Transcript Tom Barber
Precepting medical students in
ambulatory clinical settings:
from barriers to opportunities…
Tom Barber, MD
Co-director, Ambulatory Internal Medicine
Clerkship, BUSM
Associate Professor, BUSM
Moving from barriers to
opportunities: what works?
Setting the agenda
Orientation
Introductions; staff, too
Space, flow, workstations, schedules
Establish expectations: student’s role;
number of pts to be seen/session;
format for presentations, documentation
Learning goals (more to follow on this)
Plan time for feedback – immediate, at
mid-rotation, at the end
“Learning contracts:”
McDermott, et al
Medical Education 1999; 33: 374-81
Set learner-centered learning goals
Establish discrete goals: knowledge
(understand pharmacotherapy of diabetes
mellitus), attitudes (a change in attitude
towards patients or adapting to a medical
practice philosophy) and/or skills (cardiac
auscultation)
Specify for learner and teacher how
and when goals will be assessed and
accomplished
Home-grown guidelines
Orientation, learning goals; brief morning
“huddle” (to “prime” student)
Make learning experiential rather than
didactic in a formal sense
Set realistic goals: fast pace, hands on,
focused on teachable moments, practicing
clinical skills
Focus on our strengths: volume, diversity,
opportunities to hone knowledge, skills,
attitudes
Homegrown guidelines,
p.2
Focus on skills and attitudes as much as, or
more than on knowledge:
History taking
Physical dx
Clinical reasoning and decision-making
Ddx and synthesis
Communicating effectively
Making and carrying out plans
Coordinating care
Professionalism and ethics
Homegrown guidelines,
p. 3
Avoid “the complete H&P” with full presentation and
note; instead have the student
Perform focused histories and/or exams
Practice taking history from pts w special challenges
(somatizing, tangential, etc)
Actively observe (not “shadow”) your evaluation of a
pt, debriefing afterward with or without pt about key
moments
Present in front of the patient, interrupting for
clarification
Participate in clinical decision making: use of testing,
choice of drug, etc
Research cultural, linguistic, anthropological
questions that arise in caring for pts from other
cultures
Homegrown guidelines,
p. 4
Practice motivational interviewing skills
Ask pt to give student feedback about
interviewing skills, facility with physical
exam, pt education, etc.
Verbalize your thinking and reasoning,
preferably in presence of the pt.
Try to make precepting students a “winwin-win” experience for the student, the
attending physician, and for the patient
Reflection
(Arseneau, Exit rounds: a reflection exercise Acad
med 1995; DaRosa Strategies for making ambulatory teaching lite: less
time and more fulfilling Acad Med, 1997, Smith the roles of experience and
reflection in abmulatory care education Acad Med 1997)
What are your questions?
What did you learn from seeing
patients today?
What troubled, surprised, moved or
inspired you today?
What progress have you made on
your learning goals?
Moving from the ideal to reality while
training the next generation of physicians
to be expert clinicians