CLIME-Effective-efficient-Bedside-teaching-v4_all-slides-.pptx
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CLIME-Effective-efficient-Bedside-teaching-v4_all-slides-.pptx
- 1. EFFECTIVE & EFFICIENT BEDSIDE TEACHING UWSOMCLIME April 27, 2021 Andrea Christopher, MD, MPH Paul Cornia, MD Melissa (Moe) Hagman, MD Justin Kappel, MD, MPH
- 2. INTRODUCTIONS Speaker intros Visual audience intros:Turn your camera on if the prompt fits you. Geographic location Clinical practice setting Learners
- 3. DISCLOSURES No financial conflicts to disclose
- 4. GUIDELINES FOR DISCUSSION •All of you is welcome here • If you are able, please turn on video • We welcome participation through the chat & unmuting to speak • If we get zoom bombed, we will turn off cameras and chat •Assume positive intent & turn to wonder •Step up / Step back
- 5. OBJECTIVES 1.Teach clinical reasoning at the bedside 2. Maintain patient AND learner centeredness 3. Complete teaching and clinical tasks in the time allotted
- 6. AGENDA Why teach at the bedside When, where and how to teach at the bedside Strategies for effective and efficient bedside teaching Tools and language to improve your bedside teaching
- 7. WHY TEACH AT THE BEDSIDE
- 8. HISTORY OF BEDSIDETEACHING • Bedside teaching was previously the norm, what happened? • Medical technology, EMR, expanded documentation requirements • Resident duty hour restrictions • Absence of role models and experienced facilitators Reichsman F, et al. J Med Educ, 39. 147-63. Fihn s, et al. 2000. J Gen Intern Med, 15, 451-6. Jan Hirschmann, MD JoyceWipf, MD Steven McGee, MD Erika Goldstein, MD, MPH
- 9. CHALLENGES WITH BEDSIDETEACHING Limits to time “Thin ice syndrome” Space and privacy for patients During the COVID19 pandemic: exposure risk, limited available PPE No data showing improved patient outcomes Ramani S, et al. Acad Med, 78, 384-90. Wang-Cheng, et al. J Gen Intern Med, 4. 284-7.
- 10. BENEFITS OF BEDSIDETEACHING Opportunity to give feedback: Communication with patient Skills such as physical exam, patient education Role modeling with the patient Engage the patient in decision making Make time spent on patient care transparent to patients and their loved ones
- 11. SMALL GROUP #1 (15 MIN) Introduce yourselves Why are you here today?What do you hope to learn? Reflect on / share any notable stories where bedside teaching went well or poorly. What has been challenging for you when doing bedside teaching?
- 13. WHEN/WHERE/HOW TO TEACH AT THE BEDSIDE
- 14. ROUNDINGVSTEACHING Rounding: Review clinical data Develop plan of care Inform the patient and healthcare team Teaching: Expand learner’s clinical knowledge Develop information gathering skills and medical decision making “Test” learner in real-world scenario in order to give formative feedback
- 15. ROUNDINGVSTEACHING Lessons from Rhetoric : “the capacities of writers or speakers needed to inform, persuade, or motivate particular audiences in specific situations”
- 16. ROUNDINGVSTEACHING Rounding -> bedside rounding -> bedside teaching Adding more audiences Adding complexity and competing needs Blurring the specific context and goals of the clinical situation Testing the “myth” of multi-tasking
- 17. GETTINGTHE MOST OUT OF BEDSIDE TEACHING Communicate, communicate, communicate! Flexibility Creativity Practice
- 18. STRATEGIES FOR EFFECTIVE AND EFFICIENT BEDSIDE TEACHING
- 19. PREPARETHETEAM Team meeting before 1st rounding session Get to know each other “People don't care how much you know until they know how much you care”,Theodore Roosevelt Get buy-in Explain the “why” Define bedside roles Attending, resident, intern, medical student Oral presentations (1) McGee S. JAMA. 2014;311(19):1971-1972.
- 20. PREPAREYOURSELF Review charts Develop high yield teaching scripts, exam maneuvers, etc. Role model “Real time” clinical reasoning Acknowledge uncertainty, discuss how you deal with it (eg, discuss with colleagues/specialists, lit review, etc)
- 21. PREPARETHE PATIENT Ask permission Ensure patient comfort Verghese – “What are the two most important buttons in medicine? Not the left and right mouse button.The light switch and the button that raises the bed.” Introduce team members Acknowledge family members, loved ones, etc. that are present
- 22. QUESTIONS?
- 24. SMALL GROUP #2 (15 MIN) Case #1 – “Just a rash…”
- 25. CASE 1 – DEBRIEF
- 26. TOOLS AND LANGUAGE TO IMPROVEYOUR BEDSIDE TEACHING
- 27. TEACH LIKE A CHAMPION – Create an Effective Learning Environment J Factor Normalize Error WaitTime
- 28. TEACH LIKE A CHAMPION – Engage the Learner Ratio The Hook Take a Stand
- 29. TEACH LIKE A CHAMPION – Set High Academic Expectations Stretch It Right Is Right Break It Down No Opt Out Format Matters
- 30. SMALL GROUP #3 (15 MIN) Case #2 – A Most Helpful Patient
- 31. CASE 2 – DEBRIEF
- 32. OBJECTIVES 1.Teach clinical reasoning at the bedside 2. Maintain patient AND learner centeredness 3. Complete teaching and clinical tasks in the time allotted
- 33. IN CONCLUSION Prepare yourself Prepare the team Prepare the patient Communicate Be flexible Get creative
- 34. IN CONCLUSION Practice, practice, practice!
- 35. THANKYOU! Special thanks to Dr. Jessica Lu and Dr. Alex Chen of the UW Family Medicine Residency as well as theVA Boise Simulation Lab: Brian Cruthirds Tara Nyborg Jenn Snyder Lydia Carbis (IdahoWWAMI)
- 36. THANKYOU! Please reach out with questions/feedback: Moe Hagman (mhagman@uw.edu) Justin Kappel (kappeljd@uw.edu) Andrea Christopher (andrea.christopher@va.gov) Paul Cornia (paul.cornia@va.gov)
Editor's Notes
- Geographic location – Seattle / Washington vs WWAMI Clinical practice setting – inpatient vs outpatient ? Learners – students, residents, fellows
- We recognize the wealth of experience and wisdom in this crowd, so hope to use discussion to engage with our content today We promise no role playing exercises With intentionality of creating today’s teaching space, we have some guidelines for discussion today
- In 1679, the father of bedside teaching, Franciscus de le Boe Sylvius, wrote: “My method, hitherto unknown here, and possibly anywhere else [is to] lead my students by the hand to the practice of medicine, taking them every day to see patients in the public hospital, that they may hear the patients’ symptoms and see their physical findings. Then I question the students as to what they have noted in the patients and about their thoughts and perceptions regarding the causes of illnesses and the principles of treatment” (Le Boë and Schacht, 1679, Linfors and Neelon, 1980). In 1964, Reichsman et al study at U Rochester – teams rounded at the bedside for 75% of all patient cases presented during rounds Billing changes in 1995 with the Medicare Teaching Physician Rule (TPR) to standardize billing and prevent double billing by attending physicians on teaching patients, associated with reduction in scheduled teaching by 30% and more of a shift to supervision.
- Emphasis of financial productivity by attendings over teaching time “Thin ice syndrome” described by Linfors and Neelon in 1980 – in which faculty feel they have too little knowledge to reactive in an expert way to the patient and their problems “which might draw them onto thin ice” Also applies to trainees – Wang-Cheng report 2% residents and 4% medical students report comfort presenting at the bedside. Cite issues of patient comfort, privacy, fear of embarrassment and compromised doctor-patient relationships (if trainee is found to be wrong in a bedside discussion”
- - What are the areas of discomfort / is uncomfortable about bedside teaching
- When we think about what rounding and teaching are…very different things Adding the “bedside” – rounding can be a bit of a tougher sell as the claims for efficiency, quality, satisfaction are not particularly robust but bedside teaching is actually a very great way to meet some of these goals. Patients are our best teachers, each one has something to offer.
- Corbett, E. P. J. (1990). Classical rhetoric for the modern student. New York: Oxford University Press. p. 1.; Young, R. E., Becker, A. L., and Pike, K. L. (1970). Rhetoric: discovery and change. New York: Harcourt Brace & World. p. 1. https://en.wikipedia.org/wiki/Rhetoric#cite_note-6
- Consequences: More opportunities for communication to breakdown and goals to go unmet More confusion on part of participants as to their role Multitasking involves engaging in two tasks simultaneously. But here's the catch. It's only possible if two conditions are met: at least one of the tasks is so well learned as to be automatic, meaning no focus or thought is necessary to engage in the task (e.g., walking or eating); and they involve different types of brain processing. For example, you can read effectively while listening to classical music because reading comprehension and processing instrumental music engage different parts of the brain. However, your ability to retain information while reading and listening to music with lyrics declines significantly because both tasks activate the language center of the brain. - https://www.psychologytoday.com/us/blog/the-power-prime/201103/technology-myth-multitasking
- Communicate –(goals and roles) Firm goal-setting and definitions of roles Flexibility -Adjusting approach to the patient context and learner needs. Consider splitting rounds and teaching to be more direct with eac hone Creativity - How can we unlock the potential learning in each patient interaction? What role does the patient play? Are they an audience, are they the teacher, are they the demonstration? Practice - Don’t expect every one to go perfectly. Debrief and learn from each experience
- Thanks, Justin, I’ll now discuss some suggested specific approaches to bedside teaching. I’ll use the frame: preparing the team, preparing yourself, and preparing the patient. Team meeting is absolutely essential. As was discussed at the outset, bedside teaching is now uncommon so it is critical to prepare your team members before you do it the first time. Get to know each other How will we deal with microaggressions? Why are we doing this? It is patient centered; patients appreciate seeing us discuss their case and explain plans in front of them Allows me to directly observe you and then offer feedback (communication, professionalism) Some things can only be taught at the bedside or are become more meaningful in the context of a specific patient Roles I am ultimately responsible for patient care and teaching Resident is team leader, will make initial patient care decisions. I may occasionally change these decisions. Intern or medical student will best know patients and will present at bedside. I will have reviewed charts in advance which allows us to be more efficient and to teach and learn at the bedside. Generally, 2-2 ½ hours of rounding
- Chart review Accessibility of the EMR allows attendings to gather data relatively easily, rather than gathering it from trainees on rounds. chart review has also become the norm. Consider (you) presenting the first case to the team The intent is not to point out omissions from the oral presentation, unless making a key teaching point. Teaching Distinct from chalk talk or classroom session Play to your strengths (eg, I do periop med consults so when we have patient requiring surgery on our service….) Maximum 2-3 minutes Repeated over time, honed Exam finding (measuring JVP in patient with decompensated heart failure) Teaching scripts (Intern, “I’m actually not sure why the ED admitted Mr. A….”, perfect opportunity to discuss pneumonia severity scoring scales and CURB-65 can easily be remembered and used at the bedside) Role model Fear of “not knowing the answer” is common and understandable but presents wonderful opportunity think out loud and role model your approach
- Ask permission to take 2-3 minutes to teach, acknowledge that some of this may be about diseases that patient does not have Bedside teaching is a privilege, treat it as such
- - What are the areas of discomfort / is uncomfortable about bedside teaching
- - What are the areas of discomfort / is uncomfortable about bedside teaching
- Power of setting, patient role, when to bail, ok for things to go wrong
- When is your next opportunity to teach at the bedside going to be? What kind of learners will be there? What kind of patient will you teach about? How can you prepare?