PGY 1 Retreat 6/16/15

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PGY 1 Retreat6/16/15

• Thinking about education
• How to be a good ward resident- small groups with
  the Chiefs
• Intern class reflection
• Changes for next year administrative issues
  misc..

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But first

• Working alone, list the top 10 drugs prescribed
  in the United States in 2015 in terms of the
  number of monthly perscriptions..

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• Now, repeat this exercise, working in small
  groups with the people sitting near you..

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Number of monthly perescriptions

• 1.Synthroid, 22.6 million
• 2.Crestor, 22.5 million
• 3.Nexium, 18.6 million
• 4.Ventolin HFA, 17.5 million
• 5.Advair Diskus, 15.0 million

• 6. Diovan, 11.4 million
• 7. Lantus 10.1 million
• 8. Cymbalta, 10.0 million
• 9.Vyvanse, 10.0 million
• 10. Lyrica, 9.6 million

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• As a resident- your job is to foster a positive
  team environment
• Emotional intelligence
• Working in teams

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Giving Feedback

• Keith Armitage
• Case Western Reserve University

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Giving Feedback

• Case scenarios

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Introduction

• Defining feedback
• The importance of feedback
• Examples of good and bad feedback
• Techniques for giving feedback

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• Feedback is not criticism!!
• You are a coach
• The ability to reflectan essential part of
  modern medical practice

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Introduction

• Most feedback in medical education is self
  feedback based on the observation of self and
  others.
• Depends on the ability of the learner to give
  self feedback.
• Most good internists have this ability.
• Optimally self feedback is confirmed and
  augmented by external feedback.

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Defining feedback

• Rocket science model
• Feedback in the control of a system by
  reinserting into the system the results of its
  performanceif the information is able to change
  the general method and performance, we have a
  process which may be called learning.
• Humans are more complex clinical performance is
  more complicated than rocket science

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Defining feedback

• Formative
• Non-judgmental presenting information, not
  judgmental
• Rocket science model
• Neutral, not good vs. bad
• coach
• Summative
• After the fact, sum of performance, grade
• evaluation, compared to peers
• judge
• vs. encouragement

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The importance of giving feedback

• Obligation in all training situations
• Learner feels adrift without feedback
• Misinterpretation of nonspecific signals
• Bi-directional!
• Role of providing information/corrective action
• Correction of mistakes in the clinical setting
• Vanishing Feedback
• Monthly faculty reminders

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Examples of good and bad feedback

• Good
• Timely, specific, nonjudgmental, devoid of
  emotion, private/appropriate setting, given in
  climate of trust, diagnostic/useful, goal
  oriented, focused on performance, not personal,
  supportive, objective, occurrence based, useful
• Bad
• Vague, public, given in anger, non-timely,
  personal, punishment,

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Examples of good and bad feedback, cont

• Your differential diagnosis was O.K., but you
  might have also considered tuberculosis.
• Your differential diagnosis was poor/inadequate.

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Techniques for Giving Feedback

• The sandwich
• Beginning and ending with positive observations
• Positive feedback- corrective feedback-positive
  feedback

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Techniques for Giving Feedback, cont.

• The Club Sandwich
• Reinforce success
• Corrective feedback
• Affirmation in your belief that the learner can
  move forward
• Plans for moving forward
• Commitment to support them in their plans

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The Club Sandwich, cont.

• I am impressed that you know your patients labs
  so well
• The critical next step is interpreting the labs
  for instance, describe the anemia as microcytic,
  and discuss what this means
• I am confident that you can take this next step
• Do you have ideas about how to do accomplish
  this?
• I would be happy to help work with you on this
  issue

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Techniques for Giving Feedback, cont.

• Micro feedback
• Small opportunities with students as they arise
• Capitalize on the moment
• Catch them doing something well
• Good history- he was a tough guy to talk to
• Use a nonjudgmental rule statement
• When patient come in with so and so, it is
  important to ask about
• Give the learn a chance to re do their
  performance
• Why dont you go back and ask about

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Techniques for Giving Feedback, cont.

• The tell me how you think you are doing.
• Take advantage of situations as they arise in the
  clinical setting.
• Focused on goals
• Do you want to be the best intern/doctor you
  could be?
• Turn negative feedback into challenge

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Techniques for Giving Feedback, cont.

• Assess learners level of receptivity to feedback
• Encourage learners to ask for feedback
• Test your hypothesis about what the problem is
• Diagnosing your learners
• Avoid overloading
• Follow-up is key

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Impediments to giving feedback

• Time
• Inadequate observations
• Time to meet
• Concern over popularity
• Not wanting to hurt feelings, damage student
  teacher relationship

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Techniques for Giving Feedback, cont.

• Avoid focusing on personality traits, unless they
  affect clinical care

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Impediments to giving feedback

• Past experiences that were emotionally difficult
  fear that feedback will elicit an emotional
  reaction
• Concerns about the impact of feedback leads to no
  feedback at all

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Impediments to giving feedback

• Humiliation
• External emotion that can be avoided if the
  teacher provides nonjudgmental feedback
• Embarrassment
• Internal emotion, sometimes cant be avoided, may
  be motivational
• Dealing with tears/anger
• Emphasize your willingness to help and their
  ability to improve

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Now that you are a believer in feedback

• Feedback is bi-directional
• Please take evaluation of your attendings
  seriously
• Cumulative data with comments is returned to
  attendings
• Promotion and tenure

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Armitages general hints for dealing with
feedback/administrative situations

• Never begin a conversation in anger or assuming
  the other person is at fault
• If you make the issue patient care, you will
  (almost) always win
• Always make it patient centered
• Kick it upstairs

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Mindfulness

• Paying attention, on purpose, to ones own mental
  and physical process during everyday tasks to act
  with clarity and insight
• (the first thing you do at a code.)

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Habits of Mindful Practitioners

• Attentive observation
• Processing.
• Critical Curiosity
• Tolerating and enjoying being wrong
• Presence
• Control of anxiety
• Egoless focus on tasks
• Tolerating contradictory ideas
• Compassion based upon insight

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Mindfulness

• Understanding your reaction to patients
• Incorporating ethics into decision making
• Reflection..!
• Being purposely mindful

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And Finally- another10 minutes on education

• Models of learning
• 1 minute preceptor

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RIME

• Reporter
• Interpreter
• Manager
• Educator

• Diagnosing the learner.

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The One Minute Preceptor

• What do you think?
• Why do you think that/what else did you consider
• What I am thinking
• Where do we go from here- positive feedback and
  next steps

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Teaching the 4 Cs of Effective Oral
Presentations on Work Rounds
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The 4 Cs of effective oral presentationwill
only be successful . . .

• . . . if the resident sets the expectations at
  the start of a rotation

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Remember the 4 Cs

• COHERENT
• CONCISE
• COMPLETE
• COMPELLING

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COHERENT

• Introduction (one sentence!)
• Subjective
• Vital signs
• I/Os
• Physical Exam (pertinent)
• New study results
• Review of chart (nurses notes, etc)
• Assessment and Plan

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CONCISE ( 1-2 minutes)

• Essential
• Pertinent
• Uncluttered
• The student should be . . . brief and lucid
• The student should speak . . . crisply and
  clearly without notes

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The 4 Cs algorithm will be successful only with

• APPROPRIATE FEEDBACK
• Without feedback, mistakes go uncorrected, good
  performance is not reinforced, and clinical
  competence is achieved empirically or not at all
  
• - Jack Ende, M.D.
  

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• Four steps of clinical teaching
• Needs assessment
• Teaching to the learner
• Feedback
• Reinforcement

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Teaching Clinical ReasoningOn the Fly
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Key Points to Remember

• Teach while you work
• Clinical reasoning is most effectively taught as
  you care for patients together, not in a lecture
  hall or conference room
• Live what you teach
• If you dont role model sound clinical
  reasoning as you discuss all your patients, the
  students wont think its really important

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Bottom Line

• Teach as you work and live what you teach!
• Be systematic and think out loud
• What are the problems? Foreground and background.
• Whats the differential? Focus on likelies and
  high stakes possibles.
• Let your differential drive work-up and management

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Long term career goals

• Use elective time for scholarly projects
• Work with clinical mentors
• Meet with your PD to discuss..
• If you are interested in subspecialty training-
  apply at end of PGY2 year..