Issue: The transfer of a patient from one clinician to another is a high-risk event. Errors are c... more Issue: The transfer of a patient from one clinician to another is a high-risk event. Errors are common and lead to patient harm. More effective methods for learning how to give and receive sign-out is an important public health priority. Evidence: Performing a handoff is a complex task. Trainees must simultaneously apply and integrate clinical, communication, and systems skills into one time-limited and highly constrained activity. The task demands can easily exceed the information-processing capacity of the trainee, resulting in impaired learning and performance. Appreciating the limits of working memory can help identify the challenges that instructional techniques and research must then address. Cognitive load theory (CLT) identifies three types of load that impact working memory: intrinsic (task-essential), extraneous (not essential to task), and germane (learning related). The authors generated a list of factors that affect a trainee's learning and performance of a handoff based on CLT. The list was revised based on feedback from experts in medical education and in handoffs. By consensus, the authors associated each factor with the type of cognitive load it primarily effects. The authors used this analysis to build a conceptual model of handoffs through the lens of CLT. Implications: The resulting conceptual model unpacks the complexity of handoffs and identifies testable hypotheses for educational research and instructional design. The model identifies features of a handoff that drive extraneous, intrinsic, and germane load for both the sender and the receiver. The model highlights the importance of reducing extraneous load, matching intrinsic load to the developmental stage of the learner and optimizing germane load. Specific CLT-informed instructional techniques for handoffs are explored. Intrinsic and germane load are especially important to address and include factors such as knowledge of the learner, number of patients, time constraints, clinical uncertainties, overall patient/panel complexity, interacting comorbidities or therapeutics, experience or specialty gradients between the sender and receiver, the maturity of the evidence base for the patient's disease, and the use of metacognitive techniques. Research that identifies which cognitive load factors most significantly affect the learning and performance of handoffs can lead to novel, contextually adapted instructional techniques and handoff protocols. The application of CLT to handoffs may also help with the further development of CLT as a learning theory.
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The one-minute preceptor (OMP) was originally developed in the ambulatory care setting as a time-... more The one-minute preceptor (OMP) was originally developed in the ambulatory care setting as a time-efficient teaching technique for learner-centered clinical training. There are also possible advantages of using the OMP in the gross anatomy laboratory. However, in a previous study it was found that providing training to experienced gross anatomy teachers in the use of the OMP did not result in improvement in students' perceptions of their learning, probably due to the fact that the experienced teachers had already developed their own pedagogical approaches. In the current study, we examined the effects of training novice teachers with about four years of gross anatomy teaching experience, in the use of the OMP in the gross anatomy laboratory, by surveying students to collect their views on their learning experiences, by observing the teachers' teaching behaviors before and after they were trained in OMP, and then by interviewing them. More students reported a better learning experience in the session after the teachers had been trained in the OMP than reported worse, in eight out of the nine items related to their learning experiences. The novice teachers were receptive to the OMP. After the OMP training, the novice teachers were observed to engage more in getting commitments from the students and in reinforcing what the students have done right, two of the five OMP microskills. They considered the OMP to be very useful for their development as anatomy teachers.
CONTEXT Although health professions education scholarship units (HPESUs) share a commitment to th... more CONTEXT Although health professions education scholarship units (HPESUs) share a commitment to the production and dissemination of rigorous educational practices and research, they are situated in many different contexts and have a wide range of structures and functions. OBJECTIVES In this study, the authors explore the institutional logics common across HPESUs, and how these logics influence the organisation and activities of HPESUs.
Journal of General Internal Medicine, Mar 30, 2010
Clinical teachers often observe interactions that may contribute to health care disparities, yet ... more Clinical teachers often observe interactions that may contribute to health care disparities, yet may hesitate to teach about them. A pedagogical model could help faculty structure teaching about health care disparities in the clinical setting, but to our knowledge, none have been adapted for this purpose. In this paper, we adapt an established model, Time-Effective Strategies for Teaching (TEST), to the teaching of health care disparities. We use several case scenarios to illustrate the core components of the model: diagnose the learner, teach rapidly to the learner's need, and provide feedback. The TEST model is straightforward, easy to use, and enables the incorporation of teaching about health care disparities into routine clinical teaching.
A goal of interprofessional clinical learning experiences is to facilitate learning through co-co... more A goal of interprofessional clinical learning experiences is to facilitate learning through co-construction of knowledge in support of patient care. Yet, little is known about knowledge construction processes among health professions students working together to care for patients. Understanding knowledge construction processes can guide health professions educators in the design of interventions to support knowledge construction and high-quality learning in clinical placements. In this article, we describe findings from a proof of concept study that explores the feasibility and utility of using Gunawardena's Interaction Analysis Model (IAM) to evaluate health professions students' knowledge construction processes in clinical placements. The IAM has been used to study knowledge construction processes in computersupported collaborative learning environments, but not in interprofessional education. The IAM describes five phases of knowledge construction -sharing/comparing; exploring dissonance; co-constructing meaning; testing; coming to agreement/applying co-constructed knowledge -each representing a progressively higher-level learning process. Application of the IAM to learner dialogue proved laborintensive but feasible and useful as a research tool to characterize learners' knowledge construction behaviors. Our findings suggest that the IAM warrants further study and may offer a framework to guide the design of clinical placements and analysis of interprofessional learning behaviors.
Background: Increasingly, non-English speaking countries use English as the medium of instruction... more Background: Increasingly, non-English speaking countries use English as the medium of instruction (EMI) to teach academic subjects. This study investigated the challenges and adaptation strategies of teachers and students in an EMI medical education program in China. Methods: Data were collected on EMI and non-EMI students' test performances and student and teacher perceptions of the program. Test scores and survey results were analyzed using SPSS. Focus group transcripts and open-ended comments from surveys were examined using thematic coding. Results: There were no significant differences in admission and graduation test scores for EMI and non-EMI students. Four challenges with the EMI program were identified: (1) insufficient/inappropriate teaching materials, (2) unsatisfactory teaching, (3) inadequate class interactions, and (4) failure to teach medical humanities. To address these challenges, teachers and students used adaptive strategies, such as the use of alternative textbooks, selflearning skills and Chinese language. Conclusions: EMI programs are difficult to initiate, requiring faculty development and institutional support, and student self and peer group learning strategies to be successful. The adaptive strategies employed by both students and teachers offer insights into how other EMI programs might strengthen their implementation.
linical teachers differ from clinicians in a fundamental way. They must simultaneously foster hig... more linical teachers differ from clinicians in a fundamental way. They must simultaneously foster high-quality patient care and assess the clinical skills and reasoning of learners in order to promote their progress toward independence in the clinical setting. 1 Clinical teachers must diagnose both the patient's clinical problem and the learner's ability and skill. To assess a learner's diagnostic reasoning strategies effectively, the teacher needs to consider how doctors learn to reason in the clinical environment. 2-4 Medical students in a classroom generally organize medical knowledge according to the structure of the curriculum. For example, if pathophysiology is taught according to organ systems, then the student's knowledge will be similarly organized, and the recall will be triggered by questions related to specific organ systems or other contextual clues. In the clinical setting, the patient's health and care are the focus. Clinical problems may involve many organ systems and may be embedded in the context of the patient's story and questions. Thus, in the clinical setting, the student's recall of basic science knowledge from the classroom is often slow, awkward, or absent. Only after learners make new connections between their knowledge and specific clinical encounters can they also make strong connections between clinical features and the knowledge stored in memory. 5,6 This report focuses on how clinical teachers can facilitate the learning process to help learners make the transition from being diagnostic novices to becoming expert clinicians.
Background The clinical learning environment (CLE) is a priority focus in medical education. The ... more Background The clinical learning environment (CLE) is a priority focus in medical education. The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review's (CLER) recent addition of teaming and health care systems obligates educators to monitor these areas. Tools to evaluate the CLE would ideally be: (1) appropriate for all health care team members on a specific unit/project; (2) informed by contemporary learning environment frameworks; and (3) feasible/quick to complete. No existing CLE evaluation tool meets these criteria. Objective This report describes the creation and preliminary validity evidence for a Clinical Learning Environment Quick Survey (CLEQS). Methods Survey items were identified from the literature and other data sources, sorted into 1 of 4 learning environment domains (personal, social, organizational, material) and reviewed by multiple stakeholders and experts. Leaders from 6 interprofessional graduate medical education quality...
After successive Liaison Committee on Medical Education accreditation reports that criticized the... more After successive Liaison Committee on Medical Education accreditation reports that criticized the University of California, San Francisco, School of Medicine for lack of instructional innovation and curriculum oversight, the dean issued a mandate for curriculum reform in 1997. Could a medical school that prided itself on innovation in research and health care do the same in education? The authors describe their five-phase curriculum change process and correlate this to an eight-step leadership model.
Introduction: Health professions faculty members often struggle deciding on career paths balancin... more Introduction: Health professions faculty members often struggle deciding on career paths balancing their identities as clinicians, educators, and scholars. Identity formation research has identified three major influences: context, roles, and agency. Identity influences career decisions and, in turn, affects engagement in medical education and faculty development. We designed a single-session workshop to foster educator identity formation. Methods: The workshop varied from 1 to 3 hours. It explored how identity develops and considered how self, role, and context could be shaped to grow and sustain identity. Participants used a handout called Identity Quakes to indicate satisfaction with their support, engagement, and empowerment. The workshop employed direct instruction to provide language and tools to scaffold conversation and self-reflection leading to future plans aligning participants' professional identities and roles with resources to support further development. Results: From 2016 to 2020, we offered the workshop to faculty members from diverse professions, including medicine, nursing, dentistry, physical therapy, and others, on 11 occasions (locally, nationally, and internationally) with audiences of 15-200 participants. At offerings that collected evaluations, the workshop received high ratings of 4.61-4.90 (very good-excellent) on a 5-point scale. Discussion: This single-session workshop is a valuable opportunity to reflect on identity, which faculty members rarely get to do formally. The Identity Quakes handout prompts participants to challenge their assumptions about their professional identities and roles, employ their agency/choice, and consider future career choices.
The One-Minute Preceptor (OMP) model of faculty development is used widely to improve teaching, b... more The One-Minute Preceptor (OMP) model of faculty development is used widely to improve teaching, but its effect on teaching behavior has not been assessed. We aim to evaluate the effect of this intervention on residents' teaching skills. DESIGN: Randomized controlled trial. SETTING: Inpatient teaching services at both a tertiary care hospital and a Veterans Administration Medical Center affiliated with a University Medical Center. PARTICIPANTS: Participants included 57 second-and thirdyear internal medicine residents that were randomized to the intervention group (n = 28) or to the control group (n = 29). INTERVENTION: The intervention was a 1-hour session incorporating lecture, group discussion, and role-play. MEASUREMENTS AND MAIN RESULTS: Primary outcome measures were resident self-report and learner ratings of resident performance of the OMP teaching behaviors. Residents assigned to the intervention group reported statistically significant changes in all behaviors (P < .05). Eighty-seven percent of residents rated the intervention as`u seful or very useful'' on a 1±5 point scale with a mean of 4.28. Student ratings of teacher performance showed improvements in all skills except``Teaching General Rules.'' Learners of the residents in the intervention group reported increased motivation to do outside reading when compared to learners of the control residents. Ratings of overall teaching effectiveness were not significantly different between the 2 groups. CONCLUSIONS: The OMP model is a brief and easy-toadminister intervention that provides modest improvements in residents' teaching skills.
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Papers by David Irby