On the Job Teaching Vinod Patel Bernadette O’Hare
Clinical Teaching is a bit like… Discovering the Tomb of Tut’ankhamun… Everyday! In a way ? !
Medical Education From Theory to Practice Teachers , Facilitators & Teaching Environment Modified David M Kaufman 2003 Curriculum Student Teaching methods Assessmen t methods Clinical Settings Outcome Knowledge Learning Experience Attitudes Best Clinical Practices Skills Clinical Skills Communication Skills Improved patient outcome Current or Future Patients
Aim. • To help you to improve your service based teaching.
Objectives. • To agree the particular strengths of OTJ teaching. • To identify barriers to OTJ Teaching and some solutions • To learn and share basic OTJ tools for everyday use.
Format of the session. • • • Strengths and Weaknesses analysis Tools of teaching OTJ Bit of Philosophy Logbook Mention Concluding Discussion
“The best teaching is that taught by the patient …. ” From Ed Peile “Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert. Medicine is learned by the bedside and not in the classroom. Let not your conceptions of the manifestations of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first. ” [ William Osler 1919]
Bedside teaching dying out? • 75% of clinical teaching at the bedside 1964 Reichman F et al (1964) J Med Educ 39: 147 -63 • 16% in 1978 (USA) Collins GF et al (1978) J Med Educ 53: 429 -31 • “Still less” 1997 La. Combe MA (1997) Annals Internal Medicine 126: 217 -220 • Teachers and Learners think 15 – 30% appropriate Kroenke et al 1997 From Ed Peile
Opportunities • Teaching Clinical Observation • Teaching Ethics / Values-based Medicine • Teaching Problem-solving/Evidence-based Medicine • Teaching Communication Skills • Teaching Professionalism From Ed Peile
Why are some sessions not good? • • • Sessions not involving patient! Repetition “Inappropriate for bedside…” Trying to cover too much / too long No valuable feedback “Too dogmatic, authoritative, and downright degrading” Langrish J, Informal Oxford Student Survey 2003 From Ed Peile
What do students find awkward about bedside teaching? • • • Consent / reluctant patient Dignity Introductions What can be said in front of the patient? What does the patient already know? From Ed Peile
The patient perspective • 77% of patients enjoy bedside teaching* • 83% of patients did not find bedside teaching provoked any anxiety* • 99% in OPD do not mind having students in OPD (Medicine, Surgery n=100) *Nair BR et al (1997) Med Educ 31: 341 -346
On the Job Teaching The SWOT Analysis! Please conduct a SWOT analysis of Teaching OTJ • • Strengths Group A: Please focus on Ward Rounds Weaknesses Opportunities Group B: Please focus on Clinics Threats and Barriers Group C: Please focus on Theatre work Group D: Your peculiar work place
Why is bedside teaching more difficult than it used to be ? • • Patients spend less time in hospital The patients in hospital are often too ill Patients are more empowered – may refuse More tests and investigations means patients are not available (relatives!) • Many more psychosocial problems – not just physical signs
Elements of Effective Learning and Teaching General principles of effective learning and teaching which apply to any learning encounter: 1. Discover what the trainee wants to learn 2. Discover what the trainee needs to learn 3. Negotiate the content, methods and priorities of the session 4. Use appropriate methods and techniques 5. Plans for further learning 6. Example of good practice that reinforces learning 7. Establish a relationship with the trainee 8. Evaluate the teaching.
On the Job Teaching Shared Tips for Teaching 1 • • List of cases that students must see Asking student s to following up points from previous learning Giving students responsibility for a few patients Opportunities to use students as resources Ensure students shadow a range of professionals Availability of list Use of the full theatre staff “Dual specialty” teaching
On the Job Teaching Shared Tips for Teaching 2 • • • Saltatory teaching (Nodes of Ranvier) Time management Promote Education as culture • • . .
Teaching on the Job On-the Job Training for Physicians: DH Hargreaves et al 1997. RSM
“Teaching without needs assessment” is like………. . treatment before diagnosis
Johari window model © Alan Chapman 2003 www. businessballs. com
Teacher Knows Does not Know No Point Teaching Be Taught? Teach Cannot Teach! Student Does not Know This! Important Clinical Competencies: Need to be taught with competency assessment Johari concept in Education
Questioning strategies to extend student thinking • Provide thinking time (at least 5 seconds after ? ) • Think-pair-share (Pose a question, ask them to talk in pairs, then share) • Follow-up questions (with the same student) • Withhold judgement • Ask for a summary of what has been learnt so far • Play Devil’s Advocate • Invite a contradictory response • Get the students to ask the questions
Socratic questioning Principles • “Teacher as midwife, helping the student to give birth to her own ideas” • Questions are used as a way of approaching truth through the use of reason in a shared enquiry. • Teacher professes ignorance (in reality to hold back knowledge temporarily) in order to provoke, motivate and facilitate thinking of students
Socratic questioning Techniques • Questions that seek clarification – Can you explain that? • Questions that probe reasons and evidence – Why do you think that? • Questions that explore alternative views – What would be alternative explanations…in a different setting? • Questions that test implications – What follows from what you say? What is the management plan? • Questions about questions/discussion – Do you have a question about that? – Who can summarise so far?
Knowledge Failure Type 1 Knowledge Failure • The student simply does not know! Type 2 Knowledge Failure • The student knows but cannot access Waterhouse Friderichsen Syndrome Low BP Septicaemia Low Platelets Purpura Isolated Facts Purpura Clinical Knowledge
Knowledge Failure Type 1 Knowledge Failure • The student simply does not know! Type 2 Knowledge Failure • The student knows but cannot access Hiatus Hernia Saint’s Triad Diverticulosis ? Another condition Isolated Facts Gallstones Clinical Knowledge
The One Minute Teacher Five microskills for clinical teaching Model recognises that most clinical teaching takes place when busy. Five microskills: assess, instruct, and give feedback more efficiently. 1. Get a commitment – What do you think is going on here? Asking the trainee how they interpreted the “situation” is the first step in diagnosing their learning needs. 2. Probe for supporting evidence – What led you to that conclusion? Ask the trainee for their evidence before offering your opinion. Allows you to find out about what they know and identify where they have gaps.
Five microskills for clinical teaching 3. Teach general rules and principles – When this happens, do this… Instruction will be remembered better if in the form of a general rule or principle. 4. Reinforce what was right – Specifically, you did an excellent job of… Skills in learners that are not well established need to be reinforced. 5. Correct mistakes – Next time this happens try this instead… Mistakes which are left unattended have a good chance of being repeated. The One Minute Preceptor: Five Microskills for Clinical Teaching. K Gordon, B Meyer, D Irby, D Wall 1997
Pendleton's Rules (of feedback) • Student: First discuss what went well. – Ask: what did you do well? • Teacher: then discusses what went well. – State: what went well • Student: What could have been better and recommendations for change. – Ask: how would you have done it better? • Teacher: discusses what could have been better and recommendations for change. – State: how could it have gone better – Allow further discussion!
How to encourage active participation rather than passive observation Need to engage all students all of the time 1. allocate roles to each student and then to bedside 2. Share history taking and examination between students, one can do presenting complaint another social history, one to do general exam. Another the specific system. 3. Specific roles such as Student A will state observations to the House Officer and Student B will locate and study the Drug Chart 4. The Nodes of Ranvier Idea !?
History Outline Total 10 Minutes Referral details: GP, A & E, Self, OPD Introduction Wash Hands! Details about one system and other details eg risks History of Presenting Complaint “Open” 3 -4 Minutes History of Presenting Complaint “Open/Closed” Past Medical History Social + Family History 2 -3 Minutes Drugs and Allergies Systemic Review Cardiovascular, Respiratory, Gastro-intestinal Central Nervous System, Other Ideas + Concerns + Expectations 2 -3 Minutes
Examination Outline General Observations • End of Bed • Specific: BP, Pulse rate, Temp Introduction General Examination Hands, Pulse, Neck, tongue, lymph-nodes Systemic Examination CVS, RS, Abdo, CNS, other Clinical Conclusion
Approaches to Clinical Diagnosis ?
3 Different Models of arriving at a Clinical Diagnosis Full systematic history and examination: Hypothetico-deductive reasoning: Pattern Recognition:
3 Philosophical Approaches to Clinical Diagnosis • Plato (427 BC- 347 BC): "forms" to describe the true essence of material objects in the world • A chair is not defined by what we see but rather by its nature or "chair-ness. " • An object is therefore defined by its closeness to the idea or form of what it means to be a chair. • Thus a tree stump, possessing the qualities of a elevated object conducive to humans sitting on it, has a quality of chair-ness and has the form of a chair. • This idea of the form exists in a quasi-heavenly realm that can only be understood by the mind.
3 Philosophical Approaches to Clinical Diagnosis • Plato: The idea and application of theory of forms is best illustrated in the allegory of the cave. • Story: prisoners are restrained and are looking at the wall of the cave. They are able to see the distorted shadows of things that are going by but not the actual things themselves. • So: the material things we perceive are shadows while thing producing the shadow is the true form. • Most people never break free from the prison of their own perceptions to grasp the reality of the forms. Those that do are the truly wise and learned that Plato would have us rise to the level of philosopher kings.
3 Philosophical Approaches to Clinical Diagnosis • Hegel (1770 -1831): The triad thesis, antithesis, synthesis describes some philosophy of Hegel • The triad is usually described in the following way: q The thesis is an intellectual proposition. q The anti-thesis is simply the negation of thesis, a reaction to the proposition. q The synthesis solves the conflict between thesis and antithesis by reconciling their common truths and forming a new thesis, starting the process over.
3 Philosophical Approaches to Clinical Diagnosis • Hegel: The triad thesis, antithesis, synthesis is often used to describe the philosophy of Hegel
3 Philosophical Approaches to Clinical Diagnosis • Husserl (1859 -1938): A philosophy or method of inquiry based on the premise that reality consists of objects and events as they are perceived or understood in human consciousness and not of anything independent of human consciousness.
3 Philosophical Approaches to Clinical Diagnosis • Husserl (1859 -1938): A philosophy or method of inquiry based on the premise that reality consists of objects and events as they are perceived or understood in human consciousness and not of anything independent of human consciousness. {n}
3 More Philosophical Approaches to Clinical Diagnosis • Bayes’ Theorem (1701 -1761): Probability theorem with two distinct interpretations. It expresses how a subjective degree of belief should rationally change to account for evidence. • Until the last half of the 20 th century, Bayes’theorem was largely rejected by the mathematics community as unscientific. • However, it is now widely accepted. • .
3 More Philosophical Approaches to Clinical Diagnosis • Bayes Theorem: Probability theorem with two distinct interpretations. • Wikipedia example: Suppose someone told you they had a nice conversation with someone on the train. Not knowing anything else about this conversation, the probability that they were speaking to a woman is 50%. Now suppose they also told you that this person had long hair. It is now more likely they were speaking to a woman, since most long-haired people are women. Bayes' theorem can be used to calculate the probability that the person is a woman.
3 More Philosophical Approaches to Clinical Diagnosis • Bayes Theorem: Probability theorem with two distinct interpretations. • • • W represent the event that the conversation was held with a woman, and L denote the event that the conversation was held with a long-haired person. It can be assumed that women constitute half the population for this example. So, not knowing anything else, the probability that W occurs is P(W) = 0. 5. Known that 75% of women have long hair, which we denote as P(L|W) = 0. 75. (read: the probability of event L given event W is 0. 75). But 30% of men have long hair, or P(L|M) = 0. 30, where M is the complimentary event of of W, i. e. , the event that the conversation was held with a man (assuming that every human is either a man or a woman). Our goal is to calculate the probability that the conversation was held with a woman, given the fact that the person had long hair, or, in our notation, P(W|L). The numeric answer can be obtained by substituting the above values into this formula. This yields i. e. , the probability that the conversation was held with a woman, given that the person had long hair, is about 71%.
3 More Philosophical Approaches to Clinical Diagnosis • Daniel Kahneman (1934 -): 2002 Nobel Prize Economic Science. • Prospect theory is a behavioral economic theory that describes the way people chose between alternatives that involve risk • Probabilities of outcomes are usually known. • The theory states that people make decisions based on the potential value of losses and gains rather than the final outcome
3 More Philosophical Approaches to Clinical Diagnosis • Daniel Kahneman (1934 -): 2002 Nobel Prize Economic Science. • The theory states that people make decisions based on the potential value of losses and gains rather than the final outcome • People evaluate these losses and gains using certain heuristics (or simple rules and concepts) • It tries to model real-life choices, rather than theoretical best decisions (eg computer)
3 More Philosophical Approaches to Clinical Diagnosis • Hanuman: Hindu Myth BC: Lakshmana is severely wounded during the battle against Ravana, Hanuman is sent to fetch the Sanjivani, a powerful life-restoring herb, from the Himalayas These are he specific instructions of the physician called Sushena who stated that Lakshmana would perish if untreated by daybreak
3 More Philosophical Approaches to Clinical Diagnosis • Hanuman: Hindu Myth BC: Lakshmana is severely wounded during the battle against Ravana, Hanuman is sent to fetch the Sanjivani herb, from the Himalayas On reaching the mountain he cannot identify the exact herb so he lifts the entire mountain Although attacked on the way (friendly fire), the mountain is delivered to the battlefield in Lanka. Sushena then identifies and administers the herb, and Laksmana lives
Personal Approaches to Clinical Diagnosis Difficult to teach but essential clinical skill • • • Plato Hanuman Bayes Hegel Husserl Kahneman Your Method?
Presentation Outline: The 4 Point Presentation General Findings On Examination the patient was comfortable Important Positive Findings My main findings were jaundice and an enlarged liver that was hard and nodular Important “Negative” Findings However, there was no ascites Clinical Conclusion These findings would be consistent with malignancy
Teaching on the Job On-the Job Training for Physicians: DH Hargreaves et al 1997. RSM
Teaching on the Job • COPD Patient OSCE – – – – – history taking examination discussion of differential diagnosis writing the prescription chart explanation of treatment reviewing the chest x-ray sharing bad news written clinical communication discussion with colleagues and carers – At the end of each task the learner is encouraged to reflect and then provided with constructive feedback on the clinical and communication task.
Clinical and Communication Skills: • Clinical Skills teaching: examination, treatment planning, safe prescribing, procedures (venepuncture, suturing, CPR)1 • Communication Skills: aim to develop effective (clear and sensitive) communication with patients, carers and colleagues. General Medical Council (2002) Tomorrow’s doctors. London.
Clinical Investigations
Clinical Skills and Communication Skills Two strands can be taught together!
Clinical and Communication Skills Relationship with patient, History, Examination, Problem Solving and Management Clinical Skills (g, h) • Work out drug dosage and record the outcome accurately. • Write safe prescriptions for different types of drugs. Communication Skills • Explain drugs action • Side effects
Clinical Decision Making Clinician’s expertise based on clinical skills and circumstances Evidence based recommendations Patient preferences Knowledge based
Clinical Work Observed ACAT, Cb. D, Ce. X, OSLER Does Shows how OSCE Short Answer-Reasoning Knows how Written Exams Knows MCQ Miller GE (1990) Acad Med (Suppl) 65 : S 63
Clinical Teaching Resource: • Guidelines • Clinical Evidence • ? PDA/Computer • Simulation models • Textbooks • X-rays, test results • Pictures A Clinical Skills Trolley
What’s good about OTJT? • Arises from everyday work, so has the right content. • Work constantly reveals our “learning needs”. • The “Situational learning” principle. • Great for modelling (skills, consultation etc)
What’s good about OTJT? • Great for role modelling of best behaviours, esp humanistic and “life long learning” • Allows teaching of all domains; knowledge, skills and attitudes. • Opportunity to get the right “hidden curriculum”.
What’s good about OTJT? • Allows checking of “real” not “professed” knowledge, beliefs and actions. • Often provides the benefits of small group teaching, eg group input, interactive, team supporting, one to one, targeted teaching points. • Allows assessment of performance, not just competence. (see Miller)
What’s good about OTJT? • Regularly varied and lively environment eg on the ward round, stimulates minds. • Opportunities for team based learning. • Can be entirely trainee dictated, esp when on the hoof, eg: “what did you find trickiest on take last night? ”, or “what shall we talk about? ”
On the Job Teaching • Evidence from RCTs that interactive continuing medical education is effective in positively changing clinical performance 12 12. Davis D et al Do conferences, workshops, round and other traditional continuing education activities change physician behaviour or health care outcomes? JAMA 1999 Sep 1; 282: 867 -74.
Education Quote 10 “To study the phenomena of disease without books is to sail an uncharted sea. “Whilst to study books without patients is not to go to sea at all” William Osler (1849 -1919)
The Kolb Cycle The Experiential Learning Cycle Theorising Reflection New Actions Experience “Every interaction can be a mini educational cycle” Andrew Whitehouse
Summary • • Organised, short sessions Patient and students briefed “Comfortable” environment Clear focussed learning objective Use the patient and the environment Use the “tools” Feedback on performance Subsequent discussion and reflections
Physicians learning - the human dimension In becoming physicians, students pass through three initial phases: 1. Gaining technical competence in dealing with disease. – This is the principal preoccupation at medical school. Students are immersed in the biological sciences and quickly learn the value system of the medical establishment: The primary task of medicine is the recognition and treatment of disease. Everything else - communication, psychological, social, and environmental factors - become peripheral. One result of this arrangement is the deterioration of students' ability to communicate effectively with patients as they progress through medical school
Physicians learning - the human dimension 2. Developing a professional identity. – This phase usually is begun during clinical clerkship and completed during residency training. It is only when students work as part of the clinical team and have responsibility for patient care that they begin to feel like doctors. The metamorphosis is dramatic; students usually become comfortable with their strengths and limitations, develop a clearer sense of their professional roles, and refine their ability to appraise critically their own performance
Physicians learning - the human dimension 3. Learning to heal. – During this phase, physicians learn to be instruments of healing, accepting with humility and wisdom the power to heal bestowed upon them by their patients. This phase takes at least 5 to 10 years and is not accomplished by all physicians. It is important to note that learning to be a healer continues after formal education is completed. The seeds are planted during the training period, but only grow and develop as physicians experience the power of the healing relationship in practice.
Physicians learning - the human dimension 4. Healing: The Professional Stage – It has been one of the most basic errors of the modern era in medicine to believe that patients cured of their diseases (cancer removed, coronary arteries opened, infection resolved, walking again, talking again, or back home again) are also healed; are whole again. Through the [doctorpatient] relationship it is possible, given the awareness of the necessity, the acceptance of the moral responsibility, the understanding of the problem and mastery of the skills, to heal the sick; to make whole the cured, to bring the chronically ill back within the fold, to relieve suffering, and to lift the burdens of illness. Patient-centered medicine: transforming the clinical method. Moira Stewart et al, Sage. 1995 pp 120 -131
Characteristics of the competent trainer • Teaching knowledge – understand basic teaching methods and be able to apply this knowledge • Teaching skills – to give good feedback observation skills analysis skills to foster reflection in the trainee
Characteristics of the competent trainer • Teaching attitude – giving latitude to the trainee having respect for trainee having an interest in the trainee being available for consultation individualized teaching approach • Personality traits – enthusiasm – flexibility – patience – self-insight Boendermakera, Schulinga, et al. Family Practice 2000 Vol. 17, No. 6, 547 -553
What makes a good teaching session? • • • Small groups Interesting signs / classical case Focussed area for teaching Observed examination with feedback Combined with theory and case discussion Langrish J, Informal Oxford Student Survey 2003
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