IMPROVING THE QUALITY OF PATIENT CENTERED CARE AND CLINICAL TEACHING
The Merrin Bedside Teaching Program
NYU School of Medicine, Department of Medicine, Section of Primary Care, 550 First Avenue, NY, NY, 10016 Merrin Master Clinician F ll M i M t Cli i i Fellows: Tanping Wong, MD; G T i W MD Gregory Mi t MD S b i F l Mints, MD; Sabrina Felson, MD Merrin Leadership: Adina Kalet, MD, MPH; Mitchell Charap, MD; Marian Anderson, RN, MA, MS
CHALLENGES
CONTEXT
Many have noted that recent generations of Physicians have been trained without emphasis on the diagnostic and therapeutic importance of the bedside physical exam. Yet exam. the physical exam continues to account for 80% of 80% diagnosis as well as playing a critical role in monitoring therapeutic response. response. Contributing factors to the decline in skills include: overinclude: overdependence on procedures, laboratory and imaging tests, less access to patients as a result of shortened hospital stays, pressure to see more patients in less time and resident work hour restrictions. Despite the fact the restrictions. medical students continue to take a basic Physical Diagnosis course it is rare for these skills to be reinforced during clinical training because most housestaff and many relatively junior faculty members do not have adequate skills themselves or feel confident enough to teach them. them. To pressure clinical training sites to pay attention to this problem the Internal Medicine Residency Review Committee of the ACGME and the AAMC made adequate bedside teaching an accreditation priority. priority. The potential benefits to increased proficiency in bedside teaching include: decreased costs (less use of technology, include: less time to accurately diagnose); more involvement of diagnose); patients in decision-making; opportunities to role model decision-making; best practices and professionalism. professionalism. To address this at NYU School of Medicine, in 2004 we established a comprehensive program aimed at increasing the quantity and improving the quality of bedside teaching in the Department of Medicine. With a generous gift from a Medicine. private donor, early phases of this Department of Medicine Bedside Teaching Program concentrated on using experiential techniques to improve confidence and competence in running bedside rounds. While twenty-six rounds. twentyfull time faculty members participated, it became clear that a more in-depth program was needed to accomplish our ingoals. goals. In 2006, we initiated a second phase of the program, the 2006, aim of which is to create a cadre of master bedside teachers who would, when provided with resources, create programs for their peers to improve the quality and quantity of bedside teaching in the Department of Medicine. Medicine.
• Identify barriers and facilitators of teaching physical diagnosis at the bedside • Create a curriculum model that enhances faculty’s physical diagnosis teaching skills
OUTCOMES
• Developed a unique clinically meaningful teaching model for the cardiac exam • Established collaboration with Blaufuss Multimedia to design a computer based program for testing and teaching the cardiac exam • Conducted extensive piloting of electronic Stethoscopes to select one for use with Wireless technology to facilitate group teaching of heart sounds
APPROACHES TO CHALLENGES – KEY INITIATIVES
Development of the Merrin Bedside Teaching Program Faculty Development Sessions focused on Bedside Teaching Skills with 26 hospitalists from BH and Tisch; Included various combinations of: • • • • Pre and Post Objective Structured Teaching Evaluation Review Video tape of the OSTE 4 small group “teaching rounds” Peer Observed rounds and debriefing
NEXT STEPS
• Second cohort of Merrin Fellows to be selected after application process with selection of other focused clinical areas faculty• Monthly faculty-attended bedside rounds with expert diagnosticians • Complete the Competency/ clinically based on-line testing and onteaching modules (Neck Veins, followed by Murmurs/Maneuvers, Echos and Chest X-Ray) • Videotape clinician cardiologists at the Bedside to capture the art and clinical pearls of the physical exam. exam. • Faculty Development Workshops to facilitate teaching the cardiac exam • IRB Approval to study the impact of intervention on changing bedside teaching skills • Characterization of the link between improved competencies
Merrin Master Clinician Fellows Program (2-Years) (2Highly respected junior faculty leaders charged with: with: • Proposing a focused clinical area in which to become ‘expert’ ‘expert’ • Designing an educationally sound, evidence-based, evidenceselfself-learning program using local experts as mentors • Implementing a set of learning experiences for faculty, residents and medical students using new technologies • Share the work through publications, presentations
LESSONS LEARNED
• Excellent bedside teaching is about understanding physiology and pathophysiology! pathophysiology! • Dissecting a case with expert faculty and peers is a rare and very intellectually satisfying experience. experience.
• Movement from novice to expert takes time and a commitment to lifelong learning o s s d co e o e o g ea g of skills And techniques
FOCUS: THE CARDIAC EXAMINATION
Merrin Master Clinician Fellows in Cohort 1: Selected group project to develop a method to assess learners’ cardiac examination skills and teach those skills using state-of-the state-ofart methodologies and technologies g g Developing Expertise: Team made weekly bedside teaching rounds with a selected group of Clinical Cardiologists widely recognized as excellent bedside teachers.
• Wireless technology for use in the cardiac exam lags behind identified need.
in the physical exam and patient outcomes
Acknowledgment:
The Merrin Bedside Teaching Program is made possible through a generous donation from the Merrin Family Foundation