Supervising the Learning Environment

1. Supervising the Learning Environment Shannon L Venance MD PhD FRCPC January 24, 2014 Continuing Professional Development

2. My Guidelines • To share best practices and tips on methods and structures to promote excellence in teaching • Teaching Tips • What questions to ask of learners? • How to give learners feedback?

3. Overview • Introductions • Reflections on Teaching • 4 elements of clinical teaching: • Objectives • Priming • Questioning • Feedback

4. Objectives As a result of this session, participants will be able to: Use learning objectives appropriate for level of learner Use priming prior to sending a trainee to assess a patient Use questioning to facilitate deeper learning Provide constructive feedback to students to enhance their learning; Create an environment conducive to learning

5. Teaching: A Professional Responsibility Be willing to teach and learn from medical students, residents, other colleagues, and other health professionals (CMA Code of Ethics)

6. REFLECTIONS ON TEACHING • What is a your role in teaching? • What have been your most/least effective learning experiences? • What have been your most/least rewarding teaching experiences?

7. It’s About the Learner… Focus should be on the learner, not on the teacher

8. Adults as learners ….. are independent and self-directing can draw on their experience as a rich resource for learning value learning that integrates with demands of their everyday life are interested in immediate, problem-centred approaches are more motivated by internal than external drives

9. Seven Principles to Guide Teaching Learners should be active contributors to learning process Learning should closely relate to understanding and solving real life problems Learners should be given the opportunity and support to use self-direction in their learning Current knowledge and experience are critical to learner understanding of new situations Opportunities for practice with feedback are important Opportunities for reflection are important Role models are influential

10. Common Problems with Clinical Teaching Lack of clear objectives and expectations Focus on factual recall > problem-solving Pitched at the wrong level Passive > active learner participation Inadequate supervision and feedback Limited opportunity for reflection/discussion Teaching by humiliation Lack of respect for patient privacy/dignity Lack of congruence with remainder of curriculum

11. OBJECTIVES

12. Learning Objectives instructional objective; performance outcome a statement in specific and measurable terms that describes what the learner will be able to do as a result of the activity 1 or 2 learning objectives/encounter e.g. After watching the video and practice, the 3rd year surgical clerk demonstrates the correct technique for tying a two-hand square knot.

13. SMART Objectives Specific and clearly Stated Measurable and Manageable Attainable Realistic and Relevant Time-bound and Trackable

14. objectives, feedback and assessment - why?

15. Accreditation • Standards-based, peer review process • Continuous quality improvement • An external lens • Two independent processes • Undergraduate (LCME/CACMS) • Postgraduate (RCPSC/CFPC)

16. Examples of UME Standards ED-3: dissemination of the educational objectives ED-5A: active learning, independent study and life long learning ED-24: resident preparation for teaching ED-27: direct observation of student performance ED-30: formative and summative assessment

17. PRIMING & CLINICAL REASONING

18. Priming A teacher – directed orientation of the learner to the patient and the task before the interaction Serves to focus the learner to increase the efficiency of the interaction

19. Four Elements of Priming TASK – clearly define what the learner needs to accomplish; specify the time frame YOUR ROLE – be clear about how you will reconnect with the learner PATIENT – briefly discuss patient related issues PRODUCT – outline what the trainee is expected to produce at the end of the encounter

20. Priming Specific needs assessment and determination of goals and objectives • Ever work in this environment before? (i.e. E.R., wards) • Ever see or manage a case like this before? Define the task • Separate and acknowledge the difference between the learning objectives and the service requirements • Define what questions/issues will need to be answered following the case • What is the diagnosis or differential diagnosis? • How will we manage the symptoms? • What are the patient’s outcome goals? • What is the prognosis?

21. Tips for Priming • Establish realistic learning objectives • Trainee level appropriate • Allow time for learner to organize knowledge beforehand • Question to probe for understanding and to identify any potential problems • Encourage questions and clarifications before the encounter

22. Your Turn Think of a clinical scenario in which you would routinely send a trainee to assess a patient Take a few minutes to consider how you might “prime” the trainee Pair off, and “practice priming” How did it go?

23. The One-Minute Preceptor Model of teaching in the clinical setting Facilitates making the most of the case presentation experience

24. The One-Minute Preceptor Method Get a commitment Probe for supporting evidence Reinforce what was done well Give guidance about errors and omissions Teach a general principle Conclusion

25. Get a Commitment • Get learner to verbally commit to an aspect of the case • What do you think is going on with this patient? • What tests do you think we should order? • What treatment do you recommend? • GOAL: gain insight into learner’s reasoning

26. Probe for Supporting Evidence • Explore the basis for the learner’s opinion • Resist the urge to pass judgment on their response • What factors in the history and physical support your diagnosis? • Why would you choose that particular medication?

27. Reinforce What Was Done Well • Positive feedback should be specific to be helpful • “You correctly recognized the localizing significance of the motor findings” • “You appreciated some important contraindications limiting the treatment options for this patient”

28. Give Guidance About Errors and Omissions • Again, be specific • “Organizing your physical examination in a standard sequence will help avoid potentially important omissions” • “I agree that an MRI could offer useful information, but the results of blood work may have a more immediate impact on management”

29. Teach a General Principle Brief, focused teaching drawing on the encounter There are many possible points that could be made around any given case Be flexible

30. CanMEDS Roles • Roles • Medical Expert • Communicator • Collaborator • Manager • Health Advocate • Scholar • Professional • Teaching can be around any of these roles

31. Conclusion Respects importance of time management in clinical teaching Ends the teaching interaction Defines role of learner going forward Don’t rely on the learner to limit or cut off the interaction – our role!

32. QUESTIONING

33. Questions – good & bad What makes a question helpful vs. not helpful?

34. Two Main Types of Question • Questions that clarify the clinical story: • Fill in gaps in the case presentation • Understand the case presentation • Questions that facilitate learning: • Promote needs assessment • Facilitate knowledge retrieval and integration • Stimulate deeper thinking • Explore attitudes & feelings • Get students into the habit of asking their own questions • BOTH question types can be educational

35. Open vs. Closed Questions Closed-ended: • “What is the usual starting dose for simvastatin?” • “What is the name for procedure Z?” • “What is the target BP for a patient with diabetes and hypertension?” Open ended: • “What diagnoses are you considering?” • Why do you think that? • “What might be some contributors to Mr. Jones heart attack?” • “How would you justify the use of test X in this case?”

36. Questioning Tips Avoid playing “Guess what I’m thinking.” • e.g. “What do you think is the key to success in managing hypertension?” • You’re thinking about adherence but…. the reasonable answers could include • regular follow-up • clear explanations • appropriate drugs and doses • discussion of potential side effects • how they will be monitored • or….

37. Questioning Tips Include questions that help students explore their attitudes and feelings How would you describe that patient’s impact on you? What made that a difficult encounter?

38. Questions to Promote Reflection “What assumptions are you making about this patient?” “Did anything surprise you about this encounter?” “Is there other information you could ask to facilitate your decision-making?” “Would you do anything differently next time?”

39. Address the Effect of Questioning in Front of Patients Ensure sensitivity to patients’ needs (questions which may be confusing, embarrassing or frightening) Balancing clinical teaching and clinical care

41. FEEDBACK

42. Were our learners successful? How are they performing?

43. Assessment of the learner linked to the learning objectives specified at the beginning formative and/or summative achievement of intended outcomes

44. Brainstorming Assessment Formative Summative

45. Assessment • Formative • Guides learning and next steps • Assessment for the learner (Feedback) • No grade attached • Summative • Measures achievement • Assessment of the learner (Evaluation) • Formal grade assigned

46. Characteristics FORMATIVE • specific, descriptive • based on observations and behaviours • timely and well-timed • frequent, small amounts • constructive, corrects mistakes

47. Characteristics SUMMATIVE • fair • linked to objectives/outcomes • end of study period • based on standards/norms • grade/mark (pass/fail) • a judgment

48. Clinical Setting • opportunity for feedback • “learning on the job” • ensure that time for feedback is built in • positive when possible; promotes self reflection and self awareness • incorporate self assessment • How do you think you did? • What are your next steps? • Use a feedback grid?

49. Feedback Grid Continue… Begin or do more… Stop or do less… Consider (a stretch)… Comment on aspects of performance that were effective. Be specific and describe impact. Identify behaviour the learner knows how to do, and could do, or do more often. Describe actions thatwere not helpful, or could be harmful. Be specific, and indicate potential impact. Highlight a point of growth for the learner, a “doable” challenge for future interactions. 49 Developed by the Institute for Health Care Communication

50. Feedback Begin with learner’s self-assessment Relevant and tied to the goals of the learner Balance positives and“do different”using the feedback grid Elicit or suggest alternative behaviours Provide opportunity to try out or practice new behaviours Address realistic changes in“do-able”steps Establish clear follow-up plans