Continuing professional development to foster behaviour change: From principles to practice in health professions education.

Healthcare professionals need to continuously improve their knowledge, skills and performance to effectively function in an ever-changing healthcare environment. They depend on continuing professional development programs (CPD), either within or outside their institutions, to reflect on and update their clinical practice. Professional growth requires more than knowledge transfer; it requires curiosity, humility, self-awareness and a motivation for mastery. Educators can build on these factors and create effective learning experiences to develop complex skills including communication, interprofessional collaboration, teamwork, leadership and reflective practice. CPD program leaders should adopt an evolved approach to program design that leverages adult learning principles, active learning and longitudinal curricula, while identifying and overcoming system barriers to change, and targeting meaningful behaviour and health outcomes. In this article, we describe principles and strategies that CPD leaders can apply to their own programs, categorized under three steps: (1) Program design, (2) Program implementation and (3) Program evaluation. Under each step, we provide theoretical principles as well as practical tips, focusing on strategies that can motivate and facilitate change.

Creating "innovator's DNA" in health care education.

Serious deficits in health care education have been identified recently, yet proposed solutions call for faculty skill sets not typically developed in health professional schools or in continuing professional development (CPD) programs. The authors propose that addressing the oft-cited problems in health care education (e.g., it is not learner-centered and does not take advantage of insights gained from the learning sciences) requires faculty to develop "innovator's skills" including the ability to facilitate organizational change. Given increased social responsibilities and decreased financial resources, it is imperative that more health care educators and health care delivery system leaders not only become innovators themselves but also develop systems that support the next generation of innovators. Dyer et al conducted a comprehensive study of successful innovators and found five behavioral and cognitive "discovery" skill sets that constitute the "innovator's DNA": associating, questioning, observing, networking, and experimenting. This article uses the prism of innovator's DNA to examine a CPD program for health care educators, the Harvard Macy Institute (HMI), whose overarching purpose is to develop innovation skills in participants so that they can build their own educational models customized for implementing changes in their home institutions. A retrospective review of HMI alumni from 1995 to 2010 suggests that innovator skills can be taught and applied. The conceptual framework of the innovator's DNA provides a useful model for other CPD program leaders seeking to enable health care educators to develop the capacity for successfully examining problems and then customizing and implementing organizational change to solve them.

Investigation of pulmonary contusion extent and its correlation to crash, occupant, and injury characteristics in motor vehicle crashes.

BACKGROUND: Pulmonary contusion (PC) is a leading injury in blunt chest trauma and is most commonly caused by motor vehicle crashes (MVC). To improve understanding of the relationship between insult and outcome, this study relates PC severity to crash, occupant, and injury parameters in MVCs. METHODS: Twenty-nine subjects with PC were selected from the Crash Injury Research and Engineering Network (CIREN) database, which contains detailed crash and medical information on MVC occupants. Computed tomography scans of these subjects were segmented using a semi-automated protocol to quantify the volumetric percentage of injured tissue in each lung. Techniques were used to quantify the geometry and location of PC, as well as the location of rib fractures. Injury extent including percent PC volume and the number of rib fractures was analyzed and its relation to crash and occupant characteristics was explored. RESULTS: Frontal and near-side crashes composed 72% of the dataset and the near-side door was the component most often associated with PC causation. The number of rib fractures increased with age and fracture patterns varied with crash type. In near-side crashes, occupant weight and BMI were positively correlated with percent PC volume and the number of rib fractures, and the impact severity was positively correlated with percent PC volume in the lung nearest the impact. CONCLUSIONS: This study quantified PC morphology in 29 MVC occupants and examined the relationship between injury severity and crash and occupant parameters to better characterize the mechanism of injury. The results of this study may contribute to the prevention, mitigation, and treatment of PC.

An online spaced-education game to teach and assess medical students: a multi-institutional prospective trial.

PURPOSE: To investigate whether a spaced-education (SE) game can be an effective means of teaching core content to medical students and a reliable and valid method of assessing their knowledge. METHOD: This nine-month trial (2008-2009) enrolled students from three U.S. medical schools. The SE game consisted of 100 validated multiple-choice questions-explanations in preclinical/clinical domains. Students were e-mailed two questions daily. Adaptive game mechanics re-sent questions in three or six weeks if answered, respectively, incorrectly or correctly. Questions expired if not answered on time (appointment dynamic). Students retired questions by answering each correctly twice consecutively (progression dynamic). Posting of relative performance fostered competition. Main outcome measures were baseline and completion scores. RESULTS: Seven-hundred thirty-one students enrolled. Median baseline score was 53% (interquartile range [IQR] 16) and varied significantly by year (P<.001, dmax=2.08), school (P<.001, dmax=0.75), and gender (P<.001, d=0.38). Median completion score was 93% (IQR 12) and varied significantly by year (P=.001, dmax=1.12), school (P<.001, dmax=0.34), and age (P=.019, dmax=0.43). Scores did not differ significantly between years 3 and 4. Seventy percent of enrollees (513/731) requested to participate in future SE games. CONCLUSIONS: An SE game is an effective and well-accepted means of teaching core content and a reliable and valid method to assess student knowledge. SE games may be valuable tools to identify and remediate students who could benefit from additional educational support.

Teaching plastic surgeons how to be better teachers.

The purpose of this article is to introduce plastic surgeons to a theory of adult education. Most surgeons have been hired by their parent institution because of their clinical skills, and rightly so. At the same time, these same surgeons choose or are expected to be involved to varying degrees in the surgical education process with medical students, surgical residents, fellows, and allied health workers. Likewise, busy surgical residents are also expected to teach other residents and students, and yet these two groups of teachers of surgery have little or no training in the theory and practice of adult education. This article has four major sections. The first is a scenario designed to bring to mind a context and set of ideas with which the reader is already familiar. The second provides new information, Kolb's theory of adult learning and Arseneau and Rodenberg's teaching principles, and discusses their implications. The third section is designed to give the reader an opportunity to work with the new knowledge and practice possible applications, and the fourth encourages the reader to use the new knowledge in concrete ways in a real-world environment.

Image segmentation and registration algorithm to collect homologous landmarks for age-related thoracic morphometric analysis - biomed 2011.

Adults 65 years of age and older currently constitute more than 12% of the total population and the elderly population is projected to reach nearly 20% by 2030. Previous studies have shown that skeletal and physiological resilience decline with age, resulting in a decreased ability for the body to withstand traumatic insults. In the current study, an algorithm was developed to quantify age and gender-specific variations in the thoracic skeletal morphology. Normal chest CT scans of males and females ages 0-100 were collected from a radiological database. Image segmentation and subsequent image registration was used to collect landmark data from the ribs. Rigid, affine, and non-rigid, non-linear transformations are used to morph segmented ribs from different subjects to a “rib atlas”. The atlas consists of a normal chest CT scan from an average male with over 100 landmarks placed per rib. The transformation matrices are used to map landmarks from the atlas coordinate system to the coordinate system of each CT scan, effectively allowing for collection of homologous (or comparable) rib landmarks across all subjects. Geometric morphometrics will be used in future work to analyze the landmark data to formulate age and gender-specific shape and size variation functions. These functions will be used to create a scalable finite element model of the thorax that will be used to predict thoracic injury response for different ages and genders.

What can medical education learn from the neurobiology of learning?

The last several decades have seen a large increase in knowledge of the underlying biological mechanisms that serve learning and memory. The insights gleaned from neurobiological and cognitive neuroscientific experimentation in humans and in animal models have identified many of the processes at the molecular, cellular, and systems levels that occur during learning and the formation, storage, and recall of memories. Moreover, with the advent of noninvasive technologies to monitor patterns of neural activity during various forms of human cognition, the efficacy of different strategies for effective teaching can be compared. Considerable insight has also been developed as to how to most effectively engage these processes to facilitate learning, retention, recall, and effective use and application of the learned information. However, this knowledge has not systematically found its way into the medical education process. Thus, there are considerable opportunities for the integration of current knowledge about the biology of learning with educational strategies and curricular design. By teaching medical students in ways that use this knowledge, there is an opportunity to make medical education easier and more effective. The authors present 10 key aspects of learning that they believe can be incorporated into effective teaching paradigms in multiple ways. They also present recommendations for applying the current knowledge of the neurobiology of learning throughout the medical education continuum.

Online "spaced education progress-testing" of students to confront two upcoming challenges to medical schools.

PURPOSE: U.S. medical students will soon complete only one licensure examination sequence, given near the end of medical school. Thus, schools are challenged to identify poorly performing students before this high-stakes test and help them retain knowledge across the duration of medical school. The authors investigated whether online spaced education progress-testing (SEPT) could achieve both aims. METHOD: Participants were 2,648 students from four U.S. medical schools; 120 multiple-choice questions and explanations in preclinical and clinical domains were developed and validated. For 34 weeks, students randomized to longitudinal progress-testing alone (LPTA) received four new questions (with answers/ explanations) each week. Students randomized to SEPT received the identical four questions each week, plus two-week and six-week cycled reviews of the questions/explanations. During weeks 31-34, the initial 40 questions were re-sent to students to assess longer-term retention. RESULTS: Of the 1,067 students enrolled, the 120-question progress-test was completed by 446 (84%) and 392 (74%) of the LPTA and SEPT students, respectively. Cronbach alpha reliability was 0.87. Scores were 39.9%, 51.9%, 58.7%, and 58.8% for students in years 1-4, respectively. Performance correlated with Step 1 and Step 2 Clinical Knowledge scores (r = 0.52 and 0.57, respectively; P < .001) and prospectively identified students scoring below the mean on Step 1 with 75% sensitivity, 77% specificity, and 41% positive predictive value. Cycled reviews generated a 170% increase in learning retention relative to baseline (P < .001, effect size 0.95). CONCLUSIONS: SEPT can identify poorly performing students and improve their longer-term knowledge retention.

Reform of a traditional clinical curriculum in Japan: experiences at Tokyo Medical and Dental University.

BACKGROUND: Until recently, Japanese legislative guidelines dictated that undergraduate clinical training consisted of students' observations of clinicians' work. In 2006, Tokyo Medical and Dental University initiated a reform of their traditional undergraduate clinical curriculum. The reform integrated students into patient care teams, and included the implementation of a clinical faculty 'tutor'. AIMS: This short communication describes a formative assessment of the reform work. METHOD: In 2007, students, residents, and tutors were surveyed to determine their perceptions of students' integration into clinical activities, and patients' acceptance of students in their medical care. An external consultant observed students' patient care activities, and assessed the methods of and perceived barriers to clinical teaching. RESULTS: Surveys indicated that students were most engaged in history-taking, procedures, and case presentations. Observations revealed students' activities and teaching to be focused on students' case presentations. Perceived barriers to teaching included insufficient time and personnel. Respondents felt that patients were accepting students in their clinical care. CONCLUSIONS: This clinical reform effort includes an increase in students' interactions with patients through history-taking, and teaching through case presentations.

Interactive spaced-education to teach the physical examination: a randomized controlled trial.

BACKGROUND: Several studies have documented that physical examination knowledge and skills are limited among medical trainees. OBJECTIVES: The objective of the study is to investigate the efficacy and acceptability of a novel online educational methodology termed 'interactive spaced-education' (ISE) as a method to teach the physical examination. DESIGN: The design of the study is randomized controlled trial. PARTICIPANTS: All 170 second-year students in the physical examination course at Harvard Medical School were eligible to enroll. MEASUREMENTS: Spaced-education items (questions and explanations) were developed on core physical examination topics and were content-validated by two experts. Based on pilot-test data, 36 items were selected for inclusion. Students were randomized to start the 18-week program in November 2006 or 12 weeks later. Students were sent 6 spaced-education e-mails each week for 6 weeks (cycle 1) which were then repeated in two subsequent 6-week cycles (cycles 2 and 3). Students submitted answers to the questions online and received immediate feedback. An online end-of-program survey was administered. RESULTS: One-hundred twenty students enrolled in the trial. Cycles 1, 2, and 3 were completed by 88%, 76%, and 71% of students, respectively. Under an intent-to-treat analysis, cycle 3 scores for cohort A students [mean 74.0 (SD 13.5)] were significantly higher than cycle 1 scores for cohort B students [controls; mean 59.0 (SD 10.5); P < .001], corresponding to a Cohen's effect size of 1.43. Eighty-five percent of participants (102 of 120) recommended the ISE program for students the following year. CONCLUSIONS: ISE can generate significant improvements in knowledge of the physical examination and is very well-accepted by students.

Using an outcomes-logic-model approach to evaluate a faculty development program for medical educators.

PURPOSE: This study used an outcomes-logic-model approach to examine the impact of participating in a nontraditional professional development program. Building and using a logic model provides a structure for the program to examine the degree that the desired learner outcomes, the program delivery methods, and the measurement approaches are aligned. METHOD: Structured telephone interviews were conducted in 2001 with 16 Harvard Medical School (HMS) participants in the Harvard Macy Program for Physician Educators (HM-PE): five who completed the program in 1998, five in 1999, and six in 2000. Interviews were also conducted with four Faculty Scholars, alumni of the HM-PE program who taught in subsequent programs. In 2004, online questionnaires were sent to the 16 participants and four Faculty Scholars. Immediate outcomes, such as greater use of active learning principles, and intermediate outcomes, such as commitment to medical education, were examined. RESULTS: Of those interviewed in 2001, 80% responded to the 2004 online questionnaire. Thirteen of 16 (81%) HMS respondents reported increased knowledge about and confidence using learner-center teaching methods; 10 of 16 (63%) said they gave fewer lectures and added alternative educational methods. Thirteen of 16 (81%) reported a stronger commitment to the field of medical education: almost one third felt the HM-PE program was a turning point in their careers. CONCLUSIONS: The outcomes logic model provided data to judge how well the program mission and plan were implemented, and whether outcomes had been attained.

Can a simulated critical care encounter accelerate basic science learning among preclinical medical students? A pilot study.

PURPOSE: To explore whether a simulated critical care encounter can accelerate basic science learning among preclinical medical students. METHOD: Using a high-fidelity patient simulator, we "brought to life" a paper case of a myocardial infarction among a convenience sample of first-year medical students (n=22 [intervention]). Students discussed the case as part of a routine tutorial session, and then managed the case in the simulator laboratory. Using an identical six-item test of cardiac physiology, students were evaluated immediately after the simulator session and at 1 year (n=15). Performance was compared with controls (case discussion but no simulator session) at both baseline (n=37) and 1 year (n=48). RESULTS: Performance among simulator-exposed students was significantly enhanced on immediate testing (mean score 4.0 [control], 4.7 [intervention], P = .005). Gains among the simulator cohort were maintained at 1 year (mean score 4.1 [control], 4.7 [intervention], P = .045). Multivariable analysis confirmed that the intervention was a significant determinant of performance across time (P = .001). CONCLUSION: Compared with controls in this pilot study, an additional simulation exercise improved immediate performance on a short written test of cardiovascular physiology. Enhanced performance was again seen at 1 year, raising the possibility that the extra teaching session produced accelerated and sustained learning compared with the routine teaching method. Given the preliminary nature of this investigation, further study is required to distinguish transient from lasting effects of simulation versus alternative teaching approaches in the basic medical sciences.

Medical education as a process management problem.

With complaints that new doctors are less prepared for residency and practice than expected, are burdened with debt, and then take even longer to complete their specialty training, the authors ask whether medical education can be designed more effectively. Curriculum redesign and pedagogical reform efforts to date address fragments of medical education-the content of particular courses or clerkships or the way in which the courses or clerkships are conducted. However, these reforms do not typically address the relationships among the various elements, that is, in what order skill sets should be sequenced, how communication should occur between disciplines, and by what mechanisms skills or knowledge should be mastered and assessed by the end of one phase so students are prepared adequately for the next. In failing to address these systems issues, current reform efforts may forgo some opportunities to convey and properly insure greater mastery of knowledge and skills in less time, at less cost. A case study of a typical student's third- and fourth-year clerkships illustrates how focusing only on educational elements leads to the exclusion of opportunities to systemically facilitate the relationships among them. This situation is contrasted with how other demanding, high-tech, knowledge-intensive industries with outstanding operations have learned to achieve superlative performance by managing and designing both the elements and the interactions among them within complex work and learning systems. The authors' exploratory research offers suggestions for medical education reform and frames additional opportunities for further discussion.

Transformative professional development of physicians as educators: assessment of a model.

PURPOSE: Medical education reform has been the clarion call of U.S. medical educators and policymakers for two decades. To foster change and seed reform, Harvard Medical School created a professional development program for physicians and scientists actively engaged in educating future physicians that sought to transform both participants and their schools. This study focused on identifying the long-term effects of a professional development program on physician educators. METHOD: A follow-up survey of the 1995-97 cohorts of the Harvard Macy Program for Physician Educators was conducted by sending the 99 program participants a questionnaire two years after their participation. Main outcome measures studied were individual changes as reflected in participants' self-reported shifts in teaching behaviors, academic productivity, career advancement, and sense of commitment. RESULTS: A total of 63 participants completed the questionnaire, for a response rate of 63.6%. Two years following participation in the program, a majority (88.8%) of respondents reported that participation had significantly affected their professional development, including long-term changes in teaching behaviors (77.8%), engagement in new educational activities from committee work (86%) to grant funding (52.4%), and renewed vitality/identification of themselves as educators. CONCLUSIONS: Long-term follow-up of participants enrolled in an intensive program for physician educators suggests that professional development programs that create an immersion experience designed in a high-challenge, high-support environment, emphasizing experiential and participatory activities can change behaviors in significant ways, and that these changes endure over time.