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G A M E S , G R O U P S A N D K A H O O T SA TO O L K I T F O R C A P T U R I N G T E AC H A B L E M O M E N T S I N I N T E R - P R O F E S S I O N A L L E A R N I N G T E A M S
A L E X F R I E D M A N , M DE L I S A B E T H H OWA R D, C N M R OX A N N E V R E E S , M D
B R O W N U N I V E R S I T Y A L P E R T S C H O O L O F M E D I C I N E
W O M E N & I N F A N T S H O S P I T A L O F R H O D E
DISCLOSURES • No financial interests/disclosures
LEARNING OBJECTIVES:By the end of this workshop, attendees will be able to:
• Understand the complexities and challenges of teaching in an academic hospital
• Identify foundational adult learning theories, and appropriate material to be covered with each approach
• Apply learning theories to designing educational activities to foster best practices in education
• Identify methods for incorporating best practices into interdisciplinary teams
A TYPICAL DAY IN ACADEMIC MEDICINE
https://www.youtube.com/watch?v=8NPzLBSBzPI
A TYPICAL DAY IN ACADEMIC MEDICINE
A TYPICAL DAY IN ACADEMIC MEDICINE
A TYPICAL DAY IN ACADEMIC MEDICINE
A TYPICAL DAY IN
ACADEMIC MEDICINE?
TODAY’SGUIDE• Whyiseducationharderthanever?
• Whatlearningtheoriessupportacquisitionofskills?
• HowcanIusetheoryinpractice?• Smallgroupbrainstorm:teachingdifficulttopics
• Grouppresentations
K A H O O T !
G O TO K A H O OT. I T
IF YOU ALWAYS DO WHAT YOU’VE ALWAYS DONE…W H Y C H A N G E S I N E D U C AT I O N A N D C L I N I C A L F LO W D E M A N D N E W A P P R O A CH E S
PHYSICIANS ARE BUSIER THAN EVER…In the current practice environment, physicians face
mounting demands on their time and increasing administrative requirements for health care delivery
(e.g., service and authorization requests, utilization review processes), which encroach on time spent
with patients [and trainees]
Dugdale 1999
KEY CHANGES IN HEALTH CARE AND MED ED HAVE SHIFTED WORKFLOW • Clinical volume
• Administrative duties
• Patient characteristics
• Changing educational needs
CLINICAL DUTIES CONTRIBUTE TO INCREASED DEMANDS ON PHYSICIANSMore patients, declining numbers of MDs
• Rapid Growth in US population (~25 million people each decade)
• By 2020, growth continue 0.8% per year
•Delayed growth of physician supply
• Current physicians spending less time in the hospital
Salsberg 2006, Sinsky 2016
INCREASED ADMINISTRATIVE DUTIES HAVE ADDED TO ALREADY STRAINED SCHEDULES Increased demands on time
• For every 1 hour spent on clinical care, 2 hours are spent on EHR/desk work
• Physicians spend on average 1-2 hours after work on clerical duties
Salsberg 2006, Sinsky 2016
MODERN PATIENTS PLACE INCREASING DEMANDS ON AN ALREADY STRAPPED PHYSICIAN COHORT Patient vs. consumer • Cost shifting to individuals • Technology
Information sources • Sources of information• Information at fingertips
Belby 2016, Friedman 2016
PATIENT CARE DEMANDS LEAVE LESS TIME FOR EDUCATION
New methods are needed to help academic physicians efficiently fit education into already overwhelmed schedules.
Patient volumePatient demand Administrative requirements
Lower physician supply/pipelineFewer free hours in/out of work
Mor
e D
eman
ds
Less Tim
e
EDUCATION DEMANDS RESULT FROM INCREASING KNOWLEDGE AND BROADER SCOPE• Exponential increase in knowledge
• Importance of lifestyle medicine/public health
• Technologic changes
Academic physicians must now “do more” with less time
Densen 2011
In 2020, the estimated doubling time of medical
knowledge will be 73 days, verses 50 years in
1950
LEARNERS DEMAND EASY TO DIGEST RESOURCES PRESENTED LIKE THE NEWS
INCREASING FOCUS ON TEAM BASED, INTERDISCIPLINARY CARE Patient Centered Medical Home Model
“Team Based Care”
Increasing coordination with additional providers:
• Nurse Practitioners
• Midwives
Schottenfeld 2016
New methods are needed to help prepare trainees for future interdisciplinary work
WHILE THE CHANGES IN CLINICAL FLOW AND EDUCATION ARE DAUNTING…
…With sound educational theory and
modern technology, we
can improve education for our trainees.
[MODERN] LEARNING THEORYMAKING EDUCATION EVIDENCE BASED
WHAT DO YOU KNOW ABOUT
ADULT LEARNING?
Adult Learning
Topic 1
Topic 5
Topic 4 Topic 3
Topic 2
Adult Learning
Informal teaching
Extra-curricular
Multi-media
Groups
Part of normal
life
Talks
Night School
Conference
Grand Rounds
Youtube
Videos
Podcasts
”Just what I do” Job Prep
Non-traditional activities
Bee Keeping
Non-traditional
learner
Mentors
Peers
Pottery
ADULT LEARNING THEORY RECOGNIZES THE LEARNER AT THE CENTER OF EDUCATION
Basic principles:
• Driven by “WHY”
• Based in real-life situations
• Self Directed/Internally driven
• Supported by life experiences
TEAL 2011
DIFFERENT TEACHING TASKS ARE SUPPORTED BY DIFFERENT EDUCATIONAL THEORIES
Definition
Behaviorist Promotes specific replicable behavior outcomes
Social Learning Learning from observation and interactions with the environment
Cognitivist Develop internal framework for knowledge processing
Humanist Learner assumes responsibility for education to achieve full potential
Constructivist Critical reflection used to inform understanding and practice
Torre 2006
These theories are not mutually exclusive or a
completely exhaustive list
IN THEORY, THERE IS NO DIFFERENCE BETWEEN THEORY
AND PRACTICE. BUT IN PRACTICE,
THERE IS.
-YOGI BERRA
THE BEHAVIORIST MODEL PROMOTES CONSISTENT AND REPRODUCIBLE ACTIONS
• Main outcome is the behavior itself
• Can be thought of as “ABCD” Model: Audience, Behavior, Condition, Degree
• Works well for redundant behaviors that can be broken into steps
Torre 2006, Rostami 2010
Example: How to make a specific apple crisp recipe
TEACH-BACKS AND SIMULATION ENSURE SPECIFIC BEHAVIORS ARE INTERNALIZED
SIMULATION
• Learner applies skill set in safe environment
• Test for understanding and setting specific practice
• Ensures internalization of knowledge
• Interdisciplinary coodrination
EXAMPLES
• Shoulder dystocia maneuvers• Steps of Cesarean Section • Management of Preeclampsia • Characterization of blood loss • Management of postpartum
hemorrhage
Grobman 2013, Slater 2017, Samuels-Kalow 2012, Deeting 2013
SIMULATION IS MOST EFFECTIVE WHEN COUPLED WITH CHECK BACKS
Grobman 2013, Slater 2017, Samuels-Kalow 2012, Deeting 2013
• Debriefing
• Checklists
• Video and review
THE SOCIAL LEARNING MODEL PROMOTES EDUCATION THROUGH APPRENTICESHIP • Learner gains knowledge through observation of already skilled teacher
• Learning occurs in a real life setting, without disrupting usual activities
• Works best when interaction goes beyond just watching
Example: Learning to make apple crisp by cooking with your grandmother
Torre 2006, Rostami 2010
OBSERVING ROLE MODELS PROVIDES GUIDANCE FOR DESIRED BEHAVIORS
ROLE MODELING
• Hallmark of medical education where students observe how to be physician, supervisor, teacher and person
• Teaching in real-world setting
Bahmanbijari 2017, Bodenheimer 2013
EXAMPLES
• Preceptorships • Ambulatory clinic• Wards teaching
CONVERTING PASSIVE SHADOWING INTO ACTIVE EXPERIENCES PROMOTES LEARNING • Medical student checklists
• Directed bedside teaching of physical exam
• Appointed teaching position on wards
• Reciprocal teaching
• One-minute preceptor
Bernal 2014, Centofanti 2014, Young 2012, Lockspeiser 2015
THE ONE MINUTE PRECEPTOR HAS HIGH SATISFACTION AND INCREASES FEEDBACK
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Diagnose the learner
Teach to the gap
Provide feedback
What do you think is going on?What do you want to do for this patient?
What led you to that conclusion?What else did you consider? Rule out?
When this happens, you should…A way of thinking about the problem is…
Specifically you did an excellent job…Your presentation was well organized
What would you do differently?The likely diagnosis is X, but don’t miss Y
Patient interview
THE COGNITIVIST MODEL BUILDS MENTAL STRUCTURES FOR FUTURE KNOWLEDGE • Learner builds a skill set to apply to future problems
• Learning includes development of cognitive constructs, not just an approach to a particular issue
• Best for knowledge application and development of critical thinking/trouble shooting
Example: Learning to make a dessert from a recipe
4 COMPONENTS OF INSTRUCTION DESIGN (4CID) BUILDS PLATFORMS FOR CRITICAL THINKING
Vandewaetere2014 , Postma 2014
CONCEPT MAPPING HELPS LEARNERS TO BUILD SCHEMA FOR UNDERSTANDING • Visual model of relationships between
concepts, providing 2D representation of knowledge framework
• Learners build networks of interconnected ideas
• Chain, spoke, net for increasing complexity
• Used as teaching tool and assessment
Spoke
Idea
Idea
IdeaIdea
Idea
Chain Idea Idea
Conran 2017
Adult Learning
Informal teaching
Extra-curricular
Multi-media
Groups
Part of normal
life
Night school
Grand Rounds
Talks
Conference
Youtube
Videos
Podcasts
”Just what I do” Job Prep
Non-traditional activities
Bee Keeping
Non-traditional
learner
Mentors
Peers
THE HUMANIST MODEL PROMOTES LEARNING AS SELF ACTUALIZATION • Learner selects tasks based on personal drive and desire to reach full potential
• Learning is self-directed
• Best for creating a spirit of inquiry and lifelong learning
Torre 2006, Rostami 2010
Example: Learning how to make apple crisp to reach one’s full potential making desserts
LEVERAGING MULTIMEDIA PLATFORMS PROMOTES SELF-DIRECTED LEARNING• Increase in multimedia educational tools
– Twitter, blogs, podcasts, video
– “Enhanced podcasts”
• Significant advantages
– Flexible
– Convenient
– cost-effective
– engaging
Enhanced Podcasts: AUDIO
+‘multimedia information
such as slides, pictures, images, photographs, and
short videos’
Griffin 2009, Kay 2012, Hurst 2016, Lin 2015
NOT ALL VIDEOS ARE CREATED EQUAL.
https://www.youtube.com/watch?v=eTkSYWVk0GE&t=81s
LEVERAGING MULTIMEDIA PLATFORMS PROMOTES SELF-DIRECTED LEARNING
• Current lack of peer reviewed materials
• Quality indicators have been proposed:
– Use of interactive content (modeling, mental practice)
– Transparency, credibility and decreased bias
Mental Practice: Rehearsing task without physical
movement
Modeling:Observing examples
to gain skill
Griffin 2009, Kay 2012, Hurst 2016, Lin 2015
LEVERAGING MULTIMEDIA PLATFORMS PROMOTES SELF-DIRECTED LEARNING
• Outcomes
– superiority to traditional learning
– Improved self-motivation for learning
– More efficacious with combination of mental practice and modeling
coefficients of 0.97 for the key events checklist, 0.90 for the mean number of critical errors,and 0.76 for the Ottawa global rating scale. As such, the average scores of the two raterswere used in statistical analyses.
Our sample size calculation was based on an effect size of 1.0, which is considered aslarge and appropriate for educational intervention. Assuming an effect size of 1.0 and apower of 0.8, we calculated a sample size of 16 students per group (Cohen 1988).
Results
Sixty-three medical students were recruited for this study. There were no significant dif-ferences between the four groups in terms of (1) gender (v2 = 2.76, df = 3, p = 0.43), (2)year of training (v2 = 13.27, df = 12, p = 0.35), (3) previous airway managementexperience (v2 = 7.72, df = 9, p = 0.56), (4) previous experience using podcasts(v2 = 9.89, df = 9, p = 0.36), (5) previous experience using medical podcasts (v2 = 15.9,df = 12, p = 0.196), or (6) previous experience in a manikin-based simulation environ-ment (v2 = 15.9, df = 12, p = 0.196).
Multiple choice questionnaires (MCQs)
The two-way ANOVA revealed a significant main effect of time (F(1,61) = 169.365,MSError = 0.01, p\ 0.01), and group (F(1,61) = 3919.725, MSError = 0.01, p\ 0.01).More importantly, there was a significant time by group interaction (F(3,61) = 6.822,MSError = 0.01, p\ 0.01), indicating that the students’ improvements from the baseline toretention MCQs differed based on the group to which they were randomized. A one-wayanalysis of variance of the baseline MCQ scores with group as the subjects variablerevealed that the groups did not differ at the baseline level (F(3,65) = 0.805,MSError = 0.01, p = 0.50). However, the analysis of variance of the retention MCQ scoresshowed a significant effect of group (F(3,65) = 19.797, MSError = 0.01, p\ 0.01). Thecontrol group scored significantly lower in comparison to the other three groups (allps\ 0.01). There was no significant difference in scores between the MP and modeling
Fig. 1 Baseline and retention multiple choice questionnaire scores with standard error of mean (AllMSError = 0.01)
794 F. Alam et al.
123
Griffin 2009, Kay 2012, Hurst 2016, Lin 2015
OB/GYN RESIDENTS PREFER CONCISE, EASILY ACCESSIBLE SOURCES• Most commonly utilized sources of information (% identifying use as “frequent”)
– Guidelines and practice bulletins 95%
– UpToDate 92%
– Google 88%
• Most useful sources of information (% identifying as “helpful”)
– Guidelines and practice bulletins 100%
– UpToDate 99%
– Textbooks 97%
• Acceptability of podcast as educational tool
– 10 minute 97%
– 20 minute 92% Friedman 2016
THE CONSTRUCTIVIST MODEL BUILDS LEARNING FROM CRITICAL APPRAISAL OF EXPERIENCE
• Learner translates experiences into knowledge needs and goals
• Focuses on improving future actions through understanding current practice
• Best for developing methods for continuous improvement
Torre 2006, Rostami 2010
Example: Observing past experiences with cooking and recognizing personal areas of growth
HOW DOES REFLECTION INFLUENCE FUTURE BEHAVIOR?
“A metacognitive process that occurs before, during and after situations with the purpose of developing a greater understanding of both the self and the
situation”
Sanders 2009
HOW DOES REFLECTION INFLUENCE FUTURE BEHAVIOR?
“Those who cannot remember the past are unable to repeat it”
Incorporate best practices
“Those who cannot remember the past are
condemned to repeat it”
Learn from mistakes
Quote from George Santayana
HOW DOES REFLECTION INFLUENCE FUTURE BEHAVIOR?
GUIDED REFLECTIONS ALIGN VALUE AND EDUCATION, HELPING GUIDE PURSUITS • Complex medical system requires self-reflection and reflective practice
• Identification of strengths and areas of improvement outside of training
• Variety of domains:
– Assessing milestones
– Assess clinical acumen
– Improving individual learning process
• Diverse methods
– Self-assessment tool
– Identifying key learning points
– Portfolio reflection/writings
– Group discussions
Gostelow 2017, Kanthan 2011, Aronson 2011, Smith 2011
FACILITATING DISCUSSION WHILE PROTECTING ANONYMITY
https://padlet.com/mafriedman88/6z1mp3t5ubxr
DIFFERENT TEACHING TASKS ARE SUPPORTED BY DIFFERENT THEORIES Theory Crisp Example Behaviorist How to make an exact recipe
Social Learning Watching grandma make crisp
Cognitivist How to make desserts from a recipe
Humanist Learning to make crisp as part of reaching one’s potential
Constructivist Reflecting on catching the oven on fire
Torre 2006
HOW DOES THIS APPLY TO ME?USING MODERN LEARNING THEORY TO IMPROVE YOUR DAY
PATIENT CARE DEMANDS LEAVE LESS TIME FOR EDUCATION
New methods are needed to help academic physicians efficiently fit education into already overwhelmed schedules.
Patient volumePatient demand Administrative requirements
Lower physician supply/pipelineFewer free hours in/out of work
Mor
e D
eman
ds
Less Tim
e
IN BUSY CLINICAL PRACTICES, TECHNOLOGY AND THEORY CAN GUIDE MORE EFFICIENT EDUCATION
Behaviorist
Social Learning
Cognitive
Humanist
Constructivist
Simulation
Role Modeling
4CID/CM
Video/ELearning
Guided Reflection
Examples
with interdisciplinary
Integration across all
approaches
IN BUSY CLINICAL PRACTICES, TECHNOLOGY DRIVEN BY THEORY CAN GUIDE MORE EFFICIENT EDUCATION
Behaviorist
Social Learning
Cognitive
Humanist
Constructivist
Making teaching more efficient
1 minute preceptor
Taking teaching out of clinical time
E-learning/Enhanced podcasting
REMOVING STEREOTYPED TEACHING ALLOWS FOR MORE MEANINGFUL INTERACTIONS• Repetition breeds burnout
• Not all tasks need to be customized
• Application is more meaningful than memorization
• Customization increase satisfaction
MULTIMEDIA MODELS ALLOW LEARNERS TO ARRIVE “PREWRAPPED”
The "Unwrapped" Learner
•Knows nothing •Needs facts and repetition •Requires time to absorb information
The "Pre-wrapped" Learner
•Knows what, needs to learn "how"•Can interact with content •Needs customized guidance and application
THE TEACHING POSSIBILITIES ARE ENDLESS…
Giving Feedback
Meds in Preg
Informed Consent
MTX admin
Team based care
Team Roles
PreOp AntiCoag
GDM: Insulin
Circ Consent
Cardinal movement
Getting consent
Foley insert
r/o Ectopic
Laparoscopic entry
TOB Counseling
AUB
Cesarean Section
Bad News
H&P
ERAS
TOPICS FOR INNOVATIVE TEACHING
NOW IT’S YOUR TURN!
A P P LY I N G T E A C H I N G T H E O R I E S TO E V E RY D AY E D U C AT I O N A L P R O B L E M S !
T H A N K Y O U
W E W O U L D L O V E T O A N S W E R YO U R Q U E S T I O N S .
A L E X F R I E D M A N M F R I E D M A N @ W I H R I . O R G
REFERENCES
REFERENCES • Belby https://www.forbes.com/sites/joannabelbey/2016/04/15/communicating-with-the-consumer-versus-the-patient/2/#131dd7de23c9
• Joseph, C., Conradsson, D., Wikmar, L. N., & Rowe, M. (2017). Structured feedback on students’ concept maps: the proverbial path to learning?. BMC medical education, 17(1), 90.
• Cepeda, M. S., Chapman, C. R., Miranda, N., Sanchez, R., Rodriguez, C. H., Restrepo, A. E., ... & Carr, D. B. (2008). Emotional disclosure through patient narrative may improve pain and well-being: results of a randomized controlled trial in patients with cancer pain. Journal of pain and symptom management, 35(6), 623-631.
• Charon, R. (2001). Narrative medicine: form, function, and ethics. Annals of internal medicine, 134(1), 83-87.
• Deering, S., & Rowland, J. (2013, June). Obstetric emergency simulation. In Seminars in perinatology (Vol. 37, No. 3, pp. 179-188). WB Saunders.
• Densen, P. (2011). Challenges and opportunities facing medical education. Transactions of the American clinical and climatological association, 122, 48.
• Lockspeiser, T. M., & Kaul, P. (2015). Applying the one minute preceptor model to pediatric and adolescent gynecology education. Journal of pediatric and adolescent gynecology, 28(2), 74-77.
• Postma, T. C., & White, J. G. (2014). Developing clinical reasoning in the classroom–analysis of the 4C/ID-model. European Journal of Dental Education.
• Samuels-Kalow, M. E., Stack, A. M., & Porter, S. C. (2012). Effective discharge communication in the emergency department. Annals of emergency medicine, 60(2), 152-159.
• Schottenfeld L, Petersen D, Peikes D, Ricciardi R, Burak H, McNellis R, Genevro J. Creating Patient-Centered Team-Based Primary Care. AHRQ Pub. No. 16-0002-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2016.
• Slater, Becky Ann, Yinjiang Huang, and Preeti Dalawari. "The Impact of Teach-Back Method on Retention of Key Domains of Emergency Department Discharge Instructions." The Journal of Emergency Medicine (2017).
• TEAL Center Staff (2011). TEAL Center Fact Sheet No 11: Adult Learning Theroies. TEAL Center. https://lincs.ed.gov/sites/default/files/11_%20TEAL_Adult_Learning_Theory.pdf
• Wallwiener, S., et al. (2016). Pregnancy eHealth and mHealth: user proportions and characteristics of pregnant women using Web-based information sources - a cross-sectional study. Archives of Gynecology and Obstetrics, 294(5), 937-944.
• Torre, D. M., Daley, B. J., Sebastian, J. L., & Elnicki, D. M. (2006). Overview of current learning theories for medical educators. The American journal of medicine, 119(10), 903-907.• Bernal Bello, G.d.T., Jaenes Barrios Martínez Lasheras, de Arriba de la Fuente , Rodríguez Zapata., The resident as teacher: Medical students' perception in a Spanish university. Rev Clin Esp. ,
2014. 214(7): p. 371-6.• Centofanti, J.E., et al., Use of a daily goals checklist for morning ICU rounds: a mixed-methods study. Crit Care Med, 2014. 42(8): p. 1797-803.• Vandewaetere, M., Manhaeve, D., Aertgeerts, B., Clarebout, G., van Merriënboer, J., & Roex, A. (2014). 4C/ID in Medical Education: How to design an educational program based on
whole-task learning: AMEE Guide No 93.Medical Teacher• Young, H.N., et al., Medical student self-efficacy with family-centered care during bedside rounds. Acad Med, 2012. 87(6): p. 767-75.• Griffin, D. K., Mitchell, D., & Thompson, S. J. (2009). Podcasting by synchronising PowerPoint and voice: What are the pedagogical benefits? Computers & Education, 53(2), 532–539.
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recommendations by an international cohort of health professions educators. Postgraduate medical journal, 91(1080), 546-550.• Frosch, D. L., Kaplan, R. M., & Felitti, V. J. (2003). A randomized controlled trial comparing internet and video to facilitate patient education for men considering the prostate specific
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REFERENCES
OB GYN RESIDENTS VALUE EASY TO DIGEST EDUCATIONAL RESOURCES MOST
Rare Occasional FrequentPercentage n Percentage n Percentage n
Guidelines and practice bulletins0.52% 1 4.64% 9 94.85% 184
UpToDate 1.54% 3 6.67% 13 91.79% 179Google 1.55% 3 10.82% 21 87.63% 170
Wikipedia 17.53% 34 25.26% 49 57.21% 111Primary research articles
6.25% 12 36.98% 71 56.77% 109
Textbooks/ Online textbooks22.16% 43 32.47% 63 45.36% 88
Videos 33.68% 65 36.27% 70 30.05% 58Youtube 27.32% 53 42.78% 83 29.89% 58Question banks 71.13% 138 18.04% 35 10.82% 21Other 75.28% 67 7.87% 7 16.86% 15Podcasts 81.87% 158 10.36% 20 7.77% 15
