Why Guidelines are an Important Part of Medical Education

The Problem

Like women a year after childbirth who have fuzzy memories of the experience, preceptors don’t remember what it was like not to know X. Their fingers don’t remember the inability to tie knots and they are unable to list the steps in a procedure because it is performed automatically, both mentally and physically. Therefore guidelines seem too simplistic or obvious to experts. Even changes to guidelines are rapidly assimilated if they fit into the medical patterns that experts already have.

Medical Students Don’t Have Patterns

Medical students leave the university with vast chunks of information, but only practice in the real world forms those chunks into the patterns that denote medical expertise. Both their bodies and their minds are awkward participants in the new learning process that forms the clinical years.

Clinical Guidelines

Guidelines promote clinical learning for the following three reasons:

  1. memorizing steps is a familiar learning process for students, it’s concrete in an environment that may feel nebulous and unpredictable to recent graduates
  2. guidelines act as a bridge to pattern making, with increasing practice and confidence the student begins to understand the links to deeper knowledge and understanding
  3. guidelines are a concrete tool for feedback. Instead of the nebulous “great job”, preceptors can ask the clerk or resident how well they followed a particular guideline.

Just for fun, take a look at how one physician is encouraging the use of guidelines. How might you promote the use of guidelines?

Online Study at the University of Alberta

My congratulations to the University of Alberta for jumping into online learning in a creative and innovative way!
Excerpted from Biomedical Library Blog
The University of Alberta School of Medicine has embraced one of the newest trends in medical education – providing online interactive and collaborative study tools within their learning system. Homer – think Greek mytology and students setting out on “an epic journey of lifelong learning” – is their newly created sytem that contains links to the information med students need – class notes, slides, and schedules – and also learning games, journal articles, email, Facebook and other networking tools.
What is particularly unique is the student interactivity. Students can post their own quizzes or questions, provide study tips and help monitor others posts for possible errors. The project is mostly self-policed by the med students who find and correct any errors. As one might expect, “Some first-year students objected at first, saying they just wanted to know what they were going to be tested on.” However, perhaps offering the high praise Homer’s creators were hoping for, they acknowledge later on that “Homer helped them study.”
See the full story at The Chronical of Higher Education, “Medical-School Curriculum Goes Interactive, Online, … and Hip-Hop.”
Watch the “Diagnosis Wenckebach” video created by a group of 2nd year med students at U of Alberta
. Click twice to play.

Active Learning – Making Meaning

Active learning techniques fall into one of the following four categories:
1. Remembering
2. Meaning Making
3. Creating Meaningful Artifacts
4. Connecting
This article will focus on active teaching techniques that help students understand what they are learning on a deeper level (higher order thinking). Higher order thinking does not come easily to students, they need to see you role modeling your thinking process and they need opportunities to practice in a safe environment which is non-judgemental, open to alternative viewpoints, respectful of students experiences and beliefs and provides marks for risk taking and creativity. Listed below are some of the options for helping students to delve deeper into your curriculum.

Creative Attention Focus

Play a quick game at the beginning or middle of the class to open the student mind to creativity and to focus/refocus attention. See Thiagi’s site for examples http://www.thiagi.com/games.html

Questioning

Asking questions throughout your course helps students develop a critical thinking mindset. Questions should always be open ended and avoid the "read my mind" format that can close off student participation. If you assign reading material, always include pre-reading questions that will focus their reading and assist them to highlight/take notes. The following are some additional question techniques:

  • Question Star
    • Brainstorm a list of at least 12 questions about the topic, concept or object. Use these question-starts to help you think of interesting questions:
    • Review the brainstormed list and star the questions that seem most interesting. Then, select one or more of the starred questions to discuss for a few moments.
    • Reflect: What new ideas do you have about the topic, concept or object that you didn’t have before?
  • Creative Questioning
    • Pick an everyday object or topic and brainstorm a list of questions about it.
    • Look over the list and transform some of the questions into questions that challenge the imagination. Do this by transforming questions along the lines of:
      • What would it be like if…
      • How would it be different if…
      • Suppose that …
      • What would change if …
      • How would it look differently if …
    • Choose a question to imaginatively explore.
    • Reflect: What new ideas do you have about the topic, concept or object that you didn’t have before?
  • Thinking Keys (Stephanie Martin created)
    • Form: What is it like?
    • Function: How does it work?
    • Connection: How is this like something I have seen before?
    • Reflection: How do you know?
  • Case Based
    • Begin with a case that doesn’t have a clear solution
    • Ask students to explore issues, assumptions, or questions before trying to solve the case.

    Write, Pair, Share

    • Write or draw an idea, a question, an argument
    • Discuss with one or more other students
    • Share (discuss, post)

    Brainstorming

    • Definition : Coming up with as many ideas as possible no matter how absurd. The Absurd inspires solutions that are more creative.

    Viewpoints

    • Roleplay from the point of view of someone else
    • Ask “What would ….. think about this theory, or event?”
    • Tug of war: Ask for tugs, reasons for supporting each side.

    Compass Points

    Compass Points is a method of organizing students thinking into four categories:

    1. What do students need to know/find out more about?
    2. What gets them excited about this issue or theory?
    3. What concerns/worries the student about this theory/issue?
    4. What suggestions does the student have for next steps? or Where do they currently stand on this issue/theory?

    Compass.png

    Explanation Game

    • Display an object, an image, a video
    • Instructor says “I notice ….”
    • Ask “Why do you think it happened that way or it is that way?”
    • Ask “What makes you think …?”

    Claim, Support, Question

    • Draw three columns
    • Insert a theory in the first column
    • Ask students what supports that theory or questions the theory
    • Discuss “What is criteria for evidence?”

    Option Diamond

    The Option Diamond allows students to expand their thinking and be more creative about possible options. Draw the following image on the board, fill in the two options and the compromise but focus most of your attention on the creative option at the top.
    Diamond.png

Active Learning – Remembering

Active Learning is a teaching strategy that encourages students to write/type, click, discuss, act and create in order to engage in the learning process. Students who are engaged in learning are more likely to remember what they learned over time.
cone_of_learning.gif
Edgar Dale Cone of Experience Media by Jeffrey Anderson is licensed under a Creative Commons Attribution-Share Alike 3.0 United States License.
Based on a work at www.edutechie.ws
Active learning techniques fall into one of the following four categories:
Remembering
Meaning Making
Creating Meaningful Artifacts
Connecting
This article will focus on teaching techniques that improve memory.
Helping Students’ Remember
Cognitive scientists have shown that active learning helps students:
1. pay attention
2. connect new knowledge with previously learned content
3. retrieve information/processes when needed.
Active Pause – Pausing to allow students to refocus their attention is a favourite technique of lecturers. Pausing and asking students to write down their ideas, answers to questions, etc. makes the pause technique active.
Active Reading/Listening – Before asking students to read an article or watch a video or listen to a lecture, give them two or three questions to focus their attention and interaction with the content. Creating online reading and listening resources allows students to click on links for more information. Innertoob is a unique tool that allows you to add questions and comments to audio http://www.innertoob.com/
Memory Aides/Mnemonics – Our memory retrieval is limited to about seven items, but you can increase that number by linking items to other items either numerically (There are seven steps) or alphabetically (Dow Jones Industrial Average Closing Stock Report”: Duodenum, Jejunum, Ileum, Appendix, Colon, Sigmoid, Rectum.) For more ideas, see http://www.medicalmnemonics.com/ . Memory aides are most effective if you challenge students to create them.
Mindmapping – Creating a visual image of how information links to other information will help students store new knowledge in an easily retrievable format. Visual mnemonics is a type of mindmapping that uses images instead of words http://www.ttuhsc.edu/SOM/Success/images/peptgly.jpg . Here is a site that lists mindmapping software, http://www.mind-mapping.org/ and a site for creating collaborative mindmaps http://www.mindmeister.com/
Online drill and practice – WebCT, PAWS or class websites can have drill and practice utilities such as Hot Potatoes http://hotpot.uvic.ca/ added.
Rapid Response Games – Both competitive games like Jeopardy and solitary games like Snakes and Ladders have been used in medical education to make memorization enjoyable. Ask Educational Support and Development for information on educational games.
Simulations – Simulations are becoming increasingly popular in medical education. Here are some examples http://www.hhmi.org/biointeractive/vlabs/index.html and http://www.sp.tamucc.edu/pulse/
Singing/Rhyming –Similar to mnemonics the beat of a song or rhyme increases the amount of material that can be retrieved. See an example at http://www.youtube.com/watch?v=KXROnzpsrlg
Student Response Systems (Clickers) – Clickers are used during class to check student’s previous knowledge about a subject, to give feedback during class about what is being learned and to affirm how much students have learned at the end of class. The College of Medicine has installed clickers in the main lecture theatre and has portable sets available.

Second Life

doctorann1.png
Second Life is a virtual world that has become a popular location for cutting edge educational resources. The population of this virtual world is greater than the population of the prairies.
ScienceRoll (the blog of a medical student studying genetics) has a posting about the top ten medical education sites in Second Life.
http://scienceroll.com/2007/06/17/top-10-virtual-medical-sites-in-second-life/

Assessing Students Problem Solving Skills (Part 1)

Case
The following case illustrates how good problem solving requires more than medical knowledge.
An 18-year-old student and her boyfriend come to emergency because she is having trouble breathing. She has a history of viral asthma and her parents had always accompanied her in previous emergencies. Upon examination, the resident determines that she is not having an asthma attack and takes the boyfriend aside and tells him she is faking and walks away. A month later, she arrives by ambulance, unconscious after trying to walk to the hospital alone because her boyfriend assumed again that she was faking and refused to take her to the hospital.
Let’s assume that the initial diagnosis of “not an asthma attack” is correct, where did the resident fail in his diagnostic and therapeutic management?
Attribution error: The resident’s use of the term “faking” says a lot about why he overlooked talking to the patient about whether stress (leaving home, exams, boyfriends) had led to contracting an irritated airway and did not suggest she find a family doctor for management of her asthma. If she was indeed faking, then he didn’t make any attempt to identify why because attribution is a common reason for making the value judgement that someone is not worthy of thorough care.
Ethical error: The resident told the young man the patient was faking, but did not tell her what he thought.
When designing an assessment plan, the following steps should be followed:
1. Review the components of a useful assessment plan
2. Review the objectives for the rotation
3. Determine what specifically your plan will test
4. Identify assessment tools
5. Plan how students and college will receive results
6. Train the administrators
7. Evaluate utility of the plan
1. Review the components of a useful assessment plan
According to Dr. Gordon Page from the UBC College of Medicine, his research has shown that the Utility or usefulness of an assessment plan can be expressed by the following formula: U = R X V X E X A X C
Reliability is the result of increasing preceptor experience with a tool and evidence that the device tests what it is supposed to test. A single instance of student performance is not considered reliable in medical training.
Validity in a clinical setting is the result of testing for application of knowledge not recall, diagnostic and therapeutic reasoning not thoroughness, and an adequate sampling of behaviour (6-10 observations).
Educational impact is a combination of the impact this testing device has on the student, preceptor and institution.
Acceptability by the student, preceptors and institute is a key factor of ongoing utilization.
Cost is the final element.
A combination of paper cases and direct observation meets the above utility requirements better than cases or observation alone.
2. Review the objectives for the rotation
Problem solving objectives should have been included in the student orientation to the rotation. As previously discussed, an example can be found here http://www.hsc.stonybrook.edu/som/solving.cfm.
3. Determine what specifically your plan will test
Ask yourself and colleagues “What behaviour will tell me that a student has achieved the objectives?” The more specific and observable the behaviour the easier it will be to test. Ex. Student uses appropriate social and cultural criteria when making a therapeutic diagnosis rather than Student doesn’t make attribution errors.
4. Identify assessment tools
If you need to create assessment tools rather than using ready-made instruments, please consult with the assessment specialist in Educational Support and Development or some other group with experience in creating assessment devices.
5. Plan how students and college will receive results
If assessment is being done primarily to improve learning, then a feedback process needs to be determined. Written and verbal feedback are both useful at this stage. If you are assessing competence at the end of a rotation, then a more formal process needs to be determined.
6. Train the administrators
Observation of problem solving and giving feedback are skills that faculty may feel inadequately prepared for to administer.
7. Evaluate utility of the plan
The best laid plans ……
Stay tuned for the next installment on testing methods.

Informal mentoring

A Critical Friends Group is a professional learning community consisting of approximately 8-12 educators who come together voluntarily at least once a month for about 2 hours. Group members are committed to improving their practice through collaborative learning. For more information see http://www.nsrfharmony.org/faq.html#1
This seems like a great way to introduce new and innovative teaching methods to the College of Medicine

Another innovative mentoring program

Glaxo-Smith-Kline has an innovative mentoring idea they call “key talent mentoring“. Management identifies positions that will be needed in the next 5 years, then identifies possible candidates. Mentors are then chosen to assist those possible candidates to develop the skills/experience necessary to apply for those positions.
We frequently talk about succesion planning in medical schools and this might be an interesting area to explore.

Fear as an Educational Technique

In a recent discussion with medical residents, someone asked the question “What’s wrong with fear as an educational technique?” Several people then told about how fear had worked to increase their preparation for class or exams.
I was mildly shocked that someone would even suggest that this was a legitimate teaching technique, but then I sat down and did some more thinking about the theories of teaching and learning.
Spare the rod and spoil the child is a concept that has been around for a very long time. It is part of an authoritarian system that required an authority (church, father, king, husband or teacher) to know what is best for others. The others must be guided to follow the authority figure without question because they don’t have the ability to make decisions. If they don’t obey, then punishment must be used to bring the rebel, unbeliever or lazy student back into the fold for their own good. Those who respond positively to the authority figure are rewarded with praise, promotion and belonging. In educational theory, this is called Behaviorism. If you want passive, unquestioning students, behaviorism works. Non-conforming students are removed from the system through failure or opting out. Industrial economies require an authoritarian educational system.
Constructivism is another educational theory that has become increasingly popular in the last thirty years as we move into the information economy. Constructivism is based on the idea that all knowledge is a construction of the human mind. Knowledge is shared from person to person, but acquisition is always the result of individual learning. This result will differ from person to person based on ability, culture, exposure and motivation. Teachers facilitate the opportunities for student acquisition of knowledge, skills and attitudes, but they don’t control it. The student is expected to bring their personal motivation to learn to the table. They are expected to be or to become self-directed, lifelong learners. Punishment is considered to be disrespectful and counter-productive of that student’s right to learn.
Between these two very different approaches to education is the question we are continually asking, “What is the best way to educate future physicians?”

Preparing Students to Work with Addiction Issues

Several medical Blogs have been commenting on alcoholics and drug addicts tricking doctors into giving them drugs. Many of these Blogs suggest that heightened vigilance is the answer to this problem even if this means not giving pain medication to patients who need it.
As physicians preparing students for medical practice, this important issue needs to be more closely examined and prepared for in medical school. Here are some suggestions:
1. Increase awareness of addiction treatment including how the desire to take responsibility for stopping the addiction results in physicians playing futile control games with addicts. Identifying what is and is not in the physician’s control is essential here.
2. Teach students to handle stressful situations in ways that avoid becoming involved in power struggles with patients. Acceptance of things the student cannot change is essential to this process.
3. Increase awareness of how and when pain medication is needed even when facing addiction issues including the information from the National Cancer Institute below.
People who take cancer pain medicines rarely become addicted to them. Addiction is a common fear of people taking pain medicine. Such fear may prevent people from taking the medicine. Or it may cause family members to encourage you to “hold off” as long as possible between doses. Addiction is defined by many medical societies as uncontrollable drug craving, seeking, and use. When opioids (also known as narcotics) — the strongest pain relievers available — are taken for pain, they rarely cause addiction as defined here. When you are ready to stop taking opioids, the doctor gradually lowers the amount of medicine you are taking. By the time you stop using them completely, the body has had time to adjust. Talk to your doctor, nurse, or pharmacist about how to use pain medicines safely and about any concerns you have about addiction.