e-learning

The Days of the Blue Pages

This week, the second-year medical students in my tutorial group were supposed to diagnose a patient with an acoustic neuroma. Not a real patient of course, but a carefully constructed fictional patient with the typical presentation and uncomplicated history never seen except in cases designed for training junior medical students. On Tuesday evening, the students should have completed the readings in their textbook necessary to answer the guiding questions generated during the Monday afternoon tutorial session. They would have come up with the correct diagnosis by Wednesday, if everything had gone according to schedule.

Each new Brain and Behaviour case begins on Monday, and the first pages of case material are ceremoniously passed around the circle of eight students seated at the table. The first is simply a title page. The title page is followed by the blank piece of blue paper that separates each set of pages from the next; a thin, azure line that recurs in regular intervals throughout the package containing eight copies of the patient with the acoustic neuroma. Each year, there is inevitably one student, usually female, who collects these blue sheets for some obscure purpose, setting them carefully aside.

As the tutor, it is my job to dole the patient out in discrete parts, like courses in a meal: after the title page, then the history of presenting illness (HPI). The HPI must be well chewed and digested before they can have the physical examination (and its blue in-between paper). Some groups are able to serve themselves – is this an acute or slow onset, how fast is the progression, does this sound like a neoplastic process or a vascular one? Other times I cut their food for them, even though I know I’m not supposed to do this. As the facilitator, I am the ‘guide on the side’ not the ‘sage on the stage.’ The point of the problem-based learning format is to help the students learn to think in a clinical fashion rather than absorbing facts in lectures that may not seem connected to human beings in any discernible manner.

I tell my students that they need not just to reach the right conclusion, but to know how they did so. They’re supposed to be learning to think like doctors.

Usually the first three pages of the case are enough for one day. The third blue page is like the period at the end of a sentence spoken by someone who has said enough. The students are supposed to go home with questions and speculations. Then they are to look through the books we told them to buy and come back on Wednesday with ideas, theories, and perhaps, a diagnosis.

When I started tutoring the Brain and Behaviour unit seven years ago, that was more or less how it worked.

This week, we have barely passed the second pages around the table before one student, typing thoughtfully on his Blackberry, comments, “I wonder if this could be an acoustic neuroma.”

Immediately, the three students in the group with laptops (logged on to the wireless internet available in the new tutorial rooms) begin to type. “How do you spell that?” his friend asks.

“Here it is on Wikipedia,” says another. “Acoustic neuroma. Sensorineural hearing loss, vertigo, tinnitus. Involvement of the nearby facial nerve can lead to ipsilateral facial weakness. May lead to increased intracranial pressure, with associated symptoms such as headache.”

Around the table, those without computers nod in agreement or make notes. “So, can we go home now?” asks one of the young women.

I look down at the remaining sheets of paper in front of me: the physical examination, laboratory and diagnostic imaging reports, course and treatment, each section separated by a line of blue so thin it can barely be seen. The students have skipped over several courses of dinner, and greedily downed their dessert before I could stop them.

When this course was designed, students did not bring computers to tutorial with them. They found information in their textbooks, or sometimes in journal articles. They went home and thought about a case, read up on the anatomy and physiology, and tried to connect these to the clinical symptoms of the patient.

Now students type symptoms – hearing loss, tinnitus, facial paralysis and headache – into the search engine of their choice, and almost instantly are presented with the diagnosis. What happens next? I am trying to figure that out. So, can we go home now?

I will say, as physicians have said since the time of Hippocrates, that things were different in my day. When I started working on the wards as a clerk, I carried two books in the pocket of my white coat. One was a small clinical handbook with step-by-step instructions on how to approach everything from chest pain to decreased urine output. The other was a little black notebook that I bought, with lined pages. As clerkship progressed, I would write down the folk wisdom of the housestaff on each service as I rotated through.

The only thing I can recall is that I had dutifully recorded that chlorpromazine was useful for hiccups. Now Google can provide me with 237,000 results for ‘chlorpromazine, hiccups’ in 0.36 seconds. I’d have to be an intractable Luddite not to recognize that the students’ Blackberries are far superior to the little black book of my clerkship days.

Instead of tossing the papers in the air and dismissing tutorial early, I make some grumpy comment about how I had to actually learn this stuff when I was a medical student. We go back over the case and discuss why exactly an acoustic neuroma would cause the symptoms as described. I try to get them to think, to analyze, to be curious, just as they were supposed to back before the electronic world provided them with an auxiliary brain that already knows everything about medicine long before they do.

On days like this, I think of all the other ways we could cover this material. Integrated e-learning options have the potential to completely transform the way we teach this and other courses. We could create cases using video and simulation that would bypass the papers altogether, cases that would be more complex. This might require the students to actually listen to and comprehend what the patient says, instead of picking out key words from a page and searching them on the internet. We could use on-line forums where the students would post their own research so I could see who is actually finding this information and who is passively absorbing it from the group discussion. We could create scenarios where they have to manage the simulated on-line patient, request particular test results in order to receive them, and interpret imaging studies. The horizons are very broad.

Perhaps the way we teach would eventually catch up with the way the students are already opting to learn.

I know there would be resistance, and hurdles to overcome. My own efforts at using technology to implement on-line tutorials for the psychiatry clinical skills training has led to one headache after another. The operating system is too inflexible. I don’t know enough about how these things work to get it running without some help, and nobody seems to be willing/able to assist me. I have to see patients, and I don’t have time to try and learn this stuff. And I’m actually keen to do this, as opposed to most of the academic physicians who probably haven’t given this much thought at all. I can just imagine the looks of horror I would get from all corners of the hospital and the medical school if I suggested we scrap the Brain and Behaviour tutorials and start again with e-learning cases.

Tutorial ends early, as has been the case over most of the term. I slip an elastic band around the remaining pages, which I will save until Wednesday. But I wonder how many more years I will be doing this. Not too many, I hope. In future, the conversation won’t unfold according to the itinerary of those who would control the way knowledge is transferred. Like it or not, students are not going to go back to the old way of doing things, any more than patients are about to stop using the internet to research their illnesses. The days of the blue pages are numbered.

What is it I do, exactly?

I found this week’s article, “A framework of teaching competencies across the medical education continuum” by W. M. Molenaar, very thought-provoking. I was especially interested in the six Domains of education they described: Development, Organization, Execution, Coaching, Assessment, and Evaluation. As junior faculty in one of the clinical departments (psychiatry) it is quite striking how rarely one hears specific terms used to describe the education activities that faculty members participate in. Without a language and a framework for these activities, sometimes it becomes difficult to understand, or even track, what exactly it is I spend my time doing.

Sometimes people say to me, you do a lot of teaching, don’t you? As I read this article, I thought about the fact that while it is true that I do a great deal of direct teaching (“Execution” it would be called in this framework), many of my Education responsibilities actually fall into other categories, and it is these activities that often take up a great deal of time.

Consider our psychiatry patient-doctor program, for which I am responsible. At the beginning of the block, I meet with the students as a group for an introductory session, which is direct teaching or “Execution”: but that is only part of what I do.

I have developed and revised curriculum for this block, which would be “Development”. Lately I have spent a great deal of time meeting with people about trying to get on-line tutorials for this block on to some sort of user-friendly technology, a task I would consider to be “Organization”. I plan and deliver an annual tutor workshop, which is a form of “Coaching” for those who provide most of the direct teaching and supervision in the program. I review the overall results for the block (this is “Assessment”, and it is the lightest responsibility of them all, as nobody ever fails), and the evaluations the students complete on their supervisors (“Evaluation”). I am hoping to do some research on my latest innovation in the curriculum for this unit, an objective on self-reflection which I hope could be useful in teaching professionalism.

Co-ordinating the patient-doctor teaching is just one example of the many education-related activities I undertake in our department. I believe my contribution to our department’s education mandate is significant, but it has not always been easy to say what I do and why it is more than just “teaching”. Hopefully using this framework to explain my activities to myself and to others can help me to set goals, focus my efforts and continue my professional development as an educator.

being an adult learner

Five characteristics of adult learners (Knowles)

1. Adult learners move from dependence to self-direction in learning.
2. Adult learners have a rich reservoir of experience to apply to their learning.
3. Adult learners value learning that is relevant to their daily life.
4. Adult learners have a greater focus on problem-centered than on subject-centered learning.
5. Adult learners are motivated by internal rather than external motivators.

Thinking about this as an adult learner, I am particularly struck by number 2 and number 3. With this masters, I have been very concerned about relevance, and it is my experience that dictates what I find relevant.

"Today’s physicians continue to witness significant change in the nature of health care delivery. The roles of all health professionals, hospitals, patients, funding bodies, and governments are evolving at a hurried pace. Practice is changing daily, with literally thousands of medical journals documenting our evolving understanding of biological, social, and clinical sciences. Patients are treated in more diversified settings. They spend less time in hospitals, and those who are there are older and sicker. We live in an era with a rising emphasis on accountability and a declining appreciation of professionals and various authorities. Never has the true nature of a physician been such at risk. The question arises, as it did at the Royal College at the beginning of the 1990s: “How can we best prepare physicians to be effective in this environment and truly meet the needs of their patients?”" (Page One, CanMEDS 2005).

My question: what does it mean, "Never has the true nature of a physician been such at risk?" What is the true nature of a physician anyway? And is that even proper English?

CanMEDS

For the first week, we were asked to look at a document from our field that provides an over-arching educational structure. CanMEDS seemed like the logical choice. It was good to actually look at it in detail, because to be honest, it's one of those things that I've never really taken the time to read.

The CanMEDS Manager Role

Essay on Curriculum Issue: The CanMEDS Role of Manager
The Manager Role, as defined by the CanMEDS framework, is an important part of medical practice. According to the Royal College, “Postgraduate programs have a mandate to ensure that learners are well prepared for the specific managerial responsibilities that their graduates will be expected to fulfill.” (Razack S and Dath D, 2006. The CanMEDS Assessment Tools Handbook: An introductory guide to assessment methods for the CanMEDS competencies. Ottawa. The Royal College of Physicians and Surgeons of Canada.) It seems reasonable that preparation for this role should begin during undergraduate medical training, with an introduction to the competencies associated with management at the organizational and personal level.
Despite its importance, the Manager Role is also recognized as one of the most challenging of the Roles to teach and assess. One study found that programme directors across a variety of specialties were less satisfied with the way they assessed the Manager and Health Advocate Roles than they were with the assessment of other Roles such as Medical Expert. Despite the fact that the CanMEDS Assessment Tools Handbook suggests that oral examinations are not the best way to evaluate trainees on their performance in the Manager Role, 31.5% of respondent programs were doing so. The authors concluded that there was “some urgency in the need to examine the Manager and Health Advocate Roles, what they mean in various specialties, and why they appear to be difficult to assess.” (Chou S, Cole G, McLaughlin K & Lockyer J; CanMEDS evaluation in Canadian postgraduate training programmes: tools used and programme director satisfaction Medical Education Sep 2008, Vol. 42 Issue 9, p879-886)
In defining the Manager Role, CanMEDS recognizes management responsibilities as core requirements for the practice of medicine. Responsibilities exist at the organizational level, such as developing and implementing processes and policies related to patient care, and at the individual level when physicians make decisions about how to allocate their time among professional and personal priorities. Elements of the Manager Role include collaborative decision-making, quality assurance, managing change, leadership, administration, and time management. Career development is also included as one of these elements, and the ability to manage career and practice effectively is considered a Key Competency. (Frank, JR. (Ed). 2005. The CanMEDS 2005 physician
competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada.)

Teaching the Manager Role

Instructing learners about the Manager Role can be difficult due to the lack of exposure to this role in training settings. Clinical rotations do not usually provide the opportunity for trainees to participate in activities that contribute to organizational effectiveness. Strategic planning, quality assurance, budgeting, accreditation, and other activities are routinely carried out alone in a physician’s office, in committee meetings, and in other administrative settings that may not be accessible to residents or medical students. Because of the way residency and clerkship are structured, most learners spend only a limited time on a clinical service, which makes it difficult for students to contribute meaningfully to, engage in, or even understand discussions around management issues. In clinical training, patient management skills are generally taught through modelling and practice. For the Manager Role, these naturalistic learning opportunities are largely absent in most clinical rotations. Even when students observe practice management on the part of preceptors, it seems likely that there is seldom explicit teaching or discussion about competencies such as setting priorities, implementing processes to ensure personal practice improvement, or justly allocating healthcare resources.
An alternate way to develop managerial skills would be to involve trainees in organizational activities in which they could participate in over a longer period of time than would be available on clinical rotations. Residents and medical students can be asked to sit on committees of the departments or medical school. Student organizations can be another venue for practical exposure, and students who take leadership positions could be given specific training in leadership and management skills. This approach poses its own challenges, particularly with regards to evaluation, but it does provide an authentic experience of what the Manager Role looks like in practice.

Evaluating the Manager Role

The CanMEDS Assessment Tools Handbook suggests that the preferred tools for assessing the Manager Role include multi-source feedback and peer evaluation, simulation, and use of portfolios, as well as direct observation. Multi-source feedback can include specific questions that elicit information regarding key competencies of the Manager Role. Complex simulations may be designed to develop skills in planning, delegation, communication, providing feedback, and other tasks. Assessment portfolios can include items such as committee work, practice organization innovations, audits and quality assurance projects, along with reflections generated by these experiences. The inclusion of narrative reviews of discussions with academic mentors is also suggested (Razack and Dath, 2006).
The authors of the Handbook suggest supervisors in clinical scenarios can assess learner’s managerial skills by observing the resident’s capacity for time management, effective mobilization of health care resources, and appropriate delegation of tasks related to patient care (Razack and Dath, 2006). While it may be possible to comment on how learners perform in these areas of individual practice management, such observations provide little information about how they are fulfilling other aspects of the Role, such as developing their careers, gaining leadership skills, and participating in the organizational dynamics of the health care system.

Future Directions

In addition to the practical challenges of teaching and evaluating the Manager Role, there are other questions that need to be addressed. Managerial skills training falls outside of what has traditionally been seen as the mandate of residency programs or undergraduate medical education, which traditionally focussed only on the Medical Expert Role. There are potential financial costs, and concerns that that CanMEDS-based education might detract from trainees’ time to provide service and gain exposure to patients (Frank J, Danoff D. 2007. The CanMEDS initiative: implementing an outcomes-based framework of physician Competencies. Medical Teacher 29: 642–647).
It is possible that the Manager Role is one that becomes more relevant to physicians as they move forward in their careers. A recent study of emergency room physicians in two academic centers found that the Manager Role was identified as one of three professional development priorities along with Medical Expert and Scholar, while Communicator, Collaborator, Health Advocate and Professional were less highly-rated. (Sherbino J, Upadhye S, and Worster A. 2009 Self-reported priorities and resources of academic emergency physicians for the maintenance of competence: a pilot study. CJEM: Journal of the Canadian Association of Emergency Physicians. Vol. 11;3 (230-4) It may be that increased efforts to provide continuing medical education regarding the Manager Role would be the most effective way to develop competency within the profession as a whole.
In developing the Manager Role, it seems logical to incorporate knowledge that his been developed within other fields, particularly business administration. There is a surprising lack of literature to suggest that efforts have been made to integrate business teaching models into programs training physicians to fulfill managerial roles.
Conclusion
The Manager Role represents an important function for physicians if we wish to make a significant contribution to the effectiveness of our health care systems. Our medical schools and training programs require physician educators with excellent managerial as well as teaching skills in order to meet the needs of learners and the community at large. Career development skills, as well as the ability to achieve personal and professional balance, can help doctors enjoy more rewarding lives. Despite the challenges, there are great potential benefits in incorporating education in the Manager Role into our medical training programs.

Bibliography
Chou S, Cole G, McLaughlin K & Lockyer J; CanMEDS evaluation in Canadian postgraduate training programmes: tools used and programme director satisfaction Medical Education Sep 2008, Vol. 42 Issue 9, p879-886

Frank, JR. (Ed). 2005. The CanMEDS 2005 physician
competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada.

Frank J, Danoff D. 2007. The CanMEDS initiative: implementing an outcomes-based framework of physician Competencies. Medical Teacher 29: 642–647

Razack S and Dath D, 2006. The CanMEDS Assessment Tools Handbook: An introductory guide to assessment methods for the CanMEDS competencies. Ottawa. The Royal College of Physicians and Surgeons of Canada

Sherbino J, Upadhye S, and Worster A. 2009 Self-reported priorities and resources of academic emergency physicians for the maintenance of competence: a pilot study. CJEM: Journal of the Canadian Association of Emergency Physicians. Vol. 11;3 (230-4)

First class

Tonight was the first week of "Current Research and Theory in Curriculum." I'm back in school, after a long time away. I was talking to Cheryl and she was saying how excited she was before starting her first class: I felt surprisingly anxious. I've done a lot of thinking about this. Why do I want to do a Masters Degree anyway? I do a lot of teaching and curriculum development, and some education administration, and certainly it would be nice improve my skills and knowledge in these areas. But the real reason is that I feel like I have reached a plateau in my professional development. It's a happy plateau, and I like the view from here, but I need some new challenges.

But there are so many things that interest me! Philosophy, theology, literature, art, history, political theory, economics... Why am I doing a Masters in Education, when I could take courses in these areas? Because somehow, I think this will have a more practical benefit in my career. I wish I had a clearer picture of what I am hoping to accomplish, but as my favorite quote says, "Some people never learn anything because they understand everything too soon."

One of the weaknesses I am trying to "manage around" is my difficulty in learning names and faces, so I'm really working on that. It's a diverse group, with dentists, pharmacists, dental hygienists, nurses, and an assortment of physicians (surgeons, a family doctor, residents, etc.). I'm the only psychiatrist. I'm pleased about that: it's good to get a variety of perspectives.

At the end of the course, I'll have to write a retrospective commentary on the course, so keeping a blog should be useful. I also will be doing a 'curriculum development project.' I can already tell the problem will be choosing between options. Right now, my list includes; our interprofessional learning elective, developing a narrative foreclosure grand rounds presentation, incorporating self-reflection in the Med II pt/dr curriculum, BLS in pt-dr, designing a humanities curriculum for psych residents. There's probably more, too.

Karen Mann spoke, and some of the points that struck me were:

1. Curriculum should keep changing - it's not about 'getting it right' and then leaving it in place forever.

2. Knowledge, skills, and attitude together form 'competencies.'

3. Too much focus on discrete competencies can distract from consideration of integrated performance.

4. How far should students be allowed to determine their own objectives? What should be core and what should be optional? In the UK "Tomorrow's Doctors" document, they suggest students should be allowed to determine 20% of their material through self-selection. This was particularly relevant to me today, because I was teaching Med II students, and I'm always aware that many of them would not choose to be there if given the option. Med school isn't about training the undifferentiated general physician any more, but pre-specialty specialization.

5. Our IPE elective should probably include specific teaching about collaboration as part of the planned curriculum, and not just part of the delivered curriculum. We also need to think about the experienced curriculum. I wonder if we can get honest feedback from the students about their experiences.

My homework is to get a copy of a document which is a 'driver for developing curriculum' and 'interview the document'. I'll post a copy of my assignment here on my blog.

I have a generally positive feeling about this, which for a pessimist like me, is a good start.

Ideation

I've been reading a book on identifying your strengths, and when I did the on-line self-survey, one of my main strengths was 'ideation', which seems to mean, 'coming up with ideas.' This fits with what the author of "Refuse to Choose" (I've been reading a lot of books like this lately) suggests, which is that there are some people who excel at creating ideas and that you are not meant to follow through on all of them. While that's a liberating concept in many ways, the fact is that I do have to take action on at least some of my ideas if I want to advance in my professional life. The problem is, which ones?

As I start my Masters degree, my mind is swimming with ideas about what I would like my first project to be. I have so many areas of interest. How am I going to focus enough to get anything done?

One thing the strengths book suggests is that in order to excel, you need to build on your strengths and manage around your weaknesses. Putting my ideas into action is one of those weaknesses I need to learn to manage around.