Teaching and Learning in a Clinical setting

Kazakhstan Health Technology Transfer and Institutional Reform Project

Teaching and Learning in a Clinical setting


Learning Objectives

By the end of this session, participants will be able to:

• Define a teaching moment• Use bedside teaching, side-by-side teaching,

and case presentations as teaching strategies• Understand how to teach with patients present• Discuss assessment strategies


If learners are removed from the clinical environment, isolation from patients can lead to a dislocation of theory from practice.


• Consultants and others are seen as effective role models who demonstrate professionalism

• But… the literature implies that there is wide variation in the quality and reliability of teaching


Teaching Moment• An opportunity to share a piece of information, demonstrate

a technique, or expand on the implications of a clinical observation

Examples:– Demonstration of a physical exam– Allowing learner to feel/hear/observe something abnormal upon

patient examination that you, as mentor, have experienced– Discuss management options


When and Where Do Teaching Moments Occur?

• In a variety of settings:– Primary care offers some advantages over

secondary care settings

• Anytime:

• Difficult to plan! Can be unpredictable, variable and lack continuity….but each only needs to last a moment!


Educational Prescriptions• When a topic is raised during a ward round or clinic for

which the trainee does not have an answer or when the teacher cannot provide the evidence to support an assertion, then a script is written requiring the person to seek evidence and present the results briefly at the next meeting of those concerned.

• The trainee is afforded the opportunity to provide the results of this search


What is an educational prescription?

• It specifies the clinical problem that generated the question.• It states the question, in all of its key elements.• It specifies who is responsible for answering it.• It reminds everyone of the deadline for answering it (taking

into account the urgency of the clinical problem that generated it).

• Finally, it reminds everyone of the steps of searching, critically appraising and relating the answer back to the patient.


Teach by example• Model question formulation for your learners. • This not only helps with question formulation

but also demonstrates that we all have knowledge gaps and that it is ok to admit that we have them.


Example• A patient has atrial fibrillation. • What questions might we ask a learner?


Tips for using educational prescriptions

• Include them as a regular part of rounds.• Use them for Journal Club, morning report etc.• Ask your learners to write educational prescriptions for

you.• Make 2 copies of the prescription, 1 for the learner and

1 for you.• Use the opportunity to introduce the learner to the local

clinical librarian who can help 'fill' the prescription.


Target opportunities • Postcall rounds with a group of exhausted

housestaff may not be the ideal time for teaching about formulating clinical questions.

• Identify other opportunities like during morning report, work rounds, noon rounds


What are the obstacles to evidence based medicine?


Hot Review

• In a postgraduate setting where the trainee is undertaking a clinical placement, actually building into the sessions a structured teaching activity that makes use of the hot review, is an effective way of stimulating thinking and enhancing the learning experience.


• the trainer puts aside some time to spend with the trainee to discuss the cases seen during the session.

• the trainer will review (usually with case-notes) what the trainee has done.


• It is helpful for the sessional time to be planned and protected – Systematic Hot Review:– Random Case Analysis – Problem Case Analysis


Teaching Styles in Hot Reviews◗Listening to and clarifying facts about the case.

◗Organising… ‘What was going through your mind when you heard that . . ?’

◗Probing …‘Did you ask about . . ?’

◗Providing feedback on the performance. ‘What would you do differently next time?’


The One Minute Preceptor• is useful to explore elements of a case.

For example, the choice of an antibiotic.

• Getting commitment and reasons focuses the learner, and encourages analysis.

• The process encourages use of feedback.


Bedside Teaching• Teaching in the presence of a

patient.

• “…the best teaching is that taught by the patient himself”

Sir William Osler


Bedside Teaching

• Defined as teaching and reinforcing skills at patient’s bedside:– A common approach in medical education– Reinforces classroom learning– Allows mentor to model important clinical skills,

attitudes, and communication in the context of patient care, as well as observe mentee’s skills

• Strengths and weaknesses of mentees become very clear at the bedside


Barriers

• Fear of patient discomfort

• Lack of privacy and confidentiality

• Patients are often hard to locate

• Learners do not want to go to the bedside

• Teachers feel uncomfortable (may lead to discussion of medicine teacher is not familiar with).


• Takes time• Requires specific skills and techniques

Barriers 2


Advantages

Opportunity to: •Gather additional information from the patient •Directly observe student’s skills •Role model skills and attitudes•Active learning process in which adults learn best


Advantages

• Humanizes care by involving patient

• Patients feel activated and part of the learning

• Improves patients’ understanding of their disease and the work-up


Advantages• Allows role modeling.

• Helps preceptors model effective ways of asking questions and demonstrating sensitivity to patient’s comfort and concerns.


• Enables tutor to teach observation.


Prior planning is important• To recognise the learners knowledge and

needs• To know what the patient will offer• To know your intended learning points


Patient Comfort Issues

1.Ask for permission from the patient.

2.Limit length of teaching session in front of the patient.

3.Explain all examinations and procedures to the patient.

4.Make sure the patient understands

all discussions.


Patient Issues• Patients value being part of bedside

rounds and are more likely to be satisfied with their care and report better understanding of their illness.

• Rather than being upset patients were reassured and mostly enjoy the experience.


• Maintain a comfortable & positive environment for the patient, learners and you!

• Not a place for pointed questioning or criticism of learners.

• Use open questions

• Be careful about how you phrase things

• Provide a positive learning experience.


• Remember to thank the patient (in front of the learner) even if it was a brief aside during a consultation.

• Check with the patient that nothing in the teaching has confused them or made them anxious.


Using Questions in front of the Patient


After consultation:

• Review and summarize key points.• Solicit questions from mentee, and discuss

any identified problems.• Offer specific positive and constructive

feedback.• Agree on an area of improvement and

formulate a plan for how to improve.


Bedside Teaching Pearls

• Establish rules of conduct for bedside presentation early in the rotation.

• Patients should be allowed to decline

• students should not whisper in the patient’s room

• calls should be made directly

outside the room


• laughing at a patient and the patient’s responses is never appropriate

• describing the patient’s sex and race in front of the patient is awkward

• behavior should be proper and respectful-never flippant!


2. Make appropriate introductions between the patient and the learners.


3. Ensure that the setting of the room is suitable for learning.

• -pull the patient’s bedside curtain• -shut the patient’s door for privacy• -invite family members and friends to wait in the lobby• -ask the patient for permission to shut off the television


• 4.Demonstrate appropriate communication techniques and allow the patient the opportunity to clarify the case presentation.


• 5.Teach in the presence of the patient.

• gives the patient the opportunity to learn

about his/her disease & the patient receives confirmation that the team is actually considering every aspect of the case.

• prompts new information from the patient.


6.Be careful about asking the student or resident who is caring for the patient a question that they are unable to answer.

- can lead to undermining the patient’s confidence in the team’s knowledge.


• 7.Avoid medical talk.

• Using medical jargon without including the patient in the discussion can lead to apprehension in the patient.

• -use “education-level appropriate”language


• 8.Find out from the team what portions of the physical exam give them difficulty then discuss and demonstrate proper techniques.

• -patient should be appropriately draped and that the patient’s dignity is protected!


• 9.As the bedside presentation closes…

• Leave the patient with an overview of his/her disease process.

• Always give the patient an opportunity to

ask remaining questions.

• Make and discuss plans in the patient’s presence


Faculty Development needs• Teachers should be well prepared for each

teaching exchange.

• They should be able to assess the learning needs of students, and subsequently set (and deliver) optimum learning outcomes for their students.

• Teaching should be aligned when appropriate to the assessment methods which are to be applied.

• They need to develop the habit of spotting teaching moments


Inspirational Faculty• Good knowledge base, • But…admits what they don’t know,• inspirational, enthusiastic, • encourages participation, • exemplary professional bedside manner, • flexible in use of teaching opportunities.


Assessment in the workplace• This section will focus only on

– direct observations by Faculty, and will lead in to – the use of OSCEs


• How often do Faculty really observe and check their trainees performance?

• Do Faculty all have the same standards when assessing?– How can we improve this?


Faculty training for direct observation

• Need to define what is a clear pass and what is a marginal performance– Define the minimum criteria for a satisfactory

performance

• Faculty reach a consensus together


Example• A resident (junior doctor) is to see a patient who

needs to start new medication.• What are the criteria for a superior performance of

patient counselling?

• When you have done this check off those criteria which would demonstrate a satisfactory performance

• Think about Knowledge, Skills, Attitude


Example 2• You are to observe a student performing a

cardiac examination in a patient with chest pain

• What criteria mark a superior clinical encounter?

• What would be a satisfactory encounter?


Mini CEX• focuses on trainees’ encounters with a variety

of real patient issues, in their normal, routine clinical practice.

• Important for all healthcare assessors• Increasingly expected by the public and part

of best practice


Overview of Approach• A clinician will observe the trainee with a

patient in a routine clinical encounter, for example, undertaking a focused history and physical examination and then offering a diagnosis and management plan.

• The clinician will rate the observed performance, scoring the trainee on a structured form.


• They will then offer immediate feedback to the trainee, indicating both the strengths of the performance that has been observed and the areas for development.

• From this discussion a set of actions will be agreed.


• Real patients, • Real conditions• Real workplace setting• Real tasks

• Multiple assessors• Multiple encounters• Multiple settings• Multiple judgments


Disadvantages• No standardization of encounters or assessors

• If the stakes are high reliability and validity may not be acceptable

• Harder if you are both the trainer and the assessor


Example videos

Teaching and Learning in a Clinical setting

Documents

Transcript of Teaching and Learning in a Clinical setting