Time Efficient Clinical Time Efficient Clinical TeachingTeachingMargo H. Vener, MD MPHMargo H. Vener, MD MPH

Walt Mills, MD, MMMWalt Mills, MD, MMMUCSF School of Medicine and Santa Rosa Family UCSF School of Medicine and Santa Rosa Family

Medicine Residency ProgramMedicine Residency ProgramJune 7, 2011June 7, 2011

Session OutlineSession Outline BackgroundBackground Introduction to the One-Minute Preceptor Introduction to the One-Minute Preceptor

ModelModel One-Minute Preceptor PracticeOne-Minute Preceptor Practice Introduction to feedback and the Brief Introduction to feedback and the Brief

Structured Clinical Observation (BSCO)Structured Clinical Observation (BSCO) BSCO practiceBSCO practice RIME FrameworkRIME Framework

Challenges with Clinical Challenges with Clinical TeachingTeaching

Time pressuresTime pressures Competing demands - clinicalCompeting demands - clinical Often opportunistic - makes planning Often opportunistic - makes planning

challengingchallenging Lack of rewards/recognition for teachersLack of rewards/recognition for teachers Patient acceptance of learnersPatient acceptance of learners

Time Time Average duration of ambulatory Average duration of ambulatory

teaching encounter - 4-10 teaching encounter - 4-10 minutesminutes11

JacksonJackson22

50 ambulatory encounters50 ambulatory encounters 75% of time spent discussing 75% of time spent discussing

patient case/mgmtpatient case/mgmt 30 seconds for feedback30 seconds for feedback

1. Irby DM. Acad Med 1995.2. Jackson JL. Teach Learn Med 2002.

One-Minute PreceptorOne-Minute Preceptor Teaching model initially developed for use Teaching model initially developed for use

in the outpatient settingin the outpatient setting33

Involves 5 steps:Involves 5 steps: Get a commitmentGet a commitment Probe for supporting evidenceProbe for supporting evidence Teach general rulesTeach general rules Reinforce what was done rightReinforce what was done right Correct mistakesCorrect mistakes

3. Neher et al. JABFP 1992.

OMP: Step 1OMP: Step 1 Get a commitment from the learnerGet a commitment from the learner

Ask the learner what he/she thinks about the Ask the learner what he/she thinks about the casecase

Get a commitment to a diagnosis, work-up, Get a commitment to a diagnosis, work-up, treatmenttreatment

OMP: Step 2OMP: Step 2 Probe for supporting evidenceProbe for supporting evidence

Ask the learner for evidence that supports Ask the learner for evidence that supports his/her opinionhis/her opinion

Allows you to identify where there are gaps in Allows you to identify where there are gaps in knowledgeknowledge

OMP: Step 3OMP: Step 3 Teach general rules Teach general rules

Provide general rules/concepts that are Provide general rules/concepts that are targeted to the learner’s level of targeted to the learner’s level of understandingunderstanding

If there is no new information to be added, If there is no new information to be added, you can skip this stepyou can skip this step

OMP: Step 4OMP: Step 4

Reinforce what was done rightReinforce what was done right Reinforcing correct behavior helps the Reinforcing correct behavior helps the

behavior become firmly establishedbehavior become firmly established Comments should focus on specific behaviors Comments should focus on specific behaviors

rather than general praiserather than general praise

OMP: Step 5OMP: Step 5 Correct mistakesCorrect mistakes

As soon after mistake as possible, find an As soon after mistake as possible, find an appropriate time to discussappropriate time to discuss

If possible, allow the learner to critique his/her If possible, allow the learner to critique his/her performance firstperformance first

OMP: Step 6?OMP: Step 6? Encourage self-directed learningEncourage self-directed learning

OMP ClipOMP Clip

OMP: The EvidenceOMP: The Evidence OMP faculty training associated with an OMP faculty training associated with an

increase in specific feedback in increase in specific feedback in ambulatory encountersambulatory encounters44

Videotaped teaching encounters: OMP vs Videotaped teaching encounters: OMP vs TraditionalTraditional Faculty perceive that they are better able to Faculty perceive that they are better able to

assess student skills and are more confident assess student skills and are more confident in their ratings with OMP modelin their ratings with OMP model55

Students preferred OMP model for quality of Students preferred OMP model for quality of feedback it providesfeedback it provides66

4. Salerno S. J Gen Int Med 2002.5. Aagaard E. Acad Med 2004.6. Teherani A. Med Teach 2007.

OMP PracticeOMP Practice

Other teaching models…Other teaching models… SNAPPS ModelSNAPPS Model77

SSummarize findingsummarize findings NNarrow the DDxarrow the DDx AAnalyze the differentialnalyze the differential PProbe the preceptor about uncertaintiesrobe the preceptor about uncertainties PPlan managementlan management SSelect case related issues for self-studyelect case related issues for self-study

Has been shown to facilitate expression of Has been shown to facilitate expression of clinical reasoning and uncertaintyclinical reasoning and uncertainty88

7. Wolpaw et al. Acad Med 2003 8. Wolpaw et al. Acad Med 2009

FeedbackFeedback Information on the student’s performance Information on the student’s performance

given given for the purpose of improving future for the purpose of improving future performanceperformance

Analogous to coachingAnalogous to coaching Key step in the acquisition of clinical skillsKey step in the acquisition of clinical skills Medical students and residents Medical students and residents

dissatisfied with the amount and quality dissatisfied with the amount and quality of feedbackof feedback

The ChallengeThe Challenge Limited opportunities for observationLimited opportunities for observation Lack of specificity of feedbackLack of specificity of feedback

Tips for Giving FeedbackTips for Giving Feedback Immediate Immediate Self-reflection firstSelf-reflection first Both positive and correctiveBoth positive and corrective Focus on behavior - not personFocus on behavior - not person Specific, not generalSpecific, not general Amount limited to what the student can Amount limited to what the student can

incorporate (not too much!)incorporate (not too much!) Check to ensure clear communicationCheck to ensure clear communication

Brief Structured Clinical Brief Structured Clinical Observation (BSCO)Observation (BSCO)

Tool for brief, real-time feedbackTool for brief, real-time feedback Attending enters patient room during patient Attending enters patient room during patient

encounterencounter Watches silentlyWatches silently Leaves when 3 feedback points obtainedLeaves when 3 feedback points obtained

Feedback discussed that dayFeedback discussed that day

BSCO PracticeBSCO Practice

BSCO TipsBSCO Tips Orient student and patientOrient student and patient Consider asking student for observation Consider asking student for observation

focusfocus Carefully position yourself in the room; try Carefully position yourself in the room; try

to remain silentto remain silent Consider times when you are required to Consider times when you are required to

be in the roombe in the room

RIME FrameworkRIME Framework

((OObserver) bserver) RReporter eporter

IInterpreter nterpreter MManageranagerEEducatorducator

Pangaro Acad Med 1999.

OBSERVEROBSERVER - - struggling to report accuratelystruggling to report accuratelyREPORTERREPORTER Works professionally with patients, staff, colleagues; Works professionally with patients, staff, colleagues;

complete, reliable, accurate; gathers info, clearly complete, reliable, accurate; gathers info, clearly communicates with proper termscommunicates with proper terms

Understands pathophysiologyUnderstands pathophysiology Answers “What” questions. Answers “What” questions. INTERPRETERINTERPRETER Identifies, prioritizes problems Identifies, prioritizes problems Offers 2 or 3 Offers 2 or 3 reasonablereasonable possibilities with reasons applied possibilities with reasons applied

to the patient. (Students do not have to be “right”) to the patient. (Students do not have to be “right”) Answers "Why" questions. Answers "Why" questions.

MANAGERMANAGER Selects among options Selects among options withwith the patient the patient Proactive rather than simply reactiveProactive rather than simply reactive Plans should be Plans should be reasonable,reasonable, include test options, include test options,

student’s preferences, merits of therapies student’s preferences, merits of therapies Answers “How" questions. Answers “How" questions. EDUCATOREDUCATOR Identifies questions that can't be answered from Identifies questions that can't be answered from

textbooks textbooks Cites evidence on relevant new therapies, tests Cites evidence on relevant new therapies, tests Active in educating self, colleagues, and patientsActive in educating self, colleagues, and patients

SummarySummary Orient learner to goals/expectationsOrient learner to goals/expectations Choose a tool for clinical teaching (?OMP)Choose a tool for clinical teaching (?OMP) Incorporate frequent observation and Incorporate frequent observation and

feedback (?BSCO)feedback (?BSCO) Think about your learner’s skill level and Think about your learner’s skill level and

what the next steps are in their what the next steps are in their development as a physiciandevelopment as a physician