Improving Teaching Skills: Yes, you have time to do it

1
Improving Teaching Skills Yes, you have time to
do it!

• Joseph Gilhooly, MD
• Doernbecher Childrens Hospital

Grand Rapids Medical Education Research
Center September 30, 2009
2
Disclosures

• I have no relevant financial relationships with
  the manufacturer of any commercial product or
  provider of commercial services discussed in this
  CME activity. I do not intend to discuss an
  unapproved/investigative use of a commercial
  product/device in my presentation.

3
Objectives

• Describe the challenges to clinical teaching
• Improve your understanding of todays learners
• Recognize the effectiveness of the One Minute
  Preceptor
• Know how to assess knowledge and clinical
  reasoning
• Consistently integrate feedback
• Spend more time observing your learners

4
Overview

• Teaching in the good ol days
• Todays challenges to teaching
• How to teach effectivelytoday
• The One Minute Preceptor revisited
• Bedside rounds and the EMR

5
When I was an intern

• Autonomy!
• Attending rounds 3 times per week
• See one, do one, teach one
• Learned everything?

6
It was good

• Mentorship
• Pearls of wisdom
• Confidence

7
and it wasnt so good

• Little taught about
• Staying current
• Using evidence
• How to teach
• Quality Improvement
• Health care systems

8
And it wasnt so good

• Too much autonomy?

9
Was your copy machine voted Teacher of the Year?
10
We are training a group of physicians who have
never been observed

• Ludwig Eichna, MD
• NEJM 1980303727-34

11
And then it became really complicated
12
Teaching Learning
2009 Teaching Under Attack
Competing Academic Missions
Decreased Funding
Faculty Driven Care
EMR
Duty Hours
Generational Differences
ACGME Competencies
Outdated Curriculum
13
Faculty Driven Care

• OHSU has embraced the concept of faculty
  driven care based on the belief that faculty
  physician leadership is essential in the
  provision of high quality, cost effective care.

14
Loss of Resident Autonomy

• We dont want hospitalists in-house at night,
  thats our time.

15
Disincentive to TeachProductivity-based
Physician Compensation

• I dont want any students/residents in my
  clinic they reduce my ability to generate RVUs.

16
Faculty are Frustrated Students just arent
reading the textbooks anymore
17
Faculty are Frustrated
I think Ive acquired some wisdom over the
years, but there doesnt seem to be much demand
for it.
New Yorker, 2001
18
Electronic Medical Record All I do, is talk to
the back of residents heads
19
Changing Generational Values Affect Student
Behavior

• Use of new educational technologies
• Loss of hierarchy
• Need for clear expectations
• Need for immediate feedback to improve skills

20
ACGME and the Competencies

• Your program should demonstrate
• Learning opportunities in each competency domain
• Evidence of multiple assessment methods

21
Resident Duty Hour Limits Less time for
education

• Shift of resident patient care activities to
  faculty
• ACGME duty hour limits may be lowering Board
  Examination scores

22

• Prepare for specific and focused careers
• Provide a continuum of learning

EIP
23
How can I be an effective teacher in todays
health care environment?

• The Question

24
We owe it to these Master Educators

• Richard Sarkin, MD Steven Miller, MD

25
Parker J. Palmer, PhD
26
The power of our mentors is not necessarily in
the models of good teaching they gave usTheir
power is in the capacity to awaken a truth with
us
27
what we teach will never take unless it
connects with the inward, living core of our
students lives
28
The Sandlot 1993
29
In 000230 this young teacher

• Taught in the real world
• Established himself as a mentor
• Gave encouragement and feedback
• Learned about his learner
• Created a fun learning environment
• Gave pearls of wisdom
• Brought the topic into context
• Gave the opportunity to practice skills
• Helped his student succeed

30
Recreating the Academic Environment

• Teaching is a priority
• Learners are engaged in their education
• Self directed learning is facilitated
• Evaluation and Feedback are priorities
• Learners are challenged

31
Getting Started

• Know Your Learners
• Set Expectations
• Assess the Learner
• Teach
• Give Feedback

32
Know Your Learner

• Generational Values
• Theyre adults
• Pedagogy vs. Andragogy?
• Learning styles VARK

33
Generational Values

• Gen X and Millennials value relationships at work
• They want teachers to know them as individuals

34
Andragogy Adult LearningMalcolm Knowles 2005

• Need to know the reason for learning
• Experience (trial and error)
• Responsible for their education
• Subject should be immediately relevant
• Problem centered (not content centered)
• Internal motivators (not external)

35
Internal Motivators Self Directed Learning
36
Medical Students and Residents are lousy adult
learners

• Interesting but not exactly in line with
  pediatric topics for the test.

but its not their fault.
37
(No Transcript)
38
Know your Learners
http//www.vark-learn.com/english/index.asp

• Visual
• Aural
• Read/write
• Kinesthetic

Validated self-assessment tool
39
Clear Expectations

• Orientation is critical
• Review competency-based objectives
• Define expected behaviors
• Review learning activities

40
Assessment, Teaching, FeedbackThe One Minute
PreceptorRevisited

• Get a commitment
• Probe for supporting evidence
• Teach general rules
• Give Feedback

Kay Gordon, Barbara Meyer, Richard Sarkin, David
Irby, Larrie Greenberg
41
Effectiveness of the One Minute
PreceptorAargaard, Teherani, Irby, Acad Med
20047942-49

• Improved confidence in rating students
• Fund of knowledge
• Clinical reasoning skills
• Rated as effective and efficient

42
Get a commitment.Probe for supporting evidence.

• What do you think is going on with this patient?
• Why do you think that?
• What else did you consider?
• What do you want to do?

Assessment of Knowledge and Clinical Reasoning
43
Implementing the One Minute PreceptorThe
Teaching Team Pause

• The student/resident presents the patient
• Pause, avoid the temptation to start teaching
• Ask the 4 questions to assess the learner
• Then teach to their level of understanding

44

• What do you think is going on with this patient?
• Why do you think that?
• What else did you consider?
• What do you want to do?

45
Assessment of Clinical Reasoning

• Your assessment of the student or residents
  clinical reasoning is more important than any MCQ
  exam they will take.

46
How Doctors Think
Educational Strategies to Promote Clinical
Diagnostic Reasoning Judith L. Bowen, MD NEJM
20063552217-25
47
Teach general rules.

• Faculty have to stop being The Resource
• Challenge your students
• Give them tasks
• Help them find appropriate resources
• Have them present back what they learned to the
  team
• Add your pearls of wisdom

48
Theme of the Day

• Allows you to cover the curricular content
• Lesson planner

49
Self-Directed Learning Not a foreign concept
to Generation X and Millennials

• Use of technology in education
• Learning at your own pace
• Podcasts, Streaming video, Web-based modules
• Interactive teaching methods
• Small group activities, seminars
• Increased focus on self-directed learning
• Learning portfolios

50
Give Feedback.

• Stop thinking about it as a separate entity
• It is integrated into each One Minute Preceptor
  encounter
• Incorporate it into conversations between
  teachers and learners

51
Turning Praise into Feedback

• Need Feedback that is FAST
• Frequent
• Accurate
• Specific
• Timely
• Make it two way

Managing Generation X, Bruce Tulgan, 2000
52
Generational Expectations for Feedback

• Silents
• No news is good news.
• Boomers
• If you werent getting yelled at, you felt like
  that was praise.
• Xers
• Tell me what I did right and what I did wrong.
• Millennials
• I expect consistent feedback.

53
You get almost no positive feedback, ever, but
you always hear about it when you screw up.
Lack of Effective Feedback

• Physician in first-year internship
• Managing Generation X, Tulgan, 2000

54
Baby Boomers and Feedback

• Want to be liked
• Were groovybaby!
• Create the feedback sandwich

55
Working with Gen X MillennialsA better sandwich

• Need clear expectations
• Hate to be micro-managed
• Need feedback

56
Still nervous about giving feedback?

• Start with learner
• self-reflection

57
Where should we teach?
58
Teaching in front of the patientIt saves time,
allows the patient to contribute, and the teacher
sees the learner interacting with the
patient.Lewis R. First, MDEffective Teaching
April 28, 2001
59
There are many explanations for the paucity of
feedback in medical education, the most obvious
is the failure to make firsthand observations of
trainees.

• Jack Ende, MD
• Feedback in Clinical Medical Education
• JAMA 1983250777-81

60
The Past Morning Chaos
Confirm plan with patient
Write orders
Attending
Patient
Chart
Intern
Intern
MAR
Medical Student
Rounds
Nurse
Computer
Communicate plan with RN
Resident
Bedside
by Windy Stevenson, MD
61
Current State EMR and Bedside Rounds
Patient Room
Attending
Nurse
Patient
Student-Intern Diad
Happy Intern going to conference or going home
Patient
EMR
Computer on Wheels (COW)
Resident
by Windy Stevenson, MD
62
Bedside RoundsEveryones Happy!

• Improved patient care and satisfaction
• Improved resident/student education and
  satisfaction
• Improved nurse satisfaction
• Improved hospitalist job satisfaction

63
Can the EMR be Good for Teaching?
COW (Computer on Wheels)
64
The COW as a Teaching Tool

• Take it on rounds
• Look at images real time
• Look up evidence
• Educate the teamand the patient

65
Computerized Physician Order Entry

• Should it be done on rounds?

66
Progress Notes and the Electronic Medical Record

• What do students need to learn about
  documentation?
• Are they notes or billing invoices?
• Cut and paste or document personally
• Need to focus on the assessment and plan

67
Top 10 List for Educators

• Be a role model and mentor
• Set expectations
• Show you care about the learner learning
• Give learners independence
• Value their contributions to the team
• Observe them in action
• Teach Share your knowledge experience
• Be practical and relevant
• Give Feedback
• Make learning fun