution of inter- personal ascendant simulation through the same historical course. Development of Interpersonal Ascendant Simulation As the final part of Chapter III, the treatment of the specific area has been parallel to that of the develOp- ment of Media Ascendant Simulation. TOpical headings are China and Japan, Europe, the United Kingdom and the United States. A direct chronological treatment has been utilized for Europe and the United Kingdom. For the United States, a sectional breakdown has been employed to include dis- cussions of the Military, Business, Education and Medical Education. As previously instituted, the chronological discussions have been continued within each of these 139 sections. Interpersonal ascendant simulation, by limita- tion and definition, has included activities associated with live modeling, role play, games and patient games (when participants role play). The historical development of this specialized form of simulation parallels accomplish- ments within the scOpe of media ascendant simulation. For this reason occasional reference to other forms of simu- lation have been employed to achieve continuity. China and Japan Prior to the war game diffusion into Europe (Prussia), the earliest form of interpersonal ascendant simulation was in the form of gaming, such as gaming simu- lation and/or operational gaming. Gaming simulation pro- cedures have both a venerable and a clearly discernible pedigree primarily relating to war games. "Wei-hai," which 141 to means encirclement, has been estimated by Wilson have originated about three thousand years Before Christ (B.C.). Primarily of Chinese ancestry, it has been traced as the predecessor to the Japanese game called "Go." While not specifically mentioned, Chess was probably a derivative of one of these earlier forms of encirclement games. Prior to the writing of this paper, on January 15, 1977, this researcher learned to play the game of "Go." 141A. Wilson, The Bomb and the Computer (New York: Delacorte Press, 1968). 140 The board contained a grid about twice the density of our checker squares. The chips were round and were available in two shades, black and white. By the rules the more accomplished player accepted the white chips, while I took the black ones. Basically, the rules permitted the place- ment of the chips to compliment a strategy to envelope the competitor. These maneuvers, as the result of a tactic, could be extended to encircle your Opponent in numerous ways only bound by the placement of his chips. The place- ment of the chips was done in an arbitrary fashion, each player drawing from his reservoir of chips. When an encirclement was completed, the encircler could remove those chips that constituted the capture and retain them for a later count. Each player was placed in a position of a role player as the leader of an advancement of troops to take control of a battle area. The placement of chips and the encirclement and capture of opposing chips continued until the one role player runs out. The speed of the game (in this instance about one hour to complete one game) was simply determined by the placement of the chips, in an alternate fashion, by each player on the board. According to the game setting and the feeling of the role players, the tempo of concentration could be established quickly. While role play was involved, this encounter could quite possibly be considered a non- simulation game as it was competitive and abstract to 141 motivate the learning of a set of principles and skills for a particular discipline. Likewise, the act of each player trying to encircle his competitor (enemy) may be considered a simulation. We were working within a gaming Operation, however, the role play still exhibited some spontaneity. Europe As indicated on page 49, it was not until the turn of the eighteenth century that gaming began to be viewed as an important approach to training. In Prussia during the early nineteenth century, two war games were in use. TO recapitulate, the first rigid war game, tended to be more of a decision making process without the use of exten- sive role play. It tended to operate in an environment fostering competition similar to that experienced by checker or chess players. The second type of game employed an increasing element of fidelity as an essential ingredient. These games, by their very nature employed (required) mili- tary leaders and numbers of men. These groups were placed in situations by probability and strict rules. The inter- pretation of the rules was performed by umpires and members of these armies were involved in a role playing process. This performing situation that the game implied sought to satisfy objectives of reinforcing transfer from the train- ing experience to the real life (battle field) situation without the loss of valuable men and equipment. This 142 'Smn-youmoymncndrvboeuothomwmilmmumm mmtomdmdnnmt' Figure 2.--Prussian Role Play War Game.* *J. L. Taylor and R. Walford, Simulation in the Classroom (Baltimore: Penguin Books, Inc., 1972), preface. 143 game was a more complex activity because it relied on more formalized procedures and a greater structure of relation- ships. The behavior and interaction of the players in a game involved competition, cooperation, conflict and collusion but the fidelity usually controlled its pre- scription and limitation. To develop the desired strate- gies, an initial situation was identified and some direction was given about the way the simulation was expected to work. The umpires were usually tasked with this duty. This type of war game was designed to give primary direction to understanding the decision making process as a product of role play. Not an extinct methodology, secondary and tertiary objectives were established to understand the battle model and finally the process which the game itself represents. Even in Prussia there was a growing belief that war was becoming less Of an art and more of an exacting science. The continued search by the military for increased training efficiency led to more widespread use of inter- personal ascendant simulation. This importance remains evident to the present day. In EurOpe, as well as the United States, World War I was preceded by role playing gaming strategies to train leaders in maneuvering capability. 144 United Kingdom As indicated on page 57, a direct progression of events, depicting this country's participation in the transition of war gaming simulation to the west was not easy to discern. With the war game activity being pursued in Prussia, there was a growing belief that war was rapidly becoming less of an art and more of a science. Gaming began to be viewed as an important approach to training. During the eighteen seventies, the method of these games was incorporated by the British Army. The continuing mili- tary search for increased learning efficiency, while reducing the chances of destruction to life and equipment, led to greater and more widespread investment in the tech- nique. This promoted a military situation which has been beneficial from that time until the present day. Within military spheres the activities incorporated by the British, used internally and spreading elsewhere, consisted primarily of simulation gaming. This form of interpersonal ascendant simulation consisted primarily of Operational gaming. This form of interpersonal ascendant simulation is a complex activity because it relies on more formalized procedures and an extensive structure of rela- tionships. Within the military, individuals acting as role players, but usually performing in their trained jobs, worked as individuals or within groups to perform their part of the mission as an executor or decision maker. 145 These activities took place in a homogeneous setting which was prescribed. The prescription was apprOpriately defined by rule systems and methods of procedure. Within these settings the behavior and interaction of the players in a game usually involved a form of com- petition, COOperation, conflict or collusion according to the structure of the prescription. While decision making has its relevancy, the military Operational game is pri- marily designed to interpret the model used as a strategy to complete the mission. The design of the operational game must be critical in building an explicit theory about the referrent system. In this case the referrent system applies to the impending circumstances, which are to be faced by’a 142 'To understand the model confrontation with the enemy. used as the strategy, implies understanding of the con- ditions of Operation, which are representative of the real (battlefield) world with actions and consequences of behav- iors similar to the real battle situation. This further implies a form of evaluation. In the beginning, the component personnel and their groups had little to say with respect to evaluation of battle field effectiveness. 'Over the years, however, this has changed in that even the military has granted 142C. H. Cherryholmes, "Some Current Research on Effectiveness of Educational Simulation: Implications for Alternative Strategies," American Behavioral Scientist, 10(2) (February, 1966), pp. 4-7. 146 143 premise that the learner some recognition to Herron's involved with the simulation should be given the oppor- tunity to evaluate and give input to the training activity so that the total simulation experience can benefit from the learner's assistance. In Britain the business games were a direct out- growth of the activity created by war games and the activ- ities of the American Management Association. As in the United States, all forms of gaming simulation became pOpular through the introduction of the TOp Management Simulation in 1956.144 Within the British contributions, as previously outlined, these games consisted of role players, working as individuals or part of a group, and the appropriate media to help control the movement Of the game. In this instance students would role play their positions within the formality of the gaming procedure. The requirement still exists that the student participant accept a new identity, but display of that identity is tightly con- trolled by the elements of the game. 143L. W. Herron, Executive ActioaSimulation (Engle- wood Cliffs, New Jersey: Prentice-Hall, Inc., 1960). 144F. M. Riccardi a3 al., T p Management Decision Simulation: The AMA Approach (New York: The American Management Association, 1967). 147 These controlling constraints were incorporated into the structure of the game to control direction for decision making opportunities. For example, the British European Airways used a simulation game to train young executives and managers. As with the military, the behav- ior of the players may involve competition, OOOperation, conflict and collusion in business games. While most Of the early games described utilized interpersonal ascendant simulation, their application to education started in 1968 with several landmark activities. In the United Kingdom, education was exposed to simulation with role players through simulations constructed by .business and industry. General educational experimentation in Britain was mildly influenced by American initiatives. Notable studies and applications of role playing simulation coupled with their parent games have occurred in social studies, general studies, history and geography. As previously cited, the history of British activity has not enjoyed the financial backing, both in magnitude and longevity, that is seen in America. In medical education a representative activity at the University of Leeds seems to indicate total involve- ment in utilizing role playing simulation. During 1972 the present course in medical communications was revamped to include the training of actors to perform as simulated 148 patients. These patients were then allowed to interact with the medical students in the form of an interview. Sequences were videotaped and played back for constructive feedback by the class.145 Live model role playing was used in a constructive setting in which the actors could spon- taneously perform, however, not outside of the training area. Each actor assumed a new identity and acted and reacted as apprOpriately as possible. In a pediatric setting, student actors and medical students underwent the interactions necessary according to the given information of the simulation. The students of the communication class as a group found that the experience and its playback were quite relevant in their attempt to understand this inter- action. 4 In the United States, research into interpersonal ascendant simulation was fostered by adequate financial backing from many sources. The United States adopted the idea, along with other forms of simulation, from the British Army before the turn of the century. In this country the military was the first establishment to consider the potential of simulation. The next section addresses these movements in the United States from the military to business, education and medical education. 145R. Meadow and C. Hewitt, "Teaching Communica- tion Skills with the Help of Actresses and Video-Tape Simulation," British Journal of Medical Education, 6(4) (December, 1972), pp. 317-322. 149 United States This section treats the evolution of interpersonal ascendant simulation in the U.S. within four prominent sectors. In military, business, education, and medical education, the treatment has continued to center on live modeling, role playing, gaming and patient games. Those activities carried on during the expression of other forms of simulation have been referenced in the interest of con- tinuing continuity. Militapy.--As previously indicated prior to and between the World Wars, there seemed to be a lull in the discussion Of significant activity pertaining to the use of simulation in the military. However, a build up of the war effort in response to the activities fostered by Germany and Japan, coupled with financial activity to establish a viable program, obviously had an effect on the use of simulation in the military. A primary reason to use simulation in the military was to effect the appropriate learning activity during a reduced time frame without jeo- pardizing lives, equipment and security. As a case in point, this researcher completed several interviews with the Instructional DevelOpment Staff at the Air Training Command (Air Force) during December 1976. The gist of these interviews seems to indicate this approach, with respect to media and role play simulation since World War II. During our involvement in World War II, 150 the United States Government was convinced that the imple- mentation of media, in many expressions, would be a viable method to help effect the training of many student soldiers for the war. A training program had to be carried on utilizing a minimum time frame, while not jeopardizing students' lives nor the equipment with which they were to become familiar. A usual trend would be to use both media and role playing/gaming simulation, when those considera- tions were not thwarted. When simulation was used by business beginning in the middle fifties, this segment of the private sector became wholly involved with develOping and refining the media portion as a state-of-the-art. Most pointedly, the development and refinement of computer hard-' ware (see page 74) added a dimension to simulation to further effect that goal. However, it was quickly seen that pure media simu- lation would not satisfy the exacting requirements of those students beyond the entry level of training. An increment of fidelity was needed to display the human voice, but within the protected realm Of simulation and its original goal. For these primary reasons peOple, usually other students or instructors, provided the human element of fidelity in conjunction with the computer controlled modus Operandi. When the student competencies rose from the entry levels to the more advanced, such that the reasonable 151 probability of injury to life and equipment was lower, then the use of interpersonal ascendant simulation was increased. Countless "simulation exercises" utilizing many individuals and employing different competencies were brought together as components of a working unit. This unit, in turn, would perform a simulation with each person working as a constituent to effect his portion of the mission. These missions may be written to correspond to a plan of attack dictated by the needs of a specific scenario. It would not be uncommon to change the fidelity, extent or involvement of people and equipment to help eliminate boredom and diversify activities (see footnotes 146 and 147). More recently, during the Observations and inter- views of this researcher at the Air Training Command, it was apparent that the military is now employing computer controlled simulations which are pre-programmed, including their variations, to provide diversified activities and incorporate the management feature of feedback integrated with student's personal and educational background. During this researcher's exposure to the School of Applied Aerospace Science several simulations were investi- gated. A high degree of role playing by advanced students was employed during the training Of control tower Operators. Operating as computer assisted instruction, many variations of aircraft approaches were placed into memory. These data constituents were then assembled at the direction of the 152 pilot (role player). The pieces of data were assembled into an aircraft approach, which was then communicated to the student air traffic controller. The pilot would give various pertinent information such as heading, altitude, on board problems, fuel reserve, and weather at.a pre- determined distance from the airport. The controller would pick up the aircraft on the sc0pe, identify it, and, based ' on these criteria, would decide on the best approach and priority for landing (holding pattern or not). The role playing pilot would continuously talk with the controller, responding to his instructions. The sc0pe would provide instant feedback to the controller by pictorially dis- playing the results on each heading instruction and subse- quent aircraft change. In the meantime, the computer would. establish a simulated aircraft on the scope to respond to the problem data and the data of correction furnished by the student controller. Such fidelity items as radar antennas, real aircraft, alerted airport and crash equip- ment and a real pilot in the craft have been eliminated since these items are not necessary and may jeopardize men and equipment during this level of training.146 146Class notes taken in Education 93l-A, Seminar in Instructional Technology: History and DevelOpment (East Lansing: Michigan State University, College of Education. Department of Secondary Education and Curriculum, Dr. Paul W. F. Witt, Instructor, Fall Term (1975); P. Saettler, a History of InstructionaLfiTechnology(New York: McGraw-Hill Book Company, 1968); and Interview with Lt. Col. L. R. Filkins, Maj. B. Rathon, Capt. E. Grace, Capt. W. McLane, 153 The Air Force News Service has cited a case in which the breadth of interpersonal ascendant simulation has been increased in magnitude to satisfy that increment of fidelity. Announced during December 1976, and known as Blue Flag, this constituted a mass simulation involving large member constituents to carry on a mission. Both media and interpersonal ascendant simulators took advantage of natural environments such as terrain, airspace, electronic threat computer simulations and weapons ranges to develOp the fidelity level in the scenarios to require real time decision making. The constituent elements to effect the decision making involved command structure, control devices, communications, reconnaissance and intelligence Operations in a high fidelity threat environment. A number of On line aircraft (F-4, RF-4, F-lOS, C-l30 and KC-l35) were employed. In this instance, the simulation utilized competent individ- uals working in their positions to respond to a problem. East role player used the abilities and equipment at his disposal to work as a part of a large group to simulate a response to a war threat. The simulation was designed such that the jeopardy to lives and equipment was held to a minimum. Real weapons were not activated as this phase of total fidelity was not necessary to generate the feedback and SSG S. Vosberg (Keesler AFB, Mississippi: United States Air Force, Air Training Command, School of Aerospace and Allied Studies, December 5-16, 1976). 154 apprOpriate to evaluate the effectiveness of the decision making effort.147 Business.--In consideration of the interpersonal ascendant, there has been a direct parallel depicting the rationale and justifications for simulation develOpment as there were for other types of simulations found on page . Industry was faced with a task of maintaining a sufficient number of able persons to fill the supply of management positions becoming available. To lure these people from other firms did not solve the problem. An in-house train- ing program was needed to satisfy the problem. While the business world had appropriate funds to carry on such train- ing, the conventional modes, namely intellectual and on-the- job activities were both leaving a measurable void. In 1956 the American Management Association devel- Oped the TOp Management Decision Simulation, a training technique which was designed to incorporate all the desir- 148 This form able traits of the former training methods. of gaming became a pOpular training activity for univer- sities as well as for business and commerce. The attrac- tiveness of the technique, coupled with the buoyancy of 147Air Force News Service, "Blue Flag Exercise Emphasizes Realism," Keesler News, 38(48) (December 10, 1976), p. l. . 148P. J. Tansey and D. Unwin, Simulation and Gaming pp Education (Toronto: Methuen Educational, Ltd., 1969). 155 modern business enterprise, has led to the design of over 250 business games.149 The TOp Management Decision Simulation was a highly competitive device. Primarily an Operating game, the activity was highly complex, relying on more formalized procedures and greater structure in relationships. As in the military, simulated role play was incorporated into the gaming sequences within a prescribed format. While the game did incorporate the definitions of the specific learn- ing functions as operational task items, the required situ- ational stimuli were such that added expense was precluded without interfering with the transfer of learning. The degree of realism was not overly subscribed in order to obtain a replica of the real life situation. Equivalent stimuli were used, in keeping with the later published .150 Likewise, added expense was prOposition by Gagne' necessary for the replication. The games were designed to thrust the student (young executives and managers) into a learning strategy in which the experience of making a decision (and sometimes playing the role of problem givers) was such that a prudent decision would be made to correspond 149P. A. Twelker, Instructional Simulation: A Research Development and Dissemination Activity (Corvallis, Oregon: Continuing Education and ERIC Publication, 1969. 150R. M. Gagne',_The Conditions of Learning (New York, New York: Holt, Rinehart, and Winston, Inc., 1965). 156 to the accomplishment of operational tasks responding to situational stimuli. The students were, of course, respond- ing to these situations to learn the decision making process, while not jeOpardizing the profit structure of the company in the process. The cost of research, design, training, assessment and development for each of these games far out- weighed the cost to the profit structure of an immature decision. The advent of the computer was used to facilitate game accomplishment and this is treated in detail on page Education.--Since 1960 education has incorporated the techniques of simulation. The transitions have been basically handed over from the military and business. In 'the beginning the permeations were slow to start, but increasingly dispersal has been widespread throughout the discipline. This section treats some of the relevant devel- Opments of interpersonal ascendant simulation. References to concurrent, parallel developments in other simulation forms have been made in order to continue to establish meaningful transitory effects and maintain continuity. The reader is invited to reference the section treating the evolution of salient educational activities in media ascendant simulation starting on page 81. While the main thrust for the incorporation of interpersonal ascendant simulation came to education from precedent activities in the military and business, a rather interesting but sketchy form of role play was evident in 157 this country prior to 1960. The origins and development of role play appear to be the most Obscure of the major simulation types, e.g., gaming, live modeling and patient gaming. The obscurity has been suggested to have been due to the very simplicity of role play. Due to the reference as a spontaneous performance of participants, it implied an indignity by the thought that it was a technique having had widespread use. During the 19303 role play seems to have extended into more sophisticated, more overt and more conscious uses, aside from activities in the military. During this time, a growing interest in small group behavior by psycho- logists, psychiatrists and sociologists led to the use of role play as a device for extending research in varied learning environments for human behavior. Conceivably, role play came into use as a form of therapy for those with mental or emotional disorders. Role play was considered instructional during those early years in carrying through the idea in the cause of better personal relationships.151 Role play was given sharp impetus from the develop- ment of drama as a liberating and self-educating activity for pupils in the schools. This feature was quite distinct 151J. Klein, Working with Groups: The Social Psychology of Discussion and Decision (London: Hutchinson and Company, Ltd., 1961); and J. L. Taylor and R. Walford, iamulation in the Classroom (Baltimore: Penguin Books, Inc., 72). 158 and almost Opposite from the normal considerations involved in appreciation of the theater. The mere fact of a school play did not necessarily mean that drama was being used educationally at the institution. Those unwilling intro- verts, who were being urged to do their piece for the good of the institution, were in fact working in reverse of the anticipated effect. Also, in 1940, drama was appearing as regular activity in some schools for the first time and as a result, increasing numbers of drama teachers were coming from colleges and universities to establish the subject in schools in its own right. Teachers used drama material, not only to read plays, but to develop a sense of character and experience to their students. These senses had an affective (value and attitude) rather than a cognitive (knowledge) intent in a majority of the learning settings. The idea of role play became a common one in free form situations in drama and language settings. During the 19503 and 19603, theater in education experienced continued growth through projects sponsored by local repertory theaters, for those schools which were fortunate enough to have such affiliations. These reper- tory theaters visiting the schools nurtured this growth, thus giving tremendous success to this learning experience. The success of these ventures has underlined the general value of drama in the schools as role play remains an 159 instrumentality of its expression, while remaining a teach- ing methodology in many other subject areas.152 A landmark use of interpersonal ascendant (role play and gaming) activities in simulation within education occurred in America about eighteen years ago, as a response to a need for an effective decision making system for school principals. The endeavor became a classic known as the Jefferson Township School District simulation. The study was designed to draw conclusions about administrator's 153 In performance and personality of the participants. addition to the employment of media, role playing, as a functional part of the scenario, was utilized to provide the situational environment for the study of apprOpriate decision making practices. The substance of the simulation used a set of exercises as scenarios, which in part required the participants to role play someone else such as a principal, teacher, community member or school board per- sonnel. In the role Of the principal, the player was pre- sented a situation which afforded him the Opportunity of making a decision. By role playing the student was given the Opportunity to represent his activity with that of the 152J. L. Moreno, The Theatreaof Spontaneity (Das Stegreiftheater) (Beacon, New York: Beacon House, Inc., 1967). 1967); and J. L. Taylor and R. Walford, Simulation in the Classroom (Baltimore: Penguin Books, Inc., l972. 153P. J. Tansey and D. Unwin, Simulation and Gaming in Education (Toronto: Methuen Educational, Ltd., 1969). 160 real world. With a closer match to the real world the level of psychological fidelity will be raised and, hope- fully, the level or accuracy of transfer to the real envi- ronment.154 The Jefferson simulation was designed to cause the participants to become involved in role playing activities, a forerunner to the simulated patient in medicine. The participants had to learn from the consequences (Operant learning) of their behavior and the conditions that became associated with their decision (respondent learning) through the apprOpriate reinforcement. This system caused the participants to learn by doing, the mere essence of the student activity in a selected learning environment. In 1961 Bersh Y. Kersh employed the mechanisms (see page ) of management decision making simulation, with modifications, for pre-service teacher training. Utilizing media to provide the situational givens, the student was asked to role play a teacher. Once the class situation was displayed by the media, the role playing student was required to make a decision to correct or improve the setting. Mediated feedback (reinforcement) sequences, which were keyed to the type of decision, were shown. By having the student assume the role of the 154P.A. Twelker, "Classroom Simulation and Teacher Preparation," School Review, 75(2) (February, 1967), pp. 40-43. 161 supervising teacher and make management decisions accord- ingly via a simulation sequence, an efficient and effective method of converting learning theory to practical appli- cation settings has been realized within the approximation of real life. With elementary research beginning in 1962 and culminating ten years later in a viable program,.Inter- personal Process Recall (IPR) was develOped at Michigan State University by Dr. Norman I. Kagan. IPR is a training program designed specifically to enable people to learn to be more effective in their interpersonal communications, while having a positive influence on human interactions. IPR originated and still maintains instructional formats in interpersonal skills through the use of filmed demon- strations with the client which are then played back to the client in the presence of an interrogator for investigation. This interaction was designed to facilitate a specific, yet dynamic, interpersonal task. In an effort to confront professional clients with their own reaction to emotional stimuli, actors were trained to simulate the affective films previously used. Employing role play within con- .straints, these simulators were trained to act out the emotional stimuli previously designed. The role player was placed into an interactive session with the client. While this interaction was progressing, the entire episode was videotaped. During the videotape replay, the client 162 was able to observe his feelings and reactions toward a trained role player. A trained inquirer or interrogator was present to help the client participant recall his feel- ings and hopefully learn by discovery the affective con- siderations of the videotaped session.155 In part, the interaction of the client with the trained actor finds a justification for learning within the contextual response simulation posed by Twelker. The client is now practicing a role, which he currently has, e.g., counselor. In this role performing position the objective has been the reinforcement of those affective feelings in the form of a transfer from the training experience to the real life situation. Indirectly, the actor was enacting a life like response, which was the affect of his limited training to portray the conditions 156 of the part. An effort to depict a closer representa- tion of the real life situation, by using live actors to 155N. I. Kagan and P. G. Schauble, "Affect Simu- lations in Interpersonal Process Recall," Journal of Psy- chology, 16(4) (April, 1969), pp. 309- 313 (a); . I. Kagan et Ll., "Interpersonal Process Recall," The Journal of Nervous and Mental Disease, 148(4) (April, 1969), pp. 365- 374 (b); N. I. Kagan, Can Technology Help Us Toward Reli- ability in Influencing Human Interaction?", Educational Technology: (February, 1973), pp. 44- 51; and Office of the Educational Development Program, Educational Development at Michigan State University (East Lansing: Michigan State University, Author, No. 7, Spring, 1975). 156P. A. Twelker, Instructional Simulation: A Research IDevelopment and Dissemination Activity (Corvallis, Oregon: Continuing Education and ERIC Publication, 1969) 163 portray the affective feeling instead of film or other media, has represented an attempt to affect a better transfer of learning to client learner by the design of the IPR.157 Nurses and physicians were exposed to a system in which these students were asked to role play and live model a patient with a neurological disability. Conducted through the Department of Rehabilitative Medicine at New York Medical College, students were asked to simulate this patient by having them walk and talk under the conditions of a distorted sensory flow. Fidelity was enhanced by using a tape recorder with a delay speech feature. When the speech was delayed for a portion of a second, then the resulting product was distorted so as to portray a case of stuttering. Lateral rotation of the visual field was simulated by a fellow student wearing special goggles to produce the loss Of balance and ataxic gait. These media simulations, in addition to the role playing of the gait and imbalance gestures by the students, served to impress the entire group of the physical disability caused by this malfunction. This experience was further intended to help students be able to establish and maintain a more adequate rapport with real patients who have these disabilities. 157P. A. Twelker, "Classroom Simulation and Teacher Preparation," School Review, 75(2) (February, 1967), pp. 40- 43; and B. Y. Kersh, Classroom Simulation: A New Dimen- sion in Teacher Education (Monmouth. oregon State System ‘Singher Education, Teaching Research Division, 1963). 164 This activity suggests that a contextual response simu- lation was justified as the students were asked to simu- late by role play with media assist for added realism to the situational stimuli. A reinforcement was sought to transfer the learned affective attitudes for this type of patient to the real life situation.158 During 1969 Beck and Monroe seemed to extend pref- erential treatment to the definitions of various simulation types, design considerations, research and evaluation. While their definitions indicate an increase in the degree of formalization and operational constraints as one pro- gresses from role play to gaming, there seems to be an impression that those types of interpersonal ascendant activities can be used with considerable overlap to accom- modate a particular situational strategy.159 Completed in 1972 the National Special Media Insti- tute prepared the Instructional Development Institute, which was designed to, in part, the nine celled model as an expedient to the employment of a systems approach for 158A. J. Dinnerstein and M. Lowenthal, "Teaching Demonstrations of Simulated Disability," Archives of Physical Medicine and Rehabilitation, 49(3) (March, 1968), pp. 167-169. 1591. H. Beck, Some Dimensions of Simulation, a paper presented at the Symposium on Simulation for the American Educational Research Association (Orange, Califor- nia: Bruce Monroe and Insgroup, Inc., February, 1969); and I. H. Beck and S. Monroe, "Some Dimensions of Simulation," Educational Technology, 9(10) (October, 1969), pp. 45-49. 165 the management and implementation considerations for the solution of instructional problems. Within this forty hour exposure, the designers have incorporated several simu- lation exercises, one of which is the Innovation Inter- action Game. The game incorporates the student (participant) body to carry out the scenario of situations in the form of a role play. The participants display their affective inclinations according to a set of rules to satisfy the Objectives of the game. The role play incorporates a somewhat spontaneous performance on the part of the stu- dents in an effort to have the participants realize the affective feelings with respect to the frustrations and communications deficiencies inherent in a committee.func-I tioning. As in the early war games, the referees are available to facilitate the game movement and to make sub- jective decisions during the group role play. This opera- tional game proceeds according to surface rules, while the rules for winning are deliberately hidden. During the game clues to the hidden rules are provided by the referee. The role play is stopped by the referee at a strategic time in order to debrief (feedback) and explain a greater number of the hidden rules. Motivation has been enhanced by the inclusion of a quality point system for an effec- tive instructional program.160 160T. E. Harries, Innovation Interaction Game, Unit 3, Module 2, Of the Instructional Development Institute produced by the National Special Media Institute, 1972. 166 Within a definition of role play exhibiting the interactions of interpersonal process recall, a series of mediated (televised) simulations was developed at the University of Pittsburgh to help nursing students seek the apprOpriate identification and care of patient needs. Included with the Oklahoma Regional Medical Program, the twenty minute role play situations characterized better, mediocre, and unacceptable nursing behavior. Where the design deviates from the perfected Kagan model is in a short discussion (feedback) session after the role playing activ- ity. This session consisted of the student role player and the nursing coordinator. Their ensuing discussions of feedback were also televised. While the authors refer to this type of simulation being presented to over 250 stu- dents, the design lends itself nicely to a point to point communications dissemination network for remote student groupings. At the conclusion of the televised sequence, the local nursing leaders continued discussion (feedback) with their hands on groups. The design was set up to accommodate the transfer of affective behavior and att- tudes rather than in recognizing solutions (cognitive behavior) to those interactions.161 161D. J. Barlow and J. G. Bruhn, "Role-Plays on Television--A New Teaching Technique," Nursing Outlook, 21(4) (April, 1973), PP. 242-244. 167 Instructional television served as a medium to address the interaction of role play simulation to a large group of peOple, at the Adelphi University. Corresponding to the contextual responsive approach, nursing students were asked to role play a self-selected handicap and interest in a live situation with those classmates in the simulated role of the nurses. Both an affective and cog- nitive requirement were being transferred from the theory mode to the application phase as in a real life situation. The situational context of this role play simulation was designed to instill affective manifestations in both the simulated patient and nurses and cognitive skills in the simulated nurses. This design, in part, demonstrated multi-dimensional nature and a probability to change the course of classroom interaction as the students become aware of their reactions and those of their role play partners and Observing students to their simulated handicaps.162 Effective contributions to instructional problems using role play, live modeling and gaming in education have been varied. Medical education (including only the allopathic and osteopathic disciplines) has enjoyed the 162R. Butt, The Advantages of Simulapion and Gaming as Instructional Dev1ces: Changing Classroom Transactions (Montreal: McGill University, Center of Learning and Devel- Opment. Bulletin 6(3), December, 1974-January, 1975), pp. 1-6; and E. Pasquali and B. Joyce, "An Approach to Teaching Empathy," New York State Nursipg Association Journal, 6(3) (November, 1975): Pp. 10-12. 168 benefits of these forms of interpersonal ascendant simu- lation. The following and concluding treatment of the interpersonal ascendant has been coordinated to address some of the contributions of this form of simulation to medical education. Medical Education.--Some of the relevant applica- tions of interpersonal ascendant simulation in allopathic and osteOpathic education will be considered in this section. To Observe the tradition of continuity, certain facts implying reference to other forms of simulation have been incorporated in addition to the inclusion of transi- tions to other parts of this text. This section has been designed to consider the chronological develOpments of role play, live modeling, gaming, and patient games in medical education. The advent of interpersonal ascendant simulation occurred as an outgrowth of the classroom, teacher prepara- tion and social science simulation endeavors in education. However, one must not rule out the continuing overtones generated by the endeavors carried on in departments of the military and business. With respect to medicine, however, there seemed to be a number of key individuals involved with this threshold. Treatment of these occurrences was chronological by date, but some intertwining was present. The key individual and probably the first to clearly and concisely define the need for patient 169 simulation was David Seegal. As Howard S. Barrows, a noted authority in his own right, explains: since I had not heard of the simulated patient tech- nique prior to our use in 1962, I have frequently been asked how the concept of simulated patients came into existence. This does not seem hard to identify. As a neurological consultant to the Goldwater Memorial Hospital, Columbia Division on Welfare Island (New York City) during 1959 and 1960, I came in contact with David Seegal who impressed me with his dedi- cation and charisma as a teacher. He described how necessary it was to observe a medical student inter- view and examine a patient.163 What Seegal was doing was demonstrating to others that a serious void in medical education was apparent because physician training did not include techniques of inter- viewing. While the literature does not indicate that Seegal used a simulated patient on his service, he did. render the necessary evaluations to his students to per- fect the examination technique and then arranged to pro- vide an environment, whereby students could practice on patients on a repetitive basis, if necessary. During 1962 and 1963, Howard Burrows, then Pro- fessor of Neurology at the University of Southern Cali- fornia, determined a need for better evaluation of the neurological performance of their clinical clerks as a result of poor examinations. At that point Dr. Barrows undertook the task of training a subject who previously had been used to film techniques of the neurological 163H. S. Barrows, Simulated Patients (Springfield, Illinois: Charles C. Thomas, Publisher, 1971). p. v. 170 examination. The subject was trained to role play and live model on a simulated format certain signs of neurological pathology. Working with Abrahamson, a rather high level of fidelity (physical, at least) was achieved in an enacted role performing situation through the use of staged clinical facilities with role playing and live modeling patients. As a result of the success Of this innovation, the term programmed patients was introduced into the literature by 164 Barrows and Abrahamson to be changed to the term patient 165 simulators in 1968. Using programmed patients as a tool for the evaluation of the performance, provide student guidance and determine teaching effectiveness. While these activities were Considered a pioneer study to foster further research in this direction, an important conclusion was drawn: Not only does this technique avoid the problems incurred when an observer is present, it offers the far more important advantage of guaranteeing that the patient is constant for all students being tested. Thus, faculty may far more easily determine the strengths and weaknesses of the teaching program through a careful analysis of the types of errors made by students. In addition records of the per- formance by individual students may be readily analyzed for purposes of further individual 164H. S. Barrows and S. Abrahamson, "The Programmed Patient: A Technique for Appraising Student Performance in Clinical Neurology," Journal of Medical Education, 39(8) (August, 1964), pp. 802-805. 165H. S. Barrows, Op. cit. 171 instruction and counseling. While it is true that other techniques of measurement of clinical perform- ance may be used similarly, the virtual elimination of the variable of patient behavior seems to make the use of the programmed patient a most effective evaluation tool.16 Almost concurrently with those early activities of Barrows and Seegal, systematic studies were undertaken at the University Of Illinois, College of Medicine, Chicago, under the direction of Frederick Lewy. Dean Lewy's con- tribution has been stated by McGuire and Solomon thusly: Dr. Lewy's concern for the efficiency and effective- ness of programs of continuing education led them to underwrite the initial develOpment of the first set of branched (design strategy) simulations for the assessment of educational programs and the diagnosis of educational needs and undertook the basic research essential to the validation of simulation teihniques as a method of professional self-assessment. 6 This priority has served as an impetus, in part, for extended work with role play and live modeling by Christine H. McGuire and others at this institution. In 1962 David Seegal and Arthur Wertheim continued to further refine their definition of the problem of observing a medical student interview and student exami- nation of a patient. The authors indicated, "one of the unexpected results of the development of the increasing precise and useful diagnostic measures in the laboratory 166H. S. Barrows and S. Abrahamson, op. cit., p. 802. 167C. H. McGuire and L. M. Solomon, Clinical Simu- lations (New York, New York: Meredith Corporation, 1971), preface. 172 is a significant decrease in the emphasis on the training of the medical student to perform with excellence the average comprehensive physical examination."168 Seegal a; a;., at least touched on the point that an apprOpriate evaluation of the student examination techniques by a com- petent instructor was available. Likewise, the American Board of Internal Medicine Examiners clearly stated the examination technique to be a good cause of failure and that candidates should demonstrate competency in this area before taking the examination for certification. Time has permitted the use of patient simulation to eradicate the failure to be indoctrinated on the sound principles and techniques of the physical examination and patient inter- lviews during the undergraduate (medical) instruction. In 1964 a paramount study in role play and live model simulation was unveiled at the Massachusetts General Hospital by John H. Bowker and associates. A rather complicated scheme of physical devices was used to increase the physical fidelity of the situation to be portrayed by the trained actor. The patient was simu- lating three separate conditions. These were hemiplegia, lower-extremity amputation, and rheumatoid arthritis. Each of these manifestations were live modeled separately. To 168D. Seegal and R. Wertheim, "On the Failure to Supervise Student's Performance of Complete Physical Examinations,” Journal of the American Medical Association, 170(6) (May 12, 1962), p. 472. 173 simulate the hemiplegia a prosthesis was designed (much like an actual device) to help the modeling actor show the abnormal gait to include right-sided spastic equinovarus and hip adduction. The lower-extremity amputation simu- lation was portrayed by the live model actor using an adjustable shank tube. The tube was used to show knee disarticulation by being cut to twenty-five centimeters to allow for greater stump length of the bent-knee posi- tion. The patient model would simulate by beginning with the locked knees and progress to the freely flexed knees position. To model the rheumatoid arthritis state, the actor used his hand. This assist was worn on the hand bilaterally and consisted of a dorsal splint, which molds the wrist into flexion, ulnar deviation and a leather strap, which limits finger motion. The model was designed to restrict hand and wrist movement to a pinch between the thumb and the proximal phalanx on the index finger.169 In incorporating the media aids to enable this actor to role play and live model the three abnormalities, the authors and designers were still enjoying the benefits of a learning experience without the costs of obtaining the patients or moving the students to those patients, the risks to those real patients of having them exposed to a 169J. H. Bowker a3 al., "Disease-Simulation Tech- nics in Rehabilitation Teaching," New En land Journal of Medicine, 270 (January 30, 1964), pp. 2 ’:244. 174 number of students, the inefficiencies portrayed as it would be very difficult to obtain a suitable number of 'real patients with exactly the same abnormality and the inconvenience of patient access and patient abnormality standardization for student exposure.170 During 1968 Howard Barrows, while still at the University of Southern California, continued to refine and expand his work with interpersonal ascendant simu- lation. While continuing to refine the mainstay of his work, that 13, refine models to evaluate the clinical per- formance of third year medical students in the neurology clerkship, he directed other efforts to use live models and their training for anatomy classes.. Within the model format he became instrumental in having models simulate apprOpriate candidates to be used in the learning environ- ment for life long education classes in neurology. His added involvement was with the training of the live models to incorporate the element of feedback (reinforcement) as part of the evaluation activities in large classes or workshOps. Prior to this expansion, role play and modeling actors trained as simulated patients to assist with student 170H. S. Barrows, Simulated Patienpa (Springfield, Illinois: Charles C. Thomas, Publishers, 1971). 175 evaluation had been used just with the junior medical stu- dents clerkships.171 Though it was previously spawned through the efforts of Dr. Frederick Lewy, Christine McGuire announced the incorporation of an evaluative technique for the role playing actor to use. On the Chicago campus of the Univer- sity of Illinois, three situations were designed for use with role play simulation. These situations were used with apprOpriate evaluation mechanisms to have the role players, in part, evaluate the resident physicians taking the medi- cal specialty board examination. While the majority of the evaluations of candidate interaction with the simulator was determined by the physician examinators, the actors were also involved in the composite process. The exami- nations were structured to test the candidate's ability to perform a diagnostic and treatment interviews and partici- pate and effectively carry out a patient management con- ference. When the actors must perform under these con- ditions, a role play with some live modeling was performed. The flexibility of the actor in this situation was reduced. Furthermore, the accurate portrayal of the same criteria for each student had to be as identical as possible. The 171H. S. Barrows, "Simulated Patients in Medical Teaching," Canadian Megica; Association Journal, 98 (April 6, 1968), PP. 674-676. 176 actor operated in a gaming situation in a role play imply- ing some formal restraints.172 As part of a study to analyze medical interview training, role playing was used to validate the Counselor Verbal Response Scale. A group of second year medical stu- dents used simulated patients to make up an interview, which were videotaped. In this study eight role players were used. Their function was to role play problems, which ranged from a nearly married male who feared he had venereal disease, to a Black woman suspicious of doctors and com- plaining of chronic stomach pain, to a pregnant woman with a history of miscarriages. All problems were designed to be enacted with emotional overtones. All simulators were drama students and/or contracted individuals, who had no academic ties with the treatment group--second year medical students. EmplOying a derivative mechanism of interpersonal 173 process recall (IPR) prOposed by Kagan, each student 172H. G. Levine and C. H. McGuire, "Role Playing as an Evaluative Technique," Journal of Educational Measurement, 5(1) (January, 1968), pp. 1-8. 173N. I. Kagan and P. G. Schauble, "Affect Simu- lation in Interpersonal Process Recall," Journal of Counsai- ing Psychology) 16(4) (April, 1969), PP. 309-313 (a); N. I. Kagan 33 al., "Interpersonal Process Recall," Journal of Nervous and Mental Dipaase, 148(4) (April, 1969), pp. 365- 374 (b); N. I. Kagan, "Can Technology Help Us Toward Reli- ability in Influencing Human Interaction?", Educational Technology, (February, 1973). pp. 44-51; and Office Of’the Educational Development Program, Educational Development at Michigan State University (East Lansing: MiEhigan State University, Author, No. 7, Spring, 1975). 177 simulator session was videotaped. Following the interview each subject (medical student subjected to the interview) received instructions by simulated videotape recall from those proficient with the recall technique. Then the feed- back was undertaken by the medical students and others in the form of being involved with the reactions, feelings, and thoughts of each medical student during that student's observations of his previously videotaped interaction with the role player in an interview. Using interpersonal ascendant simulation (role play), the medical student learned how to establish a relationship with a simulated patient in a situational setting to make the patient feel comfortable and to be more sensitive to the patient's particular problems.174 During the period from 1967 to 1969, salient refine- ments in the use of interpersonal ascendant simulation in the form of role play were evident in interviewing tech- niques and management decision encounters for evaluation of problems solving skills. McGuire and associates had established a simulation design whereby physicians and patients would meet. Conducted as a participant simulation, role play was used by members of the game to accommodate 174A. Resnikoff, The Relationship of Counselor Behavior to Client Response and an Analysis of a Medical Interview Training Procedure Involving Simalated Papiants (East Lansing: Michigan State University, College of Edu- cation, unpublished doctoral dissertation, 1968). 178 a scenario calling for the student physician to problem solve the given of a simulated role play patient. Once the given information had been portrayed to the student physician, then he was expected to utilize his management theory previously learned in order to arrive at a viable solution for the patient's medical problems.175 Working at the University of Oklahoma School of Medicine, Froelich and others develOped a course employing simulation as an instrument to teach effective interview- ing techniques. This course seemed to indicate an early attempt to integrate the newer simulation techniques with previously accepted student-real patient encounters to broaden the learning experience. Students were exposed to observations of skill and interviews, to the interviewing of real patients and to the performed role play and inter- acted with programmed patients. In this sense, the pro- grammed patients performed role play in accordance with the Operational format of the game.176 At the University of Colorado, a comparison study was initiated using role play to simulate mothers. The 175C. H. McGuire and B. Babbott, "Simulation Tech- niques in the Measurement of Problem Solving Skills," Journal of Educational Measurement, 4(1) (Spring, 1967), pp. 1-100 176R. E. Froelich, "A Course in Medical Inter- viewing," Journal of Medical Education, 44(12) (December, 1969). pp. 1165-1169. 179 objective of the study was to determine the ability of both first and fourth year undergraduate medical students to conduct a pediatric interview. Women were taught to role play the mother of a child with an organic disorder. The scenario also called for the inclusion of psychological and/or interpersonal problems. The students then inter- viewed the simulators on videotape. While it was important for the role play to be as identical as possible for each student, the students employed different tactics to elicit their information. The first year students generally asked fewer leading questions. However, they were able to secure more information about the interpersonal aspects of the problem. The fourth year students were able to obtain more factual and organic information. Thus by using inter- personal ascendant simulation, a contradition was estab- lished to the then long standing assumption that a medical student's ability to conduct a pediatric interview was develOped during his years of training.177 During 1970 an interesting proposal was aimed at medical educators as a solution to meet the current demands on practitioners. The author approaches basic philosophical questions by prOposing the construction or inclusion into the curriculum of procedural knowledge as a realistic 177R. Helfer, "An Objective Comparison of the Pedia- tric Interviewing Skills Of Freshman and Senior Medical Students," Pediatrics, 45(4) (April, 1970), pp. 623-627. 180 approach to the study of medicine. By the inclusion of art and philOSOphy the author proposes an adequate coverage of the theory and science of the methods and grounds of medical knowledge with reference to its limits and validity. The decision finds laudable, interest in a player interaction and Operational gaming as viable forms of interpersonal ascendant simulation that are suggested as part of the instrumentation of the procedural model.178 Schneider and DePerrot have pointed out, in their presentation in defense of role playing, that the doctor- patient relationship has two characteristics. These are irreversibility and decision making. Their context serves to point up the advantage of role play as a representation of these characteristics in the environment of the doctor' patient relationship.179 The elements of irreversibility and decision making in the doctor patient relationship were shown to be further enhanced by Bamford at the New York Medical College. The evaluation of students was conducted by using role playing patients within a game operation to reveal marital and/or 178G. DeLOdzia, "Procedural Training: The Next Step in Medical Education," Journal of Medical Education, 45(6) (June, 1970), pp. 421-423. 179P. B. Schneider and E. DePerrot, "Role Playing as an Instrument for Teaching and for Research into the Doctor/Patient Relationship," Psychotherapy and Psychoso- matics, 18(1) (January, 1970): PP. 90-99. 181 sexual problems. Due to the nature of the scenario, the designers of the simulation thought it best not to tell the students that the patients were simulating the con- dition. This affected the training environment for the actor and the setting of the interview. The setting had to be within a very real enclosure to promote the confi- dentiality that the student physician would expect. Feed- back (reinforcement) from the simulators had to be delivered through the instructor to the student.180 Thus far, the activities of these experimenters and others have indicated that a closer review of the uses of interpersonal ascendant simulation reveals advantages for education. As indicated by Barrows,181 role play, Operational gaming and live modeling have allowed for better control of learning since a complex task can be presented for instruction in graduated segments keyed to the level of student learning. The duties the subjects perform in order to learn are the same in real and simu- lated instructional environments. Barrows contends that the similarities are so close that there should be very little difference in the amount of learning necessary to 180J. C. Bamford, Jr., "The Simulated Patient in Clinical Teaching," Journal of Surgical Research, 11(11) (November, 1971), pp. 563-569. 181H. S. Barrows, Simulated Patients (Springfield, Illinois: Charles C. Thomas, Publisher, 1971). 182 succeed in either the real or simulated situation. This difference can be equated in terms of participation obser- vation of simulated versus real patient-physician inter- action. A case in point occurred at the University of Geneva where Barrows was a participant observer at repeated neurological clinics. At one of these clinics, Dr. Gauthier presided over a presentation using a simulated trained patient in role playing. After the presentation the good Doctor announced that his patient was simulating the abnormality and had been trained to do so. The partici- pants were surprised as they had been fooled by the simi- larity to the real abnormality. The margin of difference was very small indeed. During the year 1971, more structure and formality was displayed in the designs Of simulation schemes to teach interviewing techniques. In this context, a year long course in patient interviewing was established at the Bowman Gray School of Medicine. The objectives included physician self-awareness and sensitivity to patients and understanding of the emotional components in illness. One of the instruments used to carry out these objectives was role play. The patients were instructed on the emo- tional aspects of the illness they were to portray. The object of this course was to place the theoretical 183 constructs of affective behavior into an environment to promote practice action.182 While Dr. Kretzschmar was still located at the University of Utah the doctor-patient interview training was incorporated into the pelvic examination sequence. Professional patients were taught to role play the scenario. These role players then would scenario as a simulation to teach interpersonal skills (interviewing for history) needed in the gynecological interview. These interactions were audiotaped for use by the instructor and simulated actions were audiotaped for use by the instructor and simulated patient to teach and reinforce specific inter- viewing skills. Dr. Kretzschmar saw the need to implement the Patient-Physician Rating Scale. This instrument pro- vided a means for the simulated patient to provide feedback to the student on established time schedule. During exami- nation sessions, teams of simulated patients would work to evaluate, provide feedback (reinforcement) and teach interviewing and examination skills to the students.183 1820. M. Kayes 33 al., "Preparation of Medical Students for Patient InterVIewing," Journal of Medical Education, 46(10) (October, 1971), pp. 863-868. 183R. M. Kretzschmar, Teaching Program Review (Ogden: University of Utah, College of Medicine, Steering Committee for COOperative Teaching in Obstetrics and Gynecology, Newsletter NO. 2, January, 1971). 184 At the conclusion of 1971, Dr. Jack L. Maatsch, at Michigan State University, proposed the concept of the patient game. The simulated patient incorporates the principles of role play, live modeling and player inter- action and basic learning axioms to devise a practical and more cost effective method of teaching. When first designed, the method was applied to teaching diagnostic and patient management fundamentals in the classroom. The idea was contrived from the use of simulation by the National Aero- nautical and Space Administration, the military establish- ment, and business. These organizations had used both media and interpersonal ascendant simulation to teach stu- dents very complex skills in which they attained a high degree of proficiency before being allowed to practice those skills in real life situations. The role play may be performed by peers or trained actors. The patient game has been used to promote learning and retention of what was previously learned, transfer of learning and under- standing. The games satisfy these criteria within the bounds of an economic and a cost conscious Operation. The overall design of these games complies with Gagne's guidelines for the design of simulations. In part, this approach requires the definition of learning functions in terms of specific Operational tasks and situation stimuli that are relevant to the tasks of the simulation design. These games use situational stimuli which are not all an 185 exact replica of real life, however, they use equivalent stimuli as much as possible. These designs comply with Gagne's contention that a scheme need not be the exact physical duplication of real life Since duplication does not guarantee maximum transfer of learning. Patient games capitalize on increased psychological fidelity and reduced physical fidelity. A number of patient games have been designed to include Abdominal Pain, Box-Interpersonal Ascendant Simulation, and Gastro Intestinal Bleeder as of 1974.184 The mechanisms of interpersonal process recall (IPR) were incorporated into the development of role play- ing in simulated interviews at the University of Dundee. The study utilized a doctor, who was an experienced prac- titioner, and an actor who was trained to role play a patient with a specific symptom of a problem. Inaambi- ence of high physical fidelity the objective was to video- tape the interaction. A concerted effort was made during replay to develOp an apprOpriate observation schedule to objectively note different aspects of the performance of the physician patient interaction. Records of various interviews were compared to assist in develOpment of a 184J. L. Maatsch, An Introduction to Patient Games: Some Fundamentals of Clinical Instruction (East Lansing: Michigan State University, Office of Medical Education Research and DevelOpment, 1974); and R. M. Gagne', Th3 Conditions of Learning (New York, New York: Holt, Rinehart, and Winston, Inc., 1965). 186 training model for medical students specializing in family practice.185 Fred C. Tinning directed an empirical study involv- ing first year osteopathic medical students at Michigan State University which was completed in 1973. A comparison was designed in order to investigate simulated (role play) and real clinical training variables in performing a neuro- logical examination. In treatment groups, student atten- tion was given to learning psychomotor skills, affective behaviors and cognitive knowledge. Finally, a measure of clinical competency was used to evaluate the performance of the subjects during the neurological history and physical examination. Tinning's study used eight individ- uals working as simulated patients. Each patient pOrtrayed one neurological problem and was taught how to give detailed reinforcement to the student. Both college and noncollege personnel were used. The role play initiated by the simu- lators was within the dictates of the design and performed within Operational constraints. The results revealed that role play provided students with an Opportunity to vary their behavior, make decisions and solve problems in a positive environment free of distractions. Interpersonal ascendant simulation, in part, enabled newly learned 185A. Morrison and M. C. Jones, “A Procedure for Training for General Practice,” British Journal of Medical Education, 6 (June, 1972), pp. 125-132. 187 critical behaviors of the students to be transferred to real clinical settings.186 By the close of 1974, the work of Dr. K tasc r done at the University of Utah during 1971 has b incor- porated into the curricula elsewhere. Between 1971 and 1974 Robert K tzschmai moved his employment from Utah to the Universi y/of/lOwa. With the culmination of work by Froelich at the University of Oklahoma and Kretzschmar at Utah, the literature indicates the acceptance at several other medical schools of experimentation with role playing patients to teach and evaluate the pelvic examination pro- cedure. Godkins ag’ai.,187 reviewed this application of interpersonal ascendant simulation at the Universities of Iowa, Oklahoma, Utah and Washington by Froelich, Kretzschmar and Louis Vontuer. The use of formative and summary evalu- ation procedures has become more extensive with each application. For the first time in this literature search, the use of simulated (role play) patients was employed to 186F. C. Tinning, An Experimental Study Investi- gating the Effects of Real and Simulated Clinical Tra1ning on Psychomotor, Affective, and Cognitive Variables During Real Clinical Performance of First Year Osteopathic Medical Students (East Lansing: Michigan State University, Depart- ment of Counseling, Personnel Services, and Educational Psychology, 1973). 187T. R. Godkins a§_al,, "Utilization of Simulated Patients to Teach the Routine Pelvic Examination,“ Journal of Medical Education, 49(12) (December, 1974), pp. 1174- 1178. 188 teach and evaluate the pelvic examination to physician assistant students at the University of Oklahoma. In this perspective, the use of interpersonal simulation enabled the realization of some refined learning advantages but also facilitated specific savings in a reduction of spe- cific contact time. The use of simulated patients was a teaching ele- ment afforded physician assistants at the University of Oklahoma, in 1975 the use of simulated patients to maintain more autonomy was identified. The use of simulated patients as teachers of specific procedures was carried on at the Michigan State University. In addition to the training necessary for these role play patients, additionaljmore involved training became necessary to enable those patients to completely carry on the activity without the aid of physician instructors. The program was designed to simu- late patient mothers who could teach pediatric interviewing techniques to junior year medical students. These simu- lated mothers had to role play the apprOpriate scenario to convey the cognitive knowledge and affective feelings appropriate to interviewing mothers about their children. Real mothers were screened, trained as interview respondents and then instructed on how to give reinforcement to stu- dents. What made these scenarios unique was that the case materials were actual medical occurrences, which the patient mothers had experienced with their own children. 189 Incorporating a method derived from the interpersonal process recall procedures, the interactions were videotaped while the students interviewed the trained mothers to obtain the pediatric history. During replay the mothers would give constructive feedback to the student. The find- ings revealed, in part, that nonphysician, simulated patient mothers were as effective as pediatrician instructors in assisting students to learn the interview process. In terms of student learning benefits and resource requirements effecting costs, the authors made the following observations: (1) the patient mothers devoted their efforts to appraising their students on interviewing matters, not content concerns as did the physicians, during feedback, (2) when the mothers talked, the medical students conversed more and were given more positive feedback about the student's skills, (3) the instructor time lost to subject them to the same training for giving interviewing instructions had no monetary com- parison to that of the patient mothers. The cost only approached twenty to twenty-five of the physicians salary, (4) the interviewing interaction provided the faculty with much needed information about each student prior to reaching the pediatric clerkship, and (5) patient mothers were just as effective in providing the advanced organizers for students to interview, question, listen 190 and build rapport as did physician instructors at less COSt. 188 189 continued with the basic Johnson and Brown ideas of Kretzschmar at the University of Utah in a study to determine the effectiveness of media versus interper- sonal ascendant simulation. The media approach utilized lecture, film.and GYNNY, the pelvic examination model. The interpersonal aspect incorporated the use of role playing patients who used a programmed Operation to give the same instruction. The object of both approaches was to teach pelvic examination procedures to second year medical students. The conclusions indicated that the interpersonal method was well accepted by the students. The faculty identified their acceptance, in part, by remarking on the added dimension of realism (physical and psychological), which has been included in the study of obstetrics and gynecology. Dr. Fred C. Tinning expressed his research activ- ity (previously discussed on page 171) in the form of a monogragékiThis document has served as an effective 188R. Helfer gt al., "Pediatric Interviewing Skills Taught by Nonphysicians,"_American Journal of Diseases of Children, 129(10) (September, 1973), pp. 1053-1057. 189G. H. Johnson et 31., "Teaching Pelvic Exami- nations to Second Year Medical Students Using Programmed Patients," American Journal of Obstetrics and Gynecology, 121(5) (March 1, 1975), PP. 714—717. 191 dissemination of a review and organization of the concepts from the field of educational simulation, relating those concepts to medical education. It reveals procedures for designing, using and evaluating the effectiveness of simu- lation in medical education. This monograph rigorously testifies to the availability of relevant empirical evidence surrounding the use of simulation within medicine. Within the scope of the publication, salient arguments advocating the use of simulation are backed up by the empirically designed studies to validate the use of instructional simu- lation in the education of medicine.190 In 1976 during the refinement of the systems approach to management, design and evaluation of simulation applications incorporating the interpersonal ascendant a very unique and well founded contribution to the litera- ture was available. Ms. Holly Holdman of Michigan State University develOped a procedural manuscript for the training of simulated patients for medical education. A brief discussion of this writing is included here to accent the relevance of a systematic procedure in prepar- ing an individual to be a simulated patient. Within a sequential format, the author has addressed the criteria for selecting a simulated patient. This 190F. C. Tinning, Simulation in Medical Education (East Lansing: Michigan State University, College of Osteopathic Medicine, Office of Medical Education, Research and Development, 1975). 192 includes avenues of resource for locating a battery of candidates, the selection criteria to be used, the neces- sity of variety and appropriate problem areas to be con- sidered. Addressed to the trainer, who may be a faculty member, the activities of this person are indications of the success of the simulators in performing the simulation. In meeting the needs of the simulation design, the trainer must cultivate the insights and creativity of his actor while continuing to address his attention to the needs of the students. To meet these objectives, the trainer should consider the type-of case orientation, style of interviewing to be used, the inclusion of improvision flexibility, how. the simulated patient should respond to digressing tangents, patient behavior alone and its impending affect on the chosen fidelity and performance vitality. Whether an individual is a professional or a faculty member his role as a teacher of simulated patients and his success at it will be dealt with in the author's discourse on how to compensate for those variables to promote success in the function of the simulation exPerience. Other treatments for consideration in the training and management of these patients are a systematized approach to the training procedure, suggested guidelines for setting the functional limits of the simulators, the need for clear direction, the physical setting and considerations, the establishment and maintenance of simulator performance, 193 the management of the feedback process during all phases of the interaction, the understanding with the student phys- ician and the relevancy of debriefing the actors. The com- pletion of this manuscript includes some cases to address salient points in an overall attempt to lay a solid founda- tion for those interested in utilizing interpersonal ascendant simulation. This contribution has succeeded in filling a void in knowledge of design considerations to facilitate the use of this type of simulation.191 Summary The approach to and depth of this literature search was intended to accentuate the develOpment of interpersonal ascendant simulation as a viable strategy of instructional development in medical education. This development has enveloped the subject at hand within a larger body of simu- lation activity. The design of this search was specific- ally intended to accommodate the rather close proximity of these simulation forms. In that vein, the first part of Chapter III turned its focus on media ascendant simulation in China and Japan, Europe, United Kingdom angfiggi£ed States. To refine and enhance the focus of the treatment the same geographical treatment was afforded interpersonal lng. Holdman, The Training of Simulated Patients (East Lansing: Michigan State University, Office of-Medical Education Research and DevelOpment, 1976). 194 ascendant simulation which formed the second and concluding part of Chapter III. CHAPTER IV ANALYSIS OF THE HISTORICAL LITERATURE The refinement of simulation from its rather restricted use over three thousand years ago to the many faceted applications today has been limited only by the imagination of man. Simulation, as the parent base of an instructional strategy in medical education, has grown many fold in recent years. The activities reported by the contributors to this evolution reveals definite charac- teristics as one progresses through time. The object, therefore, of this section will be to analyze the con- tributors' data used by this researcher when matched with the Selective and Evaluative Criteria. It is hOped that this treatment may further reveal the probable future manipulations of interpersonal ascendant simulation reflected through the trials and tribulations of what has transpired in the past. 195 196 Selection Criteria The following criteria have been used to gather information to answer the eight research questions (see pages 16 or 248): 1. Does the study contribute to the amount of knowledge about media ascendant simulation? 2. Does the study contribute to the amount of knowl- edge about interpersonal ascendant simulation? 3. Does the study identify the apprOpriate discipline and time of application? 4. Does the study provide a descriptive briefing of the instructional problem? 5. Does the study provide a descriptive briefing of the simulation application? 6. Does the study provide a descriptive observation on documented fact or evaluation which was derived from it? 7. Does the study provide other contacts and resources for further inquiry and study to help eliminate collection bias of sole-sources? Evaluative Criteria In order to provide a valid and reliable assess- ment of the historical data, certain evaluative criteria have been used. The following evaluative criteria are recommended for historical research as reported from 197 historian‘s literature and concurred by interviews with researchers in the field on this campus:1 1. Does the contributor(s) speak of the event as being closest to it in time and space, if not an actual observer or participant? Does the contributor(s) demonstrate competence as being most capable of understanding and describ- ing the situation? Does the contributor(s) demonstrate minimal impar- tiality by disallowing omissions, additions or emotional involvement in the event? Does the contributor(s) present the information objectively? While the use of the written word implies skepti- cism on the part of the reader, does the contribu- tor(s) separate the findings from the conclusions? The researcher must have some faith in the written word by acknowledging a possible threat to the professional reputation of the contributor(s), if he/they were caught within the insecurity of non- truths. 1T. E. Felt, Researching, Writing and Publishing Local History (Nashville: American Association of*State and Local History, 1976); and Interviews with J. C. Moore. East Lansing: Michigan State University, College of Educa- tion, Secondary Education and Curriculum, Assistant Chair- person. Counsel held during March, 1978 and S. Chojnacki, Graduate Director. East Lansing: Michigan State University, Department of History. Counsel was held during August, 1977 and February, 1978. 198 In addition the following evaluative criteria were used to investigate those descriptive findings from sources which incorporate empirical designs:2 7. 10. Does the contributor(s) incorporate a design model appropriate for the study to be conducted, i.e., nonequivalent, nesting, crossed, or balanced con- siderations? Does the contributor(s) incorporate the statistics appropriate for the design under consideration, i.e., nonparametric, parametric, univariate or multivariate considerations? Does the contributor(s) incorporate data which is valid for the design chosen, i.e., sampled from right group, populations and done so properly? Is the dependent variable indicative of the vari- able of interest? Does the contributor(s) incorporate reliable data as an issue in the study under consideration, i.e., interrater reliability, subject mortality, objective design, and pre-post test relationships and frequency of administration for proper design? The use of all information, wherever derived, was based on the previous selection and/or evaluative 2Interviews with S. Gitterman. East Lansing: Michigan State University, College of Education, Office of Research Consultation, Research Consultant. Counsel was held on April 5, 1978. 199 criteria. Where possible and practical, primary sources were used. If the contributions met the selection and evaluative criteria, they were entered in the timeline according to the date of publication. Secondary sources were used when the primary contributions exhibited the following attributes: 1. Referred to a source for further clarification. 2. Referred to a resource as an alternative of fostering study of possible significance. 3. Was obtained during a time frame when there was a minimum of published information. 4. Primary sources did not exist. Analysis Procedure In order to complete this task, the treatment adhered to a data display through the establishment of a matrix for each of the eight research questions (see pages 16 or 248). Entitled as Tables 1 through 8 inclusive, each matrix has specifically identified vertical and hori- zontal axes. The horizontal axis is numbered from one (1) to seven (7) for the Selective Criteria and one (1) to ten (10) for the Evaluative Criteria. These numbers represent the ordered presentation of the Selective and Evaluative Criteria starting on page 196 and ending on page 198. The horizontal number is presented in ascending order from left to right of the broadside page for each criterion group. 200 The vertical axis is presented on the left-hand side of the broadside page. This axis incorporates the surname and first and second initial (where applicable) or partial title of all contributors to a particular research question. The names and/or partial titles are in alphabetical order. A number precedes each name or partial title to facilitate cross-referencing to the identical numbered item in the List of References on page 287. The reader may cross-reference to the selected resources in the List of References as a bibliographical source for further inquiry. Each matrix continues on successive pages until completed at the end of the alphabet for the particular research question. The research questions continue in order-- questions 1 through 8, Tables 1 through 8 respectively. The matrix serves as a convenient, ordered, display to reveal the rating system used by this researcher. At the intersection of a given horizontal and vertical axes is a number which represents a judgment based on the Selective and Evaluative Criteria. The purpose of the number serves as a convenient index to the authenticity and validity of the data provided by each contributor as measured against the Selective and Evaluative Criteria used by this study for each research question. Under this design, not all contributors will be included, as not all authors in the List of References 201 were used to prepare Chapter III, Review of the Historical Literature. The design also included contributors who did not direct any information to media and/or interpersonal ascendant simulation. These sources were included for their input to substantiate a cause or effect of a simula- tion strategy. Likewise, some authors contributed wholly or in part to more than one research question, thus those names appear more than once. To facilitate this process, the index numbers with their assigned values are listed as follows: 0 = Insufficient data presented to make a judgment of authenticity and worth. 1 = Marginally sufficient data to make a judgment of authenticity and worth. 2 = Sufficient data presented to make a judgment of authenticity and worth. 3 = More than sufficient data presented to make a judgment of authenticity and worth. Analysis Data The following material, indicated as Tables 1 through 8 inclusive--Analysis Data for Research Questions l through 8--respectively, represents the results of the matrix displayed in an order which conforms to the pre- ceding Analysis Procedure description: As previously stated, the purpose of the numbers will serve as a convenient index to the authenticity and validity of the data provided by each contributor as measured by the guidance of the Selective and Evaluative 202 AucmNonusm cuss measum new uemNonmzmuN .ucmNoNumsm NNchNmNezuN .ucmNonmsmaNuov N N N N N N N N N N N N N o N o o .3 .mNccmm .eN N N N N N m m N N N N N N N N N N .m .N .xomm .NN N N N N N N N N N N N N N N N e N .m .e .oNNemm .NN N N N N N N N N m N N N o. N N o o .e .3 .Nossmm .ON N N N N N N N N N N N N N N N o N .o .o .uumcnmm .eN N N N N N N N N N N N N o N N o o .> .e .mocNunNmm .NN o o o o N N N N N N N N N N N o N .m .N .meem .NN o e o o N N N N N N N N N N N o N .2 .o .smrmua .NN o o o c N N N N N N N N N N N N N .s .n .Nmuda .ON 0 o o o N N N N N N N N m N N N N .e .m .3muoea .m N N N N N N N N N N N N o. N N o o .n .comumoce .m N N N N N N N N N m N N N N N N N .s .N .umoceme4 .N e o o o N N N o o m o o N o N N N .moue newsmmmemz wmoem>c< .m N N N N N N N N N N N N N N N N N .o .o .ubN .e N N N N N N N N N N .N N N N N N N .o .o .une .N N N N N N N N N N N N N N N N N N .o .o .una .N N N N N N N N N N N N N N N N N N .o .o .una .N ON a N N e m e m N N N e m e N N N .02 OHUNB «mauumm Ho mEmz EmuH MNHOHNHU O>Num3Nm>m mwumufiuo O>Nuomamm IIIOIII‘II ‘ .N :oNummso noummmmm New name mNm>HMC¢II.H magma 203 AucmHOHuwsm cane OHOZHM can ucmHOkusmnN .ucmHOmesm NHHmchNmzuN .ucoHonmsmcHuov .3 .o .mmsNorsuumno .ee .3 .NmNmmmo .me .< .chosm .Ne .2 .4 .mcmsum .oe .3 .n .chaum .mm .N3 ..3 .3 .uocmum .NN .NH ..2 .m .uocmum .mm .3 .3 .Nomum .mm .m .3 .Nm3om .mm .3 .o .36330m .NN .m .xooooom .Nm .3 .m .mmmNm .om .N .3 .3onNm .mN .N .3 .3onNm .NN .o .2 .NmNuNm .NN .3 .umHsvaOm .mm o e4 H c: N e4 N c>.H o ech C>r4 Flea o c: N r4 H on o e4 o «4 o Nata C>r4 H r4 o cacu Fara 01¢: ~1<3 H 01cu oacu hiCV olcu OICV OICV OICV oacu o: N cue» oars N oocw oacu N O‘CV oncv N on cu N c744 N oats N 036V N one» H ours N cu N card N och N oacv N o:rn H oacu N cu N OJCV N oacv N Ndcu N osrn N one» N N e4 N cu N oavd 01rd N oqcu ~1cu N cw N N on N cu N cu N cu N 01 N as m cu N on N C» N 01rd H oars H oacv N OJCV N onto N cu o oalq our“ N o¢<3 oars N '4‘0 oarn N PiCV N on N o¢rn o c>cu H para o OICD N cu o och 016“ N on o och Olrfi N on N on .m .m .mcmw>Huc0m .mN 0H m m h m m v m N H h m m v m N H .02 OHDHB HmHuHmm HO mamz EmuH mHumuHHU m>Humon>m MHNOUHHU O>HuomHom .tmscNucoouu.N mNnms 204 AucmNoNNNsm 3833 muozuN new ecoNonmsmuN .ucmNonusm NNchNmumzuN .ucmNoNuuschuos N N N N N N N N N N N N N N N o N .o .mNmNsuem .ee N N N N N N N N N N N N N N N N N .e .3 .3on:3 .NN N N N N N N .N N N N N N N N N N N .3 .3 .3eosmNa .NN N N N N N N N N N N N N o VN N o o .N .3 .mumzmo .oe o o e o N N N N N N N N N N N o N .o .3 .3cmNma .33 e o o o N N N N N N N N N N N e N .s .3 .Nmneoamo .NN N N N N N N N N N N N N N N N o N .3 .3 .Nmnsooma .NN N N N N N N N N N N N N N N N e N .3 .3 .Nmnsoomo .NN e o o e N N N N N N N N N N N o N .3 .3 .Nmnsoomo .NN e o o e N N N N N N N N N N N N N .3 .3 .3emnmonsuo .NN N N N N N N N N N N N N N N N e N .3 .3 .oooouo .NN N N N N N N N N N N N N N N N e N .o .e .3ommuo .NN e e e o N N N N N N N N N N N o N .3 .mcmuo .33 o o o o N N N N N N N N o N N o e ...:oNumosnm chscNueoo .33 N N N N N N N N N N N N N N N e N .3 .NmsceuncmNoo .NN o o o e N N N N N N N N N N N e N .3 .3 .mNoo .Ne o o e e N N N N N N N N N N N N N .3 .3 .333No .me ON 3 3 N e N e N N N N 3 m e N N N .03 mNuNs NmNuumm No msmz smuN MHHmuHHo m>HumsHm>m mHHmuHNU O>HuOMHOm 1" .cmscHucouul.H mHnme 205 AucmNoN33am 3333 muozuN 3:3 .ucmNoNuusmnN .ucmNoN33sm NNchNmumzuN .ucmNoNuuschuoc o o o o N N N N N N N N N N N o N .o .3 .3333333 .33 N N N N N N N N N N N N N N N o N .3 .30333330 .N3 3 o o e N N N N N N N N N N N N N .N .3 .NNmmNNo .N3 3 o 3 o N N N N N N N N N N N N N .3 .o .mmsNuu .N3 3 3 o o N N N N N N N N N N N o N .3 .a .33NN33N33 .33 o o o o N N N N N N N N N N N e N .o .o .maNNmou .3N o o o o N N N N N N N N e N N e o .3 .3 .echoo .3N o o o o N N N N N N N N N N N o N .3 .3 .303333 .3N N .N N N N N N N N N N N N N N N N .3 .3 ..memmu .3N N N N N N N N N N N N N N N N N N .3 .3 ..mcmmo .eN o o o o N N N N N N N N o N N o o .o .3 .3333 .NN e o o e N N N N N N N N N N N N N .3 .3 .3oNNoouo .NN o o o e N N N N N N N N N N N N N .3 .3 .cmsme33 .eN N N N N N N N N N N N N N N N N N .3 .3 .3333N33303 .33 o o o o N N N N N N N N N N N o N .3 .mNmuusm3 .33 o o o o N N N N N N N N N N N N N .3 .3 .33333333 .33 N N N N N N N N N N N N o N N 3 o .3 .aomonum .33 ON 3 3 N 3 3 e N N N N 3 3 e N N N .03 mHuHB HMHuNmm mo mamz EmuH MHNmuHNU m>HumsHm>m mHumuHNo 0>HuomHmm .3333Nucooun.N mNnms 206 AucoHOHmmsm :mna mHOZHm can eucmHonuzmuN .ucoHOHmmsm NHHmchumzuH .ucmHoHMHSmcHuov .4 .U .GOmGSOh .HHH .: .GOmmn .cHN .3 .30333 .moH ...onm:nozo suH3 m3mH>NmucH .mOH .m .h .oumnnzm .VCH .3 .A .Hm>oom .mOH .O .EN03 .NON .m .m .Hmmmom .00H .m .m .memom .mm .o .3 .cmsNNN3 .33 .0 .b .HHHm .Nm .3 .3 .NNN33333 .33 .3 .3333 .N3 .9 .mOHNHmm .03 .3 .mmeNmm .33 .3 .mmmHNmm .Nm .3 .Ucoaamm .33 N Nara Faro N c: N oat» oat» N c: o c: o O U 0 0 Ed r4 0 caaq F1F4 o c><3 Nat: N —4 o»<: o oa t» c><= 34.4 Nat: c>t3 o t» N oat» N fl1€V N warn H oat» o oat» N t» N 04¢“ N oat» N «urn H oat» o oat» N t: c c>t» C’C» o oa.H oa o NA.H c: o c: c eN 3 3 N 3 3 e N N N N 3 3 e N N N .03 mHuHa HMHuumm No oEmz EmuH MHNouHHU m>HumsHm>m MHNouHHU m>HuomHom .UODGHHCOUII.H mHnme 207 AUCOfiOHMHH—m mafia—H. GHOZHM UCM NUCTHOHMMQWHN sUCTHOfiHHDW hflflflfiflmhflznfld NUCQHOMHMSWCHHOV .3 .3 .33N033333 .NNN .3 .3 .333N33 .3NN .3 .3 .33333 .3NN .3 .3 .chN33N3 .NNN .3 .3 .3333 .3NN .3 .3 .33333 .3NN .3 .3 .33333 .3NN .3 .3 .33333 .NNN .3 .3333 .NNN .3 .3333 .3NN .3 .33333 .3NN .3 .33333 .3NN .3 .33333 .NNN .2 .33333 .3NN .o .3333 .3NN .o .o .3 .33303 .3NN .3 .3 .3033303 .NNN O O O H #4 H +4 N H H M H N N N H H N N 0 Fl O O O N M H N H N N N H H N H O H O O O H H H N H H H N N H N H O H C O C H N F! N H H H N H H N 0-! O H O O O N N N N N N N N N N N N N N N N N N M N N N N N N N N N N N N N N O N N N M N N N N N N N N N N N N N N M N N N M N N N M N N N N N N O N M N N M N N N N N N N N N M N N I"! N N N M M M N N M N M H H M H O N H N N N N N N N N N N O N 0-1 H N N N N M N N N N N M N M N N N N O N M O M N N N H N N N N O O N .C O N N N N N N N H N N N N N H H O O N N N N N N N N N M N M N N N N o 0-! O O N N N N H H O O C O C O' O .H N M O N N N N N N N N N O O N H P! 0H m m h m m 3 m N H h m m v m N H .02 EmuH wHuHe HmHuumm NO 3532 mHHmuHHU 0>H333H3>m mHuouHNU 0>HuooHom .UmacHucoola.N mNnma 208 Aucmwowmmsm cane muozum 6:3 .ucmfiowmwsmnm .ucmwowmmsm adamcwmumzua .ucm3owmmsmcHuov 3 3 3 3 N N N N N N N N N N N N N .3 .3 .3033333 .333 3 3 3 3 N N N N N N N N N N N N N .3 .333333 .N33 3 3 3 3 N N N N N N N N 3 3 N 3 3 .3 .3333333 .333 3 3 3 3 N N N N N 3 3 N 3 3 3 3 3 .3 .3 .333333333 .333 3 3 N N N N N N N N N N N N N N N .3 .3 .33333333 .333 N N N N N N N N N N N N 3 3 N N N .3 .3 .3333333 .333 3 3 3 3 N N N N N N N N 3 3 N 3 N .3 .3 .3333333 .333 3 3 3 3 N N N N N N N N N N N 3 N .3 .3 .3333333 .333 N N N N N N N N N N N N 3 3 N 3 3 .3 .3 .33333333 .333 3 N 3 3 N N N 3 N N N N N N N 3 N .3 .3 .33333333 .333 3 3 3 3 N N N N N N N N 3 N N 3 3 .3 .3 .3333333 .N33 3 N N 3 3 N N 3 N N N 3 N 3 N 3 N .u .3 .300333 .333 3 3 3 3 N N N N N N N N N N N N N .3 .3 .3333333 .333 3 3 3 3 N N N N N N N N N N N 3 3 .3 .3 .33333333 .333 N N 3 N N N N N N N N N N 3 N 3 N .3 .2 .33303 .333 3 3 3 3 N N 3 N N N 3 N 3 3 N 3 N .3 .3omc3>33 .333 3 3 3 3 N N N N N N N N N N N 3 N .3 .3 .333>33 .333 33 3 3 3 3 3 3 3 N 3 3 3 3 3 3 N 3 .32 33333 3333333 no 3332 3333 mwumuHHU 0>flHMSHM>m 33333330 3>3u03333 .333333303--.3 33333 209 Aucmfioamusm cane «Moanm nan .ucmfiowmmsmum .ucmHOmesm haamcwmumzua .ucmfloflmmsmcHuov .q .0 .mmzom .mha . .mxusom .mha .mummom .vha .mummom .mha z :5 2 ca mask-1&0 .mummom .mwa .z .m .mumoom .Hna ... map on uuommm .mmH .u .m .cmmm .nma .3 .w .>m5mm .mma .m .H .m>amm .qma .¢ .h .mcoumum>o .mma ... mg» «0 mofimuo .Nma .3 .d .wumccsz .HoH .m .anmusz .oma .m .9 .amcmaanz .mma .w .0 .umaaflz .mma .m .Hmucmz .mma OHHOHHOOONHOOHHOO OHHCHHOHONHOOHHOO OHHOHHOHOHHOOI—IHOC OHHOt—IHOHOHHOOHHOC NNNNNNNNNNNNNNNNN NNNNNNNNNNNNNNNNN NNNNNNNNNNNNNNNNN NNNNNHNHNNNNNNNNN NNNHNHNNMNNNNNNNN HNNONOMNNMHOONNHN NHNu—ONONHNNNCONNNN NMNNNNHNNNNNNNNNN ONNCNHHNNMNOOCOOO HHNONHNNNMNOOOOHI—I NNNNNNMNNNNOOOOHN OOHOHNOOONNOOCOOO ONNHNNNNNNNOOOOOO OH m m h m m v m N H h m m v m N H .02 EmuH maufle Hmfluumm Ho mamz maumufluo m>flumsam>m wflumufluu m>wuomamm It," Aft-f'zll. III..- l;!ll.|l[ .I'Il’ll: .UGSGAHGOUII.H manna 210 Aucmfl0fimm§m cane muoznm can .ucmwOHmmzmuN .ucmfloflmmsm haamcfimumzua .ucmfloflmmamcHnov .¢ .n .muozm .mma .m .cflmzm .mma .m .o .uuazmum .vma .o .scmmmum .mma .« .n .uonummsxumum .mma .m .m .>m>fimm .H¢H .m .3oaoxom .oma .u .q .nuHEm .mma .o .suflsm .mma .> .2 .xomam .hma .m .m .comaum>awm .mma .o .m ~muuflnm .mma .m .3 .mumnm .vma .q .q .mcmnm .mmH .o .acam>amm .oma .¢ .nfiflmm .mpa .n .< .uflummm .mna NOHHOOHHHHHONHNOO NCNHOCHHHHHONHNOC NOHHOOHHHOHOHHHCO NCNHOOHHNOHOHHHOO NNNNNNNNNNNNNNNNN NNNNNNNNNNNNNNNNN NNNNNNNNNNNNNNNNN NNNNNNNNNNNNNNNNN NNMMHMNNMNNMNHMNM NNNNHNNNNNNNNNNNN NONNHNNNNNNNNNNNH NNNNCNNNNHNNNOHMv—l NNNNCNNNHNNNNNHMN NOMNNNNNNNNNNNNNN HNNOONOHOHOCHONNO NNNNNNNNNHNNNOONH OH m m b m m v m N H h m m c m N H .02 mange HMfluumm no mamz EmuH wwumufluo m>fiumzaw>m mwumuwuo m>fiuomamm .cmSCHucoont.H manna 211 Aucwwowmmam :mna muozum can .ucmwoflmmamum .ucmflowmusm NNNMGNUHMEHH..ucmNonwnmcHuov N N N N N N N N N N N N N N N N N .m .m .umcumz .NNN o o o o N N N N N N N N o N N o o .N .nmNmz. .NNN o o o o N N N N N N N N N N N o N .m .N .umNmncoch> .NNN N N N N N N N N N N N N N N N a N .m .mNNmz ma cm> .NNN N N N N N N N N N N N N N N N N N .N .m .umemza .NNN N N N N N N N N N N N N N N N N N .< .m .umemse .NNN N N N N N N N N N N N N N N N N N .< .m .umemse .NNN N N N N N N N N N N N N N. N N N N .4 .m .umemza .NoN N N N N N N N N N N N N N N N N N .N .o .Nxm3oumNnmNNe .NoN o o o o N N N N N N N N o N N o o .N .N .Nucoamue .voN o c o o N N N N N N o o N o N o N .m .uuomsmue .NoN N N N N N N N N N N N N N N N N N .u .m .chchs .NoN N N N N N N N N N N N N N N N N N .u .m .chche .NoN N N N N N N N N N N N N N N N o N .o .m .comaccme .ooN N N N N N N N N N N N N N N N o N .u .3 .uoNNma .NNN o o o c N N N N N N N N N N N N N .N .N .uoNNma .NNN N N N N N N N N N N N N N N N N N .N .m .Nmmcma .NNN NN N N N o N N N N N N m N N N N N .02 mauwa Nmfluumm no wEmz EmuH mwumuflnu m>Numst>m mwumufiuu m>NuomNmm .omscNucoouu.N mNnme 212 NucmNoNNNsN cane mquuN can .NcmNonuzmuN .ucmNonmzm NNNMGNmNmzuN .ucmwoflmusmcHuov N N N N N N N N N N N N o N N o o .m .9 .mnsuuoz .NNN o o o c N N N N N N N N o N N o N .z .N .zounooz .NNN N N c o N N N N N N N N o o o o N .N .z .m .NNN: .oNN o o o o N N N N N N N N N N N N N .N .z .mumuch .NNN o o o o N N N N N N N N N N N N N .4 .comNNz .NNN o c o o N N N N N N N N N N N N N .N .w .cochxNNz .NNN o o o o N N N N N N N N o N N o o .N .n .cNmumz .NNN N N N N N N N N N N N N o N N o o .2 .umnmz .NNN o o o o N N N N N N N N N N N N N NuNmum>Nca mamum chmz .NNN ON N N N N N v N N N N N N N N N N .02 mNuNa NNNNNNN no mamz amuN mwumufluu m>Numst>m mwumuwuo m>NuomNmm .UGSCNu:0011.N mNnms 213 NucmHowwmsm cane mNOZHM can .ucmwofiuusmum .ucmNONmmsm >HHmcfimHmzuH .ucmflofiuwsmcHuov .: .o .NmaNosNuumso .NN .m .uusm .Nq .m .h .umxzom .vm .m .m .HQSOm .mm .m .xooooom .Hm .3 .mwacmm .NN .: .N .xomm .NN .m .H .xomm .NN .n .3 .H055mm .oN .m .: .m3ouumm .mH .m .: .mzouumm .mH .m .m .mzouumm .NH .n .0 .30Humm .mH .NN ..o .n .QNONENm .NN .> .n .mmoNucNmm .NN 00N>umm m3mz mouom MN« .m .U .0 .un¢ .v r4 o N4 H c><3 H c: H N4r4 Nicv o c: 0 —1 H c>uq Ndca o N4 o»a4 N 01.4 01:: c>c3 H H c>.4 Ncca c c: o N4.H N4vq cha o c:.H H c>.4 N1<3 o ca‘o r4 H Naoq N4<3 c:<: H cu Nicv nacu nacv «new one» nacv anew oecv (V anew oucu nae» anew «wcw oacu anew our» N nacv N o:cu N our» m OICV N anew N a: N OICV N.OICV N oacv N nacv N nacv N a: N Nae» N oacu N oqrn N OICV N Nae» m on cu H F4CV N «urn m och N aura H «sch N N oar» N o¢cv N 04¢» N 01rd N oacu N on N OICV N OGCV N cacv N nacu N 01rd N on N oaca N o¢cv N ca 0 N4}4 «urn o «wen N N 03:4 N oqcu nacu N Nirq o oq.4 Nicv N cu N oacv N oacu N N4cv N oacv N N4<3 OICV o oaca o oqcv‘ OH m m b m m v m N H h m m w m N H .oz mNuNa NNNNNNN No mamz smuN mwumufluu m>NumsHm>m mwumuwuo m>NuomHmm .N .02 coNummso soummmmm How mama mNmNHmcdus.N mHnt 214 AucmfloHumsm cane muozum was .ucmfloflwmsmuN .ucmwowumsm NHHMGNmHMZHH .ucmfiowumsmcHnov N o N o N N N N N N N N N N N o N .m .N .NNN: .NN N o N N N N N N N N N N N N N N N .3 .N .couumm .NN N N N N N N N N N N N N N N N N N .N .NNNNNN .NN N N N N N N N N N N N N N N N N N .N .umNNmm .NN N N o N N N N N N N N N N N N N N .m .N .NNNHHNN .NN N N N N N N N N N N N N N N N N N .m .a .NNNNHNN .NN N N o o N N N N N N N N N .N N o N .N .N .cmNNoo .NN N N N N N N N N N N N N N N N N N .N .a .maNxNoo .NN N N N N N N N N N N N N N N N N N .3 .N ..mcmmo .NN N o o N N N N N N N N N N N N N N .o .N .NNNN .NN N N N N N N N N N N N N .N N N N N .m .N .noNNmouN .NN N N N N N N N N N N N N N N N N N .m .comonum .NN o N N N N N N N N N N N N N N N N .N .N .cNmumumcha .NN N N N N N N N N N N N N o N N N N .N .N .Numzmo .NN N o N N N N N N N N N N N N N N N .o .NNNNono .NN N N o N N N N N N N N N N N N N N ...:oNuNosomeancNunoo .NN o o N N N N N N N N N N N N N N N ... mmuo: mmNNo .NN NN N N N N N N N N N N N N N N N N .02 mNuNN NNNNNNN no mamz smuN mNHmUNHU 0>NumsHm>m mwumuNuo 0>NuomHmm .NmsaNucoonu.N mNaNe 215 Aucmflowmmzm cone mHOZHm and .ucmwowmwsmuN .ucmNowmmsm NHHchmumzuH .ucmNONwmsmcHnov N N N N N N N N N N N N N N N N N .N .cNmNN .NNN N N N N N N N N N N N N N N N N N .N .: .NNNNNNNN .NNN N N N N N N N N N N N N N N N N N .N .N .mme .NNN N N N N N N N N N N N N N N N N N .N .N .Nmumx .NNN N N N N N N N N N N N N N N N N N .z .N .NNNNN .NNN N N N N N N N N N N N N N N N N N .N .z .NNNNN .NNN N N N N N N N N N N N N N N N N N .N .z .cmmmx .NNN N N N N N N N N N N N N N N N N N .N .z .NNNNN .NNN N N N N N N N N N N N N N N N N N .N .z .NNNNN .NNN N N N N N N N N N N N N N N N N N .u .NcsN .NNN N N N N N N N N N N N N N N N N N .N .w .comcnon .NNN N N N N N N N N N N N N N N N N N .< .o .comcgoN .NNN N N N N N N N N N N N N N N N N N .N .NomNN .NNN N N N N N N N N N N N N N N N N N .N .NommN .NNN N N .N N N N N N N N N N N N N N N...:NsumuuNo nuNz msmN>umu:N. .NNN N N N N N N N N N N N N N N N N N...Nxochoao nuNs msz>umucN .NNN N N N N N N N N N N N N N N N N N .N .NNENNoN .NNN NN N N N N N N N N N N N N N N N N .02 mNuNN NNNNNNN No mamz amuN mNHmuNuo m>NumsHm>m MNHmuNHU m>NuomHmm .nmncfluGOUIl.N mHnms 216 N N N N N N N N N N N N N N N N N ... on» o» Nuoamm .NNN N N N N N N N N N N N N N N N N N .m .NNNNNNNN .NNN N N N N N N N N N N N N N N N N N ... map No moNNNo .NNN N N N N N N N N N N N N N N N N N .N .comNuuoz .NNN N N N N N N N N N N N N N. N N N N .N .N .ocwuoz .NNN N N N N N N N N N N N N N N N N N .N .Nmucoz .NNN N N N N N N N N N N N N N N N N N .N .3oNNmz .NNN N N N N N N N N N N N N N N N N N .N .NomNoz .NNN N N N N N N N N N N N N N N N N N .N .N .oNasomNoz .NNN N N N N N N N N N N N N N N N N N .N .o .muNsuoz .NNN N N N N N N N N N N N N N N N N N .N .o .muNsooz .NNN N N N N N N N N N N N N N N N N N .u .3 .NNNNmooz .NNN N N N N N N N N N N N N N N N N N .N .N .mzmsumz .NNN N N N N N N N N N N N N N N N N N .N .N .nomummz .NNN N N N N N N N N N N N N N N N N N .N .N .Nomummz .NNN N N N N N N N N N N N N N .N N N N .w .m .m:N>mN .NNN N N N N N N N N N N N N N N N N N .z .N .Nmsnomuuoux .NNN NN N N N N N N N N N N N N N N N N .02 mNuNN NNNNHNN No meNz amuN mwumufluo m>wumsHm>m wwumufiuo m>NuomHmm .cmscNuGOUII.N mHnme 217 Nucmwonmam cane mHOZMM can .ucmwowmmzmuN .ucmfioflmwsm NHHMCNmHmzuH .ucmNonmsmcHuov N N N N N N N N N N N N N N N N N .N .N .Nucosmua .NNN N N N N N N N N N N N N N N N N N .o .N .NchcNa .NNN N N N N N N N N N N N N N N N N N .o .N .NNNNNNN .NNN N N N N N N N N N N N N N N N N N .N .N .NoNNNN .NNN N N N N N N N N N N N N N N N N N .N .N .Nmmcme .NNN N N N N N N N N N N N N N N N N N .o .scmmmum .NNN N N N N N N N N N N N N N. N N N N .N .Nmmmmm .NNN N N N N N N N N N N N N N N N N N .N .N .umNNmsnoN .NNN N N N N N N N N N N N N N N N N N .N .NmNuumNN .NNN N N N N N N N N N N N N N N N N N .N .w .mmzom .NNN N N N N N N N N N N N N N N N N N .m .N .mxusom .NNN N N N N N N N N N N N N N N N N N .z .m .mumNom .NNN N N N N N N N N N N N N N N N N N .2 .m .mumNoN .NNN N N N N N N N N N N N N N. N N N N .z .m .mummom .NNN N N N N N N N N N N N N N N N N N .z .N .mumNoN .NNN N N N N N N N N N N N N N N N N N .z .N .NnumooNN .NNN N N N N N N N N N N N N N N N N N .N .NNoNNamom .NNN NN N N N N N N N N N N N N N N N N .02 wHuNB Hafiuumm Ho mEmz EmUH mNumuNuo m>NumsHm>m mNquNHU m>NuomHmm .cmaCNu:OUII.N mHnme 218 AucmNoNumsm cuss mu02um new .ucmNONwwsmuN .ucmfiowwwsm NHHchmHman .ucmNoNuwsmcHnov .N .a .anuuo3 .NNN .N .3 .N .uuN3 .NNN .N .NONNN3 .NNN .N .o .NONNNNNN3 .NNN .N .N .NNNNN3 .NNN .z .umnm3 .NNN .N .NNNN3 .NNN .< .m .umemza .NNN .4 .N .umeose .NNN H cn c»N4 o c: o N4 N H 6n o N4 o c: 0 N4 N Norm o’ra o c: c c: N .4 «wio N4«c cweo c: N oaen N cuen N «wen N N oeen N «een N «wen N OGCV N.oeen neen N N omen «wen N an N «a N «wen N oaen N Neen en m N4 H «wen Nerd N N on N on N on N en N N «wen N oeen N N4en «wen o awe: H Nie: o H flied Neen N N4 c on N «wen «ten N N4 c on N nee: o caeq Nee: o N cn o c: o N4.N on o OH m m N m m v m N H h m m v m N H .02 EmuH mNuNB HmNuNmm no mamz mwumuwuo m>Num=Hm>m MNumuNNU m>NuomHmm .vmscwucooel.m mHnma 219 Nucmwowmmsm case mnozum cam .pcmwowmwsmuN .ucmNonmsm NHHmcflmnmzuH .ucmwoflmmsmcHuov N N N N N N N N N N N N N N N N N .o .m .NNNNoo .NN N N N N N N N N N N N N N N N N N, .N .N .NNNEoooo .NN N N N N N N N N N N N N N N N N N .9 .m .NNoEoooo .NN N N N N N N N N N N N N N N N N N .N .N .Nmoeoooo .NN N N N N N N N N N N N N N N N N N .N .N .Nmneoooo .NN N N N N N N N N N N N N N N N N N .N .ocmno .NN N N N N N N N N N N N N N N N N N .N .o .moeNoNNnnono .NN N N N N N N N N N N N N N N N N N .4 .NNNNNN .NN N N N N N N N N N N N N N N N N N .N .N .nocsnm .NN N N N N N N N N N N N N N N N N N .nN ..z .m .nNoNnm .NN N N N N N N N N N N N N N N N N N .4 .m .Nnmnm .NN N N N N N N N N N N N N N AN N N N .N .Nooooom .NN N N N N N N N N N N N N N N N N N .N .N .Noom .NN N N N N N N N N N N N N N N N N N .N .N .onNmom .NN N N N N N N N N N N N N N N N N N .N .m .3onoc4 .N N N N N N N N N N N N N N N N N N .N .N .noccmon4 .N N N N N N N N N N N N N N N N N N .o .o .no4 .N NN N N N N N N N N N N N N N N N N .oz oNnNN NNNunNN no oamz souN mNnmuNno m>NumsHm>m mNnGUNnU m>NuomHmm .m nrl.--e 4" '1'.» II- I'.‘ .Illlww. '1. I e. .02 :oNummDO sonmmmwm now mama mflmmec¢II.m mHnme 220 Nucmwowmmsm coca mnozum can .ucmNoNuuamuN .ucmNonmzm NHHmcfimnmzuH .ucmNONmmamcHuov N N N N N N N N N N N N N N N N N .N .N .Nmnox .NNN N N N N N N N N N N N N N4 N N N N .N .N .Nmnox .NNN N N N N N N N N N N N N N N N N N .N .N .gmnox .NNN N N N N N N N N N N N N N N N N N .N .z .NNNNN .NNN N N N N N N N N N N N N N N N N N .N .z .NNNNN .NNN N N N N N N N N N N N N N N N N N .N .z .NNNNN .NNN N N N N N N N N N N N N N N N N N .o .o .N .mocoN .NNN N N N N N N N N N N N N N N N N N .N .N .Nnmoosm .NNN N N N N N N N N N N N N N N N N N .o .N .cNaNNNN .NN N N N N N N N N N N N N N. N N N N .N .N .NNNNNeo: .NN N N N N N N N N N N N N N N N N N .o .3 .mmoNnNN .NN N N N N N N N N N N N N N N N N N .2 .o .moeNno .NN N N N N N N N N N N N N N N N N N .2 .N ..NNNNN .NN N N N N N N N N N N N N N N N N N .2 .N ..maNNo .NN N N N N N N N N N N N N N N N N N .4 .N .nmnanNN .NN N N N N N N N N N N N N N N N N N .N .4 .3oNoam .NN N N N N N N N N N N N N N N N N N .N .N .ocoeNNo .NN NN N N N N N N N N N N N N N N N N .oz mNnNN NNNnnNN no oeNz amnN mNnmuNno 0>Num2Hm>m MHHQHHHU 0>flUO®H0m .nmzcwucouww.m mHnt 221 Aucmwoflwmsm cans mn02um can .ucmNonuamuN .ucmNonmsm NHHchmnman .ucmwowwmsmcHuov N N N N N N N N N N N N N N N N N .o .3 .noNNNN .NNN N N N N N N N N N N N N N N N N N .N .N .noNNNN .NNN N N N N N N N N N N N N N N N N N .N .N .Nomcma .NNN N N N N N N N N N N N N N N N N N .o .Ncmmonm .NNN N N N N N N N N N N N N N N N N N .n .N .Nomnno>NNN .NNN N N N N N N N N N N N N N N. N N N .N .N .ocmnm .NNN N N N N N N N N N N N N N N N N N .o .NNco>NNN .NNN N N N N N N N N N N N N N N N N N ... on» No ooNNNo .NNN N N N N N N N N N N N N N N N N N .N .a .NNNNNNN2 .NNN N N N N N N N N N N N N N N N N N .o .o .noNNN2 .NNN N N N N N N N N N N N N N N N N N .N .N .Nonm2o2 .NNN N N N N N N N N N N N N N N N N N .N .o .onNooo2 .NNN N N N N N N N N N N N N N N N N N .N .o .onNsooz .NNN N N N N N N N N N N N N N N N N N .N .3 .Nnunmoo2 .NNN N N N N N N N N N N N N N N N N N .o .Nom:N>oN .NNN N N N N N N N N N N N N N N N N N .N .N .NuNooean .NNN N N N N N N N N N N N N N N N N N .o .4 .NmnNN .NNN NN N N N N N N N N N N N N N N N N .oz oNuNN Nmnunmm no mamz sonn MflHmuflHU 0>HUM9HM>W mNnmuNnU m>NuomHmm .vmscwucouww.m mHnme 222 Aucmfiowwmsm cone mnozum .ucoNoNNNNNuN .ucmNonmsm NHHchmnmzuH .ucmNoNumnmcHuov N N N N N N N N N N N N N N N N N .2 .N .3onNoo3 .NNN N N N N N N N N N N N N N N N N N .m .N .nocnm3 .NNN N N N N N N N N N N N N N .N N N N .N .N .noNNNNomNN> .NNN N N N N N N N N N N N N N N N N N .4 .N .noNNoza .NNN N N N N N N N N N N N N N N N N N .4 .N .noNNoza .NNN N N N N N N N N N N N N N N N N N .4 .N .noNNoze .NNN N N N N N N N N N N N N N N N N N .N .o .NxmzonNNooNnN .NNN NN N N N N N N N N N N N N N N N N .oz mNuNB HMNunmm no mez EmuH mwnmuwno m>Numst>m mNnmuNno w>NuomHmm .vmscflucouee.m mHnms 223 NucmNoNumsm coca on02um can .ucoNONumsmnN .ucoNonmsm NHHmcwmnMZHH .ucoNonmsmcHuov N N N N N N N N N N N N N N N N N .N .z .NNNNN .NNN N N N N N N N N N N N N N N N N N .N .o .Nomcnon .NNN N N N N N N N N N N N N N N N N N ...NNNxNNn NNNs m3on>nonoN .NNN N N N N N N N N N N N N N N N N N .N .nmNNo: .NN N N N N N N N N N N N N N N N N N .N .9 .NoNnnNN .NN N N N N N N N N N N N N N N N N N .N .9 .NNNNNoo .NN N N N N N N N N N N N N N N N N N .2 .N ..ooNNo .NN N N N N N N N N N N N N N N N N N .2 .N ..ooNNo .NN N N N N N N N N N N N N N N N N N ... mono: mmmNo .NN N N N N N N N N N N N N N N N N N .N .o .moaNoNNnnono .NN N N N N N N N N N. N N N N N N N N .N .nnam .NN N N N N N N N N N N N N N N N N N .N .N .noxzom .NN N N N N N N N N N N N N N N N N N .N .N .mzonnmm .NN N N N N N N N N N N N N N N N N N .N .N .msonnmm .NN N N N N N N N N N N N N N N N N N .N .N .Nsonnmm .NN N N N N N N N N N N N N N N N N N mon>nom msoz oonom nn4 .N N N N N N N N N N N N N N N N N N .Nonm newENNNoN2 nooom>o4 .N NN N N N N N N N N N N N N N N N N .oz oHuNB HMNunmm no mamz EouH mNnouNnU 0>NumsHm>m ownmuwnu w>NuooHom I'll'c .N .02 coNumoso conmommm n0m mama mNmNHmccle.v mHnma 224 AnsoNoNNNNN :ms9 ono2uN Nam .ncoNoNanNuN .ncoNoNNNaN NNNNNNmnN2uN .ncoNoNNNsmcnuNN .N .noNnnomN .NNN .4 .Nmoxnomom .NNN .m .NNNNNNNN .NNN ... man no QONmmo .NNN .N .N .ooono2 .NNN .m .3oomo2 .NNN .N .h .nomummz .NMH .o .2 .ooN>mN .NNN .o .N .NnNooEonN .NNN .z .m .nmesomNnonx .NNN .N .oNoNN .NNN . .nmnon .NNN .zmnox .NNN .nmnon .NNN .cmmmx .mHH zzzmmm .ommmn .NNN 94 H #4 N >4 N H N N H N N H H O N H H O H O N C H N N H N H H H O N H H O H O N O H H H H N H H H O H C O O H C N O H H H H N H H H O H O O C H C N O N N N N N N N N N N N N N N N N N N N N N N N N N O N N N N N N N N N N N N N N N N N N N N N N N N N N M N M N N N N O N N N N H N N N M N N N N N H M N N N N H H N N N M M M M N M H M O N M N H O N N N N N N N N N N N N N N N N O N N N N N N M N M N N O N N N N N N N N N N. N N N N H N O N M N N H N N N N N N N N N .H N C N N N H H N N N N N N M N M N N O N N N N N N N- N N N N O O O O N H N M N O N O N N N N N N N N N O H O O O M N N H N .ommmn .NNN 0H m m h o m N m N H h m m w m N H .02 EQUH oHuNB HMNunmm no oEmz mwnouflno o>NumsHm>m oNnmuNnU o>NuooHom .ooscnncooue.N oNoN9 225 Aucofloflwmsm cone mnozum van .ucoflowwmsmuN .ucmNonwsm NHHmcwmnmzuH .ucoNonmomcHuov N N N N N N N N N N N N N N N N N .4 .NoNNn3 .NNN N N N N N N N N N N N N N N N N N .4 .N .noxNo39 .NNN N N N N N N N N N N N N N N N N N .4 .N .nonNo39 .NNN N N N N N N N N N N N N N N N N N .u .N .NoNccn9 .NNN N N N N N N N N N N N N N N N N N .o .N .Nanccn9 .NNN N N N N N N N N N N N N N N N N N .N .N .noNNN9 .NNN N N N N N N N N N N N N N N N N N .N .N .Nomom9 .NNN N N N N N N N N N N N N N N N N N .o .NNNmoN .NNN NN N .N N N N N N N N N N N N N N N .oz mNNN9 NoNnnNm no o2oz 2onN mNnouNnU o>NumsHm>m mNnouNno o>Nuoonm . UGSCfiUCOUII . v QHDMB 226 NucoNONmmsm cone on02um @cm .ucoNonmsmuN .ucoNonmsm NHHMGNmnmSuH .ucoNonmsmcHuov N N N N N N N N N N N N N N N N N .9 .2 .NNNEoooo .NN N N N N N N N N N N N N N N N N N .9 .2 .Nmnaoooo .NN N N N N N N N N N N N N N N N N N .9 .2 .Nmoeoooo .NN N N N N N N N N N N N N N N N N N .9 .2 .Nmoeoooo .NN N N N N N N N N N N N N N N N N N .4 .N .oooono .NN N N N N N N N N N N N N N N N N N .o .N .nooono .NN N N N N N N N N N N N N N N N N N .2 .oomno .NN N N N N N N N N N N N N N N N N N .nN ..z .2 .noomnm .NN N N N N N N N N N N N N N N N N N .2 .o .coozom .NN N N N N N N N N N N N N N N N N N .2 .m .mmon .NN N N N N N N N N N N N N N N N N N .2 .N .xoom .NN N N N N N N N N N N N N N N N N N .2 .N .xoom .NN N N N N N N N N N N N N N N N N N .o .o .nnmonmm .NN N N N N N N N N N N N N N N N N N .N .2 .3onoo4 .N N N N N N N N N N N N N N N N N N .N .oomnooo4 .N N N N N N N N N N N N N N N N N N oon>nom m3oz monom nn4 .N N N N N N N N N N N N N N N N N N .o .o .no4 .N NN N N N N N N N N N N N N N N N N .oz oNnn9 NmNnnNN no mamz Noun NNnmuNnU o>NumsHm>m mNnouNno o>Nuoonm .m .02 coNumoio nonmommm now mama mNmNHMCnmncn .NNN N N N N N N N N N N N N N N N N N .o .2No2 .NNN N N N N N N N N N N N N N N N N N .N .2 .noNNo2 .NNN N N N N N N N N N N N N N N N N N .2 .N .NNNn22o2 .NN N N N N N N N N N N N N N N N N N .o .3 .mmoNnN2 .NN N N N N N N N N N N N N N N N N N .2 .2 .noNNoonN .NN N N N N N N N N N N N N N N N N N .3 .NNoanoN .NN N N N N N N N N N N N N N N N N N .N .2 .NooeNNo .NN NN N N N N N N N N N N N N N N N N .oz oNnn9 NNNnnNN no oeNz sonn mNnouNnU 0>NumsHm>m mNnouNnU 0>NuooHom .ooacNucoow1.m mHnme 228 Aucmwowwmsm 22:8 mnozum U22 .ucmwowmmsmnN .ucoNonmsm NHHMGNmnmzuH nucoNonwsmcHuov N N N N N N N N N N N N N N N N N .4 .N .nonnmo32nmnm .NNN N N N N N N N N N N N N N. N N N N .N .2 .ocmnm .NNN N N N N N N N N N N N N N N N N N .o .NNNN>NNN .NNN N N N N N N N N N N N N N N N N N .N .4 .nNNNNN .NNN N N N N N N N N N N N N N N N N N .2 .noNnnomm .NNN N N N N N N N N N N N N N N N N N .o .2 .Noom .NNN N N N N N N N N N N N N N N N N N .2 .222n22 .NNN N N N N N N N N N N N N N N N N N .o .o .noNNn2 .NNN N N N N N N N N N N N N N N N N N .2 .2 .2o2m2o2 .NNN N N N N N N N N N N N N N N N N N .2 .N .oNo2oo2o2 .NNN N N N N N N N N N N N N N N N N N .2 .o .onnnoo2 .NNN N N N N N N N N N N N N N N N N N .2 .o .onNsooz .NNN N N N N N N N N N N N N N N N N N .2 .o .onnsoo2 .NNN N N N N N N N N N N N N N N N N N .2 .3 .Ngnnmoo2 .NNN N N N N N N N N N N N N N N N N N .N .z .NNNoN .NNN N N N N N N N N N N N N N N N N N .N .2 .ocn>o2 .NNN N N N N N N N N N N N N N N N N N .2 .2 .n2mno2 .NNN NN N N N N N N N N N N N N N N N N .oz oNnn9 NNNnnNN no oeNz amnn MNnmuNnU m>NuoaNm>m mNnouNnU 0>NuooHom .omncwucouwl.m oHnma 229 Nncononmmsm 2229 ono2uN 2:2 .naoNoNNNNNuN .ncoNoNNNoN NNNNNNmnN2uN .ucoNonmamcHuov N N N N N N N N N N N N N N N N N .2 .2 .3on2oo3 .NNN N N N N N N N N N N N N N N N N N .4 .comNn3 .NNN N N N N N N N N N N N N N N N N N .2 .2 .nocnm3 .NNN N N N N N N N N N N N N N N N N N .2 .N .nonncomcn> .NNN N N N N N N N N N N N N N N N N N .2 .oNNN3 mo 22> .NNN N N N N N N N N N N N N N N N N N .4 .2 .no2N239 .NNN N N N N N N N N N N N N N N N N N .4 .2 .no2Noz9 .NNN N N N N N N N N N N N N N N N N N .4 .2 .no2N239 .NNN N N N N N N N N N N N N N N N N N .4 .2 .noxNo39 .NNN N N N N N N N N N N N N N N N N N .2 .o .N2m3onmNnmNn9 .NNN N N N N N N N N N N N N N N N N N .2 .2 .20222229 .NNN N N N N N N N N N N N N N N N N N .o .3 .noNNN9 .NNN N N N N N N N N N N N N N N N N N .N .N .noNNN9 .NNN N N N N N N N N N N N N N N N N N .N .2 .222229 .NNN N N N N N N N N N N N N N N N N N .4 .N .Nnozm .NNN NN N N N N N N N N N N N N N N N N .oz oHuNB Hmwunmm no @522 EmuH mNnouNnU m>NumsH2>m mwnouflno o>NnooNom .Noscnncooue.N oNnm9 230 NucmNonmam cans on02um 6:2 .ucowowmmamuN .ucmNonmsm NHHmchnmzuH .ucmHonmsmcHuov c o o c N N N N N N N N o N N o o .3 .20222 .oHH o o o o N N N N N H N N c N N o o .2 .20222 .moH H H o o m N N N N N N N m H N N N mcHxHHh :qu mBmH>noucH .ooH o o o o N N N N m m H H m H H m o .m .cmEUHom .HOH o o c c N N N N N N N N N N N N o .3 .N .connom .mm H H H H N N N N N N N N N N m N o .m .nowHom .Nm N N H H N N N N N N N N N m m N N .m .anHmm .mm H H o c N N N N N m H N N N N N H .m .B .moNnnmm .om H H H H N N N N N N N N N N N H N .m .9 .mownnmm .22 N N H H N N N N N H N N N N N N o .m .B .mcwxooo .NN H H H H N N N N N H N N N N N m m .2 .m ..ocmmw .mb N N N N m m m m m H m m H N N H H .2 .m ..ocmoo .NN H H H H N N N N N N N N N N N N N .2 .0 .mmEHonNnnonU .NN H N H H N N N N N N N N H H N N N .m .H .xomm .mN H N H H N m m N N N N N H H N N N .m .H .xoom .NN o o o o N N N N N m N N N N N N o .m .m .mzonnmm .NH o o o o H N N N H H N N N N N N N ooH>nmm 2302 oonom nwd .2 OH m 2 N o m N m N H h o m N m N H .oz oHuHe HmNunmm no mEmz EouH manouNnu o>NumsHm>m NHnouNnU o>HuooHom .2 .oz :oNummso zonmomom now mama mHmNHMCNII.m oHnma 231 Aucmonmmsm cane muozum can .ucmHOHmwzmuN .ucmHoHumDm %HHmchHman .ucmHonmDmcHuov N N N N N N N N N N N N N N N N H .0 .m .mchcHa .HcN o o o e N N N N N H N N N H N N N .A .n .uoHNme .NNH H H H H N N N N N H N N N N N N N .N .m .Nmmame .NNH c o o o N N N N N N N N N N N N N .m .umHuummm .NNH o o o o N N N N H H N N N H N c N .H .n .ocmuoz .NNH o o o c N N N N N o c N c o o o o .H .N .ochomxoz .omH o o o o N o N N N H N c N o o N N .H .N .nomummz .oNH H H o o N N N N N N N N N N N N N .H .N .nomummz .NNH H H o o N N N N N N N N N N N N o .H .N .nomummz .NNH H H H H N N N N H H N N H H N o N .N .chHm .NNH H H H H N N N N N N N N N N N o N .N .m .zmumx .mNH N N N N N N N N N N N N N N N o N .N .m .nmumx .eNH H H H H N N N N N N N N N N N o N .w .m .nmumx .NNH N N H H N N N N N N N N N N N N N .H .z .nmwmx .NHH N N H H N N N ,N N N N N N N N N N .H .z .ammmm .NHH H H H H N N N N N N N N N N N N N .H .z .cmmmm .NHH N N N N N N N N N N N N N N N N N .H .z .cmmmx .NHH oH N N N N m N N N H N m N v N N H .oz mHuHa HmHuHmm Ho mEmz EmuH MHHmuHuU m>HumsHm>m MHumuNuu m>HuomHmm .wmscHucooll.w mHnme 232 " r’ HucmHoHNNsm cane mquuN can .uamHoHNNauuN.u:mHoHNN:N NHHmchumzuH .ucmHoHumsmcHuov H H H H N N N N N N N N N H H N N .N .N .ummeza .NNN H H H H N N N N N N N N N H N N N .4 .m .ummeze .NoN N N N N N N N N N N N N N N N N N .4 .m .ummeza .NoN H H H H N N N N N N N N N H N N N .N .m .ummezs .NoN H H H H N N N N N N N N N N N N H .o .m .mchaHa .NoN oH N N N N m N N N H N N m N N N H .oz . mHuHs HmHuumN No mamz aouH maumufluo m>Humsz>m mHumuHuU m>HuomHmm .UmSCNHCOUII.m mHnme 233 Hucmwowwmsm cane muozum ccm .uGMNOHmmsmuN .ucmHonuzm NHHmcwmumzuH .ucmNOHumsmcHnov N N H H N N N N N H N N N N N N N .N .xoooooN .HN H H H H N N N N N N N N N N N N N .m .N .mmmHN .NN N N H H N N N N N N N H N N N N N .A .N .nonHm .NN N N o o N N H H N N N H H N N o N .4 .N .NOHoHN .NN o N N N N N N N N N N N .N H N N N .N .N .Ncmm>HuamN .NN o o N o N N N N N N N N N N N N N .N .m .mzouumm .NH H H o N N N N N N N N N N N N N N .N .N .mzouumm .NH o N N o N N N N N N N N N N N N o .N .N .m3oNNmN .NH H H H H N N N N N N N N H N N o N .o .o .uumcumm .NH H H H H N N N N N N N N N N N N N .HN ..u .N .ouomamm .NH H H H H N N N N N H N N N H N o o .> .N .NNNHNNHNN .NH N N o N N N N N N N N N N N N o N .N .4 .umxmm .NH N o o N N N N N N N N N N N N o N .z .w .ENNNH4 .HH o o N o N N N N N N N N H H N H H .a .N .umum4 .NH N N o o N N N N N N N N N N N H N .N -N .3munq4 .N H H H H N N N N N N N N o N N o N .N .comumcc4 .N H H H H N N N N N N N N N N N H N .o .o .un4 .N NH N N N N N N N N H N N N N N N H .oz . mHuHB Hmwuumm Ho memz EmuH mHumuNHU 0>NumsHm>m mwnmuwuu m>NuomHmm .N .02 :oNummso noummmmm How mama mNmNHmcNumsHm>m MHHQUHHU 0>NuomHmm .owscHHGOUII.N mHnme 235 AucmHonmsm Gaza muoznm cam .ucmHONumamuN .ucmHonuzm NHHMCHUNMZHH .uzmHoHumamcHuov .m .m .umumoz .NN .o .m .NNEHHHN .NN .m .umuHmm .NN . .m .umNHmN .NN .m .9 .mmHuumm .NN .U .3 .mmmHumm .mm .0 .z .mmmHuNN .NN .o .3 .cmammmm .NN .H .N .HHmmNuu .NN. .4 .o .msuHmmNuo .NN .U .U .wcHHmow .NN .m .9 .mcHxNoo .NN .z .N ..mcmmw .NN .m .m .noHHmouN .NN .m .m .noNHmouN .HN .m .N .cmeomHuN .NN .2 .m .Nsummecom .NN cu o N4c> cv nacu barn anew one» anew «new OICV «new CV OICV o‘cn oIcV «new anew nacv hICV one» cu nacu oacn anew filtV nacu filtV nucu OICV N coca Olffl nacv «Ira N omen nacv N cu N (V oacv «vcn oscu 03¢» nacv OICV nacv anew cu N oq¢n N494 N cu N N4 N cu m on N cu N cu oacu ouch n:NuwsHm>m mHumuHHU m>HuomHmm .Nmchucou:u.N mHnma 236 Hucmwowmuzm cans muozum can .ucoHowmmsmuN .ucmNOHmwsm NHHchmHmzuH .ucmHonmsmcHuov N N H H N N N N N N N N N. N N N N .o .m .m:H>mq .NNH N N N N N N N N N N N N N _N N N N .N .N .m:H>mH .NNH H H H H N N N N N N N N N N N N N .z .N .umanomuumux .HNH N N N N N N N N N H N N N N N N N .4 .N .NNmN .NNH H H H H N H N N H N H H N H N N N .2 .o .NNNNN .NNH N N N N N N N N N N N N H H N H N .z .Nemx .NNH N N H H N N N N N N N N N N N N N .H .z .NNNNN .NHH N N H H N N N N N N N N N N N N N .H .z .Nmmmx .NHH H H H H N N N N N N N N N N N N N .H .z .NNNNN .NHH N N N N N N N N N N N N N N N N N .H .z .NNNNN .NHH H H H H N N N N N N N N N N N N N .o .NNNN .NHH H H H H N N N N N N N N N N N N N .N .o .comccoN .NHH N N N N N N N N N N N N N N N N N .N .Nommn .NHH N N N N N N N N N H N N N N N N N .N .commN .NNH N N N N N N N N N N N N N N N N N...onNNNonu squ mzmH>umucH .NNH H H H H N N N N N N N N N N N H N .N .N .Numnnsm .NNH N N N N N N N N N N H H N x N N N .m .cmsoHoN .HNH NH N N N N N N N N H N N N N N N H .oz mHuNB HmHuHmm Ho mEmz EGUH mwumuNHo m>HumsHm>m mwumuNHU m>NuomHmm .fimncHucooll.N MHQMB 237 Nucmonmwzm CMSE muozum cam .ucmHOkuflmuN NucmNonmflm NHHHMGHOHMZHH .gcmHonuzmcHuov H H H H N N N N N H N N N N N N N ... may 0» uuomom .NNH N N N N N N N N N N N N N N N N N .3 .N .Nmsmm .NNH N N N N N N N N N N N N N N N N N .N .HHNNNNNN .NNH H H H H N N N H H N N N H H N N N ... map No moHNNo .NNH H H H H N N N N N N N N N N N H N .3 .4 .Numccsz .HNH N N N N N N N N N N N N N N N N H .4 .comHNNoz .NNH H H H H N N N N N N N N N N N N N .N .Nomqoz .NNH H H N N N N N N N N N N N H N N N .N .czocxoz .HNH N N N N N N N N N N N N N N N N N .N .o .muHsNoz .NNH N N N N N N N N N N N N N N N H N .N .o .muHsoo: .NNH H H H H N N N N N N N N N N N H N .N .o .muHsooz .NNH N N N N N N N N N N N N N N N N N .o .2 .NHNNNuoz .NNH N N N N N N N N N N N N N N N N N .N .N .mzmnumz .NNH H H N N N N N N N N N N N N N N N .N .N .nomummz .NNH H H N N N N N N N N N N N N N N N .N .N .Nomummz .NNH N N N N N N N N N N N N N N N H H .m .N .unmsmmNH .NNH N N N N N N H N N N H N H H N N N .N .Nom:H>mq .NNH NH N N N N N N N N H N N N NA N_ N H .oz mHuHB HMHuumm no mEmz EmuH mHumuNuU m>HumsHm>m NHumufiuuwm>HuomHmm .NmscHucoouu.N mHnma 238 Aucmfloflwwuum €659 GHOZHM UGM NUCOflUflHHDmHN NUGQHUHHMSW %HHMG%DHM2HH NHCGflOHMNSmCH—HHOV .H .o .mezoumHnmNNN .NNN .N .uuomsmus .NNN .o .N .NNHNNHN .NNN .u .N .NNHNNHN .HNN .u .3 .HOHNNN .NNH .N .NHmzm .NNH .o .scmumum .NNH .4 .N .umsummzxumum .NNH .N .N .NN>HNN .HNH .o .3 .nuHsN .NNH .> .3 .xomHN .NNH .m .N .comuum>HHN .NNH .N .HmNmmN .NNH .N .N .umNHoczoN .HNH .4 .NHNNN .NNH .4 .Nmochmmm .NNH NOHOHHHONHOHNHON NOHOHHHONHOHMHQN NcHoHHooHHOHMHON NOHGHHCOHHcHMHoN NNNNNNNNNNNNNNNN NNNNNNNNNNNNNNNN NNNNNNNNNNNNNNNN NNNNNNNNNNNNNNHM NNNNNNNMNNMNNNNM NNNMNNNMNHNmmmNN NNNHNNNNNNNNNNom NONHNNNNNNNNNNOH NNNNNNHNNommmrnHr-n NNNNNNNNNNNMNNON NONNNNNNNNNNMMHN NNNNOHHOHONONNON HNOONNHNNONNHHNN NH N N N N N N N N H N N N N N N H .oz EmUH mHuNB HNHuumm no mEmz mwuouNuU m>HumsHm>m afluvufluo m>NuomHmm .NNNNHucoon-.N mHnme 239 ’ HucmHonmsm cane muo2um van .ucmHonmsmuN .ucmHOHmusm NHHMCNmHm2nH .ucmHOHmwsmcHuov H H H H N N N N N H N N o H N o o .2 .Hmnmz .mHN o c o o N N N N N H N N o H N o o .h .anmz .NHN NH N N N N N N N N H N N N N N N H .oz mHuHa HNHNNNN no mamz Em mHHGUMHU 0>flflfl5dfl>m ”HHGHHHU QN/Huomflmm HH .NmscHacoouu.N «Hams 240 AucmHOHmwnm can? 0H02um 0cm .ucmHOHmunmflN .ucmHOHmmzm >HHMGH0HM2HH .HCMHOHmemGHro . N N N N N N N N N N N N N H H N N .o .N .NNNN .NN N N N N N N N N N N N N N N N H N .m .N .noHHmouN .NN H H H H N N N N N N N N N N N N N .N .N .NoHHmouN .HN N N N N N N N N N N N N N N N N N .N .N .Numzma .NN N N N N N N N N N N H H H H N N N .o .NHNnonN .NN N N N N N N N N N N N N N N N N N .N .N .xcmsmNoHNuo .NN N N N N N N N N N H N N N N N N N ... :oHumosomxwaHscHucoo .NN N N N N N N N N N N N N N N N N N .N .uusm .NN N N N N N N N N N N N H N H H N N .N .N .mezom .NN N N H H N N N N N H N N N N N N N .N .xooooom .HN N N N N N N N N N N N N N N N N N .N .N .mzouumm .NH H H N N N N N N N N N N N N N N N .N .N .msouumm .NH N N N N N N N N N N N N N N N N N .N .N .mzouumm .NH H H H H N N N N N N N N N N N N N .NN ..u .N .Nuomenm .NH H H H H N N N N N H N N N H N N N .> .N .mNNHuNHNN .NH N N N N N N N N N N N N N N N H N .N .N szucc4 .N H H H H N N N N N N N N N N N H N .u .u .un4 .N NH N N N N N N N N H N N N N N N H .oz V .. . mHuNB HNHuumm no @502 EmuH mHHouHHU 0>NumsHm>m mHumuHHu m>HuomHmm .m .02.:0Nummso noummmmm How mama mHmNHmcélu.m mHnma 241 HucmHoHumnm cans ouo2um 6cm .ucmHonuamuN .ucmNOHmusm NHHMCNmHm2uH .ucoNonwamcHuov H H H H N N N N N N N N N N N N N .z .N .Nmenomuuoux .HNH N N N N N N N N N H N N N N N N N .4 .N .mme .NNH H H H H N H N N H N H H N H N N N .NNNNN .NNH N N H H N N N N N N N N N N N N N .H .z .NNNNN .NHH N N H H N N N N N N N N N N N N N .H .z .NNNNN .NHH H H H H N N N N N N N N N N N N N .H .z .NNNNN .NHH N N N N N N N N N N N N N .N N N N .H .z .NNNNN .NHH H H H H N N N N N N N N N N N N N .o .NNNN .NHH H H H H N N N N N N N N N N N N N .N .u .Nomcnon .NHH N N N N N N N N N N N N N N N N N .N .NoNNN .NHH N N N N N N N N N H N N N N N N N .N .NommN .NNH N N N N N N N N N N N N N N N N N...HNoNNNono NuHs msmH>umucH .NNH N N N N N N N N N N H H N H H N N .N .NmaNHoN .HNH H H H H N N N N N N N N N N N N N .N .umNHmN .NN N N H H N N N N N N N N N N N N N .N .NNNHNN .NN H H N N N N N N N N H N N N N N H .N .9 .NNHNHNN .NN N N H H N N N N N H N N N N N N N .N .a .mcHxNoN .NN NH N N N N N N N N H N N N N .N N H .oz mHuHB HNHuumm no 0562 EmuH MNumuHuo m>Hum5Hm>m MHHmuHHQ 0>HuomHmm . UGflCfiUGOUII . Q 0HQMH. 242 HucmHOHmmsm cane muo2um can .ucoHonmsmnN .ucmHOHmwsm NHquHmHM2uH .ucmNOHmmnmcHnov H H H H N N N N N N N N N N N N H .o .N .NNHNNHN .NNN N N N N N N N N N N N N N N N N H .u .N .NNHNNHN .HNN H H H H N N N N N H N N N N N N N ho .Ncmmmum .NNH H H H H N N N N N N N N N N N N N .N .N .umNHmcnoN .HNH N N N N N N N N N N N N N N N N H .4 .NNoNHcmmN .NNH H H H H N N N N N. H N N N N N N N ... an» o» uuommm .NNH N N N N N N N N N N N N N N N N N .N .HHNNNNNN .NNH H H H H N N N H H N N N H H N N N ... on» No moHNNo .NNH N N N N N N N N N N N N N N N N H .4 .comHuNoz .NNH H H H H N N N N N N N N N N N N N .N .Nomqoz .NNH N N N N N N N N N N N N N N N N N .N .o .mustoz .NNH N N N N N N N N N N N N N N N H N .N .u .manooz .NNH N N N N N N N N N N N N N N N N N .o .3 .NHNNNooz .NNH N N N N N N N N N N N N N N N N N .N .N .msmnumz .NNH H H N N N N N N N N N N N N N N N .4 .N .nomummz .NNH H H N N N N N N N N N N N N N N N .3 .N .nomummz .NNH N N H H N N N N N N N N N N N N N .o .N .m:H>mq .NNH NH N N N N N N N N H N N N N. N N H .oz mHuHB HMHuumm No @562 EmuH mNumuHHU m>HumsHm>m mNHmuHHU 0>HuomHmm .NmscHucoouu.N mHnma 243 P s, HucmHoHNNNN cane muozuN Nam .uNmHoHNNNNuN .ucmHoHNNNN NHHNNHNNmzuH .ucmHoNNNNNNHnNN H H H H N N N N N H N N N H N N N .2 .umnm3 .NHN N N N N N N N N N H N N N H N N N .N .smHm3 .NHN NH N N N N N N N N H N .N N 4N .N N H .oz mHuHB HMHuumm Ho 0862 EmuH mHumuHuU m>NumsHm>m mfiumuHHU 0>NuomHmm .cmscHucooll.m mHnt 244 Criteria used by this study for each research question. The researcher of this study will make a summative inter- pretation of all the data provided by the contributors and expressed as numbers 0, l. 2, or 3, in Tables 1 through 8, Research Questions No. 1 through 8, respectively, starting on page 202. As indicated on page 201, 0=Insufficient, l=Marginally Sufficient, 2=Sufficient, and 3=More Than Sufficient Data. This terminology (qualifiers) will con— tinue to be used, but the word "data" will be changed to “evidence." For example the words, "Marginally Sufficient Data," to represent a value judgment on the authenticity and validity of the contributor's input to a particular research question will become the words, "Marginally Suf- ficient Evidence." The qualifier, "Marginally Sufficient Evidence," will now be used to express the summation of all contributor's authentication and validation to sub- stantiate a particular conclusion (answer) of a research question starting on page 253, To better explain the systematic thought process undertaken by the researcher, consider the first conclusion to Research Question No. 1, page 268. The first cOnclusion (answer) reads as follows: Marginally sufficient evidence indicates that the game of Chess is the oldest form of simulated game using media. Chess came from the Eastern (China) culture prior to 1800 (Taylor, J. L., and Tansey, P. J.). As indicated above Marginally Sufficient Evidence equals a summative value of one (1). This means that when the 245 contributor's data were reviewed in Table 1, Analysis Data for Research Question No. 1, pages 202 to 212, the total contributions by the authors averaged approximately number one (1). This average of number one (1) may only include a select number of contributors from within the total authors in Table 1. Each table includes the total listing of contributors for each research question, not necessarily the total listing of authors for each conclusion (answer). Every research question has a number of conclusions (answers). With this example the contributors which pro- vided data did so in a credible fashion, but the number of authors doing so were few, thus the determination to be marginally sufficient evidence. If the number of contri- butors were few, even though the inherent input was higher, this had an effect on the overall evidence summation judg- ment. This identical thinking was followed for the judg- ment qualifiers used on every conclusion (answer). A summary of this process will be provided for the conveni— ence of the reader on page 267, entitled Conclusions. Summary Chapter IV opens with an introduction to the layout and overall direction of the section. This Selective and Evaluative Criteria are restated as a prelude to the Analysis Procedure which has apprised the reader of the specific purpose of the data in the matrix. The subsection further explains the design of the matrix in addition to 246 the details of the measurement scale used by this researcher. The Analysis Data is displayed in table form to identify the value of the respective contributors' information toward responding to the specific questions guiding this study. CHAPTER V SUMMARY, CONCLUSIONS AND RECOMMENDQTIONS Chapter Five has been divided into five parts. The first part will reiterate the purpose of the study and place it in perspective. In the second section the research design of the study will be reviewed. The third unit will present an overall summary. The fourth section will state the conclusions as they relate to the research questions. In the last segment, a number of recommendations, derived from the chronological study, and a personal reflection will be presented. Purpose of the Study_ Medical education.is responding to the need for increased accountability by implementing programs employing various instructional strategies. Simulation is just one such strategy being employed. The strategy has often led to curricular modifications and a more positive learning experi- . . 1 . . . .- ence for instruction. These curricular modifications are 1Report to the Faculty. (Urbana: University of Illinois, College of Medicine, Center for Educational Development Bulletin, 1972-1973.(Mimeographed) and F. C. Tinning, An Experimental Study_Investigating the Effects of 247, 248 are now finding their way into medical education.2 The applications of different learning situations over time may serve as a historical lesson for future development and use strategies. Use of the information from this study should assist instructional developers in designing simulation strategies that will provide students with a closer approxi- mation of the skills that medical schools are accountable for teaching. By means of investigation and analysis, the purpose of this study has been to critically describe the evolu- tionary trends of media ascendant simulation and interper- sonal ascendant simulation as a strategy used in instruc- tional develOpers in medical education. To fulfill this purpose, this study addresses the following research questions: 1. What are the critical events that have occurred in the evolution of media ascendant simulation in the Eastern and Western cultures to the present? 2. What are the critical events that have occurred in the evolution of interpersonal ascendant simula- tion in the Eastern and western cultures to the present? Real and Simulated Clinical Training on Psychomotpr, Affec- tive, and_Cognitive yariables During Real Clinical Perfor- mance of First Year Osteopathic Medical Students (East Lansing: fiichigan State University, Department of Counseling, Personnel Services, and Educational Psychology, 1973). 2F. C. Tinning, 1973, op. cit. and J. Walsh, ”Medical Education: Carnegie Panel Urges Expansion and Acceleration," Science, 170 (November 13, 1970). PP. 713-714. 249 3. What are the student learning benefits in terms of evaluation, feedback and transfer which have been derived through media ascendant simulation? '4. What are the student learning benefits in terms of evaluation, feedback and transfer which have been derived through interpersonal ascendant simulation? 5. How does media ascendant simulation compare to alternative instructional strategies in terms of resource requirements affecting costs? 6. How does interpersonal ascendant simulation compare to alternative instructional strategies in terms of resource requirements affecting costs? 7. What are the effects of the evolution of the media ascendant on the evolution of interpersonal ascendant simulation in medical education? 8. What is the present state-of-the-art in terms of learning benefits and costs for interpersonal ascendant simulation in medical education?. Research Design of the Study This study employs data gathering techniques de- signed to initiate a "historical inquiry."3 The object of the endeavor was to address the development of simulation, primarily the interpersonal type, in order to provide an accurate description of its evolution and current state-of- In the develOpment of both media and interpersonal ascendant simulation, the synthesis has traced activity in China and Japan, Europe, United Kingdom, and United States. Within the United States, treatment has been confined to 3B. R. WOrthen and J. R. Sanders, Educational Evaluation: Theory and Practice (WOrthington, DhIS: Charles A. Jones Publishing Company, 1973). 250 the military, business, education and medical education. Almost without saying, the reader should realize that a particular activity may include information for both types of simulations. The analysis of the literature is intended to reveal evolutionary changes in these simulation strategies in answering the research questions. These historical evolu- tionary changes have relevance for uses of simulation. These changes show how the strategy was used in the past. They may provide important inputs for helping to determine the efforts of employing simulation. The summary, conclu- sions and recommendations in this chapter have each been derived from.those historical events. Summary This study has revealed much about the evolution of interpersonal ascendant simulation and its subsequent use in medical education. This form of human interaction has been accomplished through research and applications that began three thousand years before Christ. China and Japan The earliest identification of simulation occurred during a Chinese dynasty some three thousand years before Christ. Known as "Wei Hai" and regarded as the probable predecessor to the Japanese game of "Go," the game capita- lized, to win, on an encirclement strategy. While abstrac- tions were evident in the requirement to mentally map out a 251 plan of attack to encircle the opponent, a meaningful role play was evidenced by the designer and mover of the chips. While not specifically documented in this search, it would be reasonable to assume that such role play must have found some additional relevance in the military as a training and simulation device before trOOps entered into a battle. Use of this game as practice and planning for a battle would obviously have had value for the military leaders as a device to force them to consider all variables. Euro Be A tremendous gap exists between the activities of "wei Hai" and "Go” to the two types of war games used in Prussia. These games were designed to accentuate the use of media and interpersonal ascendant simulation, but with each type in prominence for its respective game. The for- mality of these games was evidenced by the mode of opera- tion with staging requirements, umpires, equipment and men, an acknowledgment of the increasing importance the developers had for them. Striving for battlefield perfection was a priority while keeping the risk to men and equipment minimal. These simulations were run in an environment of controlled fidelity in order to control costs, time, and security considerations. The endeavor to control these aspects of fidelity; however, bears no resemblence to the measures employed today by the military. Most important, the Prussians, at that point in early history, saw and 252 identified the use of simulation including role play as a viable method of training and advanced organization for impending battle. The transition from.those early uses of simulation in China and Japan could have been accelerated if a better means of dissemination had been perfected. As it is, this search cannot really identify how the information about the methodology permeated to Prussia. Possibly in that country the idea was contrived from common sense (why not try it before we use it during a real encounter?). Likewise, the use of simulation showed up in the British Army during the latter part of the nineteenth century. During this time the idea of using simulation employed greater connotation as a science than as an art. The Prussians advanced the structure of operations and the design considerations to approximate the more exacting standards of scientific thought and delivery. During the late 19603, the EurOpeans turned to using simulation as a method of instructional development in such areas as business, education and medical education, uses which were developed in the United States. While this does not discount some evolution in their own countries, the major diffusion did come from the New world. United Kingdom The best evidence suggests that the United Kingdom adopted the idea of simulation from Prussia during 1870. 253 The British refined the method, providing more exacting requirements of scientific thought. For example mathematics was used by them in the planning, preparation and execution of simulated maneuvers. To expedite the processing of many calculations, the British incorporated the use of machines to reduce time and error. These machine simulations were further used to build chance and random.elements into the design. Paralleling concurrent advances within the United States, the advent of the first generation computers by ERSAC, LED and others were initially designed to find answers about the simulation. Later the computer, through refinement, was used to evaluate the process of simulation. Britain contributed to the evolution of the effectiveness of simulation through these hardward innovations.through evaluation. The conveyance of military simulation to the United States occurred sometime prior to WOrld War I. Britain has continued to use simulation with its military until the present day. Simulation games employing role play was matched with the processing ability of the machine calcula- tor then with the computer. Only through the development of the computer and the advent of business simulations from the American Manage- ment Association did the potential of the methodology spread to other users. British business, government, edu- cation, and medical education seemed to incorporate its potential in turn. Computer assisted simulation was the 254 main form of methodology diffused until very recently, except for the role play utilized by the military. With the spread of media and interpersonal ascendant simulation in the United States during the nineteen sixties and seventies and with the availability of money for simulation in Britain, advancements, especially in education and medical education, have been occurring. The interpersonal ascendant displays of simulation were given impetus in Britain by available funding and initiatives by the U.S. researchers. WOrks by Kersh, Barrows and Seegal have been formally, at least, acknow- ledged as the pioneers for the promotion of the activity in the United States. From this search, it was not until 1968 that development of role play simulations were initi- ated in British education. With similar activities taking place in the United States, computer research having reached an advanced stage in Britain, and simulation designs having been utilized in British military and business, English education was now ready to incorporate these ideas but was hampered by the availability of money. Consequently, diffusion of this training device into British education and medical education has never been commensurate with that of the United States. Likewise, Britain has been the first case in point whereby research activity associated with media ascendant simulation has far outstripped research into interpersonal 255 ascendant simulation. The rapid advance of computer hard- ware has directly led to those situations which promote media ascendant simulation. The computer has been a device additionally used to research interpersonal ascendant simulation. With computer design came software packages capable of evaluating the process of simulation. In this context, many research activities employing the use of interpersonal ascendant simulation was then subjected to the evaluation packages. In Britain now, as elsewhere. the impetus to utilize inter- personal ascendant simulation lies in the fact that evalu- ation procedures are now being used to substantiate the time and money saved and the improvement in learning reten- tion and transfer to the real world. This situation has been used to promote the use of interpersonal ascendant simulation as a viable alternative to satisfy some of the accountability pressures brought upon learning institutions in difficult economic times. United States Since the introduction of simulation in this country, probably during the turn of the century, the United States has been blessed with the human and financial resources to initiate substantial, worthwhile contributions to the continued refinement and application of all forms of simulation. No one will probably know exactly when the idea was introduced into the country, but we do know that 256 the military was the prime instrument of acceptance and subsequent conveyance. Militagy. The United States military accepted the idea of using war gaming simulation from the armed forces of the United Kingdom at the turn of the Twentieth century. By the time that simulation had diffused into this country, refinements in the strategy by the British reflected their application of science to the art of war. The military carried on the use of war games in an extensive and extra- vagent style. These activities were most obvious prior to and during the First WOrld war. Even then, the appeal of simulation enabled the military to utilize a training method that was more efficient: less costly in terms of money, lives and equipment; and tended to appeal to security requirements. While the build up for the Second World War was taking place, the viability of the method was given a high priority subsequently causing the federal government to pour in large sums of money to research and develop other forms of simulation. From this decision and With the initial development of computers, media ascendant simulation was used by the military. In the beginning, various forms of mechanical trainers, such as the Link Trainer, turned the student from a competitive, collaborative and collusive atmosphere with a human opponent to that of non-competitive interaction with an inanimate simulator. The feasibility 257 of evaluating the effectiveness of the student and the simulator during participation were further enhanced by the introduction and refinement of the computer. Both inter- personal and media ascendant simulation enabled the military to train large numbers of personnel efficiently and effec- tively in less time and with an appropriate transfer of learned tasks to the battle field situation. After the Second.Wbr1d war the trend of universities and non-profit agencies as the sole agents for develOping and refining sophisticated computers was no more. Business began accepting government contracts to take over that mission. With the advent of the American Management Simula- tion in 1956, pedagogical considerations were undertaken by business to refine all forms of simulation, not only for government and military needs, but also for their own requirements. Business and industry have mainly contributed hardward to the refinement of the state of the art. How- ever, with those development, the business sector has accommodated educational requirements in their technology designs. In recent years the military has benefited sub- stantially from the business input. The military is not only considered the initial user of simulation in the United States, but remains one of the most ardent customers for implementations of the strategy for various training situations. As long as priority funds are directed into the military for developing efficient and effective training 258 units, the use of simulation has been further justified as an expedient to effect economical training with reduced teaching manpower. This concept is in keeping with the general trend of the military to automate and appropriately complicate war functions through use of the computer. As long as the systems become more complicated and expensive, the risk to train operators, at least at the entry level, on these systems will jeopardize the lives of the trainees and the cost of the equipment, an implied factor of accountability. Within this format both interpersonal and media ascendant simulation will remain a viable teaching methodology. Business. Primarily, through the introduction of the American Management Association's decision-making simulation in 1956, a long and enduring marriage of business and the strategy of simulation resulted. With the early computing advances from 1950 to 1955, instructional appli- cations by the American Management Association were rapidly developed. The idea and incentive for the strategy were offshoots from the military. Business had a handle on a powerful procedsing tool, the computer. It was only a matter of time before the strategy would be combined with the tool as an instrumentality for education. Those con- siderations were primarily developed to satisfy a business problem, the preparation and continued grooming of their decision makers. 259 Operating within the same general sphere as the military, business needed a training method to enable their selected managers to effectively and efficiently learn and transfer decision making tactics to their real world envir- onment on the job. Simulation provided a viable solution to enable managers to carry on these learning activities without the threat of adversely instituting a solution which would reduce their profit margin. Interpersonal and media ascendant simulation provided an environment in which these management students could literally, "try before you buy." Business seemed to utilize both media and role play or simulation gaming in equal doses. The relevance of role play to carry on the operational characteristics of the game retained its stature while the introduction of third and fourth generation computers enabled easier execution of the game. In a manner different from the military, the concept of feedback and the employment of evaluation methods were used in the beginning of the business simulations and, with refinement and added flexibility and versatility, have been in continued use. Drawing on a parallelism, business has contributed to the advent of simulation in education and medical edu- cation. Business has made available the design, develop- ment and manufacture of the computer as an instrument of process for simulation activity. While the initial cost 260 of this hardware has been a deterrent, the outcomes in these areas of consideration have been very effective. Business has acquired the staff and personnel to synthesize the needs of military, education and medical education so that computer hardward designs may be develOped to meet all of these user's present and expending needs. Software packages have been designed by business enterprise to satisfy specific user needs. To satisfy business' own educational requirements, the needs of customer users have been refunneled into the educational systems presently in use. Interpersonal and media ascendant simulation have been prime considerations for both customer needs and business desires. Simulation has been touted as the best method for business to teach decision making strategies in a cost/effectiveness sense. As the rules and regulations of Operations become more complex, thus increasing the number of variables, management decision analysis and training will continue to employ simulation in the future. With the computer hard- ware contributions made by business and its use of that hardware to process simulations, these promotions, in part, fostered salient activities in education. Education. Formally, one might determine that the Jefferson Township School District Simulation was the first use of a simulation in education. The simulation incorpo- rated previously used strategies from the military and 261 business to arrive at a successful package to train princi- pals and other educational managers to become more effective and efficient in decision making. Existing techniques of both media and interpersonal ascendant simulation were applied in careful proportion to satisfy the objectives of a new discipline. While simulation had an early introduction into education through the Jefferson Township application, salient, but non-connected applications of the strategy, had been used in education and psychology since the nine- teen thirties. Role play was used by psychologists to extend research in human behavior in various learning environments. Ten years later role play was quite instru- mental in school related drama as a key device for develop- ing a sense of character and experience in students. Un- fortunately, concurrent applications of simulation in drama and psychology did not generate the same impact as the application to decision making, even though they treated common effective objectives. If these earlier shared, common objectives had diffused to education, then possibly the use of simulation in education would have "grown” more rapidly. The only prime mover would then have been the adoption of the com- puter as the process facilitator in later years. As it was, simulation grew rather slowly but deter- minedly as salient studies were unveiled. A powerful tool was introduced to the business of education people in order 262 to enhance the process. As various studies were announced, simulation was applied in new ways within the discipline. Its growth seemed to be impaired only by imagination. With the acceptance and adoption of computer technology, pro- cessing time was reduced, but.more importantly, evaluation studies on various components of simulation were made possible. Precise control of internal variables, e.g., fidelity, situational settings, role play interactions and media employment, was possible and subsequent effects on their outcome could be evaluated. With evaluation facili- tated, simulation became an accepted method whose effects on educational accountability could be accessed. In the health.disciplines, the use of simulation was expanded during the middle to late sixties. Diffusion of this innovation was somewhat slower due to the tendencies of the medical establishment to resist change. However, when permeation was accomplished, the coincident avail- ability of the computer enhanced the acceptance of media ascendant simulation. Role play, live modeling and patient gaming were diffused more slowly but, when accepted, usually met with success. As the health disciplines have been a recent adopter of simulation, these disciplines have been able to utilize techniques of simulation perfected by research, development and evaluation undertaken by the military, business and education. In the United States medical education has now documented enough accomplishments 263 so that simulation studies have been either kindled or accelerated in other countries. In the beginning the use of media as opposed to interpersonal simulation may have been slightly more popular. Also, research.has been concentrated more on the media (primarily due to computer adaptions). Media ascendant simulation has more research and evaluation application to learning behavior change. Only very recently has research into interpersonal ascendant simulation in- corporated enough.stringent evaluative procedures to identify conclusively the potential of the methodology. Accordingly, only recent evaluative studies have identified interpersonal ascendant simulation as a viable learning strategy which meets the requirements of accountability. Medical Education. David Seegal's observation of the necessity for students to be_evaluated while examining patients, inspired Howard S. Barrows to use role play and live modeling to simulate a patient with a neurological pathology. Dr. Barrows is considered by many, including this researcher, as the father of simulation (especially the interpersonal ascendant) in medical education. Likewise, the medical profession would eventually incorporate many forms of media ascendant simulation, e.g., written, mannequins, computer assisted and multi media, which have been used in varying forms by the military, business and education. The effects of the computer 264 simulation had been recognized by the military and business. Parallel growth of the computer in medical education was closely followed by other areas of medically related edu- cation. While the adoption of computerized simulations were slow to start,.;g>;ecame prominant once incorporated into the curriculum. Written and multi media continue as a complimentary application of simulating to the more sophisticated computer applications. The design and devel- opment of mannequins fostered by industrial technology also continues to be used in medical education. Simulation has demonstrated its relevance not only by empirically proven effects in learning, but by documented savings in instructional time and money. Students may have media and interpersonal simulators on call or at their disposal whenever convenience dictates. The simulations do not require the presence of real patients, which are difficult to find and impossible to keep. With the advent of simulation the privacy and dignity of real patients can be maintained without depriving medical students of essen- tial practical experience. At present, media ascendant simulation has enjoyed more research, development and evaluation than has the interpersonal ascendant. But, even without the empirical justifications, descriptive observations by learning theorists cause them to view interpersonal simulation as a viable approach to learning experiences for medical stu- dents. Simulations which employ role play, live modeling 265 and patient gaming have more recently been subjected to empirical study. Recent works by Barrow, Froelich, Tinning, Maatsch, McGuire, Kretschmar, Helfer, Elstein, Jones and others justify their findings by empirical methods rather than Opinion. Learning theorists such as Twelker, Gagne, Tansey and Unwin are using findings from.simulation.studies outside medical education to reinforce findings from within the discipline. The successes with simulation in U.S. medical edu- cation have stimulated original application studies in other countries. Likewise, the United States has not closed its doors to research, development and evaluation studies from outside the country. In the past the professional medical schools, whether public or private, enjoyed operations within a closed setting. The operations were stabilized with suffi- cient funds to carry on their teaching activities pretty much at will. During the late sixties and to this point in the seventies, the financial appropriations have been more limited and conditional. Private institutions are now applying for and receiving capitation grants from state treasuries. The states have realized it is more prudent to assist private institutions to school their residents than to establish new medical schools. The demand for financial accountability has paralleled the time when diffusion of the simulation innovation as an instructional strategy for accountable learning was offered, proposed and 266 accepted by those learning institutions. Today, medical schools are being asked, pointedly, to account for their expenditures. A logical way to meet this demand has been to employ those methods which have been reaponsible for more efficient and effective learning. Simulation, both media and interpersonal, has proved a viable strategy to achieve those ends. While financial accountability has held the lime light in recent years, the medical teaching profession has been faced with other demands from the public sector. The demand for more family practitioners, a reduced time frame for undergraduate medical training and, in general, a demand for more physicians for certain parts of the country have each had their effects on curriculum modifi- cation and develOpment. In light of the demands, simulation has been offered and tailored to meet those specific needs. Within recent years, with justification, states have identified a need to improve continuing educational programs for practicing physicians. Rapid advances in methods, technolOgy and research have to be disseminated to those working in the field. All forms of simulation have been tapped or are being explored as teaching strate- gies to accommodate the limited time the practitioner can take from the care of his patients. The successful execution and implementation of media plus role playing, live modeling and patient gaming 267 simulation has required the expertise of other professional people working with the physician as content specialists. Conclusions This section lists conclusions or answers to the research questions. Following each research question, the conclusions will be listed as answers. These answers will be placed in chronological order to the degree content permits and will include identification of specific refer- ences. These references are taken from Tables 1 through 8-- Analysis Data for Research Questions 1 through 8--respec- tively on pages 202 to 243. References for each of the conclusions are taken from the table by either the author's sur name plus first and second initial or by partial title of the work. The names and/or titles will be used exactly as they appear in the table for easy cross-referencing to the table and/or subsequent numerical cross-referencing from the table to the List of References on page 287. In each answer there will be a qualifying phrase which identifies the researcher's interpreation of the data in each table for the respective research question. The qualifying phrase will only include the terms, Insufficient (Evidence, Marginally Sufficient Evidence, Sufficient Evidence or More Than Sufficient Evidence. These terms are equated to a numerical rating scale found on page 201 and are used at the bottom of each broadside page of the table for convenience of reference. The terms above, as used in 268 the answers of the research question, represent a summative interpretation of the contributor's data as evidence by this researcher. There may he answers presented for a specific research question whereby an evidence qualifier will be used which deviates from the main stream of the summative interpretation of the table. The researcher has justified this deviation in terms of the specific depth contribution, or lack of it, by a select number of sources which are not commensurate with the total interpretation of the table. Researchguestion No. 1 What are the critical events that have occurred in the evolution of media ascendant simulation in Eastern and western cultures to the present? 1. Marginally sufficient evidence indicates that the game of Chess is the oldest form of simulated game using media. Chess came from the Eastern (China) culture prior to 1800 (Taylor, J. L. and Tansey, P. J.). 2. Marginally sufficient evidence indicates that the Prussian military was the first recognizable unit to develop the rigid war game. This development effected the movement of the belief that war was progressing from an art to a science prior to 1870 (Taylor, J. L. and Tansey, P.J.). 3. Marginally sufficient evidence indicates that the Prussian military was responsible for passing the rigid war game (media ascendant) idea of simulation to the British Army after 1870 (Taylor, J. L. and Tansey, P. J.). 4. Marginally sufficient evidence indicates that the British Army was primarily responsible for the diffusion of media ascendant simulation as part of war games to the United States about the turn of the twentieth century (Taylor, J. L. and Tansey, P. J.) 10. 11. 269 Marginally sufficient evidence indicates that the United States military has used media ascendant simulation as part of the simulated war games prior to the First World War (1900) to this day (Taylor, J. L., Interview with Filkins . . . and Air Force News Service). Sufficient evidence indicates from approximately 1945 to the present, the funding for media ascendant simulation research, design and evaluation received greatest priority in the United States (Guetzkow, E., Tennyson, R. D., and Beck, I. 3.). Sufficient evidence indicates that the advent of the American Management Association's Management Decision Making Simulation in 1956, business‘began using computer assistance as an information processor for a simulation to satisfy internal training needs (Tansey, P. J., Taylor, J. L., and Twelker, P. A.). Sufficient evidence indicates that education utilized film.and tape recordings of situations as the media component of the Jefferson Townshi Simulation in 1960. This was prObably the first use of simulation in education (Hemphill, J. K. and Tansey, P. J.). Sufficient evidence indicates that in 1960 the Jefferson Township Simulation incorporated basically the same overall designs and sc0pe as had been previously accomplished with the strategy in business and the military, but without the assis- tance of the computer (Hemphill, J. K. and Tansey, P. J.). More than sufficient evidence indicates that from approximately 1963 to the present, medical educa- tion used media ascendant simulation (written, audiovisual, mannequins, computerized and multi- media simulation and simulation centers) (McGuire, C. E., Levinson, D., Spivey, B. E., Entwisle, G. and Bryans, A. M.). Sufficient evidence indicates from approximately 1965 to the present, British education adopted media ascendant simulation as a result of the United States diffusions of strategy applications from business sources and through development of the computer (Riccardi, F. M., Cherryholmes, C. E., and Tansey, P. J.). 270 Research.guestion No. 2 What are the critical events that have occurred in the evolution of interpersonal ascendant simulation in the Eastern and Western cultures to the present? 1. Marginally sufficient evidence indicates that evolving from the Eastern (Japan) culture prior to 1870, the games of ”wei Hai" and "Go" were the first interactions using a form of role play to achieve tactical and strategical advantages over an opponent (Taylor, J. L., Tansey, P. J., and Wilson, A.). Marginally sufficient evidence indicates that prior to 1870, the Prussian military was the first recognizable unit to develop war games utilizing role play in both small and large member partici- pation to include rules with umpires (Tansey, P. J. and Taylor, J. L.). Marginally sufficient evidence indicates that after 1870 the Prussian military was responsible for passing the role play simulation to the British army (Tansey, P. J. and Taylor, J. L.). Marginally sufficient evidence indicates that from 1870 to the present, the British army used simulated role play without any diffusions to other English institutions until subsequent diffusions from the United States (approximately 1965) and refinement of the computer in both Britain and United States (approximately 1945 to the present) (Tansey, P. J., Taylor, J. L., Vinsonhaler, J. E., and Murrphy, B.). Marginally sufficient evidence indicates that the British army was primarily responsible for the diffusion of role play simulation as a war game to the United States about the turn of the twentieth century (Taylor, J. L. and Tansey, P. J.). Marginally sufficient evidence indicates that within the United States, the military used interpersonal ascendant simulation as part of the simulated war games prior to the First World war (1900). The use and relevance of interpersonal ascendant simulation has remained paramont in the armed forces to this day (Taylor, J. L., Tansey, P. J., Interview with Filkins . . . and Air Force News Service). lo. 11. 12. 13. 271 Marginally sufficient evidence indicates that role play was used while in the United States during the nineteen thirties and forties in psychology and drama, but it did not diffuse with the impact of the accelerated use of interpersonal ascendant simula- tion in the military during world War Two (Taylor, J. L., Moreno, J. L., and Klein, J.). Sufficient evidence indicates that from 1945 to the present, the funding for interpersonal ascendant simulation research, design and evaluation did not receive the priority elsewhere that had been experi- enced in the United States (Tansey, P. J., Beck, I, H., and Taylor, J. L.). Sufficient evidence indicates that with the advent of the American Management Association‘s Management Decision Making;Simulation in 1956, business used role play taken from the U. S. military as a simula- tion to satisfy internal training needs (Tansey, P. J., Taylor, J. L., and Twelker, P. A.). Sufficient evidence indicates that education uti- lized role play as the interpersonal component of the Jefferson Township Simulation in 1960. .This was believed to be the first use of simulation in education (Tansey, P. J. and Twelker, P. A.). Sufficient evidence indicates that in 1960 the Jefferson Township Simulation incorporated basically the same overall designs andfiscope just as business and military had previously done in the United States (Tansey, P. J. and Twelker, P. A.). More than sufficient evidence indicates that medi- cal education was first believed introduced to the strategy of interpersonal ascendent simulation in 1962. This occurred by using the tactics of role play and live modeling in order to provide a means of evaluation for the examination of neurological pathogens by students in a neurological clerkship (Barrows, H. S. and Seegal, 0.). Sufficient evidence indicates that from 1962 until the present, the terms of role play, live modeling, programmed patients and simulated patients have been used by many experimenters without clear dis- tinction and definition. In recent years there has been some slight attempts to reduce the inter- changeability of these terms (see definitions starting on page 22) (Froelich, R. E., Maatsch, J. L., and Tinning, F. C.). 272 14.. Marginally sufficient evidence indicates that from approximately 1965 to the present, British education accepted interpersonal ascendant simulation as the result of the diffusions from the United States. The diffusion was made possible through the efforts of strategy applications from business and military sources and development of the computer (Tansey, P. J., Cherryholmes, C. E., and Riccardi, F. M.). Figure 3, Critical Events Trace in the Evolution of Interpersonal and Media Ascendant Simulation, is designed to assist the reader in understanding the conclusions (answers) to Research Questions Numbers One and Two. The figure contains vertical and horizontal axes. The horizon- tal axis presents the timeline found in the chronology of Chapter Three (also used in Figure l, Topical Superimposition of Chapter Three on a Timeline, page 47). This timeline reads from left to right on the broadside page. When reading from left to right, please notice that the timeline is presented in reverse logarithmic (approximate, that is) order, meaning the compression effect is at the left side of the page. This proportional effect is used to save space in dating the earlier years. The horizontal and vertical lines, as explained in the Legend of the figure, represent, within graphical error, the critical events trace for interpersonal and media ascendant simulation. The vertical axis lists the topical headings as found on the Table of Contents for Chapter Three. Please note that these headings are only listed once permitting the use of two distinct lines to represent the trace of interpersonal and media ascendant simulation. .cOHuMHsaHm usoosoom4 MHQoz pom HmconuomuoucH mo :OHusHo>m on» cH momma muco>m HmoHuHu0I|.m owsmHm _ Ho .znT.Ean: HstH oz. wo>o mmowu . . . no .qa|.::s u NuH>Huo¢ ooumHomH No -I+.i. u xcHH no nosmum oONHcmooom _ _ u coHHMHsaHm acoocoomc HmcomwmmwoucH nnnnnn u coHHMHsaHm usoocoond MHooz common ocHHosHN. mm.- 05. #5.. NB. OF. 00. GO. 00. mm. Om. m#. 09. Om. FH- OomH Oh. OOQWHV .om Hm0H6m2 I. :oHumosom lual-nllnanli-llnuw . mmochsm NNNHHHHz moumum omuHco 3“--- -- --. -ul»-|-l---lu|-ul-un.. . aooosHM p.325 — omouom comma w ocHno mOHmoa 274 The order of the headings are listed in order from the top to the bottom of the left-hand portion of the broadside page. Figure 3, Critical Events Trace in the Evolution of Interpersonal and Media Ascendant Simulation, represents the conclusions (answers) to Research Questions Numbers One and Two conforming to the order just described. Researchyguestion No. 3 What are the student learning benefits in terms of evaluation, feedback and transfer which have been derived through media ascendant simulation? 1. Marginally sufficient evidence indicates that prior to 1870, the Prussian's rigid war game had a specific code of rules which implied the use of feedback during execution (Tansey, P. A. and Taylor, J. L.). 2. Marginally sufficient evidence indicates that after 1870 the British army utilized media ascendant simulation to enhance the degree of fidelity. The mediated fidelity was necessary to effect transfer of the war process to the battlefield similar to the strategy used by the Prussians (Taylor, J. L. and Cherryholmes, C. H.). 3. Marginally sufficient evidence indicates that from approximately 1915 and 1941, the intensive build-up for the WOrld Wars provided the impetus for media ascendant simulation to be used. The strategy was necessary to evoke learning behaviors in response to highly technical activities. The strategy was used in the United States to help solve the same type of training needs as had been accomplished in the British army before being diffused here approxi- matly 1900 Interviews with Filkins . . ., Taylor, J. L., Tansey, P. A., and Witt, P. W. F.). 4. Sufficient evidence indicates that from approxi- mately 1945 to the present, a true relevance and importance of the application of media ascendant simulation came from the inclusion of evaluation to be used for student feedback and determining program efficiency and effectiveness to evoke transfer (Interview with Filkins . . . and Taylor, J. L.). 275 5. Marginally sufficient evidence indicates that starting with the military in 1945 to the present in business, education and medical education, media simulation provides a stimulus to increase student motivation, improve problem solving and performance, refine psychomotor skill development and groom decision making (Tinning, F. C. and Kersh, B. Y.). 6. Sufficient evidence indicates that from approxi- mately 1955 to the present, through the continued refinement of the processing capability of the computer aided in facilitating student feedback (reinforcement) and program evluation which was a concern that had to be manually accomplished in earlier years in the military (Vinsonhaler, J. E., Knight, K. E., WOodrow, K. M., and Beck, I. H.). 7. Sufficient evidence indicates that in many business simulations shortly after 1956, the computer was used to keep participants in roles and interested and for program evaluation and student feedback, a continuing and refined application of some past activity in the military (Knight, K. E. and Shane, Lo Lo). 8. Sufficient evidence indicates that substantiated by initial study in 1963 and other studies to the present, fidelity can be reduced. Fidelity can be reduced in appropriate media simulation designs to accommodate situational considerations without lose of learning effectiveness and a decrease in transfer to real world environments. In prior years within the military and business this con- sideration had not been studied to realize learning benefits (Interviews with Filkins . . ., Kersh, B. Y., and Twelker, P. A.). 9. Sufficient evidence indicates that since 1965 with the inclusions of appropriate evaluative (computer assisted) methodologies, students, instructors, programmed patients and simulation directors have all benefited from the measurement of efficiency and effectiveness in addition to the transfer of learned behaviors into the real world environment (Barnett, G. 0., Kamp, M., and Bleich, H. L.). Researchguestion No. 4 What are the student learning benefits in terms of evaluation, feedback and transfer which been derived through interpersonal ascendant simulation? 276 Marginally sufficient evidence indicates that evolving from the Eastern (Japan) culture prior to 1870, the games of "wei Hai" and "Go" were the first interaction using a form of role play to provide feedback of the tactical and strategical advantages in play (Tansey, P. J., Taylor, J. L., and Wilson, A.). Marginally sufficient evidence indicates that prior to 1870 the Prussian‘s role play war game including exacting rules with umpires to make decisions and provide feedback somewhat sflmilar to that environ- ment of "Wei Kai" and ”Go" (Taylor, J. L. and Tansey, P. J.). Marginally sufficient evidence indicates that probably from first use in 1900 until the present, a true relevance and importance of interpersonal ascendant simulation came from the use of the human voice to add an increment of fidelity to media ascendant simulation for training above the entry level in the military (Taylor, J. L., Tansey, P. J., Gagne, R. M. and Interviews with Filkins . . .). Marginally sufficient evidence indicates that role play was used in the United States during the nineteen thirties and forties as a method of be- havior modification in psychology and character identification in drama. The intent and direction of the strategy as used in this application seemed to have no connection with what had been accomplished in the past in the military. Further, there seemed to be no connection with future activity in the military, business, education or medical education (Moreno, J. L. and Klein, J.). Marginally sufficient evidence indicates that from approximately 1915 and 1941, the intensive build-up for the WOrld Wars provided the impetus for inter- personal ascendant simulation to be used. The strategy was necessary to evoke learning behaviors in response to highly technical activities. The strategy was used in the United States, after being diffused from the British army in 1900, to help solve the same type of training needs as had been accomplished in the United Kingdom (Interviews with Filkins . . ., Taylor, J. L., Tansey, P. A., and Witt, P. W. F.). Marginally sufficient evidence indicates that starting with the military in 1945 and progressing to the present with business, education and medical education, interpersonal ascendant simulation 277 provides a stimulus to increase student motivation, improve problem solving and performance, refine psychomotor skills development and groom decision making (Tinning, F. C., Gagne, R. M., Bruner, J. S., Kersh, B. Y., and Twelker, P. A.). Sufficient evidence indicates that from 1956 until the present, in many business simulations, i.e., Management Decision Making, role play was used to groom executives in providing the fidelity necessary to evoke a situational setting to.make decisions to be transferred to the job (Gagne, R. M., Advanced Management Program, Taylor, J. L., and Tansey, P. JiY. Sufficient evidence indicates that from 1962 to the present, the incorporation of existing learning theories and the modification of these theories was possible with the use of interpersonal ascendant simulation (Twelker,~P. A., Kersh, B. Y., and Kagan, N. I.). Sufficient evidence indicates that substantiated by initial study during 1963 and other studies to the present, fidelity can be reduced in appropriate interpersonal simulation designs. These designs accommodate situation considerations without a loss of learning effectiveness and a decrease in transfer to real world environments (Air Force News Service, Tinning, F. C., Maatsch, J. L., and Gagne, R. M.). Research Question No. 5 How does media ascendant simulation compare to alternative instructional strategies in terms of resource requirements affecting costs? 1. Marginally sufficient evidence indicates that prior to 1870 the rigid war game used by the Prussian military afforded training without the loss of men and equipment and without jeopardizing national security over conventional training methods than available (Tansey, P. J. and Taylor, J. L.). Marginally sufficient evidence indicates that after 1870 the British army used media ascendant simula- tion. The strategy afforded training without the loss of men and equipment and jeopardizing national security over conventional training methods then available. This was the same resource saving effecting cost which had carried on by the Prussian military previously (Murrphy, B., Tansey, P. J., and Taylor, J. L.). 278 3. Sufficient evidence indicates that since 1870 to the present, media ascendant simulation effected cost savings in the United Kingdom, United States and later elsewhere. The savings were realized in terms of shortened training time, not jeOpardizing lives and security and not compromising equipment in the military compared with existing training methodologies being used (Taylor, J. L., Interviews with Filkins . . ., Air Force News Service and Saettler, P.). 4. Sufficient evidence indicates that from 1956 to the present in business, the computer helped process data for simulation facilitation, program evaluation and provide students feedback (reinforcement) with less cost than by human manipulation. This computer facilitation would continue in business and diffuse to education and medical education (Shane, L. L., Knight, K. E., and Vinsonhaler, J. F.). S. Sufficient evidence indicates that since 1960 until the present with media ascendant simulation used in education, a cost savings was realized through decision training without jeopardizing the operation of the schools and classrooms then had been achieved with conventional methods (Twelker, P. A., Kagan, N. I., and Kersh, B. Y.). 6. Sufficient evidence indicates that from 1960 until the present in education and later in medical edu- cation with the continued refinement of the com- puter, simulation designs saved additional time in terms of cost for student completion through expeditious processing as compared with non- computer, traditional training programs (Vinsonhaler, J. F., WOodrow, K. M., and Beck, I. H.). 7. Marginally sufficient evidence indicates that from approximately 1965 until the present, the process of providing feedback inherent in simulation strategies with some evaluation to students and instructors was accomplished in less time than conventional methods still in use (DeDombal, F. T., Tansey, P. J., Kirsch, A. D., and Crane, R.). Research Question No. 6 How does interpersonal ascendant simulation compare alternative instructional strategies in terms of resource requirements affecting costs? 279 Marginally sufficient evidence indicates that after 1870 the Prussian role play war game afforded training without experiencing the loss of men and equipment and jeopardizing security compared to existing training methodologies (Tansey, P. J. and Taylor, J. L.). Marginally sufficient evidence indicates that after 1870 the British army used role play simulation to afford training without the loss of men and equip- ment and jeopardizing national security of war plans and maneuvers as compared with traditional training strategies then in use (Tansey, P. J. and Taylor, J. L.). Marginally sufficient evidence indicates that since 1870 but documented more recently until the present, interpersonal ascendant simulation has been the answer to some instructional problems. The strategy offers the opportunity to approximate the real life setting in a situational environment without some of the operational costs, environmental inefficiency and inconvenience as compared to then traditional training methods (Cherryholmes, C. E., Gagne, R. M., Kagan, N. I., and Harries, T. B.). Marginally sufficient evidence indicates that from about 1945 until the present, interpersonal ascendant simulation effects cost savings by shorting training time, not jeopardizing lives and national security and not compromising equipment in the military as compared to non-simulation training methods then in use (Saettler, P., Taylor, J. L., and Tansey, P. J.). Sufficient evidence indicates that from 1956 to the present, in business role play was a necessary component in the simulation so that transfer to the job environment could be achieved without jeopar- dizing corporate profits during training as compared with traditional existing training programs (Beck, I. H. and Twelker, P. A.). Marginally sufficient evidence indicates that from 1960 to the present, with role play used in edu- cation, a cost savings may be realized by a simula- tion strategy which carried on learning without jeopardizing the operations of the schools and the classrooms as compared to other training methodo- logies (Twelker, P. A., Kagan, N. I., and Kersh, B. Y.). ' 280 Marginally sufficient evidence indicates that after the advent of the computer, the British first used in 1968 interpersonal ascendant simulationitoleffect cost savings in terms of profit loss and worker's safety when grooming executives during the business management decision training as compared to existing educational methodologies (Tansey, P. J. and Taylor, J. L.). Researchguestion No. 7 What are the effects of the evolution of media ascendant on the evolution of interpersonal ascendant simu- lation in medical education? 1. Marginally sufficient evidence indicates that since the games of ”Wei Kai" and ”Go" to the present, various games and instructional situations which utilize simulation as a strategy have employed mediated supplements to enhance any interpersonal components (Taylor, J. L., Tansey, P. J., Kersh, B. Y., Twelker, P. A., Saettler, P., and Wilson, A.). Marginally sufficient evidence indicates that from approximately 1945 until the present, the develop- ment of the computer in the United States and United Kingdom offered the potential of the ability to process the simulation, but with minimum player contact. This application took place in the military on a small scale, but later in business (1956) and education (1962) on a much larger scale (Vinsonhaler, J. P., Murrphy, B., Kirsch, D., and Crane, R.). Sufficient evidence indicates that in 1945 with the advent of the non-commercial design and development of the first generation computer, role play simula- tions were assisted by the potential of processing, motivating and providing student feedback and pro- gram evaluation. The first generation computer was used to assist simulation strategies develOped in the military with subsequent generations being utilized in the military, business, education and medical education (Vinsonhaler, J. P., Sharp, W. P., and Knight, K. B.). Sufficient evidence indicates that while inter- personal ascendant simulation is available as an alternative strategy, the majority of the research and evaluation procedures have been carried on primarily with media simulation, since approximately 1956 until the present. This research with media simulation, especially the computer format, had had 281 a positive affect on the facilitation of interper- sonal simulation (McGuire, C. H., Tinning, F. C., Kretzschmar, R. M., and Delodzia, G.). Sufficient evidence indicates that in 1978 the efforts of research are still primarily directed toward media ascendant simulation even though salient activity is taking place in interpersonal ascendant simulation. Media simulation is still having a facilitating effect within the designs of interpersonal ascendant simulation (Tinning, F. C., Maatsch, J. L., Morrison, A., Schneider, P. B., and Godkins, T. R.). Research Question No. 8 What is the present state-of-the-art in teams of learning benefits and cost for interpersonal ascendant simu- lation in medical education? 1. Sufficient evidence indicates that since 1962 in medical education, as with education and business, research findings have been disseminated at a rather slow rate to other countries. Likewise, the medical community and others have now excepted the research activity of others in an attempt to improve the useability of interpersonal ascendant simulation (Tinning, F. C., Morrison, A., McGuire, C. H., and Levine, H. G.). Sufficient evidence indicates that from 1962 and still continuing until the present and while criti- cal points of view of interpersonal ascendant simulation do exist, many positions lack empirical evidence (Seegal, D., Barrows, H. S., and Bowker, J. H.). Sufficient evidence indicates that since 1962 until the present, student proficiency is increased by repeated exposure to role play patients or live models with timely feedback (reinforcement) so that the student may be constantly modifying his learning behavior (Butt, R., Bowker, J. H., Barrows, H. S., Levine, H. G., and Kagan, N. I.). Sufficient evidence indicates that)as_in—the—past- since 1962, interpersonal ascendant simulation can meet the needs of future medical training in the appropriate setting provided that adequate research, design, development and evaluation tehniques are used (Resnikoff, A., McGuire, C. H., Kagan, N. I., Froelich, R. E., and Schneider, P. B.). 10. 282 Sufficient evidence indicates that with the appli- cation of interpersonal ascendant simulation in medical education from 1962 until the present, the strategy has been designed to afford an environment which has built-in controls for unforseen con; tingencies. The student may undergo his training in a protective environment such that jeopardizing patient privacy and recovery have been avoided (Schneider, P. B., Barrows, H. S., Kayes, D. M., Maatsch, J. L., Johnson, G. H., and Holdman, H.). Sufficient evidence indicates that since 1962 inter- personal ascendant simulation has been the answer to some medical instructional problems by approxi- mating the real life setting in a situational environment. This has occurred without some of the operational costs, environmental inefficiency, in- convenience and not having to rely on a ready supply of real patients with consistant pathologies required for course objectives (Barros, H. S., McGuire, C. H., Seegal, D., Helfer, R., Tinning, F. C., Maatsch, J. L., and Johnson, G. H.). Sufficient evidence indicates that since the use of interpersonal ascendant simulation in medical edu- cation from 1962, the strategy is certainly not the methodological solution to every learning problem (Tinning, F. C., Kretzschmar, Rm M., Maatsch, J. L., and Morrison, A.). Sufficient evidence indicates that since approxi- mately 1963, but more frequently since 1973 until the present, empirical studies do exist which use Jeeeginterpersonal ascendant simulation for solving medical education problems (Tinning, F. C., Helfer, R., Kagan, N. I., and Resnikoff, A.). Sufficient evidence indicates that from approxi- mately 1970 until the present in an increasing select number of institutions, the once closed com- munity of medicine is opening up to a diffusion campaign. This campaign includes, in part, inter- personal ascendant simulation-as just one viable training strategy (Erickson, E., Baldridge, J. V., Weber, M., Tinning, F. C., Maatsch, J. L., Kretzschmar, R. M., Morrison, A., and Godkins, T. R.). Sufficient evidence indicates that from approxi- mately 1972 until the present, empirical evaluation has been applied to the use of simulation in medi- cal education (Tinning, F. C., Helfer, R., Jason, H., and Johnson, G. H.). 283 ll. Sufficient evidence indicates that since approxi- matly 1974 until the present, the medical educa- tional community is faced with financial constraints and has offered with success, interpersonal ascendant simulation. This form.of simulation, as a vehicle of instructional development to improve training programs with respect to product quality, staff time and cost, meets the needs of accountability (Bower, H. R., Wilkinson, G. L., Jason, H., Maatsch, J. L., Tinning, F. C., Godkins, T. R., and Morrison, A.). Simulation in general has been looked upon for its excessive time and expense for initial implementation and lack of acknowledged evidence identifying its success or lack of it. This study was an information disseminating document written under a historical format. Its purpose was to collect historical information and use it to descriptively answer eight questions about the track record of simulation in solving some instructional problems as a viable alternative. In that regard interpersonal and media ascendant simulation has been presented to portray its success in most of the sources investigated. As its use continued through the years, the often deep seated potential of the strategy and its effect on expeditious learning in a situa- tional context apart from.the real world risks become more known. Whether in the military, business, education or medical education, the use of simulation has demonstrated that a controlled learning environment may be designed for students. With the removal of outside world risks afforded by the strategy, students' interactions will satisfy learning objectives. The potential that this strategy may 284 hold for medical education and other disciplines, in solving their unique problems, is limited only by the imagination of the researchers. It is this attitude and endeavor with this which the researcher willwish to contribute. This study has permitted this writer to gain a broad perspective of what has transpired. It has enabled one to realize the direction from which the strategy has come and hopefully may provide a reasonable footing from which this researcher may wish to embark. It is still the convenced feeling of this writer that the accountability of a reasonable representation of what has occurred in any discipline will obviously afford future effortst the spared time, money and personal energy by not duplicating the mistakes of others. As far as my efforts are concerned, this document will serve as a pre- liminary screening device in order help better organize the precise direction of needed resources. In this endeavor this document and many others will each fill their niche in the sequence of events to establish a viable simulation strategy for a specific training environment. As long as training environments may be designed to effectively and efficiently carry out the learning endeavor, then account- ability will be just one step closer to satisfaction. Recommendations The final segment of the chapter lists recommenda- tions resulting from this historical study. 285 .Recommendations for Further Study_ The following recommendations for further study are presented in order of their perceived importance with one (1) being most important: 1. This investigation could conceiveably establish a foundation to which future segmented historical studies of others could be added. Due to the time lag from the point this and other simulation studies are completed until publication and dissemination, the incorporation of interper- sonal ascendant simulation research results into a common retrieval system, is suggested. This historical study may serve as an impetus to inspire authors to include historical information to their studies, thus allowing their readers to become knowledgeable on project derivatives. The study could provide some salient activities for those institutions (and there are a few), who have not considered the feasibility of this instructional alternative. Professional health education institutions should be tied into at least one health information retrieval system in order to disseminate research findings utilizing interpersonal ascendant simula- tion. The retrieval center should collect the simulation research data into an on going account, which could be tapped at will according to the desired read out of the user. A retrieval storage system could eliminate the process many schools go through doing duplicate research on solutions or parts of solutions, which have been previously validated, but not disseminated in a timely manner. Investigate the present prevailing trend to document simulation applications with empirical justifica— tions. Continue to investigate fidelity of simulated patient portrayals to determine the effect on learning behavior and transfer to the real world. 10. 11. 12. 13. 14. 15. 286 Continue investigation of the use of the interper- sonal process recall methodology as an evaluation instrument on student competencies and as a stimu- lus to the promotion of more effective and efficient ways to teach doctor-patient relationships, in- cluding bedside manner. iInvestigate continued use of upper level students and.non medical students in role play and live model experiences for physican assistant and para- medic training programs. Investigate the use of physician assistants and paramedics as patient.simulators for freshman level training in the medical curriculum, Continue to investigate the use of interpersonal ascendant simulation for training in general man- agement, patient management and physician affect within clinical and office settings. Continue investigation of physican assistant, paramedic, non medical and instructor programmed patients in the effect each of these source feed- backs and evaluation have on the medical student's learning behavior change. Continue to investigate the programmed patient technique in terms of cost and effectiveness. Salient considerations are necessary in order to continue to equate and justify this method of instructional development with.more traditional approaches to help satisfy the cry for institutional and instructional accountability. It is hoped some of these Recommendations for Further Study may kindle that certain "something" in order to initiate research. 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"How to DevelOp a Teacher-Rating Instrument: A Research Approach," Journal of Higher Education, 46(6) (November/ December, 1975), 653-663. APPENDIX A STUDY OF SIMULATION TECHNOLOGY IN MEDICAL EDUCATION (Transmittal Sheet) APPENDIX A STUDY OF SIMULATION TECHNOLOGY IN MEDICAL EDUCATION1 (Transmittal Sheet) This annotated bibliography was compiled by the Office of Medical Education, Research, and DevelOpment (OMERAD) under contract to the National Library of Medicine. It is part of a larger study to assess the status and potential use of Simulation Technology in Medicine. We were materially aided in this task by the very informal and considerate guidance provided by Harold Wooster, M.D., Ph.D., Special Assistant for Program Devel- Opment, Lister Hill National Center for Biomedical Communi- cations, and Gary Kahn, M.D., of the National Medical Audio—Visual Center. 1J. L. Maatsch, J. D. Hoban, S. A. Sprafka, and N. A. Hendershot, A Study of Simulation Technology in Medical Education, Volume 4: An Annotated Bibliography Tfiast Lansing: Michigan State University, Office of Medical Education, Research, and Development, October, 1976, for the Department of HEW, National Library of Medicine), p. i. 308 309 In this research the ultimate burden for the detailed work of collecting, filing, editing, verifying, typing, proofing, and copying fell upon a number of OMERAD Fellows, Research Assistants,* Graduate Assistants, and Secretaries. We are deeply indebted to Stephen Abrahamson, Ph.D., Howard Barrows, M.D., Richard Friedman, M.D., Fred C. Tinning, Ph.D., and Christine McGuire, Ph.D., and the Center for Educational Development, University of Illinois College of Medicine, who graciously provided us copies of specialized bibliographies which complimented ones held by Project members. These formed the basis for an even more exhaustive and complete literature Search. In this connection we also, in the beginning, drew heavily upon Brigham and Kamp.2 2C. R. Brigham and M. Kamp, "A Selected Bibliog- raphy to Computerized Instruction in the Health Sciences," Computers in Biology and Medicine, 3(3) (October, 1973), pp. 337-342. *This writer worked as a research annotator and verifier under direction of J. D. Hoban (see footnote number one above).