Jay Rosenfield

Exploring the Gap between Knowledge and Behavior: A Qualitative Study of Clinician Action Following an Educational Intervention

Purpose. Many medical education interventions improve clinicians’ knowledge but fail to change behavior. The authors exposed this knowledge–behavior gap through standardized clinical interactions, thus allowing in-depth exploration of the contributing factors. Method. A typical evidence-based educational intervention in one clinical domain (early signs of autism) was administered to family medicine residents at the University of Toronto in 2001–02, and change in knowledge was assessed through a multiple-choice test. Six to eight weeks later, participants’ relevant knowledge was documented, and their clinical behavior was observed during four interactions with standardized patients. Factors producing a knowledge–behavior discrepancy were then explored using semistructured interviews, which were audiotaped, transcribed, and analyzed using grounded theory methods. Results. Half of participants demonstrated varying degrees of knowledge–behavior gap. Eight main rationalizations (relationships, patient agenda, knowledge deficit, clinical style, means to an end, ideals, autism stigma, and systems barriers) were used to justify choices of clinical behavior, and the same rationalizations were used to justify opposite choices of behavior. Two conditions that promote clinical action based on knowledge (level of certainty and sense of urgency) were identified. Conclusion. The knowledge–behavior gap was exposed and factors reported to influence clinicians’ decisions about whether to implement new knowledge were elicited. That identical rationalizations were used to justify opposite behaviors implies these factors may not be behavioral determinants. Sense of urgency and level of certainty promote clinical action based on knowledge; focusing on these may increase the impact of education on practice.

Toward Defining the Foundation of the MD Degree: Core Entrustable Professional Activities for Entering Residency.

Currently, no standard defines the clinical skills that medical students must demonstrate upon graduation. The Liaison Committee on Medical Education bases its standards on required subject matter and student experiences rather than on observable educational outcomes. The absence of such established outcomes for MD graduates contributes to the gap between program directors’ expectations and new residents’ performance. In response, in 2013, the Association of American Medical Colleges convened a panel of experts from undergraduate and graduate medical education to define the professional activities that every resident should be able to do without direct supervision on day one of residency, regardless of specialty. Using a conceptual framework of entrustable professional activities (EPAs), this Drafting Panel reviewed the literature and sought input from the health professions education community. The result of this process was the publication of 13 core EPAs for entering residency in 2014. Each EPA includes a description, a list of key functions, links to critical competencies and milestones, and narrative descriptions of expected behaviors and clinical vignettes for both novice learners and learners ready for entrustment. The medical education community has already begun to develop the curricula, assessment tools, faculty development resources, and pathways to entrustment for each of the 13 EPAs. Adoption of these core EPAs could significantly narrow the gap between program directors’ expectations and new residents’ performance, enhancing patient safety and increasing residents’, educators’, and patients’ confidence in the care these learners provide in the first months of their residency training.

In the spirit of Flexner: working toward a collective vision for the future of medical education in Canada.

The Association of Faculties of Medicine of Canada launched the Future of Medical Education in Canada (FMEC) Project in 2007. The FMEC Projects overarching goal was to comprehensively examine the current state of undergraduate medical education, concentrating on its alignment with current and future societal needs. Like Flexners work, the FMEC Project used a process of reflection and renewal; unlike Flexners work, the FMEC Project used multiple techniques to gather information, including literature reviews, key informant interviews, international visits, and a series of consultations with stakeholders and expert groups. The projects final report, The Future of Medical Education in Canada: A Collective Vision, put forth 10 recommendations that summarized priority areas for academic medicine and medical training in Canada at the start of the 21st century. The current article reviews FMEC Project recommendations in relation to the priorities set out by Flexner in 1910. In some areas, such as the scientific basis of medical education, there is striking congruence between Flexners views and todays collective vision. In other areas, such as community-based learning, opinion appears to have shifted markedly over the past century, and concepts such as interprofessionalism may represent distinctly modern domains. While Flexnerian themes tend to center on the notion of medicine as science, present-day priorities converge on the link between academic medicine and societal needs. By looking back on Flexners work, we can see where his vision has taken us. As well, we see more clearly the new frontiers that academic medicine will continue to explore.

Integration of Community Health Teaching in the Undergraduate Medicine Curriculum at the University of Toronto

Background In 1999, Determinants of Community Health was introduced at the Faculty of Medicine, University of Toronto. The course spanned all 4 years of the undergraduate curriculum and focused on addressing individual patient and community needs, prevention and population health, and diverse learning contexts. Purpose To demonstrate the value of an integrated, longitudinal approach to the efficiency of delivering a public health curriculum. Design Time-series comparing the curricular change over two periods of time. Setting/participants Undergraduate medical students from 1993 to 2009. Intervention Using a spiral curriculum, the educational materials are integrated across all 4 years, based on the concept of medical decision making in a community context. Main outcome measures This study compares measures of student satisfaction and national rankings of the University of Toronto with the other 16 Canadian medical schools for the “Population Health, Ethical, Legal, and Organizational aspects of the practice of medicine” component of the Medical Council of Canada Qualifying Examination Part 1. Results The University of Toronto has been ranked either first or second place nationally, in comparison to lower rankings in previous years (p<0.02 on the Kruskal–Wallis test). Student ratings indicated the course was comparable to others in the curriculum. Conclusions For the same amount of curricular time, an integrated spiral curriculum for teaching public health appears to be more effective than traditional approaches.

Affordances of knowledge translation in medical education: a qualitative exploration of empirical knowledge use among medical educators.

Purpose Little is known about knowledge translation processes within medical education. Specifically, there is scant research on how and whether faculty incorporate empirical medical education knowledge into their educational practices. The authors use the conceptual framework of affordances to examine factors within the medical education practice environment that influence faculty utilization of empirical knowledge. Method In 2012, the authors, using a purposive sampling strategy, recruited medical education leaders in undergraduate medical education from a Canadian university. Recruits all had direct teaching and curricular development roles in either preclinical or clinical courses across the four years of the undergraduate curriculum. Data were collected through individual semistructured interviews on participants’ use of empirical evidence, as well as the factors that influence integration of empirical knowledge into practice. Data were analyzed using thematic analysis. Results Fifteen medical educators participated. The authors identified both constraining and facilitating affordances of empirical medical education knowledge use. Constraining affordances included poor quality and availability of evidence, inadequate knowledge delivery approaches, work and role overload, faculty and student change resistance, and resource limitations. Facilitating affordances included faculty development, peer recommendations, and local involvement in medical education knowledge creation. Conclusions Affordances of the medical education practice environment influence empirical knowledge use. Developing strategies for effective knowledge translation thus requires careful assessment of contextual factors that can enable, constrain, or inhibit evidence use. Empirical knowledge use is most likely to occur among medical educators who are afforded rich, facilitative opportunities for participation in creating, seeking, and implementing knowledge.

Measuring Educational Workload: A Pilot Study of Paper-based and PDA Tools

Background: Teaching is an important professional role for most faculty members in academic health sciences centres. Careful delineation of educational workload is needed to foster and reward teaching efforts, and to facilitate equitable allocation of resources. Aims: To promote recognition in teaching and facilitate equitable resource allocation, we developed, piloted, and qualitatively assessed a tool for delineating the educational workload of pediatric faculty in an academic health sciences centre. Methods: A prototype educational workload measurement tool was developed. Between 2002 and 2004, three successive phases of pilot implementation were conducted to (1) assess the face validity of the tool, (2) assess its feasibility, and (3) develop and assess the feasibility of a PDA (Personal Digital Assistant) version. Participants were interviewed regarding strengths, weaknesses, and barriers to completion. Data were analyzed for recurrent themes. Results: Faculty found that the tool was usable and represented a broad range of educational activities. The PDA format was easier to use and better received. Technical support would be imperative for long-term implementation. The greatest barriers to implementation were skepticism about the purpose of the tool and concerns that it would promote quantity over quality of teaching. Conclusion: We developed a usable tool to capture data on the diverse educational workload of pediatric faculty. PDA technology can be used to facilitate collection of workload data. Faculty skepticism is an important barrier that should be addressed in future work.

Study protocol for a pilot study to explore the determinants of knowledge use in a medical education context

RATIONALE, AIMS AND OBJECTIVES While the science of knowledge translation (KT) has been growing steadily for the past decade in relation to understanding processes and actions which are embedded within clinical practice settings, little is known about how empirical knowledge is used within the medical education system. Despite an increase of research in this domain, we know very little about the contribution of this evidence in the development of medical students into effective physicians. This pilot study aims to: provide a synthesis of the evidence for educational strategies within medical education; explore the perceptions and experiences of faculty in undergraduate (UG) medical education in relation to their use of evidence in their educational practices; and illuminate how medical education evidence is formally integrated into a UG medical curriculum. METHOD The study will involve three phases. First, a scoping review of the medical education research literature will be undertaken to generate insight into the evidence available for curriculum development, teaching and assessment activities within this domain. Second, a content analysis of undergraduate courses at the University of Toronto will be undertaken to generate an additional insight into the extent that medical education research has been formally integrated into the UG curriculum for medical students at the University. Finally, a purposeful sample of 30-40 medical education leaders from a single large university, selected as it aims to deliver a rigorous research-oriented medical curriculum, will be interviewed to understand how they use the available evidence in their education practices. DISCUSSION This study will lay the grounds to generate initial data into the determinants of knowledge use in a medical education context. In doing so, the findings will also inform the development of a larger, pan-Canadian study at medical schools that will generate a comprehensive account of the processes and challenges related to KT within an educational context. This larger study will also begin to explore the relevance of the Knowledge-to-Action model to a medical education context.

Methylphenidate (Ritalin) Effects on the Grapho-Motor Artwork of Children with Attention Deficit Hyperactivity Disorder

We examined the artwork of children with attention deficit hyperactivity disorder (ADHD) to identify any changes produced by methylphenidate (MPH). Seven children diagnosed with ADHD were examined under double-blind, placebo-controlled conditions in the context of a clinical assessment of their responsiveness to medication (MPH). These childrens artwork tended to use more page space and show a more expansive style on placebo and baseline compared to performance on test sessions after stimulant medication. Some children on MPH may experience cognitive constriction, manifested in drawings, that occurs at higher doses. More work is needed to understand the frequency and with whom this occurs.