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Teaching Strategies to Enhance Acute Care Clinical Reasoning Across the Continuum
Bose, S. PT, DPT, MHS, BSPT | Marshall University
Greenwood, K. PT, DPT, EdD, MS, GCS | Northeastern University
Gorman, S. PT, DPTSc | Samuel Merritt University
Fein, B. PT, DPT, EdD | Sacred Heart University
Objectives
By the end of this session, the participant will be able to:By the end of this session, the participant will be able to:
• Examine how teaching about acute care is enhanced by intentionaluse of educational theory.
• Describe four effective methods of delivering and assessing acutecare content in the academic curriculum or clinical setting.
• Identify acute care content that would be appropriate for eachteaching and assessment method.
• Develop a plan for integrating at least one new method of deliveringor assessing acute care content.
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 2
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Summary Zoom
Teaching strategies to enhance acute care clinical reasoning ‐ACEC 2018. Bose, et al.
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Defining Acute Care Education*
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al.
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Challenge of Teaching Acute Care
An acutely ill patient is a moving target
Approach to a patient with myriads of “constantly moving” signs & symptoms is “scarcely” taught at entry‐level
• Challenge of time
• Challenge of adequately trained faculty
Constant need for differential diagnosis
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 5
Why the Need for Differential Diagnosis
The Rationale for hospital admission
The approach to a patient with Signs of Symptoms of Clinical, OR Subclinical disease
The relative unfamiliarity of physicians with what PTs do…
• The challenge of the PTOT consult
The relative unfamiliarity of the non‐acute care
specialist with what they are supposed to be
addressing
The incomplete medical chart
Others…
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 6
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What Needs to be Taught in Acute Care?*
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 7
Acute care therapists think differently than other types of physical therapists in part because they often make decisions when patients are in medical crisis (Masley et al., 2011).
This decision making process relies heavily on the therapist’s interprofessional relationships with the medical team, management of emotions, and ability to make judgments in action that are best for an individual patient’s circumstances (Holdar, Wallin, & Heiwe, 2013; Masley et al., 2011; M. Smith, Higgs, & Ellis, 2010).
Acute care practice requires emotional intelligence and professional behaviors which have been identified in physicians and other health professions (Galal, Carr‐Lopez, Seal, Scott, & Lopez, 2012).
What Is Out There to Guide How to Teach Acute Care?*
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 8
Each individual physical therapist curriculum is guided by the Normative Model of Physical Therapist Education (American Physical Therapy Association, 2006).
Nationwide Acute Care Practice Analysis (Gorman, 2010).
Core Competencies of Entry‐Level Practice in Acute Care Physical Therapy (Greenwood et al.).
Learning
Teaching strategies to enhance acute care clinical reasoning ‐ACEC 2018. Bose, et al.
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Learning
Involves:
• Making connections
• Linking to priorexperiences
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Each new connection
• Influences approach tofuture situations
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Educators need to:
• Identify & acknowledge experiences of the learner
• Help establish those connections
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Filters – Individual Factors that Influence Teachers & Learners*
All learning is grounded in our own experiences, which influences how we learn
All learning is grounded in our own experiences, which influences how we learn
Dewey, J. Experience & Education. New Jersey. New York, NY. Simon & Shuster; 1938Dewey J. How we think. Amherst, NY: Prometheus Books; 1991
How Does Learning Occur?
• Requires learner’s interaction with the environment
• Incorporate new information or experiences with what they already know or learned
Active Process
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5
Environmental Factors that Affect Learning
Society & Culture
Structure of Pattern of Stimuli
Effectiveness of Role Models & Reinforcements
Feedback for Correct & Incorrect Responses
Opportunities to Process and Apply Learning to New Situations
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 13
Learning Theories for Medical Educators & How to Apply to Acute Care
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al.
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At the Core of What We Do…
A working knowledge & understanding of key learning theories is essential
Helps inform teaching practice by providing
• Rational basis for selection of specific instructional strategies
• Fostering articulation of important learning objectives
• Facilitating implementation of evaluation strategies well matched to curricular goals
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 15
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Learning Theories for Medical Educators*
Behaviorist Orientation
Cognitivist Orientation
Humanistic Orientation
Social Learning Orientation
Constructivist Orientation
The Socratic Method
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 16
Merriam S, Caffarella R. Learning in Adulthood. San Francisco, CA: Jossey‐Bass, Inc., 1999.
Behaviorist Orientation
• Development of Competencies
• Demonstrating Technical or Psychomotor SkillsUseful in:
• Change in behavior is desired outcome of educational endeavorGOAL:
• Manipulate environment for learners to elicit specific response
• Delineate specific behavioral objectives
Teacher Center Approach
• How various stimuli are presented or arranged in external environment
Locus of Learning Based on:
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 17
Implications of Behaviorist Orientation in Acute Care/Medical Education
• COMPETENCY BASED CRITERIA – e.g.:
• Clinical skills instruction
• Simulated case scenarios
Development and evaluation
of
• Learners observe the exact manner or technique
• Perform the exact behavior as instructed
• Graded on a scoring rubric – e.g. checklist, rating forms, direct observation…
Teachers model specific behaviors
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 18
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Behavioral Objectives Should Include
• What the learner will be able to do… or what behavior will beperformed
Performance or Behavior
• Which are necessary for the performance, or, under which theperformance must be performedConditions
• What measure of criteria defines unacceptable performanceCriteria
• Given a simulated patient with Myocardial Infarction and Troponinelevation with T‐wave inversion (condition), learner will identify ECG‐change (performance), with 80% accuracy (criteria)
Example
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 19
Cognitive Orientation
Locus of Learning:
• Learner’s internal environment and cognitive structures
• Learners seek to understand the structure of knowledge
Approach:
• Learner uses cognitive tools (insight, information processing, perceptions, memory) to facilitate learning by assigning meaning to events
Teacher’s Role:
• Facilitate cognitive processing …
• Help learner “learn how to learn” – Self‐directed learning
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 20
Cognitive Orientation
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 21
• Individuals learn with concepts
• Meaningful learning results from relating new knowledge to what is already known
Ausubel:
• Objects, events, situations, or, properties that possesscommon criteriaConcepts are:
• Develops critical thinking by reflectionBrookfield:
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Applying Cognitive Orientation in Acute Care/Medical Education
• Intent is for learners to connect newconcepts to what they already knowConcept Maps
• Recall events and reflect backReflective Thinking
• A student‐centered, active learning process surrounding a problem (case)
Problem‐based Learning
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 22
Humanist Orientation
• Learning is viewed as a personal act necessary to achieve learner’s full potentialSelf‐directed:
• Autonomous via internal drive to achievehighest potential
Goal: Learner to become ‐
• Plan, carry out, evaluateLearner endeavor:
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 23
Implications of Humanist Orientation to Acute Care/Medical Education
Use of well‐designed, technology‐based assist
Computer‐assisted simulations
Problem‐based learning scenarios
• Drill & practice exercises with immediate feed back (e.g. BLS & ACLS training)
Role playing exercises
• Interprofessional training events (helps in understanding specific roles inhealthcare team)
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 24
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Social Learning Orientation
• Acquire a cognitive representation of a modeled or observed experience
• Form and store an image of that modeled behavior
• Retrieve that image when the learner is motivated to act
Hypothesis Based on Observation & Modeling
in a Social Context
• The person
• The learning environment
• Desired behavior
Locus of Learning ‐Interaction between:
• Modeling new roles
• Guiding behaviors
• Providing opportunities to practice these new roles & behaviorsTeacher Responsibility:
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 25
Implications of Social Learning to Acute Care & Medical Education
Role modeling/ mentoring
Collaborative learning
Teaching with case studies
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 26
Constructivist Orientation
Integrating learning activities & experiences in knowledge & beliefs
• Developing meaning
• Achieving understanding
• Assigning significance to others
Locus of learning:
• Assist learners in understanding how they developed certain assumptions
• Question learners whether those assumptions remain valid
Teacher’s role ‐ foster critical reflection and negotiate meaning:
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 27
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Strategies in Applying the Constructivist Orientation to Acute Care Education
Reflective Journaling
Problem‐based Learning (PBL)
Writing Practice Narratives
Developing Course Portfolios
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 28
5 Key Strategies Used by This Faculty
Use of Concept Maps in Acute Care Education
• Acquisition and recall of ideas and meanings about a topic
• Depict complex relationships among ideas
• Extract core concepts from textbook/journal articles/clinical case study
• Plan presentations/papers
• Aid to brainstorming & sharing ideas
Facilitates:
• Learners identify key issues – a central concept
• Draw relationships between concepts
• Identify connections with linking words
Process involves:
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 30
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Concept Mapping
Central idea Branching thoughts Infinite levels deep*
Allows any level of critical thinking
My personal uses for Concept Mapping
•Critical Analysis
•Differential Diagnosis
•Planning rehabilitation priorities
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 31
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Tools for Concept MappingMindmeister – http://www.mindmeister.com
Bubbl.us ‐ https://bubbl.us/
Coggle.it ‐ https://coggle.it/
Lucidchart ‐ https://www.lucidchart.com/pages/education/K12
Mindmup 2 ‐ https://app.mindmup.com/
Gliffy ‐ http://gliffy.com/
Google Draw ‐ http://www.educatorstechnology.com/2013/10/this‐is‐how‐to‐create‐mind‐using‐google.html
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 32
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Guide to Concept Mapping ‐ http://www.schrockguide.net/concept‐mapping.html
Concept Map Example
HPI: Pt is an 38 year old female with bronchiectasis admitted to the hospital with increased cough and secretions. CXR on admission revealed a L LL pneumonia and diffuse changes associated with bronchiectasis throughout the both lungs. Her ABG was also taken on admission and it revealed 7.32/60/90/29 on 1L. She reports she is coughing up 1 cup of yellow/tan mucus per day. Pt is referred to inpatient PT for an evaluation on day #1 of her admission. PFTs on her day of admission reveal an FEV1 was 35% of predicted, FVC was 55% of predicted and the FEV1/FVC ratio was 45%.
PMH: Cystic fibrosis, pancreatic insufficiency, CF related diabetes, osteoporosis
Medications: Creon, Dornase Alfa, Albuterol Inhaler, IV Tobramycin, Novalog, Fosamax (for her osteoporosis)
Social History: Lives with her husband in a house with 2 steps to enter and 12 within the house. She is a full‐time mother of 2 kids (6 year old daughter and 8 year old son). She is independent with ADLs, but slower due to DOE. She reports she is using percussion and vibration with postural drainage performed by her husband twice daily and does not participate in aerobic activity. She increases this if she is more congested (which she required for the last 2 weeks). Her baseline mucus production is about 1/2 cup of yellow mucus.
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Concept Map Rubric
The 3‐minute version, which can be helpful on clinical and in the classroom
What are the top three things I want to see this student thinking about?
Have they considered all factors for safety and
efficacy?
Is there evidence they are extending their thoughts beyond todays evaluation
to be prepared?
Simulation Training
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 35
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Identify & Overcome Barriers
Teaching strategies to enhance acute care clinical reasoning ‐ACEC 2018. Bose, et al.
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Objectives Specific
Limited
Targeted
Scen
ario Realistic
Layered
Formative vs. Summative
Deb
rief Safe
Planned
Facilitated Assessm
ent
Useful
Targeted
Multi‐modal
Teaching strategies to enhance acute care clinical reasoning ‐ACEC 2018. Bose, et al.
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Acute Care Confidence Survey & ICU Skills Self‐
Efficacy Survey
Performance Assessment of Communication & Teamwork (PACT)
Interprofessional Collaborative
Competencies Attainment Survey (ICCAS)
Debriefing Assessment for Simulation in Healthcare
(DASH)
Teaching strategies to enhance acute care clinical reasoning ‐ACEC 2018. Bose, et al.
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“I'm on my lunch break on my first day of my ICE and I just HAD to email you! THANK YOU for everything you taught us because my first patient of the day was a bilateral lung transplant in the ICU. Yellow swan line and everything and I felt very prepared! So thank you! (I do think that my CI was a little impressed too!)”
Knowledge
Behaviors
Performance
Online Reflection
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 39
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Developing Critical Thinking by ReflectionBoud & Walker: Three stages to reflective learning
• Returning to, & replaying the experience
• Attending to the feelings that the experience provoked
• Re‐evaluating the experience
Process of reflection may occur during or after the experience in question
Reflection ON action
• Thinking through a situation AFTER it has happened
Reflection IN action
• Thinking about actions AS they are performed
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 40
Reflective Thinkingin Acute Care/Medical Education
• Students identify a significant clinicalexperienceRecall Event –
• Student describes the event
• Summarizes what was learned (from event)Reflection –
• What could have been done differentlySpeculate on –•Hospital floors
• Lecture settings
• Small group sessions
• Simulated environments (Standardized, OR, Virtual Patients)
Use in: Teaching strategies to enhance acute care clinical reasoning ‐
ACEC 2018. Bose, et al.41
Reflective Journaling Example
Column 1 – Describe a Case
Column 2 – Articulate thoughts and feelings
about that case
Column 3 – Return at later date – Reflecting
on their learning
Small group discussions – Similarities &
Dissimilarities in their cases & impact of the
case
Teaching strategies to enhance acute care clinical reasoning ‐ACEC 2018. Bose, et al.
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2 Types of Reflective Thinking Approaches
1‐minute Preceptor Approach
SNAPPS Approach
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 43
One-Minute Preceptor
Get a commitment
1
Probe for supporting evidence
2
Teach general rules
3
Reinforce what was done right
4
Correct mistakes
5
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 44
SNAPPS* – 6 Steps to Reflective Thinking (Learner-centered Model)
•Summarize briefly the history & findingsS:
•Narrow the differential to two or three relevant possibilitiesN:
•Analyze the differential by comparing and contrasting the possibilitiesA:
•Probe the preceptor by asking questions about uncertainties, difficulties, or, alternate approachesP:
•Plan management for the patient’s problem issuesP:
•Select a case‐related issue for self‐directed learningS:
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 45
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Video – SNAPPS Introduction
Teaching strategies to enhance acute care clinical reasoning ‐ACEC 2018. Bose, et al.
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Source: https://youtu.be/BPNOdPKUFDE
Video – SNAPPS Conclusion
Teaching strategies to enhance acute care clinical reasoning ‐ACEC 2018. Bose, et al.
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Source: https://youtu.be/BPNOdPKUFDE
Problem- based Learning
• Integration, discussion,negotiation, conflict resolution
•Self‐assessment and acceptance offeedback
• Self‐directed learning and use ofevidence
•Development ofhypotheses
Students “open” new case:
Determine what they need to learn and divide up research topics
Students “open” new case:
Determine what they need to learn and divide up research topics
Research in books, articles, media,
people resources, guest speakers
Research in books, articles, media,
people resources, guest speakers
Return to tutorial to share the results of their research; integration of case
Return to tutorial to share the results of their research; integration of case
Evaluation: Peer eval, self eval and
eval by tutor
Evaluation: Peer eval, self eval and
eval by tutor
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Problem-based Learning vs. Traditional Curriculum
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 49
Problem‐based Learning
• Student‐centered
• Active learning
• Problem (case) is stimulus for learning
• Students seek out appropriateresources and learn to use research literature effectively
• Facilitates communication & interpersonal skill development
Traditional Curriculum
• Teacher‐centered
• Passive learning
• Learn content in silos within individual courses. A case may beused to “tie things up” afterward
• Students have “required” readings
• Doesn’t specifically developaffective skills
Creating a Curriculum Using PBL
Case contentSimple to complex
Multiple layers: anatomy, physiology, medical/surgical management, labs, pharmacology, psychosocial issues, PT exam & intervention, decision‐making dilemmas
Create caseCases should stimulate students to seek out information
Embed “teasers” to provoke students to investigate topics
Create a small number of guiding questions to assist
Objectives What do you want the learner to learn?
Case Construction
Purposes of Case
• Provides context forlearning
• Connects basic science & clinical content
• May provoke discussionof controversial issues
• Promotes retention oflearned information
Start with Objectives (Issues List)
• What do you want students to learn?
• “Triggers” for criticalissues
• Cases reflect realities ofpractice
• Supporting info?
• Labs, videos, EMR, infoavailable if requested
Resources
• Guiding Questions
• Access to the issues list?
• Provision of key resources vs. self‐directed research after info literacy orientation
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 51
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Unique Considerations in Problem-based Learning
Role and training of tutorsRole and training of tutors
Other class structures: large group discussion, labs, otherOther class structures: large group discussion, labs, other
• Tutorial evaluation (content and process in tutorial)
• OSCEs (Objective structured clinical examination)
• Triple Jump
Unique evaluation methodologiesUnique evaluation methodologies
• Consistent vs. inconsistent – module, course, curriculum, year
How and when to use PBLHow and when to use PBL
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 52
Team‐based Learning
Student‐centered, active learning but managed by teacher
Pre‐assigned reading/preparation
Students take Individual Readiness Assurance Test (IRAT)
Each group takes Group Readiness Assurance Test (GRAT)
Faculty teaches based on difficulties encountered in IRAT/GRAT
Problem‐solving activity using a clinical case
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The Socratic Method
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Application of the Socratic Method in Health Profession Education
Cooperative argumentative dialogue using question & answer format
01Dialectical Method in which:
• Two or more people holding different POVs about a subject but wish to establishthe truth through REASONED ARGUMENTS
02Method involves
• Hypothesis elimination, with better & stronger hypothesis being revealed step‐wise and in due course
03
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 55
Closing Summary
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 56
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Summarizing the Session
Challenges in acute care practice
1
Learning theories that inform teaching of acute care content
• Application Examples of the Learning Theories into actual Acute Care Education
2
Explored 5 strategies (stemming from the learning theories) that you can immediately apply in your teaching
3
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 57
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Patient at the Center
He who studies medicine without books sails an uncharted sea….But he who studies medicine without patients, does not go to sea at all.
He who studies medicine without books sails an uncharted sea….But he who studies medicine without patients, does not go to sea at all.
• ‐ Sir William Osler
References – *Slide Courtesy
Greenwood CG, Nippins M, Panasci K. Being an acure care educator: The How, The What, and The Why.
Reference Examples of Some Concept MapsConceptualize History & Physical –
https://mm.tt/721487197?t=B9P4Zvy5jd
Steps in Symptomatic Differential Diagnosis –
https://mm.tt/718685883?t=7a7pXRJJGX
Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 60
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References
• Merriam S, Caffarella R. Learning in Adulthood. San Francisco, CA: Jossey‐Bass, Inc., 1999.
• Torre DM, Daley BJ, Sebastian JL, et al. Overview of current learning theories for medical educators. AmJ Med. 2006 Oct;119(10):903‐7.
• Ausubel DP. Educational Psychology: A Cognitive View. New York, NY: Holt, Rinehart & Winston, 1968
• Brookfield S. Becoming a Critically Reflective Teacher. San Francisco, CA: Jossey‐Bass, Inc., 1995.
• Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner‐centered model for outpatient education. AcadMed. 2003 Sep;78(9):893‐8.
• Barangard H, Afshari P, Abedi P. The effect of the SNAPPS (summarize, narrow, analyze, probe, plan, and select) method versus teacher‐centered education on the clinical gynecology skills of midwiferystudents in Iran. J Educ Eval Health Prof. 2016 Nov 15;13:41. eCollection 2016.
• SNAPPS. YouTube® presentation. Available online at: 1. https://youtu.be/rywuzkm8nmY. 2.https://youtu.be/BPNOdPKUFDE.
• Ian Edwards Mark Jones Judi Carr Annette Braunack‐Mayer Gail M Jensen. Clinical Reasoning Strategies in Physical Therapy. PTJ. Volume 84, Issue 4, 1 April 2004, Pages 312‐330.https://doi.org/10.1093/ptj/84.4.312
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Selected References about Problem-based Learning
Albanese MA, Mitchell S. Problem‐based learning: a review of literature on its outcomes and implementation issues. Acad Med. 1993;68(1):52‐81.
Koh GC, Khoo HE, Wong ML, Koh D. The effects of problem‐based learning during medical school on physician competency: a systematic review. CMAJ. 2008;178(1):34‐41. doi:10.1503/cmaj.070565.
Neville AJ. Problem‐based learning and medical education forty years on. A review of its effects on knowledge and clinical performance. Med Princ Pract Int J Kuwait Univ Health Sci Cent. 2009;18(1):1‐9..
Vernon DT, Blake RL. Does problem‐based learning work? A meta‐analysis of evaluative research. Acad Med. 1993;68(7):550‐563.
Neville, A. The problem‐based learning tutor: Teacher? Facilitator? Evaluator? Medical Teacher. 1999; 21(4):393‐401.
Papinczak, T., Tunny, T. & Young, L. Conducting the symphony: a qualitative study of facilitation in problem‐based learning tutorials. Medical Education. 2009; 43:377‐383.
Questions
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Teaching strategies to enhance acute care clinical reasoning ‐ ACEC 2018. Bose, et al. 64
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