Clinical Teaching: The 1 Minute Preceptor

1. Clinical Teaching:The 1 Minute Preceptor Mary McDonald, MD KUMC – Dept of Family Medicine, Division of Geriatric Med and Palliative Care ChiefResidentImmersionTraining Landon Center on Aging University of Kansas School of Medicine

2. Types of Teaching • Pimping • Lecture • Apprenticeship • Mentorship Venues for Teaching Inpatient vs Outpatient

3. Pimping • Often occurs on rounds • Both teacher and learner are active • Patient-specific or hypothetical • Warning: Fine line between educational quizzing and emotional belittlement

4. Lecture • Teacher active but learner is passive

5. Apprenticeship • Teacher passive but learner active • Can occur on teaching rounds

6. Preceptorship • Teacher active and learner passive • Occurs in bedside teaching

7. PROs CONs Case PresentationPresenting in Front of the Patient

8. Bedside Presentations* • Patients reported: • Doctors spent more time with them (10 vs. 6 min) • Perceptions of their care were slightly more favorable • Doctors were more likely to explain problems adequately *Lehman L, N Eng J Med 1997:336:1150

9. Bedside Presentations* Bedside presentation patients reported: • Did not provoke worry (88%) • The practice should continue (82%) • Helped them understand their illness (51%) • Too much confusing medical terminology (46%) • Perceived that the purpose of rounds was to teach and not to provide care (94%) *Lehman L, N Eng J Med 1997:336:1150

10. Improving Bedside Presentations* • Patients should be given the opportunity to say more • All physicians in room should introduce themselves • Physicians should be more attentive to the presentations • There should be fewer physicians in the room *Lehman L, N Eng J Med 1997:336:1150

11. Improving Bedside Presentations* • The physicians should respect the patients privacy more • Physicians should ask permission to present at the bedside • Physicians should be seated during the presentation *Lehman L, N Eng J Med 1997:336:1150

12. How is teaching in an outpatient setting different?

13. Teaching in the Clinic In-depth Lectures Seminars Formal Educational Sessions Extensive Discussion 1-8

14. Efficient and effective ambulatory care teaching requires that both the student and preceptor accept the limitations of the outpatient setting. Extensive discussions of differential diagnosis, pathophysiology and psychosocial problems are not possible nor necessarily desirable. 1-9

15. Pitfalls in Clinical Case-Based Teaching • “Taking over” the case • Inappropriate lectures • Insufficient “wait-time”: 3-5 sec • Pre-programmed answers • What do you think is going on? Could it be an ulcer? • Rapid reward • Effectively shuts down the student’s thinking • Pushing past ability • Persist in carrying the students beyond their understanding

16. The “One Minute Preceptor” teaching model was developed at the Department of Family Medicine at the University of Washington, Seattle. See: Neher, J. O., Gordon, K. C., Meyer, B., & Stevens, N. (1992). A five-step "microskills" model of clinical teaching. Journal of the American Board of Family Practice, 5, 419-424.

18. The One-Minute Preceptor • Get a commitment • Probe for supporting evidence • Reinforce what is right • Give guidance about errors or omissions • Teach general principles • Conclusion

19. Commitment • Why? • Learner becomes more active in teaching encounter • Allows you to assess how learner has processed information presented • Even if answer is incorrect, learning has occurred • Example • What do you think is going on here? • What would you like to do next?

20. Probe for Evidence • Why? • Uncovers learners reasoning process for arriving at the conclusion (Not a lucky guess) • Example • “What factors support your diagnosis?” • “Why did you choose that treatment?”

21. Reinforce What Was Right • Why? • Behavior specific feedback will promote and encourage desirable clinical behaviors. • Example • “I liked that your differential took into account the patient’s age, recent exposures, & symptoms.”

22. Give Guidance About Errors or Omissions • Why? • Behavior specific constructive feedback discourages incorrect behaviors and corrects misconceptions. • Example • “During the ear exam the patient seemed uncomfortable. Let’s go over holding the otoscope.”

23. Teach General Rules • Why? • Helps learner effectively generalize knowledge gained from this specific case to other clinical situations • Example • “Remember 10-15% people are carriers of strep, which can lead to false positive strep tests.”

24. Conclusion • Why? • Helps control time and sets clear agenda and roles for remainder of encounter • Example • …“Let’s go back in the room and I’ll show you how to get a good throat swab. Tell me when we have the results, and I’ll watch you go over the treatment plan.”

25. Adapted from Materials…… • Effective Clinical Teaching, Rohan Jeyarajah, MD and Hari Raja, MD • Lehman LS,et.al. The effect of bedside case presentations on patients’ perception of their medical care. NEJM 1997;336:1150. • The “One Minute Preceptor”:Time Efficient Teaching in Clinical Practice. Preceptor Development Program, developed by MAHEC. Funded by HRSA Family Medicine Training Grant # 1D15PD50119-01 • The One-Minute Preceptor &The One-Minute Observation Effective & Efficient • Outpatient Clinical Teaching. JHUSOM Department of Neurology, December 21, 2006