1. Improving ED Bedside Teaching & Resident Evaluation Stanford EM Faculty Development May 21 st, 2003

2. Michael Gisondi, MD - Stanford Emergency Medicine Objectives Review recent literature regarding ‘Bedside Teaching’ and ‘Resident Evaluation’ Discuss the ACGME Outcomes Project and related performance assessment tools Provide a forum for faculty discussion of issues related to resident education, with a goal of improving teaching skills

3. Michael Gisondi, MD - Stanford Emergency Medicine Scope of the Problem EM Residents (in general) report low rates of bedside teaching and skills evaluation –Burdick WP and Schoffstall J. “Observation of emergency medicine residents at the bedside: how often does it happen?” 1995. Acad Emerg Med. 10(2): 909-13. Our EM residents and 4 th -year medical students continue to report a perceived inadequacy of bedside teaching (amount or quality?)

4. Michael Gisondi, MD - Stanford Emergency Medicine What is Bedside Teaching? Occurs at the bedside Encompasses a variety of medical skills –History-taking –Physical Examination –Procedures Demonstrative or observational Includes real-time feedback or reflection

5. Michael Gisondi, MD - Stanford Emergency Medicine Why bother? Bedside teaching allows the faculty member to role-model behaviors that have been shown to improve the learners’: –Clinical skills –Ethical problem-solving –Humanism & Professionalism –Communication Skills –Standardized examination scores (USMLE)

6. Michael Gisondi, MD - Stanford Emergency Medicine Why don’t we do it? Most significant barriers to bedside teaching: –Declining bedside teaching skills, especially for junior faculty members –The “aura of bedside teaching”: are the necessary skills essentially unobtainable? –Belief that such teaching is not valued –Erosion of the teaching ethic Ramani S et al. “Whither bedside teaching? A focus-group study of clinical teachers.” 2003. Acad Med. 78(4): 384-390.

7. Michael Gisondi, MD - Stanford Emergency Medicine True or False? “EM Faculty don’t have the time for bedside teaching.” Berger T et al. “Does the demand for clinical productivity compromise teaching in academic emergency departments? Acad Emerg Med. 2003. 10(5): 473-5. Residents and students were surveyed regarding the quality of teaching they received by the ED attending. Survey results were compared to EM specific RVUs. No statistical relationship between clinical productivity and effective teaching.

8. Michael Gisondi, MD - Stanford Emergency Medicine How does one improve their bedside teaching skills? What determines quality bedside teaching? Requires preparation for focused encounter The patient should agree to participate Learners should be oriented to the encounter Requires debriefing and feedback

9. Michael Gisondi, MD - Stanford Emergency Medicine Some good articles to review: Ramani S. “Twelve tips to improve bedside teaching.” 2003. Med Teach. 25(2): 112-115. (provided) –Reprint purchased and copy placed in 701 conference room library –Attached to handout Janicik RW, Fletcher KE. “Teaching at the bedside: a new model.” Med Teach. 2003. 25(2): 127-130. –Discusses faculty development skills workshop for junior faculty Shayne P et al. “Protected clinical teaching time and a bedside clinical evaulation instrument in an emergency medicine training program.” Acad Emerg Med. 2002. 9(11): 1342-1349. –Discusses “teaching attending” position at Emory Univ.

10. Michael Gisondi, MD - Stanford Emergency Medicine Some good articles to review: Cydulka RK et al. “Evaluation of resident performance and intensive bedside teaching during direct observation.” Acad Emerg Med. 1996. 3(4): 345-51. –CWRU’s program improved faculty job satisfaction! Thomas H. “Teaching procedural skills: beyond ‘see one – do one’.” Acad Emerg Med. 1994. 1(4): 398-401. –Attached to handout Hedges JR. “Pearls for the teaching of procedural skills at the bedside.” Acad Emerg Med. 1994. 1(4): 401-404. –Attached to handout

11. Michael Gisondi, MD - Stanford Emergency Medicine What makes for quality EM-specific bedside teaching? Encounters planned around common entities Brief, direct learning objectives for each case Allow time for direct observation Provide immediate ‘areas for improvement’ and find a time to observe the resident again A point for discussion and potential research!

12. Michael Gisondi, MD - Stanford Emergency Medicine Outcome Measures Medical educators historically study the wrong endpoints, focusing more on process (learner satisfaction) than product (quality patient care, clinical outcome measures) How do you choose an outcome measure when evaluating resident education?

13. Michael Gisondi, MD - Stanford Emergency Medicine The ACGME Outcome Project Focuses on accomplishments, not potentials 2 Phases –Phase 1: Implement 6 “General Competencies” –Phase 2: RRC to mandate adequate assessment of resident competencies by individual programs Go to: http://www.acgme.org/outcome/project/OutIntro_fnl1.htm http://www.acgme.org/outcome/project/OutIntro_fnl1.htm to view a slideshow on the history and goals of the ACGME Outcome Project

14. Michael Gisondi, MD - Stanford Emergency Medicine The 6 “General Competencies” Patient Care Medical Knowledge Practice-based learning and improvement Interpersonal communication skills Professionalism Systems-based practice –Full text descriptions of each competency at: http://www.acgme.org/outcome/comp/compFull.asp

15. Michael Gisondi, MD - Stanford Emergency Medicine Assessment = Evaluations What is the best method of evaluating each competency? One universal assessment tool for all six? Universal assessment tool for each specialty? ACGME provides a number of examples of educational assessment tools at: http://www.acgme.org/Outcome/assess/Toolbox.pdf

16. Michael Gisondi, MD - Stanford Emergency Medicine Making the Competencies EM-specific Competency assessment tools are a popular topic in EM education literature The Nov 2002 issue of Acad Emerg Med provides a number of articles regarding novel methods for resident assessment Article with good EM perspective: –Strauss RW. “The quiet revolution in postgraduate training.” Acad Emerg Med. 2002. 9(11): 1222-25.

17. Michael Gisondi, MD - Stanford Emergency Medicine Other Stanford Resources Stanford Faculty Development Center –Courses on bedside teaching (internist driven) –http://www.stanford.edu/group/SFDP/ ACEP Teaching Fellowship –Wait list is well over a year long! Call now! –http://www.acep.org/1,32536,0.html

18. Michael Gisondi, MD - Stanford Emergency Medicine Points for Tonight’s Discussion? Brainstorm ideas for improving the teaching skills of our faculty –Are we really failing the residents? –How do we improve? Faculty Teaching Retreat? Discuss our current evaluation process –Are we really addressing the details of the ACGME Competencies? –If not, how do we improve the process?