Friday, April 19, 2013

Teaching in an ambulatory clinic - how to make routine follow up unboring

One of my colleagues doing a botulinum toxin injection
I have worked with students in my outpatient botulinum toxin injection clinic for about five years now.  The students who work with me in this clinic are generally first year students.  When I first signed up to have students work with me in this clinic, it was primarily because from a scheduling standpoint, it made the most sense as I often have a fourth year student from the neurology clerkship working with me on my other afternoon clinic, and the first year students are in class all morning.  It was only after I had the students working with me for a few weeks that I realized I was doing the same thing over and over again.  Injecting botulinum toxin is fun to watch a few times, but after that, it all looks the same.  I've tried to use some strategies which can be used in any clinic to help students in this experience to still get value out of the clinic even after being with me for 10 weeks.

1)  Discuss communication and encourage empathy:   I spend a lot of time talking about how
I try to shift my approach from a communication standpoint with each patient.  We talk a lot about how I approach patients who may have personality quirks or special circumstances.  As many of the patients in my clinic have been seeing me for years, I try to provide background for the students about how other aspects of their care have affected their lives in general, and how I've needed to make adjustments to their dystonia treatment over time.  I can talk about a wide-range of conditions including some very deep discussions I've had with patients about end-of-life issues in the past.  This allows each patient encounter to create a space to talk about more than just "This is another cervical dystonia," and turn it into a more rich discussion of this is how I I talked to this patient about cervical dystonia in the light of a new cardiac diagnosis and what changes we made.  Those changes don't have to be made that day for it to be a salient discussion point with the student.

2) Even small amounts of participation is appreciated:  This works better for first year students who often have little clinical experience, but I think it does  help even with more experienced learners.  In the botulinum toxin injection clinic, I will have the students only observe for the first day or so.  After that I have them clean the injection area with alcohol swabs, and hook up the EMG ground and reference leads.  Although that doesn't sound like much, for a student, it makes them understand that they are being helpful and are a valued part of your team.  In truth, it does make things go faster as it takes about the same amount of time to wash my hands as it does to prep the patient for the injections.  As possible, I also try to let the students do one injection in a relatively straight forward site by the end of the ten weeks.  It doesn't always work out that a good patient/ injection works out on the last day of the rotation.  But, even doing one injection for a student is potentially a big deal.  Not as big a deal if they were in healthcare prior to med school, but most of the students who have worked with me would probably put that .25 cc IM injection on their list of highlights for the year.  You just need to put yourself back in the shoes of a first year student to remember how excited you were to do just about anything back then.  Then let the student do a very low risk part of the procedure.  Let's be clear, I'm not advocating for the student to do an injection into the iliopsoas (an injection with an EMG needle into the anterior thigh very near the femoral nerve/ artery/ vein).  But doing something on a small scale is good.

3)  Ask them what they are currently learning and try to find a connection:  Doesn't always work, but if they are learning about microbiology, have them read between patients about clostridium.  If they are learning about basic physiology, have them read about neuromuscular junction synapse function.  If they are learning about cardiac function, have them look up the anticholinergic effects of botulinum toxin.  Or if a patient you see has A fib, have them look that up and listen to their heart in clinic.  The trick is to try to make it not feel too constrained, and not feel like you are making something up for them to do, but to make it something they see value in learning more about.   This also applies to the professionalism or clinical skills teaching sessions most students are learning as well in first and second year.

4)  Show them a bit of the business side of medicine:  This again sounds boring to you and me, but most students don't have much exposure to how the billing system works.  At least once or twice during the course of their experience with me, I'll have the students look over my shoulder as I input the billing codes for the patients.  I explain briefly the difference between a CPT code and an E&M code.  I talk about how I put in the prescription for the toxin.  I understand this system will probably change a bit before they are billing, but I again try to put myself in the position of where I was as a first year student, and I had no clue what that stuff was all about.

There are a few lessons I've learned in the ambulatory setting.  But using these thoughts, I recently had a student write on one of my faculty reviews how they were worried once they found out they were in a procedure clinic for 11 weeks, but were amazed how interesting it was each week.  I also have had students who have been requesting to work with me for the past several years.  I'm sure this is not a novel list, and others have thought about this before. 

1 comment:

  1. I received an email from a colleague who read this post asking about how I include students in history taking, here's my response:

    In terms of getting students involved in history taking in a busy clinic, for me it depends a bit on the student’s level. The only time I send a first year student in with a patient (unless I have only one patient on the schedule due to cosmic-cataclysm level of cancelations) is for follow up patients. I usually tell them specifically what I want them to ask the patient. In Botox clinic, I tell them, “Find out whether the last injections worked as well as previous injections, whether they had any side effects, and whether they are on any new medications or have new medical problems.” With that specific set of objectives for the student, they usually come back out in about about 5-10 minutes. They still feel like they got to practice history taking, and every once in a while, the patients will tell them what a good job they did, or wish them good luck in their training (which they never really say if the student is leaning against the wall).

    If I’m in a non-procedure clinic with a fourth-year student. I kind of anticipate being behind in my schedule a bit. So, I’ll usually have one point in the afternoon where a return patient has arrived, and a new patient is also arrived. When that happens, I’ll have them room both patients, and I’ll see the return, while the student sees the new. I tell the student to do everything up to the PE, and then we do the PE together. While they present the patient to me, I type the history into EPIC. Will still slow you down a bit, but it’s not a huge time sink as they do help summarize the history, and usually I then have more focused questions to ask when I go into the room.

    I haven’t tried this as much, but I some people (I think Bill Toffler does this) will go in the room with the student, and have the student take the history with the faculty being the ‘shadow’. The faculty can document in EPIC while they are talking. You can also immediately ask for clarification questions if the student gets off.

    I also encourage the students if they are watching me doing a history to feel free to ask a question if I have not covered something they think is important. Honestly, a few times it has brought up something I should have asked in the first place.