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