2022 TEACH Education Day

[Dr. Shari Wicker] Welcome, everybody. Thank you all so much for being here. So many people in person, even more people online. This is wonderful for this special day. Thank you for joining us. It's bittersweet: we all wish that Dr. Vari were here with us celebrating, as he so loved to do. The sweet part of it is that we have his family here. We have also had so many kind, amazing, generous people who have donated to make sure that this happened this year and also in many years to come for…in honor of Dr. Rick Vari. So, thank you all for that. So, I’m going to invite Dean Learman to provide some welcoming remarks and also to introduce our esteemed speaker today. [Dean Lee Learman] Thank you, Dr. Whicker, and it's a pleasure to be with you this afternoon. And I also want to acknowledge the presence of Rick Vari's family. We're so glad you're able to be here. I really want to thank everyone here for joining us for the TEACH Education Day keynote address on our very first, inaugural Vari Endowed Lecture at the Virginia Tech Carilion School of Medicine. The lectureship was created in honor of Dr. Vari's impact on medical education as a whole and his remarkable contributions to us here at VTC, as he launched our inaugural curriculum. He's our inaugural curriculum Dean here. And as you all know, nearly a year ago, as the toll of ALS was making it too difficult for him to continue his work in full force, we celebrated Dr. Vari's retirement here in this room with career-long tributes from his colleagues, students, and friends. And at that time, we made the following announcement: In honor of his retirement after joining the Virginia Tech Carilion School of Medicine on April 1, 2008 as founding Associate Dean for Medical Education, and in appreciation of his commitment, dedication, and service as Senior Dean for Academic Affairs and architect of our innovative curriculum, we are delighted to announce the creation of the Richard C. Vari, Ph.D. Endowed Lectureship established on October 29th, 2021. Well, Rick passed away too soon on June 12th of this year, leaving a sense of  loss for all of us who knew and loved him and   were really hoping he could be here with us today.  We're incredibly fortunate that he invested the   last 14 years of his life creating an enduring  legacy and identity for our medical school as a   place of educational innovation and excellence. Choosing the Inaugural Vari Lecturer was no   easy task. I want to thank the planning committee for creating a list of possible speakers who are luminaries in medical education in the US and internationally. Any of the people on that list would have been a fantastic choice. But when Dr. Vari learned that we had reached out to Dr. Louis Pangaro and that he had accepted our invitation, it brought a huge smile to his face because of Rick's enormous respect for Dr. Pangaro's contributions to medical education. It is now my challenge to summarize just some of those achievements, that I'm tempted for you to turn my speed to 1.5 because it's going to take a little while. So, Louis N. Pangaro is Professor of Medicine at the Hébert School of Medicine of the Uniformed Services University of Health Sciences. He received his medical degree from Georgetown University and stayed there for his internal medicine residency and his endocrinology fellowship training. He then went on to complete a research fellowship in endocrinology at the Walter Reed Army Medical Center, where he developed a radioimmuno-assay -assay for a familiar hormone, called 3,5 Diiodothyronine. Otherwise known as your main thyroid hormone. Should we call it the main hormone? The most important hormone? [Dr. Louis N. Pangaro] It’s actually unimportant. [Dean Learman] It's an unimportant hormone! Well, congratulations on discovering an unimportant hormone. And I'm sure you went on to do other things in your career, Dr. Pangaro. Dr. Pangaro joined the Uniformed Services University in 1981 and grew hrough leadership positions in medical education, including Director of 4th-Year Programs, Clerkship Director, Vice Chair for Education in the Department of Medicine. On his retirement from the Army in 1998, he was appointed professor with tenure. He served as a Medicine Department Chair from 2008 to 2018 and helped lead the medical school's curricular re-design from 2009 2014, and served as Interim Dean of the School of Medicine from August 20, 2020 to May 2021. Dr. Pangaro’s scholarly work is comprehensive. He's done a lot of work on competency-based assessment. That work's been disseminated in articles, chapters, books, presentations, and visits to many medical schools. Using the model he just cited of the radioimmunoassay, he created standardized examinees to calibrate the validity of the prototypic clinical skills exam from NBME and US Medical Licensing Exam. He introduced the concept of synthetic developmental frameworks for defining expectations of learners and underlying the ACGME milestones. His landmark 1999 publication in Academic Medicine introduced the RIME Framework: Reporter, Interpreter, Manager, Educator Framework. For that for over the past two decades has nearly replaced the traditional KSAs or Knowledge, Skills, and Attitudes paradigm used in most medical schools. Dr. Pangaro's impacts on medical education are evidenced by the breadth of his service contributions and award recognitions as well. He's served as an at-large member of the NBME and on the editorial boards of Academic Medicine and Teaching and Learning in Medicine. He's past chair of the Research in Medical Education or RIME Conference Committee for the AAMC as well. Dr. Pangaro has served as president of both the Clerkship Directors in Internal Medicine and for the Alliance of Clinical Education, which serves as a coordinating council for eight national organizations of American clerkship directors from different specialties. In 2022, the Alliance established the Louis N. Pangaro Medical Educator Award for recognition of national contributions to interdepartmental education. He was honored with a AAMC’s Glaser Distinguished Teacher Award, an award that Rick also received, and with the NDME's Edith Levitt Distinguished Service Award. The Clerkship Directors in Internal Medicine bestowed Dr. Pangaro with all three of their awards and renamed one of them, the Outstanding Program Development Award, the Louis Pangaro Award. He was recognized by the American College of Physicians Army Chapter with its inaugural Master Teacher Award, which was later renamed the Louis Pangaro Master Teacher Award, and by the Washington, DC ACP chapter with its Sol Katz, still Sol Katz, Teaching Award and its Laureate Award. In 2010, Dr. Pangaro was named a Master of of the American College of Physicians. And in 2012, he received the Distinguished Medical Educator Award of the Association of Program Directors in Internal Medicine. In 2018, he received the John P. Hubbard Award from NBME for excellence in the field of evaluation and medical education. One of his most intriguing awards was received in 1990. I'm not going to expect any of you to guess what it was. It was from British Embassy Players for his production of Shakespeare's Hamlet. So, during our half-hour meeting together, as we might have talked about all sorts of arcane issues in medical education administration, we spent a goodly amount of time discussing what linkages we can make between his side career in acting and production of Shakespeare and the roles we play as physicians in our lives. And it was just a fascinating conversation, certainly a Renaissance man, pun intended, Dr. Pangaro had that he's won that award for the British Embassy players, with a tongue and cheek at the time, I'm sure for them. So hidden within this impressive list of career accomplishments and perhaps fueling them is Dr. Pangaro's humanism, his passion for developing physicians, and his efforts developing medical educators across the continuum so they can achieve their greatest potential with their learners, be they medical students, residents, fellows, or faculty colleagues. Dr. Pangaro has personally evaluated and given individual feedback to several thousand medical students and nearly all of them are still a part of the military medical community. As a facilitator of the Stanford Faculty Development Program, he has worked with more than 1,000   military faculty on their teaching skills. In 2000, Dr. Pangaro created a six-day course for military GME program directors in assessing competence, and nearly 500 program directors have participated. He's published and spoken widely on faculty development and leadership in medical education. He co-directs the annual Harvard Macy International Program for a systems approach to assessment of the health sciences education. And as a department chair, he launched both the master’s and Ph.D. Program in medical education. Reading through Dr. Pangaro's awards and recognition reminded me of the parallels in Dr. Vari's career, but the strongest memories of Dr. Vari were evoked by Dr. Pangaro's humanistic contributions while supporting so many students, residents, and faculty in their lifelong learning to excellence and impact. You'll also notice Dr. Pangaro's unique title for presentation on medical education. This was intentionally designed by him as an homage to Dr. Vari's commitment and passion to physiological sciences. So now and finally, please join me in welcoming Dr. Louis Pangaro to the podium as our inaugural Richard Vari Endowed Lecturer and support his talk, “What does physiology teach us about assessment and evaluation?” [Dr. Pangaro] Thank you very much for inviting me to give the  inaugural Vari Lecture. I met Dr. Vari when I was   active with IAMSE as part of the Alliance for  Clinical Education about 12 years ago, and hearing   what his friends and family have said about him  and what I've read about him I think we are gifted   to be in the presence of someone who's effect  will just have Ripple waves through generations   for people who never met him um his his family  or never knew anything about Hungarian meatballs   um that I think we're all privileged to be part of  that um I I'm what passes as an expert for medical   education but when I take care of patients with a  thyroid problem I have a molecular understanding   of how how thyroid hormone interacts with the  nucleus when I take care of patients with diabetes   mellitus I can look at studies with thousands  of patients randomized to different courses of   treatment this kind of expertise is not available  yet to you and me in medical education we need to   be very humble about this and I will speak with  great dramatic force today about my ideas but I   do not confuse the vehemence with which I speak  with any kind of certainty and I will try to pay   tribute to the work that Dr Barry and carillion  has done in Virginia Tech because this is an   extraordinary School some of the things that has  happened here um probably could not happen in a   school that's been around for a hundred years The  Innovation and the ability to create a new way of   looking at the process of Education I will try  to pay tribute to that and at the same time try   to extend some of those ideas into areas that may  be a little bit controversial I'm always always   glad if I can say something that is a little  outside of the outside of the box um I'll speak   as clearly as I can I tend to have everything I  say in the slides I often talk to International   audiences where English is not a first language  and I'll always make my slides available so people   don't have to take so I apologize for some very  old-fashioned power PowerPoint type technology   and if I run out of time we'll just jump to the  end um so down I think is so um that's the title um there's something I want to emphasize  in this tribute to to Rick this emphasis   on Adult Learning in a patient-centered context   uh we'll I will pick up two of those themes is  what does it mean to learn as an adult what does   it mean for a res resident or a medical student  to say here's what I need to know and then what   is the idea of the patient-centered context have  to do with the system in which they'll function   um in a sense I'm after a unified theory  of Medical Practice competence readiness   and evaluation in the clinical setting and  my theme is always to think of everything   but not do too much to embrace complexity and  act with Simplicity I think is what what the   medical profession needs to be paid to do  need to focus on it's a kind of a judgment   and expertise that is not simply guidelines  based or routinized so that will be the kind   of underlining theme I'd like to start off  by saying how do we define success for the   curriculum for you and me as as teachers so  I want you to imagine I I am working with a   beginning intern from my own medical school  who sees a patient with thyrotoxicosis an   overactive thyroid gland and we're about to  put that patient on medicine I would be happy   if this my medical school graduate could describe  iodine metabolism and how methimazole Works how   it interfered with her I would be happy about  that but if this resident not knowing these   basic mechanisms did not on their own without  my coaching fill the Gap in their knowledge   then I would drop dead with embarrassment this is  my simple way of evaluation of saying what's the   difference between what's essential and what's  desirable and faculty you and me our job the   curriculum is to create Independence capability  so that the graduate can fill this gap on their   own they have to and have internalized  some concept of what expertise looks like   and I'll be talking about that in this talk and  what is the role of faculty in fostering that but   basically at the end the student our graduate has  to be able to independently learn from experience without me being there to prod them   and if my graduate has a problem in physiology  how does methimazole interfere with the synthesis   of thyroid hormone and they don't say God I  don't know that I've got to figure that out   and they don't have that itch then I have  to drop dead with embarrassment I failed   so this is a distinction between the essential  and the desirable and the part of the importance   of this to me is so much of what I have to  do in my daily work with patients or students   is desirable but not essential and I worry about  economy of action and all the things I as chair of   medicine I had a thousand faculty between Bethesda  and Honolulu all the things they are asked to do   and the central role of faculty in creating this  capability and respect for what their needs are   is very important to my own thinking so this  is the disclaimer everything I say is does not   represent the Department of Defense okay oh or  the uniform services University you heard me you   heard me say this okay I said uh and there's  a couple of disclaimers we don't need this   um I need to tell you a little about something  about some of the words that I'm going to use   when I say learner or student sometimes I'll say  student but it could be a resident or it could   be a fellow sometimes it'll just be a student and  by Readiness I'm going to use the word Readiness   rather than competency we use the word competence  competency in very loose ways so readiness   from a pre-clerkship student to go into the  clerkships ready for a fourth year student   to become an intern ready for a resident for  independent that's what I say what some people   mean is competence uh I'm capable of of being  independent I'm going to use the word assessment   in its etymologic sense sitting next to to observe  the student or the resident and I'm going to use   evaluation to mean an interpretation of what I  see I'm saying this because other communities use   these words differently so for instance if I had a  student who was a good reporter they could get the   facts but not much of an interpreter they couldn't  couldn't explain why the patient had a had a fever   so they had basically the syndrome was failure  to go from reporter to interpreter that's what my   observation is that's the assessment if this was  a first-year medical student that would be fine   if it was a pgy2 in medicine Family Medicine  repeats that would not be fine so the observation   is the same the assessment is the same but the  evaluation the meaning is different depending   on context so I wanted to explain how I'm using  the words because not everybody uses them the   same word overall everything that we do  from the beginning of med school to the   end of gme is a movement from understanding  into action and this will come repeatedly in   my thinking today because you'll hear a lot of  repetition because my theme is the commonality   of everything we do taking care of patients  taking care of students taking care of each other   so this movement from understanding into action  so understanding how the student is doing is   assessing and evaluating and then we have actions  seen on the lower right hand corner here grading   in my lexicon is not an educational activity a few Deans can scream if they wish it's an  administrative action a classification as you   get credit you're ready for advancement this is  a summative decision as opposed to feedback which   is an educational activity which Any teacher can  do based on their own observations they've made   an observation student is a reporter not moving  interpreter on this patient today placing it in   context this is okay for a beginning first year  student or a second year student I'll give you   feedback based on that you can give feedback based  on information but to make a summative decision   you get to graduate this requires a much higher  degree of certainty or knowledge so what is the   end what is a physician and what is the role of  Science in practice and what I'm going to use is   etymology here physics physiology physician  these three words desire derived from the Greek   word for nature so we claim to understand human  nature whether at the bottom of this triangle   at the level of molecules in genes  at the middle of this triangle   at the level of the patient or in terms of  the whole system so we can say this is basic   science clinical science or recently what we're  calling system science but at each of these three   levels a physician makes a commitment  to understand mechanism how things work that gives us is part of our Authority  to violate practice guidelines a knowledge of mechanism plus  a sense of Duty to the patient   so this commitment to mechanism and the first  tribute to Rick and he wrote papers on endocrine   physiology and teaching about 20 years ago I  don't have time to go into all of them but the   idea is you understand how that drug Works in this  patient so you're committed to mechanism whether   it is at the level of the gene the patient or the  whole system in our own curriculum it uses uh we   called it molecules to military medicine because  we expected our students to be able to embrace   all of those domains this is the three domains as  areas within knowledge which you must understand   so again the emphasis physician physiology  physics it's a commitment to understanding nature   do Physicians use basic science this was  controversial in the 90s because when you talk   to doctors about how they decided it was pneumonia  what did they say it looked like pneumonia   or had you decide it was nephrotic  syndrome like nephrotic syndrome so   there was some thought that doctors don't  do this and then there was a nice series   of articles by Patel and Hank Schmidt  and others um I give you one reference   there is that the science is there below the  surface that he used the term encapsulations   that you understand the physiology it's all  encapsulated in a pathophysiologic mechanism   so when we use the concept of fast thinking  this is Kahneman the Nobel Prize winner he   was a psychologist but he wanted for economics  fast thinking is pattern recognition the patient   has polyure polydipsia so it must be diabetes  Nellis So that's fast thinking that's recognition   but what a physician needs is X-ray vision  that you can you can visualize the glomerulus   and a nephron and you have this idea of an osmotic  diuresis that you can do the slow thinking to   figure things out this to me is the CNA Quan on a  physician and Physiology and if the faculty allows   the student to graduate without a commitment to  understanding the mechanism whether it's at the   level of the gene the patient or the system  then we have to drop dead with embarrassment so what is the role of basic science in practice  so essentially we make a promise of Duty and   expertise and our commitment to understandings  whether it's at the level at the bottom I'm   using the triangle as a metaphor that may be  the wrong metaphor it could be upside down it   could be sideways allow that triangular I like the  point you know tiny little molecules or genes and   of course these people won the Nobel Prize for  their work and crisprs and what's going on with   the G so that's at the bottom of the molecule  and the mo of the trial and then at the top   we had this revolution of health system science  um uh Jed Gonzalo who is here now uh did a   presentation at iamsi uh Rick was the president  of iamsi and some of the papers I'll be citing   um like Roe here and others uh uh Rick is on  all of these papers I will be citing but often   he's the senior author so he's not the first  person on the list so you'll see other names   and health system science is at if you will the  top it's the most broad concept and is spoken   of as one of one of the three pillars so building  uh building health system science education is a   core domain was one of the fundamental things was  happening here at Virginia Tech carillion and this   is paper by Dr music that that cited this Rick  is one of the authors uh co-authors in this paper   um uh I think Patty you were a  co-author on this paper too if   I were if I recall Dean Lerman you  I think you were on that one too   um so building in systems thinking and uh you've  taken steps that other schools I wish we had in   build working with Radford to to build in uh uh  interprofessional education and when we speak of   things as mapping we're seeing things as domains  mapping is how the faculty organize the structure   but there's another question about integration  not what the faculty do but how the students   integrated into their head and suppose instead of  mapping with different domains and I've shown you   my triangle again a lot of repetition because  I think it's an important concept mapping is   looking at the domains basic clinical and Science  Now suppose Health Systems Science which we're   now introducing were used as a lever to get  students to think that everything is a system basic science and biochemistry  right remember gluconeogenesis   is part of a system the body is trying  to maintain the glucose because the brain   needs glucose suppose the same terminology  of systems was used not just at the biggest   macro level but actually at the micro level  so that when the students learn biochemistry   it's the same jargon terminology  as if it were health system science so what are these Sciences of basic and health  system what is this system so here's a definition   from reichton's famous book on why Eagles can't  swim a collection of different things which   working together produce a result not achievable  by things alone in other words a system is trying   to maximize one thing to avoid something else  and to protect something uh when we're taking   care of patients we call this efficacy and safety  of course so it's it's true at the clinical level   in the middle of the triangle so what is the  system trying to maximize so this is physiology   is Claude Bernard there as homeostasis  the system is trying to maximize X   the system says I would be happy if and the system  is trying to avoid why hypoglycemia what happens   if you get hypoglycemia your blood sugar is 20  you seize you're in the Primal jungle you get   eaten by a saber-toothed tiger so I will drop  dead not just with embarrassment but literally   do you see how the prioritization  I would be happy and I'm using the   physiologic concept of homeostasis to support  this the maintenance of the the internal milieu   there's a set point the body has a set  point for sugar osmolality blood pressure the patient has a set point for what they're  trying to achieve and so does the system so   the set point implies there's a constant  maintenance there's a constant dialogue   in the system about what we're trying to  maximize and what we're trying to minimize   so we're trying to maintain the internal milieu  we're trying to maintain cerebral glucose and   avoid hypoglycemia because in this in the Primal  jungle if your sugar gets too low you get eaten so the very notion of gluconeogenesis and homeostasis which we teach  in physiology is the same principle at the health   system science level what is the system trying to  maximize health of populations the experience of   patients and minimizing costs that remember  that we have a quadruple AIM now but that   was the triple aim right what are we trying to  maximize so at each level does your student or   your finishing resident have they internalized  the concept of what has to be what has to be   internalized developed or maximized in the student  in order to be able to function and expertise then   for a graduating student or resident  may be the capability to say   what do I need to maximize for this  patient and what do I need to avoid   it's a systems thought whether it's at the level I  need to I need to avoid I want to maximize control   of their blood sugar I don't want it greater  than 200 but damn I got to avoid hypoglycemia   because that's really bad that's at the level  of the basic science what do I need to maximize   for the patient what are the patients values  and what does the patient wish to avoid that's   at the center of my triangle and then what is the  system trying to maximize and avoid and expertise   bottom of the slide is the capability  to ask and answer these questions   and duty is a commitment to find the answer and  here I'm here I'm saying what are the priorities   in the science so basic science clinical science  in the middle of the patient and on the right   the care system basic science we're trying to  avoid we're maximizing glucose and osmolality   the patient's priorities in the center may  be my pain I want you to take away my pain   my job the cost of me and what is the health  care System trying to maximize and minimize   and can we as faculty be sure that the  student knows that each three level   what is to be maximized and what is to  be avoided systems thinking at all three   levels and here I'm dependent on the ethicist Dr  Pellegrino who never actually wrote what is on   the slide but I heard him say it many times to  our students that professionalism is a promise   it's a promise of expertise and a promise of  Duty and so for the next few slides I'm going   to be talking about what does a student need to  know as an example of expertise and how does a   student relate to patients in making decisions  as an example of Duty I think almost everything   we say about competence these Milestones epa's  rhyme is a footnote to Pellegrino professionalism   is a promise of expertise and a promise of  Duty and competences being able to deliver it what does expertise look like The Faculty has  to judge what has the student internalized and   these are the two problems cognitive and then  when you move from understanding into action to   take care of patient what does that Duty look  like and here broadly speaking the beginning   of med school to the end of residency you're  moving from understanding into action from   what I call a reporter interpreter into manager  educator and on the left understanding making   a diagnosis going from the findings the symptoms  the labs and whatever to a diagnosis is primarily   cognitive and requires a lot of expertise but  once we move and we say to the patient with   a thyroid problem for instance um you have an  overactive thyroid we could talk about surgery   radioactive iodine or medications the patient's  values are now part of that conversation right   once we're talking about values this is  no longer simply cognitive this is ethical   so the movement from understanding  into action into this field of action   of decision making shared decision making  with a patient is also an ethical concern   so I'm going to first take the cognitive part of  this what is understanding what is knowledge well   again the overall movement is from understanding  into action you see something you think about it   you do something observation reflection action  this is the Rhythm that underlies all human   activity pdsa Cycles all sorts of business IPO  all of that stuff is basically another way of   saying you see something you think about it and  then you do something so let's imagine you're   you're a faculty member in the hospital  and you have a resident You observe that   at the bottom of the slide here You observe the  resident and then you as a teacher give feedback   you have taken some information you've decided  what it means and then if you've seen many   observations over time multiple teachers then the  competency committee decides whether or not this   pgy1 becomes the pgy2 that decision that a pgy1  becomes the pgy2 is a movement from understanding   into action because advancement a summative  grade and advancement decision is an ethical   decision and action to be taken by the committee  now I'm going to parse this a little bit more   stay with my attempted Graphics here so we have  a movement from data to information I made an   observation and decided that the resident was okay  to certainty I've now not just had one observation   of the residents today with diabetes but we've  had five teachers observing the resident in 20   cases of different kinds of heart failure  pneumonia clots renal problems infections   whatever is appropriate in your discipline so I  now have I'm moving from information to knowledge   to certainty because of sampling and now I'm  ready to make a decision which requires wisdom   so where does knowledge fit in to go from data  information means you have to have a knowledge of   expectations or a framework to go from information  to certainty it's a sampling problem and then to   go from certainty to a decision requires input  of values so I'm saying the same thing multiple   ways you see something you think about it you do  something data information knowledge or certainty   and wisdom understanding into action so we're  talking about now the cognitive issue of knowledge   um here this is one of Bloom's taxology taxonomies  uh writer at the University of Chicago starting   in the 50s and looking at cognitive as we move  from the bottom left of the pyramid remember   something as true being able to explain it  then apply it and justify it then evaluate   it make decisions and ultimately others others  added this to bloom about 20 years later create   study extend so this is in a sense a cognitive  process you don't just remember something but   you can apply it you can explain it right and  then you can ultimately do something with it   same rhythm I know something I can apply something  and I can make a decision so what is knowledge well knowledge is necessary to move from  data to information I gave you the example   if I observe someone and they're just  a reporter not much of an interpreter   I have an observation right if now I tell you  in context it's a it's a first-year medical   student you say that's okay it's a second year  resident it's not okay so our knowledge of the   framework is what allowed us to interpret  the data and move from data to information   and I'm going to be spending some time later  in the talk about Frameworks and how they   affect what the teachers do but knowledge is  necessary to convert an observation into some   information and knowledge is also necessary to  interpret a sampling of data through a blueprint   into some kind of a decision so knowledge  is applied in this process I think you know   this the reason why I'm showing it in this graphic  form is to set up this ancient idea that knowledge   is Justified true belief and I'm going to play  with this idea in my own way for the next minute   so JTB knowledge as the Bedrock of going  from understanding to action what the   student or the resident tells you about  how methimazole affects the physiology   a thyroglobulin and iodine  metabolism must be remembered as true   they have to report it accurately  right I think we all accept that they have to justify it meaning the student or the  resident can say I can apply it in this situation   and I can interpret these results accurately  this is what happened to the patient's thyroid   hormones as a result of this or they can explain  it justification is a kind of an explanation   it's what people when they write multiple choice  tests call uh deeper level or advanced level or   level two questions it's not just remembering it's  interpreting something and finally and this is the   point of this joke I'm making with JTB now is  belief there is a commitment to acting basing   Management on it the student has enough confidence  in their knowledge of the physiology to say   I'm going to make a decision affecting  this patient's Health based on this I'm using this antibiotic this anti-hypertensive  I'm going to do this operation on the belly this   laparoscopicily cystectomy I I have enough  confidence in my knowledge of the anatomy   that I'm going to base this patient's Health  on it do you see what I'm using I'm using the   word belief here as an emotional commitment  not just that they remember it correctly it's   true not just that they can explain it they  can justify it but they goddamn believe it   now how many of us when we're asking a  resident or a student a question try to assess   their confidence in it if they if they come close  I find myself saying yeah that's great and I want   to move on because I'm in a hurry but the real  question is have they internalized this sense This   Promise of expertise Pellegrino's promise that I  got this I understand the anatomy of physiology   well enough I'm going to bet this patient's life  on it so I like this idea this this idea of JTB   so the teacher's role does the does the student  recall in the information quickly that you asked   him the facts do they apply it but some trying  to Foster their confidence is the student's   professional identity such that they say I have  a promise to this patient that I understand   their Anatomy before I walk into the room I  know the anatomy of the right upper quadrant   and I'm not going to walk into the room  dor for the lap Coley until I I have that   building confidence and capability is more than  just cognitive and anyway that's the point I'm   making I'm using physiology as the example because  of Rick but it could be it could be Anatomy   so what do I need to know can the student  or the resident internalize the idea of   what is adequate knowledge what is adequate  knowledge look like what do I need to know so I'm looking for my what  do I need to know cards here   but I basically give to every resident student  an endocrine fellow I work with and say within   24 hours of having a patient who's say  thyroid allow me the endocrine reference   you have to know how methimazole  Works how good is it and how bad is it   I want you to internalize this  idea that your promise of expertise is to say how does it work how good is and  how bad is it and if you don't know that   then your promise of professional expertise  is lacking now I don't say it in dire terms   like I'm going to fail you or anything like  that but you see the concept that I'm after   that the student has to internalize an idea  of what it looks like and it's not sufficient   that they know the answer to the question but that  they realize that they sought these answers and   that the faculty expects them to know how does  it work how good is it and how bad is it and   there's other jargons for this you could call this  self-regulated learning not just self-directed   self-regulated because they knew what they were  looking for they weren't reading Harrison as if   it were fiction they're reading it for the answers  you could call this metacognition there's a lot of   jargon for this but do you see the concept that  the faculty says the student has internalized a   set point the same way that the hypothalamus as a  set point for glucose and osmolality we've built   into the student a set point for what adequate  knowledge and a promise of expertise looks like   I think you guys have been doing this  I'm just kind of given my jargon for it   so what do I need to know everything  is a movement from understanding into   action reporter interpreter manager educator and  curriculum then is an invitation so if I have a   clerkship medical student who reports the facts  and says the patient has a cough and spewed them   I say what do you think is going on give me two  or three possibilities I don't want you're not a   resident you don't have to have the right answer  you're a student tell me what you're thinking   give me three possible explanations and why  curriculum is an invitation to advance from report   or to interpreter to manager ultimately you go  from understanding into action so what is action   moving into shared decision making uh for being  being a manager for a sub intern it would be   suggesting a diagnostic and therapeutic plans  a resident should have an effective safe plan   I think we would all agree the Criterion is is  a little higher applying knowledge to specifics   so how on how is understanding form understanding  moving into action I said before that once you   move into action and we're talking about decisions  that affect patients life this is now ethical   values are now at play and how do you build  this in what is the context of making a decision   that affects the patient's life  for the physician and for us can you form the correct understanding of the patient's world and what adequate knowledge of the patient's world  looks like in a classroom even in pbl which Rick   introduced which I love is great that's very very  interactive Dr steinweg is teaching in that course how do you build in that context well Rick had the idea when he was building the  new curriculum here and he wrote about this years   before he got here actual student patient contact  under preceptor supervision with real patience   nursing homes Hospital as well as standardized  patients he was envisioning that the correct   understanding cannot be formed in the classroom  the promise of of expertise the promise of Duty   is not made to me or you or to the multiple  choice test the promise is made to patients so unless there is work with actual real patience we don't know if that I shouldn't say we don't  know I mean I went to medical school 40 years   ago right I turned out okay I think some  of you did too even though we were in the   classroom but but trying to think of the role  of Health Systems Science and seeing the big   system essentially requires it so at Virginia  Tech carillion begins with real patience in   the first this was extraordinary only a  few schools are still even doing that now   so this is her this is a real achievement  and as you go from 49 to double that students   it takes resources it takes  an investment in faculty facults means capability The Faculty are the  people who create the capability in the students   so in the 20th century model the flexner  report Carnegie one was the two plus two   in which you learn basic science that's the  bottom of my triangle before you saw patience   I cited a paper that was from Miami that edffinity  at Rick got the finnerty award from iamsi for as   many contributions that's why I felt I needed  to cite that but that was the old model and the   question is what do you do to to vary around this  so this is uh my medical school but others look   like that um the pre-clerkshire period in red is  no longer two years it's only a year and a half   and so you start working with real patients  but is that as good as seeing real patients   from the beginning of first year I don't know  nobody we don't have these randomized trials   um the pediatrician bronfinbrenner came up  with the idea of the patient at the center   of a huge series of concentric circles but  what we're after through health system science   and here I'm making the transition  from the cognitive to the ethical   is the patient's universe is not what  happens with me in the clinic today so what happens when they go home and I ain't  there now sometimes with virtual care we can   actually follow up now new Innovative idea  of the medical student or the intern calls   the patient in videos with them at home a  week or so later to see what's happening   but being able to visualize the patient's  universe and their values now becomes important   people have tried spiral curricula here  you're having early care I wonder if we   should abandon the flex through notion of two  plus two and go back to what they were doing in   the 19th century and you start by seeing  patients on the tutelage of Chad Dumont and you have science at the same time the question  I'm asking is can you form the correct kind of   understanding about action being ethical in the  context of the classroom and I don't know the   answer to that now I want to transition to the  role of the faculty in evaluating evaluation   the root the etymology the word evaluation  I've underlined that there is value comes   from the Latin Valerie to be strong strengths  capability what is the strength we have in mind   the purpose is this resident that I'm working  with today on the wards in the hospital building   capability are they making progress towards  independence have they internalized this idea   of what expertise and Duty looks like so we in  creating capability in the resident or the student   not just simply have to make sure they learned  how methimazole works or what's the anatomy   but they have internalized a concept  of what adequate knowledge looks like   this is a standardized set point in the Resident  I love the question on your face Lee it's great   a standard against which Learners  judge their current performance   what they just did or what they  are in the process of doing   how they internalized some standard of what  expertise and Duty look like against which   they are comparing their own performance  do they have a mental model of this   in the pre-clerkship period it's JTB justify  true beliefs are they building enough knowledge   that they have confidence in in the clinical  years it's moving from understanding to into   action when we talk about capability I'm going to  make the traditional def distinction here between   training and education to show you what I mean  training means you can train somebody to what's   common typical and predictable the guidelines work  and you probably don't need Physicians for this   and maybe one of the ways we break the cost curve  of what 20 percent of the GDP in the economy now   is on dollars and it's hurting the economy  it's hurting the very nature of democracy   maybe Physicians are doing too much maybe we  need more uh other people physicians assistant   Advanced nurse practitioners others who do things  Advanced nurse practitioners of course could   deal with more complicated patients but you see  what I mean non-physicians doing things you can   train a corpsman to put in an IV you can train uh  cornman sorry it's a military person a physician's   assistant to say that's a simple cystitis give  them this drug and we'll be okay education   means we're training we're preparing for the  unpredictable complex the need to figure it out so that's an educational process that's the  specific capability that we are trying to create   the traditional definition of competence  Epstein and 100 this is 20 years old now the   habitual and judicious use of communication  knowledge skills reasoning emotions values   and reflection and daily practice for the  individual this is what I called this is   the 1999 paper an analytic framework it breaks  competence apart as opposed to a more synthetic   definition which says is the ability to give  to each situation all that the situation needs   and not a lot more economy of action each patient  needs a sep special combination of my head my hand   and my gut KSA knowledge skills and attitudes and  how do we build that capability so capability is a   kind of thinking reason decision making and  here I want to emphasize as I have through   the whole talk commonality of all the ideas so  observation reflection action data information   knowledge wisdom report interpret knowledge and  these are all the same ideas just different jargon   so the acgme introduced milestones uh and  the purpose was to make the competencies   understandable Dr nasca wrote this in his 2007  essay that the competencies weren't working so   we had 23 Milestones five stages each three to  five behavioral anchors per stage so you end up   with 23 different sheets that look like this how  many of you are program directors using this Con   this kind of stuff there you go um and this stuff  is written by people like me for people like me   and and there and there are some reasons why we're  doing this the acgme God bless them is trying to   keep Congress out of our business so they've  adopted a very granular model but I want to   propose something that's a little simpler um and  uh that's that may not be legible to you across   the top but basically can we simplify this this is  observing this is reporting this is interpreting   this is managing and this is educating and if you  look I can do this for all all the Specialties   here's one for Dr Lerman this is obstetrics  this is patient care and obstetrics and it's   the same thing reporting interpreting managing  educating not because rhyme not because I'm smart   but because that's the rhythm of all activity you  see something you think about it you do something   people ask me how I invented Ron I did not invent  rhyme I just coined some jargon that rhythm   you can find in Francis Bacon you can find it in  the rigveda you can find it in avicenna you can   find it in Aristotle you see something you think  about it's the basis of what we teach medical   students from the beginning of med school oh my  my colleague Paul Hammer calls these rhinestones   uh epa's the current trendiness in medical  education is epas now the epa's come I'm not   talking about Ola ten kata's idea of judging the  resident against some idea of do you trust them   or not I'm talking here about epa's promulgated  by the double AMC these 13 list of things that we   think all graduates should be able to do that's  what I mean by epas and those are on the left   here I'm sorry on the right here in blue but it's  it's not a framework it is a list and what we've   done and there's a publication on this about  how Gathering a history performing a physical   documenting a clinical encounter that's up here  providing an oral presentation collaborating   these are what we would call dimensions of being  a reporter can you prioritize the differential   diagnosis can you recognize a patient who's  sick these are interpreter functions so we use   we use uh the epas as a pre-digested performance  dimensions and this is business drug and frame of   reference training performance Dimension training  so we use we um the of the 13 epa's eight or nine   of them were true when I was a medical student  40 years ago and incidentally they never worked   they never worked that's the problem people don't  like lists so you might want to think about using   a framework so modern curricular pedagogy has  changed from a focused to more student-centered   education in case decision this is Rick's paper  and what should be the content of these these   conversations the teacher should be happy if the  student can describe iodine metabolism but if not   knowing these then you have to be a little bit  embarrassed so the the resident has to be able   to recognize the Gap has an adequate concept  of knowledge a search strategy and a commitment   I'm asking faculty to determine whether or not  in this student and certainly in this resident   they have internalized a set point against which  they judge their own performance in the same way   that the hypothalamus says is the osmolality okay  or not that's my job not just to make sure they   know methimazole but they've internalized what  they need to know about methimacil finally we're   going to talk about the problem of students in  evaluation this is a typical pattern I've adopted   this from Liz Armstrong from the Harvard Macy  Emily Watson in her class she rotates through   medicine OB like this and all these different  hospitals with all these different teachers   and Emily has a problem getting all all her  teachers on the same page do they all think alike or is it a crap shoot   you get Don steenweg for your attending you  lucked out you get pangaro you're screwed professionalism is a promise and what  is the faculty's expertise what do we   promise if the learner cannot trust the  faculty's evaluations as Fair which may   affect them getting their in residency  of choice what does professionalism mean   this is an obsession of mine the fairness  the students trust leadership do they trust   the faculty an evaluation our values in  the word evaluation teach the student   what professionalism is and and if they cannot  trust the evaluation system then I think the   concept of professionalism is very suspect  so evaluation we have to be fair to society   that The Graduate is ready fair to students with  transparency feedback and trust and finally this   is the final point I'm making we have to be  fair to teachers that they have the time and   the training and they have protection and  there are two kinds of protection in many   schools now I the chair of medicine or when  I was the dean I would say somebody wants to   get promoted to associate professor what do  the students say about this faculty member   and if they had pangaro and he happened to be  a hawk or they thought I was a hawk and I was   being fair and they write down he some negative  things is the promotions committee can say well   we can't promote Lou because he's too strict we  have to be fair to teachers but quite apart from   that there's the emotional issue of asking  me to grade we do not ask teachers to grade   teachers clinical faculty do not give the patient  heart failure or cancer they make a diagnosis   we do not grade the student give the student a  grade we classify them as acceptable or not or   in my jargon is that a reporter an interpreter or  a manager because faculty are very good at making   diagnosis so I would be happy if the feedback  I gave this student today helped her with her   next medicine attending but I would drop dead  with embarrassment if the feedback I gave the   student made them worse with the next attending  because the advice I gave them damat disagreed   with or sweet disagreed with so I hurt the  student so you have to make sure that the system   guarantees that the feedback is useful and that  when I give feedback I'm not speaking for myself   I'm speaking for the Department of medicine or  surgery repeats so how does the physiology help   what is the faculty's OWN set point I'm back to  set point of back to homeostasis I'm back to Rick   what is the construct in the head of the teachers  and is it aligned across all the teachers in   medicine and maybe even between medicine and Peds  and Family Medicine maybe even surgery and Psych   what is in the head and do the  teachers have receptors from my jargon   so here I'm using the notion of this is another  article from your group communities of practice   what is an educator look at the bottom of the  slide education ex-duterate means to lead out   of dependence into Independence that's the ancient  Roman word pedagogy the Greek word means the same   thing pedagoguing leading a child extujury  leading out of dependence into Independence   creating capability so here's the image from  the Stanford faculty development program   faculty learner patient care in a word Progressive  Independence is what we're after in an image at   the end of the process The Faculty need no longer  be physically present that's what we're doing   now I have to take care of the patient and  the patient's well-being but to the extent   that I'm there for the resident my job is  to Foster their independence they are not   my tool I am there to help them become  independent so this notion of capability   so physiologically I'll go through this quickly  this is um basically a spinal reflex arc right   you feel some pain afferent spinal reflex  Ephraim right signal integration response   observation reflection action now here's at the  level of the cell surface receptor signaling cell   surface receptors internal signal recognition  and cell signaling so something changes   everybody understands this in medicine it's  a three-phase process you see something you   think about it you do something observe reflect  act report interpret manage and so my final plea   is the Simplicity of fairness to faculty  that we do something that works for them   so every faculty member understands history and  physical assessment and plan or soap that's the   rhythm of rhyme reporter interpreter manager and  it's kind of saying that we communicate through   neurotransmitters body communicates rapidly  through dopamine which has a molecular weight   of 150. not through immunoglobulin which has a molecular weight of 150 000. so here's the   six acgme competencies now reflected to you as something with a molecular weight of 150   000. this stuff is written by people like me  for people like me it's not written for my   thousand faculty we must be fair to faculty if  we want consistent evaluation so do we need six   competencies 13 epas or something like Grime so  here again is this idea of the rhythm of rhyme   is on the left and the details the epas can be  used to populate wrong if you're in gme pgy one   two and three in the bottom reporter interpreter  matter on the y-axis and you expect people to get   better of course but not only do you expect  them to get better by the end of the process   at the last year you expect them to be at the  manager educator level up there on the upper left   everything in the core so an internal medicine  for heart failure pneumonia pulmonary embolism for   surgery say appendectomy Cola whatever it is it  ought to be in the core for internal medicine if   this x is down here is in the core if that patient  with the X down here on the lower left if if this   was a GI bleed for a resident in  Internal Medicine that'd be a red flag   because it's in the core but suppose it was  pheochromocytoma or malignant fibrocystiosotoma   it's not in the court so the faculty needs  to know what's in the core and needs to know   at what level of capability manager educator for  anybody finishing the Olympic so here's the final   slides the lessons of physiology unifying ideas  expect understanding of mechanism build capability   which means they have internalized a physiologic  set point for what expertise and Duty look like   and then the framework use a meta mental models  that the patient that the faculty already have receptors for like the rhythm of rhyme Embrace  complexity act with simplicity thank you Rick.