Mariana G. Hewson

Giving Feedback in Medical Education: Verification of Recommended Techniques

AbstractOBJECTIVE: We investigated naturally occurring feedback incidents to substantiate literature-based recommended techniques for giving feedback effectively. SETTING: A faculty development course for improving the teaching of the medical interview, with opportunities for participants to receive feedback. PARTICIPANTS: Seventy-four course participants (clinician-educators from a wide range of medical disciplines, and several behavioral scientists). MEASUREMENTS AND MAIN RESULTS: We used qualitative and quantitative approaches. Participants provided narratives of helpful and unhelpful incidents experienced during the course and then rated their own narratives using a semantic-differential survey. We found strong agreement between the two approaches, and congruence between our data and the recommended literature. Giving feedback effectively includes: establishing an appropriate interpersonal climate; using an appropriate location; establishing mutually agreed upon goals; eliciting the learner’s thoughts and feelings; reflecting on observed behaviors; being nonjudgmental; relating feedback to specific behaviors; offering the right amount of feeback; and offering suggestions for improvement. CONCLUSIONS: Feedback techniques experienced by respondents substantiate the literature-based recommendations, and corrective feedback is regarded as helpful when delivered appropriately. A model for providing feedback is offered.

Strategies for managing uncertainty and complexity

AbstractOBJECTIVES: To identify strategies involved in the diagnosis and treatment plans of primary care problems that are uncertain and complex. METHODS: In this exploratory study we observed primary care physicians encountering standardized patients who portrayed typical primary care problems involving uncertainty and complexity. First, we analyzed 10 tapes of nine physicians with a range of clinical experience (first-year residents through faculty physicians) interacting with four standardized patient cases (headache, back pain, hypertension, and abdominal pain). We analyzed the 10 tapes to determine the regular occurrence of physician behavior patterns that we later described as strategies. Then, using a written questionnaire, 19 general internal medicine faculty physicians from our hospital and from an affiliated hospital rated the perceived importance of these strategies for clinical practice in general. Finally, we checked the incidence of the strategies: (1) across a range of six cases (headache, back pain, hypertension, abdominal pain, fatigue, and well-adult care) using six first-year residents (a total of 19 encounters), and (2) across different levels of clinical experience using the standardized patient case of headache involving eight physicians (first-year residents through faculty physicians). RESULTS: Nine strategies were identified, and each was rated as important to primary care clinical practice. The strategies were: (1) defines the context of the diagnosis and explains the signs and symptoms as part of the expected spectrum of the disease; (2) eliminates alternative diagnoses by dealing with patient fears, giving reasons in the context of the patient’s belief system; (3) describes the prognosis in terms of the likely course of the disease and expectations of treatment; (4) negotiates key problems or issues that are important to both patient and physician; (5) negotiates the plan and ensures patient understands, and is willing and able to comply, given his/her particular context; (6) keeps diagnostic options open by making provisional diagnoses while keeping alternatives in mind; (7) is circumspect and takes action to minimize the possibility of missing other critical diagnoses; (8) plays for time by allowing signs and symptoms to develop to help clarify the diagnosis; and (9) plans for contingencies by providing appropriate if/then statements concerning situations requiring further action. The strategies were used in each of the six cases, and by physicians with all levels of clinical experience. CONCLUSIONS: The nine strategies led to the generation of a construct we termed “strategic medical management,” which refers to the management (diagnosis and proposed treatment) of uncertain and complex medical problems in primary care. The construct provides a more elaborated framework in which to view clinical decision making and integrates recent ideas concerning doctor-patient communication into this process. Strategic medical management appears to be based on tacit knowledge that is seldom explicity articulated or taught. It has potential implications for enhancing instruction and assessment in medical education.

Successful lecturing: A prospective study to validate attributes of the effective medical lecture

AbstractOBJECTIVE: In a study conducted over 3 large symposia on intensive review of internal medicine, we previously assessed the features that were most important to course participants in evaluating the quality of a lecture. In this study, we attempt to validate these observations by assessing prospectively the extent to which ratings of specific lecture features would predict the overall evaluation of lectures. MEASUREMENTS AND MAIN RESULTS: After each lecture, 143 to 355 course participants rated the overall lecture quality of 69 speakers involved in a large symposium on intensive review of internal medicine. In addition, 7 selected participants and the course directors rated specific lecture features and overall quality for each speaker. The relations among the variables were assessed through Pearson correlation coefficients and cluster analysis. Regression analysis was performed to determine which features would predict the overall lecture quality ratings. The features that most highly correlated with ratings of overall lecture quality were the speaker’s abilities to identify key points (r=.797) and be engaging (r=.782), the lecture clarity (r=.754), and the slide comprehensibility (r=.691) and format (r=.660). The three lecture features of engaging the audience, lecture clarity, and using a case-based format were identified through regression as the strongest predictors of overall lecture quality ratings (R2=0.67, P=0.0001). CONCLUSIONS: We have identified core lecture features that positively affect the success of the lecture. We believe our findings are useful for lecturers wanting to improve their effectiveness and for educators who design continuing medical education curricula.

Clinical teaching in the ambulatory setting

THERE IS a widespread need to improve clinical teaching in general, especially in the ambulatory setting, v3 This applies to teaching in both hospital wards and clinics, for residents and medical students. A major issue for clinical teaching is that conventional strategies do not appear to be applicable. For example, the lengthy lecture, which is used ubiqui tously throughout medical school, has little place in clinical teaching. In this position paper I propose an instructional approach based on a model of learning as conceptual change. The model is derived from both phi losophy of science and cognitive psychology (particularly constructivist psychology) and is focused on cognitive structures (involving understanding) rather than cognitive abilities. This model has implications for improving clinical teaching in general, but it is particularly per t inent in ambulatory settings, where senior clinicians (attending physicians) f requent ly teach students and residents on a one-to-one basis.

Making the continuing medical education lecture effective

&NA; Although the lecture appears to be synonymous with continuing medical education (CME), the effectiveness of lecture‐based CME remains in question. Despite conflicting data, the lecture continues to be widely used in the delivery of CME. This study was conducted to identify the attributes of an effective medical lecture and to assess the impact of a computerized audience response system (ARS) in a large CME course. Data were prospectively collected over 3 years from physicians participating in an intensive review of an internal medicine course. Features of the effective medical lecture and the use of a computerized ARS in facilitating learning were assessed with a study‐designed questionnaire. The most important features of the effective lecture included clarity and visibility of slides, relevance of material to the audience, and the speakers ability to identify key issues, engage the audience, and present material clearly and with animation. More than 85% of respondents felt that the ARS facilitated teaching clinical reasoning and medical facts and helped maintain alertness and identify their weaknesses. Lectures using ARS were statistically significantly better rated than those not employing it. These data identify specific attributes of the effective medical lecture that faculty can use to optimize teaching in CME courses. ARS technology improves the perceived effectiveness of the medical lecture and may facilitate learning, especially with large audiences.

RADPED: an approach to teaching communication skills to radiology residents

Background: The Accreditation Council for Graduate Medical Education mandates that radiology residency programs teach communication skills to residents. Objective: The purpose of this paper is to present a mnemonic, RADPED, that can be used to enhance communication in the radiology setting. It reminds the resident of the salient points to address during an imaging encounter with pediatric patients and their families for the purpose of enhancing communication. Materials and methods: Recent history and research in medical communication are reviewed. Various communication guides used by primary care physicians, such as SEGUE, and the Kalamazoo consensus statement are discussed. This methodology was adapted into a format that could be used to teach communication skills to radiology residents in the context of an imaging encounter. Results: RADPED reminds the resident to establish rapport with the patient, ask questions as to why the patient and family are presenting for the study, discuss the exam, perform the procedure, use exam distractions, and discuss the results with the referring physician and family when appropriate. This guide is available with movie clips as part of an on-line pediatric radiology curriculum, http://www.pediatricradiology.clevelandclinic.org. Summary: This simple memory aid promotes the key points necessary to optimize the radiology resident’s encounter with pediatric patients and their families.

Reflection in Clinical Teaching: An Analysis of Reflection-On-Action and Its Implications for Staffing Residents

In order to improve clinical teaching in the ambulatory care setting, clinical teachers need to know the range of instructional strategies available to them. One potentially useful strategy is that of reflection. In this paper, reflective practice will be described in the context of the professional training of physicians, with the purpose of improving clinical teaching. An example of reflective practice--a transcript of a video tape of an attending physician and a resident in a general internal medicine clinic--will be analyzed. In this transcript, reflective comments by both the attending physician and resident are integrated into the original dialogue.

Evaluation of Resident Performance in an Outpatient Internal Medicine Clinic Using Standardized Patients

Objective: To observe and evaluate the performance of primary care internal medicine residents within the outpatient clinic milieu.Design: Longitudinal descriptive study.Patients/participants: 48 internal medicine resident encounters with two standardized patients at the University of Wisconsin General Internal Medicine Clinics.Intervention: Residents were rated by the standardized patients with a medical skills checklist and an interpersonal skills checklist, and by the staffing physician with a clinical reasoning skills checklist. The investigators reviewed audiotapes of the standardized patient encounters for strategic management skills.Main results: Resident performance on these scales was examined for improvement with years of training; when considered separately, no such effect was seen for either standardized patient case. When the cases were grouped together, however, there was significant improvement on the Clinical Reasoning Instrument. The grouped standardized patient data were compared with data from inpatient faculty evaluations of the residents. Faculty evaluations correlated with standardized patient evaluations of resident performance only on the medical checklist. Finally, comparison of the four assessment scales demonstrated a significant correlation between interpersonal skills, as assessed by the patient, and strategic management skills.Conclusion: Resident outpatient performance, measured in a blinded setting, does not improve with year of training. Faculty inpatient assessments of residents correlate with medical “thoroughness” as measured by a medical skills checklist, and interpersonal skills as rated by standardized patients correlate with resident use of strategic medical management.

Patient education through teaching for conceptual change

SummaryIt is not enough for clinicians to gather good patient information and then dictate management plans. If patient education is to be successful, attention must be paid to tailoring educational input to the patient’s particular needs. If the conceptual change approach is followed, patient differences due to factors such as age and culture will be taken into account. Likewise, the different types of patient education described earlier can be accommodated, since the patient and his or her particular needs are always the focus of all medical conversations. The conceptual change approach for patient education potentially can help clinicians avoid the temptation to ignore patients’ perspectives and provide instruction tailored to patient needs, thereby reducing the possibility of educational negligence.

Teaching the Medical Interview: Methods and Key Learning Issues in a Faculty Development Course

OBJECTIVETo describe the American Academy on Communication in Healthcare’s (AACH) Faculty Development Course on Teaching the Medical Interview and report a single year’s outcomes.DESIGNWe delivered a Faculty Development course on Teaching the Medical Interview whose theme was relationship-centered care to a national and international audience in 1999. Participants completed a retrospective pre-post assessment of their perceived confidence in performing interview, clinical, teaching, and self-awareness skills.PARTICIPANTS AND SETTINGA total of 79 participants in the 17th annual AACH national faculty development course at the University of Massachusetts Medical School in June 1999.INTERVENTIONA 5-day course utilized the principles of learner-centered learning to teach a national and international cohort of medical school faculty about teaching the medical interview.MEASUREMENTS AND MAIN RESULTSThe course fostered individualized, self-directed learning for participants, under the guidance of AACH faculty. Teaching methods included a plenary session, small groups, workshops, and project groups all designed to aid in the achievement of individual learning goals. Course outcomes of retrospective self-assessed confidence in interview, clinical, teaching, self-awareness, and control variables were measured using a 7-point Likert scale. Participants reported improved confidence in interview, clinical, teaching, and self-awareness variables. After controlling for desirability bias as measured by control variables, only teaching and self-awareness mean change scores were statistically significant (p < .001).CONCLUSIONSThe AACH Faculty Development course on Teaching the Medical Interview utilized learner-centered teaching methods important to insure learning with experienced course participants. Perceived teaching and self-awareness skills changed the most when compared to other skills.