Teaching in the Real World

1. Teaching in the Real World Tips for Integrating Learners into Busy Practice Settings November, 2003

2. Our sincere thanks to several hundred experienced clinical preceptors, residents and students who have contributed these “Teaching Tips” at faculty development workshops over the last thirteen years

3. Objectives By the end of this session, participants will be able to: • list five new ideas for efficient teaching in busy clinical settings; • demonstrate that they can plan ahead for effective clinical teaching; and • actively participate in clinical teaching to a greater extent than previously

4. Introduction • Goals • Needs • Objectives • Methods • Evaluation

5. Introduction • Goals • Needs • Objectives • Methods • Evaluation

6. This talk is devoted to “Methods” • There are many things that experienced preceptors ask learners to do that save them time, while adding quality to their practice and teaching However . . .

7. Methods should not drive objectives!Objectives should reflect the learner’s needs! • Be clear about matching your objectives to the learner’s needs • One learner’s teaching objective may be another learner’s “scut work” • If it doesn’t match, label it as “scut work” • Tell the learner that any time s/he helps to save you will be made up in dedicated teaching time • Say thanks at the end of the day

8. How can I teach and practice at the same time? • Clinical teaching is similar to clinical practice • You don’t need to do it all at once • Feel free to prioritize • Pay attention to educational priorities • Pay attention to clinical priorities

9. Plan ahead Provide an orientation Have learners do things that save you time and benefit your practice Learn from your learner Plan how you will use space Teach on the fly Scheduling: Tailor the schedule to meet clinical and teaching objectives Look for unique educational opportunities Establish guidelines for communication Tips for using the medical record General Principles

10. Planning • If you don’t plan it, it won’t happen • Working the student into your schedule • Schedule protected times • Formal first-day orientation • Mid-point evaluation • End of rotation • Other protected times for problem-solving, discussion, feedback, evaluation • Plan other scheduled activities • Plan for days when you are not available • Offer a menu based on needs, interests

11. Orientation – four aspects • Orient the student • Orient your patients • Orient your staff • Orient yourself

12. Orient the Student • Pre-clerkship: Invite the student to visit • Is this right for you? • Does the student meet certain criteria (e.g. language, etc) • First day: Plan a formal orientation session • Prepare a written description of the practice • Have one student prepare a written description to be used with future students • Provide a copy of your mission statement (Community Health Center) • Set up a web site for students; mention them on your practice web site

13. Orient the Student (cont) • Prepare written guidelines of expectations • Logistics: Include specifics about dress, hours, parking, use of staff areas, food, etc • Educational guidelines: Set progressive goals through the weeks • Expectations about confidentiality • Provide a learning contract • What are your needs? What do you want to learn? • List specific learning objectives • Orient the student to your life style • Personal • invite them into your home • Professional - hospital, committees, call, etc.

14. Orient your patients • Announce your role • Sign in the waiting room • Name on the door • Handouts, pictures • Invite patients to be teachers • Develop a questionnaire (or have a student develop a questionnaire) • Has the student added to the visit? • Provide a business card for the student

15. Orient your staff • Make them active participants in the educational planning process • Make it a team approach • What can each staff member contribute to the learner’s education? • Have the staff orient the student, give tours • Provide an opportunity for the staff to participate in providing feedback or evaluation

16. Orient your staff (cont) • Introducing the student to the staff • At a staff meeting • At a social gathering • Introducing the student to patients • Plan explicit guidelines with your office staff • How will students be introduced to patients? • How will you obtain permission from patients?

17. Orient yourself • Read the curriculum • Read the readings • Participate in faculty development

18. Tell students that anything they can do to save you time will be made up in active teaching time Thank the student at the end of the day! Activities that can save you time: Take vitals, chart notes Talk to patients who are waiting when you are running behind – it’s “better than a magazine” Write prescription refills Write out patient instructions Go over written patient education materials Make medication lists, ID bracelets Do asthma education Construct a genogram Go through the chart to see if health maintenance guidelines are up to date Have students do things that save you time and benefit the practice

19. Have students do things that save you time and benefit the practice (cont) • Working with younger patients: • Perform Denver Developmental Testing • Working with older patients: • Perform Mini-Mental status exam • Interview other caregivers • Help elderly patients get dressed and undressed • Talk to elderly patients • Procedures – Students need to be allowed to do things • Phlebotomy • Ear flushing

20. Have students do things that save you time and benefit the practice (cont) • Have a student focus on a puzzling problem • Working with a patient or family that has been a puzzle • Interview family members • Make a home visit • Research a difficult clinical issue • Office projects • Develop evidence-based medicine resources • Develop patient education materials • “Why won’t my baby sleep?” “How big will my baby be?”

21. Learn from the Student • They may know better . . . • Use of a Palm Pilot, technology resources • About new drugs, yesterday’s lecture • Personal issues • About their culture, their own life experiences • Dealing with clinical questions • “ “Take a day, get back to me” • Don’t feel threatened by a student who knows something you don’t know • Don’t confuse knowledge with information

22. Think about the use of space • Provide space for the student: a desk, a shelf, in and out boxes, a TV table, etc. • If an extra exam room is available, you can have the student use it, while you move ahead as needed • Use your consult room for history taking • Use your partner’s desk on his/her day off • Rotate desk in a large practice • Move phlebotomy to the exam room

23. Methods for teaching “on the fly” • Have the student see the patient ahead of you • Observe the student interview the patient • Try not to interrupt • Stand behind the student • Stand behind the patient • Have the student present to you in front of the patient

24. Teaching on the fly (cont) • Teaching in front of the patient • Works best: • Present the history • Skills: Physical exam, procedures • Doing patient education • Modeling • Use of questioning (vs. “pimping”) • Riskier • Complex problem solving • Differential diagnosis • Bad news

25. Scheduling: Tailor the schedule with clinical and teaching objectives in mind • Schedule events that will help the student • Review the schedule ahead of time • Review charts ahead of time • Double book the first slot, allowing the student to start along with you • Specific content areas (e.g. a required H&P): Have a patient come in early • Schedule time with others in the practice • Practice partners, Nurse Practitioners, Physician Assistants (one could serve as coordinator) • Office staff • Nurse • Health Educator • Phlebotomy • Health Assistant • Billing Clerk • Referral Coordinator • Receptionist/Appointment Clerk

26. Schedule with clinical and teaching objectives in mind (cont) • Schedule time with others outside the practice • Consultants in your building • Community resources • Nutritionist • Social worker, Outreach worker • Visiting nurse, Hospice • Day care center • Adult day care center, Nursing home • Pharmacy • Health Department • Local sheriff, local law enforcement officials • Find respite time • Send the student to read up on something that will come up later in the day • Encourage the clerkship to schedule out-of-office time • Take a second medical student, or a PA or NP student

27. Take advantage of unique educational opportunities • Share your library, educational resources • Identify patients with problems (diabetes, etc.) who are willing to act as teaching resources • Link the student with patients who will present frequently during the clerkship • Newly diagnosed patients, prenatal patients, patients in crisis, patients in transition • Provide a beeper

28. Take advantage of unique educational opportunities (cont) • Involve the student as you respond to acutely ill patients • Have the student phone patients who are acutely ill, make followup phone calls • Use of a speakerphone • Manage fewer acutely ill patients over the phone • Have the student prepare for a sick patient who is coming in • Involve the student in after-hourscall • Use of a conference-calling feature

29. Take advantage of unique educational opportunities (cont) • Involve the student in nursing home care • Challenge: Continue to see patients until you find three medications that can be discontinued • Have the patient accompany your patients • To see a consultant • To have a procedure done • To the Radiology Department • To OT or PT • To accompany the Visiting Nurse

30. Take advantage of unique educational opportunities (cont) • Review phone messages with the student • Have the student make the return calls • Have the student review lab work • Have the student call patients with results • Community activities • write a patient education column for the local paper • do a project in the community • Go together • Rounds, conferences, even to a deposition

31. Communication • Communicate by phone • Share your home phone number • Use the practice’s “inside” number • Communicate by email • Logistics • To provide feedback • Provide an orientation handout

32. Using the medical record • Have the student do chart reviews, participate in QI projects • Have the student type up notes, email them in • Regarding Medicare (and in some states, Medicaid) • “The only documentation by medical students that may be used by the teaching physician is their documentation of the review of systems and past, family and social history. The teaching physician may NOT refer to a medical student’s documentation of physical exam finding or medical decision making in his/her personal note.” AAMC tutorial: “Medicare’s Teaching Physician Documentation Instructions” • Most suggest that medical student notes should not be a part of the permanent record • Some use student notes as prompts

33. This session focuses on Methods But remember: