Evidence-Based Education: Developing Kaiser Permanente Faculty For the New Millennium | to pdf >>
By Ferdy Massimino, MD, MPH; Tom Janisse, MD; Chris Overton; John Hurley, MD

Introduction
Been to any good lectures lately? Has a great Continuing Medical Education (CME) presentation led you to change your approach to any of the common vexing clinical problems you face daily? Why do clinicians usually answer "No" to these questions? What is going on with our inability to teach effectively? Where is the evidence-based teaching to go along with an evidence-based practice?

Producing Kaiser Permanente (KP) clinicians who are skillful and effective in the art and science of teaching evidence-based Medicine is a critical factor for our success in the new millennium. Developing evidence-based educators is more than the means to an end. To successfully implement a well-conceived educational program, the faculty must be much more than content experts--they must be transfer experts. They must promote, facilitate, and foster evidence-based change.

The evolution of well-trained faculty had its origins in 1995, when the Interregional (IR) CME Directors began monthly teleconference meetings. The purpose of the initial meetings was to create an IR Education Best Practices platform. Four years ago, it became apparent that a huge amount of planning focused on what would be taught, yet little time or energy had been invested on who would do the teaching. In other words, there was little reflection on the art and science of becoming better teachers of evidence-based Medicine.

During each of the past four years, an IR Faculty Development Workshop has been conducted in conjunction with the annual IR Primary Care Conference. A focus of the workshop was to support teacher development for those instructors nominated for each cycle of the Conference.

Two key initiatives were included in the IR Education Best Practices Agenda: to complete a needs assessment of primary care clinicians as an aid in developing a Primary Care Core Curriculum and to create and implement an informal Faculty Development Program to support the project.

The goal of the first initiative was to provide primary care clinicians evidence-based modules in the subject areas they considered essential for providing high-quality, cost-effective health care.

The goal of the second initiative was to enhance the teaching abilities of the most frequently used faculty members, our own internal experts and specialists. This goal is as important--if not more so--than that of the first initiative. After all, what good is the information within an educational program if those conveying it lack good communication skills?

The conclusion was obvious: Unless faculty had a better understanding of adult instructional and learning theories, as well as educational modalities and design concepts that enhance physician behavior change, no amount of scientific data presented was likely to result in the practice changes our patients need for better health outcomes. An analysis of what would make a better instructor ensued and resulted in formulation of four basic tenets that are necessary for successful implementation of the IR Faculty Development Program:

Create a Culture of Quality
An environment must be created wherein high-quality presentation is expected and becomes the norm. To create such an environment, we must do the following:

Presentation Training and Primer
A Faculty Development/Presentation Skills Workshop that would be recommended for KP teachers must be developed and made available to all. As part of the workshop, emphasize tips on content, voice, gestures, use of projection equipment, slide format, panel discussions, engaging and responding to an audience, and other necessary skills.

We have identified certain key steps in designing such a curriculum:

To further support the Faculty Development Workshop, a revision of the Training Primer (originally developed in 1995 as a complementary training and reference tool) is essential. The revised primer could be distributed as hard copy as well as made available on the Intranet for easy access.

Faculty Development Core Curriculum and Consultation Service
Core curriculum modules should be developed for Faculty Development and become standard for all facilities within all regions. A Faculty Consultation Service should also be created to review presentation materials (slides, handouts, lectures, presentation, and program development), because a successful program requires ongoing maintenance.

Evaluation & Acknowledgment
We must be relentless regarding our commitment to the process of evaluating and appreciating our educators. Each evaluation provided to a faculty member should include recommendations which reinforce areas of presentation that were strong yet invite and challenge the individual with opportunities to improve. With each presentation of a KP educator, we must remember to express sincere appreciation to each individual who invests in our culture.

The KP Interregional Conference On Primary Care, Occupational Health and Musculoskeletal Medicine
Clinicians, many of whom have been associated with The Permanente Medical Groups for an extended period, are aware of deficiencies in our Graduate Education Training model. In 1993, a project-planning workgroup representing Internal Medicine, Family Practice, Sports Medicine, Orthopedics, Occupational Medicine, Health Education, Behavioral Medicine, and Physical Therapy met and began implementing musculoskeletal educational programs for primary care clinicians. As time passed, this interdisciplinary planning group expanded the initial mission to include other strategic areas within primary care, including Practical Primary Care Skills, Communication & Behavioral Medicine Skills and Occupational Health. This project has now evolved to become the current IR Conference On Primary Care, Occupational Health, and Musculoskeletal Medicine.

The KP Interregional Faculty Development Workshop
The IR Faculty Development Workshop has evolved during the past three years into its current form. The recommended essential elements, or skill areas, for KP teachers are: Behavior, Content, Interaction, and Diversity Awareness.

Behavior
Behavior is part of the physical process of presentation and relates to the physical skills and techniques used by a speaker communicating with the audience. Developing behavioral communication skills means having control over delivery technique by commanding the body (the instrument). Behavioral work addresses such issues as eye contact, gestures, posture, vocal variety, pause and pacing, and use of classroom space, among others. When learned and practiced, these skills can dramatically improve a presentation.

Content
Content is that which is to be communicated. Content has three separate aspects:

Being an effective presenter requires mastery of all three of these aspects of content. A teacher who is clear yet boring will not create an impact. Conversely, one who is interesting yet convoluted may frustrate the audience. Truly effective teachers are straightforward, concise, memorable, and grounded in the scientific evidence supporting the Best Practice thinking on the topic.

Interaction
Interaction skills focus on the relationship between the presenter and the audience. Presenters with strong interactive skills are always in tune with their listeners. To be in touch with students, a skilled teacher will do the following:

Diversity Awareness
Diversity has both primary as well as secondary dimensions, and successful instructors know how to focus on each, as appropriate.

Diversity has six primary dimensions: race, gender, sexual orientation, age, culture/ethnicity, and physical ability/disability.

The secondary dimensions of diversity include religion, education, family/marital status, work experience, military experience, and lifestyle.

Mastering these areas--and learners' needs--involves communicating openly, nondefensively, and in a manner that honors the differences among all of us. Insensitivity to these differences can turn a world-class presentation into a third-rate experience, however unintentionally.

For example, let us imagine an educator who, in presenting the latest strategies for preventing HIV transmission, addresses only the information that he or she assumes the audience needs. If, looking at the audience, the instructor automatically assumes they are heterosexual, educated, married, too old to be having sex frequently, and possibly uncomfortable (religiously or culturally) discussing sexual behaviors, the instructor might erroneously assign the entire audience to a low-risk category--and therefore fail to provide the audience with the diversity of information they actually need.

Previously, to participate in the annual Faculty Development Workshop, instructors accepted teaching role assignments six to nine months before presenting. The teacher would agree to develop the future presentation (30, 60, 90 minutes in length) during the workshop and to deliver portions of the presentation to the other Workshop participants as a learning exercise. Each audience member would provide feedback, and faculty candidates would receive individualized coaching from other experienced Permanente Faculty facilitators as well as from professional communication trainers.

During the three-day Faculty Development Workshop, teachers would do the following:

Workshop Evaluation
The evaluation results received at the conclusion of each of the three IR Faculty Development Workshops held to date have been overwhelmingly positive. This strong response merely confirms that the skill and wisdom needed to successfully develop evidence-based teachers lies within the Kaiser Permanente organization and our colleagues. To quote one recent attendee: "This was an extraordinary workshop, because I have never seen so much importance attributed to the quality of a presentation at a meeting."

On the overall evaluation, the 34 responses from attendees at the third IR Faculty Development Workshop expressed strong agreement with the following statements:

Looking Ahead
For KP to reach the next level of quality, we must share the answers that will facilitate a culture of learning and teaching and of providing leadership within the health care industry as the new millennium dawns. As individuals, we know much; as the KP organization, we must provide the resources to develop more effective teachers of evidence-based Medicine.

In doing so, we would have an enormous advantage. By harnessing our collective knowledge, and refining our teaching and implementation effectiveness, the KP organization will position itself to deliver the best medical care possible.

The good news is that IR CME Directors have identified Faculty Development as a key initiative. The establishment of a competency program for Faculty Development is therefore essential to the growth and prosperity of our organization. But this project will not succeed without the support of the real experts in CME: the KP clinicians--our internal customers who will tell us if we have succeeded in this effort.

Consequently, we, as KP colleagues, must consider how we can share our knowledge with one another. Doing so--and subsequently expanding the faculty development model--would deliver these results:

Conclusion
Our organizational imperative is to become better at using high-impact learning opportunities and events and to find ways to share our acquired knowledge with one another. Because time and the changing face of health care are moving as quickly as technology, our collective need to simply keep pace is greater than ever.

In becoming more effective teachers, we will discover new ways to engage with colleagues, producing consistent, positive, and often dramatic results. We will be able to develop a sense of confidence and command of our own natural style and abilities. We will work through our fears about teaching and leadership, in turn having more fun, satisfaction, and success in our everyday communication with colleagues and patients. That is the promise that the faculty development of evidence-based education holds. And it is a promise we must keep.

Acknowledgment: We would like to acknowledge the following Permanente educational leaders who have each contributed to this project in evolution: Bill Ahuna, MD, Doug Benner, MD, Ned Calonge, MD, Connie Chiulli, MPH, Philip Brennes, MD, Carol Havens, MD, Marc Klau, MD, Barry Jay Miller, MD, Bernyce Peplowski, DO, David Price, MD, Warren Scott, MD, Stan Shoor, MD, David Sobel, MD, MPH, Ken Spiegelman, MD, Helen Stallings, MSPH, Jill Steinbruegge, MD, PhD, Sam Weir, MD.