Transcript Advancing Competency-Based Curriculum using CanMEDS

Teaching 101: A Workshop for
New Teachers
Mark Robinson PGY2 MD MSc BEd
Colin Newman MD CCFP
Risa Bordman MD CCFP FCFP
Introductions
What is your experience with
teaching?
Why did you start teaching?
What are your expectations for
the workshop?
Overview
• Before the Student Arrives
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What makes a good teacher?
Today’s medical learner
Triple C and other acronyms
How to prepare your office
• After the Student Arrives
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Student-Patient Encounter
Giving Feedback
Challenges
Case discussion
Resources and SOT
Time Management
Why Teach?
“In a completely rational society,
the best of us would aspire to be
teachers and the rest of us
would settle for something less,
because passing civilization
along from one generation to
the next ought to be the highest
honor and highest responsibility
anyone could have.”
Lee Iacocca
Attributes of a Good Teacher
Reflect on the teachers you found most effective
What made them good teachers?
What does the literature say?
Sutkin G et al. What makes a good clinical teacher in
medicine? A review of the literature. Academic
Medicine. 2008;5:452-466
•Qualitative analysis of literature:
68 articles of 4914
1909-2006
Physician
Teacher
Human
Physician characteristics:
• Demonstrates medical/clinical knowledge (30)
• Demonstrates clinical & technical skills, clinical
reasoning (28)
• Shows enthusiasm for medicine (19)
• Models a close doctor-patient relationship (10)
• Exhibits professionalism (8)
• Is scholarly (6)
• Accepts uncertainty in medicine (1)
Teacher characteristics:
• Maintains positive relationships with students & a
supportive learning environment (27)
• Demonstrates enthusiasm for teaching (18)
• Is accessible/available for teaching (16)
• Provides effective explanations, answers to questions &
demonstrations (16)
• Provides feedback (15)
• Organized (14)
• Stimulates trainees reflective practice and assessment
(4)
Human characteristics
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Communication skills (21)
Acts as a role model (15)
Is an enthusiastic person in general (14)
Is personable (12)
Is compassionate/empathic (11)
Respects others (11)
Has self-insight, self-knowledge and is reflective (2)
Attributes of a Good Teacher
from Paukert and Richards, 2000
1. Teaching (good teacher, taught well)
2. Topics Taught (skills, Hx, PE)
3. Commitment to Teaching (interest, effort)
4. Role Model
5. Caring (treats students well)
8. Global (enjoyable, good person, …)
9. Supportive and Helpful Person
13. Knowledge of Medicine, well read
Attributes of a Good Teacher
from Dr. David Irby
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Enthusiasm
Clarity and Organization
Clinical Competence
Modeling Professional Characteristics
Group Instructional Skill
Clinical Supervision
Breadth of Medical Knowledge
Attributes of a Bad Teacher
• Mainly Lacks Instructional Skills
– Including limited knowledge, poor communication
• Also has Negative Personal Attributes
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Arrogance
Apparent dislike of teaching
Inaccessible
Lack of self-confidence
Unorganized boring presentations
Dogmatic
Insensitive
Belittling
Fears & Anxiety about Teaching?
What makes us anxious?
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Not knowing an answer?
Fear of being shown up by a resident?
Fear of being out of date?
Self-identity issues?
Fear of residents/students not valuing our
teaching/skills/patients/core values?
• (SECRET: Residents are anxious too!)
So how do you get better (and
conquer anxiety)?
Role model desirable behaviour
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Leadership
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Communication
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Professionalism
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Clinical Skills
Learn to be a good teacher
Gain knowledge/skills in teaching by:
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Reading & on-line modules
Attending Faculty Development sessions
Taking courses
Master’s degrees
Deliberate & reflective practice
Today’s Medical Learner
Coming from an increasingly diverse background:
Older student
average age entry 24 years
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Today’s Medical Learner
Coming from an increasingly diverse background:
Older student
average age entry 24 years
More educated
Only 7% had not completed a bachelor’s degree
(>20% with graduate degree)
More visible minorities than Canadian population
Black/Aboriginal underrepresented (1.3% vs. 8.1% in Canada, 2007)
Chinese/South Asian overrepresented (16.5% vs. 8.7% in Canada,
2007)
CMAJ Apr 16,2002;166(8):1023-1028 Effects of rising tuition fees on medical class composition and financial outlook
CMAJ Apr 16,2002;166(8):1029-1035 Characteristics of first-year students in Canadian medical schools
Medical Education 2010; 44: 577 – 586 Increasing tuition fees in a country with two different models of medical education
2011 Canadian Medical Education Statistics Volume 33
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Today’s Medical Learner
More worried about financial situation
>85% report they will graduate with debt
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2011 Canadian Medical Education Statistics Volume 33
Today’s Medical Learner
More worried about financial situation
>85% report they will graduate with debt
Pro-technology
Familiar with online resources and “The Paperless Office”
Comfortable with small-group learning
Becoming more integrated into medical school curricula
Exposed to Adult Models of Learning
Moving from pedagogy to andragogy
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An Adult Learner
Moves from dependence to independence, self-directed
Controls nature, timing, and direction or process = greater efficiency
Builds upon past knowledge and experiences
Biases can facilitate or hinder learning
Motivation often based upon performance and relevance
Identifies own knowledge gaps through situations
Wants to learn in “real-time” for instant application
Needs respect
Acknowledge their past experience, they’re not “kids”
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Typical Medical Learner Resources
The Smart Phone (not just for texting anymore)
a.k.a. their “iBrain”
Many excellent applications for quick reference:
Epocrates, UpToDate, Micromedex, LU codes, Eponyms…
Internet searches: Google, PubMed
Hardcopy Resources
•Rx Files (Cdn drug guide)
•Anti-infective Guidelines for
Community-acquired Infections
•Toronto Notes
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What Residents Need… (how you help)
1. Completion of Approved Resident Training Program
2. Completion of CCFP exam (two components)
CCFP written component
Clinical skills component (LMCC-Part II + CCFP oral exam)
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What Residents Need… (how you help)
CFPC (2013) requires resident programs to attest that:
History
Physical
Investigations
Diagnosis
Management
Referral
Follow-up
Pt-centred
Communication
Clinical Reasoning
Selectivity
Professionalism
Procedural Skill
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Where the Preceptor comes in
Frequent, timely feedback.
Field Notes
qualitative, “daily” feedback – leads to reflection.
Not for making final judgments but directing self-learning.
Evaluations:
In-Training Evaluation Reports (ITERs) (usually monthly)
A rubric check-list of CanMEDS-roles and “level of training”
HONESTY
Final In-Training Evaluation Reports (FITERs)
End of residency
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Preparation and Planning
• Preparing yourself
• Preparing the setting
• Preparing the staff
• Preparing the patients
• Preparing the student
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Before the Student Arrives
• Communication (student, staff)
– How can staff help overcome patient reluctance?
• Schedule time for orientation
• Possibly modify bookings?
• Organize room space
– Space for student
• Plan for down time
When the Student Arrives
• Expectations (student and doctor)
• Student’s prior experience
– Learning plan/contract
• What student will/won’t see
• Patients may set limits or decline
– Can this be overcome?
• Inform re schedule (start times, lunch, etc.)
• Discuss out of office involvement
• EMR 101
– How charts are organized, where to find things
• SOAP, Cumulative Patient Profiles.
When the Patient Arrives
• Review chart with student
• Decide if you will see the patient together, or
student first (Hx and/or PE)
• Notify patient of student
– Who? When?
• Set appropriate time limit for student’s
interview
Learners benefit most from
experiential, case-based learning
and subsequent discussion of cases
Bowen JL, Irby DM. Assessing Quality and Costs of Education in the
Ambulatory Setting: A Review of the Literature. Acad Med. July 2002
Vol. 77 No. 7 621-680
Effective Teaching – Key Components
Take advantage of all learning opportunities
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Direct observation
•“Fly on the wall”
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Case Discussion/Chart Review
•Read around Cases
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Bring the student in for important learning ops
•Physical findings, forms, counselling etc.
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Mini-talks to patients
•Chol, smoking, weight, immunizations
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Others can help teach
•Nurse, secretary, pharmacist, patient etc.
The One-Minute Preceptor
Five micro-skills
1. Get a commitment
2. Probe for supporting evidence
3. Teach general rules and principles
4. Reinforce what was done right
5. Correct any mistakes
Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills”
model of clinical teaching J Am Board Fam Pract 1992; 5:419-24
1. Get a commitment
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Ask a question about one aspect of the
case: diagnosis, investigation, or
treatment
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Push the trainee out of their comfort zone
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“What is the most likely diagnosis? Other diagnoses?”
“What lab tests do you want to order?”
“Do you want to hospitalize this patient?”
2. Probe for supporting evidence
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Resist the temptation to give your opinion
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Try to understand the trainee’s clinical
reasoning (did they simply guess?)
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“Why do you think this is the most likely diagnosis?”
“Why do you want to prescribe this medication?”
“Why do you want to hospitalize this patient?”
3. Teach general rules and principles
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Teach one practice pearl or summarize an
important point
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Offer advice on information search
strategies or practice management
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“When prescribing antibiotics I find this resource helpful.”
“These are the criteria for hospitalization in patients with
pneumonia.”
4. Reinforce the positive
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Skills that are not yet well-established
need to be reinforced so that they are
integrated into the next clinical encounter
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Be precise
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“Your diagnosis of “probable pneumonia” was wellsupported by your history and physical exam.”
“You did well because …”
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• “good work!” does not help the learner improve
5. Correct mistakes
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Limit your negative comments to one or
two
Offer suggestions of how to do better next
time
“I agree that we will need to order PFTs later on, but the
patient is too sick at present. For now we need his peak
flow and his oxygen saturation.”
“You mentioned that the child has fever but you did not
objectify it or mention if he looks toxic”
Case 1
The One-Minute Preceptor
Five micro-skills
1. Get a commitment
2. Probe for supporting evidence
3. Teach general rules and principles
4. Reinforce what was done right
5. Correct any mistakes
Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills”
model of clinical teaching J Am Board Fam Pract 1992; 5:419-24
Evaluating and Reflecting on Teaching
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Encourage learners to complete evaluation forms
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Ask for informal feedback from the trainee, and role
model the ability to respond to critique from others
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Seek the advice of colleagues
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Use opportunities like this workshop to reflect on
your teaching
Effective Teaching – Key Components
Give specific feedback
• LABEL IT
• In an open and non-threatening atmosphere
• Based on observation of performance
• Geared to learner’s level of training
• Positive as well as negative comments
• Offer suggestions for improvement
• Ask for self-reflection from learner
FEEDBACK-Formative
• Describes what the learner is doing in an encounter,
and relays that information back
• Used by the learner to make adjustments
• Occurs frequently
• Is tracked using Formative assessment tools,
• direct observation, checklists, field notes, simulation
• The qualitative and quantitative data that feeds into
a summative assessment process
FEEDBACK-Summative
• Summary of a sufficient collection of
formative assessments
– Multiple: sources, observers, occasions, tools
– Qualitative and quantitative.
• Matched to goals, objectives and stage of
learner
• Used to:
– refine goals to reflect the learner’s mastery
– to determine areas in need of remediation
Giving Feedback
Berguist, Phillips, Pfeiffer, Jones
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Solicited
Well Timed
Descriptive
Evaluative
Concerns what is said/done (not why)
Focus on Behaviour that can be changed
Limit the amount of information presented
Giving Feedback Cont., Phillips, Pfeiffer,
Jones
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Involves sharing of information
Need to verify
Avoid collusion
Watch the consequences
Same Case Different Resident
The One-Minute Preceptor
Five micro-skills
1. Get a commitment
2. Probe for supporting evidence
3. Teach general rules and principles
4. Reinforce what was done right
5. Correct any mistakes
Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills”
model of clinical teaching J Am Board Fam Pract 1992; 5:419-24
Student In Difficulty
• Call your Program Director
• Steinert/Levitt: Working with the "problem" resident:
Guidelines for definition and intervention. Fam Med 1993
Nov-Dec;25(10):627-32.
– What is the learner’s problem?
• Knowledge, Skills, Attitude
– What are the contributing factors?
• Teacher, system
– What is the potential impact problem?
The Different Student
Bordage/Shafir
• Reduced
– Knowledge, culture,
depression
• Dispersed
– Poor judgment
• Elaborative
– Reality
– Set limits
The Different Student Cont.
Bordage/Shafir
• Compiled/Expert
– Look for red flags
– Appropriate
questions
• Risky to skip steps!
Section of Teachers
La Section des Enseignants
Section of Teachers – Resources
for Teachers – Networking for
Teachers
The mission of the Section of Teachers is to
promote education within the discipline of
family medicine
Objectives
a) To advance the discipline of family medicine within
the objectives and strategic plan of The College of
Family Physicians of Canada.
b) To coordinate and facilitate communications related
to the undergraduate and postgraduate education,
curriculum, and accreditation issues and activities
of the College of Family Physicians of Canada
2013-2014 Slate of Officers
Activities
• Family Medicine Education Forum
• Family Medicine Forum – faculty development sessions
• CFP “Teaching Moment”
• Annual Dinner
• Ian McWhinney Family Medicine Education Award
• Program Groups
Benefits of Membership
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Teachers page in Canadian Family Physician (CFP)
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Faculty Development Resources
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Reduced Subscription Rate to Educational Journals
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Opportunity to have significant input to the educational
issues facing teachers in the College through the
Section of Teachers Executive
Resources: Faculty Development Sites
CFPC Triple C Toolkit
http://www.cfpc.ca/TripleCToolkit/
Provincial Faculty Development Resource
http://www.r-scope.ca/websitepublisher/
Institutional websites
http://med.ubc.ca/faculty-staff/faculty-development/
Resources: Faculty Development Modules
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Common topics in clinical teaching (feedback, evaluation,
time efficient teaching, learner in difficulty etc etc)
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Packages of printed modules + facilitator guide
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Designed for use in small groups of teachers – including
inter/intra professional groups
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No content expertise required
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Particularly helpful for clinical teachers remote from
traditional fac dev offerings
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Similar format to modules used in the PBSGL program, but
a separate organization
http://fhs.mcmaster.ca/facdev/pbsg-ed.html
Resources: Accredited Online Modules
Practical Prof: http://www.practicaldoc.ca/teaching/practical-prof/
STFM: http://www.stfm.org Teaching Physician
This Changed My Practice – Teaching: http://thischangedmypractice.com
AFMC: http://www.afmc.ca
Resources: Non-Accredited Online Info
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Institutional blogs
Newsletters
YouTube videos (ex. Pearls and Pitfalls for Preceptors - 3P)
A few readings…
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Ferenchick et al. Strategies for efficient and effective teaching in the
ambulatory care setting. Academic Medicine 1997;72:277-280.
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Irby et al. Time efficient strategies for learning and performance. Clinical
Teacher 2004;1(1):24-28.
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Neher et al. A five-step microskills model of clinical teaching. Journal of the
American Board of Family Practice 1992;5:419-424.
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Pangaro L. A new vocabulary and other innovations for improving
descriptive in-training evaluations. Acad Med 1999;74(11): 1203-1207.
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Usatine et al. Time efficient preceptors in ambulatory care. Acad Med
2000;75:639-642.
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Wolpaw et al. SNAPPS: a learner-centred Model for outpatient education.
Acad Med 2003;78(9):893-898.
Medical Teaching in Ambulatory Care-A Practical Guide Rubenstein
W/Talbot Y 2013
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Time Management
• Teaching takes time
– Estimate 1 minute to 8 minutes more
• Amount time inversely related to level of student
– Where to put it?
• Most community-based teachers do not reduce pt. bookings
• More booking time, breaks, end of day
– Address priorities
– Homework
• Teaching saves time
– Two patients seen at once
– Charting
– Students help with educational “chores”
Conclusions
• Good teachers are knowledgeable, have a
positive attitude and the skills to teach
• Prepare your office to accept a student
• Give the student lots of feedback
• Ask for help when faced with the challenging
student
• Be honest
• Have fun!