The Teaching Moment Expressing uncertainties difficulties Georges BORDAGE

The “Teaching Moment” Expressing uncertainties & difficulties Georges BORDAGE, MD, Ph. D Professor Department of Medical Education University of Illinois at Chicago Univ. of Tokyo Grad. School of Medicine, March 2007 1

Professor Kaga Extraordinary leadership in medical education in Japan and abroad… 2

Older woman, joint pain …I don’t know much about joint pain. A 3

Older woman, joint pain …don’t know much about joint pain. A I suggest you go and read about it. 4

Joint pain A …don’t know much about joint pain Thought B about gout… & pseudo gout… but couldn’t discriminate further 5

Older woman, joint pain Thought about gout & pseudo gout… but couldn’t discriminate B further. She’s older, with moderate pain; had surgery recently… This favors pseudogout. Which crystals are involved in each pathologies? How find out? 6

“Teaching moment” B Expressed a specific uncertainty, difficulty Received specific feedback targeted to her needs 7

How often do you know what your student or resident is thinking (Dx, reasons) when presenting a patient ? <25% 50% 75% >90% Not often Some Most 8

Not so often. . . q During outpatient case presentations 1/5 (19%) (4/5 Reporting) 9

Not so often. . . q During outpatient case presentations 1/5 (19%) (4/5 Reporting) q Medical records: SOAP notes 1/17 (6%) (Baker et al, 1999) 10

During bedside discussions with clerks, attendings: - did most of talking - provided mostly factual info. - rarely challenged clerks to think (Foley, 1979) 11

Students reluctant to show their thinking, more so their uncertainties Culture: hide errors, uncertainties 54% HS discussed errors (Wu et al, 1991) 12

Encourage their students & residents to express their thinking & uncertainties during case presentations along with the clinical facts Connell et al, 1999 13

Case presentations Two purposes o Patient care o Student education 14

Educational strategy: Learning is maximized when students try to resolve personal difficulties, uncertainties… (John Dewey, 1933) Teaching moment: express difficulties 15

n= 7 FM + 4 Int. = 11 attendings Coded: 3 levels 16

Levels of interaction 1 - Soliciting/ expressing facts 2 - Explanations 3 - Uncertainties, difficulties Faculty – Students/residents 3 -min segments 17

0 level-3: uncertainties Fac. St. Pre-training Facts 18

Long-term approach Faculty development Change the clinical culture from hiding uncertainties, errors to expressing them 19

Faculty Development Strategies Bolus a lecture, wksp Drip reflection, practice 20

Training: 3 x 3 -hr wkps/ 6 mts Goal: Elicit student’s uncertainties or difficulties about the case. Record (tapes) & reflect +/ Wksp: Discuss what worked & not Practice their own strategy 21

Clear intentions… “I’d like us to talk about how you’re thinking about problems. I’m especially interested in anything that you’re still uncertain about… anything about this case that you’re unclear or puzzled about. ” 22

Expressing uncertainties, difficulties, errors “Student’s CC” 23

Difficulties… Bordage, 1999 èNo sense of the problem overall Acute recurring large joint problem vs. Chronic small joint poly arthritis èSingle Dx in mind vs. D. Dx Septic arthritis vs. gout èMindless presentation vs. pertinent details, discrim. findings 24

Results 1/3 level-3 0 level-3 Fac. St. 25

Benefits of soliciting difficulties… J Know students better + MAXimize their learning J More info about the pts MAXimize patient care 26

Good news, bad news ½ fac. improved -- ½ not Whole team involved Faculty Students Residents 27

Avoid blame & solicit + feedback RCT: w/ w/o training 3 x, 45 -min wkps, 3 mts Ask “good” questions Express uncertainties & difficulties Egan et al, 2002 28 Practice (diary)

Q …don’t know much about joint pain! R Thought about gout & pseudogout but couldn’t discriminate further Q Could you tell R I knew about watery me about chronic and inflammatory diarrhea? but forgot about the other types and got stuck at that point. 29

Bldg on student’s prior knowledge Thought about gout & pseudo gout… but couldn’t discriminate further. She’s older, with moderate pain; had surgery recently… This favors pseudo gout. Which crystals are involved in each pathology? How would you find out? 30

Woman w/ rectal pain Residents confused… Attending: mini-lecture - External hemorrhoids - Internal hemorrhoids - Fistula 31

Woman w/ rectal pain …What’s a fistula? ! Focus on student’s difficulties Bldg on student’s prior knowledge 32

Students 3 x more questions 5 x more difficulties 33

Students 3 x more questions 5 x more difficulties but high communication apprehension! 34

“[Osler’s] criticisms of students and their work were incisive and unforgettable, but never harsh or unkindly; they inspired respect and affection, never fear. ” Henry Christian, dean at Harvard 35

Conditions for success þ Faculty development: Faculty AND Students/residents þ Create a supportive environment Disclosure without blame 36

Disclosure without blame Confident that expressing difficulties, uncertainties, errors can be a positive learning experience “TEACHING-LEARNING MOMENT” 37

Disclosure without blame Errors rounds (chief residents) 38

Usual objection… “Not enough time” ¢Does not take more time: 8 -9 min. ¢Simply takes a different focus 39

…in conclusion 40

Case presentations : 2 CCs o Patient’s CC : patient care o Student’s CC : education Expressing uncertainties, difficulties …a privileged “TEACHING MOMENT” 41

Disclosure without blame Intentions clear… interest in student’s difficulties Supportive environment Learning & patient care maximized 42

Professor KAGA Own exemplary teaching IRCME, Univ. Tokyo Sch. Med. Legacy of better teachers better educational programs Better students & residents Better patient care 43

Domo arigato ! bordage@uic. edu Bordage Med. Ed. 1987, 21: 183 -188 Bordage Ac. Med. 1994, 69: 883 -85 Chang et al. Ac. Med. , 1998, 73: S 109 -S 111 Connell et al. Ac. Med. 1999, 74: S 10 -S 12 Bordage Ac. Med. 1999, 74: S 138 -43 Nendaz & Bordage, Med. Ed. 2002: 36: 760 -66 44