@prefix vivo: . @prefix edm: . @prefix dcterms: . @prefix skos: . @prefix ns0: . vivo:departmentOrSchool "Medicine, Faculty of"@en, "Family Practice, Department of"@en, "Obstetrics and Gynaecology, Department of"@en, "Neurology, Division of"@en, "Medicine, Department of"@en ; edm:dataProvider "DSpace"@en ; dcterms:creator "Jamieson, J."@en, "Sadownik, L."@en, "Fairholm, D."@en ; dcterms:issued "2017-01-19T11:47:05"@en, "2010"@en ; dcterms:description """The booklet is an initiative of the Office for Faculty Development and Educational Support, Faculty of Medicine, University of British Columbia. It is developed to help [faculty] teach more effectively in the clinical setting. The content reviews principles and practical tips for preparing to teach, teaching around patient cases, giving effective feedback and evaluating students. It reviews many practical teaching skills such as: orientation of the learner, task specific teaching, the one minute preceptor, the OPEN model for providing feedback. The booklet can be read in approximately 20 minutes or one can flip through the quick tips for a brief overview of the principles. The following personnel were instrumental in developing this resource: Dr. Jean Jamieson, former Faculty Associate, Dr. Leslie Sadownik, Program Director, and Dr. David Fairholm, former Assistant Dean of Faculty Development. The booklet was originally printed in 2003 and reprinted in 2005, 2008, 2009 and 2010. 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. [This booklet was updated on February 17, 2012.]"""@en ; edm:aggregatedCHO "https://circle.library.ubc.ca/rest/handle/2429/26718?expand=metadata"@en ; skos:note """ 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"""@en ; edm:hasType "Book"@en ; edm:isShownAt "10.14288/1.0074586"@en ; dcterms:language "eng"@en ; ns0:peerReviewStatus "Reviewed"@en ; edm:provider "Vancouver : University of British Columbia Library"@en ; dcterms:rights "Attribution-NonCommercial-ShareAlike 4.0 International"@en ; ns0:rightsURI "http://creativecommons.org/licenses/by-nc-sa/4.0/"@en ; ns0:scholarLevel "Faculty"@en ; dcterms:subject "effective clinical teacher"@en, "Learning Cycle"@en, "clinical reasoning"@en, "One Minute Preceptor"@en, "feedback and assessment"@en, "clinical teaching survival guide"@en ; dcterms:title "Teaching skills for community based preceptors"@en ; dcterms:type "Text"@en ; ns0:identifierURI "http://hdl.handle.net/2429/26718"@en .