Time Efficient Clinical Teaching

1. Time Efficient Clinical Teaching Tali Ziv, MD KLIC-UCSF Internal Medicine Site Director Assistant Chief of Medicine, Kaiser, Oakland

2. Session Outline • Background • Introduction to the One-Minute Preceptor Model • One-Minute Preceptor Practice • Introduction to SNAPPS • Introduction to feedback and the Brief Structured Clinical Observation (BSCO) • RIME Framework

3. Challenges with Clinical Teaching • Time pressure • Competing demands • Unpredictable environment • Limited recognition for teaching • Variable patient acceptance of learners

4. One-Minute Preceptor • Teaching model initially developed for use in the outpatient setting3 • Involves 5 steps: • Get a commitment • Probe for supporting evidence • Teach general rules • Reinforce what was done right • Correct mistakes Neher et al. JABFP 1992.et al. JABFP 1992.

5. OMP: Step 1 • Get a commitment from the learner • Ask the learner what he/she thinks about the case • Get a commitment to a diagnosis, work-up, treatment WHAT> Why> Pearl> Good> Improve

6. OMP: Step 2 • Probe for supporting evidence • Ask the learner for evidence to support their opinion • This allows faculty to identify gaps in knowledge What> WHY> Pearl> Good> Improve

7. OMP: Step 3 • Teach general principles • Introduce a relevant rule or concept targeted to the learner’s level of understanding What> Why> PEARL> Good> Improve

8. OMP: Step 4 • Reinforce what was done right • Reinforcing correct behavior helps the behavior become firmly established • Focus on specific behaviors rather than general praise What> Why> Pearl> GOOD> Improve

9. OMP: Step 5 • Correct mistakes • As soon after mistake as possible, find an appropriate time to discuss • If possible, allow the learner to critique his/her performance first What> Why> Pearl> Good> IMPROVE

10. OMP Step 0 • Set a constructive learning environment. • Consider: • Space • Time • Players and roles • Goals and expectations • Prime the learner for the encounter

11. OMP Step 6 What are the next steps? What are the “to dos,” and who’s taking responsibility for them? Highlight key themes experienced in session that could be explored further. Equip the student with tools to maximize organization and efficiency.

12. OMP Clip

13. OMP: The Evidence • OMP faculty training associated with an increase in specific feedback in ambulatory encounters4 • Videotaped teaching encounters: OMP vs Traditional • Faculty student skill assessment improves5 • Students felt feedback better with OMP6 4. Salerno S. J Gen Int Med 2002. 5. Aagaard E. Acad Med 2004. 6. Teherani A. Med Teach 2007.

14. OMP Practice

15. SNAPPS Wolpaw TM et al. Acad Med. 2003. Summarize briefly the history and findings Narrow the DDx to 2-3 possibilities Analyze the DDx by comparing/contrasting Probe the preceptor about questions, uncertainties Plan mgmt for patient’s medical issues Select a case-related learning issue

16. SNAPPS – The Evidence Wolpaw T et al. Acad Med. 2009. • Third-year medical students receiving SNAPPS training • More concise in their summaries • Presentations longer (1 min) • Expressed more clinical reasoning in presentations • Expressed more uncertainty • Identified case based issues for further learning

17. Feedback • Information on the student’s performance given for the purpose of improving future performance • Analogous to coaching

18. Tips for Giving Feedback • Immediate and often • Self-reflection first • Both positive and corrective • Focus on behavior - not person • Specific, not general • Amount limited to what the student can incorporate (not too much!) • Check to ensure clear communication

19. Brief Structured Clinical Observation (BSCO) • Tool for brief, real-time feedback • Attending enters patient room during patient encounter • Watches silently • Leaves when 3 feedback points obtained • Feedback discussed that day

20. BSCO Practice

21. Incorporating the BSCO

22. BSCO Tips • Orient student and patient • Consider asking student for focus • Try to remain silent and “invisible” • Consider times when you are required to be in the room anyway

23. RIME Framework (Observer) Reporter Interpreter Manager Educator

24. OBSERVER - struggling to report accurately REPORTER • Works professionally with patients, staff, colleagues; complete, reliable, accurate; gathers info, clearly communicates with proper terms • Understands pathophysiology • Answers “What” questions. INTERPRETER • Identifies, prioritizes problems • Offers 2 or 3 reasonable possibilities with reasons applied to the patient. (Students do not have to be “right”) • Answers "Why" questions.

25. MANAGER • Selects among options with the patient • Proactive rather than simply reactive • Plans should be reasonable, include test options, student’s preferences, merits of therapies • Answers “How" questions. EDUCATOR • Identifies questions that can't be answered from textbooks • Cites evidence on relevant new therapies, tests • Active in educating self, colleagues, and patients

26. Summary • Orient learner to goals/expectations • Choose a tool for clinical teaching (?OMP vs SNAPPS) • Incorporate frequent observation and feedback (?BSCO) • Think about your learner’s skill level (RIME?) and next steps in their path

27. Thanks Special thanks to Maria Wamsley, MD who often teaches this topic with me. She has efficiently and effectively guided me on a personal path to improving my skills in Faculty Development with timely and constructive feedback  Much appreciated!