residents teaching workshop college of medicine at peoria uic university of illinois
TRANSCRIPT
Residents Teaching Workshop
College of Medicine at PeoriaUIC University of Illinois
You are doctors. Why is teaching so important?
docere: Latin for “to teach”
Resident’s role as teacher
However, residents often did not… promote participation ask problem solving questions give feedback *
* Neal Whitman, Thomas L. Schwenk, The Physician As Teacher, Whitman Press
20% of time spent teaching
What are the difficulties?????
Teaching and assessment skills improve with practice
Do you make a difference?
Workshop Overview
Setting Personal Goals
Today’s 4 Modules: Module I: Teachable Moments Module II: The “One-Minute Preceptor”: Clinical Teaching Microskills Lunch
Module III: Providing Feedback Evaluating Students Module IV: OSTE – putting it to work Reflections
Ground rules
One person at a time Everyone participates Be concise Show respect No side conversations Have fun!
3
Personal Goals (p. 7)
Please identify three learning goals to enhance your own teaching skills that you would like to address during the residents as teacher’s workshop.
Module I: Teachable Moments
At the end of this module, you will be able to Discuss some of the educational
principles behind medical education Orient the students or intern to their
new rotation Identify the goals and objectives of the
M3 clerkship in their area of residency training
Note: on-line resources on p. 8
Memorable teachers (p. 9)
Think back over medical school Poor clinical teacher Can’t remember what was taught
What did that teacher do that made the teaching so ineffective?”
5
Memorable teachers (p. 10)
Think back over medical school Exceptional clinical teacher You still remember the lessons
What did that teacher do that made their teaching so effective?”
6
Why teach?
By learning you will teach, by teaching you will learn.
Latin Proverb
I believe that every human soul is teaching something to someone nearly every minute here in mortality.
M. Russell Ballard
The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.
Alvin Toffler
Active Learning
What I hear, I forget.
What I hear and see, I vaguely recall.
What I hear, see, and discuss, I understand.
What I hear, see, discuss, and do, I remember.
What I teach to another, I master.
Types of teaching
Lecture Teacher-centered
Discussion Group-centered
Independent study Student-
centered
Teacher – learner model
Teacher Learner
Content
Context
K Skeff, Faculty Development Fellowship Workshop, April 1999
The Educational Cycle (p. 11)
Plan
Assess
Teach
Reflect
7
Teaching Encounters
Average 4.5 min * Presentation - 2.5
min. Inquiry - 1 min. Teaching - 1 min.
Presentation
Inquiry
Discussion
* DM Irby, Presentation, Faculty Development Workshop, April 1999
Teachers must Analyze quickly Teach efficiently Teach effectively
Teachable Moment
A medical student is starting a new clinical rotation. Review the film clip that will be shown to you.
http://www.med-ed.virginia.edu/courses/fm/precept/module4/m4p2.htm
Discuss the strengths and weakness of these student- resident encounters in relation to the
Plan-Assess-Teach-Reflect cycle.
p. 12
Orientation Brainstorming Exercise (p. 13)
What were your expectations for your first rotation?
Reflect back on the time you started your first rotation: Clarity of expectations?? Effective communication of expectation??
Large source of performance problems
Learner’s needs (p. 14)
Reflect back on the same experience. Put yourself in the position of the
teacher
How can you best identify and address the learner’s various expectations and needs?
Set & COMMUNICATE expectations
Defined role makes learners and teachers more confident
Base teaching activities on learner’s needs &objectives
Evaluation drives learning
Rationale:
Set expectations
The “Orient Approach” Orientation Responsibilities Interchange Education Needs Timing of follow-up session
Set Expectations
Orientation Clarify mutual goals and expectations Discuss mutual goals and objectives Start with the learner
Responsibilities Learner’s role in patient care and teamwork Call, rounds, team dynamics, charting
Interchange Balance service vs. learning during rotation
– Adapted from BeST program UC Irvine
Set Expectations
Education Model self-directed learning Suggestions for reading and learning during rotation
Needs Other questions/interests learner has Anything else going on that you might help with Students need to feel like they are progressing
Timing of follow-up session Final comments or questions Set time for follow up on goals and expectations
– Adapted from BeST program UC Irvine
Examples
”You will do one H&P each admitting day.”
”Each Friday, I meet with the students for feedback."
”What do you hope to learn during this rotation?"
1 0
Examples
”You will do one H&P each admitting day.”
”Each Friday, I meet with the students for feedback."
”What do you hope to learn during this rotation?"
1 0
Non-examples
"Rounds start at 8:30. See you there.“
What wasn’t explained??????
Goals and Expectations of M3 clerkship
How many of you are aware of the medical student clerkship requirements in your area of training?
Fulfilling the Educational Objectives of the Clerkship
3 5
Gather into groups by specialty.
Review the educational objectives for the clerkship in your specialty.
Select 2 objectives.
Fulfilling the Educational Objectives of the Clerkship
3 5
At your table:Devise a teaching
strategy to accomplish the selected objective.
p. 16
Large Group Discussion
Conclusion
One minute paper
Identify 2-3 characteristics you will utilize during orientation to help your learner transition into their clinical experience.
10 minute break
10 minutes until the workshop
resumes
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resumes at 10:45 sharp!
Please take your seats
Module II- The Microskills of Clinical Teaching
At the end of this module, the resident will be able to: Identify the five plus 2 microskills
of clinical teaching Recognize the teachable moment
and apply the microskills effectively
Teaching Encounters
Average 4.5 min * Presentation - 2.5
min. Inquiry - 1 min. Teaching - 1 min.
Presentation
Inquiry
Discussion
* DM Irby, Presentation, Faculty Development Workshop, April 1999
Teachers must Analyze quickly Teach efficiently Teach effectively
The Microskills
Easy to learn Efficient Evidence based Use day-to-day
Neher JO, et al, a Five-Step "Microskills" Model of Clinical Teaching, Journal of the American Board of Family Practice, Vol. 5, No. 4, pp. 419- 423. (1992)
Seven skills (5 + 2)
8
To use microskills
Identify teachable momentDiagnose the learnerNo hard and fast rules
To use the Microskills
When you hear a cue, use the appropriate Microskill
Listen for cues
Scripted video Vignettes: Small group discussion
Common clinical teaching situations
Look for: Opportunity to teach Best way to teach
Scene 1
Summarize in One Sentence
Cue: Scenario 1 The learner’s image of the case is
unfocused
Response
“Tell me the key points of the case in one sentence.”
1 2
Summarize in One Sentence
Helps student “see” the diagnosis
Rationale:
Brings the “big picture” into focus
(cognitive representation)
1 2
Scene 2
Generate Hypotheses
Cue: The learner does not commit to a dx, or commits to a diagnosis without
considering important alternatives...
Response: Resist the urge to list those alternatives Ask, "What other diagnoses should we
consider?”
1 4
Generate Hypotheses
Teaches learner to consider alternatives
Reveals learners knowledge
Rationale:
Prevents premature closure
1 4
Examples
“What other diagnoses did you consider, and how did you exclude them?”
“What other pathophysiologic processes could cause this presentation?”
1 4
Non-examples
“What are the 12 causes of atrial fibrillation?"
1 4
Scene 3
Get a commitment
Cue: Learner presents the
facts, then stops ...
Response:
Resist the urge to fill in the verbal blank
Ask the learner what they think
1 6
Get a commitment
Formulate an assessment Take responsibility for care
Rationale
Students must learn to:
Put a case together
1 6
Examples
What do you think is the most likely diagnosis?
"What lab tests should be ordered?"
"What is your diagnosis?”
1 6
Non-Examples
"Sounds like bronchitis to me."
“What did you do at this point?”
”Now which symptom came first?”
1 6
Probe for Supporting Evidence
Cue: The learner commits to a diagnosis…
and looks to you for confirmation.
Response: Resist the urge to pass judgment on the
opinion just stated Ask, "What data support your
assessment?"
1 8
Probe for Supporting Evidence
Reveals learner’s knowledge and gaps
"Thinking out loud" is a low-risk way for learners to make mistakes
Rationale: Learner must demonstrate problem solving skills
1 8
Examples
"What led you to that conclusion?"
"Why did you choose that medication?“
“Are there any findings that are left unexplained by your diagnosis?”
1 8
Non-examples
"I don't think this is appendicitis. Do you have any other ideas?"
"Is there any suprapubic tenderness or pyuria?"
1 8
Assess
Summarize in one sentence Generate hypotheses Get a commitment Probe for supporting evidence
Re fle ct
Plan
As s e s s
Te ach
Teacher – learner model
Teacher
Content
Context
K Skeff, Faculty Development Fellowship Workshop, April 1999
LearnerLearner
Teach a general rule
Cue: There are gaps in the learner's
knowledgeResponse:
At last! It's time to "teach" Teach useful, generally applicable
principals Talk at the learner's level Don't mini-lecture
2 0
Teach a general rule
Understanding improves recall
If neither of you know, then teach how to find the information needed
Rationale: General rules can be applied again and again
2 0
Examples
“Oxygen decreases pulmonary vascular resistance. This decreases RV pressure and increases LV filling, promoting diuresis.”
“When that happens, this is what to do…”
“Patients with vertigo and a positive Hallpike test have a non-urgent cause for dizziness.”
2 0
Non-examples
“I would not start heparin in this case.”
“I order an EKG on every patient.”
2 0
Correct mistakes
Cue: The learner demonstrates a
misunderstanding or error
Response: Give corrective feedback
2 2
Correct mistakes
Mistakes left uncorrected will be repeated
Learners who are aware of a mistake are in a "teachable" state
Rationale: Learners may not see the mistake
2 2
Examples
“That dose of acyclovir is too high for a patient with decreased renal function.”
“This may be acute gout, but you can't exclude septic arthritis unless you tap the joint.”
2 2
Non-examples
"Those lab tests were completely unnecessary.”
"You did what?!"
2 2
Reinforce what was right
Cue: A learner handled a situation very
effectivelyResponse:
Give reinforcing feedback Focus on the specific behavior Avoid general praise
2 4
Reinforce what was right
Unless reinforced, competencies may never be established
Recognizing good performance builds respect
Rationale: Learners may not know what is right
2 4
Examples
"You identified poor nutritional status in your problem list, and addressed it in your plan."
”You obtained cultures before starting antibiotics. This will allow us to select the most effective treatment."
2 4
Non-examples
"You are right. That is a good decision."
"You did that skin biopsy very well."
"Good job!"
2 4
Teach
Teach a general ruleCorrect mistakesReinforce what was right
Re fle ct
Plan
As s e s s
Te ach
Teacher – learner model
Learner
Content
Context
K Skeff, Faculty Development Fellowship Workshop, April 1999
TeacherTeacher
Conclusion
One Minute Paper
Lunch break
Module III: Giving Feedback
At the end of this Module, you will be able to State the difference between evaluation
and feedback Discuss the value of feedback in the
process of learning and medical education
Provide skillful and constructive feedback to the learners
Feedback
Learners want to know how they are doing
Surveys show they do not remember getting enough feedback on their performance
Feedback
2 5
Imagine a world without feedback
Feedback vs. Evaluation
Feedback: Ongoing; provided day-to-day Formative- help learners direct their efforts
Evaluation: Provided at the end of a course of study Summative- a judgment relative to
standards
2 5
Scenario: Typical day of morning rounds
Student, “ Ms. J is our 65 yo f with right arm cellulitis on day 3 of vanc. She has no complaints and on exam HEENT- PERRL, lungs were clear…”
Resident interrupts, “you can just give us the pertinent findings, including her vitals”
Student proceeds, “…and her cultures came back as MSSA. Since she’s improving, I thought we could continue her on the vanc for a 14 day course.”
Resident, “Typically we only use vanc when the culture comes back as MRSA because of resistance we like to limit the use of vanc in other infections.”
Rounds proceed and resident tells the student “good job” before moving to the next patient.
– Adapted with permission from Heather Harrell ( www.im.org/AAIM)
Does the student think this was feedback?
Informal setting Students often only recognize feedback in a
formal “sit down” session. Rushed setting
May not process “feedback of the fly” without reinforcement
Stressed setting Tone of the scenario unclear, but if resident
sounds frustrated or abrupt, student may fixate more on tone than content.
Contradictory message Ending the feedback with a general “good” may
confuse or even negate prior feedback. End with last thing you want the students to remember.
Was it feedback?
Feedback occurs when a learner is offered specific comments on what s/he did and its consequences. (Adapted from Ende) Student informed did not give pertinent
findings
Student was reminded vitals are considered pertinent
Consequences of indiscriminant vanc use explained.
Characteristics of Effective Feedback
Specific “you can just give us the pertinent findings,
including her vitals” Timely
During rounds is immediate Based on objective not subjective data
Direct observation on rounds Consequences explained
“Typically we only use vanc when the culture comes back as MRSA because of resistance we like to limit the use of vanc in other infections.”
Provides “next step” “Good”
Goal is to help, not punish “Resident interrupts” tone may seem punitive
Improved scenario
Student, “ Ms. J is our 65 yo f with right arm cellulitis on day 3 of vanc. She has no complaints and on exam HEENT- PERRL, lungs were clear…”
Resident interrupts, “you can just give us the pertinent findings, including her vitals”
Student proceeds, “…and her cultures came back as MSSA. Since she’s improving, I thought we could continue her on the vanc for a 14 day course.”
Resident, “Typically we only use vanc when the culture comes back as MRSA. What other antibiotic would you like to use?”
Rounds proceed, resident pulls the student aside as walking “Your presentation started out good with a clear and concise opening but I want to give you some feedback. You don’t have to provide as much detail in your oral presentations as you do in your SOAP notes, particularly in the ‘O’ (objective) part. On your next patient, try a more focused approach with the objective findings”.
Why so little feedback ??
Giving feedback:
State that you are going to give feedback
Involve the learner in the process
Use neutral, non-judgmental language
Focus on the behavior, and the learning goals, not the person
2 5
IMPROVE feedback model
I · Identify rotation objectives with the student
M · Make a feedback friendly environment
P · assess Performance · Prioritize the feedback you provide
R · Respond to the student's self-assessment
O· be Objective: report specific behaviors observed; · describe potential
outcomes of behavior
V · Validate what the student has done well or suggest alternative strategies
E· Establish a plan to implement changes (if needed) · Have the student
summarize feedback and the plan
Feedback vs. Evaluation
Feedback: Ongoing; provided day-to-day
Formative- help learners direct their efforts
Evaluation: Provided at the end of a course of study Summative- a judgment relative to
standards
2 5
Table 1.
Comparing Feedback and Evaluation Sessions
FEEDBACK EVALUATION Timing Timely Scheduled Setting Informal Formal Basis Observation Observation Content Objective Objective Scope Specific
Actions Global Performance
Purpose Improvement “Grading” & Improvement
Mid-clerkship assessment & feedbackMIDTERM FEEDBACK
M3 FAMILY MEDICINE CLERKSHIP CLINICAL PERFORMANCE AT SITE
Student Name:______________________________ Clerkship Dates:_________________________ Preceptor Name (Please Print):______________________________ Site:______________________ Please use the language of the final Clinical Performance Report wherever possible when you fill out this midterm feedback sheet. DO NOT ASSIGN A GRADE. 1. History Taking - Data Gathering
a. Improvements suggested____________________________________________________ _______________________________________________________________________
b. Skills in which student is doing well__________________________________________ _______________________________________________________________________ 2. Physical Exam - Data Gathering
a. Improvements suggested____________________________________________________ _______________________________________________________________________
b. Skills in which student is doing well__________________________________________ _______________________________________________________________________ 3. Doctor-Patient Relationship
a. Improvements suggested ___________________________________________________ _______________________________________________________________________
b. Skills in which student is doing well__________________________________________ _______________________________________________________________________ 4. Anticipatory Health Care
a. Improvements suggested ___________________________________________________ _______________________________________________________________________
b. Skills in which student is doing well__________________________________________
Mid-clerkship feedback formThe University Of Illinois College Of Medicine At Peoria
DEPARTMENT OF SURGERY
SURGERY CLERKSHIP MID-CLERKSHIP FEEDBACK FORM
STUDENT NAME: PT assessments/SOAP notes: red* yellow green Presentations on rounds: red* yellow green Interactions in OR: red* yellow green Knowledge base: red* yellow green Data management: red* yellow green Interpersonal relations: red* yellow reen Specific strengths of this student: 1. 2. Specific areas this student can improve: 1. 2. Comments (*please elaborate on any “reds”): Completed by:
FACULTY SIGNATURE FACULTY PRINTED
NAME Date: 2006 Mid-Clerkship Feedback Form #2
Example of clerkship evaluation
OBGYn
The Residents Teaching Workshop
Module IV
Module IV: OSTE
At the end of this session, the residents will be able to
Practice microteaching skills utilizing a standardized student encounter
Practice providing feedback utilizing a standard student encounter
Microskills
1. Set expectations2. Summarize in a sentence3. Generate hypotheses4. Get a commitment 5. Probe for supporting
evidence6. Teach a general rule7. Correct mistakes8. Reinforce what was right
Breakout Groups
Select a teacher Select a commentator 6 – 8 min. interaction
Case presentation Teaching opportunity
Gelula MH, Using Standardized Students to Improve Junior Faculty Teaching, Academic Medicine, Vol 73, No 5, May 1998
Three standardized student exercises
Discussion 8 – 10 min. First the “teacher” Next the commentator Also, the std. student
3 0
Questions
During the standardized student exercise What observations did you make? What approaches worked well, and
why? What approaches did not seem to work
as well, and why?
3 1
Standardized students
What did you observe about teaching
3 1
Reflection
Back to our medical student
You are still on the wardsBenoit, the M3, is finishing a month
working with youYou sit down to talk
What questions do you have for him?
Reflect
Cue: At the end of an educational experience
Response: “What went well?” “What would you do differently”? “What caught your interest?”
Re fle ct
Plan
As s e s s
Te ach
3 2
Reflect
Reorganize what was learned Build understanding
Enhances learning and recall
Encourage personal inquiry
Rationale:
3 2
The Educational Cycle
Plan
Assess
Teach
Reflect
• Set expectations
• Summarize in a sentence • Create hypotheses • Get a commitment • Probe for evidence
• Teach general rules• Correct mistakes• Reinforce right
• Make time to reflect
3 3
In summary
1. Set expectations2. Summarize in a sentence3. Generate hypotheses 4. Get a commitment 5. Probe for supporting
evidence6. Teach a general rule7. Correct mistakes8. Reinforce what was right9. Make time to reflect
3 4
The microskill-based teacher
Restrained Selective Efficient At the learner’s
level “Gives” discussion
to the learner Gives feedback
Reflection on this workshop
Lets go around the room: What is one thing you will take away
from this workshop?Again…….
Reflection on this workshop
Lets go around the room What is one thing we should do
differently next time?
For your reading pleasure…
Sir William Osler as
Teacher to Emulate
James A. Knight
3 7
Thank you from the students
And faculty of
The Resident’s Teaching Workshop