Report of Task Group #9 Diversified and Experiential Learning

Report of Task Group #9
Diversified and Experiential Learning
Co-Chairs: Drs. Don Klassen and Eunice Gill
Task Force Group Members: Dr. Ming-Ka Chan, Dr. Holly Hamilton, Ms. Gladys
Stewart, Dr. Virginie Pollet, Ms. Tara Petrychko, Dr. Phil St. John, Dr. Randy Goossen,
Mr. Eyal Kraut, Mr. Terry Colbourne, Dr. Sean Udow, Dr. Jayda MacLean, Ms. Orvie
Dingwall, Ms. Joanne Hamilton; Ms. Karen Howell (Project Manager), Ms. Jacky
Johnson (administrative support)
Outline
This group will explore ideas of how to incorporate diversified learning settings into
students‘ clinical experiences. As well, with a focus on patient-centered learning, we will
discuss ways of introducing longitudinal clinical experiences for students, where the
focus can be on continuity of care and developing ongoing relationships with patients.
Key Words
Patient-centered learning; early exposure; utilization of technology; collaborative
learning; distributed learning; multiple sites; integrated clerkships; continuity
The librarian for our group, Ms. Orvie Dingwall, conducted a literature search using our
key words. The co-chairs then reviewed the abstracts to select those that seemed
pertinent to our task. Each article was reviewed by two group members and those with
interesting and relevant information were presented and discussed. Each group member
also reviewed the web site of one of the Canadian medical schools and presented a
summary of the curriculum that could be found on the website.
It is important to note that most of the literature was Level 1 evidence. Most articles
were descriptive of a program or curriculum change, with little assessment beyond
whether the students liked it. The studies that actually had some statistical analysis of
comparison of student performance in a curricular change compared to usual curriculum,
usually had very small numbers in the trials. It is clear that further research into program
evaluation and curricular change is needed. This highlighted for our group members that
we need to build evaluation of our new curriculum into the plan from the very beginning.
We have outlined six key messages that came from our discussions and literature review.
These will each be elaborated on below but are:
1. Early Clinical Exposure
2. Longitudinal Experiences
3. Patient and/or Family Centered Care
TG#9 Div&ExpLearn.7Nov2011; Page 1 of 10
4. Practicing Clinical and Reasoning Skills/Reflection on Clinical Experiences
5. Integrated/Distributed Early Experiences and Clerkships
6. Interprofessional Education
These recommendations all have equal weight. While we have elaborated more on
Integrated/Distributed Early Experiences and Clerkships, this does not reflect that they
are of more importance but rather that there tends to be more literature on this topic.
To be successful in implementing these recommendations, there will need to be
enhancements in a number of areas. There will need to be a strong and well staffed
Department of Medical Education to evaluate curricular changes and for the faculty
development that will need to occur with innovations in the curriculum. For distributed
educational sites, it is important that there is the necessary administrative support to make
sure things run smoothly and to problem solve any issues that come up with schedules,
accommodations, information technology, etc. Teachers and learners need to have
adequate access to library resources, internet, and cell phone coverage.
It is important to involve and support rural teachers. Try and engage them early, right out
of residency so they will incorporate teaching of medical students into their schedule
from the very beginning of their medical practice. Perhaps the physicians who have
students for rural week can be engaged to be more involved in medical education. If
there could be use of a resource such as Manitoba Telehealth, these physicians could
perhaps engage in small group sessions from a distance.
Key Messages
1. Early Clinical Exposure
Early clinical experience will engage students. The clinical exposure will increase the
relevance of the clinical and basic sciences they are learning in the early stages of
medical school. As well, this early exposure will help instill a patient centered approach
in students. This can be done in a number of different ways:
a)
The Mentored Clinical Casebook Project at Harvard Medical School.
Stanton RC, Mayer LD, Oriol NE, Treadway KK, Tosteson DC.
Academic Medicine, May, 2007; 82(5): 516-520. PMID: 17457078
The Mentored Clinical Casebook Project has been used at Harvard Medical School since
2003. A first year student is assigned to one clinical mentor and follows one patient for a
year. The student is expected to spend time with the patient in both clinical and
nonclinical settings, seek help from the clinician, and consult other experts and sources to
develop a complete picture of the patient‘s life. The student must produce a casebook
that includes, but is not limited to, the patient‘s history, basic science, clinical,
socioeconomic and cultural issues. Self reflection is also a part of the casebook. The
TG#9 Div&ExpLearn.7Nov2011; Page 2 of 10
experience is intended to allow students to develop a deeper and more diverse
understanding of what contributes to a patient‘s health status, to discern the patient as a
person and the person as a patient. The experience instills early on how much they can
learn from their patients. It provides a longitudinal, integrative experience for students.
Determinants of Community Health need to be introduced early in a clinically relevant
manner. Clinical learning and classroom learning should be mutually relevant. At the
University of Saskatchewan, the students have Community Service Learning in Year 2.
It has been defined as ―a structured learning experience that combines community service
with preparation and reflection. Students engaged in service-learning provide community
service in response to community-identified concerns and learn about the context in
which services are provided, the connection between their service and academic course
work and their role as citizens‖. Students have a minimum of 4 hours of contact with the
community service agency; each student spends at least 6 hours working on the project
and a 2 hour reflective workshop.
University of Toronto has a longitudinal course throughout first and second year. 2nd
year. Determinants of Community Health is held every Tuesday morning. An outline of
the
two
courses
is
available
on
the
website;
http://www.md.utoronto.ca/program/preclerkship/year1/DOC_111Y.htm;
and
http://www.md.utoronto.ca/program/preclerkship/year2/DOC_211Y.htm
Perhaps a
longitudinal course could be combined with the community service component described
above.
2. Longitudinal Experiences
Patient centered care and relationships with patients and their families, needs to be
fostered early. This should start in Med I and continue throughout all four years of
undergraduate medical education. This can be in the form of following an individual
patient throughout all four years of medical school (expansion of the mentored clinical
casebook project as in #1 above), or through following a family through the four years of
medical school. There may be opportunities to work with already established groups
such as Winnipeg Immigrant Centre to have students follow new immigrants and/or
refugees within Manitoba. This could assist in building bridges with communities and
organizations.
The University of Toronto has a second year course called Family Medicine Longitudinal
Experience—FME 211Y. Students participate in six community-based family medicine
clinics, one or two half days per week, for a total of 24 hours. ―Students will have the
opportunity to develop an appreciation of the importance of Generalist specialties and of
Family Medicine in particular, including understanding the role Family Physicians play
within the health care system. …In addition, students will have some exposure to
important issues in our health care environment such as physician distribution, physician
remuneration, primary care reform, and social accountability.‖ At the University of
Manitoba, perhaps the WRHA Access Centres could be used as well as clinics that have a
Shared Care model between the family physician and a psychiatrist. This would address
TG#9 Div&ExpLearn.7Nov2011; Page 3 of 10
not only longitudinal experiences but also early clinical experiences. Obviously, points 1
and 2 overlap significantly. The earlier students have clinical experiences, the better
likelihood of longer longitudinal exposures.
3. Patient and/or Family Centered Care
a) Longitudinal Pedagogy: A successful response to the fragmentation of the
third-year medical student clerkship experience. Bell SK, Krupat E,
Fazio, S Roberts D Schwartzstein RM. Academic Medicine, May 2008;
83(5). 467-475. PMID: 18448900
This is a really interesting article of a pilot trial with eight medical students at Harvard.
While students went through clerkship rotations in all disciplines, they also had a
longitudinal clerkship curriculum. All their rotations had to be done at one teaching
hospital in order to facilitate meeting with mentors. The authors identified deficiencies in
the traditional curriculum and developed a program ―rooted in longitudinal mentorship
and feedback, interdisciplinary care, an emphasis on humanism and patient-centered care,
and consistent integration of the basic and clinical sciences. The article provides an
outline of the format of the sessions. There were no statistically significant differences in
the performance of the two groups on any of the subject exams or on the total score of the
comprehensive OSCE. Of interest was the ―preservation of patient-centered attitudes and
beliefs in the pilot students compared with the decline demonstrated in the traditional
students‖. They specifically addressed the hidden curriculum in the longitudinal sessions
in the pilot curriculum. The number of students in the pilot is small, but the results are
interesting and the curriculum may provide a model of something we would like to
modify for our clerkship. This program has since been further expanded to include much
larger numbers of students. It should be noted that the start up of this program required
significant financial support.
A September, 2011 commentary in the Canadian Family Physician reports: ―As students
move from undergraduate to postgraduate medical training, not all transformations are
positive. Students move from being open-minded to being closed-minded; from being
intellectually curious to narrowly focusing on facts; from empathy to emotional
detachment; from idealism to cynicism; and often from civility and caring to arrogance
and irritability.‖ Therefore, it is imperative that in our curriculum we specifically have
educational sessions to try and prevent this happening to our future physicians.
b) Using families as faculty in teaching medical students family-centered
care: what are students learning? Johnson AM, Yoder, J. RichardsonNassif, K. Teach. Learn. Med. 2006 Summer; 18(3): 222-225. PMID:
166776609
TG#9 Div&ExpLearn.7Nov2011; Page 4 of 10
In this study, 58 ―pediatric clerkship students at the University of Vermont College of
Medicine completed a home visit with a family with a child with chronic disabilities.
After the home visit, students were asked to complete a reflection paper.‖
Something like this may be able to translate into an interprofessional team based
approach. Rather than following an individual patient, students could follow a family,
either through preclerkship or through all four years of medical school. This would
emphasize a patient/family centered approach to care. This speaks not only to
patient/family centered care but also longitudinal experiences.
Rather than following a single patient, the students could have a new patient each year.
Specific attention could be made to increase the complexity of the patient‘s problems as
the students became more experienced so as to address the challenging topics of complex
care, disability, and determinants of health. Safety and Quality could also be integrated
into these experiences. Students would not have to have exactly the same experience.
Some students may follow a woman through her pregnancy until and following the birth
of the baby. Others may have a patient with cancer or a mental illness. The objectives
for the experience can be the same no matter what the clinical scenario.
4. Practicing Clinical and Reasoning skills/Reflection on Clinical Experiences
Students require more avenues to be able to practice their clinical and reasoning skills
during ―free‖ time or during scheduled self-study time. This could be done in skills labs,
the Clinical Learning and Simulation Facility, or through web based cases. There are
many articles on the use of web based, interactive cases in small group sessions or for
students to learn on their own.
The students and residents in our group want to maintain small group teaching such as
Problem Solving, but felt there needed to be increased interactive means of learning in
small groups. This would require significant time to develop, but utilization of online
resources, interactive online case-learning, etc. would likely improve the quality of the
educational experience.
Review of other Canadian medical school web sites revealed some examples of how
portfolios are being used in medical education. Portfolios are one example of how
reflection on one‘s clinical experiences can be encouraged.
At the University of Ottawa, the ePortfolio is mandatory and spans all four years of
medical school. Small groups of students and their coaches meet together at least twice a
year, with ongoing dialogue facilitated through the ePortfolio website. Each coach is
assigned a group of up to eight students for the four years of the curriculum. The
ePortfolio is related to CanMeds FM roles and allow for students to reflect on these roles
throughout their education. (http://www.med.uottawa.ca/ePortfolio)
TG#9 Div&ExpLearn.7Nov2011; Page 5 of 10
At the University of Toronto, there is a Porfolio course for students during clerkship to
reflect on their learning, professional development and analysis of their deficiencies
requiring additional learning and training, specifically related to the six non-Medical
Expert CanMEDS roles. There is a full class lecture followed by seven mandatory small
group meetings (seven to eight students per group) to discuss reflections of clinical
learning guided by a resident and faculty member for each group. There is a focus on
―story telling‖ and discussing the significance for the CanMEDS roles, with each session
devoted to a different role. By the end of the course, students will submit their portfolio
for assessment. There are similarities to the University of Ottawa ePortfolio except the
University of Toronto project only spans clerkship as opposed to all four years in Ottawa.
5. Integrated/Distributed Early Experiences and Clerkships
a) Strasser R, Lanphear J. Educ. Health.(Abingdon) 2008 Dec; 21(3): 212. PMID
19967640
The Northern Ontario School of Medicine (NOSM) model of education is built on several
recent educational developments including rural-based medical education, social
accountability of medical education and electronic distance education. Clinical education
takes place in a wide range of community and health service settings so that students can
experience the diversity of communities and cultures in Northern Ontario. While the
mandate of the University of Manitoba is not exactly the same as NOSM, there are some
elements that are similar. In Manitoba, we have a large number of underserviced
communities as in Northern Ontario. The WHO states medical schools have ―the
obligation to direct their education, research and service activities towards addressing the
priority health concerns of the community, region and the nation that they have a
mandate to serve‖. The paper by Strasser et al states the two factors most strongly
associated with entering rural practice are: 1) a rural background and 2) positive clinical
and educational experiences in rural settings as part of undergraduate medical education.
Targeted training for rural practice at the post graduate level is also essential. NOSM has
developed detailed guidelines for communities to follow to ensure they are prepared for
providing the support required by medical trainees.
b) Integrated and/or distributed clerkships need to be investigated further in order to
be able to promote more clinical exposure to the underserved populations/areas of
our province. Ideally, the educational experiences would be based within those
populations‘ community settings.
Students do not need to go abroad to
experience global health issues. While we are not advocating that all clerkships
need to be distributed, we need to continue to pursue more opportunities for
students.
The family medicine clerkship is the rotation most frequently
completed outside of urban centres at most universities. However, we need to
explore which other clerkships could offer experiences outside of Winnipeg. The
Rural Integrated Clinical Clerkships between the University of Calgary and
University of Alberta could be a model and information resource. It is important
TG#9 Div&ExpLearn.7Nov2011; Page 6 of 10
to ensure that the concept of ‗equivalent educational experiences‘ is well
developed and that there is reliable access to learning resources.
Articles related to this topic include:
i)
ii)
iii)
Establishing successful distributed clinical teaching. Hays R. Aust. J. Rural
Health 2005 Dec; 13(6): 366-367. PMID: 16313534
Comparing academic performance of medical students in distributed learning
sites: the McMaster experience. Bianchi F, Stobbe K, Eva K. Med. Teach.
2008 Feb; 30(1): 67-71. PMID: 18278654.
The use of self-learning modules to facilitate learning of basic science
concepts in an integrated medical curriculum. Khalil MK, Nelson LD, Kibble
JD. Anat. Sci. Educ. 2010 Sep-Oct; 3(5): 219-226. PMID: 20814914
While this article is focusing on using self learning modules for learning basic medical
sciences in preclerkship, it is an example of how self learning could be utilized in a
distributed clerkship. The self-learning modules were highly interactive with quizzes.
They allowed learner control, were stimulating and time efficient.
iv)
Comparability of student performance and experiences in UBC‘s distributed
MD undergraduate program: The first 2 years of implementation. Lovato
CY, Murphy CC. British Columbia Medical Journal 2008; 50(7): 380-383.
Comparability of educational experiences is essential to the success of a distributed
medical education program and is also an accreditation requirement. This study
compared the curriculum delivery and the performance and experience of students in
years 1 and 2 during the first two years of expansion to three distributed sites—
Vancouver, Victoria and Prince George. Students rated tutors and experience highly, with
little statistical differences in either year. Students rated technology highly, though there
was a slight statistical difference in picture and sound quality between sites.
v)
Summary of research literature. Medical program expansion and teaching
hospital impact. Miller J, McEachern C. Anonymous Interior Health. BC
2008.
This summary was created in the context of UBC‘s creation of a new medical school in
Kelowna. The purpose of the document was to summarize relevant literature regarding
the impact of medical program expansion to new teaching hospitals, in order to help
inform the decision-making process within BC Interior health. The paper discussed some
considerations when creating the new school: ensuring proper clinical and teaching
facilities, proper teaching technology, appropriate student services and faculty
recruitment. An alignment of priorities and vision among university, government, health
authority, physician and community stakeholders are essential to the success of the
distributed medical program expansion model and introduction of teaching hospitals into
health regions.
TG#9 Div&ExpLearn.7Nov2011; Page 7 of 10
vi)
Evaluating distributed medical education: what are the community‘s
expectations? Lovato, C, Bates J, Hanlon, N, Snadden D. Med. Educ. 2009
May; 43(5): 457-461. PMID: 19422493.
This study explored community members‘ perceptions of impact of an undergraduate
medical education program in an underserviced community. The themes outlined in the
article are important ones to consider. Four underlying themes were: an increase in pride
and status; partnership development; community self-efficacy; and community
development.
vii)
Meeting the challenges of training more medical students: lessons from
Flinders University‘s distributed medical education program. The Medical
Journal of Australia. 2010; 193(1): 34-36. PMID: 20618112
This article reviews some of the issues to be considered in distributed education sites.
6. Interprofessional Education
While we did not review the literature on Interprofessional Education, interprofessional
experiences need to be incorporated into medical education. If students have early and
longitudinal clinical experiences in community clinics, this may be a setting where there
can be students from different disciplines working together.
Perhaps the Family Medicine Enhanced Distributed Education Centres in Brandon,
Steinbach and Morden/Winkler can, at some point, be expanded to include other trainees
such as Physician Assistants, Nurse Practitioners, Occupational Therapy students, etc.
There are other communities that have both medical students and residents. We should
maximize the interactions of trainees in these settings. It was identified by the residents
in our group that their experiences as medical students in rural communities could be
quite isolating. They recommended whenever possible to have more than one trainee at a
time in small communities. That could mean sending more than one medical student to a
community or a medical student along with a resident or trainee in another discipline.
Facilitating contact with other trainees in the work setting and in engaging in activities in
the community together could go a long way to promoting appreciation for other health
care professionals and an appreciation for community life and practice in a rural setting
Strengths of the University of Manitoba
The review of the literature and websites of other Canadian medical schools has revealed
that in the area of distributed education and rural experiences, we have some real
strengths that need to be highlighted and retained in a new curriculum. As one of our
group members stated, we need to ―build smart and well on what we have rather than
start anew i.e. don‘t buy a new house, just renovate but use sustainable materials.‖
TG#9 Div&ExpLearn.7Nov2011; Page 8 of 10
Rural Week (a week in May of each year when all Med 1 students go to a
rural/northern community to ‗live and learn‘ what life and medicine are like in
those communities. Students share their experiences on the Friday evening of that
week.)
J.A. Hildes Northern Medical Unit (NMU) summer experience (a limited number
of either Med 1 or Med 2 students are selected to spend 10 weeks of their
summer, working alongside health care workers in northern communities
organized under the NMU umbrella)
Summer Work Experience and Training (SWEAT) (a limited number of either
Med 1 or Med 2 students are selected to spend 10 weeks of their summer,
working alongside health care workers in rural communities; the experience is
organized by the Department Of Family Medicine, supported by Manitoba‘s
Office of Rural and Northern Health (ORNH)
Rural Family Medicine/Public Health Clerkship rotations – all clerks (with
limited exception) do a five week rotation in rural/northern Manitoba during Med
3 or early in Med 4.
Family Medicine Enhanced Distributed Education Centres (FMEDECs) – these
are located in three larger rural sites (Brandon, Winkler/Morden, Steinbach) and
have a group of learners at all times (1-2 family medicine residents and several
clerks at each location at a minimum)
It is also very clear that students in Manitoba do not need to go abroad to experience third
world medicine.
Summary
1. We need to highlight and build on our current strengths.
2. Early exposure, preferably with a longitudinal experience combined with a
reflection component, needs to be introduced in a new curriculum. Ideally, this
would also include an interprofessional component.
3. Self-reflection of knowledge, skills and applicability needs to be fostered early
under facilitation by a mentor and on a continuum throughout the full
undergraduate medical education to support patient and family-centered care
4. We need to be able to match undergraduate medical education training with the
requirements of the population demographics, both provincially and nationally.
We are not recommending that our entire curriculum should be distributed.
Rather, we recommend that we continue to work with sites that are currently
TG#9 Div&ExpLearn.7Nov2011; Page 9 of 10
being used for education of trainees and enhance the number and type of rotations
that can be done at those sites. We believe that the more learners there are at a
site, the more likely it is that the students will experience interprofessional
education opportunities. It is also more likely they will socialize together and
have experiences in the communities that will increase the likelihood of them
practicing in a similar setting following completion of their training.
5. For curriculum renewal, both in Winnipeg and in distributed educational sites,
adequate administrative support, infrastructure and IT supports, faculty
development, and remuneration and recognition of teachers will be necessary to
sustain the curriculum.
TG#9 Div&ExpLearn.7Nov2011; Page 10 of 10