Teaching in the Clinical Setting: Microskills in Teaching

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Teaching in the Clinical Setting Microskills in
Teaching

• NYPH GME
• Core Education Committee

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Goals for Today

• Describe characteristics of effective clinical
  teachers
• Identify, analyze and practice effective clinical
  teaching, using the One Minute Preceptor

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Effective Clinical Teachers

• Communicate expectations explicitly
• Stimulate interest enthusiastically
• Interact skillfully with patients
• Involve the learner in the teaching process
• Role model desired behaviors
• Give feedback on performance

Irby DM. Ramsey P, Gillmore J, Schad D.
Characteristics of effective clinical teachers of
ambulatory care medicine. Acad Med,
19916654-55.
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What are the challenges for teaching in the
clinical setting?

• Time
• Time
• Time

Irby DM. What clinical teachers in medicine need
to know. Acad Med 199469333-342.
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One-Minute Preceptor

• Validated model for effective and efficient
  clinical teaching
• Developed for outpatient clinic but can be used
  with learners in any clinical setting
• Promotes the learners independence and active
  involvement in patient care
• Encourages the teacher to recognize teachable
  moments

Irby, D. (1997, February). The One-Minute
Preceptor. First presented at the annual Society
of Teachers of Family Medicine Predoctoral
meeting, Orlando, FL.
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And Best of All

• Allows for simultaneous care of patients and
  learners

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One Minute Preceptor

• Get a commitment
• Probe for supporting evidence
• Teach the general rule
• Reinforce what was done right
• Identify problem areas and strategies for
  improvement

Irby, D. (1997, February). The One-Minute
Preceptor. First presented at the annual Society
of Teachers of Family Medicine Pre-doctoral
meeting, Orlando, FL.
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One Minute Preceptor Plus

• Assess prior knowledge
• Get a commitment
• Probe for supporting evidence
• Teach the general rule
• Reinforce what was done right
• Identify problem areas and strategies for
  improvement
• Encourage Reflection and Promote Self-Directed
  Learning

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Set the Stage

• Assess the learners knowledge and prior
  experience
• Have you ever seen a patient like this before?
• What have you learned about..?
• What clinical rotations have you done in the
  past?

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Set the Stage

• Establish goals for the encounter
• For this patient it is important to focus on

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Do one role play

• Divide into pairs
• One of you is a resident working with a medical
  student in the outpatient clinic. It is the
  students first day working with you and her
  second week of the rotation. The next patient is
  a 4 year old boy with a history of asthma who is
  coming in now with a one day history of cough and
  increased work of breathing.
• The other one plays a student
• How would you prepare the student?

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Microskill 1Get a Commitment

• What is going on?
• The learner commits
• Can be risky
• The teachers goal is to provide a supportive and
  safe environment
• Pay attention to tone and body language

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Ask The What? Question

• What do you think is going on?
• (Differential diagnosis)
• What investigations should be ordered?
• (Diagnostic strategy)
• What is your first choice of medication?
• (Selection of therapy)
• What do you think is probably going to happen?
• (Prognosis)
• What would you like to achieve in this visit or
  patient encounter?
• (Management issue)

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What Gets in the Way?

• For the Learner
• Difficulty in making a commitment may be due to
• Fear of being wrong
• Incomplete or contradictory data
• Knowledge gaps
• Passive learning style
• Fear of teacher
• PTSD

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What Gets in the Way?

• For the Teacher
• Difficulty in making a commitment may be due to
• Fear of silence
• Cognitive processing takes 6 seconds
• Teacher jumps in and fills the gap
• Fear of being wrong
• Knowledge gaps
• Fear of being too demanding
• Fear of not being liked
• Fear of falling behind in patient care

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Microskill 2Probe for Evidence

• Encourage the learner to think out loud
• Share rationale for commitment
• Why do you think that is so?
• What factors make this diagnosis likely
• Why do you suggest getting this test first?
• Which medicines are available, and
  why did
  you choose this one?
• What if? questions allow you to further
  identify the learning edge and push to the next
  level

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Role play OMP 1 and 2

• The student sees the patient independently and
  comes out and presents
• StudentThis is a 4 yo boy with a hx of asthma,
  currently not on any meds. He presents now with a
  2 week history of cough and rhinorrhea, no fever,
  and trouble breathing since last night. On PE
  afebrile, RR 44, HR 110, O2sat 92 on RA,
  retracting and abdominal breathing. lungs
  scattered wheezes throughout. Remainder of exam
  is unremarkable

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Role play OMP 1 and 2

• Resident What do you say?
• Role play with partner
• Student Respond.

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Microskill 3Teach the General Rule

• Choose a rule at the learners level
• Consider content areas outside medical knowledge
• Professionalism
• Communication Skills
• Behavioral and Social Science Domains

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Microskill 3Teach the General Rule

• When I see a patient like this, I think about
• In school age children presenting with headache
  I always consider myopia in the differential.
• When I see a rash that I cannot diagnose, I
  define it as best as I can and then look it up
  in. If we dont solve the problem by looking at
  that reference, we need to call

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Microskill 4Give Positive Feedback

• Reinforce what was done right
• Use language that is specific and behavioral, not
  just vague praise
• You did a good job of considering multiple
  diagnoses and prioritizing them.
• I noticed how well you considered the patients
  age and concerns about cost in selecting
  medications.

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Microskill 5Identify and Correct Mistakes

• Correction must be specific and focused
• That drug is often a good choice but in the
  setting of renal failure is contraindicated.
• In children who present with diarrhea and
  vomiting, assessing the urine output is
  essential.

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Role Play OMP 3, 4, and 5

• Continue role play
• Resident note that the student did not present
  the patients history regarding prior
  hospitalizations or ER visits for asthma

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One Minute PreceptorThe 5 Ws

• What is going on?
• Get a commitment
• Why.?
• Probe for evidence
• When I see a patient like this
• Teach the general rule
• Warm and fuzzy
• Give positive feedback
• Whoops
• Correct mistakes

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One Minute PreceptorAdvantages

• Feedback is embedded
• Allows for improved teaching AND assessment
• By questioning you are not only creating a
  stimulating learning environment but also
  assessing the learners knowledge

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One Minute Preceptor Plus Encourage Reflection

• At the end of your session or at the end of the
  patient encounter
• What do you feel you did well?
• What was most challenging?
• How did the practice differ from your
  expectations?
• Did anything surprise you today?

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Reflective Practice

• In clinical practice
• Reflection on, in, and for action
• In clinical education
• Teach
• Reflect
• What worked and why?
• Get feedback from your learners
• Teach some more

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One Minute Preceptor Plus Promote Self-Directed
Learning

• What is your next question?
• Based on this case Id like you to formulate
  your next question and go to the literature to
  answer itwell discuss it tomorrow.
• Practice-based learning

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One Minute Preceptor PlusThe 7 Wicroskills of
Teaching

• What do you know?
• What is going on?
• Why do you think that?
• When I see a patient like this
• Warm and Fuzzy
• Whoops!
• What is your next question?

• Assess Prior Knowledge
• Get a commitment!
• Probe for Evidence/Facts
• Teach the General Rule
• Provide Positive Feedback
• Identify Mistakes to Correct
• Promote Reflection

Ratan, 2008
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Developed by

• Lyuba Konopasek, MD, NYPH Cornell
• Rini Ratan, MD NYPH Columbia
• Sue Bostwick, MD NYPH Cornell
• John Encandela, PhD