December 2021 Faculty Development Tip

How to teach Operational Excellence Techniques during clinical precepting

Elizabeth Eisenhardt, MD, FACP

Operational Excellence and Quality Improvement principles can provide ripe educational opportunities beyond the standard format of lectures or book reading. Quality Improvement/Operational Excellence principles can be taught “in the moment”, “at the bedside” or “just in time” during clinical precepting sessions. In the following article, I will give you some examples of how to achieve this.

To begin, let’s review the definitions of Quality, Improvement, and Operational Excellence. Quality can be defined as “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge AND the degree health services meet the expectations of healthcare users (the marketplace).” In the words of the famous scholar Juran, he describes quality as the following:

  • Attaining professionally agreed standards of care.
  • Something that is good, serves the purpose,
    and is worth the money that is paid for it
  • Reducing the variation around the target.

Improvement can be defined as “A change for the better (Kaizen), and not simply a change, but one which is supported by data, not a judgement call. “  Quality Improvement work tends to be proactive, continuous process improvement work to shift a culture or to exceed expectations.

Operational Excellence can be described as a philosophy that embraces problem-solving and leadership as the key to continuous improvement with the change ideas coming from the “real place of work” or Gemba.

One of the founding principles of Operational Excellence is the 8 types of waste as pictured in the waste wheel pictured below:

If you keep a copy of this wheel close by while precepting, it can be useful to pull it out and ask a learner to identify a type of waste they observed during a certain patient interaction. Perhaps the learner is running late, because the patient had excess WAITING time to be roomed, or to check-in, or to enter the building after being asked screening questions.  Perhaps they observed TRANSPORTATION waste if a certain medication or vaccine is kept only on one floor and the staff had to retrieve it. There are numerous examples of waste that can be observed and discussed.

Another quick way to keep Operational Excellence alive in the moment of clinical precepting is to ask a learner to come up with a KPI ( Key Performance Indicator) that could be applied to their patient to achieve a missing quality metric. For example, if they are telling you how their diabetic patient is missing their A1C (measurement of their blood sugar), you can pause and ask the learner, “Can you think of a KPI that might help you capture more A1C ‘s on your patients?”  The answer may be something along the lines of “100% of diabetic patients will schedule a one month follow-up at time of check-out” or “100% of diabetic patients seen in the office due for A1C will have this test ordered at time of visit.” KPIs can be applied to nearly any quality metric to help improve results. KPIs are then posted to the clinical sites’ KPI board and seen during Operational Excellence Gemba board walks.

Helping learners to develop their Quality Improvement skills can have multiple benefits for them including increased engagement, increased understanding of the “bigger picture” and increased appreciation for inter-professional teamwork. I hope you will try out some of the techniques above!


Website for the Institute for Healthcare Improvement: Improving Health and Health Care Worldwide | IHI – Institute for Healthcare Improvement

MMC Canvas: Quality Improvement Science Guide: Quality Improvement Science Guide (

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November 2021 Faculty Development Tip

Malia E Haddock, APRN-PMHNP

Integrating the Language of Harm Reduction in Clinical Teaching and Care

When reflecting on your clinical and teaching practices as they relate to patients with substance use disorder, it is important to consider the following:

  • The extent to which drug use and people who use drugs are subject to stigma and judgement
  • The extent to which stigmatization impacts how health care providers and trainees talk about and communicate with patients who use drugs
  • The extent to which stigma, judgment and internalized shame produce reluctance among patients who use drugs to communicate openly and honestly with their health care team

If contemplating this feels like uncharted or uncomfortable territory, Harm Reduction provides a framework and language to help bridge gaps between providers/trainees and patients who use drugs.

What is Harm Reduction?

Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs” (Harm Reduction Coalition [HRC], 2021).

Click on below to watch a short video:

National Harm Reduction Coalition – Harm Reduction Truth

The Harm Reduction Coalition, a leader in Harm Reduction education and advocacy, offers specific guidance on how patients who use drugs can approach their health care providers. As providers and trainees, becoming familiar and comfortable with this kind of approach will support therapeutic encounters with individuals who have histories of negative experiences with the health care system. The HRC training guide includes the following topics, described more fully in attached brochure (HRC, 2021):

  • Talking about drug use is personal
  • Reasons why it may be hard to talk about drug use (and why some people decide not to)
  • Some reasons why it is good to talk about your drug use
  • When talking about your drug use, it’s OK to build trust first
  • If the doctor is focusing too much on your drug use
  • Examples of things you can say to the doctor when you don’t want to talk about drug use

Facilitate Honest and Compassionate Communication through Harm Reduction

  • Harm Reduction provides a framework for providers and trainees to meet patients where they’re at
  • Harm Reduction removes judgement and stigmatization from the narrative
  • Harm Reduction reduces the power differential between those providing and seeking care

Harm Reduction Strategies – Theory into Practice


Harm Reduction Coalition. (2021). Principles of harm reduction.

Harm Reduction Coalition. (2021). Quality health care is your right.

Further reading:

HRC Training Guide

Addiction Technology Transfer Center Network, Language Matters Guide

Want to earn IPCE activity credits (CME) ? Click Here

July Faculty Development Tip

MITE Monthly Tip

The Objective Structured Teaching Exercise (OSTE): Tips for Faculty Development

Corinn Martineau, PharmD, BCACP, CDOE

It is clear that faculty development is important to enhance clinical teaching skills, however there are few objective measures of the impact of faculty development on these skills. An Objective Structured Teaching Exercise (OSTE) is both a training modality and an assessment method for the teaching skills of faculty members, preceptors, and residents. Similar to the idea of the well-known OSCE (Objective Structured Clinical Examination), the OSTE offers opportunities to engage in and practice targeted teaching skills with a standardized student (1).

Take a moment to think, “When was the last time I was observed teaching a student or resident in my clinical setting?” Clinical educators are rarely observed teaching in their clinical environment and rarely receive feedback from peers with only minimal feedback from learners. Quality of clinical teaching is generally measured by written evaluations from learners, however these generally tend to comment on a teacher’s communication skills or interest in teaching and not concrete skills.

The OSTE’s simulated teaching scenario and utilization of the standardized learner provides the opportunity for the faculty member or preceptor to develop and practice key teaching skills while being assessed objectively with immediate feedback provided to the teacher. Some of the key benefits of this modality are the ability to adjust scenarios to provide a range of difficulties (support both your junior faculty and senior faculty), provide control over the variable clinical setting, and the chance to practice teaching skills and receive immediate feedback in a safe environment (2). Furthermore, the OSTE may offer interprofessional faculty training opportunities to engage faculty members that are involved in teaching a variety of professional learners, for example, a Clinical Pharmacist Faculty member developing skills in teaching a standardized Family Medicine Resident.

Boillat and colleagues provide wonderful insight and important tips on how to use the OSTE as a faculty and preceptor development tool. Summarized below are key tips and themes gathered from their work (2):

Clarify the Goal

  • What specific teaching skill are you looking to develop or enhance?
  • Is the teacher a seasoned faculty member or a first-year resident completing a Residents as Teachers curriculum?
  • A needs assessment may be helpful prior to this step to clarify the goal prior to the creation of the scenario.
    • If the OSTE is something to be incorporated into a faculty development curriculum, a needs assessment might help identify trends multiple faculty members hope to improve upon.

Determine Context and Target Audience

  • Will the OSTE be one component of a larger faculty development curriculum?
  • Will your target audience be junior preceptors or experienced faculty?
    • This will help to guide the level of difficulty of your scenarios.
  • Consider space restrictions and/or availability of standardized learners.

Identify the Teaching Skill to be Addressed

  • Teaching skills to be addressed should be observable behaviors that can be measured.
  • Will the scenario be focused on the ability to teach a specific procedure or focused on a specific competency such as communication?
  • The sky is the limit here! Refer to the article for many helpful examples.

Prepare the Scenario

  • Consider focusing on a scenario that is based upon real life situations.
    • Perhaps the OSTE illustrates a specific teaching challenge discovered during your needs assessment.
  • Scripts should be detailed leaving minimal room for improvisation
  • Make sure the scenario is relevant to all preceptors or faculty participating.
    • Consider altering scenarios for teachers from different disciplines

Develop the Assessment Tool

  • Assessment is key and may be formative or summative.
  • Consider an objective assessment tool that outlines the observable behaviors of the teaching skill
  • Assessment may include self-assessment, assessment by standardized student(s), and assessment by peer-teachers.

In summary, the OSTE is a unique teacher and faculty development modality that consists of a standardized teaching encounter with a standardized learner and an iterative process of feedback and practice for the teacher. OSTEs are a strong faculty development tool as they offer genuine scenarios, objective, real-time assessment, and direct feedback from peers and learners. Furthermore, OSTEs can offer opportunity for targeted faculty development based upon a needs assessment with opportunity for repeated practice.


  1. Sturpe DA, Schaivone KA. A primer for objective structured teaching exercises. Am J Pharm Educ. 2014;78(5):104.
  2. Boillat M, Bethune C, Ohle E, Razack S, Steinert Y. Twelve tips for using the objective structured teaching exercise for faculty development. Med Teach. 2012;34(4):269-273.
  3. Trowbridge RL, Snydman LK, Skolfield J, Hafler J, Bing-You RG. A systematic review of the use and effectiveness of the objective structured teaching encounter. Med Teach. 2011;33(11):893-903.

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June Faculty Development Tip

Pronoun Visibility in Health Professions Education

Brandy Brown, LCSW

Program Manager, The Gender Clinic

The Barbara Bush Children’s Hospital


Learning Objectives:

  1. Understand the value of creating inclusive norms, by sharing pronouns, in medical education settings.
  2. Identify ways to professionally share pronouns in a medical education setting.

Sharing pronouns in a professional context has become the norm in major academic settings.  This is not surprising; many initiatives to improve education and healthcare come from students.  At Maine Medical Center, we have received feedback from students coming from many institutions, inquiring why our healthcare system and educational programs have not taken steps to normalize sharing pronouns.

In 2018, an MMC workgroup, collaborating with The Gender Clinic, began to look at small ways to effect change and improve support for the LGBTQ+ community in Maine.  Within a year, after consulting with providers and staff throughout the system, community members, patients, and other institutions, a recommendation was made to ask and encourage leaders to share pronoun education with their teams.  Several departments and groups began to champion this education and share it widely as a way to shift their culture.

Why is it important to include your pronouns- in your email signature line, badge, zoom, or introductions?

When we normalize sharing our pronouns, we reduce bias and assumptions among colleagues and clients. We eliminate guessing gender identity from social cues, a process that is particularly harmful to transgender community members. Instead of relying on transgender and gender-nonconforming people to inform and educate others, we can cultivate an environment of learning, respect, and inclusivity.

In 2015, Harvard University students began offering pronoun selections during student registration.  The Kennedy School of Government elevated those recommendations in the classroom, distributing stickers with pronouns on them. Gender Pronouns Can Be Tricky on Campus. Harvard is Making Them Stick.

Theodore Svoronos, 33, a lecturer in public policy, said the stickers took some of the stress out of teaching.

“I see those stickers as a gift,” he said. “It reduces the friction and the cognitive load for us to identify people the way they want to be identified.”

To understand the impact of normalizing pronouns in medical education, read about the experience of a medical student who recently published a personal narrative, Pronouns and Advocacy in Medicine, in the AMA Journal of Ethics, describing the experience of a nonbinary person sharing their experience as a medical student at BUSM and the impact that normalizing pronouns had on their medical education.   Consider also the recently shared experience of a recent Tufts graduate, planning to apply to medical school this year, Embracing Medicine- and One’s True Self.

In recent years, pronoun visibility and sharing has become more common in healthcare settings, as well as education.

“Adding pronouns to our email signatures is another step along the pathway to creating a more equitable, inclusive and accessible work environment and supports our commitment to a more safe and accepting society and healthcare system for all people.” Fenway Health, VP of Communications

“By committing to using the correct pronouns, we are creating a space of respect and inclusion for all our patients, our staff and students.” Mayo Clinic, Vice Chair of Administration

How do I edit my email signature?

Open your Outlook and select ‘New Email’ as though you are composing a new message. Select ‘Signature’ (next to attach item). Under the dropdown choices you can update an existing signature or create a new one.

What should I write in my email signature?

Consider what your pronouns are and add them following your name. At, they suggest the following format:

Jamaal Johnson Pronouns: he/him


Jamaal Johnson (pronoun: he)

There is no single best way to share pronouns. You might use “she/her/hers” or “she/her” or just “she,” which generally refers to a larger set of pronouns.

You may also want to add a link to a website, with your pronouns like this: “My Pronouns: they/them ~ See to learn more,” if you would like to include a resource that explains why you are making your pronouns visible.

How can I include my pronouns on ZOOM?

Adding your pronouns to your name on ZOOM is another great way to increase pronoun visibility in the workplace.

If you have downloaded the ZOOM app to your computer, login as usual and select the profile icon in the top right corner and then select ‘Settings.’ Select the Profile tab and click ‘Edit my profile.’ This will launch a window in your browser where you can follow the steps listed below.

(If you do not have the ZOOM app, go to on your browser and login.)

  • In the ‘Profile’ section, click ‘Edit’ far to the right of your name
  • Select ‘Display Name’


  1. Gender Pronouns Can Be Tricky on Campus. Harvard Is Making Them Stick. – The New York Times (
  2. Pronouns and Advocacy in Medicine | Journal of Ethics | American Medical Association (
  3. Embracing Medicine—and One’s True Self | Tufts University School of Medicine
  4. Fenway Offers Employees Pronouns In Email Signatures | Fenway Health: Health Care Is A Right, Not A Privilege.
  5. Mayo Clinic employees may now wear buttons displaying their preferred pronouns | Disrn

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May Faculty Development Tip-Finding Joy in Work After Hitting a Wall

Finding joy in work after hitting a wall

Elizabeth Eisenhardt, MD

Healthcare providers have been experiencing an emotional and exhausting process as they work to navigate the Covid-19 pandemic. The challenges and hardships from this pandemic stretched most humans to the end of their coping capabilities. Many health care workers felt stress and felt challenging emotional responses to the pandemic on both a personal and professional level, and yet were required and needed to be high functioning at work and at home. Interestingly, while we have a possible end to the pandemic in sight and some hope as we race to vaccinate all Mainers, many people are feeling worse than they did the same time last year at the height of the pandemic and its subsequent lockdown. Personally I find myself on the verge of tears more frequently when my patients ask me how I am doing now versus a year ago. Why don’t I feel better now during this time of renewed action against the pandemic? Psychologist Lisa Damour explored this phenomenon recently in her podcast entitled “My kids and I have hit a wall. How do we keep going? 3/25/21. In it she talks about how it is difficult for people to maintain hope even while the pandemic situation is more hopeful because we still don’t know what to expect and what the future will hold.

If we are having trouble finding hope, we need to re-discover and celebrate the joy we have in our work to combat our burnout.
The IHI ( Institute for Healthcare Improvement) feels strongly that finding joy in our work helps to prevent burnout. They published a paper on restoring joy to the workplace after asking colleagues over and over “what matters to you?” This single question enabled them to understand the barriers to finding joy in work and to develop a framework to overcome them.

In this paper, they outline four steps that leaders can take to increase joy in the workplace. The steps are as follows:
1.) Ask staff, “what matters to you?” They describe how having these important discussions help to engage staff and to identify risk of burnout.
2.) Identify unique impediments. What are the day to day pebbles that are causing annoyance verses the larger boulders that exist on an organizational level?
3.) Commit to a systems approach . What can be a small systems change that has large staff benefit?
4.) Use improvement science. Study and discuss any changes made with staff.

Wellness discussions should also center around academics and teaching burnout. It has been shown that low job satisfaction was associated with nonstatistically significant trends toward fewer peer-reviewed first-author publications, lower teaching skills confidence, and lack of institutional grand rounds presentation. Burnout was associated with a nonstatistically significant trend toward lack of institutional grand rounds presentation. Institutions may discover via these wellness discussions that their academic providers need to have better protected academic time as too often clinical demands creep in at the expense of teaching or research.

In my leadership role, I have held many what matters to you conversations. While sometimes challenging ,they have never failed to bring forth a clearer understanding of what staff need to find more joy in their work, and assist me in understanding my staff’s needs. These conversations are important to have with students and learners as well.

During one of these recent discussions, it was clear that staff were craving a safe space to express their emotional and experiences on a given week with their colleagues. In response to this need, our office created a weekly wellness huddle. We wanted to highlight its importance, thus we incorporated it into our Operational Excellence program and made it one of our Key Performance Indicators. Using this improvement tool we made it a priority to hold a weekly huddle around staff wellness. We documented staff responses to the huddle, and their direct quotes around the experience. It has developed into a bonding time with our staff, and many have commented that it has been helpful. In this strange time of seeing new hope regarding the pandemic, but not feeling it on an individual level, we are refreshed each week with our huddle and have formed tighter team work and increased empathy because of it.

I strongly encourage using the “What matters to you?” conversation and holding these conversations frequently to engage staff and faculty to develop improvement ideas which are then studied using improvement science.


Glasheen, J. J., Misky, G. J., Reid, M. B., Harrison, R. A., Sharpe, B., & Auerbach, A. (2011). Career satisfaction and burnout in academic hospital medicine. Archives of internal medicine, 171(8), 782-790.

Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at

Shanafelt, T. D., West, C. P., Sloan, J. A., Novotny, P. J., Poland, G. A., Menaker, R., … & Dyrbye, L. N. (2009). Career fit and burnout among academic faculty. Archives of Internal Medicine, 169(10), 990-995.



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

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.


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


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).

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

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.



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

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


  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).
  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.

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

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:

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.

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.

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

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.