Ambulatory Teaching: Time Efficient and Effective Strategies

1
Ambulatory TeachingTime Efficient and Effective
Strategies

• David M. Irby, PhD
• University of California
• San Francisco

2
Preview

• Identify constraints on ambulatory Education
• Describe efficient and effective teaching
  strategies
• Planning
• Teaching
• Reflecting

3
Constraints on Ambulatory Education

• Fast paced and chaotic environment
• Little teaching, observation and feedback
• Lack of orientation, collaborative learning and
  reflection

Irby, 1995. Ludmerer, 1999
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Recommendations

• Make time for teaching and target to learner
  needs
• Create opportunity space for teaching
• Develop a repertoire of teaching methods
• Offer opportunities for reflection, collaborative
  and independent learning
• Offer ambulatory care conferences
• Promote self-directed and collaborative learning

DaRosa, 1997. Ferenchik, 1997. Heidenreich,
2000. Irby, 1995.
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Teacher Reasoning and Action
Clinical Instruction
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Planning

• Orient learners to clinic
• Introduce to people, procedures, resources
• Specify case format
• Solicit learner goals
• Pre-select patients
• Prime learners

Ferenchick, 1997. Kernan, 1997. Lesky, 1995.
McGee, 1997.
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Prime Learners

• For patients with a new problem
• What are important causes?
• What are signs, symptoms, risks?
• For patients with a follow-up visit
• What are preventive measures?
• What are complications?

McGee, 1997.
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Teacher Reasoning and Action
Clinical Instruction
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Teaching with the Patient

• Model reflectively
• Observe and teach selectively
• Use the One Minute Preceptor

Cunningham, 1999. Ferenchick, 1997. McGee, 1997.
Usatine, 1997, 2000.
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One Minute Preceptor
3. Provide positive feedback 4. Teach general
rules 5. Correct errors

• Listen
• Clarify

1. Ask for a commitment 2. Probe for underlying
reasoning
Neher, 1992.
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Five Precepting Microskills
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Teacher Reasoning and Action
Clinical Instruction
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Reflection

• Ask questions to stimulate reflection
• What are your questions?
• What did you learn from seeing patients today?
• What troubled, surprised, moved or inspired you
  today?

Arseneau, 1995. DaRosa, 1997. Smith, 1997.
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Reflection

• Promote self-directed learning
• What is one thing you want to learn about?
• Encourage self-assessment and share one-minute
  feedback
• Share a success and a concern or question.
• Specifically, you did well on
• One recommendation for improvement...

DaRosa, 1997. Ende, 1995. Lesky, 1995. Neher,
1992. Smith, 1998. Usatine, 2000.
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Conclusion

• Prepare learners to be efficient
• Use a repertoire of time-efficient and effective
  teaching strategies
• Offer opportunities for reflection, collaboration
  and independent learning
• Have fun

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References 1

• Arseneau. Exit Rounds A Reflection Exercise.
  Acad Med. 70684-687, 1995.
• Bland, et al. Faculty Development Special Issue.
  J. Fam. Med. 29(4)230-293, 1997.
• Cunningham et al. The Art of Precepting
  Socrates or Aunt Minnie? Arch Ped Adolesc Med.
  153114-116, 1999.
• DaRosa, et al. Strategies for Making Ambulatory
  Teaching Lite Less Time and More Fulfilling.
  Acad. Med. 72(5) 358-361, 1997.

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References 2

• Ende et al. Preceptors Strategies for
  Correcting Residents in an Ambulatory Care
  Medicine Setting A Qualitative Analysis. Acad
  Med. 70224-229, 1995.
• Ferenchick, et al. Improving the Efficiency and
  Effectiveness of Clinical Preceptors in the
  Ambulatory Setting. Acad. Med. 72(4)277-280,
  1997.
• Heidenreich et al. The Search for Effective and
  Efficient Ambulatory Teaching Methods Through the
  Literature. Ped. 105(1Suppl)231-237, 2000.
• McGee, Irby. Teaching in the Outpatient Clinic
  Practical Tips. JGIM. 12 April(Suppl 2)
  S34-S40, 1997.

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References 3

• Irby. How Attending Physicians Make
  Instructional Decisions When Conducting Teaching
  Rounds. Acad. Med. 67630-638, 1992.
• Irby. Teaching and Learning in Ambulatory Care
  Settings A Thematic Review of the Literature.
  Acad Med. 70898-931, 1995.
• Kernan, OConnor. Site Accommodations and
  Preceptor Behaviors Valued by Third Year Students
  in Ambulatory Internal Medicine Clerkships.
  Teach Learn Med. 9(2)96-102, 1997.
• Lesky, Hershman. Practical Approaches to a Major
  Educational Challenge. Arch Intern Med.
  155897-904, 1995.

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References 4

• Ludmerer. Time to Heal. Oxford University Press,
  1999.
• McGee, Irby. Teaching in the Outpatient Clinic
  Practical Tips. JGIM. 12April(Suppl 2)S34-S40,
  1997.
• Neher, et al. A Five-step "Microskills" Model of
  Clinical Teaching. Journal of the American Board
  of Family Practice. 5419-424, 1992.
• Smith, Irby. The Roles of Experience and
  Reflection in Ambulatory Care Education. Acad
  Med. 7232-35, 1997.
• Smith et al. A Broader Theoretical Model for
  Feedback in Ambulatory Care. Advances Health Sci
  Educ. 3133-140, 1998.

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References 5

• Usatine et al. Four Exemplary Preceptors
  Strategies for Efficient Teaching in Managed Care
  Settings. Acad Med. 72766-769, 1997.
• Usatine et al. Time Efficient Preceptors in
  Managed Care Settings. Acad Med. 75, 2000.