A Resource for Difficult Ambulatory Teaching Situations Group Wisdom

Foundations of Independent Practice (FIP) Foundational science essential for practice; some diagnosis/management Biostatistics and epidemiology/ population health Social sciences, including ethics, communication/interpersonal skills Interpretation of medical literature System-based practice/patient safety

Good judgment comes from experience. Will Rogers Will Rogers

Good judgment comes from experience. And a lot of that comes from bad judgment. And a lot of that comes from bad judgment. Will Rogers Will Rogers

To err is human,

But try and make a different mistake each time. But try and make a different mistake each time.

Student is stuck in “reporter” role

Faculty suggestions Ask leading questions to guide the student differential and plan. Ask leading questions to guide the student differential and plan. Role reversal. Preceptor presents the H&P and asks the student to make the assessment and plan. Then query student for role perceptions. Role reversal. Preceptor presents the H&P and asks the student to make the assessment and plan. Then query student for role perceptions. If multiple learners, one student may be assigned the A&P after another delivers the H&P. This keeps all engaged. If multiple learners, one student may be assigned the A&P after another delivers the H&P. This keeps all engaged.

Aunt Minnie Student presents the CC and diagnosis ( or plan) in seconds Student presents the CC and diagnosis ( or plan) in seconds Student writes the note while preceptor evaluates the patient Student writes the note while preceptor evaluates the patient Preceptor gives feedback after the patient leaves Preceptor gives feedback after the patient leaves Sackett et al. Clinical Epidemiology. Little Brown 1985 Sackett et al. Clinical Epidemiology. Little Brown 1985

Underachiever- already committed to another specialty.

Faculty suggestions Professionalism demands students be the best doctor /learner they can in any situation. Professionalism demands students be the best doctor /learner they can in any situation. Help the student find the skills that are common between the current rotation and their expressed interest. Help the student find the skills that are common between the current rotation and their expressed interest. Appeal to the student’s fear of missing an important diagnosis outside their chosen field. Appeal to the student’s fear of missing an important diagnosis outside their chosen field.

Learner Centered Preceptor Standard presentation except…… the student includes their “learning need” in the chief complaint and probes the preceptor for the details they need to complete the assessment and plan. Standard presentation except…… the student includes their “learning need” in the chief complaint and probes the preceptor for the details they need to complete the assessment and plan.

Would rather study for the shelf exam than see patients.

Faculty suggestions Point out that study linked to real patients is more effective/ memorable. Point out that study linked to real patients is more effective/ memorable. Preceptors can emphasize ( brand) the Shelf Exam material that students ARE learning when they are seeing patients. Preceptors can emphasize ( brand) the Shelf Exam material that students ARE learning when they are seeing patients. Tailor didactic teaching to what the students are struggling with in their exam prep books. Tailor didactic teaching to what the students are struggling with in their exam prep books.

Learning from books vs patients Pre-establish the student’s perceived needs to hone clinical skills/gain autonomy in orientation. Pre-establish the student’s perceived needs to hone clinical skills/gain autonomy in orientation. Newer testing philosophies from NBME will reward ambulatory skill/ knowledge. Newer testing philosophies from NBME will reward ambulatory skill/ knowledge. If the student is leaving early or missing clinical opportunities the Student Dean may be able to shed light on whether this is a pattern for this student. If the student is leaving early or missing clinical opportunities the Student Dean may be able to shed light on whether this is a pattern for this student.

Student doesn’t know enough to be helpful with a complex patient.

Faculty suggestions Is the student disorganized or lacking knowledge/skills? Tailor the solution to the problem. Is the student disorganized or lacking knowledge/skills? Tailor the solution to the problem. Set a time limit. Set a time limit. Start the interview with the student to set the stage. Start the interview with the student to set the stage.

Problem Focused Assignment For a complex patient, have the student focus on a single manageable issue on the patient agenda. ( How did she do on the diet goals set last visit?) For a complex patient, have the student focus on a single manageable issue on the patient agenda. ( How did she do on the diet goals set last visit?) The preceptor can address the remaining issues confident that the student addressed one issue thoroughly. The preceptor can address the remaining issues confident that the student addressed one issue thoroughly.

Student doesn’t know enough to be helpful with a complex patient. What CAN the student help with to “purchase” teaching time with the preceptor? What CAN the student help with to “purchase” teaching time with the preceptor? Prepping patients ( disrobing, taking down dressings, getting vitals) Prepping patients ( disrobing, taking down dressings, getting vitals) Just get the patient’s “ list” of issues out on the table Just get the patient’s “ list” of issues out on the table Medication reconciliation Medication reconciliation ROS- student ROS is billable ROS- student ROS is billable Family/Social History- also billable Family/Social History- also billable Research health maintenance status/drug plan… Research health maintenance status/drug plan… Obtain outside records Obtain outside records

Micro-Skills (1 Minute Preceptor) Get a commitment on a diagnosis Get a commitment on a diagnosis Get the evidence for that diagnosis Get the evidence for that diagnosis Teach a general rule based on the case Teach a general rule based on the case Reinforce a specific thing the student did well Reinforce a specific thing the student did well Correct errors Correct errors Neher et al. J Am Board Fam Prac Neher et al. J Am Board Fam Prac. 1992

The student asks hard questions.

Faculty Suggestions Model humility and comfort with needing to find answers. Model humility and comfort with needing to find answers. Turn the question into a discusion of finding and validating answers. Turn the question into a discusion of finding and validating answers.

Modeling Problem Solving If our goal is lifelong learners…… If our goal is lifelong learners…… Preceptor should not model “ font of all knowledge” Preceptor should not model “ font of all knowledge” Student is assigned or self assigns learning objectives. Student is assigned or self assigns learning objectives. Student teaches preceptor. Student teaches preceptor.

Modeling Problem Solving Allow the student to watch you think through a problem out loud. Allow the student to watch you think through a problem out loud. Where do you look for answers? Where do you look for answers? How do you validate resources? How do you validate resources? What part of your thought process does the patient see? What part of your thought process does the patient see?

Premature Closure Premature Closure

Faculty Suggestions Novices may need to do some shadowing to see how the ambulatory H&P differs. Ask them to watch for particular components. Novices may need to do some shadowing to see how the ambulatory H&P differs. Ask them to watch for particular components. Use personal anecdotes of premature closure errors that the preceptor has committed. Use personal anecdotes of premature closure errors that the preceptor has committed. Even if the Dx is a slam dunk, require a list of alternatives. Even if the Dx is a slam dunk, require a list of alternatives.

SNAPPS Summary (deluxe chief complaint) Summary (deluxe chief complaint) Narrow (differential diagnosis) Narrow (differential diagnosis) Analyze ( how the student decided among the diagnoses using pertinent positives/negatives from the H&P) Analyze ( how the student decided among the diagnoses using pertinent positives/negatives from the H&P) Probe (the preceptor about uncertainties, difficulties, approaches) Probe (the preceptor about uncertainties, difficulties, approaches) Plan (management of the patient issue) Plan (management of the patient issue) Select (a self directed learning topic) Select (a self directed learning topic) Wolpaw et al. Academic Medicine Wolpaw et al. Academic Medicine. 2003

External locus of control

Faculty Suggestions Focus on the patient’s barriers to change. Focus on the patient’s barriers to change. Nurture empathy for how hard the changes are. Nurture empathy for how hard the changes are. Focus on incremental changes. Focus on incremental changes. Develop a coaching rather than nagging relationship with the patient. Develop a coaching rather than nagging relationship with the patient.

Motivational Interviewing Motivational Interviewing in Health Care: Helping Patients Change Behavior / Edition 1 Motivational Interviewing in Health Care: Helping Patients Change Behavior / Edition 1 Stephen Rollnick, Stephen Rollnick, Stephen Rollnick Stephen Rollnick William R. Miller, William R. Miller, William R. Miller William R. Miller Christopher C. Butler Christopher C. Butler Christopher C. Butler Christopher C. Butler

Active Observation “Shadowing” framed within teaching. “Shadowing” framed within teaching. Ex: I notice you are pretty hopeless that his patient can change their diet. Observe me and then tell me what you saw me do. Ex: I notice you are pretty hopeless that his patient can change their diet. Observe me and then tell me what you saw me do.

Culturally inappropriate actions by patients.

Medicine in Context vs Cultural Sensitivity Focus on perceptions/ feelings. Focus on perceptions/ feelings. Can the preceptor make it a learning opportunity? Can the preceptor make it a learning opportunity? How does the preceptor deal with the flirtatious patient? How does the preceptor deal with the flirtatious patient? Or one who makes racist comments directed towards him/her or towards staff? Or one who makes racist comments directed towards him/her or towards staff?

Low empathy

Low Empathy Can humanism be taught? Can humanism be taught? It can be consciously modeled. It can be consciously modeled. In can be consciously recognized when witnessed. In can be consciously recognized when witnessed. Ask, “What makes it hard for us to love this patient?” Ask, “What makes it hard for us to love this patient?” Express curiosity about the circumstances of patients’ lives. Express curiosity about the circumstances of patients’ lives. Depressed student? Depressed student? Burn out? Burn out?

Student seeks feedback but preceptor has only seen presentations.

1 Minute Observation Pick a skill to work on. (rapport, review of systems, giving advice, exam component.) Pick a skill to work on. (rapport, review of systems, giving advice, exam component.) Observe the student for 1 minute and then leave without interruption. Observe the student for 1 minute and then leave without interruption. Give feed back at the end of the visit. Give feed back at the end of the visit. Ferenchick et al. Arch Pediatr Adolesc Med Ferenchick et al. Arch Pediatr Adolesc Med. 1999

How do we share this collaboration with ambulatory preceptors?

Reference AMEE Guide No 26: clinical teaching in ambulatory care settings: making the most of learning opportunities with outpatients AMEE Guide No 26: clinical teaching in ambulatory care settings: making the most of learning opportunities with outpatients Medical Teacher, Vol. 27, No. 4, 2005, pp. 302–315