“To study the phenomena of disease without books is to said an uncharted sea. To study books without patients is not to go to sea at all.”Sir William Osler

Why is it Hard?

Patient care is top priority Patient is another actor

Hard to predict what he/she will do or say Sometimes the learners say some

crazy things… Once it’s said, it’s said It’s hard to be patient You want the patient to trust the team You want clear communication

Why is it Important?

Learners need to learn It’s hard for learners to pay attention

if they are only watching you work It is more efficient to teach in front of

the patient The patient learns too

In front of the patient is the real deal

The Ethics of Teaching with a Patient

http://jama.ama-assn.org/cgi/content/full/291/1/119

Discuss with a neighbor…how do you handle the ethics of teaching and learning using patients?

Setting the Stage…with the Learners State clear expectations Be specific about your wishes and

your pet peeves Claim your role

You will correct, educate, and add depth in front of the patient for the benefit of both the patient and the learner

This doesn’t mean the learner is not doing a good job – this is your role

Set the Stage…with the Patients Make it part of the culture to teach Assure the patient understands the

roles and who is who Use the words teaching and learning

in conversation with the patients Be clear about who is in charge

Try to have the learner do the introductions

Always make sure the senior and the attending are introduced clearly

What will you say to state your expectations to your learners, and to your patients?

Ground Rules for Teaching in front of the Patient Try to support the learner

But don’t agree if you don’t If you are responsible for the patient

at any level, say something Student presents, intern and resident

comment, attending closes Keep patient care the priority

Take over if you have to

Words that Might Help

“There are lots of ways to do it right. Another way is…”

“It’s good you are more conservative in your approach than I am because you are less experienced, I think we can go on and…”

“One thing you probably don’t yet know is…”

“That would be ok if...but here we have to…because….”

Words that Might Help

“We frequently gain more details of the history after the family has time to think about things.”

“I’m sorry to interrupt but I’d like to correct one thing…”

“You know, this is very complicated. I will come back and discuss this in more detail. What we need to do now is…”

Words that Might Help

“That is a good start. Dr. ________, what do you think?”

“It looks like you did your reading on Mr. _____ ‘s condition. Great! Experience also teaches us that…”

To the patient, “How did she do?”

Ideas to Encourage Teaching in Front of the Patient Have the learner with you Round in the room Explain to the patient, but assure that

the learner is listening Activated Observation

Set expectations beforehand Ask questions after

Show the patient the film Ask the patient to teach

Can you teach the medical student about your condition?

Tips

Let the most junior learner directly involved enter the room first and speak first

Limit jargon Balance demonstration with

observation Demonstration is when the teacher does Observation is when the learner does

Teaching Physical Exam

Teach the patient while demonstrating to the learner “I can feel your liver right here.” “I’m checking for an effusion in your joints.”

Allow the learner one piece at a time “I want Dr. _____ to learn how to do this too.

Can she check also?” Direct the learner to what they should

find “Listen to that diastolic murmur at the apex”

Instruct the learner in front of the patient to return for more PE

Teaching Physical Exam

Stress the importance of observation of the patient Everyone can do that at the same time Ex: Rashes, Respiratory Effort, Color, Tone,

etc. Make your learners expect questions about

what they saw after you leave the room

Thank the patient “for being a teacher” Don’t dwell too long

Write down one technique you will try to use

Difficulties in Teaching Procedures The learner is nervous The teacher is nervous The patient is nervous Sometimes the procedure is urgent The teacher might not know exactly

what to do Time pressures Pressure to get the procedure done

right

Steps in Teaching a Procedure Demonstrate the procedure

This may be done by another teacher Talk through step by step

This is typically done away from the patient

Let the learner rehearse or teach back

Practice with supervision

First Steps

Know how to do the procedure Use resources as necessary

Central line placement http://content.nejm.org/cgi/video/356/21/

e21/ Umbilical line placement

http://content.nejm.org/cgi/video/359/15/e18/

PE findings http://content.nejm.org/cgi/content/full/360/

18/e24/DC1

Getting Consent

Take the learner with you The person actually doing the procedure

should have been present for the consent, or should repeat the process

Be truthful in obtaining consent You can describe the work of the team

How do you respond to “Have you ever done this before?”

Teaching Procedures at the Bedside The teacher must be very actively

observing Assure appropriate set up Assure appropriate technique

The teacher should talk to the patient about what is happening, but the learner should be listening The more senior person is (should be) calmer The talking is just as much for the learner The learner can focus on the procedure if the

teacher secures the communication

Practice

Write out the steps to a procedure Laceration repair Intubation Placement of a line Arterial stick Lumbar puncture Splint placement Others

Teach it to a peer

Conclusions

We need to teach with and in front of patients for learners to learn

Set the culture to support that teaching

Have the learner with you Set the expectations with patients

and learners Practice words and tips to make it

easier

Sir William Osler