UIC DFM Preceptor Reference Manual – Best Practices in Teaching
Introduction to Preceptor Reference Manual
This is a manual of best practices as it relates to the multiple components of interfacing with students in the role of a teaching clinician within the field of Family Medicine. This manual is meant to grow and adapt over time. Your feedback and input are greatly appreciated
Best Practices in Clinical Teaching
Summary of Research in Clinical Teaching of Medical Students
I found some interesting articles in reviewing the literature on how to improve clinical teaching of medical students. Rick Guthmann at Illinois Masonic Family Medicine Residency Program made me aware of an article entitled “The On-line Clinical Teaching Perception Inventory: A “Snapshot” of Medical Teachers. This project asked physician educators to rank 28 descriptive words in order from “most like my ideal teacher” to “least like my ideal teacher”. The top descriptive words that people thought of as their “ideal teacher” were “stimulating”, then “encouraging”, then “competent”, and then “communicates”. Interestingly “empathetic” was #13 out of the 28 descriptors and “conventional” was # 26 on the list.
Another interesting article came from Academic Medicine and was entitled “Third-year medical students perceptions of effective teaching behaviors in a multidisciplinary ambulatory clerkship”. The authors found that students want a “humanistic but rigorous approach to medicine”. I have noticed that students do not mind “working hard” as long as they are treated fairly and that they “get out what they put in”. I was worried that students might be offended by me asking them to look up a question raised or by having them give me a presentation about a patient issue we had seen but I have found both verbally and on their written evaluations that they have enjoyed these exercises.
Other literature looked at incorporating evidenced based medicine into our daily clinical practice. A change in medicine and especially in medical education is an emphasis upon evaluating the quality of evidence behind what we offer our patients. The journal American Family Physician has helped lead the way in making sure that we document the quality of evidence behind diagnostic and treatment recommendations.
Literature has looked at having students get exposure to components of the patient-centered medical home (PCMH) during their family medicine clerkship rotation The PCMH concept and implementation is constantly developing but it is important to have students become aware of the basic PCMH concepts. If you come across any interesting articles related to clinical teaching of medical students feel free to bring them to my attention.
1Morrison EH, Hitchcock MA, Harthill M, et al. The On-line Clinical Teaching Perception Inventory: A “Snapshot” of Medical Teachers. Family Medicine. 2005 January; 37(1):48-53.
2Elnicki DM, Kolarik R, Bardella I. Third-year medical students’ perceptions of effective teaching behaviors in a multidisciplinary ambulatory clerkship. Academic Medicine. 2003 August; 78(8):815-9.
3White, Brandi. Making Evidenced-Based Medicine Doable in Everyday Practice. Family Practice Management. 2004 Feb; 11(2): 51-58.
4 Saluz JW, O’Neill P, Gill JM, et al. Medical student exposure to components of the patient-centered medical home during required ambulatory clerkship rotations: implications for education. Acad Med. 2010 Jun; 85(6): 965-73.
Teaching in the Ambulatory Setting
- Preceptor Approach to Teaching
- Self Defined Expectations: Ask the student every day what he or she wants or needs to learn on that day. This will empower the student and provide you, as the preceptor, the opportunity to best meet his or her needs. Ask the student, “What are your learning objectives for today?”
- Applied Expectations: Inform the student that you expect him or her to BE the physician. Require them to “step to the next level.” By informing them that you have high expectations of their performance, you are providing them the opportunity to succeed at this higher level. In doing so, you may want to give them permission to “make mistakes.” Reassure the student that it is OK to be wrong, the most important thing at this stage in their training is to engage in active learning. You, the preceptor, are there to correct the errors and assure quality care. Committing oneself to an answer or particular stance is the best way to learn, though sometimes taking these chances means making mistakes. That is OK.
- Emphasizing the Assessment and Plan: It is important to emphasize that the learner progress beyond their previous expectations of gathering information to the practice of applying that information. One should encourage the student to focus in on the Assessment and Plan and develop this fully and in as much detail as is possible. This will force the student to act as the physician, holding themselves accountable, and, thus, enforcing learning.
- Evidence Based: Give your students 5 or 10 minutes prior to presenting the patient to “research” their assessment and plan and assure themselves, through evidence, that they are considering this case appropriately. This helps the student build the skills of identifying evidence and interpreting this evidence for individual patients at the point of care.
- What Is / What Isn’t: Emphasize to the students that as they are providing their Assessment and Plan, they may not always be able to provide a definitive answer or diagnosis. In this case, they may consider providing information as to what has been ruled up or ruled down in their differential. If they are not, in essence, able to say what it is, they should comment on what it is not. This will help them broaden their differential and illustrate to their precepting physician that they are using the appropriate logic and critical evaluation.
- Practical Applied Teaching
- Medical Education / Knowledge Base
- Engaging the Student
- Medical Education / Knowledge Base
- Mini-lecture: At the beginning of the first session with each student, one might give a standard mini lecture on a particular topic such as heart sounds. One practitioner who employs this technique has found that this serves two purposes: 1) this engages the student immediately and puts them in the mindset of learning and 2) this helps him understand the level of knowledge of the student with whom he will be working thus facilitating targeted and appropriated learning.
- Approach to the patient
- Model Patient Care. Don’t simply do something in front of the student. Prompt their attention. Be an active demonstrator by stating up front, “Watch what I am going to do.”
- Prime the student. Encourage the student to “Watch / listen to my interaction with the patient and let me know how what I am doing is different than what you just did.”
- Patient Follow-up
- Encourage longitudinal care: Inform the student how you would like him or her to follow up on the labs, diagnostics, and consultations for the patients whom you saw together in clinic. Encourage the student (after touching base with you) to document the findings / results, and contact the patient.
- Readings and Student Preparation
- Active, Point-of-Care Learning: Have the student look things up. Point of care learning is an excellent way to learn.
- Lifelong Learning: Illustrate that you, as an attending, ALSO regularly looks things up. This is an important component of being a responsible physician.
- Personal Organization / Efficiency
- Productivity: Share your tips and practices with the students. How do you keep track of to do’s? How do you advance through your day? How do you assure that things don’t “get missed?” How do you use technology to help you achieve this productivity?
- Providing Evaluation and Feedback
- Student Presentations
- “At the Bedside”: Have the student present in the room with the patient. This is a great opportunity to engage the patients in student learning.
- Listen: Don’t teach until the student is done presenting. Many times they may get around to what you are noting they have missed.
- Giving Feedback
- Use the Feedback Model. See this article.
- J Gen Intern Med. 1998 February; 13(2): 111–116. doi: 10.1046/j.1525-1497.1998.00027.x
- Remind: Tell the student to remind you to give them feedback
- Use the Feedback Model. See this article.
- Student Presentations
- Strategies for Common Challenges
- Be positive in control: Don’t be flustered. You are most influential in the manner in which you handle yourself under pressure.
- Be up front with the student.
- “Flow is always a challenge in the ambulatory setting. Take note of some of the strategies that we use on a daily basis to deal with this issue.”
- Family Medicine is a busy specialty and oftentimes unpredictable. this is due to patient issues primarily. It creates challenges and we deal with them in these ways…
- Other thoughts
- Challenge is good. Students like to grow.
- Have the student hold his or her questions until the end of the session and then you can respond to the most pertinent. This helps with flow.
- If the preceptor sees the first patient him or herself, this will also help with flow.
- Having multiple students in the same session can be challenging but oftentimes can also be value added. Have the third year student help teach the first year student. The both often enjoy and get a lot out of this type of arrangement.
- Ask open ended questions
- Teaching Acronym: METRC
- Make a commitment. What do you think is going on?
- Explore Reasoning. Why do you think this? How did you come to this conclusion? Why?
- Teach to the Gap
- Reinforce what was done well.
- Correct mistakes.
- Ask the student to summarize the take home point
Building Effective Lecture based Educational Sessions and Clerkship Selectives
- Strategies for effective teaching
- Arrange the Space: It is easy to not participate if one is in the corner. Set up the chairs in a circle or horseshoe arrangement. Use the structure to encourage all to participate. Go around the circle for input. This will help to involve all the students equally.
- Start with an “ice breaker”: At the beginning of the session, go around the room and ask for names, something interesting, and input on what they are hoping to learn. This helps to engage everyone from the start.
- Encourage Oppenness:
- Disclosure: Reassure the students that there are no wrong answers.
- Whip around: Go around the room and get input from everyone.
- Take Risks: Inform the students that it is OK to make mistakes. This is one of the best ways to learn, in fact.
- Keep the material fresh: If you have a personal interest in the material that you are teaching and you are continually committed to learning yourself, keeping up on the literature, reading the latest publications, you are much more likely to be enthusiastic in the way that you teach.
- Loose Structure: Allow for (or even encourage) the discussion to wander and meander at times. This gives students the opportunity to explore and be engaged. This is often when the best learning occurs. You may want to have an outline of the salient points and as the discussion moves in that direction, you can bring out those points. You may not hit them all in the same order every time, but this type of discussion can be a lot more exciting and fun to follow – encouraging learning.
- Student Assignments / Projects
- Experiential Learning: As you are planning and preparing your selectives, try to incorporate experiential learning into your plan. Combine your selective with a trip into the community to do some education and have the students lead the discussion, as an example. This type of active learning is very valuable.
- Student Led Discussions: Give the students the opportunity to lead the discussions and present information to their colleagues.