How do we get the best specialists?

Professor Charlotte Ringsted, MD, MScHPE, PHDBMO Chair in Health Professions Education Research

Director and Scientist,The Wilson Centre

Department of AnesthesiaUniversity of Toronto and The University Health Network

SCIENTISTS• Promote creative synergies betweendiverse theoretical perspectives,and between theory and practice

Overview

• Competency-, outcome-based education– Framework and Conception

• Clinical training– Curriculum design

Frameworks of competence

• CanMEDS roles

– Medical Expert– Health Advocate– Communicator– Collaborator– Manager– Scholar– Professional

• ACGME competencies

– Medical knowledge– Patient care– Interpersonal and

communication skills– System based practice– Practice based learning and

improvement– Professionalism

The seven roles• EFPO project, 1992

– Undergraduate education, Ontario, society’s needs, eight roles

Manager

• CanMEDs project, 2000– Postgraduate

education, RCPSC, entire Canada, seven roles

Medical expert

Scholar

Communicator

Collaborator

ProfessionalWhole person

Health advocateDK

Canada and Denmark – Red and white; Neighbours; Hans Island

3 personsper km2

125 personsper km2

No 3

North America

• “Assessment rich area”– National exams– Flooded by

psychometricians– Heavy focus on reliability of

tests and exams– Strong tradition of

cognitive psychology and behaviourism

Competence as Sausage Factory

Professiona-lism

SkillsKnow-ledge

Skills

ITER

CEXOSCE

Knowledge

Essay

SAQMCQ

Professionalism

Portfolio

ITERWBA

Specialist training as Sausage FactoryFocus: Assessment and exams

B Hodges 2013

CEXOSCEITER

MCQSAQESSAY

WBAITERPortfolio

Denmark

• “Assessment free area”– Focus on training programs

and evaluation of education– No specialist exams and

no psychometricians

• “To emphasize the educational purpose of training, comprehensive formative evaluation is suggested as alternative to specialist examinations.”

Karle, Nystrup ME1995

Competence as Sausage Factory

Professiona-lism

SkillsKnow-ledge

Skills

ITER

CEXOSCE

Knowledge

Essay

SAQMCQ

Professionalism

Portfolio

ITERWBA

Specialist training as Sausage FactoryFocus: Training and Evaluation

B Hodges/C Ringsted 2013

SimulationClinical trainingLogbooks

NationalCoursesSeminarsReading

SupervisorAppraisalmeetings

RotationsProgramsTrainees’evaluationof quality of program

DK reform: C/OBE and ITAPGME 1991• NBH rules, guidelines• Goals and objectives

– Specialist societies• Speciality courses• Clinical programmes• Training posts• CRE and supervisor• Appraisal meetings (3)• Trainees’ evaluation• No exams

PGME reform 2001• NBH rules, guidelines• Goals and objectives

– CanMEDS framework• Plus ’general’ courses*• Clinical programmes• Training posts• CRE and supervisor• Appraisal meetings (3)• Trainees’ evaluation• In-training assessment

WBA, In-training assessment, Anaesthesiology Ringsted et al. Med Teach 2003

•Cusum scoring•Logbook on experience•Learning portfolio

•Communication skills (1)•Management/collaboration (2)•Academic competence (3)

1 st year

training

Clinical skills assessments (12)Observationin vivo / vitro

Assessment based on practice data and written reflective assignments/reports

Longitudinalassessments

Factors related to value of ITA Ringsted et al. ME 2004, Med Teach 2003, ASS 2003

• The link to practice– Help in structuring teaching, training and learning

• Outcomes clear, monitoring progress, identify problems• Coupling of theory to practice

– Used as licence to practice rather than end-of-training assessment

• The effect on learning– Should include a challenge to the learner– ‘We all learn more’

• Assessors’ attitudes– Enthusiasm and rigour

ITA-programs and psychometrics

In-training assessment, Anaesthesiology Ringsted et al. Med Teach 2003

•Cusum scoring•Logbook on experience•Learning portfolio

A challenge to psychoanalyse this

Schuwirth & v.d. Vleuten ME 2006

A plea for new psychometric methods

Future of Medical Education in CanadaToward a Competency-Based Approach

Long DM, Acad Med 2000

Competency-basedresidency training –

Reducing time from3 years to 1½ year

Time

CanMEDS 2015 project

• Hybrid of Time and Competence

• In-training WPB assessment• EPAs and Milestones• Focus on “Intrinsic Roles”• Patient safety and inter-

professional collaboration• Graded responsibility

A call for systems-based education

• Outcome-based curricula• Milestones, graded

responsibility• Systems/society orientation• Teamwork within and across

professions and institutions

Current practice

• Focus on individuals• Point-in-time sampling• Standardization

Future

• Focus on teams• Longitudinal WBA• Subjective, collective

CLINICAL TRAININGA MATTER OF CURRICULUM DESIGN

• The concrete taskthe near team– Patient consultation, ward round,

amb., operation, diagn. investigation

• The system context andthe broader team– Primary, secundary, and tertiary

sector and interplay withinand between these plus other stakeholders

• The wider context andthe general perspective– The speciality/society, the profession,

the region, the state, the society

Specialist training

• Experience and exposure– Time and volume

• Professional development– Deliberation

Oct 2013

Significant correlation between scores and complication rate

Experience – number of procedures and years of practice

Quartile 1 Quartile 2-3 Quartile 4Summary rating (1-5) 2.9 3.7 4.4*Laparoscopicprocedures 53 96 157*Any procedure

106 155 241*Time laparoscopic 137 123 98*Time any 110 111 85*Surgical practice (yrs) 11 9 11

Experience and exposure

Curriculum design

• Logbook of experience– Help in designing the composition of the training

program– Ensure breadth and depth in experience and

exposure

Experience is not enough

Debilerate practiceGuest et al, 2001, Coles 2002, Andersson, 2004

• Critical appraisal and reconstruction of practice - instruction, monitoring, feedback and discussions, and opportunities to improve performance repeatedly

Professional judgment

• Not so much about finding the “right” answer but rather what is “best” in the situation. Coles 2002

• Ability to manage ambiguous problems, tolerate uncertainty and make decisions with limited information. Epstein and Hundert JAMA 2002

Routine experts vs. Adaptive experts

Most of us

Expertise

Ericsson, Guest et al., Choudhry et al. 2005

Perfo

rman

ce

Experience

Innovative dimension’Adaptive experts’

Efficiency dimension’Routine experts’

Schwartz et al. 2004

Self- regulation of learning and performance Zimmerman 2011

• Self-regulated learning and performance• Forethought• Adaptation• Evaluation

• Characteristics– Motivation, proactive goal setting, strategic

learning style, monitoring, adaptation, modelling learning environment, self-efficacy, assistance-seeking, - practice, practice, practice

Thoracic surgeons – why and how did they learn a new procedure?

• Video Assisted Thoracoscopic Surgery– New technique introduced in late

90’s– Henrik Jessen Hansen & René

Horsleben Petersen

• Jensen et al. studied why and how experts learn a new procedure– Interviews in 2011 with ten VATS

experts/local pioneers

Model – Experts learning VATS

MotivationIncentive Social

contagion

Monitoringoutcomes

Socialcompetition

Selfrealisation

Self-efficacy

QualityOf care

Systems-regulation oflearning and performance

Self-regulation oflearning and performance

Society-based

coaching

Self-directedlearning

”I didn’t learn it – I taught it myself”

Jensen et al. 2012Paper in progress

Self – and system regulation Jensen et al 2012

Self – regulation• Build on prior knowledge

and skills of anatomy, disease, techniques, equipment

• Highly creative in developing technique (’towel cover’)

• Step-by-step approach, Zone of Proximal Development – time, elements, size and place

• Monitor patient outcome

System – regulation• Organiational doubts

and concerns; personal recognition

• Finances, available equipment

• Time constraints (the ’list’), co-workers (the team)

• Expectations of patients and co-specialties

• The concrete taskthe near team– Patient consultation, ward round,

amb., operation, diagn. investigation

• The system context andthe broader team– Primary, secundary, and tertiary

sector and interplay withinand between these plus other stakeholders

• The wider context andthe general perspective– The speciality/society, the profession,

the region, the state, the society

Person-Task-Context

PERSONNovice ... AdvancedKnowledge, skills,

experience

CONTEXTAlone … Team

ComplexityUncertainty

TASKSimple ... complicated

Part … Whole

Performance

Novice

Situated learning

Advanced

• Legitimate Peripheral Participation

– Single task– Simple situation– Basic procedures

– Working context– Multi-professional teams– New procedures

Professional develomentDreyfus, Epstein & Hundert

PERSONAdv. beginner

Novice

CONTEXTSmall teams

Close supervision

TASKSimpleSingle

Year 1

PERSONProficient

Expert

CONTEXTComplex systems

IndependentSupervising others

TASKComplexAtypical

Year 4-5

PERSONCompetent

CONTEXTLarger teams

Distant supervision

TASKComplicated

Typical

Year 2-3

• The concrete taskthe near team– Patient consultation, ward round,

amb., operation, diagn. investigation

• The system context andthe broader team– Primary, secundary, and tertiary

sector and interplay withinand between these plus other stakeholders

• The wider context andthe general perspective– The speciality/society, the profession,

the region, the state, the society

Integrating roles at 3 layers (EPAs)

ROLES Layer 1 Layer 2 Layer 3

Medical expert CommunicatorCollaboratorAdvocateManagerScholarProfessional

Roles at 3 levels (Milestones)

Roles Level 1 (Y1) Level 2 (Y2) Level 3 (Y 3-4)Med. expert Green Green; Yellow Green; Yellow,

Red Communicator Green Green; Yellow Green; Yellow,

RedCollaboratorAdvocateManagerScholarProfessional

Summary and conclusion

Competence?• Competency = specific capability

– ”Reflects expectations that are expressible in measurable behaviour; uses criterion standards for judging; informs learners and others about expectations” Albanese ME 2008

• Competence = holistic overall capacity– ”The habitual and judicious use of communication,

knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served” Epstein and Hundert JAMA 2002

Future directions – the goals?

Outcome goals• Clearly defined standards of performance

– Checklists– Competence cards– Rating forms– Quality of product

Efficiency dimension

Process goals• Training as Preparation for Future Learning

(PFL)– Approach to the task– Deliberation, reflection– Adaptation to situation– Critical re-construction

Innovative dimensionSchwartz 2004,2005Coles 2002Harden 1999

Curriculum design

LEARNING

Repetition andcorrection of errors

Plan and structureof the experience

Appropriate levelof difficulty Instruction

and feedback

Questions anddialogue

Critical appraisalof practice

EDUCATION

Curriculum design

• Careful and thoughtful planning of experience– Grade the tasks and responsibilities, acknowledge the

contextual issues of learning• Coach

– Stimulate innovative dimension and meta-cognition – as preparation for future learning

• Critical appraisal of practice – own and general– Using paper assignments and students as resource

Med Educ 2011

Thank you for your attention

??????

Challenge in postgraduate education

Undergraduate education

Postgraduate education

Knows

Does

Can Can

Does

Knows

School-based

Work-based

• Learn from managing cases• Learn how to manage cases•Reflect in and on practice

Cultural dimensions

IDV PDI0

10

20

30

40

50

60

70

80

90

CA DK SE NO FI

• Individualism– ‘I’ vs. ‘We’ thinking

• Power distance– Acceptance of

hierarchies

Cultural dimensions

MAS UAI0

10

20

30

40

50

60

70

CA DK SE NO FI

• Masculinity/Femininity– Competition, ‘Be the

best’, rewards for success

• Uncertainty avoidance– Control of future, rules,

principles, guidelines

ASSESSMENTEPAS AND MILESTONES

CanMEDS framework in different contexts

Training residents, studentsSupervision of residents

Leader of individualsand teamsFinal responsibility

For patient care

Knowledgeand skills

Feedback

EBM andup-to date

Teamwork

ManagementTime management

Financial aspectsWork in H organization

Cultural dimensions Hofstede • Individualism

– ‘I’ vs. ‘We’ thinking• Power distance

– Acceptance of hierarchies• Uncertainty avoidance

– Control of future, rules, principles, guidelines

• Long-term orientation– (Short) Truth, quick results,

normative• Masculinity/Femininity

– Competition, ‘Be the best’, rewards for success IDV PDI UAI LTO M/F

0

10

20

30

40

50

60

70

80

90

CA NL DK

Discussion

• The importance of contextual aspects– Cultural dimensions– Working hours (48 vs. 37); Day-care facilities– Age mean 36 (SD 4.0) vs. 44 (5.4) years– Progressive independence of trainees appear to facilitate

the transition

North America: Entrustable professional activitiesAnd graded responsibility and Milestones

– May be in conflict with organization and finansial models

ITA-programs and psychometricsIn-training assessment, Anaesthesiology Ringsted et al. Med Teach 2003

•Cusum scoring•Logbook on experience•Learning portfolio

A challenge to do psycho..analysis of this

Assessment of written assignment

Explain changes in your planAnatomy, Physiology, Pharmacology

What if? What if?

Old vs. youngPregnantBreast-feeding

Acute vs. chronicDiseases: liver, kidney,GI, CV, DM,psychiatric

Young womanLower abd.

Gen. anaesth.

Write up a plan for this patient

Assessment of written assignment

• Reflection before and after case– Description of patient and operation– Theoretical and practical consideration regarding

choice of anaesthesiological approach related to patient condition, wishes, surgery, and context

– Describe potential problems and complications and discuss strategies to minimise these

– Describe actual patient course and events– Reflection related to pre-operative considerations– Use references from literature in the reflection

Trainees’ opinion of assessment (1-9)

15141414131315N =

10

8

6

4

2

0

610

2

143

14

115

Ringsted et al. AAS 2003

About the written assignments

“Extremely good learning experience - to do this review of a patient’s course ”

“It was hard work” (Trainee) “This is really a valuable innovation in the

education - these assignments” (Trainee) “It was more easy than I thought - to

review these assignments” (Supervisor) “This is an advantage to the entire

department - we all learn from these..”

Kirsten Nørgaard, MHPE, 2004

Lessons learned

• Outcome-based education– ‘CanMEDs roles’ is a nice mental framework. Need for

both competency-goals (specific capability) and competence-goals (overall capacity)

• In-training assessment programs– Meaningful programs are tailored to clinical context

and trainees’ level of professional development, and drives learning in specialties’ weak areas.

• The process– Useful to take a design-based research approach:

Cycle of critical review of data (literature, quality of care reports, interviews); design; enactment, evaluation; and large working groups

Mastery and DevelopmentCompetency as capabilityrelated to specific tasks

1. 2. 3. 4. 5. 6.

Scoring

Competence as holisticcapacity related to any task

Time

987654321

No single method can measure it all – V.d .Vleuten 2010

assessment programs are recommended

Defined by ‘supervision’

• Beginning– Difficulty despite supervisory

efforts• Developing

– Needs supervisory assistance• Advancing

– Often without supervisor• Capable

– Usually without supervisor• Skillful

– Always without supervisorAMB care – unfamiliar cases

Surgery and Anesthesiology (CA):“We supervise themclosely all the time!!”

Internal medicine (DK):“You mean observe them -watch what they are doing????”

Defined by expectations to level

• Below Foundation– Basic consultation skills, incomplete history

• Level of completion of Foundation– Sound consultation skills, adequate history

• Level of completion of early higher training– Good consultation skills, sound history

• Level expected during higher training– Excellent and timely consultation skills, comprehensive

• Level expected on completion of higher training– Exemplary consultation skills, complex/difficult case

Crossley et al., Med Educ 2011

Tend to be ‘conservative’maintain status quo ratherthan drive learning in aspectsnot intuitively emphasized

Reliability Crossley et al, Med Educ 2011

From: Contextual Errors and Failures in Individualizing Patient Care: A Multicenter StudyAnn Intern Med. 2010;153(2):69-75. doi:10.7326/0003-4819-153-2-201007200-00002

Data collection?111 attending physicians

Incognito patientspresented biomedicaland contextual red flags

Responses to probing:•No complications•Biomedical complications•Contextual complications•Both types of complications

Physicians probed fewer contextual (51%)than biomedical red flags (63%)Probing was necessary, but not sufficient for appropriate care

Weiner et al 2010

Perspectives• Professionel competence

– The habitual and judicious use of knowledge, skills, reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served

• Approach to work– Ability to assess practice, question current practice– Life-long learning skills, search new information, critical appraise

information and new technology and apply that in new practice– Ability to accept uncertainty and ambiguity, know your own limits,

willingness to admit errors/mistakes and learn from these

During rotation ITA

Daily supervisorcan be many different persons

Competence card

Items Score•............ X•............ X•............ X•............ X•............ X

Signature

Daily supervisor

Signing off

The trainee and the supervisorat the appraisal meeting

Portfolio ofcompetencies

Competence 1 SignatureCompetence 2 SignatureCompetence 3 SignatureCompetence 4 SignatureCompetence 5 SignatureCompetence 6 SignatureCompetence 7 ..................Competence 8 ..................

Competence card no. 6

•............ X•........... X•............ X•............ X•............ X•............ X

Signature

Look!

Fine!!I’ll sign in

the logbook

Let us discussthis competence

Portfolio signatures

Experience from internship Henriksen et al. UfL 2008

• ”We take it at the appraisal meeting – go over the list and then I sign. It is not like I observe what they are doing”

• ”If he tells me he has done a procedure, I trust him and sign.”

”Its a bit like hunting for autographs”

Perspectives• Professionel competence

– The habitual and judicious use of knowledge, skills, reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served

• Approach to work– Ability to assess practice, question current practice– Life-long learning skills, search new information, critical appraise

information and new technology and apply that in new practice– Ability to accept uncertainty and ambiguity, know your own limits,

willingness to admit errors/mistakes and learn from these

Why in-training assessment?• Postgraduate education is work-based

– 50% of the physician work-force are trainees– Quality of care relies on trainees’ competence during training– ”End-of training examination is like reading yesterday’s news”

• In-training assessment, a tool for learning– Help clarify objectives according to broad aspects of

competence (CanMEDS roles)– Stimulate deep learning– Support effective and efficient education

Knowledge and skills

• Causal understanding of concepts, principles, and tool design affects retention and transfer of learning Woods et al. 2006, 2007, Schwartz 2004

• Self-regulatory processes in development of expertise Zimmerman 2006

– Forethought: Task analysis, strategic planning– Performance: Contextual adaptation of strategies– Post-task: Evaluation and reflection Bech et al. EJVS 2010

Routine expert vs. Adaptive expert

”Most professionals reach a stable,average level of performanceand maintain this mediocrestatus for the rest of their careers.”

Routine expertsPerfo

rman

ce

Experience

Ericsson, Guest et al., Choudhry et al. 2005, Schwartz 2004

Adaptive experts

Simulation training, clinical training, and follow up (Cusum-scoring) Adamsen 2002

P r e - t r a i n i n g i n g a s t r o i n t e s t i o n a l e n d o s c o p y u t i l i z i n g c o m p u t e r i z e d s i m u l a t i o n

T h e o r y ( m a n d a t o r y )( C o t t o n & W i l l i a m s , S A D E ’ s t e x t b o o k )

I n t r o d u c t i o n ( 4 5 m i n )( T e c h n i c a l h a n d l i n g , s t r u c t u r e d i n s t r u c t i o n )

P r e - p r o g r a m s c o r i n g( ” C y b e r - s c o p y ” )

S i m u l a t i o n p r o g r a m ( 2 - 3 d a y s )• c o n s e c u t i v e o r d e r

• p r o c e e d o n l y w h e n a l l c r i t e r i a m e t

• l a s t c a s e w i t h s u p e r v i s o r o b s e r v i n g

G a s t r o s c o p y : 2 0 s c e n a r i o s

p a s s p y l o r u s

r e t r o f l e c t

t o t a l t i m e < 1 5 m i n .

C o l o n o s c o p y : 2 0 s c e n a r i o s

r e a c h c o e c u m < 1 5 m i n .

e x c e s s i v e p r e s s u r e < 5 x

l o s t v i e w < 5 x

R e v i e w o f p e r f o r m a n c e , p o s t - p r o g r a m s c o r i n g( r e p e a t p r o g r a m o r p a r t o f p r o g r a m i f n e e d e d )

I n - v i v o s u p e r v i s e d e n d o s c o p y( s a m e c r i t e r i a a s a b o v e )

F i n a l p r e - t r a i n i n g e v a l u a t i o n

T r a i n i n g l o g ( C U S U M s c o r e ) C o n t i n u i n g r e p o r t i n g

t o p r o j e c t t o e v a l u a t e

i m p a c t o f s i m u l a t i o n

C r e d e n t i a l l i n g

S v e n A d a m s e n

H : S P M I

P o s t g r a d u a t e M e d i c a l I n s t i t u t e

C o p e n h a g e n H o s p i t a l C o r p o r a t i o n

In-vivo Colonoscopy After Simulation

-1

0

1

2

3

4

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15Scenario

Cus

um s

core

Transatlantic comparison of the competence of surgeons at the start of their professional career

M. P. Schijven et al. BJS 2010

Table 3 Canadian (84 hours) and Dutch (55 hours) residents on the four primary outcome measures

Canadians Dutch t40 P

CIP 0·52(0·05) 0·53(0·07) 0·18 0·856

PAME 0·85(0·06) 0·79(0·05) 3·90 <0·001

OSATS-C 0·78(0·06) 0·75(0·06) 1·33 0·192

OSATS-G 0·75(0·06) 0·74(0·07) 0·66 0·515Values are mean(s.d.). CIP, Comprehensive Integrative Puzzle; PAME, Patient Assessment and Management Examination; OSATS-C, Objective Structured Assessment of Technical Skill checklist; OSATS-G, Objective Structured Assessment of Technical Skill global rating scale.

System-based practice (manager)• Work effectively in various health care settings and

systems. Coordinate patient care within the system

• Consider cost and risk-benefit. Advocate for quality in patient care and optimal patient care systems

• Work in inter-professional teams to enhance patient safety and improve quality. Participate in identifying system errors and implementing potential systems solutions

Learning outcome and transfer

• Defining and measuring learning Wulf & Shea ME 2010

– A relatively permanent change in a person’s capability to perform, must be demonstrated by retention or transfer tests

• The concept of transfer Schwartz et al. 2004

– Assessment according to concept of preparation for future learning (PFL) rather than direct application according to an outcome-defined standard

Challenges

• Describing competence and outcome– Too detailed – Be able to manage - Lists of

procedural skills, diseases (+300 competencies)– Too general - The ‘intrinsic’ roles - difficult to define

• Disintegration of the concept ‘competence’– Seven disciplines rather than an integrated,

context-based concept of competence• Expectations at various levels of training?

– EPAs and Milestones?

Aspects of competence

CanMEDS roles– Medical Expert– Health Advocate– Communicator– Collaborator– Manager– Scholar– Professional

ACGME competencies– Medical knowledge– Patient care– Interpersonal and

communication skills– System based practice– Practice based learning

and improvement– Professionalism

Confident

More than 24 months

Survey amongNordic juniorDoctorsN = 621

Why focus on theory and reflection? Klemola

and Norros, ME 1997, 2001

• Realistic orientation– Recognition of

uncertainty and unpredictability

– Communicative relationship: each patient is unique

• Objectivistic orientation– No recognition of

uncertainty and unpredictability

– Authoritative relationship: ’a case’: coronary, asthmatic, etc

Anaesthesiology– Clinical physiology and pharmacology; Procedural skills; Monitoring of

respiratory and cardiovascular parameters; Context – patient, surgery, team

Two distinct patterns related to ‘experts’

Habit of action Klemola and Norros, ME 1997, 2001

• Interpretative– Combine monitor information with situational

information and background knowledge– Recognition of the versatility of information from

several resources, oxygen SAT, End-tidal CO2, etc.

• Reactive– Operate directly with

the numbers– Contradictory use of

monitors, emphasising importance regarding patient safety without understanding the mediated character and versatility of information

Knowledge and Anaesthsiology Klemola and Norros, ME 1997, 2001

• Forethought: physiological potentials– ”He can go uphill without getting out of breath, so probably

he will tolerate anaesthesia well. Major problem might be oxygenation and ventilation.”

• Adaptation: physio-pharmacological experiment– ”You can’t tell how an elderly patient will react. You have to

check his responses and give drugs accordingly.”• Evaluation and reflection-in-action

– ”The patient has capacity to compensate for side-effects of anaesthesia through sympathetic activation, a kind of capacity that elderly patients do not necessarily possess. That is a safe thing to observe”

Flexner ?

Influence of society of VATS

• Societal contagion – Cohesion, close direct relation, ’friendship’

• Conversation, discussion (dyad system)

– Structural equivalence, identically positioned, but not necessarily in direct contact

• Competition, status (social system)

• Both cohesion and structural equivalence– Inspiration, coach, competition

» Burt 1987 on Coleman, Katz, and Menzel's (1966) Medical Innovation (Tetracycline)

Experience is not enough

Debilerate practiceGuest et al, 2001, Coles 2002, Andersson, 2004

• Critical appraisal and reconstruction of practice - instruction, monitoring, feedback and discussions, and opportunities to improve performance repeatedly

Concreteexperience

Abstraction, generalisation

New experiencenew situations

Observationsand reflectionLEARNING

Concreteexperience

Abstraction, generalisation

New experiencenew situations

Observationsand reflection

Curriculum design

LEARNING

Repetition andcorrection of errors

Plan and structureof the experience

Appropriate levelof difficulty Instruction

and feedback

Questions anddialogue

Critical appraisalof practice

EDUCATION

Training curriculum

• Learn how to manage tasks– Preparation, instruction and

feedback• Simulation• Leaning guides and ITA

• Learn from managing tasks– Wide experience– Reflection in and on practice

– own and unit’s pracitice

Work-based education

Does

Can

Knows