Conversations with Medical Education – revamp and expansion

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The blog cum discussion board for the leading journal in research in medical education (Medical Education) has undergone a makeover and expansion. The blog will now encompass articles from The Clinical Teacher; the journal for practical application and best practices for teachers of and in clinical practice. Additionally, information from the parent organization of both journals (ASME) will be included.

The reason for this change is to provide added opportunity for the readerships of both journals to interact with each other and spur more ideas that will ultimately lead to better research and better practice in medical and clinical education. You will see a few important features on the blog, including:

  • New title: For those of you who pay attention to detail, you will notice a one-word change in the title of the blog. The web address (URL) remains the same at www.mededucconversations.com, but the title has changed from ‘Conversations with Medical Education’ to ‘Conversations in Medical Education’. The key change from ‘with’ to ‘in’ shows the blog is no longer simply conversations with one journal.
  • New look: The color scheme and layout has changed to reflect the broader coverage of the blog that includes information streaming in from the two journals and ASME.
  • New categories: Blog posts are now organized via a ‘table of contents’ of sorts, that allows you to easily find the type of information you’re looking for. You can still use the Search box in the upper right to search for specific keywords. Categories are listed below.
  1. Article Abstracts: This category links to all blog posts that simply contain the title and abstract of the article in the journal issues.
  2. Comments on articles: This category links to guest blog posts on specific articles in the journals. Guest blog posts are provided by invited authors and the e-Council for the journals on a monthly basis.
  3. Meetings: This category links to posts about virtual meetings, such as journal clubs held via Twitter, and to meetings facilitated by ASME.
  4. Virtual Issues: This category links to posts that draw together articles around a common theme from across multiple issues or volumes within a journal, or across the two journals.

As always, the benefit to you, the reader, is best when you join in active conversation with your colleagues via the ‘Comment’ bubble that is next to the title of every post. Comments are moderated to keep spam and advertisements out of the way, but this should not impede a free flow of ideas around different approaches, clarifying questions, constructive feedback, and sharing of experiences relating to the topics in the post. Go ahead; join the conversation.

Joshua Jacobs, MD

e-Editor

Excellence in clinical teaching: knowledge transformation and development required

To read on journal website, click here.

David M Irby

Context

Clinical teachers in medicine face the daunting task of mastering the many domains of knowledge needed for practice and teaching. The breadth and complexity of this knowledge continue to increase, as does the difficulty of transforming the knowledge into concepts that are understandable to learners. Properly targeted faculty development has the potential to expedite the knowledge transformation process for clinical teachers.

Methods

Based on my own research in clinical teaching and faculty development, as well as the work of others, I describe the unique forms of clinical teacher knowledge, the transformation of that knowledge for teaching purposes and implications for faculty development.

Results

The following forms of knowledge for clinical teaching in medicine need to be mastered and transformed: (i) knowledge of medicine and patients; (ii) knowledge of context; (iii) knowledge of pedagogy and learners, and (iv) knowledge integrated into teaching scripts. This knowledge is employed and conveyed through the parallel processes of clinical reasoning and clinical instructional reasoning. Faculty development can facilitate this knowledge transformation process by: (i) examining, deconstructing and practising new teaching scripts; (ii) focusing on foundational concepts; (iii) demonstrating knowledge-in-use, and (iv) creating a supportive organisational climate for clinical teaching.

Conclusions

To become an excellent clinical teacher in medicine requires the transformation of multiple forms of knowledge for teaching purposes. These domains of knowledge allow clinical teachers to provide tailored instruction to learners at varying levels in the context of fast-paced and demanding clinical practice. Faculty development can facilitate this knowledge transformation process.

Lessons learned in the pursuit of a dream

To read on journal website, click here.

Richard Reznick

Context

The author describes a career in which he combined clinical surgery with the formal study of medical education. In the 1980s, when the author embarked on this career track, it was an uncommon pathway. Over the last 30 years there has been an exponential increase in the number of individuals who have made medical education their principal academic focus. This paper provides examples from the author’s personal story and lessons derived from that experience.

Process

The author outlines his experience of attaining formal training in education and concludes that this training was a foundational element in his pursuit of a career in health education research. The author describes his involvement in the transition from paper and pencil-based tests to performance-based testing in high-stakes examinations. He describes the development of a research centre in health professions education and the establishment of a simulation centre. The author’s experiences in the development of an examination intended to measure technical skills, in the adoption of surgical safety checklists and in the elaboration of a programme in competency-based education are discussed.

Discussion

The author describes several of the lessons learned in the course of his career in medical education. He argues that successful enterprises in scholarship in medicine are almost invariably the product of interdisciplinarity. He describes the power of a joint venture between a university and an academic hospital. He argues that the geographical footprint of an emerging centre is critical. He discusses the importance of graduate studentship in an emerging discipline and enterprise.

Medical education research: a vibrant community of research and education practice

To read on journal website, click here.

Cees P M van der Vleuten

Objectives

Medical education research is thriving. In recent decades, numbers of journals and publications have increased enormously, as have the number and size of medical education meetings around the world. The aim of this paper is to shed some light on the origins of this success. My central argument is that dialogue between education practice (and its teachers) and education research (and its researchers) is indispensable.

Reflections

To illustrate how I have come to this perspective, I discuss two crucial developments of personal import to myself. The first is the development of assessment theory informed by both research findings and insights emerging from implementations conducted in collaboration with teachers and learners. The second is the establishment of a department of education that includes many members from the medical domain.

Conclusions

Medical education is thriving because it is shaped and nourished within a community of practice of collaborating teachers, practitioners and researchers. This obviates the threat of a fissure between education research and education practice. The values of this community of practice – inclusiveness, openness, supportiveness, nurture and mentorship – are key elements for its sustainability. In pacing the development of our research in a manner that maintains this synergy, we should be mindful of the zone of proximal development of our community of practice.

How much evidence does it take? A cumulative meta-analysis of outcomes of simulation-based education

To read on journal website, click here.

David A Cook

Context

Studies that investigate research questions that have already been resolved represent a waste of resources. However, the failure to collect sufficient evidence to resolve a given question results in ambiguity.

Objectives

The present study was conducted to reanalyse the results of a meta-analysis of simulation-based education (SBE) to determine: (i) whether researchers continue to replicate research studies after the answer to a research question has become known, and (ii) whether researchers perform enough replications to definitively answer important questions.

Methods

A systematic search of multiple databases to May 2011 was conducted to identify original research evaluating SBE for health professionals in comparison with no intervention or any active intervention, using skill outcomes. Data were extracted by reviewers working in duplicate. Data synthesis involved a cumulative meta-analysis to illuminate patterns of evidence by sequentially adding studies according to a variable of interest (e.g. publication year) and re-calculating the pooled effect size with each addition. Cumulative meta-analysis by publication year was applied to 592 comparative studies using several thresholds of ‘sufficiency’, including: statistical significance; stable effect size classification and magnitude (Hedges’ g ± 0.1), and precise estimates (confidence intervals of less than ± 0.2).

Results

Among studies that compared the outcomes of SBE with those of no intervention, evidence supporting a favourable effect of SBE on skills existed as early as 1973 (one publication) and further evidence confirmed a quantitatively large effect of SBE by 1997 (28 studies). Since then, a further 404 studies were published. Among studies comparing SBE with non-simulation instruction, the effect initially favoured non-simulation training, but the addition of a third study in 1997 brought the pooled effect to slightly favour simulation, and by 2004 (14 studies) this effect was statistically significant (p < 0.05) and the magnitude had stabilised (small effect). A further 37 studies were published after 2004. By contrast, evidence from studies evaluating repetition continued to show borderline statistical significance and wide confidence intervals in 2011.

Conclusions

Some replication is necessary to obtain stable estimates of effect and to explore different contexts, but the number of studies of SBE often exceeds the minimum number of replications required.

Clinical supervision and learning opportunities during simulated acute care scenarios

To read on journal website, click here.

Dominique Piquette, Maria Mylopoulos and Vicki R LeBlanc

Context

Closer clinical supervision has been increasingly promoted to improve patient care. However, the continuous bedside presence of supervisors may threaten the model of progressive independence traditionally associated with effective clinical training. Studies have shown favourable effects of closer supervision on trainees’ learning, but have not paid specific attention to the learning processes involved.

Methods

We conducted a simulation-based study to explore the learning opportunities created during simulated resuscitation scenarios under different levels of supervision. Fifty-three residents completed a supervised scenario. Residents were randomised to one of three levels of supervision: telephone (distant); in-person after telephone consultation (immediately available), and in-person from the beginning of the simulation (direct). These interactions were converted into 234 pages of transcripts for analysis. We performed an inductive thematic analysis followed by a deductive analysis using situated learning theory as a theoretical framework.

Results

Learning opportunities created during simulated scenarios were identified as belonging to either of two categories, incidental and engineered opportunities. The themes resulting from this framework contributed to our understanding of trainees’ contributions to patient care, supervisors’ influences on patient care, and trainee–supervisor interactions. All forms of supervision offered trainees incidental opportunities for practice, although the nature of these contributions could be affected by the bedside presence of supervisors. Supervisors’ involvement in patient care by telephone and in person was associated with a shift of responsibility for patient care, but represented, respectively, engineered and incidental opportunities for observation. In-person supervisor–trainee interactions added value to observation and created additional opportunities for incidental feedback and engineered practice.

Conclusions

The shift of responsibility for patient care occurred during both direct and distant supervision, and did not necessarily translate into a lack of opportunities for trainee participation and practice.

The power of questions: a discourse analysis about doctor–student interaction

To read on journal website, click here.

Jonne van der Zwet, Anne de la Croix, Laury P J W M de Jonge, Renee E Stalmeijer, Albert J J A Scherpbier and Pim W Teunissen

Context

During clerkships, teaching and learning in day-to-day activities occur in many moments of interaction among doctors, patients, peers and other co-workers. How people talk with one another influences their identity, their position and what they are allowed to do. This paper focuses on the opportunities and challenges of such moments of interaction between doctors and students during a clerkship characterised by short supervisory relationships.

Methods

This study was conducted in a 10-week internal medicine clerkship. Nine students and 10 doctors who worked with these nine students participated by regularly describing moments of interaction, using dictaphones. We performed critical discourse analysis of material sourced from a total of 184 audio diary entries and seven student debriefing interviews to reveal how participants discursively shaped the way they could think, speak and conduct themselves.

Results

The ways in which doctors and students posed and answered questions represented a recurrent and influential feature in the diaries. This Question and Answer dynamic revealed six discourses of Basic Learning Need, Care and Attention, Power Game, Exchange of Currency, Distance, and Equality and Reciprocity. These discourses and the interplay among them revealed both students’ and doctors’ frameworks of needs and expectations in a culturally defined power structure. The interplay among the discourses reflected the ways in which doctor–student interactions afforded meaningful contributions to their medical or educational practice such as in the exchange of authentic professional or personal experience.

Conclusions

By purposefully bringing power structures to the surface, we have addressed the complexity of learning and teaching as it occurs in day-to-day moments of interaction in a clerkship with little continuity in supervision. Both doctors and students should be supported to reflect critically on how they contribute to supervisory relationships with reference to, for example, the ways in which they ask or answer questions.

Effects of free, cued and modelled reflection on medical students’ diagnostic competence

To read on journal website, click here.

Cassio Ibiapina, Sílvia Mamede, Alexandre Moura, Silvana Elói-Santos and Tamara van Gog

Context

Structured reflection while practising the diagnosing of cases has been shown to improve medical students’ learning of clinical diagnosis. The present study investigated whether additional instructional guidance increases the benefits of reflection by comparing the effects of free, cued and modelled reflection on learning.

Methods

Fifty-eight Year 5 and 57 Year 6 medical students participated in a three-phase experiment. During the learning phase, participants diagnosed eight clinical cases under different experimental conditions: free reflection; cued reflection, and modelled reflection. In an immediate test and a delayed test administered 1 week later, they diagnosed new sets of eight different cases, four of which presented diseases they had studied during the learning phase. Learning was measured according to diagnostic accuracy on the cases that involved the four diseases that appeared in all phases.

Results

Repeated-measures analysis of variance (anova) of mean scores for diagnostic accuracy (range: 0–1) showed a significant main effect of experimental condition (p < 0.001), year of training (p = 0.013), and performance moment (p = 0.003), without significant interaction effects. Overall, the modelled reflection group and the cued reflection group did not differ in performance (p = 1.00), but both outperformed the free reflection group (p < 0.001 for both comparisons). Overall performance increased in the delayed test relative to the immediate test (p = 0.004) and to the learning phase (p = 0.03), but did not differ in the latter two phases. Both Year 6 and Year 5 students rated studying examples of reflection as less effortful than either cued or free reflection in the learning phase (p < 0.001 for all comparisons).

Conclusions

Students apparently learn more with less effort by studying correct structured reflection while practising the diagnosing of cases than by reflecting without any instructional guidance. Examples of reflection and cued reflection were more beneficial for learning than free reflection and may represent a useful instructional strategy for clinical teaching.

The ‘missing person’ in roles-based competency models: a historical, cross-national, contrastive case study

To read on journal website, click here.

Cynthia Whitehead, Veronica Selleger, José van de Kreeke and Brian Hodges

Context

The use of roles such as medical expert, advocate or communicator to define competencies is currently popular in health professions education. CanMEDS is one framework that has been subject to great uptake across multiple countries and professions. The examination of the historical and cultural choices of names for roles generates insight into the nature and construction of roles. One role that has appeared in and disappeared from roles-based frameworks is that of the ‘person’.

Methods

In order to examine the implications of explicitly including or excluding the role of the ‘physician as person’ in a competency framework, we conducted a contrastive analysis of the development of frameworks in Canada and the Netherlands. We drew upon critical social science theoretical understandings of the power of language in our analysis.

Results

In Canada, the ‘person’ role was a late addition to the precursory work that informed CanMEDS, and was then excluded from the final set of CanMEDS role names. In the Netherlands, a ‘reflector’ role was added in some Dutch schools and programmes when CanMEDS was adopted. This was done in order to explicitly emphasise the importance of the ‘person’ of the trainee.

Conclusions

In analysing choices of names for roles, we have the opportunity to see how cultural and historical contexts affect conceptions of the roles of doctors. The taking up and discarding of the ‘person’ role in Canada and the Netherlands suggest that as medical educators we may need to further consider the ways in which we wish the trainee as a person to be made visible in the curriculum and in assessment tools.

How do medical students form impressions of the effectiveness of classroom teachers?

To read on journal website, click here.

Luke Rannelli, Sylvain Coderre, Michael Paget, Wayne Woloschuk, Bruce Wright and Kevin McLaughlin

Context

Teaching effectiveness ratings (TERs) are used to provide feedback to teachers on their performance and to guide decisions on academic promotion. However, exactly how raters make decisions on teaching effectiveness is unclear.

Objectives

The objectives of this study were to identify variables that medical students appraise when rating the effectiveness of a classroom teacher, and to explore whether the relationships among these variables and TERs are modified by the physical attractiveness of the teacher.

Methods

We asked 48 Year 1 medical students to listen to 2-minute audio clips of 10 teachers and to describe their impressions of these teachers and rate their teaching effectiveness. During each clip, we displayed either an attractive or an unattractive photograph of an unrelated third party. We used qualitative analysis followed by factor analysis to identify the principal components of teaching effectiveness, and multiple linear regression to study the associations among these components, type of photograph displayed, and TER.

Results

We identified two principal components of teaching effectiveness: charisma and intellect. There was no association between rating of intellect and TER. Rating of charisma and the display of an attractive photograph were both positively associated with TER and a significant interaction between these two variables was apparent (p < 0.001). The regression coefficient for the association between charisma and TER was 0.26 (95% confidence interval [CI] 0.10–0.41) when an attractive picture was displayed and 0.83 (95% CI 0.66–1.00) when an unattractive picture was displayed (p < 0.001).

Conclusions

When medical students rate classroom teachers, they consider the degree to which the teacher is charismatic, although the relationship between this attribute and TER appears to be modified by the perceived physical attractiveness of the teacher. Further studies are needed to identify other variables that may influence subjective ratings of teaching effectiveness and to evaluate alternative strategies for rating teaching effectiveness.