Monday, December 15, 2008

Portfolios in Chiropractic Education

Part of our strategy as teachers in chiropractic educational settings is to encourage our students to take greater responsibility for their own learning, and where possible to personalize their learning experiences. For example, in the clinical bioethics course I teach to graduate students in clinical research, students use portfolios in part to collect articles and other ephemera that they themselves are specifically interested in. There is no caveat on what those articles might be; they simply have to reflect the student’s interests. Of course, as a means of assessment, any tool we use should enhance and support learning as well as be able to measure performance (1). One method that is gaining greater use is the student portfolio.

A portfolio is “a collection of papers and other forms of evidence that learning has taken place” (2) or “a collection of student work that exhibits the student’s efforts, progress and achievements in one or more areas” (3). Portfolios have been introduced into public school education as early as elementary school, and have found homes within professional nursing and medical education.

Friedman Ben David et al (4) note that portfolios contain student work over time demonstrating evidence for learning and progress toward educational outcomes or learning objectives. A portfolio may contain any of the following: best essays, written reports or research projects, samples of performance evaluations, videotapes of interactions with patients, records of practical procedures, letters of recommendation, annotated patient records, written reflections, journal articles, etc.

They further note that portfolios can contribute quite well to assessment. They do allow for assessment of learning outcomes, even to the point of being an effective method for examining outcomes not easily addressed by other means, such as personal growth and reflective ability. A portfolio can provide evidence of performance, which can come from numerous sources. That evidence is collected over a period of time, thus demonstrating development over time. It can track progress toward the learning outcomes as well. Finally, it has use for both summative and formative assessment.

Other benefits include the fact that portfolios may enhance interactions between students and teachers, by allowing dialogue between students and educators, by reminding students that learning is a two-way process, by stimulating teachers to reassess their teaching strategies, and by raising teacher expectation in relation to thinking ability and problem solving. Further, portfolios can enhance the use of reflective strategies on the part of the student.

As I noted above, I require my clinical bioiethics students to keep a portfolio. In it, they place their responses to a series of clinical ethics scenarios which they must address and analyze. They keep journal articles that they use for preparing a short classroom presentation, and they also keep other journal articles that they collect regarding their own personal interests. They can place newspaper articles which they find over the course of the term. They will add their final paper to the portfolio. They are encouraged to ask me to review it at any time, but they are not required to have me do so until the very end of the term. No assignment has a specific due date, except that all my students know the date at which the portfolio is to be turned in with all work completed. This allows them to allocate their time as they see fit. It has been a great success for me to see the quality of the work they do. I recommend that those interested review the references below and consider the use of the portfolio in class.

This will be my final post of the year. We are all getting ready to go on winter break, and I am doing so as well. I want to wish you all a great holiday break, good time with family and friends, and I will be back when 2009 begins.


1. Koretz D, Broadfoot P, Wolf A. Editorial. Assessment in Education, 1998;5(3)
2. Davis MH, Friedman Ben David M, Harden RM, et al. Portfolio assessment in medical students’ final examinations. Med Teacher 2001;23:357-366
3. Martin-Kneipp GO. Becoming a better teacher. Alexandria, VA; ASCP, 2000
4. Friedman Ben David M, Davis MH, Harden RM, Howie PW, Ker J, Pippard MJ. AMEE Medical Education Guide No. 24: portfolios as a method of student assessment. Med Teacher 2001;23:535-552

Monday, December 8, 2008

Relative Risk vs. Risk Difference

It is necessary to distinguish between relative risk (RR) and the risk difference (RD), because the relative risk is typically much larger than then the risk difference so that when you read results in the form of a RR it can be rather misleading. Think about reading a statement that says something has reduced the patient’s risk by 50%. This sounds quite good. However, if you think about it, it might mean nothing more than you reduced the risk from, say, 2% to 1%.

More clinically, imagine that there are three subpopulations of patients, each getting the same treatment, and for each group we see a decrease in risk of 1/3 (that is, RRR= 0.33; RR= 0.67). If this was administered to a subpopulation that has a 30% risk of dying, getting the treatment reduces that risk to 20%. When it is given to a subpopulation that has a 10% risk of dying, the treatment reduces the risk to 6.7%. And when given to a subpopulation that was just a 1% risk of dying, the treatment reduces the risk to 0.67%.

In each group, the treatment reduces the risk of dying by a third, but it really fails to adequately express the full impact of treatment. What if this treatment had a high rate of serious adverse events? Would it make much sense to offer it to the patients in the lowest risk group (where the RD is only 0.3%)? For the middle group, we’d certainly want to let them know about the risks and benefits of treatment, inasmuch as the as the absolute reduction in risk is about 3%. In the high risk group, it makes complete sense to offer this treatment, because there is an absolute benefit of 10%.

The authors of the Users’ Guide suggest that the relative risk reduction be examined in light of your assessment of your patient’s baseline risk. Obviously, you need to have information on the risk reduction of a therapy, which is not always available for chiropractic interventions but could be calculated as per our last blog post. If your know your therapy offers a relative risk reduction of 30% in a general group of patients, you might view it differently if one patient is 40 years old and in generally good health compared to one who is 70 years old and has significant co-morbidity.

This is not the easiest concept to grasp. However, the Users’ Guide offers a great resource in understanding this (1). Further information can be found at

NOTE: As I was home over the weekend, I came across this article in the Washington Post: Howell D. Making sense of science reporting (2). In it, the Washington Post Ombudsman, Deborah Howell, defends the nature of science reporting in her newspaper, but offers the following comment regarding one such article: “FIAR Director George M. Carter's chief complaint was that stories emphasized a change in "relative risk" -- a 44 percent fall in the number of heart attacks, strokes and surgical procedures among people taking the statin, compared with those in the placebo group. He said the fact that everyone in the study had an extremely low "absolute risk" for heart problems should have been emphasized more. About 1.36 percent of people taking the placebo suffered a heart attack or stroke; that fell to 0.8 percent among those taking the statin. That means that nearly 97 percent of the people using the drug would not see any benefit, he said.”

The article goes on to note the author of the news report “quoted a skeptic in the ninth paragraph and noted near the story's end that ‘the actual risk reduction for an individual would be very small, given the relatively low risk for most middle-age people, so that the benefits easily could be outweighed by the costs of thousands more people taking tests, drugs and being monitored by doctors.’”

Finally, the author said "While I would have liked to have explored many of the nuances of this study more fully, I feel confident we struck a responsible balance. I think it's crucial to provide readers with both the evidence supporting new claims and enough context and interpretation to help them gauge its significance." Independent experts, he said, concluded the study was "a very well done, very convincing piece of research."

Which, of course, was not the point. It is only that the average reader cannot draw this distinction between the absolute and relative risk reductions. That much remains clear, and points to why we need to better understand such concepts.


1. Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ guides to the medical literature: a manual for evidence-based practice. New York, NY; McGraw Hill;208:90-91
2. Howell. D. Making sense of science reporting.

Monday, December 1, 2008

Risk, Risk Reducation and Relative Risk

One of the more common reasons we read clinical trial literature is look at the association between a given treatment, such as spinal adjustment, and the outcome of that treatment (for example, reduced pain or disability). But often we do not delve with any depth into the results, and the concept of relative risk is one that we should be looking at as we assess the outcomes for a research paper.

Let us say we have a paper in which in the course of a randomized trial we are comparing a dichotomous outcome (for example, mortality rates) in patients undergoing either Treatment A or Treatment B. And further, let us say that 36 of 128 patients in Treatment group A died, while 58 of 130 in Treatment group B died. From this, we can construct what is called a 2x2 contingency table (here referring to the columns “Death” and Survival” and the rows “Treatment A” and “Treatment B,” in which we put exposure on the left and the outcome across the top. When we do, we will see that in Treatment Group A, 36 people died and 92 survived, and we will call these "a" and "b"; in Treatment group B, 58 died and 72 survived, and we will label these "c" and "d."

This now allows us to be able to calculate risk. First, we can look at the absolute risk for mortality in both groups. This is defined as the risk of the adverse event in each group, sometimes called baseline risk. So, the risk of mortality in Treatment group A is the number of people who died divided by the total number of people in the group: a/(a+b) = 36/(36+92) = 36/128 = .28 or 28%, and in Treatment group B = 58/130 = .45, or 45%.

The difference between these rates is known as the risk difference, or absolute risk reduction. That is, if we compare these risks, we can see that a patient is less likely to die if they have treatment A. The absolute risk reduction is simply the difference between groups (difference meaning subtraction is involved) = c/(c+d) – a/(a+b). Here, that is .45-.28= .17, or 17%.

Finally, rather than look at the difference between groups, we can also look at the ratio; ratio implies that we will be dividing the rates, rather than subtracting them. When we do this, we calculate the risk ratio, or relative risk. Mathematically, this would be the risk in the Treatment group A divided by the risk in Treatment group B (which is typically a control group), or [a/(a+b) / c/(c+d)]. Here, we can see that the math is .28/.45 = .63, meaning that the risk of death is Treatment group A is about 63% (or about two-thirds) that of Treatment group B.

There are complexities to this assessment, which our next entry will take up. For those who wish to read a bit further on this, let me recommend the “Users’ Guide” as a good resource (1).


1. Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ guides to the medical literature: a manual for evidence-based practice. New York, NY; McGraw Hill;208:87-90

Monday, November 24, 2008

Image File Formats

When you are working in a program such as PowerPoint and decide that you wish to insert an image into one of your slides, often you do not consider the file format in which the image has been saved. However, there are a number of different formats in which the files might have been saved, and this entry will provide a brief introduction to each. Information presented here is from the wonderful book “How to Wow with PowerPoint.” (1)

Windows Metafile: This is a proprietary format designed by Microsoft which can be used across all their platforms: Word, Excel, PowerPoint Access, FrontPage, etc. You will see such images saved as either .wmf files (16-bit information) or .emf files (enhanced metafiles, 32-bit information). Bit here refers to the amount of gray the image supports. In the case of 16-bit, that really means 2 raised to the 16th power; and for 32-bit, 2 raised to the 32nd power.

Windows Bitmap: This is generally used across Windows, and is compatible with most applications used by Windows-based computers. The problem with this format (which will be saved as .bmp, .dib, or .rle files) is that it is not compressed, meaning that if you insert such an image into, say, PowerPoint it will cause a delay in loading, projecting or advancing a slide. For large images, it is better to use a compressed format (such as a JPEG).

Computer Graphics Metafile: CGM files are used more in technical fields such as engineering, and in the military, but is not commonly used on the internet.

Graphics Interchange Format: Known as .gif files, this was originally designed for use by CompuServe, but remains in common use. Its files are limited to 256 colors, which makes their use for reproducing photographs problematic; you are exchanging file size for clarity. GIFs are typically used for embedded transparency or basic animations.

Joint Photographic Experts Group: These are known as JPEGs, and are used predominantly for formatting large photos for use in multimedia presentations, such as a slide show. This is best suited for images with many colors, but one should know that the manner in which it is processed allows data contained in the image to eliminated or deleted, so that as it is re-used it will begin to degrade.

Portable Network Graphics: This is a format that attempts to combine the best elements of JPEGs and GIF files. It has a 24-bit image and also will allow for transparency of images (which people often use to place a logo on a master slide).Older web browsers will not support this, but it is effective in presentation technology. Files are saved as .png.

Macintosh PICT: Before Mac had its OS-X (in all its large cat versions), this was the original graphic element, saved as .pct. It is becoming less common now, but may be seen when working with older programs that have embedded graphics.

Tagged Image File Format: This is the .tif file. This is used for high-quality printing projects, though such files, because of their high image quality, typically are very large. Fortunately, they can be compressed in order to reduce file size.

Vector Markup Language: This is a relatively new language that is being advanced by Microsoft and by the W3C, which is the group who sets standards for the Web. All .vml files are supported by the newest web browsers and are based on an XML exchange (a means to share information across many platforms).

This is just an overview of something we rarely think about, but which can affect the effectiveness of our multimedia presentations. There are means within programs such as PowerPoint to convert one file format into others, if ever problems exist in projecting a graphic. The Clip Organizer can do when necessary.

Please, everyone, have a wonderful Thanksgiving break.


1. Harrington R, Reckdall S. How to Wow with PowerPoint. Berkeley, CA; Peachpit Press, 2007

Monday, November 17, 2008

Excel PivotPoint Tables

This past week I attended a webinar program that demonstrated the use of Excel PivotPoint tables for analyzing information in large spreadsheet documents. As I sat through the program, I remember reaching a point where I said to myself, wow, this is really cool! And after the program ended and I had a chance to process the information while talking to some of my colleagues, they also expressed much the same sentiment about the usefulness of this component of the Excel program. I thought I would use this blog entry to simply describe what it does.

A Pivot Table is an excellent means to analyze data that is contained in a list. For example, imagine that you have a spreadsheet that contains the following information: Clothing Type (dresses, belts, pants, ties, shirts), Region (pacific, mountain, south, midwest, northeast), Sales (listed in dollars), Quarter (1,2,3,4) and Sales Type (Retail, Wholesale). And now imagine that you want to extract information from this table, which we will say contains 2400 entries. Say, you wish to look at the breakdown of wholesale versus retail sales, for each clothing type, broken down by region of the country. How can you easily do so? Well, a simple filter will not work, not with 2400 entries and with several different variables to consider. And even if you could, it would require a number of steps to get to the information, which would still be in columnar form and would require additional steps to provide the financial data. So, in a situation like this, a Pivot Table works perfectly, and has the added benefit of being able to be constructed in minutes. Not only that, but it is a simple matter to manipulate the data, which is why it is called a Pivot Table; one can pivot the axes in just two simple clicks of the mouse. Even better, a Pivot Table is something separate from the original data, so you can alter the table without affecting your original data source. It is in fact dependent on that original data.

There are a couple of prerequisites to set up a Pivot Table. You need to have a single title row across the top of your spreadsheet, with unique field headings. For the example I used just above, the headings would be as noted: Clothing Type, Region, Sales, Quarter, and Sales Type. And there can be no breaks in the data, i.e., you cannot have a missing line at line 1400, so no empty columns or rows. To make a table all you need to is make sure you have clicked on any cell within the spreadsheet; then, go to the Data menu at the top of the menu bar. Click on that, and use the pull down menu to go to the entry for “Pivot table and Pivot Chart Report…” This will open a dialogue box called the Pivot Table and Pivot Chart Wizard. Assuming you are working solely with Excel data, select the data you wish to analyze (here, it will be “Microsoft Office Excel list or database”) and then click “Next.” It will then ask you where the data is you wish to assess, and by default will enter the full spreadsheet range. Click “Next” again. It will then ask where you want to put the Pivot Table report. You can enter it either on the sheet you are working from, or have it open on its own sheet. Pick whichever you wish.

Once you do, you will be provided with a blank Pivot Table and a floating Pivot Table Field List (you use this for developing the table). From here, all you need to do is drag and drop. If you look at the blank table, you will see it has several components: on the left is a part that says “Drop Row Fields Here”, across the top is one saying “Drop Column Fields Here”; above that is one saying “Drop Page Fields Here,” and finally is the main box, which says “Drop Data Items here.” You would go to the floating box and simply drag the items you wish to analyze to the appropriate location- which depends on what you wish to analyze. For example, you could drag “Clothing Type” to the “Drop Row Fields Here” location and also drag “Region” to the “Drop Column Fields Here” location. As soon as you do, you would find that the table would tell you how many of each clothing type sold in each region of the country. And all done in seconds. And such tables can be made more complex by additional dropping; we could actually divide the clothing sales type into retail and wholesale with one simple additional drag and drop.

It is actually best to see this demonstrated. This link, to a website at Duke University, provides a very nice demonstration of how what I describe above is done.

The beauty of this tool is the ease it offers for doing detailed data analysis. It is up to the creativity of the user to find the best ways in which this can be used in educational settings.

Monday, November 10, 2008

The SPICES Model: S. Systematic vs. Apprenticeship or Opportunistic Program

In our final entry on Harden’s SPICES model (1), the S distinguishes between a planned, systematic clinical experience versus one that is built around apprenticeship where trainees are “bonded” to their master and acquire skills by following him around and working with him. Examples of this latter approach can be found in our culture through the model of, say, a Jedi knight undergoing training as a “padawan” (novice) following a Jedi master, or by those doctors lucky (or unlucky) enough to work for Gregory House on House, MD. In truth, this problems affects medical education is some ways far more than it can chiropractic education, because we do not have the breadth of hospital contacts that medical students may be involved with, but our preceptor model is built on the idea of an apprenticeship model, though for reasons we can well understand.

In the apprenticeship model, students are assigned to a single teacher, or to a clinical unit or ward, for some period of time. They work on that ward, seeing only those patients on the ward, and therefore see only those conditions that opportunistically present themselves in the unit or clinic. What this means is that these patients are not predicted, nor predictable, which might seem obvious on first thought, but which has implications for planning and training. We would not normally build classes on content that we could not predict, for example. So what students learn, what they are exposed to, is built around which patients are available, the interests of clinic doctors with whom they work, and some change. Students may never get exposure to a representative sample of chiropractic or medical practice. This is less so in chiropractic, since our patient base is typically looking for relief of back pain, but still holds true in general.

The latest thinking is that it would be better if we did not leave clinical training to chance. This requires us to look at clinical training in a new way, one that is systematic and which is designed for all students so that they all get experiences that are necessary for their training. Thus, it may require students rotating through specialties and in various kinds of settings. This still requires enough planning that students understand the expectations and are given a list of skills that need to master, as well as a list of conditions that they are expected to see. Such an approach could be adapted within our own educational settings.

Harden suggests the following factors support a move to a more systematic approach: (1) Students need to experience a range and variety of health problems. Our own research shows that most of our students are exposed to musculoskeletal problems, but not to organic disease, for example, as they do their internships in our clinics. (2) It can help rationalize competencies, letting us know which are essential and which are useful but not absolutely necessary. All chiropractic interns should see cases of shoulder pain, but they do not all need to see cases of food allergy, for example. (3) It allows for better use of time. Once we have seen certain conditions, we may not need to spend much more time seeing many more cases, in the limited training time we have. We could move on.

The benefits of an apprentice ship model include (1) It has organizational advantages. This is a far easier approach to administrate. (2) There is continuity of teaching. A good relationship with a teacher always helps enhance learning.

This completes our discussion of Harden’s model, which can be used in how you plan your curriculum, and in how you see yourself positioning your class along the spectrum that exists for all six components of the model. There is no one perfect position for each decision level; it simply requires you to consider what it is you are trying to do. I hope that it will be of help to you.


1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297

Tuesday, November 4, 2008

The SPICES Model: E. Electives vs. Standard Programs

In Harden’s SPICES model (1), the E defines distinctions between elective programs and a standard course of study. In a standard program, all the students pass through a prescribed set of course, and have few opportunities to study a subject of their own choosing that is outside those courses set in the program. This is very much what the case was when I was a student at National College of Chiropractic; there was a prescribed set of courses and only a single elective course, acupuncture (and that because many states did not allow the practice of acupuncture by chiropractic physicians).

Elective programs that students can choose from allow a student to follow his or her own muse. Such programs can occur in a number of ways: as a single stand-alone class in a given term, as an independent study course, or as a series over time. At Palmer College, students can take elective classes in a variety of chiropractic techniques, for example. In the clinical research master’s program, students can take electives in biomechanics, and they can also design their own independent study course. Such courses have, in the past, included low back outcome assessment instruments, neurophysiology, pediatric journal assessment, etc. The point is that in each case a student designed a course that allowed him or her to pursue a personal interest. And in US medical education, there are even a few programs, such as Stanford University, where the entire curriculum is elective-based, where students can choose their own basic and clinical science courses.

Electives have many benefits. Harden notes that they are a way of coping with an over-crowded curriculum. This arises because as knowledge expands, it is not possible to cover everything, and in curriculum planning using electives may be a way to help students tackle areas where they feel they have interest, or deficiency. Electives provide a means for students to take more responsibility for their own learning. Further, electives can help facilitate career choice by students, and they can help students meet their own personal aspirations. Elective courses can lead to attitude changes as well.

But there are benefits to the standard program as well. Electives require more teachers and more teaching time, and we are all already quite busy. Not all faculty may be interested in teaching such courses. But the presence of electives can have beneficial effects on the standard courses. Program assessment in a standard program is pretty well understood, but it is harder to assess electives.

A combination of electives and a standard program may help make the educational experience in chiropractic more personalized and therefore more personally meaningful. All chiropractic programs have adopted some manner of offering elective courses.


1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297

Friday, October 24, 2008

The SPICES Model: C. Community-Based Education vs. Hospital-Based Education

Furthering our examination of Harden’s SPICES model (1), the C models 2 different methods of clinical training, one based more on working within community-based systems and the other surrounding hospital-based systems. A corollary to this question inside chiropractic education would be a chiropractic college clinic education for interns vs. a preceptor-based education which places the student intern into a chiropractic office located in an external community-based setting. As Harden notes, one of the criticisms of medical education is that it’s hospital-based approach has “fostered an ‘ivory tower’ approach to medicine in which students during their training have little contact, if any, with the community which they are being trained to serve.” While this is certainly less an acute problem in chiropractic education, there remains a kernel of truth here.

In the normal course of medical training, many colleges center their teaching on their main teaching hospital. The staff of those hospitals are the teachers for medical students. And students then attend lectures, tutorials and see patients who were admitted as in-patients to the hospital. They do not see patients in the manner they would were they a general practitioner seeing them in a community office or even in the patient’s own home. One criticism of this approach is that it focuses excessively on specialists and specialization, and students only see therefore a narrow view of patients with medical needs.

On the other hand, those working in community settings see patients that truly represent the community. In medicine, this might be through a community clinic, a family planning center, a patient’s home or in a rural clinic- which is one area where chiropractic experience mimics that of medicine. Students learn a great deal more about the social and economic aspects of illness and patient care, and they learn a great deal more about community values. Health promotion, an area where chiropractic excels, is enhanced in such settings.

Factors that support community-based approaches include: (1) Providing community orientation. This works far better to rain doctors in the delivery of primary care. And doctors will be better understand their role in their community. (2) The community provides useful learning experiences. Continuity of care can be better demonstrated and taught in a community setting. (3) It makes use of untapped resources. It increases the pool of physicians serving the public outside the teaching hospital setting. (4) It encourages active learning. This is more motivating to students. (5) It avoids “student-wise” patients, who know the system and manipulate it. (6) It is a perfect introduction to what “real life” as a physician- in this case, a chiropractic physician- is all about.

Factors that support a hospital or clinic-based system include: (1) There are organizational problems with community-based systems. For example, we need to vet preceptors to make sure students will be properly trained. (2) Chiropractic college clinicians have a wealth of expertise and are trained teachers. (3) Which also means that students gain wide exposure to care management. (4) Some students may wish to enter specialty training as a result of the exposure they receive in the clinical or hospital setting.

One final comment would be to find ways to combine elements of both in clinical training. This remains very much a work in progress.

I will be gone, as many of us are, from October 25 to November 3, so the next post will occur shortly after my return. Please have a great break!


1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297

Monday, October 20, 2008

The SPICES Model: I. Integrated Teaching vs. Discipline-Based Teaching

Continuing our examination of Harden’s SPICES model (1), the I represents the spectrum from integrated teaching to discipline-based teaching. Harden states that “integration is the organization of teaching matter to interrelated or unify subjects frequently taught in separate academic courses or departments.” In more traditional medical or chiropractic educational programs, the teaching tends to emphasize classical disciplines, such as physiology, anatomy, chiropractic adjusting or radiology. The clinical exposure to patients tend to occur late in the curriculum; for example, when I was a student at the then National College of Chiropractic, I did not see my first patient (either for examination, observation or otherwise) until I began my 9th trimester of 10. The standard program organization of a traditional program is one where these foundational discipline-based courses are used as building blocks for later courses which hone the information that follows.

But we have now see movement toward integration across and through the curriculum. Instead of working in sequence only, chiropractic programs are beginning to be both vertically and horizontally integrated. Horizontal integration is integration between parallel disciplines, such as anatomy and physiology, or diagnosis and chiropractic adjusting. An example would be a course in the gastrointestinal system, in which the student learns not just the anatomy of the GI system, but its concomitant physiology and biochemistry. This course is taught not just by a single PHD anatomist, but multiple teachers from several disciplines. Vertical integration occurs when there is integration between disciplines traditionally taught in different phases of the curriculum; thus, courses early in the curriculum are integrated with courses that occur much later in the program. Here, you might see students placed into small groups for the purpose of focusing on patients with chronic disease, and over the course of a 2-year period they would apply the knowledge they learn from their coursework to the understanding of the problems facing those chronic patients. Finally, it is common for programs to incorporate elements of both vertical and horizontal integration.

Harden notes several reasons to use integration in curriculum planning and development. (1) It helps reduce the typical fragmentation of medical or chiropractic courses. It provides a better sense of the unity of information involved in health care education. (2) It can help motivate students and shape their attitude. Integration prevents students from feeling that they are becoming anatomists or physiologists, that the basic sciences are something to get through. They begin to see the relevance of these disciplines to the general practice of chiropractic. (3) It can help improve the educational effectiveness of teaching. They learn better, integrate information better, and therefore forget far less than would occur in a strict discipline-based approach. (4) It fosters higher level objectives. There is less emphasis on recall, more on integration of knowledge. (5) It promotes faculty communication and collaboration. Faculty members from different disciplines are brought together and work together to provide training.

There are also factors that support the use of a discipline-based approach. (1) This approach ensures that the content and fundamentals of a discipline are not neglected. Sometimes information does get lost in an integrated approach. (2) There can be omission of topics. An integrated approach is a systems-based approach, and without proper monitoring, topics can be lost. I saw this at National College after it moved to a problem-based approach; somehow, the entire unit on managing disc prolapse had been lost and only later was added back in. (3) Better teaching- ownership is important, and many teachers are more enthusiastic when they work in their own discipline solely. (4) Discipline-based teaching is less costly. It requires less planning and oversight. (5) teachers are more comfortable in a discipline-based approach.

In general, I think the chiropractic profession has moved toward a more integrated approach, but retains significant amounts of discipline-based teaching. We need to begin gathering more data to see which system works best.


1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297

Monday, October 13, 2008

The SPICES Model: P. Problem-Based Learning/Information Gathering

In Harden’s SPICES model (1), the P stands for differing educational approaches, either one based on problem-based learning or one based on an information gathering model. In a traditional educational approach, we impart a large volume of basic and clinical science information and facts, and then expect students to be able to synthesize that information in order to effectively apply it to patient care. Most health care institutions have followed this model, which has also been much the norm in chiropractic education. But many believe this approach is inadequate preparation for the challenges of life-long learning physicians must engage in. Thus, there has been a movement toward a problem-based approach, which focuses on integration of knowledge and on problem-solving skills.

In a problem-based approach, students are given clinical cases to use as a stimulus for learning both basic and clinical science skills. Cases have to be developed very carefully, so that the specific learning objectives (which may mix basic and clinical science information) are covered properly. Thus, in earlier years of training, the cases may focus more on delineating basic science concepts, while the later years may focus more on clinical skills and information. The primary advocate for this approach is Howard Barrows (2). The primary objective of a problem-based learning (PBL) approach is problem-solving skills, while the primary objective of an information-gathering approach is acquisition of facts and principles.

There are, of course, benefits to both methods. Factors that support a move toward a problem-based approach include that it helps develop problem-solving skills, may help develop an integrated body of knowledge, has general educational advantages, and may help mitigate the presence of an overcrowded curriculum. Problem-solving is essential to the effective delivery of health care, and perhaps the greatest problem-solver of all is Dr. Gregory House, of the TV program House, MD. Developing a body of knowledge is a desirable educational educational outcome as well, in that such integration is necessary for effective care delivery. Students get far greater feedback in a PBL approach than they do in an information-gathering one, and such a program help overcome the fact that our curricula have significant amounts of irrelevant or unnecessary information.

Factors that support a move toward an information-gathering approach include the fact understanding the fundamentals and vocabulary of each discipline is important, that the development of a logical progression of concepts in a discipline is also important, that there is resource availability, that teacher training in delivering a PBL approach may be lacking, and that students are more comfortable with the information-gathering approach. A PBL approach takes time, requires a completely different set of skills on the part of the instructor or facilitator, and requires more personnel to deliver the program effectively. Some students do not like a problem-based approach because it is an active form of learning and requires significant commitment. Finally, the general research comparing these approaches has not shown better outcomes for either, though it has shown greater amounts of student satisfaction with a problem-based approach. Balance may be necessary.


1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297

2. Barrows HS, Tamblyn RM. Problem-based learning: an approach to medical education. New York, NY; Springer Publishing Company, 1980

Wednesday, October 8, 2008

The SPICES Model: S. Student-Centered Learning/Teacher-Centered Learning

In Harden’s SPICES model (1), the S stands for the continuum between a student-centered learning approach versus a teacher-centered one. In a student-centered approach to an institution’s curriculum, the student has to take significantly more responsibility for his or her own learning. In contrast, in a teacher-centered approach, stress and importance are placed upon the instructor and what he or she teaches (i.e., content). To define the differences, Harden uses a restaurant analogy: think of the teacher-centered approach as one similar to a Prix Fixe menu, where you will be eating what the restaurant has prepared for all its guests that day, and the student-centered approach as similar to an ala carte menu where you can pick the foods you wish to eat. That is, in a teacher-centered approach, the teacher is key and we emphasize activities such as formal lecture and laboratory. Students have little say in what they learn, the order in which they learn it and the methods used to teach them. This is essentially a passive form of learning.

This is a typical teacher-centered example: I, a teacher, teach a class that meets 3 times per week for one-hour lectures. My syllabus gives only the briefest description of the weekly topics, so students really have to show up in class to receive the content. They will have a midterm examination at week 7 and a final examination at week 15. They take each test and around 10% fail both exams, but they are never provided feedback about what they missed, nor do I or anyone talk to them about their learning styles. Some of them do pass a make-up examination, but some fail and must repeat the course.

In a student-centered approach, the student is seen as key. With instructor guidance, they may select their own learning objectives, determine which resources they need to meet those objectives, determine the sequence in which they will learn and assess their own progress. An example of this would be a course where students are provided a set of objectives which outline the minimum requirements for the course. Some printed matter is made available, as are some slides, and students can use these at times convenient for them. They can also use any textbook they wish, and can contact an instructor as needed. You would see such scenarios in most problem-based learning programs and classes.

Both of these approaches have advantages. The student-centered approach places emphasis on the student (because what the student learns is more important than what the teacher teaches), may increase motivation, and is good preparation for lifelong continuing education. The teacher-centered approach best uses the experience and expertise of teachers, places fewer demands on a teacher (because it narrows the range of learning resources used), and also relies on the past experience of students, which is largely within the teacher-centered approach.

Also, it is important to note that Harden does not state that one way is better than another in all cases. All teaching will fall on a continuum where student-centered anchors one side and teacher-centered anchors the other. What is certainly the case is that most of us are far more experienced and familiar with the teacher-centered approach, and we would benefit by incorporating more of the alternative.


1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297

Thursday, October 2, 2008

The SPICES Model: Educational Strategies in Curriculum Development

Ronald Harden developed a model that places the curriculum of a medical school along a spectrum of six educational strategies (1). This model, known as SPICES (an acronym for the six strategies) can be used in curriculum planning and development, in resolving problems within a curriculum, and for guidance in teaching methods and assessment. Teachers can use this model in curriculum analysis, review and development. This entry will look at an overview of the model.

Harden came up with this model after recognizing that newer medical schools were adopting innovative teaching methodologies when compared to older and more established programs. For example, McMaster University has been a leader in innovative educational developments, using student-centered learning, integrated teaching and community-based curricular models. They do so to meet the needs of the community in which their graduates will serve, and in which they are themselves located.

The six curriculum issues fall as follows:

Student- centered ----------------------- Teacher-centered
In a student-centered approach, students take more responsibility for their learning. In a teacher-centered approach, the teacher is the key figure and there is an emphasis on formal lecture or laboratory.

Problem-based ------------------------- Information gathering
This contrasts a model of learning based upon problem-solving to develop a usable body of integrated knowledge and problem-solving skills versus one that stresses the acquisition of facts, concepts and principles.

Integrated ------------------------------ Discipline-based
Integration is the organization of teaching mater to inter-relate subjects taught in different academic courses or departments. Discipline-based teaching centers around focus on classical coursework, such as anatomy or physiology, with clinical care coming later in the program.

Community-based -------------------- -- Hospital-based
Though this relates more to medical education than chiropractic education, the traditional hospital-based approach focuses teaching within the main teaching hospital, while community-based education allows students to receive their training in a community setting.

Electives -------------------------------- Standard program
Electives give students the opportunity to select subjects or projects of their own choosing, while in the standard program all the courses have been prescribed and all students must pass through them with little chance to find subjects of their own choosing.

Systematic ------------------------------ Apprenticeship-based (or opportunistic)
The traditional medical approach involved apprenticeship training where a student trainee would be “bonded” to a “master” and acquire skills by working for him (think House, MD on television). In a systematic approach, a program is designed for all students so that the experiences for their training are therefore covered.

All medical and chiropractic colleges can locate themselves somewhere along the continua noted above. Harden himself notes that it is not possible to state where along each spectrum would be the best location. And he further notes that positions at the extreme right or left of each strategy are likely not appropriate. But he does feel that these strategies offer teachers many advantages. I will take that up in a future post.


1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Research Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297

Monday, September 29, 2008

Quality Television (Not Educationally Related)

As we get toward the end of another term, and as the combined weight of all out efforts begins to bear down on us, I thought I would take one blog entry and not write about education, research, evidence-based practice, or educational technology. Instead, I wanted to focus just bit on passion, in the sense of each of us finding something we can be passionate about. I remember that when Dr. Christine Choate had just arrived at Palmer College and was holding an initial meeting of the research department, she asked each of us to talk about something we collected. What came out of that ice breaker went far beyond just being a set of interesting comments. We learned about each other that day, and found a depth and breadth of interests that was surprising in how people’s interests lay. I suspect that the same would be true were I to poll each of you. But in this case, I’ll offer up my own comments on one of my passions, quality television.

Let me start by saying that I don’t really watch TV like other people do, or so I believe. Of course, it is one way of relaxing at the end of a long day, but I do not view TV as a form of escapism. Instead, it is a form of investment. You see, for me, the characters are everything, not the plot or storyline; I invest in the character. You can view a program such as CSI: Crime Scene Investigators as a forensics procedural, or you can view it as a continuing story involving the growth of the characters. For me, it is the latter, and it is that fact that brings a deeper reading of the show to my pleasure in watching it. But hold that thought.

The writer Kristin Thompson defines quality television as having "a quality pedigree, a large ensemble cast, a series memory, creation of a new genre through recombination of older ones, self-consciousness, and pronounced tendencies toward the controversial and the realistic" (1) From modern perspectives, the program most people would define as quality television is HBO’s The Sopranos. But this is not the program I view as exemplifying quality television. I have another in mind.

For anyone who knows me, that program would be Buffy the Vampire Slayer. Okay, so now we have a blog post dedicated to chiropractic education that is singing the praises of a now-cancelled television program about a teen-age cheerleader who is the one person in the world to fight off the threat of vampires. So sue me. :-) What makes this program quality television is that it has probably the best written scripts in TV history, scripts which exhibit self-awareness and memory, so that little bits that appear early in season 2 turn out to have major implications in season 5, where the characters grow, where good and evil are not dichotomous, where everything is shades of grey. Where the episodes range from the hysterically funny to the bone-crushingly painful and poignant, and where everything that everyone does has implications that later have to be addressed. It is no wonder that a cottage industry has arisen around the academic study of Buffy; there is a major online journal devoted to it (, many books, and yearly conferences which are attended by scholars in philosophy, religion, media studies, cultural analysis, film and video, etc. And still it remains hard to get people to see past the name of the program, which is the primary reason people do not watch. Yet, it is rich viewing.

Last year added a new program to my list of quality television. This was the spectacular HBO program In Treatment, which was an experimental series that revolved around the patients seen by a cognitive therapist, Paul, played by the actor Gabriel Byrne. The conceit was that the program was broadcast 5 days a week (weekdays), with each day of the week dedicated to a different patient: Monday was Laura, Tuesday Alex, Wednesday Sophie, Thursday Jake and Amy, and on Friday, Paul himself sees his own former mentor Gina. So the program required commitment from viewers since the storylines, while each able to stand alone, made better sense and had better resonance when viewed in total, since events that occur during the course of therapy in one patient have implications for what happens when Paul sees his other patients and in how he relates to his wife. The acting was superb, and Diane Wiest won an Emmy last week for her portrayal of Paul’s therapist Gina. But the break-out role was played by young Australian actress Mia Wasikowska as Sophie, a truly damaged young gymnast whose story goes nowhere you think it will. This is the mark of quality television; you know all the tropes (young gymnast who won’t eat equals anorexia… except, it doesn’t) and the program subverts them. (PS. The DVD arrives in mid-October).

In my pantheon of quality television, I would include Buffy, In Treatment, The Sopranos, The Wire, The X- Files, CSI: Crime Scene Investigators (Las Vegas only), NYPD Blue, The West Wing, The Simpsons, Six Feet Under, Deadwood, and Lost (which actually I dislike intensely). And truth is, when I watch, I am looking not only at the story, the characters, the memory and everything else, but for material I can even build into my lectures, presentations and professional writings. It’s the best of all worlds.


1. Cited at, accessed September 29, 2008

Tuesday, September 23, 2008

Qualitative Research, Part 4

In this last entry on qualitative research, I’d like to turn my attention to the concept of rigor. Here, we are referring to issues raised by the terms validity and reliability. And we are more familiar, and more comfortable, with what these terms mean when contextualized in a quantitative setting, where we look at questions about whether an instrument we are using actually measures what we claim it measures (such as a pain scale measuring pain) or whether we would get the same outcome in the same patient using the same instrument. But it is much harder to apply these terms to qualitative research. They have to be conceptualized differently in this setting. As Liamputtong notes, “At the heart of the problem with the concepts of validity and reliability in qualitative research is the relationship between the observer and observed ‘reality’.” (1) This is a significant issue when one considers postmodern concepts of reality, where the claim is made that there is no such thing as an observed reality, we are all observers.

In qualitative research, there are 4 approaches to rigor: naïve realism, interpretive realism, postmodernism and hermeneutic realism.

Naïve realism: In this approach, to be rigorous is to ensure that the research describes what is really there in the real world and that this is something one can do repeatedly. You will see this immediately captures standard definitions of validity and reliability. The general idea here, as embodied in positivism, is that there is a reality that exists external to the observer. This reality is fixed and is not influenced by its being observed (so, this is not necessarily the case at the level of quantum physics, for example). It is felt that this particular approach to rigor contains flaws; for example, what do we mean by a fixed reality when we are discussing someone’s culture? Is “culture” objective and unchangeable? When we study people, it is much harder to support a positivist approach, as we are studying people’s lived experiences- which mean something different to each person.

Interpretative realism: In this approach, rigor revolves around the study of social relations, taking subjectivity into account but trying to minimize its effects. This form of rigor is an outgrowth of phenomenological sociology, where the idea is for researchers to try to be “value free” in their studies. This is often seen as the most common approach to the problem if rigor in qualitative research, in that it is closest to trying to use the methods of quantitative research as its goal. It is also often called “postpositivism.”

Postmodernism: In this approach, the entire idea of rigor is rejected; or, it is entirely recontextualized as demonstrating the absence of a relationship between reality and a study’s findings. Postmodernists posit that there is no independently knowable reality; knowledge is based on assumptions and our interpretations and is constructed by us. Now, the extreme edge of this approach is known as radical relativism, which argues that that all beliefs and interpretations are equal since there is no objective reality to which we might make comparisons, but I note that this is the radical edge, and most postmodernists are not willing to take issues this far. For example, we can ask what “gender” means. How do we answer? Is it as simple as “male or female?” What does it mean to be masculine? In the United States, it might mean one thing; in Sub-Saharan Africa another. In many ways, we construct the answers to these questions, based on our own assumptions. But with regard to qualitative research, if we accept multiple interpretations of reality, how does that then affect validity? The questions asked here are important, are now part of our “culture wars” but need to be seriously considered in qualitative research settings.

Hermeneutic realism: This approach notes that research does give us information about events in the real world, but also notes that we must consider the political and socially constructed nature of the findings. It rejects the notion from naïve realism that knowledge is something whose validity can be known with certainty; it is comfortable in living with uncertainty. It does attend closely to the political implications and import of research, because our knowledge of the findings is always colored by our culture and is therefore socially constructed.

All the above are just short introductions to detailed discussions about the philosophical basis for rigor in qualitative research. They help demonstrate that conducting qualitative research requires different considerations in developing rigor; given that most of us are more familiar and more comfortable with quantitative research, should we wish to use qualitative methods it will help us understand the context in which our research should proceed. With this short few entries, I hope I have piqued your interest and you will consider conducting such a study.

1. Liamputtong P, Ezzy D. Qualitative research methods, 2nd edition. South Melbourne, Australia; Oxford University Press, 2006

Monday, September 15, 2008

Qualitative Research, Part 3

The objectives of sampling in qualitative research differ from those in quantitative research. The reason for that difference is that with qualitative research we are not concerned with our ability to generalize the information we collect to a larger population, which is the entire point of the sampling methods used in most quantitative studies. The sampling in qualitative research is called “purposive.” This means that it is intended to describe the processes of a phenomenon, and not its distribution. Our goal is to obtain information-rich cases that allow us to look in-depth into the phenomenon our study is examining. Again, the entire idea is to look at interpretation and lived experience.

Liamputtong and Ezzy (1) list a number of different sampling methods that may be used in qualitative research. They include the following:

Extreme or deviant case sampling: where we select cases that are unusual or distinctive in order to illustrate the processes under examination.
Maximum variation sampling: where we try to select cases that provide for wide ranges in the experience or process under examination.
Homogenous group sampling: here we select a sample to minimize variation and to maximize homogeneity to getter better depth in the process under examination.
Typical case sampling: where we select a case because it is not in any way unusual or atypical.
Critical case sampling: where cases are selected to illustrate processes where the processes would be thought least likely.
Criterion sampling: all cases meet some set of pre-specified criteria. This allows in-depth study of a phenomena, providing rich information.
Stratified purposive sampling: where we select cases from some previously identified subgroups.
Snowball or chain sampling: where after identifying an initial group of respondents, we ask them to suggest other possible participants.
Opportunistic sampling: where as a project develops and as new information is discovered, opportunities to go in new directions arise that are taken advantage of.
Convenience sampling: where we invite whomever we can easily locate and involve. It is often confused with purposive sampling, but Liamputtong and Ezzy (1, p. 49) note that this is a mistake because it does not theorize the sample.
Volunteer sampling: where we obtain participants by advertising for them.
Triangulated sampling: we can combine any of the above as strategies for creating our project develop.

As always, the best method to use is the one that best helps you answer the questions you are asking. It is the best tool for the situation, and the decision to use sample method as opposed to another will be driven by the needs of your project.

1. Liamputtong P, Ezzy D. Qualitative research methods, 2nd edition. South Melbourne, Australia; Oxford University Press, 2006

Monday, September 8, 2008

Qualitative Research, Part 2

Qualitative research places interpretation at the center of activity. What we are looking at is how people interpret and give meaning to their experiences and actions. There is a quote by David Karp that provides insight into this process. In his work, he was looking at depression and had this to say: “I’m not primarily interested in explaining what causes depression or how to cure it because I don’t think anyone can answer those questions. Instead, I’m interested in how depressed individuals make sense of an inherently ambiguous life situation. I’m interested in how a depression consciousness unfolds over time, how people think about psychiatry and medications, and how they deal with family and friends.” (1) He as not gathering quantitative data via, for example, a survey that asked specific questions, but instead was interested in how people interpret what it means to suffer from depression. Quantitative methods simply cannot address that question.

Rossman and Rallis (2) summarize the common features of qualitative research: that it occurs in the natural world, that it has a focus on content, that it may use multiple methods, that it is emergent and that it is interpretive. It is also worth noting that qualitative studies may often lead to quantitative studies as the basis for human belief emerges from the study of how they experience their world. What does it mean to the patient when he or she checks off a score of 6 on a Visual Analogue Scale? If I check a 6 and you check a 6, does it mean the same thing to both of us? This is not a question you can answer using quantitative statistical means.

Liamputtong and Ezzy (3) state that there are three questions which much be answered at the outset of any qualitative study. The first is, what is the theoretical framework within which the study is being conducted. The second is, what is the substantive issue being researched. The final question is, what are the desired outcomes of the study? These are all inter-related questions, and no single one of them has priority over the other two. However, the manner in which the research is conducted relates very much to the framework, and a future entry will look at some of the theoretical frameworks for conducting this interesting form of research.

1. Karp D. Speaking of sadness: depression, disconnection and the meanings of illness. New York, NY; Oxford University Press, 1996
2. Rossman GB, Rallis SF. Learning in the field: an introduction to qualitative research, 2nd edition. Thousand Oaks, CA; Sage Publications, 2003
3. Liamputtong P, Ezzy D. Qualitative research methods, 2nd edition. South Melbourne, Australia; Oxford University Press, 2006

Wednesday, September 3, 2008

Qualitative Research: An Introduction

If you look at the rubrics which comprise part of the process of applying for promotion to associate or full professor, you will see that there are separate entries for the publication of research papers, divided into quantitative and qualitative research. While most of us are more than familiar with standard quantitative research, we may be less so with regard to qualitative studies. Yet certain information can only be gleaned using qualitative methods, and so I hope here to spend a short amount of time describing a bit about this form of research.

In quantitative studies, we gather information that is converted into numbers, so that the data can be statistically analyzed. A simple example would be to conduct a study where we look at changes in pain scores before and after a chiropractic adjustment. Using statistical methods, we would derive a mean pre-adjustment score, and then a mean adjustment score, and perhaps we would then compare these pre and post scores to a second group of individuals who received a different intervention. The appropriate statistical methods would allow us to test the strength of our hypotheses and determine whether our results reached statistical significance. This is the kind of research we are familiar with. But embedded in this research are other questions. For example: what does it mean to the patient that his or her pain score improved by 2.4 points? We learn nothing about the lived experience of the patient in this study.

What qualitative research does is “elicit the contextualized nature of experience and action, and attempts to generate analyses that are detailed, ‘thick,’ and integrative (in the sense of relating individual events and interpretations to larger meaning systems and patterns).” (1) We are focused, in qualitative research, on meaning and interpretation. It is a method to help us understand what meaning people ascribe to their behaviors and actions. This is not something that can be addressed using statistical methods. Instead, we need to use different methods, equally rigorous in comparison to quantitative research, but appropriate to the kinds of questions we ask in qualitative research. As Liamputtong notes, “ Metaphors, meanings and interpretations require the more fluid, but no less rigorous, methods employed by qualitative research.” (1)

We can conduct a study that shows that people with back pain are more depressed than people without back pain’ statistics can clearly show a link between back pain and depression. But why are people with back pain depressed? Can a survey be sufficient to answer that question? Or, can we drill deeper? Qualitative methods can provide us the means to do so.

I will follow this entry with more information on qualitative methods. Hang tight until then.

1. Liamputtong P, Ezzy D. Qualitative research methods, 2nd edition. South Melbourne, Australia; Oxford, 2006:2

Monday, August 25, 2008

Learning Styles

The tendencies and characteristics that students use in their learning are known as learning styles. These styles may influence how students learn, as well as how instructors teach. Understanding something about learning styles may help instructors create the most effective learning environment and impact their instructional design. I think we are already aware, from our learning objective development process, that learning styles are combinations of cognitive, affective and physical factors, which are then used to use to help the student navigate through the learning process. As defined by Sadler-Smith a learning style is “a distinctive and habitual manner of acquiring knowledge, skills and attitudes through study or experience.” (1)

There have been a number of attempts to classify learning styles. As early as 1966, Hudson (2) made a distinction between convergers and divergers. Convergers generally followed linear thinking, using a step-by-step approach to arrive at the “right” answer. The diverger was more fluid and flexible, approaching a problem from a number of different directions, some of which might be quite novel. He felt that convergers would learn best from convergent teachers, and divergers from divergent teachers. Pask (3) used this model to develop his own, breaking learning styles into holists and serialists. The holist used an overarching conceptual framework to help contextualize learning, while the serialist learns in a piece-by-piece fashion, creating knowledge out of smaller pieces of information. Holist learning is mainly associated with art training, while serialist learning would more characterize the average medical or chiropractic setting. Kolb (4) took these 2 approaches and used them to devise his own, which involves divergers and convergers, as well as assimilators and accommodators. In his model, the divergers uses creative ideas and diverse views, the converger is good at problem-solving and implementation, the assimilators uses inductive reasoning to generate theory and integrate ideas, and the accommodator actively applies knowledge but adapts to changing circumstances. These were used to develop Kolb’s Learning Styles Inventory, which was later used to develop The Learning Styles Questionnaire of Honey and Mumford (5). This tool is still used today.

When we begin to ask how we can best develop deep learning in our students, one of the components we need to look at is the styles of learning students use. It is a challenging environment to do so. Certain technologies that younger students use today did not exist when many of us had our undergraduate, graduate or teacher training. This includes the presence of the web, and of instructional platforms such as BlackBoard and WebCT. We have to adapt to these technologies and we can do so most effectively when we understand how our students learn.

1. Sadler-Smith E. Learning style and instructional design. Innovations Educ Training Internat 1996;33:185-193
2. Hudson L. Contrary imaginations. New York, NY; Penguin, 1966
3. Pask G. Styles and strategies of learning. Br J Educ Psych 1976;46:128-148
4. Kolb DA. Experimental learning experience as a source of learning and development. London; Prentice Hall, 1984
5. Honey P, Mumford A. Using your learning styles. London; Maidenhead, 1986

Monday, August 18, 2008

Diffusion of Innovations

One of the books I have been reading lately is Everett Rogers text Diffusion of Innovations (1). What Rogers has done is demonstrate how an innovation spreads through a social system; his work is what has led to the slightly more recent concept of a “tipping point.” This is the idea that change occurs in a system through what amounts to a domino effect (2)

When we are confronted with an innovation from within a social system (consider, for example, such new technologies as myspace, facebook, pda’s, etc.) we have to consider whether or not to use or participate in that innovation. Rogers notes that there are typically 5 steps in how we do this. First, we become aware that the innovation exists, and we gather knowledge about it. Second, we form an opinion about the innovation. This step, persuasion, may lead to use considering the innovation positively or negatively. For example, my personal initial opinion regarding myspace was negative. Third, we decide whether or not we wish to adopt the innovation or not. Then, we implement it, and put it into use. Finally, we evaluate our use of the innovation, and confirm that we did the right thing.

But this is at the personal level. There are also influences that come from our social system. Rogers notes that we can divide a social system into 5 groups: innovators, early adopters, early majority, late majority and laggards. Within medical education, for example, Howard Barrows was the innovator who began the initial talks about the use of problem-based learning methodologies. Once his work had been published, a small number of early adopters began to use that methodology. Their colleagues, noticing the success of that method, began to explore use in their own classrooms; these were the early majority. Some people were late to the game, and for whatever reason put off the adoption until its use had been fairly well established. Finally, there were some who, given the choice, refused to consider the use of this method at all. Innovators are those creative types who are in the forefront of technological developments. Early adopters are often seen as opinion leaders and change agents, people whom others see as trustworthy. When we see these people adopt an innovation, that is when we feel comfortable doing the same. This is when the majority begins to use that innovation. Some come to this early, others late. Finally, the laggards are often isolated or traditional in their work environment, and often suspicious of change.

This is but a framework for this theory, which has implications across disciplines, in media, marketing, education and many other areas of life. But as noted, it may also have implications for how innovations in education can be successfully initiated.

1. Rogers EM. Diffusion of innovations, 5th edition. New Rok, NY; Simon and Schuster, 2003
2. Orr G. Review of Diffusion of Innovations, by Everett Rogers., accessed August 15, 2008

Monday, August 11, 2008

Scientific Papers: The Introduction

The Introduction to a scientific paper- whether that paper is an original data report, literature review or case report- has a very specific function. Its primary purpose is to let the reader know why your paper was written. It therefore provides context for the work you present. Typically, the introduction will provide a short overview of the topic area for your paper. For example, if you are presenting a case report on the successful management of an unusual condition, the Introduction will usually give the reader information about the condition in question, as well as some information about the intervention that was so successfully used. This information will be broad and general in nature; the Discussion section is where you can delve into the details about the condition in question.

An Introduction need not be lengthy. In fact, it is likely that a lengthy Introduction contains information that more appropriately belongs in the Discussion section. And often the Introduction is written to demonstrate where a gap in the literature exists. That is, a certain measure of literature is cited, and the author then points out areas of confusion, disagreement or question and notes where his or her paper fits into that confusion, and how it will provide information that may help to resolve some or all of that confusion.

Let me offer an example. Say we were writing a case report discussing the chiropractic management of Condition AB. My Introduction might proceed along these lines: “Condition AB is a disease affecting X% of the population at any given time, with a lifetime incidence of Y%. The condition occurs when something goes wrong in your organ system, affecting the function of this organ [AUTHOR”S NOTE: I am making this all up so am keeping comments purposely vague]. As a result, this lack of function leads to problems in the musculoskeletal system. Medical treatment for Condition X includes this, that and the other thing. However, there is no information in the literature regarding chiropractic management for Condition AB. This paper presents a case which was successfully managed using high-velocity low-amplitude adjustment.” Now, each sentence here would normally be expanded (and each factual statement referenced correctly) upon so that this entry would run to approximately 3 paragraphs, but you can see all the necessary elements in place.

I highly recommend that to get a good sense of the elements I note above, simply read over a few papers from the Journal of Manipulative and Physiological Therapeutics or other chiropractic journal. This will give you a template from which you can begin to develop not only the Introduction to your paper, but the rest of the paper as well.

Tuesday, August 5, 2008

Writing an Abstract

Not all that long, the abstract for a scientific paper was a prose paragraph that attempted to provide the 5 W’s of a piece of scientific research: who, where, why, when and what. That is, it attempted to give the reader a general sense of what question was being asked, how the researchers attempted to answer it, what they found and what they felt it meant. But studies done in the late 1980s and early 1990s indicated that the abstract was failing in is goal. Squires (1) found that 56% of abstracts did not report the technical design of a study, 79% gave no information on how subjects were selected, 86% made no mention of limitations and 93% made no recommendations for further study. To resolve this failure, the Ad Hoc Working Group for the Critical Appraisal of the Literature (2) proposed the structured abstract, and that is now the professional norm.

A structured abstract is simply that; an abstract that has a specific structure. In the case of an original data report, the structure can be as simple as: Objective; Methods; Results; Conclusion. It may be slightly expanded, so that instead of a Methods section, there are sections on Subject Selection; Site, Main Outcome Measures, etc. Some journals ask that the author prepare a Background section as well, to precede the Objective section. It is important to keep mindful that there is usually a limit of 250 words to the abstract, so brevity is important. The Background section provides context; Objective provides the intent of the paper; Methods tells what was done and how; Results provide aggregate important findings; and Conclusion briefly tells what was discovered.

Abstracts for literature reviews and case reports differ. For a literature review, the main headings should include: Objective; Study Selection; Data Extraction; Data Synthesis; Results; Conclusion. In this form of abstract, the key is in describing what search terms and databases were used, what information was taken from the yield of papers, and how that information was analyzed. In a case report, the main headings include: Objective; Clinical Features; Intervention and Outcome; Conclusion. Here, clinical features refers to important findings leading to diagnosis; intervention and outcome refers to what was done and how the patient responded.

I should also note that different journals may deviate slightly from these models and as always it is important to read Instructions to Authors. And keep mindful that your abstract is the single most important key to whether people decide to read your paper, so spending a little time to get it right serves you very well indeed.

1. Squires BP. Abstracts: the need for improvement. Can Med Assoc J 1991;144:421
2. Ad Hoc Working Group for Critical Appraisal of the Medical Literature. A proposal for more informative abstracts of clinical articles. Ann Intern Med 1987;106:598-604

Monday, July 28, 2008

New Technologies in Chiropractic Education

Let me give a confession. I do not always understand some of this newfangled technology. I watch my children using myspace and facebook and fail to see the appeal of these social networking sites. And indeed, it took me some time to build up the courage to develop this blog page, which is hosted by blogger, and which requires at least a modicum of technological expertise to use. But not all that long ago I had a bit of an epiphany, this time directed by, again, one of my children. My son Noah is a high-school teacher at Hinsdale Central High School, in Hinsdale, IL. We were talking about new technology when I made my standard rant about myspace- what good was it outside of marketing your band or looking like you had lots of friends? Noah first described how the political candidates were using myspace to maintain friend lists, in order to get the word out. And then he described how he used it to provide a means of communication to his students, and to their parents. And it all sort of clicked. That’s when I began to consider far more seriously how one might use web technology for educational purposes.

From that, I looked at various blog hosts, such as blogger (, livejournal (, wordpress (, TypePad (, and others. I played with each one and decided I would develop my page on blogger, mainly due to ease of use and what I felt were interesting design elements. This site is the result of my investigation, and I hope that people find it easy to use, informative and friendly. It is one way to provide faculty with information about educationally-related topics, and to allow for communication at the same time. But you might also consider developing blogs for the courses you teach, using the blog to post additional information for your students, and to foster their involvement in your discipline.

Beyond a blog site, you can consider developing podcasts. These do take more time, since you need to record your podcast, and this means developing scripts and planning words out. But this could be one way to provide students with additional information beyond that which you present in lecture format. This link will take you to apple’s site for podcasting: (Disclosure: I am a Mac fanatic... but this is being written on a Windows computer, and what you do is pretty much the same).

Then there is a site like ( This is a social bookmarking site, where you can gather a set of bookmarks which you share with other people. You can allow only students from a particular class to the url for that class; you can set different sites for different classes. Thus, you can provide a set of links for your students to use without the need to clutter up your personal website. Other social bookmarking sites include digg (, reddit ( and newsvine ( The latter also allows you to collect news article links to share.

This is but the tip of a growing iceberg, and one that most of us are only marginally familiar with. But sites such as these have the potential to transform education. We would do well to pay attention and figure out effective uses of these new technological developments.

Thursday, July 17, 2008


This is not an education-related post, but more for fun. RAGBRAI, the Register's Annual Great Bicycle Ride Across Iowa, is the nation's oldest and largest cross-state ride. I, along with a few other faculty, students and administrators from Palmer, will be joining 12,000 of our closest friends and riding bicycles from the western side of Iowa to the eastern shore. In fact, this year the ride ends in LeClaire, bring us back home after nearly 500 miles of bike riding.

RAGBRAI actually can be used to illustrate how a great idea can spread. This year will be, I believe, the 36th annual ride. There will be 10,000 riders registered for the complete 7-day ride, and an additional 2,000 riders per day who purchase day ride permits. And there are another 15,000 support personnel (truck drivers to transport gear, friends and family and others) who will move from overnight stop to overnight stop each day. As this mass of humanity rides acorss Iowa, they stop in small communities who over the course of an entire year will not see 25,000 people; thus, RAGBRAI is also an economic engine for these small towns. When it started, RAGBRAI had 36 riders in its first year; this grew over the years until the organizers capped the rider level at 10,000 full-time riders, plus day riders. So, in 36 years, it went from less than 50 participants, to 25,000.

And it is not a ride for the buff and fit; RAGBRAI attracts people of all ages and all sizes. I have been passed by a 76-year-old man riding a old fixed single-gear bicycle (with a sign on the back that read "Gears are for wimps"), by 8-year-olds and by grandmothers. I have seen 300-pound women riding mountain bikes with knobby tires for the entire trip, as well as seeing Lance Armstrong (who went by me so fast I thought my bike had stopped). I've ridden alongside the Reverand Robert Molsberry as he rode his hand-cranked bicycle on yet another RAGBRAI; Reverand Molsberry was paralyzed some years ago but refused to let that stop him riding. He even wrote a book about it, "Tour de Faith," which I highly recommend as a great description of the ride. In one of those bits of serendipity, I found out my son had coached his daughter during my son's stint as a student teacher at Grinnell High School. Small world!

It is in general a bit of an older crowd, but it is one that develops great friendships along the way. We will see the riders wearing cow costumes, the ones pulling huge speaker systems powererd by the sun behind them, the fellow who puts a large brick on his bike, and lots of people who otherwise would not be caught dead in skin-tight clothing wearing spandex. I am one of them. And we will eat lots of pie. In fact, the best proof of that was a cartoon in the Des Moines Register, which showed one bike rider talking to another: "How's the training going for RAGBRAI?" and the other answering "Great. I'm up to 4 pieces of pie per day." It's truth!

So I won't be posting until I return, which by that time I might even be able to sit down again. For some reason, we get asked a lot about how our butts are doing when we ride RAGBRAI... :-)

Tuesday, July 15, 2008

Ken Bain- Another Best Teacher

Yesterday at the faculty in-service we were fortunate to have nearly 3 hours with Dr. Ken Bain, who has passionately attempted to understand the qualities of those deemed best teachers. I found the presentation thought-provoking and informative, and I kept coming up with new ideas for my own classes as I participated in this one. And I note that Dr. Bain did so without relying on the use of slides or fancy technology (outside of the fact that this was a video-conference, of course); instead, he taught by asking question, rephrasing answers, and prodding the audience. Well done! So this morning I decided to look at some of his web resources. I am glad I did. I found a link to Montclaire College’s “Course Analysis Project,” which provides a list of questions an instructor can use to examine a course he or she teaches. These questions can help define your course intellectually. The full Analysis Project can be found at, and these questions come directly from that web site, for proper attribution. There are also questions about assessment and evaluation, and each question has a set of explanations to help you understand the goal of that question. We can all use these questions to help develop, revise and improve our courses.

1. What big questions will your course help students answer? Or what abilities (or qualities) will it help students develop?
2. What reasoning abilities must students have or develop to answer these questions?
3. What information will your students need to answer these questions? How will they obtain that information?
4. What paradigms of reality are students likely to bring with them that I will want them to challenge?
5. How will you help students who have difficulty understanding the questions and using evidence and reason to answer them? What questions will you ask them to focus their attention on significant issues, or to clarify concepts, or to highlight assumptions that they are likely to ignore? What writing will you ask them to do that will help them grapple with these matters?
6. How will you confront them with conflicting claims and encourage them to grapple (e. g., collaboratively) with the issues?
7. How will you find out what they expect from the course? How will you reconcile any differences between your plans and their interests?
8. How will you help students learn to learn, to examine and assess their own learning and thinking, and to read more effectively, analytically, and actively?
9. How will you find out how students are learning before you test them for a grade? How will you provide feedback before and separate from any grading of the student?
10. How will you communicate with students in a way that will keep them thinking?

Thursday, July 10, 2008

Number Needed to Treat

The Number Needed to Treat (NNT) is defined as “the number of patients who need to be treated during a specific period to achieve 1 additional good outcome.” (1) Conversely, it can also be considered to be the number of patients who need to be treated to prevent 1 additional bad outcome. The NNT is actually a measure that can help a reader of a scientific article understand whether a piece of research has practical value. And it arises in part because, while the practical interpretation of scientific research is complex, the move toward evidence-based medicine requires physicians and others to be able to interpret what they read, and journal editors and researchers understand this.

One change we are seeing is that one cannot ignore the size of an effect and focus only on statistical significance. (2) This is why we are seeing greater and greater use of confidence intervals (CI) rather than p values, because the CI provides information about both size and significance. The other change we are seeing is a move toward understanding that absolute changes in risk are more important than relative changes in risk. Bear with me here.

In the reference I cite for this entry (reference #2), Simon notes that he was told that snoring increases the risk of a stroke by 3-fold if left untreated. But, he asks not unreasonably, what was the risk before he knew that, given he is 42, in good health and has no other risk factors? Three times nothing is still nothing; 3 times some very small risk is still very small. Does he need to therefore have treatment?

Better would be some measure of absolute risk (noting that above, that 3-fold increase was a relative risk increase). And this is where number needed to treat comes in. The NNT is the average number of patients a doctor would have to treat to have 1 additional event occur. Here are a couple of examples: for prevention of stroke by taking low-dose aspirin daily, the NNT is 102; for preventing infection following a dog bite by administering antibiotics, the NNT is 16 (or, for every 16 dog bites treated with antibiotics, you would see one fewer infection on average). A perfect NNT would be 1, which is often seen in areas such as orthopedic surgery (ie, for every broken radius treated by surgery, you see 1 less broken radius- which makes perfect sense).

The NNT is calculated from a 2x2 contingency table, and is 1/(absolute risk reduction). As an example, say that among patients treated with detuned ultrasound (a placebo intervention), 17.9% of them later suffered chronic back pain, while in the group that received spinal manipulation only 1.3% later suffered chronic back pain. This is an absolute risk difference of 16.6% (17.9%-1.3%). Doing the math here shows that we have an NNT of 6, so for every 6 people who get the SMT, you will see 1 less case of chronic pain.

This is just a brief introduction to a complex and interesting measure, one that has a great deal of significance when you begin to calculate in costs of treatment, rarity of disease, and a host of other factors.

1. Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ guides to the medical literature: a manual for evidence-based practice. New York, NY; McGraw Hill, 2008; p.793

2. Simon S. Number needed to treat., accessed July 10, 2008

Monday, June 30, 2008

A Few Excellent References

I thought I would take an opportunity to list here some texts which I find to be of immense help. I highly recommend each of these books.

1. Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ guides to the medical literature: a manual for evidence-based clinical practice. New York, NY; McGraw Hill, 2008.
This is simply the best text there is about evidence-based medicine. I was able to meet two of the authors during my recent visit to McMaster University, and one (Dr. Cook) was a member of the small-group team for which I was a member. This book provides a complete and thorough overview of EBM, from the initial steps of question formulation and literature searching, through understanding articles about therapy, harm, diagnosis and prognosis, and to how to summarize evidence and apply it to practice. This is a peerless text in the field and one that everyone should have in their personal library. I cannot even begin to state how much use I get out of this book.

2. Haneline M. Evidence-based chiropractic practice. Sudbury, MA: Jones and Bartlett, 2007.
Dr. Haneline is one of ours, a faculty member at Palmer College of Chiropractic West Campus. His text takes the concepts of the Users’ Guide (above) and applies them directly to chiropractic. He is able to synthesize difficulty concepts, and chooses to discuss the most common of the methods delineated in the text by Guyatt and colleagues. Because he chooses to stick to foundational concepts, this is an excellent text to use in teaching and to introduce yourself to the ideas and concepts of evidence-based care.

3. Peat J, Elliott E, Baur L, Keena V. Scientific writing: easy when you know how. London, UK; BMJ Books, 2002.
There are a number of good texts about effective writing for science, but this text by Peat and colleagues is one of the best I have seen. It provides the reader with information covering every aspect of the publication process, from developing concepts and ideas, to preparing a manuscript and writing it, the peer review process and proper grammar. Though I spent nearly 20 years editing chiropractic journals, I find something new in this text every time I look through it. For the novice writer, this is a great source book to help walk you through the process of preparing a paper for publication.

4. Reynolds G. Presentation zen. Berkely, CA; New Riders, 2008.
I’ve noted this book in an earlier blog post, but I think it bears noting again. The use of PowerPoint is endemic in education, but often people do not more than transfer their lectures onto slides as pure test, and then read them to their class, perhaps while slightly improvising what they say. This text provides a new way to consider how to use PowerPoint in the classroom, so that we all move away from bullet points and headline-style presentations. It inspires creativity in the classroom.

5. Beauchamp T, Childress JF. Principles of biomedical ethics, 5th edition. New York,, NY; Oxford Press, 2001.
Okay, this is near and dear to my heart. But it is simply the foundational text in modern bioethics debate, the text around which nearly the entire discipline swirls, and incredibly influential. Discussions of beneficence, nonmaleficence, justice and autonomy were codified here and have taken center stage in the field of biomedical ethics. One cannot do research without taking a look through this text, and one cannot treat patients without doing the same. A dense read, but essential.

Monday, June 23, 2008

The Evidence-Based Teaching Program, Part 2

During the course of the training program at McMaster University, we had both large-group and small-group sessions. Since the primary goal of the program was to provide skill sets for physicians and others involved in health care for use in training either faculty or medical residents, these small and large-group meetings were showcases for various teaching methodologies. I thought I would discuss in brief some of the tactics that were used.

The large-group sessions were held in a standard teaching classroom. At each session, there were approximately 100 people in attendance, and each instructor used various methods for involving and engaging the audience. For example, all instructors commonly asked directed questions at the audience, and allowed time for a number of responses to be received, to be recognized and to be debated. Even when an audience member was way off the mark on a response, their answer was treated with respect, and they were questioned to guide them toward a more proper response. In this way, the fear of being wrong was reduced and this led to more people willing to offer their thoughts.

In the small group sessions (approximately 10 people per group), the main tactic was to ask each participant to present a scientific paper. The paper was organized according to type- therapy, prognosis, diagnosis, systematic review, meta-analysis- and to then discuss that paper with the group via a presentation. There was a checklist provided with each paper that guided, or could help guide, the discussion. In each case, a clinical scenario was used to drive the presentation. For example, we might have been addressing a case where a patient appears to have a condition, and there is a new paper about a new diagnostic test that could be used- for example, beta-natriuretic peptide for differentiating congestive heart failure from lung disease in patients who have dyspnea. What made this challenging is that we had to resolve the clinical question by analyzing the paper for concepts, and then present that to the small group. And we could not use PowerPoint, just a white board. As time went on, presentations became more and more novel, so as not to repeat a method someone else had used. At the end, each presenter was asked to self-critique their performance, then heard the thoughts of the other participants, and finally received comments from group facilitators.

I should note the use of what is called educational gaming. This was an aid in large-group sessions. In simple, it is the use of a “game” in the classroom. In one care, we were all given red and pink index cards, and these were initially used to write short answers to questions, which were then shared with someone not sitting right next to you. These were later used to hold “votes” about the answers to various questions. Another use of a game was an instructor awarding “prizes” to people who correctly answered questions asked of the large group. The prizes were silly, ranging from a pack of gum to, as time went on, a roll of toilet paper, but it engaged the audience for all its simplicity.

The point here is simply that everything that was done in the classroom setting, whether in large or small group, had purpose and truly engaged the learner. It was not a passive learning experience, not at any time.