The Leadership Challenge

I’ve been thinking a lot lately about leadership: what makes a good leader, how are leaders trained, and so on. And in considering this, I have come across what appears to be one of the leading, if you will, texts on this subject, The Leadership Challenge, by Kouzes and Posner (1). Their text has been a best seller and it proposes 10 commitments to leadership that good leaders follow. These comprise the main part of the book, and they discuss each commitment and offer tactics to help you learn and assignments to help you understand them. But these 10 commitments are built around 5 practices which Kouzes and Posner feel are essential for good leadership. I thought I would briefly note each one.

Model the Way: We can easily translate into vernacular: walk the walk and talk the talk. It is your behavior which earns you respect. We need to act in a way we would like to see others act. The authors note that to effectively model behavior, you have to be clear about guiding principles, and you must clarify values. Leaders do not speak for themselves; they speak for their organization and for its values. But words only go so far; deeds matter even more. What you do is important; I can’t ask you to write papers, for example, if I do not do so myself.

Inspire a Shared Vision: Leaders have a vision of what can be, not just what is, and they believe in what they see and what they think can happen. They are confident they help people get there, and they see opportunity and possibility. Some of us do this every day; we see where we want our students to be, and we help them get there; we see their future. We need to enlist others in common vision, speaking in a common language, and have others’ interests at heart. We excite others, and they then will follow us as we go forward.

Challenge the Process: we all face challenges. Perhaps it is declining enrollment; perhaps it is challenges from a competitor, or something else. We cannot keep everything the same forever; we need to change, and we need to look at what we do in order to change. Leaders venture out, says Kouzes and Posner. They do not wait for fate to smile on them, but they actively work to address challenge; they search for opportunity to innovate and grow. Our students, for example, come to this college with excellent skills in using technology; we need to answer that new challenge by learning how we can yoke the technology to better educate them. No longer can we simply stand still. Leaders create ac climate where we can feel free to try innovation, and where we can even feel safe if we fail. Leaders understand risk but accept it.

Enable Others to Act: In order to get things done, we have to act, and our leaders allow us to do so. No, they encourage us to do so. And to do so, leaders foster collaboration and help build trust. Teamwork results and we all engage. We are empowered. You will hear leaders not use “I” very much, but you will hear them use “we.”

Encourage the Heart: We are all in this together and we have all been at this a long time. I have spent, for example, 31 years in academic chiropractic, and it is always possible we can become exhausted or disenchanted (I have not, let me be clear!). Leaders encourage the heart, they care about those who work with them, and they help draw people forward. A simple note of thanks can do wonders to the person thanked. Recognizing the contributions people make is important, and celebrating them collectively is critical.

In the end, leadership is a relationship that can be developed. We are leaders in the classroom, in our professional lives, and in many other ways. There are skills we can use to become better at this, if we but take the time to do so.

References
1. Kouzes JM, Posner BZ. The leadership challenge, 4th edition. San Francisco, CA: Jossey-Bass 2007

Innovative Teaching

Let me first offer you my best wishes for the new year. I hope that during the past couple of weeks you were able to catch your breath, enjoy your time off and spend time with friends and family during the holidays. I know I very much appreciated the time off; we have all been working hard and this will help clear out the cobwebs and set us on the road for a great 2011.

While I was off, I was sent links to a site which featured the well-known statistician Hans Rosling. In viewing one of the clips I got to thinking about innovation in teaching methods and I have some thoughts to offer on that, in the context of commenting of a few of the clips I watched over the break. Let me begin by offering this link:

200 Countries, 200 years, 4 minutes: http://www.flixxy.com/200-countries-200-years-4-minutes.htm

Now, I know that we do not have access the kind of technology seen in this clip. But stop a minute and think about what you see here. Note that what Rosling does is intriguing. First, he is obviously passionate and animated about what he is discussing, and he has obviously planned out what he is going to say and the movements he makes in order to synch them properly with something he cannot actually see, since that has to be edited in later. But also note that his use of this technology helps him pass on an important learning message that would otherwise take far longer to present if he were to simply lecture or even use bullet points in PowerPoint. He has been able to show you the relationship between life expectancy and income (wealth) for 200 countries over a period of 2 centuries. And he has done so in just 4 minutes- and I think everyone who sees this could tell me what that relationship is. The key point he makes is this: “Having the data is not enough; I have to show it in ways people both enjoy and understand.” He has done so masterfully.

New Insights on Poverty: http://www.ted.com/talks/lang/eng/hans_rosling_reveals_new_insights_on_poverty.html

Another clip with Rosling. Note again how he combines passion, humor and data to present an engaging and informative lecture. Not only does he use his animated projections, but note how he integrates video clips and panoramic photography to illustrate points. And note his subtle humor about PowerPoint at around the 14.50 mark here! And I absolutely guarantee that youw ill not foget the end to this presentation. Guarantee it!

Animating the Cell: http://www.ted.com/talks/david_bolinsky_animates_a_cell.html

Another use of graphics to illustrate complex points. Imagine accessing this for use in class, or even learning how to do something like this. (PS. Ted.com is a great source of informative and educational videos).

The general idea, of course, is to use innovation in our teaching. Other ideas exist as well; Drunk History, which can be found in youtube, presents clips from American history through the lens of a purportedly drunk person discussing historical episodes and then has them acted out by famous actors. I will not post links due to the profanity on them, but I list it here as yet another novel method for presenting information. I hope to encourage us all to look for new ways to present information; new technologies do exist and we need to remain up to date with them and then use them to help our students learn more effectively.

Welcome back!

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

ABSTRACT
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

ABSTRACT
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

ABSTRACT
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.

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.

References
1. http://manoa.hawaii.edu/assessment/howto/rubrics.htm, accessed Dec 3, 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.

References
1. http://manoa.hawaii.edu/assessment/howto/rubrics.htm, accessed November 29, 2010
2. Stevens DD, Levi AJ. Introduction to rubrics. Sterling, VA: Stylus Publishing LLC, 2005

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


Workshops

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

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

ABSTRACT
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

ABSTRACT
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

ABSTRACT
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.