Pediatric Educational Excellence Across the Continuum (PEEAC)

ConferenceSept 2009

Goals

• Bring ideas from PEEAC conference• Reasons to add new tools.

– Time, Efficiency, short attention span of learner

• Present some tools for medical student and resident teaching– Strategies

– Resources – handouts from PEEAC

– Share Web-based resources and bibliography for further reading.

Medical students

• Orientation!!• “The Wave”• Priming –before student goes in the room.• Exam room presenting• Structured modeling• Limited observation – of particular portion of visit• Life-long learning journal• Learning with support staff

Efficiency: Creative SchedulingThe “Wave”

9AM-9:20AM: Student sees pt #1, preceptor sees pt #2

9:20AM-9:40AM: Pt #1 seen by both

9:40AM-10:00AM: Student charts pt #1,

preceptor sees pt #3

10:00Am-10:20AM: Student sees pt #4,

preceptor sees pt #5 and so on

Priming

• Review pt’s medical background

• Tell trainee what complaint to focus on

• Set guidelines for physical exam

• + Set time limit for encounter

• Alert student to sensitive issues

Exam room presentation

• Present at the bedside – while med student is presenting, MD can be examining child at the same time

Medical students• Orientation!!• ‘The wave’• Priming – read up/discuss before student goes in

the room.• Exam room presentation• Structured modeling• Limited observation – of particular portion of

exam• Life-long learning journal• Learning with support staff

Dr. Louis First’s Take-Home Lessons1. Never underestimate the power of “day one”

2. Always let the studententer first.

3. Feedback after every patient encounter and remember feedback is

not = to evaluation!

Resident/medical student

• One minute preceptor

• Aunt Minnie

• Two minute observation/drop in visit.

• Exam room presentations

• Narrative Medicine

• Spanish language lunches

• The next 6 slides are courtesy of Dr. Louis R First

The One-Minute Preceptor(Developed at University of

Washington)

1. Get a commitment – what is dx?2. Probe for supporting evidence3. Teach general rules4. Tell them what they did right5. Correct mistakes

Neher JO et al. J. Am. Board Fam. Pract. 1992;5:419.424

Step 1. Get a Commitment

“What do you think is going on with

this patient?”

versus

“This is obviously a case ofotitis.”

Step 2: Probe for SupportingEvidence

“What were the major findings thatled to your conclusion?”

versus

“What are the problem causes ofotitis?”

Step 3: Teach General Rules“Patients with acute otitis will have a

red non-mobile tympanic membrane.”

versus

“I think the patient needs amoxicillindue to his ear-pulling even if we can’t

see the drum.”

Step 4: Tell Them What They Did Right

“Your description of the tympanic membrane was quite accurate”

versus

“Thanks for seeing the patient first.Good job.”

Step 5: Correct Mistakes

“You can’t call a red ear otitis in acrying child without checking

mobility first. Let me show you”

versus

“You’ll learn with more experience.”

Does the One-Minute Preceptor Work?

• 29/36 faculty resurveyed 4 years after wkshp--90% still use it, 58% find it extremely helpful as clinical teachers (Neher et al. Clin Teach 1992; 5: 419-24)

• 57 residents randomized to use it at UCSF--87% of 28 residents found it useful;

• Students rated OMP residents vs controls higher in all skills except “teaching general rules”and “overall effectiveness”--also found to be more motivated to read (Furney et al. J Gen Intern Med 2001; 16:620-24)

» L. First MD

More on OMP Effectiveness(Aagaard E et al. Acad Med. 2004 79(1): 42-49)

• 116 preceptors at 7 universities watched videos of both OMP and traditional models using two cases

• With OMP model, preceptors better able to correctly diagnose pt’s condition, rated student ability higher on hx taking/PE skills, presentations, clinical reasoning, and FOK, and rated themselves more confident in rating students abilities

• OMP rated more effective and efficient than traditional model in teaching students

» L. First MD

Resident/medical student

• One minute preceptor

• Aunt Minnie

• Two minute observation/drop in visit.

• Exam room presentations

• Narrative Medicine

• Spanish language lunches

Aunt Minnie

(For developing rapid pattern recognition)• Learner sees patient, takes hx, does PE• Learner presents

– Main complaint and presumptive dx (30 sec)

• While learner writes up note, teacher sees pt, dx’s problem and creates plan (5 min)

• Discuss care w/ learner – 1-5 min reviews and signs chart 1-2 min

Resident/medical student

• One minute preceptor

• Aunt Minnie

• Two minute observation/drop in visit.

• Exam room presentations

• Narrative Medicine

• Spanish language lunches

Exam room presentation - Resident

• Especially useful for interns

• If resident is wrong, you can say “you raise an interesting point – I want to look something up – will you excuse us for a moment.” Then leave and resident comes back. Never contradict resident in the room.

Exam room presentations• No change in parent satisfaction – incl. parents seeing

resident as their doctor• Attendings preferred – able to assess resident skills,

model advice, and demonstrate PE• Residents – /less comfortable discussing sensitive

topics; embarrassed when asked a question they didn’t know the ans to. Better observation and feedback.

• No change in visit duration• Baker et al. Ambulatory Pediatrics 2007

• Promotes family centered care

Seeing residents’ patients• Study – teachers assigned rating to residents’

evaluations and the perceived severity of the care both immediately after resident presentation and again directly after seeing the patient.

• After seeing the patients, teachers rated residents evaluations less well and the patients as more severely ill

• Seeing patients took longer. – Gennis and Gennis; 1993.

• What do you do?

Also Activated Demonstration – watch how I counsel this mother on how assess potty training

readiness.

Evidence-based Physical exam

• Make the exercise evidence based– Rational Clinical Examination series - JAMA

• Ex. Does this child have appendicitis?• Bundy DG, et. al

• Systematic review– Why is this important?

– LR and summary LR ratios for physical findings

– Rebound tenderness LR=3.0

Resources

• Technology resources: 2 handouts from Drs Lopreiato and White

• Bibliography of best articles on teaching

• Web resource list

• http://library.med.utah.edu/pedineurologicexam/html/site_index_by_topic.html

• http://webmedia.unmc.edu/intmed/general/eye&ear/ear.htm 

• http://mediswww.cwru.edu/cardiacexam/ - wonderful for medical students. Not specific to peds.

• http://www.richmondeye.com/eyemotil.asp - great demonstration of cover uncover test (also afferent papillary defect)

• http://www.health.state.ny.us/nysdoh/asthma/brochures.htm Easy access to summary asthma guidelines – for medical students and residents. Also print easy to read brochures for patients – in multiple languages.

• www.breastfeedingbasics.org – nice educational module for medical students. Can complement videos distributed by Steve Caddle.

List of YouTube videos from Steve.

• http://www.youtube.com/watch?v=iSS3HnXeYSw

• http://www.youtube.com/watch?v=hqFhFwRLLB0

List distributed