Transcript Tips for Integrating Learners Into Practices

Teaching in the Real World
Tips for Integrating Learners into
Busy Practice Settings
November, 2003
©2003 Community Faculty Development Center
Our sincere thanks to several hundred
experienced clinical preceptors, residents
and students who have contributed these
“Teaching Tips” at faculty development
workshops over the last thirteen years
©2003 Community Faculty Development Center
Objectives
By the end of this session, participants will be
able to:
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list five new ideas for efficient teaching in busy
clinical settings;
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demonstrate that they can plan ahead for effective
clinical teaching; and
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actively participate in clinical teaching to a greater
extent than previously
©2003 Community Faculty Development Center
Introduction
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Goals
Needs
Objectives
Methods
Evaluation
©2003 Community Faculty Development Center
Introduction
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Goals
Needs
Objectives
Methods
Evaluation
©2003 Community Faculty Development Center
This talk is devoted to
“Methods”
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There are many things that experienced
preceptors ask learners to do that save them
time, while adding quality to their practice
and teaching
However . . .
©2003 Community Faculty Development Center
Methods should not drive objectives!
Objectives should reflect the learner’s needs!
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Goals
Needs
Be clear about matching
your objectives to the
learner’s needs
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feedback
Objectives
Evaluation
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One learner’s teaching
objective may be another
learner’s “scut work”
If it doesn’t match, label it
as “scut work”
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Methods
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Tell the learner that any time
s/he helps to save you will be
made up in dedicated teaching
time
Say thanks at the end of the
day
©2003 Community Faculty Development Center
How can I teach and
practice at the same time?
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Clinical teaching is similar to clinical
practice
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You don’t need to do it all at once
Feel free to prioritize
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Pay attention to educational priorities
Pay attention to clinical priorities
©2003 Community Faculty Development Center
General Principles
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Plan ahead
Provide an orientation
Have learners do things
that save you time and
benefit your practice
Learn from your learner
Plan how you will use
space
Teach on the fly
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Scheduling: Tailor the
schedule to meet clinical
and teaching objectives
Look for unique
educational opportunities
Establish guidelines for
communication
Tips for using the medical
record
©2003 Community Faculty Development Center
Planning
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If you don’t plan it, it won’t happen
Working the student into your schedule
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Schedule protected times
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Formal first-day orientation
Mid-point evaluation
End of rotation
Other protected times for problem-solving, discussion, feedback,
evaluation
Plan other scheduled activities
Plan for days when you are not available
Offer a menu based on needs, interests
©2003 Community Faculty Development Center
Orientation – four aspects
Orient the student
 Orient your patients
 Orient your staff
 Orient yourself
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©2003 Community Faculty Development Center
Orient the Student
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Pre-clerkship: Invite the student to visit
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First day: Plan a formal orientation session
Prepare a written description of the practice
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Is this right for you?
Does the student meet certain criteria (e.g. language, etc)
Have one student prepare a written description to be used with
future students
Provide a copy of your mission statement (Community Health
Center)
Set up a web site for students; mention them on your
practice web site
©2003 Community Faculty Development Center
Orient the Student (cont)
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Prepare written guidelines of expectations
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Provide a learning contract
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Logistics: Include specifics about dress, hours, parking, use of
staff areas, food, etc
Educational guidelines: Set progressive goals through the weeks
Expectations about confidentiality
What are your needs? What do you want to learn?
List specific learning objectives
Orient the student to your life style
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Personal
– invite them into your home
Professional - hospital, committees, call, etc.
©2003 Community Faculty Development Center
Orient your patients
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Announce your role
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Invite patients to be teachers
Develop a questionnaire (or have a student develop
a questionnaire)
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Sign in the waiting room
Name on the door
Handouts, pictures
Has the student added to the visit?
Provide a business card for the student
©2003 Community Faculty Development Center
Orient your staff
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Make them active participants in the educational
planning process
Make it a team approach
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What can each staff member contribute to the learner’s
education?
Have the staff orient the student, give tours
Provide an opportunity for the staff to participate in
providing feedback or evaluation
©2003 Community Faculty Development Center
Orient your staff (cont)
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Introducing the student to the staff
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At a staff meeting
At a social gathering
Introducing the student to patients
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Plan explicit guidelines with your office staff
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How will students be introduced to patients?
How will you obtain permission from patients?
©2003 Community Faculty Development Center
Orient yourself
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Read the curriculum
Read the readings
Participate in faculty development
©2003 Community Faculty Development Center
Have students do things that save
you time and benefit the practice
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Tell students that anything they can do to save you time will be made up in
active teaching time
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Thank the student at the end of the day!
Activities that can save you time:
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Take vitals, chart notes
Talk to patients who are waiting when you are running behind – it’s “better than a
magazine”
Write prescription refills
Write out patient instructions
Go over written patient education materials
Make medication lists, ID bracelets
Do asthma education
Construct a genogram
Go through the chart to see if health maintenance guidelines are up to date
©2003 Community Faculty Development Center
Have students do things that save you
time and benefit the practice (cont)
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Working with younger patients:
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Working with older patients:
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Perform Denver Developmental Testing
Perform Mini-Mental status exam
Interview other caregivers
Help elderly patients get dressed and undressed
Talk to elderly patients
Procedures – Students need to be allowed to do things
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Phlebotomy
Ear flushing
©2003 Community Faculty Development Center
Have students do things that save you
time and benefit the practice (cont)
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Have a student focus on a puzzling problem
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Working with a patient or family that has been a puzzle
Interview family members
Make a home visit
Research a difficult clinical issue
Office projects
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Develop evidence-based medicine resources
Develop patient education materials
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“Why won’t my baby sleep?” “How big will my baby be?”
©2003 Community Faculty Development Center
Learn from the Student
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They may know better . . .
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Personal issues
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About their culture, their own life experiences
Dealing with clinical questions
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Use of a Palm Pilot, technology resources
About new drugs, yesterday’s lecture
“ “Take a day, get back to me”
Don’t feel threatened by a student who knows something
you don’t know
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Don’t confuse knowledge with information
©2003 Community Faculty Development Center
Think about the use of space
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Provide space for the student: a desk, a shelf, in
and out boxes, a TV table, etc.
If an extra exam room is available, you can have
the student use it, while you move ahead as
needed
Use your consult room for history taking
Use your partner’s desk on his/her day off
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Rotate desk in a large practice
Move phlebotomy to the exam room
©2003 Community Faculty Development Center
Methods for teaching “on the
fly”
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Have the student see the patient ahead of you
Observe the student interview the patient
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Try not to interrupt
Stand behind the student
Stand behind the patient
Have the student present to you in front of the
patient
©2003 Community Faculty Development Center
Teaching on the fly (cont)
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Teaching in front of the patient
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Works best:
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Present the history
Skills: Physical exam, procedures
Doing patient education
Modeling
Use of questioning (vs. “pimping”)
Riskier
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Complex problem solving
Differential diagnosis
Bad news
©2003 Community Faculty Development Center
Scheduling: Tailor the schedule with
clinical and teaching objectives in mind
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Schedule events that will help the student
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Review the schedule ahead of time
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Review charts ahead of time
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Double book the first slot, allowing the student to start along with you
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Specific content areas (e.g. a required H&P): Have a patient come in early
Schedule time with others in the practice
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Practice partners, Nurse Practitioners, Physician Assistants (one could
serve as coordinator)
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Office staff
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Nurse
Health Educator
Phlebotomy
Health Assistant
Billing Clerk
Referral Coordinator
Receptionist/Appointment Clerk
©2003 Community Faculty Development Center
Schedule with clinical and teaching
objectives in mind (cont)
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Schedule time with others outside the practice
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Consultants in your building
Community resources
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Nutritionist
Social worker, Outreach worker
Visiting nurse, Hospice
Day care center
Adult day care center, Nursing home
Pharmacy
Health Department
Local sheriff, local law enforcement officials
Find respite time
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Send the student to read up on something that will come up later in the day
Encourage the clerkship to schedule out-of-office time
Take a second medical student, or a PA or NP student
©2003 Community Faculty Development Center
Take advantage of unique
educational opportunities
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Share your library, educational resources
Identify patients with problems (diabetes, etc.) who
are willing to act as teaching resources
Link the student with patients who will present
frequently during the clerkship
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Newly diagnosed patients, prenatal patients, patients in
crisis, patients in transition
Provide a beeper
©2003 Community Faculty Development Center
Take advantage of unique
educational opportunities (cont)
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Involve the student as you respond to acutely ill
patients
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Have the student phone patients who are acutely ill,
make followup phone calls
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Use of a speakerphone
Manage fewer acutely ill patients over the phone
Have the student prepare for a sick patient who is
coming in
Involve the student in after-hours call
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Use of a conference-calling feature
©2003 Community Faculty Development Center
Take advantage of unique
educational opportunities (cont)
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Involve the student in nursing home care
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Challenge: Continue to see patients until you find three
medications that can be discontinued
Have the patient accompany your patients
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To see a consultant
To have a procedure done
To the Radiology Department
To OT or PT
To accompany the Visiting Nurse
©2003 Community Faculty Development Center
Take advantage of unique
educational opportunities (cont)
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Review phone messages with the student
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Have the student review lab work
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Have the student call patients with results
Community activities
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Have the student make the return calls
write a patient education column for the local paper
do a project in the community
Go together
 Rounds, conferences, even to a deposition
©2003 Community Faculty Development Center
Communication
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Communicate by phone
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Communicate by email
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Share your home phone number
Use the practice’s “inside” number
Logistics
To provide feedback
Provide an orientation handout
©2003 Community Faculty Development Center
Using the medical record
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Have the student do chart reviews, participate in QI projects
Have the student type up notes, email them in
Regarding Medicare (and in some states, Medicaid)
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“The only documentation by medical students that may be used by the teaching
physician is their documentation of the review of systems and past, family and social
history. The teaching physician may NOT refer to a medical student’s documentation of
physical exam finding or medical decision making in his/her personal note.”
AAMC tutorial: “Medicare’s Teaching Physician
Documentation Instructions”
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Most suggest that medical student notes should not be a part of the
permanent record
Some use student notes as prompts
©2003 Community Faculty Development Center
This session focuses on Methods
Goals
Needs
But remember:
feedback
Objectives
Evaluation
Methods
©2003 Community Faculty Development Center