Time Efficient Clinical Time Efficient Clinical TeachingTeaching

Tali Ziv, MDTali Ziv, MDKLIC-UCSF Internal Medicine Site DirectorKLIC-UCSF Internal Medicine Site Director

Assistant Chief of Medicine, Kaiser, OaklandAssistant Chief of Medicine, Kaiser, Oakland

Session OutlineSession Outline BackgroundBackground Introduction to the One-Minute Preceptor Introduction to the One-Minute Preceptor

ModelModel One-Minute Preceptor PracticeOne-Minute Preceptor Practice Introduction to SNAPPSIntroduction to SNAPPS Introduction to feedback and the Brief Introduction to feedback and the Brief

Structured Clinical Observation (BSCO)Structured Clinical Observation (BSCO) RIME FrameworkRIME Framework

Challenges with Clinical Challenges with Clinical TeachingTeaching

Time pressureTime pressure Competing demands Competing demands Unpredictable environmentUnpredictable environment Limited recognition for teachingLimited recognition for teaching Variable patient acceptance of learnersVariable patient acceptance of learners

One-Minute PreceptorOne-Minute Preceptor Teaching model initially developed for use Teaching model initially developed for use

in the outpatient settingin the outpatient setting33

Involves 5 steps:Involves 5 steps: Get a commitmentGet a commitment Probe for supporting evidenceProbe for supporting evidence Teach general rulesTeach general rules Reinforce what was done rightReinforce what was done right Correct mistakesCorrect mistakes

Neher et al. JABFP 1992.et al. JABFP 1992.

OMP: Step 1OMP: Step 1 Get a commitment from the learnerGet a commitment from the learner

Ask the learner what he/she thinks about the Ask the learner what he/she thinks about the casecase

Get a commitment to a diagnosis, work-up, Get a commitment to a diagnosis, work-up, treatmenttreatment

WHATWHAT> Why> Pearl> Good> Improve> Why> Pearl> Good> Improve

Probe for supporting evidenceProbe for supporting evidence Ask the learner for evidence to support their Ask the learner for evidence to support their

opinionopinion This allows faculty to identify gaps in This allows faculty to identify gaps in

knowledgeknowledge

What> What> WHYWHY> Pearl> Good> Improve> Pearl> Good> Improve

OMP: Step 2OMP: Step 2

OMP: Step 3OMP: Step 3 Teach general principles Teach general principles

Introduce a relevant rule or concept targeted Introduce a relevant rule or concept targeted to the learnerto the learner’’s level of understandings level of understanding

What> Why> What> Why> PEARLPEARL> Good> Improve> Good> Improve

OMP: Step 4OMP: Step 4

Reinforce what was done rightReinforce what was done right Reinforcing correct behavior helps the Reinforcing correct behavior helps the

behavior become firmly establishedbehavior become firmly established Focus on specific behaviors rather than Focus on specific behaviors rather than

general praisegeneral praise

What> Why> Pearl> What> Why> Pearl> GOODGOOD> Improve> Improve

Correct mistakesCorrect mistakes As soon after mistake as possible, find an As soon after mistake as possible, find an

appropriate time to discussappropriate time to discuss If possible, allow the learner to critique his/her If possible, allow the learner to critique his/her

performance firstperformance first

What> Why> Pearl> Good> What> Why> Pearl> Good> IMPROVEIMPROVE

OMP: Step 5OMP: Step 5

OMP Step 0OMP Step 0 Set a constructive learning environment.Set a constructive learning environment. Consider: Consider:

Space Space TimeTime Players and rolesPlayers and roles Goals and expectationsGoals and expectations Prime the learner for the encounterPrime the learner for the encounter

OMP Step 6OMP Step 6 What are the next steps?What are the next steps? What are the What are the ““to dos,to dos,”” and who and who’’s taking s taking

responsibility for them?responsibility for them? Highlight key themes experienced in Highlight key themes experienced in

session that could be explored further. session that could be explored further. Equip the student with tools to maximize Equip the student with tools to maximize

organization and efficiency. organization and efficiency.

OMP ClipOMP Clip

OMP: The EvidenceOMP: The Evidence

OMP faculty training associated with an OMP faculty training associated with an increase in specific feedback in increase in specific feedback in ambulatory encountersambulatory encounters44

Videotaped teaching encounters: OMP vs Videotaped teaching encounters: OMP vs TraditionalTraditional Faculty student skill assessment improvesFaculty student skill assessment improves55

Students felt feedback better with OMPStudents felt feedback better with OMP66

4. Salerno S. J Gen Int Med 2002.5. Aagaard E. Acad Med 2004.6. Teherani A. Med Teach 2007.

OMP PracticeOMP Practice

SNAPPSSNAPPS SSummarize briefly the history and findingsummarize briefly the history and findings NNarrow the DDx to 2-3 possibilitiesarrow the DDx to 2-3 possibilities AAnalyze the DDx by comparing/contrastingnalyze the DDx by comparing/contrasting PProbe the preceptor about questions, robe the preceptor about questions,

uncertaintiesuncertainties PPlan mgmt for patientlan mgmt for patient’’s medical issuess medical issues SSelect a case-related learning issueelect a case-related learning issue

Wolpaw TM et al. Acad Med. 2003.

SNAPPS – The EvidenceSNAPPS – The Evidence Third-year medical students receiving Third-year medical students receiving

SNAPPS training SNAPPS training More concise in their summariesMore concise in their summaries Presentations longer (1 min)Presentations longer (1 min) Expressed more clinical reasoning in Expressed more clinical reasoning in

presentationspresentations Expressed more uncertaintyExpressed more uncertainty Identified case based issues for further Identified case based issues for further

learninglearningWolpaw T et al. Acad Med. 2009.

FeedbackFeedback

Information on the studentInformation on the student’’s s performance given performance given for the purpose for the purpose of improving future performanceof improving future performance

Analogous to coachingAnalogous to coaching

Tips for Giving FeedbackTips for Giving Feedback Immediate and oftenImmediate and often Self-reflection firstSelf-reflection first Both positive and correctiveBoth positive and corrective Focus on behavior - not personFocus on behavior - not person Specific, not generalSpecific, not general Amount limited to what the student can Amount limited to what the student can

incorporate (not too much!)incorporate (not too much!) Check to ensure clear communicationCheck to ensure clear communication

Brief Structured Clinical Brief Structured Clinical Observation (BSCO)Observation (BSCO)

Tool for brief, real-time feedbackTool for brief, real-time feedback Attending enters patient room during patient Attending enters patient room during patient

encounterencounter Watches silentlyWatches silently Leaves when 3 feedback points obtainedLeaves when 3 feedback points obtained

Feedback discussed that dayFeedback discussed that day

BSCO PracticeBSCO Practice

Incorporating the BSCOIncorporating the BSCO

BSCO TipsBSCO Tips Orient student and patientOrient student and patient Consider asking student for focusConsider asking student for focus Try to remain silent and “invisible”Try to remain silent and “invisible” Consider times when you are required to Consider times when you are required to

be in the room anywaybe in the room anyway

RIME FrameworkRIME Framework

((OObserver) bserver) RReporter eporter

IInterpreter nterpreter MManageranagerEEducatorducator

OBSERVEROBSERVER - - struggling to report accuratelystruggling to report accuratelyREPORTERREPORTER Works professionally with patients, staff, colleagues; Works professionally with patients, staff, colleagues;

complete, reliable, accurate; gathers info, clearly complete, reliable, accurate; gathers info, clearly communicates with proper termscommunicates with proper terms

Understands pathophysiologyUnderstands pathophysiology Answers Answers ““WhatWhat”” questions. questions. INTERPRETERINTERPRETER Identifies, prioritizes problems Identifies, prioritizes problems Offers 2 or 3 Offers 2 or 3 reasonablereasonable possibilities with reasons applied possibilities with reasons applied

to the patient. (Students do not have to be to the patient. (Students do not have to be ““rightright””) ) Answers "Why" questions. Answers "Why" questions.

MANAGERMANAGER Selects among options Selects among options withwith the patient the patient Proactive rather than simply reactiveProactive rather than simply reactive Plans should be Plans should be reasonable,reasonable, include test options, include test options,

studentstudent’’s preferences, merits of therapies s preferences, merits of therapies Answers Answers ““How" questions. How" questions. EDUCATOREDUCATOR Identifies questions that can't be answered from Identifies questions that can't be answered from

textbooks textbooks Cites evidence on relevant new therapies, tests Cites evidence on relevant new therapies, tests Active in educating self, colleagues, and patientsActive in educating self, colleagues, and patients

SummarySummary Orient learner to goals/expectationsOrient learner to goals/expectations Choose a tool for clinical teaching (?OMP Choose a tool for clinical teaching (?OMP

vs SNAPPS)vs SNAPPS) Incorporate frequent observation and Incorporate frequent observation and

feedback (?BSCO)feedback (?BSCO) Think about your learnerThink about your learner’’s skill level s skill level

(RIME?) and next steps in their path(RIME?) and next steps in their path

ThanksThanks Special thanks to Maria Wamsley, MD Special thanks to Maria Wamsley, MD

who often teaches this topic with me.who often teaches this topic with me.

She has efficiently and effectively guided me on a personal She has efficiently and effectively guided me on a personal path to improving my skills in Faculty Development with path to improving my skills in Faculty Development with timely and constructive feedback timely and constructive feedback Much appreciated! Much appreciated!