Teaching about Dementia In a Clinical Setting

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Teaching about DementiaIn a Clinical Setting

• Using the Microskills of TeachingPrepared by
  Wayne Weston

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Question

• What are some opportunities to help our students
  and residents learn about the practical uses of
  cholinesterase inhibitors?

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Objectives

• At the end of this session, participants will be
  able to
• Describe the eight microskills for clinical
  teaching
• Use the various components of the framework in
  your own clinical teaching (e.g. needs
  assessment, priming feedback)
• Apply these skills in teaching about the use of
  cholinesterase inhibitors in dementia
• Discuss how to start, switch, or stop
  cholinesterase inhibitors.

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The teaching/learning process tends to be more
effective if

• Individuals are intellectually active in the
  learning process
• Individuals have opportunities for practice with
  feedback, the goal of the latter to help them
  identify the success of their learning
• Individuals have opportunities for reflection
• Individuals are clear about what to learn

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The Value of Active Involvement
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The One Minute Preceptor

• Eight microskills
• Needs assessment
• Priming
• Get a Commitment
• Probe for Supporting Evidence
• Reinforce What Was Done Well
• Correct Mistakes
• Teach General Rules
• Reflection Integration

These 5 skills are the one minute part
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Microskill 1 Needs Assessment

• One of the most important teaching skills.
• Essential first step in deciding what to teach
• Want to focus on areas that the student needs to
  work on rather than on things they have already
  mastered
• Use orientation to find out
• What they have done before
• What they would like to get out of the
  rotation/case

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Needs Assessment, contd.

• Global needs assessment best guess based on
• Curriculum outline and objectives
• Previous experience with students at the same
  level
• Specific ongoing needs assessment based on
• Orientation
• Priming
• Questions
• Observing with patients
• Case presentation
• Chart review

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More on Orientation

• Think about the things that will facilitate their
  learning on the rotation (i.e. When you were
  starting a new rotation, what did you wish
  someone would tell you to help you get off to a
  good start?)
• Climate setting
• Approach to supervision and teaching
• Student assessment
• Additional items

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Microskill 2 Priming

• Preparing learners before they see patients

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Priming

• Create some relevance or experiential link
• Ever work in this environment before (i.e. E.R.,
  wards etc.)?
• Ever see or manage a case like this before?

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Priming, contd.

• Clarify the task
• Separate and acknowledge the difference between
• The learning objectives for seeing this case
• The service/support requirements of the case
• Define what questions will need to be answered
  following the case
• What is the diagnosis or Differential diagnosis?
• How will we differentiate these?
• How will we manage the symptoms?
• What are the patients outcome goals?
• What is the prognosis?

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Priming, contd.

• Learning focused on diagnostic skills,"Meet me
  back here in 15 minutes and present a problem
  list and differential"
• Learning focused on management issues,"The
  diagnosis is pretty clear. Review all the results
  with the patient, discuss the treatment options
  and let me know in about 30 minutes what you
  think will work the best for her".
• The learner must feel safe enough to risk a
  commitment even if it is wrong.

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Priming, contd.

• Promote reflection
• Ask students to report not only on their clinical
  findings but also their own thoughts feelings
• Self-observe what they do to prepare for each
  patient visit
• Ask, How might your prior experience with
  patients affect your decision-making in this
  case?
• Give them time for reflection /or to look things
  up
• From Ron Epstein Mindful Practice in Action II,
• Family Systems Health, Spring 2003.

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Priming, contd.

• Decide on the roles of teacher student when
  going back in the room
• Student conduct the interaction
• Consider a short role play
• Decide on a bail out plan if necessary
• Teacher take over outline your plan so that the
  student knows what to look for (but acknowledge
  it may change depending on what happens in the
  interaction)
• Some combination of above be clear about who
  does what

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Include the Patient in priming

• Saves time
• Patients like it
• Involves the patient
• Priming is even more important to help student
  perform well avoid embarrassment
• Opportunity to model effective interaction
• Make sure patient did not misunderstand comments

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Microskill 3 Get a Commitment

• The learner must feel safe enough to risk a
  commitment even if it is wrong.

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Microskill 4 Probe for Supporting Evidence

• What......( factors make this diagnosis likely)?
• Why...... (do you suggest getting this test
  first?)
• Which......(medications are available for this
  condition?)
• How...... (did this prognosis emerge as the most
  probable?)

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Microskill 5 Reinforce What was Done Well

• Some examples
• "You did a good job of considering multiple
  possibilities and prioritizing the most probable
  diagnoses"
• "I noticed how well you considered the patients
  age and concerns about cost in selecting
  medications"

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Microskill 6 Correct Mistakes

• "I agree this patients headache is worrying him,
  but from the history and in the absence of
  neurological signs, CT is more likely to distract
  us with false positive findings than change the
  diagnosis or management plan. Let me give you
  some good references on that and help you discuss
  this with the patient."
• "That drug is often a good first choice for this
  condition, but she is also taking warfarin (or
  has an elevated creatinine) and the interaction
  would be dangerous."

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If the Student had Difficulties

• Answer a few questions
• Short role play of part of the interview that the
  student had trouble with to consolidate
  learning
• Suggest references for review after the office

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Feedback Grid
Developed by the Bayer Institute for Health Care
Communication
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Time

• Frequent short feedback vs. marathon sessions
• E.g. beginnings, middle issues, endings
• Teach reflection self-assessment
• Involve others e.g. nurse, peers, patients

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The Feedback Process

• Private setting.
• Postpone feedback when you are angry.
• Invite self-assessment first.
• Link feedback with learners objectives.
• Use the feedback grid continue do
  different.
• Compare self-evaluation with your observations.

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The Feedback Process, contd.

• Elicit or suggest alternative behaviours.
• Address realistic changes in doable steps.
• Provide an opportunity to try again (with real
  patient, simulated patient or role play).
• Establish clear follow-up plans.

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Microskill 7 Teach General Rules

• "In older patients with headache, it is important
  to consider glaucoma and temporal arteritis as
  well as the primary headaches"
• When both parents come with a sick child, it
  usually indicates they are very worried and we
  need to pay extra attention to their concerns."

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Microskill 8 Encourage Reflection and
Integration

• "How did things go today from your perspective?
• Who was you most interesting patient this
  afternoon?
• "How is the practice different from your
  expectations?
• "Did anything surprise you today?
• Encourage them to keep a personal journal of
  their reflections

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Videotape example
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Exercize

• Work in small groups of 6-8
• Roles of group members
• Facilitator
• Recorder/reporter
• Expert
• Resident this role can rotate
• Teacher this role can rotate

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Roles for resident

• Use one mentioned in the initial discussion of
  opportunities
• Margaret Jones with dementia consideration of
  switching meds prime the resident
• End of a busy day. Discuss Martin Schwartz
  family wonders about Exelon
• Chart review ?inappropriate switch to Exelon

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Your task

• Decide who does what
• Select one of the role plays
• Strategize briefly
• Role play
• Get feedback
• Re-do part of the role play if desired or get
  someone else to try it
• If time, do another role play
• Report on what you learned

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