Feedback to trainees is important for motivational purposes as well as knowledge of results.

BST step 6: Provide performance feedback

As trainees practice performing the skill being trained, the trainer should observe each trainee’s performance and provide feedback (the performance feedback training strategy). The feedback should include several forms. First, the trainer should provide positive feedback in terms of specifying those aspects of the skill the trainee performed correctly and offer praise or other commendation for those actions. Second, the trainer should provide corrective feedback if necessary for any aspects of the skill the trainee performed incorrectly or omitted during the practice. Corrective feedback involves specifying what the trainee did not perform correctly and informing the trainee what s/he needs to do to correct the performance. The latter part of corrective feedback may consist of additional instruction and/or modeling for the trainee how to correctly perform specific aspects of the skill.

With both positive and corrective feedback it is also helpful for the trainer to specifically question a trainee whether s/he has any questions about performing the skill or about the trainer’s feedback, and then respond accordingly. Such an action allows an opportunity to resolve any concerns the trainee may have. It also represents a type of participative action on the part of the trainer, which can enhance trainee acceptance of the training process (Reid et al., 2012, Chapter 6).

In order for a trainer to provide sufficient positive and corrective feedback, s/he must carefully observe a trainee’s practice performance. The written summary of the target skill (used in BST step 3) should be used as a guide such that the trainer can observe a trainee’s proficiency in performing each step constituting the skill being trained. As noted earlier, preparing the written summary in a checklist format can facilitate the trainer’s observation. The trainer can observe and “check off” each step on the checklist as being correctly performed or not by each trainee.

The feedback step of BST can be time consuming to conduct, and especially if there is a large group of trainees. The trainer must spend time observing each trainee’s practice and providing individualized feedback. Consequently, there is a tendency for some practitioners to only complete part of this step. That is, some practitioners generally observe the group of trainees as a whole rather than spending time observing each trainee and providing individualized feedback. Though potentially time consuming, individual feedback is critical for successfully implementing BST and should never be overlooked.

2.2 Trainees

Trainees of cross-cultural training programs are typically international business employees, diplomats, volunteers, or university students preparing to study abroad. Since the structure of a program primarily depends on the type of participants involved, business employees, for example, will go though a quite different training program than undergraduates planning to study abroad. Training techniques used for business employees will focus on the particular issues they will be facing in the workplace and with their families, whereas programs for students studying abroad will discuss issues related to host families and schools.

Individual characteristics of the trainees, including degree of ethnocentrism and intercultural sensitivity, also play a role in the structure of the program. Highly ethnocentric individuals may benefit more from experiential activities, whereas those who are less ethnocentric and have more cross-cultural experience may gain more from discussing cultural or communication theories presented in lecture. Programs with a large number of trainees may be structured so the latter individuals serve as group discussion leaders, reporting back to the entire group while the trainer provides feedback.

Ethics Related to Basic Principles of Behavior Analysis

If trainees are not careful, they can easily misapply the basic principles of behavior analysis in a way that is inconsistent with the BACB’s Code of Responsible Conduct, therefore it is critical to provide support to them within this context. When talking about ethics as it relates to the basic principles, focus on the dangers of using extinction (Bailey & Burch, 2016, p. 130). Ensure that your trainees understand the need for delivering the functional reinforcer for appropriate behavior when using an extinction procedure. In addition, ensure that your trainees understand that one should always attempt reinforcement procedures prior to using a punishment procedure (Bailey & Burch, 2016, p. 132). In the event that a punishment procedure is necessary, one should always include reinforcement systems simultaneously (Bailey & Burch, 2016, p. 133).

Rehearsal and Performance Feedback

Use the data the trainees collected throughout the measurement activities and use those in comparison to the previously established rubrics. Have the trainees select which IOA formula to use and calculate IOA for each of the data collection systems. If the trainee has 100% agreement in the majority of situations, provide some additional samples where there is a higher level of disagreement to ensure a full understanding of the topic. Continue instruction on this topic until the trainees meet the previously established criterion. Table 3.13 provides a structure for assessing trainees’ competency around IOA.

Table 3.13. Rubric for Calculating IOA

What challenges do teacher trainees perceive in teaching information seeking and use?

The trainees found that their experiences of assessing information sources would be applicable for teaching information seeking and use and that teaching the assessment of information sources would be a major challenge. It was unexpected to see that so many teacher trainees found their own information searching and ICT skills lacking. The use of technology did not emerge as a major challenge in the trainees’ experiences of seeking and using information for lesson plans, a finding consistent with those of the pilot study (Tanni, Sormunen & Syvänen 2008). Madden and his colleagues (2005) found out that most (72%) practising teachers are confident in their ability to use the Internet, although half of the teachers studied found that students know more about the Internet than they do. The findings might be an indication of the trainees’ low self-efficacy because of the lack of training in teaching information searching using new technologies, if not an indication of an actual lack in the trainees’ skills.

Although the trainees did articulate themes that focused on higher-order thinking (preventing plagiarism and getting students to understand and discern subject content), they articulated equally the themes that focused on lower-order skills, or even on the rudimentary issues of organizing a class teaching information seeking and use. If a trainee struggles to find the time for information literacy instruction (see Madden et al. 2005) and finds students’ ICT skills lacking or the students unmotivated to seek information independently, it is not surprising that the teacher does not have far-reaching goals for integrating information seeking and use instruction into subject teaching.

The perception of students’ lack of motivation, if accurate, could indicate students’ reactions to teachers’ outsider applications of new technologies. Another interpretation is that it is the students who are stuck with the school mentality, expect that the teacher to be the sole source of knowledge and find task assignments requiring independent information seeking as curious exceptions of this rule (see Lankshear & Knobel 2003, pp. 30-1). As for the trainees’ perception of students’ lack of skills, Bennett, Maton and Kervin (2008) point out that students might indeed know how to use the Internet for their own purposes, but that this knowledge might not be applicable in searching for information using new technologies for school assignments.

10.1 Introduction

Surgical trainees have traditionally been taught by surgical staff under a structured Halstedian apprenticeship model of “see one, do one, teach one” [1]; however, with the recent mandatory reduction in resident work hours in many countries around the world, this consequently limits the time residents actually get to spend in the operating room (OR), making it questionable as to whether surgical trainees are able to obtain enough surgical experience to be considered competent to practice independently by the end of their residency or fellowship training [2]. This has led surgical educators to move more of the training outside the OR and into surgical skills laboratories where trainees, especially in the beginning of their residency, are able to acquire and practice a multitude of technical skills required for live surgery, including those for open, laparoscopic, and robotic procedures. Simulation offers a risk-free, safe, and standardized environment for trainees to acquire and develop technical skills through deliberate practice, often and ideally in the presence of feedback from expert supervisors, peers, and objective metrics that are integrated into simulators. The ultimate goal of simulation is that the surgical skills learned in the laboratory will successfully transfer to the high-stakes environment of the OR.

Historically, medical education centered on an apprenticeship model using live patients. The seminal article by Abrahamson et al. [3] brought medical simulation to the forefront with their experiential report of the effectiveness of training anesthesiology residents to perform endotracheal intubation by using a computer-based mannequin simulator (see Figure 10.1 for a modern version of this simulator). However, it took some time for simulation of medical procedures to become integrated into medical education. Simulation has surged in popularity over the past two decades, as significant advancements in technology have allowed for multiple types of novel simulators, some of which are extremely sophisticated. With competency-based education and strict assessment measures of proficiency becoming mainstream in most parts of the world, simulation is now a major component of many medical and surgical training programs. Although simulation currently exists for various types of medical training, this chapter focuses on surgical simulation—specifically historical implications of simulation, theoretical constructs, the role of skill acquisition in simulation, types of surgical simulators and considerations for their use, and the development and use of metrics for assessment of simulated surgical tasks.

Field Training

Overlaps. Once therapist trainees pass the written exam, they begin the overlap process. During an overlap, the therapist trainee accompanies a seasoned therapist to a therapy session and observes all aspects of that therapist working with the learner. Therapist trainees are required to attend approximately 12 overlap sessions, depending on the time it takes for the trainee to demonstrate mastery of all therapy competencies while working with learners. In the first session, the trainee is expected to observe and take notes. Gradually, across subsequent sessions, the trainee becomes more involved in the therapy session, until – by the end of the 12th overlap session – the trainee is completing the entire therapy session with a learner while the seasoned therapist observes.

Trainees receive feedback across the 12 overlap sessions. They are given verbal feedback in the moment, as well as written feedback that delineates 84 component competencies required during each session. These components are described in greater detail in the Field Evaluation section. For example, when learning to collect data, the trainee is provided with blank datasheets and then uses them to take data while the seasoned therapist conducts therapy. When the learner is given a break, the seasoned therapist reviews the data taken by the trainee, compares the data with her own, and gives the trainee feedback. For example, the therapist might say, “Great job with data on items 1, 3, 4, 5, 6, and 7. You marked item 2 as incorrect, but it was really a non-response. Does that make sense?” The process repeats multiple times per session, thereby providing many opportunities for performance and feedback.

During early overlap sessions, therapist trainees are required to perform only a few competencies. The number of tasks required of them gradually increases across overlaps, with feedback given throughout the process. Each overlap session is 2–3 hours in duration, so the total overlap portion of training typically lasts 24–30 hours. Therapist trainees cannot move on from this portion of the training until they demonstrate competency on all skills. The vast majority of trainees master all competencies within 12 overlaps.

Field evaluation. During a trainee’s potential final overlap session, the therapist trainee undergoes a field evaluation. A senior therapist, therapist liaison, or clinical supervisor (see Chapter 21 for job descriptions) conducts the field evaluation. The evaluator observes the therapy session and scores the trainee on a field evaluation form. All competencies being evaluated are objectively defined and include all of the competencies that were trained during the overlap process. The field evaluation form contains 84 items that evaluate the therapist across the following areas: initiative, professionalism, arranging the teaching situation, discrete trial training, teaching during downtime, use of log notes, and behavior management. An example of an item on the evaluation is, “The therapist observes the confidentiality of all clients” or “The therapist fades prompts as the learner gains independence with the target response effectively.” Each of the items are scored on a scale from 0 (never) to 4 (always). The scores of all 84 items are then averaged, and a trainee must receive an average score of 3 or higher to pass the field evaluation.

If the trainee scores below 3 on one or more items, she must retake the field evaluation within 1 week. In the interim, the trainee continues to overlap with a trained therapist, and the trained therapist targets the items on which the trainee received low scores during the initial field evaluation. If the trainee scores below a 3 on any item during the second field evaluation, she is not allowed to continue training. After the therapist trainee passes the written exam and the field evaluation, she is no longer a trainee but is a full-fledged therapist, and she is allowed to work with learners without another therapist present. For a full-time employee, the training process usually takes approximately 3 weeks from the time she is hired to the time that she passes the field evaluation and formally becomes a therapist.

Empathy Vs Blame

As a senior resident working with a competent and caring junior colleague, I recall a young Hispanic woman who arrived with four children, each under the age of 5. My junior trainee performed the initial evaluation and presented the patient’s case to me. Symptoms included pain with intercourse, incontinence, post-void dribbling and recurrent urinary tract infections, symptoms consistent with a urethral diverticulum. I asked the resident if this diagnosis matched what he found after performing his pelvic exam. To my surprise, he stated he did not perform the exam. When I asked why not, he became upset and seemed offended. He then explained that the patient brought her children to the clinic, arrived late, and had missed her two prior clinic appointments. I remained unclear about the connection between her late arrival, attendance history, and his decision not to perform this necessary diagnostic exam.

Given my trainee’s aroused emotional state, I simply suggested we talk to the patient together. On the way to her room, I asked the staff to watch the children while we examined the patient. I introduced myself, assessed the clinical situation, and repeated my understanding of her chief complaint. I then asked her how she got to the clinic, to which she replied the following:

“Doctor, I’m sorry for bringing my children. I waited as long as I could for my friend who agreed to watch my children. But when she didn’t arrive, I decided to bring them. I missed the last two appointments because the sitter didn’t show up, and I know that if you miss or reschedule three appointments, you will be kicked out of the clinic. Honestly, I would have been on time, but I had to catch three buses. I missed the second bus because we had to walk a few blocks to catch it and the three-year-old doesn’t walk fast. Since we missed the second bus we had to wait another 20 minutes for the next one.”

By the time she finished her story, my junior resident understood that she was not as he had assumed. She was not someone who didn’t care about herself and therefore somehow unworthy of his time and improvement in her health. On the contrary, she worried so much about her health that she spent hours on several buses with four young children in tow, in order to see a medical specialist. Armed with this psychological insight, the resident was apologetic and asked if he could perform the exam and appropriately complete her work-up. He later shared privately that he finally understood the point behind my frequent comment that it is not our job to judge, but it is our duty to help. We cannot and must not try to determine whether our patients are “good” or “bad” people, but we can and must treat them with compassion.

Understanding context is inseparable from quality patient-centered care. People do not become sick in a vacuum. Illness affects multiple aspects of life, and multiple factors can contribute to illness. Physicians who display warmth, friendliness, and a reassuring manner have been found to be more effective than those who do not (Di Blasi, Harkness, Ernst, Georgiou, & Kleijnen, 2001). Clinical empathy, touted by clinical psychologists for more than half a century (e.g., Rogers, 1949, 1957), is a core contributor to accurate diagnosis, humane practice, and positive patient outcomes (Halpern, 2001; Larson & Yao, 2005). But unlike clinical psychology training, medical education has traditionally lacked a formal process to positively shape learners’ perceptions and self-awareness so they are more likely to accurately empathize and less likely to inappropriately blame.

Clearly, one could argue that any patient should be punctual and make necessary arrangements for child care. But when patients do not meet our expectations, we physicians must decide as an industry how to perceive their behavior and subsequently respond. Do we blame them for audaciously showing us too little respect and deference, or do we seek to understand them and their behavior in the context of illness and vulnerability? A formal patient-centered model provides a clear answer and structure. But if the medical profession truly desires a more empathic physician workforce, it must confront a very real subculture that is consistently and painfully revealed by the “hidden curriculum” literature described in the following. To date, while counterintuitive and in violation of the admirable Hippocratic Oath described earlier, the evidence shows traditional medical culture actually grooms trainees to be less, not more, empathic.

Workshop Leader Efficacy

The preliminary trainee efficacy questionnaire data showed that the members of both trainee FWDer cohorts started out as confident in their facilitation skills, self-identified as comfortable working in teams and calling on colleagues and administrators to serve as presenters, and were good communicators. The lowest scores in the efficacy instrument were in the areas of adequate resources: their own time allocated to the effort, additional student or assistant help that might be needed, and/or specific materials to use in delivering the workshop. Individuals rated themselves very highly in the aspects of teamwork, change agency, and setting direction.

However, one-on-one informal interactions with FWDer team members at the second-tier workshops observed revealed that teams “got the job done” using a variety of different strategies. One team clearly delineated the role of each member and met infrequently, relying on each individual to do the assigned job. Several members of this team expressed some dissatisfaction with the process. They indicated a willingness and desire to be involved with a more collaborative effort where the interactions among the team members may have stimulated new ideas and alternative approaches to the workshop. They indicated that when this was “allowed” to happen, early in the planning stages, the meetings “took a lot more time than expected,” but they felt they were more engaging and very worthwhile. However, as time pressure mounted and the workshop date approached, several team members indicated that other team members took a more directive and authoritative stance rather than continuing the initially more collaborative approach. Perhaps this is what they felt was needed to create a good workshop. In the end, the workshop went very well, and the evaluations from participants were largely positive. During the course of the workshop, the participants were listened to and a closed-door session of only the minority women participants and leaders was added. This was deemed reasonable, but it did exclude several of the six team members, the evaluator, and some of the participants as well.

A different team of four persons, with two members at one institution, let those team members who were co-located take the lead. They prepared most of the recruitment materials, dealt with the site logistics, and were able to garner the most institutional support. This may have been due in part to their administrative leadership positions at the institution and being outside traditional faculty roles. One consequence of this management strategy was that recruitment materials were distributed from the lead institution, and recruitment was less successful at the other schools. The initial recruitment efforts did not produce a large enough pool of applicants. A decision was made to reach beyond the region and expand the workshop focus to be more issue-oriented and less about establishing and sustaining a regional network of women in STEM among the collaborating campuses. Other differences stemmed directly from the limited experience with, and partial understanding of, the facilitation model (personal communication, 2012). A second consequence of this approach was that the team only met to be trained in the facilitation process to be used to conduct the workshop immediately preceding the workshop. Then, during the workshop, various team members interpreted and implemented their training somewhat differently when facilitating their small groups. Some of the differences seemed to be due to individual personalities, perhaps different underlying institutional cultures, or individual communication styles. Still, this second-tier workshop stood out for the depth and quality of the interpersonal interactions, shared stories, and personal/professional support for the participants. The facilitation process of the workshop overall produced an uncommon depth and candor in the table conversations and working sessions.

One other workshop benefited from a staff member who took the time to lead the effort, convene meetings as needed, and enlist her students’ assistance in handling logistics. This workshop also chose to capitalize on an existing college (within the university) seminar series and professional association activity. These brought added resources to the effort, enabling this second-tier workshop to use the FORWARD minigrant resources to enhance the level of the outreach efforts and presentations. Consequently, there is strong institutional support to sustain the workshop into the third tier; the workshop is now the “baby” of that staff member and reliant on her continued student support; the leadership team has collapsed to solely her network of contacts. She reports that she readily calls on the original team members to identify resource people and presenters, but most likely, the workshops will continue to be given every other year so that incoming students may be included as core participants. Future third-tier efforts may lead to insights regarding a “desirable” leadership team configuration that would make ongoing workshop planning and implementation cost effective and sustainable.

Overall, there has been remarkably high implementation fidelity to the model FORWARD workshop. Participants in the second-tier workshops are having positive experiences, developing an understanding of mentor/mentee relationships, and establishing peer networks across disciplines. Follow-up interviews and the large-scale survey of participants help to understand the longitudinal impacts of these experiences.

The Pay It FORWARD team has reached its goal of successfully training and supporting 10 FORWARD workshop leadership teams (FWDers), who, in turn, have offered 16 of the 10–20 anticipated second-tier workshops. In addition, several sites intend to complete or have completed (for an overall total of 19) the third-tier workshops with supporting funds and then sustain and institutionalize their workshops at their respective institutions. Toward this goal, nearly all of the second-tier workshops invited and succeeded in having institutional administrators attend and support their workshops.

Introduction

Experiential learning takes trainees out of the classroom and provides real-life experience in their field of study. As defined by Shea and colleagues (1996), it is “an activity in which a student observes and directly participates in a quality learning experience external to the classroom setting which is structured to complement the students’ major field of study or reflect interdisciplinary goals that enhance his or her engagement and understanding of career opportunities in a diverse and ever changing world”.

Most medical and health sciences education is experiential. However, the first two years of medical school are traditionally spent in a classroom setting with mostly didactic, lecture-style teaching methodology. The anatomy lab is the lone exception during this classroom-based education. But even in that setting, where students perform dissections to gain a better understanding of the human body, the learning is highly directed and structured. It is usually not until the third year of medical school that trainees begin their clinical experience. Even then, specific exposure to geriatric medical practice is limited. Examples may include medical students taking a history from caregivers of patients with advanced dementia; observing emergency medicine residents evaluating older adults with abdominal pain; and seeing cardiology Fellows master the techniques of heart catheterization for frail elders, all under the watchful eye of experienced clinicians. Each of these activities occurs outside of the traditional classroom. In fact the majority of medical training occurs in the context of real-world patients and health care delivery. This approach is best described as a modification of the traditional apprenticeship model of education.

Yet, despite the experiential contact learners might have with older adults, a diminishing number of medical graduates are choosing to specialize in the care of the older population. According to the American Geriatrics Society, in 2000 there were 7,762 geriatricians in the United States for 16.6 million people aged 75 and older. This translates to 2,127 older adults for each geriatrician in the US. If present trends continue, by 2050 this will decline to an estimated 7,264 geriatricians for the estimated 48.4 million adults aged 75 and older. Such a demographic shift would reduce that ratio to only 1 geriatrician for every 6,700 adults at or above age 75. The shortage of graduates choosing to care for older adults is as much due to qualitative aspects of their training experiences as it is the more commonly cited financial pressures. So we must ask ourselves two questions – why is this happening and what can be done?

Many factors contribute to the declining popularity of geriatric medicine. These include professional, personal, and training factors. Professional factors are those related to practice, such as job satisfaction, prestige, lifestyle, and income. Personal factors are those related to the trainee, such as background, culture, socioeconomic class, and predisposition toward certain areas of medicine. Training factors are those related to learners’ exposure, to explicit and implicit priorities of training programs, and faculty role modeling. Psychologically, experiential learning interacts with each of these factors in ways that ultimately shape trainees’ perceptions of geriatric care.