3/1 YES!: Teaching in the Ambulatory Setting

March 01, 2024

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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.