Relevance, quick hits, and vibe: Features of meaningful teaching and learning during trainee consult interactions

Abstract

Background:

Consults are increasingly frequent on inpatient pediatric services. Consult interactions between trainees provide a rich opportunity for teaching and learning. What constitutes meaningful teaching interactions to trainees has not been described.

Objective:

Explore how consulting fellows and residents define “meaningful teaching interactions” associated with inpatient consult interactions.

Methods:

Four focus groups were conducted with 21 pediatric trainees (11 subspecialty fellows and 10 residents) at one institution. Transcriptions were analyzed using thematic analysis to inductively create categories and themes.

Results:

Five factors defined meaningful teaching interactions: (1) Relevance; (2) Quick Hits; (3) Vibe; (4) Face-to-face Interactions; and (5) Timing and Busyness. Meaningful content was described as relevant to current or future patient care. Residents valued content that would enable them to explain reasoning behind recommendations and think through next steps. Trainees highlighted brief clinical pearls as superior to longer teaching sessions. The “vibe” between resident and fellow was described as a prerequisite to meaningful teaching and included aspects of interest, receptivity, tone, and attitude. Face-to-face interactions were preferred by many trainees, from initial consult to seeing patients or co-rounding. Timing and workload reflected discordant schedules, including time of day and week, but setting a planned time for teaching was beneficial.

Conclusion:

Relevant, bite-sized educational content combined with a good vibe and optimal timing creates a context in which consult fellows can foster meaningful teaching opportunities for residents.

Introduction:

Consults, completed by fellows from nearly all subspecialties, are occurring with increasing frequency on inpatient pediatric services^1-3. Consult interactions consist of multiple points of contact between the primary resident team and the consultant service, most often between a first-year resident and a first-year subspecialty fellow^2,4. These interactions are meant to be focused on a specific clinical question from the primary team. Consult interactions, therefore, provide a rich opportunity for teaching and learning, whereby the consult fellow can utilize a clinical question to provide teaching to the primary team resident.

Despite this important educational opportunity, fellows and residents are faced with many barriers to teaching and learning during consults, which constitute a unique environment compared to other settings⁵. Miloslavsky and colleagues have detailed these barriers, which include resident perception of fellow ‘pushback,’ perception of fellow workload prohibiting time for teaching, personal familiarity, and subspecialty department/attending investment in teaching⁴. Previous work has also broadly described the “perfect” initial consult in terms of communication.⁶ However, no study has sought to understand what fellows and residents consider to be the most meaningful teaching interactions or addressed the entirety of engagement between consulting team and primary consultant service, from initial consult into ongoing daily consult interactions. This study sought to explore when and how meaningful teaching interactions can be cultivated during initial and ongoing consultations.

Methods:

Design, Setting, and Participants

We conducted a thematic analysis at Cincinnati Children’s Hospital Medical Center (CCHMC) to determine how pediatric residents and subspecialty fellows conceptualize meaningful teaching interactions during inpatient consults. We held four focus groups, two with fellows and two with residents, during January and February 2021. All second year fellows in medical specialties were invited to participate. We recruited second year fellows because they recently completed their first, and typically inpatient-predominant, year of fellowship, but were not as far removed from the experience as third year fellows. We ensured a broad representation of multiple subspecialities, including eleven total fellows from Allergy/Immunology, Endocrinology, Gastroenterology, Hematology/Oncology, Infectious Disease, Nephrology, Pulmonology, and Rheumatology. Nine second year residents and one third year resident participated. We did not recruit interns because we believed we would gather richer data and experiences from senior residents given their increased experience with inpatient consults. Participants received lunch and $25 for their time and were informed that their responses would be de-identified before analysis by other team members. This study was determined to be exempt by the CCHMC Institutional Review Board.

Data Collection

Focus groups were conducted using a semi-structured protocol (Appendices A and B) to explore what residents and fellows perceived as meaningful teaching interactions during consult interactions, including facilitators and barriers. Focus groups were conducted by two members of the research team (JR and DJS), who had no oversight relationship or supervisory role with any participants. Focus groups were audio recorded and professionally transcribed with Rev^© audio transcription services (Rev, Austin, Texas).

Data Analysis

JR is a clinical fellow and DPM is a subspecialty faculty member; both participate in inpatient consult services and provide the perspective of insiders to this clinical practice. DJS is part of a division which does not participate in inpatient consultation and represented an outside viewpoint. Taking a thematic analysis approach, all authors first familiarized ourselves with the data by reading the de-identified transcripts⁷. Next, each author inductively coded the transcripts individually and then met to agree on a final set of codes. Codes were coalesced into larger categories and finally themes that define aspects of meaningful teaching interactions. JR reviewed transcripts for supporting evidence to collate codes into potential themes. Themes were discussed, revised, named, and finalized by all authors. Following four focus groups, thematic sufficiency was determined to be met. That is, the research team decided collecting more data by conducting additional focus groups would not meaningfully change the themes that had been developed⁸.

Results:

Five central factors defined meaningful teaching interactions (Table 1). These factors comprise two themes related to the content of the interaction: relevance and quick hits. Three themes related to the conditions for a meaningful teaching interaction: vibe, face-to-face interactions, timing and busyness.

Table 1: Aspects of Meaningful Teaching –

summarized key points of findings

Aspect of Meaningful Teaching	Key Points
Content
Relevance	Teaching should apply to current or future patient care Learners can explain the plan and the rationale behind it
Quick Hits	Focus on small, specific teaching points, not long or detailed explanations
Conditions
Vibe	Set a tone of mutual interest and be receptive Ask a specific consult question and be prepared to discuss it
Face-to-face	Meaningful teaching happens in-person
Timing and Busyness	Plan ahead for a time to discuss the patient to maximize focus

Content Theme #1 – Relevance to current and future care

Two themes concentrated on the ideal content of a meaningful interaction. The first highlights the importance of content relevance to current or future patient care.

“I think a lot of it has to do with [taking] away an understanding of why things are happening so that you can apply it to future patients.”

– Resident #4

“I think if they can use it going forward in their day-to-day clinical experiences…, things that they're going to see a lot and may be expected to manage independently, I think [that] makes it meaningful.”

– Fellow #7

Participants described evidence of relevance and meaningful teaching as the capability to understand rationale behind consult recommendations. “Re-teaching,” or the ability to explain recommendations and their associated rationale to others such as nurses or patient’s family members, was cited as evidence of learning by both fellows and residents.

“I always know when I learn something when I'm able to… on rounds the next day, explain to the team or to the family, why they made those decisions and not just what we're going to do.”

– Resident #8

Fellows also described a resident’s ability to ask pertinent and thoughtful follow-up questions as an indication of meaningful teaching.

“After you do some teaching, if they then are in a position where they can ask a follow-up question for the next step, I think that says to me, "Okay, this was a successful interaction."”

– Fellow #2

Both fellows and residents relayed that a lack of relevance to current or future patient care is unlikely to result in a meaningful teaching interaction. Some consults are triggered by automatic processes in the hospital, such as seeking transfer of primary service or from the intensive care unit to regular inpatient unit, or mandatory (by hospital policy) consultation of Endocrinology for insulin management for a patient with stable type 1 diabetes mellitus. Trainees indicated that these situations do not include a question about changes in clinical care and consultation is requested only to initiate transfers or abide by policy. In these situations, teams were not seeking advice or new knowledge; therefore, meaningful teaching and learning were not expected. Other examples included consults requested by the primary attending who is the only team member uncomfortable with management or consults based on general rather than specific, clear questions.

“I would also say when there is confusion or an unclear question for the consulting team, because then everybody gets stuck on more just trying to figure out what they're doing instead of actually learning.”

– Resident #10

Content Theme #2 – “Quick hits” over “chalk talks”

The second theme related to content highlights the value of small amounts of information delivered in a timely (e.g. brief) manner. This type of teaching was referred to by many monikers, including pearls, quick hits, high points, and little teaching moments. We summarized all of these with the term quick hits.

Residents reported that smaller, more specific teaching points were especially helpful during more uncommon clinical scenarios, indicating that if it’s “stuff we just don’t deal with on a daily basis…it’s a good learning point for me” (Resident #10). Residents also emphasized that while meaningful teaching may happen in longer formats, informal or unplanned teaching is valuable.

“I think a lot of times it's more like pearls than a dedicated, structured thing…I feel like most of the time we're not usually co-rounding with other teams… Usually we're just popping in and out a lot of the time. So, it's more of like, "Here's a quick hit for why we're recommending this."”

– Fellow #9

Fellows referenced that it was more time-efficient to teach in limited amounts given their workload rather than longer “chalk talks” or didactic lectures. Fellows felt successful in teaching when they were able to impart some information, however small.

“Even if you have a really small point on every patient, by the end of rounds, it's like, oh, I've done cumulatively a fair amount of teaching today without taking a bunch of time. And they're engaged because you're still talking about that patient. So, I think that's a way to bypass a lot of the hurdles that you see sometimes when you're trying to teach.”

– Fellow #7

Condition Theme #1 – Vibe matters

The interpersonal vibe between teacher and learner reflects mutual interest and receptivity and is a prerequisite to meaningful interactions. Residents and fellows expressed that vibe can be active or passive, and that when talking to another trainee “you get a vibe right away.” (Fellow #9).

“I think there has to be some level of fostering the environment that teaching is a thing that should happen and that you should be receptive to it on the resident or whatever learner side. And for our side that we're supposed to be there to give it, because again, we are a teaching hospital - that's in the name, right?”

- Fellow #9

Participants conveyed that mutual interest and receptivity appears to be necessary, but not sufficient, to promote meaningful teaching interactions. A negative vibe signal, such as an impatient tone of voice, can be enough to prevent meaningful teaching. A positive vibe signal, such as asking insightful questions or having a positive attitude, can be the spark needed to begin a meaningful teaching interaction.

Both fellows and residents expressed that they are not willing to force the interaction if the other party does not seem receptive. In fact, both groups felt that meaningful teaching interactions should not be the goal of some encounters. Scenarios in which residents did not feel receptive to learning included while cross-covering patients, rounding post-call, and during overnight shifts. One resident noted: “When people try to teach and you're on post call rounds…I literally have nothing left…I don't have any capacity for this.” (Resident #5). This aspect of vibe and receptivity does overlap with another important theme, timing and “busyness,” which is described in detail in another section.

Participants also reported that vibe can be influenced by trainee attitude or mood. If one of the trainees is in a negative mood, this makes teaching less likely to occur:

“If you can tell they're frustrated when you’re two sentences into your consult, you're not going to ask those questions because you know they're in a bad mood…So I think it has to do a lot with the vibe you're getting from the person.”

– Resident #4

Resident preparation specifically influences fellow mood, interest, and receptivity to teaching. Fellows are “less likely to teach if…aggravated that” the resident does not demonstrate basic knowledge of the patient and the consult question (Fellow #3). Fellows also noted that having a supportive attending with an encouraging attitude or “style” toward teaching would often result in the fellow then providing more meaningful teaching as well. While some fellows reflected that they had never had the experience of an attending urging them to teach the primary team, others described individual attending physicians asking them to circulate research articles to teams while on consults, or even a division as a whole that is “really pushing teaching” (Fellow #7).

Condition Theme #2 – Face-to-face interactions

Most of the meaningful teaching interaction examples from both resident and fellow participants were face-to-face encounters. As one resident noted: “anytime someone comes in person, it's always very helpful and educational.” (Resident #9). Residents reported often seeing both the consult fellow and the consult attending, but that the fellow was the primary contact.

“I think being in the same space as the team is huge… Even if it's a two second conversation, I think it gives the opportunity for them to open up and ask questions and be receptive and also puts in a little bit of face time, so it seems like I actually do care about the recommendations I'm making…”

– Fellow #8

Co-rounding was a frequently referenced meaningful teaching interaction by both residents and fellows. A fellow further elaborated:

“A lot of times we'll run into the primary teams on rounds. And so then many times the primary attending…will directly ask us our thoughts or ask us to elaborate on where we're coming from. And so using that as a point to then expand upon different teaching things that relate to whatever topic we're talking about – I think the teams enjoy to hear our perspective.”

– Fellow #6

Fellows referenced a shared experience of being asked questions by the primary team attending during these interactions and the sometimes jarring or confusing experience of providing teaching to an attending physician. While at times fellows perceived they were being questioned in order to promote teaching for the team as a whole, there were also distinct times they felt their audience of learners included the attending. Another way attending physicians play a role in consult interactions was described by residents who reported that they found meaningful teaching from listening to conversations between primary attending and consult attending when in-person. Residents also described learning from seeing patients with consult teams to observe or listen to lines of questioning, explanation of diagnoses, or discussion of management plans.

Finally, both residents and fellows recognized the utility of planning ahead for face-to-face communication but referenced the difficulty in achieving this on a regular basis due to discordant schedules, as detailed below in our theme focused on timing. Given logistical challenges, both groups recognized that additional strategies, such as phone conversations, secure messaging, and consult note documentation, could be used to make teaching interactions meaningful despite lack of face-to-face communication.

Condition Theme #3 – Timing and “busyness”

Participants expressed timing of consult interactions and their workload as notable factors in achieving meaning within teaching interactions. Timing was defined in a variety of ways, including time of day, week, and year. Both residents and fellows acknowledged that time was influential in teaching, and while poor timing could be overcome with pre-planning or face-to-face interactions, this was not always possible.

There were multiple times of day that residents were less likely to achieve a meaningful teaching interaction. These included working overnight, while cross-covering patients, while post-call rounding, during scheduled lecture times, and at the end of the day. As one resident noted, “at like 2:30 in the morning in the ED I'm not looking to learn; I just need to see patients…” (Resident #1).

Fellows communicated similar sentiments regarding timing and reported they are more likely to teach earlier in the week when they are better rested, as opposed to later in the week when they are more fatigued. Fellows also said that the time of year played a role, noting that inexperience or lack of knowledge early in fellowship negatively impacted teaching interactions. Related to this, fellows also referenced learning time management skills and their new role as a team leader as priorities prior to advancing to a teaching role, as one noted: “I think the first half of first year, you're so busy trying to get yourself oriented that I think I honestly probably didn't teach very much at all.” (Fellow #11).

Fellows described that teaching became easier as the first year went on -- notes and other work could be completed in a more efficient manner, and their overall knowledge base was larger:

“If your knowledge is limited, you're not going to feel comfortable teaching about things that you don't know. And then as you're kind of more comfortable with what you know then you're going to communicate that to other people.”

– Fellow #3

Finally, the workload of both residents and fellows was conveyed as a significant factor in meaningful teaching interactions. Many residents described situations when clinical care responsibilities such as new patient admissions, writing notes, and responding to nursing messages precluded them from the time or capacity to receive meaningful teaching from consultants.

“I have vivid memories of being an intern and it's 11:30 and a consult service stops in, and you're viciously trying to finish all of your notes before noon conference. And you're half paying attention and you're half charting and trying to balance all those things.”

– Resident #2

“So you're sitting there talking to a service and you feel your phone vibrating. And you're …getting all of these messages from nursing…[so] I cannot completely sit down and understand what this consult service is saying.”

– Resident #6

Residents noted that fellow schedules and time may not line up with theirs and appreciated when learning opportunities were offered even if it was prevented by timing or workload. Fellows also had insight into the high resident workload and how that influences their mental capacity for learning in addition to their physical availability, reflecting that “if it’s a busy service, they're on [the secure messaging system], they're answering pages and things like that…. I don't know if I'm doing anything helpful” (Fellow #9). Fellows expressed their own limitations due to workload resulting in brief windows of time for teaching, and if that didn’t line up for the residents, it was difficult to overcome. Fellows reported their own workload as a direct barrier to providing meaningful teaching interactions, as one fellow noted: “I think busyness is the number one, two and three.” (Fellow #8).

Discussion:

Our study found that meaningful teaching interactions between residents and fellows during inpatient consults ideally involve relevant content, a mutually positive vibe, and enough time face-to-face without too many distractions. Importantly, we also found that teaching interactions are not likely to be meaningful to trainees when the nature or timing of the consult is not conducive. This finding should refine our focus toward identifying the optimal situations where meaningful teaching is primed to succeed as opposed to assuming any occurrence of teaching will be meaningful to trainees.

Previous work by Miloslavsky et al in internal medicine found that resident and fellow willingness to teach and learn as well as their workloads play a major role in whether or not teaching happens⁴. Our work suggests these are not only factors in whether teaching happens but also central consideration to creating a meaningful teaching interaction. Our study further details situations that should not be sought as meaningful teaching interactions; namely, circumstances in which trainees are not interested in teaching or learning, such as “obligatory” consults or phone calls overnight. These descriptions were comparable to the definition of an “obligatory” consult set forth by Hale et al in which hospital policy necessitates consults for certain conditions⁹. Our study also highlights the potential for utilizing vibe or interest to overcome barriers to teaching, as trainees voiced that one expression of interest from either side could spark a meaningful interaction.

Our study also further builds on the work of Pavitt and colleagues, which sought to understand “perfect” communication during an initial consult. When considering consults through the lens of meaningful teaching rather than communication, we both found that face-to-face interactions and how residents present initial consults can lead to more meaningful teaching. However, our work extends well beyond this to characterize meaningful teaching interactions focusing on relevance to current and future patient care, prioritizing “quick hits” over “chalk talks”, needing to be sensitive to timing and busyness, and further detailing how consults are presented by residents to elaborate the “vibe” alignment required from residents and fellows to create a meaningful teaching interaction.

Implications for Future

Both residents and fellows agreed that the most meaningful teaching is applicable to current or future patient care. This finding is in agreement with Knowles’ theory of andragogy which states that incorporating new knowledge is most successful when it is applicable to the real lives of learners¹⁰. Emphasis on quick hits or clinical pearls as a vehicle for meaningful teaching offers a possible tool to maximize or improve this learning, as it is a focused amount of information. Many terms are used by our participants and in the literature for quick hits, which have become an established teaching tool given their ease of use, short time investment, and effectiveness^11,12.

Our study also lends critical understanding to the literature surrounding “Fellows as Teachers.” These fellow-focused curricula based on general teaching principles have been implemented in a variety of settings, including both primary services and consult services^13-16. We add phenomenological evidence for what specific conditions and content lead to meaningful teaching during consultation, which could be incorporated into new or existing efforts, highlighting that general teaching principles or even just an effort to teach at all may not be enough alone to ensure meaningful teaching in the consult setting¹⁷. Our participants noted experience in which teachers wanted to teach, but meaningful learning did not occur because of poor timing or a bad interpersonal interaction or “vibe”. While every medical teacher aims for meaningful teaching, the important finding of trainee preference for quick hits over longer, more detailed chalk talks by consulting teams highlights the advantage of brief, relevant teaching over longer or more broad teaching points. Primary teams and residents can also be mindful of detailed preparation and a clear consult question to set up the consulting team for meaningful teaching. Asking prompting questions relevant to current or future patient care at a time opportune for the team or setting up a brief in-person touch point with consultants if timing is not ideal, are some additional learner-centric strategies to maximize meaningful teaching.

Our study has several limitations. All of our participants were trainees at a single institution, which is one of the largest within pediatrics. We believe the number and diversity of our participants positions our findings to be transferrable to other similar programs but acknowledge there may be differences among smaller institutions or those with different resources. Furthermore, while our findings may be applicable to other medical specialties, they may not apply as well to specialties focused on procedural or operative management, such as surgery. While we intentionally sought upper-level fellows and residents for their longer experience in training, it is possible that first year residents and fellows may have more recent experiences in their memory that are forgotten or change perspective later in training. This stated, we believe the time period between the first year of training and our data collection is short enough that recall bias is likely minimal. Our scope of investigation did not include the perspectives of attending physicians or advanced practice providers, who are also involved in consultation. Finally, we did not consider race, ethnicity, gender, or previous life experiences of participants in order to ensure anonymity from readers at their institution, but these factors almost certainly impact interactions between trainees and should be explored in future studies.

Conclusion

Appropriately relevant and bite-sized educational content combined with mutual interest, receptivity, and optimal timing can, in practice, create a context in which consult fellows may foster truly meaningful teaching opportunities for residents. Many of these factors can be influenced and improved in future work to enhance teaching during consult interactions.