1	Teaching and Assessing Ophthalmic Laser Competency Michael D. Abramoff MD, PhD James Folk, MD Andrew G. Lee MD H. Culver Boldt, MD Hilary A. Beaver MD Emily Greenlee, MD Timothy Johnson MD Richard Olson, MD Keith Carter, MD Thomas A. Oetting, MD
2	Objectives Competency in retinal lasers Review literature on laser competency Glean “good practices” on lasers Propose sample implementation matrix
3	Objectives Define principles of teaching & learning Introduce you to three education models Dreyfus model of expertise Ericsson deliberate practice model Schon reflection model
4	My kindergartener Rachael (age 5 years) Virginia (age 3 years)
5	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?
6	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?
7	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)
8	Paradigm Shift The Dreyfus model of skill acquisition Stages of competence Novice Beginner Advanced beginner Proficient/Competent Expert (not everyone reaches this stage)
9	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%)
10	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
11	The Dreyfus model for Evaluation using defined behavioral anchors Stages of competence Samples of behavior Novice Turn on laser Beginner Fire few spots, know how Advanced beginner Performs + supervision Proficient-Competent Independent laser Rx Expert Teaches others
12	The problems with “Norm referenced criteria”
13	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
14	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?
15	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)
16	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
17	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?
18	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
19	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!
20	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)
21	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
22	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
23	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
24	Teaching ≠ Learning
25	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
26	Methods PubMed search: “English language” (1966 to 2006): Search terms: “ophthalmic lasers”, “curriculum” & “education” Titles reviewed for topicality, selected abstracts & full papers reviewed for “good practices” Non-physician, paraprofessional, or pre-professional sources excluded
27	Guiding principles Educational inventory of existing teaching encounters, tools & infrastructure rather than creating new tools “Piggy-back” ophthalmic laser teaching on to existing teaching encounters (e.g., grand rounds, lecture, existing resident curriculum) Teach & Assess simultaneously
28	Teaching laser competency in ACGME domains Medical knowledge Patient care Communication Practice based Professionalism Systems based Lecture, grand rounds Role modeling, dry lab, web vignettes, live patients Informed consent Journal club, chart audit, chart recall Role modeling Self-reflection project
29	Assessing laser competency in ACGME domains Medical knowledge Patient care Communication Practice based Professionalism Systems based Pre-, post-testing Direct supervision & observation, sentinel event markers, simulations Informed consent Journal club, chart audit, chart recall 360 evaluation Portfolio project
30	Portfolio for lasers Written learning plan (Laser competency) Critical/sentinel events (e.g., inadvertent “fovea burn”, incomplete PRP, vitreous hemorrhage) Written-oral test scores on laser content CME in ophthalmic laser content Logs of number, type & outcome of procedures Independent learning in laser competency Global ratings forms (360 degree) Videotaped laser performance Chart audit/review of results Patient/faculty letters (concern, praise, or commendation)
31	Example of web based laser curriculum (Abramoff et al)
32	Case vignette A 65 year-old man with severe uncontrolled diabetes (HgA1c = 13) Presents with visual loss in the right eye for the past two days Vision is 20/200 in the right eye and 20/20 in the left eye The fundus examination is shown below.
33	Pre- and post-testing (scoring) Which of the following laser treatments is most appropriate? Panretinal photocoagulation in both eyes Panretinal photocoagulation in the right eye only Focal laser treatment to the right macula Focal laser treatment to both eyes Both PRP and focal laser treatment OU
34	Laser safety curriculum (systems based practice) Ocular safety Fire and electrical safety Environmental safety Laser operation Appropriate laser position Appropriate laser start up, test-fire, and calibration Stand by and ready modes used appropriately Correct use of control panel settings and buttons Shut off and shut down procedures observed Minor trouble-shooting ability
35	Dreyfus model of laser competency Novice Beginner Advanced Beginner Proficient/competent Expert
36	Cognitive laser curriculum (PGY 2) Tissue absorption of wavelengths Wavelengths to use for scatter treatment, to treat in the presence of blood, and to treat vascular structures Settings of argon laser (spot size, duration, power, time between pulses, aiming beam) Risks of various wavelengths, spot sizes, & duration: Patient perception of pain Perforation of Bruch’s membrane Presence of hemorrhage Laser absorption by lens Specific lenses (e.g., Goldman & Volk SuprAQuad) on image quality, orientation and spot size effect Medical factors in progression of diabetic retinopathy Basic optics, safety, operations, & maintenance
37	Technical skills (PGY 2) Turn laser on Adjust to different wavelengths, spot sizes, durations, & power Place laser burns in simulation (e.g., on a color photograph taped to headrest of laser)
38	Technical skills (PGY 3) Obtain informed consent (n=2) Perform under observation Discuss Rx of PDR Treat 2 x PDR under direct observation Discuss complications of treatment Show examiner 2 patients after solo Rx
39	Technical skills (PGY 4) Review FFA, photos, OCT (n = 2) Treat 3 macula slides mounted Treat 2 focal laser (directly observed) Treat 2 patients & show examiner Demonstrate technical abilities under direct observation Score >80% on 25 question written test
40	Dreyfus model scoring rubric within five domains Start-up & ease with slit lamp & patient positioning Time & Motion Settings, Lens & instrument knowledge Use of Both Hands and foot pedal Avoids & handles complication
41	Start up & ease with patient N: Unaware of needs, comfort, position issues B: Aware, doesnt recognize, refers to checklist AB: Less consciously aware but near automatic P/C: Automatic, efficient motion E: Anticipates problems & concerns in advance, able to teach others
42	Summary: What I learned from my kindergartner Dreyfus model of expertise acquisition Ericsson model of deliberate practice Schon model of self-reflection Teaching ≠ Learning
43	Summary To define competency in ophthalmic lasers To review available literature on teaching and assessing laser competency To glean “good practices” from published works on ophthalmic lasers To propose sample implementation matrix (i.e., specific tools for teaching & assessing laser competency in ophthalmology residency)
44	Thanks for attending
45	How four Iowans saved One Billion lives Norman Borlaug Henry Wallace George Washington Carver Etta May Budd
46	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
47	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)
48	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…
49	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
50	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
51	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
52	The Peanut story (Tuskegee) 325 products from peanuts >100 products from sweet potatoes Carver never made nor sought any money for his discoveries
53	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!
54	Now what is the most important part of your job? Clinical care Research Education (mentorship)
55	We hope that you have been… Energized Empowered Enthusiastic Goal: Educate your educators
56	Thanks for your time & attention