1. Clinical Teaching Led by: Charlotte Wills, MD Arianne Teherani, PhD An Educational Skills Workshop sponsored by the Office of Research and Development in Medical Education (RaDME)

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3. Objectives
Describe what makes a good clinical teacher and clinical teaching models and methods
Summarize current research on clinical teaching
Apply teaching models to different clinical scenarios
Identify challenging teaching situations and learners, and choose an appropriate teaching style for each.

4. Session Structure
Introduce clinical teaching and OMP/ESP/SNAPPS models
Discuss clinical teaching cases using models via small and large group
Work through cases of challenging scenarios and discuss via small and large group
Summarize and wrap-up discussion

5. Activity
List the qualities of good vs. bad clinical teaching

6. Clinical Teaching Literature
Two distinct areas of research
Attributes/behaviors good clinical teacher
Solid knowledge base
Clinically competent/clinical skills teaching
Supportive learning environment
Communication: listening, participation, questioning
Enthusiasm about medicine and teaching
Development of skills to be a good clinical teacher
Sutkin, 2008

7. Clinical Teaching Script
Preceding event: observation, case presentation,…
Guide the teaching encounter
Composed of 3-5 teaching points
Includes supporting material
Understanding of common learner errors
Enables focus on learner without memory overload
Scripts maybe illness or skills focused
Irby, Aagard, Teherani, 2004

8. Traditional Clinical Teaching
Teacher questions focused on diagnosing the patient and questions about factual information
Rarely questions about trainee impressions of the patient
Questioning does not directly assess the learner’s level of knowledge.
Little or no teaching or feedback to the learner
Irby, 2004

9. Traditional Clinical Teaching
Teacher questions focused on diagnosing the patient and questions about factual information
Rarely questions about trainee impressions of the patient
Questioning does not directly assess the learner’s level of knowledge.
Little or no teaching or feedback to the learner
Irby, 2004

10. Traditional Clinical Teaching
Pros:
Efficient
Puts patient care first
Cons:
What the learner knows is unclear
Often little teaching
Little or no feedback to learner

11. One-Minute Preceptor (OMP)
Step 1: Get a commitment
“What do you think is going on?” “What do you want to do next?”
Encourages learner to process further
Step 2: Probe for supporting evidence
“What else did you consider?” “How did you rule those things out?”
Assesses learner’s knowledge and thinking process
Neher, 1992

12. One-Minute Preceptor Step 3: Teach a general principle
“Following an acute stroke, prevalence of depression ranges from 20-50%;”
“Processes that causes collapse of alveoli will produce crackles on lung exam”
Can be about symptoms, physical findings, treatment, resources, etc.
Allows learning to be generalizable to future cases
Neher, 1992

13. One-Minute Preceptor Step 4: Reinforce what was done well
“Your presentation was well organized and concise”
Reinforces good behaviors
Being specific is important
Step 5: Give guidance about errors or omissions
“It is important to include an oxygen saturation when considering certain lung processes”
Corrects mistakes and forms foundation for improvement
Again being specific is key
Neher, 1992

14. One-Minute Preceptor Pros: Assesses learner knowledge
Teaches to the level of the learner
Allows for more accurate feedback
More effective teaching encounter
Cons:
More time consuming?
Not known by all faculty
Furney et al. 2001; Aagaard et al. 2004

15. Eight Step Preceptor (ESP)
Assess Level of Learner
Listen without Interruption
Get Commitment
Probe for Rationale
Make a Generalizable Teaching Point
Provide Reinforcing and Corrective Feedback
Prompt Learner to Identify Learning Objectives
Positive Learning Climate
Ottolini et. al 2010

16. A Learner-Centered Model for Case Presentations
SNAPPS
A Learner-Centered Model for Case Presentations
Learner-initiated
Learner-directed
Learner-centered
Wolpaw et al. 2003

17. In SNAPPS the Learner Summarizes history and physical
Narrows differential diagnosis to 2-3 possibilities
Analyzes differential by comparing & contrasting possibilities
Probes preceptor by asking questions about uncertainties, difficulties, etc.
Plans management for patient care
Selects issue for self-directed learning

18. Small Group Exercise: OMP Practice
How would you use the eight-step preceptor (ESP) or one-minute preceptor (OMP) model in this case?
See handout for each case for discussion questions

19. Large Group Discussion
Summarize (briefly) what made your case challenging
How did you use the OMP/ESP to address these challenges? Did it work?
If you had more time, how would you modify?
Was there a step of the OMP that you found most useful?
Would SNAPPS have added value?

20. Case 1 Your Role: ED/urgent care attending Learner: 2nd year resident
Case highlights:
26 yo woman with back pain, fever, + UA
Reported exam/history suggest pyelo
R2 is convinced this is PID, wants to get an ultrasound, admit and start doxycycline

21. Case 2 Your Role: Inpatient pediatrics attending
Learner: 3rd year medical student
Case highlights:
18 mo old boy with diarrhea, abdominal pain, fever, tachycardia
Reported exam/findings concerning for acute abdomen
Incomplete exam, mom is “angry”
Med student is not sure what to do, and has no idea what’s going on

22. Case 3 Your Role: Inpatient consult service attending
Learner:Pharmacy intern
Case highlights:
56 yo obese woman with renal failure, chronic pain
S/p hip and knee replacements
Taking Vicodin, unable to walk
Pharmacy intern minimizes her pain, thinks she is drug-seeking, wants psych consult

23. Case 4 Your Role: Primary care clinic attending Learner: Intern
Case highlights:
60 yo man with elevated screening PSA
Has symptoms of prostate enlargement, but intern afraid to do exam
Intern concerned about telling the patient he has cancer

24. Case 5 Your Role: Urgent care attending Learner: Intern
Case highlights:
35 yo man with findings consistent with peritonsillar abscess
Previously treated with “antibiotics”
Intern not sure about the physical findings, and wants to switch to another antibiotic

25. Take Home Points
OMP/ESP/SNAPPS principles can be applied in diverse clinical encounters
Diagnose the learner:
Probe understanding and thought process
Teach general principles:
“fill in the blanks” in knowledge
Provide information that can be applied in other situations
Give and ask for feedback with EACH encounter
Promote self directed learning

26. Research: OMP Clinical teachers using OMP
Equally or better able to diagnose patient
Better able to diagnose learner
More confident in their ability to diagnose
Rate it as more effective & efficient
More likely to teach about illness focusing on a broader DDX, diagnostic tests, and the natural presentation of disease.

27. Research: OMP Learners
rate OMP-trained residents higher on getting a commitment, feedback, motivating learners
Not higher on overall teaching effectiveness
Prefer the OMP and learning about natural presentation of disease

28. Research: ESP
Faculty using more ESP behaviors receive better ratings of teaching effectiveness
More use of ESP behaviors does not significantly increase duration of precepting sessions
Number of steps preclude faculty from using it fully

29. Research: SNAPPS Learners Clinical Teachers
select their own learning issues/needs
appreciate being allowed to question teacher
easy to learn
Clinical Teachers
students generate questions relevant to the case and learners’ knowledge
direct their teaching to students' self-identified learning needs

30. Research: SNAPPS Clinical teachers must guide interaction
assume role of expert facilitator
Critical to orient faculty to its steps and encourage students to use the model

31. Questions?

32. Part II: Challenging Situations and Challenging Learners
Many clinical experiences don’t fit into the “brief clinical encounter” model
However, these moments contain some of the most valuable lessons
Not every learner is “teachable”
But these students have even more to learn!
Let’s brainstorm on examples of each, from your experiences

33. Small Group Exercise Challenging clinical scenario
What challenges to teaching/learning do you see?
What are the learning opportunities
What techniques can you teach in this scenario?
See handout for each case for discussion questions

34. Large Group Discussion
Each group will:
summarize (briefly) what made your setting/learner “challenging”
what did you come up with to teach despite these challenges?

35. Scenario 1: Busy Service
Your role: Inpatient attending
Learner(s): R3, R1, MS4
Challenge(s):
Team seems stressed
Workload is high
They “divide and conquer”
“No time to teach”

36. Scenario 2: Code Blue Your role: Clinical pharmacist
Learner(s): R3, MS3, intern, nurse
Challenge(s):
Code blue/critically ill child
Med student overwhelmed
Senior resident stressed
Nurse yelling to “do something”

37. Scenario 3: Disinterested Student
Your role: Clerkship director
Learner(s): MS3 (+team)
Challenge(s):
Learner has other priorities
Seems disinterested/unmotivated
Alienates the rest of the team
Bright, but thinks he know more than he does

38. Scenario 4: Checked-out Senior
Your role: Inpatient attending
Learner(s): Senior resident (+ team)
Challenge(s):
Senior resident’s performance has fallen off
Team has given up on her
Does the minimum needed
Described as “cynical” and “burnt out”

39. Scenario 5: Overeager Learner
Your role: Outpatient clinic attending
Learner(s): MS3 (+ team)
Challenge(s):
Too eager, annoys her colleagues
Missing some basic skills in history/presentations
Highly motivated
History of academic difficulties

40. Conclusion Review of key points
We will provide you with a summary of the teaching tips/techniques
Please make sure we have your correct address and contact information!
Complete the action plan to take with you

41. References
Aagaard EA, Teherani A, Irby DM The effectiveness of the one minute preceptor model for diagnosing the patient and the learner. Acad Med 79:42–49. Furney S, Orsini A, Orsetti K, Stern D, Gruppen L, Irby DM Teaching the one-minute preceptor: a randomized controlled trial. J Gene Inter Med 16:620–624. Irby DM, Aagaard EA, Teherani A Teaching points identified by preceptors observing one minute preceptor and traditional preceptor encounters. Acad Med 79:50–55. Neher JO, Gordon KC, Meyer B, Stevens N A five-step ‘microskills’ model of clinical teaching. J Am Board of Family Practice 5:419–424. O’Malley PG, Kroenke K, Ritter J, Dy N, Pangaro L What learners and teachers value most in ambulatory educational encounters: a prospective, qualitative study. Acad Med 74:186–191. Ottolini et al Student Perceptions of Effectiveness of the Eight Step Preceptor (ESP) Model in the Ambulatory Setting. Teach Learn Med 22: Salerno SM, O’Malley PG, Pangaro LN, Wheeler GA, Moores LK, Jackson JL Faculty development seminars based on the one minute preceptor improve feedback in the ambulatory setting. J Gene Int Med 17:779–787. Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008; 83: Teherani A, O’Sullivan P, Aagaard EA, Morrison EH, Irby DM Student perceptions of the One-Minute Preceptor and Traditional Preceptor Models. Med Teach: 29: Wolpaw TM, Wolpaw DR, Papp KK SNAPPS: a learner-centered model for outpatient education. Acad Med 78:893–8. Wolpaw T, Papp KK, Bordage G. Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: A randomized comparison group trial. Acad Med 2009; 84: