Published in the August 2018 issue of Today’s Hospitalist
IN A 2011 New Yorker piece titled “The Coach in the Operating Room,” surgeon and noted author Atul Gawande, MD, pointed out that if tennis star Rafael Nadal can benefit from having a coach, perhaps the same is true for surgeons. Dr. Gawande then describes how he invited a retired surgeon and former mentor to observe him in the operating room and give him detailed feedback on what he could do better.
Faculty members with New York’s NYU Langone Health have taken that coaching concept to heart, but with a twist. While they pair up with colleagues to observe each other holding teaching rounds, the project—part of a program called Education for Educators (E4E)—aims to help both the observed and observees alike hone their teaching skills.
“The peer-to-peer program is designed to be bidirectional,” says Neil Shapiro, MD, a senior faculty member with VA NY Harbor Health Care who helped create the program, which is under the direction of his colleague Anne Dembitzer, MD. “It’s not just about one person watching another and giving feedback.”
“It’s been remarkable to actually spend time listening to people talk about the challenges they face with their learners.”
~ Neil Shapiro, MD
VA NY Harbor Health Care System
Now in its third year, the initiative fills a major gap in faculty development. “Many of us have never been observed teaching other than by our students,” says Dr. Shapiro, the associate chief of medicine at VA NY Harbor Health Care and associate program director of the NYU internal medicine residency program. He divides his clinical time between hospital medicine and a primary care clinic. “And student feedback, given the power differential, isn’t as good or as informative as it could be.”
Focusing on teaching is important, he adds, because teaching—how to get better at it, how much of a priority it needs to be—often gets lost in the shuffle at teaching centers. That’s ironic, given that teaching is what academic physicians consistently say they like most about their jobs.
“A lot of our teaching is done unconsciously: We don’t prepare for it, we just walk in and do it,” Dr. Shapiro explains. “It’s been remarkable to actually spend time listening to people talk about the challenges they face with their learners.”
How it works
Launched in 2016, E4E encompasses both a series of faculty workshops—which are held three times a year and cover topics like clinical reasoning, feedback and giving bad news to patients—and the peer-to-peer component.
“With peer-to-peer, we initially wanted to reinforce what we were learning in the workshops,” Dr. Shapiro says. “E4E is the first truly comprehensive faculty development program we’ve had here at NYU.”
Over the course of the academic year, program participants pair themselves with three other individual faculty members.
“The first round is with an actual peer participating in the program,” says Dr. Shapiro. The next pairing is with a faculty mentor who is leading the program, such as himself. For the third, “you pick someone outside the program. We’re trying to disseminate the program throughout the medical center and reach faculty who are not yet participating.”
Each pair huddles before rounds to talk about aspects of teaching that they both find challenging and are working to improve. One physician then holds teaching rounds that the other observes. “Then you do another huddle to talk about what went well and what didn’t,” Dr. Shapiro says. “I’m not just critiquing the other person. I’m observing to learn myself.”
What he’s learned
As senior faculty with the program, Dr. Shapiro has learned many good tricks by observing junior members. “I’ve learned methods to improve my time management, which I consistently struggle with. It’s helped to watch someone be very regimented and cut cases off to get to the next one, and that is something I now do.”
He’s also picked up involving all the different learners during rounds. “You need to address the medical and pharmacy students, not just the residents and interns,” Dr. Shapiro notes. “I’ve learned to utilize everybody by asking targeted questions and going around the room.”
In addition, the program deliberately pairs hospitalists with specialists to develop an educator community and break down barriers between specialties, he explains. “It’s great to have two different specialists understand what the other does on teaching rounds.”
He recalls rounding with one of the participating nephrologists. “Nephrology rounds were really eye-opening,” he says, “because they approach cases from a different vantage point.”
Another cross-pollinating factor is that participants come from—and travel to—several NYU Langone-affiliated hospitals, including the VA’s Manhattan and Brooklyn campuses, Bellevue Hospital, Tisch Hospital and NYU Langone Hospital-Brooklyn.
That makes the peer-to-peer program “tough to schedule and to get people to commit,” says Dr. Shapiro. “The biggest barrier is finding the time to go to another campus when the other person is on service.”
Beyond developing teaching skills, he believes the program helps prevent burnout, in part because it gives people time to get better at what they enjoy.
“Working one on one, you bond with people, and that increases your sense of community and of purpose within that community,” Dr. Shapiro says. “It definitely energizes people.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
reserving specialists online
TO PROMOTE learning across specialties, Neil Shapiro, MD, and his colleague Seagram Villagomez, MD, decided several years ago to launch Open Consult, a riff on Open Table. Instead of making online restaurant reservations, housestaff teams book online reservations for teaching sessions with specialists.
“Say I have a patient with small cell lung cancer and I want my team to talk to the oncologist about that cancer,” says Dr. Shapiro, who practices with the VA NY Harbor Health Care System. “We reserve a 30or 45-minute session, depending on availability, with the specialty consult attending who is on service and treating that patient.” The specialist then comes, usually with his or her fellow, to discuss the case.
The sessions are much more educational than what he calls “drive-by teaching by someone not involved in a case or a noon conference on small cell lung cancer. You can ask all the questions you have and hear the clinical reasoning behind their decisions.”
All medical subspecialties at the VA are engaged in Open Consult. “An administrator reaches out to the specialists and they put their time availability into a shared calendar,” he explains. It’s a big improvement over past iterations of “office hours,” where specialists post times when hospitalists and residents can drop by, “and nobody goes.”
The goal is for each of three internal medicine teaching teams at the VA to use the service twice a week. While that can be a challenge, Dr. Shapiro notes that it’s been a big success. “The residents are more engaged in these sessions because they are hearing about their own cases with the specialists involved. This has had a far greater impact than any other teaching endeavor we’ve tried.”