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Author: Brian S McGowan, PhD

What are the limitations of self-directed learning?

As a bit of background, the ‘Zones of Proximal Development’ is a concept introduced by Vygotsky in the early 20th century. In laymens terms the model might be best understand in the following way: The zones of proximal development describe the difference between what a learner can do without help and what he or she can do only with help. In other words, “The [model] defines functions that have not matured yet, but are in a process of maturing, that which may mature tomorrow, and that which are currently in an embryonic state; these functions could be called the buds of development, the flowers of development, rather than the fruits of development, that is, what is only just maturing.”

As adult educators it is our obligation to understand these zones as a critical element of our needs assessments AND to understand and design interventions that support the transitions through each zone. While we often explore what our learners know and what they don’t know (ie., educational gaps or needs), it seems rare to see educational groups exploring how to best help learners evolve. Applying the zones of proximal development model would mean that our needs assessments and educational planning process increasingly focus on how to move learners forward from one zone, to another, to another – while understanding what structure is required to support the learning process.Zones of proximal development

At ArcheMedX, using the Natural Learning Actions model, we have developed a structured learning model that allows learners to move through content (and across zones) in both self-paced and scaffolded ways. The primary learning objects created by partners provide the principal learning experiences, but it is the sophistication afforded by the learning architecture that allows educators to create trigger points through Educator Notes, Cuepoints, and In-Lesson Polling that extend an educator’s reach and contribute to a fully scaffolded learning experience. While many learners may be able to consume the primary learning object with little additional support, many more (it seems) require the layered and connected learning experience to truly engage and learn. And this is perhaps one of the most critical insights we have derived from the thousands of learners who have completed ArcheMedX-powered education and engaged around content to more effectively reflect and apply critical lessons to practice.

Perhaps our call to action here is to ensure that the educational community expands their definition of good educational planning and design as they realize that the creation of content is simply the first step in the educators role. To ensure success they must focus more broadly on creating a complete and structured learning experience. Considering the zones of proximal development model should drive educators to seek out and leverage more structured educational interventions, without which the limitations of learning and self-directed learner growth may be undermining the overall impact of the medical education we create.

RESOURCE: Flipped Classroom 2.0: Competency Learning With Videos

e flipped classroom model generated a lot of excitement initially, but more recently some educators — even those who were initial advocates — have expressed disillusionment with the idea of assigning students to watch instructional videos at home and work on problem solving and practice in class. Biggest criticisms: watching videos of lectures wasn’t all that revolutionary, that it perpetuated bad teaching and raised questions about equal access to digital technology.Now flipped classroom may have reached equilibrium, neither loved nor hated, just another potential tool for teachers — if done well. “You never want to get stuck in a rut and keep doing the same thing over and over,” said Aaron Sams, a former high school chemistry teacher turned consultant who helped pioneer flipped classroom learning in an edWeb webinar. “The flipped classroom is not about the video,” said Jonathan Bergmann, Sams’ fellow teacher who helped fine tune and improve a flipped classroom strategy. “It’s about the active engaged stuff you can do in your class.”

via Flipped Classroom 2.0: Competency Learning With Videos | MindShift.

ABSTRACT: Trainee and Program Director Perceptions of Quality Improvement and Patient Safety Education

Objective. To assess the current state of quality improvement and patient safety (QIPS) education at a large teaching hospital. Methods. We surveyed 429 trainees (138 residents, 291 clinical fellows) and 38 program directors (PDs; 2 were PDs of >1 program) from 39 Accreditation Council for Graduate Medical Education-accredited training programs. Results. Twenty-nine PDs (76.3%) and 259 trainees (60.3%) responded. Most trainees (68.8%) reported participation in projects culminating in scholarly products (39.9%) or clinical innovations (44%). Most PDs reported that teaching (88.9%) and project supervision (83.3%) are performed by expert faculty. Nearly half of the PDs (45.8%) and trainees (49.6%) perceived project-based learning to be of equal value to formal curricula. Compared with trainees, a greater proportion of PDs reported needs for funding for projects, teaching faculty to provide mentorship, and faculty development (P < .05). Conclusions. Providing additional financial, administrative, and operational support could enhance the value of curricula and projects. Developing expert teaching faculty is paramount.

via Trainee and Program Director Perception… [Clin Pediatr (Phila). 2014] – PubMed – NCBI.

ABSTRACT: Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions

Object On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures. Methods The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000-2002) and post-reform (2005-2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method. Results A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre- and post-duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11-1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91-1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17). Conclusions The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.

via Worse outcomes for patients undergoing brain tum… [J Neurosurg. 2014] – PubMed – NCBI.

ABSTRACT: Team-based learning in a pathology residency training program

OBJECTIVES:
Team-based learning (TBL) has been integrated into undergraduate and medical education curricula in many institutions. However, TBL has not been widely introduced into postgraduate medical education. Our study aimed to measure the effect of TBL on promoting learning and teamwork in the setting of pathology residency training.
METHODS:
Four TBL sessions were held and individual and group readiness assurance tests (IRAT/GRATs) were performed; scores were compared using Wilcoxon matched-pairs signed rank tests. Residents completed 18-item validated team performance surveys measuring the quality of team interactions on a scale of 0 (none of the time) to 6 (all of the time). Mean and standard deviation were calculated for each item.
RESULTS:
Scores on the IRAT vs GRAT were significantly different (P < .05). The team performance survey received mean scores ranging from 5.3 ± 1.1 to 6.0 ± 0.0.
CONCLUSIONS:
The use of TBL promotes teamwork and learning in a pathology residency program. Residents scored higher on the readiness assurance tests when working in teams, demonstrating the effectiveness of team learning and achievement. In addition, the Accreditation Council for Graduate Medical Education competencies of professionalism and interpersonal and communication skills were further enhanced by incorporating TBL into pathology residency training.

via Team-based learning in a pathology residenc… [Am J Clin Pathol. 2014] – PubMed – NCBI.

ABSTRACT: A survey of interprofessional education in chiropractic continuing education in the United States

Objective : The purpose of this study is to describe the state of chiropractic continuing education vis-à-vis interprofessional education (IPE) with medical doctors (MD) in a survey of a sample of US doctors of chiropractic (DC) and through a review of policies. Methods : Forty-five chiropractors with experience in interprofessional settings completed an electronic survey of their experiences and perceptions regarding DC-MD IPE in chiropractic continuing education (CE). The licensing bodies of the 50 US states and the District of Columbia were queried to assess the applicability of continuing medical education (CME) to chiropractic relicensure. Results : The majority (89.1%) of survey respondents who attend CE-only events reported that they rarely to never experienced MD-IPE at these activities. Survey respondents commonly attended CME-only events, and 84.5% stated that they commonly to very commonly experienced MD-IPE at these activities. More than half (26 of 51) of the licensing bodies did not provide sufficient information to determine if CME was applicable to DC relicensure. Thirteen jurisdictions (25.5%) do not, and 12 jurisdictions (23.5%) do accept CME credits for chiropractic relicensure. Conclusion : The majority of integrated practice DCs we surveyed reported little to no IPE occurring at CE-only events, yet significant IPE occurring at CME events. However, we found only 23.5% of chiropractic licensing bodies allow CME credit to apply to chiropractic relicensure. These factors may hinder DC-MD IPE in continuing education.

via A survey of interprofessional education in ch… [J Chiropr Educ. 2014] – PubMed – NCBI.

ABSTRACT: The expert patient as teacher: an interprofessional Health Mentors programme

BACKGROUND:
To meet future health care needs, medical education must increase the emphasis on chronic illness care, interprofessional teamwork, and working in partnership with patients and families. One way to address these needs is to involve patients as teachers in longitudinal interprofessional educational programmes grounded in principles of patient-professional partnerships and shared decision-making.
CONTEXT:
The University of British Columbia has a history of initiatives designed to bring patient and community voices into health professional education. Increasing opportunities for interprofessional education has become important because of accreditation requirements.
INNOVATION:
We describe preliminary findings from a 3-year pilot of an interprofessional Health Mentors programme, an elective patient-as-teacher initiative in which groups of four students from different disciplines learn together, with and from a mentor with a chronic condition (an ‘expert by experience’) over three semesters. The goals, achieved through six themed meetings and a symposium, are to learn about living with a chronic condition from the patient’s perspective and to develop interprofessional competencies. Groups are given suggested topics for each meeting, but function as self-managed learning communities, and are encouraged to explore their own questions. Faculty members support direct learning between students and mentors through setting broad objectives and responding to the student reflections written after each group meeting. Students and mentors rate the programme highly, and a wide range of important learning outcomes have been documented. Medical education must increase the emphasis on chronic illness care, working in partnership with patients
IMPLICATIONS:
Key characteristics, generalisable to other educational programmes, include the role of faculty staff in supporting learning between students and patients, a minimalist structure to promote ownership and creativity, and flexible delivery.

via The expert patient as teacher: an interprofession… [Clin Teach. 2014] – PubMed – NCBI.

ABSTRACT: The role of social media in clinical excellence

BACKGROUND:
The provision of excellent patient care is a goal shared by all doctors. The role of social media (SM) in helping medical students and doctors achieve clinical excellence is unknown. Social media may help facilitate the achievement of clinical excellence
PURPOSE:
This report aimed to identify examples of how SM may be used to help promote the achievement of clinical excellence in medical learners.
METHODS:
Three of the authors previously conducted a systematic review of the published literature on SM use in undergraduate, graduate and continuing medical education. Two authors re-examined the 14 evaluative studies to identify any examples of SM use that may facilitate the achievement of clinical excellence and to consider whether there were any aspects of clinical excellence for which no studies had been performed, and, if so, whether SM was relevant to these domains.
RESULTS:
Each study touched on one or more of the following domains of clinical excellence: communication and interpersonal skills; professionalism and humanism; knowledge; diagnostic acumen; exhibiting a passion for patient care; a scholarly approach to clinical practice; and explicitly modelling expertise to medical trainees. No study addressed the role of SM to promote the skillful negotiation of the health care system, and in collaboration with investigators to advance science and discovery; however, additional evidence suggested that SM may play an adjunctive role in promoting the achievement of these aspects of clinical excellence.
CONCLUSION:
This report supports the hypothesis that SM may help facilitate the achievement of clinical excellence; however, further research is needed into the role of SM in promoting the achievement of clinical excellence.

via The role of social media in clinical excellence. [Clin Teach. 2014] – PubMed – NCBI.

ABSTRACT: Resident duty hour changes: impact in the patient-centered medical home

BACKGROUND AND OBJECTIVES:
Family medicine residency programs are challenged with balancing hospital-based training with a longitudinal primary care continuity experience. In response to the Preparing the Personal Physician for Practice (P4) Initiative, the University of Missouri (MU) Family Medicine Residency Program sought to increase the presence of its residents in their continuity clinic, ie, the patient-centered medical home (PCMH). While initially successful, these efforts encountered formidable barriers with the July 2011 duty hour regulations from the Accreditation Council for Graduate Medical Education (ACGME).
METHODS:
PCMH hours and visit numbers were collected and analyzed for MU residents from July 2005 through June 2012.
RESULTS:
Comparing the 2 years before the P4 schedule changes to the first 3 years after the P4 changes, MU first-year residents experienced a 27% increase in patient visits with a 13% increase in hours. In the subsequent 2 years, which incorporated compliance with the new ACGME regulations, first-year residents experienced a 33% decrease in visits with a 25% decrease in hours. This negated the increases seen with the previous P4 schedule changes, and residents in all years of training experienced less visits, less hours, and less visits per hour.
CONCLUSIONS:
New duty hour regulations not only limit the time resident physicians spend in the hospital but also their experience in the ambulatory setting. Considering the emphasis family medicine training programs place on continuity of care and the PCMH, the new regulations will have significant implications for these programs.

via Resident duty hour changes: impact in the patient-ce… [Fam Med. 2014] – PubMed – NCBI.

ABSTRACT: Learning culture and feedback: an international study of medical athletes and musicians

OBJECTIVES:
Feedback should facilitate learning, but within medical education it often fails to deliver on its promise. To better understand why feedback is challenging, we explored the unique perspectives of doctors who had also trained extensively in sport or music, aiming to: (i) distinguish the elements of the response to feedback that are determined by the individual learner from those determined by the learning culture, and (ii) understand how these elements interact in order to make recommendations for improving feedback in medical education.
METHODS:
Using a constructivist grounded theory approach, we conducted semi-structured interviews with 27 doctors or medical students who had high-level training and competitive or performance experience in sport (n = 15) or music (n = 12). Data were analysed iteratively using constant comparison. Key themes were identified and their relationships critically examined to derive a conceptual understanding of feedback and its impact.
RESULTS:
We identified three essential sources of influence on the meaning that feedback assumed: the individual learner; the characteristics of the feedback, and the learning culture. Individual learner traits, such as motivation and orientation toward feedback, appeared stable across learning contexts. Similarly, certain feedback characteristics, including specificity, credibility and actionability, were valued in sport, music and medicine alike. Learning culture influenced feedback in three ways: (i) by defining expectations for teachers and teacher-learner relationships; (ii) by establishing norms for and expectations of feedback, and (iii) by directing teachers’ and learners’ attention toward certain dimensions of performance. Learning culture therefore neither creates motivated learners nor defines ‘good feedback’; rather, it creates the conditions and opportunities that allow good feedback to occur and learners to respond.
CONCLUSIONS:
An adequate understanding of feedback requires an integrated approach incorporating both the individual and the learning culture. Our research offers a clear direction for medicine’s learning culture: normalise feedback; promote trusting teacher-learner relationships; define clear performance goals, and ensure that the goals of learners and teachers align.

via Learning culture and feedback: an international stu… [Med Educ. 2014] – PubMed – NCBI.