Cognitive Approaches to Training

Best article on using new learning and teaching styles

and

What we can learn from Cog Psych for Education in Medicine

find your learning style

http://www.metamath.com/lsweb/dvclearn.htm

Chest had an entire supplement to what works in CME education (Chest 2009;135 supplement editorial p. 834 of main issue)

Debriefing

Best article on debriefing with good judgment

Crew Resource Management

Key elements of good CRM behaviour taught in CRM courses by Lighthall et al.12Know your team and environment Anticipate and plan Allocate attention wisely Use all available information and cross-check it Use cognitive aids (e.g., checklists, reference materials) Take a leadership role Call for help early Communicate effectively Distribute the workload Mobilise and use all available resources Go to source: ScienceDirect – Resuscitation : Six steps from head to hand: A simulator based transfer oriented psychological training to improve patient safety

Simulator to teach CRM (Resuscitation 2007 Muller MP Six Steps from head to Hand)

Physicians are very bad at rating their competence compared to external ratings (JAMA 2006;296:1094-1102)

Motor Skills

(NEJM Volume 355:2664-2669 December 21, 2006)

teaching procedural skills

These new training techniques are based on established theories of the ways in which motor skills are acquired and expertise is developed. Fitts and Posner’s three-stage theory of motor skill acquisition is widely accepted in both the motor skills literature and the surgical literature ( Table 1). 11, 12

Cognitive Stage In the cognitive stage, the learner intellectualizes the task; performance is erratic, and the procedure is carried out in distinct steps. For example, with a surgical skill as simple as tying a knot, in the cognitive stage the learner must understand the mechanics of the skill how to hold the tie, how to place the throws, and how to move the hands.

Integrative stage With practice and feedback, the learner reaches the integrative stage, in which knowledge is translated into appropriate motor behavior. The learner is still thinking about how to move the hands and hold the tie but is able to execute the task more fluidly, with fewer interruptions.

Autonomous stage In the autonomous stage, practice gradually results in smooth performance. The learner no longer needs to think about how to execute this particular task and can concentrate on other aspects of the procedure.

Ericsson has helped to elucidate the acquisition of expertise. 13, 14 Expert performance represents the highest level of skill acquisition and the final result of a gradual improvement in performance through extended experience in a given domain. According to Ericsson, most professionals reach a stable, average level of performance and maintain this status for the rest of their careers. In surgery, “experts” have been defined by Ericsson as experienced surgeons with consistently better outcomes than nonexperts. An extensive literature on the relationship of operative volume to clinical outcomes supports the hypothesis that practice is an important determinant of outcome 15; the literature also provides support for Ericsson’s contention that many professionals probably do not attain true expertise. However, volume alone does not account for the skill level among practitioners, since variations in performance have been shown among surgeons with high and very high volumes. Deliberate practice is a critical process for the development of mastery or expertise. Ericsson argues that the number of hours spent in deliberate practice, rather than just hours spent in surgery, is an important determinant of the level of expertise. 13 Deliberate practice calls for the individual to focus on a defined task, typically identified by a teacher, to improve particular aspects of performance; it involves repeated practice along with coaching and immediate feedback on performance. The attained level of expertise has been shown to be closely related to time devoted to deliberate practice in the performance of expert musicians, chess players, and athletes. In the current model of surgical training, based primarily on apprenticeship, the opportunities for deliberate practice are rare. Operations are complex, and it is difficult to focus on one small component of the procedure. In our opinion, in order to better plan instruction and assess the efficacy of curricular interventions, valid and reliable assessments of technical skills are needed. Evaluating performance in the operating room is difficult, 16 and most efforts have focused on techniques that standardize the assessment process outside the operating room. One such method is the Objective Structured Assessment of Technical Skills (OSATS), 17, 18 in which candidates perform a series of standardized surgical tasks on inanimate models under the direct observation of an expert. Examiners score candidates using two methods. The first is a task-specific checklist consisting of 10 to 30 specific surgical maneuvers that have been deemed essential elements of the procedure. The second is a global rating form, which includes five to eight surgical behaviors, such as respect for tissues, economy of motion, and appropriate use of assistants. The validity and reliability of the OSATS are similar to those of the more traditional Objective Structured Clinical Examination (OSCE) and are acceptable for summative high-stakes evaluation purposes. 19, 20,21 To date, we have created more than 40 OSATS stations; some examples are shown in Figure 1.

Deliberate Performance vs. Deliberate Practice

A review article from Klein (deliberate performance by Fadde and Klein)

Team Stepps

Resident and Medical Student Development

Applicants guide to EM Residencies (Annals EM 19:7, July 1990)

Global assessment of undergrads (Acad Emerg Med Sep 2002, 9:9, p.889)

Structured Scoring of EM Interviews (Acad Emerg Med January 2004, Vol. 11, No. 1)

An Educator’s Guide to Teaching Emergency Medicine to Medical Students (Academic Emergency Medicine Volume 11, Number 3 300-306)

Academic Emergency Medicine Volume 12, Number 6 559-561, Emergency Medicine Residency Selection: Factors Influencing Candidate Decisions

Residents having difficulties: consider non-clinical factors–Blues, birds/blokes, banks, babies, booze, bilingual background. (MJA 2005;183(9):475)

ACES curriculum Art, Chaos, Ethics and Science (Ann Emerg Med 2006;48:532)

Core Competencies

ACGME core competencies. Numbers correspond to ACGME core competency bulleted descriptors in order as listed on the ACGME Web site at http://www.acgme.net/outcome/comp/compfull.asp.

Patient care

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

1. Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families
2. Gather essential and accurate information about their patients
3. Make informed decisions about diagnostic and therapeutic interventions according to patient information and preferences, up-to-date scientific evidence, and clinical judgment
4. Develop and carry out patient treatment plans
5. Counsel and educate patients and their families
6. Use information technology to support patient care decisions and patient education
7. Perform competently all medical and invasive procedures considered essential for the area of practice
8. Provide health care services aimed at preventing health problems or maintaining health
9. Work with health care professionals, including those from other disciplines, to provide patient-focused care

Medical knowledge

Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (eg, epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to:

1. Demonstrate an investigatory and analytic thinking approach to clinical situations
2. Know and apply the basic and clinically supportive sciences that are appropriate to their discipline

Practice-based learning and improvement

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:

1. Analyze practice experience and perform practice-based improvement activities using a systematic methodology
2. Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
3. Obtain and use information about their own population of patients and the larger population from which their patients are drawn
4. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
5. Use information technology to manage information, access online medical information, and support their own education
6. Facilitate the learning of students and other health care professionals

Interpersonal and communication skills

Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients’ families, and professional associates. Residents are expected to:

1. Create and sustain a therapeutic and ethically sound relationship with patients
2. Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills
3. Work effectively with others as a member or leader of a health care team or other professional group

Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:

1. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and ongoing professional development
2. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices
3. Demonstrate sensitivity and responsiveness to patients’ culture, age, sex, and disabilities

Systems-based practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:

1. Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice
2. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
3. Practice cost-effective health care and resource allocation that does not compromise quality of care
4. Advocate for quality patient care and assist patients in dealing with system complexities
5. Know how to work with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

1. Patient Care: Emergency physicians practice patient care that is timely, effective, appropriate, and compassionate for the management of health problems and the promotion of health. Specific objectives are as follows:

a Gather accurate, essential information in a timely manner from all sources, including medical interviews, physical examinations, prehospital care personnel, medical records, and diagnostic and therapeutic procedures (1,2)
b Integrate diagnostic information and generate an appropriate differential diagnosis (3)
c Implement an effective patient management plan including therapy, appropriate consultation, disposition, and patient education (4,5,6)
d Competently perform the diagnostic and therapeutic procedures and emergency stabilization considered essential to the practice of emergency medicine (7)
e Demonstrate the ability to appropriately prioritize and stabilize multiple patients and perform other responsibilities simultaneously (8,9)
f Provide health care services aimed at preventing health problems or maintaining health (8)
g Work with health care professionals, including those from other disciplines, to provide patient-focused care (9)

2. Medical Knowledge: The Model of Clinical Practice of Emergency Medicine defines the medical knowledge base for emergency medicine. Emergency physicians formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to use available medical resources effectively and concurrent with patient care, and apply this knowledge to critical problem solving and clinical decisionmaking (1,2). Specific objectives:

a Identify life-threatening conditions
b Identify the most likely diagnosis
c Synthesize acquired patient data
d Identify how and when to access current medical information
e Properly sequence critical actions in patient care
f Generate a differential diagnosis for an undifferentiated patient
g Complete disposition of patients using available resources

3. Practice-Based Learning and Improvement: Emergency physicians evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Specific objectives are as follows:

a Analyze and assess their practice experience and perform practice-based improvement using systematic methodology (1)
b Locate, appraise, and use scientific evidence related to their patient’s health problems and the larger population from which the patient is drawn (2,3)
c Apply knowledge of study design and statistical methods to critically appraise the medical literature (4)
d Use information technology to enhance their education and improve patient care (5)
e Facilitate the learning of students, colleagues, and other health care professionals in emergency medicine principles and practice (6)

4. Interpersonal and Communication Skills: Emergency physicians have excellent interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and professional associates. Specific objectives include the following:

a Demonstrate the ability to respectfully, effectively, and efficiently develop a therapeutic relationship with patients and their families (1)
b Demonstrate respect for diversity, cultural, ethnic, spiritual, emotional, and age-specific differences in patients and other members of the health care team (1)
c Demonstrate effective listening skills and be able to elicit and provide information using verbal, nonverbal, written, and technological skills (2)
d Demonstrate ability to develop flexible communication strategies and be able to adjust them according to the clinical situation (2)
e Demonstrate effective participation in and leadership of the health care team (3)
f Demonstrate ability to elicit a patient’s motivation in seeking health care (2)
g Demonstrate ability to negotiate and resolve conflicts (3)
h Demonstrate effective written communication skills with other providers and ability to effectively summarize for the patient on discharge (2)
i Demonstrate ability to effectively use the feedback provided by others (2)
j Demonstrate ability to handle situations unique to emergency medicine (3)

Intoxicated patients
Altered mental status
Delivering bad news
Difficulties with consultants
Do-not-resuscitate/end-of-life decisions
Patients with communications barriers
High-risk refusal-of-care patients
Communication with prehospital personnel and nonmedical personnel
Acutely psychotic patients
Disaster medicine

5. Professionalism: Emergency physicians demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Specific objectives, as they pertain to the practice of emergency medicine, are defined by a set of model behaviors:

a Arrives on time and prepared for work (1,2)
b Appropriate dress and cleanliness (1,2)
c Willingly treats patients throughout the entire shift (1,2)
d Appropriate sign-outs, both giving and receiving (1,2)
e Observable patient advocacy in disposition (2)
f Completes medical records honestly and punctually (1,2)
g Treats patients/family/staff/paraprofessional personnel with respect (1)
h Protects staff/family/patient’s interests/confidentiality (1)
i Demonstrates sensitivity to patient’s pain, emotional state, and sex/ethnicity issues (3)
j Actively seeks feedback and immediately self-corrects (1)
k Shakes hands with the patient and introduces self to the patient and family (1)
l Effectively coordinates team (1)
m Unconditional positive regard for the patient, family, staff, and consultants (3)
n Accepts responsibility/accountability (1)
o Recognizes the influence of marketing and advertising (2)
p Open/responsive to input/feedback of other team members, patients, families, and peers (1,2)
q Uses humor/language appropriately (3)
r Discusses death honestly, sensitively, patiently, and compassionately (1)
s Participates in peer review process (1)
t Fairness in recruitment of residents, faculty, and staff (1,3)

Specific knowledge expectations that emergency physicians are familiar with:

5.1. Code of Conduct for Academic Emergency Medicine and American College of Emergency Physicians Code of Ethics
5.2. Definitions of justice, autonomy, beneficence, nonmalfeasance, health care decisionmaking capacity, living will, advanced directive, health care power of attorney, informed consent
5.3. Criteria appropriate to apply when allowing patients to sign out against medical advice
5.4. Documentation and billing requirements
5.5. With whom confidential patient information can or cannot be discussed
5.6. Mechanisms for appropriate transfer of patients, Consolidated Omnibus Reconciliation Act, and Emergency Medical Treatment and Active Labor Act

6. Systems-Based Practice: Emergency physicians are aware and responsive to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Specific objectives are as follows:

a Understand, access, appropriately use, and evaluate the effectiveness of the resources, providers, and systems necessary to provide optimal emergency care (1)
b Understand different medical practice models and delivery systems and how to best use them to care for the individual patient (2)
c Practice cost-effective health care and resource allocation that does not compromise quality of care (3,4)
d Advocate for and facilitate patients’ advancement through the health care system (5)

Article on integrating the core competencies into education (Acade Emerg Med 2007;14:80)

TABLE 1. Summary of Teaching and Assessment Tools for Each Competency Competency Teaching Assessment

Patient care Lectures, particularly those that are case based In-service exams Internet or CD learning CORD exams High-fidelity simulation Med-challengerbased quizzes Procedure labs SDOT Critically appraised topics Simulation Home-based exams End-of-rotation evaluations OSCE or standardized patients Medical knowledge Lectures (traditional or case based) In-service exams Small-group instruction CORD online Question Bank Morning report case conference Homegrown examinations CD or online instruction Ultrasound interpretation Journal club ECG interpretation Assigned readings Core-content area Models and simulators Mock oral assessments Direct observation Standardized direct observation Models and simulators Portfolios Communication and interpersonal skills Resident portfolio Direct observations Resident retreats 360-degree evaluations Lectures on skills Global assessment Evaluation as teaching tool Curtain evaluations Faculty model behavior Consensus evaluation Simulated cases Professionalism Didactic curriculum Written examinations of knowledge, principles, and policies Case-based discussion Computer-based or oral exams with embedded ethical issues Clinical ED experiences encompassing patient management, with application of ethical principles to clinical situations OSCEs with standardized patients Visually based teaching tools (CD-ROMs, videotapes, Internet-based teaching educational programs) Modified essay questions Colloquial settings and retreats Direct observation and SDOT 360-degree evaluation ACGME toolbox: self-administered rating forms and psychometric instruments System-based practice Administrative rotation Bedside evaluations Out-of-hospital care (EMS) rotations SDOT Departmental and hospital committees Resident portfolios Patient follow-up 360-degree evaluations (nursing, peer, ancillary staff) Case write-ups Standardized oral exams with issues involving consultants, interpreters, resources Practice-based learning Evidence-based medicine reviews of clinical questions Direct feedback on the conclusions drawn by the resident in a journal-club conference Journal clubs Feedback from the CAT conference Critically appraised topics Critical assessment of the resident’s periodic portfolio summaries Attending CQI meetings Critical assessment of the resident’s M&M conference summaries Self-assessment of portfolio Resident-led M&M conferences Mentoring by faculty

CD = compact disc; CORD = Council of Residency Directors; OSCE = objective structured clinical exams; ACGME = Accreditation Council for Graduate Medical Education; CAT = critically appraised topics; CQI = continuous quality improvement; M&M = morbidity and mortality; SDOT = standardized direct observation tool.

SBAR (Situation, Background, Assessment, Recommendation)

SBAR report to physician about a critical situation

Situation

I am calling about

<patient name and location>.

The patient’s code status is

The problem I am calling about is

____________________________.

I am afraid the patient is going to arrest.

I have just assessed the patient personally:

Vital signs are

: Blood pressure _____/_____, Pulse ______, Respiration_____ and temperature ______

I am concerned about the:

Blood pressure because it is over 200 or less than 100 or 30 mmHg below usual

Pulse because it is over 140 or less than 50

Respiration because it is less than 5 or over 40.

Temperature because it is less than 96 or over 104.

Background

The patient’s mental status is:

Alert and oriented to person place and time.

Confused and cooperative or non-cooperative

Agitated or combative

Lethargic but conversant and able to swallow

Stuporous and not talking clearly and possibly not able to swallow

Comatose. Eyes closed. Not responding to stimulation.

The skin is:

Warm and dry

Pale

Mottled

Diaphoretic

Extremities are cold

Extremities are warm

The patient is not or is on oxygen.

The patient has been on ________ (l/min) or (%) oxygen for ______ minutes (hours)

The oximeter is reading _______%

The oximeter does not detect a good pulse and is giving erratic readings.

Assessment

This is what I think the problem is:

The problem seems to be cardiac infection neurologic respiratory _____

I am not sure what the problem is but the patient is deteriorating.

The patient seems to be unstable and may get worse, we need to do something.

Recommendation

I suggest or request that you

<say what you would like to see done>.

transfer the patient to critical care

come to see the patient at this time.

Talk to the patient or family about code status.

Ask the on-call family practice resident to see the patient now.

Ask for a consultant to see the patient now.

Are any tests needed:

Do you need any tests like CXR, ABG, EKG, CBC, or BMP?

Others?

If a change in treatment is ordered then ask:

How often do you want vital signs?

How long to you expect this problem will last?

If the patient does not get better when would you want us to call again?

http://www.ihi.org/NR/rdonlyres/CE050347-B6B9-4782-AB72-4643FB315418/0/Whittington_SBAR_JtCommJ_Mar06.pdf

Signouts

The elements of a safe and effective written signout are included in the mnemonic “ANTICipate”: Administrative, New information (clinical update), Tasks, Illness, and Contingency plans. Accurate administrative information, such as patient name and location, is one of the most important components of a written signout according to surveys of internal medicine night-floats at UCSF (Unpublished data from October 2004 evaluation interviews of cross-coverage internal medicine residents at UCSF). New information includes a brief history and diagnosis, updated medications and problem list, current baseline status (eg, cardiac status), and recent procedures and significant events. Tasks are the “to-do” list, or the things that need to be completed during cross-coverage. Listing the tasks in “if, then” statements reduces the need for conjecture on the part of the cross-coverage practitioner. For example, in this case, the written signout would include: “Check CXR which was taken at 4:00 PM. If clear, call nurse to communicate results; if PTX, call thoracic surgery.” “Illness” is the primary provider’s subjective assessment of the severity of illness, and contingency planning includes statements that assist the cross-coverage in managing anticipated problems. It is also important to report what therapeutic interventions have been successful in the pastthus giving the cross-coverage provider important historical background to assist in decision making. Given our case, an appropriate contingency plan could be: “If patient is short of breath, try an albuterol inhaler (given history of COPD), but consider pneumothorax since he recently had a subclavian line placed.”

At UCSF, the transformation to a system-wide structure of written and verbal signout was facilitated by a conceptual framework to manage the change, using Kotter’s 8-step approach.(23)

1. Establish urgency. We first established a sense of urgency. Residents recognized the urgency of improved signouts quickly, but the introduction of the JCAHO patient safety goal added to the medical center’s sense of urgency.
2. Form a powerful guiding coalition. We then formed a powerful coalition which included the main stakeholders: Information Technology (IT), Medical Center, and Graduate Medical Education (GME) leadership.
3. & 4. Create and communicate a vision. We created a vision, a signout system that could grow with our new EMR, making resident work more efficient and the signout process safer for patients. We then actively communicated that vision to leadership at numerous committee meetings.
5. Empower others to act on the vision. We empowered others to act by engaging the medical center IT and GME leadership to help the core group of “champions” move forward in development of Synopsis.
6. Plan for and create short-term wins. We designed a “rounds report” linked to Synopsis (Figure 2), allowing for information consolidation and tracking increasing resident work flow efficiency. We also piloted the project on our non-teaching service, which had previously lacked a robust signout system, thus gaining enthusiasm prior to the resident roll-out.
7. Consolidate improvements, creating more change. Synopsis spread organically once residents saw its capacity on one of the pilot units.
8. Institutionalizing new approaches. We institutionalized this new system by passing policies at the GME and Medical Center level.

By using these 8 steps, coupled with a comprehensive training program, we were able to train the majority of our residents on safe and effective signout strategies. At this point, more than 50% of the patients at our 600-bed acute care hospital are cared for with the assistance of Synopsis, and this percentage continues to grow.

How to Learn

The scene: A rigorous intro-level survey course in biology, history, or economics. You’re the instructor, and students are crowding the lectern, pleading for study advice for the midterm.

If you’re like many professors, you’ll tell them something like this: Read carefully. Write down unfamiliar terms and look up their meanings. Make an outline. Reread each chapter.

That’s not terrible advice. But some scientists would say that you’ve left out the most important step: Put the book aside and hide your notes. Then recall everything you can. Write it down, or, if you’re uninhibited, say it out loud.

Two psychology journals have recently published papers showing that this strategy works, the latest findings from a decades-old body of research. When students study on their own, “active recall” recitation, for instance, or flashcards and other self-quizzing is the most effective way to inscribe something in long-term memory.

Yet many college instructors are only dimly familiar with that research. And in March, when Mark A. McDaniel, a professor of psychology at Washington University in St. Louis and one author of the new studies, gave a talk at a conference of the National Center for Academic Transformation, people fretted that the approach was oriented toward robotic memorization, not true learning.

Mastering the Techniques of Teaching by Lowman

Mann group’s student types

MANN’S TYPOLOGY OF UNDERGRADUATE STUDENT LEARNERS

(From Mann, R.D. et al. The College Classroom: Conflict, Change and Learning. NY: Wiley, 1974, cited in Joseph Lowman, Mastering the Techniques of Teaching. 2nd ed. San Francisco: Jossey-Bass, 1995)

Mann and his group studied a number of college classrooms focusing on underlying emotional development. On the basis of their data, they generalized students into a number of “types.” Although group generalizations risk glossing over significant individual variability, some people find these categories useful in trying to analyze and understand a learner population of undergraduate students.

The Mann group divides the students into the following eight types and indicate the proportion of their sample within each of these categories. The types in order of the frequency the researchers found are as follows:

Anxious-Dependent Students. (26% of the sample)

Excessive concern about grades. Want to learn exactly what the teacher wants them to know. Want any definitions given to be spelled out word for word. They are often distrustful of the teacher and expect unfair practices and “trick” questions. They combine high anxiety, ambition, and suspiciousness and may hae a low opinion of their ability (Actually they had the lowest SAT scores of the 8 groups). During tests, students in this category often look frazzled and will stay until the end. Their work is frequently unimaginative or erratic. They prefer a lecture to a discussion and may memorize details but often lack conceptual complexity. They want black and white distinctions and clear right and wrong answers. The instructor may be tempted to be impatient but it is not the right approach with them, rather it is to be supportive of where they are and encouraging to help them expand their range.

Silent Students. (20% of sample)

These students, although they do not speak in class, are very aware of how the instructor behaves toward them. They want a close relationship with the instructor but are afraid that the instructor does not think well of their work or of them. They respond by silence. The biggest mistake an instructor can make, according to Mann, is to ignore them. The instructor should make sure every student receives attention. Do this by smiling at individuals, walking to their part of classroom, making eye contact, etc. After one or two initial classes, extend a personal invitation to come by the office.

Independent Learners. (12% of sample)

These students take what the instructor has to offer and pursue their own goals at the same time. They are comfortable in doing what is asked. They prefer a seminar or discussion format in class and are high participators. They make friends with the instructor easily. They are the ideal, mature student. Often found in juniors and seniors rather than freshmen and sophmores. If the quality of the instruction is poor, they may be the ones to act as spokesperson for the group’s concerns.

Attention-Seeking Students. (11% of sample)

These students come to class because they want to socialize. They are fond of discussion. Their social needs predominate over their intellectual needs. They are pleasant to have in class and capable of doing good work if they learn they have to work well to be well thought of by their fellow students. They like to organize group review sessions or group parties. They are the socio-emotional leaders. They are easily influenced by others and need to be encouraged to focus their attention on intellectual issues. They are easy to motivate by giving them attention.

Compliant Students. (10% of sample)

These students are teacher-dependent, conventional, and highly task-oriented. They rarely question the teacher’s control. They come to class to understand the material and often prefer a lecture to a discussion. They speak in class to agree or to ask clarifying questions. They usually do well on exams but are unlikely to show independence or creativity. They are content to support the status quo and not to question authority. The instructor can help them by encouraging them to make critical comments on papers and to contribute to discussions.

Heroes. (10% of sample)

The heroes are like the independent learners. They prefer to do independent, creative work. They are anxious to have the instructor notice them but often fail to deliver on their initial promise. They are erratic, optimistic underachievers. They initially excite the instructor with their intensity and their grand plans but disappoint later with their poor execution. They probably have some underlying hostility to authority figures, according to Mann, or they are unable to commit to a goal. They miss class a lot. They love discussions but can be annoyingly argumentative and often stake out a position without having done any of the assigned readings. These students sometimes settle down in graduate school, often become late bloomers. Although they argue for independence giving it to them rarely improves their performance. It is better to channel their energy into structured assignments. They need special handling. To motivate these students, maintain good relationships with them.

Snipers. (9% of sample)

Snipers are hostile to college teachers and filled with cynicism. They have very high expectations and a positive image of self but little hope that the world will recognize the quality of their work or give them a fair share of rewards. They are habitual rebels who sit as far from the instructor as possible and often comment with cutting remarks. Usually, however, they only make an initial sally and then retreat. Mann says the instructor should control his/her temper as with the anxious folks and ignore the hostile tone of the comments but respond to whatever in the comment he/she can find that is positive. Smiling and seeking these students out doesn’t work as it makes them uncomfortable and they will try to distance even more. Best approach is to make long comments on their papers and wait for a chance to strike up a personal association later in the course. They may actually desire closeness.

Discouraged Workers. (4% of sample)

These students show a depressed, fatalistic attitude to themselves and to education. They believe they have little control over their learning. They may have worked hard in the past and feel burned out. These are often older students who do not find learning pleasurable. Instructor should provide written compliments on their best work and seek out opportunities for face to face conversation.

Medical Student Development

Medical Student Presentations

Medical Student Expanded Presentations

Learning Styles

Probably have no relevance

Resident Productivity when Supervising Medical Students

In this study, resident productivity was not affected by precepting medical students.
[West J Emerg Med. 2013;14(6):585–589.]

Tough Teachers

Tough teachers may get better results