#20 Tips for Teaching as the Consultant 

September 27, 2022 | By Molly Heublein

Sharing Pearls Left & Right with Drs. Jen Babik and Varun Phadke

Join us as Drs. Jen Babik (@jen_babik) & Varun Phadke (@VarunPhadke2) discuss pearls on how to teach as a consultant.  We cover how to identify your learner’s level of knowledge and interest, where to teach effectively, and how to communicate with the primary team.  We dive into how to support primary teams asking consult questions and how to manage conflict between the primary and specialty teams.

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Credits

• Producers/Hosts/Writers: Era Kryzhanovskaya MD / Molly Heublein MD
• Show notes: John Ong DO 
• CME: Molly Heublein MD
• Cover Art/Infographics: Charlotte Chaiklin MD
• Guest: Jennifer Babik MD/ Varun Phadke MD

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner/ Best piece of advice
• Picks of the Week
• Enjoyable parts about being a consultant
• Challenges of teaching the primary team
• Opportunities for teaching
• Identifying the learner
• Teaching the learner
• Teaching in the note or attestation
• Tips on being a consultant at morning report or noon conference
• Key ingredients to an effective consult question
• How to manage tensions/conflicts with the primary team
• Teaching pearls from Dr. Babik and Dr. Phadke
• Take home points
• Outro

Tips for Teaching as a Consultant Pearls

1. It’s important to frame who the learner is: assess their field, role, level of knowledge, and interest. Don’t assume what others are interested in. Ask if they want to hear more about a clinical decision.
2. Find your opportunities to teach, preferably in person: at the bedside, during a conference, or on a visit to the microbiology lab or radiology reading room.
3. Think about (learning) opportunities that are unique in the consultant role and share your enthusiasm with the primary team.
4. Appreciate that asking a concise consult question is challenging. Work with the primary team calling the consult to understand what their goals and needs are for the specific case.

Teaching as a Consultant is Rewarding

Consultants get to work with a wide range of  learners: those with different levels of training and from other specialties or professions.  This provides a variety of  perspectives from different learners about the same problem.  It can be very satisfying to be able to help a team and manage a patient with your expertise.

Challenges of Teaching the Primary Team

• You have a limited amount of time as a consultant, and the time you may want to teach may not overlap with the learners’ availability. When the consulting team is busy, the interaction with the team may be just about advancing care that day rather than robust teaching.
• Not having a preexisting relationship with the people on the team. This may make it hard to gauge what interest and background knowledge they have.
• Interactions may be brief or not in person, like over the phone, text/text pages, etc., where it  can be difficult to teach (Chen 2018).

Identifying the Learner

Framing who is the learner is important: assess their field, role, level of knowledge, and interest.  Don’t assume what others are interested in.  Ask if they want to hear more about a clinical decision. 

When the learner doesn’t identify what level of training they are in, you can ask, “What member of the team are you?” It is open ended and gets around guessing.  Training level doesn’t necessarily correlate to knowledge level, but gives you an idea.  Avoid asking, “Are you the intern? The resident?” It may be asked from a good place, but the learner might perceive it as the consultant wants to talk to somebody higher up or feels the information was not well presented.

Not only tease out the level of the learner, but also consider the frame of mind of the learner and how busy they are.  If someone is busy, they might not be in a place to spend a long time on the phone with you, so your teaching might be narrowly focused.  If you know the learner has free time and will be around, you can tell them upfront that you’d love to chat and give pearls, and ask when it would be a good time to meet up.  

Opportunities for Teaching

There are a number of opportunities to find shared space for teaching.  

At the bedside: 

Take learners to the patient’s bedside to review the physical exam that you would do for a specific condition.  If there might be physical findings that are relevant to your diagnostic or management approach, it is a great opportunity to do teaching at the bedside and demonstrate the findings or the exam you might do in a patient (Faletsky 2020).

Reviewing studies together:

Go to the microbiology lab (or share photos), radiology reading room, or pathology  if appropriate to your field.  Adding a visual can make a case more concrete and build knowledge.  Discussing across specialities in person can promote teaching more than just over the phone (Winn 2019).  Model discussions and questions between consultants and radiology on how to get more information out of studies.

While giving written recommendations or attending attestation:

Adding references to the note can help explain decision making in an unusual case or for a very specific protocol, not only for the other teams, but for the consultant team taking over in the future.  Including hyperlinks can be helpful for the learner to click and go directly to the information being referenced.  Adding references to educate the primary team is not generally high yield, and Drs. Phadke and Babik  instead prefer to email the reference to a team member if they think it would be valuable  (Salerno 2007).  On e-consults adding references, Dr. Babik suggests, may help expand background understanding.

At morning or noon conferences

Try not to interject about the case until the chief resident asks you a question or you have an important teaching point to make.  It’s not about you, as the consultant, getting the diagnosis early on, but instead it’s about prioritizing the resident’s thought process and their clinical reasoning.  Allow residents the space to have that process without jumping in.  Going to report more regularly can help relieve the bias of conference attendees thinking that the case they’re going to experience is related to the specialty of the consultant.  Check in with the chief or conference presenter ahead of time to see if there are specific things they would like you to provide input on.

You have more to teach than you think!

Consultant fellows, especially early on,  may not feel confident in medical knowledge or have a teaching script in a specific content area, but that’s ok!  As physicians, we teach more than just facts and schemas. There are other things we can do that are easily taught, such as how to operate within a system, how to  find outside records, and how to disclose a difficult diagnosis. The scope of our teaching is not limited to medical knowledge about one subspecialty, management reasoning is important to teach as well.

Key ingredients to an Effective Consult Question

The learning interaction begins at the time of the consult being called.  If learners calling the consult feel uncomfortable with your response, teaching will be harder in the future.  There doesn’t always have to be a well formulated question. Some consults are “mandated” and are part of a routine management of a problem.  Some consult questions may be beyond the skills of the person calling; in fact, asking a good question is an acquired skill and requires a lot of medical knowledge and  knowledge of the patient.  

Consultants are often taught to “clarify the consult question.” It is difficult to say the question “what is the consult question?” or “what is the question?” without sounding irritated or passive aggressive.  Saying the phrase in the wrong way may set up a bad interaction with the learner and make them feel like you are giving pushback, even if that is not your intention (Winn 2019).  A better way to frame or ask the question may be, “Let me make sure we are going to answer the right question…” “let me rephrase what we are looking at…” or  “how can I make sure I help you in the way that you need…”   You can also have the consulting team share  their preexisting conception of what the solution to their question might be before adding your own thoughts to it. 

Assumptions are often made by the specialist receiving the consult based on their own cognitive bandwidth, which can be a direct reflection of things such as how much sleep they have had, how long their existing consult list is, etc.  Assumptions like, “this is a question that your team or another team should be able to answer” or  “this could be a question with no answer” are not fair to the primary team seeking help.   

Ingredients for a good consult question include urgency, a concise summary, being honest with how specific or vague the question is, and if there are nuisances that won’t be able to be extracted from the chart, like when a team doesn’t want to do something for the patient and the consultant is needed to adjudicate (Goldman 1983).

How to Manage Tensions/Conflicts with the Primary Team

If a primary team is not following your recommendations, ask why.  There is often a very good reason why they are not immediately doing what you recommended.  Hear different perspectives and appreciate that you are not the holder of the only truth.  The consultant may not understand some of the complexities of the case or thought processes of  the primary team.  It’s important to center that everyone is acting in the best interest of the patient.  Sometimes there isn’t a compromise, but there is a plan to manage an alternative, safely.  Stay humble.  The Art of the Deal published in the American Journal of Medicine discusses how to navigate conflict between consulting teams and maintain good communication (Wray 2020). 

How to improve your teaching skills as a consultant

Look within your institution for workshops or lectures.  National societies for specialties have MedEd sections or groups that give talks at their national conference such as ID Week and  The Alliance for Academic Internal Medicine.

Listen to how other specialists share their expertise at reports, like virtual morning report.

For every block someone is on service, pick one skill to work on for that block

Twitter is a wonderful source of information! The ISDA Medical Education Community of Practice is a group that highlights key articles, teaching points, and pearls for those who want to improve their educator skills.

Take home Points

Find your opportunities that are unique in the consultant role- go to the bedside or radiology or lab.

Use your unique role as someone who gets to work with multiple teams with different perspectives and use this to enrich your teaching and update your scripts.

Other Stuff

Links

1. Varun’s pick of the week: The Thursday Murder Club by Richard Osman
2. Jen’s pick of the week: Stranger Things
3. Era’s pick of the week: Percentage of Heavy Drinking Days Following Psilocybin-Assisted Psychotherapy vs Placebo in the Treatment of Adult Patients With Alcohol Use Disorder
4. Molly’s pick of the week: Dopesick
5.  ISDA Medical Education Community of Practice resource for clinician educators collating resources from across social media and beyond.

Goal

Listeners will describe framework helpful to, and key aspects of, teaching as the consultant. 

Learning objectives

After listening to this episode listeners will…

1. Describe aspects of teaching as a consultant that make it unique in the medical education space
2. Name the components of an approach to use when teaching as the consultant in a busy hospital 
3. Recognize situations to apply approaches to teaching as a consultant in the hospital and how to navigate common challenges that come up in the process. 

Disclosures

Drs Babik and Phadke report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Babik J, Phadke V, Heublein M, Kryzhanovskaya E. “#20 Tips for Teaching as the Consultant: Sharing Pearls Left & Right.”  The Curbsiders Teach Podcast. http://thecurbsiders.com/teach.  September 27, 2022.