Teaching in the Outpatient Clinic Setting

Office of Medical Education Creighton University School of Medicine

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Module Objectives

After completing this module, the learner will be able to

• Discuss outpatient medicine as a valuable setting for teaching and learning

• Describe attributes of effective medical educators

• Discuss the significance of feedback to learners

• Describe 3 teaching models for outpatient medicine

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Teaching in outpatient clinic setting

Advantages: It’s busy and great care happens here.

You already know the challenges:

• Limited time and RVU pressures

• Space may be small or awkwardly-arranged

• Patient cases are variable, unpredictable

• May have limited continuity with learners

Solutions?

• Draw upon your “non-resource” tools

• Use teaching models to maximize time, focus on the learner

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Effective Medical Educators

• Great teachers do “more” than just teach

• This does not always require more time or expertise

• You can become more efficient with time for teaching CUSOM

Effective Medical Educators

“Do the kind thing and do it first.”

-William Osler, MD, CM

The literature on medical educators demonstrates the need for a combination of attitudes, knowledge and skills.

Attitudes

Passion as a teacher ▪ Accessible to learners

Role model ▪ Kindness ▪ Advocate for education

Seek knowledge of learners ▪ Know and state limitations

Stimulate curiosity ▪ Create safe learning environment

(Hatem et al. 2011)

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Knowledge Employ pedagogy ▪ Promote scholarship

Current understanding of discipline Use teaching techniques congruent with neuroscience and

behavioral psychological evidence

Skills Communicate knowledge effectively ▪ Lecture effectively

Promote critical thinking ▪ Listen effectively Adaptable ▪ Provide constructive feedback

Provide timely evaluations ▪ Use tech effectively Promote self-directed learning ▪ Demonstrate leadership

Create a learning community

(Hatem et al. 2011)

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Improving Learning

• There are many theories and models that help us understand how adults learn

• An evolving set of ideas and principles from many disciplines

• The common theme is the need to recognize differences in learners’

• Prior experiences

• Preferences

• Motivation

• Direction/regulation of learning

• Reflection

When in doubt, ASK the learner what they already know, what they want to learn, and what they learned (K – W – L)

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Feedback Improves Learning

• Feedback is the cornerstone of effective clinical teaching

• Considerable evidence to support this

Examples:

• Feedback improves learning (Boehler et al. 2006)

• Students want more feedback (De et al. 2004)

• Giving feedback will likely improve your teaching ratings (Dobbie and Tysinger, 2005)

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Feedback Defined

• Information describing students or house officers performance in a given activity that is intended to guide their future performance in that same or in a related activity (Ende 1983)

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Feedback

Feedback is NOT non-specific praise, compliments, or encouragement Feedback IS • Objective appraisal of performance • Based on observed behaviors

• Formative (during learning) assessment CUSOM

Purpose of Feedback

• Reinforce positive actions

• Correct areas for improvement

• Guide future learning

• Confirm achievement of competency

• Promote reflection

(Gigante, Dell and Sharkey 2011)

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Effective Feedback

• Specific

• Timely

• Objective (based on observed behaviors)

• Plan for improvement

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Teaching Models for Outpatient Medicine

• Traditional model: Preceptor asks students to present a case and then the preceptor asks questions. This may end with a brief teaching “pearl” from the preceptor.

• Newer models are learner-centered:

• One-Minute Preceptor

• SNAPPS Model

• RIME Framework

(Chacko, Aagard, Irby 2007; Pangaro 1999)

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The 5 Microskills Model (aka One Minute Preceptor)

SKILL EXAMPLE

Get a commitment What do you think is going on here?

Probe for supporting evidence

What led you to that conclusion? What factors in the history and exam support the diagnosis?

Teach general rules The key features of this illness are…

Reinforce what was right You did an excellent job with…and this is why that is important…

Correct mistakes The next time this happens, try this instead…

(Neher and Stevens 2003)

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Watch a demonstration

http://www.youtube.com/watch?v=VKRHLyPq9xY&feature=related

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The SNAPPS Model

STEP

S Summarize the history and findings

N Narrow the differential to 2-3 possibilities

A Analyze the differential by comparing and contrasting the possibilities

(Wolpaw, Wolpaw, Papp 2003)

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SNAPPS Model, continued

STEP

P Plan management for the patient’s medical issues

P Probe the preceptor by asking questions about uncertainties, difficulties, or alternative approaches

S Select a case-related issue for self-directed learning

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RIME Framework The RIME Framework is a developmental model that helps faculty differentiate between learner levels, set appropriate expectations, and communicate these in a common language

R Reporter: Able to accurately gather and communicate clinical data on their patients.

I Interpreter: Able to identify and prioritize problems; able to develop a differential diagnosis; able to answer “why” questions

M Manager: Able to create a diagnostic and therapeutic plan; able to make judgments between options and priorities

E Educator: Able to teach others; able to cite evidence; able to identify knowledge gaps

(Pangaro 1999)

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Summary

• Teaching in the outpatient setting does not require lectures and other didactic time

• Involving the learner, serving as a role model, and creating a positive learning environment are important aspects of teaching

• Create brief, structured opportunities to assess the learner’s knowledge and then briefly teach 1-2 points

• Create opportunities for the learner to identify knowledge gaps, create a plan to address these, and then teach you and the team CUSOM

References

Boehler ML, Rogers DA, Schwind CJ, Mayforth R, Quin J, Williams RG, Dunnington G. An investigation of medical student reactions to feedback: a randomised controlled trial. Med Educ 2006; 40:746-749. Chacko KM, Aagard E, Irby D. Teaching models for outpatient medicine. Clin Teach. 2007; 4:82086. De SK, Henke PK, Ailawadi G, Dimick JB, Colletti LM. Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship. J Am Coll Surg 2004;199:932-942. Ende J. Feedback in clinical medical education. JAMA 1983;250(6);777-781.

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References

Gigante J, Dell M, and Sharkey A. Getting beyond ‘good job’: How to give effective feedback. Peds 2011;127:205-207.

Hatem CJ, Searle NS, Gunderman R, Krane NK, Perkowski L, Schutze GE, Steinert Y. The educational attributes and responsibilities of effective medical educators. Acad Med 2011; 86:474-480.

Neher J. and Stevens N. The one-minute preceptor: shaping the teaching conversation. Fam Med 2003;35(6):391-3.

Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Acad Med. 1999 Nov;74(11):1203-7

Wolpaw TM, Wolpaw DR, Papp, KK. SNAPPS: A learner-centered model for outpatient education. Acad Med. 2003;78:893-898.

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For Additional Reading

Gordon, J. ABC of learning and teaching in medicine: One to one teaching and feedback. BMJ 2003;326:543-454.

Kernan WN, Holmboe E, and O’Connor. Assessing the teaching behaviors of ambulatory care preceptors. Academic Medicine. 2004:79:1088-94.

Parrott S, Dobbie A, Chumley H, Tysinger, JW. Evidence-based office teaching—The five-step microskills model of clinical teaching. Fam Med. 2006; 38(3)164-7.

Riddle JM. Teaching Clinical Skills. in An Introduction to Medical Teaching, 2nd Ed., KN Huggett and WB Jeffries, eds, pp 77-91, Springer, 2014.

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(Created By: Kathryn N. Huggett, Ph.D., October 2014)