tag:blogger.com,1999:blog-286914952024-03-12T12:03:27.337-10:00Not My Second OpinionA healthy discussion of philosophy, ethics and education by a family medicine physician.Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.comBlogger360125tag:blogger.com,1999:blog-28691495.post-22452563673134691642015-10-18T17:33:00.000-10:002015-10-18T17:33:12.831-10:00Rational or Rationalization?<div style="color: #222222; font-family: verdana, arial, helvetica, sans-serif; font-size: 14px; line-height: 1.42857em; margin-bottom: 0.357143em; padding: 0px;">
I'm interested in personal narratives on the interface of Rational vs Rationalization. And in that spirit, I will bear all to those I see as kindred spirits (or aligned patterns of thought)</div>
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<dfn class="dictionary-of-numbers" style="border-width: 0px !important; color: inherit; cursor: inherit; display: inline !important; font-family: inherit; font-style: inherit; font-weight: inherit; margin: 0px; position: static !important; text-decoration: inherit;">One of the chapters </dfn>of <a href="http://hpmor.com/">HPMOR</a> that struck me emotionally and literally left me breathless was on "<a href="http://hpmor.com/chapter/19">How to Lose</a>." I found my brain flashing back to various moments in my life where I refused to lose, and in doing so, lost something that mattered more. It is hard for people who try to adopt principles of optimization to lose graciously and when self-hatred is involved, it becomes a Doom Loop spiraling around self-blame, anger and excuse-seeking for imperfections. In other words, in the past, when I thought I could do better, I became aggressively angry and hostile, especially if my intellectual ego was on the line.</div>
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Cue pre-med. I was the sort of college student you might have met in organic chemistry, the quietly bright and strategic student angling for a way in to a successful career (not at any cost, but focused). And I failed to get in.</div>
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Not being admitted to medical school was probably the best thing that could have happened to me. In a period of a year, I was able to develop emotionally and step away from the meritocracy concept that I was "owed" something prestigious simply because I was intelligent. I found some<dfn class="dictionary-of-numbers" style="border-width: 0px !important; color: inherit; cursor: inherit; display: inline !important; font-family: inherit; font-style: inherit; font-weight: inherit; margin-left: 0px; margin-right: 0px; margin-top: 0px; position: static !important; text-decoration: inherit;">one that made me </dfn>happy for the first time in my life and she taught me that there's no point in driving yourself to a point of misery. I ought to seek a happy life for my own sake. I did apply for medical school again, and this time I succeeded -- but my path had changed for the better. I wasn't doing it for me (although I was curious to figure out how I worked as a human)... I was pursuing a career that I found was a calling for me to learn the life stories of new people every 15<dfn class="dictionary-of-numbers dictionary-of-numbers-quantity--1200s dictionary-of-numbers-processed" style="border-width: 0px !important; color: inherit; cursor: inherit; display: inline !important; font-family: inherit; font-style: inherit; font-weight: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; position: static !important; text-decoration: inherit;">-20 minutes</dfn> of my day. I didn't become the medical student "gunner" that would shoot other students down to look good myself. I always tried to do what was best for my patients and the medical team. I attribute a lot of this to the wisdom of the admission committees who turned me down the first time when they recognized that I needed to take time to mature and become ready for the next step.</div>
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Argyris has a great article on the Doom Loop for Professionals. <a href="https://hbr.org/1991/05/teaching-smart-people-how-to-learn" style="color: #0079d3; margin: 0px; text-decoration: none;">https://hbr.org/1991/05/teaching-smart-people-how-to-learn</a></div>
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Professionals embody the learning dilemma: they are enthusiastic about continuous improvement—and of<dfn class="dictionary-of-numbers" style="border-width: 0px !important; color: inherit; cursor: inherit; display: inline !important; font-family: inherit; font-style: inherit; font-weight: inherit; margin-left: 0px; margin-right: 0px; margin-top: 0px; position: static !important; text-decoration: inherit;">ten the biggest obstacle </dfn>to its success. What’s more, most theories-in-use rest on the same set of governing values. There seems to be a universal human tendency to design one’s actions consistently according to <dfn class="dictionary-of-numbers" style="border-width: 0px !important; color: inherit; cursor: inherit; display: inline !important; font-family: inherit; font-style: inherit; font-weight: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; position: static !important; text-decoration: inherit;">four basic values</dfn>: 1. To remain in unilateral control; 2. To maximize “winning” and minimize “losing”; 3. To suppress negative feelings; and 4. To be as “rational” as possible—by which people mean defining clear objectives and evaluating their behavior in terms of whether or not they have achieved them. The purpose of all these values is to avoid embarrassment or threat, feeling vulnerable or incompetent. In this respect, the master program that most people use is profoundly defensive. Defensive reasoning encourages individuals to keep private the premises, inferences, and conclusions that shape their behavior and to avoid testing them in a truly independent, objective fashion.</div>
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Rather than opening up, professionals are more likely to shut down after losing BECAUSE THEY ARE ACCUSTOMED TO SUCCEEDING. They don't know how to lose with grace and they don't know how to deal with the shame/guilt/anger/embarrassment To be good at losing, we need to practice losing well. And losing often.</div>
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I am an ENTP with the strongest traits of iNtuition and Thinking. This means that I can see the big picture and strategize very well. But when I am with my fiancee, an ISFJ (polar opposite personality type) we will of<dfn class="dictionary-of-numbers" style="border-width: 0px !important; color: inherit; cursor: inherit; display: inline !important; font-family: inherit; font-style: inherit; font-weight: inherit; margin-left: 0px; margin-right: 0px; margin-top: 0px; position: static !important; text-decoration: inherit;">ten clash</dfn>, like Petunia and Michael Evans-Verres -- <dfn class="dictionary-of-numbers" style="border-width: 0px !important; color: inherit; cursor: inherit; display: inline !important; font-family: inherit; font-style: inherit; font-weight: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; position: static !important; text-decoration: inherit;">one trying to make </dfn>the other feel guilty, or feel stupid. Once, in an argument, I even heard myself say "when I feel strong emotions of anger, I find that distancing myself from it through rational processes calms me down (although she would just say that it makes me colder and more robotic) and... that's rationalization."</div>
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That slip of the tongue revealed to me that I wasn't being rational. I was rationalizing. I was using a defense mechanism to avoid real issues and instead, I was trying to reinterpret my behaviors in the light of a more palatable "reasoning" process. Using rationalization makes her dislike the words "right" or "rational" because as a Feeler, she associates these words with the negative connotations of argument and disagreement.</div>
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True Reasoning moves beyond the petty boundaries of quibbles with a loved one. Don't Rationalize, people of Rationalia! Optimize your relationships and don't discount the strength of love.</div>
Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-21068919403307922262014-12-12T19:00:00.001-10:002015-10-21T04:09:41.070-10:00Rationalist Back to the Future: "It's About Time."Anxiety welled up deep within me, not knowing the sort of world we lived in.<br />
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It's tough when the world as you know it explodes in a flash of sparking light and flaming tire trails. </div>
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Now... (whatever THAT word meant)... *Now*, I didn't know whether or not the very fabric of the universe would unravel with an accidental bootstep unto the wrong butterfly. I had read about that in a Ray Bradbury novel. It disturbed me greatly that such an event could actually come to pass.</div>
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Did my personal curiosity and gnawing hunger outweigh the threat I posed to ALL OF EXISTENCE? Surely not. Yet I couldn't live in an undeveloped neighborhood that wouldn't be built in the next five to ten years. I didn't want to starve to death because I was too afraid to walk into Lou's Cafe and order a Pepsi Free. I needed safe harbor. And if I was going to find a quiet haven where I could make the least impact on history, it would be here.<br />
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I checked the address again: 1640 Riverside Drive, Hill Valley.</div>
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I didn't bother to check the time on my watch. Time was irrelevant, irrevocably broken. Oops.</div>
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I took my hands out of the pockets of my vest and flexed them several times. They were stiff and bone-white. Ever since I realized it was November 5th, in the year 1955, my hands were clenched tightly to minimize contact with the outside world. Now, I wiped them nervously on my jeans and walked up the dark driveway.</div>
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Hesitating briefly, I rapped the door and stepped back, not knowing who or what to expect. <span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">The door flew open with such frenetic gusto that I knew even before laying eyes on him, that it was the Doc himself. </span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">"Listen, Doc..."</span></div>
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"Don't... say... a word!" His eyes darted around his front lawn and he dramatically yanked me into his living room. Normal Doctors <span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">of Experimental Tinkering and Science wore starched white lab coats. Doc Brown on the other hand -- he wore a silvery nightgown. H</span><span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">is frizzled white hair was barely contained within a device that could best be described as an inverted colander with colorful lights dancing along a geodesic framework of electrical wires extruding from various contact points.</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">"I don't want to know your name, I don't want to know anything about you!" I knew better than to interrupt the Doc when he was in one of his moods. T</span><span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">he wild look in his eyes sparkled with the manic light of someone who hadn't slept in a week. </span><span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">The best you could do was hang on and play along.</span></div>
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He licked a suction cup and without my consent, he slapped it against my forehead.</div>
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"I'm going to read your thoughts," he announced with bravura, as he fussed with some dials on an electrical monstrosity that sparked and smoked in equal measure. This device was apparently supposed to be an electroencephalogram.</div>
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"Let's see now, you've come here from a great distance?" He grasped at his metallic helmet for cognitive support.</div>
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"Even if you're only trying to pull more information out of me through cold reading, grasping at the high-probability straws, you're correct."</div>
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"Quiet! Don't tell me anything." His brow furrowed in a mockery of concentration. "You want me to buy a subscription for the Saturday Evening Post?"</div>
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"You were on such a roll! Just stay evasively general and reinforce chance guesses."</div>
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"Not a word, not a word, quiet now!" Irritation curled his lips and his fingers as he waved me off. <span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">"Uh... umm... Donations! You want me to make a donation to the Coast Guard Youth Auxillary!"</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">"Your persistence in highly specific statements are not serving you well." I pinched the bridge of my nose. "</span><span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">Moreover, let's talk about your mind reading device. Have you ever heard of <a href="https://en.wikipedia.org/wiki/Hans_Berger#Biography">Dr Hans Berger? In 1924, he recorded brain waves in an attempt to discover the powers of telepathy.</a> He ALREADY INVENTED YOUR... WEIRD DEVICE. Now, neurologists use EEGs to detect sleep wave patterns and epileptic foci. But they have NEVER been able to detect surface thoughts. Especially not by using a small rubber suction cup and an electrical device more likely to trigger a seizure in your brain than it will read mine!"</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">It shocked me. Was this really the Doc? Could he possibly be the brilliant mind that taught me the rules of rationality and the methods of scientific inquiry? How could this silly 'scientist' become the man who would break the fourth dimension with backyard materials, Christmas lights, a DeLorean and a nugget of Plutonium? I was appalled, to say the least.</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">I decided to end this farce of science. "Doc... I'm from the Future..." I announced, as I yanked off the suction cup.</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">"I'm from the Future ... Scientists Youth Auxillary!" I amended, seeing his face starting to turn crestfallen. I was not lying per se. After all, I was his lab assistant in the year 1985. Or yesterday, by my biological clock.</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">"Your device TOTALLY works and it TOTALLY won't give you a seizure." His goofy grin didn't waver against the face of sarcasm.</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">"And I have a brief survey for my school project that I have been asking all of the Doctors of Experimental Tinkering and Science."</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">"It's about time!" he said triumphantly. "I knew you would come."</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">"You're right... it IS about time," I said slowly. I guided him towards his garage with blueprint plans in hand. "But not quite in the way you're thinking about. You won't get the recognition you deserve -- not for another 30 years or so, I'm guessing..."</span></div>
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<span style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">Together, we could discover whether or not I was a creature displaced from my time-stream in an alternate universe off-set by thirty years. Perhaps I was a fifth dimensional being with powers to see time in a non-linear fashion now that the illusion of causal time-event occurrences had been cast away from my reality. Perhaps the changes I made here in 1955 would be reflected further down my time-stream in 1985 in ways I would become aware of through some sort of memory-altering sequence. Perhaps time existed only as a mathematical unit and I had only "rewound the clock" backward to a point in a static time-cone that projected both forwards and backwards in a timeless physics model of reality.</span></div>
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<span style="font-family: Helvetica Neue Light, HelveticaNeue-Light, helvetica, arial, sans-serif;">There was one thing I was certain of. Doc Brown's inspired hand was guided by rational mind at odds with his own irrational behavior. I often wondered why he picked me to be his apprentice -- if it weren't for his guidance, I'm pretty sure I would have been like all of the other high schoolers who enjoyed skateboards and cars. He would occasionally have me read very specific books, like the <a href="https://en.wikipedia.org/wiki/A_Sound_of_Thunder">"Sound of Thunder" by Ray Bradbury </a>or neurology texts on EEGs that... that were hints, telling me he knew who I would become!</span></div>
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<span style="font-family: Helvetica Neue Light, HelveticaNeue-Light, helvetica, arial, sans-serif;">Doc Brown was not the brilliant mind that had been grooming me to become a future scientist. I was grooming myself. It was future-me, in the past, directing him behind the curtain. A ruse, a long-con, preparing me for this very moment of realization. It would be a very long road until I could safely test my theories on time and avoid paradox.</span></div>
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<span style="font-family: Helvetica Neue Light, HelveticaNeue-Light, helvetica, arial, sans-serif;">I had twenty five years to break the news to the Doc that I was an accidental time-traveller.</span></div>
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<span style="font-family: Helvetica Neue Light, HelveticaNeue-Light, helvetica, arial, sans-serif;">I had thirty years to save the Doc's life.</span></div>
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<span style="font-family: Helvetica Neue Light, HelveticaNeue-Light, helvetica, arial, sans-serif;">In the meantime, I would avoid destroying the universe. Great Scott... that's heavy.</span><br />
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<span style="font-family: Helvetica Neue Light, HelveticaNeue-Light, helvetica, arial, sans-serif;">[<i>My take on this scene if Marty were given a chance to teach himself everything he needed to know about time-travel... through Doc Brown.</i>]</span><br />
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<br />Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-53559253874206015302014-12-05T23:10:00.001-10:002014-12-05T23:10:25.514-10:00Semi-Public Announcement: seeking pre-alpha comments on "Medics and
Magics"I posted on G+ under "Fantasy Writing/World Building" and cross-posted on reddit/rational tonight.<div>http://www.reddit.com/r/rational/comments/2ofzm9/of_medics_and_magics_story_synopsis_for_a_new/</div><div><br></div><div>This represents my semi-public announcement for my hobbyist foray into fantasy writing in the style of free web fiction ala "Worm" or "Harry Potter and the Methods of Rationality."</div><div><br></div><div>The idea for my alt-blog has been a personal dream to unite all of my loves (science, medicine, and fantasy) into a coherent package that reflects my identity. That is NOT to say that my characters will be an "author self-insert" or a "podium" to share my personal views on the world. My main drive is to build a fun cool fantasy world that stimulates my imagination and pushes me to explore our world further in a rational, empirical fashion.</div><div><br></div><div>I recently discovered that Diane Duane has continued to publish books for her Young Wizards series that I read in elementary school with the first book: "So You Want to be a Wizard." Duane comments that the more fantasy writers mix truth in with a lie, the stronger it gets.</div><div><br></div><div>http://en.m.wikipedia.org/wiki/Young_Wizards</div><div>https://www.goodreads.com/author/quotes/11761.Diane_Duane</div><div><br></div><div>'Tis my goal to strengthen Iatropia to a fun new level for fantasy fiction. I'm trying to set myself up for success, so please check out the link above and comment!</div>Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-49543342821702100612014-12-02T19:33:00.002-10:002014-12-02T19:58:37.578-10:00My Paradigmatic AssumptionsAs a family physician with an undergraduate degree in cellular/molecular biology and a relationship-centric graduate and post-graduate training, I possess a blend of different paradigmatic assumptions. On the one hand, positing initial conditions with cause-effect relationships seen in the physical sciences, I believe in the ability of Science to justify and explain phenomena that we experience. I take it on faith that we all experience slivers of a True Reality through our perceptions. (This is called <a href="http://en.wikipedia.org/wiki/Positivism" style="color: #1155cc;">Positivism</a> by my own admission of prior <a href="http://en.wikipedia.org/wiki/Ontology" style="color: #1155cc;">ontological</a> and <a href="http://en.wikipedia.org/wiki/Epistemology" style="color: #1155cc;">epistemological</a> programming as a scientist.) On the other hand, I also believe that a simplistic, <a href="http://en.wikipedia.org/wiki/Reductionism" style="color: #1155cc;">reductionist</a> approach pursuing an "objective, external truth" removes a key <a href="http://en.wikipedia.org/wiki/Secular_humanism" style="color: #1155cc;">humanist</a> component in appreciating a "shared social 'reality'" and a "shared social good," a category in which non-physical phenomena dwell.<br />
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I do believe there are demonstrable benefits in medicine and science for pursuing an external, objective "one Truth, one Disease" reality when a physician meets a patient and diagnoses them, with say, hypertension. However, I also acknowledge that our collective beliefs shape our "shared social 'reality'" and our approach to disease. Each person possesses a unique blend of background human in-born traits like race/sex/personality. In contrast, sociocultural and epigenetic factors like ethnicity/gender/socioeconomic status. are constructed over time atop these background traits and become structural fixtures as well. (This is called <a href="http://en.wikipedia.org/wiki/Constructivist_epistemology" style="color: #1155cc;">Constructivism</a> in which truth only gains meaning [and is only known] through social construction.)<br />
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<b>Two patients with the same disease may act in very different ways</b>, since they have different constructs<b>. </b>Similarly, two physicians may act very differently, depending on whether or not they treat the disease... or they treat the patient... the community... or even society itself.<br />
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I plan to propose a robust and evocative model that addresses the philosophical differences between the Positivist and the Constructivist, as well as the potential conflicts between patients and physicians. Firstly, [my thesis] draws upon the positivist principles of natural order-assembly present in physics in phase-change states, and biology in the synthesis of organic molecules like proteins or DNA. Secondly, it accounts for constructivist scaffolding structure of inborn traits, epigenetic components, sociocultural factors, and educational influence as the basis for idea generation. Concepts like a disease-diagnosis form, catalyzed by principles of pathophysiology, cognitive "toolkit" heuristics, or past experiences. The core of the diagnosis is primed by an organized, medicalized mental case presentation pattern-matching to prior illness scripts (or instance scripts.) In looping back and engaging patients in education and shared-decision-making, aligning a patient's self-perception of disease empowers them to change themselves in cases where a disease is in part a social construct -- moving from a disease-oriented model to a patient-oriented health model.<br />
<br />
For example, a physician may react to a patient with hypertension as a machine with an elevated number that can be titrated downward with successive dosing of medications to relax the internal blood pressure. In contrast, another physician may view hypertension itself as a result of structural violence resulting from generations of low socioeconomic status, poor education, low literacy, living in a food desert without access to healthy low-salt options, lacking safe places to exercise and all things considered, a lower priority given to costly medications relative to other financial imperatives. Yet another physician may try to advocate for policy on improving access to care and reversing the obesity epidemic.<br />
<br />
Alternately, the relationship of the doctor-patient on the subject of an "invisible, risk-factor" disease like hypertension or early stages of type II diabetes is strictly paternalistic. The physician requests a bond of trust that the number they report (be it blood pressure or blood sugar) is elevated to an unhealthy or possibly even dangerous degree and the patient has to decide whether or not this is credible data. Do some patients see a physician in the same light as a mechanic who may try to convince a naive car owner to pay for additional parts and labor for something that they don't understand?Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-48736594935103155152014-12-01T19:21:00.003-10:002014-12-04T16:38:25.939-10:00Strategic Plan for Medical Education: A New Constructivist Model of Cognition<div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><i><span style="font-size: 14pt; line-height: 21.4666652679443px;">A New Model of Cognition</span></i></b></div>
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My main
driver for getting a Masters degree in Medical Education was to have the
opportunity to do high-level research in the field of clinical reasoning and
medical decision-making. Even as a fourth-year
medical student tutoring first-year students through their Problem-Based
Learning seminars, I was very keen on the process of developing a differential
diagnosis and becoming an expert diagnostician.
I recently discovered an old email showing that I looked through the literature
with a librarian for this exact question:<o:p></o:p></div>
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<span style="font-size: x-small;"><i><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Hello, I am a fourth year medical
student interested in conducting a research project on the cognitive process of
generating a differential diagnosis (ddx) geared to second year medical
students… the project I want to do involves teaching second year med students how
to be systematic in making a ddx and avoid the pitfalls, with a pre-unit and
post-unit survey to measure their progress and confidence in differentials.
Some of the questions I might ask are:</span><span style="font-family: Symbol; font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-stretch: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">How many
ddxs do you routinely make in PBL sessions on the first page of your [case]?<br /><o:p></o:p></span><span style="font-family: Symbol; font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-stretch: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">How often
do you feel that you have the right, specific diagnosis in your HCPs before the
conclusion of the case?<br /><o:p></o:p></span><span style="font-family: Symbol; font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-stretch: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">How
confident are you that you have a broad number of ddxs in your [case]?<br /><o:p></o:p></span><span style="font-family: Symbol; font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-stretch: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">How would
you rank your ability to generate a ddx compared to your peers?<br /><o:p></o:p></span><span style="font-family: Symbol; font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-stretch: normal; line-height: normal;">
</span></span><!--[endif]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Pick the
best definition for the following terms: heuristic, bayesian analysis,
attribution error, pre-test and post-test probability<br /><o:p></o:p></span><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">I have done
some general searches on Pubmed looking for articles on <b>medical education</b> and <b>differential diagnosis</b>, but I have not
found any literature that has done any similar projects in the past. It
would be helpful to know if there are any surveys that have similar assessment
measures.</span></i></span></blockquote>
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I recently discovered
a new constructivist theory that explains the cognitive process of clinical
reasoning that I am calling “[redacted, pending publication]”. In a nutshell, the current dominant
dual-process model involves weighing judgments as Type I automatic thinking vs
Type II deliberate thinking, in which we toggle between the unconscious heuristics/biases
brain and our rational, conscious brain.
I think this is incorrect. I feel
that we form ALL ideas as spontaneous, self-assembling “crystals.” The formation of diagnostic crystals is
catalyzed during the brewing process by nucleation on heuristics/rules/prior
experience under the right cognitive conditions. (see Appendix
1 for details)<o:p></o:p></div>
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<a href="https://www.blogger.com/null" name="OLE_LINK2"></a>My
vision is that <i>in the next 10 years</i><b><u>, I will change the way doctors think
about clinical reasoning</u></b>. I plan
to accomplish this <i>in the next 6 months</i>
by doing research to justify my “[thesis]” theory through a
demonstrative literature review for my Dundee thesis project. I plan on showing how my new theory meets the
criteria of quality (trustworthiness, transferability, dependability and
conformability) as well as authentic criteria of fairness (ontological,
educative, catalytic and tactical) as outlined by Guba and Lincoln (1989). Then, I plan on working as a
clinician/researcher and <i>in the next 5
years</i>, I will publish articles on this subject in several major journals (aiming
for Academic Medicine, Medical Education and Psychological Review where most of
my literature review has derived). <i>In the
next 10 years</i>, I write a book on “[redacted]” as a new theory on
the psychology of judgment.<o:p></o:p></div>
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These are “big,
hairy audacious goals (BHAGs).” I will
share my vision by telling stakeholders that "<b>We will change the way doctors think about clinical reasoning, using
procedural methods to ---[</b>to be revealed]." According to Collins and Porras,<br />
<blockquote class="tr_bq">
“A
true BHAG is clear and compelling, serves as a unifying focal point of effort,
and acts as a catalyst for team spirit... A BHAG engages people—it reaches out and grabs them. It is
tangible, energizing, highly focused. People get it right away; it takes little
or no explanation.” (Collins and Porras 1996)</blockquote>
The idea of changing
the way all doctors think is compelling.
Even though the theoretical concept will need to be explained, I feel
that everyone intuitively“gets” the concept that our brains bubble and brew and sometimes,
while we are in the shower or out on a walk – BAM! An idea comes up seemingly from nowhere. "[The thesis]" model elucidates this
process and invites people to maximize their chances of creating “Eureka!” moments.<o:p></o:p></div>
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My
institution has a Department for Clinical Decision-Making (CDM) that is
well-known for its leaders in the field of CDM. (Tufts, n.d.) We have a course for first-year medical
students called “Introduction to Clinical Reasoning” that I will be building on
by preparing fourth-year medical students for residency in an elective called “Family
Medicine Exploration Elective” in which I plan on exploring the concepts of
flow and intuition for expertise development.
In order to gain alignment with the CDM
department, I plan on utilizing <b>Kotter’s
model (1996) for Change Management</b>, to determine how to best accomplish our
shared goals. I will share a hybrid
model that adds in <b>Heath and Heath’s “Switch”
concepts (2010)</b> that use a visual analogy that making change is hard, like
a human rider trying to force an elephant to walk down a path. (Appendix 3.)<o:p></o:p><br />
<br />
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<a href="http://www.anecdote.com.au/elephant.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://www.anecdote.com.au/elephant.jpg" height="212" width="320" /></a></div>
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The first
step in the hybrid Kotter-Heath-Heath model is to <b>Motivate the Elephant</b>. This
means that I need to “Find the Feeling and Create a Sense of Urgency.” I plan on instigating a change with a shift
from the analytical Bayesian approach that the Department for CDM is used to
and publishing my radical new theory which is an intuitive “adaptive toolbox”
approach that Gigerenzer (2002) utilizes.
(Appendix 2.) Convincing the
majority of people that change is needed (Kotter recommends convincing at least
75% of managers that the status quo is more dangerous than the unknown) will
hopefully prompt a forthright discussion, leading to the next step.<o:p></o:p></div>
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Next, I will
<b>Shape the Path</b>. This means that I need to “Rally the Herd and
Form a Powerful Guiding Coalition.” My
fellowship advisor can facilitate a meeting with various members of the CDM
department to discuss the implications of my research. I need members with enough power to lead a
change effort. Kotter specifically
encourages the team to work outside the normal hierarchy:<br />
<blockquote class="tr_bq">
“This can be awkward,
but it is clearly necessary. If the existing hierarchy were working well, there
would be no need for a major transformation. But since the current system is
not working, reform generally demands activity outside of formal boundaries, expectations,
and protocol.” (Kotter 2007)</blockquote>
<o:p></o:p></div>
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Together with
a group of change agents, we will <b>Direct
the Rider</b>. In other words, “Find a
Destination and Create a Vision.” My
preliminary vision statement to share with stakeholders is: "<b>We will change the way doctors think about
clinical reasoning and help them </b>[in ways outlined in future works]." I would like to focus on medical education by changing our
curriculum for PBL and clerkships to include these scaffolding concepts. I already have a hand in creating a new
fourth-year FM elective that will integrate these principles for outpatient
primary care.<o:p></o:p></div>
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Providing
rational explanations is not enough to push the broader community to
change. Next, we will <b>Motivate the Elephant</b> by “Pointing to
the Destination and Communicating the Vision.”
If we are going to push all physicians to change how they think about
generating a differential, we have to tap into their feelings. All physicians strive to become expert
diagnosticians and are afraid of missing the diagnosis. Achieving “expertise” is nebulous, but
Ericsson (2004) provides us with a clear goal.
Deliberate practice and the acquisition and maintenance of expert
performance require 10,000 hours over 10 years of practice. It is my belief that we can get the attention
of various parties within the institution with the following message:<o:p></o:p></div>
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<ul>
<li><span style="font-family: Symbol; text-indent: -0.25in;"><span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><u style="text-indent: -0.25in;">Medical students</u><span style="text-indent: -0.25in;">: “You CAN dedicate 160
hours of 10,000 hours towards becoming an expert in Primary Care reasoning in a
month-long elective.”</span></li>
<li><u style="text-indent: -0.25in;">Family Medicine Residents</u><span style="text-indent: -0.25in;">:</span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">“You CAN accumulate around 2,000-3,000 of the
10,000 requisite hours towards becoming an expert in clinical reasoning”</span></li>
<li><u style="text-indent: -0.25in;">Family Medicine Faculty</u><span style="text-indent: -0.25in;">: “You will only
be supervising residents for ~300 hours of primary care clinical reasoning in a
year.”</span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">How do you plan on making the
best use of this time?</span></li>
</ul>
With enough
medical students, residents and faculty sufficiently motivated, we need to <b>Shape the Path </b>and “Tweak the
Environment and Remove Obstacles.” This
involves revamping the first-year medical student “Introduction to Clinical
Reasoning” curriculum so it is developmentally appropriate. I would propose moving material like illness
scripts, better suited for the onset of clinical exposure in the third-year. Additionally, memorizing numerical likelihood
ratios for determining post-test probabilities is not practical for real
clinical practice. Research by Czerlinksi,
Gigerenzer and Goldstein (1999) has shown that utilizing the Tallying heuristic
(Appendix 2) can achieve a higher predictive accuracy than multiple linear
regression analyses when applied intelligently.
After the concepts of numeracy are established, we can change these
burdensome LR to more teachable concepts like the Tallying method. A smartphone “app” can be
created to make the cognitive checklists we will design freely available for
everyone to use (<i>and hopefully if someone else does this grunt work for me... they will also make it free to the public!</i>). Many of these ideas are
nontraditional and risky, which is encouraged (Kotter 2007.)<br />
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<o:p></o:p></div>
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Finally, we
will establish a <b>set of Milestones for
the Rider and the Elephant</b> to achieve.
Typically, this is done by “Following the Bright Spots and Scripting
Critical Moves” for the Rider to perform, as well as “Shrinking the Change and
Recognizing/Rewarding Contributors” so the Elephant isn’t frightened and feels
motivated to contribute. However, my
ideas are completely novel (my initial literature search in 2009 and updated
search in 2014 provided no leads), so I will have to forge a path ahead. I hope we will be able to set up curriculum
for all years of medical school and my family medicine residency to include
relevant clinical reasoning topics.
Personally, I have already achieved some milestones for myself in terms
of spreading this information: designing medical student elective curriculum,
presenting a Grand rounds on this subject in 2012, and give a regional
conference on this topic in 2014. My
future milestones will include presenting a national conference on my thesis
material in the next 3-5 years as well as publishing in major journals in
medical education and psychology. I hope to give a TED Talk on the subject of
[redacted] as an analogy for judgment in general and spice it up with
some memorable clinical examples. Eventually,
I will strive to write a book.<o:p></o:p></div>
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Kotter has a few more steps on “Systematizing Wins” and “Institutionalizing
New Approaches” that will not matter to me specifically, unless I become a
department chair or some other leader in medical education. The vision statement and milestones I’ve set
up for myself are ambitious and I would be happy even if I can make a local change within my residency.<o:p></o:p></div>
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In summary, one of my goals in life is to become a master clinician and
systematize an approach for clinical expertise.
I feel that my theory on [redacted] is novel and opens up a
lot of avenues for future research, medical education and continuing professional
development. The hybrid
Kotter-Heath-Heath model I outlined above will help me align my personal goals
with my institution. It also helped me
develop a key strategic plan that I can enact to become a leader in the field
of Clinical Decision-Making and change the way doctors think.<o:p></o:p></div>
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<b>Appendix 1. [redacted theory.]<o:p></o:p></b></div>
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<b>Appendix 2: Gigerenzer’s
Adaptive Toolbox.<o:p></o:p></b></div>
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<b><u>Combined
Model for Change Management (Heath 2010
and Kotter 2007)<o:p></o:p></u></b></div>
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<!--[if !supportLists]-->1.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Motivate the Elephant: Find the Feeling and Establish
a Sense of Urgency<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->a.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Knowing something isn’t enough to cause
change.<o:p></o:p></div>
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<!--[if !supportLists]-->b.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Make people feel something.<o:p></o:p></div>
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</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 387.9pt;" valign="top" width="517"><div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->2.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Shape the Path: Rally the Herd and Form a
Powerful Guiding Coalition<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->a.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Behavior is contagious. Help it spread.<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->b.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Assemble a group with shared commitment and
enough power to lead the change effort<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->c.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Encourage them to work as a team outside the
normal hierarchy<o:p></o:p></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 90.9pt;" valign="top" width="121"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<v:shape id="Picture_x0020_16" o:spid="_x0000_i1030" style="height: 53.25pt; mso-wrap-style: square; visibility: visible; width: 80.25pt;" type="#_x0000_t75">
<v:imagedata o:title="MP900442207[1]" src="file:///C:\Users\NOTMY2~1\AppData\Local\Temp\msohtmlclip1\01\clip_image005.jpg">
</v:imagedata></v:shape><o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 387.9pt;" valign="top" width="517"><div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->3.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Direct the Rider: Find a Destination and
Create a Vision<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->a.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Change is easier when you know why its’ worth
it.<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->b.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Create a vision to direct the change effort<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->c.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Develop strategies for realizing that vision<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 90.9pt;" valign="top" width="121"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<v:shape id="Picture_x0020_11" o:spid="_x0000_i1029" style="height: 62.25pt; mso-wrap-style: square; visibility: visible; width: 80.25pt;" type="#_x0000_t75">
<v:imagedata o:title="MP900446568[1]" src="file:///C:\Users\NOTMY2~1\AppData\Local\Temp\msohtmlclip1\01\clip_image006.jpg">
</v:imagedata></v:shape><o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 387.9pt;" valign="top" width="517"><div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->4.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Direct the Rider: Point to the Destination and
Communicate the Vision<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->a.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Change is easier when you know where you’re
going.<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->b.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Use every vehicle possible to communicate the
new vision and strategies for achieving it<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->c.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Teach new behaviors by the example of the
guiding coalition. <o:p></o:p></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 90.9pt;" valign="top" width="121"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<v:shape id="Picture_x0020_18" o:spid="_x0000_i1028" style="height: 49.5pt; mso-wrap-style: square; visibility: visible; width: 80.25pt;" type="#_x0000_t75">
<v:imagedata cropbottom="11688f" cropleft="5844f" cropright="4592f" croptop="19619f" o:title="MP900449077[1]" src="file:///C:\Users\NOTMY2~1\AppData\Local\Temp\msohtmlclip1\01\clip_image007.jpg">
</v:imagedata></v:shape><o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 387.9pt;" valign="top" width="517"><div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->5.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Shape the Path: Tweak the Environment and
Remove Obstacles<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->a.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Remove or alter systems or structures
undermining the vision<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->b.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Encourage risk taking and nontraditional
ideas, activities, and actions<o:p></o:p></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 90.9pt;" valign="top" width="121"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<v:shape id="Picture_x0020_19" o:spid="_x0000_i1027" style="height: 77.25pt; mso-wrap-style: square; visibility: visible; width: 50.25pt;" type="#_x0000_t75">
<v:imagedata o:title="MC900056986[1]" src="file:///C:\Users\NOTMY2~1\AppData\Local\Temp\msohtmlclip1\01\clip_image008.wmz">
</v:imagedata></v:shape><o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 387.9pt;" valign="top" width="517"><div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->6.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Milestones:<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->a)<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Direct the Rider: Follow the Bright Spots &
Identify Potential Wins<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->b)<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Direct the Rider: Script the Critical Moves &
Engineer Wins<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->c)<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Motivate the Elephant: Shrink the Change &
Recognize/Reward Contributors<o:p></o:p></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 90.9pt;" valign="top" width="121"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<v:shape id="Picture_x0020_2" o:spid="_x0000_i1026" style="height: 80.25pt; mso-wrap-style: square; visibility: visible; width: 80.25pt;" type="#_x0000_t75">
<v:imagedata o:title="MC900339236[1]" src="file:///C:\Users\NOTMY2~1\AppData\Local\Temp\msohtmlclip1\01\clip_image009.wmz">
</v:imagedata></v:shape> <o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 387.9pt;" valign="top" width="517"><div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->7.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Systemize the Wins<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo3; text-indent: -.25in;">
<!--[if !supportLists]-->a)<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Motivate the Elephant: Develop/promote/hire
visionary employees<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .75in; mso-add-space: auto; mso-list: l2 level1 lfo3; text-indent: -.25in;">
<!--[if !supportLists]-->b)<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Motivate the Elephant: Tweak the Changes<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.25in; mso-add-space: auto; mso-list: l2 level2 lfo3; text-indent: -.25in;">
<!--[if !supportLists]-->a.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Reinvigorate the change process with new
projects & change agents<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->c)<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Shape the Path: Tweak the Environment and
Build Habits<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 0.0001pt 1.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->a.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Use increased credibility from early wins to
change systems, structures, and policies undermining the vision<o:p></o:p></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 90.9pt;" valign="top" width="121"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<v:shape id="Picture_x0020_20" o:spid="_x0000_i1025" style="height: 69.75pt; mso-wrap-style: square; visibility: visible; width: 73.5pt;" type="#_x0000_t75">
<v:imagedata o:title="MC900367638[1]" src="file:///C:\Users\NOTMY2~1\AppData\Local\Temp\msohtmlclip1\01\clip_image010.wmz">
</v:imagedata></v:shape><o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 387.9pt;" valign="top" width="517"><div class="MsoListParagraphCxSpFirst" style="margin: 0in 0in 0.0001pt 0.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->8.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Institutionalize new approaches<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->a)<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Direct the Rider: <o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 1.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->a.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Articulate connections between new behaviors &
corporate success<o:p></o:p></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0in 0in 0.0001pt 0.75in; text-indent: -0.25in;">
<!--[if !supportLists]-->b)<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Shape the Path:<o:p></o:p></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0in 0in 0.0001pt 1.25in; text-indent: -0.25in;">
<!--[if !supportLists]-->a.<span style="font-size: 7pt; font-stretch: normal;">
</span><!--[endif]-->Create leadership development & succession
plans consistent with the new approach<o:p></o:p></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 8.0pt; mso-bidi-font-size: 11.0pt;">Heath, C. and
Heath, D. (2010) Switch: How to Change Things When Change is Hard. Broadway Books: New York.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 8.0pt; mso-bidi-font-size: 11.0pt;">Kotter, J. (2007)
Leading Change: Why Transformation Efforts Fail. <i>Harvard Business Review</i>. Jan 2007.
Reprint R0701J.<o:p></o:p></span></div>
<span style="font-family: "Calibri","sans-serif"; font-size: 11.0pt; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</span>
<br />
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<b><u>References<o:p></o:p></u></b></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
Croskerry,
P. (2003) The Importance of Cognitive
Errors in Diagnosis and Strategies to Minimize Them. <i>Academic
Medicine</i>. 78(80) pp775-780.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
Collins and
Porras (1996) Building Your Company’s Vision. Harvard Business Review. Sept
1996. Available from: <a href="https://hbr.org/1996/09/building-your-companys-vision">https://hbr.org/1996/09/building-your-companys-vision</a><o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
Czerlinksi,
Gigerenzer and Goldstein (1999) How Good
are Simple Heuristics? In G. Gigerenzer,
P.M. Todd, & the ABC Reseach Group, Simple heuristics that make us smart
(pp. 97-118). New York, NY: Oxford University Press.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
Kruglanski
and Gigerenzer. (2011) Intuitive and Deliberate Judgments are Based on Common
Principles. <i>Psychol Rev</i>. 118(1) pp97-109.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
Gigerenzer,
G. and Selten, R. (2002) Bounded Rationality: The Adaptive Toolbox. Cambridge,
MA: MIT Press.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
Heath, C.
and Heath, D. (2010) Switch: How to Change Things When Change is Hard. New York, NY: Broadway Books.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
Kotter,
J. (1996) Leading Change. Cambridge, MA: Harvard Business School Press.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
Kotter, J.
(2007) Leading Change - Why Transformation Efforts Fail. Harvard Business Review.
Jan 2007. Reprint R0701J. Available from: <a href="https://hbr.org/2007/01/leading-change-why-transformation-efforts-fail/ar/1">https://hbr.org/2007/01/leading-change-why-transformation-efforts-fail/ar/1</a>
<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
Tufts
Medical Center: Department of Clinical Decision Making. Available from: <a href="https://www.tuftsmedicalcenter.org/patient-care-services/Departments-and-Services/Clinical-Decision-Making/Overview.aspx">https://www.tuftsmedicalcenter.org/patient-care-services/Departments-and-Services/Clinical-Decision-Making/Overview.aspx</a>
<o:p></o:p></div>
<br />
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-32711000941058968612014-11-16T16:20:00.001-10:002014-11-16T16:20:27.141-10:00Two Techniques to Make Swallowing Pills EasierQuick Tip for your Patients:<br />
<br />
<a href="http://www.annfammed.org/content/12/6/550.full">Two Techniques to Make Swallowing Pills Easier</a>:<br />
"Pop Bottle" ~60% effective<br />
"Lean Forward" ~90% effective!<br />
<br />
<img alt="Pill-Swallowing Annals of FM" src="http://www.annfammed.org/content/12/6/550/F1.large.jpg" height="400" width="328" /><br />
<br />
(Cross-posted on the <a href="http://chafmr.wordpress.com/2014/11/17/two-techniques-to-make-swallowing-pills-easier/">CHA Family Medicine Residency</a> blog)Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-33281672447849536392014-11-10T05:41:00.002-10:002014-11-10T05:41:28.683-10:00Number Needed to Treat in Severe Sepsis and Septic Shock to Save a Life = 4.<div class="separator" style="clear: both; text-align: center;">
<a href="https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcTbKVHG8PkTIdGbLbtEtVf60umXOZe42r-HyYEissTJWvlT0Qes40FWGhXx" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcTbKVHG8PkTIdGbLbtEtVf60umXOZe42r-HyYEissTJWvlT0Qes40FWGhXx" /></a></div>
<div>
<div style="orphans: 2; text-align: -webkit-auto; widows: 2;">
<span style="font-family: inherit;"><b><u>Teaching Pearl</u></b>: 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.</span></div>
<blockquote class="tr_bq" style="orphans: 2; text-align: -webkit-auto; widows: 2;">
<span style="font-family: inherit;"><i>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)</i>.</span></blockquote>
</div>
<blockquote class="tr_bq">
<span style="font-family: inherit;">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.</span></blockquote>
<div>
<div style="orphans: 2; text-align: -webkit-auto; widows: 2;">
<a href="http://journals.lww.com/ccmjournal/Abstract/2014/11000/Using_the_Number_Needed_to_Treat_to_Assess.4.aspx" style="text-align: -webkit-auto;"><span style="font-family: inherit;">http://journals.lww.com/ccmjournal/Abstract/2014/11000/Using_the_Number_Needed_to_Treat_to_Assess.4.aspx</span></a></div>
</div>
<div>
<span style="font-family: inherit;"><br /></span></div>
<div>
<span style="font-family: inherit;">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.</span></div>
Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-86273014145151161322014-11-09T09:07:00.002-10:002014-11-09T09:07:53.895-10:00Leadership - moving from models to reality<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
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 <b>Situational Leadership</b> in the clinic. Secondly, I will show how my <b>Leadership style</b> has keenly sharpened
under fire in a national organization. Finally, I will discuss how <b>Authentic Leadership</b> has affected me.<span style="font-family: Tahoma, sans-serif; font-size: 13.5pt; line-height: 115%;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<i><u>Tackling New Leadership Situations in a
Family Medicine Clinic and Residency<o:p></o:p></u></i></div>
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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 <b>Hersey and Blanchard’s (1969) Situational Leadership II (SLII) model</b>
of supportive and directive behaviors, I started with a hands-off approach. (Appendix 1)<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;">
Initially I used <u>supportive “participating” behavior</u>: 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.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;">
However, the work was not completed at the end of the week, so I switched
to a <u>coaching “selling” style</u>: 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. <o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;">
After a month went by, I sat down and used a <u>directive “telling” style</u>:
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.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
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.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
When I
recognized the utility of the SLII model , I investigated <b>Hersey and Natemeyer’s Power Perception Profile</b> (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.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
<i><u>Developing a New <b>Leadership Style</b> in the Committee of Interns and Residents<o:p></o:p></u></i></div>
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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.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
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 <b>Blake and Mouton</b> would term “<b>Impoverished
Management (1,1)</b>” with “<i>little
contact with followers and could be described as indifferent, noncommittal,
resigned, and apathetic</i>.” (Blake
and Mouton 1985, Appendix 3)<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
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.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;">
“<i>We have been absentee landlords,
holding the power and influence but letting our local staffers run the
organization</i>.” <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
In the past
year, I changed from an <b>“Impoverished
(1,1)” toward a “Teamwork (9,9)” </b>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. <o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
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 <b>George’s Authentic Leadership principles of “True North”</b> (2007) and
<b>Collins’ and Porris’ “Big Hairy
Audacious Goals”</b> (1996)<o:p></o:p></div>
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<br /></div>
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<span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">"<i>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?"</i> – Abraham Lincoln<o:p></o:p></span></div>
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<b><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">Imagine that CIR is taking
a physical journey towards a destination</span></b><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">.<o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; margin-left: .5in;">
<span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">We are the leaders of this group through the wilderness of
residency. We are the ones with vision
and direction. We are providing
guidance. <o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; margin-left: .5in;">
<b><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">Where do we want to go in
the next 3-5 years</span></b><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">?<o:p></o:p></span></div>
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<span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; margin-left: .5in;">
<b><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">Why are we walking down
some paths and not others</span></b><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">?<o:p></o:p></span></div>
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<span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; margin-left: .5in;">
<b><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">We are aiming towards the “Big,
Hairy and Audacious" True North.<o:p></o:p></span></b></div>
<div class="MsoNormal" style="background: white; margin-left: .5in;">
<span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; margin-left: .5in;">
<span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 9.5pt; line-height: 115%;"> (<i>abridged email, full exchange in attached
leadership portfolio</i>)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
As George’s
interviews with great leaders showed, <b>Authentic
Leadership</b> is about something more than traits alone: “<i>[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</i>.”(George 2007) This reflective exercise shows a few examples
from my life story in residency and fellowship.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
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. <o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;">
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.<o:p></o:p></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; text-indent: .5in;">
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.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
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. <b><i><u>I will be an Authentic Leader</u></i></b>.<o:p></o:p></div>
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Appendix 1:
Situational Leadership<o:p></o:p></div>
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Appendix 2:
Power Perception Profile<o:p></o:p></div>
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<div class="MsoListParagraphCxSpFirst" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">1.<span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Coercive</span></b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"> power is derived from having the
capacity to penalize or punish others. (French and Raven 1962)<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">2.<span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Connection</span></b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"> 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)<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">3.<span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Reward</span></b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"> power is derived from having the
capacity to provide rewards to others. (French and Raven 1962)<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">4.<span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Legitimate</span></b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"> power is associated with having
status or formal job authority. (French and Raven 1962)<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">5.<span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Referent</span></b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"> power is based on followers’
identification and liking for the leader. (French and Raven 1962)<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">6.<span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Information</span></b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"> power is based on the ability of
an agent of influence to bring about change through the resource of
information. (Raven and Kruglanski 1975).<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-bidi-theme-font: minor-latin;">7.<span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span><!--[endif]--><b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Expert</span></b><span style="font-size: 10.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"> power is based on followers’
perceptions of the leader’s competence. (French and Raven 1962)<o:p></o:p></span></div>
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<b><u>Bibliography<o:p></o:p></u></b></div>
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Blake, R.
R., & Mouton, J. S. (1985) <i>The
managerial grid III</i>. Houston, TX: Gulf Publishing Company.<o:p></o:p></div>
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Collins, J.
and Porras, J. (1996) Building Your Company’s Vision. <i>Harvard Business Review</i>.<o:p></o:p></div>
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George, B.
(2007) Discovering Your Authentic Leadership<i>.
Harvard Business Review</i>. Reprint
R0702H. <o:p></o:p></div>
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Hersey, P.
and Natemeyer, W.E. (1979<i>) Power
Perception Profile -- Perception of Self</i>. Center for Leadership Studies.
University Associates, Inc.<o:p></o:p></div>
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Hersey, P.,
Blanchard, K. and Natemeyer, W.E. (1979)
Situational Leadership, Perception, and the Impact of Power. <i>Group
Organization Management</i>. 4(4) p418-428<o:p></o:p></div>
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<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in;">
McCaffery,
P. (2010) <i>The Higher Education Manager's
Handbook</i>. Second Ed. New York: Routledge.<o:p></o:p></div>
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Raven, B.
& Kruglanski, W. (1975) <i>Conflict and power</i>. In P. G. Swingle
(Ed.), The structure of conflict. New York: Academic Press<o:p></o:p></div>
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Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-58040883294984908642013-12-30T21:27:00.000-10:002013-12-30T21:36:42.173-10:00The Development Process for a novel “Peer-Assessment Lecturer Survey” (PALS)<div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<b><u><span lang="EN-GB" style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">The Development
Process for a novel “Peer-Assessment Lecturer Survey” (PALS)</span></u></b></div>
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<b><u><span lang="EN-GB" style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">(available on request by word format)<o:p></o:p></span></u></b></div>
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<span lang="EN-GB" style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">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)<o:p></o:p></span></div>
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<span lang="EN-GB" style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">For
lecture evaluation, the <b><i>behaviourist approach</i></b> 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.<o:p></o:p></span></div>
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<span lang="EN-GB" style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">The <b><i>cognitivist
approach</i></b> 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. <o:p></o:p></span></div>
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<span lang="EN-GB" style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Keeping
the social-cognitivist theory of learning in mind, I designed a <b><u>Peer-Assessment Lecturer Survey (PALS)</u></b>
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.<o:p></o:p></span></div>
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<span lang="EN-GB">Figure 1. Sample concrete Behaviourist
skills on Movements and Gestures (Allen 1969)<o:p></o:p></span></div>
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<span lang="EN-GB" style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Figure 2. Gagné’s Instructional Event
and Learning Outcome Taxonomy Matrix<o:p></o:p></span></div>
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<span lang="EN-GB">Bibliography<o:p></o:p></span></div>
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<span lang="EN-GB">Allen, D.W. et.al. (1969) <i>Micro-teaching – A Description</i>. Stanford
University Press<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB">Bandura A (1986) <i>Social Foundations of Thought and Action. A Social Cognitive Theory</i>.
Prentice-Hall, Englewood Cliffs, NJ.<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB">Bloom, B.S. (1984) <i>Taxonomy of educational objectives</i>. Published by Allyn and Bacon, Boston, MA.<br />
<!--[if !supportLineBreakNewLine]--><br />
<!--[endif]--><o:p></o:p></span></div>
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<span lang="EN-GB">Brent, R. Felder, R. (2004) A protocol
for peer review of teaching <i>Proceedings
of the 2004 American Society for Engineering Education Annual Conference &
Exposition</i><o:p></o:p></span></div>
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<span lang="EN-GB"><br />
Gagné, R.M. (1985) <i>The conditions of
learning and theory of instruction</i>. Holt, Rinehart and Winston.<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB">Kaufman, D.M. (2011). Ch 2 Teaching
and learning in medical education: how theory can inform practice. In Swanick, T.
1<sup>st</sup> ed. <i>Understanding Medical
Education: Evidence, Theory and Practice</i> (Kindle Locations 1809-1810).
Wiley. Kindle Edition.<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB">Okey, J.R. (1991) <i>Procedures of
Lesson Design Ch. 8</i> In lnstructional Design: Principles and Application 2<sup>nd</sup> edn. Edited by Leslie J Briggs et al. Education Technology
Publications pp192-208.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB">Passi, B.K. (1976) <i>Becoming Better Teachers</i>. Baroda :
Centre for Advanced Study in Education, M. S. University of Baroda</span><span style="font-family: Tahoma, sans-serif; font-size: 13.5pt;"><br />
<!--[if !supportLineBreakNewLine]--><br />
<!--[endif]--></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">
</span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB">Wilson, R.C. (1986) <i>Improving Faculty Teaching: Effective Use of
Student Evaluations and Consultants</i>. Journal of Higher Education, 57 (2),
pp. 196-211.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB">(prepared for a Medical Education assignment)</span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB">Sample.</span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB"><br /></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<v:shapetype coordsize="21600,21600" filled="f" id="_x0000_t75" o:preferrelative="t" o:spt="75" path="m@4@5l@4@11@9@11@9@5xe" stroked="f">
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<v:path gradientshapeok="t" o:connecttype="rect" o:extrusionok="f">
<o:lock aspectratio="t" v:ext="edit">
</o:lock></v:path></v:stroke></v:shapetype><v:shape id="Picture_x0020_21" o:spid="_x0000_s1026" style="height: 38.95pt; left: 0; margin-left: 560pt; margin-top: -4.25pt; mso-height-percent: 0; mso-height-percent: 0; mso-height-relative: page; mso-position-horizontal-relative: text; mso-position-horizontal: absolute; mso-position-vertical-relative: text; mso-position-vertical: absolute; mso-width-percent: 0; mso-width-percent: 0; mso-width-relative: page; mso-wrap-distance-bottom: 0; mso-wrap-distance-left: 9pt; mso-wrap-distance-right: 9pt; mso-wrap-distance-top: 0; mso-wrap-style: square; position: absolute; text-align: left; visibility: visible; width: 36.95pt; z-index: 251663360;" type="#_x0000_t75">
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</v:imagedata></v:shape><b><u><span lang="EN-GB" style="font-family: "Arial","sans-serif";">Peer-Assessed Lecturer Survey (PALS)<o:p></o:p></span></u></b></div>
<div class="MsoNormal">
<span lang="EN-GB" style="font-family: "Arial","sans-serif";">Instructor: Topic: </span><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-bidi-font-size: 11.0pt;"> Notes & Comments<o:p></o:p></span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr>
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 311.4pt;" valign="top" width="415"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">I. Gain Attention</span></b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">:
Was your interest aroused?<o:p></o:p></span></div>
</td>
<td colspan="2" style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.75in;" valign="top" width="168"><div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [ ] Yes
[ ] No<o:p></o:p></span></div>
</td>
<td rowspan="9" style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 283.5pt;" valign="top" width="378"><div class="MsoNormal" style="margin-top: 0in;">
<i><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">When
providing comments, make them:<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .55in; margin-right: 0in; margin-top: 0in;">
<i><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">supportive,
descriptive, specific, & behavioural.<o:p></o:p></span></i></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .55in; margin-right: 0in; margin-top: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 311.4pt;" valign="top" width="415"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">II. Objectives </span></b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">were
stated at the beginning and<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">1.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Clearly
utilize active verbs from Bloom’s taxonomy<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">2.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Demonstrated
what was expected of the Learner by the end of the session<o:p></o:p></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.75in;" valign="top" width="168"><div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [ ] Yes
[ ] No<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [ ] Yes
[ ] No<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 311.4pt;" valign="top" width="415"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">III. Review</span></b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">
of prerequisite knowledge<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">3.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Started
at an appropriate challenge level<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">4.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Checked-in
with audience to adjust & match needs<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">5.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Covered
in less than 5 minutes <o:p></o:p></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.75in;" valign="top" width="168"><div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [ ] Yes
[ ] No<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [
] Yes [
] No<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [ ] Yes
[ ] No<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 311.4pt;" valign="top" width="415"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">IV.</span></b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">
ORAL <b>Presentation</b> skills<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<i><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Tally
up positive and delta points (</span></i><span style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-ansi-language: EN-US; mso-bidi-font-size: 11.0pt; mso-no-proof: yes;"><v:shape alt="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi52YfHZ071b6ZZpguOgo_EZdCLQ4Mjwsr96LSb7BNcVdX_i1Ld_F6e0I0jRR9aECClV6bEq2W5bVwF6o52TEIjaUafRrdox1uX4tRQ2vFxNKcDwCKs3Xh4SkVNED8EsNIdIbiI/s200/tally-marks.gif" id="Picture_x0020_22" o:spid="_x0000_i1028" style="height: 10.5pt; mso-wrap-style: square; visibility: visible; width: 10.5pt;" type="#_x0000_t75">
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</v:imagedata></v:shape></span><i><span style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">
</span></i><span style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-ansi-language: EN-US; mso-bidi-font-size: 11.0pt; mso-no-proof: yes;"><v:shape alt="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi52YfHZ071b6ZZpguOgo_EZdCLQ4Mjwsr96LSb7BNcVdX_i1Ld_F6e0I0jRR9aECClV6bEq2W5bVwF6o52TEIjaUafRrdox1uX4tRQ2vFxNKcDwCKs3Xh4SkVNED8EsNIdIbiI/s200/tally-marks.gif" id="Picture_x0020_23" o:spid="_x0000_i1027" style="height: 10.5pt; mso-wrap-style: square; visibility: visible; width: 10.5pt;" type="#_x0000_t75">
<v:imagedata o:title="tally-marks" src="file:///C:\Users\NOTMY2~1\AppData\Local\Temp\msohtmlclip1\01\clip_image002.gif">
</v:imagedata></v:shape></span><i><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">)
on subjects like:<o:p></o:p></span></i></div>
<div class="MsoListParagraphCxSpFirst" style="margin-top: 0in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: Symbol; font-size: 9.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Voice: <i>clarity, volume, energy, speed, um’s/er’s</i><o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-top: 0in; mso-add-space: auto; mso-list: l2 level1 lfo2; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: Symbol; font-size: 9.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Non-verbal cues: <i>directive focusing (pointing/laser
pointer), gestures/movement, & deliberate pauses</i><o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 63.0pt;" valign="top" width="84"><div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">(+)<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 63.0pt;" valign="top" width="84"><div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Δ<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 311.4pt;" valign="top" width="415"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">V.</span></b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">
A-V & <b>Guidance</b> skills <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<i><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Tally
up positive and delta points (</span></i><span style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-ansi-language: EN-US; mso-bidi-font-size: 11.0pt; mso-no-proof: yes;"><v:shape alt="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi52YfHZ071b6ZZpguOgo_EZdCLQ4Mjwsr96LSb7BNcVdX_i1Ld_F6e0I0jRR9aECClV6bEq2W5bVwF6o52TEIjaUafRrdox1uX4tRQ2vFxNKcDwCKs3Xh4SkVNED8EsNIdIbiI/s200/tally-marks.gif" id="Picture_x0020_24" o:spid="_x0000_i1026" style="height: 10.5pt; mso-wrap-style: square; visibility: visible; width: 10.5pt;" type="#_x0000_t75">
<v:imagedata o:title="tally-marks" src="file:///C:\Users\NOTMY2~1\AppData\Local\Temp\msohtmlclip1\01\clip_image002.gif">
</v:imagedata></v:shape></span><i><span style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">
</span></i><span style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-ansi-language: EN-US; mso-bidi-font-size: 11.0pt; mso-no-proof: yes;"><v:shape alt="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi52YfHZ071b6ZZpguOgo_EZdCLQ4Mjwsr96LSb7BNcVdX_i1Ld_F6e0I0jRR9aECClV6bEq2W5bVwF6o52TEIjaUafRrdox1uX4tRQ2vFxNKcDwCKs3Xh4SkVNED8EsNIdIbiI/s200/tally-marks.gif" id="Picture_x0020_25" o:spid="_x0000_i1025" style="height: 10.5pt; mso-wrap-style: square; visibility: visible; width: 10.5pt;" type="#_x0000_t75">
<v:imagedata o:title="tally-marks" src="file:///C:\Users\NOTMY2~1\AppData\Local\Temp\msohtmlclip1\01\clip_image002.gif">
</v:imagedata></v:shape></span><i><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">)
on subjects like:</span></i><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"><o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-top: 0in; mso-add-space: auto; mso-list: l1 level1 lfo3; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: Symbol; font-size: 9.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Overhead/PowerPoint/Prezi,
graphics, & videos<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-top: 0in; mso-add-space: auto; mso-list: l1 level1 lfo3; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: Symbol; font-size: 9.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Used cases,
story, analogy, examples, prompts & hints appropriately<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 63.0pt;" valign="top" width="84"><div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">(+)<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<br /></div>
<div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 63.0pt;" valign="top" width="84"><div align="center" class="MsoNormal" style="margin-top: 0in; text-align: center;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Δ<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 311.4pt;" valign="top" width="415"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">VI.</span></b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">
Facilitated <b>Practice</b><o:p></o:p></span></div>
<div class="MsoListParagraph" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">6.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Opportunity
provided for active involvement, student participation and/or practice<o:p></o:p></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.75in;" valign="top" width="168"><div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [
] Yes [
] No<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 311.4pt;" valign="top" width="415"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">VII. Feedback</span></b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"><o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">7.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Provided
active feedback to audience <o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">8.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Comments
were supportive, descriptive, behavioural<o:p></o:p></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.75in;" valign="top" width="168"><div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [ ] Yes
[ ] No<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [
] Yes [
] No<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 311.4pt;" valign="top" width="415"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">VIII. Assessment</span></b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">
of Objectives<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">9.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">The
instructor “closed the loop” on learning objectives with a post-instruction
assessment<b><o:p></o:p></b></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">10.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Higher-order
thinking questions were asked<o:p></o:p></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.75in;" valign="top" width="168"><div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [
] Yes [
] No<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [ ] Yes
[ ] No<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 311.4pt;" valign="top" width="415"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">IX. Further review</span></b><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">
after instruction<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">11.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Summary/outline
provided<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Arial;">12.<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><!--[endif]--><span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;">Additional
opportunities to master material (i.e. tools/homework) were provided for
further practice <o:p></o:p></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 1.75in;" valign="top" width="168"><div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [
] Yes [
] No<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif"; font-size: 9.0pt; mso-bidi-font-size: 11.0pt;"> [
] Yes [
] No<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<br /></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif";">The most important take-home point was: <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB">
</span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span lang="EN-GB" style="font-family: "Arial","sans-serif";">The muddiest point in the lecture was: </span><span lang="EN-GB" style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><o:p></o:p></span></div>
Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-56861275863755805892013-09-23T15:54:00.002-10:002013-09-23T15:59:32.998-10:00FUN Teaching Principles (based on learning theories)<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .5in; margin-right: 0in; margin-top: 0in;">
<span style="background-color: black; color: white;"><i><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">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</span></i><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span style="background-color: black; color: white;"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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 <b>cognitive constructivist</b> 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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span style="background-color: black; color: white;"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .25in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">My philosophy of teaching guided me to derive a set of simple
teaching principles that form a simple mnemonic: <b>FUN</b>!<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="background-color: black; color: white;"><span lang="EN-GB" style="font-family: Symbol; font-size: 12pt;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><b><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">F</span></b><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">irst things
First (Planning and Presentation)<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="background-color: black; color: white;"><span lang="EN-GB" style="font-family: Symbol; font-size: 12pt;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><b><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">U</span></b><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">nderstand the
Learner (Observation)<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-top: 0in; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<!--[if !supportLists]--><span style="background-color: black; color: white;"><span lang="EN-GB" style="font-family: Symbol; font-size: 12pt;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;">
</span></span><!--[endif]--><b><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">N</span></b><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">urture and Guide
(Active Reflection and Feedback)<o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .25in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span style="background-color: black; color: white;"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span style="background-color: black; color: white;"><b><u><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">First Things First</span></u></b><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">:<o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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 <b>Reflective Practice</b>
(1983) may help create a learner-centered lesson plan.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span style="background-color: black; color: white;"><br /></span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr>
<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.95in;" valign="top" width="379"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif;">Question<o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 177.7pt;" valign="top" width="237"><div class="MsoNormal" style="margin-top: 0in;">
<b><span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif;">Schön’s Reflective Practice<o:p></o:p></span></b></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.95in;" valign="top" width="379"><div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .5in; margin-right: 0in; margin-top: 0in; text-indent: -.5in;">
<i><span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">What was MY EXPERIENCE when I first started this subject?<o:p></o:p></span></i></div>
</td>
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">Knowing-in-action<o:p></o:p></span></div>
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<i><span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">What did I find most CHALLENGING initially?<o:p></o:p></span></i></div>
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">Surprise<o:p></o:p></span></div>
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<i><span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">What did I learn that was most IMPORTANT to me at that
time?<o:p></o:p></span></i></div>
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">Reflection-in-action<o:p></o:p></span></div>
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<i><span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">How has my understanding of this subject CHANGED since
then?<o:p></o:p></span></i></div>
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">Experimentation<o:p></o:p></span></div>
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<i><span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">How do I use the subject-matter on a DAY-TO-DAY basis?<o:p></o:p></span></i></div>
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 10pt;">Reflection-on-action<o:p></o:p></span></div>
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<span style="background-color: black; color: white;"><br /></span></div>
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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.<o:p></o:p></span></div>
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<span style="background-color: black; color: white;"><br /></span></div>
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<span style="background-color: black; color: white;"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span style="background-color: black; color: white;"><b><u><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">Understand the Learner</span></u></b><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">:<o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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 <b>Kolb Learning Cycle </b>(1984)<b> </b>and the Honey and Mumford adaptation close
the gaps through an<b> experiential
learning approach</b>, 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.<br />
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<span style="background-color: black; color: white;"><a href="http://www.blogger.com/blogger.g?blogID=28691495" name="OLE_LINK2"></a><a href="http://www.blogger.com/blogger.g?blogID=28691495" name="OLE_LINK1"><v:shapetype coordsize="21600,21600" filled="f" id="_x0000_t75" o:preferrelative="t" o:spt="75" path="m@4@5l@4@11@9@11@9@5xe" stroked="f">
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<span style="background-color: black; color: white;"><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 8pt;">Accessed 9/2013 from:
http://bonlinelearning.com.au/blog/learning-styles-in-elearning/</span><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 8pt;"><br />
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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 <b>reflective practice model</b> as well: as each student read their
scenario out loud, they reflected on what they would do (virtual<i> reflection-in-action</i>), discussed
strategies with other R2s (<i>experimentation</i>)
and then as homework, they created/utilized/tweaked personal workflows to gauge
if there were any improvements (<i>reflection-on-action</i>).
<o:p></o:p></span></div>
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<span style="background-color: black; color: white;"><br /></span></div>
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<span style="background-color: black; color: white;"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<span style="background-color: black; color: white;"><b><u><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">Nurture and Guide</span></u></b><span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;">:<o:p></o:p></span></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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 <b>Adult Learning Theory/Andragogy</b> 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
<b>Community of Practice</b>. (Wenger 1998) Scaffolding occurs by building on prior
knowledge and utilizing higher learners in a <b>Zone of Proximal Development</b> (Vygotsky 1986).<o:p></o:p></span></div>
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<span style="background-color: black; color: white;"><br /></span></div>
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<span lang="EN-GB" style="color: white; font-family: Arial, sans-serif; font-size: 12pt;"><o:p style="background-color: black;"><br /></o:p></span></div>
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<span style="background-color: black; color: white;"><a href="http://www.blogger.com/blogger.g?blogID=28691495" name="OLE_LINK4"></a><a href="http://www.blogger.com/blogger.g?blogID=28691495" name="OLE_LINK3"><v:shape alt="zpdgraph.jpg" id="Picture_x0020_3" o:spid="_x0000_i1025" style="height: 161.25pt; mso-wrap-style: square; visibility: visible; width: 217.5pt;" type="#_x0000_t75">
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 8pt;">Accessed 9/2013: http://lmrtriads.wikispaces.com/Zone+of+Proximal+Development<o:p></o:p></span></div>
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<span style="background-color: black; color: white;"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">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 “<i>what do you do to keep
yourself organized and how do you stay on track [with clinic flow]</i>?” and “<i>what sort of preparation work do you do
tonight? The morning before [you see your patients]?</i>” 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. <o:p></o:p></span></div>
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<span style="background-color: black; color: white;"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">In conclusion, the teaching principles “<b>F</b>irst things First,” “<b>U</b>nderstand
the Learner” and “<b>N</b>urture & Guide”
or <b>FUN</b>, form the basis for my
teaching philosophy. Their application
reflects the teaching theories of andragogy, reflective practice, cognitivism,
and social constructivism. <b>FUN</b> 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!<b><u><br clear="all" style="mso-special-character: line-break; page-break-before: always;" />
</u></b><o:p></o:p></span></div>
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;"><br /></span></div>
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<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in; text-indent: .5in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;"><br /></span></div>
<div class="MsoNormal" style="margin-top: 0in;">
<b><u><span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">Bibliography<o:p></o:p></span></u></b></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .25in; margin-right: 0in; margin-top: 0in; text-indent: -.25in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">Honey, P. & Mumford, A. (1982) Manual of Learning Styles.
London: Peter Honey Publications, London.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .25in; margin-right: 0in; margin-top: 0in; text-indent: -.25in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">Lave, J. & Wenger, E. (1991) Situated Learning:
legitimate peripheral participation. Cambridge University Press, New York.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .25in; margin-right: 0in; margin-top: 0in; text-indent: -.25in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">Kaufman, D.M. & Mann, K.V. (2010) Teaching and Learning
in Medical Education. In T. Swanwick (Ed) Understanding Medical Education.
ASME, Blackwell Publishing.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .25in; margin-right: 0in; margin-top: 0in; text-indent: -.25in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">Knowles MS et al. (1984) Andragogy in Action: applying modern
principles of adult learning. Jossey-Bass, San Francisco, CA.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .25in; margin-right: 0in; margin-top: 0in; text-indent: -.25in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">Kolb, D. A. (1984). Experiential learning: Experience as the
source of learning and development.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .25in; margin-right: 0in; margin-top: 0in; text-indent: -.25in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">Schön, D. A. (1983). The reflective practitioner: How
professionals think in action . New York: Basic Books.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .25in; margin-right: 0in; margin-top: 0in; text-indent: -.25in;">
<span lang="EN-GB" style="background-color: black; color: white; font-family: Arial, sans-serif; font-size: 12pt;">Vygotsky, L. S. (1986). Thought and language (A. Kozulin,
Trans.). Cambridge: MIT Press.</span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .25in; margin-right: 0in; margin-top: 0in; text-indent: -.25in;">
<span lang="EN-GB" style="font-family: Arial, sans-serif; font-size: 12pt;"><span style="background-color: black; color: white;">Wenger, E. (1998). Communities of practice: Learning,
meaning, and identity . Cambridge: Cambridge University Press.</span><span style="background-color: white;"><o:p></o:p></span></span></div>
Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-88179173691592543902013-08-08T08:12:00.001-10:002013-09-23T15:55:56.032-10:00Renewal and Reflections.So it's about time for me to restart this blog again.<br />
<br />
I made several meager attempts in medical school and residency, but I was always meek about posting patient related information and I was always pressed for time and drained of energy.<br />
<br />
However, I'm moving into a new period of my life (and a new period of the blogosphere where it is going the way of the dinosaur and may actually have more intimate readership!... i.e. just me.)<br />
<br />
I'm starting up a master teacher fellowship in medical education and we wrote a reflection in our "blogs" on a website and I figured, hey, this is good enough that I'll save it for my own site as well.<br />
<br />
<br />
<blockquote class="tr_bq">
<span lang="EN-GB" style="font-size: 12.0pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"> Before
I started medical school, I was interested in being a teacher or a
scientist. I loved analysing, studying
and sharing what I learned with others.
As I went through college and learned more about the differing
opportunities that a physician has available, I realized that I did not have to
these give up while working as a physician!</span> <span lang="EN-GB" style="font-size: 12pt;">The
concept of “how doctors think” is highly prized by learners and I want to work
on ways to provide this early on in medical school/residency curriculum. Research on this subject </span><span lang="EN-GB" style="font-family: Verdana, sans-serif; font-size: 10pt;">by Croskerry (2009) and Gigerenzer (2011) </span><span lang="EN-GB" style="font-size: 12pt;">has
inspired me to be more self-aware of this process. I plan to implement what I learn with the University of Dundee coursework to help create a framework for the development of clinical judgement
and to instill a sense of effective lifelong learning in those I work with and
those I teach.</span> <span style="font-size: 12pt;">I
am a little worried that the expected length of completion for the masters
program is 3-5 years.</span><span style="font-size: 12pt;"> </span><span style="font-size: 12pt;">This is the main
reason why I want to keep my end-goals in mind and find ways to always apply my
knowledge towards my thesis.</span></blockquote>
<br />
<div class="MsoNormal">
<span lang="EN-GB" style="font-family: Verdana, sans-serif; font-size: 10pt;">CROSKERRY, P. (2009). A Universal Model of Diagnostic Reasoning. <u>Academic Medicine</u>. 84 (8),
1022-1028.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: Verdana, sans-serif; font-size: 10pt;">GIGERENZER, G. and GAISSMAIER, W. (2011). Heuristic Decision
Making.</span><span style="font-family: Verdana, sans-serif; font-size: 10pt;"> </span><u style="font-family: Verdana, sans-serif; font-size: 10pt;">Annu. Rev. Psychol</u><i style="font-family: Verdana, sans-serif; font-size: 10pt;">.</i><span style="font-family: Verdana, sans-serif; font-size: 10pt;"> 62:451-482.</span>Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-33293976707644386012013-02-04T17:13:00.000-10:002013-09-23T16:03:59.196-10:00Tet Fe Mal<div class="separator" style="clear: both; text-align: center;">
<a href="http://cdn.shopify.com/s/files/1/0110/4882/files/tap_tap_2_grande.jpg?4804" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="http://cdn.shopify.com/s/files/1/0110/4882/files/tap_tap_2_grande.jpg?4804" width="300" /></a></div>
<i>(The case provided is inspired by a true story. I've changed the details to <i>blan </i>HIPAA standards. Random google image of a tap-tap provided for visual effect.)<br /><br />
</i><br />
Only the rushing traffic of tap-tap trucks and motos loaded to the brim with passengers stirred the stale and acrid air of the bustling city of Cap Haitien. Clouds of smoke rose from the cluttered gutters, spewing out a miasma of burnt plastic -- the country's sole way of waste disposal -- as toxic fumes.
<br />
<br />
Small currents of wind trailed behind the vehicles that swerved precariously around each other, weaving braids of smoky eddies in their wake. Paul-Jean, a small boy of 9 years, stared out the back of one such tap-tap named "Love Jesus." His eyes were transfixed by the smoky patterns and the noisy chaos of the street side merchants. It had only gotten busier in the weeks leading up to the coming of the festive <a href="http://en.wikipedia.org/wiki/Culture_of_Haiti#Festivals">Kanaval</a>. It was a big celebration throughout Haiti as their special version of Mardi Gras.
<br />
<br />
"Love Jesus" pulled over at the corner of a busy intersection after two brisk thumping strikes were authoritatively delivered against the side of the vehicle as a signal to stop. PJ got out and waited at the side of the road while his <i>manman</i> paid the driver, and then climbed out over the half-dozen passengers also stuffed in the seats.
<br />
<br />
Bzzzzzzzzzeeewwwwww!
<br />
<br />
EeeeeEEEeeeeEEEEtttt!
<br />
<br />
He heard the thubbing of the moto barreling down the road before he saw it -- the vehicle weaving and dodging the stodgy slower tap-taps and narrowly missing their side mirrors and passenger limbs sticking out the windows.
<br />
<br />
But the moto didn't miss him.
<br />
<br />
The world whirled around in a roaring redness... then black.
<br />
<br />
<br />
<br />
================================
<br />
<br />
A week later, he still flinched whenever a moto zoomed by -- and his protective <i>manman</i> folded him close into her bosom on this leg of their journey. This tap-tap (named "Bon Fet") weaved drunkenly back and forth on the path. The road was dusty and riddled with the pock-marked memory of monsoons past. On some of the deeper unavoidable potholes, PJ had to hold on to the railing and clutch at his floppy fishing cap to avoid losing his seat. His mother had saved up and given him the cute hat as a present since the accident.
<br />
<br />
He still hoped that he would get to see some of the parades of Kanaval, but <i>manman</i> insisted that that this trip was just as important.
<br />
<br />
<i>"Eske ki pwoblem ou genyen jodiya?"<br />
"Tet fe mal."</i>
<br />
<br />
The doctor asked why he was there in the hospital and his mother had blithely replied that he had a headache. He concentrated on drawing "Bon Fet," complete with a birthday cake on the top to complete the tap-tap. The adults chatted more and his mother swept off the floppy fishing cap without any dramatic flair, but by the inaudible gasp and silence that followed, she might as well have shouted and pointed.
<br />
<br />
PJ's head had been partially de-scalped and on the corner of his forehead, above his right eyebrow, a motorcycle handlebar's length off the ground, was a shiny patch of skull like an offset unblinking third eye.Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-24294027119648742712013-02-04T16:15:00.000-10:002013-02-04T16:15:32.844-10:00Interlude: Acid-Base AlgorithmI learned about a great book recently entitled Symptom to Diagnosis (Thanks Nathan!) which I started reading a few weeks ago. That, in combination with my proclivity to rewatch some old TV shows on iTunes in the evening has led me to compose less blog posts than I anticipated on this trip.
However, there are more to come -- with a different POV.
<iframe src="http://prezi.com/embed/y6s2jrt3fgwl/?bgcolor=ffffff&lock_to_path=0&autoplay=no&autohide_ctrls=0" width="550" height="400" frameBorder="0"></iframe>Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-71306581324007662672013-01-29T08:40:00.001-10:002013-01-29T08:43:11.919-10:00Week 2: Fresh, Clean Water and Nutritious FoodI spent my second week of my Haiti experience in the outpatient pediatrics clinic.
Overwhelmingly, the cases were centered around the need for reliable sources of nutritious food and clean water. I saw many ramifications of that in the form of intestinal worms and kwashiorkor malnutrition. Also, almost every kid had terrible tinea capitis.
This meant a lot of referrals to the (soon-to-be rebuilt) nutrition center for children and prescriptions for mebendazole, griseofulvin and metronidazole.
After being pleasantly surprised by the relative luxuries that the town of Milot had in terms of availability of fruits in the mountains and fresh water, I was shocked to see how many children came in with distended bellies and no weight gain over the course of months to years with "failure to thrive" as the tumbled off their growth curves. In some cases, new mothers didn't even know how often to breast feed their children thinking that their children needed more sleep and would only feed 4-5 times a day. It needs to be closer to 10-12 times per day! That made me wonder if the babies would initially cry from hunger and then after a period of dehydration and weight loss, decide to conserve that energy and just sleep most of the day.
It was also in the small single pedi clinic room with three other providers, a Haitian pediatrician, a Haitian resident (here for his year of social service) and a nurse practitioner from the States that I learned how History taking could be a team effort.
Quite often, while I was talking with my patients, the pediatrician would interrupt my translator or whip around with a chastising voice and lecture the mothers about their children for five minutes in the middle of her own clinic visits. I'd watch the exchange, initially amused by the response to my (what I thought of as) fairly benign questions and advice. And when pressed, my translator would simply say "they disagreed with my translations."
Sometimes women seemed reticent to offer their opinion on the medical situation unfolding.
Other times, the translator or resident would chuckle at their responses and tell me "they think it is a Haitian thing." It took me a few days to realize that this actually meant that there were non-Western beliefs at work; Voodoo beliefs that the patients or their parents held and in some cases, delayed care in deference to voodoo ceremonies or treatments.Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-85359111198189178622013-01-20T16:59:00.001-10:002013-01-20T17:12:37.644-10:00Week 1: Tdap, PPDs, and STI screening/_Counseling Needed!We had an awesome urology team from FL and NJ, some stellar RN students from UCSD and a wonderful cardiologist+sonographer team who were volunteering at the hospital with us this past week.<br />
<br />
I was stationed mainly in the outpatient clinic which was more like a walk-in urgent care day, but there were a surprising number of patients who came in for med refills for hypertension or mild acute complaints. There was also some urgent/emergent care, wound care and urology mixed in-between clinic sessions. Many of the wounds that I helped some of the nurses with were from motorcycle accidents and we opined the lack of resources for routine Tdap prophylaxis after routine injuries. Children are vaccinated nowadays, but some of the adults have developed <a href="http://www.crudem.org/2012/12/03/letter-from-the-president-winter-2012/">mortal cases of tetanus</a>.<br />
<br />
Here are some of the cases that I was involved in during my first week.<br />
<br />
<br />
<u>Cardiovascular/Pulmonary</u><br />
Dilated Cardiomyopathy CHF with severe mitral regurgitation (mimicking as "asthma")<br />
<a href="http://www.crudem.org/tuberculosis-in-haiti/">Active Pulmonary TB</a> (pretty much all the PPDs I ordered for suspicion of TB were 20mm in size or greater)<br />
<br />
<u>ID</u><br />
Testicular mass - massive hydroceles due to chronic filiriasis<br />
<a href="http://www.crudem.org/lymphatic-filariasis-in-haiti/">Lymphatic filiariasis</a> (Elephantiasis) of the legs<br />
Cervicitis/UTI/pyelonephritis<br />
<a href="http://www.crudem.org/tetanus-in-haiti/">Tetanus</a> -- mild and severe manifestations (with neck stiffness and muscle spasms vs risus sardonicus and trismus/lockjaw)<br />
Spinal compression fracture with cord compression due to Pott's disease with subsequent spasm and paralysis of the lower limbs<br />
<br />
<u>Derm</u><br />
Tinea versicolor<br />
Acne keloidalis nuchae<br />
Cellultitis<br />
Full thickness circumferential burn injuries<br />
<br />
<u>GI</u><br />
GERD<br />
H. Pylori (80-90% prevalence in Haiti, apparently!)<br />
<br />
<u>Heme/Onc</u><br />
Severe anemia (Hgb drop from 7 to 4.7 in two days!) due to leiomyomata of the uterus (negative pregnancy test but had a 20 week size uterus!)<br />
8x8cm Breast mass -- likely due to phyllodes tumor in adolescent, hopefully it turns out to be fibroadenoma<br />
<br />
<u>Urology</u><br />
Penile reconstruction s/p explosive trauma (a bovie explosion during an elective circumcision)<br />
Emergent secondary pseudophimosis due to a young boy slipping a metal washer around his glans (with acute swelling!)<br />
<br />
Our evenings were filled with case presentations on some of the more interesting and pertinent primary care topics.<br />
I didn't get to do much pediatrics, ED care or HIV/infectious disease, but I still have a few weeks to go! There are still a few residual cases of cholera and I'm glad that my stools have held firm thus far.<br />
<br />
And on that pleasant note, I'll be signing off!<br />
CP.Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-4822814068203914422013-01-12T14:38:00.000-10:002013-01-29T07:32:34.881-10:00Bonjou! Komon ou ye jodiya?<br />
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<br /></div>
<div>
I traveled across the turquoise waters of Turks and Caicos on 1/12 and flew across the dark blue yonder. A verdant delta emerged through the mists as we approached Haiti. There were numerous small rowboats, speckling the waters below and we sailed across a landscape of concrete walled homes with rusted corrugated roofs. I continued to peer intently out the window of this new land. A cannibalized prop plane lay abandoned on the side of the runway. We taxied over to a small airport/shed where our bags were collected into two trucks and we zipped down a paved road through Cap Haitien.</div>
<div>
<br /></div>
<div>
The colors of the small homes were bright with plastic detritus scattered across the landscape. Trucks with wooden backs called "Tap-taps" were piled full of people in the cab and hanging off the back. Apparently, when you wanted to get off the taxi, you "tap tap" the side and hop out.</div>
<div>
<br /></div>
<div>
At a crossroads between Cap Haitien, Milot and Dondon, the paved road of Cap Haitien gave way to a dusty gravel road with the occasional gaping pot hole. Motorcycles with two or three passengers hanging on the back zipped in and out of the traffic, competing with oncoming tap-taps. The road cut like a straight rut through the tropical landscape, peppered with small children carrying buckets of water on their heads, journeying to and from the local wells.</div>
<div>
<br /></div>
<div>
At a seemingly random location in our journey, we cut a right and arrived at our site.</div>
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<br /></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjknrVJokBG2zR7n_fjYAqUluKDysjUSKTr6Ih0vcY9Hz4dihyIJ_W0_OkFW-VUP05T6LjoEnxrzlxWCuhXh52f-L7gfbm8z_rQp4Mnvn6pgKQV-C2KocDZpRXur4_5oW2B0GRR/s1600/cameraroll-1358011738.917852.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjknrVJokBG2zR7n_fjYAqUluKDysjUSKTr6Ih0vcY9Hz4dihyIJ_W0_OkFW-VUP05T6LjoEnxrzlxWCuhXh52f-L7gfbm8z_rQp4Mnvn6pgKQV-C2KocDZpRXur4_5oW2B0GRR/s320/cameraroll-1358011738.917852.jpeg" width="320" /></a></div>
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The mission house site</div>
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<br />
Here I am in my dorm room on the campus, setting up my mosquito net. It would take a few days before I figured out how to use the hooks on the walls so the net wouldn't be lying directly on my face and legs.<br />
<br />
There was a period over the course of the weekend that I felt a sense of "overwhelming quietude." I think it was part of the transition into a foreign place without knowing the language, the culture, being struck simultaneously by the incredible poverty (but also the surprising degree of development)... there was just a lot of adjusting to do. <br />
<br />
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<a href="http://upload.wikimedia.org/wikipedia/commons/thumb/0/02/Sans-Souci_Palace_front.jpg/300px-Sans-Souci_Palace_front.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://upload.wikimedia.org/wikipedia/commons/thumb/0/02/Sans-Souci_Palace_front.jpg/300px-Sans-Souci_Palace_front.jpg" /></a></div>
<br />
We walked around the town and drank in the sights and sounds of this bustling town. This included a brief tour of <a href="http://en.wikipedia.org/wiki/Sans-Souci_Palace">Sans-Souci Palace</a>, a site of regal beauty (and aqueducts!) and some fascinating history involving the first King of Northern Haiti after they won their independence from the French.</div>
Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-18711806960932043772013-01-11T15:35:00.000-10:002013-01-12T15:55:07.629-10:00Boston -> Turks and Caicos, ProvidencialesRenewal.<br />
<br />
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First off, I must remark on the wonderful climate shift there is, going from the frigid New England Coast to the balmy Caribbean. Is this even real? Turks and Caicos has a surreal feel to it, but we have been met with warm weather and even warmer smiles here.<br />
<br />
On the way to our modest accommodations (I use the term loosely, since our fellow travelers/vacationers have more beautiful and swanky beach-side establishments), BB and DB commented on a recent trip their friends had taken to Iceland. It was a family who rarely travels, but they opted to go to a frozen tundra in the middle of winter to ice climb and hike on glaciers.<br />
<br />
<i>"Why not go someplace warm?"</i> they exclaimed, relishing in the warmth of Turks and Caicos.<br />
<br />
Why indeed. T&C,PLS reminds me much of home, but MUCH flatter, and everyone here drives on the wrong side of the road.<br />
<br />
"Iceland has one of the highest literacy rates in the world," I commented, drawing on random college trivia memory banks.<br />
<br />
<i>"Well, they do spend a lot of their time indoors. That makes a lot of sense."</i><br />
<i><br /></i>
In the tropics, I'm certain the literacy rates are lower when there's so much else to do. I'm reminded of the constant pull I felt to go outside and enjoy myself when I was studying in college and medical school in Hawaii as well. The competing interests of learning and relaxing outdoors... UGH! In many ways, living in Boston is a blessing as a resident where I can feel warm and cozy and guilt-free while studying and writing in my clinic charts.<br />
<br />
Well, I'm off to relax in preparation for my learning later!<br />
<br />
Signing off,<br />
CP.Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-73201392873915171852010-07-20T13:02:00.000-10:002010-07-20T13:02:11.460-10:00Number Needed to TreatThe <a href="http://en.wikipedia.org/wiki/Number_needed_to_treat">Number Needed to Treat (NNT)</a> is a hot concept in Evidence-Based Medicine since it provides a simple statistic that is a simple way for clinicians to objectively determine the effectiveness of a treatment. It is defined by wikipedia as:<br />
<blockquote>... an epidemiological measure used in assessing the effectiveness of a health-care intervention, typically a treatment with medication. The NNT is the number of patients who need to be treated in order to prevent one additional bad outcome (i.e. the number of patients that need to be treated for one to benefit compared with a control in a clinical trial). It is defined as the inverse of the absolute risk reduction. It was described in 1988. The <b>ideal NNT is 1, where everyone improves with treatment and no-one improves with control</b>. The higher the NNT, the less effective is the treatment</blockquote>That being said, EVERY medication has a number needed to treat that is greater than one. So what are some common NNTs in medicine? The answer may surprise you.<br />
<br />
Dr. Shaughnessy from Tufts Family Medicine pulled out a select few that I thought were notable.<br />
<br />
<col style="mso-width-alt: 5156; mso-width-source: userset; width: 106pt;" width="141"></col> <col style="mso-width-alt: 5888; mso-width-source: userset; width: 121pt;" width="161"></col> <col style="mso-width-alt: 5961; mso-width-source: userset; width: 122pt;" width="163"></col> <col style="width: 48pt;" width="64"></col><br />
<tr height="20" style="height: 15.0pt;"> <td class="xl68" height="20" style="height: 15.0pt; width: 106pt;" width="141"><span xmlns:xlink="http://www.w3.org/1999/xlink">Condition</span></td> <td class="xl68" style="width: 121pt;" width="161"><span xmlns:xlink="http://www.w3.org/1999/xlink">Treatment</span></td> <td class="xl68" style="width: 122pt;" width="163"><span xmlns:xlink="http://www.w3.org/1999/xlink">Outcome*</span></td> <td class="xl68" style="width: 48pt;" width="64"><span xmlns:xlink="http://www.w3.org/1999/xlink">NNT</span></td> </tr><br />
<tr height="20" style="height: 15.0pt; mso-height-source: userset;"> <td class="xl67" colspan="4" height="20" style="height: 15.0pt; width: 397pt;" width="529"><span xmlns:xlink="http://www.w3.org/1999/xlink">Prevention</span></td> </tr><br />
<tr height="60" style="height: 45.0pt;"> <td class="xl65" height="60" style="height: 45.0pt; width: 106pt;" width="141">Hypertension in patients with type 2 diabetes</td> <td class="xl65" style="width: 121pt;" width="161">Hypertension treatment</td> <td class="xl65" style="width: 122pt;" width="163">Diabetes-related death over 10 years</td> <td class="xl66" style="width: 48pt;" width="64">15</td> </tr><br />
<tr height="60" style="height: 45.0pt;"> <td class="xl65" height="60" style="height: 45.0pt; width: 106pt;" width="141">Hyperlipidemia (secondary prevention)</td> <td class="xl65" style="width: 121pt;" width="161">Various versus placebo</td> <td class="xl65" style="width: 122pt;" width="163">Heart attack or stroke over five years</td> <td class="xl66" style="width: 48pt;" width="64">16</td> </tr><br />
<tr height="60" style="height: 45.0pt; mso-height-source: userset;"> <td class="xl65" height="60" style="height: 45.0pt; width: 106pt;" width="141">Hyperlipidemia (primary prevention)</td> <td class="xl65" style="width: 121pt;" width="161">Simvastatin versus no treatment</td> <td class="xl65" style="width: 122pt;" width="163">Death over one year</td> <td class="xl66" style="width: 48pt;" width="64">163</td> </tr><br />
<tr height="20" style="height: 15.0pt; mso-height-source: userset;"> <td class="xl67" colspan="4" height="20" style="height: 15.0pt; width: 397pt;" width="529"><span xmlns:xlink="http://www.w3.org/1999/xlink">Treatment</span></td> </tr><br />
<tr height="100" style="height: 75.0pt;"> <td class="xl65" height="100" style="height: 75.0pt; width: 106pt;" width="141">Peptic ulcer</td> <td class="xl65" style="width: 121pt;" width="161"><span xmlns:xlink="http://www.w3.org/1999/xlink">Helicobacter pylori eradication therapy versus acid suppression treatment for six to eight weeks</span></td> <td class="xl65" style="width: 122pt;" width="163">Cure at one year</td> <td class="xl66" style="width: 48pt;" width="64">1.8</td> </tr><br />
<tr height="40" style="height: 30.0pt;"> <td class="xl65" height="40" style="height: 30.0pt; width: 106pt;" width="141">Migraine</td> <td class="xl65" style="width: 121pt;" width="161">Sumatriptan versus placebo</td> <td class="xl65" style="width: 122pt;" width="163">Headache relief at two hours</td> <td class="xl66" style="width: 48pt;" width="64">2.6</td></tr><br />
<br />
A more extensive list can be found at <a href="http://www.medicine.ox.ac.uk/bandolier/band50/b50-8.html">Table of NNTs on Bandolier</a>Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-31675388824805285842010-06-28T16:35:00.000-10:002010-06-28T16:36:08.744-10:00ACLS Tachycardia<div class="prezi-player"><style type="text/css" media="screen">.prezi-player { width: 550px; } .prezi-player-links { text-align: center; }</style><object id="prezi_igs-xawn-f5y" name="prezi_igs-xawn-f5y" classid="clsid:D27CDB6E-AE6D-11cf-96B8-444553540000" width="550" height="400"><param name="movie" value="http://prezi.com/bin/preziloader.swf"/><param name="allowfullscreen" value="true"/><param name="allowscriptaccess" value="always"/><param name="bgcolor" value="#ffffff"/><param name="flashvars" value="prezi_id=igs-xawn-f5y&lock_to_path=0&color=ffffff&autoplay=no"/><embed id="preziEmbed_igs-xawn-f5y" name="preziEmbed_igs-xawn-f5y" src="http://prezi.com/bin/preziloader.swf" type="application/x-shockwave-flash" allowfullscreen="true" allowscriptaccess="always" width="550" height="400" bgcolor="#ffffff" flashvars="prezi_id=igs-xawn-f5y&lock_to_path=0&color=ffffff&autoplay=no"></embed></object><div class="prezi-player-links"><p><a title="Advanced Cardiac Life Support Algorithms based on the AHA 2005 Guidelines" href="http://prezi.com/igs-xawn-f5y/acls-tachycarda-algorithm/">ACLS Tachycarda Algorithm</a> on <a href="http://prezi.com">Prezi</a></p></div></div>Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com1tag:blogger.com,1999:blog-28691495.post-38427173488768164742010-06-27T07:59:00.000-10:002010-06-27T07:59:00.473-10:00ACLS Pulseless Arrest<div class="prezi-player"><style type="text/css" media="screen">.prezi-player { width: 550px; } .prezi-player-links { text-align: center; }</style><object id="prezi_44j81dvskh3k" name="prezi_44j81dvskh3k" classid="clsid:D27CDB6E-AE6D-11cf-96B8-444553540000" width="550" height="400"><param name="movie" value="http://prezi.com/bin/preziloader.swf"/><param name="allowfullscreen" value="true"/><param name="allowscriptaccess" value="always"/><param name="bgcolor" value="#ffffff"/><param name="flashvars" value="prezi_id=44j81dvskh3k&lock_to_path=0&color=ffffff&autoplay=no"/><embed id="preziEmbed_44j81dvskh3k" name="preziEmbed_44j81dvskh3k" src="http://prezi.com/bin/preziloader.swf" type="application/x-shockwave-flash" allowfullscreen="true" allowscriptaccess="always" width="550" height="400" bgcolor="#ffffff" flashvars="prezi_id=44j81dvskh3k&lock_to_path=0&color=ffffff&autoplay=no"></embed></object><div class="prezi-player-links"><p><a title="Advanced Cardiac Life Support Algorithms based on the AHA 2005 Guidelines" href="http://prezi.com/44j81dvskh3k/acls-pulseless-arrest-algorithm/">ACLS Pulseless Arrest Algorithm</a> on <a href="http://prezi.com">Prezi</a></p></div></div>Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-1364983730468761312010-06-26T07:56:00.002-10:002010-06-26T07:59:07.915-10:00ACLS Bradycardia<div class="prezi-player"><style type="text/css" media="screen">.prezi-player { width: 550px; } .prezi-player-links { text-align: center; }</style><object id="prezi_4ux9xjc67ugb" name="prezi_4ux9xjc67ugb" classid="clsid:D27CDB6E-AE6D-11cf-96B8-444553540000" width="550" height="400"><param name="movie" value="http://prezi.com/bin/preziloader.swf"/><param name="allowfullscreen" value="true"/><param name="allowscriptaccess" value="always"/><param name="bgcolor" value="#ffffff"/><param name="flashvars" value="prezi_id=4ux9xjc67ugb&lock_to_path=0&color=ffffff&autoplay=no"/><embed id="preziEmbed_4ux9xjc67ugb" name="preziEmbed_4ux9xjc67ugb" src="http://prezi.com/bin/preziloader.swf" type="application/x-shockwave-flash" allowfullscreen="true" allowscriptaccess="always" width="550" height="400" bgcolor="#ffffff" flashvars="prezi_id=4ux9xjc67ugb&lock_to_path=0&color=ffffff&autoplay=no"></embed></object><div class="prezi-player-links"><p><a title="Advanced Cardiac Life Support Algorithms based on the AHA 2005 Guidelines" href="http://prezi.com/4ux9xjc67ugb/acls-bradycardia-algorithm/">ACLS Bradycardia Algorithm</a> on <a href="http://prezi.com">Prezi</a></p></div></div><br /><br />Prezi is a great presentation maker for algorithms and journal reports because of the free click nature of it (unlike powerpoint, you can navigate anywhere you want by selection or by "slide advancement")<br /><br />I thought I'd give it a shot with a short set of presentations based on the ACLS 2005 guidelines by AHA and the great mnemonics by ACLS.net!<br /><br />Enjoy,Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-37850208157683847532010-04-04T23:57:00.003-10:002010-04-05T00:16:21.817-10:00The Setting Sun<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://farm1.static.flickr.com/74/210545595_1f3700cdf4_m.jpg"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 240px; height: 160px;" src="http://farm1.static.flickr.com/74/210545595_1f3700cdf4_m.jpg" border="0" alt="" /></a>His steady hands were folded in his lap and his posture was erect, as if he were called to a silent attention when I walked into his room. As I gathered a medical history from him, I was reminded of someone, but I could not quite place it. He was a stoic, strong Army veteran. He fought in the land of the rising sun. In spite of all that he had seen, he tried to keep a positive attitude about everything. Recently, he told me, he had been taking miscellaneous classes at a community college for fun -- computer science, psychology, ceramics, whatever struck his fancy.<br /><br />He was an old man. He had been smoking ever since he enlisted, as a way of passing the time. In spite of all the PT he had done to stay healthy, his lungs failed him. He grew acutely short of breath a few months ago, barely able to walk across a street on the once strong legs that used to carry large crates of ammunition. His hair was thin and short, a reminder of times past. It was not because of an enforced crew-cut this time. A cycle of chemotherapy took its toll on his elderly body. In spite of all that he had been through, he tried to keep a positive attitude about everything. <br /><br />He smiled at me, a steady and determined smile when I leaned forward and touched him on the elbow.<br /><br /><span style="font-weight:bold;">“So, how do <span style="font-style:italic;">you </span>feel?”<br />“I feel okay, doc. I just want to know… when is it going to happen?”</span><br /><br />I paused, not quite sure how to answer this question.<br /><br />My brain was still reviewing the list of symptoms of chemotherapy: nausea, vomiting, diarrhea, alopecia, oral ulcers, skin rashes, pain, numbness/tingling/weakness, kidney failure, heart failure… I consciously shoved aside the ticker list scrolling across my mind and focused on the man in front of me.<br /><br />“The condition you have… the type of lung cancer that it is… is incurable. The chemotherapy only staved off the worst of it that was wrapped around your throat and the blood vessels around your heart. People typically live anywhere from a year to … weeks.”<br /><br />I looked at him and suddenly caught a glance of my <span style="font-style:italic;">Ojii-san</span>, a man who won a purple heart in the Korean War for valor. He was featured on the cover of Time magazine, according to my mother. All I could remember of my scary grandpa was his raspy breath, stained teeth and the smell of tobacco smoke. He seemed to never move from his recliner and refused to see a doctor when he developed breathing problems of his own. He passed away when I was very young.<br /><br />“I wish I could give you more specifics, but it is hard to say.”<br /><br />These men grew up in a different time and likely never thought they would survive the war.<br />In spite of everything, they had lived past their prime.<br /><br />I looked out the window where the setting sun flared across the grey clouds on the horizon.<br />“Well, I’ll come and see you tomorrow,” I said, hefting my backpack over my shoulder.<br />“I’ll do my best to see you too,” he said with a wink.<br /><br /><br />____________<br />Picture by <a href="http://www.flickr.com/photos/conceptjunkie/210545595/">conceptjunkie</a>, c/o flickrClintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com2tag:blogger.com,1999:blog-28691495.post-18281411986176733532010-03-30T21:20:00.004-10:002010-03-30T21:36:42.406-10:00Double VisionI saw a patient today who incidentally complained of double vision.<br /><br />"Look straight at me...<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNZBBMacYTdqEJU8v9EkmuPhs4VAcnK6T1LuBlOvpNxbsAsrX1q38bnlcphHfckhJwhr-bkQj7lb8ooO-VUiuYktMo1ykSUhCH7JX2I9zb9xmwbO8IwSxXTEWvfDskTl6GJ5WU/s1600/IMG_0150.JPG"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 149px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNZBBMacYTdqEJU8v9EkmuPhs4VAcnK6T1LuBlOvpNxbsAsrX1q38bnlcphHfckhJwhr-bkQj7lb8ooO-VUiuYktMo1ykSUhCH7JX2I9zb9xmwbO8IwSxXTEWvfDskTl6GJ5WU/s400/IMG_0150.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5454694768586718610" /></a><br /><br />To the left...<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQA7_GR-6W8Bp66xgJk5y_pubanmkB2SoO1kBLFYe5h_RN4ypIxIiLWx_TDksA-mtMhZefwNPE5LtHGJygI3bRIA0ofSsBqOweAxgHyCt4iGIt4c5cTbR4UNXMbKetjM14S_ZJ/s1600/IMG_0152.JPG"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 129px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQA7_GR-6W8Bp66xgJk5y_pubanmkB2SoO1kBLFYe5h_RN4ypIxIiLWx_TDksA-mtMhZefwNPE5LtHGJygI3bRIA0ofSsBqOweAxgHyCt4iGIt4c5cTbR4UNXMbKetjM14S_ZJ/s400/IMG_0152.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5454694782095857346" /></a><br /><br />And now, to the right!"<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2DVXNu5MdMxa6Gf9tEWVdo-VNzDSfh7j5Ggwf1ETfkpSA6CV-qq14cIKu-TPbJqRFBn_cqe_OyqQ2H4TvsIECbg0XE9adqk-Dmp10ckOImJ6oOs-15w5WVG5CrQhmVkarkIG-/s1600/IMG_0151.JPG"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 400px; height: 147px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2DVXNu5MdMxa6Gf9tEWVdo-VNzDSfh7j5Ggwf1ETfkpSA6CV-qq14cIKu-TPbJqRFBn_cqe_OyqQ2H4TvsIECbg0XE9adqk-Dmp10ckOImJ6oOs-15w5WVG5CrQhmVkarkIG-/s400/IMG_0151.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5454694777315481842" /></a><br /><br />The misalignment was most evident when I first awoke this patient, but you can still see that the left eye does not track well, especially when looking to the right. (Hint: look at the slight difference in the reflection between the eyes, subtle but present in all photos.)<br /><br />I was able to diagnose this patient's underlying condition, which is practically pathognomonic for...<br /><br /><br />Med students: do you know what it is?<br /><br /><br /><br /><br /><br /><br /><br /><br />----------<br /><br />Left-sided <a href="http://en.wikipedia.org/wiki/Internuclear_ophthalmoplegia">internuclear ophthalmoplegia</a>, caused by an injury to the medial longitudinal fasciculus...<br /><br />And the most common source of this lesion is <a href="https://health.google.com/health/ref/Multiple+sclerosis">multiple sclerosis</a>. This patient has chronic relapsing, remitting multiple sclerosis (curiously, the patient didn't have any visual problems until a week ago.) We prescribed an eye-patch. I was graciously given permission to photograph the eyes for educational purposes and spread the word.<br /><br /><br />Sometimes double vision can be "monocular," signifying astigmatism in the affected eye. When it is "binocular," requiring BOTH eyes to be open to create double vision, then you worry about cranial nerve and ocular muscle defects.Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-3744313197725832012010-03-24T21:02:00.000-10:002010-03-24T21:04:06.593-10:00How to Feed the World?<object width="400" height="225"><param name="allowfullscreen" value="true" /><param name="allowscriptaccess" value="always" /><param name="movie" value="http://vimeo.com/moogaloop.swf?clip_id=8812686&server=vimeo.com&show_title=1&show_byline=1&show_portrait=0&color=&fullscreen=1" /><embed src="http://vimeo.com/moogaloop.swf?clip_id=8812686&server=vimeo.com&show_title=1&show_byline=1&show_portrait=0&color=&fullscreen=1" type="application/x-shockwave-flash" allowfullscreen="true" allowscriptaccess="always" width="400" height="225"></embed></object><p><a href="http://vimeo.com/8812686">How to feed the world ?</a> from <a href="http://vimeo.com/dvanw">Denis van Waerebeke</a> on <a href="http://vimeo.com">Vimeo</a>.</p><br /><br />A strikingly simple message that everyone can (and should!) listen to.Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0tag:blogger.com,1999:blog-28691495.post-46082691144807390562010-03-10T23:52:00.002-10:002010-03-11T22:39:13.439-10:00Interesting Optho Cases<p>Here's some of the cases that I had on my Optho service. Really, that should be "Ophthal" cases, but no one seems to pronounce the "ph" anyhow. I'm not sure if this is of interest to anyone else, but reviewing this list helps me remember what I've seen. </p> <p> </p> <p><u>Most interesting/unexpected</u></p> <ul> <li>Ruptured globe -> repair -> enucleation to prevent sympathetic ophthalmia</li> <li>Herpes zoster opthalmicus</li> <li>Narrow angle glaucoma s/p laser peripheral iridotomy (visible via retroillumination!)</li> <li>Congenital cataracts, amblyopia</li> <li>Anterior uveitis, HLA B27(+), tx w/ MTX</li> <li>Anterior uveitis, secondary to psoriatic arthritis (striking case of dactylitis!)</li> <li>Exposure keratopathy secondary to CN VII palsy s/p parotid tumor resection</li> <li>Pterygium vs pinguecula</li> <li>Grave's ophthalmopathy</li> <li>CN IV palsy secondary to meningioma</li> <li>Metallic foreign body removal (rust from car) w/ 18 gauge needle, wet Q-tip and Algr brush </li></ul> <p><br></p> <p><u>Routine but important!</u></p> <ul> <li>Corneal abrasions vs ulcers</li> <li>Floaters and flashes: vitreous detachment vs retinal detachment vs ocular migraine</li> <li>Conjunctival stye vs chalazion</li> <li>Background vs proliferative diabetic retinopathy</li> <li>Open angle glaucoma</li> <li>Age-related Macular Degeneration</li> <li>YAG laser</li> <li>Cataract surgery<br></li></ul> <p><u>Glad that Ophthalmologists Know What the Heck they are Looking at</u></p> <ul> <li>Pseudophakic bullous keratopathy</li> <li>Choroidal melanoma s/p proton beam radiation</li> <li>Pigmented basal cell carcinoma</li> <li>Irvine-Gass cystoid macular edema secondary to atopy and cataract surgery</li></ul>Clintonhttp://www.blogger.com/profile/05511383754690179606noreply@blogger.com0