Clinical Teaching Workshop

1. Clinical Teaching Workshop เชิดศักดิ์ ไอรมณีรัตน์ ภาควิชาศัลยศาสตร์ คณะแพทยศาสตร์ศิริราชพยาบาล มหาวิทยาลัย มหิดล

2. Objectives • At the end of this workshop, participants will be able to: • Explain basic principles of adult learning • Apply various teaching skills in a clinical setting • Choose appropriate teaching techniques to help students learn in a clinical setting • Develop effective teaching plans and strategies for teaching in a clinical setting

3. Basic Concepts inMedical Education Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University

4. Learning • A relatively permanent change in performance or performance potential that results from experience and interaction with the world • Occurs intentionally in formal instructional settings • Occurs incidentally through experience

5. Some Basic Principles of Clinical Teaching

6. Some Basic Principles 1. Teaching is not equal to learning.

7. Effectiveness of Teaching Methods Percent of skills attained

8. Some Basic Principles 2. Adults learn differently from children.

9. Adult Learning • Based on learners’ needs • Goal-directed (self-directed learning) • Consider personal experience that serves as a resource for learning • Task- or problem-driven rather than subject focused • Intrinsically focused (their own motives) • Need to be treated with respect • Feedback is central to satisfied learning

10. Some Basic Principles 3. Learning from experience develops through cycles of careful thinking.

11. Experiential Learning Theory Kolb DA. Experiential learning. Englewood cliffs, NJ: Prentice-Hall, 1984. Schön, D. The Reflective Practitioner, New York: Basic Books, 1983.

12. Experiential Learning Theory • Recommendations • Plan for experiences in carefully selected settings. • Facilitate reflective observation. • Encourage conceptual thinking and inquiry. • Promote feedback and testing of the insights drawn from experience.

13. Some Basic Principles 4. Encourage meaningful learning

14. Two Types of Learning • Rote learning • Memorization of facts • Meaningful learning • The process of relating potentially meaningful information to what a learner already knows in a substantive way Relevance Sequence Ausubel, D. The psychology of meaningful verbal learning. New York: Grune & Stratton,1963.

15. Meaningful Learning • Make a connection of new concepts/ topics to students’ experience or available knowledge. • Arrange proper sequence • From simple to complex • From known to unknown • From example to principle • From concrete to abstract Cox KR, Ewan CE. The medical teacher, New York: Churchill Livingstone, 1982.

16. Some Basic Principles 5. Define a clear set of learning objectives

17. Educational Objectives Give trainees a clear understanding of what they are expected to know or do. Assure that all the curriculum content is covered properly, no gaps or duplications. Describe the course to interested individuals in a concise way. Help an instructor organize the course. Provide an evaluation framework. Guide the criteria for course evaluation. Educational Objectives 17

18. Writing an Objective Educational Objectives 18 • Time frame • At the completion of the lesson • At the end of the rotation • Learners • Fourth-year medical students • Second-year surgical residents • Behaviors • Standards and conditions

19. Bloom’s Taxonomy • Three types of learning • Cognitive: Mental ability • Affective: Feelings, values, attitudes, emotion • Psychomotor: Manual or physical skills

20. Behavioral ObjectivesCognitive Domain Educational Objectives 20 Knowledge: define, identify, indicate, list, state, write, name Comprehension: compare, associate, compute, contrast, describe, differentiate, interpret, predict, translate Application: apply, classify, demonstrate, solve, use, utilize Analysis: order, group, translate, summarize Synthesis: arrange, combine, create, design, develop, formulate, prepare, plan Evaluation: appraise, assess, critique, judge, rate, recommend

21. Standards and Conditions Educational Objectives 21 • How will learners be evaluated? • Standards • 90 percent of the time • Score 85% or higher • Conditions • In an MCQ exam • On a surgical ward

22. Examples Educational Objectives 22 At the end of this session, participants will be able to write at least two complete behavioral objectivesin the topic currently teach. At the end of the fifth week of surgical clerkship, fourth year medical students will be able to tie a secure square knot with a one-hand technique 100% of a time.

23. Some Basic Principles • Teaching is not equal to learning • Adult learning • Experiential learning • Meaningful learning • Educational objectives

24. Giving Feedback Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University

25. What is Feedback? • Information • Given to a learner • Specifically describes the learner’s performance • Intended to guide the learner’s future performance

26. Why Do We Give Feedback? • Reasons for feedback • To help learners… • Learn about their current levels of competence • Reflect their strengths and deficits • Engage in a dialogue with a supervisor or mentor • Become more competent

27. Effective Feedback Steps • Clarify goals of the session. • Elicit learner’s perspective on the problem. • Provide positive feedback. • Provide negative feedback addressing behaviors – not personality. • Promote mutual problem-solving. • Offer alternative approaches.

28. Feedback Guidelines • Clear information • Mutually agreed upon goals • Learner has an active role in the feedback process • Positive affect, empathy, and support

29. Clear Information • Describe issue specifically • Offer written documentation as evidence • Offer direct observation evidence • Correct mistakes by describing what was wrong and how to avoid or correct error • Timely feedback (as soon as possible) • Confronts learner when appropriate

30. Mutually Agreed Upon Goals • Indicate feedback is being given • Refer to learner’s goal • Refer to rotation/course expectation • Make arrangement for a follow up meeting

31. Learner Has An Active Role • Solicit learner’s perception of experience • Invite learner’s self-assessment of the problem • Ask about areas learner want to focus on • Link comments to learner’s statements • Develop a plan with learner to address problems • Ask about ways to maintain positive behavior

32. Positive Affect, Empathy, Support • Demonstrate positive regard for learner • Behave non-judgmentally • Work to establish or maintain a relationship with the learner

33. Feedback Tips • Good feedback • It is undertaken with teacher and student working as allies with common goals. • It is well timed and expected. • It is based on first-hand data. • It is regulated in quantity and limited to behaviors that are remediable.

34. Teaching in an Ambulatory Setting Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University

35. Importance • Changes in medical practice: inpatients tend to be more representatives of subspecialty care, and outpatients are more representatives of routine medical practice • Changes in students: increasing number of students result in inadequate number of inpatients per students • Broader expected competencies: The roles of doctors not limited to treatment, but also health promotion, disease prevention, rehabilitation Dent JA. AMEE guide no 26: Clinical teaching in ambulatory care settings: Making the most of learning opportunities with outpatients. Med Teacher 2005; 27: 302-15.

36. Barriers to effective ambulatory teaching • Inadequate space and time to teach • Sharing of teaching burden: learners may be taught by inexperienced teachers • Work pressure: learners are rarely observed • Public nature: feedback is rarely provided • Student’s orientation is inadequate • Seeking consent from patients Irby D. Teaching and learning in ambulatory settings. A thematic review of the literature. Acad Med 1995; 70: 898-931.

37. 3-Step Planning • Orient the learners • Organize the clinic • Encourage learners to take more responsibility for their own learning Sprake C, et al. Teaching in an ambulatory care setting. BMJ 2008; 337: a1156.

38. 1. Orient the Learners • Describe the OPD environment • Find out students’ names • Show them where they can store bags • Assess learning needs and expectations • Communicate with other OPD staffs

39. 2. Organize the Clinic • Manage patient consent • Inform patients about the presence of students • Poster or signs in the waiting area • Manage time • Provide appropriate amount of time for students based on appropriate mode of patient approach

40. Many Approaches in OPD • Observer model • Assistant model • Practice under supervision • Practice with a consultant

41. 3. Encourage Learners • Students should take responsibilities for their own learning • Getting involved with patient care • Learning skills • Experiential learning • SNAPPS • Logbooks

42. Experiential Learning Theory Kolb DA, Fry R. Toward an applied theory of experiential learning. In C. Cooper (ed) Theories of group Process, London: John Wiley, 1975 Schon D. The reflective practitioner, New York: Basic Books, 1983.

43. SNAPPS • Summarize briefly the history and findings • Narrow the differential diagnoses • Analyze the differential diagnoses by comparing and contrasting the possibilities • Probe the preceptor by asking questions • Plan management • Select a case-related issue for self study Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: A learner-centered model for Outpatient education. Acad Med 2003, 78(9): 893 – 8.

44. Effective Ambulatory Teaching Behaviors • Preceptor inspires student confidence in preceptor’s medical skills. • Preceptor explains the decision-making process to students. • Preceptor treats students with trust and respect. • Preceptor provides a role model. Elnicki DM, et al. Third-year medical students’ preceptions of effective teaching behaviors in a multidisciplinary ambulatory clerkship. Acad Med 2003; 78: 815-9.

45. Tips for Ambulatory Preceptors • Before you start • When you teach • When the session is over Dent JA. AMEE guide no 26: Clinical teaching in ambulatory care settings: Making the most of learning opportunities with outpatients. Med Teacher 2005; 27: 302-15.

46. Before You Start • Attend a staff development session and read any support material available. • Check students’ study guide, or any course material. • Familiarize yourself with the clinical problems usually encountered in the clinic. • Brief the students about the objectives. • Select appropriate cases for your students.

47. When You Teach • Selecting an appropriate teaching model • One student : one teacher • Several students: one teacher • Several students: several teachers

48. One Student: One Teacher • Sitting-in model • Observer role • Assistant role • Apprenticeship model (practice under supervision) • Team member model (practice with a consultant)

49. Several Students: One Teacher • Grandstand model • Supervising model • Report-back model

50. Several Students: Several Teachers • Shuttle model • Division model • Flip-flop model • Tutor model