111

Observations from Observations from SARSSARS1.1. An erratic and chaotic healthcare An erratic and chaotic healthcare

delivery delivery

2.2. A passive and dependent attitude A passive and dependent attitude of physicians at all levelsof physicians at all levels

3.3. A lack of basic discipline of A lack of basic discipline of physicians across the board of physicians across the board of medicine (general medicine)medicine (general medicine)

4.4. Inadequate supervision of Inadequate supervision of residents in training residents in training

221

Eugene Stead on Teaching Eugene Stead on Teaching of Medicine (1)of Medicine (1)

TThe art of medicine is not confined to he art of medicine is not confined to organic diseaseorganic disease; it deals with the ; it deals with the mindmind of of the patient and with his the patient and with his behaviorbehavior as a as a thinking, feeling human being. The thinking, feeling human being. The essential skills depend not simply on essential skills depend not simply on instruction but on emotional maturity instruction but on emotional maturity manifest by manifest by sensitive self-cultivation of the sensitive self-cultivation of the ability to see deeply and accurately the ability to see deeply and accurately the problems of another human beingproblems of another human being. The . The challenge is further magnified by the fact challenge is further magnified by the fact that the examining physician is himself a that the examining physician is himself a human instrument, human instrument, subject to errorsubject to error due to due to the events in his own biography.the events in his own biography.

331

Eugene Stead on Teaching Eugene Stead on Teaching of Medicine (2)of Medicine (2)

A doctor doesn’t really need much A doctor doesn’t really need much knowledge, as he/she can look up most knowledge, as he/she can look up most things. But he/she must have much things. But he/she must have much emotional stability and ability to emotional stability and ability to perform in an air of uncertaintyperform in an air of uncertainty..

The doctor must make The doctor must make decisions on the decisions on the best available databest available data and and not be not be paralyzed by his ignoranceparalyzed by his ignorance. Many . Many people cannot tolerate this people cannot tolerate this uncertaintyuncertainty..

441

Academic & Non-academic Academic & Non-academic QualitiesQualities (1999, (1999, CHMS-UK)CHMS-UK)

Recognition that patient care is the prime duty of a Recognition that patient care is the prime duty of a doctor.doctor.

Possession of good communication and listening skills.Possession of good communication and listening skills. Understanding of professional issues such as Understanding of professional issues such as

teamwork and respect for contribution of others. teamwork and respect for contribution of others. Curiosity, creativity, initiative and leadership as Curiosity, creativity, initiative and leadership as

desirable characteristics for the aspiring doctor.desirable characteristics for the aspiring doctor. Recognition that practice of medicine requires the Recognition that practice of medicine requires the

highest standards of professional and personal highest standards of professional and personal conduct.conduct.

Recognition that practice of medicine requires the Recognition that practice of medicine requires the highest standards of professional competence. highest standards of professional competence.

551

In 1993, Bill Moyers spoke at length with Tom Delbanco on the PBS special Healing and the Mind. Moyers, after watching Delbanco work with patients, said: 〝 I get the sense that you treat the body and appeal to the mind. Is that a fair characterization? 〞

〝 I hope I’m addressing both the body and the mind, 〞said Delbanco. 〝 But they’re so intertwined that it’s hard for me to differentiate. I know more about the body than the mind. It’s probably easier to study, and that’s why we learned it in medical school─ ninety-five percent body and five percent mind. But I’ll tell you, once you’re in practice, and you’re taking care of real people, it becomes much closer to fifty-fifty. 〞

~ ~ David Ewing Duncan 1996David Ewing Duncan 1996

661

MMedical care and training edical care and training

are not spectator sports. are not spectator sports.

They are hands-on matters They are hands-on matters

of life and death. You are in of life and death. You are in

it or you are out of it; there it or you are out of it; there

is no in-between.is no in-between.

~ ~ Melvin Konner 1987Melvin Konner 1987

771

Mission and ObjectivesMission and Objectives Product of Medical EducationProduct of Medical Education

1.1. Responsible and competentResponsible and competent physicians who physicians who enjoy enjoy caring for their patientscaring for their patients

2.2. Physicians who sustain continuous growth in Physicians who sustain continuous growth in maturitymaturity and in and in professional knowledge and skillprofessional knowledge and skill

3.3. Physicians who are devoted to Physicians who are devoted to teachingteaching and who and who usher the arrival of like-minded younger generation usher the arrival of like-minded younger generation of physiciansof physicians

4.4. Physicians who are Physicians who are socially mindedsocially minded and have the and have the respect from the community and the societyrespect from the community and the society

5.5. Physicians who adhere to the Physicians who adhere to the moral codemoral code of their of their professionprofession

6.6. Physicians who are Physicians who are change agentschange agents of their profession of their profession and societyand society

881

Patient care is at the Patient care is at the

center of clinical center of clinical

education. education.

General Views General Views about Medical Educationabout Medical Education

991

Knowing the patient begins from listening to tKnowing the patient begins from listening to the patient, recording what is told by the patiehe patient, recording what is told by the patient in a meaningful and organized manner to cnt in a meaningful and organized manner to careful and thorough examination of the patieareful and thorough examination of the patient. Herrmann Blumgart said, “listen to your nt. Herrmann Blumgart said, “listen to your patient, he will tell you the diagnosis”. patient, he will tell you the diagnosis”.

General Views General Views about Medical Educationabout Medical Education

10101

Intimacy with your patients Intimacy with your patients

(sympathizing with them, being (sympathizing with them, being

sensitive to their suffering), standing sensitive to their suffering), standing

by them (be responsible), doing your by them (be responsible), doing your

best to heal/ relief/ comfort them will best to heal/ relief/ comfort them will

bring satisfaction to the patients and bring satisfaction to the patients and

physicians.physicians.

General Views General Views about Medical Educationabout Medical Education

11111

To teach is to learn To teach is to learn twice.twice.

About Teaching ( I )About Teaching ( I )

12121

M & M ConferenceM & M Conference

In virtually all teaching hospital, M & Ms are the only official, routine acknowledgment of errors by physicians. They are almost always held in private, with only residents and attendings present, and no real records kept.

Forgive and Remember: Managing Medical Failure, Bosk’s book stands virtually alone among the spare offerings on this subject in frankly admitting that errors happen on a routine basis.

~ ~ David Ewing Duncan 1996David Ewing Duncan 1996

1. Patient profile2. Symptoms &

signs:origination and evolution

3. Impact on life: urgency

Relevant literature

Personal fund of knowledge

Logical processing

Sorting All Possibilities

Likely Probabilities

Working diagnosisConfirmationSpecific

therapy

Quality&

Outcomes measurement

Corrections&

Follow-up

via deduction and/or

hypothesis

Clinical Clinical ReasoningReasoning

13131

Knowledge & Skill

Truth - seeking

Problem - solving

Biology of medicine

Moral integrityMoral integrity

Sensitivity to sufferingSensitivity to suffering

IntimacyIntimacy

CommunicativenessCommunicativeness

Responsibility to Responsibility to community / societycommunity / society

LawfulnessLawfulness

Peer relationshipPeer relationship

Leadership Leadership

14141

15151

Professionalism in Professionalism in MedicineMedicine

Professionalism – a foundation of the social contract for medicineProfessionalism – a foundation of the social contract for medicine

Principles: primacy of patient welfare, patient autonomy, social justicePrinciples: primacy of patient welfare, patient autonomy, social justice

Commitments:Commitments:

Professional competence Scientific knowledgeProfessional competence Scientific knowledge

Professional responsibilities Managing COIsProfessional responsibilities Managing COIs

Patient confidentiality Honesty with patients Patient confidentiality Honesty with patients

Improving quality of care Improving access to careImproving quality of care Improving access to care

Appropriate relationships Just distribution of finite resourcesAppropriate relationships Just distribution of finite resources

( ABIM, ACP-ASIM, EFIM )( ABIM, ACP-ASIM, EFIM )

16161

Team BuildingTeam Building

How Do We Begin ?How Do We Begin ?

17171

studentstudent

resideresident nt

fellofelloww

attendiattendingng

Axis as the most effective alignment for learning, Axis as the most effective alignment for learning,

teaching and for taking care of patients.teaching and for taking care of patients.

18181

Emphasize Emphasize whatwhat is right, is right,

rather than rather than whowho is right. is right.

19191

Dialogue, not Dialogue, not monologue.monologue.

20201

Helpful InteractionsHelpful Interactions

Reciprocal trustReciprocal trust

Cooperative learningCooperative learning

Mutual growthMutual growth

Reciprocal opennessReciprocal openness

Shared problem solvingShared problem solving

AutonomyAutonomy

ExperimentationExperimentation

21211

Stanford 7Stanford 7

Establish a positive learning Establish a positive learning climateclimate

Take control of the teaching Take control of the teaching sessionsession

Communicate goalsCommunicate goals

Evaluate learnersEvaluate learners

Provide feedbackProvide feedback

Increase understanding and Increase understanding and retentionretention

Stimulate self-directed learningStimulate self-directed learning

22221

A good team leader is a

remover of obstacles and a provider of resources.

23231

Teaching occurred during

rounds, not with mini-

lectures, but with helpful

interactions. Be patient and

tolerate silence. Be non-

judgmental.

24241

Establish“professional “professional

intimacy”intimacy”

25251

““Collaboration”means sharing Collaboration”means sharing

the same set of goals and the same set of goals and

objectivesobjectives.

26261

Morning reports canMorning reports can

1.1. Integrate knowledge and skillIntegrate knowledge and skill

2.2. Formulating positive attitudes Formulating positive attitudes towards patients and family towards patients and family members.members.

3.3. Role modeling how generalists and Role modeling how generalists and specialists work together.specialists work together.

4.4. Evaluating chief residents Evaluating chief residents leadership skills.leadership skills.

5.5. Be a time-efficient method for Be a time-efficient method for supervisors to oversee a service. supervisors to oversee a service.

27271

Morning reports, bedside

rounds and consult rounds are

opportunities for sharing with

team members knowledge,

shaping attitudes and

sharpening skills.

28281

““Diagnose”the learnerDiagnose”the learner,,s level of s level of

understandingunderstanding.

29291

Examples for Diagnosing the Examples for Diagnosing the Learner Learner

What if … then what do you do? (re What if … then what do you do? (re diagnosis)diagnosis)

What is your greatest worry? (re What is your greatest worry? (re diagnosis) diagnosis)

How sick is this patient? (re diagnosis) How sick is this patient? (re diagnosis)

What is the first thing you want to do for What is the first thing you want to do for this this patient? (re treatment) patient? (re treatment)

What are the patients expectations for What are the patients expectations for treatment? treatment? (re treatment) (re treatment)

Are you planning to order any test? (re lab Are you planning to order any test? (re lab tests) tests)

Do we need any more information? (re lab Do we need any more information? (re lab tests)tests)

Do you know how much that will cost? (re Do you know how much that will cost? (re lab tests)lab tests)

30301

Feedback provided to learners

about their clinical

performance is an essential

component of the teaching-

learning process.

About FeedbackAbout Feedback

31311

Characteristics of Characteristics of feedbackfeedback

Descriptive rather than evaluative Descriptive rather than evaluative

Specific rather than generalSpecific rather than general

Should focus on behavior rather than on Should focus on behavior rather than on personalitypersonality

Involves sharing of informationInvolves sharing of information

Should be well-timedShould be well-timedShould limit to what recipient can use rather Should limit to what recipient can use rather than what can be giventhan what can be givenShould be directed toward the behavior which Should be directed toward the behavior which the receiver can do something about the receiver can do something about

Avoid deceitAvoid deceit

Feedback skills can be improvedFeedback skills can be improvedConstructive feedback is an important step Constructive feedback is an important step toward authenticitytoward authenticity

32321

Strategies of Effective Strategies of Effective FeedbackFeedback

Listen to the learners firstListen to the learners first

Be as specific as possible Be as specific as possible

( positive and negative ( positive and negative feedback )feedback )

Give feedback at a good timeGive feedback at a good time

33331

Orientation and climate:Orientation and climate: prepare person for prepare person for sessionsession

Elicitation:Elicitation: ask person for self-assessment ask person for self-assessment

Diagnosis and feedback:Diagnosis and feedback: decide where decide where person person needs to improve and how much feedback needs to improve and how much feedback is is appropriate; give reinforcing and appropriate; give reinforcing and corrective feedback corrective feedback

Improvement plan:Improvement plan: develop specific develop specific strategies for strategies for improvement improvement

Application:Application: apply strategies to real apply strategies to real situation situation

Review:Review: check person for understanding and check person for understanding and agreeing with what has been discussed agreeing with what has been discussed and negotiatedand negotiated

Feedback Feedback ModelModel

34341

Michigan State SandwichMichigan State Sandwich

Begin and end with positive

feedback, sandwiching the

negative in between.

Mutual trust is needed for

feedback to be received and

effective.

35351

GGiving feedback is essential to improving iving feedback is essential to improving

the individual performance of members of the individual performance of members of

your clinical team. Without your clinical team. Without positive positive

feedbackfeedback, medical students and residents , medical students and residents

may stop putting energy and effect into may stop putting energy and effect into

activities that they thought no one valued. activities that they thought no one valued.

Without Without negative feedbacknegative feedback, poor , poor

performance may continue because they performance may continue because they

do not know it was below your do not know it was below your

expectations– or, even if they know that, expectations– or, even if they know that,

they may not know how to improve.they may not know how to improve.

36361

CClinical skills and procedures cannot linical skills and procedures cannot

be taught in the absence of a patient. be taught in the absence of a patient.

A structured and systematic A structured and systematic

approach is essential.approach is essential.

Learn to manage learnerLearn to manage learner,,s ignorance s ignorance

into competence.into competence.

37371

A Role ModelA Role Model

Should be capable Should be capable

Should be sensitiveShould be sensitive

Should be Should be enthusiasticenthusiastic

Should be yourselfShould be yourself

38381

How Is Clinical Medicine How Is Clinical Medicine Taught Taught

1.1. Preach what you practice, or show how yo Preach what you practice, or show how you u practice medicinepractice medicine2.2. Team building Team building 3.3. Patient – centeredness Patient – centeredness4.4. Attitude shaping Attitude shaping5.5. Institution of correct value system Institution of correct value system6.6. Constant feedback, both positive and nega Constant feedback, both positive and negativetive7.7. Measure outcome Measure outcome

39391

Role Role ModelsModels

Personal characteristicsPersonal characteristics

Courage to change status quoCourage to change status quo Informed of the worldInformed of the world

AA..

toughtough EE..

consideraconsideratete

BB. .

warmwarm FF..

humoroushumorous

CC..

seriousserious GG..

smartsmart

DD..

responsibleresponsible HH..

courageocourageousus

40401

Role modeling

“ “practice what you practice what you

preach”preach”

“ “preach what you preach what you

practice”practice”~~先行其言，而後從之先行其言，而後從之 ~~

41411

Exit RoundsExit Rounds ：： A Reflection A Reflection ExerciseExercise

Exit roundsExit rounds focus on focus on recently discharged recently discharged

patientspatients and provide learners with an and provide learners with an

opportunity to opportunity to reflectreflect on what they have on what they have

learned from working with these patients.learned from working with these patients.

Exit roundsExit rounds also provide attending also provide attending

physicians with an opportunity to address physicians with an opportunity to address

emotional issues, to evaluate trainees emotional issues, to evaluate trainees

learning and performances, to deal with learning and performances, to deal with

““housekeepinghousekeeping”details and to provide ”details and to provide

closureclosure.. ~ Ric Arseneau, ~ Ric Arseneau, Acad Med 70: 684-687 1995Acad Med 70: 684-687 1995

42421

Content of Clinical Content of Clinical TeachingTeaching

1.1. Centers on Centers on patientspatients and their and their problemsproblems

2.2. Concentrates on Concentrates on problem solvingproblem solving, not o, not on n facts about a diseasefacts about a disease

3.3. Involves the teaching of Involves the teaching of clinical skillsclinical skills

4.4. Involves demonstration of Involves demonstration of valuesvalues and and acceptable acceptable attitudesattitudes

43431

General Principles of General Principles of TeachingTeaching

1.1. Actively involve learners Actively involve learners2.2. Capture attention and have fun Capture attention and have fun3.3. Connect the case to broader concepts Connect the case to broader concepts4.4. Go to the bedside Go to the bedside5.5. Meet individual needsMeet individual needs6.6. Be practical and relevant Be practical and relevant7.7. Be selective and realistic Be selective and realistic8.8. Provide feedback and evaluationProvide feedback and evaluation9.9. Using repetition, making things memorabl Using repetition, making things memorable e and dramatic (provide anecdotes)and dramatic (provide anecdotes)

44441

To seek optimal stress, the teacher and learner must To seek optimal stress, the teacher and learner must

exchange perceptions and expectations.exchange perceptions and expectations.

Learners

knowledgeknowledge

SkillSkill

dutydutyaltruismaltruism

code of ethicscode of ethics

Environment 1. Time to allow for complete understanding of patients

2. Knowledge and skill for solving problems

3. Judgment and decision making

Positive reinforcements

Attitude for correction

No errors Errors

Close follow up to check for errors

Feedback

Feedback

The Endpoint The Endpoint of of TeachingTeaching

45451

46461

The Essential Attributes of A The Essential Attributes of A PhysicianPhysician

Competency

Communication

Sensitivity to human suffering

Tolerance toward uncertainty

Responsibility to society

Moral integrity

Sense of justice

47471

Improving Communication Improving Communication in Organizationsin Organizations

Communicator

Encoding Message: following up, repetition, empathy, mutual trust, timing, use simple language, feedback, effective listening

Decoding

Receiver (s)