BEST Module 5: Work Rounds/Group Teaching

Bringing Education & Service Together (BEST) is an interdisciplinary service learning project for resident physicians

By the end of the module, residents will be able to:

Define the elements of the “LMNOPQRST” approach to small-group teaching.
Practice work rounds and personalize the “LMNOPQRST” approach by participating in a simulation exercise.
Employ effective small-group teaching techniques.

Small-group teaching may include inpatient rounds (work rounds, morning report) or other small-group settings (problem-based learning sessions, ambulatory rounds, multidisciplinary rounds and other groups).
A distinguishing challenge of small-group teaching is that the teacher must facilitate learning for multiple learners at once. These learners may be from different training levels or from different disciplines.
Even when an attending physician is present, the senior resident can still take a leadership role during rounds.

Who are all your learners for this small- group discussion?
Why are the learners here?
All team members (teacher and learners) should meet to:
1. Get to know each other.
2. Discuss mutual expectations for time together (how patient care, teaching and learning will occur).
3. Set an agenda for rounds.
4. Emphasize team cooperation and creating a safe educational environment.
Inform learner that they will be asked questions during rounds to identify areas of high-yield learning.
Help create a positive learning climate by ensuring that everyone in the group knows each member’s name, discipline and training level.

As always, teach through questioning. The "five microskills" model by Neher et al. works well. (See "Questions" below.)

How can you best organize rounds?
During the time you have?
Take into account the number of patients to discuss and any other scheduling factors (clinics, other time constraints) as well as your learning goals for the team.

When learners present their patients, have team listen without interruption.
Be a focused listener.
You can set guidelines for the length and format of case presentations and conditions that might prompt the teacher to step in.
Encourage independent thought to teach and asses clinical reasoning.
Tell learners what you expect to hear when they present new patients.
For ongoing patients, presenters can give a one-sentence case summary, followed by a summary of overnight progress and a review of the problem list with updates on management and disposition, including plans for the day.

Use the five "microskills" to maximize "teachable moments" for each case:

Make sure each team member participates in the discussion, gently prompting nonparticipants as needed.

Lower-order questions test learners' recall of factual information (e.g., "What is Murphy’s sign?").

Higher-order questions go a step further and test learners' ability to synthesize and analyze information (e.g., "Given these physical findings, how would we now alter our differential diagnosis?").
Try to incorporate some of these “thinking questions” into rounds too.

Teaching opportunities can focus on one or more of the following:

Patient care: Role-modeling, clarification of the history, PE findings, correction of clinical reasoning, communication.
Learners' questions: Questions asked explicitly by learners or implied by other comments.
Attending's agenda: Medical topic teaching, relevant medical literature, other areas of learning.
Next steps: feedback, debrief, identify areas for deliberate practice, identify learning points to revisit as a team.

Discuss resources for the team's further learning (texts, online resources, other teachers).

Bringing in resources (e.g., articles) can be very helpful in encouraging ongoing learning.

School of Medicine Resident Teaching Skills