Strategy for Offices and Clinics

Introduction

Office-based teaching is now recognized by medical educators as a distinct skill that requires training, practice, and continuous refinement. Several books and guidelines have popularized specific teaching strategies, including the one-minute preceptor. Individual schools and professional societies hold regular faculty development programs.

This broad dialogue on office-based education has produced an emerging consensus on many essential requirements for successful teaching and recognition for areas of controversy. This section of the prospectus builds on this consensus and our local experience to describe a strategy for precepting third- and fourth-year medical students. The strategy is based on the premise that office-based physician-teachers must remain efficient while they precept and assure the satisfaction of their patients, students, and staff. The strategy can be used with equal success in hospital-based clinics where faculty teach students without simultaneously seeing patients.

Successful implementation of the proposed strategies is not easy. It requires careful planning, practice, flexibility, and perseverance. Most of all, it requires dedication to the task of training students to be good doctors.

Prerequisites for the Strategy

Students usually enter practices that are designed primarily for patient care, business, or resident training rather than undergraduate education. To fulfill the new teaching mission, certain accommodations or prerequisites must be in place.

The first is a separate exam room for the student. This will enable a preceptor to see one patient while the student is seeing another. The second prerequisite is a supportive staff that can facilitate the educational mission of the practice. Receptionists, nurses, and other personnel are in key positions to enhance a student's effectiveness and sense of belonging. The third prerequisite is an academic and managerial leadership that supports the teaching activities of the preceptors. In both medical groups and faculty practices, physicians have competing responsibilities (e.g.: generation of revenue, teaching of fellows or residents, and provision of service). Unless student education is a priority, it will fail. Finally, there must be a suitable patient mix that adequately represents the population cared for by general internists.

To assure effective participation in caring for patients, the student should receive a thorough orientation to the practice, its physical layout, and its operation, including an introduction to every member of the office staff. A proper orientation conveys courtesy and a welcoming attitude that helps the student feel a part of the practice. A student's sense of belonging often translates into better performance.

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Effective learning requires a dialogue between teacher and student in which the student is able to critically examine his performance, identify new learning needs, accept advice, and request help. The dialogue is personal and requires a relationship between learner and teacher within which the student feels secure. Preceptors can promote a sense of security by conveying respect and interest in a student's development. Teacher-learner relationships that reinforce the student's sense of security and self-worth are repeatedly identified as key determinants of student satisfaction with teachers.

The requirements for dignity and security do not mean that teachers should refrain from criticism, reprimand, or dialogue intended to change learner behavior. They do mean that teachers should conduct these exchanges in a manner that strengthens mutual trust (see “Giving feedback” below).

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Nothing kills a clinical experience more quickly than misunderstanding or disagreement between student and preceptor regarding educational goals and performance expectations. Preceptor and student may avoid this misunderstanding by discussing mutual expectations at the beginning of the rotation. Topics to be covered may include:

  1. What the student expects to learn.
  2. What the preceptor expects the student to learn.
  3. The student's role in patient care.
  4. The preceptor's method of overseeing the student's patient care.
  5. The preceptor's expectations for outside reading.
  6. How and when feedback will be given and received.

Of these, the most important is the student's role in patient care. Role definition includes the number of patients the student will see per session, specific clinical responsibilities during the patient encounter, and the student's responsibility for follow-up after the clinic visit.

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Clinical teachers must regularly observe their students interviewing and examining patients as the basis for assessment, feedback and corrective guidance. Without observation, a preceptor cannot understand a student's clinical competency or learning needs. (Holmboe, Academic Medicine, 2004) even seemingly minor skills (e.g. retinal examination, knee examination) are often incorrectly reinforced by students and residents. More complex skills in advanced diagnostic maneuvers and patient communication are particularly problematic and benefit form frequent assessment.

The challenge for busy preceptors is to observe students without compromising work-flow in the office. Three suggestions may help:

  1. Observe students in skill performance just once or twice a day. Regular, effective observation is better than constant observation that interferes with work-flow and provides students autonomy.
  2. Prepare the patient and student for the observational exercise and regard it as a specified teaching incident. When students know they are being observed for a purpose, they value the exercise more highly. When patients are informed they understand and appreciate what they might otherwise observe as an odd encounter.
  3. Observe specific activities. By limiting observation to one part of a visit (e.g. the visit closure or a part of the examination), the exercise takes very little time. Provide feedback on examination techniques immediately but save comments on interviewing skills for later.
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Almost always, patients can be selected from among those with regularly scheduled appointments. Calling in “interesting” patients is rarely necessary and very time consuming. Patients with a single problem and no significant cognitive or psychiatric comorbidity may be particularly appropriate for beginning students. All students enjoy making a diagnosis in a patient who has a new and urgent problem; by facilitating access to care for such a patient (i.e.: through an urgent visit appointment), students can provide a real benefit to the practice.

Patients may expect to see only their personal physician, not the student. Prior to introducing the patient to the student, we recommend the preceptor visit the patient in the examination room to briefly ascertain his agenda and explain the student's role. Asking for the agenda enables the preceptor to decide when student involvement is inappropriate. Student involvement is not appropriate when the clinical problem is not relevant to the student's learning needs, when a patient insists upon seeing only the attending physician, or in rare instances when the student might seriously weaken the therapeutic value of an office visit. The vast majority of patients are appropriate for student involvement. We always provide opportunities for patients to privately request not to be seen by a student. Patients are likely to be dissatisfied with student involvement if it thwarts their intent to discuss very personal matters with their physician.

In explaining the student's role, preceptors should clearly refer to him or her as “medical student” to avoid misunderstanding about identity or expertise. An appropriate explanation identifies the student as a valued member of the patient-care team working in conjunction with (but not replacing) the preceptor and performing specified tasks, including history taking and physical examination. Preceptors should explain that the patient will be seen first by the student but that the preceptor will return after the history and physical to hear the student's report, review of all findings, and speak directly with the patient. Presented in this way, the student will be understood by the patient as contributing to good care. Preceptors should avoid soliciting patients with phrases such as "I'd like to ask a favor of you" that suggest the student's activities are of little value. Viewed negatively by the patient, the student may be rejected or not taken seriously.

Under special circumstances, patients may not benefit from an initial meeting alone with the preceptor. Examples include patients who are knowingly seeing the student for the second time, patients who have been prepared for first contact with students during telephone conversations with the attending, and patients who have no expectation of seeing a specific provider. In some practices, a nurse or receptionist may have adequately prepared the patient. When students do introduce themselves, they should know to give a full and clear description of their role and the role of their attending. Some preceptors prefer to have students introduces themselves and actively create the special circumstances listed above. The argument is that by seeing a patient first, a preceptor may undermine the student's relationship with that patient.

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Most students benefit from pre-visit guidance to help them focus on appropriate problems, perform a pertinent examination, and arrive at a reasonable differential diagnosis within the limited time available. The scope and content of the guidance should match the student's skill and the complexity and needs of the patient. In providing guidance, preceptors may briefly describe the patient's medical history and current problems or concerns (if known). When preceptors do provide instruction about the purpose of the visit, however, they must remind students to be alert for unanticipated patient concerns. Goals for the student's involvement with the patient should be discussed. For most encounters, the goal will be to elicit pertinent historical and physical data, develop a differential diagnosis, suggest a plan for evaluation and management, and write the note. Goals for the duration of a patient encounter are helpful for most students. By stating clear time goals, preceptors help students become efficient and minimize the prolongation of visit duration that may result from student involvement. The office stays on schedule.

Students appreciate receiving special preparation for complex or new tasks. For example, in a first patient with low back pain, the preceptors might review the basic history and physical exam in advance of the student’s meeting with the patient.

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This introduction can be very brief since student and patient have both been previously informed about each other.

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The student's oral presentation of the history and physical should be terse (no more than 3-4 minutes). Allowing the student 5-10 minutes prior to the presentation to collect his thoughts and consult texts helps to keep the presentation terse, well-informed, and well-organized. The presentation may take place either in the presence of the patient or away. Each location has distinct advantages, although we prefer hearing the presentation in the presence of the patient.

In the presence of the patient

The critical advantage of this location is efficiency. The preceptor is usually able to guarantee the accuracy and completeness of the student's work without feeling compelled to retake the history. Before the presentation, we usually invite patients to interrupt with corrections or additions. In this way, the patient becomes part of a three-way conversation and acts as a check on the student. After the presentation, we usually ask a few open-ended questions to confirm that the student has correctly identified the chief issues (e.g.: "Would you like to add anything to what [student's name] has said?").

Further questions can usually be very focused, covering only essential or missing historical data. Only on occasions when the diagnosis is uncertain or the student is not performing well will the preceptor need to independently obtain the complete history. Unnecessary repetition of the complete history disheartens the student and causes inconvenience to the patient without improving care.

Presentations in the examination room are advantageous for most patients who appreciate knowing that their symptoms and concerns have been accurately reported. Like all "bed-side" presentations, respect for the patient is foremost. Preceptors need to instruct students on appropriate etiquette.Communication of fears and personal data reported by the patient need not be avoided, but discussion of differential diagnosis is usually best done separately, away from the patient. Presentations in the examination room may also be beneficial for students who learn to speak respectfully about patients and their illnesses using words patients can understand.

Preceptors should routinely check essential parts of the physical examination to ensure accuracy and demonstrate technique. Patients seem to expect and appreciate the preceptor's examination. When appropriate, and before performing their own examinations, preceptors should observe the student repeating a component of the examination. This allows the preceptor to verify a student's competency and provide corrective instruction.

Presentation away from the patient

Presentation away from the patient affords the preceptor an opportunity to provide immediate feedback on the oral presentation. This location is well suited for occasional use with beginning students and others who need help with oral presentation. An additional benefit of the remote location is that the preceptor can help identify additional questions that the student can ask when they both visit the patient. When the student asks the questions rather that the preceptor, the student stays involved and the preceptor gains an important opportunity to observe the student's performance.

After the presentation away from the patient, the preceptor and student must visit the patient. The visit is necessary to:

  1. Guarantee that historical and physical examination data are accurate and complete
  2. Satisfy the patient's expectation for personal interaction with the preceptor
  3. Observe the student's skills for interviewing and examination
  4. Model skills for the student
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Regardless of how the case presentation is conducted, we recommend that student and preceptor meet apart from the patient for 5-7 minutes to discuss assessment and agree on a plan for evaluation and treatment. Asking first for the student's assessment and plan is critical for preserving the student's sense of responsibility and engagement, and for providing an opportunity to practice and improve reasoning skills. Only by listening to the student, furthermore, can preceptors assess reasoning skills and clinical judgment. Away from the patient, the discussion between preceptor and student will be less inhibited and incorrect inferences by the student can be managed without affecting the patient or embarrassing the student.

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When it is time to discuss diagnosis and negotiate management with the patient, preceptors may be tempted to take over from the student. Many preceptors perceive that this communication requires confidence, clarity, and style that students do not yet possess. Unfortunately, this perception may become a self-fulfilling prophesy if students never have the opportunity to learn clarity and style through practice. Rather than preempt students in this important communication, preceptors may use it as an opportunity to observe the student and later (when the patient is gone) provide feedback. Preceptor and student can agree to conduct the communication jointly, with the student taking the lead. To improve performance, preceptors should coach the student on what to tell the patient and how.

When a practice is busy, a prepared student can save the preceptor time by initially meeting alone with the patient to provide detailed information and explanations. The preceptor subsequently joins them to check the patient's understanding and satisfaction before summarizing and concluding the visit. The student maintains a central role in the patient's care and refines his communication skills. The attending, who may chart or see another patient, maximizes his or her efficiency. This alternative strategy is also beneficial for patients who often appreciate a second explanation of their diagnosis and treatment.

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Effective preceptors will seek opportunities to promote specific learning by identifying the learner's needs, asking questions, probing for explanation, and providing feedback. A learner's needs may be identified by direct questioning, by listening to unsolicited requests, or by direct observation of the student's performance. For example, after hearing a student describe and correctly asses a patient with a UTI, an attending might ask, "How can I help you with this patient?" The reply might be a request for help performing a urinalysis. If the preceptor had not asked, this learning need might have been missed. Observation of the student discussing the diagnosis of UTI with the patient may later reveal a failure to make eye contact or adequately assess the patient's understanding of treatment. However identified, learning needs should be explicitly acknowledged and discussed. When the need cannot be immediately met, student and attending should formulate a plan for meeting it later.

Although students always have learning needs, they also may know more than is apparent. When preceptors launch into spontaneous lectures or make learning assignments for topics already well-known to a student, learning is inefficient and frustration sets in. Direct inquiry about self-perceived knowledge and brief testing for that knowledge can help preceptors identify areas in which a student's knowledge is already satisfactory.

Questions help students clarify their own reasoning and identify learning needs. Well-constructed questions promote independence by teaching students to be critical, to identify decisions, and to acknowledge cultural or scientific paradigms. Open-ended questions stimulate problem solving, evaluation, or judgment (e.g.: "What is your assessment of this patient?"). Closed-ended questions test recall or ask for explanation (e.g.: "What is the diameter of a red blood cell?"). Because medical education is substantially about teaching problem solving and judgment, open-ended questions should usually be emphasized.

In promoting learning in the ambulatory setting, efficiency is essential because patient flow must be maintained. A potential pitfall is over reliance on the mini-lecture. Preceptors use mini lectures to address information deficits identified when students present a patient. Mini lectures do address learning needs in a timely manner, but they are a passive learning tool that is costly in terms of time and halts the operation of an office or clinic. The mini lecture should be used sparingly and only when it is brief, addresses a critical learning need, and directly improves patient care.

Medical students appreciate specific recommendations for problem-based reading. After a day seeing several patients, students may feel uncertain about priorities and sources for independent reading. We suggest that preceptors routinely make recommendations and check for the student's reading progress by requiring reports on findings. Assignments for independent learning are most effective when there is a meaningful consequence to the student's effort. In particular, students are highly motivated to obtain information that is not currently known to the preceptor or student and that directly influences a clinical decision.

Although our strategy emphasizes active learning by the student, role modeling is also an effective educational technique. It is useful for demonstrating attitudes, interpersonal skills, and examination techniques.

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A student's most meaningful role in patient care may occur after the patient has left the office. By calling patients to ascertain response to therapy, for example, students provide a valued service to patients and preceptors while learning about disease outcome and patient communication. As another example, the process of gathering, interpreting, and acting upon test results provides a rich learning opportunity. A student who orders a protime for a patient taking warfarin may be asked to acquire the results, decide if a dose adjustment is warranted, confer with the attending, and call the patient. In the process, the student will learn about coumarin monitoring, the international normalization ratio, and patient education.

Responsibility for follow-up should be a central objective of any ambulatory clerkship. Preceptors must actively delegate specific responsibility to students and be available to support students in their subsequent interaction with patients. To avoid therapeutic misadventure, preceptors must tell students not to give unauthorized medical advice.

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During office hours, there is insufficient time for preceptor and student to adequately review all major teaching points pertinent to patients they have seen. A convenient way to review patients without impairing office productivity is for student and preceptor to designate regular meeting times outside of office hours. The student should bring a list of patients, results of testing, results of reading, and questions.

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Feedback is critical for adult learning. In clinical education, feedback provides "information describing students' or house officers' performance in a given activity that is intended to guide their future performance in that same or in a related activity". It should target both deficient behavior, so that it is corrected, and effective behavior, so that it is reinforced. For medical students working in offices and clinics, feedback on their performance may come from their own observations, and those of their colleagues, patients, or preceptors. While feedback from some of these sources cannot always be assured, preceptors should be a predictable source.

Feedback should always be offered in the context of a collaborative and supportive teacher-student relationship. It should be given as soon as possible after a behavior is observed. Feedback should be based only on observed actions and decisions, not inferences. It should target specific, correctable behaviors, not general practices. It should be non-evaluative and should not consist of subjective judgments about the learner or his behavior. Feedback should be accompanied by efforts to develop an approach to correction. Performance standards should be high but appropriate to the student's level of experience.

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Students with no prior clinical experience, inadequate medical knowledge, or inadequate clinical skill are a special challenge for office-based preceptors. Lacking capability for satisfactory independent work, they require greater direct assistance in all aspects of patient care. While some preceptors balk at taking on these students, others understand that less-capable students simply require adaptive learning programs. Preceptors may consider several approaches:

  1. Spend more time in orientation and role-modeling so that students thoroughly understand office routines.
  2. Provide detailed coaching (e.g.: about appropriate history) before patient visits.
  3. Assign fewer patients per session (in our offices, most students see at least 2 patients per 1/2 day).
  4. Assign less complex patients.
  5. Do not hesitate to tell the student how to manage the patient's care when the student is unsure or wrong.
  6. Spend more time with the student outside clinic coaching him on basic skills, communicating your assessment of his learning needs and emphasizing your commitment to his professional development.
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Discussion

The assignment of medical students to ambulatory settings for core clinical training represents a strategic shift in medical education. The success of this shift will depend on whether we develop and implement teaching strategies and teaching skills that are suited to the new learning environment. In this paper, we have described a strategy and set of skills that may help ambulatory preceptors enhance their teaching effectiveness. Although the strategy we describe was developed for general internal medicine, we believe that it may also be suitable for many medical subspecialties, pediatrics, family practice, and surgery.

Clearly defined strategies, such as ours, lend themselves to examination and will benefit from testing to document educational effectiveness and effect on patient care. In a pilot study, we have found that a preceptor who uses this strategy can expect to spend 26 minutes assisting a student in the care of one patient. On average, patients remain in the office for one hour. Further research on precepting strategies will facilitate the design and implementation of ambulatory clerkships.