appd workshop march 30, 2012...appd workshop march 30, 2012 kimberly gifford, md associate program...

APPD Workshop March 30, 2012

Kimberly Gifford, MD

Associate Program Director, Dartmouth

Su-Ting Li, MD, MPH

Program Director, UC Davis

Mark Vining, MD

Program Director, University of Massachusetts

We have no financial interests to disclose

Reflection on coaching

Doctor Coach Overview

Toolbox: Strategies and Tools

1. Purposeful watching

▪ Systematic performance observation

2. Purposeful questioning to elicit learner reflection

▪ Planning a feedback dialog

3. Goal setting

▪ Planning for practice

Wrap-up: planning for the future

Groups of 3: Artist has 2 minutes to draw a tulip Coach has information to help with drawing Observer has checklist, but is silent

***Do not show your role information to

anyone else.

Consider the tulip exercise as well as your past experiences as a coach/learner. . .

Consider the learner experience:

What did you think/do/feel?

What did the coach do to create a learning experience?

What traits make a coach effective?

“There is a need to motivate continuous learning and improvement across the whole arc of medical training.”

Standardization and individualization Integration of formal learning with clinical

experience (reflection on learning) Develop habits of inquiry and improvement Identity formation (teacher) (Cooke et al 2010)

Shifting to a competency based medical education model [from our current time based model] requires:

“For faculty teachers an outcomes-based model that required coaching, feedback and repeated practice. . .

would be labor intensive” (Hodges 2010)

Few rigorous high level studies Minimal emphasis on developing lifelong learning skills None mention professional identity formation for

teaching Learning is often not described as: Situated - Most involve lectures or workshops Participatory - Some with simulated learners, but few in

the real clinical environment Distributed – Some teaching rotations, but few with

integrated teaching practice in real learning environment Progressive – Minimal reinforcement over time

Hill et al 2009, Post et al 2009, Fromme et al 2011

Assigning meaning to observations

Art-based medical school curricula

Systematic assessment Deconstructing expertise Deliberate practice

Self-assessment

Extensive initial assessment Developing benchmarks – individualized Goal setting Repeat measurements over time

Evidence based plus “expert opinion” Coaching relationship Individualized to meet athlete’s needs Extensive observation Frequent, progressive feedback Deliberate practice Motivation: effort, enthusiasm

Similar coaching strategies across disciplines

WHAT the coach does

Focus on the relationship and dialog/interactions Each encounter is unique and thus coaching should

be tailored to specific learner needs/circumstances Ultimate goal is for learner to develop the ability to

coach him/herself – deliberate practice

Developed by repeatedly engaging in the coaching cycle

Motivation is critical to improving effort

Performance Observation

Coach’s Assessment

Formative Feedback

Goal Setting

Facilitated Practice

Discussion about Assessment: Ask-

Tell-Ask

Important Specific Measurable Accountable Realistic Time-based

Summative Evaluation

Environment

Systematic

Synthesis

Milestones Self-

assessment

©2008 Fall & Gifford

Modeling (mental practice)

Independent practice

Guided practice

Views clinical coaching encounters as key learning experiences

Didactics to consolidate those experiences:

Reflective discussion: opportunities to reflect on clinical coaching encounters

Primers: teach key principals of each strategy

Tools: help translate strategy into clinical coaching practice

Goal Setting: plan for future practice and implementation of coaching tasks

Coaching Environment: Coach/learner relationship establishing milestones/benchmarks, lens preferences

Performance observation: purposeful watching - observation skills, systematic observation

Coach’s Assessment: synthesis of observation, preparation for feedback

Formative Feedback: Ask-Tell-Ask - feedback dialog, purposeful questioning

Goal Setting: SMART Facilitated practice: deconstructing expertise,

reconstructing expertise, teaching styles Skills sessions: physical exam, communication,

teamwork, handoffs, work-life balance

Tools introduced in didactics are integrated into clinical rotations:

Formal teaching rotations for PL3 Rotations with some teaching expectations In every patient encounter

Each new strategy/tool is framed within the Doctor Coach model to aid in professional identity formation

Emphasizes development of lifelong learning skills to set up deliberate practice : How to become your own coach

Longitudinal coaching practice Situated: longitudinal coaching practice in every rotation

Participatory: skills sessions and real coaching encounters

Distributed: in every rotation

Progressive: lessons reinforced and built on in next session

Longitudinal cross section study Resident Intervention – Resident-as-Coach Curriculum Evaluation:

Resident self-assessed use of coaching strategies (n=14)

Student assessment of resident teaching (n=34)

▪ Observed me conduct portions of histories and physicals that were specifically relevant to this course (p=0.014)

▪ Gave me relevant feedback regularly on my PE skills (p=0.008)

Student perceived learning (n=34)

▪ Helped me elicit complete or focused histories (p=0.060)

▪ Helped me perform accurate PE skills (p=0.050)

Secondary: Resident use of learning strategies

Based on your past teaching/coaching experiences, indicate how frequently you use each coaching strategy (not how often you would like to use them).



Formative Feedback

Goal Setting


Environment

Systematic Milestones


Prerequisite: prioritized milestones

Deconstructed expertise

Outcome: formative assessment

Summative evaluation comes later

Strategy: Purposeful watching

Applying observational skills through a deliberate set of lenses

Tools: checklists aid in using a systematic approach

Derived from art-based medical school curriculum

Bardes et al 2001

Berger 1980

Boudreau et al 2008

Braverman 2011

Naghshineh et al 2008

Shapiro et al 2006

Applying observation skills through a deliberate set of lenses

Observation skills we use every day in clinical medicine are applicable to learner observation as well

Know what you are looking for

Look at “everything” systematically

Note your key

observations

Give meaning to your observations

DDx based on CC

Comprehensive H&P

Problem List

Assessment

It is important to focus on the appropriate

details… But how do you know which details are

important and which you can ignore? Use a systematic approach THEN filter Ignore details only by deliberate choice

Milestones selected in advance

Goals from rotation/experience

Learner goals

Unique opportunity

Time/scheduling/flow

Balancing other learners

Patient care needs

Your lens preferences

But avoid premature closure by suspending your judgment while observing

Be sure to use both levels of filtering: Prioritize before

observation

Revisit your priorities during observation

Assess after observation Do multiple

observations over time

Whole Part Context Interactions Observer Berger 1980

Professionalism Practice Based Learning and Improvement

Patient Care Medical Knowledge

Systems Based Practice Communication

Lens preferences

We all have natural lens preferences. In order to improve our performance

observation, we must practice using the lenses that we do not naturally use.

Prerequisite: Prioritized milestones

Deconstructed expertise

Outcome

Formative assessment now

Summative evaluation comes later

Strategy: Purposeful watching

Applying observational skills through a deliberate set of lenses

Tools: to aid in using a systematic approach

Checklists improve accuracy of observations ▪ Noel et al 1992, Ringsted et al 2003, Morgan et al 2001

Many valid, reliable tools in the literature that improve: Feedback given by preceptors (6 tools): More frequent

More timely

More specific Trainee knowledge, skills and attitudes Self-assessed (9 tools)

Objectively measured (5 tools)

Kogan et al 2009

Trainee reluctance Minimal

Faculty discomfort Faculty development Practice, Practice, Practice!!!

Time Requires thoughtful integration strategies

Hauer et al 2011

Prepare the practice Make direct observation part of the culture Prime the patient and prepare the learner Choose a way to record your observations Structure time deliberately

Key Elements Focus and concentrate [coach and learner goals] Be learner-centered [learner goals] Mutual trust [comfort improves over time] Teach within a framework [milestones in context] Teach process before content [use this time to teach

what cannot be taught elsewhere] Russell & Ng2009

Has a sensory perceptive and a cognitive component Distinct from inference Made concrete through description Occurs on different levels

Whole-part-context-interactions

Occurs over time

Many cycles

Goal oriented Subject to powerful cultural determinants

Lens preferences

Carries ethical obligations Learner perspective

Boudreau 2008

Pre: Know what you are looking for What lenses to you naturally use?

What other lenses do you want to develop?

During: Look at “everything” systematically When the resident does X, what happens?

Don’t come to premature closure Post: Note your key observations Make your observations concrete through specific description

Describe rather than judge



Formative Feedback

Goal Setting



Tell-Ask

Environment

Systematic

Synthesis

Milestones


Ask

Tell

Ask

A more palatable and nutritious feedback sandwich

Ask-Tell-Ask (ATA) Planning: summarize/integrate/focus Ask: student self assessment Purposeful questioning More than just “how did it go”

Tell: instructor assessment Limited scope

Build off of self-assessment Ask: goal setting and next steps

Mark Vining, MD Clinical Associate Professor of Pediatrics University of Massachusetts Medical School Associate Program Director, Pediatrics Residency

Teacher knows Only the Learner the answer knows the answer

The Teacher knows the Answer

“Assertive”

Preceptor is testing the

learner’s knowledge.

The Learner knows the answer

“Facilitative”

Preceptor is asking the

learner’s perspective.

Teacher knows Learner knows the answer the answer ASSERTIVE FACILITATIVE

SUGGESTIVE COLLABORATIVE

Assertive Suggestive Collaborative Facilitative

Gives direction Suggests alternatives Elicits student ideas Elicits students feelings

Asks factual questions Asks leading questions Asks exploratory

questions

Asks reflective

questions

Provides information Provides organizational

structure

Allows the student to do

the organizing

Only the learner knows

the answers

What are the types of…. How can you categorize….. What is your approach

to….

What do you think/feel

about….

**Adapted from: Quirk ME. How to learn and teach in medical school: a learner-centered approach. New York: Charles C. Thomas Publishers, 1994.

Teacher Centered

Learner Centered

Question use Interaction Example

Teach problem-solving Teacher leads learner down a

preconceived path Teaches thought processes, algorithms What are the common classes of

medications for headaches? What are the benefits/risks? What do you know about this patient that

would influence your medication

choice?

Question use Interaction Example

Teaches problem solving without leading

Teacher implies: “There is a way (path) to think about this.

How do you decide what medication you would use to treat headaches? or

What are the things you need to know to determine the choice of medication for headaches?

• Both suggest that there is a framework for answering the question.

• The more the learner is determining the framework, the more “collaborative” it is.

• The more the coach is determining the framework, the more “suggestive” it is.

• Start at the more collaborative end. (At least, I do.)

What’s your plan? Or What do you think is going on?

• If the learner seems confused, move to suggesting a path. Make the path explicit.

How do you decide how to work up a child with a high BP?

• If the learner is still unsure, ask assertive questions to make the path clear.

Can you describe the types of medications used to treat high BP? When would you use each type?

• No one type is always better than another. • Choice of type depends on learner’s knowledge,

situation, and teaching point. • A Suggestive question makes the path explicit. • A Collaborating question allows the learner to

demonstrate s/he knows the path. • Both demonstrate a model that can be used

other times. • We all have a favorite style. • Be aware of your style and when to alter it.

HPI: 6 yo with 24 hours fever, tachypnea; non-productive cough; right-sided pain with cough; no sick contacts;

PMHx: Sickle cell disease (Hgb SS) PE: T: 38.5; O2 Sat 96% Decreased breath sounds

Assessment: Pneumonia (“classic”) Plan: CXR pending; IV abx ordered

What special considerations are important when evaluating a patient with Sickle cell disease who is febrile?

How is this febrile patient with decreased breath sounds different from one who doesn’t have SS disease?

What organisms do you specifically need to worry about in febrile patients with SS disease?

What do you think is important for us to teach the parents of patients with SS disease?

How can this framework be useful for feedback?

Planning for feedback?

Encouraging self-reflection?



Formative Feedback

Goal Setting



Tell-Ask


Environment

Milestones


Su-Ting Li, MD, MPH UC Davis

Important Specific Measurable Accountable Realistic Timeline Li, et al. Acad Med; 85(7): 1229-1236, 2010.

Goal must be important (relevant) to YOU.

How does this goal fit into your career plans?

Prioritize achievement of goal.

When faced with competing demands, how will you prioritize achievement of this goal?

Break broader goals into incremental steps. “I want to improve my teaching.”

▪ What specific aspect of teaching do you want to concentrate on first?

“I want to improve giving feedback.” ▪ What specific aspect of feedback do you want to

concentrate on first?

“I want to use collaborative questioning in my feedback to encourage learner self-reflection.”

Plan how you will accomplish each incremental

step.

Set a measurable outcome.

How will you/others know that this was accomplished?”

Can you answer – “did you do it?”

▪ “I will use collaborative questioning at least once a week when I give feedback to a learner.”

Use a reminder and tracking system.

Build in external accountability.

▪ Attendings, learners, colleagues

▪ “I will tell my learners during orientation that my goal is to use collaborative questioning when I give feedback. I will ask the learner at the end of the week if I used collaborative questioning with them at least once.”

Establish internal accountability.

▪ Checklist, diary

Create achievable goals. “after every patient encounter” Daily Biweekly, weekly?

Seek out and use available opportunities. “when I am ward attending”

Self-adjust your goal/strategies based on successes/barriers you encounter. Mini PDSA cycles

Develop a timeline for achieving goal.

When do you expect to finish this?

When will you work on it?

▪ “Next time I am ward attending. . .”

Incorporate goal into your daily routine.

“I already give biweekly feedback – I will incorporate collaborative questioning in my Ask-Tell-Ask feedback routine.”

“What do you think you did particularly well this week?”

“What do you want to continue to work on?” (I think the learner needs to improve their

abdominal exam skills – missed hepatomegaly.) “How do you think your physical exam skills have been?”

“What’s your plan for improving your abdominal exam skills? How can I help you?”

I: I want to improve my teaching and my learner’s reflective skills by

S: incorporating more collaborative questioning into my feedback.

M: I will use collaborative questioning at least once when giving feedback to at least 1 learner.

A: I will tell my learners during orientation that my goal is to try to use collaborative questioning to elicit self-assessment during feedback and ask for feedback on whether I did it.

R: I will ask from feedback from 1 learner a week. T: I will work on this goal when I am ward attending next week.

1. Practice goal setting by writing an ISMART plan: To improve your own coaching practice or To enhance your RAT or FD program with coaching principles

2. Use ISMART plan to help make a learner goal SMARTER. Improve my medical knowledge Improve my teaching of medical students Improve my procedural skills Improve my time management Use more evidence based medicine Become more confident in patient care decisions Improve communications with families Another goal that you commonly hear from your learners



Formative Feedback

Goal Setting



Environment

Milestones




Guided practice



Formative Feedback

Goal Setting



Tell-Ask


Summative Evaluation

Environment

Systematic

Synthesis

Milestones Self-

assessment




Guided practice

appd workshop march 30, 2012...appd workshop march 30, 2012 kimberly gifford, md associate program...

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