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Keys to Developing Expertise

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In the name of God KEYS TO DEVELOPING EXPERTISE Intuition and Metacognition in Medical Education M. Hassani Most clinical situations encountered by the novice are new ... – PowerPoint PPT presentation

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Title: Keys to Developing Expertise


1
Keys to Developing Expertise
In the name of God
  • Intuition and Metacognition in Medical Education

M. Hassani
2
Are u Lifelong Learner?
  • The hardest conviction to get into the mind of a
    beginner is that the education upon which he is
    engaged is not a college course, not a medical
    course, but a life course, for which the work of
    a few years under teachers is but a preparation.
  • Sir William Osler (1897, p. 161)

3
15 minutes with a patient
  • An old man
  • Back pain
  • Ringing in his ears
  • A bad taste in his mouth
  • Trouble sleeping
  • Headaches
  • Chest discomfort
  • Three missed appointments

4
Compare these two
  • The Cognitive Learner
  • The Metacognitive Learner

5
Compare these two
  • The Cognitive Learner
  • The Metacognitive Learner
  • Back pain
  • A bad taste in his mouth
  • Chest discomfort
  • Not enough time to get to all of Patient's
    complaints
  • Recommended plan for further testing in chest
    discomfort
  • Realizes that she cannot cover the entire list
  • Limit and prioritize
  • Patients perspective
  • Establish a relationship
  • Psychosocial issues
  • Missed clinic appointments dementia and/or
    depression
  • Depression high on the differential diagnosis
    list
  • Plan A social service referral

6
The differences between them?
  • Anticipating the limitation
  • Creating a plan and prioritizing
  • Coverage of the most serious complaints from
    both her and the patients perspective
  • Psychosocial insight to the problem list by
    including patients missed appointments
  • Reflective and self-monitoring throughout the
    interview
  • Contextualizes her learning from previous
    experience by associating characteristics of this
    patient
  • Diagnostic knowledge and skill

7
The differences between them?
  • Metacognitive Capabilities

8
Metacognitive capabilities
9
Metacognition
  • Thinking about ones own and anothers thinking
    and feeling
  • Monitoring and management of ones thinking
  • Making plans before a thinking episode
  • Regulating during the episode
  • Reflecting back afterwards
  • To revise and plan future practices
  • (Perkins Grotzer, 1997, p. 1128).

10
Metacognitive capabilities
  • Self-directed learning, critical thinking, and
    reflective behavior (Mitchell Liu, 1995)
  • Strategic knowledge
  • Regulatory strategies

11
Metacognitive capabilities Strategic knowledge
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection
  1. Declarative knowledge about ones knowledge,
    attitudes, feelings, and skills
  2. Contextual when and why to use this knowledge
  3. Procedural how to use and adapt this knowledge.

12
Metacognitive capabilities Strategic knowledge
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection
  • Strategic knowledge critical to medical
    education
  • Knowledge about ones cognitive strengths and
    weaknesses related to a clinical task (ones own
    learning style)
  • Knowledge about the patients knowledge and
    feelings regarding the presenting problem,
    diagnosis, or treatment plan (Others Perspective
    Taking)

13
Metacognitive capabilities Learning Style
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection
  • Your preferred way of thinking
  • How we prefer to take in the environment around us

14
Metacognitive capabilities Learning Style
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection
  • How do I prefer to experience the learning
    material (visual, auditory, or kinesthetic)?
  • Am I more motivated to learn by exams (external)
    or my own interests (internal)?
  • Am I more abstract (theoretical) or concrete
    (step by step) in my approach to learning?
  • Do I prefer to learn from and with others or
    independently?

15
Metacognitive capabilities Learning Style
  • visual learners
  • Kinesthetic learners
  • Visually oriented specialties such as dermatology
    and radiology
  • Skilled at receiving and expressing information
    in images, diagrams, and charts
  • Hands-on activities such as suturing and
    physical examination.
  • Actively participate in demonstrations and
    procedures
  • Specialties such as surgery and orthopedics

16
Metacognitive capabilities Learning Style
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection
  • Improve learning-style weaknesses
  • Auditory learners may need to hone visual skills
    to effectively read and interpret radiographs or
    electrocardiograms.

17
Metacognitive capabilities Perspective Taking
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection
  • The ability to seek and share in the others view
    of the world.
  • Thinking about anothers thoughts and feelings
  • Control their interpersonal interactions and
    relationships through mastery of empathy, patient
    education, and negotiation
  • Develop your perspective-taking ability

18
Metacognitive capabilities Perspective Taking
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection
  • What is it like to be the father of a 5-year-old
    severely asthmatic child at midnight in the
    emergency room?
  • What is it like to be a 45-year-old mother of
    three children who is addicted to alcohol?
  • How can I convince Mrs. Jones that her child does
    not need an antibiotic?

19
Metacognitive capabilities Regulatory strategies
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection
  • Monitor and control thoughts, feelings, and
    behaviors during a task.
  • Checking
  • Planning
  • Reflection
  • Selecting and goal setting,
  • Inferring
  • Organizing
  • Self-questioning
  • Self-assessing

20
Metacognitive capabilities Planning
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection
  • Needs assessment, anticipation, and
    prioritization
  • To direct objective setting
  • Method selection that in turn are used to control
    behavior and achieve goals
  • Performance is evaluated
  • The results are fed back into the process
  • (Quirk, 1994).

21
Metacognitive capabilities Reflection
  • The ability to observe and critically analyze
    ones own behaviors, beliefs, understanding,
    emotions, and attitudes in relation to the
    environment.
  • Strategic knowledge
  • Learning Style
  • Perspective Taking
  • Regulatory strategies
  • Planning
  • Reflection

22
TOO MUCH METACOGNITION?!
  • Too much is not good.
  • Double-edged sword
  • Asking too many open questions, especially when
    characterizing the chief complaint
    (overfacilitating communication)
  • Problem solving by generating too many hypotheses
    (the overextended differential diagnosis)

23
Always metacognition?!
  • Possession and use of metacognitive abilities,
    however, is necessary for learning but not
    sufficient to developing clinical expertise.
  • The expert physician is sometimes required to
  • act quickly without the luxury of conscious
    thinking and planning

24
Always metacognition?!
  • A student who relies on metacognition in an
    emergency can be evaluated as
  • inefficient, a poor decision maker,
  • or one who
  • lacks self-confidence
  • or
  • clinically doesnt get the big picture.

25
Thus
  • Dont become obsessive in thinking about his
    thinking and show intuitive capability.
  • During the heat of clinical medicine, Dont be
    paralyzed by
  • your metacognitive capabilities

26
Intuition
27
Scenario
  • A teenage boy with belly pain for a few days
  • He looked fine and was only somewhat tender in
    his right lower quadrant
  • I do recall he had pain when I made him jump up
    and down.
  • He was overall acting fine, and my competent
    resident thought he was fine.
  • However, something inside me kept saying that I
    should be worried about him, so I made his mother
    take him to the emergency room. And of course, he
    had appendicitis.

28
Scenario
  • A 58 year old male complains of getting dizzy
    periodically for a week
  • No chest pain, shortness of breath, no recent
    illness.
  • His past history was clean
  • I brought him into the office immediately he
    thought that ridiculous. His exam was completely
    normal.
  • I did an EKG, and it showed he had completed a
    heart attack.
  • He thinks I am a genius, I thought I was lucky.
  • But in retrospect, I knew. I brought him in
    immediately, and did the EKG, because of my
    experience with past patients.

29
Intuition in clinical medicine
  • Rapid, unconscious process
  • Context sensitive
  • Comes with practice
  • Involves selective attention to small details
  • Cannot be reduced to cause-and-effect logic
    (i.e., B happened because of A)
  • Addresses, integrates, and makes sense of
    multiple complex pieces of data

30
The only difference between intuition and
metacognition
  • Intuition is not relegated to lower-order
    behaviors that rely on autonomic processes such
    as breathing, walking, or swimming.
  • Metacognition at the unconscious level
  • Metacognitive capabilities during medical school
    and residency and throughout a lifetime of
    clinical practice will improve both intuition and
    metacognition.

31
Clinical Expertise
  • A Blend of Intuition and Metacognition

32
What is expertise?
  • Innate Talent / Hard Wired?
  • Acquired / Software?

33
Novice - expert
  • Novice
  • Advanced beginners
  • Competent
  • Proficient
  • Expert

34
Level of organisation Lower Higher
Sub process Perception Action Orientation Decision
Stage Perceives the elements of the situation Acts on those elements Recognises whole situations Makes decisions and plans to attain goals in the situation
Novice Analytical Analytical Rely on others Rely on others
Advanced beginner Intuitive Analytical Rely on others Rely on others
Competent Intuitive Intuitive Analytical Analytical
Proficient Intuitive Intuitive Intuitive Analytical
Expert Intuitive Intuitive Intuitive Intuitive
35
Developing From NOVICE to EXPERT
  • Most clinical situations encountered by the
    novice are new The novice, then, must often act
    consciouslyplanning, anticipating,
    self-assessing, perspective taking, and
    reflecting in order to add meaning to experience.
  • Metacognition and intuition may be two
    complementary operating systems in the minds of
    clinical experts one at the conscious and the
    other at the unconscious level

36
Clinical Expertise
37
Keep in mind .
  • Realise that clinical expertise is acquired
    step-by-step by intensive practice
  • Thinking intuitively without experience based on
    an analytic foundation means poor decision
    performance.
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