medical teaching in the acute care setting n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
MEDICAL TEACHING IN THE ACUTE CARE SETTING PowerPoint Presentation
Download Presentation
MEDICAL TEACHING IN THE ACUTE CARE SETTING

Loading in 2 Seconds...

play fullscreen
1 / 55

MEDICAL TEACHING IN THE ACUTE CARE SETTING - PowerPoint PPT Presentation


  • 163 Views
  • Uploaded on

MEDICAL TEACHING IN THE ACUTE CARE SETTING. Michael E. Mahla , MD Professor of Anesthesiology and Neurosurgery Assistant Dean for GME. Review the opportunities and challenges of teaching in the acute care setting and how these differ from “traditional” clinical medical teaching.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'MEDICAL TEACHING IN THE ACUTE CARE SETTING' - aisha


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
medical teaching in the acute care setting

MEDICAL TEACHING IN THE ACUTE CARE SETTING

Michael E. Mahla, MD

Professor of Anesthesiology and Neurosurgery

Assistant Dean for GME

lecture goals

Review the opportunities and challenges of teaching in the acute care setting and how these differ from “traditional” clinical medical teaching.

  • The ACGME Competencies in the acute care setting – which are important
  • Challenges of production pressure
  • Suggest techniques for optimizing education in the acute care setting – the Dreyfus model and the BID model
  • Assessment of the competencies in the acute care setting – integration of the Dreyfus model.
Lecture Goals
the six core competencies and acute care teaching

Patient Care Skills – Defined by program requirements

  • Medical Knowledge – Defined by program requirements and Board Examinations
  • Professionalism
  • Interpersonal and Communication Skills
  • Systems-Based Practice
  • Practice-Based Learning and Improvement
The Six Core Competencies and Acute Care Teaching
a scenario
A Scenario

49 yo male with history of colon CA, S/P resection and chemotherapy presents to ER with extreme SOB sitting bolt upright. History of increasing UE and facial swelling likely secondary to developing SVC syndrome. Infusaport in place – scheduled to be electively removed in 48 hours.

The patient is very frightened. Room air SpO2 = 85%, improved to 92% on facemask oxygen. All accessory muscles in use, patient cannot speak more than 2-3 words without stopping.

a scenario1

Anesthesiology resident is called to the ED to urgently secure this patient’s airway. Attending accompanies the resident to the ED.

  • Questions:
    • How much should the resident do in this life-threatening situation?
    • How can education occur in this life-threatening situation?
A Scenario
another scenario
Another Scenario

54 yo female is brought to the operating room emergently for craniotomy and removal of intracranial mass. She was seen in clinic the previous day and admitted for surgery. On the morning of the scheduled surgery, she is found unresponsive. Intubation attempt on the floor was unsuccessful, and she is brought emergently to the operating room for treatment of developing herniation syndrome.

questions
Questions

Should the resident be allowed to manage the airway given previous failed intubation attempt?

What educational opportunities are there in this acute emergency?

another scenario1
Another scenario

49yo female with severe rheumatoid arthritis presents for elective anterior cervical corpectomy followed by posterior cervical fusion. The patient has a history of well-controlled hypertension treated with lisinopril. No other significant medical history other than rheumatoid arthritis treated with gold, Imuran, and steroids. The patient is developing increasing difficulty walking.

Preoperative discussion and planning with the attending physician occurred.

another scenario2

How is this scenario different from the previous two?

  • What options are there for teaching / learning in this case that were not available in the other cases?
Another scenario
acute care teaching

The Challenges

    • Content and Direction of teaching often cannot be determined in advance
      • What do I want to learn today?  Learning What did you learn today?
      • Infrastructure for learning may not be in place if acute care learning presents challenges the student is not ready to handle.
      • Learning may be inappropriately repetitive when the learner is repeatedly exposed to scenarios that may be mastered in one or two exposures.
Acute Care Teaching
acute care teaching1

The Challenges

    • Much of acute care learning has been based solely on “Learning by Doing.”
      • Pure discovery model of learning – ASSUMPTION: students will develop appropriate rules and understandings to guide future practice.
      • Mayer RE. Should there be a three-strikes rule against pure discovery learning? The case for guided methods of instruction. Am Psychol 2004; 59: 14-19.
        • Discovery learning is ineffective and inefficient.
        • Does not guarantee students will come in contact with needed learning opportunities
        • Does not guarantee that students will learn the rules to appropriately guide future practice.
Acute Care Teaching
acute care teaching2

The Challenges

    • Teaching and patient care must occur simultaneously.
      • No teaching of this skill.
    • Many excellent clinicians cannot teach when their clinical skills are taxed.
    • Many excellent teachers cannot apply their clinical skills at the same time as teaching.
    • Learning depends on learner not teacher.
    • Quality, quantity, and content of learning variable from learner to learner.
Acute Care Teaching
acute care teaching3

The Challenges

    • Teaching adds stress to an already stressful situation.
      • Burn-out is common.
      • The challenged learner  exaggerated negative feelings in the teacher
      • The “challenged” teacher is prone to negative behavior.
Acute Care Teaching
acute care teaching4

The Benefits

    • IMPACT, IMPACT, IMPACT
      • The impact of acute care medicine will often fix concepts in the learner’s memory better than in any other learning environment.
        • Example: Failed traditional intubation  hypoxemia  subsequent application of difficult airway algorithm resulting in safe, successful intubation of the trachea.
        • Impact is a two-edged sword for multiple reasons, however.
          • Can firmly fixate WRONG concepts and approaches which just happen to work in one instance.
          • Can completely overwhelm the learning and render useful integration of the experience impossible.
Acute Care Teaching
acute care teaching5

The Benefits

    • To the teacher, acute care is rarely boring and presents both patient care challenges and educational challenges simultaneously.
      • Patients presenting with the same problems commonly behave differently.
      • Learners faced with the same problem rarely learn the same way.
Acute Care Teaching
where do the scales tip

Based on what is presented:

    • Many challenges
    • Few benefits – and some of the benefits are actually “veiled” challenges.
    • Many who are charged with teaching in the acute care setting:
      • Struggle with production pressure – academic medical centers clearly must be competitive with private institutions.
      • Education takes 2nd place – and a distant second at that.
    • Many educators have turned to simulation to address most of these challenges.
Where do the scales tip?
acute care teaching6

How can we as educators improve the effectiveness of teaching in the acute care setting and overcome many of the challenges presented?

Acute Care Teaching
know your learner

Knowing the learner is key to actively taking control of learning in the acute care setting.

  • May be difficult when there are many housestaff and medical students
  • Depends on an effective, objective evaluation system that is readily accessible to the faculty.
    • May cause bias in the approach to the student.
Know your learner
know your learner1

Dreyfus Model of Skills Acquisition:

  • Novice
    • A novice is all about following rules – specific rules, without context or modification.
    • Don’t need to “think” just “do”.
    • A rule is absolute, and must never be violated.
    • Get experience following directions and doing the new skill. All the learner is responsible for is following directions.
    • Learning environment is safe.
    • Learn the rules and correction applied when rules are not followed.
Know your learner
know your learner3

Advanced Beginner

    • Still rules based, but rules start to have situational conditions.
      • In one situation you use one rule, in other situations you use another.
      • The advanced beginner needs to be able to identify the limited need to selectively apply different rules. This is still rules-based, but has a few decision points.
        • Learner must be able to follow branch points and appropriate apply different rules.
        • This stage of competence could collapse into a larger Novice category without appropriate mentoring.
    • Learner is now responsible for some recognition. Perception is important.
    • Example - ACLS
Know your learner
know your learner4

Competent

    • Realization that learner’s skill or domain is more complex than a series of rules and branches.
      • Learner sees patterns and principles (or aspects) rather than a discrete set of rules – rules become “rules of thumb”.
      • Learner is led more by his/her experiences and active decision-making than by strictly following rules. What is developed now are guidelines that help direct competent individuals at a higher level.
Know your learner
know your learner5

Competent

    • Learner is now accountable for decisions as he / she is not following the strict rules and context of the previous stages. If a decision made doesn’t produce the desired result, the learner takes responsibility.
    • Critical tipping point for most people – and why most people never really become “competent” in most things they learn.
      • Learner must decide to just “follow the rules” or spend the time to get fully involved with and take responsibility.
  • This is a KEY Branch point that should guide all teaching in the acute care setting
    • Evaluation to determine whether someone is competent must therefore have input from the learner.
Know your learner
know your learner6

Proficient

    • At this point the learner’s understanding of the skill or domain has become more of an instinct or intuition.
      • Learner will do and try things because it just seems like the right thing to do (and will most often be right).
      • Perceives systems rather than discrete set of different parts.
      • Recognizes that there are often multiple competing solutions to a specific problem and has a “gut feeling” about which is correct.
      • Quickly knows “what” needs to be done and then formulates how to do it.
Know your learner
define the stages of competency

Difficult

    • Much disagreement about what constitutes necessary skills for each level.
  • Important to develop consensus in your program.
  • Defining the Stages carefully will allow each teacher to direct teaching appropriately.
  • Must be aware of the competency of each learner.
Define the Stages of Competency
acute care teaching9

Using the cases presented earlier, let’s teach the novice, advanced beginner, and competent learner.

  • The examples involve anesthesiology trainees, but should be readily applicable to other acute care situations – use your imagination to apply these concepts to your situations.
Acute Care Teaching
slide30
54 yo female is brought to the operating room emergently for craniotomy and removal of intracranial mass. She was seen in clinic the previous day and admitted for surgery. On the morning of the scheduled surgery, she is found unresponsive. Intubation attempt on the floor was unsuccessful, and she is brought emergently to the operating room for treatment of developing herniation syndrome.
the issues

Patient’s airway must be secured rapidly because of non-responsive state and elevated intracranial pressure.

  • Decompressive surgery must be accomplished very quickly to avoid transtentorial herniation.
The Issues
teaching the novice

What does the novice “want” to do?

    • EVERYTHING!!
  • What “should” the novice do?
    • APPLY THE RULES!
  • What are the rules? These must be very clear to the novice.
    • Securing the airway rapidly avoiding hypoxemia or hypercapnia is essential in the patient with herniation syndrome.
    • The patient must be prepared as quickly as possible for surgery.
Teaching the Novice
slide35
54 yo female is brought to the operating room emergently for craniotomy and removal of intracranial mass. She was seen in clinic the previous day and admitted for surgery. Pertinent medical history includes significant coronary artery disease treated with 4 drug-eluting stents. The patient takes 1 baby aspirin and Plavix daily. On the morning of the scheduled surgery, she is found unresponsive. Intubation attempt on the floor was unsuccessful, and she is brought emergently to the operating room for treatment of developing herniation syndrome.
teaching the advanced beginner1

What does the advanced beginner “want” to do?

    • EVERYTHING!!
  • What “should” the advanced beginner do?
    • APPLY THE RULES!
    • Use acquired skills. These may include airway management and line placement assisted as needed.
  • What are the rules? These also must be very clear to the advanced beginner as well as the situational judgment component.
    • Securing the airway rapidly avoiding hypoxemia or hypercapnia is essential in the patient with herniation syndrome.
    • Significant coronary artery disease needs to be investigated and appropriately evaluated / treated prior to surgery.
    • Coagulation status will likely be a problem – needs evaluation and planning.
    • Rapidly preparing the patient for surgery and starting surgery overrides other considerations.
Teaching the Advanced Beginner
teaching the advanced beginner2

The advanced beginner is taught that surgical considerations (e.g. in this case need for speed) may override assessment of the patient’s exercise tolerance, frequency of angina, stability of angina, coagulation status (aspirin and plavix) which would occur prior to elective surgery.

Teaching the Advanced Beginner
teaching the competent

Learner sees patterns and principles (or aspects) rather than a discrete set of rules – rules become “rules of thumb”.

  • Learner is led more by her/his experience and active decision-making than by strictly following rules.
    • Learner is now accountable for decisions as she / he is not following the strict rules and context of the previous stages. If a decision made doesn’t produce the desired result, the learner takes responsibility.
Teaching the Competent
another scenario3
Another scenario

49yo female with severe rheumatoid arthritis presents for elective anterior cervical corpectomy followed by posterior cervical fusion. The patient has a history of well-controlled hypertension treated with lisinopril. No other significant medical history other than rheumatoid arthritis treated with gold, Imuran, and steroids. The patient is developing increasing difficulty walking.

Preoperative discussion and planning with the attending physician occurred.

teaching the competent1

Resident physician has reviewed pathophysiology of RA and recognizes the instability of the cervical spine.

  • He also recognizes the significance of spinal cord compression and need to avoid significant hypotension.
  • He also recognizes the interaction of an ACE-inhibitor with general anesthetics (significant risk of hypotension).
  • He develops a plan. The teacher:
    • agrees with plan.
    • would manage the patient differently, but the plan is rational and should be fine.
    • feels plan is not a good one.
Teaching the Competent
teaching the competent2

Resident decides to manage the airway with an awake, sedated intubation and awake positioning to minimize neurologic injury.

  • He did not recognize the patient’s emotional state and extreme anxiety about waking up paralyzed from this surgery.
  • The patient cannot tolerate the awake intubation.
Teaching the competent
teaching the competent4

The competent physician learns that evaluation of the patient’s emotional state prior to dangerous surgery may lead to significant alterations of the anesthetic plan. The competent physician feels chastened that this evaluation was not done and resulted in failure of the plan. This experience enables avoidance of the problem again. Experience teaches the competent.

Teaching the Competent
additional tools for teaching in the acute care setting

Roberts NK et al. The Briefing, Intraoperative Teaching, Debriefing Model for Teaching in the Operating Room. J Am CollSurg 2009; 208: 299-303

  • Readily applicable to other acute care settings.
  • Provides a framework for learning somewhat similar to the more traditional methods of learning – but works in the acute care setting.
Additional Tools for Teaching in the Acute Care Setting
bid model

Guided discovery versus pure discovery.

  • Guided discovery:
    • Expert provides learner with preparatory information BEFORE the experience.
    • Provides appropriate level of verbal and manual guidance during the acute care experience.
    • Gives feedback afterward.
      • Mayer RE. Should there be a three-strikes rule against pure discovery learning? The case for guided methods of instruction. Am Psychol 2004; 59: 14-19.
    • Mayer demonstrated that guided discovery learning occurred more quickly (efficient), was more accurate, and was better retained than pure discovery learning.
BID Model
bid model1

Scallon SE et al. Evaluation of the operating room as a surgical teaching venue. Can J Surg 1992; 35: 173-6.

    • 60 cases observed in the OR. Clinical teaching in the OR occurred in fewer than 50% of cases!
      • What teaching did occur tended to cover history, physical findings, diagnosis, complications. It did not include operative planning discussions or discussions of the teaching physician’s past experiences with patients with similar problems.
BID Model
bid model2

Roberts NK et al. Toward a precise and practical model of debriefing for surgical education (poster AAMC meeting 2008).

    • Typical OR teaching to surgical trainees has three defining characteristics
      • Focused on getting through the case efficiently and effectively
      • Didactic teaching was mainly opportunistic – events trigger teaching “scripts”
      • Learning is likely to be defocused.
BID Model
bid model3

The BID model requires that the learner be actively involved in creating learning objectives for acute care teaching.

BID Model
try it differently
Try it differently

49yo female with severe rheumatoid arthritis presents for elective anterior cervical corpectomy followed by posterior cervical fusion. The patient has a history of well-controlled hypertension treated with lisinopril. No other significant medical history other than rheumatoid arthritis treated with gold, Imuran, and steroids. The patient is developing increasing difficulty walking.

Preoperative discussion and planning with the attending physician occurred.

bid model4

Learner’s objective: I would like to improve my airway management skills in the patient with an unstable cervical spine.

  • Teacher’s response: Great. Let’s start with your decision-making about the general approach to the airway. How do you decide what approach to take?
BID Model
bid model5

Intraoperative teaching then focuses on options for plans B and C when A doesn’t work. In addition teaching may focus on making better choices for plan A.

BID Model
summary

Acute care teaching is commonly unfocused and highly dependent on opportunity.

  • These problems have led to increasing focus on simulation for teaching.
  • Knowing the learner and taking advantage of specific learning plans relevant to the clinical scenarios of the day (learner initiated) may greatly improve the effectiveness of acute care teaching.
  • Given the ACGME mandate to evaluate the core competencies AND determine ability to practice independently without supervision, acute care teaching must become more effective and focused.
  • Simulation can help – but simulation rarely has the same impact as acute care teaching, and our learners usually much prefer acute care teaching.
Summary