Joanne L. Becker, MD

Joanne L. Becker, MDChief, Laboratory Medicine,

Roswell Park Comprehensive Cancer Center

Adjunct faculty, Department of Pathology and Anatomic Science,

University of Buffalo School of Medicine and Biomedical Sciences

Didactic Lectures to cover the curriculum • Staff

• Resident directed

Service

Technical• Validation

• QC

• PT

Clinical Correlation

Regulatory

Coding

Financial

Surprise

Fun

Joy

Suspense

Responsibility

Ownership

Curiosity

Problem

Ideas

KnowledgeLearning Issues

Course of Action

Increase motivation for self-directed learning by providing engagement in independent reading and research.

In a study of whether using PBL increases self-directed learning in residents, the finding was that they were very willing to report low levels of self-directed learning behaviors while a resident.

Arch Pediatr Adolesc Med 2001; 155:669-672

Preparation for Life Long Learning

Format for approaching questions

Increased exposure to relationships

between departments, facilities, and

institutions

Cognitive load theory says that novice

learners require explicit instruction that

explains the targeted concepts and

procedures without a need for learners to

infer anything on their own.

PBL wants the learner to begin with their

knowledge, identify what is not known,

and develop new knowledge that can be

applied to the problem

In studies of medical students, those who

were involved in PBL curriculum had

higher meaningful learning experience

scores than those with a traditional

curriculum. Unfortunately, these scores

did not continue into the clerkship years

Academic Medicine 2001;76(10):S84-S86

PBL

Understand the Problem

• Meet the Problem

• Define the Problem Statement

Patients

Correlations

Technical Issues

Abnormal Values

Critical Values

New Requests




Explore

• Gather Information /Share Information

• Generate Solutions

Who

What

Where

When

Why

How




Explore

• Gather Information /Share Information

• Generate Solutions

Resolve the Problem

• Determine the Best Fit Solution

• Present the Solution

Statement of problem

Background

What they found out

How the problem was resolved

The same problem to an intern vs 4th year

resident should not have the same

presentation.

Ask questions for which an answer should

be known

AND

Ask questions which will require more

investigation to find an answer

Anything missed in analysis

Facts for board preparedness

Patient issues

Care team issues

Coordination issues

Regulatory issues

Always bring an

additional case or two

from the previous

week ….just in case.

Be prepared to say

that you don’t know.

Have fun

Thinking is good

Learning is a process

Providing education in

different ways means

that everyone will

learn something

somewhere.

Every Case Can Teach:

Problem Based Learning (PBL) and Entrustable

Professional Activities (EPA)

Objective #3: Define EPAs and create an EPA

Gay Wehrli, MD, MBA, MSEd

University of Virginia Health SystemMonday, October 15, 2018 at 0830-1000

BCEC 252AB

Faculty Disclosure(In compliance with ACCME policy, AABB requires the following disclosures to the session audience)

• Nothing to disclose

www.aabb.org 2

Acronyms and Definitions

• ACGME: Accreditation Council for Graduate Medical Education

accrediting body for trainees

• CCC: Clinical Competency Committee

in-house committee

evaluates each trainee twice yearly on 6 core competencies set by ACGME

• EPA: Entrustable Professional Activity

documentable activity to evaluate competency in area of training

learner proficiency and educational outcomes

3

Background: We’ve come a long wayYear Advancement

1981 Accreditation Council for Graduate Medical Education (ACGME)

1999 Six (6) General [Core] Competencies endorsed by ACGME & ABMS

2001 The Outcomes Project formally launched (start using competencies)

2009 ACGME approves structure of Next Accreditation System (NAS) including Milestones

2013 Seven (7) specialties enter NAS including Milestone reporting

2014 Remaining accredited specialties & subspecialties enter NAS, including Milestone reporting (& CCC)

2015 All specialties and subspecialties begin to report Milestones data

2017 College of American Pathology publishes Entrustable Professional Activities (EPA)

2018 AABB Annual Meeting presentation on EPA

Accessed 8/11/2018: https://www.acgme.org/What-We-Do/Accreditation/Milestones/ResourcesABMS: American Board of Medical Specialties CCC: Clinical Competency CommitteeSeven Specialties: EM, IM, Neuro Surgery, Ortho Surgery, Peds, Diagnostic Radiology, Urology

https://www.acgme.org/What-We-Do/Accreditation/Milestones/Resources

Competency Based Education (CBE)

• Outcomes focus

accountability without compensatory abilities

• Emphasize ability

synthesis of knowledge, skills, and attitudes

• Progression flexibility

de-emphasize time-based training

progression on abilities and performance

• Learner centeredness

engagement

www.aabb.org 51. ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39:1176-11772. Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32:638-645.

COMPETENCY

Entrustable Professional Activity• Faculty & staff observe and evaluate trainee

Milestones• Set by ACGME Committee • Observable steps on continuum of clinical, professional development• Skills and knowledge development• Behaviors, attributes, or outcomes demonstrated• Benchmarks with feedback

ACGME Six Core Competencies• Across all ACGME-accredited programs

MILESTONEMILESTONE

MILESTONE

MILESTONE

MILESTONE

Let’s get Competent

EPAEPA

EPA

EPA

EPA

6

ACGME 6 Core Competencies and the CCC

Patient Care

(PC 1-7)

Practice-based Learning &

Improvement

(PBLI 1-2)

Medical Knowledge

(MK 1-3)

Professionalism

(PROF 1-6)

Systems-based Practice

(SBP 1-7)

Interpersonal & Communication

Skills

(ICS 1-2)

1. PC = Patient Care

2. MK = Medical Knowledge

3. SBP = Systems-based Practice

4. PBLI = Practice-based Learning & Improvement

5. PROF = Professionalism

6. ICS = Interpersonal & Communication Skills

7

• Milestones• EPAs• Evaluations• Observation• In-services

CCC

PC1: Consultation: Analyzes, appraises, formulates, generates, and effectively reports consultation (AP and CP) Has not

Achieved Level 1

Level 1 Level 2 Level 3 Level 4 Level 5

Understands the implications of and the need for a consultation

Observes and assists in the consultation

Understands the concept of a critical value and the read-back procedure

Understands and applies Electronic Medical Record (EMR) to obtain added clinical information

Understands that advanced precision diagnostics and personalized medicine (e.g., molecular diagnostic testing) may be applied to patient care for genetic, neoplastic and infectious disorders, and population health

Prepares a draft consultative report (verbal or written)

Performs timely, clinically useful consultation for requests for products or additional testing

Understands rationale for the critical value list

Knows the critical value list and participates in the critical value call-back of results

Understands the importance of accurate, timely, and complete reporting of laboratory test results

Understands the role of specific advanced precision diagnostics and personalized medicine assays, and how results affect patient diagnosis and prognosis, and overall patient care

Prepares a full consultative report with a written opinion for common diseases

Prioritizes and presents patient care issues for report after call

Answers routine pathology questions, drawing upon appropriate resources

Applies the escalation procedure for failed critical value call-backs

Effectively communicates preliminary results on cases in progress

Understands pre-analytic issues and quality control for advanced precision diagnostics and personalized medicine

Independently prepares a full consultative written report with comprehensive review of medical records on common and uncommon diseases

Runs report conference after call

Develops a portfolio of clinical consultation experience Recommends new or alternate escalation procedures for failed critical value call-backs as needed

Suggests evidence-based management, prognosis, and therapeutic recommendations based on the consultation

Provides consultation, as needed, to clinicians about utilization and interpretation of advanced precision diagnostics and personalized medicine

Proficient in pathology consultations with comprehensive review of medical records

Demonstrates an expanded portfolio of clinical and patient care experience with pathology consultation

Participates in intuitional processes of generating the critical value list

Is proficient in consultation regarding test utilization and treatment decisions based on advanced precision diagnostics and personalized medicine

Comments:

Suggested Evaluation Methods: Direct observation, Retrospective peer review, Portfolio, Feedback from clinical colleagues (360 evaluations), Peer review, HIPAA training documentation provided

Milestone:Applies EMR

Sub-competency PC1: Consultation

Developmental Progression Levels 1-5:

Sets of Milestones

Core Competency: PC = Patient Care

8https://www.acgme.org/Specialties/Milestones/pfcatid/17undefined/Specialties Accessed 8/21/2018

https://www.acgme.org/Specialties/Milestones/pfcatid/17undefined/Specialties

Why Create Entrustable Professional Activities?

• Resident comfort level with:

Daytime coverage

Night & weekend coverage

• Do we know?

www.aabb.org 9

Resident Comfort Level Covering the BBTMS

Daytime Comfort LevelN = 14 (PGY2-4)

Extremely Confident Very Confident Slightly Confident Not at all confident

Taking call for BBTMS 0 8 (57.1%) 6 (42.9%) 0

Taking a TxRx call 2 (14.3%) 5 (35.7%) 5 (35.7%) 2 (14.3%)

Calling BBTMS Attending 2 (14.3%) 9 (64.3%) 3 (21.4%) 0

UVA IRB for Health Sciences Research BBTMS = Blood Bank and Transfusion Medicine Services TxRx = Transfusion Reaction

Night/Weekend Comfort LevelN = 8 (PGY3-4)

Extremely Confident Very Confident Slightly Confident Not at all confident

Taking call for BBTMS 0 6 (75.0%) 2 (25.0%) 0

Taking a TxRx call 1 (12.5%) 6 (75.0%) 1 (12.5%) 0

Calling BBTMS Attending 1 (12.5%) 3 (37.5%) 4 (50.0%) 0

10

• PGY1-4 Residents Surveyed

• Responses from 18 of 21 (85.7%)

CAP: EPAs for Clinical Pathology

1. Compose a diagnostic report for clinical laboratory testing

requiring pathologist interpretation

2. Evaluate and report adverse events involving the transfusion of

blood components

3. Evaluate and report critical values in the clinical laboratory

4. Perform other procedures (e.g., bone marrow aspiration and

biopsy, apheresis)

McCloskey CB, Domen RE, Conran RM, et al. Entrustable Professional Activities for Pathology: Recommendations From the CAP GME Committee. Academic Pathology. 2017;4:1-9. Supplementary Materials: EntrustableProfessional Activities (EPAs) for Pathology GME: Recommendations from the CAP GME Committee.

12

CAP EPA: Evaluate and report adverse events involving the transfusion of

blood components (CP)

Description& Tasks

Pathologists are able to diagnose and manage adverse reactions related to blood component transfusion.Knowledge and skills required include the ability to:1. Provide direction for laboratory evaluation of adverse reaction related to blood component transfusion2. Assess and evaluate patient clinical history, signs and symptoms, radiology findings, and laboratory testing to

determine the cause of the adverse reaction3. Provide recommendations for treatment interventions to manage adverse reactions if indicated4. Compose a written report documenting the adverse event and workup, classifying the reaction, providing guidance

for additional transfusions, and documenting communication with clinical providers regarding the adverse reaction5. Effectively communicate handoff information for unresolved issues (e.g., pending testing) with fellow pathologists,

clinicians, or laboratory technologists6. Determine the need to report adverse events to the appropriate regulatory authority

Relevant CoreCompetencies& Milestones

1. Patient Care: PC1, PC22. Medical Knowledge: MK1, MK23. Systems‐based Practice: SBP1, SBP24. Practice‐based Learning & Improvement: PBLI15. Professionalism: PROF2, PROF3, PROF56. Interpersonal & Communication Skills: ICS1, ICS2

AssessmentMethods

1. Direct observation2. Record review of written reports/chart audits3. Portfolio

13

Developing the University of Virginia EPA for

Transfusion Reactions (TxRx)

• Develop an Acute TxRx intake form

• Develop the TxRx EPA process and form

• One hour didactic lecture introducing the above

• Response from residents

14

15BBTMS = Blood Bank and Transfusion Medicine Services

Acute Transfusion Reaction (TxRx) Intake Form

Acute Transfusion

Reaction (TxRx)

Intake Form

BBTMS = Blood Bank and Transfusion Medicine Services

EPA: Transfusion Reactions

BBTMS = Blood Bank and Transfusion Medicine Services

17


EPA #1 for Transfusion Reactions (to be completed during PGY 1 block)ACGME

Competency Present all of the following to the attending

o Obtain transfusion reaction history from clinical team ordering the transfusion reaction work-up (e.g., physician, LIP or nurse)

o Review clinical history and BBTM historyo Create initial differential diagnosis including why or why not each diagnosis is in the

differential

PC2 & MK1

Communicate to the primary team additional testing needed (e.g., Chest x-ray, blood cultures, urinalysis, BNP, etc)

ICS1 & ICS2

Communicate to the BBTM staff additional testing needed (e.g., culture unit) ICS1 & ICS2 Complete and fax to VBS/ARC an initial transfusion reaction report (e.g., TRALI, septic

reaction)ICS1 & ICS2

Initiate Beaker transfusion reaction report and send to attending for initial review SBP7

Observe a transfusion reaction work-up with the BBTMS technologist (including clerical check, serologic testing, documentation in Sunquest and on BB: 67 form and additional work such as ordering culture and/or VBS/ARC notification)

SBP6, ICS1 &ICS2

18


EPA #2 for Transfusion Reactions (to be completed during PGY 1 block or PGY 2 first block)

ACGME Competency

Present all of the following to the attendingo Review the BBTMS’s Transfusion Reaction Evaluation Form (BB: 67), after completed by

the BBTMS technologists (including all line items on the form)o Review 24-hour clinical history post-transfusion reaction o Refine differential diagnosis including how to rule in or out each differential

PC2

Communicate to the primary team additional testing needed ICS1 & ICS2

Communicate to the BBTM staff additional testing needed ICS1 & ICS2

Update Beaker transfusion reaction report and pend final to attending for review and sign-off

SBP7

Fax to VBS/ARC the final verify transfusion reaction report ICS2 & ICS2

19


EPA#3 for Transfusion Reactions(to be completed prior to taking overnight CP/LM call)

ACGME Competency

Independently perform an entire transfusion reaction review and complete the report in Beaker. Send to the attending for review and final verify sign-off.

PC2 & SBP7

20


Supporting Documents for Review and Guidance

1. Primer on transfusion reactions

2. Transfusion reaction report templates PDF

3. Writing a transfusion TxRx report in Epic Beaker: BBTM Reporting Basics

4. More about transfusion reactions: UVA Clinical Practice Guidelines for Transfusion (Transfusion Guidelines desktop icon)

5. Blood Center transfusion reaction forms

6. Acute TxRx Intake Form

7. Paradigm, Blood Bank SOP F29: Evaluation of Adverse Reaction to Blood Transfusion

8. Blood Bank BB:067 – Transfusion Reaction Evaluation Form

BBTMS = Blood Bank and Transfusion Medicine Services21

www.aabb.org 22

EPA Bystander Effect:

Transfusion Reaction Order Set

Summary

• EPAs will effectively ensure trainees achieve desired outcomes on

their pathway to become independent professionals

• EPAs are an objective method for evaluating progression and

achievement

Everyone evaluated with the same criteria

Alleviate evaluator bias

• Plan ahead! EPAs will take time to create and implement.

Stay tuned for updates from the UVA experience

www.aabb.org 23

www.aabb.org 24

What’s next in the alphabet soup of education?

Every Case Can Teach: Problem Based

Learning and Entrustable Professional

Activities

10/15/2018

Faculty Disclosures

The following faculty have no

relevant financial relationships

to disclose:

– Joanne Becker MD

– Gay Wehrli MD, MBA,

MSEd

The following faculty have a

relevant financial relationship:

– Laura Cooling MD, MS

Ortho Clinical

Diagnostics:

Consultant

www.aabb.org 2

Learning Objectives

• Describe the problem based learning models and list

learner skills attained through PBL

• Propose real-life examples for integrating PBL into a

resident rotations

• Define entrustable professional activities (EPA) and

create an EPA

www.aabb.org 3

EVERY CASE CAN TEACH! PROBLEM-BASED LEARNING & ENTRUSTABLE PROFESSIONAL ACTIVITIES

DIRECTOR: JOANNE BECKER

AABB 2018 ANNUAL MEETING

HOW MEDICAL STUDENTS MADE ME FLIP

Laura Cooling MD, MS

Professor, Pathology

Michigan Medicine

University of Michigan

CONFLICTS

Past consultant for Ortho Clinical Diagnostics

I am a student (not an expert) on medical education

LECTURE OUTLINE

Brief, broad overview of active and problem-based learning (PBL)

Flipped PBL classroom model

Experience of PBL-teaching in the new medical school curriculum

Pre-work

Classroom PBL

Identifying student weaknesses

CHALLENGES IN MEDICAL TEACHING

Expert vs Novice Learning

Passive vs Active Learning

Superficial vs Deep Learning

PROGRESSION IN MEDICAL COMPETENCY DURING GME

NOVICE ADVANCED BEGINNER COMPETENT EXPERT PROFICIENT

PATHOLOGY RESIDENCY

FELLOWSHIP

PROFESSIONAL EXPERIENCE

4TH Year

EXPERT VS NOVICE LEARNING

https://www.searlesgraphics.com/technology/database-design

EXPERT

Broad Foundation

• Knowledge

• Experience

• Problem-Solving

Clinically proficient

Holistic perspective

Recognize deviations (exceptions of the rule)

Excellent problem-solving

• Experience & pattern recognition

Practice skills

EXPERT PROBLEM-SOLVING

Forward or Linear Reasoning Skills

chief complaint

positive symptoms

negative symptoms

physical exam

laboratory studies

other studies

Possible Diagnosis

Possible Diagnosis

Possible Diagnosis

Possible Diagnosis

More diagnostic studies

FACTS

Diagnosis

ANSWER

NOVICE LEARNING

NOVICE

Foundation Under Construction

• Gathering material

• Learning how things ‘connect’

Know little of the subject

Little situational perception

Narrow focus

Rigid adherence to rules

NOVICE PROBLEM-SOLVING IS BACKWORD REASONING

https://www.dfir.training/dfir-training-categories-k2/item/124-stop-forcing-the-square-dfir-peg-into-the-round-hole

Disease

symptoms

physical findings

laboratory studies

history

radiology

Diagnosis

What fits for this disease

• History

• Symptoms

• Physical findings

• Laboratories

• Radiology

TRADITIONAL CLASSROOM

Instructor

Content expert

Broad foundational

knowledge base

Material is taught in linear fashion

LEARNING CONCEPTS

Expert vs Novice Learning

Passive vs Active Learning

Superficial vs Deep Learning

PROBLEM BASED LEARNING: ACTIVE VS PASSIVE LEARNING

Passive Learning

Teacher-centric

Teacher Student

Superficial learning

Rote memorization

IMPACT ON LEARNING, RETENTION AND COMPETENCY

https://www.t1v.com/blog/active-learning-vs-passive-learning-and-the-differences-in-classroom-technology/

DEEP LEARNING : ACTIVE LEARNING

Deep Learning: Genuine understanding of the topic

Goals for students:

Engage with topic

Elaborate on the topic

Relate the topic to the other ideas (analogy)

IMPACT ON LEARNING, RETENTION AND COMPETENCY

https://www.t1v.com/blog/active-learning-vs-passive-learning-and-the-differences-in-classroom-technology/

ACTIVE LEARNING: DEEP LEARNING

Simple Methods

Complex Methods

University of Michigan Center on Learning and Teaching (CRLT)

Problem – based

learning

WHAT IS PROBLEM BASED LEARNING (PBL)

“The best way of learning about anything is by doing” Richard Branson

PBL Guiding Principles

Adult Learning Theory

Learning builds on prior knowledge / personal experience

Applicable to life / work

Self-directed

Problem-solving

Active learning

PROBLEM-BASED LEARNING: ACTIVE LEARNING

Instructor

facilitator and

coach

Student-centric

Problem-based learning• Problem-solving

• Self-directed learning

• Peer – peer instruction

• Conflict of opinion

• Idea exchange

• Self-correction

• Communication skills

PROBLEM – BASED LEARNING IS DEEP LEARNING

DEEP LEARNING TECHNIQUES

Good questions

Analogy

Construct Mechanism / Concept Maps

Apply knowledge to new problems

Critical Thinking Skills

Peer - Peer Teaching

Feedback

Learn by doing

Practice of cognitive skills

PROBLEM – BASED LEARNING

Problem-solving

Self-directed learning

Peer – peer instruction

Idea exchange

Conflict of opinion

Self-correction

Communication skills

PBL IN MEDICAL EDUCATIONBASIC SCIENCE

Anatomy

Physiology

Pathology

CLINICAL

SCIENCE

Problem – Based Case

“virtual practice experience”

BASIC SCIENCE

Anatomy

Physiology

Pathology

CLINICAL

SCIENCEConcept Integration

Feedback Loop

• Re-inforce concepts

• New Knowledge

Pattern Recognition

• Improved recall facts

• Problem-solving skills

Two 1 hour

didactic lectures

ABO + blood components

Adverse reactions

1.5 hoursSame content

Historically 2016 2017

1 hour

2018

1 hour

M1+M2 year

(13 months total)

Transition to new curriculum

WHEN NECESSITY SPEAKS, IT DEMANDS

RUSSIAN PROVERB

FIRST REACTION WAS…..FRUSTRATION (#$%&*)

CONSIDERED SEVERAL OPTIONS……..

http://luciaandcompany.blogspot.com/2007/10/stressed-out-maxine.html

I DECIDED TO JOIN THE “FLIPPERS”

“It’s called flipping, and it almost ought to be illegal.”Donald J Trump

The New York Times

FLIPPED CLASSROOM

Didactic

Lecture

Homework

Traditional

ClassroomVideo Lecture

+/- Pre-work

Homework

Flipped

Classroom

Faculty available

Flipped Classroom Strengths

• Self-paced, personalized study

• Active learning

• Longer engagement

• Personal responsibility

The Post-Lecture Classroom: How Will Students Fare?

A new study finds moderate student gains in courses where lectures take place at home and

"homework" happens in the classroom. Robinson Meyer 9/13/2013

The Atlantic

https://www.natcom.org/communication-

currents/making-sense-students%E2%80%99-

complaints-criticisms-and-protests

The Post-Lecture Classroom: How Will Students Fare?

A new study finds moderate student gains in courses where lectures take place at home and

"homework" happens in the classroom. Robinson Meyer 9/13/2013

The Atlantic

Observational Study

University of North Carolina

Required Foundational Pharmacy Course

Historical Cohort (2011) Flipped Classroom (2012, 2013)

Homework: Textbook readings Pre-Work: Video lecture

Study questions Textbook readings

Classroom: Traditional Lectures Classroom: audience response quizzes

+ “Paired Learning” problems (2013)

5.1% increase in final exam scores using flipped classroom

FLIPPED CLASSROOM IN OPTHALOMOLOGYTANG F, ET AL: RANDOMIZED COMPARISON BETWEEN FLIPPED AND LECTURE BASED CLASSROOM

Traditional Lecture Based Instruction

2 hour didactic lecture on Ocular Trauma

30 minute question & answer

Post-class homework assignment

Due one week post-lecture

Flipped Classroom Instruction

On-line video lecture on Ocular Trauma

Pre-class homework assignment

Small group project

10 minute powerpoint presentation

Major points lecture

Specific clinical question

Classroom

10 minute summary of material by instructor

Student presentations with discussion

Wrap-up summary by instructor

Student Impression / Self - Assessment Traditional Flipped P

Course improved my motivation to learn 15% 71% 0.012

Course helped my understanding of the material 26% 51% 0.03

Course helpful for the final exam 14% 49% 0.001

The course improved my clinical thinking ability 26% 71% 0.05

I like this teaching method 43% 56% 0.25

I am satisfied with the course 51% 56% 0.61

This course is too much of a burden 6% 24% 0.007

This course takes too much time 7% 20% 0.17

FLIPPED CLASSROOM IN OPTHALOMOLOGYTANG F, ET AL: RANDOMIZED COMPARISON BETWEEN FLIPPED AND LECTURE BASED CLASSROOM

>3.5 hours pre-work

FLIPPING TRANSFUSION MEDICINE

Flipping Transfusion Medicine

a Winning idea

https://www.businessinsider.com/mcdonalds-flips-arches-upside-down-2018-3

MY FLIPPED CLASSROOM

Pre-Work (homework)

Video podcast lectures

Patient case scenarios

Open-ended questions

Step-wise progression

Patient assessment

Transfusion need, order

Evaluation transfusion reaction

Classroom teaching

3 patient cases

Multiple choice questions

Facilitated class discussion

Q & A

“pearls”

MY FLIPPED CLASSROOM: HOMEWORK

10 – 20 minutes each

Narrated

Animation where possible

Case-based examples

YouTube video links (end)

‘Pearls’

Specimen requirements

Turn-around times

Podcast Topics

ABO/Rh typing

Antibody screen, identification, DAT

Blood product overview

Blood product indications

Adverse Events to Transfusion (1&2)

Part 1) Hemolytic reactions

Part 2) Nonhemolytic and TTD

STRESSED MAKING SHORT, FOCUSED LECTURES

20 minute maximum

Step 1: RBC Grouping1. Washed, patient RBC

2. Commercial anti-A and anti-B reagents

3. RBC agglutination (Hemagglutination)

Patient RBC

Anti-A Anti-B

centrifugationHemagglutination

Example 1

Anti-A Anti-B

RBC Grouping (Forward Type)

0 0Agglutination

Score

RBC are negative for: • Group A antigen• Group B antigen

Blood Group O

Plasma Grouping (Reverse Type)

+ +

Plasma is positive for:• Anti-A antibody• Anti-B antibody

Blood Group O

A RBC B RBC

Agree

VALID Group O Blood Type

Long or IAT crossmatch

Donor RBCABO/Rh-compatibleNegative for minor RBC antigen

Patient Plasma

Incubation

37C

Wash x 3

centrifuge

Anti-human IgG

Centrifuge

Crossmatch

Incompatible

Compatible

Suitable for transfusion

MY FLIPPED CLASSROOM: HOMEWORK

Podcast Topics

ABO/Rh typing

Antibody screen, identification,

DAT

Blood product overview

Blood product indications

Adverse Events to Transfusion (1&2)

Part 1) Hemolytic reactions

Part 2) Nonhemolytic and TTD

Foundation Concepts

• ABO type

• ABO compatibility

ABO/Rh Typing

Blood Components

Transfusion Indications

PRE-WORK CLINICAL CASES

THE SESSION WILL COVER 3 PATIENTS WITH TRANSFUSION NEEDS AND

COMPLICATIONS. THE FORMAT IS TO EMPHASIZE THAT TRANSFUSION IS A

MULTI-STEP PROCESS THAT REQUIRES MEDICAL DECISION MAKING,

LABORATORY INTERPRETATION AND RISKS. THE CASES WILL GIVE A SERIES

OF CLINICAL AND LABORATORY DATA, FOLLOWED BY OPEN ENDED

QUESTION TO CONSIDER.

Topic review/competence:

ABO interpretation

ABO compatibility

Anticoagulation lectures

Pre-Work Example: Case with open ended questions

Case 2 Continued

Topic review

ABO

T&S

Sample labeling (WBIT)

CLASS INSTRUCTION

1st year

Prework

6 podcast lectures

3 multi-part cases

Classroom

Audience response technology

Optional class attendance

Lecture videotaped

Pro’s

Concentrated learning with podcasts

Spontaneous peer-peer and work groups

Disparate answers-> teaching opportunities

Discussion between students and faculty

Overall positive feedback from students

Con’s

Attendance low (33, better than most classes)

Inconsistent wifi for ART

ART prolonged lecture

• 2 cases (60’)

• 3 cases (90’)

Student complaints “time to prepare”

CLASS INSTRUCTION

2016-17

M2 year

Prework

6 podcast lectures

3 multi-part cases

Classroom



Lecture videotaped

Hematology sequence

• Removed 2.5 days!

• Reduce content

• Deletion lectures

2017-18

M1 year

Prework

6 podcast lectures

3 multi-part cases

Classroom

LOST the ART presentation!!

(digital purgatory)

Old school powerpoint

Volunteer student


Freebies to participants

2018-19

M1 year

CLASS INSTRUCTION

2016

M2 year

Pre-work

6 podcast lectures

3 multi-part cases

Classroom



Lecture videotaped

Hematology sequence

• Removed 2.5 days!

• Reduce content

• Deletion lectures

2017

M2 year

Pre-work

6 podcast lectures

3 multi-part cases

2018

M1 year

Pre-work

4 podcast lectures

• ABO/Rh

• Antibody screen, ID, DAT

• Blood Products

• Transfusion Indications

Removed Adverse Events

Clinical Case Studies

3 new clinical cases

1 extra credit case

Transition Legacy Class New Curriculum

Classroom

Powerpoint / student discussion

New

Option to upload pre-work online

Graded/student feedback

Identify/discuss problems

Old Curriculum

June 2018: Questions on Medical School Site

Student Responses: 3 options

Type in the site

Upload word document

Scan document

Upload pdf

Pre-Work Evaluation 179 students = 19 hours

Student/faculty chat room

STUDENT PRE-WORK

Identified areas for further discussion

ABO interpretation

Irradiation

Type and Screen specimen

Specimen labeling / WBIT

Review coagulation lectures (xtra credit case)

ABO INTERPRETATIONS

Cutting corners with pre-work

ABO INTERPRETATIONS

1) Trying to cut corners with pre-work

2) Confusion how you can test both RBC and plasma

a. Didn’t appreciate samples are centrifuged

b. Add a slide to ABO and ABID podcasts

IRRADIATION

Irradiation for RA common theme

Stated Logic/reasons:

• Autoimmune disease

• Immunosuppressive medications

• Old age (!)

Student Answer

Over 50% of the class got irradiation correct:

T&S AND SPECIMEN LABELING

75% - T&S before every surgery

25% - correct answer, > 3 days

Case 2 (2 parts / 6 questions

T&S AND SPECIMEN LABELINGCase 2 (2 parts / 6 questions )

Audience Participation:

What is the ABO on sample 1

What is the ABO on sample 2

What happened: WBIT

SPECIMEN LABELING: STUDENT ANSWERS

50-60% Sample / Labeling error

Laboratory (most frequent)

Mixed up the samples in the lab

Testing error

Mislabeled sample

Educational Opportunity

SPECIMEN LABELING: STUDENT ANSWERS

50-60% Sample / Labeling error

25% (“you can’t make this s#$t up” J. Becker)

ABO-incompatible bone marrow transplant (?!)

POTENTIAL WEAKNESS OF PEER – PEER TEACHING

LC: How much time did GY spend on BMT, let alone ABOi-BMT?

Laura, they haven’t had any lectures on leukemia yet. :AA

Peer – Peer Teaching GONE WRONG

https://www.theifod.com/do-lemmings-really-engage-in-mass-suicide/

NEW CURRICULUM:

MORE THAN 1 BITE OF THE APPLE

M1 year

Hematology Sequence

Introduction to Clerkships

‘Fatigue’ PBL small group

Mandatory attendance

Patient H&P

Workup of anemia

DX: WAIHA

• Review DAT, IAT

• Add eluate findings

• Treatment WAIHA

• Transfusion triggers

Surgery Rotation (3 mo)

• 1 week pathology

• Blood bank

• 3 hr small group / week

Pre-work

• Review podcasts 1-4

• Adverse events 1+2

• Video blood administration

Class: 3-4 PBL cases

Tour of blood bank & apheresis

M2 year (old M3 year)

M3/M4 YEARS: SELECT DIAGNOSTIC

PATHWAY (INCLUDES PATHOLOGY, RADIOLOGY, PHARMACOLOGY)

We are here

Curriculum in progress

THANK - YOU