kazakhstan health technology transfer and institutional reform project workshop: clinical teaching...
TRANSCRIPT
Kazakhstan Health Technology Transfer and Institutional Reform Project
Workshop: Clinical teaching using innovative technologies
Henry Averns
Kazakhstan Health Technology Transfer and Institutional Reform Project
Today
• Developing roles for a Standardized patient program
Tomorrow
Wednesday
• Communication skills course design• Introduction to a Standardized patient program
• How to run an OSCE
Kazakhstan Health Technology Transfer and Institutional Reform Project
Yesterday’s doctors
What does the graduate know?
Syllabus-basedSyllabus-basedcurriculumcurriculum
Syllabus-basedSyllabus-basedcurriculumcurriculum
Kazakhstan Health Technology Transfer and Institutional Reform Project
Tomorrow’s Doctors
What can the graduate do?
Outcome-basedOutcome-basedcurriculumcurriculum
Outcome-basedOutcome-basedcurriculumcurriculum
Kazakhstan Health Technology Transfer and Institutional Reform Project
The basic requirements
Scientific method
Scientific method
AttitudesAttitudesSkillsSkills
KnowledgeKnowledge
Basic science
Behavioural science
Clinical science
Population science
Clinical skillsCommunication
skills
Understanding
Application
ProfessionalEthical
Interprofessional
Kazakhstan Health Technology Transfer and Institutional Reform Project
Adults• Have a specific purpose in mind• are voluntary participants in learning• require meaning and relevance• require active involvement in learning• need clear goals and objectives• need feedback• need to be reflective
Kazakhstan Health Technology Transfer and Institutional Reform Project
Adults• Have a specific purpose in mind• are voluntary participants in learning• require meaning and relevance• require active involvement in learning• need clear goals and objectives• need feedback• need to be reflective
Kazakhstan Health Technology Transfer and Institutional Reform Project
Adults• Have a specific purpose in mind• are voluntary participants in learning• require meaning and relevance• require active involvement in learning• need clear goals and objectives• need feedback• need to be reflective
Kazakhstan Health Technology Transfer and Institutional Reform Project
Changes in method of teaching over last 20 years
PassiveDidactic
Sequential
ActiveSelf directedContextual
Large group Small groups
Kazakhstan Health Technology Transfer and Institutional Reform Project
Principle 1: IntegrationVertical integration = across
yearsVertical integration = across
years
Horizontal integration = between subjects
Horizontal integration = between subjects
Kazakhstan Health Technology Transfer and Institutional Reform Project
Traditional Curriculum
Biologicalsciences
Biologicalsciences
ClinicalstudiesClinicalstudies
Behavioural science
Behavioural science
Kazakhstan Health Technology Transfer and Institutional Reform Project
Revised curriculum
Basic sciencesBasic sciences
Clinical studiesClinical studies
Kazakhstan Health Technology Transfer and Institutional Reform Project
Principle 2: Logical Progression
Material should be presented in a logical order which is discernable by the students
Material should be presented in a logical order which is discernable by the students
Kazakhstan Health Technology Transfer and Institutional Reform Project
Principle 3: Planned Repetition
“Spiral curriculum”
Kazakhstan Health Technology Transfer and Institutional Reform Project
Definition of clinical skills • Clinical skills refer to the skills required for a clinician to manage a
complete patient encounter. These include
o Communication skills to allow a clinician to take a thorough history, and also to understand the patient’s experience of illness, negotiate management plans etc.
o Physical examination skills
o Clinical reasoning skills, including data gathering and interpretation; development of a differential diagnosis and the ability to synthesize this data into a management plan appropriate to the individual patient
o Technical (procedural) skills relevant to diagnosis and management
o All of the above skills require underlying foundational medical expert knowledge
Kazakhstan Health Technology Transfer and Institutional Reform Project
How to teach communication skills – lessons from the evidence
• Systematic definition of the skills
• observation of learners
• video or audio recording and review
• well-intentioned feedback
• rehearsal
• active small group learning
Kazakhstan Health Technology Transfer and Institutional Reform Project
In groupsPlease discuss for 10 minutes
• When do you start teaching clinical communication skills?
• What resources do you use ?
• Please be prepared to share this
Kazakhstan Health Technology Transfer and Institutional Reform Project
What experiential material is available to you?
• videos of real consultations
• real patients
• simulated patients
• role-play
Kazakhstan Health Technology Transfer and Institutional Reform Project
The Communication Curriculum at Queens
The Calgary Cambridge Model
Kazakhstan Health Technology Transfer and Institutional Reform Project
Defining objectives• AFMC Clinical skills document• Medical School’s own curriculum• LMCC objectives
• You will have similar objectives
Kazakhstan Health Technology Transfer and Institutional Reform Project
Resource constraints
TimeTime
SpaceSpaceMoneyMoney
PeoplePeople
Kazakhstan Health Technology Transfer and Institutional Reform Project
Course Design• The course is based around 10 groups each
made up of 10 students and 2 tutors
• It runs for a half day per week for two years
Kazakhstan Health Technology Transfer and Institutional Reform Project
Year 1• Term 1• Introduction to Interviewing• Beginning the Interview• History of the Present Illness & Questioning &
Listening• The Patient's Perspective• Completing the History and Putting it all
Together
Kazakhstan Health Technology Transfer and Institutional Reform Project
Term 1 (continued)• Vital Signs and Routine Practices• General Appearance, ENT and Lymph Nodes• Examination of the Thyroid
Mid-Term Formative Assessment
• Cardiac Examination• Respiratory Examination • Abdominal Examination • Breast and Axilla Examination• History Taking and Presenting an Oral Report • Review of Skills Learned during the Term
• Student Assessment and Course Evaluations
Kazakhstan Health Technology Transfer and Institutional Reform Project
• Faculty-delivered lecture (30 – 45 minutes) flowed by tutor-led small group learning.
• Tutor resources:– A dedicated website– A resource manual– A term schedule which includes a description of
each session– The physical examination manual
Kazakhstan Health Technology Transfer and Institutional Reform Project
Term 2• Neurological exam• Cranial nerves• Ophthalmology• MSK• Sexual history
• Pediatric sessions (x2)• Technical skills (x2)
Kazakhstan Health Technology Transfer and Institutional Reform Project
Also in Term 2• Students conduct full history and physical
examination with a standardised patient or real patients
Kazakhstan Health Technology Transfer and Institutional Reform Project
Year 2• The main objectives of year two include:
Development of clinical reasoning
Education of patients about disease and medication
Difficult conversations eg breaking bad news
Written reports
Oral reporting
Kazakhstan Health Technology Transfer and Institutional Reform Project
Term 3• Introduction to clinical reasoning (x3)
• Technical skills (x2). Suturing, catheter
• Patient education session
• Findings in real patients
• Simulated patient full history and physical
• Community hospital full hx an px
• Emergency Room visit
Kazakhstan Health Technology Transfer and Institutional Reform Project
Term 4 • Technical skills (x2) : Chest tube, blood gases, IVI
insertion• Mini OSCE • Pediatrics – neonatal examination• Real patient findings • Community hospital full history and physical• Clinical education Centre history and physical with
simulated patients• Breaking bad news session• Male genital examination
Kazakhstan Health Technology Transfer and Institutional Reform Project
• We will discuss some of these specific sessions this week when we talk about simulated patients
Kazakhstan Health Technology Transfer and Institutional Reform Project
In groups• Discuss the different assessment methods you
currently use, and their strengths and weaknesses.
• Be prepared to share this
Kazakhstan Health Technology Transfer and Institutional Reform Project
Course Assessment• Assessment Term 1
• Student self assessment week one, mid term, end of term• Tutor formative assessment mid term (downloadable forms)• Tutor final assessment• 4 “individual assessments” all mandatory and summative
– Basic hx assessed by Standardised patients (SPs)– BP, pulses, and lymph nodes assessed by nurses– Cardiac hx and px assessed by Residents and SPs– Respiratory hx and px assessed by Residents and SPs
Kazakhstan Health Technology Transfer and Institutional Reform Project
Assessment Term 2
• Early, Mid and Final tutor assessments as for Term 1
• Formative OSCE – no contribution to final score
• Final OSCE
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Calgary Cambridge Communication Framework
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What I will discuss• What is the Calgary Cambridge Approach?• The guides• Agreeing what we are trying to teach in
Communication
Kazakhstan Health Technology Transfer and Institutional Reform Project
Can communication skills be taught?Can communication skills be taught?
communication is a clinical skill
it is a series of learnt skills
experience alone is a poor teacher
Kazakhstan Health Technology Transfer and Institutional Reform Project
Can communication skills be taught?Can communication skills be taught?
there is conclusive evidence that communication skills can be taught
and that communication skills teaching is retained
Kazakhstan Health Technology Transfer and Institutional Reform Project
Methods of teaching communicationMethods of teaching communication• traditional lectures/interactive lectures + exercises• paper exercises• Video demonstrations
Consultations with simulated patientsConsultations with real patientsPatients stories of the illnesses
• web-based/e-learning• clinic/ward teaching with real patients • Visits to patient’s homes/ITU/ward/old peoples’ homes etc
Kazakhstan Health Technology Transfer and Institutional Reform Project
Traditional Medical History
• Chief complaint
• History of the present complaint
• Past medical history
• Family history
• Personal and social history
• Drug and allergy history
• Functional enquiry
Kazakhstan Health Technology Transfer and Institutional Reform Project
Why do we need a framework?• Effective history taking is essential to the
practice of high quality medicine
• This requires excellent communication skills
Kazakhstan Health Technology Transfer and Institutional Reform Project
The Interview is Our Main Diagnostic Tool
• 60-80% of medical diagnoses are made after the interview alone
• The interview determines the physical exam and investigations
Kazakhstan Health Technology Transfer and Institutional Reform Project
The Disease - Illness Model
Gathering InformationGathering Information
Patient Presents ProblemPatient Presents Problem
Parallel Search of Two Frameworks
Parallel Search of Two Frameworks
IdeasConcerns
ExpectationsFeelings
Effects on life
Understand the patient’s unique
experience of illness
IdeasConcerns
ExpectationsFeelings
Effects on life
Understand the patient’s unique
experience of illness
The Patient’s PerspectiveThe Patient’s PerspectiveThe Biomedical Perspective The Biomedical Perspective
SymptomsSigns
InvestigationsUnderlying Pathology
Differential Diagnosis
SymptomsSigns
InvestigationsUnderlying Pathology
Differential Diagnosis
Integration of the two frameworks Collaborative explanation and planning:
shared understanding and decision making
Integration of the two frameworks Collaborative explanation and planning:
shared understanding and decision making
Kazakhstan Health Technology Transfer and Institutional Reform Project
ProvidingStructure
Initiating the Session
Closing the Session
Physical Examination
Explanation and planning
Gathering information
Building the relationship
Kazakhstan Health Technology Transfer and Institutional Reform Project
Providing
Structure
Initiating the Session
preparation
establishing initial rapport
identifying the reason(s) for the consultation
providing the correct amount and type of information
aiding accurate recall and understanding
achieving a shared understanding: incorporating the patient’sillness framework
planning: shared decision making
Closing the Session
Building therelationship
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Gathering information
Physical examination
Explanation and planning
making organisation overt
attending to flow
• exploration of the patient’s problems to discover the:
biomedical perspective the patient’s perspective
background information - context
• ensuring appropriate point of closure• forward planning
using appropriate non-verbal behaviour
developing rapport
involving the patient
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•
Kazakhstan Health Technology Transfer and Institutional Reform Project
REVISED CONTENT GUIDE TO THE MEDICAL INTERVIEW Patient's Problem List Exploration of Patient's Problems Medical Perspective – disease Patient's Perspective - illness Sequence of events Ideas and beliefs Symptom analysis Concerns Relevant systems review Expectations Effects on life Feelings Background Information - Context Past Medical History Drug and Allergy History Family History Personal and Social History Review of Systems Physical Examination Differential Diagnosis - Hypotheses Including both disease and illness issues Physician's Plan of Management Investigations Treatment alternatives Explanation and Planning with Patient What the patient has been told Plan of action negotiated
Kazakhstan Health Technology Transfer and Institutional Reform Project
The following slides are also in the handout provided
Kazakhstan Health Technology Transfer and Institutional Reform Project
INITIATING THE SESSION• ESTABLISHING INITIAL RAPPORT• 1. Greets patient and obtains patient’s name • 2. Introduces self, role and nature of interview; obtains consent if necessary
• 3. Demonstrates respect and interest, attends to patient’s physical comfort • Identifying the reason(s) for the consultation• 4. Identifies the patient’s problems or the issues that the patient wishes to address with
appropriate opening question (e.g. “What problems brought you to the hospital?” or “What would you like to discuss today?”)
• 5. Listens attentively to the patient’s opening statement, without interrupting or directing patient’s
response • 6. Confirms list and screens for further problems (e.g. “so that’s headaches and tiredness; anything
else……?”) • 7. Negotiates agenda taking both patient’s and physician’s needs into account
Kazakhstan Health Technology Transfer and Institutional Reform Project
Identifying the Reason(s) for the Visit
• (“Why are you here, today?”)• Begin with an open-ended question • Listen attentively, without interruption, to the
patient’s opening statement • Confirm and screen for more problems • Negotiate an agenda for the visit
Kazakhstan Health Technology Transfer and Institutional Reform Project
Establishing All the Reasons
• “Is there anything else ....we need to take care of today?....that concerns you today?”
• Patients have an average of 3.6 problems
• In 34/51 visits the doctor interrupted after the first complaint
• In 94% of interviews, after an interruption the patient stopped volunteering information
Kazakhstan Health Technology Transfer and Institutional Reform Project
Negotiating the Agenda
• • Establish an agenda that respects your and the patient’s priorities for the encounter:
• “It sounds as though you have several problems but it seems the most important one to you is the arthritis...However, the chest pain sounds concerning to me ...shall we focus on those two today?”
Kazakhstan Health Technology Transfer and Institutional Reform Project
Sacred” 7 Characteristics of a Symptom (Morgan and Engel)
• location: site and radiation• quality or character• quantity or severity • chronology: onset, duration, frequency• setting or circumstances in which it occurs• aggravating and alleviating factors• associated manifestations
Kazakhstan Health Technology Transfer and Institutional Reform Project
Open-ended Questions• Can you tell me what happened?• “What was that like?”• “Would you tell me about the pain from the
beginning?”
Kazakhstan Health Technology Transfer and Institutional Reform Project
Benefits of Open-ended Questions• Contribute to better early diagnostic reasoning• Helps identify the illness framework• Leads to more efficient explanation and
planning• Give the clinician time to think and listen• Establishes the patient’s role as a partner in the
interaction
Kazakhstan Health Technology Transfer and Institutional Reform Project
Habits to Avoid• The leading question: – “You don’t have any
chest pain do you?”• The multiple question: – “Do you have pins
and needles, a rash or diarrhea?”
Kazakhstan Health Technology Transfer and Institutional Reform Project
GATHERING INFORMATION
• Exploration of patient’s problems
• 8. Encourages patient to tell the story of the problem(s) from when first started to the present in own words (clarifying reason for presenting now)
• 9. Uses open and closed questioning technique, appropriately moving from open to closed
• 10. Listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing
• 11. Facilitates patient's responses verbally and non–verbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation
• 12. Picks up verbal and non–verbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate
• 13.Clarifies patient’s statements that are unclear or need amplification (e.g. “Could you explain what you mean by light headed")
• 14. Periodically summarises to verify own understanding of what the patient has said; invites patient to correct interpretation or provide further information.
• 15. Uses concise, easily understood questions and comments, avoids or adequately explains jargon
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17. Actively determines and appropriately explores: patient’s ideas (i.e. beliefs re cause) patient’s concerns (i.e. worries) regarding each problem patient’s expectations (i.e., goals, what help the patient had expected for each problem) effects: how each problem affects the patient’s life
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PROVIDING STRUCTURE • Making organisation overt
• 19. Summarises at the end of a specific line of inquiry to confirm understanding before moving on to the next section
• 20. Progresses from one section to another using
signposting; includes rationale for next section • Attending to flow• 21. Structures interview in logical sequence
• 22. Attends to timing and keeping interview on task
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Building The Relationship• See Handout
Kazakhstan Health Technology Transfer and Institutional Reform Project
• Non-verbal behaviourNon-verbal behaviour
• 22. Demonstrates 22. Demonstrates appropriate non–verbal behaviourappropriate non–verbal behaviour e.g. eye contact, posture & position, e.g. eye contact, posture & position, movement, facial expression, use of voice movement, facial expression, use of voice
• 23. If reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or 23. If reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or rapportrapport
• Developing rapportDeveloping rapport
• 24. Acknowledges patient's views and feelings; accepts legitimacy; is not judgmental24. Acknowledges patient's views and feelings; accepts legitimacy; is not judgmental
• 25. Uses 25. Uses empathyempathy to communicate understanding and appreciation of the patient’s feelings or to communicate understanding and appreciation of the patient’s feelings or predicament predicament
• 26. Provides support: expresses concern, understanding, willingness to help; acknowledges coping 26. Provides support: expresses concern, understanding, willingness to help; acknowledges coping efforts and appropriate self care; offers partnership efforts and appropriate self care; offers partnership
• 27. Deals sensitively with embarrassing and disturbing topics and physical pain, including when 27. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examinationassociated with physical examination
• Involving the patientInvolving the patient
• 28. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now 28. Shares thinking with patient to encourage patient’s involvement (e.g. “What I’m thinking now is.......”)is.......”)
• 29. Explains rationale for questions or parts of physical examination that could appear to be non-29. Explains rationale for questions or parts of physical examination that could appear to be non-sequitors sequitors
• 30. During physical examination, explains process, asks permission 30. During physical examination, explains process, asks permission
Kazakhstan Health Technology Transfer and Institutional Reform Project
Explanation and planning-Broken down into four sub-sections;
1. Providing the correct amount and type of information.
2. Aiding accurate recall & understanding.3. Achieving a shared understanding:
incorporating the patient’s perspective.4. Planning: shared decision making.
Kazakhstan Health Technology Transfer and Institutional Reform Project
1. Providing the correct amount and type of informationAims; to give comprehensive and appropriate information
for individual patients; to neither restrict or overload • Chunks and checks• Assesses patient’s starting point• Asks patient what other information would be
helpful• Gives explanation at appropriate times
Kazakhstan Health Technology Transfer and Institutional Reform Project
2. Aiding accurate recall and understandingAims; To make information easier for the patient to remember and
understand
• Organises explanation.• Uses explicit categorisation or signposting e.g. there are three
important things I would like to discuss• Uses repetition and summarising• Clarity• Uses visual methods if appropriate• Checks patients understanding of information given or plans
made
Kazakhstan Health Technology Transfer and Institutional Reform Project
3. Achieving a shared understanding: incorporating the patient’s perspective.Aims; Encourage interaction, incorporate patients
perspective, thoughts and feelings.
• Relates explanations to patient’s illness framework.• Provides opportunities and encourages patient to
contribute• Picks up verbal and non-verbal cues• Elicits patient’s beliefs, reactions and feelings
Kazakhstan Health Technology Transfer and Institutional Reform Project
4.Planning: shared decision makingAims; Involve patients in decision making if they wish, increase
patient understanding and commitment
• Shares own thoughts, ideas, dilemmas• Involve patient by making suggestions rather than directives• Encourages patient to contribute their thoughts• Negotiates• Offers choices• Checks with patient
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CLOSING THE SESSION (PRELIMINARY EXPLANATION & PLANNING)
• 33. Gives any preliminary information in clear well organised manner, avoids or explains jargon
• 34. Checks patient understanding and acceptance of explanation and plans; ensures that concerns have been addressed
• 35. Encourages patient to discuss any additional points and provides opportunity to do so (eg. “Are there any questions you’d like to ask or anything at all you’d like to discuss further?”)
• 36. Summarises session briefly • 37. Contracts with patient re next steps for patient and physician
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In groups• What Issues Have you Come across with
students’ history taking?
• In groups discuss common areas where students could improve and then we will discuss them
Kazakhstan Health Technology Transfer and Institutional Reform Project
Specific Challenges• culture and social diversity • gender • dealing with emotions• age related issues – the elderly, children• the three way interview • breaking bad news• the sexual history• the psychiatric interview• the telephone interview• low literacy patients • sensory impaired patients• death and dying, bereavement• complaints• ethics • health promotion and prevention
Kazakhstan Health Technology Transfer and Institutional Reform Project
How to Teach Communication Skills• systematic delineation and definition of the
skills
• observation of learners
• video or audio recording and review
• feedback
• rehearsal
• active small group or 1:1 learning
Kazakhstan Health Technology Transfer and Institutional Reform Project
Key concept is integrationa. integration with history taking skillsb. integration with practical skillsc. integration with specialty teachingd. integration with medical records and presentationse. integration with the hidden curriculumf. the crucial role of assessment in integration
Kazakhstan Health Technology Transfer and Institutional Reform Project
• What challenges do you face when integrating your courses?
Kazakhstan Health Technology Transfer and Institutional Reform Project
In groups• Discuss either a positive or a negative
experience you or a friend has had with the medical profession
• Are there any themes here?
Kazakhstan Health Technology Transfer and Institutional Reform Project
What experiential material is available to you?What experiential material is available to you?
• videos of consultations with either a real patient or a simulated patient
• direct observation with consultations with real patients
• role-play with simulated patients
Kazakhstan Health Technology Transfer and Institutional Reform Project
Disadvantages of real patients
Rehearsal
Improvisation: not ‘emotionally’ real in this repeat situation
Standardization
Customisation
Specific issues and difficult situations
Availability – restricted types of patients
Time efficiency
Feedback
Facilitation, instruction and evaluation
Kazakhstan Health Technology Transfer and Institutional Reform Project
Advantages of simulated patients
Rehearsal
Improvisation
Standardization
Customisation
Specific issues and difficult situations
Availability
Time efficiency
Feedback
Facilitation, instruction and evaluation
Kazakhstan Health Technology Transfer and Institutional Reform Project
Challenges of of using simulated Challenges of of using simulated patientspatients
• Expense• Selection• Hidden agendas• Administrative time• Training
– understanding how patients behave– understanding how to give feedback
Kazakhstan Health Technology Transfer and Institutional Reform Project
Training actorsTraining actorsan actor needs:• to respect and be empathic with students, putting
himself in their shoes• to be committed to helping students to improve their
consultation skills• to be committed to being part of the teaching team
Kazakhstan Health Technology Transfer and Institutional Reform Project
• to be disciplined, reliable and to behave professionally at all times
• to be able to focus on the interview process and identify skills used or missing
• to be flexible with individual students and to be able to improvise
• to give appropriate, accurate, sensitive and constructive feedback
Kazakhstan Health Technology Transfer and Institutional Reform Project
• to be able to reward students for demonstrating empathy, open questions, picking up cues and giving the patient time to think, by disclosing more information
• to be familiar with and committed to the theoretical basis for the teaching (the Calgary-Cambridge approach)
• to be familiar with the roles he or she is asked to play
Kazakhstan Health Technology Transfer and Institutional Reform Project
When working with a facilitatorthe actor must:• work very closely with the facilitator and
anticipate his or her needs• move in and out of role appropriately when
asked• give feedback as directed by the facilitator
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Group work • Tables 1 and 2
– recruiting SPs– where from, – demographics– retention– payment
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• Tables 3 and 4– facilities needed to run an SP program;
– staff, – space, – trainers, – cost
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Discussion:
• Barriers to the use of SPs in the curriculum
Kazakhstan Health Technology Transfer and Institutional Reform Project
Please review the role development guideline I have provided for
tomorrow’s work
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Finally• Educational media
• Resource manuals
• Faculty Development
• Feedback
Kazakhstan Health Technology Transfer and Institutional Reform Project
Teaching the teachersTeaching the teachers
Three agendas for facilitators:•Enhancing their own communication skills•Increasing their knowledge base about communication skills theory and research•Enhancing their teaching and facilitation skills
Kazakhstan Health Technology Transfer and Institutional Reform Project
Ongoing support for facultyOngoing support for faculty
• tel/email support• web site - with theory, teaching plans, videos
of teaching etc• observation and feedback, individual and
group teaching either at regular facilitation training days or locally