Making the Most of Precepting Opportunities Michael Allison

Session Agenda Pretest assessment of you (5 minutes) Didactic presentation (10 minutes) Small group exercise Introduction (5 minutes) Exercises (20 minutes) Review/discussion of findings (10 minutes) Post-test assessment of you (5 minutes) Curriculum feedback for me (5 minutes) Total: hopefully 60 minutes

Objectives Assess audience and hopefully explain relevance Review precepting principles and techniques Become familiar with established general precepting concepts Understand basics of executing various precepting models Appreciate pros and cons for each model, and understand the need to tailor style to each precepting encounter Summarize key points

Assessment Who is involved in being a preceptor? Who has received formal education on this topic? Who is familiar with the concept of the “feedback sandwich” and “one-minute precepting/microskills”? Who has mastered precepting?

General Concepts Set the stage “Formative, not summative” Discuss responsibilities Orient to environment Selecting patients “Formative, not summative” i.e. open-ended, not close-ended Collaborative Minimize interruptions Appropriate patient load No put-downs Logistically sound Timing Speed Expected Precept in front of the patient??? Don’t assume anything Look for holes Scrutinize documentation Take care of the patient!

Precepting Models “Self-reflection”/motivational “Old” feedback sandwich “New” feedback sandwich “Microskills” “Snapps”

“Self-reflection”/motivational Method Self-assessment Preceptor comments Plan formation “What went well/wrong in that encounter?” “Yes, I think you could do better with...” “What is your plan to improve?”

“Self-reflection”/motivational Method Self-assessment Preceptor comments Plan formation Pros Learner-centric Formative Cons Requires experienced student Tends to focus on one or few aspects Not integrative Might be somewhat slow

“Old” Feedback Sandwich “You gathered an excellent history.” “Focusing on the main complaint may help you.” “But you did pick up on several things for next time.” Method Praise Critique

“Old” Feedback Sandwich Method Praise Critique Pros Quick Usually well received Cons Preceptor-centric Summative

“New” Feedback Sandwich “What might you have done better?” “Actually, I felt the differential was the weak spot.” “How can I help you improve…?” Method Ask Tell

“New” Feedback Sandwich Method Ask Tell Pros Team approach Formative also for preceptor Quick Cons 1st step dependent

5 Precepting “Microskills” Method 1. Get a commitment 2. Probe for supporting evidence and expand differential 3. Teach general rules 4. Reinforce what was done right 5. Correct mistakes “What do you think is the next step?” “What facts brought you to your #1 diagnosis? What else might it be?” “Pneumonia is a good thought. In general that’s a clinical diagnosis…” “I like the way you picked through the patient’s many complaints.” “Remember to focus your physical exam, as it could have helped here.”

5 Precepting “Microskills” Method 1. Get a commitment 2. Probe for supporting evidence and expand differential 3. Teach general rules 4. Reinforce what was done right 5. Correct mistakes Pros Integrative Formative Cons Long Artificial?

SNAPPS Method Summarize “Good history and physical. Which do you think were the key findings?” “You’re right, it could be many things. Which are the ones we need to rule out?” “Which possible diagnoses are most likely given what you’ve told me?” “How can I help you sort this out? What part of the case is not clear?” “What’s your next step in management?” “This was a tough case. What might be a good thing to look up later? Method Summarize Narrow the differential Analyze the differential Probe the preceptor Plan management Select a topic for further learning

SNAPPS Method Summarize Narrow the differential Analyze the differential Probe the preceptor Plan management Select a topic for further learning Pros Good for complex cases Learner-centric Cons Long Requires an active learner

Choosing an Approach Time? “Self-assessment” Complex case? Experienced learner? Experienced preceptor? “Self-assessment” “Old” sandwich “New” sandwich “Microskills” “Snapps”

Choosing an Approach “Old” sandwich Time? Complex case? “New” sandwich Experienced learner? Experienced preceptor? “Self-assessment” “Old” sandwich “New” sandwich “Microskills” “Snapps”

Choosing an Approach “Microskills” “Snapps” Time? Complex case? Experienced learner? Experienced preceptor? “Self-assessment” “Old” sandwich “New” sandwich “Microskills” “Snapps”

Choosing an Approach “Self-assessment” “Old” sandwich Time? Complex case? Experienced learner? Experienced preceptor? “Self-assessment” “Old” sandwich “New” sandwich “Microskills” “Snapps”

Choosing an Approach “Self-assessment” “Microskills” “Snapps” Time? Complex case? Experienced learner? Experienced preceptor? “Self-assessment” “Old” sandwich “New” sandwich “Microskills” “Snapps”

Summary Take care of the patient Take care of the student Formative when possible Experiment with different approaches Choose the right approach

Bibliography Edwards, Janine C. with Joan A. Friedland and Robert Bing-You. Residents’ Teaching Skills. Springer Publishing Company, Inc. New York, NY. 2002 Kernan, Walter N. MD. “Preceptor’s Handbook.” Ambulatory Component of the Internal Medicine Clerkship - Yale University School of Medicine. Available online. Neher JO, Gordon KC, Meyer B, and Stevens N. “A five-step ‘microskills’ model of clinical teaching.” J Am Board Fam Pract. 4: 419-24. 1992 Toffler, William L. MD with Anita D. Taylor, MEd and Peter Schludermann, MD. “Pitfalls of Precepting.” Fam Med 33(10):730-1. 2001

Small Group Outline Format Review case (2 minutes) Group discussion of prompting questions (5 minutes) Role play precepting models (8 minutes) Brief discussion of results in group (5 minutes) Group Objectives Analyze student’s presentation medically, then stop that and move on Identify which precepting model might work best Experiment with different approaches Appraise experimentation

Small Group Review Summarize student and presentation style Analyze presentation medically What did your group suspect would be best approach? What did your group find was an effective approach? Other findings?

Session Agenda Pretest assessment of you (5 minutes) Didactic presentation (10 minutes) Small group exercise Introduction (5 minutes) Exercises (20 minutes) Review/discussion of findings (10 minutes) Post-test assessment of you (5 minutes) Curriculum feedback for me (5 minutes) Total: Hopefully 60 minutes