Faculty Development

Tools to grow your skills as a teacher.

Learn to Use the Tools of a Teacher

What Teaching Tools DO residency Educators Use?
Even though we were trained as physicians, we will need new training, skills and practice to become the residency educator our learners need most. Thankfully, our master teachers are generous in sharing what they have found to be the most useful approaches to teaching residents and students.

In the 21rst century, physicians learn in the workplace. You will need to know how to observe them with a patient, what skills are needed for the task at hand and what feedback to give them to move towards less supervision. This kind of teaching is not about a data dump- your residents can use Up To Date for that. It's about the application of knowledge- bringing together the right skills- to improve patient care.

In this section, you will learn about tools that most effective medical educators use everyday on rounds, in the clinic or when seeing patients with their learners. Each tool includes the rationale, the evidence and examples for its use.
MICROSKILLS
Rationale

In the early 1990's educators assembled a sequence of questions which clinical teachers could use to engage a student or resident in decisions about the case they are seeing. Each "microskill" satisfies a learning objective in a very short period of time and will help you 'diagnose the learner' as well as the disease.

Evidence

- Use of the Microskills method increases the usable feedback given to learners a factor of 2:1.

(Salerno, et al. Faculty development seminars based on the one-minute preceptor improve feedback in the ambulatory setting. J Gen Intern Med 2002:17:17:779-87)

- Faculty use of Microskills was associated with greater success in letting learners reason through cases, in evaluating learners and in creating and identifying next steps in learning.



Resources
Review the original "One Minute Preceptor" article (now called "Microskills").
Microskills Article

Teaching Clinical Reasoning

Why Add Reasoning to your teaching?
Resident and student learners are eager to receive feedback from their senior residents and attending physicians. Studies show they rarely receive feedback on their reasoning process.

Clinical reasoning is the core skill of internal medicine. Learning to embed comments that strengthen clinical reasoning will add another dimension to your teaching.

In this section you will find tools that will help you:

1. Learn the language of clinical reasoning: Problem representation, illness scripts, pattern recognition: use the new concepts of reasoning to spot gaps in your learners’ skills.

2. Add value to the feedback
you're giving to resident and student physicians

3. Learn rapid ways to embed training on clinical reasoning as part of work rounds

4. Improve use of the core skill of internal medicine


Self-reflection

Where in your teaching activities could you integrate comments about clinical reasoning?

What heuristic errors do you recognize in your own diagnostic process? How might sharing this awareness prompt your learners to identify their own potential errors in reasoning?

How did you utilize fast and slow (pattern and analytic) reasoning processes to arrive at a recent diagnosis? How would you explain that process in a step by step conversation with a learning reasoner?
Resources
In this PDF download you will walk through a slide presentation that reviews the four steps in the diagnostic process and how you can teach them on rounds or in the clinic.
Clinical Reasoning Training
Read Judith Bowen's foundational article on Diagnostic Reasoning and how to teach it to learners.
Bowen Diagnostic Reasoning Article
Read Gurpreet Dhaliwal's explanation of how clinical reasoning happens and how every clinician can improve their skill.
Improving DIagnosis
Download this guide to 32 common reasoning errors made when pursuing a diagnosis.
Cognitive Errors

Give Feedback that Improves Resident Skills

Feedback is Critical to resident Development
One of the most important skills of a graduate educator is the ability to give feedback that is context-sensitive and actionable by the learner. Learning how to do this is harder than it seems.

We as teachers give feedback that is influenced by multiple factors, some of which are non apparent. The educational culture of our department, our own set of internal norms and comparing the resident to other residents we know, our own educational experience, and how our day is going up to that point can each influence the nature of feedback we will give. Skim this article by Jennifer Kogan to appreciate the "black box of feedback" and think about the factors we can, and cannot, control:
Black Box of Feedback
How can we observe a resident and select what to say that will help them move to a higher level of skill- something they can understand and act upon?

We are learning as a department to observe residents in the workplace setting and then use ACGME Milestones to frame our feedback. Instead of one and done, we are moving toward a feedback model that helps residents form an action plan to close gaps in their skill set. This model is iterative (multiple tries), behavioral (did the resident actually use the behavior) and utilizes coaching (utilize your relationship with residents to develop a performance plan and check back for completion.)
Feedback in the era of milestones
To understand these concepts, start with this article that frames the feedback you give by using a coaching model:
Reimagined Feedback
To understand how feedback fits into our departmental strategy to develop competent residents, open this slide set and follow the learning progression:
Feedback 2.0 Slide Set
Self-Reflection:

What aspect of this coaching model might be a challenge to you?

What is your comfort level with sharing corrective elements in your feedback with residents?

How familiar are you with the ACGME Milestones? Review the current IM Milestones here:
ACGME IM Milestones

Teaching Effective Transitions

Why Teach About Hospital Discharge?
ACGME Milestones are mapped to the broad skill sets residents need to learn how to transition a patient from the hospital to home or a second facility. So this is a learning target for our residencies.

Beyond that, consider: a safe and effective discharge improves patient care, patient safety and hospital care value. Up to 3/4 of hospital readmissions are considered preventable; 19-23% suffer an adverse event on hospital discharge that is preventable.

In addition, learning to transition patients trains a resident in usable skills for many other medical situations. Assessing barriers, training a patient in self care and recognizing when the interprofessional care team is needed are just a few.

Use this slide deck to find an overview and teaching points to build the a rationale for Effective Transitions.
Transition Slide Deck
Review this article that highlights why physicians in training need an awareness of the things that can go wrong on transition from the hospital.
Transitions Article
Self Reflection

How will you build a rationale for residents on your team to learn how to transition patients well?

How comfortable are you in giving feedback to a resident who appears unaware that a patient has serious barriers to discharge?

Which aspects of a Discharge Summary might be most challenging for a an inexperienced resident? What pointers would you give?
How can I add teaching about transitions?
Our faculty thought about this at a recent faculty development session. They decided that sharing data highlighting the dangers of failed transitions can build the rationale in a resident's thinking for becoming competent in discharge. Letting them carry out one of the key activities of discharge while you observe and give feedback is a powerful way to train these skills. Solving problems on work rounds together and connecting actions to addressing readmission is another.

What are the elemEnts of an effective discharge?
Our faculty have identified 7 key elements of a good discharge:

1. Confirm the PCP who will follow up and set an appointment time; start TCM process for a transition appointment in IMC.

2. Update the Diagnosis and Follow Up Plan/Discharge Date.

3. Reconcile Meds: train patient and family for adherence

4. Train Patient/Family for Self Care: Use Zone Education to limit learning points.

5. Assess Risks/Barriers (Geisinger scale > 14)

6. Clarify consultant tasks after discharge (Communicate!)

7. Document hospital stay in Discharge Summary (be concise, include reasoning, and an outpatient To Do list.

Address Bias in Patient Care Settings

Bias isn't a Problem here- Is it?
Actually, our residents are most likely experiencing bias based on gender, race or other socially active constructs already without comment, based on studies that indicate a high prevalence in our society.

Bias can be expressed as microaggression or macroaggression toward students, residents, fellows, attendings or care staff.

As faculty, we need to have an approach that addresses these episodes in a direct way, protecting the learner or care team staff member while preserving the acute care needs of our patients. How can we do this?
Address a bias incident
In this brief learning module you will review three scenarios where bias occurs toward a resident or student. Here are the steps you can take to address it:

1. Assess illness acuity: EMTALA requires full care regardless of bias for emergent situations.

2. Cultivate a therapeutic alliance with the patient or family. (Deemphasize the target of the discriminatory content; Emphasize the patient's care)

3. Depersonalize the event. (Comments from patients and familes often come from their fear of the unknown; try to separate their words/behaviors to address the care they require).

4. Ensure a safe learning environment for all. (Check in with your team on this; the person targeted should not be the main responder to respect emptional impact.)

You can review the entire faculty training exercise here:


Addressing Bias