Standards, and competence.

There is no common core national or provincial standard in medicine, outside the demonstration of competence. Medicine is a discipline, a profession, a trade. The priority in medicine is patient care. The curriculum in medicine is most accurately seen as not student based, or product based, but actually patient based. A large part of training in medicine is practical, and not classroom or even group based problem solving. A great deal of it, the most important crucial learning is on the ward, in the clinic, face to face with a suffering patient, and learning to provide care.

zoriah_gaza_palestine_israel_palestinians_arab_muslim_medical_crisis_hospital_doctor_supplies_05-08-06-FD9T8772ci Zoriah via Compfight

The style of learning that occurs in clinic, and that we are engaged in, can be seen as a “cognitive apprenticeship” (Morrow & Gambrell ,2011; Pimmer, Pachler, Nierle, & Genewein, 2012). The student (graduated physician) engages the clinical encounter, and practises medicine. What connotations and associations does that word practise bear? Practise is the carrying out or exercise of a profession, a verb in the English application of English. Practice is a noun, the place where one practises.

The carrying out of medicine, the exercise and practise of medicine, evolves constantly. I practise medicine completely differently now compared to when I graduated, and differently than last week. The subject is humanity. It is completely unknowable in its entirety. I have huge gaping maws of ignorance that I attempt to feed with reading, with patient interaction, with inter-professional interaction. I will never come close to knowing it all. The mere interaction with patients, the exercise of medicine, changes the practise of medicine. The sign of a competent professional is being acutely aware of those areas where the knowledge base is inadequate for appropriate decision making and patient care, and to ask for help, for a consultation.

That is cognitive apprenticeship: asking for help. Learning occurs around these interactions (Pimmer, Pachler, Nierle, & Genewein, 2012). It is a sign of competence to ask for help.

What marks a student as incompetent? What fails a student? The consistent lack of realization that the knowledge base is inadequate, and the subsequent malpractice (which should be spelled malpractise, but is not) of medicine fails a student. Frankly, one occurrence of this comes close to failing a student. A huge red flag goes up, a fireball warning flare is perceived by all; that student then is highly scrutinized, counseled, and put on a very short leash. The very young clinical clerk that asks the professor for help during every single patient interaction is demonstrating competence, that he or she is doing just fine in the program. Of course, the graduate physician that does the same thing demonstrates lack of knowledge base, or confidence, or a personality problem. The graduate physician is expected to be able to manage commonplace problems without assistance, only asking for help when things are odd.

The learning objective is to provide patient care. It’s not on the wall. We have no correlate to a CAFE menu to post, something that K-12 teachers use in their classrooms. What assessment methods do supervising physicians use to monitor a student’s progress? The examination of clinical notes, direct observation, and clinical outcomes tell it all. Students do need to pass both medical school examinations, and standardized provincial and national written examinations to practise medicine. However, they are not permitted entrance to these examinations without demonstration of competence.

How do I apply the standard of competence to my teaching? I hope, by modeling competency, looking for it, and demanding it. This is a patient based curriculum. Patient care is paramount, and supersedes learning. This reality more than anything else teaches competence. Earlier in a medical student’s career, assistance in managing the scope of material necessary to consume would be paramount.

I suppose at some point, post retirement, many of us could teach at a medical school. If I find myself in this situation, I hope to be able to find engaging alternate texts for students, so they can exert some choice, find a fit for their literacy level, and perhaps obviate the need for attending lecture (Horton, Wiederman & Saint, 2012). Medical students have literacy issues, including speed of reading, comprehension, dyslexia and dyscalculia (MacDougall, 2009), as do any other group of students. These will need to be addressed, and appropriate texts would go a long way. Some issues, such as motivation, will not be evident in this group, but my future students can certainly bear some direct teaching of certain skills and strategies. There are specific approaches to reading journal articles which increase comprehension and scientific thinking which need to be taught (Gottesman & Hoskins, 2013; Round & Campbell, 2013). I will have to think clearly about how much time my students actually have for reading, and suggest sane levels of home reading (Klatt & Klatt, 2011); perhaps alternate approaches, such as the team (Tan, Kandiah, Chan, Umapathi, Lee & Tan,  2011) or jigsaw approach can level the mountain. Multiple other approaches can assist students: the appropriate use of cohesion gaps (McNamara, 2010), spaced education (Kerfoot, Baker, Koch, Connelly, Joseph & Ritchey, 2007), or simply the direction to take a speed reading course online (Amoriggi & Shaw, 2005/6).

References:

Amoriggi, H. & Shaw, K. (2005/2006). Can SpeedReading / eSpeedReading skills training enhance the overall learning/ elearning productivity of 21st century medical students and surgical residents? International Journal of Learning. 12(12): 157-170.

Gottesman, A.J., & Hoskins, S.G. (2013). CREATE cornerstone: introduction to scientific thinking, a new course for STEM-interested freshmen, demystifies scientific thinking through analysis of scientific literature. CBE Life Sci Educ. 12(1): 59-72. doi: 10.1187/cbe.12-11-0201.

Horton, D.M., Wiederman, S.D., & Saint, D.A. (2012). Assessment outcome is weakly correlated with lecture attendance: influence of learning style and use of alternative materials. Adv Physiol Educ. 36(2): 108-15. doi: 10.1152/advan.00111.2011.

Kerfoot, B.P., Baker, H.E., Koch, M.O., Connelly, D., Joseph, D.B. & Ritchey, M.L. (2007). Randomized, controlled trial of spaced education to urology residents in the United States and Canada. J Urol. 177(4): 1481-7.

Klatt, E.C. & Klatt, C.A. (2011). How much is too much reading for medical students? Assigned reading and reading rates at one medical school. Acad Med. 86(9): 1079-83. doi:10.1097/ACM.0b013e31822579fc.

MacDougall, M. (2009). Dyscalculia, dyslexia, and medical students’ needs for learning and using statistics. Med Educ Online. 14(2). doi:10.3885/meo.2009.F0000213.

McNamara, D.S. (2010). Strategies to read and learn: overcoming learning by consumption. Med Educ. 44(4):340-6. doi:10.1111/j.1365-2923.2009.03550.x.

Morrow, L.M. & Gambrell, L.B. (2011). Best practices in literacy instruction, 4th ed. New York: The Guilford Press.

Pimmer, C, Pachler, N, Nierle, J, & Genewein, U. (2012). Learning through inter- and

intradisciplinary problem solving: using cognitive apprenticeship to analyze doctor-to-

doctor consultation. Adv in Health Sci Educ. Feb; 17:759- 778. doi 10.1007/

s10459-012-9350-7.

Round, J.E., & Campbell, A.M. (2013). Figure facts: encouraging undergraduates to take a data-centered approach to reading primary literature. CBE Life Sci Educ. 12(1):39-46. doi: 10.1187/cbe.11-07-0057.

Tan, N.C., Kandiah, N., Chan, Y.H., Umapathi, T., Lee, S.H. & Tan, K. (2011). A controlled study of team- based learning for undergraduate clinical neurology education. BMC Med Educ. 11(91). doi:10.1186/1472-6920-11-91.