Thomas M. De Fer, MD, FACPAssociate Professor of Medicine

Division of Medical Education

Department of Internal Medicine

SETTING EXPECTATIONS

I HAVE NO UNRESOLVED CONFLICTS TO DISCLOSE

AND

WILL NOT BE DISCUSSINGOFF-LABEL USE OF DRUGS

(UNLESS SPECIFICALLY NOTED)

Have you ever been in a situations where you unpleasantly surprised by previously unstated expectations? How did that make you feel?

Fundamental Teacher Responsibilities Set expectations Maintain a conducive learning climate Provide ongoing feedback Teaching and modeling of knowledge, skills,

and attitudes Fostering self-directed learning Evaluation and grading

List not intended to be all-encompassing

High achievement always takes place in the framework of high expectation.

Charles F. Kettering, American inventor, engineer, and businessman

Why Set Expectations? It is one of our fundamental responsibilities as

teachers to set the agenda If the teacher does not know what the

expectations are, we’re really in trouble!You cannot run a course without objectives and

expectationsYou cannot teach in a course without knowing the

objectives and expectations of the course The general, common sense, theory is that

expectations drive performanceHowever, there is little empirical research to support

this hypothesis

Why Set Expectations? Learners are learners precisely because they

do NOT know everything It is simply unreasonable to assume that learners

(even adult learners) will always set all the appropriate expectations for themselves

Correcting errors with be far more comfortable and impactful if the expectations have been established a prioriExpectations are the foundation of feedback

Errors of Expectation The single biggest error is failing to provide any

expectations at all The second biggest error is to provide nebulous

expectations that have insufficient details to be meaningfule.g., “I expect all of you to work hard and to be

professional and conscientious.” A third important error is providing expectations

that are not in line with those of an organized course (“rogue expectations”)

Wiese J. Teaching in the Hospital. ACP Teaching Medicine Series. 2010.

Other Expectation Caveats Acknowledge that learners bring with them

preconceived expectations on the basis their prior experiences (so do you)

People often fall back into easier more comfortable expectations (human nature)

Multiple reiterations of expectations may be necessary

Expectations of the hidden curriculum can be extremely powerful!

Wiese J. Teaching in the Hospital. ACP Teaching Medicine Series. 2010.

For What to Set Expectations Curriculum Attendance Absences Punctuality Participation Appearance Professionalism Assignments Deadlines Assessments

Consequences Evaluations Grading Appeals Grievances Due process

ExampleSPECIFIC CLERKSHIP GOALS AND GUIDELINES 11

HISTORY AND PHYSICAL EXAMINATION 11

OBSERVED HISTORY AND PHYSICAL EXAMINATION 11

WRITTEN H&P 11

ORAL PRESENTATIONS 12

DAILY PROGRESS NOTE 13

COMMUNICATION 13

PROFESSIONALISM 13

ORGANIZATIONAL SKILLS 14

WARD RESPONSIBILITIES 14

TESTS AND PROCEDURES 15

DIFFERENTIAL DIAGNOSIS SKILLS 15

KNOWLEDGE BASE 16

TOOLS 17

OPHTHALMOLOGY 17

CONFERENCES 17

FOOD AT CONFERENCES 19

STUDENT DUTY HOURS 19

DAYS OFF SCHEDULE 20

SUGGESTED RESOURCES 20

FEEDBACK EVALUATION AND GRADING 23FEEDBACK 23

CLINICAL SKILLS EXAMINATION 23

NBME SUBJECT EXAM 24

CLINICAL EVALUATION/GRADING 24

GRADING APPEALS: 25

 THE BOTTOM LINE 27

ExampleWUSM CLINICAL EVALUATION FORM 31

BEHAVIORAL CHARACTERISTICS OF HONORS LEVEL PERFORMANCE 35

VA MEDICAL CENTER PARKING 39

CLINICAL SKILLS EXAMINATIONS 41

WRITTEN HISTORY OF PHYSICAL GUIDELINES 47

MODEL WRITTEN HISTORY AND PHYSICAL 51

ORAL PRESENTATION GUIDELINES 57

MODEL DAILY (SOAP) PROGRESS NOTE GUIDELINES 59

MODEL DAILY (SOAP) PROGRESS NOTE 61

FORMULATING A DIFFERENTIAL DIAGNOSIS 63

LEARNING OBJECTIVES 73

PROFESSOR’S ROUNDS 93

EVIDENCE-BASED MEDICINE ASSIGNMENT 97

EBM EXAMPLES 101

HIGH-QUALITY CLINICALLY-ORIENTED INTERNAL MEDICINE JOURNALS 105

CORE CURRICULUM LECTURE SERIES READINGS 109

CORE CURRICULUM LECTURE SERIES SCHEDULE 113

CHIEF RESIDENTS’ ROUNDS SCHEDULE 115

CLINICAL SKILLS SCHEDULE 117

The Bottom Line Be sure you understand your resident’s and attending’s EXPECTATIONS of you. If

they do not tell you, ask them (repeatedly if necessary). If they still don’t, let someone else know (your Chief Resident, Firm Chief, or the Course Director).

Ask for FEEDBACK from your resident and attending frequently, especially at mid- and end-rotation (repeatedly if necessary). If you do not get it, even after asking, be sure to talk to someone (your Chief Resident, Firm Chief, or the Course Director) about this before the end of the rotation. Insufficient feedback canNOT be the sole grounds for a grade change. Beware of, “You’re doing just fine.”

MIDROTATION FEEDBACK (though reasonably predictive) is in no way a guarantee of a certain outcome on your rotational evaluation.

READ THE BEHAVIORAL CHARACTERISTICS OF HONORS LEVEL PERFORMANCE! Next to reading the rest of the course book, this is the single most important thing you should do.

FOLLOW THE WRITTEN H&P GUIDELINES (be sure to also ask your resident and attending about their expectations for your written H&Ps). Put your written H&Ps in the medical record. Be sure to read the Internal Medicine Model Written History and Physical. Using someone else’s written/dictated H&P as the basis for your written H&P is plagiarism and ground for potential failure!

Rectal, breast, neurologic, and fundoscopic exams are appropriate for most of your patients. Do them and document them! If you have any questions about your attending and resident’s expectations in this regard, ask!

The Bottom Line Give copies of your H&Ps to your resident and attending for critique. If they don’t give

them back, ask for them (repeatedly if necessary). FOLLOW THE ORAL PRESENTATION GUIDELINES. Give your oral presentation as

much from memory as possible. Your attending and resident may not make this expectation explicitly clear but they’ll almost certainly notice. Do it anyway! Don’t even have a photocopy in sight! Put notes on note cards or some other memory aid. Using someone else’s written/dictated H&P as the basis for your oral presentation is verbal plagiarism and ground for potential failure!

While on an inpatient rotation, WRITE PROGRESS NOTES for each of your patients everyday in a timely manner (except on your days off) and put them in the medical record.

Be ENTHUSIASTIC AND COMPULSIVE about your ward work. You should know your patients’ progress in great detail! You generally responsible for far few patients than anyone else on the team.

You should have at least a basic understanding of what’s going on with all the patients on the team. Students performing at the “honors” level will manifestly know more than the basics.

HELP OUT your team and be involved in the care of other patients on your team without being asked.

Manifestly DEMONSTRATE INTELLECTUAL CURIOSITY without being asked.

The Bottom Line READ about your patients and the core internal medicine topics. Strongly consider using

the Internal Medicine Clerkship Core Curriculum Learning Objectives to guide your general reading.

Spend at least some time RESEARCHING THE MEDICAL LITERATURE. Definitely share what you have learned with your team. Do this at least once per 4-week rotation without being asked. Don’t be shy and “hide your light under a bushel” because you don’t want to bother anybody. If you don’t demonstrate that you’ve been doing so, it will be assumed that you haven’t.

Give at least one TOPICAL PRESENTATION to your team during each 4-week rotation. Doing more than one is better. Tangible evidence of your work (such as a succinct but insightful short handout) is a great idea. If you have trouble selecting a topic, ask your attending or resident.

You are REQUIRED TO PASS THE CLINICAL SKILLS EXAMINATION in order to pass the clerkship.

You are REQUIRED TO ATTEND ALL STUDENT-SPECIFIC CONFERENCES: Professors Rounds, Physical Diagnosis Rounds (including supplemental sessions with the teaching resident), Radiology Rounds, ophthalmology clinic/group session, Chief Resident Rounds, and Core Lecture Series. Be sure to be as prompt as you can.

BE ORGANIZED and mark your calendars with all important clerkship dates. Particularly note your assigned Professor’s Rounds day and ophthalmology clinic day.

KNOW WHEN AND WHERE TO SHOW UP EVERY MORNING and always make sure you check in with your team before leaving for the day.

The Bottom Line CHECK YOUR EMAIL ACCOUNT AND WEAR YOUR PAGER DAILY. Not doing so is

unprofessional behavior. ALL ABSENCES MUST BE REPORTED directly to the clerkship administrator or the

clerkship director on the day the absence actually occurs. Either a phone message or email will suffice. Unreported absences are considered unprofessional behavior and will result in the submission of a Professionalism Concern Form. Documentable dishonesty regarding absences is unprofessional behavior and grounds for failure! Under no circumstances may residents approve absences but you should definitely make your team aware.

If you miss more that 5 working days (typically intended for illness and family emergencies only) during the 12-week clerkship, you will be required to do make-up work.

Requests for specific call schedules in order to accommodate days off during the clerkship must be made at least 4 weeks in advance of the first day of the 4-week rotation in which the day(s) off will occur!

You CAN be failed for unprofessional behavior ALONE. ALL internal medicine clerks should meet ALL of the above bottom line

expectations. Meeting all of these expectations does NOT in any way imply that you will receive an “honors” grade for this clerkship.

Any questions/concerns about your evaluations/grades should be taken up with the Clerkship Director FIRST. NOT DOING SO WILL NEGATE ANY POSSIBILITY OF A GRADE CHANGE!

The Bottom Line You are REQUIRED TO ATTEND ALL STUDENT-SPECIFIC CONFERENCES:

Professors Rounds, Physical Diagnosis Rounds (including supplemental sessions with the teaching resident), Radiology Rounds, ophthalmology clinic/group session, Chief Resident Rounds, and Core Lecture Series. Be sure to be as prompt as you can.

BE ORGANIZED and mark your calendars with all important clerkship dates. Particularly note your assigned Professor’s Rounds day and ophthalmology clinic day.

KNOW WHEN AND WHERE TO SHOW UP EVERY MORNING and always make sure you check in with your team before leaving for the day.

CHECK YOUR EMAIL ACCOUNT AND WEAR YOUR PAGER DAILY. Not doing so is unprofessional behavior.

ALL ABSENCES MUST BE REPORTED directly to the clerkship administrator or the clerkship director on the day the absence actually occurs. Either a phone message or email will suffice. Unreported absences are considered unprofessional behavior and will result in the submission of a Professionalism Concern Form. Documentable dishonesty regarding absences is unprofessional behavior and grounds for failure! Under no circumstances may residents approve absences but you should definitely make your team aware.

If you miss more that 5 working days (typically intended for illness and family emergencies only) during the 12-week clerkship, you will be required to do make-up work.

The Bottom Line Requests for specific call schedules in order to accommodate days off during the clerkship

must be made at least 4 weeks in advance of the first day of the 4-week rotation in which the day(s) off will occur!

You CAN be failed for unprofessional behavior ALONE. ALL internal medicine clerks should meet ALL of the above bottom line

expectations. Meeting all of these expectations does NOT in any way imply that you will receive an “honors” grade for this clerkship.

Any questions/concerns about your evaluations/grades should be taken up with the Clerkship Director FIRST. NOT DOING SO WILL NEGATE ANY POSSIBILITY OF A GRADE CHANGE!

If you are having problems come to us early. That’s what we’re here for. READ THE REST OF THIS COURSE BOOK! If you don’t, you’re seriously handicapping

your own performance.

Impactful Expectations Establish a rationale for each expectation It is fine to establish expectations that are a

matter of style but identify them as such to highlight those that are based on some important reason

Use the person’s name to establish gravity, importance, personal accountability

Verbal and in writing if possible Ask for their expectations of YOU

Impactful Expectations Your expectations should be reasonable,

observable, and mindful of:Time constraintsLevel of trainingLearner individualityOther responsibilitiesThe expectations of the courseExternal regulationsRecognition that everyone sometimes makes

mistakes, even the teacher

Don't lower your expectations to meet your performance. Raise your level of performance to meet your expectations. Expect the best of yourself, and then do what is necessary to make it a reality.

Ralph Marston, The Daily Motivator

Anger always comes from frustrated expectations.

Elliot Larson

Correcting errors with be much more comfortable if the expectations have been establish a priori

It can save you a lot of discomfort at evaluation/grading time!

You have to expect things of yourselves before you can do them.

Michael Jordan