Challenging students’ conceptual relationships in clinical education

I just wanted to share a thought while preparing our case notes for the Applied Physiotherapy module we’re developing. One of the designers made a note of the “guideline answers” for facilitators to some of the questions that we might use to trigger students’ thinking. I wrote the following as a comment and didn’t want to lose it when the document is finalised, so I’m putting it here.

“I think we should make sure that, in addition to the ‘answers’, we should identify the main concepts we want students to understand. Remember that we’re using our paper patient (i.e. the case) as a framework for students to learn about concepts. Then, they apply those concepts in the real world to patients. They reflect on those real-world interactions and identify dissonance between their experienced reality (the patient contact) and their abstract conceptions of reality (how they originally conceived of the patient contact). After the patient contact, they feed back to their small groups and facilitators, who together help students create new relationships between concepts. So, in short, the clinical concepts are learned initially through the paper patient, tested in the real world with an actual patient, discussed online (maybe) and then brought back to the classroom for further reflection and refinement. The next week they are exposed to new concepts that build on their previous experiences, and then they get to test those abstractions in the real world again.”

I’m trying to take an intentional approach to using Laurillard’s conception of academic learning that I’m exploring in “Rethinking University Teaching”

Applying theoretical concepts to clinical practice

Concept map about concept mapping taken from IHMC website

I just finished giving feedback to my students on the concept mapping assignment they’re busy with. It’s the first time I’ve used concept mapping in an assignment and in addition to the students’ learning, I’m also  trying to see if it helps me figure out what they really understand about applying the theory we cover in class to clinical contexts. They’re really struggling with what seem to be basic ideas, highlighting the fact that maybe the ideas aren’t so basic after all. I have to remind myself that clinical reasoning is a skill that takes many years to develop through reflection and isn’t really something I can “teach”. Or is it?

For this assignment I wanted the the students to set a learning objective for themselves (I gave examples of how to do this, including using SMART principles of goal setting). They also needed to highlight a particular clinical problem that they wanted to explore and how they would use concepts from the Movement Science module to do this. They needed to describe a clinical scenario / patient presentation and use it to identify the problem they wanted to explore. From that short presentation, they should derive a list of keywords that would become the main concepts for the concept map.

Here’s a list of the most common problems I found after reviewing their initial drafts:

  • Many of them lacked alignment between the patient presentation, the learning objective, keyword / propositions and the final concept map
  • Many of the learning objectives were vague. They really found it hard to design appropriate learning objectives, which meant that their whole assignment was muddled
  • There were two processes going on in the students’ minds: patient management, and their own learning. This assignment was about student learning, but most of the students were focused on patient management. This was especially clear in the learning objective and actual maps they created, which all had a clinical focus on the interventions they would use to treat the patient, rather than the learning concepts they would apply
  • Most of the students created hierarchical maps which failed to identify complex relationships between concepts

After going through their initial drafts, I had another session with them to go through the feedback I’d given and providing more examples of what I expected from them. This assignment is proving far more difficult for the students than I’d expected. However, I’m not sure if it’s because they can’t apply theoretical concepts to clinical scenarios, or if they just don’t have a good understanding of how to create concept maps. I think that they’re having difficulty thinking in terms of relationships between concepts. The maps they’ve been drawing are appropriate in terms of the interventions they’d choose to manage their patients, but the students can’t seem to transfer the concepts from the classroom into clinical contexts.

They’re used to memorising the content because that’s how we assess them i.e. our assessments are knowledge-based. Then they go into clinical contexts and almost have to re-learn the theory again in the clinical environment. There doesn’t seem to be much transfer going on, in terms of moving knowledge from the classroom context to the clinical one. I haven’t researched this yet, but I wonder what sort of graduate we’d get if we scrapped classroom teaching altogether and just did everything on the wards and in the clinics? I understand the logistical issues of an apprentice-based approach to teaching large groups but if we didn’t have classroom time at all, maybe it’d be possible?

Social networks and clinical education: presentation at SAAHE

My presentation at the SAAHE conference is a more in-depth look at the same project that I presented at the conference in 2010. The key points I wanted to make were that:

  • Students struggle to develop practice knowledge because it is hidden from them i.e. they can’t “see” our thinking process as we reason our way through clinical issues
  • One way to externalise practice knowledge is by sharing experiences and outcomes as colleagues or peers
  • Social networks facilitate that sharing
  • Reflection needs to be facilitated and structured, otherwise students feel lost
  • Pedagogically sound teaching principles must be integrated no matter what tools you’re using

Here is the presentation that I gave earlier today:

SAFRI 2011 (session 2) – day 3

Began today with a session on workplace-based learning, spent some time “developing a model” for learning a new skill after actually trying to learn (what was for many) a new skill…spinning a top. My group came up with the following model which, truth be told was obviously based on Kolb’s learning cycle.

Reviewed educational model of Teunissen et al (2007)

Models are fluid frameworks that help to develop understanding, not algorithms that need to be followed

Readings:

  • Teunissen et al, (2007). Attending doctors’ perspectives on how residents learn. Medical Education, 41: 1050-1058
  • Teunissen et al (2007). How residents learn: qualitative evidence for the pivotal role of clinical activities. Medical Education, 41: 763-770

 

One minute preceptor / 5-step micro-skills

Has led to modest improvements in teaching skills (Furney et al, 2001), has been found to be equal to or better than traditional methods of clinical teaching in time-constrained environments e.g. bedside, ward rounds (Aagaard et al, 2004).

The one-minute preceptor is a framework (Neher et al, 1992):

  1. Get a commitment: statement of understanding / intent, should be verbal (“What do you think?”)
  2. Probe for supporting evidence: question student for further depth / detail i.e. probe the statement (“Why do you say that?”)
  3. Reinforce what was done well: provide feedback on appropriate behaviour / performance
  4. Give guidance about errors or omissions: error correction
  5. Teach a general principle: extrapolate the situation / event to more general terms
  6. Conclusion: end with clear steps for moving forward

Readings:

  • Furney et al, 2001. Teaching the one-minute preceptor: a randomised controlled trial. Journal of General Internal Medicine, 16: 620-624
  • Aagaard et al, 2004. Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: proof of concept. Academic Medicine, 79: 42-49
  • Neher et al, 1992. A five-step “microskills” model of clinical teaching. Journal of the American Board of Family Practice, 5: 419-242

 

Portfolios

What is a portfolio? A collection of learning objects / experiences, aggregated over time, directing at documenting the achievement of developmental objectives. Demonstrates progress. Must be measurable although this is hard to do.

Short session on designing portfolio tasks, asked to design a task for something we currently teach. This is a useful framework for an assignment. I chose a task for Movement Science:

  • What – To understand the relationships between concepts in movement science and apply those concepts to clinical practice (challenging for students)
  • Activity – Develop a concept map of an activity (e.g. observed movement of a patient with a movement disorder), using concepts from module to explore / explain the activity
  • Where – Clinical setting / patient encounter
  • How – Short patient history, with an associated concept map
  • Reflection – Each link on the concept map must have a note explaining the observed movement / activity, it’s relation to the module concept, and be linked to the patient history
  • Measure – concept maps can demonstrate understanding of relationships between concepts (theory) and their application to practice (patient presentation)

Type of learning taking place in above example:

  • Clinical reasoning
  • Professionalism (i.e. note taking and patient presentation)
  • Reflective practice
  • Interpreting data

Assessment is a snapshot of learning

Students worry that they didn’t learn something that you might ask them in an assessment

Be strategic in what you’re going to measure

Portfolios are about “doing”, there should be consideration of patient management involved

Portfolio assessment is often not feasible in a resource-constrained environment as it can be labour intensive. The document should serve as an indicator to guide assessment of the student. It must assess something different to what is already being assessed.

Assess reasoning. Knowledge is better assessed with other methods e.g. MCQ

Portfolios are not just another thing to do

 

Reflection

Reflection raises awareness → exploration of alternative methods

Asked to do a short reflection on personal / professional development since beginning with SAFRI programme:

“My SAFRI project began as a study that would look (in retrospect) quite superficially at the use of a social network to development clinical / ethical reasoning skills.

Over time it became clear that the method involved little more than describing “what students did”, which I found deeply unsatisfying. “Is there more to this?”

I began looking into theoretical frameworks that could help to structure the research. I’m now analysing the data with a structure (i.e. theoretical framework) that is helping me develop a deeper understanding of the process.

This has played a role I changing how I think about research. I find myself questioning a lot more in other parts of my life…”Why is it like that?”

We discussed the challenges of evaluating personal (and often deeply personal) reflections. Giving marks clouds the issue, as students then write what they think you want to hear in order to get a better mark, in contrast to sharing honest, open, authentic experiences.

It’s important to link their reflections with expected outcomes

In the community block that I supervise, students share and discuss their reflections in a group. I do this because I think it’s important to hear what others are going through (i.e. to “normalise” the experiences and emotional responses). I understand that this can change the reflections that students produce i.e. will they be honest and open if they know the reflection will be shared? I’ve found that students give still give honest reflections when they realise that the feedback is non-judgemental and that it can help them to move to deeper understanding

Does reflecting actually change practice? Is there a difference between what they say and what they do?

Strategies to improve clinical teaching: a workshop

Photo from paukrus on Flickr

On Saturday I attended a workshop at Groote Schuur hospital that had the aim of providing “…clinicians with the opportunity to improve their ability to facilitate learning in clinical practice”. Objectives included improving the understanding of theories of learning, methods of enhancing learning and assessment practices and the role of assessment in learning. I was impressed with the number of clinical educators and supervisors (about 40) who gave up their Saturdays to attend. Here are my notes:

Learning in clinical practice

Brainstorming:

  • How do I learn? Immersive, pulling in additional material, alternative ideas, I need to see the big picture
  • How do I learn best? Personal, vested interest, answering a question of relevance, application to a relevant problem, can be associated with different sensory modalities
  • How did I develop “expertise”? Socially, conversation, discussion, sharing, questioning, choosing to “own” something, pushed out of your comfort zone
  • How does learning happen? Reducing to basic principles, commitment, dedication
  • When last did you learn something new?

Students feel lost and disorientated when first arriving on a placement, no matter how much they prepare, they still feel unprepared

Theory is linear, it’s neat and “tight”, whereas practicals are messy and untidy. So, theory doesn’t prepare you for practice, only practice does

Students should be allowed to make mistakes, but when a patients health and well-being are at risk, mistakes are problematic. Students want to be “right” (maybe because we stress how important it is that they get it “right”). Clinical skills labs are useful to address the problem of practising and being allowed to make mistakes. But clinical skills labs are expensive

“Learning” is the process of turning information into knowledge through engagement

Learning is about making meaning

Students struggle with theoretical concepts until they have the opportunity see / feel the concept in the real world e.g. low tone, ataxia

Learning happens by linking new ideas to older, established ideas, which is why our perceptions of the world are highly individual

What do we do to develop student, as well as professional identity. The notion that students are “socialised” into the profession

Once students cross a “threshold”, the learning experience opens up to them

Students sometimes know the words, but not what they mean

Many students have trouble navigating between different professional contexts

Reducing power differentials helps students feel at ease and more comfortable with the idea of sharing ideas / themselves, you “humanise” the interaction

Students often don’t have a framework for self-evaluation i.e. they don’t know what a 3rd year should be able to do relative to a qualified practitioner. Their frame of reference is limited to themselves and a few teachers whose thinking process exists inside a black box

Correct errors gently, create a space of emotional safety, learning doesn’t happen in an emotional / financial / social / personal vacuum (in another workshop that I attended the other day, the presenter mentioned the “kind teacher”, an idea that I’ve been thinking about a lot)

Predicting the future by understanding the past allows us to look back at our practice and make long term plans for patient management

Enhancing learning in clinical situations

Why is the clinical learning situation so unique? Good place to apply theory, real world scenarios, BUT also a place that can inspire levels of fear that are not present in a classroom

We can ask students to assess their fears i.e. what are they afraid of and why. Then create an environment in which they can confront their fears and see the outcomes of their fears realised e.g. take off the cardio leads and hear the alarm go off, but also see that the patient continues breathing

Educational theories and frameworks can give students a structure for thinking, can help guide their thought processes, but do they necessarily need a deep understanding of the theory e.g. social constructivism?

Creating relationships between pathology and “normal” helps students understand dysfunction. However, this does little to help them develop a management protocol i.e. relate dysfunction to intervention

Facilitating ethical reasoning in student clinical practice. The relationship between ethical principles should be analysed in the light of their impact on the patient

In the early stages of their training, students don’t yet have the language to articulate ethical dilemmas

Feedback to students around ethical dilemmas should acknowledge the experience, but not pass judgement on any of the parties involved

Students often don’t emphasise the moral and ethical components of their practice, as they believe that technical ability is what they will be assessed on (which is true)

Assessment isn’t perfect

Use rubrics to prepare students in terms of providing a framework for their learning

Students won’t expose their weaknesses if they believe that they will be judged on them

Students must be able to act on the feedback given, which means that it must be timeous in order to be relevant

Students need to “learn how to know”