challenges of effective clinical teaching · •these are the entrustable professional activities...
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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