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Seven Clinical Teaching "Microskills"

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Title: Seven Clinical Teaching "Microskills"


1
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3
The Residents Teaching Workshop
Arizonas First University.
4
Workshop Faculty
  • Joseph S. Alpert
  • Sarver Heart Center/Office of the Dean
  • Randy Horwitz
  • Department of Medicine
  • Nancy Koff
  • Office of Medical Student Education

5
Workshop Facilitators
  • Joseph Alpert
  • Rosemary Browne
  • Colleen Cagno
  • Conrad Clemens
  • Janet Campion
  • Carol Galper
  • Randy Horwitz
  • Lane Johnson
  • Patricia Lebensohn
  • Tieraona Low Dog
  • Phil Malan
  • Rick Mandel
  • Kevin Moynahan
  • Amy Waer
  • James Warneke

6
Workshop Support
  • Nicole Capdarest
  • María Chavez
  • Liz da Cunha
  • Angelica Gomez
  • Raquel Givens
  • Susan Knowles
  • Saira Sheikh
  • Hildi Williams

7
Workshop Sponsor
  • Philip Malan, PhD, MD
  • Vice Dean for Academic Affairs

8
Icebreaker
  • At each table
  • Introduce yourself
  • Where are you from?
  • Where did you go to medical school?
  • What is your new residency program?
  • Tell us one unusual thing about yourself, for
    example, Read Grays Anatomy while skydiving!

9
Time Remaining
10 minutes
10
Residents Role as Teacher
20 of time spent teaching
  • However, residents often do not…
  • promote participation
  • ask problem solving questions
  • give feedback

Skills improve with practice
Whitman, Schwenk, The Physician As Teacher,
Whitman Press (1995)
11
Workshop Objectives
  • Illustrate the importance of the residents role
    in teaching
  • Identify opportunities for teaching
  • Present simple, effective teaching techniques
  • Review principles for providing feedback

12
Our Real Goal
  • For each of you to
  • Affirm the value of good teaching your role is
    very important
  • Commit to becoming a skillful teacher
  • Integrate teaching into your work

13
Ground rules
  • One at a time
  • Speak clearly
  • Be concise
  • Be respectful
  • Have fun!

14
Workshop Structure
  • Dramatic vignette
  • Small group discussion
  • Analysis of vignette
  • Teaching approaches
  • Large group discussions combined with short
    presentations of good teaching principles

15
Educational Philosophy
  • First, a comment about lectures

16
Value of Lectures
  • Longstanding tradition
  • Useful in
  • Quickly broadcast information
  • Introductory material
  • New information
  • Overview
  • Potentially compelling

17
Limitations of Lectures
  • Three criticisms
  • Implies learning is passive data acquisition
    passive learning has poorer retention of material
    than active learning
  • Data is not accurately or fully transferred
  • Poorly suited for higher-order learning

Huh?
Bligh, What's the Use of Lectures?, Penguin
(1972)
18
Educational Philosophy
  • Teach learn through
  • Dialogue
  • Inquiry
  • Exploration

Higher order learning
19
Vignette 1
  • An attending physician is rounding with a
    resident and a medical student

20
PRODUCTION
Resident's Teaching Workshop
DIRECTOR
DATE
Ingmar Bergman
June 26
TAKE
SCENE
2
Vignette 1
CAMERA
Chavez
21
Small Group Assignment
  • Think back over your education…
  • Ineffective teaching
  • Forgettable teaching (I cant remember what was
    taught…)

What did your teacher do that made their teaching
so ineffective?
22
Time Remaining
8 minutes
23
Discussion
  • What did your teacher do that made their teaching
    so ineffective?

24
Small Group Assignment
  • Think back over your education…
  • Skillful, effective teaching
  • You still remember the lessons

What did your teacher do that made their teaching
so memorable?
25
Time Remaining
8 minutes
26
Discussion
  • What did your teacher do that made their teaching
    so memorable?

27
MicroSkills
  • Easy to learn
  • Efficient
  • Evidence based
  • Use while you work

Neher JO, et al, A Five-Step "Microskills" Model
of Clinical Teaching, J Am Board of Fam Pract,
1992 Wolpaw, et al. SNAPPS a learner-centered
model for outpatient education. Academic
Medicine. 78(9)893-8.
28
MicroSkills
  • Selected questions that are strategically asked
    during case presentations discussions

29
To use the MicroSkills
  • Listen for a cue
  • When you hear the cue, use the MicroSkill

30
How do I know if Im using the MicroSkills
correctly?
  • Teaching will be integrated in your daily
    activities
  • Students will be talking more than you

31
The Educational Cycle
Plan
Assess
Reflect
Teach
32
MicroSkills in Practice - 1
  • A medical student is joining the team today
  • An opportunity for teaching

33
The First MicroSkill
  • To teach effectively, what should I say?
  • Great. I like having students on the team.
  • OK. Rounds start at 800 on 7-West.
  • Welcome. So, what do you hope to learn during
    this rotation?

34
Set Expectations
  • Cue
  • Beginning a new educational experience
  • Response
  • Don't assume students will just catch on
  • Ask about their learning needs
  • Set goals for learning

35
Examples
  • What do you hope to learn during this rotation?
  • Each admitting day your job will be to perform
    one HP.
  • Every Friday I meet with the students for
    feedback.

36
Set Expectations
Rationale
  • Defining a learners role builds confidence
  • Using the students needs to set objectives
    increases learning

37
MicroSkills in Practice - 1
Rationale
  • An effective use of MicroSkill 1…
  • Setting Expectations

38
The Educational Cycle
Set expectations
Plan
Assess
Reflect
Teach
39
MicroSkills in Practice - 2
  • The medical student is presenting a case …
  • An opportunity for teaching

40
MicroSkill 2
  • To teach effectively, what should I ask?
  • Thats the worse case presentation Ive ever
    heard. Who taught you how to present like that?
  • Did you check for tactile fremitus, egophony,
    and whispered pectoriloquy?
  • Can you summarize the key points of this case
    for me in one sentence?

41
Summarize the Key Points
  • Cue
  • A presentation is unfocused, rambling
  • Response
  • Resist the urge to state your synopsis
  • Ask the learner to summarize the essentials

42
Summarize the Key Points
  • What are the essential points of this case?
  • Give me a one sentence summary of the case.

43
Summarize the Key Points
  • Rationale
  • Creates a clear mental image of the basic
    clinical problem
  • Discriminates which details are key to making a
    diagnosis

44
MicroSkills in Practice - 2
Rationale
  • An effective use of MicroSkill 2…
  • Summarize the Key Points

45
MicroSkills in Practice - 3
  • The medical student continues…
  • An opportunity for teaching

46
MicroSkill 3
  • To teach effectively, what should I say?
  • Great. Lets read about those and talk about
    them tomorrow.
  • So, what tests should we order?
  • Of all those possibilities, what 2 or 3
    diagnoses are most likely?

47
Narrow the Choices
  • Cue
  • The learner lists many possible diagnoses
  • Response
  • Resist the urge to name your favorites
  • Have the learner select several diagnoses for
    serious consideration

48
Narrow the Choices
  • Examples
  • In this case, what three diagnoses are most
    likely?
  • Which diagnoses can we reasonably exclude at
    this point?

49
Narrow the Choices
  • Rationale
  • Students must learn to consider the likelihood of
    each diagnosis
  • Disease prevalence
  • Context of the case
  • A fundamental step in diagnosis

50
MicroSkills in Practice - 3
Rationale
  • An effective use of MicroSkill 3…
  • Narrow the Choices

51
MicroSkills in Practice - 4
  • The medical student continues…
  • An opportunity for teaching

52
MicroSkills
  • To teach effectively, what should I say?
  • Ok, lets get a CXR, metabolic panel, UA,
    cultures, cocci and pertussis serology, and a
    pulm consult.
  • Lets just give her a Z-Pac and see if she gets
    better.
  • What points from the history support the
    diagnosis of, say, coccidioidomycosis?

53
Analyze with Evidence
  • Cue
  • The student selects 2 or 3 likely diagnoses, and
    then waits…
  • Response
  • Restrain the urge to blurt out the answer
  • Have the student use case data to discriminate
    between possibilities

54
Analyze with Evidence
  • Rationale
  • Use knowledge of disease to compare and contrast
  • Learners reveal their
  • Reasoning
  • Factual knowledge
  • Gaps in understanding

55
Analyze with Evidence
  • Examples
  • What points from the history and exam support
    the diagnosis of _____?
  • Of these two diagnoses, which do you think is
    more likely, and why?
  • What diagnosis can you exclude at this point,
    and why?

56
MicroSkills in Practice - 4
Rationale
  • An effective use of MicroSkill 4…
  • Analyze with Evidence

57
The Educational Cycle
Set expectations
Plan
Assess
Reflect
Summarize Key Points Narrow the Choices Analyze
with Evidence
Teach
58
Vignette 2
  • Outline the dialogue
  • Watch for opportunities to teach
  • Ask yourself
  • What did the students say (or not say) that
    created an opportunity for teaching?
  • How could the teacher use each of these
    opportunities to teach effectively?

59
PRODUCTION
Resident's Teaching Workshop
DIRECTOR
DATE
Woody Allen
June 26
TAKE
SCENE
5
Vignette 2
CAMERA
Givens
60
Small Group Assignment
  • What opportunities for teaching could you
    identify?
  • How could the teacher use each of these
    opportunities to teach effectively?
  • Think of some opportunities when you could take
    some time to teach.

61
Time Remaining
8 minutes
62
Discussion
  • What opportunities for teaching could you
    identify?
  • How could the teacher use each of these
    opportunities to teach effectively?
  • Think of some opportunities when you could take
    some time to teach.

63
MicroSkills in Practice - 5
  • The medical student is presenting a case…
  • An opportunity for teaching

64
MicroSkills
  • To teach effectively, what should I say?
  • What gross incompetence!
  • Oh, dont worry. Those drug rashes are really
    no big deal.
  • That prescription could have caused a drug
    reaction. It is important to check the chart for
    allergies whenever prescribing.

65
Repair an Error
or
  • Cue
  • The learner demonstrates a misunderstanding or
    error
  • Response
  • Provide constructive feedback to correct the
    mistake

66
Examples
  • That dose of gabapentin is too high for a
    patient with decreased renal function.
  • This may be acute gout, but you can't exclude
    septic arthritis unless you tap the joint.

67
Non-examples
  • Those lab tests were completely unnecessary.
  • You did what!?

68
Repair an Err
or
Rationale
  • Learners may not see the mistake
  • Mistakes left uncorrected will be repeated
  • Learners who become aware of a mistake are
    especially teachable

69
MicroSkills in Practice - 5
Rationale
  • An effective use of MicroSkill 5…
  • Repairing an Error

70
MicroSkills in Practice - 6
  • The medical student continues…
  • An opportunity for teaching

71
MicroSkills
  • To teach effectively, what should I say?
  • Whoa! This is going to be one expensive urinary
    tract infection.
  • So, what evidence supports routine colon cancer
    screening in healthy 58 y/o women?
  • You identified three needed interventions. This
    could have an important impact.

72
Highlight what was Right
  • Cue
  • A learner handled a situation very effectively
  • Response
  • Give reinforcing feedback
  • Focus on the specific behavior
  • Avoid general praise

73
Examples
  • You identified poor nutritional status in your
    assessment, and addressed it in your plan. That
    is important to wound healing.
  • You obtained blood cultures before the first
    dose of antibiotics. Thats important because
    failure to identify the pathogen can lead to
    incorrect therapy.

74
Non-examples
  • I agree with you.
  • You did that procedure well.
  • Great!

75
Highlight what was Right
Rationale
  • Learners may not be sure what is correct
  • Unless reinforced, competencies may never be
    established
  • Recognizing good performance builds respect

76
MicroSkills in Practice - 6
Rationale
  • An effective use of MicroSkill 6…
  • Highlight the Right

77
MicroSkills
  • The medical student continues…
  • An opportunity for teaching

78
MicroSkills in Practice - 7
  • To teach effectively, what should I say?
  • Doesnt that seem like overkill?
  • Well, we got a lot of antibiotic resistance out
    there. You cant be too careful.
  • In treating cystitis, what are the indications
    for a obtaining a urine culture?

79
Pick a Point for Learning
  • Cue
  • Some aspect of the patients condition remains
    uncertain
  • Response
  • Resist the urge to keep moving
  • Pause and capture the learning issue

80
Example
  • A recent meta-analysis raised concern about
    rosiglitazone. Should we consider stopping this
    medication?

81
Pick a Point for Learning
  • Rationale
  • Integrates learning with patient care
  • Lessons are more memorable
  • Encourages inquiry and the use of best practices

82
MicroSkills in Practice - 7
Rationale
  • An effective use of MicroSkill 7…
  • Pick a Point for Learning

83
The Educational Cycle
Set expectations
Plan
Assess
Reflect
Summarize Key Points Narrow the Choices Analyze
with Evidence
Teach
Repair an Error Highlight what was Right Pick a
Point for Learning
84
Vignette 3
  • Outline the interaction
  • Ask yourself
  • What did the teacher say that was effective?
  • What was ineffective?
  • What should the teacher do differently next
    time?

85
PRODUCTION
Resident's Teaching Workshop
DIRECTOR
DATE
Federico Fellini
June 26
TAKE
SCENE
9
Vignette 3
CAMERA
Koff
86
Discussion
  • What did the teacher say that was effective?
  • What was ineffective?
  • What should the teacher do differently next time?

87
Time Remaining
7 minutes
88
Discussion
  • What did the teacher say that was effective?
  • What was ineffective?
  • What should the teacher do differently next time?

89
MicroSkills
  • An approach to feedback that you can use

Branch, Paranjape. Feedback and reflection
teaching methods for clinical settings. Academic
Medicine. 77 1185-8
90
Feedback
  • Learners want to know how they are doing
  • Surveys show they rarely get feedback on their
    performance

91
Feedback vs. Evaluation
  • Evaluation
  • Provided at the end of a course of study
  • Summative- a judgment relative to standards
  • Feedback
  • Ongoing provided day-to-day
  • Formative - help learners direct their efforts

92
The Opening
  • Ask the learner to evaluate their own
    performance
  • How do you think it went?
  • Respond to their self-assessment

93
The Dialogue
  • Build on positive behavior
  • You seemed relaxed and at ease.
  • You greeted everyone in the room.
  • … then move to what can be improved

94
The Dialogue
  • Focus on specifics
  • You used a term that he didnt understand.
  • Not
  • You didnt communicate very clearly.
  • Limit to one or two points

95
The Dialogue
  • Use non-judgmental language
  • I dont think he understood your explanation.
  • Not
  • That was a poor job explaining why we are
    changing his medication.

96
The Dialogue
  • When you are subjective, label it as such
  • I felt that you were uneasy explaining why we
    changed his medication.
  • Not
  • You were struggling.
  • Acknowledge the learners emotions

97
The Plan
  • Problem solve together to change behavior
  • What could we do next time that would help you
    communicate more effectively?

98
The Closing
  • End on a positive note
  • You certainly have a good working relationship
    with the patient and his family.
  • Plan future feedback sessions
  • Lets talk again on Friday.

99
MicroSkills in Practice - 8
  • The student talks to you after rounds
  • An opportunity for teaching

100
MicroSkills
  • To teach effectively, what should I say?
  • So long. Farewell. Auf wiedersehen. Adieu.
  • Remember to check those preventive care tracking
    sheets.
  • From your experience, what stands out as
    important to remember?

101
Make Time for Reflection
  • Cue
  • Its the end of an educational experience
  • Response
  • Sit down for a few minutes
  • Review the learning experience
  • Reflect on notable highlights

102
Examples
  • What went well?
  • What caught your interest?
  • Is there anything that you would do differently?

103
Make Time for Reflection
  • Rationale
  • Reorganize in memory what was learned
  • Deepen understanding
  • Enhances learning and recall
  • Encourage personal inquiry

104
MicroSkills in Practice - 8
Rationale
  • An effective use of MicroSkill 8…
  • Make Time for Reflection

105
The Educational Cycle
Plan
  • Set expectations

Assess
Reflect
  • Summarize Key Points
  • Narrow the Choices
  • Analyze with Evidence
  • Make Time for Reflection

Teach
  • Repair an Error
  • Highlight what was Right
  • Pick a Point for Learning

or
106
Feedback Skills
  • The Opening
  • Self evaluation
  • The Dialogue
  • Build on the positive
  • Focus on specifics
  • Use non-judgmental language
  • The Plan
  • Problem solve together
  • The Closing
  • Summarize on a positive note

107
The MicroSkill-based teacher …
  • Efficient
  • Interactive
  • Learner-centered
  • Patient-focused

108
and learner…
  • By learning you will teach, by teaching you
    will learn.
  • Latin Proverb

109
… does make a difference.
  • For medical students
  • Experiences are formative
  • Will be long remembered

110
And, finally…
  • Please take a moment to complete the evaluation
    form for this workshop
  • Thank you teach well!

111
The Residents Teaching Workshop
112
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