Teaching Attending Responsiblities and Teaching Resources

The Department of Medicine greatly appreciates the contribution that the full time and voluntary faculty make to the education of our house staff and medical students.  We recognize the considerable teaching experience and expertise that resides among our faculty, and we also welcome new faculty members.  Here you will find important information about serving as a teaching attending.  We have also included some suggestions and resources about teaching methods for your consideration.

Rounds

Attending Rounds schedule is as follows:

Mondays:       9am to 10am all ward attendings and PGY-2/3/students attend faculty conference in 18B Conf. Room

                       10am to 10:30am ward attendings should spend 30 minutes of one on one time with their med students

Tuesdays:     9:30am to 10:30am "Walk and Work" Teaching Rounds (after Grand Rounds that end at 8:30am)

Wednesdays: 9am to 10:30am teaching rounds--any format you like

Thursdays:    9:30am to 10:30am "Walk and Work" Teaching Rounds (after the 8am to 9am resident morning report)

Fridays:          9:00am to 10:30am teaching rounds--any format you like

During "Walk and Work" Teaching Rounds, the teaching attending should round participate as a teacher and direct observer of the team's work rounds.  Direct observation of competence in history taking and physical exam, along with "teaching on the fly" of topics, is encouraged.

Pre-planning of the 30 minutes of dedicated one on one medical student-attending time should take place the week before to maximize the experience.  Actitivies should include hearing a case and going to the bedside.

Attendings may round earlier than scheduled times if they clear this plan with their resident and the rounding does not interfere with any conferences.

All house staff must attend noon conference, and interdisciplinary rounds begin at 10:30am on most if not all days on the floors.

Going to the Bedside

The goal should be to go to the bedside with your team each and every day, with the absolute minimum being 3 days per week of bedside teaching.  

"Bedside teaching" includes many things and it is always valuable for house staff and students to see how an attending physician talks to patients, takes a history and conducts an exam.   

Valuable teaching can occur without the need to conduct or observe a lengthy  "complete history and physical."  Focusing on a couple teachable points is always a great approach.

Teaching the History and Physical Examination: Moving from "How" to "How Accurate"

We are emphasizing to our learners that physical exam techniques are true diagnostic tests, with accompanying sensitivities and specificities.  

Physical exam textbooks usually teach the "how" of the history and physical exam, and learning proper questioning and examination technique is of course the essential first step. But knowing how to detect ascites or how to administer the "CAGE" questionnaire is only the first step. 

To really harness the power of the H&P--or know where it is not useful--one must know to what extent the presence of a fluid wave increases the likelihood that ascites is present, or how much the chance of alcohol dependence is increased if someone answers yes to the CAGE questions.

An increasingly large body of literature on the history and physical examination is helping shift the focus from simply "how" to "how accurate". 

Leading the charge in this effort are JAMA's series, The Rational Clinical Examination.  Evidence-Based Physical Diagnosis, by Steven McGee, is the best textbook on the topic.  Use of these resources is encouraged.

A great example of an article that talks about not only the process, but also the accuracy, of the physical examination is "Does this patient have a pleural effusion?", from the January, 2009 issue of JAMA.  There are many others like it.

Feedback, Feedback, Feedback!

In 1983, Jack Ende, MD, of the University of Pennsylvania, published the first major article about the role of feedback in medical education. It is widely considered a classic, cited by educators hundreds of times.

Ende's recommendations are enduring.  He writes that feedback should be:

1. Undertaken with the teacher and trainee working as allies, with common goals.

2. Well-timed and expected.

3. Based on first-hand data.

4. Regulated in quantity and limited to behaviors that are changeable.

5. Phrased in descriptive (not evaluative) language.

6. Focused on specific performance, not generalizations.

7. Focused on decisions and actions, rather than assumed intentions or interpretations.

Here are some other suggestions for giving feedback:

1.  It should be given in real time--immediately if possible and appropirate.

2.  Give clear and specific suggestions for improvement. 

3.  Give the learner a chance to demonstrate that they have heard what you said.

4.  Remember the "feedback sandwich":   Positive feedback then constructive feedback, topped off with a dab of more positive feedback.

5.  Say the word feedback out loud--it will register with the learner more clearly that you are giving them feedback. ("Let me give you some quick feedback.")

Using E-mail to Enhance the Teaching and Learning Experience

For Feedback

Feedback should always be given in person as frequently as possible.  But e-mail can serve as an effective complement to verbal feedback. 

When I start a service month, on the first day I ask for everyone's e-mail address.  During the month, in addition to frequent verbal feedback, I send individual team members feedback by e-mail. An e-mail provides a learner the chance to review and reflect back upon your feedback, and accounts for the fact that sometimes people may not register all the details of a verbal feedback session.

I title all these e-mails I send "Feedback".  At the end of the block, I search my e-mail for those titled "Feedback" and I have plenty of material to mention in my evaluations.

For Teaching

E-mail is a very effective way to distribute articles or other teaching materials to your team. 

Learners certainly appreciate when a faculty member e-mails them a particular article related to a case they have.  When you e-mail materials to learners, they go directly into the learners' "virtual file cabinet" (aka an e-mail account) for reference at any time in the future.

In addition, many house staff and students carry a flashdrive with pertinent articles, pictures or other reference materials.  Resources that you e-mail them can be then be transferred to their flashdrive so they can pull them up anywhere.

Teaching and the Curriculum

The Training Program is tremendously appreciative of the time faculty give towards teaching, and we consider ourselves lucky to be able to mine and employ the vast collective teaching experience that exists among the BI faculty.  

Each ward rotation, including the MICU, CCU and Step Down Units, have their own curriculum.  The curriculum is a list of essential topics that need to be covered during a rotation.  That being said, by all means if you have subspeciality knowledge in a particular area, feel free to teach it!

These topics may be covered in various ways.  You may lecture on some, they may be covered through discussion of cases, the house staff and medical students can present topics on the curriculum, etc.

We suggest that you hand over the curriculum to the resident for them to "manage", as they use this as a guide also for topics to teach. 

It's good to do a mid-rotation "curriculum check" to see what has been covered and what remains.

Curriculum Topics By Rotation (Please download, review and discuss all topics with your team)

Oncology                      9-S/Nephrology             9-L Medicine/HIV

Pulmonary                    Cardiology                     Rapid Response Team

MICU                             Resp Step Down           Medical Consultation  

CCU                              General Medicine          Geriatrics

Neurology                     11-L Medicine                Infectious Disease Elective

It Only Takes An Hour to Make A Mini Syllabus!

Learners respond well to expectations. Most will greatly appreciate if a teaching attending selects 4-5 relevant articles to be handed out for reading and discussion over the course of the block as a "mini syllabus".

Suggestions include clinical guidelines related to your speciality, relevant clinical trials or other review articles.  We most certainly encourage faculty to teach to their strengths and areas of expertise (as long as the curriculum is covered!).

Excellent resources from which to put together a collection of articles include:

1.  Academic organization websites (American College of Cardiology,American College of Chest Physicians, American Diabetes Association, etc).  These often have easily downloaded guidelines.

2.  PubMed searches of basic topics will identify the most recent material which can often be retrieved in full text PDF.

3.  The American College of Physician's Journal Club  (known as "ACP Journal Club") is an excellent resource that provides succinct reviews of clinically relevent articles, as well as editorials by the thought leaders in evidence-based medicine.

The One Minute Preceptor and Teaching Skills Resources

In 1992, Neher et al. published a landmark article about a teaching method that employed 5 "microskills"; this method has been called the "One Minute Preceptor" and is widely accepted by medical educators as easy, fast and effective. It is one of only a few teaching approaches that has been tested in a randomized controlled trial and found to be highly rated by those who use it.  We strongly encourage use of the One Minute Preceptor model--it is a great approach to use during attending rounds, walk rounds and to use in your daily contact with the house staff year round.

Great teaching resources:

The One Minute Preceptor model and other ways of teaching rapidly when time is limited (BMJ)

An article that describes aspects of master teachers in a narrative review

Attributes of highly rated teaching attendings (NEJM)

Strategies to promote diagnostic reasoning in trainees (NEJM)

The Mini Clinical Evaluation Exercise (Mini-CEX)

The American Board of Internal Medicine requires that evidence of direct observation of a trainee's bedside skills be documented in the form of the Mini-CEX.  

A Mini-CEX must be completed for each house officer on your team.  It should be a focused exercise, lasting only 5 to 20 minutes, and addresses numerous specific behaviors and areas of competence.  

It may be focused and for those behaviors not witnessed, then faculty may check off "not observed".

The Mini-CEX evaluations should be entered online into New Innovations. 

How Faculty Evaluate House Staff and Students

You will be asked to evaluate all members of your team. Evaluations are critical to the development of our house staff and students.  The comments section is particularly important, as these comments can form the actual content of a trainee's official residency Program Letter or a medical student's Dean's Letter.  Constructive feedback helps trainees improve and track their development and helps program directors counsel trainees.

There is a mandatory minimum for each evaluatee (about 35 words).

The comments on your evaluation form of a trainee should:

1.  Focus on specifics--cite instances in which a trainee did something well or in a way that could be improved.

2.  Give clear suggestions for improvement.

3.  Be discussed in person with the trainee.

4.  Be honest. Giving constructive feedback is much harder than giving positive feedback, but it is critical for trainee development.

Evaluations are done online at New Innovations. To access the log-in screen, click here.

All faculty should have recieved a username and passord for New Innovations.

For instructions on to complete your evaluations please e-mail Joan Neufeld in the IM Residency Program Office.

How House Staff and Students Evaluate Faculty

All house staff and students on your team will complete an anonymous evaluation of your performance. 

Your division chief or section leader is responsible for reviewing this feedback with you.  Maintaining the anonymity of the house staff and student evaluations is of the utmost importance to the training program and under no circumstances will this be compromised.

The first step to ensuring a strong performance and strong evaluations from those you will be teaching is to know what you will be evaluated on. 

You can view the form that house staff use to evaluate faculty, which was re-developed in July, 2009 with faculty input, by clicking here.

Medical Students

Medical students from the Albert Einstein College of Medicine and other schools rotate on the Medical service during their third year medicine clerkship and their fourth year subinternship.  We value their presence and the vibrance they bring, and it is a major priority of the department to provide them with a top-notch clinical and academic experience.

Christopher Lau, MD, is the Site Director for the Third Year Medicine Clerkship, and you may e-mail him with any questions on his chpnet.org e-mail.

Third year medical students should:

--Present a new case to you on the day after each call day.

--Give topic presentations at attending rounds as decided upon by you, the resident or the student.

--Give mini-topic presentations on resident work rounds, at the discretion of the resident team.

--Be taken to the bedside at all possible opportunities.

--Hand in one case write-up per week to you, which you should read, give feedback on and return to the student within 24 to 48 hours.

--Should fill out H+P forms for their new admissions and write daily progress notes in the chart, but neither of these supplant the house staff's H+P and progress notes.

Fourth year medical students (subinterns):

--Function as interns, under the supervion of the resident.

--Carry more patients than third year students; closer to an intern's level, at the discretion of the resdent.

--Write H+P's and progress notes that may go in the chart, under the supervision and signature of the resident.