Show Notes

Description

Dr Bethany Panchal visits the studio as we consider teaching medical learners in busy clinical environments. The current state of medicine demands increased productivity. How can we best meet this demand without sacrificing meaningful teaching and quality patient care? Tune in to find out!

Topic

Clinical Teaching in a Busy Practice

Learning Objectives

At the end of this activity, participants should be able to:

1. Describe strategies for creating psychologically safe, team-based learning environments.
2. Apply efficient teaching and precepting models during real-time patient care.
3. Analyze methods for integrating competency-based education and assessment into clinical practice.
4. Evaluate approaches for balancing learner autonomy with patient safety.

FD-ED Credit

This episode is approved for FD-ED credit through the Center for Faculty Development at Nationwide Children’s Hospital. FD-ED credit expires 3 years from this episode’s release date.

Claim FD-ED credit here! 

Guest

Dr Bethany Panchal
Family and Community Medicine
The Ohio State University College of Medicine

Links

Center for Faculty Advancement, Mentoring, and Engagement

Training Future Family Physicians to Become Master Adaptive Learners
ACGME Program Requirements for Graduate Medical Education in Family Medicine
Excellence in Medical Education Series
Graduate Medical Education in Family Medicine
Graduate Medical Education in General Surgery
Graduate Medical Education in Pediatrics
Graduate Medical Education in Psychiatry 

Previous Episodes with FD-ED Credit

Mentorship and Coaching in Academic Medicine – FAMEcast 001
Teaching on a Busy Clinical Service – FAMEcast 007
The Evolving Role of Artificial Intelligence in Medical Education – FAMEcast 009
Creating Safe, Impactful Space… for Medical Learners! – FAMEcast 016
Tips and Tricks for Giving an Engaging Presentation – FAMEcast 017ert

Episode Transcript

[Dr Mike Patrick]
This episode of FAMEcast is brought to you by the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine.

[MUSIC]

[Dr Mike Patrick]
Hello, everyone, and welcome once again to FAMEcast. We are a faculty development podcast from the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine.

I want to welcome all of you to the program. This is Dr. Mike. I am coming to you from the campus of Ohio State. It’s episode 18. We’re calling this one Teaching Medical Learners in Busy Clinical Environments. I want to welcome all of you to the program.

We are so happy to have you with us. You know, pressure continues to rise for clinical productivity, and that’s not surprising given that healthcare organizations are businesses with very high overhead, and there are typically more patients seeking care than capacity in today’s systems. This means we have to increase our efficiency to see and treat more patients and families, and yet our responsibility to educate medical learners remains essential.

What strategies can we employ to see patients efficiently without sacrificing the quality and impact of our teaching and while also keeping patients safe? Well, in this episode of FAMEcast, we are going to explore practical tips and tools for building meaningful teaching into clinical environments that happen to be busy without compromising patient care. Of course, in our usual FAMEcast fashion, we have a terrific guest joining us in the studio to discuss the topic, Dr. Bethany Panchal. She is a family physician at The Ohio State University College of Medicine. This episode of FAMEcast is also available for FDED credit. So, if your institution or department requires faculty development education credit, also known as FDED, we have good news for you.

Select episodes of FAMEcast, including this one, ones that deal with teaching and learning, do come with FDED credit from the Center for Faculty Development at Nationwide Children’s Hospital. It’s easy to claim that credit. Simply listen to the podcast, which you are about to do.

Look for the FDED link in the show notes over at FameCast.org and follow that link to Cloud CME. You’ll need to register or sign into your free account and then take a brief survey. It’s in the materials tab and then you will get the FDED credit.

You can even download a transcript of your credits to share with your institution or department. Some previous episodes with that same credit, we did one on mentorship and coaching, teaching on a busy clinical service that was more focused on inpatient teaching, whereas today we’re going to talk more about outpatient teaching, the evolving role of artificial intelligence in medical education, creating safe, impactful space for medical learners, and tips and tricks for giving an engaging presentation to learners.

Those are all past episodes with that FDED credit, and we will put links to all of those in the show notes for this episode 18 over at FameCast.org. We also have some additional resources I want you to know about because I’m going to reference them a little bit in today’s episode, but just so you have some idea ahead of time. If you head over to FameCast.org, up at the top of the page you’ll find a resources tab and there are two links to faculty development modules on Scarlet Canvas. One is a group of modules that solely focus on advancing your clinical teaching and then another group is faculty development for medical educators. Again, those are all available over at FameCast.org. Again, just click the resources tab up at the top of the website here at FameCast.org and that’ll take you right over there to it. And we’ll put links in the show notes again as well because there’s just scores of learning modules there. And as we talk about clinical teaching, I just wanted to make sure you know that those resources are available right here at the get-go. So, let’s go ahead and take a quick break.

We’ll get Dr. Bethany Panchal settled into the studio and then we will be back to talk about teaching medical learners in busy clinical environments. It’s coming up right after this.

[MUSIC]

[Dr Mike Patrick]
Dr. Bethany Panchal is Director of the Family Medicine Residency Program and an Associate Professor of Family Medicine at Ohio State. She has been a leader in graduate medical education for the past 15 years, teaching residents in a busy full-spectrum practice that includes obstetrical care. So, what then are the strategies that she uses to integrate learners in a busy clinical environment? Well, you are about to find out because that is what she is here to talk about.

But before we dive into the conversation, let’s offer a warm FAMEcast welcome to our guest, Dr. Bethany Panchal. Thank you so much for stopping by the studio today.

[Dr Bethany Panchal]
Yeah, thank you so much for having me. I really appreciate being able to come out here and talk with you guys.

[Dr Mike Patrick]
I’m really looking forward to this conversation for a couple of reasons, which I think will become clear as we move along. But you know, when we think about the learning environment for residents, really in any specialty, traditionally it’s been focused mostly on inpatient care. Like residents are learning in a hospital environment and a lot of times it’s inpatients.

And in the past, there’s always just been, okay, you ought to also have like an outpatient clinic that you go to once a week or whatever. But more and more, we are putting residents in outpatient settings, which is important, but it also slows things down and we know that the outpatient setting has a little bit of a lower profit margin, so to speak. And so, you kind of have to move people through and yet we want it to be a good learning environment.

So, you know, what are the reasons that this is such an important thing to talk about? I think I’ve teed you up pretty well for it.

[Dr Bethany Panchal]
Yeah, absolutely. No, I think that’s such a great point that it’s interesting because I think some of the feedback we get after residents graduate and stuff is like, you know, the inpatient stuff was great, but I’m not doing that at all, you know, especially in family medicine, you know, I think 90% of our graduates end up doing all outpatient care. So, I think we’ve done a good job in family medicine of really trying to keep the focus, a lot of focus on outpatient setting because that is what they’re going to be doing when they graduate for the most part.

I mean, obviously the inpatient side of things is really super important as well, but, you know, often that’s not what they’re going to end up doing for the rest of their career. And so, giving them those skills in the outpatient setting I think is really, really important.

[Dr Mike Patrick]
Yeah, and there is kind of a line that we’re, you know, walking across very tightly in terms of being able to move patients because we want patient satisfaction, we want folks to be seen, and that teaching part of it. So, how do you balance, you know, being in a busy clinic but also learning?

[Dr Bethany Panchal]
Yeah, I mean, such a great question and trying to get that balance there. You know, there’s a lot of different ways that we can do that. A lot of it is, you know, direct teaching during that direct clinical care and finding those opportunities.

And for faculty, a lot of it is about role modeling as well, the skills and the clinical reasoning, you know, being aware of what’s happening as faculty. You know, we are a key part of keeping things moving in the practice and recognizing that our residents might get, you know, caught in a room and a patient who is either very complex or just has lots and lots of questions and our residents haven’t developed that skill of, you know, creating an agenda and helping to stick to it. So, that’s our job as faculty to kind of being aware of what’s happening with the resident, with the patient, and kind of intervening when we need to, but also recognizing that, like, yeah, you need to teach, but sometimes that teaching needs to be done in a more efficient manner than maybe you would do on an inpatient setting where you have a whole half-hour time to do the teaching.

[Dr Mike Patrick]
And I suspect there’s little tips and tricks that you share with residents, you know, just as an example, sitting down in the room if there’s a stool rather than standing up makes it feel to the patient like you’ve been there longer than you actually have. Like, I had time to sit.

[Dr Bethany Panchal]
There’s actually, like, studies proving that. It’s really interesting.

[Dr Mike Patrick]
Yeah, yeah. So, as part of, you know, we want to definitely do a good job. We want our clinical care to be excellent, but we also want our learners to learn, and sometimes those things don’t always add up, and it can be difficult for sure.

Yeah. We also want the learning environment to feel safe for our residents, especially if, you know, maybe they don’t understand a particular thing, or they need to look something up, or they’re consulting, you know, the faculty member. How can we make sure that the clinic time remains patient-centered, team-based, but also psychologically safe?

[Dr Bethany Panchal]
Yeah, I like, yeah, like that term psychological safety is so important when it comes to learners, you know, in general. So, what that is, is it’s an environment that really needs to be adaptable to that learner’s level of knowledge, right, and what their skill and what their needs are. It really needs to be a place where the learner, the resident, they believe they can ask questions.

They can admit their uncertainty. They can report errors and raise concerns, and the keys here are that there’s no concerns. They can do that without fear of humiliation, retaliation, or negative impact on their actual evaluation.

So, things that we can do as attendings to help with this is, again, modeling that uncertainty. I am the first person to admit to them sometimes that I don’t have all the answers, and that’s okay, but we can look things up together, and I think that really helps with that just modeling of, like, you know what, you don’t have to have all the answers because I don’t have all the answers, and I’ve been doing this for 20 years, and then framing mistakes as, like, learning opportunities, you know, and separating it from that summative evaluation that we give these residents at the middle of the year and in the end of the year. Huddling before clinic, you know, that can be really helpful, reminding the whole team that anyone can pause for safety concerns, and then faculty development.

I think faculty development is very important, you know, addressing biases, microaggressions, the power hierarchy of supervision, and just making faculty aware and really giving them that knowledge of what it is to create these safe environments because learners, you know, they need to know that they’re allowed to learn, they’re allowed to make mistakes while still providing that safe patient care because they are being supported, you know, by the faculty and by the clinic and that structure that we have set up for them, and really all the team members need to be engaged with this because, you know, yeah, the research will show, you know, that the learners feel safe, they are optimized for higher quality and engagement in the learning and greater satisfaction and well-being, actually, and then, of course, down the road, it’s a trickle-down effect if they’re safe, they’re going to speak up, it’s going to strengthen the team communication, which leads to more patient-centered decisions and safer care.

[Dr Mike Patrick]
Yeah, absolutely, and I love the fact that you brought faculty development into this because, as physicians, we really are lifelong learners, and there’s so many more opportunities on the humanistic side of medicine compared to the technical side, just in terms of how we get along with other people, how we use emotional intelligence and contextual intelligence that we’ve talked about before in this program, and so as we learn more about those skills in ourself, modeling them and teaching them in the clinic is really a great way that faculty development certainly impacts faculty, but it really impacts trainees as well as we pass on the knowledge that we’re learning to them. Have you seen that in action?

[Dr Bethany Panchal]
Yeah, yeah, for sure, you know, I think we’ve done a great job, I think, at our program, and I can’t take any credit for it because it was in place before I became program director, but we have faculty development scheduled quarterly and it’s a half day, so like this is a time period, three hours our faculty are able to come together, we try to provide, you know, development on the things that are really key for how do we keep our residents, you know, what’s great for developing the faculty, but also keeping them teaching and doing a good job and teaching them well, the residents, you know, how to give feedback, what, how do you create a safe environment and giving these direct observations and things like that, and if we’re not teaching, it’s not, sometimes it’s not intuitive for everyone, and I would say most anyone, you really need to have these skills taught to you and developed over time.

[Dr Mike Patrick]
Yeah, and there’s a skill too, I keep, I know I keep mentioning this, but all of these things that we want to get across and teach and really encourage our trainees to be the best that they can be, all of these things do take time, and so that busy clinical schedule can be a disruption, so how can we best integrate residents into those clinical workflows without disrupting the flow and the care?

[Dr Bethany Panchal]
Yeah, I like that a lot, and I think it’s really important to kind of give the resident the ownership of the clinic, ownership of the patient. It, I think if the resident feels like this is just something that they have to do and see these patients that they don’t know who these patients are, they’re not going to be as engaged and the workflow is not going to be as efficient, right, but if we give these residents the ownership and acknowledge them as being part and very crucial part of the team of that clinic, that’s going to be a way that we can really keep the workflow going and keeping the residents integrated. So I’ll give you an example, and this is happening in family medicine in general, but in our clinic, we give our residents their own panel of patients, okay, these are their patients, and from day one, July 1st, when we start our residents, they have a panel of about 100 patients, and it grows over time in their three years, and, you know, we try to keep those patients coming in to see them as often as we can and vice versa so that the resident’s seeing their patients, the ownership, and that really does help with that flow of the clinic because it’s integrating that resident there, and then that’s how we can engage them. Other ways we can engage with residents is the running of the clinic, you know, this is a great opportunity to teach them and engage them in quality improvement, practice management, patient safety, workflow, redesign, these are the things that they’re going to need to know how to do once we’re done teaching them in residency, and they’re independently practicing, and so teaching them now while they’re in residency is really, really important.

[Dr Mike Patrick]
Yeah, yeah, for sure, and I would imagine that when they have a panel of patients like that, it does save time because there’s continuity of care, like they know what’s been done in the past, we don’t have to get the extended history like from a brand-new starting point every single time.

[Dr Bethany Panchal]
Exactly.

[Dr Mike Patrick]
Yeah, and that’s going to build some efficiency, and that may be more difficult in subspecialty clinics, you know, where you’re seeing folks, you know, who are coming in for a very specialized reason, and you might not see them again, or you only see them a couple times, so we may have to get creative in terms of how we can improve efficiencies there. One way that I was thinking is, you know, medicine today more than ever is a team sport, and so we have a lot of interprofessional teams, members that can do some things that maybe traditionally physicians had done that would make it take longer for that visit, and I’m thinking about like social issues, nutrition, have other team members from different professions that are interacting with the residents and can sort of help with those efficiencies a little bit.

[Dr Bethany Panchal]
Yeah, yeah, that is a really good point, because it’s not one of those solo sports, you know, we definitely have to be part of a team, and as physicians, you know, kind of helping to how to be a leader of that team as well and managing that team. So, yeah, in our particular clinic, we are able to have those interprofessional staff with us, you know, we have pharmacists, we have social workers, we have our own psychologists and care managers, and I think one of those things that we really need to acknowledge is that as, I think as physicians, we want to make sure we’re doing everything that we can for these patients, but, you know, we can’t do it alone, we got to have the team with us, and so part of that with a resident clinic is really teaching from day one, like this is how, you know, this is who this person is and what they can do for you, and let’s, you know, bring them in with this patient, because yeah, they’re having housing insecurity, you’re not going to fix that alone on your own, but here’s somebody that’s in our clinic that might be able to help us with this, and overall, that’s going to be great for the patient care. Pharmacy is a great example of that, like we have an awesome pharmacist in our clinic, and she helps co-manage almost all of my diabetic patients, and I’m like, I can’t, I don’t have the time to bring them in with me every week that we need to do adjustments in their insulin or not, but she can, you know, she can help me with that, and so it’s really a co-managing thing, and modeling that as a faculty member I think is important, but also just showing the residents, like hey, you don’t have to do this alone, like we have these team members here, and you can learn so much from them as well, and making sure that they’re recognizing that too.

[Dr Mike Patrick]
I have always loved engaging with other professions within medicine to help, and I learned so much from them, so you know, I’m an emergency medicine doc over at Nationwide Children’s Hospital, and we have a pharmacist in the ER 24-7, and you know, and of course social work is an integral part of what we do, and so just having those other team members, I agree, is so important, and I always encourage residents to engage with them as much as possible, because there’s a lot of learning to do, and you know, they are looking at things from a slightly different lens, and it’s always good to be aware of that.

[Dr Bethany Panchal]
Yeah, and I think it’s also, you know, we got to be aware, we have 20 minutes with this patient, maybe, because you know, by the time they get roomed and everything, we have a very limited amount of time, and so we’re not going to be able to address all the issues, and we have to have these team members. We just, we really can’t function without them.

[Dr Mike Patrick]
Yeah, yeah, and unfortunately, in a lot of outpatient settings that folks then, when they’re done with their residency, will go into, they may not have those resources, but maybe they will have liked them so much that they’ll really push for them, you know, wherever it is that they end up.

[Dr Bethany Panchal]
And maybe they learned, you know, they learned from them, kind of the skills that they can take with them, hopefully.

[Dr Mike Patrick]
Now, in a teaching environment, there is an extra step that takes some time that is not present in, you know, once you’re out and practicing on your own, and that is really precepting. So, you know, a resident sees a family, they then go to the attending, sort of present what the case is, what it is that they want to do, what their plan is, and so there’s that extra step there of just sort of ensuring, and especially when folks are early on in their training. So, you know, if they’re interns, you’re going to spend more time with that.

Hopefully, by the time that they’re in their final year of residency, that’s not taking nearly as much time. What are some tips and tricks to precepting in an efficient manner? I know there are several of them, and I would encourage folks to check out the FAME program.

We’ll have a link to the Center for Faculty Advancement, Mentoring, and Engagement in the show notes. There’s a lot of modules that we have over there on teaching. And so, what are some of the ways that we can do it efficiently?

Like, get a lot of info across, but in a short amount of time.

[Dr Bethany Panchal]
Yeah. Well, you know, I think, again, there’s the faculty development, I think is so important in teaching these skills of how to do this efficiently. There are a lot of teaching models and a lot of precepting models that are out there, but, and help to maintain that efficiency, right?

But one particular method that I think is, can be intuitive, we might not know that we’re actually following a model, is called the one-minute preceptor. You know, in a busy clinic, you know, we got to keep things moving. And so, the one-minute preceptor model is, it’s simple and effective, and it can be used in a variety of settings in the ER or in the outpatient setting.

But it consists of these five micro skills, which some teachers, again, they may do it intuitively, but it’s actually kind of laid out in this model. So, you know, the first one is, you know, get a commitment. What are they thinking?

What is the resident thinking that’s going on with this patient? And what do they want to do? And then probing for supporting evidence.

Why do they think that this is what’s happening? And what is the evidence behind that? And then three, teaching some general roles.

So, this is kind of an opportunity for the preceptor to fill in the gap in that resident’s knowledge base. But you got to keep this kind of information general and avoiding any anecdotal things. You know, like, oh, I saw this patient one time, you know, 10 years ago, and this is what it was.

But so that’s not really important in this kind of thing. But also, if this is a third-year resident, and they’re, you’re like, you just hit that, hit it out of the park, you can skip this, you know, you can skip this stage. And then the fourth skill there is reinforcing what that learner got right.

So, giving that positive feedback, it builds that self-esteem and allows the learner to grow. Focusing on a specific behavior, you know, that was observed. And then kind of trying to avoid that general praise, you know, that like, oh, good job, you know, like, that’s, that’s not helpful.

And then fifth is correcting any mistakes. So, here, you know, it’s important, you got to be tactful but really direct with providing this correction. You know, what is that specific deficit?

What is that specific thing that they did that maybe was a mistake? Or they didn’t think about this diagnosis that’s a don’t miss diagnosis or something, you know? And then why is it not correct?

And then move on from there. And I think that’s a really kind of just simple model that we say it’s the one-minute preceptor. I’m pretty sure it probably is going to take a little bit more than one minute, depending on what’s going on, you know, the complexity of the patient and the level of learner.

But I think if you generally can follow those, that, that model, it can be helpful to keep things moving. Yeah, yeah.

[Dr Mike Patrick]
I would imagine that doing something, you know, like that, the one-minute preceptor, is going to be easier if you have a relationship and know the trainee, because you’re going to know what their strengths are, what their weaknesses are. If it’s not someone that you work with on a regular basis, it may be a good idea right at the onset of the clinic to say, hey, you know, what do you want to work on? And just kind of see, you know, what do they want to get out of the clinic experience today?

What are some places in their training that maybe they feel like they could use a little bit more direction, a little more experience with, and they may have questions. And, but again, that takes, you know, being intentional, but really it takes less than five minutes, you know, to have that conversation.

[Dr Bethany Panchal]
It really does. Yeah.

[Dr Mike Patrick]
Yeah. And I think that’s definitely an important, important thing. So how then can we sort of optimize how our clinic runs to make all of this fit together?

You know, how can we optimize the clinic for moving patients through, but also providing teaching time?

[Dr Bethany Panchal]
Yeah. Yeah. Yeah.

That’s a, that’s a question I think that I’m not sure there’s like a solid, like, this is the answer, you know, to, to this, this lifelong question. But, you know, I think keeping, keeping things optimized for the resident learning and kind of being able to keep things going is, is I think a good way is in that continuity context, right? Of giving that resident ownership, you know, what are, what are the ways that, you know, we could really foster that longitudinal continuity patient care over time.

Of course, giving them that, that panel of patients, but also, you know, some of the strategies that we, we use is that panel stability, you know, assigning that panel. So that, that, that first year and then keeping that panel with them and letting them grow it over those three years. Scheduling protection.

I think it’s important that we prioritize these continuity relationships and clinic above all else. And that includes inpatients, you know, call, things like that. So, we, we really try to focus on, there’s this clinic first model that we have in family medicine.

And just to say like, this is your, this is your patient panel. This is your population. This is your clinic.

And you really need to prioritize that. Like we’re going to schedule your inpatient rotations with your continuity clinic in mind and not vice versa, right? It’s not an afterthought.

And then that longitudinal preceptorship, you mentioned that. And I think that’s important. So, we have a core group of faculty who actually practice out of the same clinic as our residents.

And we have our own patients as well. And so, we can model it, but also, you know, we can watch these residents from day one to graduation. And so, given that context of, we can see the trajectory of how they’re going and, you know, the competency that that’s, you know, are they becoming competent?

What’s the entrustment that’s happening with this particular resident? We can see that trajectory. But also, with the patients themselves, you know, I’ve been in my practice for 13 years now and the patients that are being precepted to me, I know better sometimes than the resident does, because even though it’s on their patient panel, just because I’ve been here for so long and this is a patient coming.

And I think that gives a lot of context and helpful support to the resident when they’re seeing that patient.

[Dr Mike Patrick]
You had mentioned competencies and we are sort of migrating to a system of competency-based education where we say, okay, these are skills that you need that are the most important to be a family practice doctor successfully in your future. There are different competencies if you’re an orthopedic surgeon, but really any specialty we can think there are key things that we really want to make sure that are solid, you know, when a person is then done with a residency and is out practicing. How do you ensure that all of those competencies are being met, especially in a clinic where you’re not sure what’s going to come in from day to day?

[Dr Bethany Panchal]
Yeah. Yeah. You know, that’s such a great question because you’re right.

Competency-based medical education and evaluation is really, I mean, I don’t want to say it’s the newest thing because it’s been in, you know, it’s been in education for a really long time. We see it in elementary kids, you know, in elementary school, they’re looking for that competency over time. You know, when you think in medical education, of course, that class, you know, we think about the ACGME, what are the ACGME 6 competencies and what are we looking at there?

And every specialty has their milestones that are a part of those competencies. In family medicine, you know, we’ve come out now with these core outcomes of what are the things we need our family physicians to be competent in. In other words, I, as a program director, can say you can independently practice with, you know, we know that you’re competent in that.

And it really is, you know, we’re in that process of learning what’s the best way to do that. But it really is, you know, it’s training the resident to become proficient in these skills and the knowledge needed to independently practice. That’s what we’re talking about when we’re talking about competencies.

And like you said, every specialty has their own specific things. And the important thing is that it’s not dependent on a timetable anymore. Even though we still say we have three years of residency or five years or however long your residency is, we’re trying to get away from saying it’s a timetable.

It really is based upon that individual resident and their progress toward that competency in that specific area. One of the ways we incorporate it into our clinic is through the direct observations. So, kind of the premise behind this is to provide real-time feedback in the moment directly focused on maybe a specific competency or skill.

It can be molded to fit into each encounter, each level of training. It should only take a minute or two. You know, it could really be folded into that one-minute preceptor model as well.

And kind of what this looks like is that you as a faculty are making sure that you’re observing the skill intentionally, whatever that skill might be. It could be anywhere from you’re watching them actually take the history or, you know, you’re thinking about watching them do a physical exam and what, you know, how that’s going. What is their clinical decision making?

How are they presenting? And these are some of those skills that we’re talking about observing. And then, you know, providing that direct feedback about it.

And then, of course, it’s really important to write it down for that summative feedback mid-year and at the end of the year because what we’re doing is on a trustment scale. And like, okay, this person had to shadow me versus I had to give a little bit of support, a lot of support to a little bit of support. Like, oh, they did this on their own.

You know, I was just there as an observer. Or, you know what, they were modeling this. They were teaching a medical student about this.

That’s how good they are. And that’s how we are in that trustment scale. And so, I think incorporating, you know, that knowledge and kind of like thinking about it that way when you’re in the clinic and you’re precepting will really help us to judge to see where they are on the trajectory of that competency.

[Dr Mike Patrick]
Yeah. Yeah. I always tell residents that it’s what you know is almost not as important as knowing what you don’t know.

[Dr Bethany Panchal]
Yeah. I agree. I agree.

[Dr Mike Patrick]
And then because you’re not going to be safe if you just think you know everything and nobody really can. So, when you do have those things that they’re not quite sure about, all of us, when we’re out in practice, we have to look things up from time to time. Do you incorporate that into the clinic environment?

So, sort of some self-directed learning, hey, you can look this up on up-to-date or you can, you know, there’s lots of more AI tools out there now for looking things up in the clinical setting. But it seems like that’s a really good skill to have. How do you incorporate that sort of self-directed learning during a busy clinic?

[Dr Bethany Panchal]
Yeah, I think that’s such a great point because it’s interesting because especially if they’re in a time crunch, right? They’re feeling the time constraints and that’s when it’s really become important of like encouraging the self-directed learning. I mean, this happens fairly often where they come to me and I can tell, you know, where they are and kind of in their trajectory and they’ll sit down if they’re, it’s funny, an intern, they’re going to try their hardest.

They’re not like, I’m going to look this up, do everything I can beforehand. And then they become a second year, and they think they know a lot, you know, and then they come to me and then they’re just like, what do you think I should do? And I’m like, that’s not how this works, you know?

And, you know, you could be lighthearted and jokey about it, but I think it’s really important to just keep highlighting and like you need to, this isn’t my patient, this is your patient, you know, you need to, how do you look this up? What are some of the resources that you have? Where can you find this information?

Can I tell you the dosage and how many days you’re going to do it for this antibiotic? Yeah, I can because I’ve done it for so long, but I’m not going to because this is something you can look up on your own and you know how to do it. And as a faculty member, just being aware, like, yeah, of course, there’s some time constraints.

Sometimes they need a little more handholding and help with that and kind of recognizing where are they? Are they stressed out? What’s happening with that?

But in general, I think we really do need to be aware of like not handholding too much. Like, okay, yes, you’re asking for my advice, and I can give you the answer right now, but I need to keep myself from doing that, you know, and jumping the gun of like, oh, this is the diagnosis before they even got a chance to say it.

[Dr Mike Patrick]
You know, sometimes it’s faster just to tell a resident, hey, this is what we need to do. And especially when there’s that pressure of there’s a lot of patients in the waiting room and we’re trying to move things through. But your way might not always be the absolute best way for that particular patient.

And we all practice a little bit differently. And so, you know, if I have a resident that wants to do something in a way that maybe I wouldn’t do it, but if they can explain why they want to do it and like it makes sense from a medical standpoint, and it’s not unsafe for the patient, then I’m all for that. I’m all for residents like critically thinking through what they want to do rather than me just telling them what to do.

And that takes, I don’t know, that takes some practice on the faculty members because it’s easier just to say do this.

[Dr Bethany Panchal]
No, I totally agree with you. And I think it takes practice. I think it takes skill and it takes a little bit of trust.

You know, you have to you have to kind of give that autonomy, which is a huge thing for residents, to that that resident and let them, you know, make their decisions. Maybe it’s not the most efficient decision. Maybe it’s not the most cost-effective decision.

But this is something that they need to learn from and to do. And also, you weren’t in the room with the patient. Maybe, you know, maybe you weren’t there for that whole conversation or this is their continuity patient.

This is the fifth time they’re seeing them for this exact thing, and they know what they’ve tried and done, and it hasn’t worked, you know. And so, I think you as a faculty just really need to be flexible and allow them to make and develop their own practice.

[Dr Mike Patrick]
Yeah. Yeah. How then do we balance resident autonomy with keeping things safe?

Like we want them to critically think and come up with a plan, but we want there to be safety in there as well. And then how do we mitigate errors?

[Dr Bethany Panchal]
Yeah. That’s a that’s such a great question. It’s a really, it’s kind of a difficult question to answer because it’s kind of one of those soft skills that we develop as faculty of kind of recognizing when and how much autonomy we can give.

And honestly, it’s actually one of the areas that I get feedback that I get from the residents about faculty that they want more autonomy. And so, it’s like, you know, teaching the faculty what does that actually look like and when can you give it and how do you know you can give it. So, you know, that’s a faculty development thing, but it’s also skills and just something that develops over time.

You know, I can’t expect a brand-new faculty member who is fresh out of residency themselves perhaps to understand that, oh, this third-year resident that you’re precepting, they’re good to go. You don’t have to, like, you know, handhold them, but it’s something that they develop over time. Again, but, you know, me teaching faculty is good as well.

But, you know, what also we need to think about is we need to adjust the autonomy, you know, dynamically depending on the case complexity, the acuity, what does the learner demonstrate that they can perform. You know, they feel safer and they actually feel more autonomous when the expectations are clear as well. So, giving those expectations early on.

So, maybe, you know, clarifying at the beginning of a clinic session what tasks that are on their calendar, on their schedule require direct versus indirect supervision. You know, for instance, yes, this procedure, I have to be there for this procedure, not only because of billing purposes, but also it’s a procedure and I need to make sure that you’re doing it safely versus, you know, you can go in and take care of this hypertensive patient and I don’t need to be there the entire time while you’re talking to them. And then, of course, ensuring that the physician, the attending physician is easily accessible.

Yeah, they want autonomy, but it’s not time for you to, you know, go away. You know, you still have to be around, you still have to be available so that they do have those questions and they need that real-time decision support that you’re there. You know, you need to be able to allow your student that freedom, the resident the freedom to learn and develop their own unique practice as we just talked about, but there are those constraints of ensuring that they’re maintaining that patient safety.

You know, and that’s another reason why longitudinal preceptors is really a good idea because that really helps with that, allowing that more autonomy over time.

[Dr Mike Patrick]
Yeah, yeah. I mean, we really do have to be sort of the safety net as the attending in the clinic and to know enough about what’s going on with each patient that things are heading in the right direction, even if it’s not exactly how I would have would have would have done it. Yeah.

Tools, digital tools that can help us, you know, answer questions. Are there other technologies that that you’re using in clinic to help with, you know, efficiency and to make things go a little better?

[Dr Bethany Panchal]
Yeah, and I think it’s the same things that that’s kind of happening across. I know here at Ohio State we have DAX, you know, which is our new AI scribe. We actually are limiting that for residents.

We have allowed our third years to have DAX. You know, part of that is an efficiency thing. But first of all, they need they we need to know that they can write notes.

We need to know that they can process it and actually look, you know, put down their own ideas and not just like let the computer do it for them. But, you know, there’s other ways to kind of support that self-learning and, you know, embedded in the EMR, there’s those best practices and things that you can look up and all kinds of, you know, medical apps that have can answer these questions for you. You know, open evidence, I think, is a great resource and up to date, a great resource as well.

So, there’s some of the things that I know that we use.

[Dr Mike Patrick]
Yeah. Do you have a lot of templates in your electronic medical record?

[Dr Bethany Panchal]
Yeah. Yeah. Good point.

Yeah. A lot of templating. We have one of our faculty members who was a previous resident with us actually has developed a ton of templates that I think all the residents just like steal from automatically.

And so, you know, that really helps with just kind of keeping things flowing and efficient. Yeah. Yeah.

[Dr Mike Patrick]
How do you keep patients sort of engaged and keep wanting to come back? Because it can be a little trying. You know, you had a resident come in and talk to you and then the attending comes in and you repeat the story and you’d said it one time before with all of that with the nurse.

Do you find that patients are, you know, willing to be there maybe a little longer and to tolerate the learning environment?

[Dr Bethany Panchal]
Yeah. I mean, I’m not going to say the same, you know, every single resident, every single patient, you know, that they’re some patients, you know, may not appreciate it. But I think for the most part they do.

I think they also recognize Ohio State as a learning environment. Right. So, they I think I think patients need to be told up front and they do in our clinic.

They are in our clinic. Like this is a resident clinic. This is a teaching clinic.

And you know, we need to we need to try to fully engage them in that teaching process. And it might be a little bit different for us because we have that primary care exception where we actually don’t have to be there for the entire visit. Right.

And in fact, I don’t have to go in and see every single patient depending on the complexity and the level of that we might have for each patient. So that helps, you know, give that patient that trust in the resident. But I think it’s important.

I really do like going in and seeing the patients with the resident because it’s a great time for me to do a direct observation. You know, what’s the interaction with the patient like? How are their communication skills?

But it’s you know, you need to have that dialogue about the medical decision making, you know, with the patient as well. I always introduce myself. I’m the supervising physician.

But then I step back, you know, like it’s still the resident show. They’re still the ones that are making the decisions. And I’m just there to support some of that body language.

You know, I take a step back, you know, I kind of stand in the corner or I’m, you know, I’m looking at the resident when they’re talking, you know, even though the patient, I see all the time they talk to me, you know, but I’m like, I’m looking at the resident like I’m trying to like focus them on the resident of what they’re doing and what they’re talking about. And then when I am talking, when I’m giving some instruction, I try to say, you know, hey, can I add something, you know, not like say, I’m going to take over here. And then teaching with the patient, right?

I think that’s a good opportunity. Like if I’m going looking at a rash or something like that, I’m going to be talking out loud. What am I thinking?

What’s going on engaging both the patient and the resident. And it’s really interesting because, you know, I’ve been here for 13 years and some I’ve seen it over and over here from the patients are like really like coming to this. I like seeing the residents.

I really feel part of the teaching and helping to teach that next generation of physicians. And I think if we can keep that attitude and keep them with that knowledge, it’ll just keep them engaged.

[Dr Mike Patrick]
Yeah. Yeah, absolutely. And this is really where residents learn about lifelong learning and taking, you know, what they’re learning in the clinic with them, but also continuing to seek to seek new knowledge and to follow research.

And how do you really promote that culture of lifelong learning in the clinic and hope that your trainees take it with them?

[Dr Bethany Panchal]
Yeah. Yeah. Well, you know, it’s something unique that we’re able to do as a resident clinic as we’ve actually blocked that first visit and we have a 15 minute, we call it a nugget, a teaching nugget.

And we do that at the beginning of each clinic session. So, morning and afternoon. So, the faculty member gives a quick 10, 15-minute nugget teaching.

You know, it’s just that way of making it. It’s a normal thing. This is our normalcy.

We are going to learn something before we even start clinic. And so, I think that right there is a good way to just kind of like set off the tone off. Right.

It’s like we’re going to learn. We’re learning today. And then, you know, like I said before, as faculty, we need to model that lifelong learning, you know, being OK with not knowing the answer and being vocal about it and saying, I don’t know the answer.

Can you guys help me? You know, sometimes my nugget is, hey, I have this patient. Give me some ideas of what to do with them, you know.

And I get so many great ideas from the residents in that because, you know, they’re on the wars with the cardiologist. Like, what’s the cardiologist doing right now? Tell me.

And so, I think that’s a good way, just like modeling that lifelong learning as well.

[Dr Mike Patrick]
Yeah. Yeah, absolutely. And to be humble and, you know, show that we don’t have to know everything.

But again, we need to know what we don’t know and where to find the answer.

[Dr Bethany Panchal]
Yes, exactly. Exactly.

[Dr Mike Patrick]
This has been a great conversation. We are going to have lots of resources over in the show notes. So, if you head to Famecast.org, this is episode 18. And look for the show notes and we’ll have those links for you. One of the references is actually a series of books from Springer called Excellence in Medical Education. And there’s one for family medicine, general surgery, pediatrics and psychiatry.

They each have their own book and hopefully there will be more in the future. But those look like really great resources, you know, in terms of just self-learning, faculty development topics on your own. And then, of course, I would encourage folks to check out the Center for Faculty Advancement, Mentoring and Engagement.

Lots of great resources there in terms of elevating your teaching and learning lots of those little tricks, you know, to help elevate education that we provide in the clinical environment. So once again, Dr. Bethany Panchal, Family and Community Medicine at The Ohio State University College of Medicine. Thank you so much for stopping by today.

[Dr Bethany Panchal]
Thank you so much. It was really great talking with you.

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[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making FAMEcast a part of it. We really do appreciate your support. Also, thanks again to our guest this week, Dr. Bethany Panchal with Family Medicine at The Ohio State University College of Medicine. Don’t forget, you can find FAMEcast wherever podcasts are found. We are in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible and most other podcast apps for iOS and Android. Our landing site is famecast.org.

You’ll find our entire archive of past programs there, along with show notes for each of the episodes, our terms of use agreement, and that handy contact page if you would like to suggest a future topic for the program. Or if you just want to say hi, I love hearing from listeners and that contact page is a great way to get in touch with me. I do want to mention once again that this episode is available for FDED credit.

So, if your institution or department requires faculty development education credit, also known as FDED, we have good news for you. Select episodes, so ones that deal with teaching and learners, do come with FDED credit from the Center for Faculty Development at Nationwide Children’s Hospital. Really easy to claim the credit.

Just listen to the podcast, which you have now done. Look for the FDED link in the show notes over at famecast.org. This is episode 18.

Follow that link to Cloud CME and then register or sign into your free account. You’ll need to take a brief survey. Literally, it’ll just take you five minutes and that’s in the materials tab when you click over to get into Cloud CME.

Take that survey and score the credit. You can even download a transcript of your credits to share with your institution or department. And as I mentioned at the beginning, we do have several other episodes of FAMEcast that offer the same credit.

And we’ll put a link to all of those in the show notes for this episode 18, so you can find them really easily. And then again, additional resources you can find on our website. If you click on the resources tab at the top of the page, again at famecast.org, two links will take you to some faculty development modules on Scarlet Canvas. One group is Advancing Your Clinical Teaching and the other is Faculty Development for Medical Educators. And really all of those are going to be very helpful in relationship to the things that we have been talking about today. So be sure to check those out.

Again, the resources tab over at famecast.org. That’s it for today. Thanks again for stopping by.

And until next time, this is Dr. Mike saying, stay focused, stay balanced, and keep reaching for the stars. So long, everybody.

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