the “teaching moment” expressing uncertainties & difficulties georges bordage, md, phd...
TRANSCRIPT
The “Teaching Moment”Expressing uncertainties & difficulties
Georges BORDAGE, MD, PhD Professor
Department of Medical Education University of Illinois at Chicago
Univ. of Tokyo Grad. School of Medicine, March 2007
Professor Kaga
Extraordinary leadership in medical education in Japan and abroad…
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Older woman, joint pain
…I don’t know much about joint pain.
A
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Older woman, joint pain
…don’t know much about joint pain.
I suggest you go and read about it.A
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Joint pain
Thoughtaboutgout… &pseudo gout…but couldn’tdiscriminate further
…don’t know much about joint pain
AB
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Older woman, joint pain
Thought about gout & pseudogout… but couldn’t discriminatefurther.
She’s older, with moderate pain; hadsurgery recently… This favors pseudo-gout. Which crystals are involved ineach pathologies? How find out?
B
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“Teaching moment”
Expressed a specific uncertainty, difficulty
Received specific feedback targeted to her needs
B
How often do youknow what yourstudent or residentis thinking (Dx, reasons)when presenting a patient ?
<25% 50% 75% >90%
Not often Some Most
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Not so often...
During outpatient 1/5 (19%) case presentations (4/5
Reporting)
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Not so often...
During outpatient 1/5 (19%) case presentations (4/5
Reporting) Medical records: SOAP notes 1/17 (6%) (Baker et al, 1999)
During bedside discussionswith clerks,attendings:
- did most of talking- provided mostly factual info.- rarely challenged clerks to think
(Foley, 1979)
Students reluctant to show their thinking,
more so their uncertainties
Culture: hide errors, uncertainties
54% HS discussed errors(Wu et al, 1991)
Encourage theirstudents & residentsto express theirthinking & uncertaintiesduring case presentationsalong with the clinical facts
Connell et al, 1999
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Case presentations
Two purposes
Patient care
Student education
Educational strategy:
Learning is maximized when students try to resolve personal difficulties, uncertainties… (John Dewey, 1933)
Teaching moment: express difficulties
n= 7 FM + 4 Int. = 11 attendings
Coded: 3 levels
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Levels of interaction
1- Soliciting/ expressing facts
2- Explanations
3- Uncertainties, difficulties
Faculty – Students/residents 3-min segments
0
1
2
3
PRE-WKSP
Fac.St.
0 level-3: uncertainties
Facts
Pre-training
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Long-term approach
Faculty development
Change the clinical culture from hiding uncertainties, errors to expressing them
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Faculty Development Strategies
Bolus a lecture, wksp
Drip
reflection, practice
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Training: 3 x 3-hr wkps/ 6 mts
Goal: Elicit student’s uncertainties or difficulties about the case.
Record (tapes) & reflect +/- Wksp: Discuss what worked & not Practice their own strategy
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Clear intentions…
“I’d like us to talk about how you’re thinking about problems.
I’m especially interested in anything that you’re still uncertain about… anything about this case that you’re unclear or puzzled about.”
Expressing uncertainties,
difficulties, errors
“Student’s CC”
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Difficulties… No sense of the problem overall
Acute recurring large joint problem vs. Chronic small joint poly arthritis
Single Dx in mind vs. D.Dx Septic arthritis vs. gout
Mindless presentation vs. pertinent details, discrim. findings
Bordage, 1999
Results
0
1
2
3
PRE-WKSP WKSP-3
0 level-3
1/3 level-3
Fac.St.
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Benefits of soliciting difficulties…
Know students better MAXimize their learning
More info about the pts MAXimize patient care
+
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Good news, bad news
½ fac. improved -- ½ notWhole team involved
Faculty Students Residents
Avoid blame &solicit + feedback
RCT: w/ w/o training 3x, 45-min wkps, 3mts Ask “good” questions
Express uncertainties & difficulties
Practice (diary) Egan et al, 2002
…don’t knowmuch aboutjoint pain!
Could you tellme about chronic diarrhea?
Thought aboutgout & pseudogoutbut couldn’tdiscriminate further
I knew about watery and inflammatorybut forgot about the other types and got stuck at that point.
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Bldg on student’s prior knowledge
Thought about gout & pseudo gout…
but couldn’t discriminate further.
She’s older, with moderate pain;had surgery recently… This favorspseudo gout. Which crystals areinvolved in each pathology? Howwould you find out?
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Woman w/ rectal pain
Residents confused…
Attending: mini-lecture
- External hemorrhoids
- Internal hemorrhoids
- Fistula
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Woman w/ rectal pain
…What’s a fistula?!
Focus on student’s difficulties Bldg on student’s prior knowledge
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Students
3x more questions 5x more difficulties
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Students
3x more questions 5x more difficulties
but highcommunication apprehension!
“[Osler’s] criticisms of students and their work were incisive and unforgettable, but never harsh or unkindly; they inspired respect and affection, never fear.”
Henry Christian, dean at Harvard
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Conditions for success
Faculty development: Faculty AND Students/residents
Create a supportive environment
Disclosure without blame
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Disclosure without blame
Confident thatexpressing difficulties,uncertainties, errorscan be a positive learning experience
“TEACHING-LEARNING MOMENT”
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Disclosure without blame
Errors rounds (chief residents)
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Usual objection…
“Not enough time”
Does not take more time: 8-9 min.
Simply takes a different focus
…in conclusion
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Case presentations : 2 CCs
Patient’s CC : patient care Student’s CC : education
Expressing uncertainties, difficulties
…a privileged
“TEACHING MOMENT”
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Disclosure without blame
Intentions clear… interest in student’s difficulties
Supportive environment
Learning & patient care are maximized
Professor KAGA Own exemplary teaching IRCME, Univ. Tokyo Sch. Med.
Legacy of better teachers better educational programs
Better students & residents Better patient care
Domo arigato !
Bordage Med. Ed. 1987, 21:183-188Bordage Ac. Med. 1994, 69: 883-85Chang et al. Ac. Med., 1998, 73: S109-S111Connell et al. Ac. Med. 1999, 74: S10-S12Bordage Ac. Med. 1999, 74: S138-43Nendaz & Bordage, Med. Ed. 2002:36: 760-66