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Author: Brian S McGowan, PhD

ABSTRACT: Defining Clinical Excellence in Hospital Medicine: A Qualitative Study

INTRODUCTION:
There are now more than 50,000 hospitalists working in the United States. Limited empiric research has been performed to characterize clinical excellence in hospital medicine. We conducted a qualitative study to discover elements judged to be most pertinent to excellence in clinical care delivered by hospitalists.
METHODS:
The chiefs of hospital medicine at five hospitals were asked to identify their “clinically best” hospitalists. Data collection, in the form of one-on-one interviews, was directed by an interview guide. Interviews were transcribed verbatim, and the informants’ perspectives were analyzed using editing analysis to identify themes.
RESULTS:
A total of 26 hospitalists were interviewed. The mean age of the physicians was 38 years, 13 (50%) were women, and 16 (62%) were non-white. Seven themes emerged that related to clinical excellence in hospital medicine: communicating effectively, appreciating partnerships and collaboration, having superior clinical judgment, being organized and efficient, connecting with patients, committing to continued growth and development, and being professional and humanistic.
DISCUSSION:
This qualitative study describes how respected hospitalists think about excellence in clinical care in hospital medicine. Their perspectives can be used to guide continuing medical education, so that offered programs can pay attention to enhancing the skills of learners so they can develop towards excellence, rather than using only competence as the desired target objective.

via Defining Clinical Excellence in Hospital Medicine: A Qualitative Study. – PubMed – NCBI.

The Science of Storytelling: What Do Stories Look Like?

With all of the buzz around ‘telling better stories’ as a means of making educational interventions more memorable – a noble pursuit for sure – there doesn’t seems to be a lot of agreement on what this really means. As a result there appears to be little progress being made (and maybe even some confusion and contention)!

Enter science 😉

In a recent publication, Reagan et al have leveraged semantic analysis and a big data approach to deconstruct the general emotional arcs of more than 1,300 stories. Here is their abstracts:

“Advances in computing power, natural language processing, and digitization of text now make it possible to study a culture’s evolution through its texts using a “big data” lens. Our ability to communicate relies in part upon a shared emotional experience, with stories often following distinct emotional trajectories and forming patterns that are meaningful to us. Here, by classifying the emotional arcs for a filtered subset of 1,327 stories from Project Gutenberg’s fiction collection, we find a set of six core emotional arcs which form the essential building blocks of complex emotional trajectories. We strengthen our findings by applying Matrix decomposition, supervised learning, and unsupervised learning. For each of these six core emotional arcs, we examine the closest characteristic stories in publication today and find that particular emotional arcs enjoy greater success, as measured by downloads.”

To dig into their methods and broader conclusions click here!

I have been doing some related work over the past few years, helping educational designers to visualize the rhythm of their own ‘stories’….an eye-opening endeavor for sure (see figure).

I have had the pleasure of working with designers to inspect and understand their own ‘learning grams’ which depict how their educational activities unfold, each icon representing a learning moment they have designed to drive reflection or nudge a learning action. This is yet another benefit of the Learning Actions Model – it allows designers to create moments that support the key elements of their content and in doing so perfectly paints the picture of the story they intend to tell.

For reasons both obvious and less-than-obvious, story telling in medical education is not exactly the same as story telling in fiction; but the value of studying the ‘shape’ of stories is no less valuable. And as I read Reagan’s work on stories, and as I reflect on the reaction designers have to ‘seeing’ their own stories deconstructed within the ArcheViewer; I feel like the science of storytelling is finally coming together!

Science of Learning: The 2017 Spring Tour

One of my favorite parts of the Spring is the various meetings and symposia I am invited to – whether face-to-face or virtual – the opportunity to learn from and share with various learning professionals is perhaps my favorite part of being a Chief Learning Officer.

Over the next month or so I will be leading a session at the 2nd Annual Learning-Technology-Design Conference hosted by Tagoras, as well as Keynoting the America Medical Writer Association Annual Meeting and the Lehigh Valley Health Network’s Innovation in Education Meeting. Each meeting allows me to engage with an audience of peers and to continue to advocate for the Science of Learning.

While the commitment of time and planning can be overwhelming at times, I fully subscribe to the adage that, “if you really want to learn something, teach it…” – and this year I have committed to work on three separate, but related topics. As I get closer to each presentation, I thought I might share a few new ideas I have come to learn!

Later this week, the Spring tour begins with a session entitled, “Measure Well: ‘Hacking’ Learning Analytics.” The goals of this session are to help learning professionals develop their own ‘work smarter, not harder’ approaches to gathering, understanding, and leveraging learning data. In preparing for this session I reflected on how frustrating ‘outcomes’ can be for those professionals that fail to effectively operationalize a framework and quickly find their efforts being wasted – efforts that should take minutes, instead take hours (or weeks) – or simply fail altogether. This recognition is summarized in one of my introductory slides:

Stop #2 on the Spring tour takes place a few weeks later with a session entitled, “What Do We Really Know About Learning?” The goals of the second session are to deconstruct learning and to simplify its foundational science. This is a talk I have given dozens of times, but each time I prepare I challenge myself to find a new angle – to tell the story in a slightly different way. This time I’ve forced myself to revisit the fore-fathers of behavioral economics and to look for ways to apply this seemingly unrelated field to better understand the science of learning. In doing so I may have stumbled on the most (simple and) critical lesson an educational designer may ever learn:

Stop #3 on the Spring tour takes place in April when I will visit colleagues at LVHN where my Keynote is entitled, “(Effective) Learning and Behavior Change Requires Time.” In this third session I will make the case that one-off and episodic educational interventions are – with very few exceptions – never going to help us achieve the outcomes we desire! The simple truth is that learning is rarely ever a moment, instead it is a process – as is teaching – and therefore both learners and educators need time:

In preparing for each of these sessions I can spend hours and hours huddled away in my office re-crafting, honing, and simplifying my stories…and it is all worth it!

Each time I walk on stage, I whole-heartedly believe that we are moving the community forward; I believe that sharing from the gospel of ‘learning science’ will empower educational professionals; and I believe that only when advancing collectively will the continuing education of healthcare professionals drive achievement of the triple aim.

And when I look at the big picture this way, I just can’t help but get a bit fired up!

(Though, to be fair, the downside of all this preparing for the Spring tour is that I really need to get out more…or at least move near an open window…)

Where does the ’17 years’ data point come from?

In 2010, after years of hearing that “[it takes on average]…17 years from research to practice…” I spent some time to dig into the facts…and I came away both impressed (by the underlying science) and concerned (by the barriers we face). The following is what I shared with my colleagues at Pfizer at the time….which generated MUCH conversation:

Here is the authors’ theoretical evidence: 

And, here is the authors’ empirical evidence: 

 

And finally here is the description of the simple mathematical construct for the 17 year reference:

 

Oh, by the way, this ’17 years’ measure is only getting us to 50% utilization of clinical recommendations!

Other (chilling) thoughts – remember this is 17 years ago, things are likely much worse:

  • Passive diffusion does not work:
    • If a doc were to read 2 articles a day, by the end of any year they would be centuries behind!
    • A general physician would have to peruse 19 articles a day to keep up with relevant science
    • Textbooks are often wrong, outdated, and misleading (w/ refs to support)
    • 75% of docs admitted having problems understanding statistics commonly found in journals
  • Medical education and the acquisition of professional credentials do not guarantee that medical knowledge will be coupled rigorously to the decision making processes needed in practice
  • Innovative technologies are needed to deliver credible and evidence to the point of care

So, as we all make our way out to the west coast for the annual Alliance meeting, keep these challenges in mind. On one hand, very little has gotten better since 2010, on the other hand I believe we may be closer than ever to bending the innovation curve!

If our paths cross this week, I’d love to hear your thoughts on the topic!

For those interested in digging into these ideas for themselves, here is a link to the full reference:

​Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT, editors. Yearbook of Medical Informatics 2000: Patient-Centered Systems. Stuttgart, Germany: Schattauer Verlagsgesellschaft mbH; 2000:65-70.

 

ABSTRACT: Study skills in anatomy and physiology: Is there a difference?

Many factors influence the way individual students study, including but not limited to: previous coursework, attitudes toward the class (motivation, intimidation, risk, etc.), metacognition, and work schedules. However, little of this research has involved medical students. The present article asks the question, “Do individual medical students study differently for different classes?” Study skills surveys were given to United States medical students at an allopathic medical school and an osteopathic medical school. Students were surveyed near the end of their first year gross anatomy course and again near the end of their first year physiology course. Survey items included Likert scale and open-ended questions about study habits and basic demographic information. The survey responses were correlated with each student’s final grade percentages in the courses. Analysis revealed that the four most common study habits were reviewing lecture notes, taking practice examinations, completing learning exercises, and making drawings and diagrams. The two surveys (anatomy and physiology) from each individual were also compared to see if students reported different study habits in anatomy versus physiology. A negative correlation was found between changing study habits between courses and final anatomy grade percentages. Additional analyses suggest that those students who do change their study habits between courses are increasing the number of study strategies that they attempt. This increase in the number of study strategies attempted may not allow the student to reach the same depth of understanding as their colleagues who utilize fewer strategies.

via Study skills in anatomy and physiology: Is there a difference? – PubMed – NCBI.

ABSTRACT: Actual drawing of histological images improves knowledge retention

Medical students have to process a large amount of information during the first years of their study, which has to be retained over long periods of nonuse. Therefore, it would be beneficial when knowledge is gained in a way that promotes long-term retention. Paper-and-pencil drawings for the uptake of form-function relationships of basic tissues has been a teaching tool for a long time, but now seems to be redundant with virtual microscopy on computer-screens and printers everywhere. Several studies claimed that, apart from learning from pictures, actual drawing of images significantly improved knowledge retention. However, these studies applied only immediate post-tests. We investigated the effects of actual drawing of histological images, using randomized cross-over design and different retention periods. The first part of the study concerned esophageal and tracheal epithelium, with 384 medical and biomedical sciences students randomly assigned to either the drawing or the nondrawing group. For the second part of the study, concerning heart muscle cells, students from the previous drawing group were now assigned to the nondrawing group and vice versa. One, four, and six weeks after the experimental intervention, the students were given a free recall test and a questionnaire or drawing exercise, to determine the amount of knowledge retention. The data from this study showed that knowledge retention was significantly improved in the drawing groups compared with the nondrawing groups, even after four or six weeks. This suggests that actual drawing of histological images can be used as a tool to improve long-term knowledge retention.

via Actual drawing of histological images improves knowledge retention. – PubMed – NCBI.

ABSTRACT: Anatomy education for the YouTube generation

Anatomy remains a cornerstone of medical education despite challenges that have seen a significant reduction in contact hours over recent decades; however, the rise of the “YouTube Generation” or “Generation Connected” (Gen C), offers new possibilities for anatomy education. Gen C, which consists of 80% Millennials, actively interact with social media and integrate it into their education experience. Most are willing to merge their online presence with their degree programs by engaging with course materials and sharing their knowledge freely using these platforms. This integration of social media into undergraduate learning, and the attitudes and mindset of Gen C, who routinely creates and publishes blogs, podcasts, and videos online, has changed traditional learning approaches and the student/teacher relationship. To gauge this, second year undergraduate medical and radiation therapy students (n = 73) were surveyed regarding their use of online social media in relation to anatomy learning. The vast majority of students had employed web-based platforms to source information with 78% using YouTube as their primary source of anatomy-related video clips. These findings suggest that the academic anatomy community may find value in the integration of social media into blended learning approaches in anatomy programs. This will ensure continued connection with the YouTube generation of students while also allowing for academic and ethical oversight regarding the use of online video clips whose provenance may not otherwise be known.

via Anatomy education for the YouTube generation. – PubMed – NCBI.

MANUSCRIPT: Determinants and outcomes of motivation in health professions education: a systematic review based on self-determination theory

PURPOSE:
This study aimed at conducting a systematic review in health professions education of determinants, mediators and outcomes of students’ motivation to engage in academic activities based on the self-determination theory’s perspective.
METHODS:
A search was conducted across databases (MEDLINE, CINHAL, EMBASE, PsycINFO, and ERIC databases), hand-search of relevant journals, grey literature, and published research profile of key authors. Quantitative and qualitative studies were included if they reported research in health professions education focused on determinants, mediators, and/or outcomes of motivation from the self-determination and if meeting the quality criteria.
RESULTS:
A total of 17 studies met the inclusion and quality criteria. Articles retrieved came from diverse locations and mainly from medical education and to a lesser extent from psychology and dental education. Intrapersonal (gender and personality traits) and interpersonal determinants (academic conditions and lifestyle, qualitative method of selection, feedback, and an autonomy supportive learning climate) have been reported to have a positive influence on students’ motivation to engage in academic activities. No studies were found that tested mediation effects between determinants and students’ motivation. In turn, students’ self-determined motivation has been found to be positively associated with different cognitive, affective, and behavioural outcomes.
CONCLUSION:
This study has found that generally, motivation could be enhanced by changes in the educational environment and by an early detection of students’ characteristics. Doing so may support future health practitioners’ self-determined motivation and positively influence how they process information and their emotions and how they approach their learning activities.

via Determinants and outcomes of motivation in health professions education: a systematic review based on self-determination theory. – PubMed – NCBI.

MANUSCRIPT: Ultrasound-based lectures on cardiovascular physiology and reflexes for medical students

Ultrasound has become a widely used diagnostic technique. While its role in patient evaluation is well known, its utility during preclinical courses such as anatomy and physiology is becoming increasingly recognized. The aim of the present study was to assess the feasibility/utility of integrating ultrasound-based sessions into conventional undergraduate medical school programs of physiology of the cardiovascular system and cardiovascular reflexes and to evaluate student perceptions of an ultrasound-based didactic session. Second-year medical students enrolled in the University of Padova attended a didactic session during which basic concepts regarding ultrasound instrumentation, image production, and spatial orientation were presented. Five anatomic sectors (the heart, aorta, neck vessels, inferior vena cava, and femoral veins) were then examined on a volunteer. Student perceptions of the images that were projected, the usefulness of the presentation, and the reproducibility of the experience were assessed at the end of the lecture with an anonymous questionnaire consisting of positive and negative items that were rated using a 5-point Likert scale and with two questions. One hundred eleven students attended the lecture; 99% of them found it very interesting, and none considered it boring or a waste of time. More than 96% thought it helped them to gain a better comprehension of the subject and would recommend it to a colleague. In conclusion, as ultrasound has been found to be a valuable resource for the teaching of physiology of the cardiovascular system and cardiovascular reflexes, efforts should be made to integrate ultrasound sessions into the traditional human physiology curriculum.

via Ultrasound-based lectures on cardiovascular physiology and reflexes for medical students. – PubMed – NCBI.

ABSTRACT: Using Objective Structured Clinical Examinations to Assess Intern Orthopaedic Physical Examination Skills: A Multimodal Didactic Comparison

Patient care is 1 of the 6 core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). The physical examination (PE) is a fundamental skill to evaluate patients and make an accurate diagnosis. The purpose of this study was to investigate 3 different methods to teach PE skills and to assess the ability to do a complete PE in a simulated patient encounter.
DESIGN:
Prospective, uncontrolled, observational.
SETTING:
Northeastern academic medical center.
PARTICIPANTS:
A total of 32 orthopedic surgery residents participated and were divided into 3 didactic groups: Group 1 (n = 12) live interactive lectures, demonstration on standardized patients, and textbook reading; Group 2 (n = 11) video recordings of the lectures given to Group 1 and textbook reading alone; Group 3 (n = 9): 90-minute modules taught by residents to interns in near-peer format and textbook reading.
RESULTS:
The overall score for objective structured clinical examinations from the combined groups was 66%. There was a trend toward more complete PEs in Group 1 taught via live lectures and demonstrations compared to Group 2 that relied on video recording. Near-peer taught residents from Group 3 significantly outperformed Group 2 residents overall (p = 0.02), and trended toward significantly outperforming Group 1 residents as well, with significantly higher scores in the ankle (p = 0.02) and shoulder (p = 0.02) PE cases.
CONCLUSIONS:
This study found that orthopedic interns taught musculoskeletal PE skills by near-peers outperformed other groups overall. An overall score of 66% for the combined didactic groups suggests a baseline deficit in first-year resident musculoskeletal PE skills. The PE should continue to be taught and objectively assessed throughout residency to confirm that budding surgeons have mastered these fundamental skills before going into practice.

via Using Objective Structured Clinical Examinations to Assess Intern Orthopaedic Physical Examination Skills: A Multimodal Didactic Comparison. – PubMed – NCBI.