Blended learning framework to teach clinical reasoning

A framework underpinned by cognitive load theory and collaborative team based learning to teach clinical reasoning skills.

Underpinned by an innovative flipped learning model, ensures that both the online content and the classroom activities are based on the same pedagogical principles and cognitive psychology.

The online content is specifically designed to introduce new concepts through a series of worked examples that allow the student to process the information through decision making tasks, clinical reasoning and observations.

The relevant science is described in context to support understanding of the condition being presented.  Cases feature a video demonstration of patient symptoms or presenting complaint to provide authenticity to the scenario.  The clinical reasoning required to explain symptoms and signs, order and interpret investigations and start management is demonstrated as the case develops.

The inclusion of authentic learning tasks, guided instruction and supportive information will assist in knowledge acquisition and the transfer of learning to new contexts.

Students complete scenario based assessments to determine readiness for group discussion.

Students are equipped to attend the face to face activity with:
•       a good understanding of the relevant basic science and patient presentation
•       basics in clinical reasoning and decision making.

The format of the group discussion has been designed as an interactive case based discussion, drawing upon elements of the online case, but providing different contexts to enable students to apply and practice their clinical reasoning skills to new patient scenarios. The format is structured to ensure small group collaboration around authentic patient tasks.

 

blended learning and assessment framework

In Summary

Preparation phase – readiness to attend classroom activity – worked examples/reflection/assessment – to determine knowledge level

(instructional strategies – visual design, multimedia design, interaction design (reduce cognitive load)

Case based scenarios using worked examples – showing clinical thinking processes of expert clinician

  • 3 example cases – reference to different systems

Collaborative team based learning phase

  • Initial testing
  • Scenarios – group collaboration
  • Reflection with resident/registrar facilitator

Workplace phase

  • Application to clinical work setting
  • Collection of patient stories
  • Supervisor assessment

Post activity phase

  1. Reflection in action
  2. At point of care guidelines – summary from prep docs/learning points from f2f
  3. Practical tips to suppor future clinical practice

Program evaluation

  • Supervisor perception
  • Revision of content and teaching strategy to inform quality improvement process

 

How engaging is your eLearning content?

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Image source: storylines.com

In the late 1990s online education was going to revolutionise the way higher education institutions delivered learning.  At that time hardcopy materials (pdfs and powerpoints) were uploaded to learning management systems and this was how ‘elearning’ courses were presented.  Known then as ‘shovel- ware’ – an information dump of static content and electronic page turning.

The delivery of content in this format evokes a passive consumption of information, that allows little to no interaction or engagement.

Sadly, not much has changed in the past 20 years in the design and delivery of online education.  Today many higher education institutions have implemented policies that mandate the recording of lectures or the production of voice over powerpoints (VOPPs) and these are the ‘standard’ delivery format of elearning resources.  The most interactivity a student will experience is ‘click the next button’.

The potential of digital technologies offers so much more, it provides the opportunity to move from the ‘transmission’ of content to enabling students to actively engage, interact and ‘create knowledge’.

With the advances in technology, and the potential of technology enhanced learning why are we still trying to emulate the traditional didactic lecture IN the ‘online space’?

  1. Being constrained by clunky learning management systems and basic authoring software
  2. Poor understanding of the principles of learning design and effective #presentationskills
  3. Lack of faculty support and professional development in terms of technology enhanced learning, digital or Web 2.0 teaching tools, best practice in online design
  4. Lack of institutional resources to create online content from scratch (born digital content)
  5. Adoption of across the board policies and work procedures that constrain the development of interactive approaches to design eg mandatory recording of lectures and voice of powerpoint (VOPPs)
  6. Little student engagement in the design process
  7. Implications of  how the digital savvy student learns best. (anywhere anytime access/short information chunks/influence of social media)
  8. Little reference to learning theory and elearning pedagogy

Learning management systems

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Current issues:

  • Majority are antiquated systems designed by an out of date’folder’ structure
  • Poor navigation and not being user friendly deters both faculty and students from using the system
  • aren’t aligned with current web 2.0 approaches that enhance user experience and communication and collaboration

Faculty support – what is needed?

  • We need to value, develop and engage academic staff to embrace innovative teaching practice and develop skills to design effective elearning content and deliver active face to face learning experiences with in-class technology
  • How to integrate social media and free open access resources in the delivery of their education programs.
  • To work closely with academics to identify the optimal educational options for delivery using blended learning models, web 2.0 tools & learning design approaches to create immersive digital learning experiences.

blended learning and assessment framework

  • Back to the basics regarding presentation skills

Born digital content – content designed from scratch

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Image source: lucasarchives.com
  • What are the objectives, what are the learning outcomes.
    • What is the learner going to do with the content – what activities can be included to move the learner from a static/passive observer and consumer of information to active involvement and engagement.
  • The story – relevant to the learner, authentic conversational.
  • Visual design, the selection of media/ images/video/audio. How will the media best represent the content or learning activity.
  • What is the sequence of activities, questions, feedback.
    • Creating decision making scenarios
    • Embedding decision points/decision paths that reflect the complexities of the task.
    • Incorporating feedback that help learners build models that they can transfer to the work environment.

Storyboard is the first step to bring all these elements together.

With the inclusion of authentic stories and relevant context online content can be dynamic, interactive and thought provoking.  See creating eLearning in medical education

Student engagement – students as co-creators of content

  • Students to be actively involved in the implementation of TEL strategies, providing ideas and suggestions that will enrich their learning experience
  • Value student contribution in the teaching process and promote students as co-creators of content
  • Engage students in learning design and content creation, scaffold with design workshops, background in learning theory and principles of online design.

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  • Provide opportunities for students to gain experiences using the tools to create eLearning content
  • Opportunities to create content, showcase and use as resources for future students

See students as co-creators and doctor as digital teacher

Relevance of learning theory

Flipping the classroom

The flipped classroom describes a reversal of traditional teaching where students acquire exposure to new material outside of the class room. Class time is then dedicated to assimilating that knowledge through strategies such as problem solving, discussion or debate (Vanderbilt University, Center for Teaching).

The recent trend of ‘Flipping the classroom” has seen a proliferation of video lectures available for students to access online. These examples of content delivery evoke a passive consumption of information…with little thought to instructional design, learning outcomes, learner engagement or behavioural change.

To create online learning experiences that encourage active learning, the content needs to be redesigned or re-created from scratch (born digital content).   The redesign of the learning materials into interactive activities promoting decision making and problem solving ensures user engagement and higher order thinking, thus promoting deeper learning. Emphasis is placed on chunking content into learning snacks that allow the user to reflect, synthesize and perform.

This then frees up the the valuable face-to-face workshop time to focus on interaction, discussion, and the practical application of the online content. The key to the success of this flipped approach is that BOTH delivery components (online and face to face) involve active learning and engagement.

I have been using the flipped classroom approach for a number of years,  and work closely with content experts/clinical teachers/academics to create high quality online modules that compliment and support their teaching programs.

I have adopted this flipped classroom model to support the teaching program for 3rd and 4th Year medical students at the UQ Rural Clinical School, Toowoomba, Australia.

The online content is specifically designed to introduce new concepts through a series of activities and demonstrations that allow the learner to process the information through decision making tasks, clinical reasoning and observations. The learner is then equipped to attend the workshop with:

  • a good understanding of the concepts and theory
  • basics in clinical reasoning and decision making

This allows for interactive discussion, sharing perspectives and transfer of knowledge and skills to new cases or context (under the guidance of the clinical expert).

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The following 4th year programs illustrate this approach

  • Flipped Simulation: A series of online simulation scenarios that support the clinical skills simulation program offered to 4th year medical students. In creating the online content, the LIVE simulation learning materials (scenarios and scripts) are re-designed to incorporate authentic decision making activities.  Students work through the scenario demonstrating how they would communicate with the health professional team, and interact with the patient to inform their diagnosis and manage the patient.  Each scenario is supported by observation charts, pathology, radiology and relevant medical notes. Students attend the live scenario feeling better prepared and more confident in their ability to diagnose the presenting complaint and manage the patient.
  • Flipped intern readiness program: a series of e-Tutorials followed by cased based workshops.
    • The introductory learning package consists of an online ward round where the student is taken on a virtual patient round and completes tasks such as handover and filling in medical charts as they move through the activities of the ward round. This is then followed by a live classroom mock scenario, in which students are given patient details and then complete the medical notes, order investigations (pathology, radiology). This exercise is followed by small group reflective discussion with past residents and clinical teachers.
    • Ward Skills: Preparing for the Ward Round, Attending the ward round, After the ward round
      • the eTutorials provide practical examples and demonstrations and tasks; the face to face interactive workshops are based on mock ward round scenarios, hands-on activities, small group reflective sessions.
  • Intern readiness presentation AMEE2015 (Click link)

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the eLearning journey at our teaching hospital

I have worked in medical education for 10 years now as education advisor to our clinical training director (an amazing emergency medicine specialist who has a natural gift for teaching…we have grown together in the job, supporting one another in our roles managing the junior doctor education program at our hospital. Having a background in education and a Masters in Education Technology I was continually searching for ways to provide online support to our juniors’ training program.  This was  a challenge at first..

In 2009 I implemented Moodle LMS to support their training. I moved all the mandatory training modules onto the LMS, to free up our intern orientation week, I added orientation resources for each department rotation and then recorded the weekly education sessions so that they were available online.  This led to developing other education modules around topics of relevance.

Access to computers was difficult so other delivery methods were investigated.

In 2011, final year medical students (n=30) who were about to commence work at Toowoomba Hospital were invited to complete an online survey regarding their mobile learning habits :

  • use of digital  technology to access information and learning
  • type of mobile devices used
  • usefulness of mobile learning resources to support their training and likelihood of future access

Survey results confirmed a high percentage of mobile access to digital content via smartphones.  100% indicated they would like resources to be distributed in this format.

A mobile learning initiative was established to transform the delivery of information to support junior doctors in decision making at point of care.  With the transformation of delivery comes transformation of content design. Information presented needed to gain attention quickly, and focus on specific relevant knowledge required at point of access for the current workplace or learning need.

The following resources were developed for mobile distribution :

  • ABF guide and clinical documentation
  • Managing Diabetes in the Ward
  • Blood Gas Interpretation
  • Ward Call guidelines

Mobile technologies have opened up new ways of thinking about delivering content and meeting the needs and expectations of a more connected generation of learners.

The next phase was adopting the flipped classroom model for their formal education program.  Creating preparation modules for the weekly education sessions. Interactive content was created to engage the user in decision making processes.  This was then followed by an interactive classroom discussion around relevant case scenarios.

This flipped model was also utilised with the re-design of the Teaching on the Run Program for the clinical teachers at the hospital.  The six 3 hours workshops where reformatted into   6 online preparation modules followed by shorter interactive workshops. This approach was well received by both participants and facilitators of the program.


			

Twitter: connect, communicate, collaborate, contribute, create…

I was introduced to twitter at AMEEMilan in 2014. where I participated in a Twitter workshop where three impressive educators (Natalie Lafferty, AnneMarie Cunningham and Margaret Chisolm) gurus in the field of social media, introduced me to a new world of connectedness, learning and sharing.

I am using twitter to follow the experts in my field, and those that i believe are making an impact in medical education and social media.  Over the last two years my personal learning network has grown and through these connections I have been able to collaborate on projects, share and contribute to the conversations and grow both personally and professionally. The following image represents a  portion of my personalised learning network and includes medical educators that have added value to my learning journey. It illustrates project collaborations, learning opportunities and events that have evolved through online social interaction.

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