1. Challenges in Clinical Teaching
charlotte Wills, MD
residency program director
highland emergency medicine residency
alameda health system
Andi marmor, MD
Professor of pediatrics
Zuckerberg san francisco general
Poll everywhere:
Pollev.com/andimar or text ANDIMAR to 22333
Center for Faculty Education

2. Creative Commons License
Attribution-NonCommercial-Share Alike 3.0 Unported
You are free:
to Share — to copy, distribute and transmit the work
to Remix — to adapt the work
Under the following conditions:
Attribution. You must give the original authors credit (but not in any way that suggests that they endorse you or your use of the work).
Noncommercial. You may not use this work for commercial purposes.
Share Alike. If you alter, transform, or build upon this work, you may distribute the resulting work only under a license identical to this one.
See for full license.

3. Pollev.com/andimar or text ANDIMAR to 22333
session structure
Get to know the group.
Identify teaching challenges.
One Minute Preceptor as a teaching tool.
Work through practice scenarios in small group
1. Apply OMP
2. Develop other skills for common teaching challenges
Share ideas in large group.
Summarize and wrap-up.
Pollev.com/andimar or text ANDIMAR to 22333

4. introduction exercise
Divide into FOUR groups
Name, setting, learners
Have a rep enter your ONE WORD teaching challenges

5. List in ONE WORD the qualities of a good teacher.
Activity
List in ONE WORD the qualities of a good teacher.

6. good teachers: the literature
Solid knowledge base
Clinically competent/clinical skills teaching
Supportive learning environment
Communication: listening, participation, questioning
Enthusiasm about medicine and teaching
Sutkin, 2008

7. traditional clinical teaching
Teacher questions focused on diagnosing the patient and questions about factual information.
Rarely questions about trainee impressions of the patient.
Questioning does not directly assess the learner’s level of knowledge.
Little or no teaching or feedback to the learner.
Irby, 2004

8. pros and cons of tradition
What the learner knows is unclear
Often little teaching
Little or no feedback to learner
Pros:
Efficient
Puts patient care first

11. So how does this work?

12. checklists in medicine

13. one minute preceptor Step 1: Get a commitment
“What do you think is going on?” “What do you want to do next?”
Encourages learner to process further
Step 2: Probe for supporting evidence
“What else did you consider?” “How did you rule those things out?”
Assesses learner’s knowledge and thinking process
Neher, 1992

14. one minute preceptor
Step 3: Teach a general principle
“Following an acute stroke, prevalence of depression ranges from 20-50%;”
“Processes that causes collapse of alveoli will produce crackles on lung exam”
Can be about symptoms, physical findings, treatment, resources, etc.
Allows learning to be generalizable to future cases

15. one minute preceptor Step 4: Reinforce what was done well, and why
“Your presentation was well organized and concise”
Being specific is important
Ensures continuation of good behaviors
Step 5: Give guidance about errors or omissions
“It is important to include an oxygen saturation when considering certain lung processes”
Again being specific is key
Corrects mistakes, forms foundation for improvement

17. one minute preceptor? Pros: Assesses learner knowledge Cons:
Teaches to the level of the learner
Allows for more accurate feedback
More effective teaching encounter
Cons:
More time consuming?
Not known by all faculty
Furney et al. 2001; Aagaard et al. 2004

18. Small group exercise 1: OMP Practice cases (20 minutes)
Each group has a different case
Follow the discussion guide to practice using the steps of the OMP in your group’s scenario
Make a note of key points that come up in the discussion

19. Discussion: OMP practice Cases
Did using the OMP help you teach in this situation?
Was there a step of the OMP you found most useful?
Teaching case #1: Inpatient pediatric attending supervising a student who doesn’t perform a complete exam.
Teaching case #2: ED/Urgent Care supervisor precepting an NP student who settles on an incorrect diagnosis.
Teaching case #3: Primary Care Attending precepting the medical student with a likely false positive test result.
Teaching case #4: Urgent Care attending supervising an intern who is on the right track, but leaping to some larger diagnoses and test.

20. Small group exercise 2: Challenging scenarios (20 minutes)
Each group has a different case
See case for instructions and discussion questions
Be prepared to discuss…
What made your case challenging?
What were the learning opportunities?
What teaching skills could you use to teach in this scenario?

21. Empathy vs Sympathy

22. scenario 1: High Workload
Your Role: Inpatient nephrology attending
Learner: medical student, intern, senior resident, NP, pharmacy resident
Challenges:
A large team with a large workload
Divide and conquer mentality deployed by the senior resident - “no time for teaching”.
Wide range of inter-professional learners.

24. scenario 2: Code Blue
Your role: Pediatric Urgent Care attending physician
Learners/team: RN, senior resident, intern, med student
Teaching Challenges:
Critically ill patient
Lack of clear roles/ no organization
Emotional family/very emotionally charged situation
Teaching during a crisis?

25. scenario 3: challenging team
Your role: inpatient attending
Learners: senior resident, MS4, MS3, social worker
Teaching Challenges:
Senior seems checked out
MS4 is on iphone.
MS3 has other priorities alienates the rest of the team.
Social worker is disappointed with the more junior members of the team and their attitudes.

27. scenario 4: the difficult patient
Your Role: Attending in the Dental Clinic
Learners: Dental residents and students
Teaching Challenges:
Angry hostile patient with dental pain
AND a concerning infection
Resident minimizes her pain, thinks she is drug-seeking
The whole team adopts a negative attitude.

28. summary points
OMP principles can be applied in diverse clinical encounters, and can help us overcome many common teaching challenges.
Diagnose the learner:
Probe understanding and thought process
Teach general principles:
Limit to “pearls” of informatoin
Provide information that can be applied in other situations
Give and ask for feedback with EACH encounter
Promote self directed learning

29. references
Aagaard EA, Teherani A, Irby DM The effectiveness of the one minute preceptor model for diagnosing the patient and the learner. Acad Med 79:42–49.
Furney S, Orsini A, Orsetti K, Stern D, Gruppen L, Irby DM Teaching the one-minute preceptor: a randomized controlled trial. J Gene Inter Med 16:620–624.
Irby DM, Aagaard EA, Teherani A Teaching points identified by preceptors observing one minute preceptor and traditional preceptor encounters. Acad Med 79:50–55.
Neher JO, Gordon KC, Meyer B, Stevens N A five-step ‘microskills’ model of clinical teaching. J Am Board of Family Practice 5:419–424.
O’Malley PG, Kroenke K, Ritter J, Dy N, Pangaro L What learners and teachers value most in ambulatory educational encounters: a prospective, qualitative study. Acad Med 74:186–191.
Ottolini et al Student Perceptions of Effectiveness of the Eight Step Preceptor (ESP) Model in
the Ambulatory Setting. Teach Learn Med 22:
Salerno SM, O’Malley PG, Pangaro LN, Wheeler GA, Moores LK, Jackson JL Faculty development seminars based on the one minute preceptor improve feedback in the ambulatory setting. J Gene Int Med 17:779–787.
Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008; 83:
Teherani A, O’Sullivan P, Aagaard EA, Morrison EH, Irby DM Student perceptions of the One-Minute Preceptor and Traditional Preceptor Models. Med Teach: 29:
Wolpaw TM, Wolpaw DR, Papp KK SNAPPS: a learner-centered model for outpatient education. Acad Med 78:893–8.
Wolpaw T, Papp KK, Bordage G. Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: A randomized comparison group trial. Acad Med 2009; 84: