"This is an information resource designed to help you understand the nature of a medical condition and the surgical procedure most commonly used to treat it.

Our hope is that we will help you to:

• gain a better understanding of your medical condition,
• know your treatment options,
• understand the risks of surgery - as well as the risk should you decide not to have the treatment your doctor recommends.
• You should also know what to expect on the day of surgery
• and know how to care of yourself during recovery."

I think it might also be useful for premed and 1st year students.

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.

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

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.

American Medical News has an article discussing twitter as a tool to increase the web presence of your practice, connect to patients and network with other providers.

Chris Thorman, who normally blogs about electronic medical records at Software Advice explores Twitter as an epidemiology tool for tracking diseases.

Dr. Shock is interested in how Twitter is being used in educational settings by students and lecturers.

Twitter's reputation as a mundane socializing tool for updating friends has never been my experience and I am pleased to see the creative use of this tool expanding. What ideas do you have for using Twitter in healthcare?

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?

The Award will be presented during the CAME Annual General Meeting in Edmonton at the 2009 Canadian Conference on Medical Education, Sunday, May 3.

Acknowledging that it is the social determinants of health such as income, literacy, and housing that impact people's health, we provide care to children in core neighbourhoods, embracing the community paediatrics model which shifts away from one child but to 'all children in the community, within the context of the family and the community'. We adhere to the principals of cultural competency.

The clinic is collaborative; i.e. seeking to work across sectors such as Education, Social Services, Justice, Law Enforcement etc; as well as integrated, i.e. working alongside teachers, councilors, social workers psychologists, ENT, Child Psychiatry.

The clinics are currently based out of St. Mary's Elementary School (Mon/ Tues/ Wed); as well as W.P. Bate Elementary school on Thursday afternoon. It is staffed by 2 Paediatrcians from the department of paediatrics. Appointments are not mandatory, drop-ins are welcomed. A referral by a Family Physician is not required; patients/families/ teachers, etc may all refer. We work with the family and the community, as well as the schools, to make ourselves and the other health-care professionals whom we may refer our patients to, more accessible, recognizing the many obstacles that people who live in poverty, face.

A huge part of our work is dedicated to advocacy; for the patients and for their families.

- Submitted by Dr. Maryam Mehtar