Role Modeling as a Teaching Strategy in Residency Education

Transcription

1 Health Sciences Education Rounds Thursday February 10, 2011 Mala Joneja, M.D., M.Ed., FRCPC Gurjit Sandhu, Ph.D. Role Modeling as a Teaching Strategy in Residency Education

2 Introduction Role modeling is a feature of medical education Reviewed at HSER and in The Teaching Doctor

3 Background The term role model first used in the setting of medical students Clinical teachers have a strong influence on students and trainees Learners pattern themselves on physicians they respect and trust

4 Background cont d Role modeling is something that happens, and there is literature describing this Can role modeling be used as a teaching strategy? Something deliberate, that a teacher makes happen

5 Questions to Consider How can teachers capture and document this teaching strategy? We know it exists! Generally, it is implicit, can we make it explicit? Can we take a phenomenon and make it into a tool for teaching?

6 Rationale Pre-Survey Questionnaire

7 What are clinical teachers doing when they say that they are role modeling?

8 Literature Review Role Modeling Cueing

9 Role Modeling Teaching by example Way of demonstrating skills and desirable behaviours Patterning activities after physicians admired for their ways of being and acting as professionals Clinical educators are role models at all times when teaching and in social situations Conscious and unconscious teaching of behaviours Unconscious incorporation of behaviours onto residents belief and bahaviour patterns Positive and poor role models no one is a perfect role model at all times

10 Cueing Cues signal the teacher s communicative intention to manifest new and relevant knowledge Providing cues, reduces the number of integrations the learner needs to make, thereby lowering the extraneous load and facilitating the learning process split-attention effect E.g. spoken text in combination with visual cues reduce split-attention effect Joint attention - process by which one cues another to a stimulus via nonverbal means Cognitive load theory calls the unnecessary memory load caused by the presentation format of instructions extraneous load

11 Methods Pragmatic Quality assurance 1 residency program 8 clinical teaching faculty Individual interviews Open-ended questions

12 Sample Questions Some open-ended questions asked: 1. I understand that there are a number of different contexts in which you teach, such as clinic, ward, etc. Please tell me about how you teach in each context. 2. In what ways do you teach the non-medical expert competencies? 3. In what ways do you teach the medical expert competencies? 4. You use the term role modeling. I. Please explain what you mean by role modeling. II. Please describe a recent experience where you were role modeling.

13 Findings: 3 Themes Implicit/ Explicit although some aspects of role modeling will remain implicit, there is a conscious effort to make lessons learned implicitly through role modeling more explicit to the learner Emulate/ Imitate learners consciously pattern behaviour after positive role models; and unconsciously pattern behaviour after poor role models; Reflection thinking about what we do, how we behave, how we handle specific situations

14 An end of life discussion with a patient Before I have this conversation with a patient, I have a pre-meeting with the resident to plan the discussion. During this meeting, I tell the resident to act as an observer and to watch what I do. This includes surveying my body posture, body language, what I say and how I say certain things. After the discussion with the patient, during the post-meeting, I ask the resident what they observed. I provide him or her with feedback concerning what I was thinking during the discussion, how I felt during the conversation and what I feel are important points to take away from the experience.

15 Communicator Role Explicit cueing Reflection for action Observation Questioning for clarification Pre-test / Post-test Feedback

16 In the operating room When I walk into the OR, the way in which I say hello and talk to the team members matters. Before beginning the surgery, I conduct a pre-flight checklist for the patient. This includes confirming the patient, the operation that is about to take place, the side of the incision, whether or not the patient has allergies, and that pre-operation antibiotics have been administered. This ensures every team member is on the same page. In one room you may have nurses, an anesthetist, more than one resident and faculty member. When there is a group of people talking and music playing in the background, it can be difficult to communicate with the resident who is assisting in the surgery. I usually ask the team if they would mind turning off the music.

17 Manager Implicit Imitation Checklist Review Discussion Conflict resolution

18 The systematic hierarchy of residency rotations In a rotation there is usually a clerk, junior, senior and chief. In the ER, for example, the clerk may make the initial assessment of the patient. The junior will then take over for the clerk, the senior will take over for the junior and eventually the chief resident will see the patient. Sometimes the faculty member will observe the residents from a distance and assess the patient independently before collaborating with the chief resident to discuss the plan of action for patient care. For example, the faculty may say, what s your plan, and how does it match with my plan? This hierarchy occurs in round table discussions, as well as in the OR.

19 Collaborator Implicit Reflection in action Discussion Direct observation Compare and contrast

20 Advocating for your patient While on rounds with a resident you see that a patient is getting worse by the minute and needs a CT scan. You could fill out a requisition form and leave it at that, knowing the investigation will take place a week from today. If you want the test to be done in 1-2 days, you fill out the order and call the radiologist. However, if you feel that it is imperative for the test to be completed as soon as possible, you fill out the form, walk it down to radiology, and advocate to the radiologist on the patient s behalf. When things have to be done, I role model by doing it myself.

21 Health Advocate Implicit Imitate Problem-solving

22 The learning climate: ethical and sustainable practice Sometimes remediation is required to rectify resident s cultural issues, rather than knowledge deficiencies. Faculty have expressed the need for early identification, but struggle with how to address the issue. For example, a male resident may have a problem with taking direction from a female nurse. This issue is quite complex in that it involves gender and power conflicts. Faculty members could refer to Dr. Melissa Andrew, Director of Resident Affairs for assistance.

23 Professional Explicit Reflection clinician educator and learner Problem-solving Review Guided reading

24 Reflection as self diagnosis Faculty members have expressed the need for residents to be more reflective in their scholarly practice. If residents can reflect upon their learning, identify gaps in their knowledge base and communicate their deficiencies, faculty members will be able to identify their specific zone of proximal development and direct their teaching accordingly. When residents are aware of their personal weaknesses, they are more likely to have those aha moments. The earliest identification that can occur is self diagnosis by the learner.

25 Scholar Reflection on action; reflection for action Scaffolding Writing process

26 Findings: 3 Themes Implicit/ Explicit although some aspects of role modeling will remain implicit, there is a conscious effort to make lessons learned implicitly through role modeling more explicit to the learner Emulate/ Imitate learners consciously pattern behaviour after positive role models; and unconsciously pattern behaviour after poor role models; Reflection thinking about what we do, how we behave, how we handle specific situations

27 Conclusion Steps toward this transformation: Acknowledge role modeling Make students aware Encourage clinical teachers to articulate what they are modeling Document, in journal or portfolio, the viewpoint of residents

28 Challenges Making anything which is implicit into something explicit requires openness and communication There is potential for judgment, miscommunication and differences of opinion Environment needs to be openminded, safe and somewhat forgiving

29 Discussion

30 References Association of Faculties of Medicine of Canada. The future of medical education in Canada (FMEC): A collective vision for MD education. ( Published Retrieved August 18, Brainard, A.H., & Crislen, H.C. (2007). Learning professionalism: A view from the trenches. Academic Medicine, 82(11), Cruess, S.R., Cruess, R.L., & Steinert, Y. (2008): Role modeling Making the most of a powerful teaching strategy. BMJ, 336, Dronan, T. (2005). Osler, Flexner, apprenticeship and the new medical education. Journal of the Royal Society of Medicine, 98(3), Frank, J.R., (Ed.). (2005). The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada. Kenny, N.P., Mann, K.V., & MacLeod, H. (2003). Role Modeling in physicians professional formation: Reconsidering an essential but untapped educational strategy. Academic Medicine, 78(12),

31 Matthews, C. (2000). Role modelling: How does it influence teaching in Family Medicine, 34, Rose, G.L., Rukstalis, M.R. & Schuckit, M.A. (2005). Informal mentoring between faculty and medical students. Academic Medicine, 80(4), Saultz, J. (2007). Are we serious about teaching professionalism in medicine? Academic Medicine, 82(6), Stern, D.T., & Papadakis, M. (2006). The developing physician - Becoming a professional. The New England Journal of Medicine, 355(17), Wright, S. (1996). Examining what residents look for in their role models. Academic Medicine, 71(3), Wright, S.M. & Carrese, J.A. (2002). Excellence in role modelling: insight and perspective from the pros. Canadian Medical Association Journal, 167(6), Wright, S.M., Kern, D.E., Kolodner, K., Howard, D.M., & Brancati, F.L.. (1998). Attributes of excellent attending-physician role models. The New England Journal of Medicine, 339(27),