Practical Tips and Tools To
Improve Your Skills as a Clinical
Teacher
MEDS – March 14, 2013
Charlie Goldberg, MD
Professor of Medicine, UCSD SOM
Staff Physician (Internal Medicine) SDVAHS
charles.goldberg@va.gov
• What type of teaching do you do?
Pitfalls in Clinical Education
•
•
•
•
•
Revert to comfort zone
Information doesn’t fit learners needs
Inappropriate techniques
Blame “the system” & punt
Lost opportunities
• No feedback
• Not bedside/in the moment
• Teacher & Student satisfaction highly variable
Challenges for the Teacher
• Lack of prep as teacher
• Students @ multiple levels
– What do they know? Can I trust them? Do
I/can I incorporate them into patient care?
• Competing demands:
–
–
–
–
Patient care
Your education (for residents)
Time constraints
Lack of MD knowledge
Many Teaching Styles & Venues
• Traditional lecture (extensive preparation)
• Mini-talk (some prep)
• Set aside time (e.g. attending or resident rounds)
(some prep)
• Back to bedside (some prep)
• Computer assisted (some prep)
• In the moment - on the fly (? prep)
Typical Day
Teaching &
Learning
.
Everything
Else
A Better Typical Day
Teaching &
Learning
Everything
Else
Practical Tips To Improve and Expand Your
Clinical Teaching Clinical Teaching
1. Incorporate teaching into your “every day”
activities. Teaching should be inextricably
integrated with your patient care activities.
Teaching
The patient care factory
Integrating Teaching With Your
Typical Work
Patient
care
Other
Teaching
Lectures
Bedside
Teaching
Direct
Patient
Care
2. Don’t wait for things to just “get better” on
their own. Nor should you put off teaching
fro when “things” are less busy, stress
levels are lower, etc etc. Be the educator
that you want to be – right now!
Island of Educational
Peace and Tranquility
3. Establish expectations for yourself & learners.
Particularly important given volume of
clinicians & students cycling in & out
@ various intervals.
Repeat frequently.
4. Plan teaching activities ahead of time.
Set up yourself (& your learners) for
educational success.
5. Bringing order and predictability creates
time. Create space for teaching by:
– establish ground rules
– create documents that cover basic info
– create educational scripts for common/high
yield topics
6. Give and receive feedback about education,
teaching and clinical performance every
day.
You’re never “good to go.”
Ask: “What’s working, what’s not,
why adjust”
7. Match the educational goals and techniques
to the setting and learners.
“I'm not a role model... Just
because I dunk a basketball doesn't
mean I should raise your kids.”
Charles Barkley
8. You are a role model – good or bad.
-Show your own vulnerability – it’s fine and
appropriate to say “I don’t know.”
-Don’t ask of others what you wouldn’t do yourself
-Guide and develop the educators of the future
9. Be creative – to engage and clarify the
connection between what you’re teaching
and how it applies – know your resources:
Images
Videos
Apps
Patients and findings
Other personnel w/knowledge, fieldtrips
The “Few” Minute Teacher:
Micro-skills of Clinical Teaching – Time
Limited/On The Fly
• Establish Expectations
• Identify the teachable moment
“Diagnosing”
1. Get a commitment
The Learner
2. Probe for evidence
3. Teach a few key points
4. Feedback
– Tell them what they did right
– Correct mistakes…. gently
Neher. J Fam Pract. 1992; 5: 419-24.
• Homework - solidify key points
• Revisit same issue to assess application w/future patient
Why Does This Work?
• Simple and practical
– Broadly applicable - inpatient, ambulatory, all fields
– Meets specific needs of learner
– Provides teacher w/explicit framework
• Efficient & Active
– Fits busy world
– Fits many situations (bed side, hall, office)
– Engages the learner
• Effective
– It works!
– It’s well received - both student and teacher
• Empowering
encourages teaching
Aagaard. Acad Med 2004; 79: 42-9.
Step 1: Set up for Success
• Expectations: Establish early, avoid
assumptions
• This environment
– Challenges, opportunities, our interactions
– Describe Your style - Presentations, feedback, etc
• What I need from you
– What do you know (where are you in training)?
– What do you need to know (course, ACGME
requirements/goals, etc)?
– What do you want to know (personal goals)?
• Get the patient on-board
Step 2: Identify the Teachable
Moment
• Missed opportunities = Single greatest
impediment to teaching
• Happening all around you, all the time
• Identified by yourself (teacher initiated) or
when question raised (student initiated)
• Takes time & effort to make something
happen
Step 3: Get a commitment
Purpose:
This is the starting point
• Forces the learner to focus and put things
together
• Forces them to commit to an assessment or
treatment strategy
Getting them to commit..
Examples:
Helpful:
• “What condition are we treating?”
• “What do you think is going on with this patient?”
• “What do you think is the main problem?”
• “If you were the only MD in this hospital, what
treatment would you use?”
Unhelpful:
• “This patient clearly has pneumonia and needs to
be admitted.”
Step 4: Probe for Supporting
Purpose:
• Identify the rationale behind their thinking
• Identify gaps in knowledge
• Clarify clinical reasoning
– What path did they take to come to their conclusions?
– Gets the learner to think out loud
Probe for Underlying Understanding…
Examples:
Helpful:
• “What were the findings that lead you to this dx?”
• “Why is this case different then the others we’ve
seen?”
• “What else can cause similar symptoms?”
• “What are the typical treatments used for this
condition?”
Unhelpful:
“Are you kidding me?”
“Didn’t you go to my last lecture on the
management of the pediatric trauma patient!?!”
Step 5: Feedback
Purpose:
• Highlight the positive
• Gently correct errors
Keys:
• 3:1 (positive : corrective) – skip the sandwich
• Frequent (daily) & immediate
• Not a personal attack, don’t embarrass
• Be specific – give news you can use
• Solicit feedback on your performance
Feedback - Examples
Helpful:
• “I agree that the patient has depression” (positive)
• “While depression is a clinical diagnosis, we still
need to obtain labs to assure that there’s no
metabolic component. (corrective)
Not so helpful:
• “Great job!”
• “That’s a ridiculous answer – I’ll go talk w/the
patient and figure it out myself!”
Step 6: Make a few key points..
(i.e. Take Home Messages - THMs)
Purpose:
• 1-5 THMs - bite sized nuggets of
knowledge
• Points that are well understood, applicable –
& not overwhelming!
Teach a few key points Examples
Helpful:
“Ceftriaxone is a good choice for empiric coverage of
meningitis while you’re waiting for culture results. It
covers the most common pathogens – strep and h flu.”
“Holding off on antibiotics if there are no white cells in the
LP and the kid looks ok is a good decision.”
Unhelpful:
“As you know the STAR-D trial had 3 clinical limbs – the
first used welbutrin alone at a dose of 75 mg/d. The 2nd
limb used prozac. The cross-over arm…”
Step 7: Homework & Later
Application
• Encourage outside readingcement & more
advanced questioning
• Look for similar/related situations in future
– reinforce key points
– apply lessons learned
– Explore @ greater depth
Demonstrate &
Refine Knowledge
Elbow Pain In The ER
Example - One Minute Preceptor
From:(http://www.practicalprof.ab.ca/teaching_nuts_bolts/one_minute_pr
eceptor.html)
The Critical ‘X’ Factors
• Environmental elements as or more important then
knowledge/content/teaching technique
– Enthusiasm
– Patience
– Genuinely giving of your time
• effort dependent
• not cost neutral
– Kindness & an environment where ok to take risks, ask
questions, “fail,” try again
Example from the inpatient medicine svc: 54
yo male, Hospital Day 2 For Cellulitis of Foot
An Intern presentation on morning walk rounds:
“Mr. Tomasina is Hospital day 2 for cellulitis - Day 2 of Vanco
Events over the past 24h:
- Glucose has ranged 150-250, with SS coverage
- X-ray yesterday of foot neg for osteo
- He has minimal pain & used 2 percocet over past 24h
Focused exam: He looks good
- T max 101, down from 103 on admit
- P 80-100, BP 140-150s
- Top of foot and great toe remain red and swollen, similar to
yesterday. No regression from inked line
Labs of note: ESR 105, wbc 10, creat 1.4 (stable), a1c 9, blood cx .”
Foot Cellulitis (cont)
Intern’s Summary:
“I think he’s doing pretty well. And I think
that the cellulitis is just beginning to turn
around
Plan:
- continue Vanco - transition to bactrim in
few days - covering mrsa or other GPCs
- Keep foot elevated
- Percocet for pain
- SS insulin for DM”
You (the attending) go in to see
the patient with the team..
…and note the following:
Looks well - chatty
Bottom of foot is insensate to your touch
Pulses non-palpable
Great toe and MTP area rather swollen and
red – though minimally tender
Your (attending level)
Conclusions…
1. DM with peripheral arterial disease and
peripheral neuropathy
2. Likely osteo - given degree of swelling,
elevated ESR, and risk factors
You conclude (internally) that the plan should
include:
– MRI foot
– ABIs to assess inflow
Intern: “He has a fever, his
symptoms are acute, his foot is
red, and we certainly see a lot
of cellulitis. “
Teachable Moment: DM and Treatment Goals
1. Get a commitment:
You: “Why do you think this is simple
cellulitis?”
Intern:“Well, the amount of swelling is
more than we usually see. I guess it’s
also unusual for him to have such a high
sed rate. And your exam demonstrated
that he has nerve and inflow problems thanks for going to the bed side - I wish
“To
look for deeper problems,
everyone did that! So, You:
I guess
it could
we should
do imaging that will
You: “You’re right – he
be something more serious
”
provide greater detail. And assess
definitely has an infection. And
his inflow - which may explain why
your antibiotics are reasonable he got the infection - and given
since this isacute - and could be
insight into how likely it is to get
mrsa, mssa or even strep.
However, he has substrate that Intern: “Ok - that makes better. How might we do
would put him at risk for deeper sense. Given that, maybethat? “
problems. Like poor blood flow we should order an
You: “ You
and neuropathy that may impair MRI and ABIs “
got it!“
ability to feel pain”
2. Probe for evidence:
You: “Which data supports that? What about his
DM puts him at risk for more serious problems?”
3. Feedback
– Tell them what they did right - using general rules
– Correct mistakes
4. Teach a few key things
Teachable Moment (cont)
5. Homework & reapplication:
Lets take a look at some images of what diabetic
neuropathy can lead to:
•For the intern: Provide a focused readings on DM and osteo
•As the teacher: look for future situations to reassess lessons
learned & explore issues at a higher level:
e.g.: review data from DCCT, field trip to the vascular lab
and to MRI to review findings, review evidence
for duration of therapy, role surgery (if osteo).
Teaching “on the fly” Not
Always Appropriate
• Very complex subject
• You don’t know the answer
• Learners @ multiple levels
&/or very different educational
needs
• Severe time crunch
• Someone(s) just dont “get it”
Preparing for the next Teachable
Moment:
Know the epidemiologic info that defines your world:
– Use this to think about an educational/teaching plan.
– What might you emphasize for each common topic ?
– What resources could you use?
Getting Better
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•
•
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Identify opportunities (they’re everywhere) & take risks
Don’t be intimidated; extraordinary knowledge or talent not reqd!
Pay attention to others - why are/aren’t they effective?
Prepare when possible - decreases your stress level/anxiety re
unknown
• When using “few minute preceptor” don’t get hung up on order ,#s,
or straying from script – It’s “a” way, not “the” way of teaching
• Practice
– The more you teach, the better you’ll become
– Synergistic effect across venues
There’s no magical way of doing this!
•What’s expected is difficult to achieve.
• Nothing takes care of itself.
• Everything worthwhile is effort dependent
• All good educational products are the
result of good design, planning & hard work.
Consider evolving as an educator
Faculty Development
Developing Ed Tools (apps and
Web
Sites)
Teaching Groups,
Mentoring, Coaching
The
1:1 Teaching
Medical
Education
Tree
Inter-professional Collaboration
create a web site
Creating Curriculum
Create a case
Writing Cases
When An Educational Opportunity
Presents Itself, Ask Yourself:
•
•
•
•
•
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Who am I teaching?
What do they want/need to learn?
What do I want/need to teach?
Where will the teaching occur?
How much time do I have? Other limitations?
Are there any ways of creating additional
engagement (bed side, media, field trips)?
• How will I get feedback?
– Did they learn?
– Is my approach working?
References
• Neher J, et al. A Five-Step “Microskills” model of clinical teaching. J
Am Board Fam Pract. 2992; 5: 419-24.
• Parrott S, et al. Evidence-based office teaching - the five-step
mircroskills model of clinical Teaching. Fam Med; 2006; 38 (3): 1647.
• Aagaard E, et al. Effectiveness of the one-minute preceptor model for
diagnosing the patient and the learner: Proof of concept. Acad Med
2004; 79: 42-9.
• Ramani S. Twelve tips to improve bedside teaching. Med teacher
2003; 25 (2): 112-5.
• Ahmed M. What is happening to bedside clinical teaching? Med E
2002; 26: 1185-8.
• Katzelnick D, et al. Teaching psychiatric residents to teach. Academic
psychiatry.
• Janick R, et al. Teaching at the bedside: a new model. Med Teacher
2003; 35 )2): 127-30.
• Kroenke K. Bedside teaching. S Med J 1997: 90 (11): 1069-74.
References (cont)
• Committee on Graduate Education, American Psychiatry Assoc.
Psychiatry Residents as Teachers: A Practical Guide. 2001-2.
http://www.psychiatry.org/MainMenu/EducationCareerDevelopment/Res
identsMembersinTraining/residentasteacher.aspx
• Salerno S, et al. Faculty development seminars based on the one-minute
preceptor improve feedback in the ambulatory setting. JGIM 2002; 17:
779-87.
• Irby D, et al. Teaching points identified by preceptors observing oneminute preceptor and traditional preceptor encounters. Acad Med 2004;
79: 50-5.
On-line teaching related resources:
• Teaching Students and Resident to Teach – Michigan State University
http://www4.umdnj.edu/cswaweb/med_pres/lkteaching%2001/
• Resident as teacher: UC Irvine http://www.residentteachers.com/
• Basics of teaching: U of Ohio
http://www.oucom.ohiou.edu/fd/monographs/monographs.htm
References (cont)
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Teaching Support Resources - University of Alabama Birmingham
http://www.uab.edu/uasomume/cdm/resources.htm
General Teaching Effectiveness, University of California, Berkeley
http://teaching.berkeley.edu/compendium/
Effective clinical teaching, U Mass
http://www.umassmed.edu/cfdc/teachingmodules/flash/set1/EffecTeachClinica
l.html
Teaching clinical skills, Dartmouth: http://dms.dartmouth.edu/ocer/,
http://dms.dartmouth.edu/ocer/precepting/tools/simple/
University of Kansas: http://wichita.kumc.edu/strategies/
University of North Carolina: http://www.med.unc.edu/epic/
Madigan Army Hosp – Teaching Skills:
http://www.usafp.org/Fac_Dev/Resource-Center-Teaching-TOC.htm
Ohio State University – Teaching Basics
http://www.medicine.osu.edu/physiciandevelopment/