Ambulatory Teaching: Time Efficient and Effective Strategies

1. Ambulatory Teaching:Time Efficient and Effective Strategies David M. Irby, PhD University of California San Francisco

2. Preview • Identify constraints on ambulatory Education • Describe efficient and effective teaching strategies • Planning • Teaching • Reflecting

3. Constraints on Ambulatory Education • Fast paced and chaotic environment • Little teaching, observation and feedback • Lack of orientation, collaborative learning and reflection Irby, 1995. Ludmerer, 1999

4. Recommendations • Make time for teaching and target to learner needs • Create opportunity space for teaching • Develop a repertoire of teaching methods • Offer opportunities for reflection, collaborative and independent learning • Offer ambulatory care conferences • Promote self-directed and collaborative learning DaRosa, 1997. Ferenchik, 1997. Heidenreich, 2000. Irby, 1995.

5. 1. Planning • Orient • Select • Prime 3. Reflecting • 2. Teaching Teacher Reasoning and Action Clinical Instruction

6. Planning • Orient learners to clinic • Introduce to people, procedures, resources • Specify case format • Solicit learner goals • Pre-select patients • Prime learners Ferenchick, 1997. Kernan, 1997. Lesky, 1995. McGee, 1997.

7. Prime Learners • For patients with a new problem • What are important causes? • What are signs, symptoms, risks? • For patients with a follow-up visit • What are preventive measures? • What are complications? McGee, 1997.

8. 1. Planning • Orient • Select • Prime 3. Reflecting • 2. Teaching • Model • Observe • 1 Min Precept Teacher Reasoning and Action Clinical Instruction

9. Teaching with the Patient • Model reflectively • Observe and teach selectively • Use the One Minute Preceptor Cunningham, 1999. Ferenchick, 1997. McGee, 1997. Usatine, 1997, 2000.

10. 1. Case Present 3. Teach Discussion Diagnose Patient 2. Inquiry Diagnose Learner One Minute Preceptor 3. Provide positive feedback 4. Teach general rules 5. Correct errors • Listen • Clarify 1. Ask for a commitment 2. Probe for underlying reasoning Neher, 1992.

11. Diagnose Learner 1. Get a Commitment 2. Probe for 5. Correct Underlying Errors Reasoning 3. Provide 4. Teach Positive General Feedback Teach Rules Five Precepting Microskills

12. 1. Planning • Orient • Select • Prime • 3. Reflecting • Reflect • Learn • Feedback • 2. Teaching • Model • Observe • 1 Min Precept Teacher Reasoning and Action Clinical Instruction

13. Reflection • Ask questions to stimulate reflection • What are your questions? • What did you learn from seeing patients today? • What troubled, surprised, moved or inspired you today? Arseneau, 1995. DaRosa, 1997. Smith, 1997.

14. Reflection • Promote self-directed learning • What is one thing you want to learn about? • Encourage self-assessment and share one-minute feedback • Share a success and a concern or question. • Specifically, you did well on… • One recommendation for improvement... DaRosa, 1997. Ende, 1995. Lesky, 1995. Neher, 1992. Smith, 1998. Usatine, 2000.

15. Conclusion • Prepare learners to be efficient • Use a repertoire of time-efficient and effective teaching strategies • Offer opportunities for reflection, collaboration and independent learning • Have fun

16. References 1 • Arseneau. Exit Rounds: A Reflection Exercise. Acad Med. 70:684-687, 1995. • Bland, et al. Faculty Development Special Issue. J. Fam. Med. 29(4):230-293, 1997. • Cunningham et al. The Art of Precepting: Socrates or Aunt Minnie? Arch Ped Adolesc Med. 153:114-116, 1999. • DaRosa, et al. Strategies for Making Ambulatory Teaching Lite: Less Time and More Fulfilling. Acad. Med. 72(5): 358-361, 1997.

17. References 2 • Ende et al. Preceptors’ Strategies for Correcting Residents in an Ambulatory Care Medicine Setting: A Qualitative Analysis. Acad Med. 70:224-229, 1995. • Ferenchick, et al. Improving the Efficiency and Effectiveness of Clinical Preceptors in the Ambulatory Setting. Acad. Med. 72(4):277-280, 1997. • Heidenreich et al. The Search for Effective and Efficient Ambulatory Teaching Methods Through the Literature. Ped. 105(1:Suppl):231-237, 2000. • McGee, Irby. Teaching in the Outpatient Clinic: Practical Tips. JGIM. 12; April(Suppl 2): S34-S40, 1997.

18. References 3 • Irby. How Attending Physicians Make Instructional Decisions When Conducting Teaching Rounds. Acad. Med. 67:630-638, 1992. • Irby. Teaching and Learning in Ambulatory Care Settings: A Thematic Review of the Literature. Acad Med. 70:898-931, 1995. • Kernan, O’Connor. Site Accommodations and Preceptor Behaviors Valued by Third Year Students in Ambulatory Internal Medicine Clerkships. Teach Learn Med. 9(2):96-102, 1997. • Lesky, Hershman. Practical Approaches to a Major Educational Challenge. Arch Intern Med. 155:897-904, 1995.

19. References 4 • Ludmerer. Time to Heal. Oxford University Press, 1999. • McGee, Irby. Teaching in the Outpatient Clinic: Practical Tips. JGIM. 12:April(Suppl 2):S34-S40, 1997. • Neher, et al. A Five-step "Microskills" Model of Clinical Teaching.Journal of the American Board of Family Practice. 5:419-424, 1992. • Smith, Irby. The Roles of Experience and Reflection in Ambulatory Care Education. Acad Med. 72:32-35, 1997. • Smith et al. A Broader Theoretical Model for Feedback in Ambulatory Care. Advances Health Sci Educ. 3:133-140, 1998.

20. References 5 • Usatine et al. Four Exemplary Preceptors’ Strategies for Efficient Teaching in Managed Care Settings. Acad Med. 72:766-769, 1997. • Usatine et al. Time Efficient Preceptors in Managed Care Settings. Acad Med. 75:, 2000.