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!