an approach to meningitis for the internist and family practitioner

Resident as Teacher:Teaching in the Clinical Setting

Resident-As-Teacher Interest GroupThe Academy at Harvard Medical School

AgendaAgenda

• Residents as Teachers• Adult Learning Theory• Knowing your learners• Setting expectations• Showing respect and enthusiasm• Thinking out loud• Giving specific, prompt feedback

• Ask about prior education and background• Become familiar with learner’s goals and objectives• Give learner clear expectations

• Introduce yourself and share your love of medicine• Use first names and introduce learner to others• Be kind when pimping

• Include learner in your thought process• Probe learners to ensure they follow your reasoning• Allow learner opportunity to ask clarifying questions

Some Basic Principles

Know your learners

Be respectful and

enthusiastic

Think out loud

• Choose right setting/timing for feedback• Provide positive and constructive SPECIFIC feedback• Solicit and formally deliver feedback at end of encounter

Give specific real-time feedback

Residents As TeachersResidents As Teachers

• LCME mandate• ACGME mandate• Residents spend up to 25% of time teaching (Busari JO,

2002)• Medical students attribute one-third of their knowledge to

teaching from residents (Bing-You RG, 1992)


• Qualities of excellent clinical teachers (Wright, NEJM 1998)

– Spend more than 25% of time teaching (especially beyond assigned responsibilities)

– Stress doctor-patient relationship– Stress psychosocial aspects of medicine– Give more in-depth, specific feedback to learners– Get to know trainees on personal level


• Qualities of excellent clinical teachers– Prepared, perform needs assessment– Know cases ahead of time– Preplanned curriculum mixed with improvisation– Assess resident’s knowledge while diagnosing patient– Limited teaching points

Adult Learning TheoryAdult Learning Theory

• Adult learners bring life experiences and extensive knowledge to any situation

– Learning happens when new information is linked to prior knowledge and experience

– Knowledge is constructed, not received• For adults, learning is most meaningful when actively

engaged in solving problems– Learn by answering clarifying questions– “What data or examples support that point of view?”

Know your learnersKnow your learners

• Scenario: You are a night float working with a clerkship student. During an admission for a new diagnosis of likely MS, you give him an overview of the clinical features and diagnostic workup. You find out later he has published on the genetics of MS. How could you approach this scenario differently?

a) Ask briefly if he is familiar with MS and gauge his level of knowledge by asking probing questions

b) When first introducing yourself to the resident, ask him about his background knowledge in neurology

c) Once you learn of his research, stop trying to teach himd) Ask him how his research informs the case, while explaining

your thought process


• Ask about learner’s background and prior experience– Educational background– Prior clinical experience– Career plans– Learner’s goals for educational encounter

• Become familiar with learner’s other responsibilities outside of your setting

– Central medical school obligations– Continuity clinic– Clerkship specific didactics and clinics


• Year I (Aug – May)– Introduction to the

profession– Basic science courses– Patient Doctor I– Epidemiology– Ethics– Social medicine

• Year II (Aug – Apr)– Human systems– Pharmacology– Health care policy– Patient Doctor II– USMLE Step 1


• Year III (May – Apr)– Principal Clinical

Experience (PCE)– Clerkships– Patient Doctor III– Primary Care Clinic

• Year IV (May – Jun)– Required subinternships– Required clinical

electives– Other electives– Residency interviews– USMLE Step 2


• Who is an HMS Third Year?– Traditional Student– MD/PHD Student– HST student– Oral Surgery Resident– Visiting (foreign) students– Advanced students– Observers

• Third year rotations for most students begin in late April


• Required Third Year (Core) Clerkships– Medicine – 12 weeks– Surgery – 12 weeks– OB/GYN – 6 weeks– Pediatrics – 6 weeks– Radiology – 4 weeks– Psychiatry – 4 weeks– Neurology – 4 weeks


• Principle Clinical Experience (PCE)– Student completes all clerkships at one hospital– Provides structure and community for students– Weekly student-run case conferences (afternoon)

• Primary Care Clinic (PCC)– Weekly continuity clinic (Tue or Thu afternoon approx 1-5P)– Some are off site and require travel time

Students need to be released without guilt for their central PCE and PCC responsibilities

Set clear expectationsSet clear expectations

• Educational compact between learner and teacher• Become familiar with clerkship goals and objectives

– Understand clerkship curriculum– Become familiar with call schedule– Clarify level of responsibility for students

• Explicitly state your expectations of learner– Team schedule– Number of admissions– Protocol for assigning and role during procedures– Documentation responsibilities– Patient care responsibilities

Be respectful and enthusiasticBe respectful and enthusiastic

• Scenario: Three new medical students arrive to morning rounds in the conference room during the middle of a new case presentation. The senior resident should:

a) Ignore them and hope they go awayb) Interrupt the junior presentation to have a group hug with the

studentsc) Pause for brief introductions and then resume case

presentation, with a more complete orientation to team after rounds

d) Acknowledge the students and suggest that the junior complete the presentation before formal introductions and orientation to the team


• Respect– Introduce yourself and your background– Learn and use first names– Introduce learners to other providers– Include everyone in team discussions, and speak to all levels

of knowledge– Pimp kindly, but do pimp (engage learners in process rather

than dictating to them)– Invest early by explaining logistics, expectations and then

reinforcing with frequent feedback– Divide tasks among all members of team, including both trivial

and high level– Advocate for learners and back them up


• Enthusiasm– Share with learners why you chose your field– Remind yourself intermittently why you chose to do what you

do– Find something interesting in every case– No great teacher was every noted for their apathy to content

or students– When feeling burned out, tell a peer and/or share with team

your frustrations– Remember that even when you are not explicitly teaching,

you are actually teaching through role modeling

Think Out Loud

• Scenario: You are paged for the 10th time by the ED junior to review a consult as the night senior. You have 5 floor consults and a death by cardiac criteria case to triage in the ICU. The case presented by the ED junior is straightforward carotid dissection and you tell them to get an MRA with fat sats, start heparin, and admit to CMF. How could you teach more effectively in this context?

a) Send them three articles (PDF’s) on dissectionb) Copy and paste the summary from Up-To-Date to an emailc) Give them a chalk-talk on ASA vs. anti-coagulation in stroked) Briefly explain your rationale for suspecting dissection, the

imaging modalities that can be used, and the ambiguous evidence for treatment but your favored approach/reasoning

Think Out Loud

• Include learner in your thought process– Summarize key aspects of case– Explicitly state guiding principals

• Give learner opportunity to ask clarifying questions– Helps to consolidate principals– Further informs whether they understand key principals– Be open to saying “I don’t know” (“but I will find out for you”)

Think Out Loud

• Probe learner to ensure they follow your reasoning– Pimping shows interest, keeps students engaged– Allows teacher to identify knowledge gaps– Allows teacher to model sound clinical reasoning– Use first names– Pose questions to group before calling on individual– Avoid “wrong” or aggressive grilling– Rephrase question to lead learner toward “discovering” the

correct answer– Acknowledge effort and challenge– Start junior and work toward more senior learners to avoid

embarrassment

Think Out Loud

• Five types of questions– Factual: How long has patient had abdominal pain?– Broadening: What are potential causes?– Justifying: What supports your diagnosis?– Hypothetical: What if the patient were immunocompromised,

how would this change your diagnosis?– Alternative: What is the advantage or disadvantage of

watchful waiting vs. endoscopy?

Think Out Loud

• More effective questions– What major findings lead to your diagnosis?– Is there anything else we should be concerned about?– What were two other diagnoses you considered and why did

you eliminate them?

• Less effective questions– What is the most common symptom associated with this

diagnosis? – What are the three most common causes of this syndrome?– What is the sensitivity of testing for the 2nd and 3rd diagnoses?

Think Out Loud

• Teaching at bedside– Prepare – directed questioning and examination– Practice – seek feedback from experts– Include patient – no one is more invested in the findings and

they can be an ally in engaging and teaching the learners– Observe – step back and let the learner take a stab– Debrief – make sure learners received the information you

intended, discuss what went well and what could be better, leave time for questions

Think Out Loud

• Teaching on work rounds– Be flexible – adjust amount and type of teaching to needs of

team and service– Be explicit – do not assume everyone is following your

thought process; think out loud and verify that learners understand concepts and decisions

– Role model – every interaction has implications (you are always being watched!)

– Do it – there is no time like the present; no need for fancy presentations

Think Out Loud

• Teaching on call– Set expectations at outset (take first admission, try to see

another one, come with me to ED, etc.)– Include students in potential learning moments when possible

(paged to see unstable patient on cross-cover)– Engage student to help with duties they can perform while

learning, making them a part of your team (even if team of two)

– Confirm history and examination findings, demonstrate additional findings, review and give feedback on notes

– Role model (always!)

Think Out Loud

• Teaching procedures– Ask about prior experience (Have you done this before? What

was challenging in the past?)– Demonstrate (simulation, or live) – Repeat steps out loud while demonstrating– Watch trainee and give verbal feedback– Have trainee teach it back to you– As learners gets more expertise, provide small tips

Give (High Quality) Feedback

• Scenario: A student on DMD performs at an expected level, including admitting one admission on call nights, being reliable with work and notes, and demonstrating a good knowledge base. You tell him that he did “well” and there was no specific feedback. He then goes on to MAS, where his team has a similar impression. At his exit interview, he is told of his “solid” performance and later gets an “honors” grade. He wonders how he could have done better. More effective feedback includes:

a) Specific advice to take on more patientsb) Reviewing specific aspects of the exam to improvec) Recommending targeted reading on his patients to present to

the teamd) Pointing out specific strengths of his performance


• Good feedback is…


• Good feedback is…– Timely– Respectful– Non-judgmental– Bidirectional– Self-directed– Honest– Positive and constructive– Actionable– SPECIFIC


• Feedback best deferred to clerkship director– Inappropriate Dress - Delicate topic– Mental health - Concerns about depression, substance use – Serious professionalism issues

• Ask about prior education and background• Become familiar with learner’s goals and objectives• Give learner clear expectations

• Introduce yourself and share your love of medicine• Use first names and introduce learner to others• Be kind when pimping

• Include learner in your thought process• Probe learners to ensure they follow your reasoning• Allow learner opportunity to ask clarifying questions

Some Basic Principles

Know your learners

Be respectful and

enthusiastic

Think out loud

• Choose right setting/timing for feedback• Provide positive and constructive SPECIFIC feedback• Solicit and formally deliver feedback at end of encounter

Give specific real-time feedback

an approach to meningitis for the internist and family practitioner

Documents