1. Graduated Responsibility
From Medical Student to Physician
University of BC
Faculty of Medicine
Department of Family Practice
Post Graduate Program
As students progress in their medical training and gain more knowledge and skills they will be expected to gradually assume more responsibility. This module will review how the teacher and learner progress from a highly supervised interaction to a supported but much more independent interaction.

2. Residents are ADULT LEARNERS
What are some of the characteristics of adult learners?
Take two minutes to write down several characteristics of adult learners.
As children we are usually taught a curriculum determined by our teachers and presented in a uniform way to all students. Although adults can learn in this manner, learning is enhanced if the teaching methods used addresses the learning characteristics of a adult. What are the characteristics of an adult learner that we should keep in mind when teaching our residents?

3. Adult Learners are: Self directed Learner centred Problem oriented
Curiosity driven
Reflective
Individually and culturally different
Adult learners are self directed. Your resident should have goals and objectives for his or her rotation with you. As a teacher, your job is to provide learning opportunities, identify strengths and weakness and help your resident learn to think as a physician. The resident is responsible for insuring that he or she acquires the necessary knowledge. What is taught is directed by what the resident needs as opposed to what the teacher has to offer.
Learning that is related to real cases and problems is much more likely to “stick”. The “need to know” is a very powerful tool. The resident is reflective. New knowledge, skills and understanding are weighed against previous experiences and evaluated as to how they apply to the resident himself or herself. Residents come from an variety of backgrounds. International Medical Graduates will, in particular, have significantly different experiences and expectations which will require the teacher to modify his or her approach and guidance.

4. Remember !
With Adult learners our role is that of a GUIDE as much as a teacher.
As a teacher/guide you need to determine your student’s level of skill and knowledge and the student’s ability to apply their skill and knowledge to medical practice. You then help them move towards their goals.

5. Challenge
Finding the balance between supervision and independence when teaching family practice residents.
What are the consequences of too little or too much independence?
The balance between supervision and independence should change significantly as the resident progresses through his or her training. When you first meet a resident, particularly early in their first year, it will take some time for you to assess their level of knowledge and skill. During this time in training a lot of supervision is required. As the resident progresses, however, it is critical that the resident be given more independence to reflect their increasing competence. The resident will need to have the skill and confidence to practice independently at graduation. What are the consequences of two little independence? What are the consequences of too much independence?

6. Too little responsibility
Boredom
Demeaning
Unchallenged
Limited Progress
No confidence
Too little responsibility will lead to loss of interest and boredom. Students need to demonstrate and be given credit for the competences they have acquired. Acknowledgement of accomplishments will encourage students to reach to new goals. If a student feels unchallenged their progress will be limited. If a resident has demonstrated knowledge of a problem or competence with a skill, allow him to complete this task independently the next time it is encountered. You may review the task with the resident afterwards if you feel this is necessary. When you feel comfortable with the resident she should be able to tell you when she feels comfortable without direct supervision.

7. Too Much Responsibility
Do not feel safe to challenge themselves
Fear
Medical error and undesired outcomes
Conversely, too much responsibility will leave a student uncertain and fearful and can lead to undesirable outcomes.

8. Educational Diagnosis
Deciding where your learner is
What is an educational diagnosis?
How do we decide how much independence our resident should have? Where is he or she in the learning continuum? The Bordage Model will help you understand how a learner progresses as they acquire knowledge and skill.

9. Bordage stages of learning
I Reduced knowledge
II Dispersed knowledge
III Elaborated knowledge
IV Compiled knowledge
Bordage I: Reduced Knowledge: The resident has never learned anything about a particular subject or once knew it and cannot for whatever reason recall it.
Bordage II: Scattered or Dispersed Knowledge: The student has some knowledge of a topic but it is only partially or sometimes accurate. He or she does not enough recall to be able to make a reasoned decision but is beginning to have a grasp of some subjects.
Bordage III: Elaborated Knowledge: Now has sufficiently well developed knowledge base and can accurately work through an educational algorithm and make informed and usually accurate decisions.
Bordage IV: Compiled Knowledge: Very quick to see to the heart of a problem. Pattern recognition of illness presentations allows for accurate and confident diagnosis and rapid decision making. The mark of a seasoned and confident clinician.

10. 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?
Where should they be?
At what Bordage level do you think a second year medical student should be? A first year resident? A second year resident? Learners will not be at the same Bordage level in different subject areas. How might you approach students differently relative to the level they are at?

11. 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 Benchmark document can be downloaded and printed to review the expected levels of competency at each level of their training.

12. Start of 1st year Hospital Hx and Px taking an hour
Large Knowledge gaps
Common vs. Uncommon?
Little deductive ability
Therapeutics weak
Contextual issues weak
At the beginning of the residency, especially until you know the resident well it is important to observe the resident frequently and review each case they see. Most procedures should be supervised.

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

14. 2nd half of 1st year Crisper and more focused Hx and exam
Better appreciation of range of common problems. (fewer esoteric dx.)
Better active listening
More rational use of investigations
Better therapeutics
By the second half of the first year the resident will have fewer gaps in his or her knowledge and will be competent in many situations and with some procedures. Less supervision as you become comfortable with the residents skill level.

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

16. 2nd year to graduation Significantly less supervision.
As the resident progresses give him or her more opportunity to be independent.
As the resident progresses through their final year of training they are heading for the day when they will have no supervision at all. You should be approximating that by the end of the second year. At some point you should allow the student to manage the patients without you, giving you a summary at the end of a half day or checking with you when they need you guidance. It is still a good idea to occasionally observe the resident or review a visit to reinforce that your confidence is appropriate and to continue to give pointers and direction.

17. 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?

18. Teaching Techniques Case Discussion
For First Year residents needing greater supervision
Case Review
Chart Review and recall
- For Second Year residents or those needing less supervision
Are you using different teaching techniques as your resident progresses? Reviewing cases with a resident after he or she has seen a patient using techniques such as “The One Minute Preceptor” gives significant support to the more junior resident who still needs significant support. As the resident progresses less support is required. Reviewing cases after the resident has seen several cases is a good next step. If the resident is doing well, cases could be reviewed at lunch and the end of the day, going over cases that gave the resident trouble. To further explore topics ask “What if” questions. “What if the patient were older? What if this were a sudden onset pain? To work in this way you must have confidence in the residents history and physical findings. This also allows you to see more patients, be more on time and therefore leave more time for review later in the day. Going through the charts at the end of the day or choosing two or three charts which the resident has seen that day and going over the resident’s ideas and plans for the patient are other good ways of working with a more senior resident who requires less supervision. Remember that all residents need to be occasionally observed but the frequency of observation should decrease as the resident progresses.

19. Suggestion: 1st day, resident watches you
Next 2-3 days, you watch to make an educational diagnosis
Then, regular but decreasing direct observations
“Credit” demonstrated competencies
Micro-skills (one minute preceptor)
Graduate to reviews
Critical reflection, Open ended questions
This is a suggested progression. With a first year resident it will be some time before you reduce the level of observation and regular review of cases. With a second year student, as soon as they have demonstrated their competence you can begin to reduce the level of supervision.

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

21. Ask yourself:
Is the resident more independent during the last week than the first?
Is part of your teaching objective to encourage independence?
Has the resident acquired skills for which he/she is justifiably confident?
Your teaching techniques and interaction with the resident should be significantly different on the first and last day of a rotation, especially if the resident has been with you for a longer block of time. Be sure that, in addition to helping the student acquire knowledge and skill you are also helping them acquire confidence and independence.

22. 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. Christie Newton, Faculty Development, UBC Family Practice