1	All I really need to know about the competencies I learned from my kindergartener Andrew G. Lee, MD Associate Program Director Director New Educational Initiatives, Graduate Medical Education Office Professor of Ophthalmology, Neurology, and Neurosurgery The University of Iowa Hospitals & Clinics
2	Objectives Define principles of teaching & learning Introduce you to three education models Dreyfus model of expertise Ericsson deliberate practice model Schon reflection model
3	What’s wrong with the way we do things now? Apprenticeship model (“We teach now”) “We’re doing a good job now”! Structure-process assessments Evidence of teaching (lectures) “We make good residents now, don’t we?”
4	New paradigm demands more from our educational system Is apprenticeship model adequate? (You teach but do they learn?) Are we doing a good job?: Patient safety issues (100,000 lives), medical error, patient satisfaction? What are the outcomes? (proof) What is the evidence of learning?
5	Apprenticeship model Read one See one Do one
6	Apologies to Mr. Fulghum
7	My kindergartener Rachael (age 5 years) Virginia (age 3 years)
8	How do I teach my kids … how do they learn? Do we really need ACGME speak to answer these questions? Don’t we teach already? What do we already know but don’t realize that we know?
9	How do we teach residents? Read one See one Do one The apprenticeship model (is this the best way) Can apprenticeship model measure any outcomes?
10	Rachael learning to ride a bike What her learning process was NOT… Read one, see one, do one She cant read! (yet) Watching me ride a bike wont help! All learners progress through stages of learning (the Dreyfus model)
11	Paradigm Shift The Dreyfus model of skill acquisition Stages of competence Novice Beginner Advanced beginner Proficient/Competent Expert (not everyone reaches this stage)
12	Status quo: Norm referenced global evaluation Global evaluation form (peer benchmarked) Excellent surgeon (>75%) Good surgeon (50-75%) Fair surgeon (10-50%) Bad surgeon (<10%)
13	The Dreyfus model for Evaluation using defined behavioral anchors Stages of competence Samples of behavior Novice Prep, Drape, Anesthesia Beginner Capsulorhexis Advanced beginner 1 handed techniques Proficient-Competent 2 handed techniques Expert < 15” case
14	The problems with “Norm referenced criteria”
15	The problem with norm referenced criteria Use your piece of paper Write down if you are a competent driver? (Yes or No) Write down if you are an expert driver? (Yes or No) Now write down if you think that you are a below average, average or above average driver (for this room)
16	Self-reflection on global evaluation How long is your form? Is it valid? Are the scores all bunched at the top of the scale? (7s and 8s on 9 scale) Can faculty really measure some of these domains? (professionalism, practice based, systems based)? Are we kidding ourselves?
17	Global ratings over-estimate resident competence Turnbull et al. J Gen Intern Med 1998;13:317-23. Silber et al. Acad Med 2004;79:549-556. Schwind et al. Acd Med 2004;79:453-7.
18	No single evaluation can or should be used to measure all of the competencies! Over-reliance on the global evaluation form
19	Faculty ratings do not correlate well with global knowledge on in service Hawkins et al. Am J Med 1999;106:206-10.
20	Is Rachael “above average, average, or below average” for learning to ride a bike? Does that information help at all? Practice under supervision Practice with training wheels Remove training wheels Practice, practice, practice Go ride your bike…don’t forget your helmet
21	Tae Kwon Do Rachael: Dad, how many years? Dad: What? Rachael: How many years do I have to go to class to get my black belt? Dad: It doesn’t work like that, you have to progress thru Dreyfus stages, engage in Ericsson’s deliberate practice, & self reflect on progress with the Schon model Rachael: Huh….Daddy…How many years?
22	How many years? How many years does it take to become a PGY 1: One How many years does it take to become a PGY 2: Two Regardless of what color belt you actually are!!!!! (scary)
23	Old accreditation model “Minimum numbers” Procedure Class I Class I + III Cataract 45 75 Strabismus 10 15 Cornea 0 5 Glaucoma laser 5 10 Glaucoma filter 5 10 Retina/vitreous 3 10 Other retinal 10 10 Oculoplastics 15 25 Globe trauma 4 6 Class I: Direct supervision by faculty Class III: Resident first assistant
24	PGY system is also minimum numbers How long until I am a second year…one year How long until I am a third year…one year Tae Kwon Do does NOT work like that so why should medical education?
25	5-Why’s 1. Rachael: “Why did I get my arm hurt?” Daddy: “Well, you were running with scissors, when I told you not to.” 2. Rachael: “Why” Daddy: “Because, you shouldn’t run with something sharp” 3. Rachael: “Why” Daddy: “Well, you have your own kid scissors and we shouldn’t leave those adult scissors around” 4. Rachael: “Why” Daddy: “Because you’re too young to use real scissors” 5. Rachael: “Why” Daddy: Because I said so…
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27	Paradigm shift: Ericsson model Practice, practice, more practice Wet lab practice Capsulorhexis (small parts of cases over and over again until comfortable) Do one part of an otherwise perfect case Keep practicing within Dreyfus stage until ready to proceed to next level Repetition & refinement
28	Practice makes perfect…but deliberate practice makes experts Michael Jordan: Shot 500 free throws/day Tiger Woods: 2 hours on just “awkward shots from difficult lies” Yo-Yo Ma practices cello hours per day They don’t practice because they get paid more to do it
29	Tiger Woods misses cut at 106^th U.S. Open June 2006 When asked what he was going to do next… Tiger responded: “Practice”
30	It’s not about number of times! How many times? As many as it takes to move to the next level in the Dreyfus model How many is that? It might be 1, it might be 100 Every learner is different!
31	Time for audience reflection How did you learn something new? How did you teach this to a learner? Learning process Asked a question Didn’t learn it from lecture likely Asked a mentor Practice, practice, practice
32	Schőn’s model of reflective practice Reflection in action (“thinking on your feet”) Surprise (response to unexpected) Information seeking Solve problem Reflection on action (information => knowledge) Review & reflect after event Evaluate information Apply knowledge & enhance practice Goal: Knowing in action (Reach “expert” level)
33	Systematic approach to reflection in practice Cognitive knowledge (read one) Reflection on knowledge Assist and observe (see one) Reflection on action Perform under direct supervision Reflection in action Perform without supervision (do one) Knowledge in action
34	How I learned to dance I did not READ ONE, SEE ONE, DO ONE I had a rationale & motivation for learning (“I wanted to impress my wife”) I moved thru the Dreyfus model I deployed Ericsson’s deliberate practice model I reflected on my performance, made adjustments, & improved over time
35	Teaching the kids to read
36	The problem with norm referenced criteria… A: “My kids are really smart” B: “Oh, how so?” A: “Well, my daughter uses the mouse on computer, remote on DVD & TV, & microwave. I never did those things when I was four years old” B: “Uh….you didn’t have those things when you were four years old!”
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38	You need a mentor Role model Mentor Self reflection Appropriate self-directed learning Practice
39	The “hidden curriculum” You are mentor and role model (even when you think that no one is watching) Positive & negative role models We have to look at ourselves as faculty members too
40	Role models in the hidden curriculum
41	Self-reflection
42	Role modeling can be a force for good (or evil)
43	Teaching vs. learning (blatantly stolen from my friend Karl) Me: I taught my five year old daughter how to use my Blackberry device Karl: Wow, that’s great how’d you do that
44	Teaching ≠ Learning (from my friend, Karl Golnik) Me: Well, I gave her a lecture on the mechanics of the device, then each day I show her how I use it, & then I give her the Blackberry to practice Karl: Wow, let me see her use it Me: I said I taught her to use the Blackberry not that she actually learned to use it
45	Teaching ≠ Learning
46	Structure-Process-Outcome Old paradigm Structure-process Lecture schedule Titles of talks Rotation schedule Faculty members Teaching venues Apprenticeship model New paradigm Outcomes Pre-/Post-test Chart audit Practice based improvement Visual outcomes Learner satisfaction Patient satisfaction Proof of learning Competency model
47	Standardization is key Why do we need standardization? In a word….Betamax
48	Great Baltimore Fire of 1904 February 7, 1904: Basement Hurst Bldg. Fire departments called from local cities Washington, Philadelphia, NYC, Annapolis, Wilmington, Chester, York all responded Fire trucks arrived within 3 hours of call But….hoses & hydrant couplings didnt match
49	The tragedy of lack of standards There was no shortage of water! 1526 buildings burned 70 city blocks 1231 firefighters watched helplessly
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51	Summary: What I learned from my kindergartner Dreyfus model of expertise acquisition Ericsson model of deliberate practice Schon model of self-reflection Teaching ≠ Learning
52	What is the most important part of my (your) job in academics? Clinical care Research Education (Mentorship)
53	How did four people from the small state of Iowan save one billion lives worldwide?...and what does this have to do with education?
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55	Norman Borlaug Born, Crestor, Iowa (1914) Won Nobel Peace Prize (1970) Wheat/corn hybrids in arid climates But that’s not the cool part
56	But…no Borlaug without Henry Wallace Born: Adair County, Iowa 1888 Iowa State College at Ames 1910 High-yielding strains of corn 1913 Secretary of Agriculture (FDR) 1933 Vice President of United States 1940 Interred Glendale Cemetery, Des Moines
57	Henry Wallace 1940, Henry Wallace: vacation in Mexico Wallace noted yield of corn was much lower than his native Iowa Idea - start an agriculture experimental station like Iowa Rockefeller foundation funded Pioneer Hi-bred International (1926)
58	The Mexico Agricultural Station Borlaug selected for agricultural station in Mexico started by Henry Wallace Wheat & corn hybrids in arid climates Norman Borlaug single-handedly prevented worldwide famine & saved an estimated one billion lives! But that’s not the cool part…
59	Who influenced Henry Wallace As a child (his father was a Iowa State dairy professor), Henry Wallace used to take walks with a student at ISU named ….George Washington Carver “His (Carver’s) faith in me aroused in me a natural instinct to excel and deepened my appreciation of plants in a way I can never forget.”—H. Wallace
60	George Washington Carver Born a slave Orphaned in infancy Mother kidnapped by slavers Couldn’t get an education because of the color of his skin Started formal school at age 12
61	Who helped Carver? First black student at Simpson College (Iowa) studying art & piano Etta May Budd was his art professor Helped him find gardening odd jobs Encouraged him to study plants Helped admit to Iowa State (1894) where her father was Professor/Chair of Horticulture Carver => First black student & first black teacher at Iowa State before his amazing career at Tuskegee
62	The Peanut story (Tuskegee) 325 products from peanuts >100 products from sweet potatoes Carver never made nor sought any money for his discoveries
63	How four Iowans saved One Billion lives Norman Borlaug Henry Wallace George Washington Carver Etta May Budd
64	Why am I telling you this story?... You might not be a Norman Borlaug You might not be a George Washington Carver You might not even be a Henry Wallace But you can be, should be, are an Etta May Budd!
65	Now what is the most important part of your job? Clinical care Research Education (mentorship)
66	We hope that you have been… Energized Empowered Enthusiastic Goal: Educate your educators
67	Thanks for your attending
68	Thanks for your time & attention