Effective Precepting Instructional Module

Effective Precepting Module

“The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.”

William Arthur Ward

A printable overview of this topic is available HERE

I have chosen the quote by William Ward to begin this module, not for its eloquence, but because I don’t agree with it! Certainly great teachers inspire, but don’t they also tell, explain, and demonstrate, as the situation requires? There are no concrete guidelines for the delivery of effective instruction because each encounter is unique in regard to the learner, the subject, and the teacher. So in the absence of ‘hard and fast’ rules, what follows are suggestions for teaching that you may find helpful:

1. Organization - Encourage all learners to follow the SOAP format for note organization and patient presentations. If necessary spend some time describing each component of the SOAP format. You can download a patient encounter form HERE that your learner can use to organize the information they gather in the SOAP format. Another important function of this form is the way in which it encourages learners to address medical complaints in a systematic fashion. Have the learner complete the form in the following manner:

a) Develop a differential diagnosis based on the chief complaint before entering the patient’s room.

b) Gather historical data to reorganize the differential diagnosis.

c) Perform a physical examination to further organize the differential diagnosis.

d) Order laboratory or radiographic tests if necessary to finalize the differential diagnosis.

e) Make a final assessment(s) of the chief complaint.

f) Generate a plan-of-care for the assessment(s).

2. The One-Minute Preceptor - This approach to precepting was first described by Neher et al. It is a five-step process that assists preceptors in focusing their teaching in an organized and efficient manner. The entire process can be completed in about ten minutes either in the presence of the patient or outside of the examination room. It can be learned in a short period of time (usually 1-2 hours) and can be applied to almost any clinical encounter. Preceptors wishing to employ this approach should follow the steps below:

a) Get a commitment - After the learner presents a case ask them to develop a diagnosis, work-up, or therapeutic plan based on their findings. If the learner pauses after giving a presentation you can facilitate the process by asking an open-ended question such as, “What do you think is going on with this patient?” Try to resist offering your explanation for the findings until after the learner has made their commitment. By developing this commitment the learner not only takes an active role in patient care but also demonstrates the ability to process and interpret the information they have gathered. Errors made by the learner at this stage can be used to identify gaps in knowledge.

b) Probe for supporting evidence - Once the learner has stated a diagnosis, work-up, or therapeutic plan; ask them to expand upon their commitment by providing supportive evidence. This can be accomplished by asking open-ended questions such as, “What factors lead to your conclusion?” or “Why do you want to perform that particular test?” or “Why did you chose that particular medication?” The goal of this step is to analyze the learner’s clinical reasoning and identify any weaknesses that may need to be addressed.

c) Teach general rules - When the first two steps have been completed, any weaknesses in clinical reasoning or gaps in knowledge should be used to identify teaching points. Try to keep the teaching points general so that the learner can apply what they have learned to subsequent cases. A patient with an unclear diagnosis can be a valuable resource because they give you the opportunity to share your favorite resources with the learner e.g. textbooks, journal articles, Internet sites, colleagues.

d) Reinforce what was right - Timely and specific feedback has been shown to be the most effective in reinforcing positive performance. Try to avoid general statements such as “You did a good job with that last patient.” Feedback like this does not identify the areas of an encounter or presentation that were ‘good’. Instead, focus on specific areas of the encounter or presentation when giving feedback. Examples might be: “You did a good job collecting the family history on the last patient” or “Your focused physical examination covered all the areas that were necessary.”

e) Correct mistakes - Again, timely and specific feedback is the most effective in preventing future mistakes. Avoid being too judgmental as this can make the learner feel uncomfortable. An example might be “I think a better approach to this situation might have been to _______” If appropriate, refer to the mistake as “Not the best” instead of “Bad”.

3. Questioning - The following are suggestions for effective questioning:

a) Always try to ask open-ended questions. Questions that can be answered with a “Yes” or a “No” provide you with little insight into the learner’s thought process.

b) Give the learner sufficient time to respond to your questions.

c) Avoid asking multiple questions at one time.

d) Avoid ‘leading’ questions such as “I think this is a viral URI, do you?”

e) Try to think out loud so that the learner can see how an experienced practitioner approaches a problem. An example might be “At this point I ask myself which medication would be the most appropriate based on side-effect profiles.”

f) Try not to focus questions solely on the cognitive domain. Explore affective issues by asking questions such as "How did you feel when Mr. H started crying?” or “Why do you think the patient became angry?”

4. Flexibility - Teaching and learning within a busy practice must be flexible in order to succeed. Patient flow and unexpected eventualities can put a well-prepared teaching session into disarray. You do not need to give a mini lecture on every patient or topic. In most instances a single general fact per encounter is appropriate. If you become especially busy have the learner either perform duties other than patient care (outlined in the Time Management module) or ask them to observe you passively and write down any questions they may have. Try to address these questions during breaks, lunchtime, or at the end of the day when you are not so busy.

5. 5. Collaboration - Allow yourself to be taught. Learners will bring a lifetime of experiences to your clinic as well
as recent/current training in an academic facility. By reversing the teacher-learner role you can foster an intellectual partnership that will enrich the rotation and give the learner an important sense of collaboration.

Effective Precepting Module

“The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.”

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