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Exploring and Embracing Complexity in a Distance - learning


									                                                        S   P E C I A L       T   H E M E   A   R T I C L E

                   Exploring and Embracing Complexity in a
                   Distance-learning Curriculum for Physicians
                          Greg Ogrinc, MD, MS, Mark E. Splaine, MD, MS, Tina Foster, MD, MPH, MS,
                                     Martha Regan-Smith, MD, EdD, and Paul Batalden, MD


      The recent pressures on clinical medicine such as the                           journey from a classroom-based curriculum to an IV-based
      attention to medical error and the challenges of in-                            curriculum, the authors and others involved in the
      terdisciplinary care have also exerted pressure on health                       program learned the basic tenets of IV sessions, redefined
      professions education. Educators must now gauge how to                          the roles of the teachers and learners, and discovered an
      redesign education systems to adapt quickly to these                            IV environment that functions as a complex adaptive
      disruptions. Sometimes disruptions can be self-inflicted,                        learning system. This distance-learning curriculum can be
      such as the VA National Quality Scholars Fellowship’s                           a model for other health professions education, since it
      decision to use interactive video (IV) as its primary                           starts with simple rules, changes from within, has
      medium for delivering the curriculum to its six sites                           a tolerance for unpredictability, and continually moves
      around the nation. The authors describe how this                                forward and transforms itself despite tension.
      disruption to their education system helped to fashion                             Acad. Med. 2003;78:280–285.
      a learning environment that is adaptable. Along the

     n this article, we describe a fellowship-training program                        evolution of a learning environment. Finally, we discuss the
     in which the introduction of technology caused                                   roles of the teacher and the learner in this new environment
     a disruption in the learning environment. We review                              and the implication of these roles for future health
     how understanding technology can lead to effective                               professions education.
curricular design and how viewing the learning environment
as a complex adaptive system offers new insights into the                                                     B ACKGROUND

                                                                                      Health professions education faces many forces that threaten
      Dr. Ogrinc is the VA Undersecretary’s Special Fellow in Quality, White River
      Junction VA Medical Center, White River Junction, Vermont, and assistant
                                                                                      the current roles of health professions educators. Some of
      professor of community and family medicine and of medicine, Dartmouth           these disruptive forces are the current structuring and
      Medical School (DMS), Hanover, New Hampshire; Dr. Splaine is assistant          restructuring of health care, the challenges of defining
      professor of medicine and community and family medicine, DMS; co-director,
      VA National Quality Scholars Fellowship Program, DMS; and senior scientist
                                                                                      quality, and the attention to patient safety and medical
      for measurement and statistics, Dartmouth–Hitchcock Medical Center,             error.1,2 These have raised important questions about
      Lebanon, Lebanon, New Hampshire; Dr. Foster is assistant professor of           whether learners are prepared to understand and function
      obstetrics and gynecology, DMS; Dr. Regan-Smith is professor of medicine
      and community and family medicine, DMS; and Dr. Batalden is professor of
                                                                                      in this new clinical and educational environment.3,4 In
      pediatrics and community and family medicine, and director, Health Care         addition, health professions educators are pressured to
      Improvement Leadership Development, DMS.                                        increase both clinical and academic productivity, address
      The opinions and findings contained herein are those of the authors and do not   the evolving interdisciplinary nature of care, find resources
      necessarily represent the opinions or policies of the Department of Veterans    for teaching, and use new technologies in their teaching.5,6
      Affairs, the Dartmouth Medical School, or the Dartmouth–Hitchcock Medical
                                                                                         Understanding health care as a system composed of inter-
                                                                                      acting processes has been a useful concept for those seeking
      Correspondence should be addressed to Dr. Ogrinc, White River Junction VA
      Hospital, 11Q, 215 North Main Street, White River Junction, VT 05009;           to improve the quality and value of health care.7 This work
      e-mail: hgreg.ogrinc@dartmouth.edui.                                            has focused on the link between process and outcomes and

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                               COMPLEXITY    IN   DISTANCE-BASED CURRICULUM,     CONTINUED

the need to understand each in order to improve the value      n   Recognizing the IV sessions as a complex adaptive system
of care. This model has also been used to describe the dif-        (CAS) as a method to improve the curriculum
ferent stakeholders in health professions education and the
importance of demonstrating the value of education to these        We describe these transformations below.
stakeholders.8 However, little has been written about the
potential implications of viewing health professions educa-
                                                               Adapting a Classroom-based Curriculum
tion as a system, much less about how an educational system
can respond effectively when provoked by external pressures.
                                                               The common curriculum in the VAQS programs was based
                                                               on an existing curriculum in the master’s degree program at
                                                               the Center for the Evaluative Clinical Sciences at Dartmouth
                                                               Medical School. The first challenge was to adapt three
                                                               courses providing approximately 140 contact hours in a
The experience of the VA National Quality Scholars
                                                               classroom setting to become IV courses totaling 50 contact
(VAQS) fellowship program, discussed below, provides an
                                                               hours. The curriculum was designed using the domains of
example of how an educational program redesigned itself to
                                                               knowledge for the improvement of health care published by
adapt to a disruption and to fashion an adaptable learning
                                                               the Institute for Healthcare Improvement—see Table 1.10
environment. The program began in 1998 as a two-year
                                                               These domains formed the core learning objectives for the
postgraduate fellowship program for physicians. A detailed
                                                               fellowship in the common curriculum.
description of the VAQS program has recently been
                                                                  The fellowship is a two-year program, with new fellows
published.9 In brief, the VAQS program creates a context
                                                               being admitted each year, so repetition of topics was
for scholarly study to foster:
                                                               necessary. Even though certain topics in the sequence were
                                                               repeated each year, the readings, exercises, examples, and
n   application of the knowledge and methods of health care
                                                               what is taught about the topic vary from year to year. For
    improvement to the care of veterans,
                                                               example, one early session each academic year is focused on
n   education of health professionals about health care
                                                               understanding change concepts (see Table 1, domain no. 4).
    improvement, and
                                                               The readings and pre-work assignments are new each year so
n   research and development of new knowledge about the
                                                               that the same topic can be approached from a different angle.
    improvement of the quality and value of health care
                                                                  As teaching moves from face-to-face interaction to IV,
                                                               some content of the communication is lost, resulting in
                                                               decreased richness of the message. This causes a disruption
   The program is centered at Dartmouth Medical School in
                                                               in the learning process. Sometimes this disruption can be
Hanover, New Hampshire, in partnership with the VA Office
                                                               helpful if it is recognized as a provocation that fosters action,
of Academic Affiliations in Washington, DC. There are six
                                                               provides a sense of direction, encourages checking and up-
sites in different geographic locations across the United
                                                               dating about the actual situation, and facilitates respectful
States (Birmingham, Alabama, Cleveland, Ohio, Iowa City,
                                                               interaction during any clarification.11 In our case, simple
Iowa, Nashville, Tennessee, San Francisco, California, White
                                                               adaptation of classroom lectures was insufficient; the IV
River Junction, Vermont); each site is located at a VA
                                                               technology demanded that learning sessions be updated and
medical center partnered with a university. Sites function
                                                               modified to fit the medium and the experiences of both
independently and each is led by a Senior Scholar, an ac-
                                                               teachers and learners using the new medium.
complished academic physician. Learning in the program is
a combination of local and common experiences. The faculty
at Dartmouth Medical School coordinate common learning         Improving Learning during the IV Sessions
activities. The example discussed here focuses on the de-
velopment of the VAQS program’s common learning expe-          The IV sessions are formatted in two-hour blocks to max-
rience and the lessons learned during that process.            imize the time available to deliver content while minimiz-
   The VAQS program’s common curriculum has had the            ing the fatigue of learners due to the television medium.
following significant transformations:                          Certain elements are built into each session. First, before
                                                               each session there are preparatory readings. Second, there
n   Adapting a classroom-based curriculum to be an             is a lecture component to introduce the topic. Third, learners
    interactive video (IV) curriculum                          present some aspect of their work. Finally, one of the Senior
n   Improving the learning during the IV sessions              Scholars presents a structured summary about the main
n   Helping teachers and learners evolve their roles for IV    ‘‘take-home points’’ from each session. The way these
    sessions                                                   elements are built into individual sessions may differ from

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                                           COMPLEXITY          IN   DISTANCE-BASED CURRICULUM,                     CONTINUED

Table 1

  Eight Knowledge Domains for the Improvement of Health Care*

                              Domain                                                                                   Description
  1. Customer/beneficiary knowledge                                           Identification of the needs and preferences of the person, persons, or groups for whom
                                                                               health care is provided
                                                                             The relationship of the health care provided to those needs and preferences
  2. Health care as process, system                                          The interdependent people procedures, activities, and technologies of health care that
                                                                               come together to meet the need(s) of individuals and communities
  3. Variation and measurement                                               The use of measurement to understand the variation of performance in processes and
                                                                               systems of work
  4. Leading, following, and making changes in health care                   The general and strategic management of people and the health care work they do
                                                                               (financing, information technology, daily care-giving)
  5. Collaboration                                                           The knowledge, methods, and skills needed to work effectively in groups; the valuing of
                                                                               the perspectives and responsibilities of others
  6. Developing new, locally useful knowledge                                The recognition of the need for new knowledge and the skill to develop knowledge
                                                                               through empiric testing
  7. Social context and accountability                                       An understanding of the social context and the financial impact of health care
  8. Professional subject matter                                             The ability to apply professional knowledge and connect it to all of the above
                                                                             Integration of knowledge with core competencies published by professional boards,
                                                                                accrediting organizations, and certifying entities
  *These domains, which formed the core learning objectives of the fellowship discussed in this article, were published by the Institute for Healthcare Improvement.10

session to session; however, it soon became apparent that the                              versus face-to-face lectures, IV subjects perceived the
IV medium created disruptions in each session.                                             medium as ‘‘annoying [and] distracting.’’16 Guidelines for
   For example, the lecture component was designed to                                      IV use in distance learning for health professionals have
provide highlights of the material and to integrate ideas from                             addressed some of these challenges (see List 1).14,15
the readings. Feedback from participants in free-form e-mails                                 Attention to these basic rules of IV is a necessary first step
made it clear that an hour-long lecture in an IV format                                    when adapting a distance learning curriculum from a tradi-
made it difficult to maintain concentration, no matter                                      tional classroom curriculum. However, even though these
how interesting the material. Thus, lecture elements were                                  guidelines provided initial direction for the VAQS program’s
redesigned as multiple segments, each lasting no more than                                 IV sessions, the continued disruptive nature of IV as a
10–15 minutes. Also, presentations from fellows initially                                  teaching and learning medium demanded the continual up-
occurred from all six fellowship sites at each IV session. This                            dating of the IV sessions.
was time-consuming, and learners sometimes lost interest,
especially when the presentations covered similar material.
Revising the schedule to only two or three presentations with                              Helping Teachers and Learners Evolve
structured critique by fellows from other sites brought more                               Their IV-session Roles
interaction and made more time available for discussion.
   Similar kinds of technologic disruptions in distance                                    Senior Scholars at the individual sites frequently participated
learning are reflected in literature from resident training,                                in the IV sessions. Initially, they shared comments or
nursing, and allied health professions education, where the                                observations whenever they wished. However, there was
use of distance-learning technologies is more advanced than                                great variation in the degrees of participation, ranging from
in medical education.12–15 Distance learning refers to the                                 a few words to waxing eloquent for 10–15 minutes. The
situation in which learners receive instruction at a site that is                          timing often interfered with other planned elements of the
physically separate from the teacher. While this technology                                session, as long commentaries do not suit the IV medium
brings great promise, it has presented many challenges for                                 (List 1).14,15 Assigning specific roles and times for reviewing
health professions educators.15 Even though Lewis et al.                                   aspects of the session to those faculty who were present
demonstrated equal learning of content by residents in IV                                  helped to organize this part of the IV session.

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                                      COMPLEXITY       IN   DISTANCE-BASED CURRICULUM,     CONTINUED

List 1                                                                   Continually Improving the IV Sessions

  Simple Rules for Teaching with Interactive Video14,15
                                                                         While these modifications were helpful in engaging the
                                                                         learners, they were insufficient to promote further evolution
  Tips for success                                                       of the curriculum and learning environment. After these
     Train instructors how to use the equipment                          initial planned changes were instituted, other unplanned
     Be interactive                                                      changes began to occur. As these took hold, it emerged that
     Speak in a usual volume level                                       the IV sessions were behaving as a complex adaptive system.
     Look into the camera when you speak
                                                                            A complex adaptive system (CAS) is ‘‘a collection of
     Be cognizant of the delay in video and audio transmission
     Allow learners to be teachers to the group
                                                                         individual agents who have the freedom to act in ways that
                                                                         are not always predictable and whose actions are intercon-
  Pitfalls to avoid                                                      nected such that one agent’s actions change the context for
     Extra noises and movements, which should be kept to a minimum
                                                                         the other agents.’’7,19–22 Small groups also often behave as
     Long periods (.10 minutes) of one type of presentation by the
        same individual (e.g., lectures)
                                                                         complex systems23 and the VAQS program’s IV session was
     Allowing only the teachers to present material                      a unique, small learning-group with its members connected
                                                                         through technology. Complexity concepts that are applicable
                                                                         to education include the importance of a ‘‘flexible and
                                                                         evolving content’’ that is ‘‘driven by needs’’ and results in
                                                                         ‘‘dynamic and emergent personal learning.’’22 Key properties
   Even with these efforts, learners still reported that the             of CAS and examples from the VAQS programs’ IV sessions
experience was too passive. The introduction of ‘‘real-time’’            are shown in Table 2. The VAQS programs’ IV sessions take
exercises to stimulate learners’ thinking and interaction with           advantage of these properties through regular feedback and
the material helped make learning more active. Allowing                  the creativity that comes from the diversity of the sites.
learners to go ‘‘off-line’’ (i.e., mute the video and audio and             Feedback is one of the simple rules and adaptable elements
discuss a topic at their local site) for a few minutes and then          that is part of the IV sessions (Table 2, property 1). A certain
prepare responses to specific questions helped to break up the            amount of trust is needed for learners to offer feedback—they
time and reinvigorate the discussion. This ‘‘off-line’’ time             must know that it is safe to offer and that it will be used in an
helped learners become more invested in the discussion. In               appropriate manner. In addition to the IV curriculum, the
many ways, the learners began to take on the teachers’ role.             VAQS program participants meet face-to-face three times
   The evolution of the roles of the teacher and learner in              per academic year. After the face-to-face meetings (in
the IV sessions (i.e., de-emphasizing the Senior Scholar’s               August, December, and February of each academic year),
contribution and facilitating fellows’ input) can be considered          we have observed more active participation in the IV
a leverage point for enhancing the IV educational experi-                sessions. Feedback is an expected and powerful part of the
ence. The teacher becomes a facilitator rather than the                  learners’ role. They are invested in the educational process
explicit director of the learning. The teacher relies on much            and clearly see the benefit of offering insights and ideas about
of the teaching to come from learners in their preparation               how to improve. It is one example how the IV sessions have
and discussions. Likewise, learners in this setting must take            become adaptable and evolve to meet the learners’ needs.22
an active role in the discussion. Learner preparation must be               As each fellowship site has its own local culture, personnel,
detailed and may require research from one session to the                and resources, it is imperative to take advantage of this
next. This active learning may extend beyond the original                diversity (e.g., the Cleveland site is different from the
scope of a case and often requires integration from other                Nashville site). The diversity of sites means that outcomes
areas.17,18                                                              are not predictable in detail, but the learning system and
   The VAQS programs’ IV sessions are topic-based, and                   interactions must be observed to be understood (Table 2,
several different strategies are used, including readings, case          property 5). This interplay of the different local contexts helps
presentations, lecture segments, real-time exercises, active             to enhance the IV sessions. For example, all the fellows at the
critiques, and summaries of others’ work. This creates                   White River Junction, Vermont, site complete master’s-level
a challenge in preparing for an IV session, as the teacher               courses in quality improvement; but the fellows at the San
must consider which learning strategy to build into the                  Francisco site focus more on research methods and data
experience. Since many of these methods are interactive,                 analysis. This disparity in local experience creates some
learners must prepare in advance and be ready to engage in               tension within the program (quality improvement projects
the learning. Learners develop skills in critiquing and                  versus rigorous research method) but is a strength of the
distilling the content of what they have learned, benefiting              program. It creates a cadre of internal consultants who critique
the individual and the group of teachers and learners.                   projects and presentations from different points of view. This

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                                          COMPLEXITY           IN   DISTANCE-BASED CURRICULUM,          CONTINUED

Table 2

  Key Properties of Complex Adaptive Systems Linked to Examples from the VAQS Program’s Interactive Video Experience7,19–22*

          Property                                    Description                                     Example from VAQS IV Sessions
  1. Adaptable elements               - Elements can change themselves          - Feedback occurs for every session; there is explicit commitment to
                                      - Change occurs from within                 respond to it in a constructive fashion and change content and process as
                                                                                - Participants are committed to the educational process and willing to try
                                                                                  new approaches

  2. Simple rules                     - Provide guidance for action             - Explicit, simple ground rules for participants, e.g., keep the space open for
                                      - Detailed behaviors arise from             exploration, no stealing, have fun, share time management, honestly talk
                                        interactions within the system            about what is going on, practice listening and dialogue rather than telling
                                                                                  and discussion, work from differences you discover, build on others’ ideas.
                                                                                - Informal rules for session structure and process, e.g., keep presentations
                                                                                  less than 15 minutes in length; assign pre-readings for every session; have
                                                                                  at least two sites report on a given topic, with commentary by fellows from
                                                                                  another site; faculty member or second year fellow comments on ‘‘What
                                                                                  haven’t we figured out yet?’’ at end of every session.

  3. Non-linearity                    - Small changes may have big              - Going ‘‘offline’’ for 3–5 minutes greatly enhanced IV discussions
                                        effects while large changes             - Changing the format to have a designated Senior Scholar comment each
                                        may have small effects                    week had relatively little impact

  4. Novelty                          - Continual creativity                    - Roles of teachers and learners are often interchangeable
                                                                                - Participants are encouraged to bring new ideas and interests to the
                                                                                  session, which may develop into themes or become part of the curriculum
                                                                                  (e.g., one Senior Scholar’s interest in and study of the theory of
                                                                                  constraints has added new depth to the material and discussions).

  5. Not predictable                  - Forecasting is inexact                  - Discussions and agenda may be adjusted to follow themes that emerge.
     in detail                        - Must observe a system to                - Approach to a given topic changes from year to year based on
                                        understand it                             observations of past sessions and needs of participants in the current

  6. Inherent order                   - System is orderly, even                 - Each IV session has 3–4 predictable elements (e.g., revisit muddy points
                                        without central control                   from previous session, lecture material, reports from Fellows on their work
                                      - Order emerges with                        with commentary by Fellows at other sites).
                                        parameters and simple rules             - Order and emphasis change with each session (e.g., in one session,
                                                                                  discussion may focus on Fellows’ ‘‘reports,’’ while in another a particular
                                                                                  concept or challenge related to Fellows’ ongoing projects may be the

  7. Context and                      - Context and interrelationships          - Fellows and Senior Scholars have defined roles and clear expectations of
     embeddedness                       among the parts matter                    what is required to prepare for each session, although these may be
                                        in fundamental ways                       slightly different depending on the particular site.
                                                                                - Conscious attempts are made to highlight contextual issues at the various
                                                                                  sites that affect the fellows’ experiences and understanding of the material.

  8. Co-evolution                     - Moves forward through                   - Differences in the expertise and focus at each site may cause tension but
                                        constant tension, uncertainty,            enhance richness of the discussions.
                                        paradox, and anxiety                    - Senior Scholars, program faculty, and fellows all participate in an ongoing
                                                                                  process of evaluation of the program content and curriculum; regular
                                                                                  contact in addition to the IV sessions helps this evolution.
                                                                                - Tension, uncertainty, and paradox are called out in the sessions and
  *VA National Quality Scholars fellowship program.

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                                  COMPLEXITY     IN   DISTANCE-BASED CURRICULUM,           CONTINUED

diversity spawns creativity in project design and analysis and       and adapted to the IV, can be a model for future health
strengthens the overall products (Table 2, property 7).21            professions education.
   These properties have helped us recognize that we have
created a complex adaptive learning environment. When                                               R EFERENCES
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