ATTENDING MODELING of

End-of-Life Care

James Hallenbeck, MD

VA Palo Alto HCS

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

Seven Educational Categories

• Learning Climate

• Control of Session

• Communication of Goals

• Promotion of Understanding and Retention

• Evaluation

• Feedback

• Promotion of Self-Directed Learning

Lot’s 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?

TEACHER LEARNER

CONTENT

T-L-C EDUCATIONAL MODEL

TEACHER LEARNER

PATIENT

TEACHER CONNECTED WITH LEARNER

The Challenge...

• How does the teacher immerse himself or herself in the role without loosing the learner?

• Specifically, how does the teacher facilitate the learner’s involvement with the content, if the teacher is ‘on stage’?

TEACHER LEARNER

PATIENT

TEACHER IMMERSED IN CONTENT

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

LEARNER

CONTENT

EDUCATIONAL OBJECTIVE

The Context

• Part of continuity experience?

• Linked to didactic session(s)

• Who are the learners?– ? Mixed skill levels or homogenous

• Special learning opportunities?

Questions to ask...

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?”

Three phases of the patient encounter

• Before

• During

• After

Each phase has its own skillsEach phase has its own skills

Before seeing the patient

• Reinforce theme, if present

• Collect data

• Set patient specific tasks-– That you wish to accomplish– Tasks for learners

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 I’m done, examining him, I want you to try

it”

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- it’s a life-time practice

The Echo

• Definition: A verbal reflection of internal thought processes

• Method:– Explain what you are doing– Filter what you don’t want patient to hear– Interpret what you mean so patient/family can

understand

• Example: Patient with red-eyes

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– “You’re the one with pain, what can you teach

us about pain (or dying)”

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

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

Learner’s 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

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

Teaching from ignorance

• We can’t 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

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