Education Consult Service Web-based Best Practices Exchange

Teaching "Persona"

2011-04-20T12:22:00.007-04:00

At our Education Group meeting this week the topic of "Teaching Persona" came up as a topic for discussion. Teaching persona was defined by one source as "beyond technique or curriculum.. the teacher's own way of being with students"*. Another source suggested that a teacher's persona was "an image that the teacher presents to the class**" that could be actively chosen. Of all that I read, it seemed that authenticity was considered important. However, one school of thought was that one could be authentic and still provide different "images" to different groups or contexts. The most common example was the differing contexts of giving a grand rounds versus teaching on the inpatient service. In this example, the attending could exhibit a formal "expert" persona during grand rounds and a more relaxed informal teaching persona during teaching rounds. Our group was split on this topic with some feeling that persona changes could lead to confusion and uncertainty on the part of learners who may withold sharing their "true self" because they don't feel they have a handle on the "true self" of the teacher. Others shared their own experience of "getting up" for a teaching encounter minimizing their own more introverted side and maximizing their ability to engage and interact with their students. Do you have any thoughts on this topic?

Together or Apart, Is There a Better Way to Teach?

2011-03-23T15:41:00.004-04:00

I subsribe to the DR-ED Listserve out of Michigan State University. This is a really good listserve of mainly medical educators, although others chime in every once in awhile to liven things up a bit. Over the past two weeks there has been a lively thread concerning the best way to teach. The choices given were 1) interactive facilitation or independant reading with lectures. Each side provided literature to back up their beliefs. The usual arguements were posed. "You may learn more stuff by attending a lecture, but the depth of understanding will be superficial" and "Knowing facts (stuff) is important, you can't problem solve without knowing the underlying facts." I think maybe I've been in this education business too long, as I have seen these arguements surface time and again. Since I have access to this BLOG, I'm going to share my thinking on this.

From all my years of study and practice, I have distilled all of the equivical literature about how best to teach down to three commandments>

Thou shalt engage the learner - If students (at any level) are not engaged, they will not learn. What engages learners depends on the content, the learner and the context. Learners can be fully engaged by interacting with an interesting essay, a well designed textbook, a computer learning module, short excellent lectures and small group activities.
When teaching about complex concepts, thou shalt offer opportunities for learners to "elaborate" on new concepts - When topics are complex or controversial learners usually benefit from hearing others point of view and having the opportunity to articulate their understanding and receive feedback from experts and peers. Although the norm is face-to-face during discussion groups, on-line electronic discussions work well for certain content and learners. The disadvantage of "solitary study" is that the learner is stuck with only 2 perspectives (the teacher and him or herself)
Thou shalt design and share goals for any instructional activity - Purposeless chats about anything that crosses our minds may be therapeutically beneficial, but are not a good basis for learning. Carefully crafted cases can provide the goal as can experienced facilitators.

Perhaps overly simplistic, but I've found these three commandments to be very serviceable.

Simulation in Medical Education

2011-03-15T17:13:00.008-04:00

We had an interesting talk about the use of simulation in medical education this morning and it made me think about how far we have come from the "apprenticeship model' of the late 19th and early 20th century. The concept of practicing medical procedures on inanimate objects rather than on patients (especially me) seems a "no brainer", yet medicine has been slow to take full advantage of simulations. Perhaps the allure of the "cadaver lab" was lost on previous generations of medical students and residents, even though these labs provided the only opportunity to "do no harm" while developing skills. Today's high-tech simulation labs provide the opportunity for students and residents to practice everything from interviewing skills with standardized patients to intubation and team ACLS with high-tech mannequins.

We are designing a multi-purpose, multi-site simulation system here at the Clinic that appears to take full advantage of modern technology, all the while honoring the tradition of low-tech human-human interaction. I was impressed with the fore-thought and planning that went into the design. ...My generation marvels at robotic surgery, social media and high tech simulators, imagine the simulations that could be conceived by future generations who interact with avatars in pre-school. Will it be better medicine?? I don't know.

ACGME and vocabulary

2011-03-07T15:20:00.003-05:00

I just returned from the ACGME Annual Education meeting in Nashville on Saturday. It was a really good meeting with great plenary speakers, and the opportunity for me to network with others who are interested in developing Program Director Training Programs at there institutions.

I want to start out positive, because I will quickly reverse direction and explode with frustration. As a faculty development professional, I have spent many years "translating" the educational concepts central to the "Outcomes Project" to our PD's and faculty. Competencies, competency-based learning objectives, and benchmarks were all new concepts to many of the PD's. All are smart people, many of whom sincerely wanted to understand how this new approach to education would benefit their residents. Ultimately we have made great progress.

Now,... new leadership, new vocabulary! The "Milestone Project" has recently been established. I went to one meeting at which a whole new set of terms were identified. Entrustable Professional Activities (EPA's), Landmarks and Milestones were introduced. The presenters had good slides and spent time educating us about the use of these new concepts in planning program development and evaluation. All the concepts seemed educationally sound.

That said, where do we start? Are milestones, that are determined by each specific discipline (Internal medicine has identified 142) like objectives or are they different? What is the difference between "landmarks" and "benchmarks". If after 25 years in education, I'm confused... imagine our PD's who have a few other things on their minds.

Things change... I get it! However, it sure would be great if these changes came with a logical "bridge" between old and new language and rationales for change.

Cleveland Clinic Teachers' BLOG Rises Again

2011-01-20T12:58:00.005-05:00

Now in our third year (with a few months off here and there) the Cleveland Clinic Teachers' BLOG is back! Here are the differences. First, it will be more like a traditional BLOG rather than our first iteration which more like an informal curriculum. Neil and I and some others will post ideas in medical education. Second, after today, there will be no email reminders. If you want notification when a new message or comment is posted, click on the archives for August 2010 and follow the simple directions (I even got this right). I hope you read the BLOG and respond to ideas that interest you.

Best Regards

Christine

Staying Up-to-date with Blogs and Medical Literature

2010-08-06T14:04:00.002-04:00

There is no debate that we are all swamped with data being sent to us via e-mail and we often feel like we are drowning in this deluge. This can cause several problems:

The stress generated by trying to keep up
Time spent/wasted going through unwanted/useless e-mails
Difficulty in separating the wheat from the chaff - the signal-noise ratio is getting progressively lower.
Missing out on critical information that gets buried amongst other useless data - losing the proverbial needle in the haystack

The solution is to get some control over the e-mails being sent to you and increasing the signal to noise ratio. One way to do this is RSS (Real Simple Syndication). This solution has been around for a long time and several of you may have heard of it or use it already. The reason I write about this today is to point out how you can use this functionality to:

Get updates from blogs that you find interesting - using this blog as an example.
Get updates from journals in your area of interest - using medical education journals as an example.
Presently we are sending out e-mails to a vast group of people (about 1000) and we don't want to add to the deluge problems listed above. So if users start subscribing to this blog, we can stop sending out e-mails to folks who may not want to receive them.

So what is RSS?

A simple way to think about it is to compare junk mail that fills up our mail boxes with subscriptions to magazines and newspapers. RSS is a way to subscribe (for FREE) to information streams that you want. Again this is FREE and most blogs and journals provide a way to subscribe to their updates, abstracts etc. but you do need a way to receive this stream. There are multiple options but the one that I use is called Google Reader. It works for me because:

It is accessible via any browser and most data enabled mobile devices
It lets me share items from my subscriptions with others in multiple ways
It lets me create a simple way to share my subscriptions with others (we will see this shortly)
It takes advantage of Google's search engine
It allows classification and organization of the data in multiple ways.
I already have a Google account and use various Google applications like Gmail, Blogger and Buzz.
I am (almost) always plugged into the Net and thus don't need to store these subscriptions on my hard drive - easier to leave them in the "Cloud" and access them from anywhere.
I don't want the data to get interspersed with my regular work applications like Outlook. I prefer to choose when I want to review this information (like reading the NY Times on a Sunday morning).

So if these seem like reasonable reasons, then read on.

Subscribing to blogs:

This blog has two ways to subscribe to it

Just enter your e-mail address where you want to get notified of new posts on this blog and follow the steps. You can then set up rules in your e-mail inbox to handle these messages in a specific manner e.g. move them to a folder.
Use RSS. Make sure you have a Google account (create one HERE). At the top right corner of this blog is a link to Subscribe to Posts or Comments. Click on the down arrow next to it and choose Google. On the next screen choose Google reader. You may have to sign in using your Google account and then you will be taken to the Google Reader screen with a summary of posts from this blog. You can use the same steps with most other blogs.

Subscribing to Journals:

There are several ways to subscribe to journals

Use a subscription bundle created by someone else. I have created a bundle of medical education journals. You can access and preview it HERE. It has feeds of abstracts from 7 journals including Academic Medicine, Teaching and Learning in Medicine, Medical Education etc. Click on subscribe to get these feeds into YOUR Google Reader. That's it, you are done! My bundle of Medicine Journals is accessible HERE
In Google Reader you can click on the down arrow next to Subscriptions and click on Add Subscriptions and then type in name of Journal. Some journals may have multiple listings while others may not show up.
On the Journal Web site, there is a button to subscribe to RSS feed. Clicking on this may give you a an option to subscribe using google reader. Others may take you to a page with the feed. Copy the URL of that page and paste it into the add subscription box mentioned in step 2 above
If the Journal website does not have an RSS button, go to PubMed and type in name of journal. Then click on RSS (top of page orange button). Click create RSS and then click XML. On the page that loads, copy the URL of the page and then paste it into the add subscription text box mentioned in step 2.

You can use the PubMed step to create a custom query (search) and save the RSS feed to Google Reader. Thus if you area of interest is prosthetic valve infections you can create a feed for this and get an abstract of any article indexed by PubMed on this topic.

Almost done; now you have to just remember to go back periodically to review all this information flowing into Google Reader. If you want to read up more about how I personally use Google Reader to tag and classify and search for information click HERE and HERE.

Dear to My Heart

2010-06-16T12:46:00.002-04:00

I had an experience the other day that was just so incredibly cool that I have to share it. I am the Director of Faculty Development and so my "students", for the most part, are the faculty. I was sitting at an early meeting, half asleep, when I heard one of the faculty raise the issue of "instructional alignment" and the need to align learning objectives, instruction and assessment process for an old course that had received sub-standard reviews. Now my ears always perk up when I hear any of the faculty using educational terminology, but this case was classic. Not only had he used the terms correctly, he was descibing in great detail how and why this was so important. And... in a moment of pure egocentrism I thought... "he learned that from me'!

Well this has certainly happened before, but this was a special case. This particular individual had let me know early in our conversations that he thought "all this education mumbo-jumbo" was just that. He had attended two or three faculty development sessions and seemed to be changing his opinion; then stopped coming. This meeting was the first time I had seen him for a few months, so hearing him describe "instructional alignment" to his peers was one of those "peak moments".

Now, I'm sure my clinical colleagues have those moments all the time as they teach residents, students and patients. You get the chance to see daily the intellectual growth of your learners and the progress that patients make based on your careful management. In my field, however, those moments don't come everyday. I'll bet that if you devote your time to faculty development, you are smiling right now and thinking about a moment like this that you have had. It is great isn't it

A Case for High-stakes Summative Examinations?

2010-06-02T16:15:00.000-04:00

The role of examinations like the USMLE Step 1 has been called into question due to:

Tests only medical knowledge - not the other competencies that go towards making a "good physician"
Forces students to memorize content just to regurgitate it at exam time
Most physicians may not need to use the content memorized for this test in later life.
Biomedical science information is growing so fast that there is no way to cover all this content within the span of an average medical school curriculum

Medical Education recently published a very interesting study [pdf; abstract] regarding year 4 medical students in Germany learning EKG interpretation.

Summary of the study:

Cohort 1 - winter 2008-09 - Summative assessment at end of EKG course - randomized to:

Traditional lectures
Small group peer teaching

Cohort 2 - summer 2009 - formative assessment at end of EKG course - randomized to:

Traditional lectures
Small group peer teaching

In addition to a test before and after the EKG course, each cohort had an unannounced test 8 weeks after the EKG course.

Thus the study was designed to look at the impact of 2 types of learning (traditional lecture vs. small group peer learning) and the impact of a high stakes summative examination on the learning.

They found that in the Cohort 2 where there was only a formative assessment at the end of the course (performance did not count towards grades) the small group peer learning group did better at the immediate post test and also retained the information better at the 8 week surprise test.
On the other hand in Cohort 1, the high stakes summative test seemed to eliminate all the differences between the 2 groups.

The question:
What is it about the summative test that improved learning and retention? Did it force students to spend more time in self-study preparing for the test or did it force them to concentrate better at the lectures, taking notes etc?

Reading this study made me think about how this might apply to even higher-stakes summative tests like the USMLE Step 1. Scores from this one test can determine a student's career.

One student who had spent the first 2 years in small group PBL sessions, told me that as he was preparing for the USMLE Step 1 at the end of year 2, everything seemed to fall in place. We discussed this further and it seemed that having to read all the different subjects in a concentrated time span helped him to develop mental connections between various pieces of information in his memory thus improving his understanding.

So what do you think? What is the role of high stakes summative tests in medical education? Are they good, bad, a waste of time, a distraction, or something that we should have more of?

More Thoughts about Conference Attendance

2010-05-14T09:28:00.005-04:00

Last week while Lily was attending the AERA conference, I attended the Pediatric Academic Societies annual meeting. As a PhD medical educator, I was in the minority as most of the attendees were pediatricians in academic medicine. I must admit that I felt like a bit of a fish out of water when I first looked through the program guide as many of the sessions were scientific presentations with titles containing unfamiliar terms and acronyms. I was worried about whether I really belonged at this conference. Upon closer inspection, however, I identified lots of sessions related to medical education including topics such as reflective practice, developing measurement tools in education, and giving feedback. I decided to attend a mixture of sessions with most related to education along with a few scientific presentations and public health sessions in hopes of experiencing the “big picture” of pediatrics.

At the end of four days, I left the conference with a much greater appreciation for the educational issues that are of interest within pediatrics and the larger context in which they exist. A consistent theme was the need for the evaluation of educational interventions to build an evidence-base for educational activities that could be shared across programs.

I, like Lily, came away from the meeting more aware of the benefits of thinking about medical education through a lens other than the one in which I am trained and more convinced of the need for collaboration between those trained in medicine and in education.

We are wondering what your experiences are in attending conferences outside your area of academic expertise and what were the important takeaways from those meetings for you? Are there conferences that you would recommend to your colleagues in medical education?

Medical Education Conferences: Which meetings to attend and why?

2010-05-14T07:25:00.001-04:00

This entry is a post from Lily .

Christine and I attended the AERA (American Educational Research Association) annual meeting in Denver the first week of May. For those of you unfamiliar with AERA, it boasts 25,000 members who are dedicated to educational scholarship and learning. The group is diverse, including educators, administrators, public employees, researchers, psychometricians, behavioral scientists and students. The AERA is committed to scholarly inquiry related to education and evaluation.
This was my first time attending AERA, and I was privileged to present a paper on our Cleveland Clinic REALL (Resident Educator and Lifelong-Learner) Program during a Division I (Education in the Professions) session entitled “Means and Effects of Scholarly Teaching.” Our project was was well-received and I got valuable feedback from the chair of the session, Casey B. White (University of Michigan Medical School), and Luann Wilkerson (UCLA). The feedback from these individuals was very specific and detailed. You could tell that they had read the paper thoughtfully and carefully. Drs. Wilkerson and White took their responsibilities to heart - they had much to offer in the areas of scholarship in medical education, using theoretical constructs and applying these theories to practice. They analyzed our REALL project within these frameworks.
I also chose to participate in Division I's pilot program, Peer Review and Feedback on Junior Scholar's Presentations, an interactive program where I obtained a critique of my presentation skills from Dr. Ann Frye (UT Galveston). Of course, I had the obligatory audio-visual problems from the get-go (there were 3 different feeds into the LCD projector, 2 Mac computers and my Windows netbook, which the AV assistant cursed because his fingers were bigger than the keyboard!) Dr. Frye offered me several useful tactics to improve my presentation style. As my background and education are based in clinical medicine, many of the topics and sessions at AERA were new to me. I found this meeting to be very different from the AAMC and CGEA; the vast majority of the topics fell outside the medical field – with Special Interest Groups such as Constructivist Theory, John Dewey Society, Motivation in Education, just to name a few. Like many doctors, I seem to attend the same meetings mechanically year after year, listening to the same people talk. Attending this one was an eye-opener, and a great opportunity for cross-fertilization of ideas. I encourage you to check it out at http://www.aera.net/ and consider attending the 2011 meeting in New Orleans, April 8 - April 12.Lily

What can Medical Educators do to Reduce Health Care Costs?

2010-04-19T10:24:00.000-04:00

Molly Cooke in a recent article in the NEJM (Cooke, Molly Cost Consciousness in Patient Care -- What Is Medical Education's Responsibility? N Engl J Med 2010 0: NEJMp0911502) suggests that medical educators may have failed in their task of teaching medical students and house staff appropriate use of various diagnostic tests and therapeutic procedures.

While she acknowledges that there are various factors why physicians may order more tests or procedures, she states that medical educators need to do more to help change practice behavior of these future physicians.

Schools and residency programs already educate trainees on the concepts of Number Needed to Treat, Absolute and Relative Risk Reductions, Sensitivity, Specificity of Tests, Positive and Negative Predictive Values, Likelihood Ratios etc.

The New York Times in a recent article discusses whether the new health care reform act will lead to decrease in health care spending.

Do you think more training regarding cost conscious use of tests and procedures in medical school will lead to change in practice behavior of future physicians? Will other drivers like financial incentives overcome any effect of training? What do you think we can do as medical educators that will truly impact the cost of health care?

Neil Mehta

duty hours debate: does promoting patient safety necessarily mean further reductions in duty hours?

2009-11-05T15:20:00.008-05:00

In December of 2008, the Institute of Medicine published a report titled: Resident Duty Hours: Enhancing Sleep, Supervision and Safety. I have to admit that I have only read the Report Brief and the table of recommendations found on their website, however, it appears clear that the report suggests modification of current ACGME rules for shift length (although not theoretically reducing the overall 80 hours), and tightening of monitoring processes by the ACGME are needed.

The report was published almost a year ago, why bring it up now? One of the Staff here at the Cleveland Clinic brought the open letter from Dr. Thomas Nasca (CEO for ACGME) to my attention yesterday. I was so impressed by Dr. Nasca's thoughtful response to the report that I decided to scrap the topic planned for November and bring your attention to this document. After reading Dr. Nasca's letter, I wondered what our community was thinking about the IOM report and the ACGME response.

It would be hard to imagine that any physician group would argue against patient safety. The primacy of keeping patients' safe is one of the foundational principles of the social contract that physicians have with the public. After reading Dr. Nasca's letter, I can see that there are many contributing factors to a safe clinical environment. Sometimes these 'competing goods' are in conflict. A well rested resident is a good thing. Fewer staff hand-offs during care is also a good thing. If you haven't read Dr Nasca's letter and you teach residents, I suggest you take the time. I hope you also take the time to share your opinions on this vitally important issue.

http://acgme.org/acWebsite/home/NascaLetterCommunity10_27_09.pdf

SEPTEMBER/OCTOBER SUMMARY

2009-11-05T14:45:00.004-05:00

Strong opinions were voiced by our respondents to the question: Are Academic RVU's the Answer to Making Time for Teaching? It appeared that either the respondent was strongly in favor or strongly opposed. Those in favor thought that, although not perfect, academic RVU systems provide a way to "account for and recognize" academic efforts. A few of those opposed, seemed "opposed in principle", not really articulating a rationale. However, a small number cited the problem of reducing a highly complex activity (teaching, advising, mentoring) into an artificial formula. In fact, one reader stated that "going down this "slippery slope" could be likened to "pandering to the bean counters". Whether or not Academic RVU's surface again as an option, we know that there will be strong opinions on both sides.

ARE ACADEMIC RVUs THE ANSWER TO MAKING TIME FOR TEACHING?

2009-09-21T11:05:00.016-04:00

The problem of finding time for teaching and having that time “honored” as valuable to the institution has been an ongoing concern for academic medical departments; but perhaps never more than now. Some departments have begun exploring adapting the familiar clinical metric, RVU’s or relative value units as a way to place comparable value on time taken by physicians in their roles as teachers and researchers.

In a 2007 article in J Am Coll Radiol (see link below) the authors state: "Despite the importance of teaching, research, and related activities to the mission of academic medical departments, no useful and widely agreed-on metrics exist with which to assess the value of individual faculty members’ contributions in these areas.

They go on to describe the use of RVUs as a common metric. In their model, all academic activity is quantified and weighted based on "estimates of effort, impact, and value to the department" (Mezrich,R & Nagy, PG. 2007). In the category of teaching, for example, classroom teaching and student feedback are factored into the equation, while clinical teaching is factored into clinical productivity. It is an article well worth reading if you are considering an RVU-based system. Their experience details the complexity of the process and the importance of linking departmental goals to the weighting system

In theory it sounds good, but how do you truly account for time spent preparing new interactive seminars, case-based teaching sessions, facilitating PBL or the development of innovations like online teaching modules. How do you account for time for providing feedback, writing evaluations and mentoring students and residents? Can we deconstruct teaching into RVUs… Should we? What do you think?

For ohiolink users

For citation and abstract

AUGUST 2009 SUMMARY

2009-09-21T10:17:00.008-04:00

The concept of introducing or expanding online learning in medical education stimulated a good discussion. Some of our readers described their experience with online learning as boring, painful, and passive, while others described their experiences as interactive, satisfying and effective. How do you account for the disparity of experience and opinion? One reader suggested that the question was phrased too simply. Like most questions in medicine and medical education, the answer usually begins with "it depends". Our readers thought that "it depended" on the purpose of the instruction, the learning style and motivation of the students, the skill of the teacher and the ability of the technology used to create interaction. One reader thought that the generation of the student cohort might also influence the effectiveness of the instruction. Neil, on September 2 (see comments) really did a nice job of addressing the complexity of the question He concluded, as did others, that a blend of online and face-to-face methods may be the best approach. For more information see link below:

http://www.ed.gov/rschstat/eval/tech/evidence-based-practices/finalreport.pdf

IS ONLINE LEARNING READY FOR PRIME TIME IN MEDICINE?

2009-08-12T14:47:00.008-04:00

Everyone who uses a computer learns online. We learn when we Google a topic and sort and read the resulting hits. We gather new information and use it immediately (time of a movie) or reflect on it and weave it into our understanding of a new or familiar theme.

What about using online learning as the primary method for learning about medicine? Can our students, residents and fellows (as well as ourselves) effectively learn what we need to know through online classes? Numerous studies have clearly indicated that some people can learn very effectively online. Other studies indicate that the effectiveness of online learning is dependant on the subject matter, the skill of the teacher to create online learning environments, and the learning style and personal characteristics of the learner.

In response to reduced duty hours, the introduction or expansion of online or distance education classes seems to make good sense. Online CME offerings also become more attractive as travel restrictions due to the lingering recession limit CME choices.

Sometime in the next year someone is going to ask you about online learning. What do you think? Is it ready for PRIME TIME?

Should we forget about lectures and get the very best teachers to create online courses that our students and residents can access day or night?

Are there topics that can not be taught online?

Are there types of learners that you think will have problems with online learning?

If you have taken an online CME course, or taught an online course, what type of experience was it for you? If you have no experience but have an opinion, let us know. Let’s see what the collective wisdom is about integrating online learning into our medical schools and hospitals.

JUNE/JULY SUMMARY

2009-08-12T14:43:00.001-04:00

REMEDIATION – WHAT WORKS

We only received 8 responses to this question, but those who responded had a lot to share. All of the responders recognized that solid remediation takes work; work in planning and work in follow-through. Planning without follow-through is just plain not worth the effort and can leave the resident feeling even more hopeless. A couple of our responders indicated that hardly anyone has the time to do this right. Another thread of the discussion looked at our ability to listen and diagnose problems correctly. As we all know a “prescription” based on a faulty diagnosis is unlikely to be effective. Read the attached article for some ideas on developing good remediation plans.

http://ovidsp.tx.ovid.com/spa/ovidweb.cgi?&S=DDDJFPDCGDDDNHOHMCFLCBOKGOAHAA00&Link+Set=S.sh.38%7c4%7csl_10

REMEDIATION - WHAT WORKS

2009-06-23T10:25:00.003-04:00

Teaching is pretty easy when we have bright, motivated students and residents who share our values and “hang on our every word”. But that is not always the case.

I was facilitating a group of faculty at a conference this spring where the topic was “the problem student/resident.” One member of the group was describing the terrible time she was having with a certain resident and how she “had to come down hard on him” and how she didn’t see much hope of him improving his clinical performance as he had a “rotten attitude” and a “poor work ethic”. She was quick to let our group know that she never had any trouble with “good residents”.

As our group tried to help her explore her main issues, it struck me that I had heard that many times before – “I never have trouble with the good student or good resident”. Well the truth is, NOBODY DOES. Those students and residents would learn no matter what we did. They make us feel like good teachers and so we become better!

Our real challenge as teachers comes when the student or resident 1) is working at top mental capacity and just barely making it, 2) does not share our values or social mores, and/or 3) does not share our expectations for work productivity. At some point, we identify students or residents who need some “special action” on our part. That “special action” is often called remediation. Remediation can be a simple learning plan designed by the resident or student and monitored by a faculty member, or it can be a formal learning plan that is designed by the faculty, approved by a committee and monitored closely with specific consequences attached to not meeting benchmarks.

The issue for discussion for June/July is REMEDIATION ACTIVITIES. What has been your experience? What works? What doesn’t work? Are their specific types of student or resident issues that are more amenable to change through a specific type of remediation? Should we try, as a community, to formalize a series of “remediation steps” that all programs within an institution would follow depending on the severity of the problem? I’ve posed lots of questions,… Now let’s hear what you think.

MAY 2009 SUMMARY

2009-06-23T10:06:00.006-04:00

We had an interesting discussion about "problem residents" and whether one can really know whether a resident is just getting a slow start, or will not realistically be able to become a competent physician. As you might have guessed, no one had a definative "formula" that we could follow. Two readers commented on the interview process and its limitations in exploring values and work ethic. Others commented that "substance use" should always be explored when faced with undesireable behavior. Three readers mentioned two characteristics that had been good predictors of success. The first predictor was a willingness by the resident to acknowledge the problem and the second was an ability to reflect on the feedback given and pose a plan. Finally, one readers posed a rule to follow - "always be working in the best interest of the resident".

CUT YOUR LOSSES or LATE BLOOMER???

2009-05-07T15:20:00.005-04:00

New residency program directors have limited experiences and face multiple problems each day. One new PD has recently had a challenging time managing two residents, one a third year and one an intern. The third year had posed a professionalism problem from his first year along with some problems integrating into the system and organizational challenges. Things had not gotten too much better over the course his training and lots of time and energy had been invested in getting this resident through the program. Now a new intern was showing the same beginning pattern. He wondered if he should just cut his losses on this intern now rather than waiting three years. His "sample of 1", indicated that he was taking on a 3 year problem. But we all can think of examples of residents who begin with problems and end up being "STARS". So his question: What percent of new residents who show both professionalism problems and knowledge problems in their first year ever turn it around and become contributing members of the residency program? What is your experience?

APRIL 2009 SUMMARY

2009-05-07T15:09:00.003-04:00

The topic for April, THE MILLENIUM GENERATION IN HEALTH CARE, struck a cord with a few of our readers. The responses seemed to be divided between those who indicated that making a generalization about a whole generation seemed somehow "flawed" and others who seemed to believe that there was merit in the premise and that there was adequate evidence of differences to warrant discussion. Both are reasonable. I doubt that we will ever be able to conclude this debate with hard evidence. However, we have noted generational trends in the past and this one might be worth watching.

Millennium Generation in Health Care

2009-03-29T13:28:00.007-04:00

For the past few months, I have heard more references to the Millennium Generation than I had in the last year. In giving workshops on teaching techniques, the subject has come up. At a recent meeting, a respected leader asked whether the incentive packages needed to be changed to factor in the values of the Millennium Generation. So being the dutiful “baby boomer” that I am, I felt the responsibility to learn more (and bring you all in on the lesson).

The Millennium Generation or Generation Y (approx. 1980 – 2000) are just entering our graduate schools, medical schools and residencies and they are making an impact. According to experts, we can expect a different set of values and expectations from this group of young people and potential conflict with older “baby booming” authority figures.

Some of the common characteristics of the Millennium Generation noted by observers are:

Tech savvy – They grew up with computers and relate to the world through technology. This characteristic can also lead to the tendency to be impatient and expect instant gratification
Image driven, sometimes called “trophy children”. They grew up being told they were “special”. This belief can sometimes lead to a false sense of entitlement.
Value personal time and time for family, they believe they should be able to “have it all”
Efficient multi-taskers (see tech savvy)
Adaptable. Some attribute this to their early entry into “day care”, “early team sports” and doting parents who included children in all types of activities and travel. Whatever the reason, the Generation “Y”ers believe they can “get it done”

Do we change the system to adapt to this new generation? Or should we change at all?

What kind of educational systems will appeal to the best and brightest of this generation?

Have any of you thought this through?

Have you noted any differences in the last few classes that have entered your graduate schools, medical schools or residency programs? Or is this all "psycho-babble"?

Do you have any advice for the rest of us? We would love to hear what you think!

February-March Summary (Technology and Teaching)

2009-03-29T13:13:00.004-04:00

The topic of Technology and Teaching did bring out some strong feelings and some really great ideas. The article that sparked this discussion suggested that “skills in critical thinking and analysis” had declined as a result of the use of technology in learning environments. Now that is a pretty bold statement and a very general one. Are all forms of technology to blame? That hardly seems likely as technology is a multifaceted tool that has many applications. So what could it be about technology that could result in these findings? Our readers commented and their comments fell into 3-4 categories.

Five of the 17 responders believed that their residents and students had “lost skill”. Three of the responder thought this might be attributed to “speed” of connectivity and searches. According to our readers’ thinking, students and residents quickly search using key words and don’t think things through or critically analyze. They have an answer before they have really thought out the question. I tend to agree with this point of view. Google anything and you will receive multiple answers. Analyzing the quality of those answers is another story. This however does not mean that technology is a villain. The tool is not to blame. Could we as teachers expect more from our learners? Should we teach them how to use the technology tools that science has given the? Yes, of course.

Another group seemed generally “miss-trustful” of too much technology.

The third group of responders really explored technology as a tool. As Neil so aptly stated, “technology gets bad press when it might just be the teaching method that is at fault” Often, technology is just a “delivery method”. Of course it can be more and we have to monitor how we use technology as a part of our repertoire of methods and tools. If critical thinking is what we want, then we need to consider how best to stimulate our learners to analyze.

DOES TECHNOLOGY HAVE A PRICE?

2009-02-23T15:46:00.006-05:00

Every innovation has both an intended effect and other effects that are unintended. Technology is no different. ScienceDaly recently published an article titled "Is Technology Producing a Decline In Critical Thinking and Analysis?" that summarized a study that recently appeared in "Science". In this article, Dr. Patricia Greenwood from UCLA reviewed over 50 studies. One conclusion from this review was that while visual intelligence had gone up, "skills in critical thinking and analysis have declined."

Another interesting finding, particularly relevant to schools that provide and promote the use of laptops, was that "students who were given access to the internet during class did not process what the speaker said as well as student who did not have access". Although many of the studies reviewed were completed with children, the results are no less important for those of us who teach students and residents in the health professions.

Click on the link http://www.sciencedaily.com/releases/2009/01/090128092341.htm and check out the summary and find the citation for the full "Science" article.

What are your thoughts about these findings? Does this disturb you? Is it just a predictable evolution of man? Do we need to change our expectations? Should we offer more opportunities for discussion and problem solving? Should we reduce the number of computer simulations? Is it too late by the time students come to us to make a difference? It would be great to hear from readers who grew up in the technology age and also from those of us who grew up with "books". Respond to any of these questions or just react to the findings of this study.

JANUARY/FEBRUARY SUMMARY

2009-02-23T15:03:00.004-05:00

Our January “Education Item from the News” from The New York Times, titled “At MIT, Large Lectures Are Going The Way Of The Blackboard” really seemed to spark some interesting conversation. The vast majority of the 18 posts seemed interested in rethinking Grand Rounds to make it more engaging, while a few others thought that Grand Rounds was OK, and described it as a unique educational venue in which experts presented interesting findings on topics of interest. The perhaps missed point was that “Grand Rounds” was just an example of a teaching venue that might benefit from “rehab”. Individuals do not learn unless they are engaged and teaching formats that rely on “listening” alone as the means of engagement disadvantage many learners.

One of our readers suggested the use of the Audience Response System (ARS) as a means of promoting engagement in large groups. ARS has been found to increase attention on the part of participants and may be a great way to encourage engagement. A few other ideas from our BLOGGERS were to:

“Allow invitees to large lectures to submit questions to the speaker a few days PRIOR to the session to allow them to customize their presentations.”
“Archive the presentations in a way that can be accessed later by non-attendees and attendees who would like to review.”
"Grand Rounds"-- when given by residents and fellows and arranged properly so that feedback can be given-- can serve the very important function of allowing trainees to hone their public speaking skills. It is important for doctors... as teachers... to possess such communication skills.”
“Teaching to smaller groups provides an opportunity to engage all participants in a discussion that presumably, enhances an active learning; the lecturer, acting as a moderator, can gauge the level of understanding and effectively ensure the learning of the information”

WHAT'S SO GRAND ABOUT GRAND ROUNDS?

2009-01-22T09:34:00.003-05:00

A recent article in The New York Times Education Section
http://www.nytimes.com/2009/01/13/us/13physics.html?partner=permalink&exprod=permalink described an enormous change in the way the introductory science courses are taught at MIT; yes, Massachusetts Institute of Technology! Rather than the traditional crowded lecture hall, small groups of students explore the problems of science by interacting with peers and using faculty as resources and facilitators. The “50 minute expert lecture” is dead; instead, professors engage students in small group work while clarifying key concepts as they roam from table to table.

How’s it working out?

“Last fall, after years of experimentation and debate and resistance from students, who initially petitioned against it, the department made the change permanent. Already, attendance is up and the failure rate has dropped by more than 50 percent.”

What does this have to do with Medical Education and Grand Rounds?

Everything!! For years, many of the Basic Science and Clinical teachers in medical schools and residency programs across the country have been “bucking” the “case-based and/or collaborative teaching” trends by saying that there is simply too much to “cover” to use these more interactive concept-based teaching approaches. It is true that you can cover more ground with a lecture, but if no one is awake, much less learning, what is the point?

Will medical and residency education be “brave enough” to follow the example of MIT? Can we resurrect interaction, clinical reasoning discussions and vigorous debate at some of our education meetings?

Can we change “Grand Rounds” into something really GRAND? Click on the link above and read the whole article. It is fascinating. We want to hear what your think?

CAN CLINICAL TEACHING BE BOTH HIGH QUALITY AND EFFICIENT?

2008-11-01T16:28:00.000-04:00

I don't think Cleveland Clinic is alone in attempting to balance high standards for clinical teaching quality and the need for greater clinical productivity. The same way that experienced clinicians seem able to efficiently care for patients without a drop in patient satisfaction or quality of care, so then, experienced clinical teachers seem to be able to "teach" both efficiently and well.

The other day I was observing a clinical teacher with a group of residents and students during rounds. It was quite a sight. I wish I would have had a video camera, because this was a clear example of teaching expertise in action. The attending interacted with everyone on the team, the flow was quick and there did not seem to be a minute wasted as the team moved from room to room. The questions she asked were insightful. She provided quick feedback and was at the same time respectful to the "senior", asking him to "teach" at one point.

So... What is your secret? How do you make time to observe, give feedback, provide focused teaching? If each person that receives this BLOG could share one idea, we would really have something worth saving!

OCTOBER SUMMARY

2008-10-31T13:54:00.000-04:00

Dear Teacher’s BLOG Readers:
The responses to the October’s Question, “GLOBAL RATING SCALES: USELESS AS A TOOL FOR IMPROVING PERFORMANCE” were insightful and honest as well as practical. If you have not already read them, I encourage you to go to the OCTOBER Archives and read each one. The following are just a few “pearls” from the list.

There was a consensus that “global ratings” alone do little to assist our learners in improving practice. Some quotes:

“The student requires a specific notion of what should be improved and therefore numeric value will be useless if there are no specific comments that will provide further feedback and insight”.
“I agree that a global rating scale number such as "7" alone provides little information to a student about performance. Descriptive feedback is definitely better at elucidating areas of strength and weakness. This type of feedback allows the student to internalize and re-assess their performance with opportunity to adapt to expectations and/or standards.”

Others responded to GRS reliability and the use of data to compare students or residents. Some notes and quotes:

“Just like with Likert scales, things are given a numerical assessment and each number is exactly the same distance from the other, yet what these numbers mean is not uniform in distance. For example, the distance between what someone would rate a 5 and an 8 on these scales is much smaller than the difference between 1 and 4. In fact I don't even know if 1 exists! This renders the scale even more arbitrary than what is just personal point of view of what an 8 means, etc. This has direct implications on using the numbers in any way - for example averaging and comparing.”
“…. I think that the information from these GRFs becomes more meaningful when there are a number of raters. In this case, if a student consistently is scroing much lower than his or her peers, (across several stations) then we can intervene with that student and provide targeted input, correction, remediation -- whatever you want to call it. Yet, the students say that they learn the most from the narrative comments that the SP's put on each section of the form, noting what the student did well and what could be improved. I don't think that it's really a question of GRFs vs. narative feedback; we need both as they meet different aims

There are good questions about the value and psychometric properties of Global Rating Scales. A nice short article that addresses the inherent problems with GRS is listed below.
Farrell, S E. (2005) Evaluation of student performance: clinical and professional performance. Academic Emergency Medicine. 12(4): 302e6.

GLOBAL RATING SCALES: USELESS AS A TOOL FOR IMPROVING PERFORMANCE

2008-10-15T14:20:00.010-04:00

Probably, all of us can agree that the ACGME Six Core Competencies are important measures of a good physician. They have resonated with medical schools so well that a large number of schools have incorporated these competencies into their expectations for graduates. Who could argue with the concept that we want our graduates to be knowledgeable, clinically proficient, professional, good communicators, lifelong learners, and good stewards of the healthcare system in service to their patients.

The problem, as I see it, is not the competencies, but how we assess them. For the first five years after the introduction of the Competencies, new Global Rating Forms (GRFs) were introduced as the "answer" for assessing the competencies. In this approach, students or residents are assigned a number from a scale, for example, a "5" out of a possible "10" on one of the competencies. The faculty member has "done his/her duty", but how satisfying is the process for our teachers, and what in the world does that student or resident do with that "5".

Our medical school (CCLCM) is a competency-based school that approaches assessment systematically by emphasizing formative narrative feedback organized through a portfolio sytem. Students never are assigned a number, rather they receive narrative feedback about their "strengths" and "areas needing improvement". This seems to be working really well, although, there is a bit of a "learning curve".

So.. what do you think? Are there some strengths to GRFs that I am missing? Have you found ways to make those "numbers" tell a story that leads to improvement? Let us know what you think? Any residents or students reading this link? What do you think?

SEPTEMBER SUMMARY

2008-09-30T14:16:00.000-04:00

We had a record “20” responses this month. If you have not already read them, I encourage you to go to the September Archives and read each one. The following are just a few “pearls” from the list.

3 or 4 of our responding BLOGGERS mentioned the importance of keeping material new, reading and adding up-to-date information to the “talk”. New findings with their implications for practice can be a great springboard for comparing old with new and many other teaching strategies and stories that go beyond the simple facts
Another theme was changing from thinking about what and how to teach to thinking about your learners’ needs. What do they need to learn? Where are they now? And What can you offer to help “fill the gap” By focusing on each new groups’ learning needs, you are probably starting at a different place and covering similar material but with the focus not on teaching , but helping the learners succeed.
Another theme was very practical and focused on extrinsic as well as intrinsic rewards. Extrinsic rewards come from students, one BLOGGER suggested keeping those positive letters and notes from students for a “rainy day” when your motivation needs a boost. Others used feedback as a tool in refining their teaching. Intrinsically reward yourself by communicating with other dedicated teachers.
Finally, TRY NEW THINGS!!! Get out of your “comfort zone”, go to workshops when offered and learn new approaches to teaching. And most importantly do it with enthusiasm. If you don’t feel enthusiastic, “fake it”, then feed off the students response until you really feel it. Or as one BLOGGER offered, Just say, I’m not on my “A” Game today, let’s go get coffee and do “flash cards”
My humble addition is to mentor a new teacher on the faculty. No, not that “star” that is a natural, but that highly motivated, limited teaching skill faculty member that really needs you! When I hear that faculty member has gotten great reviews by students, I’ve got a smile on my face a mile wide.
Hope these suggestions were useful to you!

KEEPING A FRESH PERSPECTIVE ON TEACHING

2008-09-01T16:15:00.002-04:00

Let's face it, Teaching is not rewarded in the same way that Clinical Work and Research are in most large academic medical teaching centers. It may be that we simply are not able to measure outcomes in teaching the same way we can in the other two "legs on the academic stool".

Some faculty say, "teaching is its own reward" and I would agree. But how do you keep your teaching "fresh" in the face of all the other demands on your time. This was not the question I had planned for September, but a gifted "early career" teacher stopped me today and asked, "How do they do it! How do some of these guys teach year after year and act like they are teaching this material for the first time? How can I keep my enthusiasm? Sometimes I just feel tired"

So this question is to our faculty who have been doing this for a few years. How do you keep it "fresh" (or appear to)? Any tips you have for keeping your enthusiasm and avoiding burnout would be most welcome. Let's break our record of 10 responses.

AUGUST SUMMARY

2008-08-31T16:06:00.002-04:00

The responses to the Augusts’ Question, “Shhhh! Quiet Learner at Work” were insightful as well as practical. We also had our highest response with faculty posting 10 different responses and ideas. If you have not already read them, I encourage you to go to the August Archives and read each one. The following are just a few “pearls” from the list.

Two of the responders thought that giving quieter students or residents a specific role to play can increase their interaction.
One responder mentioned assigning a paper, then asking the quieter student to present the next day, another suggested asking them to serve as “teacher”
In one-to-one teaching it is not as much of a problem since dialog is pretty much mandated. However, if you want to increase students’ one and two word responses, first, ask more open-ended questions and second, make your expectations for depth of response clear.
One responder suggested killing two birds with one stone by enlisting the “talker or dominant student” to solicit opinions from the quieter student.
Two responders thought that one needed to consider cultural background as certain cultures regard speaking out as impolite. Again, expectations need to be made clear
Finally, before labeling the student as quiet and non responsive make sure your own behavior is not intimidating to all but the most aggressive learner.

One thing I might add from years of working with faculty (who can also fall into this category) is to create a “reason for communicating”. Many times the learner themselves prefers to learn through observation and checking the “answer in their head” with those verbalized. They have no personal need to verbalize their understanding. GIVE THEM A REASON!
Hope these suggestions were useful to you!

Shhhh! Quiet Learner at Work

2008-08-04T15:31:00.002-04:00

Have you ever spent a week or even a month with a group of students/residents and when it comes time to complete their evaluations you are not at all sure of what they know or don't know. Sure they show up on time and complete their work, but whenever you try to engage them in discussion to see if they really understand, the most you get for your trouble is a short response. You perceive no interest, no passion... It is frustrating!!!!

The dilemma of the "quiet student"!

I've often wondered "Who's problem is it anyway?" Maybe it is just me? The more reflective quiet student or resident seems fairly content handling their learning. Or do we do them a disservice by not challenging them?

How do you all handle "quiet students?" Has anyone found a way of engaging these reluctant participants and getting a good sense of their knowledge and understanding?

Please "comment" if you have an idea.

JULY SUMMARY

2008-07-31T14:48:00.002-04:00

The responses to the July’s Question, “When Learners get it Wrong: Handling Incorrect Responses without Intimidating the Learner Discussion” were great examples of the fact that there really isn’t one right way to address any teaching question. The following are just a few “pearls” from the list.

It is important to build a safe learning environment so that learners are willing to ask and answer questions.

If the learner is more advanced and seems certain of an incorrect fact, ask a follow-up question concerning their source. If no one has supporting evidence send the individual or group out to find the correct response.

Look for a “kernel of truth” in the response and work from there.
For early learners, ask questions in a form that doesn’t require “one right answer”.
When asking questions, know the difference between “wrong” and “not my way” and respond accordingly.
Try to avoid “what am I thinking” questions
Respectfully correct the response and “move on”

What our faculty “bloggers” were telling us on this issue is that their solutions depend on the context. In this case “time” was sometimes a factor. Another factor was “importance of the answer to “good practice”. Another factor was the existing relationship you have with the learner group. Teaching, like medicine and to a lesser degree science, is an "it depends" profession!

WHEN LEARNERS GET IT WRONG

2008-07-10T13:39:00.004-04:00

WHEN LEARNERS GET IT WRONG: Handling Incorrect Responses Without Intimidating the Learner and Turning Off Discussion.

When doing observations of teaching in the classroom and clinics, I often pay special attention to how faculty handle incorrect responses. Some teachers use the incorrect response as a springboard for teaching. Others -move on- asking another student or resident to help out. Another group answers the question themselves while still another group (unfortunately) ridicules or makes fun of the incorrect response. While we all can agree that the last strategy is probably not the best, is there one best way to make sure the learner and the rest of the group are clear about the correct answer while not shutting down that learner or the others that are in the group?

What works for you? Is there one best way? Is there clearly a wrong way? Do we worry too much about hurting our learners feelings?

June Summary

2008-06-30T13:33:00.001-04:00

The responses to the June Question, “How Do You Effectively Teach Multi Level Learner Groups?” were great examples of expertise in teaching. If you haven’t already read through the comments be sure to click on the Archives for June to read each great idea.
Our faculty came through with 13 excellent suggestions. The following are just a few “pearls” from the list. The advice from the faculty was given primarily in the context of “teaching rounds” :

Set expectations for teaching rounds. Give each level learner a specific role. Three of our responders suggested giving the student the first question and asking the more senior learners to “build on” the student response. Another approach was to start with the student and a pathophysiology question, then move on to interns for signs and symptoms and differential while saving the management questions for the resident.
Give opportunities for senior residents to teach. This can be planned (where the senior and the team know that the senior will be “running the show” for a certain number of cases) or impromptu where you ask the senior for their opinion and direct the student questions to them for response. In both instances, give the senior feedback on their teaching

Hopscotch Teaching.. or Teaching to Multi-level Groups

2008-06-06T10:38:00.001-04:00

Both clinical and basic science teachers often ask me questions about teaching/facilitating groups composed of learners at different levels. From my observations, I’ve found that it is not uncommon for faculty to conduct hospital teaching rounds where the team is composed of medical students, interns, residents and possibly some fellows. Researchers facilitate conferences and lecture to groups that include graduate students, medical students, fellows, and colleagues. The question is, how do you keep them all engaged and learning?

Have you ever faced this situation before? If so, how did you handle it?

May Summary

2008-05-31T10:25:00.002-04:00

Our question for May asked how clinical teachers (especially young teachers) strike the right balance between being considered overly accommodating (pushover) and being considered overly strict (task master).

Our faculty came through with six excellent suggestions. The advice from the faculty was to:

Set expectations or standards early in the process; this way students and residents will know how to prepare and won’t feel “ambushed”
Use the ASK-TELL-ASK approach to giving feedback, always starting with the learners’ perspective, using their concerns as a springboard for teaching
Model the behavior you expect from your learners

Two other comments reflected on the difficulties young clinical teachers face as they transition from resident or fellow to attending and develop their own teaching persona. Anecdotally, new faculty have described difficulties especially when joining the faculty at the institution in which they trained, citing evaluating past peers as the most difficult. I reviewed the literature and could find nothing helpful concerning this transition. Perhaps this is an open area for educational research!!

Task Master or Pushover Dilemma

2008-05-12T10:51:00.000-04:00

In trying to create a "safe" environment, teachers can over compensate and become so accepting that "anything" seems "ok". In these settings the learners can lose motivation to perform. It is really hard to find just the right balance between being a "task master" and being overly supportive.

Young teachers have often come to me with this dilemma. They in particular feel "singled out" by students and residents as being "too harsh" if they attempt to hold high standards.

Have you shared this experience?, or have some ideas to contribute? Join the discussion. We want to hear from you!