How can i teach under managed care by DrWarrenDO


									Effective (and Efficient)

Evaluation and Feedback

An Approach to Diagnosing the Learner in the Outpatient Setting
Louis Pangaro MD, FACP
Educational Programs Medicine, USUHS

The rhythm of productivity In general
• Observation

• Assessment • Evaluation • Feedback or Grading

• Reflection

• Action

some definitions
• Assessment = making the observation
– “sitting next to”

• Evaluation = assigning value
– not grading; uses words
– based on goals – diagnoses what “step” they’re at

some definitions
• Feedback = “course correction”
– not feeling good – based on evaluation – get them to “next step”

Evaluation vs. Grading
Grading “gradus” steps

(F, D, C, B, A)

Evaluation “value” strength

Goals (“ends”) Curriculum (“means”, “objectives”) Evaluation
individual programmatic


Teacher Tasks
• Diagnose the Patient • Diagnose the Learner
– Teach One Thing the Learner Needs to get to “the Next Step”

• Diagnose the Teacher (reflection)
– at the end of clinic with feedback from the student

How do you decide what the “next step” is for a learner?

Diagnosing the Learner: goals (“analytic”)

• attitudes
• skills • knowledge

AAMC Med School Objectives Project (MSOP)
• Goals*: a Physician is:

– Dutiful
– Altruistic – Skillful – Knowledgeable
* each goal has multiple objectives

Knowing the goals for the learner’s level of training

• A “synthetic” approach R.I.M.E. System
- Reporter - Interpreter - Manager/Educator

R.I.M.E. System
USUHS Medicine

Reporter: reliably get the facts, works with patients, identifies problems, Interpreter: prioritizes, reasonable differential diagnosis, more confidence Manager: works with patients on Diagnostic and therapeutic Plan Educator: a plan for the doctor: gets to the next level of knowledge and evidence

What “level” would you expect of the learner?
• clinic patient : a 45 year old woman with hypertension; routine lab studies showed a total cholesterol of 340 mg/dl. – if the learner is a third year student? – an intern in August? – a senior resident?

• Diagnosing the Student yields:
– What the next step is, what he/she should learn

– a question of “what” to tell the learner
– “doing the right thing”

• Reflecting on Teaching yields:
– How do you make feedback effective? – A question of “how” to tell the learner – “doing the thing right”

Teaching Suggestion

• One thing at a time:
–With “beginners”, Don’t try to do it All –What’s the priority agenda for feedback? –“Diagnosis” of the learner

How to Assess a learner Quickly:

Student/early intern: mainly observation/listening • Dose the HPI lead to reasonable diagnoses? • pertinent positives/negatives • problem list (semantic competence)

Diagnosing the Novice Learner

Is the “description” adequate?
• Can you conclude on the likely structures/organs involved?
– Is the chest pain heart, lung, gut, chest wall?

• Can you decide on the likely process involved?
– Is this trauma, infection, metabolic, neoplastic, iatrogenic, etc.

Diagnosing the Novice Learner(2)

Expecting complete problem lists
• Problem lists quickly reveal:
– – – – comprehensiveness level of semantic competence ability to synthesize movement toward “interpreter” level

Risks in complete problem lists
• we try to cover it all • our compulsiveness wins out • we bring up all the interesting, fascinating, aspects of a great case • we try to do the inter-relations for the student • we start to lecture the student/resident

“Semantic Competence”
• Bordage’s term for active use of correct terms that show pattern awareness. • e.g. “This patient has a distal, symmetric, polyarthritis.” implies a student has the knowledge and skill to move to “interpreter” • options: listen to summary statement, or ask for “problem” list

Diagnosing the Advanced Learner

How to Assess a learner Quickly:

• The details in H&P have implications for action. • The Problem List reveals an ability to analyze a case (semantic competence) and synthesize it (embrace complexity) • embedding the present problem in larger context • Can answer “How Can I help?

The “heart” of our method
• Internal Medicine teaches a method to embrace complexity, so one can act with simplicity. • The Problem List reveals the learner’s ability to analyze a case (semantic competence) and synthesize it (embrace complexity)

Internal Medicine Clerkships
• Different from others in third year: embedding the present problem in larger context (necessary for High Pass and certainly for Honors level) • Dy’s “cogito”: I think, therefore I.M.

Caveat: Case Specificity of Analytic Skill
• A learner can be a novice on one case (reporter level) • And an closer to expert, a “manager “ on another case

Reflection to Action
• Evaluation to Feedback • Converting your Evaluation of a Student into Educational Management

Teaching Skill The “One Minute” Preceptor
• Five “Microskills” for Clinical Teaching
A disciplined approach to pacing from the University of Washington, Seattle

The “One Minute” Preceptor
• Start with a Commitment from the Learner • Probe for Supporting Evidence

• Teach General Rules • Positive Feedback for what was right • Correct Mistakes

Intern and High Cholesterol
• Intern: This lady should be started on pravastatin • Teacher: Why? • Intern: She has a risk of heart disease • Teacher: What else would you do? • Intern: Bring her back in three months

Intern and High Cholesterol
• Teacher: Generally, be sure of your diagnosis first. You’re right that cholesterol is a risk for heart disease, but you need to be sure about causes like hypothyroidism. • Teacher: Let me tell you what tests and therapy I’d like you to order today, and what you should read about tonight.

Kinds of Feedback
• Minimal
– “good”, “ugh!”, a shrug or nod

• Behavioral
– “that was good because…” – “you can improve by…”

• Interactive
– let them react, or better yet, self-evaluate
after Stanford Faculty Dev Program

HOW to Give Effective Feedback
• be specific (what they did, not who they are)

• be timely, but watch the setting
• “positive” too; a “feedback sandwich” (catch the learner doing something right) • label it “feedback” • have an action plan

• use “interactive” method
after SFDP

What To Give Feedback On
• do you agree with their diagnosis/management
• making the transitions ? (RIME) • their self-evaluation (is it similar to yours?) • an action plan for their time (give it now or after clinic)

• Another aspect of “doing the thing right” • The “One Minute Manager/Preceptor” Model gives permission to limit the time you talk • Creates the need to prioritize what you and the learner do together, today

Teaching Tip let the student do the work
• Transferring incentive and initiative to the student

• can we incentivize efficiency in the student??

What motivates students to do the work?



Teaching Tip Let the Learner Do the Work
• Don’t lecture about what can be learned by reading
• Save Extensive Knowledge Transfer for the Learner’s Own Time • give the student a chance at High Pass

let the student do the work

• Preparation :
– in advance identify patients to see – how was the diagnosis made, how treated – what is our agenda for coming visit? – write down what to ask, to look for, labs to check (index card)

Working with the Patient
• Student memorizes the lines: “Mrs. J----------, I’ve had a chance to review your record and I believe you’re here to follow-up on your diabetes. .. Is there anything else you’d like us to go over in the 20 minutes we have together?”

managing the educational goals: Beginners
• “reporter” stage
– interview/exam show only basic knowledge and skill

• “interpreter” stage
– interview/exam show good focus on pertinent info

• student excused (or observer) and attending offers A&P to the patient • student given homework and tasks

• student allowed to offer assessment
– presence of patient?

• attending offers plan
– student excused or observer

Managing the educational goals: : Advanced learners
• Force residents to move to Manager/ Educator Level (first, confirm they are advanced; diagnose the learner) • Ask them to self-evaluate and determine their educational needs • Let them Know their Growing Independence is Important to You • “How Can I Help?”

Summary: Five Tips
1. Know the “next step” for this learner (RIME); 2. “One thing at a Time” 3. Practice the “One Minute Preceptor” 4. For students: let them do the work 5. For residents: “How can I help?”

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