Branch Plenary ICCH09 PowerPoint

The Road to The Road to Professionalism:Professionalism: Reflective Learning and Reflective Learning and

Reflective PracticeReflective Practice

WILLIAM T. BRANCH, JR., MD, FAACH, MACPWILLIAM T. BRANCH, JR., MD, FAACH, MACP

Director, General Internal MedicineDirector, General Internal Medicine

Emory University School of Medicine, Atlanta, GAEmory University School of Medicine, Atlanta, GA

ICCH – MIAMI ‘0911

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.If I was Going to Die

If I was going to die,And I just had a couple of weeks,Or months,Or whatever,I would just have to,You know,Prepare.You know,Because we all going,You know,All my loved ones,You know,I just don't want mine to be suffering.

Branch WT, Jr, Torke, AM. If I Was Going to Die. J Gen Inter Med. 2006; 21: 96-98

TEACHING TEACHING PROFESSIONAL PROFESSIONAL

VALUESVALUES “In theory, this cannot be “In theory, this cannot be

done in practice…”done in practice…”

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THE PATIENT-DOCTOR COURSETHE PATIENT-DOCTOR COURSEHarvard Medical School, 1985 - PresentHarvard Medical School, 1985 - Present

Small-groups meet weekly, years 1 and 3Small-groups meet weekly, years 1 and 3

8 students, 2 – 3 faculty per group8 students, 2 – 3 faculty per group

Total 240 students and over 100 facultyTotal 240 students and over 100 faculty

Semi-structured, problem-based learningSemi-structured, problem-based learning

Faculty development component Faculty development component

Branch WT Jr, Pels RJ, Calkins D, Forrow L, Harper G, Mandell F, Maynard E, Peterson L, Arky RA. A new educational approach Branch WT Jr, Pels RJ, Calkins D, Forrow L, Harper G, Mandell F, Maynard E, Peterson L, Arky RA. A new educational approach for supporting the professional development of third year medical student. JGIM 1995; 10:691-694 for supporting the professional development of third year medical student. JGIM 1995; 10:691-694

Branch WT Jr, , Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. . Teaching medicine as a human experience: A patient-Branch WT Jr, , Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. . Teaching medicine as a human experience: A patient-doctor relationship course for faculty and first-year medical students. Annals of Intern Med. 1991;114(6):482-9.doctor relationship course for faculty and first-year medical students. Annals of Intern Med. 1991;114(6):482-9.

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CURRICULUM OF PATIENT-DOCTOR CURRICULUM OF PATIENT-DOCTOR COURSECOURSE

Harvard Medical School, 1985 - PresentHarvard Medical School, 1985 - PresentYear 1Year 1

(Examples)(Examples) Listening to patients’ storiesListening to patients’ stories Patient-interviewing skillsPatient-interviewing skills Reflection on interviewsReflection on interviews

-- building a building a relationshiprelationship-- biopsychosocial biopsychosocial modelmodel-- alcohol and alcohol and substance substance abuseabuse-- sexual history-takingsexual history-taking-- difficult relationshipsdifficult relationships

Year 3Year 3(Examples)(Examples)

Communication issuesCommunication issues-- giving bad newsgiving bad news

Medical mistakesMedical mistakes Difficult relationships Difficult relationships Health policyHealth policy Ethical issues for studentsEthical issues for students

-- informed consentinformed consent-- DNR decisions-DNR decisions-

Critical incident narrativesCritical incident narratives

Branch WT Jr, Pels RJ, Calkins D, Forrow L, Harper G, Mandell F, Maynard E, Peterson L, Arky RA. A new educational approach for supporting the professional development of third year medical student. JGIM 1995; 10:691-694 Branch WT Jr, , Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. . Teaching medicine as a human experience: A patient-doctor relationship course for faculty and first-year medical students. Annals of Intern Med. 1991;114(6):482-9.

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LEARNING THEORY OF PATIENT-DOCTOR LEARNING THEORY OF PATIENT-DOCTOR COURSECOURSE

- Experiential learning of communication skillsExperiential learning of communication skills- Skills “open the door” to reflective learningSkills “open the door” to reflective learning- Topics related to the communication issuesTopics related to the communication issues- Topics address issues students encounterTopics address issues students encounter- Narrative writingNarrative writing- Critical reflectionCritical reflection- Transformative learning Transformative learning

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Branch WT Jr, Pels RJ, Calkins D, Forrow L, Harper G, Mandell F, Maynard E, Peterson L, Arky RA. A new educational approach for supporting the professional development of third year medical student. JGIM 1995; 10:691-694 Branch WT Jr, , Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. . Teaching medicine as a human experience: A patient-doctor relationship course for faculty and first-year medical students. Annals of Intern Med. 1991;114(6):482-9.

TRANSFORMATIVE LEARNING By Reflection

Empathic Identification with Patients (Philosophy of Caring)

While drawing blood for gas measurements from a dying non-English-speaking man, a student communicated with him “through the anguish on my face” so that he would know “that I was suffering along with him.”

Branch WT Jr, Pels RJ, Lawrence RS, Arky RA. Becoming a doctor: “critical-incident” reports from third-year medical students. N Engl J Med. 1993;329:1130-2.

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TRANSFORMATIVE LEARNING Reflection on Students’ Narratives

Moral Dissonance With the Team’s Values (Moral Development)

An indigent woman refused to see a medical student in the walk-in clinic. The attending physician explained that it was a teaching unit” and the patient “had no choice.” The patient stormed out. The student wondered “how this patient, who fit the bill for the type of person I had always seen myself helping, actually saw me aligned with Dr. N. against her.” Branch WT Jr, Pels RJ, Lawrence RS, Arky RA. Becoming a doctor: “critical-incident” reports from third-year medical students. N Engl J Med. 1993;329:1130-2. Branch WT Jr. Supporting the Moral Development of Medical Students. J Gen Intern Med. 2000;15:505:510. Branch WT Jr. Use of Critical Incident Reports in Medical Education: A Perspective, J Gen Intern Med, 2005; 20: 1063-67.

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A Paradigm for Professional Growth

MORAL DEVELOPMENT IN MEDICAL STUDENTS

Post conventional morality (young adults)

conventional morality conventional morality (adolescents) (medical trainees)

Branch WT Jr. Supporting the moral development of medical students. J Gen Intern Med 2000;15:505-510

Kay J. Traumatic deidealization and the future of medicine. JAMA. 1990;263:572-573.

Hundert EM, Hafferty FW, Christakis D. Characteristics of the informal curriculum and trainees’ ethical choices. Acad Med,

1996;71:624-630.

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SOCIALIZATION IN MEDICAL TRAINEES

THE INFORMAL AND HIDDEN CURRICULA

Informal interactions between students,

residents, teachers, and administrators at an institution transmit strong messages

These messages may have more

educational impact than the formal curriculum

Hundert EM, Hafferty FW, Christakis D. Characteristics of the informal curriculum and trainees’ ethical choices. Acad Med, 1996;71:624-630.

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THE INFORMAL CURRICULUM

INFLUENCES ATTITUDES TOWARD ETHICS AND PROFESSIONALISM

In a survey of medical students, the majority felt their moral values were eroded

Widespread abuse of medical students by those

in positions of power over them 74% of residents directly observed

mistreatment of patients Freudtner C et al. Acad. Med.1994;69:670-9 Sheeham KH et al. JAMA.1990;263;533-7 Balwin DC. West.J.Med.1991;158:140-5 Balwin DC, et al. Acad.Med.1998;73:1195-200

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EXAMPLE OF THE “INFORMAL” EXPERIENCES OF A 2ND YEAR RESIDENT

When I was in the MICU, I was called by cross-cover to evaluate a patient for transfer. She had a slightly altered mental status and was hypotensive….We were giving her fluids, blood, pressors; it was around midnight. I got another admission and went to the ER to start seeing him. The first patient coded, and I went up to take care of her again. It was a terrible, endless, isolated night. I went back to the ER to see the new admission, and another code as called. I went to that. I was the only resident who responded. That patient died. I went back ot the ER, but another code was called in the MICU…..When I got to the MICU, my intern was running the code, and then we called and the patient was dead….. Brady, D, Branch WT, et al The Use of Narratives Ann of Inter Med,2002;137:220

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EXAMPLE OF THE “INFORMAL” EXPERIENCES OF A 2ND YEAR RESIDENT

(Cont’d) ….The next morning on rounds, my attending asked how

many had survived. He said we didn’t need to talk about any

that had died….It was a hellish night of nearly unbearable

stress and in the morning it was never acknowledged, as if it

had never happened, as if (my patients) had never existed…..

What bothers me most about it, was that I felt completely flat.

They were dead, and I didn’t feel anything at all. Brady, D, Branch WT, et al. The Use of Narratives Ann Inter Med 2002;137:220

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WHAT LIES BEHIND THE INFORMAL

CURRICULUM

Interns begin by seeking their professional identities

The middle years: potential burnout and disillusionment

Possible defenses: -distancing (loss of empathy) -in-group behavior (sardonic humor) -loss of moral sensitivity

The final year of training: reconciliation and rediscovery of professional and moral values

Brady D, Branch WT Jr. et al The Use of Narratives Ann Intern Med. 2002;137:220-223. Konner M. Becoming a Doctor: A Journey of Initiation in Medical School New York: Viking Penguin. 1987.

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Critical Incident ReportCritical Incident Report

Three Years on the Faculty Three Years on the Faculty

I laid my pen down carefully, placed both palms down on I laid my pen down carefully, placed both palms down on thethe desk, and made eye contact with my patient. Without desk, and made eye contact with my patient. Without wastingwasting time, I directly broached the subject of HIV risk time, I directly broached the subject of HIV risk and testing.and testing.

I felt a smile creeping across my face as I triumphantly I felt a smile creeping across my face as I triumphantly completedcompleted the consent form. It was as if I’d sold her a the consent form. It was as if I’d sold her a new carnew car

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Manning, KD. A person of status. JAMA. 2009; 300:483-84


Three Years on the Faculty Three Years on the Faculty - cont’d -- cont’d -

ThatThat day, I resolved to take my first ever day, I resolved to take my first ever voluntary HIV test atvoluntary HIV test at a local community a local community AIDS outreach center.AIDS outreach center.

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Three Years on the FaculThree Years on the Faculty ty - cont’d -- cont’d -

- As I took myAs I took my seat in the waiting area. My palms seat in the waiting area. My palms became sweaty as I grippedbecame sweaty as I gripped the laminated the laminated fuchsia card tightly in my hand. I looked aroundfuchsia card tightly in my hand. I looked around

at the other people in the room and somehow at the other people in the room and somehow felt we were kindredfelt we were kindred spirits. What were their spirits. What were their thoughts, their risks, their fears?thoughts, their risks, their fears? The simple The simple truth was thattruth was that I was afraid. I was afraid.

1717Manning, KD. A person of status. JAMA. 2009; 300:483-84


Three Years on the Faculty Three Years on the Faculty - cont’d - - cont’d -

Finally, the counselor prepared to give me Finally, the counselor prepared to give me my firstmy first "real" HIV test result. The ear-"real" HIV test result. The ear-pounding returned full throttlepounding returned full throttle as I braced as I braced myself for information that could change myself for information that could change life aslife as I knew it forever.I knew it forever.

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Three Years on the Faculty Three Years on the Faculty - cont’d –cont’d –

I pushed open the glass door, stoppedI pushed open the glass door, stopped with with closed eyes, and felt the warm sun on my face. closed eyes, and felt the warm sun on my face. WithoutWithout warning, I began to cry. It surprised me. warning, I began to cry. It surprised me. Tear after tear fellTear after tear fell as I thought of every single as I thought of every single HIV-positive patient I’dHIV-positive patient I’d ever encountered.ever encountered.

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TRANSFORMATIVE LEARNING TRANSFORMATIVE LEARNING

Transformative learning is the expansion of Transformative learning is the expansion of consciousness through the transformation of basic consciousness through the transformation of basic worldview and specific capacities of the self.worldview and specific capacities of the self.

Individuals change their frames of reference by critically Individuals change their frames of reference by critically reflecting on their assumptions and beliefs and reflecting on their assumptions and beliefs and consciously making and implementing plans that bring consciously making and implementing plans that bring about new ways of defining their worlds.about new ways of defining their worlds.

It is also a profound experience that can be described as It is also a profound experience that can be described as emotional or spiritual transformations as well emotional or spiritual transformations as well

Boyd RD, Gordon MJ. Transformative education. Int. J. of Lifetime Educ.1988; 7: 261-284Mezirow J. Transformative dimensions of adult learning. San Fran: Jossey-Bass 1991

SEMINAL EVENT circa 1965

“I remember going with a mentor regularly on bedside rounds even before I entered medical school. Rounds were quite a pageant with the great professor, his fellows, the residents, and finally the medical students trailing behind. I became increasingly fascinated with the patients’ stories, which came tumbling out as my mentor seemingly magically opened some a lock around the patient’s heart.

Branch WT Jr, Kern D, Haidet P, Weissmann P, Gracey CF, Mitchell G, Inui T.. Teaching the Human Dimensions of Care in clinical Settings. JAMA 2001;286:1067-1073.

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SEMINAL EVENT

“……The professor began exploring what the patient thought had triggered these life-threatening events. She told the story of her life in Germany and survival in a concentration camp, her attempts to smuggle food to her parents and siblings, and her despair and guilt when they were exterminated. When she was done, he turned slowly to face the group. Tears were streaming down his face. I will never forget that moment. I know he was teaching me what it meant to be a doctor.

Branch WT, Jr., Kern D, Haidet P, Weissmann P, Gracey CF, Mitchell G, Inui T. Teaching the human dimensions of care in clinical settings. JAMA 2001; 286:1067-1074.

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ACTIVE ROLE MODELING Teachable Moment - SEMINAL EVENT

“A new third year student was assigned to my office.

The patient was a thirty-eight year old woman who was just coming in to establish care. The student found that the patient had lost twenty pounds in the previous four months which she had attributed to working hard and eating less. We ordered an HIV test, which came back positive.”


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SEMINAL EVENT Active Role Modeling with Reflection

“I told the student that I wanted her to come with me when the patient returned. I also gave her an article on delivering bad news and we talked about the strategies mentioned. The student was with me when I told the patient the results. We sat and listened as the patient started to digest the news. We had quite a long wait during which both the patient and the student began crying. After the patient left we discussed how we felt about the visit.


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PAUSE FOR REFLECTION

Ask reflective questions

Consider: What would the student say about this

learning? If asked weeks or months after the event? Consider: What would the teacher say about it?

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ACTIVE LEARNING IN CLINICAL SETTINGS

In bedside teaching of humanism, active learning generally coincides with teaching rounds.

A “teachable moment” is utilized by an attending who

has won the team’s trust.

Learners are “primed” to observe and/or participate in the patient-interaction.

Feedback and reflection are key components, necessary

in learning for psychological growth.

o Examples of reflection: “What did we learn from this? How do you think the patient felt? What made this work for the patient?” “Can we spend this much time with our patients?”

o


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Faculty Development Faculty Development for Reflective Learning and Reflective for Reflective Learning and Reflective

PracticePractice

Faculty Development Faculty Development for Reflective Learning and Reflective for Reflective Learning and Reflective

PracticePractice A longitudinal faculty development process to A longitudinal faculty development process to positively influence professional and personal positively influence professional and personal growth in key faculty membersgrowth in key faculty members

Faculty development alternated experiential Faculty development alternated experiential teaching skills with reflective exercisesteaching skills with reflective exercises

We hypothesized that the group process over We hypothesized that the group process over time would enhance faculty commitment to time would enhance faculty commitment to humanism and professionalism humanism and professionalism

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Branch WT Jr, Frankel R, Gracey CF, Haidet PM, Weissmann PF, Cantey P, Mitchell GA, Inui TS. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.

METHODSMETHODSMETHODSMETHODS Groups of 8-12 faculty participants from 5 Groups of 8-12 faculty participants from 5

medical schoolsmedical schools

18 months of weekly or bi-monthly sessions 18 months of weekly or bi-monthly sessions

Experienced facilitator with promising and/or Experienced facilitator with promising and/or influential teachersinfluential teachers

6-months curriculum addressing key topics, 6-months curriculum addressing key topics, following by 12 months of group-planned following by 12 months of group-planned sessions sessions

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Branch WT Jr, Frankel R, Gracey CF, et al. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.Branch WT Jr, Frankel R, Gracey CF, Haidet PM, Weissmann PF, Cantey P, Mitchell GA, Inui TS. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.

Internal Family Med/ > 5yr post

Total Male Medicine Medicine Peds. Others residency,

Baylor college of Medicine 7 70% 43% 14% 14% 28% 86%Emory University SOM 7 30% 100% 57%Indiana University 7 70% 15% 28% 28% 28% 42%University of Minnesota 5 60% 80% 20% 60%University of Rochester 8 87.5% 100% 33%

34 65% 68% 8% 12% 12% 55%

Faculty Development Program Completers

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Branch WT Jr, Frankel R, Gracey CF, Haidet PM, Weissmann PF, Cantey P, Mitchell GA, Inui TS. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.

Survey Questionnaire Survey Questionnaire EvaluationEvaluation

Survey Questionnaire Survey Questionnaire EvaluationEvaluation

A humanistic teacher-evaluation questionnaire A humanistic teacher-evaluation questionnaire

Items based on “themes and domains” of Items based on “themes and domains” of humanistic teaching identified from narratives humanistic teaching identified from narratives from early faculty development sessionsfrom early faculty development sessions

Responses to each item recorded on a linear Responses to each item recorded on a linear analog scaleanalog scale

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Inspires me to grow personally and professionallyInspires me to grow personally and professionally 10%10% .0018.0018

Actively uses teaching opportunities to illustrate humanistic Actively uses teaching opportunities to illustrate humanistic carecare

15%15% <.0001<.0001

Stimulates reflection by the team on our approach to the Stimulates reflection by the team on our approach to the patientpatient

13%13% <.0001 <.0001

Serves as outstanding role model for how to build strong Serves as outstanding role model for how to build strong relationships with learners as well as patientsrelationships with learners as well as patients

13%13% .0004.0004

Explicitly teaches communication and relationship-building Explicitly teaches communication and relationship-building skillsskills

14%14% .0014.0014

Results: Humanistic Teaching Evaluation InstrumentResults: Humanistic Teaching Evaluation Instrument Absolute DifferencesSubjects vs. Wilcoxon

Qualities Controls p – Value Examples

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Reflective Process:Reflective Process: Appreciative InquiryAppreciative Inquiry

Appreciative inquiry identifies and works Appreciative inquiry identifies and works from strengths and inspires those from strengths and inspires those engaged in the process to emulate each engaged in the process to emulate each other. It also enhances self awareness. other. It also enhances self awareness. We used appreciative inquiry as a faculty We used appreciative inquiry as a faculty development tool. development tool.

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Appreciative InquiryAppreciative Inquiry

““Upon my return from clinic, I learned of a Upon my return from clinic, I learned of a reportedly seamless meeting with a patient’s reportedly seamless meeting with a patient’s family. They decided that no further heroic effort family. They decided that no further heroic effort should be made and that the patient’s comfort was should be made and that the patient’s comfort was the ultimate goal. That evening the patient the ultimate goal. That evening the patient arrested. Her loved ones immediately panicked arrested. Her loved ones immediately panicked and frantically asked to have the “DNR” decision and frantically asked to have the “DNR” decision reversed. Later the family told the ICU team that reversed. Later the family told the ICU team that they did not know really what to expect and that they did not know really what to expect and that they felt afraid.they felt afraid.

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Appreciative InquiryAppreciative Inquiry

Less than five minutes before my next (teaching) Less than five minutes before my next (teaching) session, I decided to do something completely session, I decided to do something completely different. I sat down and took a deep breath. I shared different. I sat down and took a deep breath. I shared with them the case of a patient with a necrotic leg (a with them the case of a patient with a necrotic leg (a case I had as an intern). I explained to the team that case I had as an intern). I explained to the team that this patient was not likely to have a satisfactory this patient was not likely to have a satisfactory outcome, and that a family meeting was needed to outcome, and that a family meeting was needed to discuss this with her loved ones. The catch? I will be discuss this with her loved ones. The catch? I will be playing the role of the patient’s loving daughterplaying the role of the patient’s loving daughter

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FOSTERING THE DEVELOPMENT OF YOUNG FOSTERING THE DEVELOPMENT OF YOUNG FACULTY MEMBERS: FACULTY MEMBERS: THE PROMISING YEARSTHE PROMISING YEARS

Appreciative Inquiries, Five Years of Faculty DevelopmentAppreciative Inquiries, Five Years of Faculty Development Assoc Prof: It was unpopular but I had to discipline a medical student Assoc Prof: It was unpopular but I had to discipline a medical student

for unprofessional conduct.for unprofessional conduct. Asst Prof: I gained confidence from a mentor in my ability to lead my Asst Prof: I gained confidence from a mentor in my ability to lead my

residency program. Now residents come to me for advice and residency program. Now residents come to me for advice and encouragement.encouragement.

Assoc Prof: Was proven correct in her clinical judgment even when Assoc Prof: Was proven correct in her clinical judgment even when the resident disagreed; resident later admitted he had learned an the resident disagreed; resident later admitted he had learned an important lesson from her . important lesson from her .

Asst Prof: Successfully supported medical students having personal Asst Prof: Successfully supported medical students having personal difficulties interfering with their studies.difficulties interfering with their studies.

Asst Prof: Recognized when he needed to intervene to support a Asst Prof: Recognized when he needed to intervene to support a resident in his role as associate program director.resident in his role as associate program director.

Asst Prof: Experiences success as a role model of an empathic Asst Prof: Experiences success as a role model of an empathic teacher and physician. teacher and physician.

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Higgins S, Bernstein L, Manning K, Schneider J, Kho A, Brownfield E, Branch, W T Jr. Fostering the Development of Young Faculty Members: The Promising Years. Submitted for publication 2009

RANDOMIZED TRIALS SHOWING THAT EDUCATIONAL INTERVENTIONS RANDOMIZED TRIALS SHOWING THAT EDUCATIONAL INTERVENTIONS IMPROVE IMPROVE

COMMUNICATION SKILLS AND INFLUENCE VALUES AND ATTITUDESCOMMUNICATION SKILLS AND INFLUENCE VALUES AND ATTITUDES

Smith RC. Lyles JS, Mettler JA, et al. A strategy for improving patient satisfaction by Smith RC. Lyles JS, Mettler JA, et al. A strategy for improving patient satisfaction by intensive training of residents in psychosocial medicine: a controlled randomized study. intensive training of residents in psychosocial medicine: a controlled randomized study. Acad.Med.1995;70:729-32.Acad.Med.1995;70:729-32.-- Patients “more satisfied” with care by trained residents (P = .02)Patients “more satisfied” with care by trained residents (P = .02)

Smith RC. Lyles JS, Mettler JA, et al. The effectiveness of intensive training for residents in Smith RC. Lyles JS, Mettler JA, et al. The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann.Inter Med. 1998;128:118-26.interviewing: a randomized, controlled study. Ann.Inter Med. 1998;128:118-26.-- Trained residents had superior interviewing skills with patients (P< .05) Trained residents had superior interviewing skills with patients (P< .05)

Moore GT, Block SD, Briggs-StyleC, Mitchell R. The influence of the new pathway curriculum Moore GT, Block SD, Briggs-StyleC, Mitchell R. The influence of the new pathway curriculum of Harvard medical students. Acad Med.1994;69:983-9.of Harvard medical students. Acad Med.1994;69:983-9.-- Students in new pathway demonstrated better relationship skills and Students in new pathway demonstrated better relationship skills and humanistic attitudes (P< .05)humanistic attitudes (P< .05)

Alon PA. Margalit, MD, PhD, Shimon M. Glick, MD, Jochanan Benbassat, MD, Ayala Cohen, Alon PA. Margalit, MD, PhD, Shimon M. Glick, MD, Jochanan Benbassat, MD, Ayala Cohen, PhD. Effect of a Biopsychosocial Approach on Patient Satisfaction and Patterns of CarePhD. Effect of a Biopsychosocial Approach on Patient Satisfaction and Patterns of Care. . JGIM. 2004; 19: 485-491.JGIM. 2004; 19: 485-491.

-- Improved patient satisfaction after physicians received reflective/active learning Improved patient satisfaction after physicians received reflective/active learning compared to controls (received lectures) (P< .05)compared to controls (received lectures) (P< .05)

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Branch Plenary ICCH09 PowerPoint

Education

Transcript of Branch Plenary ICCH09 PowerPoint