Practical Strategies for Improving the Frequency and Quality of - - PDF document
Practical Strategies for Improving the Frequency and Quality of Direct Observation of Learners Jennifer R. Kogan, MD Professor of Medicine Assistant Dean, Faculty Development Director Undergraduate Education, Department of Medicine
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Jennifer R. Kogan, MD Professor of Medicine Assistant Dean, Faculty Development Director Undergraduate Education, Department of Medicine
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Swanwick T. Br J Hosp Med.2009;70:290-3
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KNOWS KNOWS HOW SHOWS HOW DOES
Multiple choice exam Problem based learning
Standardized patients Direct Observation/ WBA
Miller GE. Acad Med.1990; 65:S63-7
Expertise Authenticity
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Watch the following encounter between a patient and a PGY-2 resident
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Hampton JR et al. BMJ 1975; 2(5969):486-9 Peterson MC et al. West J Med. 1992; 156(2):163-5 Graber, M et al. Acad Med. 2002;77(10):981-92 National Academy of Medicine. Improving Diagnosis in Medicine, 2015 Makary MA et al. BMJ. 2016; 353:i2139 doi: 10.1136/bmj.i2139
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Williams S et al. Fam Prac.1998;15:480-92 DiMatteo M. Patient Educ Counsel. 2004;55:339-44 Stewart M . CMAJ. 1995; 152:1423-33 Vermeir P et al. Int J Clin Pract. 2015;69:1257-1267.
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Med 2002; Fox. Med Educ 2002; Mangione. JAMA1997; Braddock.1999
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LEARNING ASSESSMENT
Legitimizes the skills Ensures assessment of essential skills
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“. . . closer supervision leads to fewer errors, lower patient mortality, and improved quality
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THE PATIENT
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Safe, effective patient-centered care Trainee performance*
* a function of level of competence in context
Appropriate level of supervision**
**a function of attending competence in context
Kogan JR et al. Acad Med; 2014;89:721-7
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Berendonk C et al. Adv Health Sci Educ. 2013;18:559-71 Kogan JR et al. Med Educ. 2011;45:1048-60 Kogan JR et al. Med Educ. 2012;46:201-15 Govaerts MJB et al. Adv Health Sci Educ Theory Pract. 2011;16:151-65 Hatala R et al. Med Teach. 2008;30:414-19 Bing You RG et al. JAMA. 2009;302:1330-1 Watling C et al. Med Educ. 2012;46:593-60
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Unsatisfactory Satisfactory Superior Below Expectation At Expectation Exceeds Expectation
ORDINAL NORMATIVE GESTALT
Kogan JR et al. Med Educ. 2011;45:1048-60
???? ???? ????
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Missing evidence based elements Most evidence based elements All evidence based elements
BEST PRACTICE SELF
Kogan JR et al. Med Educ. 2011;45:1048-60
Not What I Do Close to What I Do What I Do (or better)
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Variable, sometimes deficient
making
Ramsey PG et al. JAMA 1993;269:1655-60 Paauw DS et al. JAMA 1995;274:1380-2 Vukanovick-Criley JM et al. Arch Intern Med. 2006;166:610-16 Braddock CH 3rd et al. J Gen Intern Med. 1997;12(6):339-45 Kogan JR. et al. Acad Med. 2010;85(S10):S25-8 Levinson W. BMJ Qual Saf 2011;20:823-5 Frankel RM et al. Acad Med 2011;86:445-52
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Kogan JR. et al. Acad Med. 2010;85(10 Suppl):S25-8
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recognized
validated for accuracy
wrong
Govaerts MJB et al. Adv Health Sci Educ Theory Pract. 2011;16:151-65 Kogan JR et al. Med Educ. 2011;45:1048-60
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Kogan JR et al. Med Educ. 2011;45:1048-60 Kogan JR et al. Med Educ. 2012;46:201-15
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Being Observed
Being the Observer
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*** GOAL: HELP THE LEARNER AND THE PATIENT ***
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INTERVIEW PHYSICAL EXAM COUNSELING
setting
PROCEDURES
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patient
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Identify specific dimensions of a competency in behavioral terms Discuss the criteria and qualifications required for each dimension of that competency Develop an evidence based SHARED MENTAL MODEL
Holmboe ES ABIM 2010
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including starting a medication
*** Make certain components described behaviorally
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Makoul GT. 1993/1999 Lane JL et al. Pediatrics. 2000;105:973-7. Braddock CH et al. JAMA 1999; 282:2313-2320
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Benefits of Performance Dimension Training
Kogan JR et al. Med Educ; 2015; 49(7):692-708.
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educational “judgment” using a compare and contrast process
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Dreyfus SE and Dreyfus HL. A 1980 Carraccio CL et al. Acad Med 2008;83:761-7
Time, Practice, Experience Novice Advanced Beginner Competent Proficient Expert/ Master
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Required supervisor for safe practice Generally autonomous, some guidance required Autonomous practice
Weller JM et al. Br J Anaesth. 2014;112(6):1083-91 Gofton WT et al. Acad Med. 2012;87:1401-7
I had to do I had to talk them through I had to prompt them from time to time I needed to be in the room just in case I did not need to be there
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experience
(generalizability coefficient 0.7)
Weller JM et al. B Jrn Anaesthesia 2014.112(6):1083-91 Crossley J et al. Med Educ 2011;45:560-9 Grofton WT er al. Acad Med 2012;87:1401-7 Reckman J et al. Acad Med 2015; 91:186-90.
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for mastery
identify goals/drive
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Detect Outliers Feedback/development
Early Late
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multiple points in time
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