Time Flies: Teaching Efficiently and Effectively in a Busy PracticeAllen Last, MD, MPH

September 25, 2015

Goal:

Participants will be equipped with techniques for efficiently incorporating learners (students and residents) into their practice

How to teach efficiently• Be Prepared• Set Expectations• Orient the Learner• Various Learning Opportunities• Learner as part of the team• Scheduling considerations

Be Prepared• Specific orientation helps new preceptors

• For UW Primary Care Clerkship http://www.fammed.wisc.edu/sites/default/files//webfm-uploads/documents/med-student/pcc/preceptor-guidebook.pdf

• For MCW Family Medicine Clerkship• http://

www.mcw.edu/Family-Medicine/Pre-Doctoral-Education/M3-Clerkship.htm

• Resident preceptors should receive an orientation from the home program• Supervision, goals / objectives, billing and

documentation, and didactic expectations, schedule

Be Prepared• Know when the learner is coming

• An onsite point-person is very helpful

• Look at / manage your clinic schedule• This can be done quickly even in the morning

• “Learning scenarios” for continuity experience• Patients who will return again during rotation• Patients who need to go through ancillary services

• Know which patients to take by yourself

Set Expectations• Should vary by learner level

• Medical students – which year?• Goals may be given for formal clerkships• Electives or Sub-I experiences should be

tailored • Strengths of your site• Needs / interests of the student

• Reviews and feedback• LCME requires documentation of mid-rotation review• Daily? Weekly? At the end?• Major issues on the part of the preceptor or the

learner?

Set Expectations•Residents

• Goals and objectives required vs elective rotations• Documentation needs?

• What does your compliance department say?• Remember whose documentation is billable

• What time to be where? • Remember DUTY HOURS

• Reviews / feedback • Structured, documented• Daily? Weekly? Mid-way point? All at the end?• What to do if this isn’t working out

Orient the Learner and the Practice

• Point-person•Very helpful, may be necessary

• Times to be where• Watch for / remind of compliance needs• Pictures / bio in key area

•Nursing stations•ER•Check-in desk for patients to see

Orient the Learner and the Practice

• Students• May find it helpful to “shadow a patient”

• Follow through check-in, lab, Xray, etc• Orientation to the medical record

• Is student EMR access allowed by your group?

• Residents• May need to “shadow a doctor” briefly• May want to “shadow a patient” to know workflow• May want to follow the preceptor “all the time”

Various Learning Opportunities

• Strengths of your site•Ancillary services•Unique opportunities / special teachers•Full spectrum view

• Even if you don’t do entire spectrum yourself

• Taking call• ER shifts• Public health viewpoint

Learner as part of the team• Medical Student

•Everything is still NEW•Typically love being able to show-off•Let them shine in solid areas•Support them in areas of growth opportunity

• Resident•What YOU do is new and different to them•Need to have progressive independence

Learner as part of the team• General principles

• “Pimping” is no longer appropriate• Malicious and / or degrading

•Asking questions is helpful for everyone• To expand the learner’s knowledge• To find growth opportunities teacher and

learner

• Opportunities for supervised growth• “See one, do one, teach one”

Scheduling considerations• Students

• Work your schedule • Leap-frog over student to keep you on time• Make your schedule reduced load?

• How many preceptors – just you?• Multiple viewpoints / opportunities for

feedback• Experience with the “on call” doctor?• One preceptor can have growth perspective

Scheduling considerations• Residents

•Can they have their own schedule?•Scope of patients seen – are there gaps?•Need to attend didactics•Need to monitor Duty Hours•What is their responsibility?•Can they document in your EMR?

• If so, what can they document in your EMR?

How do we teach effectively

• What are we trying to accomplish?• How do adults learn?• Common models of teaching

•One minute preceptor (5 microskills method)

•Other methods

What are we trying to accomplish?

MJA • Volume 181 Number 6 • 20 September 2004

Student/Intern

Graduating Resident

Adult Learning Principles Adult Leaners:• Learn what they want to learn• Learn what they need to learn• Learn through problem solving based on reality• Learn by doing• Need prompt and appropriate feedback • Learn best in an informal and non-threatening environment• Need material that is related to existing knowledge• Want to be treated as individuals• Learn best when self-paced• Value variety in teaching methods

How can we use these when teaching?Teaching to Diverse Styles. Jo Anne Preston

Millennial Learners (generalizations)

• Accustomed to group work• Prefer active learning• Multi-task with ease (so they think)• Expert in technology• Want structure• Goal oriented

Efficient Teaching Techniques

• One Minute Preceptor (5 microskills)• RIME• SNAPPS• Skeff• McGee and Irby• POwER Precepting

Evaluation and Feedback

Evaluation and Feedback• What is the difference?

Feedback Principles• Focus on observed behaviors• Invite the learner to self-reflect• Offer specific recommendations for growth• Listen attentively to the response• Formal – at specific time points – half way

point and end of rotation for example, expected to be more comprehensive

• Informal – daily, limited to specific encounters

Effective feedback should be…

• Timely• Specific• Constructive• In an appropriate setting• Focused on just 1-2 key areas• Positive in general when can be

Feedback Sandwich

Feedback might sound like this

• “When you…” (describe behavior factually)• “I feel…” or “I think…” (describe the impact of

the behavior on the observer or patient)• “Because I…” (describe why affected)• PAUSE to let the learner respond• “I would like…” ( offer suggestion for change)• “Because…” ( why this will help)• “What do you think?” ( learner involvement and

engagement)Adapted from: Scholtes, P., Joiner, B., & Streibel, B. (2003). The Team Handbook. Madison: Oriel Inc.

Evaluation• Formative and/or Summative• Ideally valid and reliable information• Biases are common• Written Comments are extremely

helpful when done well• Milestones and Entrustable

Professional Activities

Formative vs. Summative• Formative – intended to promote

development, usually through feedback• Summative – intended to provide a

summary of performance that can be used to make decisions about the learner (pass/fail, grading…)•Compared to normative behavior•Compared to pre-determined standards or competencies

Validity• Does it actually measure what it is

intended to measure?•Enough experience with the learner?•Assessment tool designed to capture what it is supposed to?

•Consequences – high stakes or low stakes

Reliability• Ability to produce the same results

when used multiple times.•Rater variability is a big issue

Common Biases• Halo Effect – an evaluator ignores specifics

that are to be assessed and treats all traits as one. Must be good at something because good at other things.

• Leniency vs severity – some raters are easy or hard on everyone

• Central tendency – almost never gives 1’s or 5’s unless performance is truly outside the norm

Writing Comments• Constructive• Concise• Specific• Actionable

• What the learner did well• What could be improved• Avoid vague, global statements such as

“great to work with” unless add specifics.

Issues…• What issues have you had with giving

feedback or completing evaluations?

What's New?• Milestones• Entrustable Professional Activities

Milestones• In residency and soon to be in medical

school• Similar to Denver Developmental

Milestones• Based on Dreyfus model where learners

progress from novice to advanced beginner to competent to proficient to master with experience and learning.

Entrustable Professional Activities (EPAs)

• Integrates the competencies and reframes them in the clinical context of professional activities physicians in each specialty specifically need to be able to do independently to practice.

• Estimated that each specialty will have 50-100 EPAs

Care of the Normal Newborn

In order to demonstrate competence in performing this activity one must have knowledge of maternal conditions affecting the infant, be able to perform a thorough physical examination with attention to congenital abnormalities, educate the mother about caring for her newborn using language that is understandable to her and respectful of her cultural background and its child rearing practices, and also provide continuity in transferring care from the hospital to the community provider.

Billing and Documentation

Supervision and Documentation Requirements

In order to receive full reimbursement by CMS for services involving residents, the teaching physician must:

1) Bill for service under their own name (not the resident’s).

2) Be physically present during the “critical or key portions” of the service.

3) Provide proper documentation. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/gdelinesteachgresfctsht.pdf

Supervision and Documentation Requirements

• Supervision –•Students and residents may see the patient without you being present, but you must see all the patients at some point.

•The supervising physician must be present for the key or critical parts of the visit (can be abbreviated) for residents and all of it (have to take the history and do the exam yourself) for students

Supervision and Documentation Requirements

• The old days are not like the new days.

• The supervising physician now must actually see all of the patients

Supervision and Documentation Requirements

• Documentation –•Essentially, no part of a student note counts, you must write your own note in its entirety. (Past Med Hx, Meds, Allergies, ROS, Social Hx do count)

•All of a residents note can be used, but your presence must be documented and that you agree with the resident documentation (you have to actually agree with it though…)

Documentation ExamplesResident involved in care and documents• If resident has everything right:

“Pt interviewed and examined by me and I

was involved in the medical decision making.

I agree with [Resident Name]’s note.”• If the resident does not have everything documented

correctly:

“Pt interviewed and examined by me and I was involved in the medical decision making. I

agree with [Resident Name]’s note expect as

below… ”

BillingBill as usual but add GC modifier if resident involved• From EPIC: SERV PERF IN PART BY

RES UNDER DIR OF A TEACHING PHYSICIAN [GC]

Bill as usual without any modifiers if student involved.

Resources• Society of Teachers of Family Medicine

• www.stfm.org• Faculty resources for residency and medical school• New faculty boot camp• Residency Curriculum Resource• Teachingphysician.org

• Family Medicine Digital Resource Library• www.fmdrl.org• Curriculum parts / powerpoints

Resources• ACGME

•www.acgme.org •Milestones for all specialties

• American Acad of Family Physicians•www.aafp.org

• American Acad of Pediatrics•www.aap.org

Questions/Answers/Evaluations Time

Contact me at:alast@mcw.edu