CAREERS IN CANCER EDUCATION: INFINITE OPPORTUNITIES DURING

CHANGING TIMES

Ajit K. Sachdeva, M.D., F.R.C.S.C., F.A.C.S.Director, Division of EducationAmerican College of Surgeons

55TH ANNUAL SAMUEL C. HARVEY MEMORIAL LECTUREAMERICAN ASSOCIATION FOR CANCER EDUCATION

Saturday, October 14, 2006

Samuel C. Harvey, M.D., Ph.B., F.A.C.S.1886 - 1953

SAMUEL C. HARVEY, M.D., Ph.B., F.A.C.S.

• A consummate surgeon, scholar, educator, role model, historian, and philosopher

• Chairman, Department of Surgery, Yale University School of Medicine for 23 years

• President, American Surgical Association; First Chairman, Coordinators of Cancer Teaching

• Introduced active learner-centered education (“Yale System”)

• Enjoyed a cigar or pipe, a book, and a desire to stay longer in bed!

A CAREER IN CANCER EDUCATION

• It is October 2016

• A Surgeon-Educator, Dr. John Smith, has been invited to deliver the 65th Annual Harvey Memorial Lecture at the AACE Meeting in San Diego

• Dr. Smith reflects on the past 10 years, that have shaped his career as a cancer educator

A History of the Future

2006: A MILIEU OF CHANGE IN CANCER EDUCATION

• Unprecedented scientific and technologic advances

• Changes in clinical practice

• Different roles of physicians and other health care professionals within high performance teams

• Intense focus on competence, accountability, and patient safety

2006: A MILIEU OF CHANGE IN CANCER EDUCATION

• Impact of new regulations and mandates

• Definition of the six core competencies

• Restrictions on resident duty hours

• Emphasis on increasing efficiencies and documenting outcomes of educational interventions

• Change in demographics of the workforce

• Advances in medical and health sciences education

THE PARADIGM SHIFT

Continuing Medical

Education

ContinuousProfessionalDevelopment

KEY DIFFERENCES BETWEEN TRADITIONAL CME AND CPD

• Episodic interventions for • Lifelong learning for group of learners individual learners

• Teacher-centered and • Learner-centered and teacher-driven learner-driven

• Principal focus clinical • Comprehensive in scope

• Lecture formats • Variety of learning commonly used formats and media used

• Mostly conducted in • Conducted in different formal settings venues

CME CPD

Sachdeva, Arch Surg, 2005

Identify Area for Improvement

Engage in Learning

Apply New Knowledge and

Skills to Practice

Check for Improvement

CYCLE OF PRACTICE-BASED LEARNING AND IMPROVEMENT

Sachdeva & Blair, Surg Cl N Am, 2004

KEY CONCEPTS IN CPD AND PBLI

• Based on specific individual learning needs identified through review of clinical practice and benchmarking data

• Ongoing, contextually relevant education

• Emphasis on helping clinicians achieve requisite levels of competence and performance and not on punitive measures

• Focus on expertise and mastery

Key Concepts

NEW DIRECTIONS IN MEDICAL EDUCATION

• Learner-centered educational approaches

• Experiential teaching and learning methods

• Structured clinical skills teaching, learning, and assessment

• Structured technical skills teaching, learning, and assessment

ASSESSMENT OF THE CLINICAL SKILLS OF ENTERING SURGICAL RESIDENTS

Model: 18-station OSCE (9 couplets)

Length of SP stations - 15 min.

Length of PN stations - 7 min.

Total testing time - 3.3 hours

Results: Overall reliability = 0.91

ANOVAs revealed significant variation in individual residents’ clinical skills as assessed by SPs (F = 4.56, p < 0.01), PNs (F = 11.09, p < 0.001), or both (F = 10.9, p < 0.001)

Sachdeva et al, Surgery, 1995

ACS OSCE FOR ENTERING SURGICAL RESIDENTS

TO ADDRESS PATIENT SAFETY

OBJECTIVE STRUCTURED ASSESSMENT OF TECHNICAL SKILLS (OSATS)

Model: R-1 to R-6 surgical residents (n=48)

8 bench model simulations

Length of each station - 15 min.

Total testing time - 2 hours

Specific checklists and global ratings completed by surgeons

Results: Reliability = 0.78 for checklists and 0.84 for global ratings

Construct validity demonstrated

Reznick, et al, Am J Surg, 1997

ACS/VA STRUCTURED EDUCATION MODULE TO ADDRESS MANAGEMENT

OF ADVERSE SURGICAL EVENTS

Model:R-2 and R-3 surgical residents (n=7) participated in a 3-part exercise involving pre-operative meeting with standardized patient and spouse; intraoperative management of massive hemorrhage from IVC in a bench model simulation; post-operative meeting with the standardized spouse. Debriefings and review of videotaped performance of residents conducted by faculty

Brewster, et al, Am J Surg, 2005

ACS/VA STRUCTURED EDUCATION MODULE TO ADDRESS MANAGEMENT

OF ADVERSE SURGICAL EVENTS

Results:

Residents performed at or above

the expected levels; SP ratings

higher than faculty ratings

(p<0.05); residents found model

realistic, challenging, and a

beneficial learning experienceBrewster, et al, Am J Surg, 2005

SPECTRUM OF SIMULATION IN MEDICAL EDUCATION

• Computer-based simulations

• Standardized patients

• Part-task trainers

• High and low fidelity simulators

• Virtual reality

POTENTIAL APPLICATIONS OF SIMULATION IN MEDICAL EDUCATION

• Acquisition and maintenance of competence; demonstration of optimum performance; achievement of excellence

• Improvement in patient safety and outcomes of surgical care

• Increase in the efficiency of educational processes; assurance of educational outcomes

• Demonstration of greater accountability to the public and large consumer groups

• Curriculum integration

• Range of difficulty level

• Repetitive practice

• Feedback

USE OF HIGH FIDELITY MEDICAL SIMULATORS TO FACILITATE LEARNING

• Multiple learning strategies

• Clinical variation

• Controlled environment

• Individualized learning

Issenberg, et al, Med Teach, 2005

Important Considerations

CURRENT LIMITATIONS IN THE USE OF SIMULATION IN MEDICAL EDUCATION

• Prevalence of weak curricula; technology driving the educational opportunities

• Insufficient fidelity of simulation for certain procedures

• Problems relating to costs, logistics, access

• Absence of large-scale research to evaluate the added value of simulation in medical education

ON-LINE CLINICAL INFORMATION

• Credibility of source

• Relevance

• Unlimited access

• Speed

• Ease of use

Important Considerations

Bennett, et al, JCEHP, 2004

ON-LINE CONTINUING EDUCATION COURSES

• Quality of content

• Interactivity; case-based formats

• Ease of accessibility and use

• Convenience in obtaining continuing education credits

Factors that Encourage Participation

Casebeer, et al, JCEHP, 2004

• Greater focus on CPD and PBLI efforts

• Verification and documentation of knowledge and skills following participation in educational programs

• Regional support for innovative educational interventions; establishment of learning communities

• Enhancement of e-learning programs

OPPORTUNITIES TO ADVANCE CANCER EDUCATION: 2006 - 2016

• Focus on interdisciplinary work

• Emphasis on communication skills and professionalism

• Need for leadership to catalyze change

• Importance of mentorship in career development

• Involvement of patients as partners in health care

• Pursuit of innovative research to advance the science of cancer education

OPPORTUNITIES TO ADVANCE CANCER EDUCATION: 2006 - 2016

INTERDISCIPLINARY TEAMWORK IN PATIENT CARE

• Hypercomplexity of systems

• Task interdependence

• Mitigation of the impact of hierarchy

• Distributed decision-making

• High degree of accountability

• Immediate feedback

Characteristics of High Reliability Organizations

Baker, et al, Health Research and Educ Trust, 2006

INTERDISCIPLINARY TEAMWORK IN PATIENT CARE

• Team leadership

• Mutual performance monitoring

• Mutual support

• Adaptability

• Shared mental models

• Team orientation

• Mutual trust

Team Competencies

Baker, et al, Health Research and Educ Trust, 2006

INTERDISCIPLINARY TEAMWORK IN PATIENT CARE

• Technical expertise

• Problem-solving and

decision-making skills

• Interpersonal skills

Skill Requirements

Katzenback & Smith, Harvard Bus Rev, 2005

INTERDISCIPLINARY TEAMWORK IN PATIENT CARE

• Exemplary communication

skills and professionalism

• Active listening skills

• Negotiation and conflict

management

Special Challenges

AAMC ETE Course, 2006

• Situational awareness

• Problem identification

• Decision-making

• Workload distribution

• Time management

• Conflict resolution

TEAM COMMUNICATION IN THE OPERATING ROOM

Key Elements

Davies, ACTA Anesth Scand, 2005

TRAINING IN INTERDISCIPLINARY TEAMWORK TO ENHANCE PATIENT CARE

• Role modeling in real

environments

• Discussions of care vignettes

• Experiential courses

• Standardized, immersive

experiences with feedback

• Delivery of optimum patient care

• Promotion of patient safety

• Increase in patient compliance

• Enhancement of doctor-patient relationship

• Reduction of liability risk

• Improvement in time efficiencies

IMPACT OF EFFECTIVE COMMUNICATION ON PATIENT CARE

• Situation

• Background

• Assessment

• Recommendation

STANDARDIZED COMMUNICATION TO ENHANCE PATIENT SAFETY

Leonard, et al, Qual Saf Health Care, 2004

BARRIERS TO SAFE PATIENT HAND-OFFS

• The physical setting

• The social setting

• Language barriers

• Medium of communication

Solet, et al, Acad Med, 2005

U.S. AND CANADIAN PHYSICIANS’ ATTITUDES AND EXPERIENCES REGARDING

DISCLOSURE OF ERRORS TO PATIENTS

• Involvement in serious error, 55%; minor error, 73%; near-miss, 62%

• Support for disclosing serious errors, 98%; minor errors, 78%, near-misses, 35%

• 66% agreed that disclosing serious errors would decrease risk of lawsuits

• 74% thought disclosing serious errors would be very difficult

Gallagher, et al, Arch Int Med, 2006

• Ethical practice of medicine

• Delivery of optimum patient care

• Fulfillment of responsibilities to patients, the public, and society

• Enhancement of the doctor-patient relationship

IMPACT OF EXEMPLARY PROFESSIONALISM ON PATIENT CARE

• Behavioral approaches

• Cognitive approaches

• Social approaches

EDUCATIONAL INTERVENTIONS TO ENHANCE COMMUNICATION SKILLS

AND PROFESSIONALISM

Underlying Principles

DIFFERENCES BETWEEN LEADERS AND MANAGERS

• Cope with change • Cope with complexity

• Set a direction • Plan and budget

• Align people • Organize and staff

• Motivate and inspire • Control and problem-solve

Kotter, Harvard Bus Rev, 1998

Leaders Managers

DIFFERENCES BETWEEN LEADERS AND MANAGERS

• “Twice-born” • “Once-born”

• Risk-takers • Risk-averse

• Imaginative and inspiring • Rational and controlled

• Proactive in establishing • Reactive in establishing goals based on desires goals based on necessity

Zaleznik, Harvard Bus Rev, 2004

Leaders Managers

DIFFERENCES BETWEEN LEADERS AND MANAGERS

• Develop fresh approaches • Address problems by to problems, explore new coordinating and options

balancing opposing views

• Send messages • Send signals

• Very comfortable with • Most comfortable solitary activities working with others

• Relate to others in intuitive • Work with others in and empathetic ways traditional ways

Zaleznik, Harvard Bus Rev, 2004

Leaders Managers

CREATING A CULTURE THAT SUPPORTS EFFECTIVE LEADERSHIP

Kotter, Harvard Bus Rev, 1998

• Developing and pursuing a clearly defined plan for leadership succession

• Using challenging opportunities and specific assignments to develop the skills of individuals with leadership potential

• Providing longitudinal educational experiences and mentoring to develop leadership skills

• Recognizing and rewarding mentors

PROGRESSION OF THEEDUCATIONAL RELATIONSHIP

BETWEEN TEACHER AND LEARNER

Didactic

Supervisory

Collaborative

Consultative

Magill et al, Med Teach, 1986

CHARACTERISTICS OF A MENTOR

O’Donnell, J Cancer Educ, 1995

• Wise and trusted advisor, listener, counselor and supporter

• Encourages reflection

• Promotes personal growth and satisfaction

• Benefits from greater self-awareness, new insights, and improvement

KEY FEATURES OF MENTORSHIP

Sachdeva, J Cancer Educ, 1996

• Grounded in a developmental-contextual framework

• Long, comprehensive, intense professional relationship

• Involves teaching and learning activities; career advancement; personal support

• Both mentee and mentor reap great rewards, are transformed in the process

• One-on-one; may include multiple mentors

STAGES OF SUCCESSFUL MENTORSHIP

Initiation

Cultivation

Separation

Redefinition

Kram, Acad Manag J, 1983

• Offer training in new teaching, learning, and assessment methods

• Focus on the effective use of cutting-edge educational technologies

• Recognize and reward surgical faculty for their educational accomplishments

FACULTY DEVELOPMENT AND SUPPORT TO IMPLEMENT

INNOVATIVE MEDICAL EDUCATION

RECOGNITION AND REWARDS FOR SURGEON-TEACHERS AND SURGEON-EDUCATORS

MasterEducator

Sachdeva, et al, Acad Med, 1999

Educator

Master Teacher

Teacher

• Support for full participation of patients in their care

• Dissemination of valid and reliable information

• Delivery of individually tailored, scientifically sound patient education

• Confirmation of achievement of requisite knowledge and skills

ROLE OF PATIENTS AS PARTNERS IN MEDICAL CARE

• Learning

• Performance

• Outcomes

EVALUATION OF THE IMPACT OF EDUCATIONAL INTERVENTIONS

Impact on

• Core competencies

• CPD and PBLI

• Interdisciplinary teamwork

• Communication skills and professionalism

• Leadership

• Mentorship

• Patient Education

OPPORTUNITIES FOR RESEARCH IN CANCER EDUCATION

The key role of the American

Association for Cancer Education

2006 – 2016: AN EXCITING CANCER EDUCATION ODYSSEY

• Infinite opportunities to improve cancer care through innovative education

• Collaboration critical in designing new approaches to cancer education

• Opportunities for a spectrum of rewarding careers in cancer education

• Pivotal role of AACE in education and career development

“Nothing endures but change.”

Heraclitus, c. 540 - 480 B.C.

“For I dipped into the future, far as

human eye could see,

Saw the vision of the world, and all the

wonder that would be.”

Lord Tennyson, 1842

“Never give in, never, never, never.”

Sir Winston Churchill, 1941