Clinical Uncertainty in Primary Care: The challenge of collaborative engagement

Chapter 109

Using Practice Inquiry to Engage Uncertainty in Residency Education

On-line Resource #1

Educational Inquiry

Tina Kenyon ACSW, Lucia S. Sommers DrPH

Analogous to the uncertainty encountered in the clinician –patient relationship, educators who train health professionals encounter uncertainty in the professional socialization process. Learners begin training at different levels of skill and preparation and have their own unique needs. The learning environment can also present challenges. The interface between learner and educational system can create a variety of uncertainties. A medical student, for example, receives specific, consistent feedback about his poor performance which only marginally improves during the four week rotation. The student then requests a letter of recommendation from the preceptor. What contributions did the student, preceptor and environment make to these events? What are the relevant learning points?

The Practice Inquiry (PI) (Sommers et al, 2007) is easily adapted to become Educational Inquiry (EI), a process for addressing uncertainty in the educational process. Potentially useful in all varieties of professional training settings, EI can be used within an educator small group to diagnose a student’s issues, identify investigation options, and design appropriate interventions. The term “educator” is used broadly to include any member of the interdisciplinary team (e.g., nurses, medical assistants, care manager, laboratory staff, pharmacist, physician teachers.) In an ‘EI group', those with significant contact with the learner participate. Most often, physician teachers, behavioral science specialists and residency program leadership comprise EI groups. (“Student” is used generically below to refer to either a medical student or a resident.)

The Educational Inquiry Table

Within a teaching program, educators work together to prepare the student for practice after training. What one educator observes in a student’s behavior may or may not be congruent with the observations of other educators. When concerns are raised, EI offers a structured approach for educators to collaborate in managing those concerns. The student (medical student or resident) perspective is elicited separately and students are not present in EI sessions. To model conversations about individual students in the EI group, the “Inputs to Judgment” Table is modified to become the ‘EI Table’:

Educator’s uncertainty statement:

Key learner information:

Presenter questions:

Educator experience / Interface between learner
and education team/environment / Educational literature
Presenter’s unique context / Learner’s unique context

Educational Inquiry Formats

Practice Inquiry colleague group discussion formats are adapted for EI:

1)  “Take home students:” EI group members are asked to think about a student that raises a concern based on particular observations or interaction with that resident that remains with them after the work day ends. Discussing the concern in the EI group:

·  Helps provide the student context that may be missing (life stressors, etc.)

·  Explores whether or not the presenter’s experience is isolated

·  Provides a forum for identifying a coordinated response as needed

Example: A resident participated in a very challenging patient’s birth experience that did not go well. This event significantly impacted the entire team in a variety of ways. It was unclear how she well she was coping because she is quiet and stoic by nature. The faculty, her colleagues and other team members offered support, and she would answer, “Thanks, but I’m fine”. The faculty remained concerned about her. Using the EI framework, the EI group helped identify ways to monitor her coping and compiled resources that were offered to her.

2)  “Surprises:” The EI group discusses students who behave differently than their usual pattern, either positively or negatively.

Example: A third year medical student, early in the year, was paired with a physician teacher during a clinical session. Given the skill level of most students at this stage, the teacher expected the student to shadow him, intermittently participating in patient visits. When the student requested more independence, the teacher allowed the student to see a well-known patient who enjoys talking with students. When the student demonstrated strong skills and a knowledge base that was more consistent with a more advanced student, the teacher was quite surprised. The conversation in the EI group focused on how to sufficiently challenge high performing students (e.g., encourage student to take initiative in low risk situations, to follow up on actions taken, and to carefully evaluate patient and learning outcomes).

3)  Single medical student discussion: The EI group discuss contributing factors in a resident’s struggles with one or more areas of learning or providing care.

Example: A resident struggled with completing electronic chart documentation in a timely manner. In reviewing the resident’s performance with others, the resident’s advisor realized that the resident has difficulty remaining on time during patient care sessions and frequently works to the edge of duty hour restrictions. When asked for his observations, the resident discloses he feels he must address all the issues a patient brings to a visit to provide the best care and sees how this compromises time management. The conversation in the EI group focused on how to help the resident address patient priorities, maintain a thorough approach and remain on time.

4)  Multi-case presentations: The EI group identify a subgroup at risk (e.g., first year residents at mid- year during winter), or patterns of behavior in more than one resident (e.g., members of the inpatient team are missing teaching sessions in a particular week ), and identify interventions

5)  “Practice portrait:” The EI group members each reflect on their own teaching sessions in clinic to review:

·  Workflows and teacher availability to students

·  Students’ patterns of documentation about visits

·  Patient issues that create uncertainty and how they are addressed by teachers and students

·  How students are integrated into the patient care flow

·  Student performance in time management and collaboration with team

Through these reviews, individual students may emerge as needing more focused attention; workflow issues may benefit from further examination. For example, a resident becomes overwhelmed during a clinical session. When exploring this further, it becomes apparent that the resident is under-utilizing his nurse colleague for patient education. The EI group uses the EI table to examine the situation and the individual resident’s performance from a global perspective. A workflow change could include team member role clarification regarding patient education during the daily pre-clinic meeting. As a result, the team educates the resident about how to share patient education responsibilities with a nurse. The resident feels less overwhelmed, the patient benefits from team attention, and the nurse has opportunities to use different skills.

Using Literature and the Team in Educational Inquiry

The literature from a variety of sources informs the process of assessing student difficulties and providing potential interventions (Smith 2007). Through identifying whether the difficulty is related to knowledge base, skill level, preparation for learning, or impairment, the EI group suggests appropriate interventions (Kahn 2001). Other literature can offer time management hints (Covey 2004). Educators act as resources in bringing literature of value to students.

For example, a resident struggling with time management problems is observed by a physician teacher to understand contributing factors. The appropriate team member then provides targeted resources such as:

o  A senior resident helps a first year resident learn an algorithm for streamlining patient handovers to increase competence and efficiency

o  A nurse offers suggestions about how to use the electronic medical record during a visit while maintaining respectful interaction with the patient

o  A physician teacher coaches a resident in how to prioritize and allot time to tasks

EI at New Hampshire Dartmouth Family Practice Residency Program

Educational Inquiry at New Hampshire Dartmouth occurs on an as-needed basis. EI groups are facilitated by the educator who also facilitates the resident and faculty Practice Inquiry colleague groups. Follow-up is tailored to the unique situation. For residents discussed in the EI group, the residents’ advisors may meet with them directly. A physician teacher or other educator who observed the concerning behavior may meet alone with the resident or with the resident and advisor. More extensive work may be necessary (e.g., a senior resident or physician teacher observing the resident in clinic and/or providing coaching).

Conclusion

Similar to the clinician-patient relationship, the teacher-learner relationship presents its own unique uncertainties. In adapting the Practice Inquiry framework to become Educational Inquiry, educators gain an important tool for addressing uncertainty in the learning process. In using this systematic approach, the EI group collaborates in diagnosing issues and identifying contributing factors. Based on learners’ needs, the group designs specific interventions to address educational uncertainties in teacher-learner encounters.

References

Covey, SR. The 7 Habits of Highly Effective People. New York: Free Press 2004.; 145-155

Kahn, NB. Dealing with the Problem Learner. Family Medicine 2001; 33(9):655-57

Smith, CS, Stevens, NG, Servis, M. A General Framework for Approaching Residents in Difficulty. Family Medicine 2007;39(5):331-6.

Sommers, L. Morgan, L, Johnson, L. Yatabe, K.(2007) Practice Inquiry: Clinical Uncertainty as a Focus for Small-Group Learning and Practice Improvement. Journal of General Internal Medicine; 22: 246-252.