Wednesday, April 10, 2013

Raising the Bar for Clinical Teaching

Today we observed a committed physician educator share his insights about what it means to be "present" as a clinical teacher.  I'm not sure what you will remember from the required readings and the PP slides and practice opportunities, but what is reinforced for me each year when I work with Bud on this session is that it is possible to be both a dedicated practitioner and an effective teacher.  Is time a factor.. of course.  Is context a factor... of course.  What I loved hearing was the different ways proposed for modifying what you heard from Bud into your own setting.  The principles supporting  "teach general rules", asking "high yield questions" and "reflection on action", are universal.  They don't just pertain to teaching in a General Internal Medicine outpatient setting, or even clinical teaching. 

This session, I suspect, was a more difficult session for our non-clinical masters students.  I hope the cases helped, but I can imagine you had to work harder at extrapolating principles and tips to your own setting.  Comments on the readings, presentation or your own wonderful inspired thinking are welcome.

15 comments:

Pilar Castro said...

I really enjoyed our session this morning. It is always wonderful learning new tips and techniques from a master educator. From the discussion, one of the things that I liked the most is the reflection on action theory. Many times I think we miss opportunities for teaching not only medical knowledge but to model professionalism, systems based practice and interpersonal and communication skills because we don't make the point of highlighting the difficult situation, encounter or medical decision and discussing it with our residents and students. Many times what for us seems assumed, natural or known is something that our resident has not seen or explored before. "Making the implicit, explicit" to use Dr. Taylor's words is critical.
Feedback is also an essential component of the whole process and making sure it is given in a constructive way is necessary. We have to make the time also to answer questions and clarify any issues the resident or student may have at the end of the day.

R Prayson said...

The challenges I have in my interaction with residents are related to a limited amount of face time. Residents are assigned for 45 minute signout times a day for about 7-8 days a month when on service. They often are coming in late from conference (not their fault, conferences frequently run over time), since my signout time immediately follows resident conference. There are typically several trainees present for signout (medical students, residents from other departments and pathology residents at varying levels of training). The pathology residents have to leave and move onto the next service after the scheduled 45 minutes are up; so, there is no opportunity to individually debrief on how things went. The clinical teaching approach that seems to work best is asking questions related to the slides we are looking at I the moment. Some questions can be generally directed to everyone present, especially recall type questions. The comprehensive or analysis question can be more directed to the more experienced trainees. I think the more junior trainees benefit from hearing the discussion on the more complex questions. It also gives them an idea of what will eventually be expected of them. The trick is responding to what is said without embarrassing anyone, which is sometimes an issue when a medical student is able to answer a higher level thinking questions that the more senior residents can not. This approach can be easily incorporated into the signout routine without taking much additional time. I am open to any other ideas/suggestions to use in this setting.

Maged Argalious said...

The good news here is that there are multiple ways that can be successfully used for clinical teaching. In one of the assigned articles, the author mentions how he was surprised by the multitude of successful but different ways that his peers were utilizing for bedside teaching.
Having a framework of different clinical teaching methods certainly helps, but tailoring these methods to the clinical situation and "trying out" different methods will guide the teacher to the highest yield method, which may be different with different scenarios and with different learners.
To give an example, I used to frequently use "reflection in action" in the operating room environment. What I did not realize is that trainees can lose their focus and get distracted (especially when performing technical tasks) if the reflection in action takes more than a few seconds or is done while they are in a perceived stressful situation. Choosing the appropriate time is crucial for giving feedback and in the busy and stressful operating room environment, reflection on action gives me the opportunity to provide feedback while the learners are actively listening.

Bernard richard said...

I wish that in future such posting should go on.

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Brian Johnson said...

The use of the reflection on action model we discussed works well in the OR environment. I liked discussing the use of the reflection in action model and have been thinking about how to employ it in the OR environment to save time. One potential way I have thought of is during a procedure when a trainee is struggling. I often find that they just repeat the same steps over and over, without adjusting or changing techniques. I think that if I had them reflect on what they were doing and what they may change for the next attempt. Also I liked the part of finding out what they are interested in learning. Finding out that focus will help guide the teaching this is much like the finding out what they are focused on during feedback sessions, using ask-tell-ask.

Anonymous said...

Kathy Baker

I agree with Rich that there are restraints with face to face time in certain situations. Though I am not a physician and not the main educator of our unit, as the most senior middle manager I tend to interact with the new employees about their education and orientation process more frequently. It was so interesting that this course occurred two weeks ago, as we had 7 new hires that started that Monday. This will pose a challenge to me to ensure I meet with them weekly and implement the ask-tell-teach-ask method now, as I have been utilizing the ask-tell-ask method. I think that my new middle managers will be a great asset to assist me in this task, as some of the new hires are working predominately night shift. Similar to Brian and Maged, I use the reflection in action method not only with the new hires but also with my other managers, as they are still learning in their new positions. I think this class was very beneficial and provided insight to those of us that were not physicians to allow us to relate more realistically with the scenarios.

Heidi Gdovin said...

Although the session is titled “Essentials: Clinical Teaching” I feel there is still value to non-clinical employees to hear and learn from great educators about effective ways to teach. Whether I am working with new employees or an undergraduate intern, the lessons learned in the session can be applied. And yes, having non-clinical examples in class was useful in the role play activity! There were a number of items I found useful from this session and readings. I read a sentence in one of the assigned readings that stated “Maslow observed that effective teachers are observant, non-controlling and inquisitive.” I felt this also went along with the discussion in class. I thought those are three good qualities to keep in mind when working with people. We should observe the environment and interactions, ask questions to learn more about the person, their experiences, needs and goals, be flexible and try not to control every moment. Many times the educator may only think of their workload, environment and demands and forget that the learning experience should be about the student and not about the teacher. Educators should be focused on the learner, new employee, intern or whoever it may be. As Dr. Isacson demonstrated, the educator needs to take a step back and think about making the experience a collaborative one, create the effective learning environment and be able to adapt the experience to the learner. It is then the learning can advance for the students.

Anonymous said...

David Wheeler

Clinical teaching is the discipline wherein all the ideas of educating the adult medical professional are reduced to their consequences in action. This is the endeavor that puts into action the epistemological, constructivist, transformative etc.. This is where the rubber hits the road. It is critically important the clinical instructor manage the expectations and intentions of the learner. The clinical instructor is charged with creating an environment of clarity for the learner. In many clinical scenarios ambiguity can be extremely destructive. In order to provide this clarity the instructor must spend time with the student getting to know them as a human being. This knowledge will help to guide the instructor in the modeling of the affective domain for the learner and build a sense of trust with the learner. It is also interesting to note that if you invest time early with a student you will enhance their learning experience and increase their clinical efficiency. I think it is important to frame the relationship as a partnership in learning. We have all learned a great deal from the students we have worked with in clinical and nonclinical environments. Additionally, when reflecting with the learner on their clinical experience it is important to reinforce their areas of strength and assist them in creating goals that will further their clinical knowledge. The critical reflection on the experience is an absolute must as it allows the instructor or mentor or coach to really engage the learner in the areas of strength and focus them on areas where they need to grow. This critical reflection also allows the learner to do the same with the instructor; it is really an opportunity for growth on both ends of the equation.

Brian Burkey said...

I was not able to be present for the class, but completely enjoyed the article by Beckman on bedside teaching. It resonates with my own experience of teaching and my impressions of learning from the evaluation of others. When I was on the RRC for Otolaryngology, my evaluations of other programs never failed to elicit improvements in my own program in which I was the program director. I saw things that I had overlooked, as the other programs acted as a mirror on my own, much as Beckman points out. Similarly, one of my most beneficial experiences as a clinician was the ability to evaluate another colleague’s patient interactions at his request. The request was humbling and yet, I thought, a waste of my time; however, the evaluation led to many insights on ways in which I was probably ineffective as a communicator or perhaps even rude. It is interesting that the acts which seem so trivial may elicit the most benefit if one opens themselves to be completely honest and thoughtful, ie. Present in the moment.
I also appreciated the insights that Beckman describes and particularly the point that we commonly miss opportunities to provide any feedback, especially constructive feedback. I continue to believe that the US training system is most effective because of the constant dialogue that occurs, or can occur, between the teacher and learner compared to the more hierarchical system present in European systems. Feedback allows the learner to remodel their theories and construct more appropriate models of reality, and the more frequently this is done the more quickly the model matures and fine adjustments made. The difficulty with feedback is usually time, but good feedback can be given in just a few minutes and can be interjected during care transitions or at breaks, eg. Lunch or end of day rounds. The key is to provide honest information when it can be absorbed, and in a nonthreatening way and place. The constant challenge in clinical teaching is to be imaginative in order to achieve such goals. BB

Karen George said...

Clinical teaching method's objectives can be useful whether working with students, employees or patients. Assessing the patients needs is something we do on a daily basis but I do not think we've focused on assessing the individual needs of students or employees. All come with different learning experiences as we discussed in our first semester and this is important to recognize and incorporate into our learning plan for each student/employee. I was reassured in the Beckman article on bedside teaching that teachers improve with age and experience and found the question asking segment to be the most helpful. Having been educated clinically many years ago I've witnessed berating and demeaning interactions at bedside teaching opportunties by attendings and staff which framed the need in my experience to find a better way to teach. Well balanced, well timed feedback even in the smallest doses can make a huge impact not only on the student but the whole bedside learning community.
Feedback does not need to be patient related and can be about interactions with other staff and learners. Being a co-learner with your student is also a key element. No one knows everything and admitting that is putting yourself alongside your learner.

Shelley Frost said...

As a non-clinical healthcare professional, I probably did have to work harder at this, but I definitely agree with the universal truths and general principles of "teach general rules", asking "high yield questions" and "reflection on action". It seems that life for everyone these days is increasingly stressful and there are not enough hours in a day to accomplish everything that must be done. However, teaching does take time to do it right and have the learner gain the highest yield possible. Dr. Lashner had some great comments and insight into the time constraints in teaching. Experiential learning takes place but the value of reviewing the experience to fully reinforce the importance and value with our learners cannot be understated. This was a great class taught by two expert educators!
Shelley Frost

Anonymous said...

Matt Celmar said...
I enjoyed the “Essentials: Clinical Teaching” session that we attended. The discussion and activities were thought provoking and seeing how other educators approach clinical teaching gave insight to my understanding. The points of teaching general rules, high yield situations, and reflection in action kept ringing true in the teaching that I do with my mentee’s. Because I am able to interact with my mentee’s on a daily basis, I can engage them in a longitudinal training process.
Early in their training I find myself doing a great deal of explaining. Providing them with the ground rules therapy, prompting, and reinforcement. All the while, being careful to explain every action and allow for debriefing at the end of the day.
As they progress my teaching shifts to decrease explaining and increase in the moment reflection on action. I use a lot of cause and effect in my teaching. The mentee is able to see how their actions influence their therapy and patient outcomes.
When the trainee acquires greater skill, I will question their immediate decisions in order to give me an immediate analysis of their therapy. This allows them to not only inform me of their thought process but also be aware of their decision making based on wheat they whiteness.
By the end of the training program the mentee should be able to no only demonstrate their competence but also explain/teach other in order to demonstrate a higher for of understanding.
I even find myself asking “high yield questions” and “reflecting in action” with seasoned staff. If we are working though a difficult situation or problem I will put on the brakes and investigate what we can be doing differently with a patient to get better outcomes. I don’t always do this intentionally but because of this program I can blame it on my desire to make a constructivist learning environment.

Elias Traboulsi said...

What I enjoyed the most about our session were the exercises that involved role playing as a recipient of and as a provider of feedback. Role playing is a strong educational method that allowed me, the student, to experience the challenges of the task at hand. It forces thinking and behavior towards the best possible level of performance. This was most effective as my partner Brian was an experienced educator. Simulation, as know is extremely important in preparation for live performance, whether one is learning medical examination and interview techniques, procedures or surgery, or if one is practicing for difficult interactions. Haven't we all practiced a presentation? anticipated questions and how we would answer them? Good artists always make preparatory drawings, sketches and even small paintings before they attempt the full-blwn masterpieces. Elias

Anonymous said...

Felecia
Action Theory along with reflection in action for me is much the same as having a teaching moment. In the clinical setting, instructors should play close attention to their students, learning to get a read on their emotions or expressions would give an individual an opportunity to clarify procedure or explain a diagnosis. Having a working and positive repoire with students is critical to enable an educator to implement some of the helpful strategies ie..employing the ask tell ask for high yield questions,or reflection in action to elicit the understanding or not of a trainee to name a couple learned in this class.

Rachel Steines said...

One of my favorite things learned in the masters program was the ask tell ask method. I consciously try to use the method as much as possible. Needless to say, I was very excited to learn the ask tell teach ask method as well. I think the process of questioning our actions and the actions of our students is a pivotal degree of growing as a healthcare professional. That being said, it's equally important for our students to be willing and open to questioning us as there educator as well. Educators hold knowledge and wisdom that our students look up to and are more than likely seeking to obtain themselves. This means it's extremely important to establish a warm and welcoming environment. It peeves me to an incredible degree when an educator acts annoyed that they have an unexpected student. I was in a situation once where the educator complained that she had no warning right in front of the student. It's at no fault of the student when this happens, and we are virtually closing the door on learning, at least at first, when this happens. Like we learned, it doesn't take much of an effort to make our students feel welcome; an extra 5 minutes maybe, but they're learning experience may improve by an untellable degree. It is a virtue that will make you a master educator like our educator.