supervising the learning environment shannon l venance md phd frcpc january 24, 2014 continuing...
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Supervising the Learning Environment
Shannon L Venance MD PhD FRCPCJanuary 24, 2014
Continuing Professional Development
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?
OverviewOverview
Introductions Reflections on Teaching 4 elements of clinical
teaching: Objectives Priming Questioning Feedback
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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
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ObjectivesObjectives
Be willing to teach and learn from medical students, residents, other colleagues, and other health professionals (CMA Code of Ethics)
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Teaching: A Professional Teaching: A Professional ResponsibilityResponsibility
REFLECTIONS ON TEACHINGREFLECTIONS ON TEACHING
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•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?
Focus should be on the learner, not on the teacher
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It’s About the Learner…It’s About the Learner…
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
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Adults as learners …..Adults as learners …..
Seven Principles to Guide Seven Principles to Guide TeachingTeaching
1. Learners should be active contributors to learning process
2. Learning should closely relate to understanding and solving real life problems
3. Learners should be given the opportunity and support to use self-direction in their learning
4. Current knowledge and experience are critical to learner understanding of new situations
5. Opportunities for practice with feedback are important6. Opportunities for reflection are important7. Role models are influential
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
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Common Problems with Clinical Common Problems with Clinical TeachingTeaching
OBJECTIVESOBJECTIVES
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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.
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Learning Objectives
Specific and clearly StatedMeasurable and ManageableAttainableRealistic and RelevantTime-bound and Trackable
SMART Objectives
objectives, feedback and assessment - why?
Accreditation
Standards-based, peer review process Continuous quality improvement An external lens Two independent processes
Undergraduate (LCME/CACMS) Postgraduate (RCPSC/CFPC)
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 teachingED-27: direct observation of student
performanceED-30: formative and summative
assessment
PRIMING & CLINICAL PRIMING & CLINICAL REASONINGREASONING
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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
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PrimingPriming
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
Four Elements of 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?
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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
Tips for Priming
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?
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Your TurnYour Turn
Model of teaching in the clinical setting Facilitates making the most of the case
presentation experience
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The One-Minute PreceptorThe One-Minute Preceptor
1. Get a commitment2. Probe for supporting evidence3. Reinforce what was done well4. Give guidance about errors and omissions5. Teach a general principle6. Conclusion
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The One-Minute Preceptor The One-Minute Preceptor MethodMethod
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
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Get a CommitmentGet a Commitment
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?
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Probe for Supporting EvidenceProbe for Supporting Evidence
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”
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Reinforce What Was Done WellReinforce What Was Done Well
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”
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Give Guidance About Errors and Give Guidance About Errors and OmissionsOmissions
Brief, focused teaching drawing on the encounter
There are many possible points that could be made around any given case
Be flexible
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Teach a General PrincipleTeach a General Principle
Roles1. Medical Expert2. Communicator3. Collaborator4. Manager5. Health Advocate6. Scholar7. Professional
Teaching can be around any of these roles
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CanMEDS Roles
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!
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ConclusionConclusion
QUESTIONINGQUESTIONING
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What makes a question helpful vs. not helpful?
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Questions – good & badQuestions – good & bad
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
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Two Main Types of QuestionTwo Main Types of Question
Open vs. Closed Questions
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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?”
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…. 36
Questioning TipsQuestioning 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?
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Questioning TipsQuestioning Tips
“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?”
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Questions to Promote ReflectionQuestions to Promote Reflection
Ensure sensitivity to patients’ needs (questions which may be confusing, embarrassing or frightening)
Balancing clinical teaching and clinical care
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Address the Effect of Questioning in Front of Patients
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FEEDBACKFEEDBACK
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Were our learners Were our learners successful? How are successful? How are
they performing?they performing?
of the learner linked to the learning objectivesspecified at the beginningformative and/or summativeachievement of intended outcomes
AssessmentAssessment
Formative
Summative
Brainstorming AssessmentBrainstorming 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
AssessmentAssessment
CharacteristicsCharacteristics
FORMATIVEspecific, descriptivebased on observations and behaviours timely and well-timed frequent, small amountsconstructive, corrects mistakes
CharacteristicsCharacteristics
SUMMATIVE fair linked to objectives/outcomesend of study periodbased on standards/normsgrade/mark (pass/fail)a judgment
opportunity for feedback “learning on the job”ensure that time for feedback is
built inpositive 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?
Clinical SettingClinical Setting
Continue… Begin or do more…
Consider (a stretch)…
Stop or do less…
Developed by the Institute for Health Care Communication
Feedback GridFeedback Grid
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.
Highlight a point of growth for the learner, a “doable” challenge for future interactions.
Describe actions that were not helpful, or could be harmful. Be specific, and indicate potential impact.
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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
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Feedback
Feedback
Focus on observations, not inferences “You did… vs. you are…”
Focus on descriptions, not judgments “What I observed was… vs. that was inadequate.”
Focus on specific details, not generalities “At the start of the interview with Mrs. Jones, I noticed…vs. your introductions are all
Attend to the learner’s response Feedback may fall on deaf ears if…
It conflicts with self-concept It threatens self-esteem It lacks credibility It fails to align with the learning focus
Creating a learning environment conducive to constructive feedback is key
Feedback
We briefly covered……We briefly covered……
Objectives
Priming
Questioning
Feedback
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Thanks for your attention!Thanks for your attention!
SSMD Office of Continuing Faculty Development workshops excellent opportunities to learn more Teaching Certificate program
Acknowledge Chris Watling for many of the slides
Evaluation forms
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