Article of the Month
Article of the Month is a resource from the Office of Educational Improvement (OEI) within the Department of Academic Affairs. Each month we identify an article that should be of interest to our teaching faculty.
October’s article discusses Master Adaptive Learners, a conceptual framework used by medical educators to develop “adaptive expertise” in trainees. The authors found that the Master Adaptive Learners, or MALs, they studied in residency were intrinsically motivated by a drive to provide quality care for their patients rather than being motivated by external sources such as feedback or assessment.
- The authors propose the “brick wall” concept, in which a resident will continue to work through the details of a case until they consciously realize they don’t know what to do next and begin to engage in intense self-reflection.
- Intentionally seeking feedback from multiple members of the healthcare team, including ancillary staff and trainees junior to them in the hierarchy, was a knowledge gap identification skill residents became more comfortable with over time.
- Study participants almost universally responded “no” when asked whether they received formal training on how to learn.
- Participants reported that relying on workplace learning alone resulted in superficial learning, with deep learning requiring additional effort and study during personal time.
- Discussions with learners about “trial and error” and “productive struggle” may aid them in viewing such experiences as formative and better support development of resilience and adaptive expertise.
- The authors found that MALs in their study did not set short-term learning goals. Rather, they triaged the learning opportunities available to them in the clinical setting, suggesting a significant influence of immediacy of learning needs.
- “Intentional adaptation” should be encouraged during the transition from medical school to residency, with trainees being aware that struggles will take time and iterative development to overcome.
September’s article discusses ‘pedagogical validity,’ a combination of skills, goals, and values held by an educator. The authors assert that meaningful reflection and improvement of educational skills require an understanding of one’s pedagogical validity and describe four types of pedagogical validity instructors can use to define their understanding of ‘good’ teaching.
- Limiting the definition of ‘good teaching’ to a toolbox of pedagogical skills is flawed.
- Assessing good teaching requires an understanding of the values and assumptions that influence teaching goals.
- Intellectual validity seeks to explain core concepts and expand learners’ mastery of content into the ability to think and reason through conditions of uncertainty. This is the most commonly used form of pedagogical validity in medical training.
- Relational validity views learning as the product of a relationship between the educator and learner, in which learners seek explanations and role modeling from their educators. Relational validity is particularly important in the context of giving and receiving feedback, a process requiring trust and respect.
- Moral validity involves making judgements and decisions in complex environments in which rules and guidelines are insufficient to address situations. Moral validity requires educators to not only role model behavior but also articulate the reasons for thinking and acting in certain ways.
- Cultural validity relies on awareness of how values and norms influence the way we view and think about the world around us. Teaching is a role that is culturally defined, requiring us to both enculturate learners and foster critical reflection on the culture(s) involved in learning and practicing in a healthcare environment.
August’s article is an editorial emphasizing the need to carefully define competence for developing and implementing assessment programs. The author asserts there are risks and limitations to applying stakeholder theory, a business framework, to educational assessment in the training of physicians. She proposes involving multiple stakeholders in the design and development of workplace-based assessment programs to better understand stakeholder values and what competence really means in our environment.
- We may be rushing into developing assessment programs based on a construct we don’t fully understand (competence).
- Our collective values in medical education shape trainee characteristics.
- Programs of assessment should be inclusive of different stakeholders and their values.
Yarris, L.M (2019, June). Defining trainee competence: Value is in the eye of the stakeholder. Academic Medicine, 94(6), 760-762.
May's article is an editorial and comment on trust in competency-based medical education, or CBME. The authors assert that trust is paramount in CBME and underpins the entire medical education system. Trusting relationships are essential between learner and supervisor, trainees and training programs, and training programs and society.
- Entrustable Professional Activities, or EPAs, provide a shared model for the desired outcomes of our educational efforts.
- We are entering a period of inquiry surrounding CBME, focusing on relationships that encompass the medical education system and emphasize the importance of trust.
- In CBME, feedback is essential to help learners understand their development and identify areas for growth.
- A productive feedback process relies on trusting relationships.
- Building an effective CBME system is dependent on attention to relationship development and may best be designed with longitudinal, continuity experiences.
Young, E., and Elnicki, D.M. (2019, April). Trust as a scaffold for competency-based medical education. J Gen Intern Med, 34(5), 647-8. DOI: 10.1007/s11606-019-04927-6
April's article discusses the psychological environment and its influence on learning. The authors emphasize the importance of creating a safe environment in which trainees can learn. They recommend seven basic strategies: embrace learning as a core value, utilize the clinical care system as an education-rich environment, develop individual-level skills to optimize the learning process, incorporate rituals and rewards, establish a just culture, remove competing factors, and build communities of practice.
- Cognitive Load Theory highlights three components that contribute to the formation of working memory: intrinsic load, extrinsic load, and germane load.
- Optimal learning experiences occur at an ideal intrinsic load (not too simple or complex) while minimizing extrinsic load (distractions) and facilitating the learner's use of germane load (active processing) to incorporate their learning into working memory.
- Clinical preceptors are essential to promoting learner self-efficacy, or their ability to operate with increasing autonomy.
- Learners become empowered in a psychologically safe environment that allows them to speak without fear of consequences, exploring new theories and testing assumptions.
Caverzagie, K.J., Goldenberg, M.G., Hall, J.M. (2019, February). Psychology and learning: The role of the clinical learning environment. Medical Teacher. DOI: 10.10080/0142159X.2019.1567910
March’s article is a letter from the editor of Academic Medicine on the Match process. The author asserts that the current Match process is expensive, inefficient, and encourages excessive focus on USMLE examination scores, making it an overall unfair system. The National Resident Matching Program, or NRMP, was founded in 1952 to address problems in the residency selection process and make the system “fair, efficient, transparent, and reliable (1).” However, many of the problems the Match was created to solve have resurfaced in recent years, leading to a “system with perverse outcomes (1).”
- USMLE Step 1 scores have been increasingly used as an initial screen for the ever-growing number of residency program applicants.
- Medical students have increasingly focused their learning on preparatory materials for Step 1 rather than other important curricular activities, undermining the medical school curriculum and ceding medical education authority to commercial resources.
- A range of suggestions to improve the process exist, including, but not limited to, improving the information provided by medical schools to residency programs and realigning the Step 1 exam to reflect competencies of interest to program directors.
- Fixing the Match will require medical educators to ask difficult questions about the process and desired outcomes.
February’s article focuses on the trust relationship between teachers and learners.
- Without trust in the teacher-learner relationship, learners may reject or resist information and teachers may be unlikely to share in patient care responsibilities.
- Teachers are increasingly called to assess competence while lacking control over the learning environment or a longitudinal relationship with the learner.
- Learning is based on exploring, adjusting, and improving based on feedback.
- Negotiating the power imbalance between teachers and learners is critical for development of a relationship that fosters trust.
- Commitment to a healthy working environment is important in creating a trusting relationship between teachers and learners.
- Social relationships between teachers and learners should be avoided during the time of active supervision.
Abruzzo, D., Skalr, D.P., and McMahon, G.T. (2019, February). Improving trust between learners and teachers in medicine. Academic Medicine, 94(2), 147-150. DOI: 10.1097/ACM.0000000000002514
January’s article focuses on competency-based medical education (CBME) and the determination of competency based on assessment of entrustable professional activities (EPAs). The authors assert that three major decisions are required to transition to CBME: defining the terminology to be used to describe constructs being evaluated, deciding which rating tools and raters to include in the assessment program, and determining how to make promotion decisions based on longitudinal EPA data.
- Changing to a competency-based model in undergraduate medical education will likely meet with resistance and cynicism.
- We should not be threatened by the desire for a set level of competency, as this is meant to be a minimum requirement for entering post-graduate training.
- Programs can maintain some autonomy on deciding elements of CBME to incorporate into their own unique programs.
- UME programs are already evaluating individual behaviors within each of the defined EPAs, which means the task at hand is mapping EPAs to existing activities.
- A focus on preparing students for entering residency shifts focus from successful completion of individual clerkships to one of overall competency, requiring a change in how we collect and analyze performance data.
Veale, P., Busche, K., Touchie, C., Coderre, S., and McLaughlin, K. (2019, January). Choosing our own pathway to competency-based undergraduate medical education. Academic Medicine, 94(1), 25-30. DOI: 10.1097/ACM.0000000000002410
- Provide opportunities for creativity and problem solving
- Increase resilience training
- Offer robust career counseling
October’s article shares the authors’ recommendations for how to deal with uncertainty when assessing learners in the clinical setting.
- Be learner-centered to understand the learner’s context and address their needs and concerns.
- Use clear communication to understand the learner’s values and concerns in the face of uncertainty.
- Engage in self-reflection to stay attuned to your own and the learner’s emotional reactions to the situation at hand.
- Seek input from your colleagues.
- Avoid premature closure on your assessment.
- Remember that every assessment opportunity does not have to end in a final judgement.
Scott, I., Gingerich, A., and Eva, K.W. (2018, October). Twelve tips for clinicians dealing with uncertainty when assessing learners. Medical Teacher, DOI: 10.1080/0142159X.2018.1494381
September’s article shares the author’s perspective on the importance of teaching caring in medical profession, especially in an age of rapid technological advancement.
- While knowledge is more abundant and easier to access, the ability for a physician to retain and process all the information available is limited.
- Technological advancements provide opportunities for enhancing medical care but are incapable of replacing the humanistic art of medical practice.
- Most medical school curriculums devote a lot of time and attention to rote memorization and data analysis, skills that may be less relevant in the growing age of artificial intelligence.
Johnston, S.C. (2018, August). Anticipating and training the physician of the future: The importance of caring in an age of artificial intelligence. Academic Medicine, 93(8), 1105-1106.
July’s article discusses how to approach creating an academic teaching portfolio. The authors share twelve tips for organizing and reporting your teaching activities.
- Prepare in advance to allow yourself time to collect, collate, and reflect
- Review your CV to ensure it is updated
- Establish a “shoebox” to collect your information
- Collect evidence of the quality of your teaching
- Participate in peer review of your teaching
- Provide mentorship
- Solicit letters of support
- Demonstrate evidence of scholarship
- Think about your goals and objectives
- Write down your educational philosophy
- Document your professional development
- Have an expert review your portfolio prior to submitting it
June’s article discusses how to respond to negative comments on course evaluations. The author discusses personal reactions to negative student comments and suggests ways to avoid over-reacting.
- Step back
- Look again later
- Decide what you’re going to do
- Talk to a trusted colleague
- Talk to a few students
- Recognize that you are not alone
- What to Do About Those Negative Comments on Course Evaluations
Weimer, M. (2018, May 30). What to do about those negative comments on course evaluations. Faculty Focus, Teaching Professor Blog.
May’s article defines the term “resilience” in the medical education context and discusses why resilience training is important to our learners. The authors discuss challenges healthcare learners face in a fast-paced, dynamic practice environment and the consequences of burnout.
- Protection against burnout requires development and promotion of interventions to foster resilience amongst trainees.
- Individual interventions are unlikely to be effective on their own in addressing the complex issue of resiliency and burnout.
- Prevention of burnout calls for defining resilience in the context of overcoming adversity rather than as an intrinsic personal attribute.
Teodorczuk, A., Thomson, R., Chan, K., and Rogers, G.D. (2017). When I say…resilience. Medical Education, 51(12): 1206-1208.
February’s article discusses opportunities and challenges with transitioning to competency-based assessment and grading in undergraduate medical education (UME). The authors discuss progress made in graduate medical education with development and implementation of competencies and milestones.
- UME struggles with transitioning to competency-based medical education due to a continued reliance on grades.
- Reliance on proxy assessments rather than direct observation of learners continues to be problematic in UME.
- Use of norm-based criteria in the residency application process places pressure to provide this type of data to programs.
- Successful implementation of competency-based assessment will require consensus between UME and graduate medical education.
Pereira, A.G., Woods, M., Olson, A.P.J., van den Hoogenhof. S., Duffy, B.L., and Englander, R (2017). Criterion-based assessment in a norm-based world: Can we move past grades? Academic Medicine. doi: 10.1097/ACM.0000000000001939.
January’s article of the month shares one physician’s thoughts on the relationships between academic and community physicians. The author discusses medical schools’ increased reliance on community physicians to teach students and residents and suggests ways to enhance these relationships.
- Failure for academic and community physicians to work together could have serious consequences for medical education.
- Community physicians need access to high-quality, evidence-based training on teaching.
- Mutual respect and feedback are critical to building successful relationships between “town” and “gown” physicians.
Gundersen, E. (2017, October 10). The accidental academic: Bridging the gap between town and gown [Web log post]. Harvard Macy Institute. Retrieved January 26, 2018, from The Accidental Academic: Bridging the Gap between Town and Gown
December's article of the month focuses on deep learning and approaches to encourage it in coursework. Deep learning results in overall understanding of a concept, whereas surface learning focuses on rote memorization of information. Promoting deep learning means having students do something with the information, not just requiring them to remember it.
Highlights of the article include:
- Deep learning results in the ability to not only understand information but transfer that knowledge to new and different situations.
- Cooperative learning experiences play a key role in deep learning, as interaction is a key characteristic.
- Efforts for deep learning should focus on key knowledge and skills essential for students to advance to the next course or practice in their chosen discipline.
- Deep learning is fostered through mindful sequencing of activities designed to promote thoughtful processing of and interaction with the course material.
Millis, B.J. (n.d.) Promoting Deep Learning: IDEA Paper #47. Retrieved December 18, 2017, from Promoting Deep Learning
November's article of the month focuses on interprofessional education (IPE) and its role in the future of healthcare. The authors discuss reasons for engaging in IPE, various approaches to incorporating it into health care curriculum, and IPE's potential to transform health care delivery in the future.
- Longitudinal, patient-centered IPE experiences have the potential to increase students' knowledge and awareness of complex patient needs.
- IPE is rooted in the patient safety movement, an effort to improve multidisciplinary teamwork and communication.
- IPE as a field is still evolving, with research to be done on core concepts and curriculum integration.
- When done well, IPE has the power to develop health care teams better able to handle uncertainty and complexity.
- With movement toward value-based payment models in health care, the ability for providers to focus their problem solving in an integrated manner becomes increasingly important.
Dow, A., and Thibault, G. (2017, August 31) Interprofessional education - A foundation for a new approach to health care. N Engl J Med, 377(9), 803-805.
October's article of the month focuses on active learning in the face-to-face classroom. The author discusses approaches to active learning and the research that supports adoption of active learning methods.
- Metacognition, or awareness of one's own thought processes, is central to learning.
- Educators are responsible for designing learning experiences that will engage students.
- Educators should continually reinforce the value of active learning approaches, clarifying their expectations and emphasizing that the approaches will be reflected in graded activities (tests, quizzes, assignments).
- Educators should practice "transparent teaching," in which their methods and motives for active learning approaches are shared with the learners.
- Educators should create a supportive classroom climate to foster active student participation.
Millis, B.J. (n.d.) Active learning strategies in face-to-face courses. IDEA Paper #53. Retrieved from Active Learning Strategies in Face-to-Face Courses
September’s article of the month shares two medical educators’ perspectives on efforts to move away from traditional lecture-based courses. The authors discuss approaches to education and the need to prepare medical students for future practice.
- Content-heavy slides may be an efficient way to teach but are likely an ineffective way to learn.
- Learning can be facilitated by the instructor but must be driven by the student.
- Students aren’t learning when they are unengaged.
- Questioning, particularly using “why” and “how” questions, facilitates the transfer of knowledge.
- We should aim for a culture of continuous quality improvement in medical education, just as we do with clinical practice.
Schwartzstein, R.M., & Roberts, D.H. (2017, August 17). Saying goodbye to lectures in medical school – Paradigm shift or passing fad? N Engl J Med, 377: 605-607. DOI: 10.1056/NEJMp1706474
August’s article of the month shares a medical educator’s experiences with trying to teach in a time-constrained environment. The author discusses struggling to engage residents in active learning in the face of competing demands.
- Time constraints and clinical demands may divert attention away from formal teaching.
- Tension exists between fostering active learning and providing information to aid in the passage of high-stakes exams.
- Lack of objectives and related assessment may confuse the learning environment.
- Faculty development can help address the need for continual education of clinical preceptors.
Sklar, D.P. (2015). Just because I am teaching doesn’t mean they are learning: Improving our teaching for a new generation of learners. Academic Medicine, 92(8): 1061-1063. DOI: 10.1097/ACM.0000000000001808
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