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

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

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

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

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

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

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

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


REFERENCES

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

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

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

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

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

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

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


REFERENCES

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

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

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

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

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

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


REFERENCES

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

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

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

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

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

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

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

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

REFERENCES

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

The SPICES Model: Educational Strategies in Curriculum Development

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

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

The six curriculum issues fall as follows:

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

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

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

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

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

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

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


REFERENCES

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

Quality Television (Not Educationally Related)

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

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

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

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

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

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


REFERENCES

1. Cited at http://72.14.209.104/search?q=cache:Mu4rK9VuVDcJ:davidlavery.net/Essays/50_Key_Buffy.pdf+quality+television&hl=en&ct=clnk&cd=191, accessed September 29, 2008

Qualitative Research, Part 4

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

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

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

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

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

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

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


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