1. TEACHING METHODS: PRINCIPLES & PRACTICES Yvonne Steinert, Ph.D. Linda Snell, MD, MHPE, FRCPC, FACP McGill University How to reference this document: Steinert. Y., Snell. L., Teaching Methods: Principles & Practice. Train-the-Trainer Program on Professionalism. 2009.

2. OBJECTIVES By the end of this session, participants will be able to: Outline general principles for teaching and learning professionalism Describe the key concepts of situated learning theory Identify principles of adult learning & instructional design Identify teaching methods/tools available in their settings Match teaching methods to objectives in their own settings

3. SESSION OUTLINE A Review of General Principles An Overview of Situated Learning Theory An Update on Principles of Adult Learning Key Concepts of Instructional Design An Overview of Teaching & Learning Methods Completion of an Action Plan Conclusion

4. THE CHALLENGE … How to impart knowledge of professionalism to students and residents How to encourage the behaviors characteristic of the “good” physician...

6. WHAT IS NEEDED ? 1.Cognitive base > teach it explicitly 2.Experiential learning > provide opportunities on a regular basis 3.Role modeling > requires knowledge and self-awareness 4.Self-reflection > provide opportunities through the curriculum 5.Environment > must be supportive of professional values

7. THE “BOTTOM LINE” Promote an integrated approach Define core content & provide conceptual frameworks Use multiple teaching & learning strategies Enable experiential learning & reflection Link evaluation to teaching...

8. Methods of instruction may vary with curricular design and place in the curriculum... BUT …The principles of professionalism should not vary

9. FOR DISCUSSION How do you currently teach professionalism? What theoretical frameworks guide your thinking?

10. WHAT IS THEORY? Theories represent various aspects of reality in an understandable way. Theory simplifies reality by ignoring a large number of variables (like a map) and often stress the importance of certain variables by giving them special names or stressing their importance in words, figures or formulas. Adger, 2002

11. WHY THEORY? The particular theory we subscribe to is likely to dictate how we work. An awareness of theoretical frameworks will allow us to make informed choices about how we approach teaching and learning Without theoretical frameworks to guide our practice, there is a danger that there will be too much reliance on intuition or common sense.

12. There is nothing so practical as a good theory. - Lewin, 1951

13. SITUATED LEARNING THEORY Situated learning is based on the notion that knowledge is contextually situated and fundamentally influenced by the activity, context, and culture in which it is used. Brown et al, 1989

14. WHY SITUATED LEARNING? It is particularly appropriate to educating professions that are communities or cultures “joined by intricate, socially constructed webs of belief”... It brings together the cognitive base and experiential learning needed to facilitate the acquisition of professionalism

15. SITUATED LEARNING Cognitive Apprenticeship –Modelling –Scaffolding –Coaching –Fading Collaborative Learning Reflection Practice Articulation

16. MODELLING The resident observes, then mimics, the teacher in the performance of a task. Is most effective when teachers make the target processes visible, often by explicitly showing the resident what to do. Enables residents to observe normally invisible processes and to begin to integrate what occurs with why it happens.

17. SCAFFOLDING Refers to the support teachers give residents in carrying out a task. Can range from almost doing the entire task to giving occasional hints as to what to do next. Supports and simplifies a task as much as necessary to enable residents to learn Facilitates the transfer of what residents already know to the task at hand.

18. FADING Fading is the notion of slowly removing support... giving the learner more and more responsibility. Fading is a critical step in the trajectory of becoming an independent practitioner.

19. COACHING Runs through the entire apprenticeship experience Involves helping residents while they try to learn or perform a task Includes directing learner attention, providing hints and feedback, structuring tasks, and providing additional challenges or problems Helps residents to maximize use of their cognitive resources and knowledge...

20. COLLABORATIVE LEARNING Includes: –Collective problem-solving; –Displaying and identifying multiple roles; –Confronting ineffective strategies and misconceptions; –Developing collaborative work skills.

21. REFLECTION Reflection IN Action: while performing an act/role, analyze what is being done Reflection ON Action: after performing the act/role, reflecting on the impact of the action on the patient and oneself Reflection FOR Action: reflecting on what has been learned for the future -Schön,1983; Lachman & Pawlina, 2006

22. PRACTICE Serves to test, refine, and extend skills into a web of increasing expertise – in a social context of collaboration and reflection. Enables skills to become deeply rooted and “automatically” mobilized as needed.

23. ARTICULATION Includes two aspects: –The concept of articulating or separating out different component skills in order to learn them more effectively –Getting students to articulate their knowledge, reasoning, or problem-solving processes in a specific domain Also helps to make learning – and reflection – visible

24. IN SUMMARY... Situated learning is based upon the idea that knowledge is contextually situated and fundamentally influenced by the activity, context and culture in which it is used. In this model, teachers must assume the role of coach in addition to that of pedagogue – and they must act as models for performing tasks. At the same time, students become experts and engage in reciprocal teaching, and the role of apprentice and master are shared.

25. INSTRUCTIONAL DESIGN Evaluation Content Teaching Methods and Aids Goals and Objectives Topic Target Audience Participant Needs

26. PRINCIPLES OF ADULT LEARNING Adults are independent. Adults come to learning situations with a variety of motivations and definite expectations about particular learning goals and teaching methods. Adults demonstrate different learning styles. Much of adult learning is “relearning” rather than new learning.

27. ADULT LEARNING (CONT’D) Adult learning often involves changes in attitudes as well as skills. Most adults prefer to learn through experience. Incentives for adult learning usually come from within the individual. Feedback is usually more important than tests and evaluations.

28. IN SUMMARY… Create a climate of respect and “safety” Encourage active participation – in design and implementation Build on experience Encourage collaborative inquiry Empower participants – to carry out their learning plans....

29. LET’S TRY THIS OUT...

30. TEACHING AND LEARNING METHODS

31. 1.Context 2.Different methods for different levels? 3.Strategies / methods 4.Do all roles have to be taught all the time? 5.What if resources are limited? TEACHING AND LEARNING METHODS

32. 1.Context 2.Different methods for different levels? 3.Strategies / methods 4.Do all roles have to be taught all the time? 5.What if resources are limited? TEACHING AND LEARNING METHODS

33. CONTEXT Standard of accreditation: –Curricular content broadly outlined –Expectation that assessment will occur Little guidance re implementation: –Need to translate general into specific –Teaching methods that will be effective For specialty For level of resident

34. LEARNING ABOUT PROFESSIONALISM OCCURS… Teaching Rounds Academic Half Days Core Seminars Journal Clubs Conferences Informal discussions Self-directed contexts … Bedside Wards ER Clinics OR Lab …

35. TEACHING AND LEARNING METHODS 1.Context 2.Different methods for different levels? 3.Strategies / methods 4.Do all roles have to be taught all the time? 5.What if resources are limited?

36. ADAPT TO LEARNER LEVEL

37. Level of learner Imparting core knowledge Promoting self-reflection, application  level of sophistication Medical studentResidency PreclinicalClinical  capacity to personalize Increasing complexity Increasing reflection

38. TEACHING AND LEARNING METHODS 1.Context 2.Different methods for different levels? 3.Strategies / methods 4.Do all roles have to be taught all the time? 5.What if resources are limited?

39. knows knows how shows does ‘Miller triangle’

40. Knowledge acquisition Understanding Patterning Participation Application to practice Self-evaluation … LEARNING PROFESSIONALISM - GOALS

41. knows knows how shows does Harder to teach Harder to evaluate

42. Strategies for Teaching Professionalism Report of the CanMEDS Working Groups – 2005 2005

43. Strategies for Teaching Professionalism Lectures Web Reading Group discussion Workbooks Simulations Video review Role play Mentoring Team learning Recognition, ceremonies Faculty Development Role- modeling Encounter cards Bedside learning Experiential learning Guided reflection & feedback Case discussion Vignettes Portfolios Narratives Patient stories Logbooks Critical incidents Personal learning projects

44. Teaching & Learning Methods Lectures, Interactive Lectures Directed reading, Web-based learning Small group discussions Case discussions / Clinical vignettes Critical Incidents Simulation / Role Play / Video review Experiential Learning Encounter Cards Role Modeling Guided Reflection Portfolios Narratives Knowledge Acquisition Understanding Patterning Participation Application to practice Self- evaluation

45. INTERACTIVE LECTURES LECTURES, INTERACTIVE LECTURES Excellent for transmitting facts, core knowledge Increasing interaction likely improves understanding and promotes ‘deeper’ learning Efficient use of resources

46. READING, WEB-BASED Excellent for transmitting facts, core knowledge Using workbooks with question guides, or interacting on-line may improve understanding Efficient use of resources

47. GROUP DISCUSSIONS

48. VIGNETTES, CASE DISCUSSION Promote understanding and application to practice Stimulate reflection, with guided questions Cases or vignettes can be ‘paper’, video, Web - based

49. CASE VIGNETTE EXAMPLE CASE - A long-time patient of yours requests a note from you documenting a non-existent illness in order to recover cancellation penalties from the airlines on a nonrefundable ticket.

50. Case #1 Case #2 Case #3 Case #4 Case #5 Caring and CompassionA sympathetic consciousness of another's distress together with a desire to alleviate it. InsightSelf-awareness; the ability to recognize and understand one's actions, motivations and emotions. OpennessWillingness to hear, accept, and deal with the views of others without reserve or pretense. Respect for the Healing Function The ability to recognize, elicit and foster the power to heal inherent in each patient. Respect Patient Dignity & Autonomy The commitment to respect and ensure subjective well being and sense of worth in others and recognizes the patient's personal freedom of choice and right to participate fully in his/her care. PresenceTo be fully present for a patient without distraction and to fully support and accompany the patient throughout care. CompetenceTo master and keep current the knowledge and skills relevant to medical practice. CommitmentBeing obligated or emotionally impelled to act in the best interest of the patient; a pledge given by way of the Hippocratic oath or its modern equivalent. ConfidentialityTo not divulge patient information without just cause. AutonomyThe physician’s freedom to make independent decisions in the best interest of the patient and for the good of society. AltruismThe unselfish regard for, or devotion to, the welfare of others; placing the needs of the patient before one's self interest. Integrity and HonestyAn adherence to a code of moral values; incorruptibility. Morality and Ethical Conduct To act for the public good; conformity to the ideals of right human conduct in dealings with patients, colleagues, and society. TrustworthinessWorthy of trust, reliable. Responsibility to the Profession The commitment to maintain the integrity of the moral and collegial nature of the profession and to be accountable for one's conduct to the profession. Self-RegulationThe privilege of setting the standards; being accountable for one's actions and conduct in medical practice and for the conduct of ones colleagues. Responsibility to SocietyThe obligation to use one's expertise for, and to be accountable to, society for those actions, both personal and of the profession, which relate to the public good. TeamworkThe ability to recognize the expertise of others and to work with them in the patient's best interest.

51. CRITICAL INCIDENTS A discussion, analysis and reflection on a ‘real life’ vignette, of excellent or poor professional behaviors. Good to start reflection and self-evaluation

52. SIMULATION, ROLE PLAY, VIDEO REVIEW ‘Rehearsal in a safe environment’ Patterning Stimulates reflection, with guided questions

53. SIMULATION, ROLE PLAY: EXAMPLE Standardized patient communication sessions around ethical issues Followed by feedback from SP, tutor-observer and peer-observers Questions to guide reflection and improve skills

54. ENCOUNTER CARDS Stimulate self-evaluation Stimulate reflection Make the implicit explicit Provide a framework

55. ENCOUNTER CARDS - EXAMPLE P-MEX Mini-CEX ER shift evaluation and feedback cards | | Professionalism | Mini-Evaluation | Exercise | | P-MEX | | Evaluation Forms | Faculty of Medicine McGill University

56. PROFESSIONALISM MINI-EVALUATION EXERCISE Evaluator:_______________________________________ Student/Resident:________________________________ Level: (please check) 3rd yr 4th yr res 1 res 2 res 3 res 4 res 5 Setting Ward Clinic OR ER Classroom Other ► Please rate this student’s/ resident’s overall professional performance during THIS encounter: UNacceptable BELow expectations MET expectations EXCeeded expectations ► Did you observe a critical event? no yes (comment required) Listened actively to patient Showed interest in patient as a person Recognized and met patient needs Extended him/herself to meet patient needs Ensured continuity of patient care Advocated on behalf of a patient Demonstrated awareness of own limitations Admitted errors/omissions Solicited feedback Accepted feedback Maintained appropriate boundaries Maintained composure in a difficult situation Maintained appropriate appearance Was on time Completed tasks in a reliable fashion Addressed own gaps in knowledge / skills Was available to colleagues Demonstrated respect for colleagues Avoided derogatory language Maintained patient confidentiality Used health resources appropriately

57. Mini-CEX

58. EXPERIENTIAL LEARNING Includes Learning from role models Reflection and self evaluation ‘Learning by doing’

59. EXPERIMENTIAL LEARNING – ROLE MODELING Major influence in the creation of a physician Affects career choice Part of the formal & informal curriculum Patterning Participation

60. ...Individuals admired for their ways of being and acting as professionals. Côté & Leclère: Acad Med, 2000 Role models “must first attempt to reflect core attributes of physicians.” Skeff: NEJM,1998 ROLE MODELS: WHO ARE THEY?

61. Positive Negative Clinical Competence knowledge, skill, reasoning communication Teaching Skills explicit about what is modeled, makes time for teaching respects students’ needs, feedback, encourages reflection Personal Qualities compassionate, caring, honesty and integrity, enthusiastic, interpersonal skills, commitment to excellence, collegial CHARACTERISTICS OF ROLE MODELS Cruess, Cruess, Steinert BMJ 2008

62. STRATEGIES TO IMPROVE ROLE MODELING Demonstrate clinical competence Protect time for teaching Demonstrate a positive attitude Implement a student-centered approach Facilitate reflection Encourage dialogue Be aware of the importance of role modeling Be explicit about what is being modeled (when possible) Participate in faculty development Work to improve the institutional culture Cruess, Cruess, Steinert BMJ 2008

63. EXPERIENTIAL LEARNING – GUIDED REFLECTION Reflection: purposeful thought provoked by learner’s unease when they recognize that their understanding is incomplete Dewey, 1933 Participation Application to practice: –hands-on, supervised patient care –mentoring

64. ACTIVE OBSERVATION OF ROLE MODEL UNCONSCIOUS INCORPORATION OF OBSERVED BEHAVIORS REFLECTION & ABSTRACTION GENERALIZATION & BEHAVIOR CHANGE ACTIVE EXPLORATION OF AFFECT AND VALUES Making the Unconscious Conscious Translating Insights into Principles and Action After Epstein et al, 1998 Linking Reflection & Role Modeling

65. PORTFOLIOS A collection of documents or other media where reflection, professional attitudes & behaviors are expressed Stimulate reflection Stimulate self-evaluation Need for review ?

66. PORTFOLIOS: EXAMPLES Might contain: –Personal notes, reflections, ‘diary’ –Letters to self or others –Case report examples –Evaluations –Letters from patients, supervisors –Logs –Professional roles in organizations –Professionalism education sessions attended, –Professionalism awards –

67. NARRATIVES Narrative competence – the ability to absorb, interpret and act on the stories and plights of others R Charron Stimulate reflection, with guided questions Stimulate self-evaluation

68. Use stories about patients & about own professional development as a means of learning … “When I was a resident ….” “I experienced this today in clinic …” “Let me tell you about a student I had …” “I cared for a patient who had experienced…” NARRATIVES: EXAMPLES

69. LET’S USE WHAT WE HAVE JUST LEARNED

70. TEACHING AND LEARNING METHODS 1.Context 2.Different methods for different levels? 3.Strategies / methods 4.Do all roles have to be taught all the time? 5.What if resources are limited?

71. DO ALL ROLES HAVE TO BE TAUGH ALL THE TIME?

72. THE ‘SLIDING SCALE’ OF CANMEDS Not for every rotation Not for every objective Sometimes one size does not fit all, so identify –where the competency is best taught, and –where it is least appropriate to be taught Have a rationale for why you teach it

73. TEACHING AND LEARNING METHODS 1.Context 2.Different methods for different levels? 3.Strategies / methods 4.Do all roles have to be taught all the time? 5.What if resources are limited?

74. WHEN RESOURCES ARE LIMITED… Adopt Adapt Create Share Don’t forget the learning environment

75. CONSIDER ALL TEACHERS … Faculty Residents Other health professionals Patients

76. THE LEARNING ENVIRONMENT Be aware of & address professionalism barriers Time Context Competing activities … Support, recognize & reward good professionalism: Ceremonies Awards

77. KEY MESSAGES Remember the goal of the teaching Identify opportunities for teaching within your own context/setting Match teaching method/tool to context & objective No single method can do it all It is unnecessary to teach all roles all the time Include other health professionals Tie teaching to assessment Positively affect the learning environment

78. The greatest difficulty in life is to make knowledge effective, to convert it into practical wisdom. Sir William Osler Sir William Osler

79. ACTION PLAN Take a few minutes to reflect on this half-day, and complete the relevant section of the action plan