A New Lens.

Mariam Fofana, M.D. 

Resident in Emergency Medicine

Brigham and Women's Hospital/Massachusetts General Hospital 

PGY 4

06/08/2021

I came to the VBHD course as a skeptic. I consider health to be a public good and was wary of treating it as a business/industry like any other. Although the course takes a business school approach to examining specific healthcare delivery models, I very much appreciated the focus on value for patients. The concept of value as articulated in the course was new to me and I found it very helpful in framing the challenges encountered by healthcare systems and developing solutions. 

It is also very helpful to understand how to speak the language of business to convey ideas to certain stakeholders such as executives and funders. My primary career interest is in research and I don’t necessarily anticipate being involved in major healthcare transformation efforts, but I also have a significant interest in global health, and thinking about value as part of outcome assessment of interventions could help make healthcare more accessible and more equitable. The course has given me a new lens through which to consider how we deliver care and will likely prompt me to be more critical of some of the practices that we take for granted, or the systems that we think immutable.

Improving Quality and Value in Healthcare Delivery.

Matthew Joseph Best, M.D. 

Fellow in Orthopaedic Sports Medicine

Massachusetts General Hospital 

PGY 6

06/09/2021

Matthew Joseph Best, M.D. 

The value based healthcare delivery course allowed me to understand important concepts of the providing high quality medical care by improving outcomes and decreasing costs. The principles emphasized in this course will be important in various areas of my future career including my clinical practice, research groups, and in leadership positions. 

An understanding of how to improve value, accurately track outcomes, reduce costs, and provide high quality medical care are vital aspects of physician education and can benefit trainees from all medical disciplines.

Currently, I am utilizing some of the skills learned from this course in multiple research projects to accurately assess and measure costs and reduce cost variability in different domains of orthopedics. These themes can help to ultimately reduce healthcare costs and improve overall value. Additionally, I plan to use these skills in future clinical and research based leadership roles.

COE Healthcare Policy Course Through HBS

Martina Mustroph, M.D., Ph.D. 

Resident in Neurosurgery 

Brigham and Women's Hospital 

PGY 4

06/08/2021

I enrolled in this course at the recommendation of my coresidents who had taken it last year. In particular, they had stressed that for trainees to have access to some of this country’s experts in healthcare policy is one of the many benefits of training at an academic medical center with affiliated professional schools.

The course was held over zoom, and in my opinion successfully so. I particularly got a lot out of the daily evening hour-long small group discussions, in which 4 of my peers and I would be in an individual zoom room. We would complete the guiding questions pertaining to the day’s reading, but we also informally exchanged our experiences of training in different departments currently or (for fellows) in the past for residency. For instance, a fellow in a related specialty I have worked with closely for the past year spoke candidly about his residency experience as it compares to his current institution.

For me, the course was an excellent way to take a step back and look at the broader healthcare system in the U.S. and abroad. I think this is sometimes hard to remember to do while immersed in training. The course has given me a conceptual framework and vocabulary for assessing healthcare delivery. I am looking forward to my thinking about healthcare being less myopic.

A Valuable Perspective.

Laura Nicholson, M.D. 

Resident in Internal Medicine/Primary Care

Brigham and Women's Hospital 

PGY 3

06/09/2021

The Value-Based Healthcare Delivery course was a valuable educational experience and provided a unique opportunity to engage in discussions of healthcare payment and policy during residency. After three years of residency focused on learning clinical skills, this course offered an important systems-perspective that will inform how I think about the systems I deliver clinical care in the future. One of the most unique aspects of the course was the chance to engage with residents from different programs and levels of training. 

As an internal medicine resident, I do not often enter discussions with surgeons, emergency medicine, or radiology residents around these type of topics, and I found this to be a great learning opportunity. The case-based discussions allowed for a deep engagement with the various principles we discussed; they offered insights into payment systems and hospital programs that are different from those I have encountered as a trainee. The case discussion related to strategies hospitals have taken to address social determinants of health at both the individual and population level were especially informative. As an internal medicine resident going into primary care and hospitalist medicine, I am eager to apply these principles and ideas from this course to my future career as a generalist.

A Valuable Foundation.

Kelly Marie Scheuring, M.D. 

Resident in Internal Medicine and Primary Care

Brigham and Women's Hospital/Atrius Health 

PGY 2

05/26/2021

Kelly M. Schuering, MD

Participating in the Value-Based Health Care Delivery Course helped me to further develop the skillset I will continue using to advocate for higher value care for the medically complex and socially vulnerable in society. Despite trials of many unique approaches within complex care over the past decade, providing consistent value remains a major challenge. Through case studies of successful health care institutions, the course expanded my understanding of integrated practice units, outcomes measurement, time-driven activity-based costing, culture change, and expanding a care network, all of which are critical tools to increase value. The course also introduced me to like-minded trainees across MGB that I hope to continue to work with in the future, not to mention exposure to world-class leaders in business!

Though my focus has been primarily clinical to date, I know my desire to improve the flawed systems that I see failing patients will inevitably lead to administrative roles in the future. This course has helped prepare me to be a more effective agent in change in building a more efficient, but equitable health care system throughout my medical career as a primary care provider.  Though it is just the beginning, this course laid a strong foundation upon which I can hope to build a career and a system that warrants it’s own case in the future! Thanks so much for such a transformative experience!

The Value Proposition of Standardized Care Processes

James C. Etheridge, M.D. 

Resident in General Surgery 

Brigham and Women's Hospital 

PGY 3

06/02/2021

James C. Etheridge, M.D. 

The benefits of standardized care processes are well-established.  Clinical pathways and protocols, when properly implemented, have been shown to improve adherence to evidence-based practices, efficiency of healthcare, and patient outcomes.  Enhanced recovery pathways, for example, have been enormously successful in surgery.  However, the benefits of these approaches are seldom explored from a value perspective.  As such, the Value Based Healthcare Delivery Course helped me to see these approaches in a new light.

Standardized care processes tend to be discussed from a “high-reliability” perspective.  The argument is logical and reasonable: if we can ensure timely adherence to evidence-based practices, patients will do better and leave the hospital sooner.  There is a tacit emphasis on process measures from this perspective – outcomes are frequently presumed to follow improved process adherence.  The only element of value routinely explored is the denominator, most commonly in terms of length of stay.

Certainly, there is a benefit to improving best-practice adherence and streamlining care.  From a value perspective, however, these process-oriented advantages are secondary.  Standardized care practices are, rather, a prerequisite to value-based healthcare delivery.  A health system has no way to assess the costs of care processes and the return on investment for these processes without standardization.

Consider a patient with uncomplicated appendicitis.  A system with a systematic approach to care delivery will be able to predict the choice of antibiotics, operative or non-operative management, surgical devices used, and postoperative care provided.  With this data, the system can anticipate costs and likely outcomes.  Process improvements to reduce costs or improve outcomes can be made and studied with confidence.  A system comprising a conglomeration of individual providers, lacking standardized approaches to patient care, can do none of these things.  Failure to standardize thus does not simply promote errors – it prohibits the functions necessary to a well-designed, value-based healthcare delivery system.

This realization was one of many insights I gleaned from the Value-Based Healthcare Delivery Course.  Sessions on costing methods, organization of care around common conditions or organ systems, and rationalization of increasingly consolidated healthcare systems were thought provoking and stimulating.  Nonetheless, as an implementation researcher with an interest in care standardization, I found this realization profound.  I am thankful for this opportunity to refocus my efforts from processes and outcomes to value.

Necessary for All Residents

Hilary Gallin, M.D. 

Resident in Anesthesiology 

Massachusetts General Hospital 

PGY 4

06/08/2021

Massachusetts General Hospital

I had the pleasure of attending the Value Based Healthcare Delivery Course. It was an opportunity to step outside my clinical duties and explore patient centered care, quality in healthcare, and payment structures. The course taught us how to be successful leaders with a range of leadership styles. In addition to the outstanding faculty, I had the opportunity to meet a number of trainees across the MGB system with different perspectives from multiple specialties and institutions. 

As an anesthesiologist, I hope to use these lessons when approaching projects to improve operations, patient safety, and patient experience. This course was a reminder that as a physician we have a duty to engage not only in medicine but broader healthcare delivery. It provided a vocabulary and structure to start improving care.

Terrific Course for thinking about health system strategy

Gregory James Zahner, M.D., M.S.C. 

Resident in Internal Medicine

Massachusetts General Hospital 

PGY 1

06/02/2021

Gregory James Zahner, MD, MSC

I signed-up to take the Value-Based Health Decisions course to develop a framework for thinking about value-based healthcare that was more than a fashionable buzzword. I have previously worked in healthcare strategy and after residency hope to again work at the intersection of clinical medicine and healthcare management/policy.

In my prior experience, most health systems still define value in monetary terms without relation to patient outcomes. Operational measures are considered to the extent that they reflect efficiency and impact the bottom line (e.g., pre-noon discharges, LOS for a given MS-DRG, etc.). Population needs are rarely considered unless to identify a profitable untapped market. While the transition from FFS to capitated and other prospective payment mechanisms is well underway, health systems still focus on high margin services that tend to be procedural, regardless of value to the patient. For example, one health system was under-penetrated in spine surgery (i.e., lower market share in spine relative to their overall market share). From a finance perspective the estimated “loss” was ~$10M in margin annually, but the reason for the under-penetration was a robust PT and PM&R outpatient program that they had established to non-surgically manage many cases. This program reportedly yielded great patient outcomes, but no financial margin.

Additionally, a lot of current healthcare strategy still focuses on “payor mix optimization.” Given the vastly higher rates paid by commercial insurers relative to Medicare and Medicaid, health systems focus on several levers to improve their payor mix. This includes “aligning” physicians with favorable payor mix, improving their ambulatory footprint by building clinics and ambulatory surgery centers in wealthy suburbs, and investing in service lines with the highest proportion of commercial patients. These strategies can make a health system very profitable and are justified for the purposes of cross-subsidizing healthcare for Medicaid patients. However, the focus on competing for commercially insured patients only reinforces many of the healthcare disparities that exist and destroy value at a societal level.

There were several takeaways from this course that will impact my career. 1) You can be wildly successful with non-commercially insured patient populations through customer segmentation and wrap-around services (e.g., Oak Street). 2) Payor-mix optimization doesn’t have to be the end-all of healthcare strategy. Effective deployment of a network strategy that maximizes optimal site-of-care (e.g., CHOP), integrated practice units organized around diseases (e.g., Cleveland Clinic), and patient-centered outcomes (e.g., Martini Klinik) can all be used to improve value in terms of margin as well as patient outcomes while remaining agnostic to payor mix. 3) Bundled payments are an ongoing improvement project. Although early efforts have been underwhelming, a sustainable competitive advantage can be built by being the first in market to perfect bundled payments for an ever-growing range of high-volume services (e.g., New England Baptist). 

Learning beyond the patient encounter

Giovanni Rodriguez, M.D. 

Resident in Emergency Medicine

Brigham and Women's Hospital/Massachusetts General Hospital

PGY 2

06/09/2021

Doors to the Emergency Room

The VBHD course taught me so much in such a short amount of time. As an intern and with no prior administration training, this course opened the doors to learning more about systems and approaches to creating models. This course has helped me to begin to chip at the iceberg of the health administration/policy world. Although I have no formal training in these systems, I have always been interested in creating access and equitable healthcare. 

This course reaffirmed my interest in learning more about models that are efficient, well rounded, and equitable. I am very interested to continue to learn and apply what I have learned thus far.  I think that more trainees should take this course because as physicians we are always focused on the art of medicine, but we also have the right and privilege to engage in the delivery in the care of our patients.

Valuable Lessons in Value-Based Healthcare Delivery

Frances Y. Hu, M.D., M.S.C

Resident in General Surgery 

Brigham and Women's Hospital 

PGY 3

06/01/2021

Frances Y. Hu, MD, MSc

The Value-Based Healthcare Delivery course was a wonderful exposure to concepts often overlooked in clinical training yet still integral to patient experience and outcomes. With significant restructuring on the part of the organizers, the course had been well-adapted to a virtual format, and the case-based sessions remained engaging and rich with discussion. At the conclusion of many sessions, we had the chance to interact with healthcare leaders who had taken the initiative to implement system-wide change and learn from their experiences.

I particularly enjoyed the small group discussions when we were asked to consider the frustrations we encountered as clinical providers across Mass General Brigham and brainstorm solutions to better integrate patient care and increase value within our own healthcare system. Hearing from trainees in a variety of specialties drew attention to opportunities for improvement we had in common and emphasized the benefits to multidisciplinary efforts in improving care delivery. Overall, the course offers a more comprehensive understanding of the contrasting perspectives of various stakeholders in the healthcare system and allows trainees more awareness of strategies to align value with patient care.

Learning to view healthcare in a bigger picture.

Fei Wu, M.D. 

Resident in Anesthesia

Massachusetts General Hospital 

PGY 1

05/26/2021

The Value-Based Healthcare Delivery course had been a rather mind-opening experience for me. It had allowed me, a clinical trainee to start viewing the bigger picture in healthcare. We can not do the best for our patient if the system is not working in a sustainable, consistent, and efficient way. 

I really liked the concept of focusing on “value”, and discussions on how to organize healthcare in a way to deliver better value for our patients. It was lots of fun to learn about different hospitals and their respective history and development course. 

It even helped me to identify what I am missing in my clinical practices, like outcome measurements. This course had been a cornerstone for me to be more aware of the things I see every day, big or little, and think about its impact on the healthcare system. And hopefully with these concepts I have learnt from this course, I would be better able to contribute to healthcare on an organizational level in the future.

Empowering the Next Generation of Healthcare Leaders.

Douglas Spivak
Administrative Fellow
Massachusetts General Hospital 

06/09/2021

Reading for the Course

The Value-Based Healthcare Delivery course is a great opportunity to learn, discuss, and acquire the knowledge and tools to drive change toward innovative value-based care in our healthcare industry. Not only is this HBS course taught by world-renowned faculty, but the case readings are brought to life when the case protagonist joins the discussion to provide their first-account insight and answer questions from the class. The cases are relevant, recent, and inspiring as the faculty often worked closely with the protagonists to plan, measure, and improve value-based care. This course is so important for young professionals in healthcare because we know this is the future direction of our industry and we have the power influence change together as we progress in our careers. This course allowed me to question the very makeup of our current healthcare system and challenge the realities of our care models, costs, and reimbursement structures.

As an Administrative Fellow, I felt empowered leaving this course to seek opportunities to lead TDABC initiatives in future administrative and leadership roles. I am still surprised by the notion that we as a healthcare industry do not comprehensively know our actual costs. I now view healthcare costs and finance in an entirely new lens. Additionally, this class is a great way to step outside of work mode and focus on learning through insightful discussion with colleagues in different corners of our health system. For me personally, this was a great opportunity to connect with young physician careerists, understand each other’s perspectives, and put our minds together to discuss these emerging trends in healthcare. I realized that our clinical and administrative backgrounds have real opportunity to learn from each other, to collaborate, and to passionately drive the future of value-based care. Ultimately, I encourage future clinical and administrative colleagues to take this course, continue to seek learning opportunities, and work together to drive value. 

To Improve, It Must Be Measured!

Amar Deshwar, M.D. 

Resident in Emergency Medicine 

Brigham and Women's Hospital/Massachusetts General Hospital

PGY 2

06/01/2021

Amar Deshwar, M.D. 

I recently was fortunate enough to participate in the Zoom edition of the Value Based Healthcare Delivery course. A large portion of the course involved case studies of different hospital systems tackling their toughest problems. If you were to ask anyone, individual physicians and hospital systems included, if they wanted to improve patient safety, drive down costs and raise profits my guess is that they would all say of course! But what are they doing to make this happen?

For me, this the point that I will take from having been a part of this course: being able to precisely measure an outcome is the first step towards improving it. This sounds so simple and yet seemed to be the key realization of the majority of these cases in turning around their respective projects. Everyone agrees that healthcare is too expensive and yet determining how much it costs to provide care for an individual’s hospital stay is still evasive. 

For me as an emergency resident in training I think there are many takeaways from this. I hope to be able to translate this into my own practice by tracking the procedures that I perform and having regular evaluations of their various outcomes, as well as accounting and comparing the costs for patients that I see that end up being admitted from the ED to the ICU, the floor or to ED Observation units.

Learning how to continue to learn at the Clinical Teaching Skills course.

Nupur Dandawate, MD

Resident in Internal Medicine

North Shore Medical Center/Salem Hospital 

PGY 2

Nupur Dandawate, MD

Getting into an internal medicine residency was a dream come true for me. After having the opportunity to build on my medical knowledge and clinical judgement while I train, it only seems natural for me to want to help guide those who train after me. I have had the pleasure of having so many great teachers and I wanted to help grow my skill set to be able to impart what I have learned to others. 

The clinical teaching skills course allowed me to really understand what I knew about teaching, what my preconceived notions about it were and it helped guide me to a place of growth and understanding in this area. 

I always imagined myself in some form of a teaching role later in my career, the clinical teaching skills course strengthened this belief as I now feel more confident in my ability to incorporate pockets of teaching within a busy day, give feedback in an effective way and how to, hopefully, drive those I am training to grow themselves. 

 Amongst the vast majority of expectations from clinicians such as continuously building our clinical knowledge, interpersonal skills with colleagues and patients, academic duties, we often may not have the bandwidth to acquire the skills required to be an effective teacher. Hence, with the clinical teaching skills course I was able to pause and reflect on this. As clinicians we will continue to learn throughout our careers, that being said, being aware of areas we need to work on and taking control is always beneficial and will only help us improve. 

 From this course, I hope to incorporate what I learned about the psychosocial aspect of giving and receiving Feedback. I really enjoyed our discussions around this topic with Dr Shubha Ramani who was amazing and I would love to spend more time with. I believe that as I hopefully progress in my career, I continue to reflect on what I learnt at the course which is to pause and look at the meaning behind why we incorporate different types of teaching techniques and our skills in giving feedback. I hope to understand my learners better as well as myself as a learner too. There will always be someone superior to us and vice versa, by understanding ourselves first and where our learners and superiors are coming from, we can improve our abilities of creating a harmonious learning environment.

Learning to Teach

Sara Cromer, MD

Fellow in Endocrinology 

Massachusetts General Hospital 

PGY 6

02/22/2021

Sara Cromer, MD

Everyone in medicine is a teacher, at least for a time. Interns teach medical students, residents teach interns, fellows teach residents, and attendings teach everyone. Despite this, most training on how to teach is informal, even unspoken, based on observing others and practicing skills on your own. Not so the COE Clinical Training Skills (CTS) course!

Although I have sought teaching roles for years, this course was the first to provide formal and focused instruction on adult learning theory and concrete methods of feedback. These lectures affirmed my own experience, defending teaching methods from which I’ve benefitted in the past, while also challenging some of my assumptions. These lectures suggested many ways to improve both the experience of learners and their likelihood of retaining key lessons which I plan to implement immediately.

Additionally, this class provided dedicated and focused time to practice both small-group teaching and providing constructive feedback alongside other learners who are motivated to learn and help others learn these skills. This very practical application and feedback has already influenced the way I stage and conduct brief teaching sessions and my ability to provide timely, actionable, and specific feedback. Thanks for a helpful course, COE!

Amazing, highly applicable course!

Yuh-Shin Chang, MD

Fellow in Neuroradiology 

Massachusetts General Hospital 

PGY 6

03/12/2021

Massachusetts General Hospital

This truly amazing, highly applicable Clinical Teaching Skills Course consists of three excellently crafted evidence-based 45 minute-lectures that cover “Challenges of clinical teaching”, “How adults learn and implications for teaching” and “How to create and promote a feedback culture”. In the final hour, participants are divided into subgroups where they get the chance to apply the taught principles among their peers using pre-prepared 5 min lectures.

All this material is presented in a fun and interactive manner. The course left me with a new perspective towards the approach to teaching and interaction with trainees while at the same time providing insight how to maximize my own role as a learner. I am so happy to learn these tools at this stage in my training and highly recommend this course!   

Reflection on the COE teaching course

McKenna Longacre, MD

Resident in Anesthesiology 

Brigham and Women's Hospital 

PGY 4

02/23/2021

I recently had the opportunity to guide very bright and motivated medical student through his first few intubations. Each attempt he got a little closer to success, though I fumbled to find the right words to describe the differences between my technique and his own.

The COE-CTS teaching course reminded me of the humbling fact that even the best teachers only convey 30% of what the learner needs to know, that learning is an exciting and uncomfortable process, and that so much of what we can do is to encourage the growth mindset that motivates students to continue to approach new challenges with open minds and hearts. I am also now officially on a quest to learn to articulate that elusive 70% of the technical skill that we rarely convey to eager students. Wish me luck! 

The Teaching-Learning Toolkit

Mary D. Maher, MD

Fellow in Neuroradiology 

Massachusetts General Hospital 

PGY 7

03/11/2021

Boston Skyline

I appreciate the time invested in creating and sharing the Clinical Teaching Skills curriculum. The course was a healthy reminder of one of the three core missions of every teaching hospital: EDUCATION, clinical care and research. After so many years of education, it’s surprising to learn that there is still so much more to know about teaching and adult learning. As the sun is setting on my formal training, the course benefits me both as teacher and forever learner. Aware that the body of knowledge in my field is infinite and at every moment grows greater, I have questioned the attributes and knowledge that I can bring to learners as incomplete learner and an imperfect teacher. This course has provided both the tools and the encouragement to know that perfect isn’t required to be genuinely good and caring in both capacities. I am grateful for the tool sets of the teacher-learner to carry into the next phase of academia and of life.

Learning To Teach

Julia Carlson, MD

Fellow in Neurocritical Care 

Massachusetts General Hospital/Brigham and Women's Hospital 

PGY 5

03/04/2021

Julia Carlson, MD

Academic medicine has many components to the “hidden curriculum,” with perhaps one of the most omnipresent being the expectation that all residents, fellows, and attendings double as teachers on the wards and the clinics.  Teaching how to be a teacher is no small undertaking – it’s why teachers go to school to obtain degrees in the discipline.  Luckily for us, the Center of Expertise in Medical education is offering seminars in clinical teaching. A short but thorough introduction into the major concepts of pedagogy will help trainees of all levels to gain tools and the confidence needed to return to the wards as clinician educators.  As a part of this course, we practiced and received feedback on a five-minute lesson we prepared on topics we have come across working with our colleagues from different disciplines to gain insight into where we currently stand as teachers.  By exposing and better equipping trainees to be model teachers on the wards, we can continue to improve a culture of excellent clinical education. 

Clinical Teaching Skills course was insightful!

Jean Cournoyer-Rodrigue, MD

Fellow in Abdominal Diagnostic Radiology 

Brigham and Women's Hospital 

PGY 6

03/11/2021

Brigham and Women's Hospital 

I was fortunate to attend the Clinical Teaching Skills course. Although it was given through a Zoom meeting, it was very inspiring to hear the science behind teaching skills and feedback principles. This course opened my eyes toward a different way of approaching these concepts in real life. I am gonna be more open, supportive, engaged and efficient in sharing my knowledge to my future students. It will definitively make a difference in my academic career!

Structured feedback enhances clinical skills teaching for pre-clerkship medical students

James C. Etheridge, MD

Resident in General Surgery

Brigham and Women's Hospital 

PGY 3

03/03/2021

Students in the Introduction to Clinical
Medicine Course

Despite a strong feedback culture in the Brigham and Women’s General Surgery Residency, many medical students report that they would benefit from improved feedback from their surgical preceptors.  The Clinical Teaching Skills course provided a set of tools to improve the quality and utility of feedback.

 As a preceptor for the Harvard Medical School Introduction to Clinical Medicine course, I routinely ask students to assess themselves and seek feedback from their peers before sharing my own feedback.  Results have been mixed.  Many students find it difficult to identify specific, actionable areas for improvement.  It is particularly difficult for students to communicate “negative” feedback to their peers.

 The Clinical Teaching Skills course highlighted three structured feedback instruments I have found particularly useful.  These instruments provide a shared language for us to assess each other.  They also help to “depersonalize” constructive feedback: the feedback technique provides a sort of buffer, making it easier to both give and receive feedback without it feeling like a personal attack.

 We first introduced the Plus/Delta feedback tool.  After every patient presentation, each student now identifies a few areas where they performed well and a few areas for improvement.  Their peers then supplement this self-assessment with their own observations.  The quality of peer feedback has improved immeasurably.  Instead of “you did very well” or “I could have done better,” I now commonly hear specific, actionable points from each student.  “I think I get all the information I need in the HPI, but I have trouble organizing it linearly,” or “you did a great job describing the abdominal exam, but I don’t think it was necessary to describe the whole neuro exam” are some recent examples.

 I also started using the Advocacy-Inquiry method when observing physical exams.  “I noticed that you were struggling with the abdominal exam,” for example, can be followed by “it seems like it would have been easier if you asked the patient to get back in bed.  Why did you try the exam with the patient in a chair?”  This allows the student to share their thought process.  Perhaps they knew that the patient requires a two-person assist to get back in bed.  There may be a perfectly reasonable explanation that would be lost with unstructured feedback such as “you should have performed the exam with the patient supine in bed.”

 We are now experimenting with the R2C2 feedback model.  This approach has been shown to improve feedback assessment and promote coaching.  In the first stage, we build rapport.  This is largely accomplished through our longitudinal relationship, one of the strengths of the Introduction to Clinical Medicine course.  However, we also take time to discuss matters of interest or concern to the students at the beginning of each session.  Topics have ranged from humanism in medicine to dealing with hierarchy in the workplace.  We then explore reactions to feedback.  Students have generally felt quite positive about their feedback, particularly constructive feedback.  This may reflect their preexisting growth mindsets, but I believe the feedback techniques mentioned above reinforce this mindset.  By exploring the content of their feedback, we can identify specific areas of concern for the student.  Perhaps the peripheral vascular exam has been a challenge.  Perhaps they struggle most with organizing the HPI or coming up with a plan.  Without exploring areas of greatest concern, it is impossible to accomplish the next step: coaching for change.  We develop an individualized plan for each student, complete with a “check-in” point to promote accountability.  Plans may center on additional physical exam practice, making effective use of written notes, organizing a plan by systems – regardless, it is critical that these plans are co-created with the student.

Responses from the students to these feedback instruments have been glowing.  Anecdotally, I have observed rapid improvements in their clinical skills over a very short time.  From a purely selfish perspective, using these feedback tools has made my job as a preceptor easier.  The cognitive load of assessing and providing feedback is lessened considerably just by using these frameworks.

Certainly, the insights I gained from the Clinical Skills Teaching course are not limited to feedback techniques, and I will leverage all of these lessons to the best of my abilities.  However, learning these feedback methods has been the most meaningful and relevant element for me and will continue to serve me well throughout my career as a medical educator.

Clinical Teaching Skills COE: Focusing on “how” instead of “what”

Harry Han, MD

Fellow in Hospice & Palliative Care Medicine 

Massachusetts General Hospital/Dana Farber Cancer Institute

PGY 4

03/09/2021

Harry Han, MD

The COE-CTS course was a great opportunity to hone in on “how” clinicians can improve their teaching skills. As a resident and fellow, I often am faced with multiple competing roles while teaching in the clinical sphere—team and time management, clinical decision-making, and learner education, often with the first two taking precedence. Even within the education sphere, my focus has commonly been on “what” needs to get taught without much thought placed in how I teach and what my learners take away from my teaching. Despite being put into an educator role, I was not taught “how” to teach.

The COE-CTS course provided me a deep dive crash course into “how” adult learners learn in the workplace, including discussions about adult learning theory (audience engagement, spaced learning, guided questions, cognitive load) and feedback. It made me realize that my often “on the fly” 2–5-minute teaching attempts or my attempts to cram too many learning points into these sessions may not necessarily be the most ideal for retention. Rather, being an effective educator relies more on being deliberate, prepared, and thoughtful about content. More importantly, the half day reinforced that a safe learning environment and relationships building with learners are critical for learning and feedback. Moving forward, I want to be more deliberate in cultivating and fostering my learning environment and relationships with my learners. I also want to be more deliberate about my teaching, being more succinct with my learning goals, and identify threads between topics to enable recall and repetition.

 Thank you for allowing me to participate in this course. It has become a launching pad for me to dive deeper in the education literature—after taking this course, I have many more questions to think about. 

An Opportunity to Grow.

George Kavalam, MD

Resident in Internal Medicine

North Shore Medical Center

PGY 1

03/09/2021

George Kavalam, MD

The CTS clinical course was an excellent experience and something that I was keenly looking forward to. The key element that stood out to me while I applied for the course was the emphasis on feedback. I am a foreign medical graduate who has recently started my internal medicine residency and feedback is a major part of this program and I have grown to like that. One of our attending even call it “Feedback Friday”. All this while I had two wrong notions about it. Some part of me felt afraid to ask for feedback since I considered any negatives as a flaw and not so much as an opportunity to grow (ignorance is bliss), the other being feedback only applied to initial levels of training. This is what got me interested in attending the CTS clinical course.

 This program allowed me to be part of a group of people with similar interests one common goal. Improve the overall work dynamics- be it one's efficiency and skills through feedback and how to communicate effectively. It was uplifting to look at feedback in a different eye than previously mentioned and has indeed changed my perspective on how I feel about it. I am no longer worried that I might hear something I don’t like, rather that is exactly what I want to hear because that is what is going to make me grow. Another key element of the course to me was how to be an effective communicator while teaching. Moving forward a few years in my career I see myself in a teaching role. Being excellent at your field doesn’t necessarily guarantee that you would be a great teacher, there is the part of effective communication and connecting with the audience which makes world of difference. Even as part of our training we have several medical students from across New England who rotate with us and teaching sessions are common daily, and the role is usually taken on by the 2 or 3rd years. It was important for me to realize my strengths and weakness before I take on such a role in a few months. Recording myself to teach and hearing the feedback from two other fantastic physicians was a fun and learning experience.

 Overall, I am so delighted that I could be a part of this wondering program. I have learned to embrace the feedback culture and more so on how to deliver the feedback most constructively. Trainees need to have such an experience because this is the only way we will get better at what we do. This will then lead to professional excellence and eventually our contribution to society. Having said that, just like any other learning experience, there will be trial and error, but if we know that there is room for improvement and our actions are in someone’s best interest, I would still consider it a win.

A Valuable Opportunity to Practice Teaching

Eric L. Tung, MD

Resident in Radiology Diagnostic

Massachusetts General Hospital 

PGY 2

02/27/2021 

Eric L. Tung, MD

As a radiologist-in-training who is passionate about teaching, I was immediately drawn to the Partners GME Centers of Expertise Clinical Teaching Skills course. Throughout medical school and residency, I have experienced a wide variety of educational approaches in both classroom and clinical settings. The process of developing my own teaching style thus far has been largely experiential – emulating techniques from different teachers that I have found effective. I entered the Clinical Teaching skills course excited to undergo my first formal training experience in education.

The course met and exceeded my expectations. My favorite part was the opportunity to practice teaching material relevant to my specialty and receive feedback from peers passionate about education. In radiology, incorporating imaging into lectures through computer-based supplemental materials is necessary for all educators. As an early radiology trainee, I entered the course with little experience in designing presentations that primarily use imaging to teach. The clinical skills course provided me the opportunity to create a presentation that I will use for future medical student teaching and experiment with Powerpoint design to effectively present radiology images. I received valuable personalized feedback from my peers, which allowed me to both improve my presentation and my overall skills as a radiology educator. I left the class feeling more comfortable designing radiology presentations, a confidence I will bring to future teaching opportunities during residency and beyond. I am thankful for the rare opportunity to teach and receive detailed feedback specifically on my skills as an educator.

The Clinical Teaching Skills Course provides the
rare opportunity to design a presentation, teach peers
and receive valuable feedback on your teaching.

I believe that all trainees can benefit from this course, even if they do not anticipate teaching as a major component of their future career. One of the most valuable components of the course was the lecture and readings on evidence-based techniques to improve adult learning. In residency and fellowship, trainees are constantly learning both medical knowledge and procedural skills. Even beyond training, physicians continue to learn throughout their career in the ever-changing field of medicine. Understanding the limitations of adult learners and strategies to overcome these limitations is critical for physicians dedicated to practicing evidence-based medicine based on the latest research and guidelines. I plan to use these techniques in my own learning and design lectures that promote these techniques to improve the retention of my material by my audience.

Participating in the COE Clinical Teaching Skills course allowed me to improve my abilities as an educator and learner through lectures and hands-on teaching activities. I highly recommend this course to all medical trainees.

Learning to Teach.

Diana Barragan-Bradford, MD

Fellow in Critical Care Anesthesia

Massachusetts General Hospital 

PGY 5

02/25/2021

I was thrilled to be selected to participate in the COE Clinical Teaching Skills (CTS) course since it provided a fantastic opportunity to understand the science behind adult learning and made me more mindful about the way I approach medical education.

 As a fellow, I primarily spend my time in the hospital teaching residents and students at the beside. This course challenged me to think about my own teaching style, and to reflect on the critical importance of feedback in the whole educational experience. I rarely get the opportunity to take a step back and identify concrete ways to engage with learners to make teaching more effective.

 It was great to see how other trainees from different disciplines engage their own learners. I look forward of using these new skills moving forward to better serve my residents!

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The image attached belongs to the Department of Anesthesia and Critical Care at Massachusetts General Hospital. The people that appear in the picture (including myself) gave consent for publication.

COE Course Supports Learning & Encourages Feedback

Catherine Wang, MD

Resident in Internal Medicine

Brigham and Women's Hospital 

PGY 1

03/02/2021

Catherine Y. Wang, MD. 

The Partners Centers of Expertise (COE) Clinical Teaching Skills (CTS) course proved to be a fantastic learning opportunity. Hearing from leaders in the medical education world empowered me to learn more about cognitive science to build a more strategic plan when approaching teaching scenarios or feedback. I now have a much better understanding of how to provide and receive effective feedback that is specific, measurable, and actionable. I also have a better sense of how to target teaching for a specific audience.

This course was exactly the opportunity I needed to hone my teaching through a skills practice. Designing a 5 minute teaching scenario was an excellent way to replicate what may happen on rounds next year as a junior resident when teaching medical students and interns. Peer feedback was an important component of this experience and helped me fine-tune the didactic material. This course was of huge aid to my future career in medicine as I hope to continue in the academic setting and be involved in undergraduate and graduate medical education in the future.

 It is of utmost importance for trainees to have experiences like this while training because, whether we receive formal training or not, a large portion of what we learn during our residency years are taught to us by our near-peers versus our attendings. An excellent teacher who is able to convey topics succinctly is a precious resource in the trainee community. Receiving formal education regarding teaching pedagogy and the latest practices in providing feedback are two ways that you can elevate a medical student or intern’s experience as a junior or senior resident. As we become better teachers we concurrently have the opportunity to become better learners. This course is not only didactic in nature but also affords us the opportunity to reflect on how we learn, which in turn emboldens us to become more effective learners and teachers. I would absolutely recommend this course to a trainee at any level whose aims are to teach and provide feedback in a more meaningful way. 

We Are Only Human!

Caitlin Burke, MD

Critical Care Anesthesiology 

Brigham and Women's Hospital 

PGY 9

Caitlin Burke, MD

During the Clinical Skills Teaching Course, I was disheartened to find out that research supports the “70-30” rule.  Namely, I receive only 30 percent of what I need to know in order to perform new tasks from my teachers.  In light of the other 70 percent that depends on each of us and on our learning environments, teaching effectively started to feel like a futile effort.  Moreover, our brains are not as powerful as I imagined, as I came to better understand our limited mental working capacities.  Namely, multi-tasking (including processing my environment) may cause my knowledge acquisition and performance to plummet.  Importantly, it is this same mental overload that may leave some trainees deaf to feedback, due to no fault of their own.

 

With respect to my role as a clinical and operative teacher, the Clinical Skills Teaching Course allowed me to embrace the fact that we are only human and to be more patient in my own teaching efforts as well as to focus my attention on the concept of continuous practice of both teaching and giving feedback.  To that end, I will continue to ask questions to clarify understanding, allowing trainees to practice putting their patient assessments into words more often in order to practice delivering information with clarity.  I will optimize the environments in which I deliver feedback and ensure that I have developed a relationship with trainees such that my advice is credible. 

 

This course is important for trainees while in training because it illuminates the challenges we face as learners and teachers and establishes a common ground for tactics to improve moving forward.  With the knowledge I gained from this course, I am optimistic about optimizing my own learning and teaching and intent on focusing a portion of my attending career on surgical education given that there is still so much work to do.

Growing Together

Ayumi Maeda, MD

Fellow in Obstetric Anesthesiology 

Brigham and Women's Hospital 

PGY 11

02/22/2021

Ayumi Maeda, MD

I’m a very nervous person, to begin with.  I hate public speaking; in fact, speaking up in class was not always a virtue in the culture I grew up.  And what’s worse, English is not my first language.  Giving a lecture in English, therefore, had been nothing but a torture – I would have done anything to be exempt from such an obligation.  Every time I give an assigned lecture to residents, I wish I could have been a better lecturer and didn’t have to waste their precious time.  And I hated being like that.  With this desperate frustration, I signed up for this Clinical Teaching Skills course – as if jumping off the cliff.

This course didn’t improve my public speaking skills nor reduce my accent in English.  However, it did help me shift my focus from myself (being an unskilled teacher) to the audience of my lectures and the receivers of my feedbacks.  

I was reminded by Dr Milligan’s lecture that even the best lecture can be meaningless if the students don’t have the availability to listen (I regret reviewing my 50+ page slides with a resident at 2am; it wasn’t the perfect time for teaching).  The 70/30 rule Dr Baker presented helped me understand why teaching a math to my child is so challenging (I didn’t know I was providing only 30% of the information he needed!).  Dr Ramani surprised me by saying that all the assumptions I had on feedbacks were actually wrong.  For me, the best take-home message from today’s session was from her: I want to live the rest of my life with a growth mindset, not a fixed mindset.

Peer trainees who were in the same small group advised me that my presentation could be more interactive and informative if I started off by asking the audience what they do and do not know.  I’ve realized how much I was worried about me – my slides, my accent, my fluency etc – and how little I was caring about their expectations.

I had an epiphany today that I can become a better teacher by prioritizing how I can help them improve, rather than how good or bad my lectures or feedbacks would sound to them.  By centering them and them alone, and seeking for how best I can help them grow, I can ultimately grow to be a better educator myself.  I really appreciate this career-changing opportunity, and would like to take this time to thank everyone who organized this CTS course in the midst of the pandemic – Drs Milligan, Baker and Ramani, Lisa and Sadie.

The Clinical Teaching Skills Course is Eye-Opening!

Amar Desai, MD

Resident in Anesthesiology 

Brigham and Women's Hospital 

PGY 3

02/22/2021

Amar Desai, MD

We begin learning as soon as we are born and never truly stop learning at any point in our lives. But how often are we taught how to learn? And even more rare, when are we taught how to teach? How I studied in medical school was drastically different than how I studied in college and high school. And how I study now, after long days of clinical duties, is different still. This course debunks many preconceived notions we have about adult learning with indisputable evidence. It has experts in the field of medical education take us through interactive discussions and personal teaching sessions to reveal our own strengths and areas of improvement when it comes to teaching and providing feedback to others.

 No one would question that teaching is important. But what is the best way to teach something complex and nuanced to a learner who is brand new to that topic? Is there even a “best way” for every person or are there different learning types toward which we need to tailor our teaching? How do we give constructive feedback to learners in the most warm, thought-provoking, and helpful way? And how do we possibly find the time in our busy clinical lives to even do all of this? Taking this course has given me insight into all of these questions as well as allowing me to witness my own style of providing teaching and feedback to others. The goal of this course isn’t to suddenly make someone a better learner or teaching. That is a skill that gets honed over a lifetime. But rather, this course and its leaders provide a framework of the principles of effective teaching and evidence-based learning practices that we can incorporate into our own lives as lifelong learners and educators. This course allowed me to reflect upon the most impactful teachers in my life and realize why they were so effective. It has fundamentally changed the way I will approach future teaching and feedback sessions. The potential beneficiaries of this course are not limited just to residents and fellows, or even all healthcare workers, but rather to all adults who have a passion for growth, learning, and teaching, regardless of profession or status. 

Learning for Residency and Beyond!

Allisa Alpert, DO 

Resident in Internal Medicine

North Shore Medical Center 

PGY 3

02/26/2021
 

Allisa Alpert, DO

Probably one of the most surprising things about my experience with the clinical skills teaching course is that the learning began long before the class had begun. The questions in the application started me thinking months in advance about the challenges, successes and failures I have experienced as a learner and a teacher throughout my residency career. These reflections even made their way into my interviews for post-residency hospitalist positions. I began to realize just how vital teaching is to my identity as a physician and I started to explore the ways in which I could incorporate teaching into my future career. As an attending I will have the opportunity to precept medical students and I hope to also help introduce formal didactics such as journal club to my hospitalist group. 

One of the most important aspects of medicine is life-long learning, and participation in courses such as this one not only deliver teaching of valuable concepts which residents can use every day, but also fosters engagement in the life-long learning culture.  

Learning about Learning: An Intern's Guide to Clinical Education.

Alice Ruo Wei Tang, MD

Resident in Neurology 

Brigham and Women's Hospital/Massachusetts General Hospital

PGY 1

02/26/2021

Attending this session allowed me to practice generating a lesson plan, teaching in front of an audience, and receiving feedback on how to improve. Adult learning theory was key in reminding me how to help learners learn. One key takeaway was that people will look for patterns even where none exist, so giving enough information to allow reasoning from first principles and crafting an easy-to-follow narrative is the best way to maximize success. I feel more excited to teach and take on academic leadership roles in the future. Medicine is highly structured and experience-dependent; at all stage we are simultaneously teachers and students. I think it’s important to have some amount of teaching experience and understand the needs and challenges to ultimately provide better care to our patients. Day to day, I teach medical students on the floors and this course has helped me structure short teaching sessions that are easy to slot in to morning rounds.

The COE course on medical education was so enlightening!

Melissa P. D'souza, MD

Fellow in Geriatric Medicine

Massachusetts General Hospital 

PGY 4

10/26/2020

Melissa P. D'souza, M.D. 

This COE course allowed a space for us trainees to truly understand the complexity of medical education. It made me realize the certain characteristics that are most memorable from our favorite teachers is not knowledge alone but the ability to engage and their dedication to teaching. It has changed the way I will approach learners and how to tailor the same educational session to varying levels of students.  A current technique I am using is to engage learners more often in a session which allows me, the teacher, to truly appreciate their understanding of the knowledge. This then allows for tailored and more meaningful education.