1. Masterclass in Clinical Education An innovative teaching / learning / teamwork tool for faculty, resident and student development Natascha Lautenschläger, MD, MSPH Hayam Shaker, MD

2. Goal Improve Physician Teaching Improve Physician Performance Improve Physician Learning ALL AT THE SAME TIME!!

3. Objectives Background teaching theory and ideas: Andragogy vs. Pedagogy studies in peer review/observation/teaching – what we are already trying in medicine Masterclass application: benefits, challenges then our first masterclass in precepting.

4. “Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem.”

5. The Musical version “ The fact is that the culling of students perceived as less talented, less accomplished, or less musical is generally accepted as necessary and inevitable in conservatory life, even if this is accomplished in an unpleasant fashion.”

6. What Musicians can teach Doctors Performance: clinical practice (overshadowed by science changes) Coaching, experiential learning (live, hands on, reflection, abstract conceptulization, active experience – Endless performance without feedback drifts into stagnation – Master in coaching is not taught, rewarded or studied

7. What Musicians can teach Doctors Stardom ≠ great coaching Training, practice, experience beats talent every time Time 7-10 years medically, more musically Art; technical skill and true musicality – “Science using interpretive activity” Practice: listen, slow it down, break it apart – ? Video review

8. What Musicians can teach Doctors Teamwork – docs still as autonomous Repertoire, improvising Specialization (instrumentalists) vs. generalists (conductors) – Rushing vs. pt. daily load – Counterpoint synch with and in response to pt., hearing both simultaneously

9. Setting: Masterclass Seminar In open view of audience: – Faculty, fellow musicians of all levels, faculty of all levels – Master teacher – Master = all in seminar format

10. If musicians learned to play their instruments as physicians learn to interview patients, the procedure would consist of presenting in lectures or maybe in a demonstration or two the theory and mechanisms of the music producing ability of the instrument and telling him to produce a melody. The instructor, of course, would not be present to observe or listen to the student's efforts, but would be satisfied with the student's subsequent verbal report of what came out of the instrument. George Engel, after visiting 70 medical schools in North America `

11. Doceo / docere Agoge Pedagogy Andragogy

13. Andragogy Self-concepts – dependant personality  self-directed human beings Experience – a growing reservoir of experience that becomes an increasing resource for learning Readiness to learn – become oriented to developmental task of his social roles Orientation to learning – from postponed application of knowledge to immediate application

14. PedagogyAndragogy The learnerDependent. Teacher directs what, when, how a subject is learned and tests that it has been learned Moves towards independence. Self-directing. Teacher encourages and nurtures this movement The learner's experienceOf little worth. Hence teaching methods are didactic A rich resource for learning. Hence teaching methods include discussion, problem- solving etc. Readiness to learnPeople learn what society expects them to. So that the curriculum is standardized. People learn what they need to know, so that learning programmes organised around life application. Orientation to learningAcquisition of subject matter. Curriculum organized by subjects. Learning experiences should be based around experiences, since people are performance centred in their learning

15. Andragogy vs. Pedagogy

16. Andragogy: Appearances Imposter Phenomenon 255 surveys sent, 181 replied (Wisconsin) 30% FM residents in study (41% F 24% M) 90 % getting education needed (all interviewed) Oriel K, et al. Fam Med Oriel K, et al. Fam Med 2004

17. Define Shifting dullness

18. Death by Power Point You cannot fool yourself that because you lectured, it was learned.

19. PREPARE the Sleepers (Cartoon removed) Audience Participation

20. Feedback Tango Cybernetics concept = output is returned to a system to regulate a dynamic function Giving feedback is hard for attendings and residents How can teachers encourage students and residents for honest feedback?

21. Tensions: How the Desire for Feedback and Reticence to Collect and Use It Can Conflict. Within self – desire feedback but fear “disconfirming” info – conflicts with self appraisal Between people: desire for feedback: – Want dialogue → fear @ looking dumb or sharing deficiencies – not trusting feedback or unable to solicit it – worry @ damaging relationship Mann K. Academic Medicine 2011

22. Tensions: How the Desire for Feedback and Reticence to Collect and Use It Can Conflict. 1.Within self 2.Between people: desire for feedback: (Imposter?) 3. Learning / practice environment – stated curriculum vs. active curriculum – authentic self assessment vs. playing the “evaluation game” Mann K. Academic Medicine 2011

23. Medical Teacher Development: Ten experienced medical teachers give input Use of feedback, mentors and co-teaching rec by many studies but rarely used. Emotional context of teaching Medical teaching learned by observing others, understanding, practicing skills “Medical teachers need time to try out new teaching techniques on the job.” Macdugall J. Med Ed 2005

24. What do we want? Feedback. When we want it? Now! Benefits: – Learning new things – easier to relax, immediate, – reinforcement for teacher – Also Desired feedback from simulated patient Concerns: – novice feedback – anxiety @ correction – “home team” pressure, the friendship factor – competition Cushing Medical Teacher 2011 Year 1 MS; OSCE sessions as candidate (3X), examiner (6X), observer.

25. What do we want? Feedback. When we want it? Now! Factors for acceptance/credibility of negative feedback: 1. Credibility (teacher, direct observance, related to standards) 2. Emotions (challenge to personal perception, resistance to accepting feedback) 3. Time for Reflection on feedback Cushing Medical Teacher 2011

26. What do we want? Feedback. When we want it? Now! “Giving feedback should be core communication skill, manner given influences effectiveness.” More effective learning when peer feedback is included. Manner given influences effectiveness. Timing: Immediate, attention to disparity between actual/perceived performance. Cushing Medical Teacher 2011

27. Direct Observation, Knowledge, and Feedback : @ 8000 internet surveys med stud/res registered for USMLE 2008 – 360 degree evaluation Trainees also valued feedback from those they supervise & nurses A minority would give feedback withOUT having observed person Mazor Academic Med 2011

28. Direct Observation, Knowledge, and Feedback: Feedback challenges: – commentator may not have had enough chances to observe learner learner perception: – with less value if felt not observed enough Mazor Academic Med 2011

29. F I T A B L E FEEDBACK FIT Frequent Interactive Timely ABLE Appropriate for learner level Balanced Behavior based Labeled Empathetic

30. PREPARE FOR AUDIENCE PARTICIPATION

32. Current peer learning in medicine Peer to peer observation Peer Review – evaluation of one element of an individual’s performance by trained colleagues using a valid review instrument to facilitate developmental feedback. Peer assisted learning / teaching

33. Is it acceptable? Peer observation of teaching to GP teachers Questionnaire to London teaching docs @ peer obs Majority felt benefits for teachers/students – reflection, encouragement to try new methods, decrease isolation as teacher 49% wished to take part, 45% no, 6% undecided. Being ill at ease with video recording a session corresponded to not wanting to do it. (getting feedback from educationalist), then time and concern @ motivations of department (why do it?). Not related to workload or time of GP

34. Become a better clinical teacher: A collaborative peer observation process “Co attending” to in-pt team who gives feedback, written comments, observes rounds. All had issues with timing and appropriateness of questions Wards: challenge to think of appropriate question in the moment How to engage different learner levels Jr faculty benefited from both observing and being observed. Sr teachers also identified new techniques. Finn K. Med Teach 2011

35. Helping each other to learn – a process evaluation of peer assisted learning Volunteer Fifth-year medical student tutors: Second year learners Benefits: safe learning environments, cooperation, promotive interaction (Encourage, facilitate each other in order to reach groups goals, exchange of resources and info) – Giving & receiving feedback – Mutual influence – Modeling low performing students as tutors actually gained more cognitively than as ‘students’ When we learn to teach, we appear to learn better, than when learning to be tested (even children) Glynn LG, BMC Med Ed March 2006

36. Twelve tips for peer observation of teaching. Medical Teacher 1. Choose observer carefully – trust! 2. Time: enough 3. expectations 4. Familiarity with content/class 5. Select the instrument wisely (if needed) 6. Include students 7. Objectivity 8. Avoid comparison to your own 9. Do not intervene 10. feedback, debriefing most important 11. Maintain confidentiality 12. Make it a learning experience Siddiqui ZS. Med Teach 2007

37. Benefits of Peer XXX Teacher development (current and future) Enhanced learning Improved cognitive skills Self confidence, self reflection Promotive interaction Both teacher and Learner practice Immediate feedback Teaching “should be monitored and maintained by those who engage in it.”

38. Barriers to Peer XXX Time / clinical responsibilities Recruitment and retention of faculty Convincing others of program value. Less individual time because of group Fear of negative feedback / Imposter Discomfort with knowledgeable colleague critiquing Performance fear No data on outcomes

39. Now to the Masterclass (image removed)

40. Masterclass Defined loosely as “dialogue” between master and student with student’s performance as focal point. Feedback and instruction during the concert and makes a new effort then and there.

41. What is Masterclass seminar? Teach and learn in public Performing in front of others Open for audience comments and critiques Can include short lectures if needed A streamed dialogue between performer and audience Consider this as a laboratory to improve communications

42. All opinions are not equally brilliant, but all opinions can be a vehicle to learning by those who propose or oppose them. Discussion to Dialogue

43. Cushing Med Teach 2011 Learning Theory Social cognitive theory: – importance of learning from others – dynamic reciprocal interaction between learning environment – vicarious learning through watching others’ action and consequences, self efficacy Situation learning and communities of practice – collective learning – learning by being in community – learning is inseparable from the context in which it occurs, – new members contribute through participation.

44. Participation in a master class: experiences of older amateur pianists Sharing balance of power, joint collaborators with audience. – Mutual support and interest from the audience Watching others  accepting of new ideas Valuable practice in public performing. All noted worth doing even if disagreeing with suggestions. Generally seen as a positive to self esteem, musical self efficacy, acquiring new music skills, stimulated participants to energize their peers. Taylor. Music Ed Research 2010

45. Teaching and learning music performance: The masterclass Use of metaphors, nonverbal communication, demonstration, discussion Imitation – learn by doing before understanding Students are likely to perform the music in concert, ability to execute and memory (develop templates to use when practicing) Audience can transfer their learning beyond the examples used Challenges for “master” spot assessment, decisions and prepare lesson in seconds Students learn to handle instructions, feedback in front of learned others Hanken. FJME 2008

46. Gordon J. ABC’s of Teaching. BMJ 2003

47. Advantage of the Masterclass Learning by observing others being taught On-spot education Vicarious reinforcement Participation – Taking part in the learning process Find problem and try to solve it if live Audience learns as well

48. Challenging Arena Psychological challenge – Performance anxiety Subject one’s self to continuous critique in public. Cognitive challenge – Decisions on the spot – Not prepared in advance – Involving all learners Ours: not live, video Faculty / res precepting out patient Pt confidentiality

49. Peer Evaluation Initial Reaction with Learner Quality of Questions Use of Time Verbal and Non-Verbal Communications Teaching Moments Feedback Closing

50. Video of faculty precepting a 3 rd year resident (Natascha is faculty, presentation is preop visit) Too large to load

51. Participant section – how would they do it?

52. Future IDEAS Patient encounter Immediate feedback during didactics (see didactics as a performance) – Grand Rounds as the same Caveat – we are trialing different forms of Masterclass ideas. Research is going to take time to assess the effectiveness

53. Points to Present What makes the masterclass Effective? Is it effective to observers? What are the challenges when learning and teaching in front of audience? What is the function of this class on younger junior faculty?

54. Evaluation Form Knowledge of Master Class – Are you familiar with this type of teaching? – Have you ever participated in one? Settling in – What have you Learned? – Are you convinced? Would you be willing to try this new method? – Was it Helpful? – Any comments or Suggestions? What aspects did you like and what would you change?

55. Contacts Natascha.lautenschlaeger@pardeehospital.org Hayam.shaker@pardeehospital.org Hendersonville Family Medicine Residency MAHEC (Rural sister program to Asheville) Hendersonville, NC

56. Related Talks @ STFM Download? Teaching Trainee Teachers – a resident & faculty teaching workshop Thurs WIP 10:30 Feedback & Evaluation: Intentions, realities & practical strategy: Thurs S 2-3:30 Demo of active learning & the neuroscience behind its effects Thurs S 4-5:30 Teaching your Teachers: a practical approach to fac development: Thurs S 4-5:30 Developing a robust peer feedback system to strengthen fac performance & competence: Thurs S 4-5:30

57. Related Talks STFM Friday Resident to Teacher Roles Reversed; How do we teach residents to teach Fri L 10-11:30 (Download) Using neuropsychology for effective presentations: Sat L 11:15 Improving the precepting encounter for the teacher, learner & pt: Sat L 2:15 Ekstasis: A peer consultation model for med ed: Sat S 3:45- 5:15 Pulling the plug on power-point: 5 experiential techniques for teaching enhancement and creativity: Sat S 3:45-5:15

58. STFM talks, related? Dynamic Tensions of resident advising relationships: mentorship vs eval: Sat L 4:30 Informal Precepting and learning to live with uncertainty: Sat RT 7-8am B59 Equal or same, responding to diff in ed for male and f residents: Sat RT 7-8am B83

59. Posters Teaching resident reflection & self assessment skills through reflection groups & papers: Thurs P 5:30-7 BP6 Group video review – safety first you might feel a little pinch: Thurs P 5:30-7 BP13 Cultivating the active learner: Sat RT 7-8am B69 Obs of phys- pt communication, lessons learned from communication research in a fam med res clinic: Sat RT 7-8am B91 Great presentations – simple ways to create outstanding lectures: Sat RT 7-8am B96

60. Extra Tidbits, studies

61. Andragogy Internal Motivations

62. The planning and implementation of a faculty peer review teaching project (Lecture) Concern @bias in student evaluations (grades, popularity) Teaching “should be monitored and maintained by those who engage in it.” Barriers: – fear of negative feedback – right to teach behind closed orders – discomfort with knowledgeable colleague critiquing Schultz AJPE 2006

63. The planning and implementation of a faculty peer review teaching project (Lecture) Successful review needs: – Faculty by in, periodic reminders, time, adequate training for the process, to be asked to participate. – Immediate feedback – Not required or reviewed by chairperson Teaching “should be monitored and maintained by those who engage in it.” Schultz AJPE 2006

64. Teaching medical students how to teach: A national survey (Peer assisted teaching) 44 % Schools with formal SAT programs Benefits: development of future teachers, enhancement and medical student learning, providing teaching assistance to faculty, curriculum development, strengthening student teachers clinical skills. Barriers: time, recruitment and retention of faculty, convincing others of programs value, medical student commitment, and adequate evaluation process the student teachers. Soriano R. Academic Med 2010

65. Review of peer teaching and learning in clinical education Improved cognitive development Clinical skill development/psychomotor (student and clinical evaluator noted) improved. – Increase clinical practice comfort, skills Empathy-no comment Satisfaction: Increased self-confidence, reasoning, self- evaluation, collaboration with peers. Increased student leadership skills & time management skills. Internal motivation important to outcomes. Concerns: Incompatibility of students, less individual time with instructor. Seacomb J. J Clin Nur 2007

66. Adult Learning Models for Large-group continuing medical education activities Asked CME respondents lecture format, interactive session, procedural sessions, short blast sessions. Most 46% preferred lecture (majority) format, but 39% remember more from interactive sessions. Interactive sessions are more effective for retention and most effective for pt care. More likely to answer board type questions correctly after interactive session Stephens MB. Fam Med 2011

67. Medical Student Life Revisited: Where we come from 1.The patient is the priority of medical education Faculty want to favor their specialty Students want the courses “easier” 2.Learning is a thinking, problem-solving process that takes time. Medical school focuses more on rote memorization

68. Medical Student Life Revisited 3.Continuum of past education and current. 4.Balance between apprenticing and formal teaching Clinical skills not taught as well as expected Depends on years: 1-2 vs 3-4 5.Evaluation that assess progress and competence Do not test for competence in clinical skill and problem solving.

69. Medical Student Life Revisited 6. Has a standard of excellence – Marginal, failing students are passed 7.Requires the highest ethical conduct Overworked house staff pass on indifference Attendings see patients as teaching material

70. A peer review pilot Project: A potential system to support GP appraisal Is international system for external review possible? 15 educators (volunteer) trained as peer reviewers & feedback coordinators using validated peer feedback instrument GP appraisers submitted videos for feedback Barriers / find: – Need a national standard, proceed geographical variations, proceed contextual variations. – Appraisers: professional judgment versus being judgmental, – willingness to except peer-reviewed was if purulence had undergone appropriate training. Appraisers did not feel equipped to judge their colleagues performance CONSIDER short mention, but not in-depth review for talk

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