The One Minute Preceptor for Natural Medicine
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Transcript The One Minute Preceptor for Natural Medicine
A Naturopathic Clinical Algorithm
An Adaptation of the “5-Clinical Microskills Model”
for Naturopathic Practice
Rich Barrett ND
Paul Kalnins ND, LAc
Dickson Thom DDS, ND
Plan
Rich Barrett presents the 5 Microskills model
Dick Thom and Jeremy Mikolai will role play a clinical preceptor
encounter
Paul Kalnins will present a naturopathic version of the 5
microskills
Dick Thom and Jeremy Mikolai will continue their role play
The Problem
Clinical teaching is challenging
◦ We have to diagnose and treat our patients
◦ We typically do this through an intermediary, a medical
student or resident.
◦ We also have to diagnose and teach these learners
New information
and clinical reasoning
Clinical teaching skills are not innate
The thorough examination of clinical teaching by
Koen and Vivian identified five major modes and 18
micro skills in effective clinical teaching
John Neher and colleagues at the University of
Washington in collaboration with Koen pared these to
Five “microskills”
Advantages of the 5 Microskills
Focuses the consultation on the decision-making process used
by the medical student
Reveals the fund of knowledge available to the student
Designed to be efficient: most encounters take about five
minutes
Can vary according to the complexity of the case and the needs
of the student
The 5 Microskills
1.
2.
3.
4.
5.
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was done right
Correct mistakes
First Microskill:
Get a commitment
Student presents the history, physical findings and any labs
available
Early in the consultation they should be encouraged to make a
commitment to a diagnosis, workup, or therapeutic plan
Gives student more responsibility for patient care
Encourages them to process and analyze information gathered
from the encounter
Get a commitment
Failure to commit may indicate a student has not processed
the information, is afraid to expose a weakness, or is
dependent on the thinking of others
It is critical that the environment be supportive to promote
intellectual honesty
It’s better before the learner to be incorrect, than not
commit. Being wrong is a learning opportunity
Get a commitment
The cue for this microskill occurs when the student presents
the facts of the case, and then pauses, waiting for
interpretation from the attending physician
Resist the urge to fill in the verbal blank!
Instead ask:
◦ What do you think is going on with this patient?
◦ What laboratory tests do you think are indicated?
Second Microskill:
Probe for supporting evidence
Find out what evidence supports this commitment
“ What were the major findings that led to your diagnosis?”
What other diagnoses did you consider? What kept you from
that choice?
By having the student “think out loud” the preceptor can
identify what the student knows and does not know
Third Microskill:
Teach general rules
This step allows the teacher to generate and communicate a
general teaching point resulting from the case
A teaching point will be apparent from their omissions or
mistakes
Instruction is more memorable and more transferable to other
cases when it is offered as a general rule
Fourth Microskill:
Reinforce what was done right
Rewards competence
Builds professional self-esteem
Caveat: Avoid general praise which reinforces no particular
behavior i.e. “ You did a good job”
Both praise and criticism need to be as specific as possible
Fifth Microskill: Correct mistakes
Do this last
Choose the appropriate time and place
Vague, judgmental statements such as “This case was badly
mismanaged” are not helpful or appropriate
It is generally a good idea to ask the student to critique
their own performance first
Suggest outside reading or other learning
Studies supporting the use of the
five-step multiskills model:
Aagard, Salerno, Furney, Jones, Tehernani
Faculty rated Microskills more efficient
Increased likelihood of the correct diagnosis
Twice as much higher order verbal feedback
Higher quality and quantity written feedback
Students were more motivated to do outside reading
Case Example using the Five-Step Microskills
with a Resident at the NCNM Clinic
40 Year Old White Female
CC: Gas/bloating, constipation, right
upper quadrant pain, hyperlipidemia
The 5 Microskills
1.
2.
3.
4.
5.
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was done right
Correct mistakes
Biomedical 5-Clinical Microskills Model
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Advantages for Clinical Training
Engages the student in the thinking and decision processes
Attempt is made at gathering the best available evidence
Builds a student’s confidence
Fosters a genuine collaborative approach between all members of a patient’s treatment team
Disadvantages for Naturopathic Medicine
Approach is based on the biomedical disease model:
Once diagnosis is made, treatment protocols are often established
Not reflective of naturopathic approach to preventative care and wellness (naturopathic wellness model)
Naturopathic treatments often based on factors independent of the disease diagnosis
What is the Naturopathic Approach to Patient Care?
Benedict Lust ND, DO, MD (1872-1945)
Founded naturopathic medicine (~1902) & first naturopathic medical school
Roots in European “Nature Cure” movement
Amalgamated many medical traditions & techniques:
Hydrotherapy
Physical medicine
Herbal medicine
Homeopathy
Diet therapy
Core Concepts of Naturopathy
First do no harm
Respect the Vis medicatrix naturae
Identify & treat the causes
Doctor as teacher
Treat the whole person
Prevention
Vis medicatrix naturae, “Healing power of nature”
Self-regulatory mechanisms in the organism
Modern interpretation: milieu interieur (Bernard, 1985), homeostasis (Cannon, 1930’s)
Role of psycho-neuro-endocrine-immune system
Naturopathic practice: identify & remove factors inhibiting the Vis medicatrix
Restore homeostasis
What is the Naturopathic Approach to Patient Care?
A Functional Approach to Illness
History
Physical
Tests
Biomedical Assessment/Diagnosis
Migraine with Aura
Biomedical Treatment
Diet/lifestyle/exercise
Medications
Triptans
NSAIDS
Ergot derivatives
Beta-blockers
Calcium channel blockers
Antidepressants
Antiseizure medications
Etc.
Naturopathic Assessment/Diagnosis
Naturopathic Treatment
Hepatic-Biliary
General Support
Dietary changes
Lifestyle/exercise
Stress reduction
Self-care techniques
Poor liver phase I & II detoxification?
Cholestasis?
Digestive
Pro-inflammatory diet/food triggers?
Food allergies/sensitivities?
Integrity of intestinal mucosa?
Nervous-Endocrine
HPA-axis/cortisol dysregulation?
Poor clearance of estrogen metabolites?
Poor methylation processes?
Lack of neurotransmitter clearance?
Cardio-Circulatory
Endothelial dysfunction?
Cardiovascular inflammation?
Renal
Poor renal elimination of metabolites?
Subtle acid-base balance shifts?
Structural
Head/neck structural or soft-tissue issues?
Specific Support
Botanical medicine
Homeopathic medicine
Essential fatty acids
Vitamins/minerals
Etc.
Physical Support
Physical medicine
NMT
Acupuncture
Other modalities
Other Support
Counseling
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
Gather History
Physical Exam
Pre-Assessment
Biomedical Assessment
Define context of care
What is your biomedical diagnosis?
15-25 minutes
10-15 minutes
Naturopathic Assessment
What is your functional diagnosis?
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Treatment
What is your treatment plan?
10-15 minutes
Follow-up
What are your follow-up and/or
referral recommendations?
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What is your Pre-Assessment?
Is this case today acute or chronic?
Does the patient have a primary care physician?
Are there financial limitations that must be considered?
What is the patient willing to do?
◦ Are they really interested in naturopathic treatment?
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What is your Biomedical Assessment?
What is your biomedical diagnosis?
◦ Working diagnosis?
◦ Important differentials to rule out?
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
◦ Need for urgent referral or biomedical treatment?
◦ What labs and/or imaging would you like to obtain?
What are the current standards of care for your diagnosis?
◦ Consult practice guidelines
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What is your Naturopathic Assessment?
Will vary by practitioner
Typological assessment
◦
◦
Temperament, miasm, constitution
Blood type, body type, etc.
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Organ-gland-systems assessment
◦ Functional assessment
◦ Renal, GI/hepato-biliary, Respiratory, Endocrine, Heart-circulation, Nervous, etc.
Pattern differentiation
◦ Tissue state/terrain: Hot/cold, dry/damp, etc.
◦ Homeopathic patterns assessment
◦ Chinese medicine pattern differentiation
Other
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What is your Treatment Plan?
Basic support
◦
◦
◦
◦
◦
Vitamin/mineral therapy
Essential fatty acids, probiotics, etc.
Herbal medicine
Glandulars
Homeopathic support
Bio-identical hormone therapy
Specific support: Physical Modalities
◦
◦
◦
◦
◦
Diet recommendations
Lifestyle, exercise
Stress reduction
Home hydrotherapy
Other
Specific Support: Natural Remedies
◦
◦
◦
◦
◦
◦
Other modalities
◦
◦
◦
Constitutional hydrotherapy
Physical medicine, NMT
Acupuncture
Ultrasound, cold laser, TENS, microcurrent, etc.
Massage
Counseling
Biofeedback/neurofeedback
Other
Biomedical Support
◦
◦
◦
Prescription medications
Surgery
Other
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What are your Follow-up Recommendations?
Has patient understood their diagnosis?
◦ Important things they need to look out for?
Has patient understood the treatment plan?
◦ Ask the patient if they think they can manage this plan
When do you want the patient to return?
◦ Acute cases
Check in by phone in 24-48 hours
Follow-up in office in 1 week
◦ Chronic cases
Follow-up in office in 4 weeks
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
Gather History
Physical Exam
Pre-Assessment
Biomedical Assessment
Define context of care
What is your biomedical diagnosis?
15-25 minutes
10-15 minutes
Naturopathic Assessment
What is your functional diagnosis?
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Treatment
What is your treatment plan?
10-15 minutes
Follow-up
What are your follow-up and/or
referral recommendations?
Citations
Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching.
J Am Board Fam Pract. 1992 Jul-Aug;5(4):419-24.
Jones K, Reis S. Learning through vulnerability: a mentor-mentee experience. Ann Fam Med.
2010 Nov-Dec;8(6):552-5.
Aagaard E, Teherani A, Irby DM. Effectiveness of the one-minute preceptor model for
diagnosing the patient and the learner: proof of concept. Acad Med. 2004 Jan;79(1):42-9.
Teherani A, O'Sullivan P, Aagaard EM, Morrison EH, Irby DM. Student perceptions of the one
minute preceptor and traditional preceptor models. Med Teach. 2007 May;29(4):323-7.
Salerno SM, O'Malley PG, Pangaro LN, Wheeler GA, Moores LK, Jackson JL. Faculty
development seminars based on the one-minute preceptor improve feedback in the
ambulatory setting. J Gen Intern Med. 2002 Oct;17(10):779-87.
Salerno SM, Jackson JL, O'Malley PG. Interactive faculty development seminars improve the
quality of written feedback in ambulatory teaching. J Gen Intern Med. 2003
Oct;18(10):831-4.
Furney SL, Orsini AN, Orsetti KE, Stern DT, Gruppen LD, Irby DM. Teaching the one-minute
preceptor. A randomized controlled trial. J Gen Intern Med. 2001 Sep;16(9):620-4.
Zeff J. The process of healing: a unifying theory of naturopathic medicine. J Naturopath Med
1997;1:122-126.