ucsf educational skills workshop

[email protected] Educational Skills Workshop

Clinical Teaching

Faculty Developer Team:

Duncan Henry MDSarah Summerville MDJessica Tashjian MD

April 19 2021

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Objectives

Describe qualities of a good clinical teacher

Summarize current research on clinical teaching

Apply the OMP (One Minute Preceptor) model in clinical teaching scenarios

Apply teaching models to challenging teaching situations

What makes a great clinical teacher

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OMP: The One-Minute Preceptor Model Small groups: Apply OMP in practice cases

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Challenging cases in clinical teaching Small groups: General teaching challenges

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Equity and Antiracism in clinical teaching Small groups: Brainstorming activity

Share, summarize, and wrap-up

Session Outline

Zoom Etiquette

Whenever possible...

• Video ON

• Audio OFF

Feel free to comment

• In the chat

• By "raising your hand" in Zoom to make a verbal comment

Introductions – Breakout Groups

Name

School ("School of Pharmacy, Nursing, Medicine, Dentistry, etc")

Who are your learners? (Students, Residents, Post-Docs, etc)

"If you knew me well you would know..."

Reflection Exercise

What makes a great clinical teacher?

Clinical Teaching Literature

Attributes/behaviors good clinical teacher

• Solid knowledge base

• Clinically competent/clinical skills teaching

• Supportive learning environment

• Communication: listening, participation, questioning

• Enthusiasm about medicine and teaching

Development of skills to be a good clinical teacher

Sutkin, 2008

A Framework for Conceptualizing Your Learner’s Role – (O)RIME

Observer – Struggles to report accurately

Reporter – Answers “what” questions

Interpreter – Answers “why” questions

Manager – Answers “how” questions

Educator – Active in educating self, colleagues,

and patients

Pangaro LN, Acad Med, 1999

Evidence-based Models of Clinical Teaching

Didactic model

SNAPPS

One Minute Preceptor (OMP)

• Eight Step Preceptor (ESP) – adds learner

assessment, learning climate, and learner-identified

objectives to OMP

Didactic Model

Focused on patient’s diagnosis, facts

Rarely elicits trainee’s impressions or basis for conclusions

Teaching based on patient, not learner

Little or no feedback to the learner

Pros:

• Efficient

• Puts patient care first

Cons:

• What the learner knows/needs is unclear

• Teaching/feedback is not individualized

Irby, 2004

SNAPPS

• Summarize briefly the history and findings

• Narrow the DDx to 2-3 possibilities

• Analyze the DDx by comparing/contrasting

• Probe the preceptor with questions/clarification

• Plan mgmt for patient’s medical issues

• Select a case-related learning issue

Wolpaw TM et al. Acad Med. 2003.

One-Minute Preceptor: 5 steps

• Make a commitment

• Probe for supporting evidence

• Teach a general principle

• Reinforce what was done right

• Correct mistakes

Neher et al. JABFP 1992.et al. JABFP 1992.

Quick Stretch Break

4/16/202114

OMP: Step 1

Get a commitment from the learner

• Ask the learner what he/she thinks about the case

• Lock in a commitment to a diagnosis/work-up/treatment

WHAT> Why> Pearl> Good> Improve

OMP: Step 2

Probe for supporting evidence

• Ask the learner for evidence to support their opinion

• This allows faculty to identify gaps in knowledge

What> WHY> Pearl> Good> Improve

OMP: Step 3

Teach a general principle

• Introduce a relevant rule or concept targeted to the

• Target to the learner’s level of understanding

What> Why > PEARL> Good> Improve

OMP: Step 4

Reinforce what was done right

• Reinforcing correct behavior helps the behavior

become firmly established

• Focus on specific behaviors rather than general praise

What> Why> Pearl> GOOD> Improve

OMP: Step 5

Correct mistakes

• As soon after mistake as possible, find an appropriate

time to discuss

• If possible, allow the learner to critique his/her

performance first

What> Why> Pearl> Good> IMPROVE

And Now for a Role Play

By us ….

•Set a constructive learning environment.

•Consider• Space

• Time

• Players and roles

• Goals and expectations

• Prime the learner for the encounter

OMP Step 0

•Next steps?

•To Do’s

•Key themes to highlight or explore?

•Tips for success?

OMP Step 6

Breakout Group #1 – 30 min

• Groups of 3 (teacher, learner, observer)

• Select one of the cases on the handout

• Teacher - practice applying the OMP

• http://tiny.ucsf.edu/clinicalteaching, "OMP Practice – Breakout 1"

• We will place the OMP steps in your chat

• Plan for 10 minutes for each person to practice and debrief

• Switch roles and select a different case and repeat –each person has a turn in each role (3 cases total)

We may be stopping by (press the ? on your nav bar if you need help or have a question)

http://tiny.ucsf.edu/clinicalteaching

OMP Large Group Debrief

• What went well in your practice of OMP skills?

• What was challenging?

• How might you incorporate the OMP into your teaching?

Break

10 min break, please return promptly

• We suggest turning your video off so you indicate you have “left” and turning your video on to indicate that you have returned

OMP: The Evidence

• OMP faculty training associated with an increase in specific feedback in ambulatory encounters

• Videotaped teaching encounters: faculty assess OMP vs Traditional/didactic interactions

• Faculty better able to assess students' skill level

• Faculty generally rated students's skills better when they used OMP

• Students felt feedback better with OMP

Students rated OMP as "more effective" than didactic method

Salerno S. J Gen Int Med 2002; Aagaard E. Acad Med 2004; Teherani A. Med Teach 2007.

OMP: Pros and Cons

• Pros:

• Assesses learner knowledge/problem-solving

• Target teaching to the learner

• Incorporates feedback

• More effective teaching encounter?

• Cons:

• More steps = more time consuming?

• Requires knowledge of the model

Furney et al. 2001; Aagaard et al. 2004

OMP in the Hospital

•Broaden participation

•Target questions to appropriate level

•Seek input across professions

•Establish a cadence between leaders

Zeidman et al, Journal of Hospital Medicine, Feb 2015

OMP vs. SNAPPS

No difference in the expression of clinical reasoning

• # of differential diagnoses, justification of selected diagnosis, etc

Superiorities for SNAPPS group:

• Expressed significantly more questions and uncertainties

• More often presented/justified the diagnosis

• Neither of these things extended the length of the teaching session!

Fagundes et al, Perspect Med Educ, May 2020

Part II: Challenging Situations and Challenging Learners

• Many clinical experiences don’t fit into the “brief clinical encounter” model

• However, these moments contain some of the most valuable lessons

• Not every learner is “easily teachable”

• But these students have even more to learn!

Breakout #2 – 35 min• Read and discuss the challenging clinical scenarios together

• What challenges does this case present?

• How might you get a commitment?

• How would you "assess the level of the learner" for this case?

• What general rules could you teach?

• What feedback would you give about what the learner did right/wrong?

• For reporting out: Please assign a reporter

• Please fill out the “Skills Assessment” form

‒ http://tiny.ucsf.edu/clinicalteaching

• How did you adapt your teaching to these challenges?

• What is one take home point from your case?


Large Group Discussion

Summarize (briefly) what made your

setting/learner “challenging”

How did you adapt your teaching to these

challenges?

ONE take-home point from your group

Break

10 min break, please return promptly

• We suggest turning your video off so you indicate you have “left” and turning your video on to indicate that you have returned

Diversity and Antiracism in Clinical TeachingWe should bring attention to diversity and equity and employ anti-

racist practices in all elements of clinical care – including clinical teaching.

• How do we invite discussion and dialogue about these issues within the context of a clinical encounter, a single case presentation?

• Can the One Minute Preceptor be a useful tool to invite these discussions and dialogue?

Diversity and Antiracism in Clinical TeachingSo how about one of our own cases …

• Your fellow approaches you noting a discrepancy between treatment of two children. Both are admitted to the ICU. Both have chronic lung disease and require mechanical ventilation via a tracheostomy. Both have multi-drug resistant organisms.

• The young black child has contact precautions in place and can not leave the room to go outside with nurses. Your fellow notes that his parent, due to needing to work and transportation limitations, is not available to advocate for removal of these precautions.

• The young white child is not on contact precautions, leaves the room regularly, and has a vocal parent who routinely asks for explanations regarding hospital policies and is perceived to be a vocal advocate for their child.

Breakout #3 – 15 min

In what ways might you use elements of the OMP to invite discussion about the role race plays (or not) in this case?

• In small groups

‒ Choose one or two elements of the OMP steps and try to come up with questions you might ask

‒ Try out phrases you might use to engage in a conversation explicitly about race.

• Feel free to also bring in your own experiences or own cases (even if you didn’t know what to say in the moment)

Large Group Discussion

What did you try that worked? What didn’t?

Where was it easy to ask questions, encourage or invite participation?

Where was it hard?

Diversity and Antiracism in Clinical Teaching Set a constructive learning environment

• Explore with the student what biases related to race/ethnicity or other characteristics may influence that commitment.

• What biases have they heard about ( what biases do others have)?

Get a commitment v. Ask Permission

• Do you feel comfortable, in a space, interested in exploring how race may be a factor in this patient’s care?

• What do they (think) they know about the potential relationship between these characteristics and disease patterns/outcomes/patient care and what is this based on? How can we examine such biases?

• What issues related to equity may play into the patient case?

Probe for supporting evidence

• How do you think the biases you have heard about play into this patient’s case today?

• How might you explore with the patient how bias and inequity has played into their care throughout their lifetime?

Diversity and Antiracism in Clinical Teaching

Teach a general principle

• Teach a general principle about known biases and or equity issues in relation to the patient case, and how this may impact patients/patient care

• Teach one pearl about how to combat bias or inequity in this patient’s care today.

Reinforce what was done right

• State that recognizing bias is an important first step in mitigating bias

• State that recognizing equity issues is essential to ensure all patients receive equitable care

Correct mistakes

• What will we do differently next time?” knowing what we do now?

Next Steps

• Consider ”assigning” a self-reflection (or modeling it)

Diversity and Antiracism in Clinical Teaching – Additional Resources

Center for Faculty Educators Workshops

• Diversity, Equity and Inclusion Champion Training (1 and 2)

• Advanced Skills in Effective Feedback: Feedback Across Differences

• Inclusive Leadership

• Is it Hot in Here? Learning Climate in Medical Education

https://meded.ucsf.edu/faculty-educators/faculty-development/educational-skills-workshops

https://meded.ucsf.edu/faculty-educators/faculty-development/educational-skills-workshops

Wrap-up

OMP principles can be applied in diverse clinical encounters

Diagnose the learner:

• Probe understanding and thought process

Teach general principles:

• Targeted to learner’s needs

• Applicable to other situations

Give and ask for feedback with EACH encounter

Promote self directed learning

Be a model of inviting learners to engage in brave clinical conversations about race, equity and antiracism

Evaluate us! http://tiny.ucsf.edu/clinicalteaching


References Aagaard EA, Teherani A, Irby DM. 2004. The effectiveness of the one minute preceptor model for diagnosing the

patient and the learner. Acad Med 79:42–49.

Furney S, Orsini A, Orsetti K, Stern D, Gruppen L, Irby DM. 2001. Teaching the one-minute preceptor: a randomized controlled trial. J Gene Inter Med 16:620–624.

Irby DM, Aagaard EA, Teherani A. 2004. Teaching points identified by preceptors observing one minute preceptor and traditional preceptor encounters. Acad Med 79:50–55.

Neher JO, Gordon KC, Meyer B, Stevens N. 1992. A five-step ‘microskills’ model of clinical teaching. J Am Board of Family Practice 5:419–424.

O’Malley PG, Kroenke K, Ritter J, Dy N, Pangaro L. 1999. What learners and teachers value most in ambulatory educational encounters: a prospective, qualitative study. Acad Med 74:186–191.

Ottolini et al. 2010 Student Perceptions of Effectiveness of the Eight Step Preceptor (ESP) Model in

the Ambulatory Setting. Teach Learn Med 22: 97-101.

Salerno SM, O’Malley PG, Pangaro LN, Wheeler GA, Moores LK, Jackson JL. 2002. Faculty development seminars based on the one minute preceptor improve feedback in the ambulatory setting. J Gene Int Med 17:779–787.

Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008; 83: 452-66

Teherani A, O’Sullivan P, Aagaard EA, Morrison EH, Irby DM.2007. Student perceptions of the One-Minute Preceptor and Traditional Preceptor Models. Med Teach: 29: 323-7.

Wolpaw TM, Wolpaw DR, Papp KK. 2003. SNAPPS: a learner-centered model for outpatient education. AcadMed 78:893–8.

Wolpaw T, Papp KK, Bordage G. Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: A randomized comparison group trial. Acad Med 2009; 84:517-24.

Eight Step Preceptor (ESP)

1. Assess Level of Learner

2. Listen without Interruption

3. Get Commitment

4. Probe for Rationale

5. Make a Generalizable Teaching Point

6. Provide Reinforcing and Corrective Feedback

7. Prompt Learner to Identify Learning Objectives

8. Positive Learning Climate

SNAPPS The Evidence

•Student summary of case more concise

•Expressed more uncertainty & clinical reasoning

•Identified case-based issues for further learning

•Encouraged progression to ACGME competency

•Consider SNAPPS-plus (with PICO as the last step)

Wolpaw T et al. Acad Med. 2009.Pascoe, J Hospital Medicine Feb 2015Nixon, Acad Med 2014

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