Improve Your Ward Attending Skills: Integrating Learner and Faculty Perspectives on Successful...
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Improve Your Ward Attending Skills: Improve Your Ward Attending Skills: Integrating Learner and Faculty Integrating Learner and Faculty
Perspectives onPerspectives onSuccessful RoundsSuccessful Rounds
Robert M CentorRobert M CentorBrita RoyBrita Roy
Lisa WillettLisa Willett
22ndnd Annual Education Summit Annual Education SummitUniversity of Alabama at BirminghamUniversity of Alabama at Birmingham
Research and Innovations in Medical Education WeekResearch and Innovations in Medical Education WeekSeptember 28September 28thth, 2012, 2012
Bad news…Bad news… Your mother (or other loved one) is sick. Your mother (or other loved one) is sick.
Your previous UAB IM resident is the Your previous UAB IM resident is the doctor taking care of her.doctor taking care of her.
What specific skills do you want that What specific skills do you want that doctor to have?doctor to have?
ReflectionReflection What is the What is the purposepurpose of the attending? of the attending?
What is the What is the purposepurpose of rounds? of rounds?
OutlineOutline
Background (10 min)Background (10 min) Group exercise / expert panelGroup exercise / expert panel
Ward rounds scenariosWard rounds scenarios Integrated didacticsIntegrated didactics
Discussion (20 min)Discussion (20 min) Conclusions and Take Home Points (5 min)Conclusions and Take Home Points (5 min) Evaluations (2 min)Evaluations (2 min)
IntroductionsIntroductions NameName AffiliationAffiliation Number of ward attending months per yearNumber of ward attending months per year
ReflectionReflection What is the What is the purposepurpose of the attending? of the attending?
What is the What is the purposepurpose of rounds? of rounds?
Attending ResponsibilitiesAttending ResponsibilitiesPatientsPatients Diagnose the patientDiagnose the patient Supervise patient Supervise patient
care care TreatmentTreatment CommunicationCommunication Systems based careSystems based care BillingBilling
LearnersLearners Diagnose the learnerDiagnose the learner TeacherTeacher Role modelRole model CoachCoach Protect the professionProtect the profession Ensure the future of Ensure the future of
medicinemedicine
ACGME - AttendingACGME - Attending Monitor for fatigue, burnout, depressionMonitor for fatigue, burnout, depression Ensure days off and duty hour complianceEnsure days off and duty hour compliance Complete your evaluationsComplete your evaluations Provide feedbackProvide feedback Etc., Etc. Etc., Etc.
Challenges are plenty…Challenges are plenty… Balancing patient care/teaching in pressured Balancing patient care/teaching in pressured
environmentenvironment Increased documentation requirementsIncreased documentation requirements Short attending rotations (2 wks)Short attending rotations (2 wks) Teams are changingTeams are changing
Night floatNight float
Meeting other responsibilitiesMeeting other responsibilities Find the joyFind the joy
……but it’s worth itbut it’s worth it Fundamental educational function in internal Fundamental educational function in internal
medicine training programsmedicine training programs
It is the most important thing we can do for our It is the most important thing we can do for our professional future professional future
Embrace it and learn to do it wellEmbrace it and learn to do it well
Learning ObjectivesLearning Objectives
Explain the domains of successful ward Explain the domains of successful ward attending rounds – give you a frameworkattending rounds – give you a framework
Demonstrate effective techniques to excel in Demonstrate effective techniques to excel in these domainsthese domains
Explore ways to improve your own ward Explore ways to improve your own ward attending rounds by using this frameworkattending rounds by using this framework
Excellent Ward AttendingsExcellent Ward Attendings
Very different Very different ““stylesstyles””Both receive excellent evaluationsBoth receive excellent evaluations
Dr. Chalk TalkDr. Chalk Talk Sit down roundsSit down rounds Board talksBoard talks
Topic orientedTopic oriented Planned Planned
Focused bedside Focused bedside teachingteaching
Dr. BedsideDr. Bedside Walking roundsWalking rounds Teaching at bedsideTeaching at bedside
Patient dependentPatient dependent SpontaneousSpontaneous
Few board talksFew board talks
Excellence definedExcellence defined
Teaching ExcellenceTeaching Excellence11
Positive Learning ClimatePositive Learning Climate Control of Teaching SessionControl of Teaching Session Communication of GoalsCommunication of Goals Understanding and RetentionUnderstanding and Retention Evaluation of the LearnerEvaluation of the Learner Providing FeedbackProviding Feedback Self-Directed LearningSelf-Directed Learning
Excellent Clinical TeacherExcellent Clinical Teacher22
Teach >25% of timeTeach >25% of time Teach/Round >25 hours/weekTeach/Round >25 hours/week Stress doctor-pt relationshipStress doctor-pt relationship Teach psychological aspect Teach psychological aspect
medicinemedicine Chief residentChief resident
1KM. Skeff, et al.. Stanford Faculty Development Center Stanford University School of Medicine2Wright SM NEJM 1998;339:1986-93
Ward Attending RoundsWard Attending Rounds
Both very successful ward attendingsBoth very successful ward attendingsShare Share ““somethingsomething”” in common in common
Dr. Chalk TalkDr. Chalk Talk Dr. BedsideDr. Bedside
Ward Attending RoundsWard Attending Rounds
Dr. Chalk TalkDr. Chalk Talk Dr. BedsideDr. Bedside
Ward Attending RoundsWard Attending Rounds
• You don’t have to recreate yourself• You must be deliberate• You have to care
Learning AtmosphereLearning Atmosphere Clinical TeachingClinical Teaching Teaching StyleTeaching Style Communicating ExpectationsCommunicating Expectations Team ManagementTeam Management
Roy B, et al. Using Cognitive Mapping to Identify Key Domains for Successful Ward Attending Rounds. J Gen Int Med 2012
5 Domains for Successful 5 Domains for Successful Ward RoundsWard Rounds
Learning AtmosphereLearning Atmosphere
Be approachable - not intimidating. Be approachable - not intimidating.
Insist on respect for all team members. Insist on respect for all team members.
Showing enthusiasm. Showing enthusiasm.
Showing appreciation of team members. Showing appreciation of team members.
Giving positive and negative feedback. Giving positive and negative feedback. Allowing room for mistakes.Allowing room for mistakes. Encourage a serious but relaxed atmosphere. Encourage a serious but relaxed atmosphere.
Clinical TeachingClinical Teaching
Teaching by example (ie. good bedside manner). Teaching by example (ie. good bedside manner).
Sharing of attending’s thought processes. Sharing of attending’s thought processes.
Setting aside time to teach.Setting aside time to teach. Ensure attending’s comprehensive knowledge base. Ensure attending’s comprehensive knowledge base.
Integrate theory with actual patients and findings.Integrate theory with actual patients and findings. Teaching throughout rounds. Teaching throughout rounds.
Teaching StyleTeaching Style
Ask questions of team about decisions (what Ask questions of team about decisions (what and why). and why).
Have part of rounds at bedside, demonstrate Have part of rounds at bedside, demonstrate key physical findings. key physical findings.
Communicating ExpectationsCommunicating Expectations
Stating expectations for residents/students. Stating expectations for residents/students.
Allow team some independence in decision-Allow team some independence in decision-making. making.
Team ManagementTeam Management
Conduct rounds in an organized, efficient, & Conduct rounds in an organized, efficient, & timely fashion. timely fashion.
Having a consistent, coherent plan of care. Having a consistent, coherent plan of care.
Allow time on rounds for residents to meet other Allow time on rounds for residents to meet other responsibilities. responsibilities.
Let’s practice…Let’s practice…
Common Scenarios on Ward Common Scenarios on Ward Attending RoundsAttending Rounds
Scenario #1Scenario #1 8:00 am8:00 am New ward teamNew ward team
You are meeting your senior resident for the You are meeting your senior resident for the first time…first time…
http://www.youtube.com/watch?v=mEsikH6PdDA&feature=plcp
ExampleExample What went well?What went well? What did not go well?What did not go well? What could have been done differently?What could have been done differently?
New TeamNew Team Communicating expectationsCommunicating expectations
Setting expectations of the team and of youSetting expectations of the team and of you Are there specific things you do or say when picking up a Are there specific things you do or say when picking up a
new team?new team? Handout with goals/expectations listedHandout with goals/expectations listed
Ask team members to write down goalsAsk team members to write down goals Learning EnvironmentLearning Environment
Positive attitudePositive attitude ““Biography rounds”Biography rounds” Atmosphere of shared learningAtmosphere of shared learning
8:20 am Intern presents a patient admitted for deep Intern presents a patient admitted for deep
vein thrombosis.vein thrombosis. Hypertensive on admission, new diagnosisHypertensive on admission, new diagnosis
Started metoprololStarted metoprolol
Teaching Key PointsTeaching Key Points Teaching StyleTeaching Style
Ask why this medication was chosenAsk why this medication was chosen Clinical TeachingClinical Teaching
Demonstrate your thought process for Demonstrate your thought process for choosing 1choosing 1stst line antihypertensive line antihypertensive
Integrate evidence into clinical reasoningIntegrate evidence into clinical reasoning
Top Ranked AttendingsTop Ranked Attendings
Teaching Style
Clinical Teaching
Learning AtmosphereTeam Management
Communicating Expectation
9:00 am9:00 am
Third year student presents a patientThird year student presents a patient 59 year old man with chest pain59 year old man with chest pain
9:15 am9:15 am Same third year student, Same third year student, still still presenting presenting
the patient with new onset chest painthe patient with new onset chest pain Substernal, dull burning, worse lying downSubsternal, dull burning, worse lying down Started this morning, lasted 1 hourStarted this morning, lasted 1 hour
Student differential: acute MI, pericarditis, cardiac Student differential: acute MI, pericarditis, cardiac tamponadetamponade
Efficiency, Broadening Efficiency, Broadening DifferentialDifferential
Team ManagementTeam Management Do you interrupt the student?Do you interrupt the student?
Clinical TeachingClinical Teaching Demonstrate clinical reasoning for non-Demonstrate clinical reasoning for non-
cardiac causes of chest paincardiac causes of chest pain Ask questions of the group (moving from Ask questions of the group (moving from
medical student “up the ranks” to residents)medical student “up the ranks” to residents)
9:20 am9:20 am Examining the patient with chest painExamining the patient with chest pain
Blood pressureBlood pressure Grade II/VI diastolic blowing murmur and Grade II/VI diastolic blowing murmur and
grade III/VI systolic murmurgrade III/VI systolic murmur JVP 6 cmJVP 6 cm
Bedside ExaminationBedside Examination Teaching StyleTeaching Style
Importance of having rounds at the bedsideImportance of having rounds at the bedside Clinical TeachingClinical Teaching
Teaching physical exam findingsTeaching physical exam findings Importance of BP in both armsImportance of BP in both arms How to listen for diastolic murmursHow to listen for diastolic murmurs How to evaluate JVPHow to evaluate JVP
0
1
2
3
4
5
6
7
8
Discussion Mini-lecture Physical exam Modeling
Perc
eive
d Q
ualit
y of
Tea
chin
g(O
rdin
al O
dds
Ratio
)
Teaching Methods
P < 0.001 P < 0.001P =0.03 P = 0.04
Communication
Perceived Teaching QualityPerceived Teaching Quality
1.0
2.0
3.0
4.0
None Any One Any Two > Two
Perc
eive
d Q
ualit
y of
Tea
chin
g
Teaching Methods
P for trend < 0.001
Perceived Teaching QualityPerceived Teaching Quality
Scenario #2Scenario #2 6:30 am6:30 am Post-call dayPost-call day 10 new case presentations + 8 old patients10 new case presentations + 8 old patients
Prioritization/organizationPrioritization/organization
Learners’ Priorities Based on Learners’ Priorities Based on Call-CycleCall-Cycle
Teaching Style Learning Atmosphere
Clinical Teaching
Team Management
Dynamic Domain Emphasis Dynamic Domain Emphasis by Top-Ranked Attendingsby Top-Ranked Attendings
Teaching StyleClinical TeachingLearning AtmosphereTeam Management
7:30am7:30am Intern presents a new patient with nausea, Intern presents a new patient with nausea,
vomiting and abdominal painvomiting and abdominal pain KUB interpretation: constipation, abundant stoolKUB interpretation: constipation, abundant stool Assessment: pancreatitis vs. gastroparesisAssessment: pancreatitis vs. gastroparesis
Expediting CareExpediting Care Team ManagementTeam Management
Demonstrating efficiency in careDemonstrating efficiency in care Expediting and escalating careExpediting and escalating care Allow time to call consults/enter ordersAllow time to call consults/enter orders
Clinical TeachingClinical Teaching Demonstrating pitfalls of biasesDemonstrating pitfalls of biases
8:30 am8:30 am Third year student presents a patient with Third year student presents a patient with
pneumocystis jirovecii pneumoniapneumocystis jirovecii pneumonia A diagnosis the student knows little aboutA diagnosis the student knows little about
Teaching New InformationTeaching New Information Team ManagementTeam Management
When and how to teach?When and how to teach? Teaching StyleTeaching Style
Ask questions, teach key pointsAsk questions, teach key points Chalk talkChalk talk
Now or tomorrow?Now or tomorrow? Ask student to prepare presentation to the Ask student to prepare presentation to the
groupgroup
8:35 am8:35 am In the patient’s room with PJPIn the patient’s room with PJP
New diagnosis of HIV for the patientNew diagnosis of HIV for the patient
Communication SkillsCommunication Skills Clinical TeachingClinical Teaching
Demonstrating good beside mannerDemonstrating good beside manner Role-modeling patient communication skillsRole-modeling patient communication skills Teaching the patientTeaching the patient
OtherOther FeedbackFeedback
When, where?When, where? FormatFormat
Evidence-based medicineEvidence-based medicine
Large Group DiscussionLarge Group Discussion
DiscussionDiscussion
What specific changes will you implement What specific changes will you implement based on this information?based on this information?
Successful Ward Attending Successful Ward Attending RoundsRounds
Clinical TeachingTeam Management
Communicating ExpectationsLearning Atmosphere
Teaching Style
ConclusionsConclusions Everyone can be a great attendingEveryone can be a great attending Deliberate about teachingDeliberate about teaching Try one thing – anything!Try one thing – anything! CoachCoach Protect the professionProtect the profession Ensure the future of medicineEnsure the future of medicine