Precepting medical students in ambulatory clinical settings: from barriers to opportunities…

1. Precepting medical students in ambulatory clinical settings: from barriers to opportunities… Tom Barber, MD Co-director, Ambulatory Internal Medicine Clerkship, BUSM Associate Professor, BUSM

2. Moving from barriers to opportunities: what works?

3. Setting the agenda • Orientation • Introductions; staff, too • Space, flow, workstations, schedules • Establish expectations: student’s role; number of pts to be seen/session; format for presentations, documentation • Learning goals (more to follow on this) • Plan time for feedback – immediate, at mid-rotation, at the end

4. “Learning contracts:” McDermott, et al Medical Education 1999; 33: 374-81 • Set learner-centered learning goals • Establish discrete goals: knowledge (understand pharmacotherapy of diabetes mellitus), attitudes (a change in attitude towards patients or adapting to a medical practice philosophy) and/or skills (cardiac auscultation) • Specify for learner and teacher how and when goals will be assessed and accomplished

5. Home-grown guidelines • Orientation, learning goals; brief morning “huddle” (to “prime” student) • Make learning experiential rather than didactic in a formal sense • Set realistic goals: fast pace, hands on, focused on teachable moments, practicing clinical skills • Focus on our strengths: volume, diversity, opportunities to hone knowledge, skills, attitudes

6. Homegrown guidelines, p.2 • Focus on skills and attitudes as much as, or more than on knowledge: • History taking • Physical dx • Clinical reasoning and decision-making • Ddx and synthesis • Communicating effectively • Making and carrying out plans • Coordinating care • Professionalism and ethics

7. Homegrown guidelines, p. 3 • Avoid “the complete H&P” with full presentation and note; instead have the student • Perform focused histories and/or exams • Practice taking history from pts w special challenges (somatizing, tangential, etc) • Actively observe (not “shadow”) your evaluation of a pt, debriefing afterward with or without pt about key moments • Present in front of the patient, interrupting for clarification • Participate in clinical decision making: use of testing, choice of drug, etc • Research cultural, linguistic, anthropological questions that arise in caring for pts from other cultures

8. Homegrown guidelines, p. 4 • Practice motivational interviewing skills • Ask pt to give student feedback about interviewing skills, facility with physical exam, pt education, etc. • Verbalize your thinking and reasoning, preferably in presence of the pt. • Try to make precepting students a “win-win-win” experience for the student, the attending physician, and for the patient

9. Reflection (Arseneau, Exit rounds: a reflection exercise Acad med 1995; DaRosa Strategies for making ambulatory teaching lite: less time and more fulfilling Acad Med, 1997, Smith the roles of experience and reflection in abmulatory care education Acad Med 1997) • What are your questions? • What did you learn from seeing patients today? • What troubled, surprised, moved or inspired you today? • What progress have you made on your learning goals?

10. Moving from the ideal to reality while training the next generation of physicians to be expert clinicians