1. Academy of Medical Educators: Clinical Teaching
Development Program

2. Precepting pitfalls: Did you catch yourself…
Review
Precepting pitfalls: Did you catch yourself…
Taking over?
Over-reaching?
Teaching monologue?
Asking too many close ended questions?

3. Skills Review Ask WHAT? Ask WHY? Quick pearl Good that you…
The 1-minute Preceptor
Get a commitment
Probe for supporting evidence
Teach a general rule
Reinforce the good
Correct mistakes
Ask WHAT?
Ask WHY?
Quick pearl
Good that you…
Next time try…

4. Orchestrating Chaos: Teaching a group of multi-level learners
What are the similarities between this picture and what we do?
--playing all different instruments (working on different skills, playing different parts)
Who is the audience there to see?
--the musicians! They are the important ones. Not us…you only see our back.

6. Learning Objectives
Create an effective learning climate in a busy clinical environment
Formulate and communicate expectations for multiple levels of learners

7. Acknowledgement to UCSF Center for Faculty Educators: Drs
Acknowledgement to UCSF Center for Faculty Educators: Drs. Irby, O’Sullivan, and Richie for framework of learning climate content.

8. Let’s look at this learning climate…
Just like a patient, we want to examine with intent.
Eager, engaged 3rd year student on the left.
Intern facing the computer trying to keep the house moving.
Experienced senior resident doing her best.
Observe. Take notes of what attending does and says that sets the learning climate…

9. Learning Climate Exhibit Enthusiasm Balance Challenge and Support
Welcome and Respect Diversity
Model Humility
Balance Challenge and Support

10. Types of ineffective learning climates
Stressed watch-watcher
Displeased dictator
Overly casual goofball
Disengaged aloof-ball

11. Exhibit Enthusiasm
Introduce yourself & describe your passion for learning and patient care.
Ask and use learner names.
Display a positive and optimistic attitude toward the team and learning.
Voice, gestures, passion for teaching, learning and inquiry, humor….not always serious…or intently serious

12. Welcome and Respect Diversity
Create a welcoming and supportive climate.
Consider personality and cultural differences that might affect learner’s participation.
Communicate clear goals and expectations.
Hospitality – treats?
Give time for learning names, little of background, sharing, establish and reinforce
Stated in expectations
Respect opinions
Welcoming input
Making sure all voice heard—inviting
Dealing with small stuff—house keeping

13. Model Humility Admit your own limitations, errors, and concerns.
Encourage questions and independent thinking.
Think aloud and invite learners to do the same.
Acknowledge:
learner insecurities
fear of harming patients
when & how to ask for help
What is the opposite of humility? Arrogant and dogmatic. This is the most frequently used descriptor of the worst clinical teachers – Irby 1979.
Build on the previous two steps,
Clarify question expectations—too many questions can undermine trust
Model reflection—what is that…what would it look like
Maybe model an example emphasizing building on data and reviewing why we were doing it that way…
“I’m sorry, I will never do that again” Reactive but not reflective…..
Why reflection is an important strategy
Elaborate and add to them.

14. Balance Support and Challenge
Provide support for uncertainties and problems.
Challenge learners to advance their understanding and make new connections.
Give reinforcing and constructive feedback
Collect ideas from the group

15. Support and Challenge Low Challenge High Challenge Low Support Stasis
Fear
High Support
Confirmation
Growth and Development

16. The Praise to Criticism Ratio
Business team communication
Looked at ratio of positive comments
What a great idea!
to negative comments
“We shouldn’t even consider doing that”

17. Rank yourself. Share our strengths!

18. Practice: Enthusiasm, Welcome, Humility
You are meeting the learners you’ll be working with for the next week.
How can we convey:
Introductions and Interests?
Approachability and Accessibility?
Engagement and Enthusiasm?

19. Practice: Enthusiasm, Welcome, Humility
Assignment: Take 3 minutes to write out your “opening monologue”
Tell them who you are
Questions you’ll ask your learners
Pair and share your ideas

20. Create a Positive Learning Climate
Exhibit Enthusiasm
Welcome and Respect Diversity
Model Humility
Balance Support and Challenge

21. Police the learning climate

22. Scenario
You are working with a group of 4 learners--senior resident, intern and students. The intern is a gunner, wants to impress everyone with her knowledge. She interrupts the students to correct them and asks them pointed factoids. When she proposes a dx/plan that gets altered, she immediately retorts “Oh yeah, that’s what I meant to say…that’s what I was thinking too.” The resident is often times on his phone/laptop trying to get stuff done while care decisions are being discussed and made. He refers to the students collectively “Yo studs, come see this CT scan.” He is a seasoned 3rd year, a little jaded, and you have heard him bad mouth difficult patients, complain about ED nurses, and battle with the SW.
In your groups, develop a strategy to “police” this learning climate…

23. Small Group Report Out

24. Psychological Size and Distance
Another Everyone agrees that attendings have greater Psych size. Attendings feel like size difference is less than it REALLY is for the learner.
Size difference didn’t affect resident satisfaction with preceptors.
In terms of difference, attendings felt it was lower than residents.
DID have significant NEGATIVE correlations with resident satisfaction, professional competence, and relationship with learners

25. What’s your size?
Draw a circle that shows your psychological size near the middle of your paper.
In relation to your circle, draw the location and size of your boss.
In relation to your circle, draw the location and size of a typical learner for you.

26. Psychological Size
Everyone agrees that attendings have greater Psych size. Attendings feel like size difference is less than it REALLY is for the learner.
Size difference didn’t affect resident satisfaction with preceptors.
In terms of difference, attendings felt it was lower than residents.
DID have significant NEGATIVE correlations with resident satisfaction, professional competence, and relationship with learners

27. Psychological Distance
In terms of difference, attendings felt it was lower than residents.
DID have significant NEGATIVE correlations with resident satisfaction, professional competence, and relationship with learners

28. Psychological Distance
In terms of difference, attendings felt it was lower than residents.
DID have significant NEGATIVE correlations with resident satisfaction, professional competence, and relationship with learners

29. Psychological size and distance
Attendings perceive LESS difference in psychological size than learners.
Size difference didn’t affect learner satisfaction
Residents perceive MORE psychological distance
Greater distance correlated with worse ratings of preceptors

30. Strategies to alter psychological size and distance
When might you need to increase your psychological size? Decrease it?
When might you need to decrease psychological distance?

31. Setting and Communicating Expectations
An orchestra of multi-level learners…
Roles and Skills
In the future, this will link to assessment and feedback

32. Roles in the clinical environment
Who?
Does what?
When/How?
Why?
Attending
Senior resident
Intern
Student

33. Once we agree what role they should be playing, how well do they play the part?

34. A clinical task: Gathering information
Collective “expectations” of what this skill looks like
Progression across developmental milestones
NoviceProficientIndependent Expert

35. Inaccuracies common due to misinterpretation of patient comments
Level 1
Information gathered following a template with little directed questioning
Inaccuracies common due to misinterpretation of patient comments
Level 2
Information gathered tends to be either cursory or extensive
Recalls clinical information in the order elicited without prioritization
Level 3
Accurately gathers information tailored to pertinent positives
Prioritizes information to suggest the developing differential diagnosis
Level 4
Gathers essential information, including pertinent positives and negatives
Precisely organizes information in a hypothesis-driven fashion
Level 5
Gathering of essential information targeted to individual patient features
Discriminates between diagnoses with subtle distinguishing features
Goal of delineating these

36. Performing a Basic Procedure
Scenario
M3 Student
Intern
Senior level resident
Performing a Basic Procedure   
Generating a Differential Diagnosis 
Interpret diagnostic test/data
With your like-minded group, fill out this table of your shared mental model of what

37. Debrief.

38. Learning Objectives
Create an effective learning climate in a busy clinical environment
Formulate and communicate expectations for multiple levels of learners

39. What will you do differently as a result of this session?

40. Summary

42. This is the sheet music.