1. Teaching Adult Learners Jacob Prunuske, MD, MSPH PCFDP October 15, 2010 Pictures have been removed from this presentation to ensure adherence to copyright law.

2. Rules Contribute – peer education Ask questions Speak up when it’s not working Share with others after the session

3. Introductions Help me know you! Name Roles in education What you want to learn in this session

4. Nature or Nurture Which has greater influence on teaching? –Nature –Nurture

5. Nature vs Nurture Tribute to hard work… Kenneth Eble, The Craft of Teaching, 1988

6. Teaching is complex Content –knowledge & skills Instructional methods Learner factors External demands Druckman & Bjork Learning, Remembering, Believing: Enhancing Human Performance. National Academy of Press, 1994

7. Objectives Incorporate small group facilitation skills into your teaching repertoire to improve your teaching evaluations Become a more efficient teacher in the clinical setting and leave earlier when working with learners Model professionalism for your learners

8. When you are the learner… Ineffective

9. When you are the learner… Effective

10. When you are the learner… Share

11. Pedagogy

12. Adults learn best when… Relevant & practical Patient or Problem Focused Safe Learning Environment - respect Autonomy/self-direction Goal oriented Feedback Active & engaged Build on existing experiences/knowledge RadioGraphics 2004; 24:1483–1489

13. Roles in student education Small Groups Patient Care –Outpatient –Wards Didactics Others

14. Small group facilitation

15. Small group development Forming Storming Norming Performing Adjourning Tuckman, B. (1965) Developmental Sequence in Small Groups. Psychological bulletin, 63, 384-399 Tuckman, B & Jensen, M (1977) Stages of Small Group Development. Group and Organizational Studies, 2, 419-427

16. Forming Safe, simple, avoid controversy Look to leader for guidance & direction Desire for acceptance by other members Explore similarities & differences Orientation to tasks

17. Storming Interpersonal conflict and competition Task organization – how to get it done Exploring boundaries Testing leader Structural clarification –Responsibilities, rules, rewards –Evaluation criteria

18. Norming Group Cohesion Engaged Acknowledge others’ contributions Change opinions & preconceived ideas Increased trust Sense of belonging

19. Performing Interdependence & flexibility Roles & responsibilities shift to meet need Functional independence Strength in diversity Group identity, loyalty, high morale Energy directed at tasks

20. Adjourning Role end Task completion Reduction of dependency Sense of loss

21. Integration 1 minute Write down 1 – 3 things you just learned

22. Environment Room shape/size Table shape/size Power positions Lighting Technology Group Dynamics

23. Small group facilitation In the Beginning… The Creation of Adam. Michelangelo. 1508-1512.

24. Small group facilitation In the Beginning… –Introductions, learn names –Expectations –Start on time –Invite learners’ opinions, independent thinking –Outline the session –Confidentiality –Model respect –Acknowledge your own limitations

25. Facilitating discussion

26. Stop talking Actively listen Use names Make eye contact Enthusiasm for all contributions (not just ‘right’ answers) Encourage peer teaching

27. Witnessing

28. Role playing Initiator Reconciler Pathfinder Supporter Aggressor Interrupter Hijacker Silent Participant Talker Joker Instant Expert

29. Closing a small group session Summarize Identify unmet goals Homework Plan for next session

30. Integration 1 minute Write down 1 – 3 things you just learned

31. Clinical teaching

32. Doctor as teacher: roles Instructor: Convey information Evaluator: Assess competence Doctor: Patient well-being and comfort Colleague: Want to be liked/respected Mentor: Role Model Recruiter: Convey enthusiasm for discipline Business person: Do it all without significant loss of productivity John Brill, MD, MPH

33. Contribution to the Hidden Curriculum Knowledge Attitude Behavior Skill Mind what you have learned. Save you it can. -Yoda

34. RIME Observer (early m1) Reporter (late m1/m2) Interpreter (early m3) Manager (late m3/m4) Educator (residents) Pangaro L. Academic Medicine 1999;74(11):1203-7. Sepdham et al. Fam Med 2007;39(3):161-3.

35. Relevant Know the educational goals of the clerkship or experience Congruent with present

36. Tips for efficiency Establish teaching environment Communicate with everyone involved Tailor to learner’s needs Share teaching responsibilities Keep observation/teaching brief Broaden learner responsibilities Biagioli F, Chappelle K. How to be an efficient & effective preceptor. Family Practice Management. May/June 2010

37. ONE MINUTE PRECEPTOR

38. Barrier Exercise In groups of two… Identify & write down as many barriers as you can to “Ideal” ambulatory teaching You have 1 minute!

39. Barriers Preceptor factors Learner factors Patient factors Office factors Healthcare system factors

40. Learners Disrupt patient care Decrease clinical productivity Lengthen work day Want to grow & develop Want to demonstrate knowledge & skill Want feedback & fair assessment

41. Scenario A Two volunteers please…

42. Traditional Precepting Patient care focused, not learner focused Low-level questions to clarify clinical data Mini-lectures Little or no feedback May be associated with decreased student satisfaction and learning Difficult to assess learner’s thought processes or level of understanding

43. One Minute Preceptor* 1.Get a commitment 2.Probe for underlying reasoning 3.Provide positive feedback 4.Teach general rules 5.Correct errors * Neher, Gordon, Meyer, Stevens. A five-step “microskills” model of clinical teaching. JABFP 1992

44. Get a commitment Cue: The learner stops & looks at you… Action: Ask learner to commit to a diagnoses or plan Reason: 1 st step in diagnosing learning needs, provides focus for teaching Example: Want do you think is going on?

45. Probe for Underlying Reasoning Cue: The learner looks to you to confirm dx/plan or suggest an alternative Action: Ask learner for evidence and/or DDx; do NOT give your opinion Reason: Insight into thought processes & knowledge; identify gaps Example: What facts support your conclusion?

46. Provide positive feedback Cue: Learner did good Action: Identify and comment on 1 specific good thing the learner did, and the effect it had Reason: reinforces skills Example: You listened well, allowing the patient to trust you and disclose a sensitive issue she was concerned about.

47. Teach general rules Cue: Learner needs to know something Action: Teach general rules or concepts targeted to the learner’s level of understanding Reason: memorable & transferable Example: In a young woman with abdominal pain, you should always consider the possibility of pregnancy

48. Correct Errors Cue: Error, omission, misunderstanding Action: Choose time/place, learner self- critique, discuss error and prevention Reason: Errors uncorrected will repeat Example: You may be right that this patient is drug-seeking, but you have to consider other possibilities for his pain and do an exam.

49. Scenario B Two more volunteers…

50. One Minute Preceptor Learner-centered Supports assessment of learner’s knowledge and clinical reasoning skills Supports focused teaching to learner’s needs Encourages feedback to reinforce desired behaviors and reduce undesired behaviors

51. OMP Effective for both teaching & patient care –Preceptors as good or better at correctly diagnosing patient’s medical condition –May provide more information in same amount of time (or same info in less time) Aagaard E, et al. Academic Medicine Jan 2004

52. In groups of 3 Practice Case Role 1 = Student Role 2 = Preceptor Role 3 = Observer for this exercise Student starts, Preceptor uses OMP Observer to provide feedback 8 minutes to complete

53. FEEDBACK Dr. Jeremy Smith

54. Integration 1 minute Write down 1 – 3 things you just learned

55. Professionalism

56. Commitment to… Professional competence Honesty with patients Patient confidentiality Maintaining appropriate relations with patients Improving quality of care Improving access to care A just distribution of finite resources Scientific knowledge Maintaining trust by managing conflicts of interest Professional responsibilities

57. Contemporary Role Models House Scrubs Grey’s Anatomy You must unlearn what you have learned. - Yoda

58. Model Professionalism Responsibility –On time, task completion Maturity –Response to failure, stress, feedback Communication –Sarcasm, volume, disruptive Respect –Patient, sensitive to others, discrimination Proc (Bayl Univ Med Cent) 2007;20:13–16

59. Respect for specialties Bashing occurs on all rotations 67% students: non-constructive criticism 79% students: bashing unprofessional Source of negative comments –Faculty 42.5% –Resident 55.3% –Student 55.4% Holmes et al. Fam Med 2008;40(6):400-6. Campos-Outcalt et al. Fam Med 2003;35(8):573-8.

60. When it’s not working Connect with… –Self –Learner –Clerkship/course director –Dean of students –Residency director –Med Ed office –Dept. Chair DOCUMENT

61. Integration 1 minute Write down 1 – 3 things you just learned

62. Objectives Incorporate small group facilitation skills into your teaching repertoire to improve your teaching evaluations Become a more efficient teacher in the clinical setting and leave earlier when working with learners Model professionalism for your learners

63. Discussion

64. Thanks!