VIEWS: 7 PAGES: 6 POSTED ON: 12/3/2011
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 ABSTRACT 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 I 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 Center. 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: firstname.lastname@example.org. has focused on the link between process and outcomes and 280 ACADEMIC MEDICINE, VOL. 78, NO. 3 / MARCH 2003 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 ONE E XPERIENCE OF E XPLORING the Center for the Evaluative Clinical Sciences at Dartmouth AND E MBRACING C OMPLEXITY 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, services. 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 ACADEMIC MEDICINE, VOL. 78, NO. 3 / MARCH 2003 281 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. 282 ACADEMIC MEDICINE, VOL. 78, NO. 3 / MARCH 2003 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 ACADEMIC MEDICINE, VOL. 78, NO. 3 / MARCH 2003 283 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 needed - 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 session. 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 focus). 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 explored. *VA National Quality Scholars fellowship program. 284 ACADEMIC MEDICINE, VOL. 78, NO. 3 / MARCH 2003 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 the VAQS programs’ IV experience was considered in light of 1. Kohn L, Corrigan J, Donaldson M (eds). To Err is Human: Building a Safer knowledge about complexity, new ways to respond to perceived Health System. Washington, DC: National Academy Press, 2000. challenges emerged. Accepting, indeed embracing, the need 2. Briere R (ed). Crossing the Quality Chasm: A New Health System for for ongoing change and evolution, respecting learners as the 21st Century. Washington, DC: National Academy Press, 2001. creative decision makers, and continuing to assess context and 3. Halpern R, Lee M, Boulter P, Phillips R. A synthesis of nine major interrelationships enhance the experience for all. This requires reports on physicians’ competencies for the emerging practice environ- ment. Acad Med. 2001;76:606–15. a tolerance for uncertainty as well as for failed experiments that 4. Rabinowitz H, Babbott D, Bastacky S, et al. Innovative approaches to nevertheless moved us forward. Thinking about the IV as educating medical students for practice in a changing health care envi- a complex adaptive learning system suggests other avenues for ronment: The National UME-21 Project. Acad Med. 2001;76:587–97. continued improvement of the program, such as examining 5. Headrick L, Knapp M, Neuhauser D, et al. Working from upstream to patterns of behavior to understand attractors and using these improve health care: The IHI Interdisciplinary Professional Education Collaborative. Joint Comm J Qual Improv. 1996;22:149–64. attractors to effect meaningful change and improvement. 6. Asprey D, Zollo S, Kienzle M. Implementation and evaluation of a telemedicine course for physician assistants. Acad Med. 2001;76:652–5. D ISCUSSION 7. Wilson T, Holt T. Complexity and clinical care. BMJ. 2001;323:685–8. 8. Ogrinc G, Headrick L, J B. Understanding the value added to clinical In this article we have shown how the VA Quality Scholars care by educational activities. Acad Med. 1999;74:1080–6. 9. Splaine M, Aron D, Dittus R, et al. A curriculum for training quality (VAQS) fellowship program has developed a novel curric- scholars to improve the health and health care of veterans and the com- ulum, delivered by IV, that functions as a complex adaptive munity at large. Quality Management in Health Care. 2002;10(3):10–8. learning system using simple rules, adaptable feedback, and 10. Batalden P, Berwick D, Bisognano M, Splaine M, Baker G, Headrick L. creativity to guide its evolution. By adapting a classroom- Knowledge Domains for Health Professional Students Seeking Compe- based curriculum, improving the IV sessions, and redeﬁning tency in the Continual Improvement and Innovation of Health Care. Boston, MA: Institute for Healthcare Improvement, 1998. the roles of the teachers and learners, the IV sessions have 11. Weick K. Emergent change as a universal in organizations. In: Beer M, become an exciting educational experience. Nohria N (eds). Breaking the Code of Change. Boston, MA: Harvard We recognize that this case study is limited by several Business School Press, 2000:223–41. factors. Although the VA trains a signiﬁcant percentage of 12. Fetzer S. A pilot study to investigate the impact of interactional television on student evaluation of faculty effectiveness. J Nurs Educ. 2000;39:91–3. health professionals in this country, the generalizability of 13. Walker EA. Characteristics of the adult learner. Diabetes Educator. this report may be limited. All the teachers and learners bring 1999;25(6 suppl):16–24. pre-existing interests in the material and an openness to 14. Ware S, Olesinski R, Cole C, Pray M. Teaching at a distance using change. They are highly motivated individuals, so the prin- interactive video. J Allied Health. 1998;27(3):137–41. ciples outlined above might be more difﬁcult to apply if the 15. Chandler G, Hanrahan P. Teaching using interactive video: creating learning were mandatory. It is also important to note that connections. J Nurs Educ. 2000;39:73–80. 16. Lewis Y, Bredfeldt R, Strode S, D’Arezzo K. Changes in residents’ scheduled face-to-face meetings (three times per academic attitudes and achievement after distance learning via two-way inter- year) are a vital part of the VAQS program’s curriculum; active video. Fam Med. 1998;30:497–500. these opportunities ‘‘widen the bandwidth,’’ allowing people 17. Nandi PL, Chan JN, Chan CP, Chan P, Chan LP. Undergraduate to directly understand the nuances, humor, and personalities medical education: comparison of problem-based learning and conven- seen on the IV sessions, which in turn enrich later IV tional teaching. Hong Kong Med J. 2000;6:301–6. 18. Sweeney G. The challenge for basic science education in problem-based sessions. Finally, if the curriculum had not been set at the medical curricula. Clinical and Investigative Medicine—Medecine beginning, perhaps the early struggles with the technology Clinique et Experimentale. 1999;22(1):15–22. would have been easier to overcome, as we would not have 19. Plsek P. Redesigning healthcare with insights from the science of been tied to a previous model. complex adaptive systems. In: Briere R (ed). Crossing the Quality Chasm: A New Health System for the 21st Century. 1st ed. Washington, The VAQS fellowship program has embraced the disrup- DC: National Academy Press, 2001:309–17. tive nature of the IV technology and used it to develop 20. Plsek P, Greenhalph T. The challenge of complexity in health care. BMJ. a complex adaptive learning environment. This requires the 2001;323:625–8. ability to change from within, the willingness to develop (and 21. Plsek P, Wilson T. Complexity, leadership, and management in health- follow) simple rules, a tolerance for unpredictability, and the care organisations. BMJ. 2001;323:746–9. ability to move forward despite tension.19,20 22. Fraser S, Greenhalph T. Coping with complexity: educating for capability. BMJ. 2001;323:799–803. The transformation of our small learning group over the 23. Arrow H, McGrath J, Berdahl J. Small Groups as Complex Systems: course of multiple IV sessions is a unique, continuing ex- Formation, Coordination, Development, and Adaptation. 1st ed. Thou- perience. Perhaps this small learning system, disrupted by sand Oaks, CA: Sage, 2000. ACADEMIC MEDICINE, VOL. 78, NO. 3 / MARCH 2003 285
"Exploring and Embracing Complexity in a Distance - learning "