really good stuff becoming used to others being in the room, the value of watching other students being interviewed, and the usefulness of having their practice interview recorded. This format of practice interview is very time-efficient: 80 students were interviewed and provided with feedback in a total of 20 interview hours. The involvement of 14 staff member interviewers and a few hours of administrative staff time for scheduling and room bookings spread the load amongst all involved, making this a practical and acceptable way of providing interview practice to large numbers of students. Correspondence: Anna T Ryan, Austin Hospital Clinical School, The University of Melbourne, PO Box 5555, Heidelberg, Victoria 3084, Australia. Tel: 00 61 3 9496 4737; E-mail: [email protected] doi: 10.1111/medu.12449
An operationalised approach to biopsychosocial formulation David A Ross, Gerrit I van Schalkwyk & Robert Rohrbaugh What problem was addressed? A core skill in all disciplines of medicine is the ability to understand complex patient presentations. Although the classroom setting may allow for in-depth exploration of foundational knowledge, this experience may be distinct from the development of ‘clinical judgement’ skills that are typically learned in situ. Such clinical learning often has a practical or utilitarian quality, emphasising higher-level pattern recognition, and may be divorced from a deeper understanding of the underlying processes. In psychiatry, one such core clinical skill is the ability to construct a comprehensive formulation that incorporates data from biological, psychological and social domains. Trainees are frequently in awe of experts’ ability to craft well-articulated formulations, seemingly out of thin air. Although inspiring, such performances may also be frustrating as trainees do not know how their mentors achieve this task. This all too common gap reflects the stages of learning described by Dreyfus and Dreyfus,1 whereby a master may perform at a high level without conscious awareness of how he or she is doing so, but a novice requires explicit focus on relevant rules that the expert may or may not be able to provide. We sought to deconstruct this expert skill into a clear operationalised approach that would meet the
needs of the novice learner at his or her stage of learning. We believe that explicit emphasis on the underlying process will help trainees learn faster and more accurately and, ultimately, have a deeper understanding of the material. What was tried? We developed a new method for teaching biopsychosocial formulation that is based on an explicit notation system, applied to a written case report. As trainees read the case, we ask them to identify and label primary data in the text and then arrange the data into a simple, jargon-free, organisational framework. For example, as a first step in the psychological formulation, we ask the trainee to place an asterisk above any identifiable stressors, to place brackets around strong thoughts and feelings, and to circle any adaptive or maladaptive coping mechanisms. Importantly, for each case the trainee formulates, he or she is now able to directly compare this work with an answer key that reflects the primary process by which an expert would approach the same material. After introducing the basic approach using sample materials, we meet weekly to analyse cases the trainees are actively treating. As they progress, we gradually introduce them to more advanced conceptual frameworks that can be easily superimposed on our model. What lessons were learned? The course has been positively received by trainees, who report that this experience translates well into the clinical setting: previously, when asked to demonstrate formulation skills, residents would describe feeling ‘lost’; using our new method they now feel more comfortable and confident. Critically, by creating an objective assessment measure, this approach provides trainees with a richer formative feedback experience while enabling us to directly measure progress towards our curricular learning objectives. We believe that this type of approach could be of benefit in other medical disciplines that struggle with the issue of how to optimise the teaching of complex clinical topics to novice trainees. REFERENCE 1 Dreyfus S, Dreyfus H. A Five-Stage Model of the Mental Activities Involved in Directed Skill Acquisition. Berkeley, CA: California University Berkeley Operations Research Center 1980. www.dtic.mil/cgi-bin/ GetTRDoc?AD=ADA084551. [Accessed 16 February 2014.] Correspondence: Gerrit I van Schalkwyk, Department of Psychiatry, Yale University, 300 George Street, 9th Floor, New Haven, Connecticut 06511, USA. Tel: 00 1 203 393 5891 E-mail: [email protected] doi: 10.1111/medu.12448
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 522–548
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An operationalised approach to biopsychosocial formulation David A Ross, Gerrit I van Schalkwyk & Robert Rohrbaugh What problem was addressed? A core skill in all disciplines of medicine is the ability to understand complex patient presentations. Although the classroom setting may allow for in-depth exploration of foundational knowledge, this experience may be distinct from the development of ‘clinical judgement’ skills that are typically learned in situ. Such clinical learning often has a practical or utilitarian quality, emphasising higher-level pattern recognition, and may be divorced from a deeper understanding of the underlying processes. In psychiatry, one such core clinical skill is the ability to construct a comprehensive formulation that incorporates data from biological, psychological and social domains. Trainees are frequently in awe of experts’ ability to craft well-articulated formulations, seemingly out of thin air. Although inspiring, such performances may also be frustrating as trainees do not know how their mentors achieve this task. This all too common gap reflects the stages of learning described by Dreyfus and Dreyfus,1 whereby a master may perform at a high level without conscious awareness of how he or she is doing so, but a novice requires explicit focus on relevant rules that the expert may or may not be able to provide. We sought to deconstruct this expert skill into a clear operationalised approach that would meet the
needs of the novice learner at his or her stage of learning. We believe that explicit emphasis on the underlying process will help trainees learn faster and more accurately and, ultimately, have a deeper understanding of the material. What was tried? We developed a new method for teaching biopsychosocial formulation that is based on an explicit notation system, applied to a written case report. As trainees read the case, we ask them to identify and label primary data in the text and then arrange the data into a simple, jargon-free, organisational framework. For example, as a first step in the psychological formulation, we ask the trainee to place an asterisk above any identifiable stressors, to place brackets around strong thoughts and feelings, and to circle any adaptive or maladaptive coping mechanisms. Importantly, for each case the trainee formulates, he or she is now able to directly compare this work with an answer key that reflects the primary process by which an expert would approach the same material. After introducing the basic approach using sample materials, we meet weekly to analyse cases the trainees are actively treating. As they progress, we gradually introduce them to more advanced conceptual frameworks that can be easily superimposed on our model. What lessons were learned? The course has been positively received by trainees, who report that this experience translates well into the clinical setting: previously, when asked to demonstrate formulation skills, residents would describe feeling ‘lost’; using our new method they now feel more comfortable and confident. Critically, by creating an objective assessment measure, this approach provides trainees with a richer formative feedback experience while enabling us to directly measure progress towards our curricular learning objectives. We believe that this type of approach could be of benefit in other medical disciplines that struggle with the issue of how to optimise the teaching of complex clinical topics to novice trainees. REFERENCE 1 Dreyfus S, Dreyfus H. A Five-Stage Model of the Mental Activities Involved in Directed Skill Acquisition. Berkeley, CA: California University Berkeley Operations Research Center 1980. www.dtic.mil/cgi-bin/ GetTRDoc?AD=ADA084551. [Accessed 16 February 2014.] Correspondence: Gerrit I van Schalkwyk, Department of Psychiatry, Yale University, 300 George Street, 9th Floor, New Haven, Connecticut 06511, USA. Tel: 00 1 203 393 5891 E-mail: [email protected] doi: 10.1111/medu.12448
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 522–548
529
