November 10, 2020

Episode 41: The future of clinical education

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Description

Our guest for this episode is an expert on clinical education and is helping to answer a question that is close to Dr. Nurse Dan’s heart: “How do we train the doctors and nurses of the future?” 

Lawrence Sherman is the CEO of Meducate Global, a consultancy whose goal is to improve the education of healthcare professionals around the world. He and Dan talk about how the landscape for clinical education is changing, and how those changes have been accelerated by the COVID-19 pandemic as learning has moved from a face-to-face setting to a digital one. 

Lawrence shares his thoughts on how the role of clinical educator needs to evolve from a one-directional transferer of knowledge to a facilitator of learning. He also shares advice for nurse leaders who want to build on the innovation happening in academia and embed that into their own culture of continuous learning. We also talk about the benefits and challenges of interdisciplinary learning in a hospital setting. 

Links to recommended reading: 

Podcast

Transcript

Dan:
Lawrence welcome to the show.

Lawrence:
Well, hello Dan.

Dan:
I always love our conversations and usually they've been in San Diego with a huge cup of coffee. I mean, huge. And it always goes in places that are interesting and exciting and fun. I'm hoping this happens today.

Lawrence:
Well, I'm sure it will. And it's always nice to drink coffee out of something you can swim in.

Dan:
I know. I don't know how you don't have a fib. I know you have the Apple watch to check for that. That gives me palpitation.

Lawrence:
Well, at my age, I think the Apple watch is more to check for falls.

Dan:
I was using the Apple watch to check... My son had open heart surgery to fix a ventricular septal defect and we use the Apple watch to check his vital signs and stuff at post-surgery. It was amazing.

Lawrence:
You know you can do a 12 lead with it depending on where you place it?

Dan:
Oh, really?

Lawrence:
Yeah.

Dan:
I was using the wrist and his finger on the little button and got the tracing, but I didn't know you could get a full 12 lead.

Lawrence:
Yeah. I read a paper somewhere where they placed the watch over where you put the precordial leads, et cetera. And if you put your finger there you get a different snapshot. Obviously it's not clinically relevant, but you can see the differing patterns. It's interesting. I wouldn't do it. I wouldn't trust it.

Dan:
I'm not going to be diagnosing an EMI with it but...

Lawrence:
Here we go, it's time for a STEMI.

Dan:
That's right. I set my alarm for... When I'm going to have my STEMI. At least they got the rate and rhythm of it. And that was good enough to help with the cardiologist to understand when he was having some attack with cardiac if it was something to worry about or not. It's interesting.

Lawrence:
Well, and the reality is I hope he's doing okay.

Dan:
He's doing great. He's doing awesome. But one of the things I was thinking about is... I was talking to one of the physicians, the cardiologist, and she was saying, "I don't nano watch, I don't know what it can do. But it sounds it's okay." And I think that speaks to a gap in our clinical education of these tools. And many of them are becoming FDA approved that are consumer grade tools. How are clinicians incorporating that into their education? They know what to trust? What not to trust? Or are we missing the boat on that?

Lawrence:
Well, it's an interesting path because actually there's many paths. Theoretically learning science tells us that adults seek information and education from questions that arise in practice or in the workplace or when they find that I call it a learnable moment. Teachable moments are what teachers create learnable moments are what happened amongst practitioners when they say, "I need to learn something." It should drive them to look for the right information. Education problem is 100 of them happen a day. And by the time they have the time to pursue, look at, find the information that they thought about 99 of those go away.

Lawrence:
Even though they have that moment of Zen, that aha moment I need to learn more about it they don't. I think that's a challenge. The other challenge from a curriculum and faculty perspective is we often don't in CPD and interprofessional continuing education. Think about building that in there so that we're connecting. What we're doing is we're focusing so much on information rather than the transfer of practice that oftentimes we miss those moments. The good news is I think it's getting better, but I think a lot of those moments are missed.

Dan:
Define for our listeners CPD.

Lawrence:
It's Continuing Professional Development. Anybody that's a practitioner out there in any of the health professions commits to be a lifelong learner. And we've always used the term continuing education. Whether it's continuing medical education, continuing nursing education, continuing pharmacy education, any of those terms. We've focused on the science and the clinical stuff. There's a big school of thought that CPD is inclusive of CME. But all the other stuff you need to know to practice, to work, regardless of your environment whether you're a clinical practitioner, a public health practitioner, you have that other stuff that you need besides the medical or scientific information. Interestingly around the world, CPD is used synonymously with CME in a lot of places. There's no real agreement on that.

Dan:
Yeah. I mean, I think when at least nurses here CNE or continuing education they think of the PowerPoint. They're forced to click through to renew their license or the annual evaluation where they have to show that they can do restraints once a year or whatever. They don't really associate it with a way to evolve their practice or innovate or become advanced practitioner. It's a task at hand. How does medicine see that?

Lawrence:
It's not just medicine. And I think of it from a global perspective because I do so much work outside the U.S. We're very spoiled in the United States. In that we have such tightly defined instruction frameworks for recertifying, relicensing all that. Regardless of any of the questions that are coming up about MOC and stuff like that. In medicine, the reality is we're very lucky that we have access to 1000s and 1000s of educational activities. Some of them to your point Dan suck because they are boring standard. I'm reading these slides to you. And I don't care if you learn it or not. I'm telling you how smart I am.

Lawrence:
And there's the other end of the spectrum where there's directed self-learning where there's strong faculty. I know where you engage with your learner or learners and you try to understand what their specific needs are and you guide them down a path. It's that educational learner journey to get from where they are to where they need to be. It's not just in medicine but across the board. What we're doing is we're seeing a hopefully a revolution in faculty development. Let me say this. I think the pandemic has helped. Helped? How can a pandemic help anything? Well, I think it's created that pathway from innovation to disruption.

Lawrence:
We've had to become digital educators whether we like it or not. And we've had to innovate, which in my world means doing the same thing we've done all along but a little bit differently. Initially we had to innovate, but the disruption means what we're going to make a change that's sustainable. And it's different from the way we did it before. And I think we've seen that. And interestingly faculty have had to up-skill, re-skill and unskilled in order to be more effective teachers, because they think about engagement more digitally than a lot of them thought about it at least in my experience, then they thought about when they were face to face.

Dan:
Yeah, I think you're right. The pandemic. And we've seen in non-pandemic situations too. The adoption of medical records forced the hand to move away from paper and actually getting the data. The pandemic is forcing us. We can't do the traditional sit in a seat and listen to me lecture or what my physician colleagues have called chalk talks or a sage on the stage. it's not able to happen now. And it's forced people to think about different ways of delivering content now whether they're innovative or not. I think we could probably debate, but I know it's for some people to think about things completely differently because the option to go backwards is not there anymore.

Lawrence:
That's exactly right. And it's funny. I don't call myself an educator or a teacher. I call myself a GILF, a GILF. A Global Inspirational Learning Facilitator, nothing more, nothing much Dan.

Dan:
I was going to go another direction, but we won't go there.

Lawrence:
I know you were. But and obviously the double entendre may well have played into my creating it, but that's what it is. Ronald Harden, who's The General Secretary of The Association for Medical Education Europe. Wrote a book on The Eight Roles of The Medical Teacher. It's really The Eight Roles of The Health Professions Teacher and defined three years ago what the educator needs to be. And one of them is really a facilitator rather than that sage on the stage. Because it's about the learner regardless of the time in the health education continuum, whether it's undergraduate postgraduate or CPD. You need to be a facilitator of the learning, not a giver of everything that you know.

Dan:
That makes a lot of sense. And I think that's a mindset shift for a lot of faculty that have been around a while. Because that's always been looked at as success, how much you know and not how well you facilitate. And how are you shifting that mindset in schools and associations across the world? How do you get a faculty to realize there are... It's great they have content knowledge and there's value to that. But the facilitation is that transfer and they need to think differently about how they've been teaching for potentially decades.

Lawrence:
Well, the good news is the good health professions educators worldwide already knew that. I think the challenge is helping those who are forced to teach rather than those who choose to teach them. Those who are... When you're in healthcare, it's inevitable that you're going to be asked to teach at least in the clinical environment and maybe in a semi-academic environment. And if you've not been taught how to teach, if you don't know learning science I don't mean you have to be a learning scientist or learning Scientologists depending where you live, you're in California right?

Dan:
Yes.

Lawrence:
But you need to understand the general principles. I think the good ones were the good ones and the good ones are the ones who help to guide the others. The others have to be willing to learn. And I think the challenge is, and this is what I think you're getting at. There are people who are put into the role of teacher without selecting that role. And then they teach the way they were taught. And the worst expression in the world Dan is, "Well, that's the way we've always done it." And that doesn't mean we've always done it. With that said I had to lead a webinar for health professions educators, mostly from schools of medicine, nursing pharmacy around the world, through AMEE, The Association for Medical Education Europe. And it was on how do you become a more effective digital educator? And how do you pivot your curriculum from face-to-face to digital?

Lawrence:
And we had up until now, it was live and then archived. I think it's over 7,000 participants from over 70 countries. People know, but what's really interesting is... I talked to some faculty to prepare for it. I did my little needs assessment and I got those little areas where the faculty were really struggling. Right after I did that I got contacted by the European Medical Students Association. And they asked me if I could do a session for them about what they needed to do to learn better in this environment. And I said, "Okay. We can have a call with a couple of you guys. I understand what your challenges are." And their challenges were identical. Different place on the timeline, but identical to the challenges of the faculty. While the faculty were saying, "We need to be sure we're providing the right education, the right format, right timeframe." The students were saying, "We want to make sure that we're getting the right education, the right timeframe, the right format." And they weren't talking. I got them talking.

Dan:
That's awesome. And that's pushback I've heard. I was recently working with a university, a nursing school and that was the pushback about some of these innovative technologies and different ways of teaching team-based learning and stuff. And moving away from the lecture and it was well, our students in their feedback want to hear a lecture and take notes and see the PowerPoint slide. And my response was, why are we letting someone who is not an expert in teaching or learning dictate how we teach and transfer knowledge? We should take that feedback and say, "Okay. Maybe there's something here and dig in with it." But you shouldn't revert back because the user who is not an expert is giving you feedback like that. We should be figuring out ways to engage on both sides and come to understanding of what's expected and what the best practices are to teach.

Lawrence:
I'm shocked that was the result of that survey. Unless the survey design was this, "One question, please check the box if you prefer to learn via lectures, if you leave the box uncheck we will assume that you prefer to learn by check lecture." Because in any survey and in any conversation I've ever had that would be the least chosen of any survey responses.

Dan:
Yeah. I don't know what the validity of the survey was or if it was an excuse. But I mean, I think there is a level and it's... I'd be interested to hear what the students said is I think there's a lot of pre-research that goes into students that go into clinical track education. They go into these student groups, they see what other students are going through. They follow the cohort through and this is how it's going to happen. And this is how you do. And then you get into a new medical school or a new nursing school who is trying something different it's not what you were expecting. There probably is some friction there.

Lawrence:
Sure. And listen, even when medical schools 10 or 15 years ago were being... And I'm using air quotes innovative by digitally recording every lecture and not making attendance mandatory. What they saw was attendance went down, grades went up and the people who went to the lectures were often accessing the digital recordings. Those who didn't go to the lectures were accessing the digital recordings. And by letting the students self determine how they best learn, they had better grades. If you think about it, sometimes the students do know a little bit, or at least they know their own personal learning styles. And I think that's something else Dan, that we may not have paid a lot of attention to. We say, "Listen, we have 110 students in this year's class, and this is what they're going to do.

Lawrence:
And this is how they're going to follow. And this is what they're getting." And we restrict them rather than help them. My current area of interest now is how do we create the master adaptive learner? How do we create the learner that is trained from as early as possible in school? That they need to be continuously thinking about how and where they learn and what they should do and where they should consult them, what they should do as a result of what they learned by looking something up. That's the goal of where we need to shift.

Dan:
Yeah. I think that's definitely an area where we standardized the way this class is going to be taught. And there's very little flexibility and aligning with people's learning needs. As let's say, I'm a healthcare leader in a health system, a hospital setting or acute care ambulatory whatever it is. How do I take what academia is pushing the walls on? And then embedded into a culture so that my practicing clinicians can have that same experience and have a continuous idea of learning?

Lawrence:
That's secret sauce there. And I think you said the right word. I think you said culture, and I think you have to have a culture before you have a strategy. Because there's that saying, that's a culture eats strategy for breakfast, lunch and dinner. But you can have the greatest strategy, but if the environment won't handle it, it's not going to happen. You have to create a culture where learning isn't required but supported. And that lifelong learning on an individual and collective experience is the ideal environment. What do I mean by that? What I mean by that is traditionally we've taught our students and our practicing clinicians separately. It's something you and I have talked about extensively over those toilet bowl size cups of coffee, which is we teach them separately and we expect them to practice together.

Lawrence:
And now in the clinical setting, we have the opportunity to actually do that. When you have that healthcare environment, then you have to say, "Hey, here is a topic where there's an interprofessional team and here's our interprofessional needs assessment." And it may not just be knowledge, but it may be awareness of roles. It may be respective roles. It may be presumption of role in management, whatever it is. And we're going to have these as ongoing classes, courses, whatever lessons in an environment where it's safe, where you're protected because you're using your own data and your own experience as the needs assessment to fuel the education. You have to have a safe space. You have to have a culture that supports the education and you have to have top level buy-in. Because the thing I hear most especially in the interprofessional environment is if there's not only a champion, but top level buy-in people don't do it.

Dan:
Yeah. I agree with that. And I remember back to when I was working at the bedside an ER, they used to have M&Ms around the trauma. But it was all physician driven and the door was closed and no one else was allowed but the physicians. And then ultimately we were able to, "If you want to come, you can be invited." And some nurses would show up and listen, but they were never asked to contribute to the case or anything like that. And then they opened up to pharmacy and they could come in or whatever. And it really created this culture of, "Well, you can come and listen to us, but you're not really going to interact with us." And it's our decision-making that drives how we're going to change and do things differently. Do you have tactics on blowing that up? And maybe some an example where you've seen that interprofessional collaboration and learning happen really well?

Lawrence:
Some of the experiences are most of the experiences that I have in the interprofessional team is from open teams rather than closed teams. Where people were invited to participate in continuing education activities, not within their own institution. And the professions and the teams were actually... We put them together rather than them coming together as teams. And then what happened was we had some really great education. A lot of it was in diabetes where we had primary care physicians. We had endocrinologist, we had diabetes educators, we had nurses and we had pharmacists and we challenged them with problem-based learning. And the beauty of problem-based learning in the CME CPD interprofessional CE world is the faculty don't teach they respond. We deliberately placed all of the professions at each table and we had them work through the cases and then present to us.

Lawrence:
And then the faculty commented and what we heard at the time of the education they loved it. They loved it and they enjoyed it and they enjoyed the interactivity and they had even the faculty had aha moments. And then what we heard in followup was they went back to their own institutions and brought that idea back. That's number one. But number two, you need faculty that are fast style to do the interprofessional teaching. They have to understand what it means to have an interprofessional planning committee, because if we're doing education where you learn from with and about each other, it needs to be planned together. You can't have super nurse Dan putting something together with his expectations of what the team needs to know and then teach the interprofessional team because that doesn't meet the definition. In any of the environments that I've seen at work, it was also because the faculty brought in and were willing to learn how to do it.

Lawrence:
I published a study a couple of years ago on how do you train interprofessional continuing education faculty. And we did a study using role-play. Where we had all of these interprofessional faculty folks come in, deliberately seated them at tables where they were with other professional educators. And we had them take different roles. If they were physician, they had to take any role. We had them pick cards. And we took the physician card out and then they had to pick other rules. And maybe they were a nurse, maybe they were a pharmacist. Maybe they were a patient. Maybe they were patient's family caregiver or something like that. It was phenomenal because you watch them as they had to think deliberately about what that other profession needed to consider in planning education.

Dan:
Yeah. I love that. That was something we talked about with the Kaiser Med School was with these students on day one, before they even develop their professional identity, have them do a skit about the assumptions they have about the other professions. And we were going to take what they did in those skits and then use that as the discussion afterwards to explicitly address. Well, why do you think nurses do that? Or why do you think physicians do that? Or whatever it was. And I think that's a really interesting way to level the playing field and put people there and make it fun, but then also uncover those unconscious bias and then address it right there. Because I think that's one of the fundamental reasons teams fail is they have these assumptions that don't get mad and people get frustrated and then it goes down from there.

Lawrence:
I think that's exactly right. I think that's really interesting, but that's a scary improv thing to do where you never know what someone is going to say.

Dan:
Right. We were scared. I don't think we actually settled on that as the activity, but we did. As faculty planning it, we were having fun about what could happen.

Lawrence:
I know what I would say, and I probably would have enjoyed my first and only day of school.

Dan:
Right. Sorry, Lawrence. We will be escorted you off campus with security.

Lawrence:
Yeah. We're a sensitive organization. We believe in diversity, equity, inclusion, gender roles, et cetera. You failed every letter.

Dan:
Yeah. You failed you're out. That's funny. To switch gears really quickly on this. There's a lot of technologies that have come out to support learning things like osmosis.org, who we interviewed their nursing leader Jannah on a previous episode. And it seems technology is popping up to help support these new insights into learning science and teaching and that stuff. What do you think is the most disruptive tech out there that's really pushing the walls and helping faculty execute on a better way of teaching?

Lawrence:
I know this is going to sound a cop out answer, but any tech that gets employed and used is a disruptive tech and you know I'm right.

Dan:
I know.

Lawrence:
I won't pick just one. I mean, I know the Osmosis folks, but what we're seeing is in many cases tech is simply replacing things that were archaic, but we'd been doing a different way the whole time again. Whether it's an innovation in my definition or a disruption, I think what will be completely disruptive is if we don't need any classroom time. That would be sort of tech and completely replaced. But I think what we're seeing now is more adjuncts and enhancements and embellishments. And that's great because osmosis.org is terrific. And I actually walked up to some of their folks who presented at a conference last year, when you were allowed to leave your home to go to a conference and said that I really thought they were doing great work. But what they're doing is they're simply becoming... Not simply they're elegantly becoming part of some people's personal learning network.

Lawrence:
And that's the disruption. The disruption is students are being encouraged or are figuring out on their own that they can develop their own personal learning network. And whether they learn peer to peer or through mentors or through experts in Twitter or Facebook or... And I know a guy but in Texas, who is a cardiologist. Who is got hundreds of thousands of followers on TikTok. And he does what I considered to be funny, but some people consider to be the most ridiculous little videos but he's making an impact. His shtick is about the low carb lifestyle which I followed for a long time, but he's making it interesting to people. That kind of the disruption is the personal learning network and what people choose to put in it. It's not the individual tech, it's the opportunity to use different technologies together.

Dan:
That personal learning network is an interesting point. I think I haven't really thought about it education that way, but I think technology is allowing us to break out of where we were before, which is books and faculty as your only source of information. And now you can tap people all over the world and videos and different ways of explaining things and really tailor content consumption in the way that works best for your learning style.

Lawrence:
Yeah. It's interesting in... I've been giving a lot of these virtual conference presentations but people getting away on the cheap these days Dan.

Dan:
I know.

Lawrence:
Because they don't you have to get apply anywhere. They don't have to give you an honorarium. They are, "I would grow up to be a part of our thing." A lot of what I've been talking about is that how do you teach better digitally? But also how do you develop better learners? And I've been sprinkling in a lot more about that personal learning network stuff because I think we need to understand the environment of our learners better. And we know that they were doing this uncoordinated without support without encouragement. Now if we encourage them and we provide them with some guidance as good GILFs, then what we're doing is we're helping them. And we're not just telling them. It's like the definition of a mentor. A mentor doesn't give answers. A mentor helps you find the answers. These learning facilitators are really educational mentors throughout the life cycle of a health profession student, learner, practitioner and retiree.

Dan:
Yeah. I mean, I feel like that's freeing as a faculty because you don't have to memorize the heart anatomy anymore and lecture on something that is lectured on at every single school across the entire world. You can leverage resources that do it a million times better. And now your role as an educator and even in the leadership education side, you're now facilitating the connection of context to the population you're in or the group or the organization or whatever it is. And you don't have to bog your mind down with this stuff that is repetitive. And it's been done before.

Lawrence:
We've always taught the what, the how, the where, but what we should be doing is supporting the why. Why do I need to know this? Why does this happen in this patient? Why is this a better choice than another? Why should I be respectful of my team members? It's making them think it's critical thinking skills. If you think of the people who apply to be physicians, apply to the schools, it's often good learners. Because historically had high grades. And I think the shift over the last 20, 25 years is you got to look beyond the grades. And it's not so much that 70% and this person knows 80%, but I know 162%. And you're exactly right. I give a TEDx talk in 2011. What would say about 100 years ago now Dan?

Dan:
Yeah, it was pre-COVID is just a blur. It doesn't..

Lawrence:
Yeah. In there I showed a picture of the Cecil Textbook of Medicine that you would have used if you went to school if you were my age. And I showed that, I found that actual edition on eBay for sale for 5 cents. Seriously, 5 cents. I put up a picture of the ad. And it goes to show you that knowledge changes and what you learned years back may or may not still be relevant, but knowing how and where and why to pursue the information that you need is what you need in a good lifelong learner.

Dan:
Yeah, I agree. And that goes not only for clinical education, but for leadership education as well. But why you're doing something and not throwing something at the wall and seeing what sticks is the essence of how teams work and how leaders can be more effective moving forward as well. I love that. One of the things we like to do here at the end of the show is handoff that nugget of information to our audiences that they should take away and act on tomorrow. What would you like to hand off to our audience?

Lawrence:
Oh well, that's a great question Dan. I'd like to hand off the fact that faculty need to be supportive learning facilitators learners regardless of what stage they are in their educational continuum. Need to be open to learning new things, but really to challenge and ask why it's important, but also be willing to get rid of the educational residue that gunks up their brains and blocks them from doing the right thing from time to time.

Dan:
I love it. The unlearning is the most important piece, which is so cool to talk about when you're talking about learning and teaching. Thank you so much for being on the show. Where can listeners find you? Where do you hang out online?

Lawrence:
Well, professionally you mean?

Dan:
Yes.

Lawrence:
On Twitter I'm @medicate. And if you look up my little consulting company it's Medicaid Global. And we have a nice Facebook presence and a website as well under that moniker.

Dan:
Love it. And so go check out Medicaid. He has some amazing resources and works across the globe in helping people change the way they educate and train the future of healthcare leaders and clinicians. Lawrence, thanks so much for being on the show I really appreciate it. And hopefully we can continue to disrupt healthcare education and bring it into the 21st century.

Lawrence:
Yeah. And remember, we still have plans to do something together beyond a podcast.

Dan:
That's right. And whenever this pandemic goes away, we can educate people to do the right thing and make this go away. We will make that happen.

Lawrence:
What? There's a pandemic?

Dan:
Oh yeah. I forgot.

Lawrence:
I got it from the news.

Dan:
All right, everyone. Thanks for joining. And we'll talk to you next time on the handoffs.

Thank you and welcome to the Trusted Community!
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