Workshops

This series is designed to be a unique and thorough exploration of active learning for faculty engaged in the training and education of future health care professionals. The College of Medicine is moving towards more active learning at all levels of the educational enterprise: undergraduate, postgraduate, and continuing professional learning. This is part of a wider trend to orienting teaching to learning (its natural outcome) and to evidence based medical education.

Through reading, discussion, design and creation exercises, and individual consultations faculty who take this series will become more knowledgeable about active learning, more skilled at using various active learning strategies, and better able to advocate for active learning in their home departments. And of course, their students will learn more and retain it longer! All participants will receive a key resource to use and keep: Promoting Active Learning: Strategies for the College Classroom by Chet Meyers and Thomas Jones (1993).

This series is divided into three (3) basic parts:

Part 1 consists of two workshops on the first four chapters of the book. These two workshops must be taken to complete the series and should be taken before any of the others.

Part 2 is a series of optional/complementary workshops on strategies and issues important to active learning. You must take two of the five remaining workshops in Part 2 for a total of four altogether from Parts 1 and 2. We think that many of you will want to take all seven workshops.

Part 3 is an extension of your use of active learning that begins in the workshops. We will assist with your planning and evaluation of your use of some active learning strategies in your own teaching settings. One short coaching cycle must be completed to receive credit for the series. Details of the coaching in Part 3 will be given at the other workshops and can be arranged on a case by case basis. If you have questions about this please contact us at any time.

This series can be completed by attending a combination of workshops and individual consultations. If the timing of the workshops does not suit you due to other important commitments please contact our office to arrange for an individual 90 minute tutorial for a selected workshop. To complete the series more than half of the sessions need to be completed in the scheduled small group workshops with other participants. Discussion with other teachers is a critical component of this series.

On completion, participants will receive a certificate.

Overview of Teaching and Learning (OV)

Overview of teaching and learning provides an organized understanding of teaching and learning and principles of adult learning. Offered before some half day workshops, this one or one and a quarter hour session is a prerequisite but need be taken only once. To complete the series "Active Learning Strategies for Health Professions Education" both workshops 1 and 2 must be taken. To complete the series "Active Learning Strategies for Health Professions Education" two of these five workshops (3, 4, 5, 6, and 7) must be taken.

"The Case for Active Learning" Chapter 1

"Creating an Active Learning Environment" Chapter 3

More and more conferences, educators, administrators and teachers are recommending and making the move away from passive to active lectures, from active teaching to active learning. The first chapter sets out the rationale for such a shift and prepares teachers at all levels and circumstances to understand and adopt active learning approaches. In Chapter 3 the four essential elements of a workable active-learning environment are explained: clarifying course objectives and content, creating positive classroom tone, coping with teaching space, and knowing more about our students.

Objectives

Workshop participants will be able to:

• list and explain three good reasons for adopting active learning strategies
• list and explain three reasons for rejecting active learning (with response)
• list and explain potential barriers to implementation of active learning
• describe issues in active-learning related to content, classroom tone, space, and prior knowledge.

"What is Active Learning?" Chapter 2

"Informal Small Groups" Chapter 4

This workshop will explore the four elements (talking and listening, reading, writing, and reflecting) that singly or in combination are the building blocks common to all active-learning strategies. We will also look specifically at one of the easiest and most productive ways to introduce active learning: the informal small group.

Objectives

Workshop participants will be able to

• describe and explain at least one way that each of the four elements can be used to generate effective active learning
• structure and manage small groups effectively
• prepare an active learning exercise for a personal teaching session.

"Cooperative Student Projects" Chapter 5

This workshop deals with the five essential elements for effective cooperative groups: Positive interdependence, individual accountability, face-to-face interaction, social skill teaching, and group processing. Broad purpose and specific structures are also described.

Objectives

Workshop participants will be able to

• explain each of the five essential elements of cooperative groups
• describe and explain the purposes and common structures of cooperative groups
• design a cooperative group experience for a personal teaching episode.

Simulations and case studies allow learners to practice knowledge and skills in context. These practice opportunities include role-playing, games and exercises, computer simulations and case studies.

Objectives

Workshop participants will be able to:

• give examples of types of simulations used in medical education and explain the advantages and disadvantages of each
• describe the purpose of case studies
• construct different types of case studies.

Without stimulating resources of various kinds, our best efforts to design active learning may not work well. This workshop will explore the effect of various resources on the active learning strategies and opportunities available to us in our teaching.

Objectives

Workshop participants will be able to:

• apply knowledge of purpose to design effective guided reading assignments from current or future teaching sessions
• create a plan to integrate a guest lecturer into a course or module
• develop an approach to the use of simple, realistic, and practical uses of technology to enhance active learning in current or future teaching.

This workshop will focus on the particular challenges of incorporating active learning with large groups of students (over 20). There will be pre-reading and reflection to do before the actual workshop which will include a video explanation and demonstration of active learning, discussion among workshop participants, and planning of active learning for actual upcoming teaching sessions.

Objectives

Workshop participants will be able to:

• select appropriate active learning activities for large classes to accomplish a variety of purposes (introduction to content, application exercises, practice and feedback)
• plan the management of time, resources, and movement.

Active Learning Kim West

Active Learning for Large Groups

Games foster active learning and allow for interactivity, promote collaboration, peer-learning and team work, and increase motivation. They can be used to address cognitive, psychomotor and affective domains of learning and to support different learning styles. In this interactive workshop, the evidence for use of games in education will be discussed followed by a demonstration of such games. The participants will then explore the PowerPoint game templates provided and proceed to create one or more games that they could use in their own teaching sessions.

Objectives

Workshop participants will be able to

• discuss the rationale for using games in their classroom and give examples of games that can be used effectively in medical education
• create one or more games using PowerPoint for a teaching session.

Student Response Systems

Pedagogical Principles for Learner Engagement

For learning to occur, students need to be given opportunities to engage in activities that help them create their own meaning, relating new information to what they already know. Active learning strategies provide such opportunities. A variety of active learning strategies – from simple to complex, exist and teaching methods can be chosen according to suitability. One of the strategies is the use of student response systems in the classroom.

The student response system is a combination of software and hardware that allows students to deliver almost instantaneous feedback to their instructor. This technology allows instructors to collect information in a timely and efficient way and engage students even in large classes.

In this interactive session, participants will learn to use (and practice using) one such system. The session will begin with a description of student response systems in general and the rationale for using such systems in classes. The different types of response systems currently available will be described. The pedagogical principles for using these systems to inspire learner engagement will be discussed followed by a demonstration of use, misuse and overuse of one type of voting system.

Objectives

Workshop participants will be able to:

• Describe the different types of electronic voting systems available
• Identify a variety of situations where it can be used to engage learners
• Demonstrate the use of pedagogical principles for inspiring learner engagement in specific situations

Problem Based Learning (PBL) is both a method and a philosophy. It is an educational process where learning is centred around problems as opposed to discrete subject-related courses. Learning results from the process of working towards the understanding or resolution of a problem.

At the end of the workshop, you will be able to:

• Define PBL and explain what distinguishes it from other types of teaching and learning
• Describe the steps involved in approaching a PBL session
• Identify some challenges facing PBL tutors and some strategies to deal with these
• Observe a PBL session.

One of the requirements for those who aspire to leadership in instructional settings of all kind is a fuller understanding of how people learn. It would be futile and foolish to try to improve teaching and instruction without knowing how people actually learn.

This series of workshops is the beginning of the quest to comprehend how people learn and to discover some of the implications for instruction. In particular we will explore how medical students and residents become expert problem solvers.

Novices and experts think differently and they approach problems in very different ways. To oversimplify, experts just know a lot more about the subject than novices. Unfortunately, we don't know that much about how to transform a novice into an expert! This seminar will begin to explore this challenge. By the end of this seminar, you should be able to:

• Explain key differences between novices and experts
• Describe some implications of this difference for how we train/educate medical students and residents (and all other students as well).

The vast majority of teachers are operating under the two central assumptions of the Information Processing Model of Problem Solving. A more accurate model could lead to appropriate changes in how to help students acquire problem solving and thinking skills. By the end of this workshop you will be able to:

• State two central assumptions of the Information Processing Model of Problem Solving
• Explain some objections to these assumption; and
• Consider appropriate educational implications of this different understanding or problem solving

There are some key principles of learning that have been repeatedly validated. One of them is that what people already know. The better and more extensive prior learning, the faster and better will be additional learning. Another is that the transfer of learning is very difficult. These principles have huge implications for the design and delivery of courses, programs and the whole curriculum. By the end of this seminar you should be able to:

• Explain how prior learning plays a role in new learning
• Describe ways in which we currently take advantage of prior learning and situations where this principle is not being fully implemented
• Explain transfer of learning and why it is so difficult to achieve

One of the major impediments to learning is lack of alignment, especially in medical education. Each of these four factors plays a large role in the quality and quantity of learning. We need to make our programs and courses more learner centered, knowledge centered, assessment centered, and community centered.

• By the end of the workshop you will be able to answer these questions:
• What does alignment mean?
• What are we doing at the College of Medicine to align our courses and curriculum and
• How is that supposed to work in our own situations

The most asked question among faculty who attend workshops offered by our unit relates to the amount of content that they are supposed to ‘cover’ in their courses. The simple fact is that we can only be more effective by teaching less better. The question is not, “Should we teach less?” but, “How much less, what do we leave out, and what do we do instead of giving more information?”  By the end of this session you should be able to:

• describe what it means to teach less better
• explain how teaching less can result in more learning
• suggest ways to decide on the optimum content

Cognitive Stuffing

Elusive Content

The foundational document outlining the educational philosophy for the undergraduate program at the College of Medicine highlights four key types/approaches to learning: Cooperative Learning, Self-directed and Experiential. To help faculty understand these concepts and implications for teaching and learning for medical students ES&D has created two new workshops that focus on self-directed and experiential learning. We hope that these two workshops will help faculty to improve their teaching in ways that are consistent with the general discussion endorsed by the Curriculum Committee. Workshops on cooperative and active learning (the other two components of the CASE curriculum) can be taken as part of the Active Learning Series.

Self-directed learning is seen as any study form in which individuals have primary responsibility for planning, implementing, and even evaluating their effort. By engaging students in a variety of authentic tasks that require strategic planning, creative approaching and complex thinking skills, they can be challenged to become self-directed learners. In this workshop, examples that demonstrate how students can practice self-directedness in the classroom will be discussed and demonstrated.

Objectives

Workshop participants will be able to:

• explain the usefulness of self-directed approaches in higher learning
• describe self-directed learning controversies
• provide examples of self-directed learning activities that could be incorporated into their classroom
• identify on activity that could be used in an upcoming teaching session.

To meet the demands of society, learning must be dynamic, lifelong, and relevant to learner needs. This session will explore experiential learning as a process of learning and a method of instruction. Examples of innovative experientially based learning activities will be discussed.

Here is an article on the use of reflection in medical education as a key component of experiential and active learning.

Objectives

Workshop participants will be able to

• define experiential learning and describe the four stages
• discuss predominant forms of experiential learning in higher education
• identify issues relating to selection, control and evaluation of the learning process
• use a systematic approach to designing experiential learning activities.

The Clinical Teaching Series consist of three modules originally developed by the University of British Columbia’s Department of Medicine. The modules have since been modified to suit Saskatchewan’s unique clinical needs. Participation in this series and TIPS for Clinical Teachers is equivalent to the TIPS for Faculty program required by all new faculty members at the University of Saskatchewan, College of Medicine.

This module provides you will some concrete information on the following:

• Identifying your personal teaching style
• Scheduling student/patient time
• Preparing patients for students
• Orienting the student in your clinic
• Managing student projects

This module examines how the Deliberate Practice method can be used to teach diagnostic and therapeutic reasoning. Included in this section will be information on such techniques as the 5-minute preceptor, student presentation of cases and mini skill-based teaching sessions.

This module will include an overview of assessing knowledge, skills and attitudes in clinical setting, as well as exploring the following assessment techniques:

• Rating scales
• Effective feedback
• Deliberate question techniques

The following 2 hour workshops deal with issues identified by clinical faculty.

• Teaching Clinical Reasoning
  • Describe how clinical reasoning is a taught rather than an innate process
  • Describe a 3 step process for teaching novices the clinical reasoning process
• Teaching Professionalism
  • Using the CanMeds roles as a starting point, identify teaching strategies appropriate for each competency
• Teaching Advocacy
  • Using the CanMeds roles as a starting point, identify teaching strategies appropriate for each competency
• Working with a Resident Experiencing Academic or Personal Issues
  • Identify the type of learning/personal issue
  • Use a concept map to identify strategies for assisting the student.

Making Pass/Fail work is designed in particular for teachers of first and second year medical students. By the end of the workshop you will be able to explain the rationale for a P/F system, distinguish between norm referenced and criterions referenced evaluation, and describe at least two ways to successfully implement a P/F grading system into your course. Please bring course material with you. There will be time to draft plans for a P/F evaluation system for your lectures/courses.

This workshop focuses on the elements of sound elevation practices. It is a pre-requisite for "Writing Multiple Choice Questions" Participants will be able to:

• List the advantages and disadvantages of commonly used evaluation instruments
• Explain the common weakness of student evaluation programs (along with constructive suggestions for improvement)
• Decide on appropriate ways to evaluate students and;
• Distinguish between formative and summative assessment.

Related - Foundational Principles: Assessment of Student Learning

MCQ tests are the most commonly used in the College of Medicine and in most health sciences colleges.  As easy as these are to mark, high quality MCQ are difficult to write.  You should plan to attend this workshop if you’ve ever wondered about how to write (and score) MCQs.

Objectives

 Workshop participants will be able to:

• Identify and avoid the common flaws of low quality MCQs
• Write technically correct MCQs (one best answer)
• Create MCQs that assess higher level cognitive skills

Using Competencies in Medical Education is a workshop designed to help you construct and write competencies for your courses, lectures, and sessions.  There will be pre-reading, discussion, and practice.  Please come with material from your teaching for which you can begin to write competencies.  This workshop should be taken together with “Making Pass/Fail Work”.

By the end of this workshop you will be able to construct and write clear, relevant, achievable competencies.

Peer evaluation is an assessment process where groups of individuals rate their peers.  This workshop has the following objectives:

• Define peer evaluation
• Examples of methods used
• Best practice tips.

Session Description:

Evaluation of content addressed in any course needs to be congruent with the course objectives and learning experiences. Examination blueprinting is one way of establishing congruency. In this session, the definition, the rationale for the process, literature evidence of its impact and the step by step process of creating a blueprint will be described. At the end of the session, participants will be able to create their own blueprint for their own courses.

Objectives:

The session participants will be able to:

• define examination blueprinting
• describe the rationale for the process
• acquire the skills to create their own blueprint.

Classroom incivilities (disruptions) occur all too frequently even in college and university classes. They are as upsetting to students as they are to professors. Dealing with these is not a matter of genetic endowment - effective skills and strategies can be learned. Plan on attending this workshop to learn:

• How to prevent classroom incivilities before they occur
• How to manage disruptions when they do occur

"Writing Learning Objectives Right" is a workshop designed to help you construct and write objectives for your courses, lectures, and sessions. There will be pre-reading, discussion, and lots of practice. Please come with material from your teaching for which you can begin to write objectives of with objectives that you have already written.

By the end of this workshop you will be able to construct and write clear, relevant, achievable objectives.

This workshop will focus on encouraging higher order thinking techniques in the classroom. Objectives are:

• List Higher Order Thinking (HOT) assessment tools that could be used in university classes
• Create a HOT rubric to mark student work.

This workshop will cover the following objectives:

• Discuss the 2/9 ethical principles stated in the article
• Identify its relevancy to the College of Medicine and University
• Discuss methods for adopting and implementing these ethical principles.

Chapter 1: Experiencing a Paradigm Shift Through Assessment

1. Articulate the need for a change toward a learner-centered paradigm in College teaching and assessment.
2. Explain the two main purposes of assessment, the connection to objectives, and common critiques of MCQs.
3. Describe the changes necessary in individual instructors, as well as entire systems, needed to shift to a learner-centered educational paradigm.
4. (Continue to) feel wildly enthusiastic about teaching and learning!

Questions for directed reading: (SKIP pp. 15-24)

1. Why is the traditional lecture not the most effective way to help students learn? (pp. 3-4)
2. Comparing student-centered with teacher-centered learning, how do they differ in terms of:
   1. Teacher role/practice
   2. Student role
   3. Role of assessment
   How learning takes place
   4. Learning environment/culture (pp. 4-5)
3. Why is there a need for systems thinking? (p. 6-7)
4. What are the two main purposes of learner-centered assessment? (p. 8)
5. How are intended learning outcomes of institutions or entire programs (i.e. competencies) tied into learning goals of courses and classes (i.e. objectives)? (p. 10)
6. Evaluate the common critiques of objective tests like MCQs and true-false. (pp. 11-13)
7. How might an instructor’s use of time in a learner-centered educational system be different compared with the traditional teacher-centered approach? (pp. 25-26)

Chapter 2:  Understanding Hallmarks of Learner-Centreed Teaching and Assessment

Objectives:

1. Describe the various components of effective learning environments.
2. Describe how the role of instructors and students changes in a learner-centred approach to education.
3. Analyze (parts of) current health sciences curricula for these components.

Questions for directed reading:

1. Given the theory of constructivism, what is it about lecturing that promotes the learning of PROFESSORS? (p. 35)
2. To what extent and in what ways is comparison of college education to performance-based learning (arts and sports) justified? (pp. 35-36)
3. What does it mean to teach “gray” to students (as opposed to black and white) using ill-defined problems, and why is this important?  (pp. 37-38)
4. What is the central question of authentic assessment (and how does that related to health sciences education)? (p. 42)
5. Briefly describe the relationship between basic knowledge and process skills? (p. 42)
6. Analyze the writing and statistics example. What are the three main problems with the curriculum organization? (pp. 44-45) How does this situation compare with health sciences curricula?
7. How do errors ultimately help lead to excellence?  How can instructors facilitate an environment of continuous improvement and what role do scoring rubrics play?  (pp. 46-47)
8. What is the importance of prior learning and experience? (p. 49)
9. What is generative knowledge? (p. 50)  What is the importance of this concept for health sciences?
10.  In terms of teaching and assessment, describe how the role of instructors changes with a learner-centered approach.  (pp. 53-55)
11. How can instructors assess their own performance?  Why is it important for students to see instructors as learners?  (pp. 56-57)
12. What are the learning benefits of respect and the problems with fear in learning environments? (pp. 58-60)

Chapter 4:  Setting Direction with Intended Learning Outcomes

Objectives:

1. Articulate the importance of intended learning outcomes for educational institutions and instructors.
2. Describe the characteristics of effective learning outcomes.

Questions for directed reading

1. In learner-centered instruction, how does the focus on teaching goals change?  (p. 93)
2. What are the main purposes of assessment?  How is assessment linked to learning outcomes?  (pp. 94-96)
3. Describe the link between intended learning outcomes of institutions and those of individual instructors.  (pp. 96-97)
4. Explain the benefits of sharing intended learner outcomes with students.  (pp. 97-98)
5. Using the first two criteria of effective learning outcomes, create two intended learning outcome statements.  (p. 99)
6. How do educational institution’s mission and values statements shape intended learning outcomes of individual instructors?  (pp. 100-106)
7. Explain the importance of an entire systems approach to intended learning outcomes.  (pp. 107-111)
8. Discuss the benefits of moving from “subject matter” objectives or “content” outcomes toward “process” outcomes or “developmental” objectives.  (pp. 112-115)
9. Given the final criteria (pp. 116-117), compose one intended learning outcome that might occur at the program level in your area of specialty and one that would be appropriate and satisfy it at the individual lesson level.

Chapter 6:  Using Rubrics to Provide Feedback to Students

Objectives:

1. Describe how rubrics, shared with students, increase learning.
2. Describe the role rubrics play in providing effective feedback to learners.
3. Be able to construct quality, useful rubrics to use in your teaching.

Questions for directed reading:

1. What is the most important aspect of feedback for students which they often do not receive?  (p. 153)
2. Describe the role of “revelation” in giving effective feedback.  (pp. 154-155)
3. How do rubrics function as a feedback tool?  (p. 155)
4. What are the two types of criteria to consider when designing a rubric?  (p. 166)
5. Describe the benefits of grouping criteria into categories.  (p. 167)
6. Describe why detailed commentaries, including consequence descriptions, are so useful for learners.  (pp. 167-169)
7. Describe how rubrics educate students.  (pp. 169-172)
8. Describe the link between rubrics and intended learning outcomes.  (p. 173)
9. How can rubrics be used to provide intermediate feedback (i.e. before the end of a project or assignment)?  (pp. 174-175)
10. What do you need to consider when creating the criteria for your rubric?  (pp. 178-179)
11. What are the advantages of using clear, objective descriptions, as well as qualitative differences, in your achievement level rubric areas?  (pp. 180-183)
12. How do intended learning outcomes help guide your rubric construction?  (pp. 186-187)
13. What factors might cause your rubric to change over time?  (pp. 188-189)
14. Sum up the characteristics of effective feedback in a learner-centered environment.  (pp. 193-195)

Chapter 7:  Assessing Students’ Ability to Think Critically and Solve Problems

Objectives:

1. Articulate the importance of using ill-structured problems for College students, including undergraduates.
2. Describe how three types of knowledge – declarative, procedural, and metacognitive – are integrated and used to improve students’ ability to think critically and solve problems.
3. Create appropriate and effective assessment tasks in your area of expertise.

Questions for directed reading:

1. What are the advantages of ill-defined problems over typical “textbook” problems?  (pp. 202-205)
2. Do these advantages apply to the health sciences?  Explain.
3. Describe how working to solve ill-defined problems benefits students.  (pp. 212-213)
4. Describe the three types of knowledge needed to think critically and solve problems.  (pp. 215-220).  Include the following:
   1. How can instructors help students learn facts and concepts?
   2. How is expert problem-solving automaticity a barrier when teaching students how to use knowledge?
   3. What are some examples of “domain specific procedural knowledge” in your field?  Which heuristics are used?  Which algorithms or reasoning strategies?
   4. How can instructors explicitly teach metacognition to their students?
5. How do “true tests” differ from traditional objective assessments?  (pp. 221-222)
6. Which “characteristics of an exemplary assessment task” can be best addressed by using ill-defined problems? Explain.  (pp. 225-227)
7. Using the three types of knowledge discussed in this chapter, describe how instructors can use their intended learning outcomes to create effective assessment  tasks.   (pp. 227-229)
8. Using #7 (p. 230) and figure 7-10 (p. 223), which assessment formats would work the best in your area of expertise?

Chapter 8:  Using Portfolios to Promote, Support, and Evaluate Learning

Objectives:

1. Describe the factors involved in designing a portfolio system to promote student learning and evaluate programs.
2. Articulate the benefits of using portfolios, for both students and professors, to promote and support learning.

Questions for directed reading:

1. What are two benefits of using portfolios to assess students?  (p. 234)
2. Describe advantages and disadvantages of all-inclusive portfolios.  Of electronic portfolios.  (pp. 235-36)
3. How can portfolios help in the development of metacognitive skills?  (p. 238)
4. Describe how portfolios can be used to gain a deeper understanding of typical student achievement in a program.  (pp. 239-240)
5. List some advantages of the portfolio method in program evaluation.  (p. 241)
6. Describe the metacognitive benefits of portfolios.  (p. 244)
7. Describe the link between active learning in a student-centered environment and portfolios.  (pp. 244-245)
8. What are the benefits when students select entries for their portfolios?  (p. 247)
9. Describe some obstacles in the process of student self-evaluation/reflection.  (pp. 248-252)
10. How can instructors help students deal with emotional issues that may result from self-reflection?  (pp. 253-254)
11. How does the professor-student relationship differ from the traditional dynamic to a learner-centered environment using portfolios?  (pp. 255-256)
12. What role do rubrics play in portfolios?  (p. 256)
13. Explain how multiple perspectives, normally a sign of unreliability, actually enhance the feedback students receive regarding their portfolios.  (pp. 258-259)
14. What is the fundamental difference between using portfolios in assessment compared with most other methods?  (p. 259)
15. Describe the benefits of portfolios to professors.  (pp. 259-262)
16. Describe the benefits of using portfolios for students.  (p. 262)

Introduction

International medical graduates (IMGs) form an important component of the Canadian physician workforce.  They represent a diversity of views that can be an invaluable asset in the provision of patient care.  IMGs have much to offer the Canadian health care system, the patients they see, and the residents and teachers with whom they interact, and we must prepare them effectively for their professional work in their new communities of practice.

Although IMGs are often viewed as a single homogeneous category, they are not.  Moreover, while many IMGs may express the same learning needs as Canadian residents, their medical training, culture, language, life and work experiences often differ, and teachers and supervisors must take these individual experiences and differences into account.  This program has been designed to help teachers work with IMGs in a more effective manner.  IMGs face many unnecessary barriers to licensure.  We believe that teachers and supervisors need to be better prepared for their work with IMGs so that they will not become an “unnecessary barrier”.

Program Goals and Target Audience

The goals of this Faculty Development Program for Teachers of International Medical Graduates are twofold:  to help prepare teachers in diverse settings to work with IMGs in an effective and collaborative manner; and to enhance the learning – and practice – experience of IMGs.

Moreover, although this program has been written primarily for teachers of IMGs, these materials can benefit all teachers working with Canadian-trained physicians and other internationally educated health care professionals.  All of the workshops involve teaching and learning content and strategies that can be used in diverse settings with learners at all levels of the educational continuum.

A number of the workshops can also be used directly with teachers of all internationally educated health care professionals (e.g. Educating for Cultural Awareness).  Other workshops can easily be adapted to meet the needs of other health care professionals, including nurses, physical and occupational therapists and pharmacists (e.g. Assessing Learner Needs; Delivering Effective Feedback).  Some workshops contain materials that can be used directly with IMGs (e.g. Orienting Teachers and IMGs), and others contain content and resources that are relevant to teachers of medical students and residents in a variety of settings (e.g. Promoting Patient-Centred Care and Effective Communication with Patients; Untangling the Web of Clinical Skills Assessment).

In summary, this program has been written for diverse audiences and is appropriate for use by:

• Individuals who are responsible for faculty development or facilitate faculty development activities.
• Residency program directors, IMG program directors, and individuals with an interest and/or expertise in medical education.
• Teachers “in the trenches”, in both university and community settings.

Program Overview

This program, which has been funded by Health Canada and is part of a larger initiative designed to prepare teachers of all internationally educated health care professionals, is the result of an earlier report entitled "Building on Diversity:  A Faculty Development Program for Teachers of International Medical Graduates".  This report was commissioned by the Canadian Task Force on Licensure of International Medical Graduates.

These workshops are based on a program created by The Association of Faculties of Medicine of Canada.  For more details, and the text of their full modules, please visit their website.

International medical graduates form an important component of the Canadian medical landscape. They comprise approximately one-quarter of practicing physicians in Canada. However, there has also been a significant number of IMGs who have not been able to practice in Canada. This group of physicians have recently become the focus of renewed efforts to integrate them into the Canadian health care system. Currently, most of these physicians will be entering the system through a residency program. This group of IMGs is not homogeneous and demonstrates variability in a number of areas including: the duration, content, and process of training; clinical experience; and interpersonal competencies.

Similarly, teachers have had different experiences with individual IMGs, and many have had minimal IMG teaching experience. Those with experience report a satisfying but time- consuming, and at times frustrating, experience. This frustration appears, in part, to be related to a lack of knowledge about IMGs coupled with limited educational resources to identify and address issues as they arise.

This workshop is focused on developing an understanding of the IMG as a learner and as a physician. This information provides a context that should enhance the development of a supportive learning environment and encourage the development of appropriate teaching strategies. These strategies do not differ significantly from those that are used with Canadian trained residents and students. However, this workshop will identify and focus on strategies to address typical areas of challenge for IMG learners. It is critical to remember that the backgrounds of individual IMGs are very diverse and that each IMG learner will have different strengths and gaps requiring an individualized approach.

Included in this workshop are the following topics which are meant to create a foundation for building a learner-centred approach to teaching IMGs:

• Understanding the experiences of IMGs, including the immigrant experience in general as well as experiences specific to the medical role.
• Examining the strengths, common areas of challenge, and typical cultural and attitudinal issues that faculty report when teaching IMGs.
• Exploring the Canadian cultural lens and examining the assumptions, values and beliefs faculty hold about IMGs.
• Orienting faculty members to a specific IMG.

This workshop presents materials that can be used by teachers to orient IMGs to the Canadian health care system. This orientation will highlight features of the Canadian educational system that may differ from the IMGs’ previous learning and medical experiences. This workshop focuses on making explicit many factors that are often implicit when teaching Canadian trained residents.

The areas to be covered in Orienting IMGs include:

• An overview of the Canadian health care system, the role of the physician within this system, the patient-centered approach, and the team-based practice environment.
• A model that will highlight the typical Canadian learning setting and examine some potential differences between this environment and the IMGs’ previous experience.
• A brief overview of self-directed learning, problem solving and the role of feedback.
• Interpersonal competencies including patient-centered interviewing, socio-cultural training and ethics.

Many of the components presented here are examined in more detail in other workshops.

This workshop involves educating for cultural awareness.  Cultural differences can be misinterpreted as a lack of competence or confidence, and can influence the relationship between the teacher and learner in a multitude of ways.  Teachers and supervisors can benefit from becoming sensitive to their own cultural beliefs and assumptions in order to work more effectively with learners and colleagues of other cultures.  Each individual is unique and different from her or his peers.  Hence, teachers and supervisors need to be mindful of their own cultural identity and develop strategies for cross-cultural collaboration and supervision.

Additionally, internationally educated health care professionals (herein IEHCPs) can encounter unique problems in the health care system as a result of a lack of culturally sensitive policies, practices and organizational culture.  For example, a learner of Muslim faith might have trouble finding appropriate spaces for prayer within a hospital.  Teachers must be cognizant of these systemic problems and support the IECHP learner.

Educating for cultural awareness addresses these concerns, offering a set of resources that can be used across Canadian medical and health professional programs to help foster development of cultural awareness and responsiveness in teachers and supervisors of internationally educated health care professionals.

Educating for cultural awareness involves:

• Helping teachers develop an understanding of their own ethno-cultural backgrounds, beliefs, attitudes, and values (self-awareness).
• Fostering acquisition of a greater understanding of, and empathy for, the cultural backgrounds and life experiences of IEHCPs (cultural diversity awareness).
• Promoting the development and integration of self-awareness and cultural diversity awareness into the teacher's activities (skill development), and introducing methods by which a teacher can encourage these skills among internationally educated health care professionals.
• Framing cultural awareness and responsiveness as a process of life-long learning for educators and health professionals alike.  Building cultural awareness and responsiveness involves the development of qualities and approaches, as opposed to expert knowledge of a concrete set of tasks and skills.

Assessing learner needs in all teaching and learning situations is critical. However, this becomes even more important when working with international medical graduates because of issues related to personal loss, previous medical training and cultural differences.

Traditionally, the Canadian health care system has depended on IMGs to meet physician resource needs.  Often, IMGs bring to the educational system many years of training in specific disciplines, and they can act as an important resource to other learners.  In a diverse and multicultural country, they are able to provide culturally specific care to communities of patients.  Moreover, they often have finely honed clinical skills, developed in countries without ready access to testing and with diseases and conditions rarely encountered in this country.  Finally, if they are older and professionally more mature, they bring this seasoned experience to their work and the clinical setting.

Although Canadian medical school graduates are certainly diverse in many ways, and may have similar needs as IMGs, they are grounded in a similar medical culture, unlike IMGs, who have tremendous cultural diversity.  Moreover, although all teachers make assumptions about their students based on their own past experiences, both as students and as educators, these assumptions need to be re-examined in working with learners from different social and medical cultures.  It is important to hold IMGs to the same standards of excellence as Canadian trainees; however, approaches may need to be modified to meet their special circumstances.  It is critical to identify each learner’s areas of strength and build on them, rather than depend on a “deficit model” of “fixing the gaps”.  The diversity in backgrounds clearly suggests that teachers need to “tailor” a program to individual needs.  It is important to take a learner-centred approach to teaching and to assess needs early and in an ongoing way.

This workshop includes information about the challenges and obstacles faced by IMGs, different educational systems, and cultural differences that may be critical to teaching and learning.  It also addresses different ways of assessing learner needs, the development of learning plans (or agreements), the value of portfolios to document previous experiences and accomplishments, and the need to create an individualized and supportive environment for learning.

Feedback to learners in the clinical setting involves the ongoing provision of information to learners about their performance in a given clinical activity, to guide and improve future efforts.  It is important to distinguish between feedback and evaluation:  the latter is information given to the learner which is a judgment on overall performance.  While feedback can, and perhaps should, be included in an evaluation, the purpose of feedback is essentially formative rather than summative.  An evaluation literally sums up the past performance of the learner and is a rating of that performance.  It has implications for promotion and advancement and is highly emotive for learners.  Ideally, feedback is seen more as a type of coaching, or performance enhancement.

Providing learners with feedback on their performance is a vital component of teaching; without intentional feedback from teachers, learners tend to determine for themselves the quality of their work. Unfortunately, self-assessment can be unreliable.   Without reinforcement from teachers, desirable and helpful behaviours on the part of learners may be extinguished, and bad habits may become well-entrenched.  Thus, providing feedback, which identifies learner strengths and makes suggestions for improvement, is a key part of clinical teaching.  There may be cultural differences in the expectation of receiving critique and the interpretation of critique as failure to some IMGs. This will be elaborated in this workshop.

A. Identified IMG Learning Needs

Communication skills and the doctor-patient relationship have been identified by both IMGs and teachers as an important area requiring attention. Communication is inextricably linked to both language and culture, and it involves verbal and non-verbal expression, listening and interpretation, all of which are influenced by personal assumptions, experiences and beliefs. As such, this represents a predictable, yet complex, issue of importance for IMGs.

Both IMGs and faculty have identified communication as a priority area requiring attention. Some of the specific issues frequently identified include:

• Lack of training in communication skills and/or psychiatry.
• Discomfort or uncertainty in exploring psycho-social issues with patients.
• Lack of familiarity with Canadian cultural norms and expectations.
• Difficulty with patient autonomy and patient-centredness.
• Discomfort and need for skill development in approaches to specific issues such as:
  • Abortion
  • Sexuality and sexual orientation
  • Teen pregnancy
  • Infertility
  • Divorce and marital difficulty
  • Delivering bad news
  • Death and dying

It is not only popular culture but also the culture of medicine and education that may differ from the Canadian experience. Many of the methods for teaching communication skills commonly used in Canada, such as videotapes and interactive group-based activities requiring self-disclosure and evaluation, will be unfamiliar. Cultural differences in role identity and attitudes towards authority figures can lead to the misinterpretation of IMG behaviour. For example, silence, meant to be deferential and respectful, may be interpreted as a lack of interest, confidence or knowledge.

At times, the IMGs’ preoccupation and concern with proper language use in the interview may interfere with their ability to attend to other aspects of communication in the interview, such as the non-verbal. Many IMGs come from countries where epidemic disease, physician shortages and disparities in education leave little time for communication with patients.

B. Communication VS. Language Skills for IMGS

This workshop will draw a distinction between language and communication skills. The ability of IMGs to communicate effectively involves both language usage (e.g. vocabulary; grammar; pronunciation and accents; word and phrase selection; use of the vernacular) as well as communication approaches (e.g. interview strategies and doctor-patient relationship skills). This workshop will focus on communication skills in the medical setting specific to the role of the physician.

The issue of language ability of IMGs has a number of dimensions and is only partially addressed in this faculty development program. The workshop on Untangling the Web of Clinical Skills Assessment provides an approach for teachers to identify and provide feedback for IMGs on their “medical literacy”. Although language skills are usually assessed prior to IMG selection, and the availability of other resources such as language and speech coaches is critical, it is important for teachers to be aware that IMGs are often concerned about their language skill and appreciate feedback on their choice of words and phrasing, whenever possible. The workshops on Orienting Teachers and IMGs provides some additional suggestions for approaching this area with sensitivity.

Assistance for IMGs with language difficulties remains a challenge for programs across Canada and requires additional resources, such as language coaches, that are not routinely available. Faculty with program-level responsibility for integrating IMGs may need to advocate for such resources.

C. Issues Specific to the Role of the Physician

Patient-centred care as a philosophical concept is inter-professional; however, the tasks of the medical interview are discipline-specific. Given the enormous complexity that exists for IMGs in making the transition to communication in a new context and language, it is helpful to address communications specifically in the context of the doctor-patient relationship. This allows a specific communication approach, such as “The Patient-Centred Clinical Method”, to be utilized.

Clinical Skills Assessment

Clinical Competence:

The purpose of this workshop is to help teachers work with IMGs to improve their clinical skills.  IMGs in Canadian training programs often complain that they are held to a different, higher standard than Canadian graduates.  This may occur because they tend to confuse, as do their teachers, educational goals with the evaluation standards used in programs.  Expectations of the standard of clinical competence of IMGs should be no different from those expected of Canadian graduates.  However, their educational needs may be quite different.  This workshop provides information to help teachers assess the clinical skills of IMGs, and to guide them in adapting to and adopting Canadian professional standards.  In some respects, the required educational strategies are no different from those used in supervising Canadian graduates, but there are some substantive differences among IMGs relative to Canadian-trained practitioners.  This workshop will highlight those differences and provide suggestions and materials for dealing with them.

 In considering the elements of professional competence required of all physicians, many program evaluations are heavily weighted toward core knowledge and a few basic skills that can be reliably evaluated.  Other important professional competencies - cognitive, integrative, habits of mind, technical, context, relationship, and affective/moral - are difficult to assess.  The problems that teachers encounter in assessing these competencies are due primarily to their essentially individual, or internal, nature.  Many of them are learned - or tacitly absorbed - through the process of medical socialization during training.  Many of these competencies require sophisticated language capability.  These competencies, including language, are assumed to be present unless the learner overtly does something to call attention to a problem (e.g. questionably ethical behaviour).  As IMG physicians will have had quite a different socialization process in their heritage country, and the more "abstract" competencies may be most challenging for the IMG, they may also make some IMGs appear less competent, even though they possess appropriate attitudes and skills.  The major problem is often a lack of knowledge of local norms, cultural disjunction, or difficulty with English as a second language (ESL).

Most of the competencies mentioned above are interrelated - the tangled web of clinical skills.  In particular, communication and “habits of mind” (metacognitive) skills are required at high level to be able to behave professionally.  This workshop clearly cannot address all these issues specifically, although you will see that a majority are touched upon due to the integrated nature of competence.  Moreover, decisions about the specific topics to be included in a potentially immense workshop have been driven by considering the areas which most frequently cause particular trouble for IMGs and/or those that may not be commonly encountered as teaching/learning problems in working with Canadian graduates.  How these topics are addressed in this workshop is driven by recognition of some (incorrect) assumptions commonly held by teachers, which include the following:

• Content (not students and learning) should drive instructional decision-making
• Teaching excellence is nothing more than a matter of technique
• Teaching requires no training or ongoing professional development
• Pedagogical practice and scholarship can exist without standards
• The wisdom of teaching practice entails no really worthwhile knowledge

These (incorrect) assumptions devalue teaching and should be counteracted at all times.

This workshop focuses on pedagogical content knowledge (how to teach, rather than what).  In working with Canadian graduates, we take for granted the cultural background, both medical and societal, and thus, it is relatively easy to focus primarily on biomedical content.  But if the focus is primarily on content, all too frequently the other four assumptions listed above are operating.  This will not work with IMGs, because the difference in cultural background, experience, and language interacts so strongly with their medical knowledge in influencing their performance.  Therefore, this workshop emphasizes how to think about approaching the educational interaction with IMGs.  There will be less attention on specific tips or techniques, since one size does not fit all.  The other reason for paying more attention to observing and thinking about the IMG’s performance is that these clinical skills are all so intimately connected.  Expertise, or competence, cannot develop in the absence of any one or more of these interacting skills.  For instance, an evident lack of knowledge (content) in an IMG may be due to true absence of specific information, an inability to access it due to language difficulties, or a lack of appreciation that it is important in this context.  Making the correct educational diagnosis is essential to helping the IMG fill the gaps in their competence.  "Untangling the web" of clinical skills is a difficult and complex task.

The previous paragraph should make it clear that assessment, as used here, does not mean the evaluations undertaken by the training program of all learners, both Canadian and IMG.  The role of the teacher, as conceptualized here, is to assess the level of clinical competence and then help the IMG improve to an agreed upon standard.

Definition of "Clinical Skills"

The content in this workshop covers only some of the skills required for clinical practice.  Other skills, such as the patient-centred model of interviewing can be found in the workshop on Promoting Patient-Centered Care and Effective Communication with Patients.  Some skills, such as discipline-specific technical skills, will not be included. Thus, this workshop will cover those clinical skills that are applicable to most practice settings involving patient care, and those in which the variability of skill among IMGs is most evident.  The skills covered in this workshop include:

• Physical examination.
• Evidence-based medicine (EBM) and literature appraisal.
• Medical literacy:
  • Language assessment.
  • Oral communication (i.e. doctor-patient; interprofessional).
  • Written communication (i.e. intra- and inter-professional).

These topics are considered together because they represent a primary and necessary competency of physicians:  that of collecting, organizing, and interpreting information, all of which are necessary to accomplish the goal of patient care.  These skills also require, but are distinct from, the physician’s biomedical knowledge base.

It has been noted that more than 75-85% of information used in the diagnosis and management of a patient problem comes from the interview.  The physical examination provides additional information, frequently confirming the hypothesis(es) generated in the interview.  The two skills of interviewing and physical examination must be applied using a good knowledge base, with expertise in clinical reasoning.  The issue of adequacy of knowledge base will not be addressed directly in this workshop, since it is so domain-specific, but it will come up in discussion of the assessment techniques for each skill.  The topic of literature appraisal and EBM is included because it is so related to current approaches to clinical reasoning, and it is a skill IMGs often say that they lack.  Finally, in almost all instances, physicians must be able to communicate their information, reasoning, and conclusions to someone else in a concise and coherent way.  The issue of medical literacy is frequently a major problem for IMGs as they try to adapt to the Canadian medical system.

A final note about the teaching context: it is Canadian.  The major difference between IMGs and other learners is that they are not Canadian-trained.  Many things that we take for granted (i.e. our tacit assumptions) are unknown to IMGs. They do not know the system - the organization, the roles people play, and how they are expected to behave.  A major challenge for the teacher is to constantly examine the clinical context in which the IMG is working, and to make these unconscious attitudes and behaviours explicit to the IMG. Failure to do so will result in frustration on both sides, and will result in the IMG looking less capable.  One of the most frequent comments made by IMGs is:  "I just didn’t know that was how it worked."  (Please see the workshop on Orienting Teachers and Learners for more information on this important issue.)