Transcript How Can I Teach Under Managed Care?

Effective (and Efficient)
Evaluation and Feedback:
An Approach and Some Tips
for Outpatient Teaching
Louis Pangaro MD, FACP
Educational Programs
Medicine, USUHS
some definitions
• Assessment = making the observation
– “sitting next to”
• Evaluation = assigning value
– not grading; uses words
– based on goals
– diagnoses what “step” they’re at
some definitions
• Feedback = “course correction”
– not feeling good
– based on evaluation
– get them to “next step”
Community
Goals
(“ends”)
Curriculum
(“means”, “objectives”)
Evaluation
individual
programmatic
Feedback
Evaluation vs.. Grading
Grading
“gradus”
steps
(F, D, C, B, A)
Evaluation “value” strength
Teacher Tasks
• Diagnose the Patient
• Diagnose the Learner
– Teach One Thing the Learner Needs to get to
“the Next Step”
• Diagnose the Teacher
(reflection)
– at the end of clinic with feedback from the student
How do you decide what the
“next step” is for a learner?
Diagnosing the Learner:
goals (“analytic”)
• attitudes
• skills
• knowledge
AAMC Med School
Objectives Project (MSOP)
• Goals*: a Physician is:
– Dutiful
– Altruistic
– Skillful
– Knowledgeable
* each goal has multiple objectives
Knowing the goals
for the learner’s level of training
• A “synthetic” approach
R.I.M.E. System
- Reporter
- Interpreter
- Manager/Educator
R.I.M.E. System
USUHS Medicine
Reporter: reliably get the facts, works with
patients, identifies problems,
Interpreter: prioritizes, reasonable differential
diagnosis, more confidence
Manager: works with patients on Diagnostic
and therapeutic Plan
Educator: a plan for the doctor: gets to the
next level of knowledge and evidence
What would you expect of the
learner?
• clinic patient : a 45 year old woman with
hypertension; routine lab studies showed a
total cholesterol of 340 md/dl.
– if the learner is a third year student?
– an intern in August?
– a senior resident?
• Efficient: a question of “how”
– “doing the thing right”
• Effective: a question of what
– “doing the right thing”
Teaching Tip
• One thing at a time
–With “beginners”, Don’t try to
do it All
–What’s the agenda for
feedback?
Kinds of Feedback
• Minimal
– “good”, “ugh!”, a shrug or nod
• Behavioral
– “that was good because…”
– “you can improve by…”
• Interactive
– let them react, or better yet, self-evaluate
after Stanford Faculty Dev Program
HOW to Give Effective Feedback
• be specific (what they did, not who they are)
• be timely, but watch the setting
• “positive” too; a “feedback sandwich”
(catch the learner doing something right)
• label it “feedback”
• have an action plan
• use “interactive” method
after SFDP
What To Give Feedback On
• do you agree with their
diagnosis/management
• making the transitions ? (RIME)
• their self-evaluation (is it similar to yours?)
• an action plan for their time (give it now or
after clinic)
How to Assess a learner Quickly
student: mainly observation/listening
• pertinent positives/negatives
• problem list (semantic competence)
resident: observation but mainly questions
• “How can I help?
“Semantic Competence”
• Bordage’s term for active use of correct
terms that show pattern awareness.
• e.g. “This patient has a distal, symmetric,
polyarthritis.” implies a student has the
knowledge and skill to move to
“interpreter”
• options: listen to summary statement, or ask
for “problem” list
Expecting complete problem lists
• Problem lists quickly reveal:
–
–
–
–
comprehensiveness
level of semantic competence
ability to synthesize
movement toward “interpreter” level
The “heart” of our method
• Internal Medicine teaches a method
to embrace complexity,
so one can act with simplicity.
• The Problem List reveals the learner’s
ability to analyze a case (semantic
competence) and synthesize it (embrace
complexity)
[residents, too?]
Internal Medicine Clerkships
• Different from others in third year:
embedding the present problem in larger
context (necessary for High Pass and
certainly for Honors level)
• Dy’s “cogito”: I think, therefore I.M.
Teaching Tip
The “One Minute” Preceptor
• Five “Microskills” for Clinical
Teaching
A disciplined approach to pacing from the
University of Washington, Seattle
The “One Minute” Preceptor
• Start with a Commitment from the
Learner
• Probe for Supporting Evidence
• Teach General Rules
• Positive Feedback for what was right
• Correct Mistakes
Intern and High Cholesterol
• Intern: This lady should be started on
pravastatin
• Teacher: Why?
• Intern: She has a risk of heart disease
• Teacher: What else would you do?
• Intern: Bring her back in three months
Intern and High Cholesterol
• Teacher: Generally, be sure of your
diagnosis first. You’re right that cholesterol
is a risk for heart disease, but you need to be
sure about causes like hypothyroidism.
• Teacher: Let me tell you what tests and
therapy I’d like you to order today, and
what you should read about tonight.
Risks in complete problem lists
• we try to cover it all
• our compulsiveness wins out
• we bring up all the interesting, fascinating,
aspects of a great case
• we try to do the inter-relations for the
student
• we start to lecture the student/resident
Teaching Tip
let the student do the work
• Transferring incentive and initiative to the
student
• can we incentivize efficiency in the
student??
What motivates students to do the work?
Motivations
Barriers
Teaching Tip
Let the Learner Do the Work
• Don’t lecture about what can be
learned by reading
• Save Extensive Knowledge Transfer
for the Learner’s Own Time
• give the student a chance at High Pass
let the student do the work
• Preparation :
– in advance identify patients to see
– how was the diagnosis made, how treated
– what is our agenda for coming visit?
– write down what to ask, to look for, labs
to check (index card)
Working with the Patient
• Student memorizes the lines:
“Mrs. J----------, I’ve had a chance to review
your record and I believe you’re here to
follow-up on your diabetes. ..
Is there anything else you’d like us to go over
in the 20 minutes we have together?”
managing the educational goals
• “reporter” stage
– interview/exam show
only basic knowledge
and skill
• student excused (or
observer) and
attending offers A&P
to the patient
• student given
homework and tasks
• “interpreter” stage
– interview/exam show
good focus on
pertinent info
• student allowed to
offer assessment
– presence of patient?
• attending offers plan
– student excused or
observer
Teaching Tip : “How Can I Help?”
• Force residents to move to Manager/
Educator Level (first, diagnose the learner)
• Ask them to self-evaluate and determine
their educational needs
• Let them Know their Growing
Independence is Important to You
• “How Can I Help?”
Summary: Five Tips
1. Know the “next step” for this learner
(RIME);
2. “One thing at a Time”
3. Practice the “One Minute Preceptor”
4. For students: let them do the work
5. For residents: “How can I help?”