Technology is constantly advancing.  New tools arrive on the scene each year, and often we don't know whether to ignore them or incorporate them into our teaching.  The slideshow below is a compilation of 100 tools that can be used help our students understand content. Take a look and let me know what tools you use in the classroom. How do you determine whether they're tools or gimmicks?

Top 100 Tools for Learning 2011 from Jane Hart

The Microskills

It's a typical Saturday night in the department.  You're busy.  I mean really busy; the "too busy to make a run to the bathroom and empty your overly distended bladder" busy.  Your resident comes up to you with their next patient.  At first, you think of just hearing out the chief complaint, telling them what to order, and moving on to the next patient.  Fortunately, a voice in your head reminds you that there is a better way, a way to promote a morsel of learning despite the challenges stacked before you.  Enter the microskills.

The microskills model of teaching, also referred to as the "One Minute Preceptor," is a series of easily performed steps that allow you to maximize a teaching encounter when time is precious.  The steps are:

1. Get a commitment: I love using this step to shorten the presentations from my learners.  Too often, they get lost in the forest when presenting a case.  Simply stepping back and asking, "What do you think is causing their symptoms?" allows me to hone in on the important parts of their presentation.  I can then focus my questions to help me understand why they are concerned about possible conditions on the differential that they have created.  "I don't know" is not an acceptable answer.

2. Probe for supporting evidence: The follow up.  Once they take a stand, you're able to ask the why and what if questions.  The more direct questioning focuses them on the task at hand and allows you to understand the history a little better as well as determining the learners decision-making process.

3. Teach general rules: The time to teach a mini-lecture is not when time is limited.  Instead, focus on a key point of the case, whether a historical factor, workup issue, or interpersonal problem and teach short and succinct pearls.

4. Reinforce what was done right: Reward the learner for their efforts.  Point out the good catches on the history or exam, congratulate them on making the correct diagnosis or picking the most effective workup.

5. Correct mistakes: Feedback is always critical.  Point out errors in their decision-making and explain methods to correct them in the future.  Point them toward resources for future learning.

The microskills have been employed in clinical teaching for over 20 years now.  While effective use of the skills takes more than the allotted "one-minute" advertised by the other name, the skills are quite helpful at keeping the teaching encounter short and focused.  When it gets too busy to teach, reach into your armamentarium for this quick and easy teaching tool. You'll be glad that you did.

Reference:

Parrot S, Dobbie A, Chumley H, Tysinger JW. Evidence-based office teaching-the five-step microskills model of clinical teaching. Fam Med. 2006 Mar; 38(3): 164-7. PMID: 16518731 

Whither bedside teaching?

Observe, record, tabulate, communicate.  Use your five senses.  Learn to see, learn to hear, learn to feel, learn to smell, and know by practice alone you can become expert.  Medicine is learned at the bedside and not in the classroom.  Let not your conceptions 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.

-Sir William Osler

I recently received my quarterly faculty evaluation.  I usually take a cursory look into the scores and file the report away for future reference.  On occasion, the residents take the time to write some useful comments that help me to become a better teacher.  I was a little surprised by such a comment with this evaluation:

"Please do not ask the resident medical questions in front of patients, wait until we have exited the room."

In my practice, I find it exceedingly difficult to go to the bedside with my learners.  I often fall victim to the nursing station presentation as I hurry off to see other patients.  Despite this, I make the occasional effort to get to the bedside with my residents and students.  As Osler points out, the best learning is that which is done at the beside with a patient.  While less frequent than I desire, these encounters are fulfilling as a teacher and really allow me to see my learners in action.

Perhaps that is why I find the above comment troubling.  Have we abandoned the bedside for so long that our learners are so uncomfortable in front of patients with a teacher?  Are they so afraid of appearing to be wrong when asked more advanced questions?  I can respect their fear.  I've been there.  I have also learned far more from being wrong and making mistakes.  It's simply part of being a learner.   

Reflecting upon the comment, I decided to pull out one of my favorite articles on bedside teaching and review some tips for making it work.

Before going to the bedside:

Prepare: Formulate goals, know learning needs of your students and residents

Orient learners: Learners should know what is expected before going in.  I guess I have failed to explain to them that it is okay to be wrong.  Uncomfortable, yes, but still okay.

Orient Patients: Let the patient know everyone and their role; they should already know the learner.  Explain that you'll be asking some medical questions and make sure to thank them for their role in teaching the learner

At the Bedside:

Establish the environment: Try to make the atmosphere comfortable.  I try to keep the discussion less formal.  I'll ask some clarifying questions of the patient and then focus on the learners.  The key is to challenge them intellectually without humiliating them.  

Respect learners and patients: Be human.  You must remain sensitive to the patient and how illness affects them.  I do find that patients enjoy learning at the same time as the learners.  Often, the medical discussion forces me to really focus on communicating the same information to the patient in a manner that they can understand.

Engage everyone: Often not a problem where I practice; usually it is just one learner, but if you teach in a setting with a lot of learners, make sure you have questions for all, from the beginning medical student to the PGY-IV resident.

Involve the patient: Make sure to allow the patient to correct unclear parts of the history.  Make sure that they're able to ask questions as well.

Match teacher and learner goals: This topic fits into the "before" category as well.  I try to start my shift by asking my learners what their goal for the day will be.  This allows me to cater the learning to their needs and wants.  With residents, I'm also able to cater to their deficiencies since I work with them often.

After leaving the bedside:

Debrief:  This has 2 purposes: clarify the encounter and plan and to provide feedback.  The learner gets some time for questions, we finalize our workup plan, and then I can provide brief feedback on how to improve.

While bedside teaching is underutilized, with practice it is one of the best clinical teaching tools.  We all have something to offer to our learners, sometimes skills that can only be learned through observation, practice, and reinforcement at the bedside.  Unless we go there and face our (and our learners) discomfort, we cannot begin to realize our full potential.

Reference:

Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med. 2003 Apr;78(4):384-90. PMID: 12691971

Why Blog?

Why create a blog or use a wiki for education?  One good reason is that blogging fulfills the "write something" mandate that Atul Gawande recommends as one of the keys skills in becoming a positive deviant; another is the metacognitive aspect of the experience discussed in this video:





There are many reasons why people blog.  As an educator, I have found that my students depend more and more upon web-based resources.  Learning to use these resources, and better yet, create them, offers an incredible opportunity to teachers.  Lets say that you've decided that you're going to take the leap and begin to blog, or create a wiki, for your students.  What tips can get you started?  If you're unaware of the "Twelve Tips" series published in Medical Teacher, check them out.  The following tips are a few that I found helpful from an article published from that series regarding these web 2.0 tools.


1.  Appreciate the uses of blogs and wikis


These web 2.0 resources have 3 main uses: read, write, and interact.


Reading a blog or wiki are easy to access.  As the author, many programs allow easy incorporation of digital media such as video or pictures that can be shared with the learner.  Links to outside sources are easy to add as well.


Writing can be done by the learner.  This is useful for creating reflection in learners.  These tools can also be used to create online portfolios for the learners.  For some time, I've wanted to do an experiment with my residents and see whether learners in difficulty would benefit from writing a blog covering the content that they find difficult.


Interaction is fairly easy through blogs and wikis.  Through the use of co-authoring or comments, these tools foster the creation of an online discussion board.  Learners can even exchange documents.  While interaction holds the biggest potential, I've found it to be the most difficult use to facilitate in my learners.


2.  Be clear about why you are using a blog or wiki. These tools do have some limitations.  Make sure you are matching the technology to the needs of the learner.  These tools tend to have reduced functionality compared to tradition websites which can limit the amount of content delivery.  Fortunately, as technology improves, the amount of content that you can deliver via these tools only seems to increase.


3. Decide how you want to use the reading of a blog or wiki as a method to enhance learning. I use both a wiki and a blog.  The wiki hosts the entire formal curriculum for the residency.  Residents can download their assignments at their leisure, log the completion of assignments, and a few even have personal pages where they share their knowledge with the rest of the class (EKG and Critical Care pages).  From a teachers perspective, our curriculum is literature based and I'm able to rapidly change reading assignments to keep the curriculum current, and well ahead of any textbook.  The blog is more of a hobby.  It allows me to digest the materials that I'm studying and keep them handy for future reference.


4. Choose appropriate technology to create the blog or wiki.  The tools that "create" your sites vary in their functionality and cost.  Some are completely free but others will increase in cost as the feature go up.  For our wiki, we use Google Sites, which is simple to use and inexpensive ($10 per year for the storage we need).  One thing that we're now finding we need is the ability to limit access to certain pages.  The site unfortunately doesn't allow this feature.  Knowing what you might need in advance will save you time and headaches in the long run.


5. Expect barriers.  While many of todays learners are tech savvy, I've encountered moderate resistance from some.  Participation from the learners varies widely, with some jumping right in and creating content to others who just use it to download their assignments.


These are just some of the tips with my own 2 cents added.  The article provides 7 more which you will find useful if you're just jumping into this.  One thing is fairly certain.  Web 2.0 tools are going to be around for a while and are very popular to the learners coming through the system currently.  Mastery of their use offers a unique opportunity to improve their learning and possibly even accelerate knowledge translation.


Reference:

Sandars J. Twelve tips for using blogs and wikis in medical education. Med Teach. 2006; 28(8): 680-2. PMID: 17594577 

Teaching Residents Soft Skills

Professionalism.  Communication.  Empathy.  Skills needed for all physicians.  Unfortunately, with the hustle and bustle of everyday work and the "do more in less time" mentality that pervades our practice, relationship skills are often overlooked or frankly ignored.   If one was to look at the satisfaction with practice in emergency medicine, they would find a significant amount of burnout and unhappiness with practice.  Keeping this in mind, how do you work with residents to teach them the soft skills which lead to the rewarding practice of medicine and a more satisfying relationship with patients?


Wright et al set out to identify a list of practices that lead to a more fulfilling practice life.  The list that they have created captures behaviors and attitudes that may help achieve this goal on a personal level.  Even more helpful to the educator, the list creates a wonderful set of tasks that you use to help a trainee assess themselves and continue on the journey to personal and professional growth.


To use the list, I've begun to create a set of cards, each containing one precept.  I like to start a shift by asking the resident what they want to learn on that particular shift.  I often find that their list is somewhat generic, such as "I want to work on my procedures."  Instead, by pulling out these cards resident can pick any card and suddenly we have a simple task to practice.  I can then observe their behavior and offer simple feedback on their success with the task.  


The list can be customized, expanded, and is designed to change as medicine changes.  Look it over and try it out.  I think that you'll find it helps both the learner and the teacher.  As Robert Heinlein pointed out, "When one teaches, two learn."


The List:


Promotion of relationships with patients
1. Greet patients by their names, tell them you name and your role in their care
2. Smile
3. Sit down when talking to patients
4. Listen
5. Be wholly present when interacting with patients and avoid unnecessary interuptions
6. Learn who your patients are and consider sharing something about yourself with them

7. Show the utmost respect for all patients

8. Be humanistic, compassionate and caring

9. Even if it is a struggle to think positively of a patient, always speak of them in a positive way; this will influence your thinking positively

10. If you are feeling negative emotions towards a patient, try to understand why you are feeling this way

Principles of the effective clinician

11. The history and physical examination are not like a biopsy fixed in formalin, but are dynamic entities that should be revisited frequently

12. A patient’s history should not be “aspirated”; it should instead be “built” purposefully with effective communication skills

13. Be curious – seek to find out exactly how and why events occurred and do not accept diagnoses and conclusions made by others

14. Recognize the patient as teacher

15. Elaborate a differential diagnosis that is as broad as the history and physical examination dictate

16. After forming a diagnostic hypothesis, focus on any symptoms or signs that are either atypical or incompatible with the diagnosis; these must be explained and not ignored

17. Always consider and exclude catastrophic treatable diseases

18. Continually strive to improve your diagnostic skills by mentally committing to a specific answer or conclusion before definitive testing

19. Watching patients walk is a critical component of the physical examination, particularly if their level of function is compromised

20. Look at the sacrum and heels of any patient who is bed-bound

21. Think about and plan for how to best deliver the information before telling important news to patients about their health

22. Explain medical concepts in simple language; avoid medical jargon and make sure that the patient understands

23. Teach patients what they need to know to make an informed decision

24. Strive to become a healer

25. Solicit help when you are stumped or at a loss in caring for a patient

26. Review your patient’s drug list and require explicit justification for every medication

27. Remember that the ill patient is not at his best

28. Do not discuss patients in public places (eg, elevators)

29. Appreciate the contributions of all members of the health care team

30. Try to be as organized as possible – be prepared and be thorough yet efficient

31. Focused reading to answer specific clinical questions is more nourishing leafing through a current issue of a medical journal

32. Know that much practice, reading, and years of hard work are essential parts of becoming an excellent physician

33. When you have made a mistake in the care of a patient, follow these steps: (a) admit it, (b) inform the patient, (c) if possible, initiate reparation, (d) institute a mechanism whereby you will not repeat the error, (e) attempt to establish a mechanism whereby others in the system cannot make the error, (f) forgive yourself

Growth and improvement

34. Strive to achieve personal awareness and an understanding of your beliefs, values, and attitudes

35. Recognize and acknowledge powerful experiences

36. Seek out and embrace helping relationships

37. Make time for reflection

38. Observe other physicians carefully and learn from role models

39. Realize that people are watching you closely – strive to be a role model for others

40. Be creative and innovative

41. Try to look into an accurate mirror

Values to guide one’s career in medicine

42. Avoid being cynical

43. Understand that medicine is a public trust

44. Be humble

45. Be ethical in all of your work as it relates to the profession of medicine

46. Aspire to become a great teacher

47. Stand up for what you believe in

48. Aim for a comfortable balance between your personal and professional lives

49. Try your best

50. Continually search for meaning in your work in medicine

51. Celebrating successes may help to avoid burnout

52. Be thankful and happy that you are in medicine

Reference:

Wright SM, Hellmann DB, Ziegelstein RC. 52 precepts that medical trainees and physicians should consider regularly. Am J Med. 2005 Apr;118(4):435-8. PMID: 15808145

Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety

Have you ever stopped and wondered what good clinical supervision means? Supervision is one of those concepts in academics that we are expected to do with little, if any, guidance. Many factors within medicine have led to an increase in the expected levels of supervision recently. Work hours restrictions, Medicare rules, and a call to arms about patient safety have prompted calls for more and better supervision. The problem is, "What is appropriate clinical supervision?" This article took a qualitative observational research approach to looking at this exact problem with a goal of defining a conceptual model of clinical supervision.

Methods:

This study uses a qualitative approach referred to as grounded theory methodology. Participants were faculty and teaching teams from the emergency department and general medical floor. To minimize the Hawthorne effect, incomplete disclosure was employed, i.e. the participants knew they were being observed, but they didn't know what was being observed. Observational data were collected and refined over a single calendar year.

Results:

Their analysis revealed that supervisory activities related to patient care are distinct from other types of supervision, such as formal teaching. These activities seem to fall along a continuum from less to more involved.

Routine Oversight: These are activities planned in advance and expected by all involved in the clinical setting. In a sense, routine oversight is simply monitoring the trainees activities. In emergency medicine, this type of oversight is used when hearing case presentations from students or residents followed by probing, refinement, and confirmation of the management plan.

From my perspective, this is the bread and butter supervision that we all do from shift to shift.

Responsive Oversight: In this type of oversight, the direct involvement of the supervisor increases either as a result of a direct request from the trainee or in response to a concerning clinical situation. This can involve repeating history and exam findings, observing trainees in action, or coaching learners at the bedside (i.e. supervising procedures).

Triggers that increase supervisor vigilance often result in responsive oversight. These include:

• Clinical Cues: unexpected changes in patient conditions, unstable patients
• Information from a secondary source: family or nursing concerns brought to the supervisor
• Language Discrepancies: Clinical presentation not matching clinical data (labs, radiology, etc)

I find that this level of supervision varies from learner to learner depending on my trust in the trainees abilities and confidence.

Direct Patient Care: This is the highest level of supervision and often is initiated when the supervisor realizes that the clinical situation has exceeded the learners ability to manage the care of the patient. This may happen quickly, as one would expect when working with medical students, or may happen only in extraordinary situations with senior trainees.

Personally, when working with senior trainees, I find that this becomes more of "Team Management" with the senior assuming control of some tasks while I handle other tasks to manage a critical ill patient.

Backstage Oversight: The final type of oversight occurs with little trainee knowledge. Backstage oversight includes seeing patients independently of the trainees (we do this a LOT in emergency medicine) or reviewing pertinent patient data such as labs or radiology in the absence of learners.

Final thoughts: As a junior faculty member, finding the right balance of supervision to learner autonomy has been a challenge. This article confirms what we probably all do in our day to day clinical practice. It demonstrates that supervision is a fluid process involving an ebb and flow of involvement that is linked to learner and patient factors. Increased awareness of factors that should prompt us to upgrade our level of supervision will benefit our learners and potentially make patient care a little bit safer.

Reference:

Kennedy TJT, Lingard L, Baker, GR, Kitchen L, Regehr G. Clinical Oversight: Conceptualizing the Relationship Between Supervision and Safety. J Gen Intern Med. 2007 Aug;22(8):1080-5. PMID: 17557190