1. Teaching 101: A Workshop for New Teachers Mark Robinson PGY2 MD MSc BEd Colin Newman MD CCFP Risa Bordman MD CCFP FCFP

2. Introductions What is your experience with teaching? Why did you start teaching? What are your expectations for the workshop?

3. Overview Before the Student Arrives – What makes a good teacher? – Today’s medical learner – Triple C and other acronyms – How to prepare your office After the Student Arrives – Student-Patient Encounter – Giving Feedback – Challenges – Case discussion – Resources and SOT – Time Management

4. Why Teach?

5. “In a completely rational society, the best of us would aspire to be teachers and the rest of us would settle for something less, because passing civilization along from one generation to the next ought to be the highest honor and highest responsibility anyone could have.” Lee Iacocca

6. Attributes of a Good Teacher Reflect on the teachers you found most effective What made them good teachers?

7. What does the literature say? Sutkin G et al. What makes a good clinical teacher in medicine? A review of the literature. Academic Medicine. 2008;5:452-466 Qualitative analysis of literature: 68 articles of 4914 1909-2006

8. Teacher Physician Human

9. Physician characteristics: Demonstrates medical/clinical knowledge (30) Demonstrates clinical & technical skills, clinical reasoning (28) Shows enthusiasm for medicine (19) Models a close doctor-patient relationship (10) Exhibits professionalism (8) Is scholarly (6) Accepts uncertainty in medicine (1)

10. Teacher characteristics: Maintains positive relationships with students & a supportive learning environment (27) Demonstrates enthusiasm for teaching (18) Is accessible/available for teaching (16) Provides effective explanations, answers to questions & demonstrations (16) Provides feedback (15) Organized (14) Stimulates trainees reflective practice and assessment (4)

11. Human characteristics Communication skills (21) Acts as a role model (15) Is an enthusiastic person in general (14) Is personable (12) Is compassionate/empathic (11) Respects others (11) Has self-insight, self-knowledge and is reflective (2)

12. Attributes of a Good Teacher from Paukert and Richards, 2000 1.Teaching (good teacher, taught well) 2.Topics Taught (skills, Hx, PE) 3.Commitment to Teaching (interest, effort) 4.Role Model 5.Caring (treats students well) 8.Global (enjoyable, good person, …) 9.Supportive and Helpful Person 13. Knowledge of Medicine, well read

13. Attributes of a Good Teacher from Dr. David Irby Enthusiasm Clarity and Organization Clinical Competence Modeling Professional Characteristics Group Instructional Skill Clinical Supervision Breadth of Medical Knowledge

14. Attributes of a Bad Teacher Mainly Lacks Instructional Skills – Including limited knowledge, poor communication Also has Negative Personal Attributes – Arrogance – Apparent dislike of teaching – Inaccessible – Lack of self-confidence – Unorganized boring presentations – Dogmatic – Insensitive – Belittling

15. Fears & Anxiety about Teaching?

16. What makes us anxious? Not knowing an answer? Fear of being shown up by a resident? Fear of being out of date? Self-identity issues? Fear of residents/students not valuing our teaching/skills/patients/core values? (SECRET: Residents are anxious too!)

17. So how do you get better (and conquer anxiety)?

18. Role model desirable behaviour Leadership Communication Professionalism Clinical Skills

19. Learn to be a good teacher Gain knowledge/skills in teaching by: Reading & on-line modules Attending Faculty Development sessions Taking courses Master’s degrees Deliberate & reflective practice

20. Plan your execution Show enthusiasm for teaching by: Take interest in your learner Provide supportive environment Align your staff Space for learner? Help your learner improve/accomplish! Feedback

21. Today’s Medical Learner Coming from an increasingly diverse background: Older student average age entry 24 years 21

22. Today’s Medical Learner Coming from an increasingly diverse background: Older student average age entry 24 years More educated Only 7% had not completed a bachelor’s degree (>20% with graduate degree) More visible minorities than Canadian population Black/Aboriginal underrepresented (1.3% vs. 8.1% in Canada, 2007) Chinese/South Asian overrepresented (16.5% vs. 8.7% in Canada, 2007) CMAJ Apr 16,2002;166(8):1023-1028 Effects of rising tuition fees on medical class composition and financial outlook CMAJ Apr 16,2002;166(8):1029-1035 Characteristics of first-year students in Canadian medical schools Medical Education 2010; 44: 577 – 586 Increasing tuition fees in a country with two different models of medical education 2011 Canadian Medical Education Statistics Volume 33 22

23. Today’s Medical Learner More worried about financial situation >85% report they will graduate with debt 2011 Canadian Medical Education Statistics Volume 33 23

24. Today’s Medical Learner More worried about financial situation >85% report they will graduate with debt Pro-technology Familiar with online resources and “The Paperless Office” Comfortable with small-group learning Becoming more integrated into medical school curricula Exposed to Adult Models of Learning Moving from pedagogy to andragogy 24

25. An Adult Learner Moves from dependence to independence, self-directed Controls nature, timing, and direction or process = greater efficiency Builds upon past knowledge and experiences Biases can facilitate or hinder learning Motivation often based upon performance and relevance Identifies own knowledge gaps through situations Wants to learn in “real-time” for instant application Needs respect Acknowledge their past experience, they’re not “kids” 25

26. Typical Medical Learner Resources The Smart Phone (not just for texting anymore) a.k.a. their “iBrain” Many excellent applications for quick reference: Epocrates, UpToDate, Micromedex, LU codes, Eponyms… Internet searches: Google, PubMed Hardcopy Resources Rx Files (Cdn drug guide) Anti-infective Guidelines for Community-acquired Infections Toronto Notes 26

27. What Residents Need… (how you help) 1. Completion of Approved Resident Training Program 2. Completion of CCFP exam (two components) CCFP written component Clinical skills component (LMCC-Part II + CCFP oral exam) 27

28. What Residents Need… (how you help) CFPC (2013) requires resident programs to attest that: 28 Pt-centred Communication Clinical Reasoning Selectivity Professionalism Procedural Skill History Physical Investigations Diagnosis Management Referral Follow-up

29. 29

30. Where the Preceptor comes in Frequent, timely feedback. Field Notes qualitative, “daily” feedback – leads to reflection. Not for making final judgments but directing self-learning. Evaluations: In-Training Evaluation Reports (ITERs) (usually monthly) A rubric check-list of CanMEDS-roles and “level of training” HONESTY Final In-Training Evaluation Reports (FITERs) End of residency 30

31. Preparation and Planning Preparing yourself Preparing the setting Preparing the staff Preparing the patients Preparing the student 31

32. Before the Student Arrives Communication (student, staff) – How can staff help overcome patient reluctance? Schedule time for orientation Possibly modify bookings? Organize room space – Space for student Plan for down time

33. When the Student Arrives Expectations (student and doctor) Student’s prior experience – Learning plan/contract What student will/won’t see Patients may set limits or decline – Can this be overcome? Inform re schedule (start times, lunch, etc.) Discuss out of office involvement EMR 101 – How charts are organized, where to find things SOAP, Cumulative Patient Profiles.

34. When the Patient Arrives Review chart with student Decide if you will see the patient together, or student first (Hx and/or PE) Notify patient of student – Who? When? Set appropriate time limit for student’s interview

35. Effective Teaching –Key Components Get to know your learner Teach to the learner’s needs Set clear and realistic expectations Set the stage for feedback and evaluation Create a positive learning environment Gradual increase in autonomy See one, do one, teach one?

36. Learners benefit most from experiential, case-based learning and subsequent discussion of cases Bowen JL, Irby DM. Assessing Quality and Costs of Education in the Ambulatory Setting: A Review of the Literature. Acad Med. July 2002 Vol. 77 No. 7 621-680

37. Effective Teaching – Key Components Actively involve your learner – they learn more! Select appropriate patients Encourage synthesis of case as much as possible for level of training Use a variety of teaching methods, eg. focus on a theme, teach in the patient’s presence, reflective modeling, One- Minute Preceptor

38. Effective Teaching – Key Components Take advantage of all learning opportunities Direct observation “Fly on the wall” Case Discussion/Chart Review Read around Cases Bring the student in for important learning ops Physical findings, forms, counselling etc. Mini-talks to patients Chol, smoking, weight, immunizations Others can help teach Nurse, secretary, pharmacist, patient etc.

39. The One-Minute Preceptor Five micro-skills 1. Get a commitment 2. Probe for supporting evidence 3. Teach general rules and principles 4. Reinforce what was done right 5. Correct any mistakes Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching J Am Board Fam Pract 1992; 5:419-24

40. 1. Get a commitment Ask a question about one aspect of the case: diagnosis, investigation, or treatment Push the trainee out of their comfort zone “What is the most likely diagnosis? Other diagnoses?” “What lab tests do you want to order?” “Do you want to hospitalize this patient?”

41. 2. Probe for supporting evidence Resist the temptation to give your opinion Try to understand the trainee’s clinical reasoning (did they simply guess?) “Why do you think this is the most likely diagnosis?” “Why do you want to prescribe this medication?” “Why do you want to hospitalize this patient?”

42. 3. Teach general rules and principles Teach one practice pearl or summarize an important point Offer advice on information search strategies or practice management “When prescribing antibiotics I find this resource helpful.” “These are the criteria for hospitalization in patients with pneumonia.”

43. 4. Reinforce the positive Skills that are not yet well-established need to be reinforced so that they are integrated into the next clinical encounter Be precise “Your diagnosis of “probable pneumonia” was well- supported by your history and physical exam.” “You did well because …” “good work!” does not help the learner improve

44. 5. Correct mistakes Limit your negative comments to one or two Offer suggestions of how to do better next time “I agree that we will need to order PFTs later on, but the patient is too sick at present. For now we need his peak flow and his oxygen saturation.” “You mentioned that the child has fever but you did not objectify it or mention if he looks toxic”

45. Case 1

46. The One-Minute Preceptor Five micro-skills 1. Get a commitment 2. Probe for supporting evidence 3. Teach general rules and principles 4. Reinforce what was done right 5. Correct any mistakes Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching J Am Board Fam Pract 1992; 5:419-24

47. Evaluating and Reflecting on Teaching Encourage learners to complete evaluation forms Ask for informal feedback from the trainee, and role model the ability to respond to critique from others Seek the advice of colleagues Use opportunities like this workshop to reflect on your teaching

48. Effective Teaching – Key Components Give specific feedback LABEL IT In an open and non-threatening atmosphere Based on observation of performance Geared to learner’s level of training Positive as well as negative comments Offer suggestions for improvement Ask for self-reflection from learner

49. FEEDBACK-Formative Describes what the learner is doing in an encounter, and relays that information back Used by the learner to make adjustments Occurs frequently Is tracked using Formative assessment tools, direct observation, checklists, field notes, simulation The qualitative and quantitative data that feeds into a summative assessment process

50. FEEDBACK-Summative Summary of a sufficient collection of formative assessments – Multiple: sources, observers, occasions, tools – Qualitative and quantitative. Matched to goals, objectives and stage of learner Used to: – refine goals to reflect the learner’s mastery – to determine areas in need of remediation

51. Giving Feedback Berguist, Phillips, Pfeiffer, Jones Solicited Well Timed Descriptive Evaluative Concerns what is said/done (not why) Focus on Behaviour that can be changed Limit the amount of information presented

52. Giving Feedback Cont., Phillips, Pfeiffer, Jones Involves sharing of information Need to verify Avoid collusion Watch the consequences

53. Same Case Different Resident

54. The One-Minute Preceptor Five micro-skills 1. Get a commitment 2. Probe for supporting evidence 3. Teach general rules and principles 4. Reinforce what was done right 5. Correct any mistakes Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching J Am Board Fam Pract 1992; 5:419-24

55. Student In Difficulty Call your Program Director Steinert/Levitt: Working with the "problem" resident: Guidelines for definition and intervention. Fam Med 1993 Nov-Dec;25(10):627-32. – What is the learner’s problem? Knowledge, Skills, Attitude – What are the contributing factors? Teacher, system – What is the potential impact problem?

56. The Different Student Bordage/Shafir Reduced – Knowledge, culture, depression Dispersed – Poor judgment Elaborative – Reality – Set limits

57. The Different Student Cont. Bordage/Shafir Compiled/Expert – Look for red flags – Appropriate questions Risky to skip steps!

58. Section of Teachers La Section des Enseignants Section of Teachers – Resources for Teachers – Networking for Teachers

59. The mission of the Section of Teachers is to promote education within the discipline of family medicine

60. Objectives a) To advance the discipline of family medicine within the objectives and strategic plan of The College of Family Physicians of Canada. b) To coordinate and facilitate communications related to the undergraduate and postgraduate education, curriculum, and accreditation issues and activities of the College of Family Physicians of Canada

61. 2013-2014 Slate of Officers

62. Activities Family Medicine Education Forum Family Medicine Forum – faculty development sessions CFP “Teaching Moment” Annual Dinner Ian McWhinney Family Medicine Education Award Program Groups

63. Benefits of Membership Teachers page in Canadian Family Physician (CFP) Faculty Development Resources Reduced Subscription Rate to Educational Journals Opportunity to have significant input to the educational issues facing teachers in the College through the Section of Teachers Executive

64. Resources: Faculty Development Sites CFPC Triple C Toolkit http://www.cfpc.ca/TripleCToolkit/ Provincial Faculty Development Resource http://www.r-scope.ca/websitepublisher/ Institutional websites http://med.ubc.ca/faculty-staff/faculty-development/

65. Resources: Faculty Development Modules -Common topics in clinical teaching (feedback, evaluation, time efficient teaching, learner in difficulty etc etc) -Packages of printed modules + facilitator guide -Designed for use in small groups of teachers – including inter/intra professional groups -No content expertise required -Particularly helpful for clinical teachers remote from traditional fac dev offerings -Similar format to modules used in the PBSGL program, but a separate organization http://fhs.mcmaster.ca/facdev/pbsg-ed.html

66. Resources: Accredited Online Modules Practical Prof: http://www.practicaldoc.ca/teaching/practical-prof/http://www.practicaldoc.ca/teaching/practical-prof/ STFM: http://www.stfm.org Teaching Physicianhttp://www.stfm.org This Changed My Practice – Teaching: http://thischangedmypractice.comhttp://thischangedmypractice.com AFMC: http://www.afmc.cahttp://www.afmc.ca

67. Resources: Non-Accredited Online Info Institutional blogs Newsletters YouTube videos (ex. Pearls and Pitfalls for Preceptors - 3P)

68. A few readings… Ferenchick et al. Strategies for efficient and effective teaching in the ambulatory care setting. Academic Medicine 1997;72:277-280. Irby et al. Time efficient strategies for learning and performance. Clinical Teacher 2004;1(1):24-28. Neher et al. A five-step microskills model of clinical teaching. Journal of the American Board of Family Practice 1992;5:419-424. Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med 1999;74(11): 1203-1207. Usatine et al. Time efficient preceptors in ambulatory care. Acad Med 2000;75:639-642. Wolpaw et al. SNAPPS: a learner-centred Model for outpatient education. Acad Med 2003;78(9):893-898. Medical Teaching in Ambulatory Care-A Practical Guide Rubenstein W/Talbot Y 2013

69. Time Management Teaching takes time – Estimate 1 minute to 8 minutes more Amount time inversely related to level of student – Where to put it? Most community-based teachers do not reduce pt. bookings More booking time, breaks, end of day – Address priorities – Homework Teaching saves time – Two patients seen at once – Charting – Students help with educational “chores”

70. Conclusions Good teachers are knowledgeable, have a positive attitude and the skills to teach Prepare your office to accept a student Give the student lots of feedback Ask for help when faced with the challenging student Be honest Have fun!