 Good morning, everyone. Can you hear me in the room, Teresa? Good, thumbs up, good. So I am just hopping in an Uber heading to Washington DC for the mid-year forum meeting, but I did want to give a relatively proper introduction to Teresa Long. So Teresa Long is one of our residents. She came to us by way of University of Missouri, medical school originally from central Missouri. Teresa took a bit of a brave path, stepping a little bit outside of what I call the path of least resistance and exploring a new pathway and really a new specialty in ophthalmology, and that is as an inpatient ophthalmologist. Now, along the way as well, Teresa's really shown some education chops, and I am personally elated that the rest of you get to see some of what you can expect from Teresa in the future as one of our faculty. She's someone who will have a significant impact on our training of residents, training of medical students, but particularly the early mentoring of our residents as they go through the consult service and really learn how to become a thoughtful thinking ophthalmologist. So I can't speak highly enough of Teresa, and again, I'm elated that you get a little glimpse into some of the things that she's going to bring to the Miranda Center. All right, take it away, Teresa. All right, so good morning, everyone. I'm really excited to talk with you about some of the things that I have been brewing on for a long time now. So the title of my talk is Andragaji at the Patient Bedside, so Adult Learning Theory and Improving the Resident Consult Experience. I never thought that I would be an ophthalmic hospitalist, but this is the career that I have fallen into and I've come to love, and so I'm so excited to really think about how our consult service can be a jumping board for resident education and the best service on the entire ophthalmology department. So I think Dr. Petty told you a little bit about me, but I think pictures are probably the best way. So I grew up in rural Southwestern Missouri. My hometown has a population of less than 2,000 people. I went to undergrad in medical school at the University of Missouri in Columbia, and so you can see Doc Truman, as he known. So Truman the Tiger is our mascot of the University of Missouri, because Harry S. Truman is from Missouri. And I grew up in the beautiful kind of backwards of Stockton Lake. And so there's a photo. It's actually one of the premier sailing lakes in the Midwest. So a lot of people will go out on the lake for the weekend and it's deep in the Ozark, we call the Ozark Mountains, but really you can kind of see that there's Ozark Hills. So there's these rolling oak and hickory forests. So it was a beautiful place. And I really think my mom and my dad were really my first teachers in life. My dad teaching me about wildflowers and all the animals, the flora, the fauna. And my mom was a second grade teacher and were my first educators. So fast forward, we moved to Utah. Utah has just been really wonderful for me with all the outdoor activities. But the best part I would say about Utah is actually finding this guy. And so this is Logan Turra. He's my fiance. He's originally from Atlanta, but he loves skiing. That was the first thing that I heard about Logan when I first met him from my friends. They were like, oh yeah, Logan, he really loves skiing. And that is true. So this is a picture on the lower left of him on the top of the grand. And he loves ski mountaineering. So he's been really fun. We go on a lot of adventures together. And this is up in the West Hatch Mountains on a hike. So I have no financial disclosures. So today I really wanna reflect on knowledge and learning. I wanna reflect on how we learn in residency and learning in general in residency. And I want to discuss adult learning theories. Talk about a really helpful teaching technique that I find called the one minute preceptor. And then last, we're gonna touch on everyone's favorite topic, feedback. So knowledge versus learning. So from the audience, what is knowledge? How would you define knowledge? Anybody? You can shout it from the back and I'll repeat it. So is there anybody in the chat? Our audience is feeling shy. Rachel. So knowledge is a base of things that you have acquired and you can draw on for different situations. So what is it composed of? Do you think it's just, is it facts? Is it just information or does it go beyond that? So I really think that knowledge goes beyond that. It's facts, information and skills, right? You have the skills and the training. And so technically when we're learning surgery, you have to learn those skills with your hands. And then you also have to have the book knowledge and kind of integrate everything together. And this is really different from learning. And so you could say that learning is the acquisition of knowledge. So has anyone read Make It Stick? If you haven't, it's a really wonderful book. I think we think that we know a lot about learning and knowledge, but this book really kind of puts it in a new perspective, especially for adult learners. So for all the residents out there, I would recommend it. So in Make It Stick, they talk about acquiring knowledge and skills and having them readily available from memory so you can make sense of future problems and opportunities. So they really say that learning requires really three main things that requires memory. You need to keep the learning and remember and you need to keep learning and remembering all of our lives. And this is really important for mastery of job skills at work. And you think about you were in school, for elementary school, but you don't stop learning as an adult. That's a lot of the reason why maybe many of us chose medicine, we're lifelong learners. And learning is an acquired skill. You can get better at learning over time. So this slide credit has to go to Dr. Sravakunta and Dr. Rachel Patel, who I think about two years ago started revamping our curriculum. And so think about a time that you had to learn something new. And I think they asked the same question and I really loved it. What were you trying to learn and what was it like? Anyone share an experience with me? There's some laughing from the residents back there. Were they trying to learn something new recently? So Tony says that he was joking with Brandon, but he said, scleral depression, that was a really tough skill to learn. And they were really struggling with it. And now has it gotten better? You can find your depressor. But what was it like in the beginning? You thought you could find your depressor in the beginning and then you realized you're actually like not posterior enough, right? So absolutely. So I think learning is hard. And I think in adult learning, it's really challenging. So how do you learn in residency? Really thinking about this. I love these photos of us that they take every spring and your cohort. And is it kind of like this? Is it kind of like this? Kind of like this. So it's really interesting. All three of these people are kind of in totally different situations. Like the first one's like, I'm actually drowning and I'm really drowning. The second one looks like they're doing okay, but is actually like, help, help. I really need some help. And the third one is terror, like terrified. And then all of a sudden someone's like, oh, stand up. And he's like, I'm fine. I'm fine, I'm actually okay. So I think we've all had experiences like this in the middle of residency as well. Or is it like this? Or like this? Who can figure out which resident is the bulldog? So I sat down and I was like, I wanted to make a list of everything that we have to learn in residency and to kind of think about it. And there's a lot. If you think there's, in addition to just the major topics, glaucoma, plastics, retina, uveitis, we have to learn how to interpret imaging, OCTs, visual fields, MRIs. We have to learn how to triage phone calls. We have to learn surgical skills. We have to learn how to be efficient. We have to work on our interpersonal skills. So there's a ton that is happening in these four years. And switching gears now to go to pedagogy and androgogy. So this slide credit also goes to Dr. Shrava Gupta. But pedagogy gives the instructor the main responsibility for making decisions about learning content method and evaluation. And androgogy was a theory that started in the 1950s. In Germany, but Malcolm Knowles, I think, is the person who described this the best. And he has six theories of adult learners. And this was really refined through the 1970s and 1990s. So to compare and contrast these two, in pedagogy, the learner's dependent on the teacher. The teacher is the one who evaluates progress. They assume full responsibility. The learner, the learner comes to the table with a little bit of life experience, but the child's like a blank state. And students advance once they have completed the next step. And learning is, you know, the instructor is the one that's responsible. And they're motivated by external sources. So parents, teachers, whereas androgogy or adult learning, the learner's dependent on self. So in residency, I feel like so much of our learning and our learning in our adult life is really something that we want to do. It requires self-evaluation and the self takes responsibility for the process. The learner has a lot more life experiences in contrast to a child. And adults learn from an instructor, but they also learn from one another, the entire environment is different. Learning is triggered by any number of life experiences, not necessarily led by an instructor. And the learners identify a problem and they see a knowledge gap and they seek to work to remedy that gap. And then in contrast, learners are motivated by intrinsic means. So their quality of life, problem solving, quest for recognition, and then topics are completed as they master them. So adult learning theory, Malcolm Knowles isn't the only one who's tried to describe how people learn. There are experiential learning, self-directed learning, situated learning, transformative learning, and they're really all pieces of the puzzle that try to describe this process of how adults acquire knowledge. Really big slide and lots of things, but I really just wanted to point out a few. So other theories of adult learning, so we could start thinking about this a little more. So a reflective practice. So new information is interpreted in light of past knowledge and experience. So for example, fourth year resident breaks bag because they fake out deep while they were trying to get out a piece and they learn, oh, I shouldn't fake out in the bag anymore, right? That's a great example of experiential learning. And so that reflection on what happened and what caused the problem allows them to make changes in the future. It's very similar to transformative learning. And then I think it's really interesting if you look at learning in communities of practice. So learners move from peripheral participation into full participation, embracing the values and experiences within the community. I think this is a really interesting idea to describe maybe how when you join a new practice or you join a new academic institution, you kind of are out of the periphery and then you become more and more involved and you become a leader in the department and then you embrace the values and experiences within the community that you have. And then we've all heard of self-directed learning, which is also really great. So Malcolm knows six assumptions of adult learners. So I really love thinking about these and so I wanna take some time and go through them. So adult learners have self-concept. They're capable, they're self-directed and they have their own set of beliefs of what they want to accomplish. They may have clinical, sorry, clinical experiences and unique backgrounds and approaches to education. So the conversation that you would have with someone who has a PhD in an area that you're like, say in an area of the eye and they're on a particular rotation would be very different than maybe a PGY1 resident. They're ready to learn. They're eager to know what they need to learn to achieve X, Y and Z. And learning should help them perform tasks or deal with the problem. And they have a strong internal motivation. They wanna have job satisfaction and more opportunities. And then my favorite is they need to know why. So I absolutely love, and I ask all the residents all the time, why am I asking you that question? When I ask you a question, what you think about the why? And the adult learners need to know the why. Why is this important? Why do you feel like I need to have the skill? So how can we apply this to resident teaching? And I think a lot of this is theory. And I think, how do we put this actually into clinical practice? So because adult learners need to know the why, you wanna assess the learner's needs at the outset and their outcomes after teaching. So maybe at the beginning of the rotation, you say, what are your goals for this rotation? What do you want to accomplish? You foster a climate of learning and inquiry and accept formative feedback from the learners to retailer your teaching. So it's really more of a two-way street. And then also providing constructive feedback that encourages accurate self-assessment and self-reflection. So we're gonna talk about feedback today as part of this. To help support the adult learner self-concept, you have to motivate their autonomy and respect in a relationship of respect, rough respect, and seek their input. So that way they feel valued as an adult learner and can and feel like a valued member of the team. With regards to past learning experiences, you wanna adjust the teaching to different contexts, cultures, and levels of prior knowledge. And you can also establish rapport with learners and use examples that are familiar to them. I think about this a lot when you think about, you're a teacher as a physician and you teach your patient something. If the concept of health literacy, which we all learned in medical school, it's very different talking to someone about diabetes management when they've maybe had type one diabetes for a long, long time. And you're seeing them in clinic for a retina exam. And the amount of knowledge that they have on how to measure their blood sugars over time since they've done it for so long versus someone maybe who's a type two diabetic and has a lower health literacy level. How you tailor that information to them is really important. Evaluate evidence of learning to determine readiness for new roles. I think this is a classic thing that happens in residency. As you get better at surgery, you get more cases, right? And so you have to be ready for the next steps. Be a positive role model, provide supervision and advocacy appropriate to the learner level. And then last, recognize the practical reasons that the adult learner has to learn. So summarize teaching and to take home points, what's the most relevant information and capitalize on teachable moments, which is my favorite. So how do you do that in practice? You're like, oh, that's nice, Teresa. That's a lot of ideas. But how can I have a really busy clinic? We have like 50 patients today. I have a patient that comes back that needs, you know, 25 minutes of my time or an hour of my time. So has anyone heard of this, the concept of the one minute preceptor? It was actually something that was published at the, or it was not originally published, but they had a pulse article on it recently, which is where this came from. So a teaching method that was originally described in 1992 by a group of family physicians at the University of Washington. Their goal was to provide clinical preceptors the tools necessary to teach a general principle in five minutes or less, which is great. You have a busy clinic, you need to get a teachable concept and then you need to move on with seeing patients. So you're adult learners, so I have to tell you why. Why is this important? Learners rely on interactions with clinical preceptors to learn how to practice the art and science of medicine. That clinical experience reinforces that classroom learning and it gives trainees the opportunities to practice medical decision making in a safe and supportive environment. It's effective and a rapid teaching method that optimizes patient care. So you can teach and you can stay on time. So how do you do it? So here are your learning objectives. So after this lesson, I want you to be able to describe the five micro skills of the one minute preceptor and I want you to apply this approach, educating learners and busy clinical settings. So I'll give you kind of an example of this as we go through it. Here are the five micro skills. Get a commitment, probe for supporting evidence, teach a general principle, reinforce what was done well and correct mistakes. You're like, how does this all happen within five minutes? I can't believe it. So Dr. Kennedy comes to me, he has a patient in the ER and he is worried about, like we were consulted for an open globe. And so he's telling me about the story. He's like, oh yeah, he's a 35 year old Hispanic male. He works construction. He was roofing and the nail gun ricocheted and hit him in the eye. And so for example, they give you this story and you could say, okay, well, his vision is hand motion. I didn't check the pressure because I was worried about an open globe but I looked at his cornea and it looks weird. Say it's really early on in PGY one year. His cornea looks weird. And you say, oh, okay. And I think that he has an open globe injury. So then I would say, okay, Brandon, how did you arrive? So how did you arrive at conclusion and say, okay, Brandon, you said his cornea looks weird and you think that he has an open globe. So what makes you think that he has an open globe? And you'll say, well, I see this brown tissue that's coming out of the cornea. And it's like there and the cornea doesn't look normally shaped, right? And so this would give me a kind of a level to an ability to kind of assess the knowledge of that learner. So then you can teach a general principle. So for example, you could say, you go see the patient together and you say, Brandon, this patient actually has a positive Seidel sign, which is why you know that he has an open globe. So we can talk about the Seidel sign. Seidel sign is where we will test for an open globe. We use a fluorescein strip. We look for egress fluid from the inside of the eye. And so this brown tissue that you saw was UVA and there's actually a corneal laceration. So you can provide your clinical pearl and you can reinforce what was done well. So for example, you could say, really good. You identify that there was an open globe. We talked about the CT scan and you realize that he needed a CT scan because it was a male gun injury and CT scans are really important in evaluating patients for open globes, especially with high velocity metallic foreign body type injuries. And then you can correct mistakes. So then I would say, Brandon, I wanna work on your description of the patient's clinical exam findings. So here we identified a corneal laceration. Typically I want you to measure it and I want you to describe that you see prolapse UVL tissue plugging the wound. So that's just kind of a quick example of how you can do all of these things in less than five minutes. And by the way, Brandon definitely knew there was a corneal laceration and had a way better description. So I took it back to a PGY1, pre-PGY1 level because I've been working with our current PGY1s. Actually, you know, Brandon is a PGY2 with the VA and they are knocking my socks off. So how does it actually work? So here's a randomized controlled trial on teaching the one minute preceptor. So the one minute preceptor model is widely used to improve teaching but its effect on teaching behavior has not been assessed. So this is an inpatient teaching service at a tertiary care hospital and a VA medical center affiliated with the University Medical Center at the University of Michigan. They had 57 second and third year internal medicine residents randomized to the intervention or control. And the intervention was a one hour session incorporating lecture group discussion and role play on how to utilize the one minute preceptor. And turns out it works fairly well. So the residents self-reported and learn the outcomes where the resident self-report and learner ratings of resident performance of the one minute preceptor teaching behaviors. The residents assigned to the intervention group reported a statistically significant changes in all behaviors. And 87% of residents rated the intervention as useful or very useful. Let's see. So learners in the residents in the intervention group reported increased motivation to do outside reading when compared to learners and residents in the control group. Wouldn't you love it if all the residents all with the outside reading? So overall, it was brief and easy to administer that provides modest improvements in resident teaching skills. So switching gears to our last topic. So this is a common phrase, but Dr. Petty, I want more feedback. So I found this graph in an article somewhere and it talks about how there are generational differences between feedbacks and feedback preferences. And I thought this was really interesting. So if those of you who are listening are in the baby boomer generation, you would say feedback should be provided once a year with lots of documentation and that's it. And then transitioning to our gen X and gen Yers, a feedback whenever I want it at the push of a button, right? Which I think has become the trend in our residency and that's why we're hearing these things. So recognizing that your learner and whoever you're working with may have a different opinion of how often or how you should give feedback is really important. So feedback is a dynamic process and to confirm positive behaviors and correct performance. Why do we need to provide feedback to learners? It's a really interesting question. It's essential for personal and professional growth. It's required from all sources, our educators, our colleagues and yes, even our patients. When learners don't get feedback, they can mistakenly assume they're doing well when they aren't or they may learn about shortcomings too late to have the opportunity to form meaningful improvement. And unfortunately, feedback often breaks down under the rigor and the pressure of clinical activity. We are just too busy, right? We're just too busy. So in general, what not to do? Good job or work harder are really not specific. You wanna set up for feedback. You wanna find a private location. So you can let the learner know that you're providing feedback but one of my favorite things to do is say, hey, is now a good time where we can, I can give you some feedback. So a really great example of this is that Dr. Hu and I finished a glow very late in the evening or early in the morning. And usually I like to debrief about the case after we finished the surgery. And I said, hey, Catherine, I wanna talk about the case and debrief is now a good time for me to give you some feedback and for us to talk about the case. And she said, you know what? It's really late. I have a lot of notes to do. She's like, tomorrow would be better. And I was like, no problem. We'll give you, I'll give you a call tomorrow, right? So feedback should be timely, specific, relevant, objective and provides opportunity for improvement. If this is something that they can't really improve, should you be giving feedback on it? So here are my 10 pearls for learners. So residents, this is for you. The most important critical part is to complete a quality self-assessment. Reflection is essential. You have to think about realistically, what are you struggling with? What are you doing well? And then when you elicit that feedback, it's kind of like a test, right? Remember that we all have blind spots. No one is perfect. We, even I have blind spots. I realized this last night, Logan and I are trying to plan our wedding. And I said, Logan, we talked about suits two months ago and there still are no clothes for you to wear for the wedding. I don't wanna nag you. But then I realized, maybe I didn't communicate efficiently enough or effectively enough for him to realize that he's an architect, he needs a deadline or I needed to communicate that this was more of his responsibility than mine, right? So we all have blind spots. So in that space, my communication and my lack of communicating exactly what I wanted was an example of a blind spot. Develop a relationship with the person you are seeking feedback from. I think this is key. If that person knows you care about them, it's a lot easier to have hard conversations if you know they're invested. Okay, they asked for it. So this is part of our feedback Fridays. We have every month, there's a one cheater. It doesn't go in the residents files, but we are kind of doing this with our mall committee. So we're excited for all of our faculty. And just a pro tip, instead of asking for feedback, shift your vocabulary and say, I'm asking for advice. So Dr. Warner, I want your advice on what I should do with the situation and patient that I saw on call. Very different situation than saying, hey, I want some feedback on my performance in clinic. Be confident in positive feedback. You do things well. Imposter syndrome is very real. Think the person who's giving you feedback and be attentive to the details of the positive as well as the constructive. So sometimes people are like or say, oh, you did a really nice job with that patient. No, no, no, I was okay. I was just doing my job. You did a really nice job with that patient. Thank you, I appreciate that. Yes, control your feelings. I think the growth mindset is really big here. If you're having a moment where you're having feelings, put them away for a minute and reevaluate and have that conversation when it's a time when you can not have your feelings involved. Take an action plan. Acknowledge the generations. So you remember the table. And be specific about your questions. So remember that instructors don't get a lot of teaching on how to give good feedback, but for now. And last, be ready. It can be given at any time. Sometimes this is a hard thing. You're like, oh, you just gave me feedback on that. And I really wasn't in the headspace to hear that. But I'm gonna focus on the content and trust that you have a good heart. And this can be really hard, not the way that it was said, but the content. Okay, so our one minute preceptor. I want you to describe the five micro skills and apply this approach when educating learners in busy clinical settings. So we can kind of go back to review that. Maybe. So get a commitment. Probe for supporting evidence. Teach a general principle. Reinforce all of this unwell and correct mistakes. And with that, I'll take any questions. Thanks, Dr. Ramlis. I'm assuming the folks online wouldn't probably wouldn't be able to hear the wonderful comment that Dr. Ramlis just made, but he was reflecting on the generational differences first between how different generations view feedback and saying that that's a very real thing. And then he said that he was also reflecting on how it is really important that we hear from the residents on how the teachers are doing, and how the faculty are doing, and the residents provide feedback to the faculty as well. And then the second thing was kind of commenting on the stereotypes of the Gen Xers and the Gen Ys that were all snowflakes, and we melt with hard conversations. So which I think is interesting that comes from somewhere. And so maybe thinking about the way that the information was given or the context or what the content was, I think looking at all those things are really important. Any questions from online? Dr. Dardeen. Absolutely, so for those of you who are online, Dr. Dardeen was reflecting that sometimes teaching the thought process and teaching the application of clinical skills rather than just the knowledge can be really challenging in a busy clinical setting. And so I think that that's very true. I will say though, you have to have the foundational building blocks and kind of the book knowledge before you can start applying things and drawing conclusions and integrating things. But yes, that process of teaching critical thinking skills is really challenging. Dr. Warner. Yes, absolutely. Thank you. So for those of you online, Dr. Warner commented that she saw a play called Fireflies last night. And one of the characters in the play was a lifelong teacher and she made the distinction between pupils and students. So being that pupils are someone to just kind of fill the seat, be there, go through the process where students are more self-directed, self-motivated learners. And that as teachers, our job is really not to kind of point out, factoids and hope that someone observes it, but to really help develop and mentor those critical thinking skills. And she is hopeful that we have lifelong learners and students of ophthalmology here at the Moran. Absolutely, I think that's a great point, Austin. Thank you. That is something that actually hasn't come up. So I really appreciate that. So Dr. Nakasuka said that it's also important to take into account cultural differences when you are teaching or learning and that he's reflecting on kind of growing up with an Asian tiger mom. And so scoldings were like a normal part of his life and then even cultural differences between the East Coast and the West Coast and how sometimes it's related or so how it should be different from ethnicity because there's so many different things that make up a person and where they come from. Dr. Kennedy. Yeah, absolutely. So I actually haven't run into any literature. So the question was, have I come across any literature or information about how to develop coachability, I guess you would say, in the learner? He said that Dr. Kennedy was kind of reflecting on his experiences coaching. And he said, some kids or peers that you have or students are more coachable than others. And so what really makes that the case? I actually haven't, that's a really interesting area. And I think looking into the coaching literature would be really interesting. So Dr. Jardine said there's actually a great book that covers this, it's called Thank You for the Feedback and then he gave a little story about a married couple that are friends of theirs where the husband and wife were not communicating in a way where they really understood what the other one was saying. Oh wow, there are a lot of comments in the chat. Let me see if I can pull it up. So actually I have it on my computer so I can read it. Rob Treft, thank you for your comment. Knowledge is the awareness of things as they are and were. Technically the learning is the acquisition of knowledge. And Dr. Olson's comment with our field's knowledge base changing about 50% every five years. We have to be lifelong learners or we will be left behind. And then Dr. Petty, one comment of the preceptor model is that any systemic approach will be superior in a randomized trial than the fluid status quo. Was there something unique to this that would make it superior or other feedback models or anything systematic is better? So Dr. Petty with respect to your question, I think doing something and being intentional about it is better than nothing. And so really thinking about how we teach as educators, that's where we're in the business here in residency is really critical. But I appreciate your point about the randomized control trial scientifically. I think that's it. Let's end early and have a good morning.