DID-ACT meets in Bern: Interim report, sustainability and dissemination

After a long wait due to the pandemic, the DID-ACT project team with partners and associate partners had the opportunity to once again meet face-to-face. From the 22-23rd of September, teammates from Slovenia, Malta, Germany, and Poland travelled to Bern, Switzerland. Regrettably, due to travel restrictions, the Örebro team members, as well as Steve Durning from the USA, could not attend physically. Despite this limitation, they were fully present virtually alongside other associate partners. Thanks to the fantastic technical support by Bern University, all partners from home could be switched to the meeting and were present on a separate screen in the room. The audio and video quality were very good and synchronous discussion was possible.

Our virtual participants from Örebro University

Objectives of Meeting in Bern

The main objectives of the meeting were to many beyond catching up with the status of the project. We spent significant time discussing the evaluation and feedback results from the interim report, immediate and longer term next steps, as well as initiating the sustainability and integration guideline deliverables.

Interim Report for the DID-ACT Project

The interim report feedback was quite positive. However, there is also some room for improvement. Improvements highlighted include documentation and visibility of project outcomes concerning quality indicators, document structure, and better connection between related work packages (WP) 5, 6 and 8. Alongside these, connection to our central work packages and creating the learning units (LUs) in WP3 and 4.

Our next challenge is the upcoming pilot implementations to be held at the various institutions. Starting in September 2021, we still have some learning units in the realm of clinical reasoning left to develop. The curriculum development workload continues at high speed until the end of the year. Our previous process, including our process for reviewing learning units, will be fine-tuned for a more practical and effective approach. These were discussed during the meeting at Bern and will be further highlighted in a coming blogpost.

Sustainability & Dissemination in a Clinical Reasoning Curriculum

While the topics of dissemination and sustainability have been ongoing throughout the project, we took our face-to-face meeting as an opportunity to cement next steps. We feel that the sustainability concepts resulting from the pilots will be very valuable. There will also be external feedback included. We will create a minimal plan for cost-covering in the first years after the project ends based on the many ideas that surfaced in the meeting. Additionally, we will focus on integration of project results into partner curricula and inclusion of associate partners to also recruit people and keep the project content alive.

In addition to the very fruitful and motivating discussions held during the day, the evening was equally well-spent. We had a team lunch followed up by some ice cream, as well as dinner and a walk around the ‘old town’.

Group picture (from left to right: Martin Adler ( Instruct), Christian Fässler (ETH Zürich), Živa Ledinek (University of Maribor), Alice Bienvenu (University of Augsburg), Jennifer Vrouvides (EDU), Inga Hege (University of Augsburg), Melina Körner (University of Augsburg), Sören Huwendiek (University of Bern), Claudia Schlegel (Berner Bildungszentrum Pflege), Monika Sobočan (University of Maribor), Małgorzata Sudacka (Jagiellonian University), Andrzej Kononiwcz (Jagiellonian University) and virtual participants Desiree Wiegleb Edström (Örebro University), Samuel Edelbring (Örebro University), Marie Lidskog (Örebro University), Daniel Donath (EDU), Steve Durning (Uniformed Services University)).

It was a great pleasure to at least meet the vast majority of the team in a face-to-face environment. We plan to have our next face to face meeting in Maribor early next year. Following that, we hope that rescheduling our next meeting in May 2022 in Krakow can be held. We are hopeful that the COVID19 situation will allow these meetings. This face-to-face time is a great experience for the development of the project as well as for our development as colleagues. 

Thanks to our host Sören Huwendiek organizing the meeting and all partners and associate partners contributing to this project meeting.

Covid-19 Summer Term 2020

Summer term 2020 was special. Most universities start their summer term in April and thus, with the onset of the Corona outbreak in March, their preparation time given the circumstances was reduced drastically. One of the major challenges was that face-to-face lectures had to be planned online. In a very short amount of time, new online conference systems were established, and the necessary technical support was partially organized with the help of student tutors. Even though people who work on international projects are already used to video conferencing solutions, the amount of potential technical difficulties is still high and bandwidth issues can destroy all previous efforts.

Instruct, as an e-learning provider, observed a strong increase in online lectures and virtual patient usage in our system. Even institutions that already use our system CASUS and offer numerous online courses outperformed their previous numbers (Graphic 1).

Graphic 1: Comparison of completed virtual patient cases by students from one exemplary university from April to July 2019 and April to July 2020.

The peak in July is the result of exam preparation. We also registered slightly more support requests, however, these were still easily manageable.

In the media, both researchers and newspapers made online learning one of their central themes, especially regarding possibilities on how the current circumstances will impact e-learning in the future. Their findings are not necessarily novel, as can be seen in an article from the New York Times (https://www.nytimes.com/2020/06/13/health/school-learning-online-education.html?smid=em-share), “[…] students tend to learn less efficiently than usual in online courses […]. But if they have a facilitator or mentor on hand, someone to help with the technology and focus their attention — an approach sometimes called blended learning — they perform about as well in many virtual classes, and sometimes better.”

In an article from the German newspaper, Sueddeutsche Zeitung, called „Schluss mit dem Digitalgejammer!“ (“Stop complaining about Digitalization!”) (https://www.sueddeutsche.de/bildung/hochschulen-und-corona-schluss-mit-dem-digitalgejammer-1.4985116 ), the author highlights the discrepancy between educators moaning about a lack of personal interaction, exchange and dialogue in e-learning, while in reality seminars and lectures are quite often overcrowded permitting no interactivity whatsoever, not to mention dialogues and conversations are rarely feasible. The author states that students might miss pre-Corona campus life, but educators believe and hope that various other reasons also play into this.

It’s exciting to see how this transformation will shape the future, and it seems as though we have a special winter term in store for us, too – this time we will have slightly longer to prepare. One thing is for sure: it’s time for more and better blended learning solutions.

Online ideation workshop

In our specific needs analysis we have identified a wide range of barriers and needs for the implementation of a clinical reasoning curriculum in a survey and semi-structured interviews. As a next step we had planned a face-to-face design thinking workshop on May 5th in Krakow, Poland, to develop solutions to overcoming these barriers and addressing the needs. Due to the travel restrictions we decided to try something new and do the workshop in a synchronous online meeting after an asynchronous individual preparation phase.

For the preparation phase we setp up a course in our learning management system and the team members had time to familiarize themselves with the identified barriers and needs. They were asked to submit at least five (better ten) ideas on how these needs and barriers could be addressed including at least one crazy/absurd idea.

In our online meeting on May 5th we divided the 18 participants into four small groups (using the zoom break out rooms) in which they had to present their ideas and clarify any questions. After 20 minutes we met in the plenary in which each group presented their ideas and we documented and clustered those (using the integrated whiteboard). Finally, each particpant was asked to identify three solutions that are easy to do / hard to do / have a high impact.

Overall, the online workshop worked very well, only the simultaneous presentation of ideas and clustering on the whiteboard was tough, and could be better done in two phases with first collecting the ideas and then clustering them.

During the next weeks we will continue the discussion and refinement of the solutions and publish a final version as D1.2 report by the end of June.

Participants: Medical educators

Learning units: Person-centered approach and the role of patients
Level: Teacher

Description: Offered as part of the faculty development to faculty educators.
Mode: Part to the faculty development program with emphasize on the educational potential of clinical reasoning teaching techniques

Technical Integration: Access to the DID-ACT Moodle, synchronous sessions were held via the virtual platform NewRow.

Tips & Tricks:

Participants: Multi-professional educators (nurses, physicians, paramedics)

Learning units: What is Clinical Reasoning and Models
Level: Teacher

Description: Offered as additional faculty development opportunity to staff members of the Medical Education Department.
Mode: Option / additional part to the faculty development program with emphasize on the educational potential of clinical reasoning teaching techniques

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face.

Tips & Tricks: Give participants time to familiarize themselves with the learning material between the sessions. Do not put too much in one day - better to meet twice for shorter sessions. Face-to-face sessions lead to more productive discussions than Zoom meetings. Focus on discussion with the audience and on examples from practical teaching to illustrate the learning objectives.

Participants: Multi-professional educators

Learning units: Differences and similarities in clinical reasoning among health professions
Level: Teacher

Description: Offered as part of the faculty development program, it was held as a blended learning course with the synchronous phase online.
Mode: Part of the faculty development program with certificate

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held online via Zoom.

Tips & Tricks: Give good practical information how Moodle works and how the participants can find and work with the different assigments of the learning unit. Emphasize the importance to the participants to work with the different individual tasks, as the discussions will be more interesting and fruitful. Also important that all the participants from different occupations feel comfortable to meet and that they all are a part of the discussion. This is an important and maybe the primary task for the facilitator!

Participants: Multi-professional and international educators

Learning units: Clinical Reasoning teaching and assessment & What is Clinical Reasoning and Models
Level: Teacher

Description: Offered as optional learning unit for participants of the Master of Medical Education (MME) program in Bern/Switzerland.
Mode: Part of the faculty development program with certificate

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face.

Tips & Tricks: To foster a valuable learning experience it is indispensible to provide good case examples that are tailored to the needs and experiences of the participants, so that they can relate to their prior knowledge. Thus, the provided examples in this learning units might need some adaptations for your target group of educators.

Participants: Multi-professional educators across German-speaking coutries

Learning units: Differences and similarities in clinical reasoning among health professions
Level: Teacher

Description: Offered as part of the faculty development program at the University of Augsburg, but open to participants from Germany, Austria, and Switzerland. It was held as a blended learning course with the synchronous phase online. Participants were eager to exchange their experience and disucss their views across institutions and professions.
Mode: Part of the faculty development program with certificate

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held online via Zoom.

Tips & Tricks: To foster a valuable interprofessional experience the participants should represent a balanced mix of professions and also ideally the facilitators should at least represent two different professions. This allows a good discussion and also guarantees that the small groups can work interprofessionally. Our experience with a less-balanced group composition was that the over-represented profession dominates the discussions and it was quite difficult to counter-balance this.

Target group: Medical students in year 2

Learning units: Person-centered approach to clinical reasoning
Level: Novice

Description:The Learning Unit was run as an extra-curricular session as a virtual class. The facilitators were trained on this topic by attending the Train-the-trainer learning unit on "Person-centered approach and the role of patients".
Mode: Extracurricular activity

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held online via NewRow.

Tips & Tricks: Learning objective cross-referencing with the existing curriculum helps identify the level of integration. Encouraging and helping students to get familiar with Moodle before the session facilitates a smooth integration of the asynchronous phases.

Target group: Medical students in year 4 and 5

Learning units: Generating differential diagnoses and deciding about final diagnoses
Level: Novice

Description: The learning unit was integrated into a pediatric emergency department clerkship with a relation to virtual patients already used in this clerkship. Facilitators were trained by attending the train-the-trainer unit on "Information gathering, Generating differential diagnoses, Decision making, and Treatment planning".
Mode: Part of a regular curricular activity

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face.

Tips & Tricks: Integration into clerkships works well, especially with a relation to already used content.

Target group: Medical students in year 1-6

Learning units: All 25 learning units of the DID-ACT curriculum
Level: Novice - Advanced

Description:
Longitudinal integration of the DID-ACT learning units into a clinical skills & communication course with the following suggested distribution across years:
Year 1: What is Clinical Reasoning, Person-centered approach to clinical reasoning, Health profession roles in clinical reasoning, and Biomedical Knowledge & Clinical Reasoning. (Required time in curriculum ca. 5 hours / semester)
Year 2: Dual Process Theory, Illness scripts, Collect and prioritize key clinical findings/problems, and What is clinical reasoning and How can theories be put into practice (Intermediate). (Required time in curriculum: ca. 4 1/2 hours/semester)
Year 3: Generating differential diagnoses and deciding about final diagnosis, Biases and cognitive errors - an Introduction, Analyzing and avoiding errors. (Required time in curriculum: ca. 4 1/2 hours/semester)
Year 4: Using the Outcome Present State Test Model, Developing a treatment plan, Metacognition, reflection and models for reflection, Collaboration of health professions in Clinical Reasoning (Intermediate). (Required time in curriculum: ca. 6 hours/semester)
Year 5: All remaining intermediate learning units: Shared Decision Making in Clinical Reasoning, Decision Support Systems, Ethical aspects - patient management and treatment, Uncertainty. (Required time in curriculum: ca. 5 hours/semester)
Year 6: All 6 advanced learning units: Collaborate with others in clinical reasoning, Decision Support Systems, Biases and cognitive errors, Uncertainty, Metacognition, reflection and models for reflection, Analyzing and avoiding errors.
(Required time: ca. 6 hours / semester. Final year students often have a day/week off from clinical work so these days could be used for DID-ACT learning units and optional participation in the train-the-trainer units)
Years 1-5: Virtual Patients (VPs) as additional deliberate practice activities in increasing number and complexity (e.g. starting with 5 VPs (=ca. 1.5 hours)/semester) in Year 1 and increasing to 10 VPs/semester) in Year 3-5.
Mode: Integrated into a clinical longitudinal course that runs from year 1 to 6 resulting in a total of 2.4 ECTS.

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions face-to-face or online.

Tips & Tricks:
Alining a longitudinal curriculum with curricula of other health professions remains a challenge and requires careful and early planning, but the asynchronous phases might be a good starting point for interprofessional teaching sessions. The VPs can be quite easily aligned with other curricular courses e.g., based on key symptoms.

Target group: Medical students in year 3

Learning units: Person-centered approach to clinical reasoning
Level: Novice

Description: The learning unit was integrated into the Laboratory Training of Clinical Skills. This course consists of six face-to-face meetings for groups of around 10 students. Within the meetings the students discuss various topics related to communication skills and person-centered approach. The fifth of the six meetings of the course was replaced by the DID-ACT learning unit. Students could then refer back to this learning unit during final session of the course.
Mode: Part of a regular curricular activity

Technical Integration: Access to the DID-ACT Moodle via EduGain, synchronous sessions were held face-to-face. If possible, a uniform technology to provide access to the online resources in the class (using university tablets in our case) and support of the technical staff on-site was helpful to lower the technical barrier.

Tips & Tricks: Changing of the standard format of classes is interesting and motivating for the students. Virtual patients are a tool to present authentic clinical scenarios which are appreciated by the students. A blend of role-play and virtual patients allows students to take advantages of the two methods to reach the learning objectives.

Target group: Medical students in year 2 and nursing students in year 3 across Europe

Learning units: Collaboration of Health Professions in Clinical Reasoning
Level: Intermediate

Description:
This learning unit was implemented with , aside from clinical reasoning, tow additional objectives: 1) providing internationalization experience for students without traveling. 2) Deepening the knowledge of one's own professional roles and responsibilities and knowledge of another profession .
Mode: Extra-curricular interprofessional learning session with international participants

Technical Integration: Self-registration on DID-ACT Moodle, synchronous sessions via zoom.

Tips & Tricks: Facilitators running this course and supporting the discussions should be careful about supporting and encouraging all the participating professions' perspectives.

Target group: Medical students in year 1 and 2 (preclinical) across Europe

Learning units: Introduction into Clinical Reasoning & Health profession roles in clinical reasoning
Level: Novice

Description: The course was offered as a blended learning module to students from different medical schools in Europe as an international elective. Synchronous phases were held online via Zoom. The international aspect was very motivating for students and they learnt a lot from each other by exchanging their perspectives and how they are taught clinical reasoning vaspects. This teaching mode could also be implemented as an activity to welcome or prepare new Erasmus students. Facilitairs were trained by attending the train-the-trainer learning unit on "Differences and similarities in clinical reasoning among health professions".
Mode: Elective course

Technical Integration: Self-registration on DID-ACT Moodle, synchronous sessions via zoom and use of Padlet for interactivities.

Tips & Tricks: The organization with the registration of students was a bit complex, so, we suggest just setting dates and let students book. Allow enough (more time) for discussion and introduction rounds as participants do not know each other and are eager to hear and learn from peers at other schools and countries. Ideally, this session could also be held interprofessionally, however, it makes the finding of suitable dates even more complex.

How to teach synchronously in a virtual setting

  • You need a reliable camera, microphone, and virtual platform and be familiar with its features, such as whiteboard, chat, polling, breakout rooms, etc.
  • At the beginning establish communication rules, e.g. whether participants should raise their (virtual) hand, use the chat, and/or just speak. Also, we recommend asking participants to turn on their camera
  • For small group work break out rooms work very well, just be clear about the tasks the groups should work on prior to dividing them into the groups.
  • For collaboration the use of integrated virtual whiteboards or other platforms such as Padlet are very useful. Just make sure prior to the session that you have everything setup and the links at hand, e.g. to post them in the chat.
  • Allow a bit more time for starting the session and the group works as there might be participants who are not familiar with the platform or technical problems might occur.

How to motivate unprepared participants

  • Make clear that the asynchronous assignments are a core part of the course and that its content will not be repeated. Even if it is difficult, stick to that when starting the synchronous teaching session.
  • If you expect unprepared participants, you can start the session with a student-centered group exercise mixing prepared and unprepared students to increase peer-pressure and make them realize that being unprepared does not feel good.  
  • Use the introductory or closing quizzes / tests so that participants can self- assess whether they have the required knowledge and you as a facilitator can see the level of knowledge and preparation of your participants.

Further recommended reading:

How to involve participants with different levels of experience

  • To account for such different levels, we recommend making use of the asynchronous preparatory phases which also include introductory quizzes in which participants can self-assess their prior knowledge and you as a facilitator can assess the differences within your group. Participants with less prior experience can also be guided to additional preparatory resources.
  • Encourage participants to work in pairs or small groups when preparing so that they can help and learn from each other. You could even facilitate this by dividing them into groups with different levels of experience.
  • Similarly, during the synchronous phases, we recommend forming groups with participants different levels of experience and emphasize the peer support aspects of such group activities.
  • We also recommend starting with rather smaller groups and allow more time than stated in the course outlines, if you expect a heterogenous level of experience. This way you can better manage this challenge.
  • Encourage your participants to ask questions, emphasizing that nobody knows everything and that it is important for learning to ask questions.  
  • Especially in the train-the-trainer course you might have to deal with over-confident participants, who especially in an interprofessional setting can dominate the group. This is a complex cultural challenge, but you could try to establish (and follow) communication rules at the beginning of a session.  

How to address potential overlaps or redundancies

  • Identify what is already included and what is missing in your curriculum related to clinical reasoning outcomes and compare it to the DID-ACT blueprint. Prioritize learning outcomes that are not yet covered but regarded as important.
  • Identify activities, resources, or teaching sessions with similar learning outcomes that might be in need for change anyway because of low evaluation results, teachers or students struggle with it. These could be suitable for adding or replacing parts with DID-ACT activities.
  • Ask teachers and students about overlaps and gaps they see in their teaching / learning of clinical reasoning and where they struggle. This could also be done by a reflection round after related teaching activities in the curriculum
  • Although ideally a longitudinal integration is aimed at, we recommend to starting small with a pilot implementation to gain experience and develop a show case.

How to teach in an interprofessional setting

  • Allow for enough time prior to the teaching for the organization and motivation / encouragement of stakeholders and participants
  • Allow for enough time and guidance during the course so that the participants from the different professions can get to know each other and their professions and discuss their different perspectives. This might mean that you need to calculate some extra time in addition to the suggested duration of the learning unit.
  • There may be a different understanding of clinical reasoning in the different health professions, so we recommend making participants aware of this. You could for example use and adapt activities from the learning units on the health profession roles to facilitate this.
  • Courses in an interprofessional setting should not come too early in the curriculum (not before professions have formed their own professional identity - however, this also depends on the aim of the course). 
  • Make sure you have enough participants from different professions. If possible, the facilitator could divide the participants in smaller groups with an equal distribution of professions. 
  • Similarly, you need an equal distribution of facilitators / facilitators from different professions.
  • Develop customized learning materials considering the different professions. If needed you can adapt the material and activities provided in the DID-ACT curriculum.

Further recommended reading:

van Diggele, C., Roberts, C., Burgess, A. et al. Interprofessional education: tips for design and implementation. BMC Med Educ 20, 455 (2020). (Link)

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