web viewif we want to have a model teaching program, we need to staff that program with model...

Faculty Development Workbook2nd Edition

Faculty Development FellowshipDepartment of Family Medicine

Madigan Healthcare SystemTacoma, Washington 98431

Preface

If we want to have a model teaching program, we need to staff that program with model faculty. If we want model faculty, we must train them. Recognizing the importance of ongoing training for teaching staff, the ACGME includes faculty development as a common program requirement for residency education. Every ACGME certified training program must engage in faculty development and document how this is done. To be successful, faculty development needs to be an integral part of the process of training interns, residents and students. In fact, the quality of a training program may be judged, in large degree, by the quality of the faculty development it provides.

The purpose of this workbook is to make faculty development both more robust and easier to accomplish. This workbook contains eight sections that address core faculty skills. Each section has a preparation checklist, learning needs and resources assessment, attendance roster, evaluation sheets, an example of how the material could be taught, handouts and background material for the presenter. The accompanying DVD has this same material plus an example of a PowerPoint presentation that can be modified to meet the needs of your faculty.

We hope that you will use this resource to improve your training program. This workbook is designed to be a starting place. It is in no way an exhaustive manual on all things faculty development. To become or remain a model program, each site will need to grapple with its own challenges and provide the needed faculty development to meet those challenges. Please use and adapt this workbook to your needs.

Sincerely,

The Faculty Development Fellowship

Madigan Healthcare System

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Acknowledgements

This is the second edition of the Faculty Development Workbook. Much of the basic content finds its origins in the original Video Workbook created over fifteen years ago by Dr. Fred Miser and the Faculty Development Fellows under his leadership. Much of what is found in the original workbook harkens back to the work of fellows many years previous to that. We gratefully acknowledge the work of Fred Miser and so many others who, through their insightful work, made this second edition possible.

This current edition was assembled in November, 2011 by the following individuals:

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Shawn Alderman Scott GroganDavid Brown Kevin KellyTien Bui Garrett MeyersGary Clark Kristian SanchackAmanda Cuda Erik SchweitzerJason Ferguson Mark Stackle

Please send us your comments, additions, deletions, corrections and questions:

[email protected]

The Faculty Development Fellowship is a two year, degree producing fellowship open to active duty Army, Navy and Air Force physicians of all specialties. The Fellowship’s focus is to produce world class teaching faculty and leaders prepared to change the world. For more information about the fellowship, please use the above email.

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The ideas and concepts put forth in this work book represent the opinions of the authors and not those of the Department of Defense.

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Table of Contents

Chapter Topic Page

One Active Learning: Dialogue Education, the Eight Steps of Planning and the Four I’s 4

Two Excellence in Clinical Teaching 26

Three Giving Dynamic Presentations 48

Four Bedside Teaching 64

Five Giving Effective Feedback 82

Six Small Groups and Effective Discussion 102

Seven House Officer Evaluations 120

Eight The Teaching Clinic Preceptor 146

Chapter Contents

Each chapter contains the following resources:

Group Leader ChecklistLearner Needs and Resources Assessment (LNRA)Attendance SheetEvaluation FormExample Eight StepsHandoutSummary of Supporting References and Resources

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Chapter 1Dialogue Education:

Active Learning, the Eight Steps of Planning, and the Four I’s

Faculty Development SeriesMadigan Healthcare SystemTacoma, Washington 98431

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Dialogue Education: Active Learning and The Eight Steps of Planning

Checklist for the Group Leader

Before the Session...

___ 1. Review the suggested eight steps of planning for this presentation.

___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.

___ 3. Duplicate and distribute the LNRA to faculty.

___ 4. Have faculty return the LNRA at least 5 days before the session.

___ 5. Review the faculty LNRA prior to the session.

___ 6. Modify the suggested eight steps and write your plan to fit your needs.

___ 7. Modify the PowerPoint and handout to fit your plan.

___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation forms, and handouts.

During the Session...

___ 9. Have each participant sign-in using the attendance roster.

___ 10. Distribute the handout(s) to the participants.

___ 11. Conduct the session based on your eight steps of planning.

After the Session...

___ 12. Collect the evaluation forms from the faculty.

___ 13. Keep the attendance roster for the session in your department and provide the appropriate amount of CME to each participant.

___ 14. Reflect on the seminar - How did it go? What was good about it? What could have been better? Is there a better approach to this topic? Were there needs identified during this session that would be the basis for future seminar(s) in your program?

___ 15. Where will your program go from here based on this seminar?

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Learner Needs and Resources Assessment

Please complete the following needs assessment for the upcoming seminar on Dialogue Education: Active Learning, Designing a Successful Learning Event as part of your faculty development program.

The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, and a discussion period.

The purpose of this needs assessment is to determine your learning needs and interests, so that the seminar is most useful for you. This needs assessment should also stimulate you to think about active learning before the seminar begins. We need your enthusiastic participation now, and in the seminar. It will be fun, and at the end of it, we'll be asking for your feedback!

Please turn this in to your group leader (______________) no later than (_____________). Your group leader will return this form to you at the beginning of the session. 1. Have you any formal training in characteristics of Dialogue Education/Active Learning? Yes No

2. How much of the content taught in your residency lectures is actually retained by the learners?

5-10% 10-30% 30-50% 50-70% 70-100%

3. Describe the typical format of lectures/learning activities in your department:

4. What active learning activities have you used in your presentations?

5. List three things you would like to learn/take away from this session:

a.

b.

c.

Any other comments / concerns for this presentation:

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ATTENDANCE ROSTER – Page____of_____Pages

Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Series – Dialogue Education: Active Learning, Designing a Successful Learning Event

Course Content: Didactic, and Group Discussion –An Introduction to the Eight Steps of Planning a Learning Event

Instructor (Group Leader):____________________________

Date:____________ Time: Began___________ Ended________ Total ___________

Name RankCheck One

Department or Mailing AddressStaff

PhysicianResident Physician

Other Professional Discipline

Total Number of Learners Attending This Activity: _________

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Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Series – Dialogue Education: Active Learning, Designing a Successful Learning Event

Course Content: Didactic, and Group Discussion –An Introduction to the 4 I's of Learning Tasks



Name RankCheck One





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Faculty Development Session Evaluation Form

Date Speaker Topic

Please rate the speaker using the scale below:

Strongly Disagree

Disagree

Somewhat Agree

Agree Strongly Agree

Content was relevant to my needs

The speaker conveyed the subject matter clearly

The speaker used active learning techniques to teach this subject

The speaker gave adequate time for questions

Audiovisual / handout material added to the presentation

Overall, the speaker was effective

List one thing that you learned from this presentation:

Please add your comments/suggestion for improving this session on the back—they are VERY helpful


Date Speaker Topic


Strongly Disagree

Disagree

Somewhat Agree










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Dialogue Education: Active Learning and the Eight Steps of Planning

Example Eight Steps

The eight steps presented below may be used as a guide for your planning.Modify these steps to meet your specific needs.

Who: 20 faculty learners from the Department of Family Medicine.

Why: Enhance didactic teaching as part of a required faculty development curriculum. The intent of this chapter is to emphasize that knowledge transfer from traditional lecture-and-listen presentations is very low. Thus, much of the time that we spend in lectures is lost. With ever increasing demands upon our time as clinical teachers and with seemingly ever increasing limitations to resident work hours, we must become more effective and more efficient in knowledge transfer. Only then will our residents/students leave our programs with the knowledge, skills and attitudes needed to successfully care for patients.

When: 0730-0900 on a Wednesday morning, blocked schedule for faculty development.

Where: Classroom, individual desks, accessible, AV supported, requires own computer.

What: Will explore the eight steps of planning an outstanding learning experience. Informed by the LNRA.

What For: By the end of this session, we will have:

Prioritized the 8 Steps of Planning a Learning Activity Reviewed the 8 Steps Applied the 8 Steps to a future talk Committed ourselves to teaching using active learning techniques

How: General: Active learning: small group activities and discussion, larger group discussion, minimal PowerPoint slides. Room contains individual desk. Will pre-configure desks into larger half-moon shape. Within larger half-moon configuration, will group four desks in smaller half-moon shape for five groups of four learners each. This will facilitate small group activities followed by larger group discussions. The session will take place at 0730, so will provide refreshements.

Grabber: Use the opening slides to get participants thinking about the way we traditioinally teach medical topics.

Induction Tasks: 1. Began with LNRA and continued in first activities. Using the first page of the handout, have the group work in pairs to decide on which two of the 8 steps are the most important, in their opinion. Have each pair share their top two with the

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group and explain why they choose those two. Allow them to ask any questions about the 8 Steps that came up during this exercise. Use the hyperlinked slide to teach about any of the 8 steps that need clarification.

Input Tasks:1. Use the hyperlinked slide to teach about any of the 8 steps that need clarification.

Implementation Tasks:1. Next, have the participants fill in the eight steps on the worksheet for an upcoming (or recently given) learning event. Have them share their plan with their neighbor. Note: skip step 7 as this will be covered in the next presentation.

2. Ask a few participants to share their 8 Steps with the larger group.Be sure to provide lavish affirmation to all who participate.

. Integration Tasks:Ask the participants to commit to using the 8 Steps as they design future learning

events.

So What:Learning: Learners understand the eight steps and how to apply them to their own teaching.

Transfer: Learners begin using the eight steps of planning for their own presentations.

Impact: Departmental didactic teaching is enhanced, improved learning and success for residents.

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Active Learning-Using the 4 I’s to Plan Learning Tasks

Example Eight Steps



Why: Enhance didactic teaching as part of a required faculty development curriculum. The intent of this chapter is to emphasize that knowledge transfer from traditional lecture-and-listen presentations is very low. Thus, much of the time that we spend in lectures is lost. With ever increasing demands upon our time as clinical teachers and with seemingly ever increasing limitations to resident work hours, we must become more effective and more efficient in knowledge transfer. Only then will our residents/students leave our programs with the knowledge, skills and attitudes needed to successfully care for patients.



What: Will explore the eight steps of planning an outstanding learning experience. Informed by the LNRA.


Reviewed the 4 I’s

Listed learning tasks for each ‘I’

Selected learning tasks for presentation

Committed themselves to using the 4 I’s in preparing learning events in the

future

How: General: Active learning: small group activities and discussion, larger group discussion, minimal PowerPoint slides. Room contains individual desk. Will pre-configure desks into larger half-moon shape. Within larger half-moon configuration, will group four desks in smaller half-moon shape for five groups of four learners each. This will facilitate small group activities followed by larger group discussions. The session will take place at 0730, so will provide refreshements.

Grabber: Show the video clip from Ferris Buler and ask learners to ponder what they see happening

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Induction Tasks: 1. Began with LNRA and continued in first activities. In pairs, have the learners discuss the following:

• What did you see happening?• Why was it happening?• When this happens to you as a learner, what do you do?• How can you prevent this from happening when you are teaching?

Input Tasks:1. Use the PowerPoint presentation to teach about the 4 I’s Include the video from Dead Poets Society and ask similar questions of the group as during the inductive task.

2. Using the handout, have the participants familiarize themselves with the definitions of each of the 4 I’s by completing the matching activity. and asking for their questions.

3. Continue with PowerPoint presentation, review an example of the 4 I’s

4. Have the learners brainstorm a variety of learning tasks for each of the 4 I’s and record them on 4 dry erase boards with each board representing a different I. Have the four groups rotate to each of the dry erase boards and add any additional examples of learning tasks they came up with.

Implementation Tasks:1. Have the participants use their handout to record at least one learning activity for each I.

2. Ask a few participants to share their I’s.

Integration Tasks:Ask the participants to commit to using the 4 I s to plan learning tasks for their

next lecture.

So What:Learning: Learners understand the 4 I’s and how to apply them to their own teaching.

Transfer: Learners begin using the 4 I’s for their own presentations.

Impact: Departmental didactic teaching is enhanced, improved learning and success for residents; improved board scores and improved patient care.

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The Eight Steps of Planning1 HandoutDesigning a Successful Learning Event

Consider a future learning event you are involved in planning.

1. Who? Consider number and profile of participants. What do they already know? How do they learn best? Do a learning needs assessment.

2. Why? Consider why this course is important, why the participants need to learn the material and what the need is.

3. When? Consider the timing and length of the event.

4. Where? Consider location. How will the location facilitate active learning tasks? What AV equipment will be available? What will I need to bring with me?

5. What? Describe the content of the course; name the subject matter: what knowledge, skills, and attitudes will be taught?

6. What for? The objectives2: What participants will do with what they have learned.

7. How? In what order will you sequence the material? What learning tasks will you have the participants do with the material? What materials will you need to do these learning tasks?

8. So What? How do they know they know?

Learning: New skills, knowledge, attitudes manifested as behaviors Transfer: Taking the material learned above into your workplace

1 Vella, J. (2002). Learning to listen, learning to teach. San Francisco, CA: John Wiley & Sons, Inc.2 Kern, D.E., Bass, E.B., Howard, D.M., Thomas, P.A. (1998). Curriculum development for medical education: a six-step approach. Baltimore, MD: The Johns Hopkins University Press.

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Objectives should be:

specific, measurable, and expressed as a

verb.

Format suggestion:Who will do how

much (or how well) of what by when?

Example: Participants will list the 8 steps of planning by the end of

this session.

Impact: Systems changes in your organization due to this trainingActive Learning In Action

Directions: Work in pairs to brainstorm your learning tasks for each objective. Some of these will be shared with the large group. Consider how you can apply active learning principles to the

design of the course. Be prepared to discuss your thoughts.

How? Plan the learning tasks for the course.

1. Inductive Tasks – consider open question, grabber, or activity. Draw upon the knowledge, skills and attitudes that the learners bring with them to the learning event.

2. Input Tasks – the presentation of new material that you want the learners to take away with them.

3. Implementation Tasks – learners practice using what was taught during the input phase.

4. Integration Tasks—ways to use the new material taught in clinical practice, a call to action.

Brainstorming about tasks that I could use in my department for other presentations

Inductive -

Input -

Implementation -

Integration -

Call to action

Use the 4 I’s above to plan active learning into your next teaching session.

Be an ambassador for active learning: encourage your staff to do the same.

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Active Learning and Effective Presentations

Elements of Active LearningActivity- so our brains can process information by doing something with it

Variety- so the training will appeal to all of our different learning styles

Participation- with others, so that our learning environment feels safe and we can effectively engage with the topic

The 4 I’s

Inductive - connect with what they know:

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1. Small group discussion – Have the audience break up into groups of four or five and ask them to discuss a patient they have cared for with your subject condition. What difficulties did they encounter in diagnosis, treatment, compliance, referral or co-morbidities? What rewards? Then each small group should pick one person to describe his or her case to the whole room.

2. Quiz – Either true/false or multiple choice quizzes are a great way to open a talk and review boring basics like epidemiology and pathophysiology without a lecture.

3. Worksheet – A resident at Madigan recently began a talk with handout. It was a blank chart listing eleven different types of transfusion reactions, arranged into two categories of either immune-mediated or non-immune-mediated. Before even beginning to lecture, she asked everyone to rank them in order of severity and then in order of how commonly they occur. Learners then filled out the chart as she described the incidence, pathophysiology, signs and symptoms, diagnosis, and treatment of each transfusion reaction. On the back of the handout was a treatment algorithm for transfusion reactions.

4. Role playing – Utilize the aspiring actors in your department to help you illustrate psychosocial aspects of a condition or demonstrate the difference between a clear and concise history and physical and a disjointed one.

5. Actual patient interview – You need sensitivity, judgment, and a sound relationship to approach a patient with this kind of request. But if you know a patient with interesting physical findings or stigmata of a particular condition it is unfair to keep them to yourself. Many patients are happy to help in the education of physicians, especially if you offer to buy them lunch. A real live patient is invaluable in teaching and puts a human face on a disease.

6. Video clip -- ask the learner what they see happening, why is it happening, when it happens to you, what do you do, how can we prevent this from happening?

7. Audience response system -- Audience response system can be used to gather information about the baseline knowledge level of the participants and can be used along the way to check on knowledge transfer.

Input - learn something new:

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1. Videos – There are many excellent medical education videos available for free on the internet.

2. Case-based – Start with a case and develop it using a series of questions such as: What else do you want to know? What is your differential diagnosis? What further studies would you order? What is the etiology of that condition? Teach each topic as you go.

3. Article-based – Distribute the article beforehand and then discuss the article. Alternatively you can go through the article using a worksheet like a Journal Club.

4. Game shows – A game of “Jeopardy!” keeps the audience involved and adds a spirit of competition if you break the audience into groups. One colleague used PowerPoint to design the game “Battleship,” where a correct answer allows the team to choose coordinates to try to find and sink their opponents’ ships. Be sure this is content rich as well as fun as it is easy to have the learning get lost in the fun.

5. Small groups – Provide each small group the resources they need to teach a portion of the subject matter. Give them 15 minutes to learn it and then 10 minutes each to teach it to the larger audience. Initiate a contest after the teaching is over by giving a quiz on the subject material. The small group that teaches their subject the best, wins.

6. Audience choice – Provide a handout of not yet covered material and have the learners fill it out using their own experience and knowledge (A matching worksheet would be a good example). Then provide the answers and ask learners which of the topics they have questions about. Present only the slides that answer their questions.

7. PowerPoint presentation, outlining the new content

8. Reading material, handed out to learners. Each reads and highlights points that speak to him/her. Then each has a turn to present what they highlighted and why. What was missing from the material presented? What did you disagree with?

9. Be an ambassador – Give learners a new identity (each of you is going to be a different type of anemia) and provide them a sheet of paper that describes who they are and what the key characterists are about that type of anemia. These sheets might be on yard around their neck with the type of enemia printed on one side and the information about it on the back.Then ask them to move about the room looking for others who have a different type of anemia. Have them quiz you and you quiz them about that type of anemia. When a pair think they have each other’s anemia mastered, they break up and look for other types of anemia. This continues until each learner has been exposed to every anemia type available. You might follow this with a post-test or jeopardy game with the learners divided into teams. Keep score to see which team gets the most correct.

Implementation - practice what they learned

Integration – take it home and use it

Active Learning Matching Exercise: The 4 I’s

Working with your neighbor, match the ‘I” with the definition:

4 I’s Definition

____ 1. Inductive A. Take it home and use it

____2. Input B. Practice what they learned

____3. Implementation C. Connect with what they already know

____4. Integration D. Learn something new

Supporting References and Resources

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1. Problem solving – After a brief “how to” didactic let the learners solve some problems (cases), either individually or in pairs. Start out easy and build up complexity of problems.

2. Medical equipment – Feeling a bulky O2 canister is very enlightening for learners. Looking at the actual O2 generator provides a deeper understanding about the patient with COPD requiring oxygen therapy. During your talk on sleep apnea, bring in a CPAP machine. When discussing low back pain borrow a TENS unit.

3. Hands on – This works well for skills that can be done cheaply on each other such as plaster splints, ultrasounds, or osteopathic manipulation.

4. Simulation – Simulation provides hands-on learning in a controlled atmosphere and doesn’t hurt a patient. A variety of relatively inexpensive simulators are available such as joints for injection, necks for cricothyroidotomy, sternums for intraosseous access, and backs for lumbar puncture.

This cannot be observed during the learning event, of course, but there are ways to encourage this to happen.

1. Ask learners to discuss in pairs, in groups, or just to write down what they are going to do differently later today (or next week) based on what they have learned today.

2. Call or email learners a week or two later to see how they are applying the new information and what questions they have about it.

Active Learning

Just Say No to Death by PowerPoint!

(Or, tips on how to use active learning so that people will actually enjoy and remember your presentation.)

Kelly Latimer, MDLCDR MC USN

Faculty Development FellowMadigan Army Medical Center

We’ve all been there: Noon lecture. Residents and faculty shuffle in, lunches and coffee cups in hand, making small talk. Some poor second-year resident purposefully marches up to the lectern, fires up the projector, and dims the lights. The first slide: “Decontamination of the Oropharynx and Digestive Tract in ICU Patients.” Within four minutes, twenty pairs of eyes have glazed over in unison and twenty brains are switched off, victims of “Death by PowerPoint”.

Can you believe PowerPoint has been brightening lecture halls and meeting rooms for twenty years? PowerPoint was originally designed for businessmen to create a “visual aid” for business presentations. Prior to PowerPoint, one had to laboriously type up legible text and find copy-legible graphics and struggle to coax a fire breathing Xerox machine into producing a readable acetate for the overhead projector, (for those of you old enough to remember what an overhead projector is). Now the presenter could develop and produce the presentation with ease by themselves. Entire graphics departments disappeared overnight, replaced by a laptop computer and a small projector.

Critics say PowerPoint has evolved into a presentation “crutch.” Marshall McLuhan recognized the concept with regards to television in his 1964 book, ‘Understanding Media,’ and coined the aphorism “the medium is the message”. Often a PowerPoint lecture is not a means to an end, but an end unto itself. Yet it is the cornerstone of medical teaching, used in settings that range from residency didactics to national meetings. This is especially ironic, since good studies have proven the average adult retains only 5% of a PowerPoint lecture. In fact, of all the teaching modalities that exist, a PowerPoint lecture by itself is the least effective. (Figure 1) Since resident work hour restrictions already constrain the time available to teach an increasing amount of skills and information, we would be prudent to use our didactic teaching time more efficiently.

Does this mean we should abandon PowerPoint completely? Or, phrased another way, has the quest for world domination by a certain billionaire in Redmond, Washington failed? Hardly! PowerPoint can be a very effective tool when combined with other learning modalities. When properly used it can help focus on the message but not be the message.

The intrepid second-year resident in the opening scenario of this article invested a lot of time preparing his lecture. He had hoped at the very least for his colleagues to stay awake and at best to learn a new skill or concept they could retain and use. To accomplish these goals, he

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needed to understand the basics of adult learning theory. Volumes of textbooks and journals abound on this topic; I am barely going to scratch the surface.

With a few notable exceptions medical students, residents, and faculty are adult learners. We can apply four assumptions to our adult learners. (Table 1) First, they are already endowed with a wealth of knowledge, life experiences, and perceptions on most subjects. Even though we may be the “experts,” when teaching adults we are wise to anticipate that our audience will know something on the subject we don’t. Teachers of adults should aim for a dialogue instead of the usual monologue, trying to connect students’ prior experiences to new subject matter. Second, adult learners deserve to be respected as equals by their instructors. While fear has traditionally been a motivating factor on medical rounds, true dialogue only occurs in an atmosphere of safety. Third, adult learners are self-motivated. They want to learn this stuff. That should make our job easy, right? The last and most important assumption about adult learners is they are only motivated as long as the material is practical, relevant, and goal-oriented. They need to know they can use the material in their daily life and they need to be engaged with that material on an emotional and physical as well as an intellectual level. Our learners’ goals depend upon their level of training and range from simply surviving the wards, to passing the boards or earning CME.

Table 1:Characteristics of Adult Learners:Foundation of knowledge and experience Mutual respectSelf-directedRelevancy-orientedPracticalGoal-oriented

To increase the effectiveness of his talk, our second-year resident also needs to understand the basics of active learning, which simply put is learning that occurs at the bottom of the learning pyramid in Figure 1. Active learning involves connecting adults to what they know already, learning something new, and then doing something with that new content. (Table 2) Active learning requires creativity on the part of the instructor, and effort on the part of learners. This extra work is far more fruitful than simply sitting back and passively being told what they need to know.

Table 2:The Sequence of Active Learning1. Inductive – connect to the learner; the “grabber”2. Input – new material that is practical and relevant3. Implementation – practice doing4. Integration – actually using it in real life

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We must tailor content to our audience. Obviously a talk aimed at medical students should be different than one for board-certified physicians. Let’s assume for simplicity we are planning to instruct our own family medicine department about a medical topic. Most of us have developed a small library of “canned” PowerPoint talks over the years on a variety of subjects. How can we use this material but break away from the oppressive lecture and move towards dialogue and active learning? If necessary modify your PowerPoint slides to conform to the rules of Table 3. Pay close attention to rule #12. Time should be set aside for active learning tasks. So a 30 minute talk should at most have 20 slides, leaving 10 minutes for your learning tasks.

Table 3:Do’s & Don’ts of PowerPoint 1. Do use an easy to read, constant color scheme 2. Do begin your talk with 2-4 objectives 3. Do end your talk reiterating 2-4 key points 4. Do use pictures whenever possible 5. Do keep font size 32 or bigger 6. Do use spell check 7. Don’t use more than 4-5 lines of text per slide 8. Don’t use animation schemes or fancy transitions 9. Don’t use busy slides10. Don’t read your slides11. Don’t talk too fast12. Don’t have more than 1 slide per minute of talk

I have listed some specific strategies you can use to add active learning to your PowerPoint lectures. This list is not exhaustive. The strategies should be combined and interspersed within the lecture to add variety and keep the audience mentally engaged. Initially, you should follow the tried and true sequence of active learning in Table 2.

A) Inductive - connect with what they know:

1. Small group discussion – Have the audience break up into groups of four or five and ask them to discuss a patient they have cared for with your subject condition. What difficulties did they encounter in diagnosis, treatment, compliance, referral or co-morbidities? What rewards? Then each small group should pick one person to describe his or her case to the whole room.

2. Quiz – Either true/false or multiple choice quizzes are a great way to open a talk and review boring basics like epidemiology and pathophysiology without a lecture.

3. Worksheet – A resident at Madigan recently began a talk with handout. It was a blank chart listing eleven different types of transfusion reactions, arranged into two categories of either immune-mediated or non-immune-mediated. Before even beginning to lecture, she asked everyone to rank them in order of severity and then in order of how commonly they occur. Learners then filled out the chart as she described the incidence, pathophysiology, signs and symptoms, diagnosis, and treatment of each transfusion

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reaction. On the back of the handout was a treatment algorithm for transfusion reactions. I suspect many of those residents kept that handout in their lab coat pocket for reference on the wards.

4. Role playing – Utilize the aspiring actors in your department to help you illustrate psychosocial aspects of a condition or demonstrate the difference between a clear and concise history and physical and a disjointed one.

5. Actual patient interview – You need sensitivity, judgment, and a sound relationship to approach a patient with this kind of request. But if you know a patient with interesting physical findings or stigmata of a particular condition it is unfair to keep them to yourself. Many patients are happy to help in the education of physicians, especially if you offer to buy them lunch. A real live patient is invaluable in teaching and puts a human face on a disease.

6. Audience response system can be used to gather information about the baseline knowledge level of the participants and can be used along the way to check on knowledge transfer.

7. Video clip -- ask the learner what they see happening, why is it happening, when it happens to you, what do you do, how can we prevent this from happening?

B) Input - learn something new:

1. Videos – The old adage, “See one, do one, teach one,” is active learning at its best. The New England Journal offers excellent 10-minute downloadable files covering various procedures. These videos discuss contraindications and informed consent as well as technique. Unfortunately you need a subscription to access them. Fortunately there are many excellent medical education videos available for free on the internet.

2. Case-based – Start with a case and develop it using a series of questions such as: What else do you want to know? What is your differential diagnosis? What further studies would you order? What is the etiology of that condition? And so on. The answers are always somewhere in the audience.

3. Article-based – Distribute the article beforehand and then discuss the article. Busy clinicians may not always find the time to read it. Ideally you can jump straight to the implementation phase. Alternatively you can go through the article using a worksheet like a Journal Club.

4. Game shows – A game of “Jeopardy!” keeps the audience involved and adds a spirit of competition if you break the audience into groups. One of my colleagues used PowerPoint to design the game “Battleship,” where a correct answer allows the team to choose coordinates to try to find and sink their opponents’ ships. Be sure this is content rich as well as fun as it is easy to have the learning get lost in the fun.

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5. Small groups – Provide each small group the resources they need to teach a portion of the subject matter. Give them 15 minutes to learn it and then 10 minutes each to teach it to the larger audience. Initiate a contest after the teaching is over by giving a quiz on the subject material. The small group that teaches their subject the best, (as measured by the overall score of the entire group on their questions), wins.

6. Audience choice – Provide a handout of not yet covered material and have the learners fill it out using their own experience and knowledge. Then provide the answers and ask learners which of the topics they have questions about. Present only the slides that answer their questions.

7. Reading material, handed out to learners. Each reads and highlights points that speak to him/her. Then each has a turn to present what they highlighted and why. What was missing from the material presented? What did you disagree with?

8. Be an ambassador – Give learners a new identity (each of you is going to be a different type of anemia) and provide them a sheet of paper that describes who they are and what the key characteristics are about that type of anemia. These sheets might be on yard around their neck with the type of anemia printed on one side and the information about it on the back. Then ask them to move about the room looking for others who have a different type of anemia. Have them quiz you and you quiz them about that type of anemia. When a pair think they have each other’s anemia mastered, they break up and look for other types of anemia. This continues until each learner has been exposed to every anemia type available. You might follow this with a post-test or jeopardy game with the learners divided into teams. Keep score to see which team gets the most correct.

9. The pneumonic game – Have teams work as a group to develop a pneumonic device to help them remember key points of the presentation

C) Implementation - practice what they learned:

1. Problem solving – After a brief “how to” didactic let the learners solve some problems, either individually or in pairs. Start out easy and build up complexity of problems. Great examples to use this: reading EKG’s, interpreting PFT’s, calculating acid-base status, explaining patterns of liver enzyme abnormalities.

2. Medical equipment – Feeling a bulky O2 canister is very enlightening for learners. Looking at the actual O2 generator provides a deeper understanding about the patient with COPD requiring oxygen therapy. During your talk on sleep apnea, bring in a CPAP machine. When discussing low back pain borrow a TENS unit. Let students lay hands on these things and try them on for size.

3. Hands on – This works well for skills that can be done cheaply on each other such as plaster splints, ultrasounds, or osteopathic manipulation.

4. Simulation – Simulation provides hands-on learning in a controlled atmosphere and doesn’t hurt a patient. A variety of relatively inexpensive simulators are available such as joints for injection, necks for cricothyroidotomy, sternums for intraosseous access, and backs for lumbar puncture.

25

5. Gallery Walk—Small groups use the information taught to problem solve, generate ideas, brainstorm on the topic at hand. They record their ideas on butcher block or a dry erase board. Other groups work on a different case, concept or problem and each group rotates to each of the buthcer blocks/boards and adds information. When the time is up, one group describes what is listed on each butcher block/board.

D) Integration – start using the new information in your daily work

This cannot be observed during the learning event, of course, but there are ways to encourage this to happen.

1. Ask learners to discuss in pairs, in groups, or just to write down what they are going to do differently later today (or next week) based on what they have learned today.

2. Call or email learners a week or two later to see how they are applying the new information and what questions they have about it.

Incorporating active learning into your medical lectures may seem awkward at first, but the more you do it the easier it becomes and the more you expect it in your own learning experiences.

Don’t be discouraged. Anyone can be ensnared by PowerPoint’s allure. My ten-year old son and a classmate were assigned to teach their 5th grade colleagues about a particular Indian tribe here in Washington State. He proudly showed me the slides that he and his buddy had so laboriously prepared. They had exploited nearly every annoying feature of PowerPoint, from sounds to animation to gaudy colors and charts. Each slide had a different background and was crammed full of barely readable words of varying fonts, sizes, and colors. I cringed, knowing full well that my fellowship director would have a heyday critiquing it. I attempted some gentle yet constructive criticism to no avail. He considered the effects “cool” and assured me that the other kids and his teacher would as well. I have yet to see his grade from the project.

26

Figure 1: The Learning Pyramid

Adapted From National Institute for Applied Behavioral Science

The power of active learning

References

Vella, J. (2002). Learning to listen, learning to teach. San Francisco, CA: John Wiley & Sons, Inc.

Vella,J. (2000). Taking Learning to Task. San Francisco, CA: John Wiley & Sons, Inc.

Kern, D.E., Bass, E.B., Howard, D.M., Thomas, P.A. (1998). Curriculum development for medical education: a six-step approach. Baltimore, MD: The Johns Hopkins University Press

27

Lecture 5%

Reading 10%

Audiovisual 20%

Demonstration 30%

Discussion Group

50%

Practice By Doing

75%

Teaching Others

90%

Average

Learning

Retention

The Learning Pyramid

.

Chapter 2Excellence in Clinical Teaching

Faculty Development Series Madigan Healthcare System Tacoma, Washington 98431

28

Excellence in Clinical Teaching


Before the Session....









During the Session....




After the Session....





29


Please complete the following needs assessment for the upcoming seminar on Excellence in Clinical Teaching as part of your faculty development program.

The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, and small group discussions.


Please turn this in to your group leader (______________) no later than (_____________). Your group leader will return this form to you at the beginning of the session.

1. Have you any formal training on the characteristics of excellence in teaching? YES NO

2. What do you already know about excellence in teaching? Answer briefly below:

a. What are some characteristics of an excellent clinical teacher?

1. 3.

2. 4.

b. What are some characteristics of an ineffective clinical teacher?

1. 3.

2. 4.

3. Have you ever conducted a self-assessment of your clinical teaching abilities? YES NO

4. Have your clinical teaching abilities ever been reviewed by a peer? YES NO

5. What barriers are impeding our ability to improve as teachers at our organization?

6. What three things do you most want to learn or discuss regarding excellence in teaching?

a.

b.

c.

30


Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Workbook Series – Excellence in Clinical Teaching

Course Content: Didactic and Group Discussion, characteristics of excellent teaching, barriers, solutions and tools to achieve excellence in teaching.



Name RankCheck One





31


Date Speaker Topic


Strongly Disagree

Disagree Somewhat Agree











Date Speaker Topic


Strongly Disagree










Please add your comments/suggestion for improving this session on the back—they are VERY helpful.

32

Excellence in Clinical Teaching

Example Eight Steps



Why: Enhance clinical teaching as part of a required faculty development curriculum.



What: Driven by the LNRA. Will explore what characteristics contribute to an excellent clinical teacher, identify barriers to improvement and potential solutions, and will discuss tools that can be used to improve our clinical teaching.


• Recognized characteristics of an excellent clinical teacher• Identified barriers and solutions to achieving teaching excellence at our

organization• Performed a self-assessment of our clinical teaching abilities• Explored peer-review methods as a tool for improving our clinical teaching

abilities

How: General: Active learning: small group activities and discussion, larger group discussion, minimal PowerPoint slides. Room contains individual desks. Will pre-configure desks into larger half-moon shape. Within larger half-moon configuration, will group four desks in smaller half-moon shape for five groups of four learners each. This will facilitate small group activities followed larger group discussions. The session will take place at 0730, so will provide coffee and bagels.

Grabber: Discuss the many roles filled by military medical faculty and how these roles are connected to our ability to teach our residents. Our stakeholders are counting us to teach well, especially in the clinical setting. Our residents are counting on this to be successful.

Induction Tasks: 1. Began with LNRA and continued in first activities. Learners reflect on their experiences with excellent and ineffective clinical teachers.

2. Learners discuss barriers to improving clinical teaching abilities at our organization.

33

Input Tasks:1. Discuss reference material provided in this chapter. Explore what characteristics of excellent teachers were identified in several studies. Present recurring themes.

2. Present additional barriers to improving clinical teaching.

3. Present self-assessments, peer-reviews, and OSCE-like reviews as potential tools for improving teaching abilities.

Implementation Tasks:1. Conduct self-assessement of clinical teaching abilities and identify individual strengths and weaknesses.

2. Discuss potential solutions to barriers in order to build upon our strengths and improve our areas of weakness.

3. Discuss issues identified in the LRNA using collective knowledge generated during the session.

Integration Tasks:1. Challenge learners to act on the results of their self-assessment.

2. Provide learners with peer-review sheet and get a commitment from them to seek input from their colleagues in order to assess and improve teaching abilities.

3. Learners commit to seeking “in-the-moment” reviews of their clinical teaching using OSCE or OSTE-like tools.

So What:Learning: Learners understand characteristics of an excellent clinical teacher. Introduced to tools for improvement and conducted a self-assessment to identify their own strengths and weakness. Individual and organizational barriers to improvement identified and solutions explored.

Transfer: Learners build upon their self-assessments through peer-review and improve their clinical teaching by addressing areas or weakness and building upon their strengths. Learners model excellence in clinical teaching to peers and residents. Barriers to improvement identified and addressed

Impact: Departmental clinical teaching is enhanced, improved learning and success for residents.

34

Excellence in Clinical TeachingHandout

Take Home Points

Clinical teaching is unique and demanding

We have experienced both excellent and poor clinical teaching – Embrace the good

Learner reviews, self-assessments, and peer-reviews can improve our clinical teaching

Fostering a culture of honest and specific feedback is the key to improvement

Activity One: Characteristics of Excellent Clinical Teachers

Think back to your medical school or residency experience. What were some of the characteristics of your best clinical teacher? Write them below. Discuss these characteristics in your group and add to your list.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes an excellent clinical teacher?

Accessible to their residents – they don't simply respond to inquiries, they make time for questions and group discussions

Enthusiastic about teaching – draw students in and stimulate intellectual curiosityKnowledgeable – know their topics and how to present the same material in a variety of ways

and from different perspectivesDisplay a command of clinical skillsWell organized – prepared, use time effectivelyRespectful – genuinely welcome other opinions, respond professionally and care about their

learners’ needsCommunicate clearly – promote dialoguePresent material logicallySet goals and provide feedback

Clinical instructors teach medical skills, but the best ones teach far, far more. By instilling a love and enthusiasm for medicine, and being an inspiring role model, excellent teachers give medical residents the desire and ability to continue learning throughout their careers.

35

Activity Two: Characteristics of Ineffective Clinical Teachers

Think back to your medical school or residency experience. What were some of the characteristics of your worst clinical teacher? Write them below. Discuss these characteristics in your group and add to your list.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What makes an ineffective clinical teacher?

Negative attitude, intimidating Poor feedback skills Inaccessible Limited knowledge Fail to recognize extra effort Poor communication skills Fail to adhere to schedule

Subjective Reviews of Clinical Teaching Matter!Ineffective Teaching Impacts Success

Griffith, Charles H., Georgesen, John C., Wilson, John F.: Six-Year documentation of the association between excellent clinical teaching and improved student examination performance. Academic Medicine. 75:62-64, 2000 A prospective cohort study of 502 third-year medical students rotating through a general internal medicine clerkship conducted over a six year period. Faculty clinical teachers were rated as good, mediocre and poor through past resident surveys and end-of-rotation evaluations. Those students that rotated with the good clinical teachers scored significantly higher on the internal medicine portion of USMLE Step 2.

Good clinical teachers were thought to improve comprehensive scores because they “engendered a learning climate that makes learning fun, enjoyable, and exciting” as opposed to the simple relaying of medical facts.

36

Activity Three: Faculty Self-Assessment

Self-assessment is a way of reviewing one's strengths and weaknesses, of taking stock and establishing useful goals. After completing this form, you may want to review this with your Program Director. This should be done semi-annually.

This first section calls for self-assessment of a variety of positive statements. "Learners" refers to both medical students and residents. Circle those statements that apply to you.

STATEMENTS:

I have an enthusiastic and stimulating teaching style.I easily establish a good rapport with learners.When I teach, I actively involve learners.I am good at providing direction and feedback to learners.I am readily accessible to learners (they can easily find me for questions or problems).I ask questions in a nonthreatening manner.If I don't know something, I am willing to admit it to learners.I am a good role model of a military physician.I present material in a clear and organized fashion.I make difficult concepts easy to understand.When I teach, learners have fun and learn something.I am a good clinic attending.I review charts regularly and often write residents constructive comments. I give residents enough "rope" to work comfortably with, but not enough to hang themselves.I debrief residents after procedures using specific praise and criticism.I round each day while on the wards, communicating with residents verbally or through the chart.My presentations (lectures) are dynamic. I am good at leading effective small group discussions.I meet regularly with my advisees (if applicable).I frequently attend faculty meetings.I frequently attend morning report.I keep up with the medical literature. I am actively involved in scholarly activities.

Considering all things, I would give myself the following grade as a faculty member (circle one):

A B C D F

37

Faculty Self-Assessment (continued)

PERSONAL STATEMENT

Consider each of the following statements. Do you agree or disagree?

I am satisfied with my faculty role.

I am satisfied with the balance between patient care and teaching in the residency.

I am satisfied with the balance between work and not work.

COMMENTS:

1. Three general tasks that I have done well over the last 6 months are:

a.

b.

c.

2. Three areas that I have improved over the last 6 months are:

a.

b.

c.

3. Three areas that I want to improve over the next 6 months are:

a.

b.

c.

4. Three goals that I have for the next 6 months are:

a.

b.

c.

38

Activity Four: Barriers or Challenges to Excellence

What are some of the barriers to achieving individual and collective excellence in clinical teaching at our organization? Write them below. Discuss these barriers in your group and add to your list. We will discuss solutions to these barriers later.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Potential Barriers and Challenges

Limited feedback from learners and peers Vague or unhelpful feedback Ego or self-misperception Organizational culture Time pressures: increased responsibilities and pressure to see greater numbers of patients Simultaneously teach learners who are at various levels of training Medical cases are unpredictable - preparation is not always possible Wide variety of teaching methods is required - from bedside teaching to Socratic dialogue Responsible not only for teaching, but also for ensuring excellent patient care

Activity Five: Solutions to Barriers to Excellence

Now that we know a little more about our own strengths and weaknesses, let’s turn our attention to our organization. How can we overcome the barriers discussed earlier? Write your solutions below. Discuss this in your group and add to your list.

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Discussion: Additional Concerns Specific to Us

39

A few questions were posed by your colleagues in the LNRA. We will discuss them now. Write those questions down and record responses that speak to you.

Question ___________________________________________________________________

Responses ___________________________________________________________________ ____________________________________________________________________________________________________________________________________

Question ___________________________________________________________________

Responses ___________________________________________________________________ ____________________________________________________________________________________________________________________________________

Question ___________________________________________________________________

Responses ___________________________________________________________________ ____________________________________________________________________________________________________________________________________

Integration Task: Peer Reviews

Peer reviews can be used as a tool to provide you with additional feedback to improve your clinical teaching skills. The key is to collect thoughtful, specific and actionable feedback from your colleagues. Ask for and be prepared to accept honest feedback and use it constructively.

Two peer review tools are provided at the end of this handout. The first is a general review of your overall clinical teaching abilities and mirrors the self assessment you conducted earlier. Make a few copies of the peer review and ask at least two fellow faculty to complete the review within the next week. Assure them that you want honest and constructive feedback. Review any differences or similarities between your self-assessment and the reviews from your peers. Consider giving this review to some of your learners to elicit their feedback as well.

The next tool is an OSCE-like checklist to be used during a clinical teaching experience. Ask a colleague to shadow you during your teaching session and provide feedback using the checklist. You can modify the example checklist to create one that suits your needs and settings.

Clinical Teaching Assessment – Faculty Peer Review

40

Peer reviews are a tool that can be used to identify strengths and weakness and offer an opportunity for improvement. The following brief assessment is meant to act as an aid for thoughtful and constructive feedback. Please take a moment to reflect and then answer each of the following questions.

Faculty Member Being Reviewed:Reviewer: Date:1. This first section calls for an assessment of a variety of positive characteristics. "Learners" refers to both medical students and residents. Circle those statements that apply to the faculty member.

Enthusiastic and stimulating teaching styleEasily establishes a good rapport with learnersWhen teaching, actively involves learnersGood at providing direction and feedback to learnersReadily accessible to learnersAsks questions in a nonthreatening mannerWilling to admit uncertainty to learnersGood role model of a military physicianPresents material in a clear and organized fashionMakes difficult concepts easy to understandWhen teaching, learners have fun and learn somethingA good clinic attendingReviews charts regularly and often writes residents constructive commentsGives residents enough "rope" to work comfortably with, but not enough to hang themselvesDebriefs residents after procedures using specific praise and criticismRounds each day while on the wards, communicating with residents verbally or through the chartPresentations (lectures) are dynamicGood at leading effective small group discussionsMeets regularly with advisees (if applicable)Frequently attends faculty meetingsFrequently attends morning reportKeeps up with the medical literature Actively involved in scholarly activities

2. Three general tasks that the faculty member has done well over the last 6 months are:

a.

b.

c.

3. Three areas that faculty member could improve over the next 6 months are:

a.

b.

c.

Checklist for Peer Feedback on Inpatient Clinical Teaching

41

The example checklist presented below can be used to provide peer feedback of clinical teaching during an inpatient rotation. Consider using this checklist during your next inpatient teaching experience. Modify this checklist to meet your needs in any setting.

Example Checklist for Inpatient Clinical Teaching Skills

1 Rotation/clerkship goals and expectations reviewed No Yes2 Rounds were begun and ended on time No Yes3 Literature searches or topic discussions were assigned No Yes4 Resident/student history and physicals were reviewed No Yes5 Residents/students were treated as team members Never Sometime

sAlways

6 A broad knowledge of clinical issues was demonstrated Never Sometimes

Always

7 Education and patient management were balanced Never Sometimes

Always

8 Residents/students were encouraged to formulate their own Assessment and Plan

Never Sometimes

Always

9 Residents/students were encouraged to ask questions Never Sometimes

Always

10

Constructive feedback was provided Never Sometimes

Always

11

Physical findings were reviewed and demonstrated Never Sometimes

Always

12

Clinical decisions (i.e. selection of tests) were explained Never Sometimes

Always

13

Clinical findings (i.e. X-rays) were reviewed and demonstrated Never Sometimes

Always

14

Professional and ethical behavior were modeled Never Sometimes

Always

15

Effective interpersonal and communication skills were modeled Never Sometime Always

Comments:

42

Adapted from: Conigliaro, Rosemarie L; Stratton, Terry D.: Assessing the quality of clinical teaching: a preliminary study. Medical Education. 44:379-386, 2010.

43

Supporting References and ResourcesExcellence in Clinical Teaching

Gierde CL, Coble RJ: Resident and faculty perceptions of effective clinical teaching in family practice. J Fam Prac 14:323-7,1982. Combined rating of 58 teaching behaviors by 47 faculty and 69 residents in seven family practice residency programs.

Ranking of Teaching Behaviors

Rank Mean Rating* Behavior

1 1.17 Takes time for discussion and questions2 1.21 Is willingly accessible to residents3 1.24 Answers questions clearly4 1.26 Is well prepared for teaching sessions5 1.28 Provides constructive feedback6 1.28 Provides opportunities for technical and problem solving skills7 1.30 Discusses practical applications of knowledge and skills8 1.32 Demonstrates enthusiasm for teaching9 1.33 Asks questions in nonthreatening manner10 1.36 Shares his or her knowledge and experience11 1.38 Willing to admit when he or she does not know12 1.38 Demonstrates genuine interest in resident13 1.41 Encourages expression of different viewpoints14 1.43 Demonstrates sensitivity to patient needs15 1.44 Explains clinical problems in a comprehensible manner16 1.47 Summarizes major points at conclusion of teaching17 1.48 Asks questions that stimulate problem solving18 1.49 Explains basis for his or her actions and decisions

52 > 3.50 Fails to recognize extra effort53 > 3.50 Bases judgment of residents on indirect evidence54 > 3.50 Is difficult to summon for consultation after hours55 > 3.50 Fails to adhere to teaching schedule56 > 3.50 Discourages resident/faculty relationships outside clinical areas57 > 3.50 Corrects resident's errors in front of patients58 > 3.50 Questions residents in intimidating manner

*Rating Scale:I = very helpful2 = moderately helpful3 = somewhat helpful4 = not helpful at all

44

Gierde CL, Coble RJ: Resident and faculty perceptions of effective clinical teaching in family practice. J Fam Prac 14:323-7, 1982. continued

The effective clinical teacher has 3 broad areas of teaching skills:

1. Two-way communication takes time for discussion and questions answers questions clearly discusses practical applications asks questions in a non-threatening manner shares knowledge and experiences presents clinical problems comprehensibly stimulates problem solving explains the basis for his or her actions and decisions

2. Creating an environment that facilitates learning readily accessible to residents is enthusiastic about teaching is willing to admit when he or she does not know maintains an atmosphere that encourages expression of different viewpoints shows a genuine interest in residents

3. Providing feedback provides constructive feedback compliments residents and others for good performance

The ineffective clinical teacher has 3 major deficiencies:

1. Negative attitude toward residents questions residents in an intimidating manner appears to discourage resident-faculty relationships outside clinical areas

2. Lacks skills in providing feedback

corrects resident's errors in front of patients fails to recognize extra effort bases judgments of residents on indirect evidence

3. Inaccessibility

45

Hilliard RI: The good and effective teacher as perceived by pediatric residents and by faculty. AJDC.144:1106-10,1990.

The good teacher: Is enthusiastic about teaching and the interaction with students and residents, i Is able to stimulate intellectual curiosity and to encourage and motivate the residents to

self-directed learning Is a good, competent and credible physician who serves as a good role model in

dealing sensitively with patients and families Presents material or leads discussions in an organized, clear fashion Emphasizes conceptual understanding of the subject and problem solving Makes difficult concepts easy to understand Helps to develop thought processes Answers questions carefully and precisely Encourages participation, open to questions and discussion Includes content material that is interesting, practical, relevant, accurate, in depth, and up

to date, emphasizing what is important Is able to develop a good, positive relationship with the residents, has a genuine interest

in residents and is aware of their needs and problems, is available and willing to help Provides fair and constructive criticism without belittling the residents

The most important characteristics of the excellent teacher: Teaches approaches to problems, basic concepts, and not simply facts Able to communicate ideas and knowledge clearly and presents discussions in a clear,

lucid and organized fashion Excellent clinician, able to deal with medical problems in a thorough, complete

organized approach Able to stimulate intellectual curiosity and promote self-directed learning Enthusiastic about teaching and seems to enjoy interaction with students and residents An excellent role model in the way he or she deals with patients and families

Irby D, Rakestraw P: Evaluating clinical teaching in medicine. J Med Ed. 56:181-6,1981.Study of the evaluations of 105 OB/GYN UW faculty by medical students - those items correlated most strongly with "Overall Teaching Effectiveness" were.... "is enthusiastic and stimulating" (0.80) " establishes rapport" (0.77) 161, actively involves students" (0.76) it provides direction and feedback" (0.75).

Irby DM, Ramsey PG, Gillmore GM, Schaad D: Characteristics of effective clinical teachers of ambulatory care medicine. Acad Med. 66:S4-S, 1991.

46

Mail survey in 1988 of 122 graduating UW students, and 60 medicine residents asking them to identify important aspects of effective clinical teaching. Effective teachers involved students in the learning process, communicated expectations for the learner's performance, stimulated the learner's interest, and interacted skillfully with patients. Important characteristics included a broad knowledge of medicine, enjoyment of teaching and patient care, demonstrated caring concern for patients, personable and approachable, showed respect for others, enthusiastic respecting the autonomy of the learner and nurtured self-directed learning.

Three characteristics most descriptive of the best clinical teacherso Enthusiasm/Stimulation => the best teachers are enthusiastic, dynamic, enjoy

teaching, and have interesting styles of presentationo organization/clarity => the best clinical teachers explain clearly, present material

in an organized manner, summarize, emphasize what is important, and communicate what is expected to be learned

o clinical competence => the best clinical teachers objectively define and synthesize patient problems, demonstrate skill at data gathering, use of consultants, and interpreting laboratory data, work effectively with the health care team members, and maintain rapport with the patient.

Most frequently listed characteristics of the worst clinical teacherso lacked good teaching skillso arroganto apparent dislike of teachingo limited knowledgeo inaccessibility

o lack of self-confidenceo unorganized and boring

presentationso dogmatismo insensitivity to otherso belittling of students and residents

Irby DM: What clinical teachers in medicine need to know. Acad Med. 69:333-42,1994. Advice from six recognized outstanding clinical teachers at UW.

Actively involve learners - highly interactive teaching sessions through use of questions Capture attention and have fun - in order to make learning memorable, teaching must

capture and retain attention, use humor, dramatic case examples, suspense, enthusiasm connect the case to broader concepts

Connect learners' knowledge of the patient's particular problems to a broader understanding of the relevant disease – generalize

See the patient together when the case is unclear or the diagnosis doesn't seem to fitmeet individual needs - one of the great difficulties with clinical teaching is dealing with the diversity of learners' knowledge and skills (one example of team bedside rounds: ask students questions about pathophysiology, ask interns questions about day-to-day treatment, and ask senior resident questions about broader medical and health care issues)

Be practical and relevant Be selective and realistic - focus on a few important teaching points per case, prioritized

time among cases to deal with a few cases in depth, and establish realistic expectations for learning during the rotation - the more you say, the less people learn

Provide constructive feedback and evaluation

Seven Factors Influencing the Effectiveness of Faculty - Skeff KM: Enhancing Teaching Effectiveness and Vitality in the Ambulatory Setting. J Gen Intern Med, 3:S26-33, 1988.

47

1. Establish a positive learning climate Learning climate = tone or atmosphere of the teaching environment -> reflects the degree of stimulation,

enthusiasm, comfort and excitement generated by the teaching process - do students and housestaff want to be in this environment as learners?

Faculty can create a positive learning climate by demonstrating enthusiasm both for the content being taught and for teaching

2. Control the teaching session Task-management approaches a teacher uses to focus and pace a teaching interaction

o Ability to address relevant teaching topics efficiently in clinic setting - intense pressure for efficient use of time in a clinic that is busy and understaffed

o teachers must be available and able to set teaching agendas that emphasize key points of patient care and teaching, while matching the learner's level and available teaching time

3. Communicate learning goals The process by which teachers establish and communicate the expectations for students and housestaff -

should include not only what educational experiences they should have, but also what attitudes, knowledge and skills should be acquired in the learning process . goal statements can guide faculty instruction and evaluation of trainees to see if the institution is accomplishing its desired objectives

4. Enhance understanding and retention Refers to the teaching methods used in a learning experience, with specific emphasis on whether the

methods used are likely to enhance the learners' understanding and retention of the educational goals primary goals of clinical teaching

Ensures that learners understand and retain important attitudes, knowledge, and skills for the practice of medicine to facilitate knowledge acquisition, teachers should present material in a clear and organized way emphasize the key points to be remembered actively involve the learners in the learning process to acquire skills, learners should practice desired behaviors with feedback

5. Evaluation Consists of the processes used to determine whether learners are achieving desired knowledge, skills and

attitudes two types Is formative evaluationo Can be conducted throughout an educational experience - information gained can guide the

teacher in planning future educational experiences to help the learner master desired goalso Ongoing process to help the learner o Summative evaluation: assessment of the learner at the end of the teaching experience to judge the

learner's final competence6. Provide feedback

The process bv which the teacher provides information to the learners about their behavior for the purpose of improving their performance

o Critical to the learning environment - takes time and skillo Should inform, reinforce, or praise trainees when the performance is acceptable to excellent, and

inform and constructively criticize learners when their performance needs improvemento Difficult to do - feedback to learners is often done poorly or infrequently

7. Self-directed learning An individual learner's initiative to identify and act on his/her needs, with or without the

assistance of others The processes by which a teacher encourages learners to use methods to continue learning throughout their

careero Encouraging further reading, encouraging learners to identify and respond to their own limitations,

encouraging asking questions and getting consultation when appropriateo Modeling and teaching self-directed learning behaviors is essential!

Conigliaro, Rosemarie L; Stratton, Terry D.: Assessing the quality of clinical teaching: a preliminary study. Medical Education. 44:379-386, 2010.

48

A structured, 15-item objective structured clinical examination (OSCE)-like tool was used to assess clinical teaching abilities in this small pilot study. The study’s goal was to identify an objective alternative for clinical teaching assessment. Historically, teaching abilities have been assessed using subjective input from learners or peers that may be biased, personality driven, and subject to other confounders (i.e. halo effect).

Select faculty members were followed by trained observers during inpatient rounds. Each teacher was assessed by two raters within a one week period and scores were evaluated using generalisability theory analysis. The study was limited in size and found significant variability of inter-observer ratings, so further research is needed to develop an optimal tool for objective assessment. However, the checklist could be useful for inexperienced teachers and provide senior teaching staff with a mentorship tool to develop inexperienced faculty. Furthermore, the checklist could be modified to meet specific requirements or settings.

Inpatient Clinical Teaching Checklist1 Clerkship goals and expectations reviewed No Yes2 Rounds were begun and ended on time No Yes3 Literature searches or topic discussions were assigned No Yes4 Students’ history and physicals were reviewed No Yes5 Students were treated as team members Never Sometime

sAlways

6 A broad knowledge of clinical issues was demonstrated Never Sometimes

Always

7 Education and patient management were balanced Never Sometimes

Always

8 Students were encouraged to formulate their own A and P Never Sometimes

Always

9 Students were encouraged to ask questions Never Sometimes

Always

10

Constructive feedback was provided Never Sometimes

Always

11

Physical findings were reviewed and demonstrated Never Sometimes

Always

12

Clinical decisions (i.e. selection of tests) were explained Never Sometimes

Always

13

Clinical findings (i.e. X-rays) were reviewed and demonstrated Never Sometimes

Always

14

Professional and ethical behavior were modeled Never Sometimes

Always

15

Effective interpersonal and communication skills were modeled Never Sometime Always

Griffith, Charles H., Georgesen, John C., Wilson, John F.: Six-Year documentation of the association between excellent clinical teaching and improved student examination performance. Academic Medicine. 75:62-64, 2000 A prospective cohort study of 502 third-year medical students rotating through a general internal medicine clerkship conducted over a six year period. Faculty clinical teachers were rated as good, mediocre and poor through past resident surveys and end-of-rotation evaluations. Those students that rotated with the good clinical teachers scored significantly higher on the internal medicine portion of

49

USMLE Step 2. Good clinical teachers were thought to improve comprehensive scores because they “engendered a learning climate that makes learning fun, enjoyable, and exciting” as opposed to the simple relaying of medical facts.

50

Chapter 3Giving Dynamic Presentations

51

Faculty Development SeriesMadigan Healthcare SystemTacoma, Washington 98431Giving Dynamic Presentations



















52



Please complete the following needs assessment for the upcoming seminar on Giving Dynamic Presentations as part of your faculty development program.

The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, several short video clips, several group activities and a discussion period.

The purpose of this needs assessment is to determine your learning needs and interests, so that the seminar is most useful for you. This needs assessment should also stimulate you to think about dynamic lectures before the seminar begins. We need your enthusiastic participation now, and in the seminar. It will be fun, and at the end of it, we'll be asking for your feedback!

Please turn this in to your group leader (______________) no later than (_____________).

1. Have you had any formal training in giving presentations? YES NO

2. What do you already know about giving dynamic presentations? Answer briefly below:

a. What are the advantages and disadvantages of the lecture format?

b. What characteristics make for an outstanding presentation?

1. 4.

2. 5.

3. 6.

c. What are the characteristics of an outstanding visual aid?

d. What are the characteristics of an outstanding handout?

3. Think about presentations given in your program. Who does them? Are they engaging? Critique your own lecture style, visual aids, and handouts – what are their strengths, and which areas need improvement? Be prepared to share your thoughts with the group during the seminar.

4. What 3 things do you most want to learn or discuss regarding giving dynamic presentations?

a.

b.

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c.

5. Any other comments, concerns, or interests for this topic?


Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Series – Giving Dynamic Presentations

Course Content: Didactic and Group Discussion – An introduction to preparing and leading engaging learning activities



Name Rank

Check One

Email AddressStaff Physician

Resident Physician


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Date Speaker Topic


Strongly Disagree

Disagree

Somewhat Agree











Date Speaker Topic


Strongly Disagree

Disagree

Somewhat Agree








55



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Giving Dynamic Presentations

Example Eight Steps



Why: Improve presentations skills as part of a required faculty development curriculum.



What: Driven by the LNRA. Will explore which characteristics contribute to excellent, as well as poor, presentation preparation and delivery. Identify common pitfalls of delivering presentations and offer solutions to improve faculty skill set.

What For: By the end of this session participants will have:

Reviewed presentation preparation using the 7 Steps and 4 I’s Appraised effective PowerPoint tips Applied PowerPoint tips to a presentation Discussed public speaking strategies Assessed several public speaking examples Applied speaking strategies to a short presentation Reviewed tips on preparing effective handouts

How: General: Active learning: small group activities and discussion, larger group discussion, using both ideal and poor PowerPoint examples. Video clips will also be utilized for examples, appraisals, and impact. Room contains individual desks. Will pre-configure desks into larger half-moon shape. Within larger half-moon configuration, will group two to three desks in smaller half-moon shape for multiple groups of two to three learners each. This will facilitate small group activities followed larger group discussions. The session will take place at 0730, so will provide breakfast and beverages.

Grabber: Show JFK video; ask audience to reflect upon whether or not video compliments or detracts from the speech.

Induction Tasks: 1. Began with LNRA.

2. Learners discuss JFK video, it’s strengths, and it’s weaknesses.

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Input Tasks:1. Review Eight Steps and Four I’s of planning and how they relate to preparation of an effective, dynamic presentation.

2. Present techniques to enahnce the content of presentations.

3. Present the common pitfalls of PowerPoint presentations and offer tips to counter them.

4. Present techniques for effective public speaking.

Implementation Tasks:1. Interview one member of the small group and record several interesting facts about that individual.

2. Design two to three PowerPoint slides to introduce their group member.

3. Appraise two video clips and discuss as a group the strengths and weaknesses of each presentation.

4. Develop and deliver a one to two minute speech utilizing techniques from this session to present the interviewed group member.

Integration Tasks:1. Challenge learners to apply concepts from this session to enhance their future

presentations.

So What:Learning: Learners understand effective preparation, content enhancement, and delivery perils as well as techniques to mitigate them.

Transfer: Learners build upone their current presentation delivery skill set and use these techniques to design and deliver excellent future presentations.

Impact: Departmental teaching is enhanced, improved learning and success for residents.

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Giving Dynamic PresentationsHandout

"A boring teacher is someone who talks in someone else's sleep."

Overview

Advantages: complements a speaker’s presentation by reinforcing key concepts, decreases time required for taking notes

Disadvantages: If confusing or complicated, the audience may spend the session reading instead of listening

Preparing Useful Handouts

Tailor it to your audience: Students tend to prefer incomplete handouts that outline the key concepts but allow room for note-taking. Staff and residents prefer complete, clinically relevant handouts that can serve as a future reference

Concentrate on critical points of presentation: Be clear, logical and succinct Include useful reference charts and lists Use an annotated bibliography: Provides guidance to those who want to learn more

Summary

Techniques that create an engaging presentation - 3-5 main points - Maintain eye contact- Use body language - Use anecdotes- Vary inflection & pacing - Show enthusiasm

Visual aids should follow the 4 R’s- Readable - Relevant- Reliable - Repetitious

Handouts are an excellent tool for increasing retention of information

Group Discussion Ideas Discuss your program’s lectures – Are they engaging? Why or why not?

Critique your own lecture style, visual aids, and handouts discussed in this session

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Giving Dynamic PresentationsHandout

Activity One: Preparation

In groups of 2-3, choose a group member to introduce. Develop 3-4 items that you would share with this audience when introducing that group member. Please write the items you plan to

share below. Item #1

Item #2

Item #3

Item #4

Activity Two: Content Enhancement

In your same group of 2-3 table members, design 1-2 PowerPoint slides on your computer that convey the items you learned about each other in Activity #1. Feel free to use text, images from

the internet, or other creative ideas.

You can use the back side of this handout to draw out ideas for your slides before creating them or if you don’t have access to a computer with PowerPoint.

Activity Three: Delivery

In your group of 2-3, develop a 1-2 minute speech introducing your table member. Use your PowerPoint slides as content enhancement aids. Present your speech to the other members at the

table. Please be sure to stand while delivering the presentation. Speaking Notes

Remember the 4 R’s of Audio Visual Aids:

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Area for Slide Design

61

Supporting References and ResourcesGiving Dynamic Presentations

Purposes of A-V Aids Support and enhance the clarity of the presentation Emphasize the important points Stimulate the audience’s senses Reinforce key concepts

Advantages of using A-V Aids Can complement spoken part of presentation and lead to increased retention Much learning occurs from visual sources

Disadvantages of A-V aids It is easy to rely too heavily on them If poorly done, they can become a distraction

The 4 R’s of Audio-Visual Aids

Readable

Don’t use a chalkboard when speaking in a 400 seat lecture hall For text slides, use 6 or fewer lines with fewer than 6 words per line Ensure that charts and graphs are simple to understand Be consistent in use of font, text size, and designs

Reliable

Test all your equipment prior to presenting Develop a back-up plan if audiovisual aids fail

Relevant

Each slide or graphic should deal with one main concept Make sure that all audiovisual tools support the main objectives

Repetitious

Should repeat main point of the presentation since repetition is the mother of all learning (Repetitio Est Mater Studiorum)

Also helpful to vary the ways you present the same information (visual, tactile, auditory, and affective)

Preparation and Delivery of Effective and Dynamic Presentations

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Readable

Reliable

Relevant

Repetitiou

Background Information

“The art of lecturing takes practice and preparation. Using a few basic oratorical techniques, along with carefully prepared visual aids, can make the difference between a routine lecture and a dynamic, engaging presentation.”

Introduction Residents have spent hundreds of hours in lecture halls during their training Many presentations are helpful Other lectures leave students more bewildered than when the talk began A few presentations are enthralling and leave the audience with a clear understanding and a

renewed enthusiasm What separates average lectures from the exceptional ones is the ability to draw the audience in Engaging the audience does not require a flair for the theatrical Using a few basic speaking techniques and effective audiovisual aids can transform a presentation

into an interactive learning experience

Advantages of Traditional Lecture Presentations Excellent way to synthesize a broad range of research and information Provides a coherent framework for material Allows for presentation of information that may not be readily available in the literature Familiar and economical method that can be given to large audiences

Weaknesses of Lectures Does not account for students' individual differences Offers little opportunity to judge audience understanding Places heavy reliance on students' note taking skills and memory Demands sustained listening Limits active learner participation

Basic Guidelines for Delivering an Effective Presentation Organize the talk around 3-5 main points: Like a good story, have a beginning (intro), a

middle (body), and a conclusion (summary). Don’t try to cover the topic exhaustively – confine the activity to 3-5 main points.

Use body language: Emphasize certain points Vary inflection and pacing: Avoid monotone delivery Maintain eye contact with the audience: Don’t focus on your notes Personalize the material: Use humorous or dramatic anecdotes from your own experiences.

Choose your stories well – only use anecdotes that support the point you are trying to make. Show enthusiasm for your topic Create a diverse, interactive environment: The best way to engage the audience is to ask

questions, even if they are only rhetorical. Questions force the audience to think about the material. Demonstrations are also helpful in clarifying theoretical concepts.

Use audiovisual aids properly: If done correctly, they can enhance a presentation and greatly improve understanding and retention.

Delivering the PresentationSpecific Techniques for the Dynamic Lecture

Use demonstrations

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Provide anecdotes – use to make a point, not substitute for scientific practice Use metaphors to make examples vivid

(“Bursae function to reduce friction – like holding a partially filled balloon which is covered in oil between your palms”)

Use questions effectively - Ask one questions at a time- Wait for a response for at least 3-5 seconds

- Call on students and encourage participation

Delivering Dynamic Presentations Begin with a cordial, friendly line of greeting Exhibit enthusiasm Talk loud enough Stand erect Make eye contact - very powerful - makes connections Smile - look as if you are happy to be there Use movement and gestures - the larger the group, the larger the gestures & voice inflection

should be ALWAYS keep within the time limit Relax and enjoy the performance

Combat Nervousness Be prepared (best defense) - know content of lecture, be familiar with the room Rehearse, rehearse, rehearse - “Perfect practice makes perfect!” Release - go for a walk or stretch Launch - walk up confidently, stand up straight, and smile Avoid annoying mannerisms such excessive movement, playing with remote clicker or keys in

pocket, fiddling with hair Use coffee cup - helps set an informal atmosphere, provides reason to pause periodically

Using Handouts (Advantages) Complements the learning activity Reinforces key concepts Provides a take home reference Lessens needs for audience to take notes

Using Handouts (Disadvantages) Audience may focus their attention on handout rather than speaker

Handout Content (The ABC’s of Quality Content) Accuracy - data and concepts reflect verifiable information Appropriateness - relevant to the needs of the learner Arguments - adequately addresses areas of controversy Background - covers necessary background information Balance - theory and practice are appropriately balanced Bibliography - references well outlined and useful Currency - information is up-to-date Comprehensiveness - broadly comprehensive while appropriately succinct Coordination - integrates necessary data of other disciplines

When Should You Provide the Handout? Prospective

- Given in advance of the lecture- Allows the audience to read preparatory material or to ponder particular questions- Allows lecturer to cover more subject material or begin at a higher level

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- Often goes unread or not brought to class

Concurrent - Provides a program guide for the lecture - Allows key points to be highlighted - Eases the strain of note taking problems- Encourages daydreaming if audience pays more attention to the handout than to the speaker

Retrospective - Given at the end of class - Note taking becomes more time consuming

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Tips on Delivering This Presentation

One approach to this session is as follows: Using the LNRA from the faculty, identify which of the three areas discussed above are most

relevant to your audience. If time is limited, focus only on those areas indicated by the audience.

Consider using the example speaking script that is included within the slide presentation associated with this chapter.

Begin the session by establishing the goals for the seminar, and introduce the topic. Consider using the included grabber, which is a speech by President Kennedy (“Ask not what your country can do for you…”) that is coupled with an ineffective and distracting PowerPoint presentation. This will plant the seed that even exceptional content can be ruined by ineffective audiovisual aids.

After reviewing the agenda and objectives for the session, review the 8 steps of planning and share how you applied those steps to teaching this session.

For the first activity, use the first page of the handout and have the audience work in groups of 2-3 to prepare a short introduction of one of their group members. They should discover 3-4 interesting facts about that individual and begin to think how they will introduce that person to the audience.

The next section will cover content enhancement. You should introduce the 4 R’s of audiovisual aids (Readable, Reliable, Relevant, and Repetitious) and review examples of each in the PowerPoint presentation.

The second activity will allow the audience to apply the 4 R’s to their own PowerPoint slides that they can use to supplement the introduction of their partner. You should encourage them to seek out images, use text, or devise other creative ways to share information.

Next, show the short introduction video by Dick Hardt. This will emphasize that creativity in audiovisual aid design can be very powerful.

For the final section on content delivery, start with the Seinfeld clinic about the fear of public speaking. You can then introduce the London Times poll results showing that public speaking is the number one fear of many people.

Solicit feedback from the crowd about what effective speaking techniques they have heard.

Share the included speaking tips with the audience.

Show audience two video clips of public speeches. Have the audience evaluate the speakers on things such as enthusiasm, body language, movement, audience interaction, eye contact, and speech rhythm and tone.

For the final activity, have each group present their partner introduction to the group. Encourage them to stand up and apply some of the lessons learned over the session.

Close by showing the speech by President Kennedy accompanied by a more effective set of slides.

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At the close of the presentation, consider having the audience critique the handout they used through the session. Have them identify what they liked and what they didn’t.

Throughout the session, ensure that you provide lavish affirmation to those who participate. This helps to create a safe learning environment and promotes interaction.

Ask the participants to commit to using what they learned in the session for the next learning activity they lead.

Another technique would be to videotape several faculty presenting their lectures and review those video clips during a separate session. This would allow an opportunity to apply the learning to a personal and pertinent event.

After the session: Review the evaluation forms completed by the participants;

Reflect on the seminar - how did it go? What was good about it? What could have been better? Is there a better approach to this topic? Were there needs identified during this session that would be the basis for future seminar(s) in your program?

Where will your program go from here based on this seminar?

References

Dynamic PresentationsWhitman N: Creative Medical Teaching. 1st ed. 1990. University of Utah School of

Medicine. A humorous, well-written book on all aspects of teaching medicine.

Whitman N: There is No Gene for Good Teaching: A Handbook on Lecturing for MedicalTeachers. 1982. University of Utah School of Medicine. a classic, good, concise overview.

Kroenke K: The Lecture - Where It Waivers. Am J Med 77(3):393-6, 1984. Written by a military internist, excellent overview with 10 practical rules for giving a great lecture.

Findley LJ, Antczak FJ: How to Prepare and Present a Lecture. JAMA 253(2):246. 1985. Short, concise commentary on practical lecturing tips.

Irby DM: Preparation and Delivery of Dynamic Presentations. Univ of Washington Workshop given on 23-4 October 1996. Dr. Dave Irby is one of the gurus in medical education; much

of the Dynamic Lecture talk came from this workshop.

Creative HandoutsMacLean 1: Twelve Tips on Providing Handouts. Med Teacher 13(l):7-12,1991.

Amato D, Quirt I: Lecture Handouts of Projected Slides in a Medical Course. Med Teacher 12(3/4):291-6, 1990.

Kroenke K: Handouts: Making the Lecture Portable. Med Teacher 13(3): 199-203, 1991.

McLeod PJ, Tenenhouse A: Peer Review of Class Handouts. Med Teacher 10(l):69-73, 1988.

McLeod PJ: How to Produce Instructional Text for a Medical Audience. Med Teacher 13(2):135-44, 1991.

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Chapter 4Bedside Teaching:

Recovering a Lost Art


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Bedside Teaching




















69


Please complete the following needs assessment for the upcoming workshop on Bedside Teaching: Recovering a Lost Art as part of your faculty development program.

The seminar will consist of an introduction by your group leader, a short PowerPoint presentation and interspersed small group activities and class discussions.


Please turn this in to your group leader (______________) no later than (_____________).

1. Have you had any formal training in bedside teaching? YES NO

2. What are some advantages to teaching at the bedside?

3. What are some barriers to bedside teaching at your hospital?

4. Think about the bedside teaching rounds made in your program. Who does them? Are they effective? What are the strength(s) of bedside rounds in your program, and which areas need improvement? Be prepared to share your thoughts with the group during the seminar.

5. List three things you would like to learn/take away from this session:

a.

b.

c.

Any other comments / concerns for this presentation:

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Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Series – Bedside Teaching: Recovering a Lost Art

Course Content: Didactic and Group Discussion – Instruction on Bedside Teaching techniques and strategies to systematically implement Bedside Teaching



Name RankCheck One





71


Date Speaker Topic


Strongly Disagree

Disagree

Somewhat Agree




The speaker used active learning techniques to teach this subjectThe speaker gave adequate time for questions

Audiovisual / handout material added to the presentationOverall, the speaker was effective




Date Speaker Topic


Strongly Disagree

Disagree

Somewhat Agree




The speaker used active learning techniques to teach this subjectThe speaker gave adequate time for questions

Audiovisual / handout material added to the presentationOverall, the speaker was effective



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Bedside Teaching

Example Eight Steps


Who: 8-10 faculty learners from the Department of Family Medicine.


When: 1400-1500 on a Thursday afternoon, blocked schedule for faculty development.


What: Driven by the LNRA. How to plan and execute bedside rounds. Models to cover include: Ramani model (12 steps), Janicik model (3 domains). Identify barriers to implementation and explore strategies to overcome them. Commit to an implementation plan for the group.


• Listed obstacles to bedside teaching• Identified advantages of bedside teaching• Tried out models for bedside teaching• Found ways to overcome obstacles• Planned integration of bedside teaching into inpatient rounds

How: General: Active learning: small group activities and discussion, larger group discussion, minimal PowerPoint slides. Room contains one large table with chairs, white board, smart board connected to computer. Will group chairs to form two groups of 4-5 learners each. This will facilitate small group activities followed larger group discussions. The session will take place at 1400, so will provide coffee and cookies.

Grabber: Osler quote “Medicine is learned at the bedside and not in the classroom.” Crumlish study numbers showing staff and residents value bedside teaching (may contrast with institutional experience/perceptions).

Induction Tasks: 1. Began with LNRA and continued in first activities. Learners reflect on their experiences with bedside teaching.

2. Learners discuss obstacles to bedside teaching. Write list on board/easel or other prominent site in room and keep visible throughout session. Use LRNA responses to jumpstart the conversation, starting with “time” (universal barrier).

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3. Learners discuss advantages to bedside teaching. Write and display as with obstacles above. Affirm the learners by comparing their list to data from the Crumlish study. Use LRNA responses to prepare slide.

Input Tasks:1. Introduce the Ramani and Janicik models described on the handout. Note that an excerpt from the models is also provided for the next task.

2. Have small groups review the models.

Implementation Tasks:1. Have small groups use a case from their experience to formulate a bedside teaching session using the excerpt from one model. Allow 15min for this task. Discuss what struck them about it at the end of the learning task.

2. Discuss potential solutions to obstacles they have identified. Note this may occur naturally at any point in the session.

3. Discuss any other issues identified in the LRNA not yet addressed, as time allows.

Integration Tasks:1. After reviewing and affirming the work of the learners to this point, discuss and commit (as a group) to a plan for implementation. Suggest inclusion of minimum baselines such as frequency, duration, site, and people included in bedside group. Note the need to remain flexible in day-to-day practice. Write their commitments on the board/easel/other prominent place. At the end of the session, copy this list.

2. One month after the session, e-mail the site POC for feedback on the session. Include their list of commitments from the session and request assessment of impact.

So What:Learning: Learners have identified obstacles to and advantages of bedside teaching. They have reviewed two models to plan and structure bedside teaching sessions. They have identified strategies to overcome obstacles to implementation of regular bedside teaching. They have committed to a plan for regular bedside teaching.

Transfer: Learners implement regular and effective bedside rounds into their inpatient care rotation. They continue to identify and seek ways to overcome obstacles.

Impact: Residents and other learners improve their understanding of and performance in many dimensions of medical care. Morale and enthusiasm for inpatient care, teaching and learning all improve.

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Bedside Teaching HandoutBlending Tradition, Humanity, Art & Science

“No books, no tapes, no audio-visual aids, no seminars, no avant-garde philosophy will ever be substitutes for the discipline of bedside medicine—the one-to-one situation where

tradition, humanity, art, and science are blended." ~Unknown

Bedside Teaching: The Imperative

94% of residents believe bedside teaching time is valuable82% want more bedside teaching in the curriculum

Crumlish, et al, 2009

Teachable moment: The moment when a unique, high interest situation arises that lends itself to discussion of a particular topic.

Breaking Down the BarriersBarriers Recommendations

Limited time Be selective: not every patientDon’t wait for a quorumBe flexible

Attending inexperience or fear Faculty DevelopmentAcknowledge self as “imperfect scholar”Share the teachingEncourage self-directed learning (SDL)

Perceived patient discomfort Ask permission85% of patients prefer bedside roundsEnhances patient and family centered care

Overreliance on technology Explain the importance of diagnostic skillsIncorporate the technology at the bedside

Learner resistance Be persistentInclude all learnersNever undermine the learner in front of

patient

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Seek and Make the Most of Teachable Moments

Provide Frequent and Timely Feedback to All Learners on Team

Prepare, Brief, Experience, and Debrief

Break Down Barriers with Flexibility, SDL, and Persistence

Take Learning to the Bedside

“The best teaching is taught by the patient himself.” ~ Sir William Osler

Small Group Teaching: The Basics

Learning Environment:Low pressure Stimulate discussion and doubt

Teach from the middle Encourage self directed learningEngage the learners / Share teaching Think out loud

Effective Feedback Principles (SOME TLC):Specific Timely

Objective LimitedModifiable behaviors Constructive

Expected (Frequent)

Provide Effective Feedback:Ask What did you do well? What questions or challenges did you have?

Tell / Teach I observed… Then give a few general teaching points.Ask / Act What will you do differently next time? Develop an action plan.

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Prepare Objectives:

- Identify target learners

- Determine teaching objective (e.g. interviewing, physical exam, interacting with family)

Brief Participants:

- Ask patient and explain event

- Brief learners:

- Discuss expectations

- Assign roles

Debrief:

- Ask learners for their observations

- Provide feedback

- Encourage self-directed learning

Clinical Experience:

- Explain

- Demonstrate

- Learner experiences

- Assess

The Teaching Cycle

Improving Bedside TeachingBreaking Down OUR Barriers

Task #1 Bedside Teaching where I work Task #3

Obstacles

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

Solutions

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

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Bedside Teaching

Task #2 – Road Maps OR Focused Teaching – 15 minutes

RAMANI MODEL: Draw a road map (steps 1-4), orient learners (steps 5-7)

1) Medical system to be covered

2) Skills or aspects to be taught

3) Observation vs. demonstration

4) Define which patients and how long

5) Objectives, expectations, ground rules

6) Assign roles (presenters, examiners, jargon police, etc.)

7) Set limits (no coverage of highly sensitive issues, etc.)

JANICIK MODEL: Focused teaching (steps 1-4), Group Dynamics (steps 5-7)

1) Role model professional behavior, communication

2) Physical exam or procedural skills

3) Teach general concepts

4) Give feedback (patient can also give feedback)

5) Limit the time and goals for the session

6) Include everyone in teaching and in feedback

7) Assign roles to everyone

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Pick ONE model below. Use a case you have seen on the ward.

Work through the steps listed as if you were going from here to rounds.

Bedside TeachingReference model #1

The 12 Step Model (adapted from Ramani, et al, 2003)

1) Prepare goals for the sessiona. Use the curriculumb. Meet the learners at their level

2) Draw a road map ***a. Medical system to be coveredb. Skills or aspects to be taughtc. Observation vs. demonstrationd. Define which patients and how long

3) Orient learners ***a. Objectives, expectations, ground rulesb. Assign roles (presenters, examiners, jargon police, timekeeper, etc.)c. Set limits (no coverage of highly sensitive issues, etc.)

4) Introductiona. Introduce whole team and road map to patientb. Note primary goal is teaching

5) Interaction – Role model professional behavior for the learners6) Observation – Step out of the limelight, support learner as primary caregiver7) Instruction – Challenge the learners intellectually, don’t humiliate them

“DO’s” “DON’Ts”Gentle corrections Keep team all engaged One upmanshipAdmit knowledge limits Learn from your students “What am I thinking?”Teach professionalism Teach hands-on skills Ask juniors after seniorsTeach observation skills Use teachable moments Long didactics

8) Summarization – Recap for learners and the patient

9) Feedback – From learners, what went well and/or not well10) Debrief

a. Time for questions/clarificationsb. Assign further reading/researchc. Discuss sensitive areas

11) Reflect12) Prepare for next time

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BEFORE

AFTER

DURING

Bedside Teaching Reference Model #2

The 3 Domains Model (adapted from Janicik, et al, 2003)

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Attend to Patient Comfort

1) Ask the patient’s permission in advance2) Introduce everyone on the team3) Start with a brief overview from the primary caregiver (learner)4) Give explanations without using medical jargon5) Base the teaching points on that patient6) Use a genuine, encouraging closure statement7) Return later to check for and resolve misunderstandings

Focused Teaching

1) Diagnose the patient2) Diagnose the learner3) Provide targeted teaching ***

a. Role model professional behavior, communicationb. Physical exam or procedural skillsc. Teach general conceptsd. Give feedback (patient can also give feedback)

4) Debrief after the session

Group Dynamics ***

1) Limit the time and goals for the session2) Include everyone in teaching and in feedback3) Assign roles to everyone

Supporting References and ResourcesBedside Teaching

Cox, K. (1993). Planning Bedside Teaching. The Medical Journal of Australia, Vol. 158-9.University of New South Wales School of Medicine. Series of 8 articles describing a teaching cycle in detail. Source for Teaching Cycle in the handout. Full conceptual diagram:

WorkingDebriefing Preparation knowledge

Clinical ExplicationEncounter

PreparationBriefing for next time Reflection

Crumlish, C. M., Yialamas, M. A., McMahon, G. T. (2009). Quantification of Bedside Teaching by an Academic Hospitalist Group. Journal of Hospital Medicine, 4:304-7.Author from Brigham and Women’s Hospital, Boston, Internal Medicine residency. Study examined time spent at the bedside during rounds (17%, deemed too low) and what residents value about bedside teaching.

Most valuable parts of BT:Physical ExamCommunication/Interpersonal skillsFocus on pt-centered careIntegrating clinical exam w/dx/mgmt decisions

Ende, M. J. (1997). What if Osler Were One of Us? Inpatient Teaching Today. Journal of General Internal Medicine, 12:S41-S48. Author from University of Pennsylvania School of Medicine. He examines challenges and planning modern bedside teaching using Osler as an example of excellent practice.

Principles of Learning Corresponding Rec’s for Teaching1) Knowledge is constructed, Begin with students’ conceptualization;

not accumulated Use probing questions; encourage reflection2) Expertise depends on experience Focus discussions on the patient;

with cases Teach at the bedside; compare/contrast cases3) Students learn when they Provide challenge and support; stimulate interest;

are involved Make rounds fun; encourage independent learning4) Learning is both a personal and Develop a learning community; provide orientation;

a social process Leaven credibility with authenticity; Know your learner

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Experience

Cycle

Explanation

Cycle

Ende, M. J. (1997). (con’t)Questions to guide planning “rounds that work”

What do you hope to accomplish?What is your point of view?How will your learners be engaged?How will you meet the needs of each learner?How will rounds be organized?Are your rounds successful?How will you make the time?

Gonzalo, J. D., Masters, P. A., & Simons, R. J. (2009). Attending Rounds and Bedside Case Presentations: Medical Student and Medicine Resident Experiences and Attitudes. Teach Learn Medicine, 21 (2):105-110. Authors and study from Penn State College of Medicine. 3rd year med students, Internal Medicine and Med-Peds residents surveyed about time, value and concerns over bedside rounds. Time at bedside: mean 27% of rounds (73% of rounds had <25% of time at bedside). Value: 1) Learners that had seen bedside rounds prefered bedside rounds more

than those who hadn’t seen them (42% vs 13%). 2) Bedside rounds somewhat or very important for learning physical exam (89%),

communication (83%), professionalism (72%), patient mgmt (59%), history-taking (55%), pain mgmt (43%).

Concerns: Prevents freedom of discussion about patient’s case (75%), patient comfort (66%), concern for patient’s feelings (66%)

Kroenke, K., Omori, D.M., Landry, F.J., Lucey, C.R. (1997). Bedside Teaching. Southern Medical Journal, 90 (11):1069-74. Primary author from USUHS, Dept of Medicine. Review of five common obstacles to bedside teaching and potential solutions for each:

Obstacle Potential SolutionsTime constraint Pre-designate time during rounds (30min/day, 1 pt/day, etc);

Be selective in target for each encounter

Selecting targets Attending picks based on presentation (confusing hx, abnormal exam);Attending asks team to pick; Someone notes a great learning point independently

Demonstrate vs. Demonstrate advanced skills;observe Observing residents slower but better learning

Staff insecurity "No finding is too mundane"; Chronic findings still valuable;Learn together as a team; Role model compassion/professionalism

Learner dislikes Plan ahead, limit single-resident exam timeBoredom Set the tone before bedside rounds; Teach vice putting on the spot;Fear of embarrassment Specify goals/agenda

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Janicik R. W., Fletcher, K. E. (2003). Teaching at the bedside: a new model. Medical Teacher, 25 (2):127-130.Source for model cited in handout.

Lehmann, M. L., Brancati, M. M., Chen, M. M.-C., Roter, D. D., & Dobs, M. M. (1997). The Effect of Bedside Case Presentations on Patients’ Perception of Their Medical Care. The New England Journal of Medicine, 336:1150-1156. Authors and study from Johns Hopkins Hospital, Internal Medicine inpatient service.RCT design. Patients with bedside presentations reported doctors spent more time with them, reported slightly better quality of care. Lower education level associated with more complaints of doctors using jargon.

Mooradian, N.L., Caruso, J.W., Kane, G.C. (2001). Increasing Time Faculty Spend at the Bedside During Teaching Rounds. Academic Medicine, 76 (2):200.Essay from authors at Jefferson Medical College.Residents evaluated attendings by time on ward, gave feedback to PD (no names), increased incidence of teaching at the bedside from 30% to 70%.Points for successful rounds:

Obtain pt consent prior to rounds Ask residents/students to demonstrate PE findingsExplain to pt purpose of rounds Model professionalismIntroduce team Allow pt to stop sessionBe courteous Allow pt the last word/question

Ramani, S., Orlander, J. D., Strunin, L., & Barber, T. W. (2003). Whither Bedside Teaching? A Focus Group Study of Clinical Teachers. Academic Medicine, 78 (4):384-390. Author is from Boston University. Focus groups among faculty describe obstacles/solutions.

Specific BarriersTeacher Declining BT skill System Interruptions

Inexperience Short admissionsPerformance pressure Technology overloadLack of controlTough to engage whole team Patient Patient discomfort w/idea of BT

Not believing BT worthwhile Patient too ill (unstable)Belief BT is for residents to do Patient off ward

Patient misunderstanding lingoClimate Limited time Patient privacy

Lack of faculty training Uncooperative/angry patientLack of faculty rewardsLack of role models

Miscellaneous Crowded roomNo blackboard/X-ray view-boxCan't refer to textbookTeacher/learner hesitancy in discussing Differential DxFear of undermining house staffLearner fatigue

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Ramani, S., et al (2003). (con’t)Strategies to Increase/Improve BTPre-rounds Prepare goals for each session

Orient learners to those goals (PE, communication, professionalism)Orient patients to purpose of rounds

During rounds Establish safe environment ("I don't know" is OK)Respect learners (1° caregiver, challenge don't humiliate)Respect patients (humans, not specimens)Engage everyone in the roomInvolve the patientMatch teacher-learner goals

Post-rounds Debrief

Ramani, S. (2003). Twelve Tips to Improve Bedside Teaching. Medical Teacher, 25 (2):112-115. Source for model cited in handout.

Williams, K. N., Ramani, S., Fraser, B., & Orlander, J. D. (2008). Improving Bedside Teaching: Findings from a Focus Group Study of Learners. Academic Medicine, 83 (3):257-264. Authors from Boston University. Focus groups among residents describe obstacles/solutions.

Barrier StrategyPersonal Low initiative Institutional incentives

Low teacher/learner expectations Set explicit expectations/objectivesLow BT teaching skills Set good learning environment

Acknowledge learners needsPlan flexibility per workloadSelectively/efficiently integrate BT w/workSet teaching time limits

Low clinical knowledge/skills Faculty developmentReassure: EVERYONE has something to offer

Interpersonal Pt uncooperative Ask beforehandOrient pt to format/goalsInclude/inform pt

Lack of learner autonomy Respect learner-pt relationshipNegotiate level of autonomySupportive learning environmentShare teaching w/team members

Learner/pt fear of embarrassment As above (interpersonal category)

Environmental No time (workload/turnover rate) Team cap, add nonteaching serviceCompeting faculty duties Reduce themLow expectation/incentive to teach Set explicit expectation/objectives

Create incentivesLow recognition Create rewardsFocus on technology vice clin skill Faculty development, EBM on clinical skillInterruptions, excessive noise (no strategy offered)Lack of privacy/space in room (no strategy offered)

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Wright, M. S., Kern, M. M., Kolodner, S. K., Howard, D. D., & Brancati, M. M. (1998). Attributes of Excellent Attending Physician Role Models. The New England Journal of Medicine, 339:1986-1993.Authors from Johns Hopkins University, study examined four teaching hospitals. Residents identified excellent role models, those role models and other “control” teaching staff were queried via questionnaire regarding various attributes. Those attributes associated with being identified as an excellent role model included:

1. >25% of time spent teaching2. > 25hrs/week teaching or rounding while on an inpatient service3. Stressing importance of the doctor-patient relationship in one’s teaching4. Teaching psychosocial aspects of medicine5. Having served as a chief resident

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Chapter 5Giving Effective Feedback


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Giving Effective FeedbackChecklist for the Group Leader



















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Learner Needs and Resources Assessment***Consider using internet based survey systems to design and administer your surveys (Survey Monkey for example)***

Please complete the following needs assessment for the upcoming seminar on Giving Effective Feedback as part of your faculty development program.


The purpose of this LNRA is to determine your learning needs and interests so that the seminar is most useful for you. This needs assessment should also stimulate you to think about active learning before the seminar begins. We need your enthusiastic participation now and during the seminar. It will be fun, and at the end of it, we'll be asking for your feedback!


1. Have you any formal training on how to give effective feedback? YES NO

2. What do you already know about giving effective feedback? Answer briefly below:

a. What are some characteristics of effective feedback?

1. 3.

2. 4.

b. What are some characteristics of an ineffective feedback?

1. 3.

2. 4.

3. In your experience, what are barriers to giving effective feedback?

4. What three things do you most want to learn or discuss regarding giving effective feedback?

a.

b.

c.

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Resident / Student Feedback Assessment***Consider using internet based survey systems to design and administer your surveys (Survey Monkey for example)***

We will be having a faculty development seminar on Giving Effective Feedback and would like your important impute to better design our seminar.

Please turn this to the faculty POC (______________) no later than (_____________). Your group leader will return this form to you at the beginning of the session.

1. How important is receiving feedback to you?

a. Very Importantb. Importantc. Moderately Importantd. Of little Importancee. Unimportant

2. In your experience, the amount of feedback you receive from faculty is:

a. Too muchb. Just rightc. Too little

3. In your experience, the quality of feedback you receive from faculty is:

a. Very goodb. Goodc. Acceptabled. Poore. Very Poor

4. Which TWO features of feedback are most important to you?

a. Specificb. Objective (not hearsay but something observed)c. Modifiable Behaviors (focus on things that can be changed)d. Expectede. Timely (Right time and right place)f. Limitedg. Constructiveh. Other:____________

5. List ways faculty can improve your feedback experience.

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Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Workbook Series – Giving Effective Feedback

Course Content: Didactic and Group Discussion



Name RankCheck One






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Date Speaker Topic


Strongly Disagree












Date Speaker Topic


Strongly Disagree











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Giving Effective Feedback

Example Eight StepsThe eight steps presented below may be used as a guide for your planning.

Modify these steps to meet your specific needs.


Why: Enhance the ability to give effective feedback as part of a required faculty development curriculum.


Where: Classroom, individual desks, accessible, AV supported, requires own computer and sound system. Conducive to small group activities.

What: Driven by the LNRA. Will explore characteristics of effective feedback, identify barriers, and will discuss tools and techniques that can be used to improve feedback giving skills.


• Reviewed importance of feedback • Defined feedback vs. evaluation • Identified barriers to feedback • Identified ingredients of effective feedback • Applied effective feedback techniques

How: General: Active learning: small group activities and discussion, larger group discussion, minimal PowerPoint slides. Room contains individual desk. Will pre-configure desks into larger half-moon shape consisting of five or six learners. Within larger half-moon configuration, will group desks in smaller half-moon shape of two to three learners each. This will facilitate small group activities followed larger group discussions. The session will take place at 0730, so will provide coffee and bagels.

Induction Tasks: 1. This also serves as a “Grabber.” Play video containing funny feedback

moments in the movie industry. This will help learners draw from past experiences. Ask group if any of these has every happened to them.

2. Ask learners to write down two or three things that come to mind when they think of feedback. Have learners share.

3. Show result of student / resident feedback survey. Ask group to discuss results. Where there any surprises? Are our students’ expectations and beliefs in regards to feeback different then ours? Is there a feedback gap?

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Input Tasks:1. Learners read brief article about giving effective feedback. Have learners

highlight reasons for giving feedback, principles of effective feedback, and ways to give effective feedback. Have learners share.

2. Feedback vs Evaluation exercise. Have learners match discriptive words with either feedback, evaluation, or both. Show slide of our own list and ask learners if they got something different an discuss.

3. Ask group to share their barriers to giving effective feedback. Then show slide of LNRA response to this question. Then ask group to share possible solutions to these barriers.

Implementation Tasks:1. Introduce SOME-TLC acronym for giving effective feedback. Have learners

in groups of two or three pick one of feedback scenarios which discribes events and obserations and have them highlist key points that they would want to sue to give feedback.

2. After introducting Ask-Tell-Ask-Act feedback techique, have learners practive giving each other feedback.

Integration Tasks:1. Review student / resident feedback survey. How will knoweldge and skills

learned today be used to narrow or decrease gap?

2. Review staff survey about barriers to feedback. Break learners in 2-3 groups to address how they will mitigate or resolve these issues.

3. Ask group to discuss and write down what they will do for the next month to improve feedback to learners.

So What: Learning: By the end of the event, learners will have demostrated knoweldge of importance, characteristics, and skills needed to provide giving feedback. The fact that members actively participated in discussion and generation of solutions to feedback challenges and practiced giving effective feedback demostrates learning.

Transfer: This will be achieved through integration tasks noted above. The key to have each participant commit to making a change to improve how they give feedback.

Impact: Departmental feedback to learner improves with overall improved learning and education. This can be measured in a post event LNRA to faculty and to students / residents.

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Giving Effective Feedback Handout:Making a Better Sandwich

Take Home Points

• Feedback is essential • Feedback is desired by learners

• Effective feedback requires preparation• Give SOME-TLC via Ask-Tell-Ask-Act

Activity #1 – Feedback Reflection – 3 minutes

Write down 1-2 words that come to mind when you think of feedback. Share these with the others at your table.

Be prepared to discuss any common themes that are present. Word #1

Word #2

Common Themes:

Activity #2 – Feedback in Literature – 8 minutes

Highlight concepts of effective feedback that are important to you.

Be prepared to discuss with the group.

Giving Effective Feedback by W. Fred Miser, M.D.

The feedback we give to students should be for one primary purpose - to keep them on course so they arrive successfully at their predetermined destination (the attainment of the skills, attitudes and behaviors that will make them outstanding physicians).

Feedback is not "rocket science." It is an objective description of a student’s performance intended to guide future performance. Unlike evaluation, which judges performance, feedback is the process of helping our students assess their performance, identify areas where they are right on target and provide them with tips on what they can do in the future to improve in areas that need correcting. Students will invariably say they do not receive enough feedback from us as teachers. Think about your own training. Did your teachers let you know what you were doing right, and what areas needed improvement? Did you receive enough feedback? Chances are your teachers let

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you know when you strayed off course, but did they focus on what could be done in the future so that you would not repeat the error? To be effective, feedback should consist of these characteristics:

1. Good feedback should be timely. The best feedback occurs on a daily basis, not just at the end of the rotation. If done frequently, our comments will seem less like an evaluation, and more like helpful suggestions. Take time after an encounter or procedure to provide feedback to the students.

2. Feedback is meant to be constructive. It is intended to improve future performance, and should be given for no other reason. It is not meant to demean or punish the student. Describe your observations and your own reactions.

3. The best feedback is specific. Use precise language about what specifically they did right or what they need to do to improve. Students may momentarily feel good about themselves when you say, "You did a good job." However, they will also wonder what specifically they did that earned your praise. Instead of saying, "You are clumsy," provide specific feedback such as, "The patient appeared uncomfortable when you were using the otoscope."

4. Feedback is focused on behavior, preferably ones that can be repeated, and not on the individual. Focusing on the behavior allows a dispassionate dialogue with the student.

5. Good feedback should be based on personal observations, not on hearsay.

6. Feedback should be verified. Make sure the student understood your feedback, and then follow up with a plan to monitor and assist the student in those areas that need correcting.

There is an art to giving feedback. If not done properly, or done with the wrong intention, the student will take your comments as criticism. At the beginning of the rotation ask the students how often they would like feedback, and develop a plan on providing that feedback to them. Then, before you provide feedback, take a few moments to choose the words you will use, and confirm your motivation that you are providing that feedback to improve their performance. Avoid evaluative language; its use can cause the student to respond defensively.

Feedback should be done as soon as possible, unless emotions will interfere with the session. Excellent feedback given at an inappropriate time may do more harm than good. Often after a bad outcome, students are working through their own emotions, and are often quite critical of their performance. At this time, brief feedback and emotional support are best, followed later by a more detailed feedback session. Feedback should also be done in private, unless it can be given in such a manner as to not be embarrassing. An old axiom is to "praise in public" and "critique in private."

It is often helpful to ask the students to assess their own performance. Often they will be more harsh about their performance, which then allows you to be more positive in your approach. It is much easier and more effective for you if the students identify areas for improvement; you can then help them develop a plan of action as to how they can do things differently in the future.

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When assessing performance, focus on what went well, and what can be improved. Gain consensus with the students; feedback is more effective if you and the students agree on this assessment. Some educators advocate the P-N-P (positive-negative-positive) sandwich approach to providing feedback. Begin with a positive statement, then give corrective feedback and conclude with another positive assessment. However, the positive comments must be genuine, or you will lose credibility with the student. Remember to focus on the performance and behavior, not on the person. Also, focus on those behaviors that the student can do something about. Reminders about shortcomings over which the student has no control only leads to frustration.

When determining a plan of action for improvement, ask the students what they can do. Again, gain consensus with the students; future performance is more likely to improve if they agree with the plan. It is helpful to set goals for future performance. "Next time you encounter this, try this...," then verify that the students understand, and if the opportunity arises, confirm that they did change their behavior.

In conclusion, Jack Ende has written, "The goal of clinical training is expertise in the care of patients. Without feedback, mistakes go uncorrected, good performance is not reinforced and clinical competence is achieved empirically or not at all." (Ende J: Feedback in clinical medical education. JAMA 250(6):777-81, 1983).

We should provide feedback often to our students, helping them to stay on track so they can achieve their ultimate goal of being outstanding physicians. It is a skill that can be developed, and I encourage you to keep this foremost in your mind as you work with the students in your office.

Activity #3 – Feedback versus Evaluation– 3 minutes

Using an arrow, place the descriptive words under the appropriate heading. Some words may fall under both headings.

FEEDBACK EVALUATION

ObjectiveImmediateScheduled

InformalFormal

ObservationalDialogue

MonologueGrading

ImprovingEvent Specific

Global Performance

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Activity #4 – Cases – 3 minutes

In groups of 2, each person pick one scenario that you will later (activity #5) give feedback for. Highlight items from your scenario that you would use to provide feedback keeping in mind SOME-TLC.

Case #1: (Medical resident scenario)You observe a resident performing a colposcopic exam, and biopsies. The resident was

excellent in the explanation and consent of the procedure to the patient. The patient jumps slightly during the placement of the speculum and states, “that’s

uncomfortable!” The resident repositions the speculum slightly and states “ Sometimes it is going to hurt a little”. The resident follows the appropriate sequence of actions, identifying an appropriate area to biopsy. As the resident continues with the procedure, the patient intermittently makes sounds of slight discomfort when the speculum is bumped and particularly with the biopsy.

When the resident has completed the procedure, the patient asks if she can have any medication for pain. The resident replies stating, “colposcopy is not that painful, and you should be fine with over-the-counter Motrin. Even that is not needed for most people.”

The resident concludes by stating he will call the patient with results, and he feels confident that she has only minor changes, that may not require further intervention.

Case #2: (Non medical scenario)You are teaching a class via a series of interactive workshops. Most but not all students

are there as an elective course. The curriculum requires reading between sessions. All sessions require active participation

One of your students, Mary, started the course strong and you though she was going to be one of the top students. Recently, you note that a Mary is frequently 4-5 min late for each session. She often seems to be poorly organized upon arrival. She is somewhat reluctant to be involved. Today during a group session she was texting on her phone. Another student asked her to participate or leave. She set the phone down, and returned to the activity.

When she does participate she gives insightful answers to the group. She is good at following specific directions when engaged. However this does not occur every session. You overhear a student stating, “Mary is either completely unaware that she is a drag on our group, or she just doesn’t care.”

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Activity #5 – Giving Feedback – 10 minutes

Using the items you highlighted above, each person practice giving effective feedback using the Ask-Tell / Teach -Ask-Act model for your case. Your partner will play the learner who will receive the feedback. To facilate dialogue, the learner (partner receiving feedback) should incorporate the following relevent information below about their case into the feedback sesson. The person giving feedback for the case should avoid reading the learner’s additional information.

Be prepared to discuss with the group how your interaction went.

Supplement information for the learner (person receiving feedback)

Case #1: (Medical resident scenario)You know this patient very well. She has seen you for multiple muscle skeletal problems

and in your opinion has a very low threshold for pain. You saw her before the procedure and she had demanded Percocet and Xanax for the procedure. You spent 30 minutes reassuring her but did not give her any medication.

Case #2: (Non medical scenario)You have taken a similar course before and you do not find the current course

challenging. You feel that you know the material and initially did all the work for your group. You do not think this is fair. You want the other students to pull their weight.

Activity #6 – Commitment to Improving Feedback – 5 minutes

Using what you have learned today and feedback needs of our students, list what you will do in the next month to improve feedback to your learners.

Be prepared to share.

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Supporting References and ResourcesGiving Effective Feedback

Background"Human beings are purposeful organism who, if they know where they are supposed to be

going, and, along the way, know whether or not they are on course, will make the necessary adjustments.” …Unknown

The term feedback was first used by rocket engineers in the 1940's. Feedback was used to "tell" the rocket it was on course or, if off course, to guide it back onto the correct path so that it would go where it was supposed to go (i.e., reach the predetermined end point). Feedback to maintain the proper course and feedback to correct are equally important in guiding future performance.

Definition: Feedback is an objective description of performance intended to guide future

performance; the Process of letting others know your perceptions of their performance Distinct from evaluation, feedback provides information to be used to guide future

performance It is not a judgment

Review the characteristics of evaluation and feedback and think about the difference. Both are critical in assuring that your learners reach your end point and meet your standards.

Purposes of Feedback NOT to assess or judge provide information to be

used for improvement Clarify deviations from an established goal Shape behavior toward an established goal Correct inaccurate assumptions Motivate Convey an attitude of concern Learners want / need it

Characteristics of Good Feedback Measured against established standards Timely - the best feedback occurs on a day to day basis Constructive - it is intended to improve future performance and is given for no other

reason Specific - use precise and specific language Properly motivated - intended to improve future performance and not demean the

learner Directed at decision / behavior, not at the person

o Focusing on the decision allows a dispassionate dialogue with the learner

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Based on personal observations and provided by anyone who is in a position to make a valid

Observation on the learner's perform performance Verified - assure the learner understood the message Followed up with a plan to monitor and assist

Giving Feedback Establish credibility / trust - this, obviously, is a long term process Prepare - take a few moments to choose the words you will use Confirm your motivation - feedback is given solely to improve future performance Start with the learner's assessment - it is easier for you and more effective for the learner Establish the "Dx" - what went well and what can be improved upon

o Gain consensus - feedback is effective if you and the learner concur on the "Dx" Determine the "Rx"

o Ask the learnero Gain consensus - future performance is more likely to improve if the learner

concurs with the plan to monitor and assist Verify that the learner understands and follow up

Giving Corrective Feedback Credibility/trust is key: Comments must be sincere The learner will be receptive if she/he feels that the feedback is given with the single

purpose of improving her/his future performance Let the learner know it's coming Ask for the learner's assessment

o It is easier for you and more effective if the learner identifies areas for improvement

Avoid traditional P-N-P sandwich --- does not promote dialogue with learner Consider using new Ask-Tell-Ask-Act sandwich discussed below. ASARP (As Soon As Resonabily Possible). Consider emotional state of learner Done in private (unless it can be given in such a manner as to not be embarrassing and is

intended to guide the future performance of the other learners present) Try not to use "YOU" or "YOUR" (this is hard to do, but it reminds us to direct the

feedback at the performance/behavior not the person) Prepare - take a few moments to choose the words you will use Set goals for future performance Follow up on the plan to monitor and assist

Summary"The goal of clinical training is expertise in the care of patients. Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all." Jack Ende

The keys are the motivation of the giver (solely to improve future performance) and the perception of the learner (that the information is provided to promote "expertise in the care of patients").

References

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Ende J. Feedback in Clinical Medical Education. JAMA. 250(6):777-81, 1983. Excellent, pragmatic discussion of feedback. A superb reference.Latting, JK. Giving Corrective Feedback: A Decisional Analysis. Social Work. Sept 1992. 37(5): 424-30. Provides a useful twelve-part feedback model. Osborn LM & Whitman N. Ward Attending: The Forty Day Month. University of Utah School of Medicine. 1991. pp 119-46. Excellent resource especially for those supervising an inpatient service.

Giving Effective Feedback Through Dialogue with SOME TLCUFP Newsletter Section Teaching and Learning, Published Winter 2011Kristian E. Sanchack, MD

Giving Effective Feedback Through Dialogue with SOME TLC

There is an awkward moment that sometimes arises at the end of a procedure, clinic, or long inpatient day. Standing before you is the learner, perhaps a resident or medical student, with big puppy dog eyes. The eyes imply, as the student may be afraid to ask, “Will you give me some feedback?” Awareness swoops in on both of you; similar to the moment a valet drops your bags in the hotel room. It is time for the tip. A list of excuses or transitions may flash through your mind’s eye allowing the blissful escape from this moment. However, you know that feedback is essential. Barriers exist, but these barriers will fall away for the prepared educator.

Feedback is essential“The goal of clinical training is expertise in the care of patients. Without feedback mistakes go uncorrected, good performance is not reinforced and clinical competence is achieved empirically or not at all.” –J. Ende1

Feedback is the process of describing a student’s performance for a given activity, for the purpose of improvement of their knowledge, skills and attitudes. In graduate medical education it is a key process for the acquisition of clinical skills. Jack Ende also notes that feedback started being described in the literature as a system of adjustments for rocket science. This was then extended to the humanities through the study of cybernetics in the 1940s, as information relating to performance was proposed to be able to change the general manner of future performance in a process considered learning.1,2 Giving effective feedback however, does not require a degree in rocket science or cybernetics.

Feedback occurs when a learner is given insight into what the educator observed and what consequences or actions may follow. Evaluation and feedback may often be used interchangeably, but this not accurate, and leads to confusion. Feedback is a formative process that should take place as a dialogue. Evaluation is summative conclusion that comes with judgment. Feedback leads to greater self-awareness for the learner, and increases the mutual understanding between a student and teacher.1,3

Principles of Effective Feedback

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“There is an art to giving feedback. If not done properly, or done with the wrong intention, the student will take your comments as criticism.” W.F. Miser3

Now that we are aware that feedback is essential to the education process, we must review what principles are important in giving effective feedback. Now many authors have developed acronyms to help stimulate the memory. However, I relied heavily on my peers, and was rewarded by Tien Bui, DO. Dr. Bui (who denies any use of mind expanding drugs at the time) would say, “Give good feedback, by giving your learner SOME TLC.” (See Figure 1.)4

Figure 1. SOME TLC

Feedback should be specific. Phrases like “good job!” in themselves do not provide any learning benefit. Instead describe precisely what was done well, as well as specific areas where they can improve.

Feedback should be objective based upon your observations as the educator. Conversations based on hearsay are less effective and unreliable. Furthermore this allows for a more emotionally neutral conversation.

Focus on modifiable behaviors, particularly those that are likely to be repeated. Through this you address the behavior and not the person. Addressing a student concerning the fact that they heavily relied on notes, had difficulty finding labs values, and appeared like they had not prepared, does not imply that you dislike them as a person. However, if you merely tell them they are “not doing great, and need to get better,” you leave them unsure as to what they should change. Over time they may feel that you are just unfair.

Feedback should be expected. Prepare the learner for feedback sessions by defining your expectations early. For example, at the beginning of the rotation, or workday let them know that you will be giving them feedback. You want to avoid the blind side hit on the learner. Consider arranging frequent scheduled feedback sessions throughout a rotation, and/or after each procedure. Increasing the frequency limits the amount of information to be discussed, making it a faster task.

Even with scheduled sessions, feedback still needs to be timely. If something very important has occurred, it should be addressed while it is fresh in everyone’s memory. With time, the details of events are lost and can make feedback less meaningful. Certainly, it is also appropriate to allow some extra time before addressing feedback if things are emotionally charged, or if there is significant fatigue present in either the learner or educator.

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SOMETLC

Keep your feedback limited. Covering a large range of topics is difficult and often a portion of what is discussed may be lost. Frequent feedback sessions that occur on a timely basis allow you to address behaviors or performance as it happens. This provides a small focused area to reflect on, which will allow for a more effective discussion.

Finally, feedback should be constructive. Your goal is to help the leaner improve, and therefore what is discussed should occur for no other reason. While certain discussions may be uncomfortable for a learner, they should not walk away feeling insulted or demeaned1,3,4.

Dialogue EducationConsider the Johari Window (see figure 2.). The simple foursquare model graphically

represents what is known and unknown to self, and others. Through dialogue, an educator can describe what was observed, and discuss what the learner was or was not aware occurred. Furthermore, the discussion may open up areas that could not be directly observed (student’s disclosures) and enrich the quality of training that occurs. As this dialogue occurs, the public arena where learning occurs increases in size, and the other unknown areas shrink.5

Figure 2. Johari Window

An older method of providing feedback involved the positive-negative-positive sandwich approach. This has several drawbacks, some that can put off students. First, the learner does not get a chance to disclose anything, as it is not a conversation. They realize a “technique” is being used so that they can be told something negative. That sandwich is not very palatable.

However, food is a strong visual so we can go forward with a new type of sandwich (see figure 3.), which helps you engage in a conversation. Use the soft sequence of Ask-Tell/Teach-Ask-Act, slightly adapted from Lyuba Konopasek’s New Feedback Sandwich.

Figure 3. Adaption of the New Feedback Sandwich6

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Consider starting your conversation by asking the learner to assess their own performance. Typically you could start by asking, “How do you think that went?” It is possible you will need to probe further so consider “ What do you think went well?” or “Did you experience any problems?” This engages the learner and improves learning through praxis; a reflection on his action with intent to improve.

The learner may have already stated what was on your mind. If not, now is an appropriate point in which you can describe what you observed. Simple starts are “I observed…” or “ It seemed as though…” and the classic “When you do __ I feel __” statement. It is also an appropriate point to discuss short pearls. “In my experience…” or “Consider…” For example, I have had the benefit of the following sage feedback:

“Kris, when you are presenting you sometimes speak too quickly, and people can’t keep up with what you are saying. Consider taking a deep breath before starting, and consciously try to slow down (and drink less caffeine).”

Providing some brief comments can be helpful, but the best learning occurs when the student provides the solution. Rather than asking them to repeat your comments ask “What do you think of my observations?” or “what will you do differently now?” and “What can we do to improve?”6

Now that you have had a good conversation relaying effective feedback using SOME TLC you are not done. The best demonstration of learning is improving or modifying the behavior appropriately. Learning is a cycle, so trust and verify that your learner understood. Hopefully you have gained the learners confidence by being open, and the learner has taken away salient points that will improve patient care.

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Ask

Tell / Teach

Ask

Act

A Tastier Sandwich

Given the increasing restrictions on work hours in graduate medical education7, we need to effectively and efficiently maximize all learning opportunities. We cannot afford to be set on broadcast only. We must engage our students through active learning techniques. We have established that feedback is essential. Through SOME TLC you have the framework to apply principles of effective feedback. Using dialogue you have the ability to engage your learner in self-reflection, as well as determine information that is unavailable to you. The ultimate goal of feedback is clear communication. Now the awkward moments of silent expectation can be replaced with a mutually beneficial conversation.

References

1. Ende J: (1983) Feedback in clinical medical education. JAMA 250(6):777-812.Weiner N., (1950) The human use of human beings in cybernetics and society. Boston: Houghton Mifflin Co., pg 71.3.Miser, W.F. (1999) The Family Physician as Teacher - Giving Effective Feedback. The Ohio Family Physician. Vol. 51, no. 8: 12-134.Bui, T., Sanchack, K., (2010) Giving Effective Feedback. Fall Faculty Development Presentation5.Luft, J. and Ingham, H. (1955) "The Johari window, a graphic model of interpersonal awareness", Proceedings of the western training laboratory in group development. Los Angeles: UCLA 6.Konopasek, L., (2009) Using the New Feedback Sandwich to Provide Effective Feedback. Presentation available at sklad.cumc.columbia.edu/acgme/toolbox/toolbox43/mod_4.ppt accessed 10DEC20107.Nasca, T., Day, S., Amis, S., (2010) The new Recommendations of Duty Hours from the ACGME Task Force N Engl J Med 363:e3 published on website http://www.nejm.org/doi/full/10.1056/NEJMsb1005800. (Accessed 10DEC2010)

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Chapter 6Small Groups and Effective Discussions

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Small Groups and Effective Discussions



















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Please complete the following needs assessment for the upcoming seminar on Small Group Teaching as part of your faculty development program.




1. Have you had any formal training in leading an effective discussion? Yes/ No

2. What do you already know about leading effective discussions? Answer briefly below:a. What are the disadvantages of small group discussions?

b. What are the advantages of small group discussions?

c. What are four major steps in leading a group discussion?

1. 3.

2. 4.

d. What are some facilitative behaviors in leading a group discussion?

1. 3.

2. 4.

3. Think about the various small group teaching sessions used in your program. Which one(s) are effective, and which one(s) need some work? Be prepared to share your thoughts with the group during the seminar.

4. What 3 things do you most want to learn or discuss regarding leading an effective discussion?

1.

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2.

3.

5. Any other comments, concerns, or interests for this topic?ATTENDANCE ROSTER – Page____of_____Pages

Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Workbook Series – Small Groups- Effective Discussions




Name RankCheck One




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Date Speaker Topic


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Date Speaker Topic


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presentationOverall, the speaker was effective


Please add your comments/suggestion for improving this session on the back—they are VERY helpful.Small Groups – Effective Discussions

Example Eight Steps



Why: Review techniques for small group teaching, as part of Faculty DevelopmentSeries.



What: Driven by the LNRA and: Classification of learning Cognitive levels of learning SWOT analysis of small groups Steps for leading a discussion Using questions


Reviewed classification of learning, and levels of cognitive learning Performed SWOT analysis of small groups Described methods for leading small group discussions Reviewed appropriate use of questions Practiced leading small group discussions

How: General: Active learning: small group activities and discussion, larger group discussion, minimal PowerPoint slides. Room contains individual desk. Will pre-configure desks into larger half-moon shape. Within larger half-moon configuration, will group four desks in smaller half-moon shape for five groups of four learners each. This will facilitate small group activities followed larger group discussions. The session will take place at 0730, so will provide coffee and bagels.

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Induction task #1- opening slide notes pictures can be used for focused Group Discussions. Next slide shows 2 paintings, ask crowd if they recognize either. If not note that they represent a very specific medical condition. Give them a few guesses. Introduce the paintings as representation of fibromyalgia. Discuss how similar painting used during acupuncture class. Ask what aspects of picture might help you remember key information about Fibromyalgia dx and treatment. (Time 10 min)

Input#1 Classification of Learning, Level of cognitive learning Activity #1- SWOT analysis of effective discussionsInput #2 Steps for leading effective discussion Activity #2 List types of questionsInput #3 Review of questionsImplementation Activity #3a&b– 2 group discussions, topics on cards, first round with background info, but on obtuse subject, second round without background information on cards, but on a common subjectIntegration – closing, asking them how they plan to incorporate, and comment on what they believe will help them to be successful Review questions from LNRA to determine if all questions answered, and

determine if any new questions generated.

So What:Learning: Learners understand characteristics of small groups and leading effective discussions. Improve understanding of how small groups functions in learning including strengths, weaknesses, opportunities and threats. Steps of small group leadership and the use of questions to facilitate the process.

Transfer: Learners build upon their previous experience by practicing during this session leading and participating in small groups. They will then try to commit to use of small groups, with proper preparation.

Impact: Departmental clinical teaching is enhanced, improved learning and success for residents.

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Small Groups HandoutDEPARTMENT FACULTY DEVELOPMENT

Kristian Sanchack, MD#1 – Fill in the SWOT analysis

#2 – Write down different types of questions

1. ________________2. ________________3. ________________4. ________________5. ________________6. ________________7. ________________8. ________________9. ________________

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10. ________________11. ________________12. ________________

#3A&B Pick a Card. Lead the discussion!

Is a Mandatory Influenza Program effective and appropriate in the healthcare delivery setting?

Influenza Vaccination is the most effective means to prevent seasonal flu infection. (70-90% effective in <65, 30-70% effective preventing hospitalization in >/= 65, and in nursing home >65 30-40% against infection, 50-60 against infection, 80% against death)

-Fewer than half of healthcare workers report getting vaccinated (CDC current reports) and Influenza outbreaks in hospitals have been attributed to low vaccination rates among healthcare professionals

-1991-92 65 resident of long term facility acquired flu, 19 hospitalized, 2 died with only 1:10 workers immunized, NICU 19 infected,1 died, workers with only 15% rate vaccination, Internal med ward 23 % of staff became ill- total cost ended up at $35,000 to institution.

-Best voluntary efforts get vaccination rates to about 40-60% (80% of direct workers)

-Multiple studies demonstrating flu vaccination of health workers cost effective or cost neutral, at the above rates of 40-60%-generally take 80-90% to achieve herd immunity, but does this apply in healthcare setting?

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-Virginia Mason achieved 98% in first year of mandatory program. lawsuit from union though, after lawsuit though inpatient nurse still near 100% rates despite their union exemption

Can Social Media and Web 2.0 be effective forms of patient communication and healthcare delivery?

-Web 2.0 technologies provide a level user interaction that was not available before. Websites have become much more dynamic and interconnected, producing "online communities" and making it even easier to share information on the Web.

-Patients are already on the web interacting with other patients, providers for the most part are not.-2006 survey noted that about 8 million Americans searched the web for healthcare topics...PER DAY

-As of May 2011 there are over 3200 Hospital Social Networking sites-McKinsley Quarterly noted that businesses who intensely adapted to Web 2.0 benefitted by gaining greater market share and improved margins.

-UK has patient led disease management groups that heavily use web based social media-Patient satisfaction and feedback outlets?-Secure portals for virtual "home visits"

-Entrepreneurs such as Hello Health already heavily using services...

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The US and New Zealand are the only two countries where direct to consumer (DTC) advertising of prescription drugs is legal. In the US, these ads are regulated by the Food and Drug Administration (FDA) to ensure that they are not false or misleading. What are

the pros and cons of DTC advertising? Is DTC advertising ethical?

44,000-98000 deaths per year are attributed to medical errors in our country. This ranks respectively about 4th on leading cause of death in the United States. These numbers have not appreciably changed in 10 years. One consideration is that there are no limits on fully trained physician work hours. What are the pros and cons of limiting fully licensed and trained provider work schedules? Do you believe it would have an impact on medical errors?

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#4 – Did we answer everyone’s question? Check the boxes if so.If not, let’s talk!

List three things you would most like to learn about leading effective discussions.(Actual responses from LRNA)

I am prepared to be dazzled

Coordination, planning and after action review.

Staying on topic/focus Facilitating = leading. I am great as part of a group but not so good at always facilitating! Learn how to have good discussions with leadership that is not effective.

How to lead w/o giving answers 2. How to engage the non-participants 3. How to motivate faculty to participate

should I start with a specific end in mind?

How to moderate the room when multiple small groups are working. How to deal with negative personalities (the whiner, sniper, naysayer, etc) How to structure the discussion without fully controlling it

How to keep the discussion on track. 2. How to get all to participate. 3. How to manage time in the discussion.

is the socratic method acceptable for leading discussions? Is it "safe" to call on people rather than asking for volunteers?

How to keep it interesting. How to keep participants engaged. How to keep the group on task.

organizing the talk steering the group back on track

Setting the agenda, staying on task, establishing when a small group discussion is appropriate.

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Supporting References and ResourcesSmall Groups and Effective Discussions

TEACHING AND LEARNING Effective Small Group Discussions USAFP Winter 2007

By DEBRA A. MANNING, M.D. Faculty Development Fellow Department of Family Medicine Madigan Army Medical Center, WA

Medical students and residents are faced with the daunting challenge of mastering a vast amount of cognitive knowledge. Along the way, they need to develop the behaviors and values that foster ongoing professional development as physicians. There are many methods for imparting such knowledge including formal lectures, reading assignments and one-on-one teaching. One of the best ways to share information and develop longitudinal learning behaviors is small group discussions.

Adult learners are independent, self-directed, and have a great deal of experience to bring to small group learning. Small groups encourage everyone to participate, which increases the participants’ motivation to learn.1 Participants also help to shape the discussion, allowing them a sense of control in their learning. Talking through moral issues and difficult cases helps the students develop ethical standards. Discussions can change attitudes and lead to self reflection. Students develop their communication and problem solving skills, thus facilitating their learning.

Small groups vary in size, but typically have three to fifteen people. They are particularly effective for inpatient rounds, ethical discussions and after clinic conferences. Small group discussions allow instructors to measure retention of the material and create the opportunity for immediate feedback. Small groups provide an excellent setting for teaching values that need to be developed over time.

Small group discussions are not without disadvantages, however. Small groups are not well suited for covering large amounts of material. In this case, a lecture or handout would be better. Those running small groups often complain that it can be time consuming as it often requires more preparation. Instructors have less control in this situation, which may make them uncomfortable. Planning for the discussion and recognizing the success of small groups will help alleviate this discomfort. Some introverted participants find it challenging to participate in small groups.

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There are four steps to effective small group learning.2,3 The first is preparation. The instructor may want to do a Learning Needs Assessment of the group to determine current level of knowledge and to allow the students to participate in developing the goals and objectives of the discussion. Instructors need to determine the size of the group, the discussion format and the setting. Simple details such as having everyone face each other, facilitate a better discussion. Instructors must also anticipate the wide range of material that could arise in the discussion and research these areas if needed.

The second step in effective small groups is getting the discussion started. The instructor should begin by establishing a safe learning environment where mutual respect and participation are expected. They should introduce the topic, goals and agenda thus providing a sense of direction for the discussion. Getting the discussion started requires gaining the students’ attention and motivating them to learn.

The next step is to facilitate the discussion. Good instructors facilitate rather than lecture. This requires patience in allowing the conversation to develop. Knowing the students and their level of knowledge is important. It is important to be flexible, supportive and a good listener. Facilitators should clarify issues, mediate disputes and summarize key concepts. Requesting examples to clarify points and testing group consensus are important behaviors in leading small group discussions. Facilitators should not be threatening as this destroys the safety of the learning environment. One technique for encouraging participation is allowing silence. People become uncomfortable with silence, and eventually someone will begin to talk.

One of the hardest challenges in facilitating small groups is managing different personalities in the group.5 For introverted participants, the instructors should look for opportunities to bring these students into the conversation in a nonthreatening manner. “Do you have anything to add?” Some participants easily stray from the topic and it is important to refocus the discussion. “While this is an interesting and important issue to discuss, I would like to get back to today’s subject matter.” When dealing with students who dominate the conversation, it may be best to speak to them on a break. “I appreciate your enthusiasm, but I want to give everyone else a chance to participate.” This helps maintain the safety of the learning environment.

When facilitating small group discussions, instructors should take care when asking questions. Questions should be stated clearly, and asked only one at a time. Students should be given time to allow them to formulate an answer. Questions are either convergent or divergent.4 Convergent questions ask students to pool their knowledge to answer a question. “What are the drugs used when treating an acute myocardial infarction?” In contrast, divergent questions are used to promote further discussion. “Should parents be allowed to refuse life saving procedures for their children?” Divergent questions are useful when discussing ethical situations.

Questions can also be used to assess students’ level of knowledge. “What are the classes of antihypertensive medications?” Other questions determine if students can apply knowledge to a situation. “Which medication would you use in a newly diagnosed hypertensive African American male?” Finally, problem solving questions ask students to go through complicated scenarios, drawing on their fund of knowledge and ability to apply the information. “Your

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patient was admitted for an acute GI bleed and is now having a heart attack. What would you do and why?”

Facilitators use other types of questions to prompt, justify, clarify or redirect the discussion. Prompting questions are open-ended and stimulate the discussion. Justification questions have the students defend their thoughts or ideas. Sometimes a thought has not been clearly stated, and the facilitator may need to have the student give a better explanation. Extension questions are used to take the students one step further in their thinking. This can include having them apply their knowledge to different but related experiences.4

The final step in effective small group learning is to conclude the discussion. Facilitators should leave enough time to summarize key points and bring closure to the discussion. Each student should leave with a clear understanding of the most important ideas discussed. There are times when consensus is not reached, and this is acceptable. Closure can include agreeing to disagree. Instructors should allow time for feedback. Knowing what worked and did not work in the discussion will improve the next small group. Small group discussions are one of the best ways to impart the knowledge, skills and the values necessary to practice medicine. Small groups are the epitome of adult learning theory allowing for active participation in learning and the sharing of experiences. Effective small group discussions require preparation, facilitation, respect and enthusiasm.

References

1 Haugen, L. (Mar 1998). Suggestions for Leading Small-group Discussions Center for Teaching Excellence, Iowa State University.

2 Steinert, Y. (Sep 1996). Twelve tips for effective small-group teaching in the health professions. Medical Teacher, Vol. 18, Issue 3.

3 Pasquarella, M. (Nov 1996). Small Groups – Effective Discussions. MAMC Faculty Development Fellowship Video Series.

4 Hyman, R. (Aug 1992). Questioning in the College Classroom. Kansas State University Center for Faculty Evaluation and Development IDEA Paper No. 8.

5 Newble, D. & Cannon, R. (2001) A Handbook for Medical Teachers, Fourth Edition. Springer, New York.

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Chapter 7House Officer Evaluation


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House Officer Evaluation




















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Please complete the following needs assessment for the upcoming seminar on House Officer Evaluation, as part of your faculty development program.

The seminar will consist of an introduction by your group leader, a short PowerPoint presentation, reviewing articles with common standards, and a discussion period.

The purpose of this needs assessment is to determine your learning needs and interests, so that the seminar is most useful for you. This needs assessment should also stimulate you to think about evaluations before the seminar begins. We need your enthusiastic participation now, and in the seminar. It will be fun, and at the end of it, we'll be asking for your feedback!

Please turn this in to your group leader (___________________) no later than (_________________). Your group leader will return this form to you at the beginning of the session.

1. Have you had any formal training in evaluation? YES NO (Circle one)

2. In your opinion, what is the difference between a standard and a goal?

3. When planning an evaluation, what items do you think should be considered?

4. What are 4 main skills that you think should be evaluated?

1 32. 4.

5. Complete the following statement..."When I reflect on our department's evaluation system for residents, I think it provides a/an ______________ assessment." (Circle one answer below)

Extremely Inaccurate Inaccurate Neutral Accurate Extremely Accurate

6. What are some types of errors that can be made in evaluations?

1. 3. 2. 4.

7. What tools are available for making evaluations in your department?

8. What 3 things do you most want to learn or discuss regarding evaluation?

a.b.c.

9. Any other comments, concerns, or interests for this topic?

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Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Workbook Series – House Officer Evaluations




Name RankCheck One






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House Officer EvaluationsExample Eight Steps






What: Driven by the LNRA and: The importance of evaluations Essentials of evaluations Common skills assessed in resident evaluations Tools of assessment that are valid and widespread Barriers and difficulties of faculty evaluators

What For: By the end of this session, we will have: Identified essentials of evaluations Examined our definition of standards Listed common skills to assess Reviewed available tools to assist staff Recognized potential pitfalls and biases Practiced with cases

How: General: Active learning through small group activities and discussion, larger group discussion, minimal PowerPoint slides. Room contains individual desks. Will pre-configure desks into larger half-moon shape. Within larger half-moon configuration, will group four desks in smaller half-moon shape for five groups of four learners each. This will facilitate small group activities followed by larger group discussions. The session will take place at 0730, so will provide coffee and bagels.

Grabber: “You Be the Judge: 2011 X-Game BMX Big Air Competition”Break the audience into 3 groups. Explain that each group will act as a judge for a competition. Explain that each team must give each competitor a score from 1-10 (lowest to highest). Do not offer any further assistance than these instructions. Show the crowd a series of short, 1-minute video clips of three separate competitors from the 2011 X-Games BMX Big Air Competition. Be sure to pause for 1 minute between each competitor to allow each team to assign a score. If desired, the leader can tally the scoring and assign place rankings at the end. However, disregard the numerical values assigned, ask the group as a whole: How did you come to your rating for each competitor? What were some of the challenges that you discovered? Did you notice any biases in your assessments?

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Induction TaskWhy is evaluation important? Encourage the audience to reflect on: Why they think evaluation of our learners is important? What problems have they encountered in the past with evaluations?

Input #1Essentials of effective evaluations.

Activity #1In pairs, have the audience discuss some of the things that they mentally take into account before writing a learner’s evaluation. Use the concept of including what standard to measure against to transition to the next input topic.

Input #2Evaluations should be as objective as possible and aim to evaluate specific skills.Offer specific examples from ACGME core competencies.

Activity #21) Have the audience break up into their 3 original groups from the Grabber

exercise. Give them a deck of skill cards (included in this chapter). Ask the group to put the skills in a rank order from most important to least important. Have them write their rankings on butcher block or a white board to display.

2) Display the most common answers from most important skills on the LNRA on PowerPoint. Compare the LRNA answers to the group displays and comment on similarities and differences. Conclude that the group as a department likley has culturally weighted preferences of skills to evaluate but that all are important in different circumstances.

Input #3 Show audience LRNA results of their defintions of what a standard is. Ask

the group if one of the examples speaks to them more than others. Transition to generally accepted components of measurable standards.

Activity #3In pairs, distribute copies of different standards that are employed at their departments (examples included in this chapter). Have them review the standards and ask the following questions relating to the key components of effective standards: Are they written? Are they shared with staff and residents at key time periods? Are they understood? Are they current and relevant? Have they been updated and improved

recently? Summarize findings and comment on possible refinement of some of these

utilized standards.

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Input and Task #4Display a list of some common assessment tools that are available to faculty.Ask the large group to discuss some of the pros and cons of a few of them.

Input #5One of the main pitfalls in evaluation lies within evaluator bias.

Activity #5 Matching exercise of different bias types. Ask the large group to comment on:

a. Which ones do they encounter more oftenb. How do they avoid these biases?

Implementation Task Have the audience get back into pairs. Distribute 2 blank evaluation sheets

that their department uses for summative evaluations. Also distribute 2 cases for the pairs to read and discuss (examples included). Ask the groups to create an evaluation for each case.

Come together as a large group and ask the audience to comment on:a. What things they took into account about the case prior to writing?b. What skills were they evaluating?c. What standards were they using to measure?d. Where there potential biases involved?

Integration Tasks: Display the results of the LRNA question regarding their feelings of how

accurate their department’s evaluation system assesses its learners. Ask the group (time permitting) to brainstorm to processes that could be used

to improve evaluations. What personal changes will they commit to for upcoming evaluations?

So What:Learning: Learners understand characteristics of effective evaluations. Introduced key components of evaluations and standards. Established that there are several types of evaluations that can target specific skills. Explored personal and organizational biases to avoid their impact on accuracy.

Transfer: Learners build upon this knowledge and improve their upcoming written evaluations. They will commit to improve their evaluations through increased planning pertaining to their student’s personal situation, specific skills, use of standards, and awareness of personal biases

Impact: Departmental evaluations are enhanced, department standards are reviewed, leading to improved learning and success for residents.

House Officer Evaluation

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Handout

Opening Activity – Why Evaluate?

Learning Task 1 – With the End in Mind: Evaluation Essentials

Learning Task 2 – Ranking Our Learner’s Skills

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Take Home Points• Evaluations are azimuth checks for a desired endpoint• Incorporation of standards is key• Attempt to assess specific skills• Be aware of our personal biases that can affect assessment• Use the tool box• Communicating that evaluation is essential

On your own, provide answers to the following questions:

1) Why do you think evaluation is important?2) What problems have you encountered in the past with evaluations?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_________________________________________________________________________

In pairs, discuss some of the things that you mentally take into account before writing a learner’s evaluation.

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________In your original three groups:

1. Discuss the deck of cards that contain skill sets of our learners. 2. Put them in a ranked order from highest to lowest on your scale of importance.

Learning Task 3 – A Review of Our Standards

Learning Task 4 – Knowing Our Bias

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Nuts and Bolts of Standards

Written - Written standards help to ensure that they are deliberate and rational. Once they are written, it is possible to ensure that standards are upfront and understood and reviewed.

Up Front – Standards are shared with the learner and discussed prior to intervals.

Understood – Learners and teachers must understand the standards.

Reviewed – Standards should be reviewed on a regular basis to ensure awareness and relevance.

In pairs, assess your assigned set of standards by answering the following:

1. Are they written?

2. Are they shared with staff and residents at key time periods?

3. Are they understood?

4. Are they current and relevant? Have they been updated and improved recently?

___ Recent Incident Bias A. Being overly critical

___ Central Tendency B. Sitting on the fence of avoiding the extreme anchors on a scale for fear of being too strong

___ Extreme Response Bias C. The opposite of central tendency bias. Respondents tend to mark extremes rather than those in between. It is difficult to know honest ratings from the halo effect

___ Affirmation/Yea-Saying Bias D. A potential for negative bias against a trainee because of an isolated recent negative incident or statement, which does not necessarily reflect the usual work ethic of that person

___ Incompetence BiasE. Being overly charitable

___ Leniency Bias F. Occurs when evaluators assign high ratings because of lack of confidence or competence

___ Halo Effect G. The tendency to give positive responses irrespective of their context, also known as inflation of ratings

___ Contrast Bias H. A rater's overall impression of a person will affect his or her rating on each item

___ Stringency Bias I. Rating against another person's performance rather than a standard

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Examples of Additional Handouts Needed

Example of Skill Cards for Learning Task 2

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Examples of Different Standards to Review in Learning Task 3

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Minimum Program Requirements Language Approved by the ACGME, September 28, 1999Educational Program

The residency program must require its residents to obtain competencies in the 6 areas below to the level expected of a new practitioner. Toward this end, programs must define the specific knowledge, skills, and attitudes required and provide educational experiences as needed in order for their residents to demonstrate: Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

a. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

b. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

c. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

d. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

e. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

f.Evaluation Evaluation of Residents The residency program must demonstrate that it has an effective plan for assessing resident performance throughout the program and for utilizing assessment results to improve resident performance. This plan should include:

a. Use of dependable measures to assess residents' competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice

b. Mechanisms for providing regular and timely performance feedback to residents c. A process involving use of assessment results to achieve progressive improvements in residents'

competence and performance

Programs that do not have a set of measures in place must develop a plan for improving their evaluations and must demonstrate progress in implementing the plan.

Program Evaluation The residency program should use resident performance and outcome assessment results in their evaluation of the educational effectiveness of the residency program.

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a. The residency program should have in place a process for using resident and performance assessment results together with other program evaluation results to improve the residency program.

Example Cases for Integration Task

Case 1

Dr. TB has an appropriate fund of knowledge and clinical skills for a second year resident. He

recently received his ITE scores and was pleased with his 92nd percentile performance.

However, during this past FM Clinic rotation he was frequently noted being late for work by the

nursing staff. The FMIT attending mentioned in last week’s staff meeting that he left a

significant amount of work for the incoming residents who were relieving him after an overnight

call shift. His chart audits demonstrate adequate documentation; however, they were rarely

closed out within the required 72 hour period. Despite these concerns, two staff attendings

created voluntary precepting evals during this rotation containing very positive comments. One

specifically noted his ability to organize his H&P during an oral presentation, offer a broad

differential diagnosis, and devise an appropriate A/P. The second evaluation commended Dr. TB

on his pleasant demeanor and effective negotiating skills with a patient threatening to call the

patient advocacy office after she waited for 40 minutes in the waiting room.

Case 2

Dr. LB is a diligent resident who is half way done with her first year of Internship. She

routinely arrives to work early and stays late. As her current attending physician, you have

received several positive, unsolicited comments from the ward nurses about her professionalism

with the nursing and nursing staff. You have personally been asked by one of the ward patients

if she could change her PCM to Dr. LB because of her outstanding bedside manner. Yet, she has

struggled on her current clinical rotation (FMIT), lagging behind her peers in her fund of

knowledge and her ability to synthesize clinical laboratory, and radiographic data. Her daily

progress notes reflect this with limited expansions of DDx and A/P. Her November ITE score

placed her in the 50th percentile overall. Although still in the early stages of residency training,

she is already involved in a research project with an attending staff. Upon discussion with LB, it

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was learned that she lacked basic time management skills and that she was having difficulty

juggling her clinical training with her research interests and personal life.

Example of Blank Summative Evaluation Tool for Integration Task

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Supporting References and ResourcesHouse Officer Evaluation

Jeff Clark, M.D., LTC, MCMadigan AMC Faculty Development Fellowship

November 1996

PURPOSE OF PRESENTATION: The purpose of this talk is to discuss the importance of first establishing the endpoint of the training program and delineating standards to ensure our learners reach that endpoint. Evaluation serves to ensure that standards are met while feedback guides future performance so that our learners meet our established endpoint.

INTRODUCTION: An evaluation must be designed with the end point in mind and be based on appropriate standards. For this reason, prior to discussing evaluation, it is important to take the time to determine the end point of the training program. What are you striving for? This end point will direct the standards you establish.

EVALUATION“to examine and judge; appraise”

Is distinct from feedback, evaluation is a judgment of performance-o Were established standards met?

In contrast, feedback provides information, ideally in a nonjudgmental tone, which is to be used to guide future performance. Feedback is intended to shape future behavior, evaluation documents that standards have been met.

Evaluation means to decide if the learner has met the standards for the residency, year of training, rotation, etc. It is not an end in itself but a means to assure that your learners meet your established standards and reach you end point. Evaluation serves to assure residents are meeting the standards and to provide guidance to: maximize potential and support continued growth.

Why Evaluate? Obligation to society: We are stating that the learner who successfully completes our

training program is qualified to practice our specialty. For individual rotations, we are saying whether or not the learner has met established standards for specific clinical competencies.

Obligation to our peers: A learner who completes our training program is receiving our stamp of approval and is ready to join others in our specialty in the practice of medicine.

Obligation to the military: An officer/physician who completes our training program is ready to care for active duty and family members-the reason our corps exists.

Types of Evaluation FORMATIVE: an interim assessment of performance used to provide feedback. SUMMATIVE: a judgment of competency or effectiveness used to document that established

standards have been met. o Examples include end-of-rotation and quarterly evaluations.

Essentials of EvaluationThe essentials of evaluation are those critical items which should be a part of every learner appraisal. They are important for learners who exceed established standards and for those may be struggling to meet your requirements.

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1. Formal Written, explicit standards for every rotation and learning activity written, explicit summative

evaluation procedures,o rotation evaluations, quarterly evaluations, and yearly evaluations

2. Communication An open dialogue between the learner and evaluator is essential Frequent FORMATIVE evaluations Regular, scheduled SUMMATIVE evaluations Evaluation is understood, documented, and explicit

3. Documentation Summative evaluations are written and signed Plans to monitor and assist are written and signed

4. Due Process Written and understood standards Explicit evaluative process - frank and fair evaluations Plans to monitor and assist are written, understood, and signed Consequences of failing to meet established standards are explicit Formal, communication, and documentation are the essentials of due process

START WITH THE END POINT"If we do not know where we are going, it is difficult to select a suitable means

of getting there, or, for that matter, even know if or when we have arrived."RF Mager Preparing Instructional Objectives

The end point determines the standards. Standards determine what will be evaluated. Evaluation and feedback ensure our learners reach our established end point.

END POINTSomething worked toward or strived for; the object of a course of action.

What is the end point of your residency training program?. This is a fundamental question. The answer will drive, via standards, what will be evaluated. After a learner has completed your training program what do you want as the end point? In other

words, what qualities/skills/capabilities do you want her/him to possess? Do you want a physician capable of passing the boards? Probably so, but you may want more than that. You may want her/him to be a "good doctor." Defining what you mean by "good doctor" will go a long ways towards defining the end point

o The required qualities/skills/capabilities of graduates of your training program.

STANDARDA degree or level of requirement, excellence, or attainment. Of acceptable quality.

It is important to note that a standard is not a goal. Our goal may be that our residents are the very best in the galaxy but the standards we establish are designed to ensure that they meet the end point as we have defined it. (e.g., the goal may be that all residents score 99% on the in-service exam, but the standard may be a reasonable requirement such as 25%, 40%, 60%, etc.)

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Sources of Standards American Board of Your Specialty Residency Review Committee Hospital or University System Residency Program

Your training program should have standards for the residency, for each year of training, for each rotation, and for each learning activity.

Essentials of Standards1. Written

Writing down standards helps to ensure that they are deliberated and rational once written it is possible to ensure that standards are upfront, understood, and reviewed

2. Up front Shared with the learner and discussed prior to beginning the residency, promotion, each rotation,

each learning activity, etc.

3. Understanding Learners and teachers must understand the standards if they are to be met. Consider having both sign that the standards have been read and are understood

4. Reviewed Standards should be reviewed on a regular basis to ensure that all are aware and that established

standards are still relevant and current.

Types of StandardsListed are 4 types of standards which may be included within the standards for a training program, rotation, etc. or may be used as you evaluate the critical qualities/skills/capabilities you have determined you want your graduates to possess.

1. Performance Standards fund of knowledge ability to do a history & physical technical skills humanistic/interpersonal skills clinical judgment ability to recognize limitations

2. Standards of Conduct honesty substance abuse appropriate relationships with patients responsibility attendance

3. Standards for Learning Activities required readings proficiency in technical skills call appropriate level of clinical judgment minimum "score" on the evaluation form indicating a required level of proficiency

4. Promotion Standards based on rotation/learning activity evaluations

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based on in service exams based on summations of performance such as rotation and quarterly evaluations

"THE TERMINATORS" These violations will lead to termination. These are most often standards of conduct. If a learner will be terminated from your training program for a specific type of conduct, it is critical that this violation be written, upfront, understood, and reviewed.

Standards are based on the end point of the training program—what qualities/ skills/ capabilities do you want your graduating residents to possess?

Standards establish the criteria and level of attainment by which the learners will be evaluated to ensure that they reach the established end point.

Essentials of EvaluationThe essentials of evaluation are those critical items which should be a part of every learner appraisal. They are important for learners who exceed established standards and for those may be struggling to meet your requirements.

5. Formal Written, explicit standards for every rotation and learning activity written, explicit summative

evaluation procedures,o rotation evaluations, quarterly evaluations, and yearly evaluations

6. Communication An open dialogue between the learner and evaluator is essential Frequent FORMATIVE evaluations Regular, scheduled SUMMATIVE evaluations Evaluation is understood, documented, and explicit

7. Documentation Summative evaluations are written and signed Plans to monitor and assist are written and signed

8. Due Process Written and understood standards Explicit evaluative process - frank and fair evaluations Plans to monitor and assist are written, understood, and signed Consequences of failing to meet established standards are explicit Formal, communication, and documentation are the essentials of due process

How Do We Evaluate? Objective testing via in-service exams; specialty boards End of rotation evaluations Quarterly evaluations (example provided) Formal oral examinations and written examinations; often used at the end of a rotation or

other types of learning activities Simulated patients - the simulated patient and/or an observer may evaluate the learner Videotaped encounters Patient evaluations of our learners

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Nurses, admin staff, and others who are in a position to evaluate aspects of the skills/qualities/capabilities you have deemed important Nurses and other members of the staff are often in a better position than physicians to evaluate such standards as patient-physician interactions, staff interactions, timeliness, efficiency, etc.

Credibility and reliability of the evaluation are a function of the number of observations. Use many sources (faculty, nurses, admin clerks, patients). Inter and intra- observer reliability increases the

likelihood that the evaluation will reflect performance and assure that standards are met.

When to Evaluate? After each rotation and learning activity - mid-rotation evaluations (these are usually formative

evaluations) are a good time to discuss whether standards are being met and develop plans to monitor and assist

Monthly with the faculty advisor – meets with the learner to discuss the completed rotation to see if standards were met - this is a good time to review the standards, goals, and objectives for the upcoming rotation

Quarterly with the faculty adviser - usually used as a "big picture" summative evaluation to maximize the potential of the learner, support continued growth, and monitor and assist as needed

Yearly with the program director - again, a "big picture" summative evaluation which allows the director to monitor and assist each learner prior to graduation - this evaluation should be a summation of all previous evaluations and can be used to promote continued learning. There should contain no "surprises" for the learner at this point

Potential Errors in Evaluation - you may remember examples of these from your training and or faculty experiences:

Stringency: being overly critical Leniency: being overly charitable Bias/contrast: rating against an individual rather than the standard Logical error: allowing rating in one area to influence another area Halo effect: global impression influences a specific rating Central tendency: sitting on the fence

SUMMARY Evaluation is the process of deciding whether established standards have been met. The essentials (formal, communication, documentation, and due process) are important in the evaluation of all learners. There are a variety of appropriate methods (examples are provided) and times for evaluating learners. The key is to evaluate against established standards. Evaluation is not an end in itself. It is a tool, as is feedback, to ensure that your graduates reach your established end point. This end point of specified qualities/skills/capabilities of your graduates will determine, via standards, what is to be evaluated.

REFERENCESKrick JP and J Sobal. The role of the Faculty Adviser in a Family Medicine Residency. Journal of Medical Education. 60 (1985): 60-62.

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Discusses consensus and differences between learners and faculty in their perceived roles of the faculty adviser.

Short JP. The Importance of Strong Evaluation Standards and Procedures in Training Residents. Academic Medicine. 68 (1993): 522-525. Outstanding reference which discusses the importance and types of standards. Provocative and well written.

Epstein RM. Assessment in Medical Education. N. Engl J Med 2007; 356:387-96. Overview of education assessment with focus on tools developed to avoid evaluator bias.

Berk, RA. The Secret to The “Best” Ratings from Any Evaluation Scale. Journal of Faculty Development. 2010; 24: 37-39Great summary of bias types with examples seen in evaluations

ACGME. Toolbox of Assessment Methods. ACGME Outcomes Project 2000. 1-21Resource of different evaluations tools and methods acceptable by ACGME with pros and cons of each type.

Ginsburg S. Toward Authentic Clinical Evaluation: Pitfalls in the Pursuit of Competency. Academic Medicine 2010; 85: 780:786Recent study of 19 internal medicine program directors with patterns of pitfalls in clinical evaluations.

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Chapter 8The Teaching Clinic Preceptor


The Teaching Clinic Preceptor


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Please complete the following needs assessment for the upcoming seminar on The Teaching Clinic Preceptor as part of your faculty development program.

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1. Have you any formal training on serving as a clinic preceptor? YES NO

2. What do you already know about serving as a clinic preceptor? Answer briefly below:

a. What are some characteristics of a skilled clinic preceptor?

1. 3.

2. 4.

b. What are some common pitfalls for the clinic preceptor?

1. 3.

2. 4.

3. Have you ever conducted a self-assessment of your precepting abilities? YES NO

4. Has your precepting ever been reviewed by a peer? YES NO

5. What obstacles are commonly faced by clinic preceptors?

6. What three things do you most want to learn or discuss regarding precepting in teaching clinic?

a.

b.

c.


Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Workbook Series – The Teaching Clinic Preceptor

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Name RankCheck One






Date Speaker Topic


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Strongly Disagree












Date Speaker Topic


Strongly Disagree











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The Teaching Clinic Preceptor

Example Eight Steps






What: Driven by the LNRA. Will explore a method for assurance of consistent value in the preceptor encounter, several different learner types, ways to diagnose each, and strategies for maximizing benefit for any learner type.


• Examined 5 micro-skills of teaching• Examined 5 learner types• Diagnosed learner types• Developed a teaching approach for each

How: General: Active learning: small group activities and discussion, larger group discussion, some PowerPoint slides. Room contains individual desks. Will pre-configure desks into larger half-moon shape. Within larger half-moon configuration, will group four desks in smaller half-moon shape for five groups of four learners each. This will facilitate small group activities followed larger group discussions. The session will take place at 0730, so will provide coffee and bagels.

Initial Input and Induction Task: Dispersed at the tables, a brief article introducing the concept of the 5-minute or 1-minute clinical preceptor will be available. After reading the article, each attendee will be asked to reflect on recent learner behaviors they have observed, and be prepared to share their thoughts.

Input Tasks: 1. Information pertaining to each objective will be presented for participants to consider, in preparation for engaging and applying the material.

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2. The five microskills of clinic precepting will be presented with associated pictures to improve retention.

3. The learner types will be discussed, utilizing distinct images to associate with each.

4. Strategies will be presented for maximizing the benefit obtained in the preceptor encounter for each learner type.

Implementation Tasks:1. In small groups, discuss a video of a preceptor teaching a student without utilizing a structured method or the five microskills.

2. In small groups, watch each of five example videos which depict various learner types. For each, diagnose the learner type, discuss use of the 5 microskills, decide on a teaching strategy. In each case a sample of the small group work will be shared with the large group.

Integration Tasks:1. Challenge learners to consciously diagnose learners, employ the 5 microskills, and strategize their precepting encounters moving forward from today’s session.

So What:Learning: Learners understand the importance of the “teachable moments” arising in the preceptor encounter. Increased awareness of different learner types and specific strategies for assisting each allow for optimal learning in these brief but frequent encounters.

Transfer: Learners build upon this session through self-reflection, addressing areas or weakness and building upon their strengths.

Impact: Departmental precepting and outpatient clinic teaching is enhanced, improved learning and success for residents.

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The Teaching Clinic PreceptorHandout

Take Home Points

• Diagnose the learner• Adjust teaching style to match• Be a “One Minute Preceptor”

• Teach using cases as the foundation

Pre-Reading Article

Introduction

A third-year student in your busy ambulatory care clinic presents a case of a 34-year-old woman with a 3-day history of acute cough and fever. On physical examination, she has notably a temperature of 100.4 C and crackles in the right lower lobe on lung examination. How do you decide what to teach this student?

Ambulatory care for outpatients in clinic settings poses unique challenges to preceptors (teachers) and learners as a result of the pace of patient care and the limited time available for teaching. In addition to providing high-quality patient care, preceptors must integrate learners into patient care delivery, teach efficiently, provide feedback in real time and evaluate learners’ performances.1 At the same time, they must engage in clinical instructional reasoning: diagnosing patients’ problems, assessing learners’ needs and using teaching scripts to provide targeted instruction.1,2 This reasoning process is enacted through a variety of teaching/pedagogic strategies. In this article, we describe three teaching models: the traditional, One Minute Preceptor (OMP)3 and SNAPPS4 models.

Traditional model

How do you decide what and how to teach the medical student described above? Most preceptors use the traditional or patient-centered model, in which the case is presented by the learner in a standardized format. The preceptor then asks several directed questions to clarify the history and physical examination findings better, in order to establish a differential diagnosis and a treatment plan. This process may take place during or after the presentation and is sometimes followed by a brief mini-lecture, which rarely contains feedback.5

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http://onlinelibrary.wiley.com.libproxy.usc.edu/doi/10.1111/j.1743-498X.2007.00153.x/full#b4




The purpose of the traditional model is to allow the preceptor efficiently to extract the information necessary to make clinical decisions, allowing him or her to act as an expert consultant to the learner. The traditional model is perceived as both efficient and appropriate in many instances because patient care is the top priority. As both learners and preceptors are familiar with the style, no special training is required. However, several limitations of the model become apparent when evaluating how effective it is as a teaching tool in the light of current perspectives on effective clinical teaching.6 Specifically, the knowledge and reasoning of the learner remain unclear and so cannot be used to guide the teaching process. Teaching points are often general, not geared to the level of the individual learner and not readily translatable to future cases.7 Feedback to the learner, if there is any, must be inferred by the learner from the patient care decisions being dictated by the preceptor.

One-Minute Preceptor

An alternative, learner-centered approach was described in the early 1990s by Neher and colleagues.3 The One-Minute Preceptor (OMP) model was developed as a way to enhance the teaching encounter in the ambulatory setting by making use of a set of five microskills for every patient encounter. Its popularity is underscored by the adoption of this model by the Royal College of Physicians as an approach that is taught in their ‘Physicians as Educators’ programme.8 The five steps are as follows:

1) Get a commitment2) Probe for supporting evidence3) Teach a general principle4) Reinforce what was done well5) Correct learner's errors and make recommendations for improvement

The OMP offers several advantages in that it assesses learner knowledge and targets instruction to the level of the learner. Preceptors feel better able to diagnose both the patient and the learner's abilities when using this model.7 Feedback is specific to the encounter and is routinely incorporated into each interaction. Furthermore, teaching points have been demonstrated to be more disease specific and based on higher-order thinking than in the traditional teaching model.2 However, teaching staff must be trained in and practice the OMP model because it requires additional cognitive capacity on the part of the preceptor, who must both diagnose the patient and respond to the learner.

- Excerpt from Chacko, KM, Aagard, E, and Irby, D. Teaching models for outpatient medicine. The Clinical Teacher 2007; 4:82-86.

Activity One: Preceptor Video

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As you watch the video, take notes on any features that strike you regarding the interaction between the preceptor and the student. Prepare to share with your small group.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What might be done differently?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Activity Two: Videos – Learner Types

Use this space to take notes as you watch each video. Be prepared to discuss further with your small group.

Video #1What learner type is depicted?

How could you use the 5 microskills?

Decide on a teaching strategy.




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Supporting References and Resources

Bibace R, Catlin RJO, Quirk ME, Beattie KA, Slabaugh RC: Teaching styles in the faculty-resident relationship. 198 1; 13:895-900. (Slightly different perspective on differing approaches to teaching)

Irby DM: What clinical teachers in medicine need to know. Acad Med 1994; 69:333-42. (Thought provoking observations regarding six critical domains which distinguish excellent clinical teachers.)

Irby DM: Teaching and learning in ambulatory settings: a thematic review of the literature. Acad Med 1995; 70:898-909. (An excellent review.)

Irby DM: Teaching and learning style preferences of family medicine preceptors, and residents. J Fam Pract 1979; 8:1065-7. (Contrasts how certain teaching preferences (ie "dissertations") are not always valued by the learners.)

Lesky LG, Borkan SO Strategies to improve teaching in the ambulatory medicine setting. Arch Intern Med 1990; 150:2133-7. (Helpful ideas to enhance ambulatory teaching.)

Neher JO, Gordon KC, Meyer B, Stevens N: A five-step "microskills" model of clinical teaching. J Am Board Fam Pract 1992; 5:419-24. (Classic reference on an effective method to approach teaching situations.)

Schmidt HG, Norman GR, Boshuizen HPA: A cognitive perspective on medical expertise: theory and implications. Acad Med 1990; 65:611-21. (Useful theoretical evaluation of attending patient problem solving skills and thoughts on how to teach these.)

Skeff KM: Enhancing teaching effectiveness and vitality in the ambulatory setting. J Gen Intern Med (Mar/Apr Supplement) 1988; 3:S26-33. (Useful ideas on improving ambulatory teaching)

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web viewif we want to have a model teaching program, we need to staff that program with model...

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