"The One Minute Preceptor: Microskills of Clinical Teaching" was originally developed by Kay Gordon, M.A., and Barbara Meyer, M.D., M.P.H., Department of Family Medicine, University of Washington School of Medicine. This workshop handout was designed by David Irby, Ph.D., when he was at the University of Washington School of Medicine.
Neher JO, Gordon KA, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching. JABFP, 5:419-24, 1992.
Most clinical teaching takes place in the context of busy clinical practice where time is at a premium. The five microskills of the One Minute Preceptor teaching model enable teachers to effectively assess, instruct and provide feedback more efficiently. This model is used when the teacher knows something about a case that is being presented that the learner either needs or wants to know.
This workshop will define and provide opportunities to practice five microskills:
1. Get a commitment.
What do you think is going on?
2. Probe for supporting evidence.
Why do you think this?
3. Teach general rules.
4. Reinforce what was right.
Tell them what they did right and the effect that it had.
5. Correct mistakes.
Tell them what they did right.
Tell them what they did not do right.
Tell them how to improve for the next time.
When distinguished clinical teachers in medicine listen to case presentations during teaching rounds, they first diagnose the patientís problem, then assess the learnerís needs, and finally provide targeted instruction to the learnerís point of need.
The microskills in this program facilitate this instructional process. The first two microskills (get a commitment and probe for underlying reasoning) diagnose learner knowledge and reasoning. The last three microskills (teach general rules, reinforce what is right and correct mistakes) offer tailored instruction.
A new first-year resident presents a case to you while you are attending in the ambulatory clinic. The resident appears to be bright and eager to learn.
Resident: "I just saw a 48-year-old male in the clinic with a chief complaint of headaches. This patient has been in his normal state of good health recently. However, for the past few months, he has been having headaches. The headaches seem to begin in the afternoon and get progressively worse. By the evening, he usually has to take either aspirin or Tylenol or both, and must lie down to relieve the pain. After an hour or so, the pain is better, although the headache is not completely gone. By morning after a good nightís sleep, the headache is no longer present. These headaches are now occurring about three times per week. They are not associated with an aura, nausea, vomiting, or blurry vision. The patient works as an investment banker and says his job is stressful. He describes things at home as going well. He has had a history of similar headaches off and on in the past, but his headaches have not been a problem for quite some time.
"On physical exam, he appears well-developed, well nourished, in no apparent distress. His vital signs are within normal limits including a blood pressure of 120/80. His HEENT exam is unremarkable, except I didnít get a very good look at his fundi. His lung, heart and abdominal exam were normal. His neurological exam seemed fine to me."
Preceptor: "This sounds like a case of tension headaches. Iíll check his fundi really quickly, but I doubt Iíll find anything. Sounds like he needs to relax a bit. Letís go see him."
(Same case presentation by the resident as in Scenario One):
Preceptor (getting a commitment): "What do you think is going on?
Resident: "Well, Iím concerned he might have migraine headaches."
Preceptor (probing for supporting evidence): "Why do you think this?"
Resident: "Well, the headaches occur three times a week and usually begin at about the same time. Even though he has a stressful job, I think we have to rule out migraines. He says he needs to lie down and the headaches get better, so maybe theyíre migraines, even though he doesnít have an aura. Iím also worried about a brain tumor because I couldnít see his fundi. I really wish I could have seen his fundi to make sure he doesnít have a brain tumor."
Preceptor: "Are there any other causes of the headaches that you might consider?"
Resident: "Maybe tension headaches, but Iím really not sure."
Preceptor (teaching general rules): "I think the most important aspect of this case is that common things occur commonly. Of all the causes of headaches is this patientís age group, tension headaches are most common. He has a stressful job and the headaches seem to begin in the afternoon which perhaps suggests that he gets stressed at work and then gets a headache. Migraines are a possibility, but not as likely as tension headaches in this case. I agree that we should make sure his fundi are normal, but this does not sound like a classic story for a brain tumor."
Resident: "Could you show me how to get a good look at his fundi?"
Preceptor (telling what was done well and what needs to improve): "Sure. By the way, you did a good job of collecting and organizing the history and physical exam. Your presentations are improving. I particularly liked that you were able to tell me you couldnít get a good look at this patientís fundi. Itís very important to be truthful about what you can and canít do. Your knowledge about headaches is a bit concerning to me and needs to improve. I would suggest you do a bit of reading about headaches as well as the classic presentation of a brain tumor, and that we discuss headaches at your next clinic session. Letís go see your patient."
Cue: After presenting the facts of a case to you, the learner either stops to wait for your response or asks your guidance on how to proceed. In either case, the learner does not offer an opinion on the data presented. If you recognize the patientís problem, your immediate response is to want to tell the learner the answer.
Preceptor Response: Instead, you ask the learner to state what the
learner thinks about the
data that has just been presented. The learner may propose a diagnosis, suggest a management plan, try to figure out why a patient is non-compliant, or discuss whom to consult on a particular case.
Rational: Asking learners how they interpret the data is the first step in diagnosing their learning needs. Without adequate information on the learnerís knowledge, teaching might be misdirected and unhelpful. When encouraged to offer their suggestions, learners not only feel more of the responsibility for patient care but enjoy a more collaborative role in the resolution of the problem.
"What do you think is going on?"
"What other information do you feel are needed?"
"What would you like to accomplish in this visit?"
"Why do you think the patient has been non-compliant?"
It is not offering your own opinion.
"This is obviously a case of pneumonia."
It is not asking for more data nor is it Socratically leading learners to the
"Did you find out which symptom came first?"
Cue: When discussing a case, the learner has made a commitment regarding the problem presented and looks to you to either confirm the opinion or suggest an alternative. You may or may not agree with the opinion and your instinct is to simply tell what you think about the case.
Preceptor Response: Before offering your opinion, ask the learner for
the evidence that
supports the learnerís opinion. A corollary approach is to ask what other choices were considered and what evidence supported or refuted those alternatives.
Rationale: Learners proceed with problem solving logically from their knowledge and data base. Asking them to reveal their thought processes allows you both to find out what they know and to identify where there are gaps. Without this information, you may assume they know more or less than they do and risk targeting your instruction inefficiently.
"Why do you think this?"
"What were the major findings that led to your conclusion?"
"What else did you consider? What kept you from that choice?"
"What questions are arising in your mind?"
It is not list making nor an oral examination/grilling about the
"What are the possible causes of heart failure?"
It is not a judgement of the learnerís thought process.
"I really donít think this is infectious mono. Donít you have any other ideas?"
It is not your own opinion on the case.
"This seems like a classic case of..."
It is not asking for more data about the case than was presented initially.
"What do you know about her previous childbirth?"
Cue: You have ascertained from what the learner revealed that the case has teaching value. You know something about the case which the learner needs or wants to know.
Preceptor response: Teach general rules, concepts or considerations,
and target them to the
learnerís level of understanding. A generalizable teaching point can be phrased as: "When this happens, do this..."
Rationale: Instruction is both more memorable and more transferable if it is offered as a general rule or a guiding metaphor. Learners value instruction that is stated as a standardized approach for a certain problem or as a key feature of a particular diagnosis.
By targeting your instruction, the risk of misjudging the learnerís level of sophistication is minimized. The learner is neither insulted nor lost and valuable time is not wasted.
"If the patient only has cellulitis, incision and drainage is not possible. You have to wait until the area becomes fluctuant to drain it."
"Patients with cystitis usually experience pain with urination, increased frequency and urgency, and they may see blood in their urine. The urinalysis should show bacteria and white blood cells, and may also have some red blood cells."
It is not an unsupported, idiosyncratic approach.
"Iím convinced the best treatment for diarrhea with salmonella enteritis is still a liquid or soft diet."
Cue: The learner has handled a situation in a very effective manner that resulted in helping you, patients, or other colleagues. The learner may or may not realize that the action was effective and had a positive impact on others.
Preceptor response: Take the first chance you find to comment on: 1)
the specific good work
and 2) the effect it had.
Rationale: All learners need feedback. Some good actions are pure luck, others are more deliberate. In either case, learnersí knowledge, skills and attitudes are not well established and are therefore, "vulnerable." Unless reinforced, competencies may never be firmly established.
"You didnít jump into solving her presenting problem but kept open until the patient revealed her real agenda for coming in today. In the long run, you saved yourself and the patient a lot of time and unnecessary expense by getting to the heart of her concerns first. Nicely done."
"Obviously you considered the patientís finances in your selection of a drug.
Your sensitivity to this will certainly contribute to improving his compliance.
It is not general praise.
"You are absolutely right. That was a wise decision."
"You did that IV preparation very well."
Cue: The learnerís work has demonstrated mistakes (omissions, distortions, or misunderstandings) that have or will have an impact on the patientís care, the teamís functioning, or the learnerís own effectiveness.
Preceptor response: As soon as possible after a mistake has been made,
find an appropriate
time and place to discuss what was wrong and how to avoid or correct the error in the future. Allow the learners the opportunity to critique their performances first.
Rationale: All learners need feedback. Mistakes left unattended have a good chance of being repeated. Discussing what was done wrong and what could be done differently is essential.
Learners who are aware of their mistakes and know what to do differently in the future need only to be reinforced. Learners who are aware of their mistakes but unsure of how to avoid the situation in the future are very likely to be in a "teachable moment" (they are eager for and appreciate tips that will help them get out of or avoid the uncomfortable situation in the future).
Learners who are unaware that they made a mistake or are unwilling to admit the error are more troublesome. Obviously they have not seen that their action has an undesirable consequence. In order to maximize learning for them, detailing the negative effect as well as the correction are both essential for effective feedback.
"You may be right that this childís symptoms are probably due to a viral; upper respiratory infection. But you canít be sure it isnít otitis media unless youíve properly examined the ears."
Avoid vague, judgmental statements.
"You did what?"
A third-year medical student has just seen a patient in the ambulatory clinic. The student is now ready to present the case to a preceptor.
Student: "Ms. Porter is a 44-year-old patient who has a chief complaint of a cough for the past few weeks. She had been in her usual state of good health until a few weeks ago when she developed what sounds like an upper respiratory infection including a runny nose and cough. The runny nose resolved after a few days, but the cough has persisted. The cough is worse at night and now keeps her awake. She has had no fever, weight loss, change in appetite, and is not bringing up any sputum. She recalls having had coughs in the past, but not as bad as this one. She thinks she might have had bronchitis a few times when she was a child. She doesnít smoke.
"On physical exam, she looks well and is in no distress. Her vital signs are within normal limits. Her exam is unremarkable, but she did cough a few times. Her lungs were clear."
(Preceptor as expert consultant: "Sounds like she might have asthma. Letís go see her.")
Preceptor (getting a commitment): "What do you think is going on?"
Student: "I think she might have a post-nasal drip that is causing her to cough."
Preceptor (probing for supporting evidence): "Why do you think that?"
Student: "Well, she had a cold and she started to cough. Now she is still coughing. Maybe she never quite got over the cold and itís still causing her to cough even though her nose isnít running any longer."
Preceptor: "Can you think of any other possibilities to explain her cough?"
Student: "I was thinking about pneumonia, but she is not febrile and her lungs sound clear. I doubt she has lung cancer. She has never been a smoker."
Preceptor (teaching general rules): "Although post-nasal drip is a possibility, I think another diagnosis that we might think about is asthma. You didnít mention whether she has a family history of asthma or whether she has ever wheezed in the past. Patients with have been diagnosed as having bronchitis when they were children actually may have had exacerbations of asthma. An important point to emphasize is that you donít have to wheeze in order to have asthma. This patientís URI could have triggered an asthma exacerbation that now presents as cough which is worse at night."
Student: "I never thought of asthma in this patient."
Preceptor (telling what was done well and what needs to
improve): "By the way, I thought your case presentation was much better
organized than the one this morning. You seem like you are more confident when
you present. Your history was fairly complete except for not exploring the
possibility of asthma in this case. Asthma is such a common diagnosis,
particularly at this time of the year. I would suggest you do a bit of reading
about asthma. Letís go see your patient."
The five microskills of the One Minute Preceptor teaching model will now be practiced. Working in triads or small groups, each person will have the opportunity to play the role of a "learner," a "preceptor" and an "observer" of the interaction.
Learner: Use one of the trigger cases at the end of this workbook. Remember that learners make mistakes and modify your presentation accordingly! Donít offer your ideas too freely, or the preceptor will be left with nothing to do.
Preceptor: Use as many of the microskills as you can - try for at least the first two (getting a commitment and probing for evidence). Remember that these skills are counter-intuitive and may not be part of your regular teaching scripts. Thus, you will need to be purposefully aware of the microskills as you practice them.
Observer: Take brief notes on the dialogue, cues and responses. What microskills are being used? What suggestions can you make for improvement?
1. Choose roles.
2. Role play for 3 to 5 minutes beginning with the "learner" reading one of the practice cases to the preceptor.
3. The "preceptor" should then try to use the five microskills of the One Minute Preceptor model to assess, instruct and provide feedback.
4. After completing the simulation, allow the "preceptor" to critique the
role play first, then the "learner," then the "observer."
PRACTICE CASE #1
Mr. Jones is a 55-year-old male who presented with a three hour history of chest pain which began shortly after he ran up four flights of stairs at work. He noted that the pain was continuous but seemed to decrease in intensity after he rested in his office for a short period of time. When the pain did not go away completely, he came to the emergency room at which point the pain seemed to subside. Mr. Jones has no past medical or surgical history of any consequence and has not seen a physician since his Army discharge nearly 30 years ago. He does relate that he has 2-3 ounces of alcohol per day generally at dinner time and smokes 1-2 packs of cigarettes per day, a habit which he began in the service.
Physical examination revealed an alert, slightly obese male in no acute distress, blood pressure 170/90, pulse 110. HEENT was unremarkable, the lungs were clear and the heart was regular with an occasional premature beat. The abdomen was benign and the remainder of the physical examination was unremarkable.
PRACTICE CASE #2
Ms. Linden is a 25-year-old woman who presents with a 12 hour history of increasing abdominal pain. She has been nauseated, vomited a couple of times, and passed one loose bowel movement a few hours prior to being seen. She has experienced slight dysuria, but no urinary frequency or urgency. She denied any vaginal bleeding, but has had slight yellow discharge. She does not think she has had any fevers. Motrin which gave some relief when she took it shortly after the onset of the pain, does not give her any relief now. Her past medical history includes frequent UTI's and a previous pelvis infection of some sort, but is otherwise unremarkable. She takes no medications regularly.
On physical examination, she appeared in mild distress, blood pressure of 140/90, temperature of 100.8, heart rate of 120 and respiratory rate of 24. Her HEENT, neck, chest, and heart exam were normal. Her abdomen was diffusely tender, more so over the lower abdomen and RLQ. She had questionable CVA tenderness bilaterally.
PRACTICE CASE #3
Mr. Smith is a 35-year-old male who presented with a painful swollen left
leg. Mr. Smith related that over the last several days he has noticed some funny
feeling in his leg. Today, he noted that his left leg had become much larger
than his right leg and he was concerned about this problem. He denies any
history of trauma to his leg. He is an otherwise healthy person who has no other
significant past medical or surgical history. On physical examination, he looked
well and was afebrile. The only pertinent physical finding was a left leg which
was tender and larger than the right leg.
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