Resident Educator Development The RED Program A Residents-as-Teachers Curriculum Developed by Heather A. Thompson, MD

The RED Program Team Leadership How to Teach at the Bedside The Microskills Model: Teaching during Oral Presentations How to Teach EBM The Ten Minute Talk Effective Feedback Professionalism Patient Safety and Medical Errors

The Microskills Model: Clinical Teaching During Oral Presentations Resident Educator Development (RED) Program

What is the Microskills Model? A 5 step process of clinical teaching Can be used during oral presentations, bedside or sit-down rounds, or any other case-based discussion Originated in the business literature and was applied to clinical medicine as a model for enhancing education Neber, J.O., Gordon, K.C., Meyer, B., and Stevens, N. “A Five Step Microskills Model of Clinical Teaching” J Am Board of Family Practice 5: , 1992.

Is there data? Faculty members who had completed training in the Microskills model had improved scores on feedback --Journal of Gen Int Med 17(10) Oct 2002 Randomized trial of Microskills training vs. no training in surgical residents: Improved scores on an OSTE station --Academic Medicine 73(6) June 1998

The 5 Steps Get a commitment Probe for Supporting Evidence Teach General Rules Reinforce what was done right Correct Mistakes

Get a commitment After presenting the facts of a case to you, the learner may stop and wait for your response. Instead of telling them the answer, ask them to state what he or she thinks about the issues presented by the data.

Get a commitment Examples— –“What do you think is going on with the patient?” –“How can you tie all of this together?” –“What would you like to accomplish with this hospital stay (or clinic visit)?” –NOT: “This is obviously a case of viral meningitis.”

Probe for Supporting Evidence After committing him or herself on the presenting problem, the learner may look to you to either confirm or refute the opinion. Before doing that, ask the learner for evidence that he or she feels supports the opinion.

Probe for Supporting Evidence An alternative approach is to ask the presenter to expand the differential diagnosis of the patient’s presenting complaint, physical findings, or data.

Probe for Supporting Evidence “I am interested in how you came to that diagnosis.” “What were the major findings that led to your conclusion?” “What other things did you consider regarding the patient’s abdominal pain?” “What else might be causing the (pleural effusion, elevated LFT’s…)?” “What further questions are arising in your mind?”

Probe for Supporting Evidence NOT: “List all of the possible causes of post op fever.” NOT: “I don’t believe this is consistent with acute pancreatitis. Don’t you have any other ideas?” NOT: “What was their last creatinine?” NOT: “What if the patient had just immigrated from Somalia?” (read my mind questions)

Teach General Rules You have ascertained from what the learner revealed that there is a knowledge gap. At this point, provide general rules, concepts, or considerations targeted to the learner’s level.

Teach General Rules Example: “Patients with cystitis usually have pain with urination, frequency, urgency, and a positive UA. However, fever, flank pain, nausea and vomiting would be unusual, and this usually indicates the presence of pyelonephritis.” NOT: “This patient needs IV antibiotics!” “The last time I saw this condition…”

Reinforce what was done right The learner may or may not realize that their plan of action was effective and will have a positive impact. Focus on the specific deed and the effect it had.

Reinforce what was done right “You considered the cost of the medication and the schedule of dosing in your selection of an antibiotic. This will contribute to improving this patient’s compliance.” NOT: “Good job.” “Strong intern.”

Correct Mistakes In the case where the learner’s work has demonstrated mistakes, this needs to be discussed as soon as possible. --What went wrong and why --How to avoid or correct the error in the future

Correct Mistakes “You may be right to attribute this patient’s altered mental status to the UTI. However, given the history of a recent fall in a patient on Warfarin, a head CT really should be done to rule out bleed or subdural hematoma.” NOT: “Why didn’t you get a head CT?!” “You never want to miss __________”

View Video Clips “Pre-Microskills”: Med student and resident discussing case in clinic. “Post-Microskills”: same scenario only incorporating some of the Microskills steps.

Practice the Microskills Model Split into pairs. One person plays the resident; the other, the medical student. Go through the case scenarios. Use the 5 Steps to help educate your student.

Group Discussion Describe your clinical scenario and the discussion that followed. What went well? What did you like about the Microskills model? What didn’t go well? Any pitfalls to avoid?

In summary: Microskills Get a commitment Probe for Supporting Evidence Teach General Rules Reinforce what was done right Correct Mistakes