Administration Rounds:Medical Education

Yael Moussadji, PGY4Emergency Medicine

Objectives

• To review some theories of adult learning, and the teaching styles in which they are used

• To discuss medical education from the perspective of the learner, the teacher, and the institution

• To use cases to illustrate examples and problem solve around knowledge translation

Case #1

•You have been asked to give a lecture on the autonomic nervous system to a first year medical class of 120 students. This is a difficult subject for the class because it has not been explicitly covered by faculty. How can you make this topic understandable to the class in a 50 minute lecture?

Case #2

•You are a member of a curriculum committee which has been instructed to integrate the topic of ethics into the third year of the emergency medicine residency program. You have been given 6 blocks of 2 hours each over 3 months. How can you make the material engaging, understandable, and useful?

Case #3

•You are the preceptor for a first year family medicine resident during their EM block. Your shifts have been incredibly busy with little time for teaching someone so junior, and you wonder how you can contribute to providing a valuable learning experience for her.

Introduction

• In what may be called the natural method of teaching, the student begins with the patient, continues with the patient, and ends his study with the patient, using books and lectures as tools, as means to an end. For the junior student in medicine and surgery it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself.

Sir William Osler, 1903

The Learner

Adult learning theory

• Establish an effective learning climate, where learners feel safe and comfortable

• Involve learners in mutual planning of relevant methods and content

• Involve learners in diagnosing their own needs - this will help to trigger motivation

• Encourage learners to formulate their own learning objectives so they have more control over their learning

Adult learning theory

•Encourage learners to identify resources and devise strategies for using those resources to achieve their objectives

•Support learners in carrying out their learning plan

•Involve learners in evaluating their own learning and develop skills of critical reflection

Five assumptions about adult learning

• Adults are independent and self-directed

• They have accumulated a great deal of experience, a rich resource for learning

• They value learning that integrates with everyday life

• They are more interested in immediate problem centred approached than subject centred ones

• They are motivated to learn by internal drives more than external ones

Self directed learning• A method of organizing and teaching in

which the learning is within the learner’s control

• A goal toward which learners strive so that they become accountable for their own learning

• Necessary traits include the ability to be methodical and disciplined, logical and analytical, collaborative and independent, curious, open, creative, motivated, persistent, responsible, confident, competent, reflective and self-aware

Constructivism• Learners “construct” their own knowledge

on the basis of what they already know

• The teacher is viewed not as a transmitter of knowledge, but as a guide who facilitates learning

• Teachers engage students in active learning, using relevant problems and group interaction

• This is most evident in Problem Based Learning, which also used principles of self directed learning

Problem based learning: consolidation of learning theories

• Group learning facilitates not only the acquisition of knowledge but also communications skills, teamwork, problem solving, accountability for learning, sharing of information, and respect for others

• It is based on several principles of adult learning theory, constuctivism, and self directed learning theory including fostering motivation, encouraging students to set their own learning goals, and allowing them to make their own decisions about their learning

• While there is no difference in measures of traditional knowledge assessments between medical schools graduating from traditional and PBL curriculums, students from PBL curriculums seem to have superior knowledge retention

Self efficacy• Based on the principle that people’s

judgments of their own ability to deal with different situations is central to their actions, which include what they choose to do, how much effort they invest, how long they persist, and how they approach the task

• Sources of these judgments include performance attainment, observations of others, persuasion, and one’s physiological state

Reflective practice• Based on “reflection in action” - the ability to

learn and continually develop by creatively applying current and past experiences and reasoning to unfamiliar events (during)

• “Reflection in action” also occurs later and is a process of thinking back on the situation (after)

• By reflecting on their practice, the professional is developing areas of competence and wisdom

Learner’s principles• The learner is an active contributor

• Learning is closely related to understanding and solving problems

• Current knowledge and experiences are critical

• Learners need opportunity and support to use self-direction

• Learners should be given opportunity and support for practice, with self-assessment and constructive feedback

• Learners should be given opportunities to reflect on their practice

• Using role models has a major impact; we teach the way we were taught

The Teacher

Perspective on teaching

• Most of medical education is based on the idea that knowledge and learning are products of the way in which a person’s mind if engaged during the process of learning

• As people encounter new experiences, they construct representations of those experiences structured by their previous knowledge and beliefs

• The introduction of new information with existing cognitive schemas produces new knowledge, beliefs and skills

Transmission perspective

• The most common method of teaching in medical education and clinical teaching, as well as CME

• Good teaching is directly associated with content expertise, and the educator’s primary responsibility is to present the content accurately and efficiently in an additive manner that permits knowledge transfer

• Teachers take learners systematically through a set of tasks that lead to mastery of content clearly and enthusiastically

Developmental perspective

• Teaching is planned and conducted from the learner’s point of view

• Teachers understand that learning is a search for meaning, that learners search through association, and how their learners think and reason about the content

• The goal is to help learners develop increasingly complex and sophisticated cognitive structures related to the practice of medicine

• This is done using effective questioning and bridging knowledge

Apprenticeship• Starts with the assumption that learning is

facilitated when learners work on authentic tasks in real settings

• Teaching and learning are rooted in the “doing” of work, not just talking about it

• “I was so busy today, I did not have time to teach...”; this is not as important as having learners alongside in the process of doing the work, which includes managing a heavy workload

Apprenticeship• Good teaching is also more than

demonstrating skillful practice

• It is a process of enculturating learners into a set of social norms and professional identity

• Residency takes us through zones of development, learning spaces that fall between what we can do on our own and what we can do with expert guidance

• As we become more competent, our zones of development move and the teacher’s role changes

Teaching in the clinical environment

• Clinical teaching lies at the heart of medical education, and is the core of professional development during residency

• It is the only setting in which the skills of history taking, physical examination, clinical reasoning, decision making, empathy, and professionalism can be taught as an integrated whole

• Teachers must have excellent communication skills for questioning and giving explanations, and must help students identify what they already know and elaborate on that knowledge

One-minute preceptor model

• Review the patient encounter

• Get a commitment (‘what do you think is going on?”)

• Probe for underlying clinical reasoning

• Reinforce what was done well and help the learner identify and give guidance about omissions

• Teach general principles

One to one teaching and feedback

• Low efficiency compared to other teaching models, but scores extremely high in terms of active learning and modeling of behaviour

• It addresses current learning needs, promotes autonomy and self-directed learning, and links prior knowledge with new clinical experiences

• Skillful teaching is not unlike skillful history taking; provide an orientation, agree on ground rules, ask helpful questions, give feedback, and encourage reflection

Evaluation

• critical incidents and skill sets in EM

• commitment to learning

• communicating medical information

• professional behaviour, interpersonal skills

• problem solving and clinical judgement

• technical skills, dealing with emergencies

• recognition of limits

Ethics and EM• Breaking bad news

• Allocation of health care resources

• Truthfulness

• Competence

• Refusal of treatment

• Obtaining informed consent

• Confidentiality

Nuturing perspective(Self efficacy)

• Assumes that long term persistent effort to achieve comes from the heart, not the head

• People are motivated and productive when they are working on problems without fear of failure

• Achievement is within reach, is a product of the effort and ability of the learner, and is supported by their teachers and peers

• Teachers provide encouragement and support, along with clear expectations and reasonable goals

The program director?

•A medical educator who takes on a role that focuses on removing barriers or blocks to student learning

•With a bright, highly motivated group, there is less need to direct learning

•As a result, the teacher can focus on creating a supportive safe environment for learning

Social reform• Good teachers intend to change medical

practice in substantive ways

• The collective, rather than the individual, is the object of the teaching

• Social reform teachers awaken students to values and ideologies hidden in texts and common practices of medicine; challenge the status quo

• The trend toward EBM was just such a move spearheaded by a group at McMaster, and has now become the gold standard in medicine

Final thoughts on teaching

•Teaching perspectives are philosophical orientations to knowledge, learning, and the role and responsibility of being an educator

•Each of these views represents a legitimate perspective when enacted appropriately

The Institution

Curriculum design• Curriculum is from the Latin for track or

race course

• It is underpinned by a set of values and beliefs about what students should now and how they should come to know it

• Values underlying curriculum should enhance health service provision

• Four elements: content, teaching and learning, assessment, evaluation

The Other Curriculum

• Curriculum exists at 3 levels: what is planned (“this is what we do”), what is delivered (informal curriculum), and what is experienced (the hidden curriculum)

• The informal curriculum is based on unscripted, adhoc, and interpersonal teaching, learning and role modelling between faculty and learners

• The hidden curriculum is based on influences that function at the level of the organizational culture

The Hidden Curriculum

• Policy implicitly conveys messages about what is and is not valued by the institutional community (eg, most successful applicants have studied science, which is implicitly more valued by the medical community than humanities or teaching)

• Evaluation tools are also tools for conveying what is and is not important in the organization

• Resource allocation and the availability and distribution of institutional resources shapes what we value

• Institutional slang, eg medicine as a business

The Future Curriculum

• The process of learning to differentiate what is important from what is not important in real life medicine is at the heart of learning to become a doctor

• Creating structures that allow individuals to reflect upon the larger structural picture of which they are a part moves towards the notion that our education involves much more than curricula

• Structuring our efforts around competencies rather than summative measures is a positive step; emphasizes learning over teaching (CanMEDS)

The CanMEDS Framework

• Medical Expert - the central physician role in CanMEDS; physicians integrate all CanMEDS roles, applying medical knowledge, clinical skills, professional attitudes

• Communicator - effectively facilitate the doctor-patient relationship

• Collaborator - work effectively within a health care team

• Manager - integral participants in healthcare organizations (sustainable decision making, effective practice)

The CanMEDS Framework

•Health Advocate - responsibly use expertise and influence to advocate for patients, communities, and populations

• Scholar - demonstrate lifelong commitment to learning

• Professional - ethical practice, professional regulation, high standard of behaviour

Case Studies