Автор неизвестен - Mededworld and amee 2013 conference connect - страница 40

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Take-home messages: Doing outpatient clinic first and seeing more ambulatory patients seemed to confer an advantage. To improve student clinical performance, medical educators need to identify and improve upon curricular design variables that may adversely affect student learning.

4H/4

Faculty sequencing of learning experiences for medical trainees

H Carrie Chen (University of California San Francisco, Pediatrics, 505 Parnassus Ave, Box 0110, San Francisco 94143-0110, United States)

Shannon Fogh (University of California San Francisco,

Radiation Oncology, San Francisco, United States)

Brent Kobashi (University of California San Francisco,

Medicine, San Francisco, United States)

Arianne Teherani (University of California San Francisco,

Medicine, San Francisco, United States)

Patricia OSullivan (University of California San Francisco,

Medicine, San Francisco, United States)

Olle ten Cate (University Medical Center Utrecht,

Medical Education, Utrecht, Netherlands)

Background: Learning in the clinical setting can appear to rely more on opportunistic than deliberately

ABSTRACT BOOK: SESSION 4 MONDAY 26 AUGUST: 1400-1530

sequenced developmentally appropriate teaching. The cognitive apprenticeship model describes curricular sequencing/ordering of learning activities with increasing complexity, diversity, and specificity to promote learner development. This study aimed to determine if experienced clinical educators employed sequencing as a teaching strategy to structure/select clinical learning opportunities for medical trainees. Summary of work: We conducted semi-structured interviews with medical school faculty who were identified as excellent teachers and taught learners at multiple levels. We asked them to discuss their approach to teaching different level learners and their perceived role in promoting learners' developmental progression. We performed thematic analysis of the interview transcripts using open coding and then examined codes for alignment with the framework of curricular sequencing to verify the presence of sequencing in clinical teaching. Summary of results: We interviewed 14 faculty. Thematic analysis revealed that faculty described clinical teaching as mostly opportunistic with little faculty control over context. To manage the relatively fixed contexts, faculty employed sequencing to structure learning. Based on learners' levels of training and individual learner capabilities, they increased complexity, diversity, and specificity of content taught (general approaches before evidence-based management for specific situations). They also organized their teaching along hierarchies of learning (information gathering before sharing). Faculty relied on curricular objectives and developed personal sequencing approaches through experience. Conclusions: Faculty use sequencing to match available learning opportunities to learners' developmental levels. Take-home messages: Faculty development should include deliberate focus on sequencing as a teaching strategy.

4H/5

Influence of Attending Physician Specialty on the Uptake of Clinical Learning Opportunities During Simulated Morning Case Review

Laura Diachun (Schulich School of Medicine and Dentistry, Western University, Centre for Education Research and Innovation, Suite A280-Parkwood Hospital, 801 Commissioner's Road East, London N6C1Y1, Canada)

Andrea Charise (Schulich School of Medicine and

Dentistry, Western University, Centre for Education

Research and Innovation, London, Canada)

Yin Hui (Western Universtiy, Schulich School of Medicine

and Dentistry, London, Canada)

Mark Goldszmidt (Schulich School of Medicine and

Dentistry, Western University, Centre for Education

Research and Innovation, London, Canada)

Lorelei Lingard (Schulich School of Medicine and

Dentistry, Western University, Centre for Education

Research and Innovation, London, Canada)

Background: "Curriculum-by-random-opportunity" within major clerkship blocks is assumed to fulfill undergraduate learning objectives related to underprivileged curricular areas such as palliative care or geriatrics. However, research has found that teaching/learning opportunities regarding such objectives are rarely taken up by attending physicians. Using the example of geriatrics, this study explored the role of attending specialty in this phenomenon. Summary of work: Four admission histories for elderly patients were scripted to include teaching/learning opportunities regarding geriatric core competencies. A simulated student orally presented 1-3 admission histories to each of 24 internal medicine ward attending physicians (12 geriatricians and 12 internists) who were instructed to respond as they normally would during a one-hour morning round. Semi-structured interviews following the case discussions explored how attending physicians chose the topics they taught about. Transcribed audio-recordings of 66 case review discussions were analyzed using template and inductive analysis.

Summary of results: Geriatrician and internist attendings varied in terms of their degree of uptake of the geriatric teaching/learning opportunities built into the cases. Geriatricians taught about both geriatric (e.g, delirium, transitions of care, mobility) and non-geriatric issues (e.g., diabetes, pneumonia, and atrial fibrillation), while the non-geriatricians emphasized non-geriatric issues even when geriatric issues were relevant to the presenting illness.

Conclusions: In curriculum-by-random-opportunity, attending specialty influences the degree to which case review discussions take advantage of learning opportunities related to curricular objectives such as geriatrics.

Take-home messages: In curriculum-by-random-opportunity, attending specialty influences the degree to which teaching/learning opportunities are taken up in morning case review discussions.

4H/6

How can students' diagnostic competence benefit most from practice with clinical cases? Effects of structured reflection on future diagnosis of the same and novel diseases

Silvia Mamede (Erasmus Medical Centre, Institute of Medical Education Research Rotterdam, Erasmus MC -Gebouw Rochussenstraat, Gk 745 Burgemeester s'Jacobplein 51, Rotterdam 3015CA, Netherlands) Tamara Van Gog (Erasmus University Rotterdam, Department of Psychology, Rotterdam, Netherlands) Alexandre S Moura (Jose do Rosario Vellano University (UNIFENAS) Medical School, Department of Medical Education Development, Belo Horizonte, Brazil) Rosa Malena D de Faria (Jose do Rosario Vellano University (UNIFENAS) Medical School, Department of Medical Education Development, Belo Horizonte, Brazil) Jose Maria Peixoto (Jose do Rosario Vellano University (UNIFENAS) Medical School, Department of Medical Education Development, Belo Horizonte, Brazil)

ABSTRACT BOOK: SESSION 4 MONDAY 26 AUGUST: 1400-1530

Henk G Schmidt (Erasmus University Rotterdam, Department of Psychology, Belo Horizonte, Brazil)

Background: To develop diagnostic competence students should practice with many examples of clinical problems to build rich mental representations of diseases. How to enhance learning from practice with clinical cases remains unknown. We investigated the effects of reflection upon cases as compared to generating single or differential diagnosis. Summary of work: During the learning phase, 110 medical students diagnosed 4 cases of 2 criterion-diseases under three different experimental conditions: generating single diagnosis, generating differential diagnosis, or structured reflection (i.e., comparing and contrasting scripts of diagnoses considered for the case against the patient's findings). One week later, they diagnosed 2 novel exemplars of each criterion-disease and 4 cases of new diseases that were not among the cases of the learning phase but were plausible alternative diagnoses.

Summary of results: Diagnostic accuracy scores (range:0-1) did not differ among the groups in the learning phase. One week later, the reflection group significantly outperformed the other groups when diagnosing new exemplars of criterion-diseases (reflection: 0.67; single-diagnosis: 0.36, p<.001; differential-diagnosis: 0.51, p=.014) and cases of new diseases (reflection: 0.44; single-diagnosis: 0.32, p=.010; differential-diagnosis: 0.33, p=.015). Conclusions: Structured reflection while practicing with cases enhanced learning of diagnosis both of the diseases practiced and of their alternative diagnoses, suggesting that reflection not only enriched mental representations of diseases practiced relative to more conventional clinical learning approaches, but also influenced representations of adjacent but different diseases. Structured reflection seems a useful addition to the existing clinical teaching methods. Take-home messages: Providing students with guidance for reflection upon problems can foster learning of clinical diagnosis.

4I Short Communications: Postgraduate Education: Trainee Workload and

Wellbeing

Location: Club A, PCC

4I/1

Contextualizing the Canadian resident duty hours debate: results from a national survey

Jason R Frank (Royal College of Physicians and Surgeons of Canada, Office of Education, 774 Echo Drive, Ottawa K1S 5N8, Canada)

Kevin Imrie (Royal College of Physicians and Surgeons of

Canada, Office of Education, Ottawa, Canada)

Julia Selig (Royal College of Physicians and Surgeons of

Canada, Office of Education, Ottawa, Canada)

Sarah Taber (Royal College of Physicians and Surgeons of

Canada, Office of Education, Ottawa, Canada)

Katherine Moreau (Children's Hospital of Eastern

Ontario, Clinical Research Unit, Ottawa, Canada)

Kaylee Eady (Children's Hospital of Eastern Ontario,

Clinical Research Unit, Ottawa, Canada)

Background: Postgraduate resident duty hours (RDHs) impact the physician workforce around the world. However, no country has simultaneously examined the perceptions of multiple PGME stakeholders. This study compared residents', program directors', postgraduate deans', and hospital administrators' current perspectives on RDHs in Canada. Summary of work: 12,672 residents, 766 program directors, 17 postgraduate deans, and 116 hospital administrators were invited to complete an online instrument exploring perceptions. A modified Dillman method was used with four contacts, and data were analyzed using descriptive statistics in SPSS. Summary of results: Overall, 3995/13 571 completed one of the four surveys, constituting a response rate of 29%. In terms of defining a "reasonable total number of clinical hours" for residents' weekly work, 34% of residents stated 50-59 hours, 29% of program directors reported 50-59 hours, and 46% of postgraduate deans indicated 60-69 hours. In terms of reforming RDHs, 61% of residents, 77% of program directors, 85% of postgraduate deans, and 74% of hospital administrators said that RDHs should be tailored by discipline. 56% of residents, 46% of program directors, 69% of postgraduate deans, and 65% of hospital administrators indicated that they would support a reduction in the number of consecutive RDHs worked. Conclusions: These findings suggest the complexity of issues, divergent views among stakeholders regarding RDH impacts, and some homogeneity in terms of directions for RDH reform. They also demonstrate the importance of exploring this topic from various perspectives, with implications for resident wellness, patient safety, medical education, and healthcare delivery.

Take-home messages: A comprehensive view of multiple PGME stakeholders can inform evidence-based RDH policy-making.

ABSTRACT BOOK: SESSION 4 MONDAY 26 AUGUST: 1400-1530

4I/2

A study of experiential learning and continuity of care in post EWTD hospital setting

Bharathi R Chinnathurai (Queen Elizabeth Hospital, Department of Gastroenterology, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom) Muhammad A Monga (Queen Elizabeth Hospital, Department of Gastroenterology, Birmingham, United Kingdom)

Jason Goh (Queen Elizabeth Hospital, Department of Medical Education, Birmingham, United Kingdom)

Background: Experiential learning has traditionally been integral to medical education. The recent adoption of European Working Time Directive (EWTD) has limited trainees' clinical availability and opportunities to follow up patients admitted under their care. The restricted working time has also meant break in continuity of care (COC) from a patient perspective. Our aim was to quantify follow up opportunities both from patient and trainees' perspective in post EWTD - hospital setting. Summary of work: 144 patients admitted over 3 days were followed up through to discharge. Parameters of interest were systematically recorded. 113 records have been analysed so far. We present the data on 102 patient admissions, after 11 exclusions. Summary of results: 73% of patients were admitted for 2 or more days. In 32%, the discharge diagnosis was different to admitting diagnosis. 83% of doctors do not get to follow up patients they admitted. 56% of patients were seen by 4 or more different doctors during their admission. Number of different doctors caring for a patient during single admission strongly correlates with length of stay (R 0.79).

Conclusions: ETWD has meant loss of experiential learning for trainees and break in COC for patients. In our hospital, we propose that admitting trainees get an electronic copy of the discharge to compensate to some extent for the loss of experiential learning. Take-home messages: There is a need for "system" change to enhance follow up opportunities to improve medical training. Clear documentation is vital to maintaining consistent communication.

4I/3

Effect of sleep deprivation on cognitive function

Muirne Spooner (Royal College of Surgeons in Ireland, Medicine, Education and Research Centre, Beaumont Hospital, Beaumont, Dublin D9, Ireland) Rebecca Horgan (Royal College of Surgeons, Medicine, Dublin, Ireland)

Tom Branigan (Royal College of Surgeons, Medicine, Dublin, Ireland)

Noel Gerard McElvaney (Royal College of Surgeons, Medicine, Dublin, Ireland)

Background: Irish NCHDs continue to regularly work 24­36 hour shifts, despite this contravening EWTD. It has been established that sleep deprivation affects

parameters such as motor skills. Our study examined the effect on cognitive impairment.

Summary of work: Doctor cognitive function was tested at baseline and within 4 hours of finishing an on-call shift (minimum 24 hours).Total sleep, nutritional intake, subjective confidence in dealing with an emergency and subjective sharpness were recorded. Summary of results: 37 doctors performed both tests. Mean sleep time recorded: 138.7 minutes, mean length of a sleep period: 40 minutes. Post-call cognitive impairment was recorded in 19 doctors by a statistically significant change in cognitive function calculated by the CogState software. Cognitively impaired residents (CIR) had mean sleep time of 105 minutes, versus 174 minutes for cognitively unimpaired residents (CUR), p = 0.01. Ratings of personal ability to manage an emergency did not vary between CIR versus CUR. Nutritional intake demonstrated normal calorific intake. Conclusions: This study is the first to use a validated measurement tool to objectively assess the effect of sleep deprivation during on-call on residents' cognitive function. It shows 50% of doctors have significant impairment in cognition post-call. It indicates duration of sleep on-call relates to degree of cognitive decline. Residents with objective cognitive impairment did not recognise their own cognitive deterioration, when asked to rate same.

Take-home messages: Current on-call practices causing sleep deprivation negatively affect cognition and thus patient care.

4I/4

The Impact of a Health and Well-being Workshop for Interns: Focusing on Resilience and Positive Change

Mataroria P Lyndon (University of Auckland, South Auckland Clinical School, c/- Middlemore Hospital, Private Bag 93311 Otahuhu, Auckland 1640, New Zealand)

Joanna M Strom (Counties Manukau District Health

Board, Auckland, New Zealand)

Marcus A Henning (University of Auckland, Centre of

Medical and Health Sciences Education, Auckland, New

Zealand)

Andrew D MacCormick (University of Auckland, South Auckland Clinical School, Auckland, New Zealand) Susan J Hawken (University of Auckland, Department of Psychological Medicine, Auckland, New Zealand) Andrew G Hill (South Auckland Clinical School, University of Auckland, Auckland, New Zealand)

Background: Increasing burnout and poor quality of life among doctors has potential adverse implications for patient care and physician well-being. A two-day health & well-being workshop ("SMARTshop") was implemented at Middlemore Hospital, Auckland, New Zealand, for interns and its impact on interns' knowledge, attitudes and behaviours towards self-care was evaluated.

Summary of work: In 2011, 33 first-year interns each attended one of four SMARTshops. The workshop

ABSTRACT BOOK: SESSION 4 MONDAY 26 AUGUST: 1400-1530

placed a strong emphasis on self reflection and the practical application of skills and relevant tools such as identifying personal early warning signs of stress and learning a variety of relaxation techniques. A mixed-methods study was conducted to evaluate their impact and involved focus groups and a structured survey. Summary of results: Quantitative data collated from 30 (91%) surveys demonstrated knowledge, perception and attitudes toward health and wellbeing were unchanged or improved. An exploratory factor analysis identified 3 factors: developing techniques for workplace stress and time management, application of specific and immediate self-care techniques, and seeking opportunities to use self-care techniques. Focus groups were attended by 21 interns and results suggested a greater knowledge and awareness of strategies that promote health and well-being. Most commonly reported were knowledge of relaxation techniques and greater awareness of the need for work/life balance. Conclusions: A two day health and well-being workshop for interns had a positive impact on attitudes, knowledge, and behaviours related to self-care. Its ongoing effects remain of great interest for program co­ordinators.

Take-home messages: A health and well-being workshop for interns had a positive impact on attitudes, knowledge, and behaviours related to self-care.

4I/5

Mind How You Go

Lorraine Close (University of Edinburgh, Centre for Medical Education, Chancellors Building, 49 Little France Crescent, Edinburgh EH16 4SB, United Kingdom) Debbie Aitken (University of Edinburgh, Centre for Medical Education, Edinburgh, United Kingdom) Janet Skinner (University of Edinburgh, Centre for Medical Education, Edinburgh, United Kingdom)

Background: Mindfulness, the practice of learning to focus on the present moment through developing attention to breath awareness and practising daily meditation is increasingly being recognised as an effective way to help health professionals cope with burnout, stress and anxiety, all of which have a negative impact on quality of patient care. Summary of work: Research was carried out by a group of first year medical students from the University of Edinburgh to investigate if Foundation Year (FY) doctors consider themselves to suffer from stress, if they feel able to be present in the moment both in clinical practice and out of work and how open to practising mindfulness FY doctors may be. Questionnaires were issued to approximately 30 FY doctors working in the local area.

Summary of results: Initial results suggest that a high number of junior doctors feel unable to 'switch off' and have difficulty focusing on interactions with patients. Many FY Doctors were familiar with the term 'mindfulness' but did not have a clear understanding of what it means. They were sceptical about it due to a perceived lack of research

ABSTRACT BOOK: SESSION 4 MONDAY 26 AUGUST: 1400-1530

Conclusions: Full results and conclusions of this study will be presented at conference. Take-home messages: The introduction of mindfulness training to FY and medical school curricula may reduce stress amongst FY doctors, impacting positively on job satisfaction and patient care.

4J Short Communications: Junior Doctor

as Teacher Location: Club E, PCC

4J/1

Starting up a new teaching programme: 12 lessons learned from the junior doctor front-line (Miriam Friedman Ben-David 2012 Award Winner Presentation)

Tesesa Tsakok (Guy's and St Thomas' NHS Foundation Trust in London, United Kingdom)

Teresa Tsakok was awarded the 2012 Miriam Friedman Ben-David New Educator Award by unanimous vote among the Committee of AMEE for 'work in medical education covering a wide range in a relatively short time... effective in developing the skills of others as well as your own'. Here she offers a ground-level perspective on the advantages of trainee-led initiation and delivery of medical education, as well as its inherent challenges. Teresa studied Medicine at Oxford, developing an early interest in both medical education and scientific research, and has trained to date within the integrated academic pathway, first as an Academic Foundation doctor and currently as an Academic Clinical Fellow and Core Medical Trainee.

She is based at Guy's and St Thomas' NHS Foundation Trust in London, where as a first year doctor she was struck by the lack of easily accessible teaching and learning opportunities, as well as the need for greater rapport between junior doctors and medical students. She therefore set up the MedEd programme, bringing both parties together for mutual benefit, with an emphasis on bedside teaching. This has since expanded in scale to become recognized as an integral component of the undergraduate experience at King's College London School of Medicine.

The opportunities and challenges encountered, together with lessons learned along the way, will form the basis of this talk. In particular, Teresa will highlight barriers to embedding a new teaching initiative within the culture of an institution, and subsequently ensuring its sustainability. She will also discuss the continual pressure to innovate and expand a successful teaching programme, and how this may be addressed.

4J/2

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