office of medical education newsletter spring 2007

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Effective In-Training Feedback

Office of Medical EducationNewsletter

Tulane University School of Medicine

Office of Medical Education

1430 Tulane Avenue, SL-6

New Orleans, LA 70112Tel 504-988-6600

Fax 504-988-6601

[email protected]

www.som.tulane.edu/ome

Spr ing 2007Volume 1, Is su e 1MISSION

WE CONTRIBUTE

TO THE MEDICAL

STUDENTS

EDUCATION BY

PROVIDING

FACULTY

DEVELOPMENT,

EDUCATIONAL

SUPPORT AND

SERVICES TO

FACULTY AND

STUDENTS.

In this issue

Introduction......1

Effective Feedback...2

Improving Pedagogy...4

Standardized Patients.6Teaching Excellence8

The purpose of this newsletter is to provide extended on-goingprofessional development to faculty, residents, preceptors, and otherswith direct responsibilities for medical student education in the areasof:

Methods of pedagogy, Communication and assessment, Development and implementation of educational objectives, Educational Technology, and Competency-based Evaluation.

The ultimate goal of this resource is to enhance the teaching andevaluation skills of those individuals who educate medical students atTulane University School of Medicine. This resource will assisteducators in the growth of medical students knowledge, skills,behaviors, and attitudes needed in medical training and practice.

Additionally, this newsletter will provide general information onevents, support services and activities in the Office of MedicalEducation. We will also feature short articles summarizing researchliterature that provides innovative teaching methodologies in medicaleducation.

The editor welcomes short articles from the faculty that introduce orinform others about a unique teaching strategy or method currently

being used for teaching. (Read more on page 7, under Call for Submissions.)

Introducing the OME Newsletter

You are cordially invited to attend the firstTeaching Excellence Series

Thursday, May 10 at 9:00 a.m. & Friday, May 11 at 1:00 p.m.

1555 Poydras Street, 22nd

Floor

Read more on page 8.

With Dr. Ronald MarkertThe Series Begins


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OME News l e t t e r , Spr ing 2007 2Giving Effective Feedback

The clinical setting is the ideal setting for students tolearn in a real life situation. This experience

allows an opportunity to integrate knowledge, theoryand practice. Additionally, students developprofessional competencies that will affect theirbehaviors and attitudes in future roles. Effectivefeedback is essential in making trainees aware oftheir deficits. Furthermore, poor performance willgo uncorrected, and good performance will not bereinforced. The purpose of this article is to provideguidance for effective feedback.

What is effective feedback?

According to Govaerts (2006), learning andassessment are fundamentally linked and practicewithout feedback or assessment will not result inimproved performance.

Effective feedback strategies should be comprisedsystematic and ongoing assessment of habitualperformance in the real life clinical practice, withtwo purposes:

Giving feedback to the trainee to helpimprove performance, and

Providing credible and defensibleinformation on quality of performance tosupport judgment and selective decision-

making.The article proceeding will offer much insight into amethod for providing feedback and assessment inclerkship settings.

Microskills of the One-Minute

PreceptorWritten by W. Fred Miser, M.D.Associate Professor, The Ohio State University

Department of Family Medicine

Up to this point we have focused on laying thefoundation for teaching students in your office. We

will now begin the portion of the series where weaddress the necessary skills for the actual teaching

encounter. This article presents the concept of the"one-minute" preceptor and five microskills used for

teaching students efficiently and effectively afterthey have seen a patient and are presenting the case

to you.

During the case presentation, you need to

accomplish three tasks: 1) diagnose the patient,2) diagnose the student (strengths and needs),

and 3) teach the student based on the identifiedneeds. In last months issue, a suggested format

was given for the case presentation that wouldhelp you in determining the needs of the patient.

We will now turn our attention to the other twotasks.

To make this teaching encounter more effective,

a group of family physicians and educators fromthe University of Washington have identified

five microskills for ambulatory teaching (NeberJO, et al: A five-step "microskills" model of

clinical teaching.J Am Board of Fam Pract1992; 5:419-24). If done in order, they provide a

logical framework that encourages the studentsto become active learners and that allows you to

identify the learning needs of the students and toteach them based on those needs. If the student

follows the case presentation format given in lastmonths issue, the first two steps are already

accomplished.

1. Get a Commitment - After the student haspresented the patient to you, your first task is to

get him/her to commit to a decision and/or a planof action. This step encourages the student

to take responsibility, demonstrates that youvalue the student and his/her help, and promotes

satisfaction in the student. Useful questions thatyou may ask during this step are, "What do you

think is going on?" or "What would you like todo next?" Their answers to these questions allow

you to determine how the student views the case.Be careful not to ask for more data about the

patient, and dont provide the answer to the

problem yet.

2.Probe for Supporting Evidence - After the

student has made a commitment, ask him/her toprovide evidence to support their impression. As

the student provides this evidence, you candetermine whether they made a lucky guess, or

truly do have a handle on the case. This is not thetime for asking them for textbook knowledge.


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OME News l e t t e r , Spr ing 2007 3The purpose of this microskill is to help you identify

the strengths and needs of the student, which thenallows you to tailor what you need to teach about the

case. Useful questions at this time include, "Whatled you to that conclusion?" and "What else did you

consider and rule out?" Answers to these questionswill provide you insight and allow for good dialogue

with the student.

3.Tell Them What They Did Right - Thismicroskill reminds us to provide positive feedback

to the student, something he/she wants but oftendoesnt get. Comment specifically on what they did

right, and describe the positive effect of the action.Good actions need reinforcement. An example for

this microskill is, "You did a good job of ... and thisis why it is important...." State specifically what was

done well and why it is important? This is notgeneral praise; instead, it focuses on specific

behaviors that are reproducible.

4. Teach a General Rule - Based on what you havelearned about the students needs, you will now want

to teach based on their level of understanding, whichgreatly increases retention. "The key features of this

illness are..." or "When this happens, do this..." Theteaching point should help the student generalize

from this case to others. It should be brief (givenwithin a few minutes) and should not include

everything you know about the subject. It addressesthe patients concerns and the students needs.

Minimize anecdotes or zebras. As you prepare forthis microskill, ask yourself, "What one teaching you

prepare for this microskill, ask yourself, "What oneteaching point do I want the student to leave this

patients encounter with?" It is helpful to have"teaching scripts" for the common conditions that

you encounter in your practice. For example, you

could have several things prepared for teachingabout otitis media (e.g., helpful tips on making thediagnosis, commonly prescribed antibiotics, what to

do with treatment failures); when the student sees apatient with otitis media, pick one of these scripts

and talk to the student about that area. When thestudent sees another patient with otitis media,

reinforce the first point, and then focus on the nextpoint, and so on.

5. Correct Errors - If during the presentation

the student makes an error, correct the mistake.Mistakes unnoted will be repeated. Describe

what was wrong, and identify how to avoid andcorrect the error. "Next time this happens, try

this..." These recommendations should focus onimprovement and be future oriented; avoid

belittling the student. Focus on the problem, notthe student.

In summary, the five simple steps of the one-

minute preceptor are 1) "What do you think isgoing on?" (get a commitment), 2) "Why do you

think so?" (probe for supporting evidence), 3)Provide warm fuzzies (tell them what they did

right), 4) "When this happens, do this..." (teach ageneral rule), and 5) "Whoops!" (correct errors).

An example of how these five steps work inconcert during the teaching encounter is found at

the end of this article. These microskills havebeen shown to enhance the teaching encounter,

and I would encourage you to incorporate theminto your clinical teaching.Reprinted with permission from the author

Improving your Pedagogy

By effectively writing learning objectives(competencies), this will improve your ability to

teach because you will be concentrating on theexpected student outcome and how the student

will be assessed. A learning objective is astatement of what students will be able to dowhen they have completed instruction.

According to Mager (1962), there are threemajor components to a learning objective:

! Behavior: Task or performance (Whatthe student will do?) This is an actionverb.

! Condition: (How will the studentperform the task?)

! Standard: Criteria for evaluating thestudents performance (How well must

the student perform?)


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OME News l e t t e r , Spr ing 2007 4Consider the following learning objective from a

behavioral perspective:

Given a stethoscope and normal clinicalenvironment, the medical student will be able to

diagnose a heart arrhythmia in 90% of effectedpatients.

This example describes the observable behavior

(identifying the arrhythmia), the conditions (given astethoscope and a normal clinical environment), and

the standard (criteria) (90% accuracy).

As stated before, your objectives and teaching willfocus on learner outcomes. Benjamin Bloom*

identified three types of learning, which iscategorized into domains of educational activities:

! Cognitive: mental skills (Knowledge)! Psychomotor: manual or physical skills

(Skills)

! Affective: growth in feelings or emotionalareas (Attitude)

These three domains are commonly referred to in

higher education as KSAs. The Tulane UniversitySchool of Medicine has a unique set of learning

objectives with specific outcomes (competencies) forits students posted on the SOM Website:

End of second year:http://www.som.tulane.edu/objectives/2nd_year.html

By graduation:http://www.som.tulane.edu/objectives/grad.html

It is important to keep these KSAs and the following

statistical information in mind when creating your

learning objectives and include a variety of activitiesfor students in which learning can take place.

As you can see from the data, the most retention bystudents occurs by doing the real thing.

Therefore, it is very important that you create reallife applications as a part of your learning objectives.

Focusing on learning outcomes is criticalbecause this will guide your methods of teaching

and direct you as to how students can apply theknowledge to develop skills and attitudes.

One common mistake made when selecting a

task or performance for students to learn is theverb (What the student will do?). Often teachers

use verbs such as know orunderstand,which are vague. Please avoid these words and

use action verbs.


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OME News l e t t e r , Spr ing 2007 5The following is a sample list of KSAs aligned verbs

that may be used in developing learning objectives:

These verbs communicate knowledge:

Knowledge:Recall

data or information.

Cite

CountDefine

Describe

Draw

Identify

Indicate

List

NameQuote

Recognize

Record

Read

Relate

Repeat

SelectState

Tabulate

Tell

Trace

Write

Comprehension:Understand themeaning, translation,interpolation, and

interpretation ofinstructions and

problems. State a

problem in one's own

words.

Associate

Classify

Compare

Compute

Contrast

Describe

Differentiate

Discuss

Distinguish

Estimate

Explain

Express

Extrapolate

Interpolate

Interpret

Locate

Predict

Report

Restate

Review

Translate

Application:Use a concept in a newsituation orunprompted use of an

abstraction. Applies

what was learned inthe classroom into

novel situations in thework place.

Apply

Calculate

Complete

Demonstrate

Dramatize

Employ

Examine

Illustrate

Interpolate

Interpret

Locate

Operate

Order

Practice

Predict

Relate

Report

Restate

Review

Schedule

Sketch

Solve

Translate

Use

Utilize

Analysis:Separates material or

concepts intocomponent parts sothat its organizational

structure may be

understood.

Distinguishes betweenfacts and inferences.

Analyze

Appraise

Contract

Criticize

Debate

Detect

Diagram

Differentiate

Distinguish

Experiment

Infer

Inspect

Inventory

Question

Separate

Summarize

Synthesis:Builds a structure or

pattern from diverse

elements. Put partstogether to form a

whole, with emphasison creating a newmeaning or structure.

Arrange

Assemble

Collect

Compose

Construct

Create

Design

Detect

Formulate

Generalize

Integrate

Manage

Organize

Plan

Produce

Propose

Specify

Evaluation:Make judgments aboutthe value of ideas ormaterials.

Appraise

Assess

Choose

Critique

Determine

Estimate

Evaluate

Grade

Recommend

Revise

Score

Select

These verbs communicate skills:

DiagnoseEmpathize

Hold

IntegrateInternalize

Massage

MeasurePalpate

Pass

ProjectVisualize

These verbs communicate attitude:

Acquire Exemplify Realize Reflect

THESE VERBS ARE BETTER AVOIDED:

Appreciate

Believe

Understand Learn Know

Source:http://www.acoem.net/uploadedFiles/Continuing_Education/Joint_Spon

sorship/Learning%20Objectives.doc* From Benjamin S. Bloom Taxonomy of educational objectives.Published by Allyn and Bacon, Boston, MA. Copyright (c) 1984 by Pearson

Education. Adapted by permission of the publisher.

The following examples are adapted from an

article by Kevin Kruse (How to Write LearningObjectives):

For an example of how behavioral learning

objectives can be developed, let's assume that weare creating a training program for receptionists.

The goal of the program is simply to train peoplein proper phone use. What might the specific

tasks and associated learning objectives include?

An example of a poorly defined objective is:

In this course you will learn how to operate thephone and properly communicate with callers.

This statement is not an objective but adescription of the course contents. Otherexamples of poorly written objectives are:

After completing this course you will be able to:

! operate your phone! know how to greet callers! understand the procedure for transferring a

call

These objectives do not indicate observablebehaviors, making assessment of their mastery

impossible. How does one know if someoneknows or understands something? What does it

really mean to operate the phone?

The following performance objectives are goodexamples of the use of observable behaviors.

After completing this course you will be able to:

!place a caller on hold! activate the speaker phone!play new messages on the voice mail

system! list the three elements of a proper phone

greeting! transfer a call to a requested extension

These objectives are built around very discrete

tasks. Instead of the vague objective to "operate


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OME News l e t t e r , Spr ing 2007 6the phone," the learner knows exactly what is

expected for successful operation - namely, using thehold feature, speakerphone, and voice mail system.

More importantly, these behaviors are observable. Astudent can be watched as he activates the

speakerphone or listened to as she describes theelements of a good phone greeting. Because there is

no ambiguity, learner expectancy is achieved and aproper evaluation can be made.

Standardized Patients Program Moves

Into New FacilityBy Arthur Nead

After fifteen years in the old clinical skills center on

Tulane Avenue, and temporary space in the PoydrasBuilding, the Tulane Standardized Patient Programhas just moved to a newly constructed, state-of-the-

art clinical skills teaching facility. Occupying theentire 22

ndfloor of a high-rise building at 1555

Poydras St. This new facility, occupying the entire22

ndfloor of 1555 Poydras, will be home to the

Standardized Patients Program, medical simulation,and additional educational space including 8 small

group teaching rooms.

This space will now be home to the Training andAssessment of Professional Skills program, a key

part of medical education at Tulane since 1989.One of the primary goals of our program is to teach

medical students how to perform the basic range ofphysical examinations so that inexperienced medical

students just beginning to learn key exam proceduresdont have to try them out on actual patients in real-

life clinical settings, says Delia Anderson, programdirector.

SPs currently help teach students fundamental examprocedures including inspections of the eyes, ears,nose and throat; heart and lungs, musculoskeletal

exams; abdominal exams; and neurological andpsychiatric exams.

Delia Anderson talks with second-year medical student Edward Pankey inthe new state-of-the-art teaching facility for the Training and Assessmentof Professional Skills Program. Anderson is director of the program.

(Photo by Paula Burch-Celentano)

Additionally, the center provides expertinstruction on the highly invasive and sensitive

female gynecological and male urologicalexams. In addition to the physical exam, theprogram provides students with valuable

experience in dealing with the emotional side ofthese encountershow to calm agitated patients

as well as how to deal with sensitive culturalissues. We provide students with a non-

threatening place to learn and apply just aboutany newly acquired skills, says Anderson.

Another focus of the program is the assessment

of clinical skills. This is done in the form ofClinical Skills Assessments, which mirror the

current USMLE Step II exam. SPs aresupervised by medical school faculty and by the

centers staff to realistically simulate patientssuffering from a variety of illnesses.

The custom-designed training center features

class and meeting rooms, offices and anauditorium. But the heart of the facility is a suite

of 16 examination rooms. During a typicaltraining session, a group of 16 students cycles

through the rooms at regular intervals. In eachnew room, a student carries out a different exam

and makes entries on the rooms computerstation. Video cameras record every session,

making the students performances digitallyavailable for review and for critiques by the

medical faculty.


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OME News l e t t e r , Spr ing 2007 7In addition to our live standardized patients, we

will also have high fidelity simulators, saysAnderson. The Perkin Fund Simulation Laboratory,

part of the clinical skills center, has acquiredHarvey, a high-fidelity simulator used for

cardiovascular exam training. Harvey can beprogrammed to simulate almost all the findings for a

wide range of cardiovascular. The facility will beacquiring several additional simulators in the near

future, according to Anderson.

Another function of the teaching facility is providingassessments of each students progress through a

series of competency exams. We are both teachingand assessing all along the way, Anderson says.

And were not just assessing what we teach, wereteaching the integration of all the skills they are

learning as they move ahead. They are gettingclassroom knowledge, and it all comes together in

this teaching setting.

The Teaching and Assessment of Professional Skillsprogram has benefited the Medical School by

providing efficient and standardized training toclinicals aspects of the schools curriculum, and the

new high-tech training facility brings expandedcapabilities to this program.

Our program can provide basic skills training to

medical students, saving time and resources offaculty, leaving doctors free to focus on the art of

medicine and taking students to the next level oflearning. says Anderson.(Revised by N. Kevin Krane, MD)

Call for Submissions

for the OME Newsletter

The Office of Medical Education Newsletter will

be published three-four times a year as an AdobeAcrobat file that will be delivered by email and

posted on the OME Website:http://www.som.tulane.edu/ome/.

In to make this publication a successful, the

editor is requesting that individuals submit:

! Announcements! Short medical education articles (up to

500 words)

! Teaching Strategies and! Descriptions of research in progress! Reviews of research! Book reviews! Letters to the editor or faculty! Events of interest! Research ideas for collaborating! Publication notices and requests

Materials (send in Microsoft Word, or via email)

and manuscripts should be submitted to:

Annie J. Daniel, Ph.D., OME Newsletter, EditorOffice of Medical Education

1430 Tulane Avenue, SL-6Suite 1730

New Orleans, LA 70112Tel: 504-988-6600

Fax: [email protected]



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OME News l e t t e r , Spr ing 2007 8

Introducing the Teaching Excellence Series

You are cordially invited to attend the first in a series of interactive lectures. The

objectives of this professional development series are to improve your teaching skills,

ability to give effective feedback, and assessment.

OFFICE OF MEDICAL EDUCATION

PRESENTST e a c h i n g E x c e l l e n c e S e r i e se a c h i n g E x c e l l e n c e S e r i e s F e a t u r i n g

RONALD J. MARKERT , PHD

PROFESSOR

ASSOCIATE CHAIR FOREDUCATION AND RESEARCH

DEPARTMENT OF INTERNAL MEDICINE

WRIGHT STATE UNIVERSITY BOONSHOFT SCHOOL OF MEDICINE

Session I: Large Group Presentations That Work

Thursday, May 10 at 9:00 a.m. 1555 Poydras Stre et, 22nd Floor

&

Session II: Writing Flawless Multiple-Choice Tests for Medical Students

Friday, May 11 at 1:00 p.m. 1555 Poydras Street, 22 nd Floor

e r es hm en ts wi l l e s er eRefr e shmen t s w i l l b e s e r v ed RSVP: [email protected]


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OME News l e t t e r , Spr ing 2007 9Our Office Staff

Annie J. Daniel, Ph.D.

Director

Phone: (504) 988-6600

Fax: (504) 988-6601

Email: [email protected]

Byron E. Crawford, M.D.

Professor of Pathology

Associate Director

Phone: (504) 988-6603

Email:[email protected]

Doreen Barrett

Program Coordinator

Phone: (504) 988-5437


Tripp Frasch, B.A.

Educational Technologist

Phone: (504) 988-1144


Kornelija Juskaite, M.A.

Program Manager

Phone: (504) 988-8896


Office of Medical Education

1430 Tulane Avenue, SL-6

Suite 1730

New Orleans, LA 70112

Tel 504-988-6600

fax [email protected]


Our Office is available to

support faculty in the processof educating students and

supporting students in areasthat will ensure their

academic success. Presently,the Office Medical Education

has 11 missions that directlyaligns with the institutional

goals, on which it operates:

Consultation onTeaching

CurriculumDevelopment

Evaluation of MedicalStudent Performance

Program Evaluation Medical Education

Research

Publication ofScholarship in

Medical Education

Proposals for MedicalEducation Grants

Evidence BasedMedicine

Faculty Development Educational

Technology

Academic Counselingfor Students and

Residents

office of medical education newsletter spring 2007

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