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Teaching Skills for Residents Jonathan Finder, MD Jamie Johnston, MD Academy of Master Educators, Residents as Teachers Committee February 4, 2009 Introduction: One of the most important tasks given to residents is teaching. Teaching occurs at many levels and in many settings. This document is meant to serve as an outline to help residents consider ways to improve their teaching skills. Teaching occurs in 3 primary settings: work rounds, didactic sessions, and oneon-one teaching. Each setting requires different skills and involves teaching at different levels. In all settings there are common themes, which include recognizing and using teachable moments, teaching without intimidation, teaching to level, and making time to teach. 1. Work Rounds Ward rounds or work rounds involve trainees at many levels, from medical student to senior resident. The team is generally led by a physician in his/her 2nd or 3rd post-graduate year. The primary task of work rounds is that of communication: events of the past 24 hours, including the admission of new patients to the team are discussed in varying levels of details. Each new patient presentation is an opportunity to teach with potential teachable moments. Teaching opportunities in work rounds are broad, and include discussion of differential diagnosis, physical examination, pathophysiology, pharmacology, system-based practice, data interpretation, and ethical issues. The challenge for the team leader is to keep rounds on task and on time without sacrificing teaching on the altar of efficiency. Another challenge is for the least experienced members to feel involved and not overwhelmed. Teaching without use of intimidation is an important skill here. Rapid-fire questions without follow up is not a useful teaching technique. When a gross deficiency is identified in a student’s knowledge base, allowing the student to redeem him/herself to the team by a 3 minute presentation (also called the educational prescription) the following day is helpful to all (e.g., “OK, tomorrow come back with a 3 minute talk on how Kawasaki disease presents in children.”). Tied in with this technique is the resident’s unique ability to assess deficiencies in students’ skills, knowledge base, and presentation styles. Identification of weaknesses in the students is key to their development as physicians. How these weaknesses are presented to the student is also important, as it is important to avoid humiliation, intimidation, and devaluing of the individual. Minor problems are discussed in the setting of work rounds (“did you mention the family medical history?”) while major problems are best discussed privately. 2. Didactic sessions Pure didactic sessions are teaching sessions that are not a part of patient care. In general, didactic sessions are given by senior/supervisory residents. Teaching can be topic-based (“antibiotics”), skill-based (student oral presentations, physical examination techniques). The major issue in didactic sessions is making time to teach. Having a regularly scheduled time when the students can count on having a didactic session allows them better regularity in their schedules as well as gives them a chance to prepare presentations. Didactic sessions can be led by a resident or attending or can be led by students with precepting by the resident or attending. Principals of teaching described above (teaching to level, avoidance of intimidation, etc) apply to small group didactic sessions as they do to work rounds. 3. One-on-one teaching sessions Individualized teaching is generally done during the course of the work day and not on a scheduled basis. The major task here for the resident is identifying “teachable moments” when a few minutes of teaching can help cement a learning point that may have come up during the course of patient care. These sessions need not be more than a few minutes in length, but can have a considerable impact on the student experience. Positive teaching experiences tend to draw students towards the field in which the experience occurs. One-on-one sessions are the ideal format for constructive feedback (covered elsewhere in these materials). The “microskills” approach to precepting The concept of “microskills” refers to short, yet effective teaching moments applied during patient care rounds. The 5 microskills of teaching, as described in Resident’s Teaching Skills (2002, Edward, Friedland, Bing-You) are: 1. Get a commitment (what do you think is causing his fever?) 2. Probe for support evidence (“why mononucleosis?”) 3. Teach general rules (“it’s rare to see mono without lymphadenopathy”) 4. Reinforce what is right (“Good call on avoiding amox – that would have resulted in a rash in this setting.”) 5. Correct mistakes (“one of the tests you ordered costs $500 and the results are not available for 2 weeks. Shall we cancel that?”) This schema basically takes a successful precepting style and crystallizes it into a standardized formula that can be reproduced in almost any clinical setting. It is ideal for one-on-one precepting. The above scenario describes how one may approach a presentation of possible mononucleosis. This can be applied to any clinical problem.