1. John Wheat, DO Jacob Prunuske, MD, MSPH
Fundamental Skills: Teaching and Supervising Medical Students & Residents
John Wheat, DO
Jacob Prunuske, MD, MSPH

2. Objectives Describe fundamental skills needed in medical education
Use POwER method to describe and integrate teaching into ambulatory practice.
Identify barriers to medical student and resident learning in the ambulatory care setting.
Use One-Minute Preceptor tool to assess learner knowledge and focus efforts.
Discuss alternative models of teaching in practice
Review resources available for developing skills as medical educator.

3. Outline Literature Review Fundamental Skills
Current model of residency clinic
POwER Model
Discussion of others experience in residency teaching
Ideas for overcoming barriers in current model of resident education

4. Literature Review
Teaching In Your Office; Alguin, et.al., ACP Teaching Medicine Series
Informed decision about precepting
Preceptors Role:
Learner orientation; setting expectations
Provide learning opportunities and demonstrating knowledge and skill.
Assessing knowledge and giving corrective feedback
Demonstrate professionalism and enthusiasm
What did I sign up for
Decision rather than “falling into it, or feeling like is expected”

5. Literature Review 9 Lessons… Be clinically Astute –and wise
Theory and Practice of Teaching Medicine, Ende, ACP Teaching Medicine Series
9 Lessons…
Be clinically Astute –and wise
Fit Teaching to Learning – Ask how student/learner best learns
“Stimulate learner to identify salient clinical questions and find their own answers”
Be attuned to learner and environment
Assess “where learner is at”
Program considerations, expectations
Engage learners and set goals
Observe and provide feedback
Demonstrate and role model
Be organized and prepare
Improvise
Aspire to be great
Red+ what I did/do not do well – didn’t think about, forget often
Examples: procedures

6. Literature Review What do learners want to learn? Patient management
Data collection
Interpretation skills
Feedback on performance
Role model
Environment that promotes independence
“learning climate that makes learning fun, enjoyable, and exciting” Griffith CH; Acad Med 2000

7. Literature Review
“Faculty Development for Ambulatory Teaching” Wilkerson et.al. J Gen Int Med 1990; 5; S44-s53
6 essential teaching skills:
Establishing and monitoring mutual expectations
Setting Limited Goals
Asking Questions
Stimulating self-directed learning
Giving Feedback
Capitalize on role modeling

8. Lit Review
Strategies for Developing and maintaining teaching skills Wilkerson et.al. J Gen Int Med 1990; 5; S44-s53
Assessment ( self, peers, others)
Individual consultation with educational expert
Organized programs, workshops ( this one included)

9. Lit review
“The Search for Effective and Efficient Ambulatory Teaching Methods” Heidrich, C; Pediatrics Vol.105 No.1 Jan.2000
Common Ambulatory teaching Methods Distilled from literature
Orienting Learner: Site, style, expectations
Prioritizing learner needs
Problem –Oriented Learning: Focus on theme for the day
Priming: 1-2 mins before each visit
Pattern recognition: emphasizing report of chief complaint and presumptive diagnosis, not detail case presentation
Teach in patient’s presence
Limit teaching points ( 1-2)
Reflective Modeling: observe preceptor actions complimented by explanations
Questioning: allows learner to guide subsequent teaching
Feedback:
Teacher / learner reflection

10. Teaching in Residency Clinic
Current Model of FMC staffing:
3-5 residents seeing 4-7 patients / ½ day.
2 Staffers.
R1s see 1 patient at a time, staff case, staffer goes in with each patient ( 1st 6 months)
R2-3s: see 2-6 patients, staff sometimes entire half day at end

11. Teaching in Residency Clinic
Barriers with Current Model
Reactive: Take what comes, “on the fly “
Staffing process crippling to efficiency
Interrupts “team” management.
Process built on “finding the clinical pearl” on a case –by case basis. ( may not be what learner needs or desires in interaction)
Process limits opportunities for direct observation.
Healthcare asking us to provide care differently…

12. Teaching in Residency Clinic
POwER Model Lillich fam Med 2005; 37 (3);

13. Questions / Discussion
Experiences with preparing prior to each session?
Experiences with team “huddles” prior to clinic ½ day?
Experiences with “microskills” or other determined methodology during teaching?
Experiences with reviewing, debriefing for learning and feedback?

14. The Road To Excellence for Primary Care Resident Teaching Clinics” Gupta R; Acad. Med. 2016; 91;

15. Traditional Precepting
Learner Presents
Preceptor asks for additional patient data
Discussion about case and plan for patient care

16. Scenario A

17. Traditional Precepting
Patient care focused, not learner focused
Low-level questions to clarify clinical data
Mini-lectures
Little or no feedback
May be associated with decreased student satisfaction and learning
Difficult to assess learner’s thought processes or level of understanding

18. One Minute Preceptor* Get a commitment Probe for underlying reasoning
Provide positive feedback
Teach general rules
Correct errors
* Neher, Gordon, Meyer, Stevens. A five-step “microskills” model of clinical teaching. JABFP 1992

19. Get a commitment Cue: The learner stops & looks at you…
Action: Ask learner to commit to a diagnoses or plan
Reason: 1st step in diagnosing learning needs, provides focus for teaching
Example: Want do you think is going on?

20. Probe for Underlying Reasoning
Cue: The learner looks to you to confirm dx/plan or suggest an alternative
Action: Ask learner for evidence and/or DDx; do NOT give your opinion
Reason: Insight into thought processes & knowledge; identify gaps
Example: What facts support your conclusion?

21. Provide positive feedback
Cue: Learner did good
Action: Identify and comment on 1 specific good thing the learner did, and the effect it had
Reason: reinforces skills
Example: You listened well, allowing the patient to trust you and disclose a sensitive issue she was concerned about.

22. Teach general rules Cue: Learner needs to know something
Action: Teach general rules or concepts targeted to the learner’s level of understanding
Reason: memorable & transferable
Example: In a young woman with abdominal pain, you should always consider the possibility of pregnancy

23. Correct Errors Cue: Error, omission, misunderstanding
Action: Choose time/place, learner self-critique, discuss error and prevention
Reason: Errors uncorrected will repeat
Example: You may be right that this patient is drug-seeking, but you have to consider other possibilities for his pain and do an exam.

24. Scenario B

25. Practice

26. One Minute Preceptor Learner-centered
Supports assessment of learner’s knowledge and clinical reasoning skills
Supports focused teaching to learner’s needs
Encourages feedback to reinforce desired behaviors and reduce undesired behaviors

27. OMP Effective for both teaching & patient care
Preceptors as good or better at correctly diagnosing patient’s medical condition
May provide more information in same amount of time (or same info in less time)
Aagaard E, et al. Academic Medicine Jan 2004

28. Discussion