Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2823_Библиотеки_им_академика_М_И_Перельмана
.pdf
methods to help faculty improve and increase observation.
Increasing Faculty Buy-In for Direct
Observation
Getting faculty to observe learners is challenging. For
decades faculty have taken at face value the veracity of the
history and physical examination presented on rounds
without ever watching the learner perform these skills.
Furthermore, observation may only happen once or twice
during a clinical rotation. Faculty observing students on
electives, residents, and fellows occurs even less frequently. It
is therefore important to convince faculty that direct
observation is important and worthwhile. You can share the
evidence about the importance of direct observation
described in the beginning of the chapter (Box 5.1
).
It is beneficial to explore faculty’s attitudes about direct
observation at the start of faculty development workshops.
Ask faculty to recall a time when they were observed as a
learner with a patient for the purpose of getting feedback.
Have faculty reflect about that experience and whether it was
or was not helpful. Faculty can share their reflections in pairs
and then as a larger group. Some faculty will describe how
they were never observed. These faculty might describe how
the lack of observation and feedback left them uncertain
about their level of competence. Others may describe that the
lack of observation did not jeopardize their skill
development. These faculty may not believe direct
observation is necessary in clinical training (which is
important to know at the outset of faculty development).
Other faculty will describe being infrequently observed as a
student and even less frequently as a resident or fellow.
https://t.me/med1917
Many faculty recall these experiences as anxiety provoking or
as a checkbox activity.
170
Rarely, faculty will remember being
observed and finding it helpful. The point is that asking
faculty about their experiences being observed can shed light
on their perspectives about direct observation and their
potential willingness to do direct observation.
A second, related activity is asking faculty to recall a time
when they observed a learner with a patient for the purpose
of feedback. Have faculty share how it felt to be the observer
and what, if anything, was useful. This exercise can highlight
how faculty learned something new about the learner’s skills
they otherwise would not have known (e.g., a learner who
gives excellent patient presentations but has poor
interpersonal skills at the bedside). Other faculty may
describe their discomfort doing direct observation and their
uncertainty about what behaviors they should focus on.
Some faculty might describe how observing learners was
required but was not educationally beneficial for the learner.
Again, these conversations enable you to understand the
attitudes of faculty prior to faculty development or the
implementation of direct observation programs.
To increase faculty motivation for direct observation, ask
faculty to share their “You will never believe what I observed
today” experiences. That is, a time when they learned
something about their learner’s skills that they never would
have discovered had they not observed the learner with the
patient. We share an experience where one of us observed a
learner evaluating a patient with probable endocarditis. The
learner did the fundoscopic exam holding the
ophthalmoscope backward (so that the light was shining in
the learner’s, not the patient’s, eye). Without direct
https://t.me/med1917
observation we would not have realized that the statement
“the fundi were not well visualized” was because of poor
examination technique, not miotic pupils. We also share an
example where direct observation helped us appreciate what
a learner was doing well. One of us observed a learner who
appeared to have poor interpersonal skills and a negative
attitude toward patient care in the precepting room but who
was highly skilled at empathic patient-centered interviewing
during the clinical encounter. Asking faculty to identify these
“surprise” experiences allows faculty to share unexpected
insights into learners’ clinical skills through direct
observation. Doing so helps build buy-in for direct
observation.
Finding Time for Direct Observation
One of the greatest barriers to direct observation is faculty’s
real or perceived lack of time.
167
It is helpful to emphasize
that direct observation does not require watching a patient
encounter from start to finish. While observing an entire
encounter may be valuable, there is rarely time for this. It is
perfectly acceptable to watch part of a patient encounter, a socalled observation snapshot. Observation snapshots improve
the feasibility of direct observation. Furthermore, multiple
observation snapshots across various contents and contexts
by multiple faculty and other health professionals improves
the validity of the assessments and the inferences that are
made from them.
146,171
Since faculty may be used to watching
full patient encounters, have them brainstorm potential
observation snapshots.
It is important to make direct observation meaningful for
the learner. There is low value in observing a learner begin a
https://t.me/med1917
patient encounter if you already know the learner is highly
skilled in agenda setting. It would be more valuable to focus
observation on an area in which the learner is less skilled; for
example, taking a history from a nonnative language–
speaking patient using an in-person or telephone interpreter.
Additionally, direct observation should focus on observing
skills that the learner wants and needs to develop. Encourage
faculty to work with their learners to identify learnercentered snapshots (a skill the learner would like to work on
and receive feedback about). When learners perceive that
WBA is being used for learning, they are more likely to seek
out corrective feedback rather than “play to the test.”
172
Faculty should be encouraged to identify snapshots that are
also meaningful for the patient (a skill that could improve the
care a patient receives). An example snapshot is watching a
resident counsel a patient with poorly controlled type 2
diabetes about the need to initiate insulin. In this scenario,
the faculty can observe the resident and provide feedback
about the resident’s counseling skills while assisting the
learner in the conversation with the patient.
Observation snapshots should be aligned with the
competency milestones or EPAs, depending on the
educational system being used. Faculty and/or program
directors should identify observations that will inform the
milestones. For example, if a competency milestone is “the
ability to identify and incorporate patient preference in
shared decision-making,” faculty might observe a learner
discussing a controversial screening decision (e.g., screening
mammography between 40 and 50), starting a cholesterollowering medication, or engaging in a goals of care
discussion.
https://t.me/med1917
It is beneficial to help faculty identify observation
snapshots that can save time. For example, faculty can save
time by watching a learner do a shoulder exam rather than
having the learner present the shoulder exam and then going
back to see the patient and repeat the exam. This approach
benefits the patient who then does not need two exams on
their painful shoulder. In the ambulatory setting, encourage
faculty to observe one of the residents seeing their “first
patient” of the day. This strategy works well because
residents are not yet running behind or waiting to present a
patient. Observation snapshots may not simultaneously meet
all these goals of helping the learner, helping the patient, and
saving time. However, some snapshots can accomplish many
of these goals simultaneously. An observation snapshot tip
sheet is provided in Appendix 5.6.
Most importantly, observation snapshots are more likely to
happen when there is an educational culture that values and
supports direct observation and feedback.
173
Support
includes sufficient time to do direct observation. Programs
need to determine whether their current resident:faculty
staffing models permit WBA. If not, institutions should
consider reducing faculty:resident precepting ratios.
Preparing Learners for Direct
Observation
Program directors and faculty must prepare learners for
direct observation.
167
Program or course directors should
orient learners to the purpose of direct observation and
feedback and introduce learners to the concepts of deliberate
practice, feedback, and coaching. Program directors should
teach their learners how to be proactive identifying the skills
https://t.me/med1917
they want/need to develop since feedback is most effective
when the learner has a self-directed agenda. Program
directors should explain to learners how self-assessment
guided by external assessments can inform personal learning
goals about which learners can then seek feedback. Learners
can identify goals/skills independently or in a group. For
example, learners can brainstorm lists of skills that are PGY
specific (intern vs. PGY 3) or rotation specific (ambulatory vs.
critical care skills, etc.).
Learners also benefit from being taught how to elicit
effective feedback that is specific and includes an action
plan.
174
Learners can then “mentor-up” by eliciting useful
feedback from a teacher who otherwise may not have
provided effective feedback. Program directors can
demonstrate the difference between nonspecific, open-ended
questions to elicit feedback (e.g., “How am I doing?”) and
more specific questions (e.g., “How are my counseling
skills?”) and even more specific questions (e.g., “What
aspects of shared decision-making could I work on?”).
Additionally, program directors can teach learners how to
elicit a specific action plan (e.g., “What suggestions do you
have for how I can be even more patient centered when I am
counseling patients?”).
While some learners readily accept direct observation and
find WBA valuable, many learners do not see WBA as a
meaningful assessment activity for their professional
growth.
175–177
Learners often find direct observation anxiety
provoking and try to actively avoid it.
178
To address this,
direct observation and the feedback that follows are most
effective when situated in longitudinal learner and assessor
relationships.
174,179
These longitudinal relationships promote
https://t.me/med1917
the formative intent of WBA. Longitudinal relationships also
increase the likelihood learners will find feedback credible
and trustworthy (and therefore act on it). It is therefore
important that program directors maximize longitudinal
relationships when planning educational rotations.
Preparing Faculty for Performing the
Observation
Faculty often describe feeling uncomfortable doing direct
observation.
114
They worry that their presence will interfere
with and/or undermine the learner–patient therapeutic
relationship. This can be addressed by reviewing how faculty
can prepare themselves, the learner, and the patient for
observation (Box 5.4). Preparation for observation is often
overlooked or absent in faculty training.
Box 5.4
Preparing for and Performing Direct
Observation
•. Prepare learner for direct observation
• Set expectations with the learner about what will happen during
direct observation.
• Ask the learner what the observation focus should be (i.e., what
does the learner want feedback about).
•. Faculty preparation for direct observation
• Determine goals of observation.
• Consider using observational aids.
• Consider positioning in the room (triangulation).
• Consider how findings will be confirmed.
• Minimize external interruptions (e.g., avoid taking
routine calls).
•. Patient preparation for direct observation
https://t.me/med1917
• Explain the presence of the assessor in the room.
• Explain that the assessor may leave the room
before the encounter ends.
•. Avoiding intrusions
• Avoid interjecting or interrupting.
• Do interject to correct misinformation.
• Do interject if something egregious is occurring.
Prior to observation, faculty should explain to the learner
what will happen during observation. As noted earlier,
faculty should ask what the learner would like the focus of
the observation to be. This helps faculty determine the goals
of the observation before entering the patient’s room. For
example, if the goal of the observation is to observe a
learner’s physical examination skills, faculty should consider
what physical examination components are relevant to the
patient’s chief complaint or medical condition. This usually
requires hearing the patient’s history prior to observation.
Bedside presentations are an efficient way to hear about the
patient’s history and patients appreciate such
presentations.
180
Faculty can also prepare for observation by
identifying how and when they will confirm (if deemed
necessary) the learner’s findings.
When preparing the learner, faculty should encourage the
learner to “do what they would normally do,” recognizing
the presence of an observer changes the context of the
encounter. If doing an observation snapshot, faculty should
remind the learner they will not be observing the entire
encounter. If faculty plan to take notes during the
observation, faculty should inform the learner they are noting
both strengths and areas for improvement. Otherwise, the
https://t.me/med1917
learner may erroneously assume that every time the faculty is
writing, the learner is making a mistake.
It is valuable to teach faculty where to position themselves
in the room when observing. Correct positioning minimizes
interfering in the learner–patient relationship while
simultaneously ensuring that faculty can see both the learner
and the patient. Faculty observers should not be distracting
and should safeguard the learner–patient relationship
whenever possible. Fig. 5.9 demonstrates the principle of
triangulation. Triangulation maximizes faculty’s ability to
observe while minimizing visual interference. Faculty should
also prepare the patient for the observation. Either the learner
or faculty should explain to the patient why the faculty will
be present during the encounter. Faculty should inform
patients if they do not plan to stay for the entire encounter.
https://t.me/med1917
FIG. 5.9 Triangulation.
Faculty can practice their observation skills by watching a
video of a faculty observing a learner (Video 5.10, Scenario:
Conducting an Observation). After watching the video,
faculty can discuss the following questions in a group: What
did the faculty do well during the observation? What didn’t
they do well? How could the faculty be more effective doing
direct observation? How could the faculty better prepare the
learner and patient? How could the faculty better position
themselves? How could the faculty minimize distractions
and interruptions?
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана