(note: resident on service should arrive by 07:00 at the latest; if they need more time to preround on their assigned patients, they should arrive earlier, but not if it would violate duty hour rules)

07:45-08:15 Morning report (Neurology Resident Library – 4th floor hospital). Every day during summer; Tuesday and Thursdays only Sept-June.

All attendings are welcome to come and contribute to the session.

08:00-11:00* Attending Rounds (CNS = General team room; Consult = Neurology library; Stroke= Stroke team room)

* During the Summer and on Thursdays: Attending Rounds begin at 08:15, after morning report

Rounds should begin promptly at 08:00 (or 08:15 as indicated). The morning schedule is tight and starting rounds on time is essential to move forward patient care and have time for teaching.

Attending and Senior map out the day so that rounds can end by 11AM. Urgent consults, ED patients and discharge priority that need to be seen early
8:15-9:00: hear about new patient from overnight resident and radiology rounds
9:00: Start walk rounds in 4IMC then 5th floor, then boarders (CCRU, Trauma IMC, MICU), then ICU

11:00 Attending and Senior go to IDR or Attending continues rounding independently without the team

11:30-12:30 Midday Didactic Conference – Resident attendance at didactic sessions is a priority. With the exception of emergent clinical issues (i.e. acute stroke, active seizures, etc.), all clinical activities should be deferred. Emergent issues should be handled by the APP or Attending to allow residents to attend conference.

12:30-16:00 Patient care

~13:00: Family meetings
~15:00: Staff consults/new admissions

14:00-16:00 Wednesdays: Grand rounds and Case Conference)

16:30-17:00 Hand-off care of patients to Short-call resident using written sign-out template. The verbal hand-off should be observed by attending or senior resident to give junior residents feedback and ensure appropriate information is conveyed. *Evaluations of hand-offs can be entered as “on the fly” evaluations in MedHub

21:30 Short-call resident hands off care of patients to Night Float resident

Morning Learning: 07:45-08:15 (Neurology Resident Library)

All attendings are welcome to come and contribute to the session.

July-September: Every Weekday
Sept-June: Tues and Thurs

Designated QI/PS sessions:

1st Thurs of Month: BAT morning report (Stroke Team Room)

2nd Thurs of Month: Patient Safety morning report (Stroke Team Room)

Weekends

There is decreased resident complement on the weekends, with alternating schedule:

07:00-12:00 ‘Weekend float’ resident takes all new consults (including BATs). Inpatient teams will be rounding and will handle all questions on current patients. Inpatient teams are the back up for the Weekend call resident if multiple acute issues occur simultaneously.

08:00-11:00 Attending Rounds: Rounds are expected to start promptly at 08:00. This is necessary to ensure that rounds are complete by the time the call resident must take over seeing new consults at 12:00

12:00 Teams may sign-out to the Long Call resident after 12:00 if all work on current patients is done and they are stable to hand-off.

12:00-20:30 Long call resident covers all new consults/admissions and cross-cover

20:30 Long call resident hands off care of patients to Night Float resident

Attending Rounds:

Night Float Resident

New patients may have been seen by the Night float resident or the prior evening’s Short Call resident. These two will take turns presenting to the CNS, Consult, and Stroke teams. The PGY4 residents will decide on the order of presentation based on the overnight activity.
When possible, the night float resident should join the team to go see one or more of the new patients they admitted so they can get feedback on their exam and assessment.

Team Member Roles on Rounds

Senior resident: leads rounds
Providers or students not presenting act as facilitators:
- getting the RN to bedside (prepare RN for next patient)
- getting a computer to place orders
- call consults
- field questions on other patients
Presenting Provider:
- Before rounds: review data and have problem-based management plan in mind.
- Presentations: Structured and focused (see Presentation guidelines)
Nurse: Report overnight events including problems, changes in condition, and other salient issues
Attending: After presentation, set goal for each patient before walking into room.

Efficiency Strategies

Residents are expected to pre-round on the patients and have data on interval events and test results ready for rounds (Not “Discovery Rounds”).
Watch the Clock – goal ≤ 10 min per established patient
Agree to come back for more lengthy conversation with family if needed
Only round on and examine ICU patients ready to leave the ICU. All other ICU patients: just touch base with ICU team to get updates.
Having a direct number to RT, PT/OT/SLP and Pharmacy may be an alternative to having them on rounds so we can get help from them in real time.
- If we place orders, talk to therapies and call consults during rounds we are able to put plans into action sooner which helps throughput.
If the service is especially busy and rounding needs to continue beyond the usual morning time, the attending and senior resident will determine the most efficient plan (e.g. Attending and senior take med students to see remaining patients while junior residents do work/ see new consults; Attending goes with one resident at a time to see their patients, etc.)
Keep track of some process measures on the white board every day to see how we were doing and also to get an opportunity to debrief about rounds and get feedback. Examples:
- Total time on rounds and time per patient
- RN on rounds
- Orders on rounds
- Senior on rounds

Expectations

Once new patients are presented, the team will embark on walk rounds.
All patients admitted to the Neurology service must be seen daily and in person by a Neurology attending physician.
It is expected that medical students carry at least 2 patients each and be fully responsible for daily Case presentations.
Communication with the family should be a daily event by someone from the team. Medical students are very good for this task and should be instructed to answer what questions they can and promise to find answers to those they don’t know. It is expected that attending physicians will speak to families during the hospital stay.

Attending daily tasks:

Sign admission orders daily
Review and cosign progress notes/H&Ps/Consult notes daily

Patients Accepted for Transfer from OSH:

Attending

Call senior resident on service or resident on call to tell them about patient
Write a ‘Documentation Only’ note in EPIC with the details from the initial call
Follow-up on patient status through MEC if questions arise as to whether pt remains appropriate for transfer

Senior Resident

Place patient on Pending Patient list in Epic
Review pending neurology transfers report in Epic at the beginning and end of day to make sure there are not additional patient there who are not on the pending patient list.
Check Timeline for notes from MEC. Remove patients from pending list if transfer canceled.
Sign out pending patients to call resident
Nurses will page resident when they are notified that bed is available/when they receive report.
If concerns arise regarding whether patient remains appropriate for level of care (based on Epic review or nursing report), notify the attending who can follow-up with the sending provider through MEC.

General Neurology Inpatient and Consult Attending Call Schedule:

Attending blocks start on Fridays for 14 days
Call shifts are from 8AM to 8AM (i.e. Attending listed under Monday starts the call shift Monday morning at 8AM and finishes Tuesday morning at 8AM)
The weekend coverage assignments are set to optimize patient coverage continuity so that either the attending or the senior resident will be present for both the inpatient and consult teams each weekend (i.e. the Inpatient attending is on the weekend with the Consult PGY4 and the Consult attending is on the weekend with the Inpatient PGY3). For this reason, weekend call swaps are discouraged.

Guidelines for Attending Feedback to Residents

We know giving feedback is not easy, but practice makes perfect. The residents will be expecting it and have been encouraged to ask for it at least once per inpatient rotation. Here is a practical summary on how to do it.

Set expectations early.
- Be clear on how you want to proceed with rounds, presentations, patient EHR notes, etc. These will serve as criteria for feedback.
Set a time to meet privately but soon after the interaction/rotation and specifically let them know “this is feedback”
- “Feedback Fridays” are the rule, but it can be done anytime during the rotation. It is recommended that on the Friday mid-rotation (inpatient, stroke, consult), you give feedback.
Start by asking for a self-assessment
- You can use this information to start the conversation and as basis for feedback. Ask each resident how they think they are doing, their strengths and weaknesses.
Give feedback with concrete examples but with a concept to improve (no more than 3)
- The “feedback sandwich” concept:
  - Start with positive behavior reinforcement of concrete behavior not just “good job today” but “excellent job with the organizing the presentation of this difficult patient” or “Very good use of the Jendrassick maneuver to elicit reflexes”.
  - Move on to concrete non-demeaning corrective feedback e.g., “I noticed you had difficulty localizing the lesion based on the exam. This maneuver may help you tease out the lesion” or “I noticed you were overwhelmed by the patient multiple complaints, it is helpful to redirect the patient to the main complaint” etc.…
  - Conclude with an action plan - set a corrective plan and follow up on the next feedback session.
Listen to reaction but remind them about the big picture
- It is not easy to keep focused and they may want to have an explanation for each of the corrections. Remember to redirect them to the big picture and the skills you are teaching.
Take time to read resident notes, watch them examine patients, and observe how they handle their responsibilities. Feedback on all these skillsets will allow us to train residents to the best of their abilities.

References to read (included in Attending Guidelines – Appendix 4C):

1. Cantillon Peter, Sargeant Joan. Giving feedback in clinical settings BMJ 2008; 337 :a1961

2. Ramani,S. and Krackov,S.K, Twelve tips for giving feedback effectively in the clinical environment. Med Teach, 34 (10), 787-791, 2012.

3. Getting Beyond “Good Job”: How to Give Effective Feedback. PEDIATRICS Volume 127, Number 2, February 2011

Appendix 1: Documentation Guidelines

Note to Neurology Clinical Faculty:

This new age of electronic medical records has drastically changed the way that patient notes are generated, and some of our trainees appear to not understand the principles of what makes good documentation. The guidelines below have been given to neurology residents. Please keep these principles in mind when giving residents feedback on their documentation. You are ultimately responsible for the documentation on the patients under your care, so please take a moment to review notes prior to cosigning them and give trainees feedback.

How to see where information in a note originates:

Open note in patient’s chart in EPIC. On top right of the note you should see selection panel:

If you select “Copied”, then copied text will be black and all other text will fade to light gray. The dropdown arrows will open the selection to “Hover for attribution information”. When that is selected, if you place the cursor over any section of text, it will tell you where it came from (e.g. SMARTPHRASE xxx, added by xxx; copied from progress note of xxx).

Purposes of Medical Documentation

Patient care – notes must be timely, and succinctly and accurately convey the current status and plan for the patient
Legal – notes must be accurate and with sufficient detail
Billing – Documentation must be sufficient to support billing. The EMR is designed to optimize billing by making it easy to include many elements in documentation. However, this has fostered the idea that “more it better”, leading to the note bloat phenomenon in which notes frequently contain redundant, contradictory, superfluous, and/or out of date information.

Things that ARE NOT ALLOWED

Copying forward major elements of notes from prior documentation:
- This makes it unclear what has been performed that day (i.e. did you in fact check all the same elements on exam and the patient responded in exactly the same way, or did you just copy exam forward).
- It also leads to the “note bloat” phenomenon which makes it difficult to find relevant information that is needed for patient care.
- Each note should be started with a blank page and a new blank template and then ONLY a few key elements should be copied in from other places in the chart.
Pasting things into medical record from outside chart: In EPIC, you can see where copy/paste elements originate. If you write a note in word or other outside program and then copy into EPIC, it will appear as “copied from outside chart”. This will lead to legal problems as it will raise suspicion that the note may have been copied from another note in the chart that cannot be easily identified, or that it may have been copied from another patient’s chart, which is absolutely forbidden.
Copy/Pasting in sections from other authors without appropriate attribution: It may be appropriate at times to include some elements of other’s notes. If this is done, it should be clearly stated where/when/who that information is coming from.

Key Principles

MORE IS NOT BETTER. Include only information that is relevant for patient care. DO NOT pull in extraneous info and avoid ‘Note Bloat’. The more irrelevant detail you add, the harder it is to find the relevant information.
DO NOT COPY FORWARD – You should start each note with a blank page, then can bring in the basic note template and fill in the details new each day.
DO NOT use “NORMAL EXAM” TEMPLATES. The exam documented in the notes should EXACTLY match the exam that you actually performed on the patient that day. You should start each note with a blank exam and then fill in those elements that you performed. For the daily progress note templates, the Neuro exam section has been pared way down to just major categories (delete those that you have not examined that day and include only what you did). If you want the more detailed template, import phrase “.UMHNEUROEXAMTEMPLATE”
Note templates are designed to make documentation easier and more accurate. Unless there are elements that you know are required, you should delete any sections of the templates that are not relevant for the patient at that time.
You are responsible for EVERYTHING that is in your notes. The notes serve as a way to organize your thinking and demonstrate that you have reviewed relevant information and acted on it. It is not enough to have a medication list or labs pull into your note. Putting info in your note implies that you have reviewed it and acted accordingly.
If you are giving the patient a medication, it should be related to a problem that is on the patient’s problem list (implied in this is the principle that you should know what all the medications are for).
The A&P should bring together all data into your ASSESSMENT of the patient. DO NOT restate the patient’s entire HPI and hospital course at the beginning of the A&P section.
Every patient should have a progress note every day – This is also true for patients admitted the day prior. It is true that the H&P is the note used for billing on the first day of admission. However, for patient care purposes the resident who is taking over primary care of the patient should write a short progress note on day 1 that outlines patient’s current status and the plan that incorporates the discussion on rounds (which may be different from the admission plan in the H&P). A lot happens on day 1, and this should be documented. Writing a note will also help ensure that the team has reviewed the labs, meds, etc. that day.
Remember that you can (and should) always add a note when indicated for patient care – If there are major events/changes that happen in the afternoon, they should be documented when they happen rather than being saved to include in the next morning’s note.
You should view your notes not as a daily task that just needs to be completed as quickly as possible, but rather as a permanent record of the care that you have provided.
- If that record is of poor quality, patient care and your reputation as a careful and trustworthy clinician will suffer.
- Just because many notes in the medical record are of poor quality, this is not a reason for us to join that substandard group.
How to optimize medical documentation in this new age of electronic medical records is an ongoing national discussion. We should continue to try to improve the efficiency of the process, but without sacrificing the quality of the final product.
- If you have suggestions for changes to exam templates or “best practices” to be passed along, please share them.

PROBLEM LISTS

Principles for use of Problem Lists

Add the active patient problems to the list
- The diagnosis of the problem should be changed as necessary when new information is received. (Example: On admission, the problem may be “weakness”, then the next day when you have determined the cause, it can be changed to “Right MCA stroke” or “Guillain Barre”, etc.)
Keep the list accurate and up to date.
- If a problem is no longer active, it should be “Resolved” (Ex: The UTI they had 3 years ago)
- If patient has multiple entries for the same problem, duplicates should be deleted (Ex. “hypertension” and “essential hypertension”)
In “details” section under each problem, put in ONLY information that:
- Will remain true for an extended time
- Is likely to be relevant for future care of patient
- Some examples:
  - under stroke: location and likely etiology
  - under migraine: age of onset, triggers, and previously tried medications
  - under pneumonia: culture/Xray results, date of onset and planned date of completion of antibiotics
DO NOT put in information that is specific to today. Unlike a daily progress note, the problem list is a live document, so stating “today” or “yesterday” has no meaning and becomes misleading.
Keep it succinct and relevant. DO NOT add in all details of the presentation or every lab/imaging result.

How to use Problem List Appropriately in Inpatient Progress Notes

Following the above principles, update the Problem List as relevant information becomes available or changes (this can be done at any point in the day)
Each morning: Start a new daily progress note and import Problem List with details (this is done automatically in the template)
Right click on the imported problem list and “make editable” (Note: you can do this with any element in the note – use this functionality to remove things that may be irrelevant while keeping things you want)
Under each problem: Add in the relevant daily updates and Plan for the day.
- Each problem should appear only once, with the relevant data, assessment, and plan for the problem grouped together. Information should not appear in more than one place in a note (this both causes Note Bloat, and increases the likelihood of conflicting information)

Appendix 2: UMMC Policy on Admission orders (per email 10/24/16):

CMS guidelines require that all Medicare inpatients must have an admission order signed, or co-signed, by an Attending physician prior to discharge. The Attending physician must be one who has clinically provided care to the patient and has admitting privileges.

There have been numerous occasions since Epic go-live in November 2015, where Medicare patients have been discharged prior to the admission order being co-signed by the Attending physician. This leads to CMS denials, loss of revenue and possibility for an audit for all UMMS hospitals. Upon review of charts across UMMS, it was determined that some patients are still being discharged without co-signed admission orders due to a variety of reasons.

A work-group including providers, nurses, compliance, billing, patient access, IS&T and Clinical Informatics have approved a proposal to put the following additional decision support process / work-flow in place.

A Best Practice Alert (BPA) in EPIC prevents a provider from signing a discharge order for Medicare patients when the admission order still requires a co-signature.
The After Visit Summary (AVS/discharge documentation/instructions) will not print for admitted Medicare patients that do not have a cosigned admission order.

This solution may result in patient movement/patient throughput delays until nurses and providers become accustomed to the new work-flow. We take this issue very seriously, and are working with the ADT EPIC team to track patient movement delays, related to the implementation of this new requirement to ensure admitted Medicare patients have co-signed admission orders before printing an AVS at discharge. Our goal is to limit the impact to patient movement/throughput by providing targeted education to those who will be affected. In addition, we will use the data from the ADT EPIC team to follow up with providers who are consistently causing delays by not co-signing admission orders prior to the patient’s discharge.

We are hopeful that the decision support implemented will prevent the discharging of Medicare patients without a co-signed admission order, decreasing Medicare denials and risk of audit.

For more information, please refer to the following tip sheet:

Appendix 3: Compliance for Inpatient Attendings

(updated Jan 2017)

All Inpatient Documentation is Now in EPIC

Please always add correct teaching physician statement.
AND addend the statement to include the date and time that you physically saw the patient. Why?
- Your electronic signature does not record date and time clearly in printed record.
- Often you see the patient long before you get to review the note and add your TP statement.
- When YOU saw the patient (not when you signed the note) is the key to when the billable service was given. TIME IS KEY even though time methods are different between observation and admission.
If you sign the note, then realize you forgot to put in the date and time, e-mail the patient name, medical record number and date of the note to Ms. Denise Mott in OTIC dictation DMOTT@umm.edu. She will open it for you to addend.

Admission versus Observation Status – Important for Proper Billing AND CMS COMPLIANCE For Medicare Patients, arrival in ER starts the clock.

Observation Documentation

If work up requires < 2 midnights stay, then place in “Observation” status.

Not admitted but are outpatients being observed for <2 midnights since ER arrival.
- Location does not tell you what the status is – patients can be on observation status in ER or in a “floor bed”.
Please mark “observation status” on your billing sheet
- Daily Census should reflect who is on observation status
Our observations cases – neurology wrote order to observe - billing is by calendar date on which you saw them.
- If same date as resident observation H&P, bill as initial observation day by using initial inpatient codes
- If you are first seeing patient on date after observation started, bill an observation discharge if you are sending them home.
Another service or Emergency Room observations cases – other service wrote the observation order.
- Need the name of consulting MD – these are observation consults.
- Mark observation on billing sheet, and then use ER patient consult codes (99241-99245).
- Resident and attending documentation must be on SAME DATE to bill.
Same medical complexity needed for high level consultation and initial hospital day applies to observation cases. In most cases, observation will have lower medical complexity than typical admissions.

In Patient Documentation

If work up requires => 2 midnights, admit the patient.

You must log into EPIC daily. Resident should be routing admission order for your co-signature.

NEEDS TO BE COSIGNED IN <24 hours.
If you do not see admission order for patient who was admitted, please go to patient, open admission order yourself and cosign.
If an order is sent to you to cosign and you are not the correct attending, DO NOT REFUSE – select FORWARD to correct attending. If you do not know correct attending, forward to Dr. Wozniak and call her.
If the resident admits, but you want to send home in <2 midnights, please call the Physician Advisor pager 2630 Monday through Friday.
You must physically see the patient within 24 hours of the resident’s admission H&P.
If you examined the patient earlier at <24 hours but are writing your TP statement at >24 hours, say “my exam at 10 am showed …” or “I interviewed and examined the patient at 10 am”.
PLEASE USE THIS TEACHING PHYSICIAN STATEMENT: I have interviewed and examined the patient on X date & X time. I agree with the resident note of X date and X time except as below:
- You personally interviewed and examined.
- You reviewed resident note and agree.
- Add any other appropriate documentation.
- Correct errors in resident note in your note
- Never use “Seen and examined” – it is not clear that you saw and examined.
- Documenting what the nurse saw or other physician saw does not count as physician examination.

Certification of Prolonged Hospital Stay – NEW CMS DOCUMENTATION

Effective January 1, 2015, a patient hospitalized for >= 20 days must have paper certification form completed by attending physician who has clinical knowledge of the patient by day 20. Case Manager, Social Worker or a Nurse Practitioner will be asking you to complete and sign the order for certifying that patient is receiving medically necessary inpatient care.

To bill Level 4 and Level 5 consults or Level 2 and 3 initial hospital days, you must have a comprehensive history and exam!
- History: For patients unable to provide history, document in HPI section, “Patient not able to communicate, unable to obtain complete history”. This then applies to all elements of history.

Exam: NEW DOCUMENTATION GUIDANCE

If all the bulleted items of the neurology single system exam are filled in, use single system.
For patients unable to perform parts of neurological exam, USE THE MULTI-SYSTEM comprehensive exam (at least one item in >=8 systems.
With either form of exam, if the resident H&P is missing a part of exam, please put that piece of exam in your note.

Guidance on Medical Complexity/Level of Service

Initial Hospital Consultation or Initial Hospital day:

Level V Consult or Level 3 Initial patients should be:
- New patient for you AND
- Acute change in neurological status (TIA, stroke, seizure, coma) AND
- Work up is planned.
Level IV Consult or Level 2 Initial patients:
- Problem is uncertain (i.e. stroke versus physiologic weakness) OR
- New patient but no work up planned. OR
- Old patient to you with new problem and work up

Follow Up Days are Billed the Same Codes for Consults and your Inpatients

To bill high level 3 follow up, all the below must be documented:
- Your need a detailed exam. Must contain =>12 elements.
- Patient must have new problem with work up planned (new compared with yesterday) Example: MI OR aspiration pneumonia OR GI bleeding in patient admitted with stroke
- You viewed images and discussed with radiologist and reviewed lab tests.

To bill mid level 2 follow up, all the below must be documented:

Exam must contain =>6 elements.
Patient with multiple problems (stroke, diabetes, hypertension, etc)
You viewed images and discussed with radiologist.

If you patient has only 1 or 2 active problems, the resident only documents <6 exam elements and only treatments are prescription medications with no tests to review, then level I follow up.

If there is no resident note for you to link to: your note with one element of interval history, one element of exam and one problem with assessment/plan DOES support a level one follow up visit!

Appendix 4: Tips for being a great attending physician

4A. Becoming a better ward attending: Ten modifiable behaviors

By Robert M. Centor, FACP, and Lisa L. Willett, ACP Member

Many residents join academic hospitalist groups upon completion of residency training. They arrive with great clinical experience but few have had training on how to be an effective ward attending and how to maximize the educational experience for their team of residents, interns and students. We offer this list of 10 modifiable behaviors to incorporate into your rounds as you develop your own ward attending style.

1. Make your expectations clear. Have an orientation session within the first three days and let the team know how rounds will run. Each attending has individual preferences; understand your own and make them clear to the team. For example, some attendings always start with sit-down rounds while other attendings prefer walking rounds first. Let the team know how you will proceed. Include how you want to hear patient presentations: just the overnight updates, a formal, organized “soap” (subjective, objective, assessment, plan) format, or by problem list. Giving learners your preferences at the beginning of the rotation will save them angst and help them best prepare their presentations.

2. Get to know your team. Have “autobiography” rounds within the first three days. Students and interns have told us that many attendings know nothing about them. Sometimes they don’t even learn their names. At our institution, we lead a sit-down session where we share our own abbreviated history (hometown, college, medical school and residency training, when we joined the faculty, family, joys outside of medicine). We ask team members to provide a similar brief history, including their future career plans, hobbies and pet peeves. These sessions foster team bonding and show your learners you care about them as individuals. Add sessions on favorite CDs, movies, books, sport teams, etc. throughout the rotation.

3. Be enthusiastic. We believe that enthusiasm defines great attendings. When you clearly love your field and teaching, the learners get excited. They will not all choose your field, but they will enjoy their experience. This is not the time to vent or share your frustrations about your career or your boss, or your institutional challenges. Role modeling enthusiasm and the joys of medicine is a much better way to maximize the learning experience. Tell the team why you love your field and how you maintain that passion.

4. Have respect for your team. In a few short years, they will be your colleagues. Showing respect for your learners is the foundation of a good learning climate. Once the learners know you respect them, they won’t be afraid to ask questions, share their uncertainties and challenge decisions to ensure the best care is provided to patients. When you promote a respectful atmosphere, giving corrective feedback is much easier. Show respect for learners by never being intimidating or demeaning and by showing appreciation for their hard work.

5. Have respect for time. In today’s busy world of medicine, time is our most valuable commodity. The learners’ time is just as valuable as yours. Set clear times to round that don’t exceed reasonable limits. Be on time for rounds. If you must be late, call and let your team know. Minimize interruptions and distractions. Don’t answer pages during rounds that can wait until later. Round in the mornings, not in the late afternoons. Ensure that your team has time to attend required conferences and clinics. Unless necessary, write your notes after rounds are completed, not while the team waits.

6. Teach. Teach to all levels, and teach the basics. Too many attendings assume that their learners know the basics; our experience is the opposite. The best teachers “layer” their teaching. Review the basic concepts (e.g., what are the possibilities for a patient presenting with a newly elevated creatinine?) before proceeding with a more sophisticated discussion. Avoid the trap of moving to a high-level discussion that assumes implicit knowledge; make the implicit knowledge explicit prior to advancing to the discussion. Once learners have absorbed the basic concepts, you can push them to explore more advanced concepts and applications. When appropriate, demonstrate bedside skills, including physical exam findings, physician-patient interactions and professionalism. If conducting bedside rounds, remember to make the patient the focus and demonstrate respect for his or her situation.

7. Question and rescue. The best clinical teachers ask questions for several reasons. We believe the most important reason is to gauge the learners’ current knowledge and level of understanding, and to search for teaching opportunities. We frame our questioning as a method of exploration. Through questioning, we learn where the teaching opportunities lie. When the learners do not know an answer, we rejoice and let them know that we have identified a learning opportunity. This positive response to their knowledge deficit defines the rescue. By questioning, we also are trying to create moderate anxiety because that predicts receptiveness to learning. We discuss this philosophy with our learners during our orientation session and encourage them to question and rescue, too. When questioning the team, it’s important never to ask a junior member something a senior member has already missed.

8. Think out loud, and make your thoughts explicit. When you explain your thought process, learners learn clinical reasoning. By “connecting the dots” of your logic, you are teaching. This allows you also to demonstrate the uncertainty of some decisions and shows how experience adds to evidence in many patient care decisions. Learners are less likely to consider it micromanaging if you explain the why behind your clinical decisions.

9. Give feedback. Feedback is critical to shaping the clinical competence of your learners. Students who receive regular feedback learn faster and perform better. Without feedback, mistakes are not corrected and good performance is not reinforced. To give effective feedback, state clear goals and objectives at your orientation session and establish a good learning climate. After observing key behaviors, give feedback often, immediately, and with the purpose of improving performance. Be the coach, not the judge. Focus on the learners’ behavior, not their personalities. Ask for their self-reflection and input, give specific recommendations for improvement and schedule a time to follow up on the behavior to ensure the feedback was incorporated. We have found that when feedback is labeled as such (“Let me give you some feedback”), learners appreciate the suggestions and don’t feel personally criticized.

10. Stimulate self-directed learning. Ask, “What did you learn today?” or “What questions does this case generate for you?” Medicine requires lifelong learning. Once the learners complete their training, they won’t have attendings to supervise their decisions. When learners are allowed to reflect on what they learned, it reinforces their knowledge for next time. When they reflect on unanswered clinical questions, they are stimulated to find solutions. This is how physicians operate in practice, and this should be fostered in our trainees. When learners are allowed to be involved in their education, they become active participants, assume ownership of their patients, and are able to share what they’ve learned with the team. This also helps the attending know the competence level of the learners and ensure that active learning is occurring daily.

Being a teaching attending is a multifaceted job. Caring for patients, documenting for billing purposes, and finding time to teach can be competing interests. Some attendings juggle these roles better than others. In our experience, certain attending behaviors are modifiable and can be easily incorporated regardless of your attending style. We have found that those who incorporate all, or even some, of these 10 behaviors improve their learners’ education, run more efficient rounds, and have a more enjoyable overall experience as a ward attending.

Acknowledgment: Many of the concepts in this list come from the principles emphasized in the Stanford Faculty Development Center’s program on clinical teaching, co-directed by Kelley M. Skeff, MACP, and Georgette Stratos, PhD. Dr. Skeff is the internal medicine residency program director and associate chair for education at Stanford University School of Medicine. We have learned from him both directly and indirectly. He influenced us to contemplate our teaching daily, weekly and monthly.

Dr. Centor is an academic general internist at the University of Alabama School of Medicine, associate dean of the Huntsville Regional Medical Campus and a frequent ward attending at the Birmingham VA Hospital. Read his blog at www.medrants.com.

4B. The Five Microskills for Clinical Teaching

Tip Sheet adapted from Neher et al. J Am Board Fam Pract 1992; 5:419-24