1. Teaching Patient Presentation Skills Faculty Development Lecture Discussion Insert your name here Developed by Alison Dobbie, MD and James Tysinger, PhD, 2007

2. Needs assessment  Who teaches and evaluates patient presentation skills?  What problems have you noticed with learners’ presentations?

3. Session Objectives Participants will be able to: 1. State three new things they learned about teaching presentation skills 2. Use this knowledge to improve their presentation skills teaching

4. Four Lessons from the Literature (and Four Teaching Tips) 1. Learners often struggle to adapt hospital- based presentation skills to the ambulatory setting 2. Your expert patient management process is NOT transparent 3. Teachers and learners view presentations differently 4. Experts and novices deal differently with uncertainty

5. Lesson 1: Differences between Ambulatory and Inpatient presentations Ambulatory presentations are:  Shorter (3-6 minutes)  Focused versus comprehensive  Problem versus system based  Undifferentiated versus diagnosed patients  Emphasis on chronic management / prevention YET Most students and new residents have learned presentation skills on hospital patients

6. Therefore, learners may struggle to adapt hospital skills to the clinic In the clinic there is:  A faster pace, a huge range of medical content, and first contact with undifferentiated patients  There is increased importance of interviewing skills, real-time clinical reasoning, information synthesis, discrimination between important and trivial, problem prioritization, medical decision-making, organizational skills, rhetoric and time management In the context of individual preceptor’s preferences!  No wonder some learners struggle!

7. Teaching Tip 1. Easing the transition 1. Clearly explain ambulatory precepting expectations  Short, focused, problem-based presentations that include assessments and plans AND health maintenance 2. Offer a simple template (for example, see lecture handout) 3. Present back to learners, demonstrating your own skills

8. Lesson 2. Preceptors are magicians!  Novice Learners have NO IDEA how we do what we do  To them it is alchemy  We need to share our processes  We need to coach them

9. Teaching Tip 2. Demystify the clinical thinking process  Clearly explain (out loud) your own clinical thinking and decision making  Explain how you use: Abstraction Semantic qualifiers Illness scripts Pattern recognition Probability

10. More demystifying expert tips  Explain / demonstrate clearly that Your physical exam is driven by the history Your assessment / differential diagnosis is driven by the history and physical Your plan is driven by your assessment You NEVER order “shotgun” tests You almost never order a test without anticipating the result

11. Lesson 3. Teachers and learners view presentations differently Teachers  Contextual  Vehicle for communication and debate  Opportunity to share diagnostic plans and give feedback on performance Learners  Less aware of context  Rule-based regurgitation of stored information  Perfect presentation is one with no interruptions! PATIENT

12. Teaching Tip 3. Explain your perspective on presentations  A presentation is for Sharing information Debating and discussing diagnostic and treatment options  A presentation is NOT A set piece to be delivered as quickly as possible without interruptions A report on the history and PE after which the attending tells you what to do! A set piece to be performed perfectly in order to receive a good grade

13. Lesson 4. Experts and novices deal differently with uncertainty Teachers tend to:  readily acknowledge limitations in: Information available Their own knowledge Expert opinions Scientific evidence  Tolerate uncertainty “Tincture of time” Learners tend to  Hide their limitations  Dissemble  Deflect  Argue  Agree unconditionally  Abhor uncertainty “I must know the answer”

14. Tip 4. Helping learners with uncertainty  This is DIFFICULT. Learners crave the comfortable content expertise of the super sub- specialist  Role model that it is okay not to know everything Use ‘just in time’ learning Incorporate technology  Discuss that science and evidence is not always perfect and always evolving  Demonstrate that it is possible to make good decisions using imperfect information

15. How best to teach presentation skills? Use Clinical Teaching General Principles  Assess baseline competence  Use multiple interventions  Give sustained input / coaching  Provide routine feedback  Evaluate interval gains

16. Other Faculty Development Tools for Teaching and Assessing Presentations  We recommend you use two simple tools The Five Clinical Teaching Microskills and The RIME method (Reporter, Interpreter, Manager, Educator)

17. ACCURATECOMPLETE CONCISE RELEVANT A GREAT PRESENTATION IS

18. Summary and wrap up  What did you learn about teaching presentation skills?  How will you change your precepting behavior?

19. References / Bibliography 1.Bowen, J.L., Educational strategies to promote clinical diagnostic reasoning. N Engl J Med, 2006. 355(21): p. 2217-25. 2.Cuello-Garcia, C., Sharing the diagnostic process in the clinical teaching environment: a case study. J Contin Educ Health Prof, 2005. 25(4): p. 231-9. 3.Green, E.H., et al., Developing and implementing universal guidelines for oral patient presentation skills. Teach Learn Med, 2005. 17(3): p. 263-7. 4.Groves, M., P. O'Rourke, and H. Alexander, Clinical reasoning: the relative contribution of identification, interpretation and hypothesis errors to misdiagnosis. Med Teach, 2003. 25(6): p. 621-5. 5.Groves, M., P. O'Rourke, and H. Alexander, The clinical reasoning characteristics of diagnostic experts. Med Teach, 2003. 25(3): p. 308-13. 6.Haber, R.J. and L.A. Lingard, Learning oral presentation skills: a rhetorical analysis with pedagogical and professional implications. J Gen Intern Med, 2001. 16(5): p. 308-14. 7.Hasnain, M., et al., History-taking behaviors associated with diagnostic competence of clerks: an exploratory study. Acad Med, 2001. 76(10 Suppl): p. S14-7. 8.Jones, H.C., An observational study of precepting encounters in a family practice residency program. Fam Med, 2002. 34(6): p. 441-4.

20. References / Bibliography 9.Kim, S., et al., A randomized-controlled study of encounter cards to improve oral case presentation skills of medical students. J Gen Intern Med, 2005. 20(8): p. 743-7. 10.Lingard, L., et al., A certain art of uncertainty: case presentation and the development of professional identity. Soc Sci Med, 2003. 56(3): p. 603-16. 11.Lingard, L., et al., 'Talking the talk': school and workplace genre tension in clerkship case presentations. Med Educ, 2003. 37(7): p. 612-20. 12.Neher, J.O., et al., A five-step "microskills" model of clinical teaching. J Am Board Fam Pract, 1992. 5(4): p. 419-24. 13.Nendaz, M.R., et al., Brief report: beyond clinical experience: features of data collection and interpretation that contribute to diagnostic accuracy. J Gen Intern Med, 2006. 21(12): p. 1302-5. 14.Parrot, S., et al., Evidence-based office teaching--the five-step microskills model of clinical teaching. Fam Med, 2006. 38(3): p. 164-7. 15.Sepdham, D., et al., Using the RIME model for learner assessment and feedback. Fam Med, 2007. 39(3): p. 161-3. 16.Wiese, J., P. Varosy, and L. Tierney, Improving oral presentation skills with a clinical reasoning curriculum: a prospective controlled study. Am J Med, 2002. 112(3): p. 212-8.