1. Making the Most of Precepting Opportunities
Michael Allison

2. 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

3. 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

4. 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?

5. 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!

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

7. “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?”

8. “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

9. “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

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

11. “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

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

13. 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.”

14. 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?

15. 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

16. 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

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

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

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

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

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

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

23. 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:
Toffler, William L. MD with Anita D. Taylor, MEd and Peter Schludermann, MD. “Pitfalls of Precepting.” Fam Med 33(10):

24. 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

25. 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?

26. 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