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Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20

A Randomized Controlled Trial Assessing the Feasibility of Examination Room Versus Conference Room Teaching in a Psychiatric Setting a

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Linda Madson , Marcy Rosenbaum , Clarence Kreiter , Alison Lynch & Arianna Witt

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Department of Psychiatry, Carver College of Medicine , University of Iowa , Iowa City , Iowa , USA b

Department of Family Medicine, Office of Consultation and Research in Medical Education, Carver College of Medicine , University of Iowa , Iowa City , Iowa , USA Published online: 09 Jan 2014.

Click for updates To cite this article: Linda Madson , Marcy Rosenbaum , Clarence Kreiter , Alison Lynch & Arianna Witt (2014) A Randomized Controlled Trial Assessing the Feasibility of Examination Room Versus Conference Room Teaching in a Psychiatric Setting, Teaching and Learning in Medicine: An International Journal, 26:1, 40-48, DOI: 10.1080/10401334.2013.857336 To link to this article: http://dx.doi.org/10.1080/10401334.2013.857336

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Teaching and Learning in Medicine, 26(1), 40–48 C 2014, Taylor & Francis Group, LLC Copyright  ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2013.857336

A Randomized Controlled Trial Assessing the Feasibility of Examination Room Versus Conference Room Teaching in a Psychiatric Setting Linda Madson Department of Psychiatry, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA

Marcy Rosenbaum and Clarence Kreiter Department of Family Medicine, Office of Consultation and Research in Medical Education, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA

Alison Lynch and Arianna Witt Downloaded by [Heriot-Watt University] at 00:44 07 March 2015

Department of Psychiatry, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA

bedside teaching is declining.1 In a recent study, Gonzalo found that inpatient case presentations occurred at the bedside 25% of the time.2 However, other experts have pointed out that frequency of trips to the bedside during inpatient teaching rounds (about 61%) and the percentage of time on teaching rounds spent at the bedside (between 16% and 19%) has stayed remarkably stable over the last 45 years.3 Regardless of the directional trend, teaching in the patient’s presence remains important for the skill development of medical learners and is worthy of study. Many studies have addressed teaching at the bedside in inpatient settings. Almost uniformly, patients prefer bedside rounds.4–8 Student and resident reactions are more diverse, however, with some studies finding that residents and students preferred conference room teaching6,8 and other studies finding that residents and students preferred bedside rounds, especially more experienced learners.2,7,9 Learners of both preferences admitted that bedside rounds were an effective way to teach clinical skills and were better for patient care.2,4,5,7,8 Faculty perceptions are less well studied but preliminarily indicate that faculty are divided in their preferences, with younger faculty favoring conference room teaching.6 Issues raised about bedside teaching include concerns about educational value,4 patient comfort,10 ability to speak freely in the presence of the patient,7 and potential learner embarrassment in the presence of the patient.7 There are far fewer studies examining teaching in the patient’s presence, heretofore referred to as exam room teaching, in ambulatory settings. Studies have been done in a variety of clinic settings including internal medicine, neurology, pulmonology, and rheumatology.11–14 Results of these studies reveal high patient satisfaction and comfort with exam room teaching and a tendency for patients to prefer exam room teaching in the future.12–14 Learner perception data have been more mixed. Some studies find learners prefer exam room teaching12,14 whereas at least one study found residents are concerned about their

Background: Teaching in the presence of the patient is an acceptable model in medical settings. Questions have been raised about the appropriateness of this type of teaching (exam room teaching) with patients with mental health issues. Purposes: This prospective randomized controlled study examined outpatient exam room teaching in a psychiatric setting. Methods: In 2011–2012, patients in the adult outpatient psychiatry clinic at the University of Iowa were randomized to have faculty-learner presentations either in the presence of the patient or in the conference room. Teaching encounters were timed and faculty, learners, and patients completed post encounter surveys. Results: Participation included 126 patients, nine faculty, and 16 residents. Comparison of patient encounters randomized to exam room (n = 58) or conference room (n = 64) demonstrated that exam room teaching was roughly twice as time efficient as conference room teaching (p ≤ .0001). Patients expressed a preference for exam room teaching during future visits (p ≤ .003) for those patients who experienced exam room teaching during the study. Faculty were generally comfortable with exam room teaching and felt it had some advantages for patient decision making. Learners felt they had to choose their words more carefully in exam room teaching and expressed some concerns about depth of teaching. Conclusions: Once exposed to exam room teaching, this model is acceptable and feasible to faculty, learners, and patients in a psychiatry clinic setting. Keywords

resident education, exam room teaching, psychiatry clinic

BACKGROUND Teaching in the presence of the patient is a time-honored tradition in medicine dating back centuries. According to a commentary by LaCombe, which is widely cited in the literature,

Correspondence may be sent to Linda Madson, Iowa City VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246, USA. E-mail: [email protected]

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EXAM VERSUS CONFERENCE ROOM TEACHING

autonomy in exam room teaching.13 Only two studies addressed faculty perceptions of the exam room teaching model. In the first study, faculty agreed that exam room presentation was particularly beneficial.13 In the other study, faculty preferred exam room presentations as well12 citing it as having educational benefits for both learners and patients as well as benefits of time efficiency. One common concern about exam room teaching is time. Only one previous study has addressed the issue and found there were no significant differences in mean total teaching.12 Although these studies in ambulatory medicine settings suggest that exam room teaching is acceptable to patients, learners, and faculty, there have been questions about whether exam room teaching can be applied to patients with psychiatric issues. Concerns have been expressed about discussion of sensitive issues such as substance abuse, mental health, and sexuality related topics in the presence of the patient.15,16,18 This could lead to patient embarrassment and solicitation of inaccurate information.15 To date, only one study has addressed exam room teaching in a psychiatric setting.16 This study involved preselected patients interviewed by medical students who then presented the case in front of the patient. Comments made by students expressed concern that presentation in the presence of psychiatric patients could be harmful, confusing, or embarrassing for the patient. Patient comments were mixed. Some patients found the experience embarrassing, whereas others did not find it stressful or upsetting. PURPOSES This prospective randomized controlled study was undertaken to broadly clarify the feasibility and desirability of exam room teaching as perceived by patients, learners, and faculty. Our objectives were to compare satisfaction, comfort, and perceived barriers in a psychiatric setting among the three groups. We also wanted to assess the time efficiency of conference room versus exam room presentations. Based on the previous experience of the primary investigators in an outpatient setting with psychiatric patients, we hypothesized that exam room teaching would be well accepted by most psychiatric patients once they had experienced the model, but that learners may need to choose their words more carefully. We also postulated that exam room teaching would be more time efficient than conference room teaching. This study is the only study reported to date that assesses perceptions of patients, learners, and faculty in an outpatient psychiatric clinic in which staffing locations were randomized and encounters objectively timed. METHODS Procedures This study was approved by the Institutional Review Board (IRB) at the University of Iowa Hospitals and Clinics and was conducted in the adult psychiatry outpatient clinic between September 2011 and March 2012. The clinic sees adult pa-

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tients with a variety of psychiatric diagnoses (mood disorders, psychotic disorders, anxiety disorders, eating disorders, developmental disabilities, etc.) for both evaluation and long-term psychiatric management. Nine Department of Psychiatry faculty members assigned to staff the outpatient clinic were contacted in person, and all agreed to participate in the study. A voluntary 90minute teaching workshop was offered to all faculty members prior to the study’s initiation to introduce exam room teaching. The workshop conducted by the authors (LM, MR) consisted of a series of video clips demonstrating the steps of exam room teaching (orient the learner, orient the patient, focused teaching, and follow up as needed). Two of the faculty attended this workshop and two additional faculty who were unable to attend the workshop due to scheduling conflicts were oriented by the principal investigator (LM). Two of the faculty already had extensive experience with the exam room teaching and did not feel the need for further orientation. Three of the faculty were unable to orient to the model due to time and scheduling constraints, but cue cards outlining the principles of exam room teaching were placed in the conference room for reference. All learners (medical students and residents) who rotated through the clinic during the study were asked to participate and all agreed. Residents were either 3rd- or 4th-year psychiatry residents completing their rotation in outpatient psychiatry. Medical students were rotating through the clinic on their 4-week required psychiatry clerkship. Patients in the waiting room of the psychiatry clinic were approached by the research assistant (RA) and asked if they were scheduled to see a resident physician. The RA sought out available subjects who were English speaking, older than 18, without cognitive impairment, and without obvious agitation or psychotic symptoms. Patients were asked about their willingness to help with a study on resident education and their willingness to be randomized to either exam room or conference room teaching. Written and verbal information about the purpose and procedures of the study were outlined. The RA obtained consent from study patients prior to being seen by the learner or faculty physician. Randomization was performed using a random numbers table. Learners performed history and mental status examinations independently and were randomized by the RA to present the history, mental status data, and plan either in the exam room (patient’s presence) or in the conference room. Learners or faculty physicians could choose to break randomization if they felt this was clinically appropriate. This happened on four occasions during the study. Outcome Measures The RA timed the visit to record the total time of faculty involvement in the clinical encounter. In the case of exam room teaching, time was marked from when the learner and attending entered the exam room until the attending left the exam room. In the case of conference room teaching, time was marked from the beginning of the learner’s presentation in the conference

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L. MADSON ET AL.

TABLE 1 Patient responses to survey questions immediately after a clinical encounter on a Likert scale of 1 (strongly disagree) to 5 (strongly agree)

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Statement Rated by Patient I was confused by the complex medical terms used in my presence Time spent with my physician was adequate I am satisfied with the medical care I received from my doctor(s) today Listening to my doctor discuss my health concerns with another physician made (or would have made) me feel embarrassed or uncomfortable I feel my visit allowed me to participate in the medical education of the resident doctor I would prefer to listen to my doctor discuss my concerns with another physician during future visits Estimate the amount of time spent with your physician(s) today

Exam Rooma M (SD)

Conference Roomb M (SD)

1.4 (0.98)

1.7 (1.2)

0.24 (.3)

4.6 (0.9) 4.6 (0.7)

4.1 (1.1) 4.3 (1.0)

0.02 (.5) 0.05 (.35)

1.5 (0.96)

1.7 (1.1)

0.28 (.2)

4.3 (0.9)

4.2 (0.9)

0.67 (.1)

3.8 (1.1)

3.2 (1.3)

0.0033 (.5)

30.4 minutes (17.2)

35.4 minutes (18.0)

p (ES)

0.12(.29)

Note. Perceived time spent with doctor expressed in minutes. a N = 58. bN = 60.

room until the attending exited the exam room. The RA also distributed and collected surveys from the patient, learner, and faculty after each patient encounter. Surveys were similar to those used in previous studies.12 All respondents answered questions by circling single word or short-phrase responses and by rating statements on a 5-point Likert scale, 1 (strongly disagree) and 5 (strongly agree). In addition to demographic information, the patient questionnaire asked patients their primary reason for the visit or diagnosis, an estimation of the amount of time they spent with their physician, and responses to survey statements about the visit as listed in Table 1. Space for additional comments was also provided. The faculty questionnaire asked for presentation location, type of

visit (new vs. established patient), estimation of total time spent with the learner in teaching, and patient’s primary diagnosis. Faculty were also asked to rate four statements as listed in Table 2. The learner questionnaire asked for location of teaching, level of training, and response to statements as listed in Table 3. There was also extra space for additional learner comments. At study completion, faculty received a global survey documenting age, gender, academic rank, and estimation of previous experience with exam room presentations. They rated several statements regarding exam room teaching (Table 4) and reported whether they felt teaching in the exam room was more efficient, less efficient, or indeterminate than conference room teaching.

TABLE 2 Faculty responses to survey questions immediately after a clinical encounter on a Likert scale of 1 (strongly disagree) to 5 (strongly agree) Question To what degree do you feel the learner’s understanding of the patient’s condition or its management was enhanced by the style of today’s visit? Did the location of the staffing allow you to teach what you wanted to teach? If this visit was staffed in the patient’s presence, please rate your comfort level with staffing in patients presence? I was embarrassed by my lack of knowledge in front of the patient N = 58. bN = 60.

a

Exam Rooma M (SD)

Conference Roomb M (SD)

p (ES)

3.2 (1.2)

3.5 (0.9)

0.11 (.28)

3.8 (1.0)

4.1 (0.7)

0.07 (.35)

1.1 (0.2)

0.3 (.33)

4.2 (0.8) 1.2 (0.4)

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EXAM VERSUS CONFERENCE ROOM TEACHING

TABLE 3 Learner responses to survey questions immediately after a clinical encounter on a Likert scale of 1 (strongly disagree) to 5 (strongly agree)

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Statement Rated by Learner I had adequate autonomy regarding care of the patient during this visit I feel that I had adequate supervision by my intending physician I was able to ask questions or clarify any uncertainties with my attending There was adequate time for teaching and instruction for my learning benefit I was afraid of performing poorly or showing lack of knowledge in front of the patient I had to edit or choose my words carefully If staff in room: due to the patient’s diagnosis, I find it uncomfortable to staff in his/her presence If staff in room: I would have preferred to staff in the conference room Total time of faculty physician involvement in clinical encounter

Exam Rooma M (SD)

Conference Roomb M (SD)

4.9 (0.4)

4.9 (0.5)

0.44 (.00)

4.9 (0.3)

4.8 (0.4)

0.43 (.28)

4.8 (0.5)

4.8 (0.4)

0.40 (.00)

4.4 (0.9)

4.5 (0.7)

0.35 (.13)

1.8 (1.1)

1.6 (1.1)

0.41 (.18)

2.9 (1.4) 2.0 (1.3)

1.7 (1.2)

A randomized controlled trial assessing the feasibility of examination room versus conference room teaching in a psychiatric setting.

Teaching in the presence of the patient is an acceptable model in medical settings. Questions have been raised about the appropriateness of this type ...
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