Including learners with “remote” patient encounters

We’ve been focusing on classroom-based teaching tips in recent blog posts, this week, we focus on some practical tips for clinical teaching for clinicians working with learners while using telephone and computers for patient appointments.

By Debra Hamer, MD FRCPC, and Theresa Suart, MEd

Image is an overhead view of a laptop computer, smart phone, coffee cup and stethoscope.

Since March and continuing for some patient populations, physicians have shifted to “remote” technologies to conduct patient encounters, which used to take place face-to-face. This has complicated how to readily include learners – clinical clerks and residents – in those encounters.

First – let’s just put this out there – we don’t like the word “virtual” to describe working with patients using telephone or computer interfaces. This is not simulated care, it’s actual care!

Whether you’re using telephone appointments or a computer-facilitated patient interface, it can be a challenge to incorporate learners. We’re providing some suggestions based on telephone and OTN (in this case); these can be modified for your own tech situations. (As always, feel free to reach out to the UG Education team for help brainstorming solutions.)

The tasks associated with each can be divided into three parts: before, during, and after. These are things you likely do automatically with in-clinic or in-hospital patient visits that include learners because you’ve been doing it for years. Working with “remote” technologies just requires a bit of deliberate thought to what that preparation, appointment, and debrief looks like.

Depending on what social distancing is in effect, you may be in the same room as your learner, or you, the learner, and the patient may be in three different locations. The suggestions below assume you are in three different locations. If you and the learner can be in the same room, this will be simplified.

Telephone Appointments

(You may book your appointments yourself or have an administrative assistant who does so.)

Prior to Encounter:

  • When the patient’s appointment is booked, ask if a learner can be involved with the appointment.
  • If there’s a reminder call, include a reminder that a learner will be involved (if they said yes, of course!)
  • Make sure you’re in a room by yourself with no intrusions or distractions. This might seem self-evident, but work-from-home situations can change day-by-day.
  • Ensure your phone is set up to block your caller ID. On an iPhone, you need to deselect this under settings.
  • Ten minutes before the patient call, call the learner and review the referral and any pertinent information from the chart, since students won’t have access to the chart if they are not physically in the clinic. At that point, you can answer any questions or concerns the learner has

The encounter:

  • If you’re using a phone with “conference” capabilities (adding a participant) you can keep the learner on the phone while you initiate the call with the patient. (On iPhone, this is “add a call, put in the patient’s number, then press merge calls).
  • Once the patient answers, check to ensure both the patient and learner are on the call. All three participants should be able to hear each other.
  • In the greeting, you can remind the patient of the learner’s role on the call.
  • Make sure the patient understands the potential privacy issues with cell phones and consents to continue, then outline what to expect during the appointment.
  • Proceed with the patient interview/discussion/assessment as you would do ordinarily.
  • Depending on the learner’s stage, at this point they may be listening in; if not, let the patient know you will mute yourself and unmute yourself near the end to join back in. (If the learner is going for too long or going off the rails, you don’t need to wait until the end, simply unmute yourself and redirect them, as you would in a face-to-face encounter).
  • At the end of the appointment, if you haven’t already, you can unmute yourself, ask any questions and finish off.

The debrief:

  • After ending the call with the patient, call the learner back and debrief the encounter.
  • If it’s a senior learner, you may take the option to call the patient back – talk to the learner, find out a diagnosis and plan and then call back together with this. This will vary on the learner’s level. (Be sure the patient knows you are going to do this!)

Variation:

  • With a more senior learner, with the patient’s consent, you could use a three-step appointment: the learner initiates the call with patient, then ends that call to confer with you (by phone or other means), then the learner or you calls the patient back with the plan for going forward.

Pro-tip: If you use headphones, then there’s less reverberation and you can use your hands while you’re listening to the phone calls.

Computer-mediated appointment:

(Dr. Hamer uses OTN, you may use another platform. These instructions assume the patient has agreed to an internet-mediated appointment and has received the log-in instructions by email).

Preparation

  • Make sure your computer is set up with a neutral background with nothing to distract the patient.
  • Also, make sure you’re in a room by yourself with no intrusions or distractions.
  • Telephone the learner 10 minutes before the appointment time and review the case with them. End this call

The appointment:

  • Launch the appointment with the patient. (In OTN, this is either “make a video call” or clicking on the link from your schedule). Use your program’s function to add the learner. (On OTN, it’s “add a guest”
  • Ensure the patient still consents to continue with the appointment online, and outline how the appointment will go. Then mute yourself and block your video so it’s just a black box at the bottom of the screen. The learner and patient will just see each other. (This is less distracting)
  • Re-enter as needed (similar to the telephone suggestions above).
  • If there is time available on the appointment, ask the patient to stand by for a few minutes. You and the learner both mute and block your video and have a telephone discussion about the case.
  • Come back to the call to see the patient. (Make sure the gap is no more than five minutes).

Debrief

  • Once the computer-mediated appointment has finished, call the learner back to talk about the case.

Do you have advice or suggestions for facilitating learning with these types of patient encounters? Share your advice in the comments.

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Three ways to think about student engagement in remote curriculum delivery

While you’re preparing to deliver our UGME fall curriculum for Years 1, 2 and 3 predominantly via remote technologies (and some of that asynchronously), the challenge of keeping student engaged and involved may be top of mind. Three strategies (useful in any teaching, not just pandemic-restricted scenarios) are useful to keep in mind.

1. Set expectations early For many – students and teachers alike – remote teaching using a platform like Zoom is a new way to learn, so it helps to set the expectations when you start. In face-to-face teaching, this is sometimes done formally, but more often informally. A learner sitting alone in front of their computer can’t “read the room” to know what’s ok. If you’d prefer that students use the Zoom “raise hand” function to ask questions, let them know this at the start of class. If you’d rather they unmute their microphones to interrupt, set this as your norm. If you invite students to email you with questions after your session, set a reasonable time-frame for response. If you expect them to have downloaded a worksheet from Elentra ahead of time, make sure this is in your learning event’s “required preparation” section, since you can’t have a handout ready as back-up. Be clear, so no one gets frustrated.

2. Use tools effectively All the tools available in the classroom are also available in remote teaching – they just sometimes need a bit of tweaking to use effectively. For example, one really low-tech engagement tool is silence. In my early days teaching at the University of New Brunswick, I had a Post-It note on my lecture notes which said: “shut up, Theresa!” This was a succinct reminder to myself to give students time to hear and process questions before I went ahead and answered them myself. With remote teaching, we need to factor in time for student to click on their “raise hand” button or hit “unmute” along with that processing time. Silence can be uncomfortable for instructors as we think we should be filling every moment, however, using questioning and dialogue effectively remotely requires becoming comfortable with longer intervals waiting.

Most other tools you use routinely face-to-face can continue to be used via Zoom. For example, Poll Everywhere and videos were also used quite easily during the spring term. Do you sometimes use “show of hands” to get a response? Both the “raise hand” function and the “reactions” one can be used for this purpose. Some in-class tools might take a bit of strategic thinking and planning to rework for remote classes. If you have something in particular in mind, reach out for brainstorming and to capitalize on collective wisdom.

3. Assign roles Whether you’re in a Zoom class, or assigning asynchronous work, it can be helpful to proactively assign roles to individual students to keep everyone engaged and participating equitably. Whether it’s the randomizer app used by Dr. Gilic and Dr. Simpson in MEDS 115 to call on individual students for responses, or a “Someone from group X” call-out, these can all be tailored for Zoom.

If you’d like some Zoom-mediated face-to-face feedback, ask that one student from each SGL group be “on camera” during the class. Not everyone’s internet supports using video throughout, but teaching to a sea of names in black boxes makes it hard to gauge responses. Using a rotation within groups will share this responsibility. (And get more camera-shy students used to being “on” in a low-stakes way).

If you’d like a student to monitor the chat box for questions, create a roster of students who are willing to do it and share that task through the term.

If you’re using discussion boards for asynchronous teaching, break up the tasks needed to meet the learning outcomes of the discussion: have one or two students assigned to pose a discussion question based on the preparatory materials, another to moderate, someone else to write a one-paragraph summary of the discussion to share with the large group. You could also assign a student or two from each group to write multiple choice questions based on the assigned material. (If you’re interested in using discussion boards on Elentra, get in touch and we can set it up for you).


It’s true we’re in somewhat uncharted waters for teaching this way, but there are solutions to the teaching challenges. If you’re stumped or frustrated, please reach out – we can find some solutions together. Reach me best by email (theresa.suart@queensu.ca).

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Year in Review? Why wait until then?

When I worked as a journalist (about a million years ago), an annual task was writing “Year in Review” articles. These were summary or “round up” stories with the highlights of the previous year.

The stated intent was historical record, reminders and reminiscing; marking highs and lows, significant events and momentous occasions. On a more practical level, these stories could be compiled fairly easily, mostly in advance, and take up copious column inches in our weekly paper in the week between Christmas and New Year’s when nobody was reading anyway and the editorial staff wanted to take extra time off from covering newer news. Closely tied to these were “Resolutions You Should Make Now!” advice columns.

With this cultural backdrop assigning retrospection to the turn of the year, it’s easy to become cynical about such things—and reduce thoughtful review to top-ten lists and cliché-ridden commentary. For educators, however, the importance of review should not be treated so lightly. Review and reflection are important. We expect our learners to do it. Educators should give it just as much attention.

Review and reflection are integral to effective teaching practice. January is a great time for this, but so is June, or September, or some other month. Right now, for some, a semester has recently ended, for others, it’s just beginning. There are benefits to both retroactive and proactive review – and in doing it more frequently than an annual check-mark on a to-do list.

So, instead of a ‘year in review’ summary, or even a list of new year’s resolutions for medical education, here’s a sample framework for incorporating review into your teaching practice. (Use it annually, or more often, as needed).

Theresa’s Five Step Review and Revise Process

Step 1: Review & Reflect

Whether you’re considering a whole course, a few teaching sessions, or a single seminar or other learning event the process is the same. Consider:

  • What happened? What worked? What didn’t? (If you’re forecasting: What could be some pitfalls? What am I worried about?)
  • For anything that didn’t go well, or didn’t accomplish what I planned: How can I fix it? (Forecasting: Do I have a back-up plan? Do I need one?)
  • What’s a manageable change? Do I have the knowledge, skills and ability to do this? Where can I get support and/or resources? (Forecasting: Do I have the resources I need? What kind of feedback could be helpful to me on my teaching sessions?)

 Step 2: Reconsider7916463

Once you’ve reflected on what’s happened, or what you have planned, consider:

  • Did I meet my objectives (or will my plan meet my objectives)?
  • Are there things I did (or I’m planning) that are just out of habit?
  • What should I change to make my course/session/seminar more engaging/relevant/appropriate?

 Step 3: Find Resources

When you revise your teaching plans, you may also need additional resources. This could be in the form of your own skills, materials, input from colleagues. Consider:

  • What support do I need to get to where I’d like to be?
  • Do I have the abilities to do what I plan? If not, how could I acquire the necessary skills?
  • Are there existing materials that could help me? Do I need to develop new materials? Who could help with that?
  • Who could I call on for support or assistance?
  • What sort of time frame do I have?

 Step 4: Refine your plan

Evauluation ChecklistSometimes, what we’d like to do just isn’t in the cards this year—there can be a lot of constraints on our teaching in time, materials, scheduling. It’s important to refine revisions into things that are manageable and realistic. Sometimes you are in a position to make large-scale changes to how you deliver your learning events, other times, not. Avoid the “all-or-nothing” plan: Incremental changes are better than no changes. It’s better to be good, than to be perfect. Consider:

  • How realistic is my plan?
  • Are there things I consider “must haves” and things that are “nice to haves”?
  • If I could only make one change in my teaching right now, what would it be?

 Step 5: Reflect & Review

At the end (or the beginning) – take another look. Good teaching really is an iterative process with the cycle of review, revision, redeliver.

Sometimes the best way to review and reflect (and plan) is to talk it out with a colleague. Bouncing around ideas can bring new perspectives and inspire you and others to add to your teaching toolbox. If you’d like to chat about your teaching any time, get in touch with the Education Team.

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Figuring out what’s important in a faculty evaluation report

Critics only make you stronger. You have to look at what they are saying as feedback. Sometimes the feedback helps, and other times, it’s just noise that can be a distraction.

Robert Kiyosaki

 

Separating the useful feedback from the noise in students’ comments on faculty evaluation questionnaires is an annual challenge for all university instructors– not just at Queen’s School of Medicine. It was recently the topic of a Faculty Focus article by Isis Artze-Vega, associate director of the Center for the Advancement of Teaching at Florida International University. She offered solid advice for those of us who feel angst over student evaluations.

As a side-note: the headline on the Faculty Focus article points to “cruel student comments” but just because there’s negative feedback doesn’t mean the comments are (or should be) cruel or rude. Student in the School of Medicine are given guidance about completing course and faculty evaluations at the beginning of every year. They’re encouraged to be professional in completing them, so while there may be constructive feedback, it should never degenerate into merely cruel criticism. Students are also encouraged to provide concrete suggestions for ways to improve.

Dr. Artze-Vega suggests seven key approaches to responding to student evaluations.

First, she advises faculty to analyze the data. The Education Team routinely does this for course evaluations for course directors and the Course and Faculty Review Committee, but not for individual faculty evaluations. Analyzing comments is a great starting point; otherwise, human nature often has people hyper-focusing on the wrong things. Are you reading an outlier opinion, or is there a theme in multiple students’ comments? “Identifying themes will help you determine whether they warrant a response,” Artze-Vega writes.

Ask any actor or director and they’ll tell you: negative feedback is easy to remember. American film director Peter Farrelly has said: “With all of my films, if I get one bad review and a bunch of good reviews the bad one is the only one that will stay with me.” Artze-Vega cautions to resist the lure of the negative. Don’t automatically dismiss a negative comment, but “consider: Am I focusing on this because it’s ‘louder,’ or because it’s a legitimate concern?”

Considering feedback this way flows into Artze-Vega’s third key: Let your critics be your gurus. Citing a New York Times article, she points out that “we often brood over negative comments because we suspect they may contain an element of truth.”

A fourth approach is to find counter-evidence to negative comments. You can look for or remember comments that contradict the negative one. (If your faculty evaluation report is anything like some course evaluation reports, sometimes, you’ll find these comments in the same evaluation report from other students).

Artze-Vega stresses that “we should devote at least as much time to students’ positive comments as their negative ones”, so her fifth key is dwell on the positive ones. If you hyperfocus on negative feedback, you can lose sight of the many things you are likely doing well – and that students appreciate. To aid in this, she further advises to read them with a friend. “A more objective party can help you make sense of or notice the absurdity of the comments because they’re not a personally invested in them.”

Finally, Artze-Vega advises to be proactive. “If you don’t conduct this analysis yourself, you’ll be at the mercy of whomever is charged with your evaluation—and they probably won’t be as thorough,” she points out. “Also, take the time to provide explanations about any off-the-wall student complaints, so that your reviewers don’t draw their own conclusions.”

One way to be proactive, is to solicit feedback earlier, when you can still make adjustments for this cohort of students, rather than waiting for the end-of-semester one to help with next year’s planning.

When she’s teaching a full course, Sheila Pinchin, Manager, Educational Development and Faculty Support has always used her own evaluation forms three weeks into a course and three weeks later to get just this type of feedback.

Terry McGlynn, an associate professor at Cal State, also advocates this approach as one of his tricks-of-the-trade to avoid bad teaching:Young Woman Sitting Looking at Laptop Screen

“I often use a supplemental evaluation form at the end of the term. There are two competing functions of the evaluation. The first is to give you feedback for course improvement, and the second is to assess performance. What the students might think is constructive feedback might be seen as a negative critique by those not in the classroom. It’s in our interest to separate those two functions onto separate pieces of paper. Before we went digital, I used to hold up the university form and say: “This form [holding up the scantron] is being used by the school as a referendum on my continued employment. I won’t be able to access these forms until after the next semester already starts, so they won’t help me out that much.” Then I held up another piece of paper [an evaluation I wrote with specific questions about the course] and said, “This one is constructive feedback about what you liked and didn’t like about the course. If you have criticisms of the course that you want me to see, but don’t think that my bosses need to see them, then this is the place to do it. Note that this form has specific questions about our readings, homework, tests and lessons. I’m just collecting these for myself, and I’d prefer if you don’t put your names on them.” I find that students are far more likely to evaluate my teaching in broad strokes in the university form when I use this approach, and there are fewer little nitpicky negative comments.”

 

If you do decide to use this type of mid-course feedback, keep your questions few and focused. (Otherwise, there’s potential for evaluation-fatigue on the students’ part, which lowers the quality of the very feedback you want).

 

If you teach in the Queen’s UGME program and would like some assistance in separating the useful feedback from the noise, I’m available to assist you with this. Drop me an email. Reach me at theresa.suart@queensu.ca

See more on this topic from an earlier UGME blog post here.

 

 

 

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