Varun Phadke MD Profile picture
Nov 1, 2022 13 tweets 6 min read Read on X
1/ Ready for another #TweetorialTuesday from the @MedEdTwagTeam? Say no more #MedEd #MedTwitter friends!

This week we are launching our series on #SubspecialtyTeaching! Image
2/ If you’re a clinical teacher in a subspecialty & wanted to incorporate pearls from #TweetorialTuesday, you've probably said to yourself (like I did):

WHEN? My days have ZERO predictability
WHAT? My learners are all at a VERY different place
WHO? My team seems to change QOD
3/ In this series @JenniferSpicer4 and I will share strategies for YOU, focusing on teaching as a [sub]specialist.

Our scope:
🌟 Teaching as an inpatient CONSULTANT
🌟 Teaching the CONSULT team (team hoping to provide help)
🌟 Teaching the PRIMARY team (team asking for help)
4/ Let’s start with some questions:

What is the BIGGEST challenge to teaching your OWN team in your role as a consultant?

(If the poll doesn’t capture your answer, Tweet us!)
5/ What is the BIGGEST challenge to teaching the PRIMARY team in your role as a consultant?

(If the poll doesn’t capture your answer, Tweet us!)
6/ There are multiple unique challenges to teaching as a specialty consultant.

Let’s unpack a few of these as a prelude to future threads…

(This list is NOT meant to be exhaustive. Please Tweet us the challenges you struggle with to help define content you want to see!)
7/ Challenge #1 – Time

Consult teams often have a totally different flow to their day than inpatient teams. Why?

📈 Workload (aka consults) unpredictable and often without a “cap”
⚖️ Competing patient care activities & inpatient consults (specialty clinic, procedures, etc)
8/ Challenge #2 – Wide spectrum of learners

Subspecialty teachers must modulate their expectations & teaching for many learners…

⭐️ Learners on the CONSULT team
⭐️ Learners on the PRIMARY team
⭐️ Learners on OTHER teams (other consultants!)

All w/ different schedules!
9/ Challenge #3 – Meta-cognition

Specialists usually encounter patients after some workup & management has already occurred. Effective consultation is thus intrinsically metacognitive.

Being mindful of what *others* were or are thinking influences WHAT and HOW to teach.
10/ Challenge #4 – Different role

A specialist’s involvement in a case is usually “invited” & NOT the default. This comes with implications for etiquette about how to establish your role (aka “the consult question”), decision-making, & communication.

These are LEARNED skills!
11/ Challenge #5 – Uncertainty

All clinicians deal w/ uncertainty. But specialists are often asked to adjudicate decisions b/c they have more cumulative EXPERIENCE w/ problem with no right answer.

Specialists must be mindful of how INDIVIDUAL practice influences teaching!
12/ Many of these challenges affect BOTH generalists & specialists.

We'll focus on aspects that uniquely impact teaching as a specialist in the consultant role.

What others would YOU add?

(We would especially love the perspective of our procedural colleagues!) Image
13/ Next week @JenniferSpicer4 will be discussing how to structure your day on consults to get work done AND teach.

And check out #SubspecialtyTeaching @MedEdTwagTeam if you want to keep up with all our threads in one place!

Thanks for joining, and we will see you next week! Image

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More from @VarunPhadke2

Mar 14, 2023
1/
You’re starting a consult service block.

But this time is different.

-Maybe you don’t have a consult “team” to teach
-Maybe you want to showcase your specialty & recruit interested trainees
-Maybe you want to build ties to other service lines

What to do?

This week: Image
2/
@JenniferSpicer4 and I have spent the last few weeks exploring the "why", the "who", and the "when" of teaching the primary team in our role as consultants.

Now let's turn to the "what".

What repertoire of teaching scripts should we strive to develop as specialists?
3/
1⃣ Content knowledge

It's natural to gravitate toward teaching specialty-specific content - that's our expertise!

We've covered a lot of this territory in prior threads.

I'm going to highlight some of those pearls & point out specific strategies for teaching primary teams.
Read 16 tweets
Feb 28, 2023
1/
You staff a new consult w/ your team. You share pearls & make a plan.

Then:
🩻 You review the CT w/ radiology.
🤝 You chat w/ another consult service.
🗣️ You deliver your recs at the workroom.
📲 You call night float w/ an update.

So many opportunities to teach!

This week: Image
2/
Last week @JenniferSpicer4 kicked off our segment on "Teaching the Primary Team" by focusing on "The Why."



This week, for "The Who", I want to think beyond just the primary team to identify the many different learners we encounter as consultants.
3/
Why?

Even though the primary team is the obvious audience for teaching - their "ask" is what invited us into the case to begin with! - we usually interface with many other teams in the process of rendering our opinion.

All of these teams have learners we can impact!
Read 13 tweets
Feb 14, 2023
1/
2pm. Usual day on ID consults.

Learner: “So the patient had [complex multi-stage procedure w/ prosthetic material] yesterday. Turns out they were bacteremic.”

You: "and...?"

Learner: "They want antibiotic recs...I'm not sure how to approach that..."

You: 🤷

This week:
2/
Consultants are often called upon for input on management.

Typically, this means helping with a clinical decision (which test? which treatment?).

Management reasoning refers to the cognitive processes by which clinicians make those decisions.

pubmed.ncbi.nlm.nih.gov/29800012/
3/
Teaching & assessing clinical decision-making skills is HARD.

Without a framework for the cognitive processes involved, it can be challenging to isolate the specific skills a learner needs to work on.

This leads to unhelpful feedback like "lacks confidence" (which = 🤷).
Read 20 tweets
Feb 8, 2023
1/
You’re staffing a complex patient w/ a learner on your consult team.

As they present it's clear the case was challenging for them.

They get to their assessment & take a breath.

You hit ⏸️ & say…”You know what? Let’s think through this dx together.”

What next?

This week:
2/
Consultants are often asked to assist with diagnosis.

What do we bring to the table?

An easy answer is deeper knowledge of a specific subset of presenting problems & diseases.

Focused clinical exposure means that we develop a unique & rich library of schemas & scripts.
3/
Though specialty-specific knowledge is essential to effective diagnostic reasoning for consultants, it is not enough.

Our unique 'invited' role in cases means we also need to have specific (meta)cognitive skills & habits.

Those skills/habits are part of a teachable process.
Read 18 tweets
Jan 17, 2023
1/
9am. Consults.

Them: “We want you on board because ____ is 'refusing' to do this procedure but ____ says it's needed. You're the tiebreaker.”

You: [sigh] “OK.”

⌛️

Patient: “Ah! ____ said YOU'RE the one holding up my discharge!”

You: 🙄

Feeling triggered yet?

This week: Image
2/
Conflict is inevitable when working within a system.

What do I mean when I say “conflict”? 🤔 For the purposes of this 🧵 let me paraphrase a huge body of literature w/ the following definition:

Conflict is “disagreement” that causes (or has the potential to cause) “harm”.
3/
Let's unpack this a bit more w/ a focus on conflict in consultative care.

"Disagreement" is a broad term.

It can stem from...
↪️ real OR perceived differences in opinion
↪️ about diagnosis OR management
↪️ between the primary team & the consultant OR between consultants
Read 19 tweets
Dec 20, 2022
1/
5pm. ID consults.

On 📞 giving recs re: culture growing Serratia.

Them: TY for seeing our patient!

You: Of course! BTW do you know the hx of Serratia? No? Well let me tell you about Operation Sea-Spray…

⌛️

Them: ...So should we start abx? Which one?

You: 😳

This week: Image
2/
So far @JenniferSpicer4 & I have explored consultant skills pertaining to the consult "ask".

We'll now focus on how to respond to the ask, verbally & through notes.

Let's start w/ a poll of those of you who CALL consults:

What is your PREFERRED way to receive consult recs?
3/
Previous studies suggest that verbal communication of consultant recs – especially initial recs - is preferred by most clinicians.

Additionally, lack of in-person interaction w/ consultants is one factor hospitalists identify as negatively impacting learning & patient care. Image
Read 17 tweets

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