KeyLIME: Top 10 Best teaching and learning literature

Transcription

1 KeyLIME: Top 10 Best teaching and learning literature Author: Jamiu Busari, Maastricht University, Netherlands Ming-Ka Chan, University of Manitoba, Canada Date: 30 Sept, 2016

2 We do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Je n ai aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d appareils médicaux ou un cabinet de communication. Authors: Jamiu Busari & Ming-Ka Chan Date: September 30,

3 Disclaimer Dr. Chan and Dr. Busari are in the bloom of their medical education careers Dr. Chan and Dr. Busari would like to continue to be employed in their work as medical educators in future We feel that these ten articles are excellent, thought-provoking, controversial, or practical all have merits Criticisms are made in the spirit of debate, recognizing the high quality work of the talented authors. 3

4 Introductions Who are we? Who is in MKChan_RCPSC #Top10TL 4

5 Process Search engine: Medline, Pubmed, Google Scholar, Twitter, peer and expert consultation Expert judgement Keywords: "internship and residency" or "residency education" or "postgraduate education" or ("clinical teach*" W/5 residen*) Limit to 2015-present Limit to article or review 5

6 6

7 Study Why: Mentorship shown to benefit individuals and organizations Hypotheses/objective: To determine the association between professors selfperception of mentoring skills and their academic performance. Who: Imperial College London Professors What: Correlation between: Mentorship skills self assessment survey (dev by Coalition of Counselling Centres) and measures of academic performance 7

8 Results 104/215 professors Frequent use of mentoring skills & quality of relationship has positive effects on academic performance ---?reflection of commitment to organization Academic performance = publication, citation count, h-index - innovation, inter-organizational networks, cultivation of continuous improvement Formal mentorship programs across academic centres recommended 8

9 BUT - Lots of different measures of academic performance ----less well studied - Tool not validated for healthcare - Self perception only: need 360 feedback - Leap to recommend dev formal mentorship program at academic centres 9

10 Sulzer SH, et al. Medical Education 2016: 50:

11 Study Why: persistent disagreements in the research literature concerning how best to evaluate empathy among physicians. Does empathy decline or increase across medical education. Hypotheses/objective: instruments used to study empathy may not measure anything meaningful to clinical practice or patient satisfaction. What: Investigated how empathy is conceptualized in medical education research. Examined how researchers defined the central construct of empathy, what they chose to measure, and how well definitions and operationalizations matched. Systematic review, PRISMA guidlines 11

12 Results English- language publications that: (i) examined physicians, medical students or residents, (ii) operationalized empathy in an empirical study, and (iii) included some quantitative component (untill 2012) Majority of studies showed internal inconsistencies, vagueness in both conceptualization and operationalization. Empirical studies were outnumbered by commentaries Authors investigated for (i) Definition of empathy (ii) if it involved thinking and/or acting and/or feeling Thirty-two (37%) defined empathy as consisting in part or entirely of a feeling process, and 53 (61%) defined empathy as including an action component. 80 (78%) studies operationalized empathy as a global construct, 45 (44%) operationalized it as a composite construct, while 15 studies (15%) operationalised empathy in both ways. 12

13 But 1.One-fifth of the studies failed to define the central construct of empathy and instead either relied on commonsense notions of empathy or used a scale or other instrument as a de facto definition of empathy. 2.The methods used to study empathy have limited power to predict the presence or absence of empathy in clinical settings. 3.Various conceptual flaws in the review lack of definition, mismatch between definition and operationalisation, overreliance on cognition and self-report 13

14 Bolster & Rourke, Journal of Graduate Medical Education, Sept

15 Study Why: Despite 25 years of implementation and a sizable amount of research, the impact of resident duty hour restrictions on patients and residents is still unclear. Some interpret the research as necessitating immediate change; others draw competing conclusions. Hypotheses/objective: Update the literature and duty hour restrictions for clarity on it benefits if any Who: The original review included articles published between January 1, 1989, and May 21, The current search included all relevant literature between May 2010, and February What: systematic review update of the literature on duty hour restrictions conducted 1 year prior to the implementation of the Accreditation Council for Graduate Medical Education s 2011 regulations. PRISMA guidelines 15

16 Results Scheduling: shift length is the number of consecutive hours worked by residents without protected sleep. Protected time for sleep: the period during a work shift in which residents transfer all of their responsibilities to another individual, to obtain uninterrupted sleep. Night float: staffing system in which dedicated residents work during the night and not during the day. Outcome: favorable, unfavorable or neutral The interrater reliability for study inclusion was excellent (j MERSQI was used to evaluate the studies quality the largest proportion of results pointed to an unfavorable impact (16 of 41, 39%) and the second largest to no impact (15 of 41, 37%). Resident education garnered the highest proportion of unfavorable outcomes, followed by resident well-being. Many of the reviews found no conclusive evidence that duty hour restrictions improved patient care Of the 3 approaches for adapting resident schedules to duty hour restrictions, night float was associated with the highest proportion of unfavorable results. Reduced shift length demonstrated the best evidence for improved patient care, although this is still only modest evidence 16

17 But 1.Few of the studies were randomized controlled trials 2.while the most important patient care outcomes are arguably mortality and morbidity, only 60% (6 of 10) of studies that reviewed patient care looked at mortality and morbidity outcomes. 3.Regarding education, the outcome measures were largely related to attendance at teaching sessions and time with faculty. 17

18 Watling C, et al., Medical Education 2016: 50:

19 Study Why: Direct observation strengthens coaching & assessment Enables feedback and trustworthy assessment But limited use outside formal assessment setting Hypotheses/objective: Determing the cultural barriers to observation Who: 22 residents or fellows (10 male, 12 female) What: Constructivist grounded theory approach- semi structured interviews 19

20 Results Observation was not absent, but highly selective specialty specific We observe what we value the most Context of observation needs to be broadened Autonomy of Learning Balance between value of learning from having an observer and receiving feedback vs value of learning from independent decisions Willingness to ask for help Efficiency in health care provision in conflict with time needed observation Learner driven activity need to move it out of this context 20

21 BUT Single centre Interview methodology may not capture all elements of true culture 21

22 Kessler D, et al. PEDIATRICS Volume 135, number 5, May

23 Study Why: Simulation-based skill trainings are common; however, optimal instructional designs that improve outcomes are not well specified. Trainee success rates with infant lumbar puncture are poor. The model of just-in-time learning via simulation has produced clinical improvement for other medical skills such as cardiac compressions and central line dressing changes Hypotheses/objective:. Explore the impact of just-in-time and just-in-place training (JIPT) on interns infant lumbar puncture (LP) success. Who: Pediatric and emergency medicine interns, between 2009 to 2012 at 34 centers What: Prospective study, comparing 2 distinct instructional design strategies. Cohort A ( ) completed simulation-based training at commencement of internship, receiving individually coached practice on the LP simulator until achieving a predefined mastery performance standard. Cohort B ( ) had the same training plus JIPT sessions immediately before their first clinical LP. 23

24 Results Main outcome: LP success, defined as obtaining fluid with first needle insertion and <1000 red blood cells per high-power field. Process measures included use of analgesia, early stylet removal, and overall attempts. In a previous study, improved infant LP clinical success increased among pediatric trainees after a single simulation- based intervention (71% intervention group vs 27% control group). In a multicenter study, this effect could not be replicated With the addition of JIPT, the study still found no statistically discernible improvement in infant LP success rate. More specifically, the success rate (38%) for the intervention group based on data collected over a 2-year period was not statistically significantly different from the 35% success rate found in the previous year. However, there was improvement in several process measures, such as the number of attempts needed and other behaviors previously shown to be associated with success (early stylet removal technique and use of analgesia). 24

25 But 1.The asynchronous and infrequent occurrence of infant LPs limited the usefulness of the clinical encounter as a trigger for training refreshers. 2.The retention period for infant LP skills among novice providers who have been trained difficult to quantify 25

26 Lakhani et al., Acad Med. XXXX;XX: First published online doi: /ACM

27 Study Why: resource stewardship is key competency Hypotheses/objective: Determine student behaviors with respect to resource stewardship practices (rather than specialty specific practices). Who: Collaboration between Choosingwisely Canada, Canadian Federation of Medical Students and Fédération médicale étudiante du Québec What: 1) Student led task force developed set of recommendations 2) Informed development of national student survey 3) Further refinement of recommendations by taskforce 27

28 Results A) 1878 of possible 9000 Canadian students with mix of years B) 6 Recommendations: Behaviors to avoid e.g. Do not suggest ordering the most invasive test before considering less invasive options (e.g. physical exam or U/S rather than CT for suspected appendicitis). Behaviors related to medical culture that leads to overuse e.g. Hierarchy e.g. Do not hesitate to ask for clarification on tests, treatments, or procedures that you believe may be ordered inappropriately C) STARS Summit Students and Trainees Advocating for Resource Stewardship 28

29 But Need further dissemination and support structures E.g. further collaboration and endorsement by other partnering organizations (i.e. AFMC) Need further development and engagement with residents and other health care professionals Ensure opportunities in clinical learning environment that fosters questioning by learners Need role models and further faculty development 29

30 Kassam A, et al. Journal of Graduate Medical Education, March

31 Study Why: Studies have highlighted depression and burnout in resident physicians. There is a need to describe the characteristics of well-being in resident physicians in order to develop resident wellness initiatives in postgraduate medical education. Hypotheses/objective: To characterize the predictors of well-being in resident physicians by assessing personal and work- related burnout, work dissatisfaction, nutritional needs while on call, and sleep needs while on call. Who: PGY1-4 residents at the University of Calgary in Canada What: Online survey (2012). The WHO-Five Well-Being Index, personal and workrelated subscales of the Copenhagen Burnout Inventory, questions on work dissatisfaction, as well as sleep and nutrition management needs while on call, were used in the survey 31

32 Results Response rate of 45% (317 of 706 eligible residents) The instruments showed internal reliability with a Cronbach alpha value of 0.7 or greater Residents showed a substantial level of burnout and work dissatisfaction. The mean score of personal burnout was 51.6 (SD ), and the mean score of work burnout was 48.9 (SD ). Personal and work-related burnout was higher in female residents compared to male residents, - consistent with prior research. work-related burnout was not associated with well-being, after adjustment for other variables. analysis of open-ended survey responses suggested the possible erosion of boundaries with work-life balance, with work encroaching into personal time. 32

33 But 1.The results are from a single site, and the sample consisted of significantly younger residents than the group of eligible residents - sampling bias, as younger residents may be more affected by the stress of new training situations, and may respond differently to threats to well- being. 2.The survey design precluded analysis of whether respondents are representative of the overall population by specialty distribution. 3.The survey consisted of questions from several previously used instruments and additional questions on sleep and nutrition; therefore, the instrument lacks validity evidence for this population and setting. 33

34 Wong & Holmboe, Academic Medicine, Vol. 91, No. 4 / April

35 Study Why: Increased focus on QI and safety BUT No change in preventable hospital adverse events Patients receive basic elements of care inconsistently Mismatch between healthcare spending & healthcare outcomes e.g. US spends highest % of GDP but more Americans have poor health and are dying younger as compared with other dev countries. Hypotheses/objective: Perspective paper demonstrating need to integrate education outcomes with clinical outcomes What: New Model that focuses on learner-patient-clinical microsystems (informal curr) not isolated educational and patient outcomes. 35

36 Results 36

37 Results Scutwork is redefined (previously viewed as poor educational value) E.g. discharge summaries, scheduling followup and appointments - THEN - missed results - readmissions - Missed appointments - PROPOSED - Observation of discharge conversation - Review of discharge summaries and provision of feedback - Patient satisfaction with discharge process 37

38 But - Huge implications to design of curriculum, learner and faculty work and learning flow - Costs of implementation 38

39 Kirkman MA, Servadis N, et al. BMJ Open 2015;5:e

40 Study Why: significant increase in the number of publications relating to patient safety courses for residents. most interventions well received by participants, and led to improvements in safety and quality knowledge scores. However, few studies were able to demonstrate changes in learners behavior or potential patient benefit. Also multiple barriers to sustainable integration of the courses were identified. Hypotheses/objective: perform a focused review of research reporting courses that teach core concepts in patient safety that target medical students and junior physicians (since the last SR in 2009 onwards) What: systematic review of the latest evidence for patient safety education for physicians in training and medical students, updating, extending and improving on a previous systematic review on this topic. PRISMA guidlines 40

41 Results A modified version of Kirkpatrick s levels of evaluation (BEME collaboration) was used as the grading standard Agreement between the reviewers was high (κ=0.917, 95% CI to 0.963) 26 studies were published in 5 years vs. 27 in 9 years in previous review Also more studies in current review that demonstrated positive changes in participant behavior relative to the previous review None of the identified studies demonstrated patient benefit (kirkpatrick s level 4b) There were barriers to sustainable integration of the courses such as poor learner engagement, lack of expert faculty, competing educational priorities and unsupportive institutional culture. No relationship between length of the patient safety course and effect on learning outcomes, although a meaningful analysis of this is confounded by differences in course content and study design, quality and reporting. 41

42 But 1.Only English language manuscripts were included meaning that some relevant studies may have been missed. 2.significant heterogeneity across the studies in terms of number and type of participants targeted, the educational content of the course, the teaching methods employed, assessment tools used and the outcomes measured. 42

43 Telio, Regher & Ajjawi, Medical Education 2016: 50:

44 Study Why: Better understand how we use feedback Hypotheses/objective: How learners decide if feedback is credible Who: Psychiatry residents, British Columbia, Canada What: Constructivist grounded theory approach PART I: Survey re A) quality of feedback received B) education alliance scale adapted from working alliance inventory PART II: Interviews with those whose surveys had diverse scores 44

45 Results 26/34 consented to interviews conducted 8 Cognitive processes and Emotional processes COGNITIVE PROCESSES - Credibility as clinician - Targeted to specific content areas - Used impressions of strengths (open to feedback in this area) and weaknesses (less open to feedback) - Was the supervisor a good role model? link to own professional identity COGNITIVE PROCESSES - Credibility in educational alliance A) Perceived authenticity enthusiasm, dedication, feedback (for improvement of learner) B) Perceived learner presence broader learner identity, learning experience, collaboration in learning experience C) Perceived feelings towards learner trust, respect and fondness 45

46 Results Emotional Processes negative emotional response when have weak educational alliances not linked necessarily to content of feedback Consequences of credibility judgments 1) Immediate consideration of feedback 2) Future engagement with supervisor in feedback encounters If highly credible - Learners willing to be candid - Highly receptive to feedback even if delivered poorly PREP is key develop educational alliance before feedback encounter (trust, listening etc) Implications in how we teach, design educational experiences 46

47 BUT Small sample size One centre Psychiatry residents only? different reflection skills Typical Longitudinal experiences not found in all specialties 47

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