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Teaching skills for community based preceptors 2010

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 Teaching Skills for Community Based Preceptors 1 Table of Contents Preamble ............................................................................ 2 A What is an effective clinical teacher?  (Dr. Leslie Sadownik) .......................................................... 4 B How do we learn? (Dr. Leslie Sadownik)  1) The Learning Cycle ................................................. 6  2) Using the learning cycle to your advantage ............ 8 C Preparing to teach (Dr. Jean Jamieson) 	 1)	 Prepare	your	office ................................................ 10  2) Prepare your patients ............................................. 11  3) Prepare yourself .................................................... 13  4) Prepare an educational plan .................................. 13 D Teaching with patients (Drs. Jean Jamieson and David Fairholm)  1) Provide a variety of active learning    opportunities .......................................................... 18  2) Focus on clinical reasoning ................................... 19  3) Use a variety of teaching techniques    a. Ask questions .................................................. 22    b. Try the “One Minute Preceptor” ..................... 24    c. Teach procedural skills ................................... 26 E Observation, feedback & assessment (Dr. Leslie Sadownik)  1) Observation and providing feedback .................... 28  2) Assessment ............................................................ 33 F What to do with learners with problems?  (Dr. Jean Jamieson) .......................................................... 35 G  For more information (Dr. Jean Jamieson) ....................... 39 Acknowledgements .......................................................... 42 Clinical teaching survival guide ....................................... 43 (This guide can be removed for your convenience) Office for Faculty Development 2 Preamble As members of a profession, we are entrusted with a re- sponsibility to continuously renew our ranks by educating the next generation of physicians.  Despite many adverse circumstances, we have a professional duty to teach young physicians. If you are a practicing physician you may have the op- portunity to accept a medical student or a post-graduate resident into your busy practice. Naturally, this request may raise a number of questions such as:  •	 Why	me? 	 •	 What	can	I	teach? 	 •	 How	do	I	teach	it? 	 •	 How	can	I	learn	to	teach	it? Relax.  You have not been asked to deliver lectures or grade exams. You have been asked to share what you do everyday in your clinical practice with a learner - to serve as a preceptor.  A preceptor is a role model who can supervise, guide and facilitate the learning of a student. Whether you have been working as a preceptor for many years, or just contemplating trying it out, you may have some questions about your role as a clinical teacher. This	booklet	was	developed	by	physicians	in	the	Office for Faculty Development and Educational Support in the UBC Faculty of Medicine to help you teach more effec- tively in the clinical setting. The terms students, learners and residents are inclusive terms and can be used inter- changeably, depending on the individual circumstances. Teaching Skills for Community Based Preceptors 3 While this booklet has been written by physicians for phy- sicians, we recognize that other health care professionals deal with the same clinical teaching and learning issues. Feel free to adapt the suggestions to your own profession and working environment. The booklet will introduce you to key con- cepts in teaching and learning and help you prepare for your role as a clinical teacher.  If you	are	pressed	for	time,	try	flipping	through the Quick Tips that are highlighted throughout the booklet for a brief overview of important teaching points and practices. Good luck, and enjoy. Office for Faculty Development 4 A. What is an effective clinical teacher? Can	you	recall	someone	who	had	a	significant	impact	on your clinical training? How would you describe that person and why do they stand out in your memory? Ef- fective	clinical	teachers	have	well	identified	roles	and characteristics. Let’s start by looking at the roles and the characteristics of excellent teachers. 1. Physician Great clinical teachers are role models as physicians. They are	knowledgeable	and	competent	in	their	fields,	demon- strate strong interpersonal communication skills, work effectively in a team and serve as role models. Such a teacher demonstrates a positive attitude to patients and to their own career. 2. Teacher Excellent clinical teachers are those who are interested in teaching and learning.  They spend time with learners, explain things and answer questions. They are well organized and prepared to have learners in their clinical setting. They facilitate the students’ learning and focus on the students’ clinical reasoning skills. 3. Supervisor As a supervisor, an excellent clinical teacher provides direction and feedback and he or she delegates responsibil- ity and involves learners in management. The learner feels like they are part of the health care team. 4. Person Finally, outstanding clinical teachers are accessible, en- thusiastic, supportive and positive individuals.  Learners Teaching Skills for Community Based Preceptors 5 look forward to working with these teachers because they value and respect learners as individuals and they create an enjoyable and positive work environment. What makes these types of teachers effective is that they motivate learners to learn and to improve their clinical performance. Effective	teachers	inspire	rather	than	inform! “Who” they are and “how” they teach is often more im- portant than “what” they teach. Effective Clinical Teachers •	 provide	opportunities	for	learners	to participate	in	patient	care; •	 teach	specific	content	and	skills; •	 delegate	specific	tasks	to	the	learner; •	 are	available	to	answer	questions; •	 observe	the	learner; •	 provide	timely,	constructive	feedback; •	 provide	a	friendly	supportive	learning environment; •	 influence	and	inspire. References: Wright S, Carrese J.  Excellence in role modelling: insight and perspectives from the pros.  CMAJ 2002; 167:638- 643. Paukert JL, Richards BF.  How medical students and residents describe the roles and characteristics of their influential	clinical	teachers.	Acad	Med	2000;	75:843-5. Office for Faculty Development 6 B. How do we learn? Adapted from Teaching and Learning in Medical Practice. Peyton, J.W. 1998. It may help to understand why “how” we teach is more important than “what” we teach if we explore a model on how adults learn in the clinical setting.  In the same way that clinicians apply knowledge of basic sciences to solve clinical problems, understanding the basic principles of adult learning may be helpful to clinical teachers. 1. The learning cycle The following is a competency based model of learning that has been applied to many learning situations.  It helps to outline the different stages adults move through as they gain mastery in a subject or a skill. Let’s take a clinical example to demonstrate how this can be used in clinical teaching – learning to intubate. Teaching Skills for Community Based Preceptors 7 1.  A learner observes the physician performing a proce- dure – in this case, intubating patients – and begins to feel	confident	about	doing	the	procedure.	At	this	point the learner is unconsciously incompetent. 2.  Given the opportunity to try to do the procedure, the learner realises it may not be as easy as initially seemed. Where exactly is the larynx? The learner is now consciously incompetent and motivated to learn so as to properly perform the procedure. 3.		With	practice,	the	learner	refines	their	technique	until competent. At this stage the learner is focused on every step of the procedure. Mentally rehearsing the proce- dure before performing it is helpful. The learner may engage in background reading, such as reviewing the anatomy of the neck, to help improve performance. The learner is now consciously competent. Observa- tion of the learner by a teacher with timely and ap- propriate feedback will help the learner reach this stage more easily than if the learner is left to learn on their own. 4.  Finally, the learner stops thinking about every step of the procedure and performs the procedure based pri- marily on their practical experience. The learner is now unconsciously competent and can do the task without thinking. All independent physicians should reach this stage! Office for Faculty Development 8 Over time, physicians tend to forget the theoretical principles and steps behind each procedure – they just do	it.	At	this	point,	they	may	find	it	difficult	to	explain	to someone at the early stages of the learning cycle how to do the procedure. Learners who are consciously compe- tent are often very good teachers because they are able to explain steps involved in a procedure or clinical reasoning to learners still struggling with the skill. 2. Using the learning cycle to your advantage Learners need to do things! Mistakes will and should occur. Learners must feel okay about acknowledging they lack knowledge or skill. A learner must feel comfortable discussing mistakes. If mistakes occur in a supportive learning environment, the learner will be able to acknowledge their limitations and be receptive to constructive feedback. In an unsupportive learning environment, the learner is likely to conceal mistakes. Unsupportive learning environments hinder further learning. Teachers need to observe all learners and provide feed- back so they can continue to improve clinical performance. Teaching Skills for Community Based Preceptors 9 Adult Learning • Active 	 Adult learners need to be actively involved in their learning in order for them to develop their learning needs. • In context 	 Adults are motivated to obtain the necessary knowledge and skills to solve specific problems. • Reflective 	 Adults learn from prior experience and generalize these experiences to new situations. • Practical 	 Adults learn by doing. References: Peyton JWR, ed.  Teaching & Learning in Medical Prac- tice.  Rickmansworth, UK: Manticore Europe, Ltd.  1998. Kaufman DM.  ABC of learning and teaching in medi- cine:  Applying educational theory in practice.  BMJ 2003; 326:213-216. Office for Faculty Development 10 C. Preparing to teach 1.	Prepare	your	office Your	colleagues	and	office	staff	will	need	to	be	aware	that you	will	have	a	learner	in	your	office.		Notify	staff	well	in advance and ask for their active participation in orient- ing and teaching the student. Explain why it is important for you to have a learner and ask for their support. The learner’s	first	day	in	your	office	should	not	begin	with surprise	or	confusion	from	the	office	staff. Some	physicians	find	it	helpful	to	alter	their	sched- ule	when	a	learner	is	present	in	the	office.		The	‘wave’ schedule allows you to continue to see patients while the learner takes somewhat longer to undertake her/his assess- ment. The following is adapted from Lesky & Hersh- mann, (1995). Office	Schedule  Time 	 0900  	 0915 	 0930 	 0945 	 1000 	 1015 	 1030 Appointments Patient	A Patient	B Patient	C Patient	D Patient	E Patient	F Patient	G Patient	H Preceptor Patient	A Patient	C Patient	D Patient	F Patient	G Student Patient	B Patient	E Patient	H Patient	B Together Patient	E Together Teaching Skills for Community Based Preceptors 11 It will be much easier if there is a spare examination room for the learner to see patients alone.   If you don’t have an extra examination room, the learner could initiate the visit with one or two patients in each hour.  You can plan to use this waiting time for paperwork, phone calls and the like. 2. Prepare your patients Notify your patients beforehand if possible that a learner will	be	in	your	office.		Ask	your	staff	to	inform	patients when they make their appointments or when they arrive in the	office.		Have	a	sign	in	the	office	announcing	the	pres- ence of a learner.  This example has been adapted from the MAHEC monograph: Integrating the Learner into the Busy Practice.  Ask patients for permission to involve a student in their care and thank patients at the end of their visit. Sample	office	sign Thank You! This	practice	serves	as	a	teaching	site for	students	at	the	University	of	British Columbia	School	of	Medicine As	a	patient	of	this	practice, you	are	helping	educate	future	doctors	in	the skills	necessary	to	be competent	and	caring	physicians. ___________________________ Practice	Medical	Director/Physician Office for Faculty Development 12 If a learner will be in your practice setting for several weeks or months, consider preparing a brief letter of in- troduction for your patients, with a sketch of his/her prior training and current program. This letter can be handed to patients prior to their visit with the learner, or posted in the examining room. Most patients are quite happy to be involved when medi- cal	students	or	residents	are	present	in	the	office.		Some patients appreciate the extra attention or fresh approach to their medical concerns. Involve Your Patients •	 Don’t	surprise	a	patient	with	a	learner. •	 Introduce	learners	to	your	patients formally. •	 Select	patients	that	are	appropriate and	receptive	to	involving	a	learner. Appropriate	patients	for	new	learners are	those	with	straightforward	and/or common	problems,	and	friendly	patients who	are	good	communicators. •	 Involve	the	patient	in	teaching	by encouraging	the	patient	to	provide feedback	to	the	student.		For	example, a	patient	can	tell	better	than	anyone	if the	student	is	using	the	same	technique as	the	preceptor	to	palpate	a	joint	or prostatic	nodule. •	 Thank	patients	for	involving	learners	in their	care. Teaching Skills for Community Based Preceptors 13 Patients need to be reassured that you are still in charge of their care, aware of their health concerns and available to them directly,  if they request time with you. If you have an advanced learner or resident in your practice, it is important to stay in touch with the patient, even though the resident is conducting most of the visit(s). 3. Prepare yourself What is the reason you have been asked to have a learner in	your	clinical	setting?		What	specific	knowledge	and skills are they expected to obtain through working with you? Course directors should provide you with the educa- tional objectives for the learners. 4. Prepare an educational plan Take a few minutes to meet with the learner and together develop an educational plan.  An educational plan will outline aims and expectations, identify learning opportu- nities and establish the basis for ongoing review. Office for Faculty Development 14 Preparing a plan, either formally or informally, can be incorporated into the learners’ orientation to your practice. Orientation Introductions 	You 	 •	 Your	practice	and	usual	weekly 	 schedule 	 •	 Specific	schedule	issues	during 	 the	rotation	(on	call,	remote 	 clinics,	etc.) 	Student/Resident 	 •	 Knowledge	and	skill	level 	 •	 Experience 	 •	 Professional	and	personal	interests 	The	hospital/community 	 •	 What	is	available	or	not;	for 	 example,	obstetrics, 	 physiotherapy,	lab	and	X-ray Expectations 	Learning	objectives 	 •	 From	the	course	director 	 •	 From	the	learner 	Potential	learning	activities	for	the objectives 	Responsibilities	in	the	clinical	office 	Attendance,	dress,	conduct Practical issues 	Weekly	time	table 	Transportation	and	housing 	Hospital,	office	and/or	agency orientation Teaching Skills for Community Based Preceptors 15 What are the expectations? The	first	step	is	to	clarify	what	the	learner,	the	preceptor and the medical school expect from the community based clinical experience. You	will	need	to	find	out	about	the	learners	–	their	back- ground knowledge and clinical experience in your area. Ask	specifically	about	their	clinical	skills	–	what	have they had the opportunity to do and how comfortable do they feel with their skill level?  Inquire about their spe- cific	wants	and	needs	in	their	upcoming	experience	with you.		Ask	learners	if	they	have	specific	learning	objectives that they would like to focus on, for example, well-baby examinations.  Then describe your practice and outline your professional expectations	with	regard	to	office	and	hospital	conduct, time commitment and learner participation.  If available, review the educational objectives provided by the course director. Most of the time, these objectives are described in terms of Knowledge, Skills and Behaviour.  The as- sessment criteria for these objectives, usually an assess- ment form, can also be reviewed by both preceptor and learner at this time. How will these expectations be met? These learning objectives can be met through a number of formal and informal activities available to the learner. In the clinical setting many of these objects will be met by participating in patient care. Other learning opportuni- ties may include lectures, directed reading and research, chart reviews and participation in small group learning or seminars.  Some community based preceptors have found Office for Faculty Development 16 it helpful to develop a list of other potential learning expe- riences as a guide. Give the Learner (& Yourself) a Break •	 You	do	not	need	to	be	the	only	clinical teacher. •	 A	learner	at	different	stages	in	her/his training	can	learn	from	other	health	care professionals. •	 These	activities	can	present	general and	specific	learning	opportunities: -	 Learners	can	spend	time	with	a public	health	nurse	to	gain	general exposure	in	health	promotion	and disease	prevention	and	specific experience	in	well-baby	checks. -	 Another	opportunity	for	a	learner	is to	work	with	an	opthamologist	for general	experience	in	ocular	health and	specific	opportunities	to	see	a range	of	normal	and	abnormal	fundi. Based on your educational plan, you can outline who the learners will see, what they will do, and what they should focus	on	with	each	patient	encounter.		Be	specific,	for example: “Today	we	have	several	pregnant	patients	so	I	would like	you	to	learn	how	to	assess	maternal	well-being.	You will	interview	each	patient,	fill	in	their	prenatal	form	and measure	their	symphyseal	fundal	height.” Teaching Skills for Community Based Preceptors 17 Residents may be more autonomous or self-directed than medical students.  However it is still important to observe and monitor residents as well, especially in the early part of their rotation, and delegate an increasing level of responsibility when appropriate. How will we know when these expectations are met? The educational plan will evolve over time, as expecta- tions are met and new goals established.  See Part E – Ob- servation, Feedback and Assessment, starting on page 28. References: Gordon J.  ABC of learning and teaching in medicine: one to one teaching and feedback. BMJ 2003; 326:543-5. Hays R.  Practice-based teaching: a guide for general practitioners. Emerald, Australia: Eruditions Publishing, 1999. Langlois JP on behalf of the Mountain Area Health Education Centre.  Integrating the Learner into the Busy Practice: an educational monograph for community-based physicians.  http://www.mtn.ncahec.org/pdp/e-Learn- ing_Tools.asp  Accessed February 17, 2004. Lesky LG, Hershman WY.  Practical approaches to a major educational challenge. Training students in the am- bulatory setting. Arch Intern Med 1995; 155:897-904 Rourke J, Rourke LL.  Practical tips for rural family physicians teaching residents. Canadian Journal of Rural Medicine 1996; 1:63-9. Office for Faculty Development 18 D. Teaching with patients As stated before, most of the learning activities in the community setting will involve teaching with patients. What can you do to optimize these patient encounters? 1. Provide a variety of active learning  opportunities Learners will want to see and interact with patients and feel like they are a legitimate part of the health care team. There are different ways to involve students and you should strive towards giving the student more responsibil- ity as their experience increases.  Try any of the following techniques: Shadowing or Sitting-in Limit the use of this as the learner progresses, unless there is	something	very	specific	you	wish	to	demonstrate.  “This	baby	is	here	with	diaper	rash.	 I’d	like	you	to	see how	I	like	to	incorporate	a	brief	developmental	screen into	the	consultation.” Joint consultation  “This	man	is	here	with	a	new	back	injury.	 Why	don’t I	start	the	history	and	we	will	examine	his	back	and extremities	together?” Independent consultation with joint review  “Mrs.	Jones	has	brought	her	eight	year-old	in	today with	a	fever.	 Take	the	next	10	to	15	minutes	to	do	a focussed	history	and	examination.	 We	can	review	your diagnosis	and	management	plan	and	then	see	the	child together.” Teaching Skills for Community Based Preceptors 19 Observed consultation – all or part  “Mr.	Smith	is	here	with	back	pain.	 I	would	like	to observe	how	you	take	his	history.” 2. Focus on clinical reasoning Medical knowledge and clinical reasoning are two interdependent essentials in the development of clinical judgment.  Clinical preceptors have the unparalleled op- portunity to guide students through the thinking process of medical decision-making.  A framework for decision- making can be built around the basic steps involved in the clinical (diagnostic and therapeutic) reasoning process. First, the learner systematically gathers information, the clinical history and physical examination, and then ana- lyzes this information in a logical manner.  The teacher can use questions to guide the student through The Diag- nostic Reasoning process. For example, if a patient reports having blurred vision the guiding questions may look like the following: Office for Faculty Development 20 Steps in Diagnostic Guiding Questions  Reasoning First,	the	student	attempts		 “What	causes	blurred to	define	the	anatomical/	 vision?	Think	about	how physiological	process	at	 visual	images	are work.	 processed	starting	with 	 the	eye…” Secondly,	the	student	should	 “Now	that	we	have	gone construct	a	differential	 through	the	normal diagnosis.	 physiology,	can	you	think 	 of	where	things	might	go 	 wrong?” Thirdly,	the	student	needs	to		 “What	specific consider	what	investigations		 investigations	(blood, may	be	needed	to	support		 urine,	radiological clinical	diagnosis.	 studies)	may	be	helpful 	 to	narrow	the 	 diagnosis?” Finally,	all	of	the	factors	from		 “What	factors	from	the history,	physical	examination		 history	support	your and	investigations	are		 diagnosis?” considered	in	order	to	arrive at	a	provisional	or	working		 “Given	all	of	your diagnosis.	 information	what	is	your 	 working	diagnosis?	“ Teaching Skills for Community Based Preceptors 21 Therapeutic reasoning is also an important part of deci- sion making.  The steps involved are the same ones that we as physicians use when we are obtaining informed consent for a medical course of action and/or procedure. When we ask a learner to recommend a course of man- agement for a patient they should be able to discuss: Steps in Therapeutic Guiding Questions Reasoning The	student	attempts	to	 “What	is	likely	to	happen define	the	natural	history	 without	any	treatment?” of	the	condition.  The	student	should	be	able	 “What	are	the	options to	come	up	with	a	range	 for	treatment?” of	interventions. Now	the	student	needs	to		 “How	will	that	benefit	the weigh	the	risks,	benefits		 patient?		What	are	the and	likelihood	of	success		 possible	risks?		Do	you for	each	option.	 need	to	take	anything 	 else	into	consideration?” The	student	recommends		 “Considering	all	these a	management	plan.	 factors,	what	is	your 	 recommendation	to	this 	 patient?	“ Clinical	reasoning	is	the	fundamental	skill	of	clinical practice	and	clinical	teaching. Office for Faculty Development 22 3. Use a variety of teaching techniques There are many different teaching techniques and styles. Effective teachers use techniques that engage the learner in the thinking and reasoning process.  You may already do some of these unconsciously.  By familiarizing your- self with several other techniques, you can apply the most appropriate method to the learning situation. a. Ask questions Effective use of questions is the requisite skill of teach- ing and provides many opportunities for learning.  The structure (open vs. closed) and type of question used by the teacher can stimulate different levels of understanding by the student.  Types of questions 1. What does the learner know? Knowledge-based questions determine the level of knowledge and stimulate recall and activation of previous information. They can usually be answered with a single word, a phrase or lists.  “What	are	the	most	common	organisms	causing	acute otitis	media?”  “What	is	the	role	of	Vitamin	B12	in	erythropoesis?” 2. How does the learner use their knowledge? Application/integration questions stimulate application of knowledge. 	 “What	kind	of	anemia	do	you	see	in	Vitamin	B12	defi- ciency?	Why?” 	 “What	are	the	signs	that	may	indicate	heart	failure	as a	possible	cause	for	his	shortness	of	breath?” Teaching Skills for Community Based Preceptors 23 3. How does the learner solve a problem? Reasoning/problem-solving questions stimulate thinking and reasoning. Questions are asked as a case scenario and are	often	introduced	by	the	prefix	“what	if”.	The	preceptor can use her/his experience to bring in practical issues. 	 “What	are	your	options	for	management	if	Mrs.	Brown has	megaloblasts	in	her	peripheral	blood	smear?” 	 “What	if	Mr.	Lim	has	both	this	skin	rash	and arthralgia?” Clinical teachers are the experts at integration and rea- soning, so use these questions to your advantage.  The clinical setting is the perfect environment to demonstrate how clinical knowledge is used to solve clinical problems. It may not be the best place to teach clinical knowledge in itself. Asking Questions •	 Ask	the	right	type	of	question	for	the learning	objective	–	basic	knowledge, application	and/or	clinical	reasoning. •	 Application	and	reasoning questions	facilitate	a	deeper	level	of understanding	in	the	learner. •	 Take	advantage	of	the	clinical	setting	by encouraging	use	of	knowledge	rather than	testing	knowledge	itself. Office for Faculty Development 24 b. Try the “One Minute Preceptor” Adapted from Neher et al, A Five-Step “Microskills” Model of Clinical Teaching (J Am Board Fam Pract 1992; 5;419-24). The One Minute Preceptor is a model for clinical teach- ing which was developed by family practice preceptors. It is designed to promote clinical reasoning and decision making skills.  It also reminds the teacher to teach around patients and provide feedback to learners.  Following the presentation of a patient’s case by the learner, the precep- tor	guides	the	learner	through	these	five	steps: 1. Engage and get a commitment Ask the learner to give her/his opinion of the case. This requires the preceptor to ensure a safe, trusting learning climate. 	 “What	is	your	diagnosis?” 	 “What	is	your	recommended	treatment?” 2. Probe for reasoning and supporting evidence The learner should be able to give reasons for her/his opinion. 	 “What	factors	in	the	history	and	examination	led you	to	that	opinion?” 	 “What	do	you	expect	the	result	of	that	treatment	to be?” 3. Teach general rules Avoid lengthy discussions about atypical or individual cases.  Try to pull out the key message from each case and avoid trying to teach an entire topic. For example, if you have just seen a patient with gastroesophageal reflux	disease	you	may	choose	to	limit	your	discussion Teaching Skills for Community Based Preceptors 25 to the diagnostic work-up. Teach around any knowl- edge gaps and allow the learner to extrapolate to other situations. 	 “In	general,	I	find	that	several	elevated	BP	levels are	necessary	for	a	diagnosis	of	hypertension.” 	 “A	lateral	C-Spine	x-ray	is	mandatory	for	every- one	who	is	intoxicated	and	has	mild	or	moderate trauma.” 4. Reinforce what was done right Focus	on	specific	skills	or	behaviour,	not	just	general praise. 	 “Your	presentation	to	the	patient	was	well	orga- nized.  You	described	both	the	expectations	and risks	of	treatment.” 	 “You	have	a	very	good	grasp	of	the	steps	of	that procedure.” 5. Correct mistakes Ask the learner to evaluate her/his performance and then	provide	specific,	constructive	feedback. 	 “I	agree	that	you	rushed	into	treatment	options before	carefully	considering	other	potential	diag- noses.  It	may	be	helpful	to	take	a	minute	to	review your	history	before	focussing	on	one	specific	clini- cal	sign.” Teachable Moment •	 Each	patient’s	case	discussion	is	a stepping	stone	for	sharing	practical	tips and	advice	about	clinical	care. Office for Faculty Development 26 c. Teach procedural skills Teaching students and residents procedural skills can be enjoyable.  Teaching procedures requires some planning, even for straightforward tasks.  All procedures are made up of a series of sequential steps that have a start and an end point.  The instructor can identify these steps before starting to teach the procedure. Effective teaching can follow three basic steps: 1. Cognitive •	 EXPLAIN	to	the	learner	why	and	when	(indica- tion) the procedure is done •	 DEMONSTRATE	with	a	step-by-step,	talk-aloud description •	 Have	the	learner	ARTICULATE	a	cognitive	re- hearsal of the steps of the procedure 2. Guided practice (supervision) •	 REVIEW	the	procedure	beforehand •	 OBSERVE	the	procedure •	 Provide	GUIDANCE	and	feedback •	 Allow	the	learner	to	PRACTICE	the	procedure 3. Independent practice •	 Provide	opportunities	for	the	learner	to	PRACTICE the procedure •	 ENCOURAGE	self-assessment •	 Be	available	for	SUPPORT Supervise	progress,	but	avoid	taking	over	when the	learner	is	still	comfortable	completing	a	task unless	you	feel	patient	safety	is	in	jeopardy. Teaching Skills for Community Based Preceptors 27 Educational circumstances and venues vary widely from a formal teaching laboratory to the opportunistic, patient- based,	one-time	incident	in	the	office	or	clinic.		Wherever necessary, both learner and instructor can adapt these key principles to ensure that procedures are learned and practiced	with	efficiency	and	to	ensure	minimum	risk	to patients. References: McLeod PJ, Steinert Y, Trudel J, Gottesman R.  Seven Principles for Teaching Procedural and Technical Skills. Academic Medicine 2001; 76:1080. Neher	JO,	Gordon	KC,	Meyer	B,	Stevens	N.		A	five-step “microskills” model of clinical teaching. J Am Board Fam Pract 1992; 5:419-24. Spencer J.  ABC of learning and teaching in medicine: Learning and teaching in the clinical environment. BMJ 2003; 326:591-594. Office for Faculty Development 28 E. Observation, feedback and assessment Preceptors report that they feel ill-prepared and uncom- fortable providing feedback and assessing learners.  This is particularly so when a close working relationship has developed with the student or resident, and/or when learn- ing problems have arisen that need to be addressed. Nevertheless, assessment of student performance by fac- ulty members as future practicing physicians and potential colleagues is an important professional responsibility. Identification	of	students	who	require	improvement	in	any aspect of their clinical performance often initiates a posi- tive and constructive process of assistance and remedia- tion. Avoid	collusion.		This	is	a	special	risk	with advanced	learners	who	share	your	practice	for longer	periods	of	time.		Honest	and	thought- ful	evaluation	of	the	learner	will	engender	more respect	than	avoidance	of	difficult	but	necessary feedback. 1. Observation and providing effective feedback One of the most important things you can do as an effec- tive teacher is to observe your student or resident with your patients.  Observing what the learner does right and wrong and providing immediate feedback will help the learner	to	increase	her/his	confidence	and	improve	more quickly. Teaching Skills for Community Based Preceptors 29 Natural opportunities to observe students or residents occur most often in the hospital setting, such as observ- ing the learner interacting with patients and staff while on rounds.		In	the	office	setting	observation	needs	to	be	more deliberate but is no less important.  Allot some time in the day to observe one learner activity, for example, taking the history of the presenting complaint or performing a procedural skill.  Explain to both the patient and learner that	you	are	there	to	observe	that	specific	activity. Keep observations short.  Observing different parts of the clinical encounter (introduction, history, examination) at different times and with different patients is more time-ef- ficient	and	provides	more	focused	feedback	than	observ- ing a learner perform one complete history and physical exam on one patient. Observation ·	 Allow	the	learner	to	complete	their	task uninterrupted. ·	 Keep	observations	short	and	focused. ·	 Try	and	spread	out	your	observations over	different	times	and	different patients. Skills such as history taking, physical examination, proce- dures and patient counseling can all be observed. Office for Faculty Development 30 Feedback and Assessment are ways to convey your observations back to the learner.  The difference between feedback and assessment is outlined in the following table.  Feedback Assessment Timing	 Timely	 Scheduled Setting	 Informal	 Formal Basis	 Observation	 Observation Content	 Objective	 Objective Scope	 Specific	behaviour	 Overall	performance Purpose	 Improvement	 Certifying	competence Adapted from: Mountain Area Health Evaluation Centre. Evaluation: Making it Work. http://www.mtn.ncahec.org/pdp/e-Learning_Tools.asp We are always providing feedback to learners about their clinical performance.  We can choose to verbalize this feedback in an effective manner or let the learner collect unspoken feedback by observing our body language and tone	of	voice.		Verbal	feedback	is	needed	by	the	learn- ers in order to reinforce or improve their clinical perfor- mance. All learners can improve something! Feedback is needed by everyone - not only by learn- ers who are struggling.  It is important to make “giving feedback” a habit  balance the number of positive and constructive comments over time. For independent learners it may be essential to schedule regular feedback or review sessions, avoiding the assump- tion that “all is well” until actually seeing evidence that the learner is doing well. Teaching Skills for Community Based Preceptors 31 Feedback to the Learner Feedback	should	be: •	 Timely	–	ideally	immediate,	but	briefly postponed	when	the	situation	warrants (as	in	emergency	or	potentially embarrassing	situations) •	 Constructive	–	as	part	of	a	supportive learning	environment	where	students are	encouraged	to	learn	from	their mistakes •	 Objective	and	accurate •	 Specific	and	relevant	to	the	task	or situation.		A	useful	way	to	provide feedback	is	to	include: 			What	was	done	right 			What	needs	improving 			What	to	do	next	time Effective feedback is timely, informal, based on observa- tion,	focused	on	a	specific	action	and	meant	to	improve performance.  It is not a judgment statement.  It is ac- cepted by the learner if it is part of a supportive learning environment, from a credible source and felt to be valid. The purpose of feedback is to help learners to change their behaviors.  Learners can be overwhelmed by a long list of things that need to be changed so try to prioritize and focus on only 2-3 key points at time.  Providing helpful feedback can be broken down into three essential steps. Office for Faculty Development 32 Step one - Listen to the learners’ perspective The	learners	start	first!		Learners	need	to	be	encouraged	to reflect	on	what	they	did	well,	what	needs	improving	and how they will make these improvements. 	 “Let’s	talk	about	that	well-baby	exam.	 What	specific aspects	of	the	exam	went	well?	 Were	there	other	parts that	need	improving?“ 	 “How	thorough	was	your	history	taking?	Did	you	feel that	you	asked	about	all	of	the	important	characteris- tics	of	her	pain?	Was	there	anything	you	missed?” Step two - Share your perspective Next, share your perspective with the learners about what they did right and what needs improving.  Most of the time	the	learners	will	have	already	identified	many	of	the same strengths and weaknesses that you want to discuss. Provide	specific,	objective	observations	and	focus	on	a limited number of key issues only. First, validate what was done well: 	 “I	agree	with	you;	I	also	thought	you	asked	all	the important	questions	to	assess	her	nutritional	status.” 	 “The	patient	seemed	comfortable	with	your	technique in	obtaining	a	pap	smear.” Next,	identify	specific	actions	that	could	be	improved: 	 “The	child	seemed	quite	irritable	towards	the	end	of the	exam.	 Newborns	can	get	cold.” 	 “Although	you	didn’t	want	to	embarrass	her,	you cannot	assess	breath	sounds	adequately	through	her sweater.” Step three - Always develop a plan for next time Ask the learners to come up with strategies for improving Teaching Skills for Community Based Preceptors 33 their performance and provide guidance if they are unsure as to how to improve their performance. 	 “I	know	it	is	difficult	to	listen	for	murmurs	in	a	restless baby.	Next	time,	try	listening	for	heart	murmurs	at	the beginning	of	the	appointment	while	the	baby	is	lying quietly	with	her/his	mother.” 	 “There	are	lots	of	risk	factors	for	heart	disease. Review	your	textbook	tonight	and	we	can	discuss	them tomorrow.” 2.  Assessment At some point you may be asked by the course or program director	to	reflect	on	your	observations	and	feedback	in order to make a judgement of the learner’s clinical perfor- mance and competency. •	 Have	the	learners	met	your	expectations? •	 Have	the	learners	met	the	expectations	for	their	clini- cal experience with you? It is helpful to review the assessment form with the learn- ers at the beginning of their time with you so that you are both aware what criteria are being used to judge their performance.  If you have been engaging in regular ob- servation and feedback you should not have any problems completing the forms and the information that you put down on the form will be no surprise to the learners. Assessment of student performance by faculty members as future practicing physicians and potential colleagues is an important professional responsibility.  A construc- tive process of assistance and remediation is available to students who require improvement in any aspect of their Office for Faculty Development 34 learning.  At the UBC medical school, undergraduate students in need of assistance are referred to the Student Support and Development committee. References: Langlois JP on behalf of the Mountain Area Health Edu- cation Centre.  Giving Feedback.  An educational mono- graph for community based teachers.  http://www.mtn. ncahec.org/pdp/e-Learning_Tools.asp  Accessed February 17, 2004. Langlois JP on behalf of the Mountain Area Health Education Centre.  Evaluation: Making it work.  An educational monograph for community-based teachers. http://www.mtn.ncahec.org/pdp/e-Learning_Tools.asp Accessed February 17, 2004. Teaching Skills for Community Based Preceptors 35 F. What do you do with a learner with problems? (Adapted from Handling Problems. PEP2 Workbook, Society of Teach- ers of Family Medicine 1999) Learning problems exist whenever performance does not meet expectations.  They can take a variety of forms and may	be	brought	to	your	attention	by	a	specific	incident,	a series of incidents or sometimes just a feeling that some- thing isn’t quite right. A simple and practical approach to learning problems can help to diagnose their cause and suggest some possible solutions. Even if you are only seeing the learner on a limited num- ber of occasions, you may still make important observa- tions.  Your observation could be part of a pattern of behaviour.  Even if you don’t feel capable of dealing with the learning problem yourself, record your observations and bring them to the attention of the program director. Learners	who	could	benefit	from	additional	assistance may fall between the cracks when supervised by a large number of sporadic clinical teachers. Put the problem in context. Is	it	real? Is	it	important? Perhaps this was just a misunderstanding, a rumour or a bad day. Nevertheless, some behaviours are poten- tially serious, such as learners who assume too much responsibility or fail to recognize their limitations. Office for Faculty Development 36 While you may wish to overlook smaller problems, remember that what you see could be part of a pattern and	could	indicate	a	significant	problem. If the problem is both real and important, then you need to pursue the issue further. 1.	 Is	it	a	problem	of	knowledge	or	skill? Learners may not have the requisite knowledge or skills for a particular situation.  The situation may be new or the knowledge or skills may have been forgot- ten.  These problems are the easiest to address – the answer is education!  Ultimately, the students are re- sponsible for engaging in self-directed learning activi- ties (textbook, journal readings) that will improve their knowledge base but you may be able to provide some suggestions.  In addition, you may need to adjust your expectations, for example by reigning in some of the responsibility the learners have been given until you are again comfortable with their knowledge and skills. If a learner has the knowledge and skills to perform, but still fails to meet expectations, the teacher should consider other reasons for the problems. Teaching Skills for Community Based Preceptors 37 The Learner with Problems •	 Learning	problems	can	arise secondarily	to	personal	problems. •	 Learners	in	a	community	for	any	length of	time	should	have	an	identified	family doctor	who	is	not	the	primary	preceptor. This	person	can	deal	with	any	personal and	health	problems	so	that	these	do not	become	an	issue	for	the	preceptor. Ideally	the	family	doctor	should	be selected	before there	is	a	problem, perhaps	on	the	first	day. 2.	 Is	there	something	that	is	influencing	their	behav- iour? Learners can perform poorly due to illness, stress or misunderstanding what was expected of them.  Review your expectations with the learner and clarify any dif- ferences. 3.	 Finally,	is	the	problem	primarily	one	of	attitude? Does this learner exhibit behaviour that is interfering with his or her education? You	may	find	it	difficult	to	deal	with	problems	of	behav- iour or attitude, especially if you have developed a close relationship with the learner.  Get some assistance from the program director who will have had experience deal- ing with these situations.  At UBC, undergraduate students in need of assistance are referred to the Student Support and Development Committee. Office for Faculty Development 38 References: Garrett EA.   Module 8:  Handling Problems.   From PEP2 Workbook, KJ Sheets, project director on behalf of the Society of Teachers of Family Medicine Preceptor Education Project Committee.  1999.  Society of Teachers of Family Medicine. Teaching Skills for Community Based Preceptors 39 G. For more information There are many sources of additional information for pre- ceptors interested in furthering their knowledge and skills in clinical teaching. UBC Faculty of Medicine This	booklet	was	written	by	the	Office	for	Faculty Development and Educational Support in the Faculty of Medicine at the University of British Columbia.  Feel free to	contact	our	office	or	visit	our	website	for	information on our programs and links to other useful sites.  Office	for	Faculty	Development	and Educational Support Faculty of Medicine The University of British Columbia GLDHCC - 11th Floor, Rm 11225 2775 Laurel Street Vancouver BC  V5Z 1M9 604.875.4396 604.875.5370 fax fac.dev@ubc.ca www.facdev.med.ubc.ca Office for Faculty Development 40 Other organizations that have resources for clinical teach- ers include: College of Family Physicians of Canada, Section of Teachers www.cfpc.ca The section on resources for new teachers is particularly helpful. Society of Rural Physicians of Canada http://www.srpc.ca The SRPC has links of interest to rural physicians and has a Rural Education Interest Group that works with precep- tors in both undergraduate and postgraduate programs. Society of Teachers of Family Medicine (US) http://www.stfm.org The American-based STFM has numerous links for pre- ceptors that are intended for family physicians but useful for all preceptors in community based settings. For links to other organizations, go to our Faculty De- velopment website www.facdev.med.ubc.ca.  Almost all specialties have National organizations that offer excellent resources (newsletter, books, videos) for educators, and faculty development activities at their National confer- ences. The Association of Surgical Educators has an online medical education newsletter entitled Focus, that can be accessed online at http://www.surgicaleducation.com Teaching Skills for Community Based Preceptors 41 Suggested Reading Alguire, P. C., D. E. DeWitt, et al. (2001).  Teaching in Your Office:	A	Guide	to	Instructing	Medical	Students	and	Resi- dents. Philadelphia, PA, American College of Physicians. A concise, easy to read book with helpful checklists and reminders at the end. Hays, R. (1999).  Practice-Based Teaching: A Guide for Gen- eral Practitioners. Emerald, Australia, Eruditions Publish- ing.  An Australian publication by a rural physician/educa- tor.  Mountain Area Health Education Centre, Department of Continuing	Medical	Education	and	the	Office	of	Regional Primary Care Education Preceptor Development Program. (2003). Preceptor Development Program. Available online at: http://www.mahec.net/pdp/ Peyton, JW. (1998).  Teaching and Learning in Medical Prac- tice.  Rickmansworth UK, Manticore Europe, Ltd. Rubenstein, W. and Y. Talbot (2003).  Medical Teaching in Ambulatory Care: A Practical Guide. New York, Springer Publishing Co. Written by Canadian family physicians/educators, this guide is short yet comprehensive and recommended by postgradu- ate family practice preceptors. ABC’s of Teaching and Learning in Medicine (2003).  British Medical Journal.		Volume	326. http://resources.bmj.com/bmj/topics/abcs/ A series of 14 short articles on a many aspects of medical education.  Can be accessed online. Office for Faculty Development 42 Acknowledgements This	booklet	is	an	initiative	of	the	Office	for	Faculty	De- velopment and Educational Support, Faculty of Medicine, University of British Columbia. The following personnel were instrumental in developing this resource: Dr. Jean Jamieson, Faculty Associate* Dr. Leslie Sadownik, Program Director* Dr. David Fairholm, Assistant Dean of Faculty Development* We would like to thank Dr. Max Kamien, Foundation Professor of General Practice, University of Western Australia, whose booklet “Teaching Medical Students in Rural Practice: A Guide for Rural General Practitioners and Specialists” provided the inspiration for this project. We would also like to thank Drs. Bob Mack and Ian Scott in the UBC Department of Family Practice and the community based preceptors in Phase III of the UBC MD undergraduate program for helping to review the content. * Dr. Jean Jamieson - Sections C, D, F, G  Dr Leslie A. Sadownik - Sections A, B, E  Dr David Fairholm - Section D Originally printed 2003 Reprinted 2005, 2008, 2009, 2010, 2011, 2012 Teaching Skills for Community Based Preceptors 43 Clinical teaching survival guide •	 The	learner	does	not	need	to	see	every patient. •	 The	learner	does	not	need	to	do	the	history, physical	and	counseling	for	each	patient. •	 The	case	can	be	presented	in	front	of	the patient. •	 The	physical	exam	can	be	performed together	or	components	can	be	checked	by the	physician	while	the	learner	writes	up	the case. •	 Have	the	learner	see	one	patient	while	you see	another. •	 Teach	with	patients	rather	than	in between patients. •	 Take	time	off	from	teaching!		Allow	the learner	to	participate	in	other	learning opportunities	in	your	community	that	are suitable	for	their	level	of	medical	training. •	 Try	different	teaching	techniques	such	as the	One	Minute	Preceptor. •	 Save	in	depth	discussions	for	down time,	such	as	driving	to	a	house	call, between	cases	in	the	OR,	when	there	is	a cancellation	or	no-show,	or	during	lunch. Office for Faculty Development 44 COMPETENCY TEACHING CHECKLIST FOR CLINICIANS  Start here Competency   Obtain a well organized history   from the patient   Perform a competent patient   clinical examination   Write well organized, clear,   concise chart notes   Generate a differential diagnosis   Interpreting data (clinical,   laboratory and radiological)   correctly   Identifying the most likely   diagnosis   Therapeutic reasoning  End Here


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