Can first year medical students carry out cardiac ultrasound examinations? Recent graduates publish results of recent trial.
Two former Queen’s medical students, Thomas R. Cawthorn, MD and Curtis Nickel, MD, of the recently graduated class of Meds 2013 conducted ultrasound education research during their time as students at Queen’s School of Medicine. They worked with Dr. Michael O’Reilly, Dr. Henry Kafka, and Dr. Amer M. Johri, of Queen’s and Dr. James W. Tam, of Winnipeg. Their results have been recently published in the Journal of the American Society of Echocardiography, in the article Development and Evaluation of Methodologies for Teaching Focused Cardiac Ultrasound Skills to Medical Students.
There are several noteworthy aspects about this: One is that our students embarked on this research during their time at Queen’s UGME, and worked on medical education in echocardiography as their field.
Secondly, the Journal of the American Society of Echocardiography published an article on medical education. It’s uplifting to see focus on education in medicine as well as continuing professional development and new issues in medicine in a scholarly medical journal.
Thirdly, the article outlines an excellent, innovative education program that the authors developed, using sound pedagogy to assist learning of a key skill in medical education.
And for me, their conclusion is most exciting:
Third-year medical students were able to acquire FCU image acquisition and interpretation skills after a novel training program. Self-directed electronic modules are effective for teaching introductory FCU interpretation skills, while expert-guided training is important for developing scanning technique. (Cawthorne, et al, 302)
The authors emphasize the importance and benefits of teaching/learning via self-directed electronic modules:
- reduction of overall resource costs
- provision of readily available resource easily accessed by students for future reference
- opportunity to learn at the pace and setting desired by the learner
- provision of standardized educational material to centres where specialists may not be found (Cawthorne, et al. 307)
They cite Ruiz et al. (2006) for literature about the benefits of this type of learning. Ruiz’ excellent article is worth a read as well. (See Sources below.)
The other telling aspect of their findings is the importance of “practical small-group instruction under the supervision of experienced sonographers and echocardiographers.” They recommend that supervised simulation training be combined with practical instruction sessions on volunteer patients (Cawthorne et al, 308).
The key to Drs. Cawthorne’s and Nickel’s recommendations is the combination of demonstration, practice, and feedback. And educational literature emphasizes that these are key aspects of learning skills as well. It’s also intuitive: just think back to learning to play a sport. These three facets of skills-based learning helped you learn that sport; without one of them, you would have found the learning challenging.
Educational literature calls this “deliberate practice” where the following are involved:
- repetitive performance of intended cognitive or psychomotor skills in a focused domain, coupled with
- rigorous skills assessment, that provides learners with
- specific, informative feedback, that results in increasingly
- better skills performance, in a controlled setting. (Issenberg et al, 2005)
What does that mean for teachers? It means that despite the savings and other benefits of online learning, it’s important to pair that type of learning with practice and feedback from experts, especially in skills-based learning. That has implications for us all–online, independent, self-regulated learning works best when there is an additional face-to-face demonstration, practice/feedback component, especially when new skills are being taught. (I’ve written before about the importance of feedback–without feedback, “it’s like learning archery in the dark.”)
So rather than saving wholly on faculty’s time by building online modules for student independent learning, what this suggests is that we use faculty in other ways. Not only do faculty lecture and facilitate group work, they are instrumental in providing feedback on skills, as happens in our Clinical and Communication Courses. In clerkship this emphasis on independent learning complemented by practice and feedback becomes crucial.
Congratulations to our students for their hard work and success, and that of their mentors and colleagues as well! Dr. Sanfilippo writes,
It’s rather remarkable for medical students to produce work that would be accepted for presentation at a national meeting, and then be published in the leading Canadian cardiovascular journal. It’s also rather unique to see a study that combines cardiac and educational components. This is quite a tribute to Tom and Curtis, and to Dr. Johri who mentored and guided them through the process.
Would you like to read the article (and accompanying editorial!) yourself? Here is the link:
Cawthorne, T.R., Nickel, C. O’Reilly, M., Kafka, H., Tam, J. W., Jackson, L., Sanfilippo, A. J., Johri, A.M. (2014). Development and evaluation of methodologies for teaching focused cardiac ultrasound skills to medical students. Journal of the American Society of Echocardiography, 27(3), 302-309.
Ruiz, et al. (2006). Impact of e-learning in medical education. Academic Medicine, 81, 207-212
Issenberg, B. et al. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review: BEME guide 4. Medical Teacher, 27(1), 10-28.
Educational Resources at your Fingertips: Faculty and Students
As teachers, you may want to find resources that assist you with teaching, or find out what the latest news from the Curriculum Committee is, or find out who to contact about what. As students you may want help about people, places, policies and other “p’s” in the Undergraduate Medical Education program.
We have published two resources recently:
The first is the new Faculty Resources Community: https://meds.queensu.ca/central/community/facultyresources
NOTE: first log into MEdTech via the dashboard URL, then simply click on the community, which would be among those listed on the left side of each user’s dashboard page. All faculty members including community preceptors are members of the Faculty Resources Community, but to “see” it you’ll need to log in first.
The Faculty Resources Community was created to provide faculty members, Course Directors, Year Directors and Committee Chairs with advance notice of topics to be discussed at Curriculum Committee meetings as well as easy access to Curriculum Committee Highlights, links to faculty development on teaching and assessment and materials distributed at Course Directors’ Retreats. Other resources posted in the new community include the Future of Medical Education in Canada reports and the latest LCME accreditation standards. We welcome suggestions for additional resources.
The second resource is for students! The Student Handbook, a brilliant idea from Associate Dean Sanfilippo, and edited by Alice Rush-Rhodes, is now published on MEdTech and is available in a printable pdf format thanks to Lynel Jackson from MEdTech.
To access the Student Handbook, please go to https://meds.queensu.ca/central/community/studenthandbook and to print a copy, scroll down to the bottom of the side menu. The Student Handbook contains information on people to assist students (including peer mentors), advice on careers, CaRMS and the Dean’s Letter, lockers, MEdTech, the Curriculum, and Special Programs to name a few components.
Is there anything we should add to the Student Handbook? Any other way you’d like to see faculty ideas? Just respond to the blog and let us know, or email Sheila Pinchin at firstname.lastname@example.org
Education Workshops for New Faculty (and those who’d like a refresher)
The Education Team is providing workshops for new faculty (and those who’d like a refresher) on a variety of topics.
What we’ll cover:
The 3.5 hour session will give you the basic tools you need, including:
• Foundations of the UGME curriculum
• Who’s Who in UGME & what they can help you with
• Introduction to Small Group Learning (SGL)
• Assessment 101 (MCQs and Beyond)
• MEdTech & You
• Classroom equipment
And, we’ll share with you information on other training that the Education Team can provide for you.
Three sessions to choose from:
Monday, August 26
9 a.m. – 12:30 p.m. (Then join us for lunch with the incoming first year class)
Monday, August 26
1 -4:30 p.m (But come at 12:30 for lunch with the incoming first year class)
Friday, September 20
8:30 – 4 p.m.
We are submitting this workshop for approval for CME credits for you.
To register, please email
Theresa Suart (email@example.com), indicating your preferred session.
(For the August 26 sessions, please register by August 21, so we can let the Orientation team know how many to expect for the lunch. For the September 20 session, please register by September 16).
Clinical Problem Solving: A student and a teacher talk about lessons learned from an online course
By Heather Murray, MD, and Eve Purdy, MD Candidate, 2015
For many medical students, the process involved in turning a presenting complaint into an appropriate and focused differential diagnosis seems like a big black box. For clinicians who do this many times every day, the process is unconscious, and it is hard to explain to medical student learners how to break it down. Both students and teachers sometimes struggle with how to transition early medical learners to competent diagnosticians.
So, when a clinician (Heather Murray) and a second year medical student (Eve Purdy) independently stumbled across the link to a Massive Open Online Course (MOOC) on Clinical Problem Solving offered through Coursera both of us jumped at the opportunity to learn more about diagnostic reasoning. Eve registered with the hope of shedding light on the type of problem solving that she might be faced with in clerkship, while Dr. Murray registered with the intention of improving her teaching around diagnostic reasoning for students.
Though it is difficult to summarize the six-week course in one blog post there were a few takeaways from the course that we will outline. These key points might help medical students improve clinical reasoning and the same tips might help teachers in clarifying the process for learners. Much of this approach to clinical reasoning comes from the NEJM article “Educational Strategies to Promote Clinical Reasoning” by Judith Bowen (2006).
1. Organize the way you learn about diseases using Disease Illness Scripts
If you have a structured approach to the way you learn about diseases, then you will be more efficient at recalling that information and comparing diseases effectively. One way to organize information is into “Disease Illness Scripts”. This requires organizing information about the conditions into four broad categories.
|-who gets the disease?-what are the risk factors?
-making a mental picture of who you would expect to see with the disease can help
|-over what time period does the condition present?
acute on chronic
-a good way to think about this is where you would expect to see the patient (ER, vs walk-in vs family doctor)
|-what are the symptoms?
*key features are signs and symptoms that are essential to the diagnosis
*differentiating signs and symptoms are those that make this disease different then diagnoses that present similarly
*excluding signs and symptoms are those that, if present, exclude the disease
|-describe and understand the underlying disease mechanism|
2. Organize the way you think about patients using Patient Illness Scripts
When thinking about patients try to frame their presentation using the same structure as the disease illness scripts.
|What important risk factors does the patient have-age
-relevant medical history
-presentation specific risk factors i.e. recent transcontinental air travel in a patient with shortness of breath
|How long has the patient had the symptoms, have they changed?||What symptoms and clinical signs does the patient have?
-try to group as many as possible to shorten the list (e.g. group febrile, tachycardic and hypotensive as septic)
3. Compare disease illness scripts and patient illness scripts to generate a tiered differential diagnosis
Generate a differential diagnosis based on the chief complaint. You can compare your understanding about each disease on your differential with your patient using the illness scripts easily. Pay close attention to key features, differentiating features and excluding features. The closer a disease illness script is to the patient illness script the higher it should end up on your differential. Your final differential has three tiers:
Tier 1: Diseases that are those most likely belong here. The epidemiology, time course and clinical presentation are concordant with the patient illness script.
- Tier 1e: Diseases on tier 1e are diagnoses that may be less likely than tier 1 but if missed will cause immediate and serious harm. These are dangerous diagnoses! The “e” in this tier stands for “emergency” and diseases on this list must be ruled out, even if they are less likely.
Tier 2: Diseases that have some similarities to the patient illness script but aren’t a perfect fit belong here. They are still possible but less likely than tier 1 diagnoses.
Tier 3: Diseases on your original list that do not fit the illness script. They may have excluding features or lack key features.
4. Use your tiered differential to determine what tests to order
The tier that a possible diagnosis falls into will help you decide what tests to order to determine the final diagnosis. Think of each tier as a pretest probability.
Tier 1 diagnoses have a “high” pretest probability
- No tests or few tests may be needed to convince you that a diagnosis in tier 1 is responsible for the patient’s presentation and similarly you would need very convincing information to take it off your list completely.
- These and Tier 1e diagnoses should drive your initial investigations
Tier 1e diagnoses may have varying pretest probability
- These diseases may or may not be likely but regardless tests with high sensitivity are needed to rule them out (remember “SnOUT”)
Tier 2 diagnoses have a “medium” pretest probability
- Diseases on this tier are tricky. You really have to evaluate the sensitivity, specificity and information given from each test. You may need a few good tests get from a “medium” pretest probability to final diagnosis.
Tier 3 diagnoses have a “low” pretest probability
- Even relatively good tests may not move diagnoses from Tier 3 up to tier 1. The positive result that you get might be due to chance. Investigating these diagnoses should be a last resort.
These four tips won’t magically turn a medical student into an expert at clinical reasoning but they might serve to expose the way that experts think. They offer concrete ways for medical students to approach clinical reasoning and a common language for experts to discuss their approach with their learners.
For more information about MOOCs and why explicit discussion of clinical reasoning is important, see these links.
- Many MOOCs are available at Coursera on everything from jazz improvisation, to biostatistics, to the principles of cardiopulmonary resuscitation and everything in between.
- “Teaching Clinical Reasoning” by Michelle Lin (@M_Lin) at Academic Life In Emergency Medicine
- “Teaching Clinical Reasoning” by Nadim Lalani (@ERMentor)
- “Thinking about teaching thinking” by Robert Centor (@medrants)
- Lauren Westafer’s (@LWestafer) great medical student thoughts on “Thinking About Thinking” and “Metacognition for the Pragmatist”
- For a review of the Course and thoughts about how it might be applied to Facilitated Group Learning at Queen’s see Eve’s blog posts here and here.
- MOOC’s as they relate to Free Open Access Medical Education, “What is a MOOC” by Chris Nickson (@precordialthump)
MedEdPortal: a great resource
MedEdPortal is a repository of online modules, and other tools that are vigourously peer-reviewed and suitable for medical and other health professions education. To find out more about this great resource, to to their short video: www.mededportal.org/about
Exam Wrappers: A novel way to review exams
Here’s a new and very interesting tool called “Exam Wrappers” that you can add to your exam review after mid-terms and even finals. It enables students to think more carefully about their studying and learning. It is from a chapter by Marsha C. Lovett, (2013) Chapter 2, in Make Exams Worth More Than the Grade, in the book, Using Reflection and Metacognition to Improve Student Learning, edited by Matthew Kaplan, et al, Stylus Publishing, Sterling, Virginia.,
This is a technique that engages students in reflection, metacognition (learning to learn) and self-regulated learning. Prof. Lovett’s approach was to “build metacognitive practice around exams” and in so doing satisfy the many constraints that challenge metacognition in a curriculum.
What are Exam Wrappers?
Exam wrappers are short activities that direct students to review their performance (and the instructor’s feedback) on an exam, with an eye toward adapting their future learning. Exam wrappers ask students three kinds of questions: How did they prepare for the exam? What kind of errors did they make on the exam? What could they do differently next time?
Prof. Lovett provides examples in Appendices A1 and A2 of her book. Here is a summary of her work on the three questions above:
1. How did you prepare for the exam?
Benefits of this question:
• Challenge student to confront study process and implicit or explicit choices they made about their studying
• Asks themselves if they studied enough or with enough lead time
• Focusing on diverse study methods (reviewing notes, solving practice problems, rereading the textbook) points out that there are many approaches they can use for next time
2. What kinds of errors did you make?
Benefits of this question:
• Challenges students to move beyond marks: with high marks, they tend to be relieved and move on; with low marks, they may leave the “painful event behind.”
• Allows opportunity to analyze in greater depth, e.g. considering level of difficulty of the questions they may have had problems with, looking for patterns in types of errors.
• Gives them a lexicon re. self-assessment: e.g. “Did they read the question carefully? Did they have trouble setting up the problem? Did they fail to understand the concepts involved?” Or “Did they make mistakes on the required math, chemistry, physiology, anatomy, etc.?”
3. How should you study for the next exam?
Benefits of this question:
• Ties responses from #1 and 2 together
• “A key goal of the third type of question is to help students see the association between their study choices and their exam performance so they can better predict what study strategies will be effective in the future.” (Lovett, 2013)
• Asks students to attribute their problems from #2 to some specific study errors, or look back at #1 and #2 and ask how they would specifically prepare differently.
Benefits of exam wrappers:
1. Impinge minimally on class time.
2. Are as easily completed by students within the time they are willing to invest.
3. Are easily adaptable. (Faculty can add their own concerns in #2, for example, asking about test anxiety or other issues). Can be used with other types of graded assessments.
4. Are repeatable yet flexible. (can add new questions or change questions slightly to keep things “fresh”)
5. Exercise the key metacognitive skills instructors want their students to learn: assess strengths and weaknesses, identify strategies for improvement, and generate adjustments.
Steps for Exam Wrappers
1. Hand back exams.
2. Assign “Wrapper” with questions.
3. Students complete, either during the exam review, for homework, or online (non-graded but required element). Students can also share study techniques with classmates.
4. Instructor collects and reviews to gain new knowledge of student needs, and patterns of behavior (e.g. amount of hours spent studying)
5. Hand back wrappers, or remind students about them as they might begin studying for another exam.
6. Repeat for subsequent exams (you can streamline a wrapper for a later exam, eg.)
Thanks to the Tomorrow’s Professor Digest for this idea from Prof. Sharon Lovett.
New resource for electrocardiogram interpretation
Queen’s own Dr. Adrian Baranchuk is the Editor of the newly published Atlas of Advanced Electrocardiogram Interpretation. With Contributing Editors Drs. Hoshiar Abdollah, Damian Redfearn, and Christopher Simpson, one could call this “The Queen’s Atlas of ECG”! The atlas is “a practical guide to recognizing and analysing a wide spectrum of cardiac conditions.” There is free access for the next 25 days at http://asandk.com/ecg/ It’s available for PC and Mac.
The atlas provides:
Tracings, data, descriptions, interpretations, and tips from the expert contributors
Straightforward and consistent style encourages logical and step-wise ECG interpretation, as well as rapid recognition based on the study of repeated patterns
There are 100 “real world” tracings with contributions from 100 of the world’s leading cardiologists and electrocardiographers.
Cases are divided into 12 chapters covering key disorders and abnormalities.
Bibliographic information is provided to facilitate further reading.
Images from each chapter are available to download to your computer for use as teaching and learning aids.
A great teaching idea: The 3-2-1 Assignment
Here is a great teaching idea from Dr.Geraldine Van Gyn, professor in the School of Exercise Science at the University of Victoria.
She writes in the e-zine Faculty Focus about the “Purposeful Reading Assignment” or the “3-2-1” assignment.
It goes like this:
Requirement 1: Students read what is assigned, then choose and describe the three most important aspects (concepts, issues, factual information, etc.) of the reading, justifying their choices.
Requirement 2: Students identify two aspects of the reading they don’t understand, and briefly discuss why these confusing aspects interfered with their general understanding of the reading. Although students may identify more than two confusing elements, they must put them in priority order and limit themselves to the two most important ones. Students seldom understand everything in a reading and, knowing that they must complete this part of the assignment, will reflect on their level of understanding of all the reading’s content.
Requirement 3: Students pose a question to the text’s author, the answer to which should go beyond the reading content and does not reflect the areas of confusion in requirement 2. The question reflects students’ curiosity about the topic and reveals what they think are the implications or applications of the reading content. This last requirement lets you know how well students understood the article’s intention.
This would be a great assignment to try in Health Sciences classes. In Meds, perhaps we could modify it so that the students share with their group Requirement 2 and hand in Requirement 3 for feedback. We could use an e-template to complete these and allow faculty to give quick e-feedback.
Prof. Van Gyn reports that in analyzing her mid-and end of term feedback, The purposeful, 3-2-1 reading report is the most frequently cited in all courses (mid-term =72% of all students, n= 549, end of term = 65% of students, n= 513) as being of greatest benefit to the students’ learning.
If you’d like to learn more about 3-2-1, just drop me a line.
Van Gyn, Geraldine. It’s The Little Assignment with the Big Impact: Reading, Writing, Critical Reflection, and Meaningful Discussion. Faculty Focus May 6, 2013.
Case Reports Database
Dr. Kanji Nakatsu shared this resource with us recently. It’s a bank of Case Reports, from Biomed Central and supplemented by the Journal of Medical Case Reports. It is searchable and freely accessible. This is a resource for physicians, but may also be used in medical education. “By bringing similar case reports together, through the Cases Database, researchers and clinicians can start to look for new knowledge – new associations, new side effects, new thoughts about disease processes, new understandings about the impact of disease on our patients and our communities.”
Access it by going to
Updated Faculty Resources Community Available
The newly-updated Faculty Resources Community is now available in MEdTech Central. This online resource contains great teaching and assessment ideas, highlights of Curriculum Committee, notes and slides from the retreats, and more.
The resource material available includes refresher instructions on the audio-visual equipment in teaching theatres 132 and 032 (including a map of the numbered student microphones), e-learning resources and links to the small group learning community.
This Faculty Resource Community is open to all faculty at the School of Medicine. For more information, please contact Sheila Pinchin (firstname.lastname@example.org) or Theresa Suart (email@example.com).