1. Teaching in the Clinical Setting
Professional Development Series
October 20, 2011

2. Professional development interests identified in the Faculty Development Committee survey
Teaching methods/evaluations
Time management
Stress management
Negotiation skills
Communication skills
Resources for grant writing
Work/life balance
Supervisory/Management skills

3. Clinical Teaching Workshop
Purpose: Improving capacity for clinical faculty to find and take advantage of “teaching moments” with students, residents and fellows in direct patient settings.
Outcome: Best practices for teaching in clinical settings despite the barriers

4. Workshop Agenda 7:30 Welcome and video, Dr. Ellen Hartenbach
7: What gets in the way of teaching in clinical settings? Dr. Laura Sabo
8:00 Table conversations. Facilitator Darrin Harris
What works well (best practices) for teaching in the clinical setting?
Facilitated Discussion of Assembled Group: collection of best practices
8:45 Teaching Modules: 1 Min Preceptor: Dr. Mary Landry
BID model: Dr. Steve Rose
9:20 Discussion of ongoing learning and application: Dr. Ellen Hartenbach
9:45 Closing remarks, Dr. Ellen Hartenbach
Next Professional Development Series:
Feedback & Evaluation, Feb. 16, 7-9 AM

5. How not to teach….

6. How can each one of us improve our teaching in the clinical setting?
Reflect on our experience- what techniques did or favorite educators/mentors utilize
Review our feedback- how do the learners rate our teaching performance
Peer mentoring- listen to colleagues/award winning teachers in the department
Ask the experts- review the literature
Make a plan to try new approaches- make a commitment to improve

7. Madison, Wisconsin
And in our beuatiful city of madison…..

8. What gets in the way of teaching in clinical settings? Dr. Laura Sabo

9. Teaching Challenges Time Schedule issues
Adapting to varying levels of learner knowledge, skill and/or quality
Not certain of expectations
Difficulty relaying constructive criticism
Don’t feel skilled in teaching
This comes from survey done prior to last year’s education conference and a faculy meeting when asked to put number one teaching challenge on a note card. Overwhelming issue was time realted

10. Teaching Challenges Time Schedule issues
Adapting to varying levels of learner knowledge, skill and/or quality
Not certain of expectations
Difficulty relaying constructive criticism
Don’t feel skilled in teaching
This comes from survey done prior to last year’s education conference and a faculy meeting when asked to put number one teaching challenge on a note card. Overwhelming issue was time realted

12. The One Minute Preceptor Model- Dr. Mary Landry
10 Minutes of “Teaching Time”... (average for teaching encounter in the clinical setting)
3 Minutes (clarifying preceptor questions)
Questioning
The One Minute Preceptor teaching model was developed at the Department of Family Medicine at the University of Washington years ago, and it has been used in a variety of settings with a variety of learners.
Is the “One Minute Preceptor” model going to help you do all your precepting in one minute? No.
Studies have shown that the average teaching encounter takes 10 minutes:
6 minutes for the learner to present.
3 minutes for the preceptor to ask questions and clarify information.
This leaves 1 minutes of discussion and teaching time.
The One Minute Preceptor strategy still takes longer than a minute. But it provides a structure to the encounter that helps you maximize the amount of time for teaching.
Discussion
1 Minute (actual teaching time)
Presentation
6 Minutes (learner presentation)
Neher et al, J Am Board of Fam Prac, 5, (1992)

13. The One Minute Preceptor Model 5 microskills
Get a Commitment:
Probe for Supporting Evidence:
Teach a General Rule:
Reinforce What Was Done Right: Feedback!
Correct mistakes: Feedback!
The “One Minute Preceptor” strategy is based on 5 steps that build on each other.

14. What commitment you ask for depends on what you are trying to teach…
Gathering info: Differential diagnosis
Secondary amenorrhea, pelvic pain, 3rd trimester elevated BP, IUGR
Processing info: Management decisions
Abnormal PAP, intrapartum non reassuring FHT’s, adnexal mass, intra-op bleeding
Providing care: How you do What you do
From an attending perspective- Performance
From a patient perspective- Quality of care

15. Get a Commitment Why? Examples...
Encourages learner to process further and problem solve.
Examples...
What is your differential? What would you bet $100 is the cause?
What is your plan? What would you like to do next?
How do you think that case went? Did the patient seem content with your assessment? Do you think the patient will follow your recommendations?
The first step is to get a “commitment” from the learner about what they thing is going on, what they think the plan should be, or how they think the case should be followed up.
This commitment helps invest the learner further in the case. And it helps you assess their problem-solving skills.
What you ask the learner to commit to depends on their level -- you want to encourage them to stretch beyond their current comfort level and problem solve.

16. Probe for Supporting Evidence
Why?…
Helps you to assess the learners knowledge and thinking process.
Examples...
“What factors did you consider?”
“Why other options?”
Step 2 is to probe the learner for supporting evidence of what they’ve just committed to -- explore the basis of their opinion. Was it a lucky guess, or was it a well-reasoned, logical answer?
This step gives you insight into their clinical reasoning skills.

17. Teach General Rules
Symptoms, treatment options, or resources to look information up
Why?… Allows learning to be more easily transferred to other situations.
Examples… “Remember, the false negative rate for PAP smear is 40%”
The next step is teaching a general principle.
One of the most important and challenging tasks for the learner is to take information from an individual situation and accurately generalize it to other situations.
This can be about how a symptom usually manifests, treatment options, what resources are available in your community -- or what references to look something up in.
This isn’t a major teaching session -- but 1or 2 statements can have a significant impact on the learner.

18. Reinforce What Was Done Right: Feedback!
Describe specific behaviors and likely outcomes
Why?... Behaviors that are reinforced will be more firmly established.
Example… “I liked that your differential took into account the patient’s age, recent exposures,
& symptoms.”
Starting with step 3, you can give the learner some feedback. Start with positive feedback, and reinforce what was done well.
Skills and positive behaviors need repeated reinforcement to become firmly established. With a few sentences, you increase the likelihood that these behaviors will be incorporated into further clinical encounters.
Describe specific actions the learner took (“good job” is too vague), and describe the likely outcomes of these actions.

19. Correct Mistakes: Feedback!
Describe what was wrong (be specific), what the consequence might be, and how to correct it for the future
Why?… Corrects mistakes and forms foundation for improvement.
Example… “During the pelvic exam
the patient seemed uncomfortable.
Let’s go over how to insert the speculum”
Last is correcting the learner’s mistakes or omissions.
Again, describe specific actions and potential negative outcomes. It’s important to also suggest ways the learner can improve. Think about your wording -- if you focus on actions and ways of changing, and avoid negative labels such as “bad” or “poor”, the learner is less likely to feel judged and more likely to see the criticism as constructive.
It’s important to notice and provide feedback to the learner on both the things they do well and the areas they need to work on.

20. Get a Commitment Why? Examples...
Encourages learner to process further and problem solve.
Examples...
What is your differential? What would you bet $100 is the cause?
What is your plan? What would you like to do next?
How do you think that case went? Did the patient seem content with your assessment? Do you think the patient will follow your recommendations?
The first step is to get a “commitment” from the learner about what they thing is going on, what they think the plan should be, or how they think the case should be followed up.
This commitment helps invest the learner further in the case. And it helps you assess their problem-solving skills.
What you ask the learner to commit to depends on their level -- you want to encourage them to stretch beyond their current comfort level and problem solve.

21. Recipe for a good teacher and judge of performance… Let them fly
Insight
Experience
Confidence
Closed sphincters (oral and anal)
Open coronaries

23. BID Surgical teaching model: Dr. Steve Rose
Brief
Intraoperative Teaching
Debrief
Roberts et al, J Am Coll Surg, 208 (2), 2009

24. Brief 2-3 minute interaction at scrub sink
jointly establish learning objective to guide both learner and teacher
attending surgeon asks about resident’s previous experience and goal for learning during the operation
Briefing
This is a short (2- to 3-minute) interaction at the scrub
sink. The purpose of the interaction is to assess the needs of
the learner, to cause the learner to assess her own learning
needs, and to jointly establish learning objectives to guide
both learner and teacher. Ideally, the learner establishes her
own objectives for the operation. The teaching surgeon
assists by prompting and guiding the formulation of the
objective.Having learners involved in setting the objectives
allows them to begin the process of deliberately identifying areas in which practice is needed, and deliberately reviewing
past experiences to formulate needs to be addressed in
the current operation. This process allows learners to integrate
the experience into their semantic networks,12 making
it more likely that the information can be retrieved
later.
The attending surgeon starts the conversation with a
brief question about goals for the operation or previous
experiences. Learning objectives can follow from this brief
needs assessment.
Example
“Tom, you’ve probably done 100 laparoscopic cholecystectomies.
What do you have left to learn in the performance
of this procedure?”
“I want to work on my efficiency. I end up having to
reposition the instrument in my left hand too often, so I
want to work on positioning of the fundus grasper.”
This briefing took place at the scrub sink, and took less
than 5 minutes to accomplish. By setting objectives at the
beginning of the operation, the preceptor served to focus
the attention of the learner, and also created a mechanism
to guide his own teaching during the operation.
Example- How many laparoscopic BSO’s have you done? What would you like to work on this time?

25. Intraoperative Teaching
Attending surgeon guides resident through operation with focus on the learning objective(s) set in the briefing
Teaching is not simply a nonspecific flow of talk, but instead, discussion focused on mutually shared learning objective(s)
Intraoperative teaching
The objectives set in the briefing focus the intraoperative
teaching. Although other standard forms of intraoperative
communication will still be present (ie, the
attending physician will still coach and guide the learner
through the operation), the focus of most of the didactic
talk will be on the one or two learning objectives set for
this operation. This ensures that the teaching is not
simply a nonspecific flow of talk, but instead, discussion
focused on mutually shared learning goals. Irby7 argued
that, over time, medical teachers develop teaching
scripts. The preceptor can still use teaching scripts, but
those scripts are manifest in the briefing session and in
the intraoperative teaching and are based on mutually
developed learning objectives.
Example
“Tom, can you talk me through your decision-making process
as you position your left hand? What will help you with
your goal of working on efficiency?”
“I need to choose a spot with the left-handed grasper to
be able to expose the triangle of Calot adequately, but still
be able to see the other areas for dissection.”
Later: “So how many times have you had to reposition
your left hand?”
“Only three times–that’s really good for me.”
“That’s great. What do you know now about how to do
the initial positioning?”
“It needs to be low enough to be able to expose the
triangle of Calot, but the positioning needs to allow me to
start dissecting the liver bed without moving it too many
times.”
Example- Walk me through your next step. How will you improve efficiency?

26. Debrief
After the operation is finished, during the closing, the teacher and learner debrief about the operation
Debriefing consists of four elements: reflection, rules, reinforcement, and correction
Debriefing begins with attending physician asking the learner to reflect on his or her performance and attainment of stated objective(s)
Debriefing
After the operation is finished, ideally during the closing,
the preceptor and the learner debrief about the encounter.
The debriefing consists of four elements: reflection, rules,
reinforcement, and correction. Because the debriefing is
focused specifically on the intraoperative teaching, which is
focused on objectives set at the beginning of the encounter,
it is short. In our example, debriefing the learner during the
closing took less than 5 minutes.
Debriefing begins with the attending physician asking
the learner to reflect on his or her performance and attainment
of stated objective. This allows the preceptor to understand
the perspective of the learner, and to diagnose any
problems the learner is having with his perception of the
encounter. Most importantly it requires the learner to assemble
his own thoughts about what was learned during
the encounter.
Example
“Tom, how do you think you did with your goal of positioning
your left hand appropriately?”
“I think I did well this time. Just focusing on it seemed to
help.”
“I agree. Your time to complete the case was very good,
which was, in part, because of your efficiency with
positioning.”
The learner should leave the encounter with some
rule to guide future practice. Ideally, it is a rule the
learner has formulated based on dialogue with the attending
physician.

27. Debrief
Example-
Teacher: “Were you able to improve your efficiency today?”
Learner: “I think I did pretty well by positioning quickly and deciding where to place ports ahead of time”
Teacher: “I agree, your efficiency improved with focus and planning. Make sure you place your ports in a strategic position and directly through the abdominal wall next time to improve your angle to the surgical site”

28. Great job Almost done with this workshop!

29. Educational Resources
Association of Professor’s of Gynecology and Obstetrics (APGO)
UW Health GME website
Association of American Medical Colleges (AAMC)
AAMC Med Ed Portal