ATTENDING MODELING of End-of-Life Care

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ATTENDING MODELING of End-of-Life Care
James Hallenbeck, MD VA Palo Alto HCS
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GOALS

• Introduce T-L-C Educational Model
• Identify special challenges of attending role
  modeling
• Suggest specific techniques used in modeling
• Get you excited about role modeling as an
  educational intervention

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Seven Educational Categories

• Learning Climate
• Control of Session
• Communication of Goals
• Promotion of Understanding and Retention
• Evaluation
• Feedback
• Promotion of Self-Directed Learning

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Lots of questions...

• Everybody talks about role modeling but
• Is being a great physician enough to be a great
  role model?
• What skills/techniques are useful?

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T-L-C EDUCATIONAL MODEL
TEACHER
LEARNER
CONTENT
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TEACHER CONNECTED WITH LEARNER
TEACHER
LEARNER
PATIENT
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The Challenge...

• How does the teacher immerse himself or herself
  in the role without loosing the learner?
• Specifically, how does the teacher facilitate the
  learners involvement with the content, if the
  teacher is on stage?

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TEACHER IMMERSED IN CONTENT
TEACHER
LEARNER
PATIENT
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The Big Picture

• The goal of education is to foster an enduring
  relationship between the learner and the content.
• Content areas include
• Attitude
• Knowledge
• Skill

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EDUCATIONAL OBJECTIVE
LEARNER
CONTENT
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The Context
Questions to ask...

• Part of continuity experience?
• Linked to didactic session(s)
• Who are the learners?
• ? Mixed skill levels or homogenous
• Special learning opportunities?

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Setting a theme

• Useful especially if seeing patients in series
• May link to didactic session, special learner
  needs and learning opportunities
• Assign learner tasks within a theme
• Examples
• Why is this patient here?
• Look at the walls and tabletops
• What does home mean to this patient?

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Three phases of the patient encounter

• Before
• During
• After

Each phase has its own skills
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Before seeing the patient

• Reinforce theme, if present
• Collect data
• Set patient specific tasks-
• That you wish to accomplish
• Tasks for learners

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A word about tasks

• Tasks may be
• Cognitive
• Determine how we might adjust pain meds
• Observational
• Watch to see what techniques I use to put the
  patient at ease
• Behavioral
• When Im done, examining him, I want you to try
  it

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The patient encounter

• Goal- Immerse yourself totally in the
  relationship, but continue to involve the learner
• Analogous to a good actor- must become the role,
  but in a manner that allows the audience to see
• This so difficult- its a life-time practice

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The Echo

• Definition A verbal reflection of internal
  thought processes
• Method
• Explain what you are doing
• Filter what you dont want patient to hear
• Interpret what you mean so patient/family can
  understand
• Example Patient with red-eyes

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The Lateral Pass

• Definition A means of changing roles to
  facilitate new forms of interaction
• Method Make patient (or learner) the teacher
• Examples
• Difficult math problem
• Youre the one with pain, what can you teach us
  about pain (or dying)

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Separating what is modeled from modeling technique

• What do you wish to model?
• Example respect
• What method do you wish to use?
• Example sitting with patient, using last name
• What effect do wish this have have on learners
• Example change in attitude, behavior

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After the patient encounter

• Opportunity to re-connect learner to content
• What questions do you have?
• Opportunity to evaluate
• What did you see?
• What was I trying to show when I
• Time to comment- fill in the blanks
• Time to reinforce/summarize

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Learners goals

• Important to identify
• Adult learners tend to filter information in line
  with their goals
• If not addressed a barrier to learning new
  information
• Opportunity to demonstrate respect
• May tailor modeling (or other educational
  encounters) to these goals

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Teaching un-traditional medicine in a traditional
medical environment

• Modeling a different kind of care
• Traditional medical environment has strong
  rules/rituals
• May be an ally (familiar turf to teacher/student)
• May be a foe (rules of the game may get in the
  way of what you are trying to teach)
• Example Pimping
• How to detoxify questions

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Teaching from ignorance

• We cant know everything
• Great potential in teaching from ignorance
• Importance of modeling comfort with
  ignorance-balanced by desire to learn
• Potent tool to connect learner to content
• Requires self-confidence

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SUMMARY

• Modeling- a powerful teaching method
• Little formal work done on the skills involved in
  modeling in medicine
• Definable, teachable modeling skills exist
• By working on your skills, you will become a more
  effective teaching