Diagnosing the Learner Question Learner to determine their understanding of the case Determine Learner’s strengths and weaknesses based upon answers Determine Teachable Moment based on responses Determine Learner’s Level based upon defined standards
Ask for a Commitment Use open-ended questions and not yes/no questions. Avoid jumping in with your opinion of what is going on. Be patient. Wait a few seconds for a response and ask for elaboration.
Ask for a Commitment What do you think is going on? What other types of information do you feel are needed? What is your working diagnosis for this patient?
Probe for underlying reasoning Probe for evidence that supports the diagnosis. Have the learner think out loud so you can analyze his or her thought process. Do not take over the case, and remember that probing for evidence is different from grilling.
Probe for underlying reasoning What were the major findings that led to your conclusion? What else did you consider? What kept you from that choice? Why would you choose that particular medication
Evaluation Standards The RIME System Reporter –M3, Can do H&P well, report findings Interpreter –M4, Interprets case and labs well –Well-developed differential diagnosis Manager –Intern, Can manage the case Educator –Upper resident to staff, Can determine teaching points and educate the team.
RIME and Grading Students and residents should be at expected level 1 level below is a concern 2 levels below may be a reason for failure 1 level above is above expected or near honors 2 levels above is outstanding or honors
Teaching in One Minute 1.Teach General Rules 2.Provide Positive Feedback 3.Correct Errors
T each General Rules Create “rules of thumb” that can be applied to other patients. Correlate this patient with previously seen patients. Think out loud. Tell “war stories” or use hypothetical situations to make the point more memorable.
Teach General Rules If the patient only has cellulitis, incision and drainage is not possible. You have to wait until the area becomes fluctuant to drain it. Patients with cystitis usually experience pain with urination, increased frequency and urgency and they may see blood in their urine.
Provide positive feedback Reinforce what is done right Be specific and explicit to reinforce desired behavior.
Provide positive feedback Reinforce what is done right “You didn’t jump in to solving her presenting problem but kept open until the patient revealed her real agenda for coming in today. In the long run, you saved yourself and the patient a lot of time and unnecessary expense by getting to the heart of her concerns first. Nicely done.”
Correct Errors Be specific and descriptive, not personal and judgmental. Concentrate on fixable problems.
Correct Errors “You may be right that this patient’s symptoms are probably due to a viral URI. But you can’t be sure it isn’t otitis media unless you have properly examined the ears.”
In Summary Ask for a Commitment Probe for Underlying Reasoning Diagnose the learner for teaching and evaluation Apply standards to the evaluation process (RIME) Teach General Rules Provide Positive Feedback Correct Errors Use this method to teach and give feedback in a busy clinical practice.
References Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Prac. 1992:5:419-424. Sarkin, R. The One Minute Preceptor: Microskills of Clinical Teaching. http://www.im.org/facdev/…/Strategies %20Tampa%20Sarkin.ht