Exploring and embracing complexity in a distance-learning curriculum for physicians

Using a Logic Model to Design and Evaluate a Quality Improvement Leadership Course

Strong leadership is an essential factor in the success of quality improvement (QI) initiatives that generate and sustain improvements in patient outcomes. Notably, there is a rising need for frontline clinicians, who are often charged with leading QI efforts, to receive training in blended QI and leadership methods and skills. The Leading Healthcare Improvement (LHI) course is a longitudinal leadership course embedded within the Department of Veterans Affairs Quality Scholars (VAQS) program, a multisite interprofessional QI fellowship program. The LHI course was developed to provide frontline clinicians who are emerging QI leaders with the skills to lead and advance improvement efforts at their institutions. It consists of eight 60-minute online sessions and was implemented and delivered to a cohort of interprofessional fellows at 9 sites during the 2017-2018 academic year.This article describes the use of a logic model as a framework to guide the planning, implementation, and evaluation of the LHI course. The authors developed 5 logic model components: inputs, activities, outputs, short-term outcomes, and long-term outcomes. They defined the short-term outcomes using feedback from fellows and an evaluation of the fellows' abstract submissions to the VAQS Summer Institute. Submissions were reviewed to identify how fellows applied the LHI course concepts to QI projects at their respective sites. The authors also collected preliminary impact data from fellows to determine long-term outcomes.Finally, they used the logic model to inform changes to the LHI course based on the evaluation data they collected and developed plans to measure the impact of the course on learners, patients, and the health care system. The authors conclude with lessons learned to guide others who are implementing similar QI efforts.

A comparison of sonography and radiography student scores in a cadaver anatomy class before and after the implementation of synchronous distance education

Distance education is a solution to expand medical imaging education to students who might not otherwise be able to obtain the education. It can be a mechanism to reduce the health care worker shortage in underserved areas. In some cases, distance education may be a disruptive technology, and might lower student performance. This study compares student scores in a cadaver anatomy course in the four cohorts preceding the implementation of distance education to the first three cohorts that took the course using a multiple campus design. The means and medians of the lecture exam average, the laboratory component score, and the final course score of the nondistance education cohorts were compared with those of the distance education cohorts using nonparametric statistical analysis. Scores in an anatomy course were compared by campus placement among the distance education cohorts, and the independent effect of distance education on the laboratory component, lecture examination average, and final course scores, while controlling for cumulative grade point average and site (originating/distant), was assessed. Students receiving the course in a nondistance education environment scored higher in the anatomy course than the students who took the course in a distance education environment. Students on the distant campus scored lower than students on the originating site. Distance education technology creates new opportunities for learning, but can be a disruptive technology. Programs seeking to implement distance education into their curriculum should do so with knowledge of the advantages and disadvantages.

Self-organisation, integration and curriculum in the complex world of medical education

CONTEXT

The world of medical education is more complex than ever and there seems to be no end in sight. Complexity science is particularly relevant as medical education embraces a movement towards more authentic curricula focusing on integration, interactive small-group learning, and early and sustained clinical and community experiences.

DISCUSSION

A medical school as a whole, and the expression of its curriculum through the interactions, exchanges and learning that take place within and outside of it, is a complex system. Complexity science, a derivative of the natural sciences, is the study of the dynamics, conditions and consequences of interactions. It addresses the nature of the conditions favourable to change and transformation (learning).

CONCLUSIONS

The core process of complexity, self-organisation, requires a system that is open and far from equilibrium, with ill-defined boundaries and a large number of non-linear interactions involving short-loop feedback. In such a system, knowledge does not exist objectively 'out there'; rather, it exists as a result of the exchange between participants, an action that becomes knowing. Understanding is placed between participants rather than being contained in one or the other. Knowledge is not constructed separately in the mind of the knower, but, rather, it emerges; it is co-created during the exchange in an authentic recursive transactive process. Learning and knowing become adaptive responses to continuously evolving circumstances. An approach to curriculum based on self-organisation is characterised as rich, recursive, relational and rigorous and it illuminates how a curriculum can be understood as a complex adaptive system. The perspective of complexity applied to medical education broadens and enriches research questions relevant to health professions education. It focuses our attention onto how we are together as human beings. How we respond to and frame the issues of learning and understanding that challenge contemporary medicine and, by extension, medical education, in a complex and rapidly changing world can have profound effects on the preparedness of tomorrow's health professionals and their impact on society.

The Department of Veterans Affairs National Quality Scholars Fellowship Program: experience from 10 years of training quality scholars

The Department of Veterans Affairs (VA) National Quality Scholars Fellowship Program (VAQS) was established in 1998 as a postgraduate medical education fellowship to train physicians in new methods of improving the quality and safety of health care for veterans and the nation. The VAQS curriculum is based on adult learning theory, with a national core curriculum of face-to-face components, technologically mediated distance learning components, and a unique local curriculum that draws from the strengths of regional resources. VAQS has established strong ties with other VA programs. Fellows' research and quality improvement projects are integrated with local and regional VA leaders' priorities, enhancing the relevance and visibility of the fellows' efforts and promoting recruitment of fellows to VA positions. VAQS has enrolled 98 fellows since 1999; 75 have completed the program and 24 are currently enrolled. Fellowship graduates have pursued a variety of career paths: 17% are continuing training (most in VA), 31% hold a VA faculty/staff position, 66% are academic faculty, and 80% conduct clinical or research work related to health care improvement. Graduates have held leadership positions in VA, Department of Defense, academic medicine, and public health agencies. Combining knowledge about the improvement of health care with adult learning strategies, distance learning technologies, face-to-face meetings, local mentorship, and experiential projects has been successful in improving care in VA and preparing physicians to participate in, study, and lead the improvement of health care quality and safety.

Integrating practice-based learning and improvement into medical student learning: evaluating complex curricular innovations

BACKGROUND

Because practice-based learning and improvement (PBLI) is a core competency for residents, the fundamentals of PBLI should be developed in medical school.

PURPOSE

Evaluate the effects of a PBLI module for 1st-year students at Dartmouth Medical School in 2004-05.

METHODS

Design. Randomized two-group trial (early and late intervention). Intervention. One half of students received the standard curriculum--reviewing student-patient-preceptor reports with their small-group facilitator and student colleagues. The other half received the PBLI-DMEDS module--reviewing student-patient-preceptor reports and applying PBLI methods to history and physical exam skills.

ANALYSIS

The module was assessed on (a) core learning of PBLI (pre- and postmodule); (b) student self-assessed proficiency in PBLI (pre- and postmodule); (c) student, faculty, and course leaders' satisfaction; and (d) time costs.

RESULTS

Pretest PBLI knowledge scores were similar in both groups; intervention students scored significantly higher after the PBLI-DMEDS module. satisfaction of students, faculty, and course leaders was mixed. the time cost required to implement the module was excessive.

CONCLUSIONS

The intervention effectively taught the basics of PBLI but did not integrate well into the core curriculum. Our multifaceted evaluation approach allowed us to amplify aspects of the intervention that worked well and discard those that did not.

Building a transcontinental affiliation: a new model for academic health centers

The recent affiliation of The Methodist Hospital (TMH) with Weill Medical College (WMC) of Cornell University and NewYork-Presbyterian Hospital is the first transcontinental primary affiliation between major, not-for-profit academic health centers (AHCs) in the United States. The authors describe the process followed, the issues involved, the initial accomplishments, and the opportunities envisioned. The key enablers of this affiliation were a rapid process, mutual trust based on existing professional relationships, and commitment to the project by Board leadership. Because of their geographic separation, the parties were not competitors in providing clinical care to their regional populations. The affiliation is nonexclusive, but is reciprocally primary in New York and Texas. Members of the TMH medical staff are eligible for faculty appointments at WMC. The principal areas of collaboration will be education, research, quality improvement, information technology, and international program development. The principal challenge has been the physical distance between the parties. Although extensive use of videoconferencing has been successful, personal contact is essential in establishing relationships. External processes impose a slower sequence and tempo of events than some might wish. This new model for AHCs creates exciting possibilities for the tripartite mission of research, education, and patient care. Realizing the potential of these opportunities will require unconstrained ideas and substantial investment of time and other critical resources. Since many consider that AHCs are in economic and cultural crisis, successful development of such possibilities could have importance beyond the collective interests of these three institutions.

Nurturing educational research at Dartmouth Medical School: the synergy among innovative ideas, support faculty, and administrative structures

In recent years, Dartmouth Medical School has increased its commitment to educational research within the school, and in collaboration with other schools across the country. Passionate faculty members with ideas and expertise in particular curricular areas are one critical component needed for a successful educational research program. Other components include an atmosphere that fosters research collaborations and mentoring, and various types of institutional support structures. This same model has effectively supported basic science and clinical research for decades. Because of the complexities involved in studying medical education, Dartmouth Medical School has invested in support structures for educational grant and manuscript development, financial support for pilot projects and partial salary support for investigators and key staff members, and other support targeted toward specific research projects. Ultimately, the goal is to use the results of the school's educational research projects to improve the curriculum through cycles of hypothesis development and testing, providing evidence for subsequent curricular change. When some research findings are relevant and applicable for use in other medical schools, that is an additional benefit of the educational research process. In this report, the authors describe the development of Dartmouth Medical School's infrastructure for supporting educational research, which has helped to accelerate the educational research productivity teaching faculty now enjoy. The authors also address some of the challenges that they anticipate in the near future.