The “Teaching Moment” Expressing uncertainties & difficulties Georges BORDAGE, MD, PhD...

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…

3

Older woman, joint pain

…I don’t know much about joint pain.

A

4

Older woman, joint pain

…don’t know much about joint pain.

I suggest you go and read about it.A

5

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@uic.edu

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