CHALLENGES IN CLINICAL TEACHING

Transcription

1 CHALLENGES IN CLINICAL TEACHING CHARLOTTE WILLS, MD RESIDENCY PROGRAM DIRECTOR HIGHLAND EMERGENCY MEDICINE RESIDENCY ALAMEDA HEALTH SYSTEM OAKLAND CA ional Skills Workshop sponsored by the Office of Research and Development in Medical Educati

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3 SESSION STRUCTURE Get to know the group. Identify teaching challenges. Work through practice scenarios in small group. Share ideas in large group. Briefly touch on the literature. Summarize and wrap-up.

4 INTRODUCTIO N EXERCISE Divide into FOUR groups Name, setting, learners Teaching challenge in THREE WORDS

5 WHO IS HERE? POLL EVERYWHERE

6 ACTIVITY List the qualities of a good teacher.

7 QUALITIES OF A GOOD TEACHER POLL EVERYWHERE

8 QUALITIES OF A LESS EFFECTIVE TEACHER POLL EVERYWHERE

9 CHALLENGES TO TEACHING POLL EVERYWHERE

10 GOOD TEACHERS: THE LITERATURE Solid knowledge base Clinically competent/clinical skills teaching Supportive learning environment Communication: listening, participation, questioning Enthusiasm about medicine and teaching Sutkin, 2008

11 TRADITIONAL CLINICAL TEACHING Teacher questions focused on diagnosing the patient and questions about factual information. Rarely questions about trainee impressions of the patient. Questioning does not directly assess the learner s level of knowledge. Little or no teaching or feedback to the learner. Irby, 2004

12 PROS AND CONS OF TRADITION Pros: Efficient Puts patient care first Cons: What the learner knows is unclear Often little teaching Little or no feedback to learner

13 CHECKLISTS IN MEDICINE

14 ONE MINUTE PRECEPTOR Step 1: Get a commitment What do you think is going on? What do you want to do next? Encourages learner to process further Step 2: Probe for supporting evidence What else did you consider? How did you rule those things out? Assesses learner s knowledge and thinking process Neher, 1992

15 ONE MINUTE PRECEPTOR Step 3: Teach a general principle Following an acute stroke, prevalence of depression ranges from 20-50%; Processes that causes collapse of alveoli will produce crackles on lung exam Can be about symptoms, physical findings, treatment, resources, etc. Allows learning to be generalizable to future cases

16 ONE MINUTE PRECEPTOR Step 4: Reinforce what was done well Your presentation was well organized and concise Reinforces good behaviors Being specific is important Step 5: Give guidance about errors or omissions It is important to include an oxygen saturation when considering certain lung processes Corrects mistakes and forms foundation for improvement Again being specific is key

17 ONE MINUTE PRECEPTOR? Pros: Assesses learner knowledge Teaches to the level of the learner Allows for more accurate feedback More effective teaching encounter Cons: More time consuming? Not known by all faculty Furney et al. 2001; Aagaard et al. 2004

18 EIGHT STEP PRECEPTOR (ESP) 1. Assess Level of Learner 2. Listen without Interruption 3. Get Commitment 4. Probe for Rationale 5. Make a Generalizable Teaching Point 6. Provide Reinforcing and Corrective Feedback 7. Prompt Learner to Identify Learning Objectives 8. Positive Learning Climate Ottolini et. al 2010

19 SNAPPS A Learner-Centered Model for Case Presentations Learner-initiated Learner-directed Learner-centered Wolpaw et al. 2003

20 SNAPPS Summarizes history and physical Narrows differential diagnosis to 2-3 possibilities Analyzes differential by comparing & contrasting possibilities Probes preceptor by asking questions about uncertainties, difficulties, etc. Plans management for patient care Selects issue for self-directed learning

21 SMALL GROUP EXERCISE Challenging clinical scenarios/learners What challenges do you see? What are the learning opportunities? What teaching skills can you use to teach in this scenario? See case for instructions and discussion questions

22 SCENARIO 1: DIAGNOSIS? Your Role: Urgent care nurse practitioner Learner: NP student Case highlights: 26 yo woman with back pain, fever, + UA Reported exam/history suggests pyelonephritis NP student is convinced this is pelvic inflammatory disease, wants to get an ultrasound, admit and start doxycycline

23 LARGE GROUP DISCUSSION Summarize (briefly) what made your case challenging How did you use the OMP to address these challenges? Did it work? If you had more time, how would you modify? Was there a step of the OMP that you found most useful?

24 SCENARIO 2: HIGH WORKLOAD Your role: Inpatient attending physician Learners: R3, R1, MS4, PA student Teaching Challenges: Workload is high - efficiency prized Different strengths/needs They divide and conquer No time to teach

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26 SCENARIO 3: CHALLENGING TEAM Your role: inpatient attending Learners: senior resident, MS4, MS3, pharmacist Teaching Challenges: Senior seems checked out MS4 is on iphone. MS3 has other priorities alienates the rest of the team. Pharmacist is finding many errors with the senior resident s orders, but reluctant to approach her.

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28 SCENARIO 4: THE DIFFICULT PATIENT Your Role: Inpatient consult service attending Learners: 3rd year resident, PT student, pharmacy intern Case highlights: 56 yo obese woman with renal failure, chronic pain s/p hip and knee replacements Taking Vicodin, unable to walk Resident minimizes her pain, thinks she is drug-seeking, recommends psych consult.

29 SUMMARY POINTS OMP/ESP/SNAPPS principles can be applied in diverse clinical encounters Diagnose the learner: Probe understanding and thought process Teach general principles: fill in the blanks in knowledge Provide information that can be applied in other situations Give and ask for feedback with EACH encounter Promote self directed learning

30 REFERENCES Aagaard EA, Teherani A, Irby DM The effectiveness of the one minute preceptor model for diagnosing the patient and the learner. Acad Med 79: Furney S, Orsini A, Orsetti K, Stern D, Gruppen L, Irby DM Teaching the one-minute preceptor: a randomized controlled trial. J Gene Inter Med 16: Irby DM, Aagaard EA, Teherani A Teaching points identified by preceptors observing one minute preceptor and traditional preceptor encounters. Acad Med 79: Neher JO, Gordon KC, Meyer B, Stevens N A five-step microskills model of clinical teaching. J Am Board of Family Practice 5: O Malley PG, Kroenke K, Ritter J, Dy N, Pangaro L What learners and teachers value most in ambulatory educational encounters: a prospective, qualitative study. Acad Med 74: Ottolini et al Student Perceptions of Effectiveness of the Eight Step Preceptor (ESP) Model in the Ambulatory Setting. Teach Learn Med 22: Salerno SM, O Malley PG, Pangaro LN, Wheeler GA, Moores LK, Jackson JL Faculty development seminars based on the one minute preceptor improve feedback in the ambulatory setting. J Gene Int Med 17: Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008; 83: Teherani A, O Sullivan P, Aagaard EA, Morrison EH, Irby DM Student perceptions of the One-Minute Preceptor and Traditional Preceptor Models. Med Teach: 29: Wolpaw TM, Wolpaw DR, Papp KK SNAPPS: a learner-centered model for outpatient education. Acad Med 78: Wolpaw T, Papp KK, Bordage G. Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: A randomized comparison group trial. Acad Med 2009; 84: