Concluding Thoughts

Completing my teaching practicum over more than 2-years has been a unique and challenging experience, not least of all because it can be difficult to maintain a coherent strategy and sense of direction for extended periods of time. Notwithstanding any initial uncertainty about where all this was heading, I’d like to think I’ve staked out a teaching vision that is at once personal and scholarly.

When I first began logging teaching experiences as a Fellow, they consisted primarily of 1-hour morning report-style exercises. The objective was simply to pass knowledge forward. While working through INTAPT, I started to notice my teaching becoming more scholarly, informed not only by learned pedagogical concepts, but by new educational strategies. Be it hosting an INTAPT workshop or leading a panel-discussion on Medical Assistance in Dying (MAID), I had the opportunity to experiment with different modalities. Aided by numerous sources of feedback, I began to appreciate what worked and what didn’t.

At the heart of this journey has been a commitment to emphasizing the role of basic science in clinical education. Throughout my practicum, I’ve been increasingly focused on integration theory, infusing pre-fabricated learning modules (see appendices) with a physiology-based approach to common clinical problems. As a new staff physician, I have been teaching these to my learners over the last 2 years.

As I look to the future, my hope is to operationalize some of these initiatives on a larger level. At Bridgepoint, I am the education lead for the rehabilitation medicine elective, where I am currently developing a mini-curriculum on our teaching units. It is my hope that I will be able to implement much of what I have learned from INTAPT and my practicum when devising the core components of this curriculum, including formalizing a needs assessment, implementing various educational strategies, and creating a feedback structure. Integration of clinical science with medical education will remain fundamental to this program, for I believe now more than ever that doctors are scientists at heart. We function best when we are able to deconstruct our problems into their constituent biological, chemical, and physiological substrates. Before we can treat, we must first understand.

 

Feedback: A Reflection

An advantage of a prolonged practicum is that I have had the opportunity to obtain feedback from a variety of sources across a wide array of teaching experiences at different stages in my career. This, in turn, has allowed me to learn from my mistakes and build on my strengths.

Early in my training, I often gave “lecture-style” talks on common clinical cases. Feedback on these sessions was instrumental in identifying strengths and weaknesses in my presenting style. For example, during an early presentation on atrial fibrillation, while I received positive feedback on the breadth of my talk, observes also commented on the “overwhelming” nature of the talk. At times, I used too many slides with too much data covering an excessive amount of literature. I recognized that this was a frequent flaw. Fearing exclusion of key information, my talks had a tendency to come across as exhaustive literature reviews equipped with unnecessary statistics and extraneous tangents. Receiving honest feedback on this aspect of my teaching was invaluable to enhancing the cohesion and accessibility of my future talks.

As I transitioned to a mentorship role as a PGY3 Fellow in Hospital Medicine, my talks necessarily became more focused and clinically-oriented. Case-based discussions supplanted lectures, with my audience typically numbering only a handful of learners rather than a full auditorium. Much of the feedback I received during this ‘era’ helped confirm that I had corrected my previous errors. Over a year later, I once again gave a talk on atrial fibrillation, which was received more favourably. Participants noted my emphasis on practical applications and clinical cases. My slides were also noted to be “informative” rather than “busy.” Overall, it was helpful to see how tangible feedback led to meaningful changes in teaching effectiveness.

Moving through my practicum and my fellowship, I found myself trying to increasingly integrate basic science concepts into my clinical teaching. Feedback allowed me to see that I was having some success in this endeavor, with several learners commenting on the valuable process of “connecting physiology to medicine.” Throughout this stage, I also tried to obtain informal feedback after sessions and rotations, which I think highlights a key caveat when considering the yield of feedback. The format matters, as does the anonymity of the responder. Most, albeit not all, learners are hesitant to provide honest, constructive feedback face-to-face. This realization has been particularly helpful as I’ve transitioned to my role as a staff physician. It is important that learners are allowed an opportunity to provide anonymous feedback. Seeing my faculty evaluations on Power allowed me access more candid assessments of my teaching, as well as provide me with numerical scores that I can compare with my faculty and department peers. As with student evaluations, it is helpful to know “how I compare” with the average instructor, while also seeing first hand what works and what doesn’t for my learners.

Particularly helpful in making this determination are hand-written comments, which are typically more insightful than lickert scale-based questionnaires. As I’ve received more evaluations, I’ve started to pick up on themes. For instance, multiple learners across different types of educational experiences have commented on their appreciation for my tendency to concentrate teaching around case presentations, where students have the opportunity to see their learning come alive at the bedside. On weeks when I have failed to prioritize this, it has been cited as an item under the “room for improvement” section.

To conclude, it is clear that feedback has played an important role throughout my career, from honing my presentation skills early in training to providing reinforcement to effective teaching strategies as a staff physician.

 

 

AV Recordings: A Reflection

Watching oneself on video is a discombobulating sort of experience. One’s voice (is that really how I sound?), mannerisms (“Do I always fidget like that?”), and wardrobe choices (nailed it!) are among the superficial distractions that can detract from a substantive self-evaluation. Nonetheless, watching oneself ‘objectively’ can provide fundamental insights into the teaching process.

After my first AV session, I was quite pleased at how I tried to keep my learner engaged with Socratic questioning and regular “check-ins.” It was particularly validating to see that my peer evaluator felt the same way. Indeed many of our scores lined up, which provided some evidence that I am attuned to my own strengths and limitations. Observing differences in ratings across similar categories can draw attention to potential “blind spots” in our own teaching methods.

What I found particularly helpful about this exercise was that the first AV recording had me asking more fundamental questions about how I was teaching and, more specifically, what I wanted to get out of my practicum. As has been noted, much of my teaching practicum has been focused on improving the integration of basic science into clinical teaching. After watching my first session, while effective in its own right, I wasn’t convinced it was capturing my personal teaching philosophy very well. While there was reference to physiology, it scarcely framed the discussion. In many ways, it seemed like any other one-on-one teaching jam. There isn’t necessarily anything wrong with that, but I felt like I wanted a bit more from the experience.

Watching myself give a talk therefore provided a powerful impetus to change how I imbued my “pre-fab” lectures with my personal teaching philosophy that values integration. Thus, when I designed my second talk on hyperkalemia, I made a conscious effort to frame every part of the discussion, from objectives to etiology to treatment, with an overarching physiological structure rooted in potassium metabolism and pathobiology. I could see myself deliberately coming back to the idea that understanding physiology informs our approach to and management of this common clinical problem. I also witnessed the learner returning to core biological principles when answering questions about treatment. She was clearly able to make links between underlying causes (e.g., hyperkalemia) and management considerations (e.g., administering insulin). Seeing this integration proceed on camera was rather rewarding and spoke to the importance of ensuring basic science is woven throughout the fabric of a talk rather than presented as a pretext for a subsequent clinical discussion (Baghdady MT, 2009) (Woods NN, 2005).

In closing, I found these AV recordings an excellent tool for reflecting on my teaching. Juxtaposing self- and peer-evaluations can highlight areas for improvement, while the overall experience allows one to correct subtle bad habits such as unnecessary pauses and focus on bigger questions about what we’re trying to achieve when we teach. Oh…and apparently, that really is how I sound!

Bibliography

Baghdady MT, P. M. (2009). The role of basic sciences in diagnostic oral radiology. J Dent Educ, 73(10), 1187-1193.

Woods NN, B. L. (2005). The value of basic science in clinical diagnosis: Creating coherence among signs and symptoms. Med Educ, 39(1), 107-112.

 

Teaching Journal: A Reflection

While it took me much longer than expected to complete my practicum, compiling teaching logs over almost 3 years afforded me a birds-eye view perspective that has been immensely valuable to forming a foundation for my developing teaching career. Upon reflection, 3 general observations warrant particular focus.

First, a wide canvas of teaching opportunities permits experimentation with a wide array of teaching modalities at different moments in one’s career. When I started logging activities, I was a Fellow just learning how to mentor junior trainees. Many of these earlier experiences involved learning how to assume the “Junior Attending” role and the basic tasks (e.g., co-ordinating care, leading discussions, providing feedback) of running a team. As my career transitioned to a staff physician role, I was able to dedicate increasing time to honing a teaching style and refining previously given talks. I also had increasing opportunities to not only teach, but to “teach about teaching.” For example, in log 8 I talk about how the experience of reviewing consults was aided by using Kolb’s experiential learning style to “abstract” key concepts for teaching that learners could apply in future clinical scenarios (McLeod, 2017). Later in Logs 36 -40, after creating a family medicine teaching unit as a staff physician, I had the opportunity to teach this style of “attending” to new fellows and create an educational unit that focused both on learning for junior learners and leading for our fellow. In this way, teaching becomes a transactional exercise across generations of learners.

A second observation I’ve made is that a prolonged “education” practicum can be challenging inasmuch as it leads to a certain degree of ‘inherent disorganization.’ Despite attempting to form a cohesive and consistent experience based on a unifying teaching philosophy, I instead discovered that many teaching opportunities were haphazard, impromptu, and not necessarily closely related to my areas of interest such as integration or curriculum design. In log 28, for example, I document my somewhat unplanned and awkward experience teaching a resident how to perform a sebaceous cyst removal. While these ‘extraneous experiences’ might result in a somewhat disjointed collection of logs, they can also prove reinvigorating. I began to learn about new possibilities, unknown weakness, and the value of experimentation.

A third and final observation is that, a multitude of different experiences notwithstanding, I can still see the signal amidst the noise. As I scan over my logs, I see increasing focus over the years on my personal teaching philosophy, specifically on the value of integration. In later sessions, I was able to experiment increasingly with pre-fabricated talks that teach an approach to a common clinical problem using a physiology-based classification scheme. I increasingly came to appreciate what worked well and what didn’t. For example, in Log 43 and in accordance with previous studies in the literature, I found that integration of basic science was most effective when embedded throughout the talk with explicit links to clinical application (Baghdady MT, 2009) (Woods NN, 2005). In this teaching experience, I talked about how reticulocytosis in the bone marrow is a physiologic response to anemia that permits a classifications schema of what’s wrong (e.g., bleeding, hemolysis etc.) that clinicians can use to create a robust approach to patients with a low hemoglobin.

I can conclude by noting that, cumulatively, these experiences form a blueprint for what comes next in my teaching career. As can be seen from later logs, I have begun several program-level initiatives to build on past activities. In Log 48, I comment on the experience of designing a “rehabilitation hospitalist curriculum” for incoming residents and fellows at Bridgepoint Hospital. Here I am hoping to draw from principles of integration to design an elective experience that focuses on Systematic rather than Opportunist educational opportunities. One such activity might be a “neurology day” wherein learners have a chance to practice integrated care of neurological patients, including a supervised physical exam, an introduction to therapy, and active discharge planning. Consistent with Harden’s SPICES model of curriculum design, the objective will be to focus on structured planning of educational experiences rather than simply “hoping for the best” that residents see what they need to see on their rotation (Harden RM, 1984). Through this and other opportunities, the collection of teaching exercises that comprise my practicum continue to imbue me with a confidence that my teaching will continue to evolve in dynamic, yet systematic ways.

 

References

Baghdady MT, P. M. (2009). The role of basic sciences in diagnostic oral radiology. J Dent Educ, 73(10), 1187-1193.

Harden RM, S. S. (1984). Educational strategies in curriculum development: The SPICES model. . Med Educ., 18(4), 284-297.

McLeod, S. (2017). Kolb’s Learning Styles and Experiential Learning Cycle. Retrieved from Simplypsychology.org: https://www.simplypsychology.org/learning-kolb.html

Woods NN, B. L. (2005). The value of basic science in clinical diagnosis: Creating coherence among signs and symptoms. Med Educ, 39(1), 107-112.

 

 

 

 

 

 

Introduction & Personal Teaching Philosophy

Last edited: 1 August 2019

Hello and welcome to my e-portfolio! As I’ve transitioned from my role as a hospital medicine fellow to an academic hospitalist, I’ve had the opportunity to develop my teaching skills both in the clinical setting and, more systematically, through the completion of INTAPT and my practicum. What follows is an introduction to the teaching philosophy that has informed my work in both courses.

I decided to pursue a ‘teaching Masters’ because I believe in the transactional nature of medicine, in the idea that our profession will only survive if we transmit our knowledge, ethos, and values to the next generation. I enrolled in the MScCH with the intention of pursuing this goal in a scholarly and systematic way. While teaching “on the fly” is doable, it is neither intrinsically rigorous nor reflective. Educational theory is not a strong interest of mine, but I recognize its importance in exploring and developing educational strategies that actually work.

As I’ve moved forward in the MScCH program, I would argue that my personal teaching philosophy is strongly rooted in integration theory. Nicki Woods explained in the very first week of INTAPT how basic science can improve learning when we stop treating it as a pre-requisite for the ‘real work’ of everyday clinical practice and instead infuse it into our understanding of key clinical concepts. Studies have shown that students retain clinical knowledge longer and more effectively when they understand basic mechanisms.^1,2 I believe the cerebral learner is a better learner, and much of my quest as a lifelong student has been to always ask, and hopefully answer, the ‘why’ questions.

This curiosity for learning is mirrored in my results on the Teaching Perspectives Inventory, where I scored highest on the Transmission domain, which emphasizes “content mastery” and underscores the importance of “clarifying misunderstandings.³ This should not imply that I want to bog down my students (or myself!) with useless biological facts. I realize we are adult learners, and as Knowles argues, we want our learning to be problem-based and applicable to real-world scenarios.^4,5 In these objectives I find no contradiction, however. I believe that a thoughtful learner cares about the ‘why’ as much as the ‘how’ insofar as the former can increase her facility in executing the latter. If, for example, we can understand the functions of different brain regions, perhaps we can more effectively diagnose stroke syndromes than if we were to rely on memorizing a massive number of syndromic patterns. In hospital medicine, this ability to reason critically is imperative to handling more complex or atypical disease presentations. My hope is that learners leave my rotation with a biology-based approach to internal medicine problems that facilitates a deeper and more enduring understanding of illness.

In my practicum, I have sought to test the theory that learners are better served by instructors who emphasize the value of critical thinking over simple memorization. Many of my teaching sessions have involved careful integration of basic science into a clinical topic; for example, I developed multiple approaches to common diagnoses such as hyperkalemia or anemia that are rooted in physiology-based classification schemes. Many of these have been transformed into pre-fabricated talks that I have archived in Microsoft OneNote that I intend to revise and reuse based on learner feedback. I also sought feedback from my learners both informally and formally with respect to whether these talks were helpful. One of these sessions was recorded with a formal and objective peer evaluation. I will also be comparing formal evaluations for my ‘earlier vs later’ talks to determine whether increasing use of integration is resulting in better effectiveness scores.

In closing, I hope this spirit of curiosity and dedication to improving how we teach permeate the collection of teaching activities and reflections you will find in this portfolio. I look forward to your thoughts and welcome your comments.

References: 

1. Kulasegaram KM, Martimianakis MA, Mylopoulos M, Whitehead CR, Woods NN. Cognition before curriculum: Rethinking the integration of basic science and clinical learning. Academic Medicine. 2013;88(10):1578-1585.
2. Baghdady MT, Pharoah MJ, Regehr G, Lam EWN, Woods NN. The role of basic sciences in diagnostic oral radiology. J Dent Educ. 2009;73(10):1187-1193.
3. Pratt, D & Collins JB. A Short Questionnaire to Help you Summarize Your Views and Perceptions about Teaching. http://www.teachingperspectives.com/html/tpi_splash.htm. Accessed 3 March 2017.
4. Knowles MS. Introduction: The art and science of helping adults learn. In: Knowles MS, et al, eds. Andragogy in action: Applying modern principles of adult learning. San Francisco: Jossey-Bass; 1984:1-20.
5. Merriam SB. The new update on adult learning theory. New York: John Wiley & Sons Inc.; 2001.

 

Learning Contract: A Reflection

Of all the elements of my teaching practicum, I feel most ambivalent about the value of the learning contract. To start, there are, in my mind, 2 clear advantages to using this tool. First, a learning contract signifies a commitment to reflective learning. Being ‘contracted’ to learn requires that one has the foresight to delineate a purpose for the scholarly activity to be undertaken. This is particularly important for busy health care professionals who need to ensure that academic activities are useful, efficient, and rationally connected to their career goals. For me, this included an understanding that I wanted to focus on the value of integrating basic science into clinical problem-solving (knowledge objective), specifically through case-based learning (Skills objective). By formulating a learning contract that included specific resources (e.g., primary literature by Nicki Woods in integration theory) as well as measurable evaluation criteria (i.e., teaching logs demonstrating integration techniques), I ensured that my teaching activities were goal-directed and accountable to my underlying philosophy. Formal feedback from my learners as well peers (via the AV recording component of the practicum) helped provide objective evidence that my skills- and knowledge-based objectives were being met.

A second, related, advantage of teaching contracts is that they narrow our focus, thereby increasing the odds of meeting our goals. If I had undertaken a teaching practicum with no specific goals or measurable criteria, it likely would have resulted in a haphazard learning experience with a myriad of encounters lacking a particular objective. I may have learned something here or there, but it’s unlikely I would have a greater story to tell at the end of my experience. By focusing on integration theory – and tailoring my objectives and outcome criteria accordingly, I was able to develop a more cohesive understanding about how I can use learned principles going forward, about what works and what doesn’t. For example, having interacted with multiple learners, I discovered that a long didactic diatribe about basic physiology followed by a clinical example seemed to work less effectively than integrating basic science at each step of the learning process (from diagnosis to presentation to treatment).

Despite these positive attributes, I do have some reservations about the format of our learning contracts. To some extent, the “tangible evidence” and “measurable criteria” columns seem semantically quite similar, and I’m not sure there is much value in trying to navigate this subtle and perhaps arbitrary distinction. More generally, I sometimes feel like the ‘academicization’ of learning can degenerate into a self-indulgent need to box experiences into pre-defined categories. This compulsion to give words to every experience often dilutes their resonance. This comment is not intended to undermine the value of thoughtful reflection or planning. Rather, if anything, I think it re-affirms my commitment to achieving the attitudinal objective written in my contract: “to recognize the importance of reflection and refinement to improving teaching.” Perhaps I can now present a fairer approximation of what a learning contract is and what it is not. For me, its utility resides in the capacity to provide an intellectual framework for what I do rather than as a means to validate ex-post facto a process that otherwise proceeds organically within the scholarly mind.