The “Teaching Moment” Expressing uncertainties & difficulties

1. The “Teaching Moment”Expressing uncertainties & difficulties Georges BORDAGE, MD, PhD Professor Department of Medical Education University of Illinois at Chicago Univ. of Tokyo Grad. School of Medicine, March 2007

2. Professor Kaga Extraordinary leadership in medical education in Japan and abroad…

3. …I don’t know much about joint pain. Older woman, joint pain A

4. …don’t know much about joint pain. I suggest you go and read about it. Older woman, joint pain A

5. Thought about gout… & pseudo gout… but couldn’t discriminate further …don’t know much about joint pain Joint pain B A

6. Thought about gout & pseudo gout… but couldn’t discriminate further. She’s older, with moderate pain; had surgery recently… This favors pseudo- gout. Which crystals are involved in each pathologies? How find out? Older woman, joint pain B

7. “Teaching moment” • Expressed a specific uncertainty, difficulty • Received specific feedback targeted to her needs B

8. How often do youknow what yourstudent or residentis thinking (Dx, reasons)when presenting a patient ? <25% 50% 75% >90% Not often Some Most

9. Not so often... • During outpatient 1/5(19%) case presentations (4/5 Reporting)

10. Not so often... • During outpatient 1/5(19%) case presentations (4/5 Reporting) • Medical records: SOAP notes 1/17(6%)(Baker et al, 1999)

11. During bedside discussions with clerks, attendings: • did most of talking • provided mostly factual info. • rarely challenged clerks to think (Foley, 1979)

12. Students reluctant to show their thinking, more so their uncertainties Culture: hide errors, uncertainties 54% HS discussed errors (Wu et al, 1991)

13. Encourage their students & residents to express their thinking & uncertainties during case presentations along with the clinical facts Connell et al, 1999

14. Case presentations Two purposes • Patient care • Student education

15. Educational strategy: Learning is maximized when students try to resolve personal difficulties, uncertainties… (John Dewey, 1933) Teaching moment: express difficulties

16. n= 7 FM + 4 Int. = 11 attendings • Coded: 3 levels

17. Levels of interaction 1- Soliciting/ expressing facts 2- Explanations 3- Uncertainties, difficulties Faculty – Students/residents 3-min segments

18. 0 level-3: uncertainties Facts St. Fac. Pre-training

19. Long-term approach Faculty development Change the clinical culture from hiding uncertainties, errors to expressing them

20. Faculty Development Strategies Bolus a lecture, wkspDripreflection, practice

21. Training: 3 x 3-hr wkps/ 6 mts Goal: Elicit student’s uncertainties or difficulties about the case. • Record (tapes) & reflect +/- • Wksp: Discuss what worked & not • Practice their own strategy

22. Clear intentions… “I’d like us to talk about how you’re thinking about problems. I’m especially interested in anything that you’re still uncertain about… anything about this case that you’re unclear or puzzled about.”

23. Expressing uncertainties, difficulties, errors“Student’s CC”

24. Difficulties… Bordage, 1999 • No sense of the problem overallAcute recurring large joint problemvs. Chronic small joint poly arthritis • Single Dx in mind vs. D.Dx Septic arthritis vs. gout • Mindless presentation vs. pertinent details,discrim. findings

25. Results 1/3 level-3 Fac. 0 level-3 St.

26. Benefits of soliciting difficulties… • Know students betterMAXimize their learning • More info about the ptsMAXimize patient care +

27. Good news, bad news ½ fac. improved -- ½ notWhole team involved Faculty StudentsResidents

28. Avoid blame &solicit + feedback RCT: w/ w/o training 3x, 45-min wkps, 3mts • Ask “good” questionsExpress uncertainties & difficulties • Practice (diary) Egan et al, 2002

29. …don’t knowmuch aboutjoint pain! Could you tellme about chronic diarrhea? Thought about gout & pseudogout but couldn’t discriminate further I knew about watery and inflammatorybut forgot about the other types and got stuck at that point.

30. Bldg on student’s prior knowledge Thought about gout & pseudo gout… but couldn’t discriminate further. She’s older, with moderate pain; had surgery recently… This favors pseudo gout. Which crystals are involved in each pathology? How would you find out?

31. Residents confused… Attending: mini-lecture - External hemorrhoids - Internal hemorrhoids - Fistula Woman w/ rectal pain

32. …What’s a fistula?! Focus on student’s difficulties Bldg on student’s prior knowledge Woman w/ rectal pain

33. Students • 3x more questions5x more difficulties

34. Students • 3x more questions5x more difficulties but high communication apprehension!

35. “[Osler’s] criticisms of students and their work were incisive and unforgettable, but never harsh or unkindly; they inspired respect and affection, never fear.” Henry Christian, dean at Harvard

36. Conditions for success • Faculty development:Faculty AND Students/residents • Create a supportive environmentDisclosure without blame

37. Disclosure without blame Confident that expressing difficulties, uncertainties, errors can be a positive learning experience “TEACHING-LEARNING MOMENT”

38. Disclosure without blame Errors rounds (chief residents)

39. Usual objection… “Not enough time” • Does not take more time: 8-9 min. • Simply takes a different focus

40. …in conclusion

41. Case presentations : 2 CCs • Patient’s CC : patient care • Student’s CC : education Expressing uncertainties, difficulties …a privileged “TEACHING MOMENT”

42. Disclosure without blame • Intentions clear…interest in student’s difficulties • Supportive environment Learning & patient care are maximized

43. Professor KAGA • Own exemplary teaching • IRCME, Univ. Tokyo Sch. Med. Legacy of better teachers better educational programs Better students & residents Better patient care

44. Domo arigato ! bordage@uic.edu Bordage Med. Ed. 1987, 21:183-188 Bordage Ac. Med. 1994, 69: 883-85 Chang et al. Ac. Med., 1998, 73: S109-S111 Connell et al. Ac. Med. 1999, 74: S10-S12 Bordage Ac. Med. 1999, 74: S138-43 Nendaz & Bordage, Med. Ed. 2002:36: 760-66