Teaching about Dementia In a Clinical Setting

1. Teaching about DementiaIn a Clinical Setting Using the Microskills of TeachingPrepared by Wayne Weston

2. Question… What are some opportunities to help our students and residents learn about the practical uses of cholinesterase inhibitors?

3. Objectives At the end of this session, participants will be able to: Describe the eight microskills for clinical teaching; Use the various components of the framework in your own clinical teaching (e.g. needs assessment, priming & feedback); Apply these skills in teaching about the use of cholinesterase inhibitors in dementia; Discuss how to start, switch, or stop cholinesterase inhibitors.

4. The teaching/learning process tends to be more effective if: Individuals are intellectually active in the learning process Individuals have opportunities for practice with feedback, the goal of the latter to help them identify the success of their learning Individuals have opportunities for reflection Individuals are clear about what to learn

5. The Value of Active Involvement

6. The “One Minute” Preceptor Eight microskills: Needs assessment Priming Get a Commitment Probe for Supporting Evidence Reinforce What Was Done Well Correct Mistakes Teach General Rules Reflection & Integration

7. Microskill # 1 – Needs Assessment One of the most important teaching skills. Essential first step in deciding what to teach Want to focus on areas that the student needs to work on rather than on things they have already mastered Use orientation to find out: What they have done before What they would like to get out of the rotation/case

8. Needs Assessment, cont’d. Global needs assessment – best guess based on: Curriculum outline and objectives Previous experience with students at the same level Specific ongoing needs assessment based on: Orientation Priming Questions Observing with patients Case presentation Chart review

9. More on Orientation Think about the things that will facilitate their learning on the rotation (i.e. When you were starting a new rotation, what did you wish someone would tell you to help you get off to a good start?) Climate setting Approach to supervision and teaching Student assessment Additional items

10. Microskill # 2 – Priming Preparing learners before they see patients

11. Priming Create some relevance or experiential link Ever work in this environment before (i.e. E.R., wards etc.)? Ever see or manage a case like this before?

12. Priming, cont’d. Clarify the task Separate and acknowledge the difference between The learning objectives for seeing this case The service/support requirements of the case Define what questions will need to be answered following the case What is the diagnosis or Differential diagnosis? How will we differentiate these? How will we manage the symptoms? What are the patients outcome goals? What is the prognosis?

13. Priming, cont’d. Learning focused on diagnostic skills,"Meet me back here in 15 minutes and present a problem list and differential" Learning focused on management issues,"The diagnosis is pretty clear. Review all the results with the patient, discuss the treatment options and let me know in about 30 minutes what you think will work the best for her". The learner must feel safe enough to risk a commitment – even if it is wrong.

14. Priming, cont’d. Promote reflection: Ask students to report not only on their clinical findings but also their own thoughts & feelings Self-observe what they do to prepare for each patient visit Ask, “How might your prior experience with patients affect your decision-making in this case?” Give them time for reflection &/or to look things up From Ron Epstein: Mindful Practice in Action II, Family Systems & Health, Spring 2003.

15. Priming, cont’d. Decide on the roles of teacher & student when going back in the room Student conduct the interaction Consider a short role play Decide on a “bail out” plan if necessary Teacher take over – outline your plan so that the student knows what to look for (but acknowledge it may change depending on what happens in the interaction) Some combination of above – be clear about who does what

16. Include the Patient in priming Saves time Patients like it Involves the patient Priming is even more important to help student perform well & avoid embarrassment Opportunity to model effective interaction Make sure patient did not misunderstand comments

17. Microskill #3 – Get a Commitment The learner must feel safe enough to risk a commitment – even if it is wrong.

18. Microskill #4 – Probe for Supporting Evidence What......( factors make this diagnosis likely)? Why...... (do you suggest getting this test first?) Which......(medications are available for this condition?) How...... (did this prognosis emerge as the most probable?)

19. Microskill #5 – Reinforce What was Done Well Some examples: "You did a good job of considering multiple possibilities and prioritizing the most probable diagnoses" "I noticed how well you considered the patient’s age and concerns about cost in selecting medications"

20. Microskill #6 – Correct Mistakes "I agree this patient’s headache is worrying him, but from the history and in the absence of neurological signs, CT is more likely to distract us with false positive findings than change the diagnosis or management plan. Let me give you some good references on that and help you discuss this with the patient." "That drug is often a good first choice for this condition, but she is also taking warfarin (or has an elevated creatinine) and the interaction would be dangerous."

21. If the Student had Difficulties Answer a few questions Short role play of part of the interview that the student had trouble with – to consolidate learning Suggest references for review after the office

22. Feedback Grid

24. Time Frequent short feedback vs. marathon sessions E.g. beginnings, middle issues, endings Teach reflection & self-assessment Involve others e.g. nurse, peers, patients

25. The Feedback Process Private setting. Postpone feedback when you are angry. Invite self-assessment first. Link feedback with learner’s objectives. Use the feedback grid – “continue…” & “do different”. Compare self-evaluation with your observations.

26. The Feedback Process, cont’d. Elicit or suggest alternative behaviours. Address realistic changes in doable steps. Provide an opportunity to try again (with real patient, simulated patient or role play). Establish clear follow-up plans.

28. Microskill #7 – Teach General Rules "In older patients with headache, it is important to consider glaucoma and temporal arteritis as well as the primary headaches" “When both parents come with a sick child, it usually indicates they are very worried and we need to pay extra attention to their concerns."

29. Microskill #8 – Encourage Reflection and Integration "How did things go today from your perspective?“ ”Who was you most interesting patient this afternoon?“ "How is the practice different from your expectations?“ "Did anything surprise you today?“ Encourage them to keep a personal journal of their reflections

31. Videotape example

32. Exercize… Work in small groups of 6-8 Roles of group members: Facilitator Recorder/reporter Expert Resident – this role can rotate Teacher – this role can rotate

33. Roles for resident Use one mentioned in the initial discussion of opportunities Margaret Jones with dementia – consideration of switching meds – prime the resident End of a busy day. Discuss Martin Schwartz – family wonders about Exelon Chart review – ?inappropriate switch to Exelon

34. Your task Decide who does what Select one of the role plays Strategize briefly Role play Get feedback Re-do part of the role play if desired or get someone else to try it If time, do another role play Report on what you learned