Teaching Adult Learners

Jacob Prunuske, MD, MSPH

PCFDPOctober 15, 2010

Pictures have been removed from this presentation to ensure adherence to copyright law.

Rules

• Contribute – peer education

• Ask questions

• Speak up when it’s not working

• Share with others after the session

Introductions

• Help me know you!

• Name

• Roles in education

• What you want to learn in this session

Nature or Nurture

• Which has greater influence on teaching?– Nature– Nurture

Nature vs Nurture

• Tribute to hard work…

Kenneth Eble, The Craft of Teaching, 1988

Teaching is complex

• Content – knowledge & skills

• Instructional methods• Learner factors• External demands

Druckman & Bjork Learning, Remembering, Believing: Enhancing Human Performance.National Academy of Press, 1994

Objectives

• Incorporate small group facilitation skills into your teaching repertoire to improve your teaching evaluations

• Become a more efficient teacher in the clinical setting and leave earlier when working with learners

• Model professionalism for your learners

When you are the learner…

• Ineffective

When you are the learner…

• Effective

When you are the learner…

• Share

Pedagogy

Adults learn best when…

• Relevant & practical• Patient or Problem Focused• Safe Learning Environment - respect• Autonomy/self-direction• Goal oriented• Feedback• Active & engaged• Build on existing experiences/knowledge

RadioGraphics 2004; 24:1483–1489

Roles in student education

• Small Groups

• Patient Care– Outpatient– Wards

• Didactics

• Others

Small group facilitation

Small group development

• Forming

• Storming

• Norming

• Performing

• Adjourning

Tuckman, B. (1965) Developmental Sequence in Small Groups. Psychological bulletin, 63, 384-399

Tuckman, B & Jensen, M (1977) Stages of Small Group Development. Group and Organizational Studies, 2, 419-427

Forming

• Safe, simple, avoid controversy• Look to leader for guidance & direction• Desire for acceptance by other members• Explore similarities & differences• Orientation to tasks

Storming

• Interpersonal conflict and competition

• Task organization – how to get it done

• Exploring boundaries

• Testing leader

• Structural clarification– Responsibilities, rules, rewards– Evaluation criteria

Norming

• Group Cohesion

• Engaged

• Acknowledge others’ contributions

• Change opinions & preconceived ideas

• Increased trust

• Sense of belonging

Performing

• Interdependence & flexibility

• Roles & responsibilities shift to meet need

• Functional independence

• Strength in diversity

• Group identity, loyalty, high morale

• Energy directed at tasks

Adjourning

• Role end

• Task completion

• Reduction of dependency

• Sense of loss

Integration

• 1 minute

• Write down 1 – 3 things you just learned

Environment

• Room shape/size• Table shape/size• Power positions• Lighting• Technology• Group Dynamics

Small group facilitation

• In the Beginning…

The Creation of Adam. Michelangelo. 1508-1512.

Small group facilitation

• In the Beginning…– Introductions, learn names– Expectations– Start on time– Invite learners’ opinions, independent thinking– Outline the session– Confidentiality– Model respect– Acknowledge your own limitations

Facilitating discussion

Facilitating discussion

• Stop talking

• Actively listen

• Use names

• Make eye contact

• Enthusiasm for all contributions (not just ‘right’ answers)

• Encourage peer teaching

Witnessing

Role playing

• Initiator• Reconciler• Pathfinder• Supporter

• Aggressor• Interrupter• Hijacker

• Silent Participant• Talker• Joker• Instant Expert

Closing a small group session

• Summarize

• Identify unmet goals

• Homework

• Plan for next session

Integration

• 1 minute

• Write down 1 – 3 things you just learned

Clinical teaching

Doctor as teacher: roles

• Instructor: Convey information• Evaluator: Assess competence• Doctor: Patient well-being and comfort• Colleague: Want to be liked/respected• Mentor: Role Model• Recruiter: Convey enthusiasm for discipline• Business person: Do it all without significant loss

of productivityJohn Brill, MD, MPH

Contribution to theHidden Curriculum

• Knowledge• Attitude• Behavior• Skill

Mind what you have learned. Save you it can.-Yoda

RIME

• Observer (early m1)

• Reporter (late m1/m2)• Interpreter (early m3)• Manager (late m3/m4)• Educator (residents)

Pangaro L. Academic Medicine 1999;74(11):1203-7.

Sepdham et al. Fam Med 2007;39(3):161-3.

Relevant

• Know the educational goals of the clerkship or experience

• Congruent with present

Tips for efficiency

• Establish teaching environment

• Communicate with everyone involved

• Tailor to learner’s needs

• Share teaching responsibilities

• Keep observation/teaching brief

• Broaden learner responsibilities

Biagioli F, Chappelle K. How to be an efficient & effective preceptor. Family Practice Management. May/June 2010

ONE MINUTE PRECEPTOR

Barrier Exercise

• In groups of two…

• Identify & write down as many barriers as you can to “Ideal” ambulatory teaching

• You have 1 minute!

Barriers

• Preceptor factors• Learner factors• Patient factors• Office factors• Healthcare system

factors

Learners

• Disrupt patient care

• Decrease clinical productivity

• Lengthen work day

• Want to grow & develop

• Want to demonstrate knowledge & skill

• Want feedback & fair assessment

Scenario A

• Two volunteers please…

Traditional Precepting

• Patient care focused, not learner focused

• Low-level questions to clarify clinical data

• Mini-lectures

• Little or no feedback

• May be associated with decreased student satisfaction and learning

• Difficult to assess learner’s thought processes or level of understanding

One Minute Preceptor*

1. Get a commitment2. Probe for underlying reasoning3. Provide positive feedback4. Teach general rules5. Correct errors

* Neher, Gordon, Meyer, Stevens. A five-step “microskills” model of clinical teaching. JABFP 1992

Get a commitment

• Cue: The learner stops & looks at you…

• Action: Ask learner to commit to a diagnoses or plan

• Reason: 1st step in diagnosing learning needs, provides focus for teaching

• Example: Want do you think is going on?

Probe for Underlying Reasoning

• Cue: The learner looks to you to confirm dx/plan or suggest an alternative

• Action: Ask learner for evidence and/or DDx; do NOT give your opinion

• Reason: Insight into thought processes & knowledge; identify gaps

• Example: What facts support your conclusion?

Provide positive feedback

• Cue: Learner did good

• Action: Identify and comment on 1 specific good thing the learner did, and the effect it had

• Reason: reinforces skills

• Example: You listened well, allowing the patient to trust you and disclose a sensitive issue she was concerned about.

Teach general rules

• Cue: Learner needs to know something

• Action: Teach general rules or concepts targeted to the learner’s level of understanding

• Reason: memorable & transferable

• Example: In a young woman with abdominal pain, you should always consider the possibility of pregnancy

Correct Errors

• Cue: Error, omission, misunderstanding

• Action: Choose time/place, learner self-critique, discuss error and prevention

• Reason: Errors uncorrected will repeat

• Example: You may be right that this patient is drug-seeking, but you have to consider other possibilities for his pain and do an exam.

Scenario B

• Two more volunteers…

One Minute Preceptor

• Learner-centered

• Supports assessment of learner’s knowledge and clinical reasoning skills

• Supports focused teaching to learner’s needs

• Encourages feedback to reinforce desired behaviors and reduce undesired behaviors

OMP

• Effective for both teaching & patient care– Preceptors as good or better at correctly

diagnosing patient’s medical condition– May provide more information in same

amount of time (or same info in less time)

Aagaard E, et al. Academic Medicine Jan 2004

In groups of 3

Practice Case• Role 1 = Student• Role 2 = Preceptor• Role 3 = Observer for this exercise

• Student starts, Preceptor uses OMP• Observer to provide feedback• 8 minutes to complete

FEEDBACKDr. Jeremy Smith

Integration

• 1 minute

• Write down 1 – 3 things you just learned

Professionalism

Commitment to…

• Professional competence

• Honesty with patients• Patient confidentiality• Maintaining

appropriate relations with patients

• Improving quality of care

• Improving access to care

• A just distribution of finite resources

• Scientific knowledge• Maintaining trust by

managing conflicts of interest

• Professional responsibilities

Contemporary Role Models

• House

• Scrubs

• Grey’s Anatomy

You must unlearn what you have learned.- Yoda

Model Professionalism

• Responsibility– On time, task completion

• Maturity– Response to failure, stress, feedback

• Communication– Sarcasm, volume, disruptive

• Respect– Patient, sensitive to others, discrimination

Proc (Bayl Univ Med Cent) 2007;20:13–16

Respect for specialties

• Bashing occurs on all rotations• 67% students: non-constructive criticism• 79% students: bashing unprofessional• Source of negative comments

– Faculty 42.5%– Resident 55.3%– Student 55.4%

Holmes et al. Fam Med 2008;40(6):400-6.

Campos-Outcalt et al. Fam Med 2003;35(8):573-8.

When it’s not working

• Connect with…– Self– Learner– Clerkship/course director– Dean of students– Residency director– Med Ed office– Dept. Chair

• DOCUMENT

Integration

• 1 minute

• Write down 1 – 3 things you just learned

Objectives

• Incorporate small group facilitation skills into your teaching repertoire to improve your teaching evaluations

• Become a more efficient teacher in the clinical setting and leave earlier when working with learners

• Model professionalism for your learners

Discussion

Thanks!