1. Clinical Teaching Strategies
Faculty Development in Clinical Training
Clinical Teaching Strategies
Stephen John Cico, MD, MEd
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Assistant Dean for Education Affairs & Faculty Development Statewide Teaching Faculty

2. The Assistant Dean Team Has No Disclosures or Conflicts of Interest

3. Goals and Objectives

4. Goal Increase your confidence when teaching
Increase your effectiveness when clinically teaching
Increase your efficiency when seeing patients with students / learners
Improve the experience for your students and patients (and you!)

5. Objectives Recognize the key principles of adult learning theory
Apply strategies for preparing and delivering clinical teaching
Analyze the pros and cons of different delivery methods of clinical teaching
Share ideas and learn from the wisdom of the crowd

6. Adult Learning Theory

7. Adults learn better when…
They want or need to learn something
Previous knowledge and experiences are valued and drawn upon
Individual learning needs and styles are met
They have input into learning content / activities
Sufficient time for assimilation of new information or practice of new skills

8. Adults learn better when…
Focus on relevant and realistic problems and practical application of learning
Practice or apply successfully what they have learned
Achieve mental and physical participation
Guidance (coaching)
Measure of performance so they have a sense of progress toward their goals

9. Bedside Teaching

10. Bedside Teaching
“Medicine is learned by the bedside, not in the classroom.” Sir William Osler
Most effective method to teach clinical skills
Favored form of teaching by medical students

11. Barriers to Bedside Teaching
Low student confidence (preceptor confidence???)
No formal training
Lack of understanding of or emphasis on its benefits
Perception that patients / parents don’t like it
Seen as inefficient

12. Overcoming Barriers
Australia: 107 parents surveyed over 3 month period
Of 52 parents with previous experience with bedside teaching, only 6% dissatisfied with discussion

13. Overcoming Barriers
Australia: 107 parents surveyed over 3 month period
Of 52 parents with previous experience with bedside teaching, only 6% dissatisfied with discussion
Bedside Teaching: Important for students (98%) Improved care of others (87%) Would recommend participating in bedside teaching with other parents (98%)

14. Questioning at the Bedside: Benefits
Engages active participation in learning
Promote peer-peer collaboration
Stimulates critical thinking
Builds confidence in what they know
Models the process of inquiry in medicine (lifelong learning)

15. How much do we remember from a lecture?
100%
75%
50%
30% 5%

16. Learning Pyramid Revised
Read
5-20%
Hear 5-30%
See/audiovisual 20-40%
Demonstrate 30%
Say/discussion 50%
Do 40-75%
Say 70%
Say, hear & do 90%
Teach others 90%
Learning Pyramid Revised
Edgar Dale’s Pyramid of Learning in medical education: A literature review. Ken masters. Med Teach 2013

17. Questioning at the Bedside: Potential Pitfalls
May rely on recall-based questions which do not stimulate critical thinking
Questions may be mismatched to learner level
May seem confrontational – “pimping” – rather than a learning tool

18. Questioning at the Bedside: Step-Up Method
Let learners know the goal is to find out where they are in terms of knowledge
Teaching will then happen at the appropriate level
Ask higher and higher levels of questions Bloom’s

19. Bloom’s Taxonomy Revised
Anderson & Krathwohl, 2001

20. 12 Tips to Improve Bedside Teaching
Challenge without humiliation; gentle correction
Tell learners what they have been taught
Leave time for questions & clarifications
Find out what went well and what didn’t Get Feedback!
Self-evaluate: what would you do differently next time?
Start preparation for next encounter with new insights
Prepare
Draw Roadmap
Orient learners; negotiate goals/objectives
Introduce yourself & team to the patient; EMPHASIZE teaching nature of encounter
Roll-model physician-patient interactions
Step out of limelight; be a keen observer

21. Always label it as FEEDBACK!

22. Feedback Sandwich 1. What was done right - reinforce
2. What was done wrong - correct
3. What to do next time to improve - reinforce

23. The Interactive Feedback Sandwich
Ask
Tell

24. Ask – Tell – Ask Communication
ASK the learner how s/he thought s/he did
TELL the learner what you observed
ASK the learner how you can help him/her improve
Konopasek L. ACGME Outcome Project, New York-Presbyterian Hospital

25. Why Interactive Feedback?
Key component of Professionalism is the ability to self-assess and self-correct
Clinicians (without self-assessment and feedback) use their repeated experiences to justify their ability to repeat their mistakes with greater confidence!
Epstein RM. Med Ed 2008.

26. Ask for reflection Critical for personal growth
Self-inquiry into one’s thoughts and actions
Consideration of the larger context, the meaning, and the implications of an experience or action
Self-directed or teacher-directed
Branch. Academic Medicine, Dec 2002.

27. Ask – Tell – Ask
Self-assessment - How do you think things are going in…? - How do you think you are doing with…? - How are your … coming along?

28. Ask – Tell – Ask
Provide feedback - React to the learner’s observation - Include positive and corrective elements - Give reasons in the context of expectations, objectives and milestones

29. Tell – Language to provide non-judgmental specifics
“I saw that you appeared to have difficulty with….”
“I noticed that….”
“…commented to me about….”

30. Ask – Tell – Ask
Next steps - “Is there anything you can think of that might help with…?” - “What might you (we) do differently next time?” - “What do you think you (we) might do to move you to the next level?” - “Do you believe my interpretation of the situation is valid?” - “Do you understand my point?”

31. Hesketh EA & Laidlaw JM. Medical Teacher, 2002.
Barriers to Feedback
Fear of upsetting the learner or damaging the learner-faculty relationship
Fear of doing more harm than good
The resistant or defensive learner
Inconsistent feedback from multiple sources
Lack of respect for the source of feedback
Hesketh EA & Laidlaw JM. Medical Teacher, 2002.

32. S-FED Model for Feedback
Step
Item
Example
Self-Assessment
Allow learner time to reflect
“What do you think went well with…?”
Feedback
Descriptive
“This is what I saw that needs improvement.”
Encouragement
Show Confidence
“I have great confidence that you will be successful.”
Direction
Specific Suggestions
“Here are some suggestions you might try….”

33. Learners WANT and EXPECT feedback!

34. Clinical Strategies – What can I do?

35. Common Language & Approach – Students and Residents are Learning and Using

36. 3 Models of Clinical Teaching:
One-Minute Preceptor
- SNAPPS
- SPIT
Horizontal Reading Exercise

39. 4 – GET Model for patient interactions with a learner and a computer

40. 4 – GET Model
Optimizing teaching during clinical encounter with the EHR
- EHR is a barrier to teaching and patient care

41. Quick Tips “4 – GET” 4 – Before - Prepare the learner for the EHR
- Allow learner to preview MR
- Greet the patient w/ learner before getting on the EHR
- Arrange the room

43. Quick Tips “4 – GET”
Gather data - Acknowledge the computer and system delays - Maintain eye contact while typing - Observe the learner (scribe as learner talks)

44. Quick Tips “4 – GET”
Empathize/Examine/Evaluate - Empathize and use patient-centered communication – listen attentively - Disengage from the computer and wash hands before Examining patient - Evaluate the learner, focusing on the style/substance of the interview - This is not their EHR – don’t evaluate on efficiency of use

45. Quick Tips “4 – GET”
Teach - Actively teach core concepts; don’t assume the learner knows - Stay positive and interact with learner

46. Clinical Teaching Models

47. 1-Minute Preceptor Get a commitment Probe for supporting evidence
Teach general rules
Reinforce what was done right
Correct mistakes
What would you like to do? What do you think is going on?
What factors did you consider when making your decision? Were there other options you considered? If this patient were preg/10/100, how would this change things?
It is well-established in these patients, placing them on XXX reduces mortality. Or I haven’t encountered this before, but the best dermatology references that I have found are X and Y.
Reinforce the good. Active – “I saw” “The patient responded well when you” -- behavior focused utilizing descriptive rather than evaluative language.
Gently correct, suggest alternatives

48. Summarize the H&P briefly Narrow the differential (SPIT)
SNAPPS
Summarize the H&P briefly
Narrow the differential (SPIT)

49. SPIT Differential Serious Probable Interesting
Treatable / Immediate Treatment Needed / Emergency

50. SNAPPS Summarize the H&P briefly Narrow the differential (SPIT)
Analyze the differential by comparing/contrasting
Probe the PRECEPTOR – learner’s “muddiest point”
Plan an intervention/management
Select a case-related issue for self-directed learning (life-long learning)

51. Horizontal Learning Model

55. Illness Scripts How physicians lump-together and store information
6 week old male presents with non-bloody, non-bilious vomiting, decreased weight gain, always hungry, and the emesis “shoots out of him” like a hose.
Diagnosis: Pyloric stenosis

56. Illness Scripts How physicians lump-together and store information
6 week old male presents with non-bloody, dark colored vomit, decreased weight gain, now not eating, and less active/lethargic, and abdomen appears distended.
Diagnosis: Malrotation with Volvulus

63. Debrief

64. Which have you used previously? Advantages? Barriers? Comments?
Have you used these?
Which have you used previously?
Advantages?
Barriers?
Comments?

65. Which will you commit to trying?
Have you used these?
Which will you commit to trying?

66. Wrap-up!

67. Summary Patients and families enjoy bedside teaching
Prepare families/patients and students for the encounter
Remember probe understanding, don’t pimp recall facts
Models to help: - 4-GET - 1-minute preceptor - SNAPPS - SPIT - Horizontal Reading - Others – Just-in-time, Aunt Minnie, “Teaching When Time is Limited” (Irby)

68. Laura Torbeck, PhD Anatomy (Indy) ltorbeck@iupui.edu
Assistant Deans for Educational Affairs & Faculty Development Statewide Teaching Faculty
Stephen John Cico, MD, MEd Pediatric Emergency Medicine (Riley)
Susan Ballinger, MD Pediatric Rheumatology (Riley & South Bend)
Laura Torbeck, PhD Anatomy (Indy)
Matt Neil, MD, MBA Endocrinology (Ball)

69. Assistant Deans for Educational Affairs & Faculty Development Statewide Teaching Faculty
Thank you!

70. Clinical Teaching Strategies
Faculty Development in Clinical Training
Clinical Teaching Strategies
Stephen John Cico, MD, MEd
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Assistant Dean for Education Affairs & Faculty Development Statewide Teaching Faculty

71. Clinical Teaching Strategies
Dean’s Offices of Medical Education and Faculty Affairs & Professional Development
Clinical Teaching Strategies
Stephen John Cico, MD, MEd Susan Ballinger, MD Matt Neal, MD, MBA Laura Torbeck, PhD
INDIANA UNIVERSITY SCHOOL OF MEDICINE
Assistant Deans for Education Affairs & Faculty Development Statewide Teaching Faculty

73. Reporter Interpreter Manager Educator
The student can accurately gather and clearly communicate the clinical facts on patients. Mastery in this step requires the basic skill to do a history and physical (gather data) and the basic knowledge to know what to look for. Implicit in the step is the ability to recognize normal from abnormal.
Interpreter
The student is able to interpret the clinical data using reasoning and problem solving skills. At a basic level, the student must prioritize among problems identified in their time with the patient. The next step is to offer a differential diagnosis. Follow-up of tests provides another opportunity to "interpret" the data.
Manager
The student is able to manage the care of the patient, anticipate outcomes, make independent decisions and understand the alternatives. This step takes even more knowledge, more confidence and more judgment in deciding when action needs to be taken, and to propose and select among options for patients.
Educator
The student has mastered the prior steps, is a self-directed learner and teaches others. To be an "educator" means to go beyond the required basics, to read deeply, and to share new learning with others.

74. Language to provide non-judgmental specifics
“I saw that you appeared to have difficulty with……..”
“I noticed that ………..”
“……..commented to me about…..”

75. Comparison
I don’t think Mr. X understood what you said when you were telling him his test results.
I think that you were speaking very fast when talking to Mr. X. You might want to slow down and sit when going over test results, particularly when you recognize that the patient was appearing anxious or confused. You might also want to ask if he is following along and understanding you.