Transcript Seven Clinical Teaching "Microskills"

Residents Teaching Workshop
UIC
University of Illinois
College of Medicine at Peoria
You are doctors. Why is
teaching so important?
 docere: Latin for “to teach”
Resident’s role as teacher
20% of time spent teaching
However, residents often did not…
 promote participation
 ask problem solving questions
 give feedback *
What are the difficulties?????
* Neal Whitman, Thomas L. Schwenk, The Physician As Teacher, Whitman Press
Teaching and assessment skills improve
with practice
Do you make a difference?
Workshop Overview
 Setting Personal Goals
Today’s 4 Modules:
 Module I: Teachable Moments
 Module II: The “One-Minute Preceptor”:
Clinical Teaching Microskills
Lunch
 Module III: Providing Feedback Evaluating Students
 Module IV: OSTE – putting it to work
 Reflections
Ground rules






One person at a time
Everyone participates
Be concise
Show respect
No side conversations
Have fun!
3
Personal Goals
(p. 7)
Please identify three learning goals to
enhance your own teaching skills that you
would like to address during the residents
as teacher’s workshop.
Module I:
Teachable Moments
At the end of this module, you will be able
to
Discuss some of the educational principles
behind medical education
Orient the students or intern to their new
rotation
Identify the goals and objectives of the M3
clerkship in their area of residency training
Note: on-line resources on p. 8
Memorable teachers
(p. 9)
Think back over medical school
 Poor clinical teacher
 Can’t remember what was taught
What did that teacher do that made the
teaching so ineffective?”
5
Memorable teachers
(p. 10)
6
Think back over medical school
 Exceptional clinical teacher
 You still remember the lessons
What did that teacher do that made their
teaching so effective?”
Why teach?
illiterate
of
the teach,
21st
By
learning
you
will
IThe
believe
that
every
human
century
willyou
not will
be those
by
teaching
learn.
soul
is teaching
something
who
cannot nearly
read
and
write,
to
someone
every
Latin
Proverb
but those
who
cannot
minute
here
in mortality.
learn, unlearn,
and
relearn.
M. Russell Ballard
Alvin Toffler
Active Learning
What I hear, I forget.
What I hear and see, I vaguely recall.
What I hear, see, and discuss, I understand.
What I hear, see, discuss, and do, I remember.
What I teach to another, I master.
Types of teaching
Lecture
 Teacher-centered
Discussion
 Group-centered
Independent study
 Student-centered
Teacher – learner model
Context
Learner
Teacher
Content
K Skeff, Faculty Development Fellowship Workshop, April 1999
The Educational Cycle
(p. 11)
Plan
Reflect
Teach
Assess
7
Teaching Encounters
Average 4.5
Teachers
must
min *
 Analyze quickly
Presentation
- 2.5 min.
Inquiry

Teach -efficiently
1 min.
Teaching

Teach effectively
- 1 min.
Presentation
Inquiry
Discussion
* DM Irby, Presentation, Faculty Development Workshop, April 1999
Teachable Moment
p. 12
 A medical student is starting a new
clinical rotation. Review the film clip that
will be shown to you.
http://www.meded.virginia.edu/courses/fm/precept/mod
ule4/m4p2.htm
Discuss the strengths and weakness of these student-
resident encounters in relation to the
Plan-Assess-Teach-Reflect cycle.
Orientation Brainstorming
Exercise (p. 13)
What were your expectations for your first
rotation?
Reflect back on the time you started your first
rotation:
 Clarity of expectations??
 Effective communication of expectation??
Large source of performance problems
Learner’s needs
(p. 14)
Reflect back on the same experience.
 Put yourself in the position of the teacher
How can you best identify and address
the learner’s various expectations and
needs?
Set & COMMUNICATE
expectations
Rationale:
 Defined role makes
learners and teachers more
confident
 Base teaching activities on
learner’s needs &objectives
 Evaluation drives learning
Set expectations
The “Orient Approach”






Orientation
Responsibilities
Interchange
Education
Needs
Timing of follow-up session
Set Expectations
Orientation
Clarify mutual goals and expectations
Discuss mutual goals and objectives
Start with the learner
Responsibilities
Learner’s role in patient care and teamwork
Call, rounds, team dynamics, charting
Interchange
Balance service vs. learning during rotation
– Adapted from BeST program UC Irvine
Set Expectations
 Education
Model self-directed learning
Suggestions for reading and learning during rotation
 Needs
Other questions/interests learner has
Anything else going on that you might help with
Students need to feel like they are progressing
 Timing of follow-up session
Final comments or questions
Set time for follow up on goals and expectations
– Adapted from BeST program UC Irvine
Examples
10
 ”What do you hope to learn during this
rotation?"
”You will do one H&P each admitting day.”
”Each Friday, I meet with the students for
feedback."
Examples
10
 ”What do you hope to learn during this
rotation?"
”You will do one H&P each admitting day.”
”Each Friday, I meet with the students for
feedback."
Non-examples
"Rounds start at 8:30. See you there.“
What wasn’t explained??????
Goals and Expectations of
M3 clerkship
How many of you are aware of the
medical student clerkship requirements in
your area of training?
Fulfilling the Educational
Objectives of the Clerkship
Gather into groups by
specialty.
Review the educational
objectives for the clerkship
in your specialty.
Select 2 objectives.
35
Fulfilling the Educational
Objectives of the Clerkship
 At your table:
Devise a teaching strategy to
accomplish the selected
objective.
p. 16
35
Large Group Discussion
Conclusion
One minute paper
Identify 2-3 characteristics you will utilize
during orientation to help your learner
transition into their clinical experience.
10 minute break
9
8
7
6
5
4
3
minutes
until
the
10
2
minutes
until
the
Please take your seats
workshop resumes
at 10:45 sharp!
Module II- The Microskills of
Clinical Teaching
At the end of this module, the
resident will be able to:
Identify the five plus 2 microskills of
clinical teaching
Recognize the teachable moment and
apply the microskills effectively
Teaching Encounters
Average 4.5
Teachers
must
min *
 Analyze quickly
Presentation
- 2.5 min.
Inquiry

Teach efficiently
- 1 min.
Teaching

Teach effectively
- 1 min.
Presentation
Inquiry
Discussion
* DM Irby, Presentation, Faculty Development Workshop, April 1999
The Microskills
Seven skills (5 + 2)
Easy to learn
Efficient
Evidence based
Use day-to-day
 Neher JO, et al, a Five-Step "Microskills" Model of Clinical Teaching, Journal of the
American Board of Family Practice, Vol. 5, No. 4, pp. 419- 423. (1992)
8
To use microskills
Identify teachable moment
Diagnose the learner
No hard and fast rules
To use the Microskills
 Listen for cues
 When you hear a cue,
use the appropriate
Microskill
Scripted video Vignettes:
Small group discussion
Common clinical teaching situations
Look for:
 Opportunity to teach
 Best way to teach
Scene 1
Summarize in One Sentence
12
Cue: Scenario 1
 The learner’s image of the case is unfocused
Response
 “Tell me the key points of the case in
one sentence.”
Summarize in One Sentence
Rationale:
 Brings the “big picture” into focus
(cognitive representation)
 Helps student “see” the diagnosis
12
Scene 2
Generate Hypotheses
14
Cue:
The learner does not commit to a dx, or
commits to a diagnosis without considering
important alternatives...
Response:
Resist the urge to list those alternatives
Ask, "What other diagnoses should we
consider?”
Generate Hypotheses
Rationale:
 Prevents premature closure
 Teaches learner to consider alternatives
 Reveals learners knowledge
14
Examples
14
 “What other diagnoses did you consider, and
how did you exclude them?”
 “What other pathophysiologic processes
could cause this presentation?”
Non-examples
14
 “What are the 12 causes of atrial fibrillation?"
Scene 3
Get a commitment
Cue:
 Learner presents the facts,
then stops ...
Response:
 Resist the urge to fill in the
verbal blank
 Ask the learner what they think
16
Get a commitment
Rationale
Students must learn to:
 Put a case together
 Formulate an assessment
 Take responsibility for care
16
Examples
16
 "What is your diagnosis?”
 What do you think is the most likely diagnosis?
 "What lab tests should be ordered?"
Non-Examples
 ”Now which symptom came first?”
 "Sounds like bronchitis to me."
 “What did you do at this point?”
16
Probe for Supporting Evidence
18
Cue:
 The learner commits to a diagnosis…
and looks to you for confirmation.
Response:
 Resist the urge to pass judgment on the
opinion just stated
 Ask, "What data support your assessment?"
Probe for Supporting Evidence
18
Rationale:
 Learner must demonstrate problem solving skills
 Reveals learner’s knowledge and gaps
 "Thinking out loud" is a low-risk way for
learners to make mistakes
Examples
 "What led you to that conclusion?"
 "Why did you choose that medication?“
 “Are there any findings that are left
unexplained by your diagnosis?”
18
Non-examples
18
 "I don't think this is appendicitis. Do you
have any other ideas?"
 "Is there any suprapubic tenderness or
pyuria?"
Assess




Summarize in one sentence
Generate hypotheses
Get a commitment
Probe for supporting evidence
Plan
Assess
Reflect
Teach
Teacher – learner model
Context
Learner
Learner
Teacher
Content
K Skeff, Faculty Development Fellowship Workshop, April 1999
Teach a general rule
20
Cue:
There are gaps in the learner's knowledge
Response:
At last! It's time to "teach"
Teach useful, generally applicable principals
Talk at the learner's level
Don't mini-lecture
Teach a general rule
20
Rationale:
 General rules can be applied again and again
Understanding improves recall
If neither of you know, then teach how to
find the information needed
Examples
20
 “Patients with vertigo and a positive
Hallpike
test have a non-urgent cause for dizziness.”
“Oxygen decreases pulmonary vascular
resistance. This decreases RV pressure and
increases LV filling, promoting diuresis.”
“When that happens, this is what to do…”
Non-examples
“I would not start heparin in this case.”
“I order an EKG on every patient.”
20
Correct mistakes
Cue:
The learner demonstrates a
misunderstanding or error
Response:
Give corrective feedback
22
Correct mistakes
22
Rationale:
 Learners may not see the mistake
 Mistakes left uncorrected will be repeated
 Learners who are aware of a mistake are in
a "teachable" state
Examples
“That dose of acyclovir is too high for a
patient with decreased renal function.”
“This may be acute gout, but you can't
exclude septic arthritis unless you tap the
joint.”
22
Non-examples
"Those lab tests were completely
unnecessary.”
"You did what?!"
22
Reinforce what was right
24
Cue:
 A learner handled a situation very effectively
Response:
 Give reinforcing feedback
 Focus on the specific behavior
 Avoid general praise
Reinforce what was right
24
Rationale:
 Learners may not know what is right
 Unless reinforced, competencies may never
be established
 Recognizing good performance builds
respect
Examples
24
"You identified poor nutritional status in your
problem list, and addressed it in your plan."
”You obtained cultures before starting
antibiotics. This will allow us to select the
most effective treatment."
Non-examples
"You are right. That is a good decision."
"You did that skin biopsy very well."
"Good job!"
24
Teach
Teach a general rule
Correct mistakes
Reinforce what was right
Plan
Assess
Reflect
Teach
Teacher – learner model
Context
Teacher
Teacher
Learner
Content
K Skeff, Faculty Development Fellowship Workshop, April 1999
Conclusion
One Minute Paper
Lunch break
Module III: Giving Feedback
At the end of this Module, you will be able
to
State the difference between evaluation and
feedback
Discuss the value of feedback in the process
of learning and medical education
Provide skillful and constructive feedback to
the learners
Feedback
25
Feedback
Learners want to know how they are doing
Surveys show they do not remember getting
enough feedback on their performance
Imagine a
world without
feedback
Feedback vs. Evaluation
25
Feedback:
Ongoing; provided day-to-day
Formative- help learners direct their
efforts
Evaluation:
Provided at the end of a course of study
Summative- a judgment relative to standards
Scenario: Typical day of
morning rounds
 Student, “ Ms. J is our 65 yo f with right arm cellulitis on day 3 of
vanc. She has no complaints and on exam HEENT- PERRL, lungs
were clear…”
 Resident interrupts, “you can just give us the pertinent findings,
including her vitals”
 Student proceeds, “…and her cultures came back as MSSA. Since
she’s improving, I thought we could continue her on the vanc for a
14 day course.”
 Resident, “Typically we only use vanc when the culture comes back
as MRSA because of resistance we like to limit the use of vanc in
other infections.”
 Rounds proceed and resident tells the student “good job” before
moving to the next patient.
– Adapted with permission from Heather Harrell ( www.im.org/AAIM)
Does the student think this
was feedback?
 Informal setting
Students often only recognize feedback in a formal “sit
down” session.
 Rushed setting
May not process “feedback of the fly” without
reinforcement
 Stressed setting
Tone of the scenario unclear, but if resident sounds
frustrated or abrupt, student may fixate more on tone
than content.
 Contradictory message
Ending the feedback with a general “good” may confuse
or even negate prior feedback. End with last thing you
want the students to remember.
Was it feedback?
Feedback occurs when a learner is offered
specific comments on what s/he did and
its consequences. (Adapted from Ende)
Student informed did not give pertinent
findings
Student was reminded vitals are considered
pertinent
Consequences of indiscriminant vanc use
explained.
Characteristics of Effective
Feedback
 Specific
“you can just give us the pertinent findings, including
her vitals” 
 Timely
During rounds is immediate 
 Based on objective not subjective data
Direct observation on rounds 
 Consequences explained
“Typically we only use vanc when the culture comes back
as MRSA because of resistance we like to limit the use of
vanc in other infections.” 
 Provides “next step”
“Good” 
 Goal is to help, not punish
“Resident interrupts” tone may seem punitive 
Improved scenario
 Student, “ Ms. J is our 65 yo f with right arm cellulitis on day 3
of vanc. She has no complaints and on exam HEENT- PERRL,
lungs were clear…”
 Resident interrupts, “you can just give us the pertinent
findings, including her vitals”
 Student proceeds, “…and her cultures came back as MSSA.
Since she’s improving, I thought we could continue her on the
vanc for a 14 day course.”
 Resident, “Typically we only use vanc when the culture comes
back as MRSA. What other antibiotic would you like to use?”
 Rounds proceed, resident pulls the student aside as walking
“Your presentation started out good with a clear and concise
opening but I want to give you some feedback. You don’t have
to provide as much detail in your oral presentations as you do
in your SOAP notes, particularly in the ‘O’ (objective) part. On
your next patient, try a more focused approach with the
objective findings”.
Why so little feedback ??





Giving feedback:
25
 State that you are going to give feedback
 Involve the learner in the process
 Use neutral, non-judgmental language
 Focus on the behavior, and the learning
goals, not the person
IMPROVE feedback model
I · Identify rotation objectives with the student
M · Make a feedback friendly environment
P · assess Performance · Prioritize the feedback you provide
R · Respond to the student's self-assessment
O
· be Objective: report specific behaviors observed; · describe potential
outcomes of behavior
V · Validate what the student has done well or suggest alternative strategies
E
· Establish a plan to implement changes (if needed) · Have the student
summarize feedback and the plan
Feedback vs. Evaluation
25
Feedback:
Ongoing; provided day-to-day
Formative- help learners direct their efforts
Evaluation:
Provided at the end of a course of study
Summative- a judgment relative to standards
Table 1.
Comparing Feedback and Evaluation Sessions
FEEDBACK EVALUATION
Timing
Timely
Setting
Informal
Basis
Observation
Content
Objective
Scope
Specific
Actions
Purpose
Improvement
Scheduled
Formal
Observation
Objective
Global Performance
“Grading” &
Improvement
Mid-clerkship assessment & feedback
MIDTERM FEEDBACK
M3 FAMILY MEDICINE CLERKSHIP
CLINICAL PERFORMANCE AT SITE
Student Name:______________________________
Clerkship Dates:_________________________
Preceptor Name (Please Print):______________________________
Site:______________________
Please use the language of the final Clinical Performance Report wherever possible when you fill out this midterm feedback sheet. DO
NOT ASSIGN A GRADE.
1.
2.
3.
4.
History Taking - Data Gathering
a.
Improvements suggested____________________________________________________
_______________________________________________________________________
b.
Skills in which student is doing well__________________________________________
_______________________________________________________________________
Physical Exam - Data Gathering
a.
Improvements suggested____________________________________________________
_______________________________________________________________________
b.
Skills in which student is doing well__________________________________________
_______________________________________________________________________
Doctor-Patient Relationship
a.
Improvements suggested ___________________________________________________
_______________________________________________________________________
b.
Skills in which student is doing well__________________________________________
_______________________________________________________________________
Anticipatory Health Care
Mid-clerkship feedback form
The University Of Illinois College Of Medicine At Peoria
DEPARTMENT OF SURGERY
SURGERY CLERKSHIP
MID-CLERKSHIP FEEDBACK FORM
STUDENT NAME:
PT assessments/SOAP notes:
red*
yellow
green
Presentations on rounds:
red*
yellow
green
Interactions in OR:
red*
yellow
green
Knowledge base:
red*
yellow
green
Data management:
red*
yellow
green
Interpersonal relations:
red*
yellow
reen
Specific strengths of this student:
1.
2.
Specific areas this student can improve:
1.
2.
Comments (*please elaborate on any “reds”):
Completed by:
FACULTY SIGNATURE
NAME
Date:
2006 Mid-Clerkship Feedback Form #2
FACULTY PRINTED
Example of clerkship
evaluation
 OBGYn
The Residents Teaching Workshop
Module IV
Module IV: OSTE
At the end of this session, the residents
will be able to
Practice microteaching skills utilizing a
standardized student encounter
Practice providing feedback utilizing a
standard student encounter
Microskills
1.
2.
3.
4.
5.
6.
7.
8.
Set expectations
Summarize in a sentence
Generate hypotheses
Get a commitment
Probe for supporting evidence
Teach a general rule
Correct mistakes
Reinforce what was right
Breakout Groups
30
Three standardized student exercises



Discussion
Select
a teacher

8 – 10a min.
Select
commentator

the “teacher”
6 –First
8 min.
interaction




Next
commentator
Casethe
presentation
Also,
the std.
student
Teaching
opportunity
 Gelula MH, Using Standardized Students to Improve Junior Faculty Teaching,
Academic Medicine, Vol 73, No 5, May 1998
Questions
31
During the standardized student exercise
What observations did you make?
What approaches worked well, and why?
What approaches did not seem to work as
well, and why?
Standardized students
What did you observe about teaching
31
Reflection
Back to our medical student
You are still on the wards
Benoit, the M3, is finishing a month
working with you
You sit down to talk
What questions do you
have for him?
32
Reflect
Cue:
At the end of an educational experience
Response:
Plan
“What went well?”
“What would you do differently”?
Reflect
“What caught your interest?”
Teach
Assess
Reflect
Rationale:
Reorganize what was learned
Build understanding
Enhances learning and recall
Encourage personal inquiry
32
The Educational Cycle
33
Plan
• Set expectations
Assess
Reflect
• Make time to reflect
• Summarize in a sentence
• Create hypotheses
• Get a commitment
• Probe for evidence
Teach
• Teach general rules
• Correct mistakes
• Reinforce right
In summary
1.
2.
3.
4.
5.
6.
7.
8.
9.
Set expectations
Summarize in a sentence
Generate hypotheses
Get a commitment
Probe for supporting evidence
Teach a general rule
Correct mistakes
Reinforce what was right
Make time to reflect
34
The microskill-based teacher
Restrained
Selective
Efficient
At the learner’s level
“Gives” discussion to
the learner
Gives feedback
Reflection on this workshop
Lets go around the room:
What is one thing you will take away from
this workshop?
Again…….
Reflection on this workshop
Lets go around the room
What is one thing we should do differently
next time?
For your reading pleasure…
37
Sir William Osler as
Teacher to Emulate
James A. Knight
Thank you from the students
And faculty of
The Resident’s Teaching Workshop