1. “To study the phenomena of disease without books is to said an uncharted sea. To study books without patients is not to go to sea at all.” Sir William Osler

2. Why is it Hard?  Patient care is top priority  Patient is another actor  Hard to predict what he/she will do or say  Sometimes the learners say some crazy things…  Once it’s said, it’s said  It’s hard to be patient  You want the patient to trust the team  You want clear communication

3. Why is it Important?  Learners need to learn  It’s hard for learners to pay attention if they are only watching you work  It is more efficient to teach in front of the patient  The patient learns too  In front of the patient is the real deal

4. The Ethics of Teaching with a Patient  http://jama.ama- assn.org/cgi/content/full/291/1/119 http://jama.ama- assn.org/cgi/content/full/291/1/119

5. Discuss with a neighbor…how do you handle the ethics of teaching and learning using patients?

6. Setting the Stage…with the Learners  State clear expectations  Be specific about your wishes and your pet peeves  Claim your role  You will correct, educate, and add depth in front of the patient for the benefit of both the patient and the learner  This doesn’t mean the learner is not doing a good job – this is your role

7. Set the Stage…with the Patients  Make it part of the culture to teach  Assure the patient understands the roles and who is who  Use the words teaching and learning in conversation with the patients  Be clear about who is in charge  Try to have the learner do the introductions  Always make sure the senior and the attending are introduced clearly

8. What will you say to state your expectations to your learners, and to your patients ?

9. Ground Rules for Teaching in front of the Patient  Try to support the learner  But don’t agree if you don’t  If you are responsible for the patient at any level, say something  Student presents, intern and resident comment, attending closes  Keep patient care the priority  Take over if you have to

10. Words that Might Help  “There are lots of ways to do it right. Another way is…”  “It’s good you are more conservative in your approach than I am because you are less experienced, I think we can go on and…”  “One thing you probably don’t yet know is…”  “That would be ok if...but here we have to…because….”

11. Words that Might Help  “We frequently gain more details of the history after the family has time to think about things.”  “I’m sorry to interrupt but I’d like to correct one thing…”  “You know, this is very complicated. I will come back and discuss this in more detail. What we need to do now is…”

12. Words that Might Help  “That is a good start. Dr. ________, what do you think?”  “It looks like you did your reading on Mr. _____ ‘s condition. Great! Experience also teaches us that…”  To the patient, “How did she do?”

13. Ideas to Encourage Teaching in Front of the Patient  Have the learner with you  Round in the room  Explain to the patient, but assure that the learner is listening  Activated Observation  Set expectations beforehand  Ask questions after  Show the patient the film  Ask the patient to teach  Can you teach the medical student about your condition?

14. Tips  Let the most junior learner directly involved enter the room first and speak first  Limit jargon  Balance demonstration with observation  Demonstration is when the teacher does  Observation is when the learner does

15. Teaching Physical Exam  Teach the patient while demonstrating to the learner  “I can feel your liver right here.”  “I’m checking for an effusion in your joints.”  Allow the learner one piece at a time  “I want Dr. _____ to learn how to do this too. Can she check also?”  Direct the learner to what they should find  “Listen to that diastolic murmur at the apex”  Instruct the learner in front of the patient to return for more PE

16. Teaching Physical Exam  Stress the importance of observation of the patient  Everyone can do that at the same time  Ex: Rashes, Respiratory Effort, Color, Tone, etc.  Make your learners expect questions about what they saw after you leave the room  Thank the patient “for being a teacher”  Don’t dwell too long

17. Write down one technique you will try to use

19. Difficulties in Teaching Procedures  The learner is nervous  The teacher is nervous  The patient is nervous  Sometimes the procedure is urgent  The teacher might not know exactly what to do  Time pressures  Pressure to get the procedure done right

20. Steps in Teaching a Procedure  Demonstrate the procedure  This may be done by another teacher  Talk through step by step  This is typically done away from the patient  Let the learner rehearse or teach back  Practice with supervision

21. First Steps  Know how to do the procedure  Use resources as necessary  Central line placement  http://content.nejm.org/cgi/video/356/21/e21/ http://content.nejm.org/cgi/video/356/21/e21/  Umbilical line placement  http://content.nejm.org/cgi/video/359/15/e18/ http://content.nejm.org/cgi/video/359/15/e18/  PE findings  http://content.nejm.org/cgi/content/full/360/18/e24/D C1 http://content.nejm.org/cgi/content/full/360/18/e24/D C1

22. Getting Consent  Take the learner with you  The person actually doing the procedure should have been present for the consent, or should repeat the process  Be truthful in obtaining consent  You can describe the work of the team  How do you respond to “Have you ever done this before?”

23. Teaching Procedures at the Bedside  The teacher must be very actively observing  Assure appropriate set up  Assure appropriate technique  The teacher should talk to the patient about what is happening, but the learner should be listening  The more senior person is (should be) calmer  The talking is just as much for the learner  The learner can focus on the procedure if the teacher secures the communication

24. Practice  Write out the steps to a procedure  Laceration repair  Intubation  Placement of a line  Arterial stick  Lumbar puncture  Splint placement  Others  Teach it to a peer

25. Conclusions  We need to teach with and in front of patients for learners to learn  Set the culture to support that teaching  Have the learner with you  Set the expectations with patients and learners  Practice words and tips to make it easier

26. Sir William Osler