Clinical Teaching Workshop เชิดศักดิ์ ไอรมณีรัตน์ ภาควิชาศัลยศาสตร์ คณะ แพทยศาสตร์ศิริราชพยาบาล มหาวิทยาลัย มหิดล

Objectives At the end of this workshop, participants will be able to: –Explain basic principles of adult learning –Apply various teaching skills in a clinical setting –Choose appropriate teaching techniques to help students learn in a clinical setting –Develop effective teaching plans and strategies for teaching in a clinical setting

Basic Concepts in Medical Education Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University

Learning A relatively permanent change in performance or performance potential that results from experience and interaction with the world –Occurs intentionally in formal instructional settings –Occurs incidentally through experience

Some Basic Principles of Clinical Teaching

Some Basic Principles 1. Teaching is not equal to learning.

Effectiveness of Teaching Methods Percent of skills attained

Some Basic Principles 2. Adults learn differently from children.

Adult Learning Based on learners’ needs Goal-directed (self-directed learning) Consider personal experience that serves as a resource for learning Task- or problem-driven rather than subject focused Intrinsically focused (their own motives) Need to be treated with respect Feedback is central to satisfied learning

Some Basic Principles 3. Learning from experience develops through cycles of careful thinking.

Experiential Learning Theory Kolb DA. Experiential learning. Englewood cliffs, NJ: Prentice-Hall, Schön, D. The Reflective Practitioner, New York: Basic Books, 1983.

Experiential Learning Theory Recommendations –Plan for experiences in carefully selected settings. –Facilitate reflective observation. –Encourage conceptual thinking and inquiry. –Promote feedback and testing of the insights drawn from experience.

Some Basic Principles 4. Encourage meaningful learning

Two Types of Learning Rote learning –Memorization of facts Meaningful learning –The process of relating potentially meaningful information to what a learner already knows in a substantive way Relevance Sequence Ausubel, D. The psychology of meaningful verbal learning. New York: Grune & Stratton,1963.

Meaningful Learning 1.Make a connection of new concepts/ topics to students’ experience or available knowledge. 2.Arrange proper sequence –From simple to complex –From known to unknown –From example to principle –From concrete to abstract Cox KR, Ewan CE. The medical teacher, New York: Churchill Livingstone, 1982.

Some Basic Principles 5. Define a clear set of learning objectives

Educational Objectives 1.Give trainees a clear understanding of what they are expected to know or do. 2.Assure that all the curriculum content is covered properly, no gaps or duplications. 3.Describe the course to interested individuals in a concise way. 4.Help an instructor organize the course. 5.Provide an evaluation framework. 6.Guide the criteria for course evaluation. 17Educational Objectives

Writing an Objective Time frame –At the completion of the lesson –At the end of the rotation Learners –Fourth-year medical students –Second-year surgical residents Behaviors Standards and conditions 18Educational Objectives

Bloom’s Taxonomy Three types of learning –Cognitive: Mental ability –Affective: Feelings, values, attitudes, emotion –Psychomotor: Manual or physical skills

Behavioral Objectives Cognitive Domain Knowledge: define, identify, indicate, list, state, write, name Comprehension: compare, associate, compute, contrast, describe, differentiate, interpret, predict, translate Application: apply, classify, demonstrate, solve, use, utilize Analysis: order, group, translate, summarize Synthesis: arrange, combine, create, design, develop, formulate, prepare, plan Evaluation: appraise, assess, critique, judge, rate, recommend 20Educational Objectives

Standards and Conditions How will learners be evaluated? Standards –90 percent of the time –Score 85% or higher Conditions –In an MCQ exam –On a surgical ward 21Educational Objectives

Examples At the end of this session, participants will be able to write at least two complete behavioral objectives in the topic currently teach. At the end of the fifth week of surgical clerkship, fourth year medical students will be able to tie a secure square knot with a one-hand technique 100% of a time. 22Educational Objectives

Some Basic Principles 1.Teaching is not equal to learning 2.Adult learning 3.Experiential learning 4.Meaningful learning 5.Educational objectives

Giving Feedback Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University

What is Feedback? Information Given to a learner Specifically describes the learner’s performance Intended to guide the learner’s future performance

Why Do We Give Feedback? Reasons for feedback –To help learners… Learn about their current levels of competence Reflect their strengths and deficits Engage in a dialogue with a supervisor or mentor Become more competent

Effective Feedback Steps 1.Clarify goals of the session. 2.Elicit learner’s perspective on the problem. 3.Provide positive feedback. 4.Provide negative feedback addressing behaviors – not personality. 5.Promote mutual problem-solving. 6.Offer alternative approaches.

Feedback Guidelines Clear information Mutually agreed upon goals Learner has an active role in the feedback process Positive affect, empathy, and support

Clear Information Describe issue specifically Offer written documentation as evidence Offer direct observation evidence Correct mistakes by describing what was wrong and how to avoid or correct error Timely feedback (as soon as possible) Confronts learner when appropriate

Mutually Agreed Upon Goals Indicate feedback is being given Refer to learner’s goal Refer to rotation/course expectation Make arrangement for a follow up meeting

Learner Has An Active Role Solicit learner’s perception of experience Invite learner’s self-assessment of the problem Ask about areas learner want to focus on Link comments to learner’s statements Develop a plan with learner to address problems Ask about ways to maintain positive behavior

Positive Affect, Empathy, Support Demonstrate positive regard for learner Behave non-judgmentally Work to establish or maintain a relationship with the learner

Feedback Tips Good feedback – It is undertaken with teacher and student working as allies with common goals. – It is well timed and expected. – It is based on first-hand data. – It is regulated in quantity and limited to behaviors that are remediable.

Teaching in an Ambulatory Setting Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University

Importance Changes in medical practice: inpatients tend to be more representatives of subspecialty care, and outpatients are more representatives of routine medical practice Changes in students: increasing number of students result in inadequate number of inpatients per students Broader expected competencies: The roles of doctors not limited to treatment, but also health promotion, disease prevention, rehabilitation Dent JA. AMEE guide no 26: Clinical teaching in ambulatory care settings: Making the most of learning opportunities with outpatients. Med Teacher 2005; 27:

Barriers to effective ambulatory teaching Inadequate space and time to teach Sharing of teaching burden: learners may be taught by inexperienced teachers Work pressure: learners are rarely observed Public nature: feedback is rarely provided Student’s orientation is inadequate Seeking consent from patients Irby D. Teaching and learning in ambulatory settings. A thematic review of the literature. Acad Med 1995; 70:

3-Step Planning 1.Orient the learners 2.Organize the clinic 3.Encourage learners to take more responsibility for their own learning Sprake C, et al. Teaching in an ambulatory care setting. BMJ 2008; 337: a1156.

1. Orient the Learners Describe the OPD environment Find out students’ names Show them where they can store bags Assess learning needs and expectations Communicate with other OPD staffs

2. Organize the Clinic Manage patient consent – Inform patients about the presence of students – Poster or signs in the waiting area Manage time – Provide appropriate amount of time for students based on appropriate mode of patient approach

Many Approaches in OPD Observer model Assistant model Practice under supervision Practice with a consultant

3. Encourage Learners Students should take responsibilities for their own learning – Getting involved with patient care – Learning skills Experiential learning SNAPPS – Logbooks

Experiential Learning Theory Kolb DA, Fry R. Toward an applied theory of experiential learning. In C. Cooper (ed) Theories of group Process, London: John Wiley, 1975 Schon D. The reflective practitioner, New York: Basic Books, 1983.

SNAPPS 1.Summarize briefly the history and findings 2.Narrow the differential diagnoses 3.Analyze the differential diagnoses by comparing and contrasting the possibilities 4.Probe the preceptor by asking questions 5.Plan management 6.Select a case-related issue for self study Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: A learner-centered model for Outpatient education. Acad Med 2003, 78(9): 893 – 8.

Effective Ambulatory Teaching Behaviors Preceptor inspires student confidence in preceptor’s medical skills. Preceptor explains the decision-making process to students. Preceptor treats students with trust and respect. Preceptor provides a role model. Elnicki DM, et al. Third-year medical students’ preceptions of effective teaching behaviors in a multidisciplinary ambulatory clerkship. Acad Med 2003; 78:

Tips for Ambulatory Preceptors Before you start When you teach When the session is over Dent JA. AMEE guide no 26: Clinical teaching in ambulatory care settings: Making the most of learning opportunities with outpatients. Med Teacher 2005; 27:

Before You Start Attend a staff development session and read any support material available. Check students’ study guide, or any course material. Familiarize yourself with the clinical problems usually encountered in the clinic. Brief the students about the objectives. Select appropriate cases for your students.

When You Teach Selecting an appropriate teaching model – One student : one teacher – Several students: one teacher – Several students: several teachers

One Student: One Teacher Sitting-in model – Observer role – Assistant role Apprenticeship model (practice under supervision) Team member model (practice with a consultant)

Several Students: One Teacher Grandstand model Supervising model Report-back model

Several Students: Several Teachers Shuttle model Division model Flip-flop model Tutor model

When the Session is Over Provide students the opportunity to discuss what they have learned: reflection Identify aspects of learning outcomes they have been illustrated Clarify any misunderstandings Reflect on yourself: what you will change in the next session

Clinical Supervision Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University

Clinical Supervision “The provision of monitoring, guidance & feedback on matters of personal, professional & educational development in the context of a trainee’s experience of providing safe and appropriate patient care”.

Effective Supervisors Good interpersonal skills Good teaching skills Clinically competent Knowledgeable

Preparator y theory Clinical practice Briefing Follow up Evaluation Follow up Evaluation Debriefing Laboratory Clinical Learning Cycle

Purposes Assess student’s readiness for practice Identify concerns related to practice Set objectives and levels of performance Assess student’s understanding Checking preparation Providing encouragement Questioning the student’s plan of care Negotiate the roles to be taken in clinical practice Exploring the opportunities for feedback during clinical practice Briefing session

Purpose Acquisition of the skills of clinical competence with a lesser emphasis on the accumulation of theoretical knowledge Clinical practice

Purposes Reflection on clinical experience Identify discoveries, new learning, insight Analyze thinking and feeling about the experiences Confirm or confront personal bias or beliefs Obtain and give feedback on performance Debriefing session

Helpful Supervisory Behaviors Ensuring trainee competence and level of supervision Giving direct guidance on clinical work Linking theory and practice Engage in joint problem-solving Offering feedback and reassurance Providing role model

Confucius "It does not matter how slowly you go so long as you do not stop."