Graduated Graduated ResponsibilityResponsibility

From Medical From Medical Student to Student to PhysicianPhysician

University of BC University of BC Faculty of Medicine Faculty of Medicine

Department of Family Department of Family PracticePractice

Post Graduate ProgramPost Graduate Program

Residents are Residents are ADULT LEARNERSADULT LEARNERS

What are some of the What are some of the characteristics of adult characteristics of adult learners?learners?Take two minutes to write Take two minutes to write

down several characteristics of down several characteristics of adult learners.adult learners.

Adult Learners are:Adult Learners are:

Self directedSelf directed Learner centredLearner centred Problem orientedProblem oriented Curiosity drivenCuriosity driven ReflectiveReflective Individually and Individually and

culturally differentculturally different

Remember !Remember ! With Adult With Adult

learners our learners our role is that of a role is that of a GUIDE as GUIDE as much as a much as a teacher.teacher.

ChallengeChallenge Finding the balance between Finding the balance between

supervision and supervision and independence when teaching independence when teaching family practice residents. family practice residents.

What are the consequences What are the consequences of too little or too much of too little or too much independence?independence?

Too little Too little responsibilityresponsibility

BoredomBoredom DemeaningDemeaning UnchallengedUnchallenged Limited Limited

ProgressProgress No confidenceNo confidence

Too Much Too Much ResponsibilityResponsibility

Do not feel safe Do not feel safe to challenge to challenge themselvesthemselves

FearFear Medical error Medical error

and undesired and undesired outcomesoutcomes

Educational DiagnosisEducational Diagnosis

Deciding Deciding where your where your learner islearner is

What is an What is an educational educational diagnosis?diagnosis?

Bordage Bordage stages of stages of learninglearning

I Reduced knowledgeI Reduced knowledge II Dispersed knowledgeII Dispersed knowledge III Elaborated knowledgeIII Elaborated knowledge IV Compiled knowledgeIV Compiled knowledge

Discuss:Discuss:

Think of the resident you Think of the resident you have now or have had have now or have had recently. At what stage are recently. At what stage are they with many of the topics they with many of the topics you deal with?you deal with?

Where should they be?Where should they be?

BenchmarksBenchmarks The Program has developed a list The Program has developed a list

of benchmarks to help you of benchmarks to help you understand the levels of understand the levels of knowledge and skills a resident knowledge and skills a resident should have developed at each should have developed at each stage of their residency. See:stage of their residency. See:

http://www.familymed.ubc.ca/http://www.familymed.ubc.ca/residency/facultydevelopment/residency/facultydevelopment/BordageModel.htmBordageModel.htm

Start of 1Start of 1stst year year

Hospital Hx and Px taking an hourHospital Hx and Px taking an hour Large Knowledge gapsLarge Knowledge gaps Common vs. Uncommon?Common vs. Uncommon?

Little deductive abilityLittle deductive ability Therapeutics weakTherapeutics weak Contextual issues weakContextual issues weak

You need to:You need to: Observe Hx and ExamObserve Hx and Exam Observe pelvic exams and Observe pelvic exams and

proceduresprocedures Daily observation of parts of visitsDaily observation of parts of visits Question reasoningQuestion reasoning Correct mistakesCorrect mistakes Encourage resident to read around Encourage resident to read around

issuesissues

22ndnd half of 1 half of 1stst year year Crisper and more focused Hx and Crisper and more focused Hx and

examexam Better appreciation of range of Better appreciation of range of

common problems. (fewer esoteric common problems. (fewer esoteric dx.)dx.)

Better active listeningBetter active listening More rational use of investigationsMore rational use of investigations Better therapeuticsBetter therapeutics

You need to:You need to: Discuss each case but briefer and Discuss each case but briefer and

focusedfocused Allow resident more decision makingAllow resident more decision making Watch for gaps and encourage reading Watch for gaps and encourage reading

up, rapid EBM? Online information?up, rapid EBM? Online information? Review interviews and exams regularly Review interviews and exams regularly

and formally weekly. and formally weekly. Watch for over confidenceWatch for over confidence

22ndnd year to year to graduationgraduation

Significantly less Significantly less supervision.supervision.

As the resident As the resident progresses give progresses give him or her more him or her more opportunity to opportunity to be independent. be independent.

Teaching TechniquesTeaching Techniques

Take a couple of minutes and Take a couple of minutes and write down what teaching write down what teaching techniques you use when techniques you use when working with a medical student, working with a medical student, a first year or a second year a first year or a second year resident? Do you have resident? Do you have techniques that allow increasing techniques that allow increasing degrees of responsibility?degrees of responsibility?

Teaching TechniquesTeaching Techniques

Case DiscussionCase DiscussionFor First Year residents For First Year residents

needing greater supervisionneeding greater supervision Case ReviewCase Review Chart Review and recallChart Review and recall

- For Second Year residents or - For Second Year residents or those needing less supervisionthose needing less supervision

Suggestion:Suggestion: 1st day, resident watches you1st day, resident watches you Next 2-3 days, you watch to make an Next 2-3 days, you watch to make an

educational diagnosiseducational diagnosis Then, regular but decreasing direct Then, regular but decreasing direct

observationsobservations ““Credit” demonstrated competenciesCredit” demonstrated competencies Micro-skills (one minute preceptor)Micro-skills (one minute preceptor) Graduate to reviewsGraduate to reviews

Critical reflection, Open ended questionsCritical reflection, Open ended questions

ProgressionProgression

Observation and direction, knowledge Observation and direction, knowledge without application – without application – Medical StudentMedical Student

Application of knowledge, Freedom to Application of knowledge, Freedom to err in a safe environment – err in a safe environment – Early Early ResidencyResidency

Some independence with regular Some independence with regular review – review – Late Residency Late Residency

Independence with occasional review Independence with occasional review and observation – and observation – End ResidencyEnd Residency

Ask yourself:Ask yourself: Is the resident more Is the resident more

independent during the independent during the last week than the first?last week than the first?

Is part of your teaching Is part of your teaching objective to encourage objective to encourage independence?independence?

Has the resident Has the resident acquired skills for which acquired skills for which he/she is justifiably he/she is justifiably confident?confident?

Thank YouThis module was written as an aid to

the Preceptors in the Postgraduate Family Practice Program at the University of BC. Study credit is available to groups of

preceptors who complete the module Please give us your feedback on the module

so that we may improve it for others. Email you comments to Dr. Fraser Norrie,

Faculty Development, UBC Family Practice fraser.norrie@vch.ca