Clinical Teaching Workshop เชิดศักดิ์ ไอรมณีรัตน์ ภาควิชาศัลยศาสตร์ คณะ แพทยศาสตร์ศิริราชพยาบาล มหาวิทยาลัย มหิดล

Role Play in Clinical Teaching Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University 2

Role Play การแสดงบทบาทสมมติ Taking a role and enacting or playing that character A learning activity in which you assume a role to practice a variety of skills

Advantages Enable people to rehearse new behaviors safely in situation which they may not otherwise experience. – Challenges their interpersonal abilities – Facilitates the exploration in affective aspects – Provides support to players – Gives valuable feedback to players

Disadvantages Require teachers who are sensitive to clues about feelings and emotions Time-consuming process

Process Phase I: Selecting the situation Phase II: Recruitment of players Phase III: Adopting roles Phase IV: Roles played out Phase V: Experience explored Phase VI: De-roling Cox KR, Ewan CE. The Medical Teacher. Churchill Livingstone, Edinburgh 1982.

Phase I: Selecting the Situation Define learning objectives Choose a case that fits with the learning objectives Not a very rare or impossible condition or situation

Phase II: Recruitment of Players Players should not be forced into roles Gentle social pressure may be needed to overcome natural shyness, but strong pressure leads to hostility and impaired role performance

Phase III: Adopting Roles Players should not use their own names Some information is made known to all players, while some piece of information would be known only to a particular player is derived privately with the teacher.

Phase IV: Roles Played Out With an unscripted play, there is no prior knowledge of what will happen, like in real life. Time loosely controlled Observation: – Incidents that trigger thinking and feelings of players – Verbal and non-verbal clues of struggle – Inability to make the scenario progresses

Phase V: Experience Explored Players are asked about their feelings and reactions, using open-ended questions Audience participation is encouraged Avoid value judgment, speculations or blame on persons

Phase VI: De-Roling An important step that cannot be omitted Players are relieved from discomfort they carried during the role play When any role-based emotions have bee resolved, the teacher can asked the player if their real-life self has any advice for their role-playing identity

Guidelines for Effective Use of Role Play State clear aims and objectives about task and roles Create roles that reflect real experiences and appropriate levels of challenges Relate the role play to broader contexts in which students are learning Acknowledge potential difficulties in role play Nestel D, Tierney T. Role-lay for medical students learning about communication: Guidelines for maximising benefits. BMC Med Educ 2007; 7: 3

Guidelines for Effective Use of Role Play (2) Provide sufficient time for role preparation Provide appropriate feedback Respond to student preferences for working with friends Write reflections on the experience Ensure tutors are enthusiastic Provide opportunities for debriefing Use audiovisual recording for playback Nestel D, Tierney T. Role-lay for medical students learning about communication: Guidelines for maximising benefits. BMC Med Educ 2007; 7: 3

Students’ Description of Unhelpful Role Play “was not real… it would not be the same had it been done for real” “Have to concentrate on acting too much.. Distract from thinking about what and why we are doing” “Poor structure: haven’t been told enough about what to do” “Too many students in the room so it was noisy and hard to concentrate” Nestel D, Tierney T. Role-lay for medical students learning about communication: Guidelines for maximising benefits. BMC Med Educ 2007; 7: 3

“I was unsure if the advice given by my peers was the same advice a teacher would give…. I was uncertain about the quality of feedback” Students’ Description of Unhelpful Role Play (2) Nestel D, Tierney T. Role-lay for medical students learning about communication: Guidelines for maximising benefits. BMC Med Educ 2007; 7: 3

Ward Round Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University 17

Key Characteristics Some conflicts in the process between patient care needs and education. Effective education can happen when both teachers and learners are active. A patient is a critical component of the activity.

Ward Round: Components Teacher-Learner-Patient Triangle (Sheets and Schwenk, 1989)

Principle 1 Establish an efficient format that satisfies time constraints. – Set up clear expectations for time efficiency. – Important but not necessarily all points are discussed. – Patient presentation in a SOAP format in no more than five minutes

Principle 2 Prevent dominance of the discussion by someone (especially yourself) – The round is not a lecture. – Main objective = clinical reasoning and decision making…. Can be obtained with learner involvement in solving the problems – Use silence effectively to encourage participation. – Learners are allowed to answer wrong in a safe environment.

Principle 3 Use open-ended questioning as the dominant mode of teaching – Short answers are insufficient to show learners’ deep understanding. – Learners should be asked to clarify, justify, correlate, critique, evaluate, analyze, interpret, and predict.

Principle 4 Base all teaching on the data generated by or about the patient – The only purpose of teaching at the bedside is to teach knowledge, attitudes, and skills related directly to the patient who is there.

Principle 5 Always show respect to the patient – Showing due respect for the patient’s comfort and dignity not only is necessary for good patient care, but also models excellent professional behavior by the teacher for the learners. – Leaving bedside with an optimistic statement to the patient.

Principle 6 Give feedback – Observing learners’ performance at the bedside is an excellent opportunity to evaluate the learner’s ability. – Providing feedback, both positive and negative, is critical to improve students’ future performance.

Summary 1.Establish an efficient format that satisfies time constraints 2.Prevent dominance of the discussion by someone (especially yourself) 3.Use open-ended questions 4.Base all teaching on the data generated by or about the patient 5.Always show respect to the patient 6.Give feedback Schwenk TL. Whitman N. Residents as teachers: A guide to educational practice. Salt Lake City, UT: University of Utah Medical School, 1984.

Small Group Teaching Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University 27

Small Group Teaching A teaching method conducted in a small group:- -Provide a setting for students to discuss with friends and instructors -Allow students to apply their basic knowledge to solve particular problems -Simply put, small group teaching is a discussion session wigth a purpose. 28

Goals of Small Group Teaching Discussion with a purpose: – The development of three things Thinking skills Communication skills Attitudes

Key Skills of Teachers for A Successful Small Group Session 1.Encourage participation by learners 2.Develop professional intimacy with learners 3.Control the tension in the group during the session Whitman N, Schwenk TL. A handbook for group discussion leaders: Alternatives to lecturing medical students to death. Salt Lake City: University of Utah School of Medicine 1983.

Principle 1 Prepare for group discussion more than you would for a lecture – Knowledgeable about the subject in the level that can respond to any students’ questions – A list of potential questions to stimulate students – A list of common confusion and misunderstandings – Cases or examples to motivate students’ curiosity

Principle 2 Set ground rules for the group process – Make sure that the topic is clear, well-defined, realistic, and relevant to learners – Clear educational objectives – Clear expectations: no lecture and participation is required – Seat arrangement in a circle and have everyone introduce themselves to the group – Define timetable of the session

Principle 3 Encourage participation – Various skills: silence, open-ended question, paraphrasing, summarizing, encouragement, challenges or problems – Welcome all comments and questions – Avoid using closed end question, esp. yes/no type – Short and clear questions from teacher – Distribute questions to the whole group, avoid dominance by a particular student

Principle 4 Dealing with difficult situations – Negative or unpleasant feelings (e.g., ethical dilemma, dying patient, abortion) Explore these feelings and provide support – Conflict between teacher and students or among students Acknowledge the conflict, then provide suggestions on how to resolve the conflict based on literature – Students are uncomfortable with the group process Revisit the rationale and objectives of a small group session

Principle 5 Summarize at the end, both the process and learning objectives – A good session needs a good opening, and also a good ending. Commend positive contributions of each student Summarize the content that has been discussed Clarify misconceptions Evaluate the group process

Summary 1.Prepare for group discussion more than you would for a lecture 2.Set ground rules for the group process 3.Encourage participation 4.Dealing with difficult situations 5.Summarize at the end, both the process and learning objectives Schwenk TL. Whitman N. Residents as teachers: A guide to educational practice. Salt Lake City, UT: University of Utah Medical School, 1984.

Teaching with a Time Constraint Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University 37

Clinical teaching 38 Teaching on the Run Teaching students or residents while simultaneously taking care of patients is a challenging endeavor. – This requires thinking in the midst of action. – This sometimes involves multiple levels of learners. – This usually occurs with limited amount of time. – This occurs in settings that may not be suitable for teaching (e.g., bedside, OR, ER, hallway). – This often occurs in a setting of little control.

One-minute Preceptorship Irby DM. How attending physicians make instructional decisions when conducting teaching rounds. Acad Med 1992; 67: Neher JO, et al. A five-step “microskills” model of clinical teaching J Am Board Fam Pract 1992; 5: 419 – 24. Clinical Teaching 39

Clinical teaching 40 One-Minute Preceptorship Make a commitment Explore reasoning Teach general rules Reinforce what was right Correct mistakes

One-Minute Preceptor Case Presentation Ask Questions Discussion Diagnose Patient Diagnose Learner 1.Make a commitment 2.Explore reasoning Teach 3.Teach general rules 4.Reinforce what was right (+feedback) 5.Correct mistakes (-feedback)

One-Minute Preceptor  Make a commitment  Explore reasoning  Teach general rules  Reinforce what was right  Correct mistakes Questioning + feedback - feedback

One-Minute Preceptor Case Presentation Ask Questions Discussion Diagnose Patient Diagnose Learner 1.Make a commitment 2.Explore reasoning Teach 3.Teach general rules 4.Reinforce what was right (+feedback) 5.Correct mistakes (-feedback)

Multiple Cycles Clinical Teaching 44

Let’s Practice ให้อาจารย์ใช้โจทย์ปัญหาผู้ป่วยที่ได้รับ แจกในการฝึกทักษะ one-minute preceptorship โดยให้อาจารย์จับกลุ่มกัน แล้วสมมติให้คนหนึ่งเป็นอาจารย์อีกคน หนึ่งเป็นนักศึกษาแพทย์ คนที่เหลือทำ หน้าที่สังเกตการณ์ เมื่อการสอนสิ้นสุดลง ให้ผู้สังเกตการณ์ comment กระบวนการที่ เกิดขึ้น หลังจากนั้นแล้วคนสังเกตการณ์ทำ หน้าที่อาจารย์ คนเป็นอาจารย์เปลี่ยนเป็น นักศึกษา และนักศึกษาเปลี่ยนเป็นคน สังเกตการณ์

Clinical teaching 46 One-Minute Preceptorship Make a commitment Explore reasoning Teach general rules Reinforce what was right Correct mistakes