The Microskills of Clinical Teaching and Learning

Objectives Describe characteristics of effective clinical learning encounters Identify, analyze and practice effective clinical teaching, using the One Minute Preceptor

Residents as Teachers Residents make a major contribution to student education Teaching improves resident learning and acquisition of knowledge “to teach is to learn twice” Miriam Bar-on, MD

Effective Clinical Teachers Communicate expectations explicitly Stimulate interest enthusiastically Interact skillfully with patients Involve the learner in the teaching process Role model desired behaviors Give feedback on performance Irby DM. Ramsey P, Gillmore J, Schad D. Characteristics of effective clinical teachers of ambulatory care medicine. Acad Med, 1991:66: & Learners

What are the challenges for teaching in the clinical setting? Time Irby DM. What clinical teachers in medicine need to know. Acad Med 1994;69:

Irby 2000

One-Minute Preceptor Validated model for effective and efficient clinical teaching Developed for outpatient clinic but can be used with learners in any clinical setting Promotes the learner’s independence and active involvement in patient care Encourages the teacher to recognize “teachable moments” Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

And Best of All… Allows for simultaneous care of patients and learners…

One Minute Preceptor 1.Assess prior knowledge 2.Get a commitment 3.Probe for evidence 4.Give positive feedback 5.Identify and correct mistakes 6.Teach the general rule 7.Encourage reflection and promote self directed learning Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #1: Assess Prior Knowledge Assess the learner’s knowledge and prior experience Establish goals for the encounter

Microskill #1 Assess Prior Knowledge Learners: Would you feel ready to see this patient? Teachers: How might the teacher have helped the learner in advance of seeing the patient? VIDEO

One Minute Preceptor 1.Assess prior knowledge 2.Get a commitment 3.Probe for Evidence 4.Give positive feedback 5.Identify and correct mistakes 6.Teach the general rule 7.Encourage reflection and promote self directed learning Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #2 Get a Commitment What is going on? The learner commits –Can be risky –The teacher’s goal is to provide a supportive and safe environment Pay attention to tone and body language

Ask The “What?” Question What do you think is going on? –(Differential diagnosis) What investigations should be ordered? –(Diagnostic strategy) What is your first choice of medication? –(Selection of therapy) What do you think is probably going to happen? –(Prognosis) What would you like to achieve in this visit or patient encounter? –(Management issue)

Microskill #2 Get a Commitment How might the teacher have solicited a commitment from the learner? VIDEO

What Gets in the Way? For the Learner: Difficulty in making a commitment may be due to ?

What Gets in the Way? For the Teacher: Difficulty in making a commitment may be due to: –Fear of silence –Fear of being wrong –Knowledge gaps –Fear of being too demanding –Fear of falling behind in patient care

One Minute Preceptor 1.Assess prior knowledge 2.Get a commitment 3.Probe for Evidence 4.Give positive feedback 5.Identify and correct mistakes 6.Teach the general rule 7.Encourage reflection and promote self directed learning Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #3 Probe for Evidence Encourage the learner to think out loud Share rationale for commitment Why do you think that is so? “What if…?” questions allow you to further identify the learning edge and push to the next level

Microskill #3 Probe for Evidence What was done well? What could have been done better? VIDEO

One Minute Preceptor 1.Assess prior knowledge 2.Get a commitment 3.Probe for Evidence 4.Give positive feedback 5.Identify and correct mistakes 6.Teach the general rule 7.Encourage reflection and promote self directed learning Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #4 Give Positive Feedback Reinforce what was done right Use language that is specific and behavioral, not just vague praise –“You did a good job of considering multiple diagnoses and prioritizing them”. –“I noticed how well you considered the patient’s age and concerns about cost in selecting medications.”

One Minute Preceptor 1.Assess prior knowledge 2.Get a commitment 3.Probe for Evidence 4.Give positive feedback 5.Identify and correct mistakes 6.Teach the general rule 7.Encourage reflection and promote self directed learning Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #5 Identify and Correct Mistakes Correction must be specific and focused –“That drug is often a good choice but in the setting of renal failure is contraindicated.” –“In children who present with diarrhea and vomiting, assessing the urine output is essential.”

Microskills #4/#5 Reinforcing and Corrective Feedback Was this useful feedback? How might the learner have handled the situation differently? VIDEO

One Minute Preceptor 1.Assess prior knowledge 2.Get a commitment 3.Probe for Evidence 4.Give positive feedback 5.Identify and correct mistakes 6.Teach the general rule 7.Encourage reflection and promote self directed learning Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #6 Teach the General Rule Choose a rule at the learner’s level Consider content areas outside medical knowledge –Professionalism –Communication Skills –Behavioral and Social Science Domains

Microskill #6 Teach the General Rule When I see a patient like this, I think about… –“In school age children presenting with headache I always consider myopia in the differential.” –“ When I see a rash that I cannot diagnose, I define it as best as I can and then look it up in…. If we don’t solve the problem by looking at that reference, we need to call…”

One Minute Preceptor 1.Assess prior knowledge 2.Get a commitment 3.Probe for Evidence 4.Give positive feedback 5.Identify and correct mistakes 6.Teach the general rule 7.Encourage reflection and promote self directed learning Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #7 Encourage Reflection and SDL At the end of your session or at the end of the patient encounter –“What do you feel you did well?” –“What was most challenging?” –“How did the practice differ from your expectations?” –“Did anything surprise you today?”

“What is your next question?” “Based on this case I’d like you to formulate your next question and go to the literature to answer it…we’ll discuss it tomorrow.” Practice-based learning Microskill #7 Encourage Reflection and SDL

Microskills #6/#7 General Rules, Reflection and SDL What did the learner do well? What did the teacher do well? VIDEO

Reflective Practice In clinical practice –Reflection on, in, and for action In clinical education –Teach –Reflect –Teach some more

One Minute Preceptor Advantages Feedback is embedded Allows for improved teaching AND assessment… –By questioning you are not only creating a stimulating learning environment but also assessing the learner’s knowledge

What do you know?Assess prior knowledge Why is going on?Get a commitment! Why do you think that?Probe for evidence/facts Warm and FuzzyPositive feedback Whoops!Identify, correct mistakes When I see a patient like thisTeach the general rule What is your next question?Promote reflection The 7 Wicroskills of Teaching

Acknowledgments This workshop was developed by: Rini Ratan, MD Andrew Mutnick, MD Lyuba Konopasek, MD Sue Bostwick, MD