1. Kazakhstan Health Technology Transfer and Institutional Reform Project Teaching and Learning in a Clinical setting

2. Kazakhstan Health Technology Transfer and Institutional Reform Project Learning Objectives By the end of this session, participants will be able to: Define a teaching moment Use bedside teaching, side-by-side teaching, and case presentations as teaching strategies Understand how to teach with patients present Discuss assessment strategies

3. Kazakhstan Health Technology Transfer and Institutional Reform Project If learners are removed from the clinical environment, isolation from patients can lead to a dislocation of theory from practice.

4. Kazakhstan Health Technology Transfer and Institutional Reform Project Consultants and others are seen as effective role models who demonstrate professionalism But… the literature implies that there is wide variation in the quality and reliability of teaching

5. Kazakhstan Health Technology Transfer and Institutional Reform Project Teaching Moment An opportunity to share a piece of information, demonstrate a technique, or expand on the implications of a clinical observation Examples: – Demonstration of a physical exam – Allowing learner to feel/hear/observe something abnormal upon patient examination that you, as mentor, have experienced – Discuss management options

6. Kazakhstan Health Technology Transfer and Institutional Reform Project When and Where Do Teaching Moments Occur? In a variety of settings: – Primary care offers some advantages over secondary care settings Anytime: Difficult to plan! Can be unpredictable, variable and lack continuity….but each only needs to last a moment!

7. Kazakhstan Health Technology Transfer and Institutional Reform Project Educational Prescriptions When a topic is raised during a ward round or clinic for which the trainee does not have an answer or when the teacher cannot provide the evidence to support an assertion, then a script is written requiring the person to seek evidence and present the results briefly at the next meeting of those concerned. The trainee is afforded the opportunity to provide the results of this search

8. Kazakhstan Health Technology Transfer and Institutional Reform Project What is an educational prescription? It specifies the clinical problem that generated the question. It states the question, in all of its key elements. It specifies who is responsible for answering it. It reminds everyone of the deadline for answering it (taking into account the urgency of the clinical problem that generated it). Finally, it reminds everyone of the steps of searching, critically appraising and relating the answer back to the patient.

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10. Teach by example Model question formulation for your learners. This not only helps with question formulation but also demonstrates that we all have knowledge gaps and that it is ok to admit that we have them.

11. Kazakhstan Health Technology Transfer and Institutional Reform Project Example A patient has atrial fibrillation. What questions might we ask a learner?

12. Kazakhstan Health Technology Transfer and Institutional Reform Project Tips for using educational prescriptions Include them as a regular part of rounds. Use them for Journal Club, morning report etc. Ask your learners to write educational prescriptions for you. Make 2 copies of the prescription, 1 for the learner and 1 for you. Use the opportunity to introduce the learner to the local clinical librarian who can help 'fill' the prescription.

13. Kazakhstan Health Technology Transfer and Institutional Reform Project Target opportunities Postcall rounds with a group of exhausted housestaff may not be the ideal time for teaching about formulating clinical questions. Identify other opportunities like during morning report, work rounds, noon rounds

14. Kazakhstan Health Technology Transfer and Institutional Reform Project What are the obstacles to evidence based medicine?

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16. Hot Review In a postgraduate setting where the trainee is undertaking a clinical placement, actually building into the sessions a structured teaching activity that makes use of the hot review, is an effective way of stimulating thinking and enhancing the learning experience.

17. Kazakhstan Health Technology Transfer and Institutional Reform Project the trainer puts aside some time to spend with the trainee to discuss the cases seen during the session. the trainer will review (usually with case- notes) what the trainee has done.

18. Kazakhstan Health Technology Transfer and Institutional Reform Project It is helpful for the sessional time to be planned and protected –Systematic Hot Review: –Random Case Analysis –Problem Case Analysis

19. Kazakhstan Health Technology Transfer and Institutional Reform Project Teaching Styles in Hot Reviews ◗ Listening to and clarifying facts about the case. ◗ Organising… ‘What was going through your mind when you heard that.. ?’ ◗ Probing …‘Did you ask about.. ?’ ◗ Providing feedback on the performance. ‘What would you do differently next time?’

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21. The One Minute Preceptor is useful to explore elements of a case. For example, the choice of an antibiotic. Getting commitment and reasons focuses the learner, and encourages analysis. The process encourages use of feedback.

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24. Bedside Teaching Teaching in the presence of a patient. “ …the best teaching is that taught by the patient himself ” Sir William Osler

25. Kazakhstan Health Technology Transfer and Institutional Reform Project Bedside Teaching Defined as teaching and reinforcing skills at patient ’ s bedside: – A common approach in medical education – Reinforces classroom learning – Allows mentor to model important clinical skills, attitudes, and communication in the context of patient care, as well as observe mentee ’ s skills Strengths and weaknesses of mentees become very clear at the bedside

26. Kazakhstan Health Technology Transfer and Institutional Reform Project Barriers Fear of patient discomfort Lack of privacy and confidentiality Patients are often hard to locate Learners do not want to go to the bedside Teachers feel uncomfortable (may lead to discussion of medicine teacher is not familiar with).

27. Kazakhstan Health Technology Transfer and Institutional Reform Project Takes time Requires specific skills and techniques Barriers 2

28. Kazakhstan Health Technology Transfer and Institutional Reform Project Advantages Opportunity to: Gather additional information from the patient Directly observe student’s skills Role model skills and attitudes Active learning process in which adults learn best

29. Kazakhstan Health Technology Transfer and Institutional Reform Project Advantages Humanizes care by involving patient Patients feel activated and part of the learning Improves patients’ understanding of their disease and the work-up

30. Kazakhstan Health Technology Transfer and Institutional Reform Project Advantages Allows role modeling. Helps preceptors model effective ways of asking questions and demonstrating sensitivity to patient’s comfort and concerns.

31. Kazakhstan Health Technology Transfer and Institutional Reform Project Enables tutor to teach observation.

32. Kazakhstan Health Technology Transfer and Institutional Reform Project Prior planning is important To recognise the learners knowledge and needs To know what the patient will offer To know your intended learning points

33. Kazakhstan Health Technology Transfer and Institutional Reform Project Patient Comfort Issues 1.Ask for permission from the patient. 2.Limit length of teaching session in front of the patient. 3.Explain all examinations and procedures to the patient. 4.Make sure the patient understands all discussions.

34. Kazakhstan Health Technology Transfer and Institutional Reform Project Patient Issues Patients value being part of bedside rounds and are more likely to be satisfied with their care and report better understanding of their illness. Rather than being upset patients were reassured and mostly enjoy the experience.

35. Kazakhstan Health Technology Transfer and Institutional Reform Project Maintain a comfortable & positive environment for the patient, learners and you! Not a place for pointed questioning or criticism of learners. Use open questions Be careful about how you phrase things Provide a positive learning experience.

36. Kazakhstan Health Technology Transfer and Institutional Reform Project Remember to thank the patient (in front of the learner) even if it was a brief aside during a consultation. Check with the patient that nothing in the teaching has confused them or made them anxious.

37. Kazakhstan Health Technology Transfer and Institutional Reform Project Using Questions in front of the Patient

38. Kazakhstan Health Technology Transfer and Institutional Reform Project After consultation: Review and summarize key points. Solicit questions from mentee, and discuss any identified problems. Offer specific positive and constructive feedback. Agree on an area of improvement and formulate a plan for how to improve.

39. Kazakhstan Health Technology Transfer and Institutional Reform Project Bedside Teaching Pearls Establish rules of conduct for bedside presentation early in the rotation. Patients should be allowed to decline students should not whisper in the patient’s room calls should be made directly outside the room

40. Kazakhstan Health Technology Transfer and Institutional Reform Project laughing at a patient and the patient ’ s responses is never appropriate describing the patient ’ s sex and race in front of the patient is awkward behavior should be proper and respectful-never flippant!

41. Kazakhstan Health Technology Transfer and Institutional Reform Project 2. Make appropriate introductions between the patient and the learners.

42. Kazakhstan Health Technology Transfer and Institutional Reform Project 3. Ensure that the setting of the room is suitable for learning. -pull the patient’s bedside curtain -shut the patient’s door for privacy -invite family members and friends to wait in the lobby -ask the patient for permission to shut off the television

43. Kazakhstan Health Technology Transfer and Institutional Reform Project 4.Demonstrate appropriate communication techniques and allow the patient the opportunity to clarify the case presentation.

44. Kazakhstan Health Technology Transfer and Institutional Reform Project 5.Teach in the presence of the patient. gives the patient the opportunity to learn about his/her disease & the patient receives confirmation that the team is actually considering every aspect of the case. prompts new information from the patient.

45. Kazakhstan Health Technology Transfer and Institutional Reform Project 6.Be careful about asking the student or resident who is caring for the patient a question that they are unable to answer. - can lead to undermining the patient’s confidence in the team’s knowledge.

46. Kazakhstan Health Technology Transfer and Institutional Reform Project 7.Avoid medical talk. Using medical jargon without including the patient in the discussion can lead to apprehension in the patient. -use “education-level appropriate”language

47. Kazakhstan Health Technology Transfer and Institutional Reform Project 8.Find out from the team what portions of the physical exam give them difficulty then discuss and demonstrate proper techniques. -patient should be appropriately draped and that the patient’s dignity is protected!

48. Kazakhstan Health Technology Transfer and Institutional Reform Project 9.As the bedside presentation closes… Leave the patient with an overview of his/her disease process. Always give the patient an opportunity to ask remaining questions. Make and discuss plans in the patient’s presence

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51. Faculty Development needs Teachers should be well prepared for each teaching exchange. They should be able to assess the learning needs of students, and subsequently set (and deliver) optimum learning outcomes for their students. Teaching should be aligned when appropriate to the assessment methods which are to be applied. They need to develop the habit of spotting teaching moments

52. Kazakhstan Health Technology Transfer and Institutional Reform Project Inspirational Faculty Good knowledge base, But…admits what they don’t know, inspirational, enthusiastic, encourages participation, exemplary professional bedside manner, flexible in use of teaching opportunities.

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54. Assessment in the workplace This section will focus only on – direct observations by Faculty, and will lead in to – the use of OSCEs

55. Kazakhstan Health Technology Transfer and Institutional Reform Project How often do Faculty really observe and check their trainees performance? Do Faculty all have the same standards when assessing? – How can we improve this?

56. Kazakhstan Health Technology Transfer and Institutional Reform Project Faculty training for direct observation Need to define what is a clear pass and what is a marginal performance – Define the minimum criteria for a satisfactory performance Faculty reach a consensus together

57. Kazakhstan Health Technology Transfer and Institutional Reform Project Example A resident (junior doctor) is to see a patient who needs to start new medication. What are the criteria for a superior performance of patient counselling? When you have done this check off those criteria which would demonstrate a satisfactory performance Think about Knowledge, Skills, Attitude

58. Kazakhstan Health Technology Transfer and Institutional Reform Project Example 2 You are to observe a student performing a cardiac examination in a patient with chest pain What criteria mark a superior clinical encounter? What would be a satisfactory encounter?

59. Kazakhstan Health Technology Transfer and Institutional Reform Project Mini CEX focuses on trainees’ encounters with a variety of real patient issues, in their normal, routine clinical practice. Important for all healthcare assessors Increasingly expected by the public and part of best practice

60. Kazakhstan Health Technology Transfer and Institutional Reform Project Overview of Approach A clinician will observe the trainee with a patient in a routine clinical encounter, for example, undertaking a focused history and physical examination and then offering a diagnosis and management plan. The clinician will rate the observed performance, scoring the trainee on a structured form.

61. Kazakhstan Health Technology Transfer and Institutional Reform Project They will then offer immediate feedback to the trainee, indicating both the strengths of the performance that has been observed and the areas for development. From this discussion a set of actions will be agreed.

62. Kazakhstan Health Technology Transfer and Institutional Reform Project Real patients, Real conditions Real workplace setting Real tasks Multiple assessors Multiple encounters Multiple settings Multiple judgments

63. Kazakhstan Health Technology Transfer and Institutional Reform Project Disadvantages No standardization of encounters or assessors If the stakes are high reliability and validity may not be acceptable Harder if you are both the trainer and the assessor

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65. Example videos

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