Clinical Teaching Led by: Charlotte Wills, MD Arianne Teherani, PhD An Educational Skills Workshop sponsored by the Office of Research and Development in Medical Education (RaDME )

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Objectives n Describe common clinical teaching models and methods n Summarize current research on clinical teaching n Apply teaching models to different clinical scenarios n Identify challenging teaching situations and learners, and choose an appropriate teaching style for each.

Session Structure n Introduce OMP/ESP/SNAPPS models n Discuss clinical teaching cases using models via small and large group n Work through cases of challenging scenarios and discuss via small and large group n Summarize and wrap-up discussion n Fill out action plan

Clinical Teaching Literature nTnTwo distinct areas of research uAuAttributes/behaviors good clinical teacher FSFSolid knowledge base FCFClinically competent/clinical skills teaching FSFSupportive learning environment FCFCommunication: listening, participation, questioning FEFEnthusiasm about medicine and teaching uDuDevelopment of skills to be a good clinical teacher Sutkin, 2008

Traditional Clinical Teaching n Teacher questions focused on diagnosing the patient and questions about factual information n Rarely questions about trainee impressions of the patient n Questioning does not directly assess the learner’s level of knowledge. n Little or no teaching or feedback to the learner Irby, 2004

Traditional Clinical Teaching n Pros: u Efficient u Puts patient care first n Cons: u What the learner knows is unclear u Often little teaching u Little or no feedback to learner

n Step 1: Get a commitment u “What do you think is going on?” “What do you want to do next?” u Encourages learner to process further n Step 2: Probe for supporting evidence u “What else did you consider?” “How did you rule those things out?” u Assesses learner’s knowledge and thinking process Neher, 1992 One-Minute Preceptor (OMP)

One-Minute Preceptor n Step 3: Teach a general principle u “Following an acute stroke, prevalence of depression ranges from 20-50%;” u “Processes that causes collapse of alveoli will produce crackles on lung exam” u Can be about symptoms, physical findings, treatment, resources, etc. u Allows learning to be generalizable to future cases Neher, 1992

One-Minute Preceptor n Step 4: Reinforce what was done well u “Your presentation was well organized and concise” u Reinforces good behaviors u Being specific is important n Step 5: Give guidance about errors or omissions u “It is important to include an oxygen saturation when considering certain lung processes” u Corrects mistakes and forms foundation for improvement u Again being specific is key Neher, 1992

One-Minute Preceptor n Pros: u Assesses learner knowledge u Teaches to the level of the learner u Allows for more accurate feedback u More effective teaching encounter n Cons: u More time consuming? u Not known by all faculty Furney et al. 2001; Aagaard et al. 2004

Eight Step Preceptor (ESP) 1. Assess Level of Learner 2. Listen without Interruption 3. Get Commitment 4. Probe for Rationale 5. Make a Generalizable Teaching Point 6. Provide Reinforcing and Corrective Feedback 7. Prompt Learner to Identify Learning Objectives 8. Positive Learning Climate Ottolini et. al 2010

SNAPPS A Learner-Centered Model for Case Presentations n Learner-initiated n Learner-directed n Learner-centered Wolpaw et al. 2003

In SNAPPS the Learner n Summarizes history and physical n Narrows differential diagnosis to 2-3 possibilities n Analyzes differential by comparing & contrasting possibilities n Probes preceptor by asking questions about uncertainties, difficulties, etc. n Plans management for patient care n Selects issue for self-directed learning

Small Group Exercise: OMP Practice n How would you use the eight-step preceptor (ESP) or one-minute preceptor (OMP) model in this case? n See handout for each case for discussion questions

Large Group Discussion Summarize (briefly) what made your case challenging How did you use the OMP/ESP to address these challenges? Did it work? If you had more time, how would you modify? Was there a step of the OMP that you found most useful? Would SNAPPS have added value?

Case 1 n Your Role: ED/urgent care attending n Learner: 2 nd year resident n Case highlights: u 26 yo woman with back pain, fever, + UA u Reported exam/history suggest pyelo u R2 is convinced this is PID, wants to get an ultrasound, admit and start doxycycline

Case 2 Your Role: Inpatient pediatrics attending Learner: 3 rd year medical student Case highlights: – 18 mo old boy with diarrhea, abdominal pain, fever, tachycardia – Reported exam/findings concerning for acute abdomen – Incomplete exam, mom is “angry” – Med student is not sure what to do, and has no idea what’s going on

Case 3 Your Role: Inpatient consult service attending Learner: 3 rd year resident Case highlights: – 56 yo obese woman with renal failure, chronic pain – S/p hip and knee replacements – Taking Vicodin, unable to walk – R3 minimizes her pain, thinks she is drug- seeking, wants psych consult

Case 4 n Your Role: Primary care clinic attending n Learner: Intern n Case highlights: u 60 yo man with elevated screening PSA u Has symptoms of prostate enlargement, but intern afraid to do exam u Intern concerned about telling the patient he has cancer

Case 5 n Your Role: Urgent care attending n Learner: Intern n Case highlights: u 35 yo man with findings consistent with peritonsillar abscess u Previously treated with “antibiotics” u Intern not sure about the physical findings, and wants to switch to another antibiotic

Take Home Points n OMP/ESP/SNAPPS principles can be applied in diverse clinical encounters n Diagnose the learner: u Probe understanding and thought process n Teach general principles: u “fill in the blanks” in knowledge u Provide information that can be applied in other situations n Give and ask for feedback with EACH encounter n Promote self directed learning

Research: OMP n Clinical teachers using OMP u Equally or better able to diagnose patient u Better able to diagnose learner u More confident in their ability to diagnose u Rate it as more effective & efficient n More likely to teach about illness focusing on a broader DDX, diagnostic tests, and the natural presentation of disease.

Research: OMP n Learners u rate OMP-trained residents higher on getting a commitment, feedback, motivating learners u Not higher on overall teaching effectiveness u Prefer the OMP and learning about natural presentation of disease

Research: ESP n Faculty using more ESP behaviors receive better ratings of teaching effectiveness n More use of ESP behaviors does not significantly increase duration of precepting sessions n Number of steps preclude faculty from using it fully

Research: SNAPPS Learners n select their own learning issues/needs n appreciate being allowed to question teacher n easy to learn Clinical Teachers n students generate questions relevant to the case and learners’ knowledge n direct their teaching to students' self- identified learning needs

Research: SNAPPS Clinical teachers must n guide interaction n assume role of expert facilitator Critical to orient faculty to its steps and encourage students to use the model

Questions?

Part II: Challenging Situations and Challenging Learners n Many clinical experiences don’t fit into the “brief clinical encounter” model u However, these moments contain some of the most valuable lessons n Not every learner is “teachable” u But these students have even more to learn! n Let’s brainstorm on examples of each, from your experiences

Small Group Exercise n Challenging clinical scenario u What challenges to teaching/learning do you see? u What are the learning opportunities u What techniques can you teach in this scenario? n See handout for each case for discussion questions

Large Group Discussion n Each group will: u summarize (briefly) what made your setting/learner “challenging” u what did you come up with to teach despite these challenges?

Scenario 1: Busy Service n Your role: Inpatient attending n Learner(s): R3, R1, MS4 n Challenge(s): u Team seems stressed u Workload is high u They “divide and conquer” u “No time to teach”

Scenario 2: Code Blue n Your role: Outpatient peds attending n Learner(s): R3, MS3, intern, nurse n Challenge(s): u Code blue/critically ill child u Med student overwhelmed u Senior resident stressed u Nurse yelling to “do something”

Scenario 3: Disinterested Student n Your role: Clerkship director n Learner(s): MS3 (+team) n Challenge(s): u Learner has other priorities u Seems disinterested/unmotivated u Alienates the rest of the team u Bright, but thinks he know more than he does

Scenario 4: Checked-out Senior n Your role: Inpatient attending n Learner(s): Senior resident (+ team) n Challenge(s): u Senior resident’s performance has fallen off u Team has given up on her u Does the minimum needed u Described as “cynical” and “burnt out”

Scenario 5: Overeager Learner n Your role: Outpatient clinic attending n Learner(s): MS3 (+ team) n Challenge(s): u Too eager, annoys her colleagues u Missing some basic skills in history/presentations u Highly motivated u History of academic difficulties

Conclusion n Review of key points n We will provide you with a summary of the teaching tips/techniques n Please make sure we have your correct address and contact information! n Complete the action plan to take with you

References Aagaard EA, Teherani A, Irby DM The effectiveness of the one minute preceptor model for diagnosing the patient and the learner. Acad Med 79:42–49. Furney S, Orsini A, Orsetti K, Stern D, Gruppen L, Irby DM Teaching the one-minute preceptor: a randomized controlled trial. J Gene Inter Med 16:620–624. Irby DM, Aagaard EA, Teherani A Teaching points identified by preceptors observing one minute preceptor and traditional preceptor encounters. Acad Med 79:50–55. Neher JO, Gordon KC, Meyer B, Stevens N A five-step ‘microskills’ model of clinical teaching. J Am Board of Family Practice 5:419–424. O’Malley PG, Kroenke K, Ritter J, Dy N, Pangaro L What learners and teachers value most in ambulatory educational encounters: a prospective, qualitative study. Acad Med 74:186–191. Ottolini et al Student Perceptions of Effectiveness of the Eight Step Preceptor (ESP) Model in the Ambulatory Setting. Teach Learn Med 22: Salerno SM, O’Malley PG, Pangaro LN, Wheeler GA, Moores LK, Jackson JL Faculty development seminars based on the one minute preceptor improve feedback in the ambulatory setting. J Gene Int Med 17:779–787. Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008; 83: Teherani A, O’Sullivan P, Aagaard EA, Morrison EH, Irby DM Student perceptions of the One- Minute Preceptor and Traditional Preceptor Models. Med Teach: 29: Wolpaw TM, Wolpaw DR, Papp KK SNAPPS: a learner-centered model for outpatient education. Acad Med 78:893–8. Wolpaw T, Papp KK, Bordage G. Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: A randomized comparison group trial. Acad Med 2009; 84: