ChallengesofEffectiveClinicalTeachingMichaelG.Hueber,DOAssistantDeanClinicalEducationAssistantProfessorFamilyMedicine

LibertyUniversityCollegeofOsteopathicMedicineCenterforMedicalandHealthSciences

Objectives• Reviewthebasicprinciplesofclinical teaching.

• Understandthesixessentialclinicalteachingskills.

• Discuss methods of getting students engaged in clinical thinking.

• Utilize the One-Minute Preceptor in a practice setting.

• Discussmethodsoffeedbacktomillennials.

• Discuss the importance of written comments on medical students.

• Describe structure and content of written commentswhich make themuseful

inanevaluation

ReflectionsAsastudent,myworstexperiencewithapreceptorwaswhen…

ThebestpreceptorIeverhad…

Manypreceptorsneedtrainingon/about…

Ifacolleagueaskedhowtogetreadyforhis/herfirststudent,Iwouldtellthem…

Tomakethemostofmyteachingtime, Ihopestudentswill…

Togetthemostoutofmyrotation,studentsshould…

ReflectionsThestaffinmyofficethinkstudentsshould…

TheworststudentIeverhad…

Themostdifficultthingaboutbeingapreceptoris…

Tohelpmeasapreceptor,themedicalschoolshould…

Toenhancemyofficeasatrainingsite,themedicalschoolcouldprovide…

Themostrewardingthingsaboutbeingapreceptorare…

TeachingMedicalStudentsinCommunity-Based Hospitals• Pros:

• Allowsforindividualizedteaching: one-on-one• Rolemodelsfor students• Introducedto“realworld”ofmedicinefromthe beginning

• Cons:• Rapid pace• Time constraints• Multipledemandsonthe preceptor• Limitedtimefor teaching• Preceptorsneedhelpinidentifyingstudent’slearning style• Lackofresidenttraining

PrinciplesofClinical Teaching

• Learningis evolutionary

• Assessthedevelopmentallevelofthestudent(1strotationvs.6th rotation)

• Participation,repetition,andreinforcementstrengthenandenhancelearning

• Varietyinlearningactivitiesincreases interest

• Readinesstolearnenhancesretention

• Immediateuse of informationand skills enhances retention

• Learningisenhancedifthestudentfeelshe/sheismakingprogress(feedback)

PrinciplesofClinical Teaching• Teachandhavestudentsdevelopclinical(critical)thinking skills

• Teachthestudenthow to:• Takeathoroughyetfocusedmedicalhistoryand physical• Beabletoreflectontheinformationgathered• Comeupwithanassessmentandeffectivemanagement plan

• SinkorSwimModel• Anxietyiscreatedfromalearningsituationrequiringhighindependencewithlowexperience

• Structured Approach• Frustration occurs when low independence is allowed for students with highexperience levels

Clinical Teaching

• Focusonskillsandattitudesasmuchas,ormorethan, onknowledge• History taking• Physical examinations• Clinicalreasoninganddecision making• Developingdifferential diagnosis• Communication(casepresentations,oraland written)• Makingandcarryingout plans• Coordinating care• Professionalismand ethics• ThesearetheEntrustableProfessionalActivitiesofthefuture

SixEssentialTeaching Skills

• Establishing and monitoringmutual expectations

• Settinglimitedgoals

• Asking questions

• Stimulatingself-directed learning

• Giving feedback

• Capitalizeonrolemodeling

Wilkersonet.al.JGenIntMed1990;5;44-53

HowdoYou IncreaseEffectivenessandDecreaseStress asYouJuggletheRoleofTeacherand Clinician?1. Prepareyourselfandyourstafftohaveamedical student

2. Reviewthesyllabus

3. Setexpectationsofthe student(printedlist)

• Dress,starttime,officeorhospitalrules,parking,EMR,lunch,safetyandsecurityissues

• Casepresentations,topicreports,pre-rounds,post-rounds,after-hour call

4. Havethestudentgivehis/herexpectations (Whatwouldhe/sheliketoworkoninyour specialty?)

SchedulingStrategiesfor Precepting

• Focused observation

• Focusedhalf days

• Wave scheduling

• Appointmentmodification

• Combinationpatient/researchdays

Focused Observation• Studentsobservethepreceptorduringpatient encounters

• Students observeyouasarolemodelforspecificaspectsofthepatient’svisit

• Allowsthestudenttoobserveyouintroducevariationsofhistory,physical exam andpatient care, depending on the patient’s needs, andidentifies what you believe isimportant in every encounter

• Initially(partsoffirst1-2days)helpful• Excellentforthebeginningstudent(thosefirst1-2 rotations)• Notappropriatefortheentirerotation• Situational (difficult patient, bad outcome)

FocusedHalf Days

• Thepreceptorcanseetheprojectedschedule(morningandafternoon)and selectoneortwopatientsonwhomthestudentcan concentrate.

• Thefocuscanberelatedtoage,condition,assessmentskills,oralignedwiththeobjectivesforthecoursethestudentis taking.

• Allowsstudentstimetoreviewnecessaryinformationfromthechartand/orfromtheevidencebase, sotheywillbepreparedtoaskthepatientappropriatequestionsandperformafocusedexaminationanddeveloptheirdiagnosisandplanof action.

• Whilethestudentisdoinghisorher assessment, thepreceptorcanseeotherpatientsandkeepthescheduleon track.

• Increasesconfidenceinstudents• Lessoverwhelmingtonewer students• Keepsthepreceptoron course

Wave Scheduling2-3patientsarescheduledatthesametime,andthenthetimeslotisfollowedbya10- to15-minute break.

Studentseesonepatientwhilethepreceptorseestheother 1-2.

Thereistimeforthepreceptortoseeanddiscussthestudent’spatientandnotfallbehind.

Requirescoordinatingby theofficestaff.

Combination Days• Divideyourdaywiththe student

• Assignpatients,rounds,surgeries for 1/2to2/3 oftheday

• Assignothertasksinafternoon:research,currentpatientissue,case presentation

• Have student give presentation that afternoon or early next morning

• Allowsyoutofinishafternoonsontime

SixEssentialClinicalTeaching Skills• Establishing and monitoringmutual expectations

• Settinglimitedgoals• Asking questions• Stimulatingself-directed learning• Giving feedback

• Capitalizeonrolemodeling

Wilkersonet.al.JGenIntMed1990;5;44-53

Traditional Precepting

• Learnerexaminesandpresentsthecasetothepreceptor

• Preceptorasksforadditionalpatientdata

• Discussion about the case and care plan for the patient’s care

• Problemswiththismethod:

• Patientcare focused, notlearner focused

• Lowlevelquestionstoclarifyclinical data

• Littleorno feedback

• Difficulttoassessthelearner’sthoughtprocessesorlevelof understanding

One-MinutePreceptor5-Step Microskills

• Geta commitment

• Probeforsupporting evidence

• Reinforce whatwas done right or well

• Giveguidanceabouterrorsandomissions(correctmistakes)

• Teachageneralprincipleaboutthecase

• https://www.youtube.com/watch?v=54rNxIJyt9I

1.Geta Commitment• When:Immediatelyafterthestudenthaspresentedhis/her case

• Pushthelearnertomovebeyondhisorher levelofcomfort, andmakesthestudentactiveintheteaching encounter.

• Allowsyoutoassesshowthelearnerhasprocessed information

• Whatdoyouthinkisgoingonwiththispatient?(toptwodiagnoses)

• Whatlaboratory/imagingstudiesorinformationdoyouthinkweshouldget?

• Howdoyouthinkweshouldtreatthispatient?

• Whatotherdiagnoseswouldyouconsiderinthissetting?

• Allrequireacommitmentfromthestudentdoctor.(Givesyouinsightintothelearner’s reasoning).

• Seehowthelearnerreactsunder pressure.

1.GetaCommitment• Cue:Afterpresentingthefactsofacasetoyou,thelearnereitherstopstowaitforyourresponseorasksyourguidanceonhowtoproceed.Ineithercase,thelearnerdoesnotofferanopiniononthedata presented.

• Ifyourecognizethepatient’sproblem,yourimmediateresponseistotellthelearnertheanswer.DON’T !!

• Preceptor:Instead, askthelearnertostatewhathe/shethinksabouttheissuepresentedbythedata.Issuesmayincludegatheringmoredata,proposingahypothesis,developingamanagement plan.

• Rationale:Askingalearner howtheyinterpretthedataisthefirststepindiagnosing learning needs.

• DON’T:

• Offeryour opinion

• Saythingslike,“Thisisobviouslyacaseof pneumonia.”

1.Geta Commitment

2.ProbeforSupportingEvidence• Askwhatunderliesthecommitment statement.• Allowsyoutoobservethestudent’sskillsinclinical reasoning.• Youcandetermineifthelearnerhadadequateevidenceforthe commitment.• Youneedtofishoutthelucky guesses.• Youcancorrectanyfaulty inferences.

• Heartheir thinking.• WhatfactorsintheHandPsupportyourthoughts?• Whatfactorsdidyouconsiderinmakingthatdecision?• Whatfactssupportyour conclusion?• Werethereotheroptionsyouconsideredanddiscarded? Why?• Whywouldyouusethat medicine?• Whydoyouthinkthispatientneedshospitalization?

• Opportunitytoteachthe logic.

1. Geta Commitment2. ProbeforSupporting Evidence

3.Reinforce what was done well(Positive feedback)

• Includespecificbehaviorsthatdemonstratedknowledge,skillsor attitudes valuedbythe preceptor

• Reinforcegood skills• Persistincarryingthestudentbeyondhisorherunderstanding

• “Ilikedthatyourdifferentialtookintoaccountthepatient’sage,recentexposures,and symptoms.”

• “Yourdiagnosisofpneumoniawaswellsupportedbyyour assessment.”• “Yourassessmentwaswell organized.”• “Niceincorporationofresponseto therapy.”• “Well-organizedcase presentation.”

1. Geta Commitment2. ProbeforSupporting Evidence3. ReinforceWhatWasDoneWell

4.Give Guidance about Errors andOmissions

• Tellthemwhatareasneedimprovement,correctanyerrorsandomissionsormisperceptions.

• Errorsuncorrectedwillbe repeated• “Duringtheearexam, thepatient seemed uncomfortable.Let’sgooverholdingtheotoscope.”

• “YourpresentationdetailedtoomuchinformationinthePMHthatwasnotrelevanttoyour case.”

• “IagreethatatsomepointPFTswillbehelpful,butrightnowthepatientisacutelyillandtheresultsmaynotreflectherbaseline.Wemightgetmoreappropriateinformationfromapeakflowandpulseoximeteratthis time.”

1. Geta Commitment2. ProbeforSupporting Evidence3. ReinforceWhatWasDoneWell4. GiveGuidanceAboutErrorsandOmissions

5.Teach a General Principle about the Case• Briefteachingspecificallyfocusedtotheencounterisaveryeffectivelearning tool.

• Helpslearnereffectivelygeneralizeknowledgegainedfromthisspecificcasetootherclinical situations

• Targettothelearner’slevelof understanding• Teach1-3generalrulesrelatedtothe case“Remember, 10-15%ofpeoplearecarriersofstrep,whichcanleadtofalsepositivestrep tests.”

• “Thenaturalprogressionofthisdisease is…”

• “Smokersaremorelikelytobeinfectedwithgramnegativebacteriathannon-smokers,soyoumightconsiderusingabroaderspectrum antibiotic.”

Clinical Thinking

Themoreastudentprocessesandthelessyousay,themoresuccessfultheencounterislikelytobe.

Makethem think.

Askmorequestionsofthemthantheyofyou.

GoogleImages 2017

Example

• Student: I saw a 47-year-oldmale with a complaintof cough, feverandSOBthathasbeengoingonfor4days.ThecoughisgettingprogressiveasistheSOB.Itseemstobeworseatnight.Heisdeveloping some left-sided chest pain that getsworse when he coughs. He has tried OTC coughmeds but they doesn’t help. He istakingTylenolandibuprofenforthefeverandchestpain.Hestatesheisnormallyingoodhealthwiththeexceptionofcontrolledhypertension.HetakeslisinoprilfortheHTNandhesmokes1-2packs/dayX25years.

• OnPEheisAOX3NAD.Heisfebrile.Hisheartexamappearedoktome. His lungshad either crackles or rhonchi and some whistling in theleftside.HisENTexamlookedoktome.

Example• Preceptor(gettingacommitment):“Whatdoyouthinkisgoing on?”• Student:“Ithinkhehas pneumonia.”• Preceptor(probingforsupportiveevidence): “Whydoyouthinkthis?”

• Student:“Wellitisprogressiveinnature,andheisasmokerandhehaslungsoundssuggestiveof pneumonia.”

• Preceptor: “Whatotherthingscouldcausesimilarfindingsinthis patient?”• Student:“Maybebronchitisor cancer?”• Preceptor(reinforcingwhatwasdoneright): “Yourphysicalexamwasgoodandyour casepresentationconciseand organized.”

• Preceptor(givingguidanceaboutmistakes): “Iwouldsuggestthatyoustateyourphysicalfindingsandnotsaythingsliketheheart exam appearednormaltome.Toovague, andIdo notknowyourdepthofknowledgeabouttheheartexam.”

• Preceptor:“Whatwouldyouliketostartasa treatment?”• Student:“Antibiotics,maybesomethinglike Keflex.”

• Preceptor (teachingmoment): “Peoplewithchronictobaccoabusewhodeveloppneumoniahaveahigherriskofgramnegativeinfections.Consideranantibioticwithabroaderspectrum.”

Example #2• Student:"Ijustsawa48-year-oldmaleintheclinicwithachiefcomplaintof headaches.Thispatienthasbeeninhisnormalstateofgoodhealthrecently.However,forthepastfewmonths,hehasbeenhavingheadaches.Theheadachesseemtobeginin theafternoonandgetprogressivelyworse.Bytheevening,heusuallyhastotake eitheraspirinorTylenolorboth,andmustliedowntorelievethepain.Afteranhourorso, thepainisbetter,althoughtheheadacheisnotcompletelygone.Bymorningaftera goodnight’ssleep,theheadacheisnolongerpresent.Theseheadachesarenow occurringaboutthreetimesperweek.Theyarenotassociatedwithanaura,nausea,vomiting, orblurryvision.Thepatientworksasaninvestmentbankerandsayshisjobisstressful. Hedescribesthingsathomeasgoingwell.Hehashadahistoryofsimilarheadachesoffandoninthepast,buthisheadacheshavenotbeenaproblemforquitesome time.

• "Onphysicalexam,heappearswell-developed,wellnourished,innoapparent distress.Hisvitalsignsarewithinnormallimits, includingabloodpressureof120/80.HisHEENTexamisunremarkable,exceptIdidn’tgetaverygoodlookathisfundi.Hislung,heartandabdominalexamwerenormal.Hisneurologicalexamseemedfineto me."

One-Minute Preceptor

• Preceptor(gettingacommitment):"Whatdoyouthinkisgoing on?"

• Student:"Well,I’mconcernedhemighthavemigraine headaches."

• Preceptor(probingforsupportingevidence):"Whydoyouthink this?"

• Student:"Well,theheadachesoccurthreetimesaweekandusuallybeginaboutthesametime.Eventhoughhehasastressfuljob,Ithinkwehavetoruleoutmigraines.Hesaysheneedstoliedownandtheheadachesgetbetter, so maybethey’remigraines,eventhoughhedoesn’thaveanaura.I’malsoworriedaboutabraintumorbecauseIcouldn’tseehisfundi."

• Preceptor:"Arethereanyothercausesoftheheadachesthatyoumightconsider?”

• Student:"Maybetensionheadaches,butI’mreallynot sure."

One-Minute Preceptor• Preceptor (teachinggeneral rules): "I think the most important aspect of this case is thatcommonthingsoccurcommonly.Ofallthecausesofheadachesisthispatient’sagegroup,tensionheadachesaremostcommon.Hehasastressfuljobandtheheadachesseemtobeginintheafternoon, whichperhapssuggeststhathegetsstressedatworkandthengetsaheadache.Migrainesareapossibility,butnotaslikelyastensionheadachesinthiscase.Iagreethatweshouldmakesurehisfundiarenormal,butthisdoesnotsoundlikeaclassicstoryforabrain tumor."

• Student: "Could you showme how to get a good look at his fundi?"

• Preceptor (tellingwhat was donewell and what needs to improve): "Sure. By the way, youdidagoodjobofcollectingandorganizingthehistoryandphysicalexam.Yourpresentationsareimproving.Iparticularlylikedthatyouwereabletotellmeyoucouldn’tgetagoodlookatthispatient’sfundi.It’sveryimportanttobetruthfulaboutwhatyoucanandcan’tdo.Yourknowledgeaboutheadachesisabitconcerningtomeandneedstoimprove.Iwouldsuggestyoudoabitofreadingaboutheadachesaswellastheclassicpresentationofabraintumor,andthatwediscussheadachesatyournextclinicsession.Let’sgoseeyour patient."

One-Minute Preceptor• Learner-centered

• Supportsassessmentoflearner’sknowledgeandclinicalreasoning skills

• Supportsfocusedteachingtolearner’sneeds

• Encouragesfeedbacktoreinforcedesiredbehaviorsandreduceundesiredbehaviors

• Asking questions

• Stimulating self-directedlearning

• Giving feedback

One-Minute Preceptor

WhatMakesaGoodPreceptor

Themostimportantqualityiswillingnessto teach

Questions?

Themedicalfacultyandstaffof LibertyUniversityCollegeofOsteopathicMedicinethankyouforallyouhavedoneforour

student doctors

References• NeherJO,GordonKC,MeyerB,StevensN.Afive-step“microskills”modelofclinicalteaching.JAmBoardFamPrac.

1992:5:419-424.

• SeimHCandJohnsonOG,ClinicalPreceptors:TipsforEffectiveTeachingwithMinimalDowntime.FamMed1999;31(8):538-9.

• BaldwinLM,ManagingClinicTimeWhilePreceptingMedicalStudents.STFM/FamilyMedicine 1/97.

• BurnsC,BeauchesneM,Ryan-KrauseP,MasteringthePreceptorRole:ChallengesofClinicalTeaching.JPediatrHealthCare, 2006;20(3):172-183

• GraysonMS,KleinM,LugoJ,BenefitsandCoststo Community-BasedPhysiciansTeachingPrimaryCaretoMedicalStudents.JGenInternMed1998:13:485-489.

• DobbieAE,TysingerJW,FreemanJ,StrategiesforEfficientOfficePrecepting.FamMed2005,37(4)239-41

• CayleyWE,EffectiveClinicalEducation:StrategiesforTeachingMedicalStudentsandResidentsintheOffice.WMJ,2011;10(4)178-181

Feedback

MENTORINGMILLENNIALSLinda S.Mintle,PhDDirectorof StrategicDevelopmentforClinicalAffairsChair,DivisionofBehavioralHealthDeputyIXCoordinator

Free AssociationMILLENNIALS

WeNeedYou!

• 70millionbabyboomersaboutto retire

• Replacedbyfewerthan50million genXers

• Needmillennials:Thinkrecruitmentfromtheground up

The Match

• Boomers:Mostexperiencedphysiciansinanorganization; entitled,driven,competitive, anti-authoritarian, personal fulfilment, buy now /pay later

• Generation X:Self-directed, cynical, highly educated, balanced, self-oriented,autonomy,close friends and family, personal growth

• Millennials:Eco-friendly,digitalnatives,cultural diversity,truth, instantgratification, confident, want to contribute immediately, feedbackandteamoriented

Millennials:What Attracts?• Radicaltransparencyabouteverything(thinksocialmedia)

• Iftheyareacoginthewheelofhealthcare,theywon’tbeinterested

• Beexceptionalandtheywillcome--thisisthegenerationthatrecommendseverything

• Mentoring!Thosewhostay,morelikelytohavebeenmentored.

• Theyteachyoutechnology,youteachbedsidemanner(Forbes)

Millennials:What Attracts?

Trendsand Observations

• Greatestfearisfailure -- theyhaven’tbeentrainedto fail

• Successmeasuredbyresults,notbyobedience

Trends& Observations

• Community Service: Diminished desire compared to medical studentsofthepast

• Less likely to value social rewards and altruism than previous generations

• SurveyData (UniversityofMichigan)showmillennialsdemonstrate40%lowerempathythanpriorgenerations

• Theydon’twantpeopletellingthemwhatto do

• Theyneed structure

• Theyhavesurfaceknowledgebutstrugglewith depth

Trends& Observations

JohnsHopkins study

• Medicalinternsspendonly12%oftheirtimeinteractingwith patients

• Comparesto40%oftimeonthecomputer

• WHY?Increasingneedfordocumentationorcomfort?

• Givethemconstant challenges

• Lotsoffeedback, encouragement

• Askthemwhatthey need

• Wantmeasurable outcomes

• Wanttobepartofthe team

• Theyhavegreatideas, sodon’tcrush them

• Letthemspeakearlyintheprocess; listen

• Wantauthenticlove,community

Modern MentoringTeamwork:ThinkGoogle andSenseof Purpose

Modern Mentoring

• Theystilllookuptoseniorphysiciansasmodels

• Charismaticmentorsliveonforever

• Worksbothways—youcanlearnfromthem,ex:palliative care

• Worklifebalance—Workharderformoremoneynotreinforcing(flexandreduced hours)

• Be flexible• Good listener• Developyouremotional intelligence• Lessdefensive,moreopen,assumegoodintentions• Build teams• Honorwork/life balance• Maintain humor• Helpwithwhat andwhy,letthemdo how• Investinthemaspeople• Usetechnologytohelp

Summary

References

• https://www.psychologytoday.com/blog/modern-medicine/201611/can-millennial-physicians-carry-medicine

• http://www.physicianspractice.com/mgma15/make-your-medical-practice-millennial-friendly

• Lim,A.&Epperly,T.(May-June,2013).Generationgap:EffectivelyleadingphysiciansofallagesFamilyPracticeManagement(3), 29-34.

ANoteof Appreciation