ResidentEducatorDevelopment

The RED ProgramA Residents-as-Teachers Curriculum

Developed by Heather A. Thompson, MD

The RED Program

• Team Leadership• How to Teach at the Bedside• The Microskills Model: Teaching during

Oral Presentations• How to Teach EBM• The Ten Minute Talk• Effective Feedback• Professionalism• Patient Safety and Medical Errors

Team Leadership

Resident Educator

Development (RED) Program

Video Clip

“Switch Day on the New Rotation—Utter Chaos”

What is Team Leadership?

• Recall a resident you have worked with that seemed to have good leadership skills.

• Write down a few characteristics that made them a good team leader.

Is there data?

• U of Hawaii Internal Medicine Program: Retreat on Leadership Skills results in improved confidence levels Academic Medicine 76(5): 554 May 2001

• U of Washington: 6 hour course on Leadership and Teaching skills results in improved resident ratings Academic Medicine 74(8): 938-42, Aug 1999

U of MN Med Students: E*Value

• Our residents are usually rated highly in terms of teaching.

• However, lower scores are noted in three particular areas:

--setting expectations--overall organization of the

rotation --giving feedbackThese fall under the general umbrella of Team Leadership.

Objectives

• By the end of this session, the resident should be able to recognize the necessary skills for effective team leadership.

• The resident will recognize time savers vs. time wasters.

• The resident should be able to describe practical tools and tricks and apply them to their rotations on the wards.

• A good team leader: --Sets Expectations--Delegates Tasks--Uses Role Modeling--Upholds Professionalism--Gives Feedback--Effectively Manages Time

Setting Expectations

• On day one, describe the role of the various team members in running the service.

• Be explicit! • Start with very basic expectations.

Example: Student

• “As the third year student, you will follow 1-3 patients.”

• “On work rounds, obtain vitals, direct questions and physical exam, and follow up any tests”.

• “Give input into the A/P when we round with the attending. Ask me questions at any time.”

Example: Intern

• Admitting patients on call.• Following patients each day

(usually, all but the student’s patients).

• Updating the signouts.• Knowing the student’s patients.• Being responsive to pages.• When to call for cross cover help.

Setting Educational Expectations

• Informally: ask, what do they want or need to learn on this rotation?

• Formal Educational Objectives: can refer to Written Curriculum and Rotation Descriptions for your particular program (Peds, Surgery, Medicine).

• Student clerkship objectives are listed on their website and in their handouts.

Organization

• On any given day there are many activities going on, often simultaneously:

--Clinics--Required Lectures,

Workshops--Short call, long call--Days off

Organization

• It helps to map out a “Calendar of Events” for the entire month.

• Communication is key: when, where, what time.

• Can also refer to Rotation Descriptions (Written Curriculum, Website) prior to starting your rotation for a “day in the life”.

Delegating Tasks

• There is always a certain amount of busywork that needs to get done.

• Try to avoid simply doing tasks for the team but teach them how to get it done efficiently.

• Consider a “To-Do Checklist” or other system of tracking.

Delegating Tasks

• Delegate educational tasks as well.

--Write an Educational Rx www.ebm.umn.edu--Schedule rotating 10

Minute Talks among members of the team on the calendar

Role Modeling and Professionalism

• Professionalism is taught largely by role modeling, which occurs through daily interactions.

• Therefore, residents are teaching professionalism more than anyone else (attendings, grand rounds lecturers, curriculum committees, etc)

Role Modeling

• Common observations:--how you conduct rounds--how you interview the patients--how you access information (PDA,

Up to Date, etc)--how you do a lit search--how you interact with the

attending--how you call a consultant

Professionalism

• Therefore, being a team leader also means upholding professionalism.

• What is professionalism?--Competence--Engagement --Reliability--Dignity--Agency--Dual focus on illness and disease--Concern for quality in health care

Archives of Internal Medicine, 163(2) 145-149, 27 Jan 2003

Professionalism

• Good communication: with patients, with nurses, with other teams.

• “This is how I would want my mother treated if she were in the hospital.”

• During residency, professionalism also involves respecting educational time and the process of teaching and learning.

“Top Ten” examples of unprofessional behavior

• Poor conference attendance (i.e. grand rounds)• Poor documentation (H&P’s, notes, signouts; late or

incomplete discharge summaries)• Signing out early with things left undone• Coming in late on a consistent basis• Ignoring the attending’s instruction• Not answering pages in a timely fashion• Complaining about “soft” admits, “rocks” on the

service• Disrespectful of nursing, social work, ward clerks• Disrespectful of other medical specialties• Poor communication with other MDs, patient/family

Feedback

• Giving feedback to the intern and medical students on the team is often a new role for the senior resident.

• Can be anxiety producing.

HOW to give effective feedback

• Comfortable for all involved (timing, location)• Elicit learner’s opinion• Establish joint goals• Not too much feedback (2-3 suggestions at

most)• Relate to specific behaviors, not the person• Make observations, not assumptions• Give reactions, not judgments• Use specific examples• Offer suggestions for improvement• Use a specific technique: ORIME,

Pendleton’s Rules

Pendleton’s Rules

1. Subject gives positive aspects2. Observer gives positive aspects3. Subject gives areas for

improvement4. Observer gives areas for

improvement

Why Pendleton’s Rules Work

1. Subject speaks first gives the person being evaluated a feeling of control

2. Positive comments first lessens anxiety3. Subject often identifies exact same

issues4. Conversely—if subject has no insight,

outside help might be in order (Chief Resident, Attending, Clerkship Director)

ORIME

• O: Observer (passive)• R: Reporter (data gathering)• I: Interpreter (differential diagnosis)• M: Manager (formulates a treatment

plan)• E: Educator (reads up on a topic,

teaches the team)• Summarize where they are at, and what

it takes to get to the next level

Time Management

• Efficiency, without compromising teaching and learning, is key

• Work Hours: an added dimension• Managing your team; managing

your attending

Brainstorm: Time Wasters vs. Time Savers

• Activities that consume time, have low personal or professional value, and that could be streamlined or eliminated

• Habits or approaches that increase efficiency and effectiveness

Time Waster Personalitiesfrom the APDIM “Time Trap” Workshop

• The Crisis Manager• The Undisciplined Procrastinator• The Easily Distracted• The Perfectionistic Resitern• The Systematically Inefficient• The Non-Communicator• The Impulsive Wanderer

The Crisis Manager

• Constantly putting out fires

• Doesn’t plan ahead

• Disorganized• Doesn’t learn

from mistakes

• Organize tasks on a daily and weekly basis

• Identify issues on work rounds

• Help anticipate problems

• Help structure rounds

The Undisciplined Procrastinator

• “It can wait”• Likes to socialize• Little self-

discipline

• Set timelines• Build in time for

educational activities, socializing

The Easily Distracted

• Is derailed by interruptions

• Tends to leave tasks unfinished

• Help them prioritize

• Emphasize completing each step

• Consider taking cross cover pager

The Perfectionistic Resitern

• “I can do it best”• Attempts too

much• Can’t delegate

tasks• Fear of failure

• Constructive Feedback

• Convey the importance of delegation

• Emphasize role of team leader, educator

The Systematically Inefficient

• Tied up with paperwork

• Tied up in meetings--Educational conferences--Health Team Rounds--Attending rounds

• Inadequate support

• Enlist help (other residents, dayfloat, fellow, attending)

• Prioritize tasks• Learn the system• Protect

conference time

The Non-Communicator

• “Who’s in Charge?” “What’s the Plan?”

• Doesn’t communicate back to team; or,

• Does things without input from resident or attending

• Delays in care

• Constructive feedback

• Address the attitude behind the behavior

• Make suggestions for change

The Impulsive Wanderer

• Off the wards frequently

• Work related: tracking down patients, charts, studies

• Personal reasons• Physical space,

travel time

• Access to information

• Enlist help of nursing staff, ward clerks

• Make “rounds” in lab, Xray

• Address outside concerns

Work rounds

• “There’s no team you can’t work round on in an hour.” –former VA Chief Resident

• Keep up the pace with work rounds; this is a time for data gathering.

• Ideally, write orders immediately after attending rounds (or write as you go).

• Finish up progress notes and have them in the chart by noon.

Attending Rounds

• Consider how to best spend time with the attending (set goals, objectives)

--During sit down rounds, can discuss interesting cases with teaching points only; “run the list” later with resident

--On walk rounds, decide who needs to be seen together

• If attending rounds are extremely difficult, speak with chief residents, program directors

Student Admits

• Students are taught an exhaustive, thorough H&P in 2nd year medical school: teach them how to focus on the problem at hand.

• Students are used to starting with a “blank slate”: teach them how to get information.

• When observing a student admission, the senior resident can often complete most of their note at the same time.

Intern Admits

• Similar principles apply.• Can work on some basic orders

while the intern is interviewing the patient.

• Consider taking the cross cover pager to minimize disruptions.

Managing Educational Time

• Students and residents alike prefer focused mini-talks (10-15 min) on topics related to patients they are following.

• Other quick educational activities: PE rounds, looking at CXR’s, EKG’s, peripheral smears (even if normal!)

In summary

• Recognize the characteristics of a good team leader:

--Sets Expectations--Delegates Tasks--Gives Feedback--Uses Role Modeling--Upholds Professionalism--Effectively Manages Time