Residents as Teachers ……… (?)

1. Residents as Teachers ……… (?) • Objectives: • Discuss which ACGME competency is most related to teaching ability. • Debate the professional obligation to teach. • Recognize the signs of becoming unconsciously competent and consider • the antidote. • Propose a teaching plan for each potential learning scenario. • Explain the benefits of resident teaching to colleagues. Gary Loy , MD MPH Maternal-Fetal Medicine

2. Residents should teach? Of course, but what is the evidence of utility, the value; and is it worth the effort? My guiding principles in preparation - • Evidence based, interactive, relevant and practical, with take home messages and materials. ( So you may be called on ).

3. Justification for, benefits of, value of   spotlighting Residents as Teachers • Educational Policy basis – What are the relevant ACGME competencies • Professional basis – Why teach? What is the Hidden Curriculum? • Conceptual basis – who is best suited to teach medical students? • Utilitarian basis – who has the greatest opportunity to teach students? • Evidence – what outcomes should be measured

4. Educational Policy basis – What are the relevant ACGME competencies • Professional basis – Why teach? • Conceptual basis – who is best suited to teach medical students • Utilitarian basis – who has the greatest opportunity to teach students • Evidence – what outcomes should be measured Quote: Practice Based Learning - "facilitate the learning of students and other health care professionals” ACGME 1999, Reese 1998

5. Under which competency do teaching skills fall. Resident Debate Conclusions: (PER OUR RESIDENTS YESTERDAY) Knowledge Patient Care/clinical skills Interpersonal and communication skills Practice-based learning Professionalism Systems-based practice

6. Educational Policy basis – What are the relevant ACGME competencies • Professional basis – Why teach? • Conceptual basis – who is best suited to teach medical students • Utilitarian basis – who has the greatest opportunity to teach students • Evidence – what outcomes should be measured Potential Benefits of spotlighting residents as teachers: Contribution to the Hidden Curriculum

7. Professional basis – Why teach? What is the Hidden Curriculum? Potential Benefits of spotlighting residents as teachers: Contribution to the Hidden Curriculum Is this measurable? Or does it have enormous “immeasurable” benefits? Residents are without a doubt the unsung heroes of teaching. Teaching each other and teaching medical students, they deliver the key lessons of the Hidden Curriculum

8. The Resident Teacher • Is it easy for them? • What are competing professional responsibilities? • What is the value

9. Previous studies of the training of residents to teach have shown improvement in student perception of the learning experience (Wamsley 2004), but consistent impact on student performance has not been proven Busari 2004, Morrison 2004, Stern 2000 • The development of resident teaching skill has potential for great impact on medical students. Opportunities for medical students to learn actively from residents regularly occur on the wards in a clinical practice environment where acquisition of skills is efficient and knowledge remains durable Hovelynck 2003, Lave 1991

10. ……warnings……………. • Failure to learn skills results in poor test performance and potentially poor patient care provided by the learner Busari 2004 • The negative impact of residents who are poor teachers on student learning is thought to be significant by students, because they consider resident physician influence as the most important contribution to their learning Walmsley 2004 • Furthermore, if teaching is ineffective, students and young residents may become frustrated with the challenges of medical training and turn away from the field Griffith 2000

11. Residents have competing interests and pressures. (surprise) • Constraints of duty hour restrictions, completing patient care, and leaving work on time often compete with spending additional time on teaching Skeff 1997 • The culture of efficiency in patient care and administrative obligation may oppose the culture of teaching and reflection. Residents who are highly successful within the former culture of efficiency may neglect participation in the latter (not always the case)

12. Even more alarming……………………… • Restrictive duty hour pressure causes efficiency to be a highly valued competency by both residents and faculty. Efficiency is continuously reinforced and rewarded in the obstetrics and gynecology program by the time-pressured faculty. A cascade of influences, creating a hidden curriculum that undermines the teaching effort, flows from the influential attending to the resident as learner • Further trickle down occurs as the upper level resident fails to value the responsibility of teaching. The student and the junior residents may be quite effectively taught not to teach. These social influences in medical education are part of the hidden curriculum within obstetrics and gynecology programs Wilkes 2002

13. …… but back to the UPSIDE justifications • Educational Policy basis – What are the relevant ACGME competencies • Professional basis – Why teach? • Conceptual basis – who is best suited to teach medical students • Utilitarian basis – who has the greatest opportunity to teach students • Evidence – what outcomes should be measured

14. Procedure Instruction (psychomotor skill instruction) is more than just aping a motor performance • Knowledge of the procedure, indications, contraindications • Skills that are required for success • Attitudes that promote professionalism • Behaviors that yield positive results for patients and providers Future slide question: Who can best pull this all together and give students what they need to learn?

15. Psychomotor skills teaching and development of expertise “Expertise, as the formula goes, requires going from unconscious incompetence to conscious incompetence toconscious competence, and finally tounconscious competence. The coach provides the outside eyes and ears and makes you aware of where you're falling short. This is tricky. Human beings resist exposure and critique: our brains are well defended. “ Atul Gawande referring to the well described development of psychomotor skills. New Yorker, October 3, 2011 • How might you help move a learner along from w,x,y,z - What does it take at each step? • Why might Residents be particularly well suited to teach? (in the context of the expert competence progression)

16. Psychomotor skills teaching and development of expertise unconscious incompetence to conscious incompetence to conscious competence, and finally tounconscious competence ……………. Or W-X-Y-Z • How might you help move a learner along from w,x,y,z - What does it take at each step? • Why might Residents be particularly well suited to teach? (in the context of the expert competence progression) Hunt EA, et al. Resuscitation Education: Narrowing the Gap Between Evidence-Based Resuscitation Guidelines and Performance Using Best Educational Practices. Pediatric Clinics of North America, Volume 55, Issue 4, Pages 1025-1050

17. Educational Policy basis – What are the relevant ACGME competencies • Professional basis – Why teach? • Conceptual basis – who is best suited to teach medical students • Utilitarian basis – who has the greatest opportunity to teach students • Evidence – what outcomes should be measured

18. Consider for a moment the distinct snippets of time/ of focused activities that provide opportunity for residents to teach medical students. Ambulatory realm Surgical realm Reflect (said to be key to learning): In what realm do you find yourself most often, what can you offer, what is most efficient/relevant to ask questions about, what do you know the most about. Perhaps most importantly remember how much more practical knowledge you have compared to a year ago and share the wealth. Ferenchick G. Acad Med 1997;72:277; Wolpaw, T. Acad Med. 2003 Sep;78(9):893-8

19. Who is responsible for resident education towards these competencies ? Who are the residents’ teachers? So what can we do? • Modeling – what makes a great teacher? Qualities aspect Attitudes, skills, behaviors aspect • Facilitating – creating time and opportunity Attention, space and time • Alerting them to specific tools and opportunity

20. Who is responsible for resident education towards these competencies ? • Modeling – what makes a great teacher? Qualities aspect Attitudes, skills, behaviors aspect Irby D. Academic Medicine 1993

21. What concrete steps can we take to impact on resident teaching? Facilitating – creating time and opportunity Attention, space and time

22. Since much of the residents’ teaching goes on un-witnessed - The department has supported a new initiative to aid in the development of the resident teacher. Brenda, Megan, Sean and I have taken on the College of Medicine pelvic exam simulation teaching of the medical students ---------- specifically in order to partner with the residents to provide an opportunity for residents to practice teaching, to be observed and evaluated and developed in teaching ability/style through verbal and written feedback.

23. We figure residents know how to do the pelvic exam, and the students don’t. • It is an ideal opportunity for residents to teach a psychomotor skill. Four faculty members have committed to being available to observe and provide feedback on their work during a structured venue employing scenario and model simulation. • We imagine that residents will benefit from the opportunity to shine, to be directly observed doing well, to be credited towards acgme competency development

24. Diagram of the plan – the flow and the data derived Student orientation to the PELVIC EXAM teaching/learning session Student verbal instructions (they will be given a scripted intro) Key aspects of the script – • Clinical scenario, students perform and learn as if in a real situation, history is already done, exam is the key activity. • Opportunity to be taught by residents: (consider - why again is this an opportunity?) • Opportunity to learn through simulation (why is simulation useful? In general, In particular with respect to a psychomotor skill?)

25. Opportunity evidence in addition to theoretical basis of competency level In a study of thought processes relating to clinical diagnoses, students were more highly influenced by resident explanations in justifying diagnoses than by attending explanations Bordley 2000.

26. Some support of simulation Active learning, employed during simulation and practice, improves medical student performance as would be expected considering principles of adult education. In a study of psychology students comparing active learning - “anything that involves students in doing things and thinking about the things they are doing” - with traditional book or video content, students participating in active learning consistently scored higher on assessments Yoder 2005

27. Notice some byproducts: More opportunity to provide coaching and feedback – Supervision with respect to all the competencies related to teaching skill • In the context of Direct observation (aside - the value of direct observation is LCME, ACGME, RRC recognized and expected as an ESSENTIAL component of assessment) • When, how can be generalized, can be followed up in other scenarios/ teaching and learning opportunities. This formal opportunity is just a start.

28. Educational Policy basis – What are the relevant ACGME competencies • Professional basis – Why teach? • Conceptual basis – who is best suited to teach medical students • Utilitarian basis – who has the greatest opportunity to teach students • Evidence – what outcomes should be measured (what are we interested in changing, what do we expect our results will be, what is important, who cares, so what and what good is this?)

29. Opportunities to measure value in outcomes: specific student skill acquisition resident teaching ability improvement student and resident attitude toward the interaction student performance as related to resident teaching an enhancement of the already superb culture Ultimately, however, educational efforts should be related to patient satisfaction and outcomes. We imagine this should be the case (more highly trained providers), but have no measure yet.

30. Who is responsible for resident education towards the competencies relevant to teaching skills? So how can we help……. Continued Alert them to pertinent tools and teaching opportunities

31. These are adults; what aspects of this process of teaching the pelvic exam using a simulator satisfies the principles of teaching adults? Principles of Adult Learning- principles that apply to all learning environments • Motivation is established, the material is useful • Assurance that learning is active-not a passive environment • Concepts not facts are taught • Feedback is provided promptly and appropriately • Environment is non-threatening • Material is related to existing knowledge • Learners are treated as individuals • Learning is best when self-paced

32. Alert them to pertinent tools and teaching opportunities • Snapps - see my cheat sheet • Coaching – see my handout.

33. Learner-centered model for case presentations to the preceptor follows a mnemonic called SNAPPS consisting of six steps: • (1) Summarize briefly the history and findings; • (2) Narrow the differential to two or three relevant possibilities; • (3) Analyze the differential by comparing and contrasting the possibilities; • (4) Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches; • (5) Plan management for the patient's medical issues; and • (6) Select a case-related issue for self-directed learning. • Wolpaw, T Acad Med. 2003 Sep;78(9):893-8 • Tell students to ASK questions, present often, take responsibility

34. Skills teaching involves demonstration, feedback, re-direction, repetition, reinforcement - it is coaching What to do in a student session that teaches a psychomotor skill. Lessons from PeeWee soccer coaching: Keep them all busy, always. Smoot and DaRosa. Effective teaching in the operating room. Plastic and Reconstructive surgery 1993:92-133 Grealish L. The skill of a coach are essential in clinical learning. J Nurs Educ 2000;39:231

35. Are You Conscious of Your Competence? •  Objectives: Residents Should Teach ALOT. • Discuss which ACGME competency is most related to teaching ability. • Debate the professional obligation to teach. • Recognize the signs of becoming unconsciously competent and consider • the antidote. • Propose a teaching plan for each potential learning scenario. • Explain the benefits of resident teaching to colleagues. Gary Loy , MD MPH Maternal-Fetal Medicine

36. Thank You and Have Fun

37. FISH PHILOSOPHY REMINDER: BE THERE. CHOOSE YOUR ATTITUDE. MAKE THEIR DAY. PLAY.