C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Clinical Teaching: The 1 Minute Preceptor Mary McDonald, MD KUMC – Dept of Family Medicine, Division of Geriatric Med and Palliative Care C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Types of Teaching  Pimping  Lecture  Apprenticeship  Mentorship Venues for Teaching Inpatient vs Outpatient

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Pimping  Often occurs on rounds Both teacher and learner are active Patient-specific or hypothetical  Warning: Fine line between educational quizzing and emotional belittlement

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Lecture  Teacher active but learner is passive

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Apprenticeship  Teacher passive but learner active  Can occur on teaching rounds

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Preceptorship  Teacher active and learner passive  Occurs in bedside teaching

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Case Presentation Presenting in Front of the Patient PROs CONs

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Bedside Presentations*  Patients reported: Doctors spent more time with them (10 vs. 6 min) Perceptions of their care were slightly more favorable Doctors were more likely to explain problems adequately *Lehman L, N Eng J Med 1997:336:1150

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Bedside Presentations* Bedside presentation patients reported:  Did not provoke worry (88%)  The practice should continue (82%)  Helped them understand their illness (51%)  Too much confusing medical terminology (46%)  Perceived that the purpose of rounds was to teach and not to provide care (94%) *Lehman L, N Eng J Med 1997:336:1150

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Improving Bedside Presentations*  Patients should be given the opportunity to say more  All physicians in room should introduce themselves  Physicians should be more attentive to the presentations  There should be fewer physicians in the room *Lehman L, N Eng J Med 1997:336:1150

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Improving Bedside Presentations*  The physicians should respect the patients privacy more  Physicians should ask permission to present at the bedside  Physicians should be seated during the presentation *Lehman L, N Eng J Med 1997:336:1150

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine How is teaching in an outpatient setting different?

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine 1-8 Teaching in the Clinic In-depth Lectures Seminars Formal Educational Sessions Extensive Discussion

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine 1-9 Efficient and effective ambulatory care teaching requires that both the student and preceptor accept the limitations of the outpatient setting. Extensive discussions of differential diagnosis, pathophysiology and psychosocial problems are not possible nor necessarily desirable.

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Pitfalls in Clinical Case-Based Teaching  “Taking over” the case  Inappropriate lectures  Insufficient “wait-time”: 3-5 sec  Pre-programmed answers What do you think is going on? Could it be an ulcer?  Rapid reward Effectively shuts down the student’s thinking  Pushing past ability Persist in carrying the students beyond their understanding

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine The “One Minute Preceptor” teaching model was developed at the Department of Family Medicine at the University of Washington, Seattle. See: Neher, J. O., Gordon, K. C., Meyer, B., & Stevens, N. (1992). A five-step "microskills" model of clinical teaching. Journal of the American Board of Family Practice, 5,

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine The One-Minute Preceptor 1. Get a commitment 2. Probe for supporting evidence 3. Reinforce what is right 4. Give guidance about errors or omissions 5. Teach general principles 6. Conclusion

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Commitment  Why? Learner becomes more active in teaching encounter Allows you to assess how learner has processed information presented Even if answer is incorrect, learning has occurred  Example What do you think is going on here? What would you like to do next?

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Probe for Evidence  Why? Uncovers learners reasoning process for arriving at the conclusion (Not a lucky guess)  Example “What factors support your diagnosis?” “Why did you choose that treatment?”

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Reinforce What Was Right  Why? Behavior specific feedback will promote and encourage desirable clinical behaviors.  Example “I liked that your differential took into account the patient’s age, recent exposures, & symptoms.”

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Give Guidance About Errors or Omissions  Why? Behavior specific constructive feedback discourages incorrect behaviors and corrects misconceptions.  Example “During the ear exam the patient seemed uncomfortable. Let’s go over holding the otoscope.”

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Teach General Rules  Why? Helps learner effectively generalize knowledge gained from this specific case to other clinical situations  Example “Remember 10-15% people are carriers of strep, which can lead to false positive strep tests.”

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Conclusion  Why? Helps control time and sets clear agenda and roles for remainder of encounter  Example …“Let’s go back in the room and I’ll show you how to get a good throat swab. Tell me when we have the results, and I’ll watch you go over the treatment plan.”

C hief R esident I mmersion T raining Landon Center on Aging University of Kansas School of Medicine Adapted from Materials……  Effective Clinical Teaching, Rohan Jeyarajah, MD and Hari Raja, MD  Lehman LS,et.al. The effect of bedside case presentations on patients’ perception of their medical care. NEJM 1997;336:1150.  The “One Minute Preceptor”: Time Efficient Teaching in Clinical Practice. Preceptor Development Program, developed by MAHEC. Funded by HRSA Family Medicine Training Grant # 1D15PD  The One-Minute Preceptor & The One-Minute Observation Effective & Efficient  Outpatient Clinical Teaching. JHUSOM Department of Neurology, December 21, 2006