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Learning Curves for
Medical Education
Martin V. Pusic MD PhD
Division of Pediatric Emergency Medicine
Children’s Hospital ...
Acknowledgements
• Kathy Boutis MD
• Martin Pecaric PhD
• Royal College Medical Education Grants
Acknowledgements
Outline
• Learning Curve General Principles
• Medical Example of Learning Curves
• Implications
Ericsson 1993
What is the Atomic Unit of
Emergency Medicine Practice?
The Atomic Unit of Emergency
Medicine
DECISION
The Atomic Unit of Emergency
Medicine
DO TEST
DON’T
The Atomic Unit of Emergency
Medicine
TREAT
DON’T
TREAT
The Atomic Unit of Emergency
Medicine
ADMIT
DISCHARGE
The Atomic Unit of Emergency
Medicine
ADMIT
ADMIT
Rash
ECG
Radiograph
Ankle Radiology Example
• PERC collaborative project
• Div of Pediatric Emergency Medicine
– University of Toronto
– Colum...
Screen shot of application
Item Bank
Case 1
Item Bank
Case 1 Case2
Item Bank
. . .
Case 1 Case2 Case3 Case4 Case 5 Case xx
Advantages of Image Bank
• Fidelity
• Repetitive Deliberate Practice
Dilemma #1
How do we measure the learning?
2 x 2 Table
Significant
Pathology
+
No
Pathology
--
User
Says +
a b a+b
User
Says --
c d c+d
a+c b+d a+b+c+d
Ankle Study
• Recruited broad
spectrum of subjects:
• All responses logged
in a MySQL database
Medical
Students
20
Residen...
Results
• Five institutions participated
• Took approximately 4 hours to complete all 234
• Overall Cohen’s Effect Size fo...
Five Levels of Expertise
-.50.511.52
dPrime
MS RES FELLOW PEM RAD
Dilemma #2
How do we detect the learning that is
happening along the way?
Five Levels of Expertise
-.50.511.52
dPrime
MS RES FELLOW PEM RAD
Rater 99 LR+ and LR-
0.00
0.50
1.00
1.50
2.00
2.50
3.00
1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 17...
Rater 101 LR+ and LR-
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145...
Rater 105 LR+ and LR-
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 13...
Rater 107 LR+ and LR-
0.00
0.50
1.00
1.50
2.00
2.50
3.00
1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 1...
LR+ and LR-
0.00
1.00
2.00
3.00
4.00
5.00
6.00
1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 172 181 190...
Rater 107 LR+ and LR-
0.00
0.50
1.00
1.50
2.00
2.50
3.00
1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 1...
Five Levels of Expertise
-.50.511.52
dPrime
MS RES FELLOW PEM RAD
0.1.2.3.4.5.6.7.8.91
(mean)dPrime
0 50 100 150 200 250
Sequence
MS RES
FELLOW PEM
RAD
dPrime
Summary
• Roughly 2/3rd
follow the Thurstone Pattern
• Not all curves same form:
– Medical Students Shallow Curves
– Resid...
Ericsson 1993
Distributed Practice
Ability to interpret heart sounds overAbility to interpret heart sounds over
time (Butterworth 1960)time (Butterworth 1960)
Outline
• Learning Curve General Principles
• Useful Parameters
• Medical Example of Learning Curves
• Examples abound
• G...
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
Learning Curves in Medical Education
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Learning Curves in Medical Education

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Dr. Martin Pusic (Columbia University) speaks about Learning Curves and Degradation of knowledge as it applies to medical education through his studies on medical education assessments and educational technology.

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Learning Curves in Medical Education

  1. 1. Learning Curves for Medical Education Martin V. Pusic MD PhD Division of Pediatric Emergency Medicine Children’s Hospital of NY-Presbyterian Columbia University
  2. 2. Acknowledgements • Kathy Boutis MD • Martin Pecaric PhD • Royal College Medical Education Grants Acknowledgements
  3. 3. Outline • Learning Curve General Principles • Medical Example of Learning Curves • Implications
  4. 4. Ericsson 1993
  5. 5. What is the Atomic Unit of Emergency Medicine Practice?
  6. 6. The Atomic Unit of Emergency Medicine DECISION
  7. 7. The Atomic Unit of Emergency Medicine DO TEST DON’T
  8. 8. The Atomic Unit of Emergency Medicine TREAT DON’T TREAT
  9. 9. The Atomic Unit of Emergency Medicine ADMIT DISCHARGE
  10. 10. The Atomic Unit of Emergency Medicine ADMIT ADMIT
  11. 11. Rash
  12. 12. ECG
  13. 13. Radiograph
  14. 14. Ankle Radiology Example • PERC collaborative project • Div of Pediatric Emergency Medicine – University of Toronto – Columbia University • Image Bank of 234 Ankle X-ray Cases – Others in Development
  15. 15. Screen shot of application
  16. 16. Item Bank Case 1
  17. 17. Item Bank Case 1 Case2
  18. 18. Item Bank . . . Case 1 Case2 Case3 Case4 Case 5 Case xx
  19. 19. Advantages of Image Bank • Fidelity • Repetitive Deliberate Practice
  20. 20. Dilemma #1 How do we measure the learning?
  21. 21. 2 x 2 Table Significant Pathology + No Pathology -- User Says + a b a+b User Says -- c d c+d a+c b+d a+b+c+d
  22. 22. Ankle Study • Recruited broad spectrum of subjects: • All responses logged in a MySQL database Medical Students 20 Residents 6 Fellows 12 PEM 5 Radiologists 3
  23. 23. Results • Five institutions participated • Took approximately 4 hours to complete all 234 • Overall Cohen’s Effect Size for the intervention was 0.55 (95% CI: -0.4, 1.5)
  24. 24. Five Levels of Expertise -.50.511.52 dPrime MS RES FELLOW PEM RAD
  25. 25. Dilemma #2 How do we detect the learning that is happening along the way?
  26. 26. Five Levels of Expertise -.50.511.52 dPrime MS RES FELLOW PEM RAD
  27. 27. Rater 99 LR+ and LR- 0.00 0.50 1.00 1.50 2.00 2.50 3.00 1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 172 181 190 199 208 217 226 235 Case Number LREstimate LR-- LR+
  28. 28. Rater 101 LR+ and LR- 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 172 181 190 199 208 217 226 235 Case Number LREstimate LR-- LR+
  29. 29. Rater 105 LR+ and LR- 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 172 181 190 199 208 217 226 235 Case Number LREstimate LR-- LR+
  30. 30. Rater 107 LR+ and LR- 0.00 0.50 1.00 1.50 2.00 2.50 3.00 1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 172 181 190 199 208 217 226 235 Case Number LREstimate LR-- LR+
  31. 31. LR+ and LR- 0.00 1.00 2.00 3.00 4.00 5.00 6.00 1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 172 181 190 199 208 217 226 235 Case Number LREstimate LR-- LR+ Rater 84
  32. 32. Rater 107 LR+ and LR- 0.00 0.50 1.00 1.50 2.00 2.50 3.00 1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 172 181 190 199 208 217 226 235 Case Number LREstimate LR-- LR+
  33. 33. Five Levels of Expertise -.50.511.52 dPrime MS RES FELLOW PEM RAD
  34. 34. 0.1.2.3.4.5.6.7.8.91 (mean)dPrime 0 50 100 150 200 250 Sequence MS RES FELLOW PEM RAD dPrime
  35. 35. Summary • Roughly 2/3rd follow the Thurstone Pattern • Not all curves same form: – Medical Students Shallow Curves – Residents and Fellows Steepest – Attendings Plateau • Overall Education Management • Individual Feedback
  36. 36. Ericsson 1993
  37. 37. Distributed Practice
  38. 38. Ability to interpret heart sounds overAbility to interpret heart sounds over time (Butterworth 1960)time (Butterworth 1960)
  39. 39. Outline • Learning Curve General Principles • Useful Parameters • Medical Example of Learning Curves • Examples abound • Group vs. Individual Considerations • Implications • Trajectories more accurate representation

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