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Price N, Jowsey T, Weller J. Reflecting on insight and insights into reflection: a systematic review of insight and reflection in post graduate medical education. ANZ J Surg 2023; 93:2589-2599. [PMID: 37749849 DOI: 10.1111/ans.18693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/29/2023] [Accepted: 09/02/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Clinicians recognize insight as important for safe independent medical practice. Clinical education literature focuses on self-reflection. The aim of this review is to describe how clinical educators conceptualize reflection and ask is it analogous to how clinicians conceptualize insight? METHODS Using PRISMA guidelines, a systematic review of the literature around insight and reflection in postgraduate medical education was undertaken. A thematic analysis of the concepts of insight and reflection was performed. RESULTS A total of 75 reports were included in the analysis. The literature focussed predominantly on reflection with little discussion of insight. Three main themes were generated: episodic reflection; cyclic reflection; reflection as a state. Reflection as a state seemed to be the professional quality most often aspired to but was less well defined in terms of educational interventions. When more than one model was described, it was often with a reflective state being the ideal that episodic or cyclic reflection may approximate. It is not clear that it is possible to progress up the hierarchy. CONCLUSION We present a novel description of a hierarchy from discrete episodes of reflection, to cyclic processes that involve reflection, through to a state in which the practitioner is reflective. There is no unified understanding of how an individual ascends this hierarchy, or a cohesive description of what insight is for an independent medical practitioner. This review highlights the need for research into how practicing clinicians conceptualize and characterize insight in their training and practice.
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Affiliation(s)
- Neil Price
- Centre for Medical and Health Sciences Education, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Tanisha Jowsey
- Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Jennifer Weller
- Centre for Medical and Health Sciences Education, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Stephenson CR, Yudkowsky R, Wittich CM, Cook DA. Learner engagement and teaching effectiveness in livestreamed versus in-person CME. MEDICAL EDUCATION 2023; 57:349-358. [PMID: 36454138 DOI: 10.1111/medu.14996] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Engaging learners in continuing medical education (CME) is challenging. Recently, CME courses have transitioned to livestreamed CME, with learners viewing live, in-person courses online. The authors aimed to (1) compare learner engagement and teaching effectiveness in livestreamed with in-person CME and (2) determine how livestream engagement and teaching effectiveness is associated with (A) interactivity metrics, (B) presentation characteristics and (C) medical knowledge. METHODS A 3-year, non-randomised study of in-person and livestream CME was performed. The course was in-person for 2018 but transitioned to livestream for 2020 and 2021. Learners completed the Learner Engagement Inventory and Teaching Effectiveness Instrument after each presentation. Both instruments were supported by content, internal structure and relations to other variables' validity evidence. Interactivity metrics included learner use of audience response, questions asked by learners and presentation views. Presentation characteristics included presentations using audience response, using pre/post-test format, time of day and words per slide. Medical knowledge was assessed by audience response. A repeated measures analysis of variance (anova) was used for comparisons and a mixed model approach for correlations. RESULTS A total of 159 learners (response rate 27%) completed questionnaires. Engagement did not significantly differ between in-person or livestream CME. (4.56 versus 4.53, p = 0.64, maximum 5 = highly engaged). However, teacher effectiveness scores were higher for in-person compared with livestream (4.77 versus 4.71 p = 0.01, maximum 5 = highly effective). For livestreamed courses, learner engagement was associated with presentation characteristics, including presentation using of audience response (yes = 4.57, no = 4.45, p < .0001), use of a pre/post-test (yes = 4.62, no = 4.54, p < .0001) and time of presentation (morning = 4.58, afternoon = 4.53, p = .0002). Significant associations were not seen for interactivity metrics or medical knowledge. DISCUSSION Livestreaming may be as engaging as in-person CME. Although teaching effectiveness in livestreaming was lower, this difference was small. CME course planners should consider offering livestream CME while exploring strategies to enhance teaching effectiveness in livestreamed settings.
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Affiliation(s)
- Christopher R Stephenson
- Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Rachel Yudkowsky
- Department of Medical Education, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Christopher M Wittich
- Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - David A Cook
- Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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Pereira J, Meadows L, Kljujic D, Strudsholm T. Do learners implement what they learn? Commitment-to-change following an interprofessional palliative care course. Palliat Med 2022; 36:866-877. [PMID: 35260018 PMCID: PMC9087309 DOI: 10.1177/02692163221081329] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care educators should incorporate strategies that enhance application into practice by learners. Commitment-to-change is an approach to reinforce learning and encourage application into practice; immediately post-course learners commit to making changes in their practices as a result of participating in the course ("statements") and then several weeks or months later are prompted to reflect on their commitments ("reflections"). AIM Explore if and how learners implemented into practice what they learned in a palliative care course, using commitment-to-change reflections. DESIGN Secondary analysis of post-course commitment statements and 4-months post-course commitment reflections submitted online by learners who participated in Pallium Canada's interprofessional, 2-day, Learning Essential Approaches to Palliative Care (LEAP) Core courses. SETTING/PARTICIPANTS Primary care providers from across Canada and different profession who attended LEAP Core courses from 1 April 2015 to 31 March 2017. RESULTS About 1063 of 4636 learners (22.9%) who participated in the 244 courses delivered during the study period submitted a total of 4250 reflections 4 months post-course. Of these commitments, 3081 (72.5%) were implemented. The most common implemented commitments related to initiating palliative care early across diseases, pain and symptom management, use of clinical instruments, advance care planning, and interprofessional collaboration. Impact extended to patients, services, and colleagues. Barriers to implementation into practice included lack of time, and system-level factors such as lack of support by managers and untrained colleagues. CONCLUSIONS Examples of benefits to patients, families, services, colleagues, and themselves were described as a result of participating in the courses.
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Affiliation(s)
- José Pereira
- Pallium Canada, Ottawa, Canada (Non-profit Foundation).,Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Canada.,Institute for Culture and Society (ICS), University of Navara, Spain
| | - Lynn Meadows
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Tina Strudsholm
- School of Health Sciences, University of Northern British Columbia, Prince George, BC, Canada
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Ametrano RM, McGillicuddy ML, Sanyal S, Topor DR. Training Interprofessional Staff in Whole Health Clinical Care at the Veterans Health Administration. Glob Adv Health Med 2022; 11:2164957X221092361. [PMID: 35433116 PMCID: PMC9008845 DOI: 10.1177/2164957x221092361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/15/2022] [Accepted: 03/21/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction The Veterans Health Administration (VHA) initiated a system-wide redesign in
2011 toward a patient-centered approach called the Whole Health System (WHS)
of care. Education of VHA clinical staff in WHS-informed care, Whole Health
Clinical Care (WHCC), is one critical element of this redesign effort. At a
minimum, WHCC education should address core competencies for clinicians and
be considered satisfactory for learners. This is the first study to evaluate
learner satisfaction and perceived achievement of course objectives in WHCC
that incorporated active learning strategies. Method A large VA Healthcare System developed an in-person workshop focused on WHCC
that used multiple active learning activities. These activities included
case presentations, role playing, experiential learning, and group
discussion. Results Sixty-two interprofessional staff attended the workshop in November 2019.
Forty (64.50%) participants completed post-workshop surveys within 30 days.
Data suggest participants were highly satisfied with the workshop and that
they successfully met stated learning objectives. Conclusions We call on VHA and private-sector hospitals to train clinical staff in WHCC
that incorporates use of active learning strategies.
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Arnold Rehring SM, Steiner JF, Reifler LM, Glenn KA, Daley MF. Commitment to Change Statements and Actual Practice Change After a Continuing Medical Education Intervention. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2021; 41:145-152. [PMID: 33758129 DOI: 10.1097/ceh.0000000000000340] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Continuing medical education (CME) interventions often evaluate participant commitment to change (CTC) clinical practice. Evidence linking CTC to actual practice change is limited. METHODS In an intervention that combined live CME with changes to the electronic health record to promote judicious antibiotic use for children with urinary tract infections (UTIs), we evaluated CTC and subsequent prescribing behavior in Kaiser Permanente Colorado, an integrated health care system. CTC was assessed immediately after the session using closed-ended questions about session learning objectives and open-ended questions to elicit specific practice changes. Perceived barriers to implementing recommended changes were also assessed. RESULTS Among 179 participants, 80 (45%) completed postsession evaluations and treated one or more child with a UTI in the subsequent 17 months (856 UTIs in total). In closed-ended responses about session learning objectives, 45 clinicians (56%) committed to changing practice for antibiotic choice and duration, whereas 37 (46%) committed to implementing new practice guidelines. When asked open-ended questions to identify specific practice changes, 32 (40%) committed to antibiotic choice change and 29 (36%) committed to treatment duration change. Participants who made specific CTC statements had greater improvement in antibiotic choice (relative rate ratio 1.56, 95% CI 1.16-2.09) and duration (relative rate ratio 1.59, 95% CI 1.05-2.41) than participants who did not make specific commitments. Few perceived barriers affected subsequent prescribing. DISCUSSION Commitments to changing specific clinical behaviors were associated with sustained changes in prescribing for children with UTIs. Linking self-evaluations with clinical data in integrated health care systems is an important tool for CME evaluators.
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Affiliation(s)
- Sharisse M Arnold Rehring
- Dr. Arnold Rehring: Director, Department of Medical Education, Colorado Permanente Medical Group, Denver, CO, and Clinical professor, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO. Dr. Steiner: Senior Investigator, Department of Medical Education, Colorado Permanente Medical Group, Denver, CO, and Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, and Professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. Ms. Reifler: Biostatistician, Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO. Ms. Glenn: Data specialist, Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO. Dr. Daley: Associate Professor, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, and Senior Investigator, Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
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Ratelle JT, Wittich CM, Yu RC, Newman JS, Jenkins SM, Beckman TJ. Effect of Pause Procedures on Participant Reflection and Commitment-to-Change in Continuing Medical Education. TEACHING AND LEARNING IN MEDICINE 2020; 32:552-560. [PMID: 32749160 DOI: 10.1080/10401334.2020.1779070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Problem: Conferences are the most common form of continuing medical education (CME), but their effect on clinician practice is inconsistent. Reflection is a critical step in the process of practice change among clinicians and may lead to improved outcomes following conference-based CME. However, reflection requires time to process newly-learned material. Adequate time for reflection may be noticeably absent during many conference presentations. Intervention: The pause procedure is a 90-second 'pause' during a 30-minute presentation so learners can review and discuss content. The goal of the pause procedure is to stimulate learners' active engagement with newly learned material which will, in turn, promote learner reflection. Context: Fifty-six presentations at two hospital medicine CME conferences were assigned to the pause procedure or control. Study outcomes provided by conference participants were validated reflection scores and commitment-to-change (CTC) statements for each presentation. A post-hoc survey of the intervention group was conducted to assess presenters' experiences with the pause procedure. Impact: A total of 527 conference participants completed presentation evaluations (response rate 72.7%). Presentations incorporating the pause procedure failed to lead higher participant reflection scores (percentage 'top box' score; intervention: 39.2% vs. control: 41.7%, p = 0.40) or participant CTC rates (median [IQR]; intervention: 4.64 [3.04, 10.57] vs. control: 8.16 [5.28, 17.12], p = 0.13) than control presentations. However, the majority of presenters (16 out of 17 survey respondents) had never before used the intervention and little active engagement among learners was noted during the pause procedure. Lessons Learned: Adding the pause procedure to CME presentations did not lead to greater reflection or CTC among clinician learners. However, presenters had limited experience with the intervention, which may have reduced their fidelity to the educational principles of the pause procedure. Faculty development may be necessary when planning a new educational intervention that is to be implemented by conference presenters.
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Affiliation(s)
- John T Ratelle
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Roger C Yu
- Division of Hospital Medicine, Scripps Clinic, La Jolla, California, USA
| | - James S Newman
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah M Jenkins
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas J Beckman
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Ravyn D, Goodwin B, Lowney R. Continuous learning in multiple sclerosis care: a qualitative study of the expanded learning model for systems. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2019; 10:122-128. [PMID: 31256072 PMCID: PMC6766394 DOI: 10.5116/ijme.5cfa.29cb] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 06/07/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES This study characterized how an online continuing education activity affected knowledge, attitudes, and practices of healthcare professionals who care for patients with multiple sclerosis (MS) and whether those changes reflected theorized translational mechanisms proposed in The Expanded Learning Model for Systems (TELMS). METHODS This preliminary study used semi-structured interviews (thematic analysis) to assess whether and how translational mechanisms underpinning the TELMS theory might be revealed in learners' attitudes and practice behavior. Eighteen participants (primarily neurologists and nurses) were interviewed by telephone or online. Thematic analysis identified relevant themes according to sensitizing concepts derived from TELMS and the recognition of emergent themes. RESULTS Textual interpretation of interview data revealed that MS providers act in various scenarios that validate the principles of TELMS model of learning engagement. Further, elements of translational mechanisms proposed by TELMS were consistently observed in the narrative reflections. Emergent themes included the importance of practices such as goal setting, coordination of care, systems-level MS care, and economic considerations. Practitioners particularly drew on ideas from TELMS when facing challenges in diverse cultural and sociocultural settings. CONCLUSIONS We identified mechanisms of change reflected in the TELMS model that is useful for the design and evaluation of future educational activities. These include attitudes and beliefs about the application of evidence-aligned MS care, as well as the commitment to multidisciplinary strategies, enhanced coordination of care, and promotion of systems-based changes. Future studies are needed to further validate the TELMS model.
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Affiliation(s)
- Dana Ravyn
- CMEology, West Hartford, Connecticut, USA
| | | | - Rob Lowney
- CMEology, West Hartford, Connecticut, USA
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Tawanwongsri W, Phenwan T. Reflective and feedback performances on Thai medical students' patient history-taking skills. BMC MEDICAL EDUCATION 2019; 19:141. [PMID: 31088550 PMCID: PMC6518691 DOI: 10.1186/s12909-019-1585-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 04/30/2019] [Indexed: 05/15/2023]
Abstract
BACKGROUND Reflective practice (RP) plays a crucial role in encouraging learners to think critically and consciously about their performances. Providing constructive feedback can further enhance RP. But non-Western learners might face different learning barriers compared to learners in the West, where RP originated. METHODS In this retrospective study, we assessed RP and feedback performances on Thai medical students' patient history-taking skills. We applied RP and peer feedback, along with feedback from the instructors, during the history-taking sessions of the ten-week introduction course for fourth-year medical students. Twelve history-taking sessions were used for the analysis. Two instructors assessed students' reflective performance and categorised them into one of the six stages of Gibbs' reflective cycle; their feedback performances were analysed using Pendleton's model. We investigated the correlations between students' overall grade point average (GPAX) and patient history-taking scores on the Objective Structured Clinical Examination (OSCE). Students' opinions of the RP teaching method were also collected. RESULTS All (n = 48) students participated in our study. The students' mean age was 21.2 ± 0.5 years. The majority of the students were female (64.6%). The data indicated that 33 and 4% of the participants were categorised into the evaluation stage and action plan stage of Gibbs' reflective cycle, respectively. In addition, 22 and 15% of the participants were able to state what their peers did well and suggest how peers could improve their skills, respectively. All students passed the minimum passing level of four history-taking OSCE stations. Participants agreed that RP was a useful tool (mean 9.0, SD 0.1), which enhanced their thought processes (mean 8.4, SD 0.2) and future performances (mean 8.2, SD 0.2). However, there was no correlation between the students' highest Gibbs' reflection levels and their history-taking OSCE scores. CONCLUSIONS RP, together with feedback, proved to be a useful technique to help fourth-year Thai medical students improve their reflection skills, enhance their medical knowledge, and improve patient history-taking skills. Further study with longer monitoring is required to further explore negative and positive influential factors affecting students' achievement of better reflection performances.
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Affiliation(s)
- Weeratian Tawanwongsri
- School of Medicine, Walailak University, 222 Taiburi, Tha Sala, Nakhon Si Thammarat, 80161 Thailand
| | - Tharin Phenwan
- School of Medicine, Walailak University, 222 Taiburi, Tha Sala, Nakhon Si Thammarat, 80161 Thailand
- School of Nursing and Health Science, University of Dundee, Dundee, DD1 4HJ UK
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Nelson BA. Creating Effective and Efficient Pediatric-Specific CME Content: More than Just Checking a Box. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2019; 39:64-68. [PMID: 30632991 DOI: 10.1097/ceh.0000000000000237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
States dictate the type of continuing medical education (CME) required for licensing; however, CME providers are not mandated to create content relevant to all specialties. This often forces pediatricians to engage in educational activities that are irrelevant to their practice. This is contrary to what constitutes effective CME. The goal was to develop pediatric content using adult learning theory that aligns with effective CME principles while simultaneously satisfying state licensure requirements. A targeted needs assessment of pediatric providers revealed that pediatric-specific CME activities satisfying the state's requirement for pain management and end-of-life issues were lacking. Webinars adhering to adult learning principles were created in consultation with content experts. Five hundred ninety-seven learners across 30 states successfully completed the webinars and received CME credit. To satisfy ongoing state licensing requirements, 44% of learners had completed similar activities in the past, but 72% of those learners participated in activities focused on adult medicine due to the lack of available pediatric modules. Until states and regulators allow for more flexibility in satisfying licensing requirements, it will be incumbent on those who create CME to develop educational activities that satisfy state requirements while aligning with the principles of effective CME. With strategic planning, this is possible and will hopefully empower physicians to engage in CME without resorting to "checking a box."
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Affiliation(s)
- Benjamin A Nelson
- Dr. Nelson: Assistant Professor of Pediatrics, Program Director, Pediatric Pulmonary Fellowship MGHfC, and Associate Director CME, Department of Pediatrics MGHfC. Department of Pediatrics, MassGeneral Hospital for Children. Boston, MA
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