Graduated Responsibility From Medical Student to Physician University of BC Faculty of Medicine Department of Family Practice Post Graduate Program

Residents are ADULT LEARNERS What are some of the characteristics of adult learners? What are some of the characteristics of adult learners? Take two minutes to write down several characteristics of adult learners. Take two minutes to write down several characteristics of adult learners.

Adult Learners are: Self directed Self directed Learner centred Learner centred Problem oriented Problem oriented Curiosity driven Curiosity driven Reflective Reflective Individually and culturally different Individually and culturally different

Remember ! With Adult learners our role is that of a GUIDE as much as a teacher.

Challenge Finding the balance between supervision and independence when teaching family practice residents. Finding the balance between supervision and independence when teaching family practice residents. What are the consequences of too little or too much independence? What are the consequences of too little or too much independence?

Too little responsibility Boredom Boredom Demeaning Demeaning Unchallenged Unchallenged Limited Progress Limited Progress No confidence No confidence

Too Much Responsibility Do not feel safe to challenge themselves Fear Medical error and undesired outcomes

Educational Diagnosis Deciding where your learner is Deciding where your learner is What is an educational diagnosis? What is an educational diagnosis?

Bordage stages of learning I Reduced knowledge I Reduced knowledge II Dispersed knowledge II Dispersed knowledge III Elaborated knowledge III Elaborated knowledge IV Compiled knowledge IV Compiled knowledge

Discuss: Think of the resident you have now or have had recently. At what stage are they with many of the topics you deal with? Think of the resident you have now or have had recently. At what stage are they with many of the topics you deal with? Where should they be? Where should they be?

Benchmarks The Program has developed a list of benchmarks to help you understand the levels of knowledge and skills a resident should have developed at each stage of their residency. See: The Program has developed a list of benchmarks to help you understand the levels of knowledge and skills a resident should have developed at each stage of their residency. See: cy/facultydevelopment/BordageMode l.htm cy/facultydevelopment/BordageMode l.htm

Start of 1 st year Hospital Hx and Px taking an hour Hospital Hx and Px taking an hour Large Knowledge gaps Large Knowledge gaps Common vs. Uncommon? Common vs. Uncommon? Little deductive ability Little deductive ability Therapeutics weak Therapeutics weak Contextual issues weak Contextual issues weak

You need to: Observe Hx and Exam Observe Hx and Exam Observe pelvic exams and procedures Observe pelvic exams and procedures Daily observation of parts of visits Daily observation of parts of visits Question reasoning Question reasoning Correct mistakes Correct mistakes Encourage resident to read around issues Encourage resident to read around issues

2 nd half of 1 st year Crisper and more focused Hx and exam Crisper and more focused Hx and exam Better appreciation of range of common problems. (fewer esoteric dx.) Better appreciation of range of common problems. (fewer esoteric dx.) Better active listening Better active listening More rational use of investigations More rational use of investigations Better therapeutics Better therapeutics

You need to: Discuss each case but briefer and focused Discuss each case but briefer and focused Allow resident more decision making Allow resident more decision making Watch for gaps and encourage reading up, rapid EBM? Online information? Watch for gaps and encourage reading up, rapid EBM? Online information? Review interviews and exams regularly and formally weekly. Review interviews and exams regularly and formally weekly. Watch for over confidence Watch for over confidence

2 nd year to graduation Significantly less supervision. Significantly less supervision. As the resident progresses give him or her more opportunity to be independent. As the resident progresses give him or her more opportunity to be independent.

Teaching Techniques Take a couple of minutes and write down what teaching techniques you use when working with a medical student, a first year or a second year resident? Do you have techniques that allow increasing degrees of responsibility? Take a couple of minutes and write down what teaching techniques you use when working with a medical student, a first year or a second year resident? Do you have techniques that allow increasing degrees of responsibility?

Teaching Techniques Case Discussion Case Discussion For First Year residents needing greater supervision For First Year residents needing greater supervision Case Review Case Review Chart Review and recall Chart Review and recall - For Second Year residents or those needing less supervision

Suggestion: 1st day, resident watches you 1st day, resident watches you Next 2-3 days, you watch to make an educational diagnosis Next 2-3 days, you watch to make an educational diagnosis Then, regular but decreasing direct observations Then, regular but decreasing direct observations “Credit” demonstrated competencies “Credit” demonstrated competencies Micro-skills (one minute preceptor) Micro-skills (one minute preceptor) Graduate to reviews Graduate to reviews Critical reflection, Open ended questions Critical reflection, Open ended questions

Progression Observation and direction, knowledge without application – Medical Student Observation and direction, knowledge without application – Medical Student Application of knowledge, Freedom to err in a safe environment – Early Residency Application of knowledge, Freedom to err in a safe environment – Early Residency Some independence with regular review – Late Residency Some independence with regular review – Late Residency Independence with occasional review and observation – End Residency Independence with occasional review and observation – End Residency

Ask yourself: Is the resident more independent during the last week than the first? Is the resident more independent during the last week than the first? Is part of your teaching objective to encourage independence? Is part of your teaching objective to encourage independence? Has the resident acquired skills for which he/she is justifiably confident? Has the resident acquired skills for which he/she is justifiably confident?

Thank You This module was written as an aid to the Preceptors in the Postgraduate Family Practice Program at the University of BC. Study credit is available to groups of preceptors who complete the module Please give us your feedback on the module so that we may improve it for others. you comments to Dr. Fraser Norrie, Faculty Development, UBC Family Practice