Show Notes
Description
Dr Daniel McFarlane visits the studio as we consider teaching on a busy clinical service. We explore creating a positive learning climate, setting reasonable expectations, supporting clinical reasoning, and providing meaningful feedback… while keeping patient flow moving and quality care at the center of business. We hope you can join us!
Topic
Teaching on a Busy Clinical Service
Learning Objectives
At the end of this activity, participants should be able to:
- Describe strategies for establishing a safe and effective learning climate on busy clinical services.
- Apply teaching tools such as the One-Minute Preceptor, SNAPPS, and chalk talks.
- Implement effective goal-setting and feedback techniques tailored to learners’ developmental needs.
- Evaluate learners’ clinical reasoning and growth using frameworks like the RIME model.
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.
Guest
Dr Daniel McFarlane
Associate Professor of Internal Medicine and Pediatrics
Director, FAME Curriculum Design Program
The Ohio State University College of Medicine
Links
Center for Faculty Advancement, Mentoring, and Engagement
PENN PEARLS: Perfecting the Micro Teaching Point
The Coach’s Guide to Teaching
Just in Time Teaching App (Apple)
Just in Time Teaching App (Google Play)
Advancing Your Clinical Teaching Modules
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.
Hello everyone and welcome once again to FAMEcast. We are a faculty development podcast from The Ohio State University College of Medicine.
This is Dr. Mike. It’s episode seven and we’re calling this one teaching on a busy clinical service. I want to welcome all of you to the program.
So busy clinical services can feel overwhelming for staff and attendings and also for our learners, but they’re also incredible opportunities for effective teaching. So today on FAMEcast, we’re going to explore practical strategies aimed at establishing a positive learning climate, setting reasonable expectations, supporting clinical reasoning and providing meaningful feedback, all while keeping patient flow moving and clinical care at the center of business. These are essential things to juggle as we effectively teach and provide quality patient care.
Of course, in our usual FAMEcast fashion, we have a terrific guest joining us in the studio to discuss the topic, Dr. Daniel McFarlane. He’s an associate professor of internal medicine and pediatrics, also director of the Fame Curriculum Design Program at The Ohio State University College of Medicine. If your institution or department requires faculty development education credit, also known as FDED, we do have some good news for you.
Select FAMEcast episodes, including this one, ones that deal with teaching and learners come with faculty development, education credit from the Center for Faculty Development at Nationwide Children’s Hospital. Really 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 for this episode over at FameCast.org. Again, this is episode seven. Follow that link to Cloud CME, register or sign in for your free account and then take a brief survey.
It’s on the materials tab. Once you go there and you get the credit, you can even download a transcript of your credit to share with your institution or department. So again, episodes with that FDED credit, the very first FAMEcast episode on mentorship and coaching in academic medicine.
And then this one, episode seven, teaching on a busy clinical service, both offer free FDED credit. Again, just head to the show notes, click on the link for the credit, and that’ll take you to Cloud CME. Click on the materials tab and take the brief survey and you will get your credit.
Do want to remind you the information presented in every episode of FAMEcast is for general educational purposes only. Your use of this audio program is subject to the FAMEcast terms of use agreement, which you can find at FameCast.org. So, let’s take a quick break.
We’ll get Dr. Dan McFarlane settled into the studio, and then we will be back to talk about teaching on a busy clinical service. It’s coming up right after this.
Dr. Daniel McFarlane is an associate professor of internal medicine and pediatrics at The Ohio State University College of Medicine and director of the Curriculum Design Program for the Center for Faculty Advancement, Mentoring and Engagement. He has a passion for advancing medical education with practical skills such as curriculum design and tips and tools for teaching on a busy clinical service. The latter is what we are discussing today, but before we dive into our topic, let’s offer a warm FAMEcast welcome to our guest, Dr. Dan McFarlane. Thank you so much for stopping by today.
[Dr Daniel McFarlane]
Thanks for having me.
[Dr Mike Patrick]
Yeah, we really appreciate you taking time to chat with us. This is really an important consideration because medical education is really, really important to the future of medicine and patient care is really important.
And it seems like, you know, all of us are very busy in the clinical environment. So how do we go about the beginnings of creating a positive learning climate despite maybe being on a really busy clinical service?
[Dr Daniel McFarlane]
Yeah, I think that’s really a really key point in terms of how to start off on the right foot and sort of establishing that learning climate is going to be really, really important. I think there’s really four main keys in my opinion of establishing a really positive learning climate. Number one is being enthusiastic and enjoying what you do and actually showing that passion to your learners.
Welcome the students, introduce yourself, be excited about what you’re, you’re going to engage them with will go a long way. I think the other thing is introductions. So, learn a little bit about who you’re teaching.
What do they want to be when they grow up and, and where do they come from and how did they find their way to you? I think is really important in sort of creating that welcoming and what do they want to do when they’re done with that, that current level of training, using their names when you talk to them shows a huge amount of respect in creating a learning climate where they feel respected and included. The third thing I think it can be really hard for some people, I think really want to be humble and modeling good behavior really goes a long way.
And sort of the idea of the hidden curriculum of the things that we don’t explicitly say and how important those things are. So, if you don’t know, it’s okay to say, I don’t know either, but let’s look it up together and showing them that you don’t have to know everything and you don’t have to be sort of the hero all the time, I think is going to really important and go a long way. And the last thing I really do is explicitly outline that this is their safe space.
Sort of creating that psychological safety is really important and allowing them the freedom to take a shot, put their nickel down on something, take a chance, try something new, think critically about it and just put an idea out there and that it’s okay to be wrong. I always tell them that I can fix wrong. Fixing wrong is easy.
I can’t fix wishy-washy. So, if you’re going to give me a bunch of, I don’t knows and we could, I can’t really teach you much, but if you really take a shot, this is your chance to do that. And this is the place to do that.
And we’re not going to ridicule you or mock you. We’re going to, we’re just going to fix things and sort of learn together. I think the really important parts of learning climate.
[Dr Mike Patrick]
I really love that. And I think it’s easy, especially if you’re on a clinical service where the learners kind of come and go. So, like for me in emergency medicine on a given shift, I may have different residents and some of them I may have worked with before and other ones I haven’t.
I feel like that’s a little bit different than when someone’s with you for a month. But if they’re with you briefly, I love this idea of always pausing at the beginning and finding out, you know, what their background is, what’s important for them to learn right now. And I love that creating the safe space for being able to ask questions.
And I always tell residents, it’s as important to know what you don’t know as knowing what you do know. And it’s okay if you don’t know, you just have to figure out how do we find the answer and you know, an evidence-based answer. And I’m sure there’s other expectations that are important to sort of set out at the beginning, you know, creating that safe environment is one understanding, you know, where they’ve come from, what their background is, where they’re going with their career.
What are some other expectations that are important?
[Dr Daniel McFarlane]
I think setting expectations is probably the most important thing you can do. And it takes surprisingly little time. So even if you’re on only with a shift or even seeing a few patients with somebody, I think it’s going to be really important to take a minute and set expectations.
Learners feel ill at ease when they don’t exactly know what’s going on. And especially if they’re new to a space or new to an attending and they worry often more about what might happen than actually learning anything. And so, taking just a few moments to really get that off the table can really go a long way to set them at ease and really open them up to learning.
So, I go over, how do I teach? What does a typical day look like? Or what is the shift going to look like?
How would you interact with a patient? What do you want them to do? Do you want them going by themselves?
You want to go in together? How would you like them to present? And how many patients would you expect them to follow?
What does it look like for them to pre-round? All of those things are really important. The other thing is, is what can they expect of you?
So how are you going to teach? How are you going to show up for them? How can they contact you?
What is the best way to get a hold of you and when to contact you and when not to contact you? I think that really will help them. And I think the most important thing that learners really want to know is when and how am I getting feedback?
So, one of the things I go over is what does feedback look like for me? I tend to be somebody who gives feedback in the moment. A couple of sentences like, here’s what I think you did well, here’s what I think you do next time.
And I label that up front for them. If you hear these two sentences from me, this is this is feedback. And we do feedback at the end, too.
But helping them understand what that’s going to look like is really important. And I think it allows them to move forward. Learners who have expectations set up front will either meet or exceed those expectations without being prompted.
[Dr Mike Patrick]
Yeah, yeah, absolutely. In addition to expectations, another important thing is setting goals. So, you know, again, what’s the background been of this learner?
Where are they going? What do they want to get out of this experience or what’s going to be important for them to get out of it? How do you go about figuring out what a goal should look like for each individual learner?
Because it may be a different goal for different learners all at the same time.
[Dr Daniel McFarlane]
And I actually will go through each of my learners and say, what is your goal? Right. And the thing is, is that, you know, oftentimes when we think of goals, we think of these lofty aspirations.
And really, I want to know a SMART goal, right? Specific, measurable, attainable, relevant and time bound to the time that we have together. So that may be a shift.
What do you want to get out of this shift? Right. Or for the two weeks that we have together on an inpatient service.
And I try and get them to narrow their down to one or two things that that they want to accomplish, and they feel like they’re struggling with. And honestly, what’s really interesting about setting goals is it’s just as beneficial for me as the teacher as it is for them as the learner. As the teacher, my philosophy is not always to pave the road, right?
I can’t pave the road of education. My goal is to maybe fill some potholes along the way. And if you allow them to show you their insights to what they’re struggling with and what they’re working on, you know exactly which potholes to fill.
And that’s going to allow them to really get a lot out of the rotation because you’re going to give them really specific feedback that they really feel like they need. And then you’re going to be able to focus in on teaching them those things that are really going to be the most beneficial to them. So, I really think that that’s really beneficial.
It also allows you to think to kind of look at their self-assessment and think about is their self-assessment in line with my assessment, right? So, am I agreeing with them? A lot of students and learners will identify goals that you would never have come up with, especially the high achieving ones.
Oftentimes it’s really hard to give them constructive or next steps for them, but they’re going to identify this is the area I struggle with. And then you can really hone in on that, observe that, give them really pointed feedback, and it helps them improve.
[Dr Mike Patrick]
Taking a step back really quick, you mentioned SMART goals and some of us in the audience may have may be familiar with SMART goals, others this may be the first time that they’ve heard, or they just need a refresher. Can you just explain what that is again really quick?
[Dr Daniel McFarlane]
So, I think SMART goals are they’re specific, measurable, attainable, so something you can attain, relevant to the scenario and time bound. So, they’re usually like in the next week I’m going to do this. I think of SMART goals as, look, we got two weeks together.
What do you want to learn in the next two weeks? Pick one or two things, right? So it might be, I want to talk to families, right?
I want to learn how to talk to families and engage with families more. I want to learn how to really hone in my presentations. I really want to work on my assessments and plans.
Pick something that’s really, that is a small enough goal that we actually can achieve it in the next week, and we maybe can give you, get you a couple of steps. Maybe not be perfect, but a couple of steps more advanced than you are now, rather than I want to be the best doctor I can, or I want to be whatever, right? Something that’s really specific and to your area of weakness, then I think that’s the better, better goal to pick.
[Dr Mike Patrick]
Yeah. And it may even be in a day instead of two weeks. So, like, again, in an ER shift, it may very well be that I just want to learn, or I want to get better at doing neuro exams in toddlers.
And so, we’ll find that opportunity for you. That’s very specific, but it is something that is doable in that time space.
[Dr Daniel McFarlane]
And that’s the best thing about SMART goals really is that they can be anything, and the time can be any time, right? So, and there’s always something to learn in a shift. And so, what do you want to get out of this?
This, our time together is really important.
[Dr Mike Patrick]
Yeah. Yeah. One of the important things that we do daily as physicians that kind of set us apart a little bit from like AI or just spitting something in and getting data back out of a system is that critical thinking and clinical reasoning piece.
That is, that’s tougher to teach because it’s, it’s not individual facts. It’s synthesizing data to get to a particular place. What are some effective strategies for, for teaching that?
[Dr Daniel McFarlane]
So, yeah, I think clinical reasoning is probably the, the most difficult thing to teach, and I focus more on the process of the teaching rather than the, than the outcome itself, right? So, I don’t care that, you know, whatever the diagnosis is, it’s, can you get close to the diagnosis? So, when I think about turning all of those different, you know, symptoms into a diagnosis, I really think about what is that process?
So, for me, you really want to have some structured models. There are some structured models. Sometimes it’s deliberate questioning, but for me, it’s about why.
So, I ask why about five or six times to try and think about, well, why did you get to there? How did you get to the next step? Why did you think to do that?
What do you think that your pre-test probability for that test is? Or why do you want to get that test? And what do you think it’s going to accomplish for you at the end?
And where are you going? What are you trying to, to, to determine from that test? So, a lot of it is about, again, not just what are we going to do, but why are we doing that and how are we getting there?
So, I really like to help them build that differential and think about what is, why is it more likely this versus that? And why, and, and really focus on that prioritization of most likely to least likely. And, and again, all of that information needs to, new information either needs to strengthen or dismiss something, right?
And so, every piece of information either goes to solidify a diagnosis or further refute a diagnosis. And I think that that’s really the important thing. And I think we teach preclinical and early clinical med students that, but, but a lot of clinicians have the benefit of experience, which they don’t have, right?
And so, we have to be really deliberate about those whys with those younger learners because they don’t have that quick, you know, cognitive processing ability where they can look at an illness script, right? So, what we call an illness script is sort of like the, the, what does a disease process actually look like in most people from the textbook? And then you can kind of look at what is the disease process and symptoms, and epidemiology look like in my patient, and did they match?
And we sort of, more experienced clinicians will, will sort of rifle through that in their head really quickly. And they’ll sort of be like, well, this matches, this matches a little bit, this doesn’t match at all. And the younger students don’t have the benefit of that experience yet.
And so being very deliberate about how you get from step to step and talking through your thought process out loud is probably the most important thing for establishing clinical reasoning skills.
[Dr Mike Patrick]
Yeah. Yeah. And I love also that you mentioned where the learner is in their educational journey.
In the beginning, you’re really just trying to identify those data points, like which ones are the most important ones to think about. But then when you have more senior residents who can come up with the right answer but now let’s take it back. What data did you use to get there?
And when you have those early learners and those late learners together, that can really, I think, be helpful when you sort of sort through the process of what’s the data, how did you get here? And then the younger learners can see how the more senior learners went about it. And it’s a reminder for the senior ones that, hey, which data points are important and are you leaving any of them out as you do this more quickly?
[Dr Daniel McFarlane]
One of the other games I really like to play, too, is the what-if game, right? So, you can change some of the details of your patient and try and figure out why and how that would change sort of the things that you consider. And that’s often really helpful with some of those sort of senior level learners as well.
OK, so what if this patient was immunocompromised or what if this patient was 75 instead of 25 or right. And so sometimes you can change the details of that and work through a different differential and see how does that kind of change the scenario. But it’s still kind of under the guise and umbrella of a patient.
So, it brings relevance to that.
[Dr Mike Patrick]
Yeah. Yeah. And it does give you an expanded view of what these things can look like or how different data would have changed where you go in your in your clinical decision making.
Right. Yeah. One strategy that is helpful in a really busy clinical scenario is the one-minute preceptor.
What exactly is that?
[Dr Daniel McFarlane]
So, one minute preceptor is a really just a scaffolding technique, right? So, it’s a framework for sort of how we build an encounter that allows you to really push a learner to kind of think through the patient. So, the one-minute preceptor is five steps.
So, first is get a commitment. Number two is probe for supporting evidence. Three is reinforce and praise what they did well.
Four is correct errors or omission. And five is teach a general principle. So, this is really just a scaffolding.
So, I think the most important piece about this is getting the commitment. Right. So, ask them what they want to do or what they think the diagnosis is.
Again, you can fix wrong, but you can’t fix wishy washy. So, I think the most powerful thing is getting them to think through and make a decision. And then you ask them why.
So, probing that support supportive evidence. So how did they get there? Again, is really like solidifying those clinical reasoning pieces and sort of how did they put that puzzle together?
And then if they’re right, you want to, you know, justify their answer. Right. And because they might have just stumbled on the answer.
So, again, the end goal is not the be all and end all. Right. It’s the process.
And how did they get there? And if they’re wrong, you can kind of back them up with the whys and kind of figure out where they went off track and send them down the right direction. Number three is reinforcing what went well.
So obviously you want to praise them on the things that they did well. How did they get there? Those kinds of things.
And then number four is correcting errors and omissions. And I really want to emphasize I can’t emphasize this enough, but not correcting an error or omission makes it correct in their mind. And so, the other thing, too, is often we’ll try and be like, oh, well, that’s a good thought.
It’s not a good thought. Don’t say it’s a good thought. And that’s OK that it’s not a good thought.
But don’t falsely give them ideas that what they were doing was correct just because you’re trying to be nice. There are nice ways to say, like, oh, I’m not sure that that’s correct. So, what I would say is that’s really interesting thought.
How did you get there? And I kind of try and kind of back them up a little bit and say, I actually wouldn’t think that wouldn’t do that. I want to would do this instead.
Do you see why? Right. And explain to them why.
[Dr Mike Patrick]
Yeah.
[Dr Daniel McFarlane]
But saying that’s a good thought or something like that or not saying anything at all makes that correct. And then lastly, teaching something. So, what is the general principle about whatever disease state or process?
And honestly, all of that together can take a minute. Right. It’s called one minute predictor for a reason.
So, you can do that with each patient, with one or two patients for the day. And it’s really easy to do in an ER setting as well.
[Dr Mike Patrick]
Yeah. Yeah. So let me see if I can remember this.
It is getting a commitment, ask probing questions like how did you get to where, you know, you the decision that you made? How did you get there?
[Dr Daniel McFarlane]
Yeah.
[Dr Mike Patrick]
What was the third one?
[Dr Daniel McFarlane]
Praising what they did? Well, positive and negative feedback.
[Dr Mike Patrick]
Yes. And then correcting omissions and errors.
[Dr Daniel McFarlane]
And then the last part is teach them something.
[Dr Mike Patrick]
OK, that totally makes sense. And it’s and it’s using what’s happening on that clinical service with the patient. So, you’re also getting work done.
But then in doing that work, you’re also providing teaching points and nuggets quickly.
[Dr Daniel McFarlane]
And oftentimes this is part of the presentation. Right. So, they’re presenting, you know, kind of a tied-up picture for you.
And you’re like, OK, let’s what do you think this is it? What do you think this is? What do you think is going on?
Right. I mean, as you’re talking through the plan, this really sort of becomes really natural. Right.
Yeah.
[Dr Mike Patrick]
Yeah, absolutely. In addition to the one-minute preceptor, if you don’t like that model, there’s another one you can use called SNAPS. It’s also a strategy for clinical teaching.
Tell us about that one.
[Dr Daniel McFarlane]
So, SNAPS is a little bit more clinically focused, but same idea. Right. So, a quick way to sort of assess how they got where they were going and is their clinical reasoning appropriate.
So, SNAPS stands for summarized history and findings. So that’s sort of part of your presentation. Two is narrow the differential.
So, prioritizing your differential. What do you think is more and less likely and why? Three is analyzing.
So that’s really the comparing and contrasting the top two or three. And again, those probing questions about why four probe is. Right.
So again, asking them questions. And then five is planned. So how are you going to manage this patient?
What are you going to do about it? What are your next steps? And then six is select something to learn.
So very similar to one minute preceptor. But again, really getting them to make a commitment and explain how they got there.
[Dr Mike Patrick]
And I they really are very similar. And I think the key here is, like you said, make a commitment. You know, don’t be wishy washy.
And then once you make that commitment, it’s fine to be wrong. Let’s explore how you got there and figure it figured out from there. And then, you know, what are we going to do?
So, you look back at how you got here and now what are we going to do moving forward?
[Dr Daniel McFarlane]
Yeah. And I always tell them, look, look, I’m all wrong all the time. Like, it’s OK to be wrong.
Right. You’re going to be wrong a lot in your career. The most important thing is recognizing what you know and what you don’t know in order to make sure that the patient’s safe.
[Dr Mike Patrick]
Yeah. Yeah. One thing on clinical services, not so much in like an office setting or an emergency department or an urgent care, but really on hospital wards, pre-rounding is a large part of the learning process where learners, you know, look over all the data for the day and they’re going to use this to present during rounds.
How can that pre-rounding time, how can learners best utilize that to their advantage?
[Dr Daniel McFarlane]
So, I think the learners can utilize the pre-rounding time by kind of thinking through patients that they don’t know or things that they don’t know or things that they have questions for. And they can kind of look up some of that stuff if they have time. It’s certainly a really crunch time for the learners.
As a teacher, I actually utilize pre-rounding time for a couple of things. I certainly am going to pre-round and look up things clinically on my patient. But I kind of, when I’m on teaching service, I pre-round for education.
And so, I use that to kind of think about not only the new data and the developing of the plan for the patient for the day, but what am I going to teach on today? So, I use it to kind of pick out patients that are interesting, patients that have a cool physical exam finding, patients that have a real bread and butter diagnosis that we can really talk about how best to manage, patients who have maybe an evidence-based clinical guideline for their diagnosis that we can talk through. And so, I try and pick a few key patients to teach on rounds.
And I use pre-rounding as that beginning of establishing those teaching things, because realistically, no attending has time to teach on every patient on rounds every morning. It’s not realistic. And so, I pick four or five patients that are interesting, and I do that during the pre-rounding time.
It also gives me time to kind of look things up that maybe I’m not entirely certain about. And so that way, when I go to teach it on rounds, I’m actually teaching them something that’s evidence-based or that’s true. And I think that it sort of makes you look like you know everything, but you don’t.
Right. I mean, we all look things up. And so, like if you have a patient with new kidney injury, like maybe you’re going to teach what’s the differential or how do you work up kidney failure or AKI?
It’s really an opportunity for that. You may have. The other thing I think about is what are my learner goals today?
So, like you may have a patient who wants to talk to families or break bad news to them, and you have somebody that you have to give bad news to. So, you can pull that learner in and say, look, OK, here’s an opportunity for you to practice this on rounds today. Let’s walk through that together.
Again, other rare findings would be another key for that. But I take one, you know, they shouldn’t be long things to teach on. It’s like one to five minutes.
And if you do that on three or four patients a day, you’re going to really your learners are really going to feel like you’re teaching them something on rounds. And so, I utilize that pre-rounding time to really hone in and focus my learning.
[Dr Mike Patrick]
Yeah. Yeah. As we think about our learners and sort of where they are on their educational journey, the RIME model sort of describes that progression from reporter to interpreter, to manager, to educator.
That’s the RIME as they’re progressing. Let’s think about each of those. Like what does a typical learner look like when they’re just a reporter?
Sure.
[Dr Daniel McFarlane]
So, the RIME criteria for me is that Dreyfus model, right? So that novice to expert continuum, right? And we sort of want them to move to the continuum.
The thing I like the most about the RIME model and talking through that with the learners is not only do they figure out where they are in the RIME model, but what are the next steps for me as a learner? So, if I’m an interpreter, how do I get to manager? What does that look like?
The other thing is, is that I think we have to be cognizant of with the RIME model is that different skill sets may be in different places on the RIME model. So, they might have they might be really, really good at talking to families and they might be sort of at that manager level of that. But they may be presentations might be a little bit lower for them.
So, again, it can be used with clinical sets, clinical skills and with clinical reasoning. But the reporter is really kind of think of a TV reporter. They’re able to gather information, organize that information, and then regurgitate that information in a concise way.
These are really probably thinking about that early clinical student. So early third years, maybe early fourth years, early to late third years and early fourth years, because they’re really working on those presentations and kind of organize that information. Interpreters sort of take it that the next step of clinical reasoning.
So, they’re starting to interpret some of that data. Why is this data important? Reporters tend to include everything, right?
These are all the things I know. Interpreters start beginning to think like, you know, that’s not really relevant to this patient. It might be relevant to the other patient next door, but it’s not relevant here.
And so how can I interpret some of that leave out data to make it more concise? Or what does that CAT scan mean in order here? Or what does that test or lab mean?
And start putting some of that those puzzle pieces together. Managers are really thinking about those plans, right? But also, what are the other things that they need?
So, I would say interpreters really focus on the day to day. What am I doing with the plan today? What am I adding to the plan?
Am I ordering a test? Am I getting a study? Am I getting this lab?
Am I treating them for this, right? Managers are starting to think about what else is going on. So, does this patient need appointments for discharge so that they stay out of the hospital?
Does this patient need social work or ancillary support in some way? Like, do we need medication assistance in order to get them their medications because they don’t have insurance, right? So, beginning to manage some of those other bigger things.
And then our educators or experts, sometimes people say E is expert, are really thinking about being able to do all those things, teach down to the folks below them. Also are really expert in managing that 10,000-foot view and really getting those patients out of the hospital and working with the interdisciplinary teams.
[Dr Mike Patrick]
Yeah, and I think when you’ve identified sort of where your learner is on that, as you say, then it becomes a little easier to figure out what is the next step for that particular learner. So, I think that’s why that’s an important thing to keep in mind.
[Dr Daniel McFarlane]
Yeah, it makes it very easy to say, look, this is where you need to be next, and this is how you get there.
[Dr Mike Patrick]
Yeah, that is in effect feedback. What are some key principles to do that effectively, especially on a busy clinical service?
[Dr Daniel McFarlane]
Well, feedback can be difficult. Feedback’s always difficult. And most people think that feedback needs to be sort of this long, 20-minute conversation that encompasses every learner’s skill.
It’s a lot of pressure to put on yourself. Feedback really just needs to be normalized as a way to improve. I think learners have been asking more and more for feedback.
I mean, that’s probably the first thing I get asked when I meet a learner is, well, are we going to do feedback? Of course we’re going to do feedback. And they crave feedback, but they really, I think, are also nervous to get feedback at the same time.
And so, my philosophy with feedback is to sort of demystify it and make it sort of a normal. Everybody has something that they can improve, and this is just pointing out what we can improve so that we see it and we can actively make improvements to it. So, I really love this book called The Coach’s Guide to Teaching by Doug Limov.
And he really shares two sentences that make feedback in every day. So, thinking of like a coach perspective, a sports perspective, the coach is going to yell out to you like, hey, you need to move your feet more. You need to get in position better.
Right, they’re going to kind of do it in the moment. So, he describes two sentences. I like how you did X, and next time try Y.
And so, I always will tell them, if you hear these two sentences out of my mouth, it’s feedback. I also think that feedback in the moment is really, really important. So again, demystifying that feedback like, hey, let’s talk about your presentation on the way to the next patient.
Like you did really well with these things. This, you know, this small part was disorganized. Next time, try and kind of put this piece over here instead, right?
And it takes two seconds, and it really makes feedback kind of not a big deal. And so, I think that if you’re going to do more of a kind of a bigger feedback session or you have more difficult feedback or more constructive feedback to give somebody, I think the way that I think about that is using actually the spikes model, which is actually a palliative care kind of way of breaking bad news. And I think in some ways we sort of think as feedback is bad news.
So, I think it works really well. Spikes is the first part of spikes is the setting. So, making sure that you’re in a private space and that you have gone somewhere and given them some privacy and respect of sort of like not giving them feedback in front of other people.
The P stands for perception. So, I always ask, what do you think’s going on? How do you think things are going?
What do you think you’re doing well with? What do you think that you’re struggling with? And I try and get their perspective and see if that aligns with my observation.
Oftentimes it does, right? So, they’re going to say exactly what you were going to tell them. And that makes it really easy.
Sometimes it doesn’t. And they think they’re doing really well, and you don’t. Or they think they’re doing really poorly, and you don’t, right?
So, they might be doing awesome and they’re really hard on themselves. But that really gives you some insight into where they land and how much work you have to do to sort of get on the same page. The other thing that’s important about P is permission.
So, asking permission to give feedback is really important. I’ve often had learners that just really aren’t in a good mental space to receive feedback at that moment. And I can kind of fire a warning like, okay, it’s now a good time to give feedback.
And if they say no, I’m okay with that. And I tell them, I give them permission to say no. Almost never get a no, but if I do, I’ll be like, okay, well, when can we get feedback?
How about tomorrow morning? And let’s set a time for that. Which is sort of I, that is sort of invitation is what it stands for, but I think of it as permission.
K in Spikes is knowledge. So, this is where you sort of drop it on them, right? So, here’s what I think you did.
The key is really if you’re giving constructive feedback is to focus on the action itself and not sort of how you interpret that action. So, what happened? What did you see?
So, I saw you on your phone during rounds and it could be perceived that you’re disconnected or that you’re not engaged, right? Not like you really seem to be checked out on rounds, or you don’t seem to be paying attention, right? Because it’s hard to know what they’re doing.
Maybe they’re looking up the patient’s labs on their phone or maybe they’re looking up the diagnosis to sort of see if they can educate the patient. So, you really want to just focus on the action itself instead of the interpretation. And then E is empathy or emotion.
Sometimes learners are going to have emotions and it’s okay. They might be upset by what you’re telling them. They might be angry about what you’re telling them.
And the key there is to really call that out. And seems like you’re really frustrated about this feedback, tell me why. And get them to talk about their emotions and call out their emotions.
And sometimes they’re not able to do that. And it’s time to put a time out on that. Like, okay, it seems like this has really upset you.
Why don’t you go home and think about it and let’s talk about this thing again tomorrow. That can be really helpful. Let them process the emotions and get in a better place to really think about the feedback because otherwise they’re going to dismiss everything else that you’re saying.
And then S is strategize or next steps. So, feedback is not complete until you give them a way to get better, right? So, you can’t tell somebody that they’re not good at something without giving them a way out, right?
Or a way up. And so that’s, in my opinion, the most important part of feedback is the next time try this, right? So how can they get better in that?
And then when are you going to be able to maybe reassess them or reevaluate them? You may not, this may be your only time with them. You may not reassess them and you can sort of give them, here’s what I would do next time.
Otherwise, it’s like, hey, let’s try this again tomorrow or the next day and let’s see if we do better.
[Dr Mike Patrick]
Do you have to deal with emotional reactions to feedback very often? Is that something that you find?
[Dr Daniel McFarlane]
I think it’s once in a while, right? I think if you do a really good job of getting their insight, oftentimes, I would say the most often, they know where they’re not doing well or where they’re struggling. And so, it’s not a surprise to them and you can sort of piggyback on that.
It’s the learners that really don’t have a clue as to that they’re not doing well or maybe disagree with the feedback that you have to give them or the feedback is like more professionalism or conduct rather than like, you don’t know enough or your clinical reasoning skills need work, right? Some of those things are a little bit more emotion provoking. But I’ve had learners cry, and it happens sometimes.
But instead of like powering through that, I think a lot of people sort of like ignore the elephant in the room and keep going. You can’t do that because they’re not hearing you. It’s not worth your time.
So, you just say, look, that sounds like it’s really hard for you. You’re really struggling hearing that feedback. Can you tell me why?
And try and explore that a little bit.
[Dr Mike Patrick]
As you’re talking about feedback, I noticed one thing you did not mention is the feedback sandwich. So, we all learn that like once upon a time, but that’s not really that helpful, is it?
[Dr Daniel McFarlane]
I think it depends. I think that no matter what, people are going to focus on the negative, right? Constructive, right?
I mean, I can still remember constructive feedback that I got when I was a resident, right? So, we’re talking like pushing 20 years ago that I got this feedback, and that’s what sticks with me, right? It’s not all the time that I heard that I was good at this or good at that, right?
And we learn, I think, most effectively through mistakes or failures. And so, I think those are the things that are going to stick with people. And I think the feedback sandwich sort of placates people into like, kind of it’s like a pat on the tush at the end, like, oh, well, you know, you did great.
And so, I don’t tend to use that, but I always give them positive feedback and constructive feedback, because I think both of those are important. And if they really have a strong emotion, I might give them their positive feedback at the end. So, they go out on a high note.
[Dr Mike Patrick]
But yeah. So, there’s a little bit of a sandwich there, but it’s not necessarily something that you should strive for every single time. I mean, just having the open line of communication, being vulnerable and, you know, modeling when you don’t know something or you make a mistake, kind of owning up to it.
And sometimes you can even say like, oh, I have empathy for that mistake you made, because maybe I did that same thing when I was a resident or, you know, this is how I learned that or, you know, kind of to bring it back around to yourself.
[Dr Daniel McFarlane]
Sharing stories is super powerful. I can’t stress that enough. I think that, you know, normalizing it is really important.
The other thing is that I also will give them opportunity to give me feedback, because I think that, you know, and what I say is, is everybody has an area for improvement. Are there any areas that you can see that I can improve in? Or, and I also open it up to like their peers, right?
Like, so your residents or medical students, right? I sort of allow them to give feedback to everybody to kind of help them understand that feedback is normal. Everybody has something we can improve.
[Dr Mike Patrick]
Yeah, yeah, absolutely. And certainly, we want to be the best teachers we can be. And you may get feedback that you don’t agree with, but on the other hand, it may really impact the way that you present things or interact and engage with learners in the future.
[Dr Daniel McFarlane]
And I will say that if they really are vehemently against what I’m telling them, I will say like, look, at the end of the day, you have to decide how valid this feedback is. This is what I observed. This is what I think.
These are the things that I think you can do to improve. And you have to sort of process that at home and kind of think about, like, do you agree or disagree? And you may disagree and that’s okay.
You can move forward with that. Because at the end of the day, it’s their feedback to take.
[Dr Mike Patrick]
Yeah, right. I mean, and as adult learners, they’re responsible for growing and maturing in medicine. And hopefully they’re taking what we say in stride.
[Dr Daniel McFarlane]
And I think that’s really the power of self-reflection. I think I used to, as a medical student and a resident, I used to think self-reflection was sort of like silly, you know, emotional, you know, I don’t know. I just didn’t find any value in it.
But I really, as a teacher, I feel that it’s really valuable in thinking about what you’re doing well and what you’re not doing well and being open to not doing well and stuff because everybody has and also giving yourself grace too. Like, maybe you just had a bad day and that’s okay too.
[Dr Mike Patrick]
When you do have a little bit more time for teaching, so maybe things, you know, there’s a little bit of downtime. We’ve gotten through rounds. The idea of a chalk talk is something that you’re a proponent of.
What exactly is a chalk talk?
[Dr Daniel McFarlane]
So, I love chalk talks. I think chalk talks, it’s sort of an old idiom, right? You know, when we used to sort of write with chalk on the board.
I think of chalk talks as sort of like tending rounds or afternoon rounds. When I was a resident, our attending used to come back in the afternoon and teach for like an hour. And I don’t know that that’s an effective tool.
Chalk talks, in my opinion, are a 10- to 15-minute-high yield talk on something. They aren’t a lecture. They don’t have slides.
They might have a handout or something that you write on the board, some pictures or bullet points to help keep people engaged, but really should be focused on a patient, ideally, right? So, somebody that needs something from you and that is relevant to like something you just talked about really anchors that as you move forward. But I love the idea of chalk talks because it really engages them.
The other thing that I think is really important about chalk talks is, again, the timing. The residents are busy, right? They’re answering pages, they’re getting labs, they’re talking to nurses, they’re talking to social workers, consultants, et cetera.
So, if you are going to sit down and teach them for 30 or 45 minutes or an hour, they’re going to be in and out. They’re going to be missing pieces. With a chalk talk, if you really keep it to 10, 12 minutes, maybe, you really could say, look, give me your undivided attention for the next 10 minutes.
Let’s, you know, unless there’s an ERT or emergency response or something like that, like let’s ignore our pages. It’s a reasonable amount of time to get back to a nurse about some patient care thing that’s not emergent. Give me your undivided attention.
I’m going to teach you something and then let you go about your business. And it shows how much you respect what they’re doing as well. But I think that, again, you know, chalk talks, I use pictures, handouts, something that I can draw on the board.
You can even use technology for this. So, you might have a picture that you’re drawing on an iPad or something like that, or a picture you’ve already drawn, a series of pictures, right? Or something on an iPad where they can fill in the blanks or like a flow sheet or a flow diagram or something like that, right?
That gives them something to anchor it to. And the other thing is, is that I think attendings will be, if you give a chalk talk well, then you have that in your back pocket. So, I keep all the chalk talks that I have.
I have about five or six that I kind of are my bread-and-butter ones. And typically, we have a patient that they’re relevant to, and I can come and give them a 10-to-15-minute talk. They really engage with that material, but it’s something I’ve done many, many times and comes really easily for me.
[Dr Mike Patrick]
Do you ever have like a senior resident on a service do a presentation like that?
[Dr Daniel McFarlane]
So yeah, you can have, I often have the medical students do it. And you sort of tailor it to their level of learning. So medical students, I might say, hey, this is a really interesting disease.
Why don’t you just look up the illness script, right? So, what’s the epidemiology? Who gets it?
What are the symptoms? How do they present? What do you test for?
How do you diagnose it? And then what do you treat it with? And then let them kind of give us a few minute primer on that.
Or if the residents want to participate, I’ll allow them to do it as well. Just say, hey, why don’t you give us a little talk on this? A lot of the residents are really interested in something too, right?
So, most of them are probably going to go into fellowship. So, in my introductions and my setting expectations, I find out what are you doing next year, right? Or in two years, you’re going to be a cardiologist.
Okay, hey, this patient had pretty complicated heart failure. Why don’t you give us a couple minute talk on heart failure?
[Dr Mike Patrick]
Yeah, yeah. And they probably love that actually. Yeah, it’s something they’re interested in.
Yeah, and then that gives them the beginnings of a chalk talk to have in their back pocket that they may give to interns or medical students at some later date, depending on what kind of opportunities that they might have. So, let’s say you’re teaching, and this may be during a chalk talk. It could be during rounds.
And you realize later that something you said was not accurate or it was more nuanced or there might be exceptions. How do you handle, especially when some time has passed that you’ve realized, oh wait, this wasn’t correct. I would think that’s an important thing to bring up with your learners and your modeling good behavior.
[Dr Daniel McFarlane]
Yeah, I own it, is the only thing I can really say. It’s a huge part of the learning environment to understand that even attendings make mistakes. I don’t know how many times I’ve learned something from my residents, right?
So oftentimes there’s a newer guideline that has come out or a drug has gone off a formulary or we’ve changed the antibiotics because of the antimicrobiogram has changed or whatever, like this is what we’re doing now. I would say my residents are in the hospital much more than I am, even as an attending as I’m not 100% clinical. So, learning from them is valuable.
And so, I’m humble enough to be like, oh, that’s great. Can you show me the guideline or like what’s the new guideline? Can you talk me through it?
I think that’s really great. And I think honestly, if you’re the one that realizes it’s wrong, I just say like, hey, I looked this up and I realized I was incorrect. This is actually the newest guideline or the best treatment or whatever, right?
And that shows that you can be wrong and that it’s okay and that it’s important to look stuff up even if you think you know it, if you have any question or any doubt. The other thing, if things aren’t going the way that they’re expected, right? It’s time to, or data doesn’t fit.
It’s time to kind of take a step back and be like, what if I’m wrong? And I always say that that’s the question I ask myself all the time. Like, what if I’m wrong?
What next, right? So, starting over your clinical reasoning is important. And so, I think just owning that and saying like, yeah, I made a mistake.
That’s not what this is. This is actually what it is, is probably the most important thing you could do.
[Dr Mike Patrick]
Yeah, yeah. More and more we’re having grounds with a multidisciplinary team. And so there may be other opinions and a clinical pharmacist, for example, may say, oh wait, this other antibiotic would be a better choice in this situation, or a lot of different things that we can learn from other professionals in rounds.
More so today, I think, than when you and I were training. You know, sometimes there may be dietitians on rounds in the newborn intensive care unit. There’s, you know, respiratory therapists in the ICU can be a part of rounds.
How can we really best utilize the various members of a multidisciplinary team to bring teaching to light with their inclusion?
[Dr Daniel McFarlane]
So, I think, first of all, I think accepting them for the level of their expertise. I think gone are the days when the doctor is sort of the be all and end all. Obviously, the decision will stop with the attending, right?
But understanding that there’s valuable information that is beyond your scope is really important. And I think that, I think again, modeling that and accepting that. I think really one of the things that has really empowered people is sort of multidisciplinary rounding.
So, it was used to be that sort of everybody came in on their own and then the doctors came by, and we made the plan. And we may or may not have had that information. And so, I really like rounding with our nurses and maybe the dietitian or maybe the PT or OT or maybe the social worker or discharge planner, right?
And pulling them in and helping kind of have all the information and giving them the floor is really important. So, as the attending, I will ask them, what do you think about this? Or what are your biggest concerns?
Or what is the thing that you need help from us with? Something like that. And giving them time and space to sort of share what their area of expertise brings is really important.
I love rounding with our pharmacists. Our clinical pharmacists have been invaluable in terms of making sure that medications are appropriate, that we’re using the right things, that their home medications are in correctly. And so, I really value their input as well and love when they round with us.
So, I think realistically just modeling acceptance and inclusion of those people and showing how much, they bring to the table is really the best way to learn.
[Dr Mike Patrick]
Yeah, absolutely. And I love our clinical pharmacists too. I just want to point out in the emergency department, they are wonderful and a great, great resource.
This has been a terrific conversation and hopefully we’ve shared some nuggets of information that folks can utilize when they’re teaching on a busy clinical service. We are going to have some support documents for you in the show notes over at famecast.org. And this is episode seven.
One is going to be to pin pearls, perfecting the micro teaching point. That’s a really handy page on the web. And then the book that you had mentioned, The Coach’s Guide to Teaching by Doug Lamov, we’ll have a link to that as well.
And then there’s an app that’s available in Google Play and the Apple App Store called Just-In-Time Teaching. Have you, are you familiar with that?
[Dr Daniel McFarlane]
Yeah, I use that a lot. I use that for chalk talks. So Just-In-Time Teaching is actually infographics.
So, they’re all infographics which you would use, which is sort of what you would use for a chalk talk anyway. So, you can actually look at the infographic and kind of draw it out for some of those things or have a good foundation for a chalk talk. Pin pearls I use for those sort of key teaching points that I kind of look at it while I’m pre-rounding and give them sort of key points.
And I would be remiss if I didn’t tell you about what Fame has to offer in terms of improving your teaching. So, we have an online course called Advancing Your Clinical Teaching that I developed with Dr. Marsha Niki and Nelms and many of the teaching faculty across Fame, across Ohio State College of Medicine. It’s interdisciplinary, really high yield, done at your own pace.
It’s online, 18 online modules to really help you think about how well you teach in areas like teaching philosophy and learning climates, setting expectations, feedback, all those things.
[Dr Mike Patrick]
Yeah, and we’ll put links to all of that in the show notes. So again, if you head over to FAMEcast.org and look for episode seven, we’ll have links in the show notes to those resources for you. So once again, Dr. Dan McFarlane, Associate Professor of Internal Medicine and Pediatrics and Director of the Fame Curriculum Design Program at the Ohio State University College of Medicine. Thank you so much for stopping by today.
[Dr Daniel McFarlane]
Thanks for having me.
[Dr Mike Patrick]
We are back with just enough time to say thanks to all of you for taking time out of your day and making FAMEcast a part of it.
Really do appreciate that. Also, thanks again to our guest this week, Dr. Dan McFarlane, Associate Professor of Internal Medicine and Pediatrics at the Ohio State University College of Medicine. Don’t forget, you can find FAMEcast wherever podcasts are found.
We’re 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.
Also 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. Reviews are also helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show.
And don’t forget this particular episode, we do offer FDED credit. So, if your institution or department requires faculty development education credit, also known as FDED, we have good news for you. This episode and also the first episode of FAMEcast, those two, because they deal with teaching and learners, come with FDED credit from the Center for Faculty Development at Nationwide Children’s Hospital.
It’s free and it is easy to claim your credit. Just listen to the podcast, which you’ve already done. Look for the FDED link in the show notes over at famecast.org for this episode number seven. Follow that link to Cloud CME, register or sign in to your free account. And then you’ll want to click on the materials tab and there you’ll find a brief survey. Take that survey and score the credit.
You can even download a transcript of your credits to share with your institution or department. And again, we do have FDED credit for episode one of FAMEcast. That was on mentorship and coaching in academic medicine.
And then this one, episode seven, teaching on a busy clinical service also has that credit attached to it. Some additional resources you can find on our website over at famecast.org. These are going to be on the resources tab up at the top of the page.
And there’s two links that you may find interesting. One is advancing your clinical teaching, which Dr. McFarlane talked about in the podcast today. We’ll also put a link to that in the show notes for this episode, but you can always find it on the resources tab at the top of the website over at famecast.org.
We have advanced your clinical teaching, and then we also have FD4ME, so faculty development for medical education. And those are learning modules. Both of those sites are on Scarlet Canvas.
So be sure to follow those links to find more useful information, specifically targeting academic medical faculty. 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. So long, everybody.
