Creating a Community of Expert Thinkers and Learners A toolkit for medical educators

1. Creating a Community of Expert Thinkers and LearnersA toolkit for medical educators Amy Fleming, M.D.

2. Introductions • Amy Fleming • Introduction of Participants

3. Conflict of Interest • Amy E. Fleming, M.D. has NO financial relationships to disclose.

4. Goals • To provide an introduction to core concepts in critical thinking • To explore strategies for active teaching of critical thinking in the preclinical and clinical years • To build an educator’s tool kit for teaching critical thinking skills

5. Objectives During the session participants will: • Explore core concepts in critical thinking • Examine strategies for teaching critical thinking • Will develop commitment sheet: • Teaching plan for your own practice • How to share information with their own faculty.

6. Expert Thinkers • Desired outcome of Medical education • Excel at “critical thinking”

7. Expert Thinkers • Desired outcome of Medical education • Excel at “critical thinking” • But, the term “critical thinking” is not mentioned by • LCME • ACGME • UK, UME standards • Can MEDS doctor competency framework Krupat et al, 2011

8. Year two curriculum Marshall University SOM • In Year Two, students continue their integration of basic science with clinical medicine in a systems-based curriculum. Students have seven courses which include Approach to Patient Care, Immunology, Microbiology, Advanced Clinical Skills, Pharmacology, Pathology, and Psychopathology. The teaching blocks include Core Concepts, Infectious Organisms and Antimicrobials, Introduction to Neoplasia and Hematology, Nervous System, Cardiovascular System, Pulmonary & Ear, Nose and Throat, Gastrointestinal System, Endocrine and Renal Systems, Musculoskeletal and Genitourinary Systems, and Dermatology, Eye and Toxicology. The curriculum is designed to teach life-long learning and critical thinking skills as students build upon their differential diagnoses with each subsequent block. The Approach to Patient Care course focuses on tying together the instruction from the basic science courses into clinical vignettes, illustrating the challenges and depth of patient care. Through this instruction, the students are prepared to transition more effectively into their clinical years.

9. Student Research at MUSOM • Research will strengthen your critical thinking skills and fortify your understanding of the basic science concepts. It will ultimately broaden your perspective from bench to bedside.

11. What is Critical Thinking?

12. What is Critical Thinking? • “The intellectually disciplined process of actively and skillfully conceptualizing, applying, synthesizing, and/or evaluating information…” -Scriven and Paul, 2010 • “concerned with reason, intellectual honesty, and open-mindedness as opposed to emotionalism, intellectual laziness, and close-mindedness.” -Kurland, 1995

13. Critical Thinking Evaluating information Evaluating our own thought In a disciplined way.

14. Our brand of Critical thinking:Clinical Reasoning Clinical Pathophysiology Made Ridiculously Simple Aaron Berkowitz

15. Krupat Medical Teacher 2011 Critical Thinking: • A Process: of synthesis and analysis • A skill or ability • Characteristics of the individual, personality traits, habits of mind: (careful attention, curiosity, courage, thinking deeply/openly, awareness of self and others)

16. Krupat Medical Teacher 2011 • Engage in data gathering: • H&P, go to literature, order tests, consult with experts • Integrate, organize, synthesize, utilize information: • define and explore all causes, weigh risks/benefits, prioritize • Communicate with Patients: • Show respect, inform and involve patients • Make Decisions and Take action: • use best available evidence, ensure information is complete, make plans for follow up • Act in ways that are self-reflective: • recognize uncertainties, doubts, limits of knowledge, biases. Understand that one might be wrong.

17. Perkins: conceptual frameworkGood Thinking • Sensitivity: awareness of flow of events, need for more information, value of understanding alternatives • Inclination: committed to invest the effort in thinking the matter through • Ability: knowledge, skills, how to frame questions, integrate information, apply one’s knowledge

18. What is Critical thinking? • How can we foster a climate throughout our university that is focused on the development of thinking abilities? • “Critical thinking is not something to be devoured in a single sitting nor yet in a couple of workshops. It is to be savored and reflected upon. It is something to live and grow with, over years, over a lifetime.” • a teachable cognitive skill independent of specific knowledge

19. How did you learn critical thinking? www.media.photobucket.com

20. How did you Learn Critical Thinking? • Often not “taught” • Practice, experience • Unconscious learning • Talking out loud • By being challenged with questions… why? What are you thinking? • Expert modeling

21. 4 Stages of Competence • Unconscious Incompetence • Do not recognize the deficit • Neither understand nor know how to do something • Conscious Incompetence • Realize you don’t know • Conscious Competence • Understand/know how to do something, but demonstrating the skill/knowledge requires concentration/consciousness • Unconscious Competence • Second nature, like riding a bike • Hard to teach/break down this automatic thinking 1940's psychologist: Abraham Maslow

22. 5th Stage of Competence If unconscious competence is the top level, then how on earth can I teach critical thinking? • Reflective competence -David Baume, May 2004 • Conscious competence of unconscious competence • Superconscious Meta-competence • Move beyond thinking intuitively and are able to teach in a very deliberate way • Person's ability to recognize and develop unconscious competence in others

23. Stages of Competence Courtesy of Will Taylor, Chair, Department of Homeopathic Medicine, National College of Natural Medicine, Portland, Oregon, USA, March 2007

24. BUT… by Sidney Harris

25. Tool Kit: • Priming and Framing • Learning Script • Active Observation • One Minute Preceptor • SNAPPS • Illness Scripts

26. Priming • Provide patient-specific information before learner enters the room • “4-year old boy with global developmental delay, a congenital heart defect, and respiratory distress.” • Prepare the learner for the encounter by asking case-based questions • What should you ask to understand the respiratory distress? • What will you ask regarding the congenital heart defect history?

27. Framing • Tell the learner what should be accomplished during the visit and how long it should take • “This child has a history of global developmental delay and congenital heart disease but is being admitted for respiratory distress. Focus on the evaluation for the respiratory distress acutely. Make sure to cover his history of heart disease as it pertains to his acute presentation. Don’t dwell on the developmental history. Spend about 30-45 minutes on the H and P, then come find me.”

28. Priming

29. Framing

30. Priming and Framing • Shadowing • Standardized Patients: • Hypothesis-Driven Physical Exam • (1) orientation, (2) anticipation, (3) preparation, (4) role play, (5) discussion-1, (6) answers, (7) discussion-2, (8) demonstration and (9) reflection. Nishigori, Bordage, et al: Medical Teacher, Feb 2011. Eva, Bordage, et al: Med Educ. Aug 2010. • Independent Learners • Quick search on chief complaint

31. Priming and Framing • Priming: Comprehensive knowledge of the gross and microscopic structure of the human body to provide  an anatomical basis  for disease presentations.  • Framing: To introduce CT scans, and the interpretation of anatomy as visualized by this technique.

32. Learning Script • Works best when a presentation is involved. • After participating in activity (histology lab, on call autopsy, case discussion, oral presentation on rounds) learner writes 2-3 things that s/he wants to learn on an index card • Learner gives card to teacher and then presents • During presentation, teacher can address issues or questions on card or they can wait until later. • At completion of case, return card to learner • Learner picks 1 or 2 issues to research. Follow up next time!

33. Learning Script • Learner centered • Teacher doesn’t have to anticipate learner needs • Expectation that learner will have questions • Emphasizes curiosity, questioning, learner motivation • Allows teaching at multiple levels

34. Active Observation • Can be used for learners with little to no medical training, such as undergraduates • Can be used in large case settings, lectures, clinical shadowing, critical situations (codes) • Explain rationale for focused observation (medical anthropologist)

35. Active Observation • Tell learner what to observe: • 3 columns on 3x5 card • See - Reaction - Why • Review what is written on card after the experience • Learner can also write questions on the card • Give feedback on observations • Excellent mechanism for teaching at the level of the learner • Allows teaching on “attitudes”, professionalism, communication

36. Active Observation

37. Active Observation: colloquium

38. One Minute Preceptor • Learner has presented encounter with patient • Get a commitment from learner • “What do you think is going on?” • Probe for supporting evidence (reasoning) • “What led you to that conclusion?” • “Did you consider alternatives?”

39. One Minute Preceptor • Reinforce what was done well • “Your diagnosis of X was well supported by Y” • Identify omissions or correct errors • “Although your suggestion is possible, in a situation like this I think that Z is more likely because…” • Teach general principles and next learning steps • Help learner build foundations and structure for future questions.

40. SNAPPS Learner-centered model in which the learner: • SUMMARIZES briefly the history and findings • NARROWS the differential to 2-3 possibilities • ANALYZES the differential by comparing and contrasting the possibilities • PROBES the preceptor by asking questions about uncertainties, difficulties, or alternative approaches • PLANS management for the patient • SELECTS a case-related issue for self-directed learning Wolpaw

41. Illness Scripts • Breaking down the way physicians approach clinical reasoning to a very basic level. • The patient who “read the book.”

42. Practice Problem Representation • 18yo woman

43. Practice Problem Representation • 18yo woman • Admitted for acute abdominal pain.

44. Practice Problem Representation • 18yo woman • Admitted for acute abdominal pain. • Has associated anorexia

45. Practice Problem Representation • 18yo woman • Admitted for acute abdominal pain. • Has associated anorexia • Initial pain peri-umbilical, now localized in RLQ

46. Practice Problem Representation • 18yo woman • Admitted for acute abdominal pain. • Has associated anorexia • Initial pain peri-umbilical, now localized in RLQ • Has rebound tenderness and pain over McBurney’s point

47. Illness Script • 8yo boy

48. Illness Script • 8yo boy • Admitted for acute abdominal pain and poor PO intake.

49. Illness Script • 8yo boy • Admitted for acute abdominal pain and poor PO intake. • Has a purpuric rash in a waist-down distribution.

50. Illness Script • 8yo boy • Admitted for acute abdominal pain and poor PO intake. • Has a purpuric rash in a waist-down distribution. • Presents with proteinuria and large joint pain.