Process Engineering in Anesthesia Education Dr. Kurt...

Process Engineering in Anesthesia Education

Dr. Kurt Domuracki PGY 2

Anesthesia Resident McMaster University

Starting with Why

Starting with Why

What are we all spending right now that we will never get back

???

Starting with Why

TIME = LIFE

None to Waste

Outline � Definitions � The current state of anesthesia education

�  Concerns � The ideal educational structure

�  The two sigma study � Applying cognitive and metacognitive design

principles � The future at McMaster

Process Engineering vs. Curriculum design

� Process Engineering or Process Systems Engineering �  “Focuses on the design, operation, control, and

optimization of processes through the aid of systematic computer-based methods for the duration of a project (or career) life cycle”

� Curriculum-discrete entity of education �  “Planned education experience. ..From one session to

an entire training program”

Engineering Anesthesia Education

� Process engineering in medical education �  Applying design principles and structures to ensure

skill and knowledge retention- process driven

� Curriculum in medical education �  Discrete instructional event or events - content driven

Changes In the Wind •  Working hour reforms

•  Reduced clinical and academic time •  New assessment structures

•  Increased production pressure •  Reduced clinical exposure

•  Expanding knowledge base •  Information overload

•  Medicolegal constraints •  Supervision

Anesthesia Education •  5 year-Apprenticeship

•  1 year basic clinical training •  1 yr internal medicine (internal/ICU) •  3 yrs anesthesia

•  Didactic program of lectures (Must now reflect National curriculum 2010)

•  Interim exams AKT •  Final written and Oral exam

Are there Problems? Gaba 1991

differences between second-year anesthesia residents (CA2) and experienced anesthesiologists were not statistically significant

Unplanned errors and management flaws still occurred with experienced subjects

Are there Problems?

Conclusion: … A trainee who “knows how” in an oral examination may not necessarily be able to “show how” in a simulation laboratory

Are there Problems?

Conclusion: Our results suggest that an experiential training session allowed junior residents to achieve skills superior to those of senior colleagues after a five-year residency. This training was retained for two to four years as they continued to outperform their comparative controls.

Re-envisioning Anesthesia Education

Re-envisioning Anesthesia Education

�  1) Time on task does not necessarily equate to improved performance.

�  2) Knowing how is not enough. �  3) Important skills MUST be systematically taught

Re-envisioning Anesthesia Education-The Ideal

Re-envisioning Anesthesia Education-The Ideal

Ideal Anesthesia Education Model

Is Anesthesia Education Still an Apprenticeship?

Is Anesthesia Education Still an Apprenticeship?

Is Anesthesia Education Still an Apprenticeship?

Prerequisites for traditional apprenticeship

Constraints in current healthcare system

Possible solutions

CLINICIAN-TEACHERS Continuity of supervision Discontinuity Mentorship Time Lack of time Make sessional commitments to teaching explicit Teaching accorded high

priority Teaching below service delivery, administration and research in priority

Develop promotion tracks for educators

Themselves trained by apprenticeship

Lack of an apprenticeship tradition Faculty development

LEARNING ENVIRONMENT Personal Impersonal Personalize attachments as far as possible, and make them

long enough for learners and teachers to get to know one another

Person-focused Technology-focused Space for students No space Give students a base close to where care is delivered

STUDENTs Manageable numbers Huge expansion in numbers Disperse learning and ensure individual mentorship

!

Is Anesthesia Education Still an Apprenticeship?

Prerequisites for traditional apprenticeship

Constraints in current healthcare system

Possible solutions

CLINICIAN-TEACHERS Continuity of supervision Discontinuity Mentorship Time Lack of time Make sessional commitments to teaching explicit Teaching accorded high

priority Teaching below service delivery, administration and research in priority

Develop promotion tracks for educators

Themselves trained by apprenticeship

Lack of an apprenticeship tradition Faculty development

LEARNING ENVIRONMENT Personal Impersonal Personalize attachments as far as possible, and make them

long enough for learners and teachers to get to know one another

Person-focused Technology-focused Space for students No space Give students a base close to where care is delivered

STUDENTs Manageable numbers Huge expansion in numbers Disperse learning and ensure individual mentorship

!

Is Anesthesia Education Still an Apprenticeship?

Prerequisites for traditional apprenticeship

Constraints in current healthcare system

Possible solutions

CLINICIAN-TEACHERS Continuity of supervision Discontinuity Mentorship Time Lack of time Make sessional commitments to teaching explicit Teaching accorded high

priority Teaching below service delivery, administration and research in priority

Develop promotion tracks for educators

Themselves trained by apprenticeship

Lack of an apprenticeship tradition Faculty development

LEARNING ENVIRONMENT Personal Impersonal Personalize attachments as far as possible, and make them

long enough for learners and teachers to get to know one another

Person-focused Technology-focused Space for students No space Give students a base close to where care is delivered

STUDENTs Manageable numbers Huge expansion in numbers Disperse learning and ensure individual mentorship

!

Is Anesthesia Education Still an Apprenticeship?

Prerequisites for traditional apprenticeship

Constraints in current healthcare system

Possible solutions

CLINICIAN-TEACHERS Continuity of supervision Discontinuity Mentorship Time Lack of time Make sessional commitments to teaching explicit Teaching accorded high

priority Teaching below service delivery, administration and research in priority

Develop promotion tracks for educators

Themselves trained by apprenticeship

Lack of an apprenticeship tradition Faculty development

LEARNING ENVIRONMENT Personal Impersonal Personalize attachments as far as possible, and make them

long enough for learners and teachers to get to know one another

Person-focused Technology-focused Space for students No space Give students a base close to where care is delivered

STUDENTs Manageable numbers Huge expansion in numbers Disperse learning and ensure individual mentorship

!

Is Anesthesia Education Still an Apprenticeship?

Prerequisites for traditional apprenticeship

Constraints in current healthcare system

Possible solutions

CLINICIAN-TEACHERS Continuity of supervision Discontinuity Mentorship Time Lack of time Make sessional commitments to teaching explicit Teaching accorded high

priority Teaching below service delivery, administration and research in priority

Develop promotion tracks for educators

Themselves trained by apprenticeship

Lack of an apprenticeship tradition Faculty development

LEARNING ENVIRONMENT Personal Impersonal Personalize attachments as far as possible, and make them

long enough for learners and teachers to get to know one another

Person-focused Technology-focused Space for students No space Give students a base close to where care is delivered

STUDENTs Manageable numbers Huge expansion in numbers Disperse learning and ensure individual mentorship

!

Is Anesthesia Education Still an Apprenticeship?

Prerequisites for traditional apprenticeship

Constraints in current healthcare system

Possible solutions

CLINICIAN-TEACHERS Continuity of supervision Discontinuity Mentorship Time Lack of time Make sessional commitments to teaching explicit Teaching accorded high

priority Teaching below service delivery, administration and research in priority

Develop promotion tracks for educators

Themselves trained by apprenticeship

Lack of an apprenticeship tradition Faculty development

LEARNING ENVIRONMENT Personal Impersonal Personalize attachments as far as possible, and make them

long enough for learners and teachers to get to know one another

Person-focused Technology-focused Space for students No space Give students a base close to where care is delivered

STUDENTs Manageable numbers Huge expansion in numbers Disperse learning and ensure individual mentorship

!

Re-envisioning Anesthesia Education

•  5 year-Apprenticeship ( room for improvement?) •  1 year basic clinical training •  1 yr internal medicine (internal/ICU) •  3 yrs anesthesia

•  Didactic program of lectures (Must now reflect National curriculum 2010)

•  Interim exams AKT

Is Anesthesia Education Still an Apprenticeship?

Prerequisites for traditional apprenticeship

Constraints in current healthcare system

Possible solutions

CLINICIAN-TEACHERS Continuity of supervision Discontinuity Mentorship Time Lack of time Make sessional commitments to teaching explicit Teaching accorded high

priority Teaching below service delivery, administration and research in priority

Develop promotion tracks for educators

Themselves trained by apprenticeship

Lack of an apprenticeship tradition Faculty development

LEARNING ENVIRONMENT Personal Impersonal Personalize attachments as far as possible, and make them

long enough for learners and teachers to get to know one another

Person-focused Technology-focused Space for students No space Give students a base close to where care is delivered

STUDENTs Manageable numbers Huge expansion in numbers Disperse learning and ensure individual mentorship

!

Re-envisioning Anesthesia Education

Why Is Continuity Important in Education

�  In the human tutoring literature CONTINUITY is important for: �  Diagnosing errors and misconceptions

�  Socratic dialogues �  For repetition and consolidation of knowledge and

continued challenge

� WITHOUT continuity process structures are necessary to ENSURE SKILL AND KNOWLEDGE RETENTION due to rapid decay.

Continuity and Decay

RESULTS: No significant retention was measurable at 55 days.

Continuity and Decay

Continuity and Decay

Time

Ret

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Continuity and Decay

Continuity and Decay �  Options

�  One-one-One human tutoring �  Expensive �  Logistically difficult

�  Longitudinal assessment �  Lack of structures and objective validated tools

�  Peer assessment �  Privacy

�  Intelligent systems �  Tutors-full dialogue and adaptive

�  Currently limited �  Intelligent reminder systems

�  Simple �  Cheap �  Effective for BOTH declarative and procedural knowledge

Continuity and Decay

Conclusions: Online spaced education improves the acquisition and retention of clinical knowledge

Continuity and Decay

Continuity and Decay

Time

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Continuity and Decay

Time

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Continuity and Decay

Conclusions: Our current model of training surgical skills using short courses (for both CME and structured residency curricula) may be suboptimal. Residents retain and transfer skills better if taught in a distributed manner. Despite the greater logistical challenge, we need to restructure training schedules to allow for distributed practice

Closer to Home �  MUMC

�  Pediatrics and Adults

�  St. Joseph’s �  Regional anesthesia

�  Anesthesia curriculum renewal �  Lecture format �  Resident scheduling �  Simulation �  Procedural skills

Continuity and Decay

Time

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Continuity and Decay

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Continuity and Decay

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Continuity and Decay

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Continuity and Decay

Results: During the intervention period (Weeks 1–36), clinicians receiving spaced education emails ordered signifıcantly fewer inappropriate PSA screening tests than control clinicians Over the 72-week period following the intervention (Weeks 37–108), spaced education clinicians continued to order fewer inappropriate tests compared to controls

The Bottom Line � Anesthesia education is changing

� There are opportunities to further enhance and optimize the quality learning that already occurs

� Using process principals allows real lasting long term learning and behavioral change

References �  Bell, D. S., Harless, C. E., Higa, J. K., Bjork, E. L., Bjork, R. a, Bazargan, M., & Mangione, C. M. (2008). Knowledge retention after an

online tutorial: a randomized educational experiment among resident physicians. Journal of general internal medicine, 23(8), 1164-71. doi:10.1007/s11606-008-0604-2

�  Bloom, B. (1984). "The 2 Sigma Problem: The Search for Methods of Group Instruction as Effective as One-to-One Tutoring", Educational Researcher, 13:6(4-16).

�  Chiu, M., Arab, A. a, Elliott, R., & Naik, V. N. (2012). An experiential teaching session on the anesthesia machine check improves resident performance. Canadian journal of anaesthesia = Journal canadien d’anesthésie, 59(3), 280-7. doi:10.1007/s12630-011-9649-5

�  Deanda, A., & Gaba, D. M. (1991). Role of Experience in the Response to Simulated Critical Incidents, (4), 308-315. �  Dornan, T. (2005). Osler, Flexner, apprenticeship and “the new medical education”. Journal of the Royal Society of Medicine, 98(3), 91-5.

doi:10.1258/jrsm.98.3.91 �  Evens, M., & Michael, J. (2005). One-on-One Tutoring by Humans and Computers (p. 496). Lawrence Erlbaum Associates. �  Hirsh, D. a, Ogur, B., Thibault, G. E., & Cox, M. (2007). “Continuity” as an organizing principle for clinical education reform. The New

England journal of medicine, 356(8), 858-66. doi:10.1056/NEJMsb061660 �  Kerfoot, B. P., Baker, H. E., Koch, M. O., Connelly, D., Joseph, D. B., & Ritchey, M. L. (2007). Randomized, controlled trial of spaced

education to urology residents in the United States and Canada. The Journal of urology, 177(4), 1481-7. doi:10.1016/j.juro.2006.11.074 �  Kerfoot, B. P., Lawler, E. V., Sokolovskaya, G., Gagnon, D., & Conlin, P. R. (2009). Interactive Spaced Education Improves Clinicians’

Screening for Prostate Cancer: a Multi-Institutional Randomized Controlled Trial. The Journal of Urology, 181(4), 190-190. doi:10.1016/S0022-5347(09)60548-6

�  Kerfoot, B. P., Lawler, E. V., Sokolovskaya, G., Gagnon, D., & Conlin, P. R. (2010). Durable improvements in prostate cancer screening from online spaced education a randomized controlled trial. American journal of preventive medicine, 39(5), 472-8. doi:10.1016/j.amepre.2010.07.016

�  Moulton, C.-A. E., Dubrowski, A., Macrae, H., Graham, B., Grober, E., & Reznick, R. (2006). Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Annals of surgery, 244(3), 400-9. doi:10.1097/01.sla.0000234808.85789.6a