Julie G. Nyquist

Integrating Addiction Medicine Into Graduate Medical Education in Primary Care: The Time Has Come

Substance use disorders create an enormous burden of medical, behavioral, and social problems and pose a major and costly public health challenge. Despite the high prevalence of substance use and its consequences, physicians often do not recognize these conditions and, as a result, provide inadequate patient care. At the center of this failure is insufficient training for physicians about substance use disorders. To address this deficit, the Betty Ford Institute convened a meeting of experts who developed the following 5 recommendations focused on improving training in substance abuse in primary care residency programs in internal medicine and family medicine: 1) integrating substance abuse competencies into training, 2) assigning substance abuse teaching the same priority as teaching about other chronic diseases, 3) enhancing faculty development, 4) creating addiction medicine divisions or programs in academic medical centers, and 5) making substance abuse screening and management routine care in new models of primary care practice. This enhanced primary care residency training should represent a major step forward in improving patient care.

Shaping professionalism in pre-clinical medical students: Professionalism and the practice of medicine

Background: Increasing emphasis is placed on teaching and assessment of professionalism in the continuum of medical education. Consistent and longitudinal instruction and assessment are crucial factors that learners need in order to internalize the tenets of professionalism. Aim: We aimed to develop a novel longitudinal course in professionalism spanning the first 2 years in a medical curriculum. Methods: This is a description of the process undertaken over the past 7 years to develop and implement a professionalism curriculum. We used the conceptual framework of constructivism, principles of adult learning, experiential learning and reflective practice to integrate learning with experience. We included student input in session development. Faculty mentors serve as role models to guide, assist and counsel students. Assessment of learners is accomplished using self, peer and mentor evaluation, and a student portfolio. Program evaluation is by course and faculty evaluation. Results: Students are given a final grade of pass or fail, together with a brief narrative. Course evaluations were positive. A survey questionnaire showed that more than 60% of the students reported gaining skills related to course goals. Conclusions: A longitudinal curriculum for the pre-clinical years was successfully launched. Plans are under way to expand this into the clinical years.

A “Medical Student Practice Profile” as the Foundation for a Case-Based Curriculum Revision

Background: In 2001, the Keck School of Medicine of the University of Southern California initiated a major curriculum reform with fully integrated teaching of the basic sciences. Description: The new curriculum integrated a set of selected clinical cases called the student practice profile (SPP). The SPP cases were designed to (a) define the core target knowledge base and essential clinical experience of all graduating students, (b) to improve the relevance of basic science teaching, and (c) to serve as the overarching organizational structure for the 4-year curriculum. Evaluation: Evaluation data demonstrated that implementation of the SPP project has been moderately successful and students have reported high exposure to the SPP cases and confidence in their ability to diagnose and manage problems. Improvement in teaching the basic sciences in a clinically relevant manner is suggested by a small continued improvement in USMLE scores since the SPP project was fully implemented. Conclusions: The SPP design represents a uniquely successful pathway to curriculum redesign.

Creating the health care team of the future: the toronto model for interprofessional education and practice.

Sioban Nelson, Maria Tassone, and Brian D. Hodges. Ithaca, NY: ILR Press, 2014. ISBN-13: 978-08014-7941-0, 176 pages,

Leaders Eat Last: Why Some Teams Pull Together and Others Don't

75.95 US (hard cover),

Book Review Teaching Naked: How Moving Technology Out of Your College Classroom Will Improve Student Learning. Jose Antonio Bowen . San Francisco : Jossey-Bass , 2012 . ISBN-13: 978-1-118-11035-5 . 352 pages,

24.82 (paperback),

36.00 US .

20.60 (Kindle). Creating the Health Care System of the Future makes a strong case for the importance of interprofessional education and interprofessional care (IPE/C), and shares the University of Torontos journey from 2002 until the books publication in 2014. The authors possess extensive experience in the topic and provide a well-written and complete introduction, providing definitions of key terms, background information, and an overview of the project and the book. This background was essential for the reader because it set the stage. The University of Toronto uses the World Health Organization (WHO) definition for interprofessional education, which “occurs when two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.” Interprofessional care is defined as “provision of comprehensive health services to patients by multiple health caregivers who work collaboratively to deliver quality care within and across settings” (page 7). These definitions ground the book along with 4 basic principles for provision of excellent patient care: (1) practitioners must understand that they are part of a diverse team; (2) practitioners must communicate effectively with the patient and family, as well as with other members of their team; (3) practitioners must know what other members do, to limit duplication and prevent gaps in care; and (4) practitioners must know how to work together to optimize care so that the patient journey from inpatient care to home care, or from primary care to the specialist clinic is experienced as seamless (page 2). The authors stated that this is a workbook designed for professionals “charged with revising curricula to incorporate interprofessional components,” those in clinical settings “introducing IPE/C in their clinical programs” as well as those “charged with enhancing quality and patient safety” (pages 4–5). They also noted that this is meant to be used as a workbook with the reader accessing sections as needed, and is not intended to be read all in one sitting. Chapters 1 and 2 tell the story of how the University of Toronto built its IPE/C program. The discussion of the University of Toronto story is quite detailed and probably will be of most interest to those actually working on establishing their own IPE/C system. However, I would recommend Chapters 3 to 5 to all readers, since these chapters provide important and basic information about common goals for IPE/C, and activities for classroom and clinical settings. Moreover, Chapters 3 and 4 in particular provide excellent stories about core courses, electives, and clinical experiences. These stories can allow any reader to relate to what has been accomplished and can stimulate thoughts about what might be possible in his/her school or clinical setting. Each chapter is described in more detail below. The book was very carefully organized and used a chapter “compass” as a visual image to display the 17 major learning points. These 17 points nicely summarize the books key messages. Each chapter opens with the relevant segment of the “compass.” Chapter 1: Getting Started provides a detailed history of the development of interprofessional education and care (IPE/C) at the University of Toronto and in its affiliated hospitals and other practice settings. This chapters major points include the importance of champions, engaging key leaders, and establishing a unified vision for education and practice. Chapter 2: Structuring for Success describes the organization and structure of the University of Toronto and its network of affiliated teaching hospitals, called the Toronto Academic Sciences Heath Network (TASHN). The key points from the “compass” are creating partnerships among disciplines, building enabling structures, creating leaders at all levels, and how IPE/C is paid for. Chapter 3: Building the Curriculum discusses the curricular goals and basic structure that is shared by the 9 health sciences programs at the University of Toronto: medicine, nursing, occupational science and occupational therapy, pharmacy, physical therapy, physician assistant, social work, speech-language pathology, kinesiology, dentistry, and medical radiation sciences. It includes the objectives, a description of each of the 3 core classroom experiences, and wonderful stories about sample elective courses. Their framework for learner development of values and competencies is presented as a Table on pages 52 to 53. It includes 3 basic constructs: values and ethics (eg, self-knowledge, respect for values of others, IP ethical decision making, and performance in an IP team), communication (eg, listening, giving, and receiving feedback, sharing information, building a common language, and dealing with conflict), and collaboration (eg, context and culture of the health care system, roles and responsibilities of each profession, decision-making, self-reflection and change). It also describes the 3 levels of training in their model, 2 preclinical (exposure or introduction and immersion or development) and 1 at the clinical level (competence or entry to practice). The primary “compass” points are creating time and space for IPE, fostering engagement, maintaining commitment, and overcoming challenges. Chapter 4: Creating a Strong Education-Practice Interface describes the evolution of the development of the growing number (just over 50 in 2012–2013) clinical “placements” that provide IPE experiences for the 3700 health sciences students at the University of Toronto. This chapter is particularly rich in stories, including many examples of how individual experiences were built in a multitude of clinical settings. The learning points from the compass were preparing the sites for clinical placements, coaching staff to support learners, and building team skills in practice. Chapter 5: Thinking about Impact and Sustainability from the Start discusses current thinking on IPE/C and addresses the role of accreditation of programs and hospitals, the place that competency frameworks have, and progress in relation to evaluation of learning and participant/client outcomes. There also was a very cogent discussion of the challenges facing any transition to interprofessional education and care. The final “compass” points are accreditation for education programs and service providers, evaluation – new directions, and competency in interprofessional education and practice. The IPE/C experts in Toronto express a clear willingness to share their projects and process and even include QR codes (matrix or 2 dimensional bar codes) in the margins for direct linkage to key resources. Finally, they provided an annotated bibliography of key publications from their group that expands the available resource base. The book was eye opening. I was astonished by how much this group of dedicated professionals has accomplished in a short span of time. The book felt like a call to action – this is important – we did it – this is how – you can do it, too – now get started! I believe that you will feel the same way and there is a role for everyone – patient, family member, student, practitioner, educator, and administrator. Each of us can and should take part in a change toward IPE/C.

Self‐report versus observation of continuing education activities: Cancer case conferences

As I picked up Leaders Eat Last, with its preface written by a retired Lieutenant General and its focus on business, I wondered if its contents would connect to those of us in health care. However, as I read the book I was struck by the similarities. As academia becomes “more like a business” and medicine becomes increasingly businesslike, the challenges discussed and insights offered seem very relevant. A key statement in the forward was particularly resonant, “Organizations where people share values and where people are valued succeed over the long term in good and bad times.” Mr. Sineks description of leaders of great organizations, who “do not see people as a commodity to be managed to help grow the money,” but instead, “see money as the commodity to be managed to help grow their people” also was insightful. Hospitals, schools of chiropractic, and outpatient practices all are organizations that require excellence from every person within them, making this admonition very relevant. In chiropractic education this impact is magnified further as young professionals build their professional identities, and the values that will guide their care of others throughout their careers. Thus, the relevance of this book to us.

Assessing the teaching of procedural skills: can cognitive task analysis add to our traditional teaching methods?

We are delighted to review the book Teaching Naked: How Moving Technology Out of Your College Classroom Will Improve Student Learning. This book introduced us to many concepts in relation to the utilization of technology to enhance student learning. Although the book was written for college teachers and administrators with undergraduate education in mind, the majority of concepts are described in a manner that can easily be applied to health professions instruction (classroom and clinical). The book is divided into three sections. Part 1, “The New Digital Landscape,” starts slowly with a chapter on the global competition faced by universities recruiting undergraduate students; this is really more applicable for college administrators. However, it picks up quickly with two outstanding chapters on social media, the virtual classroom and customizing learning for the 21st century. In Chapter 2, the discussion of forms of e-communication is a primer for those of us who do not use social media (eg, Twitter, blogs, texting, Facebook, etc.) on a daily basis. One reviewer (AS) is a clinician and found this chapter to be one of the most compelling and relevant to her work as a clinical instructor. The other reviewer (JN) is a professional educator and veteran classroom instructor. She found Chapter 3, which discusses games and customization of learning, equally compelling, with its review of key learning principles and discussion of data demonstrating the educational value of video gaming. Another highlight is Dr. Bowens description of the gaming-related skill sets that millennial learners (lifelong gamers) bring to education, such as systems thinking, sequential problem solving, lateral thinking, distributed knowledge, and cross-functional teams (page 69). It is our challenge to take advantage of these gifts. The book provides teachers with tools to do so. In Part 2, “Designing 21st Century Courses,” there are five chapters, each highlighting a different element of utilization of technology. Chapter 4 explores how to design courses to be more like video games by applying the motivational principles of “high expectations with low stakes.” Chapter 5 focuses on technology for information delivery and first exposure to content in order to make “face time” more about application and integration and less about acquisition of facts. For example, e-mail and podcasts can be used for guiding study or providing information prior to meeting with the faculty member. This allows the instructor to use time together in other ways. All instructors, clinical or classroom, can take full advantage of the information provided in Chapter 6, which is titled “Technology for Engagement.” This chapter raises awareness with statements such as, “Knowledge in the Internet age is plentiful, but is useful only if we can digest and evaluate simultaneously.” Advice is provided on how to engage students in gaining these crucial skills. Clinical teachers need to remember that decrying the inaccuracy of information from the Web is no longer enough; we must provide the skills for learners to utilize the Web, their primary lifelong source of information. Chapter 7 focuses on technology usage for assessment of learners. What was most interesting was the idea that you should share grading rubrics with the learners as part of the instruction to guide learning as well as guide assessment (page 163). When learners know the standards, they are more likely to meet them, by simply making the implicit more explicit. The final chapter in this section challenges faculty members to make classrooms more interactive and learner centered and reminds readers that the best learning is participatory and that students can learn from each other. This is something that chiropractic education has always taken advantage of for skill instruction but perhaps could better utilize in building the cognitive base. Part 3, “Strategies for Universities of the Future,” includes three chapters. Chapter 9 describes the changing landscape from locally focused education toward global availability of much of the cognitive base. Chapter 10 exhorts educational administrators to provide the support needed for faculty to move education into the Internet age. Chapter 11 explores the campus of the future. These materials should be of most interest to administrators and educational leaders, since the challenges faced by undergraduate education today could be faced very soon by health professions education. Dr. Bowen has developed a website, http://www.teachingnaked.com. At the site you can explore the “basics” and then click on the tab labeled “borrow,” where you can locate resources to assist you in applying some of the principles from the book. This is a useful supplement to the book. In health professions today there is talk of “flipping” the classroom, moving the lectures out and moving interaction and problem solving in. This book can provide some innovative tools. If you are open to change, the book can also alter your perspective as it has ours as we now think about technology more as an imperative than a supplement. We are already thinking about ways to alter teaching to be more compatible with the skills and preferences of this generation. If you choose to read this book, we believe it will stimulate you to examine your teaching and perhaps to innovate. In todays “age of the Internet” you could have the “book” in your hands in less than 10 minutes. You too could be “teaching naked.”

Educational Characteristics of Tumor Conferences in Teaching and Non‐teaching Hospitals

Background: Observation is often recommended by experts in program evaluation, but it is considerably more expensive to implement than is self‐report or self‐study. Purpose: This study examined the accuracy of self‐reports estimating the frequency of specific activities in comparison to the observed frequency of these activities. Tumor conferences served as the setting for this study. Methods: This study compared estimates from the chairs of 25 general (hospital‐wide) tumor boards from a sample of Southern California hospitals to observer ratings of 450 of their conferences. Results: Results showed a disparity between tumor chairs’ estimates of the frequency of selected educational activities versus the percentage of sessions in which these activities were observed, with all significant differences being in the direction of overstatement. Conclusions: The 2 methods resulted in identical ranking of activities by occurrence, so self‐report may be adequate for program improvement. However, for research purpo...