Becoming a better ward attending

By Robert M. Centor

18 may 2008--Many residents join academic hospitalist groups upon completion of residency training. They arrive with great clinical experience but few have had training on how to be an effective ward attending and how to maximize the educational experience for their team of residents, interns and students. We offer this list of 10 modifiable behaviors to incorporate into your rounds as you develop your own ward attending style.
Remember that your learners' time is just as valuable as yours.

1. Make your expectations clear. Have an orientation session within the first three days and let the team know how rounds will run. Each attending has individual preferences; understand your own and make them clear to the team. For example, some attendings always start with sit-down rounds while other attendings prefer walking rounds first. Let the team know how you will proceed. Include how you want to hear patient presentations: just the overnight updates, a formal, organized “soap” (subjective, objective, assessment, plan) format, or by problem list. Giving learners your preferences at the beginning of the rotation will save them angst and help them best prepare their presentations.

2. Get to know your team. Have “autobiography” rounds within the first three days. Students and interns have told us that many attendings know nothing about them. Sometimes they don’t even learn their names. At our institution, we lead a sit-down session where we share our own abbreviated history (hometown, college, medical school and residency training, when we joined the faculty, family, joys outside of medicine). We ask team members to provide a similar brief history, including their future career plans, hobbies and pet peeves. These sessions foster team bonding and show your learners you care about them as individuals. Add sessions on favorite CDs, movies, books, sport teams, etc. throughout the rotation.

3. Be enthusiastic. We believe that enthusiasm defines great attendings. When you clearly love your field and teaching, the learners get excited. They will not all choose your field, but they will enjoy their experience. This is not the time to vent or share your frustrations about your career or your boss, or your institutional challenges. Role modeling enthusiasm and the joys of medicine is a much better way to maximize the learning experience. Tell the team why you love your field and how you maintain that passion.

4. Have respect for your team. In a few short years, they will be your colleagues. Showing respect for your learners is the foundation of a good learning climate. Once the learners know you respect them, they won’t be afraid to ask questions, share their uncertainties and challenge decisions to ensure the best care is provided to patients. When you promote a respectful atmosphere, giving corrective feedback is much easier. Show respect for learners by never being intimidating or demeaning and by showing appreciation for their hard work.

5. Have respect for time. In today’s busy world of medicine, time is our most valuable commodity. The learners’ time is just as valuable as yours. Set clear times to round that don’t exceed reasonable limits. Be on time for rounds. If you must be late, call and let your team know. Minimize interruptions and distractions. Don’t answer pages during rounds that can wait until later. Round in the mornings, not in the late afternoons. Ensure that your team has time to attend required conferences and clinics. Unless necessary, write your notes after rounds are completed, not while the team waits.

6. Teach. Teach to all levels, and teach the basics. Too many attendings assume that their learners know the basics; our experience is the opposite. The best teachers “layer” their teaching. Review the basic concepts (e.g., what are the possibilities for a patient presenting with a newly elevated creatinine?) before proceeding with a more sophisticated discussion. Avoid the trap of moving to a high-level discussion that assumes implicit knowledge; make the implicit knowledge explicit prior to advancing to the discussion. Once learners have absorbed the basic concepts, you can push them to explore more advanced concepts and applications. When appropriate, demonstrate bedside skills, including physical exam findings, physician-patient interactions and professionalism. If conducting bedside rounds, remember to make the patient the focus and demonstrate respect for his or her situation.

7. Question and rescue. The best clinical teachers ask questions for several reasons. We believe the most important reason is to gauge the learners’ current knowledge and level of understanding, and to search for teaching opportunities. We frame our questioning as a method of exploration. Through questioning, we learn where the teaching opportunities lie. When the learners do not know an answer, we rejoice and let them know that we have identified a learning opportunity. This positive response to their knowledge deficit defines the rescue. By questioning, we also are trying to create moderate anxiety because that predicts receptiveness to learning. We discuss this philosophy with our learners during our orientation session and encourage them to question and rescue, too. When questioning the team, it’s important never to ask a junior member something a senior member has already missed.

8. Think out loud, and make your thoughts explicit. When you explain your thought process, learners learn clinical reasoning. By “connecting the dots” of your logic, you are teaching. This allows you also to demonstrate the uncertainty of some decisions and shows how experience adds to evidence in many patient care decisions. Learners are less likely to consider it micromanaging if you explain the why behind your clinical decisions.

9. Give feedback. Feedback is critical to shaping the clinical competence of your learners. Students who receive regular feedback learn faster and perform better. Without feedback, mistakes are not corrected and good performance is not reinforced. To give effective feedback, state clear goals and objectives at your orientation session and establish a good learning climate. After observing key behaviors, give feedback often, immediately, and with the purpose of improving performance. Be the coach, not the judge. Focus on the learners’ behavior, not their personalities. Ask for their self-reflection and input, give specific recommendations for improvement and schedule a time to follow up on the behavior to ensure the feedback was incorporated. We have found that when feedback is labeled as such (“Let me give you some feedback”), learners appreciate the suggestions and don’t feel personally criticized.

10. Stimulate self-directed learning. Ask, “What did you learn today?” or “What questions does this case generate for you?” Medicine requires lifelong learning. Once the learners complete their training, they won’t have attendings to supervise their decisions. When learners are allowed to reflect on what they learned, it reinforces their knowledge for next time. When they reflect on unanswered clinical questions, they are stimulated to find solutions. This is how physicians operate in practice, and this should be fostered in our trainees. When learners are allowed to be involved in their education, they become active participants, assume ownership of their patients, and are able to share what they’ve learned with the team. This also helps the attending know the competence level of the learners and ensure that active learning is occurring daily.
Being a teaching attending is a multifaceted job. Caring for patients, documenting for billing purposes, and finding time to teach can be competing interests. Some attendings juggle these roles better than others. In our experience, certain attending behaviors are modifiable and can be easily incorporated regardless of your attending style. We have found that those who incorporate all, or even some, of these 10 behaviors improve their learners’ education, run more efficient rounds, and have a more enjoyable overall experience as a ward attending.