INTERVIEW WITH DR. KATH ERIN E CHEN ... 2
A STUDEN T -RUN PROGRAM FOR SOCIAL JUSTIC E .... 5
MEDIC AL EDUC ATION RESEARCH CORN ER: CRITICAL ASSESSMEN T OF REC ENT LITERATU RE .... 8
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The Rossi MSSM
MED IC AL E DU CA TIO N NE WS , RE SEA RC H RE VI EW S, TE AC HI NG T IP S, CON VE RS AT IO NS WI TH E DU CA TI ON LE AD ER S
Welcome to The Rossi: Medical Education Quarterly Dr. Erica S. Friedman Associate Dean for Education Assessment and Scholarship at Mount Sinai School of Medicine In medicine, as with other fields, developing effective leaders and educators is essential to our profession. Teaching is a vital role of all physicians, and good teaching directly improves patient care. Similar to other aspects of medical practice, becoming an effective teacher requires training and experience. An increasing number of medical students, residents, and practicing physicians are seeking advanced training in education to provide them with a conceptual and scholarly foundation for their educational responsibilities, and to enhance their leadership potential and increase their effectiveness in their profession. Mount Sinai’s Institute for Medical Education (IME) serves the vital need for creating, educating, mentoring and retaining the
best educators for our students, residents and faculty. Fostering the success of our educators includes recognizing and rewarding those who display dedication and excellence in their work, and providing programs that develop and reinforce their scholarship, teaching skills and successful promotion. The birth of this publication signals a formal mechanism for showcasing model educators, highlighting key education research, fostering medical trainee engagement in the growing medical education community and nurturing their development into medical education leaders. This publication will provide regular updates on the accomplishments and trends in medical education within our local as well as international medical education
community. We hope by sharing best practices in education and by profiling top educators, we will recruit and develop medical trainees as education leaders and facilitate their involvement in education scholarship. This publication provides a forum for medical professionals at all levels of training to share their ideas and ask the real questions about medical education. We will describe how questions can be transformed into scholarly projects or education research. We look forward to a communitywide conversation about the needs, challenges and innovative solutions in medical education. Welcome to The Rossi.
“The Rossi” is named after Dr. Miriam Rossi, a graduate of the first medical school class at Mount Sinai School of Medicine in 1970. A dedicated medical educator and mentor, she has served as the Associate Dean of Student Affairs and Associate Dean of Admissions at the Faculty of Medicine at the University of Toronto among other educational posts. The Rossi staff is proud to acknowledge her contribution to teaching in medicine.
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THE ROSSI STAFF
Interview with Dr. Katherine Chen
MD, Mentor, Mother, Mensch K. H. Vincent Lau EDITOR K. H. VINCENT LAU ASSOCIATE EDITOR LENARD BABUS EDITOR-AT-LARGE DR. ERICA FRIEDMAN WEB EDITOR MIGUEL YAPORT WRITERS DEMETRI BLANAS GRACE CHARLES DANI DUMITRIU H. CINDY KO LOHEETHA RAGUPATHI SUSAN YIN PHOTOGRAPER DAVID BERMAN
Photographer: David Berman academic world, you needed to be a clinical expert with productive research activities. So I went down that path first. I spent several years focusing on Obstetric Infectious Diseases, gathering clinical research skills, and performing studies. When I turned 40, I realized that the projects I enjoyed most were the ones I did with Recognized for her excellence in teaching students and residents. I couldn’t get away from through various awards at Harvard Medical teaching. School and Columbia University, her most recent honor in 2012 is the Mount Sinai Institute of You’ve had an extensive history of awards, Medical Education Excellence in Teaching most recently the Excellence in Teaching award. She was also a faculty member AOA Award this year at Sinai. Can you share with inductee two years ago. us your philosophy on teaching? First and foremost, my philosophy is to The Rossi editor-in-chief had a chance to sit make teaching fun and interactive. I utilize the down with Dr. Chen and discuss her Game Method whenever possible. For example, philosophies on teaching, as well as her life as a on the Labor and Delivery Unit, I would ask the physician, mother and book enthusiast. student to provide me with a roadmap of which Dr. Katherine Chen is an Associate Professor and Vice Chair of Education for the Obstetrics/Gynecology Department at Mount Sinai School of Medicine. She also directs the third year medical student Obstetrics/ Gynecology clerkship.
“First and foremost, my philosophy is to make The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation. - Sir William Osler
teaching fun and interactive. I utilize the Game Method whenever possible.” patient I should see first, second, etc. – a game to test their triage skills. When I lecture, I like to use many images and videos and invite students to participate. Of course, there’s also the Guinness Book of Ob-Gyn Records! In the review sessions, I’d ask students who had delivered the biggest baby or removed the largest fibroids et cetera. Another principle I value is to get to know my students. I’m picky about making What was this midlife crisis? nametags at the beginning of every clerkship to I always knew I had a knack for teach- help me learn the students’ names. I make an ing, even while I was a resident. But at that time, effort to sit down with each student on midI had gotten advice that to advance in the rotation day to provide feedback. What attracted you to Mount Sinai? I came here specifically for an administrative position in education. Prior to that, I was at Columbia University on an NIH grant, primarily doing research – 75% research, 25% clinical. Then I had a midlife crisis and decided I wanted to focus more on education. I’m very grateful to my chair Dr. Brodman for offering me the position and for supporting me in my endeavors.
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You’ve shared your story with stude nts about having a baby during the New York City Blackout of 2003. What else can you tell us about your personal life? I can tell you that my husband and two children are very important to me and I relish the time spent with them. That’s why I tell students that I try not to check my emails after I leave work. There was a New York Times article recently about addiction to electronic devices. Everyone’s heard the term “crackberry.” Outside of the hospital I really focus on my family. I am a movie buff. I’m on a few mailing lists where I’m invited to attend screenings for movies that are in production. Sometimes I go with my husband, sometimes with my children, and other times as a family – depends on the demographic target of the movie. I’m also an avid reader. Recently, Dr. Muller was giving books to thank faculty who worked on LCME accreditation. He let the committee members pick the book they wanted. However, I looked through the selection and I had read all of them already! What are some of your recent favorite books? My favorite in 2011 was Abraham Verghese’s Cutting for Stone. Others that I have enjoyed are Tina Fey’s Bossypants and the Hunger Games series yes, I do read my older daughter’s books. Favorite authors – Geraldine Brooks; my classmate in college and medical school,
Dr. Chen with her husband Dr. Benjamin Chen, an Associate Professor in Medicine at MSSM, and two daughters in 2006. Recent non-medical shows I’ve liked are two British series: Sherlock Holmes and Downtown Abbey. Do you have any advice for medical students trying to juggle their life in the hospital and outside? You have to choose a career that you thoroughly enjoy. When you choose something you love, you get things done much faster and you’re much more efficient at work. At the end of the day, there isn’t as much work left over or problems to worry about to take home. And I’ll
“It’s been studied that attention span for your generation isn’t quite as long, but you can multitask!” Atul Gawande; mystery writer Elisabeth George; and Agatha Christie. Do you watch any medical shows? I don’t watch much TV, but when I was a resident I watched ER. I did watch the first season of Grey’s Anatomy as a young attending, but I didn’t continue.
say this: your family, friends, significant others – they really are more important than your job. The most difficult times in my career where I really had to learn how to balance family/work life is the first two years of each of my daughter’s lives. My mother and husband were a big help.
Given our generation’s emphasis on work/life balance, do you think we also have a different view on studying medicine? Your generation is an interesting one… “The Millennial Generation”, “The Internet Generation”, “The Digital Natives”. You do have different learning methods. It’s been studied that attention span for your generation isn’t quite as long, but you can multitask! I think what is important is for educators to make learning very interactive and at the same time, very organized. The students need to be engaged but also know what is expected of them. You’re the only teacher who started a Twitter account for your clerkship. How did that come about? I learned about the idea from an educational conference. However, I’ve stopped using the Twitter account. When I polled the students, only one or two were active Twitter users. In contrast, many use Facebook. I have not thought of a useful way to utilize Facebook yet. For now I’ve reverted back to just email to post notifications or to elicit questions from the students. It’s not anonymous though, which I thought was the benefit of Twitter.
Medical education is not completed at the medical school; it is only begun. - Dr. William H. Welch 3
What advice do you have for stude nts interested in a career in me dical teaching? It’s important to understand how adult learners learn. There are medical education conferences that you can go to -some that are specific to one specialty, and others focused just on education which are attended by all specialties. The challenge is that there’s no formal educator training programs, so it’s harder to gather the skills you need. It’s different than going into research, where you can receive formal training and receive a degree. If you want to be a great clinician, there’s mentorship and ways to practice and refine your skills. I suggest attending conferences, emulating others, and paying attention to student feedback. As for attaining teaching positions, always show interest in whatever way you can at your academic center. Be able to negotiate so that you can teach and be rewarded for it, while maintaining the objectives of your department. What’s a typical week for you as a me dical educator?
Where in the hospital is your happy place? My office is my happy place, because that’s where I meet with students and trainees. I interview high school students for my college in my office. I meet with college kids interested in medicine. Obviously, I spend much time with medical students. I see residents, fellows, and young attendings in my office to advise and mentor. I also spend time with the coordinator of the clerkship and electives – Ms. Bustamante – brainstorming and organizing. You were recently inducted as a Mount Sinai AOA Honor Society Faculty me mber. What was the process of you receiving the award? That was a great privilege and one of the awards I treasure most. That is because Harvard Medical School, my alma mater, didn’t have an AOA society, so it wasn’t an honor that I could achieve then. I actually don’t know the process and just assumed the graduating students of that year nominated me.
“If you think you need to make a change, go ahead and do it. Women are less likely to make major changes. I would advocate that they do.” Three and a half days of the week, I am doing administrative work which is related to the Ob-Gyn clerkship, 1st – 2nd year courses, 4th year electives, residency applicants, the residency program, and fellowships. On Wednesday mornings, I co-direct an Infectious Diseases Obstetrics Clinic. On Fridays, I supervise the Labor and Delivery Unit which is the most challenging and stressful part of my week.
Do you have mentors of your own that have shaped you? I’ve had many mentors for my career. All my chairs have played significant roles. There are also many female faculty members in and out of Ob-Gyn that have helped me. I am still enlisting new mentors as I go through my career. The way they have helped is to listen to my goals and set me in the right direction.
How do you resemble some of your me ntors today? I emulate the part that I admire in each mentor. There was one mentor who really knew how to balance her work life and her family, so I learned that from her. Another was very quick in decisionmaking and always followed through, so I picked that up from her. Another mentor used the Socratic method to teach, so I’ve incorporated his technique into my own clinical teaching. If you could speak to yourself as a young me dical student in Harvard, what advice would you give to her? Make sure you enjoy what you do. That’s why I moved into education. Also, recognize that your passion can change. I was passionate about research at one point, now I am excited about education. If you think you need to make a change, go ahead and do it. Women are less likely to make major changes. I would advocate that they do. Finally, take advantage of opportunities outside of the United States. I regretted not going to Oxford during my years as a Stanford undergraduate when the two institutions had a strong program. If you could impart one quality in all me dical student graduates at Sinai, what would that quality be? I would like all my students to become great educators. No matter what field in medicine, you’re always a teacher to your patients. In academia, you teach trainees; and in private practice, you teach your staff. There is so much knowledge out there, so much information, that you must distill for your patients, students, and staff in a meaningful way. Thank you very much for this interview, Dr. Chen. It was a pleasure. I have to say this – I’ve been very happy at Sinai because of my position. It was a great move from Columbia to Sinai and it’s great to know that others appreciate my teaching.
There is no short cut, nor 'royal road' to the attainment of medical knowledge. The path which we have to pursue is long, difficult, and unsafe. In our progress, we must frequently take up our abode with death and corruption, we must adopt loathsome diseases for our familiar associates, or we shall never be acquainted with their nature and dispositions; we must risk, nay, even injure our own health, in order to be able to preserve, or restore that of others. - Dr. John Abernethy 4
A Student-run Program for Social Justice An interview with Salina Bakshi, Marie Hennelly, Andrea Jakubowski and Aisha James Dani Dumitriu In the increasingly complex world of medicine where clinical knowledge is estimated to double every 18 months, four Mount Sinai School of Medicine students recognized that their education was missing an important component. Salina Bakshi, Marie Hennelly, Andrea Jakubowski and Aisha James took a critical look at the medical school curriculum and realized that while anatomy trains future surgeons and child development trains future pediatricians, there was no designated course discussing important issues in social justice. Thus, in 2011, in the midst of their busy first year schedule, they started the Human Rights and Social Justice Scholars Program (HRSJ), a comprehensive one-year track giving students the tools, resources and mentorship to pursue the diverse aspects of
health equity and social justice. I met Salina, Marie, Andrea and Aisha in the student lounge during the week before they would begin their third year clerkships. Given their tremendous accomplishment, I was expecting a rambunctious group, eagerly speaking and interrupting each other. Instead, I was met by a group which exuded quiet confidence and intelligence. They spoke thoughtfully and precisely – each contributing their unique expertise and experiences. What is meant by “social justice”? As Salina explained to me: “a biopsychosocial approach to health and wellness to understand the underlying factors of a patient’s condition both scientifically and socially in order to better understand what factors might prevent them
Andrea Jakubowski, Aisha James, Dr. Holly Atkinson (immediate past president of PHR, faculty advisor of MSSM's PHR student chapter, faculty advisor of the HRSJ Scholars Program), Salina Bakshi, Dr. Phil Landrigan (Dean for Global Health, faculty mentor of the HRSJ Scholars Program, Chair of Dept of Preventive Medicine, and Director of MSHC's Children's Environmental Health Center), and Marie Oliva Hennelly. In May 2012 at the end of year Human Rights Celebration, a reception celebrating the inaugural year of the HRSJ Scholars Program. 5
from receiving equitable and adequate healthcare.” Marie was quick to note the inspiration provided by being physically located on the border between Manhattan’s very rich and very poor. “Being a student chapter of Physicians for Human Rights we believe health is a human right, so equitable delivery of healthcare is a justice issue. Harlem residents and Upper East Side residents should receive equal health care.” The first group of 11 students accepted into the HRSJ scholars program started the program in September 2011. The curriculum is comprised of five interlinked components: coursework, career panel series, research, a policy and advocacy service project and mentorship. The coursework consists of an 8-week student-run “Health, Human rights, and Advocacy” course, taught by a combination of clinicians, researchers and advocates. The course was originally started in 2010 by the Mount Sinai leaders of Physicians for Human Rights, and remains open to all students as an elective, though it is now mandatory for students enrolled in the HRSJ program. Topics feature a variety of domestic and global health issues, such as disaster response, environmental toxins, and minority health. The career panel series complements the didactic curriculum and provides an opportunity to engage with pioneers who have dedicated their lives to human rights and health, such as Homer Venters, head of the NYC Correctional Health Services. These round table dinner discussions offer students the opportunity to interact one-on-one with leaders in social justice and learn about a variety of career paths within the field. The research component – in many ways the central aspect of the HRSJ track – is designed to demonstrate that research methods within the field of social justice can be as academically rigorous as those within clinical and basic sciences. The ultimate goal, Marie explained, is “evidence -based advocacy.” An excellent historical example is the Campaign to Ban Landmines run by Physicians for Human Rights, who in 1991 published comprehensive research reports on the overwhelming devastation of innocent civilians by landmines in Cambodia. By 1997, their efforts led to an international Mine Ban Treaty signed by 122 countries, a momentous achievement awarded the Nobel Peace Prize the same year. The take-home message, Aisha explains, is that Physicians for Human Rights accomplished this major policy change via rigorous research and facts, not by publishing educated opinions. Could these data have been gathered by non-physicians? Maybe. But physicians have the unique
Salina Bakshi, Marie Hennelly, Andrea Jakubowski, Aisha James and the first eleven HRSJ scholars skill set and knowledge base to understand a problem from a medical perspective, and therefore contribute with a more authoritative voice. “There is a privilege that comes with a white coat,” Salina adds, “and with that trust and respect it is our responsibility to use our knowledge and our position of power to effect change.” The next component of the track – policy and advocacy service project – helps students develop practical skills for implementing change in ways that benefit the East Harlem community. One student partnered with Boriken to assess the barriers, risks and opportunities of HPV vaccination. The goal of the project is to develop educational tools for both staff and patients in order to encourage an increase in vaccination rates. Finally, absolutely integral to the HRSJ program is the mentorship component, which pairs
each student with both a faculty mentor as well as a peer mentor from the class above. As the program grows, the hope is that peer mentorship will create a tightly woven network of students from all four years of medical school, thus develop into
juniors as they transfer leadership responsibilities in longitudinal projects. How did such a comprehensive program evolve in such a short time? Salina, Marie, Andrea and Aisha became interested in social justice as first years medical students while taking the “Health, Human Rights, and Advocacy” elective, which at that time was run by Physicians for Human Rights. In one class, the Physicians for Human Rights National Conference in Boston was advertised and the group decided to go. At the conference, they came across a poster detailing a Health Equities Scholars program at the University of Michigan, The program was nowhere near as extensive as their own future creation, but for Salina, it was a revelation: “These concepts can be taught in an objective and organized way,” she
“There is a privilege that comes with
a white coat, and with that trust and respect it is our responsibility to use our knowledge and our position of power to effect change.” a community dedicated to social justice. This type of collaboration will create a community-wide forum for social justice issues, and will also serve as a formal mechanism by which seniors can train
Medical education is not just a program for building knowledge and skills in its recipients... it is also an experience which creates attitudes and expectations. - Abraham Flexner 6
realized. In the midst of first year jitters HRSJ program, starting September 2011. Program is jointly owned by the Center for about why she’d decided to pursue a medi- This translates into 16% of the incoming Multicultural Affairs, Department of cal degree, she was reminded of her medical school class, showing how big a Medical Education, the Global Health original goal for applying to medical gap the program fulfills. Their only regret Center, and four faculty advisers: Drs. school: to fight for social justice and health is not being able to accommodate all Holly Atkinson, Yasmin Meah, Anu Anaequity. interested students due to the limiting fac- daraja, and Ann-Gel Palermo. At present it Immediately after the conference, tor of available mentors. In addition to the is considered a “program” rather than a they began outlining the skeleton of the overwhelming positive response from stu- “track”. The student leaders hope that as program. Andrea, Aisha and Marie all dents, this year they were awarded the the program demonstrates sustainability agree that the program was Salina’s brain- AOA Medical Student Service Leadership within the next few years, it will become child, though they were quick and willing Award for the program, honoring not only an official track offered as part of Mount recruits. With an amused smile, Salina their effort, but also giving them $8000 in Sinai’s medical curriculum. They are also recalls an incident of telling a friend about funds to develop the program over the next working with the administration to create a the idea, who looked at her in dismay and three years. new distinction – Distinction in Social said: “Don’t you think that’s a little I asked if they feel they could Justice – which future medical students much?” But this was the only negative have put together such a program at any may receive upon graduation, similarly to comment any of the four can remember. other institution. Without hesitation, the currently available achievements of Within a couple of days, they pitched their I received a unanimous “No.” Mount Sinai Distinction in Medical Education and Disidea to Dr. Philip Landrigan, Chair of is unique not only in harboring leaders in tinction in Research. Preventive Medicine and Director of the social justice work, but also by being This year, Mount Sinai’s Children’s Environmental Health Center, the only medical school to promote “Touching Points” letter to its new stuwho was encouraging and recomdents included a description of mended they meet with Dean Mount Sinai is unique not only in the HRSJ program. “Last David Muller. They were met by week,” Salina recalls, “I got an the same supportive attitude from email from a student who is Dean Muller who immediately harboring leaders in social justice work, starting this Fall. She just connected them with mentors for wanted to let me know that the the project. “There was such but also by being the only medical school HRSJ program was the reason galvanizing support from the she ended up choosing this beginning,” says Salina. “There to promote advocacy. medical school.” Although she were so many opportunities for remained poised, I could detect red tape, but it never happened.” advocacy. In fact, its Medical Education the slightest crackle of pride in her voice. For the remainder of their first Mission Statement asserts: “To produce There is a lot left to be done, but year spring semester and summer, Salina, physicians and scientists who are what Salina, Marie, Aisha and Andrea Andrea, Aisha and Marie worked over 30 prepared to enter society as informed have accomplished is beyond impressive. hours per week, outlining their ideas, mak- advocates and activists, able to advance For anyone, student or faculty, interested ing contacts in the community, putting clinical care and science, and capable in social justice, they have created a nettogether presentations and finding of promoting change.” In addition, work for the exchange of expertise and mentors. Because of other obligations, Mount Sinai, perhaps by virtue of being a experience, and a community of faculty their meetings tended to start as late as 10 stand-alone medical school, lacks the and students sharing the same passion. pm and ran until 2 or 3 in the morning. roadblocks often put in place at large Ultimately, their dream is that social jusBalancing the program’s development institutions by complex bureaucratic tice will become “the third leg of the stool, with a heavy course load was difficult, but networks. “They are very receptive to along with basic science and clinical - with their education in a new context – students making their own path and work.” Given the overwhelmingly positive also motivating. To their delight, their want to support them in every way response from the administration, students efforts paid off. They received 23 possible.” and faculty – they might just succeed! applications for the 11 seats in the first Currently, the HRSJ Scholars
UPCOMING MEDICAL EDUCATION MEETINGS Association of American Medical Colleges (AAMC)
Northeastern Group on Educational Affairs (NEGEA)
Annual Meeting
Annual Meeting
(includes Conference on Research in Medical
April 12-13, 2013 in New York, NY
Education—RIME)
https://www.aamc.org/members/gea/regions/negea/meetings/
Nov. 2-7, 2012 in San Francisco, CA
(Abstracts due December 5)
https://www.aamc.org/meetings/annual/2012_annual_meeting/
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MedEd Research Corner Critical Assessment of Recent Literature H. Cindy Ko and Grace Charles PROGRAM DESCRIPTION: A 90-minute web-based module with three simulated clinical Standardized patient-narrated web-based learning modules encounters was narrated by an expert clinician and SP to explain improve students' communication skills on a high-stakes expected history-taking, physical examination, and communication clinical skills examination. skills behaviors. All 147 students were encouraged to review the Lee CA, Chang A, Chou CL, Boscardin C, Hauer KE. module one month before the CPX. J Gen Intern Med. 2011 Nov;26(11):1374-7. Epub 2011 Jul 16. PROGRAM EVALUATION: One hundred and six students (72%) viewed the web-based BACKGROUND: module. Students who watched the module performed significantly Use of web-based standardized patient (SP) modules is higher on the CPX communication score (+2.67%, p < 0.01) and associated with improved medical student history-taking and overall score (+2.12%, p = 0.03), even after controlling for USMLE physical examination skills on clinical performance examinations Step 1 and clerkship summary ratings. Use of the module did not (CPX), but a benefit for communication skills has not been shown. significantly affect history/physical examination scores (+1.89%, AIM: p = 0.12). We describe an innovative web-based SP module using detailed DISCUSSION: SP and faculty commentary to teach communication skills. Students who watched an optional web-based SP module prior to SETTING: the CPX performed higher than those who did not on A public medical school in 2008-2009. communication skills. The web-based module appears to be an effective CPX preparatory activity to enhance communication PARTICIPANTS: performance. Fourth-year medical students. ABSTRACT OF STUDY #1:
Critique of Study #1 H. Cindy Ko Standardized patient (SP) encounters are a common tool employed by medical schools to prepare students for clinical skill examinations and future patient interactions. The advent of web-based learning modules has provided a unique opportunity to enhance these traditional SP learning methods and increase the clinical competency of medical students. This current study aims to evaluate the effectiveness of a web-based teaching module on the communication skills scores of fourth year medical students on Clinical Performance Examinations (CPX). To supplement mandatory SP training 6 months prior to CPX, students were invited to view a web-based module one month before the examination. The module consisted of three separate 20 min videotaped student-SP encounters with narration and teaching commentary from a highly-trained SP and an experienced clinician. A majority of students (79% of those who watched) viewed the videos within the last 48 hours before their exam. Students who watched the video modules (n = 106) scored significantly higher in the communications skills
portion of the CPX compared to their classmates who did not watch (n = 41). The scores for history taking and physical exam scores were not significantly different between the two groups. Also, significantly fewer students in the group
may be an effective study tool for the communication skills portion of CPX. One of the major aims of a medical school is to develop a generation of well-trained and compassionate physicians. At the outset, the use of
The techniques of careful listening and effective communication are an intangible set of skills that are
only
acquired
and
learned
through
experience and feedback. who watched the module failed the CPX (n = 3), compared to those who did not watch (n = 7). The study controlled for baseline differences between the two groups by using Step 1 scores and a diverse set of clerkship ratings as covariates as part of the analysis. Additionally, the gender composition of those who watched the modules was consistent with that of the general class. The authors suggest that generalized feedback from web-based case vignettes 8
standardized patients in allows for the newly minted physicians to comfortably and reliably apply their clinical skill set. On a more global level, the overall preparedness and clinical skills of the individual graduate translate to a better reputation for the school. Thus, it is no surprise that medical schools are constantly searching for ways to improve teaching techniques in an effort to maximize the clinical readiness of their students.
The task of teaching scientific medical knowledge is more objective and concrete than passing on the skills needed to develop empathetic doctor-patient interactions. There are a finite number of lecture hours set for each course, and students’ knowledge can be evaluated with reasonable accuracy by administering a multiple choice test at the end of the unit. It seems obvious that the non-science aspects of medical learning are equally important for the development of a great physician. However, the transfer of this type of knowledge proves to be less straightforward. The techniques of careful listening and effective communication are an intangible set of skills that are only acquired and learned through experience and feedback. Virtually all medical schools have adopted the use of standardized patients to train medical students through supervised versions of real life clinical encounters. This study takes the SP encounter to a new format—a web-based video module—for the purpose of improving students’ communication skills without the time or cost of the traditional SP clinical experience. The web-based tutorial also allows students to review the expectations of the CPX in a “last-minute” time frame. Assessing the Study The fact that 79% of those who viewed the module did so within 48-hours of the CPX raises the question of whether
the intervention produced a lasting impact on students. Furthermore, the increase in communication scores may reflect an improvement in test taking ability rather than an actual improvement in clinical skills. These possibilities also raise the issue of whether evaluations of clinical skills, such as those made during the CPX, are accurate indications of a student’s real-life clinical abilities. Do their efforts to create bitesized, web-based teaching modules serve to artificially inflate the perceived communicative abilities and clinical skills of these future physicians? It is also relevant to consider which elements belong on a standardized “communications skills checklist.” What seems like a core component of the evaluation would likely vary in content depending on whether it was composed from the SP’s perspective vs. the clinician’s observation, and even from medical school to medical school. An itemized analysis of the communications skills portion of the CPX evaluation would have provided the necessary detail to support the arguments being made about the web module’s efficacy. Furthermore, it would also have been salient to include the CPX communications scores in years prior to the implementation of the web modules for a more complete review. Lastly, the study falls short of providing detail about the evaluation of the three students who failed their CPX, despite the fact that they had watched the module. If the module was able to raise the
ABSTRACT FOR STUDY #2:
average communication score of most students, we can either make the assumption that the CPX failures were unrelated to their communication score, or that the module’s teaching was not effective for their learning. A targeted analysis of the performance of those who did not pass is necessary to understand this distinction. Assessing the Applicability While the use of a web-based module for teaching communication skills is an innovative idea, its effectiveness will need further evaluation prior to wide-spread adoption. This study would be more robust if there were a comparison to student performance in previous years prior to introducing the module. The study’s authors also acknowledge that it would be important to demonstrate the long -term effects of the module in a follow-up study. If, for example, the CPX scores could be correlated with subsequent Step 2 CS performance, it would provide a comparison to a similar high-stakes test, as well as a valid long-term assessment of communication skills. In the face of rising medical education costs, the use of web resources to teach communication skills as opposed to hiring actors as SPs is an attractive idea, but will require further research to demonstrate its’ effectiveness. This type of web based module may be useful for teaching and/or reinforcing other skills taught during live encounters including higher level communication skills such as giving bad news or admitting an error.
procedure, on graduation from medical school and 18 months into postgraduate training.
Predictive validity of the multiple mini-interview for selecting medical trainees. RESULTS: The median reliability of eight administrations of the MMI in various coEva KW, Reiter HI, Trinh K, Wasi P, Rosenfeld J, Norman GR. horts was 0.73 when 12 10-minute stations were used with one examinMed Educ. 2009 Aug;43(8):767-75. er per station. The correlation between performance on the MMI and number of stations passed on an objective structured clinical examinaINTRODUCTION: tion-based licensing examination was r = 0.43 (P < 0.05) in a postgraduIn this paper we report on further tests of the validity of the multiple mini- ate sample and r = 0.35 (P < 0.05) in an undergraduate sample of subinterview (MMI) selection process, comparing MMI scores with those jects who sat the MMI 5 years prior to sitting the licensing examination. achieved on a national high-stakes clinical skills examination. We also The correlation between 'cognitive' and 'non-cognitive' assessment incontinue to explore the stability of candidate performance and the extent struments increased with time in training (i.e. as the focus of the assessto which so-called 'cognitive' and 'non-cognitive' qualities should be ments became more tailored to the clinical practice of medicine). deemed independent of one another. DISCUSSION: Further evidence for the validity of the MMI approach to making admissions decisions has been provided. More generally, the reported findings cast further doubt on the extent to which performance can be captured with trait-based models of ability. Finally, although a complementary predictive relationship has consistently been observed between grade point average and MMI results, the extent to which cognitive and non-cognitive qualities are distinct appears to depend on the scope of practice within which the two classes of qualities are assessed.
METHODS: To examine predictive validity, MMI data were matched with licensing examination data for both undergraduate (n = 34) and postgraduate (n = 22) samples of participants. To assess the stability of candidate performance, reliability coefficients were generated for eight distinct samples. Finally, correlations were calculated between 'cognitive' and 'non-cognitive' measures of ability collected in the admissions
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Critique of Study #2 Grace Charles Medical schools have long used applicant interview performance as a key component of the selection criteria for admission. Although the interview is unanimous in the admissions process, the format is not; varieties include a single interview, multiple interviews, and group interviews with variable numbers of interviewers and interviewees present. Recently, the Multiple Mini-Interview (MMI) has gained support in the American medical school admissions process. Widely used in Canada and brainchild of researchers at McMaster University, the MMI requires students to rotate through approximately ten 8-minute stations. Station tasks may include responding to ethical dilemmas, working with another applicant on an assignment, writing an essay, answering a traditional interview question, or role-playing with an actor. At each station, the interviewees are scored on their performance. The selecting institution focuses the MMI around the domain it deems appropriate, e.g. ethics, professionalism, or communication. At McMaster University, for instance, the MMI is directed towards ethical decisionmaking. Why would a medical school require applicants to rotate through an exhausting round of mini-exams on their interview day? Studies have found traditional interviews to have low reliability, meaning the score an interviewee receives at one interview will not necessarily be the score he or she receives at another interview. Furthermore, interview scores often do not correlate with later job performance, thus indicating poor validity as the interviews may not fulfill their intended purpose. On the other hand, previous research has shown that the MMI achieves reliability and validity in the context of undergraduate medical school admissions to predict performance on clerkships and national licensing examinations. The journal article presented here consists of several small studies regarding the MMI. In one, the authors found that the total MMI score produces a satisfactory reliability coefficient of 0.69 to 0.79 for use as an interviewing tool; generally >0.7 is considered acceptable. Furthermore, the authors studied a cohort of 22 residents to evaluate the ability of the MMI to predict interpersonal skills as measured by Part II of the Canadian national licensing exam
(MCCQE). Postgraduate students took the skills-based MCCQE and within nine months took a MMI focused on ethics and nonclinical decision making. The authors found the MMI to be predictive of the percentage of stations candidates passed (r = 0.43) although not statistically significant with respect to the total score. The authors replicated the study with 34 participants who took the MMI upon admission to medical school 5.5 years prior to taking the MCCQE. At the time of admission, data regarding applicants’ GPA, ABS (autobiographical submission), a simulated tutorial to evaluate applicants’ interactions with other applicants, and a personal panel-based interview with three interviewers was also collected. Of the five factors, the MMI was the only statistically significant factor correlated with the number of stations passed on the MCCQE (r = 0.35), and none of the indicators, MMI included, were statistically significant with regard to overall score. Assessing the Study While the study sample sizes are small, this paper suggests that the MMI offers real advances in the interview process: a reliable score that correlates
of the MCCQE, in which students rotate through sixteen 10-minute stations, while to compare the other measures utilized in the study to the MCCQE is to compare apples and oranges. Furthermore, it is questionable whether the outcome of more stations passed on the MCCQE is a meaningful measure for the selection of future medical students. Assessing the Applicability An institution considering the MMI must discuss the practicality of implementing it. The MMI is resource intensive, requiring up to a dozen stations, each run by at least one scorer, to be performed every interview day. Is this a reasonable cost and time commitment to an institution that interviews hundreds of applicants? Instructors and facility requirements aside, the amount of time and cost put into organizing and training individuals to run each station will undoubtedly be many more times that of a standard interview with a single faculty member. Parenthetically, one solution would be to set up centers where applicants could complete the MMI and then have their scores transmitted to all medical schools. However, this would preclude the ability
Recently, the Multiple Mini-Interview (MMI) selection process has gained support in the American medical school admissions process. with the number of stations passed on a licensing exam. As exciting as such novelty may be, it behooves us to further interrogate the data before us. The 12-station MMI boasts a reliability of approximately 0.73 while any one station has a consistently low reliability of under 0.25. This suggests improved reliability with an increased number of distinct stations scored by different examiners. While the relationship between the MMI and the MCCQE Part II is statistically significant, the sample sizes are small and the correlation coefficient is a meager 0.35. The authors also point out that of all the tools used to evaluate the applicants, the MMI was the only measure that showed a statistically significant correlation with MCCQE. However, the MMI method and scoring is very similar to that 10
of the selecting institution to choose the specific focus of its MMI. In addition, isolating an individual’s interpersonal skills to a specific domain, such as McMaster does with ethics, reduces the ability to understand the full scope of an applicant’s interpersonal skills. Medical schools often desire a well-rounded student body. Denying applicants the opportunity to interact freely with an interviewer denies the school an opportunity to know the applicant as an individual. Furthermore, cognitive competencies, such as prior training in ethics, may confound one’s score on the MMI. The lessons from this study are those of the scientific method: systematic investigations in which standardized score cards are used by a large set of investigators to evaluate each applicant
will produce more reliable results than will a single interview. An institution looking to make novel advances may therefore consider piloting a program with more interviews per applicant, for example four 20-minute interviews per applicant. Such
an arrangement would be an interesting area of research that need not add significant cost or time to the interview day. As for validity, it is the responsibility of the selecting institution to stipulate what it is attempting to gain from the interview
and what interpersonal qualities it requires of its students. Piloting a standardized scoring card targeted at identifying these qualities, as well as training interviewers to recognize these traits, may improve interview score reliability and validity.
Best Practices PowerPoint Presentation Design Demetri Blanas PowerPoint software is a ubiquitous medium of communication and teaching in academic medicine. Its versatility provides teachers with a wide range of options for conveying concepts and ideas. However, misuse of the PowerPoint format can be distracting to audiences. We outline here a set of best practices guidelines for designing PowerPoint presentations. Text slides: Individual PowerPoint slides should convey a single primary point. Any individual slide should have no more than seven lines. Text should stay within slide borders. Write in point form – use key points or phrases instead of full sentences. Font type and size: Presentations should employ a single uniform font-type. Font types are divided into “serif” and “sans serif” ("no serif"). Serifs are the structural details at the end of letter strokes that in written text can guide the reader’s eye. In computer projected text, however, they are considered distracting. Choose only sans serif fonttypes for PowerPoint presentations. Font sizes should be kept to two (titles and non-titles). Use at least 18 size. Letter case: Reader comprehension is improved with lower case letters compared to upper case. Therefore, consider minimizing the use of upper case font even for titles. Interestingly, readers recognize letters first by the top half of the letter, and lower case letters present a distinctive shape whereas upper case letters consist of block forms that are generally more difficult to distinguish from each other. Color: Use no more than three colors per slide or for the entire presentation. Ensure adequate contrast between text and background (light font on dark text or vice versa). Avoid red or green for color-blind members of the audience. If you use an additional color, use it to emphasize a point. Transitions: Avoid complex transitions with animation or sound effects. These generally distract the viewer from the content of the presentation, and may be associated with amateur use. Tables and graphs: Tables and graphs should be kept to a maximum of three columns and three rows. They should be clearly labeled. Charts should have only one main point to convey to the audience. Pace: Use no more than 1-2 slides per minute. References: Appropriately reference any tables or quotes used during your presentation. Include an asterix or numbers, and indicate the reference at the bottom of the slide. Disclosures: Include a slide disclosing any personal or financial relationships that could present a conflict of interest. PowerPoint software has greatly facilitated and standardized presentations, providing presenters with a wide range of flexibility and options. By adhering to simple principles, presenters can create more effective and engaging presentations. Source: Collins J. Education techniques for lifelong learning: making a PowerPoint presentation. Radiographics 2004;24(4):1177-83.
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Can you spare a byte? Mobile technology and medical education Loheetha Ragupathi Few professions can match the rapid pace of discovery and innovation present in medicine. Our briskly evolving knowledge base poses great challenges to medical educators. Optimizing the synthesis and delivery of this growing information to medical trainees of all levels is key to providing efficient and quick access to cutting edge breakthroughs. Recently, mobile technology has emerged as a novel method for delivering information in small "bytes". The success of these ventures stems from a combination of portability, novelty, and ease of incorporation into life outside the classroom and hospital. For example, a quick glance at a drug database on a smart phone enables medical students to retrieve up-todate information developed by physicians, and the convenience of a question bank on the same phone helps maximize efficiency of learning by making use of short periods of downtime. The utility of these technologies was recently evaluated in a study on the education of neurosurgery residents in UCLA1. The residents were given mobile tablet devices with remote access to a variety of learning tools. After a year, residents reported an increase in the amount of time used to study outside the hospital, attributing this to the digital technology. Their performance on the Congress of Neurological Surgeons-Self Assessment in Neurological Surgery improved significantly after their first year of residency. A limitation of the study was that there was no control group, making it unclear what portion of the improvement could be specifically attributed to the technology use, and what portion to one year of clinical training. Another study from Ohio State University2, used the latest social media applications, or "push technology", to provide an emergency ultrasound curriculum to fourth year medical students via 140-character tweets. These were delivered daily over ten months as a supplement to additional educational materials. Although at first glance educational tweeting may seem like a radical teaching method, it actually parallels traditional medical education on the wards. Normally, students learn by
incorporating what they see, hear and do from a variety of sources in the hospital, which range from fellow students to experienced attending physicians. Over time, students compile these small factoids and experiences to strengthen their knowledge base, similar to the process of learning via
tweets. However, the study did not include a pre- and post- knowledge assessment. Nevertheless, the trend towards harnessing the latest technologies to supplement medical education is clear and unstoppable. As these necessary new technologies emerge, their effect on trainees, in terms of when, where and what to learn, remains to be seen. 1. Gonzalez NR, Dusick JR, Martin NA. Effects of mobile and digital support for a structured, competency-based curriculum in neurosurgery residency education. Neurosurgery 2012;71(1):164-72. 2. Bahner DP, Adkins E, Patel N, Donley C, Nagel R, Kman NE. How we use social media to supplement a novel curriculum in medical education. Med Teach 2012;34(6):439-44.
Harold Paredes, fourth year medical student, using a smart phone. 12