Tuesday, February 24, 2009

The IRB and Expedited Review

Most IRBs have procedures for expedited review for specific types of research involving no more than minimal risk. These include procedures that follow, adapted from the Code of Federal regulations (45 CFR 46).

Prospective collection of:

1. Biological specimens for research purposes by noninvasive means such as: hair and nail clippings in a non-disfiguring manner; deciduous teeth at time of exfoliation; permanent or deciduous teeth if routine patient care indicates a need for extraction; excreta and external secretions (including sweat); uncannulated saliva collected either in an unstimulated manner or stimulated by chewing gum base or wax or by applying a dilute citric acid solution to the tongue; placenta removed at delivery; amniotic fluid obtained at the time of rupture of the membrane prior to or during labor; supra- and subgingival dental placque and calculus, provided the collection procedure is not more invasive than routine prophylactic scaling of the teeth and the process is accomplished in accordance with accepted prophylactic techniques; mucosal and skin cells collected by buccal scraping or swab, skin swab, or mouth washings; sputum collected after saline mist nebulization.

2. Blood samples by finger stick, heel stick, ear stick or venipuncture collected no more than twice weekly from health, nonpregnant adults who weight at least 110 pounds in amounts not to exceed 550ml in an 8-week period, or from other adults and children, considering the age, weight, and health of the subjects, the collection procedure, the amount of blood to be collected, and the frequency with which it will be collected, but the amount drawn may not exceed the lesser of of 50ml or 3ml per kg in an 8-week period.

3. Research involving materials (data, documents, records, or specimens) that have been collected or will be collected solely for non-research purposes (such as medical treatment or diagnosis).

4. Data obtained through noninvasive procedures (not involving general anesthesia or sedation) routinely employed in clinical practice, excluding procedures involving x-rays or microwaves. Any medical devices must be already approved for marketing and not currently being tested for safety and effectiveness. Examples: physical sensors that are applied to the either the surface of the body or at a distance and do not involve input of significant amounts of energy into the subject or an invasion of the subject’s privacy; weighing or testing sensory acuity; magnetic resonance imaging; electrocardiography, electroencephalography, thermography, detection of naturally occurring radioactivity, electroretinography, ultrasound, diagnostic infrared imaging, Doppler blood flow and echocardiography; moderate exercise, muscular strength testing, body composition assessment, and flexibility testing where appropriate given the age, weight, and health of the individual.

5. Data from voice, video, digital, or image recordings made for research purposes.

6. Data on individual or group characteristics or behavior (such as research on perception, cognition, motivation, identity language, communication, cultural beliefs or practices, and social behavior) or research employing survey, interview, oral history, focus group, program evaluation, human factors evaluation, or quality assurance methodologies.

Decisions on exemption at Palmer College initially start with consideration by the Human Protections Administrator. If exempt, you are free to conduct your research; if not, the IRB will review the project proposal.

Monday, February 16, 2009

Using Television Shows to Teach Communication

An interesting new paper by Wong and colleagues (1) discusses how they used excerpts from two television shows to help teach their internal medicine residents better communication skills. As has long been understood, good communication skills are a necessary part of patient care; these skills help build trust, help communicate information at a level the patient can understand, and therefore also help to increase patient satisfaction. While communication skills are now a core competency within the medical profession, I am not certain that this is the case within chiropractic. Certainly, within Palmer College, attention is given in practice management courses to better communication, and there is also our SPEAK organization, which is designed to provide opportunity and training to our students in public speaking. This is but another form of communication, of course. However, a standardized curriculum or teaching approach does not exist.

In 1999, medical educators met in Kalamazoo, Michigan to develop such guidelines (2).There model had seven essential elements: building a relationship, opening the discussion, gathering information, understanding the patient’s perspective, sharing information, reaching agreement on problems and plans, and providing closure. As Wong et al note, no formal teaching method for this model exists in the literature. There therefore tried to develop such a model based on what is know as cinemeducation, or the use of clips from popular television and movie clips.

Their project used clips from the programs House, MD and Grey’s Anatomy. Episodes were carefully selected to demonstrate important and/or sensitive situations in doctor-patient relationships. The scenarios helped to demonstrate the importance of the seven competencies provided by the Kalamazoo model. Here, the scenarios looked at end-of-life issues, psychosocial aspects of illness, and disclosure of medical errors. After watching, residents were asked to answer questions related to the seven aspects of the Kalamazoo model, and to have interactive reflection about what they experienced while watching.

While it is true that television programs have a heightened sense of reality, and are drama driven, their use as a teaching tool may not be used as effectively, or even as much, as possible. Within my field of bioethics, House, MD provides significant grounds for discussion. I have even posted an earlier blog post using one of its episodes as grounds for discussion. I’d like to suggest that some consideration be given to using this mode of teaching, which will engage our students at a cultural, as well as an educational, level.

1. Wong RY, Saber SS, Ma I, Roberts JM. Using television shows to teach communication skills in internal medicine residency. BMC Med Educ 2009;9:9 doi:10.1186/1472-6920-9-9
2. Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001;277:390-393

Monday, February 9, 2009

Social Capital

Social capital is a concept derived from sociological research which can be applied to the educational setting. It refers to the connections that exist with and between social networks as well as connections among individuals (1). The core idea of social capital is that social networks have value and may play a significant role in the productivity of faculty within an institution of higher learning. (2) Adler and Kwan define social capital as “the goodwill that is engendered in the social relations of social systems, and that can be mobilized to facilitate collective action.” (3)

Social capital as an idea has been useful in aiding our understanding of organizational behavior. In specific, it has been used to examine cooperation and trust. Notably, it exists only within its specific setting, and is seen by management researchers as an important source of competitive advantage. One of the great problems facing those looking at social capital is, how do we create it? A paper by Pastoriza and colleagues (4) argues that a critical component of social capital is the daily personal interaction of personnel at all levels of the organization. The issue becomes how to foster and facilitate trust, associability and identification as chief components of social capital.

We are not social scientists here at Palmer. Most of us do not consider management theory in our interactions with friends, colleagues, administration or academic leadership. Yet we all know that there are good ways to enter into discussion, and there are less effective ways to do so. Management theory looks at issues such as self-interest, opportunism and note that human agency may be an important driver in our interactions, i.e, what is in it for me? Entire disciplines are built around this, such as agency theory and transaction cost analysis, and therefore efforts need to occur to overcome the limitations of self-interest. Mind you, this should not be seen as a negative. We wish to see self-motivated faculty working to advance themselves while also working to hone their draft. But of course, all of us are mindful that we are doing so within an organizational system, in our case a chiropractic education institution.

Pastoriza notes that organizational social capital has two main components: associability (collective goal orientation) and shared trust. Associability is defined as “the willingness and ability of organizational members to subordinate their parochial interests to firm’s collective goals.” (5) Here, the idea is that we care for others’ well being. Shed trust refers to one individual fully internalizing the other’s preferences. Organizations with high levels of social capital have high levels of identification trust.

Social capital can be created, but it takes work. AS one can read from this short description, a main goal in creating social capital is to enhance trust and associability, both of which work to enhance human relations. Success in its creation works to the benefit of both the organization and the people working for it.

1. Portes A. Social capital: its origins and applications in modern sociology. Ann Rev Soc 1998;24:1-24
2. Putnam R. Bowling alone: the collapse and revival of Americna community. New York, NY; Simon and Schuster, 2000
3. Adler PS, Kwan S. Social capital: prospects for a new concept. Acad Management Rev 2002;27:17-40
4. Pastoriza D, Arino MA, Ricart JE. Ethical management behaviour as an antecedent of organizational social capital. J Business Ethics 2008;78:329-341
5. Leana CR, Van Buren HJ. Organizational social capital and employment practices. Acad Management Rev 1999;24:538-555

Monday, February 2, 2009

Small Group Learning

Small group learning is one effective method health care educators can use to enhance student learning. As noted by Crosby (1), it “recognizes a movement towards learner-centered, problem-based and self-directed learning.” Crosby notes that there is no definitive answer to what constitutes “small” in terms of number of students, but what is important is that a small group must exhibit three attributes: active participation, a specific task, and reflection. By this, she means that those involved must all actively engage in the interaction, must have a clearly defined task and must reflect so that deep learning is achieved.

There are a number of benefits to small group learning. They include:

– Actively learn. When one works alone, it is often difficult to be able to understand what you have learned, what you do not understand and what you need to understand. Using group discussions can aid in understanding and in determining what information a student is not comprehending. Further, it helps that each student brings to their discussions an individual knowledge base which can be shared.
– Encourages self-motivation. Being actively involved motivates persons to learn and to learn more effectively.
– Allows application and development of ideas. Ideas generated by the group can be applied and tested, and therefore also help understanding of the issues involved.
– Promotes deep learning. Surface learning is the learning of facts, which requires nothing more than memorization. Small group work has been found to be better able to achieve deep learning, a better sense and understanding of the material.
– Promotes an adult style of learning. Part of our goals in educating our students is to expose them to adult learning principles. Our students come in as a mix of both traditional students (such as those who have come straight from a traditional undergraduate background) and adult learners (those who may have had experience in a work setting for some time before entering chiropractic college). Once everyone graduates, adult learning styles become critically important; the newly minted doctors need to know how to locate, synthesize and apply information without being led there by an instructor. Small group learning works with these principles and encourages individual responsibility for learning.
– Develop transferable skills. These skills include leadership, teamwork, organization, collaboration, time management, etc. They are skills that can be used in many settings within health care.

Cosby also notes the challenges to small group learning:

– Students do not like small group work. They are not accustomed to it, particularly those who come in from traditional undergraduate programs. It is alien to their experience. They don’t see the value, have been acculturated to passive learning, can wreak havoc in group dynamics, and it can be difficult for the students to see how learning is occurring.
– Staff do not know how to teach in small groups. Most of us grew up as traditional teachers, content experts who know our discipline and have found means to effectively (we think) teach our craft. This experience requires a new role for an instructor, one that differs from our past experience.
– We do not have enough teachers for small group work. This is always a challenge, because it does require additional time involvement by the instructors.
– There are too few rooms. This is also a problem in many institutions, and could potentially be so here were we to use this form of teaching in more widespread fashion.
– It is a waste of time- students do not learn anything. We feel that because we did a lecture on a topic and because students were there to hear it, they have learned it. And there is solace in that. We cannot see the learning in small group like we do in lecture, because we cannot see “the lecture” in those sessions. Therefore we often may believe no learning has occurred.

There are certainly challenges in using small-groups, but there is also great opportunity as well.

1. Crosby J. Learning in small groups. Med Teacher 1997;19:189-202