Blog | Monday, November 27, 2017

Tips for internal medicine ward attendings, the attending as coach


Today I have been listening to a podcast featuring a boxer. This boxer discusses coaching and its importance. Anyone who has competed in a sport can relate to the importance of accurate coaching. Coaching requires immediate feedback, both positive and negative. The feedback works best when you receive it immediately after you perform.

What do learners tell us? They want feedback, specifically feedback on how to improve. Therefore, during clinical teaching we owe our learners clear actionable feedback.

The first thing we should do is explain that we are giving feedback. Many years ago, I thought I was giving feedback, but the learners did not interpret my critiques as feedback, rather as a critique. Now this difference seems semantic, but semantics matter.

You have a new medical student who is getting ready to present to you for the first time. First, I explain how I want the history or present illness (HPI) presented. Then I tell them that I have low expectations of their first presentation, and our goal is to make the second presentation very good and the third presentation excellent. I tell them that we will stop after the HPI for feedback and questions.

Sometimes I restate the HPI, sometimes I ask the team what information was not said out loud. We discuss the philosophy of a good HPI presentation.

I make clear that there is a difference between collecting the history and relevant data and presenting that same information. So the feedback does not relate to their data collection, but rather their storytelling.

We do the same thing with the physical exam (although we wait until we go to the bedside to confirm their findings). We do the same thing with laboratory test interpretation and understanding.

Almost all learners improve after specific time appropriate feedback. When they improve we can praise their improvement. And that is positive feedback.

Coaches work hard to get their “players” to advance. When I am working out, I appreciate the coach suggesting that I can improve my form, and thus my results. I want them to push me to excel.

We have a responsibility to gently push our learners to improve each day. In my experience, today's learners want to become great physicians. They always thank me for making explicit my expectations and coaching them to improve. Fortunately, we are working with high achievers who almost always improve dramatically. That represents good coaching and thus good ward attending.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.