3/1 YES!: Teaching in the Ambulatory Setting
March 01, 2024ID11407
To CiteDCA Citation Guide
- 00:00Today we have a clinical teaching topic.
- 00:05I mean as you remember we're
- 00:07alternating kind of things that could
- 00:09be more classroom or or professional
- 00:11development for for academic writing.
- 00:13So today we have something that's
- 00:15near and dear whether you're teaching
- 00:17the ambulatory setting or you're
- 00:18teaching where time is limited,
- 00:20this will hopefully be a useful
- 00:22session for you.
- 00:23We do have a few more and they'll
- 00:25we'll sessions before we end
- 00:27for this academic year.
- 00:29They'll be flashed up in front of
- 00:31your eyes at the end along with AQR
- 00:34code for you to access the website.
- 00:35But if you're ever wanting
- 00:37to listen to past recordings,
- 00:39if you go to Yale City Medical
- 00:41Education under Educator Development,
- 00:43you'll see past recordings there.
- 00:45Let me turn it over to Andreas Martin,
- 00:48my partner in crime who is helping
- 00:50and we are running this this
- 00:52series for this year and he's
- 00:55gonna introduce today's speaker.
- 00:57Thank you.
- 00:58Thank you,
- 00:59Dana.
- 00:59So
- 01:02it's really wonderful to to
- 01:05welcome Jen Jen Rockfeld,
- 01:08I I told her that I wouldn't spend much time,
- 01:11only 45 minutes or so go going over her CV.
- 01:15But we agreed there was probably
- 01:17shortening that significantly.
- 01:18And I think that that what you see on the
- 01:20slide really tells a lot of who Jen is
- 01:22and does and how that will inform what
- 01:24we're going to be learning about today.
- 01:26So we are together in the Center
- 01:29for Medical Education and Jen works
- 01:34in educational development for the
- 01:37ambulatory setting within the center
- 01:40and also in the Northeast Medical Group,
- 01:43this very,
- 01:44very large consortium of outpatient services.
- 01:47She is the Director of Education
- 01:51Education Development.
- 01:52So how, how can we as physicians
- 01:55become more better at teaching
- 02:00at the not by the bedside but at the
- 02:02seat side or something like that? So Jen,
- 02:06welcome and take it away.
- 02:09Thank you, Andreas. Yes.
- 02:10So I I have been teaching in the
- 02:14ambulatory setting for a long time now,
- 02:16from residents to medical students and now
- 02:18I even teach some PAS and APRN students.
- 02:21So a broad range.
- 02:23And I'm hoping that all of you,
- 02:25whatever setting you're in,
- 02:26can come away with something from this
- 02:28talk that you can apply to your teaching.
- 02:30I'm going to, I can't see the chat,
- 02:34so I have people fielding the chat.
- 02:36For me, the number is in the chat already.
- 02:38For the participation,
- 02:39it's down here on the bottom
- 02:40of the slide as well.
- 02:42I have no disclosures
- 02:46and Linda will put it in again.
- 02:47Thank you, Linda.
- 02:50So my learning objectives for today
- 02:52are for us to recognize that there
- 02:54are both benefits and barriers to
- 02:57teaching in the ambulatory setting.
- 02:59I want us to really think about and
- 03:01identify what are the key roles of
- 03:03an outpatient preceptor and then get
- 03:05really granular and talk about four
- 03:07distinct strategies that you can use
- 03:09to teach in the ambulatory setting.
- 03:11And finally, I want to take a step
- 03:13back at the end and just to reflect
- 03:16on this unique experience between an
- 03:18outpatient preceptor and a student.
- 03:19Because most of the time there's a
- 03:22longitudinal experience that they
- 03:23may not experience anywhere else.
- 03:25And how can you serve as a role model
- 03:27in this experience in a multiple
- 03:29in a multitude of ways.
- 03:31So before we get started,
- 03:32I did want to put out a brief poll just to
- 03:35get a sense of who the audience is today.
- 03:38So give me one moment.
- 03:39I'm just going to launch a poll to try
- 03:41to find out where you're all coming from.
- 03:54So it was launching on my end when we
- 03:59practice and now it doesn't seem to be
- 04:01you need to be in display mode slideshow,
- 04:11but I don't have the screen to
- 04:13launch it in this mode. Ed, are you
- 04:15able to launch the pool yourself?
- 04:21Yep, I can launch it.
- 04:22Give me one second. OK.
- 04:23Thank you. I appreciate it.
- 04:24So just launch the first question
- 04:25and then the second question and
- 04:27then I'll share it with everyone.
- 04:28All right. So you could,
- 04:32I can, if everyone can see it.
- 04:34I'm just trying to find out what
- 04:35learner levels people are precepting.
- 04:36So you can choose multiple answers,
- 04:39but I just want to get a sense so
- 04:41that I could cater my talk to it
- 04:50Great. So it looks like
- 04:52really a variety and we've
- 04:54got enough participation.
- 04:56I'll share it with you
- 04:56all so you could see too.
- 05:00You can see now we've got
- 05:02people precepting 1/4.
- 05:04Precepting clerk, clerkship,
- 05:05pre clerkship students another half.
- 05:07Clerkship students 1/2.
- 05:09Residents, 35% fellow. So really arrange.
- 05:11And then there's some other an NA people
- 05:14are here who are precepting other groups.
- 05:16So thank you all for for sharing that.
- 05:17I'll try to talk about which techniques
- 05:20work best with each level of students. Ed,
- 05:23if you could just launch the second question.
- 05:25Oh, I could do it now. Thank you.
- 05:26Now I could see it.
- 05:28There we go.
- 05:30So what type of ambulatory
- 05:31setting are you teaching in?
- 05:32So I really only listed ambulatory
- 05:35practice and community practice,
- 05:36and if there are others out there
- 05:37I would love to see in the chat
- 05:39where you're teaching so I can
- 05:40get a sense of that as well.
- 05:52OK. So you could see over 50%
- 05:55are in the ambulatory practice,
- 05:571/4 in the community practice.
- 05:58And anybody in the chat with other places,
- 06:01they're they're teaching.
- 06:10OK, so, so I will talk.
- 06:13Some of this has to do with
- 06:15the community setting.
- 06:16Pretty much all of it can
- 06:17apply to the academic setting.
- 06:18So let's go through it.
- 06:19So you know, I'm going to.
- 06:23So teaching the ambulatory setting
- 06:24has really traditionally been
- 06:26neglected in the literature,
- 06:27despite the fact that most
- 06:29doctors spend most of their
- 06:30time in the ambulatory setting.
- 06:32So in 1984,
- 06:34only 7% of internal medicine
- 06:37residency programs required
- 06:39an outpatient rotation.
- 06:40By 2001, that went up to 94%.
- 06:43So a tremendous increase in the number
- 06:46of internal medicine residents going
- 06:48into ambulatory settings for training.
- 06:50And then in terms of medical schools,
- 06:52all medical schools require an
- 06:54outpatient experience as well
- 06:56as a primary care experience.
- 06:57So when you think about it,
- 06:59academic practices cannot
- 07:00accommodate all of these students.
- 07:03And then we're shifting into community sites.
- 07:05And in the community sites,
- 07:06there's competition from all
- 07:08health profession schools.
- 07:09So competition from medical schools,
- 07:10PA schools,
- 07:12nursing schools where everyone's
- 07:14competing for these ambulatory sites.
- 07:16So you would think that there'd
- 07:17be a lot more attention being
- 07:19paid to how this is going.
- 07:20But it actually still there's not
- 07:22that much literature out there.
- 07:24And perhaps because it's so diverse,
- 07:26it's sort of hard to study best practices.
- 07:29But there are a few things out
- 07:30there that have been shown to be
- 07:31helpful and I'm going to go through
- 07:33what the literature shows today.
- 07:36So it is 1235 on your clinical day
- 07:40and you just finished a busy morning,
- 07:43you had a couple of chatty patients,
- 07:44you were supposed to finish at 12.
- 07:46It got pushed a little bit later and
- 07:48you realize either you have a student
- 07:50coming to your office that afternoon
- 07:52to work with you or you're subbing in
- 07:54for resident clinic that afternoon and
- 07:56you got to rush over there and precept.
- 07:58So what are some some feelings and thoughts
- 08:00that come to your mind when this occurs?
- 08:08Surgery OR in the chat or you could
- 08:11put it in the chat and it is popping
- 08:13up for me so I could see when you're
- 08:17so you're running to the OR,
- 08:18it's a typical day. Yeah.
- 08:27It's heart sync. Yes.
- 08:29I've had that chaos approaches
- 08:35Great right. Shoving something
- 08:36in your mouth as you run over.
- 08:39Yeah. So fun. Thank you, Ada.
- 08:41So. So that's what we're
- 08:43going to talk about, right?
- 08:44There are benefits and barriers to teaching.
- 08:47So let me talk a little bit about
- 08:49the benefits to the learner and then
- 08:50let's talk a little bit about the
- 08:52benefits to the faculty members.
- 08:54So the learner has a tremendous amount
- 08:56of knowledge that they can acquire
- 08:58in the outpatient setting, right.
- 09:00So we are seeing acute issues.
- 09:02We are doing chronic disease management,
- 09:04which you don't get to see as
- 09:06much on the inpatient setting.
- 09:07Health maintenance is a huge
- 09:09area in the outpatient setting.
- 09:11Psychosocial care,
- 09:11I cannot stress enough and I'll
- 09:13come back to that at the end.
- 09:15They get to see you use all
- 09:17of your communication skills,
- 09:18your physical exam skills,
- 09:20your procedural skills.
- 09:22And then finally,
- 09:23they get to see this longitudinal
- 09:24relationship and it's the longitudinal
- 09:26relationship you have with your patients,
- 09:28with your staff and then the
- 09:30longitudinal relationship you
- 09:31develop with them as they come
- 09:33to your office week after week.
- 09:34And some preceptors also stress that they,
- 09:37they schedule patients to come to see
- 09:38the student again and again so the
- 09:41student can develop this longitudinal
- 09:42relationship with a patient,
- 09:43which is really special.
- 09:45So benefits to faculty.
- 09:47So I'll let you take over for a moment,
- 09:49throw them in the chat.
- 09:50What are what are good things
- 09:52that you get out of preceptor
- 09:53students or residents.
- 09:59Yeah. And I see that somebody had
- 10:01written time before which I will talk
- 10:03more about that paying it forward
- 10:05huge people really feel that teaching
- 10:07is an opportunity to pay it forward.
- 10:10Rejuvenation nation keeping us up to date
- 10:18regain our students present, right.
- 10:20So we learn from them as they learn from us.
- 10:22The enthusiasm, the satisfaction and yes,
- 10:27the FaceTime with the patient.
- 10:28I'm going to talk about that too,
- 10:29whether students actually allow
- 10:31more FaceTime with patient,
- 10:32which has been shown.
- 10:33So you hit on all the points
- 10:35that I have as well.
- 10:36So just to pull them up, it helps
- 10:39faculty keep their knowledge up to date.
- 10:41It enhances their enjoyment of patient care.
- 10:42And these are all evidence based.
- 10:44It improves the quality of their practice,
- 10:46right? So they're keeping up to date.
- 10:48They feel like they're providing better care.
- 10:49As a result, they're giving
- 10:51something back to the profession.
- 10:53They're able to serve as a positive role
- 10:55model and perhaps recruit people into their
- 10:58field and then all the extrinsic benefits.
- 11:00So extrinsic benefits can range
- 11:03from resources, library access,
- 11:05academic appointments,
- 11:06faculty development,
- 11:07being able to go to conferences like this,
- 11:09being part of a larger system.
- 11:11So there are a lot of extrinsic benefits
- 11:13and then in some cases, money stipends,
- 11:15which comes into play as well.
- 11:18So we talked about the benefits now barriers.
- 11:21So throw them in.
- 11:23I think we're going to probably see the
- 11:25same themes coming up again and again.
- 11:30You're drowning. Why?
- 11:32Why do we feel like this sometimes?
- 11:34Because of teaching time,
- 11:36Yes. Lack of time.
- 11:41So. So let's talk about time for a minute.
- 11:44Yes, time. So I I knew that
- 11:45would be the biggest one.
- 11:46So it has been shown that that comes
- 11:48up again and again in the literature
- 11:50and space I'm going to talk about too.
- 11:52So when you bring a student into an office,
- 11:56it has been shown to increase the
- 11:58length of a clinical session,
- 12:001/2 day session by about 30 to 50 minutes,
- 12:03so an hour to almost two hours
- 12:06for the length of the day.
- 12:08And they've shown that in in community
- 12:10practices specifically the community
- 12:12physicians don't cut down on the
- 12:15number of patients they're seeing.
- 12:17So they're still seeing the
- 12:18number of patients,
- 12:19but it's just taking more time.
- 12:21And then all of us, as you know,
- 12:23have all the extra work that we have to do.
- 12:25So the writing notes,
- 12:26the fielding are in baskets.
- 12:27Everything else we have to do gets
- 12:29put on the back burner.
- 12:30So that has to be done later.
- 12:32The EHR has been cited again and
- 12:34again as a source of tremendous stress
- 12:36and burnout and taking more time
- 12:40to look at it another way,
- 12:41which which Peter had mentioned about
- 12:43how much time you get with the student.
- 12:44It's been shown that most people feel
- 12:46like being an encounter with the student
- 12:49takes about 3:00 to 5:00 minutes.
- 12:51So if you're spending three to 5 minutes with
- 12:53these small encounters throughout the day,
- 12:56both preceptors and students are
- 12:58saying we don't get enough time.
- 13:00But you add them together,
- 13:02the the students seize a patients,
- 13:03that adds up to time that
- 13:04you're spending with them.
- 13:05So it's both not enough time
- 13:06to spend with the the students,
- 13:08not enough time to get your own work done.
- 13:11We all want to be good clinicians.
- 13:13We all want to be good teachers.
- 13:14How are we able to do both successfully?
- 13:17A couple of other points that
- 13:18have come up in the literature.
- 13:19Some people feel like it increases
- 13:21the cost of business if you bring
- 13:24a student into your office.
- 13:25Stress levels.
- 13:26We talked about there are some
- 13:29concerns about effects on patients
- 13:30and staff of having a student,
- 13:32but it's been really not substantiated
- 13:35that most patients actually like
- 13:37having a student in the practice.
- 13:38It gives the practice some prestige.
- 13:40They feel like they get more attention.
- 13:41So that hasn't been substantiated.
- 13:44And then finally,
- 13:45in the more recent literature,
- 13:47some clinicians feel like they're out.
- 13:49They're out of touch with current medical
- 13:51education and with current students.
- 13:53So they feel that there's this sort
- 13:54of gap between how they were trained
- 13:56and how students are trained now and
- 13:58a generational gap that makes it the
- 14:00the practice feel less fulfilling.
- 14:02So how do we fulfill this role,
- 14:05be excellent clinicians,
- 14:06be excellent preceptors and not
- 14:08feel like we're drowning.
- 14:10So this was a great study done.
- 14:14It was a while ago now by Judy Bowen
- 14:16and David Irby in Academic Medicine,
- 14:18and they found they just looked at
- 14:20ambulatory education as a whole.
- 14:21And they they found that the three
- 14:24main components of ambulatory
- 14:25education are the learners,
- 14:27which I I'm not going to spend a
- 14:29tremendous amount of time on today.
- 14:31The preceptors us,
- 14:31which I'm going to spend the most
- 14:33of my time on, and the environment,
- 14:35which I'm going to touch on a little bit.
- 14:37I know many of us can't alter
- 14:39our environment, but if we can,
- 14:40there are some tips that might
- 14:42make it easier to teach.
- 14:46So when do you think about precepting these?
- 14:49This is a conglomerate of a lot
- 14:51of literature, so they're really,
- 14:52these are the key roles that
- 14:54I see a preceptor performing.
- 14:56So the first one is sort of the preparation.
- 14:59So you're preparing both the
- 15:01the learning environment,
- 15:01the office and the learner for
- 15:03entering what is really a different
- 15:05setting than they're used to.
- 15:07If you think about it,
- 15:08most of their clerkships are
- 15:09spent in the inpatient setting.
- 15:10So this is really an unfamiliar setting and
- 15:12it does take a little a bit of orientation.
- 15:15You're going to provide them
- 15:16with learning opportunities,
- 15:17you're going to deliver feedback,
- 15:19you're going to evaluate the
- 15:21learner's performance.
- 15:22That's part of your role as
- 15:23a preceptor and then the role
- 15:24modelling that comes into place.
- 15:26And I'm going to specifically talk
- 15:28about role modelling humanism and
- 15:30we're role modelling professionalism.
- 15:32So I'm not going to spend a tremendous
- 15:34amount of time on feedback and evaluation.
- 15:36That's a whole separate talk and
- 15:38definitely part of this Yes series.
- 15:41But feedback does come into play a
- 15:42little bit with the learning opportunities.
- 15:44So I'm going to start with preparing
- 15:46the office and orienting the learner.
- 15:48So to prepare your office,
- 15:50there's couple things to think about.
- 15:52If you have control over your schedule,
- 15:54which not all of us do,
- 15:56I'm going to just show you in the
- 15:58next slide a way you can to make your
- 16:00schedule to make it a little bit easier.
- 16:01And this is specifically for people bringing
- 16:03students into their office residents,
- 16:05obviously they're seeing their own patients.
- 16:07It's a slightly different,
- 16:08you don't have to really prepare a schedule,
- 16:10they're doing that.
- 16:10They have their own schedule.
- 16:11Set space and access is a big
- 16:14issue and something that LCME
- 16:16looks at for accreditation.
- 16:17There has to be enough space for
- 16:18the student to put their stuff.
- 16:20There has to be space for them to
- 16:21work and there has to be space
- 16:22for you to precept them.
- 16:23And someone had mentioned that as a barrier,
- 16:26I also think it's very important
- 16:28for the student to have their
- 16:30own room so that if you could see
- 16:32a patient simultaneously,
- 16:33if you're sharing one room,
- 16:35that makes it a lot harder to
- 16:37teach and then patients.
- 16:38And I'm going to talk very briefly
- 16:40about how to pick the right patients,
- 16:42how to Orient the patients to this process.
- 16:44So this is an example of a wave schedule
- 16:47and I'm just going to walk you through it.
- 16:49So if you are able to set
- 16:51up your own schedule,
- 16:53this may make it easier for you to see
- 16:55patients simultaneously with the student.
- 16:57So I put this down for 20 minutes
- 16:59slots and really the only thing
- 17:01you're doing is you're double
- 17:02booking at the top of every hour.
- 17:04So at 8:00,
- 17:06the normal schedule will be patient 123456,
- 17:09but at 8:00 you are having
- 17:11patients one and two come.
- 17:13At 8:00,
- 17:14the student is seeing one of those patients
- 17:17and you're seeing the other.
- 17:18Once you're done with your patient,
- 17:21you are then precepting the student
- 17:23and have that extra 20 minute
- 17:24time slot to go back with the
- 17:26student to see that that patient.
- 17:28And then when you're seeing
- 17:30your third patient,
- 17:30the students charting on their patients,
- 17:33so they're seeing one patient in
- 17:34the time it's taking you to C3,
- 17:36it doesn't set you back.
- 17:38You're still seeing the three patients
- 17:40you need to see in that hour.
- 17:41But it's it's altering how they're
- 17:43slotted so that it gives you a little
- 17:45bit more time to spend with the student.
- 17:47So it's just one example of a
- 17:49schedule that might make it easier
- 17:51if you're able to do that when
- 17:53thinking about choosing patients,
- 17:55these are the three factors
- 17:56that come into play.
- 17:57This was an interesting article.
- 17:58So they said the three factors you
- 18:00should think about when you're
- 18:01choosing patients are how much
- 18:03time is it going to take because
- 18:04you you need to be efficient.
- 18:06What's the educational value of
- 18:07this patient and then what's your
- 18:09relationship like with this patient?
- 18:11Because if you could hit on two of them,
- 18:14so if you could pick a patient that
- 18:16is really going to be efficient and
- 18:17you have a good relationship with,
- 18:19it might not have the best educational value,
- 18:21but that's OK.
- 18:22But you might want to pick a patient
- 18:24that has high educational value and
- 18:25you have a great relationship with,
- 18:27but it might compromise time.
- 18:29So you know,
- 18:30you can look at this in many ways,
- 18:31but when you're thinking about what
- 18:33patients might be good for a student to see,
- 18:35this is a way to think about it.
- 18:37I also,
- 18:38from the patient's perspective,
- 18:40I think it's really nice to Orient
- 18:42them to what's going on.
- 18:43So sometimes you'll have see a
- 18:45sign in a doctor's office that
- 18:47says we have a student with us.
- 18:49Here's a little bio about the student.
- 18:51You know thank you for supporting
- 18:53the students education or something
- 18:55that says we're really proud to be
- 18:57associated with the Yale School of
- 18:59Medicine seeing patients as invaluable
- 19:01to developing future physicians and
- 19:03thank you for participating in this.
- 19:05So something that the patient
- 19:06comes in and is aware that the
- 19:08students going to be there.
- 19:09And I always say that the
- 19:10staff should be aware too.
- 19:12So the staff should,
- 19:13you should should know the student,
- 19:15introduce them right away.
- 19:16They should be telling the patient
- 19:18right when they room them that
- 19:19a student might be coming in.
- 19:21Obviously with residents this is different.
- 19:22But for students this is really
- 19:24important that the patient is
- 19:26aware and gives permission that the
- 19:27student is coming in to see them.
- 19:29So let's talk about orienting the learner.
- 19:32So orienting the learner in this setting
- 19:34is quite similar to any other setting.
- 19:37You want to make sure you
- 19:39have mutual expectations.
- 19:40You want to diagnose the
- 19:41learner at the beginning and
- 19:43figure out their level of experience.
- 19:45You want to provide learning
- 19:46opportunities for them and then
- 19:48you want to provide assessment and
- 19:49feedback and let them know how that's
- 19:51going to happen in this space.
- 19:53So when I talk about developing
- 19:56mutual expectations,
- 19:57you know it is a new setting for them.
- 19:59I think sometimes it's helpful
- 20:01to just sort of outline up front
- 20:02what it's going to look like,
- 20:04how much time they have to see each patient,
- 20:06what you expect from them when
- 20:08they see each patient.
- 20:10One thing that a picture that I love to show.
- 20:13Is this picture from team steps
- 20:14of a shared mental model.
- 20:16So shared mental model is important
- 20:18in a lot of what we do.
- 20:19The definition of a shared mental
- 20:22model is the understanding or
- 20:24knowledge about a situation or
- 20:26process that is shared amongst teams
- 20:29members through communication.
- 20:30So I might think you're thinking
- 20:32the same thing I am about this
- 20:34experience and we might be on
- 20:36completely different wavelengths,
- 20:37so it really is through communication.
- 20:39So you have to tell them,
- 20:42you know,
- 20:42these are what the goals and
- 20:44expectations are.
- 20:44What are your goals and expectations?
- 20:46Let's come to a mutual understanding of what
- 20:48you're going to get out of this rotation,
- 20:50right.
- 20:51And and one example I give where I failed
- 20:54at this was when I first transitioned,
- 20:56I used to precept residents and then flipped.
- 20:59And what started teaching
- 21:01second year medical students.
- 21:02And the first time I had
- 21:03a student come with me,
- 21:04a second year medical student,
- 21:05I said OK why don't you go into
- 21:07the office and do an HMP and then
- 21:09come out and talk to me about it.
- 21:11And I remember I was waiting and
- 21:13waiting for her and it was like 50
- 21:14minutes in and I knocked on the door
- 21:16and I said why didn't you come out now?
- 21:18She said,
- 21:19OK And she came out and she starts
- 21:21presenting to me and she presents
- 21:23this detailed history and I'm like,
- 21:25OK and what'd you find in physical?
- 21:26And she's like, oh, I didn't,
- 21:27I didn't have time for a physical
- 21:29And I'm like,
- 21:30Oh my goodness,
- 21:30you were in there for 50 minutes.
- 21:32What did you do?
- 21:33And I was just had no sense of I
- 21:35didn't diagnose her and I didn't set
- 21:37any expectations and I could have
- 21:39fix that quite easily by figuring out
- 21:41where she was and then being clear,
- 21:43you have 30 minutes to see this patient.
- 21:46I'd love for you to perform a focused
- 21:47history and physical and then
- 21:49come out and we can talk about it.
- 21:50And that would have been a
- 21:52completely different dynamic.
- 21:52So I think it's really important and
- 21:55when I talk about diagnosing the learner,
- 21:57there's so many ways to do that.
- 21:59A very simplistic way which most of
- 22:01you use and know about is the ride method.
- 22:03And I I do think it's helpful just
- 22:04to get a sense at the beginning,
- 22:06you would think that a early student,
- 22:09a pre clinical student is a reporter
- 22:10as they become a clerkship student,
- 22:12they're transitioning into
- 22:13interpreter and hopefully manager
- 22:15and then is there a resident there,
- 22:17a manager and educator.
- 22:18It's not always the case, right?
- 22:21Every learner is different,
- 22:22every learner is at a different step.
- 22:23A clerkship student in January is not the
- 22:25same as a clerkship student in July, right.
- 22:28So, so really getting a sense of them
- 22:30and we could do that with a simple
- 22:32observation at the beginning and I'll
- 22:33talk a little bit about that at the end.
- 22:37So I'm going to spend the bulk of the
- 22:40time talking about providing learning
- 22:42opportunities and ways to do so.
- 22:44And as part of learning opportunities,
- 22:46there is sort of in the moment feedback.
- 22:48I'm not talking about summative
- 22:50feedback or feedback on a larger
- 22:52level or models to deliver feedback,
- 22:54but built into some of the models
- 22:56I'm going to talk about is feedback.
- 22:59So the three,
- 23:00the four models I'm going to talk
- 23:03about are active observation,
- 23:05precepting in the presence of the patient,
- 23:07which Andreas is what you were
- 23:08saying before it was.
- 23:09It's not really bedside,
- 23:11but it's chair side teaching the one minute
- 23:15preceptor or the micro skills and snaps.
- 23:17And this is also a place that
- 23:19I'd love to get a sense of who
- 23:22has used these in the past.
- 23:24So,
- 23:26Ed,
- 23:26can I use your help again to launch the pole?
- 23:30Yep. Well, it's a nail.
- 23:32Thank you. So who has used these models?
- 23:35And once again you could take
- 23:37multiple choices because I would
- 23:39like to have a bit of a discussion
- 23:41after I go through them of of your
- 23:42experiences and I just want to see
- 23:43which ones you're most familiar with.
- 23:59Great,
- 24:02so I will share it with all of you.
- 24:03So all of these models have
- 24:06been used and I'm love that.
- 24:09So you could see active observation.
- 24:12Almost everyone, 75% of people have
- 24:15replied have used it precepting
- 24:17bedside teaching also used a lot,
- 24:191 minute preceptor.
- 24:21Many of you snaps less so which is great.
- 24:25So let's talk about them,
- 24:26and let's see if any of them might
- 24:27fit into your future preceptor.
- 24:34OK, so
- 24:38there's not many pictures of people
- 24:39teaching at the bedside. So this is me.
- 24:42This is teaching with a student
- 24:45who actually had the pleasure of
- 24:46spending once a week for his whole
- 24:48first and second year in my office.
- 24:50So I spent a lot of time with him and then he
- 24:53decided to go into interventional radiology,
- 24:55which was a bit disappointing.
- 24:57But I do believe he's practicing very
- 25:00patient centered interventional radiology.
- 25:02So let's talk about teaching and shadowing.
- 25:06So I know that when the learners come to you,
- 25:11residents any level,
- 25:11they don't want to shadow anymore,
- 25:13even the first day of Kirkship,
- 25:14they don't want to shadow anymore.
- 25:17I personally find there is tremendous
- 25:19benefit to watching a colleague of
- 25:22mine perform a history, physical,
- 25:24hear their clinical reasoning,
- 25:26see them do a procedure.
- 25:28We still can learn from each other.
- 25:30And I try to tell my learners
- 25:31whatever level you're at,
- 25:32there's something I could teach
- 25:34you and by modelling it.
- 25:35And then I'd love your feedback.
- 25:37I'd love to hear from you what you thought
- 25:39about what I did and get better at it.
- 25:41So shadowing and an active observation
- 25:43of the preceptor is something
- 25:45that can be included in any level.
- 25:47And the best thing to do when you're
- 25:50setting that up is to prime the
- 25:51student or to prime the resident.
- 25:53So priming is just so important for them
- 25:55to start activating their clinical reasoning.
- 25:58We talk about it a lot in clinical reasoning,
- 26:00but an active observation.
- 26:02You really want to tell them
- 26:04why they're watching you.
- 26:05It's not like going and just
- 26:06I'm out of time and you know,
- 26:08just come in with me,
- 26:09my last patient,
- 26:10You've come in with me to this patient.
- 26:12I've been trying to get this
- 26:14patient to quit smoking.
- 26:15I'm going to try to use
- 26:17motivational interviewing here.
- 26:18Just watch and see what tools I'm using and
- 26:20let I'd love to hear afterwards what you
- 26:22think worked and what you think didn't work.
- 26:25OK,
- 26:25so so watch motivational interviewing.
- 26:28This is what I'm doing with this patient.
- 26:30I go in,
- 26:30I do it and we come out and we debrief.
- 26:33We reflect on the experience.
- 26:35What did you think?
- 26:36What did you see me doing that worked?
- 26:38What did you think didn't work?
- 26:40What could you use next time?
- 26:41What would you want to try out?
- 26:42Maybe I can come watch you
- 26:44next time you do motivational
- 26:45interviewing and see how it goes.
- 26:47So then the next step is you almost could
- 26:49you could you could do it again and again,
- 26:51but you could flip it,
- 26:52right?
- 26:52So now you're watching the student
- 26:54or resident do something.
- 26:56And this can be ranging from the the
- 26:59student or resident doing a physical exam
- 27:02to doing something really complicated,
- 27:03right?
- 27:04So doing something that they've
- 27:06struggled with in the past,
- 27:08you know,
- 27:09something that they feel uncomfortable
- 27:10with that you're watching them do.
- 27:11I found that most patients
- 27:13are comfortable with me in
- 27:14the room and are still able
- 27:16to direct their attention.
- 27:17If I make myself inconspicuous to
- 27:19the resident or the student and I
- 27:22say I'm just a family on the wall,
- 27:23don't talk to me, talk to this person.
- 27:26And this is a really nice
- 27:28opportunity to diagnose the learner.
- 27:29So I know most of us don't have time to
- 27:32go in the room for a 30 minute encounter,
- 27:35but you, you know,
- 27:37you know that they're working on a skill.
- 27:39They're they're working on, you know,
- 27:45physical exam skill. Excuse me,
- 27:46I'm trying to think of something,
- 27:48you know, the cardiology exam,
- 27:49like I'm really having trouble
- 27:51doing JVP and I and observing it.
- 27:53OK, so why don't you call me
- 27:55in when you get up to that?
- 27:57I'm going to watch you for that
- 27:58particular point a couple of
- 27:59minutes and then we'll debrief
- 28:01about it afterwards, right.
- 28:02So it's a place for you to to
- 28:03sort of diagnose the learner or
- 28:05they're having trouble sort of
- 28:06delivering a plan to the learner.
- 28:08You know they're at that higher
- 28:09level and they're just having
- 28:10trouble getting through or the the,
- 28:12I mean to this to the patient
- 28:14or the patient's not, you know,
- 28:16following a A, a, a,
- 28:19a plan that they had prescribed
- 28:20in the past and helping them
- 28:22figure out what's the lesion here.
- 28:23Why is it not going through,
- 28:25what am I seeing that you're
- 28:26doing that's not working.
- 28:27So just picking part to go in
- 28:29and observe and always have
- 28:31that deep briefing at the end.
- 28:33I really like the term precepting
- 28:35in the presence of the patient.
- 28:37This was something on the bottom left.
- 28:38There was a curbsiders about
- 28:40this and I really loved it.
- 28:42It was a short little podcast
- 28:43if you have time,
- 28:44but I like that term because it's really,
- 28:46that's what you're doing.
- 28:47You're precepting with the patient there.
- 28:49So instead of precepting in a
- 28:50separate room off to the side,
- 28:52you're bringing the resident back in the
- 28:53room with the patient or the student,
- 28:55and you're doing the precepting
- 28:56in front of the patient.
- 28:57And they've studied this.
- 28:59They found that it's efficient, right?
- 29:01So they found that it's patient centered.
- 29:04The patient feels like they're engaged.
- 29:06You're actually spending more time in
- 29:07the presence of the patient because
- 29:09you're precepting with the patient there.
- 29:11This could work for all levels of learners.
- 29:13So it doesn't have to be for
- 29:15a higher level learner,
- 29:15it could be for a lower level learner.
- 29:18And you get to see those subtle
- 29:19things you wouldn't see otherwise.
- 29:20So how are they communicating?
- 29:22How are they altering their language?
- 29:24How what's their,
- 29:25what's their body language like?
- 29:27The disadvantages is basically
- 29:29that the learner doesn't always
- 29:31feel comfortable with that,
- 29:32because the learner feels like they
- 29:34have to change things when they precept
- 29:36in the presence of the patient.
- 29:37It's not the worst thing in the world, right?
- 29:38It's good for them to be able to
- 29:40learn how to present a case with the
- 29:43patient present and then you know
- 29:44ensuring patients allow the learner to lead.
- 29:47So you really do have to set some
- 29:48ground rules with the patients
- 29:49and pick the right patient.
- 29:50So they're not going to jump in
- 29:52and say that's not what I said,
- 29:53I said something totally different,
- 29:54right like let,
- 29:55let me hear and then we welcome you
- 29:57to clarify any things that went wrong
- 29:59or ask any questions afterwards,
- 30:01but let let the learner present
- 30:02the case and then
- 30:03we'll talk to you about it afterwards.
- 30:04So so making sure that they they allow
- 30:06room for the learner to present.
- 30:10So the one minute preceptor or micro skills.
- 30:13I feel like this is pretty old and
- 30:15a lot of you've heard this before.
- 30:17It's from 1992 which seems like ages ago,
- 30:19but I do think it's still works and serves
- 30:21A vital role, especially if you just
- 30:24need a structure to precept a learner.
- 30:26The nice thing about micro skills is the
- 30:28learner doesn't have to know you're doing it.
- 30:30They do not play an active role in this.
- 30:31So you could follow this model.
- 30:33They could have no idea, and that's fine.
- 30:36And when we talk next about Snaps,
- 30:38they have an active role.
- 30:40So they really do need to
- 30:41understand the model and follow it.
- 30:43For the woman, a preceptor,
- 30:45the first step is that you get
- 30:47a commitment from the learner.
- 30:48What do you think's going on?
- 30:50Right.
- 30:50So this is hugely important and
- 30:52a step that many of us skip when
- 30:54we don't have enough time.
- 30:55They present a case to you and
- 30:58they you sort of just say, oh,
- 31:00yeah, that sounds, that's easy.
- 31:01That's gastroenteritis, right?
- 31:02Because it's like you want
- 31:04the learner to commit.
- 31:05What do you think is going on?
- 31:07And usually I tell the learner,
- 31:09I just know that it's one thing.
- 31:11I want you to give me a couple of
- 31:12things you think might be going on.
- 31:14I really want a differential diagnosis,
- 31:15because if that's if you're
- 31:16wrong with that one thing,
- 31:17we've got nothing to fall back on.
- 31:19So give me a differential diagnosis.
- 31:22Probe for supporting evidence.
- 31:26Dana, Sorry, I'm just seeing
- 31:27what you popped in. Yes.
- 31:29So if you're going to precept
- 31:30in the presence of the patient,
- 31:32talk to them before about if
- 31:33there's something they want to ask
- 31:35ahead of time they're unsure of
- 31:36addressing in front of the learner.
- 31:38I think that's wonderful.
- 31:40Thank you. And no offence to
- 31:42interventional radiologists.
- 31:43I just want everyone to go into primary care.
- 31:45So after you get the commitment,
- 31:48you probe for supporting evidence.
- 31:49So why? What made you think that?
- 31:53What led you to that conclusion?
- 31:57And you're going to teach
- 31:58a general principle,
- 31:59so you you know that's your Pearl.
- 32:01So when you see this, you can remember this.
- 32:03Or when you, you know, I saw you,
- 32:05you listed these two things on
- 32:07your differential diagnosis.
- 32:08This third thing should always be included
- 32:10because that's a do not misdiagnosis, right?
- 32:12So. So teach a general principle.
- 32:15Tell them what went well.
- 32:17You did a great job about
- 32:18picking up that murmur.
- 32:19That's wonderful.
- 32:20Next time you know it would be
- 32:22really good to check for pitting
- 32:23edema because that would be helpful
- 32:25for me to know when you precept,
- 32:27when I precept you.
- 32:29So it's quick and probably isn't one minute,
- 32:32but it's not that much more.
- 32:34I've seen other models,
- 32:35I've seen an 8 minute precept,
- 32:37an 8 step preceptor model where they
- 32:40added in listening without interruption,
- 32:43making connections to past patients and then
- 32:45giving learning objectives for the future.
- 32:48I think that's those are
- 32:49all nice things to add in,
- 32:51but this is sort of a very basic model
- 32:53and I want to show you an example of this.
- 32:55I'm going to show you a video and I do
- 32:57want to say I'm going to show 2 videos.
- 32:59One is for this model and one
- 33:01is the same teacher,
- 33:03faculty member and learner with
- 33:04the snaps model because we're
- 33:06going to compare them afterwards.
- 33:08And the videos are also a bit old,
- 33:10so the medical knowledge is a bit outdated,
- 33:12but really look for what they
- 33:14do with the teaching.
- 33:15So I'm just going to end this for one
- 33:18minute and I'm going to pull up a video.
- 33:39OK.
- 33:44Please let me know if you
- 33:45have any trouble hearing it.
- 33:47So this is the the one minute
- 33:50preceptor encounter. Julie, did you
- 33:51get a chance to see our first
- 33:52patient in clinic this morning?
- 33:56The Dewey skin cream from Tatcha
- 33:58with a rich creamy feel? Sorry
- 34:00about that for
- 34:02Julie. Did you get a chance to see
- 34:03our first patient in clinic this morning?
- 34:05I did. This is Miss Linda Baum.
- 34:06So she is a 70 year old female,
- 34:08has a history of diabetes,
- 34:10hypertension and paroxysmal atrial
- 34:12fibrillation and she's currently
- 34:13in normal sinus rhythm and really
- 34:15would like to stop taking warfarin
- 34:16because she's just tired of getting
- 34:18her INRS checked so frequently.
- 34:20OK, so I think she needs to stay
- 34:22on the warfarin though because her
- 34:24Chad's vascular is actually 4,
- 34:26which puts her at a high risk of stroke.
- 34:28OK. Do you know about anything other
- 34:32other than Coumadin that she could use to
- 34:34decrease her risk of stroke in the future?
- 34:37Well, I had heard that there were
- 34:38some newer agents for atrial fibrillation
- 34:41for stroke prevention, but honestly,
- 34:43I really don't know that much about them.
- 34:44OK, All right. That's OK.
- 34:45There's a lot of new ones,
- 34:46and I think it's hard to
- 34:48keep track of all of them.
- 34:49So let me show you this website
- 34:51here since we have a couple minutes.
- 34:53This is the teamanticoag.com website,
- 34:56and you can pull it up.
- 34:57I'll let you look over this
- 34:59tonight if you want. OK?
- 35:00But this, we'll go over a lot of
- 35:02the newer oral anticoagulants other
- 35:05than warfarin and talk about the
- 35:08risks and benefits of each of them.
- 35:10I agree her Chad's vast score is high and
- 35:12I you're correct in saying that it's 4.
- 35:15So she probably should stay on
- 35:17some sort of anticoagulation.
- 35:18But we can probably give her another
- 35:19option other than Coumadin if she
- 35:21really doesn't want to stay on that.
- 35:22OK.
- 35:22So tonight when you go home,
- 35:25why don't you look at a couple
- 35:26of the medications that she could
- 35:28potentially use and tomorrow when you
- 35:29come back and you can tell me which
- 35:31one you would choose for her if we
- 35:33decide to not use Coumadin on her.
- 35:35OK, OK,
- 35:39great. I'm just going to
- 35:41share my other screen.
- 35:42And John, I love that language you
- 35:45put in the chat about and I I like
- 35:47that language when actually asking
- 35:49if the student can see the patient
- 35:50in the 1st place about that This
- 35:52is an opportunity and a privilege,
- 35:53not just can they.
- 35:56So I'm going to keep that video
- 35:58on the back of your head.
- 35:59Let's talk a little bit more.
- 36:01So the the supporting evidence
- 36:02for the one minute preceptor.
- 36:04It improves teaching effectiveness,
- 36:06it improves in efficiency,
- 36:08it can be pretty quick,
- 36:10You are giving more feedback to
- 36:12the student with specific teaching
- 36:13points and then it increased learner
- 36:16motivation for outside learning.
- 36:17So so it has shown to be beneficial.
- 36:20Now let's talk about snaps
- 36:22which is slightly different.
- 36:24So snaps,
- 36:25as I mentioned before the learner has to
- 36:27know because they are driving this encounter.
- 36:30So this is a learner driven
- 36:33precepting encounter.
- 36:34So the learner comes in,
- 36:35they're going to summarize
- 36:36the patient case for you.
- 36:37This should just take no more than 3 minutes.
- 36:40It should be a quick summary of the case.
- 36:42They're going to narrow the differential.
- 36:44They're going to tell you there are
- 36:46a couple of options and then they're
- 36:47going to analyse the differential.
- 36:49So this really gets at
- 36:50their clinical reasoning.
- 36:51So what are they thinking?
- 36:53So it's less knowledge based
- 36:55and more reasoning based.
- 36:56So they narrow the narrow, the differential.
- 36:58They analyse the differential,
- 37:01then they ask you the question.
- 37:02So they don't know something,
- 37:04so they can't figure out.
- 37:05So they're asking you, well,
- 37:06I don't know what tests to order next.
- 37:08What would you order next to figure this out?
- 37:10Or like,
- 37:11what medication would you add
- 37:12to control their hypertension?
- 37:13Like, you know,
- 37:15so they're asking you the question,
- 37:17Then together you're coming up with
- 37:19a management plan and then they're
- 37:21picking an issue that they're
- 37:22going to learn about in the future.
- 37:24So they're selecting something
- 37:25that was a knowledge gap,
- 37:27and then they're going to learn about
- 37:28it and bring it back to you afterwards.
- 37:30So I'm going to show the example
- 37:33of Snaps with the same two people
- 37:37and then we'll talk about both.
- 37:58OK.
- 38:02I'm sorry, give me one minute.
- 38:03It's just taking a minute
- 38:04to pop up without the ad.
- 38:21I'll say while you're getting that on,
- 38:22it's probably self-evident that these are
- 38:24also really great strategies for teaching
- 38:26on the fly in the inpatient setting too.
- 38:29Yes, thank you Dana. And I apologize,
- 38:34I had gotten rid of the ads already,
- 38:36but I guess it took too long.
- 38:37So now they just wanted
- 38:38to re show them to me.
- 38:40OK, Can everybody see my screen?
- 38:44Yeah, I'm going to share this Mr.
- 38:45Ryan, he is a 40 year old man with
- 38:48Lightheadedness as his chief complaint
- 38:50has no past medical history and he was
- 38:52found to be an atrial fibrillation,
- 38:54which is a new diagnosis for him.
- 38:57So I think the differential for his
- 38:59Lightheadedness actually is pretty broad,
- 39:00but sort of narrowing to my top two
- 39:04diagnosis would be symptomatic atrial
- 39:07fibrillation and orthostatic hypotension.
- 39:10OK, good. Which one are you leaning
- 39:13towards more right now and why?
- 39:15Well, I think I'm leaning more towards
- 39:17the symptomatic atrial fibrillation
- 39:18because this is a new diagnosis for him.
- 39:20So certainly a new onset could be
- 39:22causing him to have a new symptom and
- 39:24he doesn't really have anything in
- 39:25his history that would suggest that
- 39:27he's at risk for volume depletion,
- 39:29hasn't had any GI symptoms,
- 39:31no decrease in his oral intake,
- 39:34and we checked orthostatic blood
- 39:35pressures on him, which were normal.
- 39:37Great. OK, perfect.
- 39:39Do you have any questions about
- 39:41his case or his presentation?
- 39:43Well,
- 39:43I was wondering what underlying
- 39:45causes of atrial fibrillation we
- 39:47need to be concerned about in him.
- 39:49Good, Good question.
- 39:50The two easiest things to get started
- 39:52with since there are a lot of things
- 39:54that we should be thinking about.
- 39:56One is to ask him a question about
- 39:58his alcohol intake because that
- 40:00can cause atrial fibrillation.
- 40:01And the second thing would be to make
- 40:04sure that his thyroid levels are normal.
- 40:06That can also cause atrial fibrillation.
- 40:08We can talk about the other things
- 40:10too that can cause or contribute
- 40:12to a fib as as we learn him and
- 40:14and talk to him a little bit more.
- 40:17So the plan for him today I think is
- 40:21rate control for his atrial fibrillation
- 40:24and to think about anticoagulation
- 40:26for stroke prevention for him.
- 40:28Perfect,
- 40:28perfect.
- 40:28So tonight when you go home,
- 40:31since he's young and maybe a little
- 40:32bit different than some of our other
- 40:34patients that have atrial fibrillation,
- 40:36why don't you read about the
- 40:37indications for a long term oral
- 40:39anticoagulation in a patient like him?
- 40:41OK,
- 40:41OK.
- 40:41All right.
- 40:45So she actually directed the learning,
- 40:47which was interesting,
- 40:48but I'm going to, I'm going to put
- 40:51the screen so we could actually,
- 40:52I'm going to stop sharing completely
- 40:54so we could just see each other.
- 40:56But I don't know if you're willing to
- 40:58to mention how you do a stealth snap.
- 40:59So I would love to to hear that.
- 41:02So because a lot of students don't know,
- 41:05right. They're willing to just
- 41:07present the patient to you,
- 41:08which is great and they're willing
- 41:10to do the assessment and plan,
- 41:11but they don't always do the differential.
- 41:13So I always have to kind of like
- 41:15ask them for the differential.
- 41:17But I I tell them at the beginning
- 41:19of the of the session,
- 41:21we all set goals and I say what,
- 41:22what do you want to work on?
- 41:23What do you want to work? And I say
- 41:24I want to work on making sure
- 41:26that everybody asks me at least
- 41:27one question with every patient.
- 41:28So that's kind of the prelude
- 41:30to the asking the preceptor,
- 41:31probing the preceptor.
- 41:32And then during the patient,
- 41:34I say, so what's your,
- 41:36what are your questions about this patient,
- 41:38right, Because you have to have them.
- 41:40That's my goal for me, that I have to
- 41:42make sure that you ask me questions.
- 41:44And so they all ask me questions and then
- 41:47at the end we we plan and then I say,
- 41:49So what are you going to read
- 41:51about about this patient?
- 41:52And so they don't have to know that
- 41:54snaps is occurring, but it's occurring.
- 41:57I love that.
- 41:59Thank you for sharing.
- 42:01I want to hear how other people have used it,
- 42:03or in watching the videos,
- 42:05how you if you think you could use it,
- 42:13can I just
- 42:14put one plug in for considering
- 42:16using it explicitly?
- 42:17And I love that Atta can use
- 42:18it in a as a stealth way.
- 42:20But it's also probably not cheating
- 42:23to let them know explicitly like
- 42:26the rationale for why you might be
- 42:30having them do the work because they
- 42:32have to come up with the differential
- 42:35and identify why it is that they're
- 42:37not sure the TB is not more likely
- 42:39than you know Mycoplasma for it
- 42:41because they don't know something.
- 42:43Is there a lot of TB in Costa Rica?
- 42:45That's the thing I don't know otherwise.
- 42:48So it's really great for this Master
- 42:50Adaptive Learner model that we're
- 42:52having for the coaches that would
- 42:53be would be like all educators to
- 42:55really embrace for the learners
- 42:56that they the process of using
- 42:58snaps is that we're trying to get
- 42:59them to identify the gap and to get
- 43:02them to identify how to pursue it.
- 43:04And you can facilitate that process.
- 43:06But it's it could there could be
- 43:08some advantage in calling out
- 43:10what the model is useful for.
- 43:13I just have a thought.
- 43:14I'm thinking that the snaps model
- 43:16probably be more easily applied
- 43:18and more appropriate for more
- 43:20advanced students or residents.
- 43:21I'm thinking maybe
- 43:22stealing my next slide. Yeah.
- 43:24OK, OK That that's just a no,
- 43:25no go on. No, please. Yeah, I know.
- 43:27I think the one minute precept
- 43:29that would work great for an early
- 43:30student was just just getting used
- 43:32to meeting patients and and assessing
- 43:34them and presenting them to us.
- 43:36Just just thoughts that Ioffer
- 43:38that's completely true. I agree.
- 43:41And I think what Dana had mentioned
- 43:44about expressing uncertainty or
- 43:45or acknowledging knowledge gaps,
- 43:47that's a skill to learn in of itself
- 43:49that the SNAPS model teaches.
- 43:50And I think an early learner might not
- 43:52even know where their knowledge gaps are,
- 43:53where as a more advanced learner,
- 43:55you're teaching them to acknowledge it,
- 43:57you're helping them fill it,
- 43:58and then if you can't fill it,
- 44:00you're teaching them how to find the answer.
- 44:01Which is also showing humility
- 44:03and saying I don't know either,
- 44:05but this is how it would go about
- 44:06looking it up to teach them that process.
- 44:08So it works in a lot of ways.
- 44:13Other people's input. If you've
- 44:14used the models or if you let if
- 44:16you like anything about them, yes.
- 44:28But somebody speaking,
- 44:29Yeah, I was what I found.
- 44:31One of the modules is like we work together,
- 44:34so the student and I will look
- 44:40at something together later on,
- 44:42rather than giving that information
- 44:46for the student to look at afterwards.
- 44:50And that seems to work very well, I feel.
- 44:55I think that's great,
- 44:56'cause it's efficient,
- 44:57'cause you might not have
- 44:58time right then to look it up,
- 45:00but then you're partnering with them
- 45:02later to to look it up together and
- 45:04see what the latest information is.
- 45:06And I think they don't feel
- 45:09as intimidated by anything.
- 45:10They feel like we are actually
- 45:12working together.
- 45:15I think that's great. Thank you.
- 45:19OK, so I'll put up the screen
- 45:21for the last few slides.
- 45:24So the evidence behind snaps.
- 45:32So they found that learners provide
- 45:34more items in their differential
- 45:35and more justification with them.
- 45:37Learners are more likely to seek
- 45:39information so they're more likely to
- 45:41ask questions or acknowledge uncertainty.
- 45:43When you use Snaps,
- 45:44the focus does shift to management
- 45:46so that's more of a a more advanced
- 45:48learner because you're really
- 45:50focusing on that management part.
- 45:52And then the learners are initiating
- 45:54their self study selections.
- 45:55And when you compare the two models
- 45:59the the woman in preceptors more
- 46:01teacher LED but as I just showed you
- 46:03can sort of lead snaps that way too and
- 46:05the snaps model is more learner LED.
- 46:07Both of them are a collaborative
- 46:09dialogue and feedback right? That's huge.
- 46:11They're both a back and forth.
- 46:13The woman in preceptor could be
- 46:15used at all levels and then the
- 46:17snaps for for advanced learners,
- 46:19the woman in preceptor is
- 46:20more focused on knowledge,
- 46:21whereas the snaps is more focused
- 46:23on their reasoning skills.
- 46:25And then the woman in preceptor you're
- 46:26sort of directing their learning,
- 46:28whereas the snaps they're
- 46:29directing their own learning,
- 46:30but both really helpful and useful and
- 46:34very time efficient in my experience.
- 46:37So I just wanted to spend the last few
- 46:40minutes talking about role modelling.
- 46:42And I think role modelling in
- 46:44the ambulatory setting is,
- 46:45is really unique because we do have
- 46:47these relationships with our patients,
- 46:49some of us for for many,
- 46:51many years and the students seeing
- 46:53that and learning from that.
- 46:55And I just wanted to talk about
- 46:57all the issues that come up in
- 46:59the outpatient setting.
- 47:00And I'm just pulling them up.
- 47:02There could be,
- 47:02I could fill this screen
- 47:04with hundreds of them.
- 47:05But there's so many issues that
- 47:07come up that aren't sort of the,
- 47:09the medicine they learn necessarily in in
- 47:11the first couple of years in medical school,
- 47:13there are things that come up that
- 47:15they they see for the first time
- 47:16in this setting and they never
- 47:18really learned how to deal with it.
- 47:19And they're, they're tough situations.
- 47:22And I find especially for residents,
- 47:25you know,
- 47:25this is hard when you're seeing a
- 47:27patient for the first time by yourself
- 47:29and you're dealing with intimate
- 47:31partner violence or you're dealing with,
- 47:33you know,
- 47:33post traumatic stress disorder
- 47:35or they're experiencing bias.
- 47:36And even though you might have had
- 47:38a lecture about that at some point,
- 47:39but when you're the the provider
- 47:41yourself and you're you're by yourself
- 47:42with this patient and this is your
- 47:44patient and you're dealing with these things,
- 47:46these are,
- 47:47these are hard things to deal with.
- 47:49So I really want to talk about
- 47:51how we could shift,
- 47:52you know,
- 47:52in the outpatient setting from the science
- 47:54of medicine to what I would consider
- 47:56the art of medicine and the art of practice.
- 47:58And I came across this paper from
- 48:00academic medicine several years ago,
- 48:01and I really loved it,
- 48:02and I wanted to share with everyone.
- 48:04So this paper talked about
- 48:07precepting humanism,
- 48:08and they characterized humanism as a
- 48:11culture that demonstrates integrity,
- 48:14excellence, compassion, altruism,
- 48:17respect, empathy and service.
- 48:21It's a lot, but we do it.
- 48:22We do it every day.
- 48:24So.
- 48:24So how do you precept?
- 48:26And you you bring these issues
- 48:28to the forefront.
- 48:29You make your learners aware of them.
- 48:30You make them know that this is important.
- 48:33So the first step that they describe
- 48:36is to just establish A humanistic
- 48:38practice and learning climate.
- 48:39And I think that, you know,
- 48:41we all do this already,
- 48:43but you want the learner to know
- 48:44that this is important to you.
- 48:46You want the learner to know that that
- 48:49practicing humanism is important to you.
- 48:50And you want to say that I want some
- 48:53of our goals over our time together
- 48:55to talk about humanistic care.
- 48:56I want you to be able to tell
- 48:58me about situations that you
- 49:00feel really uncomfortable in.
- 49:01And and because I have those situations too.
- 49:04And I want us to talk about them
- 49:06together and think about them
- 49:07together and come up with strategies
- 49:09and reflect on how things went.
- 49:11Because this is these,
- 49:12these are the places we learn.
- 49:13So you want to really set a safe learning
- 49:16environment to talk about these issues
- 49:19and then developing an educational diagnosis.
- 49:21They talk about this like the
- 49:23stages of change model.
- 49:24So you're basically diagnosing is
- 49:26your learner pre contemplative?
- 49:27Like they don't at all think
- 49:29about these issues,
- 49:30Are they contemplative and they're
- 49:31starting to think about them but like
- 49:33they're not really really there yet.
- 49:34Are they actively thinking about them?
- 49:36You know,
- 49:37are they or or,
- 49:38you know,
- 49:39so you're sort of just diagnosing
- 49:40like have you ever thought about,
- 49:42you know that those patients says
- 49:44that they can't eat well because they
- 49:46can't afford to buy healthy food?
- 49:48Like you know what,
- 49:50what can we do?
- 49:51You know, I've had learners that just
- 49:53give the same plan to every patient,
- 49:55you know, eat organic produce and do
- 49:57100 push ups a day and go for a walk.
- 49:59And I'm like it's not
- 50:01one-size-fits-all right,
- 50:02Like not everybody could do this.
- 50:03So.
- 50:03So really,
- 50:04getting them to understand that
- 50:06how do we deal with these issues?
- 50:09How do we integrate psychosocial
- 50:10issues into precepting?
- 50:11I always try during the course of a
- 50:14day to have one psychosocial issue
- 50:17we touch upon in my precepting.
- 50:19Reflection is huge. It takes time.
- 50:22It's hard to do.
- 50:23But I think just taking a moment
- 50:26and just reflecting like, oh,
- 50:28that was a hard encounter.
- 50:29How'd that go?
- 50:30Or like, you know,
- 50:31how do you feel after that encounter?
- 50:33Like people have emotional responses
- 50:34and we tend to just push them aside so
- 50:37we can move on in the sake of time.
- 50:39But if you could take two minutes
- 50:41to just reflect on it and think
- 50:43about it and talk about it,
- 50:44I think it makes a tremendous difference
- 50:47for the learner providing them feedback.
- 50:49And I'm planning follow up.
- 50:51You know that was really hard for you.
- 50:53I I could see that it was hard for
- 50:54me to let's try it again with the
- 50:56next learner and let's you know,
- 50:57see how it goes.
- 51:00And I always sort of share whoops,
- 51:04excuse me,
- 51:05a case at this point that that I
- 51:07had that I do share with students
- 51:09sometimes because it was a moment
- 51:11where I didn't practice humanistic
- 51:12medicine and it was
- 51:14my new practice that currently
- 51:15I've been out about six years.
- 51:17So I know my patients well.
- 51:18But it was my first day I had a new patient.
- 51:22He had terribly controlled diabetes and we
- 51:25talked about it and we sort of made a plan.
- 51:28And then he started no showing.
- 51:30He he would no show to the appointments
- 51:33or he would come to the appointment,
- 51:34he would check in and then he would leave.
- 51:37And I was only, you know,
- 51:38I was really trying hard not to run late.
- 51:40You know, I was trying to be on time,
- 51:41but I'd be like 5 minutes late,
- 51:4310 minutes late.
- 51:44And he he was gone.
- 51:46And I got to the point that it
- 51:47happened over the course of multiple,
- 51:49multiple visits that I, you know,
- 51:50said I'm going to have to discharge
- 51:52this patient.
- 51:52You know, because they're not,
- 51:53they're not coming to visits.
- 51:55I can't control their diabetes.
- 51:56I can't provide medical care and
- 51:59I believe we sent a letter to
- 52:00his his home saying you know,
- 52:02you need to really come to your
- 52:04visits and his wife called me and
- 52:05and she said can I talk to you.
- 52:07You don't have to tell me
- 52:08about any information,
- 52:09but I want to share with you that my husband
- 52:13was abused by his by his pediatrician.
- 52:18And when you say the words physical exam
- 52:20or you're here for your annual exam,
- 52:23when he hears exam from the front desk staff,
- 52:27he he freaks out and he has anxiety and he
- 52:29leaves because he's afraid of being examined.
- 52:32And there was another time that
- 52:34he was admitted for DKA and
- 52:35when he went back to work,
- 52:36they the rumour was that he had HIV and
- 52:40that sort of these are his experiences
- 52:42with the healthcare system and this
- 52:45is what causes him so much fear.
- 52:47So I did, you know,
- 52:49I said thank you for telling me is it
- 52:50OK if I talk to my team about this?
- 52:52Because I won't give specifics,
- 52:54but I need to.
- 52:55We need to change the language and we
- 52:57need to change how we how we treat him.
- 52:59So my team was instructed never to say this.
- 53:01You know, you're coming for a follow up.
- 53:03We never said exam.
- 53:04You never said annual exam,
- 53:05you know, physical exam.
- 53:06We didn't use those words.
- 53:08As soon as he came,
- 53:09they put him in a room.
- 53:09He didn't have to wait in a waiting room
- 53:11anymore around other people because they
- 53:13made him anxious and I didn't examine him.
- 53:15I don't know how many visits,
- 53:16but it was many, many visits.
- 53:18And until I finally asked him,
- 53:19are you comfortable with me examining you?
- 53:21And it was funny because he was like,
- 53:22of course, why not at that point.
- 53:24But I waited a while till I felt
- 53:26like we had developed a relationship.
- 53:28And I shared this with learners because,
- 53:30you know,
- 53:30I had made these assumptions.
- 53:32I was frustrated.
- 53:33I was really angry.
- 53:34I was being judged on my A1C control
- 53:36in terms of my new practice, right.
- 53:39So you got these progress reports every
- 53:41month about how I was doing and he was
- 53:44skewing that and I didn't know his story.
- 53:45So you know it's just something to
- 53:47share that we all make mistakes and
- 53:49sometimes we can fix them and if we
- 53:51can you know make the efforts to do so.
- 53:53But it's it's reflecting on the patient's
- 53:56experience is hugely important.
- 53:58So I know we're out of time.
- 53:59I just have two quick wrap up slides.
- 54:02So
- 54:06just in summary, benefits and
- 54:08barriers to teaching in the setting.
- 54:11You can make changes in your
- 54:13environment to optimize learning.
- 54:15Diagnosing the learner allows you
- 54:17to vary your precepting techniques
- 54:19in order to meet their needs,
- 54:21the act of observation, the precepting,
- 54:23and the presence of the patient.
- 54:25I like all these acronyms.
- 54:26The one minute precept or the
- 54:28snaps are just helpful models.
- 54:30If you want to try them,
- 54:32I'm going to drop a handout into
- 54:34the chat with just describing them,
- 54:37and then opportunities to precept
- 54:39humanism exist in every encounter.
- 54:41And if you have the extra
- 54:42few minutes to do so,
- 54:43I think it goes a long way.
- 54:46So I hope by the end of my talk I've
- 54:48given you some kind of lifeboat so you
- 54:50don't feel like you're drowning when
- 54:52you're precepting in this setting.
- 54:54And I really appreciate all of your time.
- 54:57I welcome any questions and this is
- 54:59the evaluation form for the talk.
- 55:02Should I leave this up, Dana?
- 55:04Yes, please. If you could leave it out
- 55:06so you can scan it and then there's a
- 55:10slide after this that will remind people,
- 55:12which we can go to in after the
- 55:16countdown that reminds people of the
- 55:19next sessions that are coming up.
- 55:21But do you do you want to feel some? Oh,
- 55:23there was one question in the chat.
- 55:24I see, Frederick said.
- 55:25Was the wife allowed to share
- 55:27information on behalf of the husband?
- 55:29That's an interesting question.
- 55:30I do allow patients family members to
- 55:32share information with me without me
- 55:34disclosing any information to them.
- 55:36I'm wondering if if you do otherwise,
- 55:38I'm not sure if you're still here. Well,
- 55:42I, you know, in in my practice at least
- 55:45what I'm aware of in terms of ethical care,
- 55:49the patient is the first and only
- 55:52source for information unless
- 55:54that patient gives permission.
- 55:56And that's a consistent, you know,
- 55:58intake question that's asked.
- 56:00You know, can I call the home?
- 56:02If your wife answers may I
- 56:04share information with her.
- 56:06So you know, I I don't know what
- 56:09everybody else thinks but I, I,
- 56:12I just raised that as a question.
- 56:14You know, something to think about,
- 56:17maybe read about myself rather
- 56:21than sending a letter.
- 56:22I would, you know, just as a thought,
- 56:25I would have asked the front desk to
- 56:26say let me know the minute he comes in.
- 56:28I would have left my patient,
- 56:30come and taken him aside and say,
- 56:32hey, you know, I'm, I'm seeing this,
- 56:34but I don't understand it.
- 56:35Maybe you can help me,
- 56:37you know, understand what's
- 56:39going on and encourage him to disclose.
- 56:42So those are my only two thoughts.
- 56:43Otherwise I thought you did a
- 56:45fantastic job. No, thank you.
- 56:47I do appreciate that.
- 56:48So I will say that I did try
- 56:50so many times to catch him or
- 56:52to call him or to reach him.
- 56:54So I did before we sort of got to
- 56:55that letter point. But I agree.
- 56:57So and I don't share any
- 56:59information with the we do have.
- 57:01They have to sign a form for us
- 57:03to share information.
- 57:04But I do.
- 57:06I do have family members want to
- 57:08share information with me a lot and
- 57:10I allow them to do so without any
- 57:12feedback on how I'm going to incorporate it.
- 57:14Sometimes they just I have people
- 57:16you know kids write letters to me
- 57:17like I want to let you know what
- 57:19I'm seeing with my dad but I don't
- 57:21ever you know I don't ever respond
- 57:23with anything about the patient.
- 57:25I just take that in so it is
- 57:28interesting I I it's but but thank
- 57:32you I appreciate your your feedback.
- 57:34Can
- 57:35you go to the next slide just while
- 57:37you're fielding some questions.
- 57:39Sure yes. Just as people go
- 57:43away if anybody wants to see the
- 57:46upcoming but keep asking questions.
- 57:48Sorry to interrupt.
- 57:59Any other questions?
- 58:00Oh, just a comment.
- 58:02Thank you so much, Jen.
- 58:03It's so clear and I appreciate
- 58:06this forum. We don't
- 58:07have enough for to talk
- 58:08about it precepting and
- 58:09you're reinvigorating me. How much
- 58:11we do we take read including the
- 58:15I guess the encouragement to
- 58:17model humanistic practice.
- 58:20That's yeah. Thank you Peter.
- 58:22I I agree. I'm putting the message
- 58:25in the chat with everybody.
- 58:26Whoops. I agree.
- 58:27I think that I when I come back to
- 58:31that is is invigorating for me too, right.
- 58:34It makes me remember why I do it
- 58:36which is why I do come back to it.
- 58:37So there's a selfish
- 58:38motivation in it as well.
- 58:46Thanks everybody for attending
- 58:48and for your your great feedback.
- 58:50We will take every little bit into
- 58:53account to keep tweaking the series.
- 58:55And thanks Jen, for a great session.
- 58:58Yeah, thank you for having me.
- 59:00Thank you. Bye everybody.