- Email: [email protected]
Educational strategies to foster bedside teaching
Surgery xxx (2019) 1e3
Contents lists available at ScienceDirect
Surgery journal homepage: www.elsevier.com/locate/surg
Educational strategies to foster bedside teaching Roger H. Kim, MD, FACSa, John D. Mellinger, MD, FACSa,* a
Division of General Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 17 June 2019 Available online xxx
Owing to increasing external pressures on both faculty and learners, the practice of bedside teaching is declining. The objective of this paper is to provide an overview of educational strategies to foster bedside teaching in the current clinical practice environment for surgical educators. General strategies include building a culture within the program that promotes the atmosphere of a learning community, and providing scaffolding for trainees that fosters gradual progression to autonomous practice. Specific techniques for bedside teaching include CAMEO, the “one-minute preceptor”, and mini-presentations or peer-teaching. The intentional and proactive implementation of these strategies alongside others can assist educators in capturing the “redeemable moments” that occur in the course of routine clinical care at the patient’s bedside. © 2019 Elsevier Inc. All rights reserved.
Introduction Surgeons involved in graduate medical education often feel conflicted owing to the ever increasing “time crunch.” There are mounting external pressures on faculty to meet performance metrics in terms of clinical and research productivity, despite decreasing resources to support academic activities. This leads to decreased faculty-resident interactions and teaching.1,2 Meanwhile, there are also limits placed on the amount of resident time available for learning owing to duty-hour restrictions.3 Teaching activities also take place within the environment of increased regulations and mandates by various accrediting and certifying bodies and compliance requirements by hospital partners and third-party payors. The result of these external pressures is a growing need by surgical educators to be efficient in the time that is available to us for teaching, both for medical students and residents. Although there has been extensive discussion of how to accomplish this in the intraoperative setting, learners also spend a significant amount of time in clinical settings outside the operating room, whether on the wards, the intensive care unit, the emergency room, or in outpatient clinic. There is evidence that the practice of bedside teaching is declining.4 The objective of this paper is to review educational strategies to foster teaching at the bedside in the context of the current clinical practice environment. Although the
* Reprint requests: John D. Mellinger, MD, FACS, J. Roland Folse Endowed Chair in Surgery, Vice Chair, Department of Surgery, Professor and Chair of General Surgery, SIU School of Medicine, P.O. Box 19638, 701 N. First St., Springfield, IL 62794-9638. E-mail address: [email protected] (J.D. Mellinger). https://doi.org/10.1016/j.surg.2019.06.007 0039-6060/© 2019 Elsevier Inc. All rights reserved.
strategies outlined in this article are by no means a comprehensive list, they should provide a good starting point for improving bedside teaching. General strategies Building a culture Perhaps the most important general aspect to consider in redeeming the time available for teaching in all clinical venues is the educational culture of the program. This area has come under increasing focus at the institutional level through Accreditation Council for Graduate Medical Education initiatives including the Clinical Learning Environment Review visit strategy.5 While recognizing the importance of institutional learning culture, the program milieu is even more important to the surgery resident. Historically, surgical programs have been singled out for what is sometimes described as a “malignant” culture, and general surgery continues to have the highest program attrition rates in the graduate medical education universe, despite attracting an increasingly competitive applicant pool.6 The hidden curriculum embodied in program educational culture is, in many ways, both more pervasive and important in its influence on learning than more overt curricular structures. Envisioning the residency program itself as a learning community7 and fostering a relational milieu and communal behaviors that serve and prioritize education as a collective habit is impactful in ways that cannot be overemphasized. How can program directors and educators facilitate that type of environment? This is obviously a complex topic, but the authors would offer the following suggestions.
2
R.H. Kim, J.D. Mellinger / Surgery xxx (2019) 1e3
First, program, department, and educational leaders need to model the way in inspiring an environment that prioritizes learning as a fundamental discipline at all levels. The tone for this can be set by simple behavioral disciplines, including humility about the limits of one’s knowledge and an expectant joy about adding to it with the goal of serving others. A chairman or program director who acknowledges their ignorance at a morbidity and mortality conference and calls on a colleague for assistance, who expresses their own experience and knowledge as something humbly offered for the benefit of others, and who self-corrects or apologizes for breaches of that standard is critical to such cultural formation. Second, exemplary behaviors can be celebrated through meaningful awards and appreciative inquiry exercises that draw learner attention to the habits and disciplines of faculty who personify competency in knowledge and other areas of professional development critical to the growth of learners. As an example of this, we have used resident focus groups to identify faculty exemplars of each core competency, interviewed the identified faculty, and presented a grand rounds on the specific habits and disciplines they engage in regularly to develop and maintain their mastery in that particular competency domain. Third, program directors and educators can give intentional energy to the chief residents as operational leaders of program culture through leadership development strategies that promulgate the values being described. We have pursued this for over a decade through a leadership skilleoriented course for rising chief residents that focuses on skills including time management, emotional intelligence, team building skill, conflict resolution, and other core leadership competencies. The course is followed by a longitudinal and relational leadership book club with the chief residents over the course of their chief year. A number of residents have commented that this latter, ongoing reflective exercise has been among the most personally valuable experiences of their residency, and in one resident’s experience, it was cited as instrumental in preserving his marriage. Finally, all faculty, especially educational program leaders, can adopt the mindset characterized for ancient Israel in Deuteronomy 6. In that context, the next generation’s development is described as an immersive and continual effort on the part of parents to apply the principles to be learned in a continuous and seamless fashion, regardless of the activity. In such an environment, there is no “down time,” and no activity that is deemed useless for learner development. Viewed through such a lens, the teacher and learner together experience each day as a continual curricular opportunity, irrespective of the task, duty, or other activity at hand. Such a growth mindset is powerful in its impact, honors our Hippocratic oath as a profession, and turns the 80 hours we have into a feast of shared potential, rather than portraying it as the trimmed and overly lean meal our learners are often told they must endeavor to survive on. Scaffolding Lev Vygotsky originally developed the concept of the zone of proximal development (ZPD), defined as “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined by problem solving under adult guidance or in collaboration with more capable peers.” When applied to medical education, the ZPD refers to learning that occurs when the trainee is being assisted by a faculty member or peer with a higher skill set. The resident or student is unable to complete the task or skill without the assistance of the faculty member. This assistance is continued until the trainee can perform the task independently. The process by which
the faculty member achieves this can take the form of scaffolding, in which the help or assistance provided is gradually tapered off in the same way that construction workers gradually remove a scaffold from a building as the support it provides is no longer needed for the stability of the structure. One of the guiding principles of this approach is that faculty members must be mindful to identify the learner’s next skill that they can perform with assistance but are unable to perform without such assistance.8 A skill that a resident cannot perform even with assistance and one that can be performed independently both fall outside the ZPD and would, therefore, not be suitable targets. In terms of bedside teaching, this could take the form of deliberate assignment of patients to be seen in clinic based on the resident’s current level of performance in evaluating the given clinical problem. For example, a resident could be instructed at first to focus on the initial workup of a patient presenting with a new breast mass. After demonstrating the ability to perform the appropriate workup independent of the attending’s assistance, the resident could gradually transition to a stage in which he or she would be assigned to counsel a patient with a new diagnosis of breast cancer on the recommended course of treatment. Specific examples CAMEO Clinical Assessment and Management ExaminationeOutpatient (CAMEO) is an instrument designed to evaluate resident performance in the surgical clinic setting.9 Although the intention and design of CAMEO is an assessment tool, the instructions for its use provide a framework for promoting intentionality in teaching residents in the clinic setting: Have the resident take the lead on this initial patient encounter in your clinic. Before going to see the patient, give the resident the intake file absent any test results. Ask the resident, “What test results do you want?” Give the resident the tests results and have the resident interpret them. Then ask the resident the following questions: 1) How confident are you that the presumptive diagnosis is correct? 2) What are the main competing diagnoses that remain for you? 3) What do we need to do to firm up the diagnosis when we see the patient?10 This initial phase is akin to the “briefing” element of the Briefing, Intraoperative Teaching, Debriefing model and serves to set the learning objectives for the outpatient clinic encounter for the resident.11 This helps focus the resident’s attention on the educational aspect of the task rather than the service aspect of being in clinic, and also can guide the attending’s teaching during the remainder of the encounter. Although it is probably not feasible to engage in this teaching model for every single patient and every learner in a very busy outpatient clinic, choosing 1 or perhaps 2 appropriate patient encounters for this type of indepth learning may maximize educational benefit when compared with having a resident participate in a dozen patient encounters without this level of intentionality. This approach emphasizes maximizing the quality of educational opportunities over quantity. One-minute preceptor Neher et al first described the approach that has been dubbed the “one-minute preceptor” (OMP) model, which focuses on a 5step process to teaching at the bedside.12 (Table I) In the first step, the attending asks the learner to commit to a presumed diagnosis. “What do you think is going on?” is a typical
R.H. Kim, J.D. Mellinger / Surgery xxx (2019) 1e3 Table I One-minute preceptor model Step Step Step Step Step
1 2 3 4 5
Get a commitment Probe for supporting evidence Teach a general principle Reinforce what was done well Give guidance about errors or omissions
question asked here. Second, the learner is asked to support their clinical reasoning: “What factors support your diagnosis?” By going through these first 2 steps, the faculty member should be able to identify the learning gap, that is, “What is it that the resident or student does not know that I can teach?” Once identified, this is addressed in the third step, where the relevant general principle is described. Feedback is then given in steps 4 and 5, highlighting what the learner did well (“You accurately described the patient’s abdominal exam findings”) and suggesting corrective actions (“In a female patient presenting with right lower quadrant pain, it is important to consider and rule out an ectopic pregnancy”). As implied by its moniker, the OMP model can be a highly efficient tool in both inpatient and outpatient clinical settings. Like the use of CAMEO, it may not be appropriate to use the OMP for every single patient encounter during inpatient rounds, but its selective application can facilitate a systematic approach to bedside teaching.13 Mini-Presentations and Peer-Teaching To complete the analogy drawn earlier to the Briefing, Intraoperative Teaching, Debriefing model, assignments of future learning issues can be a powerful way to promote student engagement after the bedside patient encounter has been completed as part of the “debriefing” phase. This technique can be used both for inpatient and outpatient bedside encounters and can act as extensions of both the CAMEO and the OMP. After the attending has identified a future learning need from the bedside encounter, a relevant learning topic is assigned to the student or resident. The learner is given an opportunity to research the topic away from the patient bedside and then return to give a mini presentation, usually less than 5 minutes, on the topic. This can often take place as peer teaching, in which the learner teaches the topic to his or her peer group of students or residents. By engaging in peer teaching, the learner gains the benefit of reinforcing his or her own knowledge.14 This strategy, when applied to bedside teaching, can be both highly effective and highly efficient. In conclusion, there are “redeemable moments” in the course of routine clinical care that afford the opportunity to recapture some of the bedside teaching practices that have been threatened by, if not lost to the time pressures placed on surgical educators by the current health care system. In the general and specific strategies outlined earlier, the fundamental requirement is for faculty to seek to create these moments in the midst of our regular duties. The pilot study currently being conducted by the American Board of Surgery on the feasibility of implementing Entrustable Professional
3
Activities in general surgery residency programs15 shares this mindset of “redeemable moments,” in that completing the Entrustable Professional Activities micro assessments require an intentionality and proactiveness by attendings that is similar to that required to successfully employ the strategies outlined earlier. Faculty members need to remain actively engaged in shared activities such as clinic, rounds, and consultations in a way that invites the opportunity for learning to occur and continues to foster the irreplaceable impact that teaching at the patient bedside can have on our trainees. Funding/Support The authors have indicated that they have no funding regarding the content of this article. Conflict of interest/Disclosure Neither Dr. Kim nor Dr. Mellinger have any conflicts of interest to disclose. References 1. Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ. Effects of limited work hours on surgical training. J Am Coll Surg. 2002;195:531e538. 2. Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355:1339e1344. 3. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259:1041e1053. 4. Peters M, Ten Cate O. Bedside teaching in medical education: a literature review. Perspect Med Educ. 2014;3:76e88. 5. Long TR, Doherty JA, Frimannsdottir KR, Rose SH. An early assessment of the ACGME CLER program: a national survey of designated institutional officials. J Grad Med Educ. 2017;9:330e335. 6. Khoushhal Z, Hussain MA, Greco E, et al. Prevalence and causes of attrition among surgical residents: a systematic review and meta-analysis. JAMA Surg. 2017;152:265e272. 7. Lave J, Wenger E, Brown JS, Heath C, Pea R. Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press; 1991. 8. Sanders D, Welk DS. Strategies to scaffold student learning: applying Vygotsky's Zone of Proximal Development. Nurse Educ. 2005;30:203e207. 9. Wilson AB, Choi JN, Torbeck LJ, Mellinger JD, Dunnington GL, Williams RG. Clinical Assessment and Management Examination–Outpatient (CAMEO): its validity and use in a surgical milestones paradigm. J Surg Educ. 2015;72:33e40. 10. The American Board of Surgery. General Surgery Resident Performance Assessments. Available from: http://www.absurgery.org/default.jsp?certgsqe_ resassess. Accessed July 12, 2019. 11. Roberts NK, Williams RG, Kim MJ, Dunnington GL. The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg. 2009;208:299e303. 12. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching. J Am Board Fam Pract. 1992;5:419e424. 13. Ferenchick G, Simpson D, Blackman J, DaRosa D, Dunnington G. Strategies for efficient and effective teaching in the ambulatory care setting. Acad Med. 1997;72:277e280. 14. Yu TC, Wilson NC, Singh PP, Lemanu DP, Hawken SJ, Hill AG. Medical studentsas-teachers: a systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract. 2011;2:157e172. 15. Brasel KJ, Klingensmith ME, Englander R, et al. Entrustable Professional Activities in general surgery: development and implementation. J Surg Educ; 2019;S1931e7204:30123-0 https://doi.org/10.1016/j.jsurg.2019.04. 003. Accessed July 12, 2019.
Contents lists available at ScienceDirect
Surgery journal homepage: www.elsevier.com/locate/surg
Educational strategies to foster bedside teaching Roger H. Kim, MD, FACSa, John D. Mellinger, MD, FACSa,* a
Division of General Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 17 June 2019 Available online xxx
Owing to increasing external pressures on both faculty and learners, the practice of bedside teaching is declining. The objective of this paper is to provide an overview of educational strategies to foster bedside teaching in the current clinical practice environment for surgical educators. General strategies include building a culture within the program that promotes the atmosphere of a learning community, and providing scaffolding for trainees that fosters gradual progression to autonomous practice. Specific techniques for bedside teaching include CAMEO, the “one-minute preceptor”, and mini-presentations or peer-teaching. The intentional and proactive implementation of these strategies alongside others can assist educators in capturing the “redeemable moments” that occur in the course of routine clinical care at the patient’s bedside. © 2019 Elsevier Inc. All rights reserved.
Introduction Surgeons involved in graduate medical education often feel conflicted owing to the ever increasing “time crunch.” There are mounting external pressures on faculty to meet performance metrics in terms of clinical and research productivity, despite decreasing resources to support academic activities. This leads to decreased faculty-resident interactions and teaching.1,2 Meanwhile, there are also limits placed on the amount of resident time available for learning owing to duty-hour restrictions.3 Teaching activities also take place within the environment of increased regulations and mandates by various accrediting and certifying bodies and compliance requirements by hospital partners and third-party payors. The result of these external pressures is a growing need by surgical educators to be efficient in the time that is available to us for teaching, both for medical students and residents. Although there has been extensive discussion of how to accomplish this in the intraoperative setting, learners also spend a significant amount of time in clinical settings outside the operating room, whether on the wards, the intensive care unit, the emergency room, or in outpatient clinic. There is evidence that the practice of bedside teaching is declining.4 The objective of this paper is to review educational strategies to foster teaching at the bedside in the context of the current clinical practice environment. Although the
* Reprint requests: John D. Mellinger, MD, FACS, J. Roland Folse Endowed Chair in Surgery, Vice Chair, Department of Surgery, Professor and Chair of General Surgery, SIU School of Medicine, P.O. Box 19638, 701 N. First St., Springfield, IL 62794-9638. E-mail address: [email protected] (J.D. Mellinger). https://doi.org/10.1016/j.surg.2019.06.007 0039-6060/© 2019 Elsevier Inc. All rights reserved.
strategies outlined in this article are by no means a comprehensive list, they should provide a good starting point for improving bedside teaching. General strategies Building a culture Perhaps the most important general aspect to consider in redeeming the time available for teaching in all clinical venues is the educational culture of the program. This area has come under increasing focus at the institutional level through Accreditation Council for Graduate Medical Education initiatives including the Clinical Learning Environment Review visit strategy.5 While recognizing the importance of institutional learning culture, the program milieu is even more important to the surgery resident. Historically, surgical programs have been singled out for what is sometimes described as a “malignant” culture, and general surgery continues to have the highest program attrition rates in the graduate medical education universe, despite attracting an increasingly competitive applicant pool.6 The hidden curriculum embodied in program educational culture is, in many ways, both more pervasive and important in its influence on learning than more overt curricular structures. Envisioning the residency program itself as a learning community7 and fostering a relational milieu and communal behaviors that serve and prioritize education as a collective habit is impactful in ways that cannot be overemphasized. How can program directors and educators facilitate that type of environment? This is obviously a complex topic, but the authors would offer the following suggestions.
2
R.H. Kim, J.D. Mellinger / Surgery xxx (2019) 1e3
First, program, department, and educational leaders need to model the way in inspiring an environment that prioritizes learning as a fundamental discipline at all levels. The tone for this can be set by simple behavioral disciplines, including humility about the limits of one’s knowledge and an expectant joy about adding to it with the goal of serving others. A chairman or program director who acknowledges their ignorance at a morbidity and mortality conference and calls on a colleague for assistance, who expresses their own experience and knowledge as something humbly offered for the benefit of others, and who self-corrects or apologizes for breaches of that standard is critical to such cultural formation. Second, exemplary behaviors can be celebrated through meaningful awards and appreciative inquiry exercises that draw learner attention to the habits and disciplines of faculty who personify competency in knowledge and other areas of professional development critical to the growth of learners. As an example of this, we have used resident focus groups to identify faculty exemplars of each core competency, interviewed the identified faculty, and presented a grand rounds on the specific habits and disciplines they engage in regularly to develop and maintain their mastery in that particular competency domain. Third, program directors and educators can give intentional energy to the chief residents as operational leaders of program culture through leadership development strategies that promulgate the values being described. We have pursued this for over a decade through a leadership skilleoriented course for rising chief residents that focuses on skills including time management, emotional intelligence, team building skill, conflict resolution, and other core leadership competencies. The course is followed by a longitudinal and relational leadership book club with the chief residents over the course of their chief year. A number of residents have commented that this latter, ongoing reflective exercise has been among the most personally valuable experiences of their residency, and in one resident’s experience, it was cited as instrumental in preserving his marriage. Finally, all faculty, especially educational program leaders, can adopt the mindset characterized for ancient Israel in Deuteronomy 6. In that context, the next generation’s development is described as an immersive and continual effort on the part of parents to apply the principles to be learned in a continuous and seamless fashion, regardless of the activity. In such an environment, there is no “down time,” and no activity that is deemed useless for learner development. Viewed through such a lens, the teacher and learner together experience each day as a continual curricular opportunity, irrespective of the task, duty, or other activity at hand. Such a growth mindset is powerful in its impact, honors our Hippocratic oath as a profession, and turns the 80 hours we have into a feast of shared potential, rather than portraying it as the trimmed and overly lean meal our learners are often told they must endeavor to survive on. Scaffolding Lev Vygotsky originally developed the concept of the zone of proximal development (ZPD), defined as “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined by problem solving under adult guidance or in collaboration with more capable peers.” When applied to medical education, the ZPD refers to learning that occurs when the trainee is being assisted by a faculty member or peer with a higher skill set. The resident or student is unable to complete the task or skill without the assistance of the faculty member. This assistance is continued until the trainee can perform the task independently. The process by which
the faculty member achieves this can take the form of scaffolding, in which the help or assistance provided is gradually tapered off in the same way that construction workers gradually remove a scaffold from a building as the support it provides is no longer needed for the stability of the structure. One of the guiding principles of this approach is that faculty members must be mindful to identify the learner’s next skill that they can perform with assistance but are unable to perform without such assistance.8 A skill that a resident cannot perform even with assistance and one that can be performed independently both fall outside the ZPD and would, therefore, not be suitable targets. In terms of bedside teaching, this could take the form of deliberate assignment of patients to be seen in clinic based on the resident’s current level of performance in evaluating the given clinical problem. For example, a resident could be instructed at first to focus on the initial workup of a patient presenting with a new breast mass. After demonstrating the ability to perform the appropriate workup independent of the attending’s assistance, the resident could gradually transition to a stage in which he or she would be assigned to counsel a patient with a new diagnosis of breast cancer on the recommended course of treatment. Specific examples CAMEO Clinical Assessment and Management ExaminationeOutpatient (CAMEO) is an instrument designed to evaluate resident performance in the surgical clinic setting.9 Although the intention and design of CAMEO is an assessment tool, the instructions for its use provide a framework for promoting intentionality in teaching residents in the clinic setting: Have the resident take the lead on this initial patient encounter in your clinic. Before going to see the patient, give the resident the intake file absent any test results. Ask the resident, “What test results do you want?” Give the resident the tests results and have the resident interpret them. Then ask the resident the following questions: 1) How confident are you that the presumptive diagnosis is correct? 2) What are the main competing diagnoses that remain for you? 3) What do we need to do to firm up the diagnosis when we see the patient?10 This initial phase is akin to the “briefing” element of the Briefing, Intraoperative Teaching, Debriefing model and serves to set the learning objectives for the outpatient clinic encounter for the resident.11 This helps focus the resident’s attention on the educational aspect of the task rather than the service aspect of being in clinic, and also can guide the attending’s teaching during the remainder of the encounter. Although it is probably not feasible to engage in this teaching model for every single patient and every learner in a very busy outpatient clinic, choosing 1 or perhaps 2 appropriate patient encounters for this type of indepth learning may maximize educational benefit when compared with having a resident participate in a dozen patient encounters without this level of intentionality. This approach emphasizes maximizing the quality of educational opportunities over quantity. One-minute preceptor Neher et al first described the approach that has been dubbed the “one-minute preceptor” (OMP) model, which focuses on a 5step process to teaching at the bedside.12 (Table I) In the first step, the attending asks the learner to commit to a presumed diagnosis. “What do you think is going on?” is a typical
R.H. Kim, J.D. Mellinger / Surgery xxx (2019) 1e3 Table I One-minute preceptor model Step Step Step Step Step
1 2 3 4 5
Get a commitment Probe for supporting evidence Teach a general principle Reinforce what was done well Give guidance about errors or omissions
question asked here. Second, the learner is asked to support their clinical reasoning: “What factors support your diagnosis?” By going through these first 2 steps, the faculty member should be able to identify the learning gap, that is, “What is it that the resident or student does not know that I can teach?” Once identified, this is addressed in the third step, where the relevant general principle is described. Feedback is then given in steps 4 and 5, highlighting what the learner did well (“You accurately described the patient’s abdominal exam findings”) and suggesting corrective actions (“In a female patient presenting with right lower quadrant pain, it is important to consider and rule out an ectopic pregnancy”). As implied by its moniker, the OMP model can be a highly efficient tool in both inpatient and outpatient clinical settings. Like the use of CAMEO, it may not be appropriate to use the OMP for every single patient encounter during inpatient rounds, but its selective application can facilitate a systematic approach to bedside teaching.13 Mini-Presentations and Peer-Teaching To complete the analogy drawn earlier to the Briefing, Intraoperative Teaching, Debriefing model, assignments of future learning issues can be a powerful way to promote student engagement after the bedside patient encounter has been completed as part of the “debriefing” phase. This technique can be used both for inpatient and outpatient bedside encounters and can act as extensions of both the CAMEO and the OMP. After the attending has identified a future learning need from the bedside encounter, a relevant learning topic is assigned to the student or resident. The learner is given an opportunity to research the topic away from the patient bedside and then return to give a mini presentation, usually less than 5 minutes, on the topic. This can often take place as peer teaching, in which the learner teaches the topic to his or her peer group of students or residents. By engaging in peer teaching, the learner gains the benefit of reinforcing his or her own knowledge.14 This strategy, when applied to bedside teaching, can be both highly effective and highly efficient. In conclusion, there are “redeemable moments” in the course of routine clinical care that afford the opportunity to recapture some of the bedside teaching practices that have been threatened by, if not lost to the time pressures placed on surgical educators by the current health care system. In the general and specific strategies outlined earlier, the fundamental requirement is for faculty to seek to create these moments in the midst of our regular duties. The pilot study currently being conducted by the American Board of Surgery on the feasibility of implementing Entrustable Professional
3
Activities in general surgery residency programs15 shares this mindset of “redeemable moments,” in that completing the Entrustable Professional Activities micro assessments require an intentionality and proactiveness by attendings that is similar to that required to successfully employ the strategies outlined earlier. Faculty members need to remain actively engaged in shared activities such as clinic, rounds, and consultations in a way that invites the opportunity for learning to occur and continues to foster the irreplaceable impact that teaching at the patient bedside can have on our trainees. Funding/Support The authors have indicated that they have no funding regarding the content of this article. Conflict of interest/Disclosure Neither Dr. Kim nor Dr. Mellinger have any conflicts of interest to disclose. References 1. Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ. Effects of limited work hours on surgical training. J Am Coll Surg. 2002;195:531e538. 2. Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355:1339e1344. 3. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259:1041e1053. 4. Peters M, Ten Cate O. Bedside teaching in medical education: a literature review. Perspect Med Educ. 2014;3:76e88. 5. Long TR, Doherty JA, Frimannsdottir KR, Rose SH. An early assessment of the ACGME CLER program: a national survey of designated institutional officials. J Grad Med Educ. 2017;9:330e335. 6. Khoushhal Z, Hussain MA, Greco E, et al. Prevalence and causes of attrition among surgical residents: a systematic review and meta-analysis. JAMA Surg. 2017;152:265e272. 7. Lave J, Wenger E, Brown JS, Heath C, Pea R. Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press; 1991. 8. Sanders D, Welk DS. Strategies to scaffold student learning: applying Vygotsky's Zone of Proximal Development. Nurse Educ. 2005;30:203e207. 9. Wilson AB, Choi JN, Torbeck LJ, Mellinger JD, Dunnington GL, Williams RG. Clinical Assessment and Management Examination–Outpatient (CAMEO): its validity and use in a surgical milestones paradigm. J Surg Educ. 2015;72:33e40. 10. The American Board of Surgery. General Surgery Resident Performance Assessments. Available from: http://www.absurgery.org/default.jsp?certgsqe_ resassess. Accessed July 12, 2019. 11. Roberts NK, Williams RG, Kim MJ, Dunnington GL. The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg. 2009;208:299e303. 12. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching. J Am Board Fam Pract. 1992;5:419e424. 13. Ferenchick G, Simpson D, Blackman J, DaRosa D, Dunnington G. Strategies for efficient and effective teaching in the ambulatory care setting. Acad Med. 1997;72:277e280. 14. Yu TC, Wilson NC, Singh PP, Lemanu DP, Hawken SJ, Hill AG. Medical studentsas-teachers: a systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract. 2011;2:157e172. 15. Brasel KJ, Klingensmith ME, Englander R, et al. Entrustable Professional Activities in general surgery: development and implementation. J Surg Educ; 2019;S1931e7204:30123-0 https://doi.org/10.1016/j.jsurg.2019.04. 003. Accessed July 12, 2019.