The Key Literature in Medical Education podcast this week covers one of the topics I have been struggling to understand: complexity. Here are some great starting points if you want to “Start” your own deep-dive.
Competency-based medical education has been beaten up for the deconstruction of a physician (complex) into competencies (linear).
The article this week attempts to bridge the two extremes of this debate, suggesting practical solutions that advance medical education.
As always, the abstract is below, but the good stuff is on the podcast.
KeyLIME Session 102 – Article under review:
View/download the abstract here.
Durning SJ, Lubarsky S, Torre D, Dory V, Holmboe E. Considering “Nonlinearity” Across the Continuum in Medical Education Assessment: Supporting Theory, Practice, and Future Research Directions. The Journal of Continuing Education in the Health Professions. 2015 Jul;35(3):232-43
Reviewer: Linda Snell
The conception of competence as the appropriate assembly of knowledge, skills, and attitudes, as well as the psychometric approach to assessment may be overly simplistic. Rather, competency, in clinical reasoning for example, requires the combination of different abilities in such a way that the whole is bigger than the sum of its parts. This is confounded as clinical practice is uncertain, ambiguous, chaotic and is as well a social process. So the authors question the assumption that competence is linear (“the more knowledge a physician possesses, the more competent they are”); and other individuals, the system, and their interactions are noise.
The authors propose:
- That the interactions between a physician and their environment and the individuals within it impacts how medical competence is identified, taught, and assessed.
- Alternative models to devise a program of assessment might better reflect the complexity of medical practice (not be adequately captured by a psychometric model)
Type of Paper
Nonlinearity is a relationship with multiple paths or outcomes, interactions and a non-relationship between stimulus and response.
This is typical of the practice of medicine and medical education: multiple outcomes for a given process may be acceptable. Specifically the assessment of clinical reasoning must look at the (nonlinear) process, not just outcome.
Theories that involve nonlinearity include script theory, concept mapping, self-regulated learning and situated cognition.
The authors apply these concepts to assessment strategies:
- Script concordance tests: acknowledges that expert clinicians have illness scripts that differ and even simple clinical situations may have an element of uncertainty.
- Concept maps: graphic representations that learners draw to show understanding of the meaning of a set of concepts; an organized visual schema of related concepts.
- Work based assessment needs a narrative to explain or describe the context to capture nuances “explicit documentation of physician, environment/system and patient factors, as well as their interactions.”
- Look at process as well as outcome – direct observation needed.
The authors conclude that medical education and practice are full of nonlinearity that is not adequately captured using current assessment methods. The principles of nonlinearity provide a useful lens for medical education and practice. Approaches that assess the process in addition to the outcome can assist with assessing nonlinearity.
Spare Keys – other take home points for clinician educators
This paper gives an excellent overview of some of the major theories in medical education.
Nonlinearity provides an interesting lens for CEs to approach the common challenge of how to assess a learner in the messy world of clinical medicine
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