How do we get the best specialists?
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Transcript of How do we get the best specialists?
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