Enhancing Medical Education on Wards: Effective Supervision and Learning Strategies

1. Teaching on the wards DeeptiRao, MD

2. Objectives At the end of this lecture, you should be able to: • Identify the top 5 learning objectives selected for ward rotations • Integrate various assessment and learning activities into your daily work on the wards and coordinate them with the above learning objectives • Discuss various topics including a suggestion for how ward rounds should be conducted

3. THE CIRCLE OF LEARNING & BERMUDA TRIANGLE OF EDUCATION Motivating Environment OBJECTIVES Pre-Existing Knowledge Meta-cognition SignificantLearning Experience ASSESSMENT CONTENT Learning with Understanding

4. Motivating environmentExamining what resident look for in their role models—Wright, Academic Medicine, 3/96

5. Motivating environmentEffective Supervisory BehaviorsEffective educational and clinical supervision, Medical Teacher 29, 2-19 • Helpful • Giving direct guidance on work • Linking theory and practice • Engaging in joint problem solving • Offering feedback • Reassurance • Ineffective • Rigidity • Low empathy • Failure to offer support • Failure to follow supervisee’s concerns • Not teaching • Being indirect and intolerant • Emphasizing evaluation and negative aspects

6. Motivating environmentEffective Supervisory BehaviorsEffective educational and clinical supervision, Medical Teacher 29, 2-19 • Good interpersonal skills • Involving trainees in patient care • Negotiation and assertiveness skills • Counselling skills • Appraisal skills • Self-awareness • Warmth, empathy, respect, supportive, positive, enthusiastic • Clinical competence • Teaching skills • Offering opportunities to carry out procedures • Giving direction • Giving feedback • Knowledge of teaching resources • Individualizing the teaching approach

7. THE CIRCLE OF LEARNING & BERMUDA TRIANGLE OF EDUCATION Motivating Environment OBJECTIVES Pre-Existing Knowledge Meta-cognition SignificantLearning Experience ASSESSMENT CONTENT Learning with Understanding

9. Objectives for ward rotation At the end of this ward rotation, you should be able to: • Gather data through patient history and physical to lead to a well developed problem list, differential diagnosis and management plan • Interpret technical investigations and analyze their indications • Apply clinical diagnostic reasoning skills to patient care • Demonstrate knowledge of common medical conditions • Demonstrate effective communication behaviors and skills

10. What are some learning activities to help us achieve these objectives • Clinical diagnostic reasoning • Observation/Checklisting • Feedback • Questions

11. Clinical Diagnostic Reasoning • Hypothetico-deductive (unclear diagnosis) • Scheme-inductive (dysphagia) • Pattern recognition

12. Educational strategies to promote clinical diagnostic reasoningJudith Bowen, NEJM 355;21

13. Problem representation • One sentence summary defining the specific case in abstract terms • Facilitates the retrieval of pertinent information from memory “My cough began 2 days ago. I also had a temperature of 101 and shaking. I am bringing up yellow mucus.” turns into … Acute onset of productive cough, fever, and chills in an elderly male

14. Semantic qualifiers • Paired, opposing descriptors that can be used to compare and contrast diagnostic considerations. • Associated with strong clinical reasoning

15. Semantic qualifiers

16. Illness script • Expert clinicians store and recall knowledge as simplified models (contain little knowledge about pathophys but a wealth of clinical information) that are connected to problem representations. • Conceptual models vs memories of specific syndromes or patients • Anchor points develop in the scripts based on defining and discriminating features (compare and contrast)

17. Educational strategies to promote clinical diagnostic reasoningJudith Bowen, NEJM 355;21

18. Suggestions to promote clinical diagnostic reasoning • Must see an adequate number of patients • Articulate an accurate problem representation • Different levels of learners and teacher • Reason aloud based on your problem representation and illness script/discriminating features • Compare and contrast • Force learners to prioritize differentials and explain reasoning • Students should see very typical presentations of common illnesses to solidify accurate illness scripts • Provide cognitive feedback • Reading habits • Novice learners should read about 2 related dx at same time based on a patient they have worked up

19. Top 9 diagnoses • Pneumonia • Poisoning and toxic effects of drugs • Cirrhosis and etoh hepatitis • Heart failure and shock • Chest pain • Gi hemorrhage • Sepsis • Disorders of pancreas • Renal failure

20. SNAPPS • Summarize history and findings • Narrow the differential • Analyze by comparing and contrasting • Probe the preceptor • Plan for management • Select a learning issue

21. One minute teacher

22. Checklisting and observation • We don’t observe our learners. • based on resident survey data summary 5/10 in answer to question, “Do faculty routinely evaluate your interview and physical exam techniques.”-26% answered no • Effectiveness of clinical rotations as a learning environment for achieving competences. Daelmans, HEM, et al, Medical Teacher, 2004 • Assuming effective learning depends on adequate supervision, feedback and assessment, a survey of medical students found that conditions for learning are poor. • “…most of the time supervision was not based on direct observation and apparently was inferred from vicarious information.”

23. Observation • Time • Not sure what checklists available/what are we observing for • Subject to biases • Racial and sex biases • Halo effect • Different standards

24. Checklisting/Observation

25. Checklisting/Observation • Mini-CEX • Structured way to give feedback • Reliable way of assessing post-grad performance • Need 12-14 observations • VA • My own experience

26. ChecklistingUNM-SOM Clinical Note Global Grading Template

27. Checklisting

28. Feedback • We are not giving our residents feedback. • Based on Resident survey data summary 5/10 in answer to “Do all of your supervising faculty review your performance with you at the end of each rotation?” • 26% answered no

29. Feedback-Ende • Done with both parties working as allies • Expected and well timed • Self assessment • Based on specific actions, examples and observed behaviors • Objective

30. FeedbackNorcini, Workplace-based assesment as an educational tool, Medical Teacher 2007 • Encourage trainees to engage in a process of self-assessment prior to receiving external feedback • Permit trainees to respond to feedback • Ensure feedback translates into a plan of action for the trainee

31. Debriefing with good judgementRudolph, et al,Anesthesiology Clinics, 2007

32. Debriefing with good judgement • Result, action, advocacy, inquiry • “I see Mr B was not placed on antibiotics yesterday. I did not see an order for the antibiotics in powerchart. I thought we discussed placing him on antibiotics yesterday on rounds. I am wondering how you saw our discussion?”

33. Few tips on asking questions • Allow at least 10-15 seconds for responses • Don’t answer your own questions • Involve everyone • Open ended questions “What do you want to do?”

34. How do we integrate objectives, assessment and learning activities

35. Wards • Difficult environment • Time • Competing demands • Opportunistic learning

36. Residents thoughts about effective hospitalist attendings • 1. Help with scut work/seeing patients • 2. Allow the resident to run rounds however they are most comfortable • 3. Do not use residents as an information sink. Use team rounds to discuss and see higher acuity patients

37. Teaching attending power tips • Plan to finish by noon • Set expectations first day • Full presentations without interruption • Primary provider • Teach what you know

38. How should wards run • Attending and resident to meet in am and decide on acuity of patients and who is to be seen on rounds (A,B,C) • Full presentations only on sickest patients, otherwise concerning patients and discharges • If time can use to hear more about less sick/improving patients. • Attending to see less sick and stable patients on own • This allow rounds to be very efficient and can usually finish by noon

39. How wards should run • Make work rounds—write orders while rounding • Allow presenter to finish presentation before interrupting. At end of presentation, have presenter ask any questions they have • Allow resident or intern to answer questions first • Walk vs sit ? • Both interns vs one at a time ?

40. How should wards run • Maintain good working relationships with everyone from PT to consultants • Use precall days as “teaching days” by presenting articles and modules or opting to checklist notes/communication • Use the night call day to put the resident on the spot and have them formulate plans for patients. Do teaching on special topics for the resident/medical student on those days • I would propose we develop teaching activities based on each person’s area of special interest • On the post call days have other members of team formulate problem representations and problem lists for cases • Force learners to prioritize and explain differential • Observation? • Compare and contrast readings • Learning issues • Afternoons for getting work done

41. How should wards run? • What experience have you had with rounding and what works and what does not? • Should we be observing our learners? • How often should we give formal feedback? • How can we get our learners to self assess and use metacognition more?