03-07-25 YES!: Teaching in the Ambulatory Setting with Jennifer Rockfeld, MD

Transcript

• 00:00Hello, everyone,
• 00:02and welcome to,
• 00:04this afternoon session of,
• 00:06Yes.
• 00:08And, Jen, one more thing.
• 00:10If you could swap your
• 00:11displays.
• 00:16Perfect. Thank you.
• 00:19So thank you for joining
• 00:19us this afternoon. This is,
• 00:21part of the Yale medical
• 00:23education
• 00:24educator series.
• 00:26And today,
• 00:27I'm very happy that we're
• 00:29gonna be learning about very
• 00:30practical, very clinical content
• 00:33and tips from,
• 00:35Jen Rockfeld.
• 00:37Jen
• 00:40has
• 00:42has been with us here
• 00:43at Yale for some years.
• 00:45But in reading her CV,
• 00:47I learned that she had
• 00:47been in Connecticut for,
• 00:50more years. And I was
• 00:52semi kidding with her, telling
• 00:53her that she should have
• 00:54been she was en route
• 00:55to become the dean of
• 00:58Clinipiac,
• 00:58medical school because she was
• 01:00there from its inception and
• 01:02had so much to do
• 01:03in developing some of its,
• 01:05clinical skills programs and,
• 01:08really rose to this position
• 01:10of, assistant dean of clinical
• 01:11curriculum,
• 01:13which was
• 01:14a skip a quick skip
• 01:16to where she,
• 01:18came to Yale as, medical
• 01:20director
• 01:20of educator development through the
• 01:22Northeast Medical Group, where she
• 01:24still holds that position.
• 01:27And,
• 01:28she also is part of
• 01:29the Center for Medical Education
• 01:31faculty where we get to
• 01:32hang out from time to
• 01:33time.
• 01:35Jen is a consummate
• 01:37educator. Her whole career has
• 01:38been about improving
• 01:40ways of, clinical education.
• 01:43So I am very,
• 01:44happy to be co learning
• 01:46with you. And, Jen, take
• 01:47it away.
• 01:53Thank you, Andreas. I appreciate
• 01:55it.
• 01:56Hi, everyone, and welcome.
• 01:58I will just put up
• 01:59the first slide so you
• 02:00could text your attendants to
• 02:01get the the CME credit.
• 02:04Four five nine five two
• 02:06is the number at the
• 02:06bottom,
• 02:08and I do not have
• 02:09any disclosures.
• 02:11And,
• 02:14the next slide is the,
• 02:16clinician educator milestones that all
• 02:18the yes talks are mapped
• 02:19to. This one is mapped
• 02:21to teaching and facilitating learning
• 02:22and learner assessment.
• 02:25And to introduce myself, Jen
• 02:27Rockfeld.
• 02:29I
• 02:30love doing faculty development for
• 02:32the reason that we are
• 02:33all teaching all the time.
• 02:35And despite the amount of
• 02:36education we get how to
• 02:37be physicians and clinicians,
• 02:39we get very little education
• 02:41during our training on how
• 02:42to be teachers.
• 02:44So I love talking about
• 02:45teaching. I love learning about
• 02:46teaching, and I hope that
• 02:47you leave this talk with
• 02:48some practical advice you can
• 02:50implement
• 02:51and maybe some food for
• 02:52thought for the future.
• 02:54So my objectives today
• 02:56are for us to recognize
• 02:58both the benefits and barriers
• 02:59to teaching in the ambulatory
• 03:01setting,
• 03:02to identify what the key
• 03:04roles of an outpatient preceptor
• 03:06are. This is the realm
• 03:07that I primarily work and
• 03:08teach in.
• 03:09Discuss four strategies
• 03:11for teaching in the ambulatory
• 03:13setting, and then to spend
• 03:14some time at the end
• 03:15just reflecting on the unique
• 03:17attributes of the longitudinal relationship
• 03:19between the preceptor and student.
• 03:21And when I say I
• 03:22will fluctuate between saying student
• 03:24and learner,
• 03:25I think this pertains to
• 03:26all levels of education. But
• 03:28if there are specific times
• 03:29that pertains to one or
• 03:30the other, I will point
• 03:31that out.
• 03:32I'd like to get a
• 03:33sense of who
• 03:35you are teaching.
• 03:37So if you're able to,
• 03:38if you can join,
• 03:40my poll everywhere,
• 03:42and you can enter more
• 03:43than one response, but it
• 03:44would be helpful for me
• 03:45to focus my talk based
• 03:46on who people are teaching
• 03:47out there. So if you
• 03:48could just scan it on
• 03:49top, and hopefully this works.
• 03:52And I can't see your
• 03:54your QR code we should
• 03:55be seeing.
• 03:56You cannot. Oh, okay.
• 03:58That's interesting. I could see
• 03:59it. Let me see if
• 04:00I do the swap screens
• 04:02again if it's only on
• 04:05can you see it now?
• 04:09No.
• 04:10No. Okay.
• 04:13Okay. So,
• 04:17you don't see it at
• 04:18the top of the window.
• 04:19Not there for you?
• 04:20No. Okay.
• 04:22So let me
• 04:28get out. Let me share
• 04:29this. Give me one quick
• 04:31minute,
• 04:32and I will just share
• 04:34directly from the Poll Everywhere
• 04:35so everyone can get in.
• 04:36And then, hopefully,
• 04:37we won't have to just
• 04:39copy it into chat. Somebody
• 04:40suggested.
• 04:42The QR code?
• 04:43Right? Yeah. Okay.
• 04:45Let's see if that works.
• 04:50Okay.
• 04:55Sorry about that. The technical
• 04:56difficulties
• 04:57always
• 04:59stop us. So
• 05:02do you see my PowerPoint
• 05:03now?
• 05:06We do.
• 05:08Okay. So let me drop
• 05:09the QR code in for
• 05:10you.
• 05:27Doesn't seem to
• 05:28be going.
• 05:32Here. I'm gonna send you
• 05:33the other one.
• 05:36This
• 05:38hopefully will be
• 05:39able to join by text.
• 05:42Let's see if that works.
• 05:42Does everyone see that?
• 05:47Yeah.
• 05:48Yes.
• 05:49And please let me know.
• 05:50If anyone's letting me know
• 05:51if they're able to get
• 05:52in.
• 06:04No. Still not working?
• 06:07Okay. No. So,
• 06:11okay.
• 06:12We will move on. I
• 06:13apologize. It looks like it's
• 06:14running from my screen, and
• 06:15I had done it before.
• 06:16But let's just you can
• 06:17drop into the chat. I
• 06:19opened it up on my
• 06:19screen.
• 06:20I see
• 06:21preschoolers, which I love,
• 06:24and high school students,
• 06:26all different levels.
• 06:27Fellows, grad students, undergrads, residents.
• 06:30Wonderful.
• 06:32High school.
• 06:35I don't know if this
• 06:36is gonna pertain to high
• 06:37schoolers, but I'd be happy
• 06:38to hear feedback on that.
• 06:40Residents, fellows, and med students.
• 06:42Wonderful. So the whole range.
• 06:47That students.
• 06:49MPA students. Yeah. And I
• 06:51think for med students and
• 06:52other health profession students, we're
• 06:54using the same concepts to
• 06:55teach.
• 06:57Undergrad, grad, and postgrad. Great.
• 06:59Okay.
• 07:02So I'll move on.
• 07:04So teaching in the ambulatory
• 07:06setting has been traditionally neglected
• 07:09even though most of us
• 07:10spend most of our time
• 07:11there. And there were two
• 07:12main shifts,
• 07:14that led to more teaching
• 07:15in the ambulatory setting. So
• 07:16So in the nineteen eighties,
• 07:18it was found that many
• 07:19common conditions were now being
• 07:21seen in the ambulatory setting
• 07:23instead of the hospital. So
• 07:24experts recommended to bring learners
• 07:27more into the ambulatory setting
• 07:28so they could see the
• 07:29common conditions that are, occurring.
• 07:32And then in the nineteen
• 07:32nineties, there was a different
• 07:34push to build up the
• 07:35primary care workforce,
• 07:37which I will say that,
• 07:38you know, it's been thirty
• 07:39plus years, and I don't
• 07:40know if we're anywhere near
• 07:41where we need to be.
• 07:42But they also encourage,
• 07:44students to be going into
• 07:45primary care settings to expose
• 07:47them to primary care and
• 07:48hopefully get more people going
• 07:49into that field.
• 07:51So if you look at
• 07:52the difference in nineteen eighty
• 07:53four,
• 07:54seven percent of internal
• 07:56medicine residents rotated in an
• 07:58outpatient experience. And in two
• 08:00thousand and one, it was
• 08:01ninety four percent.
• 08:03So all medical schools require
• 08:05an outpatient experience as well
• 08:06as a primary care experience.
• 08:09And academic,
• 08:10ambulatory clinics just don't have
• 08:12the capacity
• 08:13to accommodate these growing number
• 08:14of students. Now And when
• 08:15you think about it, it's
• 08:16not just the growing number
• 08:17of med schools and med
• 08:19students. It's all of the
• 08:20health professional schools that are
• 08:22competing for the same ambulatory
• 08:23sites.
• 08:24And, ideally, you'd want ambulatory
• 08:26sites that provide a high
• 08:28quality preceptorship for your students.
• 08:30So while this area is
• 08:32becoming increasingly needed,
• 08:34the research on how to
• 08:35incentivize and and grow this
• 08:37area is is not as
• 08:39as robust as it should
• 08:40be. And it and it's
• 08:42harder to do so because
• 08:43if you think about how
• 08:44to teach in the ambulatory
• 08:45setting, it's going to be
• 08:46very different depending on what
• 08:47setting they practice in. And
• 08:49you want it to be
• 08:50different and diverse, and you
• 08:52want it to be authentic.
• 08:53So you're not gonna standardize
• 08:54that experience.
• 08:56But,
• 08:57there is it is helpful
• 08:58to have a little bit
• 08:59of structure to think about
• 09:00when you're teaching in the
• 09:01ambulatory setting. So I'm gonna
• 09:02review that literature
• 09:04today on how to structure
• 09:05that experience.
• 09:07So, unfortunately, my word cloud
• 09:09is not gonna look, but
• 09:10not gonna work. But if
• 09:12you think about it, it's
• 09:13just picture yourself on a
• 09:14busy clinic day. It's It's
• 09:16twelve thirty five. You just
• 09:17finished. You had some more
• 09:18of your chatty patients that
• 09:19morning. You ran a little
• 09:21bit behind. You're about to
• 09:22grab lunch, and you realize
• 09:23at one o'clock, you have
• 09:24a new student starting with
• 09:25you that afternoon.
• 09:27So if you wanna drop
• 09:27it into the chat box,
• 09:29what are the first thoughts
• 09:30that might come to your
• 09:31mind when you think about,
• 09:33oh, no. A new student's
• 09:34coming. Or, oh, yes. A
• 09:35new student's coming.
• 09:38Oh, Leslie, you're in the
• 09:39pool everywhere.
• 09:41Yeah. I used the the
• 09:43gen,
• 09:44Rockfeld,
• 09:47three eight three four to
• 09:48three seven six zero seven.
• 09:50It took, like, about two
• 09:51minutes to show up, but
• 09:52it worked. Is that do
• 09:54other people wanna try it
• 09:55and see if we can
• 09:55get this going? You wanna
• 09:56just try to see do
• 09:57you see the title on
• 09:58top, or you want me
• 09:58to drop it into the
• 09:59chat again?
• 10:03Don't see it.
• 10:04Okay. Yeah. I used the
• 10:06one where you said to
• 10:07send to Jen Rockville, three
• 10:09four two three seven six
• 10:10zero seven. It's in the
• 10:11chat.
• 10:12The one thing on that
• 10:13slide, though, it didn't have,
• 10:14like, a, b, c. Alright.
• 10:16So should we just assume
• 10:17that it should be a,
• 10:18b, c
• 10:20to For this for this
• 10:22slide? This slide's a word
• 10:23cloud, so you just type
• 10:24in a word for this
• 10:27one. Or you could type
• 10:28it into the chat if
• 10:29that's not working.
• 10:31Oh, boy. There it comes.
• 10:32Thank you.
• 10:44Oops.
• 10:54Goals,
• 10:55pace,
• 10:56change,
• 10:58excited,
• 10:59introduce,
• 11:01no,
• 11:12Scratch.
• 11:14I wonder if I'm interested
• 11:16in scratch.
• 11:22So so I I I
• 11:23think, you know, it is
• 11:25a when we have a
• 11:26student enter our practice, it
• 11:27changes the dynamics completely. And
• 11:29whether you're excited about it
• 11:30or stressed about it, there
• 11:31are reasons
• 11:34benefits to having, students coming
• 11:37into our practice. And I'm
• 11:38gonna just touch on them,
• 11:39and then we're gonna talk
• 11:40more about the barriers.
• 11:42So what are the benefits
• 11:43to the learner? So these
• 11:44are pretty straightforward. Learners get
• 11:46to see a wide,
• 11:48diversity of issues in the
• 11:49outpatient setting. So they get
• 11:51to see acute issues. They
• 11:52get to see chronic disease
• 11:54management. They get to see
• 11:55health maintenance.
• 11:56As a primary care doctor,
• 11:57every day, I have acute
• 11:59spots reserved. I have follow-up
• 12:01spots reserved, and I have
• 12:02annual exams. So a learner
• 12:03in one given day will
• 12:04see all of these things
• 12:05in my office.
• 12:06Psychosocial care, social determinants of
• 12:09health is a huge part
• 12:10of what we do in
• 12:11the ambulatory setting.
• 12:12Clinical skills that they learn,
• 12:14in their first and second
• 12:15year and supposedly throughout school,
• 12:18they should be practicing their
• 12:19history taking, their physical exam
• 12:21skills, or clinical reasoning skills
• 12:23in the outpatient setting. They'll
• 12:25be getting to do procedures.
• 12:27When I used to work
• 12:27with residency education, we did
• 12:29a tremendous amount of teaching
• 12:30around population
• 12:32health and panel management, so
• 12:33residents are learning that. And
• 12:35then they're learning about a
• 12:36longitudinal relationship between,
• 12:38the doctor and the clinic
• 12:40or the clinician and the
• 12:41patient, and then the longitudinal
• 12:42relationship that they form with
• 12:44the clinician. So we're gonna
• 12:46talk a little bit more
• 12:47about the how that relationship
• 12:48pans out later on.
• 12:50So what are the benefits
• 12:51to faculty for teaching?
• 12:53So faculty say that it
• 12:54keeps their knowledge up to
• 12:55date. They have to be
• 12:56sharp in order to teach
• 12:58concepts.
• 12:59It enhances their enjoyment of
• 13:00patient care.
• 13:01Many faculty feel like it
• 13:03improves the quality of their
• 13:04practice. They're more thoughtful about
• 13:05the care they're providing when
• 13:07they have someone watching them.
• 13:08They're able to give something
• 13:09back to the profession,
• 13:11serve as a positive role
• 13:12model, and potentially recruit people
• 13:14into their field.
• 13:16And then there are a
• 13:17slew of extrinsic benefits that
• 13:18are offered,
• 13:20faculty appointments for people who
• 13:21are not part of the
• 13:22faculty,
• 13:23CME and faculty development,
• 13:25library or other resources, and
• 13:27then financial benefits in terms
• 13:29of stipends.
• 13:30And this is hot off
• 13:31the press. This is this
• 13:33issue of academic medicine. If
• 13:34anybody wants to check it
• 13:35out, they did an article
• 13:37about how physicians learn medicine
• 13:39in authentic clinical context, which
• 13:41is quite interesting. But the
• 13:43commentary is is why. What
• 13:45drives clinicians to teach while
• 13:46caring for patients?
• 13:48And we're gonna be doing
• 13:49a medical education discussion group
• 13:51on this topic in April,
• 13:52and I'd invite anyone to
• 13:53join who might be interested.
• 13:56So although we know there
• 13:57are many benefits to teaching
• 13:58in the ambulatory setting,
• 14:00sometimes,
• 14:01it feels like this. I'm
• 14:03sure all of you have
• 14:04had days like this.
• 14:05So the biggest
• 14:07issue for teaching in the
• 14:09ambulatory setting is time. That
• 14:10is the number one, two,
• 14:11and three most cited concern.
• 14:14Studies have shown that it
• 14:15increases the length of the
• 14:16workday by about thirty to
• 14:18fifty minutes per half day
• 14:19of clinic.
• 14:20So ambulatory preceptors tend to
• 14:23extend their workdays
• 14:24rather than decrease their clinical
• 14:26load, probably because it's very
• 14:27difficult to decrease your clinical
• 14:29load. So a lot of
• 14:30times, they're taking work with
• 14:31them. They're not able to
• 14:33complete all their work when
• 14:34they have a student or
• 14:35or precepting a resident.
• 14:37And on the flip side,
• 14:40most studies show that interactions
• 14:42between preceptors and learners tend
• 14:43to be about three to
• 14:44five minutes each. So both
• 14:46learners and preceptors feel like
• 14:48more time is needed to
• 14:49teach. So we all wanna
• 14:51be good clinicians. We wanna
• 14:52be good teachers, but lack
• 14:53of time limits our ability
• 14:55to be successful.
• 14:56A couple of other concerns
• 14:58about teaching in the outpatient
• 14:59setting. So for private practices,
• 15:02some feel it increases their
• 15:03cost of business.
• 15:04It increases their stress levels.
• 15:07The electronic health record has
• 15:08been a big hindrance to
• 15:09teaching because a lot more
• 15:11documentation is required, and that's
• 15:13limited people's,
• 15:14ability to teach.
• 15:16Some practices have limited space.
• 15:18It is hard to teach
• 15:19if you have limited space.
• 15:20And then some are concerned
• 15:22about the stress toward the
• 15:23for their staff or patients,
• 15:25but there have been multiple
• 15:26studies that show that staff
• 15:27and patients both like having,
• 15:29students present.
• 15:32And
• 15:33one big topic that's been
• 15:35coming through more recently in
• 15:36the literature is that clinicians
• 15:38feel,
• 15:39increasingly isolated
• 15:41from both the medical school
• 15:42and the newer models of
• 15:43education.
• 15:45So and
• 15:46younger generations of students are
• 15:47coming in. They feel disconnected.
• 15:49They don't feel like they're
• 15:50able to make the difference
• 15:51or the impact that they
• 15:52made in the past, and
• 15:52that's led to them stopping
• 15:54teaching.
• 15:55So so how do teachers
• 15:56fulfill the role as an
• 15:57educator and reap the benefits
• 15:59that we talked about without
• 16:00feeling like they're drowning while
• 16:01doing so.
• 16:03So this is a study,
• 16:06by two excellent medical educators,
• 16:08Judy Bowne and David Irby.
• 16:09This was in two thousand
• 16:10and two,
• 16:11and it just shows that,
• 16:13there are several components that
• 16:14go into ambulatory education, and
• 16:16these are similar components that
• 16:17go into any educational experience.
• 16:20But the three they focused
• 16:21on were the learners, the
• 16:23preceptors, and the environment. And
• 16:25I'm gonna spend most of
• 16:26the time today talking about
• 16:27the preceptors.
• 16:28I'm gonna touch a bit
• 16:29on the environment. I'm not
• 16:30really gonna talk about learner
• 16:32characteristics because that's something that
• 16:33we really don't have control
• 16:35over in this talk, but
• 16:36let's talk about the other
• 16:37two factors.
• 16:39So this is a conglomerate
• 16:40of several studies that I
• 16:41pulled together just to think
• 16:43about the key roles of
• 16:44a preceptor.
• 16:45I'm going to go through
• 16:46them one by one. I'm
• 16:47gonna focus mainly on preparing
• 16:49the office and orienting the
• 16:51learner and providing learning opportunities.
• 16:54I'm not gonna talk as
• 16:55much about feedback even though
• 16:56some of the models include
• 16:58feedback, but feedback is its
• 16:59own talk in of itself
• 17:01as is evaluating learner learner
• 17:03performance. And then I'm gonna
• 17:05just touch briefly at the
• 17:06end about serving as a
• 17:07role model for both professionalism
• 17:09and humanism in the ambulatory
• 17:10setting.
• 17:13So the first thing I'm
• 17:14gonna talk about is preparing
• 17:16the office and orienting the
• 17:17learner.
• 17:18So part of preparing your
• 17:20office is creating an educational
• 17:22culture. So sites that are
• 17:24conducive to learning have to
• 17:25have several variables present. They
• 17:28have to have enough opportunities
• 17:29for students to engage with
• 17:31patients and learn, and then
• 17:32they also have to have
• 17:33preceptors who have the time
• 17:34and the space for them
• 17:35to do so.
• 17:36So one thing to think
• 17:38about is scheduling your patients,
• 17:39and I'm gonna talk about
• 17:40a potential schedule next. I
• 17:42know most of us don't
• 17:43have control over how our
• 17:44template looks, but a potential
• 17:46schedule that might make it
• 17:47easier to teach if you
• 17:48have a student coming with
• 17:49you.
• 17:49This is different than a
• 17:51resident who has their own
• 17:52schedule and their own patients.
• 17:53This would be, specifically for
• 17:55a student.
• 17:56Space and access is a
• 17:58huge part of it. This
• 17:59is actually an LCME requirement
• 18:01that students have to feel
• 18:02like they have enough space
• 18:03to work, that they have
• 18:04enough space to see patients,
• 18:06put away their things.
• 18:08Staffing is something that we
• 18:10don't think about all the
• 18:11time, but this is a
• 18:12nice opportunity
• 18:13to teach students about how
• 18:14to work in interprofessional
• 18:16teams.
• 18:17So I make sure that
• 18:18when a student comes to
• 18:19work with me, they understand
• 18:20everybody who I'm working with.
• 18:22They understand their role, their
• 18:23responsibilities,
• 18:24and that the the MA,
• 18:26the nurse, the front desk
• 18:27people understand who the student
• 18:28is.
• 18:29They know how to speak
• 18:30about the student to patients.
• 18:31I find that it's much
• 18:33better if they start knowing
• 18:34that there's a student present
• 18:36right at the onset of
• 18:37the visit instead of by
• 18:38the time I come in.
• 18:39So, everybody knows that how
• 18:41to talk about the students,
• 18:43how to explain to patients
• 18:44that, you know, we work
• 18:45within an academic environment and
• 18:47students are involved.
• 18:48And patients
• 18:49usually want to be involved.
• 18:51Evidence shows that they also
• 18:53feel like they're contributing to
• 18:54the next generation of physicians.
• 18:56So if you ask them,
• 18:58most patients will want to
• 18:59be involved.
• 19:01So this is an example
• 19:02of a wave schedule.
• 19:04I don't know if anyone's
• 19:05used a wave schedule before,
• 19:07but I'm gonna talk you
• 19:08through it.
• 19:09I use this when I
• 19:10have a student with me.
• 19:11It's hard to sometimes always
• 19:13use it, but I try
• 19:14to use it as much
• 19:14as possible.
• 19:16So the way the wave
• 19:17schedule works is that normally
• 19:18if you have twenty patient
• 19:20twenty minute patient spots, you're
• 19:21gonna have one patient come
• 19:22every twenty minutes.
• 19:24The difference is is that
• 19:25I have my first and
• 19:26second patient come at the
• 19:28onset of my session. So
• 19:30either at eight o'clock or
• 19:31one o'clock, I will have
• 19:32two patients come. And this
• 19:34does not require me changing
• 19:35my template. This just requires
• 19:36me alerting a patient in
• 19:39advance that a student's gonna
• 19:40be there and can they
• 19:41come twenty minutes early to
• 19:42their appointment.
• 19:44So while I'm seeing the
• 19:45first patient,
• 19:46the second patient will be
• 19:48seen or either either way,
• 19:49the student will see one
• 19:50patient, and I will see
• 19:51the other patient.
• 19:52I will complete
• 19:53my patient, and then I
• 19:54will have the next twenty
• 19:55minutes to preset my student,
• 19:57whether I'm precepting them in
• 19:58an office or at the
• 19:59bedside, which we'll talk about
• 20:00afterwards.
• 20:01And then when I go
• 20:02to see my third patient,
• 20:03the student has that twenty
• 20:04minutes to write their note
• 20:06for the first
• 20:07patient. So, basically, the student's
• 20:09getting that hour to see
• 20:10one patient, and we're accomplishing
• 20:12three patient visits in that
• 20:13time. And I find this
• 20:15really helpful.
• 20:16I tend to look at
• 20:17my first two patients of
• 20:18of a session and decide
• 20:20who might be the better
• 20:21one for the student to
• 20:22see and then just ask
• 20:24them advance. But and if
• 20:26you repeat this cycle every
• 20:27three patients, you don't fall
• 20:28as far behind. This does
• 20:30require two rooms that not
• 20:31everybody has,
• 20:33and a little bit of
• 20:33extra space that you might
• 20:35need, but, it tends to
• 20:36work very nicely if you're
• 20:37able to do this.
• 20:40This was an interesting study
• 20:41thinking about how to choose
• 20:43a patient for a student
• 20:44to see or or a
• 20:45learner to see.
• 20:47They said there were three
• 20:48key components to choosing a
• 20:50patient,
• 20:51the time and efficiency it
• 20:52will take to see that
• 20:53patient,
• 20:54the educational value of that
• 20:55patient, and then the doctor
• 20:57patient relationship.
• 20:58And if you could get
• 20:59two of those in, you're
• 21:01doing a great job.
• 21:03Personally, I tend to put
• 21:05educational value and my relationship
• 21:07with the patient a bit
• 21:08higher and sacrifice time and
• 21:10efficiency and give the student
• 21:11more time if they need
• 21:12to, but that doesn't always
• 21:14happen. But I like to
• 21:15think about these three things
• 21:17when I'm thinking about which
• 21:19who might be a better
• 21:19fit for the patient. I
• 21:21know we always think about,
• 21:22wow. This is a great
• 21:23case. We want a patient
• 21:24a student to see it,
• 21:25educational value, and then maybe
• 21:27one of the other two
• 21:28will come into play.
• 21:34Any questions about preparing the
• 21:36office before we talk about
• 21:37orienting the learner? And, Sarah,
• 21:38if you could if you
• 21:39could field if anything's come
• 21:40up so far.
• 21:42Jen, this is Leslie Rick.
• 21:43Yeah. I have a question.
• 21:45Sure. I appreciate the advice
• 21:47to, like, take a just
• 21:48a few minutes at the
• 21:48beginning and make sure everybody
• 21:50knows who everybody is. I
• 21:51think that helps the student
• 21:52not feel so what kinda
• 21:54lost and what am I
• 21:55doing and and that,
• 21:57makes a little bit more
• 21:58positive environment.
• 21:59In terms of the preparing
• 22:01the clinic, like,
• 22:02who calls the patient to
• 22:04come in early? It seems
• 22:05like that's kind of
• 22:07I don't know if unfair
• 22:08is the right word, but
• 22:09now there's somebody spending forty
• 22:11plus minutes there versus the
• 22:12person that's in and out
• 22:13in twenty.
• 22:15Yes. It's a great point,
• 22:16Leslie.
• 22:17So
• 22:18I am currently not part
• 22:20of the, connection center. So
• 22:22I have my front desk
• 22:23staff that work pretty closely
• 22:24and frankly know most of
• 22:26my patients. So I'll pick
• 22:27a patient that they know
• 22:28well, that I know well,
• 22:30that would likes to talk,
• 22:31likes to have
• 22:33two doctors listen to me.
• 22:34I've had patients say that.
• 22:35I had two doctors listen
• 22:36to me today and ask
• 22:37them to do that. Granted,
• 22:39they may not always be
• 22:40that person. Right? So it
• 22:41it doesn't always work out,
• 22:43but if I can identify
• 22:44a person in a dream
• 22:45world, I'll know a student's
• 22:47coming months in advance, and
• 22:48I'll schedule someone for that
• 22:49first time slot, but that
• 22:50doesn't usually happen. So that's
• 22:52that's how I do it.
• 22:55So and, you know, you
• 22:57could see. I know that
• 22:58it might be different with
• 22:59your practice. So but I'm
• 23:01sure you have patients who
• 23:02come back who would love
• 23:03to have somebody else take
• 23:04a look at them. For
• 23:05sure. My,
• 23:06second question is I think
• 23:08we all chatty patients. My
• 23:09second question is,
• 23:12how how do you
• 23:13when do you notify your
• 23:15patients that they might see
• 23:16a student? Is there something
• 23:17that's sent out ahead of
• 23:18time to new patients, for
• 23:19example? Like, these these are
• 23:21the learners you might meet
• 23:22in clinic. And then,
• 23:25do you
• 23:26just pop your head in
• 23:27at the beginning? Or when
• 23:28you say you let them
• 23:29know in advance, what does
• 23:30that mean exactly?
• 23:31Yeah. That's a great point.
• 23:33So it actually, when I
• 23:34used to work at Quinnipiac,
• 23:35we used to actually give
• 23:36students these
• 23:37cards
• 23:38that they would bring to
• 23:39their community preceptor's office, and
• 23:41it would go
• 23:42in in front of the
• 23:43front desk, like a you
• 23:44know, in a board saying
• 23:45who they are, where they're
• 23:47coming from, what their interests
• 23:48are, like and we would
• 23:49say, we have a student
• 23:50working with our practice right
• 23:51at the front desk.
• 23:54We have a student working
• 23:55with doctor Rothfeld this month.
• 23:55We're so excited to have
• 23:56her here. This is who
• 23:57it is. So they'll tell
• 23:58them at the front desk,
• 23:58and then I have my
• 23:59MA is the official person
• 24:01who asks permission.
• 24:02So when my MA goes
• 24:03in, she'll say to that
• 24:05patient, you know, doctor Rothfeld
• 24:06has a student with her
• 24:07today. Are you comfortable with
• 24:08seeing the student?
• 24:09So that's and I do
• 24:10tend to just double back
• 24:12in and peek in right
• 24:13before I see them and
• 24:14say, Christina said you're okay
• 24:15with the student, and they
• 24:16say, yeah. That's fine. You
• 24:17know? But I do have
• 24:19them hear it at multiple
• 24:20steps before I'm asking them.
• 24:21Sometimes I feel like they
• 24:22don't wanna say no to
• 24:24me,
• 24:24and they're more comfortable with
• 24:26the earlier steps saying no,
• 24:27and I never want
• 24:29you know, the patients who
• 24:30don't wanna see students are
• 24:31not the best patients for
• 24:32the students to see is
• 24:33what I usually find.
• 24:35Yeah. That makes sense. Thank
• 24:36you. Yeah.
• 24:38So orienting the learner to
• 24:40the practice.
• 24:41So,
• 24:42orienting the learner is relatively
• 24:44similar in all clinical settings.
• 24:45So the only thing with
• 24:47the ambulatory setting is I
• 24:48find this is a bit
• 24:49of a newer environment for
• 24:50them, so there might be
• 24:51a little bit more logistics
• 24:52upfront.
• 24:54But the main part of
• 24:55orientation is to establish mutual
• 24:57expectations
• 24:58to diagnose your learner by
• 24:59figuring out their level of
• 25:01experience,
• 25:02to provide learning opportunities for
• 25:03them and to give them
• 25:05assessment and feedback.
• 25:07So when I think about
• 25:08setting mutual expectations, I always
• 25:09show this TeamSTEPPS slide. I
• 25:11don't know if people have
• 25:13see heard of TeamSTEPPS before,
• 25:15but this is a slide
• 25:16of a shared mental model.
• 25:18Does anybody wanna chime in
• 25:19who knows what a shared
• 25:20mental model is
• 25:25or drop it into the
• 25:26chat?
• 25:41Okay.
• 25:42Well, I'll give I'll
• 25:45give a hint. So, basically,
• 25:46a shared mental model
• 25:49is the perception or understanding
• 25:50of a situation
• 25:52or a process that's shared
• 25:53among team members through communication.
• 25:55And I can't underemphasize
• 25:57or I can't overemphasize
• 25:59the through communication part because
• 26:01we all think
• 26:02that we have a shared
• 26:03mental model. You think they
• 26:04think the same thing you
• 26:05do, but that is not
• 26:06always the case.
• 26:08So it's helpful to talk
• 26:09to the learner right up
• 26:10front about their goals and
• 26:11expectations,
• 26:13your goals and expectations,
• 26:14and then come to a
• 26:15mutual agreement about what the
• 26:17goals are for this rotation
• 26:18and the strategies you're gonna
• 26:20use to accomplish these goals.
• 26:21And I would be really
• 26:23very concrete, and I'm gonna
• 26:24give an example. So, I
• 26:26used to work in graduate
• 26:28medical education as an APD
• 26:29in an ambulatory setting, and
• 26:31I always precepted residents. And
• 26:32when I first moved to
• 26:33Connecticut, I was so excited.
• 26:35I was precepting a second
• 26:36year medical student.
• 26:38And I sent her into
• 26:38the room, and I said,
• 26:39you know, go in, do
• 26:40your thing, and I'll see
• 26:41I'll see you soon. And,
• 26:42like, forty five minutes in,
• 26:44I I knocked on the
• 26:45door and I said, you
• 26:46know what? You wanna come
• 26:46out and present? And she
• 26:47goes, give me a few
• 26:48more minutes. And then she
• 26:49took about ten more minutes,
• 26:50and she came out. And
• 26:51I said, okay. Why don't
• 26:52you present? And she gave
• 26:53me this really, really thorough
• 26:55history.
• 26:56And I said, great. And
• 26:57what did you find on
• 26:58physical exam? And she was
• 27:00like, you wanted me to
• 27:01do the physical exam? I
• 27:02didn't have time for physical
• 27:03exam.
• 27:04And I was shocked. You
• 27:05know, it was an hour
• 27:06in the room with the
• 27:07patient. But I think that
• 27:08could have been really easily
• 27:10solved by talking at the
• 27:11beginning
• 27:12and saying, I'm expecting you
• 27:13to do a focused history
• 27:15and physical in thirty minutes.
• 27:16Is this something that you
• 27:17feel comfortable and skilled at?
• 27:19Right? So if we set
• 27:20that expectations upfront, it could
• 27:22have saved us a lot
• 27:23of headache later trying to
• 27:24backpedal,
• 27:25and then I got be
• 27:26fined, and it was frustrating
• 27:27because I had to go
• 27:27back in and do everything,
• 27:28you know, and and there's
• 27:29no reason for any of
• 27:30that. So I think it's
• 27:31really important to make sure
• 27:33you're both on the same
• 27:33page about the goals and
• 27:34expectations.
• 27:36And when you diagnose a
• 27:38learner, most of you have
• 27:39seen the rhyme,
• 27:40algorithm. It's very, very straightforward.
• 27:42It's just a general,
• 27:44impression developed by Lupe Naro
• 27:46in nineteen ninety three to
• 27:48assess your learner.
• 27:49And
• 27:50the way that it goes
• 27:51is this is higher level
• 27:53of,
• 27:54competency as you go up.
• 27:55So it's Rhyme reporter, interpreter,
• 27:58manager, and educator. Some people
• 28:00put an l at the
• 28:01end I've seen as a
• 28:01leader.
• 28:02A reporter is your typical
• 28:04preclinical student.
• 28:05They can gather data for
• 28:07you and give it to
• 28:08you, and then you decide
• 28:09what to do with it.
• 28:10Once they move up into,
• 28:12you know, the end of
• 28:13their preclinical clinical years, they
• 28:15should be able to interpret
• 28:16that data, the history, the
• 28:17physical exam, any imaging studies,
• 28:19any labs that come along
• 28:21with it.
• 28:22Managers, what you're thinking of
• 28:23as a higher level medical
• 28:24student moving into residency that
• 28:26they could actually manage, develop
• 28:28a clear assessment and plan,
• 28:29and carry it out. And
• 28:30then an educator is somebody
• 28:32who's able to teach that
• 28:33to others.
• 28:34I will say that is
• 28:35the typical progression, but you
• 28:36will have a resident who
• 28:37comes to you as an
• 28:38intern who's still a reporter,
• 28:40and you will have a
• 28:40third year medical student who's
• 28:42able to manage. So it's
• 28:43really important to get a
• 28:44sense.
• 28:45I try to diagnose
• 28:47myself what the learner is,
• 28:48and I also tell them
• 28:49to self diagnose and tell
• 28:50me what they're working on
• 28:51and what their goals are
• 28:52for the rotation,
• 28:54so I know that I
• 28:54could help them in certain
• 28:55areas.
• 28:59So learning opportunities. So I'm
• 29:01gonna spend most of my
• 29:02time talking about the learning
• 29:03opportunities. And I will say
• 29:04that delivering feedback
• 29:06works into a lot of
• 29:07these.
• 29:08So we'll be talking about
• 29:09delivering feedback a bit as
• 29:11well. So the four strategies
• 29:13that I'm gonna talk about
• 29:14today, there are many others,
• 29:15but these are the four
• 29:16main ones I'm gonna focus
• 29:17on, Our active observations,
• 29:21precepting in the presence of
• 29:22the patient or PIP, which
• 29:23is the fancy way of
• 29:24saying bedside teaching,
• 29:26one minute preceptor and micro
• 29:28skills, and snaps.
• 29:29And if our
• 29:32Poll Everywhere is working,
• 29:34let me know what models
• 29:35you've used in the past
• 29:37by choosing them on the
• 29:38Poll Everywhere slide.
• 29:44I
• 29:46I can't see a poll.
• 29:46No. But yeah. It's not
• 29:48coming up again?
• 29:50It didn't launch?
• 29:52Oh, some people are getting
• 29:53it. No. It's there. So
• 29:54now? Okay. Thank you.
• 30:07Okay.
• 30:09So the first two more.
• 30:11So I can't hear that
• 30:12as much.
• 30:13We'll talk about all of
• 30:14them, and then I would
• 30:15love to have a little
• 30:16bit of time for people
• 30:17who have used them in
• 30:17the past to give your
• 30:19feedback on how they went
• 30:20after I explained them to
• 30:21everybody.
• 30:24So it's hard to find
• 30:25pictures of doctors teaching. So
• 30:27this is a picture of
• 30:27me teaching one of my
• 30:29former former students. We actually
• 30:30had students spend one afternoon
• 30:32a week with us for
• 30:33two years. So Andy was
• 30:35with me for two years
• 30:36and then decided to go
• 30:37into interventional radiology,
• 30:39which was you know, broke
• 30:40my heart in some ways,
• 30:41but I am hoping that
• 30:42he learned patient centered skills
• 30:43that he's practicing when he
• 30:44does that.
• 30:46So the first point that
• 30:48I wanna make, and I
• 30:49make this to my to
• 30:50my learners really upfront, is
• 30:51that there is value in
• 30:53shadowing.
• 30:54I think we just need
• 30:55to shift how we think
• 30:56about shadowing.
• 30:58I know as a faculty
• 30:59member, watching my colleagues see
• 31:01patients, watching my colleagues teach
• 31:03is invaluable
• 31:04to me.
• 31:05So at any level, there
• 31:07is value. Obviously, we used
• 31:08it at earlier levels more,
• 31:10but but I'm gonna talk
• 31:11about how the three,
• 31:13aspects called priming,
• 31:15modeling, and debriefing
• 31:16that will make this experience
• 31:18into an active observation.
• 31:20So when you think about
• 31:22bringing a student in with
• 31:23your resident and with you,
• 31:24priming is really important. And
• 31:29And I think priming is
• 31:29important for any encounter because
• 31:29that's how clinical reasoning works.
• 31:31You before you go in
• 31:32to see the patient, you
• 31:33have some information that helps
• 31:35you frame the rest of
• 31:36your encounter.
• 31:37So when I prime a
• 31:38learner, I tell them why
• 31:40I'm having them observe the
• 31:41observe observe my, exam or
• 31:44observe my history taking. So
• 31:45I'll say,
• 31:47this patient's working on quitting
• 31:48smoking.
• 31:49I want you to watch
• 31:50how I use the skills
• 31:51of motivational interviewing.
• 31:53Specifically,
• 31:55focus on how I roll
• 31:56with resistance when she tells
• 31:57me why she can't quit.
• 31:59Okay? So so I'm telling
• 32:00them what to look for.
• 32:02I'm bringing them in. I'm
• 32:03modeling the skill, and then
• 32:05we're debriefing.
• 32:06And when I'm debriefing with
• 32:07the learner, I use it
• 32:09as a chance to show
• 32:10humility and ask the learner
• 32:11for feedback. So I say,
• 32:12how do you think I
• 32:13did? Right? This gives the
• 32:14learner a chance to give
• 32:15you feedback on your skills,
• 32:17hear what they got out
• 32:18of the interaction.
• 32:20I'll tell them, like, I
• 32:21think I did this well.
• 32:22I could've done this better.
• 32:23Next time, I'm gonna try
• 32:24this. We talk about it.
• 32:26And then in a dream
• 32:27world, the learner can go
• 32:28into a different encounter and
• 32:29do the same skill, and
• 32:30you could watch them do
• 32:31it. And this can be
• 32:32used for any skill. So
• 32:34this can be used for
• 32:35skills such as history taking
• 32:37to, obviously, procedural skills. We
• 32:39do this a tremendous amount.
• 32:40But,
• 32:41sometimes I'll even do this
• 32:42for clinical reasoning. You know?
• 32:43Watch me think out loud,
• 32:45and I'll just think out
• 32:46loud to them and show
• 32:47them how I go through
• 32:48clinical reasoning and then talk
• 32:49about it afterwards.
• 32:51If you're gonna do an
• 32:52active observation of a student,
• 32:55what I would say is
• 32:56think about
• 32:57small pieces,
• 32:59small observations that add up.
• 33:01It's really hard for any
• 33:03of us to take our
• 33:04time to go into a
• 33:05a student encounter for thirty
• 33:06to forty minutes and watch
• 33:07it from beginning to end.
• 33:09It's just quite difficult.
• 33:10So if I'm gonna observe
• 33:12a student, I'm picking a
• 33:13skill that I'm observing them
• 33:14doing. Oh, you're working on
• 33:16your lung exam. Oh, you're
• 33:17working on how to explain
• 33:19prostate cancer to this patient.
• 33:21So I'm gonna come in
• 33:22with you when you do
• 33:23that, and then I'm gonna
• 33:24give you feedback afterwards.
• 33:25So we set up the
• 33:26priming.
• 33:27And sometimes if they need
• 33:28to, we'll go through the
• 33:29steps. You know? Oh, you're
• 33:30working on this exam. What
• 33:31are the steps you're gonna
• 33:32do for this exam? Making
• 33:33sure they really know what
• 33:34they're doing before they go
• 33:35in.
• 33:36Watch them do it and
• 33:37then debrief how it went.
• 33:39I find it really so
• 33:39I say just grab me
• 33:40when you're ready to do
• 33:41this. I'll come in for
• 33:42five minutes, and then we'll
• 33:43talk about it outside the
• 33:44room.
• 33:47So moving from active observation
• 33:48to precepting in the presence
• 33:50of the patient, this is
• 33:51derived from bedside learning. It
• 33:52has multiple names, but it's
• 33:54basically moving into the patient's
• 33:56room when you precept the
• 33:57student.
• 33:59The advantages to this is
• 34:00that it's efficient. It takes
• 34:01less time. It's patient centered.
• 34:04It's good for all levels
• 34:06of learners,
• 34:07and you get to see
• 34:08a lot when you're in
• 34:09the room with the patient
• 34:10and the student. You get
• 34:11to see how they communicate,
• 34:12if their body language. You
• 34:14see more than you do
• 34:15see when you precept outside
• 34:16the room.
• 34:17The disadvantages
• 34:18are primarily the learner comfort
• 34:20with doing it
• 34:21and also that ensuring the
• 34:23patients allow the learner to
• 34:25present.
• 34:26So, what I usually say
• 34:27to the patient is, I'm
• 34:29gonna have the student present
• 34:30to me in front of
• 34:30you. I'm gonna have the
• 34:31resident present to you in
• 34:32front of me, present to
• 34:33me in front of you.
• 34:35Please listen. I'm sure there's
• 34:36some things you wanna clarify.
• 34:37If you don't mind, just
• 34:38waiting till they're done, and
• 34:40then I'm gonna turn to
• 34:40you, and I welcome any
• 34:41clarification or anything that wasn't
• 34:43correct. I know things get
• 34:44lost in translation, but just
• 34:46let's let them present first
• 34:47for their learning experience.
• 34:48So I want to give
• 34:50the patient time, but I
• 34:51want to also allow the
• 34:52learner to do what they
• 34:53need to do.
• 34:55There was a study done
• 34:56on this. This is this
• 34:57is from a randomized control
• 34:58trial.
• 35:00The patients liked it better.
• 35:02The the faculty liked it
• 35:03better.
• 35:04More time was spent with
• 35:05the patient,
• 35:06but, overall, the same amount
• 35:08of time was spent for
• 35:09the entire encounter.
• 35:11The biggest difference was that
• 35:12the the learners felt like
• 35:13they had to choose their
• 35:14words
• 35:15more carefully, and they didn't
• 35:17like that.
• 35:18But, honestly, I don't think
• 35:19that's a bad thing. So
• 35:21I do think it is
• 35:22a hard skill to shift
• 35:23from doctor speak to patient
• 35:24speak and back again, and
• 35:25I think it's something that's
• 35:26really important for all training
• 35:28physicians to learn.
• 35:31So now I'm gonna talk
• 35:33about the one minute preceptor
• 35:34on micro skills. This is
• 35:35an this is very old.
• 35:36This has been around. I
• 35:38remember hearing about this when
• 35:39I first was the resident,
• 35:41I believe.
• 35:42This came out in nineteen
• 35:43ninety two. It was based
• 35:44on principles from observational studies
• 35:47about effective clinical teaching.
• 35:49They it has been proven
• 35:51in multiple studies to work.
• 35:53There's many iterations of this.
• 35:54This is sort of the
• 35:55main iteration.
• 35:57So the one minute preceptor
• 35:59can be used for any
• 36:00student, the or or resident.
• 36:01They do not need to
• 36:02know how to participate in
• 36:04this. They you could just
• 36:05lead it. When we talk
• 36:06about snaps next, the the
• 36:08learner has to drive it.
• 36:10So that's a little bit
• 36:11different.
• 36:12So for one minute preceptor,
• 36:13the first part is that
• 36:14you get a commitment. So
• 36:15the resident comes out,
• 36:17presents to me, and I
• 36:18say, what do you think
• 36:19is going on? So I
• 36:20make sure I get a
• 36:21commitment from them about what's
• 36:23going on.
• 36:24The second part is I'm
• 36:25probing for their clinical reasoning.
• 36:27This is a huge portion
• 36:28of what I'm doing.
• 36:29What led you to this
• 36:30conclusion? What was your supporting
• 36:32evidence?
• 36:33What maybe went against it?
• 36:34What other things are on
• 36:35your differential diagnosis? Right? So
• 36:37this is really where I
• 36:38get them to explain their
• 36:39clinical reasoning to me.
• 36:41And then I teach a
• 36:42general principle or a pearl.
• 36:45You know, when you see
• 36:46this, you can always think
• 36:47of this. This is pathognomonic
• 36:49for this. This is very
• 36:50specific.
• 36:51You know, this is have
• 36:52you ever heard of the
• 36:53center criteria for the for
• 36:54diagnosing strep throat? So so
• 36:56these are things that I
• 36:57teach a general principle related
• 36:59to the patient.
• 37:01And then reinforcing what went
• 37:03well, which I will say
• 37:05is so important for early
• 37:06learners. I have seen learners
• 37:08change how they do things
• 37:09each time they see a
• 37:10patient because no one told
• 37:11them they were doing it
• 37:12right. So by telling them
• 37:13they're doing something right, they
• 37:15can use that skill again
• 37:16and again.
• 37:17So reinforcing what went well
• 37:19and, obviously, correcting any errors
• 37:21or omissions. You know, next
• 37:22time, you know, consider this
• 37:24in your differential diagnosis.
• 37:26You know? You so,
• 37:28this is pretty straightforward,
• 37:29really easy to do.
• 37:32One thing I wanna add
• 37:33is there is an eight
• 37:34minute preceptor that was developed
• 37:35by by PEDS.
• 37:37And one thing I really
• 37:39liked about it is at
• 37:40the end, they said have
• 37:41the learner generate,
• 37:43learning
• 37:44objectives. So the learner leaves
• 37:46and has things they wanna
• 37:47look up as a result
• 37:48of this case.
• 37:49So the supporting evidence,
• 37:51it approves teaching
• 37:53effectiveness
• 37:54and efficiency.
• 37:55You end up giving more
• 37:56feedback to the learner if
• 37:57you're working through this model.
• 37:59You give more deliberate specific
• 38:01teaching points, and it increases
• 38:03learner motivation for outside learning.
• 38:06So I'm gonna talk about
• 38:07snaps, and then we'll compare
• 38:09the two. So snaps was
• 38:11published in two thousand three
• 38:12in academic medicine by Walpole.
• 38:15This was a little bit
• 38:16different. This was based on,
• 38:18cognitive activity,
• 38:20scale, so it was a
• 38:21little bit different. And it
• 38:22shifts the focus of the
• 38:23presentation a little bit because
• 38:25it's learner driven, and it's
• 38:28really, really focused
• 38:29on, expression of their clinical
• 38:31reasoning.
• 38:32So the learner needs to
• 38:34understand how to do this.
• 38:35So I've had preceptors I've
• 38:36worked with that train all
• 38:37their residents to present like
• 38:38this. Their residents know how
• 38:40to present like this, and
• 38:41it's just it flows. Once
• 38:43they learn it, it's easy
• 38:44to do.
• 38:45They come in. They summarize
• 38:46the case. It shouldn't take
• 38:48more than a couple of
• 38:49minutes. This is only about
• 38:50fifty percent of the time
• 38:51you're spending with them. So
• 38:52they summarize the case in
• 38:53a few minutes.
• 38:55They narrow their differential diagnosis
• 38:58to a couple of options,
• 39:00and then they analyze their
• 39:01differential for you. So they
• 39:03tell you the supporting and
• 39:04refuting evidence of each other
• 39:05option,
• 39:07then they prove you. So
• 39:08at this point, they're telling
• 39:09you, I am not sure
• 39:11about this.
• 39:12Can you help me?
• 39:14They're they're telling you where
• 39:15they're uncertain, and they're asking
• 39:17you to fill in the
• 39:17gaps.
• 39:18This can be intimidating, I
• 39:20think, especially for new preceptors
• 39:22because they're not driving the
• 39:23learning points. The they're getting
• 39:25asked.
• 39:26But if you don't know,
• 39:27I think this is a
• 39:28wonderful opportunity to say, hey.
• 39:30I don't know what the
• 39:30latest recommendations are around this.
• 39:32Let's look it up together.
• 39:33This is how I would
• 39:34find this information.
• 39:36I think the skill of
• 39:37finding information
• 39:38is one of the most
• 39:39important skills that any learner
• 39:40can,
• 39:41know because information is changing
• 39:43on such a regular basis.
• 39:45And then finally, they're planning,
• 39:47making a plan together, and
• 39:48they're selecting an issue for
• 39:50self directed learning.
• 39:51So,
• 39:52the difference with snaps
• 39:54so the learners provided more
• 39:56items in the differential diagnosis
• 39:57and justification for them, And
• 39:59they were more likely to
• 40:00seek information and to ask
• 40:02questions and acknowledge uncertainty because
• 40:04it was part of the
• 40:05model. Right? We're we're telling
• 40:06them they have to do
• 40:07this. They're focusing on the
• 40:08management, which as we talked
• 40:10about in the Ryan scheme
• 40:11is a more advanced skill,
• 40:13and then the learners are
• 40:14picking what they wanna follow-up
• 40:15on.
• 40:16So when you compare the
• 40:17two,
• 40:18one is teacher led and
• 40:19one is learner led,
• 40:21they're both a collaborative dialogue.
• 40:24One minute preceptor can be
• 40:25used for all levels. Snaps
• 40:27does tend to be better
• 40:27for more residents in GMA
• 40:29than it does for early
• 40:30learners.
• 40:31One minute preceptor is really
• 40:32focused on the knowledge, whereas
• 40:34snaps is focused on the
• 40:35clinical reasoning,
• 40:36and you're directing the learning
• 40:38for the one minute preceptor
• 40:39as opposed to snaps where
• 40:40the the student is directing
• 40:42the learner learning or the
• 40:43resident is.
• 40:45I wanna just take a
• 40:46moment,
• 40:47just gonna stop a share,
• 40:48and see who's used these
• 40:50and what your feedback is
• 40:51or any tips you wanna
• 40:52share for anyone else in
• 40:54the room.
• 41:11I think,
• 41:12I tend to use snobs
• 41:14more with
• 41:16somebody who, like, feels more
• 41:17comfortable with, like, taking the
• 41:19initiative and, like, tell me
• 41:20what's going on as opposed
• 41:21to, like, somebody who's still
• 41:22very
• 41:23early in your
• 41:25training English. I may prefer,
• 41:26like, the one minute learner
• 41:28experience. And have you and
• 41:29have you you've used snaps
• 41:31with learners?
• 41:32Yes. So, for example,
• 41:34when I'm on service with
• 41:35the fellow,
• 41:37it's mostly a snaps where,
• 41:38like Mhmm. I just wanna
• 41:40hear from you, and, like,
• 41:41I want you to tell
• 41:42me what you're thinking and,
• 41:44what you wanna do for
• 41:45this patient.
• 41:46As opposed to, like, a
• 41:47medical student or, like, a
• 41:49resident in clinic,
• 41:51in whom, like, as you
• 41:52were saying,
• 41:53I wanna, like, give them,
• 41:55like, the teaching pro from
• 41:57the patient they just saw.
• 41:58Mhmm. And maybe they don't
• 42:00have a whole grasp of
• 42:01what's going on because, like,
• 42:02maybe it's, like, their first
• 42:03time in clinic or, like,
• 42:04their first week doing their
• 42:06elective. So I think
• 42:07that's when they use one
• 42:09or the other.
• 42:10Yeah. Great. And do you
• 42:11feel like they're both effective
• 42:13to use?
• 42:14Yeah. Yeah. And I I
• 42:15like that you can tailor
• 42:16what approach you're using to
• 42:18what learner you have in
• 42:18front of you. Like Yes.
• 42:20I think that's what's helpful.
• 42:22Great.
• 42:24Other thoughts? And I'm actually
• 42:25gonna drop into a the
• 42:26chat a bit a handout
• 42:28about the two models just
• 42:29if anybody wants to take
• 42:30that with them.
• 42:36I I think I I
• 42:37I haven't used any of
• 42:38these formally, but now hearing
• 42:40these,
• 42:42I think with
• 42:45medical students, I prob or,
• 42:47like, very new residents, I
• 42:49probably use the active observation
• 42:51a little more.
• 42:52I do try to stop
• 42:54right outside the room or
• 42:55you know, it's a lot
• 42:56they're really pretty good at
• 42:57preparing. So a lot of
• 42:58times, they've, like, at least
• 42:59looked at the chart.
• 43:00And so I tell them
• 43:01a little bit, like, at
• 43:02the beginning, this is what
• 43:03I'm looking for. This is
• 43:04what I think kinda kinda
• 43:05like what you were saying.
• 43:06This is what they might
• 43:07say.
• 43:08These are some nuances that
• 43:09I'm looking for.
• 43:11And then sometimes while I'm
• 43:12doing the exam, you know,
• 43:13because I'm doing all pelvic
• 43:15exams, so Mhmm. I have
• 43:16to be pretty sensitive. I
• 43:17don't want, you know, to
• 43:19make the patient feel uncomfortable.
• 43:21So I sometimes will say
• 43:22to the patient, depending on
• 43:23the patient,
• 43:24I'm gonna talk out loud
• 43:25a little bit here. Is
• 43:27that okay? Again, kinda gauging
• 43:29who that patient is. And
• 43:31then sometimes during the exam,
• 43:33in the spirit of explaining
• 43:34it to the patient,
• 43:36I'm sort of explaining it
• 43:37to the learner as well.
• 43:38Like, I'll kinda use that
• 43:40a little bit,
• 43:41again, depending on the patient
• 43:43a little bit. So I
• 43:44I think but I I
• 43:45like having some formal
• 43:50structures, you know, for the
• 43:51bedside and this for the
• 43:52snaps and the bedside to
• 43:54be a little more intentional.
• 43:56Yeah. I love that. And
• 43:57I love that you're asking
• 43:58permission from the patient to
• 43:59to talk out loud and
• 44:00that when you're doing it,
• 44:01you're sort of getting both
• 44:02parties engaged at the same
• 44:04time. And I do think
• 44:05patients feel like they learn
• 44:06a lot from when the
• 44:07learner's in the room, more
• 44:08so than when you're just
• 44:09explaining it to them. So
• 44:10that's great.
• 44:14Any other thoughts?
• 44:22K.
• 44:23So just to I'm gonna
• 44:24go back to my presentation.
• 44:27So the last thing I
• 44:29wanna talk about
• 44:31is the role modeling,
• 44:33because this is such a
• 44:34tremendous part of what we
• 44:36do. Some people call it
• 44:37the hidden curriculum or the
• 44:38informal curriculum, but, you know,
• 44:40they are watching every move
• 44:41you make whether you know
• 44:42it or not, and they
• 44:43are performing judgments. And that
• 44:45is just part of, you
• 44:47know, learning how to be
• 44:48a good clinician. You pick
• 44:49up what you wanna do,
• 44:50and you pick up what
• 44:51you don't wanna do when
• 44:52you see it role modeled.
• 44:54So in the ambulatory
• 44:55setting,
• 44:57the learners spend a tremendous
• 44:58amount of time with you,
• 44:59and there are so many
• 45:00issues. I'm just throwing up
• 45:01a few of them that
• 45:02come up
• 45:03outside of medical knowledge.
• 45:06So psychosocial issues are at
• 45:08the forefront.
• 45:09My patients
• 45:10come to me with with
• 45:12these kind of concerns every
• 45:13single day.
• 45:15So I just wanna talk
• 45:16for a minute about how
• 45:17to teach around these and
• 45:18how to shift from the
• 45:19science of medicine
• 45:21to really what I would
• 45:22consider to be the art
• 45:23of medicine.
• 45:25I'm sure there are plenty
• 45:26more, but these are just
• 45:27some things that come to
• 45:28mind when we're in the
• 45:29office with the patient in
• 45:30an ambulatory setting.
• 45:32So
• 45:33this is a paper that
• 45:34I found from academic medicine.
• 45:36I have not seen it
• 45:37before I started giving this
• 45:38talk, but I really liked
• 45:39it, and I wanted to
• 45:40include it. And they talked
• 45:41about precepting humanism,
• 45:43And they they
• 45:45quoted that humanism was characterized
• 45:47by respectful and compassionate relationships
• 45:50among physicians, their patients, and
• 45:52other members of the health
• 45:53care team that flourishes within
• 45:55a humanistic culture.
• 45:56They described humanistic professionals as
• 45:59those who demonstrate integrity,
• 46:01excellence,
• 46:02compassion,
• 46:03altruism,
• 46:04respect,
• 46:06empathy, and service.
• 46:07And I know we all
• 46:09do this, so this is
• 46:10about how to precept
• 46:11human humanism.
• 46:13So the first step is
• 46:14just stating that this is
• 46:15something that's important to you.
• 46:17So,
• 46:18you know, I really wanna
• 46:20talk about humanism, and and
• 46:22I know that's something we
• 46:22don't always talk about.
• 46:24You might not feel fully
• 46:25comfortable with it, but I
• 46:26want this to be a
• 46:27place that you can express
• 46:28uncertainties.
• 46:29You can express
• 46:31learning gaps. You can tell
• 46:32me about things that make
• 46:33you uncomfortable, and we could
• 46:34talk about them because you'll
• 46:35be in encounters that might
• 46:36make you feel uncomfortable.
• 46:40Talk about some goals that
• 46:41might include humanistic care.
• 46:43When you're thinking about a
• 46:44a student or a learner,
• 46:47I try to diagnose them
• 46:48the same way I diagnose
• 46:49them, in terms of behavior
• 46:51change. So I think about
• 46:52if they're precontemplative
• 46:53and they never even thought
• 46:54about this, or they're contemplative
• 46:56and they've thought about it,
• 46:57but they haven't really delved
• 46:58into this at all, or
• 46:59they're in the planning stage,
• 47:01or they're actively doing it.
• 47:02Right? So so I think
• 47:04about that when I talk
• 47:05about humanism. Like, you know,
• 47:06how often do you talk
• 47:07to people about housing insecurity
• 47:09or, you know, that they
• 47:10can't afford their medications or
• 47:11they can't adhere to their
• 47:12medications or they just can't
• 47:14afford healthy food. Right? Like,
• 47:15these are things that come
• 47:16up, and how comfortable do
• 47:17you feel talking about it?
• 47:20You diagnose them like I
• 47:21mentioned before. You integrate these
• 47:23psychosocial issues into your precepting.
• 47:25So instead of just making
• 47:27every pearl about a medical
• 47:28issue, you might throw in
• 47:30a pearl or a learning
• 47:31point that's about a psychosocial
• 47:32issue.
• 47:33And then the biggest part,
• 47:35I think, is debriefing
• 47:36and reflecting on the experience,
• 47:39to really talk about I
• 47:40I tell, students when encounters
• 47:42are difficult for me.
• 47:44I tell them, I really
• 47:45struggled with that. When the
• 47:46patient said this to me,
• 47:47I didn't know how to
• 47:48respond.
• 47:50How do you think that
• 47:51went? What were your thoughts
• 47:52about it? I really try
• 47:53to bring that up to
• 47:53them,
• 47:56and then,
• 47:57providing feedback to them
• 47:59and planning follow-up.
• 48:01So I just wanna say
• 48:02that these opportunities always exist.
• 48:04And, I tell this story,
• 48:06as part of this talk
• 48:07that when I first started
• 48:09in my new the my
• 48:10practice actually, not new. I've
• 48:11been there eight years now.
• 48:12But the first day I
• 48:13started there, I had a
• 48:14patient
• 48:15who subsequently did not show
• 48:17up to any appointments. Or
• 48:18if he showed up, he
• 48:19would come in for a
• 48:19minute to the waiting room
• 48:20and then leave. And I
• 48:22pride myself on running on
• 48:23time. I work very, very
• 48:25hard not to be very
• 48:26late, and I would get
• 48:26very upset that, you know,
• 48:27if I was running five
• 48:28minutes late that this patient
• 48:30would leave.
• 48:31And he had terrible diabetes,
• 48:33very uncontrolled. I was having
• 48:34a lot of trouble taking
• 48:35care of him, and I
• 48:36was also being evaluated on
• 48:38my care of patients with
• 48:39diabetes. So it was frustrating
• 48:41to me.
• 48:42So,
• 48:43I eventually, you know, he
• 48:45got the no show letter
• 48:46that, you know, you know,
• 48:47showed for so many appointments,
• 48:48and you have to start
• 48:49coming to appointments that we
• 48:50send after three appointments that
• 48:51they they no show where
• 48:52they show up and leave.
• 48:53And his wife called me,
• 48:55and she said that I'm
• 48:56so sorry this is happening,
• 48:57but I wanted to let
• 48:58you know that my husband
• 48:59was, abused by his pediatrician.
• 49:02So as soon as he
• 49:03walks into a doctor's office,
• 49:04he gets very traumatized,
• 49:06and he just leaves.
• 49:07And especially if he hears
• 49:08the word physical exam, anything
• 49:10like that,
• 49:11which
• 49:12I had no idea. He
• 49:13probably would have never told
• 49:14me. So we made a
• 49:16whole plan with my whole
• 49:17office,
• 49:18that, you know, we don't
• 49:19say physical exam. We never
• 49:21coming in for a follow-up.
• 49:22I didn't do a physical
• 49:23exam. As soon as he
• 49:24walks into the office, he
• 49:25gets put in a room.
• 49:26He doesn't have to sit
• 49:27in the waiting room.
• 49:28And we've come a long
• 49:29way. It's been eight years.
• 49:31I will say that I
• 49:32saw him about three weeks
• 49:33ago. He walked into the
• 49:35office, and then he ran
• 49:36back out again.
• 49:37My medical assistant chased him
• 49:39to his car,
• 49:40and he said, I'm sorry.
• 49:41And she said, it's okay.
• 49:42Why don't you come in
• 49:43the side door? Walked into
• 49:44the room, sat him down.
• 49:46And as soon as I
• 49:46came in, he said, I'm
• 49:47so sorry.
• 49:48As soon as I see
• 49:49you and I see your
• 49:50team, I'm okay. But just
• 49:52as soon when I walk
• 49:53through the door, I just
• 49:54can't help it sometimes. And
• 49:55I said, no problem. So,
• 49:56but I was really angry
• 49:57at this patient. And, you
• 49:58know, these are the kind
• 49:59of things that come up
• 50:00and that, like, talking about
• 50:02your feelings around it and
• 50:03what really what's underlying it
• 50:04and how to deal with
• 50:05it. And I think this
• 50:06is a huge learning experience
• 50:08for anybody who's gonna become
• 50:09a physician.
• 50:11So just wrapping up at
• 50:13the end, in summary,
• 50:14there are benefits and barriers
• 50:16to teaching in the ambulatory
• 50:17setting.
• 50:18Chi little small changes in
• 50:20your environment can optimize learning.
• 50:22If you're able to diagnose
• 50:23your learner, you could sort
• 50:24of vary your precepting technique
• 50:26based on the level they're
• 50:27at.
• 50:28Active observation,
• 50:29precepting in the presence of
• 50:31the patient, the one minute
• 50:33preceptor and snaps are all
• 50:34helpful models that you could
• 50:35use, and I did drop
• 50:36that handout if you wanna
• 50:37print it out.
• 50:39And then opportunities to precept
• 50:40humanism exist in every encounter.
• 50:42And just thinking about when
• 50:44they come up and making
• 50:45them explicit and having the
• 50:46learner reflect can go a
• 50:47long way.
• 50:51And these are some upcoming
• 50:52events
• 50:54if you wanna take a
• 50:55look. And
• 50:57then I'll end the show,
• 50:58and and you can ask
• 50:59any questions you might have.
• 51:07That was my boat that
• 51:08I hope can keep some
• 51:09people afloat when they feel
• 51:10like they're drowning when they're
• 51:12teaching. So any questions for
• 51:13me or thoughts or other
• 51:15things you wanna add?
• 51:17Hi. Yes. Anita Koli Pemnani.
• 51:19So my question was, are
• 51:21there, like, for specific learners,
• 51:23is there a specific model
• 51:25that works better for them?
• 51:26Like, I you know, would
• 51:27you go with the
• 51:29the,
• 51:30educator directed model versus the
• 51:32snaps model for a particular
• 51:34learner, or what do you
• 51:35do if it's a shy
• 51:36learner? Is it better to
• 51:37just sort of, like, begin
• 51:38with your own observational
• 51:40teaching and then
• 51:42move them on the snap
• 51:43when they're ready? Or
• 51:44Yeah. That's a great question.
• 51:46So when I think about
• 51:47the learner, I was talking
• 51:48more about their sort of
• 51:49level of learner, but, in
• 51:51terms of their personality,
• 51:53you know, I think
• 51:54people appreciate when they if
• 51:56they understand how the Snaps
• 51:57model works and and you're
• 51:59just asking them to come
• 52:00in and summarize the case
• 52:01and then sort of talk
• 52:02through their clinical reasoning, I
• 52:03think you could get if
• 52:04you create a comfortable learning
• 52:06environment,
• 52:08you could get anyone to
• 52:09do that. I think it's
• 52:10a bit harder. You know,
• 52:10I used to precept for
• 52:11residents in a room with
• 52:12other preceptors, and sometimes people
• 52:14would feel intimidated. They walk
• 52:15into a room with all
• 52:16this faculty and have to
• 52:17explain themselves.
• 52:19But I think if you
• 52:19could set up the learning
• 52:20environment and make them feel
• 52:22comfortable with expressing their uncertainties,
• 52:25and showing them your uncertainties,
• 52:27I think it could go
• 52:27a long way. But that
• 52:29being said, I have not
• 52:30really used snaps at all
• 52:31for medical students. I really
• 52:33save snaps for residents, whereas
• 52:35the one minute preceptor, I've
• 52:36used across the spectrum.
• 52:52Bill, I see that you
• 52:53wrote earlier that you like
• 52:54that the one minute preceptor
• 52:56has what went well to
• 52:57support learners' confidence in learning.
• 52:59I agree. I you know,
• 53:00the optimal ratio, they say,
• 53:02is five
• 53:03pieces of reinforcement feedback to
• 53:05every one piece of corrective
• 53:07feedback, which is a hard
• 53:08ratio to get down. But
• 53:10as much as you can
• 53:11reinforce good behavior, I would
• 53:13recommend it.
• 53:14Yeah. I like that too.
• 53:15Thank you.
• 53:20I just wanted to thank
• 53:21you for this lecture.
• 53:23I
• 53:24wish that I had had,
• 53:26this kindness and this
• 53:29teaching example
• 53:30during my residency. I'm currently
• 53:32a fellow,
• 53:34and getting ready to head
• 53:35out,
• 53:36for a job,
• 53:37which would be a a
• 53:38clinician educator.
• 53:40So I'm soaking all of
• 53:41this in, and and I
• 53:43I thank you for this.
• 53:44I really appreciate it.
• 53:46Great. Thank you, and good
• 53:47luck.
• 53:58Great.
• 54:00Thank you all for your
• 54:01time.
• 54:03Linda, do you need me
• 54:03to put the slide back
• 54:04up with the with the
• 54:05future
• 54:06events?
• 54:16Jen, do you have this
• 54:17Yeah. The slide with the
• 54:18evaluation?
• 54:19I did put the evaluation
• 54:20in chat, and we greatly
• 54:22appreciate all of your feedback
• 54:24and comments.
• 54:25There you go.
• 54:31Yes. There we go. Great.
• 54:32Thank you.
• 54:34Thank you, everyone.
• 54:37This slide has a one
• 54:38minute timer. You can see
• 54:40the bar
• 54:41moving from the right.
• 55:36Okay. Thank you, everyone, for
• 55:37your time.
• 55:40Thank you. Thank you, Jen.
• 55:41That was amazing.
• 56:00Alrighty. Hal and Nicole, everyone
• 56:02have a great day.
• 56:03Alright. Bye bye, everyone. Thank
• 56:04you. Bye.