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Acad Med. 2004 Jan;79(1):83-8.

"The mirror" and "the village": a new method for teaching practice-based learning and improvement and systems-based practice.

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Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA.



Practice-based learning and improvement (PBLI) and systems-based practice (SBP) may be conceptually difficult for both residents and faculty. Methods for introducing these concepts are needed if PBLI and SBP are to be incorporated into education and practice.


In 2001, PBLI and SBP were introduced at Johns Hopkins Bayview Medical Center in Baltimore, Maryland, using the metaphors "the mirror" and "the village." PBLI was likened to residents' holding up a mirror to document, assess, and improve their practice. Specific tools for residents (e.g., weekly morbidity and mortality morning reports, continuity clinic chart self-audits, and resident learning portfolios) became the mirrors. SBP was introduced through specific training activities (e.g., multidisciplinary patient care rounds, nursing evaluations, and quality assessment-systems improvement exercises) using the metaphor of the village made famous by Hillary Clinton in the phrase: "It takes a village to raise a child." Residents completed a questionnaire in which they rated these initiatives' impact on their training.


The majority of residents who participated in specific activities agreed that quality assessment-systems improvement exercises (92.9%), multidisciplinary rounds (92.1%), morbidity and mortality morning reports (86.8%), clinic chart self-audits (76.4%), and nursing evaluations (52.8%) helped to improve their proficiency in specific aspects of PBLI and SBP. Residents' retrospective self-assessments of their PBLI abilities demonstrated significant improvement after the introduction of specific training activities.


PBLI and SBP can be introduced effectively in residency training by incorporating specific activities that use the metaphors of the mirror and the village.

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