Jennifer Joyce M D Andrea Milam M S

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Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Analysis of the Impact of Rural Clerkship Experience on Medical Students’ Transformation into Reflective

Analysis of the Impact of Rural Clerkship Experience on Medical Students’ Transformation into Reflective Practitioners STFM Predoctoral Conference Charleston, South Carolina February 4, 2006 Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Objectives During this presentation we will: Ø Share the results of our experience with

Objectives During this presentation we will: Ø Share the results of our experience with medical students in the Rural Primary Care Clerkship. Ø Suggest one model for contextualizing learning in medical education. Ø Discuss methods for building reflection into educational experiences. Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Transform(ative) Ø Simple definition: To change in character or condition Ø Powerful results: New

Transform(ative) Ø Simple definition: To change in character or condition Ø Powerful results: New awareness of culture, self and others Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Contextual Model More than place Ø Creation of learning environment Ø Attention to relationships

Contextual Model More than place Ø Creation of learning environment Ø Attention to relationships Ø Valuing community partners Ø Building in and valuing reflection Ø Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Community Immersion Credibility key Ø Collaborative objectives Ø Continuity Ø Listening Ø Receiving as

Community Immersion Credibility key Ø Collaborative objectives Ø Continuity Ø Listening Ø Receiving as much as we give Ø Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Evaluation Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Evaluation Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Composition of Cohort Student Gender RPCC Location “Home”: R = Rural U = Urban

Composition of Cohort Student Gender RPCC Location “Home”: R = Rural U = Urban Residency Choice Area 1 F Morehead R Neurology 2 M Morehead R Family Medicine 3 M Hazard R Anesthesiology 4 F Morehead R Med/Peds 5 M Hazard U Med/Peds 6 F Hazard R Neurology 7 F Hazard U Surgery Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Quantitative (Descriptive) Analysis

Quantitative (Descriptive) Analysis

Quantitative (Descriptive) Analysis Ø Equivalency (RPC vs. non-RPCC) n Satisfaction n Performance: Student n

Quantitative (Descriptive) Analysis Ø Equivalency (RPC vs. non-RPCC) n Satisfaction n Performance: Student n n Ø Grades Procedural log books Preceptor feedback/ratings Performance: Preceptor n n Ø Triangulation of select items n Student ratings n n Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T. Item analysis, course evaluations (S) Item analysis, retreat evaluations (S, F) Student ratings of preceptors Preceptor ratings of students Retreat evaluations

Equivalency: Performance Outcomes Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P.

Equivalency: Performance Outcomes Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Preceptor Ratings of Students: RPCC vs. AHEC (non. RPCC) RPCC students rated higher on

Preceptor Ratings of Students: RPCC vs. AHEC (non. RPCC) RPCC students rated higher on all dimensions Ø Particularly noteworthy, RPCC students received higher ratings on the following Ø Communication (↑ 2. 5%) n Prevention (↑ 2. 0% higher) n Responsibility (↑ 2. 6% higher) n Relationships (↑ 2. 0% higher) n Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Student Ratings of Preceptors Ø Average rating AHEC non-RPCC = 4. 65/5 n RPCC

Student Ratings of Preceptors Ø Average rating AHEC non-RPCC = 4. 65/5 n RPCC = 4. 9/5 n Ø Selected items, of interest My attending/resident modeled a humanistic attitude toward patients (RPCC = 5/5; NRPCC = 4. 6/5) n My attending/resident was an excellent role model (RPCC = 5/5; NRPCC = 4. 7/5) n Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Satisfaction Course Eval: RPCC FM, 04/05 All FM Clerkship , 04/05 All M 3/M

Satisfaction Course Eval: RPCC FM, 04/05 All FM Clerkship , 04/05 All M 3/M 4 Clerkship, 04/05 3. 1 2. 8 2. 7 N=83 -92 N=821 -937 Retreat Evaluations, comments relating to: Faculty Student Reflection 1/7 comments 6/7 comments Cultural Awareness 2/3 comments 3/7 comments Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Qualitative Analysis

Qualitative Analysis

Qualitative Analysis Ø Sources Group Interview (6/7; April 2005) n Reflective Papers (7/7; April

Qualitative Analysis Ø Sources Group Interview (6/7; April 2005) n Reflective Papers (7/7; April 2006) n Focus Group (3/7; January 2006) n Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Qualitative Analysis Comments characterized in terms of those that provided insight into the degree

Qualitative Analysis Comments characterized in terms of those that provided insight into the degree of internalization and integration of their development as “reflective practitioners” Ø Krathwohl and Bloom’s taxonomy used to characterize the statements and suggest level of commitment Ø Extrapolated to identify elements of instructional design Ø Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Themes Commitments (Krathwohl, Bloom) Ø Instructional methods Ø Outcomes Ø

Themes Commitments (Krathwohl, Bloom) Ø Instructional methods Ø Outcomes Ø

The Classification of Educational Goals: Affective Domain Receiving (I) Ø Responding (II) Ø Valuing

The Classification of Educational Goals: Affective Domain Receiving (I) Ø Responding (II) Ø Valuing (III) Ø Organization (IV) Ø Characterization (V) Ø - Krathwohl, Bloom, Masia (1970) Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Major Themes: Commitment to… Ø Self Awareness – Organizing Ø Cultural Awareness - Valuing/Organizing

Major Themes: Commitment to… Ø Self Awareness – Organizing Ø Cultural Awareness - Valuing/Organizing Ø Contextualized Patient Care (biopsychosocial model? ) – Organizing Ø Empathy – Valuing Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Self Awareness “When I first got there, while I was new and started seeing

Self Awareness “When I first got there, while I was new and started seeing patients, they asked where I was from. I was just always, whether I did it or not, I always made sure that I told them I was not from there…I was from somewhere else. ” - Focus Group “You don’t really realize what prejudices or biases that you have until you sit down and think about yourself and how you think and things like that. ” - Focus Group

Self Awareness “All the while cementing my belief that rural Kentucky is where I

Self Awareness “All the while cementing my belief that rural Kentucky is where I have been called to serve. ” - Reflective Paper

Cultural Awareness “It is almost like the disparities are just the tip of the

Cultural Awareness “It is almost like the disparities are just the tip of the iceberg. It makes you realize the gaps are even wider than you thought. There are two extremes in Kentucky…either you have a lot or you have a little. Each rural community is a reflection of all of the health care disparities. ” - Focus Group “It showed me how much we easily label people, and that the ‘medicine speak’ we do does not accurately reflect the person who is on the other end. . . ” - Group Interview

Empathy “I just realize… you can talk about national health care and you can

Empathy “I just realize… you can talk about national health care and you can talk about welfare and the working poor – we can talk (easily) about ‘those people’ – but to go /really live there and to realize that – it was an eyeopening experience. The line is not so clear between people - the ‘haves’ and the ‘havenots’. ” - Focus Group

Biopsychosocial Model “…People come to us when they are the most vulnerable…when families are

Biopsychosocial Model “…People come to us when they are the most vulnerable…when families are in crisis…and it is the intersection of so many things – it’s a person’s physical health, but also it’s their emotional health, their mental health…the intersection of faith and religion. All of that comes together and may come out in the clinic. To discredit someone in the mountains and their feelings…that would be to totally not treat them. ” - Focus Group

Biopsychosocial Model “…cannot have a healthy patient unless have a healthy community and family

Biopsychosocial Model “…cannot have a healthy patient unless have a healthy community and family and I have a responsibility to that. Unless I am part of the community, am I really healing? ” - - - Focus Group “Staying an extended time back in my home town allowed me to reacquaint myself with the people and the community. I know this gives me a totally different perspective. ” - - Reflective Paper

Themes: Instructional Methods Ø Context Ø Collaborative Learning Ø Self-Reflection Jennifer Joyce, M. D.

Themes: Instructional Methods Ø Context Ø Collaborative Learning Ø Self-Reflection Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Context “Pairing medical students with cooperative extension agents - that was brilliant!” - Focus

Context “Pairing medical students with cooperative extension agents - that was brilliant!” - Focus Group “You have to take risks in order to do this. . . I haven’t talked to anybody that did a onemonth AHEC program that felt like they became part of the community like we did. ” - Focus Group

Collaborative Learning “Directly involved me in helping to shape my experience…asked me, ‘What do

Collaborative Learning “Directly involved me in helping to shape my experience…asked me, ‘What do you want to do…what do you need? ’” -Focus Group

Self-Reflection “Medical school has none of this reflective stuff…not that it is discouraged, it

Self-Reflection “Medical school has none of this reflective stuff…not that it is discouraged, it is just nobody has stopped to say, ‘hey – think about what you saw and what you did. ’” - Focus Group “I carry a notebook with me now – I didn’t do that before…to purge good and the bad from the day. I learned that from the rural track. ” - Focus Group “With my reflection, I had to sit back and figure out what does being a doctor mean to me? Most people think of the doctor as someone that doesn’t have or spend much time with you. I was able to think about that and after this experience – I am more aware that a doctor is a servant. ” - Focus Group

Reflection Follows meaningful encounters or teachable moments Ø Keys to successful use of reflection

Reflection Follows meaningful encounters or teachable moments Ø Keys to successful use of reflection in clinical teaching: Ø Role modeling n Gaining the trust of the learners n Skills to facilitate reflection - Branch & Paranjape, 2002 n Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Outcomes

Outcomes

Outcomes Ø Intended n Valuing n n n Cultural differences Community resources Contextual patient

Outcomes Ø Intended n Valuing n n n Cultural differences Community resources Contextual patient care Differences (discipline, cultural, individual) Organization of a value system n n Self awareness Self-reflection “Better” doctors as a result Self identity Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Outcomes Ø Bonuses Journaling n Desire to practice and have a life n Permission

Outcomes Ø Bonuses Journaling n Desire to practice and have a life n Permission to follow career paths n Servant leadership n Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Outcomes Ø “Gain so much as a doctor if you do this…very few of

Outcomes Ø “Gain so much as a doctor if you do this…very few of the rotations give you anything that is going to make you a better doctor…this DOES!” - Focus Group

Conclusions The community provided an important context for learning Ø Planned, mentored, valued opportunities

Conclusions The community provided an important context for learning Ø Planned, mentored, valued opportunities for self reflection provided the opportunity for students to practice and Ø Self-reflection supports the development of the knowledge, skills, and attitudes associated with cultural awareness Ø Collaborative education yields engaged learners Ø

Unanswered questions Given Krathwohl and Bloom’s taxonomy, where does the majority of medical education

Unanswered questions Given Krathwohl and Bloom’s taxonomy, where does the majority of medical education “live”? Ø Are there some outcomes that truly do happen best out in the community, as opposed to within the academic medical center? Ø Do we take every student out of his/her comfort zone, or is this for some of the students some of the time? Ø Jennifer Joyce, M. D. Andrea Milam, M. S. Ed. , P. T.

Thank you!

Thank you!