Improve Your Ward Attending Skills: Improve Your Ward Attending Skills: Integrating Learner and Faculty Integrating Learner and Faculty

Perspectives onPerspectives onSuccessful RoundsSuccessful Rounds

Robert M CentorRobert M CentorBrita RoyBrita Roy

Lisa WillettLisa Willett

22ndnd Annual Education Summit Annual Education SummitUniversity of Alabama at BirminghamUniversity of Alabama at Birmingham

Research and Innovations in Medical Education WeekResearch and Innovations in Medical Education WeekSeptember 28September 28thth, 2012, 2012

Bad news…Bad news… Your mother (or other loved one) is sick. Your mother (or other loved one) is sick.

Your previous UAB IM resident is the Your previous UAB IM resident is the doctor taking care of her.doctor taking care of her.

What specific skills do you want that What specific skills do you want that doctor to have?doctor to have?

ReflectionReflection What is the What is the purposepurpose of the attending? of the attending?

What is the What is the purposepurpose of rounds? of rounds?

OutlineOutline

Background (10 min)Background (10 min) Group exercise / expert panelGroup exercise / expert panel

Ward rounds scenariosWard rounds scenarios Integrated didacticsIntegrated didactics

Discussion (20 min)Discussion (20 min) Conclusions and Take Home Points (5 min)Conclusions and Take Home Points (5 min) Evaluations (2 min)Evaluations (2 min)

IntroductionsIntroductions NameName AffiliationAffiliation Number of ward attending months per yearNumber of ward attending months per year

ReflectionReflection What is the What is the purposepurpose of the attending? of the attending?

What is the What is the purposepurpose of rounds? of rounds?

Attending ResponsibilitiesAttending ResponsibilitiesPatientsPatients Diagnose the patientDiagnose the patient Supervise patient Supervise patient

care care TreatmentTreatment CommunicationCommunication Systems based careSystems based care BillingBilling

LearnersLearners Diagnose the learnerDiagnose the learner TeacherTeacher Role modelRole model CoachCoach Protect the professionProtect the profession Ensure the future of Ensure the future of

medicinemedicine

ACGME - AttendingACGME - Attending Monitor for fatigue, burnout, depressionMonitor for fatigue, burnout, depression Ensure days off and duty hour complianceEnsure days off and duty hour compliance Complete your evaluationsComplete your evaluations Provide feedbackProvide feedback Etc., Etc. Etc., Etc.

Challenges are plenty…Challenges are plenty… Balancing patient care/teaching in pressured Balancing patient care/teaching in pressured

environmentenvironment Increased documentation requirementsIncreased documentation requirements Short attending rotations (2 wks)Short attending rotations (2 wks) Teams are changingTeams are changing

Night floatNight float

Meeting other responsibilitiesMeeting other responsibilities Find the joyFind the joy

……but it’s worth itbut it’s worth it Fundamental educational function in internal Fundamental educational function in internal

medicine training programsmedicine training programs

It is the most important thing we can do for our It is the most important thing we can do for our professional future professional future

Embrace it and learn to do it wellEmbrace it and learn to do it well

Learning ObjectivesLearning Objectives

Explain the domains of successful ward Explain the domains of successful ward attending rounds – give you a frameworkattending rounds – give you a framework

Demonstrate effective techniques to excel in Demonstrate effective techniques to excel in these domainsthese domains

Explore ways to improve your own ward Explore ways to improve your own ward attending rounds by using this frameworkattending rounds by using this framework

Excellent Ward AttendingsExcellent Ward Attendings

Very different Very different ““stylesstyles””Both receive excellent evaluationsBoth receive excellent evaluations

Dr. Chalk TalkDr. Chalk Talk Sit down roundsSit down rounds Board talksBoard talks

Topic orientedTopic oriented Planned Planned

Focused bedside Focused bedside teachingteaching

Dr. BedsideDr. Bedside Walking roundsWalking rounds Teaching at bedsideTeaching at bedside

Patient dependentPatient dependent SpontaneousSpontaneous

Few board talksFew board talks

Excellence definedExcellence defined

Teaching ExcellenceTeaching Excellence11

Positive Learning ClimatePositive Learning Climate Control of Teaching SessionControl of Teaching Session Communication of GoalsCommunication of Goals Understanding and RetentionUnderstanding and Retention Evaluation of the LearnerEvaluation of the Learner Providing FeedbackProviding Feedback Self-Directed LearningSelf-Directed Learning

Excellent Clinical TeacherExcellent Clinical Teacher22

Teach >25% of timeTeach >25% of time Teach/Round >25 hours/weekTeach/Round >25 hours/week Stress doctor-pt relationshipStress doctor-pt relationship Teach psychological aspect Teach psychological aspect

medicinemedicine Chief residentChief resident

1KM. Skeff, et al.. Stanford Faculty Development Center Stanford University School of Medicine2Wright SM NEJM 1998;339:1986-93

Ward Attending RoundsWard Attending Rounds

Both very successful ward attendingsBoth very successful ward attendingsShare Share ““somethingsomething”” in common in common

Dr. Chalk TalkDr. Chalk Talk Dr. BedsideDr. Bedside

Ward Attending RoundsWard Attending Rounds

Dr. Chalk TalkDr. Chalk Talk Dr. BedsideDr. Bedside

Ward Attending RoundsWard Attending Rounds

• You don’t have to recreate yourself• You must be deliberate• You have to care

Learning AtmosphereLearning Atmosphere Clinical TeachingClinical Teaching Teaching StyleTeaching Style Communicating ExpectationsCommunicating Expectations Team ManagementTeam Management

Roy B, et al. Using Cognitive Mapping to Identify Key Domains for Successful Ward Attending Rounds. J Gen Int Med 2012

5 Domains for Successful 5 Domains for Successful Ward RoundsWard Rounds

Learning AtmosphereLearning Atmosphere

Be approachable - not intimidating. Be approachable - not intimidating.

Insist on respect for all team members. Insist on respect for all team members.

Showing enthusiasm. Showing enthusiasm.

Showing appreciation of team members. Showing appreciation of team members.

Giving positive and negative feedback. Giving positive and negative feedback. Allowing room for mistakes.Allowing room for mistakes. Encourage a serious but relaxed atmosphere. Encourage a serious but relaxed atmosphere.

Clinical TeachingClinical Teaching

Teaching by example (ie. good bedside manner). Teaching by example (ie. good bedside manner).

Sharing of attending’s thought processes. Sharing of attending’s thought processes.

Setting aside time to teach.Setting aside time to teach. Ensure attending’s comprehensive knowledge base. Ensure attending’s comprehensive knowledge base.

Integrate theory with actual patients and findings.Integrate theory with actual patients and findings. Teaching throughout rounds. Teaching throughout rounds.

Teaching StyleTeaching Style

Ask questions of team about decisions (what Ask questions of team about decisions (what and why). and why).

Have part of rounds at bedside, demonstrate Have part of rounds at bedside, demonstrate key physical findings. key physical findings.

Communicating ExpectationsCommunicating Expectations

Stating expectations for residents/students. Stating expectations for residents/students.

Allow team some independence in decision-Allow team some independence in decision-making. making.

Team ManagementTeam Management

Conduct rounds in an organized, efficient, & Conduct rounds in an organized, efficient, & timely fashion. timely fashion.

Having a consistent, coherent plan of care. Having a consistent, coherent plan of care.

Allow time on rounds for residents to meet other Allow time on rounds for residents to meet other responsibilities. responsibilities.

Let’s practice…Let’s practice…

Common Scenarios on Ward Common Scenarios on Ward Attending RoundsAttending Rounds

Scenario #1Scenario #1 8:00 am8:00 am New ward teamNew ward team

You are meeting your senior resident for the You are meeting your senior resident for the first time…first time…

http://www.youtube.com/watch?v=mEsikH6PdDA&feature=plcp

ExampleExample What went well?What went well? What did not go well?What did not go well? What could have been done differently?What could have been done differently?

New TeamNew Team Communicating expectationsCommunicating expectations

Setting expectations of the team and of youSetting expectations of the team and of you Are there specific things you do or say when picking up a Are there specific things you do or say when picking up a

new team?new team? Handout with goals/expectations listedHandout with goals/expectations listed

Ask team members to write down goalsAsk team members to write down goals Learning EnvironmentLearning Environment

Positive attitudePositive attitude ““Biography rounds”Biography rounds” Atmosphere of shared learningAtmosphere of shared learning

8:20 am Intern presents a patient admitted for deep Intern presents a patient admitted for deep

vein thrombosis.vein thrombosis. Hypertensive on admission, new diagnosisHypertensive on admission, new diagnosis

Started metoprololStarted metoprolol

Teaching Key PointsTeaching Key Points Teaching StyleTeaching Style

Ask why this medication was chosenAsk why this medication was chosen Clinical TeachingClinical Teaching

Demonstrate your thought process for Demonstrate your thought process for choosing 1choosing 1stst line antihypertensive line antihypertensive

Integrate evidence into clinical reasoningIntegrate evidence into clinical reasoning

Top Ranked AttendingsTop Ranked Attendings

Teaching Style

Clinical Teaching

Learning AtmosphereTeam Management

Communicating Expectation

9:00 am9:00 am

Third year student presents a patientThird year student presents a patient 59 year old man with chest pain59 year old man with chest pain

9:15 am9:15 am Same third year student, Same third year student, still still presenting presenting

the patient with new onset chest painthe patient with new onset chest pain Substernal, dull burning, worse lying downSubsternal, dull burning, worse lying down Started this morning, lasted 1 hourStarted this morning, lasted 1 hour

Student differential: acute MI, pericarditis, cardiac Student differential: acute MI, pericarditis, cardiac tamponadetamponade

Efficiency, Broadening Efficiency, Broadening DifferentialDifferential

Team ManagementTeam Management Do you interrupt the student?Do you interrupt the student?

Clinical TeachingClinical Teaching Demonstrate clinical reasoning for non-Demonstrate clinical reasoning for non-

cardiac causes of chest paincardiac causes of chest pain Ask questions of the group (moving from Ask questions of the group (moving from

medical student “up the ranks” to residents)medical student “up the ranks” to residents)

9:20 am9:20 am Examining the patient with chest painExamining the patient with chest pain

Blood pressureBlood pressure Grade II/VI diastolic blowing murmur and Grade II/VI diastolic blowing murmur and

grade III/VI systolic murmurgrade III/VI systolic murmur JVP 6 cmJVP 6 cm

Bedside ExaminationBedside Examination Teaching StyleTeaching Style

Importance of having rounds at the bedsideImportance of having rounds at the bedside Clinical TeachingClinical Teaching

Teaching physical exam findingsTeaching physical exam findings Importance of BP in both armsImportance of BP in both arms How to listen for diastolic murmursHow to listen for diastolic murmurs How to evaluate JVPHow to evaluate JVP

0

1

2

3

4

5

6

7

8

Discussion Mini-lecture Physical exam Modeling

Perc

eive

d Q

ualit

y of

Tea

chin

g(O

rdin

al O

dds

Ratio

)

Teaching Methods

P < 0.001 P < 0.001P =0.03 P = 0.04

Communication

Perceived Teaching QualityPerceived Teaching Quality

1.0

2.0

3.0

4.0

None Any One Any Two > Two

Perc

eive

d Q

ualit

y of

Tea

chin

g

Teaching Methods

P for trend < 0.001

Perceived Teaching QualityPerceived Teaching Quality

Scenario #2Scenario #2 6:30 am6:30 am Post-call dayPost-call day 10 new case presentations + 8 old patients10 new case presentations + 8 old patients

Prioritization/organizationPrioritization/organization

Learners’ Priorities Based on Learners’ Priorities Based on Call-CycleCall-Cycle

Teaching Style Learning Atmosphere

Clinical Teaching

Team Management

Dynamic Domain Emphasis Dynamic Domain Emphasis by Top-Ranked Attendingsby Top-Ranked Attendings

Teaching StyleClinical TeachingLearning AtmosphereTeam Management

7:30am7:30am Intern presents a new patient with nausea, Intern presents a new patient with nausea,

vomiting and abdominal painvomiting and abdominal pain KUB interpretation: constipation, abundant stoolKUB interpretation: constipation, abundant stool Assessment: pancreatitis vs. gastroparesisAssessment: pancreatitis vs. gastroparesis

Expediting CareExpediting Care Team ManagementTeam Management

Demonstrating efficiency in careDemonstrating efficiency in care Expediting and escalating careExpediting and escalating care Allow time to call consults/enter ordersAllow time to call consults/enter orders

Clinical TeachingClinical Teaching Demonstrating pitfalls of biasesDemonstrating pitfalls of biases

8:30 am8:30 am Third year student presents a patient with Third year student presents a patient with

pneumocystis jirovecii pneumoniapneumocystis jirovecii pneumonia A diagnosis the student knows little aboutA diagnosis the student knows little about

Teaching New InformationTeaching New Information Team ManagementTeam Management

When and how to teach?When and how to teach? Teaching StyleTeaching Style

Ask questions, teach key pointsAsk questions, teach key points Chalk talkChalk talk

Now or tomorrow?Now or tomorrow? Ask student to prepare presentation to the Ask student to prepare presentation to the

groupgroup

8:35 am8:35 am In the patient’s room with PJPIn the patient’s room with PJP

New diagnosis of HIV for the patientNew diagnosis of HIV for the patient

Communication SkillsCommunication Skills Clinical TeachingClinical Teaching

Demonstrating good beside mannerDemonstrating good beside manner Role-modeling patient communication skillsRole-modeling patient communication skills Teaching the patientTeaching the patient

OtherOther FeedbackFeedback

When, where?When, where? FormatFormat

Evidence-based medicineEvidence-based medicine

Large Group DiscussionLarge Group Discussion

DiscussionDiscussion

What specific changes will you implement What specific changes will you implement based on this information?based on this information?

Successful Ward Attending Successful Ward Attending RoundsRounds

Clinical TeachingTeam Management

Communicating ExpectationsLearning Atmosphere

Teaching Style

ConclusionsConclusions Everyone can be a great attendingEveryone can be a great attending Deliberate about teachingDeliberate about teaching Try one thing – anything!Try one thing – anything! CoachCoach Protect the professionProtect the profession Ensure the future of medicineEnsure the future of medicine