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Teaching Students on the Wards: What students say:
The Literature and Locally
Shobhina Chheda MD MPHOctober 24, 2007
no finances to disclose
Case
Dr. W is a 48 yo male physician who on Sunday at 0300 suddenly woke from a nightmare about having a society without general internists.
He was beginning his 2 weeks of GMED ward attending the next day and realized he didn’t read the email introducing the third year student who would be working with him.
He also realized that his time to teach would be limited given the high ward census and the fact that both his son and daughter were playing soccer championship games over the next 2 weeks (on different teams!)
So, since he couldn’t sleep…
• He made a list of all the specific teaching and feedback activities/behaviors he wanted to engage in for the benefit of his student…
• Then, he circled the 3 most important…
Learning objectivesParticipants will:
• Consider the outcomes we want from our teaching medical students on the wards
• Discuss three 2006 studies regarding teaching/feedback to medical students
• Review 2006-07 CSC/VA faculty evaluations
• Consider and modify your specific teaching behaviors while on the ward
• Leave feeling inspired!
Which outcome(s) are you aiming for?
Student satisfaction
(Pursuit of GIM career)
Improved learning
(Excellent physician)
Effect of the Inpatient General Medicine Rotation on Student Pursuit of a Generalist Career
Arora V, Wetterneck TB, Schnipper JL et al. J Gen Intern Med 2006 21:471-5.
Funding: AHRQ
Goal
• Assess the effect of satisfaction with the inpatient general medicine rotation on student entry into GIM– Overall satisfaction– Attending– Resident– Teaching
Arora V. J Gen Intern Med 2006 21:471-5.
Design
• Multicenter cohort study– Data from Multicenter Trial of Academic
Hospitalists (6 sites)
• Third year medical students between July 2001-June 2003
Arora V. J Gen Intern Med 2006 21:471-5.
Methods• 22 item end of rotation questionnaire
– 3 domains– 5 point Likert scale
• Pursuit of IM career– Match into IM residency– “How likely are you to pursue GIM career?”
• Very likely or certain
– Did not envision inpatient practice setting
• Pre clerkship interest
Arora V. J Gen Intern Med 2006 21:471-5.
Results
• 54% (402/751) Response rate
• 89% (354/397) of students were satisfied or very satisfied
• 28% (87/307) matched in IM (range 21-31%)
• 8% (25/307) met criteria for students pursuing a career in GIM
Arora V. J Gen Intern Med 2006 21:471-5.
Results
• Overall satisfaction with rotation was an important INDEPENDENT predictor with pursuit of career in GIM
– OR 3.91; CI (1.52-10.07); p value .01
Arora V. J Gen Intern Med 2006 21:471-5.
Elements of Inpatient rotation that predict increased overall satisfaction
(adjusted for pre clerkship interest and site)
Predictor (n=402)
Odds ratio
95% CI P value
Teaching 1.72 1.12 -2.65 .01
Quality of attending rounds
1.92 1.12-2.65 .01
Relationship with attending
1.81 1.17-2.82 .01
Arora V. J Gen Intern Med 2006 21:471-5.
Limitations
• Sampling bias- 54% response rate– Responders and non-responders did not differ
in match rates into IM
• Assessed pre clerkship interest retrospectively– No association between pre clerkship interest
and overall satisfaction
Arora V. J Gen Intern Med 2006 21:471-5.
Bottom Line
• We can make a difference in third year !
• Increased satisfaction with the inpatient general medicine rotation promotes student pursuit of a career in GIM
Arora V. J Gen Intern Med 2006 21:471-5.
Impact of Instructional Practices on Student Satisfaction with Attendings’
Teaching in the Inpatient Component of Internal Medicine Clerkships
Guarino CM, Ko CY, Baker LC, Klein DJ, Quiter ES, Escarce JJ
JGIM 2006; 21:7-12.
Source of funding: Atlantic Philanthropies; RAND Project HE387
Goal
Identify specific teaching practices used by attendings that affect student satisfaction with the quality of teaching that they receive in the inpatient component of IM clerkship
Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.
Design
• Nationwide survey of simple random sample
• 2250 4th year medical students (2001-2002)
• 121 allopathic 4 year schools in US
Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.
Survey
• 4 categories of questions– Attending teaching practices– Behaviors in IM clerkship– Organizational features of clerkship– Student satisfaction with quality of teaching by
attendings
Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.
Survey
• Administered Spring 2002
• 30 minutes to complete; confidential
• Response enhancement– Multiple mailings, telephone follow up,
monetary incentive
Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.
Results
• 1,530 surveys completed- 68.3% response rate
• No differences between responders and non-responders– Age, sex, race/ethnicity, MCAT
• Quality of teaching– 78% satisfied – 20% neutral or dissatisfied
Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.
Probability of students being satisfied with quality of attending teaching based on
perception of teaching behavior
Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.
*62%
*21%
*50%
*51%
*12%
* Frequency of always or almost always
Limitations
• Based on student reports
• Asked to consider attendings as “group”
• No association of students satisfaction with attending teaching and subsequent clinical performance
Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.
Bottom Lines
• Certain attending teaching practices and behaviors are correlated with higher satisfaction
• Strive to maintain these teaching practices
• Importance of not appearing rushed– Parallel processes used with patients
Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.
An investigation of medical student reactions to feedback:
a randomized control trial
Boehler ML, Rogers DA, Schwind CJ, Mayforth R, Quin J, Williams RG, Dunnigton G. Med Educ. 2006; 40:746-749.
Funding: None
Goal
To evaluate learning outcomes and perceptions in students who received feedback compared to those who received general compliments
Boehler et al. Med Ed 2006; 40: 746-749
Design
Pre testvideotape
Pre interventionvideotape
Post interventionvideotape
N=33Knot tying instruction
randomized
compliments
feedbackPost intervention
videotape
Boehler et al. Med Ed 2006; 40: 746-749
Boehler et al. Med Ed 2006; 40: 746-749
Medical student reaction to feedback
• Outcome – Objective measurement of knot tying
• 3 faculty evaluators-blinded• Evaluated videotapes via validated instrument
– Student satisfaction rating on 7 point Likert scale
Results
• Subjects– No difference in two groups
• Inter-rater reliability >0.8– Pre test– Pre intervention– Post test
Results
Compliment group
Feedback group
p value
Performance 17.00 21.98 0.008
Global satisfaction
6.0 5.0 0.005
Boehler et al. Med Ed 2006; 40: 746-749
Limitations
• Small group, single institution
• No evaluation of “positive feedback”
• Motor skill studied
Boehler et al. Med Ed 2006; 40: 746-749
Bottom Lines• Student satisfaction ratings are not an
accurate indicator of quality of feedback– Satisfaction reflects praise– Improved performance reflects feedback
• Avoid using satisfaction as measure of feedback effectiveness
• Need tools that accurately measure effects of feedback on performance
Boehler et al. Med Ed 2006; 40: 746-749
2006-07 UW/VA student responses regarding attending teaching behaviors (N= 153)
Most days
About every other day
Once a week
Never
Included me in discussions re my pts
86% 10% 4% 0%
Discussed reasoning behind patient care
84% 14% 1% 0%
Feedback on oral presentations
67% 17% 14% 2%
2006-07 UW/VA student responses regarding attending teaching behaviors (N= 153)
Most days Every other day
Once a week
Never
Feedback on admission H/P
25%
(at least 6)
25%
(at least 4)
30%
(at least 2)
20%
Feedback on progress notes
26% 25% 34% 15%
Bedside physical exam
22% 31% 33% 14%
Bedside communication skills
41% 25% 25% 9%
2006-07 UW/VA student responses regarding attending teaching behaviors (N= 153)
Yes No Not sure
Made expectations clear at beginning
75% 12% 13%
Provided end of rotation feedback
88% 8% 3%
Provided mid-way feedback
67% 25% 7%
“Overall, as a role model I consider my ward attending to be…” (N=153)
• 54% Excellent
• 35% Very good
• 8% Average
• 3% Fair
• 0% Poor
“I can't change the direction of the wind, but I can adjust my sails to always reach my destination.”
- Jimmy Dean
So Back to you…..
• Review your list
• Reconsider your “top 3”– Be specific, Add “frequency”
• Share with the person next to you….
"Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it's the only thing that ever has.“
Margret Mead
"Do not wait for leaders;do it alone,
person to person."
Mother Teresa
“ I really appreciate Dr.X stating her expectations right from the start. I also loved that she provided feedback “on the spot”, for oral presentations. She had all of us teaching something related to medicine which was a great learning experience. She was extremely efficient and if there was any down time, she used it to teach…..”
“…Her enthusiasm for medicine is inspiring and I feel I learned a lot from watching her interactions with families regarding difficult decision making issues. She has made me consider medicine as a career.”
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