Five Microskills of Clinical Teaching (One Minute Preceptor) Instructor Name

Goal Residents will be able to effectively integrate the 5 microskills of clinical teaching into the daily clinical routine.

Objectives At the end of the session, the learner will be able to: Identify the 5 clinical microskills Describe rationale for each of the microskills Demonstrate the technique for each of the microskills

What You are Working With... Your considerable medical knowledge Your desire to be an effective teacher Your uncertainty about what you may need to teach Your uncertainty how to best teach a topic Your limited time = Challenge to fit teaching into your daily routine

What You Already Do … Much of clinical teaching is discussing a patient Student/Intern interviews & examines patient Presents to preceptor (i.e., YOU) Make clinical decisions Diagnosis, tests to order, treatment On average, this takes approximately 10-minutes

What You Already Do …

Teacher Reasoning During Case Presentations & 5 Microskills for Clinical Teaching

Example Student: "I just examined a 26 year-old female, with dysuria for the past few days. She has never had a urinary tract infection. She denies abdominal pain, fever or seeing blood in her urine. She thinks her last menstrual period was a couple of weeks ago. I don’t know if she is sexually active. I wasn’t sure if I was supposed to ask those kinds of questions.”

Example Student: "On exam, she looked well. She was afebrile and the rest of her vital signs were O.K. Her lungs were clear and her heart was regular without any murmurs. Her abdomen was soft and not tender and I didn’t think her spleen or liver were enlarged. That’s all I examined."

Example Preceptor : "Get a urine and write for Cipro.” In this example, the student was not given an opportunity to learn or really think rather, the student was simply told what to do.

Five Microskills of Teaching 1. Obtain a commitment 2. Probe for supporting evidence 3. Teach general rules 4. Reinforce what was right 5. Correct mistakes Neher JO, Gordon KC, Meyer B, Stevens N. A five- step "microskills" model of clinical teaching. Journal of the American Board of Family Practice 1992; 5:

No. 1: Obtain a Commitment When the case is presented to you ask the learner what they think Example Questions LIKELY to Get a Commitment: “What do you... think is going on with this patient?” want to do next in the work-up?” want to accomplish during this hospitalization?”

No. 1: Obtain a Commitment Commitment on ANY clinical decision... What other diagnoses would you consider? What lab tests do you think we should get? How should we treat this patient? What antibiotic do you want to use? Do you think the patient needs to be hospitalized? Based on the history, what parts of the physical exam should we focus on?

No. 1: Obtain a Commitment Example questions NOT LIKELY to get a commitment: “Sounds like pneumonia, don’t you think?” “Anything else?” “Did you find out which symptoms came first?”

No. 2: Probe for Supporting Evidence When discussing the case, before offering your opinion, ask learners for evidence supporting their opinion Helpful approaches: “What were the major findings that led to your conclusions?” “What else did you consider?” “What did you rule out that choice?”

No. 2: Probe for Supporting Evidence Non-helpful approaches: “What are the possible causes of the elevated temperatures?” “I don’t think this is good. Do you have any other ideas?” “This seems to be a classic case of...” “What do you know about her last admit?”

No. 3: Teach General Rules Learner’s responses reveal that he/she need to know something. Provide general rules, concept, etc at learner’s level of understanding. Helpful approaches: “If patient only has... then... is not possible.” Patients with... usually experience pain w/... The labs should show...”

No. 3: Teach General Rules Non-helpful approaches: “This patient needs... now. Don’t start the... until tomorrow. “I’m convinced that to diagnose... you need a... “

No. 4: Reinforce What They Did Right Learner has handled the situation well Comment on the SPECIFIC good work and effect it had Helpful approach: “You did a very thorough job evaluating the patient’s abdominal complaints. Identifying the... was critical in making the diagnosis.”

No. 4: Reinforce What They Did Right Non-helpful approaches: “You are absolutely right. That was a wise decision.” “Nice job taking care of those patients today.”

No. 5: Correct Mistakes Learner has demonstrated mistakes Find appropriate time and place to discuss ASAP. First allow learner to own performance. You then detail negative effect & correction needed.

No. 5: Correct Mistakes Helpful approach: “I agree the patient is probably drug seeking, but we still need to do a careful H&P before we make any recommendation.” Non-helpful approaches: “You did what?” “I can’t believe you ever got into medical school!”

Microskill Demonstration Teaching Scenarios Videos from the University of California, Irvine’s BEST Program: Copyright © The Regents of the University of California. All rights reserved.

Microskills of Teaching 1. Obtain a commitment 2. Probe for supporting evidence 3. Teach general rules 4. Reinforce what was right 5. Correct mistakes Neher JO, Gordon KC, Meyer B, Stevens N. A five- step "microskills" model of clinical teaching. Journal of the American Board of Family Practice 1992; 5:

Example Student: "I just examined a 26 year-old female, with dysuria for the past few days. She has never had a urinary tract infection. She denies abdominal pain, fever or seeing blood in her urine. She thinks her last menstrual period was a couple of weeks ago. I don’t know if she is sexually active. I wasn’t sure if I was supposed to ask those kinds of questions.”

Example Student: "On exam, she looked well. She was afebrile and the rest of her vital signs were O.K. Her lungs were clear and her heart was regular without any murmurs. Her abdomen was soft and not tender and I didn’t think her spleen or liver were enlarged. That’s all I examined.“ Based on what you just learned about microskills, what would be a better question to ask?

1. Get a Commitment Preceptor: "What do you think is her problem?" Student: "I am concerned that it might be a urinary tract infection."

2. Probe for Understanding Preceptor: "What do you see here that might indicate a urinary tract infection?” Student: "She has pain on urination but not much of a problem with frequency or urgency of urination. I thought UTIs had other symptoms like that.” Preceptor: “What else could she have?”

3-5. Teach General Rules, Provide Positive Feedback, Correct Errors Preceptor: "You identified the most probable concern in this case but you need to complete the physical exam and get a sexual history. Without more information, we can’t be sure of what we have."

3-5. Teach General Rules, Provide Positive Feedback, Correct Errors Preceptor: "Do you want me to model how to take a sexual history and do a pelvic examination or would you like me to observe you do them?“ Student: "I would really appreciate your demonstrating how to do them.“ Preceptor: “Okay, let’s go and see the patient."

Key Points Your teaching time is limited Make the most of the time you have Incorporate it into what you do everyday Microskills enable you to effectively assess, instruct, and give feedback more efficiently

Questions???