TeachingLearning

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Teaching/Learning

• In the Clinical Setting

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What is Learning?
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How do you know it is happening?
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• Because of a change in behaviour, following an
  identical stimulus.

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Learning occurs naturally!
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What is teaching?
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What do teachers do?
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What do teachers do?

• Choose content
• Choose setting
• Choose means of delivering or exposing content
• Promote activity
• Assess
• Give feedback

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How many psychiatrists does it take to change a
light bulb?
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Motivate!
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The name for each thing we want students to learn
is
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Objectives
Stimulus
Response or behaviour
Subject or student
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The name for all the objectives, the setting, the
activities, the assessments is
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The name for all the objectives, the setting, the
activities, the assessments is

• Curriculum !

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Lessen 1
Traditional, classroom teaching
Lessen 2
Lessen 3
exam
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Lessen 1
Objectives
Lessen 2
Setting
Lesson plan
Lessen 3
audiovisuals
exam
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Clinical Teaching

• ER, ambulatory, Ward
• Patient driven
• Service driven

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Problem
Learning need
Teaching need
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Clinical Teaching

• Less predictable
• But
• More natural!

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How does natural learning occur?
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Problem
Apply Previous knowledge
Find New Knowledge
Learning Cycle
Need for new knowledge
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Calculate a T test on a Spread Sheet
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Calculate a T test on a Spread Sheet
Find the document, open the spreadsheet. Find
the data.
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Calculate a T test on a Spread Sheet
Find the document, open the spreadsheet. Find
the data.
Need to find the function, apply to two columns.
Need to get help
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Calculate a T test on a Spread Sheet
Find the document, open the spreadsheet. Find
the data.
Open help, read the instructions
Need to find the function, apply to two columns.
Need to get help
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Calculate a T test on a Spread Sheet
Find the document, open the spreadsheet. Find
the data.
Open help, read the instructions
Need to find the function, apply to two columns.
Need to get help
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• What part of this can be done in the clinical
  setting?

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Problem
Remind/Refresh Previous knowledge (eg, taking a
history)
Apply Previous knowledge
Find New Knowledge
Learning Cycle
Need for new knowledge
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Problem
Apply Previous knowledge
Find New Knowledge
Learning Cycle
Promote/motivate Need to learn (What do I look
for on physical exam?)
Need for new knowledge
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Problem
Apply Previous knowledge
Find New Knowledge
Learning Cycle
Teach new concepts or skills, or practice EBM
(Web site on physical exam)
Need for new knowledge
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Problem
Reinforce new skills, or evaluate learning (try
my new skill on this, or next patient)
Apply Previous knowledge
Find New Knowledge
Learning Cycle
Need for new knowledge
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Problem
Remind/Refresh Previous knowledge
Reinforce new skills, or evaluate learning
Apply Previous knowledge
Find New Knowledge
Learning Cycle
Promote/motivate Need to learn
Teach new concepts or skills, or practice EBM
Need for new knowledge
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• Choosing What to Teach

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Exercise

• Fourth Year medical student
• First day of rotation in orthopedics
• First patient possible fractured hip in ER
• Second patient chronic, stable groin pain.

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Objectives

• Student will be able to identify risk factors for
  fracture
• Student will be able to identify complications of
  fracture
• Student will be able to examine the hip
• Student will be able to list the principles of
  fracture treatment.
• Student will be able to take a history from a
  patient will an acute problem
• Student will demonstrate the ability to describe
  the effect of disease on function

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Exercise

• Choose one or more objectives to teach on these
  patients
• Indicate the way that you would achieve this
  objective, with this student, on these patients!

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Points

• Assess the student
• Focus or prep the student
• Evaluate or assess the student, and give feedback
• Care for the patient!

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Questions?
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Summary

• Learning is a natural process
• Teaching helps the student to learn a selection
  of objectives, and involves choices
• Clinical learning is more unpredictable, but more
  motivating
• Clinical education still uses the same
  principles, but requires flexibility.

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Next Time

• Covering the curriculum in an unpredictable
  setting
• Choosing what to teach to this student with this
  patient.
• Getting the most value from a short interaction.

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Clinical TeachingPart 2

• What is learning?
• What is teaching?
• What is an objective?
• How to choose what to teach.
• How best to teach.

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Examples

• You are the resident looking after a fifty year
  old man an alcoholic hospitalized with
  cardiomyopathy.
• Your first student in in the first year of a
  clinical skills course on communication
• Your second student in a course on clinical
  skills
• Your third is a first year resident in medicine

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First What to teach?
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First What to teach?

• Objectives for their courses or rotations
• Prior experience or ability of the student
• The time available
• The condition, and willingness of the patient

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First year student

• Has had three sessions talking to patients
• Objectives The student will be able to take a
  history regarding substance abuse
• Patient very cooperative, no tests booked,
  comfortable.

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Getting the correct information
Where do you intervene?
Ideas about questions
Asking the questions
Looking up correct questions
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Getting the correct information
You review the history, with our without the
patient
Set the task
Ideas about questions
Asking the questions
What questions should you ask?
The student sees the patient
Looking up correct questions
Confirm eg, CAGE
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Lesson?

• You make the objectives clear to the student
• If necessary, you prepare the student
• The student actively practices
• You assess the student
• You give Feedback to the student

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Physical Skills

• Second year student has done a lot of
  histories, and some physical exam (eg, BP,
  pulse). Has done normal exam.
• Objectives The student will be able to find and
  assess JVP
• The patient Many abnormal findings, very
  cooperative, has lots of time.

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Find JVP
Knows find normal, has idea about abnormal
Applies current skills
No need to read, hear more
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Set task, ask to take history, but tell student
that you will review JVP
Find JVP
Review patient with student
Knows to find normal, has idea about abnormal
Applies current skills
No need to read, hear more
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Lessons

• Student models more of encounter
• Is still clear on objectives
• Student learns more about context, still gets
  feedback

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Student 3

• First year resident
• Objective Will be able to diagnose CHF in the
  patient with cardiomyopathy

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Make diagnosis
History and physical exam data
Test abilities and judgement
New ways of applying knowledge?
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ProblemDiagnose
Set task Can you diagnose?
History and physical exam data
Ask resident to give history, exam, and think
aloud reasoning process
What is wrong, have I seen this?
Test abilities and judgement by committing to
diagnosis
New ways of applying knowledge or new knowledge
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Presentation of patient

• Before, or after seeing the patient?

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ProblemDiagnose
Set task Can you diagnose?
Reconciliation
History and physical exam data
Ask resident to give history, exam, and think
aloud reasoning process
What is wrong, have I seen this?
Test abilities and judgement by committing to
diagnosis
New ways of applying knowledge or new knowledge
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Presentation of patient

• Before, or after seeing the patient?
• Before Why?
• Can discuss possibilities without frightening the
  patient
• Can focus on learner, not patient
• Can use questioning to probe thinking of the
  learner
• Can then clarify problems (eg, poor history, exam
  etc) with patient

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Other possibilities

• Observe throughout encounter
• Very junior learner
• Very new task
• Sensitive situations (exam or history)
• Observe by reading notes
• Senior learner (eg, fellows clinic)
• Ward histories
• For either Give Feedback

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Feedback on Presentation

• Listen
• Ask questions at clear points after history,
  exam, ddx
• Why did you think that? What if?, What else
  would you ask? look for?
• What tests you do? Why?
• What should you tell the patient?

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Feedback after seeing patient

• Try to do as often as possible
• Make it positive! Good history, excellent exam,
  good idea!
• For negatives give a positive, then Try this
  next time!
• May suggest reading, but make it specific!
• Model EBM.

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Time?

• A minute or less to set task
• Well review your joint exam of this patient
• A few minutes to ask questions during
  presentation What did you find in the knee?
• A minute or two to give feedback after patient.
  Next time, try checking stability

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Good Teachers

• Enthusiastic
• Knowledgeable
• Give feedback
• Are aware of needs of learners

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Covering the curriculum
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Covering the curriculum

• Key objectives list
• Log Books
• Asking the student!
• Choosing the patient for the student
• Pen and paper cases.

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Cox Model of Clinical Teaching
Patient two
Reflection and feedback
Patient one
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Continuity!

• Apply lessons learned to next patient
• History and physical exam to diagnosis
• Diagnosis to management
• Communication skills to patient education
• Comfort, confidence in the ability and
  personality of the student
• Trust of the student in the teacher

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Summary

• Using the Cox model to teach communication,
  examination, and clinical reasoning for a variety
  of learners
• Covering the curriculum
• Giving feedback.

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Next

• Teaching professional behaviour and attitudes in
  the Cox Model.

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Teaching/Learning

• In the Clinical Setting

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Today

• Teaching Behaviour and Attitudes

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Domains

• Communication
• Ethics
• Professionalism
• Attitudes
• responsibility

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What is Learning?
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What do teachers do?

• Choose content
• Choose setting
• Choose means of delivering or exposing content
• Promote activity
• Assess
• Give feedback

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Objectives
Stimulus
Response or behaviour
Subject or student
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Problem
Apply Previous knowledge
Find New Knowledge
Learning Cycle
Need for new knowledge
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Cox Model of Clinical Teaching
Patient two
Reflection and feedback
Patient one
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Observing behaviour
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Observing behavior

• Speech
• Body language
• Attendance
• Participation
• Written communication

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Deducing attitude

• Engaged vs Distant
• Empathetic vs distrustful
• Altruistic vs Self centred
• Respect vs contempt

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Exercise

• Reflect upon your own attitudes towards medicine,
  patients, co-workers and patients
• Write about one experience that changed your
  attitudes or behaviour.

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Questions

• For how many of you was this in a formal teaching
  session?
• For how many was this in the presence of a
  patient?
• For how many of you was this a situation that
  involved some anxiety, or discomfort?

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My own change
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Conclusions

• You must reflect on an action or observation
• You must name the behaviour observed
• You must link the behaviour to a belief or
  attitude
• You must examine the belief
• The belief may change
• The belief informs new behaviours

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Conclusions

• You must reflect on an action or observation
• You must name the behaviour observed
• You must link the behaviour to a belief or
  attitude
• You must examine the belief
• The belief may change
• The belief informs new behaviours

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Conclusions

• You must reflect on an action or observation
• You must name the behaviour observed
• You must link the behaviour to a belief or
  attitude
• You must examine the belief
• The belief may change
• The belief informs new behaviours

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Conclusions

• You must reflect on an action or observation
• You must name the behaviour observed
• You must link the behaviour to a belief or
  attitude
• You must examine the belief
• The belief may change
• The belief informs new behaviours

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Conclusions

• You must reflect on an action or observation
• You must name the behaviour observed
• You must link the behaviour to a belief or
  attitude
• You must examine the belief
• The belief may change
• The belief informs new behaviours

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Conclusions

• You must reflect on an action or observation
• You must name the behaviour observed
• You must link the behaviour to a belief or
  attitude
• You must examine the belief
• The belief may change
• The belief informs new behaviours

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Question

• What motivates the initial Reflection?

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Example

• You are on the elevator with some of your
  colleagues. You are discussing a difficult
  patient, who refuses treatment for his chronic
  disease. One of the other residents makes a joke
  about the patients preference for traditional,
  complementary medicine, and that this relates to
  his ethnic background. You notice someone of
  similar background in the elevator.

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Exercise

• What is wrong here? Ie, what is the behaviour?
• What is (are) the names of the principles to be
  considered?
• What are your beliefs related to this?
• What difference in behaviour would you
  contemplate on your part?

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Motivators

• Internal
• Guilt
• Dissonance
• Outcomes

• External
• Social pressure
• Feedback
• Structure

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Motivators

• Internal
• Guilt
• Dissonance
• Outcomes

• External
• Social pressure
• Feedback
• Structure

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Motivators

• Internal
• Guilt
• Dissonance
• Outcomes

• External
• Social pressure
• Feedback
• Structure

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Cognitive dissonance is a psychological term
which describes the uncomfortable tension that
comes from holding two conflicting thoughts at
the same time, or from engaging in behavior that
conflicts with one's beliefs.
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Motivators

• Internal
• Guilt
• Dissonance
• Outcomes

• External
• Social pressure
• Feedback
• Structure

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Motivators

• Internal
• Guilt
• Dissonance
• Outcomes

• External
• Social pressure(or role modelling)
• Feedback
• Structure

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Social Learning

• Principles
• 1. The highest level of observational learning is
  achieved by first organizing and rehearsing the
  modeled behavior symbolically and then enacting
  it overtly. Coding modeled behavior into words,
  labels or images results in better retention than
  simply observing.
• 2. Individuals are more likely to adopt a modeled
  behavior if it results in outcomes they value.
• 3. Individuals are more likely to adopt a modeled
  behavior if the model is similar to the observer
  and has admired status and the behavior has
  functional value.

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Motivators

• Internal
• Guilt
• Dissonance
• Outcomes

• External
• Social pressure
• Feedback
• Structure

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Motivators

• Internal
• Guilt
• Dissonance
• Outcomes

• External
• Social pressure
• Feedback
• Structure

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To Summarize

• In order to change, you have to Name what you are
  doing, and want to do something different
• You have to reconcile the new behaviour with
  belief, and perhaps re-evaluate that belief
• Change may occur because of internal or
  externally driven factors.

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Warning

• In poorly constructed circumstances, the learning
  may go in the wrong direction (eg, poor role
  models).
• Students can be socialized to abandon behaviours
  based upon previously held beliefs.
• Have you found yourself doing this? Why?

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Setting the Scene

• Using these principles to help students

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What Can We do in the Clinical Setting?

• Recognize the motivators
• Help name the behaviours, and ask about the
  underlying beliefs
• Point out the dissonance
• Make reflection a behaviour to be copied.

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Recognize the motivators

• Students want to be us
• We become the social in social learning
• This occurs at all times.
• Make use of difficult situations for teaching

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Name the Behaviours and ask about Beliefs

• Give feedback to students you were very
  comforting to that patient, or You looked
  uncomfortable
• Do you believe the patient is in pain? What
  principle should we apply here?
• Is the patient entitled to demand a prescription?
  What do we owe them?

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Point out the Issues

• Is there a duty on our part to help?
• If the patient is in pain, what is our
  responsibility?
• Do you represent the profession when you are off
  duty?
• Use the words Altruism, Professionalism, etc.

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Model Reflection

• That didnt go well.
• I rushed the history on that patient, I didnt
  give them a chance to talk
• Ive been frustrated by her lack of compliance.
• I should have done better I know that I should
  have sat down and listened first.

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Patient two
Reflection and feedback
Patient one
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Summary

• Reflection leads to the identification of
  behaviours as learnable or teachable
• Life is easier if there is a fit between belief
  and behaviour (ie, no dissonance)
• In the realm of attitudes/professionalism, we are
  always in our teaching role.