1. ©2003 Community Faculty Development Center Teaching in the Real World Tips for Integrating Learners into Busy Practice Settings November, 2003

2. ©2003 Community Faculty Development Center Our sincere thanks to several hundred experienced clinical preceptors, residents and students who have contributed these “Teaching Tips” at faculty development workshops over the last thirteen years

3. ©2003 Community Faculty Development Center By the end of this session, participants will be able to: list five new ideas for efficient teaching in busy clinical settings; demonstrate that they can plan ahead for effective clinical teaching; and actively participate in clinical teaching to a greater extent than previously Objectives

4. ©2003 Community Faculty Development Center Goals Needs Objectives Methods Evaluation Introduction

5. ©2003 Community Faculty Development Center Goals Needs Objectives Methods Evaluation Introduction

6. ©2003 Community Faculty Development Center There are many things that experienced preceptors ask learners to do that save them time, while adding quality to their practice and teaching However... This talk is devoted to “Methods”

7. ©2003 Community Faculty Development Center Be clear about matching your objectives to the learner’s needs One learner’s teaching objective may be another learner’s “scut work” If it doesn’t match, label it as “scut work” Tell the learner that any time s/he helps to save you will be made up in dedicated teaching time Say thanks at the end of the day Methods should not drive objectives! Objectives should reflect the learner’s needs!

8. ©2003 Community Faculty Development Center Clinical teaching is similar to clinical practice You don’t need to do it all at once Feel free to prioritize Pay attention to educational priorities Pay attention to clinical priorities How can I teach and practice at the same time?

9. ©2003 Community Faculty Development Center Plan ahead Provide an orientation Have learners do things that save you time and benefit your practice Learn from your learner Plan how you will use space Teach on the fly Scheduling: Tailor the schedule to meet clinical and teaching objectives Look for unique educational opportunities Establish guidelines for communication Tips for using the medical record General Principles

10. ©2003 Community Faculty Development Center If you don’t plan it, it won’t happen Working the student into your schedule Schedule protected times Formal first-day orientation Mid-point evaluation End of rotation Other protected times for problem-solving, discussion, feedback, evaluation Plan other scheduled activities Plan for days when you are not available Offer a menu based on needs, interests Planning

11. ©2003 Community Faculty Development Center Orient the student Orient your patients Orient your staff Orient yourself Orientation – four aspects

12. ©2003 Community Faculty Development Center Pre-clerkship: Invite the student to visit Is this right for you? Does the student meet certain criteria (e.g. language, etc) First day: Plan a formal orientation session Prepare a written description of the practice Have one student prepare a written description to be used with future students Provide a copy of your mission statement (Community Health Center) Set up a web site for students; mention them on your practice web site Orient the Student

13. ©2003 Community Faculty Development Center Prepare written guidelines of expectations Logistics: Include specifics about dress, hours, parking, use of staff areas, food, etc Educational guidelines: Set progressive goals through the weeks Expectations about confidentiality Provide a learning contract What are your needs? What do you want to learn? List specific learning objectives Orient the student to your life style Personal – invite them into your home Professional - hospital, committees, call, etc. Orient the Student (cont)

14. ©2003 Community Faculty Development Center Announce your role Sign in the waiting room Name on the door Handouts, pictures Invite patients to be teachers Develop a questionnaire (or have a student develop a questionnaire) Has the student added to the visit? Provide a business card for the student Orient your patients

15. ©2003 Community Faculty Development Center Make them active participants in the educational planning process Make it a team approach What can each staff member contribute to the learner’s education? Have the staff orient the student, give tours Provide an opportunity for the staff to participate in providing feedback or evaluation Orient your staff

16. ©2003 Community Faculty Development Center Introducing the student to the staff At a staff meeting At a social gathering Introducing the student to patients Plan explicit guidelines with your office staff How will students be introduced to patients? How will you obtain permission from patients? Orient your staff (cont)

17. ©2003 Community Faculty Development Center Read the curriculum Read the readings Participate in faculty development Orient yourself

18. ©2003 Community Faculty Development Center Tell students that anything they can do to save you time will be made up in active teaching time Thank the student at the end of the day! Activities that can save you time: Take vitals, chart notes Talk to patients who are waiting when you are running behind – it’s “better than a magazine” Write prescription refills Write out patient instructions Go over written patient education materials Make medication lists, ID bracelets Do asthma education Construct a genogram Go through the chart to see if health maintenance guidelines are up to date Have students do things that save you time and benefit the practice

19. ©2003 Community Faculty Development Center Working with younger patients: Perform Denver Developmental Testing Working with older patients: Perform Mini-Mental status exam Interview other caregivers Help elderly patients get dressed and undressed Talk to elderly patients Procedures – Students need to be allowed to do things Phlebotomy Ear flushing Have students do things that save you time and benefit the practice (cont)

20. ©2003 Community Faculty Development Center Have a student focus on a puzzling problem Working with a patient or family that has been a puzzle Interview family members Make a home visit Research a difficult clinical issue Office projects Develop evidence-based medicine resources Develop patient education materials “Why won’t my baby sleep?” “How big will my baby be?” Have students do things that save you time and benefit the practice (cont)

21. ©2003 Community Faculty Development Center They may know better... Use of a Palm Pilot, technology resources About new drugs, yesterday’s lecture Personal issues About their culture, their own life experiences Dealing with clinical questions “ “Take a day, get back to me” Don’t feel threatened by a student who knows something you don’t know Don’t confuse knowledge with information Learn from the Student

22. ©2003 Community Faculty Development Center Provide space for the student: a desk, a shelf, in and out boxes, a TV table, etc. If an extra exam room is available, you can have the student use it, while you move ahead as needed Use your consult room for history taking Use your partner’s desk on his/her day off Rotate desk in a large practice Move phlebotomy to the exam room Think about the use of space

23. ©2003 Community Faculty Development Center Have the student see the patient ahead of you Observe the student interview the patient Try not to interrupt Stand behind the student Stand behind the patient Have the student present to you in front of the patient Methods for teaching “on the fly”

24. ©2003 Community Faculty Development Center Teaching in front of the patient Works best: Present the history Skills: Physical exam, procedures Doing patient education Modeling Use of questioning (vs. “pimping”) Riskier Complex problem solving Differential diagnosis Bad news Teaching on the fly (cont)

25. ©2003 Community Faculty Development Center Schedule events that will help the student Review the schedule ahead of time Review charts ahead of time Double book the first slot, allowing the student to start along with you Specific content areas (e.g. a required H&P): Have a patient come in early Schedule time with others in the practice Practice partners, Nurse Practitioners, Physician Assistants (one could serve as coordinator) Office staff Nurse Health Educator Phlebotomy Health Assistant Billing Clerk Referral Coordinator Receptionist/Appointment Clerk Scheduling: Tailor the schedule with clinical and teaching objectives in mind

26. ©2003 Community Faculty Development Center Schedule time with others outside the practice Consultants in your building Community resources Nutritionist Social worker, Outreach worker Visiting nurse, Hospice Day care center Adult day care center, Nursing home Pharmacy Health Department Local sheriff, local law enforcement officials Find respite time Send the student to read up on something that will come up later in the day Encourage the clerkship to schedule out-of-office time Take a second medical student, or a PA or NP student Schedule with clinical and teaching objectives in mind (cont)

27. ©2003 Community Faculty Development Center Share your library, educational resources Identify patients with problems (diabetes, etc.) who are willing to act as teaching resources Link the student with patients who will present frequently during the clerkship Newly diagnosed patients, prenatal patients, patients in crisis, patients in transition Provide a beeper Take advantage of unique educational opportunities

28. ©2003 Community Faculty Development Center Involve the student as you respond to acutely ill patients Have the student phone patients who are acutely ill, make followup phone calls Use of a speakerphone Manage fewer acutely ill patients over the phone Have the student prepare for a sick patient who is coming in Involve the student in after-hours call Use of a conference-calling feature Take advantage of unique educational opportunities (cont)

29. ©2003 Community Faculty Development Center Involve the student in nursing home care Challenge: Continue to see patients until you find three medications that can be discontinued Have the patient accompany your patients To see a consultant To have a procedure done To the Radiology Department To OT or PT To accompany the Visiting Nurse Take advantage of unique educational opportunities (cont)

30. ©2003 Community Faculty Development Center Review phone messages with the student Have the student make the return calls Have the student review lab work Have the student call patients with results Community activities write a patient education column for the local paper do a project in the community Go together Rounds, conferences, even to a deposition Take advantage of unique educational opportunities (cont)

31. ©2003 Community Faculty Development Center Communicate by phone Share your home phone number Use the practice’s “inside” number Communicate by email Logistics To provide feedback Provide an orientation handout Communication

32. ©2003 Community Faculty Development Center Have the student do chart reviews, participate in QI projects Have the student type up notes, email them in Regarding Medicare (and in some states, Medicaid) “The only documentation by medical students that may be used by the teaching physician is their documentation of the review of systems and past, family and social history. The teaching physician may NOT refer to a medical student’s documentation of physical exam finding or medical decision making in his/her personal note.” AAMC tutorial: “Medicare’s Teaching Physician Documentation Instructions” Most suggest that medical student notes should not be a part of the permanent record Some use student notes as prompts Using the medical record

33. ©2003 Community Faculty Development Center But remember: This session focuses on Methods