1. Time Efficient Clinical Teaching Tali Ziv, MD KLIC-UCSF Internal Medicine Site Director Assistant Chief of Medicine, Kaiser, Oakland

2. Session Outline Background Background Introduction to the One-Minute Preceptor Model Introduction to the One-Minute Preceptor Model One-Minute Preceptor Practice One-Minute Preceptor Practice Introduction to SNAPPS Introduction to SNAPPS Introduction to feedback and the Brief Structured Clinical Observation (BSCO) Introduction to feedback and the Brief Structured Clinical Observation (BSCO) RIME Framework RIME Framework

3. Challenges with Clinical Teaching Time pressure Time pressure Competing demands Competing demands Unpredictable environment Unpredictable environment Limited recognition for teaching Limited recognition for teaching Variable patient acceptance of learners Variable patient acceptance of learners

4. One-Minute Preceptor Teaching model initially developed for use in the outpatient setting 3 Teaching model initially developed for use in the outpatient setting 3 Involves 5 steps: Involves 5 steps: Get a commitment Get a commitment Probe for supporting evidence Probe for supporting evidence Teach general rules Teach general rules Reinforce what was done right Reinforce what was done right Correct mistakes Correct mistakes Neher et al. JABFP 1992.et al. JABFP 1992.

5. OMP: Step 1 Get a commitment from the learner Get a commitment from the learner Ask the learner what he/she thinks about the case Ask the learner what he/she thinks about the case Get a commitment to a diagnosis, work-up, treatment Get a commitment to a diagnosis, work-up, treatment WHAT> Why> Pearl> Good> Improve

6. Probe for supporting evidence Probe for supporting evidence Ask the learner for evidence to support their opinion Ask the learner for evidence to support their opinion This allows faculty to identify gaps in knowledge This allows faculty to identify gaps in knowledge What> WHY> Pearl> Good> Improve OMP: Step 2

7. OMP: Step 3 Teach general principles Teach general principles Introduce a relevant rule or concept targeted to the learner’s level of understanding Introduce a relevant rule or concept targeted to the learner’s level of understanding What> Why> PEARL> Good> Improve

8. OMP: Step 4 Reinforce what was done right Reinforce what was done right Reinforcing correct behavior helps the behavior become firmly established Reinforcing correct behavior helps the behavior become firmly established Focus on specific behaviors rather than general praise Focus on specific behaviors rather than general praise What> Why> Pearl> GOOD> Improve

9. Correct mistakes Correct mistakes As soon after mistake as possible, find an appropriate time to discuss As soon after mistake as possible, find an appropriate time to discuss If possible, allow the learner to critique his/her performance first If possible, allow the learner to critique his/her performance first What> Why> Pearl> Good> IMPROVE OMP: Step 5

10. OMP Step 0 Set a constructive learning environment. Set a constructive learning environment. Consider: Consider: Space Space Time Time Players and roles Players and roles Goals and expectations Goals and expectations Prime the learner for the encounter Prime the learner for the encounter

11. OMP Step 6 What are the next steps? What are the next steps? What are the “to dos,” and who’s taking responsibility for them? What are the “to dos,” and who’s taking responsibility for them? Highlight key themes experienced in session that could be explored further. Highlight key themes experienced in session that could be explored further. Equip the student with tools to maximize organization and efficiency. Equip the student with tools to maximize organization and efficiency.

12. OMP Clip

13. OMP: The Evidence OMP faculty training associated with an increase in specific feedback in ambulatory encounters 4 OMP faculty training associated with an increase in specific feedback in ambulatory encounters 4 Videotaped teaching encounters: OMP vs Traditional Videotaped teaching encounters: OMP vs Traditional Faculty student skill assessment improves 5 Faculty student skill assessment improves 5 Students felt feedback better with OMP 6 Students felt feedback better with OMP 6 4. Salerno S. J Gen Int Med 2002. 5. Aagaard E. Acad Med 2004. 6. Teherani A. Med Teach 2007.

14. OMP Practice

15. SNAPPS Summarize briefly the history and findings Summarize briefly the history and findings Narrow the DDx to 2-3 possibilities Narrow the DDx to 2-3 possibilities Analyze the DDx by comparing/contrasting Analyze the DDx by comparing/contrasting Probe the preceptor about questions, uncertainties Probe the preceptor about questions, uncertainties Plan mgmt for patient’s medical issues Plan mgmt for patient’s medical issues Select a case-related learning issue Select a case-related learning issue Wolpaw TM et al. Acad Med. 2003.

16. SNAPPS – The Evidence Third-year medical students receiving SNAPPS training Third-year medical students receiving SNAPPS training More concise in their summaries More concise in their summaries Presentations longer (1 min) Presentations longer (1 min) Expressed more clinical reasoning in presentations Expressed more clinical reasoning in presentations Expressed more uncertainty Expressed more uncertainty Identified case based issues for further learning Identified case based issues for further learning Wolpaw T et al. Acad Med. 2009.

17. Feedback Information on the student’s performance given for the purpose of improving future performance Information on the student’s performance given for the purpose of improving future performance Analogous to coaching Analogous to coaching

18. Tips for Giving Feedback Immediate and often Immediate and often Self-reflection first Self-reflection first Both positive and corrective Both positive and corrective Focus on behavior - not person Focus on behavior - not person Specific, not general Specific, not general Amount limited to what the student can incorporate (not too much!) Amount limited to what the student can incorporate (not too much!) Check to ensure clear communication Check to ensure clear communication

19. Brief Structured Clinical Observation (BSCO) Tool for brief, real-time feedback Tool for brief, real-time feedback Attending enters patient room during patient encounter Attending enters patient room during patient encounter Watches silently Watches silently Leaves when 3 feedback points obtained Leaves when 3 feedback points obtained Feedback discussed that day Feedback discussed that day

20. BSCO Practice

21. Incorporating the BSCO

22. BSCO Tips Orient student and patient Orient student and patient Consider asking student for focus Consider asking student for focus Try to remain silent and “invisible” Try to remain silent and “invisible” Consider times when you are required to be in the room anyway Consider times when you are required to be in the room anyway

23. RIME Framework (O bserver) R eporter I nterpreter M anager E ducator

24. OBSERVER - struggling to report accurately REPORTER Works professionally with patients, staff, colleagues; complete, reliable, accurate; gathers info, clearly communicates with proper terms Works professionally with patients, staff, colleagues; complete, reliable, accurate; gathers info, clearly communicates with proper terms Understands pathophysiology Understands pathophysiology Answers “What” questions. Answers “What” questions.INTERPRETER Identifies, prioritizes problems Identifies, prioritizes problems Offers 2 or 3 reasonable possibilities with reasons applied to the patient. (Students do not have to be “right”) Offers 2 or 3 reasonable possibilities with reasons applied to the patient. (Students do not have to be “right”) Answers "Why" questions. Answers "Why" questions.

25. MANAGER Selects among options with the patient Selects among options with the patient Proactive rather than simply reactive Proactive rather than simply reactive Plans should be reasonable, include test options, student’s preferences, merits of therapies Plans should be reasonable, include test options, student’s preferences, merits of therapies Answers “How" questions. Answers “How" questions.EDUCATOR Identifies questions that can't be answered from textbooks Identifies questions that can't be answered from textbooks Cites evidence on relevant new therapies, tests Cites evidence on relevant new therapies, tests Active in educating self, colleagues, and patients Active in educating self, colleagues, and patients

26. Summary Orient learner to goals/expectations Orient learner to goals/expectations Choose a tool for clinical teaching (?OMP vs SNAPPS) Choose a tool for clinical teaching (?OMP vs SNAPPS) Incorporate frequent observation and feedback (?BSCO) Incorporate frequent observation and feedback (?BSCO) Think about your learner’s skill level (RIME?) and next steps in their path Think about your learner’s skill level (RIME?) and next steps in their path

27. Thanks Special thanks to Maria Wamsley, MD who often teaches this topic with me. Special thanks to Maria Wamsley, MD who often teaches this topic with me. She has efficiently and effectively guided me on a personal path to improving my skills in Faculty Development with timely and constructive feedback Much appreciated!