Academy of Medical Educators: Clinical Teaching Development Program

Precepting pitfalls: Did you catch yourself… Review Precepting pitfalls: Did you catch yourself… Taking over? Over-reaching? Teaching monologue? Asking too many close ended questions?

Skills Review Ask WHAT? Ask WHY? Quick pearl Good that you… The 1-minute Preceptor Get a commitment Probe for supporting evidence Teach a general rule Reinforce the good Correct mistakes Ask WHAT? Ask WHY? Quick pearl Good that you… Next time try…

Orchestrating Chaos: Teaching a group of multi-level learners What are the similarities between this picture and what we do? --playing all different instruments (working on different skills, playing different parts) Who is the audience there to see? --the musicians! They are the important ones. Not us…you only see our back.

Learning Objectives Create an effective learning climate in a busy clinical environment Formulate and communicate expectations for multiple levels of learners

Acknowledgement to UCSF Center for Faculty Educators: Drs Acknowledgement to UCSF Center for Faculty Educators: Drs. Irby, O’Sullivan, and Richie for framework of learning climate content.

Let’s look at this learning climate… Just like a patient, we want to examine with intent. Eager, engaged 3rd year student on the left. Intern facing the computer trying to keep the house moving. Experienced senior resident doing her best. Observe. Take notes of what attending does and says that sets the learning climate… http://www.youtube.com/watch?v=b7isn84Xouc

Learning Climate Exhibit Enthusiasm Balance Challenge and Support Welcome and Respect Diversity Model Humility Balance Challenge and Support

Types of ineffective learning climates Stressed watch-watcher Displeased dictator Overly casual goofball Disengaged aloof-ball

Exhibit Enthusiasm Introduce yourself & describe your passion for learning and patient care. Ask and use learner names. Display a positive and optimistic attitude toward the team and learning. Voice, gestures, passion for teaching, learning and inquiry, humor….not always serious…or intently serious

Welcome and Respect Diversity Create a welcoming and supportive climate. Consider personality and cultural differences that might affect learner’s participation. Communicate clear goals and expectations. Hospitality – treats? Give time for learning names, little of background, sharing, establish and reinforce Stated in expectations Respect opinions Welcoming input Making sure all voice heard—inviting Dealing with small stuff—house keeping

Model Humility Admit your own limitations, errors, and concerns. Encourage questions and independent thinking. Think aloud and invite learners to do the same. Acknowledge: learner insecurities fear of harming patients when & how to ask for help What is the opposite of humility? Arrogant and dogmatic. This is the most frequently used descriptor of the worst clinical teachers – Irby 1979. Build on the previous two steps, Clarify question expectations—too many questions can undermine trust Model reflection—what is that…what would it look like Maybe model an example emphasizing building on data and reviewing why we were doing it that way… “I’m sorry, I will never do that again” Reactive but not reflective….. Why reflection is an important strategy Elaborate and add to them.

Balance Support and Challenge Provide support for uncertainties and problems. Challenge learners to advance their understanding and make new connections. Give reinforcing and constructive feedback Collect ideas from the group

Support and Challenge Low Challenge High Challenge Low Support Stasis Fear High Support Confirmation Growth and Development

The Praise to Criticism Ratio Business team communication Looked at ratio of positive comments What a great idea! to negative comments “We shouldn’t even consider doing that”

Rank yourself. Share our strengths!

Practice: Enthusiasm, Welcome, Humility You are meeting the learners you’ll be working with for the next week. How can we convey: Introductions and Interests? Approachability and Accessibility? Engagement and Enthusiasm?

Practice: Enthusiasm, Welcome, Humility Assignment: Take 3 minutes to write out your “opening monologue” Tell them who you are Questions you’ll ask your learners Pair and share your ideas

Create a Positive Learning Climate Exhibit Enthusiasm Welcome and Respect Diversity Model Humility Balance Support and Challenge

Police the learning climate

Scenario You are working with a group of 4 learners--senior resident, intern and students. The intern is a gunner, wants to impress everyone with her knowledge. She interrupts the students to correct them and asks them pointed factoids. When she proposes a dx/plan that gets altered, she immediately retorts “Oh yeah, that’s what I meant to say…that’s what I was thinking too.” The resident is often times on his phone/laptop trying to get stuff done while care decisions are being discussed and made. He refers to the students collectively “Yo studs, come see this CT scan.” He is a seasoned 3rd year, a little jaded, and you have heard him bad mouth difficult patients, complain about ED nurses, and battle with the SW. In your groups, develop a strategy to “police” this learning climate…

Small Group Report Out

Psychological Size and Distance Another Everyone agrees that attendings have greater Psych size. Attendings feel like size difference is less than it REALLY is for the learner. Size difference didn’t affect resident satisfaction with preceptors. In terms of difference, attendings felt it was lower than residents. DID have significant NEGATIVE correlations with resident satisfaction, professional competence, and relationship with learners

What’s your size? Draw a circle that shows your psychological size near the middle of your paper. In relation to your circle, draw the location and size of your boss. In relation to your circle, draw the location and size of a typical learner for you.

Psychological Size Everyone agrees that attendings have greater Psych size. Attendings feel like size difference is less than it REALLY is for the learner. Size difference didn’t affect resident satisfaction with preceptors. In terms of difference, attendings felt it was lower than residents. DID have significant NEGATIVE correlations with resident satisfaction, professional competence, and relationship with learners

Psychological Distance In terms of difference, attendings felt it was lower than residents. DID have significant NEGATIVE correlations with resident satisfaction, professional competence, and relationship with learners

Psychological Distance In terms of difference, attendings felt it was lower than residents. DID have significant NEGATIVE correlations with resident satisfaction, professional competence, and relationship with learners

Psychological size and distance Attendings perceive LESS difference in psychological size than learners. Size difference didn’t affect learner satisfaction Residents perceive MORE psychological distance Greater distance correlated with worse ratings of preceptors

Strategies to alter psychological size and distance When might you need to increase your psychological size? Decrease it? When might you need to decrease psychological distance?

Setting and Communicating Expectations An orchestra of multi-level learners… Roles and Skills In the future, this will link to assessment and feedback

Roles in the clinical environment Who? Does what? When/How? Why? Attending Senior resident Intern Student

Once we agree what role they should be playing, how well do they play the part?

A clinical task: Gathering information Collective “expectations” of what this skill looks like Progression across developmental milestones NoviceProficientIndependent Expert

Inaccuracies common due to misinterpretation of patient comments Level 1 Information gathered following a template with little directed questioning Inaccuracies common due to misinterpretation of patient comments Level 2 Information gathered tends to be either cursory or extensive Recalls clinical information in the order elicited without prioritization Level 3 Accurately gathers information tailored to pertinent positives Prioritizes information to suggest the developing differential diagnosis Level 4 Gathers essential information, including pertinent positives and negatives Precisely organizes information in a hypothesis-driven fashion Level 5 Gathering of essential information targeted to individual patient features Discriminates between diagnoses with subtle distinguishing features Goal of delineating these

Performing a Basic Procedure Scenario M3 Student Intern Senior level resident Performing a Basic Procedure      Generating a Differential Diagnosis  Interpret diagnostic test/data With your like-minded group, fill out this table of your shared mental model of what

Debrief.

Learning Objectives Create an effective learning climate in a busy clinical environment Formulate and communicate expectations for multiple levels of learners

What will you do differently as a result of this session?

Summary

This is the sheet music.