Dawn E. DeWitt, MD, MSc, FACP Douglas S. Paauw, MD, FACP 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 Problems, questions, problem learners Malpractice coverage (provided by the program for learners) Scope of practice: credentialing HCFA documentation requirements

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

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.

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

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

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”

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

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

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

Wave Schedule Preceptor Learner 8:00 Patient visit 8:20 Patient visit 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

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

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

“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”

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

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.

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?

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

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

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

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

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.

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...

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?

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

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

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

Grading learner Write-ups General 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

Grading learner Write-ups History 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

Grading learner Write-ups Physical 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)

Grading learner Write-ups Assessment 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

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

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

Questions? Dawn E. DeWitt, MD, MSc, FACP Douglas S. Paauw, MD, 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