November 16, 2014

Two Techniques to Make Swallowing Pills Easier

Quick Tip for your Patients:

Two Techniques to Make Swallowing Pills Easier:
"Pop Bottle" ~60% effective
"Lean Forward" ~90% effective!

Pill-Swallowing Annals of FM

(Cross-posted on the CHA Family Medicine Residency blog)

November 10, 2014

Number Needed to Treat in Severe Sepsis and Septic Shock to Save a Life = 4.

Teaching Pearl: In severe sepsis and septic shock, only 7 out of 10 survive.  the NNT for antibiotics (in general is 4.)  There is good evidence to consider broadening coverage if: there are risk factors of surgery or prior antibiotic use.
The prevalence-adjusted pathogen-specific number needed to treat (PNNT) with appropriate antimicrobial therapy to prevent one patient death was lowest for MDR bacteria (multidrug-resistant bacteria) (PNNT = 20) followed by Candida species (PNNT = 34), methicillin-resistant Staphylococcus aureus (PNNT = 38), Pseudomonas aeruginosa (PNNT = 38), Escherichia coli (PNNT = 40), and methicillin-susceptible S. aureus (PNNT = 47).
Conclusions: Our results support the importance of appropriate antimicrobial treatment as a determinant of outcome in patients with severe sepsis and septic shock. Our analyses suggest that improved targeting of empiric antimicrobials for multidrug-resistant bacteria, Candida species, methicillin-resistant S. aureus, and P. aeruginosa would have the greatest impact in reducing mortality from inappropriate antimicrobial treatment in patients with severe sepsis and septic shock.

They note a few other risk factors identifies by multivariate logistic regression analysis as: resistance to cefepime, resistance to meropenem, and presence of multidrug resistance, but these are less useful clinically since they can only be determined post-hoc.

November 09, 2014

Leadership - moving from models to reality

Leadership models illuminate areas for personal growth and development using various lenses to focus on different blind-spots.   My personal journey in leadership has progressed with fits and starts, finally gaining momentum as I moved into residency as I developed a personal vision of how I could and would lead.  I’ve discovered new skills, styles and situations to be a more thoughtful and deliberative leader.  Through anecdotes from residency, I will share my current progress.  Firstly, I will show my Situational Leadership in the clinic.  Secondly, I will show how my Leadership style has keenly sharpened under fire in a national organization.   Finally, I will discuss how Authentic Leadership has affected me.

Tackling New Leadership Situations in a Family Medicine Clinic and Residency
Our clinic has small teams for coordinating care with patient outreach.  We have weekly meetings to review our tasks like calling patients to come in for routine appointments, developing cancer screening scripts/protocols and other routine tasks.  As an intern, I discovered that leading a medical team on rounds in the wards does not work the same way as a multidisciplinary setting with a secretary, medical assistant and nurse.  For example, when I started working with “Jay,” a front-desk staff member, I needed to titrate my leadership downward to suit his level of development.   Following Hersey and Blanchard’s (1969) Situational Leadership II (SLII) model of supportive and directive behaviors, I started with a hands-off approach.  (Appendix 1)
Initially I used supportive “participating” behavior: High-relational, low-task behavior.  I gave “Jay” control of day-to-day decisions while I was available to facilitate problem solving.  I sent messages along with some tips on how to manage the work through the day.
However, the work was not completed at the end of the week, so I switched to a coaching “selling” style: high-relational and high-task behavior. I asked another front desk secretary to sit down and coach his outreach to give him tips on how to complete the tasks in a timely fashion.  
After a month went by, I sat down and used a directive “telling” style: low-relational, high-task behavior.  I gave him direct tasks and directly supervised him carefully.  Only under this level of scrutiny did I discover that his inbox was cluttered with multiple versions of my messages I kept sending to him that he was afraid to touch or act upon them without direct approval.

My initial problem was not matching “Jay” with his appropriate development level.   Directive and supportive behavior needs to match with the development level of the follower on a competence/commitment continuum.  I had initially assumed that “Jay” was a D3 employee with moderate/high competence, when in fact he was a D1-2 employee with low competence.   However, he does not have the associated "high commitment" level.  In order to work with him effectively, I need to help motivate him.

When I recognized the utility of the SLII model , I investigated Hersey and Natemeyer’s Power Perception Profile (1979) to assess what my preferences were for a utilization of various power bases and identify which type of maturity or development level best suited my preferences.  There is a spectrum of power bases necessary to influence people's behavior at specific levels of maturity: from coercive-connection to reward-legitimate to referent-information and finally, expert.  (Appendix 2)  My highest scoring preferences were in the highest level domains of Expert and Information.  According to Hersey and Natemeyer, this correlates with a high maturity follower and I work best with M3-M4 followers.  “Jay” is an M1 follower so a better method of approaching his situation would be to form strong connections with influential/important people in the front desk and provide small observable rewards for those who do well.  A criticism I have with this model is that it implies that low maturity followers respond best to “sticks rather than carrots” and it encourages a coercive power base over a reward power base in some situations.  While this may hold true in some fields like the military, I do not think that harsh discipline has positive effects in the healthcare field except to drive people away and hurt relationships.  Finding this leadership model lacking in some respects, I sought out other ways I could work better with a team.


Developing a New Leadership Style in the Committee of Interns and Residents
In residency, I signed up as a union representative and quickly rose through the ranks from regional delegate to hospital chapter president to state executive board member for the national organization.   During my fellowship, I have worked as an elected resident board member on the Committee of Interns and Residents (CIR), a U.S. national union organization for resident-physicians.  Connecting with other future leaders, having discussions about our collective residency mission/vision/values and developing national programming around these issues has been exciting and stimulating for me.  However, it took me two years to become the authentic leader we needed.

Initially I had a laissez-faire leadership style with a hands-off attitude.  During our monthly phone calls, I would mute myself and tune out while doing other work.  I was disengaged in the tasks and had only superficial relations with the other board members and senior CIR staff.  I was inexperienced and untrained in leadership.  I did not engage in an ongoing dialogue between the resident delegates.  I showed poor governance; I neglected to help develop policies for success and I did not monitor for policy compliance/adherence.  I engaged in what Blake and Mouton would term “Impoverished Management (1,1)” with “little contact with followers and could be described as indifferent, noncommittal, resigned, and apathetic.”   (Blake and Mouton 1985, Appendix 3)

However, at the end of my first year, we had an internal leadership crisis – the staff executive director was up for a 5-year term contract renewal and we found out that about half of the senior staff was dissatisfied with his management.  There were an unprecedented number of union negotiations ongoing in addition to new chapters being recruited while record amounts of chapter losses also took place.  As a result CIR suffered low staff morale, divisive internal conflicts, and a high attrition of key staff members through both resignations and firings.  I found myself face-to-face with the sinking realization that I was a poor leader in a situation where strong governance in a period of stress and change was critical. A series of emergency meetings by the board was called.  A key quote made by the ex-president has stuck with me.
We have been absentee landlords, holding the power and influence but letting our local staffers run the organization.”

In the past year, I changed from an “Impoverished (1,1)” toward a “Teamwork (9,9)” leadership style with high concern for results and people.  (Blake and Mouton 1985, Appendix 3)  In order to do so, I considered the personal frames of Expert and Informational power, my areas of strength.   I applied these personal frames toward knowledge development and relationship-building to better engage in concerns on results and people.  I became an expert on the subject of leadership through the Dundee course and used this competence to solidify a strong corporate mission, vision, values statement and five year strategic plan.  Energizing fellow resident board members, I developed strong relationships despite a growing division between two sides of the board and we were able to agree on core parts of a leadership development plan for our executive director.

 Here is a key passage from an email exchange during the discussion process that illuminates how I drew connections between steps of our strategic plan development, using George’s Authentic Leadership principles of “True North” (2007) and Collins’ and Porris’ “Big Hairy Audacious Goals” (1996)

"A compass, I learned when I was surveying, it'll... it'll point you True North from where you're standing, but it's got no advice about the swamps and deserts and chasms that you'll encounter along the way. If in pursuit of your destination, you plunge ahead, heedless of obstacles, and achieve nothing more than to sink in a swamp... What's the use of knowing True North?" – Abraham Lincoln
Imagine that CIR is taking a physical journey towards a destination.
We are the leaders of this group through the wilderness of residency.  We are the ones with vision and direction.  We are providing guidance.
Where do we want to go in the next 3-5 years?
We can walk towards a hospital and rally a group of dissatisfied residents, we can walk to a town hall and support legislation, we can go to a conference or class room and learn about something we aren't getting in our residency, etc.  … Some paths may lead us down dead-ends or take us on a long, expensive tangent.  Others may be shortcuts that attract new members or engage our current members to participate more in the journey.
Why are we walking down some paths and not others?
I feel that this is because deep down; we know what we want at the end of residency.  We know why we went into medicine.  And we are looking for ways to help our patients, to help our fellow residents and to pave the path and make it safer and higher-quality.  These are the core values.
We are aiming towards the “Big, Hairy and Audacious" True North.
Each step should take us a little closer.  Each activity we have should reflect a value … that provides the driving motivation to keep us walking.
                                                (abridged email, full exchange in attached leadership portfolio)
As George’s interviews with great leaders showed, Authentic Leadership is about something more than traits alone: “[the] team was startled to see that you do not have to be born with specific characteristics or traits of a leader.  Leadership emerges from your life story.”(George 2007)  This reflective exercise shows a few examples from my life story in residency and fellowship.

The components of Authentic Leadership model are self-awareness, internalized moral perspective “true north,” balanced processing and relational transparency.  (Appendix 4)  Reflecting on this model raised my awareness that developing Authentic Leadership meant two things for me. 
1) My relationship with “Jay” has struggled due to my “false front” and lack of transparency with my feelings.  I have been passive-aggressive in my leader-member interactions and I will strive to be more open without coming across as abrasive or aggressive.
2) Initially in CIR, I contributed to a culture of disengagement.  In a period of critical change, I recognized how I was complicit and at fault.  I helped shift the CIR executive board from a management organizing/staffing discussions toward a leadership paradigm with vision-boarding and coalition-building.

Moving forward in future leadership positions, I will be open and aware of my own personal failings.  I will center myself around my internal moral compass.  I will become even-keeled and measured in my emotions, thoughts, and actions.  I will develop deeper bonds with my team to find out what drives us all so we can pump each other up when we are down.  I will be an Authentic Leader.



Appendix 1: Situational Leadership



Appendix 2: Power Perception Profile
1.       Coercive power is derived from having the capacity to penalize or punish others. (French and Raven 1962)
2.       Connection power is based on connections with influential or important people… in which compliance occurs because they try to gain favor or avoid disfavor of the powerful connection.   (Hersey, Blanchard and Natemeyer 1979)
3.       Reward power is derived from having the capacity to provide rewards to others. (French and Raven 1962)
4.       Legitimate power is associated with having status or formal job authority. (French and Raven 1962)
5.       Referent power is based on followers’ identification and liking for the leader. (French and Raven 1962)
6.       Information power is based on the ability of an agent of influence to bring about change through the resource of information.   (Raven and Kruglanski  1975).
7.       Expert power is based on followers’ perceptions of the leader’s competence. (French and Raven 1962)





Appendix 3: Leadership Style Grid


Appendix 4: Authentic Leadership


Bibliography
Blake, R. R., & Mouton, J. S. (1985) The managerial grid III. Houston, TX: Gulf Publishing Company.

Collins, J. and Porras, J. (1996) Building Your Company’s Vision. Harvard Business Review.

George, B. (2007) Discovering Your Authentic Leadership. Harvard Business Review.   Reprint R0702H.

Hersey, P. and Natemeyer, W.E. (1979) Power Perception Profile -- Perception of Self. Center for Leadership Studies. University Associates, Inc.

Hersey, P., Blanchard, K. and Natemeyer, W.E. (1979)  Situational Leadership, Perception, and the Impact of Power.  Group Organization Management.  4(4) p418-428

McCaffery, P. (2010) The Higher Education Manager's Handbook. Second Ed. New York: Routledge.

Raven, B. &  Kruglanski, W. (1975) Conflict and power. In P. G. Swingle (Ed.), The structure of conflict. New York: Academic Press




December 30, 2013

The Development Process for a novel “Peer-Assessment Lecturer Survey” (PALS)

The Development Process for a novel “Peer-Assessment Lecturer Survey” (PALS)
(available on request by word format)

The peer-evaluation of an instructor can be approached from different perspectives.  In reviewing methods of evaluation, I found the social-cognitivist theory elucidated by Bandura (1986) to be helpful. It links the behaviourist approach, which emphasises the influence of the environment on our actions, and the cognitive approach, which emphasises the importance of cognition in mediating our learning and functioning. (Kaufman 2010)

For lecture evaluation, the behaviourist approach focuses on the presentation process, learning environment and instructor content.  This is best demonstrated by microteaching of skills of Allen (1969) and Passi (1976) seeing the instructor from a mechanical perspective.  For example, the microskill of “stimulus variation” in which an assessor may critique “using gestures to help convey extra meaning” or “at various times, the teacher was noted in the left, right, forward, and back of the teaching space” (Figure 1) (Allen 1969).  These principles are old-fashioned and mechanistic but useful.

The cognitivist approach shifts the emphasis to learner-centred content and outcomes where the substantive parts of evaluation occur internally within the minds of the instructors and students.  Lecture evaluation may utilize instructor processes such as Gagné’s nine instructional events (1985), the one-minute paper by Schwartz (Wilson 1986) or the course material and classroom observation checklists designed by Brent and Felder (2004).  For example, Gagné’s eighth instructional event of “assessing performance” (1985) helps the assessor gauge the success of achieving a stated instructional outcome.


Keeping the social-cognitivist theory of learning in mind, I designed a Peer-Assessment Lecturer Survey (PALS) which unites the requisite components of an instructor’s cognitive process, content organization and presentation behaviours into a simple checklist.  The PALS follows an instructor’s instructional event matrix (Figure 2) (Gagné 1985, Okey 1991) and utilizes a simple yes/no checklist to quickly tick off points and provide comments as it unfolds in real-time.  This procedural framework provides opportunities for both a rigid process checklist and as well as subjective, interpretive and content-based comments similar to Brent and Felder (2004.)  Instead of including numerous sub-checklists or Likert scales, a short tally of “positive” and “delta” points is used with cues that mentally prime the assessor to actively provide presentation and guidance comments on lecture skills (Allen 1969, Passi 1976).  Finally, the inclusion of questions from the one-minute paper (Wilson 1986) helps the assessor hone in on the most important points for peer-feedback.


Figure 1. Sample concrete Behaviourist skills on Movements and Gestures (Allen 1969)




Figure 2. Gagné’s Instructional Event and Learning Outcome Taxonomy Matrix

Bibliography

Allen, D.W. et.al. (1969) Micro-teaching – A Description. Stanford University Press

Bandura A (1986) Social Foundations of Thought and Action. A Social Cognitive Theory. Prentice-Hall, Englewood Cliffs, NJ.

Bloom, B.S. (1984) Taxonomy of educational objectives.  Published by Allyn and Bacon, Boston, MA.

Brent, R. Felder, R. (2004) A protocol for peer review of teaching Proceedings of the 2004 American Society for Engineering Education Annual Conference & Exposition

Gagné, R.M. (1985) The conditions of learning and theory of instruction. Holt, Rinehart and Winston.

Kaufman, D.M. (2011). Ch 2 Teaching and learning in medical education: how theory can inform practice. In Swanick, T. 1st ed. Understanding Medical Education: Evidence, Theory and Practice (Kindle Locations 1809-1810). Wiley. Kindle Edition.

Okey, J.R. (1991)  Procedures  of  Lesson  Design  Ch.  8   In lnstructional Design: Principles  and Application  2nd edn. Edited by Leslie  J Briggs et al. Education  Technology  Publications pp192-208.

Passi, B.K. (1976) Becoming Better Teachers. Baroda : Centre for Advanced Study in Education, M. S. University of Baroda

Wilson, R.C. (1986) Improving Faculty Teaching: Effective Use of Student Evaluations and Consultants. Journal of Higher Education, 57 (2), pp. 196-211.


(prepared for a Medical Education assignment)

Sample.

Peer-Assessed Lecturer Survey (PALS)
Instructor:                                                                    Topic:
                                                                                                                                                                                    Notes & Comments
I. Gain Attention: Was your interest aroused?
  [  ]  Yes       [  ]  No
When providing comments, make them:
supportive, descriptive, specific, & behavioural.


II. Objectives were stated at the beginning and
1.     Clearly utilize active verbs from Bloom’s taxonomy
2.     Demonstrated what was expected of the Learner by the end of the session

  [  ]  Yes       [  ]  No
  [  ]  Yes       [  ]  No

III. Review of prerequisite knowledge
3.     Started at an appropriate challenge level
4.     Checked-in with audience to adjust & match needs
5.     Covered in less than 5 minutes

  [  ]  Yes       [  ]  No
  [  ]  Yes       [  ]  No
  [  ]  Yes       [  ]  No
IV. ORAL Presentation skills
Tally up positive and delta points ( ) on subjects like:
·         Voice: clarity, volume, energy, speed, um’s/er’s
·         Non-verbal cues: directive focusing (pointing/laser pointer), gestures/movement, & deliberate pauses
(+)


Δ


V. A-V & Guidance skills
Tally up positive and delta points ( ) on subjects like:
·         Overhead/PowerPoint/Prezi, graphics, & videos
·         Used cases, story, analogy, examples, prompts & hints appropriately
(+)




Δ
VI. Facilitated Practice
6.     Opportunity provided for active involvement, student participation and/or practice

  [  ]  Yes       [  ]  No

VII. Feedback
7.     Provided active feedback to audience
8.     Comments were supportive, descriptive, behavioural

  [  ]  Yes       [  ]  No
  [  ]  Yes       [  ]  No
VIII. Assessment of Objectives
9.     The instructor “closed the loop” on learning objectives with a post-instruction assessment
10.   Higher-order thinking questions were asked

  [  ]  Yes       [  ]  No

  [  ]  Yes       [  ]  No
IX. Further review after instruction
11.   Summary/outline provided
12.   Additional opportunities to master material (i.e. tools/homework) were provided for further practice

  [  ]  Yes       [  ]  No
  [  ]  Yes       [  ]  No

The most important take-home point was:
The muddiest point in the lecture was: 

September 23, 2013

FUN Teaching Principles (based on learning theories)

Teaching is the process in which learning is facilitated through planning, presentation, observation, active reflection and feedback that results in external stimuli being perceived, translated, converted and comprehended in a manner which results in cognitive and/or behavioural changes.

Kaufman and Mann’s ‘Teaching and Learning in Medical Education’ chapter in “Understanding Medical Education” inspires this personal definition of teaching.  My interpretation reflects a cognitive constructivist philosophy in which the teacher and learner engage in a “continuous, dynamic, reciprocal interaction among three sets of determinants: personal, environmental (situational) and behavioural.” (Kaufman & Mann 2010)  The personal factors are the behind-the-scenes models/schemas the learner mentally constructs, the environmental factors are the learning setting/material and the behavioural factors primarily are the outcomes, building on prior knowledge.

My philosophy of teaching guided me to derive a set of simple teaching principles that form a simple mnemonic: FUN!
·         First things First (Planning and Presentation)
·         Understand the Learner (Observation)
·         Nurture and Guide (Active Reflection and Feedback)
These principles are not a step-by-step guide to develop a lesson plan, but they provide a framework for considering elements of cognitivist and social constructivist perspectives.  I will elucidate these points and provide an example from a lesson plan I developed with second-year residents on office efficiency.

First Things First:
Before a teacher picks up a set of learning objectives/syllabus or launches Powerpoint to make lecture notes, it is important to reflect and set priorities.  A series of questions based on Schön’s Reflective Practice (1983) may help create a learner-centered lesson plan.

Question
Schön’s Reflective Practice
What was MY EXPERIENCE when I first started this subject?
Knowing-in-action
What did I find most CHALLENGING initially?
Surprise
What did I learn that was most IMPORTANT to me at that time?
Reflection-in-action
How has my understanding of this subject CHANGED since then?
Experimentation
How do I use the subject-matter on a DAY-TO-DAY basis?
Reflection-on-action

These questions walk a teacher through a mental progression starting as a novice learner, synthesizing the content into a mental model and then applying it.  Schön’s steps can help a teacher to recall a time when he or she was an early learner so as to avoid the expert’s pitfall of unconscious competence: taking mental short cuts and making assumptions that novices find difficult.
For example, when I created a lesson plan to teach second year residents how to function efficiently in the outpatient clinic, I first stepped back and recalled how I felt at that time in my learning.  I was overwhelmed and often fell behind because of the increased load of patients that I had to see in 20-minute segments.  I often felt I survived the day only by finishing hasty notes that felt sparse and inadequate.  I learned tools and workflows from co-residents and a teaching fellow.  Eventually with time and reflection, I was able to change my practices to shift from a 40-minute visit per patient to a more efficient 20-minute visit per patient mentality.
Based on this reflection, I decided that my lesson planning would follow a “typical day in clinic”: I would have each resident read and react to scenarios that progress through a normal resident’s workday.  The teaching would focus on practical issues like chart review/prep-work, lecture note-taking/review, and clinic/charting workflows, while reflecting on the frustrations of time management, chart closing, and difficult patients.


Understand the Learner:
While the first step emphasizes the teacher’s personal perspective to assist with priority setting and lesson planning, Understanding the Learner shifts the focus to learners’ perspectives to understand what learning styles may need to be considered in the lesson.  The Kolb Learning Cycle (1984) and the Honey and Mumford adaptation close the gaps through an experiential learning approach, building in elements that reinforce the lessons to be learned long-term.  During the process of lesson planning, the teacher considers where students enter the learning cycle and engages them using a variety of approaches.


Accessed 9/2013 from: http://bonlinelearning.com.au/blog/learning-styles-in-elearning/

For example, in my lesson on office efficiency, I devised various case scenarios from a typical day to access Kolb’s “concrete experience” and “reflective observation” stages.  The group’s discussions accessed “abstract conceptualization” and their homework and subsequent ‘real work’ would access “active experimentation” to complete Kolb’s learning cycle.  These steps mirrored the reflective practice model as well: as each student read their scenario out loud, they reflected on what they would do (virtual reflection-in-action), discussed strategies with other R2s (experimentation) and then as homework, they created/utilized/tweaked personal workflows to gauge if there were any improvements (reflection-on-action).


Nurture and Guide:
Using the ‘clinic as the curriculum’ is a prime driver for my residency and this orientation helps facilitate individual learners to become self-directed adult learners and information masters, drawing strongly from an Adult Learning Theory/Andragogy model.  Knowles’ principles (1984) encourage a fun and safe environment, resident engagement in diagnosing learning needs and developing their own learning resources, and aiding them in carrying out their learning plan.  A curriculum that promotes an open, accepting, transparent and sharing culture of learning promotes a strong Community of Practice. (Wenger 1998)  Scaffolding occurs by building on prior knowledge and utilizing higher learners in a Zone of Proximal Development (Vygotsky 1986).


Accessed 9/2013: http://lmrtriads.wikispaces.com/Zone+of+Proximal+Development

Initially, the suggestion to learn more about office efficiency came from the residents as they were transitioning to more solid roles within the clinic.  This is an example of andragogy, wherein the R2s actively engaged with their curriculum development.  I deliberately crafted the office efficiency lesson so they would scaffold each other’s learning using principles of social constructivism.
The scenarios I created provide a framework: embedded within the cases are best practices that they share aloud.  The scenarios end with a point of contention: questions like “what do you do to keep yourself organized and how do you stay on track [with clinic flow]?” and “what sort of preparation work do you do tonight? The morning before [you see your patients]?”  If they are stumped, they can turn to me as a resource: as a fellow, I am a step between residency and attending, placing me in the role of a “more knowledgeable other.”  My recent experiences make me receptive to their needs and subsequently, they are receptive to my pearls.

In conclusion, the teaching principles “First things First,” “Understand the Learner” and “Nurture & Guide” or FUN, form the basis for my teaching philosophy.  Their application reflects the teaching theories of andragogy, reflective practice, cognitivism, and social constructivism. FUN is an easy to remember mnemonic, a practical tool to implement and most importantly, it provides a short checklist to help make teaching and learning fun!



Bibliography
Honey, P. & Mumford, A. (1982) Manual of Learning Styles. London: Peter Honey Publications, London.
Lave, J. & Wenger, E. (1991) Situated Learning: legitimate peripheral participation. Cambridge University Press, New York.
Kaufman, D.M. & Mann, K.V. (2010) Teaching and Learning in Medical Education. In T. Swanwick (Ed) Understanding Medical Education. ASME, Blackwell Publishing.
Knowles MS et al. (1984) Andragogy in Action: applying modern principles of adult learning. Jossey-Bass, San Francisco, CA.
Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development.
Schön, D. A. (1983). The reflective practitioner: How professionals think in action . New York: Basic Books.
Vygotsky, L. S. (1986). Thought and language (A. Kozulin, Trans.). Cambridge: MIT Press.
Wenger, E. (1998). Communities of practice: Learning, meaning, and identity . Cambridge: Cambridge University Press.