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Orienting Learners to the Outpatient Setting: Goals, Expectations, Learning Strategies

Orienting Learners to the Outpatient Setting: Goals, Expectations, Learning Strategies. Dawn E. DeWitt, MD, MSc, FACP Douglas S. Paauw, MD, FACP. Program Coordinator Site Orientations. Site selection Set expectations for the site Curriculum, Feedback and Evaluation

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Orienting Learners to the Outpatient Setting: Goals, Expectations, Learning Strategies

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  1. Orienting Learners to the Outpatient Setting: Goals, Expectations, Learning Strategies Dawn E. DeWitt, MD, MSc, FACP Douglas S. Paauw, MD, FACP

  2. Program Coordinator Site Orientations • Site selection • Set expectations for the site • Curriculum, Feedback and Evaluation • Problems, questions, problem learners • Malpractice coverage (provided by the program for learners) • Scope of practice: credentialing • HCFA documentation requirements

  3. Preceptor Selection • Interest!!! • Qualifications: Board Certified • Malpractice coverage • Teaching Experience • Willing to work with the program

  4. Preceptor Myths and Realities • I won’t have time. • Teaching takes time; about 1 hour per day • “Wave” schedule enables productivity • I don’t know what to teach. • Preceptors offer practical knowledge and hands-on experience just in day-to-day doings. • Learners crave “real world” experiences with role models who care for their patients. Learners want meaningful responsibility so that they can participate in patient care.

  5. Benefits for Preceptors • The stimulation of teaching. Learners put a fresh face on medicine. • An association with the program and an opportunity to become clinical faculty • Access to University faculty • Access to email/internet information through Universities • CME credits and Teaching Certificates/Awards

  6. Role Modeling and Mentoring • Learners are trying your job and life on for size • Model positive enthusiasm • Learners especially watch how we deal with difficult situations • Allow learners to see long term relationships with patients • Studies show internists don’t encourage learners to go into GIM and underestimate learner interest

  7. Before the Learner Starts • A letter and call telling them when and where to arrive the first day • Program expectations • Learner’s “schedule” and days off • Dress Code • Housing (if offsite), Transportation, Parking, Community Activities • Block out time for “orientation”

  8. Orienting Learners: the first day • Set aside time! “This is your Orientation.” • Tell them a bit about you and your practice • Ask them about • their previous outpatient experience • their specific learning goals • their career goals • Explicitly set a mid-rotation feedback time

  9. Orientation: the Office • Introduce them to your staff • Exam Rooms: gloves, gowns, etc. • “Their” Work space • Charting/Dictation • Expectations about charting • Telephones • Library/Computer Access

  10. Patient Scheduling • Clinic Schedules: 1-2 new and 3-5 follow-up per day • Call Schedules • Other learning opportunities • Home visits • Nursing Home • Physical Therapy • Lab, Blood draw • Business meetings

  11. Preceptor 8:00 Patient visit 8:20 Patient visit 8:40 Learner patient 9:00 Patient visit 9:20 Patient visit 9:40 Patient visit 10:00 Learner patient Learner 8:00 Chart review #1 8:20 Patient visit #1 8:40 Present patient 9:00 Charting #1 9:20 Chart review #2 9:40 Patient visit #2 10:00 Present patient Wave Schedule

  12. Seeing Patients • Learners need meaningful (supervised) responsibility • Review the learner’s schedule for the day with them • Select patients if possible • Inexperienced learners do best seeing simple cases and classical presentations • Consider urgent visits versus chronic problems • Good historians

  13. Introducing the Learner • Patient acceptance • Title and learner’s role • “Teacher of the day” • Permission to have the learner present in front of the patient

  14. “Meaningful Responsibility” • Students and Residents need “meaningful responsibility” • Balance “seeing it all” with student independence • Ideally: their own space and schedule • Residents should be “accountable colleagues”

  15. Making it Great: Expectations • Explicit • Professional behavior • Duties • Curricular • Weekly goals • Week 1: communication • Week 2: physical diagnosis • Week 3: differential diagnosis • Week 4: therapeutics and follow-up

  16. Priming the Learner: Uncomplicated Patients • Uncomplicated patient for “routine visit” • What screening or preventive issues are important? • Common problem like “fatigue”: • Let’s generate a differential. • What symptoms and signs should we look for? • What tests might help us? • Here is a short resource.

  17. Priming the Learner: Complicated Patients • Complicated patient with urgent issue • Differential in setting of chronic issues • How will we decide if this patient needs to be hospitalized for this problem? • Complicated patient with multiple issues • Please focus just on diabetes management. What complications/problems should we worry about?

  18. Framing the Visit • Time limit • How much to do (Hx and PE or just Hx) • Goal for presentation • I want a 3 minute SOAP presentation vs. I want a 1 minute consult presentation

  19. Presentations: In the Room? • Patient preference • involves the patient/extra attention • saves time • observe learner/patient interaction • demonstrate eliciting additional history, physical findings, or patient education • satisfies HCFA requirements

  20. Presentations: Out of the Room? • Better for • analyzing the learner’s thought processes • discussion of differential diagnosis • literature debates or pathophysiology • allowing learners to have a bigger role in patient education

  21. Balancing Teaching and Patient Care • Goals for attending/learner interactions • Diagnose the patient • Diagnose the learner’s needs • Be conscious of patient flow • Provide educational experience for learner • Provide excellent patient care

  22. Assessing the Learner • Importance of meaningful independence • Observe learner doing parts or a complete H&P • TRY not to take over • Take notes on technique, approaches, organization, etc.

  23. One Minute Preceptor • Get a commitment • What do you think is going on? What do you want to do? • Probe for supporting evidence • What led you to that conclusion? What else did you consider? • Teach general rules • Tell them what they did right and the effect it had • Correct mistakes • Next time consider trying...

  24. Learner-Centered Problem-Solving Attending • What is their major question about this case? • What is the patient’s agenda and why this/now? • What is the student’s most likely dx? • What else did they consider? • What do they want to do next?

  25. After the Visit • Debrief after each patient with one or two brief teaching points • Emphasize follow-up • Problem lists and medication lists • Review or summarize goals for that patient’s care • “To do” lists

  26. Learning Agendas • History-taking and Physical diagnosis • Case management • Charting • Doctor-patient communication • Practice style and efficiency • Telephone triage and telephone medicine • Preventive medicine • Urgent vs. Chronic care

  27. Learning Strategies • Should always be learner-centered • Literature “review” • Reflection on what went well/wrong • Games: find the finding • Teach me something • Chart review • Goal of the day

  28. Grading learner Write-upsGeneral • Timely: when you expect it to be completed • Legible: acceptable mistakes, initialed • Signed and Patient ID on each page • Length: review • Organized: sections identified/ordered • Avoid repetition, e.g. ROS and PL/PMH • Problem/system-based A&P • Appropriate language and abbreviation • Spelling

  29. Grading learner Write-upsHistory • Problem List • Medication List: generic names & doses • HPI: Pertinent • positives and negatives • ROS, FH, SH for complaint • previous work-up • Allergies: with reaction • PMH (other inactive problems) • Brief and Pertinent FH, SH

  30. Grading learner Write-upsPhysical Exam • Organized by system • Questions re CV exam/pulses, etc. • Neurological and Musculoskeletal • Organized within system • e.g. observation, auscultation, percussion, palpation • Appropriate level of detail • e.g. cranial nerves (“intact” or each described)

  31. Grading learner Write-upsAssessment and Plan • Problem or System Based • Order of problems • Groups appropriately: e.g. type 2 DM, proteinuria, neuropathy • Expands differential: most likely and “do not miss” • Justifies most likely • Incorporates outside reading • Depth of discussion

  32. Honors Work & Behavior • Knowledge • Has the information • What they do with it • “RIME” method • Reporter • Interpreter • Manager • Expert/Educator • Professionalism/Preparedness/Punctuality • Follow-up with patient/educational issues

  33. Resources • Paauw D, Burkholder L, Migeon M, eds. Guide to Internal Medicine, Mosby, 1999. • Fihn & DeWitt eds. Outpatient Medicine, Saunders, 1998.

  34. Questions? Dawn E. DeWitt, MD, MSc, FACP WWAMI Coordinator, Medicine Residency Medicine 665 Wyoming and UWMC Ambulatory Clerkship Coordinator email: dewitt@u.washington.edu Douglas S. Paauw, MD, FACP Medicine Clerkship Coordinator email: dpaauw@u.washington.edu

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