November Faculty Development: Exercises in Virtue

Exercises in Virtue by Michael Stanley, MS4

Please open the PDF and see text icon in upper left hand corner for the lecture. For access to the original Power point document please email Medical Education at mededuc@mmc.org

October Faculty Development: Tips for Teaching High Value Care on Rounds

Tips for Teaching High Value Care on Rounds     Emily Zarookian, MD

Teaching high value care in medical education is an essential, although recent addition to many graduate and undergraduate medical education curriculums. High value care has become an essential part of medical education as healthcare expenditures continue to rise with up to 30% ($765 billion) of those costs identified as potentially avoidable costs. 1

As teaching high value care can be a new skill for many seasoned attendings physicians it is not surprising that multiple studies have found a lack of teaching high value care on rounds. One study found that only in 20% of observed rounding episodes was there any discussion of high value test ordering principles.2

The following two exercises are examples of easy to use exercises on rounds to emphasize the principles of high value care.

Exercises to use on rounds:

Ask the “five questions” before ordering tests.

The American College of Physicians published five questions physicians should ask before ordering tests.3 Choose one patient on daily rounds and ask the team these five questions before ordering a test.

  1. Whether a diagnostic test other than a CBC, BMP, CMP, or INR was previously performed
  2. Whether diagnostic test results would affect care
  3. Whether a test result represented- or a study under consideration might produce a false positive result
  4. Whether the patient would experience short-term harm if a test were not ordered
  5. Whether the team considered patient preferences towards a diagnostic study

Focus on “Choosing Wisely”

 Select one of the Hospital Medicine “Choosing Wisely” initiatives for the week. Focus on this initiative by asking one team member to track progress throughout the week on decreasing utilization of unnecessary foley catheters, low utility telemetry, or repetitive daily labs. Report progress daily.

Society of Hospital Medicine “Choosing Wisely” 

  1. Don’t place, or leave in place urinary catheters for incontinence, convenience, or monitoring of output for non-critically ill patients.  Suggest team members track foley catheters using EHR to remind team members which patients have foley catheters in place
  2.  Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications
  3.  Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of  active coronary disease, heart failure or stroke.
  4. Don’t order continuous telemetry monitoring without using a protocol that governs continuation
  5. Don’t perform repetitive CBC, CMP in the face of clinical and lab stability.  Suggestion: use comparemaine.org to quickly review the costs of tests and procedures at different facilities in Maine. This        will give learners insight into how expensive unnecessary daily labs can be.

 Additional Resources

  1. JAMA Internal Medicine Teachable Moments Series : Short, easy to read articles that each begin with a clinical vignette in which unnecessary care resulted in patient harm followed by a quick evidence based review of the subject. This series is first authored by learners. Consider encouraging a learner to submit a “teachable moment” if occurs.

References:

  1. Smith, Cynthia MD et al. “Teaching High-Value, Cost-Conscious Care to Residents: The Alliance for Academic Internal Medicine- American College of Physicians Curriculum.” Annals of Internal Medicine. 2012; 157:284-286.
  2. Pierce Cason MD et al. “ Frequency of Attending Physician-Led Discussion of Test-Ordering Principles during Teaching Rounds” JAMA Internal Medicine. 2016; 176:2:261-262
  3. Qaseem  A, Alguire  P, Dallas  P,  et al.  Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012;156(2):147-149.

August Faculty Development: Education Video Production: A How-To-Guide

Educational Video Production: A How-To Guide by:           Alex Fiorentino, MD, Maine Track ’17

Learners of many types are increasingly utilizing online educational videos, and medical learning is no exception to this trend.  As an example, the massive open online course platform Khan Academy has generated a video series geared toward helping nursing students prepare for the NCLEX-RN licensing exam.  At the time of this writing, the platform’s overview of nephron function has been viewed more than 1.6 million times1.

Unfortunately, clinician educators wishing to use video as a tool for teaching students, residents, or patients may feel ill equipped for the task.  Hiring a professional video production team is expensive, while producing one’s own videos presents unfamiliar technical challenges.

The video below highlights key steps to planning, filming, and editing your own educational videos.  It emphasizes low-cost solutions and attempts to demonstrate that with a thoughtful approach, any clinical educator can create polished and effective video lessons.


For additional resources and literature on educational video production, please see the attached PDF.

References:

  1. Khan, S. (2010, March 3). The kidney and nephron.  Retrieved from https://www.youtube.com/watch?v=cc8sUv2SuaY.

 

July Faculty Development: Teaching Clinical Reasoning with the Think Aloud Technique

Teaching Clinical Reasoning with the Think Aloud Technique                      by Kelly M. Brooks, MD, Maine Track ‘16

“Expert clinicians frequently use automatic unconscious thinking processes as they gather and analyze clinical information to generate diagnoses. When experts use think aloud techniques, they articulate their thinking as they are reasoning and by doing so make their thinking processes clear to students.” 1 Think aloud is most commonly utilized as a research method for studying cognition, and is considered a reliable method for capturing peoples’ thought processes.

Researchers at the Dunedin School of Medicine at the University of Otago in New Zealand, piloted a program in their clinical reasoning curriculum that incorporated online modules and training in the think aloud technique. Their pilot study found that the think aloud technique is an example of teaching clinical reasoning in an explicit, transparent way that allows students to better understand a clinicians thinking along the trajectory of a clinical problem and arriving at a diagnosis. Not only did researchers find that this model can be used to teach medical students, but can also serve as a means for attending physicians to assess a learner’s clinical reasoning skills and provide immediate feedback on their student’s thought process.

Tips for incorporating the think aloud  technique (examples incorporated from the pilot study by Pinnock, et al. 2016):

1) Have the student present a patient on the inpatient wards outside of the patient’s room. As the student presents the patient, have the student pause intermittently; during these pauses, the supervising physician will say out loud how she/he is thinking at each stage of the presentation. This will allow the student(s) to understand how the supervisor analyzes the information during the presentation to come to a diagnosis.

2) Have the student present a patient she/he has seen in clinic outside the exam room. Have the student pause during her/his presentation to explain how/what she is thinking. This allows the supervising physician to assess each stage of the student’s reasoning.

3) Consider the learner’s level of experience—for example, pausing after the HPI may help to gather the learner’s initial instincts and broad differential, compared to talking through their thinking after the subjective/objective portion of the presentation for a more fully developed and specific assessment and plan.

4) Clinicians in this study appreciated the minimal training required to use this technique and that this style of teaching incorporated all stages of clinical reasoning, and could continue to educate students on core clinical reasoning skills such as utilizing pattern recognition and hypothetic–deductive thinking.

5) Potential barriers: Clinician supervisors voiced their concern about time limitations in the clinical setting that may prevent them from utilizing this technique. Researchers are following up with a study to help better understand this and other barriers to teaching clinical reasoning with the think aloud technique.

1 Pinnock R, Fisher TL, Astley J. Think aloud to learn and assess clinical reasoning. Med Educ 2016 May;50(5):585-586. PMID: 27072473

June Faculty Development: Use of Social Media as a Supplement to Medical Education Curricula

Use of Social Media as a Supplement to Medical Education Curricula by Nate Rogers, MD, Maine track ‘16

Though the majority of medical education literature has studied social media and issues of professionalism in relation to its use, medical professionals are beginning to recognize its potential as a powerful educational tool. Twitter and Facebook represent two of the largest and most widely studied social media platforms in medical education, with healthcare professionals finding creative uses of the apps to enhance learning.

Bahner et al. supplemented a novel ultrasound curriculum with Twitter’s “push technology” (i.e., “pushing” information/messages to followers from publishers, rather than requested, or “pulled,” by followers from publishers) and supplemented this delivery with online discussions in Facebook “Pages” and/or “Groups.” The writers offered the following easy-to-follow guide on how to implement its use. Learners will be required to have memberships to Twitter and Facebook, while teachers will benefit from the use of third-party apps in addition to these two platforms.

Step 1: Register for Facebook and Twitter accounts (once registered with these social media outlets, third-party apps will allow you to “sign in” using account name and password from Facebook or Twitter). Instruct learners that they must register for these accounts to participate in discussion and must “follow” the account you create (be sure to share username with potential audience members).

Step 2: Create a “Page” in Facebook to facilitate tweet-related discussions (e.g., “ED Ultrasound page”). Learners can find this page by using the “search” function (be sure to inform them of the Page name). Pages are open for anyone to view and may be linked to Twitter for simultaneous displays of tweets on Facebook. If a private group discussion is required, a “closed” group will need to be created. Learners can join this Group one of two ways:

  • By invitation (using Facebook names and/or email address), or
  • Pressing the “Join Group” button on the Group’s page and awaiting approval from the Group Creator/Administrator.

Step 3: Sign into third-party app (Twuffer or HootSuite) to upload educational pearls as scheduled tweets (≤140 characters +/- image), which will be simultaneously posted to your Facebook Page. Posting once per day at a consistent time is ideal, as this allows time to discuss the pearl before progressing to the following day’s lesson. Use the bit.ly app to include links to articles that would otherwise exceed  Twitter’s 140-character limit.

Step 4: Ensure learner engagement through topical conversation in an “open” (viewable by all) Facebook “Page” or a “closed” (viewable only by invitation) Facebook “Group.”

In-depth descriptions of the above-mentioned apps are included in the attached table.

The use of social media as an educational tool in medicine is an emerging area of research in a rapidly progressing technological field.  A trial of the above plan is an excellent starting point to gain familiarity with the use of social media, while also acting as a good starting point from which to exercise creativity in its use as an educational resource.

Social Media What? Pros Cons Notes
Facebook

www.facebook.com

 

Users make account profiles with personal demographic and post messages on Users’ / Groups’ / Pages’ “walls” ●       Open or closed groups for discussion of common interests

●       Tweets can be simultaneously linked to Facebook (allows audience expansion & further discussion)

Personal account required (privacy concerns) ~1.59 billion active monthly users
Twitter

www.twitter.com

 

Users post “tweets” (≤140 characters each) that are received by “followers” (audience) but visible to the public. ●       140 character limit allows for high yield info in short statement

●       Easy image posting (e.g., radiology, derm, etc.)

●       Large reach allows for sharing of educational info outside of institution’s boundaries.

●       Useful for real-time discussion in conference/lecture environments w/ live twitter feed on large screens

●       Discussion uncommon – unilateral receiving of information more common (see Facebook “Pros” for remedy)

●       Still relies on users to sign up for content

~305  million active monthly users
Twuffer (“Twitter Buffer”)

www.twuffer.com

3rd-party app allows scheduling of posts for later date & time ●       Allows consistent delivery time of tweets.

●       Relieves daily posting burden (schedule multiple tweets at once)

HootSuite

www.hootsuite.com

 

3rd-party social media managing app allows easy use of multiple social media platforms (e.g., Facebook, Twitter, etc.) ●       Allows posting to multiple platforms simultaneously.

●       Allows scheduling of future posts.

●       Allows scheduling and batch-uploading of many tweets from a single text file (greater ease/speed of uploading)

$6/month fee required for most features
bit.ly

www.bitly.com

 

 

3rd-party app that compresses web addresses ●       Allows posting of links that would otherwise have exceeded Twitter’s 140 character-limit

●       Allows archiving of links

●       Produces basic statistics for assessing usage by Twitter followers

Other useful/interesting social media apps:

  1. Figure 1: Medical image sharing for healthcare professionals. Find/share de-identified info of new and interesting cases, page specialists for quick feedback, take part in discussions of cases, and customize app to your experience/specialty. Includes an in-app consent form, the ability to remove details by swiping, and automatic face blocking for HIPAA-compliant de-identification.
  2. YouTube: Useful for visual walk-throughs of some clinical procedures.

Other well-known social media platforms with potential use as educational tools include Google+, Blogs, Podcasts, Picasa, and Flickr.

  1. Bahner DP, et al. How we use social media to supplement a novel curriculum in medical education. Medical Teacher. 2012: 1-6.
    1. Twitter account used for the above study:
      1. “@EDUltrasound,” http://twitter.com/#!/EDUltrasound
    2. Paton C, et al. Experience in the use of social media in medical and health education. Nursing and Health Professions Faculty Research. Paper 6.

 

May Faculty Development: ARCH, A Guidance Model for Providing Effective Feedback to Medical Learners

ARCH Model for Guiding Effective Feedback for Medical Learners by:   Conor Walsh, M17

Although feedback is a vital component of medical education and is important to ensure that standards are met, providing effective and appropriate feedback can be difficult for medical students, residents, and practicing physicians. Oftentimes, feedback can be too general (thereby making it difficult to set specific goals), untimely (i.e. given several weeks to months after a rotation), or be given without an explicit plan for improvement.

Characteristics of effective feedback include:

Considering emotions of both learner and teacher be:

  • Partially based on learner’s self-assessment and be well timed and expected
  • Based on direct observation and reliable information
  • Be specific, not general
  • Given in descriptive non-evaluative language
  • Given in a collaborative spirit

The ARCH concept helps provide a model for structured feedback for medical students and residents.

Allow/ask for self-assessment

Reinforce what is being done well (attitudes, skills, and knowledge)

Confirm what needs Correction or improvement

Help the learner with a plan for improvement and coach as needed

Allow/ask for self-assessment-

  • -Ask the learner to self-assess what they did well and what they could work on.

Example: “How do you feel about your interview with Mr. Smith? What do you think went well? What do you think you could continue to improve on?”

Reinforce what is being done well (attitudes, skills, and knowledge)

Example: “I agree that you were able to take a thorough history and that it was well organized.”

Confirm what needs Correction or improvement

Example: “Although you were thorough in your review of systems, it appeared to me that Mr. Smith really wanted to talk more about his joint pain. Did you notice that as well?

Help the learner with a plan for improvement and coach as needed

Example: “Why don’t you write up our discussion today with the goals to work towards this week and email it to me. I’ll make time this week to make sure we discuss your progress towards achieving those goals.

References:

  1. MacLeod L. Making SMART goals smarter. Physician Exec 2012; Mar/Apr:38(2):68-72.
  2. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79(10 Suppl):S70–81.
  3. Bienstock JL, Katz NT, Cox SM, et al. To the point: medical education reviews—providing feedback. Am J Obstet Gynecol 2007 Jun;196(6):508-13.

April Faculty Development: Tips for Educators Early in their Careers

Growing as a new teacher: Tips for educators early in their careers

By Benjamin Levin, MD

For new medical educators developing their career is important, here are 12 tips to help young early career medical educators get their careers started.

  1. Articulate your areas of interests

Ask yourself “what kind of career do I want?” use this as a starting point to set up your career and see how you can fit the needs of your institution

  1. Define what success means to you

Think about the goals of your career, both personal and professional

  1. Create a 5-year strategic plan

Take your career trajectory and goals and set out milestones and steps to achieve your goals

  1. Develop strong communication skills

The ability to craft a message to effectively reach an audience is a vital skill; set aside dedicated time for working on communication.

  1. Cultivate relationships with mentors

Mentors help with ideas, career development and can help you navigate academic medicine

  1. Be a good mentee

Respect your mentor’s commitment to you and use it effectively

  1. Build a network of peers

Colleagues can help with personal or professional challenges; expand beyond your department and training background

  1. Craft multiple elevator pitches

You have multiple audiences and need multiple pitches, retain the interest of the listener

  1. Be a team player

This starts before you become a faculty member

  1. Build resilience as your armor

Life isn’t fair or easy, be adaptive, be persistent and overcome the challenges

  1. Understand that medical education is a field not a discipline

A field brings people together; this can provide opportunities and challenges

  1. Embrace your identity as part of the medical education field

You are a contributor to the community of scholars; strive for the best quality in your work

These steps can help an early career medical educator develop their career but as time progresses go back and review these to help your continued development as an academic physician.

Sources: Cristancho S, Varpio L. Twelve tips for early career medical educators. Med Teach. 2016 Apr;38(4):358-63. doi: 10.3109/0142159X.2015.1062084. Epub 2015 Oct 22. PubMed PMID: 26492100

March Faculty Development: Giving and Receiving Valuable Feedback

Giving and Receiving Valuable Feedback

By Shannon M Bennett, DO

The importance of feedback:

Feedback is an integral part of the medical education process.  Both learners and educators need to know how to give as well as receive valuable feedback.  We all have areas we can improve upon and effective feedback is intended to guide future performance and growth.

“Helpful feedback is a supportive conversation that clarifies the trainee’s awareness of their developing competencies, enhances their self-efficacy for making progress, challenges them to set objectives for improvement, and facilitates their development of strategies to enable that improvement to occur.”  1

 

“The ultimate goals for feedback providers are to: (1) increase their own comfort and skill in providing constructive feedback, and (2) to increase in their learners the comfort and skill in seeking, receiving and using feedback.”2

Tips for giving valuable feedback

  • Choose an appropriate time/place (“in the moment” versus a set meeting)
  • Ensure the receiver knows it is feedback
  • Ask the learner to self-assess first
  • Be specific and relevant, focus on observed performance
  • Reinforce good elements, suggest or demonstrate ways to correct/change substandard performance
  • Engage in reflective problem solving (discuss ways to improve)
  • Provide an opportunity for the learner to demonstrate improvement

Tips for receiving feedback

  • Self-assess first
  • Remember it is not a negative conversation, we all can benefit from constructive feedback
  • Take initiative, seek out feedback
  • Be ready to receive feedback at any time
  • Ask for suggestions on ways to improve
  • Set a time for review and follow up

 

1 Lefroy J. et al. Guidelines: the do’s, the don’ts and don’t knows of feedback for clinical education. 2015. Perspect Med Educ. 4:284-299.

2 Sargeant, J. & Mann, K.  (2010).  Feedback in Medical Education:  Skills for Improving Learner Performance, in P. Cantillon & D. Woods (Eds.), ABC of Learning & Teaching in Medicine (pp. 29-32). 

December Faculty Development: Tips for Effective Presentation Slides

Why effective presentation slides matter

Presentation software like Microsoft PowerPoint, Apple Keynote, and Prezi are ubiquitous in medical education and the business of healthcare. When used appropriately in a direct presentation format, these tools let educators display visual aids, emphasize key points, and interact with learners to promote their understanding.

Unfortunately, these widely used tools can also interfere with learning when used in suboptimal ways. Complex material has high intrinsic cognitive load, and poor presentation of complex material needlessly adds extraneous cognitive load.1-3

When designing slides for your presentation, consider the following best practices to reduce cognitive load and increase understanding:

Assertion-Evidence slide design

“Traditional” slide design includes a top-center headline phrase, followed by a bulleted list of information and/or a supporting image or figure. When used indiscriminately, bulleted lists can skew the presentation of information, whether by fragmenting, oversimplifying, or oversaturating.1-3

As an alternative, Assertion-Evidence (A-E) slide design encourages the following structure for each slide:

  1. A headline that contains the main assertion or message in the form of a sentence: This ensures that the most important information is clearly stated on each slide.
  2. Supporting evidence for the main assertion: Visual evidence is preferable over words. Bulleted lists are avoided.4 This means that speakers won’t be able to use slides themselves as presentation notes but must still be able to explain the evidence clearly.3

citric-acid-cycle
Studies comparing traditional slide design to A-E slide design in engineering and veterinary students have shown increased comprehension and retention of presented material in the A-E slide design group.3,5,6

Pearls for formatting presentation slides

  • Aim for legibility:
    • Use large font sizes. Sizes greater than 18 pt on text, graphs, and diagrams will ensure that learners in the back of the room will be able to read your slides.7
    • Choose simple fonts. Ornate or stylized fonts are less legible and make reading times slower.8,9
    • Apply high-contrast colors. This usually means light text on a dark background, or vice versa. Note that some color combinations can make reading challenging – e.g. red on blue, or green on red. Use bright colors with care, as they may be harsh on eyes when used in large amounts.10 Learners may have color blindness, so test your slides’ color combinations using a color blindness simulator.
    • Avoid centering text. Remember that English readers read from left-to-right, and blocks of text are usually left-justified.
  • Find the right diagram for the task. As an alternative to bulleted lists, ask if information can be displayed differently. For example, a list of times or dates may be better understood as a timeline.3
  • Avoid using unrelated “clip art”, graphics, or sound effects. Research has shown that unrelated content can decrease recall and generally aren’t favorably viewed by learners.1
  • Strive to keep slides “light”. Studies suggest displaying no more than 20 projected words per minute. Try to keep blocks of text to 2 lines at the most.3
References
  1. Bartsch RA, Cobern KM. Effectiveness of PowerPoint presentations in lectures. Computers & Education. 2003;41(1):77-86. doi:10.1016/S0360-1315(03)00027-7.
  2. Craig RJ, Amernic JH. PowerPoint Presentation Technology and the Dynamics of Teaching. Innovative Higher Education. 2006;31(3):147-160. doi:10.1007/s10755-006-9017-5.
  3. Root Kustritz MV. Effect of Differing PowerPoint Slide Design on Multiple-Choice Test Scores for Assessment of Knowledge and Retention in a Theriogenology Course. Journal of Veterinary Medical Education. 2014;41(3):311-317. doi:10.3138/jvme.0114-004R.
  4. Alley M. The Craft of Scientific Presentations. New York, NY: Springer New York; 2013. http://link.springer.com/10.1007/978-1-4419-8279-7. Accessed Oct 11, 2016.
  5. Garner JK, Alley MP. How the Design of Presentation Slides Affects Audience Comprehension: A Case for the Assertion–Evidence Approach. International Journal of Engineering Education. 2013;29(6). http://www.craftofscientificpresentations.com/uploads/5/6/1/4/56145985/ae_comprehension.pdf. Accessed Oct 13, 2016.
  6. Garner JK, Alley MP. Slide Structure Can Influence the Presenter’s Understanding of the Presentation’s Content. International Journal of Engineering Education. 2016;32(1A).
  7. Make your PowerPoint presentations accessible. Microsoft. https://support.office.com/en-us/article/Make-your-PowerPoint-presentations-accessible-6f7772b2-2f33-4bd2-8ca7-dae3b2b3ef25. Accessed Oct 13, 2016.
  8. Morrison S, Noyes J. A Comparison of Two Computer Fonts: Serif versus Ornate Sans Serif. Usability News. Aug 2003. http://usabilitynews.org/a-comparison-of-two-computer-fonts-serif-versus-ornate-sans-serif/. Accessed Oct 13, 2016.
  9. Bernard M, Lida B, Riley S, Hackler T, Janzen K. A Comparison of Popular Online Fonts: Which Size and Type is Best? Usability News. Jan 2002. http://usabilitynews.org/a-comparison-of-popular-online-fonts-which-size-and-type-is-best/. Accessed Oct 13, 2016.
  10. Lane R. Combining Colors in PowerPoint – Mistakes to Avoid. Microsoft. https://support.office.com/en-us/article/Combining-Colors-in-PowerPoint-–-Mistakes-to-Avoid-555e1689-85a7-4b2e-aa89-db5270528852. Accessed Oct 13, 2016.
  11. Tutorial for the Assertion-Evidence Approach. Assertion-Evidence Approach. http://www.assertion-evidence.com/tutorial.html. Accessed Oct 13, 2016.

July Faculty Development: Teaching Tips for the OR

The OR is an important teaching environment that presents unique challenges for both preceptor and student. Achieving an effective learning experience in this time sensitive setting with consideration of patient safety is the goal. In addition to modeling professionalism, teamwork and respect, a deliberate and consistent structure to operative teaching can enhance the experience for both learner and teacher.

The Briefing, Intraoperative Teaching, Debriefing (BID) Model described by Roberts and colleagues (1) provides an outline that can be used by preceptors in the operative setting to achieve their educational objectives within the confines of a busy OR schedule. Both student and attending surgeon focus on similar objectives for the case, which then guide the intraoperative teaching and inform the end of encounter feedback.Table1