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The following workshop materials were developed at an invitational conference on ambulatory education sponsored by the national Center for Medical Education Research at the University of Washington and the University of North Carolina under funding from Health Services and Resources Administration Bureau for Health Professions and Pharmacia/UpJohn. Our goal was to provide a new tool for training community preceptors to use a variety of strategies in supervising medical students in the ambulatory setting using a learner-centered approach. We have utilized a simulation format for the workshop developed by Linda Lesky, M.D., and LuAnn Wilkerson, Ed.D., for preceptor development at Harvard Medical School (Using "standardized students" to teach a learner-centered approach to ambulatory precepting. Academic Medicine, 69: 955-957, 1994).
These materials are available for your use and can be modified to meet
the needs of your individual preceptors. If you decide to use the materials,
we ask only that you collect participant evaluations of the experience using
the form attached and share the results with us. We are currently developing
a pre-post test to assess changes in knowledge about precepting as a result
of the workshop. This test is available from us on request. Please mail
results to LuAnn Wilkerson.
If you wish to discuss the workshop, please call or e-mail either of us. Above all else, have fun with the materials and the students. They are wonderful faculty developers!
Richard Sarkin, M.D. |
LuAnn Wilkerson, Ed.D. |
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Our roles as teachers are often defined by the environment in which we
were primarily trained and now teach -- the hospital. Student and resident
education has occurred mainly on inpatient wards and as teachers, we have
developed habits and skills for teaching during formal rounds, at the bedside,
and in conference room settings. The increased use of ambulatory settings
in medical education demands new roles and new skills from us as teachers.
Although the ambulatory patient encounter offers numerous opportunities
to teach, these teachable momentsn may be lost due to a lack of effective
strategies for teaching within the constraints of patient care and restrictions
of time.
During this workshop, we will focus on the identification of learner
needs in the ambulatory patient encounter and the development of teaching
skills for responding to those needs. The workshop will include simulations
in which we will explore the teaching opportunities present in the typicaln
ambulatory setting in which you teach.
Hewson M. Clinical Teaching in the Ambulatory Setting. Journal of
General Internal Medicine, 7: 76-82, 1992.
Lesky LG & Borkan SC. Strategies to Improve Teaching in the Ambulatory
Medicine Setting. Archives of Internal Medicine, 150: 2133-2137,
1990.
This workshop was developed by Richard Sarkin, M.D., SUNY Buffalo, and LuAnn Wilkerson, Ed.D., UCLA, with the assistance of the other members of the Working Group for Faculty Development at the Icicle Creek Ambulatory Care Education Conference, August 21-24, 1996, Leavenworth, Washington, under funding from HRSA Bureau of Health Professions and Pharmacia/UpJohn.
STU: Mr. Evans is a 40 year old white male with a 5-year history of HTN
who comes in today with a complaint of puffy eyelids x 2 weeks and weight
gain. He has no history of recent infection, travel, change in urination,
rash or liver disease. His medications include Aldomet, 250 mg/tid and Dyazide,
1 q/day. This has not been changes in 2 years and his BP has been generally
well controlled. He admits to drinking a six-pack a day. The exam today
reveals his BP to be 140/85. There is not much that is remarkable except
for periorbital edema and a few crackles at the base line. I think we ought
to do a U/A and check his electrolytes.
ATT: Did you document his weight?
STU: 162 lbs, but there was no baseline on the chart. Mr. Evans thinks he's
gained 15 lbs.
ATT: Does he have foamy urine?
STU: I don't think so. He didn't mention it.
ATT: (Silently pondering the case): Interesting case. Let's go see him.
STU: Mr. Evans, this is Dr.____________.
ATT: Hello, Mr. Evans. Dr. _____ has told me about your situation. I
would like to ask you a couple of questions. Have you noticed any foamy
urine?
PAT: You know, doc, I thought I was losing my mind. It's been foaming
up like a head of beer.
ATT: Do you have any pain in your sides?
PAT: No, I haven't noticed any.
ATT: What medications are you taking?
PAT: Aldomet and Dyazide, like I told the doc here.
ATT: Nothing else?
PAT: Maybe an occasional aspirin, but that's all.
ATT: (Silently examining the patient -- face, lungs, heart): (to the
Student) Does he have pedal edema?
STU: Oh, I don't think that I checked that. (Examines the lower leg.)
ATT: (Frustrated glance): It's been nice meeting you, Mr. Evans. will
be back in to talk to you in just a moment. (Walking outside of the room).
Very interesting case. He could indeed have nephrotic syndrome. Let's add
a liver enzyme test and a VDRL to his bloods. Why don't you go back in and
let him know about the tests that we want to do?
STU: (hesitantly) OK.
Case by Linda Lesky, M.D., University of Illinois
Stu: Billy Smith is a 6-year-old boy who comes to the office today with
a complaint of a cough for the past three weeks. He has had a runny nose,
but has been acting well and has had no fever. His cough seems to be worse
at night. Actually, for the past two nights, he has gotten up several times
because of the cough. His appetite has been normal. His mother has given
him some cough medicine, but the cough has not gotten better. On physical
exam, he looks well and is afebrile. He has a slight runny nose, but the
rest of his exam is normal. His lungs are clear. I think he probably needs
a chest x-ray.
Att: Are there any smokers at home?
Stu: Uhhh, I'm not sure.
Att: Does anyone in the family have asthma?
Stu: I don't know. I guess I should have asked about that.
Att: (frustrated glance) Yes, perhaps you should have. Why don't we go
see him
(entering exam room, student stands in the back) Hello, mom, I'm Dr. _________.
Hello, Billy. I understand Billy has been coughing quite a bit.
Mom: Yes, last night he seems to have coughed all night long.
Att: Billy, would you take a deep breath and then blow out as hard as
you can?
Billy: O.K.
Att: (auscultates as Billy takes a deep breath and blows out) Hmmmmm.
Sounds like Billy might be wheezing a bit.
Mom: Oh.
Att: I'm going to treat Billy as though he might have asthma with some
medicine that he will breathe in. I will be back in a moment to explain
what I think is going on and how to use the medicine. Sound O.K., Billy?
Billy: O.K.
Att: (walking outside exam room) Your recommendation for a chest x-ray?
I don't think so. Let me write out a prescription and then we can go talk
to the mother and explain things.
Stu: (hesitantly) Uhhhh. O.K.
Adapted byRichard Sarkin, M.D., SUNY Buffalo, from a teaching case developed by Linda Lesky, M.D., University of Illinois, Chicago.
Objective:
To assist a third-year medical student in the ambulatory setting to learn
by observing your interaction with a patient.
Task:
You are a busy clinician in a busy ambulatory setting. This is the first
week of an ambulatory rotation for a third-year medical student. Your student
has recently completed a two-month inpatient clerkship in Internal Medicine,
but has had no ambulatory experience. Among your patients today is Fred
Thomas, an 17-year-old patient of yours. You have seen Fred once in the
past for a school checkup and today he presents with a sore throat.
You decide that since the student is new to your office that he/she would
benefit from observing your interaction with this patient.
The simulation begins as you tell your student that he/she will be observing
this patient visit. A member of the group will play the role of the patient.
Objective:
To learn from observation of your preceptor's interaction with a patient.
Task:
Your role is that of a third-year medical student. You are a motivated,
enthusiastic student who has had very little experience in the ambulatory
setting. You have recently completed a two-month clerkship in Internal Medicine
which was totally inpatient based.
Your preceptor will ask you to observe a patient interaction. If asked, tell your preceptor that you would be very interested in learning how to take a history from an adolescent. During the simulation, when you enter the room with the preceptor, hang back until the preceptor indicates where you should sit or stand and what you should be doing.
As you observe the interaction, please indicate which of the following is
accomplished:
| Not done | Partially done | Done |
1. Sets up observation. a) Determines student's relevant knowledge. b) Identifies what student should learn from observation. c) Provides clear guidelines for what the student should do during the observation
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2. Introduces student to the patient.
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3. Includes student in discussions with and examination of the patient.
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4. Provides for a brief discussion of learning points after the observation.
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5. Sets an agenda and opportunity for future learning.
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Objective:
To observe a third-year medical student with a patient for two minutes.
Task:
You are a busy clinician in a busy ambulatory setting who is also precepting
a third-year medical student. You are well aware that medical students are
rarely, if ever, observed interacting with patients in ambulatory settings.
For the past week, your student has been independently performing histories
and physical examinations on your patients and then presenting you each
case. You have never actually observed your student taking a history or
performing a physical examination. You have decided that you will now observe
two minutes of your student s next encounter with a patient. Your student
is about to see one of your patients, Fred Thomas, a 17-year-old with a
sore throat for three days.
Objective:
To be observed by a preceptor while your are taking a history or performing
a physical examination.
Task:
You are a third-year medical student doing an ambulatory rotation. You
have been independently taking histories and performing physical examinations
and then presenting each case to your preceptor. None of your interactions
with patients have ever been observed by your preceptor. Your next interaction
will be observed by your preceptor for two minutes. Your patient is Fred
Thomas, a 17-year-old with a sore throat for three days.
For this simulation, you are to follow your preceptor's lead. If asked to take a history, take a history. If asked to do a physical exam, do a physical exam. Simply, follow your preceptor's lead.
As you observe the interaction, please indicate which of the following
is accomplished:
| Not done | Partially done | Done |
1. Discusses the purpose of the observation with the student.
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2. Explains to the student how the observation will be conducted.
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3. Once in the room, explains or has the student explain to patient what will take place.
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4. Observes student-patient encounter without interrupting.
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5. Leaves patient room without disrupting the student/patient exchange.
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6. Provides feedback to the student based on the observation.
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7. Sets an agenda and opportunity for future learning.
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Objective:
To interact with a third-year medical student using a case-based model.
Task:
You are a busy preceptor in a busy ambulatory setting. You are working
with a third-year medical student during his/her ambulatory clerkship. Your
student has just taken a history and performed a physical examination on
one of your patients. Your student is now ready to present you this case.
Interact with your student in whatever way you think will be most effective
to facilitate the student s learning. You will have 5 minutes for this simulation.
Objective:
To present a case to your preceptor in an ambulatory setting.
Task:
You are a third-year medical student working in your preceptor's busy
ambulatory setting. You have just taken a history and performed a physical
examination on one of your preceptor's patients. You will read the following
case and then follow your preceptor's cues. Please take on the role of a
third-year medical student who does not know everything there is to know
about this particular case.
Fred Thomas is a 17-year-old patient who comes to the office today with
a complaint of a sore throat for the past three days. His throat has been
getting progressively worse. He took some Tylenol last night for a low grade
fever and because his throat hurt. He has been able to drink fluids, but
could not eat anything this morning because of the pain. He feels tired
and sick now and says that his fever is higher than it was last night. He
is a senior at the local high school and says that a couple of kids in his
class have had sore throats. He has not been sick very much in the past.
He has no allergies and takes no medication.
On physical examination, he looks a bit ill. His temperature is 101.2. His throat looks red, but you didn't see any exudate. His anterior cervical nodes are tender. The rest of his exam was unremarkable. Now stop and wait for your preceptor's lead.
As you observe the interaction, please indicate which of the following
is accomplished:
| Not done | Partially done | Done |
1. Uses questions to: a) establish the student's understanding of the patient's problem. b) ask for the most likely diagnosis. c) ask for a management plan.
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2. Clarifies the student/preceptor roles before seeing the patient.
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3. If the patient is seen, the preceptor includes the student in discussions with and examination of the patient.
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4. Provides constructive feedback on student performance.
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5. Sets an agenda and opportunity for future learning.
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Objective:
To simulate the role of a patient as part of an interaction between a
preceptor and a third-year medical student in an ambulatory setting.
Task:
You are Fred Thomas, a 17-year-old patient who has had a sore throat
for 3 days. Your throat seems to be getting worse each day. Today you feel
tired and are having difficulty swallowing. You have been able to drink
liquids, but were not able to eat today because of the pain. You began to
have a low grade fever last night. You took some Tylenol for the pain and
fever last night, but your throat hurts worse today and your fever feels
like it is a bit higher.
If someone examines you, tell them your throat hurts when you open your
mouth. Also, if your neck is examined, tell them it hurts on both sides
under your jaw.
Please feel free to fill in any other details during the simulation that you think a 17-year-old patient might say regarding this visit to the doctor.
There are many models for case-based teaching in the ambulatory setting.
The classic case-based encounter between a student and a preceptor may be
described as follows: the student is asked to independently perform a history
and physical examination on a patient and then present the case to the preceptor.
What happens next?
I. Ask Two Key Questions, That's Enough
1. What do you think is going on?
2. Why do you think that?
II. Ask Two Key Questions and a Few More -- That's More Than Enough
III. Use Socratic Questioning
IV. Make a Focused Teaching Point
V. Teach a General Rule
VI. Give a Mini-Lecture
VII. Provide Expert Consultation
VIII. Engage in Joint Problem Solving
IX. Be a One-Minute Preceptor
(Kay Gordon, Barbara Meyer, M.D., and David Irby, Ph.D., University of Washington)
1. Get a commitment. (What do you think is going on?)
2. Probe for supporting evidence. (Why do you think that?)
3. Teach general rules.
4. Tell them what they did right and the effect it had.
5. Correct mistakes.
X. Delay Discussion -- There's No Time Right Now, Let's Go In Together
XI. Recommend a Time Out -- You Need to Do Some Reading
XII. Yell When You're Ready -- We'll Discuss the Case in Front of the Patient
Overview with objectives.
Lost Teachable Moments (choose adult or pediatric version)
Activated Demonstration - Preceptor Role
Two Minute Observation - Preceptor Role
Case-Based Teaching - Preceptor Role
Models for Case-Based Teaching in the Ambulatory Setting
Facilitator Guide (if a small group facilitator model is used, facilitators should have copies of all of the following)
Activated Demonstration - Student Role (to student)
Activated Demonstration Checklist (1 copy for every participant)
Two Minute Observation - Student Role (to student)
Two-Minute Observation Checklist (1 copy for every participant)
Case-Based Teaching - Student Role (to student)
Case-Based Teaching Checklist (1 copy for every participant)
Patient Role (same for each simulation)
The workshop begins with the discussion of the case Lost Teachable Moments
in either the adult or pediatric version which is intended to loosen up
the group and point out the difficulties as well as the opportunities of
teaching during patient care. We recommend that you ask for 3 (adult) or
4 (pediatric) volunteers to actually read the parts in the case.
This workshop on precepting has as its central component three simulations
using the same case to teach in three different ways. There are several
formats that can be used for the simulations. Whatever format is used, we
recommend doing the simulations in small groups. Each simulation takes approximately
30 minutes, including the debriefing. The focus is on matching teaching
strategies to individual student needs.
One format for the workshop is to have one workshop leader who divides
the large group into small groups of three participants per group. Participants
would then take turns playing the roles of the preceptor, student, and patient.
Once the small groups have completed the first simulation and discussed
what happened in their group, the workshop leader would lead a debriefing
with the entire group and distribute the checklist before moving back to
the small groups and the next simulation.
Another format is to use actual medical students as "standardized
students." The students are not playing themselves although we think
that the scenarios will be ones that will be familiar to them. Participants
can work in groups of 3-8 with each group having one student who will do
all three roles. It is preferable if each group has a facilitator but one
facilitator can shepherd several groups working in the same room. The facilitator
role is described in the accompanying Facilitator Guide. (The use of students
in standardized roles is described in Lesky LG and Wilkerson L. Using Standardized
Students to Teach a Learner-Centered Approach to Ambulatory Precepting.
Academic Medicine, 69: 955-957, 1994.)
After the three simulations have been completed, the workshop can conclude
with a summary of the essential precepting skills for teaching around patient
cases that have been explored in the simulations. The handout, Models for
Case-Based Teaching in the Ambulatory Setting, may be used to suggest additional
"arrows in the quiver."
You will be responsible for organizing the workshop simulations and facilitating
their discussion. The workshop leader should already have reviewed the objectives
of the workshop and done the Lost Teachable Momentsn case. As a small group
facilitator, you will have several tasks:
1. Have participants introduce themselves
2. Explain the simulation exercise and tell them that you will need a
volunteer each time to serve as the preceptor. The first simulation, Activated
Demonstration, is the easiest so it does not pay to delay. Consider this
a learning opportunity. The preceptor role for Activated Demonstration is
in the workshop handout and you should review it before the start of the
workshop.
3. Set up 2 chairs away from the small group for the student and the
preceptor. Ask the student to take one of the chairs. The student has already
seen his/her role but a copy is enclosed in the packet for you.
4. Ask the group to read the preceptor sheet for Activated Demonstration.
Recruit a volunteer for the role of the preceptor. You may need to discuss
the precepting assignment if there are questions.
5. Remind the preceptor that he or she has only 10 minutes for this task
given the busy nature of the practice (more time is always desirable; this
is a minimum). Watch the time and call stop at minutes even if the simulation
is not finished. You will have plenty to discuss.
6. Ask the preceptor how it went. The person in the hot seat gets to
respond first!
7. Open up the discussion to the entire group. What else might they have
included and why? What should be a priority if time is limited?
8. Ask the student for any suggestions.
9. Pass out the Activated Demonstration checklist with the comment, "This
is a summary of the strategies that we have been discussing. What did we
cover?" Read quickly down the sheet and make a few comments on any
ideas that were not raised in the simulation and its discussion. It has
been my experience that everything gets raised. You might ask that participants
individually assess their own use of this teaching format using the form
as a summary for this simulation.
10. Repeat the same process with the other two simulations, Two-Minute
Observation and Case-Based Teaching. The Preceptor Roles are in the participants'
handouts and the Checklists should be handed out as needed.
11. A Patient Role has been included and may be used for any or all of the simulations. You will need to recruit a volunteer to play the patient. You probably won't have time for the preceptor and the student to "see the patient together" in the Case-Based Teaching simulation but some preceptors prefer to hear the case with the patient present rather than in the hallway. It is usually helpful to talk about recruiting patients to see students during the debriefing on this simulation.
Please use the following scale to rate aspects of the workshop:
5 = Excellent
4 = Very Good
3 = Good
2 = Fair
1 = Poor
| Workshop leader's facilitation skills |
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| Small group facilitator's skills |
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| Quality of the workshop materials |
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| Workshop's relevant to your needs |
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| Overall workshop effectiveness |
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What did you find most useful about this workshop?
Identify one teaching behavior that was discussed in this workshop that
you would be willing to try in your own teaching setting.
Comments.
Developed by Richard Sarkin, M.D., SUNY, Buffalo , and LuAnn Wilkerson, Ed.D., UCLA .
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