1. “I Don’t Have Time For Students” Showing Preceptors How to Be more Efficient with Students Oregon Health & Science University Frances Biagioli, M.D., biagioli@ohsu.edu biagioli@ohsu.edu Associate Professor, OHSU Family Medicine Claire E. Hull, MHS, PA-C – Clinical Coordinator OHSU Physician Assistant Program

2. Objectives Identify the most common causes of running behind with students. Identify concrete solutions to those causes. Create tools for clinical preceptors so they can become more efficient teachers. Create scripts and to use when recruiting clinical preceptors to respond to the comment: “I don’t have time for a student.”

3. Barriers to the Recruitment and Retention of Clinical Preceptors Preceptor Perceptions –Patient population not accepting of students –Lack of teaching experience –Decreased productivity –Not enough time to teach When a preceptor has a student, what are the barriers to running on time and thus maintaining productivity?

4. We are here to discuss solutions Remind Preceptors of the Benefits Show them how others succeed Provide preceptors with resources to help them succeed.

5. Benefits for Clinical Preceptors Increased enjoyment of clinical practice Sense of giving back to the profession Decreased sense of professional isolation Satisfaction in being a role model for students Adjunct or volunteer faculty appointments CME for teaching Teaching improves own skills

6. “I’m Too Busy to Take a Student” Classic teaching method used is an inefficient and ineffective way of teaching an learning It is possible for preceptors to be effective educators while maintaining high clinical productivity

7. OHSU Faculty Teaching Hours vs. Productivity RVU/clinic Clinical Teaching Hours RVU/clinic 0 10 20

8. Strategies Used * Orient students to the practice setting Clarify expectations to students Schedule patients in such a way that maximizes teaching and productivity Provide frequent and immediate constructive feedback to students Share students with other practice partners *Seim HC and Johnson OG. Clinical Preceptors: Tips for Effective Teaching with Minimal Downtime. Fam Med1999; 31(8):538-9.

9. Practice Tips from Productive OHSU Clinical Preceptors See one, Do One, Teach One Faculty is busy while student is – while student is in one room faculty is seeing one, two, or three other patients. Don’t repeat student questions – rather, summarize and clarify history. Student is Value Added Team Member: patient education, vitals, assist with getting patient ancillary services

10. SMALL GROUP Discussion Questions Do you have clinical preceptors that seem to have an endless capacity for students? –What types of things do those preceptors do differently? What educational materials or methods exist to help preceptors be more efficient?

11. Discussion Key Points Good communication is critical! –Orient student to the practice on first day –Set clear goals and expectations; refine and update goals as rotation progresses –Provide feedback that is immediate and constructive Quality not Quantity –The quality of the patient encounter (having the student follow one patient thoroughly, look something up, and order their labs) and the teaching point is more important than the number of patients the student is seeing. If the student is seeing nearly every patient with you – that is too much.

12. Discussion Key Points Observation is important! –Observe H&Ps and other skills over time with multiple patients – don’t observe an entire physical all the time. –Don’t need to observe from start to finish all the time. Choose which components of the patient encounter to observe based on patient’s medical problem and student’s skill level –Have student keep track of what skills have been observed (HPI, P.E., procedures, patient education, etc). Communicate with student about what skills still need to be observed and plan accordingly.

13. Discussion Key Points Mix up the type of teaching you do. –The classic teaching method of having the student see the pt, come out and present the case, then the two of you going back in can be very inefficient. –Sometimes you can go in and observe the student “I am going to be a fly on the wall” (and write your notes while they do everything). –Sometimes go in after they do the history. –Sometimes you do the history and they do the physical (you repeat what is needed). –Sometimes just have them observe you.

14. Time Management Begin clinic on time! Double book patients such that the student can see one patient and the preceptor sees the other patient; maintains productivity Set time deadlines for students: (“You have 10 minutes to see this patient”) Teamwork: As the student is obtaining the history or performing the exam, the preceptor can enter the information into the electronic medical record (or visa versa) Not necessary to repeat the entire HPI and PE obtained by the student, just summarize with the patient what you heard and add any clarifying statements.

15. Time Management Plan ahead: Look at your schedule and pre- select the patients the student will see… some patients you know will take forever. Utilize the student fully: –Don’t repeat unnecessary items that you know student does well, just clarify. –Have students look up questions that the patients have and after they discuss it with you call patients back. –Have students call patients with results after you discuss them with the student. –Have the student call specialists and help facilitate care with ancillary services.

16. Time Management Share the teaching responsibilities: –Share teaching with practice partners –Utilize nurses, medical assistants, lab assistants to teach students in how to give injections, perform lab tests, obtain an EKG, practice blood draws, etc. –The office manager, billing specialist, scheduler, can teach the student about the business side of clinical practice –If you have more than one student they can teach each other

17. Time Management Use a Step-Wise Approach to Teaching –Have student focus on one aspect of a patient encounter rather than a comprehensive approach with each patient. –Example: For patient “A” who complains of shortness of breath, the student should focus on the HPI only. For patient “B” with asthma, the student should focus on patient education. For patient “C” who developed a new rash, the student should focus on the physical exam. –Example: Instead of allowing the student to perform an entire procedure have him/her perform the digital block/lidocaine injection the first time, and the next time remove the toenail. –Emphasize key teaching points only; lengthy discussions usually not necessary.

18. Create the Right Environment Patients are more accepting of students if they are incorporated into the practice setting on a regular basis The preceptor’s passion for teaching will have a positive effect on the students, staff, and patients Do students need training to access the EMR system? How/when will this be done? Consider the physical aspect of the clinic: –Is there a place for the student to work? –Are there enough exam rooms?

19. Resources The One-Minute Preceptor A strategy for instruction in the health care setting that consists of the following steps: –Get a commitment from the student –Probe for supporting evidence –Reinforce what was done well – be specific –Give guidance about errors and omissions –Teach a general principle –Conclusion Neher, J. O., Gordon K. C. et al. (1992). A five-step "microskills“ model of clinical teaching Journal of the American Board of Family Practice, 5, 419-424

20. Resources Preceptor Education Project Sheets K and Garret E., Co-directors. Preceptor Education Project: Facilitator’s Guide, 2 nd edition. Society of Teachers of Family Medicine. 1999. Available to order at http://stfm.org/bookstore http://stfm.org/bookstore

21. References 1. Zayas TT. Qualities of Effective Preceptors pf Physician Assistant Students. Perspective on Physician Assistant Education 1999;10(1):7-11. 2. Seim HC and Johnson OG. Clinical Preceptors: Tips for Effective Teaching with Minimal Downtime. Fam Med1999; 31(8):538-9. 3. McKee MD, Steiner-Grossman P, et al. Quality of student learning and preceptors productivity in urban community health centers. Family Medicine 1998;30(2):108-12. 4. Salerno SM, O’Malley PG et al. Faculty development seminars based on the one-minute preceptor improve feedback in the ambulatory setting. J Gen Intern Med 2002; 17:779-787. 5. Skeff KM, Stratos GA, et al. Clinical teaching improvement: past and future for faculty development. Fam Med 1997;29(4):252-7. 6. York NL, DaRosa DA, et al. Patients’ attitudes toward the involvement of medical students in their care. Am J Surg 1995;169:421-3.

22. References 7. O’Malley PG, Omori DM et al. A prospective study to assess the effect of ambulatory teaching on patient satisfaction. Acad Med 1997; 72:1015-7. 8. Gress TW, Flynn JA et al. Effect of student involvement on patient perceptions of ambulatory care visits. J Gen Intern Med 2002; 17: 420-427. 9. Simon SR, Peters AS, et al. Effect of medical student teaching on patient satisfaction in a managed care setting. J Gen Intern Med 2000; 15:547- 561. 10. Neher JO, Gordon KC, et al. A five-step “micro skills” model of clinical teaching. J Am Board of Family Practice 1992; 5:419-424. 11. Sheets K and Garret E., Co-directors. Preceptor Education Project: Facilitator’s Guide, 2 nd edition. Society of Teachers of Family Medicine. 1999. Available to order at http://stfm.org/bookstore http://stfm.org/bookstore http://www.oucom.ohio.edu/fd/monographs http://stfm.org