April Faculty Development Tip: The Education of Psychiatry – Caring for Patients Experiencing Homelessness

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The Education of Psychiatry – Caring for Patients Experiencing Homelessness

Malia E. Haddock, MS, PMHNP-BC

Although trainees incidentally care for patients experiencing homelessness throughout residency and beyond, intentional didactic and clinical experiences with homelessness create unique opportunities to increase interest, confidence and ability among resident psychiatrists in the care of underserved patients.

It is well known that individuals with unstable housing have disproportionally high rates of severe psychiatric and substance use disorders compared to their housed counterparts. Indeed, untreated psychiatric and substance use disorders are cited as primary causes of homelessness, and once homeless, psychiatrically-symptomatic individuals face additional barriers to accessing psychiatric care. Common obstacles include lack of affordable or reliable transportation, variable access to telephone/internet, and systems barriers such as scheduled appointments and attendance policies. However, intangible barriers such as provider discomfort with homelessness may further distance patients from psychiatric care.

HPATHI

The Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI) is a validated 19-item instrument designed to “assess medical students’ and physicians’ attitudes towards homeless persons and to measure their level of interest and confidence in their ability to deliver health-care services to the homeless population” (Buck et al., 2005).  The impetus for this inventory traces back to a 1985 publication on access to care among individuals with unstable housing. The report’s author, Elvy, writes, “The disinclination of the homeless to seek care may be due in part to the ways in which many health-care workers respond to them. A less investigated but possibly equally important circumstance is the attitudes that health-care professionals have toward the homeless” (as cited in Buck et al., 2005, p. 2). More contemporaneous academic discussions also play a role in HPATHI’s inception, particularly those involving the role of humanism and Social Determinants of Health curricula in undergraduate and graduate medical education (Buck et al., 2005).

Opportunities for Psychiatry

In “A Survey of American Psychiatric Residency Programs Concerning Education in Homelessness” McQuistion et al. found that while 60% of programs offered optional clinical and/or didactic experiences, only 11% of programs reported mandatory rotations in the care of patients experiencing homelessness. Lack of widespread mandatory programming was attributed to several factors, most notably lack of attending psychiatrists with expertise in caring for patients experiencing homelessness; lack of funding and/or logistical support to create programming; and perceived lack of homelessness in suburban and rural areas (2004).

Given the prevalence of severe psychiatric illness and substance use disorder among individuals experiencing homelessness, psychiatry trainees have much to gain from intentional exposure and training in this area. Over time, measurable improvements in interest, confidence and ability among learners may result in more accessible and culturally attuned care for this population.

 

Why HPATHI in Medical Education?

  • Acknowledges the impact of provider attitudes and behaviors on engagement with underserved patients
  • Raises awareness among educators and learners of the unique needs of patients with unstable housing
  • Establishes baseline data on attitudes, interest, confidence and ability in caring for patients experiencing homelessness
  • Uncovers experience and knowledge gaps that can be specifically addressed through curriculum development
  • Over time may lead to structural changes in both educational practice and care delivery to meet the needs of learners and underserved patients

References

Buck, D.S., Monteiro, F., Kneuper, S. et al. Design and validation of the Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI). BMC Med Educ 5, 2 (2005). https://doi.org/10.1186/1472-6920-5-2

McQuistion HL, Ranz JM, Gillig PM. A survey of American psychiatric residency programs concerning education in homelessness. Acad Psychiatry. 2004 Summer;28(2):116-21. doi: 10.1176/appi.ap.28.2.116. PMID: 15298863.

March Faculty Development Tip-The Prebrief: More than just an Orientation

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February Monthly Faculty Development Tip

Shelly Chipman, RN

The Prebrief: More than just an Orientation

Our passion and responsibility as educators is to facilitate the acquisition of knowledge and/or skills upon our students. Traditionally, this has been a rather passive process, where faculty provide information and learners absorb by listening or watching; transference of knowledge is teacher focused.  Newer modalities of teaching, such as team based learning, case based and experiential learning provide a more active learning environment, thus moving accountability of learning to the student/learner (Cheng, 2016).  Simulation is one such experiential educational activity, which allows learners to participate in a reproduction of a realistic clinical experience. A reflective discussion about that experience called the debrief follows and is facilitated by the instructor, and is a critical component of active learning. It provides an opportunity for deeper learning and translation of technical, cognitive and behavioral skills to clinical practice (Arefeh, 2010).

While the debrief is well recognized as an essential component of simulation education, the less well known “prebrief” is also important to learning, and sets the stage for the simulated experience and debrief. Several components of the prebrief are necessary in order to optimize learning and learner engagement:

Psychological Safety: This provides the foundation for the deep reflection needed for learning and translation of that learning to clinical practice. Psychological safety is established in the prebrief so learners feel comfortable discussing potential errors, gaps in knowledge or even successes that were revealed during the simulation scenario.

Review Expectations: Providing a clear description of what the learners can expect and what is expected of them is critical to a successful session.

Explain format-rational-agenda: This description of expectations should include an outline of agenda, explanation of any ground rules and clarification of any questions or preconceived notions that the learners may have.  Transparency, clarity of objectives and rationale for training (formative vs summative) prior to the scenario is key to optimal learner participation.

Basic Assumption: Part of establishing psychological safety is setting the basic assumption of healthcare simulation, an underlying belief that learners are intelligent, well trained and want to improve (Rudolph, 2006).  By setting this tone and assumption, mistakes during simulation are viewed as puzzles to be solved, rather than mistakes or faults in skill. Although this is not explicitly stated in the prebrief, it is recognized by faculty behaviors throughout the simulation session.

Review confidentiality: This includes the concept of “what happens in simulation, stays in simulation”, addressing any observers and their purpose for observing and keeping the scenarios confidential, avoiding “scenario leak” to other leaners.

Introduce Environment: This includes the space, manikin, the equipment or any other unique aspects. Introduction to the environment is critically important to provide “buy in” and prevent learners from “blaming” the lack of fidelity as an issue that may have affected their performance (Rudolph, 2014).

Encourage embracing the uncomfortable: Evidence supports the concept that some level of stress and emotion helps enhance memory (Clapper, 2014). Simulation provides an opportunity for the learners to reach that sweet spot of learning, where they are uncomfortable enough to learn, but not so uncomfortable that they cannot perform.

Fictional contract: This is where learners are asked to suspend disbelief and faculty acknowledge that it is not a perfect replica of the clinical environment must be addressed in order to make the experience more valuable.

As simulation educators, it is vitally important to provide a prebrief that sets the stage for a successful debrief and experiential learning session. By practicing each of these important components and providing a prebrief in every simulation education session, educators can provide an environment that is engaging and enhances learning. These components can be utilized in many learner-focused educational activities to promote engagement.

 

Psychological safety

Review expectations

Explain format-rational-agenda

Basic assumption

Review confidentiality

Introduce Environment

Encourage embracing the uncomfortable

Fiction contract

 

Further Reading: (attached)

Rudolph, J, Raemer D, Simon, R. Establishing a Safe Container for Learning in Simulation: The Role of the Presimulation Briefing. Simulation in Healthcare. 2014 December 9(6): 339-349.

 

References:

Arafeh,J, Hansen, S, Nichols, A. Debriefing in Simulated-Based Learning, Facilitating a Reflective Discussion. Journal of Perinatal Nursing. 2010 24(4): 302-309.

Clapper, T. C. Beyond Knowles: What those conducting simulation need to know about

adult learning theory. Clinical Simulation in Nursing. 2010 January  VOL(6), e7-e14. doi:10.1016/j.ecns.2009.07.003

 

Cheng, A. Morse, K., Rudolph, J., Abeer, A. Runnacles, J, Eppich,W. Learner-Centered Debriefing for Health Care Simulation Education: Lessons for Faculty Development.  Simulation in Healthcare. 2016 February 11(1):32-40.

Eppich, W, Cheng, A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): Development and Rationale for a Blended Approach to Health Care Simulation Debriefing. Simulation in Healthcare.  2015 April 10(2): 106-115.

Rudolph, J, Simon, R, Dufresne, R, Raemer, D. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simulation in Healthcare. 2006 1(1):49-55.

January Faculty Development Tip-Creating a Culture of Psychological Safety as Medical Educators

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Creating a Culture of Psychological Safety as Medical Educators

Jillian Gregory, DO

As the COVID-19 pandemic has led to changes in medical infrastructure in the US, many new medical teams, often with medical student and resident learners, have formed in varying capacities to help mitigate the influx of patients.  Many vaccination clinics, testing centers, outpatient and inpatient facilities, and ICUs have emerged and/or expanded. As medical educators and team leaders, creating a culture of psychological safety is a key to providing quality care for patients, and is integral to supporting our learners on the frontlines as they practice in unfamiliar territory.

Psychological safety (PS) is a term used to describe feeling comfortable, sharing thoughts, opinions, and observations without the fear of ridicule or embarrassment.  An example is a junior member of a team admitting an error they made to the attending physician without fear of shame. This same junior member should also feel safe admitting an error they attribute to the attending physician without fear of retribution. Psychological safety is strongly associated with how residents rate their clinical learning experience and has also long been recognized as part of successful patient safety and quality improvement processes (1,2).

How can you help to create a culture of psychological safety on your team as a medical educator and team leader? By inviting input from all team members, promoting active listening, and acknowledging the limits of your own knowledge.

The Agency for Healthcare Quality and Research suggests the use of these phrases by any member of the team during a meeting (3,4):

  1. Maybe someone has a different perspective? I’d really like to hear some other opinions.
  2. If you see anything you are concerned about, please speak up. We’re a team and we have each others backs.
  3. It’s totally fine to disagree. That is why we are talking about this together.
  4. Let’s go around and hear everyone’s reaction to this.
  5. I’m not sure I’ve done this right and would appreciate if someone can double check me.
  6. Thank you for pointing out my mistake. You just saved me from a bigger problem!

The Institute for Healthcare Improvement also recommends team leaders meet with the individuals who report to them in short one-on-one meetings. They should be asked for feedback and the response to this feedback is key. They then should conduct frequent huddles where some of the individual feedback received can be shared freely as a group (4). It is almost important to quickly address behaviors that are counterproductive to PS culture such as ignoring the opinions of team members or blaming others for mistakes.

By leading a team with PS in the forefront, educators and leaders can create an environment where every team member feels valued. Learners can feel safe and supported to speak up for clarity in their learning process and for the safety of their patients. Quality care can be delivered to patients in new environments, even with unfamiliar team members and in stressful situations.

For further reading: Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White Paper. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017

References

  1. O’donovan R, Mcauliffe E. A systematic review of factors that enable psychological safety in healthcare teams. Int J Qual Health Care. 2020 Jun 4;32(4):240-250. doi: 10.1093/intqhc/mzaa025. PMID: 32232323
  2. Torralba, K.D., Jose, D. & Byrne, J. Psychological safety, the hidden curriculum, and ambiguity in medicine. Clin Rheumatol39, 667–671 (2020). https://doi.org/10.1007/s10067-019-04889-4
  3. Torralba KD, Loo LK, Byrne JM, et al. Does Psychological Safety Impact the Clinical Learning Environment for Resident Physicians? Results From the VA’s Learners’ Perceptions Survey. J Grad Med Educ. 2016;8(5):699-707. doi:10.4300/JGME-D-15-00719.1
  4. Creating Psychological Safety In Teams. Agency For Healthcare Research and Quality Website. Updated August 2018. Accessed January 14 2021. https://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/psychological-safety.pdf

November Faculty Development Tip: Tips on Clinical Teaching and Precepting Using Telehealth

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MITE Tip November, 2020
Tips on clinical teaching and precepting using telehealth
Ruth Frydman, M.D.

Since the start of the COVID-19 pandemic in the U.S., there has been an abrupt and substantial shift to providing health care through telehealth. Staff, learners, and patients have been learning to adjust to using technology for outpatient clinical care and clinical education.

Pros of using outpatient telehealth:
-Removes geographical barriers for appointments
-Reduces spread of COVID-19
-May lower psychological barriers to seeking and receiving care for pts with anxiety and/or psychological trauma disorders
-Allows us to treat and precept remotely
-See patients in their home environment
-video platforms can improve communication for people with hearing impairments via additional hearing assistance technology, not having to use masks, and use of chat button for clarification

Cons and barriers to using outpatient telehealth:
-Lack of personal access to technology for some patients for financial, cognitive, or psychological reasons
-Poor connectivity or lack of internet access in some geographical areas
-Can be harder to develop the same rapport as with in-person visits
-Less (or different) data when not in person, especially aspects of physical exam
-Less efficient when there are technological glitches or unfamiliarity with the technology
-Loss of hallway teaching time with learners between appointments
-People may discover they have hidden hearing loss

What are some tips to creatively adapt clinical teaching when using telehealth?

Dr. Erlich’s webinar (link below), The Triumph of Teleteaching: Tips for Incorporating Students into Outpatient Telemedicine, offers a number of ways to adapt clinical teaching approaches for efficiently teleteaching with students when all are on ZOOM or other video platforms:

-Modeling:
The learner actively watches the preceptor. Prior to the appointment, ask the learner to watch how the preceptor approaches something specific in the appointment and then discuss that afterwards together. For example, the learner might be directed to observe how the preceptor shares bad news or broaches substance use.

-Pre-rooming:
The student can do typical medical assistant functions prior to your arrival at the appointment such as checking that technology is working, maintaining and editing the electronic health record, completing screenings, entering the reason for visit, medication reconciliation, or other tasks. This also builds a rapport with the patient that segues into the rest of the appointment which the student can conduct with the preceptor observing.

-Virtual Triangle Method or In-Room Precepting:
The student starts alone with the patient via phone or virtual appointment. The preceptor joins the appointment at the midway point. The student presents the patient in front of both the patient and the preceptor using patient centered language directly addressing the patient with second person grammar (you, your). The preceptor can leave the video camera off to be more of an observer. The preceptor would ideally debrief with the student by phone or ZOOM briefly after the appointment is over for feedback.

Advantages of Virtual Triangle Method:
It is more time efficient than having the student present to the preceptor away from the patient.
The patient can correct information presented by student.
Both the patient and the student can learn more about the patient’s condition with all present for discussion with the preceptor and with the preceptor modeling patient teaching and care.
The preceptor gets more face time with the patient.

Other advantages of using telehealth:
The preceptor can use private chat with students to give them
– suggestions or feedback in their interactions with patients.
– request for learner to look up evidence or educational materials for patient to give during the appointment or afterwards.
Using screen sharing for labs or other materials.

Disadvantages:
Technological glitches, although many students are technology savvy and able to help.
Patients without access to phone or internet.
Loss of time alone with student for teaching for which you can compensate by concentrating on getting across one general teaching point rather than lots of information. The preceptor can also compensate by chatting with the student in the ZOOM room after the visit or by phone at the end of the session to debrief and give feedback.

In conclusion, we all benefit from improving our clinical teaching skills in telehealth as it gets better integrated into health care and clinical teaching. Please watch the attached video for more concrete details on implementing precepting via telehealth. These same concepts apply to residents and fellows, although they can function more independently.

From Tufts CANVAS site:
The Triumph of Teleteaching: Tips for Incorporating Students into Outpatient Telemedicine
Deborah Erlich, MD, MMedEd, FAAFP

Want to earn CME Credit? Click Here

October 2020 Faculty Development Tip: How to construct good multiple-choice test questions

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MITE Monthly Tip
October 2020
Eric Brown, MD

How to construct good multiple-choice test questions:
Assessment, or testing, is an important aspect of medical teaching and learning. When done well, testing helps learners meet curricular goals while communicating what the teacher views as important. Multiple choice questions (MCQ) remain a mainstay in testing because they can assess a broad range of knowledge in short period of time, leading to a high degree of testing validity and reliability. When constructed well, MCQs can test higher order learning such as comprehension, application, and analysis. However, as anyone who has ever written a MCQ knows, they can be difficult and time-consuming to construct. Even educators formally trained in the process plan for up to an hour writing each question. For this reason, many poorly written MCQs still abound in medical education and only serve to confuse and frustrate learners. Hopefully these basic concepts and tips will help you demystify the process, avoid pitfalls, and better align learners with your curriculum.

1) Start with your learning objectives:
This probably goes without saying, but a direct relationship between learning objectives and test items must exist. Remember that learning objectives should be written around specific learner behavior and not what the program will “teach”. Following this rule will help avoid simply testing medical trivia.

2) MCQ Terminology:
The Stem
Most MCQs start with the stem, or lead in. The stem should be written as a complete sentence and the item should be answerable without reading all of the answer choices. Instead of a sentence completion (eg Treatment with beta-blockers has been shown to . . . ), the stem should be written as a complete sentence (eg Which of the following is a characteristic of treatment with selective beta-blockers?) Although clinical vignettes are used commonly as the stem, they should not be excessively verbose or contain “red herrings”. Remember that most MCQs should be written so that the learner can read and answer the question in under one minute.

Key point: The stem should be stated so that only one of the options can be substantiated and that option should be indisputably correct. As the question writer, it is wise to document (for later recall) the source of its validity. Above all, avoid negative phrasing.

The Options
These are your test-takers’ answer choices. Between three and five options is ideal. They should follow grammatically from the stem and all be of the same type (all diagnoses, all tests, all therapies). The options should all be similar in length and complexity and should not consistently overlap to avoid ambiguity.

Key point: Avoid options none of the above and all of the above. None of the above is problematic in questions of judgement, and it only informs what the test-taker knows is not correct. All of the above only requires that the test-taker understand two of the options.

The Distractors
These are the answer choices that are not correct. Distractors are essential to write well as they form the basis of an exam’s ability to discriminate (separate those who know from those you do not know).

Key point: The best distractors are statements that are accurate, but do not fully answer the question or incorrect statements that seem right to the test-taker.

3) Types of multiple-choice questions:
True/False question
These questions usually start with a stem and then ask learners to choose all the options that are true (or false). They are usually easy to write but have not been shown to discriminate well between learners that know the content and those that do not.

Key point: True/False type questions should generally be avoided. They are generally either too ambiguous or, when written to remove ambiguity, too easy without good discrimination.

Single best answer questions
This is the most common and best validated MCQ type. In their simplest form they test knowledge, but with some effort, and questions can be written to test comprehension and even higher order learning. This format helps avoid confusion on the part of the learner because they do not have to guess what the writer was “thinking”. Currently, the national board of medical examiners (NBME) uses only this type of question.

Key point: The NBME recommends the following basic rules for crafting an effective single best answer MCQ:
1) Rule 1: Each item should focus on an important concept or testing point.
2) Rule 2: Each item should assess application of knowledge, not recall of an isolated fact.
3) Rule 3: The item lead-in (and stem) should be focused, closed, and clear; the test-taker should be able to answer the item based on the stem and lead-in alone.
4) Rule 4: All options should be homogeneous and plausible, to avoid cueing to the correct option.
5) Rule 5: Always review items to identify and remove technical flaws that add irrelevant difficulty or benefit savvy test-takers.

Additional reading/references:

Mohammed O. Al-Rukban, DPHC, ABFM, SBFM. Guidelines for the construction of multiple choice questions tests. J Family Community Med. 2006 Sep-Dec; 13(3): 125–133.

Burton et. al. Multiple-Choice Test Items: Guidelines for University Faculty. Brigham Young University Testing Services and The Department of Instructional Science, 1991.

Dianne E. Campbell. How to write good multiple-choice questions. Journal of Paediatrics and Child Health 47 (2011) 322–325.

Jannette Collins, MD, Med. Education Techniques for Lifelong Learning: Writing Multiple-Choice Questions for Continuing Medical Education Activities and Self-Assessment Modules. Presented in the RSNA Faculty Development Workshop, October 2005.

Miguel A. Paniagua, MD and Kimberly A. Swygert, PhD. Constructing written test questions for the basic and clinical sciences. The National Board of Medical Examiners, 2016.

September 2020 Faculty Development Tip: Improving Education Skills in Virtual Small Group Learning

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MITE Monthly Tip – Improving Education Skills in Virtual Small Group Learning

Thomas Q. Reynolds, DO

Medical education experts have been studying the effects of both virtual learning and small group learning for many years.  Evidence suggests that virtual learning is as effective as traditional learning across multiple different types of studies and analyses.  This has been noted across both a broad field such as health professions[i] as well as in specific disciplines, such as pediatrics.[ii]  Additionally, small group learning in teams has also been studied and reviews of the literature have shown it to be a positive learning experience for students.[iii]

As we have moved into the COVID pandemic-induced age of replacing traditional face to face education with virtual education, questions remain about how to adequately design small group learning in the virtual environment.  Medical educators around the world, and at our institution, have been forced to innovate ways to adopt small group/team based learning into the virtual didactic educational session for trainees at all levels of the medical education hierarchy.

As you continue to work on adjusting your traditional face to face educational sessions for medical students and residents/fellows into the virtual world of the ZOOM platform, consider how to leverage virtual technology such as the breakout room feature to engage students more readily in educational content.  The following 5 tips should be helpful as you plan and deliver small group/team based learning in virtual sessions using breakout rooms.

  • Know your learners; do they all have the same background? Are some learners more advanced than others?  If different backgrounds (residents from different programs and different PGY-level +/- medical students), consider splitting up your groups evenly with different stage learners in each group
  • Consider assigning a specific individual in each group in advance to help facilitate in each small group. No need to ask them to do extra preparatory work, just to be willing to guide the group through whatever small group task you assign during your session.
    1. Alternatively, consider the use of the “Flipped Classroom” technique and ask your learners to read/prepare in advance of the didactic session
  • Be familiar with how to use breakout rooms in zoom (and consider coming to the virtual engagement webinar on this topic being presented on October 2 or reviewing the recording of it afterwards)
    1. Consider assigning students to rooms in advance if you know exactly who your learners are
    2. If you don’t have an accurate list of learners in advance, find one person (a colleague, chief resident, senior resident, etc) to help you with assigning small groups once the zoom didactic begins
  • Prepare your learners for different roles in the small group
    1. Ex: MSIV to read the case and provide summary statement, intern to provide initial differential diagnosis, PGY-2 to provide testing and treatment ideas, PGY-3 to summarize how to educate patient/family

[i] Tudor Car L, Soong A, Kyaw BM, Chua KL, Low-Beer N, Majeed A. Health professions digital education on clinical practice guidelines: a systematic review by Digital Health Education collaboration. BMC Med. 2019;17(1):139. Published 2019 Jul 18. doi:10.1186/s12916-019-1370-1

[ii] Brusamento S, Kyaw BM, Whiting P, Li L, Tudor Car L. Digital Health Professions Education in the Field of Pediatrics: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. J Med Internet Res. 2019;21(9):e14231. Published 2019 Sep 25. doi:10.2196/14231

[iii] Burgess AW, McGregor DM, Mellis CM. Applying established guidelines to team-based learning programs in medical schools: a systematic review. Acad Med. 2014;89(4):678-688. doi:10.1097/ACM.0000000000000162

 

 

 

June 2020 Faculty Development Tip: The Benefits of Utilizing Twitter During a Global Pandemic and Beyond

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The Benefits of Utilizing Twitter During a Global Pandemic and Beyond

Jillian Gregory, DO

Information regarding the novel Coronavirus Disease 2019 (COVID-19) has saturated all media platforms in recent months, providing an overwhelming and often anecdotal account of personal experiences. It can be difficult to sort through the abundance of information. Medical professionals need real time data during a global pandemic to treat patients when standards of care have not been established for a new disease. Social media platforms like Twitter enable health care providers from all disciplines across the world to communicate and share information instantaneously. By utilizing specific hashtags, physicians can acquire guidance and advice from leaders in their field, obtain knowledge from case series, learn about new physical exam findings or sequelae of disease processes, and access relevant evidence-based medicine at no cost during a global pandemic. Users also have the ability to network with healthcare professionals in various sub-specialties across the globe.

In a recently published article in the Pediatric Critical Care Medicine Journal entitled, “Using Social Media for Rapid Information Dissemination in a Pandemic: #PedsICU and Coronavirus Disease 2019”, the authors collected data on all tweets over a four-month period with the hashtag “PedsICU” and “COVID19” (1).

The following results were found:

  • All of the most highly shared tweets and links were from individual pediatric critical care stakeholders or established medical organizations and made available as open-access resources.
  • As #PedsICU influencers shared studies with their followers, a virtual library was created that updates automatically and is accessible to all.

The authors note that highly tweeted articles are 11 times more likely to be cited (2). In a study of articles randomized to Twitter, their promotion received almost three times as many page visits as controls. Twitter has proven to be a real time way of obtaining and disseminating data amongst healthcare leaders in a specific discipline.

For those not familiar with the platform and how to use it successfully, the faculty development website at Johns Hopkins University has published a “Best Practice and Tips for Physicians” (3). Highlights of this guide include:

  • Building and optimizing your profile for search
  • Building and monitoring your community
  • Engaging with your community and the proper way to use hashtags
  • Best practices for formatting a tweet
  • FAQs regarding engagement with patients on social media

Evidence-based medicine during a global pandemic can be found on the social media platform Twitter. By following specific hashtags for diseases as well as hashtags associated with popular medical journals, healthcare workers can stay up to date on the myriad of information published on a daily basis. This information can be shared easily amongst followers and provides a global network of opportunity amongst healthcare providers’ when treating patients during a global pandemic. Creating a profile and engaging in this community is easily accessible.

References:

  1. Kudchadkar SR, Carroll CL. Using Social Media for Rapid Information Dissemination in a Pandemic: #PedsICU and Coronavirus Disease 2019 [published online ahead of print, 2020 May 27]. Pediatr Crit Care Med. 2020;10.1097/PCC.0000000000002474. doi:10.1097/PCC.0000000000002474
  2. Eysenbach G. Can tweets predict citations? Metrics of social impact based on Twitter and correlation with traditional metrics of scientific impact [published correction appears in doi:10.2196/jmir.2041]. J Med Internet Res. 2011;13(4):e123. Published 2011 Dec 19. doi:10.2196/jmir.2012
  3. Twitter best practices: https://www.hopkinsmedicine.org/fac_development/course_offerings/twitter%20best%20practices.pdf

For further reading:

Barnes SS, Kaul V, Kudchadkar SR. Social Media Engagement and the Critical Care Medicine Community. J Intensive Care Med. 2019;34(3):175‐182. doi:10.1177/0885066618769599

April 2020 Faculty Development Tip: Trauma-Informed Approach in Medical Education Settings

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Trauma-Informed Approach in Medical Education Settings

Ruth Frydman, M.D.

Psychological trauma is common. In the United States, 61 percent of men and 51 percent of women report exposure to at least one lifetime traumatic event, and 90 percent of clients in public behavioral health care settings have experienced trauma. 1SAMHSA website: www.integration.samhsa.gov/clinical-practice/trauma    2/13/20

Psychological trauma results from “an event, set of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”2 p.7, SAMHSA.

People who have experienced trauma may feel unsafe in situations that remind them of their trauma. Trauma survivors have been in situations where they did not have a voice or safe choices. They may continue to experience shame or guilt and may tend to isolate to protect themselves.

Trauma is a violation of a person’s sense of self control and personal power.  Trauma survivors are sensitive to power differences in relationships, and these power differences are inherent to  healthcare settings.  Lack of awareness on the part of the provider can lead to a learner or patient getting re-traumatized and breakdown in communication that can result in significant barriers to delivering care.

All of us–faculty, learners, staff, and patients–can benefit from improving the learning climate where we work, train, and receive care.  Attending staff and residents are role models for medical students, so modeling trauma-informed care and relationships can have a ripple effect on learners, staff, and patients.

Learners may have experienced earlier trauma and/or maltreatment during medical education.  This can impact the quality of the treatment provided if their own personal trauma history is impacted by an unhealthy work environment.

Akin to universal precautions, we can minimize trauma and re-traumatization in healthcare settings by using the following principles in our work with trainees, colleagues, and patients:

6 key principles of a trauma-informed approach:

  1. Safety — provide and promote physical and emotional safety in our work and teaching settings e.g. treating students with respect, avoiding giving constructive or negative feedback in ways or places that could result in public humiliation.
  2. Trustworthiness and Transparency — building and maintaining trust, participating in clear communication g. setting clear expectations for learners for rotation goals and accountability, giving learners timely and honest feedback, modeling clear boundaries.
  3. Peer Support — mutual self-help, getting feedback from peers e.g access to resources such as medical student support group, peer-to-peer type programming, time to talk with other learners who may also have struggled or be struggling.
  4. Collaboration and Mutuality — shared decision making, less hierarchical e.g. teacher can model and promote collaboration and mutuality in patient care for learners and can model team based leadership appropriate for learner’s level of training
  5. Empowerment, Voice and Choice — shared decision making, promoting resilience, supporting goals, providing choice and promoting an environment where people can share without fear of negative repercussions e.g. finding out learner’s goals for the rotation; modeling shared decision making with patients;  modeling and respecting advocacy skills in learners, staff, and patients.
  6. Cultural, Historical, and Gender Issues — working on treating others with respect knowing that there are power differences that pervade our culture; understanding some have experienced cultural and historical trauma and that some have experienced trauma based on gender and gender identity; g not making assumptions about learners based on their background, displaying signage or symbols that show support for groups facing discrimination such as rainbow symbols or sharing preferred pronouns to increase sense of safety for LGBTQ people (must be backed up by behavior and attitudes).2

Use of this approach can help engage and empower people, as well as reduce trauma reactive anger and aggression. It can help make our teaching and clinical settings more psychologically safe.

A trauma-informed approach to teaching and clinical work is best supported when the larger organization is committed to using policies to support this.  At Maine Behavioral Healthcare, we are working on becoming a trauma-informed organization.

For more information on the trauma-informed approach and trauma-informed organizations, see SAMHSA’s, Concepts on Trauma and Guidance for a Trauma-Informed Approach listed below.,2

Endnotes:

  1. Substance Abuse and Mental Health Services Administration and Health Resources Services Administration. SAHMSA-HRSA Center for Integrated Health Solutions: Trauma. http://www.integration.samhsa.gov/clinical-practice/trauma. Accessed February 13, 2020.
  2. Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. In. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014:7, 10-11.

Questions for discussion:

Why should we have universal precautions regarding psychological trauma?

What are trauma-informed principles?

How might these principles be applied to working with learners?  Please give concrete examples

What are barriers you face in implementing a trauma-informed approach?  How might you address these barriers?

Goals to take away from this months tip:

-understand the high prevalence of trauma

-understand the concept of universal precautions

-develop tools for implementing the 6 principles of trauma-informed approach with respect to teaching and creating a psychologically safe learning environment

March 2020 Faculty Development: Tips for using learning theory to craft an effective PowerPoint presentation

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Tips for using learning theory to craft an effective PowerPoint presentation

Eric Brown MD

March 2020

We have all endured slide-based lectures that left us yawning or scratching our heads in confusion. Presentations with too many slides, too busy slides, or hard to see fonts and diagrams are common in medical education and can sabotage even the most dynamic speaker or an otherwise fascinating topic. Here are some tips for crafting slide-based visual aids that will better support your learning objectives and keep learners engaged

  • Remember that slides do not have to be the default option
    • For every presentation you give, ask yourself whether slide-based visuals are the ideal means to deliver your message.
      • For example, a lecture that introduces and then uses a lot of new terms may be better served with a handout with definitions that learners can reference throughout the talk.
  • Use a logical, time-tested story structure
    • The three-act storytelling structure has been around for thousands of years and is firmly imbedded in most learners’ long-term memory.
    • By visually accessing this structure in your learners’ long-term memory, you are able to create a clear pathway for learning new information in their limited-capacity working memory.[1]
      • Act 1: Introduces the setting, main character (or subject), and an unresolved state of affairs.
        • Slide titles in this phase of your talk should reference emotions or situations already familiar to the learner.
      • Act 2: Drives the story forward by picking up on the unresolved state of affairs.
        • Use a story-board approach for organizing concepts and sub-concepts.
        • Limit major concepts to 4-5.
        • Use a slide hierarchy with color coding or other visual cues to anchor the learner.
          • In this graphic, major concepts are all on slides with orange backgrounds while supporting concepts are yellow and sub-concepts are white. Visual adapted from Beyond Bullet Points 
        • Act 3: Frames a climax and resolution around your topic
          • Recycling visual cues from the first “act” can help solidify conclusions
  • Apply Mayer’s principles for designing instructional multimedia presentations
    • Four evidence-based principles for reducing learners’ extraneous processing[2]:
      • Coherence: Exclude extraneous words, pictures, and sounds
      • Signaling: Highlight essential material with yellow boxes or high contrast
      • Redundancy: Do not add on-screen text to narrated animations or videos
      • Spatial Contiguity: Place printed words next to corresponding graphics

 

  • Watch David JP Phillips “How to avoid death by PowerPoint” and then apply his “6 rules”[3] https://www.youtube.com/watch?v=Iwpi1Lm6dFo
    • One “message” per slide.
    • No text sentences (instead use written words/phrases as talking points)
      • When audience members read a sentence while you are speaking it, they hear nothing!
    • Size: The most important part of your slide should be the biggest.
      • For example, the title or heading on the slide should be smaller than the points you are trying to make.
    • Use contrast to your advantage.
      • Dark background with light text
      • Use high contrast to draw attention to important areas of busy slides
    • Six or less ‘objects’ per slide

Hopefully these tips help keep your audiences more engaged during you slide-based talks. When in doubt, try this mnemonic:

ONE message per slide

FEW matching colors

VERY FEW fonts

PHOTOS, not clipart

[1] Atkinson, Cliff (2011). Beyond Bullet Points: Using Microsoft PowerPoint to Create Presentations that Inform, Motivate, and Inspire. Microsoft Press, USA.

[2] Mayer, R. E. (2008). Applying the science of learning: Evidence-based principles for the design of multimedia instruction. American Psychologist, 63(8), 760–769.

[3] Phillips, David JP (2011). How to Avoid Death by PowerPoint. Presentation Skills Ltd. Ted Talk Video available on YouTube and davidjpphillips.com

 

 

 

 

February 2020 Faculty Development-Teaching Emotional Resilience in Difficult Clinical Experiences

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MITE Monthly Tip – Teaching Emotional Resilience in Difficult Clinical Experiences 

Thomas Reynolds, DO

Burnout is a common problem amongst medical professionals and trainees.  Medical education experts have been studying this problem and developing curricula to help teach faculty, residents, and students about promoting resilience and preventing burnout after a difficult clinical experience such as what is described in “The AAP Resilience in the Face of Grief and Loss Curriculum.”

Because poor patient outcomes and high acuity clinical experiences are common in medical student and post graduate education, this curriculum highlights certain areas that are representative of opportunities to both promote resilience and teach future medical professionals about how to manage these problems in both themselves and future trainees. These areas include understanding grief and loss, communicating with families about severe and terminal illnesses, managing emotions after difficult clinical experiences, and introducing concepts to combat burnout through personal wellness.

Using these difficult clinical experiences as opportunities to train medical students and residents how to participate in and manage a debriefing session represents an area where all levels of providers can learn to manage emotions in an attempt to promote resilience and prevent burnout.  Additionally, the inclusion of all members of the health care team in a debriefing session can be quite meaningful for all involved.

Medical educators can keep the following basic steps in mind after having a difficult clinical experience that involves trainees or health care providers at any level:

  • Recognize how a provider’s response to grief and loss can either interfere with a patient/family’s experience or may comfort the patient/family and help the provider cope as well
    • For example, try engaging with the patient and family about your own emotional responses to these situations in front of your learners as this can help both the patient/family and the learners to embrace rather than suppress these difficult feelings
  • Integrate one’s response to a difficult experience including acknowledgement of guilt, anger, or sadness into a safe discussion of the event and how to manage these feelings
    • Actively include your conscious recognition of these feelings in the discussion
  • Conduct a debriefing meeting to analyze the experience, identify one’s own emotions, consider perceptions of the various team members, and help team members reach closure
    • Find a place and time to debrief with the team about how you handled the difficult situation with the patient/family, what went well, and what you might adjust in future conversations
  • Practice the above with trainees of all disciplines and at all levels as they work through difficult rotations where acuity and mortality may be elevated
    • Its critical to allow more senior learners to both lead the discussions with patients/families and to run the debriefing sessions as well

Reference:

Serwint JR, Bostwick S, Burke AE, et al. The AAP Resilience in the Face of Grief and Loss Curriculum. Pediatrics. 2016;138(5):e20160791