Construction of an educational philosophy
My most important goal as a medical educator is the help trainees develop into autonomous decision makers. In general I employ a constructivist approach hoping to motivate learners to accelerate their professional development through effective mentoring and solid use of adult learning theory.
I’ll begin my constuctivist themed tale with a story that many of you may already know. Libby Zion was an 18 year old college student with depression admitted to New York Hospital one fateful night in 1984. Perhaps because of drug interactions, undisclosed cocaine use, or tired overworked, less experienced physicians she died. In response to her untimely death her parents became catalysts for the ACGME resident work hour rules (ACGME, 2008). The impact of the original 2003 recommendations suggests a trend towards safer care (Fletcher, 2004 and Jagsi, 2008). In 2010 work hours were further limited. Responses by the American Academy of Pediatrics, the Association of Pediatric Program Directors and Program Directors in Emergency Medicine have been contentious to say the least. Michael Singer, a recent ENT residency graduate is concerned;
“The negative impact of these developments has only been compounded by the diminution in resident decision making responsibilities (Singer, 2010)”
Medicine is about decision making – Medical training is about building decision makers
Medical educators have a duty to encourage the development of future physicians who are autonomous thinkers and independent care providers. In the era of reduced work hours we have seen an overall increase in supervision. Fellows and attendings have been tasked with more direct patient care (Harrison & Allen, 2006; Kennedy, Regehr, Baker, & Lingard, 2009). Trainees gain experience and skill through the provision of patient care.
“Because trainees are, by definition, not sufficiently experienced or skilled to practice independently, they regularly encounter clinical situations which their limited expertise precludes them from handling on their own. In such situations, the safety of the patients involved depends in part on the expectation that the trainee will contact a more senior clinician for assistance (Kennedy, et al., 2009, p. 646).”
Learner supervision is a complex matrix rather than a binary yes/no decision. The new work hours regulations are here to stay. How then, can we as educators of tomorrow’s decision makers, aid in their development. When a third year pediatric resident is uncomfortable diagnosing an ear infection without the input of their supervising physician one has to wonder whether we as educators are upholding our end of the bargain. This is concerning to me because I don’t want residents to go through training without making a clinically relevant decision. In the ED I have limited time for educational interventions. I’ve found through a combination of great mentors, deliberate practice and good old trial and error that constructivist approaches are great for teaching in a busy clinical setting. In general it entails “constructing” meaning out of the rigors of training. Learning is therefore a process of building meaning from experience.
“The core commitment of the constructivist position, is that knowledge is not transmitted directly from one knower to another, but is actively built up by the learner (Driver, 1994).”
Learners must integrate their own experience and common-sense reasoning with the knowledge and norms of the social community of medical professionals.
Let’s consider the following example. A new resident is tasked with performing a lumbar puncture in order to help differentiate between viral and bacterial meningitis. What if the patient’s family declines? What if the resident had a “bad” experience with a previous LP? This example highlights the fact that trainees need to balance their experiences with the family’s and yet still provide the standard of care. Accepting constructivism into your life as an educator can offer strategies for helping our trainees deal with this conundrum. Let’s look at two examples of how I have put this into practice as a Clinical Educator.
Confronting controversy with structure
Wheezing is a common symptom in the Pediatric ED. Many children have a diagnosis of asthma, or another respiratory condition in which wheezing is a common feature. But, it all has to start somewhere. Therefore, consider the following question; Should we obtain a chest X-Ray on a child with first time wheezing? Per the current best evidence the answer is not entirely clear.
PROS: diagnose pneumonia, cardiac disease, aspirated/inhaled foreign body
CONS: Radiation exposure, the X-Ray is likely to be equivocal or normal
Structured controversy tasks students with preparing pro or con positions to a controversial situation, and then discussing and defending their position with their peers. The teacher serves as the moderator (Watters, 1995). This approach has been used successfully in nursing education regarding ethical dilemmas (Bull, 2007 and Pederson, 1993). In the example of the first time wheezer we can use structured controversy to help enable residents to make autonomous decisions while learning from the experience. As an educator you may task at least two residents with doing a quick literature search and take the pro or con position. Then, here’s the tough part for those of use with OCD – Place the decision of whether or not to obtain the X-Ray solely in the hands of the residents. Not only does this allow residents to make a decision, it also facilitates social and self-directed learning and in a way, “crowd sources” the act of teaching in a busy clinical environment. In order to be successful, instructors must function primarily as a guide. They must be willing to give up control. This also requires planning ahead of time, knowing which conditions are applicable to this method, and letting the residents know that you, as the preceptor, reserve the right to change course in the interest of the patient’s wellbeing.
The cognitive apprentice (not a sequel to that famous Disney movie)
When residents ask me a question that I know they know the answer to I reply with a question:
Resident: “Do you think that we should get a chest XRay?”
Me: “Hmmm… (rubs chin) Do you think that we should get a chest XRay?”
Why do I do this? And, how can this sort of interaction be beneficial? Let’s consider a case of a paronychia which is a painful skin infection around the nails that often has a collection of pus that must be drained via a minor surgical procedure. How about a very anxious nine year old girl with a paronychia. The intern seeing her in the ED has never performed an incision and drainage on a paronychia before. Is there a way that a supervising physician can explain how and why to do it without being pedantic?
Cognitive Apprenticeship describes the process of a master teaching a skill to an apprentice. There are countless examples throughout recorded history. Examples include blacksmiths, carpenters and barbers (the hair-cutting or blood-letting kind naturally). It was initially described by Bandura in the 1960s. He noted that in order for it to be effective (Bandura, 1967);
- Learners must be attentive and motivated
- Have access to learning materials in order for retention to occur
- Ultimately must be able to replicate the instructional activity accurately and effectively
Collins et al sought to explore the differences between traditional schooling methods and apprenticeship models (Collins, 1991). Apprenticeship involves learning a physical, tangible activity. In traditional schooling, the “practice” of problem solving is not necessarily observable to the student. Cognitive apprenticeship is a model of instruction that works to “make thinking visible.” Modern academic medicine relies of the teaching of technical skills. The “why” of learning how to do a procedure is as important as the pure technical skills involved. Helping the trainee approach this procedure in a way that maximizes learning and autonomy involves the following 3 steps.
Step 1: Identify the processes of the task and make them visible to students
This first involves discussing the risks, benefits, indications and pre-procedure planning (supplies, positioning, anesthesia) with the resident. Make sure they understand why performing this procedure is worth the risk to the family (it relieves the pain and if not performed the infection could spread).
Step 2: Situate abstract tasks in authentic contexts, so that students understand the relevance of the work
Since they’ve never done this before you’ll need to explain the general procedure technique in a way that connects with their preferred style of learning, often using visual aids (even one’s own finger can help!).
Step 3: Vary the diversity of situations and articulate the common aspects so that students can transfer what they learn
Patients will paronychias will be of varying ages and have different anatomical features. The technique is similar however. In order to provide proper anesthesia a “digital block” is necessary, which involves injecting a local anesthetic into the space at the base of the digit. This procedural skill can also be use in the repair of finger and toe wounds.
Bringing it all home
In this era of shrinking work hours if we just leave residents to their own devices we may not be able to ensure that they will be effective autonomous decision makers when the time comes for their name to be the only one on the chart. Kennedy (2005) argues that there is “limited empirical support for the current model of progressive independence in clinical learning.” The existing research is mostly qualitative and descriptive. Furthermore, Kirschner argues that despite a half-century of investigation there is “no body of research supporting” instruction with minimal guidance (Kirschner, et al., 2006). However, some of their findings suggest that “lower aptitude” students may learn less in a minimally guided environment, whereas Clark (in Kirschner et al.) notes that “more able learners have acquired implicit, task-specific learning strategies that are more effective for them than those embedded in the structured versions of the course (Kirschner et al., 2006).” I work with the latter more often, and though Kirschner’s points are well made I see the inherent value in allowing the high achievers that I teach guide themselves. Nevertheless, a solid grasp of the current literature and appropriate experience as a physician and educator are necessary in order to both model and teach effectively.
Given the dearth of knowledge on constructivist-based approaches in medical education more time must be spent developing faculty in educational methodologies that enhance their ability to foster the development of entrustable autonomy in our trainees. Especially in the pediatric ED constructivist approaches have many potential applications. It is up to us, as medical educators to figure out how to do it, and how to measure the impact.
Constructivism Learning is a process of constructing meaning from experience
Structured Controversy Tasks students with preparing pro or con positions to a controversial situation, and then discussing and defending their position with their peers
Cognitive Apprenticeship Describes the process of a master teaching a skill to an apprentice, specifically making the thought process behind decisions clear to the apprentice
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