NY Med Ed Journal Club

TEACHING AND LEARNING IN AMBULATORY CARE SETTINGS:
A THEMATIC REVIEW OF THE LITERATURE
Irby DM. Aced Med 70(10):898-931,1995.
July 1996
On-line Discussion Summary

Contributors
(alphabetical order): Stuart Green, David Irby (author), Elizabeth Kachur, Vathsala Stone

A literature review of this nature can identify "what has been" - not "what is now" or "what can be." Some of the latest developments (e.g., managed care, supervision regulations) were too recent for their incorporation.

Most individual studies/articles on ambulatory care education have a very narrow focus (e.g., on a particular program) and thus they are only a "drop in this (complex) bucket." Reviews like this one can help research move forward more rapidly.

Teaching and learning are not synonymous. Teaching does not always result in learning and learning is not always a product of good teaching. The role of self-learning needs further exploration.

We need to better understand the similarities and differences between inpatient and outpatient teaching and learning (e.g.,ambulatory care education has more of an one-to-one orientation, teachers are confronted with more unpredictable instructional situations, there is often a lack of continuity between learner and patient and learner and teacher, there is a lack of time for self-directed learning and evidence-based medicine approaches).

Once we know "what makes learning happen" in the ambulatory care setting we will better understand what teacher qualities are needed for this type of education.

There may be succinct differences between ambulatory care education for students versus for residents (e.g., difference in learning needs, level of structure, trainee centeredness).

Preceptors need to "juggle" the office environment for two outcomes: patient care and student learning."

Insufficient focus on psychosocial and contextual issues is a problem of health care, not just an educational issue.

SUNY Buffalo is engaged in an NBME-funded study towards the development of a preceptor effectiveness measure.

David Irby is organizing a national, invitational conference on new models of ambulatory care education - the application of learning theory (cognitive, experiential, and social theories of learning) to ambulatory care education. The results will be published in Academic Medicine in 1997.

AN ACTIVE-LEARNING APPROACH TO BASIC CLINICAL SKILLS
Curry RH, Makoul G. Acad Med. 1996,71(l):41-4.
May 1996
On-line Discussion Summary

Contributors
(alphabetical order): Darwin Deen, Elizabeth Kachur, Gregory Makoul (author)

Extensive programs do not suffer from "curriculum isolation" which increases their potential for success even further.
Educators need to introduce protocols for skill mastery and critical thinking in a concurrent fashion (e.g., as students are given a protocol, the reasons for each item are explored).
Students whose training is fashioned after a "discovery model" may be better prepared for evidence-based medicine.
We need to make information management and critical thinking core skills for medical education (i.e., they need to be equal to biochemistry and anatomy).

CONTENT ANALYSIS OF RESEARCH IN UNDERGRADUATE EDUCATION
Dimitroff A and Davis WK. Acad Med. 1996;71(1):60-7.
April 1996
On-line Discussion Summary

Contributors (alphabetical order):
Elizabeth Kachur, Martin Lischka

The analysis of journal content provides valid though limited insights into the state of affairs of a professional field.

Conference programs, books and other publications would be worth exploring as well.
Differences in research style/methodology between education and biomedical sciences (e.g., utilization of a controlled setting) may account for some of the communication difficulties evident between physicians and education professionals.

LEARNERS AS TEACHERS: THE CONFLICTING ROLES OF MEDICAL RESIDENTS
Yedidia MJ, Schwartz MD, Hirschkorn C, Lipkin M. J Gen Intern Med 1995; 10:615-23.
March 1996
On-line Discussion Summary

Contributors (alphabetical order):
Andrew Cohen, Stuart Green, Elizabeth Kachur, Debra Kantor, Kenneth Roberts, Susan Watson, Michael Yedidia (author)

We need to teach medical trainees that admitting "uncertainty" is not synonymous with "incompetence."

The lack of a common knowledge baseline between trainees and teachers makes it more difficult for the latter to create a safe learning environment.

Since teachers are considered to be "content experts," uncertainty (= lack of content) creates a major impediment to teaching. A switch of role expectations to "process experts" (e.g., as promoted by PBL) may ease some of these problems.

Teacher/learner role conflicts are present at all levels in medical education: residents teaching medical students, faculty teaching residents. However, the more junior the person, the more frequent they may occur.

Learning cannot be left to chance or to the individual motivation of an already overwhelmed resident.

Productivity pressures in the current health care environment are bound to intensify role conflicts.

Medical education requires trainees to have a considerable baseline of personal strengths and even then the "emotional cost" can be high.

Sometimes, problems are wrongly identified as "individual" when in fact they are "programmatic."

A full understanding of role conflicts requires a systems approach.

Some barriers to a systematic study of role conflict in medical education are: problems seem obvious, topic is very emotion-laden - "tough stuff," opening up potential "abuse" issues is dangerous, the investigators (= medical educators) suffer from similar afflictions as the study population (= medical trainees).
Needs of teachers can vary depending on their level. Junior teachers may have greater concerns about "content," senior teachers may have greater concerns about "technique."

Preparations for the teacher role need to include practical skills without falling into "educationeze."

Even though support groups seem a natural solution they are "under?available " "under-utilized" and "under-supported," and their effectiveness and efficiency has not yet been firmly established.

"Organizational rules" may help negotiate the conflict of priorities, agendas and time pressures in a patient care/teaching situation (e.g., morning work rounds).

Innovative projects reported by discussion participants that might offer solutions: Undergraduate medical tutor program: 2nd year students receive special teaching skills training to tutor 1st year students (Susan Watson, UMDNJ)
A teaching skills training program for residents (Susan Watson, UMDNJ; Kenneth Roberts, UMass)
Regularly scheduled support groups for residents (Kenneth Roberts, UMass)
Annual cohort-specific retreats (Kenneth Roberts, UMass)
Programs to assist with the transition from one training level to another (Debra Kantor, UMDNJ)

Quotes:
"The article validates what we 'know' and 'feel' about role demands in residents" (Kenneth Roberts)
"We are impatient for more concrete and elaborate strategies for change" (Michael Yedidia)

SHOULD HALF OF ALL MEDICAL SCHOOL GRADUATES ENTER PRIMARY CARE?
PERCEPTIONS OF FACULTY MEMBERS AT JEFFERSON MEDICAL COLLEGE
Gottlieb J, Fields SK, Hojat M, Veloski JJ. Acad Med 1995; 70(12):1125-1133.
January 1996
On-line Discussion Summary

Contributors (alphabetical order):
Mohammadreza Hojat (author), Elizabeth Kachur

Since attitudes can shape behaviors, attitudinal surveys are an important source of information when drastic changes are anticipated.

"Effect size" is a scale-free index that estimates practical (not statistical) differences.

Primary Care physician increase seems closely tied to a more prominent role for mid-level providers - indicating that the "50% Primary Care" issue cannot really be separated from the "Primary Care-ization" of US health care.

In order to reduce the rift between Primary Care and research, medical school admission committees should search for candidates who express an interest in research in addition to an interest in Primary Care patient care.

THE MINI-CEX (CLINICAL EVALUATION EXERCISE): A PRELIMINARY INVESTIGATION
Norcini JJ, Blank LL, Arnold GK, Kimball HR. Ann Intern Med. 1995;123:795-9.
December 1995 - January 1996
On-line Discussion Summary

Contributors (alphabetical order):
Monefa Anderson, Stuart Green, Elizabeth Kachur, John Norcini (author), Janice Rosenfeld

There was a general agreement that the Mini-CEX is a very positive new development which was long overdue. Since it resembles actual clinical practice, it will be a better indicator for competence as well as performance. Since it is more practical and less time consuming, it will result in a much needed increase in frequency of resident evaluations.

There was some notion that a combination of Mini-CEX and traditional CEX could provide the most comprehensive evaluation plan.

Although there is a high correlation among the performance dimensions on the rating scale, it is worthwhile to include them all because they assist faculty in providing more comprehensive feedback.

Questions raised:

Could Mini-CEXes serve as rater training for the traditional CEX?

What is the relationship between Mini-CEX performance and overall quality of care (also from the patient's point of view)?

If the Mini-CEX becomes routine it will be folded into the learner-preceptor contacts. Will scoring then vary between learner-centered preceptors and preceptors who are authoritarian and non-individualized?

Is the validity of the Mini-CEX score related to the preceptor-learner relationship?

Should "humanistic qualities" be treated as a performance dimension equal to history-taking, physical exam, etc. or could it rather be a baseline or prerequisite for the rest of the medical care process?

What is the optimal encounter length for performance as well as for examinee/examiner satisfaction with the assessment method?

What does satisfaction with an exam mean or where does it come from?