Medical Education Blog

There has been a lot of discussion lately about using twitter at conferences and out of that has risen a growing voice asking “How might I use twitter in a classroom setting?”

So Let’s Begin With WHY?

At the recent Teaching and Learning to the Power of Technology Conference, three professors at the University talked about what they liked about twitter in the classroom:

• Questions: Students asked questions about both the content and classroom processes (When is the exam?) and were answered by both the prof and other students which cut down on the time Profs spend answering individual emails.

• Engagement: In large classes, it can be difficult to get students to engage with each other in the learning process. Twitter increases this activity both with fellow students and with the Prof.

• Presence: In large classes, students can seem to flow together in a mass of faces. Twitter can give Profs a sense of who people are as individuals without breaching the professionalism divide.

• Acceptance of new technology: Many students use twitter as a form of note taking that can be checked through what peers are saying about the content. Prof can check on how accurate the key points are being perceived.

And Follow Up With HOW?

Begin with a course hashtag # something short, descriptive and clear that isn’t being used elsewhere on Twitter. Ideally the students will be involved in coming up with something useful. Having a class #hashtag avoids the issue of students being added to personal twitter accounts. Add the course #hashtag to your presentations.

Decide how actively you want to be involved in the #hashtag:

• Minimal: set twitter office hours when you will answer questions

• Medium: sent articles, images, reminders and other resources that might enhance the learning experience and actively encourage students to tweet images and notes on your presentations

• High: Tweet your presentation as you are giving it by using tools like Status Present. Show the twitter feed for the class on a second screen or every 15 minutes and answer questions that are posted.

If you want to comment on or add to my ideas, contact me @bonnycastle.

Posted by Deirdre at 11:19 AM | Permalink

I recently watched a presentaion where the presentor sat at the front of the room with his back to the audience, reading his overpacked slides for 25 minutes. I was astounded because his topic was important and his knowledge flawless but my retention was 0.

Subsequently, I started reading Dr. Roger Shank's book "Teaching Minds: How Cognitive Science Can Save Our Schools". In the book, he talks about how Teaching = Telling was common practice for hundreds of years. Oral traditions of teaching are holdovers from the days when books and paper were rare commodities, but then television and the Internet entered the world and changed people's ability to access vast quantities and qualities of information quickly.

Teaching = Telling isn't just outmoded, it is dangerous. The practice of non-critically believing what people tell you, particularly people in authority or people with notoriety is what has led to the refusal to vaccinate children, creationism taught as science, financial scams by trusted advisors and a proliferation of non-evidence based healing practices.

Teaching = Telling in the medical classroom doesn't engage minds in critical thinking, but it also doesn't help students remember information either. Students attention to what they hear is the key components of learning in an auditory culture. If students' attention span = 15 minutes of concentration on a good day, they will remember about 1/4 of what they heard in a 60 minute lecture. Combine the distraction of trying to pay attention to poorly constructed, overstuffed PowerPoint slides and retention drops even further.

So take a minute and think about - What is your teaching philosophy? How do you believe people learn?

For ideas about how to actively engage students in medical classrooms see the teaching techniques section on the right hand side of this blog.

Posted by Deirdre at 12:19 PM | Permalink

At the recent International Conference on Residency Education, several speakers emphasized the importance of planning when using expensive simulation labs. Residents who train exclusively on high fidelity simulators frequently complain about the complexity and confusion of learning in this manner. I decided to write an article about the best way to plan the use of 4-step progressive simulations.

Preplanning

a. Begin by analyzing what competencies should be taught in this manner. Dangerous, painful, rare and embarrassing procedures make the best candidates. Determine what level of competency is required depending on the level of the resident. Set objectives for each stage.

b. Create learning activities including written instructions for each level of the progressive process described in the following document. Train preceptors to provide the necessary role modeling.

c. Create assessment tools appropriate for each level.

d. Train raters to use the assessment tools.

1. Intentional Role Modeling

An experienced preceptor demonstrates (without comment to the trainee) the complete procedure including interactions with patients/families and team members. This provides the student with an understanding of the goal of training including completion time, explanations given to the patient, safety measures etc.

This step may involve watching a video if an experienced preceptor is not available for observation.

2. Low Fidelity Simulation

Image from Antonacci, D.M. & Modaress, N. (2008). Envisioning the Educational Possibilities of User-Created Virtual Worlds. AACE Journal. 16 (2), pp. 115-126. Chesapeake, VA: AACE. Retrieved from http://www.editlib.org/p/24253.

Low fidelity simulations use learning resources such as videos, animations and virtual reality with written procedural guides. Ideally this will involve a self directed process whereby the learner learns the basic step by step mechanics and can repeatedly use the required resources until they believe they have reached an understanding of the objective.

Assessment at this stage uses multiple choice and listing questions; either paper based or online with a pass mark of >80%. Learners must have the option to retest at this stage.

3. Mid Fidelity Simulations

Mid fidelity simulators are the body parts task trainers that expose students to the tools used to complete procedures in a portable, minimally complex manner. Again students practice with minimal supervision or peer support until they feel confident to undergo formal testing. Direct observation by raters or a lab supervisor followed by a feedback session is the usual test at this stage. Students should be allowed to retest after returning to the simulation if they don’t demonstrate proficiency.

The student now has the basic knowledge and tool proficiency to move to the interactive level.

4A. Interactive Hybrid Patient Simulation

Image copyright Roger Kneebone

Hybrid simulations are used for simple procedures which might be painful or embarrassing for patients to have beginners practice. Simulated body parts are attached to standardized patients who act out pre-arranged scenarios and provide feedback to the learner during the debriefing. More expensive than mid level task trainers, this level allows for the inclusion of interaction skills. Direct observation is the standard assessment.

4B. Interactive High Fidelity Simulation

The most expensive and complex type of simulators are the full body mannequins that require participants to practice technical + communication skills in complex scenarios. In some cases, participants may experience planned and unplanned disaster scenarios. Ideally the mannequins themselves provide immediate feedback about how well the patient is progressing because of the participants’ actions. Debriefing with a skilled preceptor is required after each session. Video observation by trained raters is the standard summative assessment.

For more complete information about simulations, see http://www.medicine.usask.ca/faculty/cbf/medical-simulations.

Posted by Deirdre at 09:30 PM | Permalink

I have been thinking about how we help students become aware of the thinking processes (pattern making, creative analysis) that we use everyday to solve problems. These processes have become habits that we rarely think about but students who see us travel from A-H see something magical or worse think we are taking shortcuts because we don't show them the underlying knowledge we use. The picture below comes from the article Role Modelling by Cruess and Steinert. I think its a great way to think about helping our students become aware of the implicit.

Before the student arrives

1. Pick two or three things you do very well and break these procedures/techniques down into steps that the student needs to know in order to replicate what you do.

2. Create two or three illness scripts for the most common issues students will see in your clinic.

3. List 5-10 attitudes that you think exemplify great physicians and think about how you are going to role model those attitudes while students are in your clinic. Pick some that relate to patients, some that relate to staff, some to other areas of you life.

While the student is in your care

1. Encourage the student to ask questions about why you made the decisions you made.

2. Pick one or two difficult cases a week and walk the student through how you made the diagnostic decisions; even if it seems obvious to you that A=F, it may not be as obvious to the student. Avoid asking students to read your mind.

3. Share your illness scripts with students before asking them to create their own.

4. Guard the appropriateness of your behaviour to patients and staff even when the day is trying.

5. Talk to students about working with patients whose values, behaviours, and illnesses can create issues for the physician. Try and reflect the guidelines of the profession even if they aren't your own (save those discussions for colleagues).

6. Demonstrate and encourage Deliberate Practice by giving students multiple opportunities to apply what you are teaching them with patients.

References

Role modelling—making the most of a powerful teaching strategy

An Intentional Modeling Process to Teach Professional Behavior: Students' Clinical Observations of Preceptors

Pathways to “Involved Professionalism”: Making Processes of Professional Acculturation Intentional and Transparent

Posted by Deirdre at 02:11 PM | Permalink

One of the most frequent issues raised by instructors who are trying to move from a teacher-centred to a team-centred classroom is “How do I get students to collaborate effectively?” The answer is not a simple one because most North American students arrive in the medical classroom from a learning environment that encouraged competition and frequently feared collaboration between students was a doorway to cheating. Many of the most successful students in this environment viewed collaborative activities as a plot to improve the grades of poor students at their expense.

So you need to help students learn to collaborate and I suggest you begin that process by familiarizing yourself with Dr. J. Salmons’ Five Levels of Collaboration, which progress from least trust required to unconscious trust.

1. Dialogue
2. Peer Review
3. Parallel Collaboration
4. Sequential Collaboration
5. Synergistic Collaboration

Dialogue
Begin your course with daily opportunities for students to practice speaking and listening to each other in order to build trust. Avoid the traditional instructor asks a question and a single student answers and use a variety of the following:
• Write, pair, share
• Clicker polls
• Clicker quizzes
• Group discussions
• Structured Controversy
• Integrated Case Learning

Peer Review
The week before the first paper or assignment is due begin the process of orienting them to critiquing each others work. Explain the concept of rubrics to the class and ask them what criteria they would use to evaluate the assignment/paper. If they have an adequate understanding of the concept, get them to create the rubric; otherwise share your rubric with them. Be open with the students that this is a stage in learning to work as a team. Choose one of the following depending on the size of the group and their readiness for the task:
• Partner – give each other feedback on the format/spelling/sentence structure but not on the content before the work is handed in
• Comment – post the assignment online in a Wiki or Blog and expect at least two thoughtful comments from each student on someone else’s work as part of their marks
• Critique someone else’s work using the established rubric and compare it to the instructor’s critique for marks.

Parallel Collaboration
At this stage, participants divide up the group’s assignment and each individual completes a section independently. The final presentation of the assignment may be vetted by one individual who is ideally the best writer/presenter but who may be just the strongest personality. In some cases, students each present their section and no teamwork is involved. To help students move through this individual stage, you might ask them to do some of the following:
• Encourage them to participate in some sort of group editing/review which can be facilitated by using either Google Docs or a Wiki
• Assign group roles such as gatekeeper, task completer, food bringer etc. or help them identify their role
• Ask group to mark each other on participation in the group role while you mark individual contributions

Sequential Collaboration
The students are developing the skills of team and task management and begin to appreciate the importance of both functions, so they need an assignment that can be accomplished in a series of stages, such as research - group writing - presentation of paper. At each stage, a product will be presented to you by a set date and the students are expected to plan, create and critique this product as a group. Marks for this stage are based on expected group performance not individual.

Synergistic Collaboration
The unconsciously competent team collaboration point may not be achievable in a single course.

Posted by Deirdre at 11:23 AM | Permalink

In the recent article, The role of conversation in health care interventions: enabling sensemaking and learning the authors summary states:

The generation of productive conversation should be considered one of the foundations of intervention efforts. We suggest that intervention facilitators consider the following actions as strategies for reducing the barriers that conversation can present and for using conversation to leverage improvement change: evaluate existing conversation and relationship systems, look for and leverage unexpected conversation, create time and space where conversation can unfold, use conversation to help people manage uncertainty, use conversation to help reorganize relationships, and build social interaction competence.

Busy clinicians complain that they don't have time for student teaching, let alone conversations. So lets look at each of the suggestions.

1. evaluate existing conversation and relationship systems

When and where do conversations occur in your practice with staff and colleagues? Do you share lunch or coffee breaks? Are their formal weekly meetings to plan or debrief? How could you bring students into the formal and informal conversations?

2. look for and leverage unexpected conversation

How might scrub sinks, hallways, change rooms, exercise areas offer opportunities for conversations however brief? When might you grab students and head for a shared coffee break? How might you use this time? What other conversations does the student need to have with staff, patients and colleagues?

3. create time and space where conversation can unfold

Where in your schedule might you organize debriefing time? Where might you arrange brief daily planning time to discuss what the student will focus on that day?

4. use conversation to help people manage uncertainty

What cues does your student present when they are unsure, embarrassed, ashamed? How do you debrief crisis, errors and other unexpected events in your practice? How do you help students deal with death and dying? Who is the best problem solver in your group?

5. use conversation to help reorganize relationships

How do you handle conflict in your office? How do you help students develop collaboration skills? Who is the best team builder in your group?

6. use conversation to build social interaction competence

A key skill in being a physician is the ability to manage the office atmosphere so people want to be working with you and for you. How can you role model this behavior to students? Who else is a master at social interaction that you might ask the student to observe?

What other suggestions do you have for implementing these six actions?

Posted by Deirdre at 11:38 AM | Permalink

An example from Britain of a student created video about the history of Public Health. What a great example of actively involving students in learning!

Medicine through Time Revision Part 1 from johannes ahrenfelt on Vimeo.

Posted by Deirdre at 09:18 AM | Permalink

Dr. Frank Papa recently presented a new approach to thinking about how we teach medical students called Application Oriented Curriculum.

Readers of my Blog know that I have made previous posts on The Difference Between Novices and Experts and Medical Problem Solving. Dr. Papa proposes an approach to medical school curriculum that addresses some of the concerns I raised in those posts.

Application Oriented Curriculum

The goal of this model is to help students construct problem specific knowledge bases that address DDX, EXPLanation, and TX capabilities.

To achieve this goal, students participate in the following five steps:
1. Self directed information acquisition through reading based on the course objectives
2. Faculty modeled clinical reasoning using cases
3. Group case based exercises in the classroom
4. Individual, interactive, online cases
5. Integration of cases in a hierarchy of complexity

To help facilitate this process, Dr. Papas has created a website http://acdet.com/demo

What do you think?

Posted by Deirdre at 11:21 AM | Permalink | Comments (1)

What is the difference between a Novice and an Expert?

One of the primary differences between novice and expert physicians is the number of illness scripts experts have developed over the years. These patterns are similar to algorithms, but more individualized to the expert's experience and personal style. The more experienced the expert, the more shortcuts will be included in the individual's patterns because of automaticity (unconscious knowledge).

Teaching Illness Scripts

You can assist learners in a clinical setting to develop their own patterns by asking them to graph common illnesses as the progress through their training. These graphs can be kept in a binder and added to as the learner increases their knowledge. You can remind them that the graph will be useful for studying for final exams. Both text-based and visual representations are acceptable depending on the student's personal learning preference. Sophisticated computer users might want to use online tools such as Mind Meister or NovaMind.

Caution: Remember this is not your illness script; it is the student's. It will not contain all the knowledge in your brain, nor will it look like what you draw on the board. This is also a developmental tool which will improve over time and experience.

To see examples of Illness maps, please see
Mind Maps in Medicine
Med Maps

For More Information

http://www.ncbi.nlm.nih.gov/pubmed/12028392

http://www.ingentaconnect.com/content/bsc/meded/2007/00000041/00000012/art00009;jsessionid=8sr1nf5kr4brc.alexandra?format=print

http://www.fammed.ouhsc.edu/robhamm/OKJDM2000/Hamm/sld001.htm

http://casemed.case.edu/curricularaffairs/scholars/2002-03Archives/scholars0203/PLtoILLgroups.pdf

http://content.nejm.org/cgi/content/full/355/21/2217

http://www.saem.org/download/kuhn.pdf

http://www.cogs.susx.ac.uk/users/bend/doh/reporthtmlnode5.html

http://www.informaworld.com/smpp/content~content=a783763088~db=all

Posted by Deirdre at 11:23 AM | Permalink | Comments (1)

Posted by Deirdre at 02:41 PM | Permalink | Comments (1)

Dr. Kalyani Premkumar continued her innovative teaching by taking an hour to use a PowerPoint game to help medical students remember medical terminology and processes. The following image shows the central game board divided into 6 categories with questions of increasing difficulty in each category for a total of 33 questions.

70 students were divided into teams to compete for prizes such as pens shaped as syringes, erasers, caps etc.

The final jeopardy question was really difficult – not directly covered in classes, but required integration. The students made their bid and submitted their answers in writing. Dr. Premkumar was amazed at the variety of plausible answers that were given after the students spent sometime discussing the answers to the final question.

Posted by Deirdre at 01:40 PM | Permalink

At the Cabin Fever conference in Alberta, I promised to write about teaching students to deliberately practice the art and skill of medicine. Why, because doctors who depend on experience without reflection:

 frequently construct a serviceable conceptual framework based on algorithms, then practice to achieve a level of performance sufficient to most needs -C. Desforges (2005)
 sub-optimal processes may achieve successful outcomes and when they do succeed, they may be reinforced -R. Rhodes (2005)
 rate evidence as good or bad based on how well it supports assumptions
 stick to beliefs even in the face of overwhelming contradictory evidence -Guest et al (2001)

Whereas physicians who used deliberate practice techniques had:

 a greater body of knowledge about their domain of expertise than other individuals
 highly adapted representations that aid in planning, prediction and evaluation (10,000-100,000 patterns)
 accurate memory for new information and patterns in their domain
 continuing high levels of performance after the age when less accomplished performers begin to decline. - K. A. Ericsson et all (1993)

Guest et al concluded that teaching deliberate practice means providing learners with opportunities to:

1. Address problems in medicine at the upper level of their ability

2. Develop a livelong habit of self monitoring (seek out blind spots)

3. Repeat tasks to improve

People who found this article useful might also enjoy Teaching your students problem solving and Teaching about cognitive error

Posted by Deirdre at 03:41 AM | Permalink

The following article is a continuation of Active Learning - Remembering

In an active learning environment, formative assessment of learning is important because:

• it allows both the professor and the students to evaluate on a regular basis how they are progressing in achieving the class objectives

• both professor and students can adjust their activities based on the feedback they receive.

The images below represent how Dr. Kalyani Premkumar, an assistant professor in our College of Medicine answered the question, “How can my students and I best understand the nature, quality and progress of their learning?”* The class had over 80 undergraduate medical and dental students studying about the general characteristics of hormones. Dr. Premkumar wanted students to demonstrate their understanding of the classification system, she had just lectured on.

Before Class Began

Classification terms were printed, cut and sorted into piles.

Piles were placed in 10 envelopes with 4X4 cards that were printed with the major headings for the classification.

After The Lecture

Groups of five students were given an envelope

The whole room was engaged in learning.

Within 5 minutes, they had completed the sorting

Dr. Premkumar checked the results and provided feedback. Class debriefed with questions.

The question "How can my students and I best understand the nature, quality and progress of their learning?" comes from the book What the Best College Teachers Do by Ken Bain http://www.hup.harvard.edu/catalog/BAIBES.html.

Posted by Deirdre at 05:02 PM | Permalink | Comments (1)

Connectivism is a new teaching theory about the importance of connecting students to people, places and ideas in order to improve their learning. In medical school, we traditionally achieve this by rotating students through a variety of clinical rotations. Ideally, students would be exposed to different specialists, different locations, and diverse patients. Most universities have standardized patients who represent a variety of cultural and medical issues in their communities.

Here at the University of Saskatchewan, we, also, have the Making the Links program, whereby selected undergraduate students experience community health and development in the contexts of rural/remote health in a northern Saskatchewan community, an urban underserved community in Saskatoon at SWITCH (the Student Wellness Initiative Towards Community Health), and in the Global South in Mozambique. Making the Links exposes students to the determinants of health and the importance of community in these various settings. Making the Links is the first step to becoming a socially accountable physician.

The Future

Dr. Rajakumar, a Saskatoon cardiologist has developed an electronic conferencing tool where families, patients and specialists located in diferent locations around the world can consult on difficult cases.

Medical Learning Objects stored in electronic repositories will make preparing learning resources easier.

Increasing use of online communication will make experts and research available to larger audiences. The image below represents the locations of the 819 people from all over the world, who read one of my other teaching blogs.

This article is a continuation of the teaching techniques series
Creating Meaningful Artifacts
Active Learning-Reflection
Active Learning-Making Meaning
Active Learning-Remembering

Posted by Deirdre at 05:40 PM | Permalink

Social bookmarking has been listed as the #1 most useful technology for university professors. Why?

1. It helps you organize and refind links to articles, websites and videos.

2. It makes sharing links with students and colleagues on a website or blog easy. To see an example of this ability to share, open my other blog The Active Learning Blog Carnival, scroll down to My Delicious Tags and click on the blue links. The larger the link, the more articles are available.

To watch a video that explains Social Bookmarking in Plain English, click twice on the video below.

Unfortunately, the university blogs don't allow me to incorporate this feature.

Posted by Deirdre at 03:42 PM | Permalink | Comments (1)

There is a lot of discussion at the University of Saskatchewan about the use of medical simulation in health science education. To understand the decisions being made in this area, you need to understand that there are four distinct categories of simulation:
1. Physical Simulators
2. Human Manipulated Physical Simulators
3. Virtual Simulators
4. Virtual Environment Simulators

Physical Simulators

Physical simulators are reusable mannequins that students practise skills on such as physical examinations, injections and other invasive treatments. Using this type of simulator provides initial practice when willing patients are in short supply or when practise could be invasive, unpleasant or painful to patients. Once the student has developed an acceptable level of skill, they complete their learning with human patients. Below you can see some examples of physical simulators manufactured by Kyoto Kagaku Co. Ltd., which were recently displayed at the university.

Human Manipulated Physical Simulators

A more sophisticated level of simulator is a full body mannequin that can be manipulated by a human operator located behind a two-way mirror. This type of simulator can answer questions, raise limbs as well as be examined/draped/treated. This provides students with a more holistic simulation in which they role-play interactions with the patient. The draw back here is a high initial cost as well as an ongoing expense of an operator.

Virtual Simulators

Virtual Simulators use 3D animation to teach parts of the body (Guide to a Healthy Heart) or to teach steps in a procedure (Sim Praxis video )
Costs to create these simulations can be very high, therefore, they are often purchased as CD’s with a textbook or accessed through sponsored online sites. See also The Visible Human

Virtual Environment Simulators

The Virtual Environment Simulators are computer-based medical scenarios that usually include a 3D model of a location, equipment, personnel and patients that students enter with an Avatar. They work well for “What if?” case studies such as disaster training, pandemic planning, problem solving and modeling of unusual diagnosis that students might not encounter in their clinical experience. Costs of initial production can be lowered by using already existing virtual worlds such as Second Life, a virtual world with a higher population than the prairies. Cost per student is frequently minimal.

The video below demonstrates how science is being taught in Second Life.

For more information, see:

A Typology of Simulators for Medical Education

Clinical Skills Training in a Skills Lab Compared with Skills Training in Internships: Comparison of Skills Development Curricula

Emergency Medicine and Patient Simulation:Opportunities for Teaching, Evaluation, and Scholarship

Ethics Involved in Simulation-based Medical Planning

The Use of Simulation in Emergency Medicine: A Research Agenda

Simulation medicine in intensive care and coronary care education.

Simulation: The New Teaching Tool.

Simulation Technology in Physician Training (a podcast)

Simulation and the future of military medicine

Simulation and Modelling Applied to Medicine

Using Human Patient Simulation to instruct Emergency Medicine Residents in Cognitive Forcing Strategies

Value of a cognitive simulation in medicine: towards optimizing decision making performance of healthcare personnel.

Virtual reality simulation in carotid stenting: a new paradigm for procedural training

Anne Meyer Medical Centre Blog about the Second Life medical course
Top 10 Medical Sites in Second Life
A video about the Heart Murmur Sim in Second Life
A video about Virtual Social Worlds and the Future of Learning
A video about using Second Life for training.

Posted by Deirdre at 04:18 PM | Permalink

Assisting students to create meaningful artifacts is the third approach to active learning. Artifacts are concrete objects that students design, create and share with others. The concept of creating meaningful artifacts of student learning originates from the theory of Constructionism originally advocated by Seymour Papert of the MIT Media Lab. http://cyberartsweb.org/cpace/ht/thonglipfei/construction.html

This article will discuss the following two types of artifacts.

1. Personal Artifacts

Personal artifacts are objects shared between a student/team and a teacher and are the most traditional type of artifact found in education. Essays, project reports, creative assignments etc. are common examples. Personal artifacts are used to assess how well a student or team has achieved. This type of artifact is generally considered the property of the student/s and is returned to them after being marked. Classmates see the artifact only if the student decides to share it.

2. Learning Artifacts

Students create learning artifacts to improve the learning of their fellow students and occasionally future students as well as to demonstrate their competency. Learning artifacts help make the learning process more visible to everyone. Some examples of this type of artifact are:

Sophisticated, teaching resources: Students may have learned to produce animations and flash files in high school. These skills could be used as an alternative assignment and will provide you with an ongoing teaching resource.

Websites: Student projects and essays can be posted on a group website where they can be shared. In the following examples, papers from a graduate class from 1997 – Present are publicly available http://www.usask.ca/education/coursework/802papers/

Blogs: A Blog is an online journal where class reflections/articles can be posted and commented on. Blogs can be private to a specific class or public. For examples see http://www2.med.umich.edu/medschool/reality/ or
http://medicalstudentblogs.blogspot.com/ The university provides blogs to faculty and students at no charge. http://www.usask.ca/its/services/webpage_hosting/blogs/.

Wiki: A wiki is an interactive document that allows a group of individuals to edit content http://davidrothman.net/list-of-medical-wikis/ and can be used to create team projects, for problem-based learning, to share research articles etc. Wiki’s can be private to a specific class or public. The university provides wikis to faculty and students at no charge. http://wiki.usask.ca/ See my wiki as an example http://wiki.usask.ca/db/index.php/Main_Page

Podcasts: A podcast is an audio file that can be downloaded to a computer or mp3 player. Here is an example of a series of podcasts from the New England Journal of Medicine http://www.podcast.net/show/59568, or Texas Tech http://www.ttuhsc.edu/SOM/FamMed/TTMedCast/ttmedcast_SOAPnote.html. An RSS feed downloads podcasts to your computer automatically. Students could use software such as Audacity to create podcasts for a class website http://audacity.sourceforge.net/ or create and host them in a commercial site http://www.mypodcast.com/index.html.

Videocasts: Videocasts are a more sophisticated mashup of video and podcast. Here is an example from the National Institute of Health http://videocast.nih.gov/default.asp and here is how it might be created by students http://www.insidermedicine.com/daily-medical-news-volunteer.aspx or http://www.youtube.com/profile?user=YouthHealth. Vodcasts can be created quickly using Blogcheese http://www.blogcheese.com/

Creative Projects: Medical students at the U of S have an annual art auction and an example illustrating the history of medicine in Saskatchewan is currently hanging in the Westwinds Clinic. Activities like this could be expanded into the classroom to create multi-modal learning resources such as models, illustrations, visual mnemonics and simulations.

Posted by Deirdre at 12:20 PM | Permalink

A short video summarizing some of the most important characteristics of students today - how they learn, what they need to learn, their goals, hopes, dreams, what their lives will be like, and what kinds of changes they will experience in their lifetime. Created by Michael Wesch in collaboration with 200 students at Kansas State University.

Posted by Deirdre at 01:20 PM | Permalink

I decided that reflection deserved an article on its own. Reflection is an important aspect of helping students and residents develop a deeper understanding of the medical curriculum that is frequently avoided because it is perceived as being difficult to teach/assess. Deliberately practicing the art and skill of medicine requires reflection yet medical students and residents have to spend most of their time being in the moment; paying attention and responding rapidly to immediate stimulus within the environment. Fatigue at the end of a shift makes end of the day reflection difficult.

I thought I would start this discussion with an image provided to me by Bronwyn Hegarty

Take notice and describe the experience

There are three ways to do this actively in a clinical setting:

1. Videotape
Videotaping teamwork and patient interactions provides an artifact of the encounter that can be examined later to check perceptions and assumptions about an event.

2. Written records
Patient records, student encounter cards, diaries, blogs can record both immediate information and patterns over time.

3. Feedback
Asking the student to state what they did well, could improve and want to know more about before they receive feedback from peers and faculty provides an opportunity for students to reflect on their knowledge/skill/understanding.

Analyze the experience

Two clinical teaching techniques could prove useful in helping students become more reflective:
Precepting Using MicroSkills (one minute preceptor) http://www.practicalprof.ab.ca/teaching_nuts_bolts/one_minute_preceptor.html and Chart Stimulated Recall http://www.practicalprof.ab.ca/teaching_nuts_bolts/chart_stimulated_recall.html

Remember when using these techniques to focus on helping the student be more reflective by using open ended, analytic questions at the beginning of the encounter.

Take action

Every reflective experience should be concluded with a plan for how this experience will be used to improve learning, interactions in the future.

Posted by Deirdre at 01:31 PM | Permalink | Comments (1)

Active learning techniques fall into one of the following four categories:
1. Remembering
2. Meaning Making
3. Creating Meaningful Artifacts
4. Connecting

This article will focus on active teaching techniques that help students understand what they are learning on a deeper level (higher order thinking). Higher order thinking does not come easily to students, they need to see you role modeling your thinking process and they need opportunities to practice in a safe environment which is non-judgemental, open to alternative viewpoints, respectful of students experiences and beliefs and provides marks for risk taking and creativity. Listed below are some of the options for helping students to delve deeper into your curriculum.

Creative Attention Focus

Questioning

• Question Star
  • Brainstorm a list of at least 12 questions about the topic, concept or object. Use these question-starts to help you think of interesting questions:
  
  
  • Review the brainstormed list and star the questions that seem most interesting. Then, select one or more of the starred questions to discuss for a few moments.
  
  
  • Reflect: What new ideas do you have about the topic, concept or object that you didn't have before?
• Creative Questioning
  • Pick an everyday object or topic and brainstorm a list of questions about it.
  
  
  • Look over the list and transform some of the questions into questions that challenge the imagination. Do this by transforming questions along the lines of:
    • What would it be like if…
    
    
    • How would it be different if…
    
    
    • Suppose that ...
    
    
    • What would change if ...
    
    
    • How would it look differently if …
  • Choose a question to imaginatively explore.
  
  
  • Reflect: What new ideas do you have about the topic, concept or object that you didn’t have before?
• Thinking Keys (Stephanie Martin created)
  • Form: What is it like?
  
  
  • Function: How does it work?
  
  
  • Connection: How is this like something I have seen before?
  
  
  • Reflection: How do you know?
    
• Case Based
  
  • Begin with a case that doesn't have a clear solution
  
  
  • Ask students to explore issues, assumptions, or questions before trying to solve the case.
  
  

  Write, Pair, Share

  • Write or draw an idea, a question, an argument
  
  
  • Discuss with one or more other students
  
  
  • Share (discuss, post)
  
  

  Brainstorming

  • Definition : Coming up with as many ideas as possible no matter how absurd. The Absurd inspires solutions that are more creative.

  Viewpoints

  • Roleplay from the point of view of someone else
  
  
  • Ask “What would ….. think about this theory, or event?”
  
  
  • Tug of war: Ask for tugs, reasons for supporting each side.

  Compass Points

  Compass Points is a method of organizing students thinking into four categories:
  
  1. What do students need to know/find out more about?
  
  
  2. What gets them excited about this issue or theory?
  
  
  3. What concerns/worries the student about this theory/issue?
  
  
  4. What suggestions does the student have for next steps? or Where do they currently stand on this issue/theory?
  
  

  Explanation Game

  • Display an object, an image, a video
  
  
  • Instructor says “I notice ….”
  
  
  • Ask “Why do you think it happened that way or it is that way?”
  
  
  • Ask “What makes you think …?”

  Claim, Support, Question

  • Draw three columns
  
  
  • Insert a theory in the first column
  
  
  • Ask students what supports that theory or questions the theory
  
  
  • Discuss “What is criteria for evidence?”

  Option Diamond

  The Option Diamond allows students to expand their thinking and be more creative about possible options. Draw the following image on the board, fill in the two options and the compromise but focus most of your attention on the creative option at the top.
  

  
  

  Posted by Deirdre at 10:23 AM | Permalink

Active Learning is a teaching strategy that encourages students to write/type, click, discuss, act and create in order to engage in the learning process. Students who are engaged in learning are more likely to remember what they learned over time.

Edgar Dale Cone of Experience Media by Jeffrey Anderson is licensed under a Creative Commons Attribution-Share Alike 3.0 United States License.
Based on a work at www.edutechie.ws

Active learning techniques fall into one of the following four categories:

Remembering
Meaning Making
Creating Meaningful Artifacts
Connecting

This article will focus on teaching techniques that improve memory.

Helping Students’ Remember

Cognitive scientists have shown that active learning helps students:

1. pay attention
2. connect new knowledge with previously learned content
3. retrieve information/processes when needed.

Active Pause - Pausing to allow students to refocus their attention is a favourite technique of lecturers. Pausing and asking students to write down their ideas, answers to questions, etc. makes the pause technique active.

Active Reading/Listening - Before asking students to read an article or watch a video or listen to a lecture, give them two or three questions to focus their attention and interaction with the content. Creating online reading and listening resources allows students to click on links for more information. Innertoob is a unique tool that allows you to add questions and comments to audio http://www.innertoob.com/

Memory Aides/Mnemonics – Our memory retrieval is limited to about seven items, but you can increase that number by linking items to other items either numerically (There are seven steps) or alphabetically (Dow Jones Industrial Average Closing Stock Report": Duodenum, Jejunum, Ileum, Appendix, Colon, Sigmoid, Rectum.) For more ideas, see http://www.medicalmnemonics.com/ . Memory aides are most effective if you challenge students to create them.

Mindmapping – Creating a visual image of how information links to other information will help students store new knowledge in an easily retrievable format. Visual mnemonics is a type of mindmapping that uses images instead of words http://www.ttuhsc.edu/SOM/Success/images/peptgly.jpg . Here is a site that lists mindmapping software, http://www.mind-mapping.org/ and a site for creating collaborative mindmaps http://www.mindmeister.com/

Online drill and practice – WebCT, PAWS or class websites can have drill and practice utilities such as Hot Potatoes http://hotpot.uvic.ca/ added.

Rapid Response Games – Both competitive games like Jeopardy and solitary games like Snakes and Ladders have been used in medical education to make memorization enjoyable. Ask Educational Support and Development for information on educational games.

Simulations – Simulations are becoming increasingly popular in medical education. Here are some examples http://www.hhmi.org/biointeractive/vlabs/index.html and http://www.sp.tamucc.edu/pulse/

Singing/Rhyming –Similar to mnemonics the beat of a song or rhyme increases the amount of material that can be retrieved. See an example at http://www.youtube.com/watch?v=KXROnzpsrlg

Student Response Systems (Clickers) – Clickers are used during class to check student’s previous knowledge about a subject, to give feedback during class about what is being learned and to affirm how much students have learned at the end of class. The College of Medicine has installed clickers in the main lecture theatre and has portable sets available.

Posted by Deirdre at 10:59 AM | Permalink

This article is a continuation of the articles about Cognitive Error and Teaching Problem Solving

At a recent presentation Carl Wieman, a Nobel Laureate physicist talked about how the K-12 and undergraduate education systems had failed to meet the needs of science because these systems were not teaching students to think like scientists. Instead, science was often taught as a series of formulas and facts to be memorized; as something frozen like a mammoth in time.

Dr. Wieman went on to say that if we taught science in the way we do science, we would:

 Practice based on good data

 Utilize research on how people learn

 Disseminate results in a scholarly manner & copy what works

 Utilize modern technology.

So let’s take a minute to examine what he says in terms of how we teach medicine.

Practice based on good data

We have made a lot of progress in developing students who are able to discriminate between good and bad data through our emphasis on evidence-based medicine. With 10,000 new books and online articles published every month, how can we improve our students’ life long need to search out new information?

Utilize research on how people learn
For 50 years, we have ignored the educational research that says the lecture method is ineffective. I sometimes think that we are like baby ducklings that are imprinted to follow our professors. We find it almost impossible to give up our place at the front of the stage.

For 30 years, cognitive scientist have told us about how much the brain can retain in short term memory, yet we continue to stuff medical students with the richness of our knowledge and are surprised at their starvation of knowing.

For 30 years, medical education research has told us that active learning increases retention, yet medical students passively continue to sit waiting for question period at the end of sessions.

Does your department have a subscription to a medical education journal?

Disseminate results in a scholarly manner & copy what works

Does your department encourage research into the best way to teach your medical specialty? Does your department actively seek grants and inter-university initiatives in educational scholarship? Who in your department last published an article in one of the numerous medical education journals? Did you read it?

Utilize modern technology

Physicians are great users of medical technology and advocate for the purchase of new equipment when it becomes available. In terms of educational technology, many of us are like the immigrant who refuses to learn English and depend on our children to negotiate our way.

Who in your department is using innovative technology to teach? How many of the following do you use?

 Educational games
 Clickers
 Simulations
 Blogs
 Wikis
 Social Networks
 Elluminate
 PAWS
 Tagging software
 Videocasts
 Podcasts
 Image banks
 Personal website
 Class website

Posted by Deirdre at 06:28 PM | Permalink

The following article is written by the Maastricht School of Health Professions Education about the study Bas de Leng, Diana Dolmans, Margje van de Wiel, Arno Muijtjens.
Medical Education 2007; 41; 181-188.

The more authentic the case, the better it triggers learning, at least that is one of the popular mantras in medical education today. But how to apply this wisdom and achieve authenticity in preclinical education where real patients are at a premium? Video cases have been suggested as a potential solution. But are they?

Studies have said about video cases:
- they can present a holistic picture of patients;
- they allow students to make observations unfiltered through a professional's perspective;
- they convey emotion and non-verbal cues;
- they are more congenial to the MTV generation student, who is typically hooked on visual images.

But what if we apply the real litmus test to video cases? Do students really learn from them, better than from less authentic, paper cases? Does all the hard work put into producing and delivering them pay off? This is what Bas de Leng and his colleagues set out to investigate. They conducted a focus group study to pinpoint the additional value, if any, of video cases as experienced by second-year undergraduate medical students and they picked the students' brains on what promotes the productive use of video cases. The students had been exposed to text-based cases and some fifteen video cases (3 to 20 minutes), including a patient in pain making a strong emotional appeal to the doctor, advanced trauma life support, 3 patients with chest pain and differing pathophysiology. The key messages from the students on the additional value of video cases and their productive use are listed below with illustrative quotations.

Additional value ofVideo cases:

are more authentic: "A physician uses his eyes first … He sees signs and symptoms and detects certain clinical pictures. We read about them in books and sometimes have little idea of how to visualise them …."

present a comprehensive picture: "In a video on shock. We had to compare 3 patients … What was good was that we started to pay attention to details. What is pale skin, what is red skin? In a text you just read red skin, it is a given."

are motivating and challenging: "A video on behavioural disorders showed a child just sitting there crying … and you did not know what was going on. You want to know what is wrong with that child. The image is challenging of itself; it really moves you."

are better retained in memory: "Yes, the image, like that epileptic patient, I can still picture it in my mind."

Productive use

The contents should not be too complete or directive: "… things were explained and the video did not engage your curiosity, it raised no questions"

The degree of difficulty should be appropriate: "Seeing an endoscopy … after having learned about the anatomy of the bowel and then being asked what do you see here … now that would be really interesting …."

Cases should be watched in a structured fashion: "… we had to compare and describe 3 patients with similar symptoms. Next we had to figure out who had had an infarction. That was a different way of watching a video … Your are motivated and made to think."

The cases should be brief and unique: "With the arthrosis cases, the second video was structured in exactly the same way, only with the questions about the hip instead of the knee. That video we just did not watch at all."

The students' messages appear to confirm advantages described in the literature, i.e. a holistic picture and emotion, visualisation of disorders to help students connect mental representations to the real world and thereby make them stick in memory. The importance of directions and structure supports that it is mistaken to assume that video cases require little effort. Because visual information is ambiguous, directions are needed to preclude too little attention for important elements or too much attention for extraneous elements. Cases should be tailored to students' current knowledge, match curricular objectives and offer cues, but not too many, because the aim is to stimulate elaboration not stifle it.

Finally, the authors propose observational studies and studies of specific attributes of video as a medium. For now, the conclusion seems to be that, provided certain conditions are met, video can actually increase authenticity and help students learn and remember.

http://www.unimaas.nl/default.asp?template=werkveld.htm&id=5KG5BU01QFTIH0H14H0P&taal=nl

Posted by Deirdre at 01:29 PM | Permalink

I started thinking about this topic during a presentation on the ROME II Criteria for IBS. An internal medicine resident said with great sarcasm, “If she’s overweight and depressed, she probably has irritable bowel syndrome.” No one in the audience challenged him on this statement.

Subsequently, I had several discussions with clinical teachers about how hard it was to give feedback to students whose medical knowledge was extensive, but who were unable to accurately diagnose or treat patients because they were making irrational inferences about or from their knowledge. When a resident has invested time, ego and energy into a particular diagnosis, it can be difficult to move them in a different direction. In some cases, the resident is so invested that s/he will respond inappropriately to suggestions they have made a mistake.

Thanks to Dr. Keith White’s presentation on medical error at the Rural and Remote Conference, I realized that many clinicians were unaware of how to diagnose cognitive errors in their students clinical reasoning. A 2005 study published in Archives of Internal Medicine found that cognitive error is the single most common cause of diagnostic errors. This post hopes to begin to help clinical teachers help students correct errors by examining four common types of cognitive error.

1. Confirmation Biases

A 37-year-old woman is severely anemic. She has previously been diagnosed with celiac disease, which causes malabsorption, and she is told to increase her iron intake. Several months later when she doesn’t improve, she is discovered to have a small tear in her esophagus. She had mentioned the pain when swallowing previously, but this symptom had been under investigated.

Confirmation biases cause you to look for proof of your diagnosis while ignoring factors that might disagree with it. They are the result of errors in cognition combined with the fast paced decision making required in many family practices and emergency rooms. These errors are frequently based on:

Availability/routine
When you see a lot of X or have studied a particular diagnosis recently, you tend to be looking for it. Ex. You have seen 6 cases of flu this week and here’s another one. You only see the symptoms of flu you are looking for and ignore the symptoms of food poisoning.

Diagnosis Momentum
When a patient has been diagnosed with A previously, the assumption is that A was a correct diagnosis and that present symptoms are probably related to the previous diagnosis. This is more likely to occur when the initial diagnosis came from an authority figure, but has also occurred when a patient self diagnoses (I have a migraine).

Lack of Experience
Lack of experience may cause the student who does not understand the variability of human biology to depend on textbook knowledge or medical studies that are incomplete. On the other hand, the student may have used the same diagnosis successfully in another situation and were hoping for the same results.

Search Satisfaction
The student may stop searching when one diagnosis is made and not look for other problems.

Overconfidence
The student is so invested in proving themselves right that the patient may be at risk. This is linked to the tendency to believe that one’s previous decision-making was better than it was. Hindsight bias, the assumed ability to see how errors were made in the past can contribute to overconfidence.

2. Attribution Errors

A 65-year-old man arrives in emergency on a very busy Friday night. Joe is unconscious after being found in an alley outside the local bar. He is well known in the ER as being severely alcohol dependent, and he is placed in a bed “to sleep it off”. When the doctor goes to send him home in the morning, Joe isn’t responding and upon examination he is discovered to be the victim of a car accident.

When stereotypes about a race, gender, religion, age, addictions etc. result in misdiagnoses, the underlying assumption is frequently that this person is judged unworthy of full attention because they are … Other examples I’ve heard are: “He lied about his military service, I don’t want him (a patient with a history of psychiatric illness) in my hospital”; “Here’s another woman with mysterious abdominal pain (a woman with a perforated uterus).” In each case, attribution errors led to misdiagnoses.

A subsection of attribution errors is liking the patient too much and not wanting to cause them pain or embarrassment, so you don’t ask them questions about their sexual history, don’t examine them for prostrate cancer, don’t ask about sleeping pill use etc.

3. Commission Bias

A 45-year-old man with terminal bone cancer is unresponsive when the resident enters the room. He successfully resuscitates the man and then remembers the DNR order.

Commission bias is the result of overwhelming internal or external pressure to do something NOW rather than wait. Doctors want to help patients and their fearful families. Antibiotics, painkillers and sleep aids have all been over administered because of commission bias. Aggregate bias or the ordering of tests and x-rays when the guidelines don’t recommend them is a form of commission bias. Omission bias is the other side of this coin and results in the student doing very little in the hope of avoiding errors.

4. Investigation Errors

A 56-year-old woman comes to emergency with pain in her left, back shoulder and a feeling that something isn’t right. The patient is given medication for indigestion and send home. Two hours later, she returns because of heart failure.

Our job as clinical teachers is to help students learn from and correct mistakes so they don’t developing habits of thinking that are ineffective and unhealthy. Investigation errors are primarily the result of asking the wrong questions because of the following factors:

Anchoring
The tendency to rely too heavily, or "anchor," on one trait or piece of information when making decisions, can lead to search satisfaction and other confirmation biases.

Base Rate Neglect
Under or over estimating how common a disease is in a community, gender, ethnic group etc.

Framing Effect
The way a patient is described influences clinical reasoning. Some students may be unable to pick up key words and nonverbal cues from nurses, patients and family members to make judgments about severity, frequency and urgency because of fatigue, coming from a different culture or inexperience. Others may rely too heavily on the frame and fail to look at the bigger picture. For example, when a patient is labeled as having fever, shortness of breath and cough, the student may jump to a diagnosis of pneumonia in a patient with pulmonary embolism.

Fear
Fear of death, fear of failure, fear of uncertainty can lead to avoiding patients with possible unpleasant outcomes. Some students become overly rational/clinical (as if the patient is an experiment) to cover the irrational fear. See the movie Wit for an example. Others become overly dependant on guidelines/evidence because their fear of failure is pushing them to the safety of outside expertise/authority.

The Last Bad Experience
If a student makes a serious error, they can run away, cover up, bluff it out, avoid or they can fight, be overly vigilant, obsess.

For more information, see previous posts on
Teaching Issues of Diversity http://blogs.usask.ca/medical_education/archive/2006/04/teaching_issues.html

Preparing Students to Work with Addiction Issues http://blogs.usask.ca/medical_education/archive/2006/08/preparing_stude.html

How Doctors Think Introduction
http://blogs.usask.ca/medical_education/archive/2007/04/how_doctors_thi.html

References

Croskerry, P. (2003) When diagnoses fail, The Canadian Journal of CME: 79-87
Crosskerry, P. (2003)The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine: 78(8):775-780
Groopman, J. (2007) How doctors think, Houghton Mifflin
Mazor, K. et all (2005) Teaching and medical errors Medical Education Journal:39:982-990
Redelmeir D. (2005) The cognitive psychology of missed diagnoses Annals of Internal Medicine Volume 142 Issue 2 | Pages 115-120
Wade, M. (2007) 26 Reasons What You Think is Right is Wrong http://www.healthbolt.net/2007/02/14/26-reasons-what-you-think-is-right-is-wrong/
Wikipedia Cognitive Distortion http://en.wikipedia.org/wiki/Cognitive_distortion

Posted by Deirdre at 11:47 AM | Permalink

The following assessment methods are used to assess clinical problem solving:

1. The script concordance test (SCT) assesses clinical reasoning in the context of uncertainty. Because there is no single correct answer, scoring is based on a comparison of answers provided by examinees with those provided by members of a panel of reference made up of experienced practitioners.

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2929.2005.02092.x

http://www.came-acem.ca/Newsletters/Volume%2013-2/Charlin%20SCT%2013.2.doc

http://www.formatex.org/micte2006/pdf/1143-1147.pdf

http://www.cme.umontreal.ca/tcs/shared/response_to_Bland_29June05.pdf

2. Observations of complex problem solving can be arranged using audio/video recordings of patient interactions or by acting as a neutral observer. Video recording is particularly useful because student’s can self evaluate and will have less opportunity for the “he said, she said” defense. Checklist and narrative assessments would be useful for recording the observations.

http://www.stfm.org/teacher/1999/julaug/julaug.html

http://www.uchsc.edu/CIS/UsingVideo.html#anchor1668279

http://www.uab.edu/uasomume/cdm/observe.htm

http://www.msu.edu/~dsolomon/r0000003.pdf

3. Problem differentiation cases use examples of history and examination findings that are similar except for one or two key points. This is useful to assess the student’s pattern recognition skills.

** http://cpsc.acponline.org/

http://www.med.uiuc.edu/FacultyDev/TeachingSkills/ProblemBased/CaseStudies/writing%20test%20questions%20for%20PBL.pdf

http://www.pbli.org/pbl/pbl.htm

4. Self-reporting inventories such as the Problem Solving Inventory (PSI) can be useful in assessing the student’s ability to recognize the level of their skills.

http://www.nncc.org/Evaluation/topic3.html#anchor42151378

http://findarticles.com/p/articles/mi_qa4040/is_200304/ai_n9217193/pg_3

http://tcp.sagepub.com/cgi/content/refs/32/3/429

5. Use the RIME method to assess where the student is performing on a 4-point scale (Reporter, Investigator. Manager, Evaluator).

http://www.stfm.org/fmhub/fm2007/March/Dan161.pdf

http://www.med.uiuc.edu/FacultyDev/Evaluation/RIME/index.php

http://www.usuhs.mil/med/evaldevprofskills.htm

http://www.aemj.org/cgi/content/abstract/12/5_suppl_1/117-b

Other Resources

Evaluation of Teaching and Learning Strategies
http://www.med-ed-online.org/f0000024.htm

Posted by Deirdre at 06:27 PM | Permalink

Case
The following case illustrates how good problem solving requires more than medical knowledge.

An 18-year-old student and her boyfriend come to emergency because she is having trouble breathing. She has a history of viral asthma and her parents had always accompanied her in previous emergencies. Upon examination, the resident determines that she is not having an asthma attack and takes the boyfriend aside and tells him she is faking and walks away. A month later, she arrives by ambulance, unconscious after trying to walk to the hospital alone because her boyfriend assumed again that she was faking and refused to take her to the hospital.

Let’s assume that the initial diagnosis of “not an asthma attack” is correct, where did the resident fail in his diagnostic and therapeutic management?

Attribution error: The resident’s use of the term “faking” says a lot about why he overlooked talking to the patient about whether stress (leaving home, exams, boyfriends) had led to contracting an irritated airway and did not suggest she find a family doctor for management of her asthma. If she was indeed faking, then he didn’t make any attempt to identify why because attribution is a common reason for making the value judgement that someone is not worthy of thorough care.

Ethical error: The resident told the young man the patient was faking, but did not tell her what he thought.

When designing an assessment plan, the following steps should be followed:
1. Review the components of a useful assessment plan
2. Review the objectives for the rotation
3. Determine what specifically your plan will test
4. Identify assessment tools
5. Plan how students and college will receive results
6. Train the administrators
7. Evaluate utility of the plan

1. Review the components of a useful assessment plan
According to Dr. Gordon Page from the UBC College of Medicine, his research has shown that the Utility or usefulness of an assessment plan can be expressed by the following formula: U = R X V X E X A X C

Reliability is the result of increasing preceptor experience with a tool and evidence that the device tests what it is supposed to test. A single instance of student performance is not considered reliable in medical training.

Validity in a clinical setting is the result of testing for application of knowledge not recall, diagnostic and therapeutic reasoning not thoroughness, and an adequate sampling of behaviour (6-10 observations).

Educational impact is a combination of the impact this testing device has on the student, preceptor and institution.

Acceptability by the student, preceptors and institute is a key factor of ongoing utilization.

Cost is the final element.

A combination of paper cases and direct observation meets the above utility requirements better than cases or observation alone.

2. Review the objectives for the rotation
Problem solving objectives should have been included in the student orientation to the rotation. As previously discussed, an example can be found here http://www.hsc.stonybrook.edu/som/solving.cfm.

3. Determine what specifically your plan will test
Ask yourself and colleagues “What behaviour will tell me that a student has achieved the objectives?” The more specific and observable the behaviour the easier it will be to test. Ex. Student uses appropriate social and cultural criteria when making a therapeutic diagnosis rather than Student doesn’t make attribution errors.

4. Identify assessment tools
If you need to create assessment tools rather than using ready-made instruments, please consult with the assessment specialist in Educational Support and Development or some other group with experience in creating assessment devices.

5. Plan how students and college will receive results
If assessment is being done primarily to improve learning, then a feedback process needs to be determined. Written and verbal feedback are both useful at this stage. If you are assessing competence at the end of a rotation, then a more formal process needs to be determined.

6. Train the administrators
Observation of problem solving and giving feedback are skills that faculty may feel inadequately prepared for to administer.

7. Evaluate utility of the plan
The best laid plans ……

Stay tuned for the next installment on testing methods.

Posted by Deirdre at 01:11 PM | Permalink | Comments (1)

First year Family Medicine residents were able to arrive at the correct diagnosis for only 25% of the presented (complex) problems – Norman, 1994

1. Pattern recognition (illness scripts, schema) is the result of years of clinical experience; this recognition is associated with higher rates of successful diagnosis (Coderre, 2003.)


2. Forward-based reasoning works well for routine and well-researched medical problems. Standard clinical teaching follows a pattern whereby several diagnostic hypotheses are generated from the patient’s signs and symptoms, then additional information is sought to confirm or refute individual hypotheses.


3. Backward reasoning means guessing at an explanation and working backward to find data that supports the explanation. Novice doctors have a tendency to use backward reasoning and should be encouraged to use this strategy for non-routine, complex cases but not those that are routine and/or well-researched.

Steps for Teaching Problem Solving

Step 1: Identify the problem solving objectives for your student
The information on the following website might be useful for identifying learning objectives http://www.hsc.stonybrook.edu/som/solving.cfm

Step 2: Reinforce problem-solving steps in clinical settings

Researching the problem
Consistently use a Subjective (what is the patient saying, what is the family saying), followed by Objective (what does the examination and tests tell you) process for patient presentation, so the student becomes used to thoroughly investigating the problem, both scientifically and affectively/culturally. Having the student draw a decision tree http://dms.irb.hr/tutorial/tut_dtrees.php may also be useful in helping them identify gaps in their investigation.
Teach students to use close-ended questions (What medication are you taking?) for diagnosing standard problems and open-ended questions (What issues is the abdominal pain causing in your day-to-day life?) for more complex problems.
Question the student to help them pinpoint gaps in their approach: “Are their other systems involved? Is there something you missed or are unclear about in the initial examination? What other information do you need that isn’t readily available? What was difficult about this patient? What assumptions are you making (possible attribution errors) about this patient?”
Differential diagnosis
You can assist students to begin to recognize patterns as well as recall previously learned information by involving them in a large number of cases, thinking out loud so the student sees your pattern making and asking questions like “What were the major findings that led you to this conclusion? What else could it be? Have you seen anything similar before? Is there something different about this case from other cases you have seen or read? What is the pattern here? How would you categorize this problem? If xxx changed, how would you approach the problem?”
Selecting criteria for possible treatment options
Ask the student “Given what you know about the patient subjectively and objectively what should be considered before suggesting a treatment plan?” There are factors that influence compliance with treatment that physicians need to consider before deciding on a therapeutic diagnosis that novice doctors may not be aware of such as the following:

• affordability


• resources in the home community or neighborhood


• cultural or religious practices


• age


• support systems


• other medical issues

Help the student to check the validity of any biases that might result in attribution errors (an unjustified tendency to assume that a person's actions depend on what "kind" of person that individual is rather than on the social and environmental forces that influence the person).
Therapeutic diagnosis
Use One Minute Preceptor technique to clarify the student’s decision-making process. http://www.oucom.ohiou.edu/FD/monographs/microskills.htm
Evaluating the solution
Metacognition or the process of thinking about how one problem solves is an important step in improving student skills. Metacognition is the result of two components in the learning environment: written reflection and probing questions from peers and instructors. Questions such as the following can be useful in creating a more reflective mind set: “What did you learn from this patient? How could you have involved other people (family, community groups, nurses) in the care of this patient?”

Students need opportunities to be challenged by cases that are more complex or difficult to define. They also need opportunities to correct mistakes safely because it is through practicing non-routine decision-making that critical thinking skills are honed. On the other hand, student and patient physical and emotional safety must be ensured if you want the student to continue to increase their skills.

References
Coderre, S. et all, Diagnostic reasoning and diagnostic success Volume 37, Number 8, August 2003, pp. 695-703.
Norman, G.R. et all, Cognitive Differences in Clinical Reasoning, Teaching and Learning in Medicine, Number 6, 1994 , pp.114–20.

Web Resources
Teaching students to think like physicians http://www.uab.edu/uasomume/cdm/issue6.htm
Teaching problem solving and decision-making https://www.cu.edu/academicaffairs/assessment/assessment_toolbox/documents/TchngPrbSlvMedEd_000.pdf
Internal Medicine Clinical Teaching Unit: Is it an Inappropriate Site for Student Learning?
http://www.leaonline.com/doi/abs/10.1207/S15328015TLM110402?journalCode=tlm
View box exercises for teaching problem solving http://www.ajronline.org/cgi/reprint/128/2/271.pdf

Posted by Deirdre at 12:15 PM | Permalink | Comments (2)

This is the first in a series of postings about teaching medical problem solving.

The following five steps in problem solving can each create unique stumbling points for students and novice doctors:

1. Researching the problem


2. Differential diagnosis


3. Selecting criteria for possible treatment options


4. Therapeutic diagnosis


5. Evaluating the solution

Researching the problem

Medical history taking, examination and reviewing test results are the standard first steps in patient problem solving. Two common mistakes can be made at this point:

1. not asking the right questions - Novice physicians are particularly prone to not asking the right questions because they do not have the vast storehouse of experience to make connections in new or unique situations. They may also not have a clear understanding of affective or cultural influences in the patient’s life.
2. listening in order to record rather than with a problem-solving ear.

Differential diagnosis

The differential diagnosis process based on medical evidence for standard medical problems works well. Every supervising clinician should be aware of the following issues that can lead to medical errors:

1. attribution errors - an unjustified tendency to assume that a person's actions depend on what "kind" of person that person is rather than on the social and environmental forces that influence the person. An example from the book How Doctors Think - a woman comes in severely underweight; the physician thinks woman + underweight = anorexia and proceeds under that assumption without identifying the celiac disease that was the problem. Another example would be the drug abuser who tells an untrue story about what brought them to the emergency room; the physician thinks drug addict + lie = manipulating for more drugs and the physician misses seeing a brain injury.
2. assuming that scientific evidence is applicable beyond the parameters of the study. For example, studies done on men are assumed to be applicable to women or studies done on one race are assumed applicable to all races.

Selecting criteria for possible treatment options for this individual

There are factors that influence compliance with treatment that physicians need to consider that novice doctors may not be aware of such as the following:

1. affordability
2. resources in the home community or neighborhood
3. cultural or religious practices
4. age
5. support systems
6. other medical issues

(It is important to avoid attribution errors by not assuming a person is a stereotype.)

Therapeutic diagnosis

Novice doctors may run into difficulty in the following situations:

1. a previous diagnosis is assumed to be correct, therefore previous treatment is continued
2. the patient has complex problems combined with multiple therapies by multiple practitioners
3. the patient follows homeopathic or other health practices which may not be disclose under questioning such as “what drugs are you taking?”

Evaluating the solution

Ongoing reflection is an important skill for physicians, but students may not have an opportunity to receive information on what happened to patients after their brief encounter. This is particularly problematic when sub-optimal care results in short term solutions that create long-term issues that the student is not aware of.

Another issue that arises occasionally for students is the lack of resources available to deal with medical error in a constructive solution oriented way rather than punishment oriented (self or authority).

Posted by Deirdre at 02:47 PM | Permalink | Comments (1)

Active learning is a teaching method that resulted from studies about how the brain stores information. Students that interacted with content through a combination of reading, writing, drawing, discussing and reflecting were more likely to remember that content than did students who passively listened to what the faculty member said. Most active learning techniques take less than five minutes of class time. To listen to a broadcast about active learning, see my website http://www.medicine.usask.ca/cbf/podcasts

Active learning techniques that could be used in medical education include:
1. The "One Minute Paper"
2. Class wikipedia (online encyclopedia or definitions)
3. Write, pair, share
4. Muddiest (or Clearest) point
5. Daily journal
6. Compare notes
7. Reading quiz
8. Clarification pauses
9. Scavenger hunts
10. Student summary of another student’s answer
11. Deposit questions in The Fish Bowl
12. Flash cards
13. Puzzles/Paradoxes
14. Evaluation of another student’s work
15. Active review sessions
16. Concept mapping
17. Visual lists
18. Role playing
19. Panel discussions
20. Debates
21. Educational games

For more information about these and other active learning techniques, sign up for the Educational Support and Development series on Active Learning. http://www.medicine.usask.ca/education/support/programs_bytitle/

Some websites that explain these techniques in more depth include:

http://blogs.usask.ca/medical_education/archive/2006/03/active_learning.html
http://cte.umdnj.edu/active_learning/active_general.cfm
http://www.vcu.edu/cte/activelearningtechniques.html
http://www.calstatela.edu/dept/chem/chem2/Active/
http://teaching.ucsc.edu/tips-actvlearn.html

Some websites with resources that might be useful for creating active learning include:

Concept Mapping http://mindmeister.com/
Crossword Puzzle Maker http://www.crossword-compiler.com/
Medical Mnemonics http://www.medicalmnemonics.com/
Online Games Generator https://egames.clsllc.com/
Thiagi Game site http://www.thiagi.com/freebies-and-goodies.html
Usask Blogs http://www.usask.ca/its/services/webpage_hosting/blogs/
Usask Wiki http://wiki.usask.ca/

Posted by Deirdre at 04:10 PM | Permalink

I recently had the pleasure of a first appointment with a specialist about some health issues I've been dealing with. As part of his history taking, he asked me questions about general health and surgeries (pretty standard stuff). The difference was he really listened to what I was saying from a problem solving (not a recording perspective) and came up with a diagnosis for a chronic health problem that had never been suggested before even though I had told 7 doctors in the last 10 years about my concerns. He then gave me material to read about his diagnosis and I went and did some research on my own that supported what he had told me.

Contrast this experience with one I had in my early twenties where I went to my doctor with severe stomach cramps. The physician introduced me to the young doctor he was teaching as another woman with mysterious stomach pain. Beyond my frustration at being typecast in that manner, I knew what was wrong but was not being listened to. A week later, I had emergency surgery for the very issue I had tried to explain. This doctor failed me as a patient but he also failed as a role model for his student.

I was of course personally interested in the specialist's ability to diagnose, but I was also professionally interested in how we teach differential diagnosis. I recently ordered a book called "How doctors think" http://www.amazon.ca/Doctors-Think-Jerome-Groopman-M-D/dp/0618610030. Dr. Groopman believes that some preventable medical errors are a direct result of not listening to the patient because we place them into categories such as women with mysterious abdominal pain (attribution errors) or rely on diagnoses from previous medical professionals that may have been incomplete.

I plan on doing a series of posts from this book when it arrives.

Posted by Deirdre at 10:09 AM | Permalink | Comments (4)

"Different kinds of experiences lead to different brain structures" - Dr. B. Berry, Baylor College of Medicine.

According to Marc Prensky, http://www.marcprensky.com/writing/default.asp in his article Digital Natives, Digital Immigrants, children born in North America after 1985 are radically different from the previous generations because they have always had digital resources in their homes and schools, they are native speakers of technology. To these digital natives instantaneous global access to people and resources has always been available at the click of a mouse; music has always been personally portable/shareable; photographs and video are for sharing with friends and relatives. In other words, vast amounts of information are instantly available in multimodal and frequently interactive formats.

To quote Marc "Educators have slid into the 21st century—and into the digital age—still doing a great many things the old way. It's time for education leaders to raise their heads above the daily grind and observe the new landscape that's emerging. Recognizing and analyzing its characteristics will help define the education leadership with which we should be providing our students, both now and in the coming decades."

According to Susan El-Shamy in her book Training for the new and emerging generations, digital natives learn differently. They need:

1. fast paced, highly stimulating presentations
2. increased interactivity with the content and each other
3. information that relates to the learner’s world
4. multiple options for obtaining knowledge.

Medical education can respond to the needs of these students by increasing the amount of :

• multimodal content (graphic, auditory, hands on)
• active learning (read, write, discuss)
• experiential/contextual learning (job shadowing, simulation labs)
• problem based learning, team projects.

Posted by Deirdre at 12:11 PM | Permalink

Here is a 7 minute video about how to improve your presentation skills. Click on the image twice.

Posted by Deirdre at 02:55 PM | Permalink

Are you mentoring premedical students? Check out the new Wiki http://more.studentdoctor.net/wiki/index.php/Main_Page. The information is primarily American but this is a great opportunity to add Saskatchewan to the information since Wiki's are meant to be edited.

Posted by Deirdre at 04:44 PM | Permalink

There is a lot of discussion about what mentoring in medical education looks like but very little discussion about what mentoring is not. Part of the confusion is because people may have multiple roles in a mentee’s life and it is difficult to understand the boundaries between those roles. In each of the situations listed below, the mentor may also be a supervisor, expert or friend.

A mentor is not a supervisor
A supervisor is responsible for evaluating and career decision-making. Roles that are not consistent with the trust and risk taking required in a mentoring relationship. A supervisor has an organizationally determined job description that may be incompatible with the mutual negotiation required when mentoring.

A mentor is not an expert
An expert is someone who offers his or her expertise in a one-way, predetermined flow of knowledge. Experts are called in to analyze, evaluate and solve problems. Mentors assist the mentee in identifying, evaluating and solving problems that are the mentee’s responsibility

A mentor is not a friend
Friends offer a social and supportive system that centre on enjoyment and support in times of personal questioning. A mentor is primarily a professional support person who facilitates new learning experiences and assists with professional connections.

Posted by Deirdre at 02:00 PM | Permalink

The American Association of Medical College's newsletter has an article on mentoring http://www.aamc.org/members/facultydev/facultyvitae/fall06/feature.htm

"Studies of mentoring in the health professions find real benefits for faculty at all career stages. Compared to those without mentors, faculty with mentors demonstrate higher levels of the following success factors:

-Teaching effectiveness, evidenced by declines in teaching anxiety and improved student ratings of teaching effectiveness
-Research productivity
-Professional socialization and interactions with colleagues
-Salary levels; and satisfaction with salary and promotion"

Posted by Deirdre at 12:32 PM | Permalink

A Critical Friends Group is a professional learning community consisting of approximately 8-12 educators who come together voluntarily at least once a month for about 2 hours. Group members are committed to improving their practice through collaborative learning. For more information see http://www.nsrfharmony.org/faq.html#1

This seems like a great way to introduce new and innovative teaching methods to the College of Medicine

Posted by Deirdre at 10:29 AM | Permalink

How we teach is mediated by our own preferences and experiences of learning. Those experiences were often influenced by theories of learning popular in the educational institutions at the time we attended. Becoming a medical educator means thinking about these theories and how they could change the way we teach.

The aspects of learning obscured by one theory are illuminated in another -M. Driscoll

1. Behaviorism (1890’s)
• a direct result of industrial age’s need for workers
• theorists Watson, Thorndike, Skinner
• people are motivated to learn by a stimulus system of rewards and punishments
• goal is behavioural change (shape the student to requirements of labour)
• hierarchal/regimental in structure
• instructor is the transmitter of knowledge


2. Cognitivism (1950’s)
• a direct result of early research about rapid learning in military environments combined with research into cognitive processing
• theorists Piaget, Wilson, Ryder, Gagne
• based on a process of systematic chunks of information, process, encode, product (information processing model)
• focus is a change in thinking (Gagne’s Events of Instruction)
• people are motivated to learn by attention, relevance, confidence, satisfaction
• programmed learning modules
• instructor involves learners to increase memory storage


3. Constructivism (1970’s)
• a direct result of increasing levels of education and research in early child development
• theorists Vygotsky, von Glasersfeld, Bruner, Jonassen
• people are motivated to learn by the context in which they interact (subculture, discipline, hobby)
• problem-based learning, inquiry learning
• the instructor should try and encourage students to discover principles for themselves
• the instructor and student should engage in an active dialog (i.e., Socratic learning).


4. Constructionism (1990’s)
• people learn through making things with other people
• theorists Papert, Shank
• creation leads to deeper level of understanding than instruction
• technology should actively engage students in creating
• people are motivated to learn by a desire to complete project-based learning
• instructor is a co-learner


5. Connectivism (2000)
   • a direct result of exponentially increasing complex technological communications
   • theorists Siemens, Downes
   • students exist in multiple networks/communities of learning (ex. Blogs)
   • people are motivated by their need to make sense of multiple, frequently contradictory, nonlinear resources
   • learning is the rapid bringing together of dispersed information through neural activity
   • instructor is a network facilitator

Posted by Deirdre at 01:07 PM | Permalink

Glaxo-Smith-Kline has an innovative mentoring idea they call "key talent mentoring". Management identifies positions that will be needed in the next 5 years, then identifies possible candidates. Mentors are then chosen to assist those possible candidates to develop the skills/experience necessary to apply for those positions.

We frequently talk about succesion planning in medical schools and this might be an interesting area to explore.

Posted by Deirdre at 10:31 AM | Permalink

Hello all from sunny San Diego.

One of the most interesting mentoring ideas I have heard so far at the AAMC conference is project-based mentoring. Junior faculty identify a project they are interested in (applying for a research grant, trying a new teaching technique) and the office of faculty affairs finds a senior faculty member who would be interested in assisting them with the project. The pairs are expected to meet regularly and report to the office of faculty affairs at the beginning, middle and end of the project. Project timelines are identified at the beginning of the project. The mentoring process is then evaluated on the basis of the final product that results.

This type of mentoring is probably one of the easiest to implement because the product (the project) is very clear from the very beginning. Mentor, mentee and institution have a build in mechanism for evaluating the process based on their progress.

Posted by Deirdre at 10:50 AM | Permalink

I am off to the Association of American Medical Colleges meeting in San Diego to participate in a series of workshops about mentoring. Physicians actively participate in mentoring throughout their carreers, so I'm hoping to bring back some pertinant ideas.

Posted by Deirdre at 02:38 PM | Permalink

At a recent workshop, the following topics were suggested for mentoring new medical faculty/new physicians:

- Decrease future problems so your workload not increased
- Prophylaxis is better than Tx
- A welcoming supporting start might recruit colleagues from residency
- “Indoctrinate” persuade local way of doing things
- Orienting quickly to the system good (efficient) clinical care
- Paying forward the debt from my teachers
- Retention in our regions
- If I was involved in recruiting them, my reputation hinges somewhat on their success
- Help new person feel there is a contact person to go to when you don’t know something about the system. Its hard to admit one doesn’t know something
- Be specific about when to meet; invite them next Tuesday for lunch or regular intervals
- Get to know personal details about their background and skills and outline the plan for this relationship
- Other persons’ expertise and get to know how do they do things where they are from
- Identify potential stresses pick up vulnerabilities early and look into preventative strategies e.g. orient new faculty to local expertise in research strategies
- Practical aspects of how to get a faculty appointment and advantages of having vs. not having an appointment FOR THEM. A mentor’s role is one of exploring IF this is a good thing or not selling them on it

Posted by Deirdre at 03:38 PM | Permalink

At a recent workshop, the following topics were suggested for pre-med student mentoring:

• Role of physician


• Why be a physician


• Why do they wish to be a physician


• How achievable is the goal of being a doctor


• Expectations of being a doctor:






• Work loads


• Call


• Enumeration


• Gender issues related to profession






• Later influences re: occupation


• Advantages and disadvantages of different forms of medical training


• Devotion of training


• Sacrifices re. occupation vs. family

Posted by Deirdre at 02:59 PM | Permalink

At a recent workshop on mentoring IMG's the following possible goals were identified:

- Integrate the person into a community of practice
- OrientationTo:

• profession
• environment
• culture of community
• ethics/norms of behavior boundaries
• patients expectations of physicians in that community

- Practical advice about community-where to live
- Helping them gain access to training – education resources
- Clinical information – resources for exams
- Community resources – Practice resources
- Emotional support
- Language support
- How to write exams

Posted by Deirdre at 01:25 PM | Permalink

At a recent workshop about mentoring the following possible goals for resident mentoring were identified:

- Encouragement, graduated responsibilities
- Non-judgmental sounding board – The power that says its OK you don’t know
- Orientation to the discipline
- Family/life balance
- How to live as a …
- How to be on call
- Help with education planning
- Electives
- Identifying Journals
- Practice interests
- Person to talk about difficult outcomes
- How to interact with other members of the team
- Identify struggling resident

Posted by Deirdre at 01:18 PM | Permalink

Dr. Dork has writes a Blog about his personal experience with depression.

"Psychologically, Dr Dork shares many traits common amongst doctors. Perfectionism, fear of failure, unforgiving of one's foibles, with a record of placing one's own needs for sleep, nutrition, exercise and rest a distant second to his vocational demands. Furthermore, Dr Dork is in many ways the typical Australian male: poor at openly discussing his emotional needs, in denial of his own distress, maintaining a resolute facade to all, and attempting to drown his demons at times.

Socially, the tendency to overload himself has been a contributory factor at times. For Dr Dork, this has been another method of 'escape', at times, which is also doomed to fail. And in his dark times, the costs to relationships, family, career and finances have been steep."

Posted by Deirdre at 11:18 AM | Permalink

Some significant trends in learning:

• Many learners will move into a variety of different, possibly unrelated fields over the course of their lifetime.
• Informal learning is a significant aspect of our learning experience. Formal education no longer comprises the majority of our learning. Learning now occurs in a variety of ways – through communities of practice, personal networks, and through completion of work-related tasks.
• Learning is a continual process, lasting for a lifetime. Learning and work related activities are no longer separate. In many situations, they are the same.
• Technology is altering (rewiring) our brains. The tools we use define and shape our thinking.
• The organization and the individual are both learning organisms. Increased attention to knowledge management highlights the need for a theory that attempts to explain the link between individual and organizational learning.
• Many of the processes previously handled by learning theories (especially in cognitive information processing) can now be off-loaded to, or supported by, technology.
• Know-how and know-what is being supplemented with know-where (the understanding of where to find knowledge needed).

Posted by Deirdre at 05:11 PM | Permalink | Comments (1)

During a recent workshop, residents brainstormed the following list of suggestions about how hospital nurses and other staff could be involved in medical education:

Have a coordinator who has all the info/contacts that students need
Give students an orientation manual that includes maps
Ask staff to wear nametags when students are new
Inform staff about the student’s schedule
Don't overwhelm students the first day with information

Ask staff ahead of time if they are willing to provide:
a tour of staff rooms, washrooms, lockers, eating facilities
an orientation to the hospitals administrative system
information about and location of equipment used
basic skills orientation such as wts, BP, IV’s
informed consent of patients who will be working with the student
a friendly, helpful, congenial, sharing environment (Golden Rule)

Posted by Deirdre at 02:48 PM | Permalink

A group of residents identified the following list of ideas for how patients might be recruited into helping with medical education:

Collect a pool of interesting, willing and practiced patients who would be willing to spend some extra time with students (ask people who might be bored, lonely, house bound)

Build rapport prior to request for assistance

Educate patients about working with students

Provide an explanation of expectations to patients

Emphasis how important the patient’s contribution to medical education is and how they impact the quality of future physicians

Post or hand out flyers to recruit patients

Ensure privacy and confidentiality

Be clear about the experience level of the learner

Respect cultural, religious and social values and beliefs of the patients

Ask permission (nurse, front desk might take this role)

Posted by Deirdre at 02:24 PM | Permalink

In a recent workshop, residents identified the following list of what they would like to see in hospital environments:

Safe parking
Lockers
Easy access 24 hours a day
Easy access to scrubs when on a short rotation away from home location
Lounge area
Adequate space in classrooms
Computer access
Comfortable call rooms with extra blankets, pillows available
An orientation
24-Hr access to food
Onsite childcare that opens early and closes late
Staff bathrooms that are easily accessible
Gym
Non-hostile environment
Security and Safewalk personnel who respond quickly

Posted by Deirdre at 02:03 PM | Permalink

Allowing medical students to correct mistakes in a respectful and understanding manner is a key element of the Deliberate Practice model.

The following quote from Promoting Patient Safety and Preventing Medical Error in Emergency Departments is particularly pertinent when contemplating this process. http://www.aemj.org/cgi/content/full/7/11/1204
Drawing from the results of a questionnaire completed by 114 internal medicine houseofficers, Wu et al. suggested that encouraging discussion of mistakes with attending physicians along with encouraging acceptance of responsibility with a view toward constructive change would better equip residents to learn from mistakes made during training. They believed that medical educators have a role in dispensing specific advice about preventing a second occurrence of the mistake, providing emotional support, and helping residents interpret the feelings of distress that are part of learning from error. These approaches would differ greatly from what Mizrahi observed during a sociological study of graduate medical education: "Little in their 3 year graduate program allowed them to work through the attendant vulnerability and ambiguity accompanying the managing of mistakes."

Mizrahi T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Soc Sci Med.1984; 19:135 -46.[Medline]

Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265 : 2089-94.

Wu AW, Folkman S, McPhee SJ, Lo B. How house officers cope with their mistakes. West J Med. 1993;159 : 565-9.[Medline]

Posted by Deirdre at 01:52 PM | Permalink | Comments (1)

An article about this issue was posted at http://medscape.typepad.com/thedifferential/2006/11/why_do_attendin.html

The comments about this article are more interesting than the article itself.

Posted by Deirdre at 01:53 PM | Permalink

Sometimes I find websites and think "Oh my, everyone should know about this." Clinical cases and images is one of those websites. http://clinicalcases.blogspot.com/

"We all know that there is a big difference between what we read in the books and what we see in our clinical practice every day. Somehow, the patients are different from their disease description in the textbooks. As one experienced physician put it succinctly: "his CHF did not read the book." How to bridge this gap between theory and practice? By creating a case-based curriculum of clinical medicine. See what the real medicine looks like.

This curriculum was started by physicians at the Cleveland Clinic and the Case Western Reserve University (St. Vincent/St. Luke) Internal Medicine Residency Program for the purpose of medical education."

Posted by Deirdre at 03:39 PM | Permalink | Comments (1)

Have you ever wished you could be alerted as soon as something new gets posted in your specialty on Medscape? Medscape now has a list of RSS feeds on different topics that will download automatically.
http://www.medscape.com/pages/public/rss

Posted by Deirdre at 03:20 PM | Permalink | Comments (2)

The dean of medicine at the University of Alberta says it's "inappropriate" that a U.S. accreditation group has proposed putting the school's medical undergraduate program on probation.

The U.S.-based Liaison Committee on Medical Education sent a letter in October warning of its plans, citing concerns over the school's teaching style. The committee said the school should rely less on traditional lecture-based lessons and more on "active learning."

http://www.cbc.ca/canada/edmonton/story/2006/11/12/alta-medical.html

Posted by Deirdre at 02:40 PM | Permalink

This website has a video about using Blogs in the classroom http://weblogg-ed.com/wp-content/uploads/2006/05/WebLoggingSmall.mov

Posted by Deirdre at 04:39 PM | Permalink

The online version of the Clinical Teaching Series is now available to faculty of the College of Medicine, University of Saskatchewan. For more information, please call (306) 966-8528.

Posted by Deirdre at 03:55 PM | Permalink | Comments (1)

One of the unwritten expectations of clinical teachers is to act as a rolemodel to students and residents. You are role modelling both clinical reasoning and patient interaction. Unfortunately, some clinical teachers forget the patient interaction and focus too strongly on the clinical reasoning. Here is an example from http://thegimpparade.blogspot.com/2006/09/providing-education.html

I hadn't met this Dr. Neuro before, and he came in with three residents. The students stood quietly in the corner while Dr. Neuro reviewed my medical history with me. All went well until he inquired if I could get up on the examining table and I replied that it was very inconvenient and suggested I stay in my scooter chair. He may well have had excellent reasons for preferring to use the table, but it was clear from his sharp response and demeanor that his sudden shift to insisting I get up on the table was related to the presence of the observing residents.

So we did it his way, with my parents and the residents assisting, and two residents helping me as I struggled to remain sitting atop the table without any useful support. Needless to say, testing the reflexes of a woman tensed to keep her head upright and her body from falling to the floor was impossible. I didn't stay up there long. It was readily apparent that the only thing to be learned was that I do indeed have severe muscle weakness, as both my patient records and I had declared.

It's easy to speculate about what this doctor intended to teach his students. What he missed was an opportunity to show how an examination of this kind could be done with the patient in her scooter where she felt more secure.

Posted by Deirdre at 04:01 PM | Permalink | Comments (1)

In a recent discussion with medical residents, someone asked the question “What’s wrong with fear as an educational technique?” Several people then told about how fear had worked to increase their preparation for class or exams.

I was mildly shocked that someone would even suggest that this was a legitimate teaching technique, but then I sat down and did some more thinking about the theories of teaching and learning.

Spare the rod and spoil the child is a concept that has been around for a very long time. It is part of an authoritarian system that required an authority (church, father, king, husband or teacher) to know what is best for others. The others must be guided to follow the authority figure without question because they don’t have the ability to make decisions. If they don’t obey, then punishment must be used to bring the rebel, unbeliever or lazy student back into the fold for their own good. Those who respond positively to the authority figure are rewarded with praise, promotion and belonging. In educational theory, this is called Behaviorism. If you want passive, unquestioning students, behaviorism works. Non-conforming students are removed from the system through failure or opting out. Industrial economies require an authoritarian educational system.

Constructivism is another educational theory that has become increasingly popular in the last thirty years as we move into the information economy. Constructivism is based on the idea that all knowledge is a construction of the human mind. Knowledge is shared from person to person, but acquisition is always the result of individual learning. This result will differ from person to person based on ability, culture, exposure and motivation. Teachers facilitate the opportunities for student acquisition of knowledge, skills and attitudes, but they don’t control it. The student is expected to bring their personal motivation to learn to the table. They are expected to be or to become self-directed, lifelong learners. Punishment is considered to be disrespectful and counter-productive of that student’s right to learn.

Between these two very different approaches to education is the question we are continually asking, “What is the best way to educate future physicians?”

Posted by Deirdre at 03:02 PM | Permalink | Comments (3)

Grand Rounds are up at The Examining Room of Dr. Charles. Grand Rounds is a weekly task preformed by different medical blogs. For more information see Blogborygmi

Posted by Deirdre at 12:42 PM | Permalink

Several medical Blogs have been commenting on alcoholics and drug addicts tricking doctors into giving them drugs. Many of these Blogs suggest that heightened vigilance is the answer to this problem even if this means not giving pain medication to patients who need it.

As physicians preparing students for medical practice, this important issue needs to be more closely examined and prepared for in medical school. Here are some suggestions:

1. Increase awareness of addiction treatment including how the desire to take responsibility for stopping the addiction results in physicians playing futile control games with addicts. Identifying what is and is not in the physician’s control is essential here.

2. Teach students to handle stressful situations in ways that avoid becoming involved in power struggles with patients. Acceptance of things the student cannot change is essential to this process.

3. Increase awareness of how and when pain medication is needed even when facing addiction issues including the information from the National Cancer Institute below.

People who take cancer pain medicines rarely become addicted to them. Addiction is a common fear of people taking pain medicine. Such fear may prevent people from taking the medicine. Or it may cause family members to encourage you to "hold off" as long as possible between doses. Addiction is defined by many medical societies as uncontrollable drug craving, seeking, and use. When opioids (also known as narcotics) — the strongest pain relievers available — are taken for pain, they rarely cause addiction as defined here. When you are ready to stop taking opioids, the doctor gradually lowers the amount of medicine you are taking. By the time you stop using them completely, the body has had time to adjust. Talk to your doctor, nurse, or pharmacist about how to use pain medicines safely and about any concerns you have about addiction.

Posted by Deirdre at 03:52 PM | Permalink | Comments (2)

I'm just back from holidays and thought I would link to an interesting Blog by the Cheerful Oncologist
Good Doctors Leave Good Tracks
The most influential mentor I ever had, who taught me how to chase and capture excellence in all aspects of patient care, and why giving one's best is the only goal worth pursuing in medicine, once told me that he had discovered a way to measure the merit of a doctor. He said, "Good doctors leave good tracks," by which he meant that one can always identify exceptional physicians by the "trail" of evidence they leave behind after their work is done - a ship's wake, if you will, that represents the effect they had on the patient's life, a trail that does not always guarantee a healthier patient but does show the world the type of doctor who captained the mission. Just as different vessels leave different wakes behind them, certain bits of evidence reveal the depth and worth of the doctor's effort. The converse of this saying is just as true: "Lousy doctors leave behind evidence of lousy work."

With a little training anyone can become an expert in deciphering the tracks of doctors just by examining the trail they leave behind at the end of the day. In my opinion these are the marks of distinction:

The Written Word. There is no easier way to separate good and bad doctors than by the dictated reports, handwritten orders and notes, and letters they produce. Good doctors have legible handwriting, no matter how much of a hurry they are in. They take the time to document the important facts of a patient's illness and the information relayed to the patient. Counseling sessions are put into the written record: the risks, possible side effects and alternatives of a treatment. The medical record should be clearly documented as if a new doctor could pick up the chart the next morning and take over the case with ease.

The Spoken Word. A good doctor speaks clearly and respectfully, avoids medical jargon and slang, shuns a prejudicial attitude, never assumes that one attempt at explanation will be sufficient, nurtures assurance and hope in a time of dread and uses humor like an ice cream vendor on a hot summer day. Great doctors use verbal communication as the best way to destroy fear, ignorance and despair.

Critical Thinking and Investigation. Good doctors never assume that a patient's symptoms are due to the same run-of-the-mill maladies that they see day after day. They excel at what is called lateral thinking, or thinking "outside the box" of routine illnesses. They ask themselves questions, such as "Do I have the right diagnosis?" and "Do I really understand what is happening to my patient?" They order tests that best fit the patient's clinical presentation. When they are stumped, they research the question until they are satisfied they have filled in the missing pieces of the medical puzzle. They ask experts for advice. Good doctors are always smarter than they were the week before.

Following-Up. Lastly, it is tedious but vital that doctors review the results of all the tests they order, that they keep in contact with sick patients, that they double-check their plan of attack for an illness and stay knowledgeable with current medical news and developments, that when matched against such villains as cancer they never assume anything but stand at the helm, ready to change course at the first sign of a troubling sky.

No other career combines the dual responsibilities of academic study and human contact as magnificently as medicine. As Sir William Osler said, "To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all."

Each morning physicians set sail into the vast blue sea of medicine on a voyage to bring their patients home safely, their eyes scanning both the horizon and the sky. By watching the foamy trail left behind we can determine which doctor is the right skipper for the journey.

Posted by Craig Hildreth

Posted by Deirdre at 04:21 PM | Permalink | Comments (4)

The University of Saskatchewan, College of Medicine is a competency-based program (for more information about competency-based education, see the previous post on this Blog.) The college has spent a lot of time determining competencies for each level of training, but that is only the first step. The next step is Gap Analysis –determining the difference between where the individual student is, and where they need to be at the conclusion of the course, year and their training if the student is to meet the competency requirement.

The Orientation to Clinical Experience is the ideal place to perform a Gap Analysis. Not performing a gap analysis means repeating material that the student may already know well, leading to an invalid assessments because the student will be assessed at a high level but won’t have learned anything. On the other hand, other areas where the student has less knowledge/skill will go unidentified and the student may be confronted with their lack of skill in a less forgiving environment. The following four steps will help improve the preceptor and the student’s experience.

1. Determine the competencies expected for the student’s time in your office or on your ward. This step is usually predetermined by the medical department, but the preceptor needs to think about what competencies he/she feels comfortable teaching.

2. Discuss where the student currently is in the development of the competencies. Ideally the student will arrive in your office with a description of what they have learned/performed previously.

3. Determine internal and external forces that might influence how much the student can achieve in the time/environment available.

4. Decide on the strategies and tactics that will be used to assist the student in meeting the competency requirements.

For more information on student orientation to clinical experience attend a workshop through Educational Support and Development on Preparing to Teach.

Posted by Deirdre at 01:31 PM | Permalink | Comments (1)

I was attending a conference recently where the participants were asked to reflect on their clinical training and one voice said “Pain, humiliation and embarrassment!” There was dead silence in the room. The speaker was a senior physician, one who was known to have had a long and successful family practice, yet there was so much emotion in those three words that I was transcended into the life of a young man thirty years in the past.

I could hear his teachers saying “Well it worked didn’t it?” and on some superficial level it did work. Like an abused child learns to answer the abuser’s questions, this young man learned to duck and cover, learned to placate and learned to fight back from a distance. He swore to never treat his students the way he had been treated.

I don’t know this physician well enough to speculate on whether he was successful in his oath to treat students better than he had been treated. I spend a lot of time thinking about how we are the product of our experiences both in the automatic using of teaching techniques that we liked and in the verbal rejection of those we disliked. I hated droning lectures when I was young, but I find myself falling into that pattern even though I know better. I become the abuser; it’s a pattern that I know, a pattern that comes easily with little forethought if I’m stressed or short on preparation time.

The teacher’s journey begins with a goal, a desire to improve or change something.

Posted by Deirdre at 11:25 AM | Permalink

An elderly war veteran never admits to the pain he feels after a diagnosis of bone cancer while in the next ward, another patient complains bitterly and demands more pain medication.

Medical schools are very good at teaching doctors how to diagnose and treat disease, but they may not be well prepared to cope with illness. As defined by Terry Tafoya, Ph.D. illness is the patient’s cultural and personal response to the disease. If the two gentlemen above are looked at through cultural lenses, Northern European cultures value stoicism (stiff upper lip) in men, while Southern European cultures believe pain and suffering should be expressed.

To further illustrate this concept here is an excerpt from http://tundramedicinedreams.blogspot.com/ about diagnosing native elders

Yupik elders often have a tendency to give long and circuitous answers to simple questions when speaking in Yupik. Interestingly, the English-speaking ones don’t seem to do it nearly so much when speaking English. It is somewhat affectionately known as “going to the moon.” A question that may be answered with a simple yes or no may engender a long story; at the end of it, the translator may sort of shrug and say “basically, she said yes (or no).” When I raise my eyebrows, the translator will say “well, she had to tell me a story about the time when her daughter…” Elders are held in very high esteem in this culture, and when an elder is speaking it is rude and unacceptable to interrupt. They go to the moon if they want to, and everyone will listen and wait until they are done.

To teach medical students to pay attention to cultural differences in a patients view of illness, Dr. Tafoya suggests using the acronym LEARN.

L isten with empathy (Active Listening)
E licit the patient’s worldview of the problem/need
A cknowledge and discuss possible differences and similarities between the patient and physician’s worldview
R ecommend a prevention/intervention/treatment plan
N egotiate a final plan

Posted by Deirdre at 02:48 PM | Permalink | Comments (2)

Dr. Michael Hebert from http://www.drhebert.squarespace.com/ talks about Medical Education

This past weekend at the Jazz Fest in New Orleans, I dropped in at the Gospel tent to listen to Sherman Washington and the Zion Harmonizers. The Zion Harmonizers are a longtime Jazz Fest staple, having performed in the Fest every year since its inception over 30 years ago. They have been a driving force in the New Orleans Gospel music community for 67 years.

Sherman Washington, its leader, joined in 1942. He was recruited by a Harmonizer at work while building Higgins assault boats in a New Orleans shipyard for the U.S. Navy during World War II . He became the group manager in 1948, and has been its organizer and spokeman ever since.

Mr. Washington took the stage first and introduced the band. A chair was brought out for him, and he sat down just left of center stage. From there the younger guys took over. An octogenarian who had recently suffered a small stroke, Mr. Washington was passing the torch to his protégés and remained onstage as the moral leader. Like any member of the crowd, he watched, clapped, tapped his feet, and joined in when the spirit moved him.

The spirit came. Working the crowd like any veteran performance group, the Harmonizers started off slow and built up energy with each successive song. A half-an-hour deep and the joint was jumping. Folks danced in the aisles, feet stomped, hands waved in the air, and the very ground moved beneath us. If the Gospel tent wasn’t sacred ground before, the Harmonizers consecrated it.

It is remarkable that any single group could lead the New Orleans Gospel community for 67 years running. To maintain its vigor, the group is constantly bringing in new voices as the older ones retire. This is not the same Zion Harmonizers that Sherman Washington joined in 1942. And yet, if I closed my eyes and listened to the Harmonizers in 2005 and a recording of the 1942 group that recruited Sherman Washington, I don’t think I would detect much of a difference.

If a group that is 67 years old and going strong has anything on its side, it has time. Time to carefully cull prospective members from the community. Time to bring them in and teach them right. Time to bond with them as family, and then inculcate every little nuance about Gospel music, Harmonizer style. With this educational process going on, very little will be lost over the generations. The Zion Harmonizer sound becomes the constant, a spirit that exists independently of its members.

The Harmonizers represent one of two strategies for learning. Their model, the apprenticeship, passes knowledge from one generation to another through close, personal instruction. Before one member, such as Sherman Washington, moves on, a new member is picked out and the elder’s knowledge is passed on as intact as possible to the new member. Just as wine takes the shape of each successive cup it is poured into, the art takes the shape of the new vessel as it is passed on, but it still retains its original flavor.

The alternative to the apprenticeship strategy is education by committee. With this approach the learner moves from expert to expert, never exclusively the student of a single person, gleaning from each teacher that bit of information the expert knows best. Medical education is by committee. The typical medical student moves from one specialty to another, from cardiology to neurosurgery to dermatology, learning the best each specialist has to offer. The thinking behind this approach is that the student picks up a little of the best of everything, and cobbles together an overall education that represents the highlights of the best; in theory, a better overall education than any single teacher can give.

There are problems with education by committee. Each teacher has his own bias, and the sum of all biases many not amount to anything meaningful. For example, a pediatrican may teach a student his love for child advocacy, and a surgeon may teach the pleasure of curing a patient through the corporal handiwork of cutting and suturing. But these two biases are different, and not necessarily complimentary. The student has no overarching philosophy offered to him by any single individual. He is left with a hodgepodge of ideas that he has to organize himself.

Like every medical student I knew, I had to make sense of medicine on my own. Knowledge was meted out to me like precious jewels, but when I completed my training all I had was a bag of gems. No organization or sense of relative value, and certainly no sense of how I was to use them. In medical school, we used to call useful clinical tips pearls. So even in our doctor’s language we were acknowledging an essential fact about our education. We had precious knowledge doled out to us bit by bit, but stringing the pearls into something of real purpose left up to us.

It was rare that a concerned teacher checked to see if we were coming up with anything. The closest I usually got was the question, “So what do you think you will specialize in?” This question often started with the casual word so, which to me was a way of saying, “I am interested in where you are going with this education you are getting, but I am probably not going to be able to help you with it.” (The underground advice in med school was that you always told the professor you were interested in going into his specialty. That way he would take an interest in teaching you. If you said you were interested in a different specialty there was a very real risk that the professor would lose interest in teaching you any more than nuts and bolts. Thus once again we students instinctively understood and tried to cope with the weakness in the committee education.)

Of course, the apprenticeship model is not perfect either. When a student learns everything the preceptor knows, he learns his teacher’s foibles as well. No one person can know everything there is to know, so a teacher’s deficiencies became a student’s deficiencies. A good preceptor should recognize his own weaknesses and send the student to other experts to supplement his knowledge. But this does not always happen. The old adage that the student can never surpass his master is rooted in the apprenticeship model.

Certainly the two approaches can co-exist. An education by committee can include a handpicked mentor who guides the student through the learning stages. An apprenticeship can be enhanced by brief training periods under other teachers. But to me, the two models are not equal choices. Committee education is cheaper and quicker, and works well when the goal is to cram a lot of information into the learner’s mind in a short period of time. A seminar, for instance. But committee education is clearly information-oriented, and not very humanistic.

Any time the goal is to instill humanity and passion, the apprentice model has to predominate. We learn our most essential lessons in life not by imbibing information but through observation and imitation. Most of us could do much worse than to pick the most admirable person we know and emulate him or her to the best of our abilities.

That is why it is perplexing that medicine, one of the most humanistic of sciences, leans so far towards education by committee. Our medical schools gulp up applicants in boluses of 100 to 200 and run them through the same paces, the same tests, the same clinical rotations, year after year. A surgeon and a psychiatrist get almost exactly the same medical education.

Older doctors wonder why the younger generation seems to treat medicine as a job rather than as a vocation. Young docs want paid vacation, retirement plans, and insurance benefits. When the clock strikes five they are out the door, and don’t call me at home. What happened to the days of yore when the doctor was a devoted, tireless pillar of the community?

Many things changed, but not the least of them is medical education. As the amount of information doctors needed to learn grew and grew, medical schools and residency programs gave up on the apprenticeship model and set up information assembly lines. Professors at my medical school used to gripe: “All they want is to be spoon-fed the information on the test.” To which I would answer (though not to their faces because I needed a good grade): “Then why don’t you stop reading off your lecture notes and talk to us once in a while?”

Without mentors, we dealt with the onslaught of data the best we could. We memorized it and regurgitated it on the test. Then we moved on to the next teacher, just as we were supposed to.

It was not always thus. The history of medicine is rich with preceptor-apprentice relationships. At one time, this was the expected method of medical education. The Oath of Hippocrates, written 2,400 years ago, gives more than a passing nod to apprenticeship:

I swear . . . . To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; To look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction.

In my years of medical training I can think of a few teachers that I cared about, but none that approach this degree of intimacy. I believe most physicians educated in today’s schools would say the same.

That is why I saw something very touching in the Zion Harmonizers’s performance. They brought out their leader, Sherman Washington, and placed him in an honored place on the stage even if he was not going to sing with them. All the younger Harmonizers had worked with Washington for years, learned his craft, and now felt his spirit within them. The Zion Harmonizers will live on after Sherman Washington is gone, unbowed, true to their original mission, because he took the time to teach them how to do it the right way and cared enough to make sure they understood his passion.

Medicine, which has depended on humanism for more than two millennia, could lose its original spirit in a few generations if doctors go from being teachers and guides to being service providers and HMO contractors.

Critics of modern medicine have wondered if doctors can in most cases be replaced with computers. The patient would enter some personal data and answer a few questions, then press a button, and out the diagnosis would come. I think if medical education does not go back to the apprentice model, in which values and personal insight replace massive data transfer, the doctor-computer is a certainty.

It is one thing to carry around a lot of data. It is another to carry the knowledge and the passion of your teachers, a desire to live out the ethical and personal vision of your forebears and then transfer it to the next generation, wholly intact.

Listen to what the Zion Harmonizers have to say about that. I did. I am a convert.

Posted by Deirdre at 10:45 AM | Permalink

-Many of you will have worked with 3rd and 4th year students
- The term clerks is not universal.
-JURSI’s at the University of Saskatchewan Junior undergraduate rotating student interview.
-A few years ago the JURSI year was extended and is now more than 15 months long. This has had many positive benefits but it does mean JURSI’s are less experienced in clinical situations than previous; especially in the early portion of the JURSI we do refer to senior and junior year JURSI’s of the history on physical examination.

THE APPROACH (PERRR)

(1) Planning
-The teacher and the JURSI meet prior to the patient encounter to discuss.
-Comfort zone of the JURSI.
-What does the JURSI have to get out of the encounter(s).
-What agent of the Hx/Px/Dx management does the JURSI feel comfortable with?
-What aspects do they feel they need help with?

A plan is developed to concentrate on 1-2 areas by mutual agreement with the next few patients.

(2) Encounter
- The JURSI sees the patient (on their own), or the teacher and JURSI go see the patient together.

Usually the JURSI feels more comfortable with the teacher; especially early in the year.

(3) Reporting
- The JURSI reports on the encounter with the patient. The information should include Hx/Px exam, different diagnosis and management. There should also be a few minutes to view what was in the plan.

(4) Review
- The teacher and JURSI review with the patient their thoughts and possible management.
- It would also be the time to review aspects of the history of physical examination.

(5) Reflect
- The teacher and JURSI reflect the encounter
- The teacher would ask the JURSI on aspects:
-how they feel it went
-what they did well
-what could they have done
- If any further review required.

Plans for the next patient or two

Posted by Deirdre at 09:44 AM | Permalink