901 N. Washington Avenue
Lansing, Michigan 48906-5137
Telephone: (517) 485-5484
FAX: (517) 485-0801
E-Mail: saem@saem.org
| ||
|
|
901 N. Washington Avenue Lansing, Michigan 48906-5137 Telephone: (517) 485-5484 FAX: (517) 485-0801 E-Mail: saem@saem.org |
| ||
Developing a Career in the Scholarship of Teaching as a Clinician-Educator
Stephen R. Hayden
Characteristics of Good Clinical Teachers
Obstacles to Effective Clinical Teaching
Components of Good Clinical Teaching
The Five-minute "Microskills" Model of Clinical Teaching
Evidence Based Emergency Medicine at the Bedside
Introduction Clinical bedside teaching is nothing new. It was Hippocrates (circa 400 BC) who abandoned temple based medicine for a practice that valued direct observation, the exact recording of the features of disease, and adherence to the principal that "You must go to the bedside, it is there alone that you can learn disease." In his address to the New York Academy of Sciences, Sir William Osler stated that there should be "No teaching without a patient for a text, and the best teaching is that taught by the patient himself." Despite this legacy there has been gradual erosion in time spent teaching at the bedside. Thirty years ago over 75% of medical teaching occurred at the patient's bedside. Several authors have recently examined the time devoted to attending rounds on inpatient medical services. They estimated that only 16 - 20 % of the time devoted to attending rounds was spent in the presence of the patient. In other studies using direct observation or videotaping it was found that the average time spent at the bedside was only 2 - 3 minutes compared with approximately 60 minutes in the classroom. In 25 % of instances teachers never saw the patient at all, whether during the case presentation or afterward. Although a number of studies have shown that approximately 85 % of patients preferred bedside rounds, only 35 % of attending physicians did so, 4 % of students, and 2 % of housestaff. The emergency department (ED) has always been regarded as a rich environment for clinical teaching with the wealth and diversity of diseases that present to our doors. Yet most academic emergency physicians are experiencing intense pressure from external sources to improve the efficiency, documentation, and cost effectiveness of emergency medicine (EM) practice. I have heard many of my colleagues lament that this results in less time for teaching residents and students in the ED. If you believe that the best teaching occurs in the doctors workstation, conference room, or lecture hall then it is understandable that you would feel this way. I'm going out on a limb here, however, and suggesting that recent external forces that require attending EM physicians to personally see and examine all patients in the ED may be the best thing that has happened to clinical teaching in EM. We have been handed a golden opportunity. As a faculty physician you now need to be there anyway, take a resident, or student, by the hand and lead them with you back to the bedside where a multitude of teaching moments can occur. In this chapter we will discuss characteristics of good clinical teachers, perceived obstacles to effective bedside teaching, strategies to overcome them, the components of good bedside teaching, and a number of practical models to use in clinical instruction. Components of Good Clinical Teaching Figure 1 As depicted in Figure 1, the process of clinical teaching can be thought of as two connected cycles each with a number of components. When teaching at the bedside, the experience cycle will come before the explanation cycle. The preparation phase involves preparation by both the teacher as well as the student. Think about what you expect your students/residents to be able to do when you take them to the bedside. What are they ready for? What is their ability level? These are important considerations when you plan what you hope to accomplish at the bedside. Learning must be targeted at the level of ability and knowledge of the student/resident; your teaching goals will be different for learners at different stages in their clinical training. This may seem obvious, but it is all too often forgotten. Faculty need to prepare themselves for the experience cycle. First target your learner, and assess their learning needs. Have a focused, and feasible teaching goal for each clinical encounter. In a busy emergency department keep these goals simple and do not attempt to teach everything in one encounter; one or two teaching goals per clinical encounter is appropriate. Save other specific teaching objectives for the next patient experience. You may have to do a little homework yourself prior to teaching regularly at the bedside. Refresh your own physical diagnosis skills, develop a set of index cards or use your Palm Pilot to keep important diagnostic criteria, key references, or specific numbers at your fingertips. You may even decide to do "theme days" where you may pick a specific physical finding (type of heart murmur, back pain exam, etc.) or a clinical presentation (cough, abdominal pain, sore throat, etc.) to focus your teaching on that day. It is then much easier to review appropriate physical examination techniques, lookup relevant references, and prepare briefly for teaching on your next shift. The next step in the experience cycle is briefing. Briefing prepares both the patient, and the student/resident for the clinical encounter. The patient can make a considerable contribution to a teaching session. As a clinical teacher, set a good example and introduce yourself to the patient and give the patient a brief indication of the purpose of the bedside encounter. Something as simple as the following will set the stage with the patient for the rest of the clinical encounter: "Hi, I'm Dr. Hayden and I'm the doctor in charge of the emergency department today. We're making rounds right now to see how you are doing. I'm going to have Dr. Sloane tell me briefly what he has learned from you so far and then we will ask you a few more questions and examine you further. If there is anything you don't understand just let us know and we will be happy to explain it to you, and feel free to ask questions, or clarify something for us at any time." All the studies of bedside teaching consistently report that patients prefer clinical teachers to introduce themselves in such manner, to inform them what the bedside session is all about, and to translate medical jargon so that they can follow the discussion. Briefing the student/resident is likewise important. This can be done at the doctor's workstation or just outside the patient's room. Instructions can be given on what is expected, the rules about what to do and what not to do, and limits set about how far to go in the encounter. How much does the patient know about his or her condition? What may or may not be said in front of the patient or family? Negotiate the rules; what will the resident do? What will the faculty do? If a procedure is to be performed, the student's familiarity with the technical and cognitive skills may be assessed. What uncertainties are there in the student/residents' minds, and what questions do they have? Briefing will make the subsequent clinical encounter go much more smoothly. During the clinical encounter there are a multitude of teaching goals that may be achieved. Focus specific goals on the learner's level of experience and limit your teaching to just one or two points. One of the major goals of bedside teaching is to cultivate the skills of acute observation. As Florence Nightingale once said, "the most important practical session that can be given is to teach students what to observe, how to observe, what symptoms indicate improvement and which the reverse, which are of importance and which are not." Interpretation comes into play only after the features have been carefully observed and described. The role of the clinical teacher during a clinical encounter is quite variable, yet however that role is seen, some of the most powerful teaching flows from your own modeling of politeness, concern, discretion, gentleness, honesty and specific techniques of history taking and physical examination. The environment should be one of openness and encouragement to both ask questions and to voice ideas. The teaching skills in this setting lie principally in: * Guiding communication with the patient and explaining clearly to the students/residents * Demonstrating a variety of clinical signs and symptoms and how to elicit them accurately * Supervising performance and providing gentle but firm feedback * Questioning and challenging interpretations of the data * Modeling professional style with the patient and persistence in obtaining the necessary clinical information Before leaving the bedside, solicit questions from the patient about what just happened and what their understanding is of the diagnostic and management plan. Debriefing after the clinical encounter allows the clinical teacher to review with the learners what went on to the bedside. It provides an opportunity to talk about the experience, to express to the teacher how the clinical interaction was understood, and to raise questions. Additionally, debriefing checks that appropriate information has been recognized and interpreted accurately. Learning from the case can be synthesized giving the student a sense of achievement, ensuring resolution of any feelings aroused during the clinical encounter, and devising learning plans for future interactions. The explanation cycle begins with reflection, where the teacher and student literally step back from the immediate experience to link practice with theory, and other evidence that can shed light on the clinical events. The shift is from "What went on?" to "What did it mean?" Reflection is the time for learners to think aloud and the teacher's purpose at this stage is to allow free flow of their thoughts, which you help clarify and link to other learning. Reflection connects this patient with other patients, and with previous learning. Explication can be described as a search for how the questions of practice can be helped by biomedical science and current best evidence. The purpose is to link the clinical experience with theory and research relevant to the case. Explication may come from journals, textbooks, and clinical experiences of the teacher and other experts. The rule is that the most current, best available evidence is sought. It is also valuable at this stage to make assignments for obtaining necessary information including questions to be asked of the medical literature, or further history from other sources such as family or private physicians. The last step in the explanation cycle is the derivation of clinical working knowledge from the clinical experience. In other words it is "What would I do next time?", "What practical ideas have I picked up from thinking about this patient?", "What could I have done differently?" The learners create working rules, or rules of thumb, for use in future practice and clinical teachers guide them through this process. This practical knowledge then contributes to the preparation for the next patient, which brings us to the beginning of the next experience cycle.
The Five-minute "Microskills" Model of Clinical Teaching You are probably saying at this point that this kind of clinical teaching is all well and good but there is no time in the ED to do this. In an ideal teaching setting, maybe during a "teaching shift" or the equivalent, all phases of the experience and explanatory cycles can be done in their pure form. In a busy ED, however, a more condensed version is necessary that still retains key elements of the clinical teaching process. Such a five-minute model has been developed: * Get a commitment * Probe for supporting evidence * Discuss a "teaching pearl" * Reinforce what was done right * Correct mistakes Getting a commitment up front involves asking the learner to interpret or synthesize the clinical information obtained from the patient encounter. It allows the teacher to immediately diagnose the learner's needs, and gives you a sense whether the student/resident is in the ballpark regarding this patient's situation. Examples of this are "What do you think is going on with this patient?", "Why do you think the patient is noncompliant?", "Which of the many complaints will you focus on this visit?" Probing for supporting evidence takes this a step further by getting learners to reveal their thought processes. It allows you to identify their knowledge gaps. You might ask "What findings led to your diagnosis?", "What else did you consider?" Discussing a teaching pearl gives you the opportunity to introduce key elements of the case in question. This may include important diagnostic features, appropriate diagnostic testing, a variety of management issues from an emergency medicine perspective, and current best evidence that pertains to the specific clinical situation. This pearl, or "teaching bite" should be focused, easily digestible, and targeted to the learners level of understanding. Examples may include "The key features of this case are...", "In the ED, when a patient presents with X, your top three priorities are..." Reinforcing what was done right solidifies the behavior you want from learners. Give specific, and timely feedback. "Sandwich" constructive criticism between two layers (statements) of positive feedback. Correcting mistakes is extremely important at this stage. Omissions, errors, misinterpreting data, will become habit and part of "muscle memory" if not corrected at the time they occur. This should be done in an appropriate setting. It may not be suitable to correct serious errors in front of patients, nursing staff, or other students/residents. For example, "Next time that happens, try the following...", "I agree the patient may be drug seeking, but it is still important to do a careful history and physical examination" You may not even be able to use this five-minute model on every patient encounter in the ED. Be selective, choose a limited number of patients of the greatest teaching value during a given shift. You can listen for clues during the case presentation to select such patients; inconsistencies or confusing aspects of the history, abnormal findings described on the physical examination, may be clues that this patient can provide a "teachable moment". Alternately you can ask the student/resident which of their patients they want to see with you at the bedside making teaching learner-centered. An additional strategy is to grab one resident (this works with either a senior or junior EM resident) during a given shift and do periodic bedside rounds on the patients they are responsible for.
Evidence Based Emergency Medicine at the Bedside Evidence based medicine (EBM) can be defined as asking a focused, relevant clinical question and answering it based on the best most current evidence available. It is often stated that the place for EBM is in journal clubs or in reading articles in the library and that there is no time for this approach in a busy ED. A skilled clinical teacher, however, can bring elements of EBM to the bedside in a busy ED. At the bedside in the ED, use questions about the history and physical examination for teaching basic principles of EBM. Take a single item of history or examination and think of it as a "diagnostic test." Take a combination of history and physical examination features as a clinical prediction rule. It is an opportunity to discuss concepts such as pretest probability, precision (simple agreement, kappa) and accuracy (likelihood ratio, positive (PPV) and negative predictive value (NPV)) of diagnostic tests, utility of diagnostic tests, and using these properties to move from pretest probability estimates to posttest probability of disease. Start with pretest probability, use the HPI to establish baseline probability of a given condition. Discuss where pretest probabilities come from; ideally from well done published studies, or quality assurance studies done in your own ED, or based on clinical experience. Next focus on the specific elements of the history or examination. For example, meningismus, Murphy's sign, effort syncope, etc. In your briefing session review how to elicit the specific findings prior to assessing the patient. After assessing the patient, review these key elements of history or examination; discuss interrater, and intrarater reliability. Highlight the difference between simple agreement, and the agreement beyond that due to chance alone (kappa). You do not have to calculate a likelihood ratio, or PPV/NPV at the bedside to discuss the accuracy of a diagnostic test. Do your homework and have these numbers immediately available and show how to use a likelihood ratio to modify the pretest odds and derive a posttest odds of disease that can then be converted back into posttest probability. Question learners on how further diagnostic testing will alter disease probability and guide treatment and disposition decisions. For residents at higher training levels discuss the accuracy of combinations of signs and symptoms derived during a patient encounter and the management implications of clinical decision rules. The skilled clinical teacher will not attempt to get through all of these teaching goals for every patient. Take one concept that seems most relevant to the current patient, and save other concepts for subsequent similar patients seen in the course of the shift. Choose clinical conditions that you commonly see in the ED to prepare for. We all see suspected appendicitis, pharyngitis, exacerbations of asthma, and many other such conditions on a daily basis. The medical literature is replete with articles on clinical findings for various diseases. When searching the literature use terms such as "physical examination", "medical history taking", "observer variation", or "interrater reliability". JAMA has a series called the Rational Clinical Examination that contains this information for many common disease presentations. Have the likelihood ratios or sensitivity/specificity of various signs and symptoms readily available for these common conditions. Then when the teachable moment arises you'll be ready to pounce.
Conclusions External forces, such as recent CMS regulations, have pushed academic EM faculty into a situation where we need to spend a great deal of time personally evaluating patients. Rather than lament the loss of teaching time in the doctors workstation, grease board, or conference room, this is a unique opportunity to go back to the bedside with our residents and students and teach them firsthand medical history taking, physical examination skills, clinical acumen, and model professional interpersonal skills with patients. This paradigm shift requires that academic EM physicians refine their clinical teaching skills. Learn to recognize and seize the "teaching moment." Have a number of "teaching bites" readily available to use when such moments arise. Become skilled at recognizing your learner's knowledge gaps and exploit them for teaching. Guide learning with high yield questions that require synthesis and interpretation. Most of all, enjoy the opportunity to learn from your students/residents at the bedside as much as they learn from you. As Osler stated in his farewell address to The Johns Hopkins Hospital in 1905, "By far the greatest work of The Johns Hopkins Hospital has been the demonstration to the profession and to the public of this country how medical students should be instructed in their art. Personally, there is nothing in life in which I take greater pride than in the introduction of the old-fashioned methods of practical instruction. I desire no other epitaph than the statement that I taught medical students on the wards, as I regard this by far the most useful and important work I have been called upon to do."
Suggested Reading 1-10 1. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching [see comments]. J Am Board Fam Pract. 1992;5:419-24. 2. Stone MJ. The wisdom of Sir William Osler. Am J Cardiol. 1995;75:269-276. 3. Cox K. Planning bedside teaching--1. Overview. Med J Aust. 1993;158:280-282. 4. Cox K. Planning bedside teaching--2. Preparation before entering the wards. Med J Aust. 1993;158:355-357. 5. Cox K. Planning bedside teaching--3. Briefing before seeing the patient. Med J Aust. 1993;158:417-418. 6. Cox K. Planning bedside teaching--4. Teaching around the patient. Med J Aust. 1993;158:493-495. 7. Cox K. Planning bedside teaching--5. Debriefing after clinical interaction. Med J Aust. 1993;158:571-572. 8. Cox K. Planning bedside teaching--6. Reflection on the clinical experience. Med J Aust. 1993;158:607-608. 9. Cox K. Planning bedside teaching--7. Explication of the clinical experience. Med J Aust. 1993;158:789-790. 10. Cox K. Planning bedside teaching--8. Deriving working rules for next time. Med J Aust. 1993;159:64 11. Sapira JD. The Art And Science Of Bedside Diagnosis. Williams & Wilkins, 1990, Baltimore, MD 
![[SAEM]](../../images/saemsmal.gif)
HomePage