pgy 1 retreat 6/16/15 thinking about education how to be a good ward resident- small groups with the...
TRANSCRIPT
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PGY 1 Retreat6/16/15
Thinking about education How to be a good ward resident- small
groups with the Chiefs Intern class reflection Changes for next year; administrative
issues; misc…………..
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But first………
Working alone, list the top 10 drugs prescribed in the United States in 2015 in terms of the number of monthly perscriptions…..
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Now, repeat this exercise, working in small groups with the people sitting near you……..
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Number of monthly perescriptions
1.Synthroid, 22.6 million
2.Crestor, 22.5 million
3.Nexium, 18.6 million
4.Ventolin HFA, 17.5 million
5.Advair Diskus, 15.0 million
6. Diovan, 11.4 million
7. Lantus 10.1 million
8. Cymbalta, 10.0 million
9.Vyvanse, 10.0 million
10. Lyrica, 9.6 million
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As a resident- your job is to foster a positive team environment Emotional intelligence Working in teams
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Giving Feedback
Keith Armitage Case Western Reserve University
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Giving Feedback
Case scenarios
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Introduction
Defining feedback The importance of feedback Examples of good and bad feedback Techniques for giving feedback
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Feedback is not criticism!! You are a coach
The ability to reflect……an essential part of modern medical practice
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Introduction
Most feedback in medical education is self feedback based on the observation of self and others.
Depends on the ability of the learner to give self feedback. Most good internists have this ability. Optimally self feedback is confirmed and
augmented by external feedback.
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Defining feedback
Rocket science model “Feedback in the control of a system by
reinserting into the system the results of its performance……if the information is able to change the general method and performance, we have a process which may be called learning.” Humans are more complex; clinical
performance is more complicated than rocket science
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Defining feedback
Formative Non-judgmental; presenting information, not
judgmental Rocket science model Neutral, not “good” vs. “bad” “coach”
Summative After the fact, sum of performance, grade “evaluation,” compared to peers “judge”
vs. encouragement
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The importance of giving feedback
Obligation in all training situations Learner feels adrift without feedback Misinterpretation of nonspecific signals Bi-directional!
Role of providing information/corrective action
Correction of mistakes in the clinical setting “Vanishing Feedback”
Monthly faculty reminders
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Examples of “good” and “bad” feedback
Good Timely, specific, nonjudgmental, devoid of
emotion, private/appropriate setting, given in climate of trust, diagnostic/useful, goal oriented, focused on performance, not personal, supportive, objective, occurrence based, useful
Bad Vague, public, given in anger, non-timely,
personal, “punishment,”
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Examples of good and bad feedback, cont
“Your differential diagnosis was O.K., but you might have also considered tuberculosis.”
“Your differential diagnosis was poor/inadequate.”
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Techniques for Giving Feedback
The sandwich Beginning and ending with positive
observations Positive feedback- corrective feedback-
positive feedback
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Techniques for Giving Feedback, cont.
The Club Sandwich Reinforce success Corrective feedback Affirmation in your belief that the learner
can move forward Plans for moving forward Commitment to support them in their
plans
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The Club Sandwich, cont.
I am impressed that you know your patients labs so well
The critical next step is interpreting the labs; for instance, describe the anemia as microcytic, and discuss what this means
I am confident that you can take this next step Do you have ideas about how to do
accomplish this? I would be happy to help work with you on this
issue
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Techniques for Giving Feedback, cont.
Micro feedbackSmall opportunities with students as they
arise Capitalize on the moment
Catch them doing something well Good history- he was a tough guy to talk to
Use a nonjudgmental rule statement When patient come in with so and so, it is important to
ask about Give the learn a chance to re do their performance
Why don’t you go back and ask about
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Techniques for Giving Feedback, cont.
The “tell me how you think you are doing.”
Take advantage of situations as they arise in the clinical setting.
Focused on goals “Do you want to be the best intern/doctor you
could be?” Turn “negative” feedback into challenge
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Techniques for Giving Feedback, cont.
Assess learners level of receptivity to feedback
Encourage learners to ask for feedback Test your hypothesis about what the
problem is Diagnosing your learners
Avoid overloading Follow-up is key
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Impediments to giving feedback
Time Inadequate observations Time to meet
Concern over popularity “Not wanting to hurt feelings,” damage
student teacher relationship
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Techniques for Giving Feedback, cont.
Avoid focusing on personality traits, unless they affect clinical care
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Impediments to giving feedback
Past experiences that were emotionally difficult; fear that feedback will elicit an emotional reaction Concerns about the impact of feedback
leads to no feedback at all
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Impediments to giving feedback
Humiliation External emotion that can be avoided if the
teacher provides nonjudgmental feedback
Embarrassment Internal emotion, sometimes can’t be
avoided, may be motivational Dealing with tears/anger
Emphasize your willingness to help and their ability to improve
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Now that you are a believer in feedback
Feedback is bi-directional Please take evaluation of your attendings seriously Cumulative data with comments is returned to
attendings Promotion and tenure
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Armitage’s general hints for dealing with feedback/administrative situations
Never begin a conversation in anger or assuming the other person is at fault
If you make the issue patient care, you will (almost) always win Always make it patient centered
Kick it upstairs
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Mindfulness
Paying attention, on purpose, to one’s own mental and physical process during everyday tasks to act with clarity and insight
(the first thing you do at a code…….)
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Habits of Mindful Practitioners
Attentive observation Processing….
Critical Curiosity Tolerating and ‘enjoying’ being wrong
Presence Control of anxiety Egoless focus on tasks Tolerating contradictory ideas Compassion based upon insight
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Mindfulness
Understanding your reaction to patients
Incorporating ethics into decision making
Reflection…..! Being purposely mindful
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And Finally- another10 minutes on education
Models of learning 1 minute preceptor
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RIME
Reporter Interpreter Manager Educator
Diagnosing the learner….
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The One Minute Preceptor
What do you think? Why do you think that/what else did
you consider What I am thinking Where do we go from here- positive
feedback and next steps
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Teaching the 4 C’s of Effective Oral Presentations on Work Rounds
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The 4 C’s of effective oral presentationwill only be successful . . .
. . . if the resident sets the expectations at the start of a rotation
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Remember the 4 C’s
COHERENT
CONCISE
COMPLETE
COMPELLING
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COHERENT
Introduction (one sentence!) Subjective
Vital signs I/O’s Physical Exam (pertinent)
New study results Review of chart (nurses notes, etc)Assessment and Plan:
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CONCISE ( 1-2 minutes)
Essential
Pertinent
Uncluttered
The student should be . . . brief and lucid
The student should speak . . . crisply and clearly without notes
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The 4 C’s algorithm will be successful only with
APPROPRIATE FEEDBACK
“Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all”
- Jack Ende, M.D.
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Four steps of clinical teaching Needs assessment Teaching to the learner Feedback Reinforcement
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Teaching Clinical Reasoning“On the Fly”
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Key Points to Remember
Teach while you work
Clinical reasoning is most effectively taught as you care for patients together, not in a lecture hall or conference room
Live what you teach
If you don’t “role model” sound clinical reasoning as you discuss all your patients, the students won’t think it’s really important
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Bottom Line
Teach as you work and live what you teach!
Be systematic and think out loud What are the problems? Foreground and
background.
What’s the differential? Focus on likelies and high stakes possibles.
Let your differential drive work-up and management
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Long term career goals…
Use elective time for scholarly projects Work with clinical mentors Meet with your PD to discuss….. If you are interested in subspecialty
training- apply at end of PGY2 year..