The One Minute Preceptor - Virginia Tech...One-Minute Preceptor Some Caveats •Probably most...
Transcript of The One Minute Preceptor - Virginia Tech...One-Minute Preceptor Some Caveats •Probably most...
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The “One-Minute Preceptor”Bruce Johnson, MD
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Objectives
At the conclusion of this discussion, the participant will:
• Identify different settings of clinical teaching and understand which setting may be more conducive to a specific teaching skill
• Understand the 5 microskills that constitute the “one-minute preceptor”
• Recognize consequences of over-emphasis of any particular teaching skill
• Utilize the “one-minute preceptor” process in clinical teaching
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Conflicts
Dr. Johnson has no conflicts to declare in presenting this topic
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Settings for Clinical Teaching
TNTC
• Grand Rounds• Classroom• PBL• Clinical skills workshop• Inpatient wards• Ambulatory clinic• Office practice• and many, many more…
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Settings for Clinical Teaching
Focus on ambulatory clinic/office practiceTypical circumstances:
– Ambulatory/outpatient
– Usually one-on-one learner and preceptor• Classically student or resident with attending physician
• Can be fellow with attending, or student with resident
– Sequential activities• Student/resident sees patient
• Student/resident presents patient case to preceptor
• Preceptor and student/resident discuss the case
• Student/resident, +/- preceptor, return to patient room
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Settings for Clinical Teaching
Characteristics of ambulatory/office setting:
– Experienced preceptor-teacher with less experienced student/resident learner
– Ambulatory implies not seriously ill
• Often smaller number of issues at any one visit
• ICU, ED, OR settings may be more suited to different style of teaching
– Time pressure
• Visits short with lots of clinical issues/decisions to consider
• Any teaching needs to be specific; not the setting for expansive lecturing
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Settings for Clinical Teaching
Characteristics of ambulatory/office setting (cont’d):
– Frequent distractions and interruptions
– In our setting (VTC/Carilion), often significant socioeconomic considerations in our patients
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Ambulatory/Office Teaching
Opportunities:
– One-on-one; full attention by preceptor
– Assess student/resident communication and clinical exam skills
Information gathering
– Assess thought processes and knowledge (cognitive skills) more than procedural ability
– Emphasizes clinical thinking
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“One-Minute Preceptor”
• Originally described by FM doctor (ambulatory preceptor) Jon Neher in Seattle. Further adapted and refined by David Irby, now in San Francisco
• Actually developed from technique used in pharmacy school teaching
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Five Microskills
• Get a commitment
• Probe for supporting evidence
• Teach general rules
• Reinforce what was done right
• Correct mistakes
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Microskills
Get a commitment
• Encourages student/resident ownership of the case
– Not simply information gathering but processing
• Avoids decision making hand-off to preceptor
– Student/resident expected to use own knowledge and information to support a diagnosis or plan
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Microskills
Get a commitment• “What do you think is going on?”
• “What tests do you feel are indicated?”
• (“Of course, to order a test you need to put down a diagnosis, so what’s your working diagnosis?”)
• “What can we accomplish at this visit?”
• “What does the lack of response to previous efforts tell us?”
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Microskills
Get a commitmentConsiderations:
– May need to ask data questions but limit these in hopes student/resident presents on his/her own
– Need not be a diagnosis; may commit to lab test or xray or consultation
• However, would encourage “working diagnosis”
– Remain sensitive to student/resident strength of commitment; don’t force when clearly don’t know
• Risk of student/resident withdrawing (“clamming up”) and losing teaching opportunity
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Microskills
Get a commitmentConsiderations (cont’d)
– Recognize when student/resident directs discussion to have preceptor give clinical thinking
• This comes later – “teach general rules”
– Avoid belittling
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Microskills
Probe for supporting evidence
• Confirms student/resident used diagnostic reasoning to arrive at conclusion
– Not just “lucky guess”
• Inquire about key information
• Discuss what one will learn from confirmatory information (tests, treatments, next steps)
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Microskills
Probe for supporting evidence• “What were the major findings that led to your conclusion?”
• “What in the patient case led you to choose that particular medication?”
• “What other diagnoses did you consider, and why do those not fit?”
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Microskills
Probe for supporting evidenceConsiderations:
• This microskill may also be called “probe for missing information”
• Don’t pass judgment, or praise (that comes later)
• Avoid temptation to grill the student/resident
─ Allow “thinking out loud” without risk
• Confirm knowledge base
• Not yet time to contradict (correct mistakes)
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Microskills
Teach General Rules
• Identify missing information not considered by student/resident
– Gaps in knowledge, data, or missed diagnostic connection
• Requires preceptor “diagnose” the learner’s inaccurate conclusion or absent information
– Sophisticated expectation of preceptor; hearing about case and diagnosing the case at same time as diagnosing the student/resident learning need
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Microskills
Teach General Rules• “In a kid with URI, it’s not enough to
listen to lungs – always examine the ears”
• “In a young person with mechanical low back pain, x-rays are usually not helpful”
• “In our patient population, we always have to consider the cost of antibiotics”
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Microskills
Teach General Rules
• Considerations
– This is the “teaching point”
• Apply to current case but try to make generalizable
• Identify gaps in knowledge or clinical reasoning
• Ideally will be basis to return to patient room for more history, symptom, or physical exam information
– Student/resident should be able to apply to other cases
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Microskills
Teach General Rules• Considerations
– Opportunity for mini-lecture• Time constraints – recall student/resident is also
concerned about time• Again, keep generalizable
– Realistic time to include:• Non-medical, i.e., socioeconomic, issues• If the preceptor admits beyond scope of his/her ability,
teach principles of referral/consultation– If student/resident has done well, OK to skip this step
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Microskills
Reinforce what was done right
• “Catch ‘em being good!”
• Be specific; more than simply “a good job”
– Specific line of questioning; interpretation of conversation; physical exam; finding data
• Ideal if something that can be generalized to other cases
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Microskills
Reinforce what was done right• “Very good to find that xray report, especially since it was
done a year ago”
• “You were right to continue questioning this lady until you got the real reason for her visit”
• “It’s good to consider if this med would interfere with your patient’s enthusiasm for sports”
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Microskills
Reinforce what was done right• Again, requires preceptor process and analyze the learner as
well as process and analyze the case
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Microskills
Correct Mistakes
• This is difficult – similar to giving bad news
• Consider timing
– May not always be best done at time of patient visit; may choose to wait until end of clinic
Unless the mistake would really cause a medical misadventure
• May also wish to find a more private setting
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Microskills
Correct Mistakes• “I agree interstitial cystitis can give changes in the UA but,
common things being common, a UTI really is more likely”
• “Yes, a CT scan of the sinuses might find mucosal thickening, but it’s unlikely another expensive test would change the plan”
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Microskills
Correct Mistakes• Again, be specific
– Identify a knowledge gap, error in clinical processing, missed physical exam finding, etc.
Don’t grill the student/resident to come up with the mistake
– Don’t say “Well, you messed that up royal!”
• Not the time for a mini-lecture, though could suggest “homework”
– Student/resident won’t be listening anyway!
• Don’t be pejorative
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“One-Minute Preceptor”
Microskills
• Get a commitment
• Probe for supporting evidence
• Teach general rules
• Reinforce what was done right
• Correct mistakes
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One-minute Preceptor
https://www.youtube.com/watch?v=t9ytKlq8wL0
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Clinical Teaching Methods
“Aunt Minnie” Method(waddle and quack)
• Pattern recognition
• May be as simple as:
1. Student/resident works up the patient
2. Gives quick overview, perhaps as little as chief complaint and presumed diagnosis or next step
3. Preceptor confirms and supports with 1-2 positive comments, or corrects mistake
4. Onto next case
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Clinical Teaching Methods
“Aunt Minnie” Method• Time efficient in very busy clinic
• Preceptor able to supervise multiple persons
• Drawbacks
– “Snap judgments” (pattern recognition)
Checklist medicine; doesn’t encourage thoughtful collection of data and clinical reasoning
– Not really teaching
– Preceptor centered, not student/resident centered
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Clinical Teaching Methods
Model Problem Solving• Preceptor demonstrates clinical problem solving
– “Here’s how I would work through this case”
• May be used with complex cases, or if student/ resident simply missed the case entirely
– Can actually structure discussion following microskillsmodel
• Removes pressure from student/resident to “perform,” he/she may be more receptive
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Clinical Teaching Methods
Learner-centered Precepting• Requires student/resident to identify his/her own learning
issue
• Sees patient, collects information, presents case without preceptor comment – then raises his/her own learning question
– “It’s clear to me this diabetic has failed oral meds. How do I start insulin treatment?”
• Assumes sophisticated student/resident
– He/she will have correctly diagnosed the case anddiagnosed the knowledge or practice deficit
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Clinical Teaching Methods
Learner-centered Precepting• Often more suited to fellows, or conversations with
colleagues or as a consultant
• Teaching lies beyond “general rules” and learning is very narrow and specific
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Clinical Teaching Methods
SNAPPSStudent/resident led interaction
• Summarize briefly history and findings
• Narrow the differential to 2-3 possibilities
• Analyze the differential by comparing and contrasting possibilities
• Probe the preceptor by asking questions about uncertainties, difficulties, alternatives
• Plan management for patient’s issues
• Select a case-directed topic for self study
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“One-Minute Preceptor”
Microskills
• Get a commitment
• Probe for supporting evidence
• Teach general rules
• Reinforce what was done right
• Correct mistakes
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“One-Minute Preceptor”
Some Caveats• Similar to technique of giving feedback; skills are readily
transferable
– Some would reverse microskills 4 and 5, so “correct mistakes” comes before “reinforce what was done right”
Reversing 4 and 5 ends interaction on more positive note
• VTC students attuned to small group/learner-led settings; student/residents from more lecture-based schools might have to be taught this interactive technique
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“One-Minute Preceptor”
Some Caveats• Probably most important microskill is “get a commitment”
– Most demanding of student/resident
– Sets tone for remainder of interaction
– Reinforces focus of interaction on student/resident
• In some settings, OK to skip one or more of the other microskill steps
– If presentation well-supported, might skip “probe for supporting evidence”
– There may be no obvious mistakes to “correct”
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“One-Minute Preceptor”
Microskills
• Get a commitment
• Probe for supporting evidence
• Teach general rules
• Reinforce what was done right
• Correct mistakes
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References
1. Neher JO, et al. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract1992;5:419-424.
2. Irby DM, et al. Teaching points identified by preceptors observing one-minute preceptor. AcadMed 2004;79:50-55.
3. Furney SL, et al. Teaching the one-minute preceptor. J Gen Intern Med 2001;16:620-624.
4. Alguire PC, et al. Teaching in your office. 2nd ed. Philadelphia PA. ACP Press. 2008. pp. 51-73.