A Resource for Difficult Ambulatory Teaching Situations

1. A Resource for Difficult Ambulatory Teaching Situations Group Wisdom

2. Foundations of Independent Practice (FIP) • Foundational science essential for practice; some diagnosis/management • Biostatistics and epidemiology/ population health • Social sciences, including ethics, communication/interpersonal skills • Interpretation of medical literature • System-based practice/patient safety

3. Good judgment comes from experience. • Will Rogers

4. Good judgment comes from experience. • And a lot of that comes from bad judgment. • Will Rogers

5. To err is human,

6. To err is human, • But try and make a different mistake each time.

8. Student is stuck in “reporter” role

9. Faculty suggestions Ask leading questions to guide the student differential and plan. Role reversal. Preceptor presents the H&P and asks the student to make the assessment and plan. Then query student for role perceptions. If multiple learners, one student may be assigned the A&P after another delivers the H&P. This keeps all engaged.

10. Aunt Minnie • Student presents the CC and diagnosis ( or plan) in 10-30 seconds • Student writes the note while preceptor evaluates the patient • Preceptor gives feedback after the patient leaves • Sackett et al. Clinical Epidemiology. Little Brown 1985

11. Underachiever- already committed to another specialty.

12. Faculty suggestions Professionalism demands students be the best doctor /learner they can in any situation. Help the student find the skills that are common between the current rotation and their expressed interest. Appeal to the student’s fear of missing an important diagnosis outside their chosen field.

13. Standard presentation except…… the student includes their “learning need” in the chief complaint and probes the preceptor for the details they need to complete the assessment and plan. Learner Centered Preceptor

14. Would rather study for the shelf exam than see patients.

15. Faculty suggestions Point out that study linked to real patients is more effective/ memorable. Preceptors can emphasize ( brand) the Shelf Exam material that students ARE learning when they are seeing patients. Tailor didactic teaching to what the students are struggling with in their exam prep books.

16. Learning from books vs patients • Pre-establish the student’s perceived needs to hone clinical skills/gain autonomy in orientation. • Newer testing philosophies from NBME will reward ambulatory skill/ knowledge. • If the student is leaving early or missing clinical opportunities the Student Dean may be able to shed light on whether this is a pattern for this student.

17. Student doesn’t know enough to be helpful with a complex patient.

18. Faculty suggestions Is the student disorganized or lacking knowledge/skills? Tailor the solution to the problem. Set a time limit. Start the interview with the student to set the stage.

19. Problem Focused Assignment • For a complex patient, have the student focus on a single manageable issue on the patient agenda. ( How did she do on the diet goals set last visit?) • The preceptor can address the remaining issues confident that the student addressed one issue thoroughly.

20. Student doesn’t know enough to be helpful with a complex patient. • What CAN the student help with to “purchase” teaching time with the preceptor? • Prepping patients ( disrobing, taking down dressings, getting vitals) • Just get the patient’s “ list” of issues out on the table • Medication reconciliation • ROS- student ROS is billable • Family/Social History- also billable • Research health maintenance status/drug plan… • Obtain outside records

21. Micro-Skills(1 Minute Preceptor) • Get a commitment on a diagnosis • Get the evidence for that diagnosis • Teach a general rule based on the case • Reinforce a specific thing the student did well • Correct errors • Neher et al. J Am Board Fam Prac. 1992

22. The student asks hard questions.

23. Faculty Suggestions Model humility and comfort with needing to find answers. Turn the question into a discusion of finding and validating answers.

24. Modeling Problem Solving • If our goal is lifelong learners…… • Preceptor should not model “ font of all knowledge” • Student is assigned or self assigns learning objectives. • Student teaches preceptor.

25. Modeling Problem Solving • Allow the student to watch you think through a problem out loud. • Where do you look for answers? • How do you validate resources? • What part of your thought process does the patient see?

26. Premature Closure

27. Faculty Suggestions Novices may need to do some shadowing to see how the ambulatory H&P differs. Ask them to watch for particular components. Use personal anecdotes of premature closure errors that the preceptor has committed. Even if the Dx is a slam dunk, require a list of alternatives.

28. SNAPPS • Summary (deluxe chief complaint) • Narrow (differential diagnosis) • Analyze ( how the student decided among the diagnoses using pertinent positives/negatives from the H&P) • Probe (the preceptor about uncertainties, difficulties, approaches) • Plan (management of the patient issue) • Select (a self directed learning topic) • Wolpaw et al. Academic Medicine. 2003

29. External locus of control

30. Faculty Suggestions Focus on the patient’s barriers to change. Nurture empathy for how hard the changes are. Focus on incremental changes. Develop a coaching rather than nagging relationship with the patient.

31. Motivational Interviewing • Motivational Interviewing in Health Care: Helping Patients Change Behavior / Edition 1 • Stephen Rollnick,  • William R. Miller,  • Christopher C. Butler

32. Active Observation • “Shadowing” framed within teaching . • Ex: I notice you are pretty hopeless that his patient can change their diet. Observe me and then tell me what you saw me do.

33. Culturally inappropriate actions by patients.

34. Medicine in Context vs Cultural Sensitivity • Focus on perceptions/ feelings. • Can the preceptor make it a learning opportunity? • How does the preceptor deal with the flirtatious patient? • Or one who makes racist comments directed towards him/her or towards staff?

35. Low empathy

36. Low Empathy • Can humanism be taught? • It can be consciously modeled. • In can be consciously recognized when witnessed. • Ask, “What makes it hard for us to love this patient?” • Express curiosity about the circumstances of patients’ lives. • Depressed student? • Burn out?

37. Student seeks feedback but preceptor has only seen presentations.

38. 1 Minute Observation • Pick a skill to work on. (rapport, review of systems, giving advice, exam component.) • Observe the student for 1 minute and then leave without interruption. • Give feed back at the end of the visit. • Ferenchick et al. Arch Pediatr Adolesc Med. 1999

39. How do we share this collaboration with ambulatory preceptors?

40. Reference • AMEE Guide No 26: clinical teaching in ambulatory care settings: making the most of learning opportunities with outpatients • Medical Teacher, Vol. 27, No. 4, 2005, pp. 302–315