Excellent Clinical Teaching in a Busy Practice:

Make the Most of Your Limited TimeLisa E. Leggio, MD, FAAP

Professor of Pediatrics

Director, Pediatric Student Education

Medical College of Georgia at Augusta University

Disclosures

• I have no disclosures

• All images used in this presentation are my own, in public domain, or marked as not requiring attribution unless otherwise labeled.

OBJECTIVES

Goal: Participants will become better teachers.

By the end of this presentation you will:

1. Ask focused questions to assess knowledge

2. Teach using techniques such as One-Minute Preceptor and SNAPPS

3. Assimilate learners into a busy clinical setting

BACKGROUNDWhy is this important?

Medical College of Georgia

• 230 students on 5 clinical campuses

• Mission to train physicians for the state of Georgia

• Highly reliant on community preceptors

• 40% of students spend at least part of their clerkship with a community physician

We wear many hats . . .

Takeuchi Seihō [Public domain], via Wikimedia Commons

Balance

Patients

Students

Willliam Osler, MD

"I desire no other epitaph … than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do."

Clinical Teaching

• Teaching in context of ongoing patient care

• Involvement of and teaching about patients

• Diagnose and treat• Patient

• Student

Bannister et al. Pediatrics 2010

HOW MUCH TIME DOES IT TAKE?

• Less Time per Patient • Charting and gathering history

• More Time per Patient: • Listening to presentations and teaching

• Bottom line is about 1 minute per patient or about one hour per day

You can minimize the impact!

Usatine. Acad Med 2000

Time-Efficient Strategies

Planning and

Preparing

TeachingEvaluating

and Reflecting

Ferenchick. Acad Med 1997, Irby. Clin Teach 2004

Plan/PrepareStrategies for Efficient Teaching

Prepare Your Staff

• Involve them in Orientation meetings

• Ask them how students can help

• Listen to their concerns about having a student in the office

• Strategize how to best incorporate a student

• Let them help you• Orient the student

• Maintain patient flow

• Teach the student procedures (vital signs, immunizations, phlebotomy)

How Can Students Help?

• Before visit• Pre-visit planning• Meet patients in hospital prior• Goal-setting before visit• Review social history

• During visit• Help families complete forms• Take patient to room• Document in EHR

• Update problem and med lists• Write/pend orders, Rx• Write notes (ROS, PMH, FH, SH)

• Medication Reconciliation• Patient Education

• After visit• Answer questions from patients• Communicate lab results• Follow-up calls• Help coordinate care

• Other:• Work with front desk/nurse/lab• Work on quality improvement• Create patient handouts• Bookmark patient education sites• Answer clinical questions

www.teachingphysician.org

Wave Scheduling

Ferenchick. Acad Med 1997, Usatine. Acad Med 2000, Lehner. J Physician Assist Educ 2016

Ferenchick 1997, Usatine 2000

Time Preceptor Student

8:30 Patient #1 Patient #2

8:45 Listen to student presentation and see Patient #2 with student pointing out key findings

9:00 Patient #3 Student writes note for Patient #2

9:15 Patient #4 Patient #5

9:30 Listen to student presentation and see Patient #5 with student pointing out key findings

9:45 Patient#6 Student writes note for Patient #5

10:00 Catch up, review student notes, teach

10:15 Patient #7 Patient #8

10:30 Listen to student presentation and see Patient #8 with student pointing out key findings

10:45 Patient #9 Student writes note for Patient #8

11:00 Patient #10 Patient #11

11:15 Listen to student presentation and see Patient #5 with student pointing out key findings

11:30 Patient #12 Student writes note for Patient #11

11:45 Review student notes, feedback, teaching, reflection

Orient Your Learner

Orientation - Mechanics

Raszka. Pediatrics 2010

Orientation - Mechanics

Raszka. Pediatrics 2010

Orientation - Mechanics

Raszka. Pediatrics 2010

Orientation - Mechanics

Raszka. Pediatrics 2010

Orientation - Process

• Awareness of Goals, Objectives, Competencies

• Awareness of student (rotations done, career goals, learning style)

• Set personally relevant education goals

• Support student’s self-reflections

• Listening to and acting on student requests – conveys respect

• Clearly define expectations and goals

Raszka. Pediatrics 2010

TeachStrategies for Efficient Teaching

WHAT MAKES A GREAT TEACHER

Cognitive

• Knowledgeable

• Clinical Skills

• Organized

• Clear expectations

• Explains concepts

• Communication skills

• Direct supervision

• Gives feedback

Non-Cognitive

• Enthusiastic

• Stimulating

• Professional

• Positive learning environment

• Encouraging

• Focus on student needs

• Listening

Bannister. Pediatrics 2010

Child vs Adult

Child

• Accumulate knowledge and skills that might be useful later in life

• Subject-centered

Adult

• Accumulate knowledge and skills they can apply right away

• Problem-centered or performance-centered

Knowles

ADULT LEARNING THEORY

• Adults will learn what is relevant

• Adults learn better if they are involved in the process

• Adults learn with practice

• Adults need feedback

• Adults need opportunity for reflection

Vella, Learning to Listen, Learning to Teach: The

Power of Dialogue in Educating Adults 2002

FOCUSED QUESTIONS

• Diagnose the learner

• What do you think is going on?

• Why do you think that is so?

• Allows focused teaching

• Don’t waste time telling something they know

• Make your teaching relevant

ONE MINUTE PRECEPTOR

Five Steps

1. Get a commitment

2. Probe for evidence

3. Teach 1-2 points related to the case

4. Reinforce what was done well

5. Correct errors

Examples

1. What do you think is going on?

2. Why do you think that?

3. Whenever you see . . . you should think about . . .

4. You gave good evidence to support your diagnosis

5. In the future, you should avoid . . .

Preceptor driven

Ferenchick. Acad Med 1997, Aagaard. Acad Med 2004, Irby. Acad Med 2004, Bannister. Pediatrics 2011

Problem Representations

• Synthesize the entire patient story into one “big picture” statement.

• Uses semantic qualifiers• Acute/chronic

• Unilateral/bilateral

• Bilious/nonbilious

Fleming. Pediatrics 2012

Problem Representation - Example

A previously healthy 5 week old first-born male presents with non-bilious projectile emesis. He is afebrile, well-appearing, and on exam has an olive-shaped mass in the right upper quadrant.

Fleming. Pediatrics 2012

Illness Scripts

• Mental representation that assists in pattern recognition

• Includes Epidemiology, Pathophysiology, and Clinical Features

Irby. Clin Teach 2004, Fleming. Pediatrics 2012

Pyloric Stenosis

Epidemiology 1-3 months, first born, male

Pathophysiology Hypertrophy of the pylorus leading to obstruction

Clinical Features Non-bilious projectile emesis, olive-shaped mass in epigastrum or RUQ, peristaltic wave, hyperkalemic, hypochloremic alkolosis

Teaching Scripts

• 3-5 points with illustrations

• Appreciate common errors learners typically make

• Effective way to help beginners build their own “illness scripts”

Irby. Clin Teach 2004

Horizontal Learning

• Compare several diagnoses side by side to easily see differences

• 3 week old with cough

Pneumococcal PNA Chlamydia PNA Pertussis

Presentation recent URI, fever, grunting, rtxs, flaring, hypoxia

“staccato”; happy tachypneic, h/oconjunctivitis; maternal STI

“paroxysmal”; post-tussive emesis; contactwith chronic cough

Labs Bandemia Eosinophilia Lymphocytosis

CXR findings Lobar Interstitial Interstitial

Treatment Ampicillin Erythromycin Erythromycin

SNAPPS

Steps

1. Summarize the case

2. Narrow the differential

3. Analyze the possibilities

4. Probe the preceptor about uncertainties

5. Plan management for the patient

6. Select case-related issues for self-study (self-directed learning)

Prepare the Student

• Orient everyone

• Cards

• Posters

• Keep track of learning topics

Learner Driven

Bannister. Pediatrics 2011, Wolpaw. Acad Med 2012

Preceptors were “ready to teachat the drop of a question”.

Other Teaching Strategies

• Role model (history, exam, thought process)

• Think aloud as you make decisions

• Make brief handouts of most commonly seen illnesses

• Give mini-lectures to the student on medical topics

• Observe a history and physical exam and give feedback

Evaluate/ReflectStrategies for Efficient Teaching

Evaluate

• Provide feedback

Irby. Clin Teach 2004

FEEDBACK SHOULD BE

• Timely

• Given in an appropriate location

• Descriptive, non-judgmental

• Based on direct observations

• Be formative, use verbs and nouns

• Reinforce what is done right

• Correct errors

• Be given on a regular basis• “Feedback Fridays”

• Specific, Timely, Objective, Plan

• Feedback Video

Gigante. Pediatrics 2011; Ende. JAMA 1983

Ask

Tell

Ask

Evaluate

• Provide feedback

• Specific comments on learner strengths

• Recommendations for improvement

• Referenced to required competencies

Irby. Clin Teach 2004

PRIME+ Model for Evaluation

• Professional – remark on professionalism

• Reporter – history and exam skills, presentations, documentation

• Interpreter – data interpretation, prioritization, diff dx

• Manager – diagnostic/therapeutic plans; procedures; managing time

• Educator – self-directed learning, response to feedback, interpreting literature, teaching others

• + - suggested areas for improvement

Holmes. Pediatrics 2014

PRIME+ Model for Evaluation

• Professional – everyone should be professional

• Reporter – expected level of 2nd year or early 3rd year med students

• Interpreter – expected level of most 3rd year medical students

• Manager – expected for late 3rd year, 4th year, and residents

• Educator – expected for 4th year and residents

• + - suggested areas for improvement

Reflect

Reflect - Learner

• Have the learner reflect on one thing they learned today

• What went well

• What could be done better

Ferenchick. Acad Med 1997, Irby. Clin Teach 2004

Reflect - Teacher

• Take 1 min to identify a teaching approach that was effective or ineffective

• Why was the approach (in)effective?

• What if anything would you do differently next time, and why?

Ferenchick. Acad Med 1997, Irby. Clin Teach 2004

WHAT WHY

Ask the

student to

make a

commitment

or decision

Probe for

evidence to

support the

commitment

or decision

Summarize the

case in a single

sentence

Diagnose the Patient

• Orient the Student to Your Practice / Clinic

• EstablishPerformanceExpectations

• Allow the student to play an active role in patient care

Teach the Learner

Identify a key point of emphasis from

the case

Link the key point of emphasis to a

generalizable, relevant teaching point for the

student to learn, based upon the student’s

learning needs.

&

Provide

feedback for

specific,

observed

behaviors

Reinforce

positive

behaviors

Correct

mistakes or

misconceptions

Diagnose the Learner

Slide used with permission from Christopher B. White, MD

An Efficient & Effective Clinical Teacher

Willliam Osler, MD

"No bubble is so iridescent or floats longer than that blown by the successful teacher."

OBJECTIVES

Goal: Participants will become better teachers.

By the end of this presentation you will:

1. Ask focused questions to assess knowledge

2. Teach using techniques such as One-Minute Preceptor and SNAPPS

3. Assimilate learners into a busy clinical setting

REFERENCES

1. Aagaard E, Teherani A, Irby D. Effectiveness of the One-Minute Preceptor Model for Diagnosing the Patient and the Learner: Proof of Concept. Acad Med 2004 79:1 42-49.

2. Bannister S, Hanson J, Maloney C, and Raszka W. Using the Student Case Presentation to Enhance Diagnostic Reasoning. Pediatrics 2011; 128:2 211-213

3. Bannister S, Raszka W, and Maloney C. What Makes a Great Clinical Teacher in Pediatrics? Lessons Learned From the Literature. Pediatrics 2010; 125:5 863-865

4. Ende J. Feedback in Clinical Medical Education. JAMA 1983; 250: 777-781

5. Ferenchick G, Simpson D, Blackman J, DaRosa D, Dunnington G. Strategies for Efficient and Effective Teaching in the Ambulatory Care Setting. Acad Med 1997. 72: 277-280.

6. Fleming A, Cutrer W, Reimschisel T, and Gigante J. You Too Can Teach Clinical Reasoning. Pediatrics 2012; 130:5 795-797

REFERENCES

7. Gigante J, Dell M and Sharkey A. Getting Beyond “Good Job”: How to Give Effective Feedback. Pediatrics 2011; 127:2 205-207

8. Holmes AV, Peltier CB, Hanson JL, Lopreiato JO. Writing medical student and resident performance evaluations: beyond "performed as expected Pediatrics. 2014 May;133(5):766-8. doi: 10.1542/peds.2014-0418. Epub 2014 Apr 14.

9. Irby D, Aagaard E, Teherani A. Teaching Points Identified by Preceptors Observing One-Minute Preceptor and Traditional Preceptor Encounters. Acad Med 2004; 79: 50-55.

10. Irby D, Bowen J. Time Efficient Strategies for Learning and Performance. Clin Teach 2004; Vol 1: No 1: 23-28.

11. Lehner V, Smith D. Wave Scheduling: Efficient Precepting in the Outpatient Setting. J Physician Assist Educ 2016. 27:4. 200-202.

12. Mutnik A. Ask-Tell-Ask Feedback Process developed at Columbia - Video https://www.youtube.com/watch?v=SYXgMobMU8U

REFERENCES

13. Raszka W, Maloney C, Hanson J. Getting Off to a Good Start: Discussing Goals and Expectations with Medical Students. Pediatrics 2010. 126:2 193-195.

14. Usatine R, Tremoulet T, and Irby D. Time-efficient Preceptors in Ambulatory Care Settings. Acad Med 2000. 75:6 639-642

15. Vella, J. Learning to Listen, Learning to Teach: The Power of Dialogue in Educating Adults. John Wiley and Sons, Inc., 2002

16. Wolpaw TM, Cote L, Papp KK, Bordage G. Student Uncertainties Drive Teaching During Case Presentations: More So with SNAPPS. Acad Med2012; 87: 1210-1217.

17. www.teachingphysician.org/become-a-preceptor/How-Students-Can-Add-Value-to-Your-Office

QUESTIONS?