1. Lutheran Medical Center House Staff Orientation
Resident as Teacher
Lutheran Medical Center House Staff Orientation
June 2014

2. What were you last month?

3. You were still a med student!

4. Don’t forget where you came from and how you got here!!!!
                                        
And Now!
Don’t forget where you came from and how you got here!!!!

5. Lutheran Medical Students
Medical Students from:
St. George’s University (SGU)
American University of the Caribbean (AUC)
New York College of Osteopathic Medicine (NYCOM)
A.T. Still University (ATSU)
State University of New York (SUNY)
Ross University School of Medicine (RUSM)

6. Medical Student Rotations
4th Year Electives
Emergency Medicine
Sub Internships in IM, Surgery, FM and OB/GYN
Cardiology
Endocrinology GI
Infectious Disease
MICU
Nephrology
Neurology
Pulmonary
Radiology
Cardio-Thoracic
SICU
Trauma
Orthopedic Surgery
Urology
3rd Year Core Rotations
Internal Medicine
Surgery
Ob/Gyn
Family Medicine
Pediatrics
Psychiatry

7. The Benefits of Teaching
Residents have a critical teaching role
20% of resident time spent in teaching activities1
Medical Students acquire >1/3 of their medical knowledge fund from Resident teaching2
Resident teaching enhances residents’ own learning and enthusiasm for teaching3, 4
“To teach is to learn twice”
1 Greenberg LW et al. Med Ed 1984
2 Bing-You RG, et al. Med Teach 1992
3 Morrison, EH et al. Acad Med 2001
4 Morrison E Med Education 2005

8. This was you…

9. Who was your favorite teacher?
Use this question to break ice and create an air of discussion around this topic—participants will get far more out of the module if they are talking as well as listening.
Why?

10. Features of excellent teachers
Enthusiastic
Knowledgeable but not afraid to say, “I don’t know”
Accessible
Shows interest in the learner and his/her progress
Actively involves the learner
Helps the learner to expand skills
Provides direction and feedback
Role model
Good bedside manner
Ideally, interns will have listed these but they frequently miss some of these, such as bedside manner and willingness to say, “I don’t know.”

11. What Makes a Good Teacher?
Never be “too busy” to teach students.
Teach enthusiastically and at every opportunity
Treat students with respect
Identify and discuss the goals and objectives of the rotation with the student
what are the practical clinical skills they need to learn?
Ask students to demonstrate what they have learned
Start with the basics

12. How can you teach when you don’t have time?
This leads into the following cases….no need to loiter on this slide unless you wish to.

13. Keep the Student Involved
Let the student help you
Get the student involved in the assessment of patients
Review physical exam findings at the bedside
Tips for keeping the student actively involved and learning. Stress that this helps information stick far better than passive participation.

14. Tips for Teaching: “Prime” the student
Before seeing a patient, give the student a bit of information to help him/her focus and be more organized
Example: “We are going to see a patient with chest pain. What are common causes of chest pain in this age group?”

15. Teaching when admitting patients: History
Have the student assess the patient on his/her own or observe the student’s H&P filling in the “holes” in the evaluation as necessary
Save your questions for the end

16. Tips for Teaching Students: Physical exam
Review physical exam findings to insure the student “observed” what you found
Review physical exam findings to insure the student “observed” what you found
If the student lacks proficiency in a part of the exam, role model that portion and then have him/her re-perform the exam in front of you
Note: Always explain to the patient that you are teaching the student to be a doctor
If the student misses a finding despite using the correct technique, try to give a tip on how to observe the finding

17. Tips for Teaching Students: Assessment and Plan
The assessment and plan is the most critical part of teaching about a new admission because it helps the student to learn how to reason clinically
Student should: summarize the patient’s presentation and findings in one or two sentences, discuss his/her differential diagnosis and plan for the chief complaint, prioritize the problem list and present a plan for the remainder of the patient’s issues

18. Helping them learn better…..
Teach your most important 1 or 2 PEARLS about each case
Lean, clean pearls are the best!
Avoid overwhelming the student with too much information
KEEP IT RELEVANT AND TO THE POINT!
Remember to repeat later or ask them what they remember
Repetition works!!

19. Teaching with an Acute Patient
Key Principles
Teach by example
Think aloud
Focus on practical teaching
Reading a chest x-ray or ECG
Reflection is critical!
Without this, the student is unlikely to learn
But be careful what you say in front of the patient or family if you think aloud; students will learn to do what you do how you do it; you are far more important to their education than you think.

20. Summary Tips for Being a Great R1 Teacher
Ask questions!!! Most students love to be queried if you are supportive and non-threatening in your questioning

21. What Makes a Good Teacher?
Focus on a few general concepts/facts per case
Do not expect to be able to address every detail for each case
Do not stick to only the topics you know best
Venture outside of your comfort zone; utilize this as a learning experience for yourself as well
Assign your student reading on the topics that are important for them and the patients
Textbook, Up To Date, Primary Source Articles
Find protected time for the student to become the teacher

22. Provide Constructive Feedback
Set aside a scheduled time with the student to provide feedback
Do this frequently throughout the rotation
Reinforce good performance at every opportunity
Suggest behavior that will improve performance

23. Let’s consider a typical morning rounds scenario
Consider replacing this picture with photos of your own residents and students.

24. Student, “ Ms. J is our 65 y/o female with right arm cellulitis on day 3 of vanc. She has no complaints and on exam HEENT- PERRL, lungs were clear…”
Resident interrupts, “you can just give us the pertinent findings, including her vitals”
Student proceeds, “…and her cultures came back as MSSA. Since she’s improving, I thought we could continue her on the vanc for a 14 day course.”
Resident, “Typically we only use vanc when the culture comes back as MRSA because of resistance we like to limit the use of vanc in other infections.”
Rounds proceed and resident tells the student “good job” before moving to the next patient.
The presenter could read this or you could assign one participant to be the student and one to be the resident. It’s not exactly role playing as they would be reading parts, so shouldn’t generate stress.

25. Was this feedback?
Feedback occurs when a learner is offered insight into what s/he did and its consequences.
Student informed did not give pertinent findings
Student reminded vitals are considered pertinent
Consequences of indiscriminant vanc use explained
This slide is animated so that participants can have an opportunity to reflect out loud about what their understanding is of feedback. (Consider going back to the previous slide so participants can look at the scenario again.) If you have a board to write on, consider writing down words or statements that come out in the discussion and are relevant characteristics of feedback. If the specific case gets lost in the general discussion of feedback, the pause after bullet 1 is an opportunity to ask participants about specific aspects of the case that were consistent with feedback.
Ende J, Feedback in clinical medical education. JAMA 1983; 250:

26. Do you think the student thought this was feedback?
Again, consider putting pictures of your own residents and students here. Pause at this slide to allow discussion of the students perspective. This is also a good time to reflect back to participants answers to the initial question about their own experiences with feedback.
Why or why not?

27. Students often only recognize feedback in a formal “sit down” session
Informal setting
Students often only recognize feedback in a formal “sit down” session
Stressful setting
May not process “feedback of the fly” without reinforcement
Rushed setting
Tone of the scenario unclear, but if resident sounds frustrated or abrupt, student may fixate on that more than content of feedback.
Contradictory message
Ending the feedback with a general “good” may confuse or even negate prior feedback
These are some reasons the student may not have perceived the scenario to represent feedback but there are certainly others possibilities that may have come up in your discussion. You may want to remove the animation depending on how quickly you want to move through this slide.

28. Traditional Feedback Sandwich
Positive Feedback
Corrective Feedback
This slide transitions us to the meat of the presentation where specific characteristics of feedback and strategies to promote feedback are reviewed.
Positive Feedback

29. Modified Feedback Sandwich
Positive Feedback
Corrective Feedback
The modified feedback sandwich was proposed to address concerns that corrective feedback could be lost or inadvertently minimized in importance by being “sandwiched” between positive feedback. This modification still ends the feedback session in a constructive (positive) way by leaving the learner with specific suggestions to improve.
Next Step

30. Characteristics of Effective Feedback
1. Specific
“you can just give us the pertinent findings, including her vitals” 
This is the first of six slides that each contain one characteristic of effective feedback. The yellow sub-bullets are examples from the initial scenario that either do (smiley face) or don’t (frowny face) demonstrated that specific characteristic.

31. Characteristics of Effective Feedback
2. Timely
During rounds is immediate 

32. Characteristics of Effective Feedback
3. Based on objective not subjective data
Direct observation on rounds 

33. Characteristics of Effective Feedback
4. Consequences explained
“Typically we only use vanc when the culture comes back as MRSA because of resistance we like to limit the use of vanc in other infections.” 

34. Characteristics of Effective Feedback
5. Provides “next step”
“Good” 
What “next step” could you suggest?
Since the scenario did not illustrate this characteristic of effective feedback, there is an opportunity for participants to suggest a “next step” as practice.

35. Characteristics of Effective Feedback
6. Goal is to help, not punish
“Resident interrupts” tone may seem punitive 
How can you avoid seeming dismissive or impatient when you are legitimately in a hurry?
What do you think about providing feedback in a more public setting like rounds? Is there a way it can be accomplished effectively?
This slide should generate a lot of discussion about the realities of trying to teach in the course of a busy work day. Other issues to consider adding into the discussion are when you should defer corrective feedback to the attending and how you can find time outside of rounds that is still timely to address issues that come up during rounds (or other more public situations).

36. Tips to Enhance “Feedback on the Fly”
Use the word “feedback”
Be respectful (feedback sandwich helps)
Provide a specific example
“Next step”
This slide reinforces a couple of key points while also adding a couple of practical strategies to enhance feedback.

37. Let’s apply these concepts to our initial scenario
You could have participants offer suggestions about how to apply the concepts before moving to the next slides which spell it out.

38. Student, “ Ms. J is our 65 y/o female with right arm cellulitis on day 3 of vanc. She has no complaints and on exam HEENT- PERRL, lungs were clear…”
Resident, “Sorry to interrupt but could you give us the vitals and then you can just move right to the pertinent findings”
Student proceeds, “…and her cultures came back as MSSA. Since she’s improving, I thought we could continue her on the vanc for a 14 day course.”
Resident, “Vanc does have good gram positive coverage but typically we only use vanc when the culture comes back as MRSA. What other antibiotic would you like to use?”
You can have your “actors” read this.

39. “Feedback on the Fly”: Transforming feedback from “good” to great
“Your presentation started out good with a clear and concise opening but I want you to have the feedback that you don’t have to provide as much detail in your oral presentations as you do in your SOAP notes, particularly in the ‘O’ (objective) part. On your next patient try a more focused approach with the objective findings”.
“Good” 
This slide is a take off on how using nonspecific feedback terms is not as good as taking a small amount of extra time to be specific and clarify that your comment is feedback. This slide can also be used to reinforce the point of limiting feedback to 1-2 key points even if there is more you could say.

40. Setting Realistic Expectations for your Learners
Medical Students are under the supervision of the intern or resident at all times
They should be fully integrated into the team
Participate in rounds and lectures
Help with all aspects of patient care
Share the scut
Medical Students can write countersigned H&Ps and daily progress notes for the assigned patients
According to the NYSDOH & JC, the notes students write are not legal notes and cannot be used instead of an intern/resident note

41. Become a Mentor Recall your training as a medical student
Can you identify who you learned the most from?
Emulate effective teaching styles
Focus on teaching students how to:
Obtain and write a good H&P and Progress Notes
Perform a complete physical exam
Present a concise and accurate case

42. In every department…
Intern Teacher of the Year

43. Next Year Will it be you????