Teaching in the Office: Assessment and Evaluation Joan E. St. Onge, M.D. UMMSM August 15, 2014

Case Based Learning 5 rules for effective teaching have been described by Neher and coworkers as a practical model of case based learning. - Combines expert consultation with the technique to address learner and patient needs efficiently and effectively. Neher JO, Gordon KC, Meyer B, Stevens N. A five step microskills model of clinical teaching. J Am Board pf Fam Prac.1992;5:

5 Micro Skills for Effective Teaching 1: Get a Commitment 2.Probe for Supporting evidence 3.Teach the general rule 4.Reinforce positive behavior 5.Correct mistakes

1. Get a Commitment Get the learner to commit to some decision or plan of action “ What do you think is going on?” “Would you recommend a surgical approach to this problem?” “Why do you think this patient is on three Antihypertensive medications?” Unhelpful methods “Sounds like pneumonia. Right?” “Can you think of anything else?” Questions do not probe for understanding, but can be answered by yes or no.

2. Probe for supporting evidence Questions that ask the learner to demonstrate his or her thinking as it pertains to the case AVOID the “GUESS WHAT I AM THINKING?” questions! Helpful approaches: “What about his presentation led you to this diagnosis?” “What did you find on the exam that makes you think it is a surgical abdomen?” Unhelpful: “What are the possible causes of dyspnea on exertion?” “This seems like a clear case of gout to me, how about you?” -Does not allow learner to demonstrate critical thinking skills.

3. Teach the general rule Whenever possible, attempt to teach the general rule “ the rule of thumb” – Helpful approaches: “In a young patient with low back pain, Xrays are not indicated initially.” “It is helpful to address code status when the patient is healthy.” – Unhelpful approaches “Mr. Smith does not need an xray today” “Why don’t we discuss code status with Mrs. Jones today?”

4. Reinforce What Was Done Right Provide positive feedback – Builds confidence, promotes self esteem, heightens awareness to corrective criticism Helpful: “You evaluated this patient in a stepwise fashion and considered the patient’s preferences in your recommendations.” “You did a good job in noting the possible role of medications side effects in the diagnosis.” Unhelpful: “Strong work!” “Great Job!”

5. Correct Mistakes Choose appropriate time and place to present this to the resident Have learners review their own performance Follow up with your own comments

Correct Mistakes Helpful – “I agree that Goodpasture’s could be a cause of this patients symptoms, but bacterial sinusitis is a more likely cause based on disease prevalance and lack of other findings.” Unhelpful – “I can’t believe you know so little at this point in the third year.”

SNAPPS:A Learner Centered Model for Outpatient Education Summarize history and physical Narrow the differential to 2-3 possibilities Analyze the differential Probe the preceptor by asking questions Plan management Select a case related issue for self directed learning

Summary – Concise – Not more than 50% of discussions – Relevant

Narrow the differential – Avoid the zebras – What caused the exacerbation? – Therapuetic options

Analyze the differential – Compare and contrast possibilities – Relevance – Enhances preceptor’s Ability to understand the resident’s level of critical thinking

Probe the precptor – Remember: this is learner centered— – The resident should be able to identify gaps in knowledge that he or she needs help with.

Plan the management – The learner initiates this, and must offer at least a brief management plan

Select a case related issue for self-directed learning.

Constructive Feedback

Descriptive, not evaluative Describes the behavior you observe without attributing value to it Good example: “You did not make eye contact with the last patient during the interview” Poor example: “You are not interested in patient care”

Specific, not general Identifies the precise behavior you wish to highlight, avoiding generalities Good example: “You were able to convey empathy and understanding during the interview” Poor example: “You did a good job”

Focused on issues the learner can control Provides tips on how to improve Good example: “When taking the history, speak slower and check for understanding” Poor example: “My patients cannot understand you because of your accent”

Well timed Makes feedback an expectation, not an exception Good example: When it is provided regularly throughout the learning experience and as close as possible to the event that brought about the feedback Poor example: When it is provided only at the end of the rotation

Limited in amount Make the message memorable Good example: When it focuses on a single, important message Poor example: When the learner is overwhelmed with information

Addresses learner goals Use of “Student Contract” Good example: When it addresses goals that were identified by the learner at the beginning of the office experience Poor example: When the learner’s goals are ignored

Feedback should be ongoing and frequent Most common complaints from students is that nobody tells them how they are doing Give the feedback as soon as possible after a critical incident Use notes to help you recall points you wish to make Describe the observed behavior Be as specific as possible End the feedback with detailed instructions for improvement Follow-up with positive feedback when the improvements occur

Patient satisfaction survery

Independent Learning

Identify the need After the presentation, have the student either identify the learning question(s) or ask the following: “Based on your patients today, what questions do you have?“ “What one area would you like to learn more about?” “What troubled you today?” “What would you like to improve on?”

Make an assessment Ask the student to formulate the question Ask the student to research the answers to the question Specify a time for the student to report back to you with the results of the research

Identify potential resources Medline or other databases Textbooks Journal articles Consultants

“Close the Loop” The student reports back on the research Gives an oral presentation Incorporates it into a patient write-up or assessment Submits a written outline

Reference “Teaching in Your Office, A Guide to Instructing Medical Students and Residents” By Patrick C. Alguire, MD, Dawn E. DeWitt, MD, Linda E. Pinsky, MD, Gary S. Ferenchick, MD