Monday, December 13, 2010

New Papers on Healthcare Education

These new papers touch on areas that we at Palmer College are involved with. I thought I would post these as a result.

1. Clark ML, Hutchison CR, Lockyer JM. Musculoskeletal Education: A Curriculum Evaluation at one University. BMC Medical Education 2010, 10:93doi:10.1186/1472-6920-10-93

Background: The increasing burden of illness related to musculoskeletal diseases makes it essential that attention be paid to musculoskeletal education in medical schools. This case study examines the undergraduate musculoskeletal curriculum at one medical school.
Methods: A case study research methodology used quantitative and qualitative approaches to systematically examine the undergraduate musculoskeletal course at the University of Calgary (Alberta, Canada) Faculty of Medicine. The aim of the study was to understand the strengths and weaknesses of the curriculum guided by four questions: (1) Was the course structured according to standard principles for curriculum design as described in the Kern framework? (2) How did students and faculty perceive the course? (3) Was the assessment of the students valid and reliable? (4) Were the course evaluations completed by student and faculty valid and reliable?
Results: The analysis showed that the structure of the musculoskeletal course mapped to many components of Kern's framework in course design. The course was subject to a high level of commitment to teaching, included a valid and reliable final examination, and valid evaluation questionnaires that provided relevant information to assess curriculum function. Analysis also identified several weaknesses in the course: the apparent absence of a formalized needs assessment, course objectives that were not specific or measurable, poor development of clinical presentations, small group sessions that exceeded normal 'small group' sizes, and poor alignment between the course objectives, examination blueprint and the examination. Both students and faculty members perceived the same strengths and weaknesses in the curriculum. Course evaluation data provided information that was consistent with the findings from the interviews with the key stakeholders.
Conclusions: The case study approach using the Kern framework and selected questions provided a robust way to assess a curriculum, identify its strengths and weaknesses and guide improvements.

2. Botezatu M, Hult H, Fors UG. Virtual Patient Simulation: what do students make of it? A focus group study. BMC Medical Education 2010, 10:91doi:10.1186/1472-6920-10-91

Background: The learners' perspectives on Virtual Patient Simulation systems (VPS) are quintessential to their successful development and implementation. Focus group interviews were conducted in order to explore the opinions of medical students on the educational use of a VPS, the Web-based Simulation of Patients application (Web-SP).
Methods. Two focus group interviews - each with 8 undergraduate students who had used Web-SP cases for learning and/or assessment as part of their Internal Medicine curriculum in 2007 - were performed at the Faculty of Medicine of Universidad el Bosque (Bogota), in January 2008. The interviews were conducted in Spanish, transcribed by the main researcher and translated into English. The resulting transcripts were independently coded by two authors, who also performed the content analysis. Each coder analyzed the data separately, arriving to categories and themes, whose final form was reached after a consensus discussion.
Results. Eighteen categories were identified and clustered into five main themes: learning, teaching, assessment, authenticity and implementation. In agreement with the literature, clinical reasoning development is envisaged by students to be the main scope of VPS use; transferable skills, retention enhancement and the importance of making mistakes are other categories circumscribed to this theme. VPS should enjoy a broad use across clinical specialties and support learning of topics not seen during clinical rotations; they are thought to have a regulatory effect at individual level, helping the students to plan their learning. The participants believe that assessment with VPS should be relevant for their future clinical practice; it is deemed to be qualitatively different from regular exams and to increase student motivation. The VPS design and content, the localization of the socio-cultural context, the realism of the cases, as well as the presence and quality of feedback are intrinsic features contributing to VPS authenticity.
Conclusions. Five main themes were found to be associated with successful VPS use in medical curriculum: Learning, Teaching, Assessment, Authenticity and Implementation. Medical students perceive Virtual Patients as important learning and assessment tools, fostering clinical reasoning, in preparation for the future clinical practice as young doctors. However, a number of issues regarding VPS design, authenticity and implementation need to be fulfilled, in order to reach the potential educational goals of such applications.

3. Deom M, Agoritsas T, Bovier PA, Perneger TV. What doctors think about the impact of managed care tools on quality of care, costs, autonomy, and relations with patients. BMC Health Services Research 2010, 10:331doi:10.1186/1472-6963-10-331

Background: How doctors perceive managed care tools and incentives is not well known. We assessed doctors' opinions about the expected impact of eight managed care tools on quality of care, control of health care costs, professional autonomy and relations with patients.
Methods: Mail survey of doctors (N=1546) in Geneva, Switzerland. Respondents were asked to rate the impact of 8 managed care tools on 4 aspects of care on a 5-level scale (1 very negative, 2 rather negative, 3 neutral, 4 rather positive, 5 very positive). For each tool, we obtained a mean score from the 4 separate impacts.
Results: Doctors had predominantly negative opinions of the impact of managed care tools: use of guidelines (mean score 3.18), gate-keeping (2.76), managed care networks (2.77), second opinion requirement (2.65), pay for performance (1.90), pay by salary (2.24), selective contracting (1.56), and pre-approval of expensive treatments (1.77). Estimated impacts on cost control were positive or neutral for most tools, but impacts on professional autonomy were predominantly negative. Primary care doctors held more positive opinions than doctors in other specialties, and psychiatrists were in general the most critical. Older doctors had more negative opinions, as well as those in private practice.
Conclusions: Doctors perceived most managed care tools to have a positive impact on the control of health care costs but a negative impact on medical practice. Tools that are controlled by the profession were better accepted than those that are imposed by payers.

This will be the last blog post of 2010. We are all soon heading into our all-too-short vacation break. I wish you all the very best for the upcoming holiday season and for the new year.

Monday, December 6, 2010

Rubrics Continued

Rubrics are comprised of 4 general parts: a task description, characteristics to be rated (usually placed in rows), levels of mastery (usually placed in columns) and a description of each mastery level; that is, of each cell.

The task description is the outcome being assessed or the instructions a student is provided for an assignment. The characteristics to be rated are the skills, knowledge or behaviors to be demonstrate by the student. The levels of mastery should be written clear language. An example might be something along the lines of: exemplary, proficient, marginal, unacceptable. Finally, each cell would contain a description of the what is required for each mastery level.

The University of Hawaii at Manoa (1) suggests that there are 6 steps to developing a rubric:

Step 1: Identify what it is you wish to assess.

Step 2: Identify the characteristics you wish to rate. Here, you would detail the skills or knowledge you plan on evaluating, limiting them to those you feel are most critical or important.

Step 3: Identify the levels of mastery: The authors recommend that you use an even number of categories to avoid the middle category being a sort of “catch all” for scoring.

Step 4: Describe each level of mastery for each characteristic (cell). Start by describing the best work you could reasonably expect to receive for that characteristic, and set that as your top category. Determine what would comprise unacceptable work and set that as your bottom category. Finally develop your mid-categories, ensuring that there is no overlap between any of them.

Step 5: Test the rubric. Apply it to an assignment, and share it with colleagues for their input. You also need to determine the minimal work that you would find acceptable for passing. This could be based on an average, a total score, or achieving a score of, say, marginal on every cell. Or, of course, you could set the standard higher than that.

Step 6: review and revise. It takes work to set these up and ensure they measure what you wish to measure. Rubrics also allow us to share grading expectations, which may be of help; for example, consider how a rubric might be used to assess a technique practical examination.

1., accessed Dec 3, 2010

Monday, November 29, 2010

Introduction to Rubrics

A rubric can be defined as “as assessment tool often shaped like a matrix, which describes levels of achievement in specific area of performance, understanding, or behavior.” (1) Rubrics are generally classified into one of two groups, the analytic rubric and the holistic rubric.

The analytic rubric provides a student with the criteria to be assessed at each level of performance and gives a score for each of those criteria. Thus, it can provide a student with a significant level of feedback, and allows for some consistent scoring among students and across evaluators (if more than one is to be used). However, these take more times to score. Analytic rubrics are best used when you wish to see the specific strengths and weaknesses of your students, and when you wish to have detailed feedback about individual performance.

The holistic rubric provides one single score for a student based on an overall impression of that student’s performance in the activity or task being assessed. These types of rubrics allow for quick scoring, an overview of achievement with detail and are efficient when you have to grade a large number of students. Obviously, it cannot provide detailed performance information, and it can be hard to determine one single overall score for a given student. Thus, this is best used a “snapshot” of student performance, and when you find that a single dimension is sufficient to evaluate quality.

Using a rubric allows you to examine complex behaviors or products efficiently using a common framework for assessment and evaluation. They are criteria-based rather than norm-based; you are not comparing student behavior to each other but to a set criterion standard. Another positive attribute of rubrics is that when used among several teachers, a rubric allows for collaboration and cooperation, leading to better assessments. There are shared expectations and grading practices.

An excellent reference text for using rubrics in higher education is “Introduction to Rubrics,” by Stevens and Levi (2). Next week I will describe the components of a rubric and the steps necessary to develop one. A good number of Palmer faculty members use them in assessment, and I hope that if you do not, you may wish to consider doing so moving forward.

1., accessed November 29, 2010
2. Stevens DD, Levi AJ. Introduction to rubrics. Sterling, VA: Stylus Publishing LLC, 2005

Monday, November 22, 2010

2011 ACC-RAC and Palmer College Represent!

The schedule for the 2011 ACC-RAC conference was recently announced and I am happy to say that Palmer College of Chiropractic is extensively represented. Please note all of the following papers and presentations and give a short note of congratulations to all involved. And consider submitting something yourself next year!

Papers accepted for platform presentation

Enhancing the Use of Evidence-Based Clinical Practice Methods Through Diffusion of Innovation Theory and a Train-the-Trainer Model in Chiropractic Education
Michelle Barber, Ron Boesch, Lia Nightingale, Michael Tunning, John Stites

WIKI a Collaborative Faculty Development Tool
Ron Boesch, Robert Illingworth

Mentored research opportunities for students in a doctor of chiropractic program
Lori Byrd, Cynthia Long, Liang Zhang, Robert Cooperstein, Joel Pickar, Charles Henderson

Improving targeting accuracy in mapping upright spinal levels to the prone position
Robert Cooperstein, Young Corlette

At What Angle of Hip Flexion Is the Gillet Test the Most Effective for Detecting Sacroiliac Motion?
Robert Cooperstein, Morgan Young, Michael Haneline

Characterizing the Toggle-Recoil Delivery of Practicing Clinicians
James DeVocht, Ram Gudavalli

Empowering student learning through rubric-referenced self-assessment
Xiaohua He, Anne Canty

Helping uni-professionally trained students to think integratively: An interactive educational intervention
Lisa Killinger

Using evidence based clinical practice principles to utilize and enhance student clinical reasoning skills in a classroom-based case management course: A pilot project
Nancy Kime

Human Subject Research: Reporting Informed Consent and Ethics Approval in Three Chiropractic Journals
Dana Lawrence

Application of the MIRC radiology database in a chiropractic educational environment
Ian McLean

The case for collaborative assessment of students: a meta-analysis
Christopher Meseke, Jamie Meseke, Rita Nafziger

For the Good of All: A Collaborative Effort to Develop and Deliver an Excellence in College Teaching Certificate Program for Chiropractic College Faculty
Rita Nafziger

Concept Mapping as a Study Tool for Chiropractic Students in a Basic Science Course
Lia Nightingale

Integration of Evidenced-Based Clinical Practice into a Basic Science Course
Lia Nightingale

Paraspinal muscle function assessed with the flexion-relaxation ratio at baseline in a population of patients with back-related leg pain
Edward Owens, M. Ram Gudavalli, Craig Schulz, David Wilder, Maria Hondras, Gert Bronfort

Effect of the mechanical characteristics (magnitude and duration) of a spinal manipulative thrust on lumbar paraspinal muscle spindle discharge
Joel Pickar, William Reed, Dong-Yuan Cao, Gregory Kawchuk

Evidence-based clinical practice in chiropractic: Description of a class assignment and survey of student knowledge and attitudes
Robert Rowell, Michael Tunning

Immunization Status of Adult Chiropractic Patients: Analyses of National Health Interview Survey (NHIS )
Monica Smith, Matthew Davis

Usual Source of Care for persons with and without Back Pain (MEPS data)
Monica Smith

Preparing for teaching moments in evidence-based clinical practice
John Stites, Ron Boesch

Developing a Clinical Practice Journal Club
John Stites, Dana Lawrence

Teaching evidence based clinical practice concepts using radiology case types at a chiropractic college
John Stites, Ian McLean

Evidence-based clinical practice: experience of an early adopter adding an assignment in EBCP to a class
Michael Tunning, Robert Rowell

Reliability of the standing hip flexion test: A systematic review
Morgan Young, Robert Cooperstein

The Effect of Problem-Based Video Instruction on Learning in Physical Examination: An Alternative Paradigm for Chiropractic Students
Niu Zhang, Sudeep Chawla

Papers accepted for poster presentation

Management considerations in a transtibial amputee with Charcot-Marie-Tooth disease
Maria Anderson, Craig Butler

Kinetic chain dysfunction in a 16-year-old soccer player with ankle pain
Maria Anderson, Michelle Barber

Cervical Spondylitic Myelopathy: A Case Report
Ron Boesch, James Owens, Steven Silverman, Mary Klimek

Glioma with Subdural Hematoma Initial Management: A Case Report
Ron Boesch, Misty Stick, Robert Illingworth, Elizabeth Borcher

Chiropractic Management of Cycling Induced Median and Ulnar Neuropathy
Richard Cole, Ron Boesch, Bradford Cole

Reliability of the Blair Upper Cervical Radiographic Analysis for the Base Posterior View: A Feasibility Study
Todd Hubbard, Joel Pickar, Dana Lawrence, Stephen Duray

Essential tremor, Migraine and upper cervical chiropractic: a case report
Todd Hubbard, Janice Kane

A Case Study Utilizing Vojta/Dynamic Neuromuscular Stabilization Therapy to Control Symptoms of a Chronic Migraine Sufferer
Dave Juehring


Challenges with chiropractic technique research
Arlan Fuhr, Ron Rupert, Christine Goertz, Rodger Tepe, Tony Rosner, Charles Woodfield III

Addressing the Hidden Curriculum in Chiropractic Education
Kinsinger and Lawrence

Monday, November 15, 2010

New Papers of Interest

The following are three new papers that I found interesting and intriguing and thought you would benefit by knowing about. They give us pause for thought.

1. Mirtz TA, Hebert JH, Wyatt LH. Attitudes of non-practicing chiropractors: a pilot survey concerning factors related to attrition. Chiro Osteop 2010;18:29 doi:10.1186/1746-1340-18-29

Background: Research into attitudes about chiropractors who are no longer engaged in active clinical practice is non-existent. Yet non-practicing chiropractors (NPCs) represent a valid sub-group worthy of study. Aim: The purpose of this research was to assess attrition attitudes of NPCs about the chiropractic profession and develop a scale to assess such attitudes.
Methods: A 48 item survey was developed using the PsychData software. This survey included 35 Likert-style items assessing various aspects of the profession namely financial, educational, psychosocial and political. An internet discussion site where NPCs may be members was accessed for recruitment purposes.
Results: A total of 70 valid responses were received for analysis. \. A majority of respondents were male with 66% being in non-practice status for 3 to 5 years and less with 43% indicating that they had graduated since the year 2000. Most respondents were employed either in other healthcare professions and non-chiropractic education. A majority of NPCs believed that business ethics in chiropractic were questionable and that overhead expense and student loans were factors in practice success. A majority of NPCs were in associate practice at one time with many believing that associates were encouraged to prolong the care of patients and that associate salaries were not fair. Most NPCs surveyed believed that chiropractic was not a good career choice and would not recommend someone to become a chiropractor. From this survey, a 12 item scale was developed called the "chiropractor attrition attitude scale" for future research. Reliability analysis of this novel scale demonstrated a coefficient alpha of 0.90.
Conclusion: The low response rate indicates that findings cannot be generalized to the NPC population. This study nonetheless demonstrates that NPCs attrition attitudes can be assessed. The lack of a central database of NPCs is a challenge to future research. Appropriate investigation of attrition within the chiropractic profession would be helpful in the analysis of attitudes regarding both chiropractic education and practice. Further research is needed in this area.

2. Langworthy J, Forrest L. Withdrawal rates as a consequence of disclosure of risk associated with manipulation of the cervical spine: a survey. Chiro Osteop 2010;18:27 doi: 10.1186/1746-1340-18-27

Background: The risk associated with cervical manipulation is controversial. Research in this area is widely variable but as yet the risk is not easily quantifiable. This presents a problem when informing the patient of risks when seeking consent and information may be witheld due to the fear of patient withdrawal from care. As yet, there is a lack of research into the frequency of risk disclosure and consequent withdrawal from manipulative treatment as a result. This study seeks to investigate the reality of this and to obtain insight into the attitudes of chiropractors towards informed consent and disclosure.
Methods: Questionnaires were posted to 200 UK chiropractors randomly selected from the register of the General Chiropractic Council.
Results: A response rate of 46% (n=92) was achieved. Thirty-three per cent (n=30) of respondents were female and the mean number of years in practice was 10. Eighty-eight per cent considered explanation of the risks associated with any recommended treatment important when obtaining informed consent. However, only 45% indicated they always discuss this with patients in need of cervical manipulation. When asked whether they believed discussing the possibility of a serious adverse reaction to cervical manipulation could increase patient anxiety to the extent there was a strong possibility the patient would refuse treatment, 46% said they believed this could happen. Nonetheless, 80% said they believed they had a moral/ethical obligation to disclose risk associated with cervical manipulation despite these concerns. The estimated number of withdrawals throughout respondents' time in practice was estimated at 1 patient withdrawal for every 2 years in practice.
Conclusion: The withdrawal rate from cervical manipulation as a direct consequence of the disclosure of associated serious risks appears unfounded. However, notwithstanding legal obligations, reluctance to disclose risk due to fear of increasing patient anxiety still remains, despite acknowledgement of moral and ethical responsibility.

3. Peets AD, Cooke L, Wright B, Coderre S, McLaughlin K. A prospective randomized trial of content expertise versus process expertise in small group teaching. BMC Medical Education 2010, 10:70 doi:10.1186/1472-6920-10-70

Background: Effective teaching requires an understanding of both what (content knowledge) and how (process knowledge) to teach. While previous studies involving medical students have compared preceptors with greater or lesser content knowledge, it is unclear whether process expertise can compensate for deficient content expertise. Therefore, the objective of our study was to compare the effect of preceptors with process expertise to those with content expertise on medical students' learning outcomes in a structured small group environment.
Methods: One hundred and fifty-one first year medical students were randomized to 11 groups for the small group component of the Cardiovascular-Respiratory course at the University of Calgary. Each group was then block randomized to one of three streams for the entire course: tutoring exclusively by physicians with content expertise (n = 5), tutoring exclusively by physicians with process expertise (n = 3), and tutoring by content experts for 11 sessions and process experts for 10 sessions (n = 3). After each of the 21 small group sessions, students evaluated their preceptors' teaching with a standardized instrument. Students' knowledge acquisition was assessed by an end-of-course multiple choice (EOC-MCQ) examination.
Results: Students rated the process experts significantly higher on each of the instrument's 15 items, including the overall rating. Students' mean score (±SD) on the EOC-MCQ exam was 76.1% (8.1) for groups taught by content experts, 78.2% (7.8) for the combination group and 79.5% (9.2) for process expert groups (p = 0.11). By linear regression student performance was higher if they had been taught by process experts (regression coefficient 2.7 [0.1, 5.4], p < .05), but not content experts (p = .09).
Conclusions: When preceptors are physicians, content expertise is not a prerequisite to teach first year medical students within a structured small group environment; preceptors with process expertise result in at least equivalent, if not superior, student outcomes in this setting.

Monday, November 8, 2010

Creating One-Piece Posters via PowerPoint in MS PowerPoint 2007

This was originally prepared by a former member of the Center for Teaching and Learning, but it holds great advice for all of us as we move toward planning for possible trips to ACC-RAC in March of 2011.

To Begin
The average size of a poster is 5’ wide x 3.5’ tall. We will be using these measurements for this tutorial. This document is also written with the intent that the user has a basic knowledge of Microsoft PowerPoint.

We view the creation of a poster in PowerPoint as one big slide; all the aspects are the same except the pasteboard is approximately 600% bigger. The posters are printed on a HP Designjet 5500 ps which has a print area of 3.5’ x 100’; the printer is physically located in The Center for Teaching and Learning.

Setting the Pasteboard
Open PowerPoint. It will open a blank slide for you. If it does not, go to the Microsoft icon in the top left corner, click there and choose Blank Presentation, and then click OK. You now have a basic pasteboard that is set up for slide or onscreen output. We will now change the dimensions of the pasteboard to reflect our poster. In the menu bar at the top of the screen choose the Design Tab, then find the Page Setup…. You will then be prompted with a dialog box that allows you to make changes to the size.

IMPORTANT NOTE: PowerPoint 2007 will not allow you to change the pasteboard size larger than 56 inches, and you will need 60 inches. Because of this, we will create the poster in half scale and print it at 200%. So instead of our pasteboard being 60” x 42” we are going to set it up at 30” x 21.” In the dialog box, here would be our settings:
Width = 30
Height = 21
Pages = 1
Slides = Landscape
Notes = (doesn’t matter)

Now is when you will cut and paste text, import graphics and drop in backgrounds in the pasteboard. Many people use textboxes for importing everything. You will find this tool as a little square with the letter “A” and some lines in it (you can also access this by going to Insert and then Text Box in the top menu bar). Click the button and move your cursor to the page, then click and drag to create a text box. The reasoning behind using a textbox it that you can move the boxes around, resize, and even overlap them.

To import graphics or pictures, go to Insert in the tool bar, then to Picture, then From File. You will be prompted to move through the hierarchy to find your graphic. When you have found it, highlight it and click insert. You can change the size of your graphic by clicking once on the graphic (this will select it, and show 8 hollow squares around the image). To scale the picture proportionally, click and drag on the corner squares; if you click and drag the top and side squares it will distort your image.

REMEMBER: you are working in half scale; if your image says it is 3x5 it will actually print at 6x10. Whatever font you are using, the point size will double in the end product. You will not be able to print the poster from your PC and should contact Nina Brooks in The Center for Teaching and Learning (x5617) to arrange for her to print your poster on the HP large-format printer mentioned previously. Please contact her well in advance of the date you will need your poster.

And last but not least, save your work often (Just in case of a crash).

Monday, November 1, 2010

ASBH 12th Annual Conference Report

Last week I attended the 12th Annual Conference of the American Society for Bioethics and Humanities. I found it a fascinating meeting, and was thrilled to see that some of the nation’s leading ethicists were in attendance; they are sort of like idols to me. But as I went to each session, I was struck by how difficult a field bioethics has become. And I was equally struck by how, within chiropractic, we often do not need to confront the issues that are daily challenges in medicine.

For example, one of my sessions addressed this problem: for children with medulloblastomas, there are three possible therapies which can be offered. Each carries a mix of difficult decisions. In one case, there survival rate for Therapy A is highest (90%), but it also carries the highest rate of leaving a child with reduced capacity for intelligence (after treatment, intelligence will be 40% what it was before treatment). In Therapy B, the survival rate falls a bit, but the rate of mental retardation decreases a bit as well. And in Therapy C, the survival rate is lowest, but intelligence is generally preserved. The question was not, which one should a parent choose? The question was, do we even tell the parent about option A, which has best survival rate but almost invariably will impair the future mental capacity of the child. And the program was devoted to discussing when and where medical paternalism might be justified.

A second session was less life-threatening in its question, but was equally interesting. How honest should a medical student be in revealing to a patient that he or she is indeed a student at all? In training, medical students (and chiropractic students, of course) gain skills by treating actual patient under the supervision of attending physicians. Do patients want to know that the person treating them is a student? Do we have an obligation to tell them? How do we respect autonomy?

Can we benefit from past wrongs? Should we use data from Nazi concentration camp experiments? Should Roman Catholics allow their children to be vaccinated using vaccines grown in the tissues of aborted fetuses or accept treatment that came from the use of human stem cell lines? Do we apply consequentialist theories here or deontological ones? Is it right to make a good from an evil? There are no easy answers here.

It turns out that bioethics is a vibrant field that can cast light onto difficult subjects and issues. And we are confronting them- genetic research, stem cell research, gene therapy, the Human Genome Project, organ transplantation, public health ethics (population as opposed to personal level bioethics) and so on. It is why I find this so fascinating.

Tuesday, October 19, 2010

Another Term’s End- the Fun Entry

Here we are again, at the end of another term, at least here in Davenport, and so it is time to take a short break and head out for a chance to catch our collective breaths. To that end, I offer up a few fun and interesting youtube clips for your entertainment.

1. Big Bang Big Boom:
This is evolution as seen on a wall painting. I can only imagine how hard it must have been to film this using stop and go techniques over long periods of time.

2. The Passenger:
A film clip in animation about a bookwork stuck on a bus that he might not wish to be on.

3. The Cat Piano:!
You know what? There really were cat pianos!

4. Rango:
Because you know you want to see a movie in which a chameleon plays a role in helping rid a town of bad guys.

5. The Fall:
Simply gorgeous, produced by Tarsem, a former video producer who also wrote and filmed the Jennifer Lopez movie “The Cell.”

6. Let Me In:
I previously sang the praises of “Let the Right One In,” and this is the American remake. While not the same as the original, which I consider a perfect movie, this is also quite good in its own way.

7. Harry Potter and the Deathly Hallows:
Because you know it’s coming soon to a theater near you, and you’ll go see it.

Have a great break, even if it is a short one!

Monday, October 11, 2010

An Introduction to Evidence-Based Clinical Practice

Evidence-based medicine developed out of a movement started by a group of medical educators at McMaster’s University during the 1980s (1). These physicians observed that a gap had developed between what occurred in clinical practice and what was obtainable in reports of clinical research. Essentially, clinicians could not stay abreast with new research because it was being produced so fast; consequently they were not putting into practice the most current information. Evidence-based methods were designed to bridge this gap. This concept has been embraced by the chiropractic profession as well, leading to what we now call evidence-based chiropractic (EBC), or evidence-based chiropractic practice (EBCP).

EBCP is unique in several ways:

• For example, chiropractic interventions are difficult to investigate by experimental methods, because it is hard, if not impossible, to design an effective placebo, and it is impossible to blind either the doctor or the patient to the interventions being studied. As a result, there are fewer chiropractic articles that use placebo group controls than in other scientific or medical disciplines.

• Chiropractors commonly use a number of treatment modalities in addition to adjustment, while clinical trials may focus on a single intervention in order to isolate its effects.

• Traditionally, it was hard for chiropractors to obtain funding for rigorous research, though this has certainly changed, all the more so here at PCC.

But these challenges have also meant that we have a uniqueness to our profession. While we might not always have the most rigorous of studies, and for understandable reasons, we have developed an impressive body of evidence to support what we do.

Sackett has stated that EBP is “ … the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” (1) This is an important statement, because in it we see that the practitioner’s clinical expertise is an important component; the goal is to integrate clinical expertise with best evidence on behalf of the patient. EBCP is therefore not in any way cookbook medicine or practice, it is the integration of best evidence with the past training and expertise of the clinician, resulting in better care for the patient. And new evidence is replacing old all the time.

Patient preferences also play an important role. This includes the personal values, concerns and expectations that patients have about their care. Considering these are critical steps in the EBCP process.

• Personal values: These are the beliefs patients have about the care being offered to them, which may be based on personal, religious or philosophical reasons.

• Patient concerns: Such as financial concerns, time constraints, office location, ease of parking, etc.

• Patient expectations: This relates to the degree that patients will accept a doctor’s recommendations. Compliance is an ongoing problem in patient care, as well as in clinical trials and other forms of research.

1. Evidence-Based Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA 1992;268:2420-2425
2. Sackett DL. Evidence-based medicine. Lancet 1995;346:1171

Monday, October 4, 2010

Effective Workshops, Part 2

Picking up from last week’s entry, let me bring this to a close by adding in these additional tips, based on the work of Dr. Yvonne Steinert (1).

7. Encourage active participation and allow for problem solving and/or skill acquisition. Steinart notes that active participation is a key ingredient of a successful workshop; therefore, you should plan to have people and groups involved in all aspects of the workshop you are leading. Invite questions, lead debate and engage attendees. In order to allow this to happen, you should work to limit the size of the small groups, so that everyone can have an opportunity to be heard and to be involved. In fact, the actual lay-out of the room can help or hinder this process; lecture rooms are not conducive to small-group activity.

8. Provide relevant and practical information. We know this from the general problem facing continuing education that often people attend programs or conferences and when they return it has changed nothing on what they do. You need to ensure that your participants have learned something new which they can apply when they return to their work setting. Your workshop can contain mini-lectures around which the small-group activities revolve, but a long lecture is not a good way to provide skills and knowledge which will be applied upon return to work. People need to interact with both you and others to reinforce learning.

9. Remember principles of adult learning. This means that we each will bring to the sessions we attend our past experiences and training, and our own personal motivations and expectations about the workshop. We need to remind ourselves that as adults, we are often re-learning, rather than learning, so we need to be careful in how we present information so that we do not create resentment among those who are in attendance. The incentive for learning is self-motivated, not externally motivated, and feedback is therefore critically important.

10. Vary your activities and your style. Consider the pacing of your presentation, and ensure that it meets with participant needs and attention. I find that I am resistant to certain kinds of group work; I tend to work best alone, but I also know that I will learn better when I have people to play ideas and thoughts against. Consider this as well.

11. Summarize your session and request feedback from the group. Always restate your goals and objectives in running the workshop in order to summarize and synthesize the points you have made. You may wish to ask the group to also summarize what they have learned, and you can ask as well for them to give you thoughts on what you might do to improve this session in the future.

12. Enjoy yourself- and have fun. There was a time when I because quite fearful before I ran sessions for professionals. It took time for me to realize that the people attending would not know whether or not I presented all I meant to present, nor would they know if I had made a flub somewhere along the line. This was liberating; I could now go and just do the session and enjoy myself and I now look forward to running workshop sessions. If you have a good time, chances are so will the people taking the session with you.

1. Steinert Y. Twelve tips for conducting effective workshops. Med Teacher 1992;14:127-131

Monday, September 27, 2010

Effective Workshops

Last week, a few members of the Palmer faculty attended a workshop by Dr. Kristi Ferguson of the University of Iowa. Her presentation was dedicated to providing faculty with information about how to teach not students, but other faculty. In her presentation, she cited the work of Dr. Yvonne Steinert, who has provided a list of tips for conducting effective workshops (1). Among her tips are the following:

Planning Phase

1. Defining your objectives for the teaching session. What are you trying to achieve in your workshop? Is this related to skills acquisition or to changing attitudes? You should determine what your goals are, because this will impact on the methods you use to teach, your course strategies, your activities and your assessment methods.

2. Find out who your audience is. If we are limited to just members of the PCC faculty, this could be broken down into such groupings as full faculty, life sciences faculty, clinical sciences faculty, clinician faculty, etc. You would not want to include, for example, life sciences faculty if the main goal of your presentation is to discuss new diagnostic methods; perhaps you might not wish to include clinicians if your goal is to discuss large group teaching strategies. You need to understand whether or not the group you are presenting to will know core concepts in your area of discussion.

3. Determine your teaching method and design the appropriate workshop activities. There are so many options here. You can use video, audiotapes, live demonstrations, small group or large group activities, and so on. Your teaching method should fold back onto the goals of your program, and you should also be aware of the group’s past experiences with various teaching methodologies.

Workshop Phase

4. Introduce the members to you and to each other. You can use whatever strategy you want to , depending on the size of the group you are working with. But this knowledge is useful for you in moving forward with your presentation and beginning the process of developing a relation with your audience.

5. Outline your objectives for the teaching session. You should let the group know in advance what it is you hope to accomplish in the workshop. Let me people know what to expect, and let them have a schedule of events for the workshop.

6. Create a relaxed atmosphere for learning. Cooperation and collaboration is essential. Ensuring that people feel comfortable and free to ask questions is equally important. I find that when there is a need to use small group activities, it is best to make sure that introductions have already occurred, because some people are not comfortable in those settings, and feeling comfortable helps them engage more effectively.

I will continue next week with the remainder of Dr. Steinert’s recommendations.

1. Steinert Y. Twelve tips for conducting effective workshops. Med Teacher 1992;14:127-131

Monday, September 20, 2010


One of the core concepts of evidence-based clinical practice (EBCP) is the development of a PICO question. You may have heard this term bandied about in discussion but may not have been exactly what is meant by it. Let me discuss that here.

One of the initial steps in applying the concepts of EBCP to clinical practice is formulate a clinical question. This is important for several reasons, one of the most important being that it helps you design an appropriate search strategy for locating information; that is, you need it to get a useful answer to the clinical question you are attempting to answer. This would occur, for example, if you were confronted with a patient for whom you are not sure how to proceed, not for one where you know exactly what you wish to do. Developing a PICO question is quite helpful in this regard.

PICO standards for: Patient (or Population or Problem), Intervention, Comparison (or Comparator) and Outcome.

P: Patient. What kind of patient is the focus of your question? That is, what is his or her diagnosis, population of problem? Typically, we are looking at a diagnostic question; we have a pteitn with a particular diagnosis that lies outside our area of general knowledge and we are trying to figure out what to do. The more carefully we can define this patient, the better we can search for information. Therefore, we need to look at not just the diagnosis, but perhaps at age range, gender, stage of illness, severity of illness, etc.

I: Intervention. What intervention are we considering using for this patient? In the case of chiropractic, it might include chiropractic adjustment, or perhaps it might involve some other supportive therapy such as physiotherapy of some sort, massage, mobilization or exercise. We could do the same if we were examining a new diagnostic test, to compare it against an established test.

C: Comparison. What do you wish to compare the intervention with? That is, what is the control you are looking at for your intervention? Normally, the comparison should be some established standard treatment for the condition of interest. At times, it might no treatment at all. For manipulation/adjustment, perhaps it would be an intervention for pain relief, such as NSAIDs, or perhaps some other form of conservative care such as exercise. It could even be surgical.

O: Outcome. What, ultimately, is the outcome you are interest in? Often in chiropractic it will be pain relief or reduction of disability, but it is certainly not limited to this. You could do the same approach for reduction of subluxation, remembering that you would compare your method of reduction measurement to some other measurement of same. You could look at sot issues, if you wanted.

Once you have the PICO question developed, it will help inform the search strategy you develop to locate information you can then assess and apply to your patient. The next step in the process of finding and applying evidence would be to conduct a literature search.

Monday, September 13, 2010

A Bunch of Good New Articles

Every now and again, I like t0 provide readers of this blog with the abstracts of new articles germane in some way to the chiropractic profession. Herewith are a few of the latest I have found, which I hope you will find equally interesting.

1. Murphy D. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession? Chiropr Osteop 2010;18:22 doi:10.1186/1746-1340-18-22

The understanding of the relationship between cervical manipulative therapy (CMT) and vertebral artery dissection and stroke (VADS) has evolved considerably over the years. In the beginning the relationship was seen as simple cause-effect, in which CMT was seen to cause VADS in certain susceptible individuals. This was perceived as extremely rare by chiropractic physicians, but as far more common by neurologists and others. Recent evidence has clarified the relationship considerably, and suggests that the relationship is not causal, but that patients with VADS often have initial symptoms which cause them to seek care from a chiropractic physician and have a stroke some time after, independent of the chiropractic visit.
This new understanding has shifted the focus for the chiropractic physician from one of attempting to "screen" for "risk of complication to manipulation" to one of recognizing the patient who may be having VADS so that early diagnosis and intervention can be pursued. In addition, this new understanding presents the chiropractic profession with an opportunity to change the conversation about CMT and VADS by taking a proactive, public health approach to this uncommon but potentially devastating disorder.

2. From Palmer faculty and staff: Pohlman KA, Hondras MA, Long CR, Haan AG. Practice patterns of doctors of chiropractic with a pediatric diplomate: a cross-sectional survey. J Comple Altern Med 2010;10:26 doi:10.1186/1472-6882-10-26

Background: Complementary and alternative medicine (CAM) is growing in popularity, especially within the pediatric population. Research on CAM practitioners and their specialties, such as pediatrics, is lacking. Within the chiropractic profession, pediatrics is one of the most recently established post-graduate specialty programs. This paper describes the demographic and practice characteristics of doctors of chiropractic with a pediatric diplomate.
Methods: 218 chiropractors with a pediatric diplomate were invited to complete our survey using either web-based or mailed paper survey methods. Practitioner demographics, practice characteristics, treatment procedures, referral patterns, and patient characteristics were queried with a survey created with the online survey tool, SurveyMonkey©®.
Results: A total of 135 chiropractors responded (62.2% response rate); they were predominantly female (74%) and white (93%). Techniques most commonly used were Diversified, Activator ®, and Thompson with the addition of cranial and extremity manipulation to their chiropractic treatments. Adjunctive therapies commonly provided to patients included recommendations for activities of daily living, corrective or therapeutic exercise, ice pack\cryotherapy, and nutritional counseling. Thirty eight percent of respondents' patients were private pay and 23% had private insurance that was not managed care. Pediatrics represented 31% of the survey respondents' patients. Chiropractors also reported 63% of their work time devoted to direct patient care. Health conditions reportedly treated within the pediatric population included back or neck pain, asthma, birth trauma, colic, constipation, ear infection, head or chest cold, and upper respiratory infections. Referrals made to or from these chiropractors were uncommon.
Conclusions: This mixed mode survey identified similarities and differences between doctors of chiropractic with a pediatric diplomate to other surveys of doctors of chiropractic, CAM professionals, and pediatric healthcare providers. The pediatric diplomate certificate was established in 1993 and provides didactic education over a 2 to 3 year span. The results of this study can be used for historical information as this specialty continues to grow.

3. Ilic D, Forbes K. Undergraduate medical student perceptions and use of Evidence Based Medicine: A qualitative study. BMC Med Educ 2010;10:58 doi:10.1186/1472-6920-10-58

Background: Many medical schools teach the principles of Evidence Based Medicine (EBM) as a subject within their medical curriculum. Few studies have explored the barriers and enablers that students experience when studying medicine and attempting to integrate EBM in their clinical experience. The aim of this study was to identify undergraduate medical student perceptions of EBM, including their current use of its principles as students and perceived future use as clinicians.
Methods: Third year medical students were recruited via email to participate in focus group discussions. Four focus groups were conducted separately across four hospital sites. All focus groups were conducted by the same facilitator. All discussions were transcribed verbatim, and analysed independently by the two authors according to the principles of thematic analysis.
Results: Focus group discussions were conducted with 23 third-year medical students, representing three metropolitan and one rural hospital sites. Five key themes emerged from the analysis of the transcripts: (1) Rationale and observed use of EBM in practice, (2) Current use of EBM as students, (3) Perceived use of EBM as future clinicians, (4) Barriers to practicing EBM, and (5) Enablers to facilitate the integration of EBM into clinical practice. Key facilitators for promoting EBM to students include competency in EBM, mentorship and application to clinical disciplines. Barriers to EBM implementation include lack of visible application by senior clinicians and constraints by poor resourcing.
Conclusions: The principles and application of EBM is perceived by medical students to be important in both their current clinical training and perceived future work as clinicians. Future research is needed to identify how medical students incorporate EBM concepts into their clinical practice as they gain greater clinical exposure and competence.

4. Hill TE. How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research. Phil Ethics Humanities Med 2010;5:11 doi:10.1186/1747-5341-5-11

Physicians, nurses, and other clinicians readily acknowledge being troubled by encounters with patients who trigger moral judgments. For decades social scientists have noted that moral judgment of patients is pervasive, occurring not only in egregious and criminal cases but also in everyday situations in which appraisals of patients' social worth and culpability are routine. There is scant literature, however, on the actual prevalence and dynamics of moral judgment in healthcare. The indirect evidence available suggests that moral appraisals function via a complex calculus that reflects variation in patient characteristics, clinician characteristics, task, and organizational factors. The full impact of moral judgment on healthcare relationships, patient outcomes, and clinicians' own well-being is yet unknown. The paucity of attention to moral judgment, despite its significance for patient-centered care, communication, empathy, professionalism, healthcare education, stereotyping, and outcome disparities, represents a blind spot that merits explanation and repair. New methodologies in social psychology and neuroscience have yielded models for how moral judgment operates in healthcare and how research in this area should proceed. Clinicians, educators, and researchers would do well to recognize both the legitimate and illegitimate moral appraisals that are apt to occur in healthcare settings.

Tuesday, September 7, 2010

Really Cool Websites for Faculty

Herewith a list of interesting, informative and unusal websites for your viewing pleasure:

1. Presentation Zen:
I’ve spoken often of this website, which was created by Garr Reynolds, a designer who is also associate professor of management at Kansai Gaidai University in Japan. This is the key website about presentation design and delivery on the internet. His goal is to change how we see and use slide technology, notably PowerPoint and Keynote. His focus is upon harmony of design, and is built around the basic ideas of Zen Buddhism. His ideas are simple yet profound and can be used to help remodel how you use slides in class, moving you away from heavily text-based slides to simpler and more illustrative slides. A visit to this site is like a visit to a peaceful garden; you have to think and consider issues here.

2. Seth’s Blog:
This is the website of noted business author Seth Godin, author of many books of which “Linchpin” is but the latest. He offers words of counterintuitive business wisdom that resonate in our academic culture and setting. He might suggest that not being in synch with your various digital technologies (Facebook, Twitter, and so on) is the sign of a leader, not a follower; maybe you would invite a passionate amateur to accomplish a task rather than an experienced professional, and so on. He is always engaging and will certainly get you thinking.

3. Pecha Kucha:
You will likely be unaware of the pecha kucha movement, but the basic goal of pecha kucha is to develop a slide presentation that uses 20 slides, each lasting 20 seconds. Why do so? Here, it is so that the presenter is forced to hone his or her ideas into its basic components and its most essential information. The wesite provides you examples of such presentations, drawn from actual pecha kucha night activities, and it also provides you a link of locations for upcoming pecha kucha. By the way, pecha kucha is a Japanese transliteration of the term “chit chat.”

4. Tom Peters:
Most of us know of Mr. Peters from his earlier works on excellence, such as A Search for Excellence. His blog is dedicated to this as well, and it covers many aspects of management related to becoming excellent at what we do. He provides free slides for you to use, and offers a series of, well, excellent video clips one can view.

5. Center for Evidence-Based Medicine:
Switching gears here, this site is dedicated to promoting EBM in healthcare education and it gives you a series of superb links to information and tools. For example, if you click on the “EBM Tools” at the top of the home page, it will then link you to a page that discusses the basic EBM approach known as the 5 A’s (which was the basis of a recent in-service at PCCD), and to online calculators for likelihood ratios, numbers needed to treat and more.

6. The Integrator Blog:
This site is maintained by John Weeks and is a leading site for information related to the business, policies and education of Cam and integrative medicine. Palmer’s own Dr. Christine Goertz is on their editorial board, and the blog does a great job at keeping up with news affecting the entire spectrum of the CAM community.

7. Slayage:
Of course, we all know of my love for Buffy the Vampire Slayer, but how many people know that there is an online academic journal dedicated to the show. Well, now you do and here it is, and I dare you to make sense of most of what you read. But hey, this is all about really cool websites, and this one surely is.

Enjoy the reading!

Monday, August 30, 2010

PowerPoint Use and Misuse

One of the more humorous things I have read lately was from a message board dedicated to, of all things, distance running (my older sons are talented distance runners, so I live vicariously through them). The actual thread had nothing to do with running; instead, it was about a man who had broken up with his girlfriend using PowerPoint to do so. This is not the best use of the technology.

So keeping in mind modern readings on the use of slide technology, I went to visit the Presentation Zen website. I’ve spoken of this in the past; this is a site maintained by Garr Reynolds and dedicated to helping the reader develop successful presentations. His focus is on the harmony of presentation- which is why he has entitled his blog Presentation Zen- and he uses modern understanding of design, harmony and even psychology to craft meaningful presentations.

As a result, he stresses the need to move away from text-based and text-heavy slides. His point is made quite well in his August 21 entry on his blog, at In this entry, he shows how General Dodonna, in Star War IV (“A New Hope”), uses a full wide-screen display to show his fighters the schematics of the Death Star- a picture here being worth many thousands of words. He then duplicates the scene but this time shows the presentation as a text slide in typical PowerPoint format. Of course, there is this caveat: “You can't see this well on this Micro Galactic ProjectionPoint, but an analysis of the plans provided by Princess Leia has demonstrated a weakness in the battle station. Follow this link at the bottom of the screen for more info if needed." There is a difference here in how we understand the information.

He closes his entry by suggesting we push back against the Imperial template propaganda and its conventional usage patterns. He recommends that when you use PowerPoint, it is far better to use visuals rather than to use lines of text which remind you what to say. See, the real issue here is what your audience learns; this technology is not a simple convenience for you to help you lecture, but is instead a powerful tool to help others learn. When it used correctly. Your visual information will help amplify the words you speak to your audience; use the Force wisely here when you do so. Otherwise, problems in learning occur will they (says Yoda, wise in all things).

Monday, August 23, 2010

The Five Dysfunctions of a Team

There is an entire genre of business books which I refer to as “business fables.” Perhaps the most well-known among them is “The One-Minute Manager,” by Spencer Johnson (1), but not far behind is Patrick Lencioni’s “The Five Dysfunctions of a Team.” (2) I always approach these types of book with my skeptical eye well open, but each time I am confronted with a book that offers me insights into working in a collegial environment, and in the case of Lencioni’s book, I took some heart in the message his book extends.

Lencioni’s book relates the story of the appointment of Kathryn Peterson as new CEO for Decision Tech. Ms. Peterson does not come from the industry in which Decision Tech competes, and she was in semi-retirement when she was recruited for the position by the Chairman of the Board for the company. Her main action during her first year on the job is to attempt to unite her senior executive team, all highly competent individuals who are unable to work together effectively. Her decision and actions are described as she moves her company forward against some very real odds. These actions are placed into the context of resolving known dysfunctions, the five of which are indicated by the title. They are not obvious.

Dysfunction 1: Absence of trust. Lencioni notes that trust is at the heart of a functioning team, but trust is not simply believing that others mean to do well. Rather, trust here centers on the idea that given that we know others mean to do well, we need not be careful around members of our team. We must become vulnerable when around each other and be confident that our vulnerabilities will not be used against us- for we each have such vulnerabilities. In such fashion we stop being political with one another, stop subtley seeking position, and work together for the common good. Otherwise, behaviors too often will influence the actions that are taken and the discussions that occur.

Dysfunction 2: Fear of conflict. We need productive conflict to be able to grow. But, too often conflict is seen as undesirable in work settings, and therefore deep discussions on issues are avoided- a “go along to get along” kind of thinking. Now, conflict here does not refer to destructive fighting or personal politics; it refers to productive ideological debate. Sometimes conflict is avoided in order to avoid hurting others’ feelings, but if we note the first dysfunction, that of trust, this problem disappears.

Dysfunction 3: Lack of commitment. Lencioni notes that commitment is a function of clarity and buy-in. If we achieve buy-in from all members, clear and timely decisions will be made. And Lencioni further notes that the two main causes of lack of commitment are (surprisingly), a desire for consensus and a need for certainty. Consensus is, to me, often a way of reducing an issue to the least-common denominator- we all agree, but no one gets what they really want. It is better that we make a decision, even one that we might not all agree with, knowing that our thoughts have been heard, appreciated and considered. And once a decision is made- where we now have certainty, at least with regard to direction, we can unite behind that certainty. We never have full information and often make decisions without knowing the best direction in which to move, but once a decision is made, we move with it.

Dysfunction 4: Avoidance of accountability. This refers to the willingness of team members to call their peers on performance or behaviors that can hurt the team. We don’t like to do this; all too often we want to be liked rather than respected, so we allow behaviors from people that we know are damaging because it is never fun to call them to account for those behaviors. We don’t hold others accountable, because conflict avoidance is easier. But peer pressure can exert such influence as well.

Dysfunction 5: Inattention to results. This refers to the tendency of team members to care about something other than the collective goals of the group: their own personal advancement, rewards, etc., and not the objective for which the team exists. Lencioni notes the influence of these factors: (1) Team status: for some, being on the team is a status reward in and of itself, and therefore the actual results may not be important to some people, since being on the team is the reward. (2) Individual status: where people focus on advancing their own positions in the organization at the expense of the team goal. We need to focus on the team results, for that is what will take the organization forward.

It is an interesting and informative group and one that has led me to think over its message. For that reason, I do recommend it, and it is a text that can be read in a brief period of time, but that has a message I think will resonate with you.

1. Johnson S. The one-minute manager. New York, William Morrow and Company, 1981
2. Lencioni P. The five dysfunctions of a team. San Francisco, CA; Jossey-Bass, 2002

Monday, August 16, 2010

The Genius Bar

I grew up with Macintosh computers. I got my first Apple, a IIe, in 1984, and I have upgraded every few years with new Mac computers at my home, with my current computer, an iMac with a 17” screen, sitting on my desk. In fact, not until I came to Palmer College had I ever worked with a Windows-based computer. When I first started, I did not know how to do even the most basic functions, for most of them were not similar in any fashion to how the interface worked on a Mac. This is just history. I do know that it would have been nice to have someone to walk me through the initial intricacies of working in a Windows environment.

Which brings me to the point of this post. Last week, during the Palmer Davenport Homecoming celebration I met with Dr. Tammi Clark, a faculty member and president of the Faculty Senate from our West campus. She related a story to me about her purchase of a Mac computer, and how she had both some problems and questions about working with her new platform. She noted that she learned about Apple’s Genius Bar, sort of by a serendipitous mistake; she was visiting an Apple Store and simply saw the Genius Bar inside. This led her to make an appointment with an Apple Genius, and that provided her skills and answers to her questions and needs.

Let me step back a moment and clarify. The Genius Bar is part of every Apple store. It is a tech support station that provides users with help and answers for their Mac-related questions. You make an appointment to visit the Genius Bar, and when you do you obtain the help of an Apple Genius, a person extensively trained in the use of Mac technology. This person will work with you to answer your questions, problem solve and offer repairs. But more than this, this person will do more than simply help you figure out what is wrong; he or she is as likely to say to you “well, let me ask you, what do you want to do with your computer?” And from that, they will help you learn how to use your computer to do what you want it to.

For me, this is sort of a powerful metaphor for how I see the Center for Teaching Learning working. There are challenges in working across three campuses when you are based at one of them, and can visit the other two only infrequently. And keeping the CTL in the front of faculty can be difficult as well. But the CTL exists to help faculty become more productive at what they already do so well. And I can work with you to meet your needs, if I only know what they are. I continue to gather information from as many sources as possible; in fact, my meeting with Dr. Clark generated a number of possible general interest topics for future in-service sessions. But beyond that, if you, the reader, can but contact me and let me know your needs, I can work with you to meet them. What is you want to do? I can provide resources, training, advice, ideas and more. Consider, for example, this simple list of possible ideas: how to effectively use PowerPoint in the classroom (and the corollary of how to use it at all, for those who may not have yet made the switch to this technology), Generation Y learning styles, classroom engagement techniques (already in discussion, so I understand), website development, test writing workshops, how to use rubrics, team-based learning, etc. This is all related to teaching, not to research or publication, making us better at our primary assignment and responsibility.

So I urge you to feel free to contact me (x5302 or and let me know your needs. I promise to help all I can. I am no genius, but I am pretty tenacious and I will certainly do what I can to help.

Tuesday, August 10, 2010


I wish to turn attention to an area of epidemiological research that is increasingly important, the concept of causality. In epidemiology, an intervention or public health action is based on the presumption that associations seen in various studies are causal, not due to bias or some other spurious research. When we say causal, we mean that the cause of, say, a disease is “an event, condition, characteristic, or combination of factors that plays an important role in the development of disease or health condition." (1) Of course, we realize that demonstrating causality can be exceedingly difficult; how do we definitively know that an association is causal?

Initial descriptions of causality were developed by Henle and Koch (2), relating more to identifying infectious agents in disease outbreaks. Here, the agent had to present in each case of the disease when cultured, could not be found in other diseases, could reproduce the disease in question when isolated and injected into animals, and must then be recovered from the infected animal. But this approach does not work as well for modern public health, where exposures to environmental factors may take years to occur. Thus, Bradford Hill (3) came up with his criteria for causality, which have been modernized into these 6 key factors:

1. Consistency: the association is seen in different settings and populations. Thus, the likelihood of a causal relation increases as the number of studies with similar findings occurs.

2. Strength: This is defined by the size of the relative risk estimate; thus, the likelihood of a causal relation increases as the summary relative risk estimate increases (bringing in a concept we have previously explored in the context of evidence-based care). The larger the effect estimate, the less likely it is due to bias or chance.

3. Temporality: that is, there has to be demonstrated an exposure to the risk prior to the development of the condition of interest. This is a critically important aspect of causality.

4. Dose-response relationship: This is defined as the observed relationship between the dose of the exposure and the magnitude of the relative risk estimate. Put another way, what this means, is that the larger the exposure (intensity or time), the greater the chance (risk) of developing the condition of interest.

5. Biological plausibility: What we know about the mechanism of action for a given risk factor and the disease outcome. What do we know about why smoking leads to cancer, for example? If we can develop a biological rationale for why the exposure leads to the condition of interest, it strengthens the likelihood that a causal relation is present.

6. Experimental evidence: This is a bit more technically sophisticated; here, defined as the presence of findings from a prevention trial in which we remove the exposure from randomly assigned individuals. If we see a reduction in the condition of interest, it strengthens the likelihood that a causal relation exists.

Our challenge becomes removing all potential confounders from consideration, and given this one can se why developing causal relations can be so difficult. An example was a study showing that coffee drinkers had a higher risk of cancer. Of course, it was not the coffee drinking which was involved; it turned out that there were more smokers among the coffee drinkers and that was what led to higher cancer rates. Another challenge is to apply this to chiropractic theory and methods, including subluxation research.

1. Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-based public health. New York; Oxford University press, 2003:30
2. Last JM, ed. A dictionary of epidemiology, 4th edition. New York; Oxford University Press, 2001
3. Hill AB. The environment and disease: association or causation? Proc Royal Soc Med 1965;58:295-300

Monday, August 2, 2010

Plagiarism Anew

A recent article in the New York Times (1) discusses how today’s students seem to misunderstand the nature of plagiarism in the digital age. The article first describes several incidents of student plagiarism where the students simply did not understand they had done anything wrong; for example, one student copied material directly from Wikipedia and then claimed that since it was a collective work it was common knowledge to be freely used by anyone. Since we live in a world where illegal downloading is commonplace, it seems that this is beginning to extend into areas of scholarship as well. On the one hand, the internet is a freewheeling locus of activity and information exchange and discovery; on the other, there are mechanisms in place to protect copyright and limit plagiarism.

What appears obvious is that the concept of authorship is not well understood, nor is the concept of intellectual property. So much information is available on the web that we forget it was produced by someone, who made an effort and who created a work product. I suspect that if we were to query our students as to how many have at some time cut and pasted material without attribution, the number would be quite high. And why not? I recall a story involving a German teenager who had written a novel that was receiving good reviews but who had been criticized for copying material from another existing source. Her argument was that her work was a pastiche or “remix” and she saw no problem with using others’ words in her work since her work represented a new creative product (2). Authorship is changing, and this is evident even in scientific publication, where one can be an author without actually writing any of the text that is later published; for this reason, the idea of “contributorship” is emerging.

The concern is that real scholarship goes wanting. Students are more concerned about finishing an assignment and getting their grade than they are the material the assignment is supposed to teach. As Susan Blum (3) notes, "it’s O.K. if you write the papers you couldn’t care less about because they accomplish the task, which is turning something in and getting a grade.”
So we have two tasks to counter this. First is to build in ethics training in our work, focusing not just on an understanding of copyright and plagiarism, but on appropriate ethical behavior for physicians. Second is to develop assignments which have meaning to our students. Both are not easy, but both are necessary. Our world is changing and we need to be ahead of the changes before they happen.

1. Gabriel T. Plagiarism lines blur for students in digital age., accessed August 2, 2010
2. Meadows C. Plagiarism or “remix”? 17-year-old author’s borrowing creates controversy., accessed August 2, 2010
3. Blum S. My word!: plagiarism and college culture. Cornell, MY: Cornell University Press 2009

Friday, July 23, 2010


I am just now getting ready to head for another RAGBRAI (Register’s Annual Great Bicycle Ride Across Iowa) and as always it occurs to me that the lessons I learn preparing for it are applicable to the work I do as a member of Palmer College. To refresh memories, RAGBRAI is the nation’s largest and oldest cross-state bicycle ride; 39 years ago perhaps 150 riders participated, and this week it will involve close to 15,000 riders and another 10,000 support personnel, all moving through the small rural towns that comprise Iowa. We will start riding on Sunday out of Sioux City, and end a week later in Dubuque. We camp along the way, and while this year the route is relatively short (442 miles), there will be days with hills (notably on our first day as we cross the Loess Hills) and days with wind (notably the 4th day, where we head due south for 60 miles). But there will be companionship and fun as well. As I think about it, here are a few considerations I think are important.

1. Training, training, training. The RAGBRAI organizers suggest that riders should attempt to have at least 500 miles of training riding accomplished before riding the tour. If, like me, you are 57 and not really an athlete, more might be better. Like any other activity we participate in, including teaching or patient care, the more you do it (that is, the more practice you get), the better you do it in the future- you get experience that benefits you and those around you. This year, I am happy to brag, I have more than 1200 miles of training done since the first day of spring, and more than 1600 since last year. So I feel confident in my abilities, similar to how I feel when I enter classroom to teach- years of practice provides significant experience to draw from.

2. Planning, planning, planning. There is little question that planning is critically important in our teaching or in our clinical duties. For instructors, this means developing goals and objectives to cover content and ensure that our tests, for example, match the objectives we set out for our class. For clinicians, this means ensuring that we review information prior to seeing specific cases, so we are up to date on the latest material that is available. As I look over the RAGBRAI route map, I am looking at which towns have aquatic centers, so that I can clean up in those towns (showers are not always easily available and can become quite crowded). It means considering how to manage my diet, by noting which vendors are located where. Planning is important in all that we do.

3. Network, network, network. RAGBRAI is an enjoyable event due in part to the people you ride with. Having a good friend while riding is a wonderful thing; it provides support, insight and enjoyment. In our work here, we are part of a community where we have others we can rely on, who will help us, and who take pleasure in our own successes. Sharing the joy helps all of us feel better.

It may not be much, and it may be common sense, but every day we bring to our work a sense of commitment, based on our training, our planning, and our support from our colleagues. It makes daily life more pleasurable and more productive. It’s a message as equally true for recreation as it is for work.

Monday, July 19, 2010

Measures of Relationships

As educators and as scientists, there are numerous times when we wish to know the relationship between one thing and another; this is often a means for us to gain knowledge about what we do and perhaps how well we do it. We could, for example, look at National Board scores, and perhaps we could assume that it is doing just what we want it to in terms of understanding how well we all teach. Of course, this could be an incorrect assumption as well. But if we look at the test as a means of teaching effectiveness, there are ways to check up on it; we can attempt to correlate how well the scores relate to some criteria we select as indicative of teaching effectiveness. What we need, of course, is some sort of an index of relationship- “a number that when low indicates a low degree and when high a high degree of relationship between two variables.” (1) This is the coefficient of correlation.

Phillips suggests the following thought experiment: Consider that we are interested in two variables, height and weight, of toy soldiers. Imagine that these soldiers are all the same shape, but that they differ in size, and thus also in weight. Imagine that we graph a series of toy soldiers, and we see that the smaller soldiers all weight less than the taller soldiers; the smaller ones are lighter and the larger ones are heavier. But what is the exact relationship here? Is it strong? Is it directly proportional? Is it perfect? If you had to put this relationship on a scale of 0 to 1.0, where would you place it, if 0 equals no relationship and 1.0 indicates a perfectly linear relationship (that is, a solder twice as large as a smaller one weights twice as much as it)?

A coefficient of correlation does just this; it places the relationship on a scale from 0-1.0, but in addition to providing you information about the strength of the relationship, it also gives you information about direction (i.e., positive or negative). There are a number of coefficients that you might see. Phillips states that the Rank-Difference Coefficient (Spearman rho) is the easiest to comprehend, while the Product-Moment Correlation (Pearson’s r) is the most useful and most frequently used. Spearman’s rho is used with ordinal data, while the Product-Moment correlation requires interval data; to put this another way, the former does not allow for the precision of the latter. Spearman’s test requires you to rank the order of the variable from smallest to largest, to then find the differences between ranks and square them, and use that information in the formula. In this test, as in the other, the size of a coefficient is independent of its direction; that is, a correlation of .75 is the same strength as a correlation of -.75. In Pearson’s test, we use the ordinary interval scores that tell us how far apart the subjects are on each variable. The product moment part of the name comes from the way in which it is calculated, by summing up the products of the deviations of the scores from the mean (2).

We do not need to concern ourselves with how these are actually calculated. We need but know that these measures demonstrate the strength of a relationship and its direction, from 0 indicating no real relationship to 1.0 or -1.0 indicating a perfect relationship, in linear fashion. This can help us with interpreting studies which demonstrate the relationships between variables that we are interested in.

1. Phillips JL, Jr. How to think about statistics. New York, NY; WH Freeman & Company;1998;44
2., accessed July 19, 2010

Wednesday, July 14, 2010

Social Media

I have just read that there are now over 350 million members on Facebook, which is more people than there are in the entire United States. Social media has transformed the nature of communication and in some ways of life itself. But what exactly is social media?

In short, social media is any Web content that is created by users and exchanged with others. As noted by Sumners (1), it is associated with Web 2.0 (second generation of the Internet), and emphasizes collaboration. Included in the concept of social media are various ways of social networking, such as blogging, microblogging, social networks and social bookmarking.

Blogging comes from the root term Web log, and refers to online journals, logs of events or whatever a writer wishes to share with others. This site, Teaching and Learning in Chiropractic, is a blog. Blogs have the advantage of being easily updated, and they can be written by a single person or a group of people; they can also be based on a single concept or a variety of topics. A host of sites allow a writer to develop a blog. This blog is hosted by Blogger, but others exist: Word Press, for example is another well-known blog hosting site, but not the only one.

Microblogging is similar to blogging, but is done on a far smaller scale. The most well-known microblogging service is Twitter, which limits the user to no more than 140 total characters per message- which is the maximum length of a cellular-telephone text message. Twitter has become so well-known because it allows people to follow the lives of celebrities and others, making the end-user a “friend” of the celebrity.

Social networking is a growing phenomenon. Facebook is perhaps the best known social networking site, but others of equal repute include MySpace and LinkedIn. Facebook really began as a college phenomenon, seen sort of as similar to a yearbook in which students could locate their classmates, see what they were up to, and find out what classes they had registered for. You created a series of “friends” by invitation, which then linked you to other “friends of friends” in a growing series of contacts. Today, facebook is used to locate old friends from high school and even earlier, to stay in contacts with children and family, to market music, and so on. LinkedIn does much the same but for professional contacts. I have membership in both, but limit my Facebook contacts to friends only. You can also be a member of a “group” on Facebook, which then gives you regular updates regarding that group, making it similar in some ways to what a blog does. All forms of social media overlap to some degree; Facebook users can post messages similar to what you might post for a Twitter update.

Social bookmarking is way to share interesting information with others, while allowing others to provide you interesting information you might not otherwise be aware of. The site Delicious will let you post URLs of interesting Web sites, and tag them with a short note that describes what the site is about. You could then search the site for Web sites with that tag, such as, for example, chiropractic. You can also locate similar sites using algorithms on Delicious that will find those sites for you. Social bookmarking sites exist even for journal articles, and include Springer’s CiteULike (, Mendeley ( and Nature Publishing Group’s Connotea (

Social media is not simply about sharing information; it is about the flow of information as a two-way communication. We are in the infancy of using social media in education; my son, a high-school teacher, uses Facebook to communicate with not just his students, but their parents as well. I write a blog for our faculty to use, and many of you are doing creative things I am not aware of. But however it is, we will surely see this used more frequently as time goes on, and so we need to be aware of possibilities in this new technology.

1. Sumners C. Social media and scientific journals: a snapshot. Science Editor 2010;33:75-79

Monday, June 7, 2010

Another Close to Another Term

Once again we are moving toward the end of a term, and as a result, this will be the now-legendary end-of-term posting. I’ll return again in a couple of weeks or so, but please enjoy this last post for the Spring 2010 term.

1. Via Ferrata: The idea of Via Ferrata grew out of World War I and II; soldiers developed means to cross mountain passes using a series of bolts and iron wiring that allowed mountain soldiers to climb areas that otherwise were impassable. Today, these same routes are used for technical hikers, mainly in Austria, Italy and other European places, and they are not for the faint of heart. Here is just one clip of a young woman walking the Martinswand:

2. The Dangerous Road: And again, well, you can do something similar on a mountain bike. Here are riders heading down the world’s most dangerous road, in Bolivia. There is no way I would even walk this, let alone ride at speed:

3. Ping pong! Hey, who doesn’t love seeing a phenomenal table tennis point:

4. Blue Cheer: well, bassist Dickie Peterson recently passed away, sad to say. I saw these guys back in 1969, with the MC5 and the Psychedelic Stooges, and it was by far the loudest concert I’ve ever attended. But you had to be there:

5. Up: This is the trailer for a movie that is so good it hurts. It has one of the most poignant
beginnings you will ever see, and this is despite the fact it is a cartoon. There are no words at all in the first 10 minutes, but what happens is incredibly moving. I highly recommend this film:

6. Ponyo: Of course, the true master of animation is Hayao Miyazake, whose past films include the astonishing Spirited Away and Princess Mononoke, among others. His latest film is just as good, Ponyo:

7. Knowing: Let’s face it; I’m a science nerd, and I loved this sleeper of a movie, which was far better than it had to be. Here is the trailer for Knowing:

8. Dr. Horrible: During the writers’ strike last year, Joss Whedon, creator of Buffy the Vampire Slayer, Angel, Firefly and Dollhouse, used the time to fashion a new approach to marketing a program. He created Dr. Horrible’s Sing Along Blog, starring Neil Patrick Harris, Nathan Fillian and Felicia Day (who herself had created The Guild, from which Whedon got the idea for his program). It’s, to be sure, a real hoot, and here is the first act:

9. Happy Trails for now, again:

Tuesday, June 1, 2010

Guiding Principles for Scientific Research

The National Research Council offers a set of six guiding principles for scientific research (1), and it bears reiterating them as an aid to those of you considering conducting educational research here at Palmer College.

Principle 1: Post significant questions that can be investigated empirically. That is, develop a question in which your observations guide your conclusions. This is actually quite hard to do; developing a research question is difficult, and often when a well-meaning faculty member discusses his or her idea for a project, and I ask them what the research question is, they get a bit confused. They think the question is what it is they wish to find out- “what my students’ perceptions of “X” are,” for example. Well, that is a question, just not the question, which is much more detailed. What we wish to do is expand on scientific knowledge from prior theory and research.

Principle 2: Link research to relevant theory. Theories are conceptual frameworks that guide research studies. They help provide the reason for a research design and provide context for interpreting findings.

Principle 3: Use methods that permit direct investigation of the question. That is, your research methods should be appropriate for the research question. You will need to provide a detailed description of your research method- and this can lead to some confusion. It is not enough to say, I am conducing a survey. Is it paper based, or is it online? If it is online, how do you recruit participants, and how to gain their consent? How to you collect data, and import to a program where you can analyze that data? A lot of thought has to go into this question. You need to consider the reliability and validity of your measurement instruments, and the proper statistical methods as well.

Principle 4: Provide a coherent and explicit chain of reasoning. Your conclusions are usually going to be based upon inferential reasoning. That is, you are making logical judgments based on the results you obtain, in the context in which you obtained them. You will also need to rule out rival explanations and other threats to the validity of your findings.

Principle 5: Replicate and generalize across studies. You need to provide sufficient detail in your methods so that an interested researcher could replicate what you did, and potentially obtain the same results you did. We need to examine whether your results can be found in other populations and contexts as well, in terms of generalizability.

Principle 6: Disclose research to encourage professional scrutiny and critique. Publish or present your work at conferences or in journals. Share your findings so that we all learn from what you did, and we all can find means to use your data in our specific settings. This is how science grows.

A few good rules here, but worth remembering.

I am pleased to note that this is the 100th entry into this blog- I hope you continue to find it useful and I look forward to posting many more entries.

1. National Research Council. Scientific research in education. Washington, DC, National Academy Press, 2002

Monday, May 24, 2010

More on What the Best College Teachers Do

In this entry I return to the work of Ken Bain, whose book on the best college teachers (1) was the basis of his presentation to Palmer Davenport faculty a couple of years ago. In his text, there is a chapter on how the best teachers prepare to teach. And in this chapter he discusses a set of questions he finds that the best teachers ask when involved in course planning.

1. What big questions will my course help students answer, or what skills, abilities or qualities will it help them develop, and how will I encourage my students’ interest in these questions and abilities?
What this means is, we start with the results we hope to foster and work backward. What is it we want out students to do- do we want them to reason, to recall or to comprehend? When we look at the questions we want to ask, do we delve behind that question to see if there are larger questions? Do we test our fundamental assumptions?

2. What reasoning abilities must students have or develop to answer the questions the course raises?
We want more than to ask students to memorize information. We want them to be able to reason out the answers, and we want to get them to do so both collaboratively and by themselves in problem-solving settings.

3. What mental models are students likely to bring with them that I will want them to challenge? How can I help them construct that intellectual challenge?
How do these models impact, either positively or negatively, the learning students need to undergo to answer the questions we have set before them? Can we then plan to use this knowledge to help them do just that?

4. What information will my students need to understand in order to answer the important questions of the course and challenge their assumptions? How will they best obtain that information?
This revolves around what students need to learn, and not what we might intend to do in the classroom or clinic. Our focus is on helping people learn to reason, to think. It moves us away from being purveyors of knowledge, dropping content into student heads and brains. It makes learning far more active, and engaging for the student.

5. How will I help students who have difficulty understanding the questions and using evidence and reason to answer them?
This is sort of a question of tactics; do we answer questions, provide explanations, develop exercises, or what? How do we then develop new skills in our students when challenges arise?

6. How will I confront my students with conflicting problems (maybe even conflicting claims about the truth) and encourage them to grapple (perhaps collaboratively) with the issues?
How true this is in chiropractic, where there are numerous and often contradictory fundamental approaches to chiropractic, to management, to concepts and constructs such as subluxation. What methods can we use to address conflicting information that may arise both inside the educational program and outside it? Addressing conflict in ideas needs to be built into the fabric of our coursework and our teaching methods.

7. How will I find out what they know already and what they expect from the course, and how will I reconcile any differences between my expectations and theirs?
We all understand this, but we still often teach in a way that controls the questions, sets the agenda and so on; we are, after all, the experts here. But how do we reconcile this with a need to provide more self-directed and active learning opportunities?

These are only some of the questions that Bain asks, and there are a good number more, but the point here is to open the teaching window and consider the students whom we teach- look to make this a more active and engaging process in which the student actively helps to construct learning. Our best teachers often do this, and may not even understand why. Bain helps to answer that question.

1. Bain K. What the best college teachers do. Cambridge, MA; hardvard University press, 2004:48-57