Graduated Responsibility

1
Graduated Responsibility

• From Medical Student to Physician
• University of BC
• Faculty of Medicine
• Department of Family Practice
• Post Graduate Program

2
Residents are ADULT LEARNERS

• What are some of the characteristics of adult
  learners?
• Take two minutes to write down several
  characteristics of adult learners.

3
Adult Learners are

• Self directed
• Learner centred
• Problem oriented
• Curiosity driven
• Reflective
• Individually and culturally different

4
Remember !

• With Adult learners our role is that of a GUIDE
  as much as a teacher.

5
Challenge

• Finding the balance between supervision and
  independence when teaching family practice
  residents.
• What are the consequences of too little or too
  much independence?

6
Too little responsibility

• Boredom
• Demeaning
• Unchallenged
• Limited Progress
• No confidence

7
Too Much Responsibility

• Do not feel safe to challenge themselves
• Fear
• Medical error and undesired outcomes

8
Educational Diagnosis

• Deciding where your learner is
• What is an educational diagnosis?

9
Bordage stages of learning

• I Reduced knowledge
• II Dispersed knowledge
• III Elaborated knowledge
• IV Compiled knowledge

10
Discuss

• Think of the resident you have now or have had
  recently. At what stage are they with many of
  the topics you deal with?
• Where should they be?

11
Benchmarks

• The Program has developed a list of benchmarks to
  help you understand the levels of knowledge and
  skills a resident should have developed at each
  stage of their residency. See
• http//www.familymed.ubc.ca/residency/facultydevel
  opment/BordageModel.htm

12
Start of 1st year

• Hospital Hx and Px taking an hour
• Large Knowledge gaps
• Common vs. Uncommon?
• Little deductive ability
• Therapeutics weak
• Contextual issues weak

13
You need to

• Observe Hx and Exam
• Observe pelvic exams and procedures
• Daily observation of parts of visits
• Question reasoning
• Correct mistakes
• Encourage resident to read around issues

14
2nd half of 1st year

• Crisper and more focused Hx and exam
• Better appreciation of range of common problems.
  (fewer esoteric dx.)
• Better active listening
• More rational use of investigations
• Better therapeutics

15
You need to

• Discuss each case but briefer and focused
• Allow resident more decision making
• Watch for gaps and encourage reading up, rapid
  EBM? Online information?
• Review interviews and exams regularly and
  formally weekly.
• Watch for over confidence

16
2nd year to graduation

• Significantly less supervision.
• As the resident progresses give him or her more
  opportunity to be independent.

17
Teaching Techniques

• Take a couple of minutes and write down what
  teaching techniques you use when working with a
  medical student, a first year or a second year
  resident? Do you have techniques that allow
  increasing degrees of responsibility?

18
Teaching Techniques

• Case Discussion
• For First Year residents needing greater
  supervision
• Case Review
• Chart Review and recall
• - For Second Year residents or those needing
  less supervision

19
Suggestion

• 1st day, resident watches you
• Next 2-3 days, you watch to make an educational
  diagnosis
• Then, regular but decreasing direct observations
• Credit demonstrated competencies
• Micro-skills (one minute preceptor)
• Graduate to reviews
• Critical reflection, Open ended questions

20
Progression

• Observation and direction, knowledge without
  application Medical Student
• Application of knowledge, Freedom to err in a
  safe environment Early Residency
• Some independence with regular review Late
  Residency
• Independence with occasional review and
  observation End Residency

21
Ask yourself

• Is the resident more independent during the last
  week than the first?
• Is part of your teaching objective to encourage
  independence?
• Has the resident acquired skills for which he/she
  is justifiably confident?

22
Thank You

• This module was written as an aid to the
  Preceptors in the Postgraduate Family Practice
  Program at the University of BC.
• Study credit is available to groups of preceptors
  who complete the module
• Please give us your feedback on the module so
  that we may improve it for others.
• Email you comments to Dr. Fraser Norrie, Faculty
  Development, UBC Family Practice
• fraser.norrie_at_vch.ca