New Material and a New Way to Learn: Students as Teachers on Grief.
Recently in a second year meds class, we were debriefing the experience our 2015 meds students had with their “First Patient Project.” During that debriefing class, we had relatively unique and very engaging learning experience about a serious and under-reported topic. My thanks to Dan Corazolla, Soniya Sharma, Lindsay Bowman, Aaron Wynn, Heather Johnston, and Mason Curtis, all Meds 2015 for their help with this article.
The First Patient Project is an 18 month project which begins right in September of medical students’ first year and continues until after December of their second year. Students in pairs follow a chronically ill patient, attending health care appointments and visiting with them in their home. The students also interact with community and faculty physicians and complete critical analysis reports about their learning.
This day, on April 30, we heard from six “student teachers.” Having students teach a formal session is reasonably unique in our medical school and the topic of their teaching was also reasonably unique in medical literature: How do physicians deal with grief, on the loss of a patient? How do they recover and go on…down the hall to the next ward room with another patient in it, to another clinic room, to home?
Six of our students encountered death over the program…two of our “Patient Teachers” sadly have died over the past two years. And another pair of students lost their patient as she was the spouse of one of the patients who passed away and could not continue with the program.
The six students met with a clinical faculty member to discuss the experience, and individual discussion/counseling was made available to them. But they also continued with the project by doing research on three areas: 1. How physicians help families when a family member dies 2. How physicians can help themselves when a patient dies, and 3. How medical literature and medical education literature give insight on how to bring this up in medical education.
Their research and presentations were excellent! I thought I’d share, with their permission, some of their findings:
From Soniya Sharma and Dan Corazolla, came these concepts in how physicians can help their patients deal with grief: the differences between “normal grief” and “abnormal grief”, the tasks of grieving, the family as a resource, and the role of the physician. They consulted nine current references to expand upon these concepts to their classmates and to link up with previous sessions on this topic in their first year classes.
The title of Lindsay Bowman’s and Aaron Wynn’s talk was “Wearing your heart on your jacket: Patient death and the importance of physician grief. “ They pulled from fifteen diverse sources from Military Medicine (great article on resilience-building) to Vasalius, (How to cope with disaster loss and mourning: Galen’s paper which was lost for centuries) to more traditional medical and medical education journals. One particular source I found intriguing was J. Shapiro’s article in Perspective: Does Medical Education Promote Professional Alexithymia? A Call for Attending to the Emotions of Patients and Self in Medical Training. Acad Med 2011;86:326-332.
Lindsay and Aaron taught convincingly about the factors that make patient death difficult to deal for physicians, why grief education is important and relevant to physicians and medical trainees, the current state of grief education in our curriculum and that of other medical schools and where it could and should be represented in undergraduate and postgraduate medicine.
The third partnership to teach about this topic consisted of Heather Johnson and Mason Curtis. Their teaching centred around healthy strategies for physicians in dealing with grief. Both Heather and Mason conducted surveys or interviews. Heather’s survey inquired into when and how we should teach about physician loss and grief in our curriculum. She gave practical strategies and a model on how to move through loss and grief and created a “grief curriculum” whose components could be shared with faculty as well as students.
Interestingly both Heather and Lindsey focused on an article that, in their words, “if you had to read only article on this topic,” this would be it: The inner life of physicians and the care of the seriously ill by Meier, D.E. et al in JAMA 2001, 286(23): 3007-14. I’ve just read it too and let me chime in—a very thorough and insightful article on this topic.
Mason had interviewed physicians and created a model of grief approaches from three perspectives. He also spoke movingly about how he had responded to his grandfather’s death at a time when in medical school he was learning about oncology, palliative care and the elderly.
Students in the class afterward said that it was really positive to learn this material from their classmates. The work was solid, the literature review broad, and the points very clearly and thoroughly presented with good handouts.
The students who taught were positive too…tho’ some had not been initially Some were hesitant to teach their classmates, and concerned that it would not be well received. They were really buoyed up by the great feedback from their peers and from faculty Dr. Sanfilippo and Dr. Leslie Flynn, Kathy Bowes, Program Coordinator, Erin Matthias, Program Assistant, and patients in the room.
What’s the next step? Well, the students and I can see a need for further exploration of this subject in clerkship and residency. As well, I hope the students will put together a poster about this for CCME.
My take on this aspect of the project is this: our six student teachers were excellent teachers! They were well-prepared, and had done a thorough job in finding out in different modes and in some cases ferretting out literature on a topic that seems to be localized in only a few aspects of medicine and medical education. They were clear speakers, and had great teaching points. Their slides were excellent and they had a good beginning, middle and end to their talks. They were convincing, authoritative, and had much to share. Turning some of the teaching over to students teaches those who teach, and their classmates. We already do student small group teaching in our Community Based Projects and our Nutrition Projects—maybe some large group teaching is in order?
Beyond the teaching method, the students taught us all about a part of medicine that appears to be kept somewhat quiet. About the culture of a “stiff upper lip” that could pervade in some medical cultures. About how may physicians act differently about their own grief than they would advise a patient to act. They gave us all a lesson in how to cope in a healthy way, when you have to move on…to the next patient, the next room, the next door and all the way home.
Are you interested in the reference lists from the students? Or would you like to contact them to find out more about their talk and what surprised them? Write back here, or write to them via email addresses on MEdTech.
Curricular Leaders’ Retreat
On June 3, from 8:15-2:00, Curricular Leaders will gather for a retreat in the new Medical Building. The retreat will feature updates by Dr. Tony Sanfilippo as a “State of the Union” or report card on UGME. As well, mini-workshops on strategies in teaching and assessment will be offered. Finally updates on innovations over the past academic year and on accreditation will be offered.
Course and Unit Directors are generally the target audience of these retreats. Course Directors are invited to bring a colleague with interest in the direction of their course.
Announcements with information about the agenda, RSVP process, and location is forthcoming.
How could I have forgotten Medical Humanities?
I arrived to the CCME amidst a huge storm on Saturday at 4:30 and immediately went off to a presentation and discussion with other Ed. Developers and new faculty in med ed. So I missed the Medical/Health Humanities Creating Spaces III symposium which had just wrapped up. However, our own Jackie Duffin did not miss it–in fact she was part of a panel on Medical Humanities to wrap up the Symposium, Medical Humanities: Whence and Whither? As well, meds students Emily Swinkin (2014) and Renee Pang (2013) presented — and a recent grad Jennifer Baxter (2012) — was attending just to listen from her family med residency in Chiliwack BC. To see more about this important initiative which I was able to attend and enjoy last year, go to http://medhealthhumanities.ca/Programme_Presentations.html
Reflecting on Reflection
Reflection in Medical Education
I love those who can smile in trouble, who can gather strength from distress, and grow brave by reflection.–Leonardo da Vinci
I thought I’d write to you about reflection in this blog entry. I can hear the meds students groaning already:) You see, we ask the meds students to do a fair bit of reflection in undergraduate medical education, starting with term 1 when we ask them to reflect on being a physician, and on through to their last portfolio assignment in pre-clerkship when we ask them to reflect on how well they have progressed in their learning about the roles of a physician.
Reflect is a rather over-used and under-thought term and so as I progress through this, you may want to substitute another term. I happen to like “critical analysis” because a lot of reflection should include that, and a lot of what we’re asking the meds students to do includes critical thinking.
When we talk to the medical students we talk to them about the stages of reflection and we use one model of reflection for learning or “reflection in and on action” (Schon, 1983), that of experiential learning by David A. Kolb. Kolb (with Roger Fry) is well-known for his conceptualization of reflection as a critical part of learning (Kolb, 1984). He postulates a cycle of reflection where a learner experiences something concrete (Concrete Experience), observes and reflects upon it (Observation and Reflection), generalizes the learning in Abstract Conceptualization and then applies the learning to new experiences in Active Experimentation. This starts the cycle again, with a spiral approach so that one is not repeating the same learning over and over. Kolb also notes that one can enter the cycle at any stage in the 4 steps.
When we present to the meds students we use this graphic:
To me this theory is important as it allows for some very practical outcomes for reflection. As Peter Drucker says, “Follow effective action with quiet reflection. From the quiet reflection will come even more effective action.” Two leaders in the field agree: Dr. John Sandars defines reflection as “A metacognitive practice that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters.” (Sandars, 2009) Jack Mezirow when writing about “transformative learning” describes reflection as critical awareness of how we are constrained, and how to reformulate so as to act. (Mezirow, 1997)
So how can we assist learners to reflect in order to change their actions? How can we promote “rigourous reflection?”
Dr. Ted Ashbury and I start by asking them to jot down some thinking: “Think of a situation where you have said, “I’m not going to fall into that trap again. I’ve thought about this, and I know I’m prone to…”! We show them the cartoon of Charlie Brown and Lucy and the infamous football… This is helpful because one goal of reflection can be to change action, to break a cycle or pattern.
Next, we ask the students to think about a situation that has engaged their attention in the past few weeks and fill in a chart based on the 4 steps in Kolb’s theoretical framework:
||Analyze:Make connections Prior experience
Links to knowledge of yourself
|Apply/Plan (Now What?)Changes or shiftsCommitment to future action/plans|
And we ask them to set some goals: SMART Goals
Specific (straightforward, not ambiguous)
Measurable (It is clear under which conditions the goals are achieved)
Acceptable (The goals should be acceptable to all stakeholders)
Realistic (The learner should be able to achieve the goals)
Time-bound (It should be clear when the goal is to be achieved)
Free Writing: We give students time to write—free writing for at least 5 minutes (an engaging and difficult task—I recommend it!) about the prompt from the beginning of the session or “Write about your First Patient Experience, your Clinical Skills experience, your learning elsewhere in term 1, a key challenge you have chosen to work on recently, Mid-terms…???” We also offer them a reflection written by a student in another meds school and a rubric that Eleni Katsoulas and I designed to help us and them assess reflective writing. They get to analyze their colleague’s writing based on the rubric:
|Prompt or Catalyst||Ideas (What?)||Connections (So what?)||Extensions (Now what?)|
|Observed behaviours of other||Describes the behavior and the context in which it occurred||-Interprets the behavior, its cause, or provides a rationale (impact)-Seeks out primary resources/information/circumstances, to connect to and make sense of the observation||– Provides an alternative to problematic behavior based on consideration of all primary observations-Discusses implications and considers how or whether to implement change in their own behaviour-Problem may be reframed, and there is an explanation of how this represents a change from previously held beliefs
-Considers impact of framework on behavior (culture, system, etc.)
-Commits to future action, reflection, or advocacy
This seems like a lot of work to accomplish reflection, doesn’t it? However, it’s like learning skills for anything…we provide opportunities to break down the skill into discrete parts, and learners time to practice. The idea is that the more they practice this, the more intuitive and natural it becomes. This doesn’t negate the possibility and importance of a 30 second reflection on an interesting, provocative, or disturbing matter, but it does lead, we hope to rigourous reflection.
I thought I’d finish this section with a quotation from a medical student who was reflecting:
“If I had to choose what I felt to be the most important thing that I have taken from these experiences, it would be to remind myself, no matter how I feel, to think about how the patient is feeling. To never forget that off-hand comments made when tired or stressed have the potential to upset people to such an extent that they remember them for years.” (Macauley & Winyard, 2012).
If this is the result of rigourous reflecting, I’m all for it!
What are your thoughts on reflection in medical education? What use do you see for it? (or do you see a use?) What strategies do you recommend? In the next blog, I’ll send some tips for reflection, along with your suggestions.
Kolb, D. A. (1984) Experiential Learning, Englewood Cliffs, NJ.: Prentice Hall.
Kolb. D. A. and Fry, R. (1975) ‘Toward an applied theory of experiential learning;, in C. Cooper (ed.) Theories of Group Process, London: John Wiley.
Schön, D. (1983) The Reflective Practitioner, New York: Basic Books
Saunders, John. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), 685-95.
Mezirow, Jack. (1997). Transformative Learning: Theory to Practice. New Directions for Adult and Continuing Education, 74, 5–12.
Macauley, CP & Winyard, PJ. (2012). Reflection: tick box exercise or learning for all? BMJ Careers. http://careers.bmj.com/careers/advice/view-article.html?id=20009702
Making D.I.L. an important part of teaching
In our model of Small Group Learning (SGL), we ask students to prepare for the SGL class by independent study of a text, online module or lecture, directed by the faculty. This “Directed Independent Learning” (DIL) is often used, but how well is it used?
If we view the DIL as a way to have a “second” teaching session with the students, this allows us to give support, explanations and/or a rationale for the reading or viewing they are doing.
A recent study advocated 10 minute “supportive” podcasts as a way to help students understand the purpose and the key concepts and terminology in a reading prior to a group learning task. The instructors chose podcasts as a way to connect with students and allow them to listen anytime and anywhere.
Whether you use a podcast, or simply write in the Teacher’s Message in MEdTech, here are some possible aspects of “teaching” with readings you can incorporate in your “DIL” teaching.
- An introduction that explains why the reading had been chosen and how it links with course content or upcoming tasks;
- Guidance on the key elements in the assigned reading on which students should focus;
- Elaboration of particularly difficult content, including different ways of phrasing or explaining essential theoretical concepts;
- Background on any concepts new to students and not explained in the reading with the goal of creating a context for the reading;
- Grounding questions described as “designed to help students relate the material to their personal/professional reality.” (p. 82) In other words, questions that encouraged students to think about how the material applied to their interests and circumstances.
What are your thoughts on using this as a method to connect with students outside the classroom?
Taylor, L., McGrath-Champ, S., and Clarkeburn, H. (2012). Support student self-study: The educational design of podcasts in a collaborative learning context. Active Learning in Higher Education, 13 (1), 77-90.
What is the difference between outcomes and objectives?
You may have heard the terms objectives and outcomes used interchangeably and certainly some of the literature is confused upon the point. Let’s try to clarify the distinction so that we can build our outcomes for our programs, and learning objectives for our courses and for sessions.
|The essential and enduring knowledge, abilities (skills) and attitudes (values, dispositions) that constitute the integrated learning needed by a graduate of a course or program.||Describe in detail the behaviours that students will be able to perform at the end of a unit such as a class, and the conditions and criteria which determine acceptable performance.|
|Achieved results or consequences; evidence that learning took place||Intended Results|
|High Level, overarching||Specific activities/assessments that lead to outcomes|
|Broader, larger scope, knowledge/skill||Specific discrete units of knowledge/skill/competency|
|Accomplished over time in several learning experiences||Can be accomplished in a short period of time—useful for a class session|
|Refer to reliable demonstrations of performance—results of a course/program—achieved results||Can be statements of intent but should be linked to assessment of specific skills/knowledge and to specific strategies suitable for the objectives|
|Contain conditions under which the student performance will be assessed, as well as criteria for assessment||Contain conditions under which the specific student performance will be assessed, as well as criteria for assessment|
Whether you are on a program or curriculum committee to develop outcomes, or are developing objectives for your course or individual session, here are helpful verbs to use and some “weasel verbs” to avoid:
|Words Open to Many Interpretations||Words Open to Fewer Interpretations—behavioural and measurable|
|To know||to write; to explain|
|to understand||to recall|
|to really understand||to identify|
|to appreciate||to sort, to organize, to compare|
|to fully appreciate||to solve, to deconstruct, to follow a model or approach|
|to grasp the significance of||to construct|
|to enjoy||to evaluate|
|to believe||to analyze|
|to be aware of||to estimate|
Developing Clear Learning Outcomes and Objectives http://www.thelearningmanager.com/pubdownloads/developing_clear_learning_outcomes_and_objectives.pdf
How to Write Program Objectives/Outcomes http://www.assessment.uconn.edu/docs/HowToWriteObjectivesOutcomes.pdf
Developing Effective Learning Outcomes & Objectives http://www.cmduke.com/2011/07/23/developing-effective-learning-outcomes-objectives/
What really drives learning?
Lessons from the famously self-taught.
Holidays are a great time to catch up on reading. My own preferences are history and biographies. This past couple of weeks, I’ve found it rather humbling to learn that some of the most influential thinkers and shapers of our society were essentially self-taught. In fact, they seemed in some cases to thrive despite the benefits of traditional education or academic success.
Benjamin Franklin (1706-1790) led a peripatetic life, meandering through a variety of career interests, excelling in all. He’s perhaps best remembered as, arguably, the most important and essential influence on the Continental Congress that would draft and ratify the American Declaration of Independence. Along the way, he was a writer/journalist/publisher/politician/diplomat and, in his spare time, a scientist of considerable renown, receiving honorary degrees from both Harvard and Yale, and becoming the first person living outside Britain to receive the prestigious Copley Medal from London’s Royal Society. Remarkably, all this was accomplished without the benefit of college or university level education. In his excellent biography of Franklin, author Walter Isaacson describes three key educational components: the formative influence of his father who encouraged conversation and debate in the home, Franklin’s insatiable curiosity that spanned a huge variety of topics, and his access to books. “Indeed”, Isaacson writes, “books were the most formative influence in his life, and he was fortunate to grow up in Boston, where libraries had been carefully nurtured”. Despite this abundance, Franklin was required to actively seek out these books, generally housed in private libraries. His apprenticeship in his brother’s print shop provided him opportunities to “sneak books from the apprentices who worked for the booksellers, as long as he returned the volumes clean”.
The facts regarding the education of Abraham Lincoln (1809-1865) are almost lost in the mythology that’s developed regarding his early life. In Team of Rivals, author Doris Kearns Goodwin describes the challenges faced by the impoverished Lincoln as a “Herculean feat of self-creation”. “Books”, she writes, “became his academy, his college. The printed word united his mind with the great minds of generations past”. He also treasured conversation and stories he shared with interesting, informed people, and would analyze and reconstruct arguments afterward. He also undertook “solitary researches” in the study of geometry, astronomy, political economy, and philosophy. “Life was to him a school, and he was always studying and mastering every subject which came upon him.”
Although Albert Einstein (1879-1955) did have the benefit of formal education, attending the Swiss Federal Polytechnic School, he was a mediocre, somewhat embittered student and was unable to secure a teaching position after graduation. It seems he found formal curriculum far too rigid and stifling. He eventually undertook relatively menial work at a patent office, which allowed him time alone to read and think. It was during those years that he developed many of the theories that would revolutionize the field of physics and define his life’s work. He also developed a social consciousness that, although less publicized than his scientific work, is in many ways equally intriguing.
So should these notable examples, drawn from three separate centuries, diminish our commitment to formal education? Obviously not. However, it would also be a disservice to simply dismiss them as prodigious intellects who managed to excel despite more primitive educational systems. Simply put, it took more than brainpower for them to rise above their circumstances and become pre-eminent learners and, as a result, leaders of their times. They also shared three essential qualities:
- Relentless curiosity and desire to understand. Although the focus of that drive may have differed, the intensity and commitment were consistent. They simply could not be deterred from learning.
- Willingness to apply themselves to their goal. We tend to believe that people as gifted as Franklin, Lincoln and Einstein came by their success effortlessly, but this is far from the case. Franklin was known by his contemporaries to habitually arrive at work earlier than anyone else and to work long into the night. Lincoln often read or worked through the night, and photographs from the time document dramatically the physical toll.
- Commitment to betterment of their communities. All three were motivated by a desire to improve their societies. In fact, the energy and commitment that was so evident in their work appears to arise from this altruism rather than any personal self-interest.
It would seem that when these three qualities triangulate in an individual, great things are possible. However, those possibilities are only realized if their environment provides a few necessary things, including access to information and people with whom they can converse, share and test ideas.
How does all this relate to our work as medical educators? I think two important lessons emerge. Firstly, it would seem that any admissions process would benefit by concentrating on means to identify within applicants the three essential attributes listed above. Any student with these attributes is essentially programmed to succeed and will do so within, or in spite of, any educational system we choose to impose. Put simply, the appropriately motivated, reasonably capable learner is essentially unstoppable. Conversely, the absence of these attributes virtually dooms the process from the start, despite our best efforts. Secondly, these examples would suggest that the learning environment we develop is at least as important as the methods we employ to deliver and assess knowledge. Providing our learners with direction and opportunities to explore concepts and develop their personal learning skills is critical and, from the perspective of their ongoing career, much more durable than simply requiring them to reproduce pre-determined dollops of factual information.
All this should reassure us that the changes we’ve undertaken over the past few years with our admissions processes, curriculum, information technology, physical space, mentoring programs and educational methodologies are all positive developments, clearly moving in the right direction. We should also be encouraged to creatively and boldly go further.
Reminder: Course Directors’ Retreat Jan. 18, 8:00-2:30, University Club
The Course Directors’ Retreat will take place on Jan. 18 from 8:00-2:30 at the University Club. Course Directors have been asked to bring a designate who will be able to bring back additional information to the course team.
Credit for the workshops will be given.
Here is the agenda: Course Directors Retreat January 18 2013 Agenda
Please RSVP to Elaine Carroll at firstname.lastname@example.org
Many thanks for tremendous work: Farewell but not goodbye
Dr. Stephanie Baxter, has moved from her position as Co-Course Director for Neurology and Ophthalmology in Undergraduate Medical Education to serve as the new Residency Program Director for the Department of Ophthalmology. She has also therefore left her position on the UGME Teaching and Learning Committee of which she was an inaugural member.
It’s difficult to express all that Stephanie has quietly accomplished in undergraduate medicine–from piloting the extremely successful Ophthalmology Skills Fair to complete course revision as she acted as one of the first exemplars of creating balanced teaching methods. Stephanie has served the Teaching and Learning Committee well for 5 years, representing clinical teaching and supporting initiatives through her own teaching practice.
Perhaps most telling, however, is Stephanie’s contribution to student learning. She is the recipient of the 2011 Aesculapian Society’s Lectureship Award, and has already made an impact with her work in teaching residents, winning the Garth Taylor Resident Teaching Award of 2012, both attesting to the way Stephanie is able to interact with students to help them learn.
We wish Stephanie well in her work in Post Graduate Medical Education, and hope that our undergraduate students will still have the benefit of her teaching. Many thanks Stephanie, for all your tremendous work!
Curriculum Matters: Giving Feedback
“Learning without feedback is like learning archery in a darkened room.” (Cross)
The terms feedback and formative assessment have been used frequently in our UG curriculum both in clerkship and pre-clerkship. It’s important that we all recognize a consistent definition of feedback, as well as consider some effective tips and strategies from the educational literature. Sue Fostaty-Young weighs in with some helpful ideas.
Feedback is information regarding students’ performance that is offered with the express purpose of improving their learning and future performance. It is considered one of the most powerful influences on learning and achievement (Hattie & Timperley, 2007).
Tips for Giving Effective Feedback:
- Prepare students to receive the feedback you’re about to give
- Unfortunately, students do not always recognize feedback as such, especially oral feedback during rounds, or in clinic, etc. Consider starting your end of the conversation by saying “I have some feedback for you”.
- Alert students at the beginning of a rotation or any workplace teaching to the fact that feedback may be oral, and part of ongoing bedside teaching.
- Ask a student how he/she thinks they’re doing
- In asking a student to comment on their own performance you initiate the process of self-reflection and emphasize the learner’s active role in the feedback process.
- You may ask them to prepare some notes prior to the feedback session or create a structure for this dialogue.
- Be specific and objective about what you observed
- Begin by identifying what students are doing correctly in their performance.
- Provide examples of what you observed, not what you inferred. For example, rather than saying “You’re shy” (an inference), you might say “I noticed you made very little eye contact with the patient and you spoke very quietly, making it difficult for her to hear your questions” (an observation).
- Give feedback in a timely fashion and in time for students to improve
- Feedback offered almost immediately after an activity has more meaning because the event and the students’ behaviours during it are fresh in their minds.
- Timely feedback allows for students to alter their performance, to practice, and improve. Set a time to review improvement if possible.
- Outline specific targets or goals; articulate expectation
- Feedback has the most impact when learning-specific information is offered.
- Offer specific feedback that is within the student’s ability to improve and a rationale for your suggestions. For example, rather than say, “Stop being so shy,” you might offer specific suggestions such as “Try to make eye contact more regularly so patients know you’re engaged and to gauge their reactions. Speak louder so your instructions can be heard.” You may want to suggest that they practice with a peer or videotape their own practice.
- Invite the student to respond to the feedback you’ve just given
- Initiating this dialogue can help establish whether the student has interpreted the feedback as it was intended, and will be able to use the feedback in a meaningful way.
- Help the student develop an action plan with timelines for improvement to help them use the feedback in a constructive way.
Hattie, J., & Timperley, H. (2007). The power of feedback. Review of Educational Research, 77(1), 81-112.