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So much more than just the numbers!Utilizing effective teaching methods in the
continuity clinic setting
2011 APPD Annual Spring Meeting
Saturday, April 2, 2011; 8:45 am - 10:15 am
Cindy Ferrell, MD, MSEd
Lynn Garfunkel, MD
Diane Kittredge, MD
Sharon Riesen, MD
Janet Serwint, MD
The Continuity Clinic Conference
The Continuity Clinic Conference - Overview
WHAT’S THE EVIDENCE? -Emerging data – see ref’s
TIME – Outside of clinic time? Pre-clinic? Post-clinic?
CONTENT – What to cover? What curriculum is best?
TEACHING STYLE – How to run the conference?
BUY IN – Who plans, who runs, who ‘owns’ ?
OFF-SITE CONTINUITY – What works in community sites?
INDEPENDENT STUDY – How to motivate?
Team projects (QI projects, data analysis, chart review?)
Online self-directed modules (how to integrate & get buy in)
Self-assessment and self-reflection (do you do it, how?)
The Continuity Clinic Conference - Specifics
Curricula
Home grown
Online – for free
Commercial for a fee
Getting buy in
Resident vs. faculty driven
Preceptor buy-in
Staying learner-centered (A-B-Cs)
A=assess need/preparation/interest
B=be realistic about what can be covered in 20 min!
C=check if this is working
The Continuity Clinic Conference - Homegrown
The Continuity Clinic Conference - HOPKINS
Johns Hopkins Harriett Lane Continuity Clinic online curriculum http://www.hopkinschildrens.org/Pediatric-Residency-Internet-Learning-Curriculum.aspx
25 online modules updated annually
Subscription -$1500-$2000/yr (based on # resid)
Interactive, case-based, /pre-post quizzes; usage tracked
Editors: Margaret Moon, Tina Change, Michael Crocetti, Janet Serwint
Can use as ‘stand-alone’ or to trigger discussion at pre-clinic conference
The Continuity Clinic Conference - YALE
Yale Primary Care Pediatrics Curriculum http://medicine.yale.edu/pediatrics/pcpc/index.aspx
Case-based, with facilitator guide plus material for learner
63 topics online (52 in the paper version)
Purchase - $150-300 (based on # residents)
Editors: J. S. Talwalkar, MD; Ada M.Fenick, MD
Example to review: “What Else?” Setting the Agenda for the Clinical Interview
The Continuity Clinic Conference –BRIGHT FUTURES
Pedicases - http://www.pedicases.org/ Case-based discussions, w/ downloadable guides
Register and use for free (MCHB and Genentech Foundation)
29 modules – behavior, growth, development and adolescent topics (~ 30 min, some are more)
Project Directors: S. Jean Emans, M.D. and John R. Knight, M.D.
Carefully developed and studied, used by 170 training institutions since 1996
The Continuity Clinic Conference – Free
Digital Library by Donna and Mike D’Alessandro www.pediatriceducation.org - A Digital Library and
Learning Collaboratory intended to serve as a source of continuing pediatric education – short cases and links. Well suited to continuity clinic conference
Wisconsin Derm Cases http://www.pediatrics.wisc.edu/education/derm/
Derm Atlas www.dermatlas.org - 12,000+ images and descriptions of skin findings.
Can search by category, diagnosis or body site. No cost.
Immunization Coalition Resources http://www.immunize.org/photos – photo collection. This site also has
FAQs on vaccines which are great for brief review/quiz, discussion.
AND MANY MORE……
The Continuity Clinic Conference - DISCUSSION
Clinical Teaching in Continuity Clinic
RIME
Learner diagnostics
Diagnosing the Learner – RIME method
Clinical teaching effectiveness requires recognition of the learner’s abilities
Not a formal evaluation, but part of the process of becoming a better teacher
Reporter
Accurately gathers information and clearly communicates
Obtains History and conducts PE Has basic knowledge Day-to-day reliability Ability to recognize normal from abnormal Identifies new problems – may not understand
significance Ownership in patient care
Interpreter
Higher level of knowledge, more skill in selecting clinical findings that support possible diagnoses
Prioritizes problems
Develops differential diagnoses - 3 reasonable diagnostic possibilities for new problems.
Understands the meaning of test results
Manager
Increasing knowledge, confidence and judgment
Understands when an action needs to be taken
What are options?
Reasonable diagnostic and therapeutic armamentarium
Tailors to each patient
Educator
Beyond basics of self-directed learning
Reads deeply, shares with others
Defines important questions
Has the drive to look for evidence on which action can be based
Has skill to know whether the evidence will stand up to scrutiny
R.I.M.E. – learner assessment
Reporter
Interpreter
Manager
Educator
Clinical Teaching
Clinical Teaching Methods
Limited evidence in literature regarding
Effectiveness
Efficiency
Very little in pediatric literature
Clinical Teaching Methods
Case presentation by learner followed by Teacher asks a few questions
Focused teaching point
Socratic questioning
Joint problem solving
Mini-lecture (‘telling’ is teaching)
Expert consultation
Time out – you need to read!
Brief Structured Observation
TIPP
Reflective Modeling - explicit
Priming
Feedback learning cycle, Kolb
The One Minute Preceptor
TIPP - Teach in the Patient’s Presence
Presentation of findings in front of patient
Reinforces trainee’s role
Facilitates feedback from patient
Verification
Need to be careful to preserve learner’s autonomy
Reflective Modeling
Passive, risk of boredom
Tell the learner what behavior or technique to observe during the encounter - EXPLICIT
Can include thinking out loud – explain reason
Reflection, discussion
Priming
Means of setting the stage for expected learning
Prepare learner’s mind for task
4 topics to include with each encounter
Task
Preceptor role
Patient
Product
The One Minute Preceptor
A good clinical educator must
Diagnose the patient's problem
Assess the learner’s needs
Finally provide targeted instruction to the learner's point of need
Focuses on the decision-making process of the learner
The One Minute Preceptor
Steps of OMP called “microskills” Assess learner level
Listen
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was done right
Correct mistakes
Identify learning objective(s)
SNAPPS Presentation Model
Summarize pertinent +/- s (less than 2 min)
Narrow the differential
Analyze the differential and commit to Dx
Probe the attending with questions
Plan management
Select a case-related issue for self directed learning
Direct Observation in Continuity Clinic
Direct Observation in Continuity Clinic
Advantages Barriers
Opportunity for expert modeling
Direct observation of resident skills and competency
Active adult learning process
Models the process for families
Faculty uncomfortable with lack of experience in bedside teaching
Residents uncomfortable being observed
Sometimes more time consuming
Direct Observation in Continuity Clinic
The “Team Baby” experience for well child care
1st ever visit – done by attending
Subsequent visits – done by a team conti resident
1 week prior Send Bright Futures info for age
Email reminder of scheduled visit
Visit day “Team baby” scheduled for
1:00 with team
1:30 with continuity resident
Informal feedback provided that afternoon by attending, peers, and family
Direct Observation in Continuity Clinic
The Hopkins experience
Conducted twice a year- fall, spring
Preceptor observes resident for any patient
Part of RRC Continuity waiver
Use of form/ written notes
Meet for review, with emphasis on both positive and constructive feedback
Copy of form given to resident and scanned in file
360⁰ Evaluation
360⁰ Evaluation
Cindy Ferrell, MD, MSEd
Lynn Garfunkel, [email protected]
Diane Kittredge, [email protected]
Sharon Riesen, [email protected]
Janet Serwint, MD
