“ To teach is to learn twice. ” – Joseph Joubert

+ The One-Minute- Preceptor Model and SNAPPS

+ Objectives As a result of this session participants will be able to: Develop an organized approach to teaching clerks and residents: Using the “One-Minute-Preceptor” model Using the SNAPPS model

+ The Five Steps Get a commitment Probe for understanding Reinforce what was done well Correct mistakes Teach a general rule

+ Step #1Get a Commitment - “What do you think is going on?” NB: The learner must feel safe enough to risk a commitment – even if it is wrong.

+ Get a Commitment – Alternative Questions The IssueHow to Ask for a Commitment Differential diagnosis What....? (do you think is going on or is most likely?) Diagnostic strategy What....? (investigations should be ordered?) Selection of therapy What....? (is your first choice of medication?) PrognosisWhat....? (do you think is probably going to happen?) Management issue Why....? (do you think this patient is non-adherent?) What....? (would you like to achieve this visit)

+ Step #2 Probe for underlying reasoning or supportive evidence.

+ Probe for underlying reasoning - Additional questions What......( factors make this diagnosis likely)? Why (do you suggest getting this test first?) Which......(medications are available for this condition?) How (did this prognosis emerge as the most probable?) What if……(the patient were 30 instead of 60?) Others…

+ More on questioning… What makes a question helpful vs. not helpful?

+ Two Main Types of Questions To clarify the clinical story: To fill in gaps in the case presentation To understand the case presentation To facilitate learning: Ongoing needs assessment Help students retrieve related knowledge & integrate it with new knowledge Practice retrieval Get them to think deeper Stimulate wonder Explore attitudes & feelings Get students into the habit of asking their own questions

+ Open vs. Closed Questions Closed-ended: “ What is the usual starting dose for simvastatin? ” “ What are the names of the 12 cranial nerves? ” “ What is the target BP for a patient with diabetes and hypertension? ” Open ended: “What diagnoses are you considering?” Why do you think that? “What might be some contributors to Mr. Jones heart attack?” “How would you justify the use of test X in this case?”

+ Questioning Tips cont ’ d. Include questions that help students explore their attitudes and feelings e.g. “ How would you describe that patient ’ s impact on you? Your internal reaction, how you felt. ” in addition to questions on clinical content.

+ Questioning Tips… Avoid playing “ Guess what I ’ m thinking. ” E.g. “ What do you think is the key to success in managing hypertension? ”

+ Step #3Reinforce what was done well

+ Reinforce What was Done Well Some examples: Be specific! "You did a good job of… considering multiple possibilities and prioritizing the most probable diagnoses" "I noticed how well you… considered the patient ’ s age and concerns about cost in selecting medications"

+ Step #4Correct mistakes

+ Correct Mistakes: Be specific! "I agree this patient ’ s headache is worrying him, but from the history and in the absence of neurological signs, CT is more likely to distract us with false positive findings than change the diagnosis or management plan.” "That drug is often a good first choice for this condition, but she is also taking warfarin (or has an elevated creatinine) and the interaction would be dangerous.”

+ Use the Field Note as a Guide: Identify behaviour the learner knows how to do, and could do, or do more often. Continue (strength to reinforce): Comment on aspects of performance that were effective. Consider (for development) a. Identify a behaviour the learner knows how to do and encourage to do more often, or b. Highlight a point of growth for the learner, a doable challenge (aka. SMART goal) for future interactions. Stop or do less (correct mistakes): Describe actions that were not helpful, or could be harmful.

+ Feedback: How to be specific Focus on observations, not inferences “ You did such and such vs. you are… ” Focus on descriptions, not judgments “ What I observed was… vs. that was inadequate. ” Focus on specific details, not generalities “ At the start of the interview with Mrs. Jones, I noticed…vs. your introductions are all… ”

Correct Mistakes… Elicit or suggest alternative behaviours. Address realistic changes in doable steps (SMART goal). Provide an opportunity to try again (with real patient, simulated patient or role play). Establish clear follow-up plans.

+ Step #5Teach general rules

+ General Rules - Examples "In (certain population) with (specific diagnosis), it is important to consider (general rule).” Even better…ask the learner about his/her take home message

+ The One Minute Preceptor Model Get a commitment Probe for understanding Reinforce what Correct mistakes Teach a general rule Field Notes

+ SNAPPS

+ Application Points: Good for providing resident or senior student with framework for case presentation and expectations Student/resident led – At the beginning the student or resident may need prompting but should quickly learn acronym and lead the discussion. Does not include a feedback component so ideal for using with field notes.

+ S – Summarize the case N – Narrow the differential A – Analyze the evidence P – Probe the preceptor P – Plan the management and follow-up S – Self-directed study topic

+ S – Summarize the case N – Narrow the differential A – Analyze the evidence P – Probe the preceptor P – Plan the management and follow-up S – Self-directed study topic

+ S – Summarize the case N – Narrow the differential A – Analyze the evidence P – Probe the preceptor P – Plan the management and follow-up S – Self-directed study topic

+ S – Summarize the case N – Narrow the differential A – Analyze the evidence P – Probe the preceptor P – Plan the management and follow-up S – Self-directed study topic

+ S – Summarize the case N – Narrow the differential A – Analyze the evidence P – Probe the preceptor P – Plan the management and follow-up S – Self-directed study topic

+ S – Summarize the case N – Narrow the differential A – Analyze the evidence P – Probe the preceptor P – Plan the management and follow-up S – Self-directed study topic* * Instead of self-directed study I use self reflection and have the resident complete their own field note.

+ Use the Field Note as a Self- Directed Learning Guide: Identify behaviour the learner knows how to do, and could do, or do more often. Tell me what you thought went well (strength): Comment on aspects of performance that were effective and good to continue. Identify something that you would like to work on or try (for development) a. Identify a behaviour the learner knows how to do and encourage to do more often, or b. Highlight a point of growth for the learner, a doable challenge (aka. SMART goal) for future interactions. Describe something that you were not happy with (correct mistakes): Describe actions that were not helpful, or could be harmful and should be stopped.

+ Role Play - Try to guide your neighbour through either one of these teaching models. Then switch roles.

+ Questions?