Becoming a Model Educator Julie M Schirmer LCSW

Becoming a Model Educator Julie M. Schirmer, LCSW Julie G. Nyquist, Ph. D Kathryn Fraser, Ph. D Wanda Gonsalves, MD Deborah R. Erlich, MD, MMed. Ed Jeffrey Morzinski, Ph. D, MSW

Disclosures • Nothing to disclose

Overall Objectives 1) Describe learning principles that underlie excellent clinical and classroom teaching 2) Self-assess and identify one’s own teaching gaps, strengths 3) Develop a map that charts one’s journey to becoming a master teacher, and 4) Incorporate ideas to explore the structure of the faculty development program in one’s own programs

ACGME Faculty Development “Faculty development activities should be designed to enhance: – Teaching – Administration – Leadership – Scholarship – Clinical knowledge and skills – Behavioral components of faculty performance. ” ACGME Program Requirements for Family Medicine. Approved July 1 st, 2015.

Educational Content • Basic Educational • Evaluating learner theory performance • Clinical Teaching (e. g. • Using the Web for precepting or at the course development bedside) • Evaluating teaching • Writing goals and effectiveness objectives • Developing effective presentations Adapted from Goodell, M. Strategies for Meeting ACGME Faculty Development Requirement. fmdrl. org.

Basic Educational Theory - Teaching to the developmental level of the learner - Scaffolding learning - Clinical precepting principles - Presentation design principles

Peak Learning and Learning Principles April 30, 2016 Julie G Nyquist Ph. D Keck School of Medicine of USC

Activity 1 - Brainstorming Things that help you learn – when you learn best v Talk to a neighbor – make a list – 2 minutes v We will then make a joint list v

Learning – Big Ideas

Session Objectives You should be better able to: 1. Describe a peak learning experience 2. Describe learning principles that underlie excellent clinical and classroom teaching 3. Utilize learning principles in your clinical and classroom teaching

Activity 2 – Story of a Peak Learning Experience Take 2 minutes – think about your own learning and jot down on a post-a-note sheet a peak learning experience Peak – a time when you were very excited about learning a new skill, a new concept, gaining a new personal insight Share with a neighbor – 3 minutes

Peak Learning Experiences Cognitive – new factual, conceptual, procedural or metacognitive knowledge; solving a problem Psychomotor – new skill Affective – new personal insight, new level of commitment

Activity 3 – Tying principles to our peak learning experience As we review principles Think about if each applies At the end you will decide which two were most in play Place your post-a-note (and its duplicate) on the giant post-a-note for those two principles

1. Prior knowledge can help or hinder Helps when. . . Can hinder if. . . Activated Sufficient Appropriate Accurate Inactive Insufficient Inappropriate Inaccurate

Prior “knowledge” can hinder if: Inactive – cannot remember Insufficient – did not know it in the first place Inappropriate – bias, prejudice, opinions from the social media, not connected to current case Inaccurate – out of date, or just wrong (learned or remembered incorrectly)

2. Organization of Knowledge How learners organize knowledge influences how they learn and apply what they know Experts have rich, meaningful knowledge structures Novices have sparse, superficial knowledge structures Novice Expert

3. Learners’ motivation determines, directs and sustains what they do to learn

Motivational States Value, Efficacy, Environment Motivational States based on leaner valuing, self-efficacy & Environment is NOT Supportive Environment is Supportive Student does NOT see **Value Student Sees Value Student does NOT see Value Student Sees Value Student *Efficacy is Low Rejecting Hopeless Rejecting Fragile Student Efficacy is High Evading Defiant Evading Motivated *Efficacy = Student confidence in their abilities to successfully achieve the goal **Value = the importance the learner places on the goal, how much they care about it or value it

4. To be life-long learners must develop metacognitive skills

4. Self-Directed Lifelong Learner Metacognitive Skills The Learner should be able to: v Assess the task at hand v Evaluate own strengths & weaknesses v Plan an appropriate approach to accomplish task v Apply strategies; monitor performance v Reflect on and adjust approach

5. Mastery of skills Acquire component skills Practice the parts and the whole Know when to apply the skill Modify the skill to fit an unusual situation Relates to the steps in the psychomotor domain

6. Goal-directed Practice with Targeted Feedback Can relate to cognitive Unequal effects of practice Early very slow growth in competence; As approach mid-level performance practice works very well to increase level of performance A Lazy S Curve

7. Learning is Developmental Current level of development interacts with the social, emotional, and intellectual climate of the program to impact learning Developmental level matters Life development (conflicts of commitment) Dreyfus level (readiness for task) Environment matters – safe, inclusive

8.

Dreyfus & Situational Teaching Stage Learner Characteristics Teacher’s Role Low KSA, high motivation, Follows rules; context free; Instruct – more formal presentation - break skill into discrete tasks, discuss concepts, rules Advanced Beginner R 2 Some KSA; Low Motivation, Confidence can exceed competence; Can apply rules; does not feel responsible for outcomes Coach - guided activities; ensure learners understand the importance of activities and of the topic Competent R 3 Much KSA, Organizes rules into principles; motivation varies; can lack confidence; responsible for own decisions Facilitate – make sure the activities allow them to share their knowledge and experience with each other Novice R 1

Activity 3 – Link peak learning experience to two key principles Take a minute to duplicate your peak learning experience v Place your post-a-note (and its duplicate) on the giant post-a-note for your two most important principles v

Discussion

Learning – Big Ideas

Take Home Message Connect learning principles to yourself first 2. Use principles to plan and guide your classroom and clinical teaching 3. Enjoy the journey 1.

Commitments and Session Evaluation Take a few moments and write on a card one thing that you plan to do differently in your teaching based on what you learned in this session.

References Ambrose SA etal. How Learning Works: Seven Research. Based Principles for Smart Teaching The Jossey-Bass Higher and Adult Education Series, 2011. Cooke M. Irby DM. O’Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. Jossey. Bass, 2010. Friedlander MJ etal. How can medical education learn from the neurobiology of learning? Academic Medicine. 2011; 86(4): 415 -420. Westberg J Jason H Collaborative Clinical Education, 1993

Bonus Slides Learning Principles

Development and Environment Current level of development interacts with the social, emotional, and intellectual climate of the program to impact learning Developmental level matters Life development (conflicts of commitment) Dreyfus level (readiness for task) Environment matters – safe, inclusive

Learning is Situated Learning is contextual – affected by the specific environment Environments should encourage collaborative and multi-disciplinary action Connect classroom teaching to the clinical environment Work to build a learning community – safe and welcoming place to learn

Bridging the Gap Between Clinician and Teacher Clinical Teaching Skills Kathryn Fraser, Ph. D , Wanda Gonsalves, MD

Objectives: As a result of this presentation, participants will be able to: • Describe characteristics and habits of effective clinical teachers • Identify steps for interactive feedback techniques— New Feedback Sandwich and ARCH model • Practice the One Minute Preceptor technique for clinical teaching

Brainstorming-Characteristics of Good Clinical Teachers

Helpful Clinical Teachers… üAnswer carefully and precisely üApproach teaching with enthusiasm üCorrect students without belittling them üMake difficult concepts easy

Helpful Clinical Teachers… üEmphasize concepts rather than facts üTeach with dynamism and energy üIdentify what they consider important üDiscuss practical applications

Five-Step Micro-Skills aka One Minute Preceptor • • • Get a commitment Probe for supporting evidence Teach a general rule Reinforce what was done right Correct mistakes https: //www. youtube. com/watch? v=l. Ceyzp. U 7 PMw

Get a commitment • Stimulates clinical reasoning and supportive environment • Examples: what is going on with this patient? What labs do you want to order?

Probe for support • What findings led to this conclusion? • What factors led you to choose that plan? • What else might you consider?

Teach General Rules • Focus on 1 -2 points per patients

Reinforce what was correct • Builds self-esteem

Correct Mistakes • Reinforce What was correct • Exchange feedback

The New Feedback Sandwich* Ask Tell Ask Adaptation of “The New Feedback Sandwich, ’ common in patientphysician communication literature; adapted by Lyuba Konopasek, MD, for use in feedback settings.

Checklist: The Feedback Dialogue ü Ask learner to assess own performance first üWhat went well and what could have gone better? üAsk specifically about the topics the learner should address. Adaptation of “The New Feedback Sandwich, ’ common in patient-physician communication literature; adapted by Lyuba Konopasek, MD, for use in medical resident feedback settings.

Checklist: The Feedback Dialogue ü Tell what you observed: diagnosis and explanation üReact to the learner’s observation üInclude both positive and constructive elements üGive reasons in the context of well-defined shared goals üRegulate quantity

Checklist: The Feedback Dialogue ü Ask about recipients understanding and strategies for improvement üWhat could you do differently? üGive own suggestions üPerhaps even replay parts of the encounter show me üCommit to monitoring improvement together

The ARCH Feedback Model • • A = Ask for self-assessment R = Reinforcement C = Correct H = Help learner develop improvement plan

Role Play: working in groups of three, participants will have the opportunity to play the part of resident or attending, or be an observer Group A: Practice Feedback Technique; Group B: Practice Microskills technique Resident: presents the case to attending Attending: listens to the resident’s presentation; tries to use Microskills or Feedback techniques in response Observer: monitors the interaction using the guide for the Microskills or Feedback models. After 5 mins the observer will stop the interaction and give feedback.

Resident Case Scenario The resident has just finished interviewing a tearful, complex patient with diabetes, heart disease, depression, and severe anxiety. The resident notes that the patient was shaking as she described her current family struggles and problems remembering to take medications. The resident did a nice job providing information on the patient’s Hb. A 1 c and hypertension; however, the resident was rather blunt regarding the patient’s anxiety saying, “ maybe you should just relax or don’t talk to your family if they make you feel this way. ” The resident also did not assess for suicidal thoughts or inquire about patient’s interest in referral to a mental health professional. • RESIDENT--Your task: present this case to the attending in a way that shows your frustration with the patient • ATTENDING—Your task: provide the resident with feedback and suggestions on how to improve their interaction with this patient • OBSERVER: Your task: after 5 minutes you will give the “attending” and “learner” feedback on what you observed in their interaction.

Large Group discussion: • Observer’s experience • Learner’s experience • Teacher’s experience

Commit to make change Write down 2 things you will do differently as a teacher after hearing this presentation on clinical teaching and feedback.

References • • • Giving feedback. Teachingphysician. org Baker D and Turner G. Advanced feedback Skills. med. fsu. edu Gigante J, M Dell and A Sharkey. Getting Beyond ''Good Job'': How to Give Effective Feedback. Pediatrics 2011; 127: 205. Ramani S and S Krackov. 12 tips for giving feedback effectively in the clinical environment. Med Teacher 2012; 34: 787 -91. Sullivan, AG. Giving Constructive Feedback. Adapted from: Scholtes, P. , Joiner, B. , & Streibel, B. (2003). The Team Handbook. May 2007. Ende, J. Feedback in clinical medical education. JAMA. 1983; 250(6): 777 -781. Konapasek, L. , Abr-on, M. Ask-Tell-Ask: A Tastier Feedback Sandwich. http: //www. acgme. org/Portals/0/PDFs/2015%20 AEC/Presentations/ses 039. pdf Baker, SD, Turner, G, Bush, SC. ARCH: A Guidance Model for Providing Effective Feedback to Learners. STFM Education Column. November, 2015. http: //www. stfm. org/News. Journals/Education. Columns/November 2015 Education. Column Neher, JO. , Stevens, NG. The One Minute Preceptor: shaping the teaching conversation. Fam Med. 2003 Jun; 35(6): 391 -3.

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