Teachers Teaching Teachers: Building Educator Competency in Pediatric Hospital Medicine

Podcast Transcript

Dr. James K. Stoller: 

Hello and welcome to MedEd Thread, a Cleveland Clinic education podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano: 

Hello, welcome to today's episode of MedEd Thread, an education podcast exploring the vital role of faculty development for educators teaching in our interdisciplinary, multilevel learner teams on a busy pediatric hospital medicine service. I'm your host, Dr. Tony Tizzano, director of Student and Lerner Health, here at Cleveland Clinic in Cleveland, Ohio.

Today I am very pleased to have Dr. Melissa Morse, pediatric clerkship director and assistant professor at Cleveland Clinic's Lerner College of Medicine of Case Western Reserve University, along with Dr. Dana Foradori Director of Cleveland Clinic's Pediatric Hospital Medicine Fellowship and associate professor at Cleveland Clinic's Lerner College of Medicine of Case Western Reserve also here to join us.

Melissa and Dana, welcome to today's podcast. So to get us started, could each of you tell us a little bit about yourselves, your educational background, what brought you to Cleveland and your roles here at Cleveland Clinic? Melissa, we'll start with you.

Dr. Melissa Morse: 

Hi, I'm Melissa Morse. I am from Buffalo, New York, and I am a pediatric hospitalist, primarily at the regional sites at Fairview and Hillcrest. I also am the clerkship director for the medical students and then am on the core residency faculty for the pediatric residents.

Dr. Tony Tizzano: 

Excellent. And Dana?

Dr. Dana Foradori: 

Uh, well, I am a native Clevelander and also a pediatric hospitalist. I work here primarily at main campus and also have a master's degree in education and some additional training through the academic Pediatric Associations educational Scholars program. So these two extra pieces of training have really helped me immensely in my current role, which is the program director for our peds Hospital medicine fellowship. Like Melissa, I also train medical students, residents, and fellows on the wards on an almost daily basis.

Dr. Tony Tizzano: 

Perfect. Well, your reputations precede you.

So in today's segment we'll explore how Cleveland Clinic's pediatric hospital medicine teams have focused on faculty development as an essential component in optimizing learning across disciplines at every level within their teams. So, Dana, if you could please help frame today's topic by providing our listeners with some context around this very important work, the impetus for it and your legacy in doing this in your department.

Dr. Dana Foradori: 

Absolutely. Most medical faculty, despite years of their own medical education, receive little to no education about how to teach others. Even when we're called upon to assume major educational leadership roles, we just may not have ever had training on how to do that. Okay, so our pediatric hospitalists play a key role in the education of med students, residents, fellows, and interprofessional trainees.

And we are so fortunate that within our own group we really have a legacy of medical education. And that stemmed from Dr. Sangita Krishna, who unfortunately is no longer with us. But as we started the podcast today, I just wanted to acknowledge how important she was for all of us in teaching us how to be teachers. And I also wanna acknowledge Dr. Katie Pestak, who's been instrumental in getting this project off the ground among our group.

Dr. Tony Tizzano: 

Well said. You know, I think the, the thing that always resonates in the back of my mind as a kind of hobby historian is we stand on the shoulders of giants. No two ways about it.

Melissa, what is the vision for Teaching Teachers series and how is it structured and implemented?

Dr. Melissa Morse: 

So our work was based on educator competencies that were grounded in graduate medical education domains, but retrofitted to educator competencies. So our goal was to inventory and grow educator competencies to optimize and provide high quality education in our busy inpatient clinical learning environments.

We wanted to provide high yield and practical strategies that our staff, residents, fellows, and NP's could use in this busy environment. We wanted to make it interactive, case-based and provide specific tools that they could use when teaching students, residents and fellows. We started with a pediatric hospital medicine clinical needs assessment where we sent a survey out to our entire group, including staff, nurse practitioners and fellows to assess competencies in each teaching domain.

And then we looked at development of a 12 month educator development series based on these competencies, and we looked at the strengths that we had in our group, the areas that people were skilled in talking about, and we created a series that would cover different topics. And our goal was to enhance self-assessments of our team in these educator competencies.

We looked at objective measures of educator skill as evidenced by their interest in becoming a better educator, pursuit of additional educator development opportunities, and increased number of faculty teaching awards. And we assess these objective measures pre starting the series and after as well.

Dr. Tony Tizzano: 

Yeah, I think that's perfect. You know, so often we figure that, gee, we're physicians. We've been in school forever, we're defacto great teachers, and we can be eminent in our careers, but not be great teachers. So you're really bringing a validation process to what are we doing and can we do it better? So Dana, what were the key takeaways from the pre-survey needs assessment and the selfs survey of educator competencies?

Dr. Dana Foradori: 

Well, our needs assessment gave us five areas for focus for our first year of the project. The first was evidence-based medical knowledge. Second was learner centeredness. Third, interpersonal and communication skills. Fourth, practice-based reflection and improvement. And finally, systems-based learning.

Dr. Tony Tizzano: 

So when you say the latter, what exactly does that mean? Systems based learning?

Dr. Dana Foradori: 

Yeah. So that's about learning how the whole health system works together. What does it mean to move from say, the inpatient environment to the outpatient environment? How do we facilitate a safe discharge? How do we incorporate social determinants of health into the care of our patients to ensure that they can continue to receive the best care, not just in the hospital, but outside of it?

Dr. Tony Tizzano, MD: 

Yeah. You know, I think that's really important. You know, we are a group of teams and I, you know, part of the central mantra at Cleveland Clinic is we function as a unit and as medicine has gotten so complex, it's an imperative. So Melissa, in looking at all of this, how have you weighed and measured the success of your efforts? And accordingly, what have you learned from the post-survey?

Dr. Melissa Morse: 

So one of the most interesting effects we had was that the self-assessments in all of the competencies actually declined. So participants stated that their skill in each of the competencies was lower then prior to starting the series. At first this could seem discouraging, but once we thought about it more, we attributed this to the Dunning Kruger effect, which is the tendency for those with limited knowledge of a topic to overestimate their abilities.

Participating in the series may have unmasked perceived needs to deepen skills. After the series, the participants stated increased interest in strengthening their skills and increased desire to pursue educational development. I think for example, they thought giving feedback was more simple than what it actually was, and once they learned more nuances, more specific examples, more scenarios, more areas to give feedback in, they realized they weren't actually as skilled at it as they thought, but luckily they were interested to learn more.

The interest in becoming a better educator increased from 74% to a hundred percent and 94% recommended series continuation, which we have continued the series now heading into our fourth year, and we've been able to have a wealth of topics from within our group. And some of these topics have been presented at national conferences as well.

The teaching awards in our group increased from 42% of respondents to 73%. As well as a threefold increase in pursuit of educator development activities within Cleveland Clinic and outside of Cleveland Clinic. And then as well, at the end of each lecture, we had participants create a commitment to change statement based on the topic.

For example, if the topic was giving feedback, they would commit to giving feedback more frequently or using a specific format to give feedback. And 60% of participants on the post survey stated they created at least one commitment to change statement, and hopefully pursuing that would allow our series to have an effect in the real world.

Dr. Tony Tizzano, MD: 

Excellent. You know, giving feedback is one thing. Learning how to accept feedback is an entirely different matter, and I never knew what to call it. The Dunning Kruger effect, is that what you said? I think every time I've asked to speak on a topic and I start looking into it, I realize I'm experiencing that because I'm nowhere near as prepared for that topic as I thought I was out the gate. Like, oh, I can talk about that. And then I look at it and I realize I got a long ways to go, or it's pointed out to me if I don't do my homework.

So Dana, given the multidisciplinary and multi-level nature of trainees within the department and your teams, how do you endeavor to flatten the hierarchy and create a psychologically safe learning environment for our trainees and learners?

Dr. Dana Foradori: 

That's a wonderful question. Several of our sessions were really focused on trainee wellbeing, psychological safety, and a sense of belonging. So for example, we had sessions on setting clear expectations for learner teams in hopes that that made them feel more in control and knew what the expectations were from the get go.

We also had sessions on providing honest, yet compassionate feedback with learners for suspected burnout, a session on unconscious biases, supporting trainee wellness in the clinical learning environment, and promoting educator wellness and role modeling so that we can role model wellness for the trainees.

That wellness really has to start with us before we teach someone else to do it too.

Dr. Tony Tizzano: 

Well that, that is well said, and I think we as leaders have an opportunity to set the stage for psychological safety. And you know, everyone wants to feel relevant. They wanna feel that they matter. It's not always easily accomplished and everyone has to get engaged and it's not easy to do, but is it not incumbent upon us as leaders to, to do that for our students when they're sitting there like deer in the headlights? Not sure what their role is just yet. Especially this time of year when everyone's new and getting started in, in many institutions with educational programs.

Dr. Dana Foradori: 

Yes, absolutely. 

Dr. Tony Tizzano: So for both of you, what lies on the horizon for advancing this competency-based educational skills among clinical faculty? At every level.

Dr. Melissa Morse: 

So I would say that residency and fellow and likely eventually medical school evaluations are moving more towards competency based. So we all need to become more familiar with competency based evaluation. One important thing will be providing time and space for direct observation. So teaching faculty how to do this direct to observation of students and residents and fellows in an effective way, teaching tools to do this during the the busy day. And then as well, we would like to eventually have faculty be able to have observation of each other doing teaching and getting feedback on that.

Dr. Tony Tizzano: 

So with that in mind, Melissa, do you think that physicians are inherently good at receiving feedback or is it something we need to work on? Do we look at it as an opportunity for growth? Or when someone begins to tell us something they think we might be able to do to improve, we start thinking of a response without really thinking about what's being said.

Dr. Melissa Morse: 

Yeah, I don't think anyone is inherently good at receiving feedback. I think it's a skill that we're all fostering. So luckily in our series, we're able to practice, so we'll have case-based, people will be able to practice how they would phrase things or take time and, and think about it and write down what they would say. So people are able to, to practice giving and receiving.

Dr. Tony Tizzano: 

Yeah, and you know one of the problems is we're always expected when someone gives us feedback to make a comment on it right away. I sometimes think we would be smart to say, you know what, I really want to think about some of the things you said and I'll get back to you. And not feel like I have to come up, 'cause I spent so much time coming up with a response that I'm not thinking about what they really had to say. And there's usually some way that I can grow from what they had to say. Some way. There's some opportunity there.

So what lies ahead of us that we can do differently to engage persons in the way that you're hoping to engage them? What's the next step?

Dr. Dana Foradori: 

Well, I think we're hoping that other groups can learn from what we've done. We do think that series like our own, have the potential to support educators in many different audiences in many different groups. And that's not just among physicians, but any healthcare professionals. The scope could be very narrow.

So for instance, one smaller specialty service, or it could be huge like our entire children's hospital. The larger the audience, of course, the more difficult it is to address very common specific challenges, but perhaps there are some intermediate options. So for instance, it might make sense for our pediatric hospital medicine group to scale up and include the pediatric ICU, the neonatal ICU and the pediatric ER, which are all sort of fast-paced, high acuity services all within our integrated care department. 'cause we have a lot of the same challenges and sort of time limitations on how we're teaching and trying to get feedback and evaluate learners in this really fast-paced environment.

And the other thing is, you know, if somebody wanted to create an educator development series for their own division, we would just highly recommend trying to embed these sort of short, high yield sessions within existing division conferences rather than adding more meetings to already very busy schedules.

I think that was the key to making this work for our group. Small, digestible information, it's relevant to what we do, and you can take it immediately into the clinical learning environment.

Dr. Tony Tizzano: 

Excellent. Does the program that you're putting together and the way that you look at this, is there a piece of it that flattens the hierarchy in a sense that, you know, you'll look at your respiratory therapists or your this or your that, other allied health professions to give feedback to students and trainees and faculty.

Because there's a lot that can be said, but if they're not brought into the fold, you know, there, it's a completely different set of skills than we often have as, as physicians. Is there opportunity for that in what you've done?

Dr. Dana Foradori: 

Yeah, I think we'd have to give that some more thought, but I, I really like that seed that you planted there. Um, because absolutely I, I think our respiratory therapists, our pharmacists, our nurses observe lots of different things that we might not see on a daily basis. And they're integral to giving that feedback otherwise the residents might not receive it.

Dr. Melissa Morse: 

I was just going to add, we did do a session led by Jody Lowry, our head nurse practitioner and Dr. Pestak, and they talked about ways to include the multidisciplinary team, for example, to get different people's perspectives on family centered rounds, including input from the respiratory therapist. We also recently did a talk about the cognitive ladder in teaching multidisciplinary level of learners, and one thing we talked about is getting the family perspective or the patient perspective on disease.

So how did this initially present to you? Can you tell us more about how this experience was? How was your diagnosis? What are your barriers to treatment? How has this impacted your life?

Dr. Tony Tizzano: 

So Melissa and Dana, we've covered a lot of really intriguing material. Are there other questions that I didn't ask that you feel are important for our listeners to know?

Dr. Dana Foradori: 

Yeah. Now that you mention it, one thing that we think might be I important to incorporate into these types of series in the future is the impact of emerging technology on medical education, and specifically how our trainees and our faculty are interacting with artificial intelligence and the impact that that's going to have on training.

So that's a topic we intend to explore more through our series this year, and I imagine we'll be exploring for many years to come.

Dr. Melissa Morse: 

So one thing is that in all levels, we are moving from a competency based evaluation to evaluating and entrustable professional activities. So this is saying that a resident or a student or a fellow can complete a specific task at the appropriate level of autonomy and that you feel ready for them to take care of your son or your daughter or your grandma without supervision.

So learning how to properly assess this, properly give feedback, and restructure our entire evaluation principle is definitely a sea change that all of us are gonna have to continue learning how to do in the best, most effective way.

In addition, just like you said, continuing to learn to give difficult feedback and sometimes more importantly, receive feedback. So that's something we're to continue working on as a group. And then finally, continuing to refresh knowledge and these skills over time as new generations of learners enter our PHM department, enter training.

And one thing we're excited about is bringing these skills to teach residents how to be teachers, teaching medical students how to be teachers, and continuing to learn this lifelong skill in an intergenerational fashion.

Dr. Tony Tizzano: 

Well, thank you so much, Melissa and Dana. This has been an interesting and wonderfully insightful podcast.

To our listeners, if you would like to suggest a medical education topic to us or comment on an episode, please email us at education@ccf.org. Thank you very much for joining, and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller: This concludes this episode of MedEd Thread, a Cleveland Clinic Education podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.