New Horizons in Medical Education
November , 2015 Weill Cornell Medicine - Qatar A Year in Review: Updates on the Literature in Medical Education
Dora J. Stadler MD, FACP New Horizons in Medical Education November 20-21, 2015 As an employee of Weill Cornell Medicine in Qatar, I am committed to providing transparency for any and all external relationships prior to giving an academic presentation Dora J Stadler DOES NOT have a financial interest in commercial products or services Goals and Objectives 1. Highlight updates/innovative ideas in medical education across the continuum 2. Provide references and a base for further research into relevant topics Overview I.Updates from curricular redesign to faculty characteristics II.Historical highlights s to regional faculty---- Insert journal covers here How this review was assembled
Include a breadth of topics and formats Address locally relevant topics The undergraduate experience
Photo Credit: Dr Fouad Otaki The undergraduate experience Curricular reform- Integration
Problem- Separation of basic science and clinical components weakens transfer of knowledge to practical context students unmotivated to learn information seemingly disconnected from practical setting (Hopkins, et al.) Targeted problem identification (Hopkins et al., Acad Med, 2015) cyclical problem of recommending but not truly achieving integration Traditional approach focus on level of curricular structure The undergraduate experience Curricular reform
Educational Literature Importance of focus on individual teachers Application to medical education Voices of the basic scientist in the literature Approaches Basic Faculty (Haramati, Acad Med, 2015) faculty development Struggles of individual educators foster community of medical educators across departments and schools align institutional priorities Consider challenge of continued basic science integration in clinical years The undergraduate experience PBL
The Problem Keep PBL engaging Targeted Problem Identification While initial PBL session is exciting, full of discussion, repeat session is mainly reporting with only passive learning taking place Students less motivated by PBL by second year The undergraduate experience PBL The undergraduate experience PBL Caffeination
Self Determination Theory Humans are intrinsically motivated as long as psychological need of autonomy, competence, relatedness are fulfilled Active Learning Theory Keeping students mentally and potentially physically active in learning process help incorporate into long term memory The undergraduate experience PBL Caffeination
Learning theories used to frame innovations for second session PBLs Patient centered Multiple short vignettes Choose your own outcome Milestone cases (final case with SP and FU with SP) Professional roundtable Video and standardized patient Team centered Debate Compare and contrast diseases Pre-return session blogging Example of PBL innovation
Choose your own outcome Patient Centered Innovation Autonomy Competence Relatedness Strong Moderate Act as MD, make Rx decisions Discover consequences of decisions Connection with paper case patient The undergraduate experience Breathing life into PBL
McLean et al. (Medical Teacher, 2015) added student led virtual sessions for more mature students Published in: Michelle McLean; Victoria Brazil; Patricia Johnson; Medical Teacher 2014, 36, Copyright 2014 Informa UK Ltd. All rights reserved: reproduction in whole or part not permitted Figure 1. (a) Main menu (dashboard) of the App to access virtual patients. (b) Main menu for an individual patient (c) Vitals for an individual patient. Flipping the classroom
Background article by Prober and Khan (Acad Med, 2013) Figure from Prober, CG. Khan S. Medical Education Reimagined: A Call to Action. Academic Medicine. 2013;88: Flipping the classroom Flipping the classroom What do students think?
2 articles from Eshelman School of Pharmacy, NC Themes from Khanova et al. (Med Ed, 2015) Greater emphasis on understanding, application Need for better implementation More time to process information, but increased workload Instructor role McLaughlin (Acad Med, 2015) Encouraged student engagement Difference in final exam grades No significant difference on overall course evaluation Figure from McLaughlin et al. The Flipped Classroom: A Course Redesign to Foster Learning an Engagement in a Health Professions School. Academic Medicine 2014:89: The undergraduate experience Longitudinal patient experiences
Advantage of working with patients in multiple points in time, across various clinical settings and phases of illness The Problem Difficulty of tracking/following patients over time Innovation Pilot by Elmore et. al, to build an extension to an existing notification system Outcome Students picked up about 20 patients in their clerkships and followed them (3-5 active at a time); The undergraduate experience The longitudinal standardized patient
Problem New time restrictions, optimize time for communication Innovation Kodner et al. (Acad Med, 2015), restructured Clinical Medicine course to base it on each student being assigned to 1 standardized patient (15/19 encounters with same patient) Longitudinal SP profiles
From Kodner, Charles MD;Bohnert, Carrie MPA .The Longitudinal Standardized Patient Project:Innovation From Necessity. Academic Medicine. 90(3): , March 2015. Graduate Medical Education GME Learning- Morning Report
Report on restructuring morning report by Dousa et al (JGME, 2014) Problem Current format of morning report was not necessarily best tailored to learners needs Pre-intervention survey 93% of residents indicated some level of disinterest Management plans addressed in < of case discussions GME Learning- Morning Report
Reorganized morning report based on recommendations Post-intervention survey 77% found morning report interesting/very interesting, 23% reported no change Content recommendations Structure/Format/Speaker Case management focus (92%) Invitation of specialists (96.5%) Diagnostic workup discussion (79%) Change of presentation team (67%) Lit review, research methods (62%) Reduce judgmental supervision (57.4%) Discuss tests, procedures (61%) GME International Perspective- Transition to competency based medical education
Ibrahim et al. (BMC Med Ed, 2015) report on transition in pediatrics programs in Abu Dhabi struggling with residency program recruitment, retention and low Arab Board pass rates CBME with a focus on 6 areas Early Outcomes Faculty development Focus on ambulatory training Assessment (for growth) Collaboration Teamwork Continuum of medical education Program Hospital (correlation) 0 applicants 12 recruited (out of 96) Decreased number of adverse events Arab Board pass rates Decreased length of stay GME- Quality Improvement Projects
Problem Need to facilitate learners acquisition of quality improvement competencies Curricular Innovation Barber et al. (Acad Med, 2015) built/restructured a 1 year QI curriculum to have residents better evaluate, analyze and improve the QI system GME-Quality Improvement Project
Engaging Understanding Improving/Translating GME- Patient Safety Handoffs
Problem Miscommunication, omissions during handoffs are a leading cause of errors Goal Improve patient handoffs and thereby patient safety INTERVENTION (Starmer et al., NEJM, 2015) I-PASS BUNDLE I-PASS Bundle 7 components
Structure integrated into written and oral handoff I Illness severity P Patient Summary A Action List S Situation Awareness/Contingency Plans Synthesis by receiver Ipass mnemonic 2 hour workshop 1 hour simulation session Computer module ofr independent leanring Faculty development program Direct observation tools for faculty to be used Process change culture campaign (exercises workshop/simulation on mededportal), details of development in 2014 Academic medicine, pediatrics Integration into EMR 7/9 sites, into GME- Patient Safety Medical Errors Preventable Adverse Events
23% relative reduction (24.5->18.8/100 admissions, p< .001) Preventable Adverse Events 30% relative reduction (4.7-> 3.3/100 admissions, p< .001) From Starmer et al. Changes in Medical Errors after Implementation of a Handoff Program. NEJM. 2014;371(19): Student/Trainee Performance- The role of the Step 1 exam
Commentary by Prober et al. (Acad Med, 2015) Reliance of PDs on the Step 1 scores Overwhelming number of applications Difficult to compare students due to variations in curricula/assessment Burden of the USMLE Step1 on students Changes in specialty goals based solely on USMLE1 score Contributes to stress/burnout in medical students Distortion among competencies Recommendation Standardized modes of assessment and reporting in clinical rotations Study of characteristics that predict success in residency Holistic view of candidates Student/Trainee Performance- Performance of the Step 2 Exam
Holtzman et al. (Acad Med, 2015) look at country to country differences in Step 2 scores Data collected from , from 88,692 first time test takers (54,955 US, 33,737 outside US) US pass rates 97%, mean score 232 (SD 22) IMGs Clinical Discipline -Generally lower scores in psychiatry, higher in surgery, comparable in medicine, obgyn, and pediatrics Clinical Task- Generally higher scores in mechanism of disease and lower scores in preventive medicine/health maintenance BUT Student/Trainee Performance on Step 2 CK
230 227 223 222 221 209 200 232 -2.1 -3.9 -5.2 -4.8 -5.3 -6.1 -8.9 -12.6 Adapted from Holtzman et alInternational Variation in Performance by Clinical Discipline and Task on the United States Medical Licensing Examination Step 2 Clinical Knowledge Component. Academic Medicine. 2014;89(11): , Medical Educator Faculty
"Medical Education Is the Ugly Duckling of the Medical World Qualitative study by Sabel et al. (Acad Med 2014) by the early Careers working Group of the Academy of Medical Educators (AoME) Themes Professional Identity dual identity crisis, linked more to primary identity than education Social Categorization- struggle to identify with medical educator group because did not have a clear picture of what a medical educator is, debate over qualifications Social Identity- dont identify with this group due to poor recognition, unclear career structure Developing identity- encouraging comment re recent developments, networking as an enabling factor, importance of networking No emotional attachment to medical education, roles more operational Medical Educators International Perspectives
Qualitative pilot study by McLean et al. (2014) looking at medical educators working abroad in the Middle East, followed by quantitative survey (McLean et al., 2015) Quantitative study describes group of 89 international medical educators as global citizens 76% speaks more than one language, 16% four or more 58% completed graduate/postgraduate training outside country of birth about 50% had worked in 1-2 countries outside of home country Medical Educators-International Perspectives
From McLean et al. Medical educators working abroad: A pilot study of educators experiences in the Middle East. Medical Teacher 2014, 36: Medical Educators International Perspective Who are international clinician educators in these programs?
Majority (74.2%) men, aged (57.7%), married (85%) While most attended medical school outside North America/Europe, 41.7% completed residency and 64.3% received fellowship training in North America or Europe 39% of CE were in educational leadership role 81.1% held no appointment or were at academic rank of assistant professor of lower junior status of CEs Self-ratings of Competence Accreditation Challenges
WORTHWHILE Leaders: Too many demands on faculty time Too many bureaucratic procedures Inadequate support from stakeholders outside the institution CEs: Too few non-physician manpower/support staff From Archuleta et al. Perceptions of Leaders and Clinical Educators on the Impact of International Accreditation. Acad Med. 2015;90:S83-90 Satisfaction 87% were totally satisfied or satisfied in their current position 46% extremely likely to remain in academic medicine in the next 5 years Marginal positive correlation (of both outcomes) with spending at least 50% of time in teaching activities Staying in academic medicine had negative correlation with being a PD/APD (aOr .42, 95% CI ) Take home points Generally CEs are satisfied With educational scholarship as a distinguishing feature of CEs and less competence in educational research- additional training is needed here Historical Highlights in Medical Education
That a formal plan is necessary for resident teaching, seems, at the outset somewhat questionable Historical Highlights in Medical Education
Review by Azer et al. (Acad Med, 2015) What type of articles have been most often cited in medical education? Where are they published? Looked at top citations by medical education journal and by keyword search Historical Highlights in Medical Education
Top 5 ME Journals (Group A) Top other journals (keyword search) (Group B) Academic Medicine (60.7%) JAMA Medical Teacher (28.6%) New England Journal of Medicine Journal of Continuing Medical Education Educational Psychologist Education in the Health Professions Annals of Internal Medicine Advances in Health Education: Theory and Practice Review of Educational Research Historical Highlights in Medical Education Top Cited Articles Type of article/topic
Articles published in general medicine journals attracted more citations than those published in medical education journals Type of article Med Ed Journals All Journals Review 48% 54% Article 34% 23% Research paper 14% Educational Guides 4% 0 % Top Cited Articles Most Popular Topics
Med Ed Journals All Journals PBL (16%) Clinical Competency Skill/Assessment (23%) Clinical Competency Skill/Assessment (14%) PBL (19%) Professionalism/professional competence (11%) Medical Simulation and standardized patients (9%) Top 3 articles Evidence Based Medicine Working Group. Evidence-based medicine: A new approach to teaching the practice of medicine (1991, JAMA) Review 1278 citations Stewart. Effective physician-patient communication and health outcomes: A review (1995, CMAJ) Research, 1210 citations Albanese, Mitchell. Problem-based learning. A review of literature on its outcomes and implementation issues (1993, Academic Medicine) Review 861 citations References Curricular redesign
Curricular redesign 1.Hopkins R, Pratt D, Bowen JL, Regehr G. Integrating Basic Science Without Integrating Basic Scientists: Reconsidering the Place of Individual Teachers in Curriculum Reform. Academic Medicine ;90(2): 2. Haramati, A. Educating the Educators: A Key to Curricular Integration. Educating the Educators: A Key to Curricular Integration. Academic Medicine. 2015;90(2): 3.Salmon M, Williams D, Rhee K. Refocusing Medical Education Reform: Beyond the How.Academic Medicine. 2015;90(2): PBL 4. Korin T, Brumbaugh, J, Kakar S, Blatt B. Caffeinating the PBL Return Session: Curriculum Innovations to Engage Students at Two Medical Schools.Academic Medicine. 2014; 89(11): 5. McLean M, Brazil V, Johnson P. How we breathed life into problem-based learning cases using a mobile application. Medical Teacher. 2014;36(10): Flipped Classroom 6. Flippedlearning.org Accessed November 1, 2015. (includes white paper, literature reviews) 7. Prober CG, Khan S. Medical Education Reimagined: A Call to Action. Academic Medicine. 2013;88: 8. Moffet, J. Twelve tips for flipping the classroom. Medical Teacher 2015;37(4). 9. Sharma N, Lau CS, Doherty I, Harbutt D. How we flipped the medical classroom. Medical Teacher. 2015; 37(4): 10. McLaughlin JE, Roth MT, et al. The Flipped Classroom: A Course Redesign to Foster Learning an Engagement in a Health Professions School. Academic Medicine 2014:89: 11. Khanova J, Roth MT, Rodgers JE, McLaughlin JE. Student experiences across multiple flipped courses in a single curriculum.Medical Education. 2015;49(10): Longitudinal Clerkship 12. Elmore SN, Kopecky KE, Jennings K, de Moya M, Beresin G et al. Supporting Medical Students' Pursuit of Longitudinal Patient Experiences: Piloting an Innovative Visit Notification Tool at the Massachusetts General Hospital. Acad Med.Epub ahead of print. 13. Kodner C, Bohnert C. The Longitudinal Standardized Patient Project: Innovation from Necessity. Acad Med. 2015;90: References GME 14. Dousa, KMA, Muneer M, Rahil A, Al-Mohammed A, AlMohanadi D, et al. Tailoring Morning Reports to an Internal Medicine Residency in Qatar. J Grad Med Ed 2014;6(4):801-4. 15. Ibrahim H, Al Tatari H, Holmboe ES. The transition to competency-based pediatric training in the United Arab Emirates. BMC Med Educ. 2015;15:65. 16. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, et al. Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med 2014;371: 17. Barber KH, Schultz K, Scott A, Pollock E, Kotecha J, et al. Teaching Quality Improvement in Graduate Medical Education: An Experiential and Team-Based Approach to the Acquisition of Quality Improvement Competencies. Acad Med. 2015;90: Student/Trainee Performance 18. Prober CG, Kolars JC, First LR, Melnick DE.A Plea to Reassess the Role of the United States Medical Licensing Examination Step 1 Scores in Residency Selection. Acad med. 2015;90:1-4. 19. Holtzman KZ, Swanson DB, Ouyang W, Dillon GF, Boulet JR. International Variation in Performance by Clinical Discipline ad Task on the United States Medical Licensing Examination Step 2 Clinical Knowledge Component. Acad Med.2014;89: Medical Educators- International GME 20. Sabel E, Archer J."Medical Education Is the Ugly Duckling of the Medical World" and Other Challenges to Medical Educators' Identity Construction: A Qualitative Study. Academic Medicine. 2014;89(11): 21. McLean M, McKimm J, Major S. Medical educators working abroad: A pilot study of educators experiences in the Middle East. Medical Teacher. 2014;36(9): 22. Mclean M, Da Silva A, McKimm J, Major S. Medical educators working abroad: Who are they? MedEDPublish 2015, 4:3 23. Ibrahim H, Stadler DJ, Archuleta S, Shah NG, Bertram A, et al.Clinician-educators in emerging graduate medical education systems:description, roles, and perceptions. Postgrad Med J. 2015;0:1-7. 24. Archuleta S, Ibrahim H, Stadler DJ, Shah NG, Chew NW, Cofranceso J. Perceptions of Leaders and Clinican Educators on the Impact of International Accreditation. Acad Med. 2015:90:S83-90. References Historical Perspective
25.Azer SA. The Top-Cited Articles in Medical Education: A Bibliometric Analysis. Acad Med.2015;90(8):1-15. The undergraduate experience Longitudinal Patient experiences The role of social Media
Social media in medical education: a new pedagogical paradigm?. (yes??) Hillman, Toby 1; Sherbino, Jonathan 2 Postgraduate Medical Journal. Criteria for social media-based scholarship in health professions education. (yes) Sherbino, Jonathan 1,2; Arora, Vineet M 3; Van Melle, Elaine 1; Rogers, Robert 4; Frank, Jason R 1,5; Holmboe, Eric S 6 Learning theory and its application to the use of social media in medical education. (yes) Flynn, Leslie 1; Jalali, Alireza 2; Moreau, Katherine A 3 Advances in Health Sciences Education (yes) December 2014, Volume 19, Issue 5, pp First online: 25 February 2014 Social media in health professional education: a student perspective on user levels and prospective applications StephenMaloney , AlanMoss , DraganIlic