Using Individualized Learning Plans to Facilitate Learner-Centered Teaching

Precision Medical Education

Medical schools and residency programs are increasingly incorporating personalization of content, pathways, and assessments to align with a competency-based model. Yet, such efforts face challenges involving large amounts of data, sometimes struggling to deliver insights in a timely fashion for trainees, coaches, and programs. In this article, the authors argue that the emerging paradigm of precision medical education (PME) may ameliorate some of these challenges. However, PME lacks a widely accepted definition and a shared model of guiding principles and capacities, limiting widespread adoption. The authors propose defining PME as a systematic approach that integrates longitudinal data and analytics to drive precise educational interventions that address each individual learner's needs and goals in a continuous, timely, and cyclical fashion, ultimately improving meaningful educational, clinical, or system outcomes. Borrowing from precision medicine, they offer an adapted shared framework. In the P4 medical education framework, PME should (1) take a proactive approach to acquiring and using trainee data; (2) generate timely personalized insights through precision analytics (including artificial intelligence and decision-support tools); (3) design precision educational interventions (learning, assessment, coaching, pathways) in a participatory fashion, with trainees at the center as co-producers; and (4) ensure interventions are predictive of meaningful educational, professional, or clinical outcomes. Implementing PME will require new foundational capacities: flexible educational pathways and programs responsive to PME-guided dynamic and competency-based progression; comprehensive longitudinal data on trainees linked to educational and clinical outcomes; shared development of requisite technologies and analytics to effect educational decision-making; and a culture that embraces a precision approach, with research to gather validity evidence for this approach and development efforts targeting new skills needed by learners, coaches, and educational leaders. Anticipating pitfalls in the use of this approach will be important, as will ensuring it deepens, rather than replaces, the interaction of trainees and their coaches.

Student Clinical Experiences in Cross-Cultural Education

OBJECTIVES

Education in cultural competence is critical to training medical students to care for patients from all backgrounds, but it is unclear what experience students have in the clinical learning environment. We describe the medical student experience in directly observed cross-cultural encounters within two clinical clerkships, and we identify areas of need for further resident and faculty training in providing high-quality feedback following these encounters.

METHODS

We collected direct observation feedback forms from third-year medical students in the Internal Medicine and Pediatrics clerkships. The observed cross-cultural skill was categorized, and the quality of feedback given to students was quantified using a standardized model.

RESULTS

Students were observed using an interpreter more frequently than any other skill. Positive feedback received the highest quality scores, averaging 3.34 out of 4 coded elements. Corrective feedback quality only averaged 2.3 out of 4 coded elements, and quality correlated with the frequency of cross-cultural skill observation.

CONCLUSIONS

Significant variability exists in the quality of feedback provided to students following the direct observation of cross-cultural clinical skills. Faculty and resident training to improve feedback should focus on corrective feedback in less commonly observed cross-cultural skills.

Describing Overarching Curricular Goals for Individualized Education

Phenomenon: The phenomenon of individualized education, an essential component of competency-based medical education, addresses individual learner needs while working toward standardized learning outcomes. One challenge with broadly implementing individualized education is the lack of a pragmatic operational definition. To formalize expectations for individualized education, the Accreditation Council of Graduate Medical Education in 2013 began requiring six months of individualized curriculum (IC) during pediatric residency; however, there is not a national standard of formal curricular goals for the IC as an educational entity. Examining and describing the overarching curricular goals of IC could provide a framework for discourse about and further study of individualized education in medicine across disciplines and the continuum of medical education. Thus, we aimed to describe the phenomenon of individualized education through the lens of the goals of the IC in pediatric residency in the United States. Approach: In 2017, a purposeful sample of Pediatric Residency leaders were recruited to represent a diverse sample of program sizes, regions of the country, and importance of the IC to the program leadership. They completed an online survey with open-ended questions describing formal and implicit goals of their program's IC. The authors analyzed responses initially using conventional content analysis, then investigated whether the themes for program goals aligned with any existing educational theory. The concepts and language aligned with the principles of self-determination theory (SDT); therefore, the IC goals were subsequently grouped using the SDT domains of relatedness, autonomy, and competence. A focus group with a subset of survey respondents was conducted for member checking and elaboration of concepts. Findings: Program leaders from a diverse sample of 36 programs participated in the survey and a subset of 11 programs participated in the focus group. The common goals across all programs are listed in parentheses and organized by domains of SDT: 1)Relatedness goals (engage in mentorship, select a career) cultivate resident's professional identity based on their desired future career path; 2)autonomy goals (create a learning plan, practice accountability) help residents plan their path; and fulfillment of their plans lead to 3)competence goals (develop targeted clinical skills and knowledge, ensure comprehensive exposure, address learning gaps), ensuring they have a comprehensive skill set for their chosen identity. Insights: This study provides a framework to describe the phenomenon of individualized education through the lens of IC curricular goals in pediatric residency. The goals for IC that emerged from this study serve as a pragmatic framework for implementation of individualized education. They provide a common language and structure to promote more rigorous and collaborative study of individualized education across programs, disciplines, and settings in medicine. They may function as a roadmap for learners to navigate educational activities and for programs to help shape the experiences of their learners and examine outcomes of individualized education in their programs. The framework can also help individual pediatric residency programs structure improvements to their IC. Disciplines beyond pediatrics may also use this framework to better structure elective experiences to capitalize on the benefits of individual education.

You can have both: Coaching to promote clinical competency and professional identity formation

Coaching is a critical tool to guide student development of clinical competency and formation of professional identity in medicine, two inextricably linked concepts. Because progress toward clinical competence is linked to thinking, acting and feeling like a physician, a coach's knowledge about a learner's development of clinical skills is essential to promoting the learner's professional identity formation. A longitudinal coaching program provides a foundation for the formation of coach-learner relationships built on trust. Trusting relationships can moderate the risk and vulnerability inherent in a hierarchical medical education system and allow coaching conversations to focus on the promotion of self-regulated learning and fostering skills for life-long learning. Herein, we describe a comprehensive, longitudinal clinical coaching program for medical students designed to support learners' professional identify formation and effectively promote their emerging competence.

Use of Individualized Learning Plans to Facilitate Feedback Among Medical Students

Self-regulated learning theory suggests that individualized learning plans can benefit medical trainees by providing a structured means of goal setting, self-monitoring, and self-evaluation. External feedback also plays an important role in affecting learner motivations, perceptions, and self-evaluations. Accordingly, having learners share individualized learning plans with preceptors might promote self-regulated learning by helping align the feedback they receive with their learning goals. Hypothesis: We hypothesized having medical students share individualized learning plans with attendings and residents would improve the quality of the feedback they received, increase the likelihood that feedback correlated to their learning goals, and improve their perceptions of feedback received. Method: In this multisite study, third-year medical students on their pediatric clerkship created individualized learning plans and shared them with residents and attendings by writing a learning goal on at least one of their required faculty feedback forms. The quality of feedback on forms with versus without a learning goal written on top was scored using a validated scoring tool and compared using a Wilcoxon signed-ranks test, and the frequency with which feedback directly correlated to a student learning goal on forms with versus without a learning goal written on top was compared using a chi-square test. Students completed a post-clerkship survey rating the quality of feedback and teaching they received, perceptions of the individualized learning plans, progress toward achieving learning goals, and whether or not they received teaching and/or feedback related to learning goals. Results: Thirty-six students completed a total of 108 learning goals and 181 feedback forms, of which 42 forms (23.2%) had a learning goal written on top. The mean (SD) feedback score between forms with [3.9 (0.9)] versus without [3.6 (0.6)] a learning goal written on top was not different (p = .113). Feedback on forms with a learning goal written on top was more likely to correlate to a student learning goal than feedback on forms without a learning goal (92.9% vs 23.0% respectively, p < .001). Student perceptions of the usefulness of learning goals did not differ between students who reported receiving teaching or feedback related to a learning goal and those who did not. Conclusions: Sharing individualized learning plans with preceptors helped align feedback with learning goals but did not affect the quality of feedback. Further research should examine the bidirectional relationship between individualized learning plans and feedback in light of other contextual and interpersonal factors.

Establishing a Pediatric and Adolescent Gynecology Subinternship for Medical Students

Within the pediatric and adolescent gynecology (PAG) community, an important issue deserving of our attention is expansion of formalized PAG training opportunities for medical students. In addition to those in obstetrics and gynecology, many physicians practicing family medicine, internal medicine, and surgery provide care to young female patients. However, residency programs provide inconsistent training in addressing specific PAG health care needs and communication skills required for delivery of care to pediatric and adolescent patients; opportunities for supervised clinical experience in these areas at the medical school level therefore have great importance because they might not be offered again during some residencies. At the undergraduate medical education level, training opportunities in PAG are currently limited, with only 3 PAG subinternships in North American medical schools. In contrast, other available subinternships include 113 in maternal fetal medicine and 82 in gynecologic oncology. To address this gap in opportunities for medical students, we developed a PAG subinternship and elective for medical students, which we describe in this report. Our 4-week PAG subinternship and 2-week elective expose students to a variety of ambulatory and surgical opportunities, with formal, informal, and self-guided learning activities. In this article, we explain the process of developing the curriculum, gaining alignment from key stakeholders, obtaining formal approval for the course, and advertising the opportunity to medical students. We also provide resources and guidance for medical educators who wish to establish a PAG subinternship or elective course at their institutions.

Completion of an Individualized Learning Plan for Otology-Related Milestone Subcompetencies Leads to Improved Otology Section Otolaryngology Training Exam Scores

OBJECTIVE

To examine the relationships among self-assessment of knowledge in otology via an individualized learning plan (ILP), otology milestone achievement rate, and otolaryngology training exam (OTE) otology scores.

STUDY DESIGN

Prospective study.

SETTING

One otolaryngology residency covering a tertiary care facility, trauma and hospital center, outpatient ambulatory surgery center, and outpatient clinics.

PARTICIPANTS

Twenty otolaryngology residents, four from each class.

METHODS

Residents identified four milestones from otology-related sub-competencies to achieve in a 3-month rotation via an ILP. During the same rotation, the residents sat for the OTE, and their overall and otology scores were analyzed.

MAIN OUTCOME MEASURES

Completion of an ILP before and at the end of the rotation, self-reported achievement of otology milestones, and OTE score components including total percent correct, scaled score, group stanine, national stanine, and residency group weighted scores.

RESULTS

Group stanine OTE otology scores were higher for those residents who completed pre- and post-rotation ILPs compared with those who did not, 4.0 (±0.348) versus 2.75 (±0.453), respectively (p = 0.04). Residents who self-reported achieving all four otology milestones had significantly higher otology group stanine scores than the residents who achieved less, 4.1 (±0.348) versus 2.9 ± 0.433, respectively (p = 0.045). Residents who performed well in their PGY program cohort on the otology OTE 1 year were less inclined to complete an ILP for otology in the subsequent year (Pearson correlation -0.528, p = 0.035).

CONCLUSION

In the otology subspecialty, residents who completed ILPs scored better on OTE examinations independent of resident class. Consequently, programs may find ILPs useful in other otolaryngology subspecialties and across residencies.

Individualized Learning Plan (ILP) Is an Effective Tool in Assessing Achievement of Otology-related Subcompetency Milestones

OBJECTIVE

To investigate the individualized learning plan (ILP) as a tool in assessment of residents' milestone achievements as they pertain to Otology subcompetencies: Chronic Ear Disease, Pediatric Otitis Media, and Hearing Loss.

STUDY DESIGN

Prospective study.

METHODS

Twenty otolaryngology residents were instructed to use an ILP and identify six milestones from three otology-related subcompetencies to focus on during the course of a 3-month rotation. They were also asked to plan out specific activities which would help them achieve these milestones, to specify whether or not they successfully achieved them, by what instructional or learning methods and to identify any barriers. The completed ILPs were reviewed by a faculty member.

MAIN OUTCOME MEASURES

The effectiveness of the ILP was assessed by response compliance rate, corroboration of self-reported milestone achievement with faculty evaluations and the ability to set attainable milestones.

RESULTS

There was 95% compliance in using an ILP to achieve milestones. Self-reported milestone scores corresponded to the faculty evaluations in a large majority (89.6%) of patients, and tended to be underestimated by the residents. Out of 114 total milestones identified, 44 (38.6%) were not achieved, with particular overestimation in the use of independent study as a learning method.

CONCLUSION

The ILP is an effective tool in measuring residents' achievement of otology-related milestones, and could possibly be used to supplement or replace faculty assessment. The ILP provides valuable information on barriers to achieving milestones and informs trainees on how to set attainable goals as they pertain to patient care and medical knowledge in otology.