Teaching on Today’s Wards:



Teaching on Today’s Wards: TEACHER’S GUIDE

Please coordinate materials with the lecture slides and the separate handout tutorials/exercise sheets.

Session #1: Improving the Teaching Process

Learning Objectives for Sessions 1 and 2:

By the end of these two sessions, the learner will:

1. Recognize teaching is a process that is open to evaluation and improvement.

2. Identify areas in his/her teaching process in which the ACGME core competencies of communication and professionalism can be taught and evaluated.

3. Identify successes and problem areas in his/her own teaching process.

4. Develop a process improvement plan for at least one specific problem area that will be incorporated into their teaching process on their next inpatient month.

Introduction (10-15 minutes)

Teaching is a process. You have learned the Stanford Improving Clinical Teaching Skills Model, which is one conceptual model that is attractive-- teaching skills reinforced with video-taped practice sessions and feedback. These are a set of core teaching skills that will serve you well in any teaching environment. However, we are going to devote the next 5 sessions to improving our process of teaching in the site-specific place of an inpatient Medicine teaching service. Exploring your teaching process while balancing the clinical, management and administrative roles we take on as the teaching attending is no small feat.

We will use the Stanford Model and the ACGME core competencies as the two pieces of a foundation to guide our own clinical teaching specifically in the inpatient setting.

This will be an active learning based set of sessions that recognizes that while we all teach differently in terms of style, content, order and amount—we all face many of the same issues and barriers.

When clinical topics arise, we will use geriatric content as the examples.

What is the process of Teaching on the wards?

Overview of the month long process

Setting goals

Setting expectations

Structure of when teaching will occur

Preventing burn out

Overview of the day picture

Setting goals

Setting expectations

Identifying the teachable moment

All of this while taking care of patients, getting your work done, getting residents home, and maintaining some semblance of balance.

Introduction to Mapping the Teaching Process (15-20 minutes)

See tutorial handout for process mapping

All learners map out their process with assistance of the tutorial handout and the

lecture instructions.

Provide a few example maps to demonstrate how to look at them.

Discuss that there are successes and problem areas in every map and that we can use them to be self-reflective life long learners. To do that, remember that the teaching attending role involves balance between teaching and clinical care.

Components of this process also map to the Core Competencies:

Communication

Provide examples from demo maps

Professionalism

Provide examples from demo maps

Breakout Session: (40 Minutes)

This session will focus on thinking about the process by using your map as a tool to reflect on your attending style. Remember that no one style is the right one, but that we can learn from each other.

There will be 4 specific activities to work on over the next 1 hour as you look at the maps of the other people in your small group as well as the example maps.

1. What surprises you as you look at the maps?

2. Begin to identify differences between the maps

3. Identify where in your maps there are links to the communication and professionalism core competencies

4. Start to identify where your process serves you well and where it may interfere with achieving the ultimate goal of achieving excellence in clinical care and teaching.

Re-Group (20 minutes)

Spend a few minutes discussing the 4 activities and the session.

Talk about barriers:

Pre-identified barriers

Time

When the resident or student clinical evaluation is crucially different from

your evaluation

Walking into a heated or volatile family situation on rounds

Walking into an acutely decompensated patient while on rounds

Motivating and maintaining resident interest

The Power Struggle on the team

When Can I be done?

Homework:

Look at your own map and more concretely identify where your process serves you well and where the problem areas are. Please create a list of barriers (external and internal) that affect your attending on the wards. These barriers will likely include external and internal barriers. Also, think about how this area in your process relates to the competencies of communication and professionalism. Be ready to actively work on this area for next session. Please bring your list of barriers to the next session.

Session 2: Improving the Teaching Process, Part II

Introduction: (5-10 minutes)

Round out a discussion on barriers to teaching. Talk some about internal and external barriers identified during the homework assignment.

Outline the small group session activities below.

Small Group Session 1: (25 minutes)

See exercise worksheet for this session “I hope I get a good team”.

You will spend the next 25 minutes working in groups discussing barriers. This discussion will be “case based” and will focus on issues about how you can be a teacher/manager given a set of challenging team dynamics. In this session, use the maps from people in your group as well as the example maps to identify barriers or highlight potential strategies to effectively managing the team. Also, be prepared to talk about where the cases naturally link to both the Stanford framework and the ACGME core competencies of communication and professionalism.

Break into 3 discussion groups. Group 1: Discuss questions 1-3. Please designate a faculty member to report back to the group as a whole when we regroup for further discussion.

You are the attending for the month on the GENS Service in January.

You are post call--your 3rd call night for the month.

Your team:

1. SR--Senior resident (3rd year, planning a career in critical care)— smart, confident, leader, decision-maker

2. IK--Intern #1–smart, polite, reserved, very detail oriented, always knows the answer

3. IT--Intern #2—smart, easy-going, aims to please

4. MP--Medical student #1—smart, confident (contributes to rounds), a jokester

5. ML--Medical student #2—smart, leaves rounds early, does not contribute to rounds, presentations lack ability to flush out a working A&P expected for level of training.

Questions for Discussion:

Keep in mind your teaching map, how you set goals for the month, your style as a manager, and role as a teacher.

Keep in mind the concepts of both internal and external barriers to teaching.

Also keep in mind that our goal is to expand the teaching on inpatient geriatric issues.

1. Based on these profiles of your team, discuss the monthly goal setting you would have done for each of the house staff and medical students described here.

2. What are the barriers to teaching in this particular group dynamic?

How can you engage SR, IK, IT, MP, ML in teaching rounds?

(Think about clinical and character strengths/ potential or real weaknesses of the individual resident/student learners, level of training issues, and how these factors play out in the group dynamic.)

3. How do you work with your senior resident without upstaging his/her autonomy to run-the-show—including teaching and topic choices?

Re-Group (10 minutes)

Each group will present talk for 2-3 minutes about their conversations. The discussant will be asked to specifically comment on barriers and strategies of interest, as well as describing the usefulness of the teaching maps in this process.

Introduction to Small Group Exercise #2 (5 minutes)

See exercise worksheet for this session “Deciding what to teach”.

During the next breakout session, we will be moving to a post-call day. You will be presented with a typical post-call general medicine service day. We want to explore barriers and identify strategies for highly effective teaching. Again, use your maps to honestly reflect on how you would manage this post-call day. Remember the goal is to provide outstanding teaching while taking care of patients, getting your work done, getting residents home, and maintaining some semblance of balance.

Breakout Session #2 (35 minutes)

Below is the list of new admissions for presentation:

Patient list: 3 olds, 1 somewhat sick, 10 news, the resident gives a one-line summary of the 10 new patients as listed below.

1. Acute pancreatitis with a fever

2. MS changes for NHP

3. Transfer from the MICU after 8 day ARDS/sepsis stay

4. Pneumonia in what may be a newly diagnoses HIV patient

5. ESRD patient with fevers, possible line infection

6. NH patient with urosepsis, stable

7. Acute asthma exacerbation, looks ok

8. Transfer from neurosurg service for patient with a subdural bleed, mental status changes, and now new onset hypoxia

9. Patient admitted with probable pneumonia but very interesting CXR with possible cavitary lesions

10. Patient with sickle crisis and chest pain

Breakout Session Questions

1. How would you prioritize seeing these patients?

2. How would you prioritize teaching on the new patients?

Re-Group (15 minutes)

Reconvene for group discussion. Pass out the Missed Teaching Opportunities handout to the faculty learners. This demonstrates the variety of Geri topics/principles that can be taught across all patient cases. Also demonstrated are the opportunities to teach across all the ACGME competencies on any given case. Finally, listed are the opportunities to use teaching tools such as the case or census audit (Session #4).

Optional materials for further group discussion:

4. When and what would you teach on case #2? Case information see below.

5. How do you handle the bait and switch of the daughter’s arrival in case #2?

6. When and what would you teach on case #6? Case information see page 6.

7. What are the motivators that you use to teach a resident or student a particular topic? How could you motivate a resident or student to the topic areas of foley catheter use and skin care/ pressure ulcers in case #6?

8. Are there cases in this list that lend themselves to teaching about professionalism and communication?

Case #2:

INFORMATION FROM PRESENTATION

You enter the room of RB, an 80 year-old who was presented as an elderly gentleman with falls without syncope, here for nursing home placement. Last night when admitted the patient’s son states that he suspects memory problems. He is on multiple medications for htn, depression, memory, diarrhea, insomnia. They include: atenolol, hctz, reminyl 8 BID, paxil 20 q hs, ambien 10 qhs, lomotil BID. Some of these medications were new according to the son.

In the ER here the patient had normal blood work, neg. CT head for an acute subdural, EKG with NSR and no acute changes.

INFORMATION FROM EXAM

On exam, the patient is unusually sleepy and difficult to arouse. He does know his name, year but not the date or place.

NEW INFORMATION FROM FAMILY MEMBER

The daughter has just arrived from out-of-state this morning and wants to know what’s going on with her father. She states that 3 weeks ago he was functioning independently and admitted to an outside hospital with chest pain with a negative work-up and sent home. From there her father became more confused and started to fall, so she requested her brother to take their father to the ER at your medical center.

FINAL ASSESSMENT

You suspect apathetic delirium with an underlying dementia, deconditioning and polypharmacy.

Case #6

INFORMATION FROM PRESENTATION

BT, a 90 year old nursing home resident admitted with MS changes deemed secondary to a UTI.

NEW INFORMATION FROM YOUR EXAM

On physical exam you note the patient has an indwelling foley catheter and some sacral breakdown neither of which were mentioned in the initial presentation.

Homework:

On your own, spend time looking at the small group case (team, patient load, questions, etc.). Think about how your own process of teaching affects your ability to be a manager and teacher. Also, critically evaluate how your approach serves the teaching of topics like geriatrics core issues. Identify one area of your process that you would like to improve and explicitly state the barrier(s) that get in the way of teaching these types of topics. Begin to think about how you could change your process to improve the teaching of these important, but seemingly difficult topics.

Evaluation Ideas for Sessions 1 and 2

Pre- and Post Survey

Teaching comfort level

Do you have a process to self-evaluate your teaching

How comfortable are you in your ability to make effective changes in your teaching strategies

Please rate your comfort in teaching: Communication/ Professionalism

Please rate your comfort in evaluating: Communication /Professionalism

List (or think of) 3 struggles that you face when teaching

How many of these are items that you have direct control over?

Do you have a concrete plan to address any of them?

When was the last time you had a concrete plan to address a teaching struggle?

Now take a look at your teaching map

How much do you think this map will aid you in your teaching process improvement?

Mapping

Try to map your teaching during your next inpatient month. Has it changed from your initial map? If so, does it reflect the specific teaching improvement process project you committed to during the sessions?

Observed Rounds

Did the learner/teacher seem to complete their specific process improvement plan?

Have learner/teacher identify something about opportunities for communication/professionalism teaching evaluating.

Learner Report

Did your attending set specific goals in the beginning of the month?

Did your attending set specific expectations in the beginning of the month?

Session #3: Systems Based Core Competencies

(Intro. 10 minutes)

The core competencies should be thought of as what goes into making a good clinical doctor providing comprehensive, up-to-date clinical care. We should be practicing across the 6 competencies areas for any individual patient case. Some of competencies are intuitive to practice and teach e.g., medical knowledge, patient care, professionalism, communication. Further, we are often most comfortable with evaluating a learners “clinical expertise.” The core competences of practice based learning and improvement (PBLI) and systems based practice (SBP),have been more difficult to teach and evaluate in clinical practice largely because most teaching faculty don’t feel they are enough of a “content” expert to teach PBLI or SBP with skill or comfort. In fact, most places that have made formal efforts at teaching PBLI and SBP have made them a stand-alone curriculum. We hope to demonstrate how PBLI and SBP can and should be a part of our practice of teaching in the clinical setting. When you walk away from here, you will have a toolbox that will allow you to teach and evaluate your learners in these areas.

Learning Objectives:

By the end of this session, the learner will be able to:

1. Describe the key components of the systems based practice competency

2. Evaluate learners’ abilities to work within the existing system of care

3. Teach the basic model of Plan, Do, Study, Act

4. Teach and evaluate inpatient teams in how their actions and care practices affect other systems within the hospital.

5. Using the PDSA model, identify and outline conceptual QI projects with their inpatient team that address systems level issues that arise during the care of patients.

Introduction to Systems Based Practice (20 minutes):

What is it? ACGME Definition

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:

• understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice

• know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources

• practice cost-effective health care and resource allocation that does not compromise quality of care

• advocate for quality patient care and assist patients in dealing with system complexities

• know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

We are going to focus on three areas that can be taught in the traditional inpatient setting (see italics above).

Taking advantage of the systems that are in place within the care setting

Critically thinking about how to improve those systems

Pre-comfort level—discussion

Why is it important?

General Introduction into the QI model (Plan Do Study (Check) Act) and the key components

It’s the system

Don’t blame

Process

Introduction to Toolbox Concept

There are specific concrete tools that you can use in clinical teaching practice to both teach and evaluate Systems Based Practice. In the following breakout session, you will re-visit the case of our elderly patient with apathetic delirium. We will focus our discussion today on evaluating and teaching Systems Based Practice. The facilitator will make sure that key points are discussed.

Breakout session (40 mins.) with Regroup discussion (25 mins.)

See Teaching Matrix on Systems of Care tutorial and exercise sheet

The major teaching points for the faculty learners include the realization that one can teach about systems on any case topic and/or care in transition from one system to another and/or system failure. There are some topical areas in which you may be a content expert and can describe the system with regard to a more detailed demographic, cost, entry criteria and give an expert opinion about what works in the system and what needs to be improved. But even if we are not a content expert on a particular system of care after this course, we should be able to describe what a system is and at the very least try to map some part of the system’s process. We can all usually describe most of a patient’s and our hospitals systems of care and discuss the workarounds within the systems that are closest to our immediate clinical care experience. Labeling these as systems of care and pointing out the strengths and weaknesses of these systems is teaching.

Optional Breakout Session on Teaching about Systems of Care (40 minutes)

Remember the case of the elderly gentleman admitted with apathetic delirium. He has done better when taken off some of his medications. The team is presenting him on the next day thinking he will be ready to go. He is not quite back to his baseline, but when they saw him that morning, he was significantly better than on admission. There were no calls from cross cover and his vitals were ok. His labs were not drawn and the senior resident feels the team should complete the dementia work-up before the patient is discharged. She tells the intern to make sure the TSH is done this morning. The intern replies that it will be fine, he will just order it stat and it will be back in a few hours, it’s frustrating but he often has to do this because his orders get lost all of the time. Although the patient is some better, you are not quite sure about his readiness for discharge.

Question #1: How would you teach or evaluate Systems Based Practice after hearing this discussion in rounds? (OPEN ENDED)

KEY POINT #1: Talk about what systems based resources need to be tapped to properly assure that this patient is safe to be discharged. How could you assess if the team is working within the available resources efficiently?

Cues if needed: Ancillary services, PT/OT, rehab, social work, case management, nursing, etc.

KEY POINT #2: Identify a broken system as an opportunity to teach and evaluate. Talk about the lab ordering issue. How does this relate to systems based care?

Cues:

1. Recognize that this is a systems problem, and not due to “lazy or incompetent people”

2. Talk about the interns work around. Is that effective? What effects might that have on other’s in this system of care? Emphasize that any change to the system one creates, will likely have far reaching effects.

3. How could you talk with your team about fixing this problem?

a. What would they need to know to solve the problem?

b. Who would be key players involved in the change process?

REGROUP (25 Minutes):

Emphasize Take Home Points:

Systems Based Practice can be taught and evaluated in real time clinical teaching

2 Major Components:

1. Working within the present system

2. Identifying methods of improvement

a. Identifying the problem

b. Identifying how individuals’ actions affect others within the health care setting

c. Outline key issues in classic QI model to address problem

Practical Toolbox Items can be used to:

1. Teach in real time clinical practice

2. Label the teaching as systems based so that learners can understand what they are learning and why it is important

3. You do not need to know the answer to the systems problem to teach and evaluate the thinking about the problem.

Homework:

1. Identify one systems based issue in your own practice that you have not previously spent much time thinking about

2. In a teaching situation, try to identify and use a tool

EVALUATION IDEAS:

Pre and Post

Comfort with Teaching Systems Based Practice

Comfort with Evaluating Systems Based Practice

Knowledge about two components of systems based practice teaching

Knowledge about Plan Do Check Act Model of QI

Comfort with Discussing Plan Do Check Act

Knowledge about roles of ancillary services in caring for patients

Comfort in evaluating effective use of ancillary services

Ability to identify the systems based teachable moment

Ability to identify key stakeholders in systems based problems

Session #4: Practice Based Learning and Improvement

PBLI is also one of the newly added core competencies that has primarily been taught and evaluated in separate educational sessions or conferences. However, we are asked to teach and evaluate students and residents during our months on the inpatient service. In order to do this effectively, it is important to understand what the key components of the competency and have strategies to effectively teach and evaluate learners. In this session, we will focus on areas of the PBLI competency not adequately taught in other areas of the residency curriculum and the competency many of the teaching faculty are least comfortable in evaluating.

Learning Objectives:

By the End of this session, the learner will be able to:

1. Describe the key components of the practice based learning competency

2. Feel comfortable in teaching and evaluating aspects about this competency

3. Incorporate Case and Census Audits into their inpatient teaching activities

4. Advocate for the teaching and practice of these skills during actual clinical practice

Introduction and Debriefing (30 Minutes):

First, debrief about experience with homework assignment (5 minutes)

We have gone over several key areas of teaching on the wards today. The sessions have consistently tried to emphasize that our teaching activity is a process that tries to maximize educational opportunities, outstanding clinical care, and practical efficiency. Today we are going to use that same approach to thinking about the other new core competency, Practice Based Learning and Improvement. Similar to the other days, we will start with an introductory discussion, followed by a breakout session, and end by re-grouping with discussion.

Introductory Discussion:

Practice Based Learning and Improvement:

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:

• analyze practice experience and perform practice-based improvement activities using a systematic methodology

• locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems

• obtain and use information about their own population of patients and the larger population from which their patients are drawn

• apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness

• use information technology to manage information, access on-line medical information; and support their own education

• facilitate the learning of students and other health care professionals

We are going to focus on two of these areas in this session for two reasons. First, students already receive formal training in many of the other areas outside of their traditional clinical training. Second, the next session will focus on issues about life long learning skills. Third, for faculty interested in learning more about information retrieval or evidence-based methods, there are existing opportunities through existing general medicine faculty development courses that cover these in some detail. Finally, these are the components of the competency that may be most foreign to most faculty teachers.

Pre-comfort level—discussion

Why is it important?

Toolbox Model: Again, we hope to provide two methods that you can be used to teach and evaluate practice based learning concepts. Each of our examples provided, highlight geriatric content, but they can be used conceptually for any topic.

CASE AUDIT: The case audit is used to review your inpatient team’s care of a patient throughout the entire hospital stay. For this to be effective, you need specific measures of quality of care. You also need to create an environment in which self-reflection is encouraged and expected. It is key that the attending sets the example for providing a blame-free, self-improvement based arena when performing the case audit. When a problem area is discovered, the team will be responsible for not only identifying the area, but also determining why it happened and how to prevent it in the future. We recommend focusing these case audits on a select few processes of care during any one audit or a particular clinical topic e.g., delirium, polypharmacy to reinforce through this “teaching” case audit model-- topic review, accepted process of care measures and personal/team improvement in a focused clinical area.

CENSUS AUDIT: The census audit looks not at an individual patient in depth, but across all of the patients under your care. To do this effectively, pick a specific (probably single) measure of quality. Then review your entire patient census to see how your team is doing in meeting that measure of quality. Key parts to this tool: 1.When the results are not satisfactory, discuss reasons and come up with solutions. 2. Consider doing an early month and late month to assess change. 3. Consider doing this when work rounding as it builds this type of teaching and evaluating into the practice of patient care. 4. Label it as practice based learning.

BREAKOUT SESSION: CENSUS AUDITS (45mins.)

See census audit tutorial and sample census audits to be handed out at the end of the exercise.

Please refer to the slide presentation discussion using a sample census audit before starting the census audit tutorial. Have the faculty work through the tutorial in diads and finish as much of the tutorial as possible. Regroup with discussion and hand out the remainder of the sample finished census audits.

OPTIONAL BREAKOUT SESSION on Case Audits (45 Minutes):

During this breakout session, you will be role playing a team. One member is the attending, one is the resident, one the intern, and one is the medical student. Spend five minutes briefly reviewing the case on your own and then begin. The attending will be responsible for setting up the discussion for a case audit. She will use one or more of the tools provided to go through the care of the patient. Remember, to explore the how and why of those areas in which optimal care was not given in a way that is about improvement and not blame.

Case # 1

82 y/o WF with an ischemic cardiomyopathy (ej fx 20%), CRI, HTN, DM type II, admitted for with rapid afib and CHF exacerbation. Came in on digoxin 0.125 qd, coumadin 5 qhs, glucotrol 5 q AM, diovan 160 qd, lasix 80 BID, EC ASA81 qd, lipitor 10 q AM.

Long hospital course. Pt has been in the hospital for 3 weeks in and out of the ICU. Did not tolerate diltiazem, beta-blocker--poor rate control, more CHF.

D/C’d home on above meds and Amiodarone 200 q AM with HR in 60s in NSR. Hgb at baseline of 10.2, Cr of 2.4 baseline and K+ of 5.1. Fasting glc #s in the 160s.

Current exam with clear lungs, trace-1+ pedal edema, pulse ox 94% RA. Can ambulate to the bathroom with walker with mild SOB and 94% RA sat.

Practice-Based Learning and Improvement Review Tools

Geriatric Discharge Case Audit

A. Discharge Planning

Answer Yes or No or N/A, unless otherwise indicated.

1. Was the patient able to make his/her own decisions during hospitalization?

2. If not, had the next of kin been identified?

3. Had discharge planning been discussed with the patient and/or the next of kin?

4. Had the social worker been involved in the discharge planning?

5. Had the case manager been involved in the discharge planning?

6. Had the patient’s attending physician been involved in the discharge planning?

7. On which hospital day did discussion of discharge planning first occur? (Note: hospital day, #1, etc.)

8. If applicable, had the patient been assessed for rehab?

9. If applicable, had the patient been assessed for skilled nursing?

10. If applicable, had the patient been assessed for home nursing and home PT?

11. Were end-of-life wishes discussed with the patient or surrogate decision-maker?

12. If applicable, had hospice been explained and offered to the patient or surrogate decision-maker?

B. Transitioning Care

Answer Yes/No or N/A, unless otherwise noted

1. Was the patient’s attending physician notified of the patient’s admission to the hospital? If so when? (Hospital day #1, etc.)

2. Was the patient’s attending physician notified of the diagnoses, time, place and circumstances of the patient’s discharge?

3. Was the patient’s attending physician notified of outstanding tests upon discharge?

4. Was the patient’s attending physician notified of changes in medications upon discharge?

C. Patient Discharge Instructions

Answer Yes/No or N/A, unless otherwise noted

1. Were the patient’s discharge instructions written in a clear, concise manner?

2. Was follow-up arranged?

3. Was the timing of this follow-up appropriate?

4. Were medications reviewed for indication?

5. Was the medication dosing correct?

6. Were there potentially any clinically significant drug-drug or disease interactions with the medications prescribed?

7. Were medication instructions correct?

8. Were the medication instructions practical?

9. Could the patient afford these medications?

10. Were there any outstanding labs or tests at the time of discharge?

11. Was the attending physician or the transfer facility made aware of these labs or tests that needed follow-up?

12. As applicable, were monitoring lab tests needed or ordered at discharge?

13. Was the attending physician or the transfer facility aware of these tests needed or ordered?

OPTIONALDISCUSSION SESSION on CASE AUDITS(20 Minutes):

Discuss problems that occurred in the case audit and have the group come up with possible solutions.

Emphasize KEY POINTS OF Practice Based Learning:

You can teach this in real time clinical practice

A fundamental component of this competency is improvement

Label these activities as Practice Based Learning.

Homework:

1. Using your own practice, perform a census audit. Try using a clinic session or a ward service.

2. In a teaching situation, try to identify and use one of these tools.

EVALUATION IDEAS:

Pre and Post

Comfort with Teaching Practice Based Learning and Improvement

Comfort with Evaluating Practice Based Learning and Improvement

Identifying specific methods of teaching Practice Based Learning and Improvement

Identifying specific methods of evaluating Practice Based Learning and Improvement

Describe Case Audit

Identify 3 key components for success

Describe Census Audit

Identify 3 key components for success

Comfort Using Case Audit for:

Teaching Practice Based Learning and Improvement

Evaluating Practice Based Learning and Improvement

Comfort Using Census Audit for:

Teaching Practice Based Learning and Improvement

Evaluating Practice Based Learning and Improvement

Session #5: Lifelong learning

Inpatient medicine, like all of medicine, is a rapidly changing field and it may not be possible to keep up with all of the latest literature in hospital-based medicine. However, as faculty who attend on the general medicine service, it is important that we are not only able to teach residents and students from our clinical strengths, but also demonstrate how we are able to identify and answer questions that arise in our clinical practice. In this session, we will provide a theoretical framework for teaching medical learners in rounds about life long learning. We will then provide suggestions about how to translate the theory into practice with specific skills including: Asking learners probing questions, identifying learners’ knowledge gap, and phrasing clinical questions.

Objectives: By the end of this session, each learner will be able to:

1. List the categories of knowledge gaps

2. Construct a four component clinical question

3. Define and provide examples of clarifying and probing questions

4. Incorporate probing questions to learners during inpatient teaching

5. Assist learners in identifying knowledge gaps and composing effective clinical questions

6. List 2 –3 attending behaviors that role model life long learning (“I don’t know the answer to that; where can we look?” “What information do we need to make this decision?” or, if the technology is available, looking up something during rounds).

Introduction and Theoretical Framework: (30-45 Minutes)

Intro into why it is important

Asking questions is a major component of clinical practice and clinical teaching. It is also one of the best ways to model and ensure life long learning. These skills also link to the Practice Based Learning and Improvement Core Competency. However, asking questions is a complex process. In clinical teaching, we are always trying to maximize educational opportunities, clinical excellence, and practical efficiency. Emphasis on one of these outcomes may adversely affect the others, which requires that we are constantly searching for the ultimate balance at any given time.

Framework for clinical questions

Background/Foreground

Foreground

4 component model

Type of question

(Therapy, diagnostic, prognosis, risk factor/prevention)

Framework for Teaching by Asking

Clarifying/Probing

Case #1:

One of your short call admissions yesterday was an 80 year old woman admitted for hallucinations and failure to thrive at home. When you saw her in the Emergency Room with the team, she was sitting up on the cart, alert, conversant, and smiling. Her conversation consisted largely of descriptions of hallucinations, plus the fear that someone was trying to steal her money. Her purse contained a bottle of risperdal, with instructions to take 1 mg twice daily. Her exam was otherwise unremarkable, and her labs were normal. The team’s assessment was that she had not been taking her medication, and that she shouldn’t be living alone. She gets the full dose of risperdal and is still agitated overnight. The covering physician gives her a dose of ativan.

The next morning, the intern reported that the patient was awake but much less responsive, and wondered if this was her underlying personality. When you saw the patient, she was sitting up with her eyes open, but wouldn’t answer your questions and seemed significantly less responsive. The rest of her exam was unremarkable.

Using this case, begin an open ended discussion of the following:

What are some strategies for leading the team discussion about this patient?

TEACHERS NOTE

Strategy 1: tell the team that the patient probably has gotten too much risperdal, to hold the next dose, and then to reduce the dose to 0.5 mg bid

This strategy is effective in achieving the goal of providing appropriate patient care. It does not achieve the goal of teaching the team life long learning skills. This strategy is best used when time is short (house officers on the way to clinic, another patient crashing, etc)

Strategy 2: Ask a series of questions that will help the team identify their knowledge gaps:

How certain are we of the diagnosis “underlying personality?”

What other diagnoses should we consider?

How would we test for these diagnoses?

What do we need to know to formulate a treatment plan?

Probing Questions

First identify that there is a knowledge gap

Understand the spectrum (aka questioning spectrum) of possible learner driven questions a teacher could ask.

Open ended (What do we need to know to care for this patient) all the way to simply providing the answer.

It may be helpful to think about these from general to specific in a step wise path.

More generalized questions require more input from the learner and provide a richer view of the thought process

The more specific questions are more directed and can be time saving

It is the teacher’s responsibility to assure that a balanced mix types of questions are asked.

One Model for Asking Questions and Reflecting on the Questioning Process

In the EBM model of answering clinical questions, there are 4 primary question types that drive most clinical decisions. They are: 1. Therapy 2. Diagnosis 3. Prognosis and 4. Risk Factor This same model can serve as a possible framework to think about how to ask your team probing questions, maintaining a balance of left and ride side of the questioning spectrum.

Demonstration Case:

77 year old male with a long history of smoking, now with cough, weight loss, and significant mental status changes is found to have a sodium of 116. Several clinical questions start to arise that could be organized by the following:

Treatment (Treat now or wait until final work up. If now, how)

Diagnosis (Hypervolemia, euvolemia, hypovolemia)

Prognosis (How sick is this patient?)

Risk Factor/Prevention (Does this patient need falls prevention?)

Breakout Session (30-45 Minutes)

The team presents a case of a 75 year old woman with a lower extremity proximal DVT. Her past medical history is notable for a diverticular bleed 6 months ago. The team wants to put in an IVC filter, rather than anticoagulating her.

Help the team identify their knowledge gaps:

Questions to be discussed

Provide some examples of general and specific questions

TEACHERS NOTES

Most General to Most Specific:

What do we need to know to make a treatment decision?

What risks do we need to identify, and quantify if possible?

What do we need to know about treatment benefits?

What is the likelihood that she will have a recurrent GI bleed that would be of high risk given her history of diverticular bleed 6 months ago?

Given her age, is her risk of anticoagulation significantly higher than a similar 40 year-old patient?

“Answers” to what is needed to answer the more general questions:

Risk of recurrent DVT

Etiology of DVT (idiopathic, thrombophilia, etc)

Risk of recurrent diverticular bleed

Risk of bleeding with warfarin therapy

Magnitude of risk of recurrent DVT with warfarin

Effects of filters: PE, DVT rates

Re-Group (20 Minutes)

Asking questions is a key part of what we can do and really models life long learning

As we have emphasized throughout these sessions, teaching is a process that can be reflected on and improved.

The methods we went over today can hopefully serve two purposes:

1. A possible method for incorporating open ended probing questions into our teaching practice

2. A method to practice self-assessment to make sure that we are asking the right balance of general and specific questions that drive clinical decision making.

Evaluation Ideas:

Knowledge: Theoretical framework, 4 types of questions (treatment, dx, prognosis, risk/prevention), define background/foreground, clarifying/probing

Describe strengths and weaknesses of:

5. Most general questions (what do we need to know to take care of this patient)

6. Most specific questions (What dose of ceftriaxone do you use in the initial treatment of presumed bacterial meningitis?)

Attitudes: Self-evaluation of comfort with using these skills specifically. Comfort with coming onto the wards/teaching on the wards.

Comfort with balance of general versus specific questions

Skills:

Behavior: Self-reported

Observation

Learner

Attending Rounds

Selected References:

1. Skeff KM, Stratos GA, Bergen MR, Albright CL, Berman J, Farquhar JW, Sox HC, Jr. The Stanford Faculty Development Program for medical teachers: A dissemination approach to faculty development for medical teachers. Teaching and Learning in Medicine 1992;4(3):180-187.

2. Elliot DL, Skeff KM, Stratos GA. How do you get to teaching improvement? A longitudinal faculty development program for medical educators. Teaching and Learning in medicine 1998;11(1):52-57.

3. LaCombe M. On bedside teaching. Ann Intern Med; 1997 126 (3):217-220.

4. Ende J. What if Osler were one of us? J Gen Intern Med; 1997 12(s2):41-50.

5. Hatem CJ. Teaching approaches that reflect and promote professionalism. Acad Med 2003;78:709-713.

6. Whelan CT, Podrazik PM, Johnson JK. A case-based approach to teaching practice-based learning and improvement on the wards. Semin Med Pract 2005; 8:64-74.

7. Mohr J, Randolph GD, Laughon MM, Schaff E. Integrating improvement competencies into residency education: A pilot project from a pediatric continuity clinic. Ambulatory pediatrics 2003; 3(3):131-136.

8. Ogrinc G, Headrick LA, Morrison LJ, foster T. Teaching and assessing resident competence in practice-based learning and improvement. JGIM 2004;19:496-500.

9. House BM, Chassie MB, Spohn BB. Questioning: An effective ingredient in effective teaching. J Contin Ed Nurs 21(5): 196-201.

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