The Internet provides a means of disseminating medical education curricula, allowing institutions to share educational resources. Much of what is published online is poorly planned, does not meet learners' needs, or is out of date.
Applying principles of curriculum development, adult learning theory and educational website design may result in improved online educational resources. Key steps in developing and implementing an education website include: 1) Follow established principles of curriculum development; 2) Perform a needs assessment and repeat the needs assessment regularly after curriculum implementation; 3) Include in the needs assessment targeted learners, educators, institutions, and society; 4) Use principles of adult learning and behavioral theory when developing content and website function; 5) Design the website and curriculum to demonstrate educational effectiveness at an individual and programmatic level; 6) Include a mechanism for sustaining website operations and updating content over a long period of time.
Interactive, online education programs are effective for medical training, but require planning, implementation, and maintenance that follow established principles of curriculum development, adult learning, and behavioral theory.
We hypothesized that the Internet could be used to disseminate and evaluate a curriculum in ambulatory care, and that internal medicine residency program directors would value features made possible by online dissemination. An Internet-based ambulatory care curriculum was developed and marketed to internal medicine residency program directors. Utilization and knowledge outcomes were tracked by the website; opinions of program directors were measured by paper surveys. Twenty-four programs enrolled with the online curriculum. The curriculum was rated favorably by all programs, test scores on curricular content improved significantly, and program directors rated highly features made possible by an Internet-based curriculum.
curriculum; computer-assisted instruction
PROBLEM BEING ADDRESSED: The continuing shortage of rural family physicians in Canada. PURPOSE OF PROGRAM: To further develop training for rural family practice so that adequate numbers of rural family physicians will be appropriately prepared. MAIN COMPONENTS OF PROGRAM: All family medicine residents should have the opportunity to experience the joys and challenges of rural family practice. Rural family medicine training streams provide the best education for family medicine residents who are planning a career in rural family medicine. Integrated training for rural family practice should be high-quality, academically sound, needs-driven, evidence-based, learner-centered, and outcome-measured. This involves comprehensive development of curricula that provide specific skills and appropriate core subjects in rural practice as well as a solid family medicine foundation. contextual and experiential learning in areas similar to or in actual areas where there is a need for rural physicians, and appropriate hospital rotations to learn skills for the hospital role of many rural family doctors, are important components of rural family medicine training. CONCLUSIONS: Postgraduate rural family medicine training programs can be further focused and developed to train more physicians with the knowledge, skills, and attitudes required for rural practice.
This article reports the results from a randomized control field trial that investigated the impact of an enhanced decoding and spelling curriculum on the development of adult basic education (ABE) learners’ reading skills. Sixteen ABE programs that offered class-based instruction to Low-Intermediate level learners were randomly assigned to either the treatment group or the control group. Reading instructors in the 8 treatment programs taught decoding and spelling using the study-developed curriculum, Making Sense of Decoding and Spelling (MSDS), and instructors in the 8 control programs used their existing reading instruction. A comparison group of 7 ABE programs whose instructors used K-3 structured curricula adapted for use with ABE learners were included for supplemental analyses. Seventy-one reading classes, 34 instructors, and 349 adult learners with pre- and posttests participated in the study. The study found a small but significant effect on one measure of decoding skills, which was the proximal target of the curriculum. No overall significant effects were found for word recognition, spelling, fluency, or comprehension. Pretest to posttest gains for word recognition were small to moderate, but not significantly better than the control classes. Adult learners who were born and educated outside of the U.S. made larger gains on 7 of the 11 reading measures than learners who were born and educated within the U.S. However, participation in the treatment curriculum was more beneficial for learners who were born and educated in the U.S. in developing their word recognition skills.
Educating medical students about health disparities may be one step in diminishing the disparities in health among different populations. According to adult learning theory, learners’ opinions are vital to the development of future curricula.
Qualitative research using focus group methodology.
Our objectives were to explore the content that learners value in a health disparities curriculum and how they would want such a curriculum to be taught.
Study participants were first year medical students with an interest in health disparities (n = 17).
Semi-structured interviews consisting of 12 predetermined questions, with follow-up and clarifying questions arising from the discussion. Using grounded theory, codes were initially developed by the team of investigators, applied, and validated through an iterative process.
The students perceived negative attitudes towards health disparities education as a potential barrier towards the development of a health disparities curriculum and proposed possible solutions. These solutions centered around the learning environment and skill building to combat health disparities.
While many of the students’ opinions were corroborated in the literature, the most striking differences were their opinions on how to develop good attitudes among the student body. Given the impact of the provider on health disparities, how to develop such attitudes is an important area for further research.
health disparities; health care disparities; focus groups; curriculum development; medical education
Competency in practice-based learning and improvement (PBLI) and systems-based practice (SBP) empowers learners with the skills to plan, lead, and execute health care systems improvement efforts. Experiences from several graduate medical education programs describe the implementation of PBLI and SBP curricula as challenging because of lack of adequate curricular time and faculty resources, as well as a perception that PBLI and SBP are not relevant to future careers. A dedicated experiential rotation that requires fellow participation in a specialty-specific quality improvement project (QIP) may address some of these challenges.
We describe a retrospective analysis of our 5-year experience with a dedicated 3-week PBLI-SBP experiential curriculum in a preventive medicine fellowship program at Mayo Clinic, Rochester, Minnesota.
Between 2004 and 2008, 19 learners including 7 preventive medicine fellows participated in the rotation. Using just-in-time learning, fellows work together on a relatively complex QIP of community or institutional significance. Since 2004, all 19 learners (100%) participating in this rotation have consistently demonstrated statistically significant increase in their quality improvement knowledge application tool (QIKAT) scores at the end of the rotation. At the end of the rotation, all 19 learners stated that they were either confident or very confident of making a change to improve health care in a local setting. Most of the QIPs resulted in sustainable practice improvements, and resultant solutions have been disseminated beyond the location of the original QIP.
A dedicated experiential rotation that requires learner participation in a QIP is one of the effective methods to address the needs of the SBP and PBLI competencies.
There are an increasing number of training programs in emergency medicine involving different countries or cultures. Many examination types, both oral and written, have been validated as useful assessment tools around the world; but learner perception of their use in the setting of cross-cultural training programs has not been described.
The goal of this study was to evaluate learner perception of four common examination methods in an international educational curriculum in emergency medicine.
Twenty-four physicians in a cross-cultural training program were surveyed to determine learner perception of four different examination methods: structured oral case simulations, multiple-choice tests, semi-structured oral examinations, and essay tests. We also describe techniques used and barriers faced.
There was a 100% response rate. Learners reported that all testing methods were useful in measuring knowledge and clinical ability and should be used for accreditation and future training programs. They rated oral examinations as significantly more useful than written in measuring clinical abilities (p < 0.01). Compared to the other three types of examinations, learners ranked oral case simulations as the most useful examination method for assessing learners’ fund of knowledge and clinical ability (p < 0.01).
Physician learners in a cross-cultural, international training program perceive all four written and oral examination methods as useful, but rate structured oral case simulations as the most useful method for assessing fund of knowledge and clinical ability.
Electronic supplementary material
The online version of this article (doi:10.1007/s12245-009-0147-2) contains supplementary material, which is available to authorized users.
Graduate medical education; Oral case simulations; Assessment tools; Curriculum development; International medical education
Learner feedback is the primary method for evaluating clinical faculty, despite few existing standards for measuring learner assessments.
To review the published literature on instruments for evaluating clinical teachers and to summarize themes that will aid in developing universally appealing tools.
Searching 5 electronic databases revealed over 330 articles. Excluded were reviews, editorials, and qualitative studies. Twenty-one articles describing instruments designed for evaluating clinical faculty by learners were found. Three investigators studied these papers and tabulated characteristics of the learning environments and validation methods. Salient themes among the evaluation studies were determined.
Many studies combined evaluations from both outpatient and inpatient settings and some authors combined evaluations from different learner levels. Wide ranges in numbers of teachers, evaluators, evaluations, and scale items were observed. The most frequently encountered statistical methods were factor analysis and determining internal consistency reliability with Cronbach's α. Less common methods were the use of test-retest reliability, interrater reliability, and convergent validity between validated instruments. Fourteen domains of teaching were identified and the most frequently studied domains were interpersonal and clinical-teaching skills.
Characteristics of teacher evaluations vary between educational settings and between different learner levels, indicating that future studies should utilize more narrowly defined study populations. A variety of validation methods including temporal stability, interrater reliability, and convergent validity should be considered. Finally, existing data support the validation of instruments comprised solely of interpersonal and clinical-teaching domains.
validity; evaluation studies; medical faculty
Residency applicants consider a variety of factors when ranking emergency medicine (EM) programs for their NRMP match list. A human cadaver emergency procedure lab curriculum is uncommon. We hypothesized that the presence this curriculum would positively impact the ranking of an EM residency program.
The EM residency at Nebraska Medical Center is an urban, university-based program with a PGY I–III format. Residency applicants during the interview for a position in the PGY I class of 2006 were surveyed by three weekly electronic mailings. The survey was distributed in March 2006 after the final NRMP match results were released. The survey explored learner preferences and methodological commonality of models of emergency procedural training, as well as the impact of a procedural cadaver lab curriculum on residency ranking. ANOVA of ranks was used to compare responses to ranking questions.
Of the 73 potential subjects, 54 (74%) completed the survey. Respondents ranked methods of procedural instruction from 1 (most preferred or most common technique) to 4 (least preferred or least common technique). Response averages and 95% confidence intervals for the preferred means of learning a new procedure are as follows: textbook (3.69; 3.51–3.87), mannequin (2.83; 2.64–3.02), human cadaver (1.93; 1.72–2.14), and living patient (1.56; 1.33–1.79). Response averages for the commonality of means used to teach a new procedure are as follows: human cadaver (3.63; 3.46–3.80), mannequin (2.70; 2.50–2.90), living patient (2.09; 1.85–2.33), and textbook (1.57; 1.32–1.82). When asked if the University of Nebraska Medical Center residency ranked higher in the individual’s match list because of its procedural cadaver lab, 14.8% strongly disagreed, 14.8% disagreed, 40.7% were neutral, 14.8% agreed, and 14.8% strongly agreed.
We conclude that, although cadaveric procedural training is viewed by senior medical student learners as a desirable means of learning a procedure, its use is uncommon during medical school, and its presence as part of a residency curriculum does not influence ranking of the residency program.
Introduction: This paper examines the use of reflective writing in a preclinical end-of-life curriculum including comparison of the role and outcomes of out-of-class (OC) versus in-class (IC) writing.
Methods: Learners were required to complete one-page essays on their experiences and concerns about death and dying after attending a series of end-of-life care lectures. From 2002–2005, essays were completed OC and in 2006 and 2007 essays were completed during the first ten minutes of small group discussion sessions. Essays were collected and analyzed for salient themes.
Results: Between 2002–2007, reflection essays were gathered from 829 learners, including 522 OC essays and 307 IC essays. Essay analysis identified four major themes of student concerns related to caring for dying patients, as well as student reactions to specific curricular components and to the use of reflection. IC essays were shorter and less polished than OC essays but utilized a wider variety of formats including poems and bulleted lists. IC essays tended to react to lecture content immediately preceding the writing exercise whereas OC varied in curricular components upon which they focused. OC essays have the advantage of giving learners more time to choose subject matter, whereas IC essays provide a structured time in which to actively reflect. Both formats served as catalysts for small group discussions.
Discussion: Writing exercises can effectively provide an important opportunity and motivation for learners to reflect on past experiences and future expectations related to providing end-of-life care.
It is challenging to create an educational and satisfying experience in the outpatient setting. We developed a 3-year ambulatory curriculum that addresses the special needs of our categorical medicine residents with distinct learning objectives for each year of training and clinical experiences and didactic sessions to meet these goals. All PGY1 residents spend 1 month on a general medicine ambulatory care rotation. PGY2 residents spend 3 months on an ambulatory block focusing on 8 core medicine subspecialties. Third-year residents spend 2 months on an advanced ambulatory rotation. The curriculum was started in July 2000 and has been highly regarded by the house staff, with statistically significant improvements in the PGY2 and PGY3 evaluation scores. By enhancing outpatient clinical teaching and didactics with an emphasis on the specific needs of our residents, we have been able to reframe the thinking and attitudes of a group of inpatient-oriented residents.
medical education; residency training; ambulatory medicine
Self-regulation is essential for professional development. It involves monitoring of performance, identifying domains for improvement, undertaking learning activities, applying newly learned knowledge and skills and self-assessing performance. Since self-assessment alone is ineffective in identifying weaknesses, learners should seek external feedback too. Externally regulated educational interventions, like reflection, learning portfolios, assessments and progress meetings, are increasingly used to scaffold self-regulation.
The aim of this study is to explore how postgraduate trainees regulate their learning in the workplace, how external regulation promotes self-regulation and which elements facilitate or impede self-regulation and learning.
In a qualitative study with a phenomenologic approach we interviewed first- and third-year GP trainees from two universities in the Netherlands. Twenty-one verbatim transcripts were coded. Through iterative discussion the researchers agreed on the interpretation of the data and saturation was reached.
Trainees used a short and a long self-regulation loop. The short loop took one week at most and was focused on problems that were easy to resolve and needed minor learning activities. The long loop was focused on complex or recurring problems needing multiple and planned longitudinal learning activities. External assessments and formal training affected the long but not the short loop. The supervisor had a facilitating role in both loops. Self-confidence was used to gauge competence.Elements influencing self-regulation were classified into three dimensions: personal (strong motivation to become a good doctor), interpersonal (stimulation from others) and contextual (organizational and educational features).
Trainees did purposefully self-regulate their learning. Learning in the short loop may not be visible to others. Trainees should be encouraged to actively seek and use external feedback in both loops. An important question for further research is which educational interventions might be used to scaffold learning in the short loop. Investing in supervisor quality remains important, since they are close to trainee learning in both loops.
Self-regulation; Workplace-based learning; Postgraduate training; Professional development; Qualitative research methods
Evidence-based medicine (EBM) has been widely integrated into residency curricula, although results of randomized controlled trials and long term outcomes of EBM educational interventions are lacking. We sought to determine if an EBM workshop improved internal medicine residents' EBM knowledge and skills and use of secondary evidence resources.
This randomized controlled trial included 48 internal medicine residents at an academic medical center. Twenty-three residents were randomized to attend a 4-hour interactive workshop in their PGY-2 year. All residents completed a 25-item EBM knowledge and skills test and a self-reported survey of literature searching and resource usage in their PGY-1, PGY-2, and PGY-3 years.
There was no difference in mean EBM test scores between the workshop and control groups at PGY-2 or PGY-3. However, mean EBM test scores significantly increased over time for both groups in PGY-2 and PGY-3. Literature searches, and resource usage also increased significantly in both groups after the PGY-1 year.
We were unable to detect a difference in EBM knowledge between residents who did and did not participate in our workshop. Significant improvement over time in EBM scores, however, suggests EBM skills were learned during residency. Future rigorous studies should determine the best methods for improving residents' EBM skills as well as their ability to apply evidence during clinical practice.
Teaching advanced communication skills requires educators who are not only excellent communicators themselves but have the ability to deconstruct the components of the interaction and develop a cognitive approach that can be used across a variety of learners, diverse content, and under different time constraints while helping the learner develop the skill of self-reflection in a ‘safe’ and effective learning environment. The use of role-play in small groups is an important method to help learners cultivate the skills required to engage in nuanced, often difficult conversations with seriously ill patients. To be effective, educators utilizing role-play must help learners set realistic goals and know when and how to provide feedback to the learners in a way that allows a deepening of skills and a promotion of self-awareness. The challenge is to do this in a manner that does not cause too much anxiety for the learner. In this article we outline an approach to teaching communication skills to advanced learners through the use of different types of role-play, feedback, and debriefing.
We sought to create a resident educator program using a Train-the-Trainer (TTT) approach with adaptable curricula at a large tertiary health care center with a medical school and 60 accredited residency programs.
The Resident Educator And Life-long Learner (REALL) Program was designed as a 3-phase model. Phase 1 included centralized planning and development that led to the design of 7 teaching modules and evaluation tools for TTT and resident sessions. Phase 2 entailed the dissemination of the TTT modules (Learning Styles, Observational Skills, Giving Feedback, Communication Skills: The Angry Patient, Case-Based Teaching, Clinical Reasoning, Effective Presentations) to faculty trainers. In phase 3, specific modules were chosen and customized by the faculty trainers, and implemented for their residents. Evaluations from residents and faculty were collected throughout this process.
A total of 45 faculty trainers representing 27 residency programs participated in the TTT program, and 97% of trainers were confident in their ability to implement sessions for their residents. A total of 20 trainers from 11 residency programs implemented 33 modules to train 479 residents, and 97% of residents believed they would be able to apply the skills learned. Residents' comments revealed appreciation of discussion of their roles as teachers.
Use of an internal TTT program can be a strategy for dissemination of resident educator and life-long learner curricula in a large academic tertiary care center. The TTT model may be useful to other large academic centers.
Educational courses for doctors and medical students are increasingly offered via the Internet. Despite much research, course developers remain unsure about what (if anything) to offer online and how. Prospective learners lack evidence-based guidance on how to choose between the options on offer. We aimed to produce theory driven criteria to guide the development and evaluation of Internet-based medical courses.
Realist review - a qualitative systematic review method whose goal is to identify and explain the interaction between context, mechanism and outcome. We searched 15 electronic databases and references of included articles, seeking to identify theoretical models of how the Internet might support learning from empirical studies which (a) used the Internet to support learning, (b) involved doctors or medical students; and (c) reported a formal evaluation. All study designs and outcomes were considered. Using immersion and interpretation, we tested theories by considering how well they explained the different outcomes achieved in different educational contexts.
249 papers met our inclusion criteria. We identified two main theories of the course-in-context that explained variation in learners' satisfaction and outcomes: Davis's Technology Acceptance Model and Laurillard's model of interactive dialogue. Learners were more likely to accept a course if it offered a perceived advantage over available non-Internet alternatives, was easy to use technically, and compatible with their values and norms. 'Interactivity' led to effective learning only if learners were able to enter into a dialogue - with a tutor, fellow students or virtual tutorials - and gain formative feedback.
Different modes of course delivery suit different learners in different contexts. When designing or choosing an Internet-based course, attention must be given to the fit between its technical attributes and learners' needs and priorities; and to ways of providing meaningful interaction. We offer a preliminary set of questions to aid course developers and learners consider these issues.
Evidence suggests that inexperienced clinical teachers are often controlling and noninteractive. Adult learning theory states that mature students prefer shared and self-directed learning and that skillful teachers favor facilitating discussions over transmitting knowledge. Similarly, education research shows that effective clinical teachers invest in relationships with learners, ask questions to diagnose learners, communicate complex information clearly, and provide meaningful feedback. On the basis of these principles, we propose a collaborative approach to clinical teaching that has 4 essential components: (1) establish a relationship with the learner, (2) diagnose the learner, (3) use teaching frameworks that engage learners, and (4) develop teaching scripts and a personal philosophy. This article includes suggestions for creating a positive learning climate, asking higher-order questions, providing meaningful feedback, and developing teaching scripts. We believe that practicing this approach, which emphasizes respectful teacher-learner relationships, improves the quality of every clinical teaching encounter.
Curricular content is often based on the personal opinions of a small number of individuals. Although convenient, such curricula may not meet the needs of the target learner, the program or the institution. Using an objective method to ensure content validity of a curriculum can alleviate this issue.
A form was created that listed clinical presentations relevant to residents completing intensive care unit (ICU) rotations. Twenty residents and 20 intensivists in tertiary academic multisystem ICUs ranked each presentation on three separate scales: how life-threatening each is, how commonly each is seen in critical care, and how reversible each is. Mean scores for the individual scales were calculated, and these three values were subsequently multiplied together to achieve a composite score for each presentation. The correlation between the two groups' scores for the presentations was calculated to assess reliability of the process.
There was excellent agreement between the two groups for rating each presentation (correlation coefficient r = 0.94). The 10 clinical presentations with the highest composite scores formed the basis of our new curriculum.
We describe a method that can be used to select the content of a curriculum for learners in an ICU. Although the content that we selected to include in our curriculum may not be applicable to other ICUs, we believe that the process we used is easily applied elsewhere, and that it provides an efficient method to improve content validity of a curriculum.
To assess whether a novel evaluation tool could guide curricular change in an internal medicine residency program.
The authors developed an 8-item Ecological Momentary Assessment tool and collected daily evaluations from residents of the relative educational value of 3 differing ambulatory morning report formats (scale: 8 = best, 0 = worst). From the evaluations, they made a targeted curricular change and used the tool to assess its impact.
Residents completed 1388 evaluation cards for 223 sessions over 32 months, with a response rate of 75.3%. At baseline, there was a decline in perceived educational value with advancing postgraduate (PGY) year for the overall mean score (PGY-1, 7.4; PGY-2, 7.2; PGY-3, 7.0; P < .01) and for percentage reporting greater than 2 new things learned (PGY-1, 77%; PGY-2, 66%; PGY-3, 50%; P < .001). The authors replaced the format of a lower scoring session with one of higher cognitive content to target upper-level residents. The new session's mean score improved (7.1 to 7.4; P = .03); the adjusted odds ratios before and after the change for percentage answering, “Yes, definitely” to “Area I need to improve” was 2.53 (95% confidence interval [CI], 1.45–4.42; P = .001) and to “Would recommend to others,” it was 2.08 (95% CI, 1.12–3.89; P = .05).
The Ecological Momentary Assessment tool successfully guided ambulatory morning report curricular changes and confirmed successful curricular impact. Ecological Momentary Assessment concepts of multiple, frequent, timely evaluations can be successfully applied in residency curriculum redesign.
Rigorous assessment of medical knowledge and technical skill inspires learning, reinforces confidence, and reassures the public. Identifying curricular effectiveness using objective measures of learning is therefore crucial for competency-oriented program development in a learner-centric educational environment. The aim of this study was to determine whether various measures of learning, including class-averagenormalized gain, can be used to assess the effectiveness of a one-day introductory bronchoscopy course curriculum.
We conducted a quasi-experimental one-group pre-test/post-test study at the University of California, Irvine. The group comprised 24 first-year pulmonary and critical care trainees from eight training institutions in southern California. Class-average normalized gain, single-student normalized gain, absolute gain, and relative gain were used as objective measures of cognitive knowledge and bronchoscopy technical skill learning. A class-average normalized gain of 30% was used to determine curricular effectiveness. Perceived educational value using Likert-scale surveys and post-course questionnaires was determined during and 3 months after course participation.
Mean test scores of cognitive knowledge improved significantly from 48 to 66% (p = 0.043). Absolute gain for the class was 18%, relative gain was 37%, classaverage normalized gain 〈g〉 was 34%, and the average of thesingle-student normalized gains g(ave) was 29%. Mean test scores of technical skill improved significantly from 43 to 77% (p = 0.017). Absolute gain was 34%, relative gain was 78%, classaverage normalized gain 〈g〉 was 60%, and the average of thesingle-student normalized gains g(ave) was 59%. Statistically significant improvements in absolute gain were noted in all five elements of technical skill (p < 0.05). Likert-scale surveys, questionnaires, and surveys demonstrated strong perceived educational value.
The effectiveness of a one-day introductory bronchoscopy curriculum was demonstrated using a pre-test/post-test model with calculation of normalized gain and related metrics.
Electronic supplementary material
The online version of this article (doi:10.1007/s00464-010-1161-4) contains supplementary material, which is available to authorized users.
Pre–post testing; Normalized gain; Competency; Training; Bronchoscopy; Education
Medical training is increasingly occurring in the ambulatory setting for final year medical students and residents. This study looks to identify if gender, school, level of training, or speciality affects learner's (final year medical students and residents) preferred site characteristics and preceptor behaviours for learning in the ambulatory setting.
All final year medical students and residents at the five medical schools in Ontario (N = 3471) were surveyed about the site characteristics and preceptor behaviours most enhancing their learning in the ambulatory setting. Preferred site characteristics and preceptor behaviours were rank ordered. Factor analysis grouped the site characteristics and preceptor behaviours into themes which were then correlated with gender, school, level of training, and speciality.
Having an adequate number and variety of patients while being supervised by enthusiastic preceptors who give feedback and are willing to discuss their reasoning processes and delegate responsibility are site characteristics and preceptor behaviours valued by almost all learners. Some teaching strategies recently suggested to improve efficiency in the ambulatory teaching setting, such as structuring the interview for the student and teaching and reviewing the case in front of the patient, were found not to be valued by learners. There was a striking degree of similarity in what was valued by all learners but there were also some educationally significant differences, particularly between learners at different levels and in different specialities. Key findings between the different levels include preceptor interaction being most important for medical students as opposed to residents who most value issues pertaining to patient logistics. Learning resources are less valued early and late in training. Teaching and having the case reviewed in front of the patient becomes increasingly less valued as learners advance in their training. As one approaches the end of ones' training office management instruction becomes increasingly valued. Differences between specialities pertain most to the type of practice residents will ultimately end up in (ie: office based specialties particularly valuing instruction in office management and health care system interaction).
Preceptors need to be aware of, and make efforts to provide, teaching strategies such as feedback and discussing clinical reasoning, that learners have identified as being helpful for learning. If strategies identified as not being valued for learning, such as teaching in front of the patient, must continue it will be important to explore the barriers they present to learning. Although what all learners want from their preceptors and clinic settings to enhance their learning is remarkably similar, being aware of the educationally significant differences, particularly for learners at different levels and in different specialities, will enhance teaching in the ambulatory setting.
The results of a number of studies which have indicated the limited effectiveness of health education efforts using the mass media are reviewed. The cause of these failures, according to the authors was the inability to apply a number of principles of effective design to the instructional materials used in the mass media. The basic slide show produced by the neighborhood health center for its own population may be more effective than a nationally televised spot announcement because locally prepared material can be sharply focused on the learner's characteristics and the specifically desired outcome behavior. The authors list 10 guidelines for the construction of effective instructional materials: define outcome measures, analyze relevant characteristics of the learner, gain and maintain the learner's attention, establish the learner's vulnerability, demonstrate the needs for action, establish the learner as an agent, establish the learner's effectiveness, provide for practice, repeat key facts, and generalize to similar situations. The principles of social reinforcement that must accompany health education instruction if behavior is to be modified are outlined. How environmental factors such as time, distance, expense, and the organization of health services hamper desired behavior outcomes is also discussed.
Faculty development has received considerable investment of resources from medical institutions, though the impact of these efforts has been infrequently studied.
To measure the impact of the Stanford Faculty Development Program in Clinical Teaching on ambulatory teaching behavior.
SETTING AND PARTICIPANTS
Eight internal medicine faculty participating in local faculty development.
Participants received 7 2-hour sessions of faculty development. Each session included didactic, role-play, and videotaped performance evaluation.
MAIN OUTCOME MEASURE
Before and after the intervention, faculty were video-taped during a case presentation from a standardized learner, who had been trained to portray 3 levels of learners: a third-year medical student, an intern, and a senior medical resident. Teacher and learner utterances (i.e, phrases) were blindly and randomly coded, using the Teacher Learner Interaction Analysis System, into categories that capture both the nature and intent of the utterances. We measured change in teaching behavior as detected through analysis of the coded utterances.
Among the 48 videotaped encounters, there were a total of 7,119 utterances, with 3,203 (45%) by the teacher. Examining only the teacher, the total number of questions asked declined (714 vs 426, P = .02) with an increase in the proportion of higher-level, analytic questions (44% vs 55%, P<.0001). The quality of feedback also improved, with less “minimal” feedback (87% vs 76%, P<.0005) and more specific feedback (13% vs 22%) provided.
Teaching behaviors improved after participation in this faculty development program, specifically in the quality of questions asked and feedback provided.
faculty development; medical teaching; medical education
The objective of the present study was to determine whether it is possible to consistently and reliably teach medical students and resident learners how to administer local anesthetics in an almost painless manner. Using the published technique, 25 consecutive medical students and residents were taught how to inject local anesthetics for carpal tunnel release by watching the senior author perform the technique once. The learner then independently administered the anesthesia to the next patient who then scored the learner’s ability to inject the local anesthetic from a pain perspective. The teaching technique is demonstrated in an accompanying online video. The learners were consistently capable of administering local anesthetics with minimal pain. During the injection process, the patients only felt pain once (‘hole-in-one’) 76% of the time. This pain was attributed to the first 27-gauge needle poke. The other 24% of the time, patients felt pain twice (eagle) during the 5 min injection process. All 25 patients rated the entire pain experience to be less than 2/10. Eighty-four per cent of the patients indicated that the experience was better than local anesthetic given at the dentist’s office. Medical students and residents can quickly and reliably learn how to administer local anesthesia for carpal tunnel release with minimal pain to the patient.
Carpal tunnel release; Local anesthesia; Medical education; Wideawake surgery
The start of residency represents an “educational handoff.” Accreditation and credentialing organizations have called for better assessments of learner and patient outcomes and improved patient safety and quality of care.
We describe the development of centralized assessments of baseline, core residency competencies at 2 institutions, and summarize principles and lessons learned for other institutions interested in developing similar interventions.
At one institution, 70% of 1 083 new residents assessed via the Objective Standardized Clinical Examination stated they learned a new skill; 80% believe it was a useful way to spend orientation; 78% felt better prepared for aspects of internship; and 80% would recommend it for next year's interns. High levels of satisfaction are expressed by participants at the other institution, especially with the immediate provision of feedback after each station. At this institution, average new resident performance in the communication skills domain approached 90%, but patient care domain scores showed wide variability. The lowest scores were related to performing the psychomotor skills of aseptic technique.
From a patient safety perspective, results suggest a need to improve the preparation of new residents, along with careful supervision of their early clinical work. The presence of skill deficits likely adds to the highly stressful transition into residency. Teaching institutions may use centralized assessment to enhance education and patient safety and to promote accountability to accrediting bodies, residents, and patients. The approach may identify gaps in the undergraduate curriculum. The addition of hand hygiene and aseptic technique teaching and assessment modules are currently being piloted at each of the institutions.