ATTENDING MODELING of
End-of-Life Care
James Hallenbeck, MD
VA Palo Alto HCS
GOALS
• Introduce T-L-C Educational Model
• Identify special challenges of attending role modeling
• Suggest specific techniques used in modeling
• Get you excited about role modeling as an educational intervention
Seven Educational Categories
• Learning Climate
• Control of Session
• Communication of Goals
• Promotion of Understanding and Retention
• Evaluation
• Feedback
• Promotion of Self-Directed Learning
Lot’s of questions...
• Everybody talks about role modeling but…
• Is being a ‘great physician’ enough to be a great role model?
• What skills/techniques are useful?
TEACHER LEARNER
CONTENT
T-L-C EDUCATIONAL MODEL
TEACHER LEARNER
PATIENT
TEACHER CONNECTED WITH LEARNER
The Challenge...
• How does the teacher immerse himself or herself in the role without loosing the learner?
• Specifically, how does the teacher facilitate the learner’s involvement with the content, if the teacher is ‘on stage’?
TEACHER LEARNER
PATIENT
TEACHER IMMERSED IN CONTENT
The Big Picture
• The goal of education is to foster an enduring relationship between the learner and the content.
• Content areas include:– Attitude– Knowledge– Skill
LEARNER
CONTENT
EDUCATIONAL OBJECTIVE
The Context
• Part of continuity experience?
• Linked to didactic session(s)
• Who are the learners?– ? Mixed skill levels or homogenous
• Special learning opportunities?
Questions to ask...
Setting a theme• Useful especially if seeing patients in series• May link to didactic session, special learner
needs and learning opportunities• Assign learner tasks within a theme• Examples:
– “Why is this patient here?”– “Look at the walls and tabletops”– “What does home mean to this patient?”
Three phases of the patient encounter
• Before
• During
• After
Each phase has its own skillsEach phase has its own skills
Before seeing the patient
• Reinforce theme, if present
• Collect data
• Set patient specific tasks-– That you wish to accomplish– Tasks for learners
A word about tasks
• Tasks may be– Cognitive
• “Determine how we might adjust pain meds”
– Observational• “Watch to see what techniques I use to put the
patient at ease”
– Behavioral• “When I’m done, examining him, I want you to try
it”
The patient encounter
• Goal- Immerse yourself totally in the relationship, but continue to involve the learner– Analogous to a good actor- must become the
role, but in a manner that allows the audience to see
• This so difficult- it’s a life-time practice
The Echo
• Definition: A verbal reflection of internal thought processes
• Method:– Explain what you are doing– Filter what you don’t want patient to hear– Interpret what you mean so patient/family can
understand
• Example: Patient with red-eyes
The Lateral Pass
• Definition: A means of changing roles to facilitate new forms of interaction
• Method: Make patient (or learner) the teacher
• Examples:– Difficult math problem– “You’re the one with pain, what can you teach
us about pain (or dying)”
Separating what is modeled from modeling technique
• What do you wish to model?– Example: respect
• What method do you wish to use?– Example: sitting with patient, using last name
• What effect do wish this have have on learners– Example: change in attitude, behavior
After the patient encounter
• Opportunity to re-connect learner to content– “What questions do you have?”
• Opportunity to evaluate – “What did you see?”– “What was I trying to show when I…”
• Time to comment- fill in the blanks
• Time to reinforce/summarize
Learner’s goals
• Important to identify
• Adult learners tend to filter information in line with their goals– If not addressed a barrier to learning new
information
• Opportunity to demonstrate respect
• May tailor modeling (or other educational encounters) to these goals
Teaching un-traditional medicine in a traditional medical environment
• Modeling a different kind of care
• Traditional medical environment has strong rules/rituals– May be an ally (familiar turf to teacher/student)– May be a foe (rules of the game may get in the
way of what you are trying to teach)• Example: “Pimping”
– How to “detoxify” questions
Teaching from ignorance
• We can’t know everything
• Great potential in teaching from ignorance– Importance of modeling comfort with
ignorance-balanced by desire to learn– Potent tool to connect learner to content– Requires self-confidence
SUMMARY
• Modeling- a powerful teaching method
• Little formal work done on the skills involved in modeling in medicine
• Definable, teachable modeling skills exist
• By working on your skills, you will become a more effective teaching
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