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Teaching on the wards Deepti Rao, MD
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Teaching on the wards

Jan 10, 2016

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Teaching on the wards. Deepti Rao , MD. Objectives. At the end of this lecture, you should be able to: Identify the top 5 learning objectives selected for ward rotations - PowerPoint PPT Presentation
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Teaching on the wards

Teaching on the wardsDeepti Rao, MD

ObjectivesAt the end of this lecture, you should be able to:Identify the top 5 learning objectives selected for ward rotationsIntegrate various assessment and learning activities into your daily work on the wards and coordinate them with the above learning objectivesDiscuss various topics including a suggestion for how ward rounds should be conducted

SignificantLearning ExperienceOBJECTIVESCONTENTASSESSMENTMotivating EnvironmentPre-Existing KnowledgeLearning with UnderstandingMeta-cognitionTHE CIRCLE OF LEARNING & BERMUDA TRIANGLE OF EDUCATION

Motivating environmentExamining what resident look for in their role modelsWright, Academic Medicine, 3/96

Motivating environmentEffective Supervisory BehaviorsEffective educational and clinical supervision, Medical Teacher 29, 2-19HelpfulGiving direct guidance on workLinking theory and practiceEngaging in joint problem solvingOffering feedbackReassurance IneffectiveRigidityLow empathyFailure to offer supportFailure to follow supervisees concernsNot teachingBeing indirect and intolerantEmphasizing evaluation and negative aspects

Motivating environmentEffective Supervisory BehaviorsEffective educational and clinical supervision, Medical Teacher 29, 2-19Good interpersonal skillsInvolving trainees in patient careNegotiation and assertiveness skillsCounselling skillsAppraisal skillsSelf-awarenessWarmth, empathy, respect, supportive, positive, enthusiastic

Clinical competenceTeaching skillsOffering opportunities to carry out proceduresGiving directionGiving feedbackKnowledge of teaching resourcesIndividualizing the teaching approach

SignificantLearning ExperienceOBJECTIVESCONTENTASSESSMENTMotivating EnvironmentPre-Existing KnowledgeLearning with UnderstandingMeta-cognitionTHE CIRCLE OF LEARNING & BERMUDA TRIANGLE OF EDUCATION

Integrate earlier learning in providing patient care17.6%3Become adept at performing history52.9%9Become adept at performing physical exam41.2%7Understanding the indication for and interpretion of tests47.1%8Become adept at gathering and reporting data35.3%6Become adept at formulating problem lists and differentials41.2%7Become adept at formulating management plans41.2%7Become adept at clinical problem solving47.1%8Become lifeleong learners23.5%4Learn management of common medical conditions58.8%10Evidence based medicine29.4%5Communication skills64.7%11Learn about the functioning of the medical team and the contributions of the various members23.5%4Ethics11.8%2Professionalism41.2%7Systems of care0.0%0Social determinats of care0.0%0Quality improvements23.5%4Show repliesOther (please specify)1

Objectives for ward rotationAt 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 indicationsApply clinical diagnostic reasoning skills to patient careDemonstrate knowledge of common medical conditionsDemonstrate effective communication behaviors and skills

What are some learning activities to help us achieve these objectivesClinical diagnostic reasoningObservation/ChecklistingFeedbackQuestions

Clinical Diagnostic ReasoningHypothetico-deductive (unclear diagnosis)Scheme-inductive (dysphagia)Pattern recognition

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

Problem representationOne sentence summary defining the specific case in abstract termsFacilitates 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

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

Semantic qualifiers

Illness scriptExpert 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 patientsAnchor points develop in the scripts based on defining and discriminating features (compare and contrast)

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

Suggestions to promote clinical diagnostic reasoningMust see an adequate number of patientsArticulate an accurate problem representationDifferent levels of learners and teacherReason aloud based on your problem representation and illness script/discriminating featuresCompare and contrastForce learners to prioritize differentials and explain reasoningStudents should see very typical presentations of common illnesses to solidify accurate illness scriptsProvide cognitive feedback Reading habitsNovice learners should read about 2 related dx at same time based on a patient they have worked up

Top 9 diagnosesPneumoniaPoisoning and toxic effects of drugsCirrhosis and etoh hepatitisHeart failure and shockChest painGi hemorrhageSepsisDisorders of pancreasRenal failure

SNAPPSSummarize history and findingsNarrow the differentialAnalyze by comparing and contrastingProbe the preceptorPlan for managementSelect a learning issue

One minute teacher

Checklisting and observationWe dont 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 noEffectiveness of clinical rotations as a learning environment for achieving competences. Daelmans, HEM, et al, Medical Teacher, 2004Assuming 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.

ObservationTimeNot sure what checklists available/what are we observing forSubject to biasesRacial and sex biasesHalo effect Different standards

Checklisting/Observation

Checklisting/ObservationMini-CEXStructured way to give feedbackReliable way of assessing post-grad performanceNeed 12-14 observationsVAMy own experience

ChecklistingUNM-SOM Clinical Note Global Grading Template1-34-78-10GeneralVague or confusing wording/documentationInformation poorly organizedSignificant incongruence between symptoms, findings and assessment and plan

Vague or confusing wording/documentationInformation poorly organizedSignificant incongruence between symptoms, findings and assessment and plan

Clear portrayal of symptoms & findingsRecorded in logical sequence Similar data grouped and labeledClear, explicit and correct congruence between symptoms, findings and assessment and plan

HistorySignificant/critical symptom information omittedOne or more essential positive and negative elements of the history omitted Significant erroneous information included.Symptom information is presented with necessary detail Most of the pertinent positive and negative elements of the history included.Complete symptom information presented with advanced level of detail (i.e. risk factor assessment, well-characterized pain assessment) All pertinent positive and negative elements of the history included

Checklisting

FeedbackWe 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

Feedback-EndeDone with both parties working as alliesExpected and well timedSelf assessmentBased on specific actions, examples and observed behaviorsObjective

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

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

Debriefing with good judgementResult, 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?

Few tips on asking questionsAllow at least 10-15 seconds for responsesDont answer your own questionsInvolve everyoneOpen ended questions What do you want to do?

How do we integrate objectives, assessment and learning activitiesObjectiveTeaching/Learning activityAssessmentData gathering and problem list, differential, managementSNAPPS, one minute teacherCase discussionHave student form problem list for anothers presentationMini-lecture (arrow in the quiver)FeedbackObservation with feedbackChecklistingSelf-assessmentIndication and interpretation of testsQuestioningMinilectureQuestioningClinical Problem solvingSNAPPSProblem representationRole modelingCompare and contrast readingQuestioningCase discussionSNAPPSFeedbackSelf assessmentManagement of common medical conditionsCommunication skillsCoaching

WardsDifficult environmentTimeCompeting demandsOpportunistic learning

Residents thoughts about effective hospitalist attendings

1. Help with scut work/seeing patients2. Allow the resident to run rounds however they are most comfortable3. Do not use residents as an information sink. Use team rounds to discuss and see higher acuity patients

Teaching attending power tipsPlan to finish by noonSet expectations first dayFull presentations without interruptionPrimary providerTeach what you know

How should wards runAttending 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 dischargesIf 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

How wards should runMake work roundswrite orders while roundingAllow presenter to finish presentation before interrupting. At end of presentation, have presenter ask any questions they haveAllow resident or intern to answer questions firstWalk vs sit ?Both interns vs one at a time ?

How should wards runMaintain good working relationships with everyone from PT to consultantsUse precall days as teaching days by presenting articles and modules or opting to checklist notes/communicationUse 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 daysI would propose we develop teaching activities based on each persons area of special interestOn the post call days have other members of team formulate problem representations and problem lists for casesForce learners to prioritize and explain differentialObservation?Compare and contrast readingsLearning issuesAfternoons for getting work done

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?