Setting expectations

1. Setting expectations Thomas M. De Fer, MD, FACP Associate Professor of Medicine Division of Medical Education Department of Internal Medicine

2. I HAVE NO UNRESOLVED CONFLICTS TO DISCLOSEANDWILL NOT BE DISCUSSINGOFF-LABEL USE OF DRUGS(UNLESS SPECIFICALLY NOTED)

3. Have you ever been in a situations where you unpleasantly surprised by previously unstated expectations? How did that make you feel?

4. Fundamental Teacher Responsibilities • Set expectations • Maintain a conducive learning climate • Provide ongoing feedback • Teaching and modeling of knowledge, skills, and attitudes • Fostering self-directed learning • Evaluation and grading List not intended to be all-encompassing

5. High achievement always takes place in the framework of high expectation. Charles F. Kettering, American inventor, engineer, and businessman

6. Why Set Expectations? • It is one of our fundamental responsibilities as teachers to set the agenda • If the teacher does not know what the expectations are, we’re really in trouble! • You cannot run a course without objectives and expectations • You cannot teach in a course without knowing the objectives and expectations of the course • The general, common sense, theory is that expectations drive performance • However, there is little empirical research to support this hypothesis

7. Why Set Expectations? Learners are learners precisely because they do NOT know everything It is simply unreasonable to assume that learners (even adult learners) will always set all the appropriate expectations for themselves Correcting errors with be far more comfortable and impactful if the expectations have been established a priori Expectations are the foundation of feedback

8. Errors of Expectation • The single biggest error is failing to provide any expectations at all • The second biggest error is to provide nebulous expectations that have insufficient details to be meaningful • e.g., “I expect all of you to work hard and to be professional and conscientious.” • A third important error is providing expectations that are not in line with those of an organized course (“rogue expectations”) Wiese J. Teaching in the Hospital. ACP Teaching Medicine Series. 2010.

9. Other Expectation Caveats • Acknowledge that learners bring with them preconceived expectations on the basis their prior experiences (so do you) • People often fall back into easier more comfortable expectations (human nature) • Multiple reiterations of expectations may be necessary • Expectations of the hidden curriculum can be extremely powerful! Wiese J. Teaching in the Hospital. ACP Teaching Medicine Series. 2010.

10. For What to Set Expectations • Curriculum • Attendance • Absences • Punctuality • Participation • Appearance • Professionalism • Assignments • Deadlines • Assessments • Consequences • Evaluations • Grading • Appeals • Grievances • Due process

11. Example Specific Clerkship Goals and Guidelines11 History and Physical Examination 11 Observed History and Physical Examination 11 Written H&P 11 Oral Presentations 12 Daily Progress Note 13 Communication 13 Professionalism 13 Organizational Skills 14 Ward Responsibilities 14 Tests and Procedures 15 Differential Diagnosis Skills 15 Knowledge Base 16 Tools 17 Ophthalmology 17 Conferences 17 Food at Conferences 19 Student Duty Hours 19 Days Off Schedule 20 Suggested Resources 20 Feedback Evaluation and Grading23 Feedback 23 Clinical Skills Examination 23 NBME Subject Exam 24 Clinical Evaluation/Grading 24 Grading Appeals: 25 The Bottom Line27

12. Example WUSM Clinical Evaluation Form 31 Behavioral Characteristics Of Honors Level Performance 35 VA Medical Center Parking 39 Clinical Skills Examinations 41 Written History of Physical Guidelines 47 Model Written History and Physical 51 Oral Presentation Guidelines 57 Model Daily (SOAP) Progress Note Guidelines 59 Model Daily (SOAP) Progress Note 61 Formulating a Differential Diagnosis 63 Learning Objectives 73 Professor’s Rounds 93 Evidence-Based Medicine Assignment 97 EBM Examples101 High-Quality Clinically-Oriented Internal Medicine Journals 105 Core Curriculum Lecture Series Readings 109 Core Curriculum Lecture Series Schedule113 Chief Residents’ Rounds Schedule 115 Clinical Skills Schedule 117

13. The Bottom Line • Be sure you understand your resident’s and attending’s EXPECTATIONS of you. If they do not tell you, ask them (repeatedly if necessary). If they still don’t, let someone else know (your Chief Resident, Firm Chief, or the Course Director). • Ask for FEEDBACK from your resident and attending frequently, especially at mid- and end-rotation (repeatedly if necessary). If you do not get it, even after asking, be sure to talk to someone (your Chief Resident, Firm Chief, or the Course Director) about this before the end of the rotation. Insufficient feedback canNOT be the sole grounds for a grade change. Beware of, “You’re doing just fine.” • Midrotation feedback (though reasonably predictive) is in no way a guarantee of a certain outcome on your rotational evaluation. • READ THE BEHAVIORAL CHARACTERISTICS OF HONORS LEVEL PERFORMANCE! Next to reading the rest of the course book, this is the single most important thing you should do. • Follow the Written H&P Guidelines (be sure to also ask your resident and attending about their expectations for your written H&Ps). Put your written H&Ps in the medical record. Be sure to read the Internal Medicine Model Written History and Physical. Using someone else’s written/dictated H&P as the basis for your written H&P is plagiarism and ground for potential failure! • Rectal, breast, neurologic, and fundoscopic exams are appropriate for most of your patients. Do them and document them! If you have any questions about your attending and resident’s expectations in this regard, ask!

14. The Bottom Line • Give copies of your H&Ps to your resident and attending for critique. If they don’t give them back, ask for them (repeatedly if necessary). • Follow the Oral Presentation Guidelines. Give your oral presentation as much from memory as possible. Your attending and resident may not make this expectation explicitly clear but they’ll almost certainly notice. Do it anyway! Don’t even have a photocopy in sight! Put notes on note cards or some other memory aid. Using someone else’s written/dictated H&P as the basis for your oral presentation is verbal plagiarism and ground for potential failure! • While on an inpatient rotation, write progress notes for each of your patients everyday in a timely manner(except on your days off) and put them in the medical record. • Be enthusiastic and compulsive about your ward work. You should know your patients’ progress in great detail! You generally responsible for far few patients than anyone else on the team. • You should have at least a basic understanding of what’s going on with all the patients on the team. Students performing at the “honors” level will manifestly know more than the basics. • HELP OUT your team and be involved in the care of other patients on your team without being asked. • Manifestly demonstrate intellectual curiosity without being asked.

15. The Bottom Line • READ about your patients and the core internal medicine topics. Strongly consider using the Internal Medicine Clerkship Core Curriculum Learning Objectives to guide your general reading. • Spend at least some timeresearching the medical literature. Definitely share what you have learned with your team. Do this at least once per 4-week rotation without being asked. Don’t be shy and “hide your light under a bushel” because you don’t want to bother anybody. If you don’t demonstrate that you’ve been doing so, it will be assumed that you haven’t. • Give at least one topical presentation to your team during each 4-week rotation. Doing more than one is better. Tangible evidence of your work (such as a succinct but insightful short handout) is a great idea. If you have trouble selecting a topic, ask your attending or resident. • You are REQUIRED to pass the Clinical Skills Examination in order to pass the clerkship. • You areREQUIRED to attend all student-specific conferences: Professors Rounds, Physical Diagnosis Rounds (including supplemental sessions with the teaching resident), Radiology Rounds, ophthalmology clinic/group session, Chief Resident Rounds, and Core Lecture Series. Be sure to be as prompt as you can. • Be organized and mark your calendars with all important clerkship dates. Particularly note your assigned Professor’s Rounds day and ophthalmology clinic day. • KNOW WHEN AND WHERE TO SHOW UP EVERY MORNING and always make sure you check in with your team before leaving for the day.

16. The Bottom Line • CHECK YOUR EMAIL ACCOUNT AND WEAR YOUR PAGER DAILY. Not doing so is unprofessional behavior. • All absences must be reported directly to the clerkship administrator or the clerkship director on the day the absence actually occurs. Either a phone message or email will suffice. Unreported absences are considered unprofessional behavior and will result in the submission of a Professionalism Concern Form. Documentable dishonesty regarding absences is unprofessional behavior and grounds for failure! Under no circumstances may residents approve absences but you should definitely make your team aware. • If you miss more that 5 working days (typically intended for illness and family emergencies only) during the 12-week clerkship, you will be required to do make-up work. • Requests for specific call schedules in order to accommodate days off during the clerkship must be made at least 4 weeks in advance of the first day of the 4-week rotation in which the day(s) off will occur! • You CAN be failed for unprofessional behavior ALONE. • ALL internal medicine clerks should meet ALL of the above bottom line expectations.Meeting all of these expectations does NOT in any way imply that you will receive an “honors” grade for this clerkship. • Any questions/concerns about your evaluations/grades should be taken up with the Clerkship Director FIRST. NOT DOING SO WILL NEGATE ANY POSSIBILITY OF A GRADE CHANGE!

17. The Bottom Line • You areREQUIRED to attend all student-specific conferences: Professors Rounds, Physical Diagnosis Rounds (including supplemental sessions with the teaching resident), Radiology Rounds, ophthalmology clinic/group session, Chief Resident Rounds, and Core Lecture Series. Be sure to be as prompt as you can. • Be organized and mark your calendars with all important clerkship dates. Particularly note your assigned Professor’s Rounds day and ophthalmology clinic day. • KNOW WHEN AND WHERE TO SHOW UP EVERY MORNING and always make sure you check in with your team before leaving for the day. • CHECK YOUR EMAIL ACCOUNT AND WEAR YOUR PAGER DAILY. Not doing so is unprofessional behavior. • All absences must be reported directly to the clerkship administrator or the clerkship director on the day the absence actually occurs. Either a phone message or email will suffice. Unreported absences are considered unprofessional behavior and will result in the submission of a Professionalism Concern Form. Documentable dishonesty regarding absences is unprofessional behavior and grounds for failure! Under no circumstances may residents approve absences but you should definitely make your team aware. • If you miss more that 5 working days (typically intended for illness and family emergencies only) during the 12-week clerkship, you will be required to do make-up work.

18. The Bottom Line • Requests for specific call schedules in order to accommodate days off during the clerkship must be made at least 4 weeks in advance of the first day of the 4-week rotation in which the day(s) off will occur! • You CAN be failed for unprofessional behavior ALONE. • ALL internal medicine clerks should meet ALL of the above bottom line expectations.Meeting all of these expectations does NOT in any way imply that you will receive an “honors” grade for this clerkship. • Any questions/concerns about your evaluations/grades should be taken up with the Clerkship Director FIRST. NOT DOING SO WILL NEGATE ANY POSSIBILITY OF A GRADE CHANGE! • If you are having problems come to us early. That’s what we’re here for. • READ THE REST OF THIS COURSE BOOK! If you don’t, you’re seriously handicapping your own performance.

19. Impactful Expectations • Establish a rationale for each expectation • It is fine to establish expectations that are a matter of style but identify them as such to highlight those that are based on some important reason • Use the person’s name to establish gravity, importance, personal accountability • Verbal and in writing if possible • Ask for their expectations of YOU

20. Impactful Expectations • Your expectations should be reasonable, observable, and mindful of: • Time constraints • Level of training • Learner individuality • Other responsibilities • The expectations of the course • External regulations • Recognition that everyone sometimes makes mistakes, even the teacher

21. Don't lower your expectations to meet your performance. Raise your level of performance to meet your expectations. Expect the best of yourself, and then do what is necessary to make it a reality. Ralph Marston, The Daily Motivator

23. Anger always comes from frustrated expectations. Elliot Larson

24. Correcting errors with be much more comfortable if the expectations have been establish a priori • It can save you a lot of discomfort at evaluation/grading time!

25. You have to expect things of yourselves before you can do them. Michael Jordan