William B. Cutrer

Use of an expert concept map as an advance organizer to improve understanding of respiratory failure

Background: Helping novices transition toward expertise requires “meaningful” learning. Advance organizers are educational tools which help connect prior knowledge with new information, a critical step in making learning meaningful. Concept maps visually represent knowledge organization and can serve as advance organizers enabling deeper and more meaningful learning while enhancing knowledge integration. Aim: To compare respiratory failure understanding of resident physicians instructed, using an expert concept map advance organizer with learners receiving traditional didactic teaching. Methods: Residents were randomized by month of service to receive either a control lecture or a session using an expert concept map as an advanced organizer. Participants completed three concept maps; pre-education (CM1), immediately post-education (CM2), and 1 week later (CM3). Concept maps were scored using a standardized structural scoring method. Results: Forty-six pediatric residents (23 control and 23 experimental) participated. To account for repeated measures within subjects, the generalized estimating equations method compared concept map improvement between groups. The experimental group improved significantly more than controls (CM1–CM2–CM3 p = 0.001; CM1–CM2 p = 0.001; and CM1–CM3 p = 0.017). Conclusions: Using an expert concept map as an advance organizer improves knowledge organization and integration while offering a tool to enhance deeper understanding of medical knowledge among resident physicians.

Diagnostic Decision-Making and Strategies to Improve Diagnosis

A significant portion of diagnostic errors arises through cognitive errors resulting from inadequate knowledge, faulty data gathering, and/or faulty verification. Experts estimate that 75% of diagnostic failures can be attributed to clinician diagnostic thinking failure. The cognitive processes that underlie diagnostic thinking of clinicians are complex and intriguing, and it is imperative that clinicians acquire explicit appreciation and application of different cognitive approaches to make decisions better. A dual-process model that unifies many theories of decision-making has emerged as a promising template for understanding how clinicians think and judge efficiently in a diagnostic reasoning process. The identification and implementation of strategies for decreasing or preventing such diagnostic errors has become a growing area of interest and research. Suggested strategies to decrease diagnostic error incidence include increasing clinicians clinical expertise and avoiding inherent cognitive errors to make decisions better. Implementing Interventions focused solely on avoiding errors may work effectively for patient safety issues such as medication errors. Addressing cognitive errors, however, requires equal effort on expanding the individual clinicians expertise. Providing cognitive support to clinicians for robust diagnostic decision-making serves as the final strategic target for decreasing diagnostic errors. Clinical guidelines and algorithms offer another method for streamlining decision-making and decreasing likelihood of cognitive diagnostic errors. Addressing cognitive processing errors is undeniably the most challenging task in reducing diagnostic errors. While many suggested approaches exist, they are mostly based on theories and sciences in cognitive psychology, decision-making, and education. The proposed interventions are primarily suggestions and very few of them have been tested in the actual practice settings. Collaborative research effort is required to effectively address cognitive processing errors. Researchers in various areas, including patient safety/quality improvement, decision-making, and problem solving, must work together to make medical diagnosis more reliable.

Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education.

Change is ubiquitous in health care, making continuous adaptation necessary for clinicians to provide the best possible care to their patients. The authors propose that developing the capabilities of a Master Adaptive Learner will provide future physicians with strategies for learning in the health care environment and for managing change more effectively. The concept of a Master Adaptive Learner describes a metacognitive approach to learning based on self-regulation that can foster the development and use of adaptive expertise in practice. The authors describe a conceptual literature-based model for a Master Adaptive Learner that provides a shared language to facilitate exploration and conversation about both successes and struggles during the learning process.

A facilitated peer mentoring program for junior faculty to promote professional development and peer networking.

Purpose To explore the design, implementation, and efficacy of a faculty development program in a cohort of early career junior faculty. Method Interested junior faculty members were divided into interdisciplinary small groups led by senior faculty facilitators. The groups met monthly for 1.5 hours to review a modular curriculum from 2011 to 2013. Using a survey at two time points (September 2011 and 2013) and an interim program evaluation, the authors collected data on participants’ demographics, faculty interconnectedness, and self-reported knowledge, skills, and attitudes (KSA) in the domains of professional development and scholarship, including the ability to write career goals and align activities with those goals. Results A total of 104 junior faculty participated in the program. They demonstrated changes in self-reported KSA in the domains of professional development (P = .013, P = .001) and scholarship (P = .038, P = .015) with an increase in ability to write career goals (P < .001), ability to align activities with those goals (P < .001), and number of and amount of time spent pursuing activities related to those goals (P = .022). These changes were more significant among female faculty and were not affected by academic rank or time since last training. Interconnectedness among faculty increased during the period of study—the number of nodes and ties between nodes within the network increased. Conclusions This facilitated peer mentoring program for junior faculty was effective in improving the KSA necessary to promote early career advancement and peer networking, especially for women.

Educational Strategies for Improving Clinical Reasoning

Clinical reasoning serves as a crucial skill for all physicians regardless of their area of expertise. Helping trainees develop effective and appropriate clinical reasoning abilities is a central aim of medical education. Teaching clinical reasoning however can be a very difficult challenge for practicing physicians. Better understanding of the different cognitive processes involved in physician clinical reasoning provides a foundation from which to guide learner development of effective reasoning skills, while pairing assessment of learner reasoning abilities with understanding of different improvement strategies offers the opportunity to maximize educational efforts for learners. Clinical reasoning errors often can occur as a result of one of four problems in trainees as well as practicing physicians; inadequate knowledge, faulty data gathering, faulty data processing, or faulty metacognition. Educators are encouraged to consider at which point a given learners reasoning is breaking down. Experimentation with different strategies for improving clinical reasoning can help address learner struggles in each of these domains. In this chapter, various strategies for improving reasoning related to knowledge acquisition, data gathering, data processing, and clinician metacognition will be discussed. Understanding and gaining experience using the different educational strategies will provide practicing physicians with a toolbox of techniques for helping learners improve their reasoning abilities.

Building learning communities: evolution of the colleges at Vanderbilt University School of Medicine.

Learning communities, which are an emerging trend in medical education, create a foundation for professional and academic development through the establishment of longitudinal relationships between students and faculty. In this article, the authors describe the robust learning community system at Vanderbilt University School of Medicine, which encompasses wellness, career planning, professional development, and academics. The Vanderbilt Advisory Colleges Program introduced in 2006 initially focused on two goals: promoting wellness and providing career advising. In the 2011–2012 academic year, the focus of the colleges expanded to incorporate an enhanced level of personal career advising and an academic component. In the four-year College Colloquium course, faculty selected as college mentors teach the medical humanities and lead sessions dedicated to student professional development in the areas of leadership, research, and service-learning. This academic and professional development program builds on the existing strengths of the colleges and has transformed the colleges into learning communities. The authors reflect on lessons learned and discuss future plans. They report that internal data and data from the Association of American Medical Colleges Medical School Graduation Questionnaire support consistently high and increasing satisfaction among Vanderbilt medical students, across the metrics of personal counseling, faculty mentoring, and career planning.

Constructing a Shared Mental Model for Faculty Development for the Core Entrustable Professional Activities for Entering Residency

In 2014, the Association of American Medical Colleges identified 13 Core Entrustable Professional Activities for Entering Residency (Core EPAs), which are activities that entering residents might be expected to perform without direct supervision. This work included the creation of an interinstitutional concept group focused on faculty development efforts, as the processes and tools for teaching and assessing entrustability in undergraduate medical education (UME) are still evolving. In this article, the authors describe a conceptual framework for entrustment that they developed to better prepare all educators involved in entrustment decision making in UME. This framework applies to faculty with limited or longitudinal contact with medical students and to those who contribute to entrustment development or render summative entrustment decisions. The authors describe a shared mental model for entrustment that they developed, based on a critical synthesis of the EPA literature, to serve as a guide for UME faculty development efforts. This model includes four dimensions for Core EPA faculty development: (1) observation skills in authentic settings (workplace-based assessments), (2) coaching and feedback skills, (3) self-assessment and reflection skills, and (4) peer guidance skills developed through a community of practice. These dimensions form a conceptual foundation for meaningful faculty participation in entrustment decision making. The authors also differentiate between the UME learning environment and the graduate medical education learning environment to highlight distinct challenges and opportunities for faculty development in UME settings. They conclude with recommendations and research questions for future Core EPA faculty development efforts.

You Too Can Teach Clinical Reasoning

* Abbreviations: HSP — : Henoch-Schonlein Purpura RLQ — : right lower quadrant As part of the ongoing Council on Medical Student Education in Pediatrics series on skills and strategies used by great clinical teachers,1–6 this article focuses on practical knowledge and skills for teaching clinical reasoning. Building on SNAPPS and One Minute Preceptor models,6 we will address the clinical assessment portion of oral and written presentations that represents the culmination of the clinical reasoning process. Using the concepts of problem representation,7 semantic qualifiers,8 and illness scripts7,9,10 defined below, we will outline how you can guide your students’ clinical reasoning development. A problem representation is “the one-liner” at the end of a presentation that synthesizes the entire patient story (history details, physical findings, and investigations) into 1 “big picture” statement.7 To create a problem representation, physicians restructure pertinent patient details into abstract terms called semantic qualifiers. Semantic qualifiers are abstractions in medical rather than lay terminology and generally exist in divergent pairs, such as acute versus chronic and severe versus mild (Table 1, step 2).8 Here is an example of a problem representation, with the semantic qualifiers in italics: A previously well, 2-year-old unimmunized girl presents with an acute history of respiratory distress. She is febrile , looks unwell , and is drooling. View this table: TABLE 1 Teaching Steps for Clinical Reasoning Novice clinicians can be taught to generate problem representations by using semantic qualifiers. First, have your students write out a 1- to 2-sentence problem representation (summary of patient information) based on either a written … Address correspondence to Joseph Gigante, MD, Department of Pediatrics, Vanderbilt University School of Medicine, 8232 Doctor’s Office Tower, Nashville, TN 37232-9225. E-mail: joseph.gigante{at}vanderbilt.edu

Competency milestones for medical students: Design, implementation, and analysis at one medical school

Abstract Competency-based assessment seeks to align measures of performance directly with desired learning outcomes based upon the needs of patients and the healthcare system. Recognizing that assessment methods profoundly influence student motivation and effort, it is critical to measure all desired aspects of performance throughout an individual’s medical training. The Accreditation Council for Graduate Medical Education (ACGME) defined domains of competency for residency; the subsequent Milestones Project seeks to describe each learner’s progress toward competence within each domain. Because the various clinical disciplines defined unique competencies and milestones within each domain, it is difficult for undergraduate medical education to adopt existing GME milestones language. This paper outlines the process undertaken by one medical school to design, implement and improve competency milestones for medical students. A team of assessment experts developed milestones for a set of focus competencies; these have now been monitored in medical students over two years. A unique digital dashboard enables individual, aggregate and longitudinal views of student progress by domain. Validation and continuous quality improvement cycles are based upon expert review, user feedback, and analysis of variation between students and between assessors. Experience to date indicates that milestone-based assessment has significant potential to guide the development of medical students.

Medical Student Contributions In The Workplace: Can We Put a Value on Priceless?

As healthcare reform evolves, economic pressure intensifies, and education budgets come under increased scrutiny, there is growing interest in understanding the specific contributions of medical students to patient care and the healthcare settings in which they train and participate. Contributions may include patient-centered (i.e. health coaching) [1] and team-centered assistance (i.e. prevention of errors) [2]. However, there are many challenges to measuring this value [3]. The first challenge is we have little shared understanding of howwe define either value or contributions. For example, many medical school faculty can point to specific instances in which their student contributions have been invaluable, but very few have an overarching framework for identifying overall value. Second, in a complex team setting, understanding the unique contributions of a single team member is difficult and in some cases impossible. As healthcare teams increasingly rely on a multitude of interprofessional teammembers (i.e. nursing, social work, pharmacy, physical therapy, etc.) individual roles and contributions become further blended. Finally, as many more medical schools are blurring the lines between the traditional Flexnerian 2+2 year model (i.e. 2 years of basic science followed by 2 years of clinical rotations) and incorporate earlier clinical rotations (i.e. after 1 year rather than 2) faculty struggle to understand the developmental trajectory and therefore roles and contributions of medical students in the workplace. In order to move our collective understanding of this problem forward, we propose that a series of research projects be undertaken. It would be very helpful to define nomenclature around medical student contributions. This would then enable stakeholders to quantify contributions across settings and students. A better understanding of the typical progression of a medical student could additionally solidify faculty expectations of students and clarify the appropriate assessment of their work. Establishment of competency goals for medical students in the workplace will help to ensure that every graduate is prepared for practice. Recording of medical students’ observable abilities, such as the demonstration of entrustable professional activities [4], may allow a transparent means to monitor their development as physician learners. Medical students and other workplace learners provide immense value to patients, healthcare teams, and the systems in which they work. Although we may never be able to fully quantify this value, having a better understanding of its scope and magnitude is an important and achievable goal.