A flipped classroom method based on a small private online course in physiology.

A small private online course (SPOC) supports blended learning on a small scale, enabling students to have a more comprehensive and deeper learning experience. It also provides instructors with a flexible and feasible model to better understand the students' learning needs and to supervise students' learning behaviors. In this study, we adopted SPOC flipped classroom blended teaching in the physiology course for clinical undergraduate students of Kunming Medical University. Compared with the control group [lecture-based learning (LBL)], the SPOC flipped classroom method significantly increased the scores of students in the preclass test (65.13 ± 12.45 vs. 53.46 ± 8.09, SPOC vs. LBL) and postclass test (80.43 ± 14.29 vs. 69.01 ± 12.81, SPOC vs. LBL), which is induced by students' increased interest in self-learning. More importantly, the significant difference between the preclass scores of the two groups suggested that the video lecture-based preview is more effective than the textbook-based preview. The study indicated that the SPOC flipped classroom was effective in enhancing the examination scores of students, reflecting an improved learning efficiency and a deeper understanding of the knowledge. In summary, the flipped classroom based on SPOC improves learning outcomes compared with LBL and has a wide application in the learning of basic medical courses.

Effect of a small-group, active learning, tutorial-based, in-course enrichment program on student performance in medical physiology.

Physiology is one of the major foundational sciences for the medical curriculum. This discipline has proven challenging for students to master due to ineffective content acquisition and retention. Preliminary data obtained from a survey completed by "low-performance" students (those maintaining a grade average below the passing mark of 70%) at Morehouse School of Medicine reported that students lacked the ability to adequately recognize and extract important physiological concepts to successfully navigate multiple-choice assessments. It was hypothesized that a specially designed, small-group, active learning, physiology in-course enrichment program would minimize course assessment failure rates by enhancing the ability of low-performance students to effectively identify important course content, successfully perform on multiple-choice assessments, and, thereby, improve overall course performance. Using self-report surveys, study skills and test-taking deficiencies limiting successful comprehension of course material and examination performance were identified. Mini-quiz assessments and assignments in formulating multiple-choice examination questions were given to help students recognize and solidify core concepts and improve test-taking ability. Lastly, self-report surveys evaluated the effectiveness of the enrichment program on overall course performance. Results showed a marked improvement in student confidence levels with regards to approaching multiple-choice assessments, and a significant improvement in grades achieved in the physiology component of the first-year curriculum, as 100% of participants achieved a final passing grade average of ≥70%. It was concluded that students became more proficient in identifying, understanding, and applying core physiological concepts and more successful in mastering multiple-choice questions.

Development of an instrument to evaluate residents' confidence in quality improvement.

BACKGROUND: Practice-based learning and improvement is a core competency that all medical residents must demonstrate. Because confidence is important in translating competence into action, effective quality improvement (QI) curricula should evaluate trainees' knowledge and confidence to perform QI. Past efforts to assess educational outcomes in QI have not adequately evaluated trainees' confidence from a multidimensional perspective. METHODS: Participants--732 internal medicine and family medicine residents from 42 training programs in the United States--completed the 31-item Quality Improvement Confidence Instrument (QICI), which was developed to measure confidence in six QI skill domains based on the Institute for Healthcare Improvement model ofQI. Confirmatory factor analysis was performed to support construct validity. Multivariate analysis of covariance was used to examine associations between residents' QI experience and other characteristics with confidence scores. RESULTS: Confirmatory factor analysis supported the QICI's multidimensional structure. Individual items yielded adequate variability, and reliability estimates for all six domains were high (> 0.86). On average, residents rated their confidence lowest for skills pertaining to choosing a target for improvement (specifically, using methods to evaluate interventions and to identify sources of process errors) and for testing a change in practice using specific tools for data collection and analysis. After controlling for program year and other characteristics, residents with previous QI experience reported significantly greater QI confidence. CONCLUSION: The QICI offers a psychometrically rigorous approach to evaluating residents' confidence levels. It can be used to gauge the appropriateness of a trainee's confidence against actual QI performance.

Delivering endocrinology and reproduction in an integrated modular curriculum.

OBJECTIVE: To ascertain the perceptions of students and faculty of Shifa College of Medicine, Islamabad regarding the delivery of Endocrinology and Reproduction module as a component of the newly introduced Integrated Modular Curriculum. METHODS: A descriptive study, using mixed qualitative and quantitative method, starting from June 6 to August 15 2008. A period of 10 weeks was spent on the study including 8 weeks of planning, 2 weeks of delivery and assessment and a 2 weeks period of post hoc analysis and data collection. A multidisciplinary team of faculty developed themes, clinical cases, objectives and table of specification of the Endocrinology and Reproduction Module for Fourth Year MBBS Class. Continuous assessment was done by theme-based assignments and student presentations. Summative assessment was done by Multiple Choice and Short Answer Questions. Likert scale-based student feedback questionnaire was administered while the students were also encouraged to comment on the module for improvement. Feedback was obtained from the faculty in a similar manner. RESULTS: Out of a class of 86 students, 47 (55%) agreed to a balance between basic and clinical concepts addressed in the module, 21 (24%) agreed that emphasis on clinical concepts was appropriate, 37 (43%) agreed that learning strategies were well integrated, 50 (58%) were of the opinion that the assigned learning material was consistent with the session objectives, while 39 (45%) agreed that case-based instruction was useful, and 40 (47%) students were of the opinion that large group discussion was useful. Faculty feedback was positive towards integrated learning. CONCLUSIONS: Integrated Endocrinology and Reproduction module received mixed response from students. This led us to modify and tailor the curriculum to better cater for the needs of students. Feedback from students and faculty is essential for improvement in the quality of educational interventions.

Feedback data sources that inform physician self-assessment.

BACKGROUND: Self-assessment is a process of interpreting data about one's performance and comparing it to explicit or implicit standards. AIM: To examine the external data sources physicians used to monitor themselves. METHODS: Focus groups were conducted with physicians who participated in three practice improvement activities: a multisource feedback program; a program providing patient and chart audit data; and practice-based learning groups. We used grounded theory strategies to understand the external sources that stimulated self-assessment and how they worked. RESULTS: Data from seven focus groups (49 physicians) were analyzed. Physicians used information from structured programs, other educational activities, professional colleagues, and patients. Data were of varying quality, often from non-formal sources with implicit (not explicit) standards. Mandatory programs elicited variable responses, whereas data and activities the physicians selected themselves were more likely to be accepted. Physicians used the information to create a reference point against which they could weigh their performance using it variably depending on their personal interpretation of its accuracy, application, and utility. CONCLUSIONS: Physicians use and interpret data and standards of varying quality to inform self-assessment. Physicians may benefit from regular and routine feedback and guidance on how to seek out data for self-assessment.

Positive illusions in adolescents: the relationship between academic self-enhancement and depressive symptomatology.

Positive illusions are systematically inflated self-perceptions of competence, and are frequently seen in areas of great difficulty. Although these illusions have been extensively documented in children and adults, their role in typical adolescent emotion regulation is unclear. This study investigated the relationship between positive illusions, depressive symptomatology, and school stress in a sample of 71 school-based adolescents. Findings revealed that adolescents who were achieving slightly below average in math significantly overestimated their performance, but adolescents did not overestimate their performance in spelling. Positive illusions in math were negatively related to depressive symptomatology. Implications for positive illusions theory are discussed.

Educating nurses about research ethics and practices with a self-directed practice-based learning program.

Learner-driven and practice-based education programs are recommended for integration of learning. A continuing education program on research ethics was introduced to five nurses in an ambulatory care setting at a Magnet® hospital, using a commercially available web-based course followed by a research practicum. The seasoned nurses reported little previous education in this area. Working with a nurse researcher, three nurses participated in a research project for improving clinic care delivery. The success of the continuing education program was determined by knowledge acquisition, satisfaction with learning activities, and perceived confidence in research participation. This continuing education program was effective in providing for knowledge and skill development in research ethics. The integrative learning format was well received.

Qualities and health of lay trainers with migraine for behavioral attack prevention.

OBJECTIVES: To evaluate the qualities of lay trainers with migraine and to quantify their self-management results. BACKGROUND: Little is known about the qualities of lay trainers with chronic diseases and the benefits for their own health. METHODS: Thirteen lay trainers (12 F, 1 M) completed a 3-step program that consisted of self-experience of a behavioral training (BT), providing BT to one fellow patient, and subsequently to a small group at home. Successful mastery of own migraine attacks was required for participation, and lay trainers received intensive guidance. Evaluation of the qualities of trainers took place post-BT by means of a specially constructed questionnaire. Their self-management was measured before self-experience of BT, post-BT, and at 6-month follow-up by a headache diary and questionnaires. RESULTS: The qualities of the 13 trainers were positively evaluated by 95 trainees, particularly their warmth, expertise, organization, explanation of BT, active control, and advice and guidance. Higher active control of lay trainers during the group sessions was significantly related to improvements on migraine frequency and internal locus of control in their trainees post-BT. Advice and guidance increased the likelihood of less attacks at follow-up and supportive encouragement promoted a higher internal locus of control. However, humor slightly increased the likelihood of more attacks post-BT, while fellowship and individualization negatively influenced internal locus of control. Lay trainers showed significantly more improvement in migraine frequency than their trainees at follow-up, as well as enhanced internal locus of control and quality of life. CONCLUSIONS: Participation in a stepwise training program can produce capable trainers and may positively influence their own health. Lay trainers may be more motivated to enhance their self-management skills as they have to present the benefits to their trainees.

Assessment and feedback to facilitate self-directed learning in clinical practice of Midwifery students.

BACKGROUND: Clinical workplaces are hectic and dynamic learning environments, which require students to take charge of their own learning. Competency development during clinical internships is a continuous process that is facilitated and guided by feedback. Limited feedback, lack of supervision and problematic assessment of clinical competencies make the development of learning instruments to support self-directed learning necessary. AIMS: To explore students' perceptions about a newly introduced integrated feedback and assessment instrument to support self-directed learning in clinical practice. Students collected feedback from clinical supervisors and wrote it on a competency-based format. This feedback was used for self-assessment, which had to be completed before the final assessment. METHODS: Four focus group discussions were conducted with second and last year Midwifery students. Focus groups were audiotaped, transcribed verbatim and analysed in a thematic way using ATLAS.ti for qualitative data analysis. RESULTS: The analysis of the transcripts suggested that integrating feedback and assessment supports participation and active involvement in learning by collecting, writing, asking, reading and rereading feedback. Under the condition of training and dedicated time, these learning activities stimulate reflection and facilitate the development of strategies for improvement. The integration supports self-assessment and formative assessment but the value for summative assessment is contested. The quality of feedback and empowerment by motivated supervisors are essential to maximise the learning effects. CONCLUSIONS: The integrated Midwifery Assessment and Feedback Instrument is a valuable tool for supporting formative learning and assessment in clinical practice, but its effect on students' self-directed learning depends on the feedback and support from supervisors.

Nursing students' self-evaluation using a video recording of foley catheterization: effects on students' competence, communication skills, and learning motivation.

An opportunity for a student to evaluate his or her own performance enhances self-awareness and promotes self-directed learning. Using three outcome measures of competency of procedure, communication skills, and learning motivation, the effects of self-evaluation using a video recording of the student's Foley catheterization was investigated in this study. The students in the experimental group (n = 20) evaluated their Foley catheterization performance by reviewing the video recordings of their own performance, whereas students in the control group (n = 20) received written evaluation guidelines only. The results showed that the students in the experimental group had better scores on competency (p < 0.001), communication skills (p < 0.001), and learning motivation (p = 0.018) than the control group at the post-test, which was conducted 8 weeks after the pretest. Self-awareness of one's own performance developed by reviewing a videotape appears to increase the competency of clinical skills in nursing students.

Embedding a longitudinal diagnostic reasoning curriculum in a residency program using a bolus/booster approach.

Background Diagnostic reasoning skills are essential to the practice of medicine, yet longitudinal curricula to teach residents and evaluate performance in this area is lacking. We describe a longitudinal diagnostic reasoning curriculum implemented in a university-based internal medicine residency program and self-evaluation assessment of the curriculum's effectiveness. Methods A longitudinal diagnostic reasoning curriculum (bolus/booster) was developed and implemented in the fall of 2015 at the University of Iowa. R1, R2, and R3 cohorts were taught the "bolus" curriculum at the beginning of each academic year followed by a "booster" component to maintain and build upon diagnostic reasoning skills taught during the "bolus" phase. Self-administered diagnostic thinking inventory (DTI) scores were collected in the spring of pre-curriculum (baseline, 2014-2015) and post-curriculum (2016-2017). Results The overall DTI scores improved in the R1 cohort, although statistically significant differences were not seen with R2s and R3s. In the original DTI categories, R1s improved in both flexibility of thinking and structure of thinking, the R2s improved in structure of thinking and the R3s did not improve in either category. R1s showed improvement in three of the four subcategories - data acquisition, problem representation, and hypothesis generation. The R2s improved in the subcategory of problem representation. R3s showed no improvement in any of the subcategories. The R3 cohort had higher mean scores in all categories but this did not reach statistical significance. Conclusions Our program created and successfully implemented a longitudinal diagnostic reasoning curriculum. DTI scores improved after implementation of a new diagnostic reasoning curriculum, particularly in R1 cohort.

Can consumers self-select for appropriate use of an over-the-counter statin? The Self Evaluation of Lovastatin to Enhance Cholesterol Treatment Study.

Access to over-the-counter (OTC) statins has the potential to improve public health by reducing cardiovascular events. The Self Evaluation of Lovastatin to Enhance Cholesterol Treatment (SELECT) Study was designed to assess consumers' ability to self-select for treatment with lovastatin in an unsupervised setting. Subjects examined proposed OTC lovastatin cartons with labels that detailed an algorithm for self-selection based on age, lipid profile, and cardiovascular risk factors. Subjects viewed a carton with either a low-density lipoprotein cholesterol-based self-selection algorithm or one based on total cholesterol. Labels also contained warnings against use based on health conditions that might increase the risk of adverse events. Subjects were asked if the drug was appropriate for their use (self-assessment) and whether they would like to purchase the drug (purchase decision). A total of 1,326 consumers provided self-assessment decisions. After viewing the low-density lipoprotein cholesterol-based label, 82%, 36%, and 82% of those who self-assessed that the drug was appropriate for their use were correct with respect to the age, lipid, and risk-factor criteria, respectively. Corresponding numbers for the total cholesterol algorithm were 85%, 50% and 75%. Almost 90% of women aged <55 years who evaluated the drug indicated the drug was not right for them, and women in this age group made up only 9% of the total group of subjects who believed the drug was appropriate for their use. The label was also effective in discouraging use by women who were or may become pregnant, consumers with liver disease, and those with potential drug interactions. In conclusion, SELECT showed that consumers could use an OTC drug label in an unsupervised setting to appropriately self-select for self-management of their cholesterol with lovastatin.

"Directed" self-assessment: practice and feedback within a social context.

INTRODUCTION: Accurate self-assessment appears to be difficult and, some would propose, even impossible. Recent reviews suggest that peer assessment may be more accurate and that multisource feedback (MSF) may inform self-assessment. We had conducted a series of studies of family physicians in an MSF program including assessments from patients, medical colleagues, and coworkers and self-assessment. Using this body of research, this article explores self-assessment within the social context of multisource feedback and investigates the influence of feedback from peers and others upon self-assessment. METHODS: This is a review article in which we synthesized findings of the series of studies with respect to self-assessment, used conclusions to propose a model for self-assessment within a social context, and suggest practical and research implications. RESULTS: Physicians compared peers' and others' assessment feedback with global self-perceptions of performance. Negative feedback, especially from medical colleagues, that was inconsistent with self-perceptions was not readily reconciled with self-assessments. Multiple internal and environmental factors influenced reconciliation and assimilation of negative feedback. Reflection upon feedback and self-perceptions appeared to be instrumental to reconciliation, and reflection could be facilitated. DISCUSSION: We propose a model of "directed" self-assessment to facilitate the integration of external feedback, especially negative feedback, with self-perceptions and enable its use for practice improvement. Implications for education and research include increasing understanding of ways physicians assimilate external feedback and of the role of educators as facilitators of "directed" self-assessment and self-learning to assist physicians in integrating external feedback.

Self-assessment of practice performance: development of the ABIM Practice Improvement Module (PIM).

BACKGROUND: Quality measurement and improvement in practice are requirements for Maintenance of Certification by the American Board of Medical Specialties boards and a component of many pay for performance programs. OBJECTIVE: To describe the development of the American Board of Internal Medicine (ABIM) Practice Improvement Module (PIM) and the average performance of ABIM diplomates who have completed the Preventive Cardiology PIM. DESIGN: Observational study of self-administered practice quality improvement. SETTING: Office practices through the United States. PARTICIPANTS: A total of 179 cardiologists and general internists completing requirements for ABIM Maintenance of Certification from 2004 through 2005. MEASUREMENTS: Physicians self-audited at least 25 charts to obtain performance measures, patient demographics, and coronary heart disease risk factors. At least 25 patients completed surveys regarding their experience of care in the physician's practice. Physicians completed a self-assessment survey detailing the presence of various practice systems. RESULTS: The mean rate for systolic blood pressure control was 48%, for diastolic blood pressure 84%, and for low-density lipoprotein (LDL) cholesterol at goal 65%. Of patients 61% rated the quality of care as excellent and 58% rated the practices excellent at encouraging questions and answering them clearly. More than 85% of patients reported "no problem" obtaining a prescription refill, scheduling an appointment, reaching someone in the practice with a question, or obtaining lab results. Targets for improvement were increasing the rates for LDL cholesterol or systolic blood pressure at goal, improving patients' physical activity, patient education, and accuracy of risk assessment. Improvement strategies included implementing chart forms, patient education, or care management processes. LIMITATIONS: Patients and charts were selected by physicians reporting their performance for the purpose of MOC. CONCLUSIONS: The Preventive Cardiology PIM successfully provides a self-assessment of practice performance and provides guidance in helping physicians initiate a cycle of quality improvement in their practices.

Assessment of functional outcome in a national quality register for acute stroke: can simple self-reported items be transformed into the modified Rankin Scale?

BACKGROUND AND PURPOSE: To enable self-reporting of functional outcome in quality registers, the corresponding questions have to be easy to interpret. In scientific research, the modified Rankin Scale (mRS) is a standard assessment method. Such methods, with an outsider observer, are not feasible to use in quality registers. For several aspects, eg, comparisons between outcome in clinical studies and observational studies, we determined to see whether the functional outcome, as assessed in a quality register, can be transformed into mRS grades. METHODS: The agreement between self-reported functional outcome (including dependency, living situation, mobility, dressing and toileting) and mRS were analyzed using 555 stroke patients registered in Riks-Stroke, the Swedish quality register for acute stroke, during a 5-month period in 4 hospitals. The self-reported outcome and the mRS grades were concurrently assessed by a telephone interview performed by an experienced nurse 3 months after stroke. RESULTS: A translation using 5 of the questions from Riks-Stroke classified 76% of the patients to the correct mRS grade. The correlation between Riks-Stroke and mRS was 0.821 and Cohen's kappa (weighted) was 0.853. CONCLUSIONS: The study shows that self-reported functional outcome can be transformed into mRS grades with a high precision, making the translation useful for future comparative purposes in stroke outcome studies.

Shift analysis versus dichotomization of the modified Rankin scale outcome scores in the NINDS and ECASS-II trials.

BACKGROUND AND PURPOSE: The SAINT I trial that showed a significant benefit of the neuroprotectant NXY-059 used a novel outcome for acute ischemic stroke trials: a shift toward good functional outcome on the 7-category modified Rankin scale (mRS). METHODS: We used the Cochran-Mantel-Haenszel shift test to analyze the distribution of the 90-day mRS outcomes in the NINDS and ECASS-II databases and compared the results with a dichotomized mRS outcome by logistic regression (0 to 2 vs 3 to 6, or 0 to 1 vs 2 to 6). We also stratified each dataset based on National Institutes of Health Stroke Scale baseline severity. RESULTS: Each dataset showed a statistically significant shift in the 90-day mRS distributions favoring tissue plasminogen activator (odds ratio, 1.6 for NINDS, 1.3 for ECASS-II). For ECASS-II, larger shift effects appeared in National Institutes of Health Stroke Scale 0 to 6 and 16 to 40 strata. Similarly, the mRS 0 to 2 analysis but not mRS 0 to 1 found similar treatment effects in both datasets (odds ratio, 1.6 for NINDS, 1.5 for ECASS-II) and similar variations in the low and high strata in the ECASS-II trial. NINDS found no significant treatment effects across the strata. After removing the strata at the fringes, the shift test lost significance in both datasets. CONCLUSIONS: Tissue plasminogen activator causes a beneficial shift toward wellness on the mRS in both the NINDS and ECASS-II trials, and ECASS-II would have been a positive trial according to the shift approach. However, the shift effect is not global for all treated patients and does not outperform the dichotomized 0 to 2 outcome. Patients with mild and severe deficits also shifted favorably on the mRS in the ECASS-II trial.

Validation of a pictorial rating scale for grip strength evaluation in 3- to 6-year-old children.

The present study aimed to validate a pictorial rating scale to evaluate the child's ability to produce grip forces. Thirty-seven children aged 3 to 6 years participated as subjects in this investigation. We used a tailor-made pictorial scale and a hand grip strength meter, as well as a Piaget's clinical interview aimed to gather information on the child's understanding of the rating scale. The sensitivity of the rating scale was measured by testing a 4-intensity-level hand grip effort with 3- to 6-year-old children. In addition, the reproducibility of this pictorial rating scale was investigated by a test and randomised re-test procedure. Statistical analysis revealed that no significant main effect (P>0.05) for test was observed in any child. In addition, no significant main effect (P>0.05) for intensity was found in 3-year-old children. However, in the 4-year-old children and over, a significant main effect (P<0.05) was found for intensity. The results also showed that 5- and 6-year-old children were able to produce four differentiated intensities of grip forces. These findings suggest that the pictorial rating scale for grip strength evaluation showed acceptable reproducibility and was sensitive to the age of the children tested. To conclude, this pictorial rating scale appears to be a valid tool to investigate accurately the child's ability to produce grip forces in young children from 5-year-old and over.