Pediatric Educational Excellence Across the Continuum (PEEAC)
ConferenceSept 2009
Goals
• Bring ideas from PEEAC conference• Reasons to add new tools.
– Time, Efficiency, short attention span of learner
• Present some tools for medical student and resident teaching– Strategies
– Resources – handouts from PEEAC
– Share Web-based resources and bibliography for further reading.
Medical students
• Orientation!!• “The Wave”• Priming –before student goes in the room.• Exam room presenting• Structured modeling• Limited observation – of particular portion of visit• Life-long learning journal• Learning with support staff
Efficiency: Creative SchedulingThe “Wave”
9AM-9:20AM: Student sees pt #1, preceptor sees pt #2
9:20AM-9:40AM: Pt #1 seen by both
9:40AM-10:00AM: Student charts pt #1,
preceptor sees pt #3
10:00Am-10:20AM: Student sees pt #4,
preceptor sees pt #5 and so on
Priming
• Review pt’s medical background
• Tell trainee what complaint to focus on
• Set guidelines for physical exam
• + Set time limit for encounter
• Alert student to sensitive issues
Exam room presentation
• Present at the bedside – while med student is presenting, MD can be examining child at the same time
Medical students• Orientation!!• ‘The wave’• Priming – read up/discuss before student goes in
the room.• Exam room presentation• Structured modeling• Limited observation – of particular portion of
exam• Life-long learning journal• Learning with support staff
Dr. Louis First’s Take-Home Lessons1. Never underestimate the power of “day one”
2. Always let the studententer first.
3. Feedback after every patient encounter and remember feedback is
not = to evaluation!
Resident/medical student
• One minute preceptor
• Aunt Minnie
• Two minute observation/drop in visit.
• Exam room presentations
• Narrative Medicine
• Spanish language lunches
• The next 6 slides are courtesy of Dr. Louis R First
The One-Minute Preceptor(Developed at University of
Washington)
1. Get a commitment – what is dx?2. Probe for supporting evidence3. Teach general rules4. Tell them what they did right5. Correct mistakes
Neher JO et al. J. Am. Board Fam. Pract. 1992;5:419.424
Step 1. Get a Commitment
“What do you think is going on with
this patient?”
versus
“This is obviously a case ofotitis.”
Step 2: Probe for SupportingEvidence
“What were the major findings thatled to your conclusion?”
versus
“What are the problem causes ofotitis?”
Step 3: Teach General Rules“Patients with acute otitis will have a
red non-mobile tympanic membrane.”
versus
“I think the patient needs amoxicillindue to his ear-pulling even if we can’t
see the drum.”
Step 4: Tell Them What They Did Right
“Your description of the tympanic membrane was quite accurate”
versus
“Thanks for seeing the patient first.Good job.”
Step 5: Correct Mistakes
“You can’t call a red ear otitis in acrying child without checking
mobility first. Let me show you”
versus
“You’ll learn with more experience.”
Does the One-Minute Preceptor Work?
• 29/36 faculty resurveyed 4 years after wkshp--90% still use it, 58% find it extremely helpful as clinical teachers (Neher et al. Clin Teach 1992; 5: 419-24)
• 57 residents randomized to use it at UCSF--87% of 28 residents found it useful;
• Students rated OMP residents vs controls higher in all skills except “teaching general rules”and “overall effectiveness”--also found to be more motivated to read (Furney et al. J Gen Intern Med 2001; 16:620-24)
» L. First MD
More on OMP Effectiveness(Aagaard E et al. Acad Med. 2004 79(1): 42-49)
• 116 preceptors at 7 universities watched videos of both OMP and traditional models using two cases
• With OMP model, preceptors better able to correctly diagnose pt’s condition, rated student ability higher on hx taking/PE skills, presentations, clinical reasoning, and FOK, and rated themselves more confident in rating students abilities
• OMP rated more effective and efficient than traditional model in teaching students
» L. First MD
Resident/medical student
• One minute preceptor
• Aunt Minnie
• Two minute observation/drop in visit.
• Exam room presentations
• Narrative Medicine
• Spanish language lunches
Aunt Minnie
(For developing rapid pattern recognition)• Learner sees patient, takes hx, does PE• Learner presents
– Main complaint and presumptive dx (30 sec)
• While learner writes up note, teacher sees pt, dx’s problem and creates plan (5 min)
• Discuss care w/ learner – 1-5 min reviews and signs chart 1-2 min
Resident/medical student
• One minute preceptor
• Aunt Minnie
• Two minute observation/drop in visit.
• Exam room presentations
• Narrative Medicine
• Spanish language lunches
Exam room presentation - Resident
• Especially useful for interns
• If resident is wrong, you can say “you raise an interesting point – I want to look something up – will you excuse us for a moment.” Then leave and resident comes back. Never contradict resident in the room.
Exam room presentations• No change in parent satisfaction – incl. parents seeing
resident as their doctor• Attendings preferred – able to assess resident skills,
model advice, and demonstrate PE• Residents – /less comfortable discussing sensitive
topics; embarrassed when asked a question they didn’t know the ans to. Better observation and feedback.
• No change in visit duration• Baker et al. Ambulatory Pediatrics 2007
• Promotes family centered care
Seeing residents’ patients• Study – teachers assigned rating to residents’
evaluations and the perceived severity of the care both immediately after resident presentation and again directly after seeing the patient.
• After seeing the patients, teachers rated residents evaluations less well and the patients as more severely ill
• Seeing patients took longer. – Gennis and Gennis; 1993.
• What do you do?
Also Activated Demonstration – watch how I counsel this mother on how assess potty training
readiness.
Evidence-based Physical exam
• Make the exercise evidence based– Rational Clinical Examination series - JAMA
• Ex. Does this child have appendicitis?• Bundy DG, et. al
• Systematic review– Why is this important?
– LR and summary LR ratios for physical findings
– Rebound tenderness LR=3.0
Resources
• Technology resources: 2 handouts from Drs Lopreiato and White
• Bibliography of best articles on teaching
• Web resource list
• http://library.med.utah.edu/pedineurologicexam/html/site_index_by_topic.html
• http://webmedia.unmc.edu/intmed/general/eye&ear/ear.htm
• http://mediswww.cwru.edu/cardiacexam/ - wonderful for medical students. Not specific to peds.
• http://www.richmondeye.com/eyemotil.asp - great demonstration of cover uncover test (also afferent papillary defect)
• http://www.health.state.ny.us/nysdoh/asthma/brochures.htm Easy access to summary asthma guidelines – for medical students and residents. Also print easy to read brochures for patients – in multiple languages.
• www.breastfeedingbasics.org – nice educational module for medical students. Can complement videos distributed by Steve Caddle.
List of YouTube videos from Steve.
• http://www.youtube.com/watch?v=iSS3HnXeYSw
• http://www.youtube.com/watch?v=hqFhFwRLLB0
List distributed
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