Medicolegal Issues

Train the Teacher


 

If you work at a teaching institution, an important part of your career track may be teaching residents the work of hospitalists. “Within academia, there are two major tracks: research[er] and clinical educator,” says Sanjay Saint, MD, MPH, hospitalist and professor of internal medicine at the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor. “We’re promoted based on our clinical work and on education evaluations; it’s helpful when we’re being reviewed if we’re seen as good teachers by our students.”

How are your teaching skills? How much thought and effort do you put into how you train your students? Do you take steps to improve your methods?

“Most of us have to work at being good teachers,” admits Dr. Saint. “We watch excellent teachers and learn as we go.” What follows is the advice of one excellent teacher.

How to Fight Skills Decline

Dr. Wiese recommends the following to help students retain the skills and knowledge they must pick up so quickly.

  • Encourage students to use the knowledge frequently, or ensure that they do so;
  • Ask students to record the data so that it’s accessible later;
  • Teach methods and approaches, not facts; and
  • Re-dose: cover the information again.

Teachers: Champions for Hospital Medicine

Jeffrey Wiese, MD, FACP, is an SHM board member and associate professor of medicine at Tulane University Health Sciences Center in New Orleans, where he also serves as associate chairman of medicine, director of the Tulane Internal Medicine Residency Program, and associate director of student programs, internal medicine. “From an [SHM] board perspective, it’s been my agenda to better situate hospitalists as teachers,” he says.

One reason he’s committed to boosting the number of hospitalist-teachers is that Dr. Wiese believes the specialty is a perfect match for imparting knowledge. “Hospitalists are better instructors primarily because of their greater accessibility for supervision,” he says. “Because of the number of things they do and the consistent repetition with which they do them, they also have a better familiarity with what students need to know and how to do it.”

Another reason that hospitalists are excellent choices to train residents: “Hospitalists work at improving hospital systems and focus on quality of care,” says Dr. Wiese. “What better group of people to teach the systems of care and practice-based learning competencies?”

Attributes of Best Physician Leaders

What makes a good leader? According to a survey of 110 physician leaders, physician educators, and medical students, the following traits and activities are seen as most important in effective physician leadership:

  • Interpersonal and communication skills;
  • Professional ethics and social responsibility;
  • Influence used with peers to encourage the adoption of new approaches in medicine; and
  • Administrative responsibility in a healthcare organization.

Survey respondents also indicated that “coaching or mentoring from an experienced leader” and “on-job experience (e.g., a management position)” are the most effective methods for developing physician leadership competencies.

Source: McKenna MA, Gartland MP, Pugno PA. Development of physician leadership competencies: perceptions of physician leaders, physician educators and medical students. J Health Adm Educ. 2004 Summer;21(3):343-354.

Coaching Versus Teaching

The basis of Dr. Wiese’s theory of teaching is that you should think and act as a coach—not a teacher. “A teacher is responsible for disseminating knowledge to his pupils; a coach is responsible for the performance of his pupils,” explains Dr. Wiese. “With a coach, the success of the job is contingent on the performance of the player—in this case, the student or resident.”

The coaching theory goes deeper than that distinction. “Components of coaching include [the following]: You have to teach the necessary skill, but you have to motivate the person to want to do it right, create a vision of how they’re going to do it, anticipate and prepare them for potential obstacles that might stand in the way of their performance, and provide feedback and evaluation when they do it,” says Dr. Wiese. “A football coach wouldn’t just tell you how to throw a ball. He would teach you the skill and then watch you do it, while providing feedback on your performance. He would tell you what the opposing team might do to oppose your performance of that skill and prepare you to overcome that opposition. And then he would instill a motivation such that you wanted to perform the skill well.”

Dr. Saint, who is familiar with Dr. Wiese’s theory, says, “I like the metaphor of coaching because a coach tries to make you better at what you’re learning. A coach may use techniques that make you uncomfortable at the time, but if you look back after a couple of years, you’ll be thankful that he pushed you.”

Another aspect of coaching that fits neatly into today’s clinical learning is the team aspect. “Medicine is no longer an individual event,” explains Dr. Wiese. “It’s a team activity, where the best patient care is provided by a team of healthcare professionals from doctors to nurses to physical therapists and others. Teaching the mentality of playing as part of a team will help residents perform better in this environment as they advance in their careers.”

Teaching in a “Vacum”

“I use the mnemonic VACUM [to describe coaching],” says Dr. Wiese. VACUM stands for:

  • Visualization: To pique interest in a topic or procedure, start by asking students to visualize themselves using the skill. Repeatedly ask them how they think they will put the skill to use.


    “Get the person to picture herself with a patient,” urges Dr. Wiese. This step both hooks learners at the beginning of a session and helps teach them the skill.

  • Anticipation: If you’re an experienced teacher and know your students well, you know where they will struggle in the learning process. “Think about the common pitfalls,” says Dr. Wiese. “Alert the student to where she will get confused or make mistakes and spend time preparing the student for how she can avoid the pitfall. For example, if you’re teaching them about putting in a central line, tell them, ‘You [might] not think about the patient’s bleeding risk prior to procedure. Make sure you know his INR [international normalized ratio] and platelet count prior to starting the procedure.’ ”
  • Content: “This is where most teachers go awry,” warns Dr. Wiese. “Medical educators try to teach too much, and students try to learn too much. Not every detail in a topic needs to be discussed. It’s far better to sacrifice details to preserve time to ensure that students have mastered the fundamental concepts of a disease or skill. They can pick up the details later—focus on what they need to know.”


    How do you know what to focus on? “The guidelines of what students must learn during their internal medicine clerkship are voluminous,” says Dr. Wiese. “Find those that you think have utility in your practice or utility to the students. The best strategy is to stick to the fundamentals. With this strategy, they will walk away with the critical components that will empower them to pick up the details during subsequent teaching sessions.”

  • Utility: “This goes with content,” says Dr. Wiese. “Teach them skills that they can utilize. Remember, utility varies from student to student. A student heading into a future career in orthopedics will find greater utility in learning about pre-operative care and management of atrial fibrillation than she will with a discourse on lupus.”
  • Motivation: Motivation includes three subcategories. “Students or residents have to know that the coach is on their side,” says Dr. Wiese. One way to do this is to learn their names—and use them frequently. You should also use physical contact to show your support.

“Give a pat on the shoulder, or shake someone’s hand,” he advises. “If you’re in a classroom, move around the room. Show that you’re accessible.” Finally, find people’s hooks—that is, what interests them.

So how do you know you’ve become a good teacher? “The ultimate goal of coaching is successful student performance—not awards or approbation. The measure of your success is defined by seeing your students months or even years later, doing right by a patient because of what you taught them to do,” says Dr. Wiese. “Focus on that goal, and everything else will fall into place.” TH

Jane Jerrard regularly writes “Career Development.”

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