1. Resident Educator Development
The RED Program
A Residents-as-Teachers Curriculum
Developed by Heather A. Thompson, MD

2. The RED Program Team Leadership How to Teach at the Bedside
The Microskills Model: Teaching during Oral Presentations
How to Teach EBM
The Ten Minute Talk
Effective Feedback
Professionalism
Patient Safety and Medical Errors

3. Resident Educator Development (RED) Program
Team Leadership
Resident Educator Development (RED) Program

4. “Switch Day on the New Rotation—Utter Chaos”
Video Clip
“Switch Day on the New Rotation—Utter Chaos”
A humorous icebreaker.

5. What is Team Leadership?
Recall a resident you have worked with that seemed to have good leadership skills.
Write down a few characteristics that made them a good team leader.
Allow 3-5 minutes for this brainstorm exercise. Then, take down a suggestion or two from the audience; jot these down on a white board or flip chart.

6. Is there data?
U of Hawaii Internal Medicine Program: Retreat on Leadership Skills results in improved confidence levels
Academic Medicine 76(5): 554 May 2001
U of Washington: 6 hour course on Leadership and Teaching skills results in improved resident ratings
Academic Medicine 74(8): , Aug 1999
In the medical education literature, there is data that team leadership is important, and that it involves skills that can be taught and measured. These are just two of many studies.

7. U of MN Med Students: E*Value
Our residents are usually rated highly in terms of teaching.
However, lower scores are noted in three particular areas:
--setting expectations
--overall organization of the rotation --giving feedback
These fall under the general umbrella of Team Leadership.
This is our “real world” example. These three areas or skills need work.

8. Objectives
By the end of this session, the resident should be able to recognize the necessary skills for effective team leadership.
The resident will recognize time savers vs. time wasters.
The resident should be able to describe practical tools and tricks and apply them to their rotations on the wards.
Objectives for our session.

9. A good team leader:
--Sets Expectations
--Delegates Tasks
--Uses Role Modeling
--Upholds Professionalism
--Gives Feedback
--Effectively Manages Time

10. Setting Expectations
On day one, describe the role of the various team members in running the service.
Be explicit!
Start with very basic expectations.
You want to set expectations on “day one”. Start by covering the basic day to day tasks of running the service. Be explicit about particular tasks; vague descriptions such as “help out the team” are meaningless. Assume nothing; previous ward experiences may have been very different.

11. Example: Student
“As the third year student, you will follow 1-3 patients.”
“On work rounds, obtain vitals, direct questions and physical exam, and follow up any tests”.
“Give input into the A/P when we round with the attending. Ask me questions at any time.”
Contrary to popular belief, people like being told exactly what to do. Students and interns want to know what is expected of them and will rise to the occasion; they are eager to help out and want to feel like they are part of the team.

12. Example: Intern Admitting patients on call.
Following patients each day (usually, all but the student’s patients).
Updating the signouts.
Knowing the student’s patients.
Being responsive to pages.
When to call for cross cover help.
Some interns may not be aware of all aspects of their role; others may have worked with residents who did things very differently. Either way, it doesn’t hurt to go over these each time.

13. Setting Educational Expectations
Informally: ask, what do they want or need to learn on this rotation?
Formal Educational Objectives: can refer to Written Curriculum and Rotation Descriptions for your particular program (Peds, Surgery, Medicine).
Student clerkship objectives are listed on their website and in their handouts.
Patient care always comes first, but educational time should also be an expectation. If you mention this on day one, it really “sets the tone” and makes teaching a priority.

14. Organization
On any given day there are many activities going on, often simultaneously:
--Clinics
--Required Lectures, Workshops
--Short call, long call
--Days off

15. Organization
It helps to map out a “Calendar of Events” for the entire month.
Communication is key: when, where, what time.
Can also refer to Rotation Descriptions (Written Curriculum, Website) prior to starting your rotation for a “day in the life”.
Many students have mentioned that the team seems “irritated” when they are pulled off the ward frequently for lectures. This stress will be lessened when everyone knows exactly when and where events are occurring. The senior resident (and the attending) can then plan ahead for things such as teaching sessions.

16. Delegating Tasks
There is always a certain amount of busywork that needs to get done.
Try to avoid simply doing tasks for the team but teach them how to get it done efficiently.
Consider a “To-Do Checklist” or other system of tracking.

17. Delegating Tasks Delegate educational tasks as well.
--Write an Educational Rx
--Schedule rotating 10 Minute Talks among members of the team on the calendar
Often times, a team member may not volunteer to research a topic unless “assigned” to do so. This is encouraged; however, try to avoid overdoing it. You don’t want to answer every single question with “I don’t know; why don’t you bring back an article for us on that tomorrow?” Pick one or two topics a week, per person, at most.

18. Role Modeling and Professionalism
Professionalism is taught largely by role modeling, which occurs through daily interactions.
Therefore, residents are teaching professionalism more than anyone else (attendings, grand rounds lecturers, curriculum committees, etc)

19. Role Modeling Common observations: --how you conduct rounds
--how you interview the patients
--how you access information (PDA, Up to Date, etc)
--how you do a lit search
--how you interact with the attending
--how you call a consultant
Be aware of this fact, and you can potentially use it to everyone’s advantage (monkey see, monkey do—students taking initiative and looking up topics on Up to Date is an example!)

20. Professionalism
Therefore, being a team leader also means upholding professionalism.
What is professionalism?
--Competence
--Engagement
--Reliability
--Dignity
--Agency
--Dual focus on illness and disease
--Concern for quality in health care
Archives of Internal Medicine, 163(2) , 27 Jan 2003
Professionalism is a term that is used frequently, but is hard to define. We touch on this only briefly in this module. This Archives article outlines the key tenets very well.

21. Professionalism
Good communication: with patients, with nurses, with other teams.
“This is how I would want my mother treated if she were in the hospital.”
During residency, professionalism also involves respecting educational time and the process of teaching and learning.
Alternative definitions of professionalism, more “practical” if you will.

22. “Top Ten” examples of unprofessional behavior
Poor conference attendance (i.e. grand rounds)
Poor documentation (H&P’s, notes, signouts; late or incomplete discharge summaries)
Signing out early with things left undone
Coming in late on a consistent basis
Ignoring the attending’s instruction
Not answering pages in a timely fashion
Complaining about “soft” admits, “rocks” on the service
Disrespectful of nursing, social work, ward clerks
Disrespectful of other medical specialties
Poor communication with other MDs, patient/family
Sometimes, it is easier to define “unprofessional” behavior than it is to define professionalism. Here are some real life examples that the residents can relate to.

23. Feedback
Giving feedback to the intern and medical students on the team is often a new role for the senior resident.
Can be anxiety producing.
Mention that we have developed an entire separate module on Effective Feedback—we only touch on these principles here.

24. HOW to give effective feedback
Comfortable for all involved (timing, location)
Elicit learner’s opinion
Establish joint goals
Not too much feedback (2-3 suggestions at most)
Relate to specific behaviors, not the person
Make observations, not assumptions
Give reactions, not judgments
Use specific examples
Offer suggestions for improvement
Use a specific technique: ORIME, Pendleton’s Rules
Examples: “When you come late for work rounds, it disrupts the flow of patient care” NOT “You’re lazy, you’re inconsiderate”. Or, offer a simple observation: “I’ve noticed you have been coming in late for work rounds.” This will often open things up for discussion without sounding harsh or judgmental.
Whenever feedback is given, specific examples are very helpful: “When you considered cost and schedule of dosing in your choice of antibiotic for Mr. Smith, it will help improve his compliance. Keep doing that”.

25. Pendleton’s Rules 1. Subject gives positive aspects
2. Observer gives positive aspects
3. Subject gives areas for improvement
4. Observer gives areas for improvement
This is a simple, set order of discussion that works very well, allows for a productive discussion to occur, and lessens the stress surrounding verbal face to face feedback.

26. Why Pendleton’s Rules Work
1. Subject speaks first gives the person being evaluated a feeling of control
2. Positive comments first lessens anxiety
3. Subject often identifies exact same issues
4. Conversely—if subject has no insight, outside help might be in order (Chief Resident, Attending, Clerkship Director)

27. ORIME O: Observer (passive) R: Reporter (data gathering)
I: Interpreter (differential diagnosis)
M: Manager (formulates a treatment plan)
E: Educator (reads up on a topic, teaches the team)
Summarize where they are at, and what it takes to get to the next level
An alternative is to relate to the learner where they are at on this ORIME scale, and what it takes to get to the next level. ORIME is very intuitive and works for students, residents, even attendings!!

28. Time Management
Efficiency, without compromising teaching and learning, is key
Work Hours: an added dimension
Managing your team; managing your attending

29. Brainstorm: Time Wasters vs. Time Savers
Activities that consume time, have low personal or professional value, and that could be streamlined or eliminated
Habits or approaches that increase efficiency and effectiveness
Use this as a breakout exercise to wake up the group and vary the stimulus. Have them discuss (in pairs or in the larger group) what they have come across in their residency training, regarding time savers or time wasters.

30. Time Waster Personalities from the APDIM “Time Trap” Workshop
The Crisis Manager
The Undisciplined Procrastinator
The Easily Distracted
The Perfectionistic Resitern
The Systematically Inefficient
The Non-Communicator
The Impulsive Wanderer
Announce a little “disclaimer” here: these are broad generalizations, characterizations of personality types that are inefficient or tend to waste time. It is not meant to be judgmental but is meant to offer tips and strategies to help the situation. Will describe each of these in more detail in the next several slides.

31. The Crisis Manager Constantly putting out fires Doesn’t plan ahead
Disorganized
Doesn’t learn from mistakes
Organize tasks on a daily and weekly basis
Identify issues on work rounds
Help anticipate problems
Help structure rounds
On the left: how you would recognize this type; On the right: potential countermeasures

32. The Undisciplined Procrastinator
“It can wait”
Likes to socialize
Little self-discipline
Set timelines
Build in time for educational activities, socializing

33. The Easily Distracted Is derailed by interruptions
Tends to leave tasks unfinished
Help them prioritize
Emphasize completing each step
Consider taking cross cover pager

34. The Perfectionistic Resitern
“I can do it best”
Attempts too much
Can’t delegate tasks
Fear of failure
Constructive Feedback
Convey the importance of delegation
Emphasize role of team leader, educator

35. The Systematically Inefficient
Tied up with paperwork
Tied up in meetings
--Educational conferences
--Health Team Rounds
--Attending rounds
Inadequate support
Enlist help (other residents, dayfloat, fellow, attending)
Prioritize tasks
Learn the system
Protect conference time

36. The Non-Communicator “Who’s in Charge?” “What’s the Plan?”
Doesn’t communicate back to team; or,
Does things without input from resident or attending
Delays in care
Constructive feedback
Address the attitude behind the behavior
Make suggestions for change

37. The Impulsive Wanderer
Off the wards frequently
Work related: tracking down patients, charts, studies
Personal reasons
Physical space, travel time
Access to information
Enlist help of nursing staff, ward clerks
Make “rounds” in lab, Xray
Address outside concerns

38. Work rounds
“There’s no team you can’t work round on in an hour.” –former VA Chief Resident
Keep up the pace with work rounds; this is a time for data gathering.
Ideally, write orders immediately after attending rounds (or write as you go).
Finish up progress notes and have them in the chart by noon.
With this slide, we now move from “types” of residents to specific daily activities, and some practical tips on time management.

39. Attending Rounds
Consider how to best spend time with the attending (set goals, objectives)
--During sit down rounds, can discuss interesting cases with teaching points only; “run the list” later with resident
--On walk rounds, decide who needs to be seen together
If attending rounds are extremely difficult, speak with chief residents, program directors

40. Student Admits
Students are taught an exhaustive, thorough H&P in 2nd year medical school: teach them how to focus on the problem at hand.
Students are used to starting with a “blank slate”: teach them how to get information.
When observing a student admission, the senior resident can often complete most of their note at the same time.
A thorough and complete H&P should not take longer than an hour to complete. If this is an issue, try to find out why. Access to information is usually one factor. Teach students and interns how to get as much information as they can from the chart, the computer, etc, even before seeing the patient.

41. Intern Admits Similar principles apply.
Can work on some basic orders while the intern is interviewing the patient.
Consider taking the cross cover pager to minimize disruptions.

42. Managing Educational Time
Students and residents alike prefer focused mini-talks (10-15 min) on topics related to patients they are following.
Other quick educational activities: PE rounds, looking at CXR’s, EKG’s, peripheral smears (even if normal!)
Remember, with educational time, less is more. This is not just due to time constraints, but also limitations on attention span and retention of material (information overload).

43. In summary Recognize the characteristics of a good team leader:
--Sets Expectations
--Delegates Tasks
--Gives Feedback
--Uses Role Modeling
--Upholds Professionalism
--Effectively Manages Time