Teaching in the Ambulatory Setting

1. Teaching in the Ambulatory Setting Gary Ferenchick, MD Michigan State University

2. Goals • To identify and improve upon existing skills in ambulatory education • To identify key factors which improve efficiency and effectiveness in ambulatory education

3. Objectives • Identify key differences between teaching in the ambulatory v inpatient setting • Understand the importance of student orientation • Understand teaching tasks involved in case-based teaching, observation, and modeling • Understand the ways to integrate teaching with patient care • To identify the process of credible feedback

4. Keys to clinical teaching • Demonstrate enthusiasm • Give meaningful (“authentic”) responsibility • Possess credible clinical skills

5. Inpatient vs ambulatory education • Team learning • Advanced preparation • Educational intimacy • Number of examiners • Time/patient pressures • Speed of evaluations

6. Teaching in the Ambulatory Setting NO In depth lectures Seminars Formal educational sessions Extensive discussion

7. Efficient and effective ambulatory care teaching requires that both the student and preceptor accept the limitations of the outpatient setting. Extensive discussions of differential diagnosis, pathophysiology and psychosocial problems are not possible nor necessarily desirable

8. Planning • Scheduling • Orienting • Priming

9. Figure 1Model Schedule

10. Traditional Schedule

11. Orientation and setting expectations Understand the student’s background and personal goals and objectives Explain your vision of the student’s role Your teaching and evaluation style About the practice Create a positive learning environment

12. Priming the trainee • Chart review • One minute summary of patients hx and areas of focus • Allow more efficient use of student/patient time

13. Overall Curricular GoalsMoving the student along the curriculum Reporter (What) Interpreter (Why) Manager (Next steps) Educator (Scholar)

14. Teaching Strategies • The “one-minute” preceptor • Modeling • The “two-minute”observation

15. Teaching StrategiesThe One-Minute Preceptor • Get a commitment • Probe for supporting evidence • Teach general rules --Take each encounter to a learning point • Provide feedback --Positive --Corrective

16. Presentation in front of patient • Saves time • Reinforces the student’s role • Reassures the patient Caution student to alert you beforehand if sensitive HX/PE info present or if they are considering a potentially serious Dx

17. Pitfalls in clinical case based teaching • Taking over the case • Inappropriate lectures • Insufficient “wait time” • 3-5 second wait to answer your question • Preprogrammed answers • What do you think is going on? Could it be gastritis?

18. Pitfalls in clinical case based teaching • Rapid reward • Effectively ends the student’s thinking process • Pushing past ability • Persisting in carrying the student beyond their understanding of what is being asked

19. Teaching StrategiesTwo Minute Observation • Explain the purpose of the observation • Explains how the observation will occur • Informs patient of what will take place • Observes without interrupting • Leaves room without disrupting the student • Provides feedback • Agenda for future learning

20. Teaching StrategiesModeling with trainees • Determine the student’s relevant knowledge • Identify what the student should learn • Provide guidelines of what the student should do during the observation • Includes student in discussions and examination of patient • Provides for brief discussion of learning points after observation

21. Overview of student-patient-preceptor encounter • Orient student to each patient encounter • Brief overview to each patient encounter • Recommendations for time and extent of exam to perform • Student sees patient independently • Student presents in front of patient • One minute preceptor • Student can demonstrate part of PE, preceptor can model certain skills

22. Tasks a student may be able to do“Service-based education” • Patient counseling • Charting/dictating • Lab/x-ray retrieval • Follow-up phone calls • Looking up articles/info (eg Medline)

23. “Session” components Inform learner Based upon direct observation (eg 1 minute preceptor) Select one item Plan for improvment Characteristics Brief/informal Situation specific Informational May not be recognized by trainee LEVELS OF FEEDBACKLevel 1: Daily Feedback

24. Characteristics of Credible Feedback • Formative • Based upon direct observation • Accurately reflects goals mutually understood • Reliably occurs (expected) • Development of plan for improvement • Well timed • Allows time for improvement

25. High-risk area Data gathering Data synthesis Patient assessment Attitude/motivation Areas to look Case presentation HX/PE Written record Diagnosing the learner

26. Other opportunities for feedback • Case based presentation • Diagnosing the learner while diagnosing patient • Two-minute observations • HX, PE, Technical procedures, Educating/Informing patients • Written record • Professional attributes

27. RIME Evaluation Framework Reporter Interpreter Manager Educator Adopted from Pangaro

28. RIME Evaluation FrameworkReporter • Accurately gather and communicate clinical facts • Requires basic skill and knowledge of what to look for • Recognizes normal v abnormal • Confidence to identify and label new problems • Consistency in “bedside” skills, sense of responsibility • These skills must be mastered to pass

29. RIME Evaluation FrameworkInterpreter • Prioritize among problems identified in patients • Offers differential diagnosis (at least three) • Follow-up of tests and their interpretations • Selecting clinical findings which support possible Dxs and applying test results to specific patients • Transitions from “bystander” to active participant in patient care

30. RIME Evaluation FrameworkManager • Deciding when action needs to be taken • Propose and select among at least three diagnostic and therapeutic options for the patient • Take into account particular patient’s circumstances and preferences • Requires more confidence, knowledge, and judgment

31. RIME Evaluation FrameworkEducator • Mastery of the basics • Self-directed learning • Reads deeply and shares new learning with others • Defining important questions to research • Takes drive, insight, skill, maturity, and confidence