May Faculty Development: The Art of Retention

The Art of Retention

Karyn King TUSM-MMC, M18

It’s midnight the night before a final exam and you’re sitting in front of a pile of notes that you half-heartedly studied while watching the entire series of Friends (again) during the past four weeks of your histology course. Driven by caffeine and an ingrained fear of failure, you realize it’s time to cram every fact you can into your brain before your 8:00 am exam tomorrow morning. Flash forward to one week later when your test scores come out. You nervously open the grading portal, an 87! You think to yourself, “not bad, what was that exam on again?!”

Does this scenario sound at all familiar?

As medical knowledge expands, those in the medical field are tasked with working towards mastery of a vastly large amount of information. Unfortunately, with the nature of multiple choice tests and standardized board examinations, several mistakes can be made while attempting to “master” this content. Below are some tips to not only help with examination performance, but also with long-term retention and subsequent incorporation of learned content into clinical activities.

Tip 1: We all forget things…and that’s ok

  • In 1880, Ebbinghaus set out to determine the relationship between learning and forgetting. Using a single-subject experimental design (i.e. using himself as the subject) he created a “forgetting curve” based on his retention of nonsense syllables over time. There have been several other attempts to classify the relationship between learning and forgetting which have produced similar, yet slightly variable forgetting curves. However, in 2015, the Ebbinghaus curve was successfully replicated by Murre and Dros, providing increased support for the validity of Ebbinghaus’ original curve created in the 1880s.1,5
  • The basic idea of the forgetting curve, whether you use Ebbinghaus’ original curve or not, has been used as a reference for tools aimed at better structuring study habits to combat forgetting learned material. While at its core, the concept of the forgetting curve is not all that surprising, the fact that we do forget content throughout the learning process is a key component of learning and cannot be overlooked.

Tip 2: Practice spaced learning instead of massed learning or “cramming”:

  • Remember the scenario we discussed earlier – the stress inducing all nighter? Well, to be fair, cramming isn’t all If you find yourself ill-prepared for an examination with very little time to dedicate to studying, cramming will certainly be of benefit to your short-term retention of the material and likely your immediate performance on the examination. The downside comes from the fact that cramming gives you minimal long-term retention of material. This is why cramming isn’t the ideal study method if you’re hoping to be able to apply the course content to future experiences, especially clinical care. This is where spaced learning comes in!
  • It has been shown in many studies that spaced learning (i.e. steady review of material over a period of time) with frequent repetitions of the material is much more beneficial for long-term retention.2,4 The most effective way to manage your spaced learning schedule is often with software (e.g. Anki) that has specific algorithms in place to help you determine appropriate spacing intervals for studying based on your specific study patterns and ability to retain information.3 However, if you are committed and your content is easily broken up into discrete chunks, you can in a sense create your own algorithm by breaking your content down into material that you study daily, every other day, weekly, immediately before the exam, etc.3
  • When considering how to apply spaced learning to clinical practice, it is important that we take the knowledge that we have acquired or the new skill we have learned and consciously and deliberately practice it in our day to day clinical work. Practice doesn’t always make perfect, but effortful and deliberate practice certainly makes you a better clinician. Spaced reminders of content as seen in the graph below will help to alter the projection of the forgetting curve and allow you to retain information longer.1, 3

 

References:

  1. Akresh-Gonzales, Josette. “Spaced Repetition: The Most Effective Way to Learn. NEJM Knowledge+.” NEJM Knowledge+, NEJM Group, 31 Jan. 2018, knowledgeplus.nejm.org/blog/spaced-repetition-the-most-effective-way-to-learn/.
  2. Ausubel, David P., and Mohamed Youssef. “The Effect of Spaced Repetition on Meaningful Retention.” The Journal of General Psychology, vol. 73, no. 1, 1965, pp. 147–150., doi:10.1080/00221309.1965.9711263.
  3. Gkiokas, Dimitris. “Spaced Repetition: Learn Once, Remember Forever.” The Metalearners, 15 Feb. 2018, www.themetalearners.com/spaced-repetition-learn-once-remember-forever/.
  4. Karpicke, Jeffrey D., and Althea Bauernschmidt. “Spaced Retrieval: Absolute Spacing Enhances Learning Regardless of Relative Spacing.” Journal of Experimental Psychology: Learning, Memory, and Cognition, vol. 37, no. 5, 2011, pp. 1250–1257., doi:10.1037/a0023436.
  5. Murre, Jaap M. J., and Joeri Dros. “Replication and Analysis of Ebbinghaus Forgetting Curve.” Plos One, vol. 10, no. 7, 6 July 2015, doi:10.1371/journal.pone.0120644.

April Faculty Development: Developing an Implicit Bias Curriculum: Six point Framework

Developing an Implicit Bias Curriculum: Six point Framework

John Gilboy, MS4 Tufts Maine Track.

Implicit bias has been shown to impact clinical decision-making and patient outcomes.1 In addition to clinical outcomes, bias among health care professionals has been linked to the gender gap within health care leadership and specialties. 2 While exploring health care disparities has been a focus in all levels of medical education, few educational interventions have adequately addressed recognition bias. Below is a six-point framework described by Sukhera et al to implement an implicit-bias-informed educational curriculum for health care provider.

Six Point Framework3

  • Creating a safe and nonthreatening learning context

Addressing bias in an educational setting is both risky and challenging for learners and educators. Often instructors and learners can be reluctant to recognize and disclose biases. However, by emphasizing and reinforcing that bias is pervasive in society and that only through explicit recognition is removal possible, learners will be more willing to reflect on personal practices and potential biases. When designing interventions, optimize learner and instructor characteristics to encourage safe and constructive discussion. Instructors should be approachable, nonthreatening, knowledgeable, and supportive of a safe nonjudgmental learning environment.

  • Increasing knowledge about the science of implicit bias

 

When addressing implicit bias recognition, include descriptions of the psychological and neurobiological components of bias and the cognitive science at the root of implicit biases. Discussing the scientific foundation of implicit bias will contextualize the pervasiveness of bias among both caregivers and patients. It also allows for discussion of the different types of biases.

 

  • Emphasizing how implicit bias influences behavior and patient outcomes

 

Emphasizing how implicit bias impacts clinical decisions and patient care is integral to this framework because it enables the instructor to align the educational intervention with health dipartites. It also facilitates discussion on the visible and invisible sociocultural forces that affect our interactions with colleagues, patient, and healthcare outcomes. When discussing with clinical learners, instructors are encouraged to compare bias to heuristic principles in clinical decision making to further highlight the effect on patient care.

 

  • Increasing self-awareness of existing bias

Implicit association test (IAT) is a computer based exercise that aims to assess a person’s automatic associations between words and pictures. Through utilization implicit association tests, instructors hope to spark discussion and self-inventory among learners. Additional techniques to increase awareness of biases work by enhancing reflective capability. Such techniques include an identity exercises in which a learner discusses the dominant and non-dominant cultures to which they belong.

  • Improve conscious efforts to overcome bias

Once identified, instructors show learners how to apply conscious effort in order to negate implicit bias in their decision-making and behaviors. Strategies discussed with learners include metacognitive strategies, which incorporate self-regulation, self-monitoring, and mindfulness training. Learners should be encouraged to set goals and longitudinal checkpoints over time to facilitate self-monitoring and reflection.

  • Enhance awareness of how implicit bias influences others

In conjunction with encouraging self-reflection, instructors illustrate the role that implicit bias plays in communication, rapport building, and empathy. Research has demonstrated that awareness of cognitive and affective components of empathy protects against the implicit bias formation and negative care effects. While social-contact-based interventions may be powerful, they can be difficult to manage in a group setting, particularly in groups with hierarchical power dynamics, and require an experienced instructor.

Figure 1 . Framework to integrate implicit bias recognition and management into health professions curricula, as proposed by the authors. The framework includes six key features: creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others. Under each key feature are a few examples of elements or strategies that should be incorporated into each category; for example, another strategy for increasing self-awareness of existing implicit biases is the use of facilitated discussions on how bias impacts care. Abbreviation: IAT indicates implicit association test.3

For more detailed explanation of framework: Framework article

To take implicit association test: https://implicit.harvard.edu/implicit/takeatest.html

Sources.

1) Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: How doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28:1504–1510.

2) Girod S, Fassiotto M, Grewal D, et al. Reducing Implicit Gender Leadership Bias in Academic Medicine With an Educational Intervention. Academic medicine: journal of the Association of American Medical Colleges. 2016;91(8):1143–1150

3) Sukhera, Javeed, and Chris Watling. “A Framework for Integrating Implicit Bias Recognition Into Health Professions Education.” Academic Medicine, vol. 93, no. 1, 2018, pp. 35–40., doi:10.1097/acm.0000000000001819.

March Faculty Development: How To Teach Quiet Learners

How To Teach Quiet Learners

 Journal Club Entry by Anne Sprogell, TUSM-Maine Track Program, M18

In order to understand how to teach a quiet learner, it is first important to understand a quiet learner. Shy, quiet, or introverted learners are generally characterized by increased reflective thinking and reduced sociability. Their strengths can include the ability to focus, pay attention to details, take thorough notes, and listen to patients and team members. However, these students can struggle with certain aspects of medical school including group discussions with a larger number of students, forming relationships quickly with colleagues in the ever-changing teams of residents and attendings on inpatient services, and in rounds when ideas need to be offered quickly and assertively. Despite these challenges, there might be a few tips that teachers can use to allow their quiet students to shine.

 

  1. Wait 5-10 seconds after asking a question for the quiet student to try to answer. Sometimes quiet students need a little more time to choose their words before they speak.
  2. If an extraverted student is dominating a small group with an introverted student, consider working with the extraverted to student to allow more time and space for the introverted student to contribute.
  3. If one student is dominating the conversation, redirect questions from that student to the quieter members of the team.
  4. Set expectations for the student’s participation and warn them the next time they will be asked to participate.
  5. If environment allows for it, offer space and time for students to practice presentations.
  6. If educational setting permits, allow introverted students time and space to recharge after socially demanding situations.
  7. Consider talking through cases one-on-one with an introverted student if they seem to be struggling in front of the entire team.
  8. If the learning environment allows for it, divide into smaller groups for discussion and use strategies like “think-pair-share.”
  9. Consider written assignments when appropriate. Quiet students might find it easier to express their thinking in a written format.
  10. Understand that quiet students may need to speak from notes, but will use them less as they become more comfortable.

References

  1. Davidson, B, et al. “Introversion and Medical Student Education: Challenges for Both Students and Educators.” Teaching and Learning in Medicine., U.S. National Library of Medicine, 13 Jan. 2015, ncbi.nlm.nih.gov/pubmed/25584478.
  2. Muller, Jessica, and David M. Irby. “Practical Teaching How to Lead Effective Group Discussions.” The Clinical Teacher, Blackwell Science Ltd, 16 May 2005, onlinelibrary.wiley.com/doi/10.1111/j.1743-498X.2005.00057.x/abstract.

February Faculty Development: How to Get the Most Out of a Survey

How to Get the Most Out of a Survey
By: Kimberly Dao, Maine Track, M’18
‘‘Let’s just do a quick survey.’’
— Someone in everyone’s program

Surveys are an easily accessible and commonly used tool in many disciplines. However, the
quality of responses and response rate can vary dramatically. Below are some basic tips to
maximize your survey.

Tip 1 : Picking the Right Survey Tool – There are countless survey tools available online. When
selecting the application, recognize the services offered, pricing, and complexity of each tool.
Qualtrics, SurveyMonkey, and Google Forms are among the most popular tools with specific
advantages to each.
a. Qualtrics: Recommended for large (>10,000 participants) sophisticated surveys that
require special types of input, allows survey takers to save their work and return later, or
if survey questions need to be integrated with other data sets. This product must be
purchased, but many institutions have this tool available for employees.
b. SurveyMonkey: Recommended for most simple research projects. Service is free with
the option for purchase of advanced services.
c. Google Forms: Recommended for simple research projects. Although it does not include
any tools to automate data analysis, you can track and monitor responses.
See below for sites that review/compare survey tools.

Tip 2 : Other Things to Consider – Do you need/require HIPAA compliance? Does your survey
support accessibility (like screen readers, text-to-speech tools, or screen magnifiers)? Does
your survey support mobile devices?
Tip 3 : Survey Design – “The Five Tenets of Survey Design” recommends avoiding: agreement
response items, multi-barreled items, unlabeled response options, unevenly spaced response
options, and non-substantive response options formatted together with substantive response
items. 1 For further explanation and examples, please see the attached table.
Tip 4 : Incentives – Studies have shown that surveys providing incentives have significantly
improved response rates. 4 The mean response rates for surveys providing incentives was
above 70%.
Tip 5 : Time Commitment – Be upfront with how long the survey will take. This enables
participants to plan appropriately.
Sites that review/compare survey tools:
a. TopTenReviews – http://survey-software-review.toptenreviews.com/(link is external)
b. Relevant Insights – http://www.relevantinsights.com/free-online-survey-tools(link is
external)
c. SocialBrite –
http://www.socialbrite.org/2010/09/16/5-top-online-survey-tools-for-nonprofits/(link is
external)

References:
1. Artino, A. R., Phillips, A. W., Utrankar, A., Ta, A. Q., & Durning, S. J. (2017). “The
Questions Shape the Answers”. Academic Medicine, 1.
doi:10.1097/acm.0000000000002002
2. Church AH. Estimating the effect of incentives on mail survey response rates: A
meta-analysis. Public Opin Q. 1993; 57: 62-79
3. Phillips, A. W., Friedman, B. T., Utrankar, A., Ta, A. Q., Reddy, S. T., & Durning, S. J.
(2017). Surveys of Health Professions Trainees. Academic Medicine, 92(2), 222-228.
doi:10.1097/acm.0000000000001334
4. Retrieved January 26, 2018, from
https://education.temple.edu/help/survey-tools-dissertations-and-research

January Faculty Development: Power Posing to Increase Presentation Quality

Power Posing to Increase Presentation Quality     

Andy Biedlingmaier, Tufts M18 Student on Medical Education Elective

Humans and nonhuman primates use open and expansive postures to convey power.  However, new research shows that these “high-power poses” not only communicate power, they also create it.  Therefore, high-power posing can be used to boost presenter confidence, and consequently improve audience evaluation, during high-stakes presentations.

Tip #1:  Spend at least 2 minutes in a high-power pose prior to a high-stakes evaluation or presentation.

Cuddy, Wilmuth, and Carney (2012) performed an experiment in which 61 Columbia University students were randomly assigned to hold either a high-power (expansive, open) pose or a low-power (contractive, closed) pose prior to performing a mock job interview.  Poses were held initially for 2 minutes, and then for an additional 5 minutes immediately before the interview.  Students assigned to the high-power poses reported feeling significantly more powerful after the interview, and scored significantly higher in terms of overall performance and hireability.  This response is believed to result from hormonal changes, as shown by Carney, Cuddy, and Yap (2010).  In their study, participants randomly assigned to high-power poses for two minutes showed a significant increase in testosterone and decrease in cortisol as compared to the low-power posers.  In fact, the low-power posers showed decreased testosterone and increased cortisol after posing for two minutes.  Additionally, high-power posers rated themselves as feeling more powerful on average, and were more comfortable with risk-taking.

Tip #2:  Use a high-power pose to re-gain control of an audience.

 Hale, Freed, and Ricotta, et al. (2017) suggest that the work by Cuddy and others as described above can be applied strategically to re-assert control over a room, or in handling a “difficult” audience member.  They recommend standing up straight with hands on hips as a method of self-assurance and to signal one’s authority to the crowd as needed.  However, one downfall to this method is that it might not be appropriate when addressing more “senior” audience members.

Overall, the work by Cuddy and others suggests a new understanding of body language.  Our posture can stimulate hormonal pathways that mediate our sense of power.  Harnessing this power through selective use of expansive “high-power” poses can improve performance during high-stakes presentations and may have applications in asserting control over an audience as necessary.

For more information on this topic, please see Amy Cuddy’s Ted Talk  

Sources:

Carney, DR, Cudy, AJC, and Yap, AJ.  2010.  Power posing:  brief nonverbal displays affect neuroendocrine levels and risk tolerance.  Pscychol Sci.  21(10):1363-1368.

Cuddy, AJC, Wilmuth, CA, and Carney, DR.  2012.  The benefit of power posing before a high-stakes social evaluation.  Harvard Business School Working Paper, No. 13-027.

Hale, AJ, Freed, J, Ricotta, D, et al.  2017.  Twelve tips for effective body language for medical educators. Med Teach.  39(9):914-919.

December Faculty Development: How do you learn best? Effective Teaching and Learning Style Preference

How do you learn best? Effective Teaching and Learning Style Preference

By: Sarah Couser, Maine Track MS4

Do you prefer to have a map or written directions when you travel somewhere new? When you pick up a

new book, do you buy a hard copy or the audiobook? As a student, did you write notes meticulously or

prefer to have a more hands-on learning experience?

As described by Neil Fleming, there are four different modes of communicating information. Visual

learners, are those that learn best when using graphs, flowcharts, or maps. Aural learners are those that

prefer to learn by listening or discussing. Read/Write learners prefer learning by reading or writing new

material. Kinesthetic learners are those that prefer multi-sensory experiences, including touch, smell, and

taste.

In 2006, Lugan and Dicarlo asked first year medical students to participate in a survey to discover their

learning style preferences. Of the 166 participants, ~5% preferred auditory information, ~5% preferred

visual information, ~8% preferred information in the form of printed words, and 18% preferred

kinesthetic learning, or learning from touch, smell, hearing, taste, and sight. The remaining 64% of

students preferred to learn with multiple modes of information. The study concluded that by knowing

students’ learning style preferences, teachers could help to provide individualized learning experiences for

their learners.

Although many of us are familiar with how we personally learn best, we often forget that others may have

different learning styles than our own. Just as you may doze off looking at diagrams or tables, others may

begin daydreaming if they are not provided with a visual during a lecture. Below, I’ve included some

helpful tips for teaching students with varying learning style preferences. Whether we are teaching in a

classroom or on clinical rounds, it is important to incorporate multiple modes of information. This will

improve our teaching, and ultimately, our students’ learning.

Visual:

• Utilize a powerpoint or videos to display important information

• Show pictures to learners or ask a patient to participate (impetigo or finger clubbing)

• Use a white board to draw diagrams, tables, or flowcharts

Aural:

• Verbally discuss important points with a group of learners

• Ask patients to participate in learning by sharing their own experiences

• Implement teach-back to provide learners additional opportunities to speak and listen

Read/Write:

• Offer lists or handouts for reading material

• Encourage learners to take notes

• Prompt learners to read outside of the hospital (UpToDate, research papers, etc.)

Kinesthetic:

• Provide learners with real-life examples or relevant cases

• Use metaphors that learners are familiar with to facilitate learning

• Ask patients to participate in teaching with physical exam findings (ascites or crackles)

Don’t know your learning style — whether you’re a Visual, Aural, Read/Write, or Kinesthetic learner?

Take the quiz here:

References:

Lujan HL, and DiCarlo SE. “First-Year Medical Students Prefer

 

November Faculty Development: Exercises in Virtue

Exercises in Virtue by Michael Stanley, MS4

Please open the PDF and see text icon in upper left hand corner for the lecture. For access to the original Power point document please email Medical Education at mededuc@mmc.org

October Faculty Development: Tips for Teaching High Value Care on Rounds

Tips for Teaching High Value Care on Rounds     Emily Zarookian, MD

Teaching high value care in medical education is an essential, although recent addition to many graduate and undergraduate medical education curriculums. High value care has become an essential part of medical education as healthcare expenditures continue to rise with up to 30% ($765 billion) of those costs identified as potentially avoidable costs. 1

As teaching high value care can be a new skill for many seasoned attendings physicians it is not surprising that multiple studies have found a lack of teaching high value care on rounds. One study found that only in 20% of observed rounding episodes was there any discussion of high value test ordering principles.2

The following two exercises are examples of easy to use exercises on rounds to emphasize the principles of high value care.

Exercises to use on rounds:

Ask the “five questions” before ordering tests.

The American College of Physicians published five questions physicians should ask before ordering tests.3 Choose one patient on daily rounds and ask the team these five questions before ordering a test.

  1. Whether a diagnostic test other than a CBC, BMP, CMP, or INR was previously performed
  2. Whether diagnostic test results would affect care
  3. Whether a test result represented- or a study under consideration might produce a false positive result
  4. Whether the patient would experience short-term harm if a test were not ordered
  5. Whether the team considered patient preferences towards a diagnostic study

Focus on “Choosing Wisely”

 Select one of the Hospital Medicine “Choosing Wisely” initiatives for the week. Focus on this initiative by asking one team member to track progress throughout the week on decreasing utilization of unnecessary foley catheters, low utility telemetry, or repetitive daily labs. Report progress daily.

Society of Hospital Medicine “Choosing Wisely” 

  1. Don’t place, or leave in place urinary catheters for incontinence, convenience, or monitoring of output for non-critically ill patients.  Suggest team members track foley catheters using EHR to remind team members which patients have foley catheters in place
  2.  Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications
  3.  Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of  active coronary disease, heart failure or stroke.
  4. Don’t order continuous telemetry monitoring without using a protocol that governs continuation
  5. Don’t perform repetitive CBC, CMP in the face of clinical and lab stability.  Suggestion: use comparemaine.org to quickly review the costs of tests and procedures at different facilities in Maine. This        will give learners insight into how expensive unnecessary daily labs can be.

 Additional Resources

  1. JAMA Internal Medicine Teachable Moments Series : Short, easy to read articles that each begin with a clinical vignette in which unnecessary care resulted in patient harm followed by a quick evidence based review of the subject. This series is first authored by learners. Consider encouraging a learner to submit a “teachable moment” if occurs.

References:

  1. Smith, Cynthia MD et al. “Teaching High-Value, Cost-Conscious Care to Residents: The Alliance for Academic Internal Medicine- American College of Physicians Curriculum.” Annals of Internal Medicine. 2012; 157:284-286.
  2. Pierce Cason MD et al. “ Frequency of Attending Physician-Led Discussion of Test-Ordering Principles during Teaching Rounds” JAMA Internal Medicine. 2016; 176:2:261-262
  3. Qaseem  A, Alguire  P, Dallas  P,  et al.  Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012;156(2):147-149.

August Faculty Development: Education Video Production: A How-To-Guide

Educational Video Production: A How-To Guide by:           Alex Fiorentino, MD, Maine Track ’17

Learners of many types are increasingly utilizing online educational videos, and medical learning is no exception to this trend.  As an example, the massive open online course platform Khan Academy has generated a video series geared toward helping nursing students prepare for the NCLEX-RN licensing exam.  At the time of this writing, the platform’s overview of nephron function has been viewed more than 1.6 million times1.

Unfortunately, clinician educators wishing to use video as a tool for teaching students, residents, or patients may feel ill equipped for the task.  Hiring a professional video production team is expensive, while producing one’s own videos presents unfamiliar technical challenges.

The video below highlights key steps to planning, filming, and editing your own educational videos.  It emphasizes low-cost solutions and attempts to demonstrate that with a thoughtful approach, any clinical educator can create polished and effective video lessons.


For additional resources and literature on educational video production, please see the attached PDF.

References:

  1. Khan, S. (2010, March 3). The kidney and nephron.  Retrieved from https://www.youtube.com/watch?v=cc8sUv2SuaY.

 

July Faculty Development: Teaching Clinical Reasoning with the Think Aloud Technique

Teaching Clinical Reasoning with the Think Aloud Technique                      by Kelly M. Brooks, MD, Maine Track ‘16

“Expert clinicians frequently use automatic unconscious thinking processes as they gather and analyze clinical information to generate diagnoses. When experts use think aloud techniques, they articulate their thinking as they are reasoning and by doing so make their thinking processes clear to students.” 1 Think aloud is most commonly utilized as a research method for studying cognition, and is considered a reliable method for capturing peoples’ thought processes.

Researchers at the Dunedin School of Medicine at the University of Otago in New Zealand, piloted a program in their clinical reasoning curriculum that incorporated online modules and training in the think aloud technique. Their pilot study found that the think aloud technique is an example of teaching clinical reasoning in an explicit, transparent way that allows students to better understand a clinicians thinking along the trajectory of a clinical problem and arriving at a diagnosis. Not only did researchers find that this model can be used to teach medical students, but can also serve as a means for attending physicians to assess a learner’s clinical reasoning skills and provide immediate feedback on their student’s thought process.

Tips for incorporating the think aloud  technique (examples incorporated from the pilot study by Pinnock, et al. 2016):

1) Have the student present a patient on the inpatient wards outside of the patient’s room. As the student presents the patient, have the student pause intermittently; during these pauses, the supervising physician will say out loud how she/he is thinking at each stage of the presentation. This will allow the student(s) to understand how the supervisor analyzes the information during the presentation to come to a diagnosis.

2) Have the student present a patient she/he has seen in clinic outside the exam room. Have the student pause during her/his presentation to explain how/what she is thinking. This allows the supervising physician to assess each stage of the student’s reasoning.

3) Consider the learner’s level of experience—for example, pausing after the HPI may help to gather the learner’s initial instincts and broad differential, compared to talking through their thinking after the subjective/objective portion of the presentation for a more fully developed and specific assessment and plan.

4) Clinicians in this study appreciated the minimal training required to use this technique and that this style of teaching incorporated all stages of clinical reasoning, and could continue to educate students on core clinical reasoning skills such as utilizing pattern recognition and hypothetic–deductive thinking.

5) Potential barriers: Clinician supervisors voiced their concern about time limitations in the clinical setting that may prevent them from utilizing this technique. Researchers are following up with a study to help better understand this and other barriers to teaching clinical reasoning with the think aloud technique.

1 Pinnock R, Fisher TL, Astley J. Think aloud to learn and assess clinical reasoning. Med Educ 2016 May;50(5):585-586. PMID: 27072473