1. Time Efficient Clinical Teaching
Margo H. Vener, MD MPH
Walt Mills, MD, MMM
UCSF School of Medicine and Santa Rosa Family Medicine Residency Program
June 7, 2011

2. Session Outline Background
Introduction to the One-Minute Preceptor Model
One-Minute Preceptor Practice
Introduction to feedback and the Brief Structured Clinical Observation (BSCO)
BSCO practice
RIME Framework

3. Challenges with Clinical Teaching
Time pressures
Competing demands - clinical
Often opportunistic - makes planning challenging
Lack of rewards/recognition for teachers
Patient acceptance of learners

4. Time Average duration of ambulatory teaching encounter - 4-10 minutes1
Jackson2
50 ambulatory encounters
75% of time spent discussing patient case/mgmt
30 seconds for feedback
Irby DM. Acad Med 1995.
Jackson JL. Teach Learn Med 2002.

5. One-Minute Preceptor
Teaching model initially developed for use in the outpatient setting3
Involves 5 steps:
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was done right
Correct mistakes
3. Neher et al. JABFP 1992.

6. OMP: Step 1 Get a commitment from the learner
Ask the learner what he/she thinks about the case
Get a commitment to a diagnosis, work-up, treatment

7. OMP: Step 2 Probe for supporting evidence
Ask the learner for evidence that supports his/her opinion
Allows you to identify where there are gaps in knowledge

8. OMP: Step 3 Teach general rules
Provide general rules/concepts that are targeted to the learner’s level of understanding
If there is no new information to be added, you can skip this step

9. OMP: Step 4 Reinforce what was done right
Reinforcing correct behavior helps the behavior become firmly established
Comments should focus on specific behaviors rather than general praise

10. OMP: Step 5 Correct mistakes
As soon after mistake as possible, find an appropriate time to discuss
If possible, allow the learner to critique his/her performance first

11. OMP: Step 6?
Encourage self-directed learning

12. OMP Clip

13. OMP: The Evidence
OMP faculty training associated with an increase in specific feedback in ambulatory encounters4
Videotaped teaching encounters: OMP vs Traditional
Faculty perceive that they are better able to assess student skills and are more confident in their ratings with OMP model5
Students preferred OMP model for quality of feedback it provides6
4. Salerno S. J Gen Int Med 2002.
5. Aagaard E. Acad Med 2004.
6. Teherani A. Med Teach 2007.

14. OMP Practice

15. Other teaching models…
SNAPPS Model7
Summarize findings
Narrow the DDx
Analyze the differential
Probe the preceptor about uncertainties
Plan management
Select case related issues for self-study
Has been shown to facilitate expression of clinical reasoning and uncertainty8
7. Wolpaw et al. Acad Med Wolpaw et al. Acad Med 2009

16. Feedback
Information on the student’s performance given for the purpose of improving future performance
Analogous to coaching
Key step in the acquisition of clinical skills
Medical students and residents dissatisfied with the amount and quality of feedback
The Challenge
Limited opportunities for observation
Lack of specificity of feedback

17. Tips for Giving Feedback
Immediate
Self-reflection first
Both positive and corrective
Focus on behavior - not person
Specific, not general
Amount limited to what the student can incorporate (not too much!)
Check to ensure clear communication

18. Brief Structured Clinical Observation (BSCO)
Tool for brief, real-time feedback
Attending enters patient room during patient encounter
Watches silently
Leaves when 3 feedback points obtained
Feedback discussed that day

19. BSCO Practice

20. BSCO Tips Orient student and patient
Consider asking student for observation focus
Carefully position yourself in the room; try to remain silent
Consider times when you are required to be in the room

21. (Observer) Reporter Interpreter Manager Educator
RIME Framework
(Observer)
Reporter
Interpreter
Manager
Educator
Pangaro Acad Med 1999.

22. OBSERVER - struggling to report accurately REPORTER
Works professionally with patients, staff, colleagues; complete, reliable, accurate; gathers info, clearly communicates with proper terms
Understands pathophysiology
Answers “What” questions.
INTERPRETER
Identifies, prioritizes problems
Offers 2 or 3 reasonable possibilities with reasons applied to the patient. (Students do not have to be “right”)
Answers "Why" questions.
Discuss grades that might flow with each level
Students MUST be "right" in Reporting, "reasonable" in Interpreting and Managing.

23. Selects among options with the patient
MANAGER
Selects among options with the patient
Proactive rather than simply reactive
Plans should be reasonable, include test options, student’s preferences, merits of therapies
Answers “How" questions.
EDUCATOR
Identifies questions that can't be answered from textbooks
Cites evidence on relevant new therapies, tests
Active in educating self, colleagues, and patients
Case discussions of students - I start with the subI example

24. Summary Orient learner to goals/expectations
Choose a tool for clinical teaching (?OMP)
Incorporate frequent observation and feedback (?BSCO)
Think about your learner’s skill level and what the next steps are in their development as a physician