Patricia A. Kritek

Training the Teachers. The Clinician-Educator Track of the University of Washington Pulmonary and Critical Care Medicine Fellowship Program

The University of Washington was the first pulmonary and critical care medicine fellowship training program accredited by the Accreditation Council for Graduate Medical Education to create a dedicated clinician-educator fellowship track that has its own National Residency Matching Program number. This track was created in response to increasing demand for focused training in medical education in pulmonary and critical care. Through the Veterans Health Administration we obtained a stipend for a clinician-educator fellow to dedicate 12 months to training in medical education. This takes place predominantly in the second year of fellowship and is composed of several core activities: fellows complete the University of Washingtons Teaching Scholars Program, a professional development program designed to train leaders in medical education; they teach in a variety of settings and receive feedback on their work from clinician-educator faculty and the learners; and they engage in scholarly activity, which may take the form of scholarship of teaching, integration, or investigation. Fellows are guided throughout this process by a primary mentor and a mentoring committee. Since funding became available in 2009, two of the three graduates to date have successfully secured clinician-educator faculty positions. Graduates uniformly believe that the clinician-educator track met their training goals better than the research-based track would have.

Strategies for Effective Feedback

Provision of regular feedback to trainees on clinical performance by supervising providers is increasingly recognized as an essential component of undergraduate and graduate health sciences education; however, many individuals have not been formally trained in this pedagogical skill. At the bedside or in the clinic, effective performance feedback can be accomplished by following four key steps. Begin by setting expectations that incorporate the trainees personal goals and external objectives. Delineate how and when you will provide feedback to the learner. Next, directly observe the trainees performance. This can be challenging while engaged on a busy clinical service, but a focus on discrete activities or interactions (e.g., family meeting, intravascular volume assessment using bedside ultrasound, or obtaining informed consent) is helpful. The third step is to plan and prioritize the feedback session. Feedback is most effective when given in a timely fashion and delivered in a safe environment. Limit the issues addressed because learners often disengage if confronted with too many deficiencies. Finally, when delivering feedback, begin by listening to the trainees self-evaluation and then take a balanced approach. Describe in detail what the trainee does well and discuss opportunities for improvement with emphasis on specific, modifiable behaviors. The feedback loop is completed with a plan for follow-up reassessment. Through the use of these relatively simple practices, both the trainee and teacher can have a more productive learning experience.

Family presence during cardiac resuscitation.

c ase vignet te Roberta is a 72-year-old woman with hypertension and chronic obstructive pulmonary disease who has smoked for the past 50 years. She is admitted to the inpatient medical service after 3 days of progressively worsening fever, chills, and productive cough. On presentation to the emergency department, her temperature is 38.4°C (101.2°F), her heart rate is 110 beats per minute, and her blood pressure is 105/62 mm Hg. The respiratory rate is 26 breaths per minute, and the oxygen saturation while she is breathing ambient air is 86%. Chest radiography reveals an infiltrate at the right lung base consistent with pneumonia. She receives ceftriaxone and azithromycin, an intravenous saline solution, and supplemental oxygen through a nasal cannula. By the time she arrives at the inpatient unit, her heart rate has slowed to 86 beats per minute, the respiratory rate is 20 breaths per minute, and the oxygen saturation is 96% while she is breathing 4 liters of supplemental oxygen. As her attending physician, you confirm with the patient that she wants to receive aggressive medical therapies, including cardiopulmonary resuscitation, if her medical condition deteriorates. The following morning, Roberta’s nurse notices that the pulse-oximetry readings have declined abruptly to 70%. When she enters Roberta’s room, the nurse is unable to arouse the patient in response to verbal stimulus or sternal rub. She cannot detect a radial or carotid pulse. She calls loudly for help and activates the cardiacarrest alert system. Chest compressions are initiated, and within 60 seconds the medical response team has arrived. At this moment, the patient’s husband and two children enter the inpatient unit. Verifying that the code team has sufficient personnel for the moment, you step out of the patient’s room and inform the family that Roberta’s condition has deteriorated rapidly and that she is currently receiving cardiopulmonary resuscitation. After conveying this information to the family, you consider whether to ask the family members to remain with a social worker in the family waiting room, where they will be given frequent clinical updates from the care team, or to invite the family into Roberta’s room to observe the resuscitation. Which one of these approaches to the broader issue do you find appropriate? Base your choice on the published literature, your own experience, and other sources of information.

Teaching at the Bedside. Maximal Impact in Minimal Time.

Academic physicians encounter many demands on their time including patient care, quality and performance requirements, research, and education. In an era when patient volume is prioritized and competition for research funding is intense, there is a risk that medical education will become marginalized. Bedside teaching, a responsibility of academic physicians regardless of professional track, is challenged in particular out of concern that it generates inefficiency, and distractions from direct patient care, and can distort physician-patient relationships. At the same time, the bedside is a powerful location for teaching as learners more easily engage with educational content when they can directly see its practical relevance for patient care. Also, bedside teaching enables patients and family members to engage directly in the educational process. Successful bedside teaching can be aided by consideration of four factors: climate, attention, reasoning, and evaluation. Creating a safe environment for learning and patient care is essential. We recommend that educators set expectations about use of medical jargon and engagement of the patient and family before they enter the patient room with trainees. Keep learners focused by asking relevant questions of all members of the team and by maintaining a collective leadership style. Assess and model clinical reasoning through a hypothesis-driven approach that explores the rationale for clinical decisions. Focused, specific, real-time feedback is essential for the learner to modify behaviors for future patient encounters. Together, these strategies may alleviate challenges associated with bedside teaching and ensure it remains a part of physician practice in academic medicine.

A Collaborative Critical Care Preceptorship for APRN Students

Advanced practice registered nurses (APRNs) increasingly are caring for critically ill patients as a part of interprofessional teams, but new APRNs may have limited critical care exposure in their training. We created a 12-week critical care preceptorship for APRN students as well as a curriculum composed of daily case-based teaching. Student assessment methods included direct observation, pretests and posttests of critical care knowledge, and presurveys and postsurveys of perceptions about critical care skills. The average score on the knowledge pretest was 50% and increased to 74% on the posttest (N = 10). Students reported increased comfort in several aspects of managing critically ill patients after the preceptorship. Descriptive feedback noted that the preceptorship is distinctive, comprehensive, and focused on student education. The evolving intensive care unit will have increasing numbers of APRNs, and a collaborative preceptorship can improve critical care know-ledge and perceptions of critical care skills in APRN students.

A Conceptual Framework for Applying the Anticipatory Theory of Complex Systems to Improve Safety and Quality in Healthcare

Effective anticipation is a fundamental characteristic of highly reliable organizations. In Rosen’s anticipatory theory of complex systems, all living systems and virtually all other complex systems require anticipatory models to maintain an organized state. This paper provides an overview of Rosen’s anticipatory theory of complex systems and presents a conceptual framework for applying this framework to improve safety and quality in healthcare. Organizational interventions based on this theory could include education of clinicians, patients, and families on how anticipatory complex systems function and improve safety in clinical environments, and systems interventions to promote optimal concordance between a team’s model of a clinical situation and the actual clinical situation. Enhanced general understandings of anticipatory complex systems and of their failure modes could help reduce communications failures that are a common cause of serious adverse events.

Family Support During Resuscitation: A Quality Improvement Initiative

&NA; Background Despite increasing support for family presence during cardiopulmonary resuscitation, a review of the literature revealed no published protocols or training curricula to guide hospitals in implementing a family support provider role. Objectives To develop a curriculum and train dedicated resuscitation team members whose role is to provide family support during in‐hospital resuscitation events. Methods An interdisciplinary team developed a 4‐hour training session for the family support staff. The session included an introduction to the evidence for family presence during resuscitation and local data on resuscitations. The training was composed of 4 sections: (1) clinical aspects of resuscitation, (2) integration into the resuscitation team and steps for providing family support during resuscitation, (3) responding to families in distress, and (4) self‐care practices. Before and after the training session, the participants completed surveys of self‐rated knowledge and attitudes toward family presence during resuscitation. Results Fifty‐nine social workers and 8 spiritual care providers were trained in 2015. There was a signifi cant increase in all rated aspects of knowledge of the family support role and self‐care strategies. Conclusion Through the creation of an interdisciplinary curriculum, an institution can effectively train health care providers in a new resuscitation team role: the family support provider. (Critical Care Nurse. 2017;37[6]:14‐23)

ICU Emergencies Simulation Curriculum for Critical Care Fellows: The Difficult Airway

Introduction Management of airway emergencies is a core skill for critical care fellows. There is no standardized training mechanism for difficult airway management among critical care fellowships, although fellows frequently cite management of airway catastrophes as an area of educational need. Methods Three simulation cases that are each approximately 15 minutes in length are presented. The cases represent airway emergencies encountered in the intensive care unit consisting of angioedema, endotracheal tube dislodgement, and endotracheal tube occlusion. Incorporated into the scenarios are planned incidents of interpersonal conflict requiring negotiation by the learner during a crisis event. The case descriptions are complete, with learning objectives and critical actions as well as all necessary personnel briefs and required equipment. Results The cases were completed over multiple simulation sessions on different days by 11 first-year critical care fellows during the 2016–2017 academic year. All participants demonstrated improvement in self-perceived confidence in airway management skills. Discussion The cases were felt to be realistic and beneficial and led to perceived improvement in management of airway emergencies and leadership during crisis scenarios.

Implementation of a Coaching Program for Peer Feedback on Large-Group Teaching

Teaching is an essential part of being an academic physician. Although teachers routinely receive learner evaluations, there are limited faculty development programs on teaching skills (1), and meaningful peer feedback is rare. Peer evaluation has been increasingly implemented in residency programs, resulting in changes in teaching behavior (2) and an increased awareness of peer feedback as a critical professional skill (3). Previous peer teaching assessment programs have resulted in faculty appreciation for the opportunity for structured discussion about their teaching and perception of an improvement in the quality of their teaching (4). Written peer feedback for faculty resulted in improved content and structure of talks, including items such as a statement of goals and a conclusion (5). University ofWashington Pulmonary and Critical CareMedicine (PCCM) faculty members deliver talks at a weekly core teaching conference attended by 20 to 30 PCCM fellows and faculty. Previously, PCCM faculty only received anonymous evaluations from peers for use in their teaching portfolios for promotion and tenure. These evaluations were primarily summative, with little constructive feedback for future teaching sessions. An in-person coaching system for PCCM faculty was implemented in 2011 to promote peer feedback and improve teaching skills in a large group setting.

How to Give a Great “Chalk Talk”

Learners are most likely to retain knowledge acquired through active engagement with the teacher and the content. “Chalk talks” incorporate principles of active learning and are inherently engaging for learners. In this instructional method, the teacher highlights key content by writing and illustrating on a chalkboard, whiteboard, or other large surface throughout the presentation. This technique incorporates learner contributions, thereby promoting a shared ownership of the content and learning environment. This format also encourages peer-to-peer instruction and group learning, as opposed to the traditional “teacher-to-student” model. The sections below prepare clinical teachers to give effective chalk talks.