Teaching Tips & Tools - Medical Expert Role

Poor Knowledge Base

Developing a “Personal Learning Plan”: Learner should review recent assessments with their program director (i.e. exams, feedback) to identify knowledge gap areas. Based on what was identified as areas needing improvement, the learner could be asked to submit a reading/review plan including a list of resources that will be reviewed. This can be done all at once or per block/rotation. In addition to text-book reading, the learner should couple studying with cased-based study practice in order to translate textbook knowledge to practical cases.

Review of Expectations: Have the resident review the educational objectives for each upcoming remedial rotation directly with their remedial preceptor prior to each new rotation. Discuss with the remediation preceptor the expectations for that trainees level of training as well as relevant RCPSC educational objectives to that rotation to assist in directing and clarifying medical expert expectations.

Pre- and post- Knowledge Tests: Program can develop a pre/post testing schedule for the resident on a weekly/biweekly/monthly basis covering key content areas of concern in relation to each rotation. A pre-test should be delivered at the beginning of the rotation and reviewed directly with the resident, to help develop a study guide/plan addresses knowledge gaps and areas of deficit and help guide studying. A summative post-rotation or end-of-remediation test (written or oral) can be administered specifically around identified areas of concern to track improvement.

Study Strategies for Content: Some tips on improving study efficiency:

1. Focus on case-based studying rather than content coverage: Since the residency context requires learners to expand upon their knowledge, it is more strategic to study around cases they’ve seen. Rather than reading through your textbooks, use text books as reference material when you get stuck with recalling certain facts or concepts when reviewing a case.
2. “Case” cards: Cue cards are excellent for practicing recall. To extend the knowledge, learners can use a similar concept making cue cards based on cases rather than content.
3. Skim-reading resources: When dealing with a large volume of study material, a more efficient use of resources (i.e. textbooks or journal articles) is to skim read rather than reading in full. Advise learners to “skim and select” – skimming through the readings (i.e. headers, images/diagrams, and tables) and identifying gap areas that need further in-depth review – go back and review just the areas needing attention.
4. Making a Connection: Connect study material to memorable cases or personal memories to make them more salient. Consider making notes in a grid form with the following columns: Content/Fact, Associated Memory, and Extension. Extension refers to “what’s next” or what/how would you apply this information in the future.

Knowledge Translation & Evidence-Based Medicine

Support it with Evidence: A resident should be instructed that, whenever presenting a patient, they must support the management decisions with 1 key piece of evidence and share the specific resource with their preceptor. As homework, find an additional piece of evidence or an alternative solution to consider. The resident could maintain a growing library of resources by doing this daily for a set duration of time. 

Study Strategies & Homework Activities for Clinical Reasoning: There are some activities in the literature that are recommended strategies for dealing with translation and enhancing clinical reasoning skill.

1. Concept Mapping: Concept mapping is a strategy using self-constructed diagrams and linking words and lines, students visibly expose their assimilation of new concepts into preexisting knowledge and how they relate to each other. The Calgary Blackbook Online Guide provides clinical examples.
2. Highlighter Exercise: This approach provides practice with identifying key features, distilling information, and selective presentation of pertinent details. Going through cases or patient charts, the learner highlights key clinical features and parts of the note that seem most important to consider in establishing a diagnosis and plan of care.
3. Script Sorting: An exercise in prioritization. Script sorting is a technique that can be used to broaden the differential before honing in on a diagnosis. The exercise prompts explicit comparing and contrasting of patient data against stored illness scripts as well as prioritization of items in a differential diagnosis.  The resident will work on learning to rule out all possibilities by comparing and contrasting certain signs and symptoms across a differential diagnosis.
4. Horizontal reading: This approach promotes storage of information in the form of scripts. The learner focuses on defining and discriminating features of similar types of diagnoses and then discriminate between these by identifying differing symptoms. This is a compare and contrast exercise of key features of related diagnoses. 

Diagnostic Thinking Inventory: This is a 56-item diagnostic thinking inventory was developed to measure two aspects of diagnostic thinking: the degree of flexibility in thinking and the degree of knowledge structure in memory. The inventory has been used to assess an individual student's and clinician's diagnostic thinking and to plan ways of improving their diagnostic thinking.

Critical Thinking Worksheet: The following Critical Thinking Worksheet was created by Dr. Heather Armson in the Department of Family Medicine at the University of Calgary. The tool is meant to help to organize the learner’s thinking process.  Preceptor to review and give feedback.

Procedural Skills

The best approach with procedural skills is continued practice, in a simulated environment or in real-time. Simulation training can take many different forms: virtual environments, patient management problems (such as through virtual patients), anatomical models or cadavers, task-trainers, standardized patients, teaching videos, etc.

The Advanced Technical Skills Simulation Laboratory (ATSSL) has access to a number of trainers and programs can coordinate with this group for access to simulation tools and time to use the space. Additionally, the Medical Skills Centre has access to training spaces and can arrange standardized patient sessions.

Tactile/Dexterity Practice: Learners can practice using their hands quickly and improving tactile skill by practicing tying knots/sutures with a timers, without looking, or in awkward position (i.e. behind your back or in a bag where you can’t see your hands). They can try tying knots timed and blindfolded.

Task-Trainers: Learners should be assigned regular practice times on task-trainers. Again, learners can challenge themselves when using the trainers by trying to: Looking away/up/not at their hands, Cover their hands or close their eye, Practice in the Dark, While having a conversation, Timing the Procedure.

Entrustment Scale: Beyond EPAs, using an entrustment approach designed for a specific task, can provide learners with a clear progress in their approach. An entrustment scale allows for progress in independence in performing particular skills.  

Progressive Approach to Complex Cases:

1. STEP 1: Direct observation and real-time verbal feedback/prompting (as needed) of any surgeries the resident has participated in. Learner should prepare and maintain a pre-surgery log-book writing out the steps of each surgery beforehand. Practicing visualization of cases.
2. STEP 2a: Continue to maintain pre-surgery log-book, writing out procedure steps before every surgery and now include 3 anticipated problems and required action steps. Discussion of cases in advance with attending including review of possible/common complications and strategies – attending should discuss & assign anticipated problems that the resident will reflect on in their pre- surgical log. Direct observation with minimal guidance (as needed) during procedures.
3. STEP 2b: Add to the surgical log by writing a summary of all surgeries including insights around: What went well, when was I independent vs. requiring assistance, what are specific areas/steps that require improvement?
4. STEP 3: Present case and plan before procedures, talking through procedure/process. Aim for limited to no intervention during procedure.

Clinical Skills (i.e. Patient Histories and Physical Exam Skills)

Reverse Observations: A learner can be assigned to shadow or observe a more Senior resident or a preceptor, taking note of differences in their approach and style, and selecting tactics and characteristics they might like to incorporate into their own practice.

Timed Patient Histories: Time-limited sessions for information gathering are meant to work on efficiency and focused history-taking skills, you can work with the learner to practice “timed” patient assessments using a timer if it is appropriate and safe to do so.

Brief Structured Clinical Observation: Brief observation of the resident in clinical practice. Preceptor will observe/take notes/assess an interaction, then debrief the learner, highlight strengths and weaknesses of each interaction. Process (for preceptors):

• Observe and record —the observer writes down the learner’s history gathering questions verbatim categorizing them as open-ended and leading or closed-ended questions.
• Debrief the learner —the preceptor asks the learner “What did you find out with that question?” and “What else might be important?”
• Review the script— the preceptor and the learner discuss what questions led to useful information and what additional questions might be needed.
• Conclude —the preceptor points out 1–2 strengths and 1–2 things to improve upon.

These can be scheduled or unannounced.

Standardized Patients: Standardized patients are actors trained to simulate a medical condition. It is a good way to provide learners with additional exposure to cases in a non-clinical setting. The Medical Skills Centre has access to training spaces and can arrange standardized patient sessions, as well as audio and video recording equipment that are ideal for facilitating debriefs afterwards.

The RIME Model: The RIME framework is another model that can be used to classify a learner’s skills. RIME stands for Reporter-Interpreter-Manager-Educator and indicates an increasing level of proficiency, expertise, and independence that learners progress through in their training.

For learners who need refreshers or extra tips on pediatric examinations, this website has videos demonstrating the pediatric physical exam and different stages and other linked content specific to pediatric medicine: 

https://cumming.ucalgary.ca/programs/pgme/supportlearnersindifficulty/teachingtips/medicalexpertstrategies

Clinical Reasoning Skills, Data Synthesis, the DDx

Oral Case Review using SNAPPS: The SNAPPS framework is an approach to encourage thinking aloud through the clinical reasoning process. SNAPPS stands for: Summarize, Narrow, Analyze, Probe, Plan, Select. It has been shown to improve clinical reasoning and developing a differential diagnosis.

The One-Minute Preceptor: The OMP model can be used as another probing model for preceptors to efficiently teach and assess the student’s thought process. The OPM process ask clinical teachers to: Get a commitment, Probe for supporting evidence, Teach general rules, Reinforce what was done right, and Correct mistakes.

Chart-stimulated recall: A tool where the learner reviews past chart notes of patients they were involved with. They review the actions taken and follow-up required through a series of probing questions. This is an exercise meant to encourage questions and stimulate reflection. See CSR worksheet.

Reverse Observation/Role-Modelling while Thinking Aloud: In this activity the learner observes mentors managing complex cases. The mentor talks through their reasoning process. The conversation can progressively turn into a back-and-forth conversation were the mentor would ask first and then articulate their thinking to compare lines of thinking. The learner can reflect on the differences in thinking to compare processes and the end result.

Clinical Decision-Making, Dx and Management Plan

Complex Case Review: Have the learner review a number of long-complex case histories. Have them highlight pertinent information to the diagnosis (or pertinent negatives using a different colour) and write a brief summary of the patient based on only the highlighted/identified information. Once this is done, have the learner try to distil the whole problem into one sentence.

Extension to Complex Patient Review:  After reviewing of a complex patient note with the learner, role-play what a follow-up meeting might look like and have the learner come up with a short and long-term management plan.

Reverse Presentations: Reverse presentations require a learner to focus on their differential diagnosis and management plan, and deemphasize the data collection and presentation of known data. This is a facilitated exercise to be done from time-to-time through role-play and/or case summaries & presentations. Reverse presentations can be practiced with a mentor or remedial preceptor during protected time each week in select blocks/rotations. Process:

1. Start case presentations with the assessment and plan
2. Present pertinent observations in support of the assessment
3. Identify any other distinguishing observations that might negate the assessment
4. Reconsider (or confirm) initial assessment
5. Develop short term (immediate next steps) and long term (to consider) plans

Cognitive Biases

CMPA Good Practices Guide: The Good Practices Guide are a series on online modules covering a wide variety of CanMEDS topics. Under the “Clinical Decision Making” module, there is a section on cognitive bias that the learner could review.

Reading and Reflection Assignment: Consider assigning, or have the learner find their own reading materials, around clinical reasoning and cognitive bias. The learner can write and submit a short reflective paper about their own reasoning processes and susceptibility to different types of biases, with examples from their own practice. Have them consider what they are thinking when collecting data, when delivering news, and when you are generating and articulating a plan. Finally, have them develop a short check-list of “shelf-check” questions to use to try and catch themselves in their bias.

Reflection Follow-up: The resident can review all the patient notes around some of the past cases. Through this review the learner can try to identify:

1. What was the difference between their conclusions and the ultimate diagnosis?
2. What features did they focus on that lead them to their conclusions?
3. What indicators did they miss that could have lead them down the right path?
4. Based on these missed indicators, how would they change their diagnosis and management plan?

To stimulate reflection, some of these TED Talks provide some remarkable stories around errors in medicine: What Doctors Worry About Playlist.

Scripted Oral Exams: Similar to the idea of a script concordance test, construct an oral-type exam that is “progressive” in that some information is provided and the learner provides an initial diagnosis and plan. Then, additional information is given to the learner, such as mock lab results or additional information from the nurses, forcing the learner reconsider their initial DDx & Tx. This can force learners to change their initial line of thinking, addressing anchoring bias.