Facilitation of clinical reasoning during bedside teaching workshop for clinical preceptors
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Learning Objectives 1. Identify strategies for Clinical Reasoning Strategies. 2. Identify the RIME Framework for Clinical Competency. 3. Identify how to facilitate Bedside Teaching (according to Cox Model).
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Facilitation of clinical reasoning during bedside teaching workshop for clinical preceptors
- 1. Facilitation of Clinical Reasoning During Bedside Teaching Workshop For Clinical Preceptors Dr. Muhammed E.M. Elgasim Educator and Clinical Skills Instructor MBBS EMDM MAcadMEd Clinical Skills Department St. George's University
- 2. Learning Objectives • Identify strategies for Clinical Reasoning Strategies • Identify the RIME Framework for Clinical Competency • Identify how to facilitate Bedside Teaching (according to Cox Model)
- 3. Discussion & Reflection • How do we interpret the patient data and generate a differential diagnosis ? • How do we teach out students clinical reasoning ? http://photos2.meetupstatic.com/photos/event/7/9/c/4/event_99331172.jpeg
- 4. Clinical Reasoning Strategies Input Output History Physical Exam Accurate Diagnosis
- 5. Clinical Reasoning Strategies 1. Pattern Recognition. 2. Hypothesis Testing. 3. Forward Thinking.
- 6. 1. Pattern Recognition What is the diagnosis ?
- 7. 2. Hypothesis Testing • 35 year old AA female with one day history of sharp, left-sided chest pain, occurring at rest and worse with inspiration and coughing. No fevers, no SOB. Meds: OCPs Normal CV, RS examination except Tachypnea 28 & Tachycardia 130 bpm. Differential diagnosis 1.CAD 2.Pneumonia 3.Pericarditis 4.PE 5.Musculoskeletal 6.Pleuritis 7.GERD
- 8. 3. Forward Thinking • 35-year-old African- American woman with 1- day history of sharp, left- sided chest pain, occurring at rest and worse with inspiration and coughing. No fever or SOB. Meds: OCPs Normal cardiopulmonary examination except R 28/min & HR 130/min. • Epidemiology: – Young Women – OCPs • Temporal course – Acute • Syndrome (Problem statement) – Pleuritic Chest Pain. – Tachycardia Illness Script
- 9. Expert Organization of Information Illness script •Demographics (Age, Gender and Race or Ethnicity). •Risk Factors: Other Conditions •Exposers Epidemiology: who gets it? •Duration of Prodrome or Symptoms: Hyperacute, Acute, Subacute, Chronic •Pattern of Prodrome or Symptoms: Constant (Stable or worsening), Episodic (Waxing and waning, Biphasic or Interment). Temporal Course: How does this disease present with respect to time? •What are the known derangements in: Anatomy, Physiology, Immunology, Biochemical pathways, Genetics, and Metabolomics. •What are known environmental contributors: Microbiology, Toxins, and Pharmacology. Pathophysiology: What are the biomedical causes of this disease? •Key and Differentiating Features ± MUST HAVE & REJECTING Features. Clinical presentation (Syndrome Statement)
- 10. Maturation of clinical reasoning Novice Expert Data Gathering Diagnostic accuracy Forward Thinking + Pattern Recognition Hypothesis Testing
- 12. Student's Clinical Knowledge Organization • 35-year-old African- American woman with 1- day history of sharp, left- sided chest pain, occurring at rest and worse with inspiration and coughing. No fever or SOB. Meds: OCPs Normal cardiopulmonary examination except R 28/min & HR 130/min. Spontaneous Pneumothorax Psychiatric Pulmonary embolism Pneumonia
- 13. Expert's Clinical Knowledge Organization From Catherine R. Lucey, MD Clinical Problem Solving https://www.coursera.org/course/clinprobsolv
- 14. Teaching Forward Thinking Symptoms Involved System(s) Symptoms Involved System(s) More Symptoms, Exposure or Risk factors Involved system(s) More Symptoms, Exposure or Risk factors Involved system(s) Signs Involved system(s) Signs Involved system(s) List of Symptoms and signsList of Symptoms and signs ForwardThinkingForwardThinking Illness ScriptIllness Script CC & HPI
- 15. Discussion & Reflection • How do we assess our trainee competency ? • How do we communicate that assessment with our trainee? http://photos2.meetupstatic.com/photos/event/7/9/c/4/event_99331172.jpeg
- 16. Clinical Competency Framework Watch the following video https://www.youtube.com/watch? v=ifTAzAiTPQY Answer the following questions • What does the trainee demonstrate for each RIME Level? • What types of questions that trainee can answer for each RIME Level? PICTURE From https://www.haikudeck.com/copy-of-rime-framework-for-medical-education-education-presentation-46d262fe5a#
- 17. RIME Clinical Competency Framework • R.I.M.E Model – Describes performance goals for trainees. – Apply to single encounter or to overall performance . From Sally Santen M.D., Ph.D: Teaching and Assessing Clinical Skills https://www.coursera.org/course/clinicalskills
- 21. Educator
- 23. Discussion & Reflection • How do you plan and conduct your bedside teaching ? http://photos2.meetupstatic.com/photos/event/7/9/c/4/event_99331172.jpeg
- 24. Cox Model for Bedside Teaching
- 25. The Learning Triad (and its environment)
- 26. Clinical Bedside Teaching: Challenges • Teacher related challenges . • Patient related challenges . • Student related challenges . • Environmental challenges .
- 27. Prepare The Teacher • Prepare The Teacher – Consider the “six domains of knowledge” 1. Medicine 2. Patients 3. Context 4. Learners 5. General principles of teaching 6. Case-based teaching scripts • Prepare The patient. • Prepare The student.
- 28. Cox Model for Bedside Teaching From John Dent et al; Getting Started In The Hospital Ward, Dundee.
- 31. Models of Bedside Teaching • Demonstrator model • Facilitator model • Observer model
- 35. When the session is over? • Preceptor and students need a framework or structure to focus the outcomes of the teaching session. • Acronym EPITOMISE links to the major learning outcomes.
- 36. E S I M O T I P E Enquiry (communication and ethics) Physical examination Investigations and interpretations of results Technical procedures Options of diagnosis Management Information handling Sciences – basic / clinical Education of the patients and yourself
- 37. Picture From John Dent et al; Getting Started In The Hospital Ward, Dundee.
- 38. Summary • Strategies for clinical reasoning strategies. • The RIME framework for clinical competency. • Facilitation bedside teaching (according to COX model).
- 39. Any Questions
- 40. References • John Dent et al; Getting Started In The Hospital Ward, Dundee. • John Dent; A Practical Guide for Medical Teachers, 4th edition. • Robert L et al; Teaching Clinical Reasoning (Teaching Medicine Series) American College of Physicians. Kindle Edition. • Mary Seabrook; How to Teach in Clinical Settings, Wiley. • Jeff Wiese; Teaching in the Hospital (Teaching Medicine Series) American College of Physicians. • From Catherine R. Lucey, MD Clinical Problem Solving https://www.coursera.org/course/clinprobsolv • From Sally Santen M.D., Ph.D: Teaching and Assessing Clinical Skills https://www.coursera.org/course/clinicalskills
Editor's Notes
- Pattern Recognition Instinctual, rapid responses; effortless and autonomous Require no active thought First impressions, no input from analytic component Valuable and usually accurate but can be source of cognitive errors Learned by repeated exposure and feedback
- Consistently good in interpersonal skills, reliably obtains and communicates clinical findings History and physical Recognizes normal from abnormal Answers “what” questions
- Able to prioritize and analyze patient problems, develop a differential diagnosis and next steps in the workup Uses clinical reasoning Includes pertinent positives and negatives (based on interpretation) Prioritizes differential diagnosis Answers “why” questions
- Consistently proposes reasonable diagnostic and therapeutic options, incorporating patient preferences Reasonable options in management and plan Patient centered Answers “how” questions
- Consistent level of knowledge of current medical evidence; demonstrates self-directed learning and contributes to others’ education Defines important questions Looks for evidence Shares what they learn
- Teacher related challenges. Clinical bedside teaching should be done by more leading doctors. Clinical bedside teaching done by more junior doctors. Inexperienced at bedside teaching. Fear of losing control of the session. Fear of difficult questions. Out-faced by large number of students. Patient related challenges. No suitable/available patient Patient too tired Patient discomfort Patient absent Patient privacy Uncooperative patient
- Prepare The teacher Knowledge of medicine: integrating the patient’s clinical problem with background knowledge of basic sciences, clinical sciences and clinical experience Knowledge of patients: a familiarity with disease and illness from experience of previous patients Knowledge of the context: an awareness of patients in their social context and at their stage of treatment Knowledge of learners: an understanding of the students’ present stage in the course and of the curriculum requirements for that stage Knowledge of the general principles of teaching, including: Getting students involved in the learning process by indicating its relevance Asking questions, perhaps by using the patient as an example of a problem-solving approach to the condition Keeping students’ attention by indicating the relevance of the topic to another situation Relating the case being presented to broader aspects of the curriculum Meeting individual needs by responding to specific questions and providing personal tuition Being realistic and selective so that relevant cases are chosen Providing feedback by critiquing case reports, presentations or examination technique Knowledge of case-based teaching scripts: the ability to present the patient as representative of a certain clinical problem; the specifics of the case are used but added to from other knowledge and experiences in order to make further generalized comments about the condition. Prepare The patient Check the availability of patients and ensure they agree to take part in the session. Prepare The student Find out how many students to expect and what stage of the course they are in.