1. Family Medicine Education: New Paradigms in Teaching Chris Jenkins, MD American Academy of Family Physicians Family Medicine Global Health Workshop Denver, Colorado September 11, 2009

2. My Background  M.D. from University of Oklahoma College of Medicine  FM residency In His Image FM Residency Program at HMC Tulsa  FM Certification 1997; recertified 2004  Faculty, In His Image FM Residency Program at HMC Tulsa 1998 to present  Family Medicine Education International, Conference Director

3. FM Consultations  Have emphasized: Concepts (role and philosophy of FM) Structures (residency organization) Curriculum Medical knowledge Resources  People  Money  Facilities  Patients  Etcetera

4. FM Consultations  All are appropriate and important  Equally important but less emphasized… Teaching methodology and philosophy  Factors that influence teaching philosophy World view Attitudes of learners Attitudes of teachers Educational milieu Understanding of adult learning (theory)

5. Family Medicine Education: New Paradigms in Teaching  What we will Cover Attempt to identify common problems in teaching methodology in medical institutions in select countries where general practice is a new specialty Briefly discuss current adult teaching theory and “best practice” teaching methodologies Discuss suggestions for constructive change in theory and methods of learning and teaching

6. Teaching and Learning: The Influence of Culture  Teaching and learning styles are influenced by factors beyond the classroom  Cultural communication styles…  Interactions between “superiors and subordinates” can either positively or negatively affect learning  The importance of understanding: communication norms interaction between superiors and subordinates ways of showing respect, etc.

7. Traditional Teaching Approaches  Current practice in many countries Authoritarian learning – “top down”  The authority makes a statement  The learners accept without question  Have you tried snakes?  Wrong, it is … Non-interactive lecture style  Reading from a page… And copying to another page  Regurgitating on a test

8. Traditional Teaching Approaches  Current practice in many countries Emphasis on theory not practice  “they will get experience on the job…”  Chief of medical staff in district hospitals as first assignment for new medical school graduates Without having significant clinical experience before hand Without having hands-on learning opportunities Questions from students not encouraged  May imply the teacher did not do a good job  Inability to give an answer may cause teacher to “lose face”

9. Non-cultural Factors that Influence Teaching Approaches  Current practice in many countries Reluctance to teach  Economics: Students represent future competition Too many doctors, or… Too few jobs  Turf: Specialists often feel GPs/FPs don’t need depth of knowledge – or shouldn’t be in their specialty teaching service at all Lack of current best evidence approach (EBM)  Using older less reliable models of research and practice

10. Traditional Teaching Approaches  Current practice in many countries Not aware of current adult learning theory  Adults not big children when it comes to learning Failure to teach the concept of learning for a lifetime  Medical or graduate school the end of personal education Lack of a teaching ambience  Senior residents not teaching junior residents  Attendings reluctant to share knowledge with colleagues or trainees Loss of power by sharing information Loss of income through competition or loss of monopoly

11. Traditional Teaching Approaches  Current practice in many countries Teaching symptom sets  One set of symptoms, one correct answer Result of teaching symptom sets:  Difficulty dealing with Ambiguity Diseases rarely present in neat classic packages The problem of co-morbidities  Shot gun approach… “I don’t know how to figure this out so I will do everything”  Missed diagnosis

12. Paradigm Shift Needed  A new view of teaching and learning  Critical thinking skills Incorporated into much of American education and taken for granted  Usually not specifically taught  Adult learning theory Should inform our teaching methods  An EBM (for example) approach requires a change in thinking about learning and sources of information

13. Effective CME – What Makes People Learn?  Johns Hopkins Systematic Review (2007)  BMJ Systematic Review (1999)  EBM Online Systematic Review (2000)  JAMA Systematic Review (1995)

14. BMJ Review  Most effective methods Learning linked to clinical practice Interactive educational techniques Outreach events Multiple educational interventions (e.g. outreach + reminders)  Less effective Audit Feedback Local consensus process Influence of opinion leaders

15. BMJ Review  Least Effective Lecture format Unsolicited printed material (including clinical guidelines)

16.  Practice behavior Multimedia-based CME has short- and long-term effect Single educational technique shows mixed results Multiple techniques shows overall effectiveness Both single and multiple exposures are effective Johns Hopkins Review

17.  Meta-analysis that included only interactive or mixed CME showed positive effect on performance  None of the 4 didactic-alone CME interventions altered performance  Conclusion: formal interactive, but not didactic, CME interventions are effective in changing physician performance EBM Online Review

18.  Conclusions Effective change strategies  Reminders  Patient-mediated interventions  Outreach visits  Opinion leaders  Multifaceted activities JAMA Systematic Review

19. Less effective  Audit with feedback and educational materials Not effective  Formal CME conferences or activities without enabling or practice-reinforcing strategies

20. Recommendations  CME in the 21st century must be: Planned systematically on the basis of needs assessment and prioritization Addressed to promote self directed learning and problem solving Based on proved effective educational process Use multiple educational techniques Avoid purely didactic methods and unsolicited distribution of printed material

21. Learning to Learn  Medical knowledge changes rapidly  Half of what is learned in medical school will be obsolete or proven wrong in ten years And we don’t know which half!  Residents need to learn how to do self learning for a life time  Faculty are responsible to teach their trainees how to learn and be analytical or critical thinkers

22. Teaching to Think  Spoon feeding trainees information is not helpful  Thinking is not cultivated by answers but questions  Not allowing trainees to ask questions and think through an issue will hinder their understanding and learning  Help the trainee know: How to ask the right questions How to analyze the research data

23. Teaching to Think  Critical thinking is a learned skill It can be developed over time Critical thinking can be improved in the same way as any learned skill: playing the piano, playing basketball, doing surgery  Understand basic principles  Regularly do self evaluation in practice (put the principles into practice and evaluate how successful you are)  Upgrade understanding and skills accordingly  It’s much easier (for the teacher) to quote a reference and expect the student to quote it back

24. Faculty Development  Faculty need to learn how to practice and teach critical thinking skills It is a way of teaching and learning affects how one thinks through the design of instruction how one thinks through the content one is learning/teaching  It is part of ongoing professional development

25. Adult Learning Theory  Much written  An emerging awareness of the need to know and incorporate ALT principles when teaching  Not well applied in America but effort is underway  Rarely applied in many developing countries  Not incredibly complicated It does require effort and a change of approach in teaching It takes time, especially initially, to incorporate It demands giving freedom and responsibility to the learner to learn  Involves a change of thinking, a paradigm change, in those not accustomed to it

26. Adult Motivation  Self-Directed  Application Oriented  Competency Concerns  Goal-Directed  The Most Effective Teaching Methods Will Take Adult Motivation into Account

27. Teaching Models: Examples  Socratic teaching method  Problem based learning Andragogical learning theory (a particular theory of adult learning)  Pedagogy = to lead a child  Andragogy = to lead a man  Others

28. EBM as a Potential Model for Teaching Analytical Thinking  Many countries are interested in understanding and applying an EBM approach to research and clinical practice  Positive Aspects Professionally appropriate and accepted An inoffensive way to teach a new way of thinking Potential for a radically new outlook on learning, educational authority, attitude toward research, etc.  Those with the most to lose by change may be the most resistant

29. Not an EBM Discussion Group But…  Step 1:Construct well-built and answerable clinical questions  Step 2:Locate the best evidence to answer these questions  Step 3:Critically appraise your findings  Step 4:Integrate findings with clinical expertise and patient needs  Step 5:Evaluate your performance of these steps and seek ways to improve  EBM is making the rounds in other countries. It may be a way to introduce new teaching concepts palatably.

30. Summary  FM consultations tend to focus on the philosophy of FM and the mechanics of FM training (which is important and necessary information)  World view, teaching methodologies, adult learning theory are relatively neglected in consultations  A paradigm shift is needed in medical education in many countries There are many challenges to implementation  Educational norms  Teaching traditions  Societal norms  Lack of knowledge (adult learning theory; best-practice teaching methodologies)  Power There are many potential benefits  Creation of critical thinkers  Better teachers  Increased learning  Better patient care and application of knowledge to particular patients  Better medical practice therefore healthier communities  Life long learners – medical practice in the community more likely to stay current Other?

31. Discussion  Feel free to comment, ask questions, share experiences  Thanks!