MEDICAL TEACHING IN THE ACUTE CARE SETTING

1. MEDICAL TEACHING IN THE ACUTE CARE SETTING Michael E. Mahla, MD Professor of Anesthesiology and Neurosurgery Assistant Dean for GME

2. Review the opportunities and challenges of teaching in the acute care setting and how these differ from “traditional” clinical medical teaching. • The ACGME Competencies in the acute care setting – which are important • Challenges of production pressure • Suggest techniques for optimizing education in the acute care setting – the Dreyfus model and the BID model • Assessment of the competencies in the acute care setting – integration of the Dreyfus model. Lecture Goals

3. Patient Care Skills – Defined by program requirements • Medical Knowledge – Defined by program requirements and Board Examinations • Professionalism • Interpersonal and Communication Skills • Systems-Based Practice • Practice-Based Learning and Improvement The Six Core Competencies and Acute Care Teaching

4. A Scenario 49 yo male with history of colon CA, S/P resection and chemotherapy presents to ER with extreme SOB sitting bolt upright. History of increasing UE and facial swelling likely secondary to developing SVC syndrome. Infusaport in place – scheduled to be electively removed in 48 hours. The patient is very frightened. Room air SpO2 = 85%, improved to 92% on facemask oxygen. All accessory muscles in use, patient cannot speak more than 2-3 words without stopping.

5. Anesthesiology resident is called to the ED to urgently secure this patient’s airway. Attending accompanies the resident to the ED. • Questions: • How much should the resident do in this life-threatening situation? • How can education occur in this life-threatening situation? A Scenario

6. The Problem

7. Another Scenario 54 yo female is brought to the operating room emergently for craniotomy and removal of intracranial mass. She was seen in clinic the previous day and admitted for surgery. On the morning of the scheduled surgery, she is found unresponsive. Intubation attempt on the floor was unsuccessful, and she is brought emergently to the operating room for treatment of developing herniation syndrome.

8. Questions Should the resident be allowed to manage the airway given previous failed intubation attempt? What educational opportunities are there in this acute emergency?

9. Another scenario 49yo female with severe rheumatoid arthritis presents for elective anterior cervical corpectomy followed by posterior cervical fusion. The patient has a history of well-controlled hypertension treated with lisinopril. No other significant medical history other than rheumatoid arthritis treated with gold, Imuran, and steroids. The patient is developing increasing difficulty walking. Preoperative discussion and planning with the attending physician occurred.

10. How is this scenario different from the previous two? • What options are there for teaching / learning in this case that were not available in the other cases? Another scenario

11. The Challenges • Content and Direction of teaching often cannot be determined in advance • What do I want to learn today?  Learning What did you learn today? • Infrastructure for learning may not be in place if acute care learning presents challenges the student is not ready to handle. • Learning may be inappropriately repetitive when the learner is repeatedly exposed to scenarios that may be mastered in one or two exposures. Acute Care Teaching

12. The Challenges • Much of acute care learning has been based solely on “Learning by Doing.” • Pure discovery model of learning – ASSUMPTION: students will develop appropriate rules and understandings to guide future practice. • Mayer RE. Should there be a three-strikes rule against pure discovery learning? The case for guided methods of instruction. Am Psychol 2004; 59: 14-19. • Discovery learning is ineffective and inefficient. • Does not guarantee students will come in contact with needed learning opportunities • Does not guarantee that students will learn the rules to appropriately guide future practice. Acute Care Teaching

13. The Challenges • Teaching and patient care must occur simultaneously. • No teaching of this skill. • Many excellent clinicians cannot teach when their clinical skills are taxed. • Many excellent teachers cannot apply their clinical skills at the same time as teaching. • Learning depends on learner not teacher. • Quality, quantity, and content of learning variable from learner to learner. Acute Care Teaching

14. The Challenges • Teaching adds stress to an already stressful situation. • Burn-out is common. • The challenged learner  exaggerated negative feelings in the teacher • The “challenged” teacher is prone to negative behavior. Acute Care Teaching

15. The Benefits • IMPACT, IMPACT, IMPACT • The impact of acute care medicine will often fix concepts in the learner’s memory better than in any other learning environment. • Example: Failed traditional intubation  hypoxemia  subsequent application of difficult airway algorithm resulting in safe, successful intubation of the trachea. • Impact is a two-edged sword for multiple reasons, however. • Can firmly fixate WRONG concepts and approaches which just happen to work in one instance. • Can completely overwhelm the learning and render useful integration of the experience impossible. Acute Care Teaching

16. The Benefits • To the teacher, acute care is rarely boring and presents both patient care challenges and educational challenges simultaneously. • Patients presenting with the same problems commonly behave differently. • Learners faced with the same problem rarely learn the same way. Acute Care Teaching

17. Based on what is presented: • Many challenges • Few benefits – and some of the benefits are actually “veiled” challenges. • Many who are charged with teaching in the acute care setting: • Struggle with production pressure – academic medical centers clearly must be competitive with private institutions. • Education takes 2nd place – and a distant second at that. • Many educators have turned to simulation to address most of these challenges. Where do the scales tip?

18. How can we as educators improve the effectiveness of teaching in the acute care setting and overcome many of the challenges presented? Acute Care Teaching

19. Acute Care Teaching

20. Acute Care Teaching

21. Knowing the learner is key to actively taking control of learning in the acute care setting. • May be difficult when there are many housestaff and medical students • Depends on an effective, objective evaluation system that is readily accessible to the faculty. • May cause bias in the approach to the student. Know your learner

22. Dreyfus Model of Skills Acquisition: • Novice • A novice is all about following rules – specific rules, without context or modification. • Don’t need to “think” just “do”. • A rule is absolute, and must never be violated. • Get experience following directions and doing the new skill. All the learner is responsible for is following directions. • Learning environment is safe. • Learn the rules and correction applied when rules are not followed. Know your learner

23. Evaluation is based entirely on being able to spit out / apply rules-based responses. • Example • BLS Know your learner

24. Advanced Beginner • Still rules based, but rules start to have situational conditions. • In one situation you use one rule, in other situations you use another. • The advanced beginner needs to be able to identify the limited need to selectively apply different rules. This is still rules-based, but has a few decision points. • Learner must be able to follow branch points and appropriate apply different rules. • This stage of competence could collapse into a larger Novice category without appropriate mentoring. • Learner is now responsible for some recognition. Perception is important. • Example - ACLS Know your learner

25. Competent • Realization that learner’s skill or domain is more complex than a series of rules and branches. • Learner sees patterns and principles (or aspects) rather than a discrete set of rules – rules become “rules of thumb”. • Learner is led more by his/her experiences and active decision-making than by strictly following rules. What is developed now are guidelines that help direct competent individuals at a higher level. Know your learner

26. Competent • Learner is now accountable for decisions as he / she is not following the strict rules and context of the previous stages. If a decision made doesn’t produce the desired result, the learner takes responsibility. • Critical tipping point for most people – and why most people never really become “competent” in most things they learn. • Learner must decide to just “follow the rules” or spend the time to get fully involved with and take responsibility. • This is a KEY Branch point that should guide all teaching in the acute care setting • Evaluation to determine whether someone is competent must therefore have input from the learner. Know your learner

27. Proficient • At this point the learner’s understanding of the skill or domain has become more of an instinct or intuition. • Learner will do and try things because it just seems like the right thing to do (and will most often be right). • Perceives systems rather than discrete set of different parts. • Recognizes that there are often multiple competing solutions to a specific problem and has a “gut feeling” about which is correct. • Quickly knows “what” needs to be done and then formulates how to do it. Know your learner

28. Difficult • Much disagreement about what constitutes necessary skills for each level. • Important to develop consensus in your program. • Defining the Stages carefully will allow each teacher to direct teaching appropriately. • Must be aware of the competency of each learner. Define the Stages of Competency

29. Using the cases presented earlier, let’s teach the novice, advanced beginner, and competent learner. • The examples involve anesthesiology trainees, but should be readily applicable to other acute care situations – use your imagination to apply these concepts to your situations. Acute Care Teaching

30. 54 yo female is brought to the operating room emergently for craniotomy and removal of intracranial mass. She was seen in clinic the previous day and admitted for surgery. On the morning of the scheduled surgery, she is found unresponsive. Intubation attempt on the floor was unsuccessful, and she is brought emergently to the operating room for treatment of developing herniation syndrome.

31. Patient’s airway must be secured rapidly because of non-responsive state and elevated intracranial pressure. • Decompressive surgery must be accomplished very quickly to avoid transtentorial herniation. The Issues

32. What does the novice “want” to do? • EVERYTHING!! • What “should” the novice do? • APPLY THE RULES! • What are the rules? These must be very clear to the novice. • Securing the airway rapidly avoiding hypoxemia or hypercapnia is essential in the patient with herniation syndrome. • The patient must be prepared as quickly as possible for surgery. Teaching the Novice

33. Teaching the Novice

34. Advanced beginner now has some technical skills and some experience evaluating patients Teaching the advanced beginner

35. 54 yo female is brought to the operating room emergently for craniotomy and removal of intracranial mass. She was seen in clinic the previous day and admitted for surgery. Pertinent medical history includes significant coronary artery disease treated with 4 drug-eluting stents. The patient takes 1 baby aspirin and Plavix daily. On the morning of the scheduled surgery, she is found unresponsive. Intubation attempt on the floor was unsuccessful, and she is brought emergently to the operating room for treatment of developing herniation syndrome.

36. What does the advanced beginner “want” to do? • EVERYTHING!! • What “should” the advanced beginner do? • APPLY THE RULES! • Use acquired skills. These may include airway management and line placement assisted as needed. • What are the rules? These also must be very clear to the advanced beginner as well as the situational judgment component. • Securing the airway rapidly avoiding hypoxemia or hypercapnia is essential in the patient with herniation syndrome. • Significant coronary artery disease needs to be investigated and appropriately evaluated / treated prior to surgery. • Coagulation status will likely be a problem – needs evaluation and planning. • Rapidly preparing the patient for surgery and starting surgery overrides other considerations. Teaching the Advanced Beginner

37. The advanced beginner is taught that surgical considerations (e.g. in this case need for speed) may override assessment of the patient’s exercise tolerance, frequency of angina, stability of angina, coagulation status (aspirin and plavix) which would occur prior to elective surgery. Teaching the Advanced Beginner

38. Teaching the Advanced Beginner

39. Learner sees patterns and principles (or aspects) rather than a discrete set of rules – rules become “rules of thumb”. • Learner is led more by her/his experience and active decision-making than by strictly following rules. • Learner is now accountable for decisions as she / he is not following the strict rules and context of the previous stages. If a decision made doesn’t produce the desired result, the learner takes responsibility. Teaching the Competent

40. Another scenario 49yo female with severe rheumatoid arthritis presents for elective anterior cervical corpectomy followed by posterior cervical fusion. The patient has a history of well-controlled hypertension treated with lisinopril. No other significant medical history other than rheumatoid arthritis treated with gold, Imuran, and steroids. The patient is developing increasing difficulty walking. Preoperative discussion and planning with the attending physician occurred.

41. Resident physician has reviewed pathophysiology of RA and recognizes the instability of the cervical spine. • He also recognizes the significance of spinal cord compression and need to avoid significant hypotension. • He also recognizes the interaction of an ACE-inhibitor with general anesthetics (significant risk of hypotension). • He develops a plan. The teacher: • agrees with plan. • would manage the patient differently, but the plan is rational and should be fine. • feels plan is not a good one. Teaching the Competent

42. Resident decides to manage the airway with an awake, sedated intubation and awake positioning to minimize neurologic injury. • He did not recognize the patient’s emotional state and extreme anxiety about waking up paralyzed from this surgery. • The patient cannot tolerate the awake intubation. Teaching the competent

43. If you were correct about his skill level (competent), then the learner should….. Teaching the Competent

44. The competent physician learns that evaluation of the patient’s emotional state prior to dangerous surgery may lead to significant alterations of the anesthetic plan. The competent physician feels chastened that this evaluation was not done and resulted in failure of the plan. This experience enables avoidance of the problem again. Experience teaches the competent. Teaching the Competent

45. Teaching the Competent

46. Teaching the Competent

47. Roberts NK et al. The Briefing, Intraoperative Teaching, Debriefing Model for Teaching in the Operating Room. J Am CollSurg 2009; 208: 299-303 • Readily applicable to other acute care settings. • Provides a framework for learning somewhat similar to the more traditional methods of learning – but works in the acute care setting. Additional Tools for Teaching in the Acute Care Setting

48. Guided discovery versus pure discovery. • Guided discovery: • Expert provides learner with preparatory information BEFORE the experience. • Provides appropriate level of verbal and manual guidance during the acute care experience. • Gives feedback afterward. • Mayer RE. Should there be a three-strikes rule against pure discovery learning? The case for guided methods of instruction. Am Psychol 2004; 59: 14-19. • Mayer demonstrated that guided discovery learning occurred more quickly (efficient), was more accurate, and was better retained than pure discovery learning. BID Model

49. Scallon SE et al. Evaluation of the operating room as a surgical teaching venue. Can J Surg 1992; 35: 173-6. • 60 cases observed in the OR. Clinical teaching in the OR occurred in fewer than 50% of cases! • What teaching did occur tended to cover history, physical findings, diagnosis, complications. It did not include operative planning discussions or discussions of the teaching physician’s past experiences with patients with similar problems. BID Model

50. Roberts NK et al. Toward a precise and practical model of debriefing for surgical education (poster AAMC meeting 2008). • Typical OR teaching to surgical trainees has three defining characteristics • Focused on getting through the case efficiently and effectively • Didactic teaching was mainly opportunistic – events trigger teaching “scripts” • Learning is likely to be defocused. BID Model