Resident as Teacher: Teaching in the Clinical Setting

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Resident as TeacherTeaching in the Clinical
Setting

• Resident-As-Teacher Interest Group
• The Academy at Harvard Medical School

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Agenda

• Residents as Teachers
• Adult Learning Theory
• Knowing your learners
• Setting expectations
• Showing respect and enthusiasm
• Thinking out loud
• Giving specific, prompt feedback

3
Some Basic Principles

• Ask about prior education and background
• Become familiar with learners goals and
  objectives
• Give learner clear expectations

Know your learners

• Introduce yourself and share your love of
  medicine
• Use first names and introduce learner to others
• Be kind when pimping

Be respectful and enthusiastic

• Include learner in your thought process
• Probe learners to ensure they follow your
  reasoning
• Allow learner opportunity to ask clarifying
  questions

Think out loud

• Choose right setting/timing for feedback
• Provide positive and constructive SPECIFIC
  feedback
• Solicit and formally deliver feedback at end of
  encounter

Give specific real-time feedback
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Residents As Teachers

• LCME mandate
• ACGME mandate
• Residents spend up to 25 of time teaching
  (Busari JO, 2002)
• Medical students attribute one-third of their
  knowledge to teaching from residents (Bing-You
  RG, 1992)

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Residents As Teachers

• Qualities of excellent clinical teachers (Wright,
  NEJM 1998)
• Spend more than 25 of time teaching (especially
  beyond assigned responsibilities)
• Stress doctor-patient relationship
• Stress psychosocial aspects of medicine
• Give more in-depth, specific feedback to learners
• Get to know trainees on personal level

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Residents As Teachers

• Qualities of excellent clinical teachers
• Prepared, perform needs assessment
• Know cases ahead of time
• Preplanned curriculum mixed with improvisation
• Assess residents knowledge while diagnosing
  patient
• Limited teaching points

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Adult Learning Theory

• Adult learners bring life experiences and
  extensive knowledge to any situation
• Learning happens when new information is linked
  to prior knowledge and experience
• Knowledge is constructed, not received
• For adults, learning is most meaningful when
  actively engaged in solving problems
• Learn by answering clarifying questions
• What data or examples support that point of
  view?

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Know your learners

• Scenario You are a night float working with a
  clerkship student. During an admission for a new
  diagnosis of likely MS, you give him an overview
  of the clinical features and diagnostic workup.
  You find out later he has published on the
  genetics of MS. How could you approach this
  scenario differently?
• Ask briefly if he is familiar with MS and gauge
  his level of knowledge by asking probing
  questions
• When first introducing yourself to the resident,
  ask him about his background knowledge in
  neurology
• Once you learn of his research, stop trying to
  teach him
• Ask him how his research informs the case, while
  explaining your thought process

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Know your learners

• Ask about learners background and prior
  experience
• Educational background
• Prior clinical experience
• Career plans
• Learners goals for educational encounter
• Become familiar with learners other
  responsibilities outside of your setting
• Central medical school obligations
• Continuity clinic
• Clerkship specific didactics and clinics

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Know your learners

• Year I (Aug May)
• Introduction to the profession
• Basic science courses
• Patient Doctor I
• Epidemiology
• Ethics
• Social medicine

• Year II (Aug Apr)
• Human systems
• Pharmacology
• Health care policy
• Patient Doctor II
• USMLE Step 1

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Know your learners

• Year III (May Apr)
• Principal Clinical Experience (PCE)
• Clerkships
• Patient Doctor III
• Primary Care Clinic

• Year IV (May Jun)
• Required subinternships
• Required clinical electives
• Other electives
• Residency interviews
• USMLE Step 2

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Know your learners

• Who is an HMS Third Year?
• Traditional Student
• MD/PHD Student
• HST student
• Oral Surgery Resident
• Visiting (foreign) students
• Advanced students
• Observers
• Third year rotations for most students begin in
  late April

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Know your learners

• Required Third Year (Core) Clerkships
• Medicine 12 weeks
• Surgery 12 weeks
• OB/GYN 6 weeks
• Pediatrics 6 weeks
• Radiology 4 weeks
• Psychiatry 4 weeks
• Neurology 4 weeks

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Know your learners

• Principle Clinical Experience (PCE)
• Student completes all clerkships at one hospital
• Provides structure and community for students
• Weekly student-run case conferences (afternoon)
• Primary Care Clinic (PCC)
• Weekly continuity clinic (Tue or Thu afternoon
  approx 1-5P)
• Some are off site and require travel time
• Students need to be released without guilt for
  their central PCE and PCC responsibilities

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Set clear expectations

• Educational compact between learner and teacher
• Become familiar with clerkship goals and
  objectives
• Understand clerkship curriculum
• Become familiar with call schedule
• Clarify level of responsibility for students
• Explicitly state your expectations of learner
• Team schedule
• Number of admissions
• Protocol for assigning and role during procedures
• Documentation responsibilities
• Patient care responsibilities

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Be respectful and enthusiastic

• Scenario Three new medical students arrive to
  morning rounds in the conference room during the
  middle of a new case presentation. The senior
  resident should
• Ignore them and hope they go away
• Interrupt the junior presentation to have a group
  hug with the students
• Pause for brief introductions and then resume
  case presentation, with a more complete
  orientation to team after rounds
• Acknowledge the students and suggest that the
  junior complete the presentation before formal
  introductions and orientation to the team

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Be respectful and enthusiastic

• Respect
• Introduce yourself and your background
• Learn and use first names
• Introduce learners to other providers
• Include everyone in team discussions, and speak
  to all levels of knowledge
• Pimp kindly, but do pimp (engage learners in
  process rather than dictating to them)
• Invest early by explaining logistics,
  expectations and then reinforcing with frequent
  feedback
• Divide tasks among all members of team, including
  both trivial and high level
• Advocate for learners and back them up

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Be respectful and enthusiastic

• Enthusiasm
• Share with learners why you chose your field
• Remind yourself intermittently why you chose to
  do what you do
• Find something interesting in every case
• No great teacher was every noted for their apathy
  to content or students
• When feeling burned out, tell a peer and/or share
  with team your frustrations
• Remember that even when you are not explicitly
  teaching, you are actually teaching through role
  modeling

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Think Out Loud

• Scenario You are paged for the 10th time by the
  ED junior to review a consult as the night
  senior. You have 5 floor consults and a death by
  cardiac criteria case to triage in the ICU. The
  case presented by the ED junior is
  straightforward carotid dissection and you tell
  them to get an MRA with fat sats, start heparin,
  and admit to CMF. How could you teach more
  effectively in this context?
• Send them three articles (PDFs) on dissection
• Copy and paste the summary from Up-To-Date to an
  email
• Give them a chalk-talk on ASA vs.
  anti-coagulation in stroke
• Briefly explain your rationale for suspecting
  dissection, the imaging modalities that can be
  used, and the ambiguous evidence for treatment
  but your favored approach/reasoning

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Think Out Loud

• Include learner in your thought process
• Summarize key aspects of case
• Explicitly state guiding principals
• Give learner opportunity to ask clarifying
  questions
• Helps to consolidate principals
• Further informs whether they understand key
  principals
• Be open to saying I dont know (but I will
  find out for you)

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Think Out Loud

• Probe learner to ensure they follow your
  reasoning
• Pimping shows interest, keeps students engaged
• Allows teacher to identify knowledge gaps
• Allows teacher to model sound clinical reasoning
• Use first names
• Pose questions to group before calling on
  individual
• Avoid wrong or aggressive grilling
• Rephrase question to lead learner toward
  discovering the correct answer
• Acknowledge effort and challenge
• Start junior and work toward more senior learners
  to avoid embarrassment

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Think Out Loud

• Five types of questions
• Factual How long has patient had abdominal pain?
• Broadening What are potential causes?
• Justifying What supports your diagnosis?
• Hypothetical What if the patient were
  immunocompromised, how would this change your
  diagnosis?
• Alternative What is the advantage or
  disadvantage of watchful waiting vs. endoscopy?

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Think Out Loud

• More effective questions
• What major findings lead to your diagnosis?
• Is there anything else we should be concerned
  about?
• What were two other diagnoses you considered and
  why did you eliminate them?
• Less effective questions
• What is the most common symptom associated with
  this diagnosis?
• What are the three most common causes of this
  syndrome?
• What is the sensitivity of testing for the 2nd
  and 3rd diagnoses?

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Think Out Loud

• Teaching at bedside
• Prepare directed questioning and examination
• Practice seek feedback from experts
• Include patient no one is more invested in the
  findings and they can be an ally in engaging and
  teaching the learners
• Observe step back and let the learner take a
  stab
• Debrief make sure learners received the
  information you intended, discuss what went well
  and what could be better, leave time for questions

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Think Out Loud

• Teaching on work rounds
• Be flexible adjust amount and type of teaching
  to needs of team and service
• Be explicit do not assume everyone is following
  your thought process think out loud and verify
  that learners understand concepts and decisions
• Role model every interaction has implications
  (you are always being watched!)
• Do it there is no time like the present no
  need for fancy presentations

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Think Out Loud

• Teaching on call
• Set expectations at outset (take first admission,
  try to see another one, come with me to ED, etc.)
• Include students in potential learning moments
  when possible (paged to see unstable patient on
  cross-cover)
• Engage student to help with duties they can
  perform while learning, making them a part of
  your team (even if team of two)
• Confirm history and examination findings,
  demonstrate additional findings, review and give
  feedback on notes
• Role model (always!)

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Think Out Loud

• Teaching procedures
• Ask about prior experience (Have you done this
  before? What was challenging in the past?)
• Demonstrate (simulation, or live)
• Repeat steps out loud while demonstrating
• Watch trainee and give verbal feedback
• Have trainee teach it back to you
• As learners gets more expertise, provide small
  tips

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Give (High Quality) Feedback

• Scenario A student on DMD performs at an
  expected level, including admitting one admission
  on call nights, being reliable with work and
  notes, and demonstrating a good knowledge base.
  You tell him that he did well and there was no
  specific feedback. He then goes on to MAS, where
  his team has a similar impression. At his exit
  interview, he is told of his solid performance
  and later gets an honors grade. He wonders how
  he could have done better. More effective
  feedback includes
• Specific advice to take on more patients
• Reviewing specific aspects of the exam to improve
• Recommending targeted reading on his patients to
  present to the team
• Pointing out specific strengths of his performance

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Give (High Quality) Feedback

• Good feedback is

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Give (High Quality) Feedback

• Good feedback is
• Timely
• Respectful
• Non-judgmental
• Bidirectional
• Self-directed
• Honest
• Positive and constructive
• Actionable
• SPECIFIC

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Give (High Quality) Feedback

• Feedback best deferred to clerkship director
• Inappropriate Dress - Delicate topic
• Mental health - Concerns about depression,
  substance use
• Serious professionalism issues

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Some Basic Principles

• Ask about prior education and background
• Become familiar with learners goals and
  objectives
• Give learner clear expectations

Know your learners

• Introduce yourself and share your love of
  medicine
• Use first names and introduce learner to others
• Be kind when pimping

Be respectful and enthusiastic

• Include learner in your thought process
• Probe learners to ensure they follow your
  reasoning
• Allow learner opportunity to ask clarifying
  questions

Think out loud

• Choose right setting/timing for feedback
• Provide positive and constructive SPECIFIC
  feedback
• Solicit and formally deliver feedback at end of
  encounter

Give specific real-time feedback