Wednesday, March 28, 2012

Second Base: Diversity, Competence, Disparities

This is the second article in a series about  subjects which have been on the collective minds of the Office of the Provost, the leadership and Board, and the community at large:  active learning, diversity, interprofessionalism.   Thanks toDr. Lynn Foord for her contribution from last month regarding active learning.  I have chosen to steal back the blog for this edition and to focus on the issue of diversity and health disparities. Alex Johnson

The Institute is in need of diversity that reflects the perspectives of the communities we serve.  Diverse students and faculty bring their unique and relevant experience to the forefront of our minds.   From dealing with individuals whose experience is different than our own we learn to listen openly, we learn to think in a non-judgmental manner, and we learn empathy.     More important, we also learn to be understood and misunderstood and how to explain ideas, diagnoses, and recommendations in a manner that is respectful and helpful.   We learn to clarify and explain with an eye toward the needs of another person or group of people.

1.  A Diverse Community Builds a Narrative
When we speak about diversity, do certain images come to your mind?  When I hear the term “diversity” images of race and language jump into my consciousness.   I work to stretch to think of diversity to include every aspect of our community and the unique cultural, social, linguistic features that are associated with the experience of another person.    Thus, a “perfect Institute” would be open to people from various social strata.   We would have strong representation from those communities that are highly underrepresented in the professions of nursing, physical therapy, and speech-language pathology.   The male voice would be more present and visible among faculty and students.   We would continue to expand discussion and provide positive visibility for LGBT students.   We also would welcome and honor every religious and political persuasion.   But assuring balanced representation by these labeled categories does not lead to cultural competence; rather this balance is just the first step.   Assuring a very heterogeneous student body and faculty insures that a voice will be present to tell important cultural and social stories that are critical to the health of the community.

2. Professional Competence Always Includes Cultural Competence.
Cultural competence goes far beyond consideration of labels.  In fact, labeling itself develops a form of bias and judgment.  What will it take for us to think of each person as a potential-filled opportunity for health and success?    What will it take for us to see communities and cultural groups as opportunities for learning, exchange, and health?  In our own work at the Institute, we often use examples of skin color, accent, or attitude as examples of why we need to be culturally competent in our service delivery.    Can I assess the skin integrity of an individual with brown or black skin?  Can I assess the communication abilities of someone who uses English as a second language (or not at all)?    Do I understand the attitudes about health and family in people from another country than my own?    These represent some fundamental examples of thinking with competence about our clients/patients.   They underestimate, however, the depth and importance of the need.    These most obvious examples are trite and are overused.  By working with our patients to understand their social, cultural, language, or religious values and uniqueness, we can come to see the complexities of their illness or disability in a new light.   When we make appropriate decisions based on these complexities and realities, as well as the reality of the patient’s condition, then we are competent.    Cultural competence IS competence

3.  Health Care Disparities Need our Immediate Attention
And what about health disparities?   It is well known that certain groups and populations have received less comprehensive service than others in the health system.   Many of our faculty members, experienced health professionals, have worked in community health centers or urban hospitals where care is rationed quite differently than in more economically advantaged settings.   We know that our country has a huge population of underinsured individuals.    I recently spoke with a friend, who has been unemployed for some time.  She has been paying her own insurance rates for her family----over $800 per month.  For this, she receives comprehensive coverage with an annual $10,000 deductible.    So, if she spends $10,000 in total for prescriptions, office visits, hospital or emergency admissions then she can be reimbursed for her care.    On the other hand, most of us with “good” insurance are paying far less for insurance because our employer purchases our insurance.  We might pay $10-20 for a co-pay for our prescriptions and visits.  All major medical tests and procedures are covered.  This is the best example that I can think of for a disparity.    By virtue of where I work I am advantaged in my health care.   I (and most of you) don’t have to make the difficult decision to choose between care and other “luxuries.”   Disparities extend far beyond these economic situations.    We also know that providers make unconscious decisions based on race, gender, sexual identity, age, and so forth.   Disparity needs to be addressed at a personal (reduce the bias),  policy (create equal access to care), and advocacy (educating the public and those who govern) level.    Our students need the expertise (competence) to address these disparities at each of these levels.

In conclusion, diversity is desirable for the Institute because it advantages our thinking, our experience,  and our understanding of each other.    Cultural competence, one feature of excellent professional skill and knowledge, is a goal for everyone in the IHP community-faculty and students.   Awareness of disparity and the mechanisms that cause it are critical to effective delivery of health and rehabilitative services for the future.  We need to prepare leaders in reducing these disparities.  

Wednesday, March 7, 2012

First Base: Active Learning by Lynn Foord, PhD

Note:  This is the first in a series of follow-up comments to last month's blog (Looking for the Institute's Triple Play: Get your Eye On the Ball).  I asked our new Director of the Prerequisites Program, Dr. Lynne Foord, to give some thoughts about Active Learning and its role at the Institute.  Read on and you will  know a bit more about active learning and its importance as one of the many dimensions for teaching and learning at the IHP!  Alex Johnson, Provost

Lynn Foord, Ph.D.
Many instructors of late have begun to consider transitioning all or part of their class time to active learning . There are lots of interpretations of active learning; all value some means of putting the learner in charge of his/her learning. Unfortunately, some interpret this to mean that faculty then simply provide or refer to resources and step away. In actuality, the instructor never steps away, only steps into a role larger than that of repository of information (“Sage on the Stage”) to apply her/his expertise and experience to the design of learning experiences for the students (“Guide on the Side”).

What will transition to active learning mean in practice?

Richard Thornburg (1996) in Campfires in Cyperspace proposes that we can think of learning happening through a combination of four different environments. The Campfire is the one-way delivery of information from a respected sage. The Watering Hole refers to the informal peer discussions that happen outside of the Campfire (or classroom). The Cave refers to the time when we reflect about what we have learned. Life is, well, life—when we apply what we know in actual practice.

This model seems ideal for health professions education. We all know that our students need access to the essential foundational information found in texts and articles and at Campfires. Equally they need to be able to learn from interactions in the health care community with peers, patients, families. And throughout they need to be able to think critically about their options and choices to be able to apply their knowledge and skills in uncertain, complex clinical situations.

Innovation is at the core of the IHP Strategy Map. Innovators don’t start from scratch; rather, innovators look between the past, the present and the future and develop new ways to use familiar resources. So how can we use our current resources in designing learning experiences that will successfully prepare our students not only to perform well in their academic and clinical education, but to continue to learn and grow throughout their professional practice?

I keep coming back to Thornburg’s model. Our faculty bring expertise, knowledge and wisdom to their courses—we need to be sure that they are available for Campfires at the right time in each course.

But let’s not stop there—let’s free up the faculty to also allow them to create Watering Holes where they can share their expertise in learning activities in which students to engage actively with the material. Some obvious examples of Watering Holes are discussions, “think-pair-share” activities, role plays, debates, case analyses, and simulations.

Consider also how we can encourage our students to use Cave Time to critically reflect upon what they have learned and visualize what they can do with their knowledge and skills? At a recent symposium on teaching at Harvard, the speakers talked about “Flipping the Classroom” presenting a challenging, authentic problem to students for critical reflection. Class time then is constructed to do what used to be homework: to explore, examine, consider the problem in authentic ways (“how would you use this in the clinic?”)by interacting with other students, and with guidance from the instructor who shares his/her experience and expertise.

The transition to active learning involves doing what we are already doing—just differently. We are fortunate here to have resources as we make the transition: Instructional Designers, our Librarian; our colleagues who have taught in 2CC, in the simulation labs, in small groups and in large classes.

We are, after all, learners as well as instructors ourselves. If we practice active learning in all of Thornburg’s environments, we can bring those experiences as well as our clinical experiences, expertise, and judgment to our students.

Berret, D. (2012) How Flipping the Classroom can improve the traditional lecture.  The Chronicle of Higher Education Accessed March 7, 2012Lambert, C. (2012) Twilight of the Lecture.  Harvard Magazine  Accessed March 7, 2012
Thornburg, D. (1996) Campfires in Cyberspace. San Carlos, CA. Starsong Publications.