Better than a thousand days of diligent study is one day with a great teacher." --Japanese proverb
Goals Discuss characteristics of interns Discuss the characteristics of the effective preceptor. Discuss the strengths and limitations of interns. Ways to deal with problem interns.
The Effective Clinician/ The Effective Preceptor Characteristics of the effective clinician Good communication skills Careful assessment of the patient Skillful management Able to motivate the patient After Tumulty, 1973
The Effective Clinician/ The Effective Preceptor Characteristics of the effective preceptor Good communication skills Careful assessment of the learner Skillful teaching and practice Able to motivate the learner
The Effective Preceptor Communication Possesses and demonstrates broad knowledge Explains basis for actions and decisions - critical for dietetic interns Answers learner questions clearly and precisely
Explain the basis for actions Interns want cut and dry answers in a field where there is often more than one right answer Experienced clinicians automatically by- pass many steps in the decision making process, which need to be made clear to interns
Answers learner questions clearly and precisely Know when intern should look something up themselves or when they need to be given an answer Fine line between encouraging independence and promoting frustration
The effective preceptor… Is open to conflicting ideas and opinions Connects information to broader concepts Communicates clear goals and expectation
The effective preceptor… Captures learners attention Makes learning fun
Careful Analysis of the Learner Accurate assessment of learner’s knowledge, attitudes and skills Uses direct observation of the learner Provides effective feedback Performs fair and thoughtful evaluations
Providing Feedback Should be specific and appropriate Should honor interns’ efforts Can be useful to have intern self- evaluate - “what do you think went well?”, “what would you do differently?”
The Effective Preceptor Skillful Teaching and Practice
Provides effective role modeling Demonstrates skillful interactions with patients Presents information with organization and clarity
Remember the preparation is for entry level! Need to know versus nice to know Example: need to know - how to calculate basic TPN nice to know - some RD’s adjust electrolytes, etc., but this is NOT an entry level skill
Skillful Teaching and Practice Organizes and controls learning experience Give appropriate responsibility to learner Balances clinical and teaching responsibilities Talk the talk and walk the walk
Motivating The Learner Emphasize problem solving Promote active involvement of learner Demonstrate enjoyment and enthusiasm for patient care and teaching Develop a supportive relationship with learner.
Motivating the Learner Many interns are adult learners and internally motivated Allowing interns to direct own learning will help make this transition
What can you expect regarding your intern? Most in distance program have extensive work experience Some may have families Many will have greater financial responsibilities They are highly committed to doing well!
Limitations of interns May have lots of book learning with limited hands on experience May have an untested work ethic May have difficulty prioritizing May lack confidence in knowledge and ability (though some may be over- confident)
Strengths Are generally very enthusiastic Often very idealistic (may be a limitation in some cases) Generally have a good knowledge base but may need to be reminded of that fact.
How to promote success Provide an orientation But don’t tell them everything - have them read policy and procedure manual Make your expectations clear and provide feedback Ask them to self-assess periodically Be focused and enthusiastic
More ways to promote success Have interns carry note cards to jot down questions throughout the day (or include in their journal) Give them activities to do during down time (while you’re on the phone, etc.) Give your intern responsibility Create an atmosphere for open communication
Providing effective feedback Characteristics of food feedback Encourages self assessment Includes positives and negatives Refers to specific, observed behavior Is timely Occurs in an appropriate place Ends with an action plan
The difficult learner When the performance does not meet expectations Examples Learner can’t sort out appropriate versus irrelevant information Learner misses important details
Using the SOAP approach Subjective What does the intern ‘say’? Has the situation occurred before? What do others say? Describe the problem/difficult behavior - rather than label it.
Subjective - example √ Intern has difficulty developing effective working relationships with other disciplines Rather than X Intern is over-bearing and is alienating staff members
Objective Start by identifying specific behaviors Comes late, leaves early Provides incorrect information in chart, to patient, etc. Avoids eye contact during patient interviews Look for other sources of information - how did intern get this far?
Assessment Are your expectations clear? Is there “stuff” going on of which you are not aware? Is there a cognitive problem? Information processing - e.g.dyslexia, attention deficit Reasoning - e.g. can’t recognize assumptions, difficulty synthesizing
Assessment, continued Is there an emotional, attitudinal, or personality problem i.e. close family member died of cancer, so intern has difficulty working with this type of patient Emotional - e.g. depression, anxiety Attitude -e.g. intolerance or lack of motivation Personality - e.g. obsessive compulsive, dependent
Assessment, continued Is the learner having difficulty ordering his/her environment? Time management Inflexible learning style Inefficient learning style
Assessment, continued Are the interns’ standards set too low? Has minimum effort been good enough in the past? Do they believe they are performing well, when in fact they don’t meet your expectations? May be some cultural issues
Plan Do you need further information? Give feedback - be timely Reset your educational goals and objectives Negotiate Collaborate Focus on interns’ strengths Establish plans for follow up
Plan - examples Knowledge deficit - provide readings to do outside rotation (or contact director) Have intern verbally walk through what they are doing so you can see where they fall short
Problems for the 21st century Inappropriate cell phone use - this was addressed during orientation Many distance interns have children, so phone calls often relate to this Interns should check with preceptor as to when they can check voice mail or return calls
Make sure you have all the information Real life situation chronically late intern renal problem, but MD unable to determine exactly what was going on. prescribed meds caused drowsiness concerned about falling asleep while driving to rotation cultural issue - did not occur to her to let her preceptor know what was happening Solution - negotiated later starting time with site
Finally… Let the internship director know what is going on.
Precepting 101 references Tumulty, Philip A. The Effective Clinician Philadelphia: W. B. Saunders; 1973. Irby, D. M.; Ramsey, P. G.; Gillmore, G. M., and Schaad, D. Characteristics of effective clinical teachers of ambulatory care medicine. Acad-Med. 1991 Jan; 66(1):54-5; ISSN: 1040-2446. Irby, D. M. Clinical teacher effectiveness in medicine. Journal of Medical Education. 1978; 53:808-815. Stritter, Frank T and Baker, Richard M. Resident preferences for the clinical teaching of ambulatory care. Journal of Medical Education. 1982; 57:33-41.
Precepting 101 References Skeff, Kelley M. Enhancing teaching effectiveness and vitality in the ambulatory setting. Journal of General Internal Medicine. 1988; 3(Mar/Apr Supplement):S26-33. Irby, D. M. What clinical teachers in medicine need to know. Academic Medicine. 1994; 69(5):333-42. Irby, D, M. Teaching and learning in ambulatory care settings. Academic Medicine. 1995; 70(10):898-931. Goertzen, J.; Stewart, M., and Weston, W. Effective teaching behaviours of rural family medicine preceptors. Canadian Medical Association Journal. 1995; 153(2):161-8. Whitman, Neal. Creative Medical Teaching. Salt Lake City: University of Utah School of Medicine; 1990.