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Advanced Precepting: A Learner Centered Approach

Linda Pinsky, MD

There is increasing interest in methods for effective, time-efficient teaching. Physician educators have suggested several different approaches on "how best to teach." In analyzing these approaches, it is helpful to consider the unique challenges of attending in the ambulatory and inpatient settings and the similarities among the different methods used to meet those challenges.

I. Challenges specific to ambulatory medicine

A. Time limitations
1. Limited time for the encounter
2. Limited or no time for preparation
B. Patient characteristics
1. Patients with symptoms related complaints often without clear diagnoses
2. Patients whose complaints require longitudinal care beyond the scope of the learner's participation
C. Learner characteristics
1. Learners' have variable level of ambulatory medicine experience, even at the same training level
2. Learners have dual inpatient and outpatient responsibilities in which the drama of hospitalized patients is often overriding
D. Productivity demands
1. Increasing emphasis on clinical productivity
2. Billing restrictions (i.e. HCFA)

II. Changes of medical education in general

A. Medical Knowledge
1. Knowledge-rich field: There are multiple areas for the teacher to know, and many of issues that may come up may be areas outside of the knowledge base
of the teacher.
2. Knowledge-dense encounters: There is an extensive body of material which can be taught about any one condition, disease, encounter both in terms of
knowledge and psychosocial dynamics.

B. Teaching demands
1. Diagnosing the learner: There is a need to ascertain the level and depth of understanding of the learner by knowledge organization type as well as by
knowledge base which may vary by particular disease, patient encounter, etc.
2. Promoting learner involvement: Learning is generally most successful if there is the learner is an active participant in the process.
3. Repertoire of approaches: Learning occurs with a variety of learners within different settings necessitating a flexible teacher equipped with multiple
techniques.

III. Overview: Teaching learning theory


A. Reflection

1. Central to the various suggested approaches to clinical teaching is the hypothesis that the experience of clinical practice is translated into learning through reflection.
2. Reflection can occur in each phase of the teaching process: planning, teaching, and reflecting.
a) anticipatory reflection: thinking about how to prepare for the visit.
b) reflection-in-action: the self-monitoring and adjustment process in the midst of the clinical encounter.
c) reflection-on-action: deliberative evaluation and planning after encounter
3. Teachers maximize their teaching skills by using reflective process and maximize the learner's education by facilitating the learners' use of reflection.

B. Transfer of knowledge

1. Occurs in a context specific setting.
a) Provide numerous opportunities for repeated practice in similar situations
b) Facilitate discussions that promote generalization.

C. Learning structures

1. Learners form individualized cognitive infrastructures to store, process and use knowledge.
2. What a learner already knows is relevant to what they will learn.
a) diagnose the learner's knowledge organization level and information base.
b) provide cues to prompt the learners' to link memory of new learning to prior experience.

IV. Learner-Centered Teaching: Tools for Success

A. Anticipatory reflection

1. Schedule appropriate patients: give anticipatory readings if appropriate.
2. Prime learner for patient if known.
3. Indicate the type of teaching interaction to follow.
a) Modeling, two-minute observation, case presentation.
b) Consider bedside presentations.
4. Empower the learner!
a) Discuss visit strategies to optimize patient care, patient satisfaction and time
management.( see appendix A)
b) Discuss learner directed case presentation approach.( See Appendix B)

B. Reflection-In-Action

1. Diagnose the patient:
a) Develop teaching scripts to facilitate succinct teaching.
b) adjust your involvement according to the severity and urgency of the patient complaint.
2. Diagnose the learner:
a) Knowledge organization:

i ) Use questions to diagnose learners' organization of knowledge: reduced (know nothing), dispersed (list like organization structure), elaborated and compiled(expert type)

b) Knowledge Base

i) One-Minute Preceptor:
Get a commitment.
Probe for supporting evidence.
Teach general points.
Tell them what they did right.
Correct mistakes.

3. Use learner directed teaching points to allow learner to maintain primary relationship with patient and feel ownership of learning interaction (See Appendix B)
a) Allow learner to describe the clinical questions to be addressed.
b) Allow learner to describe length of precepting interaction.
c) Allow learner to set agenda for in-the-room interactions.

· How much time to spend.
· What role attending will have- observant, consultant, demonstrator, etc.
· Who will introduce the attending- resident or attending.
· What will happen in the room- history, phys. exam, patient education
· How you will deal with disagreements/errors.

d) Negotiate explicitly when your assessment of learner's needs differ from learner's.
e) Follow the agenda you have negotiated.

4. Encourage learner reflection before, during, and after patient care encounter
a) Question learner as to the features of the learning context: age, gender, patient population, associated symptoms
b) Ask learner for one general teaching point (Teach pearls, not comprehensive review of the subject
c) Ask learners for assessment of psychosocial dynamics of the interaction
d) Problem solving with learner : key points
e) Utilize a repertoire of responses to case presentations:

i. Adjust your response according to the needs of the patient, the level of competency of the learner, and the time schedule

C. Reflection on Action
1. Debrief the learner; ask for learner self-assessment first; give formative feedback.
2. Define with learner areas for future study; recommend reading appropriate to learner's knowledge organization and knowledge level
3. Using other teaching forums to supplement patient care encounters: Interactive pre or post clinic conferences, ambulatory morning report, chart review, critical review of the literature, critical incident narratives, videotape reviews, etc.

V. Resources to improve teaching

A. Self-assessment
1. Use reflection, video- or audio tape review, and any feedback from others that you think is appropriate and helpful. Continue to try innovative approaches knowing that failure is inherent in future success.
B. Learners' feedback
1. Learners describe a good teacher as someone who is enthusiastic, involved and concerned. Set teaching goals and ask for specific feedback on them.
C. Education consultation sessions with colleagues
1. Take time to discuss educational success and failures. Use your colleagues as consultant similar as you would on medical issues.
D. Faculty development workshops
E. Medical education literature
1. Bordage G "Elaborated knowledge: a key to successful diagnostic thinking." Acad. Med. 1994 69(11):883-5
2. DaRosa DA Dunnington GL. Stearns J Ferenchick G Bowen JL. Simpson DE " Ambulatory teaching "lite": less clinic time, more educationally fulfilling" Acad. Med. 1997;72(5):358 61.
3. Ferenchick G Simpson D Blackman J. DaRosa D Dunnington G "Strategies for efficient and effective teaching in the ambulatory care setting." Acad. Med. 1997; 72 (4):277 80.
4. Gruppen LD "Implications of cognitive research for ambulatory care setting." Acad. Med. 1997; 72 (2):117 20.
5. Kroenke K, Omori DM, Landry FJ, Lucey CR Bedside teaching. South Med. J 1997 Nov; 90 (11):69-74.
6. Lehman LS, Brancati FL, Chen M, Roter D, Dobs AS. "The effect of bedside case presentations on patients' perceptions of their medical care. "NEJM 1997, 336(16):1150 55.
7. Lesky LG, Borkan SC, "Strategies to improve teaching in the ambulatory medicine setting," Arch Intern Med. 1990; 150: 2133-7
8. Lichenstein PR Young G, "My Most Meaningful Patient' Reflective Learning on a General Medicine Service," J Gen Intern Med. 1996;11: 406-9
9. McGee SR Irby DM "Teaching in the outpatient clinic. Practical tips." J Gen Intern Med. 1997;12 Suppl 2:s34 40.
10. Nair BR, Coughlan JL, Hensly MJ. Student and patient perspectives on bedside teaching. Med. Educ 1997 Sept;31(5):341-6.
11. Sarkin R, Wilkerson, L, "Arrows in the Quiver: Models for teaching in the Ambulatory Setting," Workshop presentation, UW, 1997.
12. Skeff KM Bowen JL Irby DM "Protecting time for teaching in the ambulatory care setting." Acad. Med. 1997;72(8):694 7.
13. Smith CS Irby DM "The roles of experience and reflection in ambulatory care education." Acad. Med. 1997; 72(1):32 5.