balancing student learning with caseload and hospital

Balancing Student Learning with

Caseload and Hospital Efficiency

Andrew West, MEd, PhD

Colorado State University

Director – CVMBS Academy for Teaching & Learning

Washington State University

April 11, 2018

www.pollEV.com/CVMBS

Balancing Student Learning with

Caseload and Hospital Efficiency

Faculty time/effort

Student time/effort

Caseload/revenue generation

Story #1

Story #2

Story #3

Faculty time/effort

Student time/effort

Caseload/revenue generation

It doesn’t have to be a zero sum game.

Strategies

Strategies

1. Pre-clinical instruction

2. Clinical instruction

3. Clinic scheduling

4. Technology

5. Assessment

1. Pre-Clinical Instruction

Asynchronous instruction that frees up

time for hands-on learning and clinical

reasoning


➣ Asynchronous instruction that frees up


reasoning

• eLectures/flipped classes

Monday Tuesday Wednesday Thursday Friday

Lecture Lecture Lecture Lecture Lecture

Monday Tuesday Wednesday Thursday Friday

eLecture

eLecture

eLecture

eLecture

eLecture Recitation

or

Lab

Recitation

or

Lab


➣ Asynchronous instruction that frees up


reasoning

• eLectures/flipped classes




reasoning




reasoning

More practice developing clinical

reasoning skills




reasoning


reasoning skills

➣

• Adaptive assessments

Adaptive Assessments

Case

Presentation

Choice A

Choice B

Choice C


Case

Presentation

Choice A

Choice B

Choice C

Choice A

Choice B

Choice C


Case

Presentation

Choice A

Choice B

Choice C

Choice A

Choice B

Choice C

X


Case

Presentation

Choice A

Choice B

Choice C

Choice A

Choice B

Choice C

X

X


Case

Presentation

Choice A

Choice B

Choice C

Choice A

Choice B

Choice C

X

X

Choice A

Choice B

Choice C




reasoning


reasoning skills

➣

• Adaptive assessments




reasoning


reasoning skills




reasoning


reasoning skills

Core competencies and alignment of

topics

Core Competencies and Alignment of Topics


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reasoning


reasoning skills

Core competencies and alignment of

topics

Strategies




4. Technology

5. Assessment

[Faculty with students on service] do not necessarily have a

longer day or spend more time with patients, and having

students does not inevitably decrease productivity (McKee,

Steiner- Grossman, Burton, & Mulvihill, 1998). In fact,

students may actually increase productivity (Fontana, De-

vine, & Kelber, 2000; Hildebrandt, 2001). However, working

with a student undeniably makes a clinical day more

complex. Reducing the complexity wherever possible is the

key to enjoyment of the day when a student is there.

(Burns et al, 2006)

2. Clinical Instruction


Support residents and house officers in

teaching and mentoring strategies




• Educational seminars

➣





• Peer observations of teaching

• Faculty observations of teaching with

reflection

➣





• Peer observations of teaching

• Faculty observations of teaching with

reflection

• Communication training

➣




More efficient use of clinical teaching time





• One-minute preceptor

➣

One-Minute Preceptor (Neher, Gordon, Meyer, & Stevens, 1992)

Micro-Skill Example

1. Get a commitment What do you think is going on?

2. Probe for supporting

evidence

What led you to that …

3. Teach general rules Many times when…

4. Reinforce what was right You did an excellent job of…

5. Correct mistakes Next time this happens, maybe

try…






• Targeted teaching rounds with individual

accountability

➣

What’s going to happen to the gap between the wooden blocks when you tighten the screw?

Assumptions:

- = drill hole = inner (=core) diameter of screw

- The wooden blocks can only shift left-right they can NOT rotate

Please select your answer:

A. It’s going to stay the same

B. It’s going to close (i.e. decrease)

C. It’s going to enlarge (i.e. increase)

Please explain your choice:







accountability

• Develop and implement a time-saving plan

➣

Time Saving Plan

Teacher

Time Saving Plan

Teacher

Student 1

Student 2

Student 3

Student 4

Time Saving Plan

Teacher

Student 1

Student 2

Student 3

Case 1

Case 3

Case 4

Case 5

Case 6

Case 7

Student 4

Case 2

Case 8

Time Saving Plan

Teacher

Student 1

Student 2

Student 3

Case 1

Case 3

Case 4

Case 5

Case 6

Case 7

Student 4

Case 2

Case 8

Residents

Interns

Time Saving Plan

Student 1

Student 2

Student 3

Case 1

Case 3

Case 4

Case 5

Case 6

Case 7

Student 4

Case 2

Case 8

Teacher

Residents

Interns

Time Saving Plan

Teacher

Student 1

Student 2

Student 3

Case 1

Case 3

Case 4

Case 5

Case 6

Case 7

Student 4

Case 2

Case 8

Residents

Interns







accountability

• Develop and implement a time-saving plan

➣

Strategies




4. Technology

5. Assessment

The expert preceptor is constantly doing

“invisible planning”—thinking ahead about

other activities that will be helpful to the

student’s progress (Skeff, Bowen, & Irby,

1997).

3. Clinic Scheduling


Day 1: Orientation + Cases

Day 2: Cases

Day 3: Cases

Day 4: Cases

…

Day 9: Cases

Day 10: Cases + wrap-up

Weekly Schedule


Day 1: Orientation + Pre-test

Day 2: Lab

Day 3: Cases

Day 4: Problem Solving Exercises

…

Day 9: Cases

Day 10: Post-test + wrap-up

Weekly Schedule


8:00-9:00am – rounds

9:00-12:00pm – cases

12:00-12:01pm – lunch

12:01-3:00pm - cases

3-4:00pm – rounds

4-6:00pm – cases/charting/etc.

Daily Schedule



9:00-12:00pm – cases

12:00-12:01pm – lunch

12:01-3:00pm - cases

3-4:00pm – rounds


Daily Schedule

+40min



9:00-12:00pm – cases

12:00-12:41pm – lunch

12:01-3:00pm - cases

3-4:00pm – rounds


Daily Schedule

+40min



9:00-12:00pm – case/cases

12:00-12:41pm – lunch

12:01-3:00pm - cases

3-4:00pm – rounds


Daily Schedule

+40min



9:00-12:00pm – case/cases + really focused teaching

12:00-12:41pm – lunch

12:01-3:00pm - cases

3-4:00pm – rounds


Daily Schedule

+40min




12:00-12:41pm – lunch

12:01-3:00pm – cases + focused observations

3-4:00pm – rounds


Daily Schedule

+40min




12:00-12:41pm – lunch


3-4:00pm – rounds + debrief the observations


Daily Schedule

+40min




12:00-12:41pm – lunch


3-4:00pm – rounds + debrief the observations

4-5:00pm – cases/charting/etc. + summarize key

ideas from the day

Daily Schedule

+40min


Focused half days - The faculty member can see

the projected schedule and select one or two

patients on whom the student can concentrate

for an entire morning or afternoon (ideally with

a focus on a timely learning issue for a student)

(Barker and Pittman, 2010)


Focused observation -- The student adopts a

‘‘fly on the wall’’ approach with the patient

encounters. This gives the student the

opportunity to observe you as a role model for

specific aspects of the patient visit and provides

material for a period of reflection at the end of

the day.



Wave-scheduling -- two or three patients are

scheduled at the same time and then that time

slot is followed by a 10 or 15 min break. The

student can see one patient while the faculty

member sees the others. There is time for the

faculty member to see the student’s patient and

not fall behind.


Strategies




4. Technology

5. Assessment

4. Technology

Clip: “Rage Against the Machines”

From: Marketplace Morning Report with

David Brancaccio

Date: 4/21/2017

https://www.marketplace.org/shows/marketplace-morning-report/04212017






4. Technology

Adaptive learning

Adaptive Learning

Case

Presentation

Choice A

Choice B

Choice C

Choice A

Choice B

Choice C

X

X

Choice A

Choice B

Choice C

4. Technology

Adaptive learning

Virtual reality/360o cases with individual

decision making

Strategies




4. Technology

5. Assessment

5. Assessment

Multiple points throughout the program

Multiple formats throughout the program

Mixture of high stakes and low stakes

5. Assessment

Year 1 (didactic)

Year 2 (didactic)

Year 3 (didactic/clinical)

Year 4 (clinical)

Knowledge

Skills

Thinking

5. Assessment

5. Assessment

Multiple points throughout the program

Multiple formats throughout the program

Mixture of high stakes and low stakes

Strategies




4. Technology

5. Assessment

It doesn’t have to be a zero sum game.

References

Burns, C., Beauchesne, M., Ryan- Krause, P., & Sawin, K. (2006). Mastering the preceptor

role: Challenges of clinical teaching. Journal of Pediatric Health Care, 20, 172-183.

Barker, E.R. & Pittman, O. (2010). Becoming a super preceptor: A practical guide to

preceptorship in today’s clinical climate. Journal of the American Academy of Nurse

Practitioners, 22, 144–149

Neher, J. O., Gordon, K. C., Meyer, B., & Stevens, N. (1992). A five-step ‘‘microskills’’

model of clinical teaching. Journal of the American Board of Family Practice, 5, 419–424.

NPR Clip: “04/21/2017: Rage against the machines”

http://www.npr.org/podcasts/381444599/marketplace-morning-report






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