A Resource for Difficult Ambulatory Teaching

Situations

Group Wisdom

Foundations of Independent Practice (FIP)• Foundational science essential for

practice; some diagnosis/management

• Biostatistics and epidemiology/ population health

• Social sciences, including ethics, communication/interpersonal skills

• Interpretation of medical literature

• System-based practice/patient safety

Good judgment comes from experience.

Will Rogers

Good judgment comes from experience.

And a lot of that comes from bad judgment. Will Rogers

To err is human,

To err is human,

But try and make a different mistake each time.

Student is stuck in “reporter” role

Faculty suggestions

Ask leading questions to guide the student differential and plan.

Role reversal. Preceptor presents the H&P and asks the student to make the assessment and plan. Then query student for role perceptions.

If multiple learners, one student may be assigned the A&P after another delivers the H&P. This keeps all engaged.

Aunt Minnie

Student presents the CC and diagnosis ( or plan) in 10-30 seconds

Student writes the note while preceptor evaluates the patient

Preceptor gives feedback after the patient leaves

Sackett et al. Clinical Epidemiology. Little Brown 1985

Underachiever- already committed to another

specialty.

Faculty suggestions

Professionalism demands students be the best doctor /learner they can in any situation.

Help the student find the skills that are common between the current rotation and their expressed interest.

Appeal to the student’s fear of missing an important diagnosis outside their chosen field.

Learner Centered Preceptor

Standard presentation except…… the student includes their “learning need” in the chief complaint and probes the preceptor for the details they need to complete the assessment and plan.

Would rather study for the shelf exam than see

patients.

Faculty suggestions

Point out that study linked to real patients is more effective/ memorable.

Preceptors can emphasize ( brand) the Shelf Exam material that students ARE learning when they are seeing patients.

Tailor didactic teaching to what the students are struggling with in their exam prep books.

Learning from books vs patients

Pre-establish the student’s perceived needs to hone clinical skills/gain autonomy in orientation.

Newer testing philosophies from NBME will reward ambulatory skill/ knowledge.

If the student is leaving early or missing clinical opportunities the Student Dean may be able to shed light on whether this is a pattern for this student.

Student doesn’t know enough to be helpful with a

complex patient.

Faculty suggestions

Is the student disorganized or lacking knowledge/skills? Tailor the solution to the problem.

Set a time limit. Start the interview with the student

to set the stage.

Problem Focused Assignment

For a complex patient, have the student focus on a single manageable issue on the patient agenda. ( How did she do on the diet goals set last visit?)

The preceptor can address the remaining issues confident that the student addressed one issue thoroughly.

Student doesn’t know enough to be helpful with a

complex patient. What CAN the student help with to

“purchase” teaching time with the preceptor? Prepping patients ( disrobing, taking

down dressings, getting vitals) Just get the patient’s “ list” of issues out

on the table Medication reconciliation ROS- student ROS is billable Family/Social History- also billable Research health maintenance

status/drug plan… Obtain outside records

Micro-Skills(1 Minute Preceptor)

Get a commitment on a diagnosis

Get the evidence for that diagnosis

Teach a general rule based on the case

Reinforce a specific thing the student did well

Correct errors Neher et al. J Am Board

Fam Prac. 1992

The student asks hard questions.

Faculty Suggestions

Model humility and comfort with needing to find answers.

Turn the question into a discusion of finding and validating answers.

Modeling Problem Solving

If our goal is lifelong learners……

Preceptor should not model “ font of all knowledge”

Student is assigned or self assigns learning objectives.

Student teaches preceptor.

Modeling Problem Solving

Allow the student to watch you think through a problem out loud. Where do you look

for answers? How do you

validate resources? What part of your

thought process does the patient see?

Premature Closure

Faculty Suggestions

Novices may need to do some shadowing to see how the ambulatory H&P differs. Ask them to watch for particular components.

Use personal anecdotes of premature closure errors that the preceptor has committed.

Even if the Dx is a slam dunk, require a list of alternatives.

SNAPPS

Summary (deluxe chief complaint) Narrow (differential diagnosis) Analyze ( how the student decided

among the diagnoses using pertinent positives/negatives from the H&P)

Probe (the preceptor about uncertainties, difficulties, approaches)

Plan (management of the patient issue)

Select (a self directed learning topic) Wolpaw et al. Academic Medicine. 2003

External locus of control

Faculty Suggestions

Focus on the patient’s barriers to change.

Nurture empathy for how hard the changes are.

Focus on incremental changes. Develop a coaching rather than

nagging relationship with the patient.

Motivational Interviewing

Motivational Interviewing in Health Care: Helping Patients Change Behavior / Edition 1 Stephen Rollnick,  William R. Miller,  Christopher C. Butler

Active Observation

“Shadowing” framed within teaching .

Ex: I notice you are pretty hopeless that his patient can change their diet. Observe me and then tell me what you saw me do.

Culturally inappropriate actions by patients.

Medicine in Context vs Cultural Sensitivity

Focus on perceptions/ feelings. Can the preceptor make it a learning

opportunity? How does the preceptor deal with

the flirtatious patient? Or one who makes racist comments

directed towards him/her or towards staff?

Low empathy

Low Empathy

Can humanism be taught? It can be consciously modeled. In can be consciously recognized when

witnessed. Ask, “What makes it hard for us to love

this patient?” Express curiosity about the

circumstances of patients’ lives. Depressed student? Burn out?

Student seeks feedback but preceptor has only seen

presentations.

1 Minute Observation

Pick a skill to work on. (rapport, review of systems, giving advice, exam component.)

Observe the student for 1 minute and then leave without interruption.

Give feed back at the end of the visit.

Ferenchick et al. Arch Pediatr Adolesc Med. 1999

How do we share this collaboration with

ambulatory preceptors?

Reference

AMEE Guide No 26: clinical teaching in ambulatory care settings: making the most of learning opportunities with outpatients Medical Teacher, Vol. 27, No. 4, 2005,

pp. 302–315