Teaching clinical skills

This afternoon my colleague Dan Vargo and I gave a session on teaching clinical skills, something that all of us struggle with in one way or another.  As much time and energy as I have invested in trying to optimize my clinical teaching, I continue to feel like I’m constantly learning new things (and, like everyone else, struggling with implementation because of the same pressure we all feel…time).

I honestly spend very little time in clinic, and when I have students with me it’s usually for the “Gee whiz!” of seeing how telemedicine works for us.  Therefore, the preponderance of my time is spent teaching in the ICU/ wards and in the OR.  OR teaching is, of course, a unique animal, and it’s one where there is still lots of space for scholarly investigation.  Therefore, I chose to teach about ward teaching, something that proved fruitful on rounds yesterday.

While Dan’s and my slides are below, here are a few things I’m looking at adding and starting to do on rounds to make them less haphazard, more planned for learning:

  • Set specific learning goals prior to work rounds, which may give learners a role that forces them to “play up”
    • “Today it is your responsibility to write all of the medication orders on rounds.”  (for an MS4)
    • “Tomorrow will be your day to take us through the examination of your patients’ wounds on rounds.” (for an intern)
    • “Friday will be chest radiograph day.  You need to be ready to read all of the chest X-rays on rounds.” (for an MS3)
  • Use a scribe or “sticky notes”
    • Assign a team member to write down a list of clinical questions that crop up during rounds
    • Keep a “sticky note” (paper or electronic) during rounds
    • Use these scribed notes or sticky notes to identify and follow-up on a couple of key clinical learning areas.
      • Real-World Example:  Metabolic manipulation in burn patients came up on ICU work rounds yesterday; we will be discussing this in more depth Monday morning during Professor Rounds, once the team has time to read up (more on this momentarily).
  • Paper rounds, or case-based learning
    • This one differs because it removes the learning entirely from work rounds
    • Key learning cases are identified in advance the discussed in a classroom/ team room setting.
    • All data relevant to the patient’s course should be accessible
    • Any aspect of their care is fair game for in-depth discussion
      • Real-World Example:  As part of our collaborative with the Department of Geriatrics, we have once-a-month geriatrics teaching rounds.  A geriatric patient’s injury and course are presented to the geriatrics faculty attending, then we have a discussion about some aspect relevant to the care of the geriatric burn patient.  Today the discussion focused on pain control.
  • Scheduled bedside teaching sessions
    • Again, completely removed from work rounds
    • A group of learners goes to the patient bedside and has a discussion about the clinical skill or clinical knowledge piece of interest.
    • Remember that the patient can (and should) be part of the teaching team here!
      • Real-World Example:  I mentioned above the plan to discuss metabolic manipulation in burns at Professor Rounds on Monday.  Our Professor Rounds involve attending surgeon identification of one patient to discuss.  We go to that patient’s bedside/ room, walk through their course briefly, then have a detailed discussion of the identified teaching topic.
  • Opportunistic (“on the fly”) teaching
    • Challenge is urgency, lack of ability to prepare
    • Solution is to have some consistent themes that arise and a “teaching script” to take advantage of these more urgent teachable moments when they arise
      • Real-World Example:  I try diligently to review depth and extent of burn wounds at the time of admission or consultation with students or residents who are present.  Granted, if it’s 2 am and the 3rd admission of the night I may do this less well.  But it is still a fairly scripted activity that I can and do walk through at almost any time.

Here’s my challenge for you:  Identify a clinical skill that you teach routinely, or a place where you could be teaching more but you’re not routinely taking advantage of the setting.  Script yourself or your activity, then try to start doing it every single time. It’s amazing how easy it becomes and how it incorporates seamlessly into your workflow.

Anyone else have wisdom/ thoughts/ ideas to share?  If so, please comment (or Tweet!).  This is some of the most important stuff that we do, and it deserves some serious reflection.