Academy of Medical Educators Clinical Teaching Development

Individual Precepting

Learning Objectives Practice framing and priming a learner for a patient encounter Review precepting pitfalls and how to avoid them Integrate the “One Minute Preceptor” into a patient encounter

Probe for Supporting Evidence Learning Objectives Assessment Teaching Methods Frame the Encounter Prime the Learner Teach a general rule Provide feedback Get a Commitment Probe for Supporting Evidence

Here you are… You, a PGY2 resident and a student are reviewing your patient list for today. You are going to divide and conquer…You’ll give the resident several of the patients to see independently & check out, and have the medical student see patients with you.

Output Focus Duration Output As you think about sending these 2 learners off into patient rooms, how should we FRAME their clinical experience? Size of your frame depends on the learner’s experience in this setting.

Framing the Clinical Setting Clinic. 15 patients on the list. 3 new patients, 12 follow-ups. Inpatient. New consult on an admitted patient.

Prime the pump

You ask a 3rd year medical student to read a chest x-ray on a 58 y/o man with CHF and COPD presenting with acute dyspnea. Which of the following would be most appropriate to prime the student? Do you think the patient has a heart failure exacerbation? Make sure you look for Kerley B lines on the x-ray What x-ray findings may help establish a diagnosis in this patient? When you read the x-ray, make note of the findings that are specific to COPD

Prime the learner for this patient 1. Provide patient specific background information 2. Review relevant medical information 3. Identify important tasks to be performed Every day is

Your goal is to get the learner thinking ahead to this visit. How can you do that? ASK>TELL

You are about to see James, a previously healthy person with a chief complaint of cough for the past week. PRIME for differential diagnosis PRIME for associated signs/symptoms PRIME management decisions that might need made   

What are a few things that can cause cough X 1 week? You are about to see James, a previously healthy person with a chief complaint of cough for the past week. What are a few things that can cause cough X 1 week? What are some of the other symptoms you might want to ask about? What parameters will you look at to see how sick he is?    

You are sending a student to see a patient in clinic you know well. She had a gastric bypass 2 years ago, still has nausea and diarrhea, which is chronic. You see her frequently to keep her out of ED and ensure she doesn’t get volume depleted.

Teaching Clinical reasoning

Characteristics of Teaching Styles Reliance on Teacher Reliance on Learner Characteristics of Teaching Styles Assertive / Suggestive Emphasis on teacher’s knowledge & experiences (Cognition) Emphasis on learner’s reasoning skills and feelings (Reflection) Collaborative / Facilitative

Teaching Clinical Reasoning Comparisons/contrasts Causes of similar clinical presentations Clinical presentation of an alternative diagnosis

A 2-year-old boy presents for a preventive healthcare examination A 2-year-old boy presents for a preventive healthcare examination. He has been growing and developing normally. The resident hears a blowing systolic murmur at the left upper sternal border.

Similar Clinical Presentations How is this murmur similar or different from the last child we listened today who had a murmur? What causes would you consider in an elderly patient with a systolic murmur in the same location?

Alternative Diagnosis What would you hear if this were mitral regurgitation? What causes would you be concerned about if the murmur was loudest at the left lower sternal border?

Precepting Pitfalls

Closed Questions You ask an intern to see a 62-year-old woman who presents with a 6-month history of left leg pain that occurs with exercise. You ask the intern: “Could this patient have peripheral vascular disease?”

Taking Over Your intern sees the patient and presents the history and physical to you, providing appropriate details suggestive of peripheral arterial disease. You respond, “Great job. Sounds like claudication. Go ahead and order an ABI.”

Soliloquy Teaching You ask an intern to see a 62-year-old woman who presents with a 6-month history of left leg pain that occurs with exercise. You spend 5 minutes describing the risk factors, clinical features and diagnostic approach for peripheral vascular disease. Inefficient use of time (poor learner retention) Does not assess learner’s baseline knowledge

Over the top Your intern sees and then presents the patient, describing the patient, “62-year-old woman with an 80 pack year smoking history, likely leading to peripheral vascular disease.” You respond, “How does smoking lead to peripheral arterial disease?”

Pitfalls in Precepting Closed questioning Over the top Taking over Soliloquy

Strategies

Make your case  Approach:  Instruct learner to convince the MD of a particular diagnosis (or treatment plan) within 20 seconds. What is critical? Demographics Hx Exam Tests

Examples: “You have a sore throat Examples: “You have a sore throat. You are convinced the problem is Group A Strep pharyngitis. You have 20 seconds to persuade the physician you are seeing that you need a throat culture and/or antibiotics.” ”Your pt has abdominal pain. You have 20 seconds to convince me that this patient has acute appendicitis and needs to go to the ED.” “You are seeing a patient with chest pain. You need to convince me to call the cath lab.”

The One minute preceptor

Ask Teach Tell 1 minute preceptor 1. Get a commitment. 2. Probe for supporting evidence. 3. Teach general rules. 4. Reinforce what was done right. 5. Correct mistakes. Teach Tell

Ask ≠ “Pimp”

Ask, then wait.

Patient Description Ask Questions Ask Questions Teach Give Feedback Provide patient specific background information Review relevant medical information Identify important tasks to be performed Patient Description Ask Questions Get a commitment Probe for supporting evidence Teach general/practical rules Reinforce what was done right Correct mistakes Ask Questions Teach Give Feedback

Cognitive Biases

Framing Effect Student: “This 40 y/o woman has an acute onset of redness and swelling of her right leg. She just needs a course of sulfamethoxazole-trimethoprim.” Student: “This 40 y/o woman has an acute onset of redness and swelling of her right leg. I am not sure if she has cellulitis or an abscess.” Different assumptions of ability depending on the way information is presented.

Affective Bias “I was already having a stressful day, then I went to clinic, and the residents were so slow and inefficient.” Mood determines the perception of future events, particularly the likelihood of positive vs. negative.

Contrast Bias “My acting intern is on top of everything, but my 3rd years are clueless.” Assessments rely on immediate examples that come to the person's mind rather than appropriate standards.

Anchoring Bias “This resident just has not improved over the course of our rotation together.” Assessments rely on early information, so that additional data does not alter impressions.

Recency Bias “I thought this student was struggling throughout the rotation, but she really showed great promise with that last presentation.” Assessments rely on the most recent behavior, instead of the totality of the work performed.