DOUTORAMENTO
PROGRAMA DOUTORAL EM MEDICINA
THE USE OF PORTFOLIOS IN MEDICAL
EDUCATION AND THEIR APPLICATION
IN THE DEVELOPMENT OF
PROFESSIONALISM
Renato Soleiman Franco
D
ii Dissertação de candidatura ao grau de Doutor em Medicina,
A ser apresentada à Faculdade de Medicina da Universidade do Porto Programa Doutoral em Medicina
iii O presente estudo decorreu no Departamento de Educação e Simulação Médica da Faculdade de Medicina da Universidade do Porto, Portugal (até outubro de 2016) e no Departamento de Ciêncas da Saúde Púbblica e Forenses e Educação Médica (CISPFEM), a partir de outubro de 2016.
Orientação
Professora Doutora Maria Amélia Ferreira
Co-orientação
iv
Júri da Prova de Doutoramento em Medicina
Presidente
Doutor José Agostinho Marques Lopes
Professor Catedrático da Faculdade de Medicina da Universidade do Porto
Vogais
Doutora Maria Amélia Duarte Ferreira
Professora Catedrática da Faculdade de Medicina da Universidade do Porto Doutor Rui Manuel Bento de Almeida Coelho
Professor Catedrático da Faculdade de Medicina da Universidade do Porto Doutor Miguel Castelo Branco Craveiro de Souza
Professor Associado da Universidade da Beira Interior Doutor Luís Filipe Vilela Pereira de Macedo
Professor Associado Convidado da Faculdade de Medicina da Universidade do Porto Doutor Filipe Nuno Alves dos Santos Almeida
Professor Auxiliar Convidado da Faculdade de Medicina da Universidade do Porto Doutor Marco Antonio de Carvalho Filho
Professor Assistente da Universidade Estadual de Campinas da Faculdade de Ciências Médicas da UNICAMP
v
Artigo 48°, § 3° - “A Faculdade não responde pelas doutrinas expendidas na Dissertação.”
(Regulamento da Faculdade de Medicina da Universidade do Porto – Decreto de Lei n° 19337 de 29 de Janeiro de 1931)
vi
Corpo Catedrático da Faculdade de Medicina da Universidade do
Porto
Professores Catedráticos Efetivos Doutora Maria Amélia Duarte Ferreira Doutor José Agostinho Marques Lopes
Doutor Patricio Manuel Vieira Araujo Soares da Silva Doutor Alberto Manuel de Barros da Silva
Doutor José Manuel Lopes Teixeira Amarante Doutor José Henrique Dias Pinto de Barros
Doutora Maria Fátima Machado Henriques Carneiro Doutora Isabel Maria Amorim Pereira Ramos
Doutora Deolinda Maria Valente Alves Lima Teixeira Doutora Maria Dulce Cordeiro Madeira
Doutor Altamiro Manuel Rodrigues da Costa Pereira Doutor José Carlos Neves da Cunha Areias
Doutor Manuel Jesus Falcão Pestana Vasconcelos
Doutor João Francisco Montenegro Andrade Lima Bernardes Doutora Maria Leonor Martins Soares David
Doutor Rui Manuel Lopes Nunes
Doutor José Eduardo Torres Eckenroth Guimarães Doutor José Manuel Pereira Dias de Castro Lopes
Doutor António Albino Coelho Marques Abrantes Teixeira Doutor Joaquim Adelino Correia Ferreira Leite Moreira Doutora Raquel Ângela Silva Soares Lino
viii Doutor Alexandre Alberto Guerra Sousa Pinto
Doutor Álvaro Jerónimo Leal Machado de Aguiar Doutor António Augusto Lopes Vaz
Doutor António Carlos de Freitas Ribeiro Saraiva Doutor António Carvalho Almeida Coimbra
Doutor António Fernandes Oliveira Barbosa Ribeiro Braga Doutor António José Pacheco Palha
Doutor António Manuel Sampaio de Araújo Teixeira Doutor Belmiro dos Santos Patrício
Doutor Cândido Alves Hipólito Reis
Doutor Carlos Rodrigo Magalhaes Ramalhão Doutor Cassiano Pena de Abreu e Lima
Doutor Eduardo Jorge Cunha Rodrigues Pereira Doutor Fernando Tavarela Veloso
Doutor Henrique José Ferreira Gonçalves Lecour de Menezes Doutor Jorge Manuel Mergulhão Castro Tavares
Doutor José Fernando Barros Castro Correia Doutor José Luis Medina Vieira
Doutor José Manuel Costa Mesquita Guimarães Doutor Levi Eugénio Ribeiro Guerra
Doutor Luís Alberto Martins Gomes de Almeida Doutor Manuel Alberto Coimbra Sobrinho Simões Doutor Manuel António Caldeira Pais Clemente Doutor Manuel Augusto Cardoso de Oliveira Doutor Manuel Machado Rodrigues Gomes Doutor Manuel Maria Paula Barbosa
Doutora Maria da Conceição Fernandes Marques Magalhães Doutora Maria Isabel Amorim de Azevedo
Doutor Rui Manuel Almeida Mota Cardoso Doutor Serafim Correia Pinto Guimarães
Doutor Valdemar Miguel Botelho dos Santos Cardoso Doutor Walter Friedrich Alfred Osswald
ix As minhas queridas Avôs Brasília (Babá), in memoriam, e Maria José (Zezé). Aos meus Pais, Ana Regina, in memoriam, e José Roberto.
Ao meu Irmão, Rafael e Jacqueline.
A toda família Isola Ament e Giuliani dos Santos, em especial, Sonia, João, Laura e Marcelo.
A minha Esposa, amiga e parceira Camila. Ao meu filho, Matias.
x
A
/A
Quando começo a pensar para quais pessoas gostaria de agradecer nem arrisco fazer a Lista. Num movimento complexo, a quantidade de pessoas envolvidas quer seja da família, do trabalho, de estudos, do círculo pessoal, ou que não pertença a esses padrões de relação é infinita.
Tudo começa com uma conversa em um final de aula que a Camila teve com a profa. Maria Amélia Ferreira. Cerca de dois anos depois, lá estávamos nós no Porto! A iniciar os estudos do doutoramento.
Pivô e mentora de todo esse processo, agradeço a profa. Dra. Maria Amélia Ferreira, por acreditar e me dar oportunidade. Gratidão que jamais terá fim. Mas tenho muito mais a agradecer pois soube nos dar tanto norte aos estudos, quanto carinho e atenção quando o coração pedia. Figura que hoje faz parte do meu modelo e identidade enquanto profissional. Estendo os agradecimentos ao Dr. António, Nuno, D. Margarida e toda família que se fez presente em momentos difíceis para mim e para minha família.
Ao Milton Severo por emprestar um pouco da sua imensa capacidade intelectual e por nos brindar com sua amizade e conjunto com a Fernanda. Agradeço pelos conhecimentos e por me estimular a ser melhor e saber usar o SPSS!
Como já disse, tenho que agradecer a todos do Gabinete de Educação, Ana Cristina, Joselina, Sofia Gramaxo e Sonia. Todas me auxiliaram e acolheram. Souberam me receber como colega de trabalho, mais do que somente um estudante estrangeiro. Muito obrigado pela forma profissional e carinhosa que me trataram.
A toda equipa da Divisão Académica e Secretaria que soube tratar com respeito e considerando as dificuldades inerentes a um estudante estrangeiro. São todos parceiros nessa Tese.
Agradeço a Elizabete e a Isabel por me receberem no local em que comecei a desenvolver todo esse projeto. Foi no Gabinete de Apoio ao Estudante que tudo teve inicio, a primeira bancada, o primeiro computador e o primeiro ambiente de
xi trabalho fora do meu país. Fui muito bem recebido, pela Elizabete, Isabel, Tania e Madalena
A Isabel, ao , D. e Sr. que mais do que o trabalho foram apoio emocionais. Em momentos difíceis, tanto pessoais como de estudos. Querida Izabel soube me dar força e estímulo, principalmente em momentos de fraqueza.
Aos amigos que fiz no Porto e me deram suporte como o Manuel, a Suzana, o pequeno (grande) Matias.
O percurso do Brasil a Portugal foi longo e muitos amigos do Brasil estiveram envolvidos, certamente não serei justo com vários.
Ao amigo Michael, Emília, Clara e Joana família linda que me inspira desde os tempos da Faculdade.
Ao prof. Dr. Emilton agradeço pelas longas conversas onde aprendi a refletir e sempre recebo palavras de estímulo e sempre um tema novo para pensar. A prof. Dra. Marcia, hoje amiga, e sempre nossa professora. Em 2010 acreditou na ideia de estudar Educação Médica, não se falava disso na nossa Escola, mas ela aceitou, orientou a mim e a Camila e deu início a minha paixão pela pesquisa. Escrevo esses agradecimentos num dia de perda para você, mas que essas singelas palavras possam completar e ajudar a dar sentido em seu caminho. Mas nada disso aconteceria sem a família. Queria começar a agradecer meu pai, o Zé. Esses últimos anos foram intensos. Cheios de amor, conquistas, realizações, luta, batalha, saudades, carinho, afeto e discordâncias num ciclo de saúde e doença. O seu cuidado com a nossa mãezinha, frágil e forte, triste e alegre, cansada e esperançosa tornou minha ida para Portugal possível. Assim, meu pai, fizemos essa Tese em parceria, ela também é sua.
Ao meu querido irmão, Rafa, e a Jacqueline pelo carinho e segurança de ter alguém para contar mesmo que “além mar”. A minha avó, Zezé, pela orações e carinho sentidos de longe. A minha tia avó, Alzira, por torcer e orar por mim. Ao meu amigo-irmão Ramiro, Vivi e às meninas, Ana e Amanda; aprendemos e crescemos juntos amigo. Obrigado pela parceria, carinho e cuidado. Estendo os
xii suporte e companheiros. Somos famílias irmãs no coração.
Aos meus tios Paulo, Jorginho (in memoriam), Chico; às minhas tias Beth, Vania, Tida pela lembranças da infância, carinho, suporte e cuidado à nossa família. Igualmente aos meus primos, Lu, Ly, Thiago e Paula por manterem a família crescendo.
À toda família Isola Ament e Giuliani dos Santos, por me acolher e ajudar em todo esse processo. Sr. Nelson e D. Nair pelo exemplo constante de parceria, cuidado, respeito e manifestações de afeto. À Lau e ao Má, por cuidarem daqueles que tanto gostamos e se fazerem presentes. À Sonia e ao João pela força, incentivo e gratidão por ter ao meu lado a pessoa mais especial do mundo, sua filha, Camila.
Quanto à Camila, agradecer é pouco para traduzir o quanto essa Tese e meu percurso até aqui devem a ela. Nem mesmo sei como me referir a você, Camila; esposa, amiga, parceira, modelo de profissional, minha confidente, meu suporte, meu Amor... A Camila é tudo isso e muito mais. Agradeço a você por eu ser uma pessoa que busca torna-se melhor. É impossível separarmos nossas conquistas e essa é igualmente sua... nossa. Nesse percurso de perdas e ganhos substanciais tivemos nossa maior conquista, nosso pequeno Matias. A ele dedico essa Tese e uma vida que nasce em mim. Em 22/06/2017 nasci novo, diferente, nasci com outro propósito, posso dizer que sei o que significa incondicional.
Por fim agradeço a minha mãe, a vovó Ana, como gostava de ser chamada nos últimos meses. Ela me carregou no colo, deu forças, estrutura, afeto e se foi. Uma fortaleza mesmo com corpo frágil, de atitude marcante e carinho sem igual. Você, o pai e o Rafa foram gentis e cuidadosos em me proporcionar que embarcasse e me dedicasse a minha realização. Essa conquista, mãe, onde você estiver é sua.
xiii “Quem ensina aprende ao ensinar.
E quem aprende ensina ao aprender.” Paulo Freire, Pedagogia da Autonomia
xiv This thesis is based on the following publications, which are referred to in the text by their Roman numerals I-V:
I. Franco RS, Franco CAG dos S, Severo M, Ferreira MA. General competences on medical professionalism: Is it possible? Med Teach. 2015;37(10):976-977. doi:10.3109/0142159X.2015.1045853.
II. Franco RS, Franco CAG, Kusma SZ, Severo M, Ferreira MA. To participate or not to participate in unprofessional behaviour – Is that the question? Med Teach. 2017;39(2):212-219. doi:10.1080/0142159X.2017.1266316.
III. Franco RS, Franco CAG dos S, Carvalho-Filho MA, Severo M, Ferreira MA. Script Test for Vignette Discussion: An Adaptation of the Script Concordance Test to Foster Discussion on Professionalism for Undergraduates. (submitted to Teaching and Learning in Medicine)
IV. Franco RS, Franco CAG dos S, Pestana O, Severo M, Ferreira MA. The use of portfolios to foster professionalism: attributes, outcomes, and recommendations. Assess Eval High Educ. 2016;39(2):1-19. doi:10.1080/02602938.2016.1186149.
V. Franco RS, Franco CAG dos S, Carvalho-Filho MA, Severo M, Ferreira MA. Portfolio Activities and Assessments Fostering the Teaching of Professionalism and Communication Skills.(Submitted to Medical Teacher)
L
IST OFA
BBREVIATIONSABIM - American Board of Internal Medicine. BEME - Best Evidence Medical Education
CCPQC - Clinical Communication and Professionalism Questionnaire of Capability CEL - Course Evaluation and Learning
CEQ - Course Evaluation Questionnaire e-Portfolio - Electronic Portfolio
FMUP - Faculty of Medicine of University of Porto
FMUP - Faculdade de Medicina da Unversidade do Porto MERSQI - Medical Education Research Study Quality Instrument OSCE - Objective Structured Clinical Examination
PUCPR - Pontifícal Catholic University of Paraná RS - Reflection Score
RW - Reflective Writing
SAA - Self-assessment Activity SCT - Script Concordance Test
SEQAA - Self-Evaluation Questionnaire in Academic Activity SEQCA - Self-Efficacy Questionnaire in Clinical Activity STVD - Script Test for Vignette Discussion
2 CHAPTER V
Table 1. Stages of the Vignette Discussion Method Table 2. A sample of the vignette discussion
Table 3. CEQ – Course Evaluation Questionnaire in elective and curricular courses
Figure 1. General Results according the Stage Methods
CHAPTER VII
Table 1. Course Evaluation Questionnaire
Table 2. Self-Assessment Activity - Questionnaires Table 3. Students’ Achievement of Activities
Table 4. Subcategory themes of the open-ended questions Table 5. Questionnaire – Statistical Analysis
Figure 1. Content Analysis and Categories Appendix 1. ‘What did you learn in...?’
Appendix 2. ‘What did you want to learn but was not taught, and other suggestions for the…?’
Appendix 3. ‘Why did the clinical activity stimulate the development of...?’
Appendix 4. ‘Why did the academic activity stimulate the development of...?’
Appendix 5. Reflective Writing Subcategories
CHAPTER VII
Figure 1. Thesis – Framework: The Use of Portfolios in Medical Education and its Application on the Development of Professionalism
3
A
BSTRACTProfessionalism in Medicine can be defined as the capacity to serve a patient's interests above your own, with altruism, responsibility, duty, integrity and respect for others. It is strongly linked to the raising of a professional identity that involves factors such as an individual's choices, one’s personal development, and one’s relation to work.
Reflection has been found to be essential for teaching and learning Professionalism. Among the instruments that stimulate reflection, the use of a Portfolio has been highlighted. More recently, the electronic format of the Portfolio (e-Portfolio), in addition to expanding the possibilities and environments of the use of a portfolio, have both been well accepted and had a good impact on learning.
As an instrument to stimulate the development and evaluation of topics covered in Professionalism as taught to medical students in Portuguese-speaking countries, we’ve sought to validate and measure the applicability of activities that will be inserted into an e-Portfolio in this thesis. For this, we started with a systematic review of the literature on the use of the Portfolio in Professionalism. After, we carried out an investigation to explore the main flaws related to Professionalism (non-professional behaviour) and another investigation into the main competencies described in documents accepted worldwide in order to define the learning objectives of an activity that focuses on Professionalism. And, finally, we elaborated a Portfolio that was evaluated during a course dedicated to the development of Medical Professionalism.
According to a systematic review on the use of a Portfolio, it could be concluded that in teaching Medical Professionalism, while reflection constitutes and defines the Portfolio, it is also developed and stimulated by it. In addition, the Portfolio has the ability to stimulate other elements of Professionalism such as learning Ethics and Humanistic Values, among others.
4 identify themes that appear more often than others, among them: Ethics, Altruism, Humanistic Values, Responsibility and Social Commitment. However, in investigating the point of view of students in Brazil and Portugal, we noticed that lapses on these behaviours are often observed by students, both in academic and clinical environments. In addition, this observation influences the student's chances in assessing it as acceptable and further on practicing such non-professional behaviour. Thus, we elaborated a course based on vignettes that included the discussion of cases and situations in dilemma regarding Professionalism. During this course on Medical Professionalism (the course took 2 months), the students elaborated a Portfolio composed by three activities. These three activities were developed to stimulate the application of the course content in practice, the self-assessment of students behaviours and self-efficacy and the reflective or critical thinking. These three activities were named, Course Evaluation and Learning, Self-Assessment Activity and Reflective Writing. To assess these activities three questionnaires were applied (Course Evaluation and Learning Questionnaire, Efficacy Questionnaire in Clinical Activity and Self-Efficacy Questionnaire in Academic) and applied the REFLECT rubric the Content Analysis for the Reflective Writing. All questionnaires presented suitable validity. When the students described what they learned and when they did a free reflection or an analysis of their self-efficacy in practice, we were able observe the key concepts of Professionalism in the Portfolio. All the themes presented in the classes were not only described by the students, but correlated with practice served as the basis for a deeper reflective analysis. It was observed an unexpected result; the inverse association between the quality of the reflection and the students’ self-efficacy. This result could be a signal that more reflective students can be less prone to practice. If in one side it can promote a safety environment for patient, it is important to consider that students with higher reflective capacity could super estimate the awareness of a situation or underestimate their capacity to practice.
5 Portfolios and, more precisely, the proposed task model were relevant in teaching Professionalism, providing a good tool for monitoring and fostering learning, and evaluation. The application of the instrument in different contexts (3 universities in Brazil and 1 in Portugal), even with a reduced number of subjects, points to the possibility of applying these strategies in these two countries encouraging studies with larger samples and other contexts.
Keywords: medical education, skills, portfolio, evaluation, ethics, professionalism.
6 O Profissionalimo em Medicina pode ser definido como a capacidade de servir os interesses do paciente acima de seu próprio, com altruísmo, responsabilidade, dever, integridade e respeito pelos outros. Está fortemente ligado à formação identidade profissional que envolve determinantes como as escolhas do indivíduo, a sua formação pessoal e sua relação com o trabalho. A reflexão tem sido apontada como essencial para o ensino-aprendizagem do Profissionalismo. Entre os instrumentos que estimulam a reflexão o uso do Portfolio tem tido destaque. Mais recentemente, o formato eletrónico do Portfolio (e-Portfolio), além de expandir as possibilidades e ambientes de uso do Portfolio, tem sido bem aceite e tido um bom impacto na aprendizagem.
Nessa tese procuramos validar e medir a aplicabilidade das atividades a serem inseridas num e-Portfolio como instrumento para o estímulo ao desenvolvimento e avaliação de temas readicionados ao Profissionalismo em estudantes de Medicina em países de língua portuguesa. Para isso, este trabalho teve início com uma revisão sistemática da literatura sobre o uso do Portfolio em Profissionalismo. Seguidamente, foi desenvolvida uma investigação para explorar as principais falhas ligadas ao Profissionalismo (comportamento não profissional) e outra sobre quais as principais competências descritas em documentos aceites mundialmente, ambas para definir os objetivos de aprendizagem de uma atividade que tenha como foco o Profissionalismo. Finalmente, foi elaborado um Portfolio que foi avaliado durante a realização de um curso dedicado ao desenvolvimento de Profissionalismo Médico.
De acordo com a revisão sistemática sobre o uso do Portfolio, foi possível concluir que no ensino do Profissionalismo Médico, a reflexão ao mesmo tempo que constitui e define o Portfolio é desenvolvia e estimulada por ele. Além disso, o Portfolio tem a capacidade de estimular outros elementos do Profissionalismo como a aprendizagem da Ética e Valores Humanísticos entre outros.
Na análise de documentos que são referência quanto ao Profissionalismo Médico foi possível identificar temas que aparecem com maior frequência, entre
7 eles, Ética, Altruísmo, Valores Humanísticos, Responsabilidade e Compromisso Social. Entretanto, ao investigarmos os comportamentos que comprometem o Profissionalismo, de acordo com o ponto de vista de estudantes no Brasil e em Portugal notamos que esse tipo de comportamento é frequentemente observado, pelos estudantes, tanto em ambiente académico quanto clínico. Além disso, essa observação influencia na possibilidade do estudante avaliá-las como aceitáveis e praticar esses comportamentos não profissionais.
Foi elaborado um curso baseado em vinhetas que incluiu a discussão de casos e situações de dilema quanto ao Profissionalismo. Durante o curso (duração de 2 meses) os estudantes elaboraram um portfólio compostos por 3 atividades. Essas atividades foram desenvolvidas para estimular a aplicação do conteúdo do curso na prática, para a auto-avaliação de comportamentos e auto eficácia dos estudantes e o pensamento reflexivo ou crítico. Essas três atividades foram denominadas Avaliação e Aprendizagem do Curso, Atividade de Auto avaliação e Escrita Reflexiva. Para avaliar essas atividades foram desenvolvidos e aplicados três questionários (Questionário de Avaliação do Curso e Aprendizagem, Questionário de Auto-eficácia em Atividade Clínica e Questionário de Auto-eficácia em Estudos Académicos) e aplicada a rubrica REFLECT e a Análise de Conteúdo para Escrita Reflexiva. Todos os questionários apresentaram validade adequada. Tanto quando os estudantes descreviam o que aprenderam, quanto quando faziam uma reflexão livre ou uma análise da sua auto-eficácia na prática foi possível observar no e-Portfolio os conceitos chave do Profissionalismo. Assim, pode-se observar que os temas apresentados nas aulas foram não somente descritos pelos estudantes, mas correlacionados com a prática e puderam servir de base para análises reflexivas mais profundas. Todos os temas apresentados nas aulas não foram apenas descritos pelos estudantes, mas correlacionados com a prática e serviram de base para uma análise reflexiva mais profunda. Foi observado um resultado inesperado: a associação inversa entre a qualidade da reflexão e a auto eficácia dos estudantes. Esse resultado pode ser um sinal de que estudantes mais reflexivos podem ser menos dispostos a realizar exercer a prática. Se por um lado isso pode promover um ambiente de segurança para o paciente, é
8 poderiam superestimar os perigos de uma situação ou subestimar sua própria capacidade prática.
O Portfolio, mas mais precisamente, o modelo de tarefas propostas foram relevantes ao ensino do Profissionalismo, propiciaram um bom instrumento de acompanhamento da aprendizagem e avaliação. A aplicação do instrumento em diferentes contextos (3 universidade no Brasil e 1 em Portugal), mesmo que com um número de sujeitos reduzido, vislumbra a possibilidade de aplicação dessas estratégias nesses dois países. Além disso encoraja a realização de estudos em amostras maiores e noutros contextos.
Palavras-chave: educação médica, competências, Portfolio, avaliação, ética, profissionalismo.
9
O
UTLINE OF THE THESISThe present dissertation is divided into chapters, which include the different manuscripts published/submitted for publication in international peer reviewed journals.
Chapter I corresponds to the introduction section. This chapter presents the most important facts published in the last years related to the present work. It constitutes a theoretical background to support the understanding and the future discussion of the information presented in the following chapters.
Chapter II refers to the aims of this research thesis which have resulted in three publications and two papers in submission process.
Chapter III includes the paper published in an international peer reviewed journal. It describes a thematic synthesis on a definition of professionalism.
Chapter IV includes the paper published in an international peer reviewed journal. It describes, for the first time, in Brazilian and Portuguese samples, the educational environment based on a unprofessional behaviour questionnaire.
Chapter V includes a paper in submission process - Script Test for Vignette Discussion: An Adaptation of the Script Concordance Test to Foster Discussion on Professionalism for Undergraduates. This paper propose a method to stimulate the discussion in classes on Medical Professionalism. After these classes students elaborated the portfolio.
Chapter VI includes the paper, published in an international peer reviewed journal. The use of portfolio to foster professionalism was systematically reviewed and it was suggested a framework to the development of portfolio.
10 Chapter VII includes a paper (in submission process), sent to an international peer reviewed journal. It describes, in a detailed manner, the design of a portfolio comprised by three activities to foster the teaching and learning of professionalism.
Chapter VIII presents a framework with the objectives and main results of each paper.
Chapter IX presents the overall conclusions of this thesis and describes the future perspectives aiming to establish, based on the current findings, new research topics for a more comprehensive study.
Chapter X lists the bibliography accessed throughout the development of the work and thesis.
11 CONTENTS Abstract 3 Resumo 6 Chapter I Introduction 12 Chapter II Aims 17
Chapter III Results Paper I - General competences on medical professionalism: Is it possible?
19
Chapter IV Results Paper II - To participate or not to participate in unprofessional behaviour – Is that the question?
21
Chapter V Results Paper III - Script Test for Vignette Discussion: An Adaptation of the Script Concordance Test to Foster Discussion on Professionalism for Undergraduates (submitted for publication)
31
Chapter VI Results Paper IV The use of portfolios to foster professionalism: attributes, outcomes, and recommendations.
52
Chapter VII Results Paper V - Portfolio Activities and Assessments Fostering the Teaching of Professionalism and Communication Skills. (submitted for publication)
72
Chapter VIII Framework of the thesis 108
Chapter IX Overall Conclusion and Future Perspectives 110
12
CHAPTER I
Introduction
13 Professionalism teaching and the use of portfolios
Since the 1960s, teaching and learning methodologies have been applied in medical courses with the aim of improving the quality of trained professionals and the development of a doctor who meets the current needs of society, always attentive to humanity and professionalism1. Professionalism is a core competency in medical training 2,3 and has been described as one of the priorities for medical education 4. The ‘Medical Professionalism Project’ suggested the ‘physician charter’, pointing out three fundamental principles, primacy of patient welfare, patient autonomy and social justice3. It comprises attitudes such as altruism, responsibility, duty, honour, integrity and respect for others, with high standards of excellence responding to the health needs of society. Allied to this, the capacity for reflection has been incorporated into most current definitions5. Professionalism includes the excellence in practice allied with respect and patient centeredness. But more than technical excellence, medical professionalism is dedicated to promoting the fair use of knowledge, focusing on benefits for the patient and society. These concepts of medical professionalism refer to virtues and attributes that lead to challenges on how to apply them in the daily practice6. The teaching and learning of professionalism increases these challenges, namely regarding the need for a transformational change in medical education ('trained faculty, facilitative environment, and insight into how to make the cultivation of professionalism relevant') and the difficulties of medical practice in a dysfunctional healthcare environment7.
Professionalism represents the expectations of patients and the community 8.To define professionalism it is important to clarify that in a profession there are tensions regarding the privilege and autonomy of having the expert knowledge and the expectation of integrity by society. It can be understood as a ‘social contract’ that needs to be taught and discussed with the students since the beginning of medical training9. As the basis of this contract the physicians have two main roles (indivisible in the practice), the healer and the professional. The first stems since ancient times, even before Hippocrates, and is closely related with caring and compassion; the second with the responsibility towards society
14 professionalism (trustworthiness, integrity, morality and others)9. These roles overlap, and it is possible to find social expectations in both. Thus, it is expected that society requires from doctors these high stakes in moral values, since the profession has been historically placed as a prominent position socially and economically.
In this way, professionalism is ‘an ideal to be pursued’10 (in contrast to rules to be followed) that must drive the physicians’ identity11. The identity can be understood as result of ‘internalised reflections’ shaped by the subject, significant people, context and the outside word12. This process of socialization involving mechanisms of acceptance, compromise and rejection with the group will have a profound influence in the professional that the student will become13. Previous experiences, role models, encounters with the patients, social expectations, formal curricula, hidden curricula and social expectations were common themes related to professional identity formation14. The student started with a peripheral participation and gradually increased their contribution and involvement in a community of practice and social interactions. The reflection and personal values are crucial in this process, contributing to the way social interactions are recognized and internalized and how they model the development of the professional identity13.
In the process of identity formation and construction of their own concepts, students often tend to reduce their conscientiousness on the judgment of unprofessional behaviour.15,16 Behaviours previously regarded as unprofessional can now be trivialized and even acquired by students during the course. This is a complex problem involving different perspectives and causes. For example, students experiencing high rates of burnout tended to have more participation in unprofessional behaviours17; it calls attention to what could be behind this unprofessional behaviours (resilience, workload, self-awareness, socialization process and others), including the high rates of student mistreatment18. Although, despite moral judgement on its causes and origins, the impact of these unprofessional behaviours to the medical students is obvious. Considering the
15 important of socialization, as described above, the unprofessional behaviours demonstrated in a group of students or in institutions reveal a lack of professionalism and should provide important information for medical educators.19
In this context of observation and participation of unprofessional behaviour and the development of the professional identity, reflection has an important role. The medical students’ in the last years of medical training recognize the importance of reflection more than in the initial years of the medical school20. It can show that the across medical training the reflection increases in importance and necessity for the practice. Although, the reflection tended to be neglected by the medical curricula21. In the development of professionalism, reflection promotes a ‘step back’ culture focused on analysing and critically assessing a situation or experience22. It is mandatory since the right thing to do, mainly in dilemmas involving professionalism, usually requires critical thinking and a deep understanding of the problems. A systematic review on the definition of reflection for medical education considered reflection as a process regarding thoughts and actions with proposals for changes 23. Reflection required metacognition (to think about the process of thinking)24, including the description of conflict or a disorienting dilemma, attending to emotions, and the analysis and meaning-making of a an external situation or of itself 25.
The Portfolio is an instrument applied in competence-based education26–28 and seems to improve reflection, although there are few high-quality evidences in this field, mostly when the assessment of reflection is considered29. The term Portfolio is broad and its use can differ in purpose, components and processes30. A definition that contemplates most of the scenarios in which it’s used refers to the Portfolio as a collection of evidences stored and presented for a specific purpose31. In Portfolios for learning purposes, reflection has been highlighted as an essential element to characterize the material as a Portfolio32. The description of the students activities (or cases), learning diaries, collection of assessments without ‘intellectual processing’ should not be considered as a learning portfolio29. Thus, the term Portfolio applied in this thesis is more connected to the definition of learning portfolios, having a broad consideration of the material inserted but
16 electronic or paper format. However, the electronic format seems to be better accepted by students and does not cause any impairment to the content and possibility of reflection.33
The importance of reflection and professionalism is undeniable, although there is no consensus on the best method to teach professionalism in medicine34. Among the forms for the teaching and learning professionalism the most cited strategies include: vignette discussions, mentoring, workplace learning, feedback, case discussions (involving ethical issues), role models and activities that stimulate personal reflections 34. Reflective learning involves the process of thinking that goes beyond the ‘what’ and highlights a wide meaning including the ‘how’ and ‘why’35,36. Vignette discussions stimulating a social interaction in a group can promote a deep understanding and reflection on medical dilemmas, promoting the learning of professionalism values37. Most of the teaching strategies on professionalism by means of workplace feedback, role models and mentoring involve a longitudinal and workplace-based approach. Cases and vignette discussions seem to be good approaches for the classes.
The portfolio allied with vignette discussions as a strategy for teaching professionalism could be reasonable to foster the students’ reflections and the learning of professionalism, but there is little data published in this field. Thus, the portfolio and its design to promote teaching and learning of professionalism must be studied in all facets to optimize its use.
17
CHAPTER II
Aims
18
Aims
This research thesis aimed to analyse the applicability of an electronic portfolio in a course for teaching medical professionalism. To achieve that, we have addressed four general objectives in which specific questions were studied:
This thesis aimed to analyse the applicability of an electronic portfolio in a course for teaching medical professionalism. To achieve that, we have addressed four general objectives in which specific questions were studied:
a) The definition of teaching strategies (a course) to foster the development of medical professionalism
a.1. Is it possible to use find a common definition on professionalism to design teaching strategies in this field (Defining Medical Professionalism - Paper I)?
a.2. Why to develop strategies to promote the learning of professionalism? (Understanding the educational environment in the medical training - Paper II)
a.3. How to organize a course to foster the teaching of medical professionalism? (Structuring a course for teaching Medical Professionalism – Paper III)
b) The elaboration of portfolio activities to foster the teaching of Professionalism and validate instruments that may assist in the assessment of Portfolio activities. b.1 What are the characteristics, benefits and risks in the use of portfolios to teach and learning professionalism? (Analysing the role of the portfolio to teaching and learning Medical Professionalism - Paper IV)
b.2. What kind of portfolio activities could foster the teaching and learning of professionalism? (Paper V)
b.3 How to assess the teaching and learning of professionalism in a portfolio? What are the outcome of these portfolios activities? (Paper V)
19
CHAPTER III
Results – Paper I - General competences on medical
professionalism: Is it possible?
21
CHAPTER IV
Results – Paper II - To participate or not to participate
in unprofessional behaviour – Is that the question?
31
CHAPTER V
Results – Paper III. An Adaptation of the Script
Concordance Test to Foster Discussion on
Professionalism for Undergraduates (Submitted for
publication to Teaching and Learning in Medicine)
Authors: Renato Soleiman Franco, Camila Ament Giuliani dos Santos Franco, Milton Severo, Marco Antonio de Carvalho Filho, Maria Amélia Ferreira
32 Problem: Teaching medical professionalism should include strategies to foster the reflective thinking of medical students. The critical appraisal of real clinical situations is crucial to consolidate the professionalism of young doctors. Vignette discussions represent an opportunity to bring real professional dilemmas to a pedagogical session. However, we still do not know the best way to promote and stimulate structured discussions in classes when using vignettes.
Intervention: A method for vignette discussions based on the Script Concordance Test (SCT), was developed and implemented in four medical schools (three in Brazil; one in Portugal) for elective and curricular courses. The vignette discussions had five stages: 1) preparation of the environment, 2) conceptual question, 3) presentation of the vignette and first judgment, 4) changing perspectives and second judgment 5) discussion and conclusion.
Context: we enrolled third and fourth-year medical students to participated in pedagogical activities targeting professionalism topics, always stimulating reflection on the process of decision-making. Outcomes: The course was highly rated in the elective (4.48 from 1 to 5) and curricular (4.8 from 1 to 5) category. Students’ judgments concerning the best option were fairly distributed, for instance, 53% of the participants deemed a certain behaviour as unprofessional, whereas 47% considered it to be professional. The same distribution occurred in the discussion’s other stages. It was found that the concept of professionalism drove the vignette’s judgment. All students asserted that the method was reflective and promoted discussion.
Lessons learned: The vignette discussion method promoted participation and seems to be enjoyable for students. Employing this method and its strategies allowed professors to know students’ previous knowledge (conceptual question) and stimulate debate and analysis collaboratively (complex concepts). The decision-making process was discussed with students once their conception concerning professionalism drove their judgement. For some students, it was an “insight,” demonstrating that they needed to think extensively to take better decisions regarding professionalism. Conclusion: The Script Test for Vignette Discussion (STVD) seems to be adequate; it needs to be disseminated and applied in other institutions to test its usability.
33 PROBLEM
Medical educators strive to guide students in their highway towards good professional behaviour. Several obstacles prevent a straightforward professional development. Several researchers unrevealed how the formal and informal curricula contribute to erode students’ humanism and professionalism. The hierarchical culture of the medical profession prevents medical students to engage in meaningful conversations to explore the reasoning process behind solving professional dilemmas. Moreover, medical students often testify unprofessional behaviour without the opportunity to reflect on these negative experiences. Reflection can foster critical thinking and internalisation of values, experiences, learning [6]. Moreover, it is crucial to critically analyse physicians own behaviour and clinical practice [7]. Considering the aforementioned points, reflection could result in students facing hardships in medical practice. Vignette discussions, mentoring, workplace learning, feedback, case discussions (involving ethical issues), role models, and activities that stimulate personal consideration have been employed to teach and learn medical professionalism [8]. Vignette discussions seem to promote reflection and support the teaching of professionalism [9–11]. However, there is a little information concerning the elucidation and process of discussion pertaining to vignettes [2]. Hence, development and structured learning of vignette discussions would be substantive for medical training and would contribute to the development of professionalism in medical practice.
The Clinical Script Concordance Test (SCT) [12,13] and, more specifically, its adjustment for ethical dilemmas [14] involves the presentation of a vignette, followed by a first and second judgment. With regard to the second judgment, it provides a new set of data that can contextualise the information acquired from the first judgment [15]. Since 2000, the application of this scheme to assess clinical reasoning has presented constructive results in urology [16], neurosurgery [17], paediatrics [18], gynaecology [19], otorhinolaryngology [20], and other clinical fields [21,22]. This test has been used for written examinations and to find consensus among experts [23]. The SCT method has been applied during undergraduate and postgraduate training to foster reflection and evaluate clinical reasoning [24]. However, such papers tend to evaluate the SCT’s
34 the relevant discussions. Vignette discussions have been employed in the field of medical education to stimulate discussions on topics concerning professionalism and social interactions among students [11]. It demonstrates that vignette discussions could promote more than metacognitive learning (one of the cores of reflection [25]), and it could also provide a socially interactive environment that nurtures professionalism. Furthermore, it could lead students to practice reflection and active listening as a part of experiential learning.
Thus, vignettes were designed and a discussion method was developed, based on the structure of the SCT. In our study, we want to analyse whether this method and the vignettes could promote students discussions, including their motivation to discuss and reflect on matters pertaining to professionalism.
35 INTERVENTION
To foster the use of vignettes for promoting reflection and learning topics concerning professionalism, a five-stage method for vignette discussions was developed, which we called the Script Test for Vignette Discussion (STVD) that includes the following: 1) preparation of the teaching and learning environment; 2) conceptual question; 3) presentation of the vignette and students’ first judgement; 4) changing perspectives and second judgment; 5) discussion and conclusion. The last three stages were adopted from the Script Concordance Test (SCT) (Table 1).
Insert Table 1: Stages of the Vignette Discussion Method.
2.1 Stage 1: Preparation of the environment
The environment needs to be safe and should foster discussion. Thus, we opted for small groups with trained teachers. Students must feel free to discuss and present their perspectives.
2.2 Stage 2: Conceptual Question – Knowing students’ concepts
The first question presented to students is a conceptual one that could exert an influence on their decision-making process or express their point of view and knowledge pertaining to a particular theme. It employs questions that prompt brief responses. The participants used a web-based platform to provide their answers, which allowed us to automatically create an online word cloud. In that word cloud, the most frequently used words are depicted in larger letters.
2.3 Stage 3: Presentation of the vignette and first judgment
These vignettes were structured to focus the students’ attention on the more obvious solutions of a problem or on judging the situation. We believe that it is essential that students do not discuss their opinions with one another at this point. It must be an introspective and self-reflective moment. The participants were informed that there are no right or wrong responses. The web-based platform was employed in this stage (two minutes to read and three minutes to vote).
36 2.4 Stage 4: Changing perspectives and second judgment
After the first question is placed (Stage 2), the teacher presents a second one, changing the perspective of the judgment and delving deeper in the reflection, in order to promote a more profound analysis of the vignette. No discussion took place at this stage, as well. This stage also used the web-based platform, in which the participants selected the option that better suits their judgement.
2.5 Stage 5: Discussion and conclusion
We started the discussion by valorising the students’ opinions and opening the discussion without ascertaining right or wrong perspectives, by stating the following: “This is a tough decision” or “It is probably difficult for you to decide what to do in this situation. But, it is difficult for me too, even though I have been practising medicine for years.” Students were informed that during the discussion, they could assume the viewpoint that they selected previously, a contrasting perspective, or even both. They were advised that the most important aspect was to discuss and reflect. Following a quick discussion (five minutes), the results for the answers of the first and second questions (Stages 2 and 3) were presented, and the discussion was continued. After 30 minutes of discussion, the conclusion was drawn together with the students. Moreover, if necessary, the teacher elucidated certain definitions or theoretical references. The aim of the discussions was to go beyond the themes that emerged from the vignettes. Furthermore, the teachers' contributions to the discussions should clarify all aspects of the students' reasoning, showing that the assumptions made by the students could lead to their respective decisions (decision-making process). The Table 2 presents a sample vignette discussion.
37 CONTEXT AND PARTICIPANTS
This intervention pertaining to vignette discussions was applied in a course on medical professionalism designed for third- and fourth-year undergraduate students in Portugal and Brazil. The undergraduate medical courses in Brazil and Portugal have a duration of six years; the last two years of the courses, primarily in Brazil, are called internships that have high workload in work-based settings [26,27]. The authors of this research applied this method initially in one elective course of three Brazilian and one Portuguese university (in groups with 7–14 participants among a total of 69 students) in between 2015 and 2016. Since 2016, it has been applied to a curricular course in a Brazilian university that also participated in the elective course. The results presented the assessment of the curricular course of 2017. The elective course was 16 hours long with four sessions, whereas the curricular course was six hours long (four encounters that were one and half hour long). The discussions were supported by a web-based software for smartphones and computers, which was used during classes to record and calculate the frequencies of the answers in time.
The learning objectives of the course were as follows: 1) promote students reflection, 2) stimulate discussions between students, 3) provide an understanding of patients’ autonomy considering their well-being as a core concept; 4) provide an understanding of medical errors, pondering the relevant consequences for patients and the possibility of failing that is inherent to humans; 5) provide an understanding of the impact of medical behaviour on social justice. For these learning objectives, three vignettes were present: patient autonomy and well-being; medical error and social justice. This paper addressed the discussions and outcomes of the first vignette (patient autonomy and well-being). The other vignettes and discussions followed the same scheme. In this paper, the following will be presented: 1) a case report and 2) evaluation of the teaching strategy. The data on course evaluation were obtained using a web-based questionnaire in which students, without identification, evaluated the course and reflected on what they learnt from the course. The data on the vignettes discussion were collected during the classes, taking the answers to each vignette’s questions into
38 Social Sciences (SPSS Version 24).
OUTCOMES
There were 158 subjects in this study, 89 from the curricular course (University 2), and 69 from the elective course (University 1 (20); University 2 (12); University 3 (31) and University 4 (7); from University 4 only 6 (six) students responded to the questionnaires and activities), with a mean age of 23.5 (SD 2.495). In the curricular course, 100% of the participants were fourth-year medical students (60% female), whereas for the elective course, 70% were fourth-year medical students (30% were third-year students), out of which 80% of the students were female.
The course evaluation was conducted using the Course Evaluation Questionnaire (CEQ) that includes questions on teaching methods, teachers’ competence, and content alignment with course purpose (Table 3). A general grade was also assigned (ranging from very bad to excellent: 1 to 5; Table 3). Participants were also questioned regarding the kind of method employed in the class, and 100% of the students pointed out that the method was reflective.
With respect to the preparation of the environment, one of the questions regarding the evaluation of the course was concerned with the sense of well-being (elective: 4.48, curricular: 4.8, as mentioned in Table 3). The participants also presented their opinion pertaining to the suitability of the method (elective: 4.07 and curricular: 4.82, as noted in Table 3).
The objective of this analysis was to measure whether the vignette promoted discussion (diverse opinions). For instance, in the case of vignette 1, presented in the first judgment (is this behaviour professional or unprofessional?), there were 134 votes (59: elective; 75: curricular); in the elective, 44.1% judged it to be unprofessional, whereas in the curricular course, 52% deemed it to be so (Pearson chi-square 0.362). Considering that there are no differences between the elective and curricular courses, the results have been presented with a general mean in Figure 1.
39 For the vignette 1, in the second judgment (what I would want to be done if it happened to me as a patient?), three options were given to the students. There were 117 votes (40: elective; 77; curricular); the total frequency of the answers for each one of the three questions were 44.4%, 2.6%, and 53.0%, without considering the differences between the elective and curricular courses – Pearson Chi-square 0.891.
Regardless of the students first judgement (professional or unprofessional), the frequencies of the second judgement (changing perspective) were not different. The frequency for who judged it to be professional in the first question was 43.1%; it was 2% and 54.9% in each option of the second judgment. Moreover, voting for the option unprofessional in the first one was 43.3%, 2.7%, and 54.1%. Thus, irrespective of whether the students judged the behaviour as professional or unprofessional, when we changed the point of view to “as a patient,” there was no correlation with the first choice.
Furthermore, we also asked for the students, before starting the vignettes discussion the following question: what is the word that better represents medical professionalism for you? There are four words corresponding to 61.5% of the total frequency of the words (there were 24 different words). These four words were as follows: we grouped competency and ethics (a more “technical concept”) and empathy and respectfulness (a more driven” definition of professionalism). The judgment of the “value-driven” definition for vignette 1 was different from that of the “technical concept.” The “value-driven” one was judged as unprofessional in 61.5%, whereas it was 41.9% for the more “technical concept,” with Pearson Chi-square valued at 0.049.
Insert Table 3: CEQ – Course Evaluation Questionnaire in elective and curricular courses
40 Preparatory courses focused on reflection, professional development, and communication should help the students to deal with the situations they face during their internship [28]. It is a pre-internship course. Professors emphasise on the importance of professionalism throughout the students’ medical training, but the internship presents students a certain sense of autonomy and strongly impacts their attitudes toward patients. It is essential to building a safe discussion setting; students need to feel comfortable and safe discussing dilemmas and sharing ideas and values. These teaching sessions are crucial for creating a culture different from that of subordination and humiliation, which students can receive in medical training, primarily in clinical settings [29].
The STVD method fosters reflective thinking and comprehensive discussion among students. In this research, the teacher tried to interfere minimally in the discussion, assuming the role of a mediator. The ground theory involved constructivism; understanding the process of acquisition of new knowledge is always based and built in connection to previous knowledge [30]. The high rate of the course assessment, considering different contexts (curricular courses, elective courses, and different universities), and the highly close frequency of the judgements can infer the fostering of reflection.
A well-designed vignette and the applied discussion method promote a higher level of discussion, starting with expressing disagreement concerning the answers. For instance, the judgment for the first vignette as unprofessional or professional is very close to both types of courses (elective and curricular). It also happened in the second judgment in which the options were somewhat distributed with respect to option 1 and 3. Medical practice is full of situations where it is important to decide. At times, extremely quick decisions need to be taken, in situations where the right thing to do is not so clear. It leads us to the role of uncertainty in medical training. Stimulating debates on uncertain and ambiguous situations should be one of the cores of medical humanities [31].
41 In a report concerning empathy, David Jeffrey (2016) argues in favour of multidimensionality and presents a broad definition of empathy considering the affective, cognitive, behavioural, and moral dimensions [32]. Empathy involves different dimensions, which influence the decision-making process. The absence of an association in the first and second judgement (changing the perspective) showed us that students did not tend to select decisions for their patients. If on one hand they can adapt to choose the patient’s needs, on the other hand they could be in a distant position, choosing for the patient what they did not deserve for themselves. Probably, both the reasons exist, and there should be other explanations in this regard. But, the most important point is to clarify these aspects for students. It allows us to discuss topics regarding empathy, compassion, and sympathy towards patients and its influence on medical decisions. Thus, depending on the doctor or the situation, the decision can be more affective, cognitive, behavioural, or moral and even be a mix of all.
The judgment of the situation as professional seems to be associated with the words that better represent professionalism for students. Students who pointed out words closest to more value-driven professionals tended to judge the situation as unprofessional. This can show us that values could drive students to more conscientiousness concerning patient needs than the technically driven students. The other inference in this regard is that if the reasoning was guided by values or technical perspectives, students could have different initial judgments. Values could be one of the most important drives for handling uncertain situations [33]. Role models and instructions could affect the way students deal with competing evidence and uncertainty. Trained teachers and decision-making training is important in medical education [34]. The vignette and the discussion method provided information to discuss with students not only their decision but also what drove them, highlighting the process of thinking. However, further studies need to be conducted primarily to achieve the impact of these strategies on competence and students’ behaviour. The students were third- and fourth-year undergraduate years (pursuing six-year courses), and we are planning to follow up with them until the completion of their medical course.
42 The participating students felt comfortable and evaluated the course with high scores, irrespective of whether they were pursuing the elective or curricular course. The most important point is to inspire a critical perspective, trying to consider a problem from a multifaceted viewpoint that allows students to be aware of the risks and benefits in their choices. The STVD method seems to be a suitable teaching strategy that fosters discussion, primarily by addressing ambiguity and uncertainty. All the stages of the vignette judgment promoted contentious opportunities for discussion and reflection. Thus, we recommend this method for teaching and learning professionalism, particularly for a small group of students.
43 LIMITATIONS
This study proposed a suitable method for vignette discussions and evaluated them. The evaluation considered the students’ point of view regarding the quality of the course/method. Their responses to the questions on the vignettes were used to evaluate the promotion of discussion and the students reasoning in the decision-making process. The samples from the elective course were heterogeneous, and few participants were present from each university, as compared to the curricular course. Owing to this fact, we have not focused on the differences between the elective and curricular courses. The participants’ point of view can be considered to be mandatory for certain aspects of the learning environment, such as satisfaction and the feeling of learning. However, the content learnt needs to be assessed systematically and reliably. To confirm this strategy to be an effective teaching method, it is necessary that it is applied to other universities and by other teachers. The content learnt was assessed through portfolios (data not shown), and another research should be conducted to measure the quality of the portfolio assessment methods and the content learnt. However, partial data suggest that the students met the expectations, according to the learning objectives of the course. The use of this strategy in different contexts indicates that it can be applied in various settings, although we do not have data pertaining to the replicability of this method by other teachers and groups.
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