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The Hospitalist as Teacher


 

In addition to being expert in acute care clinical issues, hospitalists are knowledgeable in the ways and means of the hospital.

As teachers, hospitalists are ideally situated to improve house staff’s proficiency in areas such as evidence-based medicine, effective teamwork, communication, and quality improvement.1 These areas meld with hospitalist core competencies, writes David M. Pressel, MD, PhD, director of Inpatient Service and General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del.

What makes a great hospitalist a great teacher? “I don’t think there is anything special about a hospitalist [that would make him or her] a great teacher as opposed to another kind of physician,” Dr. Pressel says. “The only caveat to that is that presumably the hospitalist has specialized knowledge that they can impart similarly to [how] another doc can [impart information] in their specialized knowledge.”

Good teaching in all specialties has the same core features. But the key component a hospitalist would want to impart, he says, is that the hospitalist should maintain a holistic view of the patient.

In Dr. Pressel’s view, a great teacher loves what he does, has a sense of humor and makes learning fun or enjoyable, makes his lessons interactive, continually learns alongside his students, and knows his strengths and weaknesses.

“A great teacher has a sense of self-awareness as to what they do well and what they don’t do well,” he says. “Some people can be dynamic speakers for a mass audience and hold a lecture hall of 200 in thrall, but one on one, they’re not that strong. Others are the opposite. It is easy to teach people who are smart, dynamic, and interested; it is more challenging for someone who is a bit slower and [finds it] harder to get it.”

A good teacher also models for his trainees, especially in more delicate conversations, such as when giving bad news or asking patients and families to make difficult decisions.

“Residents should be watching you have those kinds of conversations,” says Howard Epstein, MD, a hospitalist and the medical director of the palliative care program at Regions Hospital, St. Paul, Minn. “[Rather than saying], ‘I’m just going to go have a family conference so why don’t you go take care of this, that, and the other thing,’ we should be saying, ‘This is really important. You need to come in and watch me do this now. This is just as important as putting in those discharge orders or putting in that central line.’ ”

The Mind of the Teacher

Incorporating into your teaching all the concepts represented by VACUM is what Dr. Wiese refers to as Phase IV teaching: Teachers are motivated to fulfill the performance needs of the student. Self-awareness is the key to monitoring which teaching phase you are working from. Work toward teaching using the Phase IV paradigm. The four phases are:

Phase I: At this level, the teacher may be subconsciously thinking: “After years of not understanding this topic, I finally have got it and I’m going to need three or four witnesses to sit there while I prove to you and prove to myself that I understand it.” That teaching outlook is all about the teacher and the teacher’s ego; it is an attempt to show how much he or she knows about the topic.

Phase II: Teaching here is related to the subconscious lesson the teacher is likely to have learned during his or her teaching experience. That is, students will give you approbation for acknowledging that they even exist. When a teacher addresses an individual student: “Hey student, let me teach you something,” and the student thinks, “Oh, I love you, teacher, for acknowledging that I’m here and I’m a person,” the teaching is still being driven by the ego of the teacher rather than the performance of the student.

Phase III: The teacher is motivated by awards or financial promotion, and the interest is still based upon the teacher, not the needs of the student.

Phase IV: “This is the nirvana of clinical coaching,” says Dr. Wiese. “The simple goal is that some day, as a medical educator, you’ll turn the corner of some nameless, faceless ward and you’ll look down the hall and you’ll see a former student of yours doing the right thing—performing for the benefit of a patient—because of something you empowered them to do.” The focus has turned from the teacher to the good of the student’s performance for decades ahead. The teacher has empowered the student to do what is necessary to perform well for his or her patients.—AS

Teach versus Coach

Jeffery G. Wiese, MD, associate professor of medicine at Tulane University in New Orleans, has thought a lot about what makes a great teacher and the differences between teaching information and teaching skills. To him it is the difference between teaching and coaching.

Dr. Wiese, who is on SHM’s board of directors, believes medical education is less about the dissemination of knowledge and more about how to apply that knowledge.

“Dissemination of knowledge is requisite but not sufficient,” says Dr. Wiese. “Clinical education is about performance because ultimately it doesn’t matter if the student knows a lot if he or she can’t put it in act for the benefit of their patient. And when you change that paradigm, then you move from being a good teacher to being a great coach.”

Dr. Wiese, who is also director of the Internal Medicine Residency Program and the chief of medicine at Tulane, presented a workshop at the SHM’s annual meeting in May, titled “Great Hospitalist to Great Teacher: Clinical Coaching.”

The five main points of the presentation are represented by the mnemonic VACUM: visualization, anticipation, choosing content that has utility, and motivation.

Visualization

Great teachers empower trainees to visualize how they will use the skill or knowledge for the benefit of the patient. The average lecture on hypotension, for example, disseminates the causes of hypotension and the treatment for each. The great coaching session, however, begins with getting the student to visualize using the skill. “Picture this: You are awakened from sleep on call to see a hypotensive patient,” Dr. Wiese says. “Do you see yourself in the room? Do you see the panic, the fear of those around you? Now visualize feeling the warmth of the patient’s extremities to exclude causes of low vascular resistance. Now imagine feeling the pulse to exclude bradycardia. Are you there? Now see yourself lowering the head of the bed and starting the IV to increase his preload.” The vision makes the content stick in the student’s memory.

Anticipation

“It’s not enough to teach a trainee how to do the skill,” says Dr. Wiese. “You have to anticipate where the trainee is going to get it confused and where the pitfalls are going to be in performing that skill down the road.”

This concept is analogous to that of someone giving directions to their house. Merely giving the student the destination (i.e., what they need to know) is not sufficient. Providing a heads up on where they might take a wrong turn ensures that they arrive at the destination.

In teaching hyperosmolar nonketotic coma (HONKC), for example, a great coach will begin with the warning: “Listen, this is where you could get confused. You might be tempted to ascribe a patient’s delirium to the osmotic effects of the high glucose, and while this can happen, it does not happen with a serum osmolarity of less than 340. You could forget that the cortisol surge that comes from infection is the leading cause of HONKC. Do you see yourself in the emergency department with that patient with HONKC? OK, when it happens, make sure you check the osmolarity; if it’s less than 340, do the lumbar puncture. Meningitis may just be the cause of the delirium and the infection that has caused the HONKC.”

Clinical education is about performance, because ultimately it doesn’t matter if the student knows a lot if he or she can’t put it in act for the benefit of their patient. And when you change that paradigm, then you move from being a teacher to being a coach.

—Jeffery G. Wiese, MD, associate professor of medicine, Tulane University Health Sciences Center, New Orleans

Content With Utility

Teaching the oppressive details about a disease beyond what the student learns from textbooks probably does not have the same utility for them as learning the fundamental principles of how to diagnose, treat, and prognosticate a disease, says Dr. Wiese.

Although most hospitalists train in internal medicine, with a lesser number training in pediatrics or family practice, all hospitalist instructors are still responsible for all students—including those who may be headed for radiology or orthopedics, for instance.

“I can teach the medical content that is of utility to that student’s performance,” Dr. Wiese says, “and I still share responsibility for their performance as an orthopedic surgeon, particularly with respect to how they manage medical disease.” The important lesson is that utility is defined by the learner. “If my student has chosen a future career in orthopedics, the content of the lectures will shift away from high-end internal medicine topics and toward what I think the future orthopedist before me needs to know.”

Motivation

“Should we have to motivate students to be great physicians both professionally and in terms of patient care and knowledge competence?” asks Dr. Wiese. “At the end of the day, the answer should be no; everyone has responsibility for motivating themselves. But, like a great coach, it is still the coach’s responsibly to ensure that when the players are tired, when they’re hungry, when they’ve got other things on their mind, they will stay motivated to want to learn the skill—even before we begin to teach the skill.

“A big portion of that motivation comes from figuring out what their career goals are and helping to link the medical knowledge or the skill that you’re teaching to those hooks, those things that are going to be of interest to them.”

There are four key components to motivation, says Dr. Wiese.

“First, remember the student’s name and use it often,” he says. “Remember that they will not care what you know, until they know that you care. Second, be physical. Reach out with the handshake or pat on the shoulder when things get done correctly. Third, stay focused on their hooks: Couch all content in terms of how they will use it in their future careers, and focus your analogies on their personal interests. For example, if a student likes music, my teaching of heart murmurs is going to use analogies of the song writer and performer.”

Game Time

“The medical knowledge is analogous to the play that the team will run or the skill of throwing the ball, but [there are a lot of other factors that influence what’s needed for] the game-time scenario,” Dr. Wiese says. “It’s how you interact with the clock for the game, how you interact with the referees, how you interact with your team mates, how you interact against the defense.”

To teach in order to prepare your “players” for the realities of the challenge—or the challenges of reality, as the case may be—teachers need to do more than unwittingly repeat the methods used when they were students.

“A student who is learning about a disease from Harrison’s or Cecil’s [textbooks] can focus on all the details and knowledge they need to know,” says Dr. Wiese. “But the thing that they can’t get out of the book and that they really need from the hospitalist coach is all that game-time instruction.”

In other words, hospitalists must consider with their students how to integrate their knowledge into their interactions with the hospital system.

In this era of PDAs, wireless networking, and access to the Internet, hospitalists are way past the point of having to keep all their acquired information in their heads, Dr. Wiese says. “The issue now is how do you ask the right questions and then access that knowledge—and then more importantly, how do you take that knowledge and put it into the ‘play’ that is the patient?” And that is what a student can’t get out of a book, he says—and what they need to get from their coach.

Be an Agent for Change

Don’t automatically transfer the way you learned or the ways you were taught into how you teach your own students. “Learning and teaching are very different,” says Dr. Wiese. “Learning knowledge is focused on the details. Teaching is much more [about] how you put that knowledge into play.”

That kind of transference is easily recognizable in a situation where a student asks “Can you teach me something this afternoon?” and the hospitalist replies, “Well, let me go home tonight and prepare, and then I’ll teach you.”

“What they’re saying is, ‘Let me read up, make a list of facts—maybe worse, maybe put it in PowerPoint,’ ” says Dr. Wiese. “The student could have done that on his or her own.”

Because hospitalists are intimately familiar with the hospital system, they serve as agents of change, Dr. Wiese says.

“Hospitalists are the key group at the first level of being able to take a student or resident or fellow and say, ‘These are the patients, we’re on hospital wards, and let me show you how to put in action the knowledge and skills you have to make a success for your patients,’ ” he says.

Hospitalists know where the system doesn’t work. “The great hospitalist doesn’t [face a problem and think], ‘Oh, woe is me; I’m hopelessly at the whim of the system that is broken,” says Dr. Wiese. “A great hospitalist consistently looks at [the situation] and asks, ‘How can I improve this system?’ The only way that medical students and residents can move out of the helpless role where [they see themselves as] servants of the system is to have hospitalist teachers who have a perspective of themselves as owners and who take responsibility for improving the system. Nothing has to be the way that it is,” says Dr. Wiese. TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

  1. Pressel DM. Hospitalists in medical education: coming to an academic medical center near you. J Natl Med Assoc. 2006 Sep;98(9):1501-1504.

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