TABLE OF CONTENTS

Acknowledgements
Contact Information

Prelude
Rationale for Another Teaching Skills Manual
Structure of the Toolbox
A Brief Review of Relevant Educational Theory
Teaching Ethics in a Clinical Setting: Finding
  Teachable Moments

Preview of Toolbox Features Yet to Come

Core Teaching Skills
Overview of Skill-Based Teaching
 Goal Setting
Giving Feedback
Using the Group
Addressing Emotion
Common Teaching Challenges
  (& Tips for Recovering from Them)


Unique Teaching Issues with Special Topics
DNR Orders
Medical Errors

Resources for Teaching
Annotated Bibliography
Domains for Small Group Teaching

        


     

Faculty and learners both need to think about goal setting. For faculty, setting goals for each teaching encounter helps you get clear about your expectations and priorities for the session. For learners, specific goals help guide them to where they want to focus during the skill practice encounter. In this way, goal setting is both the starting point for all teaching encounters and also the map that points the way for future work.

RATIONALE:

Communication skills are multi-faceted and patient encounters bring up many issues. Effective goal setting helps focus attention on particular areas where you want to work.

  • In small group settings, asking learners to set goals can cue observers for areas to watch and focus on for feedback.
  • Having clear goals, as a teacher or a learner, helps you recognize when you might be heading off track and need to either re-examine your goals or re-direct your course so that you can achieve them.
  • Goal setting helps us become more intentional about our work. In a busy area such as medicine, it is easy to get reactive and just deal with whatever comes up in a given week. Goal setting allows you to assure you are getting the professional development you need.

PITFALLS:

  • Learners sometimes identify goals that are too big or too general to be useful. A learner might say, "I just want to work on communicating better."
  • The learner might identify goals that are important to them, but you as faculty have other observations about areas where they should be working.

SUGGESTED PROCEDURE:

Goal setting will often take place in a teaching context, such as a course or a clinical rotation, where there are existing curricular goals. Faculty and program directors have already mapped out areas in which they want learners to work. These curricular goals provide an important framework within which to set learner specific goals. For example, if the curricular goal of the workshop is teaching residents skills for Breaking Bad News, that now defines the universe of possible learning goals that a resident might chose to work on during the workshop; it does not yet define the target area of need for each resident. Finding out where each resident struggles with breaking bad news will help identify each individual learning edge within this global communication skills area.

Prompt Self-Reflection and Assessment. Depending on your teaching context, there may be multiple layers of goals to identify and address. For example, in a longitudinal learning context (e.g. one day to one year), you can ask participants to set goals for the entire session. What brought you here? What do you hope to leave with? What would you like to accomplish during this time together? What areas would you like to work on during this course/rotation/clinic block? Questions such as these frame the big picture for teachers and learners alike.

For shorter sessions, or within one practice block in the longer session, a separate, more focused goal setting should occur. What would you like to work on today? Given where you are now in your course/in your training, what would be most useful for you to work on during today's session? Drilling down further, during the specific skill practice encounter, the learner in the 'hot seat' can now identify a specific goal to work on with the presenting patient, ideally tied back to one of the bigger picture goals. Thinking about this patient presentation, given your goals for the day, what would you like to focus on during this encounter?

Formulating and Working with Goals. Practically speaking, it helps to write down goals where they can be reviewed and revisited during the teaching session. This might take the form of notebooks, index cards, or flip charts that can be posted around a workshop room. The act of writing down a goal confirms the learner's intention and commitment to that goal. Posting or sharing these goals with the rest of the group can help everyone support the learner in achieving the goal, and can also give learners other ideas for goals that might be useful for themselves. In long-term settings, even over the course of one-day, goals may evolve and change in response to experiences and interactions with other learners. While a commitment has been made, these should be viewed as dynamic documents.

Faculty often play an active role in helping shape learner goals. Learning to set specific goals takes time and practice. Faculty can give learners feedback on their goals in a number of ways. Often faculty can simply restate the learner's goal so that both are clear about the focus. For example:

FACULTY: Anything you want us to particularly look for, or observe for you?

LEARNER: Well, I always feel anxious in these situations, when I give bad news. I tend to run on and jump in to reassuring them too quickly and might not give them time...

FACULTY: Good. So, a concrete goal for you that I hear is that you want to work on giving the patient time to absorb the news, and also avoiding quick reassurance.

Faculty involvement may range from merely posing the question about goals at the outset to shaping the learner's unformed goals into something that is do-able in the session. Mid-range involvement might include feedback to the learner about the goal being too broad and asking them to identify a particular piece within it that would be workable in the practice session. For example,

LEARNER: I think I want to work on denial.

FACULTY: Denial, good. Can you tell us what is it about denial that you want to work on during this session? What would be most useful to you?

Faculty can also serve as a connector between previously voiced goals or learner interests and the current patient encounter. For example:

FACULTY: What are your goals? What kinds of things do you want to try to be sure to do?

LEARNER: Well it's a difficult situation, and I think it is hard to be direct and I tend to beat around bush.

FACULTY: Ok, we can watch for directness. Anything else?

LEARNER: The usual things, fumbling, staccato speech.

FACULTY: And the other thing you brought up earlier was whether you were able to figure out where he was coming from, what his goals were. So maybe we can watch for that?

Operationalizing Goals. After getting clear on the goal, faculty can help the learner identify how they will achieve the goal during the patient encounter. For example:

FACULTY: What do you want to work on?

LEARNER: I want to try and follow the patient's needs rather than my agenda.

FACULTY: How do you think you will try to do that?

By listening. Trying to just respond to what they are telling me.

FACULTY: So, sounds like active listening will be useful. What kinds of feedback would be useful to you?

Doing the work of goal setting helps the learner get more out of a skill-practice session, even though it does take time. Think of goal setting as an efficiency tool for teaching. You want to target your teaching intervention to just where the learner needs it. Good self-assessment and goal setting can help you.

Closing the Loop. An important element in goal setting is returning to the goals after the skill practice or patient encounter is completed. After spending time up front clarifying the area that the learner wants to focus on, ask at the mid-point or at the end of the encounter if the learner is meeting her goals. Following up with some questions for self-assessment can help facilitate this. For example, "You really wanted to work on silence during this encounter. I saw you use this technique at several points. How did it feel for you? (learner response) Was it challenging for you? (learner response) How do you think it felt for the patient?" These reflective questions will help reinforce the learning that has occurred in the skill practice session.

New skills and insights will undoubtedly arise during the course of the skill practice which can also be discussed. Returning to the original goals will help the learner reflect on the growth that occurred during the practice session, or perhaps will help to reinforce what learning steps should happen next. In addition to reinforcing the learning, closing the loop will help imprint the usefulness of goal setting on the learner. That is, if you set your intentions toward something, you can often achieve it!

PEARLS

  • Learning how to set effective goals taps into a higher order skill of self-assessment. One must have an awareness of limitations before being able to identify specific skills to develop next.
  • Goal setting will be most effective if faculty can return to the learner's goals at various points in the teaching session, but particularly at the end. Reflecting on how one is doing relative to the goals is part of skill development and refinement of one's ability to set goals. It will be reinforcing to the practice when the learner experiences the pay-off and the success of achieving her goals.
  • Coupling a return to the goals with reflection and goal setting for future sessions can keep the cycle of reflective practice going.