Tuesday, May 26, 2009
Institutions are influenced not only by outside forces (ie, the economy) but by inside forces as well. This internal dynamic “has its roots in the history of the organization and derives its force from the values, processes, and goals held by those most intimately involved in the organization’s workings.” (1) Decisions and actions are a reflection of the organization’s culture. For those that have been in the culture for some time, the cultural values are part of the air they breath, not often considered consciously but almost always followed nonetheless. It is only when we break the codes of our culture that we find ourselves aware that they are there. But culture is a driver in educational organizations, and as our challenges become more difficult that there is a need to look at culture as a means to help address these challenges.
Tierney notes that organizational culture encourages members to:
- Consider conflict in the broad canvas of organizational life
- Recognize contradictions that create organizational tension
- Implement decisions with an awareness of their role on the culture
- Understand the symbolic dimensions of decisions and actions
- Consider why different groups have different perceptions about performance
Thus, Tierney offers a framework for looking at culture. In this framework, he considers:
- Environment: how does the organizational define its environment and what is its attitude toward that environment?
- Mission: how do we define the mission, articulate it, and use it for decision making? How much agreement is there?
- Socialization: How do new faculty (or staff or administrators) becomes socialized? How do we find out what we need to know to survive and thrive in our new environment?
- Information: What is information, who has it, and how do I get it?
- Strategy: How are decisions made? Who makes them? What happens if I make a bad decision?
- Leadership: What does the organization wants from its leaders? Who are they? Are there informal leaders as well as formal ones?
Our culture is conveyed in the relationships we have with our colleagues, and how we view what we see happening. No organization can be immune to the effects of culture, and understanding it is critical to aiding in innovation and change.
1. Tierney WG. The impact of culture on organizational decision making: theory and practice in higher education. Sterling, VA; Stylus Publishing 2008:24
Monday, May 18, 2009
You can look at the likelihood ratio for one of the diagnostic tests you did. Why look at this? Well, the main reason is that doing so will help move you from your estimate of the likelihood the patient has a disc herniation (also called the pre-test probability) to a more accurate estimate (called the post-test probability of the target disorder). The likelihood ratio is a tool which moves us from pre-test probability to post-test probability.
Consider: the presence of a positive straight leg raise test is seen as indicative of a disc herniation. But it is not conclusive and there may be other possible explanations for its presence. But certainly, with the other information you have collected from your patient, a large likelihood ratio will likely move to you a more positive confirmation of disc herniation, and also may lead you to consider either diagnostic imaging or to a particular management protocol.
A likelihood ratio is the relative likelihood that a given test would be expected to be positive (or negative) in a patient with a disorder as opposed to one without (1). Likelihood ratios can be calculated easily from 2x2 contingency tables used to calculate sensitivity and specificity; a likelihood ratio is actually [Sensitivity/(1- Specificity)]. For the actual math involved, please see http://w3.palmer.edu/lawrence/RSCH841/Reliability%20and%20Validity.doc.
But here is the key to understanding a likelihood ratio. It indicates the extent to which a diagnostic test will increase (or decrease) the pretest probability of the target disorder. LRs of 1 mean that the pre and post-test probabilities are exactly the same; if greater than 1, it indicates an increase in the probability that the target disorder is present (and the greater this number, the greater the probability), while the converse is true for likelihood ratios of less than 1. With a likelihood ratio, you can use a nomogram (such as the one found at http://www.cebm.net/index.aspx?o=1161) to convert the pretest probability to a post-test probability.
In our case, let’s begin by assuming that the pre-test probability of the presence of herniated disc is 50%; this is based on our own clinical expertise plus any literature we may have read. From the paper we found, we see that the likelihood ratio for a straight leg raise is 12. Plugging this into the online nomogram shows us that the post-test probability of a disc herniation is now 94%. One could feel quite comfortable that this patient does indeed have a disc herniation, and can proceed accordingly.
You can find tables of likelihood ratios derived from the scientific literature, such as those seen in the Rational Clinical Examination series from JAMA. They are the most valuable test we have for the use of diagnostic tests.
1. Guyatt G, Rennie D, Meade MO, Cook DJ. Users’ Guides to the medical literature: a manual for evidence-based clinical practice, 2nd edition. New York, NY; McGraw Hill, 2008:426-430
2. Sackett D, Rennie D. The science of the art of the clinical examination. JAMA 1992;267:2650-2652
Monday, May 11, 2009
One the great problems that journal editors face today is that anyone with a computer and a word processing program can create their own tables and graphics to accompany their journal submissions. But most who do so are unaware of the typesetting protocols that go into proper table preparation and make tables that are too complex, too large, too poorly organized or too large. With a little bit of thought, it is possible to construct tables that easily convey information; that is, of course, the entire reason to have one.
Tables need to be prepared so that the information they contain are accurately understood. Tables should be used for the presentation of only certain kinds of information, including information where the numerical values are important, where there is a large amount of numerical data in a compact form, where a summary of information is needed, or where the information cannot easily be summarized in text form. The 6th edition of Scientific Style and Format (1) offers the following guidelines for tables:
- Make them complete enough that the reader does not need to continually refer to the text.
- Make them as simple as possible, and if it is not possible to make them simple, make them logical and orderly.
- There needs to be a logical basis for how you organize columns and rows.
- The units used in a table should be consistent with those in the text (which I note is a common error we find in tables).
- Do not provide the same information in both table and text format.
- Don’t make a table if you can easily explain the findings in a few lines of text.
When you prepare tables for publication, in general they are placed at the end of the manuscript, and are placed on individual new pages of the manuscript, no matter how small any given table might be. If you have 5 tables, that would take at least 5 pages to print. Each table should have a title, which is coordinated to the table number in the text. Each table should be numbered consecutively according to order of occurrence, and each should have its own call-out (that is, words that direct the reader to look at that particular table, ie, “See table 1.”). Do not use numbering where you have variants (Table 1a, 1b, 1c, etc). It is okay to use abbreviations in a table, but you should also use a footnote to let the reader know what the abbreviation means. Doing so saves space, which makes the table less costly to print. You do not need to use more than 2 significant digits in printing numerical data, and you should always provide the unit for the table so the reader knows exactly the meaning of the numerical data. Each column of entries should be aligned with its respective heading, either flush left or centered. If you have no number larger than 9999, you do not need to separate the digits with a comma, but if you go above 9999, you will have to do so (ie, 10,350). If you use decimal points, you should align on the decimal. Footnotes are used when the information they contain does not fit into the logical order of the table. Superscripts are recommended now, as numerics, not as symbols (such as asterisk, dagger, etc.). People understand the order better this way.
A lot of thought goes into table construction and it is not quite as easy as it may initially seem. Style guides such as the one referenced here can provide guidance, as can reference to the Vancouver Accords of the International Committee of Medical Journal Editors (2).
1. Style Manual Committee of the Council of Biology editors. Scientific style and format: the CBE manual for authors, editors and publishers, 6th edition. New York, NY; Cambride University Press, 1994:677
Monday, May 4, 2009
Muller and Irby (2) developed a TSP for the University of California School of Medicine in San Francisco. Their overall goal was to produce educational leaders for UCSF, and therefore they offered accepted faculty learning experiences in 7 areas: learning theory, teaching methods, curriculum development and evaluation, assessment of learning, leadership and organizational change, career development, and educational research. This program requires a weekly 3-hour seminar, with reading assignments and writing exercises. Most sessions have a short initial presentation, followed by a writing experience on the topic. This is then followed by a seminar discussion, typically student-led. Faculty participants are also required to complete a scholarly project. The model offered for learning objectives for this program is one adaptable for use within the chiropractic college setting.
The program at McGill University was developed by Steinert and McLeod (3). This program is a year in length and focuses on 5 major educational themes: curriculum design and innovation, effective teaching methods and evaluation strategies, educational program evaluation, research in medical and health sciences education, and educational leadership. Its primary goal is to help faculty learn more about educational principles and methods, pursue scholarship in medical education, and prepare for educational leadership roles. Scholars admitted into the program are expected to devote one day per week to the activities required to complete the year-long program. The program includes 2 university-based courses from the faculty of education, a monthly seminar, an educational project and participation in faculty-wide development activities. In addition, the organizers have instituted a monthly educational journal club. Assessment has indicated this program is meeting its goals quite well.
The program at the University of Washington (4) was initiated by the same David Irby mentioned about with regarding UCSF. The mission for this program is defined as “to promote academic excellence through the development of a vibrant community of leaders in education who can innovate, enliven and enrich the environment at the University of Washington.” Scholars attend sessions one-half day per week for 10 months, with many of the sessions led by the scholars themselves. They work in collaboration with program leaders to decide upon course readings, but are responsible for teaching material to each other. Scholars are exposed to topics on educational research, leadership, team building, verbal communication, learning theory, curriculum development, creating and evaluating tests, etc. Each scholar is required to complete a capstone project prior to completing the program.
The mission of the Medical Education Scholars Program at the University of Michigan is to develop educational leadership, improve teaching skills, and promote educational scholarship among the medical school faculty (5) Their program follows the academic calendar and meets weekly from September through June for 3 hours per meeting. The curriculum is divided into 5 broad domains: teaching and learning topics; cognition topics; educational assessment topics; academic leadership sessions; research methods and methodology. Scholars in the program are also mentored by senior faculty, and are required to complete a scholar’s project. Faculty scholars lead workshops and then undergo what has been termed an ‘autopsy” examining their performance as workshop leader. A journal club is incorporated into this program as well.
The program at the University of Arkansas (6) evolved over a period of years but has at its center a series of monthly 3-hour workshops related to teaching and educational research, combined with lectures from nationally well-known health science educators. Scholars are required to complete a project, similar to the other programs noted above.
1. Rosenbaum ME, Lenoch S, Ferguson KJ. Increasing departmental and college-wide faculty development opportunities through a teaching scholars program. Acad Med 2006;81:965-968
2. Muller JH, Irby DM. Developing educational leaders: the teaching scholars program at the University of California, San Francisco, School of Medicine. Acad Med 2006;81:959-964
3. Steinert Y, McLeod PJ. From novice to informed educator: the teaching scholars program for educators in the health sciences. Acad Med 2006;81:969-974
4. Robins L, Ambrozy D, Pinsky LE. Promoting academic excellence through leadership development at the University of Washington: the teaching scholars program. Acad Med 2006;81:979-983
5. Frohna AZ, Hamstra SJ, Mullan PB, Gruppen LD. Teaching medical education principles and methods to faculty using an active learning approach: the University of Michigan Medical Education Scholars Program. Acad Med 2006;81:975-978
6. Moses AS, Heestand DE, Doyle LL, O’Sullivan PS. Impact of a teaching scholar program. Acad Med 2006;81:S87-S90