The Microskills

It's a typical Saturday night in the department.  You're busy.  I mean really busy; the "too busy to make a run to the bathroom and empty your overly distended bladder" busy.  Your resident comes up to you with their next patient.  At first, you think of just hearing out the chief complaint, telling them what to order, and moving on to the next patient.  Fortunately, a voice in your head reminds you that there is a better way, a way to promote a morsel of learning despite the challenges stacked before you.  Enter the microskills.

The microskills model of teaching, also referred to as the "One Minute Preceptor," is a series of easily performed steps that allow you to maximize a teaching encounter when time is precious.  The steps are:

1. Get a commitment: I love using this step to shorten the presentations from my learners.  Too often, they get lost in the forest when presenting a case.  Simply stepping back and asking, "What do you think is causing their symptoms?" allows me to hone in on the important parts of their presentation.  I can then focus my questions to help me understand why they are concerned about possible conditions on the differential that they have created.  "I don't know" is not an acceptable answer.

2. Probe for supporting evidence: The follow up.  Once they take a stand, you're able to ask the why and what if questions.  The more direct questioning focuses them on the task at hand and allows you to understand the history a little better as well as determining the learners decision-making process.

3. Teach general rules: The time to teach a mini-lecture is not when time is limited.  Instead, focus on a key point of the case, whether a historical factor, workup issue, or interpersonal problem and teach short and succinct pearls.

4. Reinforce what was done right: Reward the learner for their efforts.  Point out the good catches on the history or exam, congratulate them on making the correct diagnosis or picking the most effective workup.

5. Correct mistakes: Feedback is always critical.  Point out errors in their decision-making and explain methods to correct them in the future.  Point them toward resources for future learning.

The microskills have been employed in clinical teaching for over 20 years now.  While effective use of the skills takes more than the allotted "one-minute" advertised by the other name, the skills are quite helpful at keeping the teaching encounter short and focused.  When it gets too busy to teach, reach into your armamentarium for this quick and easy teaching tool. You'll be glad that you did.

Reference:

Parrot S, Dobbie A, Chumley H, Tysinger JW. Evidence-based office teaching-the five-step microskills model of clinical teaching. Fam Med. 2006 Mar; 38(3): 164-7. PMID: 16518731 

See you next week!

Sorry about the lack of posting this week.  I'll be heading to sunny Florida for a quick conference and a few days rest and relaxation.  I'll be back next Tuesday with a discussion of the microskills.  Talk to you then!

Whither bedside teaching?

Observe, record, tabulate, communicate.  Use your five senses.  Learn to see, learn to hear, learn to feel, learn to smell, and know by practice alone you can become expert.  Medicine is learned at the bedside and not in the classroom.  Let not your conceptions of disease come from words heard in the lecture room or read from the book.  See, and then reason and compare and control.  But see first.

-Sir William Osler

I recently received my quarterly faculty evaluation.  I usually take a cursory look into the scores and file the report away for future reference.  On occasion, the residents take the time to write some useful comments that help me to become a better teacher.  I was a little surprised by such a comment with this evaluation:

"Please do not ask the resident medical questions in front of patients, wait until we have exited the room."

In my practice, I find it exceedingly difficult to go to the bedside with my learners.  I often fall victim to the nursing station presentation as I hurry off to see other patients.  Despite this, I make the occasional effort to get to the bedside with my residents and students.  As Osler points out, the best learning is that which is done at the beside with a patient.  While less frequent than I desire, these encounters are fulfilling as a teacher and really allow me to see my learners in action.

Perhaps that is why I find the above comment troubling.  Have we abandoned the bedside for so long that our learners are so uncomfortable in front of patients with a teacher?  Are they so afraid of appearing to be wrong when asked more advanced questions?  I can respect their fear.  I've been there.  I have also learned far more from being wrong and making mistakes.  It's simply part of being a learner.   

Reflecting upon the comment, I decided to pull out one of my favorite articles on bedside teaching and review some tips for making it work.

Before going to the bedside:

Prepare: Formulate goals, know learning needs of your students and residents

Orient learners: Learners should know what is expected before going in.  I guess I have failed to explain to them that it is okay to be wrong.  Uncomfortable, yes, but still okay.

Orient Patients: Let the patient know everyone and their role; they should already know the learner.  Explain that you'll be asking some medical questions and make sure to thank them for their role in teaching the learner

At the Bedside:

Establish the environment: Try to make the atmosphere comfortable.  I try to keep the discussion less formal.  I'll ask some clarifying questions of the patient and then focus on the learners.  The key is to challenge them intellectually without humiliating them.  

Respect learners and patients: Be human.  You must remain sensitive to the patient and how illness affects them.  I do find that patients enjoy learning at the same time as the learners.  Often, the medical discussion forces me to really focus on communicating the same information to the patient in a manner that they can understand.

Engage everyone: Often not a problem where I practice; usually it is just one learner, but if you teach in a setting with a lot of learners, make sure you have questions for all, from the beginning medical student to the PGY-IV resident.

Involve the patient: Make sure to allow the patient to correct unclear parts of the history.  Make sure that they're able to ask questions as well.

Match teacher and learner goals: This topic fits into the "before" category as well.  I try to start my shift by asking my learners what their goal for the day will be.  This allows me to cater the learning to their needs and wants.  With residents, I'm also able to cater to their deficiencies since I work with them often.

After leaving the bedside:

Debrief:  This has 2 purposes: clarify the encounter and plan and to provide feedback.  The learner gets some time for questions, we finalize our workup plan, and then I can provide brief feedback on how to improve.

While bedside teaching is underutilized, with practice it is one of the best clinical teaching tools.  We all have something to offer to our learners, sometimes skills that can only be learned through observation, practice, and reinforcement at the bedside.  Unless we go there and face our (and our learners) discomfort, we cannot begin to realize our full potential.

Reference:

Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med. 2003 Apr;78(4):384-90. PMID: 12691971

Safe Patients, Smart Hospitals

Peter Pronovost, MD, PhD is a name synonymous with patient safety.  He and his team have made patient safety a respectable area of expertise within the house of medicine.  He recently published a book, Safe Patients Smart Hospitals, which explains his quest to improve patient safety, first at Johns Hopkins, and now across the country.  While well written, I wouldn't recommend it to the random reader unless you have an interest in patient safety.

As someone who has a strong interest in making my patients safer, I found many helpful pearls within the pages.  As many of you know the recent media has a myopic focus on checklists as a major way to reduce error.  This is partially due to a misunderstanding of the work that Dr. Pronovost's team has performed.  While checklists do work, and that is clear from the NEJM article listed above, 2 very important facets of their technique have been somewhat ignored: changing culture and rigorous data gathering.

As Dr. Pronovost explains, patient safety depends on 3 things: Translating Research Into Practice (TRIP), a Comprehensive Unit-based Safety Program (CUSP), and rigorous data collection.

TRIP and CUSP have since morphed together into an inseparable approach to teaching about safety.  The two are difficult to discuss as separate entities and as I learn more, I hope to share more details with you.

TRIP is the approach to a problem from a research standpoint; it is the background research.  When they first began their central line project, the team went through all of the guidelines, recommendations, and original research and boiled it down into 5 practical points that needed to occur to reduce central line infections.  This became the checklist.

CUSP is all about culture, and changing culture.  Personally, this is where the rubber meets the road.  Without addressing culture, challenging the status quo, and making people accountable to their actions, a checklist is just a piece of paper sitting in a stack somewhere.  The CUSP program works with the individuals, identifies where failures occur, and changes the status quo. It encourages people to speak up, and gives them the authority to be able to.  It was fascinating to read about the challenges their team faced when moving from one unit to another and how CUSP made all of the difference.

The final important factor in patient safety is rigorous data collection.  Remember "Measure Something?"  This is often the limiting factor in safety research.  The data must be as good if not better than any other research trial or else the conclusion cannot be supported, and therefore, the intervention will be questioned.  The point is made over and over: Physicians are scientists at heart.  It is so true.

So what does this mean to an emergency physician?  If you take the 30,000 foot view, this is a very simple and easily reproducible approach to create change:

-Identify a problem
-Look for evidence of how to fix the problem
-Simplify the solutions as much as possible, you really want a short list
-Start to institute it in your department.

Just like in education, make sure to give feedback to your team on how they're doing, as well as soliciting their input.  If you do this and combine it with strict data collection, you will likely see marked improvements in the departments' morale all while making the care you provide much, much safer.

May the best blog win!

If you read Michelle Lin's Academic Life in Emergency Medicine or Scott Weingart's EMCrit then you already know about the quality information that these two giants are providing to Emergency Medicine.  It's no wonder that they've both been nominated for the 2010 MedGadget Weblog Awards.  Take a look and vote for your favorite!

EMCrit is Featured in the Best Medical Weblog Category

and

Academic Life in Emergency Medicine is featured in the Best Clinical Sciences Weblog Category

There's a lot of competition from some other great blogs so make sure to vote!

Why Blog?

Why create a blog or use a wiki for education?  One good reason is that blogging fulfills the "write something" mandate that Atul Gawande recommends as one of the keys skills in becoming a positive deviant; another is the metacognitive aspect of the experience discussed in this video:





There are many reasons why people blog.  As an educator, I have found that my students depend more and more upon web-based resources.  Learning to use these resources, and better yet, create them, offers an incredible opportunity to teachers.  Lets say that you've decided that you're going to take the leap and begin to blog, or create a wiki, for your students.  What tips can get you started?  If you're unaware of the "Twelve Tips" series published in Medical Teacher, check them out.  The following tips are a few that I found helpful from an article published from that series regarding these web 2.0 tools.


1.  Appreciate the uses of blogs and wikis


These web 2.0 resources have 3 main uses: read, write, and interact.


Reading a blog or wiki are easy to access.  As the author, many programs allow easy incorporation of digital media such as video or pictures that can be shared with the learner.  Links to outside sources are easy to add as well.


Writing can be done by the learner.  This is useful for creating reflection in learners.  These tools can also be used to create online portfolios for the learners.  For some time, I've wanted to do an experiment with my residents and see whether learners in difficulty would benefit from writing a blog covering the content that they find difficult.


Interaction is fairly easy through blogs and wikis.  Through the use of co-authoring or comments, these tools foster the creation of an online discussion board.  Learners can even exchange documents.  While interaction holds the biggest potential, I've found it to be the most difficult use to facilitate in my learners.


2.  Be clear about why you are using a blog or wiki. These tools do have some limitations.  Make sure you are matching the technology to the needs of the learner.  These tools tend to have reduced functionality compared to tradition websites which can limit the amount of content delivery.  Fortunately, as technology improves, the amount of content that you can deliver via these tools only seems to increase.


3. Decide how you want to use the reading of a blog or wiki as a method to enhance learning. I use both a wiki and a blog.  The wiki hosts the entire formal curriculum for the residency.  Residents can download their assignments at their leisure, log the completion of assignments, and a few even have personal pages where they share their knowledge with the rest of the class (EKG and Critical Care pages).  From a teachers perspective, our curriculum is literature based and I'm able to rapidly change reading assignments to keep the curriculum current, and well ahead of any textbook.  The blog is more of a hobby.  It allows me to digest the materials that I'm studying and keep them handy for future reference.


4. Choose appropriate technology to create the blog or wiki.  The tools that "create" your sites vary in their functionality and cost.  Some are completely free but others will increase in cost as the feature go up.  For our wiki, we use Google Sites, which is simple to use and inexpensive ($10 per year for the storage we need).  One thing that we're now finding we need is the ability to limit access to certain pages.  The site unfortunately doesn't allow this feature.  Knowing what you might need in advance will save you time and headaches in the long run.


5. Expect barriers.  While many of todays learners are tech savvy, I've encountered moderate resistance from some.  Participation from the learners varies widely, with some jumping right in and creating content to others who just use it to download their assignments.


These are just some of the tips with my own 2 cents added.  The article provides 7 more which you will find useful if you're just jumping into this.  One thing is fairly certain.  Web 2.0 tools are going to be around for a while and are very popular to the learners coming through the system currently.  Mastery of their use offers a unique opportunity to improve their learning and possibly even accelerate knowledge translation.


Reference:

Sandars J. Twelve tips for using blogs and wikis in medical education. Med Teach. 2006; 28(8): 680-2. PMID: 17594577 

Making M&M Better: The Healthcare Matrix

First, I think Michelle Lin must be psychic.  If you didn't catch her post on morbidity and mortality conference yesterday, then read it!  In fact, read her blog daily.  It contains an amazing wealth of information of interest to anyone interested in faculty development and teaching.

At the conclusion of her post, she gave a glimpse into a tool called the Healthcare Matrix.  Always showing the she is leading the curve, her program already uses it in their M&M conferences.  I had this post planned out for several days since our program is just making the switch and I think it is going to be an awesome tool.  So what if you aren't in a residency and don't have M&M conferences?  Take a close look at it, because it very nicely illustrates a method to investigate errors and suggest potential solutions.  Here we go.

The Healthcare Matrix is a tool developed by some brilliant minds at Vanderbilt  University Medical Center.  They linked the Institute of Medicine's "dimensions of quality," which are safe, timely, effective, efficient, equitable, and patient centered, with the ACGME core competencies for residency programs.  Unfortunately for educators, the competencies of professionalism, communication and interpersonal skills, and practice based learning and improvement are very difficult to teach let alone assess.  Since you cannot have quality care without quality education and vice versa, this tool attempts to present a formative approach to this problem.

So how is this tool used?  First, notice the aims across the top and the competencies down the left side.  The first step is to ask a yes/no question about patient care related to the aims.  Was the care we gave safe?  Was the care timely? And so on and so forth.  For each column that receives a "no" answer the specific competency is examined to determine their contributions to the low quality care given to the patient.  The final step occurs beneath the green bar at the bottom.  In the "Practice-Based Learning and Improvement" row, the user attempts to suggest strategies that can be pursued to improve the system of care.

In an article in the Journal on Quality and Patient Safety, Bingham et al give 2 examples of the matrix in use.  In the first case, a resident was asked to provide an account of a case that went poorly.  The resident compiled a list of "important learning topics and issues. . ."  Here is what the resident turned in:

1. DIC—what is it?

2. DIC in pregnancy—what are the causes?

3. Fibrinolysis in DIC (significance of an in vitro clot test)

4. Local anesthetic toxicity

5. Postpartum hemorrhage with regional anesthesia versus general anesthesia

6. Pulmonary edema secondary to massive transfusion/ volume resuscitation

7. Hypocalcemia from massive transfusion

8. Blood-tinged epidural aspirate—significance?

9. Carboprost, misoprostol, and methylergonovine maleate-indications and uses

10. Third-spacing—can specific IV fluids prevent it?

11. Arterial-line indications—use with massive transfusions or not?

12. Who needs a type and cross? Why does it take 30 minutes?

If you apply these 12 learning points to the matrix, you realize that they only cover 4 of the cells within the matrix, most of which fall into medical knowledge.  This is in keeping with the typical discussion that occurs in a M&M conference, with the attending physicians demonstrating how smart they are to the residents who should have "known better."  


In this case the resident was then was asked to complete the matrix and this is what was returned:

As you can now see, the resident was able to identify issues within 17 of the 36 cells.  Even more importantly, 5 cells fall into the PBLI row and have a HUGE potential for translating into improved patient care.

It doesn't take much imagination to see that the use of this tool will uncover care issues and likely will promote learning as a team.  With luck, gone will be the days of severe hindsight bias and the "shame and blame" approach to dealing with medical errors.  While the matrix contains a great deal of information, the cellular approach allows for focused learning.

With a little practice, this tool will be easy to use and will provide a nice forum for improving not only M&M but patient care overall.

If you already use this tool, please comment on it and let me know your experiences.  I'm looking forward to working with our residents with this tool and any advice will be helpful.

Some Tips:
This is best used as a framework for improvement.  Residents seem to do best when they have to relate each cell to their M&M presentation.

All of the cells do not need to be filled.  Improvements in learning will occur simply because the tool provides a guide for reflecting on all of the factors related to the case.

Try having the attending and resident each fill out the matrix and see where the similarities and differences occur.

Keep a copy of the completed record the residents portfolio, this is a great tool to document learning of competencies that have been difficult to assess and document that learning has occurred.


Reference:
Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG. Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):98-105. PMID: 15791769