This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.

The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine.

Monday, October 6, 2014

Be FAIR to students

I recently saw a great editorial in the Medical Teacher.  Medical Teacher is the official journal of AMEE, an international association for all involved with medical and healthcare professions education. The Medical Teacher “addresses the needs of teachers and administrators throughout the world involved in training for the health professions.” (1)

The editorial by Harden and Laidlaw (2) discussed the FAIR principles that teachers can use to help their students develop and that lead to better learning. As someone who works in faculty development for my department and my institution, I found these principles to be an effective faculty development tool. 

The four principles of FAIR are:

            F          provide appropriate Feedback to students
            A         make learning Active not passive
            I           Individualize learning
            R         ensure the learning is Relevant

Feedback is something that I have written about here in the past (see- Feedback or Compliments? Which is better?)  Feedback is important for learners. It helps students to get better by giving the teacher the opportunity to correct mistakes. Dr. Harden quotes a 2007 review by Hattie and Timperley. (3) The authors reviewed twelve large meta-analyses that included 196 studies that looked at feedback. They found that the average effect size of feedback on performance in several different contexts was about 0.79. For perspective, it was lower than the effect of direct instruction (0.93) but was greater than a student’s prior cognitive ability (0.71).  Not getting enough feedback is one of the most common complaints from medical students regarding their teachers. Feedback is “the most powerful single thing that teachers can do to enhance achievement of their students.” (1) An important point from this article is that is that students need to use feedback for it to be effective. Students should use feedback from the preceptors and faculty members to fix deficits through increased practice, readings, and experiences.

The second point is that learning needs to be active. Active learning has a lot of advantages for the learner—it keeps them engaged in the process, it allows them to interact with peers in small group peer teacher/learner activities, and it encourages learners to use electronic and other outside resources to enhance their knowledge acquisition. Dr. Harden makes the point that no matter what the context, learning activities should be “designed to be meaningful”. Often students feel that learning activities have no point. For some activities in medical education, I would have to agree.  

This leads into the third principle of FAIR which is that learning needs to be individualized. It is funny that Facebook, Twitter, and Google have figured this out in less than a decade while in medical education we still don’t do this. The model has remained for one hundred years, everyone gets the same curriculum taught in the same way with the same assessments at the end. There is data that suggests that students have different learning styles and benefit from individual attention to those

(reprinted from: Harden RM, Laidlaw JM. Med Teach. 2013; 35(1): 27-31)
styles (see my 2012 blog--Self Regulated Learning and Performance)  We get students into medical school from a wide variety of backgrounds and experiences, but pay little attention to these differences. Some students come from a science heavy background while others from a more liberal arts background. Some students may have been heavily involved in clinical medicine by volunteering in a free clinic while others have almost no clinical experience. More attention to these differences would maximize the students’ learning.

The final area of concern to help us be FAIR to students is relevance. This used to be a big deal in medical education. When I went to medical school, there was very little clinical education before the third year of medical school, it was all basic science. As a student you were just trying to get through that so that you could learn to be doctor later. Now as a faculty member who not only teaches in the basic science curriculum, but also directs a basic science module, I find it easier to provide the relevance. I think that we do a better job of using clinical cases and vignettes to frame basic science knowledge in the clinical context. In this setting of relevance, I believe student learning is enhanced.

I believe that the bottom-line suggestions from this article can be very helpful in structuring our teaching:

1) Recognize the importance of feedback
2) Assess the extent of active engagement of your students
3) Individually tailor the learning environment
4) Ensure the relevance of all learning activities

(2) Harden RM, Laidlaw JM. Be FAIR to students: four principles that lead to more effective learning. Med Teach. 2013; 35(1): 27-31

(3) Hattie J, Timperley H. 2007. The power of feedback. Review Educational Research. 2007; 77: 81–112.

Wednesday, September 10, 2014

Does the experience on a clinical clerkship effect performance?

I found an interesting study this week that I wanted to blog about today. This study was published in Medical Education a couple of years ago. The authors, Dong and colleagues (1) asked an important and very common question: does the experience that a student has during a clinical rotation effect their performance on that rotation? This is important for many reasons. One big reason is that developing and maintaining adequate clinical experiences is an expensive and time-consuming process. It would be nice if we knew that the experiences that we were providing for students were having a positive effect.

The authors describe two alternative theories of learning in the clinical arena. One idea is that students need to utilize deliberate practice to learn. In other words, they need specific learning experiences that are led by a qualified mentor. These learning experiences are planned and need to be varied and extensive in order for students to develop expertise. The alternative idea is based on the concept of cognitive load theory. In this theory, medical students may have difficulty learning clinical medicine when they are exposed to multiple patients and clinical problems. Instead, students might learn better if they have more straightforward instructional formats, such as simulated cases.

Clinical clerkships in all specialties spend a lot of time trying to demonstrate that the clinical experiences that they provide are similar across different sites and for different students. A previous study of clerkship directors from Internal Medicine, found that they use core cases to compare the clinical experiences of multiple students.(2)  Many clinical clerkships use paper or electronic logs to track the students’ experiences.

This study was done at the Uniformed Services University which is the military medical school. It is the only federal medical school and draws students from across the country. The authors looked at students on the internal medicine clerkship. The students kept track of all of their patient contacts using a patient log. They tracked how many patients each student saw and the number of patients with core problems that were seen.

The authors compared students’ intensity of clinical exposure with performance on the clerkship. What they found was a little surprising and maybe a bit counter-intuitive. Student performance was positively correlated with their clinical experience, but only weakly . Specifically, after they used a pre-test to control for ability, there was a weak (r = 0.19) but statistically significant association. The student’s clinical score improved by two points with every ten extra patients that they saw in the outpatient setting. Similarly, the number of core clinical problems that the students saw was correlated to their ambulatory clinical score (r = 0.19; p < 0.05). In real terms this means that a student who saw patients with all of the core problems (about 88% of all students), scored less than four points higher in ambulatory clinical points than those who did not see all of the core problems.

So what does this all mean? Well, for one thing, we need to think very carefully about how clinical experiences should be structured. More is not necessarily better at least when it comes to number of patients. A targeted approach that is thoughtful and includes more time to think about patients may actually be better.

1) Dong T, et al. Relationship between clinical experiences and internal medicine clerkship performance. Medical Education 2012: 46: 689–697.

2) Denton GD, Durning SJ. Internal medicine core clerkships experience with core problem lists: results from a national survey of clerkship directors in internal medicine. Teach Learn Med  2009; 21: 281–3.