Charlotte Ringsted NFOG_2013

Report
How do we get the best
specialists?
Professor Charlotte Ringsted, MD, MScHPE, PHD
BMO Chair in Health Professions Education Research
Director and Scientist,
The Wilson Centre
Department of Anesthesia
University of Toronto and The University Health Network
SCIENTISTS
• Promote creative synergies between
diverse theoretical perspectives,
and between theory and practice
Overview
• Competency-, outcome-based education
– Framework and Conception
• Clinical training
– Curriculum design
Frameworks of competence
• CanMEDS roles
– Medical Expert
– Health Advocate
– Communicator
– Collaborator
– Manager
– Scholar
– Professional
• ACGME competencies
– Medical knowledge
– Patient care
– Interpersonal and
communication skills
– System based practice
– Practice based learning
and improvement
– Professionalism
The seven roles
• EFPO project, 1992
– Undergraduate education,
Ontario, society’s needs,
eight roles
• CanMEDs project, 2000
– Postgraduate education,
RCPSC, entire Canada,
seven roles
Medical expert
Communicator
Collaborator
Scholar
Health advocate
Manager
Professional
Whole person
DK
Canada and Denmark –
Red and white; Neighbours; Hans Island
3 persons
per km2
No 3
125 persons
per km2
North America
• “Assessment rich area”
– National exams
– Flooded by
psychometricians
– Heavy focus on reliability
of tests and exams
– Strong tradition of
cognitive psychology and
behaviourism
SAQ
CEX
OSCE
ITER
CEX
MCQ
SAQ
ESSAY
MCQ
OSCE
Essay
ITER
Knowledge
Skills
Skills
Knowledge
WBA
ITER
Portfolio
WBA
ITER
Profes
sionalism
Portfol
io
Professionalism
B Hodges 2013
Competence as
Specialist training
Sausage Factory
SausageasFactory
Focus: Assessment and exams
Denmark
• “Assessment free area”
– Focus on training programs
and evaluation of education
– No specialist exams and
no psychometricians
• “To emphasize the educational purpose of
training, comprehensive formative
evaluation is suggested as alternative to
specialist examinations.”
Karle, Nystrup ME1995
SAQ
CEX
MCQ
OSCE
Essay
ITER
Simulation
Clinical training
Logbooks
Knowledge
Skills
Skills
Knowledge
National
Courses
Seminars
Reading
WBA
ITER
Rotations
Programs
Trainees’
evaluation
of quality of program
Profes
sionalism
Portfol
io
Professionalism
Supervisor
Appraisal
meetings
B Hodges/C Ringsted 2013
Competence as
Specialist training
Sausage Factory
SausageasFactory
Focus: Training and Evaluation
DK reform: C/OBE and ITA
PGME 1991
• NBH rules, guidelines
• Goals and objectives
PGME reform 2001
• NBH rules, guidelines
• Goals and objectives
– Specialist societies
•
•
•
•
•
•
•
Speciality courses
Clinical programmes
Training posts
CRE and supervisor
Appraisal meetings (3)
Trainees’ evaluation
No exams
– CanMEDS framework
•
•
•
•
•
•
•
Plus ’general’ courses*
Clinical programmes
Training posts
CRE and supervisor
Appraisal meetings (3)
Trainees’ evaluation
In-training assessment
WBA, In-training assessment, Anaesthesiology
Ringsted et al. Med Teach 2003
Clinical skills assessments (12)
Observation
in vivo / vitro
Longitudinal
assessments
•Cusum scoring
•Logbook on experience
•Learning portfolio
Assessment based on
practice data and
written reflective
assignments/reports
•Communication skills (1)
•Management/collaboration (2)
•Academic competence (3)
Factors related to value of ITA
Ringsted et al. ME 2004, Med Teach 2003, ASS 2003
• The link to practice
– Help in structuring teaching, training and learning
• Outcomes clear, monitoring progress, identify problems
• Coupling of theory to practice
– Used as licence to practice rather than end-oftraining assessment
• The effect on learning
– Should include a challenge to the learner
– ‘We all learn more’
• Assessors’ attitudes
– Enthusiasm and rigour
ITA-programs and psychometrics
In-training assessment, Anaesthesiology
Ringsted et al. Med Teach 2003
st
1 ar g
ye nin
i
tra
•Cusum scoring
•Logbook on experience
•Learning portfolio
A challenge to psychoanalyse this
Schuwirth & v.d. Vleuten ME 2006
A plea for new psychometric methods
Future of Medical Education in Canada
Toward a Competency-Based Approach
Time
Long DM,
Acad Med 2000
Competency-based
residency training –
Reducing time from
3 years to 1½ year
CanMEDS 2015 project
• Hybrid of Time and
Competence
• In-training WPB assessment
• EPAs and Milestones
• Focus on “Intrinsic Roles”
• Patient safety and interprofessional collaboration
• Graded responsibility
A call for systems-based education
• Outcome-based curricula
• Milestones, graded
responsibility
• Systems/society orientation
• Teamwork within and across
professions and institutions
Current practice
Future
• Focus on individuals
• Point-in-time sampling
• Standardization
• Focus on teams
• Longitudinal WBA
• Subjective, collective
CLINICAL TRAINING
A MATTER OF CURRICULUM DESIGN
• The concrete task
the near team
– Patient consultation, ward round,
amb., operation, diagn. investigation
• The system context and
the broader team
– Primary, secundary, and tertiary
sector and interplay within
and between these plus other
stakeholders
• The wider context and
the general perspective
– The speciality/society, the profession,
the region, the state, the society
Specialist training
• Experience and exposure
– Time and volume
• Professional development
– Deliberation
Oct 2013
Significant correlation between scores
and complication rate
Experience – number of procedures
and years of practice
Summary
rating (1-5)
Laparoscopic
procedures
Quartile 1
Quartile 2-3
Quartile 4
2.9
3.7
4.4*
53
96
157*
106
155
241*
137
110
123
111
98*
85*
11
9
11
Any procedure
Time
laparoscopic
Time any
Surgical
practice (yrs)
Experience and exposure
Curriculum design
• Logbook of experience
– Help in designing the composition of the training
program
– Ensure breadth and depth in experience and
exposure
Experience is not enough
Debilerate practice
Guest et al, 2001, Coles 2002, Andersson, 2004
• Critical appraisal and reconstruction of practice instruction, monitoring, feedback and discussions,
and opportunities to improve performance
repeatedly
Professional judgment
• Not so much about finding the “right” answer
but rather what is “best” in the situation. Coles 2002
• Ability to manage ambiguous problems,
tolerate uncertainty and make decisions with
limited information. Epstein and Hundert JAMA 2002
Performance
Routine experts vs. Adaptive experts
Expertise
Most of us
Innovative dimension
’Adaptive experts’
Efficiency dimension
’Routine experts’
Experience
Ericsson, Guest et al., Choudhry et al. 2005
Schwartz et al. 2004
Self- regulation of learning and performance
Zimmerman 2011
•
•
•
•
Self-regulated learning and performance
Forethought
Adaptation
Evaluation
• Characteristics
– Motivation, proactive goal setting, strategic
learning style, monitoring, adaptation, modelling
learning environment, self-efficacy, assistanceseeking, - practice, practice, practice
Thoracic surgeons – why and how did
they learn a new procedure?
• Video Assisted
Thoracoscopic Surgery
– New technique introduced in
late 90’s
– Henrik Jessen Hansen & René
Horsleben Petersen
• Jensen et al. studied why and
how experts learn a new
procedure
– Interviews in 2011 with ten
VATS experts/local pioneers
Model – Experts learning VATS
Selfdirected
learning
”I didn’t learn it – I taught it myself”
Self
realisation
Self-regulation of
learning and performance
Selfefficacy
Motivation
Incentive
Quality
Of care
Monitoring
outcomes
Societybased
coaching
Social
contagion
Systems-regulation of
learning and performance
Social
competition
Jensen et al. 2012
Paper in progress
Self – and system regulation
Jensen et al 2012
Self – regulation
System – regulation
• Build on prior knowledge
and skills of anatomy,
disease, techniques,
equipment
• Highly creative in developing
technique (’towel cover’)
• Step-by-step approach, Zone
of Proximal Development –
time, elements, size and
place
• Organiational doubts
and concerns;
personal recognition
• Finances, available
equipment
• Time constraints (the
’list’), co-workers
(the team)
• Expectations of
patients and cospecialties
• Monitor patient outcome
• The concrete task
the near team
– Patient consultation, ward round,
amb., operation, diagn. investigation
• The system context and
the broader team
– Primary, secundary, and tertiary
sector and interplay within
and between these plus other
stakeholders
• The wider context and
the general perspective
– The speciality/society, the profession,
the region, the state, the society
Person-Task-Context
TASK
Simple ... complicated
Part … Whole
Performance
PERSON
Novice ... Advanced
Knowledge, skills,
experience
CONTEXT
Alone … Team
Complexity
Uncertainty
Situated learning
•
Legitimate
Peripheral
Novice
– Single task
– Simple situation
– Basic procedures
Participation
Advanced
– Working context
– Multi-professional teams
– New procedures
Professional develoment
Dreyfus, Epstein & Hundert
TASK
Complex
Atypical
Year 4-5
TASK
Simple
Single
Year 1
PERSON
Adv. beginner
Novice
TASK
Complicated
Typical
Year
CONTEXT
Complex systems
Independent
Supervising others
PERSON
Proficient
Expert
CONTEXT
2-3 Larger teams
Distant supervision
CONTEXT
Small teams
Close supervision PERSON
Competent
• The concrete task
the near team
– Patient consultation, ward round,
amb., operation, diagn. investigation
• The system context and
the broader team
– Primary, secundary, and tertiary
sector and interplay within
and between these plus other
stakeholders
• The wider context and
the general perspective
– The speciality/society, the profession,
the region, the state, the society
Integrating roles at 3 layers (EPAs)
ROLES
Medical expert
Communicator
Collaborator
Advocate
Manager
Scholar
Professional
Layer 1
Layer 2
Layer 3
Roles at 3 levels (Milestones)
Roles
Med. expert
Level 1 (Y1) Level 2 (Y2)
Level 3 (Y 3-4)
Green
Green; Yellow Green; Yellow,
Red
Communicator Green
Green; Yellow Green; Yellow,
Red
Collaborator
Advocate
Manager
Scholar
Professional
Summary and conclusion
Competence?
• Competency = specific capability
– ”Reflects expectations that are expressible in
measurable behaviour; uses criterion standards for
judging; informs learners and others about
expectations” Albanese ME 2008
• Competence = holistic overall capacity
– ”The habitual and judicious use of communication,
knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily practice for
the benefit of the individual and the community
being served” Epstein and Hundert JAMA 2002
Future directions – the goals?
Outcome goals
Process goals
• Clearly defined
standards of
performance
• Training as Preparation
for Future Learning
(PFL)
–
–
–
–
Checklists
Competence cards
Rating forms
Quality of product
Efficiency dimension
–
–
–
–
Approach to the task
Deliberation, reflection
Adaptation to situation
Critical re-construction
Innovative dimension
Schwartz 2004,2005
Coles 2002
Harden 1999
Curriculum design
Plan and structure
of the experience
Appropriate level
of difficulty
Instruction
and feedback
LEARNING
Repetition and
correction of errors
Critical appraisal
of practice
Questions and
dialogue
EDUCATION
Curriculum design
Med Educ 2011
• Careful and thoughtful planning of experience
– Grade the tasks and responsibilities, acknowledge the
contextual issues of learning
• Coach
– Stimulate innovative dimension and meta-cognition –
as preparation for future learning
• Critical appraisal of practice – own and general
– Using paper assignments and students as resource
Thank you for your attention
??????
Challenge in postgraduate education
Postgraduate education
Schoolbased
Does
Does
Can
Can
Knows
Undergraduate education
Knows
Workbased
• Learn from
managing cases
• Learn how to
manage cases
•Reflect in and on
practice
Cultural dimensions
CA
DK
SE
NO
90
FI
• Individualism
80
– ‘I’ vs. ‘We’ thinking
70
60
50
• Power distance
40
– Acceptance of
hierarchies
30
20
10
0
IDV
PDI
Cultural dimensions
CA
DK
SE
NO
FI
70
• Masculinity/Femininity
60
– Competition, ‘Be the
best’, rewards for
success
50
40
30
• Uncertainty avoidance
20
– Control of future, rules,
principles, guidelines
10
0
MAS
UAI
ASSESSMENT
EPAS AND MILESTONES
CanMEDS framework in different
contexts
Final responsibility
For patient care
Training residents, students
Supervision of residents
Leader of individuals
and teams
Feedback
Knowledge
and skills
EBM and
up-to date
Team
work
Management
Time management
Financial aspects
Work in H organization
Cultural dimensions Hofstede
• Individualism
– ‘I’ vs. ‘We’ thinking
• Power distance
– Acceptance of hierarchies
50
– Competition, ‘Be the best’,
rewards for success
PDI
UAI
70
– Control of future, rules,
principles, guidelines
• Masculinity/Femininity
DK
80
60
– (Short) Truth, quick results,
normative
NL
90
• Uncertainty avoidance
• Long-term orientation
CA
40
30
20
10
0
IDV
LTO
M/F
Discussion
• The importance of contextual aspects
–
–
–
–
Cultural dimensions
Working hours (48 vs. 37); Day-care facilities
Age mean 36 (SD 4.0) vs. 44 (5.4) years
Progressive independence of trainees appear to
facilitate the transition
North America: Entrustable professional activities
And graded responsibility and Milestones
– May be in conflict with organization and finansial
models
ITA-programs and psychometrics
In-training assessment, Anaesthesiology
Ringsted et al. Med Teach 2003
st
1 ar g
ye nin
i
tra
•Cusum scoring
•Logbook on experience
•Learning portfolio
A challenge to do
psycho..analysis of this
Assessment of written assignment
Write up a plan for this patient
What if?
Old vs. young
Pregnant
Breast-feeding
Young woman
Lower abd.
Gen. anaesth.
What if?
Acute vs. chronic
Diseases: liver, kidney,
GI, CV, DM,psychiatric
Explain changes in your plan
Anatomy, Physiology, Pharmacology
Assessment of written assignment
• Reflection before and after case
– Description of patient and operation
– Theoretical and practical consideration regarding
choice of anaesthesiological approach related to
patient condition, wishes, surgery, and context
– Describe potential problems and complications and
discuss strategies to minimise these
– Describe actual patient course and events
– Reflection related to pre-operative considerations
– Use references from literature in the reflection
Trainees’ opinion of assessment (1-9)
Ringsted et al. AAS 2003
10
3
14
8
6
14
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About the written assignments





“Extremely good learning experience - to do
this review of a patient’s course ”
“It was hard work” (Trainee)
“This is really a valuable innovation in the
education - these assignments” (Trainee)
“It was more easy than I thought - to review
these assignments” (Supervisor)
“This is an advantage to the entire
department - we all learn from these..”
Kirsten Nørgaard, MHPE, 2004
Lessons learned
• Outcome-based education
– ‘CanMEDs roles’ is a nice mental framework. Need
for both competency-goals (specific capability) and
competence-goals (overall capacity)
• In-training assessment programs
– Meaningful programs are tailored to clinical
context and trainees’ level of professional
development, and drives learning in specialties’
weak areas.
• The process
– Useful to take a design-based research approach:
Cycle of critical review of data (literature, quality
of care reports, interviews); design; enactment,
evaluation; and large working groups
Mastery and Development
Scoring
Competency as capability
related to specific tasks
9
8
7
6
5
4
3
2
1
Competence as holistic
capacity related to any task
Time
1.
2.
3.
4.
5.
6.
No single method can measure it all – V.d .Vleuten 2010
assessment programs are recommended
Defined by ‘supervision’
• Beginning
•
Surgery
andsupervisory
Anesthesiology (CA):
– Difficulty despite
efforts
“We
supervise
them
Developing
– Needs supervisory
assistance
closely
all the
time!!”
• Advancing
– Often without supervisor
• Internal
Capable
•
medicine (DK):
– Usually without supervisor
“You
Skillful mean observe them AMB care – unfamiliar cases
–
Always
without
supervisor
watch what they are doing????”
Defined by expectations to level
Crossley et al., Med Educ 2011
• Below Foundation
– Basic consultation skills, incomplete history
be ‘conservative’
• Tend
Level ofto
completion
of Foundation
– Sound consultation skills, adequate history
maintain status quo rather
• Level of completion of early higher training
than
learning
inhistory
aspects
– Gooddrive
consultation
skills, sound
• not
Levelintuitively
expected during
higher training
emphasized
– Excellent and timely consultation skills, comprehensive
• Level expected on completion of higher training
– Exemplary consultation skills, complex/difficult case
Reliability Crossley et al, Med Educ 2011
Weiner et al 2010
From: Contextual Errors and Failures in Individualizing Patient Care: A Multicenter Study
Ann Intern Med. 2010;153(2):69-75. doi:10.7326/0003-4819-153-2-201007200-00002
Data collection?
111 attending physicians
Incognito patients
presented biomedical
and contextual red flags
Responses to probing:
•No complications
•Biomedical complications
•Contextual complications
•Both types of complications
Physicians probed fewer contextual (51%)
than biomedical red flags (63%)
Probing was necessary, but not sufficient for appropriate care
Perspectives
• Professionel competence
– The habitual and judicious use of knowledge, skills, reasoning,
emotions, values, and reflection in daily practice for the benefit of the
individual and the community being served
• Approach to work
– Ability to assess practice, question current practice
– Life-long learning skills, search new information, critical appraise
information and new technology and apply that in new practice
– Ability to accept uncertainty and ambiguity, know your own limits,
willingness to admit errors/mistakes and learn from these
During rotation ITA
Competence card
Items
•............X
•............X
•............X
•............X
•............X
Score
Signature
Daily supervisor
can be many different persons
Daily supervisor
Signing off
Portfolio of
competencies
Competence card no. 6
•............
•...........
•............
•............
•............
•............
X
X
X
X
X
X
Fine!!
Let us discuss
I’ll sign in
Look!
this competence
the logbook
Signature
The trainee and the supervisor
at the appraisal meeting
Competence 1 Signature
Competence 2 Signature
Competence 3 Signature
Competence 4 Signature
Competence 5 Signature
Competence 6 Signature
Competence 7 ..................
Competence 8 ..................
Portfolio signatures
Experience from internship
Henriksen et al. UfL 2008
• ”We take it at the appraisal
meeting – go over the list
and then I sign. It is not like I
observe what they are
doing”
• ”If he tells me he has done a
procedure, I trust him and
sign.”
”Its a bit like hunting for
autographs”
Perspectives
• Professionel competence
– The habitual and judicious use of knowledge, skills, reasoning,
emotions, values, and reflection in daily practice for the benefit of the
individual and the community being served
• Approach to work
– Ability to assess practice, question current practice
– Life-long learning skills, search new information, critical appraise
information and new technology and apply that in new practice
– Ability to accept uncertainty and ambiguity, know your own limits,
willingness to admit errors/mistakes and learn from these
Why in-training assessment?
• Postgraduate education is work-based
– 50% of the physician work-force are trainees
– Quality of care relies on trainees’ competence during
training
– ”End-of training examination is like reading yesterday’s
news”
• In-training assessment, a tool for learning
– Help clarify objectives according to broad aspects of
competence (CanMEDS roles)
– Stimulate deep learning
– Support effective and efficient education
Knowledge and skills
• Causal understanding of concepts, principles,
and tool design affects retention and transfer
of learning
Woods et al. 2006, 2007, Schwartz 2004
• Self-regulatory processes in development of
expertise
Zimmerman 2006
– Forethought: Task analysis, strategic planning
– Performance: Contextual adaptation of strategies
– Post-task: Evaluation and reflection Bech et al. EJVS 2010
Routine expert vs. Adaptive expert
Performance
Adaptive experts
Routine experts
Experience
”Most professionals reach a stable,
average level of performance
and maintain this mediocre
status for the rest of their careers.”
Ericsson, Guest et al., Choudhry et al. 2005, Schwartz 2004
Simulation training,
clinical training,
and follow up
(Cusum-scoring)
Pre-training in gastrointestional endoscopy utilizing
computerized simulation
Theory (mandatory)
(Cotton & Williams, SADE’s textbook)
Introduction (45 min)
(Technical handling, structured instruction)
Adamsen 2002
Pre-program scoring
(”Cyber-scopy”)
Gastroscopy: 20 scenarios
Simulation program (2-3 days)
pass pylorus
retroflect
• consecutive order
total time < 15 min.
• proceed only when all criteria met
In-vivo Colonoscopy After Simulation
Colonoscopy: 20 scenarios
• last case with supervisor observing
reach coecum < 15 min.
excessive pressure < 5 x
lost view < 5 x
4
Review of performance, post-program scoring
Cusum score
3
(repeat program or part of program if needed)
2
In-vivo supervised endoscopy
(same criteria as above)
1
Final pre-training evaluation
0
0
1
2
3
4
5
6
7
Scenario
-1
8
9
10 11 12 13 14 15
Credentialling
H:S PMI
Postgraduate Medical Institute
Copenhagen Hospital Corporation
Training log (CUSUM score)
Continuing reporting
to project to evaluate
impact of simulation
Sven Adamsen
Transatlantic comparison of the competence of
surgeons at the start of their professional career
M. P. Schijven et al. BJS 2010
Table 3 Canadian (84 hours) and Dutch (55 hours) residents on
the four primary outcome measures
Canadians
Dutch
t40
P
CIP
0·52(0·05)
0·53(0·07)
0·18
0·856
PAME
0·85(0·06)
0·79(0·05)
3·90
<0·001
OSATS-C
0·78(0·06)
0·75(0·06)
1·33
0·192
OSATS-G
0·75(0·06)
0·74(0·07)
0·66
0·515
Values are mean(s.d.). CIP, Comprehensive Integrative Puzzle; PAME, Patient
Assessment and Management Examination; OSATS-C, Objective Structured
Assessment of Technical Skill checklist; OSATS-G, Objective Structured
Assessment of Technical Skill global rating scale.
System-based practice (manager)
• Work effectively in various health care settings and
systems. Coordinate patient care within the system
• Consider cost and risk-benefit. Advocate for quality
in patient care and optimal patient care systems
• Work in inter-professional teams to enhance patient
safety and improve quality. Participate in identifying
system errors and implementing potential systems
solutions
Learning outcome and transfer
• Defining and measuring learning Wulf & Shea ME 2010
– A relatively permanent change in a person’s
capability to perform, must be demonstrated by
retention or transfer tests
• The concept of transfer
Schwartz et al. 2004
– Assessment according to concept of preparation for
future learning (PFL) rather than direct application
according to an outcome-defined standard
Challenges
• Describing competence and outcome
– Too detailed – Be able to manage - Lists of
procedural skills, diseases (+300 competencies)
– Too general - The ‘intrinsic’ roles - difficult to define
• Disintegration of the concept ‘competence’
– Seven disciplines rather than an integrated,
context-based concept of competence
• Expectations at various levels of training?
– EPAs and Milestones?
Aspects of competence
CanMEDS roles
– Medical Expert
– Health Advocate
– Communicator
– Collaborator
– Manager
– Scholar
– Professional
ACGME competencies
– Medical knowledge
– Patient care
– Interpersonal and
communication skills
– System based practice
– Practice based learning
and improvement
– Professionalism
Confident
Survey among
Nordic junior
Doctors
N = 621
More than 24 months
Why focus on theory and reflection?
Klemola and Norros, ME 1997, 2001

Anaesthesiology
– Clinical physiology and pharmacology; Procedural skills; Monitoring of
respiratory and cardiovascular parameters; Context – patient, surgery,
team
Two distinct patterns related to ‘experts’
• Realistic orientation
– Recognition of
uncertainty and
unpredictability
– Communicative
relationship: each
patient is unique
• Objectivistic orientation
– No recognition of
uncertainty and
unpredictability
– Authoritative relationship:
’a case’: coronary,
asthmatic, etc
Habit of action
• Interpretative
– Combine monitor
information with
situational information
and background
knowledge
– Recognition of the
versatility of information
from several resources,
oxygen SAT, End-tidal
CO2, etc.
Klemola and Norros, ME 1997, 2001
• Reactive
– Operate directly with the
numbers
– Contradictory use of
monitors, emphasising
importance regarding
patient safety without
understanding the
mediated character and
versatility of information
Knowledge and Anaesthsiology
Klemola and Norros, ME 1997, 2001
• Forethought: physiological potentials
– ”He can go uphill without getting out of breath, so probably
he will tolerate anaesthesia well. Major problem might be
oxygenation and ventilation.”
• Adaptation: physio-pharmacological experiment
– ”You can’t tell how an elderly patient will react. You have to
check his responses and give drugs accordingly.”
• Evaluation and reflection-in-action
Flexner ?
– ”The patient has capacity to compensate for side-effects of
anaesthesia through sympathetic activation, a kind of
capacity that elderly patients do not necessarily possess.
That is a safe thing to observe”
Influence of society of VATS
• Societal contagion
– Cohesion, close direct relation, ’friendship’
• Conversation, discussion (dyad system)
– Structural equivalence, identically positioned, but not
necessarily in direct contact
• Competition, status (social system)
• Both cohesion and structural equivalence
– Inspiration, coach, competition
» Burt 1987 on Coleman, Katz, and Menzel's (1966) Medical Innovation
(Tetracycline)
Experience is not enough
Debilerate practice
Guest et al, 2001, Coles 2002, Andersson, 2004
• Critical appraisal and reconstruction of practice instruction, monitoring, feedback and discussions,
and opportunities to improve performance
repeatedly
Concrete
experience
New experience
new situations
LEARNING
Abstraction,
generalisation
Observations
and reflection
Curriculum design
Plan and structure
of the experience
New experience
new situations
Appropriate level
of difficulty
Concrete
experience
LEARNING
Instruction
and feedback
Observations
and reflection
Abstraction,
generalisation
Repetition and
correction of errors
Critical appraisal
of practice
Questions and
dialogue
EDUCATION
Training curriculum
Work-based education
Does
Can
Knows
• Learn how to manage tasks
– Preparation, instruction and
feedback
• Simulation
• Leaning guides and ITA
• Learn from managing tasks
– Wide experience
– Reflection in and on practice
– own and unit’s pracitice

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