TEST: Techniques and Effective Strategies for Teaching within a Dynamic Medical Curriculum

All right good afternoon and welcome to everybody so in the normal list of times medical educators teach to a variety of learners at a variety of levels in a variety of settings and as educators it's our roles really to facilitate effective and efficient learning across the board right and i can't think of really a better set of panelists to help guide us through some techniques and strategies to help all of us reach our learners in a more effective and efficient way so today we have dr jennifer cleveland who is assistant professor in basic science education and a pharmacologist dr chad damat who is associate program director for the residency training program in internal medicine and assistant professor in internal medicine for vtcsom dr chase polson who is associate professor in the department of clinical health professions and he's also the program director for the respiratory therapy program at ruc and dr a lepton who is general surgeon and also associate professor of surgery at curling clinic and btcsom so please join me in welcoming this wonderful set of panelists to help guide our way all right thank you dr wickert thank you all for joining us this afternoon as we discuss techniques and effective strategies for teaching within the dynamic medical curriculum our learning objectives as we progress through we're going to talk about different ways to enhance the didactic learning environment we're going to talk about social presence and what that means and some strategies to overcome and help engage our learners we're going to talk about constructivism and the framework that we can utilize that within the clinical setting and then we're also going to go through and discuss challenges and strategies related to teaching within the operating room so i'm now going to turn it over to dr polson who's going to talk about effective teaching strategies for the didactive and didactic environment hi everyone i'm chase polson uh just a little bit more about myself i'm a respiratory therapist by trade i before coming to virginia i taught up in the maine community college system transitioned down here to jefferson college now radford university carilion and i also have a secondary appointment over at virginia tech school of medicine i also serve as a chair of a department so i have the uh the privilege of going in and viewing other faculty's instruction and giving them a little bit of feedback so in my 25 years of education you know like most of us that have been in education a long time we start to understand and develop a certain philosophy regarding the delivery of information and historically i think in most science-based education curriculums you would see the basic information delivered within a classroom setting that i'm going to define as a didactic setting and then transition into a laboratory competency setting and then ultimately we would see you know clinical practice or clinical competency you know evolve so through this journey you know i'm concentrating more or less on the classroom environment but i think you'll see that my philosophy of strict didactic information is is not going to be limited just to a traditional classroom setting and uh we're going to stay on the slide for a little bit and i'll i'll cue slide forward if that's okay so if i would boil my my philosophy down first i would have to say there are two you know big points that i've come to understand that that need to occur for information to be delivered uh first any barrier that that is that is in between the learner and the facilitator should be removed and i'll go into that a little bit more uh second of all through my experiences in an undergraduate education and even in my graduate education we all know that there's a certain amount of intimidation that occurs whether or not it's self-imposed or legitimate between the individual that's learning the information and then the person that is delivering or facilitating the information so they would be my first two points right one break down all barriers two be very cautious of the type of intimidation that you know exists and try to do things to remove it for myself to break down those barriers between myself and my students first of all i i like my students to call me by my first name i like to develop a relationship with them sometimes that's very hard within the classroom setting it's a lot easier within the clinical or laboratory realm or or even if they're my advisee but the more that i can connect with them on a personal level and decrease the the perception of a barrier between themselves and and myself i know the more information they will receive second of all uh removing intimidation within the classroom it's uh it's pretty difficult especially when you start to you start talking about real time assessment within the didactic setting but i think there are some technologies now that are that exist that allow us to assess real time within our didactic settings to uh to make sure that the students are receiving the information so uh if we if we start off then and and re-emphasize the point that we are as educators not just the deliverer of information we are more of the facilitator of the information being delivered i think we can we can roll right into these new technologies and new uh methodologies that we can use uh cue second slide so virginia tech school of medicine does a uh a very good job at breaking down the delivery of information within the didactic setting when i looked at their canvas uh you know posts i see that pretty much every block is broken down to a before class during class after class type of format and they're utilizing a lot of technology to to emphasize or deliver that basic didactic information now for myself i i deliver about four blocks within uh the ms-1s and ms2s and when i first started to do this for virginia tech about uh six or seven years ago you know i came in and i wanted to be the stereotypical you know kind of instructor again like i was way back when i entered education i tried to deliver a tremendous amount of information you know within a short period of time and then i i saw my uh feedback from that first year and i said yeah i really need to to scale this a different way so within those four pulmonary blocks which which are mechanical ventilation pulmonary function uh oxygen delivery devices and then arterial blood draws and line placements i moved more and more from a traditional didactic lecture type and i used more laboratory scenario small group learning type of things to deliver the information and i did a really quick uh literature review just to find out how much medical education is moving away from a lecture type format and there's a plethora and so i just cut and paste and put a bunch of different publications there that emphasizes the point uh next slide so in an eight to ten minute uh you know delivery of information to you guys what are some some key points that i think you should focus on well first and foremost you know i am amazed at the number of faculty member that simply lecture and their their slides are full of information you know they're delivering this information within a three-hour class period or two one and a half hour class periods per week and it has been proven that this is a very low level way to deliver information to the recipients right and second of all it goes hand in hand with that i think we've all heard the mnemonic kiss keep it simple stupid right we the people that lecture since we are so familiar with the information we forget that there is possibly a disconnect between the recipients of the information and ourselves and this is emphasized every single time i give a lecture to or a laboratory component to an ms-1 or ms2 and i start to talk about you know clinical situations and i'm quickly reminded that they did not have the clinical experience yet right so keep it simple stupid and please stop lecturing so i was watched i was home during this covid uh experience and my daughter who's in a nursing curriculum was uh listening to an audio tape uh prior to the the classroom and she was running it at one and a half to two times the normal speed to run through all the information and backing up and replaying sections that she didn't know and i thought wow what a great way to you do the pre-classroom type of basic information so that would be my my second sub point you know under stop lecturing i would say preload your your basic information to the prior to class part of your your block and therefore therefore you can use your classroom time to truly engage the student right and so that's the second is is engage the student without any type of or engage the student with purpose right and without reprisal you know you're going you're going to have to do things that remove that uh that thought that there is going to be retaliation if the student does not get the question correct now historically i used to do this a lot i i called it round robin you know i would go through the class if it was a relatively small class and uh ask each student a question if the student got the question wrong then we would go onto that the next person you know and obviously that was that was very intimidating for the individuals and i got slammed on my early evaluations when i was first started being a faculty member and i realized that i needed to stop doing that so we didn't have the technology yet so i said okay i'm not going to single people out anymore i'm going to do small group questions and i'm going to have them work in small groups and this wasn't more effective right it removed some of that intimidation but unfortunately i think in small groups the uh the loudest voice sometimes is heard and other other people do not process the the questions or the information as much i believe the best way for in-class engagement is through a automated response system such as the iclick module which came out about a decade ago and now there's various different modules out there but you can you can simply look at the information that you you required prior to class you can do basic questioning during class and then use this iclick module to find out you know real-time assessment of whether or not the information was delivered and then spend some of that real-time class in reinforcing the concepts that the students didn't get next point is visualization with the blocks the blocks within the medical school i quickly realized i did not want to be in a lecture situation and we started moving my my lecture you know didactic information delivery into a laboratory delivery in which i developed uh you know very very well written scenarios regarding the information that i wanted to deliver the uh the one lecture mechanical ventilation is run very well i use mechanical ventilators basic simulators with a scenario and i break the students into groups of two to three per station now we have eight stations so we can run through the whole class within two different deliveries so that that takes about four hours two hours a piece but by using the ventilators and scenarios i start to incorporate a lot of these different concepts but that concept of visualization and actually putting your hands on equipment you know and seeing the effect is is highly effective in delivering information uh cooperative learning or this the small group learning that i've discussed although i think it's it's slightly ineffective for real-time assessment like in the didactic or classroom setting i think it's extremely effective within a scenario-based setting that i was just explaining with the mechanical ventilation lab asking questions or having scenarios being delivered you know is much better than simply delivering information whether or not that inquiry-based instruction starts off and then flips the classroom back to the individuals or the small groups or if it's simply a scenario based instruction like the mechanical ventilation lab the less information that you can deliver and the more that you can pull out you know the better that information delivery is going to to happen uh differentiation obviously is all these things right if we start talking about uh you know pre-loading the information using class time for engagement using you know equipment for visualization small group for cooperative learning you know scenarios for inquiry-based instruction all of these things are going to connect a little bit differently with different types of learners so the more that you can differentiate your approach you know the better you are at you know delivering this information uh so real quickly because i'm i'm out of time but uh there's a lot of different types of technology that's a lecture unto itself and i'll end with uh you know if you can use you know your historical professional experiences that that brings in color for a lot of this this basic science-based information so i apologize if i ran a little bit over and i look forward to talking to you all right thank you very much all right so now i'm going to go ahead and start talking about social presence in the virtual environment and um i want to do a quick survey so just go ahead and put your answers in the chat i'd like to see who has taken material that has been intended for in-person instruction and tried to utilize it in the virtual environment without making any modifications and then i'm also interested to see who is also experiencing a perceived lack of engagements with our students in the virtual environment so if you'll just populate the chat with a yes or no response out that would be great this is bridget i'm trying to find the chat oh there i see it now it's at the bottom great thank you yes sorry folks if you float over on the bottom bar there's a chat bubble just click on that and then you should be able to enter information all right so i'm seeing quite a variety of answers which is actually really wonderful um i have to say that i am guilty of this and so i want to walk you through what i've experienced when i was teaching for the physician assistant program with radford university carilion so their pa program has a year-long pharmacology course and prior to kovid coming for the spring semester up until that point we had had about eight weeks of in-person class and each week i have a three-hour period with them and it's labeled as didactic but honestly i utilized those 50 minutes to uh as dr polson was saying having chats question answers and cases in group base and then i also took the 10-minute break in between each hour to try to interact with the students on a social basis and then we have multiple choice exams as for their assessment and we do that every four weeks so then covid happened and so we went virtual and so the last six weeks of the semester i changed what we had done previously and so what i did is i provided pre-recorded voice over power points um i asked the students to do two additional cases per week and they had to provide me um some references and i had criteria in regards to that then they had to respond to two discussion board posts of their peers on their cases and respond to what they thought their answers looked like and positive or even potential differences and opinions we had a weekly one-hour session by zoom to do question and answer and then they had a multiple choice exam every three weeks so i had to take a look at this because as the last six weeks were going on the students um i could just tell that their stamina and their engagement in the class was was diminishing so i had to do some reflection okay um so what was i doing what was the impact of what i did okay was i really increasing um the assignment base to increase the the rigor associated with the the material well turns out i really didn't what i was doing i was overburdening them and i was actually increasing the difficulty of the course i didn't change the academic rigor but what i did was increase the difficulty they experienced in regards to the load and i also didn't provide them the proper proper support and so my social presence wasn't where it needed to be and not only was i doing it every one of their other classes were doing the exact same thing so then i also had to think what these students were experiencing okay what was that loss of community okay how did this impact their psychological health and they've lost their traditional methods of gathering their community their study groups they were feeling depressed they were feeling isolated it was really starting to have an impact and so i needed to think about how i could address these changes and so what i did was i started looking at social presence and so the definition of social presence is that level of connectedness among instructors and students that's going to determine how motivated they are to take an active role not only in their education but also their peers education in that online environment and so when you look there's five facets that we can refer to in regards to increasing social presence and so there's social respect okay so one example of giving social respect is either giving or receiving timely responses then their social identity okay so calling them by name zoom makes that really easy for us when their names are on there so let's utilize that okay sometimes in the classroom it's a little harder but definitely by zoom we have that ability their social sharing okay so sharing information or sharing their their beliefs having an open mind creating that space where they can agree and disagree and also give positive or even negative uh feedback and then intimacy is also really important and that's allowing them to share their personal experiences and we we know that by establishing these social connected connections it's a basic human need and it's essential in our online realm and so we know that when we go through and we have this high social presence we get a positive result we see positive impacts on online learning and also that interaction profile the learner's achievement is so much more significant compared to when we don't and then there's also learner satisfaction there's affirmation support and even a sense of community when we do this and we utilize our our tricks of the trade and creating social presence and then what we have noticed when we have a lack of social presence is that we tend to have negative attitudes towards the effectiveness of the teacher but more importantly we see decreased learner achievement and a lack of engagement so here are some ways that we can walk through in regards to social presence ways that we can try to increase that social presence in the online and virtual environment one of those being instructor of the accessibility okay make sure you have some sort of online office hours you can schedule it they can make appointments whatever it is have that available to them obviously they have your email but consider giving them your cell phone number i do it um and i'll be honest with you i'm usually the last resort that they utilize they will go through all sorts of other pieces friends resources and then they'll call me so they never abuse this privilege so creating social connections and building that community so we can have private spaces so they can exchange information so they can begin that collaboration and learning about each other or you can have public discussion forums so again depending on your platforms what's available to you you can do that utilize any of the technology that we have available okay so google has a wonderful suite i know this morning it happened to go down but just know that you have drive you have documents you have sheets you have collaboration they can all work on the projects together in real time so that's so beneficial the other thing that they really love is kahoot it's a game software and they can access it from their phone and they can utilize it from anywhere the other components here is leverage the students prior experience on excitement so bringing that in a lot of them have some wonderful experiences and so let's utilize that and it'll help create that connectedness that they're all looking for um allow them the opportunity express opinions okay you have to create that safe space okay um again not being demeaning not being overbearing allowing that opportunity to collaborate is really really important and another way we can do um and a great job of creating some social presence is can consistently providing communication whether it's a weekly summary whether it's a weekly preview you can combine them all together and then timely grading is really important so if you've given them an assignment with that due date then you need to turn it around so that they can see what they need to change for the next assignment so what did i do for the summer semester well we ended up front loading pharmacology during that first six weeks in hopes that when they were allowed to go back in the building they could utilize the time for clinical skills and so we front loaded it during the first six weeks but what i did is i still gave them voice over power points it allowed that independent learning i even had one student said that he used he had his earbuds in and was walking around doing toys around the house cleaning and just listening at the same time he said he took me everywhere and then increased uh interaction time and so what we had was the question and answer sessions and we made them optional and you would think that they wouldn't potentially arrive to the session but i had almost 80 to 85 percent attendance each week so we did some social things i checked on them see how they were doing personally and then at the same token we had a question answer session that we would go through which also stimulated some conversation and probably the biggest change that i did was i allowed the students the autonomy to choose their assessment method so they got the option to choose either weekly cases which i would grade or they could take a midpoint and a final exam and you'd probably be surprised i thought it would probably be pretty split we'd have about 50 percent doing exams 50 doing cases but i had 40 out of the 42 students who wanted to do the weekly cases and they said that they learned better and it would prevent them from doing the memorize and regurgitate so i only had two people that took the midpoint and the final exams so in summary when you look at social presence take that opportunity to make small changes to engage and create a social environment knowing that in a virtual world we have to embrace this change it's not what we normally or you know expected have anticipated be transparent so if an activity that you assigned didn't go exceptionally well just say i didn't know that that was going to be that way own it and then move forward and that transparency and that openness is going to create that conversation you're going to work towards that environment of social respect and collaboration and empower that learner to make the the choices that is best for their needs for learning so that's what i have for you today and i'm now going to turn it over to dr dumas and he's going to talk to you about constructivism and how it applies to medical education okay thank you don't start turning me off yet when you hear the topic so it's a very intuitive topic and i just want to talk a little bit about it in my realm of teaching is generally the awards or you can use this in clinic um the learners that we deal with are you know we might have one or two students we might have a single resident in the clinic we might have a few residents on the wards and so that's kind of where i'm at and how we apply some of these things and so um some of this came from this constructivism i'll define it in the next slide but for right now jean piaget was a swiss um educator and he um kind of he wasn't the one that started this but he definitely brought it to the forefront of medical education and thinking about um how to utilize this and he just watched his kids basically and how his kids learned and this is where we get this topic schema where you might have heard this word before and not knowing where it came from but it really came from constructivist uh literature when you say someone's building a schema what's a schema that came from constructivism also i like this quote here the most important factor influencing learning is what the learner already knows and so hopefully i can convince you and then give you maybe a strategy later that might seem seems simple but quite a few people i see including myself have done this very incorrectly but you have to be able to know where your learner is in order to know where you're going to go from there right i um just to start off with even before we define it i love giving acid base lectures but sometimes if they're you know they've heard three lectures on it already i might just feel good about that i gave an acid base lecture but it did nothing for where the student or the learner was so knowing kind of where they are and knowing what constructions they have already on the topic is very important to building on that and create helping with the education next slide so defined loosely um constructivism is knowledge is not acquired as a blank slate but it's built upon frameworks already established and so this makes sense this is not something that's going to shock you this is where you get the word schemas and some of the terms i think piaget was the one that talked about these terms assimilation and accommodation and so what these are is that say you have let's talk about atrial fibrillation say the student or learner or resident has this concept of what atrial fibrillation is how do you diagnose it what's the problem what are the complications and so they have this built in their head and it might be correct it might be incorrect it might be correct but incomplete it could be a lot of things that you just don't know when you're working with them in the clinic and working with them on the wards and so assimilation is when you're teaching them something that is jiving with their construction but it's just additive it adds on to what they've built it adds on to their scaffolding so if maybe they didn't know about amiodarone and when would you do amiodarone when would you anticoagulate after giving amiodarone then that would be assimilation they're just they they're building the quite the right framework they're just adding to uh that framework whereas accommodation accommodation is something's kind of wrong with the framework something's incorrect something's incomplete and then when the teacher in the learning environment they're facilitating this where they're correcting this thing that's incomplete so that's accommodation these words come right from the literature so it seems common sense this is not i don't think this is a shocker to anybody and i would dare say many of us probably are doing these things and didn't know you know what educational philosophy they were built on so the teacher will use multiple ways to build or facilitate understanding and you've heard some of these i was joking when i was preparing this because i was seeing what the other uh what chase and um uh jennifer prepared and i said maybe i should have listened to them before i prepared my my thing but on how on how we facilitate this understanding and and not all it's not all unidirectional it's very important so you can see the building and the progression of this even this discussion today so that's very important in how we build this so next slide so what i will say is how do we apply this in the clinic and the words and what is an efficient way to do it and i would say ask questions and we've already seen from what chase said if i put you know 30 or 40 uh first-year second-year students in a classroom and i go around robin and i ask them questions it can be humiliating and embarrassing it can just put them on edge and make him feel threatened generally i will say in the clinical environment when you're dealing with i might have one third year on my team or a fourth year student and then an intern a resident because of that longitudinal because they're at different levels that's not as much of a problem although you can do this completely incorrectly so i want to put this big parenthesis around asking questions so some of you say well i already asked questions i already do this this is nothing new but i would say how we do it is often where the threat occurs so if you if you're asking questions to what we call pimping and you're trying to determine hierarchy and can you read my mind and these things you're just going to frustrate the learner and they're just going to run from everything that you want to try to build and everything that you want to try to do that's good for them so how we do this is very important and so i have another favorite topic that i like to give and i think i've given in this setting before is how you do kind of a modified socratic method um for getting at this in a non-threatening way and one of the things i will do is i tell every every learner that i'm with and every group that i will say listen i'm going to ask you questions and i'm going to try to do it in a non-threatening way i'm going to try to bridge your knowledge and build your knowledge so you can get the questions correctly so we can help and we can grow and we can grow with each other today even and this goes both ways i think not to digraph or get on the rabbit trail but socrates allowed his students to ask questions to him and so i think that's okay i i told my team today i said um this rodent panel with this trying to for blood products when they give blood products i just have a very loose understanding of and i told them i said listen if you can explain this to me simply where i can understand it you'd be doing me a great favor so um so this back and forth questions and um trying to rub off on what we know and what we don't know and sharing this information again many of the things jennifer talked about with this social context uh are at play here but the threat is if you're already saying i'm asking questions and i already do it correctly be very careful because i've seen a lot of people do it incorrectly and a lot of it and it's a threat to the whole method but if you're not asking questions because you're fearful of embarrassing them i wouldn't necessarily think that because the students what i find the students on my war team they're not they're not they don't so much care if i have some questions they care if i ignore them so if i ignore them that's a problem okay so those are my caveats with asking questions and and why would we do this is to determine the schema or framework that the learner already has created i don't know what they know if i'm if i don't ask them questions like when they come into my setting i haven't worked with them for six weeks or eight weeks i have them just right then and i have to kind of get at where they are in order to know how to gauge what is going to come out of my mouth and what i'm going to teach at the bedside or when i teach in clinic and so that's why it's very important to know what they know and the most efficient way that i can think about doing that in the clinical setting is to ask questions what have they already created what is what is incorrect what is incomplete and what is right and what can they build they might know something more about it than you do i've had learners that they um had previous background and undergraduate and they knew this concept i had one learner that was a previous neurosurgeon trained and so when he talked about neurology um on the awards i mean he knew far more than i did so you know don't assume that this is like a one a unidirectional thing as well on the next slide so how would we do this and what's a better way to do this so ask why and how questions helps the learner solidify the framework that they've created um i don't find it very helpful to ask a lot of epinem questions i mean that we're famous for doing this in medicine like what's it called when the uvula bobs or the order of irritation okay so they know what are they doing i'm more interested in they know that it occurs and why it occurs than to remember someone's name someone's name that doesn't add to their understanding of the topic so i think if you want to do that because historically it's fun and you want to talk about that doctor that's fine i don't think it advances learning the concept but why and how questions why does this occur why when i give this drug this happens why might i not give neos why might not give uh leave a fed or norepinephrine sorry these generic names why might i not give norepinephrine with a tachyarrhythmy why would i not do that and hearing their responses that builds on their understanding or how would they do this another thing that we can do that i find very effective are asking what if questions to help build assimilate new frameworks so it might be that we've never had a case of such and such and you can pick from several rare cases but if you get a case that's along those lines and you say well what if they had this or what if they had this finding or what if this this lab came out what would you think about that helps create those networks even without seeing a patient with that that when they do see a patient with that they've queued these problem representations and illness scripts that they're able to get to the correct answer so what i find very helpful is why and how questions and what if questions are a very effective way to ask questions so some of my colleagues might say well you still have to read and i agree so this does not take the place of reading to obtain baseline knowledge you have to know something to start building anything right so i think you have to read you have to listen you have to build on something so we can't just ask you know so i'm not a fan of just if you ask me a thousand board prep questions i can get the material i think you have to build on that before you can start applying those questions and learning the correct answers for that so so interesting topic today so talking about constructivism building on their framework helping them assimilate and accommodate and the strategy to do that would be to ask questions and how we ask the questions in the manner of which we ask the questions and what are we trying to gain with the questions that's where the success or the failure can occur so i challenge you to do this in the clinical setting i think it will really open up avenues of understanding that's all i have all right so now we're going to turn it over to dr lok tong and he's going to talk to us about teaching within the operating room environment with challenges and strategies hi everybody so i've been charged with talking about teaching in the or i'll summarize this slide by saying that i've been around teaching medical students and residents about surgery both the technical aspects as well as the uh the non-technical aspects for many years and it's from this perspective that i offer you my opinions um about teaching in the or while this uh the topic is mainly teaching in the or the principles translate and they can be implied in other cases other scenarios next slide please so in the or as in many places you have a it is a very task-based environment okay the task in the or is a safe and effective care operative care of the patient it requires a team a team effort and nobody can do this by themselves but you know with any team it requires cohesive teamwork to have a coordinated effort that produces the results that you you want in order for teams to work well together there has to be good communication there has to be good understanding of the task over overarching task at hand and um as well as an understanding of one another's roles and and the the place that each each team member plays the role that each team member plays in in the situation and it helps each person each member of the team to be prepared to understand what's coming up to be able to anticipate the next step and or and or potential problems that may crop up uh during the uh during the the care of the patient this is a very rich environment for education i consider the or to be my classroom but it's not just a physical classroom but it's a dynamic classroom in which there are many situations many scenarios many many lessons that come up just from the the context and the content of what's happening in the room next please um one one example of this is um is uh the your ability as a as a teacher to model and discuss ideal behavior um you know there's often talk about leading by example well here in the or there's plenty of opportunities for this i often talk to my my um very novice students about what what it means like to work in a team in the or and point out team interactions and where everybody's role uh is and what every person everybody does i try to point out how how to effectively communicate with team members uh in different situations um you know in in certain situations i emphasize how imp how to be a good leader in this situation uh this is especially true i'll drop down to the next couple of points here that in crisis management uh when something really bad and stressful is happening you know a good leader has to be able to maintain composure while optimizing resources recruiting health making sure that the tone of the room is not one of panic but one of uh you know deliberate and careful um you know yet uh yet rapid uh patient care uh when when that's what's called for um another area is uh process compliance and one of my new newer roles is director of um you know co-director of surgical equality and you know part of what goes with that is complying with things like the the time out and the pre-operative checklists and i point out to our students you know the importance of doing this correctly and the reasons we do this uh you know not just to go through the initial points but also to build the team and ensure that there's good team communication early on talk about room awareness you know um sometimes i point out you know the tone of the beep on the uh on the sat monitor to students who don't know that the tone goes up when the sas good and tone goes down when the sats dropping and other things within the room that are important to know i try as much as i can to comment on what's going on uh when they're good teaching points to be observed the final point is that on this slide is i try to model good um ways to educate trainees okay so when i'm when i'm talking to resident or talking to a student i'm not just talking to that student but i'm showing the senior resident or the junior resident how to how to train you know how to point out things to their their more junior colleagues so i'm modeling um how to how to be a teacher in this setting next please after patient care um you know can be a little bit like this this this this is actually alex alex honold uh climbing um climbing up uh el cap but it's you know a good bit of potential danger all the time you know sometimes there's more sometimes there's less but there's always significant danger to the patient and so you have to be careful and you have it requires prolonged concentration you don't want to you know have a lapse in concentration that results in in harm to the patient you know sometimes the the conditions change very rapidly and you have to be able to react quickly so it's in this context that we have to function uh as as you know patient care providers and as educators um and i think it's important to acknowledge that that these challenges exist um and that you know sometimes you just have to deal with the situation and teaching is not uh the priority although as a learner you know you can learn by observing the situation and how it's managed and i think it's important to to talk about those things when they come up or even before they come up next please in the end as a surgical educator i am obligated to the patient and obligated to the trainee it and sometimes this can be it can be challenging striking the right balance um i reconciled this by this challenge by you know providing appropriate supervision my general rule is as as far as the patient operation uh goes i i will either do things myself you know i will do my best to ensure that the operation is done as i would do do it or i would i'll do whatever part needs to be done myself so it's sometimes very tight supervision um especially if if the learner is less experienced and you know appropriately um graduated responsibility when the the learning is more experienced you know ultimately you want you want to be able to take a training for someone from somebody who's not experienced to to somebody who's very very competent uh in in you know small increments so they they are you know challenged but comfortable with each step um through this in through the operation through the surgical patient care i try to convey both the technical aspects of patient care as well as non-technical aspects like intraoperative judgment next please so i think many of us have been in this situation learning how to drive or teaching somebody how to drive i think it's important to to recognize that when when teaching a technical skill it's really really unnatural um when you're trying to learn something new so you have to be patient when somebody's learning a new task it helps when you're teaching a complex task to break it down you know it's real hard to learn how to drive you know steer step on the gas pedal brake um you know in in in traffic especially in heavy traffic so you break it down you go to a parking lot first and you do straight away you talk about turning backing up you know rather than doing all at once and eventually all that you know it comes together um but it's best not to overwhelm the learner by by breaking things up expect improvement to occur over time you know it it takes weeks sometimes years for surgical residents to develop skills and you can't expect too much but over weeks over months operating with the same resident i can often see improvement and it's almost like you know it it almost like it almost seems to happen magically because somebody will will be in one operation trying to do one thing over and over and over and over and not getting anywhere but the next time they they try it and another operation you know things have clicked somehow and the improvement occurs but it takes time um it's important as you're teaching somebody a technical skill skill to recognize um the the trainee's limitations you know there are there's going to be a certain point where the trainee hits a wall where they just can't do what you're asking them to do um and you have to also recognize your own you know limitations in terms of your own patience and your or or your ability to convey um the the technical aspect of what you want them to do um and when you reach that that point reach your own limitation or the trainee's limitation recognize that you need to take a break because there's there's such a thing as contra concentration fatigue or or patient fatigue and rather than get frustrated or frustrate your learner it's sometimes better to take a break and you know switch sides take over um and break up the uh the effort next please um this is a um a sign from a train park i use a train park analogy a lot everybody in the train park uh everybody in an operation learning technical skills should start small okay but before you can do before you can do the the big stuff uh you have to start small so you know starting small is is is a necessity to advancing onto the larger tasks larger more complex tasks so i try and involve students and interns as early as possible and and i remind them that everybody starts in the same place you gotta you gotta walk before you gotta crawl before you walk walk before you run recognize that there's this progression you have to do your best to escalate this difficulty when it's appropriate you don't want a advanced learner to be stuck doing stuff they they're already very comfortable doing so you have to appropriately escalate difficulty you want to try to give immediate actionable actionable feedback so immediate in that you know if if you don't give them feedback right away either you'll forget or the the the trainee will forget what what uh what you're trying to tell them you know forget the context um and actionable uh i mean by that i mean you know not just good bad terrible but why why it's good why it's bad how it could be done differently you know and good bad maybe not not be the right terms because you want to try and be as non-judgmental as possible to give them you know the feedback without the the emotion or judgment attached to it uh so they can act on you know the instruction alone rather than the the judgment or emotion so that's uh easier said than done sometimes okay and but that's one of those things you have to acknowledge about the situation about yourself you know as an as a educator that you're not always going to be free from uh emotion or judgment especially in stressful situations try to demonstrate things several different ways you know everybody learns differently so they're going to receive the information uh different ways and you know sometimes they may not understand the first way you explain it but they'll understand the second or third or fourth way you explain or fourth time you explain it it takes time and it takes some variation sometimes for for for trainees to get what you're trying to say um and demonstration helps too i mean i from from my perspective you know if i'm verbally talking to a resident and telling them how to do an operation or how to do a technique i can only get so far without saying hey let me show you okay because there's just something about the demonstration the the three-dimensional um visualization of what what's being done that goes way beyond what i can explain verbally i try my best to maintain a tone of encouragement it's you want to try and foster a good healthy learning environment uh and not beat down your learner too much because um you know it um it can be frustrating i mean you know when the learner's not doing something as well as they should be they know it you know you don't want to want to try and be encouraging and not discouraging as much as possible next please teaching judgment um yeah it's you know sometimes not easy to to teach this uh because it goes beyond just anatomy and pathophysiology it's about making choices the right choices sometimes sometimes there aren't any right choices i try my best to share bad experience my own bad experiences that have taught me good judgment i think that's from you know paraphrasing a mark twain quote um i try to think out loud as much as possible express my concerns about whatever situations uh are before us um you know and think ahead uh discussing choices of you know if we do this what happens and what if we do this what happens play out scenarios um always discussing that there needs to be an exit strategy you know if something doesn't succeed oftentimes i'm talking to my trainees about how to fail safely you know sometimes you're not going to have a win um you want to try and figure out how to how to fail less spectacularly or less dangerously um so that's part of the excess strategy conversations that i have with with my trainees next please so in summary remember um to utilize features of the environment for education not just in the or but other places there are a lot of things you can learn from the environment or context of where you are um try your best to teach through example and discussion um acknowledges the challenges of the situation you're in again this doesn't apply just in the to the or but the situation that you're in um you know has its own inherent challenges and you need to acknowledge them uh so that the learner you know understands that the context and and gets the most out of it in the end as a clinician you have to balance good patient care with training education and that's another thing you have to acknowledge that um there has to be this balance your training has to understand this and if i think if you talk about it frankly uh it makes for a better learning environment regarding technical skills remember that you got to start small start early go a little you know and go and advance in increments give feedback and above above all be patient and regarding judgment um discuss your choices think out loud um share what you're thinking um because it helps the learner to understand how how things you're processing the information and making choices that's it happy to take questions later excellent thank you so much to all of our panelists um i'm just realizing now that i've seen three out of the four i've observed their teaching in person and um and it's fabulous to see how these techniques manifest in the operating room at the bedside in um in an online or in-person um classroom setting um these these faculty members truly do um not just talk the talk but they walk the walk so thank you so much that was outstanding um are there questions for these presenters um while you have them here i know that they're more than willing to answer questions through email or such afterwards but while we're all here does anybody have any questions and feel free to unmute yourself and or um turn your videos on wait we have some chat messages um so actually i just also wanted to remind you all that there are links sandy has pasted the links for um obtaining cme a continuing medical education and or faculty development related to teaching for our virginia tech caroline school of medicine maintenance of appointment um requirement uh let's see are there any other questions we had some uh let's see stephanie asks how do you compress importantly lessons into a short amount of time any of the panelists wanna i would say you it's very hard to do and maybe don't try just give just give one little snippet and then come back or an article to read but otherwise if you try to compress it in it'll it'll fail so just one little thing go small like we've said before go small would be better than not understanding anything so i concur with that as well and one of the things that i find that helps is do cases um and those cases bring in multiple facets about one particular topic so you can cover a lot more in a shorter period of time great points great question and great answers for me a lot of what i what i do is uh repetition so i have short amount of time during the operation but i have a long amount of time over the residency and then finally pre-load the information prior to you know getting with the individual so that they have the information and you could use your time more effectively that's a really great point and you get dr paulson i noticed that you didn't use the term um some people are opposed to the term for some reason but that flipped classroom mentality where you really provide them with some information that they don't need your expertise for and then just get in deeper and explore more in greater detail when you're with them it's a great technique anybody else well this has been a great discussion of techniques and strategies that have worked well or haven't worked so well for our presenters i know that i've learned some things that will really help me in my future teaching and given the diverse representation i know that um each of you should be able to find something um with throughout this presentation that will change your teaching at least a little bit for the better so thank you all for being here and i hope you have a wonderful rest of the week enjoy your day thank you you.