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Faculty Development Workbook 2nd Edition
Faculty Development Fellowship
Department of Family Medicine
Madigan Healthcare System
Tacoma, Washington 98431
1
Preface
If we want to have a model teaching program, we need to staff that program with model faculty. If we
want model faculty, we must train them. Recognizing the importance of ongoing training for teaching
staff, the ACGME includes faculty development as a common program requirement for residency
education. Every ACGME certified training program must engage in faculty development and
document how this is done. To be successful, faculty development needs to be an integral part of the
process of training interns, residents and students. In fact, the quality of a training program may be
judged, in large degree, by the quality of the faculty development it provides.
The purpose of this workbook is to make faculty development both more robust and easier to
accomplish. This workbook contains eight sections that address core faculty skills. Each section has a
preparation checklist, learning needs and resources assessment, attendance roster, evaluation sheets, an
example of how the material could be taught, handouts and background material for the presenter. The
accompanying DVD has this same material plus an example of a PowerPoint presentation that can be
modified to meet the needs of your faculty.
We hope that you will use this resource to improve your training program. This workbook is designed to
be a starting place. It is in no way an exhaustive manual on all things faculty development. To become
or remain a model program, each site will need to grapple with its own challenges and provide the
needed faculty development to meet those challenges. Please use and adapt this workbook to your
needs.
Sincerely,
The Faculty Development Fellowship
Madigan Healthcare System
2
Acknowledgements
This is the second edition of the Faculty Development Workbook. Much of the basic content finds its
origins in the original Video Workbook created over fifteen years ago by Dr. Fred Miser and the Faculty
Development Fellows under his leadership. Much of what is found in the original workbook harkens
back to the work of fellows many years previous to that. We gratefully acknowledge the work of Fred
Miser and so many others who, through their insightful work, made this second edition possible.
This current edition was assembled in November, 2011 by the following individuals:
Shawn Alderman Scott Grogan
David Brown Kevin Kelly
Tien Bui Garrett Meyers
Gary Clark Kristian Sanchack
Amanda Cuda Erik Schweitzer
Jason Ferguson Mark Stackle
Please send us your comments, additions, deletions, corrections and questions:
The Faculty Development Fellowship is a two year, degree producing fellowship open to active duty
Army, Navy and Air Force physicians of all specialties. The Fellowship‘s focus is to produce world
class teaching faculty and leaders prepared to change the world. For more information about the
fellowship, please use the above email.
The ideas and concepts put forth in this work book represent the opinions of the authors and not those of
the Department of Defense.
3
Table of Contents
Chapter Topic Page
One Active Learning: Dialogue Education, the Eight Steps of Planning and the Four I‘s
4
Two Excellence in Clinical Teaching
26
Three Giving Dynamic Presentations
48
Four Bedside Teaching
64
Five Giving Effective Feedback
82
Six Small Groups and Effective Discussion
102
Seven House Officer Evaluations
120
Eight The Teaching Clinic Preceptor
146
Chapter Contents
Each chapter contains the following resources:
Group Leader Checklist
Learner Needs and Resources Assessment (LNRA)
Attendance Sheet
Evaluation Form
Example Eight Steps
Handout
Summary of Supporting References and Resources
4
Chapter 1
Dialogue Education:
Active Learning, the Eight Steps of
Planning, and the Four I‘s
Faculty Development Series Madigan Healthcare System
Tacoma, Washington 98431
5
Dialogue Education: Active Learning and The Eight Steps of Planning
Checklist for the Group Leader
Before the Session...
___ 1. Review the suggested eight steps of planning for this presentation.
___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.
___ 3. Duplicate and distribute the LNRA to faculty.
___ 4. Have faculty return the LNRA at least 5 days before the session.
___ 5. Review the faculty LNRA prior to the session.
___ 6. Modify the suggested eight steps and write your plan to fit your needs.
___ 7. Modify the PowerPoint and handout to fit your plan.
___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation
forms, and handouts.
During the Session...
___ 9. Have each participant sign-in using the attendance roster.
___ 10. Distribute the handout(s) to the participants.
___ 11. Conduct the session based on your eight steps of planning.
After the Session...
___ 12. Collect the evaluation forms from the faculty.
___ 13. Keep the attendance roster for the session in your department and provide the
appropriate amount of CME to each participant.
___ 14. Reflect on the seminar - How did it go? What was good about it? What could have
been better? Is there a better approach to this topic? Were there needs identified during
this session that would be the basis for future seminar(s) in your program?
___ 15. Where will your program go from here based on this seminar?
6
Learner Needs and Resources Assessment
Please complete the following needs assessment for the upcoming seminar on Dialogue Education:
Active Learning, Designing a Successful Learning Event as part of your faculty development program.
The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, and a
discussion period.
The purpose of this needs assessment is to determine your learning needs and interests, so that the
seminar is most useful for you. This needs assessment should also stimulate you to think about active
learning before the seminar begins. We need your enthusiastic participation now, and in the seminar. It will be fun, and at the end of it, we'll be asking for your feedback!
Please turn this in to your group leader (______________) no later than (_____________). Your group
leader will return this form to you at the beginning of the session.
1. Have you any formal training in characteristics of Dialogue Education/Active Learning? Yes No
2. How much of the content taught in your residency lectures is actually retained by the learners?
5-10% 10-30% 30-50% 50-70% 70-100%
3. Describe the typical format of lectures/learning activities in your department:
4. What active learning activities have you used in your presentations?
5. List three things you would like to learn/take away from this session:
a.
b.
c.
Any other comments / concerns for this presentation:
7
ATTENDANCE ROSTER – Page____of_____Pages
Department: ____________________ Institution:____________________
Title of CME Activity: Faculty Development Series – Dialogue Education: Active Learning, Designing a
Successful Learning Event
Course Content: Didactic, and Group Discussion –An Introduction to the Eight Steps of Planning a Learning
Event
Instructor (Group Leader):____________________________
Date:____________ Time: Began___________ Ended________ Total ___________
Name Rank
Check One Department or Mailing
Address Staff
Physician
Resident
Physician
Other
Professional
Discipline
Total Number of Learners Attending This Activity: _________
8
ATTENDANCE ROSTER – Page____of_____Pages
Department: ____________________ Institution:____________________
Title of CME Activity: Faculty Development Series – Dialogue Education: Active Learning, Designing a
Successful Learning Event
Course Content: Didactic, and Group Discussion –An Introduction to the 4 I's of Learning Tasks
Instructor (Group Leader):____________________________
Date:____________ Time: Began___________ Ended________ Total ___________
Name Rank
Check One Department or Mailing
Address Staff
Physician
Resident
Physician
Other
Professional
Discipline
Total Number of Learners Attending This Activity: _________
9
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
10
Dialogue Education: Active Learning and the Eight Steps of Planning
Example Eight Steps
The eight steps presented below may be used as a guide for your planning.
Modify these steps to meet your specific needs.
Who: 20 faculty learners from the Department of Family Medicine.
Why: Enhance didactic teaching as part of a required faculty development curriculum.
The intent of this chapter is to emphasize that knowledge transfer from traditional
lecture-and-listen presentations is very low. Thus, much of the time that we spend
in lectures is lost. With ever increasing demands upon our time as clinical
teachers and with seemingly ever increasing limitations to resident work hours,
we must become more effective and more efficient in knowledge transfer. Only
then will our residents/students leave our programs with the knowledge, skills and
attitudes needed to successfully care for patients.
When: 0730-0900 on a Wednesday morning, blocked schedule for faculty development.
Where: Classroom, individual desks, accessible, AV supported, requires own computer.
What: Will explore the eight steps of planning an outstanding learning experience.
Informed by the LNRA.
What For: By the end of this session, we will have:
Prioritized the 8 Steps of Planning a Learning Activity
Reviewed the 8 Steps
Applied the 8 Steps to a future talk
Committed ourselves to teaching using active learning techniques
How: General: Active learning: small group activities and discussion, larger group
discussion, minimal PowerPoint slides. Room contains individual desk. Will pre-
configure desks into larger half-moon shape. Within larger half-moon
configuration, will group four desks in smaller half-moon shape for five groups of
four learners each. This will facilitate small group activities followed by larger
group discussions. The session will take place at 0730, so will provide
refreshements.
Grabber: Use the opening slides to get participants thinking about the way we
traditioinally teach medical topics.
Induction Tasks:
1. Began with LNRA and continued in first activities. Using the first page of the
handout, have the group work in pairs to decide on which two of the 8 steps are
the most important, in their opinion. Have each pair share their top two with the
11
group and explain why they choose those two. Allow them to ask any questions
about the 8 Steps that came up during this exercise. Use the hyperlinked slide to
teach about any of the 8 steps that need clarification.
Input Tasks:
1. Use the hyperlinked slide to teach about any of the 8 steps that need
clarification.
Implementation Tasks:
1. Next, have the participants fill in the eight steps on the worksheet for an
upcoming (or recently given) learning event. Have them share their plan with
their neighbor. Note: skip step 7 as this will be covered in the next presentation.
2. Ask a few participants to share their 8 Steps with the larger group.
Be sure to provide lavish affirmation to all who participate.
.
Integration Tasks:
Ask the participants to commit to using the 8 Steps as they design future learning events.
So What:
Learning: Learners understand the eight steps and how to apply them to their
own teaching.
Transfer: Learners begin using the eight steps of planning for their own
presentations.
Impact: Departmental didactic teaching is enhanced, improved learning and
success for residents.
12
Active Learning-Using the 4 I‘s to Plan Learning Tasks
Example Eight Steps
The eight steps presented below may be used as a guide for your planning.
Modify these steps to meet your specific needs.
Who: 20 faculty learners from the Department of Family Medicine.
Why: Enhance didactic teaching as part of a required faculty development curriculum.
The intent of this chapter is to emphasize that knowledge transfer from traditional
lecture-and-listen presentations is very low. Thus, much of the time that we spend
in lectures is lost. With ever increasing demands upon our time as clinical
teachers and with seemingly ever increasing limitations to resident work hours,
we must become more effective and more efficient in knowledge transfer. Only
then will our residents/students leave our programs with the knowledge, skills and
attitudes needed to successfully care for patients.
When: 0730-0900 on a Wednesday morning, blocked schedule for faculty development.
Where: Classroom, individual desks, accessible, AV supported, requires own computer.
What: Will explore the eight steps of planning an outstanding learning experience.
Informed by the LNRA.
What For: By the end of this session, we will have:
Reviewed the 4 I‘s
Listed learning tasks for each ‗I‘
Selected learning tasks for presentation
Committed themselves to using the 4 I‘s in preparing learning events in the
future
How: General: Active learning: small group activities and discussion, larger group
discussion, minimal PowerPoint slides. Room contains individual desk. Will pre-
configure desks into larger half-moon shape. Within larger half-moon
configuration, will group four desks in smaller half-moon shape for five groups of
four learners each. This will facilitate small group activities followed by larger
group discussions. The session will take place at 0730, so will provide
refreshements.
Grabber: Show the video clip from Ferris Buler and ask learners to ponder what
they see happening
13
Induction Tasks:
1. Began with LNRA and continued in first activities. In pairs, have the learners
discuss the following:
• What did you see happening?
• Why was it happening?
• When this happens to you as a learner, what do you do?
• How can you prevent this from happening when you are teaching?
Input Tasks:
1. Use the PowerPoint presentation to teach about the 4 I‘s Include the video from
Dead Poets Society and ask similar questions of the group as during the inductive
task.
2. Using the handout, have the participants familiarize themselves with the
definitions of each of the 4 I‘s by completing the matching activity. and asking for
their questions.
3. Continue with PowerPoint presentation, review an example of the 4 I‘s
4. Have the learners brainstorm a variety of learning tasks for each of the 4 I‘s
and record them on 4 dry erase boards with each board representing a different I.
Have the four groups rotate to each of the dry erase boards and add any additional
examples of learning tasks they came up with.
Implementation Tasks:
1. Have the participants use their handout to record at least one learning activity
for each I.
2. Ask a few participants to share their I‘s.
Integration Tasks:
Ask the participants to commit to using the 4 I s to plan learning tasks for their next lecture.
So What:
Learning: Learners understand the 4 I‘s and how to apply them to their own
teaching.
Transfer: Learners begin using the 4 I‘s for their own presentations.
Impact: Departmental didactic teaching is enhanced, improved learning and
success for residents; improved board scores and improved patient care.
14
The Eight Steps of Planning1 Handout
Designing a Successful Learning Event
Consider a future learning event you are involved in planning.
1. Who? Consider number and profile of participants. What do they already know? How do
they learn best? Do a learning needs assessment.
2. Why? Consider why this course is important, why the participants need to learn the material
and what the need is.
3. When? Consider the timing and length of the event.
4. Where? Consider location. How will the location facilitate active learning tasks? What AV
equipment will be available? What will I need to bring with me?
5. What? Describe the content of the course; name the subject matter: what knowledge, skills,
and attitudes will be taught?
6. What for? The objectives2: What participants will do with what they have learned.
7. How? In what order will you sequence the material? What learning tasks will you have the
participants do with the material? What materials will you need to do these learning
tasks?
8. So What? How do they know they know?
Learning: New skills, knowledge, attitudes manifested as behaviors
Transfer: Taking the material learned above into your workplace
Impact: Systems changes in your organization due to this training
1 Vella, J. (2002). Learning to listen, learning to teach. San Francisco, CA: John Wiley &
Sons, Inc. 2 Kern, D.E., Bass, E.B., Howard, D.M., Thomas, P.A. (1998). Curriculum development
for medical education: a six-step approach. Baltimore, MD: The Johns Hopkins
University Press.
Objectives should
be:
specific,
measurable, and
expressed as a
verb.
Format suggestion:
Who will do how
much (or how well) of
what by when?
Example: Participants will list the 8 steps of
planning by the end of
this session.
15
Active Learning In Action
Directions: Work in pairs to brainstorm your learning tasks for each objective. Some of these
will be shared with the large group. Consider how you can apply active learning principles to the
design of the course. Be prepared to discuss your thoughts.
How? Plan the learning tasks for the course.
1. Inductive Tasks – consider open question, grabber, or activity. Draw upon the
knowledge, skills and attitudes that the learners bring with them to the learning event.
2. Input Tasks – the presentation of new material that you want the learners to take away
with them.
3. Implementation Tasks – learners practice using what was taught during the input phase.
4. Integration Tasks—ways to use the new material taught in clinical practice, a call to
action.
Brainstorming about tasks that I could use in my department for other presentations
Inductive -
Input -
Implementation -
Integration -
Call to action
Use the 4 I’s above to plan active learning into your next teaching session.
Be an ambassador for active learning: encourage your staff to do the same.
16
Active Learning and Effective Presentations
Elements of Active Learning
Activity- so our brains can process information by doing something with it
Variety- so the training will appeal to all of our different learning styles
Participation- with others, so that our learning environment feels safe and we can effectively
engage with the topic
The 4 I’s
Inductive - connect with what they know:
1. Small group discussion – Have the audience break up into groups of four or five and ask them to discuss a patient they have cared for with your subject condition. What difficulties did they encounter in diagnosis,
treatment, compliance, referral or co-morbidities? What rewards? Then each small group should pick one
person to describe his or her case to the whole room.
2. Quiz – Either true/false or multiple choice quizzes are a great way to open a talk and review boring basics
like epidemiology and pathophysiology without a lecture.
3. Worksheet – A resident at Madigan recently began a talk with handout. It was a blank chart listing eleven
different types of transfusion reactions, arranged into two categories of either immune-mediated or non-
immune-mediated. Before even beginning to lecture, she asked everyone to rank them in order of severity and then in order of how commonly they occur. Learners then filled out the chart as she described the
incidence, pathophysiology, signs and symptoms, diagnosis, and treatment of each transfusion reaction.
On the back of the handout was a treatment algorithm for transfusion reactions.
4. Role playing – Utilize the aspiring actors in your department to help you illustrate psychosocial aspects of
a condition or demonstrate the difference between a clear and concise history and physical and a disjointed
one.
5. Actual patient interview – You need sensitivity, judgment, and a sound relationship to approach a patient
with this kind of request. But if you know a patient with interesting physical findings or stigmata of a particular condition it is unfair to keep them to yourself. Many patients are happy to help in the education
of physicians, especially if you offer to buy them lunch. A real live patient is invaluable in teaching and
puts a human face on a disease.
6. Video clip -- ask the learner what they see happening, why is it happening, when it happens to you, what
do you do, how can we prevent this from happening?
7. Audience response system -- Audience response system can be used to gather information about the
baseline knowledge level of the participants and can be used along the way to check on knowledge
transfer.
17
Input - learn something new:
1. Videos – There are many excellent medical education videos available for free on the internet.
2. Case-based – Start with a case and develop it using a series of questions such as: What else do you want to
know? What is your differential diagnosis? What further studies would you order? What is the etiology of that condition? Teach each topic as you go.
3. Article-based – Distribute the article beforehand and then discuss the article. Alternatively you can go through the article using a worksheet like a Journal Club.
4. Game shows – A game of ―Jeopardy!‖ keeps the audience involved and adds a spirit of competition if you
break the audience into groups. One colleague used PowerPoint to design the game ―Battleship,‖ where a correct answer allows the team to choose coordinates to try to find and sink their opponents‘ ships. Be sure
this is content rich as well as fun as it is easy to have the learning get lost in the fun.
5. Small groups – Provide each small group the resources they need to teach a portion of the subject matter.
Give them 15 minutes to learn it and then 10 minutes each to teach it to the larger audience. Initiate a
contest after the teaching is over by giving a quiz on the subject material. The small group that teaches their subject the best, wins.
6. Audience choice – Provide a handout of not yet covered material and have the learners fill it out using their
own experience and knowledge (A matching worksheet would be a good example). Then provide the answers and ask learners which of the topics they have questions about. Present only the slides that answer
their questions.
7. PowerPoint presentation, outlining the new content
8. Reading material, handed out to learners. Each reads and highlights points that speak to him/her. Then each
has a turn to present what they highlighted and why. What was missing from the material presented? What did you disagree with?
9. Be an ambassador – Give learners a new identity (each of you is going to be a different type of anemia) and provide them a sheet of paper that describes who they are and what the key characterists are about that type
of anemia. These sheets might be on yard around their neck with the type of enemia printed on one side and
the information about it on the back.Then ask them to move about the room looking for others who have a different type of anemia. Have them quiz you and you quiz them about that type of anemia. When a pair
think they have each other‘s anemia mastered, they break up and look for other types of anemia. This
continues until each learner has been exposed to every anemia type available. You might follow this with a
post-test or jeopardy game with the learners divided into teams. Keep score to see which team gets the most correct.
10. The pneumonic game – Have teams work as a group to develop a pneuomic device to help them remember
key points of the presentation.
18
Implementation - practice what they learned
Integration – take it home and use it
Active Learning Matching Exercise: The 4 I’s
Working with your neighbor, match the ‗I‖ with the definition:
4 I’s Definition
____ 1. Inductive
A. Take it home and use it
____2. Input
B. Practice what they learned
____3. Implementation
C. Connect with what they already know
____4. Integration
D. Learn something new
1. Problem solving – After a brief ―how to‖ didactic let the learners solve some problems (cases), either
individually or in pairs. Start out easy and build up complexity of problems.
2. Medical equipment – Feeling a bulky O2 canister is very enlightening for learners. Looking at the actual O2
generator provides a deeper understanding about the patient with COPD requiring oxygen therapy. During
your talk on sleep apnea, bring in a CPAP machine. When discussing low back pain borrow a TENS unit.
3. Hands on – This works well for skills that can be done cheaply on each other such as plaster splints,
ultrasounds, or osteopathic manipulation.
4. Simulation – Simulation provides hands-on learning in a controlled atmosphere and doesn‘t hurt a patient.
A variety of relatively inexpensive simulators are available such as joints for injection, necks for
cricothyroidotomy, sternums for intraosseous access, and backs for lumbar puncture.
This cannot be observed during the learning event, of course, but there are ways to encourage this to happen.
1. Ask learners to discuss in pairs, in groups, or just to write down what they are going to do differently later today
(or next week) based on what they have learned today.
2. Call or email learners a week or two later to see how they are applying the new information and what questions
they have about it.
19
Supporting References and Resources
Active Learning
Just Say No to Death by PowerPoint!
(Or, tips on how to use active learning so that people will actually enjoy and remember your presentation.)
Kelly Latimer, MD LCDR MC USN
Faculty Development Fellow
Madigan Army Medical Center
We‘ve all been there: Noon lecture. Residents and faculty shuffle in, lunches and coffee
cups in hand, making small talk. Some poor second-year resident purposefully marches up to the
lectern, fires up the projector, and dims the lights. The first slide: ―Decontamination of the
Oropharynx and Digestive Tract in ICU Patients.‖ Within four minutes, twenty pairs of eyes
have glazed over in unison and twenty brains are switched off, victims of ―Death by
PowerPoint‖.
Can you believe PowerPoint has been brightening lecture halls and meeting rooms for
twenty years? PowerPoint was originally designed for businessmen to create a ―visual aid‖ for
business presentations. Prior to PowerPoint, one had to laboriously type up legible text and find
copy-legible graphics and struggle to coax a fire breathing Xerox machine into producing a
readable acetate for the overhead projector, (for those of you old enough to remember what an
overhead projector is). Now the presenter could develop and produce the presentation with ease
by themselves. Entire graphics departments disappeared overnight, replaced by a laptop
computer and a small projector.
Critics say PowerPoint has evolved into a presentation ―crutch.‖ Marshall McLuhan
recognized the concept with regards to television in his 1964 book, ‗Understanding Media,‘ and
coined the aphorism ―the medium is the message‖. Often a PowerPoint lecture is not a means to
an end, but an end unto itself. Yet it is the cornerstone of medical teaching, used in settings that
range from residency didactics to national meetings. This is especially ironic, since good
studies have proven the average adult retains only 5% of a PowerPoint lecture. In fact, of all the
teaching modalities that exist, a PowerPoint lecture by itself is the least effective. (Figure 1)
Since resident work hour restrictions already constrain the time available to teach an increasing
amount of skills and information, we would be prudent to use our didactic teaching time more
efficiently.
Does this mean we should abandon PowerPoint completely? Or, phrased another way,
has the quest for world domination by a certain billionaire in Redmond, Washington failed?
Hardly! PowerPoint can be a very effective tool when combined with other learning modalities.
When properly used it can help focus on the message but not be the message.
The intrepid second-year resident in the opening scenario of this article invested a lot of
time preparing his lecture. He had hoped at the very least for his colleagues to stay awake and at
20
best to learn a new skill or concept they could retain and use. To accomplish these goals, he
needed to understand the basics of adult learning theory. Volumes of textbooks and journals
abound on this topic; I am barely going to scratch the surface.
With a few notable exceptions medical students, residents, and faculty are adult learners.
We can apply four assumptions to our adult learners. (Table 1) First, they are already endowed
with a wealth of knowledge, life experiences, and perceptions on most subjects. Even though we
may be the ―experts,‖ when teaching adults we are wise to anticipate that our audience will know
something on the subject we don‘t. Teachers of adults should aim for a dialogue instead of the
usual monologue, trying to connect students‘ prior experiences to new subject matter. Second,
adult learners deserve to be respected as equals by their instructors. While fear has traditionally
been a motivating factor on medical rounds, true dialogue only occurs in an atmosphere of
safety. Third, adult learners are self-motivated. They want to learn this stuff. That should make
our job easy, right? The last and most important assumption about adult learners is they are
only motivated as long as the material is practical, relevant, and goal-oriented. They need to
know they can use the material in their daily life and they need to be engaged with that material
on an emotional and physical as well as an intellectual level. Our learners‘ goals depend upon
their level of training and range from simply surviving the wards, to passing the boards or
earning CME.
Table 1:
Characteristics of Adult Learners:
Foundation of knowledge and experience
Mutual respect
Self-directed
Relevancy-oriented
Practical
Goal-oriented
To increase the effectiveness of his talk, our second-year resident also needs to
understand the basics of active learning, which simply put is learning that occurs at the bottom of
the learning pyramid in Figure 1. Active learning involves connecting adults to what they know
already, learning something new, and then doing something with that new content. (Table 2)
Active learning requires creativity on the part of the instructor, and effort on the part of learners.
This extra work is far more fruitful than simply sitting back and passively being told what they
need to know.
Table 2:
The Sequence of Active Learning
1. Inductive – connect to the learner; the ―grabber‖
2. Input – new material that is practical and relevant
3. Implementation – practice doing
4. Integration – actually using it in real life
21
We must tailor content to our audience. Obviously a talk aimed at medical students should be
different than one for board-certified physicians. Let‘s assume for simplicity we are planning to
instruct our own family medicine department about a medical topic. Most of us have developed
a small library of ―canned‖ PowerPoint talks over the years on a variety of subjects. How can
we use this material but break away from the oppressive lecture and move towards dialogue and
active learning? If necessary modify your PowerPoint slides to conform to the rules of Table 3.
Pay close attention to rule #12. Time should be set aside for active learning tasks. So a 30
minute talk should at most have 20 slides, leaving 10 minutes for your learning tasks.
Table 3:
Do’s & Don’ts of PowerPoint
1. Do use an easy to read, constant color scheme
2. Do begin your talk with 2-4 objectives
3. Do end your talk reiterating 2-4 key points
4. Do use pictures whenever possible
5. Do keep font size 32 or bigger
6. Do use spell check
7. Don‘t use more than 4-5 lines of text per slide
8. Don‘t use animation schemes or fancy transitions
9. Don‘t use busy slides
10. Don‘t read your slides
11. Don‘t talk too fast
12. Don‘t have more than 1 slide per minute of talk
I have listed some specific strategies you can use to add active learning to your
PowerPoint lectures. This list is not exhaustive. The strategies should be combined and
interspersed within the lecture to add variety and keep the audience mentally engaged. Initially,
you should follow the tried and true sequence of active learning in Table 2.
A) Inductive - connect with what they know:
1. Small group discussion – Have the audience break up into groups of four or five and ask
them to discuss a patient they have cared for with your subject condition. What
difficulties did they encounter in diagnosis, treatment, compliance, referral or co-
morbidities? What rewards? Then each small group should pick one person to describe
his or her case to the whole room.
2. Quiz – Either true/false or multiple choice quizzes are a great way to open a talk and
review boring basics like epidemiology and pathophysiology without a lecture.
3. Worksheet – A resident at Madigan recently began a talk with handout. It was a blank
chart listing eleven different types of transfusion reactions, arranged into two categories
of either immune-mediated or non-immune-mediated. Before even beginning to lecture,
she asked everyone to rank them in order of severity and then in order of how commonly
they occur. Learners then filled out the chart as she described the incidence,
22
pathophysiology, signs and symptoms, diagnosis, and treatment of each transfusion
reaction. On the back of the handout was a treatment algorithm for transfusion reactions.
I suspect many of those residents kept that handout in their lab coat pocket for reference
on the wards.
4. Role playing – Utilize the aspiring actors in your department to help you illustrate
psychosocial aspects of a condition or demonstrate the difference between a clear and
concise history and physical and a disjointed one.
5. Actual patient interview – You need sensitivity, judgment, and a sound relationship to
approach a patient with this kind of request. But if you know a patient with interesting
physical findings or stigmata of a particular condition it is unfair to keep them to
yourself. Many patients are happy to help in the education of physicians, especially if
you offer to buy them lunch. A real live patient is invaluable in teaching and puts a
human face on a disease.
6. Audience response system can be used to gather information about the baseline
knowledge level of the participants and can be used along the way to check on
knowledge transfer.
7. Video clip -- ask the learner what they see happening, why is it happening, when it
happens to you, what do you do, how can we prevent this from happening?
B) Input - learn something new:
1. Videos – The old adage, ―See one, do one, teach one,‖ is active learning at its best. The
New England Journal offers excellent 10-minute downloadable files covering various
procedures. These videos discuss contraindications and informed consent as well as
technique. Unfortunately you need a subscription to access them. Fortunately there are
many excellent medical education videos available for free on the internet.
2. Case-based – Start with a case and develop it using a series of questions such as: What
else do you want to know? What is your differential diagnosis? What further studies
would you order? What is the etiology of that condition? And so on. The answers are
always somewhere in the audience.
3. Article-based – Distribute the article beforehand and then discuss the article. Busy
clinicians may not always find the time to read it. Ideally you can jump straight to the
implementation phase. Alternatively you can go through the article using a worksheet
like a Journal Club.
4. Game shows – A game of ―Jeopardy!‖ keeps the audience involved and adds a spirit of
competition if you break the audience into groups. One of my colleagues used
PowerPoint to design the game ―Battleship,‖ where a correct answer allows the team to
choose coordinates to try to find and sink their opponents‘ ships. Be sure this is content
rich as well as fun as it is easy to have the learning get lost in the fun.
23
5. Small groups – Provide each small group the resources they need to teach a portion of the
subject matter. Give them 15 minutes to learn it and then 10 minutes each to teach it to
the larger audience. Initiate a contest after the teaching is over by giving a quiz on the
subject material. The small group that teaches their subject the best, (as measured by the
overall score of the entire group on their questions), wins.
6. Audience choice – Provide a handout of not yet covered material and have the learners
fill it out using their own experience and knowledge. Then provide the answers and ask
learners which of the topics they have questions about. Present only the slides that
answer their questions.
7. Reading material, handed out to learners. Each reads and highlights points that speak to
him/her. Then each has a turn to present what they highlighted and why. What was
missing from the material presented? What did you disagree with?
8. Be an ambassador – Give learners a new identity (each of you is going to be a different
type of anemia) and provide them a sheet of paper that describes who they are and what
the key characteristics are about that type of anemia. These sheets might be on yard
around their neck with the type of anemia printed on one side and the information about it
on the back. Then ask them to move about the room looking for others who have a
different type of anemia. Have them quiz you and you quiz them about that type of
anemia. When a pair think they have each other‘s anemia mastered, they break up and
look for other types of anemia. This continues until each learner has been exposed to
every anemia type available. You might follow this with a post-test or jeopardy game
with the learners divided into teams. Keep score to see which team gets the most correct.
9. The pneumonic game – Have teams work as a group to develop a pneumonic device to
help them remember key points of the presentation
C) Implementation - practice what they learned:
1. Problem solving – After a brief ―how to‖ didactic let the learners solve some problems,
either individually or in pairs. Start out easy and build up complexity of problems. Great
examples to use this: reading EKG‘s, interpreting PFT‘s, calculating acid-base status,
explaining patterns of liver enzyme abnormalities.
2. Medical equipment – Feeling a bulky O2 canister is very enlightening for learners.
Looking at the actual O2 generator provides a deeper understanding about the patient with
COPD requiring oxygen therapy. During your talk on sleep apnea, bring in a CPAP
machine. When discussing low back pain borrow a TENS unit. Let students lay hands
on these things and try them on for size.
3. Hands on – This works well for skills that can be done cheaply on each other such as
plaster splints, ultrasounds, or osteopathic manipulation.
4. Simulation – Simulation provides hands-on learning in a controlled atmosphere and
doesn‘t hurt a patient. A variety of relatively inexpensive simulators are available such
as joints for injection, necks for cricothyroidotomy, sternums for intraosseous access, and
backs for lumbar puncture.
24
5. Gallery Walk—Small groups use the information taught to problem solve, generate ideas,
brainstorm on the topic at hand. They record their ideas on butcher block or a dry erase
board. Other groups work on a different case, concept or problem and each group rotates
to each of the buthcer blocks/boards and adds information. When the time is up, one
group describes what is listed on each butcher block/board.
D) Integration – start using the new information in your daily work
This cannot be observed during the learning event, of course, but there are ways to
encourage this to happen.
1. Ask learners to discuss in pairs, in groups, or just to write down what they are going to
do differently later today (or next week) based on what they have learned today.
2. Call or email learners a week or two later to see how they are applying the new
information and what questions they have about it.
Incorporating active learning into your medical lectures may seem awkward at first, but
the more you do it the easier it becomes and the more you expect it in your own learning
experiences.
Don‘t be discouraged. Anyone can be ensnared by PowerPoint‘s allure. My ten-year old
son and a classmate were assigned to teach their 5th grade colleagues about a particular Indian
tribe here in Washington State. He proudly showed me the slides that he and his buddy had so
laboriously prepared. They had exploited nearly every annoying feature of PowerPoint, from
sounds to animation to gaudy colors and charts. Each slide had a different background and was
crammed full of barely readable words of varying fonts, sizes, and colors. I cringed, knowing
full well that my fellowship director would have a heyday critiquing it. I attempted some gentle
yet constructive criticism to no avail. He considered the effects ―cool‖ and assured me that the
other kids and his teacher would as well. I have yet to see his grade from the project.
25
Figure 1: The Learning Pyramid
Adapted From National Institute for Applied Behavioral Science
The power of active learning
References
Vella, J. (2002). Learning to listen, learning to teach. San Francisco, CA:
John Wiley & Sons, Inc.
Vella,J. (2000). Taking Learning to Task. San Francisco, CA: John Wiley
& Sons, Inc.
Kern, D.E., Bass, E.B., Howard, D.M., Thomas, P.A. (1998). Curriculum development for
medical education: a six-step approach. Baltimore, MD: The Johns Hopkins University Press
Lecture 5%
Reading 10%
Audiovisual 20%
Demonstration 30%
Discussion Group 50%
Practice By Doing 75%
Teaching Others 90%
Average
Learning
Retention
Rates
The
Learning
Pyramid
26
.
Chapter 2
Excellence in Clinical Teaching
Faculty Development Series
Madigan Healthcare System
Tacoma, Washington 98431
27
Excellence in Clinical Teaching
Checklist for the Group Leader
Before the Session....
___ 1. Review the suggested eight steps of planning for this presentation.
___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.
___ 3. Duplicate and distribute the LNRA to faculty.
___ 4. Have faculty return the LNRA at least 5 days before the session.
___ 5. Review the faculty LNRA prior to the session.
___ 6. Modify the suggested eight steps and write your plan to fit your needs.
___ 7. Modify the PowerPoint and handout to fit your plan.
___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation
forms, and handouts.
During the Session....
___ 9. Have each participant sign-in using the attendance roster.
___ 10. Distribute the handout(s) to the participants.
___ 11. Conduct the session based on your eight steps of planning.
After the Session....
___ 12. Collect the evaluation forms from the faculty.
___ 13. Keep the attendance roster for the session in your department and provide the
appropriate amount of CME to each participant.
___ 14. Reflect on the seminar - How did it go? What was good about it? What could have
been better? Is there a better approach to this topic? Were there needs identified during
this session that would be the basis for future seminar(s) in your program?
___ 15. Where will your program go from here based on this seminar?
28
Learner Needs and Resources Assessment
Please complete the following needs assessment for the upcoming seminar on Excellence in Clinical
Teaching as part of your faculty development program.
The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, and
small group discussions.
The purpose of this needs assessment is to determine your learning needs and interests, so that the seminar is most useful for you. This needs assessment should also stimulate you to think about active
learning before the seminar begins. We need your enthusiastic participation now, and in the seminar. It
will be fun, and at the end of it, we'll be asking for your feedback!
Please turn this in to your group leader (______________) no later than (_____________). Your group
leader will return this form to you at the beginning of the session.
1. Have you any formal training on the characteristics of excellence in teaching? YES NO
2. What do you already know about excellence in teaching? Answer briefly below:
a. What are some characteristics of an excellent clinical teacher?
1. 3.
2. 4.
b. What are some characteristics of an ineffective clinical teacher?
1. 3.
2. 4.
3. Have you ever conducted a self-assessment of your clinical teaching abilities? YES NO
4. Have your clinical teaching abilities ever been reviewed by a peer? YES NO
5. What barriers are impeding our ability to improve as teachers at our organization?
6. What three things do you most want to learn or discuss regarding excellence in teaching?
a.
b.
c.
29
ATTENDANCE ROSTER – Page____of_____Pages
Department: ____________________ Institution:____________________
Title of CME Activity: Faculty Development Workbook Series – Excellence in Clinical Teaching
Course Content: Didactic and Group Discussion, characteristics of excellent teaching, barriers, solutions and tools
to achieve excellence in teaching.
Instructor (Group Leader):____________________________
Date:____________ Time: Began___________ Ended________ Total ___________
Name Rank
Check One Department or Mailing
Address Staff
Physician
Resident
Physician
Other
Professional
Discipline
Total Number of Learners Attending This Activity: _________
30
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful.
31
Excellence in Clinical Teaching
Example Eight Steps
The eight steps presented below may be used as a guide for your planning.
Modify these steps to meet your specific needs.
Who: 20 faculty learners from the Department of Family Medicine.
Why: Enhance clinical teaching as part of a required faculty development curriculum.
When: 0730-0900 on a Wednesday morning, blocked schedule for faculty development.
Where: Classroom, individual desks, accessible, AV supported, requires own computer.
What: Driven by the LNRA. Will explore what characteristics contribute to an excellent clinical
teacher, identify barriers to improvement and potential solutions, and will discuss tools that can
be used to improve our clinical teaching.
What For: By the end of this session, we will have:
• Recognized characteristics of an excellent clinical teacher
• Identified barriers and solutions to achieving teaching excellence at our
organization
• Performed a self-assessment of our clinical teaching abilities
• Explored peer-review methods as a tool for improving our clinical teaching
abilities
How: General: Active learning: small group activities and discussion, larger group discussion,
minimal PowerPoint slides. Room contains individual desks. Will pre-configure desks into
larger half-moon shape. Within larger half-moon configuration, will group four desks in smaller
half-moon shape for five groups of four learners each. This will facilitate small group activities
followed larger group discussions. The session will take place at 0730, so will provide coffee
and bagels.
Grabber: Discuss the many roles filled by military medical faculty and how these roles
are connected to our ability to teach our residents. Our stakeholders are counting us to
teach well, especially in the clinical setting. Our residents are counting on this to be
successful.
Induction Tasks: 1. Began with LNRA and continued in first activities. Learners reflect on their
experiences with excellent and ineffective clinical teachers.
2. Learners discuss barriers to improving clinical teaching abilities at our organization.
32
Input Tasks:
1. Discuss reference material provided in this chapter. Explore what characteristics of
excellent teachers were identified in several studies. Present recurring themes.
2. Present additional barriers to improving clinical teaching.
3. Present self-assessments, peer-reviews, and OSCE-like reviews as potential tools for
improving teaching abilities.
Implementation Tasks:
1. Conduct self-assessement of clinical teaching abilities and identify individual strengths
and weaknesses.
2. Discuss potential solutions to barriers in order to build upon our strengths and improve
our areas of weakness.
3. Discuss issues identified in the LRNA using collective knowledge generated during the
session.
Integration Tasks:
1. Challenge learners to act on the results of their self-assessment.
2. Provide learners with peer-review sheet and get a commitment from them to seek input
from their colleagues in order to assess and improve teaching abilities.
3. Learners commit to seeking ―in-the-moment‖ reviews of their clinical teaching using
OSCE or OSTE-like tools.
So What:
Learning: Learners understand characteristics of an excellent clinical teacher. Introduced
to tools for improvement and conducted a self-assessment to identify their own strengths
and weakness. Individual and organizational barriers to improvement identified and
solutions explored.
Transfer: Learners build upon their self-assessments through peer-review and improve
their clinical teaching by addressing areas or weakness and building upon their strengths.
Learners model excellence in clinical teaching to peers and residents. Barriers to
improvement identified and addressed
Impact: Departmental clinical teaching is enhanced, improved learning and success for
residents.
33
Excellence in Clinical Teaching
Handout
Take Home Points
Clinical teaching is unique and demanding
We have experienced both excellent and poor clinical teaching – Embrace the good
Learner reviews, self-assessments, and peer-reviews can improve our clinical teaching
Fostering a culture of honest and specific feedback is the key to improvement
Activity One: Characteristics of Excellent Clinical Teachers
Think back to your medical school or residency experience. What were some of the characteristics of your best clinical teacher? Write them below. Discuss these characteristics in your group and add to your
list.
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
What makes an excellent clinical teacher?
Accessible to their residents – they don't simply respond to inquiries, they make time for
questions and group discussions
Enthusiastic about teaching – draw students in and stimulate intellectual curiosity
Knowledgeable – know their topics and how to present the same material in a variety of ways
and from different perspectives
Display a command of clinical skills
Well organized – prepared, use time effectively
Respectful – genuinely welcome other opinions, respond professionally and care about their
learners‘ needs
Communicate clearly – promote dialogue
Present material logically
Set goals and provide feedback
Clinical instructors teach medical skills, but the best ones teach far, far more. By instilling a love and enthusiasm for medicine, and being an inspiring role model, excellent teachers give medical residents the
desire and ability to continue learning throughout their careers.
34
Activity Two: Characteristics of Ineffective Clinical Teachers
Think back to your medical school or residency experience. What were some of the characteristics of
your worst clinical teacher? Write them below. Discuss these characteristics in your group and add to your list.
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
What makes an ineffective clinical teacher?
Negative attitude, intimidating
Poor feedback skills
Inaccessible
Limited knowledge
Fail to recognize extra effort
Poor communication skills
Fail to adhere to schedule
Subjective Reviews of Clinical Teaching Matter!
Ineffective Teaching Impacts Success
Griffith, Charles H., Georgesen, John C., Wilson, John F.: Six-Year documentation of the association
between excellent clinical teaching and improved student examination performance. Academic Medicine.
75:62-64, 2000
A prospective cohort study of 502 third-year medical students rotating through a general internal
medicine clerkship conducted over a six year period. Faculty clinical teachers were rated as good,
mediocre and poor through past resident surveys and end-of-rotation evaluations. Those students that rotated with the good clinical teachers scored significantly higher on the internal medicine portion of
USMLE Step 2.
Good clinical teachers were thought to improve comprehensive scores because they ―engendered a
learning climate that makes learning fun, enjoyable, and exciting‖ as opposed to the simple relaying of
medical facts.
35
Activity Three: Faculty Self-Assessment
Self-assessment is a way of reviewing one's strengths and weaknesses, of taking stock and establishing
useful goals. After completing this form, you may want to review this with your Program Director. This should be done semi-annually.
This first section calls for self-assessment of a variety of positive statements. "Learners" refers to both medical students and residents. Circle those statements that apply to you.
STATEMENTS:
I have an enthusiastic and stimulating teaching style.
I easily establish a good rapport with learners.
When I teach, I actively involve learners.
I am good at providing direction and feedback to learners.
I am readily accessible to learners (they can easily find me for questions or problems).
I ask questions in a nonthreatening manner.
If I don't know something, I am willing to admit it to learners.
I am a good role model of a military physician.
I present material in a clear and organized fashion.
I make difficult concepts easy to understand.
When I teach, learners have fun and learn something.
I am a good clinic attending.
I review charts regularly and often write residents constructive comments.
I give residents enough "rope" to work comfortably with, but not enough to hang themselves.
I debrief residents after procedures using specific praise and criticism.
I round each day while on the wards, communicating with residents verbally or through the chart.
My presentations (lectures) are dynamic.
I am good at leading effective small group discussions.
I meet regularly with my advisees (if applicable).
I frequently attend faculty meetings.
I frequently attend morning report.
I keep up with the medical literature.
I am actively involved in scholarly activities.
Considering all things, I would give myself the following grade as a faculty member (circle one):
A B C D F
36
Faculty Self-Assessment (continued)
PERSONAL STATEMENT
Consider each of the following statements. Do you agree or disagree?
I am satisfied with my faculty role.
I am satisfied with the balance between patient care and teaching in the residency.
I am satisfied with the balance between work and not work.
COMMENTS:
1. Three general tasks that I have done well over the last 6 months are:
a.
b.
c.
2. Three areas that I have improved over the last 6 months are:
a.
b.
c.
3. Three areas that I want to improve over the next 6 months are:
a.
b.
c.
4. Three goals that I have for the next 6 months are:
a.
b.
c.
37
Activity Four: Barriers or Challenges to Excellence
What are some of the barriers to achieving individual and collective excellence in clinical teaching at our
organization? Write them below. Discuss these barriers in your group and add to your list. We will discuss solutions to these barriers later.
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
Potential Barriers and Challenges
Limited feedback from learners and peers
Vague or unhelpful feedback
Ego or self-misperception
Organizational culture
Time pressures: increased responsibilities and pressure to see greater numbers of patients
Simultaneously teach learners who are at various levels of training
Medical cases are unpredictable - preparation is not always possible
Wide variety of teaching methods is required - from bedside teaching to Socratic dialogue
Responsible not only for teaching, but also for ensuring excellent patient care
Activity Five: Solutions to Barriers to Excellence
Now that we know a little more about our own strengths and weaknesses, let‘s turn our attention to our
organization. How can we overcome the barriers discussed earlier? Write your solutions below. Discuss this in your group and add to your list.
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
38
Discussion: Additional Concerns Specific to Us
A few questions were posed by your colleagues in the LNRA. We will discuss them now. Write those
questions down and record responses that speak to you.
Question ___________________________________________________________________
Responses ___________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Question ___________________________________________________________________
Responses ___________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Question ___________________________________________________________________
Responses ___________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Integration Task: Peer Reviews
Peer reviews can be used as a tool to provide you with additional feedback to improve your clinical
teaching skills. The key is to collect thoughtful, specific and actionable feedback from your colleagues. Ask for and be prepared to accept honest feedback and use it constructively.
Two peer review tools are provided at the end of this handout. The first is a general review of your overall clinical teaching abilities and mirrors the self assessment you conducted earlier. Make a few
copies of the peer review and ask at least two fellow faculty to complete the review within the next week.
Assure them that you want honest and constructive feedback. Review any differences or similarities between your self-assessment and the reviews from your peers. Consider giving this review to some of
your learners to elicit their feedback as well.
The next tool is an OSCE-like checklist to be used during a clinical teaching experience. Ask a colleague to shadow you during your teaching session and provide feedback using the checklist. You can modify
the example checklist to create one that suits your needs and settings.
39
Clinical Teaching Assessment – Faculty Peer Review
Peer reviews are a tool that can be used to identify strengths and weakness and offer an opportunity for
improvement. The following brief assessment is meant to act as an aid for thoughtful and constructive feedback.
Please take a moment to reflect and then answer each of the following questions.
Faculty Member Being Reviewed:
Reviewer: Date: 1. This first section calls for an assessment of a variety of positive characteristics. "Learners" refers to both medical students and residents. Circle those statements that apply to the faculty member.
Enthusiastic and stimulating teaching style
Easily establishes a good rapport with learners
When teaching, actively involves learners
Good at providing direction and feedback to learners
Readily accessible to learners
Asks questions in a nonthreatening manner
Willing to admit uncertainty to learners
Good role model of a military physician
Presents material in a clear and organized fashion
Makes difficult concepts easy to understand
When teaching, learners have fun and learn something
A good clinic attending
Reviews charts regularly and often writes residents constructive comments
Gives residents enough "rope" to work comfortably with, but not enough to hang themselves
Debriefs residents after procedures using specific praise and criticism
Rounds each day while on the wards, communicating with residents verbally or through the chart
Presentations (lectures) are dynamic
Good at leading effective small group discussions
Meets regularly with advisees (if applicable)
Frequently attends faculty meetings
Frequently attends morning report
Keeps up with the medical literature
Actively involved in scholarly activities
2. Three general tasks that the faculty member has done well over the last 6 months are:
a.
b.
c.
3. Three areas that faculty member could improve over the next 6 months are:
a.
b.
c.
40
Checklist for Peer Feedback on Inpatient Clinical Teaching
The example checklist presented below can be used to provide peer feedback of clinical teaching
during an inpatient rotation. Consider using this checklist during your next inpatient teaching
experience. Modify this checklist to meet your needs in any setting.
Example Checklist for Inpatient Clinical Teaching Skills
1 Rotation/clerkship goals and expectations reviewed No Yes
2 Rounds were begun and ended on time No Yes
3 Literature searches or topic discussions were assigned No Yes
4 Resident/student history and physicals were reviewed No Yes
5 Residents/students were treated as team members Never Sometimes Always
6 A broad knowledge of clinical issues was demonstrated Never Sometimes Always
7 Education and patient management were balanced Never Sometimes Always
8 Residents/students were encouraged to formulate their own
Assessment and Plan
Never Sometimes Always
9 Residents/students were encouraged to ask questions Never Sometimes Always
10 Constructive feedback was provided Never Sometimes Always
11 Physical findings were reviewed and demonstrated Never Sometimes Always
12 Clinical decisions (i.e. selection of tests) were explained Never Sometimes Always
13 Clinical findings (i.e. X-rays) were reviewed and demonstrated Never Sometimes Always
14 Professional and ethical behavior were modeled Never Sometimes Always
15 Effective interpersonal and communication skills were modeled Never Sometime Always
Comments:
Adapted from: Conigliaro, Rosemarie L; Stratton, Terry D.: Assessing the quality of clinical
teaching: a preliminary study. Medical Education. 44:379-386, 2010.
41
Supporting References and Resources
Excellence in Clinical Teaching
Gierde CL, Coble RJ: Resident and faculty perceptions of effective clinical teaching in
family practice. J Fam Prac 14:323-7,1982.
Combined rating of 58 teaching behaviors by 47 faculty and 69 residents in seven family practice
residency programs.
Ranking of Teaching Behaviors
Rank Mean Rating* Behavior
1 1.17 Takes time for discussion and questions
2 1.21 Is willingly accessible to residents
3 1.24 Answers questions clearly
4 1.26 Is well prepared for teaching sessions
5 1.28 Provides constructive feedback
6 1.28 Provides opportunities for technical and problem solving skills
7 1.30 Discusses practical applications of knowledge and skills
8 1.32 Demonstrates enthusiasm for teaching
9 1.33 Asks questions in nonthreatening manner
10 1.36 Shares his or her knowledge and experience
11 1.38 Willing to admit when he or she does not know
12 1.38 Demonstrates genuine interest in resident
13 1.41 Encourages expression of different viewpoints
14 1.43 Demonstrates sensitivity to patient needs
15 1.44 Explains clinical problems in a comprehensible manner
16 1.47 Summarizes major points at conclusion of teaching
17 1.48 Asks questions that stimulate problem solving
18 1.49 Explains basis for his or her actions and decisions
52 > 3.50 Fails to recognize extra effort
53 > 3.50 Bases judgment of residents on indirect evidence
54 > 3.50 Is difficult to summon for consultation after hours
55 > 3.50 Fails to adhere to teaching schedule
56 > 3.50 Discourages resident/faculty relationships outside clinical areas
57 > 3.50 Corrects resident's errors in front of patients
58 > 3.50 Questions residents in intimidating manner
*Rating Scale:
I = very helpful
2 = moderately helpful
3 = somewhat helpful
4 = not helpful at all
42
Gierde CL, Coble RJ: Resident and faculty perceptions of effective clinical teaching in
family practice. J Fam Prac 14:323-7, 1982. continued
The effective clinical teacher has 3 broad areas of teaching skills:
1. Two-way communication
takes time for discussion and questions
answers questions clearly
discusses practical applications
asks questions in a non-threatening manner
shares knowledge and experiences
presents clinical problems comprehensibly
stimulates problem solving
explains the basis for his or her actions and decisions
2. Creating an environment that facilitates learning
readily accessible to residents
is enthusiastic about teaching
is willing to admit when he or she does not know
maintains an atmosphere that encourages expression of different viewpoints
shows a genuine interest in residents
3. Providing feedback
provides constructive feedback
compliments residents and others for good performance
The ineffective clinical teacher has 3 major deficiencies:
1. Negative attitude toward residents
questions residents in an intimidating manner
appears to discourage resident-faculty relationships outside clinical areas
2. Lacks skills in providing feedback
corrects resident's errors in front of patients
fails to recognize extra effort
bases judgments of residents on indirect evidence
3. Inaccessibility
43
Hilliard RI: The good and effective teacher as perceived by pediatric residents and by
faculty. AJDC.144:1106-10,1990.
The good teacher:
Is enthusiastic about teaching and the interaction with students and residents, i
Is able to stimulate intellectual curiosity and to encourage and motivate the residents to
self-directed learning
Is a good, competent and credible physician who serves as a good role model in
dealing sensitively with patients and families
Presents material or leads discussions in an organized, clear fashion
Emphasizes conceptual understanding of the subject and problem solving
Makes difficult concepts easy to understand
Helps to develop thought processes
Answers questions carefully and precisely
Encourages participation, open to questions and discussion
Includes content material that is interesting, practical, relevant, accurate, in depth, and up
to date, emphasizing what is important
Is able to develop a good, positive relationship with the residents, has a genuine interest
in residents and is aware of their needs and problems, is available and willing to help
Provides fair and constructive criticism without belittling the residents
The most important characteristics of the excellent teacher:
Teaches approaches to problems, basic concepts, and not simply facts
Able to communicate ideas and knowledge clearly and presents discussions in a clear,
lucid and organized fashion
Excellent clinician, able to deal with medical problems in a thorough, complete
organized approach
Able to stimulate intellectual curiosity and promote self-directed learning
Enthusiastic about teaching and seems to enjoy interaction with students and residents
An excellent role model in the way he or she deals with patients and families
Irby D, Rakestraw P: Evaluating clinical teaching in medicine. J Med Ed. 56:181-6,1981.
Study of the evaluations of 105 OB/GYN UW faculty by medical students - those items
correlated most strongly with "Overall Teaching Effectiveness" were.... "is enthusiastic and
stimulating" (0.80) " establishes rapport" (0.77) 161, actively involves students" (0.76) it
provides direction and feedback" (0.75).
44
Irby DM, Ramsey PG, Gillmore GM, Schaad D: Characteristics of effective clinical
teachers of ambulatory care medicine. Acad Med. 66:S4-S, 1991.
Mail survey in 1988 of 122 graduating UW students, and 60 medicine residents asking them to
identify important aspects of effective clinical teaching. Effective teachers involved students in
the learning process, communicated expectations for the learner's performance, stimulated the
learner's interest, and interacted skillfully with patients. Important characteristics included a
broad knowledge of medicine, enjoyment of teaching and patient care, demonstrated caring
concern for patients, personable and approachable, showed respect for others, enthusiastic
respecting the autonomy of the learner and nurtured self-directed learning.
Three characteristics most descriptive of the best clinical teachers
o Enthusiasm/Stimulation => the best teachers are enthusiastic, dynamic, enjoy
teaching, and have interesting styles of presentation
o organization/clarity => the best clinical teachers explain clearly, present material
in an organized manner, summarize, emphasize what is important, and
communicate what is expected to be learned
o clinical competence => the best clinical teachers objectively define and synthesize
patient problems, demonstrate skill at data gathering, use of consultants, and
interpreting laboratory data, work effectively with the health care team members,
and maintain rapport with the patient.
Most frequently listed characteristics of the worst clinical teachers
o lacked good teaching skills
o arrogant
o apparent dislike of teaching
o limited knowledge
o inaccessibility
o lack of self-confidence
o unorganized and boring
presentations
o dogmatism
o insensitivity to others
o belittling of students and residents
Irby DM: What clinical teachers in medicine need to know. Acad Med. 69:333-42,1994.
Advice from six recognized outstanding clinical teachers at UW.
Actively involve learners - highly interactive teaching sessions through use of questions
Capture attention and have fun - in order to make learning memorable, teaching must
capture and retain attention, use humor, dramatic case examples, suspense, enthusiasm
connect the case to broader concepts
Connect learners' knowledge of the patient's particular problems to a broader
understanding of the relevant disease – generalize
See the patient together when the case is unclear or the diagnosis doesn't seem to fit
meet individual needs - one of the great difficulties with clinical teaching is dealing with
the diversity of learners' knowledge and skills (one example of team bedside rounds: ask
students questions about pathophysiology, ask interns questions about day-to-day
treatment, and ask senior resident questions about broader medical and health care issues)
Be practical and relevant
Be selective and realistic - focus on a few important teaching points per case, prioritized
time among cases to deal with a few cases in depth, and establish realistic expectations
for learning during the rotation - the more you say, the less people learn
Provide constructive feedback and evaluation
45
Seven Factors Influencing the Effectiveness of Faculty - Skeff KM: Enhancing Teaching
Effectiveness and Vitality in the Ambulatory Setting. J Gen Intern Med, 3:S26-33, 1988.
1. Establish a positive learning climate
Learning climate = tone or atmosphere of the teaching environment -> reflects the degree of stimulation,
enthusiasm, comfort and excitement generated by the teaching process - do students and housestaff want to
be in this environment as learners?
Faculty can create a positive learning climate by demonstrating enthusiasm both for the content being
taught and for teaching
2. Control the teaching session
Task-management approaches a teacher uses to focus and pace a teaching interaction
o Ability to address relevant teaching topics efficiently in clinic setting - intense pressure for
efficient use of time in a clinic that is busy and understaffed
o teachers must be available and able to set teaching agendas that emphasize key points of patient care and teaching, while matching the learner's level and available teaching time
3. Communicate learning goals
The process by which teachers establish and communicate the expectations for students and housestaff -
should include not only what educational experiences they should have, but also what attitudes, knowledge
and skills should be acquired in the learning process . goal statements can guide faculty instruction and
evaluation of trainees to see if the institution is accomplishing its desired objectives
4. Enhance understanding and retention
Refers to the teaching methods used in a learning experience, with specific emphasis on whether the
methods used are likely to enhance the learners' understanding and retention of the educational goals
primary goals of clinical teaching
Ensures that learners understand and retain important attitudes, knowledge, and skills for the practice of medicine to facilitate knowledge acquisition, teachers should present material in a clear and organized way
emphasize the key points to be remembered actively involve the learners in the learning process to acquire
skills, learners should practice desired behaviors with feedback
5. Evaluation
Consists of the processes used to determine whether learners are achieving desired knowledge, skills and
attitudes two types Is formative evaluation
o Can be conducted throughout an educational experience - information gained can guide the
teacher in planning future educational experiences to help the learner master desired goals
o Ongoing process to help the learner
o Summative evaluation: assessment of the learner at the end of the teaching experience to judge the
learner's final competence 6. Provide feedback
The process bv which the teacher provides information to the learners about their behavior for the purpose
of improving their performance
o Critical to the learning environment - takes time and skill
o Should inform, reinforce, or praise trainees when the performance is acceptable to excellent, and
inform and constructively criticize learners when their performance needs improvement
o Difficult to do - feedback to learners is often done poorly or infrequently
7. Self-directed learning
An individual learner's initiative to identify and act on his/her needs, with or without the
assistance of others
The processes by which a teacher encourages learners to use methods to continue learning throughout their
career o Encouraging further reading, encouraging learners to identify and respond to their own limitations,
encouraging asking questions and getting consultation when appropriate
o Modeling and teaching self-directed learning behaviors is essential!
46
Conigliaro, Rosemarie L; Stratton, Terry D.: Assessing the quality of clinical teaching: a
preliminary study. Medical Education. 44:379-386, 2010.
A structured, 15-item objective structured clinical examination (OSCE)-like tool was used to
assess clinical teaching abilities in this small pilot study. The study‘s goal was to identify an
objective alternative for clinical teaching assessment. Historically, teaching abilities have been
assessed using subjective input from learners or peers that may be biased, personality driven, and
subject to other confounders (i.e. halo effect).
Select faculty members were followed by trained observers during inpatient rounds. Each
teacher was assessed by two raters within a one week period and scores were evaluated using
generalisability theory analysis. The study was limited in size and found significant variability
of inter-observer ratings, so further research is needed to develop an optimal tool for objective
assessment. However, the checklist could be useful for inexperienced teachers and provide
senior teaching staff with a mentorship tool to develop inexperienced faculty. Furthermore, the
checklist could be modified to meet specific requirements or settings.
Inpatient Clinical Teaching Checklist
1 Clerkship goals and expectations reviewed No Yes
2 Rounds were begun and ended on time No Yes
3 Literature searches or topic discussions were assigned No Yes
4 Students‘ history and physicals were reviewed No Yes
5 Students were treated as team members Never Sometimes Always
6 A broad knowledge of clinical issues was demonstrated Never Sometimes Always
7 Education and patient management were balanced Never Sometimes Always
8 Students were encouraged to formulate their own A and P Never Sometimes Always
9 Students were encouraged to ask questions Never Sometimes Always
10 Constructive feedback was provided Never Sometimes Always
11 Physical findings were reviewed and demonstrated Never Sometimes Always
12 Clinical decisions (i.e. selection of tests) were explained Never Sometimes Always
13 Clinical findings (i.e. X-rays) were reviewed and demonstrated Never Sometimes Always
14 Professional and ethical behavior were modeled Never Sometimes Always
15 Effective interpersonal and communication skills were modeled Never Sometime Always
Griffith, Charles H., Georgesen, John C., Wilson, John F.: Six-Year documentation of the association
between excellent clinical teaching and improved student examination performance. Academic Medicine.
75:62-64, 2000
A prospective cohort study of 502 third-year medical students rotating through a general internal
medicine clerkship conducted over a six year period. Faculty clinical teachers were rated as good, mediocre and poor through past resident surveys and end-of-rotation evaluations. Those students that
rotated with the good clinical teachers scored significantly higher on the internal medicine portion of
USMLE Step 2. Good clinical teachers were thought to improve comprehensive scores because they
―engendered a learning climate that makes learning fun, enjoyable, and exciting‖ as opposed to the simple relaying of medical facts.
47
48
Chapter 3
Giving Dynamic Presentations
Faculty Development Series
Madigan Healthcare System Tacoma, Washington 98431
49
Giving Dynamic Presentations
Checklist for the Group Leader
Before the Session....
___ 1. Review the suggested eight steps of planning for this presentation.
___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.
___ 3. Duplicate and distribute the LNRA to faculty.
___ 4. Have faculty return the LNRA at least 5 days before the session.
___ 5. Review the faculty LNRA prior to the session.
___ 6. Modify the suggested eight steps and write your plan to fit your needs.
___ 7. Modify the PowerPoint and handout to fit your plan.
___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation
forms, and handouts.
During the Session....
___ 9. Have each participant sign-in using the attendance roster.
___ 10. Distribute the handout(s) to the participants.
___ 11. Conduct the session based on your eight steps of planning.
After the Session....
___ 12. Collect the evaluation forms from the faculty.
___ 13. Keep the attendance roster for the session in your department and provide the
appropriate amount of CME to each participant.
___ 14. Reflect on the seminar - How did it go? What was good about it? What could have
been better? Is there a better approach to this topic? Were there needs identified during
this session that would be the basis for future seminar(s) in your program?
___ 15. Where will your program go from here based on this seminar?
50
Learner Needs and Resources Assessment
Please complete the following needs assessment for the upcoming seminar on Giving Dynamic
Presentations as part of your faculty development program.
The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, several
short video clips, several group activities and a discussion period.
The purpose of this needs assessment is to determine your learning needs and interests, so that the
seminar is most useful for you. This needs assessment should also stimulate you to think about dynamic
lectures before the seminar begins. We need your enthusiastic participation now, and in the seminar. It will be fun, and at the end of it, we'll be asking for your feedback!
Please turn this in to your group leader (______________) no later than (_____________).
1. Have you had any formal training in giving presentations? YES NO
2. What do you already know about giving dynamic presentations? Answer briefly below:
a. What are the advantages and disadvantages of the lecture format?
b. What characteristics make for an outstanding presentation?
1. 4.
2. 5.
3. 6.
c. What are the characteristics of an outstanding visual aid?
d. What are the characteristics of an outstanding handout?
3. Think about presentations given in your program. Who does them? Are they engaging? Critique your
own lecture style, visual aids, and handouts – what are their strengths, and which areas need improvement? Be prepared to share your thoughts with the group during the seminar.
4. What 3 things do you most want to learn or discuss regarding giving dynamic presentations?
a.
b.
c.
5. Any other comments, concerns, or interests for this topic?
51
ATTENDANCE ROSTER – Page____of_____Pages
Department: ____________________ Institution:____________________
Title of CME Activity: Faculty Development Series – Giving Dynamic Presentations
Course Content: Didactic and Group Discussion – An introduction to preparing and leading engaging learning
activities
Instructor (Group Leader):____________________________
Date:____________ Time: Began___________ Ended________ Total ___________
Name Rank
Check One
Email Address Staff
Physician
Resident
Physician
Other
Professional
Discipline
Total Number of Learners Attending This Activity: _________
52
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree Disagree Somewhat
Agree Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
53
Giving Dynamic Presentations
Example Eight Steps
The eight steps presented below may be used as a guide for your planning.
Modify these steps to meet your specific needs.
Who: 20 faculty learners from the Department of Family Medicine.
Why: Improve presentations skills as part of a required faculty development curriculum.
When: 0730-0900 on a Wednesday morning, blocked schedule for faculty development.
Where: Classroom, individual desks, accessible, AV supported, requires own computer.
What: Driven by the LNRA. Will explore which characteristics contribute to excellent,
as well as poor, presentation preparation and delivery. Identify common pitfalls
of delivering presentations and offer solutions to improve faculty skill set.
What For: By the end of this session participants will have:
Reviewed presentation preparation using the 7 Steps and 4 I‘s
Appraised effective PowerPoint tips
Applied PowerPoint tips to a presentation
Discussed public speaking strategies
Assessed several public speaking examples
Applied speaking strategies to a short presentation
Reviewed tips on preparing effective handouts
How: General: Active learning: small group activities and discussion, larger group
discussion, using both ideal and poor PowerPoint examples. Video clips will also
be utilized for examples, appraisals, and impact. Room contains individual desks.
Will pre-configure desks into larger half-moon shape. Within larger half-moon
configuration, will group two to three desks in smaller half-moon shape for
multiple groups of two to three learners each. This will facilitate small group
activities followed larger group discussions. The session will take place at 0730,
so will provide breakfast and beverages.
Grabber: Show JFK video; ask audience to reflect upon whether or not video
compliments or detracts from the speech.
Induction Tasks: 1. Began with LNRA.
2. Learners discuss JFK video, it‘s strengths, and it‘s weaknesses.
54
Input Tasks:
1. Review Eight Steps and Four I‘s of planning and how they relate to preparation
of an effective, dynamic presentation.
2. Present techniques to enahnce the content of presentations.
3. Present the common pitfalls of PowerPoint presentations and offer tips to
counter them.
4. Present techniques for effective public speaking.
Implementation Tasks:
1. Interview one member of the small group and record several interesting facts
about that individual.
2. Design two to three PowerPoint slides to introduce their group member.
3. Appraise two video clips and discuss as a group the strengths and weaknesses
of each presentation.
4. Develop and deliver a one to two minute speech utilizing techniques from this
session to present the interviewed group member.
Integration Tasks:
1. Challenge learners to apply concepts from this session to enhance their future
presentations.
So What:
Learning: Learners understand effective preparation, content enhancement, and
delivery perils as well as techniques to mitigate them.
Transfer: Learners build upone their current presentation delivery skill set and
use these techniques to design and deliver excellent future presentations.
Impact: Departmental teaching is enhanced, improved learning and success for
residents.
55
Giving Dynamic Presentations
Handout
"A boring teacher is someone who talks in someone else's sleep."
Overview
Advantages: complements a speaker‘s presentation by reinforcing key concepts, decreases time
required for taking notes
Disadvantages: If confusing or complicated, the audience may spend the session reading instead
of listening
Preparing Useful Handouts
Tailor it to your audience: Students tend to prefer incomplete handouts that outline the key
concepts but allow room for note-taking. Staff and residents prefer complete, clinically relevant
handouts that can serve as a future reference
Concentrate on critical points of presentation: Be clear, logical and succinct
Include useful reference charts and lists
Use an annotated bibliography: Provides guidance to those who want to learn more
Summary
Techniques that create an engaging presentation
- 3-5 main points - Maintain eye contact
- Use body language - Use anecdotes
- Vary inflection & pacing - Show enthusiasm
Visual aids should follow the 4 R’s
- Readable - Relevant
- Reliable - Repetitious
Handouts are an excellent tool for increasing retention of information
Group Discussion Ideas
Discuss your program‘s lectures – Are they engaging? Why or why not?
Critique your own lecture style, visual aids, and handouts discussed in this session
56
Giving Dynamic Presentations
Handout
Activity One: Preparation
In groups of 2-3, choose a group member to introduce. Develop 3-4 items that you would share
with this audience when introducing that group member. Please write the items you plan to
share below.
Item #1
Item #2
Item #3
Item #4
Activity Two: Content Enhancement
In your same group of 2-3 table members, design 1-2 PowerPoint slides on your computer that
convey the items you learned about each other in Activity #1. Feel free to use text, images from
the internet, or other creative ideas.
You can use the back side of this handout to draw out ideas for your slides before creating them
or if you don‘t have access to a computer with PowerPoint.
Activity Three: Delivery
In your group of 2-3, develop a 1-2 minute speech introducing your table member. Use your
PowerPoint slides as content enhancement aids. Present your speech to the other members at the
table. Please be sure to stand while delivering the presentation.
Speaking Notes
57
Remember the 4 R’s of Audio Visual Aids:
Area for Slide Design
58
Supporting References and Resources
Giving Dynamic Presentations
Purposes of A-V Aids
Support and enhance the clarity of the presentation
Emphasize the important points
Stimulate the audience‘s senses
Reinforce key concepts
Advantages of using A-V Aids
Can complement spoken part of presentation and lead to increased retention
Much learning occurs from visual sources
Disadvantages of A-V aids
It is easy to rely too heavily on them
If poorly done, they can become a distraction
The 4 R’s of Audio-Visual Aids
Readable
Don‘t use a chalkboard when speaking in a 400 seat lecture hall
For text slides, use 6 or fewer lines with fewer than 6 words per line
Ensure that charts and graphs are simple to understand
Be consistent in use of font, text size, and designs
Reliable
Test all your equipment prior to presenting
Develop a back-up plan if audiovisual aids fail
Relevant
Each slide or graphic should deal with one main concept
Make sure that all audiovisual tools support the main objectives
Repetitious
Should repeat main point of the presentation since repetition is the mother of all learning
(Repetitio Est Mater Studiorum)
Also helpful to vary the ways you present the same information (visual, tactile, auditory, and
affective)
Readable
Reliable
Relevant
Repetitious
59
Preparation and Delivery of Effective and Dynamic Presentations
Background Information
―The art of lecturing takes practice and preparation. Using a few basic oratorical techniques, along with carefully prepared visual aids, can make the difference between a routine lecture and a dynamic,
engaging presentation.‖
Introduction
Residents have spent hundreds of hours in lecture halls during their training
Many presentations are helpful
Other lectures leave students more bewildered than when the talk began
A few presentations are enthralling and leave the audience with a clear understanding and a
renewed enthusiasm
What separates average lectures from the exceptional ones is the ability to draw the audience in
Engaging the audience does not require a flair for the theatrical
Using a few basic speaking techniques and effective audiovisual aids can transform a presentation
into an interactive learning experience
Advantages of Traditional Lecture Presentations
Excellent way to synthesize a broad range of research and information
Provides a coherent framework for material
Allows for presentation of information that may not be readily available in the literature
Familiar and economical method that can be given to large audiences
Weaknesses of Lectures
Does not account for students' individual differences
Offers little opportunity to judge audience understanding
Places heavy reliance on students' note taking skills and memory
Demands sustained listening
Limits active learner participation
Basic Guidelines for Delivering an Effective Presentation
Organize the talk around 3-5 main points: Like a good story, have a beginning (intro), a
middle (body), and a conclusion (summary). Don‘t try to cover the topic exhaustively – confine the activity to 3-5 main points.
Use body language: Emphasize certain points
Vary inflection and pacing: Avoid monotone delivery
Maintain eye contact with the audience: Don‘t focus on your notes
Personalize the material: Use humorous or dramatic anecdotes from your own experiences.
Choose your stories well – only use anecdotes that support the point you are trying to make.
Show enthusiasm for your topic
Create a diverse, interactive environment: The best way to engage the audience is to ask
questions, even if they are only rhetorical. Questions force the audience to think about the material. Demonstrations are also helpful in clarifying theoretical concepts.
Use audiovisual aids properly: If done correctly, they can enhance a presentation and greatly
improve understanding and retention.
60
Delivering the Presentation
Specific Techniques for the Dynamic Lecture
Use demonstrations
Provide anecdotes – use to make a point, not substitute for scientific practice
Use metaphors to make examples vivid
(―Bursae function to reduce friction – like holding a partially filled balloon which is covered in
oil between your palms‖)
Use questions effectively
- Ask one questions at a time - Wait for a response for at least 3-5 seconds
- Call on students and encourage participation
Delivering Dynamic Presentations
Begin with a cordial, friendly line of greeting
Exhibit enthusiasm
Talk loud enough
Stand erect
Make eye contact - very powerful - makes connections
Smile - look as if you are happy to be there
Use movement and gestures - the larger the group, the larger the gestures & voice inflection
should be
ALWAYS keep within the time limit
Relax and enjoy the performance
Combat Nervousness
Be prepared (best defense) - know content of lecture, be familiar with the room
Rehearse, rehearse, rehearse - ―Perfect practice makes perfect!‖
Release - go for a walk or stretch
Launch - walk up confidently, stand up straight, and smile
Avoid annoying mannerisms such excessive movement, playing with remote clicker or keys in
pocket, fiddling with hair
Use coffee cup - helps set an informal atmosphere, provides reason to pause periodically
Using Handouts (Advantages)
Complements the learning activity
Reinforces key concepts
Provides a take home reference
Lessens needs for audience to take notes
Using Handouts (Disadvantages)
Audience may focus their attention on handout rather than speaker
Handout Content (The ABC’s of Quality Content)
Accuracy - data and concepts reflect verifiable information
Appropriateness - relevant to the needs of the learner
Arguments - adequately addresses areas of controversy
Background - covers necessary background information
Balance - theory and practice are appropriately balanced
Bibliography - references well outlined and useful
Currency - information is up-to-date
Comprehensiveness - broadly comprehensive while appropriately succinct
Coordination - integrates necessary data of other disciplines
61
When Should You Provide the Handout?
Prospective
- Given in advance of the lecture - Allows the audience to read preparatory material or to ponder particular questions
- Allows lecturer to cover more subject material or begin at a higher level
- Often goes unread or not brought to class
Concurrent - Provides a program guide for the lecture
- Allows key points to be highlighted
- Eases the strain of note taking problems - Encourages daydreaming if audience pays more attention to the handout than
to the speaker
Retrospective - Given at the end of class
- Note taking becomes more time consuming
62
Tips on Delivering This Presentation
One approach to this session is as follows:
Using the LNRA from the faculty, identify which of the three areas discussed above are most
relevant to your audience. If time is limited, focus only on those areas indicated by the audience.
Consider using the example speaking script that is included within the slide presentation
associated with this chapter.
Begin the session by establishing the goals for the seminar, and introduce the topic. Consider
using the included grabber, which is a speech by President Kennedy (―Ask not what your country
can do for you…‖) that is coupled with an ineffective and distracting PowerPoint presentation. This will plant the seed that even exceptional content can be ruined by ineffective audiovisual
aids.
After reviewing the agenda and objectives for the session, review the 8 steps of planning and
share how you applied those steps to teaching this session.
For the first activity, use the first page of the handout and have the audience work in groups of 2-
3 to prepare a short introduction of one of their group members. They should discover 3-4 interesting facts about that individual and begin to think how they will introduce that person to
the audience.
The next section will cover content enhancement. You should introduce the 4 R‘s of audiovisual
aids (Readable, Reliable, Relevant, and Repetitious) and review examples of each in the PowerPoint presentation.
The second activity will allow the audience to apply the 4 R‘s to their own PowerPoint slides that
they can use to supplement the introduction of their partner. You should encourage them to seek out images, use text, or devise other creative ways to share information.
Next, show the short introduction video by Dick Hardt. This will emphasize that creativity in
audiovisual aid design can be very powerful.
For the final section on content delivery, start with the Seinfeld clinic about the fear of public
speaking. You can then introduce the London Times poll results showing that public speaking is
the number one fear of many people.
Solicit feedback from the crowd about what effective speaking techniques they have heard.
Share the included speaking tips with the audience.
Show audience two video clips of public speeches. Have the audience evaluate the speakers on
things such as enthusiasm, body language, movement, audience interaction, eye contact, and speech rhythm and tone.
For the final activity, have each group present their partner introduction to the group. Encourage
them to stand up and apply some of the lessons learned over the session.
Close by showing the speech by President Kennedy accompanied by a more effective set of
slides.
63
At the close of the presentation, consider having the audience critique the handout they used
through the session. Have them identify what they liked and what they didn‘t.
Throughout the session, ensure that you provide lavish affirmation to those who participate. This
helps to create a safe learning environment and promotes interaction.
Ask the participants to commit to using what they learned in the session for the next learning
activity they lead.
Another technique would be to videotape several faculty presenting their lectures and review
those video clips during a separate session. This would allow an opportunity to apply the
learning to a personal and pertinent event.
After the session:
Review the evaluation forms completed by the participants;
Reflect on the seminar - how did it go? What was good about it? What could have been better? Is
there a better approach to this topic? Were there needs identified during this session that would
be the basis for future seminar(s) in your program?
Where will your program go from here based on this seminar?
References
Dynamic Presentations Whitman N: Creative Medical Teaching. 1st ed. 1990. University of Utah School of
Medicine. A humorous, well-written book on all aspects of teaching medicine.
Whitman N: There is No Gene for Good Teaching: A Handbook on Lecturing for Medical
Teachers. 1982. University of Utah School of Medicine. a classic, good, concise overview.
Kroenke K: The Lecture - Where It Waivers. Am J Med 77(3):393-6, 1984. Written by a
military internist, excellent overview with 10 practical rules for giving a great lecture.
Findley LJ, Antczak FJ: How to Prepare and Present a Lecture. JAMA 253(2):246. 1985. Short, concise commentary on practical lecturing tips.
Irby DM: Preparation and Delivery of Dynamic Presentations. Univ of Washington
Workshop given on 23-4 October 1996. Dr. Dave Irby is one of the gurus in medical education; much of the Dynamic Lecture talk came from this workshop.
Creative Handouts
MacLean 1: Twelve Tips on Providing Handouts. Med Teacher 13(l):7-12,1991.
Amato D, Quirt I: Lecture Handouts of Projected Slides in a Medical Course. Med Teacher 12(3/4):291-6, 1990.
Kroenke K: Handouts: Making the Lecture Portable. Med Teacher 13(3): 199-203, 1991.
McLeod PJ, Tenenhouse A: Peer Review of Class Handouts. Med Teacher 10(l):69-73, 1988.
McLeod PJ: How to Produce Instructional Text for a Medical Audience. Med Teacher
13(2):135-44, 1991.
64
Chapter 4
Bedside Teaching:
Recovering a Lost Art
Faculty Development Series Madigan Healthcare System
Tacoma, Washington 98431
65
Bedside Teaching
Checklist for the Group Leader
Before the Session....
___ 1. Review the suggested eight steps of planning for this presentation.
___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.
___ 3. Duplicate and distribute the LNRA to faculty.
___ 4. Have faculty return the LNRA at least 5 days before the session.
___ 5. Review the faculty LNRA prior to the session.
___ 6. Modify the suggested eight steps and write your plan to fit your needs.
___ 7. Modify the PowerPoint and handout to fit your plan.
___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation
forms, and handouts.
During the Session....
___ 9. Have each participant sign-in using the attendance roster.
___ 10. Distribute the handout(s) to the participants.
___ 11. Conduct the session based on your eight steps of planning.
After the Session....
___ 12. Collect the evaluation forms from the faculty.
___ 13. Keep the attendance roster for the session in your department and provide the
appropriate amount of CME to each participant.
___ 14. Reflect on the seminar - How did it go? What was good about it? What could have
been better? Is there a better approach to this topic? Were there needs identified during
this session that would be the basis for future seminar(s) in your program?
___ 15. Where will your program go from here based on this seminar?
66
Learner Needs and Resources Assessment
Please complete the following needs assessment for the upcoming workshop on Bedside Teaching:
Recovering a Lost Art as part of your faculty development program.
The seminar will consist of an introduction by your group leader, a short PowerPoint presentation and
interspersed small group activities and class discussions.
The purpose of this needs assessment is to determine your learning needs and interests, so that the
seminar is most useful for you. This needs assessment should also stimulate you to think about active learning before the seminar begins. We need your enthusiastic participation now, and in the seminar. It
will be fun, and at the end of it, we'll be asking for your feedback!
Please turn this in to your group leader (______________) no later than (_____________).
1. Have you had any formal training in bedside teaching? YES NO
2. What are some advantages to teaching at the bedside?
3. What are some barriers to bedside teaching at your hospital?
4. Think about the bedside teaching rounds made in your program. Who does them? Are they effective?
What are the strength(s) of bedside rounds in your program, and which areas need improvement? Be prepared to share your thoughts with the group during the seminar.
5. List three things you would like to learn/take away from this session:
a.
b.
c.
Any other comments / concerns for this presentation:
67
ATTENDANCE ROSTER – Page____of_____Pages
Department: ____________________ Institution:____________________
Title of CME Activity: Faculty Development Series – Bedside Teaching: Recovering a Lost Art
Course Content: Didactic and Group Discussion – Instruction on Bedside Teaching techniques and strategies to
systematically implement Bedside Teaching
Instructor (Group Leader):____________________________
Date:____________ Time: Began___________ Ended________ Total ___________
Name Rank
Check One Department or Mailing
Address Staff
Physician
Resident
Physician
Other
Professional
Discipline
Total Number of Learners Attending This Activity: _________
68
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly Disagree
Disagree Somewhat Agree
Agree Strongly Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
69
Bedside Teaching
Example Eight Steps
The eight steps presented below may be used as a guide for your planning.
Modify these steps to meet your specific needs.
Who: 8-10 faculty learners from the Department of Family Medicine.
Why: Enhance clinical teaching as part of a required faculty development curriculum.
When: 1400-1500 on a Thursday afternoon, blocked schedule for faculty development.
Where: Classroom, individual desks, accessible, AV supported, requires own computer.
What: Driven by the LNRA. How to plan and execute bedside rounds. Models to cover
include: Ramani model (12 steps), Janicik model (3 domains). Identify barriers to
implementation and explore strategies to overcome them. Commit to an
implementation plan for the group.
What For: By the end of this session, we will have:
• Listed obstacles to bedside teaching
• Identified advantages of bedside teaching
• Tried out models for bedside teaching
• Found ways to overcome obstacles
• Planned integration of bedside teaching into inpatient rounds
How: General: Active learning: small group activities and discussion, larger group
discussion, minimal PowerPoint slides. Room contains one large table with
chairs, white board, smart board connected to computer. Will group chairs to form
two groups of 4-5 learners each. This will facilitate small group activities
followed larger group discussions. The session will take place at 1400, so will
provide coffee and cookies.
Grabber: Osler quote ―Medicine is learned at the bedside and not in the
classroom.‖ Crumlish study numbers showing staff and residents value bedside
teaching (may contrast with institutional experience/perceptions).
Induction Tasks: 1. Began with LNRA and continued in first activities. Learners reflect on their
experiences with bedside teaching.
2. Learners discuss obstacles to bedside teaching. Write list on board/easel or
other prominent site in room and keep visible throughout session. Use LRNA
responses to jumpstart the conversation, starting with ―time‖ (universal barrier).
70
3. Learners discuss advantages to bedside teaching. Write and display as with
obstacles above. Affirm the learners by comparing their list to data from the
Crumlish study. Use LRNA responses to prepare slide.
Input Tasks:
1. Introduce the Ramani and Janicik models described on the handout. Note that
an excerpt from the models is also provided for the next task.
2. Have small groups review the models.
Implementation Tasks:
1. Have small groups use a case from their experience to formulate a bedside
teaching session using the excerpt from one model. Allow 15min for this task.
Discuss what struck them about it at the end of the learning task.
2. Discuss potential solutions to obstacles they have identified. Note this may
occur naturally at any point in the session.
3. Discuss any other issues identified in the LRNA not yet addressed, as time
allows.
Integration Tasks:
1. After reviewing and affirming the work of the learners to this point, discuss and
commit (as a group) to a plan for implementation. Suggest inclusion of minimum
baselines such as frequency, duration, site, and people included in bedside group.
Note the need to remain flexible in day-to-day practice. Write their commitments
on the board/easel/other prominent place. At the end of the session, copy this list.
2. One month after the session, e-mail the site POC for feedback on the session.
Include their list of commitments from the session and request assessment of
impact.
So What:
Learning: Learners have identified obstacles to and advantages of bedside
teaching. They have reviewed two models to plan and structure bedside teaching
sessions. They have identified strategies to overcome obstacles to implementation
of regular bedside teaching. They have committed to a plan for regular bedside
teaching.
Transfer: Learners implement regular and effective bedside rounds into their
inpatient care rotation. They continue to identify and seek ways to overcome
obstacles.
Impact: Residents and other learners improve their understanding of and
performance in many dimensions of medical care. Morale and enthusiasm for
inpatient care, teaching and learning all improve.
71
Bedside Teaching Handout
Blending Tradition, Humanity, Art & Science
―No books, no tapes, no audio-visual aids, no seminars, no avant-garde philosophy will
ever be substitutes for the discipline of bedside medicine—the one-to-one situation where
tradition, humanity, art, and science are blended." ~Unknown
Bedside Teaching: The Imperative
94% of residents believe bedside teaching time is valuable
82% want more bedside teaching in the curriculum
Crumlish, et al, 2009
Teachable moment: The moment when a unique, high interest situation arises that lends
itself to discussion of a particular topic.
Breaking Down the Barriers
Barriers Recommendations
Limited time Be selective: not every patient
Don‘t wait for a quorum
Be flexible
Attending inexperience or fear Faculty Development
Acknowledge self as ―imperfect scholar‖
Share the teaching
Encourage self-directed learning (SDL)
Perceived patient discomfort Ask permission
85% of patients prefer bedside rounds
Enhances patient and family centered care
Overreliance on technology Explain the importance of diagnostic skills
Incorporate the technology at the bedside
Learner resistance Be persistent
Include all learners
Never undermine the learner in front of
patient
Seek and Make the Most of Teachable Moments
Provide Frequent and Timely Feedback to All Learners on Team
Prepare, Brief, Experience, and Debrief
Break Down Barriers with Flexibility, SDL, and Persistence
72
Take Learning to the Bedside
―The best teaching is taught by the patient himself.‖ ~ Sir William Osler
Small Group Teaching: The Basics
Learning Environment:
Low pressure Stimulate discussion and doubt
Teach from the middle Encourage self directed learning
Engage the learners / Share teaching Think out loud
Effective Feedback Principles (SOME TLC):
Specific Timely
Objective Limited
Modifiable behaviors Constructive
Expected (Frequent)
Provide Effective Feedback:
Ask What did you do well? What questions or challenges did you have?
Tell / Teach I observed… Then give a few general teaching points.
Ask / Act What will you do differently next time? Develop an action plan.
Prepare Objectives:
- Identify target learners
- Determine teaching objective
(e.g. interviewing, physical
exam, interacting with family)
- Research topic as needed
Brief Participants:
- Ask patient and explain event
- Brief learners:
- Discuss expectations
- Assign roles
- Clarify objectives
- Review ground rules
Debrief:
- Ask learners for their
observations
- Provide feedback
- Encourage self-directed
learning
Clinical Experience:
- Explain
- Demonstrate
- Learner experiences
- Assess
The
Teaching
Cycle
73
Improving Bedside Teaching
Breaking Down OUR Barriers
Task #1 Bedside Teaching where I work Task #3
Obstacles
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Solutions
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
74
Bedside Teaching
Task #2 – Road Maps OR Focused Teaching – 15 minutes
RAMANI MODEL: Draw a road map (steps 1-4), orient learners (steps 5-7)
1) Medical system to be covered
2) Skills or aspects to be taught
3) Observation vs. demonstration
4) Define which patients and how long
5) Objectives, expectations, ground rules
6) Assign roles (presenters, examiners, jargon police, etc.)
7) Set limits (no coverage of highly sensitive issues, etc.)
JANICIK MODEL: Focused teaching (steps 1-4), Group Dynamics (steps 5-7)
1) Role model professional behavior, communication
2) Physical exam or procedural skills
3) Teach general concepts
4) Give feedback (patient can also give feedback)
5) Limit the time and goals for the session
6) Include everyone in teaching and in feedback
7) Assign roles to everyone
Pick ONE model below. Use a case you have seen on the ward.
Work through the steps listed as if you were going from here to rounds.
75
Bedside Teaching
Reference model #1
The 12 Step Model (adapted from Ramani, et al, 2003)
1) Prepare goals for the session
a. Use the curriculum
b. Meet the learners at their level
2) Draw a road map ***
a. Medical system to be covered
b. Skills or aspects to be taught
c. Observation vs. demonstration
d. Define which patients and how long
3) Orient learners ***
a. Objectives, expectations, ground rules
b. Assign roles (presenters, examiners, jargon police, timekeeper, etc.)
c. Set limits (no coverage of highly sensitive issues, etc.)
4) Introduction
a. Introduce whole team and road map to patient
b. Note primary goal is teaching
5) Interaction – Role model professional behavior for the learners
6) Observation – Step out of the limelight, support learner as primary caregiver
7) Instruction – Challenge the learners intellectually, don‘t humiliate them
―DO‘s‖ ―DON‘Ts‖
Gentle corrections Keep team all engaged One upmanship
Admit knowledge limits Learn from your students ―What am I thinking?‖
Teach professionalism Teach hands-on skills Ask juniors after seniors
Teach observation skills Use teachable moments Long didactics
8) Summarization – Recap for learners and the patient
9) Feedback – From learners, what went well and/or not well
10) Debrief
a. Time for questions/clarifications
b. Assign further reading/research
c. Discuss sensitive areas
11) Reflect
12) Prepare for next time
B
E
F
O
R
E
A
F
T
E
R
D
U
R
I
N
G
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Bedside Teaching
Reference Model #2
The 3 Domains Model (adapted from Janicik, et al, 2003)
Attend to Patient Comfort
1) Ask the patient‘s permission in advance
2) Introduce everyone on the team
3) Start with a brief overview from the primary caregiver (learner)
4) Give explanations without using medical jargon
5) Base the teaching points on that patient
6) Use a genuine, encouraging closure statement
7) Return later to check for and resolve misunderstandings
Focused Teaching
1) Diagnose the patient
2) Diagnose the learner
3) Provide targeted teaching ***
a. Role model professional behavior, communication
b. Physical exam or procedural skills
c. Teach general concepts
d. Give feedback (patient can also give feedback)
4) Debrief after the session
Group Dynamics ***
1) Limit the time and goals for the session
2) Include everyone in teaching and in feedback
3) Assign roles to everyone
77
Supporting References and Resources
Bedside Teaching
Cox, K. (1993). Planning Bedside Teaching. The Medical Journal of Australia, Vol. 158-9. University of New South Wales School of Medicine. Series of 8 articles describing a teaching
cycle in detail. Source for Teaching Cycle in the handout. Full conceptual diagram:
Working
Debriefing Preparation knowledge
Clinical Explication
Encounter
Preparation
Briefing for next time Reflection
Crumlish, C. M., Yialamas, M. A., McMahon, G. T. (2009). Quantification of Bedside
Teaching by an Academic Hospitalist Group. Journal of Hospital Medicine, 4:304-7.
Author from Brigham and Women‘s Hospital, Boston, Internal Medicine residency. Study
examined time spent at the bedside during rounds (17%, deemed too low) and what residents
value about bedside teaching.
Most valuable parts of BT: Physical Exam
Communication/Interpersonal skills
Focus on pt-centered care Integrating clinical exam w/dx/mgmt decisions
Ende, M. J. (1997). What if Osler Were One of Us? Inpatient Teaching Today. Journal of
General Internal Medicine, 12:S41-S48.
Author from University of Pennsylvania School of Medicine. He examines challenges and
planning modern bedside teaching using Osler as an example of excellent practice.
Principles of Learning Corresponding Rec’s for Teaching
1) Knowledge is constructed, Begin with students‘ conceptualization;
not accumulated Use probing questions; encourage reflection
2) Expertise depends on experience Focus discussions on the patient;
with cases Teach at the bedside; compare/contrast cases
3) Students learn when they Provide challenge and support; stimulate interest;
are involved Make rounds fun; encourage independent learning
4) Learning is both a personal and Develop a learning community; provide orientation;
a social process Leaven credibility with authenticity;
Know your learner
Experience
Cycle
Explanation
Cycle
78
Ende, M. J. (1997). (con’t)
Questions to guide planning “rounds that work”
What do you hope to accomplish?
What is your point of view?
How will your learners be engaged?
How will you meet the needs of each learner?
How will rounds be organized?
Are your rounds successful?
How will you make the time?
Gonzalo, J. D., Masters, P. A., & Simons, R. J. (2009). Attending Rounds and Bedside Case
Presentations: Medical Student and Medicine Resident Experiences and Attitudes. Teach
Learn Medicine, 21 (2):105-110. Authors and study from Penn State College of Medicine. 3
rd year med students, Internal
Medicine and Med-Peds residents surveyed about time, value and concerns over bedside
rounds.
Time at bedside: mean 27% of rounds (73% of rounds had <25% of time at bedside).
Value: 1) Learners that had seen bedside rounds prefered bedside rounds more
than those who hadn‘t seen them (42% vs 13%).
2) Bedside rounds somewhat or very important for learning physical exam (89%),
communication (83%), professionalism (72%), patient mgmt (59%), history-taking
(55%), pain mgmt (43%).
Concerns: Prevents freedom of discussion about patient‘s case (75%), patient comfort (66%),
concern for patient‘s feelings (66%)
Kroenke, K., Omori, D.M., Landry, F.J., Lucey, C.R. (1997). Bedside Teaching. Southern
Medical Journal, 90 (11):1069-74.
Primary author from USUHS, Dept of Medicine. Review of five common obstacles to bedside
teaching and potential solutions for each:
Obstacle Potential Solutions Time constraint Pre-designate time during rounds (30min/day, 1 pt/day, etc);
Be selective in target for each encounter
Selecting targets Attending picks based on presentation (confusing hx, abnormal exam);
Attending asks team to pick;
Someone notes a great learning point independently
Demonstrate vs. Demonstrate advanced skills;
observe Observing residents slower but better learning
Staff insecurity "No finding is too mundane"; Chronic findings still valuable;
Learn together as a team; Role model compassion/professionalism
Learner dislikes Plan ahead, limit single-resident exam time
Boredom Set the tone before bedside rounds; Teach vice putting on the spot;
Fear of embarrassment Specify goals/agenda
79
Janicik R. W., Fletcher, K. E. (2003). Teaching at the bedside: a new model. Medical
Teacher, 25 (2):127-130.
Source for model cited in handout.
Lehmann, M. L., Brancati, M. M., Chen, M. M.-C., Roter, D. D., & Dobs, M. M. (1997).
The Effect of Bedside Case Presentations on Patients’ Perception of Their Medical Care.
The New England Journal of Medicine, 336:1150-1156.
Authors and study from Johns Hopkins Hospital, Internal Medicine inpatient service.
RCT design. Patients with bedside presentations reported doctors spent more time with them,
reported slightly better quality of care. Lower education level associated with more complaints
of doctors using jargon.
Mooradian, N.L., Caruso, J.W., Kane, G.C. (2001). Increasing Time Faculty Spend at the
Bedside During Teaching Rounds. Academic Medicine, 76 (2):200. Essay from authors at Jefferson Medical College.
Residents evaluated attendings by time on ward, gave feedback to PD (no names), increased incidence of teaching at the bedside from 30% to 70%.
Points for successful rounds:
Obtain pt consent prior to rounds Ask residents/students to demonstrate PE findings Explain to pt purpose of rounds Model professionalism
Introduce team Allow pt to stop session
Be courteous Allow pt the last word/question
Ramani, S., Orlander, J. D., Strunin, L., & Barber, T. W. (2003). Whither Bedside
Teaching? A Focus Group Study of Clinical Teachers. Academic Medicine, 78 (4):384-390. Author is from Boston University. Focus groups among faculty describe obstacles/solutions.
Specific Barriers Teacher Declining BT skill System Interruptions
Inexperience Short admissions
Performance pressure Technology overload Lack of control
Tough to engage whole team Patient Patient discomfort w/idea of BT
Not believing BT worthwhile Patient too ill (unstable)
Belief BT is for residents to do Patient off ward Patient misunderstanding lingo
Climate Limited time Patient privacy
Lack of faculty training Uncooperative/angry patient Lack of faculty rewards
Lack of role models
Miscellaneous Crowded room
No blackboard/X-ray view-box
Can't refer to textbook
Teacher/learner hesitancy in discussing Differential Dx Fear of undermining house staff
Learner fatigue
80
Ramani, S., et al (2003). (con’t) Strategies to Increase/Improve BT
Pre-rounds Prepare goals for each session
Orient learners to those goals (PE, communication, professionalism)
Orient patients to purpose of rounds During rounds Establish safe environment ("I don't know" is OK)
Respect learners (1° caregiver, challenge don't humiliate)
Respect patients (humans, not specimens) Engage everyone in the room
Involve the patient
Match teacher-learner goals
Post-rounds Debrief
Ramani, S. (2003). Twelve Tips to Improve Bedside Teaching. Medical Teacher, 25 (2):112-
115.
Source for model cited in handout.
Williams, K. N., Ramani, S., Fraser, B., & Orlander, J. D. (2008). Improving Bedside
Teaching: Findings from a Focus Group Study of Learners. Academic Medicine, 83 (3):257-
264. Authors from Boston University. Focus groups among residents describe obstacles/solutions. Barrier Strategy Personal Low initiative Institutional incentives
Low teacher/learner expectations Set explicit expectations/objectives
Low BT teaching skills Set good learning environment
Acknowledge learners needs Plan flexibility per workload
Selectively/efficiently integrate BT w/work
Set teaching time limits Low clinical knowledge/skills Faculty development
Reassure: EVERYONE has something to offer
Interpersonal Pt uncooperative Ask beforehand
Orient pt to format/goals
Include/inform pt
Lack of learner autonomy Respect learner-pt relationship Negotiate level of autonomy
Supportive learning environment
Share teaching w/team members Learner/pt fear of embarrassment As above (interpersonal category)
Environmental No time (workload/turnover rate) Team cap, add nonteaching service
Competing faculty duties Reduce them
Low expectation/incentive to teach Set explicit expectation/objectives
Create incentives Low recognition Create rewards
Focus on technology vice clin skill Faculty development, EBM on clinical skill
Interruptions, excessive noise (no strategy offered) Lack of privacy/space in room (no strategy offered)
81
Wright, M. S., Kern, M. M., Kolodner, S. K., Howard, D. D., & Brancati, M. M. (1998).
Attributes of Excellent Attending Physician Role Models. The New England Journal of
Medicine, 339:1986-1993.
Authors from Johns Hopkins University, study examined four teaching hospitals. Residents
identified excellent role models, those role models and other ―control‖ teaching staff were
queried via questionnaire regarding various attributes.
Those attributes associated with being identified as an excellent role model included:
1. >25% of time spent teaching
2. >25hrs/week teaching or rounding while on an inpatient service
3. Stressing importance of the doctor-patient relationship in one‘s teaching
4. Teaching psychosocial aspects of medicine
5. Having served as a chief resident
82
Chapter 5
Giving Effective Feedback
Faculty Development Series
Madigan Healthcare System
Tacoma, Washington 98431
83
Giving Effective Feedback Checklist for the Group Leader
Before the Session....
___ 1. Review the suggested eight steps of planning for this presentation.
___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.
___ 3. Duplicate and distribute the LNRA to faculty.
___ 4. Have faculty return the LNRA at least 5 days before the session.
___ 5. Review the faculty LNRA prior to the session.
___ 6. Modify the suggested eight steps and write your plan to fit your needs.
___ 7. Modify the PowerPoint and handout to fit your plan.
___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation
forms, and handouts.
During the Session....
___ 9. Have each participant sign-in using the attendance roster.
___ 10. Distribute the handout(s) to the participants.
___ 11. Conduct the session based on your eight steps of planning.
After the Session....
___ 12. Collect the evaluation forms from the faculty.
___ 13. Keep the attendance roster for the session in your department and provide the
appropriate amount of CME to each participant.
___ 14. Reflect on the seminar - How did it go? What was good about it? What could have
been better? Is there a better approach to this topic? Were there needs identified during
this session that would be the basis for future seminar(s) in your program?
___ 15. Where will your program go from here based on this seminar?
84
Learner Needs and Resources Assessment
***Consider using internet based survey systems to design and administer your surveys (Survey Monkey
for example)***
Please complete the following needs assessment for the upcoming seminar on Giving Effective Feedback
as part of your faculty development program.
The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, and
small group discussions.
The purpose of this LNRA is to determine your learning needs and interests so that the seminar is most
useful for you. This needs assessment should also stimulate you to think about active learning before the
seminar begins. We need your enthusiastic participation now and during the seminar. It will be fun, and at the end of it, we'll be asking for your feedback!
Please turn this in to your group leader (______________) no later than (_____________). Your group
leader will return this form to you at the beginning of the session.
1. Have you any formal training on how to give effective feedback? YES NO
2. What do you already know about giving effective feedback? Answer briefly below:
a. What are some characteristics of effective feedback?
1. 3.
2. 4.
b. What are some characteristics of an ineffective feedback?
1. 3.
2. 4.
3. In your experience, what are barriers to giving effective feedback?
4. What three things do you most want to learn or discuss regarding giving effective feedback?
a.
b.
c.
85
Resident / Student Feedback Assessment
***Consider using internet based survey systems to design and administer your surveys (Survey Monkey for example)***
We will be having a faculty development seminar on Giving Effective Feedback and would like your important impute to better design our seminar.
Please turn this to the faculty POC (______________) no later than (_____________). Your group
leader will return this form to you at the beginning of the session.
1. How important is receiving feedback to you?
a. Very Important
b. Important c. Moderately Important
d. Of little Importance
e. Unimportant
2. In your experience, the amount of feedback you receive from faculty is:
a. Too much
b. Just right
c. Too little
3. In your experience, the quality of feedback you receive from faculty is:
a. Very good
b. Good
c. Acceptable d. Poor
e. Very Poor
4. Which TWO features of feedback are most important to you?
a. Specific b. Objective (not hearsay but something observed)
c. Modifiable Behaviors (focus on things that can be changed)
d. Expected
e. Timely (Right time and right place) f. Limited
g. Constructive
h. Other:____________
5. List ways faculty can improve your feedback experience.
86
ATTENDANCE ROSTER – Page____of_____Pages
Department: ____________________ Institution:____________________
Title of CME Activity: Faculty Development Workbook Series – Giving Effective Feedback
Course Content: Didactic and Group Discussion
Instructor (Group Leader):____________________________
Date:____________ Time: Began___________ Ended________ Total ___________
Name Rank
Check One Department or Mailing
Address Staff
Physician
Resident
Physician
Other
Professional
Discipline
Total Number of Learners Attending This Activity: _________
87
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful.
88
Giving Effective Feedback
Example Eight Steps
The eight steps presented below may be used as a guide for your planning.
Modify these steps to meet your specific needs.
Who: 20 faculty learners from the Department of Family Medicine.
Why: Enhance the ability to give effective feedback as part of a required faculty
development curriculum.
When: 0730-0900 on a Wednesday morning, blocked schedule for faculty development.
Where: Classroom, individual desks, accessible, AV supported, requires own computer
and sound system. Conducive to small group activities.
What: Driven by the LNRA. Will explore characteristics of effective feedback, identify
barriers, and will discuss tools and techniques that can be used to improve
feedback giving skills.
What For: By the end of this session, we will have:
• Reviewed importance of feedback
• Defined feedback vs. evaluation
• Identified barriers to feedback
• Identified ingredients of effective feedback
• Applied effective feedback techniques
How: General: Active learning: small group activities and discussion, larger group
discussion, minimal PowerPoint slides. Room contains individual desk. Will pre-
configure desks into larger half-moon shape consisting of five or six learners.
Within larger half-moon configuration, will group desks in smaller half-moon
shape of two to three learners each. This will facilitate small group activities
followed larger group discussions. The session will take place at 0730, so will
provide coffee and bagels.
Induction Tasks:
1. This also serves as a ―Grabber.‖ Play video containing funny feedback
moments in the movie industry. This will help learners draw from past
experiences. Ask group if any of these has every happened to them.
2. Ask learners to write down two or three things that come to mind when they
think of feedback. Have learners share.
3. Show result of student / resident feedback survey. Ask group to discuss
results. Where there any surprises? Are our students‘ expectations and
beliefs in regards to feeback different then ours? Is there a feedback gap?
89
Input Tasks:
1. Learners read brief article about giving effective feedback. Have learners
highlight reasons for giving feedback, principles of effective feedback, and
ways to give effective feedback. Have learners share.
2. Feedback vs Evaluation exercise. Have learners match discriptive words with
either feedback, evaluation, or both. Show slide of our own list and ask
learners if they got something different an discuss.
3. Ask group to share their barriers to giving effective feedback. Then show
slide of LNRA response to this question. Then ask group to share possible
solutions to these barriers.
Implementation Tasks:
1. Introduce SOME-TLC acronym for giving effective feedback. Have learners
in groups of two or three pick one of feedback scenarios which discribes
events and obserations and have them highlist key points that they would want
to sue to give feedback.
2. After introducting Ask-Tell-Ask-Act feedback techique, have learners
practive giving each other feedback.
Integration Tasks:
1. Review student / resident feedback survey. How will knoweldge and skills
learned today be used to narrow or decrease gap?
2. Review staff survey about barriers to feedback. Break learners in 2-3 groups
to address how they will mitigate or resolve these issues.
3. Ask group to discuss and write down what they will do for the next month to
improve feedback to learners.
So What: Learning: By the end of the event, learners will have demostrated knoweldge of
importance, characteristics, and skills needed to provide giving feedback. The fact
that members actively participated in discussion and generation of solutions to
feedback challenges and practiced giving effective feedback demostrates learning.
Transfer: This will be achieved through integration tasks noted above. The key
to have each participant commit to making a change to improve how they give
feedback.
Impact: Departmental feedback to learner improves with overall improved
learning and education. This can be measured in a post event LNRA to faculty
and to students / residents.
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Giving Effective Feedback Handout:
Making a Better Sandwich
Take Home Points
• Feedback is essential
• Feedback is desired by learners
• Effective feedback requires preparation
• Give SOME-TLC via Ask-Tell-Ask-Act
Activity #1 – Feedback Reflection – 3 minutes
Write down 1-2 words that come to mind when you think of feedback. Share these with the
others at your table.
Be prepared to discuss any common themes that are present.
Word #1
Word #2
Common Themes:
Activity #2 – Feedback in Literature – 8 minutes
Highlight concepts of effective feedback that are important to you.
Be prepared to discuss with the group.
Giving Effective Feedback by W. Fred Miser, M.D.
The feedback we give to students should be for one primary purpose - to keep them on course
so they arrive successfully at their predetermined destination (the attainment of the skills,
attitudes and behaviors that will make them outstanding physicians).
Feedback is not "rocket science." It is an objective description of a student’s performance
intended to guide future performance. Unlike evaluation, which judges performance, feedback is
the process of helping our students assess their performance, identify areas where they are right
on target and provide them with tips on what they can do in the future to improve in areas that
need correcting.
Students will invariably say they do not receive enough feedback from us as teachers. Think
about your own training. Did your teachers let you know what you were doing right, and what
areas needed improvement? Did you receive enough feedback? Chances are your teachers let
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you know when you strayed off course, but did they focus on what could be done in the future so
that you would not repeat the error? To be effective, feedback should consist of these
characteristics:
1. Good feedback should be timely. The best feedback occurs on a daily basis, not just at the
end of the rotation. If done frequently, our comments will seem less like an evaluation, and
more like helpful suggestions. Take time after an encounter or procedure to provide
feedback to the students.
2. Feedback is meant to be constructive. It is intended to improve future performance, and
should be given for no other reason. It is not meant to demean or punish the student.
Describe your observations and your own reactions.
3. The best feedback is specific. Use precise language about what specifically they did right or
what they need to do to improve. Students may momentarily feel good about themselves
when you say, "You did a good job." However, they will also wonder what specifically they
did that earned your praise. Instead of saying, "You are clumsy," provide specific feedback
such as, "The patient appeared uncomfortable when you were using the otoscope."
4. Feedback is focused on behavior, preferably ones that can be repeated, and not on the
individual. Focusing on the behavior allows a dispassionate dialogue with the student.
5. Good feedback should be based on personal observations, not on hearsay.
6. Feedback should be verified. Make sure the student understood your feedback, and then
follow up with a plan to monitor and assist the student in those areas that need correcting.
There is an art to giving feedback. If not done properly, or done with the wrong intention, the
student will take your comments as criticism. At the beginning of the rotation ask the students
how often they would like feedback, and develop a plan on providing that feedback to them.
Then, before you provide feedback, take a few moments to choose the words you will use, and
confirm your motivation that you are providing that feedback to improve their performance.
Avoid evaluative language; its use can cause the student to respond defensively.
Feedback should be done as soon as possible, unless emotions will interfere with the session.
Excellent feedback given at an inappropriate time may do more harm than good. Often after a
bad outcome, students are working through their own emotions, and are often quite critical of
their performance. At this time, brief feedback and emotional support are best, followed later by
a more detailed feedback session. Feedback should also be done in private, unless it can be given
in such a manner as to not be embarrassing. An old axiom is to "praise in public" and "critique in
private."
It is often helpful to ask the students to assess their own performance. Often they will be more
harsh about their performance, which then allows you to be more positive in your approach. It is
much easier and more effective for you if the students identify areas for improvement; you can
then help them develop a plan of action as to how they can do things differently in the future.
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When assessing performance, focus on what went well, and what can be improved. Gain
consensus with the students; feedback is more effective if you and the students agree on this
assessment. Some educators advocate the P-N-P (positive-negative-positive) sandwich approach
to providing feedback. Begin with a positive statement, then give corrective feedback and
conclude with another positive assessment. However, the positive comments must be genuine, or
you will lose credibility with the student. Remember to focus on the performance and behavior,
not on the person. Also, focus on those behaviors that the student can do something about.
Reminders about shortcomings over which the student has no control only leads to frustration.
When determining a plan of action for improvement, ask the students what they can do.
Again, gain consensus with the students; future performance is more likely to improve if they
agree with the plan. It is helpful to set goals for future performance. "Next time you encounter
this, try this...," then verify that the students understand, and if the opportunity arises, confirm
that they did change their behavior.
In conclusion, Jack Ende has written, "The goal of clinical training is expertise in the care of
patients. Without feedback, mistakes go uncorrected, good performance is not reinforced and
clinical competence is achieved empirically or not at all." (Ende J: Feedback in clinical medical
education. JAMA 250(6):777-81, 1983).
We should provide feedback often to our students, helping them to stay on track so they can
achieve their ultimate goal of being outstanding physicians. It is a skill that can be developed,
and I encourage you to keep this foremost in your mind as you work with the students in your
office.
Activity #3 – Feedback versus Evaluation– 3 minutes
Using an arrow, place the descriptive words under the appropriate heading. Some words may
fall under both headings.
FEEDBACK EVALUATION
Objective Immediate Scheduled
Informal Formal
Observational Dialogue
Monologue Grading
Improving Event Specific
Global Performance
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Activity #4 – Cases – 3 minutes
In groups of 2, each person pick one scenario that you will later (activity #5) give feedback for.
Highlight items from your scenario that you would use to provide feedback keeping in mind
SOME-TLC.
Case #1: (Medical resident scenario)
You observe a resident performing a colposcopic exam, and biopsies. The resident was
excellent in the explanation and consent of the procedure to the patient.
The patient jumps slightly during the placement of the speculum and states, ―that‘s
uncomfortable!‖ The resident repositions the speculum slightly and states ― Sometimes it is
going to hurt a little‖. The resident follows the appropriate sequence of actions, identifying an
appropriate area to biopsy. As the resident continues with the procedure, the patient
intermittently makes sounds of slight discomfort when the speculum is bumped and particularly
with the biopsy.
When the resident has completed the procedure, the patient asks if she can have any
medication for pain. The resident replies stating, ―colposcopy is not that painful, and you should
be fine with over-the-counter Motrin. Even that is not needed for most people.‖
The resident concludes by stating he will call the patient with results, and he feels
confident that she has only minor changes, that may not require further intervention.
Case #2: (Non medical scenario)
You are teaching a class via a series of interactive workshops. Most but not all students
are there as an elective course. The curriculum requires reading between sessions. All sessions
require active participation One of your students, Mary, started the course strong and you though she was going to be
one of the top students. Recently, you note that a Mary is frequently 4-5 min late for each
session. She often seems to be poorly organized upon arrival. She is somewhat reluctant to be
involved. Today during a group session she was texting on her phone. Another student asked
her to participate or leave. She set the phone down, and returned to the activity.
When she does participate she gives insightful answers to the group. She is good at
following specific directions when engaged. However this does not occur every session. You
overhear a student stating, ―Mary is either completely unaware that she is a drag on our group,
or she just doesn‘t care.‖
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Activity #5 – Giving Feedback – 10 minutes
Using the items you highlighted above, each person practice giving effective feedback using the
Ask-Tell / Teach -Ask-Act model for your case. Your partner will play the learner who will
receive the feedback. To facilate dialogue, the learner (partner receiving feedback) should
incorporate the following relevent information below about their case into the feedback sesson.
The person giving feedback for the case should avoid reading the learner‘s additional
information.
Be prepared to discuss with the group how your interaction went.
Supplement information for the learner (person receiving feedback)
Case #1: (Medical resident scenario)
You know this patient very well. She has seen you for multiple muscle skeletal problems
and in your opinion has a very low threshold for pain. You saw her before the procedure and she
had demanded Percocet and Xanax for the procedure. You spent 30 minutes reassuring her but
did not give her any medication.
Case #2: (Non medical scenario)
You have taken a similar course before and you do not find the current course
challenging. You feel that you know the material and initially did all the work for your group.
You do not think this is fair. You want the other students to pull their weight.
Activity #6 – Commitment to Improving Feedback – 5 minutes
Using what you have learned today and feedback needs of our students, list what you will do in
the next month to improve feedback to your learners.
Be prepared to share.
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Supporting References and Resources
Giving Effective Feedback
Background "Human beings are purposeful organism who, if they know where they are supposed to be
going, and, along the way, know whether or not they are on course, will make the necessary adjustments.” …Unknown
The term feedback was first used by rocket engineers in the 1940's. Feedback was used to "tell"
the rocket it was on course or, if off course, to guide it back onto the correct path so that it would
go where it was supposed to go (i.e., reach the predetermined end point). Feedback to maintain
the proper course and feedback to correct are equally important in guiding future performance.
Definition:
Feedback is an objective description of performance intended to guide future
performance; the
Process of letting others know your perceptions of their performance
Distinct from evaluation, feedback provides information to be used to guide future
performance
It is not a judgment
Review the characteristics of evaluation and feedback and
think about the difference. Both are critical in assuring that
your learners reach your end point and meet your standards.
Purposes of Feedback
NOT to assess or judge provide information to be
used for improvement
Clarify deviations from an established goal
Shape behavior toward an established goal
Correct inaccurate assumptions
Motivate
Convey an attitude of concern
Learners want / need it
Characteristics of Good Feedback
Measured against established standards
Timely - the best feedback occurs on a day to day basis
Constructive - it is intended to improve future performance and is given for no other
reason
Specific - use precise and specific language
Properly motivated - intended to improve future performance and not demean the
learner
Directed at decision / behavior, not at the person
o Focusing on the decision allows a dispassionate dialogue with the learner
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Based on personal observations and provided by anyone who is in a position to make a
valid
Observation on the learner's perform performance
Verified - assure the learner understood the message
Followed up with a plan to monitor and assist
Giving Feedback
Establish credibility / trust - this, obviously, is a long term process
Prepare - take a few moments to choose the words you will use
Confirm your motivation - feedback is given solely to improve future performance
Start with the learner's assessment - it is easier for you and more effective for the learner
Establish the "Dx" - what went well and what can be improved upon
o Gain consensus - feedback is effective if you and the learner concur on the "Dx"
Determine the "Rx"
o Ask the learner
o Gain consensus - future performance is more likely to improve if the learner
concurs with the plan to monitor and assist
Verify that the learner understands and follow up
Giving Corrective Feedback
Credibility/trust is key: Comments must be sincere
The learner will be receptive if she/he feels that the feedback is given with the single
purpose of improving her/his future performance
Let the learner know it's coming
Ask for the learner's assessment
o It is easier for you and more effective if the learner identifies areas for
improvement
Avoid traditional P-N-P sandwich --- does not promote dialogue with learner
Consider using new Ask-Tell-Ask-Act sandwich discussed below.
ASARP (As Soon As Resonabily Possible). Consider emotional state of learner
Done in private (unless it can be given in such a manner as to not be embarrassing and is
intended to guide the future performance of the other learners present)
Try not to use "YOU" or "YOUR" (this is hard to do, but it reminds us to direct the
feedback at the performance/behavior not the person)
Prepare - take a few moments to choose the words you will use
Set goals for future performance
Follow up on the plan to monitor and assist
Summary
"The goal of clinical training is expertise in the care of patients. Without feedback, mistakes go
uncorrected, good performance is not reinforced, and clinical competence is achieved
empirically or not at all." Jack Ende
The keys are the motivation of the giver (solely to improve future performance) and the
perception of the learner (that the information is provided to promote "expertise in the care of
patients").
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References
Ende J. Feedback in Clinical Medical Education. JAMA. 250(6):777-81, 1983. Excellent,
pragmatic discussion of feedback. A superb reference.
Latting, JK. Giving Corrective Feedback: A Decisional Analysis. Social Work. Sept 1992.
37(5): 424-30. Provides a useful twelve-part feedback model.
Osborn LM & Whitman N. Ward Attending: The Forty Day Month. University of Utah
School of Medicine. 1991. pp 119-46. Excellent resource especially for those supervising an
inpatient service.
Giving Effective Feedback Through Dialogue with SOME TLC
UFP Newsletter Section Teaching and Learning, Published Winter 2011
Kristian E. Sanchack, MD
Giving Effective Feedback Through Dialogue with SOME TLC
There is an awkward moment that sometimes arises at the end of a procedure, clinic, or
long inpatient day. Standing before you is the learner, perhaps a resident or medical student,
with big puppy dog eyes. The eyes imply, as the student may be afraid to ask, ―Will you give me
some feedback?‖ Awareness swoops in on both of you; similar to the moment a valet drops your
bags in the hotel room. It is time for the tip. A list of excuses or transitions may flash through
your mind‘s eye allowing the blissful escape from this moment. However, you know that
feedback is essential. Barriers exist, but these barriers will fall away for the prepared educator.
Feedback is essential
―The goal of clinical training is expertise in the care of patients. Without feedback mistakes go
uncorrected, good performance is not reinforced and clinical competence is achieved
empirically or not at all.‖ –J. Ende1
Feedback is the process of describing a student‘s performance for a given activity, for the
purpose of improvement of their knowledge, skills and attitudes. In graduate medical education
it is a key process for the acquisition of clinical skills. Jack Ende also notes that feedback started
being described in the literature as a system of adjustments for rocket science. This was then
extended to the humanities through the study of cybernetics in the 1940s, as information relating
to performance was proposed to be able to change the general manner of future performance in a
process considered learning.1,2
Giving effective feedback however, does not require a degree in
rocket science or cybernetics.
Feedback occurs when a learner is given insight into what the educator observed and
what consequences or actions may follow. Evaluation and feedback may often be used
interchangeably, but this not accurate, and leads to confusion. Feedback is a formative process
that should take place as a dialogue. Evaluation is summative conclusion that comes with
judgment. Feedback leads to greater self-awareness for the learner, and increases the mutual
understanding between a student and teacher.1,3
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Principles of Effective Feedback
―There is an art to giving feedback. If not done properly, or done with the wrong intention, the
student will take your comments as criticism.‖ W.F. Miser3
Now that we are aware that feedback is essential to the education process, we must
review what principles are important in giving effective feedback. Now many authors have
developed acronyms to help stimulate the memory. However, I relied heavily on my peers, and
was rewarded by Tien Bui, DO. Dr. Bui (who denies any use of mind expanding drugs at the
time) would say, ―Give good feedback, by giving your learner SOME TLC.‖ (See Figure 1.)4
Figure 1. SOME TLC
Feedback should be specific. Phrases like ―good job!‖ in themselves do not provide any
learning benefit. Instead describe precisely what was done well, as well as specific areas where
they can improve.
Feedback should be objective based upon your observations as the educator.
Conversations based on hearsay are less effective and unreliable. Furthermore this allows for a
more emotionally neutral conversation.
Focus on modifiable behaviors, particularly those that are likely to be repeated. Through
this you address the behavior and not the person. Addressing a student concerning the fact that
they heavily relied on notes, had difficulty finding labs values, and appeared like they had not
prepared, does not imply that you dislike them as a person. However, if you merely tell them
they are ―not doing great, and need to get better,‖ you leave them unsure as to what they should
change. Over time they may feel that you are just unfair.
Feedback should be expected. Prepare the learner for feedback sessions by defining your
expectations early. For example, at the beginning of the rotation, or workday let them know that
you will be giving them feedback. You want to avoid the blind side hit on the learner. Consider
arranging frequent scheduled feedback sessions throughout a rotation, and/or after each
procedure. Increasing the frequency limits the amount of information to be discussed, making it
a faster task.
Even with scheduled sessions, feedback still needs to be timely. If something very
important has occurred, it should be addressed while it is fresh in everyone‘s memory. With
time, the details of events are lost and can make feedback less meaningful. Certainly, it is also
S • Specific
O • Objective
M • Modifiable Behavior
E • Expected
T • Timely
L • Limited
C • Constructive
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appropriate to allow some extra time before addressing feedback if things are emotionally
charged, or if there is significant fatigue present in either the learner or educator.
Keep your feedback limited. Covering a large range of topics is difficult and often a
portion of what is discussed may be lost. Frequent feedback sessions that occur on a timely basis
allow you to address behaviors or performance as it happens. This provides a small focused area
to reflect on, which will allow for a more effective discussion.
Finally, feedback should be constructive. Your goal is to help the leaner improve, and
therefore what is discussed should occur for no other reason. While certain discussions may be
uncomfortable for a learner, they should not walk away feeling insulted or demeaned1,3,4
.
Dialogue Education
Consider the Johari Window (see figure 2.). The simple foursquare model graphically
represents what is known and unknown to self, and others. Through dialogue, an educator can
describe what was observed, and discuss what the learner was or was not aware occurred.
Furthermore, the discussion may open up areas that could not be directly observed (student‘s
disclosures) and enrich the quality of training that occurs. As this dialogue occurs, the public
arena where learning occurs increases in size, and the other unknown areas shrink.5
Figure 2. Johari Window
An older method of providing feedback involved the positive-negative-positive sandwich
approach. This has several drawbacks, some that can put off students. First, the learner does not
get a chance to disclose anything, as it is not a conversation. They realize a ―technique‖ is being
used so that they can be told something negative. That sandwich is not very palatable.
However, food is a strong visual so we can go forward with a new type of sandwich (see
figure 3.), which helps you engage in a conversation. Use the soft sequence of Ask-Tell/Teach-
Ask-Act, slightly adapted from Lyuba Konopasek‘s New Feedback Sandwich.
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Figure 3. Adaption of the New Feedback Sandwich6
Consider starting your conversation by asking the learner to assess their own
performance. Typically you could start by asking, ―How do you think that went?‖ It is possible
you will need to probe further so consider ― What do you think went well?‖ or ―Did you
experience any problems?‖ This engages the learner and improves learning through praxis; a
reflection on his action with intent to improve.
The learner may have already stated what was on your mind. If not, now is an
appropriate point in which you can describe what you observed. Simple starts are ―I
observed…‖ or ― It seemed as though…‖ and the classic ―When you do __ I feel __‖ statement.
It is also an appropriate point to discuss short pearls. ―In my experience…‖ or ―Consider…‖ For
example, I have had the benefit of the following sage feedback:
―Kris, when you are presenting you sometimes speak too quickly, and people can‘t keep
up with what you are saying. Consider taking a deep breath before starting, and consciously try
to slow down (and drink less caffeine).‖
Providing some brief comments can be helpful, but the best learning occurs when the
student provides the solution. Rather than asking them to repeat your comments ask ―What do
you think of my observations?‖ or ―what will you do differently now?‖ and ―What can we do to
improve?‖6
Now that you have had a good conversation relaying effective feedback using SOME
TLC you are not done. The best demonstration of learning is improving or modifying the
behavior appropriately. Learning is a cycle, so trust and verify that your learner understood.
Hopefully you have gained the learners confidence by being open, and the learner has taken
away salient points that will improve patient care.
A Tastier Sandwich
Given the increasing restrictions on work hours in graduate medical education7, we need
to effectively and efficiently maximize all learning opportunities. We cannot afford to be set on
broadcast only. We must engage our students through active learning techniques. We have
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established that feedback is essential. Through SOME TLC you have the framework to apply
principles of effective feedback. Using dialogue you have the ability to engage your learner in
self-reflection, as well as determine information that is unavailable to you. The ultimate goal of
feedback is clear communication. Now the awkward moments of silent expectation can be
replaced with a mutually beneficial conversation.
References
1. Ende J: (1983) Feedback in clinical medical education. JAMA 250(6):777-81
2.Weiner N., (1950) The human use of human beings in cybernetics and society. Boston: Houghton Mifflin Co., pg
71. 3.Miser, W.F. (1999) The Family Physician as Teacher - Giving Effective Feedback. The Ohio Family Physician.
Vol. 51, no. 8: 12-13
4.Bui, T., Sanchack, K., (2010) Giving Effective Feedback. Fall Faculty Development Presentation
5.Luft, J. and Ingham, H. (1955) "The Johari window, a graphic model of interpersonal awareness", Proceedings of
the western training laboratory in group development. Los Angeles: UCLA 6.Konopasek, L., (2009) Using the New
Feedback Sandwich to Provide Effective Feedback. Presentation available at
sklad.cumc.columbia.edu/acgme/toolbox/toolbox43/mod_4.ppt accessed 10DEC2010
7.Nasca, T., Day, S., Amis, S., (2010) The new Recommendations of Duty Hours from the ACGME Task Force N
Engl J Med 363:e3 published on website http://www.nejm.org/doi/full/10.1056/NEJMsb1005800. (Accessed
10DEC2010)
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Chapter 6
Small Groups and Effective Discussions
Faculty Development Series Madigan Healthcare System
Tacoma, Washington 98431
103
Small Groups and Effective Discussions
Checklist for the Group Leader
Before the Session....
___ 1. Review the suggested eight steps of planning for this presentation.
___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.
___ 3. Duplicate and distribute the LNRA to faculty.
___ 4. Have faculty return the LNRA at least 5 days before the session.
___ 5. Review the faculty LNRA prior to the session.
___ 6. Modify the suggested eight steps and write your plan to fit your needs.
___ 7. Modify the PowerPoint and handout to fit your plan.
___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation
forms, and handouts.
During the Session....
___ 9. Have each participant sign-in using the attendance roster.
___ 10. Distribute the handout(s) to the participants.
___ 11. Conduct the session based on your eight steps of planning.
After the Session....
___ 12. Collect the evaluation forms from the faculty.
___ 13. Keep the attendance roster for the session in your department and provide the
appropriate amount of CME to each participant.
___ 14. Reflect on the seminar - How did it go? What was good about it? What could have
been better? Is there a better approach to this topic? Were there needs identified during
this session that would be the basis for future seminar(s) in your program?
___ 15. Where will your program go from here based on this seminar?
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Learner Needs and Resources Assessment
Please complete the following needs assessment for the upcoming seminar on Small Group Teaching as
part of your faculty development program.
The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, and
small group discussions.
The purpose of this needs assessment is to determine your learning needs and interests, so that the
seminar is most useful for you. This needs assessment should also stimulate you to think about active learning before the seminar begins. We need your enthusiastic participation now, and in the seminar. It
will be fun, and at the end of it, we'll be asking for your feedback!
Please turn this in to your group leader (______________) no later than (_____________). Your group leader will return this form to you at the beginning of the session.
1. Have you had any formal training in leading an effective discussion? Yes/ No 2. What do you already know about leading effective discussions? Answer briefly below:
a. What are the disadvantages of small group discussions?
b. What are the advantages of small group discussions?
c. What are four major steps in leading a group discussion?
1. 3.
2. 4.
d. What are some facilitative behaviors in leading a group discussion?
1. 3.
2. 4.
3. Think about the various small group teaching sessions used in your program. Which one(s) are effective, and which one(s) need some work? Be prepared to share your thoughts with the group during the seminar. 4. What 3 things do you most want to learn or discuss regarding leading an effective discussion?
1.
2.
3.
5. Any other comments, concerns, or interests for this topic?
105
ATTENDANCE ROSTER – Page____of_____Pages
Department: ____________________ Institution:____________________
Title of CME Activity: Faculty Development Workbook Series – Small Groups- Effective Discussions
Course Content: Didactic and Group Discussion
Instructor (Group Leader):____________________________
Date:____________ Time: Began___________ Ended________ Total ___________
Name Rank
Check One Department or Mailing
Address Staff
Physician
Resident
Physician
Other
Professional
Discipline
Total Number of Learners Attending This Activity: _________
106
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful.
107
Small Groups – Effective Discussions
Example Eight Steps
The eight steps presented below may be used as a guide for your planning.
Modify these steps to meet your specific needs.
Who: 20 faculty learners from the Department of Family Medicine.
Why: Review techniques for small group teaching, as part of Faculty Development
Series.
When: 0730-0900 on a Wednesday morning, blocked schedule for faculty development.
Where: Classroom, individual desks, accessible, AV supported, requires own computer.
What: Driven by the LNRA and:
Classification of learning
Cognitive levels of learning
SWOT analysis of small groups
Steps for leading a discussion
Using questions
What For: By the end of this session, we will have:
Reviewed classification of learning, and levels of cognitive learning
Performed SWOT analysis of small groups
Described methods for leading small group discussions
Reviewed appropriate use of questions
Practiced leading small group discussions
How: General: Active learning: small group activities and discussion, larger group
discussion, minimal PowerPoint slides. Room contains individual desk. Will pre-
configure desks into larger half-moon shape. Within larger half-moon
configuration, will group four desks in smaller half-moon shape for five groups of
four learners each. This will facilitate small group activities followed larger
group discussions. The session will take place at 0730, so will provide coffee and
bagels.
Induction task #1- opening slide notes pictures can be used for focused Group
Discussions. Next slide shows 2 paintings, ask crowd if they recognize either. If
not note that they represent a very specific medical condition. Give them a few
guesses. Introduce the paintings as representation of fibromyalgia. Discuss how
similar painting used during acupuncture class. Ask what aspects of picture might
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help you remember key information about Fibromyalgia dx and treatment. (Time
10 min)
Input#1 Classification of Learning, Level of cognitive learning
Activity #1- SWOT analysis of effective discussions
Input #2 Steps for leading effective discussion
Activity #2 List types of questions
Input #3 Review of questions
Implementation Activity #3a&b– 2 group discussions, topics on cards, first
round with background info, but on obtuse subject, second round without
background information on cards, but on a common subject
Integration – closing, asking them how they plan to incorporate, and comment on
what they believe will help them to be successful
Review questions from LNRA to determine if all questions answered, and
determine if any new questions generated.
So What:
Learning: Learners understand characteristics of small groups and leading
effective discussions. Improve understanding of how small groups functions in
learning including strengths, weaknesses, opportunities and threats. Steps of small
group leadership and the use of questions to facilitate the process.
Transfer: Learners build upon their previous experience by practicing during this
session leading and participating in small groups. They will then try to commit to
use of small groups, with proper preparation.
Impact: Departmental clinical teaching is enhanced, improved learning and
success for residents.
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Small Groups Handout
DEPARTMENT FACULTY DEVELOPMENT
Kristian Sanchack, MD
#1 – Fill in the SWOT analysis
#2 – Write down different types of questions
1. ________________
2. ________________
3. ________________
4. ________________
5. ________________
6. ________________
7. ________________
8. ________________
9. ________________
10. ________________
11. ________________
12. ________________
• ________________
• ________________Strengths
• ________________
• ________________Weakness
• ________________
• ________________Opportunities
• ________________
• ________________Threats
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#3A&B Pick a Card. Lead the discussion!
Is a Mandatory Influenza Program effective and appropriate in the healthcare
delivery setting?
Influenza Vaccination is the most effective means to prevent seasonal flu infection. (70-90%
effective in <65, 30-70% effective preventing hospitalization in >/= 65, and in nursing home >65
30-40% against infection, 50-60 against infection, 80% against death)
-Fewer than half of healthcare workers report getting vaccinated (CDC current reports) and
Influenza outbreaks in hospitals have been attributed to low vaccination rates among healthcare
professionals
-1991-92 65 resident of long term facility acquired flu, 19 hospitalized, 2 died with only 1:10
workers immunized, NICU 19 infected,1 died, workers with only 15% rate vaccination, Internal
med ward 23 % of staff became ill- total cost ended up at $35,000 to institution.
-Best voluntary efforts get vaccination rates to about 40-60% (80% of direct workers)
-Multiple studies demonstrating flu vaccination of health workers cost effective or cost neutral,
at the above rates of 40-60%-generally take 80-90% to achieve herd immunity, but does this
apply in healthcare setting?
-Virginia Mason achieved 98% in first year of mandatory program. lawsuit from union though,
after lawsuit though inpatient nurse still near 100% rates despite their union exemption
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Can Social Media and Web 2.0 be effective forms of patient communication and
healthcare delivery?
-Web 2.0 technologies provide a level user interaction that was not available
before. Websites have become much more dynamic and interconnected, producing "online
communities" and making it even easier to share information on the Web.
-Patients are already on the web interacting with other patients, providers for the most part are
not.-2006 survey noted that about 8 million Americans searched the web for healthcare
topics...PER DAY
-As of May 2011 there are over 3200 Hospital Social Networking sites-McKinsley Quarterly
noted that businesses who intensely adapted to Web 2.0 benefitted by gaining greater market
share and improved margins.
-UK has patient led disease management groups that heavily use web based social media-Patient
satisfaction and feedback outlets?-Secure portals for virtual "home visits"
-Entrepreneurs such as Hello Health already heavily using services...
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The US and New Zealand are the only two countries where direct to consumer (DTC)
advertising of prescription drugs is legal. In the US, these ads are regulated by the Food
and Drug Administration (FDA) to ensure that they are not false or misleading. What are
the pros and cons of DTC advertising? Is DTC advertising ethical?
44,000-98000 deaths per year are attributed to medical errors in our country. This ranks
respectively about 4th on leading cause of death in the United States. These numbers have not
appreciably changed in 10 years. One consideration is that there are no limits on fully trained
physician work hours. What are the pros and cons of limiting fully licensed and trained provider
work schedules? Do you believe it would have an impact on medical errors?
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#4 – Did we answer everyone’s question? Check the boxes if so.
If not, let’s talk!
List three things you would most like to learn about leading effective discussions.
(Actual responses from LRNA)
I am prepared to be dazzled
Coordination, planning and after action review.
Staying on topic/focus Facilitating = leading. I am great as part of a group but not so
good at always facilitating! Learn how to have good discussions with leadership that is
not effective.
How to lead w/o giving answers 2. How to engage the non-participants 3. How to
motivate faculty to participate
should I start with a specific end in mind?
How to moderate the room when multiple small groups are working. How to deal with
negative personalities (the whiner, sniper, naysayer, etc) How to structure the discussion
without fully controlling it
How to keep the discussion on track. 2. How to get all to participate. 3. How to manage
time in the discussion.
is the socratic method acceptable for leading discussions? Is it "safe" to call on people
rather than asking for volunteers?
How to keep it interesting. How to keep participants engaged. How to keep the group on
task.
organizing the talk steering the group back on track
Setting the agenda, staying on task, establishing when a small group discussion is
appropriate.
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Supporting References and Resources
Small Groups and Effective Discussions
TEACHING AND LEARNING
Effective Small Group Discussions
USAFP Winter 2007
By DEBRA A. MANNING, M.D.
Faculty Development Fellow
Department of Family Medicine
Madigan Army Medical Center, WA
Medical students and residents are faced with the daunting challenge of mastering a vast
amount of cognitive knowledge. Along the way, they need to develop the behaviors and values
that foster ongoing professional development as physicians. There are many methods for
imparting such knowledge including formal lectures, reading assignments and one-on-one
teaching. One of the best ways to share information and develop longitudinal learning behaviors
is small group discussions.
Adult learners are independent, self-directed, and have a great deal of experience to bring
to small group learning. Small groups encourage everyone to participate, which increases the
participants‘ motivation to learn.1 Participants also help to shape the discussion, allowing them a
sense of control in their learning. Talking through moral issues and difficult cases helps the
students develop ethical standards. Discussions can change attitudes and lead to self reflection.
Students develop their communication and problem solving skills, thus facilitating their learning.
Small groups vary in size, but typically have three to fifteen people. They are particularly
effective for inpatient rounds, ethical discussions and after clinic conferences. Small group
discussions allow instructors to measure retention of the material and create the opportunity for
immediate feedback. Small groups provide an excellent setting for teaching values that need to
be developed over time.
Small group discussions are not without disadvantages, however. Small groups are not
well suited for covering large amounts of material. In this case, a lecture or handout would be
better. Those running small groups often complain that it can be time consuming as it often
requires more preparation. Instructors have less control in this situation, which may make them
uncomfortable. Planning for the discussion and recognizing the success of small groups will help
alleviate this discomfort. Some introverted participants find it challenging to participate in small
groups.
There are four steps to effective small group learning.2,3 The first is preparation. The
instructor may want to do a Learning Needs Assessment of the group to determine current level
of knowledge and to allow the students to participate in developing the goals and objectives of
the discussion. Instructors need to determine the size of the group, the discussion format and the
115
setting. Simple details such as having everyone face each other, facilitate a better discussion.
Instructors must also anticipate the wide range of material that could arise in the discussion and
research these areas if needed.
The second step in effective small groups is getting the discussion started. The instructor
should begin by establishing a safe learning environment where mutual respect and participation
are expected. They should introduce the topic, goals and agenda thus providing a sense of
direction for the discussion. Getting the discussion started requires gaining the students‘ attention
and motivating them to learn.
The next step is to facilitate the discussion. Good instructors facilitate rather than lecture.
This requires patience in allowing the conversation to develop. Knowing the students and their
level of knowledge is important. It is important to be flexible, supportive and a good listener.
Facilitators should clarify issues, mediate disputes and summarize key concepts. Requesting
examples to clarify points and testing group consensus are important behaviors in leading small
group discussions. Facilitators should not be threatening as this destroys the safety of the
learning environment. One technique for encouraging participation is allowing silence. People
become uncomfortable with silence, and eventually someone will begin to talk.
One of the hardest challenges in facilitating small groups is managing different
personalities in the group.5 For introverted participants, the instructors should look for
opportunities to bring these students into the conversation in a nonthreatening manner. ―Do you
have anything to add?‖ Some participants easily stray from the topic and it is important to
refocus the discussion. ―While this is an interesting and important issue to discuss, I would like
to get back to today‘s subject matter.‖ When dealing with students who dominate the
conversation, it may be best to speak to them on a break. ―I appreciate your enthusiasm, but I
want to give everyone else a chance to participate.‖ This helps maintain the safety of the learning
environment.
When facilitating small group discussions, instructors should take care when asking
questions. Questions should be stated clearly, and asked only one at a time. Students should be
given time to allow them to formulate an answer. Questions are either convergent or divergent.4
Convergent questions ask students to pool their knowledge to answer a question. ―What are the
drugs used when treating an acute myocardial infarction?‖ In contrast, divergent questions are
used to promote further discussion. ―Should parents be allowed to refuse life saving procedures
for their children?‖ Divergent questions are useful when discussing ethical situations.
Questions can also be used to assess students‘ level of knowledge. ―What are the classes
of antihypertensive medications?‖ Other questions determine if students can apply knowledge to
a situation. ―Which medication would you use in a newly diagnosed hypertensive African
American male?‖ Finally, problem solving questions ask students to go through complicated
scenarios, drawing on their fund of knowledge and ability to apply the information. ―Your
patient was admitted for an acute GI bleed and is now having a heart attack. What would you do
and why?‖
116
Facilitators use other types of questions to prompt, justify, clarify or redirect the
discussion. Prompting questions are open-ended and stimulate the discussion. Justification
questions have the students defend their thoughts or ideas. Sometimes a thought has not been
clearly stated, and the facilitator may need to have the student give a better explanation.
Extension questions are used to take the students one step further in their thinking. This can
include having them apply their knowledge to different but related experiences.4
The final step in effective small group learning is to conclude the discussion. Facilitators
should leave enough time to summarize key points and bring closure to the discussion. Each
student should leave with a clear understanding of the most important ideas discussed. There are
times when consensus is not reached, and this is acceptable. Closure can include agreeing to
disagree. Instructors should allow time for feedback. Knowing what worked and did not work in
the discussion will improve the next small group. Small group discussions are one of the best
ways to impart the knowledge, skills and the values necessary to practice medicine. Small groups
are the epitome of adult learning theory allowing for active participation in learning and the
sharing of experiences. Effective small group discussions require preparation, facilitation,
respect and enthusiasm.
References
1 Haugen, L. (Mar 1998). Suggestions for Leading Small-group Discussions Center for
Teaching Excellence, Iowa State University.
2 Steinert, Y. (Sep 1996). Twelve tips for effective small-group teaching in the health
professions. Medical Teacher, Vol. 18, Issue 3.
3 Pasquarella, M. (Nov 1996). Small Groups – Effective Discussions. MAMC Faculty
Development Fellowship Video Series.
4 Hyman, R. (Aug 1992). Questioning in the College Classroom. Kansas State University Center
for
Faculty Evaluation and Development IDEA Paper No. 8.
5 Newble, D. & Cannon, R. (2001) A Handbook for Medical Teachers, Fourth Edition. Springer,
New
York.
117
118
§ prompting
§ extension
§ justification § redirection
§ clarification
§
Dynamics of questioning
§ phrase questions clearly § allow ample wait time
§ one question at a time
§ maintain eye contact with others in class
§ ask question, then call on student
§ participation from the group § controlling excessive talkers
§ solicit responses from the non-talkers
References
Freightner JW: Solving problems: how does the family physician do it? Can Fam Phys 1977;
23:457. . Foster PJ: Clinical discussion groups' verbal participation and outcomes. J Med Ed 198 1; pg 56.
Hyman RT: Questioning in the college classroom. Kansas State University 1982; pg 129-32. A
Olmestead JA: Methods of small group discussion. Theory and Practice 1979; pg 99-107.
119
120
Chapter 7
House Officer Evaluation
Faculty Development Series
Madigan Healthcare System
Tacoma, Washington 98431
121
House Officer Evaluation
Checklist for the Group Leader
Before the Session....
___ 1. Review the suggested eight steps of planning for this presentation.
___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.
___ 3. Duplicate and distribute the LNRA to faculty.
___ 4. Have faculty return the LNRA at least 5 days before the session.
___ 5. Review the faculty LNRA prior to the session.
___ 6. Modify the suggested eight steps and write your plan to fit your needs.
___ 7. Modify the PowerPoint and handout to fit your plan.
___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation
forms, and handouts.
During the Session....
___ 9. Have each participant sign-in using the attendance roster.
___ 10. Distribute the handout(s) to the participants.
___ 11. Conduct the session based on your eight steps of planning.
After the Session....
___ 12. Collect the evaluation forms from the faculty.
___ 13. Keep the attendance roster for the session in your department and provide the
appropriate amount of CME to each participant.
___ 14. Reflect on the seminar - How did it go? What was good about it? What could have
been better? Is there a better approach to this topic? Were there needs identified during
this session that would be the basis for future seminar(s) in your program?
___ 15. Where will your program go from here based on this seminar?
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Learner Needs and Resources Assessment
Please complete the following needs assessment for the upcoming seminar on House Officer
Evaluation, as part of your faculty development program.
The seminar will consist of an introduction by your group leader, a short PowerPoint presentation,
reviewing articles with common standards, and a discussion period.
The purpose of this needs assessment is to determine your learning needs and interests, so that the
seminar is most useful for you. This needs assessment should also stimulate you to think about
evaluations before the seminar begins. We need your enthusiastic participation now, and in the seminar. It will be fun, and at the end of it, we'll be asking for your feedback!
Please turn this in to your group leader (___________________) no later than (_________________).
Your group leader will return this form to you at the beginning of the session.
1. Have you had any formal training in evaluation? YES NO (Circle one)
2. In your opinion, what is the difference between a standard and a goal?
3. When planning an evaluation, what items do you think should be considered?
4. What are 4 main skills that you think should be evaluated?
1 3
2. 4.
5. Complete the following statement..."When I reflect on our department's evaluation system for
residents, I think it provides a/an ______________ assessment." (Circle one answer below)
Extremely Inaccurate Inaccurate Neutral Accurate Extremely Accurate
6. What are some types of errors that can be made in evaluations?
1. 3.
2. 4.
7. What tools are available for making evaluations in your department?
8. What 3 things do you most want to learn or discuss regarding evaluation?
a.
b.
c.
9. Any other comments, concerns, or interests for this topic?
123
ATTENDANCE ROSTER – Page____of_____Pages
Department: ____________________ Institution:____________________
Title of CME Activity: Faculty Development Workbook Series – House Officer Evaluations
Course Content: Didactic and Group Discussion
Instructor (Group Leader):____________________________
Date:____________ Time: Began___________ Ended________ Total ___________
Name Rank
Check One Department or Mailing
Address Staff
Physician
Resident
Physician
Other
Professional
Discipline
Total Number of Learners Attending This Activity: _________
124
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful.
125
House Officer Evaluations Example Eight Steps
The eight steps presented below may be used as a guide for your planning.
Modify these steps to meet your specific needs.
Who: 20 faculty learners from the Department of Family Medicine.
Why: Enhance clinical teaching as part of a required faculty development curriculum.
When: 0730-0900 on a Wednesday morning, blocked schedule for faculty development.
Where: Classroom, individual desks, accessible, AV supported, requires own computer.
What: Driven by the LNRA and:
The importance of evaluations
Essentials of evaluations
Common skills assessed in resident evaluations
Tools of assessment that are valid and widespread
Barriers and difficulties of faculty evaluators
What For: By the end of this session, we will have:
Identified essentials of evaluations
Examined our definition of standards
Listed common skills to assess
Reviewed available tools to assist staff
Recognized potential pitfalls and biases
Practiced with cases
How: General: Active learning through small group activities and discussion, larger
group discussion, minimal PowerPoint slides. Room contains individual desks.
Will pre-configure desks into larger half-moon shape. Within larger half-moon
configuration, will group four desks in smaller half-moon shape for five groups of
four learners each. This will facilitate small group activities followed by larger
group discussions. The session will take place at 0730, so will provide coffee and
bagels.
Grabber: ―You Be the Judge: 2011 X-Game BMX Big Air Competition‖
Break the audience into 3 groups. Explain that each group will act as a judge for
a competition. Explain that each team must give each competitor a score from 1-
10 (lowest to highest). Do not offer any further assistance than these instructions.
Show the crowd a series of short, 1-minute video clips of three separate
competitors from the 2011 X-Games BMX Big Air Competition. Be sure to
pause for 1 minute between each competitor to allow each team to assign a score.
If desired, the leader can tally the scoring and assign place rankings at the end.
However, disregard the numerical values assigned, ask the group as a whole:
How did you come to your rating for each competitor?
What were some of the challenges that you discovered?
Did you notice any biases in your assessments?
126
Induction Task
Why is evaluation important? Encourage the audience to reflect on:
Why they think evaluation of our learners is important?
What problems have they encountered in the past with evaluations?
Input #1
Essentials of effective evaluations.
Activity #1
In pairs, have the audience discuss some of the things that they mentally take into
account before writing a learner‘s evaluation. Use the concept of including what
standard to measure against to transition to the next input topic.
Input #2
Evaluations should be as objective as possible and aim to evaluate specific skills.
Offer specific examples from ACGME core competencies.
Activity #2
1) Have the audience break up into their 3 original groups from the Grabber
exercise. Give them a deck of skill cards (included in this chapter). Ask the
group to put the skills in a rank order from most important to least important.
Have them write their rankings on butcher block or a white board to display.
2) Display the most common answers from most important skills on the LNRA
on PowerPoint. Compare the LRNA answers to the group displays and
comment on similarities and differences. Conclude that the group as a
department likley has culturally weighted preferences of skills to evaluate but
that all are important in different circumstances.
Input #3
Show audience LRNA results of their defintions of what a standard is. Ask
the group if one of the examples speaks to them more than others.
Transition to generally accepted components of measurable standards.
Activity #3
In pairs, distribute copies of different standards that are employed at their
departments (examples included in this chapter). Have them review the standards
and ask the following questions relating to the key components of effective
standards:
Are they written?
Are they shared with staff and residents at key time periods?
Are they understood?
Are they current and relevant? Have they been updated and improved
recently?
Summarize findings and comment on possible refinement of some of these
utilized standards.
127
Input and Task #4
Display a list of some common assessment tools that are available to faculty.
Ask the large group to discuss some of the pros and cons of a few of them.
Input #5
One of the main pitfalls in evaluation lies within evaluator bias.
Activity #5
Matching exercise of different bias types.
Ask the large group to comment on:
a. Which ones do they encounter more often
b. How do they avoid these biases?
Implementation Task
Have the audience get back into pairs. Distribute 2 blank evaluation sheets
that their department uses for summative evaluations. Also distribute 2 cases
for the pairs to read and discuss (examples included). Ask the groups to
create an evaluation for each case.
Come together as a large group and ask the audience to comment on:
a. What things they took into account about the case prior to writing?
b. What skills were they evaluating?
c. What standards were they using to measure?
d. Where there potential biases involved?
Integration Tasks:
Display the results of the LRNA question regarding their feelings of how
accurate their department‘s evaluation system assesses its learners.
Ask the group (time permitting) to brainstorm to processes that could be used
to improve evaluations. What personal changes will they commit to for
upcoming evaluations?
So What:
Learning: Learners understand characteristics of effective evaluations.
Introduced key components of evaluations and standards. Established that there
are several types of evaluations that can target specific skills. Explored personal
and organizational biases to avoid their impact on accuracy.
Transfer: Learners build upon this knowledge and improve their upcoming
written evaluations. They will commit to improve their evaluations through
increased planning pertaining to their student‘s personal situation, specific skills,
use of standards, and awareness of personal biases
Impact: Departmental evaluations are enhanced, department standards are
reviewed, leading to improved learning and success for residents.
128
House Officer Evaluation
Handout
Opening Activity – Why Evaluate?
Learning Task 1 – With the End in Mind: Evaluation Essentials
Take Home Points
• Evaluations are azimuth checks for a desired endpoint
• Incorporation of standards is key
• Attempt to assess specific skills
• Be aware of our personal biases that can affect assessment
• Use the tool box
• Communicating that evaluation is essential
On your own, provide answers to the following questions:
1) Why do you think evaluation is important?
2) What problems have you encountered in the past with evaluations?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_________________________________________________________________________
In pairs, discuss some of the things that you mentally take into account before writing a
learner‘s evaluation.
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
129
Learning Task 2 – Ranking Our Learner’s Skills
Learning Task 3 – A Review of Our Standards
Nuts and Bolts of Standards
Written - Written standards help to ensure that they are deliberate and rational. Once
they are written, it is possible to ensure that standards are upfront and understood and
reviewed.
Up Front – Standards are shared with the learner and discussed prior to intervals.
Understood – Learners and teachers must understand the standards.
Reviewed – Standards should be reviewed on a regular basis to ensure awareness and
relevance.
In pairs, assess your assigned set of standards by answering the following:
1. Are they written?
2. Are they shared with staff and residents at key time periods?
3. Are they understood?
4. Are they current and relevant? Have they been updated and improved recently?
In your original three groups:
1. Discuss the deck of cards that contain skill sets of our learners.
2. Put them in a ranked order from highest to lowest on your scale of importance.
130
Learning Task 4 – Knowing Our Bias
___ Recent Incident Bias A. Being overly critical
___ Central Tendency B. Sitting on the fence of avoiding the
extreme anchors on a scale for fear of being
too strong
___ Extreme Response Bias C. The opposite of central tendency bias.
Respondents tend to mark extremes rather
than those in between. It is difficult to know
honest ratings from the halo effect
___ Affirmation/Yea-Saying Bias D. A potential for negative bias against a
trainee because of an isolated recent negative
incident or statement, which does not
necessarily reflect the usual work ethic of
that person
___ Incompetence Bias
E. Being overly charitable
___ Leniency Bias F. Occurs when evaluators assign high
ratings because of lack of confidence or
competence
___ Halo Effect G. The tendency to give positive responses
irrespective of their context, also known as
inflation of ratings
___ Contrast Bias H. A rater's overall impression of a person
will affect his or her rating on each item
___ Stringency Bias I. Rating against another person's
performance rather than a standard
131
Examples of Additional Handouts Needed
Example of Skill Cards for Learning Task 2
132
Examples of Different Standards to Review in Learning Task 3
133
134
Minimum Program Requirements Language
Approved by the ACGME, September 28, 1999Educational Program
The residency program must require its residents to obtain competencies in the 6 areas below to the
level expected of a new practitioner. Toward this end, programs must define the specific knowledge,
skills, and attitudes required and provide educational experiences as needed in order for their
residents to demonstrate:
Patient Care that is compassionate, appropriate, and effective for the treatment of health problems
and the promotion of health
a. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g.
epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
b. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
c. Interpersonal and Communication Skills that result in effective information exchange and teaming
with patients, their families, and other health professionals d. Professionalism, as manifested through a commitment to carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to a diverse patient population
e. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and
responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value
f.
Evaluation
Evaluation of Residents
The residency program must demonstrate that it has an effective plan for assessing resident
performance throughout the program and for utilizing assessment results to improve resident
performance. This plan should include: a. Use of dependable measures to assess residents' competence in patient care, medical knowledge,
practice-based learning and improvement, interpersonal and communication skills, professionalism,
and systems-based practice
b. Mechanisms for providing regular and timely performance feedback to residents c. A process involving use of assessment results to achieve progressive improvements in residents'
competence and performance
Programs that do not have a set of measures in place must develop a plan for improving their
evaluations and must demonstrate progress in implementing the plan.
Program Evaluation The residency program should use resident performance and outcome
assessment results in their evaluation of the educational effectiveness of the residency program.
a. The residency program should have in place a process for using resident and performance assessment
results together with other program evaluation results to improve the residency program.
135
Example Cases for Integration Task
Case 1
Dr. TB has an appropriate fund of knowledge and clinical skills for a second year resident. He
recently received his ITE scores and was pleased with his 92nd percentile performance.
However, during this past FM Clinic rotation he was frequently noted being late for work by the
nursing staff. The FMIT attending mentioned in last week‘s staff meeting that he left a
significant amount of work for the incoming residents who were relieving him after an overnight
call shift. His chart audits demonstrate adequate documentation; however, they were rarely
closed out within the required 72 hour period. Despite these concerns, two staff attendings
created voluntary precepting evals during this rotation containing very positive comments. One
specifically noted his ability to organize his H&P during an oral presentation, offer a broad
differential diagnosis, and devise an appropriate A/P. The second evaluation commended Dr. TB
on his pleasant demeanor and effective negotiating skills with a patient threatening to call the
patient advocacy office after she waited for 40 minutes in the waiting room.
Case 2
Dr. LB is a diligent resident who is half way done with her first year of Internship. She
routinely arrives to work early and stays late. As her current attending physician, you have
received several positive, unsolicited comments from the ward nurses about her professionalism
with the nursing and nursing staff. You have personally been asked by one of the ward patients
if she could change her PCM to Dr. LB because of her outstanding bedside manner. Yet, she has
struggled on her current clinical rotation (FMIT), lagging behind her peers in her fund of
knowledge and her ability to synthesize clinical laboratory, and radiographic data. Her daily
progress notes reflect this with limited expansions of DDx and A/P. Her November ITE score
placed her in the 50th percentile overall. Although still in the early stages of residency training,
she is already involved in a research project with an attending staff. Upon discussion with LB, it
was learned that she lacked basic time management skills and that she was having difficulty
juggling her clinical training with her research interests and personal life.
136
Example of Blank Summative Evaluation Tool for Integration Task
137
138
139
Supporting References and Resources
House Officer Evaluation
Jeff Clark, M.D., LTC, MC
Madigan AMC Faculty Development Fellowship
November 1996
PURPOSE OF PRESENTATION: The purpose of this talk is to discuss the importance of first
establishing the endpoint of the training program and delineating standards to ensure our learners reach that endpoint. Evaluation serves to ensure that standards are met while feedback guides future
performance so that our learners meet our established endpoint.
INTRODUCTION: An evaluation must be designed with the end point in mind and be based on appropriate standards. For this reason, prior to discussing evaluation, it is important to take the time to
determine the end point of the training program. What are you striving for? This end point will direct the
standards you establish.
EVALUATION
―to examine and judge; appraise‖
Is distinct from feedback, evaluation is a judgment of performance-
o Were established standards met?
In contrast, feedback provides information, ideally in a nonjudgmental tone, which is to be used
to guide future performance. Feedback is intended to shape future behavior, evaluation
documents that standards have been met.
Evaluation means to decide if the learner has met the standards for the residency, year of training,
rotation, etc. It is not an end in itself but a means to assure that your learners meet your established standards and reach you end point. Evaluation serves to assure residents are meeting the standards and to
provide guidance to: maximize potential and support continued growth.
Why Evaluate?
Obligation to society: We are stating that the learner who successfully completes our
training program is qualified to practice our specialty. For individual rotations, we are saying
whether or not the learner has met established standards for specific clinical competencies.
Obligation to our peers: A learner who completes our training program is receiving our
stamp of approval and is ready to join others in our specialty in the practice of medicine.
Obligation to the military: An officer/physician who completes our training program is
ready to care for active duty and family members-the reason our corps exists.
Types of Evaluation
FORMATIVE: an interim assessment of performance used to provide feedback.
SUMMATIVE: a judgment of competency or effectiveness used to document that established
standards have been met.
o Examples include end-of-rotation and quarterly evaluations.
Essentials of Evaluation
The essentials of evaluation are those critical items which should be a part of every learner appraisal.
They are important for learners who exceed established standards and for those may be struggling to meet
your requirements.
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1. Formal
Written, explicit standards for every rotation and learning activity written, explicit summative
evaluation procedures,
o rotation evaluations, quarterly evaluations, and yearly evaluations
2. Communication
An open dialogue between the learner and evaluator is essential
Frequent FORMATIVE evaluations
Regular, scheduled SUMMATIVE evaluations
Evaluation is understood, documented, and explicit
3. Documentation
Summative evaluations are written and signed
Plans to monitor and assist are written and signed
4. Due Process
Written and understood standards
Explicit evaluative process - frank and fair evaluations
Plans to monitor and assist are written, understood, and signed
Consequences of failing to meet established standards are explicit
Formal, communication, and documentation are the essentials of due process
START WITH THE END POINT "If we do not know where we are going, it is difficult to select a suitable means
of getting there, or, for that matter, even know if or when we have arrived."
RF Mager Preparing Instructional Objectives
The end point determines the standards. Standards determine what will be evaluated. Evaluation and
feedback ensure our learners reach our established end point.
END POINT
Something worked toward or strived for; the object of a course of action.
What is the end point of your residency training program?.
This is a fundamental question. The answer will drive, via standards, what will be evaluated.
After a learner has completed your training program what do you want as the end point? In other
words, what qualities/skills/capabilities do you want her/him to possess? Do you want a
physician capable of passing the boards? Probably so, but you may want more than that. You
may want her/him to be a "good doctor." Defining what you mean by "good doctor" will go a
long ways towards defining the end point o The required qualities/skills/capabilities of graduates of your training program.
STANDARD A degree or level of requirement, excellence, or attainment. Of acceptable quality.
It is important to note that a standard is not a goal. Our goal may be that our residents are the very best in the galaxy but the standards we establish are designed to ensure that they meet the end point as we have
defined it. (e.g., the goal may be that all residents score 99% on the in-service exam, but the standard may
be a reasonable requirement such as 25%, 40%, 60%, etc.)
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Sources of Standards American Board of Your Specialty Residency Review Committee Hospital or
University System Residency Program
Your training program should have standards for the residency, for each year of training,
for each rotation, and for each learning activity.
Essentials of Standards
1. Written
Writing down standards helps to ensure that they are deliberated and rational once written it is
possible to ensure that standards are upfront, understood, and reviewed
2. Up front
Shared with the learner and discussed prior to beginning the residency, promotion, each rotation,
each learning activity, etc.
3. Understanding
Learners and teachers must understand the standards if they are to be met.
Consider having both sign that the standards have been read and are understood
4. Reviewed
Standards should be reviewed on a regular basis to ensure that all are aware and that established
standards are still relevant and current.
Types of Standards Listed are 4 types of standards which may be included within the standards for a training program,
rotation, etc. or may be used as you evaluate the critical qualities/skills/capabilities you have determined
you want your graduates to possess.
1. Performance Standards
fund of knowledge
ability to do a history & physical
technical skills
humanistic/interpersonal skills
clinical judgment ability to recognize limitations
2. Standards of Conduct
honesty
substance abuse
appropriate relationships with patients
responsibility
attendance
3. Standards for Learning Activities
required readings
proficiency in technical skills
call
appropriate level of clinical judgment
minimum "score" on the evaluation form indicating a required level of proficiency
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4. Promotion Standards
based on rotation/learning activity evaluations
based on in service exams
based on summations of performance such as rotation and quarterly evaluations
"THE TERMINATORS" These violations will lead to termination. These are most often standards of conduct. If a learner will be
terminated from your training program for a specific type of conduct, it is critical that this
violation be written, upfront, understood, and reviewed.
Standards are based on the end point of the training program—what qualities/ skills/ capabilities do you want your graduating residents to possess?
Standards establish the criteria and level of attainment by which the learners will be evaluated to ensure that they reach the established end point.
Essentials of Evaluation
The essentials of evaluation are those critical items which should be a part of every learner appraisal. They are important for learners who exceed established standards and for those may be struggling to meet
your requirements.
5. Formal
Written, explicit standards for every rotation and learning activity written, explicit summative
evaluation procedures,
o rotation evaluations, quarterly evaluations, and yearly evaluations
6. Communication
An open dialogue between the learner and evaluator is essential
Frequent FORMATIVE evaluations
Regular, scheduled SUMMATIVE evaluations
Evaluation is understood, documented, and explicit
7. Documentation
Summative evaluations are written and signed
Plans to monitor and assist are written and signed
8. Due Process
Written and understood standards
Explicit evaluative process - frank and fair evaluations
Plans to monitor and assist are written, understood, and signed
Consequences of failing to meet established standards are explicit
Formal, communication, and documentation are the essentials of due process
How Do We Evaluate?
Objective testing via in-service exams; specialty boards
End of rotation evaluations
Quarterly evaluations (example provided)
Formal oral examinations and written examinations; often used at the end of a rotation or
other types of learning activities
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Simulated patients - the simulated patient and/or an observer may evaluate the learner
Videotaped encounters
Patient evaluations of our learners
Nurses, admin staff, and others who are in a position to evaluate aspects of the
skills/qualities/capabilities you have deemed important Nurses and other members of the staff are
often in a better position than physicians to evaluate such standards as patient-physician interactions, staff interactions, timeliness, efficiency, etc.
Credibility and reliability of the evaluation are a function of the number of observations. Use many sources (faculty, nurses, admin clerks, patients). Inter and intra- observer reliability increases the
likelihood that the evaluation will reflect performance and assure that standards are met.
When to Evaluate?
After each rotation and learning activity - mid-rotation evaluations (these are usually formative
evaluations) are a good time to discuss whether standards are being met and develop plans to
monitor and assist
Monthly with the faculty advisor – meets with the learner to discuss the completed rotation to see
if standards were met - this is a good time to review the standards, goals, and objectives for the
upcoming rotation
Quarterly with the faculty adviser - usually used as a "big picture" summative evaluation to
maximize the potential of the learner, support continued growth, and monitor and assist as needed
Yearly with the program director - again, a "big picture" summative evaluation which allows the
director to monitor and assist each learner prior to graduation - this evaluation should be a
summation of all previous evaluations and can be used to promote continued learning. There should contain no "surprises" for the learner at this point
Potential Errors in Evaluation - you may remember examples of these from your training and or faculty experiences:
Stringency: being overly critical
Leniency: being overly charitable
Bias/contrast: rating against an individual rather than the standard
Logical error: allowing rating in one area to influence another area
Halo effect: global impression influences a specific rating
Central tendency: sitting on the fence
SUMMARY Evaluation is the process of deciding whether established standards have been met. The essentials
(formal, communication, documentation, and due process) are important in the evaluation of all learners.
There are a variety of appropriate methods (examples are provided) and times for evaluating learners. The key is to evaluate against established standards. Evaluation is not an end in itself. It is a tool, as is
feedback, to ensure that your graduates reach your established end point. This end point of specified
qualities/skills/capabilities of your graduates will determine, via standards, what is to be evaluated.
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REFERENCES Krick JP and J Sobal. The role of the Faculty Adviser in a Family Medicine Residency. Journal
of Medical Education. 60 (1985): 60-62.
Discusses consensus and differences between learners and faculty in their perceived roles of the
faculty adviser.
Short JP. The Importance of Strong Evaluation Standards and Procedures in Training Residents.
Academic Medicine. 68 (1993): 522-525.
Outstanding reference which discusses the importance and types of standards. Provocative and
well written.
Epstein RM. Assessment in Medical Education. N. Engl J Med 2007; 356:387-96. Overview of
education assessment with focus on tools developed to avoid evaluator bias.
Berk, RA. The Secret to The ―Best‖ Ratings from Any Evaluation Scale. Journal of Faculty
Development. 2010; 24: 37-39
Great summary of bias types with examples seen in evaluations
ACGME. Toolbox of Assessment Methods. ACGME Outcomes Project 2000. 1-21
Resource of different evaluations tools and methods acceptable by ACGME with pros and cons
of each type.
Ginsburg S. Toward Authentic Clinical Evaluation: Pitfalls in the Pursuit of Competency.
Academic Medicine 2010; 85: 780:786
Recent study of 19 internal medicine program directors with patterns of pitfalls in clinical
evaluations.
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Chapter 8
The Teaching Clinic Preceptor
Faculty Development Series Madigan Healthcare System
Tacoma, Washington 98431
147
The Teaching Clinic Preceptor
Checklist for the Group Leader
Before the Session....
___ 1. Review the suggested eight steps of planning for this presentation.
___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.
___ 3. Duplicate and distribute the LNRA to faculty.
___ 4. Have faculty return the LNRA at least 5 days before the session.
___ 5. Review the faculty LNRA prior to the session.
___ 6. Modify the suggested eight steps and write your plan to fit your needs.
___ 7. Modify the PowerPoint and handout to fit your plan.
___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation
forms, and handouts.
During the Session....
___ 9. Have each participant sign-in using the attendance roster.
___ 10. Distribute the handout(s) to the participants.
___ 11. Conduct the session based on your eight steps of planning.
After the Session....
___ 12. Collect the evaluation forms from the faculty.
___ 13. Keep the attendance roster for the session in your department and provide the
appropriate amount of CME to each participant.
___ 14. Reflect on the seminar - How did it go? What was good about it? What could have
been better? Is there a better approach to this topic? Were there needs identified during
this session that would be the basis for future seminar(s) in your program?
___ 15. Where will your program go from here based on this seminar?
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Learner Needs and Resources Assessment
Please complete the following needs assessment for the upcoming seminar on The Teaching Clinic
Preceptor as part of your faculty development program.
The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, and small group discussions.
The purpose of this needs assessment is to determine your learning needs and interests, so that the
seminar is most useful for you. This needs assessment should also stimulate you to think about active learning before the seminar begins. We need your enthusiastic participation now, and in the seminar. It
will be fun, and at the end of it, we'll be asking for your feedback!
Please turn this in to your group leader (______________) no later than (_____________). Your group
leader will return this form to you at the beginning of the session.
1. Have you any formal training on serving as a clinic preceptor? YES NO
2. What do you already know about serving as a clinic preceptor? Answer briefly below:
a. What are some characteristics of a skilled clinic preceptor?
1. 3.
2. 4.
b. What are some common pitfalls for the clinic preceptor?
1. 3.
2. 4.
3. Have you ever conducted a self-assessment of your precepting abilities? YES NO
4. Has your precepting ever been reviewed by a peer? YES NO
5. What obstacles are commonly faced by clinic preceptors?
6. What three things do you most want to learn or discuss regarding precepting in teaching clinic?
a.
b.
c.
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ATTENDANCE ROSTER – Page____of_____Pages
Department: ____________________ Institution:____________________
Title of CME Activity: Faculty Development Workbook Series – The Teaching Clinic Preceptor
Course Content: Didactic and Group Discussion
Instructor (Group Leader):____________________________
Date:____________ Time: Began___________ Ended________ Total ___________
Name Rank
Check One Department or Mailing
Address Staff
Physician
Resident
Physician
Other
Professional
Discipline
Total Number of Learners Attending This Activity: _________
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Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful
Faculty Development Session Evaluation Form
Date Speaker Topic
Please rate the speaker using the scale below:
Strongly
Disagree
Disagree Somewhat
Agree
Agree Strongly
Agree
Content was relevant to my needs
The speaker conveyed the subject matter clearly
The speaker used active learning techniques to
teach this subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, the speaker was effective
List one thing that you learned from this presentation:
Please add your comments/suggestion for improving this session on the back—they are VERY helpful.
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The Teaching Clinic Preceptor
Example Eight Steps
The eight steps presented below may be used as a guide for your planning.
Modify these steps to meet your specific needs.
Who: 20 faculty learners from the Department of Family Medicine.
Why: Enhance clinical teaching as part of a required faculty development curriculum.
When: 0730-0900 on a Wednesday morning, blocked schedule for faculty development.
Where: Classroom, individual desks, accessible, AV supported, requires own computer.
What: Driven by the LNRA. Will explore a method for assurance of consistent value in
the preceptor encounter, several different learner types, ways to diagnose each,
and strategies for maximizing benefit for any learner type.
What For: By the end of this session, we will have:
• Examined 5 micro-skills of teaching
• Examined 5 learner types
• Diagnosed learner types
• Developed a teaching approach for each
How: General: Active learning: small group activities and discussion, larger group
discussion, some PowerPoint slides. Room contains individual desks. Will pre-
configure desks into larger half-moon shape. Within larger half-moon
configuration, will group four desks in smaller half-moon shape for five groups of
four learners each. This will facilitate small group activities followed larger
group discussions. The session will take place at 0730, so will provide coffee and
bagels.
Initial Input and Induction Task: Dispersed at the tables, a brief article
introducing the concept of the 5-minute or 1-minute clinical preceptor will be
available. After reading the article, each attendee will be asked to reflect on
recent learner behaviors they have observed, and be prepared to share their
thoughts.
Input Tasks:
1. Information pertaining to each objective will be presented for participants to
consider, in preparation for engaging and applying the material.
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2. The five microskills of clinic precepting will be presented with associated
pictures to improve retention.
3. The learner types will be discussed, utilizing distinct images to associate with
each.
4. Strategies will be presented for maximizing the benefit obtained in the
preceptor encounter for each learner type.
Implementation Tasks:
1. In small groups, discuss a video of a preceptor teaching a student without
utilizing a structured method or the five microskills.
2. In small groups, watch each of five example videos which depict various
learner types. For each, diagnose the learner type, discuss use of the 5
microskills, decide on a teaching strategy. In each case a sample of the small
group work will be shared with the large group.
Integration Tasks:
1. Challenge learners to consciously diagnose learners, employ the 5 microskills,
and strategize their precepting encounters moving forward from today‘s session.
So What:
Learning: Learners understand the importance of the ―teachable moments‖
arising in the preceptor encounter. Increased awareness of different learner types
and specific strategies for assisting each allow for optimal learning in these brief
but frequent encounters.
Transfer: Learners build upon this session through self-reflection, addressing
areas or weakness and building upon their strengths.
Impact: Departmental precepting and outpatient clinic teaching is enhanced,
improved learning and success for residents.
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The Teaching Clinic Preceptor
Handout
Take Home Points
• Diagnose the learner
• Adjust teaching style to match
• Be a “One Minute Preceptor”
• Teach using cases as the foundation
Pre-Reading Article
Introduction
A third-year student in your busy ambulatory care clinic presents a case of a 34-year-old woman
with a 3-day history of acute cough and fever. On physical examination, she has notably a
temperature of 100.4 C and crackles in the right lower lobe on lung examination. How do you
decide what to teach this student?
Ambulatory care for outpatients in clinic settings poses unique challenges to preceptors
(teachers) and learners as a result of the pace of patient care and the limited time available for
teaching. In addition to providing high-quality patient care, preceptors must integrate learners
into patient care delivery, teach efficiently, provide feedback in real time and evaluate learners‘
performances.1 At the same time, they must engage in clinical instructional reasoning:
diagnosing patients‘ problems, assessing learners‘ needs and using teaching scripts to provide
targeted instruction.1,2
This reasoning process is enacted through a variety of teaching/pedagogic
strategies. In this article, we describe three teaching models: the traditional, One Minute
Preceptor (OMP)3 and SNAPPS
4 models.
Traditional model
How do you decide what and how to teach the medical student described above? Most preceptors
use the traditional or patient-centered model, in which the case is presented by the learner in a
standardized format. The preceptor then asks several directed questions to clarify the history and
physical examination findings better, in order to establish a differential diagnosis and a treatment
plan. This process may take place during or after the presentation and is sometimes followed by
a brief mini-lecture, which rarely contains feedback.5
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The purpose of the traditional model is to allow the preceptor efficiently to extract the
information necessary to make clinical decisions, allowing him or her to act as an expert
consultant to the learner. The traditional model is perceived as both efficient and appropriate in
many instances because patient care is the top priority. As both learners and preceptors are
familiar with the style, no special training is required. However, several limitations of the model
become apparent when evaluating how effective it is as a teaching tool in the light of current
perspectives on effective clinical teaching.6 Specifically, the knowledge and reasoning of the
learner remain unclear and so cannot be used to guide the teaching process. Teaching points are
often general, not geared to the level of the individual learner and not readily translatable to
future cases.7 Feedback to the learner, if there is any, must be inferred by the learner from the
patient care decisions being dictated by the preceptor.
One-Minute Preceptor
An alternative, learner-centered approach was described in the early 1990s by Neher and
colleagues.3 The One-Minute Preceptor (OMP) model was developed as a way to enhance the
teaching encounter in the ambulatory setting by making use of a set of five microskills for every
patient encounter. Its popularity is underscored by the adoption of this model by the Royal
College of Physicians as an approach that is taught in their ‗Physicians as Educators‘
programme.8 The five steps are as follows:
1) Get a commitment
2) Probe for supporting evidence
3) Teach a general principle
4) Reinforce what was done well
5) Correct learner's errors and make recommendations for improvement
The OMP offers several advantages in that it assesses learner knowledge and targets instruction
to the level of the learner. Preceptors feel better able to diagnose both the patient and the learner's
abilities when using this model.7 Feedback is specific to the encounter and is routinely
incorporated into each interaction. Furthermore, teaching points have been demonstrated to be
more disease specific and based on higher-order thinking than in the traditional teaching model.2
However, teaching staff must be trained in and practice the OMP model because it requires
additional cognitive capacity on the part of the preceptor, who must both diagnose the patient
and respond to the learner.
- Excerpt from Chacko, KM, Aagard, E, and Irby, D. Teaching models for outpatient
medicine. The Clinical Teacher 2007; 4:82-86.
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Activity One: Preceptor Video
As you watch the video, take notes on any features that strike you regarding the interaction between the preceptor and the student. Prepare to share with your small group.
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
What might be done differently?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________ _____________________________________________________________________________________
_____________________________________________________________________________________
Activity Two: Videos – Learner Types
Use this space to take notes as you watch each video. Be prepared to discuss further with your
small group.
Video #1
What learner type is depicted?
How could you use the 5 microskills?
Decide on a teaching strategy.
Video #2
What learner type is depicted?
How could you use the 5 microskills?
Decide on a teaching strategy.
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Video #3
What learner type is depicted?
How could you use the 5 microskills?
Decide on a teaching strategy.
Video #4
What learner type is depicted?
How could you use the 5 microskills?
Decide on a teaching strategy.
Video #5
What learner type is depicted?
How could you use the 5 microskills?
Decide on a teaching strategy.
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Supporting References and Resources
Bibace R, Catlin RJO, Quirk ME, Beattie KA, Slabaugh RC: Teaching styles in the faculty-
resident relationship. 198 1; 13:895-900. (Slightly different perspective on differing approaches to teaching)
Irby DM: What clinical teachers in medicine need to know. Acad Med 1994; 69:333-42. (Thought
provoking observations regarding six critical domains which distinguish excellent clinical teachers.)
Irby DM: Teaching and learning in ambulatory settings: a thematic review of the literature. Acad Med 1995; 70:898-909. (An excellent review.)
Irby DM: Teaching and learning style preferences of family medicine preceptors, and residents. J Fam Pract 1979; 8:1065-7. (Contrasts how certain teaching preferences (ie "dissertations") are not always valued by the learners.)
Lesky LG, Borkan SO Strategies to improve teaching in the ambulatory medicine setting. Arch Intern Med 1990; 150:2133-7. (Helpful ideas to enhance ambulatory teaching.)
Neher JO, Gordon KC, Meyer B, Stevens N: A five-step "microskills" model of clinical teaching. J Am Board Fam Pract 1992; 5:419-24. (Classic reference on an effective method to approach teaching situations.)
Schmidt HG, Norman GR, Boshuizen HPA: A cognitive perspective on medical expertise: theory
and implications. Acad Med 1990; 65:611-21. (Useful theoretical evaluation of attending patient problem solving skills and thoughts on how to teach these.)
Skeff KM: Enhancing teaching effectiveness and vitality in the ambulatory setting. J Gen Intern
Med (Mar/Apr Supplement) 1988; 3:S26-33. (Useful ideas on improving ambulatory teaching)
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