Orienting Learners to the Outpatient Setting: Goals, Expectations, Learning Strategies

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Orienting Learners to the Outpatient Setting
Goals, Expectations, Learning Strategies

• Dawn E. DeWitt, MD, MSc, FACP
• Douglas S. Paauw, MD, FACP

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Program Coordinator Site Orientations

• Site selection
• Set expectations for the site
• Curriculum, Feedback and Evaluation
• Problems, questions, problem learners
• Malpractice coverage (provided by the program for
  learners)
• Scope of practice credentialing
• HCFA documentation requirements

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Preceptor Selection

• Interest!!!
• Qualifications Board Certified
• Malpractice coverage
• Teaching Experience
• Willing to work with the program

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Preceptor Myths and Realities

• I wont have time.
• Teaching takes time about 1 hour per day
• Wave schedule enables productivity
• I dont know what to teach.
• Preceptors offer practical knowledge and hands-on
  experience just in day-to-day doings.
• Learners crave real world experiences with role
  models who care for their patients. Learners
  want meaningful responsibility so that they can
  participate in patient care.

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Benefits for Preceptors

• The stimulation of teaching. Learners put a
  fresh face on medicine.
• An association with the program and an
  opportunity to become clinical faculty
• Access to University faculty
• Access to email/internet information through
  Universities
• CME credits and Teaching Certificates/Awards

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Role Modeling and Mentoring

• Learners are trying your job and life on for size
• Model positive enthusiasm
• Learners especially watch how we deal with
  difficult situations
• Allow learners to see long term relationships
  with patients
• Studies show internists dont encourage learners
  to go into GIM and underestimate learner interest

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Before the Learner Starts

• A letter and call telling them when and where to
  arrive the first day
• Program expectations
• Learners schedule and days off
• Dress Code
• Housing (if offsite), Transportation, Parking,
  Community Activities
• Block out time for orientation

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Orienting Learners the first day

• Set aside time! This is your Orientation.
• Tell them a bit about you and your practice
• Ask them about
• their previous outpatient experience
• their specific learning goals
• their career goals
• Explicitly set a mid-rotation feedback time

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Orientation the Office

• Introduce them to your staff
• Exam Rooms gloves, gowns, etc.
• Their Work space
• Charting/Dictation
• Expectations about charting
• Telephones
• Library/Computer Access

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Patient Scheduling

• Clinic Schedules 1-2 new and 3-5 follow-up per
  day
• Call Schedules
• Other learning opportunities
• Home visits
• Nursing Home
• Physical Therapy
• Lab, Blood draw
• Business meetings

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Wave Schedule

• Preceptor
• 800 Patient visit
• 820 Patient visit
• 840 Learner patient
• 900 Patient visit
• 920 Patient visit
• 940 Patient visit
• 1000 Learner patient

• Learner
• 800 Chart review 1
• 820 Patient visit 1
• 840 Present patient
• 900 Charting 1
• 920 Chart review 2
• 940 Patient visit 2
• 1000 Present patient

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Seeing Patients

• Learners need meaningful (supervised)
  responsibility
• Review the learners schedule for the day with
  them
• Select patients if possible
• Inexperienced learners do best seeing simple
  cases and classical presentations
• Consider urgent visits versus chronic problems
• Good historians

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Introducing the Learner

• Patient acceptance
• Title and learners role
• Teacher of the day
• Permission to have the learner present in front
  of the patient

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Meaningful Responsibility

• Students and Residents need meaningful
  responsibility
• Balance seeing it all with student
  independence
• Ideally their own space and schedule
• Residents should be accountable colleagues

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Making it Great Expectations

• Explicit
• Professional behavior
• Duties
• Curricular
• Weekly goals
• Week 1 communication
• Week 2 physical diagnosis
• Week 3 differential diagnosis
• Week 4 therapeutics and follow-up

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Priming the Learner Uncomplicated Patients

• Uncomplicated patient for routine visit
• What screening or preventive issues are
  important?
• Common problem like fatigue
• Lets generate a differential.
• What symptoms and signs should we look for?
• What tests might help us?
• Here is a short resource.

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Priming the Learner Complicated Patients

• Complicated patient with urgent issue
• Differential in setting of chronic issues
• How will we decide if this patient needs to be
  hospitalized for this problem?
• Complicated patient with multiple issues
• Please focus just on diabetes management. What
  complications/problems should we worry about?

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Framing the Visit

• Time limit
• How much to do (Hx and PE or just Hx)
• Goal for presentation
• I want a 3 minute SOAP presentation vs. I want a
  1 minute consult presentation

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Presentations In the Room?

• Patient preference
• involves the patient/extra attention
• saves time
• observe learner/patient interaction
• demonstrate eliciting additional history,
  physical findings, or patient education
• satisfies HCFA requirements

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Presentations Out of the Room?

• Better for
• analyzing the learners thought processes
• discussion of differential diagnosis
• literature debates or pathophysiology
• allowing learners to have a bigger role in
  patient education

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Balancing Teaching and Patient Care

• Goals for attending/learner interactions
• Diagnose the patient
• Diagnose the learners needs
• Be conscious of patient flow
• Provide educational experience for learner
• Provide excellent patient care

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Assessing the Learner

• Importance of meaningful independence
• Observe learner doing parts or a complete HP
• TRY not to take over
• Take notes on technique, approaches,
  organization, etc.

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One Minute Preceptor

• Get a commitment
• What do you think is going on? What do you want
  to do?
• Probe for supporting evidence
• What led you to that conclusion? What else did
  you consider?
• Teach general rules
• Tell them what they did right and the effect it
  had
• Correct mistakes
• Next time consider trying...

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Learner-Centered Problem-Solving Attending

• What is their major question about this case?
• What is the patients agenda and why this/now?
• What is the students most likely dx?
• What else did they consider?
• What do they want to do next?

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After the Visit

• Debrief after each patient with one or two brief
  teaching points
• Emphasize follow-up
• Problem lists and medication lists
• Review or summarize goals for that patients care
• To do lists

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Learning Agendas

• History-taking and Physical diagnosis
• Case management
• Charting
• Doctor-patient communication
• Practice style and efficiency
• Telephone triage and telephone medicine
• Preventive medicine
• Urgent vs. Chronic care

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Learning Strategies

• Should always be learner-centered
• Literature review
• Reflection on what went well/wrong
• Games find the finding
• Teach me something
• Chart review
• Goal of the day

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Grading learner Write-ups General

• Timely when you expect it to be completed
• Legible acceptable mistakes, initialed
• Signed and Patient ID on each page
• Length review
• Organized sections identified/ordered
• Avoid repetition, e.g. ROS and PL/PMH
• Problem/system-based AP
• Appropriate language and abbreviation
• Spelling

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Grading learner Write-upsHistory

• Problem List
• Medication List generic names doses
• HPI Pertinent
• positives and negatives
• ROS, FH, SH for complaint
• previous work-up
• Allergies with reaction
• PMH (other inactive problems)
• Brief and Pertinent FH, SH

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Grading learner Write-upsPhysical Exam

• Organized by system
• Questions re CV exam/pulses, etc.
• Neurological and Musculoskeletal
• Organized within system
• e.g. observation, auscultation, percussion,
  palpation
• Appropriate level of detail
• e.g. cranial nerves (intact or each described)

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Grading learner Write-upsAssessment and Plan

• Problem or System Based
• Order of problems
• Groups appropriately e.g. type 2 DM,
  proteinuria, neuropathy
• Expands differential most likely and do not
  miss
• Justifies most likely
• Incorporates outside reading
• Depth of discussion

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Honors Work Behavior

• Knowledge
• Has the information
• What they do with it
• RIME method
• Reporter
• Interpreter
• Manager
• Expert/Educator
• Professionalism/Preparedness/Punctuality
• Follow-up with patient/educational issues

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Resources

• Paauw D, Burkholder L, Migeon M, eds. Guide to
  Internal Medicine, Mosby, 1999.
• Fihn DeWitt eds. Outpatient Medicine, Saunders,
  1998.

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Questions?

• Dawn E. DeWitt, MD, MSc, FACP
• WWAMI Coordinator, Medicine Residency
• Medicine 665 Wyoming and UWMC Ambulatory
  Clerkship Coordinator
• email dewitt_at_u.washington.edu
• Douglas S. Paauw, MD, FACP
• Medicine Clerkship Coordinator
• email dpaauw_at_u.washington.edu