Today was the first day of AMEE 2011, and a great start to my first international conference. Here are the notes I took.
Donald Clark – 21st century medical learning
“Death of the compliant learner” – almost all of my students are compliant, I hope Clark doesn’t buy into the idea that all of today’s students are somehow different? Even Prensky has moved on from the Digital Native debate
When the cost of education goes up, and the deliverable stays the same, you have the characteristics of a bubble → is higher education / medical education in a bubble (Malcolm Gladwell)?
Clark shows excerpt from Ferris Bueller’s day off to demonstrate poor lecturing style, gets a laugh but is caricaturing the format useful in terms of solving the actual problem?
Psychology of learning:
- Spaced practice
- Learn by doing
“The internet is shaping pedagogy”, this is the wrong way around. Effective teaching practice should make effective use of the internet.
“Lectures are ineffective for teaching”
- don’t inspire or motivate
- no critical thinking
- doesn’t emphasise values
- no social adjustment
- or behavioural skills
- only useful for transmitting information
Student and lecturer’s attention begins to fall off after 25 minutes, yet lectures often continue for much longer. Clark’s solution → record lectures! OR…change teaching practice to make use of that time more effectively
Cultural reasons for not changing teaching practice
Assessment is skewed towards favouring cramming
Is technology supporting assessment?
Surgeons who play video games perform better with laparoscopic procedures than those who don’t
I think Clark’s emphasis on technology misses the point. This isn’t the right audience to make assumptions about what technology should be used with what teaching approach. The message he’s sending is that we should use digital tools because they’re better. But he hasn’t spent enough time explaining what it’s better for and how.
The future of online continuing medical education: towards more effective approaches
Panel discussion (John Sandars, Pat Kokotailo, Gurmit Singh)
How do we get the new evidence base to change behaviour in health professionals? By delivering content and hoping → behavioural change
Online CME is about transmitting content from an “expert” to the person at home, and competing with their social lives. Does this have the intended impact of actually changing clinician’s behaviour? Sandars says “No”
How can the intended impact be achieved?
CME vs CPD
CME process whereby people keep updated regarding medical information
CPD includes CME but is more broad
e-learning implies that technology is used to enhance T&L but no definition of what technology is. I wish people would stop talking about e-learning until we demonstrate that it’s fundamentally different in terms of changing learning behaviour
List of digital tools and blending them with f2f spaces
Issues in obtaining evidence of effective CPD:
- Differing content in med ed → differing ways of delivering / teaching
- Traditional curriculum vs no curriculum
- Rare comparison between e-learning intervention and traditional intervention
- Difficulty with educational RCTs (very “medical” to think that RCTs are an important evaluative tool in education)
Kirkpatricks model to categorise the level of evaluative outcomes
Majority of research looks at participant satisfaction, but limited research demonstrating performance change in practice, no studies demonstrated that web-based CME had any effect on clinical practice
Internet learning associated with large positive effects compared with no intervention, but the effects were heterogeneous and small (internet learning interventions were broad in terms of content)
Comparison of different virtual patient desings suggest repetition, advance organisers, enhanced feedback and explicitly contrasting cases can improve learning outcomes (Cook at al, Academic Medicine, 2010)
Which “e-learning” techniques enhanced learning experiences?
- Peer communication
- Support of a tutor who was also a moderator
- Knowledge validation
- Course presentation
- Course design
Effectiveness of the online course is mediated by the learning experience
Cost effectiveness of online CPD is mainly based on self-report, so data not robust (Walsh et al, Education for primary care, 2010)
Most to least effective approaches (Bloom, International Journal of Technology Assessment in Health Care, 2005):
- Interactive techniques (audit / feedback, academic detailing / outreach, reminders)
- Clinical practice guidelines and opinion leaders less effective
- Didactic presentations and distributed print material have little to no effect
Therefore, not much evidence for the use of online learning, and the effects that do exist, are small (smaller than traditional), course design is important, and interactivity appears to be key
Improving knowledge and skills without an associated change in behaviour, is useless
- Isolated, invidualised online CME is focused on delivering content more efficiently but that misses the point
- We need to integrate social components into the learning experience
- We evaluate episodic events and expect to find behavioural change
- It’s not about one approach or the other, we need to blend different teaching methods
- We need to stop talking about e-learning, we don’t talk about overhead projector learning
Problems with CME (currently)
- Exisiting models do not improve patient care
- Current models are incomplete, and are used for different reasons
- Use is unco-ordinated
- Participation is low
- Much research names existing models as “largely irrelevant”
Moving from knowledge and skills to changing behaviour. What is the / a new model?
The outcome must be: improving patient care. This comes about through supporting information exchange, opinion and advice to make sense of the complexity of practice
Technology used must be useful and relevant
Technology + pedagogy = outcome (is it this simple?)
Should move psychological learning theory to sociological theory
Professionals learns as they go about doing things, sharing tacit knowledge, discussing and interacting with others in social networks. As people interact they share ways of thinking, feeling and acting in daly life, which influences their behaviours and habits. We are living, learning and changing in practice. They are reflexive. Learning, behaviour and change are all dynamically connected in networks and make practice complex.
Learning practive should be embodied and emergent
Reflexive networks used in teaching and learning
We should be more strategic in collaboration, rather than having collaboration forced.
How do you evaluate outcomes?
- CME credits
- Self-report: was it relevant and useful?
- Patient care audit: do patients have improved outcomes?
Tacit knowledge = useful knowledge
Practice and learning are inseparable
If individual practice is only part of the team approach, is it reasonable to expect that changing an invidual’s approach will actually impact on patient outcomes?
Interprofessional workplace-based learning using social networks
Difference between in/formal learning
80% of learning is outside the formal context. How do we make the informal learning explicit?
Between whom is learning taking place i.e. identifying actors within the network by mapping relationships between teams, professions, etc.
Look at density and information and communication flows
Everybody is involved in informal learning within networks, but the relationships are assymetrical and not collaborative or reciprocal
Network analysis is a useful method to identify relationships between professionals, but what do you do with the information i.e. how do you change the relationships?
Patient attitude to medical students experience in General Practice
Patients lack confidence to ask students to leave when receiving a personal physical examination by a GP
Female patients are less likely to have positive attitudes with regards a medical student conducting an assessment, although the numbers are quite high nonetheless
The context of the examination changes whether or not patients are happy to have students present e.g. sexual health, etc.
Learning at a clinical education ward: first and final year nursing students’ perceptions
Final year students have an emphasis on supervisor relationships and are more dependant on feedback and affirmation but don’t experience internal authenticity, which is what drives the understanding of the nursing role.
First year students focus on patient relationships with concomittant feedback
Creating a student ER
Highly integrated, student-centred, emphasis on PBL → creation of a student ER
Organisation based on teams, rather than a hierarchy. Team sees the patient concurrently, rather than consecutively
Approach allows the student to manage the patient with a focus on structured feedback. Tried to avoid students managing those with obvious serious pathology, cognitive dysfunction, etc.
Supervisor behind the student, not the other way around
Received positive feedback from students, in addition to significant improvement in student note-taking ability, among other clinical skills
Evaluating medical grand rounds – 10 years later
Mary J Bell
High numbers of repeated evaluations in order to determine reliability
We tend to give colleagues higher evaluator ratings
Highest scores had less to do with knowledge and presentation of objectives, and more to do with presenter style, level of presentation and enthusiasm → edutainment
When grand rounds were done using digital video, overal presenter ratings went down, seeming to concur with social learning theories i.e. we want to be in the same room as those we’re learning from (but is social just about physical presence?)