May 232018

Jon-Emile S Kenny MD [@heart_lung]

"What is memory but a story about how we have lived?"

-Mark Doty

During the recent ‘Hospitalist and the Resuscitationist’ conference in Montreal, there were discussions around the hemodynamics of prone positioning as well as using venous Doppler as a hemodynamic metric.  Much of this discussion was generated and driven by Dr. Andre Denault; he has been using portal venous Doppler to monitor right heart function post-cardiac surgery with very provocative findings.

As a follow up to my lectures and this discussion, I have created three new learning modules which can be accessed here; these new modules are numbers 8, 9 & 10.  The genesis and pedagogical foundations of these modules are lightly detailed below.

Theoretical Underpinning of the Learning Modules

A year ago, I defended my thesis in Medical Pedagogy.  I created and implemented a model of on-line learning which seeks to improve analogical transfer of biomedical knowledge to clinical practice [1].  The foundation of this model, ultimately, was Biggs’ notion of ‘constructive alignment’ [2].  In this paradigm, teaching and learning must focus on what the student does, rather than what the teacher does.  Further, there must be a clear thread that ties together desired learning outcomes, learning activities and assessment.


Outcomes in medical education are somewhat of a contentious subject [3], but the model that I adopted was that of Harden’s ‘3 Circle’ model [4].  This model posits that there are 3 types of outcomes nestled within one another with the innermost being, essentially, behaviouralistic or practical – the clinician ‘doing the right thing.’  Next, the middle ring is somewhat more theoretical and includes biomedical knowledge and the clinician ‘doing the thing right.’  The outermost ring is somewhat more ‘messy’ and includes the clinician understanding his or her role in the broader health care system, creating new knowledge and focusing on personal development and life-long learning [5].  This outer ring is exemplified by the German or Scandinavian concept of Bildung [6].  Thus, it is an over-arching goal of these modules to link each of these circles together in the prescribed learning activities.

Learning Activities

The learning activities are designed to merge the theoretical, cognitive models of physiology – as typified by the general idea of the ‘knowledge object’ [7] [e.g. Guyton Diagram] – to both bedside practice and life-long learning.  In other words, the learning activities are meant to mesh the ‘3 circles’ – described above – together.  Ostensibly, blurring these outcome borders will lead to the fully capable [rather than competent] clinician, as described by Fraser [8].  The capable clinician is fluid, dynamic and readily adapts his or her theoretical and clinical acumen across a broad range of shifting clinical contexts.  The learning activities seek to dissolve clear distinctions between biomedical knowledge and clinical reasoning [i.e. the ‘two world' hypothesis] into fully 'encapsulated knowledge' [1, 9]; they do so by encouraging the learner to actively apply theoretical knowledge objects [e.g. physiology diagrams] to clinical decision-making and prediction.

Additionally, the learning activities are based upon social-constructivist principles – especially the ‘knowledge creation’ metaphor [10-12].  This metaphor posits that learning requires deep cognitive manipulation [13] of new material, not alone [i.e. in monologue], not in discussion with others [i.e. in dialogue] but in the act of creating new artifacts and practices with others [i.e. the ‘trialogue'] [11].  Thus, the learning activities implore the learner to make new knowledge with a learning partner [14].  Using others will help each learner continuously ‘move’ his or her knowledge and application of physiology and, simultaneously, prevent the learner from ‘holding’ that knowledge as  static information [15, 16]; malleable knowledge will help transition across contexts.


With on-line learning, in general, classical assessment such as an examination or individual, formative assessments is simply not practical.  It is the goal of these modules to motivate self-assessment and peer assessment.  The health care professional must incorporate such strategies into his or her approach to life-long learning [5, 17].  Working with one’s peers also generates a ‘self-reference’ effect and helps the learner map his or her actual outcomes with the ideal [18]; thus, the learning activities always include tasks that drive reflection upon the intended learning outcomes [1920].  Additionally, peer dialogue allows students to teach each other freshly-learned material in a manner more attuned to each other’s needs; it exposes students to different perspectives and alternative strategies; lastly, critique from peers may be easier to tolerate than from tutors [18].   In effect, learning partners and groups can become self-managed learning teams [21].  Accordingly, it becomes the responsibility of the learners to compare their achieved outcomes with the desired outcomes and adjust appropriately, as needed.  Ultimately, this fulfills the outer ring of the ‘3 Circle’ model described above and shapes the fully capable clinician; one who is dedicated to life-long learning.



Dr. Kenny is the cofounder and Chief Medical Officer of Flosonics Medical; he is also the creator and author of a free hemodynamic curriculum at


  1. Laksov, K.B., K. Lonka, and A. Josephson, How do medical teachers address the problem of transfer? Advances in Health Sciences Education, 2008. 13(3): p. 345-360.
  2. Biggs, J., What the student does: teaching for enhanced learning. Higher education research & development, 1999. 18(1): p. 57-75.
  3. Hodges, B.D., A tea-steeping or i-Doc model for medical education? Academic Medicine, 2010. 85(9): p. S34-S44.
  4. Harden, R.M., AMEE Guide No. 14: Outcome-based education: Part 1-An introduction to outcome-based education. Medical teacher, 1999. 21(1): p. 7-14.
  5. Silén, C. and L. Uhlin, Self-directed learning–a learning issue for students and faculty! Teaching in Higher Education, 2008. 13(4): p. 461-475.
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  7. Entwistle, N. and D. Entwistle, Preparing for examinations: The interplay of memorising and understanding, and the development of knowledge objects. Higher Education Research and Development, 2003. 22(1): p. 19-41.
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  9. Norman, G., et al., The power of the plural: effect of conceptual analogies on successful transfer. Academic Medicine, 2007. 82(10): p. S16-S18.
  10. Illing, J., Thinking about research: frameworks, ethics and scholarship. Understanding medical education: evidence, theory and practice, 2010: p. 283-300.
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  14. Dahlgren, L.O., et al., To be and to have a critical friend in medical teaching. Medical Education, 2006. 40(1): p. 72-78.
  15. Fyrenius, A., S. Wirell, and C. Silén, Student approaches to achieving understanding—approaches to learning revisited. Studies in Higher Education, 2007. 32(2): p. 149-165.
  16. Fyrenius, A., C. Silén, and S. Wirell, Students’ conceptions of underlying principles in medical physiology: an interview study of medical students’ understanding in a PBL curriculum. Advances in Physiology Education, 2007. 31(4): p. 364-369.
  17. Fredholm, A., et al., Autonomy as both challenge and development in clinical education. Learning, Culture and Social Interaction, 2014.
  18. Nicol, D.J. and D. Macfarlane‐Dick, Formative assessment and self‐regulated learning: A model and seven principles of good feedback practice. Studies in Higher Education, 2006. 31(2): p. 199-218.
  19. Mann, K., J. Gordon, and A. MacLeod, Reflection and reflective practice in health professions education: a systematic review. Advances in Health Sciences Education, 2009. 14(4): p. 595.
  20. Butler, D.L. and P.H. Winne, Feedback and self-regulated learning: A theoretical synthesis. Review of educational research, 1995. 65(3): p. 245-281.
  21. Parmelee, D.X. and L.K. Michaelsen, Twelve tips for doing effective Team-Based Learning (TBL). Medical teacher, 2010. 32(2): p. 118-122.





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A Free On-Line Hemodynamic Curriculum Grows