Bedside Teaching Clinical Teaching Scholars Program Sarah R
Bedside Teaching Clinical Teaching Scholars Program Sarah R. Williams, MD Program Director, Emergency Medicine srwilliams@stanford. edu
Why? Who benefits?
Why Not?
Bedside Teaching: Enhancing Your Clinical Teaching… While Preserving Efficiency Sarah R. Williams, MD Program Director, Emergency Medicine srwilliams@stanford. edu
Goals and Objectives Brief reflection on why… Interactive review of how… summary of several methods/tools you can try Targeted to maintain efficiency Goal: make small adjustments to teaching style with big results
Sir William Osler (1849 -1919) • “To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all. ” Sir • William Osler Took doctors from their books and to the bedsides of the afflicted
Why Bedside Teaching? Improves learning; students cited bedside teaching and feedback as characteristic strategies of superior clinical teachers
How Often Is This Happening? Survey of over 20 residency programs and over 500 responders Recalled <3 observed H&Ps during their training How are they learning advanced H&P skills?
Enhances Career Satisfaction Factors for career satisfaction and protective against burnout (10 year study): Clinical teaching** Any leadership role in professional life Exciting work Fair compensation Consulting Personally rewarding Job security Political activity Cydulka RK, Korte R. Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians. Ann Emerg Med. 2008 Jun; 51(6): 714 -722. .
Teaching Evaluations Appointment and promotions Financial incentives Especially important for clinician educators
Improvement of Patient-Doctor Relationship Majority of patients enjoy participating in bedside-teaching rounds and would recommend the process to others 2/3 of inpatients felt bedside rounds increased their understanding of their illness Majority felt that teaching process maintained confidentiality
This is all very nice, but… I’M TOO BUSY!! I NEED MY RVUs!
What about RVUs? 96% of faculty felt that time demand for clinical productivity was the biggest limiting factor on clinical teaching of students (Berger et al. )* NO INVERSE RELATIONSHIP was found between quality of teaching and clinical productivity in an academic ED Huh?
What about RVUs? Subset of faculty possessed both excellent teaching skills and high RVUs Structured training programs may improve efficiency of teaching without sacrificing productivity
HOW?
10 Strategies 1. Plan the teaching session before the next shift 2. Know your team & goals 3. Choose the right time to teach 4. Set realistic expectations for yourself 5. Limit the amount of time per patient 6. Be professional 7. Use Socratic method with caution 8. Summarize and evaluate 9. The “teach-only” attending 10. Train residents how to teach at bedside
Four Levels of Learner Sophistication Teaching at higher or lower level is unproductive, frustrating, or both (Schwenk & Whitman, 1984) Competent Incompetent Unconsciously competent* (faculty) Unconsciously incompetent (just dangerous) Consciously competent (resident) Consciously incompetent (med student)
Plan the Teaching Session Before the Next Shift • • • Planning before the “teachable moment” Review key learning points for common topics: prepare teaching scripts Example: chest pain; MI is on the differential, but discuss other possibilities: • Discussion of Beck’s triad (JVD, muffled heart tones, hypotension) or (even better) echo
Choose the Right Time to Teach: Stable Patients Stable patients: identify good learning cases in between work-ups The “what if” gambit
Choose the Right Time to Teach: Sick Patients Sick patients: great opportunity for observational learning Pre-prepare short list of teaching scripts: airway, rhythm analysis Model ideal behaviors/procedures
Teaching Is Treating… Powerful concept: teaching as an extension of patient care: “teaching in the ED is treating in the ED”
Limit Amount of Time Per Patient 1 -minute hallway lecture (teaching script) to orient learner Example: pulmonary edema: pathophys, H&P findings to look for 5 -minute time limit for bedside encounter Efficiently teach or observe clinical skills at bedside without sacrificing flow CAN BE DONE DURING YOUR EVAL OF THE PATIENT*
Leverage: Train Residents How to Teach at Bedside IM: resident teachers more beneficial effect on med student test scores than attendings Closer in age, remember what it’s like to do the procedure the first time, less formal Role models, model behavior Improves resident teacher scores on exams Fosters scholarly spirit of a program
Direct Observation as Teaching/Evaluative Tool Majority of residents felt direct observation/evaluation was valuable to their education Presence of evaluators was not overly intimidating Medical students: improved access to feedback from faculty
Role Modeling Bedside teaching: great way to model professional behaviors Survey of 50 faculty: didactic seminars alone had failed to foster humanism amongst their students Bedside teaching: discourages labels: “hits”, “train-wrecks”
LISTEN! Listen more, talk less: 75% of time teacher is talking 2 -3 seconds: average time faculty will wait to let a student answer a question 17 seconds: optimal wait time. RESIST THE URGE to say “Why don’t you go ahead and get labs, EKG, CXR” LISTEN a little; VITAL to being an effective teacher
“SPIT” Serious Probable Interesting, & Treatable Advantages: Quick and easy; differentials and management steps When? At triage… after H&P… after labs back… Cool to see how list changes Easy to modify to level of learner Todd Guth: When Teaching Analytical Clinical Reasoning, Remember to SPIT
SNAPPS Summarize (history and findings) Narrow (differential, to 2 -3 possibilities) Analyze (differential: compare/contrast) Probe (questions about uncertainties, etc. ) Plan (management) Select (self-directed learning item) SNAPPS: a learner-centered model for outpatient education. Wolpaw et al. Acad Med. 2003
The One Minute Preceptor: 6 Microskills 1. 2. 3. 4. 5. 6. Get a commitment Probe for supporting evidence Teach general rules Reinforce what the learner did right Correct mistakes Identify the next learning step The one-minute preceptor: shaping the teaching conversation. Neher JO, Stevens NG. Fam Med. 2003 Can One-Minute Preceptor and SNAPPS improve your inpatient teaching? Zeidman J J Hosp Med. 2015
7 Habits of Highly Effective Educators: “TEACHER” T-eaching E-nthusiasm A-ppropriate feedback C-enteredness (learner) H-elpful E-levates to become independent R-ole model Rob Rogers, MD
Remember… Short targetted teaching scripts Observe at the bedside, give tips Teach and treat simultaneously SPIT/SNAPP to better differentials and plans The “what if” gambit Listen
Grid: adapted from “The Physician as Teacher” pg 247, Whitman and Schwenk USEFUL NOVEL Creative Teacher* NOT NOVEL Pedantic Bore NOT USEFUL Charlatan Old Goat (AVOID)
srwilliams@stanford. edu
Additional References & Resources Bedside Teaching in the Emergency Department, AZ Aldeen, MA Gisondi, Academic Emergency Medicine, June, 2006 The Impact of the Demand for Clinical Productivity on Student Teaching in Academic Emergency Departments, TJ Berger, DS Ander, ML Terrell, DC Berle, Academic Emergency Medicine 2004; 11: 1364 -1367 “The Seven Habits of Highly Effective Medical Educators”, RL Rogers, presented at SAEM, San Francisco, May 2006 (presented with permission from author) “Connoisseurship and Creativity in Teaching”, from The Physician as Teacher, N. Whitman & TL Schwenk, Whitman Associates, 1997 JAMA: Listing of the Rational Clinical Exam itemshttp: //jama. ama__assn. org/cgi/collection/rational_clinical_exam :
References (cont’d) Evaluating “ED STAT!”: A Novel and Effective Faculty Development Program to Improve Emergency Department Teaching, J Sherbino, J. Frank, C. Lee, G. Bandiera. Academic Emergency Medicine 2006: 13(5), Suppl 1: S 51 -S 52: 111 (abstract) EMF/ACEP Teaching Fellowship-Session 1 overview: http: //www. acep. org/webportal/education/Continuing. Medical. Educati on/Meetings/teachingfellowshipsession. I. htm ACGME Specialty Milestones Sir William Osler, Baronet, Biography (http: //www. whonamedit. com/doctor. cfm/1627. html
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