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Teaching Adult Learners
Jacob Prunuske, MD, MSPH
PCFDPOctober 15, 2010
Pictures have been removed from this presentation to ensure adherence to copyright law.
Rules
• Contribute – peer education
• Ask questions
• Speak up when it’s not working
• Share with others after the session
Introductions
• Help me know you!
• Name
• Roles in education
• What you want to learn in this session
Nature or Nurture
• Which has greater influence on teaching?– Nature– Nurture
Nature vs Nurture
• Tribute to hard work…
Kenneth Eble, The Craft of Teaching, 1988
Teaching is complex
• Content – knowledge & skills
• Instructional methods• Learner factors• External demands
Druckman & Bjork Learning, Remembering, Believing: Enhancing Human Performance.National Academy of Press, 1994
Objectives
• Incorporate small group facilitation skills into your teaching repertoire to improve your teaching evaluations
• Become a more efficient teacher in the clinical setting and leave earlier when working with learners
• Model professionalism for your learners
When you are the learner…
• Ineffective
When you are the learner…
• Effective
When you are the learner…
• Share
Pedagogy
Adults learn best when…
• Relevant & practical• Patient or Problem Focused• Safe Learning Environment - respect• Autonomy/self-direction• Goal oriented• Feedback• Active & engaged• Build on existing experiences/knowledge
RadioGraphics 2004; 24:1483–1489
Roles in student education
• Small Groups
• Patient Care– Outpatient– Wards
• Didactics
• Others
Small group facilitation
Small group development
• Forming
• Storming
• Norming
• Performing
• Adjourning
Tuckman, B. (1965) Developmental Sequence in Small Groups. Psychological bulletin, 63, 384-399
Tuckman, B & Jensen, M (1977) Stages of Small Group Development. Group and Organizational Studies, 2, 419-427
Forming
• Safe, simple, avoid controversy• Look to leader for guidance & direction• Desire for acceptance by other members• Explore similarities & differences• Orientation to tasks
Storming
• Interpersonal conflict and competition
• Task organization – how to get it done
• Exploring boundaries
• Testing leader
• Structural clarification– Responsibilities, rules, rewards– Evaluation criteria
Norming
• Group Cohesion
• Engaged
• Acknowledge others’ contributions
• Change opinions & preconceived ideas
• Increased trust
• Sense of belonging
Performing
• Interdependence & flexibility
• Roles & responsibilities shift to meet need
• Functional independence
• Strength in diversity
• Group identity, loyalty, high morale
• Energy directed at tasks
Adjourning
• Role end
• Task completion
• Reduction of dependency
• Sense of loss
Integration
• 1 minute
• Write down 1 – 3 things you just learned
Environment
• Room shape/size• Table shape/size• Power positions• Lighting• Technology• Group Dynamics
Small group facilitation
• In the Beginning…
The Creation of Adam. Michelangelo. 1508-1512.
Small group facilitation
• In the Beginning…– Introductions, learn names– Expectations– Start on time– Invite learners’ opinions, independent thinking– Outline the session– Confidentiality– Model respect– Acknowledge your own limitations
Facilitating discussion
Facilitating discussion
• Stop talking
• Actively listen
• Use names
• Make eye contact
• Enthusiasm for all contributions (not just ‘right’ answers)
• Encourage peer teaching
Witnessing
Role playing
• Initiator• Reconciler• Pathfinder• Supporter
• Aggressor• Interrupter• Hijacker
• Silent Participant• Talker• Joker• Instant Expert
Closing a small group session
• Summarize
• Identify unmet goals
• Homework
• Plan for next session
Integration
• 1 minute
• Write down 1 – 3 things you just learned
Clinical teaching
Doctor as teacher: roles
• Instructor: Convey information• Evaluator: Assess competence• Doctor: Patient well-being and comfort• Colleague: Want to be liked/respected• Mentor: Role Model• Recruiter: Convey enthusiasm for discipline• Business person: Do it all without significant loss
of productivityJohn Brill, MD, MPH
Contribution to theHidden Curriculum
• Knowledge• Attitude• Behavior• Skill
Mind what you have learned. Save you it can.-Yoda
RIME
• Observer (early m1)
• Reporter (late m1/m2)• Interpreter (early m3)• Manager (late m3/m4)• Educator (residents)
Pangaro L. Academic Medicine 1999;74(11):1203-7.
Sepdham et al. Fam Med 2007;39(3):161-3.
Relevant
• Know the educational goals of the clerkship or experience
• Congruent with present
Tips for efficiency
• Establish teaching environment
• Communicate with everyone involved
• Tailor to learner’s needs
• Share teaching responsibilities
• Keep observation/teaching brief
• Broaden learner responsibilities
Biagioli F, Chappelle K. How to be an efficient & effective preceptor. Family Practice Management. May/June 2010
ONE MINUTE PRECEPTOR
Barrier Exercise
• In groups of two…
• Identify & write down as many barriers as you can to “Ideal” ambulatory teaching
• You have 1 minute!
Barriers
• Preceptor factors• Learner factors• Patient factors• Office factors• Healthcare system
factors
Learners
• Disrupt patient care
• Decrease clinical productivity
• Lengthen work day
• Want to grow & develop
• Want to demonstrate knowledge & skill
• Want feedback & fair assessment
Scenario A
• Two volunteers please…
Traditional Precepting
• Patient care focused, not learner focused
• Low-level questions to clarify clinical data
• Mini-lectures
• Little or no feedback
• May be associated with decreased student satisfaction and learning
• Difficult to assess learner’s thought processes or level of understanding
One Minute Preceptor*
1. Get a commitment2. Probe for underlying reasoning3. Provide positive feedback4. Teach general rules5. Correct errors
* Neher, Gordon, Meyer, Stevens. A five-step “microskills” model of clinical teaching. JABFP 1992
Get a commitment
• Cue: The learner stops & looks at you…
• Action: Ask learner to commit to a diagnoses or plan
• Reason: 1st step in diagnosing learning needs, provides focus for teaching
• Example: Want do you think is going on?
Probe for Underlying Reasoning
• Cue: The learner looks to you to confirm dx/plan or suggest an alternative
• Action: Ask learner for evidence and/or DDx; do NOT give your opinion
• Reason: Insight into thought processes & knowledge; identify gaps
• Example: What facts support your conclusion?
Provide positive feedback
• Cue: Learner did good
• Action: Identify and comment on 1 specific good thing the learner did, and the effect it had
• Reason: reinforces skills
• Example: You listened well, allowing the patient to trust you and disclose a sensitive issue she was concerned about.
Teach general rules
• Cue: Learner needs to know something
• Action: Teach general rules or concepts targeted to the learner’s level of understanding
• Reason: memorable & transferable
• Example: In a young woman with abdominal pain, you should always consider the possibility of pregnancy
Correct Errors
• Cue: Error, omission, misunderstanding
• Action: Choose time/place, learner self-critique, discuss error and prevention
• Reason: Errors uncorrected will repeat
• Example: You may be right that this patient is drug-seeking, but you have to consider other possibilities for his pain and do an exam.
Scenario B
• Two more volunteers…
One Minute Preceptor
• Learner-centered
• Supports assessment of learner’s knowledge and clinical reasoning skills
• Supports focused teaching to learner’s needs
• Encourages feedback to reinforce desired behaviors and reduce undesired behaviors
OMP
• Effective for both teaching & patient care– Preceptors as good or better at correctly
diagnosing patient’s medical condition– May provide more information in same
amount of time (or same info in less time)
Aagaard E, et al. Academic Medicine Jan 2004
In groups of 3
Practice Case• Role 1 = Student• Role 2 = Preceptor• Role 3 = Observer for this exercise
• Student starts, Preceptor uses OMP• Observer to provide feedback• 8 minutes to complete
FEEDBACKDr. Jeremy Smith
Integration
• 1 minute
• Write down 1 – 3 things you just learned
Professionalism
Commitment to…
• Professional competence
• Honesty with patients• Patient confidentiality• Maintaining
appropriate relations with patients
• Improving quality of care
• Improving access to care
• A just distribution of finite resources
• Scientific knowledge• Maintaining trust by
managing conflicts of interest
• Professional responsibilities
Contemporary Role Models
• House
• Scrubs
• Grey’s Anatomy
You must unlearn what you have learned.- Yoda
Model Professionalism
• Responsibility– On time, task completion
• Maturity– Response to failure, stress, feedback
• Communication– Sarcasm, volume, disruptive
• Respect– Patient, sensitive to others, discrimination
Proc (Bayl Univ Med Cent) 2007;20:13–16
Respect for specialties
• Bashing occurs on all rotations• 67% students: non-constructive criticism• 79% students: bashing unprofessional• Source of negative comments
– Faculty 42.5%– Resident 55.3%– Student 55.4%
Holmes et al. Fam Med 2008;40(6):400-6.
Campos-Outcalt et al. Fam Med 2003;35(8):573-8.
When it’s not working
• Connect with…– Self– Learner– Clerkship/course director– Dean of students– Residency director– Med Ed office– Dept. Chair
• DOCUMENT
Integration
• 1 minute
• Write down 1 – 3 things you just learned
Objectives
• Incorporate small group facilitation skills into your teaching repertoire to improve your teaching evaluations
• Become a more efficient teacher in the clinical setting and leave earlier when working with learners
• Model professionalism for your learners
Discussion
Thanks!