1. Practical Tips and Tools To Improve Your Skills as a Clinical Teacher MEDS – March 14, 2013 Charlie Goldberg, MD Professor of Medicine, UCSD SOM Staff Physician (Internal Medicine) SDVAHS charles.goldberg@va.gov

2. What type of teaching do you do?

3. Pitfalls in Clinical Education Revert to comfort zone Information doesn’t fit learners needs Inappropriate techniques Blame “the system” & punt Lost opportunities No feedback Not bedside/in the moment Teacher & Student satisfaction highly variable

4. Challenges for the Teacher Lack of prep as teacher Students @ multiple levels –What do they know? Can I trust them? Do I/can I incorporate them into patient care? Competing demands: –Patient care –Your education (for residents) –Time constraints –Lack of MD knowledge

5. Many Teaching Styles & Venues Traditional lecture (extensive preparation) Mini-talk (some prep) Set aside time (e.g. attending or resident rounds) (some prep) Back to bedside (some prep) Computer assisted (some prep) In the moment - on the fly (? prep)

6. Typical Day. Teaching & Learning Everything Else

7. A Better Typical Day Teaching & Learning Everything Else

8. Practical Tips To Improve and Expand Your Clinical Teaching Clinical Teaching

9. 1. Incorporate teaching into your “every day” activities. Teaching should be inextricably integrated with your patient care activities.

10. The patient care factory Teaching

11. Integrating Teaching With Your Typical Work Other Teaching Bedside Teaching Lectures Direct Patient Care Patient care

12. 2. Don’t wait for things to just “get better” on their own. Nor should you put off teaching fro when “things” are less busy, stress levels are lower, etc etc. Be the educator that you want to be – right now! Island of Educational Peace and Tranquility

13. 3. Establish expectations for yourself & learners. Particularly important given volume of clinicians & students cycling in & out @ various intervals. Repeat frequently.

14. 4. Plan teaching activities ahead of time. Set up yourself (& your learners) for educational success.

15. 5. Bringing order and predictability creates time. Create space for teaching by: –establish ground rules –create documents that cover basic info –create educational scripts for common/high yield topics

16. 6. Give and receive feedback about education, teaching and clinical performance every day. You’re never “good to go.” Ask: “What’s working, what’s not, why  adjust”

17. 7. Match the educational goals and techniques to the setting and learners.

18. 8. You are a role model – good or bad. “I'm not a role model... Just because I dunk a basketball doesn't mean I should raise your kids.” Charles Barkley -Show your own vulnerability – it’s fine and appropriate to say “I don’t know.” -Don’t ask of others what you wouldn’t do yourself -Guide and develop the educators of the future

19. 9. Be creative – to engage and clarify the connection between what you’re teaching and how it applies – know your resources: Images Videos Apps Patients and findings Other personnel w/knowledge, fieldtrips

20. The “Few” Minute Teacher: Micro-skills of Clinical Teaching – Time Limited/On The Fly Establish Expectations Identify the teachable moment 1. Get a commitment 2. Probe for evidence 3. Teach a few key points 4. Feedback –Tell them what they did right –Correct mistakes…. gently Homework - solidify key points Revisit same issue to assess application w/future patient Neher. J Fam Pract. 1992; 5: 419-24. “Diagnosing” The Learner

21. Why Does This Work? Simple and practical –Broadly applicable - inpatient, ambulatory, all fields –Meets specific needs of learner –Provides teacher w/explicit framework Efficient & Active –Fits busy world –Fits many situations (bed side, hall, office) –Engages the learner Effective –It works! –It’s well received - both student and teacher Empowering encourages teaching Aagaard. Acad Med 2004; 79: 42-9.

22. Step 1: Set up for Success Expectations: Establish early, avoid assumptions This environment –Challenges, opportunities, our interactions –Describe Your style - Presentations, feedback, etc What I need from you –What do you know (where are you in training)? –What do you need to know (course, ACGME requirements/goals, etc)? –What do you want to know (personal goals)? Get the patient on-board

23. Step 2: Identify the Teachable Moment Missed opportunities = Single greatest impediment to teaching Happening all around you, all the time Identified by yourself (teacher initiated) or when question raised (student initiated) Takes time & effort to make something happen

24. Step 3: Get a commitment Purpose: This is the starting point Forces the learner to focus and put things together Forces them to commit to an assessment or treatment strategy

25. Getting them to commit.. Examples: Helpful: “What condition are we treating?” “What do you think is going on with this patient?” “What do you think is the main problem?” “If you were the only MD in this hospital, what treatment would you use?” Unhelpful: “This patient clearly has pneumonia and needs to be admitted.”

26. Step 4: Probe for Supporting Purpose: Identify the rationale behind their thinking Identify gaps in knowledge Clarify clinical reasoning –What path did they take to come to their conclusions? –Gets the learner to think out loud

27. Probe for Underlying Understanding… Examples : Helpful: “What were the findings that lead you to this dx?” “Why is this case different then the others we’ve seen?” “What else can cause similar symptoms?” “What are the typical treatments used for this condition?” Unhelpful: “Are you kidding me?” “Didn’t you go to my last lecture on the management of the pediatric trauma patient!?!”

28. Step 5: Feedback Purpose: Highlight the positive Gently correct errors Keys: 3:1 (positive : corrective) – skip the sandwich Frequent (daily) & immediate Not a personal attack, don’t embarrass Be specific – give news you can use Solicit feedback on your performance

29. Feedback - Examples Helpful: “I agree that the patient has depression” (positive) “While depression is a clinical diagnosis, we still need to obtain labs to assure that there’s no metabolic component. (corrective) Not so helpful: “Great job!” “That’s a ridiculous answer – I’ll go talk w/the patient and figure it out myself!”

30. Step 6: Make a few key points.. (i.e. Take Home Messages - THMs) Purpose: 1-5 THMs - bite sized nuggets of knowledge Points that are well understood, applicable – & not overwhelming!

31. Teach a few key points - Examples Helpful: “Ceftriaxone is a good choice for empiric coverage of meningitis while you’re waiting for culture results. It covers the most common pathogens – strep and h flu.” “Holding off on antibiotics if there are no white cells in the LP and the kid looks ok is a good decision.” Unhelpful: “As you know the STAR-D trial had 3 clinical limbs – the first used welbutrin alone at a dose of 75 mg/d. The 2 nd limb used prozac. The cross-over arm…”

32. Step 7: Homework & Later Application Encourage outside reading  cement & more advanced questioning Look for similar/related situations in future –reinforce key points –apply lessons learned –Explore @ greater depth Demonstrate & Refine Knowledge

33. Elbow Pain In The ER Example - One Minute Preceptor From:(http://www.practicalprof.ab.ca/teaching_nuts_bolts/one_minute_pr eceptor.html)http://www.practicalprof.ab.ca/teaching_nuts_bolts/one_minute_pr eceptor.html

34. The Critical ‘X’ Factors Environmental elements as or more important then knowledge/content/teaching technique –Enthusiasm –Patience –Genuinely giving of your time effort dependent not cost neutral –Kindness & an environment where ok to take risks, ask questions, “fail,” try again

35. Example from the inpatient medicine svc: 54 yo male, Hospital Day 2 For Cellulitis of Foot An Intern presentation on morning walk rounds: “Mr. Tomasina is Hospital day 2 for cellulitis - Day 2 of Vanco Events over the past 24h: -Glucose has ranged 150-250, with SS coverage -X-ray yesterday of foot neg for osteo -He has minimal pain & used 2 percocet over past 24h Focused exam: He looks good -T max 101, down from 103 on admit -P 80-100, BP 140-150s - Top of foot and great toe remain red and swollen, similar to yesterday. No regression from inked line Labs of note: ESR 105, wbc 10, creat 1.4 (stable), a1c 9, blood cx.”

36. Foot Cellulitis (cont) Intern’s Summary: “I think he’s doing pretty well. And I think that the cellulitis is just beginning to turn around Plan: -continue Vanco - transition to bactrim in few days - covering mrsa or other GPCs -Keep foot elevated -Percocet for pain -SS insulin for DM”

37. You (the attending) go in to see the patient with the team.. …and note the following: Looks well - chatty Bottom of foot is insensate to your touch Pulses non-palpable Great toe and MTP area rather swollen and red – though minimally tender

38. Your (attending level) Conclusions… 1.DM with peripheral arterial disease and peripheral neuropathy 2.Likely osteo - given degree of swelling, elevated ESR, and risk factors You conclude (internally) that the plan should include: –MRI foot –ABIs to assess inflow

39. Teachable Moment: DM and Treatment Goals 1.Get a commitment: You: “Why do you think this is simple cellulitis?” 2. Probe for evidence: You: “Which data supports that? What about his DM puts him at risk for more serious problems?” 3. Feedback –Tell them what they did right - using general rules –Correct mistakes 4. Teach a few key things Intern: “He has a fever, his symptoms are acute, his foot is red, and we certainly see a lot of cellulitis. “ Intern:“Well, the amount of swelling is more than we usually see. I guess it’s also unusual for him to have such a high sed rate. And your exam demonstrated that he has nerve and inflow problems - thanks for going to the bed side - I wish everyone did that! So, I guess it could be something more serious ” You: “You’re right – he definitely has an infection. And your antibiotics are reasonable - since this isacute - and could be mrsa, mssa or even strep. However, he has substrate that would put him at risk for deeper problems. Like poor blood flow and neuropathy that may impair ability to feel pain” You: “To look for deeper problems, we should do imaging that will provide greater detail. And assess his inflow - which may explain why he got the infection - and given insight into how likely it is to get better. How might we do that? “ You: “ You got it!“ Intern: “Ok - that makes sense. Given that, maybe we should order an MRI and ABIs “

40. Teachable Moment (cont) 5. Homework & reapplication: Lets take a look at some images of what diabetic neuropathy can lead to: For the intern: Provide a focused readings on DM and osteo As the teacher: look for future situations to reassess lessons learned & explore issues at a higher level: e.g.: review data from DCCT, field trip to the vascular lab and to MRI to review findings, review evidence for duration of therapy, role surgery (if osteo).

41. Teaching “on the fly” Not Always Appropriate Very complex subject You don’t know the answer Learners @ multiple levels &/or very different educational needs Severe time crunch Someone(s) just dont “get it”

42. Preparing for the next Teachable Moment: Know the epidemiologic info that defines your world: –Use this to think about an educational/teaching plan. –What might you emphasize for each common topic ? –What resources could you use?

43. Getting Better Identify opportunities (they’re everywhere) & take risks Don’t be intimidated; extraordinary knowledge or talent not reqd! Pay attention to others - why are/aren’t they effective? Prepare when possible - decreases your stress level/anxiety re unknown When using “few minute preceptor” don’t get hung up on order,#s, or straying from script – It’s “a” way, not “the” way of teaching Practice –The more you teach, the better you’ll become –Synergistic effect across venues

44. There’s no magical way of doing this! What’s expected is difficult to achieve. Nothing takes care of itself. Everything worthwhile is effort dependent All good educational products are the result of good design, planning & hard work.

45. Consider evolving as an educator Create a case 1:1 Teaching Teaching Groups, Mentoring, Coaching Faculty Development Developing Ed Tools (apps and Web Sites) Creating Curriculum Writing Cases Inter-professional Collaboration create a web site The Medical Education Tree

46. When An Educational Opportunity Presents Itself, Ask Yourself: Who am I teaching? What do they want/need to learn? What do I want/need to teach? Where will the teaching occur? How much time do I have? Other limitations? Are there any ways of creating additional engagement (bed side, media, field trips)? How will I get feedback? –Did they learn? –Is my approach working?

47. References Neher J, et al. A Five-Step “Microskills” model of clinical teaching. J Am Board Fam Pract. 2992; 5: 419-24. Parrott S, et al. Evidence-based office teaching - the five-step mircroskills model of clinical Teaching. Fam Med; 2006; 38 (3): 164- 7. Aagaard E, et al. Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: Proof of concept. Acad Med 2004; 79: 42-9. Ramani S. Twelve tips to improve bedside teaching. Med teacher 2003; 25 (2): 112-5. Ahmed M. What is happening to bedside clinical teaching? Med E 2002; 26: 1185-8. Katzelnick D, et al. Teaching psychiatric residents to teach. Academic psychiatry. Janick R, et al. Teaching at the bedside: a new model. Med Teacher 2003; 35 )2): 127-30. Kroenke K. Bedside teaching. S Med J 1997: 90 (11): 1069-74.

48. References (cont) Committee on Graduate Education, American Psychiatry Assoc. Psychiatry Residents as Teachers: A Practical Guide. 2001-2. http://www.psychiatry.org/MainMenu/EducationCareerDevelopment/Res identsMembersinTraining/residentasteacher.aspx http://www.psychiatry.org/MainMenu/EducationCareerDevelopment/Res identsMembersinTraining/residentasteacher.aspx Salerno S, et al. Faculty development seminars based on the one-minute preceptor improve feedback in the ambulatory setting. JGIM 2002; 17: 779-87. Irby D, et al. Teaching points identified by preceptors observing one- minute preceptor and traditional preceptor encounters. Acad Med 2004; 79: 50-5. On-line teaching related resources: Teaching Students and Resident to Teach – Michigan State University http://www4.umdnj.edu/cswaweb/med_pres/lkteaching%2001/ http://www4.umdnj.edu/cswaweb/med_pres/lkteaching%2001/ Resident as teacher: UC Irvine http://www.residentteachers.com/http://www.residentteachers.com/ Basics of teaching: U of Ohio http://www.oucom.ohiou.edu/fd/monographs/monographs.htm http://www.oucom.ohiou.edu/fd/monographs/monographs.htm

49. References (cont) Teaching Support Resources - University of Alabama Birmingham http://www.uab.edu/uasomume/cdm/resources.htm General Teaching Effectiveness, University of California, Berkeley http://teaching.berkeley.edu/compendium/ http://teaching.berkeley.edu/compendium/ Effective clinical teaching, U Mass http://www.umassmed.edu/cfdc/teachingmodules/flash/set1/EffecTeachClinica l.html http://www.umassmed.edu/cfdc/teachingmodules/flash/set1/EffecTeachClinica l.html Teaching clinical skills, Dartmouth: http://dms.dartmouth.edu/ocer/, http://dms.dartmouth.edu/ocer/precepting/tools/simple/http://dms.dartmouth.edu/ocer/ http://dms.dartmouth.edu/ocer/precepting/tools/simple/ University of Kansas: http://wichita.kumc.edu/strategies/http://wichita.kumc.edu/strategies/ University of North Carolina: http://www.med.unc.edu/epic/http://www.med.unc.edu/epic/ Madigan Army Hosp – Teaching Skills: http://www.usafp.org/Fac_Dev/Resource-Center-Teaching-TOC.htm http://www.usafp.org/Fac_Dev/Resource-Center-Teaching-TOC.htm Ohio State University – Teaching Basics http://www.medicine.osu.edu/physiciandevelopment/ http://www.medicine.osu.edu/physiciandevelopment/