Office Of Medical Education Newsletter Spring 2007

Office of Medical Education Newsletter Spring 2007 Volume 1, Issue 1 MISSION WE CONTRIBUTE

TO THE MEDICAL STUDENTS’

EDUCATION BY PROVIDING FACULTY

DEVELOPMENT, EDUCATIONAL SUPPORT AND SERVICES TO

FACULTY AND STUDENTS.

Tulane University School of Medicine Office of Medical Education 1430 Tulane Avenue, SL-6 New Orleans, LA 70112 Tel 504-988-6600 Fax 504-988-6601 [email protected] www.som.tulane.edu/ome

Introducing the OME Newsletter… The purpose of this newsletter is to provide extended on-going professional development to faculty, residents, preceptors, and others with direct responsibilities for medical student education in the areas of: • Methods of pedagogy, • Communication and assessment, • Development and implementation of educational objectives, • Educational Technology, and • Competency-based Evaluation. The ultimate goal of this resource is to enhance the teaching and evaluation skills of those individuals who educate medical students at Tulane University School of Medicine. This resource will assist educators in the growth of medical students’ knowledge, skills, behaviors, and attitudes needed in medical training and practice. Additionally, this newsletter will provide general information on events, support services and activities in the Office of Medical Education. We will also feature short articles summarizing research literature that provides innovative teaching methodologies in medical education. The editor welcomes short articles from the faculty that introduce or inform others about a unique teaching strategy or method currently being used for teaching. (Read more on page 7, under Call for Submissions.)

In this issue…

The Series Begins…

Introduction……...…...1 Effective Feedback…...2 Improving Pedagogy...4 Standardized Patients.6 Teaching Excellence…8

You are cordially invited to attend the first Teaching Excellence Series…

With Dr. Ronald Markert

Effective In-Training Feedback

Thursday, May 10 at 9:00 a.m. & Friday, May 11 at 1:00 p.m. 1555 Poydras Street, 22nd Floor Read more on page 8.

OME Ne wsle tte r, Spri ng 2007 Giving Effective Feedback The clinical setting is the ideal setting for students to learn in a “real life” situation. This experience allows an opportunity to integrate knowledge, theory and practice. Additionally, students develop professional competencies that will affect their behaviors and attitudes in future roles. Effective feedback is essential in making trainees aware of their deficits. Furthermore, poor performance will go uncorrected, and good performance will not be reinforced. The purpose of this article is to provide guidance for effective feedback. What is effective feedback? According to Govaerts (2006), learning and assessment are fundamentally linked and practice without feedback or assessment will not result in improved performance. Effective feedback strategies should be comprised systematic and ongoing assessment of habitual performance in the real life clinical practice, with two purposes: • Giving feedback to the trainee to help improve performance, and • Providing credible and defensible information on quality of performance to support judgment and selective decisionmaking. The article proceeding will offer much insight into a method for providing feedback and assessment in clerkship settings.

Microskills of the One-Minute Preceptor Written by W. Fred Miser, M.D. Associate Professor, The Ohio State University Department of Family Medicine Up to this point we have focused on laying the foundation for teaching students in your office. We will now begin the portion of the series where we address the necessary skills for the actual teaching encounter. This article presents the concept of the "one-minute" preceptor and five microskills used for teaching students efficiently and effectively after they have seen a patient and are presenting the case to you.

2 During the case presentation, you need to accomplish three tasks: 1) diagnose the patient, 2) diagnose the student (strengths and needs), and 3) teach the student based on the identified needs. In last month’s issue, a suggested format was given for the case presentation that would help you in determining the needs of the patient. We will now turn our attention to the other two tasks. To make this teaching encounter more effective, a group of family physicians and educators from the University of Washington have identified five microskills for ambulatory teaching (Neber JO, et al: A five-step "microskills" model of clinical teaching. J Am Board of Fam Pract 1992; 5:419-24). If done in order, they provide a logical framework that encourages the students to become active learners and that allows you to identify the learning needs of the students and to teach them based on those needs. If the student follows the case presentation format given in last month’s issue, the first two steps are already accomplished. 1. Get a Commitment - After the student has presented the patient to you, your first task is to get him/her to commit to a decision and/or a plan of action. This step encourages the student to take responsibility, demonstrates that you value the student and his/her help, and promotes satisfaction in the student. Useful questions that you may ask during this step are, "What do you think is going on?" or "What would you like to do next?" Their answers to these questions allow you to determine how the student views the case. Be careful not to ask for more data about the patient, and don’t provide the answer to the problem yet. 2. Probe for Supporting Evidence - After the student has made a commitment, ask him/her to provide evidence to support their impression. As the student provides this evidence, you can determine whether they made a lucky guess, or truly do have a handle on the case. This is not the time for asking them for textbook knowledge.

OME Ne wsle tte r, Spri ng 2007 The purpose of this microskill is to help you identify the strengths and needs of the student, which then allows you to tailor what you need to teach about the case. Useful questions at this time include, "What led you to that conclusion?" and "What else did you consider and rule out?" Answers to these questions will provide you insight and allow for good dialogue with the student. 3. Tell Them What They Did Right - This microskill reminds us to provide positive feedback to the student, something he/she wants but often doesn’t get. Comment specifically on what they did right, and describe the positive effect of the action. Good actions need reinforcement. An example for this microskill is, "You did a good job of ... and this is why it is important...." State specifically what was done well and why it is important? This is not general praise; instead, it focuses on specific behaviors that are reproducible. 4. Teach a General Rule - Based on what you have learned about the student’s needs, you will now want to teach based on their level of understanding, which greatly increases retention. "The key features of this illness are..." or "When this happens, do this..." The teaching point should help the student generalize from this case to others. It should be brief (given within a few minutes) and should not include everything you know about the subject. It addresses the patient’s concerns and the student’s needs. Minimize anecdotes or zebras. As you prepare for this microskill, ask yourself, "What one teaching you prepare for this microskill, ask yourself, "What one teaching point do I want the student to leave this patient’s encounter with?" It is helpful to have "teaching scripts" for the common conditions that you encounter in your practice. For example, you could have several things prepared for teaching about otitis media (e.g., helpful tips on making the diagnosis, commonly prescribed antibiotics, what to do with treatment failures); when the student sees a patient with otitis media, pick one of these scripts and talk to the student about that area. When the student sees another patient with otitis media, reinforce the first point, and then focus on the next point, and so on.

3 5. Correct Errors - If during the presentation the student makes an error, correct the mistake. Mistakes unnoted will be repeated. Describe what was wrong, and identify how to avoid and correct the error. "Next time this happens, try this..." These recommendations should focus on improvement and be future oriented; avoid belittling the student. Focus on the problem, not the student. In summary, the five simple steps of the oneminute preceptor are 1) "What do you think is going on?" (get a commitment), 2) "Why do you think so?" (probe for supporting evidence), 3) Provide warm fuzzies (tell them what they did right), 4) "When this happens, do this..." (teach a general rule), and 5) "Whoops!" (correct errors). An example of how these five steps work in concert during the teaching encounter is found at the end of this article. These microskills have been shown to enhance the teaching encounter, and I would encourage you to incorporate them into your clinical teaching. Reprinted with permission from the author

Improving your Pedagogy… By effectively writing learning objectives (competencies), this will improve your ability to teach because you will be concentrating on the expected student outcome and how the student will be assessed. A learning objective is a statement of what students will be able to do when they have completed instruction. According to Mager (1962), there are three major components to a learning objective: ! Behavior: Task or performance (What the student will do?) This is an action verb. ! Condition: (How will the student perform the task?) ! Standard: Criteria for evaluating the students’ performance (How well must the student perform?)

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Consider the following learning objective from a behavioral perspective: Given a stethoscope and normal clinical environment, the medical student will be able to diagnose a heart arrhythmia in 90% of effected patients. This example describes the observable behavior (identifying the arrhythmia), the conditions (given a stethoscope and a normal clinical environment), and the standard (criteria) (90% accuracy). As stated before, your objectives and teaching will focus on learner outcomes. Benjamin Bloom* identified three types of learning, which is categorized into domains of educational activities: ! Cognitive: mental skills (Knowledge) ! Psychomotor: manual or physical skills (Skills) ! Affective: growth in feelings or emotional areas (Attitude) These three domains are commonly referred to in higher education as KSAs. The Tulane University School of Medicine has a unique set of learning objectives with specific outcomes (competencies) for its students posted on the SOM Website: End of second year: http://www.som.tulane.edu/objectives/2nd_year.html

By graduation: http://www.som.tulane.edu/objectives/grad.html

It is important to keep these KSAs and the following statistical information in mind when creating your learning objectives and include a variety of activities for students in which learning can take place. As you can see from the data, the most retention by students occurs by “doing the real thing.” Therefore, it is very important that you create real life applications as a part of your learning objectives.

Focusing on learning outcomes is critical because this will guide your methods of teaching and direct you as to how students can apply the knowledge to develop skills and attitudes. One common mistake made when selecting a task or performance for students to learn is the verb (What the student will do?). Often teachers use verbs such as “know” or “understand,” which are vague. Please avoid these words and use action verbs.

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The following is a sample list of KSAs aligned verbs that may be used in developing learning objectives: These verbs communicate knowledge: Knowledge: Recall Cite List data or information. Count Name Define Quote Describe Recognize Draw Record Identify Read Indicate Relate Comprehension: Associate Distinguish Understand the Classify Estimate meaning, translation, Compare Explain interpolation, and Compute Express interpretation of Contrast Extrapolate instructions and Describe Interpolate problems. State a Differentiate Interpret problem in one's own Discuss words. Application: Apply Interpret Use a concept in a new Calculate Locate situation or Complete Operate unprompted use of an Demonstrate Order abstraction. Applies Dramatize Practice what was learned in Employ Predict the classroom into Examine Relate novel situations in the Illustrate Report work place. Interpolate Analysis: Analyze Diagram Separates material or Appraise Differentiate concepts into Contract Distinguish component parts so Criticize Experiment that its organizational Debate Infer structure may be Detect Inspect understood.

Repeat Select State Tabulate Tell Trace Write Locate Predict Report Restate Review Translate

For an example of how behavioral learning objectives can be developed, let's assume that we are creating a training program for receptionists. The goal of the program is simply to train people in proper phone use. What might the specific tasks and associated learning objectives include?

Restate Review Schedule Sketch Solve Translate Use Utilize

This statement is not an objective but a description of the course contents. Other examples of poorly written objectives are:

Inventory Question Separate Summarize

Distinguishes between facts and inferences.

Synthesis: Builds a structure or pattern from diverse elements. Put parts together to form a whole, with emphasis on creating a new meaning or structure.

Evaluation:

Arrange Assemble Collect Compose Construct Create

Design Detect Formulate Generalize Integrate Manage

Appraise Determine Make judgments about Assess Estimate the value of ideas or Choose Evaluate materials. Critique Grade These verbs communicate skills: Diagnose Integrate Measure Empathize Internalize Palpate Hold Massage Pass These verbs communicate attitude: Acquire Exemplify Realize THESE VERBS ARE BETTER AVOIDED: Appreciate Understand Learn Believe

The following examples are adapted from an article by Kevin Kruse (How to Write Learning Objectives):

Organize Plan Produce Propose Specify

Recommend Revise Score Select Project Visualize

Reflect Know

Source:http://www.acoem.net/uploadedFiles/Continuing_Education/Joint_Spon sorship/Learning%20Objectives.doc * From Benjamin S. Bloom Taxonomy of educational objectives. Published by Allyn and Bacon, Boston, MA. Copyright (c) 1984 by Pearson Education. Adapted by permission of the publisher.

An example of a poorly defined objective is: In this course you will learn how to operate the phone and properly communicate with callers.

After completing this course you will be able to: ! operate your phone ! know how to greet callers ! understand the procedure for transferring a call These objectives do not indicate observable behaviors, making assessment of their mastery impossible. How does one know if someone knows or understands something? What does it really mean to operate the phone? The following performance objectives are good examples of the use of observable behaviors. After completing this course you will be able to: ! place a caller on hold ! activate the speaker phone ! play new messages on the voice mail system ! list the three elements of a proper phone greeting ! transfer a call to a requested extension These objectives are built around very discrete tasks. Instead of the vague objective to "operate

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the phone," the learner knows exactly what is expected for successful operation - namely, using the hold feature, speakerphone, and voice mail system. More importantly, these behaviors are observable. A student can be watched as he activates the speakerphone or listened to as she describes the elements of a good phone greeting. Because there is no ambiguity, learner expectancy is achieved and a proper evaluation can be made.

Standardized Patients Program Moves Into New Facility By Arthur Nead

Delia Anderson talks with second-year medical student Edward Pankey in the new state-of-the-art teaching facility for the Training and Assessment of Professional Skills Program. Anderson is director of the program. (Photo by Paula Burch-Celentano)

After fifteen years in the old clinical skills center on Tulane Avenue, and temporary space in the Poydras Building, the Tulane Standardized Patient Program has just moved to a newly constructed, state-of-theart clinical skills teaching facility. Occupying the entire 22nd floor of a high-rise building at 1555 Poydras St. This new facility, occupying the entire 22nd floor of 1555 Poydras, will be home to the Standardized Patients Program, medical simulation, and additional educational space including 8 small group teaching rooms.

Additionally, the center provides expert instruction on the highly invasive and sensitive female gynecological and male urological exams. In addition to the physical exam, the program provides students with valuable experience in dealing with the emotional side of these encounters—how to calm agitated patients as well as how to deal with sensitive cultural issues. “We provide students with a nonthreatening place to learn and apply just about any newly acquired skills,” says Anderson.

This space will now be home to the Training and Assessment of Professional Skills program, a key part of medical education at Tulane since 1989. “One of the primary goals of our program is to teach medical students how to perform the basic range of physical examinations so that inexperienced medical students just beginning to learn key exam procedures don’t have to try them out on actual patients in reallife clinical settings,” says Delia Anderson, program director.

Another focus of the program is the assessment of clinical skills. This is done in the form of Clinical Skills Assessments, which mirror the current USMLE Step II exam. SP’s are supervised by medical school faculty and by the center’s staff to realistically simulate patients suffering from a variety of illnesses.

SPs currently help teach students fundamental exam procedures including inspections of the eyes, ears, nose and throat; heart and lungs, musculoskeletal exams; abdominal exams; and neurological and psychiatric exams.

The custom-designed training center features class and meeting rooms, offices and an auditorium. But the heart of the facility is a suite of 16 examination rooms. During a typical training session, a group of 16 students cycles through the rooms at regular intervals. In each new room, a student carries out a different exam and makes entries on the room’s computer station. Video cameras record every session, making the students’ performances digitally available for review and for critiques by the medical faculty.

OME Ne wsle tte r, Spri ng 2007 “In addition to our live standardized patients, we will also have high fidelity simulators’,” says Anderson. The Perkin Fund Simulation Laboratory, part of the clinical skills center, has acquired Harvey®, a high-fidelity simulator used for cardiovascular exam training. Harvey® can be programmed to simulate almost all the findings for a wide range of cardiovascular. The facility will be acquiring several additional simulators in the near future, according to Anderson. Another function of the teaching facility is providing assessments of each student’s progress through a series of competency exams. “We are both teaching and assessing all along the way,” Anderson says. “And we’re not just assessing what we teach, we’re teaching the integration of all the skills they are learning as they move ahead. They are getting classroom knowledge, and it all comes together in this teaching setting.” The Teaching and Assessment of Professional Skills program has benefited the Medical School by providing efficient and standardized training to clinicals aspects of the school’s curriculum, and the new high-tech training facility brings expanded capabilities to this program. “Our program can provide basic skills training to medical students, saving time and resources of faculty, leaving doctors free to focus on the art of medicine and taking students to the next level of learning. ” says Anderson. (Revised by N. Kevin Krane, MD)

7 Call for Submissions for the OME Newsletter The Office of Medical Education Newsletter will be published three-four times a year as an Adobe Acrobat file that will be delivered by email and posted on the OME Website: http://www.som.tulane.edu/ome/. In to make this publication a successful, the editor is requesting that individuals submit: ! Announcements ! Short medical education articles (up to 500 words) ! Teaching Strategies and ! Descriptions of research in progress ! Reviews of research ! Book reviews ! Letters to the editor or faculty ! Events of interest ! Research ideas for collaborating ! Publication notices and requests Materials (send in Microsoft Word, or via email) and manuscripts should be submitted to: Annie J. Daniel, Ph.D., OME Newsletter, Editor Office of Medical Education 1430 Tulane Avenue, SL-6 Suite 1730 New Orleans, LA 70112 Tel: 504-988-6600 Fax: 504-988-6601 [email protected] www.som.tulane.edu/ome

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Introducing the Teaching Excellence Series You are cordially invited to attend the first in a series of interactive lectures. The objectives of this professional development series are to improve your teaching skills, ability to give effective feedback, and assessment.

OFFICE OF MEDICAL EDUCATION PRESENTS

Teaching Excellence Series Featuring

R O NA LD J. M A RKE RT , P H D P ROFESSOR A SSOC IATE C H AIR FOR E DUC ATI ON A ND R ESEARCH D EPARTME NT OF I NTER NAL M ED ICINE W RIG HT S TAT E U NI VERSITY B OO NSHOFT S CH OO L OF M E DICI NE

Session I: Large Group Presentations That Work Thu rs day , Ma y 1 0 at 9:0 0 a.m. 15 5 5 Po yd ra s Stre et, 22 nd Fl oo r

& Session II: Writing Flawless Multiple-Choice Tests for Medical Students Fri da y, M ay 11 at 1:0 0 p.m. 15 5 5 P oy dr as St re et, 2 2 nd Flo or

Refreshments will be served RS VP: ome @ tula ne. edu ed u

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Our Office Staff…

Annie J. Daniel, Ph.D. Director Phone: (504) 988-6600 Fax: (504) 988-6601 Email: [email protected]

Office of Medical Education 1430 Tulane Avenue, SL-6 Suite 1730 New Orleans, LA 70112 Tel 504-988-6600 fax 504-988-6601 [email protected] www.som.tulane.edu/ome

Byron E. Crawford, M.D. Professor of Pathology Associate Director Phone: (504) 988-6603 Email: [email protected]

Our Office is available to support faculty in the process of educating students and supporting students in areas that will ensure their academic success. Presently, the Office Medical Education has 11 missions that directly aligns with the institutional goals, on which it operates: • • • • •

Doreen Barrett Program Coordinator Phone: (504) 988-5437 Email: [email protected]

• • • • •

Tripp Frasch, B.A. Educational Technologist Phone: (504) 988-1144 Email: [email protected]

Kornelija Juskaite, M.A. Program Manager Phone: (504) 988-8896 Email: [email protected]

•

Consultation on Teaching Curriculum Development Evaluation of Medical Student Performance Program Evaluation Medical Education Research Publication of Scholarship in Medical Education Proposals for Medical Education Grants Evidence Based Medicine Faculty Development Educational Technology Academic Counseling for Students and Residents