1. Teaching in an Ambulatory Setting Cherdsak Iramaneerat Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University 1

2. Barriers to effective ambulatory teaching Inadequate space and time to teach Sharing of teaching burden: learners may be taught by inexperienced teachers Work pressure: learners are rarely observed Public nature: feedback is rarely provided Student’s orientation is inadequate Seeking consent from patients Irby D. Teaching and learning in ambulatory settings. A thematic review of the literature. Acad Med 1995; 70: 898-931.

3. 3-Step Planning 1.Orient the learners 2.Organize the clinic 3.Encourage learners to take more responsibility for their own learning Sprake C, et al. Teaching in an ambulatory care setting. BMJ 2008; 337: a1156.

4. 1. Orient the Learners Describe the OPD environment Find out students’ names Show them where they can store bags Assess learning needs and expectations Communicate with other OPD staffs

5. 2. Organize the Clinic Manage patient consent –Inform patients about the presence of students –Poster or signs in the waiting area Manage time –Provide appropriate amount of time for students based on appropriate mode of patient approach

6. Many Approaches in OPD Observer model Assistant model Practice under supervision Practice with a consultant

7. 3. Encourage Learners Students should take responsibilities for their own learning –Getting involved with patient care –Learning skills Experiential learning SNAPPS –Logbooks

8. Experiential Learning Theory Concrete Experience Reflective Observation Abstract conceptualization Active Experimentation Kolb DA, Fry R. Toward an applied theory of experiential learning. In C. Cooper (ed) Theories of group Process, London: John Wiley, 1975 Schon D. The reflective practitioner, New York: Basic Books, 1983.

9. SNAPPS 1.Summarize briefly the history and findings 2.Narrow the differential diagnoses 3.Analyze the differential diagnoses by comparing and contrasting the possibilities 4.Probe the preceptor by asking questions 5.Plan management 6.Select a case-related issue for self study Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: A learner-centered model for Outpatient education. Acad Med 2003, 78(9): 893 – 8.

10. Effective Ambulatory Teaching Behaviors Preceptor inspires student confidence in preceptor’s medical skills. Preceptor explains the decision-making process to students. Preceptor treats students with trust and respect. Preceptor provides a role model. Elnicki DM, et al. Third-year medical students’ preceptions of effective teaching behaviors in a multidisciplinary ambulatory clerkship. Acad Med 2003; 78: 815-9.

11. Tips for Ambulatory Preceptors Before you start When you teach When the session is over Dent JA. AMEE guide no 26: Clinical teaching in ambulatory care settings: Making the most of learning opportunities with outpatients. Med Teacher 2005; 27: 302-15.

12. Before You Start Attend a staff development session and read any support material available. Check students’ study guide, or any course material. Familiarize yourself with the clinical problems usually encountered in the clinic. Brief the students about the objectives. Select appropriate cases for your students.

13. When You Teach Selecting an appropriate teaching model –One student : one teacher –Several students: one teacher –Several students: several teachers

14. One Student: One Teacher Sitting-in model –Observer role –Assistant role Apprenticeship model (practice under supervision) Team member model (practice with a consultant)

15. Several Students: One Teacher Grandstand model Supervising model Report-back model

16. Several Students: Several Teachers Shuttle model Division model Flip-flop model Tutor model

17. When the Session is Over Provide students the opportunity to discuss what they have learned: reflection Identify aspects of learning outcomes they have been illustrated Clarify any misunderstandings Reflect on yourself: what you will change in the next session

18. Cherdsak.ira@mahidol.ac.th 18