Clinical Teaching in the ED

Educational Objectives Develop skills to become a better clinical educator

How to… How to provide effective teaching while caring for patients in the ED

Residents as Teachers Residents play a critical role in medical student education Professional role models for students Impact on career choices Better understanding of students needs

Residents as Teachers General principles of clinical teaching Bedside teaching Giving effective feedback Teaching procedures Teaching with High-Fidelity patient simulators Teaching effective discussion leading and lecturing Acad Emerg Med. 2006;13:677-79.

Precepting Medical Students Make decisions at the bedside Encourage medical student independence Delegate specific tasks to the student Encourage responsible behavior

The Emergency Department Different from inpatient and ambulatory care settings Complaint oriented specialty Unique educational opportunities

Opportunities Unique to EM The undifferentiated acutely ill patient Extremes of age The poisoned or intoxicated patient Psychiatric emergencies Environmental emergencies Wound management and trauma Patients requiring emergency procedures Airway management and ultrasound

Teaching Opportunities Unique content areas Teaching clinical vignettes Multitasking and time management skills Communication skills Role modeling professional behavior Reinforce EMC goals

EMC Goals “Competencies” Perform complaint directed history and physical examinations Develop case specific differential diagnosis Present cases in a concise and organized fashion Appropriate utilization and interpretation of diagnostic studies Appropriate implementation of patient management plans Demonstrate medical professionalism Demonstrate an adequate fund of medical knowledge Demonstrate proficiency in basic procedures Temple MS IV Clerkship

EMC Objectives Directly participate and document care of at least 25 undifferentiated patients Directly participate and document care of at least 2 patients with each of the following conditions; Abdominal pain Chest pain Fever Musculoskeletal trauma / wound care Neurologic case Shortness of breath Provide & document “anticipatory guidance” for at least 5 patients Temple MS IV Clerkship

EMC Objectives Perform and / or interpret and document your participation in selected clinical skills or diagnostic tests; Interpret cervical spine radiograph Interpret chest radiograph Perform and interpret 12-lead ECG Perform intravenous access Perform phlebotomy Temple MS IV Clerkship

Observation of ED H&P’s Acad Emerg Med 2003;42:s102

Observation of Procedures Acad Emerg Med 2004;11:500

Direct Observation Direct observation of medical students performing H&P’s is uncommon Direct observation as a method of teaching is underutilized Medical students are more likely to receive both procedural instruction and assistance if selected procedures are directly observed

Diagnosing the learner Medical Student - Intern Independent Learner Dependant Learner Intern - Senior Resident Assess the learners needs Strengths and weaknesses

Case 1 35 year old male presents with CP and SOB

Case 1 Interpret the chest radiograph, provide a clinical diagnosis Document how you would manage this case

Case 1 61% of students (n=192) correctly interpreted the chest radiograph 95% of the students that correctly interpreted the chest radiograph managed the case appropriately *Needle decompression *Tube thoracostomy

Student – Patient Encounter Student evaluates patient Case presentation Preceptor verifies data Evaluation / management plan is implemented Periodic reevaluation / follow up Disposition

Case Presentation Skills Improve: *Patient care *Educational experience *Learner – teacher communication

Case Presentations “Precepting pitfalls” Interrupting the case prior before completion Taking over the case Inappropriate lectures

Case Presentations Listen carefully Allow the presenter to proceed without interruption The post presentation pause… *Feedback *Reassurance *Validation *What should I do next?

Case Presentations Brief, focused 2 – 3 minutes in length Directed opening statement *Chief complaint and pertinent PMH Description of the HPI, pertinent ROS Additional medical history, etc. Physical examination Differential diagnosis Diagnostic and treatment plan

Assessment – Oriented Presentation Opening statement includes the diagnostic impression or assessment followed by a treatment plan Followed by historical and physical examination data including pertinent positive and negative features that support the clinical assessment Acad Emerg Med 2003;10:842-47

Method of Questioning Assertive Facilitative Teaching styles Teacher Centered Learner Centered Fam Med 2001;33:344-6

Assertive Style Teacher – centered approach Can gauge the learners knowledge base Asks direct questions Provides information Gives directions

Assertive Style What antibiotics should we treat this patient with? What is the dose of _____? What is the drug of choice for_____? What is the differential diagnosis of RUQ pain?

Suggestive Style Can offer suggestions or alternative methods of patient care with questions or statements Can share opinions and practical experience

Suggestive Style “Although a KUB may be helpful, a non-contrast helical CT scan is a better diagnostic test for this patient” “Augmentin is a treatment option for strep throat, penicillin however is a more cost effective choice”

Collaborative Style Socratic approach Learner oriented Explores clinical reasoning and problem solving abilities Use of higher level questions to promote critical thinking

Collaborative Style What do you think is wrong with the patient? How should we proceed? What diagnostic studies are necessary? How should we manage this case? Do you think the patient needs to be admitted?

Facilitative Style Elicits and accepts the learners ideas to promote self understanding May also offer feelings and can encourage the learner Uses silence

Facilitative Style Ms. Jones shared some personal information about her past medical history with you. How did that make you feel?

Reactive Comments Ways to redirect and reorient the learner The delayed response *Allows the learner to reflect and reconsider *Provides an opportunity to withdraw the incorrect answer *Gives the learner a second try

Ways to redirect and reorient the learner Reactive Comments Ways to redirect and reorient the learner *Asking questions containing additional clues *Modifying the question so that the incorrect answer is correct *Treating wrong answers as possible

Precepting Models Traditional Model One Minute Preceptor Patient Centered Learner Centered

Traditional Precepting Model Patient centered Inquiry phase is diagnosis driven Most time is spent on patient care issues rather than learner issues The teacher functions as an expert consultant Focus on areas requiring clarification or areas missed during the presentation

One Minute Preceptor Model Learner centered Inquiry phase elicits the learners understanding of the case Flexible / modifiable Used in both the inpatient and ambulatory care setting Five microskills Focus on the learners reasoning Fam Med 2003;35:391-3

One Minute Preceptor Model Case presentation and discussion process Teach Teach a general rule Provide positive feedback Correct mistakes Diagnose Patient Listen Clarify Diagnose Learner Get a commitment Probe for supporting evidence

Get a Commitment Provides an assessment of the learners interpretation of the history and physical examination data Data analysis and synthesis What do you think is going on with this patient? What do you want to do for this patient? Commitment may focus on diagnosis, diagnostic evaluation, treatment plans, etc.

Probe for Supporting Evidence Exploring the underlying thought process allows you to identify any gaps in data synthesis or misconceptions What findings support your diagnosis? What else do you think could be going on with this patient?

Teaching General Rules Instruction is more memorable if offered as a general rule Teaching scripts for a particular complaint or presentation *Pearls of wisdom *Teach what learners need to know Keys features of a particular illness Treatment options Approach to a particular complaint Reason for hospital admission

Teaching General Rules “You should always consider hypoglycemia in the differential diagnosis of a patient with an altered mental status” “You should always consider AAA in your differential diagnosis of non-traumatic low back pain in the elderly”

Feedback In the setting of clinical medical education, feedback refers to information describing students’ or house officers’ performance in a given activity that is intended to guide their future performance in that same or in a related activity JAMA 1983;250:777-81

Feedback Goals Praise the learner for a job well done *Positive feedback Provide direction or suggestions on how the learner can improve their clinical performance *Constructive criticism *Guidance to correct mistakes

Feedback and Evaluation *Formative Provides an honest assessment of performance, including suggestions for improvement Evaluation *Summative Describes performance as it relates to the achievement of learning objectives Course grade

Praise – Criticism – Praise Feedback The way in which feedback is provided will influence the perception of its helpfulness Praise – Criticism – Praise

Feedback Nonjudgmental Descriptive Be consistent Well timed *Refer to specific behaviors or actions Be consistent Well timed Ask for self evaluation Always start with positive feedback Incorporate suggestions for improvement Individualized

Brief Feedback Bedside Informal Unscripted Unplanned *During observation of clinical / procedural skills *End of a patient encounter

Formal Feedback Usually more formal May also be unscripted or unplanned Usually occurs away from the bedside *End of a patient encounter *End of a shift *Midpoint or end of the clerkship

Feedback July – December 2004 *51/53 MS completed the survey 96.1% of MS reported receiving feedback during their EMC Of the students receiving feedback, 80.4% reported receiving SFICP 93.6% of the students reported the feedback they received was beneficial 97% of supervising physicians felt that the feedback they provided was beneficial    Ann Emerg Med. 2005;46:S88

Feedback No difference was noted in the frequency of feedback and SFICP provided as reported by the following groups: Academic (n=16) vs. clinical (n=9) faculty Senior (n=13) vs. junior (n=12) faculty Male (n=24) vs. female (n=9) supervising physicians Senior residents (n=8) and faculty (n=25)

Feedback The vast majority of SMS report receiving feedback Most students felt that more feedback would be helpful Supervising physicians’ perception of providing feedback matched that reported by the students

Basic Teaching Teaching facts – knowledge *Differential diagnosis for specific chief complaint *How to approach a certain clinical condition *Teaching the technique to perform a basic procedure

General Teaching Strategies Tailor specific teaching to the level of the learner and the clinical situation *Get to know the student *Tailor teaching to students career interests *Use varied ED pathology to your advantage Optimize the interaction *Focus on one teaching point *Encourage problem solving *Incorporate bedside teaching

General Teaching Strategies Seek opportunities to teach *Interesting physical examination findings *Radiographs *ECG’s *Procedures Be a professional *Be a role model *Establish a friendly learning environment *Be approachable

General Teaching Strategies Use additional resources *Hard copy texts *On-line texts *Journal articles *Educational websites *Prepared cases *Old ECG’s, Xrays, etc.

Qualities of an Effective Teacher Clinical competence Explaining the decision making process Treating learners with respect Actively involve learners Promote learner autonomy Teach with enthusiasm Communicate expectations for performance Creates a friendly teaching environment

Challenging Students Less than enthusiastic performance *Lack of initiative *Lack of attention to details *Poor use of time *Repetitive mistakes *Defensive when receiving feedback *Unprofessional behavior

Alternative Teaching Methods Brief structured observation Bedside case presentations

Brief Structured Observation Designed to increase teaching effectiveness in busy clinical settings *Easy – no preparation *Brief – little time required

Brief Structured Observation Observe the encounter Debrief the learner Conclude interaction

Observe the Encounter Brief observation *2 – 5 minutes Limited to certain aspects of H & P Preceptor records observations / statements / actions performed by the learner

Debrief the Learner Ask the learner what they learned from the observed segment *Can be done in front of the patient Directly evaluate; *Fund of knowledge *Physical examination skills *Clinical reasoning skills

Conclude Interaction Feedback Point out strengths *Positive reinforcement Give the learner one thing to work on *Suggestions for improving clinical performance

Bedside Case Presentations Addresses challenges of teaching *Effective teaching vs patient care *Time management *Assessment of the learner Increases patient satisfaction Promotes professional behavior Mixed reactions from learners

Bedside Case Presentations Implementation Learner and patient preparation *Use of medical terminology Listen to the presentation Clarify / obtain additional information Have learner present evaluation / treatment plan at the bedside ??? Address all patient concerns / questions

EM Clerkship Grades Emergency Medicine Clerkship Uniform Grading Guidelines

Evaluation of Clinical Performance Evaluation of acquired clinical knowledge, skills, attitudes, and behaviors *Clerkship goals “competencies” Ability to incorporate these competencies into clinical medicine

Evaluation of Clinical Performance "Criterion – based” or “Fixed – standard" grading *Identify goals or competencies *Determine expected standards of proficiency *Achievement of the minimum standards of proficiency would represent a “pass” grade *Performance that is above the minimum expectations could earn grades such as “High Pass” and “Honors”

TUH – EM Clerkship Clinical Evaluation Card Student Name: Date / Shift: Evaluator: Block: Clinical Skills: (Learning Objectives) 1. Perform complaint directed history & physical examinations 2. Develop case specific differential diagnosis 3. Present cases in a concise and organized fashion 4. Appropriate utilization and interpretation of diagnostic studies 5. Appropriate implementation of patient management plans 6. Demonstrate medical professionalism 7. Demonstrate an adequate fund of medical knowledge Demonstrate proficiency in basic procedures Patient acuity: High Medium Low Varied Patient encounters: 1 – 2 3 – 5 6 or more Overall grade: H HP P C F  

Feedback on clinical performance: Nonjudgmental, descriptive (refer to specific cases, performances, behaviors, or actions), objective appraisal of performance   Positive feedback (What did the student do well?): Suggestions to improve clinical performance: Any additional comments: Discussed with student Yes No

HONORS The outstanding student Comprehensive achievement of the knowledge, skills, attitudes, and behaviors Top “10%” Resourceful, efficient, and insightful In-depth medical knowledge base Perform detailed but focused H & P’s Well organized presentations Role model Strives for excellence even in difficult situations

HIGH PASS Identify major problems The solid student Perform appropriate but focused H & P’s Demonstrate professional behavior The solid student Well beyond minimum course requirements Next “25% - 35%” Resourceful and efficient Above average fund of medical knowledge

PASS The average student Meets basic course requirements Next “50% - 60%” Average fund of medical knowledge Perform an adequate H & P May omit certain portions of the H & P Presentations generally organized Demonstrate professional behavior

CONDITION / FAIL A performance that falls below expected minimum standards *Clinical knowledge, skills, attitudes, and behaviors Requires specific and detailed documentation by senior EM resident and / or attending

Expected Grade Distribution Rigid cut off values are not used Year to year the percentage of students receiving a particular grade may vary

Summative Evaluation Overall shift grade Honors (5) High Pass (4) Condition (0) Fail (0) # of patient encounters 1 – 2 (x1) 3 – 5 (x2) 6 or more (x3)

RIME Evaluation Framework Reporter Interpreter Manager Educator Pangaro LN Uniformed Services University of the Health Sciences

Reporter Accurately gathers and clearly communicates clinical facts *Medical interviewing *Physical examination skills *Case presentations

Interpreter Prioritizing the patient’s presenting complaints *Developing a problem list *Developing a differential diagnosis *Interpreting basic diagnostic studies

Manager Developing a diagnostic and therapeutic plan Tailoring the management plan to the patient

Educator Self-directed learning Critical reading skills

Barriers to Effective Teaching

Barriers to Teaching The Emergency Department The Teacher The Student The Patient

The Emergency Department Overcrowding Inadequate patient care space Unanticipated emergencies High level of acuity

Teaching Opportunities Unique content areas Teaching clinical vignettes Multitasking and time management skills Communication skills Role modeling professional behavior Reinforce EMC goals

The Teacher Lack of confidence Little experience Little or no formal training Not enough time Endless interruptions Too many other responsibilities Expectations?

The Teacher Every case has a teaching point You have more experience than the students and junior residents Directed learning *Identify interesting cases *Task oriented learning Act interested

The Student Different levels of training Variable fund of knowledge Learning attitude, enthusiasm Expectations?

The Student Identify gaps or misconceptions Teach to their level Focus on one thing at a time

The Patient Level of acuity Painful injury or illness Mental status Need for privacy Patient reluctance

The Patient Bedside teaching rounds are generally viewed as having a positive effect on patient care Most patients enjoy bedside teaching and often develop an increased understanding of their illness. Incorporate patients into the case discussion

Effective Clinical Teaching No one best teaching style or method Teaching principles *Allow the student to play an active part in learning *Use questions that promote high order thinking *Offer feedback Reinforce positive behavior / actions Provide guidance for correcting mistakes

Be flexible (different levels of training) The Bottom Line… Decide what to teach Take away point *History *Physical examination *Diagnostics *Therapeutics Be flexible (different levels of training)

Author Credit – Clinical teaching: David A. Wald DO Questions

Postresidency Tools of the Trade CD 13) Negotiation – Ramundo 14) ABEM Certifications – Cheng 15) Patient Satisfaction – Cheng 16) Billing, Coding & Documenting – Cheng/Hall 17) Financial Planning – Hevia 18) Time Management – Promes 19) Balancing Work & Family – Promes & Datner 20) Physician Wellness & Burnout – Conrad /Wadman 21) Professionalism – Fredrick 22) Cases for professionalism & ethics – SAEM 23) Medical Directorship – Proctor 24) Academic Career Guide Chapter 1-8 – Nottingham 25) Academic career Guide Chapter 9-16 – Noeller 1) Career Planning – Garmel 2) Careers in Academic EM – Sokolove 3) Private Practice Career Options - Holliman 4) Fellowship/EM Organizations – Coates/Cheng 5) CV – Garmel 6) Interviewing – Garmel 7) Contracts for Emergency Physicians – Franks 8) Salary & Benefits – Hevia 9) Malpractice – Derse/Cheng 10) Clinical Teaching in the ED – Wald 11) Teaching Tips – Ankel 12) Mentoring - Ramundo