CAREERS IN CANCER EDUCATION: INFINITE OPPORTUNITIES DURING CHANGING TIMES

1. 55TH ANNUAL SAMUEL C. HARVEY MEMORIAL LECTURE AMERICAN ASSOCIATION FOR CANCER EDUCATION Saturday, October 14, 2006 CAREERS IN CANCER EDUCATION: INFINITE OPPORTUNITIES DURING CHANGING TIMES Ajit K. Sachdeva, M.D., F.R.C.S.C., F.A.C.S. Director, Division of Education American College of Surgeons

2. Samuel C. Harvey, M.D., Ph.B., F.A.C.S. 1886 - 1953

3. SAMUEL C. HARVEY, M.D., Ph.B., F.A.C.S. • A consummate surgeon, scholar, educator, role model, historian, and philosopher • Chairman, Department of Surgery, Yale University School of Medicine for 23 years • President, American Surgical Association; First Chairman, Coordinators of Cancer Teaching • Introduced active learner-centered education (“Yale System”) • Enjoyed a cigar or pipe, a book, and a desire to stay longer in bed!

4. A CAREER IN CANCER EDUCATION A History of the Future • It is October 2016 • A Surgeon-Educator, Dr. John Smith, has been invited to deliver the 65th Annual Harvey Memorial Lecture at the AACE Meeting in San Diego • Dr. Smith reflects on the past 10 years, that have shaped his career as a cancer educator

5. 2006: A MILIEU OF CHANGE IN CANCER EDUCATION • Unprecedented scientific and technologic advances • Changes in clinical practice • Different roles of physicians and other health care professionals within high performance teams • Intense focus on competence, accountability, and patient safety

6. 2006: A MILIEU OF CHANGE IN CANCER EDUCATION • Impact of new regulations and mandates • Definition of the six core competencies • Restrictions on resident duty hours • Emphasis on increasing efficiencies and documenting outcomes of educational interventions • Change in demographics of the workforce • Advances in medical and health sciences education

7. THE PARADIGM SHIFT Continuing Medical Education Continuous Professional Development

8. KEY DIFFERENCES BETWEEN TRADITIONAL CME AND CPD CME CPD • • Episodic interventions for • Lifelong learning for group of learners individual learners • • Teacher-centered and • Learner-centered and teacher-driven learner-driven • • Principal focus clinical • Comprehensive in scope • • Lecture formats • Variety of learning commonly used formats and media used • • Mostly conducted in • Conducted in different formal settings venues Sachdeva, Arch Surg, 2005

9. CYCLE OF PRACTICE-BASED LEARNING AND IMPROVEMENT Identify Area for Improvement Check for Improvement Engage in Learning Apply New Knowledge and Skills to Practice Sachdeva & Blair, Surg Cl N Am, 2004

10. KEY CONCEPTS IN CPD AND PBLI Key Concepts • Based on specific individual learning needs identified through review of clinical practice and benchmarking data • Ongoing, contextually relevant education • Emphasis on helping clinicians achieve requisite levels of competence and performance and not on punitive measures • Focus on expertise and mastery

11. NEW DIRECTIONS IN MEDICAL EDUCATION • Learner-centered educational approaches • Experiential teaching and learning methods • Structured clinical skills teaching, learning, and assessment • Structured technical skills teaching, learning, and assessment

12. ASSESSMENT OF THE CLINICAL SKILLS OF ENTERING SURGICAL RESIDENTS • Model: 18-station OSCE (9 couplets) • Length of SP stations - 15 min. • Length of PN stations - 7 min. • Total testing time - 3.3 hours • Results: Overall reliability = 0.91 • ANOVAs revealed significant variation in individual residents’ clinical skills as assessed by SPs (F = 4.56, p < 0.01), PNs (F = 11.09, p < 0.001), or both (F = 10.9, p < 0.001) Sachdeva et al, Surgery, 1995

13. ACS OSCE FOR ENTERING SURGICAL RESIDENTS TO ADDRESS PATIENT SAFETY

14. OBJECTIVE STRUCTURED ASSESSMENT OF TECHNICAL SKILLS (OSATS) • Model: R-1 to R-6 surgical residents (n=48) • 8 bench model simulations Length of each station - 15 min. Total testing time - 2 hours Specific checklists and global ratings completed by surgeons Results: Reliability = 0.78 for checklists and 0.84 for global ratings Construct validity demonstrated Reznick, et al, Am J Surg, 1997

15. ACS/VA STRUCTURED EDUCATION MODULE TO ADDRESS MANAGEMENT OF ADVERSE SURGICAL EVENTS • Model: R-2 and R-3 surgical residents (n=7) participated in a 3-part exercise involving pre-operative meeting with standardized patient and spouse; intraoperative management of massive hemorrhage from IVC in a bench model simulation; post-operative meeting with the standardized spouse. Debriefings and review of videotaped performance of residents conducted by faculty Brewster, et al, Am J Surg, 2005

16. ACS/VA STRUCTURED EDUCATION MODULE TO ADDRESS MANAGEMENT OF ADVERSE SURGICAL EVENTS • Results: Residents performed at or above the expected levels; SP ratings higher than faculty ratings (p<0.05); residents found model realistic, challenging, and a beneficial learning experience Brewster, et al, Am J Surg, 2005

17. SPECTRUM OF SIMULATION IN MEDICAL EDUCATION • Computer-based simulations • Standardized patients • Part-task trainers • High and low fidelity simulators • Virtual reality

18. POTENTIAL APPLICATIONS OF SIMULATION IN MEDICAL EDUCATION • Acquisition and maintenance of competence; demonstration of optimum performance; achievement of excellence • Improvement in patient safety and outcomes of surgical care • Increase in the efficiency of educational processes; assurance of educational outcomes • Demonstration of greater accountability to the public and large consumer groups

19. USE OF HIGH FIDELITY MEDICAL SIMULATORS TO FACILITATE LEARNING Important Considerations • Curriculum integration • Range of difficulty level • Repetitive practice • Feedback • Multiple learning strategies • Clinical variation • Controlled environment • Individualized learning Issenberg, et al, Med Teach, 2005

20. CURRENT LIMITATIONS IN THE USE OF SIMULATION IN MEDICAL EDUCATION • Prevalence of weak curricula; technology driving the educational opportunities • Insufficient fidelity of simulation for certain procedures • Problems relating to costs, logistics, access • Absence of large-scale research to evaluate the added value of simulation in medical education

21. ON-LINE CLINICAL INFORMATION Important Considerations • Credibility of source • Relevance • Unlimited access • Speed • Ease of use Bennett, et al, JCEHP, 2004

22. ON-LINE CONTINUING EDUCATION COURSES Factors that Encourage Participation • Quality of content • Interactivity; case-based formats • Ease of accessibility and use • Convenience in obtaining continuing education credits Casebeer, et al, JCEHP, 2004

23. OPPORTUNITIES TO ADVANCE CANCER EDUCATION: 2006 - 2016 • Greater focus on CPD and PBLI efforts • Verification and documentation of knowledge and skills following participation in educational programs • Regional support for innovative educational interventions; establishment of learning communities • Enhancement of e-learning programs

24. OPPORTUNITIES TO ADVANCE CANCER EDUCATION: 2006 - 2016 • Focus on interdisciplinary work • Emphasis on communication skills and professionalism • Need for leadership to catalyze change • Importance of mentorship in career development • Involvement of patients as partners in health care • Pursuit of innovative research to advance the science of cancer education

26. INTERDISCIPLINARY TEAMWORK IN PATIENT CARE Characteristics of High Reliability Organizations • Hypercomplexity of systems • Task interdependence • Mitigation of the impact of hierarchy • Distributed decision-making • High degree of accountability • Immediate feedback Baker, et al, Health Research and Educ Trust, 2006

27. INTERDISCIPLINARY TEAMWORK IN PATIENT CARE Team Competencies • Team leadership • Mutual performance monitoring • Mutual support • Adaptability • Shared mental models • Team orientation • Mutual trust Baker, et al, Health Research and Educ Trust, 2006

28. INTERDISCIPLINARY TEAMWORK IN PATIENT CARE Skill Requirements • Technical expertise • Problem-solving and decision-making skills • Interpersonal skills Katzenback & Smith, Harvard Bus Rev, 2005

29. INTERDISCIPLINARY TEAMWORK IN PATIENT CARE Special Challenges • Exemplary communication skills and professionalism • Active listening skills • Negotiation and conflict management AAMC ETE Course, 2006

30. TEAM COMMUNICATION IN THE OPERATING ROOM Key Elements • Situational awareness • Problem identification • Decision-making • Workload distribution • Time management • Conflict resolution Davies, ACTA Anesth Scand, 2005

31. TRAINING IN INTERDISCIPLINARY TEAMWORK TO ENHANCE PATIENT CARE • Role modeling in real environments • Discussions of care vignettes • Experiential courses • Standardized, immersive experiences with feedback

33. IMPACT OF EFFECTIVE COMMUNICATION ON PATIENT CARE • Delivery of optimum patient care • Promotion of patient safety • Increase in patient compliance • Enhancement of doctor-patient relationship • Reduction of liability risk • Improvement in time efficiencies

34. STANDARDIZED COMMUNICATION TO ENHANCE PATIENT SAFETY • Situation • Background • Assessment • Recommendation Leonard, et al, Qual Saf Health Care, 2004

35. BARRIERS TO SAFE PATIENT HAND-OFFS • The physical setting • The social setting • Language barriers • Medium of communication Solet, et al, Acad Med, 2005

36. U.S. AND CANADIAN PHYSICIANS’ ATTITUDES AND EXPERIENCES REGARDING DISCLOSURE OF ERRORS TO PATIENTS • Involvement in serious error, 55%; minor error, 73%; near-miss, 62% • Support for disclosing serious errors, 98%; minor errors, 78%, near-misses, 35% • 66% agreed that disclosing serious errors would decrease risk of lawsuits • 74% thought disclosing serious errors would be very difficult Gallagher, et al, Arch Int Med, 2006

37. IMPACT OF EXEMPLARY PROFESSIONALISM ON PATIENT CARE • Ethical practice of medicine • Delivery of optimum patient care • Fulfillment of responsibilities to patients, the public, and society • Enhancement of the doctor-patient relationship

38. EDUCATIONAL INTERVENTIONS TO ENHANCE COMMUNICATION SKILLS AND PROFESSIONALISM • Behavioral approaches • Cognitive approaches • Social approaches Underlying Principles

40. • Cope with change • Cope with complexity • Set a direction • Plan and budget • Align people • Organize and staff • Motivate and inspire • Control and problem-solve DIFFERENCES BETWEEN LEADERS AND MANAGERS Leaders Managers Kotter, Harvard Bus Rev, 1998

41. •“Twice-born” • “Once-born” • Risk-takers • Risk-averse • Imaginative and inspiring • Rational and controlled • Proactive in establishing • Reactive in establishing goals based on desires goals based on necessity DIFFERENCES BETWEEN LEADERS AND MANAGERS Leaders Managers Zaleznik, Harvard Bus Rev, 2004

42. • Develop fresh approaches • Address problems by to problems, explore new coordinating and options balancing opposing views • Send messages • Send signals • Very comfortable with • Most comfortable solitary activities working with others • Relate to others in intuitive • Work with others in and empathetic ways traditional ways DIFFERENCES BETWEEN LEADERS AND MANAGERS Leaders Managers Zaleznik, Harvard Bus Rev, 2004

43. CREATING A CULTURE THAT SUPPORTS EFFECTIVE LEADERSHIP • Developing and pursuing a clearly defined plan for leadership succession • Using challenging opportunities and specific assignments to develop the skills of individuals with leadership potential • Providing longitudinal educational experiences and mentoring to develop leadership skills • Recognizing and rewarding mentors Kotter, Harvard Bus Rev, 1998

45. PROGRESSION OF THEEDUCATIONAL RELATIONSHIP BETWEEN TEACHER AND LEARNER Didactic Supervisory Collaborative Consultative Magill et al, Med Teach, 1986

46. CHARACTERISTICS OF A MENTOR • Wise and trusted advisor, listener, counselor and supporter • Encourages reflection • Promotes personal growth and satisfaction • Benefits from greater self-awareness, new insights, and improvement O’Donnell, J Cancer Educ, 1995

47. KEY FEATURES OF MENTORSHIP • Grounded in a developmental-contextual framework • Long, comprehensive, intense professional relationship • Involves teaching and learning activities; career advancement; personal support • Both mentee and mentor reap great rewards, are transformed in the process • One-on-one; may include multiple mentors Sachdeva, J Cancer Educ, 1996

48. STAGES OF SUCCESSFUL MENTORSHIP Initiation Cultivation Separation Redefinition Kram, Acad Manag J, 1983

49. FACULTY DEVELOPMENT AND SUPPORT TO IMPLEMENT INNOVATIVE MEDICAL EDUCATION • Offer training in new teaching, learning, and assessment methods • Focus on the effective use of cutting-edge educational technologies • Recognize and reward surgical faculty for their educational accomplishments

50. RECOGNITION AND REWARDS FOR SURGEON-TEACHERS AND SURGEON-EDUCATORS • Master • Educator Educator Master Teacher Teacher Sachdeva, et al, Acad Med, 1999