Portfolio

XXXXXXX

Section 1. Four Statements

1.1 Statement about how I see teaching, learning, assessment and medical education

In the years 1972-1980 I have had a Flexnerian medical education with 3 preclinical years in Brussels (Belgium) with mathematics, chemistry and biology (including plants) and 3 clinical years without any link to basic sciences in City (Country). I started as a conventional teacher (trainer of cardiology fellows) who considered knowledge and skills as the most important tools to teach. Two to three years ago, when I was preparing for a part-time job as teaching professor at the University of XXXX, I discovered the shortcomings in my knowledge of medical education.

My current opinions on effective teaching are:
1. occurring in the authentic context, basic science and clinical disciplines integrated. A lot is to be gained by this integration on the work place: combining anatomy and radiology; pharmacology and pharmacy; pathophysiology and clinical medicine. Not only for the patient but also for the healthcare workers.
2. Based on authentic clinical problems. Learning by doing and problem-based learning are concepts that illustrates that real life is the best podium for learning. The good news is that we simply can use real life patients for medical education, the bad news is that much effort is needed to convince managers in teaching hospitals that
3. Focussing on knowledge, skills and attitudes. Too long only medical knowledge and skills were important. Professional attitudes become more and more important to be addressed in a medical curriculum.
4. With sufficient feedback through direct observation of both the teacher and students in two directions, and regular formative testing.
5. In a safe learning environment were mistakes are allowed and seen as learning opportunities.

All these aspects are time and faculty consuming, in a world in which more and more output in terms of patient care is required, not only quantitatively but also qualitatively. My biggest challenge is to integrate patient care, clinical research (as a part of quality improvement, cycle of Deming) and medical education (of patients, students and healthcare workers). This was the topic of my maiden speech as teaching professor on January 14th 2005 (see enclosure).

1.2 Statement on my current medical education responsibilities

I work as a cardiologist in a large teaching hospital and mainly teach in the clinical situation. It is a 0.8 appointment. Lectures for 20 or less students. Most of the time clinical patient discussions with 10 staff members and 10 interns. In addition, I was involved in postgraduate training 4 times a year (see below).

Furthermore, I work for the Institute of Medical Education of the University in XXXXXX in a 0.2 appointment. Here I help to develop and implement a new curriculum. Key words are competence based learning, small group learning, self directed learning, direct observation and portfolio learning. The bachelor’s phase has started in 2005, the master phase in 2008.

1.3 Statement on my goals in medical education

I have three major goals.

First, it is my goal to contribute to the integration of learning, research and patient care on our department and hospital. I see this as a solution for the increasing mismatch between demands and availability of staff members, both for medical education, research and patient care. It is my opinion that patient care of prevalent clinical syndromes should be organised in standardised care, in which students may contribute in increasing complex tasks. Also students may contribute in evaluation research as part of quality care.

Second, clinical reasoning: when to use pattern recognition and when analytic thinking? Clinical reasoning is the core business of both patient care and medical education. We discovered that there is a wide variation in doctor’s therapeutic advices e.g. in elderly patients with aortic stenosis (see our report in Heart). How can we teach students when the experts don’t agree? It is my goal to develop a model for therapeutic reasoning to limit inter-doctor variation and to improve medical education.

Third, effective and efficient communication between healthcare professionals (including students) and between healthcare professionals and patients. In an era with many part-time healthcare professionals, working in teams, effective and efficient communication both between professionals and between professionals and patients, is a must. Communication deals with patient data, but also with giving or receiving feed back of observed performance and may be verbal and non-verbal. It is my goal to improve these communication techniques in our teaching hospital.

1.4 Statement on how to link my medical education responsibilities, philosophy and general goals in real life

My goals relate to an improvement of the learning climate in our hospital and to the introduction of a new modern student curriculum (master phase) in our hospital.

My goals mentioned in 1.3 are challenging. Both in diversity and in magnitude of change that is needed in our hospital. This is especially true because my time dedicated to medical education is limited. Although I have chosen my goals rather in line with the development programs of my hospital on quality care, self-evaluation and medical education, it is hard get my goals realized within a few years. It will be a continuous process of (self)-development, in which my labour will be only indirectly translated into detectable results.

This is especially true because realizing my ideas cannot occur by efforts of meas individual, but only when a large part of the medical staff and managers cooperate as a team. This urges for good communication, generating support and proper change management.

Section 2. Personal plan for professional development

I want to accomplish during the ESME Course in the next 8-9 months specifically that my understanding about teaching, curriculum planning, assessment and change management is sufficient to initiate and realize my three goals. Over a longer period of time, I am aiming at doing research on how doctors practice therapeutic clinical reasoning and how it may be improved to diminish the inter-doctor variability in therapeutic advices. And second, to perform research on inter-doctor professional communication. It is my hypothesis that the introduction of a format how a patient problem should be communicated to colleague’s, would improve the efficacy and efficiency considerably.

For the realisation of these research lines I followed recently a course given by ProfessorDr. A.S. In addition, there is a regular contact between prof.Dr. CVl, prof.Dr. A.S. and the Institute of Medical Education of my university.

Finally, the most important part of my professional development might be the development of leadership and change manager. Although I am quite comfortable to coach people, I am not a born leader. People do not follow easily my suggestions, and sometimes people are irritated by too much pressure from my side to implement changes. I wonder if this might be offset by professional development. I welcome any suggestion.

Section 3. Evidence of and reflections on activities and accomplishments in the 5 competencies

3.1 My basic framework of medical education

In the past 10 years my interests underwent a shift from clinical research to medical education. This is probably due to: (1) I experienced that change management is the natural next step after clinical research in the quality cycle of Deming (plan,do,act, evaluate). (2) after clinical research you want to implement your findings into clinical practice. I discovered that these attempts need quit a bit of change management on the meso level of clinical departments to make it a success. (3) Also, I discovered that you can not change the department without changing the individuals; in other words the field of medical education.

For example my thesis was on reperfusion therapy with thrombolytics in patients with acute myocardial infarction. This is a difficult decision in many patients because the benefit of opening the coronary vessel may be counteracted by intracranial bleeding due to thrombolytic therapy. We developed a decision model with risk score assessment. Very nice and it worked for the junior staff. The approach died soon thereafter, due to the fact that the senior staff do not think in risk scores. Now, have read the work of Norman and Schmidt, I know that experts think in encapsulated diagnostic items and pattern recognition and probably do think in the same way in therapeutic strategies. We need to adjust our approach of teaching new insights from clinical research to this. I am currently working on. Below contemporary issues in medical education as relevant for modern medical education are listed and linked to my personal situation.

3.2 My exploration and experiences in teaching, learning and assessment

My initial exploration in the world of medical education was done during the Discovery Course in XXXXX in 2004. These explorations are reported in my Maiden Speech as teaching professor at the University of XXXXXX (see enclosure).

Effective teacher

I recently discovered the power of focus groups. I started together with XXXX from our ESME class to get insight into problems with the implementation of new educational techniques (portfolio learning and mini-CEX). Now I use it to evaluate critical events in the clinic and to brainstorm about possible ways to prevent these events in the future.
To answer your question I read the AMEE guides in the course book. I must say that I picked up a few new techniques for deep learning that I will try out the next days.

Hi XX, what new techniques for deep learning from the AMEE guides did you try? How did they work? What did you learn? You might consider putting that in your portfolio with some reflection about it.

Especially, suggestions on small group learning (snow ball learning, 2x2 approach) were useful. These methods ensure that every student is involved in the learning process. It helps me to involve all students in the learning process and not only those who are most motivated and most prominently contributing to the discussions.

Skilled educational planner

I am involved in the postgraduate training of our teaching hospital. During the last years, many sessions were poorly visited. This is killing for both the organisation and for the teachers willing to give a presentation. In an attemp to change this, we analysed possible reasons for the poor attendence. It was striking that those curriculum items that dealt with patient cases in a multidisciplinary way, as multitrauma case presentations, were very well attended. But, those presentations that were not directly related to a patient problem were poorly visited. This illustrates for me how important curriculum planning is. Nowadays I first inventarize the learning needs of the medical staff and focus on patient cases only. For example, patient safety is an issue. I translated this in the start of a new kind of patient case discussion focussing on medical safety, call "the critical event discussion". Learning objectives (learn how to improve patient safety), learning strategies (preparation in small groups of staff members who were involved in the treatment of the patient, defining what went wrong and what may be improved), format of the course (10 min patient case presentation, 10 min discussion, 10 min reflection by a external safety expert and 10 min to define a action list, and assessment tools (attendence, questionaire) were defined. The first meeting was a success, the second is sceduled for januari 25th this week. Both cases deal with defective communication between healthcare workers. The next step could be that items such as professional communication is subject to a new course focus. This time with better attendence due to better motivation as the result of the critical event discussions.

Hi XX.You have identified a key ingredient in planning. People interact and attend conferences and presentations when they perceive that they are meaningful to them and at a very local level immediately useful to them. Keeping your hand on the pulse of the teaching hospital is key. "What is needed and how can I contribute" is a key question to keep in mind.

There is some follow-up in this matter. In May/June 06 the postgraduate teaching is in a major dip. Two of the four sessions (one presented by our CEO) had to be cancelled due to lack of attendance. Finally, the message is arrived in the management department. (Good suggestion: is there a problem that you want having resolved, invite your CEO to give a lecture). Because I was already working on this for a long time (see above), my analysis of the problem and suggestions on how to improve the situation was ready and I posted it to the medical staff office, CEO, director of the local educational institute, head of the local educational committee. And waited for enthusiastic reactions. Nothing of that kind. The director of the local educational institute was angry and wrote to all stakeholders mentioned above that she understood that I had taken over the direction and that she was waiting for further suggestions. I learned from this that a proper analysis of the problem is one thing, suggestions for solutions another thing, but implementation most likely the most critical and underscored part of the whole procedure of change.

Informed assessor/evaluator

Working in a teaching hospital affiliated to the XXX University of XXXXXX, we are currently in a phase of renewing the curriculum. We recently started more student-centered, problem based, small group learning, clinical experience early in the curriculum. This implies also a new view on the assessment methods. More formative testing, rather than summative alone.
More testing of competences (CanMeds2000), instead of knowledge and skills alone.
Mini-CEX
Training students merely in their last years in clinical contexts, I assess students predominantly by direct observation of clinical tasks. Recently, mini-CEX like assessments are introduced in the Netherlands for internships and subsequently for clerkships. We are currently in a phase of getting these procedures integrated in the normal daily clinical workflow, which is not as easy as it may seem. Most rewarding is the structured observation of student performance and subsequent feed back.
Multisource assessment of competences
360 degrees assessment is one of the items in the businessplan of our hospital for the medical staff. I hope to introduce this assessment method also for the students. Possibly as a pilot for the introduction of this assessment tool for the staff members.
Testing variable as outcome variable
I discovered that assessment of knowledge and skills go very well together with research of learning methods. Combining testing of knowledge and skills with some experimentation (even randomised design) I discovered that offering the data (differential diagnosis of chest pain) structured in a 3x3 tree model is not superior to offering the same data as a simple listing (AMEE 05). Also I discovered that cardiologists are not able to perform a probability estimation of disease in a similar way and that this is caused by variance in initial disease probability of disease as well as the interpretation of subsequent test results (NVMO 05). In addition, I discovered that this skill of Bayesian diagnostic reasoning can be adapted easily in a one hour training of 5th and 6th year students (AMEE 06). As a former clinical trial coordinator (European Co-operative Study Group for rt-PA) I am amazed how simple it is to perform educational research!

Hi XX.The recognition by Alf’s colleagues at the XXXUniversity of XXXXXX for more formative assessment is a big step. The use of the mini-CEX is an excellent method and requires faculty development in order for it to be effective. It would be interesting if Alf would post the research questions he is using in his new approach to research in medical education.

The research questions that were addressed during the lessons were for example:

  1. Early memorisation in 5th and 6th year medical students: the role of structuring the data offered (see enclosed abstract)
  2. Sequential probability estimation during the diagnostic proces: performance of students versus professionals (see enclosed abstract)
3.3 Bibliography

A short bibliography of what I have read during and shortly before the Portfolio portion of the Course that is relevant to my educational work is summarized in the matrix below. Also, some evidence of how I have applied in my educational activities of what I have read is listed in this matrix.

3.4 My resources for continuing medical education

Evidence that you have identified and begun to maintain resources for medical education

3.5 My plan for continued development as teacher, educator and scholar

A plan for your continued development as a teacher, educational planner and assessor is listed below.

My goals in medical education, can be summarized by: (1) integration of research, medical education and patient care by the creation of new learning. (2) Improvement of clinical reasoning, especially therapeutical clinical reasoning, in the clinical situation and (3) improvement of interprofessional communication. In fact, quite a challenge. I am happy that the philosophy of life long learning has been invented. Parallel to that, my goals may need a life long commitment of myself for their realization.

References

  1. Student’s feed back. See enclosure.
  2. Feed back of postgraduate training of Dutch cardiologists. See enclosure.
  3. Maiden speech teaching professor. See enclosure.
  4. Report of the Working Group on the Master Medical Studies at the XXXUniversity of XXXXXX. Available on request.
  5. Summer Discovery Course in Dundee 2004. Course material. Available on request.
  6. Abstract at AMEE 2005. Oral presentation. See enclosure.
  7. Abstract at AMEE 2006. Accepted for poster presentation. See enclosure.
  8. Harden RM, Sowden S. and Dunn WR. Some educational strategies in curriculum development: the SPICES model.