Supervising the Learning Environment

Shannon L Venance MD PhD FRCPCJanuary 24, 2014

Continuing Professional Development

My Guidelines

To share best practices and tips on methods and structures to promote excellence in teaching

Teaching Tips What questions to ask of learners? How to give learners feedback?

OverviewOverview

Introductions Reflections on Teaching 4 elements of clinical

teaching: Objectives Priming Questioning Feedback

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As a result of this session, participants will be able to: Use learning objectives appropriate for level of

learner Use priming prior to sending a trainee to assess

a patient Use questioning to facilitate deeper learning Provide constructive feedback to students to

enhance their learning; Create an environment conducive to learning

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ObjectivesObjectives

Be willing to teach and learn from medical students, residents, other colleagues, and other health professionals (CMA Code of Ethics)

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Teaching: A Professional Teaching: A Professional ResponsibilityResponsibility

REFLECTIONS ON TEACHINGREFLECTIONS ON TEACHING

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•What is a your role in teaching?•What have been your most/least effective learning experiences?•What have been your most/least rewarding teaching experiences?

Focus should be on the learner, not on the teacher

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It’s About the Learner…It’s About the Learner…

are independent and self-directing can draw on their experience as a rich

resource for learning value learning that integrates with

demands of their everyday life are interested in immediate, problem-

centred approaches are more motivated by internal than

external drives

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Adults as learners …..Adults as learners …..

Seven Principles to Guide Seven Principles to Guide TeachingTeaching

1. Learners should be active contributors to learning process

2. Learning should closely relate to understanding and solving real life problems

3. Learners should be given the opportunity and support to use self-direction in their learning

4. Current knowledge and experience are critical to learner understanding of new situations

5. Opportunities for practice with feedback are important6. Opportunities for reflection are important7. Role models are influential

Lack of clear objectives and expectations Focus on factual recall > problem-solving Pitched at the wrong level Passive > active learner participation Inadequate supervision and feedback Limited opportunity for reflection/discussion Teaching by humiliation Lack of respect for patient privacy/dignity Lack of congruence with remainder of curriculum

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Common Problems with Clinical Common Problems with Clinical TeachingTeaching

OBJECTIVESOBJECTIVES

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instructional objective; performance outcome a statement in specific and measurable terms

that describes what the learner will be able to do as a result of the activity

1 or 2 learning objectives/encounter

e.g. After watching the video and practice, the 3rd year surgical clerk demonstrates the correct technique for tying a two-hand square knot.

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Learning Objectives

Specific and clearly StatedMeasurable and ManageableAttainableRealistic and RelevantTime-bound and Trackable

SMART Objectives

objectives, feedback and assessment - why?

Accreditation

Standards-based, peer review process Continuous quality improvement An external lens Two independent processes

Undergraduate (LCME/CACMS) Postgraduate (RCPSC/CFPC)

Examples of UME Standards

ED-3: dissemination of the educational objectives

ED-5A: active learning, independent study and life long learning

ED-24: resident preparation for teachingED-27: direct observation of student

performanceED-30: formative and summative

assessment

PRIMING & CLINICAL PRIMING & CLINICAL REASONINGREASONING

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A teacher – directed orientation of the learner to the patient and the task before the interaction

Serves to focus the learner to increase the efficiency of the interaction

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PrimingPriming

TASK – clearly define what the learner needs to accomplish; specify the time frame

YOUR ROLE – be clear about how you will reconnect with the learner

PATIENT – briefly discuss patient related issues

PRODUCT – outline what the trainee is expected to produce at the end of the encounter

Four Elements of Priming

Specific needs assessment and determination of goals and objectives

Ever work in this environment before? (i.e. E.R., wards)

Ever see or manage a case like this before?Define the task

Separate and acknowledge the difference between the learning objectives and the service requirements

Define what questions/issues will need to be answered following the case What is the diagnosis or differential diagnosis? How will we manage the symptoms? What are the patient’s outcome goals? What is the prognosis?

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Priming

Establish realistic learning objectives Trainee level appropriate

Allow time for learner to organize knowledge beforehand

Question to probe for understanding and to identify any potential problems

Encourage questions and clarifications before the encounter

Tips for Priming

Think of a clinical scenario in which you would routinely send a trainee to assess a patient

Take a few minutes to consider how you might “prime” the trainee

Pair off, and “practice priming”

How did it go?

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Your TurnYour Turn

Model of teaching in the clinical setting Facilitates making the most of the case

presentation experience

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The One-Minute PreceptorThe One-Minute Preceptor

1. Get a commitment2. Probe for supporting evidence3. Reinforce what was done well4. Give guidance about errors and omissions5. Teach a general principle6. Conclusion

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The One-Minute Preceptor The One-Minute Preceptor MethodMethod

Get learner to verbally commit to an aspect of the case What do you think is going on with this

patient? What tests do you think we should order? What treatment do you recommend?

GOAL: gain insight into learner’s reasoning

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Get a CommitmentGet a Commitment

Explore the basis for the learner’s opinion Resist the urge to pass judgment on their

response What factors in the history and physical

support your diagnosis? Why would you choose that particular

medication?

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Probe for Supporting EvidenceProbe for Supporting Evidence

Positive feedback should be specific to be helpful “You correctly recognized the localizing

significance of the motor findings” “You appreciated some important

contraindications limiting the treatment options for this patient”

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Reinforce What Was Done WellReinforce What Was Done Well

Again, be specific “Organizing your physical examination in a

standard sequence will help avoid potentially important omissions”

“I agree that an MRI could offer useful information, but the results of blood work may have a more immediate impact on management”

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Give Guidance About Errors and Give Guidance About Errors and OmissionsOmissions

Brief, focused teaching drawing on the encounter

There are many possible points that could be made around any given case

Be flexible

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Teach a General PrincipleTeach a General Principle

Roles1. Medical Expert2. Communicator3. Collaborator4. Manager5. Health Advocate6. Scholar7. Professional

Teaching can be around any of these roles

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CanMEDS Roles

Respects importance of time management in clinical teaching

Ends the teaching interaction Defines role of learner going forward Don’t rely on the learner to limit or cut off

the interaction – our role!

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ConclusionConclusion

QUESTIONINGQUESTIONING

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What makes a question helpful vs. not helpful?

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Questions – good & badQuestions – good & bad

Questions that clarify the clinical story: Fill in gaps in the case presentation Understand the case presentation

Questions that facilitate learning: Promote needs assessment Facilitate knowledge retrieval and integration Stimulate deeper thinking Explore attitudes & feelings Get students into the habit of asking their own

questions BOTH question types can be educational

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Two Main Types of QuestionTwo Main Types of Question

Open vs. Closed Questions

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Closed-ended:

“What is the usual starting dose for simvastatin?”

“What is the name for procedure Z?”

“What is the target BP for a patient with diabetes and hypertension?”

Open ended: “What diagnoses are

you considering?” Why do you think

that? “What might be some

contributors to Mr. Jones heart attack?”

“How would you justify the use of test X in this case?”

Avoid playing “Guess what I’m thinking.” e.g. “What do you think is the key to success in

managing hypertension?” You’re thinking about adherence but…. the

reasonable answers could include regular follow-up clear explanations appropriate drugs and doses discussion of potential side effects how they will be monitored or…. 36

Questioning TipsQuestioning Tips

Include questions that help students explore their attitudes and feelings

How would you describe that patient’s impact on you?

What made that a difficult encounter?

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Questioning TipsQuestioning Tips

“What assumptions are you making about this patient?”

“Did anything surprise you about this encounter?”

“Is there other information you could ask to facilitate your decision-making?”

“Would you do anything differently next time?”

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Questions to Promote ReflectionQuestions to Promote Reflection

Ensure sensitivity to patients’ needs (questions which may be confusing, embarrassing or frightening)

Balancing clinical teaching and clinical care

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Address the Effect of Questioning in Front of Patients

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FEEDBACKFEEDBACK

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Were our learners Were our learners successful? How are successful? How are

they performing?they performing?

of the learner linked to the learning objectivesspecified at the beginningformative and/or summativeachievement of intended outcomes

AssessmentAssessment

Formative

Summative

Brainstorming AssessmentBrainstorming Assessment

Formative Guides learning and next steps Assessment for the learner (Feedback) No grade attached

Summative Measures achievement Assessment of the learner (Evaluation) Formal grade assigned

AssessmentAssessment

CharacteristicsCharacteristics

FORMATIVEspecific, descriptivebased on observations and behaviours timely and well-timed frequent, small amountsconstructive, corrects mistakes

CharacteristicsCharacteristics

SUMMATIVE fair linked to objectives/outcomesend of study periodbased on standards/normsgrade/mark (pass/fail)a judgment

opportunity for feedback “learning on the job”ensure that time for feedback is

built inpositive when possible; promotes

self reflection and self awareness incorporate self assessment

How do you think you did?What are your next steps?Use a feedback grid?

Clinical SettingClinical Setting

Continue… Begin or do more…

Consider (a stretch)…

Stop or do less…

Developed by the Institute for Health Care Communication

Feedback GridFeedback Grid

Comment on aspects of performance that were effective. Be specific and describe impact.

Identify behaviour the learner knows how to do, and could do, or do more often.

Highlight a point of growth for the learner, a “doable” challenge for future interactions.

Describe actions that were not helpful, or could be harmful. Be specific, and indicate potential impact.

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Begin with learner’s self-assessment Relevant and tied to the goals of the learner Balance positives and“do different”using the

feedback grid Elicit or suggest alternative behaviours Provide opportunity to try out or practice

new behaviours Address realistic changes in“do-able”steps Establish clear follow-up plans

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Feedback

Feedback

Focus on observations, not inferences “You did… vs. you are…”

Focus on descriptions, not judgments “What I observed was… vs. that was inadequate.”

Focus on specific details, not generalities “At the start of the interview with Mrs. Jones, I noticed…vs. your introductions are all

Attend to the learner’s response Feedback may fall on deaf ears if…

It conflicts with self-concept It threatens self-esteem It lacks credibility It fails to align with the learning focus

Creating a learning environment conducive to constructive feedback is key

Feedback

We briefly covered……We briefly covered……

Objectives

Priming

Questioning

Feedback

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Thanks for your attention!Thanks for your attention!

SSMD Office of Continuing Faculty Development workshops excellent opportunities to learn more Teaching Certificate program

Acknowledge Chris Watling for many of the slides

Evaluation forms

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