Residents Teaching Workshop College of Medicine at Peoria UIC University of Illinois

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

9 minutes until the workshop

resumes

8 minutes until the workshop

resumes

7 minutes until the workshop

resumes

6 minutes until the workshop

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5 minutes until the workshop

resumes

4 minutes until the workshop

resumes

3 minutes until the workshop

resumes

2 minutes until the workshop

resumes

2 minutes until the workshop

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