Precepting 101

1. Precepting 101 Some helpful hints

2. Better than a thousand days of diligent study is one day with a great teacher." --Japanese proverb

3. Goals • Discuss characteristics of interns • Discuss the characteristics of the effective preceptor. • Discuss the strengths and limitations of interns. • Ways to deal with problem interns.

4. The Effective Clinician/ The Effective Preceptor Characteristics of the effective clinician • Good communication skills • Careful assessment of the patient • Skillful management • Able to motivate the patient After Tumulty, 1973

5. The Effective Clinician/ The Effective Preceptor Characteristics of the effective preceptor • Good communication skills • Careful assessment of the learner • Skillful teaching and practice • Able to motivate the learner

6. The Effective Preceptor Communication Skills

7. The Effective Preceptor Communication • Possesses and demonstrates broad knowledge • Explains basis for actions and decisions - critical for dietetic interns • Answers learner questions clearly and precisely

8. Explain the basis for actions • Interns want cut and dry answers in a field where there is often more than one right answer • Experienced clinicians automatically by-pass many steps in the decision making process, which need to be made clear to interns

9. Answers learner questions clearly and precisely • Know when intern should look something up themselves or when they need to be given an answer • Fine line between encouraging independence and promoting frustration

10. The effective preceptor… • Is open to conflicting ideas and opinions • Connects information to broader concepts • Communicates clear goals and expectation

11. The effective preceptor… • Captures learners attention • Makes learning fun

12. Careful Assessment of the Learner

13. Careful Analysis of the Learner • Accurate assessment of learner’s knowledge, attitudes and skills • Uses direct observation of the learner • Provides effective feedback • Performs fair and thoughtful evaluations

14. Providing Feedback • Should be specific and appropriate • Should honor interns’ efforts • Can be useful to have intern self-evaluate - “what do you think went well?”, “what would you do differently?”

15. The Effective Preceptor Skillful Teaching and Practice

16. Skillful Teaching and Practice • Provides effective role modeling • Demonstrates skillful interactions with patients • Presents information with organization and clarity

17. Remember the preparation is for entry level! • Need to know versus nice to know • Example: • need to know - how to calculate basic TPN • nice to know - some RD’s adjust electrolytes, etc., but this is NOT an entry level skill

18. Skillful Teaching and Practice • Organizes and controls learning experience • Give appropriate responsibility to learner • Balances clinical and teaching responsibilities • Talk the talk and walk the walk

19. Motivating the Learner

20. Motivating The Learner • Emphasize problem solving • Promote active involvement of learner • Demonstrate enjoyment and enthusiasm for patient care and teaching • Develop a supportive relationship with learner.

21. Motivating the Learner • Many interns are adult learners and internally motivated • Allowing interns to direct own learning will help make this transition

22. What can you expect regarding your intern? • Most in distance program have extensive work experience • Some may have families • Many will have greater financial responsibilities • They are highly committed to doing well!

23. Limitations of interns • May have lots of book learning with limited hands on experience • May have an untested work ethic • May have difficulty prioritizing • May lack confidence in knowledge and ability (though some may be over-confident)

24. Strengths • Are generally very enthusiastic • Often very idealistic (may be a limitation in some cases) • Generally have a good knowledge base but may need to be reminded of that fact.

25. How to promote success • Provide an orientation • But don’t tell them everything - have them read policy and procedure manual • Make your expectations clear and provide feedback • Ask them to self-assess periodically • Be focused and enthusiastic

26. More ways to promote success • Have interns carry note cards to jot down questions throughout the day (or include in their journal) • Give them activities to do during down time (while you’re on the phone, etc.) • Give your intern responsibility • Create an atmosphere for open communication

27. Providing effective feedback Characteristics of food feedback • Encourages self assessment • Includes positives and negatives • Refers to specific, observed behavior • Is timely • Occurs in an appropriate place • Ends with an action plan

28. The difficult learner When the performance does not meet expectations Examples • Learner can’t sort out appropriate versus irrelevant information • Learner misses important details

29. Using the SOAP approach Subjective • What does the intern ‘say’? • Has the situation occurred before? • What do others say? • Describe the problem/difficult behavior - rather than label it.

30. Subjective - example √ Intern has difficulty developing effective working relationships with other disciplines Rather than X Intern is over-bearing and is alienating staff members

31. Objective • Start by identifying specific behaviors • Comes late, leaves early • Provides incorrect information in chart, to patient, etc. • Avoids eye contact during patient interviews • Look for other sources of information - how did intern get this far?

32. Assessment • Are your expectations clear? • Is there “stuff” going on of which you are not aware? • Is there a cognitive problem? • Information processing - e.g.dyslexia, attention deficit • Reasoning - e.g. can’t recognize assumptions, difficulty synthesizing

33. Assessment, continued • Is there an emotional, attitudinal, or personality problem • i.e. close family member died of cancer, so intern has difficulty working with this type of patient • Emotional - e.g. depression, anxiety • Attitude -e.g. intolerance or lack of motivation • Personality - e.g. obsessive compulsive, dependent

34. Assessment, continued • Is the learner having difficulty ordering his/her environment? • Time management • Inflexible learning style • Inefficient learning style

35. Assessment, continued • Are the interns’ standards set too low? • Has minimum effort been good enough in the past? • Do they believe they are performing well, when in fact they don’t meet your expectations? • May be some cultural issues

36. Plan • Do you need further information? • Give feedback - be timely • Reset your educational goals and objectives • Negotiate • Collaborate • Focus on interns’ strengths • Establish plans for follow up

37. Plan - examples • Knowledge deficit - provide readings to do outside rotation (or contact director) • Have intern verbally walk through what they are doing so you can see where they fall short

38. Problems for the 21st century • Inappropriate cell phone use - this was addressed during orientation • Many distance interns have children, so phone calls often relate to this • Interns should check with preceptor as to when they can check voice mail or return calls

39. Make sure you have all the information Real life situation • chronically late intern • renal problem, but MD unable to determine exactly what was going on. • prescribed meds caused drowsiness • concerned about falling asleep while driving to rotation • cultural issue - did not occur to her to let her preceptor know what was happening Solution - negotiated later starting time with site

40. Finally… • Let the internship director know what is going on.

41. Precepting 101 references • Tumulty, Philip A. The Effective Clinician Philadelphia: W. B. Saunders; 1973. • Irby, D. M.; Ramsey, P. G.; Gillmore, G. M., and Schaad, D. Characteristics of effective clinical teachers of ambulatory care medicine. Acad-Med. 1991 Jan; 66(1):54-5; ISSN: 1040-2446. • Irby, D. M. Clinical teacher effectiveness in medicine. Journal of Medical Education. 1978; 53:808-815. • Stritter, Frank T and Baker, Richard M. Resident preferences for the clinical teaching of ambulatory care. Journal of Medical Education. 1982; 57:33-41.

42. Precepting 101 References • Skeff, Kelley M. Enhancing teaching effectiveness and vitality in the ambulatory setting. Journal of General Internal Medicine. 1988; 3(Mar/Apr Supplement):S26-33. • Irby, D. M. What clinical teachers in medicine need to know. Academic Medicine. 1994; 69(5):333-42. • Irby, D, M. Teaching and learning in ambulatory care settings. Academic Medicine. 1995; 70(10):898-931. • Goertzen, J.; Stewart, M., and Weston, W. Effective teaching behaviours of rural family medicine preceptors. Canadian Medical Association Journal. 1995; 153(2):161-8. • Whitman, Neal. Creative Medical Teaching. Salt Lake City: University of Utah School of Medicine; 1990.