Teaching Students on the Wards: What students say:

The Literature and Locally

Shobhina Chheda MD MPHOctober 24, 2007

no finances to disclose

Case

Dr. W is a 48 yo male physician who on Sunday at 0300 suddenly woke from a nightmare about having a society without general internists.

He was beginning his 2 weeks of GMED ward attending the next day and realized he didn’t read the email introducing the third year student who would be working with him.

He also realized that his time to teach would be limited given the high ward census and the fact that both his son and daughter were playing soccer championship games over the next 2 weeks (on different teams!)

So, since he couldn’t sleep…

• He made a list of all the specific teaching and feedback activities/behaviors he wanted to engage in for the benefit of his student…

• Then, he circled the 3 most important…

Learning objectivesParticipants will:

• Consider the outcomes we want from our teaching medical students on the wards

• Discuss three 2006 studies regarding teaching/feedback to medical students

• Review 2006-07 CSC/VA faculty evaluations

• Consider and modify your specific teaching behaviors while on the ward

• Leave feeling inspired!

Which outcome(s) are you aiming for?

Student satisfaction

(Pursuit of GIM career)

Improved learning

(Excellent physician)

Effect of the Inpatient General Medicine Rotation on Student Pursuit of a Generalist Career

Arora V, Wetterneck TB, Schnipper JL et al. J Gen Intern Med 2006 21:471-5.

Funding: AHRQ

Goal

• Assess the effect of satisfaction with the inpatient general medicine rotation on student entry into GIM– Overall satisfaction– Attending– Resident– Teaching

Arora V. J Gen Intern Med 2006 21:471-5.

Design

• Multicenter cohort study– Data from Multicenter Trial of Academic

Hospitalists (6 sites)

• Third year medical students between July 2001-June 2003

Arora V. J Gen Intern Med 2006 21:471-5.

Methods• 22 item end of rotation questionnaire

– 3 domains– 5 point Likert scale

• Pursuit of IM career– Match into IM residency– “How likely are you to pursue GIM career?”

• Very likely or certain

– Did not envision inpatient practice setting

• Pre clerkship interest

Arora V. J Gen Intern Med 2006 21:471-5.

Results

• 54% (402/751) Response rate

• 89% (354/397) of students were satisfied or very satisfied

• 28% (87/307) matched in IM (range 21-31%)

• 8% (25/307) met criteria for students pursuing a career in GIM

Arora V. J Gen Intern Med 2006 21:471-5.

Results

• Overall satisfaction with rotation was an important INDEPENDENT predictor with pursuit of career in GIM

– OR 3.91; CI (1.52-10.07); p value .01

Arora V. J Gen Intern Med 2006 21:471-5.

Elements of Inpatient rotation that predict increased overall satisfaction

(adjusted for pre clerkship interest and site)

Predictor (n=402)

Odds ratio

95% CI P value

Teaching 1.72 1.12 -2.65 .01

Quality of attending rounds

1.92 1.12-2.65 .01

Relationship with attending

1.81 1.17-2.82 .01

Arora V. J Gen Intern Med 2006 21:471-5.

Limitations

• Sampling bias- 54% response rate– Responders and non-responders did not differ

in match rates into IM

• Assessed pre clerkship interest retrospectively– No association between pre clerkship interest

and overall satisfaction

Arora V. J Gen Intern Med 2006 21:471-5.

Bottom Line

• We can make a difference in third year !

• Increased satisfaction with the inpatient general medicine rotation promotes student pursuit of a career in GIM

Arora V. J Gen Intern Med 2006 21:471-5.

Impact of Instructional Practices on Student Satisfaction with Attendings’

Teaching in the Inpatient Component of Internal Medicine Clerkships

Guarino CM, Ko CY, Baker LC, Klein DJ, Quiter ES, Escarce JJ

JGIM 2006; 21:7-12.

Source of funding: Atlantic Philanthropies; RAND Project HE387

Goal

Identify specific teaching practices used by attendings that affect student satisfaction with the quality of teaching that they receive in the inpatient component of IM clerkship

Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.

Design

• Nationwide survey of simple random sample

• 2250 4th year medical students (2001-2002)

• 121 allopathic 4 year schools in US

Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.

Survey

• 4 categories of questions– Attending teaching practices– Behaviors in IM clerkship– Organizational features of clerkship– Student satisfaction with quality of teaching by

attendings

Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.

Survey

• Administered Spring 2002

• 30 minutes to complete; confidential

• Response enhancement– Multiple mailings, telephone follow up,

monetary incentive

Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.

Results

• 1,530 surveys completed- 68.3% response rate

• No differences between responders and non-responders– Age, sex, race/ethnicity, MCAT

• Quality of teaching– 78% satisfied – 20% neutral or dissatisfied

Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.

Probability of students being satisfied with quality of attending teaching based on

perception of teaching behavior

Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.

*62%

*21%

*50%

*51%

*12%

* Frequency of always or almost always

Limitations

• Based on student reports

• Asked to consider attendings as “group”

• No association of students satisfaction with attending teaching and subsequent clinical performance

Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.

Bottom Lines

• Certain attending teaching practices and behaviors are correlated with higher satisfaction

• Strive to maintain these teaching practices

• Importance of not appearing rushed– Parallel processes used with patients

Guarino CM, Ko CY, Baker LC et al. JGIM 2006; 21:7-12.

An investigation of medical student reactions to feedback:

a randomized control trial

Boehler ML, Rogers DA, Schwind CJ, Mayforth R, Quin J, Williams RG, Dunnigton G. Med Educ. 2006; 40:746-749.

Funding: None

Goal

To evaluate learning outcomes and perceptions in students who received feedback compared to those who received general compliments

Boehler et al. Med Ed 2006; 40: 746-749

Design

Pre testvideotape

Pre interventionvideotape

Post interventionvideotape

N=33Knot tying instruction

randomized

compliments

feedbackPost intervention

videotape

Boehler et al. Med Ed 2006; 40: 746-749

Boehler et al. Med Ed 2006; 40: 746-749

Medical student reaction to feedback

• Outcome – Objective measurement of knot tying

• 3 faculty evaluators-blinded• Evaluated videotapes via validated instrument

– Student satisfaction rating on 7 point Likert scale

Results

• Subjects– No difference in two groups

• Inter-rater reliability >0.8– Pre test– Pre intervention– Post test

Results

Compliment group

Feedback group

p value

Performance 17.00 21.98 0.008

Global satisfaction

6.0 5.0 0.005

Boehler et al. Med Ed 2006; 40: 746-749

Limitations

• Small group, single institution

• No evaluation of “positive feedback”

• Motor skill studied

Boehler et al. Med Ed 2006; 40: 746-749

Bottom Lines• Student satisfaction ratings are not an

accurate indicator of quality of feedback– Satisfaction reflects praise– Improved performance reflects feedback

• Avoid using satisfaction as measure of feedback effectiveness

• Need tools that accurately measure effects of feedback on performance

Boehler et al. Med Ed 2006; 40: 746-749

2006-07 UW/VA student responses regarding attending teaching behaviors (N= 153)

Most days

About every other day

Once a week

Never

Included me in discussions re my pts

86% 10% 4% 0%

Discussed reasoning behind patient care

84% 14% 1% 0%

Feedback on oral presentations

67% 17% 14% 2%

2006-07 UW/VA student responses regarding attending teaching behaviors (N= 153)

Most days Every other day

Once a week

Never

Feedback on admission H/P

25%

(at least 6)

25%

(at least 4)

30%

(at least 2)

20%

Feedback on progress notes

26% 25% 34% 15%

Bedside physical exam

22% 31% 33% 14%

Bedside communication skills

41% 25% 25% 9%

2006-07 UW/VA student responses regarding attending teaching behaviors (N= 153)

Yes No Not sure

Made expectations clear at beginning

75% 12% 13%

Provided end of rotation feedback

88% 8% 3%

Provided mid-way feedback

67% 25% 7%

“Overall, as a role model I consider my ward attending to be…” (N=153)

• 54% Excellent

• 35% Very good

• 8% Average

• 3% Fair

• 0% Poor

“I can't change the direction of the wind, but I can adjust my sails to always reach my destination.”

- Jimmy Dean

So Back to you…..

• Review your list

• Reconsider your “top 3”– Be specific, Add “frequency”

• Share with the person next to you….

"Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it's the only thing that ever has.“

Margret Mead

"Do not wait for leaders;do it alone,

person to person."

Mother Teresa

“ I really appreciate Dr.X stating her expectations right from the start. I also loved that she provided feedback “on the spot”, for oral presentations. She had all of us teaching something related to medicine which was a great learning experience. She was extremely efficient and if there was any down time, she used it to teach…..”

“…Her enthusiasm for medicine is inspiring and I feel I learned a lot from watching her interactions with families regarding difficult decision making issues. She has made me consider medicine as a career.”