Becoming a deliberately developmental organization: Using competency based assessment data for organizational development.

Medical education is situated within health care and educational organizations that frequently lag in their use of data to learn, develop, and improve performance. How might we leverage competency-based medical education (CBME) assessment data at the individual, program, and system levels, with the goal of redefining CBME from an initiative that supports the development of physicians to one that also fosters the development of the faculty, administrators, and programs within our organizations? In this paper we review the Deliberately Developmental Organization (DDO) framework proposed by Robert Kegan and Lisa Lahey, a theoretical framework that explains how organizations can foster the development of their people. We then describe the DDO's conceptual alignment with CBME and outline how CBME assessment data could be used to spur the transformation of health care and educational organizations into digitally integrated DDOs. A DDO-oriented use of CBME assessment data will require intentional investment into both the digitalization of assessment data and the development of the people within our organizations. By reframing CBME in this light, we hope that educational and health care leaders will see their investments in CBME as an opportunity to spur the evolution of a developmental culture.

Curricular needs for training telemedicine physicians: A scoping review.

PURPOSE: The use of telemedicine, a part of 'Virtual Care', is rapidly entering mainstream clinical practice. The ideal curriculum for educating physicians to practice in this emerging field has not been established. We examined the literature to evaluate published curricula for quality and comprehensiveness through the lens of Competency-Based Medical Education (CBME). METHODS: We performed a scoping review using CanMEDS as a framework. Peer-reviewed articles describing telemedicine training curricula were identified. Trainee population, curricular points, stage of implementation, evaluation depth, country, and citations (a marker of quality) were examined. RESULTS: Forty-three curricula from 11 countries were identified, addressing all training levels and covering multiple specialties. Instructional methods included lectures (60.5%), hands-on experiences (76%), directed reading (24%), online modules (21%), reflection (13%), simulation (34%), and group discussions (16%). Hands-on curricula covered all CanMEDS roles more often. Twenty-nine of the implemented curricula were evaluated; 83% were rated positively. CONCLUSIONS: Our scoping review helps inform more comprehensive and efficacious curricula for teaching telemedicine. We suggest centering curricula on a competency-based, outcomes-oriented framework such as CanMEDS with multiple teaching modalities complementing hands-on experiences. This will facilitate rigorous telemedicine training to deliver on the promise of high-quality patient care.

Microwave Processing: Current Background and Effects on the Physicochemical and Microbiological Aspects of Dairy Products.

Overheating is still a major problem in the use of conventional heating for milk and various dairy products, because it leads to the lowering of quality and sensory and nutritional values. Microwave (MW) heating has been credited with providing superior-quality dairy-based products with extended shelf-life, representing a good alternative to conventional heat treatment. The main drawback of MW heating refers to nonuniform temperature distribution, resulting in hot and cold spots mainly in solid and semisolid products; however, MW heating has been shown to be suitable for liquid foods, especially in a continuous fluid system. This review aims to describe the main factors and parameters necessary for the application of MW heating technology for dairy processing, considering the theoretical fundamentals and its effects on quality and safety aspects of milk and dairy products. MW heating has demonstrated great ability for the destruction of pathogenic/spoilage microorganisms and their spores, and also inactivation of enzymes, thereby preserving fresh characteristics of dairy products.

Monitoring and regulation of learning in medical education: the need for predictive cues.

CONTEXT: Being able to accurately monitor learning activities is a key element in self-regulated learning in all settings, including medical schools. Yet students' ability to monitor their progress is often limited, leading to inefficient use of study time. Interventions that improve the accuracy of students' monitoring can optimise self-regulated learning, leading to higher achievement. This paper reviews findings from cognitive psychology and explores potential applications in medical education, as well as areas for future research. COGNITIVE PSYCHOLOGY: Effective monitoring depends on students' ability to generate information ('cues') that accurately reflects their knowledge and skills. The ability of these 'cues' to predict achievement is referred to as 'cue diagnosticity'. Interventions that improve the ability of students to elicit predictive cues typically fall into two categories: (i) self-generation of cues and (ii) generation of cues that is delayed after self-study. Providing feedback and support is useful when cues are predictive but may be too complex to be readily used. APPLICATION TO MEDICAL EDUCATION: Limited evidence exists about interventions to improve the accuracy of self-monitoring among medical students or trainees. Developing interventions that foster use of predictive cues can enhance the accuracy of self-monitoring, thereby improving self-study and clinical reasoning. First, insight should be gained into the characteristics of predictive cues used by medical students and trainees. Next, predictive cue prompts should be designed and tested to improve monitoring and regulation of learning. Finally, the use of predictive cues should be explored in relation to teaching and learning clinical reasoning. CONCLUSIONS: Improving self-regulated learning is important to help medical students and trainees efficiently acquire knowledge and skills necessary for clinical practice. Interventions that help students generate and use predictive cues hold the promise of improved self-regulated learning and achievement. This framework is applicable to learning in several areas, including the development of clinical reasoning.

Online self-study of chest X-rays shows no difference between blocked and mixed practice.

CONTEXT: Chest radiograph interpretation is a complex skill and learners may benefit from deliberate instructional design modalities, such as mixed practice. Proposed benefits of mixed over blocked practice include the elimination of cueing and the highlighting of contrasting features. However, current evidence for the superiority of mixed practice is conflicting. OBJECTIVES: This study compares mixed versus blocked practice, after the initial teaching of concepts, among medical students using online self-study chest X-ray (CXR) modules. METHODS: Two online CXR modules were developed that cover identical content but differ in the organisation of practice images. Blocked modules provided practice CXRs after each category, whereas mixed modules randomly ordered practice radiographs after all categories had been taught. Medical students in Years 1-3 were randomised to either module and were tested on 20 new CXRs immediately after completion and at 2 weeks. The primary outcome was immediate diagnostic accuracy. Secondary outcomes included diagnostic accuracy at 2 weeks, time per module and reported module difficulty. RESULTS: A total of 58 medical students participated (32 in the blocked and 26 in the mixed module). Level of training and previous CXR experience were similar across the groups. Totals of 1160 and 1120 answers were evaluated for immediate and 2 week post-test scores, respectively. There were no significant differences in mean diagnostic accuracy between the blocked (mean score: 11.7/20) and mixed (mean score: 11.0/20) practice groups on immediate testing (t = 0.83, d.f. = 56, p = 0.41) or at 2 weeks (mean score: 11.2/20 versus 10.9/20; t = 0.518, d.f. = 54, p = 0.61). Post-test scores showed no correlation with training level (R = 0.23, p = 0.09) or completion time (R = -0.09, p = 0.5). Reported module difficulty was similar between the mixed (3.22/5) and blocked (3.19/5) groups. On multivariable linear regression controlling for completion time, training level and CXR experience, between-group differences remained non-significant. CONCLUSIONS: Performance after mixed practice was similar to that after blocked practice. Results may reflect similarities between modules in teaching, which emphasised contrast learning, greater effect of initial teaching rather than practice, or absence of tutor-led instruction. Alternatively, results may reflect the higher cognitive load in mixed practice imposed by contrasting multiple diagnoses.

Manufacture of probiotic Minas Frescal cheese with Lactobacillus casei Zhang.

In this study, the addition of Lactobacillus casei Zhang in the manufacture of Minas Frescal cheese was investigated. Minas Frescal cheeses supplemented with probiotic bacteria (Lactobacillus casei Zhang) were produced by enzymatic coagulation and direct acidification and were subjected to physicochemical (pH, proteolysis, lactic acid, and acetic acid), microbiological (probiotic and lactic bacteria counts), and rheological analyses (uniaxial compression and creep test), instrumental color determination (luminosity, yellow intensity, and red intensity) and sensory acceptance test. The addition of L. casei Zhang resulted in low pH values and high proteolysis indexes during storage (from 5.38 to 4.94 and 0.470 to 0.702, respectively). Additionally, the cheese protocol was not a hurdle for growth of L. casei Zhang, as the population reached 8.16 and 9.02 log cfu/g by means of the direct acidification and enzymatic coagulation protocol, respectively, after 21 d of refrigerated storage. The rheology data showed that all samples presented a more viscous-like behavior, which rigidity tended to decrease during storage and lower luminosity values were also observed. Increased consumer acceptance was observed for the control sample produced by direct acidification (7.8), whereas the cheeses containing L. casei Zhang presented lower values for all sensory attributes, especially flavor and overall liking (5.37 and 4.61 for enzymatic coagulation and 5.57 and 4.72 for direct acidification, respectively). Overall, the addition of L. casei Zhang led to changes in all parameters and affected negatively the sensory acceptance. The optimization of L. casei Zhang dosage during the manufacturing of probiotic Minas Frescal cheese should be performed.

Limitations of subjective cognitive load measures in simulation-based procedural training.

CONTEXT: The effective implementation of cognitive load theory (CLT) to optimise the instructional design of simulation-based training requires sensitive and reliable measures of cognitive load. This mixed-methods study assessed relationships between commonly used measures of total cognitive load and the extent to which these measures reflected participants' experiences of cognitive load in simulation-based procedural skills training. METHODS: Two groups of medical residents (n = 38) completed three questionnaires after participating in simulation-based procedural skills training sessions: the Paas Cognitive Load Scale; the NASA Task Load Index (TLX), and a cognitive load component (CLC) questionnaire we developed to assess total cognitive load as the sum of intrinsic load (how complex the task is), extraneous load (how the task is presented) and germane load (how the learner processes the task for learning). We calculated Pearson's correlation coefficients to assess agreement among these instruments. Group interviews explored residents' perceptions about how the simulation sessions contributed to their total cognitive load. Interviews were audio-recorded, transcribed and subjected to qualitative content analysis. RESULTS: Total cognitive load scores differed significantly according to the instrument used to assess them. In particular, there was poor agreement between the Paas Scale and the TLX. Quantitative and qualitative findings supported intrinsic cognitive load as synonymous with mental effort (Paas Scale), mental demand (TLX) and task difficulty and complexity (CLC questionnaire). Additional qualitative themes relating to extraneous and germane cognitive loads were not reflected in any of the questionnaires. CONCLUSIONS: The Paas Scale, TLX and CLC questionnaire appear to be interchangeable as measures of intrinsic cognitive load, but not of total cognitive load. A more complete understanding of the sources of extraneous and germane cognitive loads in simulation-based training contexts is necessary to determine how best to measure and assess their effects on learning and performance outcomes.

ECG rhythm analysis with expert and learner-generated schemas in novice learners.

Although instruction using expert-generated schemas is associated with higher diagnostic performance, implementation is resource intensive. Learner-generated schemas are an alternative, but may be limited by increases in cognitive load. We compared expert- and learner-generated schemas for learning ECG rhythm interpretation on diagnostic accuracy, cognitive load and knowledge acquisition. Fifty-seven medical students were randomized to two experiments. Experiment 1 (n = 29) compared use of traditional teaching frameworks to expert generated schemas. Participants randomly received either a traditional framework or an expert-generated schema to practice each of two content areas in a crossed design. Learning accuracy and cognitive load were measured during the training phase. Discriminating knowledge and diagnostic accuracy were tested immediately after the training phase and 1-2 weeks after. Using the same methodology, experiment 2 (n = 28) compared use of learner-generated versus expert-generated schemas. In experiment 1, learning from expert-generated schemas was associated with lower cognitive load (13 vs 16, p < 0.001), higher diagnostic accuracy on immediate testing (40 vs 29 %, p = 0.018), and higher discriminating knowledge (81 vs 71 %, p < 0.001). Both groups performed similarly on delayed testing (14 vs 8 %, p = 0.6). In experiment 2, use of learner-generated schemas reduced diagnostic accuracy during the training phase (55 vs 77 %, p < 0.001), with similar performance on the immediate (30 vs 33 %, p = 0.89) and delayed (7 vs 5 %, p = 0.79) testing phases.. Learner-generated schema generation was associated with increased cognitive load (17.1 vs 13.5, p < 0.001). When compared to traditional frameworks, use of an expert-generated schema improved learning of ECG rhythm interpretation. Participants generating their own schemas perform similarly to those using expert-generated schemas despite reporting higher cognitive load.

Deliberate practice as a framework for evaluating feedback in residency training.

OBJECTIVE: Using the theory of deliberate practice, a key component of Ericsson's theory of expertise development, this study aims to evaluate the quality of written feedback given to learners. METHODS: The authors created a feedback scoring system based on the key elements of deliberate practice and used it to assess the quality of written feedback provided to residents in 205 mini-CEX encounter forms. Scores were assigned to each feedback entry for identification of the following: Task, performance gap and action plan. RESULTS: The scoring system allowed for reliable identification of the components that facilitate deliberate practice in written feedback provided to trainees. However, only one of these components was identified in 70% of the feedback entries. A specific task was identified in 56%, whereas specific performance gaps and action plans were identified in only 3.9% and 13.7% of encounters, respectively. CONCLUSIONS: Scoring written feedback identified that tasks were often specifically described, but performance gaps and action plans were less frequently and specifically mentioned. Educators might improve feedback effectiveness by better articulating to trainees the gap between their performance and an expert standard, as well as by providing them with specific learning plans.

Strategies to Enable Transformation in Medical Education: Faculty and Trainee Development in Competence By Design.

Transformative changes in health professions education need to incorporate effective faculty development, but few very large-scale faculty development designs have been described. The Royal College of Physicians and Surgeons of Canada's Competence by Design project was launched to transform the delivery of postgraduate medical education in Canada using a competency-based model. In this paper we outline the goals, principles, and rationale of the Royal College's national strategy for faculty and resident development initiatives to support the implementation of Competence by Design. We describe the activities and resources for both faculty and trainees that facilitated the redesign of training programs for each specialty and subspecialty at the national level, as well as supporting the implementation of the redesign at the local level. This undertaking was not without its challenges: we thus reflect on those challenges, enablers, and the lessons learned, and discuss a continuous quality improvement approach that was taken to iteratively inform the implementation process moving forward.

Competence By Design: a transformational national model of time-variable competency-based postgraduate medical education.

Postgraduate medical education is an essential societal enterprise that prepares highly skilled physicians for the health workforce. In recent years, PGME systems have been criticized worldwide for problems with variable graduate abilities, concerns about patient safety, and issues with teaching and assessment methods. In response, competency based medical education approaches, with an emphasis on graduate outcomes, have been proposed as the direction for 21st century health profession education. However, there are few published models of large-scale implementation of these approaches. We describe the rationale and design for a national, time-variable competency-based multi-specialty system for postgraduate medical education called Competence by Design. Fourteen innovations were bundled to create this new system, using the Van Melle Core Components of competency based medical education as the basis for the transformation. The successful execution of this transformational training system shows competency based medical education can be implemented at scale. The lessons learned in the early implementation of Competence by Design can inform competency based medical education innovation efforts across professions worldwide.

Hybrid simulation for knee arthrocentesis: improving fidelity in procedures training.

BACKGROUND: Procedures form a core competency for internists, yet many do not master these skills during residency. Simulation can help fill this gap, but many curricula focus on technical skills, and overlook communication skills necessary to perform procedures proficiently. Hybrid simulation (HS) is a novel way to teach and assess procedural skills in an integrated, contextually-based way. AIM: To create a HS model for teaching arthrocentesis to internal medicine residents. SETTING: Internal medicine residency program at the University of Toronto. PARTICIPANTS: Twenty four second-year internal medicine residents. PROGRAM DESCRIPTION: Residents were introduced to HS, given practice time with feedback from standardized patients (SPs) and faculty, and assessed individually using a different scenario and SP. Physicians scored overall performance using a 6-point procedural skills measure, and both physicians and SPs scored communication using a 5-point communication skills measure. PROGRAM EVALUATION: Realism was highly rated by residents (4.13/5.00), SPs (4.00) and physicians (4.33), and was perceived to enhance learning. Residents' procedural skills were rated as 4.21/6.00 (3.00 - 5.00; ICC = 0.77, [0.53 - 0.92]), comparable to an experienced post-graduate year (PGY) 2-3; and all but one resident was considered competent. DISCUSSION: HS facilitates simultaneous acquisition of technical and communication skills. Future research should examine whether HS improves transfer of skills to the clinical setting.

Cardiac examination and the effect of dual-processing instruction in a cardiopulmonary simulator.

Use of dual-processing has been widely touted as a strategy to reduce diagnostic error in clinical medicine. However, this strategy has not been tested among medical trainees with complex diagnostic problems. We sought to determine whether dual-processing instruction could reduce diagnostic error across a spectrum of experience with trainees undertaking cardiac physical exam. Three experiments were conducted using a similar design to teach cardiac physical exam using a cardiopulmonary simulator. One experiment was conducted in each of three groups: experienced, intermediate and novice trainees. In all three experiments, participants were randomized to receive undirected or dual-processing verbal instruction during teaching, practice and testing phases. When tested, dual-processing instruction did not change the probability assigned to the correct diagnosis in any of the three experiments. Among intermediates, there was an apparent interaction between the diagnosis tested and the effect of dual-processing instruction. Among relative novices, dual processing instruction may have dampened the harmful effect of a bias away from the correct diagnosis. Further work is needed to define the role of dual-processing instruction to reduce cognitive error. This study suggests that it cannot be blindly applied to complex diagnostic problems such as cardiac physical exam.

Evaluation of standardized doctor's orders as an educational tool for undergraduate medical students: a prospective cohort study.

BACKGROUND: Standardized doctor's orders are replacing traditional order writing in teaching hospitals. The impact of this shift in practice on medical education is unknown. It is possible that preprinted orders interfere with knowledge acquisition and retention by not requiring active decision-making. The objective of the study was to evaluate the impact of standardized admission orders on disease-specific knowledge among undergraduate medical trainees. METHODS: This prospective cohort study enrolled Year 3 (n = 121) and Year 4 (n = 54) medical students at two academic hospitals in Toronto (Ontario, Canada) during their general internal medicine rotation. We used standardized orders for patient admissions for alcohol withdrawal (AW) and for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) as the intervention and manual order writing as the control. Educational outcomes were assessed through end-of-rotation questionnaires assessing disease-specific knowledge of AW and AECOPD. RESULTS AND DISCUSSIONS: Of 175 students, 105 had exposure to patients with alcohol withdrawal during their rotation, and 68 students wrote admission orders. Among these 68 students, 48 used standardized orders (intervention, n = 48) and 20 used manual order writing (control, n = 20). Only 3 students used standardized orders for AECOPD, precluding analysis. There was no significant difference found in mean total score of questionnaires between those who used AW standardized orders and those who did not (11.8 vs. 11.0, p = 0.4). Students who had direct clinical experience had significantly higher mean total scores (11.6 vs. 9.0, p < 0.0001 for AW; 13.8 vs. 12.6, p = 0.02 for AECOPD) compared to students who did not. When corrected for overall knowledge, this difference only persisted for AW. CONCLUSIONS: No significant differences were found in total scores between students who used standardized admission orders and traditional manual order writing. Clinical exposure was associated with increase in disease-specific knowledge.

Frameworks for Integrating Learning Analytics With the Electronic Health Record.

ABSTRACT: The information systems designed to support clinical care have evolved separately from those that support health professions education. This has resulted in a considerable digital divide between patient care and education, one that poorly serves practitioners and organizations, even as learning becomes ever more important to both. In this perspective, we advocate for the enhancement of existing health information systems so that they intentionally facilitate learning. We describe three well-regarded frameworks for learning that can point toward how health care information systems can best evolve to support learning. The Master Adaptive Learner model suggests ways that the individual practitioner can best organize their activities to ensure continual self-improvement. The PDSA cycle similarly proposes actions for improvement but at a health care organization's workflow level. Senge's Five Disciplines of the Learning Organization, a more general framework from the business literature, serves to further inform how disparate information and knowledge flows can be managed for continual improvement. Our main thesis holds that these types of learning frameworks should inform the design and integration of information systems serving the health professions. An underutilized mediator of educational improvement is the ubiquitous electronic health record. The authors list learning analytic opportunities, including potential modifications of learning management systems and the electronic health record, that would enhance health professions education and support the shared goal of delivering high-quality evidence-based health care.

Impact of adding xylooligosaccharides encapsulated in butter: Microstructural, optical, rheological and sensory aspects.

This study investigated the microstructure, rheological properties, and sensory characteristics of butters produced with free and encapsulated xylooligosaccharides (XOS). Four formulations of butter were processed: BCONT: 0 % w/w XOS (control); BXOS: 20% w/w free XOS; BXOS-ALG: 20% w/w XOS microencapsulated with alginate (XOS-alginate ratio of 3:1 w/w); and BXOS-GEL: 20% w/w XOS microencapsulated with alginate-gelatin (XOS-alginate-gelatin ratio of 3:1:1.5 w/w). The microparticles showed a bimodal distribution, low size and low span values, demonstrating physical stability to be included in emulsions. The XOS-ALG presented surface weighted mean diameter (D3.2) of 90.24 µm, volume-weighted mean diameter (D4.3) of 131.8 µm, and Span of 2.14. In contrast, the XOS-GEL presented D3.2 of 82.80 µm, D4.3 of 141.0 µm, and a Span of 2.46. Products with XOS were characterized by higher creaminess, sweet taste, and lower salty taste than the control. However, the addition form significantly impacted the other evaluated parameters. The utilization of XOS in a free form (BXOS) resulted in smaller droplet sizes (1.26 µm) than encapsulated XOS and control (XOS-ALG = 1.32 µm / XOS-GEL = 1.58 µm, / BCONT = 1.59 µm), and changes in the rheological parameters (higher values of shear stress, viscosity, consistency index, rigidity (J0), and Newtonian viscosity (ηN) and lower elasticity (τ)). Furthermore, it changed the color parameters (more yellow and dark color, lower L* and higher b* values). On the other hand, the utilization of micropaticles of XOS (BXOS-ALG and BXOS-GEL) kept shear stress, viscosity, consistency index, rigidity (J0), and elasticity (τ) more similar to control. The products had a less intense yellow color (lower b* values) and was perceived with more consistency and butter taste. However, the presence of particles was perceived by consumers. The results suggest that consumers were more attentive to reporting flavor-related attributes than texture. In conclusion, adding microparticles of XOS could improve butter's rheological and sensory properties. In conclusion, adding microparticles of XOS could improve butter's rheological and sensory properties.

Thermosonication as a pretreatment of raw milk for Minas frescal cheese production.

Minas frescal cheese is extremely popular in Brazil, with high perishability and acceptability. Among emerging technologies, ultrasound stands out for its satisfactory results regarding microbiological safety and technological and sensory aspects. The combined mild temperature application, called thermosonication, can generate even more promising results. In this study, a high-intensity ultrasound system combined with thermal heating (TS, thermosonication) was applied for the treatment of raw milk to produce Minas Frescal cheese. US energy was delivered to raw milk samples using a probe operating at a 20 kHz of frequency and nominal power of 160, 400, and 640 W. The TS system was compared with conventional pasteurization (HTST, high-temperature short-time pasteurization) at 72 to 75 °C and 15 s. Soft cheeses were prepared with different samples: (a) raw milk (control), b)conventionally pasteurized milk (HTST), and c) TS treat milk in different nominal power (TS160, TS400, and TS640). The produced cheeses were evaluated for microbiological behavior, rheology, color parameters, and bioactive compounds. TS treatment in milk resulted in higher microbial inactivation and stability during storage, improved color parameters (higher lightness (L*), and whiteness index (WI). TS treatment also showed a higher generation of bioactive compounds (higher antioxidant, and inhibitory activities of α-amylase, α-glucosidase, and angiotensin-converting enzymes) than HTST. The impact of TS on rheological properties was similar to HTST, resulting in more brittle and less firm products than the cheese produced with raw milk. The positive effects were more prominent using a nominal power of 400 W (TS400). Therefore, TS proved to be a promising process for processing milk for Minas Frescal cheese production.