7 ways to up your game in the “classroom”
Medical education is undergoing a revolution, says Carlos Gomez-Garibello, PhD (Ed). With colleagues Dr. Valérie Dory and Beth-Ann Cummings, MDCM’03, he has some practical advice for alumni entrusted with training the next generation of clinicians and researchers—to help you stay ahead of the curve.
- Test your test questions
“When I left medical school, I had a whole lot of facts in my head,” says Dory, Assistant Professor, Department of Medicine, who trained as a family doctor in Belgium. “But I found it very difficult to apply them because I hadn’t learned them in a very practical way. I hadn’t learned to make the links.” After her residency, she discovered a passion for medical education. At the McGill Faculty of Medicine since 2014, Dory is a member of both the Centre for Medical Education and the new Assessment and Evaluation (A&E) Unit.
At the A&E Unit, Dory’s innovations include creating a bank of exam questions for the Undergraduate Medical Education (UGME) program. This bank is used to assess and improve on the exams administered to medical students. It seems simple, but it is also groundbreaking.
There is, it turns out, a right way and a wrong way to word multiple choice questions. This is important: A student who aces a poorly written exam has not displayed a grasp of the material.
With the advent of the A&E Unit, guidelines for writing multiple choice questions have greatly improved, explains Cummings, Associate Dean, Undergraduate Medical Education. It has also allowed teachers to make the most of their tests. “We’re focusing on having items on exams where students can practice clinical reasoning.” With an item bank, teachers can assign specific objectives to each question and then track performance—a welcome addition to the teaching toolkit.
- How you doin’?
Dory’s main focus is the new MDCM curriculum, which has completed its four-year rollout begun in 2013. “We are still evaluating what’s worked and what needs to be improved,” she says.
The Medicine Class of 2017, the first cohort to graduate under this new curriculum, is also the first to have completed a new progress test, another innovation brought to McGill by Dory. The written test is administered six times over the four-year program and covers material the students are expected to master before receiving their degrees. It helps define a baseline for the program, while providing individual students with information on their performance. As more undergraduate medical programs follow suit and implement progress tests of their own, there may be opportunities to create shared progress tests, giving new insight into curricular strengths and weaknesses.
- Name that cognitive bias/roadblock
There are many reasons why a learner may come to the wrong conclusion regarding a diagnosis, says Dory: “Is it a knowledge problem? Are they susceptible to premature closure?” A wrong diagnosis may stem from a limited understanding of the patient’s history, or the learner may be settling on one idea before considering all the facts.
Teachers need to identify what difficulties the student is facing and target those areas specifically. It is a common mistake for learners to conclude their patient evaluation with a single diagnosis. The same tendency to narrow one’s focus occurs in teacher assessments of medical learners, Dory says. “Educators shouldn’t come up with a single diagnosis for the student.”
- Allow for emotion
According to Gomez-Garibello, Assistant Professor, Centre for Medical Education, Faculty of Medicine, the link between emotions and professional growth is crucial. “The question that I get quite often is: ‘You are saying that emotions are an important part of learning, therefore, clinical supervisors have to be happy so learners learn better?’”
That’s not the idea, he says. “Emotions are part of interactions between residents, students, and patients, but what is more important is developing mechanisms in order to identify and cope with those emotions.” Coping mechanisms may be personal, for example, a learner with anxiety that is aggravated by a particular procedure may find exercises such as meditation can help them label and regulate their emotions.
It is of course possible to become more comfortable with specific procedures through practice, Gomez-Garibello says. This is one of the principles behind the use of simulated or standardized patients, such as at McGill’s Steinberg Centre for Simulation and Interactive Learning, where students have the opportunity to practice engaging in potentially difficult conversations and interactions with patients in a safe environment.
- Assess when to trust
Clinicians in a supervisory role have to make decisions about how much trust to place in a learner, whether to conduct a patient physical examination, make a patient assessment or figure out a post-operative care plan. “As supervisors and care providers we shouldn’t assume that someone can do something based on their level of training, we should be assuming that they can do it based on evidence that they can,” says Cummings.
“This is a whole movement in medical education,” Gomez-Garibello says. Entrustable Professional Activities (EPAs) give supervisors, who aren’t education experts, but are experts in clinical reasoning, a way to measure whether learners are competent in practical situations. Learners may reach milestones at different times, based on their experience and trajectory. Within this framework, instead of comparing learners to one another, teachers acknowledge individual strengths and weaknesses, and collaborate to target clinical problem areas.
This assessment strategy was established in Europe and is now being applied in North America, where it is championed, notably, by the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. Taking a patient history, for example, requires communication skills and awareness of potential biases. “When competencies are grouped into the EPAs, that makes it easier for the supervisors to conduct the assessment,” Gomez-Garibello says.
EPAs are based on trust, patience and attention to detail. “If I review a case with someone who is a second-year resident and the patient history makes no sense to me, I could get very worried,” says Cummings. That second-year resident may not at first appear to be able to carry out the same procedures as other residents at the same stage of training. But as more information emerges, it could become clear that they are really good at taking histories with straightforward problems, but get overwhelmed when there are three or four issues, and that’s what they need to work on, Cummings says. “Clinical supervision becomes an opportunity to get to the next step.”
As of July 2017, McGill’s Postgraduate Medical Education (PGME) program is introducing competency-based training, including setting up EPAs, in the departments of Anesthesiology and Otolaryngology. Competency-based education, as opposed to standardized modules of learning based on time, places emphasis on having learners demonstrate what they can do or how they apply knowledge instead of simply recalling how much knowledge they know.
- Uncover the hidden curriculum
The hidden curriculum refers to rules and practices passed on as an unintended or unspoken side effect of one’s formal education. Learners can pick up on cues regarding how to develop professional conduct and ethics, how to pursue life-long learning, how to maintain work-life balance, and more. “As educators we have a responsibility to make what we teach as explicit as possible so that students are not having to guess what we mean,” says Norma Ponzoni, Faculty Lecturer, Ingram School of Nursing.
Maintaining a positive work-life balance is also important to successful learning, says Cynthia Perlman, BSc(OT)’85, MEd, Assistant Professor, School of Physical & Occupational Therapy, and core member, Office of Interprofessional Education. Professors within the Occupational Therapy program coordinate with each other to stagger assignment deadlines. “One of our philosophies is to look at balance—that’s what we do as occupational therapists,” Perlman says. In the Nursing program, students use journaling to acknowledge emotions and develop a reflective practice, according to Ponzoni.
One very current antidote to a hidden curriculum is interprofessional training. As Ponzoni explains, having nursing students study with medical students, for example, goes a long way to improving eventual relations in the workplace and eliminating perceived hierarchy. Otherwise, nurses “can feel uncomfortable approaching a resident or physician, because they are picking up on an unspoken hierarchy in the clinical environment.” Perlman points out that simulation activities in particular “put teamwork, collegiality and patient-centred care into action.”
“I would say it’s an extreme caricature of the way the system actually functions,” says Cummings of how learners may positively or negatively perceive themselves in relation to students in other programs. Interprofessional education helps students develop as practitioners who will respect each other’s expertise, she adds.
- Study the students
At McGill, future efforts to evaluate the new undergraduate medical education curriculum may involve following students in a longitudinal study on their experiences. “We’d like to follow students as they graduate through residency,” Dory says, explaining that this is only a dream at present—a possible new frontier in evaluation.
Michelle Pucci is a reporter and editor and has worked for the Montreal Gazette and The Walrus.