Reflection and reflective practice in health professions education: a systematic review

This article by Karen Mann and colleagues was just published online …

Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Advances in Health Sciences Education 2007 Nov 23; [Epub ahead of print; subscription required]
Abstract: The importance of reflection and reflective practice are frequently noted in the literature; indeed, reflective capacity is regarded by many as an essential characteristic for professional competence. Educators assert that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout their courses of study, integrating theory and practice from the outset. Activities to promote reflection are now being incorporated into undergraduate, postgraduate and continuing medical education, and across a variety of health professions. The evidence to support and inform these curricular interventions and innovations remains largely theoretical. Further, the literature is dispersed across several fields, and it is unclear which approaches may have efficacy or impact. We, therefore, designed a literature review to evaluate the existing evidence about reflection and reflective practice and their utility in health professional education. Our aim was to understand the key variables influencing this educational process, identify gaps in the evidence, and to explore any implications for educational practice and research. PubMed Record    Related Articles 

Rigorous development does not ensure that guidelines are acceptable to a panel of knowledgeable providers

This study, just published online in the Journal of General Internal Medicine, examined the quality of five guidelines covering various musculoskeletal disorders. The panel concluded that despite rigorous development, the quality of the published guidelines did not always meet their high standards.

Nuckols TK, Lim YW, Wynn BO, Mattke S, Maclean CH, Harber P et al. Rigorous development does not ensure that guidelines are acceptable to a panel of knowledgeable providers. J Gen Intern Med 2007 Nov 21; [Epub ahead of print]

BACKGROUND: Rigorous guideline development methods are designed to produce recommendations that are relevant to common clinical situations and consistent with evidence and expert understanding, thereby promoting guidelines’ acceptability to providers. No studies have examined whether this technical quality consistently leads to acceptability.
OBJECTIVE: To examine the clinical acceptability of guidelines having excellent technical quality.
DESIGN AND MEASUREMENTS: We selected guidelines covering several musculoskeletal disorders and meeting 5 basic technical quality criteria, then used the widely accepted AGREE Instrument to evaluate technical quality. Adapting an established modified Delphi method, we assembled a multidisciplinary panel of providers recommended by their specialty societies as leaders in the field. Panelists rated acceptability, including “perceived comprehensiveness” (perceived relevance to common clinical situations) and “perceived validity” (consistency with their understanding of existing evidence and opinions), for ten common condition/therapy pairs pertaining to Surgery, physical therapy, and chiropractic manipulation for lumbar spine, shoulder, and carpal tunnel disorders.
RESULTS: Five guidelines met selection criteria. Their AGREE scores were generally high indicating excellent technical quality. However, panelists found 4 guidelines to be only moderately comprehensive and valid, and a fifth guideline to be invalid overall. Of the topics covered by each guideline, panelists rated 50% to 69% as “comprehensive” and 6% to 50% as “valid”.
CONCLUSION: Despite very rigorous development methods compared with guidelines assessed in prior studies, experts felt that these guidelines omitted common clinical situations and contained much content of uncertain validity. Guideline acceptability should be independently and formally evaluated before dissemination.

Guidelines examined:

• American Academy of Orthopaedic Surgeons. Guidelines and support documents for hip pain, knee injury, knee osteoarthritis, low back pain/sciatica, shoulder pain and wrist pain. 2001–2003.
• American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers, Second Edition. Beverly Farms, Massachusetts; 2004.
• Intracorp. Intracorp Optimal Treatment Guidelines. Philadelphia, Pennsylvania; 2003.
• McKesson. InterQual Care Management Criteria for Workers’ Comp & Clinical Evidence Summaries. (Formerly QualityFirst® Workers’ Compensation/Disability Guidelines). Newton, Massachusetts. 2004.
• Work Loss Data Institute. Official Disability Guides (ODG), Treatment in Workers’ Compensation. San Diego, CA; 2004.

Languages, living, dying and constructed …

Are you fascinated by the diversity of languages in the world, and saddened by how many of them are dying? According to the National Geographic, a language dies every two weeks. Why does this matter?
Language defines a culture, through both the people who speak it and what it allows speakers to say. Words that describe a particular cultural practice or idea rarely translate precisely into another language. Many endangered languages have rich oral cultures with stories, songs, and histories passed on to younger generations, but no written forms. With the extinction of a language, an entire culture is lost.

Enduring Voices: Saving Disappearing Languages

Every 14 days a language dies. By 2100, more than half of the more than 7,000 languages spoken on Earth—many of them never yet recorded—will likely disappear, taking with them a wealth of knowledge about history, culture, the natural environment, and how the human brain works.

National Geographic’s Enduring Voices Project strives to preserve endangered languages by identifying language hotspots—the places on our planet with the most unique, poorly understood, or threatened indigenous languages—and documenting the languages and cultures within them.

Among the world’s disappearing tongues is northern Australia’s Magati Ke—still spoken by 70-something “Old Man” Patrick Nanudjul.

Glossary of Terms Related to Language and Language Endangerment

Here is a site from the National Virtual Translation Center:  Languages of the World

The main purpose of this website is to provide information about the language families of the world and their most important and populous members, including their history, status, their linguistic characteristics, and their writing in as simple and concise a way as possible. We base this website on the belief that all languages have evolved from the need of human beings to express their thoughts, beliefs, and desires, that all languages meet the social, psychological, and survival needs of people who use them. In this sense, all languages, no matter how small and remote, are equal. All equally deserve study because all of them provide valuable insights into human nature.
Some features …
Language Listing (introduction / structure / writing / resources); Interactive Language Map;  Test your knowledge about the languages of the world

Then there are constructed or artificial languages, also known as conlang. See these Wikipedia entries:  Constructed language; List of constructed languages (Read about such languages as Volapük; Esperanto; Idiom Neutral; Latino sine flexione; Ido; Occidental; Novial; Glosa and Interlingua)

Plagiarism and punishment

  The following editorial and commentary were published in the November 10 issue of BMJ. [Full text is available free online.] (I can never hear the word plagiarize without thinking of Nicolai Ivanovich Lobachevsky.)
See also Writing & Publishing: all posts

Godlee F. Plagiarism and punishment [editorial]. BMJ  2007;335
Extract: Plagiarism is one of the three high crimes of research fraud. The US Office for Research Integrity (ORI) puts it up there with the big boys, fabrication and falsification, in its definition of research misconduct (http://ori.dhhs.gov). Some have argued that the definition should extend to lesser crimes such as undeclared conflict of interest and duplicate publication, but to my knowledge no one has questioned that theft of another person’s work is fraud.

How big a problem is plagiarism? The Committee on Publication Ethics (COPE) lists 18 cases of alleged plagiarism reviewed from 1998 to 2005 (www.publicationethics.org.uk), but as with research fraud generally this is likely to be a substantial underestimate of the true extent. Detection has been difficult in the past, but the internet, which has made plagiarism much easier to commit, is also making it easier to detect, as Michael Cross explains …

Cross M. Policing plagiarism. BMJ  2007;335:963-964 

In the internet age, copying someone else’s work can be as simple as clicking and dragging a computer mouse over a few plausible paragraphs. By the same token, the world wide web makes fraud easy to detect. Over the past decade, a range of software products has become available for detecting plagiarism, especially by students. However, experts are questioning whether Britain’s strategy for detecting academic fraud is the right one for catching the most damaging types of misconduct.

There is no evidence that plagiarism is becoming more prevalent in research. But there is no doubt that plagiarism happens, perhaps because of mindsets acquired in education.1 The Committee on Publication Ethics, an international forum for editors of peer reviewed journals, has discussed “30 or 40” alleged cases of research plagiarism over the past 10 years, says its chairman, Harvey Marcovitch.
Sections: Defining plagiarism; Relying on a single tool; Alternative tools; Bespoke work

A Google Scholar Primer

 Almost a year ago I wrote A Google Primer, which some of you have told me you have found useful. This week I took a careful look at Google Scholar, and I’ll pass on some of the things I discovered. Scholar’s advantages and disadvantages have been well documented and I won’t go into them in detail here. See also A little Google history from the Internet Archive

See Shultz M. Comparing test searches in PubMed and Google Scholar. J Med Libr Assoc 2007; 95(4):442-445. [Open Access]

Google Scholar is terrific for serendipitous searching, especially if you use the Cited By feature. This is what I tell my students:

• Use Google Scholar as a starting point, keeping in mind limitations such as lack of subject indexing and undeterminable coverage
• Use the Advanced Scholar Search to take advantage of several advanced search features at the same time, and use the Scholar Preferences
• Enrich your searches by using other (free) databases such as PubMed or TRIP  (Turning Research Into Practice) or the Index to Chiropractic Literature because Scholar’s coverage of MEDLINE, for example, is incomplete (although Scholar does cover a lot of “grey literature” absent from PubMed)

If you compare the search features on the Google Advanced Search and Google Scholar Advanced Search pages, some puzzling differences appear. Some features may be used in both. Here are some highlights of Scholar and Google search features:

Downloading into bibliographic software

I have been frustrated by what I thought was the inability to download references from Scholar. Well, this week I discovered that you can download from Google Scholar, and into 5 different software managers. Outstanding! Simply go to Scholar Preferences , scroll down to Bibliography Manager and choose one.  See the link Import into RefMan on the bottom line in this screen shot (click on the image to enlarge it):

     Link to search (Turn on the bibliography manager in Google Scholar to see all the links.)

Boolean searchingWords and phrases in both Googles are automatically ANDed. OR can be used (uppercase). You can NOT words or phrases by using  – .Truncation or wildcard searching

In Google, use * to capture all forms of a word, e.g. chiropract*. Oddly, this does not work in Google Scholar.

Phrase searching

“Exact phrase” is an option in both advanced search screens; enter phrases in quotation marks in basic searches.

Author searching

This is a search feature in Google Scholar advanced search; au:  in basic search also works, although results may be incomplete (e.g. au: taylor-vaisey)

Publication searching

This is a search feature in Google Scholar advanced search. Caution: Titles are entered in the form in which they appear in publications, and the search screen only gives one chance to enter titles. Publication:  seems to work in some cases, but is unreliable. There is no way to capture all forms of a title in one search, as far as I can see.

Date searching

You can specify date ranges in Scholar; broad ranges only are available in Google.

Language searching

Google has a long drop box for countries on its advanced search screen. You can also choose from many languages in Google preferences. Scholar has no language feature on its search page, but you can choose 8 language limiters in Scholar Preferences. (A puzzling difference that may have to do with bias …)

File type

This is a choice on the Google advanced search page, not on Scholar. But you can limit by file type in Scholar basic search (e.g. filetype:pdf).

Domain limiting

This is a feature on the Google advanced search page, not on Scholar. But you can limit by domain in Scholar basic search (e.g. site:edu).

Citation searching

The “Cited by” feature is only in Google Scholar (see above screen shot). Also use the Related Articles feature. I don’t know how they create the latter but they seem to pick title words and authors. I tried to figure out how to find all the “cited by” records for a particular author, but this seems to be pretty random, unlike PubMed, which uses a formula.

Refining results

Google Scholar includes broad subject categories in its advanced search. In Google,  however, I just discovered that you can refine a search on a topic like “chronic fatigue syndrome” by the categories below. (These appear only after you do a search.)

Treatment; Tests/diagnosis; For patients; From medical authorities; Symptoms; Causes/risk factors; For health professionals; Alternative medicine; Patient handouts; Clinical trials; Continuing education; Practice guidelines 

A guide to the Canadian Medical Association Handbook on Clinical Practice Guidelines

  A guide to the CMA Handbook on Clinical Practice Guidelines (published in July 2007) has just been published in the November 6, 2007 issue of CMAJ:

A guide to the Canadian Medical Association Handbook on Clinical Practice Guidelines

From the Canadian Medical Association CMA  Infobase Web site:

The Canadian Medical Association (CMA) published its new Handbook on Clinical Practice Guidelines to promote systematic development and effective implementation of clinical practice guidelines. This document provides updated guidance on how to use clinical practice guidelines to achieve optimal outcomes of patient care. Among its key audience are health care practitioners, administrators, policy-maker, groups, organizations and societies involved in guideline development, adaptation and/or implementation.

From the Guide:
At the fourth meeting of the Guideline International Network, held in Toronto in August 2007, world experts from 31 countries met to discuss the challenges and innovations afforded by clinical practice guidelines.  Although each country faces unique local challenges to the implementation of effective health care, members of the guideline community have repeatedly and generously shared their solutions to these challenges, many of which are applicable in other countries. Nevertheless, it can be difficult for the local implementer with limited resources to harness this knowledge.

See also IMPLEMENTING CLINICAL PRACTICE GUIDELINES: A Handbook for Practitioners. Developed at the 1996 CMA workshop Guideline implementation: making it happen

Journal of Athletic Training: Open Access journal

  The Journal of Athletic Training is an Open Access, peer-reviewed journal, and the official publication of the National Athletic Trainers’ Association, Inc.

Mission: to enhance communication among professionals interested in the quality of health care for the physically active through education and research in prevention, evaluation, management and rehabilitation of injuries.

Free full text is available from the journal’s Web site from 2000 to the present, and from PubMed Central from 1992.

Author Instructions   PubMed Records

Advancing Medical Education: the new series of AMEE guides in medical education

  A new series of AMEE guides (Association for Medical Education in Europe) launches with the current issue of Medical Teacher:

Gibbs T. Advancing Medical Education: the new series of AMEE guides in medical education. Medical Teacher 2007; 29(6):525-526.  See also AMEE Medical Education Guides, 1-29

Excerpt: To capture an ever increasing body of interested parties, from various healthcare educators from around the world, the new AMEE guides will be for:

• the practising teacher who wants information about teaching methods, assessment, curriculum planning and other issues in medical education;
• the reflective teacher who wishes to review his/her contribution to medical education and compare it with that of others in the field;
• the teacher/researcher who wishes to learn more about a topic as a stimulus to further studies, research and evaluation;
• institutions who wish to add to their library resources relating to medical education, and to have materials available to support local staff development initiatives;
• students who wish access to a source of information about current approaches and methods in medical education, recognising the trend to involve students in the teaching process.

In order to address these needs, the new Guides will:

• be practical and up to date, providing information on current approaches to a range of issues relating to the day-to-day work of the medical teacher;
• be equally useful to those new to medical education, whilst, by encouraging reflective thought, be stimulating to those experienced in the speciality;
• adopt a seamless approach to medical education, recognizing the similarities in process between undergraduate, postgraduate and vocational training and continuing professional development;
• keep medical education as a primary target, but be of relevance to other healthcare professions’ education;
• incorporate underpinning theory where this is relevant and contribute to an understanding of the more practical aspects of education. Each guide will have a purposeful and relevant bibliography;
• reflect an international perspective of the topic and not be seen as relating only to a particular institutional or geographical context. The transference of approaches to teaching and learning into an international arena of diverse cultures, race and religions will be addressed;
• be living documents capturing the views and experiences of those engaged in the specialty by inviting their contributions to the guides. This unique feature will be achieved through the publication of supplements to the guides online and in printed format, incorporating additional material, constructive comment and a wider viewpoint.

Here are the guides in this new series:

Ross MT, Cameron HS. Peer assisted learning: a planning and implementation framework: AMEE Guide no. 30. Med Teach 2007; 29(6):527-545. [subscription required]
Abstract: Much has been written about the benefits and applications of Peer Assisted Learning (PAL) in the literature. Curriculum developers increasingly consider PAL as a vehicle to help undergraduate healthcare students learn to teach; an outcome which has received more attention in the UK since the General Medical Council stated in Tomorrow’s Doctors that medical graduates must ‘Be able to demonstrate appropriate teaching skills’.

This guide is primarily designed to assist curriculum developers, course organisers and educational researchers develop and implement their own PAL initiatives. It is structured around a PAL planning framework consisting of 24 questions. The questions are grouped in threes, around eight themes. Each question is discussed with reference to the PAL literature and other related subjects, and is exemplified by responses from a recent PAL project developed at The University of Edinburgh. Working through the 24 questions, particularly with discussion in a small planning group, will enable readers to efficiently develop their ideas for PAL into comprehensive and practical project plans cognisant of current educational theory, existing PAL literature and the local context.

The framework is particularly suitable for those who want to develop healthcare undergraduate PAL initiatives yet have little or no experience of PAL, as it provides an introduction to the relevant literature field and a step-by-step process for the design and implementation of such projects. It will also be of interest to those with experience of PAL and those seeking a structured framework for planning non-PAL curriculum developments in undergraduate healthcare curricula. 

Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach 2007; 29(9):855-871.
BACKGROUND: There has been concern that trainees are seldom observed, assessed, and given feedback during their workplace-based education. This has led to an increasing interest in a variety of formative assessment methods that require observation and offer the opportunity for feedback.
AIMS: To review some of the literature on the efficacy and prevalence of formative feedback, describe the common formative assessment methods, characterize the nature of feedback, examine the effect of faculty development on its quality, and summarize the challenges still faced.
RESULTS: The research literature on formative assessment and feedback suggests that it is a powerful means for changing the behaviour of trainees. Several methods for assessing it have been developed and there is preliminary evidence of their reliability and validity. A variety of factors enhance the efficacy of workplace-based assessment including the provision of feedback that is consistent with the needs of the learner and focused on important aspects of the performance. Faculty plays a critical role and successful implementation requires that they receive training.
CONCLUSIONS: There is a need for formative assessment which offers trainees the opportunity for feedback. Several good methods exist and feedback has been shown to have a major influence on learning. The critical role of faculty is highlighted, as is the need for strategies to enhance their participation and training.

Ellaway R, Masters K. AMEE Guide 32: e-Learning in medical education Part 1: Learning, teaching and assessment. Med Teach 2008; 30(5):455-473.
Abstract: In just a few years, e-learning has become part of the mainstream in medical education. While e-learning means many things to many people, at its heart it is concerned with the educational uses of technology. For the purposes of this guide, we consider the many ways that the information revolution has affected and remediated the practice of healthcare teaching and learning. Deploying new technologies usually introduces tensions, and e-learning is no exception. Some wish to use it merely to perform pre-existing activities more efficiently or faster. Others pursue new ways of thinking and working that the use of such technology affords them. Simultaneously, while education, not technology, is the prime goal (and for healthcare, better patient outcomes), we are also aware that we cannot always predict outcomes. Sometimes, we have to take risks, and ‘see what happens.’ Serendipity often adds to the excitement of teaching. It certainly adds to the excitement of learning. The use of technology in support of education is not, therefore, a causal or engineered set of practices; rather, it requires creativity and adaptability in response to the specific and changing contexts in which it is used. Medical Education, as with most fields, is grappling with these tensions; the AMEE Guide to e-Learning in Medical Education hopes to help the reader, whether novice or expert, navigate them. This Guide is presented both as an introduction to the novice, and as a resource to more experienced practitioners. It covers a wide range of topics, some in broad outline, and others in more detail. Each section is concluded with a brief ‘Take Home Message’ which serves as a short summary of the section. The Guide is divided into two parts. The first part introduces the basic concepts of e-learning, e-teaching, and e-assessment, and then focuses on the day-to-day issues of e-learning, looking both at theoretical concepts and practical implementation issues. The second part examines technical, management, social, design and other broader issues in e-learning, and it ends with a review of emerging forms and directions in e-learning in medical education.

Masters K, Ellaway R. e-Learning in medical education Guide 32 Part 2: Technology, management and design. Med Teach 2008; 30(5):474-489.
Abstract: With e-learning now part of the medical education mainstream, both educational and practical technical and informatics skills have become an essential part of the medical teacher’s portfolio. The Guide is intended to help teachers develop their skills in working in the new online educational environments, and to ensure that they appreciate the wider changes and developments that accompany this ‘information revolution’. The Guide is divided into two parts, of which this is the second. The first part introduced the basic concepts of e-learning, e-teaching, and e-assessment, the day-to-day issues of e-learning, looking both at theoretical concepts and practical implementation issues. This second part covers topics such as practical knowledge of the forms of technology used in e-learning, the behaviours of teachers and learners in online environments and the design of e-learning content and activities. It also deals with broader concepts of the politics and psychology of e-learning, as well as many of its ethical, legal and economical dimensions, and it ends with a review of emerging forms and directions in e-learning in medical education.

Davis N, Davis D, Bloch R. Continuing medical education: AMEE Education Guide No 35. Medical Teacher 2008; 30(7):652–666.
This guide is designed to provide a foundation for developing effective continuing medical education (CME) for practicing physicians. For the purposes of this work, continuing medical education is defined as any activity which serves to maintain, develop, or increase the knowledge, skills and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession (American Medical Association 2007; Accreditation Council for CME 2007). The term continuing professional development (CPD) is broader and has become more popular in many areas of the world. As defined by Stanton and Grant, CPD includes educational methods beyond the didactic, embodies concepts of self-directed learning and personal development and considers organizational and systemic factors (Stanton & Grant 1997). In fact, this guide describes many modalities that may be defined as CME or CPD. In the interest of simplicity, we will use the term continuing medical education (CME) throughout, with the understanding that the same strategies may be applied to non-clinical continuing professional education.

For those who do not work exclusively in CME, many terms and processes may be unfamiliar. This guide is intended to provide a broad overview of the discipline of CME as well as a pragmatic approach to the practice of CME. The format provides an overview of CME including history and rationale for the discipline, followed by a practical approach to developing CME activities, the management of the overall CME programme and finally, future trends. At the end of the guide you will find resources including readings, websites and professional associations to assist in the development and management of CME programmes.

Translating learning into practice: lessons from the practice-based small group learning program (PBSG)

  This article about the Practice-Based Small Group (PBSG) learning program appeared in the September issue of Canadian Family Physician. The program began in 1992 as a collaborative effort between McMaster University in Hamilton, Ontario, and the Ontario College of Family Physicians (OCFP). 3500 physicians across Canada now participate.

Armson H, Kinzie S, Hawes D, Roder S, Wakefield J, Elmslie T. Translating learning into practice: lessons from the practice-based small group learning program. Can Fam Physician 2007; 53(9):1477-1485.

PROBLEM ADDRESSED: The need for effective and accessible educational approaches by which family physicians can maintain practice competence in the face of an overwhelming amount of medical information.
OBJECTIVE OF PROGRAM: The practice-based small group (PBSG) learning program encourages practice changes through a process of small-group peer discussion-identifying practice gaps and reviewing clinical approaches in light of evidence.
PROGRAM DESCRIPTION: The PBSG uses an interactive educational approach to continuing professional development. In small, self-formed groups within their local communities, family physicians discuss clinical topics using prepared modules that provide sample patient cases and accompanying information that distils the best evidence. Participants are guided by peer facilitators to reflect on the discussion and commit to appropriate practice changes.
CONCLUSION: The PBSG has evolved over the past 15 years in response to feedback from members and reflections of the developers. The success of the program is evidenced in effect on clinical practice, a large and increasing number of members, and the growth of interest internationally.  PubMed Related Articles

Professionalism in Medicine: theme issue from Academic Medicine

  The November 2007 issue of Academic Medicine is a theme issue entitled Professionalism in Medicine. Selected titles [titles with links are Open Access]:

Professionalism in Medicine;  Viewpoint: Learning Professionalism: A View from the Trenches;  The Journey to Creating a Campus-Wide Culture of Professionalism;  Viewpoint: Professionalism and Humanism Beyond the Academic Health Center;  Viewpoint: Linking Professionalism to Humanism: What It Means, Why It Matters; A Complementary Approach to Promoting Professionalism: Identifying, Measuring, and Addressing Unprofessional Behaviors; Institutional Leadership and Faculty Response: Fostering Professionalism at the University of Pennsylvania School of Medicine; Faculty Development as an Instrument of Change: A Case Study on Teaching Professionalism; Promoting Professionalism through an Online Professional Development Portfolio: Successes, Joys, and Frustrations; Overcoming Institutional Challenges through Continuous Professionalism Improvement: The University of Washington Experience; From Traditional to Patient-Centered Learning: Curriculum Change as an Intervention for Changing Institutional Culture and Promoting Professionalism in Undergraduate Medical Education; Putting the Needs of the Patient First: Mayo Clinic’s Core Value, Institutional Culture, and Professionalism Covenant; Viewpoint: Infusing Professionalism into a School of Medicine: Perspectives from the Dean; Promoting an Environment of Professionalism: The University of Chicago “Roadmap”

See also Professionalism and medical education: a theme issue;  Professionalism: five articles;  The developing physician – becoming a professional;