1 STFM Faculty for Tomorrow Resident as Educators Curriculum: TEACHINGSonya Shipley, MD Meaghan Ruddy, MA, PhD

2 Learning Objectives Define teaching versus learningExplain the basic tenets of adult learning theory Examine how learning generally develops among students & residents Describe specific types of case based teaching techniques

3 The Stats Up to what percentage of residents’ education is the result of interaction with other residents? What about medical students—what percentage of their learning comes from residents? What percentage of time do you think that you spend teaching? Welcome! Thank you for attending today’s workshops. Our focus today is on residents as teachers. Your primary responsibility may not be to teach, but rest assured you do a lot of it. You teach medical students, junior residents, and other residents. (Sometimes, you teach your attendings, too!) To further underscore how important your “teaching” is, let’s look at a couple of statistics… Up to what percentage of residents’ education is the result of interaction with other residents? What about medical students—what percentage of their learning comes from residents? When looking at resident education, up to a whopping 40-50% of residents’ training comes from other residents. For medical students it is about 1/3. (Obviously, these numbers are variable, but they do underscore the point.) What percentage of time do you think that you spend teaching? 20%! So in an 8 hour work day, you teach on average about 1 hr and 36 minutes. So…you know more than you may think that you do because YOU teach, and you do it a lot! The purpose of today’s sessions is to help you teach more effectively, efficiently, and for that matter, more comfortably. Whitman N & Schwenk T. Residents As Teachers: A Guide to Educational Practice. 3rd Ed. Whittman Associates; Pacific Grove, CA. (Whitman and Schwenk, 2005)

4 Teaching How would you define this?Knowledge (more than the acquisition of information), attitudes and skills that promote the development of a physician. Teaching is both giving and offering. It includes anything done by a teacher that intends to promote learning. Teaching and learning are not by default, activities that always occur together. Learning may not occur even in the presence of good teaching, and learning can occur in spite of poor instruction.

5 Learning How would you define learning?Learning is the process through which one gains knowledge and expertise based on personal goals. Now, let’s define learning and look at just how adults learn. How or in what conditions do you learn best? In what circumstances did you NOT learn well? CATEGORIZE Answers. For example, answers might include a teacher who yelled AND a teacher who did not yell but would utter degrading comments. Both answers fall under the category of “lack of respect for learners.”

6 The Adult Learner Learn relevant informationLearn concepts and principles Learn at their own pace Motivated when helping set learning objectives Want to know what is expected Desire feedback Additional Discussion Question: What are some ways that we can encourage investment/engagement by learners? Knowles MS, Holton EF, Swanson RA. The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development. 6th Ed. Elsevier; Burlington, MA. 2005 Regan-Smith et al. An efficient and effective teaching model for ambulatory education. Acad Med, 2002, 77(7): (Knowles, Holton and Swanson, 2005; Regan-Smith et al, 2002)

7 The Resident Learner Utilize a weighted decision making processFocus on which decision is better or worse versus ‘right’ or ‘wrong’ Utilize pattern recognition and analytical thinking Yes, you teach a lot, but an important thing to take note of is the “place” in which your learner is. By doing so, you will be more able to tailor your teaching to the level of the learner. Let’s think about how residents learn. What happens during the course of a resident’s education? How does their clinical reasoning evolve? Wiese J. Teaching in the Hospital. ACP Press; Philadelphia, PA. 2010 (Wiese, 2010)

8 The Medical Student LearnerAct as data gatherers or scribes Memorize lots of information Focus on which decision is ‘right’ or ‘wrong’ Focus on symptoms rather than identifying a disease process Utilize pattern recognition May use analytical thinking Yes, you teach a lot, but an important thing to take note of is the “place” in which your learner is. By doing so, you will be more able to tailor your teaching to the level of the learner. What happens during the course of a student’s education? How does their clinical reasoning evolve? (Wiese, 2010)

9 The Good Teacher Who is your favorite teacher? Why?What are the characteristics of good teachers? At this point, you may be feeling like you don’t know ENOUGH to teach. However, knowledge is not the only prerequisite for a good teacher. Good teachers also make learning fun, enjoyable and exciting. Who is your favorite teacher? Why? What are other characteristics of good teachers? (Common answers may include the following: enthusiastic, knowledgeable but unafraid to say “I don’t know,” accessible, shows interest in learner & his/her progress, actively involve the learner, helps the learner expand skills, provides direction and feedback, role model, good bedside manner, organized, empathetic, compassionate, patient, discusses practical application of the subject, emphasize comprehension over recall.) AAIM (Alliance for Academic Internal Medicine) Toolbox (AAIM)

10 GETTING READY TO TEACH We have discussed just what the ‘good teacher’ looks like. In the following slides, we will discuss how to accomplish the tasks necessary to become a good teacher.

11 Orientation Setting goals and objectives Discussing team organizationEnsuring communication Describing the supervision – autonomy spectrum Orientation of the learner to each clinical setting is an important opportunity to establish both the learner’s and the teacher’s expectations. (Knowing what is expected is very important to the adult learner!) By clarifying expectations and answering any questions up front, a lot of confusion and misunderstanding can be avoided. In addition to getting to know your learner, this time provides an opportunity to share why your specialty is personally rewarding (enthusiastically be an ambassador for your specialty) and to find out his or her career goals. This is also a good time to find out about the learner’s career goals and to develop a learning plan for the rotation that coincides with those goals. Finally, this would be the time to also discuss previous clinical experiences to help best tailor the experience to improve clinical skills. Alguire PC, DeWitt DE, Pinsky LE et al. Teaching in Your Office: A Guide to Instructing Medical Students and Residents. 2nd Ed. ACP Press; Philadelphia, PA. 2008 AAP Residents as Teachers Curriculum (Alguire PC, DeWitt DE, Pinsky LE et al, 2008)

12 SCENARIOS Ask for volunteers or assign someone from the audience to play the role of the resident & intern as well as a resident & medical student. Any of the above listed goals for orientation may be discussed. Specific topics to be absolutely covered are listed for each role in the scenario. Instruct the audience to pay close attention and take note of what was done well or what could be improved.

13 Ready…Set…Teach! OPTIONAL: Thank you for returning for the next session! We covered quite a bit in the first session so let’s briefly review. Audience calls out what they learned and record it on white board if available.

14 General Teaching Tips Allow enough wait timeNon threatening questioning Limit teaching points Teach principles and general rules Before we get into specific teaching techniques, let’s review some general teaching tidbits.

15 Name That General Rule! 62 yo alcoholic with fever and shortness of breath. Chest x-ray with new right sided infiltrate. 48 yo with chest pain in the mid-sternum that is responsive to nitroglycerin. Initial EKG is unremarkable. 83 year old with altered mental status for the last 24 hrs. The patient resides in a nursing home and was coherent and walking one week ago. An obese 18 year old with low back pain of 2 weeks duration. No red flag symptoms such as numbness, weakness, or incontinence are present. Let’s practice! Name that General Rule! What are some general rules that you can teach for the following scenarios? Try to come up with 5-10 per case, more if you can. CONCLUSION: The moral of the story is that it is easier than you think to teach general rules. It also takes the pressure off of you to memorize a lot of random facts (of which you likely will forget a large part) so that you can “pimp” the students. You also foster UNDERSTANDING rather than memorization. You will teach information that can be easily applied to other similar patient scenarios and furthermore, will likely be remembered. You can also even further extend learning by asking the learner to look up or read about the rationale for the general rule after the teaching session. And, if the learner has done well on the case, then give positive feedback and save formal teaching for another case. It is not imperative teach “something” on every single case. In fact, this is great reinforcement for the learner and a sign of his or her progress/development. McGee and Irby. Teaching in the outpatient clinic. J Gen Intern Med Apr; 12(Suppl 2): S34–S40. doi: /j s2.5.x (McGee and Irby, 1997)

16 TEACHING TECHNIQUES Now we will move on to discussing specific types of case based teaching techniques. You typically don’t have an unlimited amount of time to teach. First, though, let us think about some pitfalls of teaching in the hospital and or clinic. What is the downside of teaching residents? Medical students? What challenges do you face in teaching residents? Medical students? Answers will probably primarily revolve around not having enough time and or felling unprepared to do so. You typically don’t have an unlimited amount of time to teach. So, now we are going to discuss some ways to integrate teaching into routine patient care in a way that is not so disruptive and overcome some of the challenges that you mentioned.

17 Priming Priming is a way to help the learner focus/organize the patient visit by giving the most critical information. Has anyone ever heard of priming? So, priming is a way to help the learner focus/organize the patient visit by giving the most critical information. Sometimes, it is necessary to perform the ENTIRE history and physical exam. However, this is not always necessary especially for established patients for whom you have previous information. With priming, the most pertinent patient information is relayed, and then the learner is given specific patient care tasks. This allows the visit to occur in the allotted time. You can also use this time to query student about the differential diagnosis of the chief complaint. If the patient has multiple stable chronic problems, then you can use this opportunity to ask about health maintenance needs.

18 Priming Examples Mr. X is a 50 yo here for his yearly exam.What are the important screening issues that need to be covered? Patient J is an 11 yo here with wheezing. What are the important components of the physical examination that need to occur? Mrs. S is here with diabetes and experiencing episodes of dizziness. What differential diagnosis might you consider? What inquiries might you make about her medications? Ms. R is here with recurrent UTI. What diagnostic testing might you consider? What additional elements of the history might you probe into further? How would you prime the following? (The italicized question represents the priming that could occur for the given scenario.) Rule Of Thumb: Asking is better than telling because it allows you to assess the learner’s “level of function” and identify any knowledge gaps.

19 Framing The learner is given a specific task to accomplish in a specified amount of time. Example: For patient J with wheezing, I want you to take a history, perform focused physical exam and report back to me in 15 minutes. This is another tool that can increase learner efficiency. The basic premise of framing is that the learner is given a specific task to accomplish in a specified amount of time. Setting such parameters greatly enhances the efficiency of the visit. Does anyone do this when working with students/other learners?

20 Modeling Useful organizational/time management strategy when you are most pressed for time or the case is too complex for the learner. Examples: “I am going to think aloud for you, or I want you to notice how I perform the physical exam. Pay attention to how I obtain the history.” This is a useful organizational/time management strategy when you are most pressed for time. It is also a good tool to utilize when the clinical case is too complex for the learner. It is the most passive teaching tool, so there is a risk of the learner becoming bored. However, it can be effectively used. It is imperative that you make sure the learner knows that this is technique you are using. For instance, say I am going to think aloud for you, or I want you to notice how I perform the physical exam. Pay attention to how I obtain the history.

21 Scenarios Scenarios: Ask for volunteers to model the following to another resident or medical student. You will need a volunteer to serve as a patient as well. As appropriate, feel free to interject other challenging scenarios that you have personally experienced. A Code Status discussion with an unresponsive patient’s family. The family is deeply religious. EEG performed by neurology shows essentially no brain activity. The patient is intubated & sedated and is on multiple vasopressors to maintain blood pressure in the setting of multi organ failure & cardiogenic shock. A discussion with a patient needing narcotics refilled but has a drug screen positive for illegal substances and has broken the pain contract by visiting another clinic in order to receive narcotics and having prescriptions filled at various pharmacies. This patient has a history of hip osteonecrosis and has had a joint replacement in the past, so there is no doubt that the pain is legitimate.

22 One Minute Preceptor Get a commitment Probe for supporting evidenceTeach general rules Reinforce what was done right Correct mistakes This technique allows you to address the needs of both the learner and the patient efficiently and effectively. There are 5 steps, and we will go into each step in detail. Get a Commitment Ask the learner what he or she thinks is going on. Other questions to consider: how would you manage this, what do you want to do, what would you do if I wasn’t available? Going through this process not only encourages the learner to feel more responsible but also fosters a sense of collaboration and encourages active learning. Probe for supporting evidence Don’t agree or disagree with the learner at this point. Instead, ask questions that probe into the though process. For instance, you could ask questions such as what findings led you to this diagnosis or why did you choose one medication as opposed to another. This step is not about grilling the learner; it is about understanding the learner’s thought process and his or her reasoning ability, Teach general rules As we discussed earlier, general rules emphasize principles that will apply to other clinical cases. Often times, these learning points are derived from clinical experience. Remember, too, that if your learner has done well, it is not necessary teach “something” on every case. Instead, give positive feedback and save formal teaching for another case. Reinforce what was done right When the learner dose well, give positive, specific feedback. The learner may not necessarily recognize what elements of his or her performance should be continued or are useful. This feedback with serve as positive reinforcement and builds self-esteem and confidence. Correct mistakes Do not be afraid to give corrective feedback. Learners typically do not make errors on purpose, and in fact, some errors are directly attributable to insufficient feedback. You can even ask the learner to review his or her own performance as he or she may have good insight into weaknesses. Afterwards, offer your own insights. Try to use terms such as “not the best” rather than “bad” or “wrong.” Additionally, offer specific suggestions for improvement and give the learner additional opportunities to practice.

23 Scenarios Ask for a volunteer to serve as the resident & the intern as well as a resident & medical student. Using the one minute preceptor model, the resident will discuss the case with the intern or medical student. Afterwards, ask the audience to remark upon what was done well or what could be improved.

24 Remember: Avoid the PitfallsTaking over the case Asking too many questions Not allowing sufficient wait time Inappropriately giving lectures Asking questions with preprogrammed answers Pushing the learner past his or her ability Not giving feedback (covered in another session) Earlier we discussed general teaching tips. It is additionally important to try to avoid these teaching pitfalls in the course of interacting with learners.

25 Summary and Review You teach A LOT!Adult learners have certain learning needs. Learner orientation is an important initial task prior to teaching. Priming & framing are useful tools to focus the visit and subsequent teaching points. Modeling is helpful when time is limited or the case is too complicated for the learner. Teach general rules which can be applied to similar patient cases in the future.

26 QUESTIONS?

27 References Whitman N & Schwenk T. Residents As Teachers: A Guide to Educational Practice. 3rd Ed. Whittman Associates; Pacific Grove, CA. 2005 Knowles MS, Holton EF, Swanson RA. The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development. 6th Ed. Elsevier; Burlington, MA. 2005 Regan-Smith et al. An efficient and effective teaching model for ambulatory education. Acad Med, 2002, 77(7): McGee and Irby. Teaching in the outpatient clinic. J Gen Intern Med Apr; 12(Suppl 2): S34–S40. doi: /j s2.5.x AAIM (Alliance for Academic Internal Medicine) Toolbox Alguire PC, DeWitt DE, Pinsky LE et al. Teaching in Your Office: A Guide to Instructing Medical Students and Residents. 2nd Ed. ACP Press; Philadelphia, PA. 2008 Wiese J. Teaching in the Hospital. ACP Press; Philadelphia, PA. 2010 AAP Residents as Teachers Curriculum