FacultyResident Collaboration on Chronic Disease Management using TeamBased

Faculty/Resident Collaboration on Chronic Disease Management using Team-Based Learning Dellyse Bright, MD Susan Andersen, MD Cabarrus Family Medicine Residency Program

Learning Objectives • To experience a Team-Based Learning session on truncated ADHD guidelines and teaching methods • To learn benefits and risks of small group teaching styles in a large group teaching format • To learn essentials of Team-Based Learning (TBL) 5/6/2014 2

The “Why” • Chronic disease management is “bread and butter” of Family Medicine. • Teach/ use evidence-based guidelines is essential. • Incorporate more engaging and interactive learning methods 5/6/2014 3

Test Time!

Attention Deficit-Hyperactivity Disorder Clinical Practice Guidelines

Screening: From Family, School and Child or teen: o Concerns o Past Medical, Family and Psychosocial History o Evaluation of coexisting conditions o Report of function in academic, work and social interactions. o Use of a Validated ADHD instrument. o Physical exam including neurologic

Screening: Child/Adolescent

Action Statement #3: Assess Comorbidities • Common coexisting conditions: – – – – Learning problems Language disorder Disruptive behavior Anxiety, mood disorders Tic disorders Seizures Developmental coordination disorder Sleep disorders – Vanderbilt questionnaire can reliably rule out common co-morbid conditions: conduct disorder, oppositional defiant disorder, anxiety, depression

Changes in DSM V • Symptoms present prior to age 12 versus 7 • Adolescents & Adults can present with 5 symptoms instead of 6 • No exclusion criteria for autism spectrum disorders

Action Statement #4: Chronic Care Model • Treatment can control symptoms and improve function, but not always curative • Identify child/youth with special health care needs • Collaborate to identify target goals & establish management team • Provide medical home for regular monitoring

Action Statement #5 a: Treatment • Preschool-aged children (4 – 5 yrs old) • First line: Behavior therapy (A/strong recommendation) • Medication only if behavior interventions do not provide significant improvement or if child has moderate to severe impairment – methylphenidate

Action Statement 5 b: Treatment • Elementary school-aged children (6 – 11 yrs) • First line: Medication (A) and/or behavior therapy (B), preferably both • First choice: FDA approved stimulants (methylphenidate & amphetamine compounds) • Alternatives: FDA approved nonstimulants – atomoxetine, ER guanfacine, ER clonidine

ADHD & Adults • • • More inattentive than hyperactive/impulsive Consider differential dx Rating scale: Diagnose using DSM criteria Treatment: pharmacotherapy – First line: Stimulants & atomoxetine – Second line: antidepressants (Wellbutrin, Norpramin) – Not enough evidence to recommend guanfacine or clonidine Misuse of stimulants – sign controlled substance agreement – random urine drug screening – scheduled follow-up

Large Group Teaching • Useful for dissemination of large volume of knowledge • Can be leader-oriented vs. learner-oriented • Humor, pictures, buzz groups, questions facilitate learner engagement and interaction • Too often death by Powerpoint

Small Group Teaching

Small Group Dynamics Benefits Pitfalls • Learning Team work • Opportunity to teach peers • Peer pressure to come prepared • Discussion clarifies principles and concepts • Active listening to peers • Self-awareness of attitudes • Reflection on attitudes • • • Overbearing member Argumentative member Unprepared member Non-participating member Distracted/bored member Complaint that they are teaching themselves

Small Group Leader • Facilitate, don’t lecture • Ask open ended questions to promote discussion. • Ask about different opinions or approachs to question. • Ask them to share their thought process with the group. • Ask each member to make a commitment on their answer

Team-Based Learning Components • • • Pre-class Work Individual Pretest Team Test with immediate feedback Group Discussion Instructor Feedback

Establish credibility without Lecture: • Ask few open ended questions before readiness individual test. • Allow students to ask limited clarification questions before readiness individual test. • At the end of the session have an appeals process to help clarify any confusion. • Take time to offer additional clarification or examples to the groups to reinforce major concepts. New Direction for Teaching and learning Chapter 4 no. 116 Winter 2008

Team Based Learning: Essential Elements • Groups properly formed and managed • Accountability of learner for individual work quality • Feedback received must be frequent and timely • Assignment design must promote learning and team development

TBL: Keys to Effective Groups (4 S’s) • Significant- case/ question that demonstrates useful concepts • Same- all groups doing the same case/ question • Specific choice- use course concepts to make a specific choice/ answer to case questions • Simultaneously report- all groups report choices simultaneously

Team-Based Learning Small Group Discussion Individual Work Class Discussion Impact on Learning Adapted Fig. 1. 3 The Essential Elements of Team-Based Learning. Michaelson LK. New Directions for Teaching and Learning, Number 116. Wiley Periodicals, Inc. Winter 2008. DOI: 10. 1002/tl. 330.

Team-Based Learning Immediate Feedback 4 points 2 points 1 point 0 point Answer Correct after 1 attempt Correct after 2 attempt 3 attempts True/False Questions 2 points Answer Correct 0 point Incorrect

Test Time!

Large Group Wrap Up

Team-Based Learning Immediate Feedback 4 points 2 points 1 point 0 point Answer Correct after 1 attempt Correct after 2 attempt 3 attempts True/False Questions 2 points Answer Correct 0 point Incorrect

Shared Guidelines Talk Timeline • 2 -3 mos prior- Faculty meets with intern • 4 weeks prior- Email guidelines to residents & faculty • 1 -3 weeks prior- Faculty approves intern’s powerpoint presentation • Day of Talk- Total Time: 90 minute session, 3 -4 faculty 5/6/2014 27

The Collaboration Intern -Look up disease guidelines and meet with faculty -Develop powerpoint to review guidelines for large group -Get powerpoint approved by faculty 5/6/2014 Faculty - Meet with intern to review disease guidelines - Develop the test using board questions from SAM, AFP Journal, AAFP, etc. - Facilitate Small group and wrap up sessions 28

Shared Guidelines Talk Timeline • • 15 min- Individual Test 30 min- Guideline Powerpoint 45 min- Group Test Small Groups 20 min- Large Group Wrap Up (and Gift) 5/6/2014 29

Cabarrus Family Medicine Lessons Learned • Individual test help residents evaluate their medical knowledge • Small group test discussions aided learning of chronic disease guidelines • Faculty and interns enjoyed co-teaching (interns 1 st presentation) 5/6/2014 30

Lessons Learned • > 1 guideline talk per month OVERLOAD • Foster healthy competition- publicize group test scores, not individual tests 5/6/2014 31

Learning Objectives ü Experienced a Team-Based Learning session on truncated ADHD guidelines and teaching methods ü Learned benefits and risks of small group teaching styles in a large group teaching format ü Learned essentials of Team-Based Learning (TBL) 5/6/2014 32

References 1. Walton H; Medical Education. 1997, 31: 459 -664 2. http: //www. kellogg. northwestern. edu/research/risk/geny/moreabout. htm 3. The Essential Elements of Team-Based Learning. Michaelson LK. New Directions for Teaching and Learning, Number 116. Wiley Periodicals, Inc. Winter 2008. DOI: 10. 1002/tl. 330. 4. Medina J, Brain Rules: 12 Rules for Surviving and Thriving at Work, Home and School. Seattle WA: Pear, 2008. Print. 5. ADHD guidelines http: //pediatrics. aappublications. org/content/early/2011/10/14/peds. 20112654 5/6/2014 33

Questions? • Dellyse Bright, MD – Dellyse. Bright@carolinashealthcare. org • Susan Andersen, MD – Susan. Andersen@carolinashealthcare. org 5/6/2014 34