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ISSUE 1 2012 QU AR TERLY

The Rossi MSSM MED IC AL E DU CA TIO N NE WS , RE SEA RC H RE VI EW S, TE AC HI NG T IP S,

CON VE RS AT IO NS WI TH E DU CA TI ON LE AD ER S

Dr. Erica S. Friedman

Welcome to The Rossi: Medical Education Quarterly

In medicine, as with other fields,

developing effective leaders and educators is

essential to our profession. Teaching is a

vital role of all physicians, and good teaching

directly improves patient care. Similar to other

aspects of medical practice, becoming an

effective teacher requires training and

experience. An increasing number of medical

students, residents, and practicing physicians

are seeking advanced training in education to

provide them with a conceptual and scholarly

foundation for their educational responsibilities,

and to enhance their leadership potential and

increase their effectiveness in their profession.

Mount Sinai’s Institute for Medical

Education (IME) serves the vital need for

creating, educating, mentoring and retaining the

best educators for our students, residents and

faculty. Fostering the success of our educators

includes recognizing and rewarding those who

display dedication and excellence in their work,

and providing programs that develop and

reinforce their scholarship, teaching skills and

successful promotion.

The birth of this publication signals a

formal mechanism for showcasing model

educators, highlighting key education research,

fostering medical trainee engagement in the

growing medical education community and

nurturing their development into medical

education leaders. This publication will provide

regular updates on the accomplishments and

trends in medical education within our local as

well as international medical education

community. We hope by sharing best practices

in education and by profiling top educators, we

will recruit and develop medical trainees as

education leaders and facilitate their

involvement in education scholarship.

This publication provides a forum for

medical professionals at all levels of training to

share their ideas and ask the real questions

about medical education. We will describe how

questions can be transformed into scholarly

projects or education research.

We look forward to a community-

wide conversation about the needs, challenges

and innovative solutions in medical education.

Welcome to The Rossi.

� MEDICAL EDUCATION

RESEARCH CORNER:

CRITICAL ASSESSMENT OF

RECENT LITERATURE .... 8

� INTERVIEW WITH

DR. KATHERINE CHEN ... 2

� A STUDENT-RUN PROGRAM

FOR SOCIAL JUSTICE .... 5

Associate Dean for Education Assessment and Scholarship at Mount Sinai School of Medicine

“The Rossi” is named after Dr. Miriam Rossi, a graduate of the first medical school class at Mount Sinai School of

Medicine in 1970. A dedicated medical educator and mentor, she has served as the Associate Dean of Student

Affairs and Associate Dean of Admissions at the Faculty of Medicine at the University of Toronto among other

educational posts. The Rossi staff is proud to acknowledge her contribution to teaching in medicine.

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Interview with Dr. Katherine Chen

MD, Mentor, Mother, Mensch

Dr. Katherine Chen is an Associate Professor

and Vice Chair of Education for the

Obstetrics/Gynecology Department at Mount

Sinai School of Medicine. She also directs the

third year medical student Obstetrics/

Gynecology clerkship.

Recognized for her excellence in teaching

through various awards at Harvard Medical

School and Columbia University, her most recent

honor in 2012 is the Mount Sinai Institute of

Medical Education Excellence in Teaching

award. She was also a faculty member AOA

inductee two years ago.

The Rossi editor-in-chief had a chance to sit

down with Dr. Chen and discuss her

philosophies on teaching, as well as her life as a

physician, mother and book enthusiast.

What attracted you to Mount Sinai?

I came here specifically for an administrative position in education. Prior to that, I was at Columbia University on an NIH grant, primarily doing research – 75% research, 25% clinical. Then I had a midlife crisis and decided I wanted to focus more on education. I’m very grateful to my chair Dr. Brodman for offering me the position and for supporting me in my endeavors.

What was this midlife crisis?

I always knew I had a knack for teach-ing, even while I was a resident. But at that time, I had gotten advice that to advance in the

academic world, you needed to be a clinical expert with productive research activities. So I went down that path first. I spent several years focusing on Obstetric Infectious Diseases, gath-ering clinical research skills, and performing studies. When I turned 40, I realized that the projects I enjoyed most were the ones I did with students and residents. I couldn’t get away from teaching. You’ve had an extensive history of awards,

most recently the Excellence in Teaching

Award this year at Sinai. Can you share with

us your philosophy on teaching?

First and foremost, my philosophy is to make teaching fun and interactive. I utilize the Game Method whenever possible. For example, on the Labor and Delivery Unit, I would ask the student to provide me with a roadmap of which

patient I should see first, second, etc. – a game to test their triage skills. When I lecture, I like to use many images and videos and invite students to participate. Of course, there’s also the Guinness Book of Ob-Gyn Records! In the review sessions, I’d ask students who had delivered the biggest baby or removed the largest fibroids et cetera. Another principle I value is to get to know my students. I’m picky about making nametags at the beginning of every clerkship to help me learn the students’ names. I make an effort to sit down with each student on mid-rotation day to provide feedback.

“First and foremost, my philosophy is to make

teaching fun and interactive. I utilize the Game

Method whenever possible.”

K. H. Vincent Lau

THE ROSSI STAFF

EDITOR K. H. VINCENT LAU ASSOCIATE EDITOR LENARD BABUS

EDITOR-AT-LARGE DR. ERICA FRIEDMAN WEB EDITOR MIGUEL YAPORT WRITERS DEMETRI BLANAS GRACE CHARLES DANI DUMITRIU H. CINDY KO LOHEETHA RAGUPATHI SUSAN YIN PHOTOGRAPER DAVID BERMAN

The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation. - Sir William Osler

Photographer: David Berman

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You’ve shared your story with students

about having a baby during the New

York City Blackout of 2003. What else

can you tell us about your personal life?

I can tell you that my husband and two children are very important to me and I relish the time spent with them. That’s why I tell students that I try not to check my emails after I leave work. There was a New York Times article recently about addiction to electronic devices. Eve-ryone’s heard the term “crackberry.” Out-side of the hospital I really focus on my family.

I am a movie buff. I’m on a few mailing lists where I’m invited to attend screenings for movies that are in produc-tion. Sometimes I go with my husband, sometimes with my children, and other times as a family – depends on the demo-graphic target of the movie.

I’m also an avid reader. Recently, Dr. Muller was giving books to thank faculty who worked on LCME accreditation. He let the committee members pick the book they wanted. However, I looked through the selection and I had read all of them already! What are some of your recent favorite

books?

My favorite in 2011 was Abraham Verghese’s Cutting for Stone. Others that I have enjoyed are Tina Fey’s Bossypants and the Hunger Games series - yes, I do read my older daughter’s books. Favorite authors – Geraldine Brooks; my classmate in college and medical school,

Atul Gawande; mystery writer Elisabeth

George; and Agatha Christie. Do you watch any medical shows?

I don’t watch much TV, but when I was a resident I watched ER. I did watch the first season of Grey’s Anatomy as a young attending, but I didn’t continue.

Recent non-medical shows I’ve liked are two British series: Sherlock Holmes and Downtown Abbey. Do you have any advice for medical stu-

dents trying to juggle their life in the

hospital and outside?

You have to choose a career that you thoroughly enjoy. When you choose something you love, you get things done much faster and you’re much more efficient at work. At the end of the day, there isn’t as much work left over or prob-lems to worry about to take home. And I’ll

say this: your family, friends, significant others – they really are more important than your job.

The most difficult times in my career where I really had to learn how to balance family/work life is the first two years of each of my daughter’s lives. My mother and husband were a big help.

Given our generation’s emphasis on

work/life balance, do you think we also

have a different view on studying medi-

cine?

Your generation is an interesting one… “The Millennial Generation”, “The Internet Generation”, “The Digital Natives”. You do have different learning methods. It’s been studied that attention span for your generation isn’t quite as long, but you can multitask! I think what is important is for educators to make learning very interactive and at the same time, very organized. The students need to be en-gaged but also know what is expected of them. You’re the only teacher who started a

Twitter account for your clerkship. How

did that come about?

I learned about the idea from an educational conference. However, I’ve stopped using the Twitter account. When I polled the students, only one or two were active Twitter users. In contrast, many use Facebook. I have not thought of a useful way to utilize Facebook yet. For now I’ve reverted back to just email to post notifications or to elicit questions from the students. It’s not anon-ymous though, which I thought was the benefit of Twitter.

Medical education is not completed at the medical school; it is only begun.

- Dr. William H. Welch

“It’s been studied that attention span

for your generation isn’t quite as long,

but you can multitask!”

Dr. Chen with her husband Dr. Benjamin Chen, an Associate Professor in Medicine at

MSSM, and two daughters in 2006.

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What advice do you have for students

interested in a career in medical

teaching?

It’s important to understand how adult learners learn. There are medical education conferences that you can go to -- some that are specific to one specialty, and others focused just on education which are attended by all specialties.

The challenge is that there’s no formal educator training programs, so it’s harder to gather the skills you need. It’s different than going into research, where you can receive formal training and receive a degree. If you want to be a great clinician, there’s mentorship and ways to practice and refine your skills. I suggest attending conferences, emulating others, and paying attention to student feedback. As for attaining teaching positions, always show interest in whatev-er way you can at your academic center. Be able to negotiate so that you can teach and be rewarded for it, while maintaining the objectives of your department. What’s a typical week for you as a

medical educator?

Three and a half days of the week, I am doing administrative work which is related to the Ob-Gyn clerkship, 1st – 2nd year courses, 4th year electives, residency applicants, the residency program, and fellowships. On Wednesday mornings, I co-direct an Infectious Diseas-es Obstetrics Clinic. On Fridays, I supervise the Labor and Delivery Unit which is the most challenging and stressful part of my week.

Where in the hospital is your happy

place?

My office is my happy place, because that’s where I meet with students and trainees. I interview high school students for my college in my office. I meet with college kids interested in medi-cine. Obviously, I spend much time with medical students. I see residents, fellows, and young attendings in my office to advise and mentor. I also spend time with the coordinator of the clerkship and electives – Ms. Bustamante – brainstorm-ing and organizing. You were recently inducted as a Mount

Sinai AOA Honor Society Faculty

member. What was the process of you

receiving the award?

That was a great privilege and one of the awards I treasure most. That is because Harvard Medical School, my alma mater, didn’t have an AOA society, so it wasn’t an honor that I could achieve then. I actually don’t know the process and just assumed the graduating students of that year nominated me.

Do you have mentors of your own that

have shaped you?

I’ve had many mentors for my career. All my chairs have played significant roles. There are also many fe-male faculty members in and out of Ob-Gyn that have helped me. I am still enlisting new mentors as I go through my career. The way they have helped is to listen to my goals and set me in the right direction.

How do you resemble some of your

mentors today?

I emulate the part that I admire in each mentor. There was one mentor who really knew how to balance her work life and her family, so I learned that from her. Another was very quick in decision-making and always followed through, so I picked that up from her. Another mentor used the Socratic method to teach, so I’ve incorporated his technique into my own clinical teaching. If you could speak to yourself as a

young medical student in Harvard, what

advice would you give to her?

Make sure you enjoy what you do. That’s why I moved into education. Also, recognize that your passion can change. I was passionate about research at one point, now I am excited about education. If you think you need to make a change, go ahead and do it. Women are less likely to make major changes. I would advocate that they do. Finally, take advantage of opportunities outside of the United States. I regretted not going to Oxford during my years as a Stanford undergraduate when the two institutions had a strong program.

If you could impart one quality in all

medical student graduates at Sinai,

what would that quality be?

I would like all my students to become great educators. No matter what field in medicine, you’re always a teacher to your patients. In academia, you teach trainees; and in private practice, you teach

your staff. There is so much knowledge out there, so much information, that you must distill for your patients, students, and staff in a meaningful way. Thank you very much for this interview,

Dr. Chen.

It was a pleasure. I have to say

this – I’ve been very happy at Sinai be-

cause of my position. It was a great move

from Columbia to Sinai and it’s great to

know that others appreciate my teaching.

“If you think you need to make a

change, go ahead and do it. Women

are less likely to make major changes.

I would advocate that they do.”

There is no short cut, nor 'royal road' to the attainment of medical knowledge. The path which we have to pursue is long, difficult, and unsafe. In our progress, we must frequently take up our abode with death and corruption, we must adopt loathsome diseases for our familiar associates, or we shall never be acquainted with their nature and dispositions; we must risk,

nay, even injure our own health, in order to be able to preserve, or restore that of others.

- Dr. John Abernethy

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In the increasingly complex world of medicine where clinical knowledge is estimated to double every 18 months, four Mount Sinai School of Medicine students recognized that their education was missing an important component. Salina Bakshi, Marie Hennelly, Andrea Jakubowski and Aisha James took a critical look at the medical school curriculum and realized that while anatomy trains future surgeons and child development trains future pediatri-cians, there was no designated course discussing important issues in social justice. Thus, in 2011, in the midst of their busy first year schedule, they started the Human Rights and Social Justice Scholars Program (HRSJ), a comprehensive one-year track giving students the tools, resources and mentorship to pursue the diverse aspects of

health equity and social justice. I met Salina, Marie, Andrea and

Aisha in the student lounge during the week before they would begin their third year clerkships. Given their tremendous accom-plishment, I was expecting a rambunctious group, eagerly speaking and interrupting each other. Instead, I was met by a group which exuded quiet confidence and intelli-gence. They spoke thoughtfully and pre-cisely – each contributing their unique ex-pertise and experiences.

What is meant by “social justice”? As Salina explained to me: “a biopsychosocial approach to health and wellness to understand the underlying factors of a patient’s condition both scientifically and socially in order to better understand what factors might prevent them

from receiving equitable and adequate healthcare.” Marie was quick to note the inspiration provided by being physically located on the border between Manhattan’s very rich and very poor. “Being a student chapter of Physicians for Human Rights we believe health is a human right, so equitable delivery of healthcare is a justice issue. Harlem residents and Upper East Side residents should receive equal health care.”

The first group of 11 students accepted into the HRSJ scholars program started the program in September 2011. The curriculum is comprised of five interlinked components: coursework, career panel series, research, a policy and advocacy service project and mentorship. The course-work consists of an 8-week student-run “Health, Human rights, and Advocacy” course, taught by a combination of clinicians, researchers and advocates. The course was originally started in 2010 by the Mount Sinai leaders of Physicians for Human Rights, and remains open to all students as an elective, though it is now mandatory for students enrolled in the HRSJ program. Topics feature a variety of domestic and global health issues, such as disaster response, environmental toxins, and minority health. The career panel series complements the didactic curriculum and provides an opportunity to engage with pioneers who have dedicated their lives to human rights and health, such as Homer Venters, head of the NYC Correctional Health Services. These round table dinner discussions offer students the opportunity to interact one-on-one with leaders in social justice and learn about a variety of career paths within the field.

The research component – in many ways the central aspect of the HRSJ track – is designed to demonstrate that research methods within the field of social justice can be as academically rigorous as those within clinical and basic sciences. The ultimate goal, Marie explained, is “evidence-based advocacy.” An excellent historical example is the Campaign to Ban Landmines run by Physicians for Human Rights, who in 1991 published comprehensive research reports on the overwhelming devastation of innocent civilians by landmines in Cambo-dia. By 1997, their efforts led to an interna-tional Mine Ban Treaty signed by 122 countries, a momentous achievement awarded the Nobel Peace Prize the same year. The take-home message, Aisha ex-plains, is that Physicians for Human Rights accomplished this major policy change via rigorous research and facts, not by publish-ing educated opinions. Could these data have been gathered by non-physicians? Maybe. But physicians have the unique

Andrea Jakubowski, Aisha James, Dr. Holly Atkinson (immediate past president of PHR,

faculty advisor of MSSM's PHR student chapter, faculty advisor of the HRSJ Scholars

Program), Salina Bakshi, Dr. Phil Landrigan (Dean for Global Health, faculty mentor of

the HRSJ Scholars Program, Chair of Dept of Preventive Medicine, and Director of

MSHC's Children's Environmental Health Center), and Marie Oliva Hennelly. In May

2012 at the end of year Human Rights Celebration, a reception celebrating the inaugural

year of the HRSJ Scholars Program.

A Student-run Program for Social Justice An interview with Salina Bakshi, Marie Hennelly,

Andrea Jakubowski and Aisha James

Dani Dumitriu

6

skill set and knowledge base to understand a problem from a medical perspective, and therefore contribute with a more authorita-tive voice. “There is a privilege that comes with a white coat,” Salina adds, “and with that trust and respect it is our responsibility to use our knowledge and our position of power to effect change.”

The next component of the track – policy and advocacy service project – helps students develop practical skills for implementing change in ways that benefit the East Harlem communi-ty. One student partnered with Boriken to assess the barriers, risks and opportunities of HPV vaccination. The goal of the pro-ject is to develop educational tools for both staff and patients in order to encourage an increase in vaccination rates. Finally, absolutely integral to the HRSJ program is the mentorship component, which pairs

each student with both a faculty mentor as well as a peer mentor from the class above. As the program grows, the hope is that peer mentorship will create a tightly woven network of students from all four years of medical school, thus develop into

a community dedicated to social justice. This type of collaboration will create a community-wide forum for social justice issues, and will also serve as a formal mechanism by which seniors can train

juniors as they transfer leadership responsibilities in longitudinal projects. How did such a comprehensive program evolve in such a short time? Salina, Marie, Andrea and Aisha became interest-ed in social justice as first years medical

students while taking the “Health, Human Rights, and Advocacy” elective, which at that time was run by Physicians for Human Rights. In one class, the Physicians for Human Rights National Conference in Boston was advertised and the group decided to go. At the confer-ence, they came across a poster detailing a Health Equities Scholars program at the Uni-

versity of Michigan, The program was nowhere near as extensive as their own future creation, but for Salina, it was a revelation: “These concepts can be taught in an objective and organized way,” she

Medical education is not just a program for building knowledge and skills in its recipients... it is also an experience which creates attitudes and expectations. - Abraham Flexner

“There is a privilege that comes with

a white coat, and with that trust and

respect it is our responsibility to use

our knowledge and our position of

power to effect change.”

Salina Bakshi, Marie Hennelly, Andrea Jakubowski, Aisha James and the first eleven HRSJ scholars

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Association of American Medical Colleges (AAMC)

Annual Meeting

(includes Conference on Research in Medical

Education—RIME)

Nov. 2-7, 2012 in San Francisco, CA

https://www.aamc.org/meetings/annual/2012_annual_meeting/

Northeastern Group on Educational Affairs (NEGEA)

Annual Meeting

April 12-13, 2013 in New York, NY

https://www.aamc.org/members/gea/regions/negea/meetings/

(Abstracts due December 5)

realized. In the midst of first year jitters about why she’d decided to pursue a medi-cal degree, she was reminded of her original goal for applying to medical school: to fight for social justice and health equity.

Immediately after the conference, they began outlining the skeleton of the program. Andrea, Aisha and Marie all agree that the program was Salina’s brain-child, though they were quick and willing recruits. With an amused smile, Salina recalls an incident of telling a friend about the idea, who looked at her in dismay and said: “Don’t you think that’s a little much?” But this was the only negative comment any of the four can remember. Within a couple of days, they pitched their idea to Dr. Philip Landrigan, Chair of Preventive Medicine and Director of the Children’s Environmental Health Center, who was encouraging and recom-mended they meet with Dean David Muller. They were met by the same supportive attitude from Dean Muller who immediately connected them with mentors for the project. “There was such galvanizing support from the beginning,” says Salina. “There were so many opportunities for red tape, but it never happened.”

For the remainder of their first year spring semester and summer, Salina, Andrea, Aisha and Marie worked over 30 hours per week, outlining their ideas, mak-ing contacts in the community, putting together presentations and finding mentors. Because of other obligations, their meetings tended to start as late as 10 pm and ran until 2 or 3 in the morning. Balancing the program’s development with a heavy course load was difficult, but - with their education in a new context – also motivating. To their delight, their efforts paid off. They received 23 applications for the 11 seats in the first

HRSJ program, starting September 2011. This translates into 16% of the incoming medical school class, showing how big a gap the program fulfills. Their only regret is not being able to accommodate all interested students due to the limiting fac-tor of available mentors. In addition to the overwhelming positive response from stu-dents, this year they were awarded the AOA Medical Student Service Leadership Award for the program, honoring not only their effort, but also giving them $8000 in funds to develop the program over the next three years.

I asked if they feel they could have put together such a program at any other institution. Without hesitation, I received a unanimous “No.” Mount Sinai is unique not only in harboring leaders in social justice work, but also by being the only medical school to promote

advocacy. In fact, its Medical Education Mission Statement asserts: “To produce physicians and scientists who are prepared to enter society as informed advocates and activists, able to advance clinical care and science, and capable of promoting change.” In addition, Mount Sinai, perhaps by virtue of being a stand-alone medical school, lacks the roadblocks often put in place at large institutions by complex bureaucratic networks. “They are very receptive to students making their own path and want to support them in every way possible.”

Currently, the HRSJ Scholars

Program is jointly owned by the Center for Multicultural Affairs, Department of Medical Education, the Global Health Center, and four faculty advisers: Drs. Holly Atkinson, Yasmin Meah, Anu Ana-daraja, and Ann-Gel Palermo. At present it is considered a “program” rather than a “track”. The student leaders hope that as the program demonstrates sustainability within the next few years, it will become an official track offered as part of Mount Sinai’s medical curriculum. They are also working with the administration to create a new distinction – Distinction in Social Justice – which future medical students may receive upon graduation, similarly to the currently available achievements of Distinction in Medical Education and Dis-tinction in Research.

This year, Mount Sinai’s “Touching Points” letter to its new stu-

dents included a description of the HRSJ program. “Last week,” Salina recalls, “I got an email from a student who is starting this Fall. She just wanted to let me know that the HRSJ program was the reason she ended up choosing this medical school.” Although she remained poised, I could detect

the slightest crackle of pride in her voice. There is a lot left to be done, but

what Salina, Marie, Aisha and Andrea have accomplished is beyond impressive. For anyone, student or faculty, interested in social justice, they have created a net-work for the exchange of expertise and experience, and a community of faculty and students sharing the same passion. Ultimately, their dream is that social jus-tice will become “the third leg of the stool, along with basic science and clinical work.” Given the overwhelmingly positive response from the administration, students and faculty – they might just succeed!

Mount Sinai is unique not only in

harboring leaders in social justice work,

but also by being the only medical school

to promote advocacy.

UPCOMING MEDICAL EDUCATION MEETINGS

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Critique of Study #1 H. Cindy Ko

Standardized patient (SP) encounters are a common tool employed by medical schools to prepare students for clinical skill examinations and future pa-tient interactions. The advent of web-based learning modules has provided a unique opportunity to enhance these traditional SP learning methods and increase the clinical competency of medical students. This current study aims to evaluate the effectiveness of a web-based teaching module on the communication skills scores of fourth year medical students on Clinical Performance Examinations (CPX). To supplement mandatory SP training 6 months prior to CPX, students were invited to view a web-based module one month before the examination. The module consisted of three separate 20 min videotaped student-SP encounters with narration and teaching commentary from a highly-trained SP and an experienced clinician. A majority of students (79% of those who watched) viewed the videos within the last 48 hours before their exam.

Students who watched the video modules (n = 106) scored significantly higher in the communications skills

portion of the CPX compared to their classmates who did not watch (n = 41). The scores for history taking and physical exam scores were not significantly differ-ent between the two groups. Also, significantly fewer students in the group

who watched the module failed the CPX (n = 3), compared to those who did not watch (n = 7). The study controlled for baseline differences between the two groups by using Step 1 scores and a diverse set of clerkship ratings as covariates as part of the analysis. Additionally, the gender composition of those who watched the modules was consistent with that of the general class. The authors suggest that generalized feedback from web-based case vignettes

may be an effective study tool for the com-munication skills portion of CPX.

One of the major aims of a medical school is to develop a generation of well-trained and compassionate physicians. At the outset, the use of

standardized patients in allows for the newly minted physicians to comfortably and reliably apply their clinical skill set. On a more global level, the overall preparedness and clinical skills of the individual graduate translate to a better reputation for the school. Thus, it is no surprise that medical schools are constantly searching for ways to improve teaching techniques in an effort to maximize the clinical readiness of their students.

MedEd Research Corner Critical Assessment of Recent Literature H. Cindy Ko and Grace Charles

ABSTRACT OF STUDY #1:

Standardized patient-narrated web-based learning modules

improve students' communication skills on a high-stakes

clinical skills examination.

Lee CA, Chang A, Chou CL, Boscardin C, Hauer KE.

J Gen Intern Med. 2011 Nov;26(11):1374-7. Epub 2011 Jul 16.

BACKGROUND:

Use of web-based standardized patient (SP) modules is

associated with improved medical student history-taking and

physical examination skills on clinical performance examinations

(CPX), but a benefit for communication skills has not been shown.

AIM:

We describe an innovative web-based SP module using detailed

SP and faculty commentary to teach communication skills.

SETTING:

A public medical school in 2008-2009.

PARTICIPANTS:

Fourth-year medical students.

PROGRAM DESCRIPTION:

A 90-minute web-based module with three simulated clinical

encounters was narrated by an expert clinician and SP to explain

expected history-taking, physical examination, and communication

skills behaviors. All 147 students were encouraged to review the

module one month before the CPX.

PROGRAM EVALUATION:

One hundred and six students (72%) viewed the web-based

module. Students who watched the module performed significantly

higher on the CPX communication score (+2.67%, p < 0.01) and

overall score (+2.12%, p = 0.03), even after controlling for USMLE

Step 1 and clerkship summary ratings. Use of the module did not

significantly affect history/physical examination scores (+1.89%,

p = 0.12).

DISCUSSION:

Students who watched an optional web-based SP module prior to

the CPX performed higher than those who did not on

communication skills. The web-based module appears to be an

effective CPX preparatory activity to enhance communication

performance.

The techniques of careful listening and effective

communication are an intangible set of skills that

are only acquired and learned through

experience and feedback.

9

The task of teaching scientific medical knowledge is more objective and concrete than passing on the skills needed to develop empathetic doctor-patient interactions. There are a finite number of lecture hours set for each course, and students’ knowledge can be evaluated with reasonable accuracy by administering a multiple choice test at the end of the unit. It seems obvious that the non-science aspects of medical learning are equally important for the development of a great physician. However, the transfer of this type of knowledge proves to be less straightforward. The techniques of careful listening and effective communication are an intangible set of skills that are only acquired and learned through experience and feedback.

Virtually all medical schools have adopted the use of standardized patients to train medical students through supervised versions of real life clinical encounters. This study takes the SP en-counter to a new format—a web-based video module—for the purpose of improving students’ communication skills without the time or cost of the traditional SP clinical experience. The web-based tutorial also allows students to review the expectations of the CPX in a “last-minute” time frame. Assessing the Study

The fact that 79% of those who viewed the module did so within 48-hours of the CPX raises the question of whether

the intervention produced a lasting impact on students. Furthermore, the increase in communication scores may reflect an im-provement in test taking ability rather than an actual improvement in clinical skills. These possibilities also raise the issue of whether evaluations of clinical skills, such as those made during the CPX, are accu-rate indications of a student’s real-life clin-ical abilities. Do their efforts to create bite-sized, web-based teaching modules serve to artificially inflate the perceived communicative abilities and clinical skills of these future physicians?

It is also relevant to consider which elements belong on a standardized “communications skills checklist.” What seems like a core component of the evaluation would likely vary in content depending on whether it was composed from the SP’s perspective vs. the clinician’s observation, and even from medical school to medical school. An itemized analysis of the communications skills portion of the CPX evaluation would have provided the necessary detail to support the arguments being made about the web module’s efficacy. Furthermore, it would also have been salient to include the CPX communications scores in years prior to the implementation of the web modules for a more complete review.

Lastly, the study falls short of providing detail about the evaluation of the three students who failed their CPX, despite the fact that they had watched the module. If the module was able to raise the

average communication score of most students, we can either make the assump-tion that the CPX failures were unrelated to their communication score, or that the module’s teaching was not effective for their learning. A targeted analysis of the performance of those who did not pass is necessary to understand this distinction. Assessing the Applicability

While the use of a web-based module for teaching communication skills is an innovative idea, its effectiveness will need further evaluation prior to wide-spread adoption. This study would be more robust if there were a comparison to student performance in previous years prior to introducing the module. The study’s authors also acknowledge that it would be important to demonstrate the long -term effects of the module in a follow-up study. If, for example, the CPX scores could be correlated with subsequent Step 2 CS performance, it would provide a comparison to a similar high-stakes test, as well as a valid long-term assessment of communication skills. In the face of rising medical education costs, the use of web resources to teach communication skills as opposed to hiring actors as SPs is an attrac-tive idea, but will require further research to demonstrate its’ effectiveness. This type of web based module may be useful for teaching and/or reinforcing other skills taught during live encounters including higher level communication skills such as giving bad news or admitting an error.

ABSTRACT FOR STUDY #2:

Predictive validity of the multiple mini-interview for selecting

medical trainees.

Eva KW, Reiter HI, Trinh K, Wasi P, Rosenfeld J, Norman GR.

Med Educ. 2009 Aug;43(8):767-75.

INTRODUCTION:

In this paper we report on further tests of the validity of the multiple mini-

interview (MMI) selection process, comparing MMI scores with those

achieved on a national high-stakes clinical skills examination. We also

continue to explore the stability of candidate performance and the extent

to which so-called 'cognitive' and 'non-cognitive' qualities should be

deemed independent of one another.

METHODS:

To examine predictive validity, MMI data were matched with licensing

examination data for both undergraduate (n = 34) and postgraduate

(n = 22) samples of participants. To assess the stability of candidate

performance, reliability coefficients were generated for eight distinct

samples. Finally, correlations were calculated between 'cognitive' and

'non-cognitive' measures of ability collected in the admissions

procedure, on graduation from medical school and 18 months into post-

graduate training.

RESULTS:

The median reliability of eight administrations of the MMI in various co-

horts was 0.73 when 12 10-minute stations were used with one examin-

er per station. The correlation between performance on the MMI and

number of stations passed on an objective structured clinical examina-

tion-based licensing examination was r = 0.43 (P < 0.05) in a postgradu-

ate sample and r = 0.35 (P < 0.05) in an undergraduate sample of sub-

jects who sat the MMI 5 years prior to sitting the licensing examination.

The correlation between 'cognitive' and 'non-cognitive' assessment in-

struments increased with time in training (i.e. as the focus of the assess-

ments became more tailored to the clinical practice of medicine).

DISCUSSION:

Further evidence for the validity of the MMI approach to making

admissions decisions has been provided. More generally, the reported

findings cast further doubt on the extent to which performance can be

captured with trait-based models of ability. Finally, although a

complementary predictive relationship has consistently been observed

between grade point average and MMI results, the extent to which cog-

nitive and non-cognitive qualities are distinct appears to depend on the

scope of practice within which the two classes of qualities are assessed.

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Critique of Study #2 Grace Charles

Medical schools have long used applicant interview performance as a key component of the selection criteria for admission. Although the interview is unanimous in the admissions process, the format is not; varieties include a single

interview, multiple interviews, and group interviews with variable numbers of interviewers and interviewees present. Recently, the Multiple Mini-Interview (MMI) has gained support in the American medical school admissions process. Widely used in Canada and brainchild of researchers at McMaster University, the MMI requires students to rotate through approximately ten 8-minute stations. Station tasks may include responding to ethical dilemmas, working with another applicant on an assignment, writing an essay, answering a traditional interview question, or role-playing with an actor. At each station, the interviewees are scored on their performance. The selecting institution focuses the MMI around the domain it deems appropriate, e.g. ethics, professionalism, or communication. At McMaster University, for instance, the MMI is directed towards ethical decision-making. Why would a medical school require applicants to rotate through an exhausting round of mini-exams on their interview day? Studies have found traditional interviews to have low reliability, meaning the score an interviewee receives at one interview will not necessarily be the score he or she receives at another interview. Furthermore, interview scores often do not correlate with later job performance, thus indicating poor validity as the interviews may not fulfill their intended purpose. On the other hand, previous research has shown that the MMI achieves reliability and validity in the context of undergraduate medical school admissions to predict performance on clerkships and national licensing examina-tions. The journal article presented here consists of several small studies regarding the MMI. In one, the authors found that the total MMI score produces a satisfactory reliability coefficient of 0.69 to 0.79 for use as an interviewing tool; generally >0.7

is considered acceptable. Furthermore, the authors studied a cohort of 22 residents to evaluate the ability of the MMI to predict interpersonal skills as measured by Part II of the Canadian national licensing exam

(MCCQE). Postgraduate students took the skills-based MCCQE and within nine months took a MMI focused on ethics and nonclinical decision making. The authors found the MMI to be predictive of the percentage of stations candidates passed (r = 0.43) although not statistically significant with respect to the total score. The authors replicated the study with 34 participants who took the MMI upon admission to medical school 5.5 years prior to taking the MCCQE. At the time of admission, data regarding applicants’ GPA, ABS (autobiographical submission), a simulated tutorial to evaluate applicants’ interactions with other applicants, and a personal panel-based interview with three interviewers was also collected. Of the five factors, the MMI was the only statistically significant factor correlated with the number of stations passed on the MCCQE (r = 0.35), and none of the indicators, MMI included, were statistically significant with regard to overall score. Assessing the Study

While the study sample sizes are small, this paper suggests that the MMI offers real advances in the interview process: a reliable score that correlates

with the number of stations passed on a licensing exam. As exciting as such novelty may be, it behooves us to further interrogate the data before us.

The 12-station MMI boasts a reliability of approximately 0.73 while any one station has a consistently low reliability of under 0.25. This suggests improved reliability with an increased number of distinct stations scored by different examiners. While the relationship between the MMI and the MCCQE Part II is statistically significant, the sample sizes are small and the correlation coefficient is a meager 0.35.

The authors also point out that of all the tools used to evaluate the applicants, the MMI was the only measure that showed a statistically significant correla-tion with MCCQE. However, the MMI method and scoring is very similar to that

of the MCCQE, in which students rotate through sixteen 10-minute stations, while to compare the other measures utilized in the study to the MCCQE is to compare apples and oranges. Furthermore, it is questionable whether the outcome of more stations passed on the MCCQE is a mean-ingful measure for the selection of future medical students.

Assessing the Applicability

An institution considering the MMI must discuss the practicality of implementing it. The MMI is resource intensive, requiring up to a dozen stations, each run by at least one scorer, to be performed every interview day. Is this a reasonable cost and time commitment to an institution that interviews hundreds of applicants? Instructors and facility require-ments aside, the amount of time and cost put into organizing and training individuals to run each station will undoubtedly be many more times that of a standard interview with a single faculty member. Parenthetically, one solution would be to set up centers where applicants could complete the MMI and then have their scores transmitted to all medical schools. However, this would preclude the ability

of the selecting institution to choose the specific focus of its MMI.

In addition, isolating an individual’s interpersonal skills to a specific domain, such as McMaster does with ethics, reduces the ability to understand the full scope of an applicant’s interpersonal skills. Medical schools often desire a well-rounded student body. Denying applicants the opportunity to interact freely with an interviewer denies the school an opportunity to know the applicant as an individual. Furthermore, cognitive competencies, such as prior training in ethics, may confound one’s score on the MMI. The lessons from this study are those of the scientific method: systematic investigations in which standardized score cards are used by a large set of investigators to evaluate each applicant

Recently, the Multiple Mini-Interview (MMI)

selection process has gained support in the

American medical school admissions process.

11

will produce more reliable results than will a single interview. An institution looking to make novel advances may therefore consider piloting a program with more interviews per applicant, for example four 20-minute interviews per applicant. Such

an arrangement would be an interesting area of research that need not add significant cost or time to the interview day. As for validity, it is the responsibility of the selecting institution to stipulate what it is attempting to gain from the interview

and what interpersonal qualities it requires of its students. Piloting a standardized scoring card targeted at identifying these qualities, as well as training interviewers to recognize these traits, may improve inter-view score reliability and validity.

Best Practices PowerPoint Presentation Design Demetri Blanas

PowerPoint software is a ubiquitous medium of communication and teaching in academic medicine. Its versatility

provides teachers with a wide range of options for conveying concepts and ideas. However, misuse of the

PowerPoint format can be distracting to audiences. We outline here a set of best practices guidelines for designing

PowerPoint presentations.

Text slides: Individual PowerPoint slides should convey a single primary point. Any individual slide should have no

more than seven lines. Text should stay within slide borders. Write in point form – use key points or phrases in-

stead of full sentences.

Font type and size: Presentations should employ a single uniform font-type. Font types are divided into “serif” and

“sans serif” ("no serif"). Serifs are the structural details at the end of letter strokes that in written text can guide the

reader’s eye. In computer projected text, however, they are considered distracting. Choose only sans serif font-

types for PowerPoint presentations. Font sizes should be kept to two (titles and non-titles). Use at least 18 size.

Letter case: Reader comprehension is improved with lower case letters compared to upper case. Therefore, con-

sider minimizing the use of upper case font even for titles. Interestingly, readers recognize letters first by the top half

of the letter, and lower case letters present a distinctive shape whereas upper case letters consist of block forms

that are generally more difficult to distinguish from each other.

Color: Use no more than three colors per slide or for the entire presentation. Ensure adequate contrast between

text and background (light font on dark text or vice versa). Avoid red or green for color-blind members of the audi-

ence. If you use an additional color, use it to emphasize a point.

Transitions: Avoid complex transitions with animation or sound effects. These generally distract the viewer from

the content of the presentation, and may be associated with amateur use.

Tables and graphs: Tables and graphs should be kept to a maximum of three columns and three rows. They

should be clearly labeled. Charts should have only one main point to convey to the audience.

Pace: Use no more than 1-2 slides per minute.

References: Appropriately reference any tables or quotes used during your presentation. Include an asterix or

numbers, and indicate the reference at the bottom of the slide.

Disclosures: Include a slide disclosing any personal or financial relationships that could present a conflict of

interest.

PowerPoint software has greatly facilitated and standardized presentations, providing presenters with a wide range

of flexibility and options. By adhering to simple principles, presenters can create more effective and engaging

presentations.

Source: Collins J. Education techniques for lifelong learning: making a PowerPoint presentation. Radiographics 2004;24(4):1177-83.

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Few professions can match the rapid pace of discovery and innovation present in medicine. Our briskly evolving knowledge base poses great challenges to medical educators. Optimizing the synthe-sis and delivery of this growing infor-mation to medical trainees of all levels is key to providing efficient and quick access to cutting edge breakthroughs.

Recently, mobile technology has emerged as a novel method for delivering information in small "bytes". The success of these ventures stems from a combina-tion of portability, novelty, and ease of incorporation into life outside the class-room and hospital. For example, a quick glance at a drug database on a smart phone enables medical students to retrieve up-to-date information developed by physicians, and the convenience of a question bank on the same phone helps maximize efficiency of learning by making use of short periods of downtime.

The utility of these technologies was recently evaluated in a study on the education of neurosurgery residents in UCLA1. The residents were given mobile tablet devices with remote access to a vari-ety of learning tools. After a year, resi-dents reported an increase in the amount of time used to study outside the hospital, attributing this to the digital technology. Their performance on the Congress of Neurological Surgeons-Self Assessment in Neurological Surgery improved signifi-cantly after their first year of residency. A limitation of the study was that there was no control group, making it unclear what portion of the improvement could be specifically attributed to the technology use, and what portion to one year of clinical training.

Another study from Ohio State University2, used the latest social media applications, or "push technology", to provide an emergency ultrasound curricu-lum to fourth year medical students via 140-character tweets. These were delivered daily over ten months as a supplement to additional educational materials. Although at first glance educational tweeting may seem like a radical teaching method, it actually parallels traditional medical education on the wards. Normally, students learn by

incorporating what they see, hear and do from a variety of sources in the hospital, which range from fellow students to expe-rienced attending physicians. Over time, students compile these small factoids and experiences to strengthen their knowledge base, similar to the process of learning via

tweets. However, the study did not include a pre- and post- knowledge assessment.

Nevertheless, the trend towards harnessing the latest technologies to supplement medical education is clear and unstoppable. As these necessary new technologies emerge, their effect on train-ees, in terms of when, where and what to learn, remains to be seen. 1. Gonzalez NR, Dusick JR, Martin NA. Effects of mobile and digital support for a structured, competency-based cur-riculum in neurosurgery residency education. Neurosurgery

2012;71(1):164-72. 2. Bahner DP, Adkins E, Patel N, Donley C, Nagel R, Kman NE. How we use social media to supplement a novel curricu-lum in medical education. Med Teach 2012;34(6):439-44.

Can you spare a byte? Mobile technology and medical education Loheetha Ragupathi

Harold Paredes, fourth year medical student, using a smart phone.