Medical Precepting Strategies – Lora Cotton, DO Fast, Fun and rewarding!!!! Medical Precepting Strategies – Lora Cotton, DO

Objectives List benefits of precepting medical learners Describe commonly perceived barriers Explore strategies to overcome barriers Review strategies to increase efficiency Review strategies for effective teaching Provide contacts on how to get involved

Benefits of Precepting (Warm-fuzzies) Increased enjoyment of work Giving back to the profession Less sense of isolation Satisfaction of being a role model Teaching improves your own skill

Benefits of Precepting (practical) CME credit – 160 1B CME for every 4-week rotation Potential opportunity for Medicaid Enhanced Reimbursement Access to all OSU-COM medical library resources and services Access to CME events

Perceived Barriers Patients won’t accept learners Lack of teaching experience Productivity will decrease if I teach Not enough time to teach if I maintain productivity

Perceived Barriers – some answers Patients won’t accept learners Most patients will accept a learner Ask permission first Define and respect stated limits of learner’s involvement Lack of teaching experience Experience comes from doing Reflect on your best (and worst) teachers Start with a clear plan and a few basic strategies

Perceived barriers Productivity will decrease Not enough time to teach True with traditional precepting model Not true with other teaching methods More efficient More effective More fun for learner and preceptor

Strategy 1 make a plan and orient the learner Dates, times, planned absences Dress code When should learner speak when both of you are in the patient’s presence? Clear point of contact – you or specified office staff

Strategy 2 agree on mutual expectations Agree that feedback will be given Ask: How do you prefer to get feedback? Agree to be accountable for answering learning issues Remember to review assigned learning issues Model life long learning – assign yourself learning issues and report back to learner

Strategy 3 Set Learning Goals Ask learner to identify 3 learning goals for the rotation Set 2-3 learning mini-goals for each learning session Discuss and agree on mini-goals at beginning of each learning session (1-3 minutes) You can’t teach everything, so focus Simple, clear, identifiable: Run and read 4 EKGs Have 2 knee exams observed and critiqued Interpret 4 sets of diabetes care labs

Strategy 4 Plan for efficiency Limit number of patients learner sees They shouldn’t see every patient with you No more than 3-6 cases/half-day Consider some double booking You see one or two patients while learner sees one patient

Strategy 4 Plan for efficiency Encourage just-in-time learning Learner steps aside to find the answer immediately One does, one scribes Set time limits Presentations - 2-3 minutes “You have 10 minutes to collect the HPI and do a physical exam, then come out and tell me what you found.”

Strategy 4 Plan for efficiency Pre-Identify good teaching cases Patients with interesting medical histories often like to tell their stories to students Debrief and plan for the next day Provide important feedback not already given Clarify learning issues for homework

Strategy 5 Vary teaching Method Day 1 – learner observes preceptor Day 2 – Learner does portions of visit while observed by preceptor Day 3 and beyond……..

Strategy 5 Vary teaching methods Learner does HPI independently, then reports Learner observes HPI and exam, then steps out to develop Assessment and Plan – compare plans later Always “Think Out Loud” and encourage learner to do so also They can hear how you describe things and how you reason You can hear how they describe things and how they reason

Strategy 5 Vary teaching Method One Minute Preceptor Teaching with patients Service learning opportunities

One minute Preceptor Five micro-skills of clinical teaching Get a commitment Probe for supportive evidence Teach general rules Reinforce what was done right Correct mistakes Don’t have to apply all 5 in the same case Learner “what do I do now?” Teacher “What do you think is going on?” “What do you think we should do next?” “What choice would you make at this point?” Evidence – . Even if they are RIGHT. Guessing or really reasoning it out, or really based on true knowledge. Knowledge base, clinical reasoning skills. “What factors did you consider in making your decision?” “What are other options you considered but then discarded?” Teach general rules: Teach something that applies to the case at hand but that can be carried forward to other cases more generally – “ACE-I decrease mortality and prolong life in pts with dilated cardiomyopathy” NOT “that pt needs an ACE-I” Limit teaching dose in each case – can’t assimilate all that there is every case. If commitment was a guess and supporting evidence was weak – assign just in time learning or homework

One minute Preceptor Five micro-skills of clinical teaching Get a commitment Probe for supportive evidence Teach general rules Reinforce what was done right Correct mistakes Don’t have to apply all 5 in the same case Ask learner to self assess – what part did you do well? What part do you think you could improve upon? Opens the conversation is a less intimidating way. Early observations of things done well often decreases learners performance anxiety – makes them more open to correction “your interview style puts patients at ease” Corrections – well timed (no surprises at end of rotation or on eval), expected (set pattern early), case specific, behavior focused, descriptive (not evaluative) “You palpated all 4 quadrants of the abdomen lightly and deeply, but you forgot to auscultate first. I’ll have you show me the abdominal exam again on the next patient.”

Teaching with patients Identify a collection of teaching patients Classic physical findings Unique histories Some can provide informal feedback Teach in the patient’s presence Teaching learner informs the patient Have learner present in front of patient – when appropriate

Service Learning Help with lab/study call backs Call pharmacy to clarify medication list Assist staff in rooming, vitals, entering histories into record Start IV’s, do EKG, place Foley’s, Shadow a patient Have students learn to teach patients Inhaler use, injection use, glucometer, post- procedure care, contraception choices

Last words Create a positive learning environment Recognize things done right, coach for improvement Case specific and skill focused, not learner focused Small doses of teaching with time for synthesis Model lifelong learning skills

Want more information on how to precept OSU-COM Medical students? Ashley.Groom@okstate.edu http://www.healthsciences.okstate.edu/medical education/clinical/clerkship.php

Want more information on precepting OSU Residents? Contact the Program Director for the training program of interest: http://www.healthsciences.okstate.edu/omeco/i nstitutions/osumc.php

Resources Biagioli, F. (2008) I Don’t Have Time for Students” Showing Preceptors How to be More Efficient with Students [PowerPoint slides]. Retrieved from http://www.fmdrl.org/index.cfm?event=c.accessResource&rid=1539 Bordley, D.R. Teaching Clinical Reasoning “On the Fly” Part 1 [PowerPoint slides]. Retrieved from http://connect.im.org/p/cm/ld/fid=437 Heaton, C.J. (2009) Patient Witnessed Precepting: Faster Precepting That is Effective and Fun. Retrieved from https://www.stfm.org/fmhub/fm2003/jun03/stevens.pdf Dobbie, A.E., Tysinger, J.W., Freeman, J. (2005) Strategies for Efficient Office Precepting . Retrieved from https://www.stfm.org/fmhub/fm2005/April/Alison239.pdf Neher, J.O., Stevens, N.G. (2003) The One Minute Preceptor: Shaping the Teaching Conversation. Retrieved from https://www.stfm.org/fmhub/fm2003/jun03/stevens.pdf