Tips for teachers from the front lines

1. Tips for teachersfrom the front lines Shirley Schipper Department of Family MedicineUniversity of Alberta

2. Survey of teachers • your best teaching tips • What makes you a good teacher • Something that improves your efficiency as a teacher • Something that you have done to your office or space that really works • Best website (for guidelines, videos, clinical pearls) • An EMR tool that the residents really like • Your favorite paper and why you use it for teaching • The thing that really helps when you have a difficult learner

3. From your colleagues • Surveyed 20 preceptors • Community preceptors and faculty • Response rate 12/20 • Themes identified • Who replied: Newest and most seasoned • Newest – more tools, sites, efficiency • Seasoned – flexibility, reasoning, analysis

4. Best tips • "Treat the resident as a mature, adult learner and as colleague. This engenders respect – which flows in both directions“ • “Sometimes by letting learners know what I don’t know…I convey that we all have limits to what we know… fosters the idea that by identifying what I don’t know about a certain condition or situation I’m more likely to seek out the answers.”

5. Best tips • Let residents work at their own pace. “To hasten this pace beyond their stage creates ineffective learning, and frustration.” • Teach worse case scenarios

6. Favorite ways to teach • “get the patients to also give specific feedback to my residents“ • Creative quizzing • "Even asking for help; for example, I’ve asked this while writing a note, “Hey what are  some of the adverse events we told that patient.” "

7. Direct Observation tips • "I would have the learner watch me on the camera while I am in the room with the patient.  We would then review/discuss the encounter.“ • “One examining room has a Happy Face on the door jamb to remind staff to always put the first patient in that room so that I can ask their permission to observe the resident…For residents/students reluctant or uncomfortable with direct observation have them watch me and provide me with feedback.”

8. Encounter notes • “When observing an encounter between student/resident and a patient I jot down the thoughts, hunches and questions I have as the interview unfolds. While many or most of my questions are answered, by sharing with learners what I’m thinking about or worried about or including in my differential diagnoses I hope they gain from my experience and mistakes.”

9. What makes a great teacher • “email or text me...anytime” • "enthusiasm and the ability to create a positive learning environment“ • “approachable and skilled in giving feedback” • "education is the lighting of a fire not the filling of a pail (not mine, some Irish poet). To that end, it’s about creating enthusiasm and fun"

10. Improving teaching efficiency • "helpful for slow residents to give themselves a time limit...ie.15 min, and to come and discuss with me what they have found so far.” • "I do a lot of direct observation with the camera when I have a new learner. I think this improves my efficiency since I can quickly get a sense of where the issues are.” • "I believe the "field note" is what I have probably used the most- it's an efficient, specific and time sensitive way to give feedback"

11. Office or space considerations • "a large table with working space for each resident; personal computer; plants – make it look less clinical.“ • " try to make the learner feel part of the clinic ( invite them to lunches/office get-togethers etc. )“ • Have a supply of good patient handouts (give one to the patient, one to the resident) • Get a baby monitor

12. Other than Uptodate... • immunization tips for travel - http://wwwnc.cdc.gov/travel/destinations/list.aspx • www.palliative.org • http://www.afmc.ca/img/default_en.htm • http://www.cfp.ca/ • risk calculators for Cardiovascular disease: http://cvrisk.mvm.ed.ac.uk/calculator/calc.asp • For A fib I use SPARC http://www.vhpharmsci.com/sparc/

13. Best website or IT tool • Therapeutics education collaboration and podcasts • ACP journal club • Canadian Digestive Health  Foundation (GI handouts) • info Poems – often a basis for our “first discussions” of the day • AMA website for guidelines

14. EMR tools • EMR access from home - improves continuity and responsibility • "Voice recognition software“ • "adhoc sessions about what we have discovered in our EMRs“ • Assigning tasks for follow-up

15. Papers and other resources • CFP papers: Goalificationand Stratification and reward chart articles • “The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives”- Annals of Family Medicine 3:82-85 (2005) • Long term outcomes of DM "they die of heart  disease not nephropathy" • Use old SOOs - have residents learn an age and gender specific SOO and examine and give feedback to each other

16. Good reading • The Talent Code • "for any competence there is an edge between what the learner already is pretty good at and what they are not yet comfortable with” • The Procrastination Equation

17. Learners in Difficulty • "My favorite tool is using video or audio. I find this so helpful especially for a learner in trouble so that I can see /hear what is going on.” • "the cause is usually not strictly education.  It’s anxiety, depression, social challenges (living away from family), and many others. My time is spent empathizing with them, making them feel at ease...”

18. Learners in Difficulty • "If I have a learner that has had difficulty in other rotations... I generally try to learn as little about that as possible. I like to be  unbiased and try to figure it out myself.” • "When residents miss something, I don’t usually make much fuss.  I will say something like...“oh, I think I noticed something else”, then show them and then ask “does that make sense?” I think they recognize errors and drawing extra attention is not necessary“ • discuss with a colleague, ideally, to get a second opinion

19. Then Tim said: • This would be a great evaluation tool for the residents to evaluate us.

20. Questions for the Residents • If there was one thing that you wish your preceptor would do to improve their teaching skills what would it be? • What is the best thing/website/guideline or comment/personal attribute/style that a teacher had that really stuck out and made it a great teaching moment? • If there was one thing that you wish your preceptor/faculty would stop doing because it would improve their teaching, what would it be?

21. Tips from Residents • Wrote all of the FMRs • N=140 • Response rate: 40/140 • Themes identified • Prefer FP’s approachability • Lots of positives • Some “almost there” • Few but strong “stop doing”

22. Take 5 minutes to teach (13) • sit down with pen and paper (as compared to "on the fly" teaching) • no more than 5-10 min, once a clinic to weekly • “more discussion around cases either at the end of the day or as they appear“ • "My best experiences have been where my preceptor/resident has sat down and taken the time to teach me something“

23. Lengthen the leash (8) • “allowing for more and more freedom as the time has passed and less supervision” • "allowing me to do more counselling when we are in the room together” • allowing patients to leave without being seen • be flexible with approach to management - your way isn't the only way • "supporting the resident in a management choice, even if it is different than what they would typically do"

24. Challenge me (6) • “make me defend my selection of investigations, therapies” • "where I am forced to make decisions on my own and verbalize why I think those decisions (or diagnoses) are the best ones“ • "take the time to alter scenarios" • "walk me through a clinical scenario and quiz me of various topics surrounding it. If I didn't know the answer, some teachers would continue to give me hints and make me think instead of just handing me the answer"

25. Watch me (5) • "I think we often find it intimidating at the time and don't like doing this but I appreciated it later.“ • "It does take some more time, but even like once or twice a week would be better than never“ • "I can only assume that my abdominal exam is adequate but I don't know for sure unless my preceptor observes me and gives me tips"

26. Give homework (5) • “identifying topics where further reading will benefit everyone and reviewing them again in a day or 2” • "He also encourages me to put together quick powerpoint presentations for my own learning of a certain topic.“ • "I think that even giving a learning assignment and following up on it is useful.“ • Caution: "I do not find it useful when I ask a teacher a question and his/her answer is, "look it up yourself." Some people have told me it is "learning by self-discovery" but come on.  

27. Keep up (5) • " think it is important for preceptors to keep up to date with the latest guidelines and be accepting of the fact that residents can actually teach them one or two things“ • "I feel there is a disconnect between guidelines...vswhat is practically done in practice.“ • "The "mainpro sessions" we do at our clinic are once a month, Saturday mornings over breakfast...I always REALLY enjoy that way  of teaching!“ • "using your resident as a resource and learning from their colleagues“ • "take any opportunity to go back to being a student again"

28. Set expectations then give small goals (5) • “point out more weaknesses once a rapport is built. My best preceptors were the ones that gave me small goals to improve on“ • "on the first day and outlined how he wanted notes, dictations, basic paperwork done, his general philosophy of care and usual types of orders to always include, and how he reviews that he covers all the bases"

29. Find out what I know first (4) • "some preceptors teach resident not knowing what is the level of knowledge or skill of that resident“ • "I wish all teachers would ask/clarify what I know about a topic before teaching me about it."

30. Develop our reasoning skills (4) • “taking the time to find out what the thought process to arrive at that answer was is REALLY helpful” • "when I make a decision for my patient,questions regarding as to why I made that decision and what are the outcomes I am looking for and what is the rationale behind? is very thought provoking and helped me develop an approach for even a situation which is new for me."

31. Up the hands on experience (4) • “Find the resident to do any/all procedures, or at least offer the procedures each time they come available.“ • " I wish he would always get me whenever he is going to do a procedure, assess a rash or a wound, or if he has an interesting clinical finding“ • "my preceptor lets me take charge of some of the practice management tasks like reviewing lab work, managing patient's PT-INRs with them over the phone, renewing prescription requests by fax, for example“ • "I also wish he would teach me a bit more about all the paperwork stuff, like WBC, AISH"

32. Think out loud and explain your reasoning (3) • "when a resident provides guidelines that should be followed and the preceptor disregards them, provide a reason why and consider  an educational conversation about why you choose not to follow the evidence“ • "they should review it (guideline) with you and discuss how you would incorporate that into practice, rather than ignoring it and doing something different“ • "Please do think out loud. Hearing the thought process of our preceptors as they think about differential diagnoses and management plans is really helpful!"

33. Help us become efficient and concise (3) • “Usually I have to take subtle signs of boredom, or being cut off as a sign that I was talking too slowly or giving too much detail“ • briefing residents before each patient - just a few sentences

34. Very few mentions of resources and websites • www.quackwatch.com • Uptodate • CFP articles • TOP guidelines • Brain Rules by John Medina

35. What we need to stop doing • Stop using general comments aka, learn how to give better feedback (5) • “"That was good" or "good job" are nice to hear, but it really helps if this is followed by what was good about it” • "ask me how I thought it went and then give me specific feedback"

36. Stop pimping (8) • "stop testing my knowledge in front of patients“ • "question/quiz you in a non-threatening/non-judgmental way (rather than "pimping") and not making you feel incompetent if you don't know  the answer“ • "When the questions are of the “pimping” closed type, both the learner and the teacher come away feeling annoyed“ • "do not quiz residents in front of the patient, especially without warning. “Michelle will now educate you about the side effects of said drug"“

37. Allow me to finish (5) • “stop barging in 'mid-consult'. It disrupts my train of thought & prevents me from taking the next step in choosing investigations and treatment“ • "Also hate when after you tell the history and physical they jump in and tell you what to do before you have a chance to say what you think” • "I start telling them the history and then ...when I get to what I want to do they cut me off and then we go see the patient.“ • "I like that she listens and never interrupts me, so patient.”

38. Limit distractions (2) • "sitting down, making eye contact, not multi-tasking on something else“ • "Not doing other things (ie answering emails and calling people) during sessions

39. Stop negative comments about colleagues (2) • we do this as well - about Fm docs and Specialists • "when physician judge patients/other physicians and talk bad about them....it just makes me sick"

40. Summary from Preceptors • Use direct observation • We have lots to share • Explore tools and websites

41. Summary from Residents the top 12 teaching tips • Do sit down teaching • Lengthen the leash • Challenge me • Watch me • Give homework • Keep up • Set expectations • Find out what I know first • Hands on • Think out loud • Don’t interrupt • Stop pimping