The One-Minute Preceptor & The One-Minute Observation Effective & Efficient Outpatient Clinical Teaching Presented to the JHUSOM Department of Neurology December 21, 2006

This workshop is based on “Teaching in the Ambulatory Setting” Produced by the Office of Medical Education Research and Development, College of Human Medicine, Michigan State University, 1999

Objectives By end of this session, participants should be able to: State the components of the “one-minute preceptor” model Recognize effective modeling State the components of the “one-minute observation”

Settings & Challenges

Teaching in the Clinic In-depth Lectures Seminars Formal Educational Sessions Extensive Discussion 1-8

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. 1-9

Trigger Tapes What is going well? What is not going well? Vignette 5 (2:19) Vignette 6 (0:58) Vignette 7 (0:20)

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

Trigger Tape (1:23) What effective teaching behaviors do you see?

The One-Minute Preceptor The 5 Microskills of Clinical Teaching Get a commitment Probe for supporting evidence Teach general rules Take each encounter to a learning point Feedback: Reinforce what was right Feedback: Correct mistakes

The One-Minute Preceptor The 5 Microskills of Clinical Teaching Get a commitment What do you think is going on? Probe for supporting evidence What led you to that conclusion? Teach general rules When this happens, do this… Reinforce what was right I really liked that you did…. Correct mistakes Next time this happens, try this…

Case Presentation Presenting in Front of the Patient PROs CONs

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

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

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 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

Modeling Trigger Tape (1:35) What is being done well?

Modeling Determine the learner’s relevant knowledge Identify what the learner should learn Provide guidelines of what the learner should do during the observation Include learner in discussion and examination of patient Provide for brief discussion of learning points after observation

The One-Minute Observation Trigger Tape (1:44)

The One-Minute Observation Explain the purpose of the observation Explain how the observation will occur Inform patient of what will take place Observe without interrupting Leave room without disrupting the student or patient Provide feedback Agenda for future learning

“Trainees do not perform required skills incorrectly on purpose…errors in performance are typically the result of insufficient feedback. They are seldom the result of insufficient interest or caring.” -Westberg and Jason, 1991 4-3

FEEDBACK IS: Information you provide to learners about their clinical performance that is intended to guide their future clinical performance -Adapted from K. Skeff 4-5

Teaching Strategies 5 Microskills: the one minute preceptor Modeling The one minute observation

Bibliography Ende J. Feedback in clinical medical education. JAMA 1983;250:777 Hewson MG. Clinical teaching in the ambulatory setting. JGIM 1992;7:76. Irby DM, et. al. Characteristics of effective clinical teachers of clinical ambulatory care medicine. Acad Med 1991;66:54. Lehman LS,et.al. The effect of bedside case presentations on patients’ perception of their medical care. NEJM 1997;336:1150. Neher JO, et. al. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract 1992;5:419. Wright SM, et. al. Attributes of excellent attending-physician role models. NEJM 1998;339:1986.