TEACHING IN THE HOSPITAL

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TEACHING IN THE HOSPITAL

• William Shockcor, M.D.

June 2, 2009
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Why be a good teacher?

• Career and life enjoyment and security.
• One thing we do that differs from private
  practice.
• Because we can its a skill we can acquire.
• Might benefit recruitment of learners into our
  field.
• Might benefit quality of care. 

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Todays Goals

• Dual jobs The conflict between patient care and
  education.
• Learning how to teach better in the IT era. Some
  nuts and bolts.
• Does any of it matter? Some outcomes data.

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NEW JOB

• 1.5 hours teaching rounds per day
• 4.5 hours other team teaching time per week
• 2 case conferences per 2 week ward rotation
• Assist with literature-based review of patient
  care topics to be delivered by learners daily
  (EBM)
• Active directed teaching of senior residents in
  how to teach junior residents/students
  (curriculum developed for this)
• Zero clinic to interfere with teaching
• Ward team patient cap 14 (just reduced from 15)

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OLD JOB

• Earn 3200, no 3600, no 3800 wRVUs per year
• Answer your pager
• Answer MARS calls within 1 minute
• Personal clinic and supervise resident clinic
• Ward team patient cap 20 (just reduced from 24
  to comply with RRC)

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Alliance for Academic Internal Medicine Education
Redesign Task Force - Members

• Association of Professors of Medicine (APM)
• Association of Program Directors in Internal
  Medicine (APDIM)
• Association of Specialty Professors (ASP)
• Clerkship Directors in Internal Medicine (CDIM)
• Administrators of Internal Medicine (AIM).
• American College of Physicians (ACP)
• American Board of Internal Medicine (ABIM)

Acad Med. 2007 8212111219.
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Alliance for Academic Internal Medicine Education
Redesign Task Force - Recommendation

• Develop a core faculty at each institution,
  consisting of clinicianeducators who have
  substantial responsibility for the clinical
  education of residents.
• Provide adequate support for the core faculty and
  for the broad group of faculty who serve as
  teaching attendings, clinic attendings, and
  supervisors.
• Develop a series of educational competencies for
  the faculty.
•  

Acad Med. 2007 8212111219.
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Redesigning Training for Internal Medicine  

• Residency programs should be designed around
  educational rather than institutional service
  needs.
• Faculty involvement in the education of residents
  is compromised by conflicting productivity
  expectations, an inadequate reward system, and
  lack of training in educational methods.
• The need for a specialized group of clinician
  educators (core faculty) who are provided
  suf?cient time ?nancial remuneration academic
  status and institutional recognition for
  teaching, evaluating, supervising, and mentoring
  trainees.
• The need to establish a set of general
  competencies for clinician educators including
  teaching, evaluating, mentoring, and
  role-modeling.
• Expose students to enthusiastic role models in
  internal medicine.

Weinberger et al, Ann Intern Med.
2006144927-932.  
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Learning to Teach Better in the IT Era
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Google Teaching Methods7 Principles of Good
Practice

• 1. Encourages Contact Between Students and
  Faculty
• Frequent student-faculty contact is the most
  important factor in student motivation and
  involvement.
• 2. Develops Reciprocity and Cooperation Among
  Students
• Learning is enhanced when it is more like a team
  effort, collaborative and social. This sharpens
  thinking and deepens understanding.
• 3. Encourages Active Learning
• Will better make what students learn a part of
  themselves.

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Google Teaching Methods7 Principles of Good
Practice

• 4. Gives Prompt Feedback
• Focuses learning, enhances improvement. Must
  have time to reflect as well.
• 5. Emphasizes Time on Task
• Allocating realistic amounts of time means
  effective learning for students and effective
  teaching for faculty.
• 6. Communicates High Expectations
• Expect more and you will get more, becomes a
  self-fulfilling prophecy.
• 7. Respects Diverse Talents and Ways of Learning
• Students need the opportunity to show their
  talents and learn in ways that work for them.
  Then they can be pushed to learn in new ways that
  do not come so easily.

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U. of Oklahoma Instructional Development Program

• Challenge students to higher level learning.
• Use active forms of learning.
• Give frequent and immediate feedback.
• Use a structured sequence of different learning
  activities.
• Have a fair system for assessing and grading
  students.

L. Dee Fink, 1999.
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Teachers in Medicine Need to Know

• Knowledge of General Principles of Teaching
• Actively involve learners (6/6)
• Capture attention and have fun (6/6)
• Connect the case to broader concepts (6/6)
• Go to the bedside (5/6)
• Meet individual needs (5/6)

Erby, Acad Med. 69(1994)333-342.
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Clinical Setting Teaching Tips

• Personal motivation. Interested and eager to
  learn (internal motivation) or learn simply to
  pass an exam (external motivation)?
• Meaningful topic. Is the topic relevant to
  learners current work or future plans? Have you
  made it clear why it is important?
• Experience-centered focus. Is learning linked to
  what learners are doing, based on care they are
  giving patients?
• Appropriate level of knowledge. Is learning
  pitched at the correct level for learners stage
  of training?

Lake and Ryan MJA 2004 180 (10) 527-528
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Clinical Setting Teaching Tips

• Clear goals. Have you articulated the outcomes
  for the session/attachment/year so that everyone
  knows where you are heading?
• Active involvement. Do learners have the
  opportunity to be actively involved in the
  learning process, to influence the outcomes and
  process?
• Regular feedback. Have you told learners what
  they are doing well, as well as what areas could
  be improved (positive critique)?
• Time for reflection. Have you learners time and
  encouragement to reflect on the subject and their
  performance (self-assessment)?

Lake and Ryan MJA 2004 180 (10) 527-528
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Location Conference Room

• Detailed discussion of differential diagnosis.
• Discussion of care plan options.
• Administrative details and chart work.
• Typical patient presentation.
• Mini-lectures.
• Medical jargon may intimidate or confuse a
  patient. Less distracting interruptions and more
  confidentiality. More comfortable for learners.
  Chalk board.

MAHEC Office of Regional Primary Care Education,
North Carolina.
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Conference Room Teaching Tips

• Remember dual role Patient care role and
  teaching role. Two column notes trick.
• Focus on Clinical Problem Solving, Clinical
  Decision-Making. Expanding Trick What If?
• Teacher Role Model use of Information sources
  net UpToDate, clinical reference articles (EBM).
• Limit Corridor Rounds. Often referred to by the
  learner as "shifting dullness" (after the
  physical finding related to ascites). At their
  best corridor rounds remain uncomfortable and at
  very high risk for violating the patients
  confidentiality.

MAHEC Office of Regional Primary Care Education,
North Carolina.
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How to Bring References to the Conference Room
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Evidence Based Medicine

• Sackett et al, Director Trout Research and
  Conference Center, Irish Lake, Ontario, 2000

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Bedside Teaching Tips

• Learners have the opportunity to use nearly all
  of their senses -- hearing, vision, smell, touch.
  The sterile facts from a presentation come alive
  and are tangible. These characteristics alone
  can help the learner remember the clinical
  situation.
• Well suited for using role modeling as a teaching
  technique and for giving immediate feedback.
• Patient respect provide advance notice of
  visit, ask permission, limit time, explain all,
  keep it understandable, visit the patient after
  rounds to answer questions, and thank the
  patient.
• Data majority of patients enjoyed the experience
  and felt that they understood their problems
  better. (Nair et al., 1997)

MAHEC Office of Regional Primary Care Education,
North Carolina.
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Effective Use of Questions

• Type of question asked (open or closed)
  pitches it at certain levels.
• Promote thinking and problem-solving by focusing
  on what learners dont know (areas of
  uncertainty) rather than what they do know
  (factual recall).
• Use names, and then pose, pause, pounce.
• Clarify, elaborate and deflect.
• Establish a supportive environment in which
  everyone can say I dont know, even the
  teacher.

Lake, Vickery, Ryan MJA 2005 182 (3)126-127
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Give Good Feedback

• Be timely. Give feedback soon after an event and
  as regularly as possible (preferably daily or
  weekly). Waiting till the end of a rotation is
  too late. Dont give feedback at times when you
  or the trainee are tired or emotionally charged.
• Be specific. Trainees want the specifics, rather
  than a global overall, you are doing fine.
• Be constructive. Help provide solutions for areas
  of weakness. The positive critique, which looks
  at what can be improved rather than what is
  wrong, encourages looking for solutions.

Vickery and Lake MJA 2005 183 (5) 267-268
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Give Good Feedback

• Be in an appropriate setting. Positive feedback
  is effective when highlighted in the presence of
  peers or patients. Constructive criticism should
  be given in private an office or some neutral
  territory where you are undisturbed is ideal.
  Phones should be off the hook, mobiles and pagers
  turned off.
• Allow the trainee input. Trainees should be given
  the chance to comment on the fairness of the
  feedback and to provide explanations.
• Involve attentive listening.
• Focus on the positive.

Vickery and Lake MJA 2005 183 (5) 267-268
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Reflection

• Opportunities occur after meaningful teaching
  encounters or so-called teachable moments.
• Re?ection could occur immediately, virtually in
  the hallway, after a ward team has seen a
  patient.
• Re?ection could occur later, in the conference
  room, after an important event, medical mistake,
  challenging encounter, or amazing success.
• Three keys to the successful use of re?ection in
  clinical teaching the teachers being a good
  role model, gaining the trust of the learners,
  and having the skills to facilitate re?ection.

Branch and Paranjape, Acad. Med. 2002771185
1188.
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Teaching Strategies

• Be enthusiastic, expecting everyones best,
  including your own.
• Give good feedback, lots of it, all the time.
• Be a good role model professional care giver and
  learner.
• Respect learners in all you do.
• Include all group members in your educational
  efforts.
• Manage time well.

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Does Any of This Matter?Some Data
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Student Involvement on Teaching Rounds

• High student involvement was an independent
  predictor of higher resident evaluation of
  teaching rounds (P lt 0.0001).

Hoellein et al, Acad Med. 200782(10
Suppl)S19S21.
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What Makes a Good Clinical Teacher in Medicine?
A Review of the Literature

• 2 authors, conceptual framework, identify 5
  themes.
• Refs. From 1909 to 2006, found 4,914 titles, 68
  articles chosen.
• 4 readers, independent qualitative analysis 480
  descriptors identified, grouped into 49 themes,
  clustered into 3 main categories physician,
  teacher, human characteristics.
• Refs were essays and methodologies including
  surveys, interviews, observations.

Sutkin et al, Acad Med. 2008 83452466.
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What Makes a Good Clinical Teacher in Medicine?
Most Common Themes

• 1. Medical/clinical knowledge
• 2. Clinical and technical skills/competence,
  clinical reasoning
• 3. Positive relationships with students and
  supportive learning
• 4. Communication skills
• 5. Enthusiasm (for Medicine, for teaching, in
  general)

Sutkin et al, Acad Med. 2008 83452466.
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Applying Adult Learning Theory to a
Residents-as-teachers Workshop Series

• Topics making effective presentations, time
  management, adult learning theory, giving
  feedback, clinical teaching, ward team
  leadership.
• 47 Rate it extremely valuable and 47 Rate it
  very valuable.
• 83 Rate quality excellent.

Baser-Decker et al, Ariz Health Sci Center Coll
Medicine
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Learning/Feedback Activities and High-Quality
Teaching

• 10 months, 170 third year medical students,
  PDAs, inpatient.
• 2,671 teaching encounters rated, regression
  analysis.
• Predictors of overall high-quality teaching
• 1. giving mini-lectures on inpatient topics
• 2. teaching test interpretation
• 3. providing feedback on case presentation
• 4. providing feedback at the bedside

Torre et al, Acad Med. 2005
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Linking Teaching to Learning

• Log data base at UPMC, third year medical
  students, multivariate analysis.
• Outcome better test scores about patient
  care/medical knowledge.
• Independent Predictors
• Student does HP alone first,
• Student given time to think about HP before
  presenting,
• Discussing patient management.

Elnicki, personal report 2009
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Summary

• Enthusiasm, liking our teaching job, is powerful.
• High expectations and respect for learners.
• Utilize IT resources to become more effective at
  teaching.
• Give feedback, allow time for reflection.
• Go to the bedside, involve everyone on the team,
  utilize mini-lectures, keep it relevant.

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• "A great teacher is one who realizes that he
  himself is also a student and whose goal is not
  to dictate the answers, but to stimulate his
  students creativity enough so that they go out
  and find the answers themselves." - Herbie
  Hancock