1. What Can We Learn From Our Successful Clinical Preceptors? Claire E. Hull, MHS, PA-C - Clinical Coordinator Frances Biagioli, M.D. - Medical Director Oregon Health & Science University Physician Assistant Program November 19, 2008

2. Acknowledgements Faculty Development Institute Joe Schwenkler, MD Toya Vigne

3. Webinar Format Audience participation If you have a question… All questions may not be answered during this webinar. However, any comments or questions can be sent to me by e-mail: hullc@ohsu.edu

4. Education Goals and Objectives Identify the characteristics of a successful clinical preceptor Describe the ways to use the experience of successful clinical preceptors to –provide faculty development to new and established preceptors –develop recruitment tools to engage new clinical preceptors

5. Challenges to the Recruitment and Retention of Clinical Preceptors Concerns about productivity Concerns that patient population will not be accepting of a student Good clinician does not equal good teacher Logistical barriers: housing, EMR, transportation, lack of space, etc. Preceptor Burnout Competition with other programs

6. Student Perspectives Top 5 characteristics obtained from a survey of 119 students 1 –Preceptors welcomed student questions (86%) –Enthusiastic about having a student (77%) –Answered questions thoroughly (77%) –Encouraged more student responsibility as the rotation progressed (66%) –Asked questions in a non-threatening manner (66%) – 1 Zayas TT. Qualities of Effective Preceptors of Physician Assistant Students. Perspectives on Physician Assistant Education 1999;10(1):7-11.

7. Preceptor Perspectives Top 5 characteristics obtained from a survey of 40 preceptors asking them to rate their own effectiveness as a preceptor 1 –Welcomed questions from students (84%) –Enthusiastic about having a student (74%) –Always available for supervision (66%) –Answered students’ questions thoroughly (61%) –Gave students clear instructions regarding clinic schedule (61%) – 1 Zayas TT. Qualities of Effective Preceptors of Physician Assistant Students. Perspectives on Physician Assistant Education 1999;10(1):7-11.

8. Student Perspectives PA students from OHSU 2 : –Students feel welcome in the practice –Open and frequent communication –Students are directly observed –Preceptor takes an active interest in the student’s learning – 2 Unpublished data collected from student surveys of clinical preceptors and rotation sites

9. “I’m too busy to take a student!” Vinson and Paden et al found that the presence of a learner adds on average 45 minutes per day

10. OHSU Faculty Teaching Hours vs. Productivity Pink is productivity per clinic session Blue is teaching hours per yr

11. Scheduling Patients Create a “student schedule” – –Schedule appointments with student – –Review the schedule each day – –Include more spots for walk-in acute problem visits Share the teaching responsibilities – –Engage other providers to get involved Double Up! – –Precepting more than one student at a time can be easier

12. Integrating the Student into the Practice Distribute a plaque or tent card to display in the office

13. PHYSICIAN ASSISTANT PROGRAM CLINICAL ROTATION STUDENTS This office has been selected as a training site for Physician Assistant students from Oregon Health & Science University. This practice has shown a sincere interest in teaching and has been carefully selected to provide students with an excellent experience in patient care. Your participation is appreciated but purely voluntary. Thank You.

14. Integrating the Student into the Practice Discuss with the staff how the student will be introduced to the patients Regular presence of students in the practice

15. Other Activities for Students Patient Education – –Chronic disease management – –Community health experience Additional Assignments – –Using EBM to answer a clinical question – –Researching a clinical problem and reporting back to preceptor

16. The One Minute Preceptor* Get a Commitment Probe for Supporting Evidence Reinforce What was Done Well Give Guidance About Errors and Omissions Teach a General Principle Conclusion *Neher JO, Gordon KC, et al. A five-step “microskills” model of clinical teaching. J Am Board of Family Practice 1992; 5:419-424.

17. Being a good clinician does not necessarily mean you are a good teacher

18. Observations made during orientation Huang WY and Monteiro FM % of preceptors who discussed this issue Student’s past rotations88% Types of patients to be seen75% Preceptors goals75% Responsibility of student in patient care63% Student’s goals63% Time to spend with each patient50% How preceptor liked to teach50% What did student wish to learn38% Specific learning objectives38% Negotiation and prioritization of goals0%

19. Observations made during teaching encounters with patients Huang WY and Monteiro FM % of preceptors who discussed this issue Student saw patient independently74% Student wrote or dictated note66% Discussed patient after student assessment64% Focused on 1 or 2 teaching points56% Taught how to do part of physical38% Gave general feedback to student9% Gave positive feedback to student9% Gave negative feedback to student0%

20. Issues discussed in the final evaluation session at end of clerkship rotation Huang WY and Monteiro FM % of preceptors who discussed this issue Student’s clinical skills75% Specific aspects of student performance75% Preceptor allowed student to assess rotation50% Preceptor allowed student to assess preceptor25% Discussed goal that were achieved0%

21. Why Evaluations Are Important Evaluating learners is a basic expectation of teaching Assist programs in making decisions regarding advancement. Preceptors help determine whether students have the knowledge, attitude and skills to be future health care providers Effective and ongoing evaluation can enhance the rotation experience

22. Evaluations Evaluations should be scheduled Formal session Ideally done at regular intervals Based on objective data and personal observation

23. Evaluation vs Feedback FEEDBACKEVALUATION TimingTimelyFormal SettingInformalFormal BasisObservation ContentObjective ScopeSpecific ActionsGlobal Performance PurposeImprovementGrading & Improvement

24. The G-R-A-D-E Strategy for Evaluation G: Get Ready R: Review Expectations with Learner A: Assess D: Discuss Assessment at Midpoint E: End with a “Grade” Langlois JP and Thach S. Evaluation using the GRADE strategy. Fam Med 2001; 33(3):158-60.

25. Strategies to keep current preceptors engaged and interested in teaching PA students? Show appreciation by giving gifts, banquets in their honor, lunches, awards, certificates of appreciation, etc. Provide CME presentations (on CD-ROM, webinar or online format) Provide materials related to teaching

26. Strategies to keep current preceptors engaged and interested in teaching PA students? Cherry-pick students for preceptors – send strong students to preceptors who may be burning out Offer adjunct/affiliate faculty appointments Write a program newsletter to keep preceptors in the loop; highlight a preceptor or site in newsletters to give them some recognition Provide student evaluations to preceptors; highlight positive

27. Case Scenario Dr. XY has been a clinical preceptor for several years and usually precepts several students a year in his pediatric office. Student evaluations of this preceptor are mediocre. Students indicate that he does not provide them with much feedback, and that “he seems too busy to teach”. Student comments also include statements such as “I spent a lot of time observing because he didn’t want to get too far behind.”

28. Possible Strategies Encourage students and preceptors to discuss individual learning and teaching styles at the outset. Emphasize importance of students seeking out additional learning opportunities Encourage sharing responsibilities of teaching with other providers Discuss ways to create a “student schedule”; student does not need to see every patient Involve office manager with logistics

29. Case Scenario You have been successful in scheduling a meeting with a family practice group who have expressed an interest in precepting PA students from your program. Although they would like to help out, they are concerned that they are too busy to have a student

30. Possible Strategies Bring to the meeting a preceptor handbook, do a formal presentation on the program, highlight benefits of precepting, learning objectives for rotation, evaluation forms. Outline expectations and goals of both the PA program and the preceptors/site. Gauge their intent: how committed are they to teaching? What are their expectations in terms student working hours? What is the practice make-up? Who would be responsible for precepting students? What is the administrative process for placing a student at the site? (EMR training, hospital privileges, etc)

31. Possible Strategies Potential concerns to address: –Make sure they understand the PA role, scope of practice –Student doesn’t need to see every patient –Discuss/reference other successful preceptors –Emphasize importance of sharing responsibility among preceptors; suggest rotating preceptors each month –Suggest a “trial run” – not locked in to precepting (and send a great student!) –Explain the skill level of the student and clearly define expectations –Strong communication between PA program and preceptors

32. Summary Key Characteristics of Effective Preceptors Provide an adequate orientation to the practice setting Make students feel welcome Clarify expectations and goals Schedule patients to maximize teaching and productivity Provide frequent and immediate constructive feedback Maintain a system of frequent and open communication with the student as well as the program

33. Remind Them of the Benefits of Precepting Students Increased enjoyment of clinical practice Sense of giving back to the profession Satisfaction in being a professional role model Decreased sense of professional isolation Adjunct or volunteer faculty appointments CME for teaching Teaching improves own skills

34. Nobody’s Perfect Please e-mail me your questions or comments: hullc@ohsu.edu

35. Resources Society for Teachers in Family Medicine: http://stfm.org http://www.oucom.ohio.edu/fd/monographs http://www.med.unc.edu/epic/ A faculty development curriculum in clinical teaching for community practitioners who serve as preceptors to health professions students

36. 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. MacDonald PJ and Bass MJ. Characteristics of Highly Rated Family Practice Preceptors. J Med Educ 1983; 58:882-893. 4. 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.

37. References 5. 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. 6. Skeff KM, Stratos GA, et al. Clinical teaching improvement: past and future for faculty development. Fam Med 1997;29(4):252-7. 7. York NL, DaRosa DA, et al. Patients’ attitudes toward the involvement of medical students in their care. Am J Surg 1995;169:421-3. 8. 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.

38. References 9. 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. 10. 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. 11. Neher JO, Gordon KC, et al. A five-step “microskills” model of clinical teaching. J Am Board of Family Practice 1992; 5:419-424. 12. 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

39. References 13. Huang WY and Monteiro FM. Teaching behaviors used by community –based preceptors for a family and community medicine clerkship. Fam Med 2000;32(10):678-80. 14. Lyons P. Get out of my office. Fam Med 2000;32(10): 675-7. 15. Langlois JP and Thach S. Evaluation using the GRADE strategy. Fam Med 2001; 33(3):158-60.