1. How Do We Teach Residents To Teach? University of Missouri Family and Community Medicine Peter Koopman, MD Betsy Garrett, MD MSPH Amanda Swenson, MD MSPH

2. Outline for Today Review the literature regarding residents as teachers Discuss PEP curriculum history and how it informs our workshop Outline the components of our teaching skills workshop Seek your input regarding strategies to improve residents’ teaching skills.

3. Residents as Teachers: Findings From Literature Review Residents serve as medical students’ primary teachers for practical clinical skills 1/3 of a medical student’s fund of knowledge is directly attributable to residents 20% of a resident’s time is spent on teaching activities

4. Residents as Teachers: Findings From Literature Review Teaching leads to better knowledge acquisition for the teacher than do self- study or lecture attendance Other research reveals that residents’ job satisfaction is augmented by teaching duties

5. Findings From Literature Review Systematic review results demonstrated that residents-as-teachers curricula can significantly improve residents’ teaching skills. Post RE. Quattlebaum RG. Benich JJ. Residents-as-teachers curricula: a critical overview. Academic Medicine. 84(3):374-80, 2009 Mar.

6. Residents as Teachers: Findings From Literature Review Systematic review found the most effective techniques: 3 and 1/2 hours or longer Included periodic reinforcement Emphasized the One Minute Preceptor Post RE. Quattlebaum RG. Benich JJ. Residents-as-teachers curricula: a critical overview. Academic Medicine. 84(3):374-80, 2009 Mar.

7. Baltimore courtesy of NASA

8. PEP2: Preceptor Education Project 2 nd edition Initially a joint project between the AAFP and STFM Target audience: Busy community preceptors who work with third year clerkship students in their office Covers broad range of core teaching topics Both efforts chaired by Kent Sheets

9. PEP2: Preceptor Education Project 2 nd edition Initial pilot testing and subsequent evals showed very positively received Meant to be a self- contained faculty development program Facilitator’s Guide very complete- even down to text, strategies, range of times possible, role plays, trigger videos, etc.

10. PEP2 Applications Small and large groups (6-60) Very interactive Can be used with multiple specialties and multiple disciplines (NP, PA, dentists, etc.) Has been very well received by residents from variety of specialties Useful for faculty as well Can do as stand alone one hour session or full day with CME or some other format Can package modules in variety of ways Participant Workbook can be stand alone: A Guide For Teaching in Your Practice available at STFM bookstore ($25 each)

11. Our Workshop-History Launched in 1999 Two 3.5-hour workshops in July Initially only Family Medicine PGY2s Evolved to involve other specialty senior residents Has ranged from 15 to 45 participants

12. Our Workshop-Structure Family Medicine faculty present-has varied from 1-3 faculty Modules and organization originally drawn from PEP curriculum and have been modified based on participant feedback and faculty experience

13. Our Workshop-Structure Uses varied teaching strategies each day such as didactic presentation, trigger video, role play, small group breakouts with debrief. Stresses audience participation.

15. Our Workshop Evaluation Evaluation data collected over 14 years from 228 participants indicate all sections of workshop positively received with >4 rating on a 5 point scale Feedback and One Minute Preceptor consistently highest rated over 12 years

16. Our Workshop Evaluation This question asked of participants since 2004. First 5 years and 50 participants this question not asked.

17. Our Workshop Comments “I really enjoyed the course. Practical, useful, real world. Useful for many settings. I felt motivated and empowered to improve teaching and feedback.” “This is an essential role- which is also part of my job-it’s good to be shown how important it is.”

18. Our Workshop Comments “One overall dedicated time to actually discuss the process of learning and teaching was very useful.” “Maybe one in 75 physicians I’ve worked with has been a good preceptor and able to provide good feedback. Physicians need to learn these skills.”

19. Our Workshop-Structure Day 1- 3.5 Hours Welcome and Opening Debrief- 20 minutes Organization and Planning- 20 minutes Observation- 65 minutes Break-15 minutes Assessment- 35 minutes Teaching- 45 minutes Eliciting 2 nd day Small Group Topics for Peer Consultation-10 minutes

20. Our Workshop-Structure Day 2- 3.5 Hours Feedback- 75 minutes Break- 15 minutes Handling Problems- 45 minutes Evaluation- 25 minutes Small Group Peer Consultations- 20 minutes each x 2 Wrap Up- 10 minutes

21. Day 1-Welcome/Opening Debrief Think-Pair-Share on most influential teacher characteristics with debrief Self define roles as teachers Summary and timeline and expectations Discussion of PEP notebooks Introductions

22. Day 1- Organization And Planning PEP2 module 2 Preventative approach-plan ahead Stresses first day/good beginnings Expectations clearly defined Progressive learning model Pearls for effective precepting

23. Day 1-Observation PEP2 module 3 Small groups to list 7 most important learning objectives from differing perspectives-M3, intern, teacher of M3, teacher of interns Which objectives are best assessed from observation

24. Day 1-Observation Discussion of mechanics, benefits and barriers to observation Choose specifics to observe, human video camera, Sherlock Holmes Film vignette of attending/student interaction to observe and discuss

25. Day 1-Assessment PEP2 Module 4 Importance (Assess is to teach as diagnosis is to treat) Discussion of learning theories:  Adult Learner  The 4 box model  Inverted U Stress Curve  The Learning Vector

26. Day 1-Assessment Scripted role play of several precepting styles highlighting One Minute Preceptor-5 microskills model.

27. Day 1-Teaching PEP2 Module 5 Challenge and support Promote active learning Teacher’s roles and choices Self-reflection exercise including what they role model You can’t not teach, You can’t not role model

28. Day 1 Peer Group Topics Elicit consensus topics for peer consultation group discussions at end of day 2 “What are your biggest challenges as a teacher?”

30. Day 2-Feedback PEP 2 module 6 Their roles in giving and receiving feedback Johari Window 3 level model of feedback 3 role plays for entire group (Observer, Teacher, Learner)

31. Day 2-Handling Problems PEP2 Module 8 Teaches preventative approach Problem assessment and response algorithm (? knowledge,? skill, ?behavior)

32. Day 2-Evaluation PEP2 Module 7 Definition and role of evaluation Discuss specifics of MU evaluation system

33. Day 2-Peer Consultation Groups Topics elicited on day 1 grouped into 4 topic groups Participants chose two topic groups and had peer discussions for 20 minutes and reported out.

34. Day 2-Peer Consultation Groups Managing your teacher role. Dealing with many learners on inpatient team, Juggling different roles and responsibilities, Time management. Teaching Challenges Teaching a topic you are uncomfortable with, Maintaining patient trust with a student, Teaching in front of patient.

35. Day 2-Peer Consultation Groups Learner centered Teaching Dealing with a student with lack of interest, Encouraging questions from learner, Eliciting topics of interest from learner that are real to them. Difficult Teaching Situations Dealing with conflicts in information from different teachers, Providing feedback which is critical.

36. A brief demonstration Feedback is often seen as one of most valuable modules Very interactive- 3 role plays done so all do each role Uses 3 levels of feedback model Will briefly review levels, have a role play modeled and all of you will have a role as well!!

37. Levels of Feedback A choice can be made as to the level of feedback provided. The recipient will have an easier time accepting the lower levels.

38. 3 Levels of Feedback Level I: What you saw the learner do (acting as a human videocamera) Level 2: Your personal reaction (not judgment) Level 3: Your prediction of the likely outcome of the behavior

39. Level 1 What you observed the person do (acting as a human video camera with no interpretation) Tennis lesson A compass Easiest to hear and easiest to act on.

40. Level 2 Your personal reaction (not judgment) My piano teacher “I statements”

41. Level 3 Your prediction of likely outcome of this behavior Judgment based on your experience (My attending)

42. Advantages of each level Level 2- Provides the person with information they would not have otherwise and ideally helps build the relationship Level 3- Allows the person to consider the consequences of their actions that they may not have otherwise Level 1- Easiest to hear and to act on

43. Logistics for each Role play Resident will give feedback- try to use all 3 levels. You will be told when to stop. Next- Observer (s) will give feedback to resident (content and process observers) Vignettes at each table, 1 minute to read, 2-3 minutes for role play, 2 minutes observer feedback, then large group debrief

44. Dress Rehearsal # 1 (lavender) Resident- senior on call that night Intern- saw a patient in ER and senior resident then also saw Observer(s)- content and process (all of you!) The patient has left the ER and the resident is sitting down with the intern to give him/her feedback (each role has a particular frame of reference and details)

45. Debrief What worked well here? Where did you have difficulties? Residents- What choices did you make ? Feedback is often about choice, timing, context- too often it can also be about assumptions Have the person self-assess first**

46. Let’s Hear from You!

47. No bubble is so iridescent or floats longer than that blown by a successful teacher -Sir William Osler