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Reebok 2009

by Kurt Wilson on Dec 01, 2009

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Clinical debriefing workshop slides

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Begin with an ice breaker, get you all talking. I’d like you to have a think about the following illustration. Introduce yourself to the person next to you- what do you think about the lines drawn out here? Do they slope? Are they parallel?
1 What about this picture? Who is it? Who is it? Clinical debriefing is a chance for us to let students reflect on their clinical experience, think about it, learn to look at their experiences in a deeper way and think again. It is also a chance for us to give students some feedback and for us to gain some feedback from them. 2 It is rather like being a driving instructor- students are learning to drive, they are concentrating on steering the car, using the gears and remembering to indicate. We are looking out for dangers in the upcoming traffic, and will be thinking of alternative routes if things look bad ahead.
These are the ILOs listed for the session. I hope to discuss what I feel is meant by clinical debriefing, and describe some aspects of the process that is currently carried out by general practitioner tutors at base hospitals. You will get the opportunity to put yourselves in the student’s shoes and visit part of a clinical debrief session. We will have the opportunity to reflect on things at the end of the session, and also have the luxury of help from two final year students who have previously attended clinical debrief sessions held by an unnamed general practitioner. Hopefully this workshop will outline some of the ways that clinical debrief sessions, and techniques used within the sessions, can enhance reflective practice and improve two-way feedback between tutor and student.
Hang on – intended learning outcomes… What about ‘intended learning outcomes’? Does a student’s learning always go as we might intend it to? Miseducation They can recognise aspects of a what they see as a good teacher / practice but they are also forming a judgement what is good patient and not a good patient. We don’t know whether this has come from the student, or more worryingly , the Doctor that they’ve been placed with. If it is from the doctor, who is functioning as a potential role model, then it is an example of what Dewey termed ‘ miseducation’ in that the students are learning things that you really don’t want them to.
Not all leaders have acted as good role models…
Recently Rachel Lindley surveyed 1 st and 2 nd year students who had undertaken some early experience visits…
communication skills and clinical abilities and lovely things like what seems like a hint at the ‘wonder’ of the GP coming up with a DDx in the middle of working.
highlighted the ‘active’ involvement of the student in the visit , by doing things and being helped to understand what was happening DDx in the middle of working.
They also valued the positive role modelling they saw.
So again there were issues around poor communication skills, at odds with what they’ve already been taught about by this stage
As a teacher – issues of GPs motivation / skills and professionalism
So they are also seeing what they view as negative role models
The students use the session time to present cases to each other and discuss the processes of history taking, patient examination and effective communication. As students become more competent at case presentation, further thought, consideration and debate about presented material can be stimulated in group members through questioning and hypothesis generation. This encourages active learning, group interaction and reflection, and there are various techniques which I have found useful to facilitate this process. Session often stimulate topic discussion, which may be tutor or student led. The group can use the cases they have presented and discussed to help them focus on different aspects of the patient journey, and link their experiences in with clinical knowledge they have gained through problem based learning.
Students learn to consider the patient journey from community, through hospital and back to community settings. This is particularly suited to tuition by community physicians and has been well received by students at Hope hospital. Here are some of the feedback comments we have had… Gain teamwork skills Actively learn Obtain and provide peer-to-peer peer-to-tutor feedback Consider and debate important health care topics which are difficult to address in other learning arenas Reflective practice
Clinical debrief sessions supervised by community physicians have been held through Salford Royal hospitals at Hope hospital for the past three years. These sessions are available for third year students undertaking their Heart, Lungs and Blood module at the hospital. They provide an opportunity for small group work; students use the sessions to present patient cases to one-another, under the supervision and facilitation of a community tutor. Central Manchester and Preston now hold clinical debrief sessions supervised by community physicians. Four community tutors have been recruited and trained for debriefing sessions based at the Manchester Royal Infirmary. Two community tutors have been recruited for sessions at the Royal Preston hospital. Google pictures…
Here are the aims and objectives of clinical debriefing sessions that are presented to tutors and students.
How best to explore this more?
Opportunity for you to hear some cases presented by the fifth year students. We can try out some of the different techniques which make case presentation more fun, stimulate discussion and debate.
Hannah- cholecystitis Ask about environment where patient was seen. How was the experience? Positive/negative experiences?
Creating a list of differential diagnoses It can be useful to ask the group to think of differential diagnoses as the history progresses. The tutor can stop the presentation at several intervals. The group can list differentials they each think of, and the tutor can ask the group member to justify a differential they offer to the group. Differentials can be noted on the flipchart in the margin. As the history progresses the differentials can be removed by the group as new information is presented and make them less likely. Alternatively, group members can be asked to rank differentials when they have been put forward. This ranking process can be repeated at a few intervals as case details are revealed. Following discussion of one element of case history taking, we can ask the students to reflect on the learning experience- any learning required, any changes they would make?
Most working diagnoses are generated through history taking and then confirmed or refuted through examination. It is useful to demonstrate this to students by asking a clinical partnership to present their clinical examination findings before they present the patient history. Students in the group can think about features they might or might not expect in the history after hearing the examination findings. They can briefly debate possible diagnoses they would put forward prior to hearing the patient history. The group will usually find that the list of diagnoses and uncertainties surrounding them are large until they hear history details. This exercise demonstrates the importance of complete and accurate history taking in working diagnosis generation. Following discussion of one element of case history taking, we can ask the students to reflect on the learning experience- any learning required, any changes they would make?
which test would most help them as a history or examination findings are presented stimulates debate and discussion. The students can be asked to justify their choice of test if they were only allowed to perform one for the patient. This exercise can also facilitate discussion about the concepts of specificity and sensitivity when performing tests.
Would the case presentations and following discussions have prompted you to think about any topics to discuss? How can we debrief our students to help them gain the most from their clinical experiences? Does a discussion about both positive and negative experiences aid professional development, encourage two way feedback and facilitate learning?
Sessions can focus on different aspects of the patient journey, and link in with clinical knowledge and experience students gain through both problem based learning and interaction with patients in the hospital and community Provide patients with information, negotiate with patients, relatives and colleagues, recognise emotional role of parents, check for compliance and encourage concordance Students need to consider treating both individual patients effectively and their duty to provide care and support for the population in general. As we know, this sometimes presents difficult ethical situations and can be an area which is useful to consider and debate. They need to develop their understanding of public health, for example infectious disease prevention and contact tracing, and screening. They need to think about the decision-making process when faced with different treatment options (practicing evidence-based medicine) Students need to consider patient autonomy, breaking bad news and dealing with dissatisfied patients, relatives and even staff.
Only had two minutes, what might you use from clinical debrief? Three perspectives – one is to support their process of learning, including positive learning from negative experience and correction of student misconceptions (stool down the staircase). Other is to help them develop an objective view of events, to develop an appreciation of different perspectives and view points Third is to stimulate deeper and more complete learning building on both their and their peer group’s experience.

Reebok 2009 Presentation Transcript

Clinical debriefing Kurt Wilson
Intended learning outcomes
- Use clinical debriefing to deliver teaching, learning and assessment
- Enhance reflective practice
- Gain greater two-way feedback through clinical debriefing
Intended learning outcomes
- ‘ Miseducation’
Miseducation
Do students learn as intended in community?
The GP - Good
The GP - Good
The GP - Good
The GP – Not so good
The GP – Not so good
The GP – Not so good
What is meant by “clinical debriefing” Margin hypothesis Best test? Examination first Debate and discussion Tutor led Student led Case presentation History Examination Investigations
What might students get out of it? … very useful to learn from fellow students… … very good as interactive and varied… … topic discussion was particularly useful as the group were able to address learning objectives not raised in PBL … feedback was constructive and very encouraging… … I felt like I was applying my knowledge & this simulates what will happen later in ‘real life’
Where does it happen at the moment?
Aims and objectives
- Students will use debrief sessions to:
Session overview
- Groups of 8 students
- 2.5 hours long
- Case presentations
- Discussion
- Use of generic techniques and structured sessions
Subsequent sessions
- Improving history taking/presentation/group interaction and case discussion
- Structure sessions
Role play
- Case presentation
- Use some skills to enhance active learning
Case one
- Margin hypothesis generation
Margin hypothesis generation
- Differential diagnosis
- “ Bigger picture”
Case two
- Examination findings first
Examination findings first
- Understand importance of patient history
- “ Bigger picture”
Case three
- Best test?
Best test?
- Only allowed one test
Summary of cases
Topics for discussion
- Issues surrounding patient centred care
- Treating individuals versus population medicine
- Disclosure, recommendation and understanding
Feedback
- How might clinical debrief aid the process of feedback between student and tutor?
- Are there any of these techniques that might help you to facilitate learning when students present cases to you?

Reebok 2009

by Kurt Wilson on Dec 01, 2009

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Reebok 2009 Presentation Transcript