University of Tasmania Rural Clinical School Clinical Supervision and Teaching Course Participant Manual Presented by Assoc. Prof Dr Deb Wilson, Rose Winter MEA
Funded through the Tasmanian Clinical Education Network with HWA support as a Clinical
Supervision Support Education Activity Nov 2013
1 Welcome to the Rural Clinical School Clinical Supervision and Teaching Course.
This short course for health professionals engaged in the supervision or teaching
of students in the clinical setting, has been funded through the Tasmanian
Clinical Education Network and Health Workforce Australia.
The course addresses, in part, the recent HWA National Clinical Supervision
Support Framework(1) by focusing on Domain 1 Clinical Supervision.
The Rural Clinical School, through this course, aims to support supervising and
teaching clinicians who are involved in RCS workplace activities which account
for approximately 70% of the clinical school program.
Despite time pressure and the competing demands of teaching and service
delivery, it is the clinically based health professional that often carries the day to
day responsibility for student learning and support. It is therefore this group of
key people with whom the RCS seeks to engage and from whom feedback about
the issues surrounding the implementation of the RCS program is highly valued.
This course provides an opportunity for shared dialogue around these issues with
input from a range of disciplines and from people at varying points within the
career continuum.
It is an opportunity rich with experience, passion and knowledge and we trust the
materials presented along with the learning processes will be of very real
practical use to all involved.
Assoc. Prof Dr Deb Wilson
Co-Director
Rural Clinical School
University of Tasmania
2 Contents
Introduction ............................................................................................................................................ 5 Course Learning Outcomes ..................................................................................................................... 6 Supervision and Teaching ....................................................................................................................... 8 Learning Styles ...................................................................................................................................... 12 What does the Rural Clinical School want students to learn? .............................................................. 17 Personal Learning Goals ........................................................................................................................ 20 How does the RCS want clinicians to teach? ........................................................................................ 22 Summary of Session 1 ........................................................................................................................... 25 Workplace Assessment at the Rural Clinical School ............................................................................. 26 Giving Feedback .................................................................................................................................... 32 Review of Feedback Examples on DVD(14) .......................................................................................... 35 Managing the Challenging Student ....................................................................................................... 36 Summary of Session 1 and 2 ............................................................................................................... 43 Handouts ............................................................................................................................................... 44 References …………………….......................................................................................................55 3 .............................................................................................................................................................. 54 References ............................................................................................................................................ 55 4 Introduction
The HWA Framework(1) identifies key elements of supervision that will be explored
in this course, these can be found at Domain 1 in the following Figure.
Figure 1 HWA Domain Structure
These key elements will be addressed through the following structure, totaling
approximately five hours of training:
Session 1
•
Introduction and program objectives •
Examining the role of the supervisor/teacher
•
Brief discussion of learning styles
•
RCS Expectations about learning on attachment and teaching models
Session 2
•
Assessment at the RCS
•
Giving feedback
•
The challenging student 5 CourseLearningOutcomes
1. Is familiar with the Principles of Adult Learning
2. Is familiar with a range of teaching resources that support quality supervision
and teaching in the clinical setting
3. Understands the role of the educational supervisor and is aware of personal
strengths and weaknesses and the key characteristics of an effective
supervisor
4. Is familiar with RCS expectations of teaching and learning in the clinical
setting including documentation about learning outcomes and appropriate
learning opportunities.
5. Is familiar with the concept of learning styles and implications for clinical
teaching
6. Demonstrates a capacity to discuss and review assessment tools
7. Understands the importance of giving student feedback and is familiar with a
model for doing so
8. Identifies students in difficulty and can apply a range of strategies to address
learning needs
9. Is familiar with RCS resources for supporting students in difficulty
10. Understands the importance of promoting a positive learning culture amongst
colleagues
Key Resources
The two main recommended resources of particular use to you during the course
and for referral as a general references are:
Teaching on the Run: Teaching Tips for Clinicians(2)
The SuperGuide(3)
6 Theoretical Foundation for Teaching at the Rural Clinical School Although many theoretical models are utilised in the design and implementation of
the RCS program, a good starting point for examining workplace learning is the work
of Malcolm Knowles.
His work in the 1970’s was a significant factor in reorienting adult educators from
‘educating people’ to ‘helping them learn’.
He coined the phrase ‘andragogy’ to describe learner directed education as opposed
to ‘pedagogy’ which had hitherto implied a teacher directed process.
The RCS seeks to ensure that the program is consistent with these fundamental
principles, known as the Principles of Adult Learning(4):
1. Adults are internally motivated and self-directed
2. Adults bring life experiences and knowledge to learning experiences
3. Adults are goal oriented
4. Adults are relevancy oriented
5. Adults are practical
6. Adult learners like to be respected
When you look at those principles, think about students with whom you have worked.
To what extent can they be described as ‘adult learners’. Do they have all these
attributes or only some?
7 SupervisionandTeaching
Before we begin, first look at this video of a student talking about what supervisors
can do to assist, do you agree with these ideas, which of these things have you
been able to achieve?
http://www.youtube.com/watch?v=2kxh2vk3cb0
A key foundation stone in understanding how to achieve quality supervision starts
by developing our understanding of self. How do we currently behave as
supervisors and teachers? How would we describe ourselves and how might others
describe us?
The following model, adapted from Gatfield(5) provides a framework for looking
closely at this question. Can you recognise yourself? What are your current
strengths and weaknesses? Do you use a combination of styles, perhaps adapting
styles to suit particular students?
Pastoral Style
Contractual Style
Supervisor provides considerable
personal care and support but not
necessarily in a task driven directive
capacity. Supervisor expects the
student to identify learning
opportunities and take advantage of
them.
Supervisor gives direction and
manages the student whilst also
promoting the interpersonal
relationship and discussion.
Laissez-faire Style
Directive Style
Supervisor is non-directive and not
committed to high levels of personal
interaction. Supervisor may appear
uninvolved. Supervisor thinks the
student is best left to find their own way
in their own time, taking a high
responsibility for their own learning and
that they will seek assistance if they
need it.
Supervisor has a close and regular
interactive relationship with the student
but avoids non-task issues. The focus
is on the student completing tasks
successfully. The interpersonal
relationship is a secondary
consideration.
8 Using the description of students below (1-4), which style of supervision do you think
would best fit them?
Student 1: Has low management skills but usually takes advantage of all the
support on offer
Student 2: Has lack of insight into their strengths and weaknesses and finds
communication difficult
Student 3: Is a confident student who is highly self-motivated and does not
usually require institutional support
Student 4: Is highly motivated and able to take direction, but can also take the
initiative when required
Did you consider the strengths and weaknesses each style has to offer?
On reflection, would you like to adapt your primary style in any way? Why?
9 In fact there are strengths and weaknesses in every style. Here is a summary of
some of the research on this topic.
Kilminster and Jolly 2000(6)
Reviewed over 300 papers on medical supervision in 2000 and decided:
•
The supervision relationship is the most important factor
•
Feedback is essential and must be clear
•
The trainee must be empowered in the process
Gatfield 2005(5)
Twelve supervisors who had been designated “excellent” placed themselves on
Garfield's grid:
9 Contractual
1 Pastoral
1 Laissez-faire
1 Directorial
And on teaching more generally Sutkin G, Wagner E, Harris, I Schiffer R(7)
Excellent clinical teaching, although multifactorial, transcends ordinary teaching and
is characterized by:
9 Inspiring
9 Supporting
9 Actively involving
9 Communicating with students.
10 In summary, the take home message for good supervision is to aspire to the
Contractual supervisory model which offers the student high levels of support and
structure, but also to be mindful that:
9 Each supervisory relationship is unique and styles must be adapted
9 The affective dimensions of: support, availability etc are valued most highly by the trainee
9 There needs to be balance between task‐
focused, effectively listening, consultative and directive.
11 LearningStyles
Much has been written on identifying individual student learning styles in order to
achieve better learning outcomes.
Most clinical teachers seek to discover how the learner engages best with the
material in order to promote active, timely and “deep” learning that can be retrieved
and adapted for new purposes.
As a general rule it is valuable to ask the learner what works best for them and adapt
the teaching style to suit.
In this course there is limited time look in detail at the different models, definitions
and typologies although a brief summary provides a starting point.
Here are three approaches to defining and understanding learning styles:
1. Myer Briggs Typologies(8) (1962)
a. Introversion/Extraversion
b. Perceiving/Judging
2. Wolf and Kolb(9) (1985) - Cycle of Experiential Learning(10)
a. Converger - practical, concrete experience
b. Diverger - ideas person, needs time to reflect
c. Assimilator - uses abstract conceptualisation
d. Accommodator – experiments and tests learning
3. VARK Learning Style Questionnaire(11) N Flemming
a. Visual
b. Aural
c. Reading/Writing
d. Kinesthetic
e. Multi-modal
12 1.
The Myer Briggs Typologies provide for self-testing for type through the use of
a psychometric questionnaire. In summary there are two axis:
introversion/extraversion and perceiving/judging. In total there are 16 different
typologies to describe personalities. The typologies can be very useful in providing
information that fosters an understanding of difference, and promotes good
communication across all typologies.
The typologies were originally developed to assist in the choice of career.
Medical students may have learnt about the Myer Briggs in the early years of the
MBBS and may have a developed awareness of self that they can describe using the
typology descriptors.
2.
Kolb’s Theory of Experiential Learning provides an explanation of the four
learning stages of the adult learner engaged in experiential learning, of which,
learning in the workplace, is one type.
The following diagram, though rather cluttered, indicates where each of the four main
learning styles are located within the experiential learning cycle. Each learner may
enter the cycle at different points, or have a dominant learning style preference.
The main point is that the cycle of: experiencing, reflecting, thinking, and
experimenting are all important aspects of workplace learning.
13 2. The VARK Learning Styles Questionnaire(11) was developed by Fleming and is
perhaps one of the best known of the learning styles tools. He describes learners
in terms of how they best take in information, in brief:
Visual:
Pictures, posters, flow charts, graphs i.e. symbols
Aural:
Prefer discussion, face to face teaching, stories, jokes etc
Kinesthetic:
Hands on, real experience, seeing and doing, physical
engagement
Read/write:
Lists, definitions, readings etc
Multi-modal:
All of the above
Handout of VARK Learning Styles is included at the end of the Manual.
In summary it is well to remember that:
9 About 60 % of the standard population are multimodal 9 Research indicates most medical students are multi‐modal, some research suggests a preference for MM with Kinesthetic 14 Even though it is important to stress the dangers of over generalizing and failing to
understand that each learner is unique, the following description of the multi-modal
student may resonate with you as a clinical teacher. .
•
Are uncertain until confirmed through a number of modes
•
When coached they want to check the oral information with the text book or
print the instructions
•
Take a long time to make a decision which can be annoying – but they are
then confident about their learning and their learning is more versatile
(multiple perspectives , generalisability, adaptation, predicting)
•
Deep learning approach not surface learning, they in turn make good teachers
•
If rushed with no time to multi-mode, they will only have half understood
•
They ask for help a lot
•
They often think they don’t get enough teaching
•
Supervisors/teachers need to use multi-modes when teaching e.g. talk and
do, talk and draw, give reading tasks etc
Have you noticed these characteristics in students?
Have you experienced the student who questioned you and needed to check out
information you offered when you expected it to be readily accepted as true?
Have you experienced the student who needs quite some time to absorb
information enough to proffer a suggestion for patient management?
15 Have you experienced the student who tends to repeat what you have said or asks
the same question a number of times? Have they actually understood but need to
hear the information again, or have they not understood?
The take home message for learning styles is:
9 The experiential process (workplace
learning) requires time to:
• Act
• Reflect
• Think
• Experiment
•
9 Students will differ about what aspect they
most value and how much time they need at
each stage
9 Use a variety of modalities for teaching
9 Give students time to confirm learning in
their own way
9 Ask students about how they learn best
16 WhatdoestheRuralClinicalSchoolwantstudentstolearn?
What useful information does the MBBS curriculum provide: • Identified attachment learning outcomes
• Personal learning goals
• Case Based Learning Topics
These three elements provide the core of the Rural Clinical School curriculum.
Essentially the attachment learning outcomes are an agreed set of topics and
competencies that students will seek to learn in each attachment.
Students combine these requirements with their own specific learning goals that
reflect where they are in their own personal learning continuum. These learning
goals are written on the first page of their End of Clinical Attachment Assessment
form.
As well, Case Based Learning Topics provide the fundamental topic structure for the
year and underpin the group learning classroom teaching program. These CBLs
also provide additional direction for attachment teaching and learning.
The following CBL topic examples from Year 4 and 5 are lists of the Major Symptom
Complexes only, the Major Subsets for each of these is not included in the following
chart but is very useful information for the clinician teaching in the workplace.
17 Case Based Learning Topics Example of Year 4 and 5
Year 4
Dyspnoea
Diabetes 1
Chest Pain
Diabetes 2 and
Obesity
Gastrointestinal Pregnancy
Bleeding
Fatigue
Diarrhoea and
Vomiting
Back Pain
Visual
Disturbance
Abdominal
Paine
Thyroid
Disease
Disability
Sexual
dysfunction
Psychosis and
Delirium
Urinary
Symptoms
Vaginal
Bleeding
Sepsis
Refugee Health
Stroke
Headache
Major Trauma
Year 5
Renal Disorders
Anaemia
Sudden Death
Post-operative
Assessment and
Management
Diabetes I
Autoimmune
Disease
The adult with a
disability
Dizziness,
Earache and
Deafness
Rheumatological Dyspnoea Cardiac
and
Autoimmune
Disease
Neoplasia
Chest Pain
Injury
Mood disorders
Febrile Illness
Mid Life
Preventative
Health Care
Aboriginal
Health
DVT/PE
Jaundice
Pre-operative
Assessment and
Management
Diabetes II
Inflammatory
Bowel Disease
Palliative Care
Dyspnoea
Respiraory
Mental health
Sleep Disorders
HIV
Common
Musculoskeletal
Problems
Aboriginal Health Extended
Communication
Skills
Neurodegenerative
Epilepsy
Disorders
Acquired Brain
Dementia
Injury
Endocrinology
ENT
(Complex)
Emergencies
Skin
Occupational
health
Poisoning and
Electrolyte
anaphylaxis
Disturbance
Aged Care
18 Clinical Attachment Learning Outcomes Example from Medicine Yr 4
Log book to be discussed with and signed off by Supervisor and viewed at mid and
end of attachment
Essential Tasks to be achieved:
Procedural skills to be performed or observed (see TSOM handbook for further
detail):
· Venepuncture /IV cannulation
· Arterial blood gases
· Wound dressing
· Insertion urinary catheter
· Write discharge summary
∙ Write up investigation forms
· Write up medication chart
· ECG recording and interpretation
· Write up death certificate
· Write referral to other health professional
∙ Observation of invasive specimen collection and monitoring
Learning Objectives in General Medicine (see TSOM Handbook for additional
detail):
∙ Take a relevant history including prescription and non-prescription drugs
· Perform a competent physical examination
· Construct a differential diagnosis
· Plan and order appropriate investigations
· Formulate a management plan
· Communicate effectively with patients and relatives
· Demonstrate a rational and safe approach to prescribing of antibiotics,
analgesics and anti-coagulation
Understanding of use of blood and blood products
· Use and interpretation of common pathology tests and medical imaging in
General Medicine and Medical Specialties
∙ Familiarity with common medical presentations
19 For each attachment students are required to write up cases in a Clinical Log Book
and on the first page of that log book is a neat summary of learning outcomes for
that attachment in the form of lists of skills and other knowledge based learning
outcomes. The example above is a direct copy of the attachment learning outcomes
for Medicine.
PersonalLearningGoals
These are written on the Clinical Attachment Assessment Form by the student after
negotiating with the clinical supervisor, ideally early in the term. They reflect the
specific focus appropriate for the individual student and are usually quite detailed
with specific learning opportunities mentioned.
The following is a good example for Yr 4 Medicine, with the key elements of: Specific,
Measurable and Achievable addressed.
Goals
1. Further develop my skills in history and examination by practice on patients
2. Focus on neurology and stroke work up and management
3. ECG interpretation and pattern recognition
4. Admission process and taking/writing up a clear concise history and examination
Outcomes
1. Good opportunity to approach stroke patients and practice history and examination (most days)
2. Now familiar with some common ECG patterns
3. Assisted in admission of patients from ED and wrote the notes and completed drug charts
Setting Personal Learning
Goals
Specific
What, when and with whom
Measurable
How will you know the student has
successfully achieved the learning
outcome?
Achievable
Is the task realistic given the clinical
context, time-frames and staff support
available?
20 In summary the RCS recommends that these Guidelines be used when determining
the teaching and learning approach in each attachment. The emphasis is on
discreet learning episodes where there is a specific skill taught and time for
questioning, practice and repetition.
Guidelines for Clinical Teaching
9
9
9
9
9
Hands On with patients
Learning is incremental
Short student/clinician dialogues
Follow‐up activities set
Time for student consolidation and practice
9 Less is more
21 HowdoestheRCSwantclinicianstoteach?
The RCS is keenly aware a major barrier to teaching includes time pressure resulting
from service delivery imperatives. Frequently, clinicians ask about the “how” of
teaching, and whilst we can aspire to spend lengthy time with students in expanded
case discussions, and this happens surprisingly frequently, the reality is that short
teaching episodes are much more likely to be achieved.
For the novice teacher the following teaching models provide simple guidelines for
how to achieve meaningful teaching in a short span of time.
The emphasis is on being specific about what is being taught and teaching to that,
looking for improvement in competence, and working incrementally in the
knowledge that over the period of the attachment the accumulative impact of such
teaching is very powerful.
Do you already have a collection of teaching “pearls” to support student learning?
22 An excellent generic guideline that can be adapted to fit most teaching episodes is
this one detailed in The Superguide(3) HETI June 2013
10 Top Tips for Teaching
1. Little by little 2. Use Pearls 3. Question and task independent learning
4. Student led 5. Allow Questions 6. Focus the learner 7. Focus the lesson 8. Teach EBM 9. Evaluate your practice
10. Seek feedback from students A Pearl(2), noted in point 2 of the guidelines, encapsulates the fundamental
aspects of a teaching episode: SET – establishing an appropriate environment for
learning, DIALOGUE – engaging with the student, using question and answer, and
CLOSURE – summarizing the learning and providing a plan for further learning and
consolidation or practice.
Teaching Pearls SET Organise the environment for teaching DIALOGUE What are you going to say/ask/explain? CLOSURE What is the take home message? 23 Another example of a short teaching episode is called the One Minute Teacher(2)
which is essentially about using a specific context to teach a general principle.
The One Minute Teacher The teacher: 1. Asks the learner to outline his or her diagnosis or management plan
2. Questions the learner for reasoning
3. Teaches general rules (take home points)
4. Provides feedback on what was done well
5. Corrects errors and suggests what could be improved
Lastly, there has been a great deal written about the teaching of procedural skills.
Walker and Peyton’s Skills (12) teaching model offers a basic process for teaching a
skill where the importance of modeling, deconstruction and guided practice are
stressed.
Walker and Peyton’s Skills The trainer:
• Demonstration : Demonstrates at normal speed, without commentary
• Deconstruction : Demonstrates while describing the steps
• Comprehension : Demonstrates with the learner describing the steps
The learner :
• Performance: Learner demonstrates while learner describes steps.
24 SummaryofSession1
In this session we have visited the fundamentals of achieving good quality
supervision, understanding learning styles, understanding the RCS teaching
requirements in the clinical setting and teaching with short episodes of learning in the
clinical setting.
The key take home messages for good supervision are:
9 Each supervisory relationship is
unique and styles must be adapted.
9 The affective dimensions of:
support, availability etc are valued
most highly by the trainee.
9 There needs to be balance between
task-focused, effectively listening,
consultative and directive.
For teaching and learning approaches:
9 The experiential process
(workplace learning) requires time
to:
Act Think Reflect and
Experiment
9 Students will differ about what
aspect they most value and how
much time
they need at each stage
9 Use a variety of modalities for
teaching
9 Give students time to confirm
learning in their own way
And for teaching episodes are:
10 Top Tips for Teaching 1. Little by little
2. Use Pearls
3. Question and task independent learning
4. Student led
5. Allow Questions
6. Focus the learner
7. Focus the lesson
25 8. Teach EBM
9. Evaluate your practice
10. Seek feedback from students
WorkplaceAssessmentattheRuralClinicalSchool
In this section you have the opportunity to become familiar with two formative
assessment tools that we ask clinicians to use in the workplace with medical
students.
The tools are relatively new to the RCS but they are very similar to formative
assessment tools that are now across the medical training continuum .
A formative assessment is one where the primary purpose is to identify learning
gaps and teach to them. This is different from a summative assessment which is
designed to test competency and make a final judgment which may impacts on
passing or failing a course or part of a course.
The two formative assessment tools to examine more closely are the Mini Clinical
Evaluation Exercise (MiniCEX), and the Direct Observation of Procedural Skills
(DOPS).
26 The Mini-CEX
Have you used this form?
What do you see as the advantages of this formative assessment?
Are there difficulties with it in the clinical setting?
27 28 Ideas to keep in mind when using the Mini-CEX:
•
Each student is required to have 2 completed in each attachment
•
The purpose of the Mini-CEX is to stimulate DIALOGUE between student
and clinician so the first one is ideally completed in the first half of the
attachment . It sets up a relationship where FEEDBACK is normalized
•
It is not necessary to assess all the skill subsets listed on the left of the form
and it is best to choose 1 or 2 skills on which to focus
•
For others reading the form such as RCS assessment staff, it is important that
the skill and the level of difficulty are noted at the top of the form
•
When attributing a score for the skills, keep in mind we are training students
over a two year period to reach Intern standard, so a score of 7 – 9 reflects
that standard. Final year students in their last 6 months may well be at that
standard, but Year 4 students may well be scored below or well below 7.
•
If a student scores below 7 this presents a wonderful opportunity for the
student to practice the skill over time and be re-assessed on the same
skill.
•
Medical students, early in Year 4 are coming to grips with the idea that they
may not immediately gain a satisfactory level of performance in the clinical
setting and that they are on a learning continuum . The clinical teacher can
help them to understand and accept the process.
•
Students do not need to rush this process, but instead, to progress carefully
with opportunity for consolidation. New learning needs to be “bedded”
down.
•
The Mini-CEX can be very helpful in determining the final overall
assessment of the student at end of term. Although a student may do well
on a Mini-CEX but not pass the term or vice-versa.
29 The DOPS
Have you used this form?
What do you see as the advantages of this formative assessment?
Are there difficulties with this form of which the RCS should be aware?
RCS students need to achieve a certain number of procedural skills over the two
year program. Recently the RCS has developed a set of skill specific DOPS forms
and the IV DOPS form below is a good example.
The DOPS assessment usually takes place after the student has had a good
opportunity to learn and practice the procedural skill.
The RCS compares favourably with other clinical schools in terms of the opportunity
students have for learning and using procedural skills. This helps them to obtain
Intern standard by end of Year 5 and ensures they are work-ready by Intern
commencement.
The RCS uses simulation extensively and it may be that you direct a student back to
the simulated environment before they can practice again on a patient. That cycle is
the preferred cycle and very useful. Students can book practice with Luanne or
Heather at reasonably short notice.
30 GivingFeedback
31 GivingFeedback
Giving feedback is a skill pertinent to the role of clinical supervisor and teacher. The
formative assessments examined in the previous section provide mechanisms for
written and verbal feedback and the RCS emphasizes at all times the importance of
DIALOGUE.
Even though the research evidence mentioned in Session 1 indicates that both
students and clinicians understand the value of the feedback process there is often
a degree of apprehension from both parties about how feedback will eventuate.
At the RCS this apprehension can result in:
•
Students avoiding the face to face feedback process at end of term by
“dropping off” a form and not being easily available for verbal feedback
•
Clinicians “sending in” a form that has been completed without the student
present and not discussed with the student
•
Student’s being surprised by the content of the assessment
•
Clinician’s making assessment judgments without full knowledge of the
student
•
Both parties feeling inadequate and awkward about the feedback process
32 Take some time to reflect on your own experience of giving or receiving feedback.
• When did this last happen for you?
• Where and how did it happen?
• What kind of feedback “model” was used?
• What went well • What could have been improved?
What have you learnt from this experience of giving or receiving feedback?
Consider these questions
•
What attitude/feelings do we bring to the task?
•
Can we talk directly about the main issues?
•
How do we know we have been heard?
•
How comfortable are we with emotional responses?
•
How comfortable are we with silence?
•
How comfortable are we with failing a student or being failed on a task or
attachment?
•
Do we use an action plan to follow up?
•
How do we use or accept praise?
Would you endorse these guidelines?
Giving Feedback Guidelines
•
Be timely
•
Be consistent
•
Be specific
•
Be constructive
•
Choose an appropriate setting
•
Use attentive listening
33 Here is a time-honoured model that is often used in medical education. It is called
Pendleton’s Rules(13). It is a guide to giving balanced feedback. Some call it the
Feedback Sandwich. Pendleton’s Rules
1. Check the learner wants and is ready for feedback
2. Let the learner give comments/background to the material that is
being assessed
3. The learner states what was done well.
4. The observer(s) state what was done well.
5. The learner states what could be improved.
6. The observer(s) state how it could be improved.
7. An action plan for improvement is made.
Have you used this model or one that is similar? How does it work for you?
Do you recognize the SET, DIALOGUE, CLOSURE structure that we discussed in
Section 1 when talking about teaching Pearls?
Feedback Tip: If the emphasis is on describing what has occurred and the
comments remain specifically focused,
without passing judgment about motives or personal elements,
the feedback process remains a safe place where deficiencies can be openly
discussed and remediation strategies planned.
The importance of non-emotive verbal and non-verbal behavior from the
clinical supervisor cannot be emphasized enough.
34 ReviewofFeedbackExamplesonDVD(14)
The DVD scenarios are part of the Teaching on the Run: Clinicians training program
and include Scenarios 1 – 4 on Giving Feedback in the Hospital Setting.
They are an excellent resource.
Reviewing the scenarios provides an opportunity to see how a clinician provides
feedback, in this case, to a junior doctor at end of term. Each example builds on the
prior until example 4 provides the exemplar to which we all aspire.
Scenario 4 provides a good illustration of a feedback process in which the trainee
has the opportunity to talk about their own performance and any perceived difficulties
and strengths before the supervisor then makes a comment.
Although the encounter takes only just under 3 mins the clinician manages to
complete the process without rushing and whilst still being able to attentively listen.
The Guidelines for Giving Feedback, mentioned earlier give a standard against
which to review each Scenario.
The take home message is, whatever feedback ‘model’ you choose, whether
Pendleton’s Rules or another, it is important that:
Giving Feedback Guidelines
•
Be timely
•
Be consistent
•
Be specific
•
Be constructive
•
Choose an appropriate setting
•
Use attentive listening
35 ManagingtheChallengingStudent
In this final section of the course we consider how challenging students present in
the clinical setting, the impact of personality on the issues at hand and what kind of
strategies are available to assist the supervising or teaching clinician in the
management of such a student.
The Trainee in Difficulty(15) is an excellent resource that is available on-line at
http://www.heti.nsw.gov.au/Global/HETI-Resources/prevocational/news/trainee-indifficulty-2nd.pdf
The information in the resource, although written for supervisors of junior doctors, is
equally useful, with some adaptations, in the supervision of medical students. Some
of the suggestions in this section are adaptations of ideas within that resource.
36 How does the challenging student present?
What are your experiences? Do these examples resonate with you?
The disappearing act:
disappearing between clinic and the ward,
frequent lateness, unexplained sick leave, leaving
early, claiming another study imperative that
prevents attendance at the attachment, becoming
isolated from peers and not wanting to engage in
conversation or give eye contact
Low work rate:
slowness at procedures, clerking, completing
letters and notes, few patient encounters, not
getting Mini-CEX or DOPS completed, no sign of
log book being completed, tiredness
Ward rage:
aggressive or passive aggressive responses when
ideas about management are questioned, shouting
matches with peers, staff or patients, disrespectful
or dismissive speech and behaviour towards
other health professionals.
Rigidity:
poor tolerance of ambiguity, inability to
compromise, difficulty prioritising, inappropriate or
vexatious complaints,
Bypass syndrome:
peers and other staff are bypassing the student
and not involving them in ward based activities or
case discussions
Career problems:
difficulty with exams, uncertainty about career
choice, disillusionment with medicine.
Insight failure:
rejection of constructive criticism, defensiveness,
counter-challenge
37 Issues can usually be grouped like this:
1. Clinical Performance Problems
2. Behaviour and Attitude Problems
3. Communication Problems
4. Health Problems
5. Other extrinsic issues
The concept of the student’s ‘FRAME’(16) or perspective
Frames provide meaning through selective simplification, by filtering people's
perceptions and providing them with a field of vision for a problem. As supervisors
we are greatly advantaged if we can understand the ‘frame’ within which the student
functions. Their frame will be shaped by established attitudes, beliefs and values.
The student may not always be consciously aware of the impact of these on their
day to day decision making.
To understand the student’s ‘frame’ we must first listen very carefully to them, and
without judgment. Unless we do so, we are at risk of mis-interpreting behaviour and
making an inaccurate and unhelpful assessment of the student.
For example, a student may have heard from an RCS staff member that 80% of face
to face attendance is required to pass the MBBS. That student may have interpreted
that as an agreed understanding amongst all teaching clinicians on the ward and
elsewhere, that 80% attendance is required. The student may assume that there is
a high expectation around self-directed learning and be using the non-clinical
attendance time to their academic advantage.
A supervising clinician who finds the student absent at times, may presume the
student is not interested or is lazy since they will expect 100% attendance and have
the view that this is an accepted rule. As a result the student may be confused about
why they are being treated with low levels of respect, even counter-claiming a lack of
genuine support which in itself further discourages participation.
The problem is not the student or the clinician’s, it is conflict that arises from the
existence of different ‘frames’.
38 Consider the following scenario, How might you manage this student?
Ralph
Ralph is a Yr 4 student in his second attachment on Medicine.
You are a medical registrar and whilst you are not his “official”
supervisor, he has been assigned to your team over the last two weeks
(the first 2 weeks) of the 4 week attachment.
The consultant has asked you what you think about this student - how is
he progressing, are there any problems?
On reflection, although the student seems socially very confident and is
very personable (can be funny, chats to everyone and the patients seem
to enjoy him), you have begun to realise that you don’t know much about
him.
He doesn’t seem to have been at morning rounds lately and you’ve just
gone to find him and no-one has seen him today. One nurse comments
that when she asked if he would like to cannulate a patient, he said “No,
that’s fine, you can do it”.
You realise you have not done a MiniCEX for him yet. He didn’t turn up
to the weekly meeting yesterday. None of the other students have seen
him either.
What are your concerns?
What are you going to do?
39 Keep in mind the Guidelines for Supervision we discussed in Session 1
9 Each supervisory relationship is unique and styles must be adapted
9 The affective dimensions of: support, availability etc are valued most highly by the trainee
9 There needs to be balance between task‐
focused, effectively listening, consultative and directive.
Use these questions to help develop a Pre-meeting Plan
1. What is the main presenting issue?
2. Assess the severity of the issue – is there a safety issue for patients or
students
3. Does this present educational or disciplinary issues or both?
4. What time-frame for meeting and review are you thinking of using?
5. What information do you need to gather before meeting with the student?
6. What will be your approach when meeting with the student? Where will you
meet? Should there be someone else at the meeting?
7. What are the main strategies you would like to implement?
8. What is the student’s FRAME?
9. Have you thought about documentation?
10. What can you do about the unknowns at this point?
11. Should you be getting assistance from other sources – the RCS or the
Consultant?
40 The scenario provides for interesting discussion. What came to mind when you read
the description of events?
Did you consider any of these possible causes?
•
Disinterest
•
Depression
•
Low confidence and fear of failure
•
Over confidence and de-valuing of workplace learning
•
Confusion over schedules
•
Personal issue with a staff member/bullying
Here are the RCS tips on how to approach such a challenge
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Act early
Make expectations REALLY clear
Confine the focus to the main presenting issue
Assess the severity of the issue –
is there a safety issue for patients or students
Determine time-frames for remediation and review
Collect information
Plan possible strategies
Refrain from pre-judging
Prepare for the unexpected
Use the SET/DIALOGUE/CLOSURE approach
Document
Be well supported and use referral
41 How can the RCS assist with challenging students?
Most students can be managed very well on the wards and most issues are relatively
minor. Clear, non-judgmental communication serves us well in these instances.
When issues are more complex or long standing and initial strategies have been
unsuccessful, the RCS is in a good position to provide support.
In summary, these are the responsibilities for the Medical Education Advisor and the
Co-Director of the RCS.
Rose Winter MEA
•
•
Background on student re
academic and any relevant
disclosed personal/health
Facilitating a meeting or helping
to structure an agreed plan –
even if very simple and
relatively informal
•
Providing support work with the
student on a regular basis
•
Facilitating referral to UTas
counselling service or
identifying available GPs,
psychologists
•
Constructing a formal Student
Support Plan if issues are
ongoing/serious
Dr Deb Wilson
Co-Director RCS
•
For serious breaches of conduct
and/or patient or student safety
issues
•
If you really think you need to talk
with another Dr
•
For complex issues where a team
brain storming approach with Deb
and Rose could be useful.
42 Summ
maryofS
Session1
1and2
me messag
ges from th
he main top
pics for disscussion within
w
Below are the key take hom
this sho
ort course.. These arre available
e on handy
y laminated key cardds.
As well, in the Re
esources and
a Hando ut section of this manual you w
will find other
n and read
dings.
useful information
We are
e keen to hear
h
back from
f
you a
about how this
t
information has bbeen usefu
ul to
you in yyour superrvision and
d teaching
g of studen
nts in the clinical
c
settting.
Thankk you for yo
our interest and comm
mitment to
o medical education,
e
and espec
cially to
supporting
g students from the Rural
R
Clinic
cal School..
43 Handouts
The VARK Modalities Example RCS Attachment Learning Outcomes ‐ Medicine Personal Learning Outcomes Example and Guide Case Based Learning Topics for Year 4 and 5 End of Clinical Attachment Assessment Form MiniCEX Form DOPS Form
44 The VARK Modalities The acronym VARK stands for Visual, Aural, Read/write, and Kinesthetic sensory modalities that are
used for learning information. Remember life (and work) are multimodal so there are no hard and fast
boundaries.
Visual (V):This preference includes the depiction of information in maps, spider diagrams, charts,
graphs, flow charts, labelled diagrams, and all the symbolic arrows, circles, hierarchies and other
devices, that people use to represent what could have been presented in words. This mode could
have been called Graphic (G) as that better explains what it covers. It does NOT include still pictures
or photographs of reality, movies, videos or PowerPoint. It does include designs, whitespace, patterns,
shapes and the different formats that are used to highlight and convey information. When a
whiteboard is used to draw a diagram with meaningful symbols for the relationship between different
things that will be helpful for those with a Visual preference.
Aural / Auditory (A):This perceptual mode describes a preference for information that is "heard or
spoken." Learners who have this as their main preference report that they learn best from lectures,
group discussion, radio, email, using mobile phones, speaking, web-chat and talking things through.
Email is included here because; although it is text and could be included in the Read/write category
(below), it is often written in chat-style with abbreviations, colloquial terms, slang and non-formal
language. The Aural preference includes talking out loud as well as talking to oneself. Often people
with this preference want to sort things out by speaking first, rather than sorting out their ideas and
then speaking. They may say again what has already been said, or ask an obvious and previously
answered question. They have need to say it themselves and they learn through saying it - their way.
Read/write (R):This preference is for information displayed as words. Not surprisingly, many teachers
and students have a strong preference for this mode. Being able to write well and read widely are
attributes sought by employers of graduates. This preference emphasizes text-based input and output
- reading and writing in all its forms but especially manuals, reports, essays and assignments. People
who prefer this modality are often addicted to PowerPoint, the Internet, lists, diaries, dictionaries,
thesauri, quotations and words, words, words... Note that most PowerPoint presentations and the
Internet, GOOGLE and Wikipedia are essentially suited to those with this preference.
Kinesthetic (K):By definition, this modality refers to the "perceptual preference related to the use of
experience and practice (simulated or real)." Although such an experience may invoke other
modalities, the key is that people who prefer this mode are connected to reality, "either through
concrete personal experiences, examples, practice or simulation. It includes demonstrations,
simulations, videos and movies of"real" things, as well as case studies, practice and applications. The
key is the reality or concrete nature of the example. If it can be grasped, held, tasted, or felt it will
probably be included. People with this as a strong preference learn from the experience of doing.
What about Mixtures? Multimodality (MM):
Life is multimodal. There are seldom instances where one mode is used, or is sufficient, so that is why
there is a four-part VARK profile. They are of two types. There are those who are flexible in their
communication preferences and who switch from mode to mode depending on what they are working
with. They are context specific. There are others who are not satisfied until they have had input (or
output) in all of their preferred modes.
They take longer to gather information from each mode and, as a result, they often have a deeper and
broader understanding. They may be seen as procrastinators but may be merely gathering all the
information before acting - and their decision making and learning may be better because of that
breadth of understanding.
45 Example RCS Attachment Outcomes – Medicine
Essential Tasks to be achieved:
Procedural skills to be performed or observed
(see TSOM handbook for further detail):
· Venepuncture /IV cannulation
· Arterial blood gases
· Wound dressing
· Insertion urinary catheter
· Write discharge summary
· Write up investigation forms
· Write up medication chart
· ECG recording and interpretation
· Write up death certificate
· Write referral to other health professional
· Observation of invasive specimen collection and monitoring
Learning Objectives in General Medicine
(see TSOM Handbook for additional detail):
· Take a relevant history including prescription and non-prescription drugs
· Perform a competent physical examination
· Construct a differential diagnosis
· Plan and order appropriate investigations
· Formulate a management plan
· Communicate effectively with patients and relatives
· Demonstrate a rational and safe approach to prescribing of antibiotics,
analgesics and anti-coagulation
· Understanding of use of blood and blood products
· Use and interpretation of common pathology tests and medical imaging in
General Medicine and Medical Specialties
· Familiarity with common medical presentations
46 Personal Learning Outcomes Example and Guide
Specific
What, when and with whom
Measurable
How will you know the student has successfully
achieved the learning outcome?
Achievable
Is the task realistic given the clinical context, timeframes and staff support available?
An exemplary example:
Goals
1. Further develop my skills in history and examination by practice on patients
2. Focus on neurology and stroke work up and management
3. ECG interpretation and pattern recognition
4. Admission process and taking/writing up a clear concise history and
examination
Outcomes
1. Good opportunity to approach stroke patients and practice history and
examination (most days)
2. Now familiar with some common ECG patterns
3. Assisted in admission of patients from ED and wrote the notes and completed
drug charts
47 Case-based Learning Topics for Year 4 and 5
Year 4
Dyspnoea
Diabetes 1
Chest Pain
Diabetes 2 and
Obesity
Gastrointestinal Pregnancy
Bleeding
Fatigue
Diarrhoea and
Vomiting
Back Pain
Visual
Disturbance
Abdominal
Paine
Thyroid
Disease
Disability
Sexual
dysfunction
Psychosis and
Delirium
Urinary
Symptoms
Vaginal
Bleeding
Sepsis
Refugee Health
Stroke
Headache
Major Trauma
Year 5
Renal Disorders
Anaemia
Sudden Death
Post-operative
Assessment and
Management
Diabetes I
Autoimmune
Disease
The adult with a
disability
Dizziness,
Earache and
Deafness
Rheumatological Dyspnoea Cardiac
and
Autoimmune
Disease
Neoplasia
Chest Pain
Injury
Mood disorders
Febrile Illness
Mid Life
Preventative
Health Care
Aboriginal
Health
DVT/PE
Jaundice
Pre-operative
Assessment and
Management
Diabetes II
Inflammatory
Bowel Disease
Palliative Care
Dyspnoea
Respiraory
Mental health
Sleep Disorders
HIV
Common
Musculoskeletal
Problems
Aboriginal Health Extended
Communication
Skills
Neurodegenerative
Epilepsy
Disorders
Acquired Brain
Dementia
Injury
Endocrinology
ENT
(Complex)
Emergencies
Skin
Occupational
health
Poisoning and
Electrolyte
anaphylaxis
Disturbance
Aged Care
48 49 50 51 52 53 54 References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Australia HW. National Clinical Supervision Support Framework 2011. Adelaide: 2011. Lake F, Ryan G. Teaching on the Run: Teaching Tips for Clinicians. 2nd ed. Pyrmont NSW: Australasian Medical Publishing Company; 2007. Institute HhEaT. The Superguide: A handbook for supervising doctors. Health N, editor. Sydney: NSW Health; 2013. Martin L. Andragogy in Action ‐ Applying Modern Principles of Adult Learning ‐ Knowles,Ms. J Curriculum Stud. 1986;18(1):103‐5. Gatfield T. An Investigation into PhD Supervisory Management Styles: Development of a dynamic conceptual model and its managerial implications. Journal of Higher Education Policy and Management. 2005;27(3):311‐25. Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Medical Education. 2000;34(10):827‐40. Sutkin G, Wagner E, Harris I, Schiffer R. What Makes a Good Clinical Teacher in Medicine? A Review of the Literature. Acad Med. 2008;83(5):452‐66 10.1097/ACM.0b013e31816bee61. Myers B. A guide to Understanding Your Results on the MBTI Instrument. 6th Edition ed. Kirby LaMK, editor. California: CPP Asia Pacitifc; 1998. Kolb AY, Kolb DA. Learning styles and learning spaces: Enhancing experiential learning in higher education. Acad Manag Learn Edu. 2005;4(2):193‐212. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. New Jersey: Prentice Hall; 1984. N F. VARK Learning Styles. [18th November 2013]; Available from: http://www.vark‐
learn.com/english/index.asp. Walker M, Peyton J. Teaching in Theatre. Rickmansworth UK: Manticore Europe Limited; 1998. Pendleton D, Scofield T, Tate P, Havelock P. The Consultation: An approach to learning and teaching. Oxford: Oxford University Press; 1984. WA U. Teaching on the Run: Training Program for Clinicians. Crawley WA: University WA; 2009. HETI. Trainee in Difficulty: A management guide for Directors of Prevocational Education and Training. 2nd ed. Sydney: NSW Health; 2012. Wikipaedia. Framing. 2013 [20/11/13]; Available from: http://en.wikipedia.org/wiki/Framing_effect_(psychology). 55