La didattica La didattica medica:medica:

necessità organizzativenecessità organizzativee strutturalie strutturali

Italo VantiniItalo Vantini

25 Giugno 201425 Giugno 2014

The logic sequence and strategic The logic sequence and strategic sequence in medical educationsequence in medical education

Health need

Professional needs

Education needs

What health professionals for the What health professionals for the XXI century ?XXI century ?

Carrier of Carrier of ::– Knowledge and competenciesKnowledge and competencies– Abilities ad attitudesAbilities ad attitudes– ValuesValues

Capable of:Capable of:: : – Up to datingUp to dating– Self-educatingSelf-educating– teamworkingteamworking

WHO:

-Problem solver- Learner for the life- Health educator

What health professionals for the XXI What health professionals for the XXI century ?century ?

Doctoring Doctoring (or nursing, etc)(or nursing, etc) Professional and specific competenciesProfessional and specific competencies

ProfessionalismProfessionalismProfessional behaviourProfessional behaviour

Knowledge ofKnowledge of: : - Heath system organization- Heath system organization

Medical and healthcare professional educationMedical and healthcare professional education

A system A system – OrganizedOrganized– PlannedPlanned– Student centred Student centred – With devoted personnelWith devoted personnel– With costsWith costs– AssessedAssessed

ResponsabilityResponsability ContractContract CertificationCertification

Il Processo di Bologna è un processo di riforma internazionale dei sistemi di istruzione superiore, che si propone di realizzare entro il 2010 lo Spazio Europeo

dell'Istruzione Superiore. Il Processo di Bologna, fondando le sue basi su Trattati precedenti, inizia nel

1999 dopo che 29 ministri dell'istruzione europei si incontrano il 18 e 19 giugno del 1999 a Bologna per

sottoscrivere un accordo, noto come dichiarazione di Bologna.

BolognaProcess

(declaration)

A changing student populationgA changing student populationgGlobalizationGlobalization

Changing educagtion needsChanging educagtion needsand approachand approach

EducationEducation(“changes the shape”; provides a new “shape”)(“changes the shape”; provides a new “shape”)

start target

Step by step, through a curriculum,triggers and produces the change

A relevent changeA relevent change

Learning

The three components ofThe three components ofhealthcare professionals healthcare professionals

(in both (in both profession and educationprofession and education))

knowledge

abilities,attitudes

values

What kind of education ?What kind of education ?

Awareness of the mission Awareness of the mission Awareness of the roleAwareness of the roleCritical approach to the knowledgeCritical approach to the knowledgeCompetence in clinical skills and practical Competence in clinical skills and practical abilitiesabilitiesMethodological/metacognitive abilities (process Methodological/metacognitive abilities (process attitudes)attitudes)Interdisciplinary approachInterdisciplinary approachIntellectual flexibilityIntellectual flexibilityRecognizing, sharing, carrying values, honesty Recognizing, sharing, carrying values, honesty and humanitiesand humanitiesAbility to “disobedience” (active citizenship)Ability to “disobedience” (active citizenship)………………..

Planning and organizing education for graduate Planning and organizing education for graduate and postgraduate students in health professionsand postgraduate students in health professions

Institutive and legal aspectsInstitutive and legal aspectsGeneral principles (Ministery of Education and General principles (Ministery of Education and Reserch) comprehensive of graduate and Reserch) comprehensive of graduate and postgraduate professional profiles postgraduate professional profiles Rules and regulations of specific schoolsRules and regulations of specific schoolsTeachers and tutorsTeachers and tutorsLogistics Logistics Curriculum:learning objectives, abilities, attitudes, Curriculum:learning objectives, abilities, attitudes, skills skills Planning of the education process, timetable, Planning of the education process, timetable, teaching/learning methodsteaching/learning methodsOrganization of the teaching/learning process and Organization of the teaching/learning process and practical activitiespractical activitiesAssessmentAssessment

A mechanicistic, A mechanicistic, reductionistic approach to reductionistic approach to medical and healthcare medical and healthcare professional education ?professional education ?

TeachingLearning

curriculumcurriculum

Education targetsEducation targets

ContentsContents

Teaching/learning methodsTeaching/learning methods

Sequence and timetableSequence and timetable

IntegrationsIntegrations

Assessment (students, teachers, Assessment (students, teachers, system)system)

studentcentred

A strategy fo the curriculumA strategy fo the curriculum

PropedeuticityPropedeuticity

Sequence of complexitySequence of complexity

Integration *Integration *

Monitorized progressionMonitorized progression

*“Integration” is often more virtual than real, being made by the association of two

or more disciplines only

Progression is “monitored” bythe sum of credits achieved in time by the student

and by the national Progress test

Neither knowledgenor competence are

the summation of information or ofthe “training” only

Adult educationAdult education- the learning pyramid -- the learning pyramid -

% retention rate

Lecture 5

Reading 10

Audiovisual 20

Demonstration 30

Discussion group 50

Practice by doing 75

Teach others 80

?

AA long, difficult, time-consuming, but long, difficult, time-consuming, but

enjoyable way: the experiential learningenjoyable way: the experiential learning

Concreteexperience

Active“experimentation”

Reflectiveobservation

Abstractconceptualization

Learning throughthe individual attitude

of observing and searching, understanding, “discovering”

KnowledgeProcess

ResponsabilityActive student

Experience

the medical the medical experience experience

To do

To feel

To think

To elaborate

Group activitiesand practical

experiences are excellent opportunities

Adult educationAdult education

Nothing can be reallylearned without the personaland individual re-elaboration of the “Knowledge” and of

the “Experience”

CARE

clinical exposureclinical exposure

In a real, stimulating setting (authenticity of In a real, stimulating setting (authenticity of the learning setting is important)the learning setting is important)

ClinicalClinicalSocial Social Inter-professionalInter-professional

TheoreticalTheoreticalPracticalPractical

Social AnthropologicPsycological

aspectsEthics

Communication and

relationshipsPatient’s needs, and

expectationsLifestyles

Trained to develop attitudeTrained to develop attitudeto appreciate, understand, and to appreciate, understand, and

manage a new situation within a manage a new situation within a new settingnew setting

Commitmentand responsability

Tutorial methodTutorial method

In tutorials(PBL, PS, DM,

case discussion, briefenig, debriefing, etc)

In the clerkship

In learning practical abilitiesand skills

Tutorial methodTutorial method

Tutorial “method”

- - small groups- interactive

- through problemsand/or experience

KnowledgeProcess

Competenceteamworking

TutorTutor- a key job -- a key job -

Tutors are Tutors are essentialessential for the education of for the education of students of medicine and of health students of medicine and of health professionalsprofessionals

They must be aware of and They must be aware of and trainedtrained in : in :– education objectives education objectives – teaching/learning methods (tutorial method)teaching/learning methods (tutorial method)– assessmentassessment

Specific training of tutorSpecific training of tutor is an essential is an essential prerequiisite for an effective tutorial approachprerequiisite for an effective tutorial approach

Learning in medicine: a variety and “cocktail” of tools

Education in medicineEducation in medicine

●Knowledge

Skills Attitude

Progress Assessment

Values

Some pollutionamong theecomponents

Medical and health professional education Medical and health professional education in in academic centersacademic centers

A A tripartite missiontripartite mission::– ResearchResearch discovery to care continuitydiscovery to care continuity– EducationEducation a learning health systema learning health system– HealthcareHealthcare excellence and coverageexcellence and coverage

IntegrationIntegration among among– Hospital (s)Hospital (s)– FacultyFaculty– Community-based partners and Community-based partners and

stakeholdersstakeholders

Medical and health professional education Medical and health professional education in academic centersin academic centers

Health structures and missionHealth structures and mission– To meet To meet education needseducation needs for different types of for different types of

health professionals and for different degrees of health professionals and for different degrees of medical education (from graduation to post-medical education (from graduation to post-graduate schools, pHD and Masters):graduate schools, pHD and Masters):

HigherHigher regional health system performing and regional health system performing and qualified centersqualified centers

ExcellenceExcellence and tertiary care are critical for and tertiary care are critical for academic health center success also in medical academic health center success also in medical education education

BalancingBalancing the clinical excellence and population the clinical excellence and population health to provide a wide spectrum educationhealth to provide a wide spectrum education

SpanningSpanning the spectrum from community based to the spectrum from community based to highly specialized hospital and post-acute carehighly specialized hospital and post-acute care

From The future of the academical medical centers, 2012From: Dzau VJ New Engl J Med 2013; 369: 991993

Medical and health professional education Medical and health professional education in academic centersin academic centers

Academic Center shouldAcademic Center should

– leverage their leverage their university affiliationuniversity affiliation– redesign care deliveryredesign care delivery according to health care according to health care

strategies and modern medical and healthcare strategies and modern medical and healthcare educationeducation

– foster and facilitate medical education and training foster and facilitate medical education and training by by fitting heathcare paradigm with medical fitting heathcare paradigm with medical educationeducation, and by mutually adapting each other, and by mutually adapting each other

– expand their focus on medical and other health expand their focus on medical and other health professionals with a robust multitask and professionals with a robust multitask and interprofessional education interprofessional education

– increase clinical and translational researchincrease clinical and translational research

Medical and health professional education Medical and health professional education in academic centersin academic centers

Academic Center should Academic Center should – amalgamateamalgamate health care units with health care units with

DisciplinesDisciplinesFaculty departmentsFaculty departmentsResearch institutes and groupsResearch institutes and groups

– Avoid decentralization as possible, that may Avoid decentralization as possible, that may introduce innovation in some fields, but can introduce innovation in some fields, but can compromize individuality and autonomy of compromize individuality and autonomy of the faculty and the the faculty and the sense of belongingsense of belonging to a to a academic institutionacademic institution

– The model of university at a academic The model of university at a academic health center is the health center is the CAMPUSCAMPUS

University campus and academic health center: e.g. project

General services and structuresGeneral services and structures

Students should have:Students should have:

– Access facility to the centerAccess facility to the center– LibraryLibrary– Informatic and computer facilitiesInformatic and computer facilities– Secretariat of the faculty at the centerSecretariat of the faculty at the center– Dressing room and professional dressingDressing room and professional dressing– RefectoryRefectory– Recreation and student acivities room and Recreation and student acivities room and

facilities facilities (e.g. sport, music, movies, etc)(e.g. sport, music, movies, etc)

Structures in the clerkship sites or for Structures in the clerkship sites or for practical activities in the clinical settingpractical activities in the clinical setting

Students should have:Students should have:

– Dressing room or siteDressing room or site– A working room shared with the medical or nursing A working room shared with the medical or nursing

staff and postgraduate at the clinical unit sitestaff and postgraduate at the clinical unit site– One meeting room for ca discussion, presentation, One meeting room for ca discussion, presentation,

staff meeting, near te clinical unitstaff meeting, near te clinical unit– Access to computer and informatic services of the Access to computer and informatic services of the

medical center consistent with medical center consistent with – All protections and warnings for their on site All protections and warnings for their on site

learning activities learning activities

Setting and students-traineesSetting and students-trainees

To expose students To expose students to a to a co-educatingco-educating

communitycommunity

SettingSettingStructures and professionalsStructures and professionals

HospitableHospitable

ComfortableComfortable

StimulatingStimulating

Making a modelMaking a model

Aware of the missionAware of the mission Aware of the learning objectivesAware of the learning objectives Experienced in assessmentExperienced in assessment Trained for tutoringTrained for tutoring

Models oforganizationfor medical education

Hirsh et al NEJM 2007; 365: 858-866

Interdisciplinarityand continuity

Malcon Cox, David M. Irby: “Continuity” as an organizing principle for clinical education reform. NEJMed 2007; 358 (8): 858-66

Discipline or tract-basedOrganization

(rotation)

Continuity,Integration, Competencedevelopment

Malcon Cox, David M. Irby: “Continuity” as an organizing principle for clinical education reform. NEJMed 2007; 358 (8): 858-66

University of VeronaUniversity of VeronaUndergraduate eUndergraduate education for health professionalsducation for health professionals

(Area delle Scienze della salute e della vita)(Area delle Scienze della salute e della vita)

Two Two 6-year 6-year graduationsgraduations– MedicineMedicine– OdontostomatologyOdontostomatology

Two Two 5-year5-year (3+2) graduations (3+2) graduations– Rehabilitation sciencesRehabilitation sciences– Nursing and obstetric sciencesNursing and obstetric sciences

Ten Ten 3-year3-year graduation for health professionals graduation for health professionals (nurse3s, physiotherapists, and technicians)(nurse3s, physiotherapists, and technicians) – Nursing, physiotherapy, laboratory, radiology, psichiatry, Nursing, physiotherapy, laboratory, radiology, psichiatry,

odontostomatology, cardiovascular pathophysiology, odontostomatology, cardiovascular pathophysiology, obstetrics, logopedist, prevention in working sitesobstetrics, logopedist, prevention in working sites

School of medicine

a “mixed” organization with

integration

School of MedicineSchool of MedicineUniversity of VeronaUniversity of Verona

- general (analogic) planning of the - general (analogic) planning of the curriculum-curriculum-

clearkship

seminars

specS

spec

clearkship clearkship

PBL

Values

PS

Relations

- Propedeuticity - Sequentiality- Different and

more appropriateand effective

teaching/learningmethods

University of VeronaUniversity of Verona3-year undergraduate schools for health professionals3-year undergraduate schools for health professionals

Organization, teachers and tutorsOrganization, teachers and tutors

– Director of the school Director of the school (professor)(professor) – School council School council – Secretary and administration Secretary and administration

– Professors of disciplinesProfessors of disciplinesBasic and propedeutic disciplines Basic and propedeutic disciplines Professional disciplinnes Professional disciplinnes

Coordinator of practical and professional trainingsCoordinator of practical and professional trainingsService or unit coordinators in training sites Service or unit coordinators in training sites Tutors for practical training and clearkshipTutors for practical training and clearkship

University of VeronaUniversity of VeronaEducation for health professionalsEducation for health professionals

(Area delle Scienze della salute e della vita)(Area delle Scienze della salute e della vita)

Ten 3-year Ten 3-year graduation for health graduation for health professionalsprofessionals (nursing and technicians)(nursing and technicians) – Nursing, physiotherapy, laboratory, radiology, Nursing, physiotherapy, laboratory, radiology,

odontostomatology, prevention in working sites, psichiatry, odontostomatology, prevention in working sites, psichiatry, cardiovascular pathophysiology, obstetrics, logopedistcardiovascular pathophysiology, obstetrics, logopedist

7 sites7 sites (“poli”) (“poli”)– VeronaVerona– TrentoTrento– BolzanoBolzano– VicenzaVicenza– RoveretoRovereto– AlaAla– Legnago Legnago

Malcon Cox, David M. Irby: “Continuity” as an organizing principle for clinical education reform. NEJMed 2007; 358 (8): 858-66

lessons

On site training and clearkship

assessment

3-year schools for healthprofessionals

A “BLOCK” SYSTEM

General principles for organizing practical General principles for organizing practical activities and clerkship - 1activities and clerkship - 1

practical acitivities should be chronologically near to the teaching/learning process of that discipline or group of disciplines of the same semester or tractstudents are organized in groupseach group should be sufficiently small to allow that students actively partecipate to clinical activitiesclinical units should be enough to receive groups of students for some weeks or months Clinical units should be in a position to provide a sufficient number of trained tutors (one on three-four students) to facilitate interactions tutor/students

General principles for organizing General principles for organizing practical activities and clerkship - 2practical activities and clerkship - 2

Units are almost continuously involved in some education activity during most of the yearthe tutor time for educational activities is longer for the tutor time for educational activities is longer for 3rd year students than for 6th year ones 3rd year students than for 6th year ones The time for care may be increased by 40% for The time for care may be increased by 40% for tutoring 3rd-4th year student, and by 25% for 6th year tutoring 3rd-4th year student, and by 25% for 6th year students students A good tutor only is able to make independent A good tutor only is able to make independent student in practical activities and to receive from student in practical activities and to receive from students some help in his/her professional activitystudents some help in his/her professional activity

Principi generali di organizzazione delle Principi generali di organizzazione delle attività pratiche – 2 attività pratiche – 2

le strutture di tirocinio devono essere provviste di un numero di tutor adeguato alla numerosità dei gruppi5-non devono sussistere ostacoli logistici o costose perdite di tempo da parte degli studenti a causa di spostamenti continui; 6- l’organizzazione dovrebbe essere principalmente semestrale e che nello stesso semestre possono coesistere Corsi integrati la cui attività frontale ed esercitativi-pratica non è indifferentemente collocabile; 7- non dovrebbero essserci sperequazioni significative fra gruppi di studenti nell’ambito delle singole attività pratiche e frontali.

Conditioning and essential factorsConditioning and essential factors

Doctors, nurses, personnel shoul aware of the Doctors, nurses, personnel shoul aware of the educational mission and that they represent a model educational mission and that they represent a model for trainees for trainees Training for tutoringTraining for tutoringTeaching experienceTeaching experienceTeaching and tutoring attitudesTeaching and tutoring attitudesEducational relationship with pupilsEducational relationship with pupilsParticipation to reasearch projectsParticipation to reasearch projectsCritical attitude towards knowledgeCritical attitude towards knowledgeContinuoing auditingContinuoing auditingPre-existing academic experiences of the staff are Pre-existing academic experiences of the staff are essential for the quality of the educatio deliveryessential for the quality of the educatio delivery

Drawbacks:

Academic Environment

Career Scientific production

Scientific assessment

Busy in an increasing clinical care

How to killHow to killacademic medicineacademic medicine

A practical handbookA practical handbookfor candidate heath for candidate heath

managersmanagers