So Let’s Begin With WHY?

At the recent Teaching and Learning to the Power of Technology Conference, three professors at the University talked about what they liked about twitter in the classroom:

• Questions: Students asked questions about both the content and classroom processes (When is the exam?) and were answered by both the prof and other students which cut down on the time Profs spend answering individual emails.

• Engagement: In large classes, it can be difficult to get students to engage with each other in the learning process. Twitter increases this activity both with fellow students and with the Prof.

• Presence: In large classes, students can seem to flow together in a mass of faces. Twitter can give Profs a sense of who people are as individuals without breaching the professionalism divide.

• Acceptance of new technology: Many students use twitter as a form of note taking that can be checked through what peers are saying about the content. Prof can check on how accurate the key points are being perceived.

And Follow Up With HOW?

Begin with a course hashtag # something short, descriptive and clear that isn’t being used elsewhere on Twitter. Ideally the students will be involved in coming up with something useful. Having a class #hashtag avoids the issue of students being added to personal twitter accounts. Add the course #hashtag to your presentations.

Decide how actively you want to be involved in the #hashtag:

• Minimal: set twitter office hours when you will answer questions

• Medium: sent articles, images, reminders and other resources that might enhance the learning experience and actively encourage students to tweet images and notes on your presentations

• High: Tweet your presentation as you are giving it by using tools like Status Present. Show the twitter feed for the class on a second screen or every 15 minutes and answer questions that are posted.

If you want to comment on or add to my ideas, contact me @bonnycastle.

Do you think it is fair to ask physicians to become familiar with resources like this or should it be the responsibility of organizations like the Canadian Cancer Association? What responsibility do patients have to inform doctors about groups they belong to?

Subsequently, I started reading Dr. Roger Shank's book "Teaching Minds: How Cognitive Science Can Save Our Schools". In the book, he talks about how Teaching = Telling was common practice for hundreds of years. Oral traditions of teaching are holdovers from the days when books and paper were rare commodities, but then television and the Internet entered the world and changed people's ability to access vast quantities and qualities of information quickly.

Teaching = Telling isn't just outmoded, it is dangerous. The practice of non-critically believing what people tell you, particularly people in authority or people with notoriety is what has led to the refusal to vaccinate children, creationism taught as science, financial scams by trusted advisors and a proliferation of non-evidence based healing practices.

Teaching = Telling in the medical classroom doesn't engage minds in critical thinking, but it also doesn't help students remember information either. Students attention to what they hear is the key components of learning in an auditory culture. If students' attention span = 15 minutes of concentration on a good day, they will remember about 1/4 of what they heard in a 60 minute lecture. Combine the distraction of trying to pay attention to poorly constructed, overstuffed PowerPoint slides and retention drops even further.

So take a minute and think about - What is your teaching philosophy? How do you believe people learn?

For ideas about how to actively engage students in medical classrooms see the teaching techniques section on the right hand side of this blog.

A doctor recently asked me about an occurrence in his practice and I realized that most doctors receive no training on how grief can interfere with the doctor/patient relationship. Doctors need to understand how grief impacts on communication and what communication tools will help the patient/family move through their grief. The following is not meant to be a complete treatise on Grief but hopefully it will facilitate you, the medical educator thinking about what you need to prepare your students for. Most medical students received some awareness of the stages of grief as stated by Dr. Kübler-Ross, so we will begin there.

Denial

We know that upon first receiving bad news, patients and family members frequently enter a state of shock where they stop being able to hear or feel because their brains are functioning at a flight/fight/freeze stage. To admit to the pain is to admit to an ending. In some cases, people use alcohol or drugs to maintain the feeling of numbness which can be useful initially but doesn’t allow the person to move through the stages. Some people belief letting go of the pain means letting go of the old self/family member.

Avoid saying:

• I know how you feel
  
• It’s part of God’s plan
  
• They are in a better place
  

Some suggestions at the initial meeting:

• Offer coffee or tea to give people time to unfog
  
• Sit silently until the person is ready to talk
  
• If information needs to be conveyed at this point, bringing a third party such as a friend or as a last resort a nurse in to take notes. Remember the person is unlikely to remember details of what you say
  
• A cycle of emotional pain avoidance can precipitate addiction and it may be worthwhile nonjudgementally mentioning the need to be careful about alcohol and drug use during this time.
  
• Expect people to cling to hope.
  

Hope

All that ever sounded like judgments and criticism are just tragic, suicidal attempts at saying please ...(meet my need) -Marshall Rosenberg

Although not a stage in Kubler-Ross, in my experience Hope goes hand in hand with denial. We are a culture that believes in miracles, popular literature is full of the power of prayer, angels and positive thinking. The patient and family will think "If it worked for a stranger it should work for me." You will find this stage a paradox because on one hand, your medical training says X and you may feel the patient is challenging your knowledge. On the other hand, you wish there could be a miracle no matter how unlikely. Understanding that hope is a normal response and your competence isn't really being questioned is important.

Anger

Never put your but (t) into the face of an angry person -Marshall Rosenberg

If the miracle cure didn't happen, the patient/family is overwhelmed with feelings of rage. Abuse of alcohol and drugs traps a person in feelings of anger. At this stage, they are looking for someone to blame. God isn't available but medical personnel and family members sometimes are. Again it's important for the resident to realize anger needs to be spoken and this is not the time for defense. At the heart of the anger is a person in profound pain. This is the time to listen with compassion. Compassionate listening deescalates violence and allows the thinking brain to come to the surface. Once it surfaces, the patient/family is ready to engage in any problem solving that is needed.

Avoid saying:

• You have so much to be thankful for
  
• You should or You will
  
• You have no right to be angry at me even if that is true, this statement will escalate anger.
  

Some suggestions for communicating with an angry patient/family member:

• Sit quietly and listen lowering your height appears less threatening
  
• Say you are sorry they are angry/in pain (you aren’t admitting guilt, you are acknowledging their pain)
  
• Ask "Have you thought about. . .?" “What can I help you with?” once they have settled down.
  

Finally help students/residents to identify their own support systems.

Resources

The Angry Patient

Breaking Bad News

Collusion in doctor-patient communication about imminent death: an ethnographic study

DEATH AND DYING in Light of Affect

Disclosing Adverse Events

Helping Patients, Families, Caregivers, and Physicians, in the Grieving Process

There are three major locations that influence the methods chosen:

1. In the Office/Hospital
You control what information the patient receives
vs. Physician Time; Expense of purchasing or creating resources

2. Community Resources
Doesn't require a lot of physician time
vs. May not have resource in your community

3. Online Resources
24 hr/7day access anywhere anonymous in many cases
vs. Physician needs to do some research about sites medical accuracy

Examples of In Office/Hospital Promotions
•paper based handouts
•reading material in the waiting room such as medical comics for kids and aboriginal teens.
•a nurse or other healthcare provider that runs educational sessions once a week
•referral sources within the hospital such as a diabetic counseling service
•use of a whiteboard to highlight key points
•one-on-one discussions during visits.

What others can you think of?

Examples of Community Promotions
•access to patient support groups
•organizations such as Kinsmen, Arthritis Society, Saskatchewan Cancer Society, FASD Support Network, Lung Association
•Aboriginal and immigrant specific programs

What responsibility do you have in helping patients connect to appropriate community groups?

Are their certain types of patients that are more likely to receive this type of support from you?

If you were to survey your community's resources, where do you think the gaps might exist?

Examples of Online Promotions
This section contains more information than the other locations because residents tend to lack awareness about what is currently available and how physicians are currently using online sites.

"My blogs saves time in exam room (when patients read content). Education occurs during, after, before & within visit." Seattle Mama Doc speaking at Swedish 100 conference.

" I think it will become malpractice to Not offer a social network prescription." Roni Zeiger MD Chief Health Strategist at Google

"If somebody has no clue about possible uses of data, should they be custodians of it?" E-Patient Dave

"The online health-information environment is going mobile. 17% of cell phone users have used their phone to look up health or medical information and 9% have software applications or "apps" on their phones that help them track or manage their health." PEW study

CBC reported "41 per cent of the Canadian adults polled said they turn to online sites centred around a specific disease, medical issue or health-related product. Nine per cent visit online patient communities such as chat rooms and support groups.What is perhaps most remarkable is that 67 per cent of the time they trust the information they're getting, the survey suggests."

1. Read Pilot Study of Providing Online Care in a Primary Care Setting

2. Take a look at the results of The Ferguson Report on The Most Useful Resource for 9 Dimensions of Medical Care--As Rated by the 191 Members of an Online Support Community

3. Look at the NNT site that might be useful for discussing evidence based risk issues.

4. The most accessed medical information sites in the US:

i. WebMD 15,700,000/mth
ii. NIH 10,800,000/mth
iii. Mayo Clinic 8,200,000/mth

What sites might be Canadian equivalents? How would you evaluate these sites? One method is to look for the Honour Code symbol. Look at the bottom of the most accessed sites in the US for the HonCode symbol. Why might it be missing from the NIH site? Check out this Canadian site.

5. Take a look at these recommended online patient support group sites including Facing Cancer Together. What type of patient might an online support group appeal to? What assumptions are you making based on age or other factors that might prevent you from recommending an online group?

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Hint
Dr. Dan Sands, MD, MPH, the Senior Medical Informatics Director at Cisco Systems has the following suggestions for working with Internet savvy patients:

1. Break the ice - "Have you ever looked for health information online?"
2. Learn from them. "Have you found anything useful?"
3. Assist your patients. "Why give an outdated paper? Why not give info on the web that's being constantly updated?"

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Final Reflection
Based on what you have been reading in this section, what method of advocating for individual patients is missing in your practice? How can you use information from patients to build your "resource library"? How might you implement changes in your practice to improve your advocacy skills? What skills do you need to improve in order to be competent in Health Promotion? Have a conversation with two of your preceptors about how you might improve your advocacy skills with individual patients.

Hierarchical View
undemanding
difficult
non-compliant
whiny
challenging authority

Patient Centered View
well informed or afraid to ask or unsure what to ask
concerned, frightened or confused
lacking trust or didn't understand or unable to comply
frightened
questioning

Take a moment and think about the times you have advocated for a patient. The circumstances probably fell within one of the following categories:

Family You want family members to start or stop doing X in order to improve the patient's health
Physicians You want a patient seen by another doctor or you want test results/procedures expedited
Other Healthcare You want a patient on a waiting list, or to receive homecare/counseling, extra service
Outside Agency/Club You want the patient to receive housing, welfare, equipment, or special services
Political Your member of parliament might help expedite an issue for a patient or their family

All of these are examples of individual patient advocacy that occur everyday. Less obvious forms of advocacy are internal. In your next day of practice, observe 5 examples of how you advocate for your patients. What skills as a collaborator or communicator did you use? What skills do you need to develop further? What barriers might occur within yourself, such as fatigue, frustration or fear that prevented you being an advocate? How might you encourage yourself to change how you respond to one of these barriers?

"Definition As Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.

Description Physicians recognize their duty and ability to improve the overall health of their patients and the society they serve. Doctors identify advocacy activities as important for the individual patient, for populations of patients and for communities. Individual patients need physicians to assist them in navigating the healthcare system and accessing the appropriate health resources in a timely manner. Communities and societies need physicians’ special expertise to identify and collaboratively address broad health issues and the determinants of health. At this level, health advocacy involves efforts to change specific practices or policies on behalf of those served. Framed in this multi-level way, health advocacy is an essential and fundamental component of health promotion.

Health advocacy is appropriately expressed both by individual and collective actions of physicians in influencing public health and policy."

Key Competencies
Physicians are able to:

1.respond to individual patient health needs and issues as part of patient care
2.respond to the health needs of the communities that they serve
3.identify the determinants of health of the population that they serve
4.promote the health of individuals, communities and populations.

Reflective Case

Dr. Smith comes into Mary Comna's hospital room and tells her and her family that he is prescribing Drug X when she leaves the hospital. He goes on to say that he does not recommend Drug Y because of its side effects. The family can pick up the prescription when Mary is discharged. Two days later, the family goes to the nursing station and finds Dr. Smith left a prescription for Drug Y. When confronted with the discrepancy, they are told Dr. Smith had the wrong prescription pad with him and no ... the nurses will not contact him about the discrepancy. One of the family members pulls out their IPhone checks out Drug Y and doesn’t like what they read. They don’t bother filling the prescription on the way home.

Reflection

Did the traditional medical hierarchy (Dr.>Nurse>Patient) impact the outcome for this patient?

What role does trust in the doctor’s decision making play in medical outcomes?

Does it make a difference in your thinking about the case if you knew the doctor had his office in the hospital?

As medical information becomes more available online, what impact will information access have on the doctor/patient relationship?

If you saw this patient after their release from hospital, would you think to check for compliance with the prescription given?

This case is meant to demonstrate how the lack of patient centered care, resulted in no one being available to advocate for the hearing of the patient's concerns.

"This is an information resource designed to help you understand the nature of a medical condition and the surgical procedure most commonly used to treat it.

Our hope is that we will help you to:

• gain a better understanding of your medical condition,
• know your treatment options,
• understand the risks of surgery - as well as the risk should you decide not to have the treatment your doctor recommends.
• You should also know what to expect on the day of surgery
• and know how to care of yourself during recovery."

I think it might also be useful for premed and 1st year students.

Preplanning

a. Begin by analyzing what competencies should be taught in this manner. Dangerous, painful, rare and embarrassing procedures make the best candidates. Determine what level of competency is required depending on the level of the resident. Set objectives for each stage.

b. Create learning activities including written instructions for each level of the progressive process described in the following document. Train preceptors to provide the necessary role modeling.

c. Create assessment tools appropriate for each level.

d. Train raters to use the assessment tools.

1. Intentional Role Modeling

An experienced preceptor demonstrates (without comment to the trainee) the complete procedure including interactions with patients/families and team members. This provides the student with an understanding of the goal of training including completion time, explanations given to the patient, safety measures etc.

This step may involve watching a video if an experienced preceptor is not available for observation.

2. Low Fidelity Simulation

Image from Antonacci, D.M. & Modaress, N. (2008). Envisioning the Educational Possibilities of User-Created Virtual Worlds. AACE Journal. 16 (2), pp. 115-126. Chesapeake, VA: AACE. Retrieved from http://www.editlib.org/p/24253.

Low fidelity simulations use learning resources such as videos, animations and virtual reality with written procedural guides. Ideally this will involve a self directed process whereby the learner learns the basic step by step mechanics and can repeatedly use the required resources until they believe they have reached an understanding of the objective.

Assessment at this stage uses multiple choice and listing questions; either paper based or online with a pass mark of >80%. Learners must have the option to retest at this stage.

3. Mid Fidelity Simulations

Mid fidelity simulators are the body parts task trainers that expose students to the tools used to complete procedures in a portable, minimally complex manner. Again students practice with minimal supervision or peer support until they feel confident to undergo formal testing. Direct observation by raters or a lab supervisor followed by a feedback session is the usual test at this stage. Students should be allowed to retest after returning to the simulation if they don’t demonstrate proficiency.

The student now has the basic knowledge and tool proficiency to move to the interactive level.

4A. Interactive Hybrid Patient Simulation

Image copyright Roger Kneebone

Hybrid simulations are used for simple procedures which might be painful or embarrassing for patients to have beginners practice. Simulated body parts are attached to standardized patients who act out pre-arranged scenarios and provide feedback to the learner during the debriefing. More expensive than mid level task trainers, this level allows for the inclusion of interaction skills. Direct observation is the standard assessment.

4B. Interactive High Fidelity Simulation

The most expensive and complex type of simulators are the full body mannequins that require participants to practice technical + communication skills in complex scenarios. In some cases, participants may experience planned and unplanned disaster scenarios. Ideally the mannequins themselves provide immediate feedback about how well the patient is progressing because of the participants’ actions. Debriefing with a skilled preceptor is required after each session. Video observation by trained raters is the standard summative assessment.

For more complete information about simulations, see http://www.medicine.usask.ca/faculty/cbf/medical-simulations.

Before the student arrives

1. Pick two or three things you do very well and break these procedures/techniques down into steps that the student needs to know in order to replicate what you do.

2. Create two or three illness scripts for the most common issues students will see in your clinic.

3. List 5-10 attitudes that you think exemplify great physicians and think about how you are going to role model those attitudes while students are in your clinic. Pick some that relate to patients, some that relate to staff, some to other areas of you life.

While the student is in your care

1. Encourage the student to ask questions about why you made the decisions you made.

2. Pick one or two difficult cases a week and walk the student through how you made the diagnostic decisions; even if it seems obvious to you that A=F, it may not be as obvious to the student. Avoid asking students to read your mind.

3. Share your illness scripts with students before asking them to create their own.

4. Guard the appropriateness of your behaviour to patients and staff even when the day is trying.

5. Talk to students about working with patients whose values, behaviours, and illnesses can create issues for the physician. Try and reflect the guidelines of the profession even if they aren't your own (save those discussions for colleagues).

6. Demonstrate and encourage Deliberate Practice by giving students multiple opportunities to apply what you are teaching them with patients.

References

Role modelling—making the most of a powerful teaching strategy

An Intentional Modeling Process to Teach Professional Behavior: Students' Clinical Observations of Preceptors

Pathways to “Involved Professionalism”: Making Processes of Professional Acculturation Intentional and Transparent

So you need to help students learn to collaborate and I suggest you begin that process by familiarizing yourself with Dr. J. Salmons’ Five Levels of Collaboration, which progress from least trust required to unconscious trust.

1. Dialogue
2. Peer Review
3. Parallel Collaboration
4. Sequential Collaboration
5. Synergistic Collaboration

Dialogue
Begin your course with daily opportunities for students to practice speaking and listening to each other in order to build trust. Avoid the traditional instructor asks a question and a single student answers and use a variety of the following:
• Write, pair, share
• Clicker polls
• Clicker quizzes
• Group discussions
• Structured Controversy
• Integrated Case Learning

Peer Review
The week before the first paper or assignment is due begin the process of orienting them to critiquing each others work. Explain the concept of rubrics to the class and ask them what criteria they would use to evaluate the assignment/paper. If they have an adequate understanding of the concept, get them to create the rubric; otherwise share your rubric with them. Be open with the students that this is a stage in learning to work as a team. Choose one of the following depending on the size of the group and their readiness for the task:
• Partner – give each other feedback on the format/spelling/sentence structure but not on the content before the work is handed in
• Comment – post the assignment online in a Wiki or Blog and expect at least two thoughtful comments from each student on someone else’s work as part of their marks
• Critique someone else’s work using the established rubric and compare it to the instructor’s critique for marks.

Parallel Collaboration
At this stage, participants divide up the group’s assignment and each individual completes a section independently. The final presentation of the assignment may be vetted by one individual who is ideally the best writer/presenter but who may be just the strongest personality. In some cases, students each present their section and no teamwork is involved. To help students move through this individual stage, you might ask them to do some of the following:
• Encourage them to participate in some sort of group editing/review which can be facilitated by using either Google Docs or a Wiki
• Assign group roles such as gatekeeper, task completer, food bringer etc. or help them identify their role
• Ask group to mark each other on participation in the group role while you mark individual contributions

Sequential Collaboration
The students are developing the skills of team and task management and begin to appreciate the importance of both functions, so they need an assignment that can be accomplished in a series of stages, such as research - group writing - presentation of paper. At each stage, a product will be presented to you by a set date and the students are expected to plan, create and critique this product as a group. Marks for this stage are based on expected group performance not individual.

Synergistic Collaboration
The unconsciously competent team collaboration point may not be achievable in a single course.

American Medical News has an article discussing twitter as a tool to increase the web presence of your practice, connect to patients and network with other providers.

Chris Thorman, who normally blogs about electronic medical records at Software Advice explores Twitter as an epidemiology tool for tracking diseases.

Dr. Shock is interested in how Twitter is being used in educational settings by students and lecturers.

Twitter's reputation as a mundane socializing tool for updating friends has never been my experience and I am pleased to see the creative use of this tool expanding. What ideas do you have for using Twitter in healthcare?