Teaching Credit Application Form

This credit only applies to individuals who participated in learning during the preparation stage for the purpose of teaching. Neither preparation nor teaching, by itself, is sufficient for the purpose of claiming CME credit.
Example: a physician has residents and/or fellows in his or her office and sets aside time for discussion of a topic related to a special interest on the part of the student, or to a patient seen at a previous visit. The physician spends time preparing for this conversation by researching the topic and learns in this process, then the physician is eligible for credit under this new guidance for the time spent discussing that topic with the student/resident.
Physicians may not claim credit simply for allowing residents/fellows to follow them around and observe for several hours, or for providing residents/fellows with feedback on the way to conduct an interview or perform a part of the physical exam based on accumulated experience over the years.
If you did not prepare to teach, and therefore did not learn anything new, spending time with residents/fellows by itself is not sufficient to receive credit. If there is no learning that can be identified in the preparation stage, there is no credit for spending time with residents or fellows.
I attest that I engaged in active learning in order to prepare to teach medical students and/or residents/fellows.

Activity Information
Topic/Title:
Date of Event: / Time Spent Lecturing:
GME Department
Program Director/Coordinator to verify program:
Number of Expected CME hours requested:
Credit Type(s) Requested
AMA PRA Category 1 Credit / American Osteopathic Association Credit (AOA) (speaker credit)
Which of the following competencies will be addressed by this program?C6 Select all that apply

ACGME/ABMS Competencies Institute of Medicine Competencies Interprofessional Education Collaborative

Patient Care and Procedural Skills Provide patient-centered care Values/Ethics for Interprofessional Practice

Medical Knowledge Work in interdisciplinary teams Roles/Responsibilities

Practice-based Learning and Improvement Employ evidence-based practice Interprofessional Communication

Interpersonal and Communication Skills Apply quality improvement Teams and Teamwork

Professionalism Utilize informatics

Systems-based Practice

What type of teaching activity were you engaged in? Select all that apply

Lecture/teaching Residents/Fellows Demonstrating clinical, research, or other skills

Supervising clinical or simulated activities Assessing performance

Developing cases Mentoring

Developing a course/curriculum Facilitating a group discussion

Program development
Describe your professional practice gap(s) on which the activity was based (maximum 100 words). (C2)
(What problem is the education addressing in the attendee)
State the educational need(s) that you determined to be the cause of the professional practice gap(s) (maximum 50 words each). (C2)
(Why is there a problem) / Knowledge need (lack of information, being aware of what to do)
Competence need (lack of skills, being able to apply/knowing how to do something)
Performance need (lack of utilization of skills, using the strategies or skills one already has)
What learning approach(es) did you apply to address your identified practice gap(s)?
What impact did this learning have on you? As a result of this learning from teaching activity, I am better able to: C6 Select all that apply

Research clinical questions online or in journals and other text sources

Reflect on teaching encounters and undertake improvements, develop learning/teaching plans

Prepare for a student/resident encounter or teaching session

Search and synthesize the literature

Discuss cases, prompt questions and seek additional information

Develop educational materials related to care or clinical problems

Incorporate more interactive teaching strategies

Appropriately identify the learning needs of my students

Apply effective teaching methods

Provide feedback to learners/students

Develop outcomes measurements

Conduct learning assessments

Teaching is more enjoyable/fulfilling

Identified Barriers?C18 Select all that apply
What potential system and/or physician barriers do you anticipate attendees may have that will prevent them from incorporating new knowledge, competence, and/or performance objectives into practice?
No perceived barriers / Patient compliance issues / Resistance to change
Insurance/reimbursement issues / Cost / Formulary restrictions
Lack of time to assess or counsel patients / Lack of administrative support/resources / Lack of consensus on professional guidelines

Attestation:

I hereby attest that I have prepared and learned from teaching as described above. All statements are true.

Physician:

Date:

You may submit this form by emailing or faxing it to (810) 606-5589

Application reviewed by the CME Steering Committee on:

Approved for CME Yes No

2