The Microskills of Clinical Teaching and Learning

1. The Microskills of Clinical Teaching and Learning

2. Objectives • Describe characteristics of effective clinical learning encounters • Identify, analyze and practice effective clinical teaching, using the One Minute Preceptor

3. Residents make a major contribution to student education Teaching improves resident learning and acquisition of knowledge “to teach is to learn twice” Miriam Bar-on, MD Residents as Teachers

4. Effective Clinical Teachers Communicate expectations explicitly Stimulate interest enthusiastically Interact skillfully with patients Involve the learner in the teaching process Role model desired behaviors Give feedback on performance & Learners Irby DM. Ramsey P, Gillmore J, Schad D. Characteristics of effective clinical teachers of ambulatory care medicine. Acad Med, 1991:66:54-55.

5. Time Time Time What are the challenges for teaching in the clinical setting? Irby DM. What clinical teachers in medicine need to know. Acad Med 1994;69:333-342.

6. Irby 2000

7. Validated model for effective and efficient clinical teaching Developed for outpatient clinic but can be used with learners in any clinical setting Promotes the learner’s independence and active involvement in patient care Encourages the teacher to recognize “teachable moments” One-Minute Preceptor Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

8. And Best of All… • Allows for simultaneous care of patients and learners…

9. Assess prior knowledge Get a commitment Probe for evidence Give positive feedback Identify and correct mistakes Teach the general rule Encourage reflection and promote self directed learning One Minute Preceptor Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

10. Assess the learner’s knowledge and prior experience Establish goals for the encounter Microskill #1: Assess Prior Knowledge

11. Learners: Would you feel ready to see this patient? Teachers: How might the teacher have helped the learner in advance of seeing the patient? Microskill #1Assess Prior Knowledge VIDEO

12. Assess prior knowledge Get a commitment Probe for Evidence Give positive feedback Identify and correct mistakes Teach the general rule Encourage reflection and promote self directed learning One Minute Preceptor Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

13. What is going on? The learner commits Can be risky The teacher’s goal is to provide a supportive and safe environment Pay attention to tone and body language Microskill #2Get a Commitment

14. What do you think is going on? (Differential diagnosis) What investigations should be ordered? (Diagnostic strategy) What is your first choice of medication? (Selection of therapy) What do you think is probably going to happen? (Prognosis) What would you like to achieve in this visit or patient encounter? (Management issue) Ask The “What?” Question

15. Microskill #2Get a Commitment • How might the teacher have solicited a commitment from the learner? VIDEO

16. For the Learner: Difficulty in making a commitment may be due to ? What Gets in the Way?

17. For the Teacher: Difficulty in making a commitment may be due to: Fear of silence Fear of being wrong Knowledge gaps Fear of being too demanding Fear of falling behind in patient care What Gets in the Way?

18. Assess prior knowledge Get a commitment Probe for Evidence Give positive feedback Identify and correct mistakes Teach the general rule Encourage reflection and promote self directed learning One Minute Preceptor Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

19. Encourage the learner to think out loud Share rationale for commitment Why do you think that is so? “What if…?” questions allow you to further identify the learning edge and push to the next level Microskill #3Probe for Evidence

20. What was done well? What could have been done better? Microskill #3Probe for Evidence VIDEO

21. Assess prior knowledge Get a commitment Probe for Evidence Give positive feedback Identify and correct mistakes Teach the general rule Encourage reflection and promote self directed learning One Minute Preceptor Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

22. Reinforce what was done right Use language that is specific and behavioral, not just vague praise “You did a good job of considering multiple diagnoses and prioritizing them”. “I noticed how well you considered the patient’s age and concerns about cost in selecting medications.” Microskill #4Give Positive Feedback

23. Assess prior knowledge Get a commitment Probe for Evidence Give positive feedback Identify and correct mistakes Teach the general rule Encourage reflection and promote self directed learning One Minute Preceptor Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

24. Correction must be specific and focused “That drug is often a good choice but in the setting of renal failure is contraindicated.” “In children who present with diarrhea and vomiting, assessing the urine output is essential.” Microskill #5Identify and Correct Mistakes

25. Was this useful feedback? How might the learner have handled the situation differently? Microskills #4/#5Reinforcing and Corrective Feedback VIDEO

26. Assess prior knowledge Get a commitment Probe for Evidence Give positive feedback Identify and correct mistakes Teach the general rule Encourage reflection and promote self directed learning One Minute Preceptor Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

27. Choose a rule at the learner’s level Consider content areas outside medical knowledge Professionalism Communication Skills Behavioral and Social Science Domains Microskill #6Teach the General Rule

28. When I see a patient like this, I think about… “In school age children presenting with headache I always consider myopia in the differential.” “ When I see a rash that I cannot diagnose, I define it as best as I can and then look it up in…. If we don’t solve the problem by looking at that reference, we need to call…” Microskill #6Teach the General Rule

29. Assess prior knowledge Get a commitment Probe for Evidence Give positive feedback Identify and correct mistakes Teach the general rule Encourage reflection and promote self directed learning One Minute Preceptor Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

30. At the end of your session or at the end of the patient encounter “What do you feel you did well?” “What was most challenging?” “How did the practice differ from your expectations?” “Did anything surprise you today?” Microskill #7Encourage Reflection and SDL

31. “What is your next question?” “Based on this case I’d like you to formulate your next question and go to the literature to answer it…we’ll discuss it tomorrow.” Practice-based learning Microskill #7Encourage Reflection and SDL

32. What did the learner do well? What did the teacher do well? Microskills #6/#7General Rules, Reflection and SDL VIDEO

33. In clinical practice Reflection on, in, and for action In clinical education Teach Reflect Teach some more Reflective Practice

34. Feedback is embedded Allows for improved teaching AND assessment… By questioning you are not only creating a stimulating learning environment but also assessing the learner’s knowledge One Minute Preceptor Advantages

35. The 7 Wicroskills of Teaching

36. Acknowledgments This workshop was developed by: • RiniRatan, MD • Andrew Mutnick, MD • Lyuba Konopasek, MD • Sue Bostwick, MD