#21 Pedagogy on Rounds: How Backward Design Creates Effective Teaching

October 4, 2022 | By Era Kryzhanovskaya

With Dr. Kendra Van Kirk

Listen as our esteemed guest and education guru Dr. Kendra Van Kirk (University of Miami) discusses how to utilize backward design to ensure effective learning on the wards! We cover the three stages of backward design, how to identify specific learning objectives for each learner, and how to create instructional activities and assessments to confirm learning and understanding have occurred.  

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Credits

• Producer/Writer/Cover Art/Infographic/Show Notes: Charlotte Chaiklin MD
• Hosts: Era Kryzhanovskaya MD / Molly Heublein MD / Charlotte Chaiklin MD
• Editor (written materials):  Era Kryzhanovskaya MD / Molly Heublein MD
• Editor (audio): Clair Morgan of Nodderly
• Guest:  Kendra Van Kirk MD FAAP MAT 

CME Partner: VCU Health CE

Show Segments

• Introduction/Disclaimer/Guest Biography
• Guest One-liner/Favorite piece of feedback 
• Picks of the Week
• Case #1 from Kashlak Memorial Hospital
• Backward Design
• Case #2 from Kashlak Memorial Hospital
• Take home points 
• Outro

Backward Design Pearls

1. Backward design is a three-stage framework for education that can be used to validate that learning and understanding have taken place.
2. Backward design starts with identifying specific learning objectives and then determining assessments and instructional activities that align with the prespecified learning objectives. 
3. On the wards, learners should actively participate in identifying their individual learning objective(s). 
4. Attending physicians should promote self reflection as it serves as the foundation for providing feedback and is an important aspect of learning.

Forward Design versus Backward Design

The three necessary pieces required for learning to take place include:

1. Goals and learning objectives of the lessons provide the foundation 
2. Instructional strategies or learning activities to deliver the content
3. Assessments to determine the efficacy of the teaching
   1. Assessment results can then be used to revise learning objectives and instructional strategies 

Forward Design

A way to create educational content by first identifying the instructional strategy or learning activities. From the learning activities, the teacher then develops assessments. Finally, the teacher determines the goals and learning objectives for the lesson. This format results in instructional strategies and assessments that are only loosely connected to the goals and learning objectives of the lesson. 

Pitfalls of Forward Design:

• Overall lesson can lack purpose
• The assessment tool may not measure the learning objectives 
• The learning experiences (i.e. instructional strategy) may not align with the goals or objectives of the lesson
• Difficult to determine with validity that the educational experience has led to true learning and understanding 

Backward Design

A framework described by Grant Wiggins and Jay McTighe that calls for educators to first determine the desired results (i.e. goals and learning objectives). From the identified goals and objectives the educator then designs the curriculum.  

The Three Stages of Backward Design

Stage One: identify your desired results

• What are the goals and learning objectives?
• What should students know and be able to do by the end of the lesson?

Stage Two: determine the assessments 

• What evidence will prove you have achieved your goals and learning objectives?
• What assessments will show true learning and understanding has been achieved?

Stage Three: create the learning experience and instruction  (Emory 2014).

Applying Backward Design to the Wards

Stage One: Identify the desired results aka the learning objectives 

• Learning objectives are the specific performance or behavior you expect the learner to be able to do before you consider them competent 
• On the first day on service, meet with your team
• Individually or in small groups based on training level (i.e. medical students, interns, and residents) ask about learning goals 
• From each learner’s identified goal develop specific and measurable learning objectives for the week on wards 

Stage Two: Determine the assessments 

• Utilize a variety of formal and informal assessments 

Examples include:

• Asking learners questions about a specific topic (informal assessment) 
• Performance based assessments such as an Objective Structured Clinical Examination (OSCE) with a rubric identifying specific expectations

Stage Three: The learning experiences

Examples include:

• Direct educator-led instruction such as walking the learner through a procedure 
• Chalk talk
• Modeling communication skills with a patient for the learner 

The educator must provide ongoing feedback to allow learners to correct misunderstandings and refine their skills. 

Tips for Stage One 

Start with a casual conversation with your learner(s) to develop a relationship.

• Try to remove the hierarchy in medicine.
• Ask your learner, what are your goals for the week and how can I, your coach, help you achieve those goals?

The goal and learning objective(s) for the week should be identified by the learner. 

• Create learner buy-in and self motivation 

For learners that struggle to identify a goal and learning objective(s), Dr. Van Kirk recommends utilizing one of the following to guide the learner in identifying their learning objective(s):

• The internal medicine clerkship syllabus for medical students 
• The core competencies for residents 
• The evaluation rubric that you must fill out as the attending at the end of the rotation

Dr. Van Kirk keeps track of the goal and learning objective(s) for each learner on a notecard to refer to and make notes on the learning progression. 

Learning objectives must be specific, measurable, achievable, and time-bound as they drive evaluations, outcomes, and learning activities. 

Bloom’s Taxonomy 

Benjamin Bloom described the cognitive learning domain which takes into consideration the various levels of understanding we have when it comes to education. Per Bloom’s taxonomy the lower levels of understanding include a learner’s ability to list or explain the educational material. As you move up Bloom’s taxonomy, the skill demonstrated by the learner becomes more cognitively complex. For example, higher levels of understanding include differentiating between two concepts, comparing and contrasting concepts, creating new ideas, or analyzing new material based on what was learned (Adams 2015).

In order to reach higher levels of understanding, the learner must first effectively achieve lower levels of understanding.

Case One from Kashlak Memorial Hospital

Charlotte is a new attending on the wards. During her day one discussion with her upper level resident Paul, Paul tells Charlotte that his goal for their time together is to become more confident with making clinical decisions.

Stage One: Identify the learning objective 

• Turn this broad goal into a specific, measurable, achievable, and time-bound learning objective by identifying what Paul means when he states he wants to become more confident.

Paul further specifies he wants to develop management plans independently using evidence based guidelines. 

Paul’s learning objective:

• By the end of the week, resident Paul will be able to independently develop thorough management plans utilizing evidence based guidelines. 

In order to support Paul, Charlotte as the attending must give resident Paul the space and independence necessary to create the management plans on his own.

Stage Two: Determine the assessments

Ways for attending Charlotte to assess resident Paul include:

• Observe Paul creating management plans when admitting patients 
• Informal checks utilizing questions during rounds
• Have Paul explain the management plan in terms of the evidence based guidelines that he used and how he understood them 

Must ensure the assessment tool aligns with the initial goal and learning objective(s). 

Stage Three: Instructional activities

Create learning experiences that align with Paul’s learning objective. 

Promoting self reflection and feedback 

Self reflection helps learners solidify information and is a key component to experiential learning theory.  Self reflection is also an important aspect of learner self assessment. 

Dr. Van Kirk often asks her team to pause for 1-2 minutes to reflect about how the patient encounter went after stepping outside of a patient’s room during rounds. To promote self reflection, Dr. Van Kirk recommends asking the following questions:

• How do you think that patient encounter went?
• What went well?
• What could we have done better?
• How was our communication with the patient during this encounter?
• Do you think that the patient understood our management plan for the day?

To maximize the reflection process, tailor your questions to the deficiencies observed during the encounter inside the patient room. 

Dr. Van Kirk then asks various groups of learners (i.e. medical students, interns, and residents) on her team to share their thoughts. She recommends against calling on individuals. 

Self reflection sets the stage for feedback 

After reflecting on a patient encounter, Dr. Van Kirk asks for feedback from the team. Feedback is multidirectional. Medical students can give the attending feedback. Interns can provide feedback to their co-interns. Residents can provide feedback to each other.

Dr. Van Kirk recommends using open ended questions to the team such as, “would anyone like to give feedback on how we could have improved the patient encounter?”

Pro Tips:

• Pick one or two patient encounters for self reflection and feedback.  
• Save the self reflection and feedback activity for non-admitting days or days with a lower patient census. 
• Take the focus off of the individual learner and place it onto patient care provided by the team.  
• Allow senior residents to step into the pretending role by putting them in charge of this activity on rounds. This activity allows senior residents to develop their leadership skills such as guiding reflection and feedback conversations. 

The attending must emphasize from day one that the overall goal on wards is to grow and become better as a group and as individuals in order to provide the best patient care. Without this understanding the process of self reflection and feedback cannot effectively take place. 

Case Two from Kashlak Memorial Hospital

Charlotte is on her second rotation as an attending physician. She has her day one goal setting meeting with her upper level resident Priscilla. Priscilla states she wants to improve her skills when teaching the medical students on the team. 

Stage One: Identify the learning objective

Questions to help create a more specific learning objective: 

• What exactly do you mean by teaching medical students? Are you referring to teaching pearls on rounds? Chalk talks? A brief review of an evidence based guideline?

Priscilla states she wants to provide a 5 minute chalk talk for the medical students by the end of the wards week. 

To help create the learning objective for Priscilla, follow up questions are needed and may include:

• What is the topic?
• What is the setting? 

Priscilla states she wants to cover oncologic emergencies during her 5 minute chalk talk for medical students after rounds.

Priscilla’s Learning Objective: By the end of the week, Priscilla will effectively deliver a 5 minute chalk talk about oncologic emergencies for the third year medical students on the wards team.  

Stage Two: Determine the assessments

Priscilla’s chalk talk serves as a formal performance based assessment. 

Dr. Van Kirk recommends utilizing a rubric to help assess the learning during formal performance based assessments. Rubrics should be provided to the learner prior to the assessment. 

For Priscilla’s chalk talk the rubric may provide a checklist of items the chalk talk should include such as:

• A learning objective at the beginning
• A teaching modality
• A way to assess learners’ understanding 

Stage Three: Instructional activities

Charlotte as the attending must teach Priscilla how to give a chalk talk via direct instruction (i.e. lecture based format). The direct instruction should cover the components of an effective chalk talk and possibly the various teaching modalities one can utilize during a chalk talk. 

Charlotte as the attending can model what an effective chalk talk looks like by providing a chalk talk to the team for Priscilla to observe. 

Resources for attendings 

Dr. Van Kirk recommends medical educators read Understanding by Design by Grant Wiggins and Jay McTighe to enhance their teaching skills. 

Take Home Points

• Backward design is an invaluable framework to ensure true understanding of content. 
• Do not fear backward design.
• With practice and time, backward design becomes intuitive.  

Links

1. Dr. Kendra Van Kirk’s pick of the week: Hey Bear Sensory Youtube Channel
2. Era’s pick of the week: Never Split the Difference by Chris Voss
3. Charlotte’s pick of the week: The Gift of Fear by Gavin De Becker   
4. Understanding by Design by Grant Wiggins and Jay McTighe
5. Taxonomy of Educational Objectives: The Classification of Educational Goals by Benjamin Bloom 

Goal

Listeners will explain the three stages of backward design and how to utilize backward design to develop learning objectives for each learner on a wards team. 

Learning objectives

After listening to this episode listeners will…  

1. Define the three stages of backward design.
2. Recognize how to encourage learners to identify specific learning objectives for the week. 
3. Describe how to promote self reflection and feedback during rounds. 
4. List the steps to create individualized learning objectives, educational activities, and assessments to meet those objectives for each learner on a wards team. 

Disclosures

Dr. Kendra Van Kirk reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Van Kirk K, Chaiklin C, Heublein M, Kryzhanovskaya E. “#21 Pedagogy on rounds: How backward design creates effective teaching.” The Curbsiders Teach Podcast. http://thecurbsiders.com/teach October 4, 2021.