John Wheat, DO Jacob Prunuske, MD, MSPH Fundamental Skills: Teaching and Supervising Medical Students & Residents John Wheat, DO Jacob Prunuske, MD, MSPH

Objectives Describe fundamental skills needed in medical education Use POwER method to describe and integrate teaching into ambulatory practice. Identify barriers to medical student and resident learning in the ambulatory care setting. Use One-Minute Preceptor tool to assess learner knowledge and focus efforts. Discuss alternative models of teaching in practice Review resources available for developing skills as medical educator.

Outline Literature Review Fundamental Skills Current model of residency clinic POwER Model Discussion of others experience in residency teaching Ideas for overcoming barriers in current model of resident education

Literature Review Teaching In Your Office; Alguin, et.al., ACP Teaching Medicine Series Informed decision about precepting Preceptors Role: Learner orientation; setting expectations Provide learning opportunities and demonstrating knowledge and skill. Assessing knowledge and giving corrective feedback Demonstrate professionalism and enthusiasm What did I sign up for Decision rather than “falling into it, or feeling like is expected”

Literature Review 9 Lessons… Be clinically Astute –and wise Theory and Practice of Teaching Medicine, Ende, ACP Teaching Medicine Series 9 Lessons… Be clinically Astute –and wise Fit Teaching to Learning – Ask how student/learner best learns “Stimulate learner to identify salient clinical questions and find their own answers” Be attuned to learner and environment Assess “where learner is at” Program considerations, expectations Engage learners and set goals Observe and provide feedback Demonstrate and role model Be organized and prepare Improvise Aspire to be great Red+ what I did/do not do well – didn’t think about, forget often Examples: procedures

Literature Review What do learners want to learn? Patient management Data collection Interpretation skills Feedback on performance Role model Environment that promotes independence “learning climate that makes learning fun, enjoyable, and exciting” Griffith CH; Acad Med 2000

Literature Review “Faculty Development for Ambulatory Teaching” Wilkerson et.al. J Gen Int Med 1990; 5; S44-s53 6 essential teaching skills: Establishing and monitoring mutual expectations Setting Limited Goals Asking Questions Stimulating self-directed learning Giving Feedback Capitalize on role modeling

Lit Review Strategies for Developing and maintaining teaching skills Wilkerson et.al. J Gen Int Med 1990; 5; S44-s53 Assessment ( self, peers, others) Individual consultation with educational expert Organized programs, workshops ( this one included)

Lit review “The Search for Effective and Efficient Ambulatory Teaching Methods” Heidrich, C; Pediatrics Vol.105 No.1 Jan.2000 Common Ambulatory teaching Methods Distilled from literature Orienting Learner: Site, style, expectations Prioritizing learner needs Problem –Oriented Learning: Focus on theme for the day Priming: 1-2 mins before each visit Pattern recognition: emphasizing report of chief complaint and presumptive diagnosis, not detail case presentation Teach in patient’s presence Limit teaching points ( 1-2) Reflective Modeling: observe preceptor actions complimented by explanations Questioning: allows learner to guide subsequent teaching Feedback: Teacher / learner reflection

Teaching in Residency Clinic Current Model of FMC staffing: 3-5 residents seeing 4-7 patients / ½ day. 2 Staffers. R1s see 1 patient at a time, staff case, staffer goes in with each patient ( 1st 6 months) R2-3s: see 2-6 patients, staff sometimes entire half day at end

Teaching in Residency Clinic Barriers with Current Model Reactive: Take what comes, “on the fly “ Staffing process crippling to efficiency Interrupts “team” management. Process built on “finding the clinical pearl” on a case –by case basis. ( may not be what learner needs or desires in interaction) Process limits opportunities for direct observation. Healthcare asking us to provide care differently…

Teaching in Residency Clinic POwER Model Lillich fam Med 2005; 37 (3); 205-2010

Questions / Discussion Experiences with preparing prior to each session? Experiences with team “huddles” prior to clinic ½ day? Experiences with “microskills” or other determined methodology during teaching? Experiences with reviewing, debriefing for learning and feedback?

The Road To Excellence for Primary Care Resident Teaching Clinics” Gupta R; Acad. Med. 2016; 91; 458-461

Traditional Precepting Learner Presents Preceptor asks for additional patient data Discussion about case and plan for patient care

Scenario A

Traditional Precepting Patient care focused, not learner focused Low-level questions to clarify clinical data Mini-lectures Little or no feedback May be associated with decreased student satisfaction and learning Difficult to assess learner’s thought processes or level of understanding

One Minute Preceptor* Get a commitment Probe for underlying reasoning Provide positive feedback Teach general rules Correct errors * Neher, Gordon, Meyer, Stevens. A five-step “microskills” model of clinical teaching. JABFP 1992

Get a commitment Cue: The learner stops & looks at you… Action: Ask learner to commit to a diagnoses or plan Reason: 1st step in diagnosing learning needs, provides focus for teaching Example: Want do you think is going on?

Probe for Underlying Reasoning Cue: The learner looks to you to confirm dx/plan or suggest an alternative Action: Ask learner for evidence and/or DDx; do NOT give your opinion Reason: Insight into thought processes & knowledge; identify gaps Example: What facts support your conclusion?

Provide positive feedback Cue: Learner did good Action: Identify and comment on 1 specific good thing the learner did, and the effect it had Reason: reinforces skills Example: You listened well, allowing the patient to trust you and disclose a sensitive issue she was concerned about.

Teach general rules Cue: Learner needs to know something Action: Teach general rules or concepts targeted to the learner’s level of understanding Reason: memorable & transferable Example: In a young woman with abdominal pain, you should always consider the possibility of pregnancy

Correct Errors Cue: Error, omission, misunderstanding Action: Choose time/place, learner self-critique, discuss error and prevention Reason: Errors uncorrected will repeat Example: You may be right that this patient is drug-seeking, but you have to consider other possibilities for his pain and do an exam.

Scenario B

Practice

One Minute Preceptor Learner-centered Supports assessment of learner’s knowledge and clinical reasoning skills Supports focused teaching to learner’s needs Encourages feedback to reinforce desired behaviors and reduce undesired behaviors

OMP Effective for both teaching & patient care Preceptors as good or better at correctly diagnosing patient’s medical condition May provide more information in same amount of time (or same info in less time) Aagaard E, et al. Academic Medicine Jan 2004

Discussion