Teaching on Today’s Wards: TEACHER’S GUIDE
Please coordinate materials with the lecture slides and the separate handout tutorials/exercise sheets.
Session #1: Improving the Teaching Process
Learning Objectives for Sessions 1 and 2:
By the end of these two sessions, the learner will:
1. Recognize teaching is a process that is open to evaluation and improvement.
2. Identify areas in his/her teaching process in which the ACGME core competencies of communication and professionalism can be taught and evaluated.
3. Identify successes and problem areas in his/her own teaching process.
4. Develop a process improvement plan for at least one specific problem area that will be incorporated into their teaching process on their next inpatient month.
Introduction (10-15 minutes)
Teaching is a process. You have learned the Stanford Improving Clinical Teaching Skills Model, which is one conceptual model that is attractive-- teaching skills reinforced with video-taped practice sessions and feedback. These are a set of core teaching skills that will serve you well in any teaching environment. However, we are going to devote the next 5 sessions to improving our process of teaching in the site-specific place of an inpatient Medicine teaching service. Exploring your teaching process while balancing the clinical, management and administrative roles we take on as the teaching attending is no small feat.
We will use the Stanford Model and the ACGME core competencies as the two pieces of a foundation to guide our own clinical teaching specifically in the inpatient setting.
This will be an active learning based set of sessions that recognizes that while we all teach differently in terms of style, content, order and amount—we all face many of the same issues and barriers.
When clinical topics arise, we will use geriatric content as the examples.
What is the process of Teaching on the wards?
Overview of the month long process
Setting goals
Setting expectations
Structure of when teaching will occur
Preventing burn out
Overview of the day picture
Setting goals
Setting expectations
Identifying the teachable moment
All of this while taking care of patients, getting your work done, getting residents home, and maintaining some semblance of balance.
Introduction to Mapping the Teaching Process (15-20 minutes)
See tutorial handout for process mapping
All learners map out their process with assistance of the tutorial handout and the
lecture instructions.
Provide a few example maps to demonstrate how to look at them.
Discuss that there are successes and problem areas in every map and that we can use them to be self-reflective life long learners. To do that, remember that the teaching attending role involves balance between teaching and clinical care.
Components of this process also map to the Core Competencies:
Communication
Provide examples from demo maps
Professionalism
Provide examples from demo maps
Breakout Session: (40 Minutes)
This session will focus on thinking about the process by using your map as a tool to reflect on your attending style. Remember that no one style is the right one, but that we can learn from each other.
There will be 4 specific activities to work on over the next 1 hour as you look at the maps of the other people in your small group as well as the example maps.
1. What surprises you as you look at the maps?
2. Begin to identify differences between the maps
3. Identify where in your maps there are links to the communication and professionalism core competencies
4. Start to identify where your process serves you well and where it may interfere with achieving the ultimate goal of achieving excellence in clinical care and teaching.
Re-Group (20 minutes)
Spend a few minutes discussing the 4 activities and the session.
Talk about barriers:
Pre-identified barriers
Time
When the resident or student clinical evaluation is crucially different from
your evaluation
Walking into a heated or volatile family situation on rounds
Walking into an acutely decompensated patient while on rounds
Motivating and maintaining resident interest
The Power Struggle on the team
When Can I be done?
Homework:
Look at your own map and more concretely identify where your process serves you well and where the problem areas are. Please create a list of barriers (external and internal) that affect your attending on the wards. These barriers will likely include external and internal barriers. Also, think about how this area in your process relates to the competencies of communication and professionalism. Be ready to actively work on this area for next session. Please bring your list of barriers to the next session.
Session 2: Improving the Teaching Process, Part II
Introduction: (5-10 minutes)
Round out a discussion on barriers to teaching. Talk some about internal and external barriers identified during the homework assignment.
Outline the small group session activities below.
Small Group Session 1: (25 minutes)
See exercise worksheet for this session “I hope I get a good team”.
You will spend the next 25 minutes working in groups discussing barriers. This discussion will be “case based” and will focus on issues about how you can be a teacher/manager given a set of challenging team dynamics. In this session, use the maps from people in your group as well as the example maps to identify barriers or highlight potential strategies to effectively managing the team. Also, be prepared to talk about where the cases naturally link to both the Stanford framework and the ACGME core competencies of communication and professionalism.
Break into 3 discussion groups. Group 1: Discuss questions 1-3. Please designate a faculty member to report back to the group as a whole when we regroup for further discussion.
You are the attending for the month on the GENS Service in January.
You are post call--your 3rd call night for the month.
Your team:
1. SR--Senior resident (3rd year, planning a career in critical care)— smart, confident, leader, decision-maker
2. IK--Intern #1–smart, polite, reserved, very detail oriented, always knows the answer
3. IT--Intern #2—smart, easy-going, aims to please
4. MP--Medical student #1—smart, confident (contributes to rounds), a jokester
5. ML--Medical student #2—smart, leaves rounds early, does not contribute to rounds, presentations lack ability to flush out a working A&P expected for level of training.
Questions for Discussion:
Keep in mind your teaching map, how you set goals for the month, your style as a manager, and role as a teacher.
Keep in mind the concepts of both internal and external barriers to teaching.
Also keep in mind that our goal is to expand the teaching on inpatient geriatric issues.
1. Based on these profiles of your team, discuss the monthly goal setting you would have done for each of the house staff and medical students described here.
2. What are the barriers to teaching in this particular group dynamic?
How can you engage SR, IK, IT, MP, ML in teaching rounds?
(Think about clinical and character strengths/ potential or real weaknesses of the individual resident/student learners, level of training issues, and how these factors play out in the group dynamic.)
3. How do you work with your senior resident without upstaging his/her autonomy to run-the-show—including teaching and topic choices?
Re-Group (10 minutes)
Each group will present talk for 2-3 minutes about their conversations. The discussant will be asked to specifically comment on barriers and strategies of interest, as well as describing the usefulness of the teaching maps in this process.
Introduction to Small Group Exercise #2 (5 minutes)
See exercise worksheet for this session “Deciding what to teach”.
During the next breakout session, we will be moving to a post-call day. You will be presented with a typical post-call general medicine service day. We want to explore barriers and identify strategies for highly effective teaching. Again, use your maps to honestly reflect on how you would manage this post-call day. Remember the goal is to provide outstanding teaching while taking care of patients, getting your work done, getting residents home, and maintaining some semblance of balance.
Breakout Session #2 (35 minutes)
Below is the list of new admissions for presentation:
Patient list: 3 olds, 1 somewhat sick, 10 news, the resident gives a one-line summary of the 10 new patients as listed below.
1. Acute pancreatitis with a fever
2. MS changes for NHP
3. Transfer from the MICU after 8 day ARDS/sepsis stay
4. Pneumonia in what may be a newly diagnoses HIV patient
5. ESRD patient with fevers, possible line infection
6. NH patient with urosepsis, stable
7. Acute asthma exacerbation, looks ok
8. Transfer from neurosurg service for patient with a subdural bleed, mental status changes, and now new onset hypoxia
9. Patient admitted with probable pneumonia but very interesting CXR with possible cavitary lesions
10. Patient with sickle crisis and chest pain
Breakout Session Questions
1. How would you prioritize seeing these patients?
2. How would you prioritize teaching on the new patients?
Re-Group (15 minutes)
Reconvene for group discussion. Pass out the Missed Teaching Opportunities handout to the faculty learners. This demonstrates the variety of Geri topics/principles that can be taught across all patient cases. Also demonstrated are the opportunities to teach across all the ACGME competencies on any given case. Finally, listed are the opportunities to use teaching tools such as the case or census audit (Session #4).
Optional materials for further group discussion:
4. When and what would you teach on case #2? Case information see below.
5. How do you handle the bait and switch of the daughter’s arrival in case #2?
6. When and what would you teach on case #6? Case information see page 6.
7. What are the motivators that you use to teach a resident or student a particular topic? How could you motivate a resident or student to the topic areas of foley catheter use and skin care/ pressure ulcers in case #6?
8. Are there cases in this list that lend themselves to teaching about professionalism and communication?
Case #2:
INFORMATION FROM PRESENTATION
You enter the room of RB, an 80 year-old who was presented as an elderly gentleman with falls without syncope, here for nursing home placement. Last night when admitted the patient’s son states that he suspects memory problems. He is on multiple medications for htn, depression, memory, diarrhea, insomnia. They include: atenolol, hctz, reminyl 8 BID, paxil 20 q hs, ambien 10 qhs, lomotil BID. Some of these medications were new according to the son.
In the ER here the patient had normal blood work, neg. CT head for an acute subdural, EKG with NSR and no acute changes.
INFORMATION FROM EXAM
On exam, the patient is unusually sleepy and difficult to arouse. He does know his name, year but not the date or place.
NEW INFORMATION FROM FAMILY MEMBER
The daughter has just arrived from out-of-state this morning and wants to know what’s going on with her father. She states that 3 weeks ago he was functioning independently and admitted to an outside hospital with chest pain with a negative work-up and sent home. From there her father became more confused and started to fall, so she requested her brother to take their father to the ER at your medical center.
FINAL ASSESSMENT
You suspect apathetic delirium with an underlying dementia, deconditioning and polypharmacy.
Case #6
INFORMATION FROM PRESENTATION
BT, a 90 year old nursing home resident admitted with MS changes deemed secondary to a UTI.
NEW INFORMATION FROM YOUR EXAM
On physical exam you note the patient has an indwelling foley catheter and some sacral breakdown neither of which were mentioned in the initial presentation.
Homework:
On your own, spend time looking at the small group case (team, patient load, questions, etc.). Think about how your own process of teaching affects your ability to be a manager and teacher. Also, critically evaluate how your approach serves the teaching of topics like geriatrics core issues. Identify one area of your process that you would like to improve and explicitly state the barrier(s) that get in the way of teaching these types of topics. Begin to think about how you could change your process to improve the teaching of these important, but seemingly difficult topics.
Evaluation Ideas for Sessions 1 and 2
Pre- and Post Survey
Teaching comfort level
Do you have a process to self-evaluate your teaching
How comfortable are you in your ability to make effective changes in your teaching strategies
Please rate your comfort in teaching: Communication/ Professionalism
Please rate your comfort in evaluating: Communication /Professionalism
List (or think of) 3 struggles that you face when teaching
How many of these are items that you have direct control over?
Do you have a concrete plan to address any of them?
When was the last time you had a concrete plan to address a teaching struggle?
Now take a look at your teaching map
How much do you think this map will aid you in your teaching process improvement?
Mapping
Try to map your teaching during your next inpatient month. Has it changed from your initial map? If so, does it reflect the specific teaching improvement process project you committed to during the sessions?
Observed Rounds
Did the learner/teacher seem to complete their specific process improvement plan?
Have learner/teacher identify something about opportunities for communication/professionalism teaching evaluating.
Learner Report
Did your attending set specific goals in the beginning of the month?
Did your attending set specific expectations in the beginning of the month?
Session #3: Systems Based Core Competencies
(Intro. 10 minutes)
The core competencies should be thought of as what goes into making a good clinical doctor providing comprehensive, up-to-date clinical care. We should be practicing across the 6 competencies areas for any individual patient case. Some of competencies are intuitive to practice and teach e.g., medical knowledge, patient care, professionalism, communication. Further, we are often most comfortable with evaluating a learners “clinical expertise.” The core competences of practice based learning and improvement (PBLI) and systems based practice (SBP),have been more difficult to teach and evaluate in clinical practice largely because most teaching faculty don’t feel they are enough of a “content” expert to teach PBLI or SBP with skill or comfort. In fact, most places that have made formal efforts at teaching PBLI and SBP have made them a stand-alone curriculum. We hope to demonstrate how PBLI and SBP can and should be a part of our practice of teaching in the clinical setting. When you walk away from here, you will have a toolbox that will allow you to teach and evaluate your learners in these areas.
Learning Objectives:
By the end of this session, the learner will be able to: