Time Efficient Clinical Teaching Margo H. Vener, MD MPH Walt Mills, MD, MMM UCSF School of Medicine and Santa Rosa Family Medicine Residency Program June 7, 2011

Session Outline Background Introduction to the One-Minute Preceptor Model One-Minute Preceptor Practice Introduction to feedback and the Brief Structured Clinical Observation (BSCO) BSCO practice RIME Framework

Challenges with Clinical Teaching Time pressures Competing demands - clinical Often opportunistic - makes planning challenging Lack of rewards/recognition for teachers Patient acceptance of learners

Time Average duration of ambulatory teaching encounter - 4-10 minutes1 Jackson2 50 ambulatory encounters 75% of time spent discussing patient case/mgmt 30 seconds for feedback Irby DM. Acad Med 1995. Jackson JL. Teach Learn Med 2002.

One-Minute Preceptor Teaching model initially developed for use in the outpatient setting3 Involves 5 steps: Get a commitment Probe for supporting evidence Teach general rules Reinforce what was done right Correct mistakes 3. Neher et al. JABFP 1992.

OMP: Step 1 Get a commitment from the learner Ask the learner what he/she thinks about the case Get a commitment to a diagnosis, work-up, treatment

OMP: Step 2 Probe for supporting evidence Ask the learner for evidence that supports his/her opinion Allows you to identify where there are gaps in knowledge

OMP: Step 3 Teach general rules Provide general rules/concepts that are targeted to the learner’s level of understanding If there is no new information to be added, you can skip this step

OMP: Step 4 Reinforce what was done right Reinforcing correct behavior helps the behavior become firmly established Comments should focus on specific behaviors rather than general praise

OMP: Step 5 Correct mistakes As soon after mistake as possible, find an appropriate time to discuss If possible, allow the learner to critique his/her performance first

OMP: Step 6? Encourage self-directed learning

OMP Clip

OMP: The Evidence OMP faculty training associated with an increase in specific feedback in ambulatory encounters4 Videotaped teaching encounters: OMP vs Traditional Faculty perceive that they are better able to assess student skills and are more confident in their ratings with OMP model5 Students preferred OMP model for quality of feedback it provides6 4. Salerno S. J Gen Int Med 2002. 5. Aagaard E. Acad Med 2004. 6. Teherani A. Med Teach 2007.

OMP Practice

Other teaching models… SNAPPS Model7 Summarize findings Narrow the DDx Analyze the differential Probe the preceptor about uncertainties Plan management Select case related issues for self-study Has been shown to facilitate expression of clinical reasoning and uncertainty8 7. Wolpaw et al. Acad Med 2003 8. Wolpaw et al. Acad Med 2009

Feedback Information on the student’s performance given for the purpose of improving future performance Analogous to coaching Key step in the acquisition of clinical skills Medical students and residents dissatisfied with the amount and quality of feedback The Challenge Limited opportunities for observation Lack of specificity of feedback

Tips for Giving Feedback Immediate Self-reflection first Both positive and corrective Focus on behavior - not person Specific, not general Amount limited to what the student can incorporate (not too much!) Check to ensure clear communication

Brief Structured Clinical Observation (BSCO) Tool for brief, real-time feedback Attending enters patient room during patient encounter Watches silently Leaves when 3 feedback points obtained Feedback discussed that day

BSCO Practice

BSCO Tips Orient student and patient Consider asking student for observation focus Carefully position yourself in the room; try to remain silent Consider times when you are required to be in the room

(Observer) Reporter Interpreter Manager Educator RIME Framework (Observer) Reporter Interpreter Manager Educator Pangaro Acad Med 1999.

OBSERVER - struggling to report accurately REPORTER Works professionally with patients, staff, colleagues; complete, reliable, accurate; gathers info, clearly communicates with proper terms Understands pathophysiology Answers “What” questions. INTERPRETER Identifies, prioritizes problems Offers 2 or 3 reasonable possibilities with reasons applied to the patient. (Students do not have to be “right”) Answers "Why" questions. Discuss grades that might flow with each level Students MUST be "right" in Reporting, "reasonable" in Interpreting and Managing.

Selects among options with the patient MANAGER Selects among options with the patient Proactive rather than simply reactive Plans should be reasonable, include test options, student’s preferences, merits of therapies Answers “How" questions. EDUCATOR Identifies questions that can't be answered from textbooks Cites evidence on relevant new therapies, tests Active in educating self, colleagues, and patients Case discussions of students - I start with the subI example

Summary Orient learner to goals/expectations Choose a tool for clinical teaching (?OMP) Incorporate frequent observation and feedback (?BSCO) Think about your learner’s skill level and what the next steps are in their development as a physician