1. Teaching and Feedback for Faculty and Residents Katie Margo, MD Predoctoral and Associate Residency Director Department of Family Medicine and Community Health University of Pennsylvania SOM

2. Goals for the session n Understand special needs of Adult Learners n Identify strategies for Ambulatory Teaching n Learn ways to give Feedback n Describe ways of Evaluation

3. Adult learners n Teaching children –Dependent –No experience to draw on –Learn at teacher’s convenience –Teacher as authority/expert n Teaching adults –Self-directed –Experience is resource –Learn when pertinent –Teacher as director/facilitator/ consultant

4. Medical students and residents are adults learners! n Assign clear responsibilities n Assess prior knowledge n Give them “real job” (minimize observation) n Give chance to practice new skills

5. Teaching n Constraints on Ambulatory Education n Describe efficient and effective teaching strategies –Planning –Teaching –Reflecting

6. Constraints on Ambulatory Education n Fast paced and chaotic environment n Little time for teaching, observation and feedback n Lack of time for orientation, collaborative learning and reflection Irby, 1995. Ludmerer, 1999

7. Planning n Orient learners (esp students) to clinic –Introduce to people, procedures, resources –Assess level (novice, experienced) –Solicit learner goals n Pre-select patients n Prime learners Ferenchick, 1997. Kernan, 1997. Lesky, 1995. McGee, 1997.

8. Role of Teacher n Novice learner - Director –Provide structure –Set expectations –Give direction –Plan experiences –Select patients

9. Role of Teacher n Intermediate learner - Facilitator –Ask questions –Listen to learners’ ideas –Share your own reasoning –Think aloud

10. Role of Teacher n Experienced learner - Consultant –Help set goals –Help evaluate progress –Exchange ideas –Serve as a resource

11. Teaching/Precepting n What do residents value in preceptors?

12. Most Helpful Teaching Behaviors 1. Corrects mistakes w/o belittling 2. Demonstrates competent care of own patients 3. Demonstrates adequate breadth of knowledge 4. Enthusiasm 5. Self-confident in patient care

13. Most Helpful Teaching Behaviors 6. Logically explains basis for decisions 7. Listens attentively 8. Frequent constructive feedback 9. Works effectively w/ other team members 10. Pleasant & helpful after hours 11. Teaching points well-organized 12. Pleasant relationship with residents & other personnel

14. Pitfalls in Clinical Teaching n “Taking over” the case n Inappropriate lectures n Insufficient “wait-time”: 3-5 sec n Pre-programmed answers –Could it be an ulcer? n Rapid reward –Effectively shuts down the student’s thinking n Pushing past ability (“pimping”) –Persist in carrying the students beyond their understanding

15. “He teaches best who shows his students shows his students not what to think, but how to think…” Alan Gregg

16. Reflection - Learner n Ask questions to stimulate reflection –What are your questions? –What did you learn from seeing patients today? –What troubled, surprised, moved or inspired you today? Arseneau, 1995. DaRosa, 1997. Smith, 1997.

17. Five Precepting Microskills n Get a Commitment n Probe for Supporting Evidence n Teach General Rules n Reinforce What Was Done Right n Correct Mistakes n From Neher 1992 - Thanks to Cyr and Schirmer for some slides

18. Microskill One: Get a Commitment

19. Example After presenting facts of the case, the resident 1. Stops 2. Asks for opinion 3. Offers no interpretation of data

20. Preceptor Response 1. Ask learner question 2. Can be about any aspect of clinical problem solving a. Further data needed b. Diagnosis c. Plan d. When approach is not working

21. Rationale Committing to a personal interpretation of the data: 1. Encourages learner to process actively 2. Allows preceptor to assess level of understanding 3. Promotes collaboration and discussion

22. Examples “What do you think is going on with this patient?” “What would you like to do next?” “What would you like to accomplish on this visit?” “Why do you think this patient has been non-adherent?”

23. Less good examples 1. Offering opinion about the case: “Sounds like pneumonia.” “I’d use amoxicillin.” 2. Grilling for more data “Any stresses at home?” “Which symptom came first?”

24. Microskill Two Probe for Supporting Evidence

25. Example 1. Resident offers opinion & looks to you to: a. agree b. disagree 2. You feel the urge to tell resident outright what you would do. RESTRAIN YOURSELF!

26. Preceptor response “What evidence supports your opinion? “What other choice were considered? What evidence supports or refutes these options?”

27. Rationale Learners should problem solve logically from own knowledge base. Asking them to reveal thought processes allows preceptor to: 1. Discover extent of knowledge 2. Discover errors in knowledge 3. Encourage deductive reasoning

28. Examples “What are major findings that lead you to that diagnosis?” “Why did you choose that particular med, given the availability of many others? “What factors did you take into account when making your exercise prescription for this patient?”

29. Less good examples 1. Ask for more data “And her social situation?” 2. Grill resident on general topic “Name 5 major clinical effects of hypophosphatemia.” 3. Offer opinion about resident’s judgment “Yeah, it’s pancreatitis for sure.”

30. Microskill Three: Teach General Rules

31. Example You have ascertained from what learner says that the case has teaching value. You are aware what the learner needs to know or wants to know.

32. Preceptor Response 1. Provide general rules, concepts or considerations 2. Target them to learner’s level of understanding of problem

33. Rationale Weaknesses in learner’s supporting arguments reveal holes in knowledge. General rules taught that target weaknesses. 1. Information is memorable since it is connected to a case. 2. “General” nature allow it to be transferred to other cases.

34. Examples “If patient has cellulitis, an I&D is not going to be very helpful. An abscess should be drained. Look for fluctuance.” “Patients with cystitis usually experience pain with urination, increased frequency & urgency, & discolored urine. A UA should have WBC’s & bacteria.”

35. Less good examples 1. Idiosyncratic approaches “No one has been able to convince me that B-12 shots don’t perk folks up!” 2. Specific orders that do not generalize “Increase the Lasix dose.”

36. Microskill Four: Tell Them What They Did Right

37. Example Resident has handled situation effectively, benefiting the: 1. Patient 2. Members of the health care team 3. Clinic or hospital 4. Anyone or anything at all

38. Preceptor response Comment on: 1. Specific beneficial behavior 2. Realized or expected effects of the behavior

39. Rationale Learners’ professional skills not well established. Good behaviors more likely to be repeated when preceptor: 1. Specifically identifies behavior 2. Informs resident why behavior is worth remembering & repeating

40. Examples “You considered pt’s finances in selection of Rx. Your sensitivity to this issue will certainly contribute to improving his compliance.” “I noticed you kept an open mind until the pt revealed her real reason for coming. I think you saved yourself & the pt a lot of unnecessary time & expense by getting to the heart of matter before leaping in.”

41. Not as good examples 1. Praise that is not focused “That vasectomy went well.” 2. Praise that does not explain beneficial outcomes “The dose of Synthroid you prescribed was perfect.”

42. Microskill Five: Correct Mistakes

43. Example Resident’s work has been either wrong or ineffective. Their action has had or will have a negative impact on: 1. Patient 2. Members of health care team 3. Clinic or hospital 4. Resident themselves

44. Preceptor Response 1. Find right time & place 2. Identify behavior that needs alteration 3. Relate negative consequences of behavior 4. Supply alternative behaviors for similar situations in future

45. Rationale 1. Mistakes left unnoticed may be repeated 2. Residents who are aware of mistakes are anxious for help 3. Residents who are unaware of mistakes need to understand consequences

46. Examples “You could be right that child’s sxs are due to a viral URI. But, without checking the ears, you could easily overlook an otitis media. At minimum, a missed ear infection will result in a cranky baby & more telephone calls, or even an avoidable trip to the ER. So try to include an ear exam on every pt with URI sxs.”

47. Not as good examples 1. Public humiliation “Tell your team mates what you did last night on call.” 2. General condemnation “That was a botched circumcision.” 3. Criticism w/o explanation of outcome “I want you to stop signing on the “dispense as written” line.”

48. Let’s try it! n Groups of three –One person resident/preceptor/observer n Read scenario and do 5 Microskills n Observer should then do feedback

49. Feedback and Evaluation

50. Kinds of Feedback n Minimal –“good”, “ugh!”, a shrug or nod n Behavioral –“that was good because…” –“you can improve by…” n Interactive –let them react, or better yet, self- evaluate after Stanford Faculty Dev Program

51. Three levels of Feedback n Level 1: What you saw –Description of observed behavior –Easy to accept n Level 2: Your personal reaction n Level 3: Your prediction of likely outcome of behavior

52. HOW to Give Effective Feedback n Be Specific (what they did, not who they are) n Be Timely, but watch the setting n “Positive” too; a “feedback sandwich” (catch the learner doing something right) n Label it “feedback” n Have an action plan n Use “interactive” method

53. Feedback Sandwich Next Step Corrective Feedback Positive Feedback

54. Feedback Session n Private, relaxed atmosphere n Outline agenda n Ask student first - LISTEN! n Share your feedback n Compare your feedback to student goals and assessment n Make plans going forward

55. Assessment

56. R.I.M.E. System n Reporter n Interpreter n Manager n Educator n Know the goals for the learner’s level of training Developed by Lou Pangaro

57. R.I.M.E. Reporter: reliably gets facts, works with patients, identifies problems Interpreter: prioritizes, reasonable differential diagnosis, more confidence Manager: works with patients on diagnostic and therapeutic plan Educator: gets to the next level of knowledge and evidence

58. Level of learner expectations n Clinic patient : a 45 year old woman with hypertension; routine lab studies showed a total cholesterol of 340 mg/dl. –if the learner is a third year student? –an intern in August? –a senior resident?

59. Evaluation n Grades - not feedback! n Awkward to do - esp with students! n Understand expectations clearly n Collect data from multiple sources

60. Final Questions? Thank you!