Resident as Teacher:Teaching in the Clinical SettingResident-As-Teacher Interest GroupThe Academy at Harvard Medical School

AgendaResidents as TeachersAdult Learning TheoryKnowing your learnersSetting expectationsShowing respect and enthusiasmThinking out loudGiving specific, prompt feedback

Ask about prior education and backgroundBecome familiar with learners goals and objectivesGive learner clear expectationsIntroduce yourself and share your love of medicineUse first names and introduce learner to othersBe kind when pimpingInclude learner in your thought processProbe learners to ensure they follow your reasoningAllow learner opportunity to ask clarifying questions

Some Basic PrinciplesKnow your learnersBe respectful and enthusiasticThink out loudChoose right setting/timing for feedbackProvide positive and constructive SPECIFIC feedbackSolicit and formally deliver feedback at end of encounterGive specific real-time feedback

Residents As TeachersLCME mandateACGME mandateResidents spend up to 25% of time teaching (Busari JO, 2002)Medical students attribute one-third of their knowledge to teaching from residents (Bing-You RG, 1992)

Residents As TeachersQualities of excellent clinical teachers (Wright, NEJM 1998)Spend more than 25% of time teaching (especially beyond assigned responsibilities)Stress doctor-patient relationshipStress psychosocial aspects of medicineGive more in-depth, specific feedback to learnersGet to know trainees on personal level

Residents As TeachersQualities of excellent clinical teachersPrepared, perform needs assessmentKnow cases ahead of timePreplanned curriculum mixed with improvisationAssess residents knowledge while diagnosing patientLimited teaching points

Adult Learning TheoryAdult learners bring life experiences and extensive knowledge to any situationLearning happens when new information is linked to prior knowledge and experienceKnowledge is constructed, not receivedFor adults, learning is most meaningful when actively engaged in solving problemsLearn by answering clarifying questionsWhat data or examples support that point of view?

Know your learnersScenario: You are a night float working with a clerkship student. During an admission for a new diagnosis of likely MS, you give him an overview of the clinical features and diagnostic workup. You find out later he has published on the genetics of MS. How could you approach this scenario differently?Ask briefly if he is familiar with MS and gauge his level of knowledge by asking probing questionsWhen first introducing yourself to the resident, ask him about his background knowledge in neurologyOnce you learn of his research, stop trying to teach himAsk him how his research informs the case, while explaining your thought process

Know your learnersAsk about learners background and prior experienceEducational backgroundPrior clinical experienceCareer plansLearners goals for educational encounterBecome familiar with learners other responsibilities outside of your settingCentral medical school obligationsContinuity clinicClerkship specific didactics and clinics

Know your learnersYear I (Aug May)Introduction to the professionBasic science coursesPatient Doctor IEpidemiologyEthicsSocial medicine

Year II (Aug Apr)Human systemsPharmacologyHealth care policyPatient Doctor IIUSMLE Step 1

Know your learnersYear III (May Apr)Principal Clinical Experience (PCE)ClerkshipsPatient Doctor IIIPrimary Care Clinic

Year IV (May Jun)Required subinternshipsRequired clinical electivesOther electivesResidency interviewsUSMLE Step 2

Know your learnersWho is an HMS Third Year?Traditional StudentMD/PHD StudentHST studentOral Surgery ResidentVisiting (foreign) studentsAdvanced studentsObservers

Third year rotations for most students begin in late April

Know your learnersRequired Third Year (Core) ClerkshipsMedicine 12 weeksSurgery 12 weeksOB/GYN 6 weeksPediatrics 6 weeksRadiology 4 weeksPsychiatry 4 weeksNeurology 4 weeks

Know your learnersPrinciple Clinical Experience (PCE)Student completes all clerkships at one hospitalProvides structure and community for studentsWeekly student-run case conferences (afternoon)Primary Care Clinic (PCC)Weekly continuity clinic (Tue or Thu afternoon approx 1-5P)Some are off site and require travel time

Students need to be released without guilt for their central PCE and PCC responsibilities

Set clear expectationsEducational compact between learner and teacherBecome familiar with clerkship goals and objectivesUnderstand clerkship curriculumBecome familiar with call scheduleClarify level of responsibility for studentsExplicitly state your expectations of learnerTeam scheduleNumber of admissionsProtocol for assigning and role during proceduresDocumentation responsibilitiesPatient care responsibilities

Be respectful and enthusiasticScenario: Three new medical students arrive to morning rounds in the conference room during the middle of a new case presentation. The senior resident should:Ignore them and hope they go awayInterrupt the junior presentation to have a group hug with the studentsPause for brief introductions and then resume case presentation, with a more complete orientation to team after roundsAcknowledge the students and suggest that the junior complete the presentation before formal introductions and orientation to the team

Be respectful and enthusiasticRespectIntroduce yourself and your backgroundLearn and use first namesIntroduce learners to other providersInclude everyone in team discussions, and speak to all levels of knowledgePimp kindly, but do pimp (engage learners in process rather than dictating to them)Invest early by explaining logistics, expectations and then reinforcing with frequent feedbackDivide tasks among all members of team, including both trivial and high levelAdvocate for learners and back them up

Be respectful and enthusiasticEnthusiasmShare with learners why you chose your fieldRemind yourself intermittently why you chose to do what you doFind something interesting in every caseNo great teacher was every noted for their apathy to content or studentsWhen feeling burned out, tell a peer and/or share with team your frustrationsRemember that even when you are not explicitly teaching, you are actually teaching through role modeling

Think Out LoudScenario: You are paged for the 10th time by the ED junior to review a consult as the night senior. You have 5 floor consults and a death by cardiac criteria case to triage in the ICU. The case presented by the ED junior is straightforward carotid dissection and you tell them to get an MRA with fat sats, start heparin, and admit to CMF. How could you teach more effectively in this context?Send them three articles (PDFs) on dissectionCopy and paste the summary from Up-To-Date to an emailGive them a chalk-talk on ASA vs. anti-coagulation in strokeBriefly explain your rationale for suspecting dissection, the imaging modalities that can be used, and the ambiguous evidence for treatment but your favored approach/reasoning

Think Out LoudInclude learner in your thought processSummarize key aspects of caseExplicitly state guiding principalsGive learner opportunity to ask clarifying questionsHelps to consolidate principalsFurther informs whether they understand key principalsBe open to saying I dont know (but I will find out for you)

Think Out LoudProbe learner to ensure they follow your reasoningPimping shows interest, keeps students engagedAllows teacher to identify knowledge gapsAllows teacher to model sound clinical reasoningUse first namesPose questions to group before calling on individualAvoid wrong or aggressive grillingRephrase question to lead learner toward discovering the correct answerAcknowledge effort and challengeStart junior and work toward more senior learners to avoid embarrassment

Think Out LoudFive types of questionsFactual: How long has patient had abdominal pain?Broadening: What are potential causes?Justifying: What supports your diagnosis?Hypothetical: What if the patient were immunocompromised, how would this change your diagnosis?Alternative: What is the advantage or disadvantage of watchful waiting vs. endoscopy?

Think Out LoudMore effective questionsWhat major findings lead to your diagnosis?Is there anything else we should be concerned about?What were two other diagnoses you considered and why did you eliminate them?

Less effective questionsWhat is the most common symptom associated with this diagnosis? What are the three most common causes of this syndrome?What is the sensitivity of testing for the 2nd and 3rd diagnoses?

Think Out LoudTeaching at bedsidePrepare directed questioning and examinationPractice seek feedback from expertsInclude patient no one is more invested in the findings and they can be an ally in engaging and teaching the learnersObserve step back and let the learner take a stabDebrief make sure learners received the information you intended, discuss what went well and what could be better, leave time for questions

Think Out LoudTeaching on work roundsBe flexible adjust amount and type of teaching to needs of team and serviceBe explicit do not assume everyone is following your thought process; think out loud and verify that learners understand concepts and decisionsRole model every interaction has implications (you are always being watched!)Do it there is no time like the present; no need for fancy presentations

Think Out LoudTeaching on callSet expectations at outset (take first admission, try to see another one, come with me to ED, etc.)Include students in potential learning moments when possible (paged to see unstable patient on cross-cover)Engage student to help with duties they can perform while learning, making them a part of your team (even if team of two)Confirm history and examination findings, demonstrate additional findings, review and give feedback on notesRole model (always!)

Think Out LoudTeaching proceduresAsk about prior experience (Have you done this before? What was challenging in the past?)Demonstrate (simulation, or live) Repeat steps out loud while demonstratingWatch trainee and give verbal feedbackHave trainee teach it back to youAs learners gets more expertise, provide small tips

Give (High Quality) FeedbackScenario: A student on DMD performs at an expected level, including admitting one admission on call nights, being reliable with work and notes, and demonstrating a good knowledge base. You tell him that he did well and there was no specific feedback. He then goes on to MAS, where his team has a similar impression. At his exit interview, he is told of his solid performance and later gets an honors grade. He wonders how he could have done better. More effective feedback includes:Specific advice to take on more patientsReviewing specific aspects of the exam to improveRecommending targeted reading on his patients to present to the teamPointing out specific strengths of his performance

Give (High Quality) FeedbackGood feedback is

Give (High Quality) FeedbackGood feedback isTimelyRespectfulNon-judgmentalBidirectionalSelf-directedHonestPositive and constructiveActionableSPECIFIC

Give (High Quality) FeedbackFeedback best deferred to clerkship directorInappropriate Dress - Delicate topicMental health - Concerns about depression, substance use Serious professionalism issues

Ask about prior education and backgroundBecome familiar with learners goals and objectivesGive learner clear expectationsIntroduce yourself and share your love of medicineUse first names and introduce learner to othersBe kind when pimpingInclude learner in your thought processProbe learners to ensure they follow your reasoningAllow learner opportunity to ask clarifying questions

Some Basic PrinciplesKnow your learnersBe respectful and enthusiasticThink out loudChoose right setting/timing for feedbackProvide positive and constructive SPECIFIC feedbackSolicit and formally deliver feedback at end of encounterGive specific real-time feedback