#AASChat questions
- What is the status of didactic instruction at your institution for medical students and residents?
- What platforms are you using to deliver didactic instruction?
- How have you adapted clinical education and skills training for your medical students and surgical residents?
- What lessons have you learned in your transition to remote learning?
- What aspects of remote distance education will you continue after pandemic restrictions are lifted?
Didactic Education
Transitioning live instruction to distance education amidst a global pandemic is challenging, but necessity is the father of invention, or in this case, ingenuity. For surgical educators that are not familiar with the concepts and best practices of distance education, the premise can be daunting. When designing efficacious distance learning materials for medical students and residents, educators should first focus on the objectives, then the assessment, and finally the content via a backwards design premise. Considerations for the efficient development of effective distance education materials include the platform, the synchronicity, the assessment type, and the strategy for faculty development.
First and foremost, stakeholders and learners should be reassured of the overall efficacy of distance education. Learners in distance education perform at least the same if not better than those receiving face to face instruction (Simonson et al, 2011). Designing objectives for distance learners should mimic the process for live instruction with minimal modification. It is important to note, however, that distance education is not and should not be an attempt to exactly replicate standard traditional classroom education. Though the learning experience, or learning outcome, should be equivalent to conventional instruction, the method of obtaining this goal may differ (Simonson et al, 1999). For distance education, it is imperative to set expectations of learner involvement, engagement and time commitment. Creating a syllabus with accessible materials and a reasonable timeline and metrics for completion are important steps for supporting and fostering surgical learners. Learner interactions with each other and faculty are essential components of distance education and should be adopted regardless of the platform (Simonson et al, 2018). For optimal learner interaction didactic distance education should be provided with a limited group of learners. A group size of up to twenty is optimal for interaction in distance education and this may require a diverse array of faculty preceptors to facilitate more robust student-student and student-facilitator interactions (Orellana et al, 2006).
The next consideration should be the student-content interaction. Richard Clark postulated based on contemporary evidence in 1983 that media are “mere vehicles that deliver instruction, but they do not influence student achievement” (Clark, 1983). While media cannot and does not replace enthusiasm and impassioned teaching, his premise is based on data from nearly forty years ago and modern media may have a different effect on the achievements of a learner. Many students can describe with disdain their subjugation to “death by Powerpoint” in which an educator brutally copies an entire textbook of words on to slides and delivers a lecture by reading off of the slides. In this example, certainly the media does not contribute to learning and thus cannot improve the learner achievement or the instructor aptitude for teaching. This type of media can be even further negatively compounded in a distance education format if a video recorded lecture or voice-over of PowerPoint slides doesn’t show the instructor – losing that personal engagement opportunity. While this format may still be applied with good efficacy, the instructor needs to modify their approach and tamper their presentation style to fit the platform rather than trying to replicate a live lecture for asynchronous distance students.
It is also imperative to apply the context of modern education and the capabilities of modern technology. Distance education has been the significant change to the process of teaching and learning over the last decade (Simonson, 2011) and continues to defined as “institution-based, formal education where the learning group is separated, and where interactive telecommunications systems are used to connect learners, resources, and instructors.” Thus, fundamental to the definition of distance education is the interactive component of media. In this regard, the media may influence student achievement through engagement which fosters understanding, retention, and transfer. Taking this into consideration, the media may in fact be the vehicle for the instructor and therefore dependent upon the instructor’s ability and capability to generate engaging content may influence and improve student achievement.
The final element to consider when transitioning didactic content to distance education is the strategy for faculty development. Faculty should be enthusiastic and motivated to teach in a distance education setting. Faculty may be intrinsically motivated to teach in a distance education setting by desire to implement new technology, intellectual challenge or curiosity, and vocational satisfaction (Betts, 1998). Faculty may also be extrinsically motivated by teaching requirements or personal gain such as promotion and tenure criteria (Maguire, 2008). When developing a strategy for faculty development, cognizance of your instructors’ motivation may inform your teaching methods. For example, intrinsically motivated faculty may benefit from a discussion of distance education theory and review of supporting evidence in addition to best practices guidance whereas extrinsically motivated faculty may prefer a more concise approach.
Transitioning a traditional classroom didactic to distance education is challenging but can be achieved with excellent results and in a rapid timeline if necessary. An understanding of the efficacy and best practices of distance education instruction are necessary to create an optimal learning environment. Educators need to be aware of the tenants of distance education, the importance of engaging student-content interactions, and the need for targeted faculty development to achieve these aims.
Clinical Education
The vast majority of surgical cases are non-emergent, elective or semi-elective cases, and the coronavirus pandemic has rapidly changed the workflow of how we initially consult with our patients or conduct follow up visits. It is hard to imagine that we will return to all in-person visits once the pandemic recedes, so attention should be focused now on teaching “webside manner.” Learning how to conduct a medical interview without being in the same room and effectively engaging patients without being able to touch them in greeting or for a full physical exam are critical skills. Learning what physical exam components CAN be done via video, including instructing patients how to take their own pulse, inspecting areas of the body, having patient’s push on their own body areas to gauge tenderness, or gathering data from a patient’s wearable device are all going to be essential skills in the post-COVID surgical clinic.
If your medical school or residency program does not already have a curriculum for this, it is a good time to start developing one and creating assessment and evaluation tools specific for telemedicine visits. One quick exercise you could try now is to simply have trainees perform a standardized patient interview remotely. Record it for later viewing or have faculty join the videoconference in real time and provide feedback. You will need to choose a digital platform or use one approved by your clinical entity, adapt your existing evaluation tool, and focus on formative feedback at this early stage, but it is potentially something that can be done right now for students sheltering at home wanting to get back to clinical rotations.
Inpatient care is shifting toward remote delivery, as well. Specifically, delivering difficult news has always been something surgeons have had to do remotely at least some of the time – critically ill patients always seem to take a turn for the worse in the middle of the night when decision-makers have left the hospital. The “No Visitor” policies of the COVID pandemic have magnified the need to be able to do this well, and developing educational scenarios for residents and students to deliver difficult news or lead discussions about medical decision-making over the phone is critical. Find a quiet room with a speaker option or use multiple-way calling on a mobile device and allow your residents to do this with an attending listening in to provide feedback. Depending on the level of the resident, allow them as much autonomy as is appropriate; resist as much as possible to jump in and take over. Prepare the resident by running through the conversation first and lay out the essential points, take detailed notes during the conversation, and spend time after the phone call to debrief and give feedback.
Teaching surgical skills remotely is more of a challenge, and this is where we all need to get more creative. High cost remote simulators exist, but are not practical, and low cost skills sessions that are readily accessible are very much needed. The SCORE (surgicalcore.org) has technical skills modules for most general surgery core operations, and while these are wonderful preparation for residents about to engage in an operation, they were never meant to substitute for hands-on learning in the OR. Many of these and other remote learning modules involve a trainee watching a video (some with excellent annotations and anatomic landmarks highlighted, some simply an edited and narrated video of a specific operation, and many publicly available that have not been reviewed for accuracy) and then answering knowledge-based questions . We hope to engage the surgical education community around this topic and share best practices for remote surgical skills learning activities in the near future.
Recommended readings:
https://www.aamc.org/news-insights/bedside-webside-future-doctors-learn-how-practice-remotely
References:
Betts, K. (1998). An Institutional Overview: Factors Influencing Faculty Participation in Distance Education in Postsecondary Education in the United States: An Institutional Study. Online Journal of Distance Learning Administration, 1(3).
Clark, R. E. (1983). Reconsidering research on learning from media. Review of educational research, 53(4), 445-459.
Maguire, L. (2008). Literature Review: Faculty Participation in Online Distance Education: Barriers and Motivators. Online Journal of Distance Learning Administration. 8:1.
Orellana, A. (2009). Class size and interaction in online courses. The perfect online course: Best practices for designing and teaching, 117-135.
Simonson, M., Schlosser, C., & Orellana, A. (2011). Distance education research: A review of the literature. Journal of Computing in Higher Education, 23(2-3), 124.
Simonson, M., Zvacek, S., & Smaldino, S. (2019). Teaching and Learning at a Distance (7th ed). Charlotte, NC: Information Age Publishing.
Simonson, M., Schlosser, C., & Orellana, A. (2011). Distance education research: A review of the literature. Journal of Computing in Higher Education, 23(2-3), 124.
Simonson, M., Schlosser, C., & Hanson, D. (1999). Theory and distance education: A new discussion. American Journal of Distance Education, 13(1), 60-75.
Abbey Fingeret, MD, MHPTT