Module 2 Teaching 101

1. Module 2Teaching 101 Residents as Teachers & Leaders Module Created by: John Culberson, M.D., M.S. Assistant Professor of Medicine & Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medicine Web Page and Module Formatting by: Maria Victoria Tejada-Simon, Ph.D. Assistant Professor of Molecular Physiology and Biophysics

2. Welcome • Welcome to Module 2: Teaching 101. You should have completed a pre-test for this module. Did you complete the “honesty pledge” question? • In that pledge you agreed to take the pre-test first, then read the module and then take the post-test after reading the module. If you did not complete the pre-test, please exit the module now and complete it; then return to the module. Your honesty is appreciated. Click here if you completed the pretest. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

3. Welcome • As a resident physician, you will provide significant and meaningful teaching to students, peers, and even senior residents and faculty. • Patient and interdisciplinary education is also an essential part of the healthcare. Your role as a resident teacher will be enhanced by adopting evidence-based teaching principles into your daily routine. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

4. Welcome • Module 2 focuses on teaching skills using a three phase teaching approach. This module is estimated to take 45-60 minutes. Resources for Module 2 can also be found on the RATL web page. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

5. Introduction • Doctor… What does this word mean to you? • A title recognizing a lot of hard work • A person skilled in the art of healing • An individual who has been taught and has an obligation to teach • An individual eligible for licensure to practice medicine Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

6. Introduction • While the term physician is defined as “a person skilled in the art of healing,” the word doctor is derived from the Latin term “doctus” “having been taught” and “docere” meaning “to teach.” • What does some of the great icons in medicine think about teaching as a physician? Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

7. Introduction • "The successful teacher is no longer on a height, pumping knowledge at high pressure into passive receptacles...He is a senior student anxious to help his juniors."  • Sir William Osler, The Student Life • This statement involves a few key traits of a great teacher. First, it recognizes that teachers are still learners themselves. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

8. Introduction • Second, it implies that the old way of trying to force information into a learner is not the best way to educate. • Third, learners are not to be passive receptacles – they should be engaged and involved in their learning. • Fourth, the teacher is anxious to help – motivated and enthusiastic about facilitating learning. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

9. Introduction • Fifth, the teacher should not place themselves in a superior position over learners, but rather be at their level to assure learning is bidirectional. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

10. Introduction • “Traditionally, medical residents have not received the formal preparation that is essential to the transmission from full-time learner to at least part-time teacher. Although many residents make that transition successfully through a sort of osmosis, many more do not, and they remain ineffective teachers throughout their residencies. But how can we expect them to do that if we in medical education don’t teach them how?” • ~Jordan J. Cohen, M.D., • Past-President of the Association of American Medical Colleges Bing-You, Friedland et al, “Resident’s Teaching Skills”, 1999 Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

11. Introduction • As a teacher, some institutions created a teaching compact between teachers and learners. Do you have a compact between your learners and your institution? Below is an example of the compact at Baylor College of Medicine – it describes the roles and responsibilities of both teachers, learners and the institution. Click on the link below to read, print or save a copy of the Baylor Compact. Click here: http://www.bcm.edu/osa/handbook/?PMID=5607 Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

12. Introduction • As you can see, there are both pledges for the teacher and the learner. Both are important in the education process. More importantly our duty as teachers is stated perfectly as… • “All participants in the education mission have a duty to sustain a learning environment conducive to maintaining the knowledge, attitudes, and skills necessary for providing contemporary standards of care. These standards should be respectful of the social contract and thinking essential to the practice of medicine.” ~BCM Education Compact Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

13. Goals • Welcome to Module 2. The goals of this module are to: • Help you develop your teacher identity. • Reflect on characteristics of excellent teachers and leaders. • Review the key principles of effective teaching, leadership, and communication. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

14. Objectives • After completing Module 2, you will be able to: • Compare and contrast the three (3) parts of organized teaching. • Describe the purpose of using learning objectives in teaching. • Observe the five steps of the “Microskills Model” of bedside teaching. • Discuss the value and proper use of feedback as an essential educational component. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

15. Agenda • Module 2 contains the following content: • Teacher Identity • Three (3) stages of clinical teaching • Creating safe learning environments • Organized & efficient teaching • Bedside teaching • Feedback and evaluation • Summary Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

16. Teacher Identity • Sir William Osler was and is considered an outstanding teacher and physician. He exemplified teaching of students and residents at the bedside. • Here’s a timeless quote regarding your teaching role by Sir William Osler… Sir William Osler, 1849-1919 Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

17. Teacher Identity • "The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.“ ~ Osler 1932 The student life, in Aequanimitas: With other addresses to medical students...3rd ed.(Philadelphia: Blakiston's Son, 1932) p.400. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

18. Teacher Identity • As a physician you are a care giver, teacher and role model. You cannot NOT teach! Your role automatically implies you are a teacher. • You will teach students, patients, peers and others. Your role as a teacher is best summed up as assisting with gaining knowledge and skills development and providing evaluation and feedback to your learners. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

19. Teacher Identity • However, most are not familiar with what they are supposed to teach during a rotation. Have you thought of your teaching role and what content areas you will teach? Think about it for a second. • Did you think only about patient care issues or did you also think about the challenges of being a physician, balance, teaching procedures, system issues and cost effectiveness? These and others are all part of your teaching role. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

20. Teacher Identity • Thus you must know what you are responsible for teaching. • Teaching is the transfer of knowledge, attitudes, and skills. These three domains correspond to cognitive, affective, and psychomotor domains respectively. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

21. Teacher Identity • The best way to know what to teach is by following a written curriculum. The written curriculum is a detailed plan that includes: • What is to be taught • How it is to be taught • How to evaluate its effects – meaning how well it was taught • All curricula should have goals and objectives to help guide you. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

22. Teacher Identity • Goals: are general statements that provide guidance to learners on what they can expect to learn. • Objectives: describe specific cognitive, affective or psychomotor behaviors that are to be accomplished by the learner while learning. Stated in terms of a measurable behavior, a well-written objective guides the teacher. Thus your student learning objectives help guide what you need to teach. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

23. Teacher Identity • Example: • Goals: To learn how to ride a bike – this is a general description of what’s to be accomplished. • Objectives: The learner will ride a 2-wheel bike- pedaling independently after a 2-hr lesson – this is a more specific description of the performance the learner will be able to do as a result of instruction. Note it is a measurable behavior. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

24. Teacher Identity • An important step to being an expert teacher is knowing what to focus your teaching on…take the time to find out what your core student learning objectives are for each rotation. Then make a list of activities you can do for each objective. • By knowing what to teach, you are taking on the teacher identity. By asking your learners what they want to learn, you become the teacher and facilitator of new knowledge, skills and attitudes! Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

25. Teacher Identity • Does your institution list your student learning objectives for your specialty? Check your medical school’s web page or with your chief resident. Ask for the core student learning objectives…they will be very impressed! (and they should – they may not even be aware of the student objectives…you could start a movement!) “Know your student learning objectives and teach them well!” Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

26. Teacher Identity • If you take the time to know your student learning objectives, you will have an idea of the main topics to teach. You are already better off than most residents because you now know where to focus your teaching efforts and what skills are involved. • While we could teach about a ton of things in medicine, you have limited time. Focus on what is needed or required, then spend extra or free time teaching other things. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

27. Teacher Identity • A Myth of Clinical Teaching: • Unfortunately, in the past, many excellent clinicians have approached clinical teaching as something that “just happens” during the course of routine patient care. • Hopefully, these modules will demonstrate that there is more to clinical teaching than simply “throwing one in the fire” or “see-one, do-one, teach-one.” Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

28. Teacher Identity • The art of clinical teaching extends far beyond “see-one, do-one, teach-one.” In assuming the role of teacher, the more prepared you are, the more efficient and effective a teacher you will be. • Did you know that the LCME, the ACGME, and the AMA all have guidelines on residents as teachers? If interested, read the charges to medical schools over the next few slides or click to skip that part. Learn more Skip Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

29. Teacher Identity • LCME: wants residents to know student learning objectives and be prepared for the teaching role. Programs should have: • Written goals/objectives • Clear guidance about roles in teaching & evaluation • Provide resources (workshops/written materials) to enhance teaching and evaluation skills • Central monitoring of resident participation • Formal assessment of the teaching/evaluation skills • Provide opportunities for remediation if inadequate • Use various assessments LCME-ED-24 Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

30. Teacher Identity • ACGME: The Sponsoring Institution must ensure that residents participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other residents and students. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

31. Teacher Identity • The AMA: • “In the face of sometimes conflicting demands on their time, educators must work to preserve the priority of education and place appropriate emphasis on the critical role of teacher.” • “People in the teaching role (including faculty, residents, and students) need guidance to carry out their educational responsibilities effectively.” Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

32. Teacher Identity • Being prepared and giving some thought ahead of time to your teaching style will make you a more efficient, organized and an overall better teacher. • For any teaching activity, keep it simple…. • Assess your learner’s level of knowledge, skill or attitude • Teach to the deficit • Assess if they understood it • This is a simple recipe for success. A 3-stage process to help you do this is to Prepare, Teach and Reflect. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

33. Three Stages of Clinical Teaching by Irby: Preparation Teaching Reflection Before During After Adapted from: David Irby, How attending physicians make instructional decisions when conducting teaching rounds. Acad. Med., 1992; 67(10):630-638. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

34. Three Stages of Teaching • Preparation, teaching and reflection. These three stages will keep you focused and organized regardless of whether you are teaching in a patient’s room, in morning report or at a national scientific presentation. Let’s go through the steps in some detail. Preparation Reflection Teaching Before During After Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

35. Preparation Preparation Reflection Preparation Teaching During After Before • Preparation: Prepare yourself and other key players for the teaching process. • Learner • Teacher • Patient • Context or learning environment Preparation Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

36. Preparation Preparation • “It is curious that so many of our most important responsibilities are undertaken without significant preparation. ….The task of medical teaching, on the other hand, is accepted deliberately and dispassionately, yet the preparation for that influential role is equally frail.” • ~ GE Miller 1980 in Educating Medical Teachers Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

37. Preparation Preparation • Preparation requires organization and the setting of expectations. Organizing & setting expectations with medical students is key!!! • Tell students what is expected of them up front. Clerkship expectations are based on their student learning objectives, expectations of professionalism, and service commitments. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

38. Preparation Preparation-Students • There are three ways that you can help students to be prepared to learn in their “clinical classroom.” • Ask them what they need to learn. • Assist learners in organizing workday and setting priorities. • Inform them that patient care is a shared responsibility by all team members. • Encourage them to take ownership for their patient’s care. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

39. Preparation Preparation-Students • Keep in mind you will have to help students understand their limitations and when to ask for help! Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

40. Preparation Preparation-Students • Assess current knowledge or the “lowest level of the learner” for each student. This is an essential task of the teacher. This helps you identify the area most in need of developing. • You can assess their level of knowledge, skill or attitude by asking questions – open ended. This allows you to accurately evaluate a learner’s level so you can teach to their deficits. Why waste time teaching what they already know? Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

41. Preparation Preparation-Students • This makes your teaching efficient. Then ask learners, students and patients, to read or learn ahead of time when possible. • With the technology available to students today, they can easily look up topics on www.uptodate.com, www.mdconsult.com • or on www.pubmed.com from the team office. Their self learning is very important for retention and efficiency during team rounds. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

42. Preparation Preparation-Students • They can also use textbooks and other resources (simulation, videos, web casts, expert opinions, etc.) to help self-teach.Then you as the teacher can focus on the clinical application of the knowledge learned. • Directing students to self-teach is a very efficient way of teaching when your time is short or it is late in the day. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

43. Preparation Preparation-Students • Ask the student a few basic, open-ended questions to identify their level of knowledge on the topic. You are making a diagnosis. If they lack basic understanding, they need to do basic self-learning preparation. • But don’t forget about yourself!! If you yourself feel uncomfortable with a topic, this method also allows time for you to self-learn before teaching at the bedside. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

44. Preparation Preparation-Self • If you feel uncomfortable with a topic, reviewing the topic ahead of time will also increase your comfort and the student’s perception of your ability. Feel free to ask fellows, chiefs, attendings, nurses, technologists, pharmacists, etc or use other resources to self-teach and prepare yourself. • Evidence exists that resident teachers learn the content better because they teach it! So teach often and you will learn better. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

45. Preparation Preparation-Self • Self-learning is vital to protect your patients, especially when teaching potentially harmful or private/personal things such as invasive procedures, a sexual history or doing pelvic exams. Also remember about confidentiality issues when teaching. Avoid discussing identifying information on patients or learners in public spaces. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

46. Preparation Preparation-Organization • In order to complete the process of preparation for teaching, the teacher and learner may organize the workday to establish specific times when teaching will occur. • It is important that the student understand that the teaching environment is a shared responsibility. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

47. Preparation Preparation-Organization • Determining in advance, specific patients to best accomplish individual teaching objectives is optimal for both teacher and learner. • The next slide consists of a 3 minute photo story sound-bite of how to orient and set expectations with a student. Click here to skip demonstration Click here to watch demonstration Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

48. Preparation Preparation-Skills • Teaching procedures requires special skills that will be covered in detail in Module 3. In general, the student must demonstrate a detailed knowledge of the anatomy and technique prior to approaching the patient. • The student should be asked to describe the potential complications and problems that might be encountered, and what action is necessary in these circumstances. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

49. Preparation Preparation-Skills • Thus you should never allow a student to perform a procedure on a patient that they are not ready to perform. There are videos, models and simulations that can be used to help students get to the level of performing procedures on patients. • You will have to be the judge to determine your own skill, your student’s skill and the risk to the patient. Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.

50. Preparation Preparation-Skills • We’ll take this time to remind you of the phrase: • “Primum non nocere!” • – First, do no harm! • Never put a patient in danger! Created by Culberson, Dewey, Ismail, Friedland, Tejada-Simon & Turner. NIH Funded Relationship-Centered Transformation of Curricula, Baylor College of Medicine, 2006.