Why Orientation is Crucial in Competency-Based Clinical Experience

The University of Saskatchewan, College of Medicine is a competency-based program (for more information about competency-based education, see the previous post on this Blog.) The college has spent a lot of time determining competencies for each level of training, but that is only the first step. The next step is Gap Analysis –determining the difference between where the individual student is, and where they need to be at the conclusion of the course, year and their training if the student is to meet the competency requirement.
The Orientation to Clinical Experience is the ideal place to perform a Gap Analysis. Not performing a gap analysis means repeating material that the student may already know well, leading to an invalid assessments because the student will be assessed at a high level but won’t have learned anything. On the other hand, other areas where the student has less knowledge/skill will go unidentified and the student may be confronted with their lack of skill in a less forgiving environment. The following four steps will help improve the preceptor and the student’s experience.
1. Determine the competencies expected for the student’s time in your office or on your ward. This step is usually predetermined by the medical department, but the preceptor needs to think about what competencies he/she feels comfortable teaching.
2. Discuss where the student currently is in the development of the competencies. Ideally the student will arrive in your office with a description of what they have learned/performed previously.
3. Determine internal and external forces that might influence how much the student can achieve in the time/environment available.
4. Decide on the strategies and tactics that will be used to assist the student in meeting the competency requirements.
For more information on student orientation to clinical experience attend a workshop through Educational Support and Development on Preparing to Teach.

The Teacher’s Journey

I was attending a conference recently where the participants were asked to reflect on their clinical training and one voice said “Pain, humiliation and embarrassment!” There was dead silence in the room. The speaker was a senior physician, one who was known to have had a long and successful family practice, yet there was so much emotion in those three words that I was transcended into the life of a young man thirty years in the past.
I could hear his teachers saying “Well it worked didn’t it?” and on some superficial level it did work. Like an abused child learns to answer the abuser’s questions, this young man learned to duck and cover, learned to placate and learned to fight back from a distance. He swore to never treat his students the way he had been treated.
I don’t know this physician well enough to speculate on whether he was successful in his oath to treat students better than he had been treated. I spend a lot of time thinking about how we are the product of our experiences both in the automatic using of teaching techniques that we liked and in the verbal rejection of those we disliked. I hated droning lectures when I was young, but I find myself falling into that pattern even though I know better. I become the abuser; it’s a pattern that I know, a pattern that comes easily with little forethought if I’m stressed or short on preparation time.
The teacher’s journey begins with a goal, a desire to improve or change something.

Understanding Disease and Illness

An elderly war veteran never admits to the pain he feels after a diagnosis of bone cancer while in the next ward, another patient complains bitterly and demands more pain medication.
Medical schools are very good at teaching doctors how to diagnose and treat disease, but they may not be well prepared to cope with illness. As defined by Terry Tafoya, Ph.D. illness is the patient’s cultural and personal response to the disease. If the two gentlemen above are looked at through cultural lenses, Northern European cultures value stoicism (stiff upper lip) in men, while Southern European cultures believe pain and suffering should be expressed.
To further illustrate this concept here is an excerpt from http://tundramedicinedreams.blogspot.com/ about diagnosing native elders
Yupik elders often have a tendency to give long and circuitous answers to simple questions when speaking in Yupik. Interestingly, the English-speaking ones don’t seem to do it nearly so much when speaking English. It is somewhat affectionately known as “going to the moon.” A question that may be answered with a simple yes or no may engender a long story; at the end of it, the translator may sort of shrug and say “basically, she said yes (or no).” When I raise my eyebrows, the translator will say “well, she had to tell me a story about the time when her daughter…” Elders are held in very high esteem in this culture, and when an elder is speaking it is rude and unacceptable to interrupt. They go to the moon if they want to, and everyone will listen and wait until they are done.
To teach medical students to pay attention to cultural differences in a patients view of illness, Dr. Tafoya suggests using the acronym LEARN.
L isten with empathy (Active Listening)
E licit the patient’s worldview of the problem/need
A cknowledge and discuss possible differences and similarities between the patient and physician’s worldview
R ecommend a prevention/intervention/treatment plan
N egotiate a final plan

Games in Medical Education

When my daughter was 13, she became very interested in the simulation game Pharaoh http://en.wikipedia.org/wiki/Pharaoh_(video_game) . This game challenges you to build a civilization from the Stone Age to the point where pyramids can be constructed. As I watched her spending hours on this game, I began to understand the educational power of games. She was learning about the interconnections between food, religion, and war. She was learning about the importance of planning strategies. Her cities burned to the ground and she started over. Today as she leaves her teenage years and becomes a young adult, I’ve noticed how aware she is of interconnectivity and responsibility of choices.
Marc Prensky http://www.marcprensky.com/ talks about people under age 20 as being Digital Natives. They have grown up during a time when there have always been computers, videogames, email and the Internet available for home use. They grew up with personal digital devices such as Gameboys, music players and cell phones. He describes this group as preferring random access and branching options to the linear stories of their parents. They are comfortable with multitasking and multiple data inputs. As a result, they access information much quicker than their parents.
They complain about school being too slow paced, too obsessed with the written word and not relevant to the real world where they can find most information within a few key strokes and communicate with people anywhere, at any time.
I and most teachers who have ventured into the world of multimedia, computer-based education come to that world as Digital Immigrants. We try to make the technology fit into our old paradigms. We are early adopters of tools like PowerPoint because it allows us to tell our linear stories more effectively. We might even venture into the world of Blogs (LOL) because of our ongoing fascination with the written word.
Exploring the world of Digital Games is one way of seeing the world as the digital native sees it –non linear, multimode, fast paced, problem based. There are four ways to introduce yourself to game technology:
1. play games
2. watch young people at play
3. talk to your students about what they are learning from the games they play
4. take the Educational Support and Development workshop on Active Learning Using Games.