10/24/2019 Indiana State University Bay Path University A - PDF document

10/24/2019 Indiana State University Bay Path University A collaborative Columbia University Icahn School of Medicine at Mount Sinai effort THANK Invitae between 18 Long Island University Post Genetic Counseling YOU Sarah Lawrence organizations TO Stanford Health Care Clinical Supervisor University of Alabama at Birmingham across the US ALL University of Arkansas Medical Sciences Training and Canada University of British Columbia THOSE University of Colorado Anschutz Medical Campus THAT University of Manitoba 2019 University of Nebraska medical Center CONTRIBUTED University of Utah Vanderbilt University Virginia Commonwealth University Wayne State University Education SIG Conflict of Interest/Disclosure Statement • Assistant Professor at the U of Manitoba • Co ‐ author of the Fundamental Teaching Activities Supervision & for the College of Family Physicians of Canada Entrustment Decisions • Paid consultant for the Medical Council of Canada Teresa Cavett BSc MD CCFP FCFP MEd • Honorarium for today’s presentation Learning Objectives Outline • Student Entrustment: • Review entrustment • Define direct, indirect and entrusted supervision. • Discuss levels of supervision • Discuss how to apply each model to provide • Integrate entrustment & supervision in Clinical mutual benefit to the experience of supervisor and student. Genetics teaching contexts • Describe strategies to determine how to guide students through the spectrum of direct, indirect and entrusted supervision. 1

10/24/2019 Why? Goal: independent practitioner… • “The object of training is to provide the patients of 1. Has knowledge but not allowed to perform the the future with high ‐ quality specialists who have had EPA ( task ) independently a wide range of useful and informative experience 2. May act under full supervision during their training years. Both the interests of the 3. May act under moderate supervision patients of today and the quality of the training experience depend on good clinical and educational 4. May act independently supervision of trainees during their training years.” 5. May act as a supervisor and instructor (p.19) ten Cate, O.; Snell, L.; Carraccio, C. (2010) • Kilminster, S.; Cottrell, D.; Grant, J.; Jolly, B. (2007) Development of Expertise Cognitive Apprenticeship • Teachers modeling their skills in real ‐ world situations Expert • Modeling • Coaching Proficient • Scaffolding • Articulation Competent • Reflection • Exploration Advanced Beginner • Collins, Brown, Newman 1987 Novice Entrustment Vygotsky’s Zone of Proximal Development • Trust: the willingness of the trustor to take a risk • All aspects of health care carry inherent risks & benefits • Challenge is identifying, measuring and mitigating risk while enhancing benefits 2

10/24/2019 Four elements to Entrustment Trustworthiness of learner • Perceived trustworthiness of the learner • Ability • Perceived risks • Integrity • Perceived benefits • Reliability • Propensity to trust by supervisor • Humility • • ten Cate, O. (2016) ten Cate, O. (2016) Perceived risks & benefits Supervisors’ propensity to trust • Risks vary with complexity of task, context of • Depends upon one’s perception & tolerance of setting, impact of negative outcome to risk • Stable personality characteristic patient/learner/supervisor/system • Benefits: learners need authentic clinical – Hawks vs. Doves • Influenced by prior experiences experiences to develop competency; patients perceive benefits from interacting with • Influences the way supervisors assess risks & learners; system benefits benefits Timeline to Entrustment 1. The task (complexity; steep vs. slow learning • Entrustment is not one final step in learners’ curves) progress 2. The context (frequency of exposure, safety • Happens continuously through training, net) throughout rotations, throughout the day 3. The student (competence & confidence) [self ‐ awareness] • Based on multiple observations 4. The supervisor (comfort & confidence) ten Cate. O & Scheele, F. (2007) 3

10/24/2019 Supervision Goldilocks Principle • “The provision of guidance and feedback on • Destructive supervision: matters of personal, professional and – Too little educational development in the context of a – Too much trainee’s experience of providing safe and • Constructive supervision: just right appropriate patient care.” • Challenge: just right changes with learner, clinical scenario & the learning environment • Kilminster, S.; Jolly, B. (2000). Levels of Supervision Direct supervision • Direct ‐ supervisor physically present* • Physically present in room or at bedside • Indirect with immediate direct supervision • Use of mirrored rooms • Indirect with available direct supervision (local • Via camera + audio or distant) • Audio alone • Oversight • Farnan et al. (2012); Kilminster (2007) Indirect with immediately available Direct supervision, con’t supervision • Supports modeling & coaching • Supervisor in office, at central station • Starting point for novice learners • Supports coaching and scaffolding learning • Supports patient safety • Consider for more advanced beginners • May be incorporated for more advanced • After gaining some experience with tasks learners with complex patient scenarios, procedures, sharing difficult news; 4

10/24/2019 Blended model (direct & indirect) Indirect with local or distant supervision • Case presentation at end of visit; learner wraps • Discussion prior to visit up visit independently • Case presentation (mid ‐ point/end of visit) • Video recording review & discussion • Return to room with learner for closure • Chart/clinical note review & discussion • Supports scaffolding, articulation and • Lab results review & discussion reflection • Supports articulation, reflection & early exploration Entrusted supervision (oversight) What is good supervision? • Giving direct guidance on clinical work; • End ‐ of ‐ day review • Linking theory and practice; • Chart/note/consult letters review • Engaging in joint problem ‐ solving • Lab results review • Offering feedback, reassurance • Video recording & review • Providing role models. • Completely independent* • Kilminster, S.; Cottrell, D.; Grant, J.; Jolly, B. (2007) What is ineffective supervision? • Best predictor: organises time to allow for both • Rigidity; teaching and care giving • Low empathy; • Establishes a good learning environment • Failure to offer support; (approachable, non ‐ threatening, enthusiastic) • Failure to address supervisees’ concerns; • Provides autonomy appropriate to learners’ level ⁄ • Not teaching; experience ⁄ competence • Being indirect, intolerant, emphasizing evaluation • Gives clear explana � ons ⁄ reasons for opinions, advice and negative aspects. actions • Stimulates independent learning • Kilminster, S.; Cottrell, D.; Grant, J.; Jolly, B. (2007) • Bruijn, M.; Busari, O.; Wolf, B.; (2006) 5

10/24/2019 How could these models work in Genetics Workflow in Genetic Counseling cases Counseling programs? 1. (Reviewing consult/referral letter) • Prenatal: positive maternal serum screen or 2. Setting a mutual agenda for the session fetal anomalies on ultrasound? (contracting) • Cancer: personal or family hx of cancer (e.g. 3. Addressing psychosocial issues and emotional hereditary breast/ovarian cancer)? concerns (ongoing) • Paediatrics: child presenting with 4. Obtain a detailed medical and family history developmental delay? 5. Providing risk assessment and risk counseling ACGC Practice ‐ based Competencies for Genetic Counselors (2015) Phases Novice Advanced beginner Competent Reviewing consult Setting a mutual agenda 6. Directing an in ‐ depth consent process for Addressing psychosocial issues genetic testing, where applicable and emotional concerns Obtain a detailed medical and 7. (Reviews findings & results) family history Providing risk assessment and 8. Disclosing results of genetic testing risk counseling Directing an in-depth consent 9. Setting and communicating screening & process for genetic testing, where applicable management plans Reviews findings & results 10. Summarizing and arranging follow ‐ up Disclosing results of genetic testing Setting and communicating screening & management plans ACGC Practice ‐ based Competencies for Genetic Counselors (2015) Summarizing and arranging follow-up Cavett, T. 2019 Supervisors’ challenges Challenges con’t. 4. I want to ensure the student does everything 1. As the responsible person, I should be the way I do… watching what the learner is doing. 5. I want to spend time with the patient as it is 2. After the learner finishes the rotation, I have personally rewarding. to follow up & fix things… 6. The patient didn’t have any idea about their 3. How do I provide feedback if I don’t observe risks so the student mustn’t have counselled the student providing counselling? well… 6