R esident E ducator D evelopment

1. ResidentEducatorDevelopment The RED Program A Residents-as-Teachers Curriculum Developed by Heather A. Thompson, MD

2. The RED Program • Team Leadership • How to Teach at the Bedside • The Microskills Model: Teaching during Oral Presentations • How to Teach EBM • The Ten Minute Talk • Effective Feedback • Professionalism • Patient Safety and Medical Errors

3. The Microskills Model:Clinical Teaching DuringOral Presentations Resident Educator Development (RED) Program

4. What is the Microskills Model? • A 5 step process of clinical teaching • Can be used during oral presentations, bedside or sit-down rounds, or any other case-based discussion • Originated in the business literature and was applied to clinical medicine as a model for enhancing education Neber, J.O., Gordon, K.C., Meyer, B., and Stevens, N. “A Five Step Microskills Model of Clinical Teaching” J Am Board of Family Practice 5:419-424, 1992.

5. Is there data? • Faculty members who had completed training in the Microskills model had improved scores on feedback --Journal of Gen Int Med 17(10) 779-87 Oct 2002 • Randomized trial of Microskills training vs. no training in surgical residents: Improved scores on an OSTE station --Academic Medicine 73(6) 696-700 June 1998

6. The 5 Steps • Get a commitment • Probe for Supporting Evidence • Teach General Rules • Reinforce what was done right • Correct Mistakes

7. Get a commitment • After presenting the facts of a case to you, the learner may stop and wait for your response. • Instead of telling them the answer, ask them to state what he or she thinks about the issues presented by the data.

8. Get a commitment • Examples— • “What do you think is going on with the patient?” • “How can you tie all of this together?” • “What would you like to accomplish with this hospital stay (or clinic visit)?” • NOT: “This is obviously a case of viral meningitis.”

9. Probe for Supporting Evidence • After committing him or herself on the presenting problem, the learner may look to you to either confirm or refute the opinion. • Before doing that, ask the learner for evidence that he or she feels supports the opinion.

10. Probe for Supporting Evidence • An alternative approach is to ask the presenter to expand the differential diagnosis of the patient’s presenting complaint, physical findings, or data.

11. Probe for Supporting Evidence • “I am interested in how you came to that diagnosis.” • “What were the major findings that led to your conclusion?” • “What other things did you consider regarding the patient’s abdominal pain?” • “What else might be causing the (pleural effusion, elevated LFT’s…)?” • “What further questions are arising in your mind?”

12. Probe for Supporting Evidence • NOT: “List all of the possible causes of post op fever.” • NOT: “I don’t believe this is consistent with acute pancreatitis. Don’t you have any other ideas?” • NOT: “What was their last creatinine?” • NOT: “What if the patient had just immigrated from Somalia?” (read my mind questions)

13. Teach General Rules • You have ascertained from what the learner revealed that there is a knowledge gap. • At this point, provide general rules, concepts, or considerations targeted to the learner’s level.

14. Teach General Rules • Example: “Patients with cystitis usually have pain with urination, frequency, urgency, and a positive UA. However, fever, flank pain, nausea and vomiting would be unusual, and this usually indicates the presence of pyelonephritis.” • NOT: “This patient needs IV antibiotics!” “The last time I saw this condition…”

15. Reinforce what was done right • The learner may or may not realize that their plan of action was effective and will have a positive impact. • Focus on the specific deed and the effect it had.

16. Reinforce what was done right • “You considered the cost of the medication and the schedule of dosing in your selection of an antibiotic. This will contribute to improving this patient’s compliance.” • NOT: “Good job.” “Strong intern.”

17. Correct Mistakes • In the case where the learner’s work has demonstrated mistakes, this needs to be discussed as soon as possible. --What went wrong and why --How to avoid or correct the error in the future

18. Correct Mistakes • “You may be right to attribute this patient’s altered mental status to the UTI. However, given the history of a recent fall in a patient on Warfarin, a head CT really should be done to rule out bleed or subdural hematoma.” • NOT: “Why didn’t you get a head CT?!” “You never want to miss __________”

19. View Video Clips • “Pre-Microskills”: Med student and resident discussing case in clinic. • “Post-Microskills”: same scenario only incorporating some of the Microskills steps.

20. Practice the Microskills Model • Split into pairs. • One person plays the resident; the other, the medical student. • Go through the case scenarios. • Use the 5 Steps to help educate your student.

21. Group Discussion • Describe your clinical scenario and the discussion that followed. • What went well? What did you like about the Microskills model? • What didn’t go well? Any pitfalls to avoid?

22. In summary: Microskills • Get a commitment • Probe for Supporting Evidence • Teach General Rules • Reinforce what was done right • Correct Mistakes