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Time Efficient Clinical Time Efficient Clinical TeachingTeachingMargo H. Vener, MD MPHMargo H. Vener, MD MPH
Walt Mills, MD, MMMWalt Mills, MD, MMMUCSF School of Medicine and Santa Rosa Family UCSF School of Medicine and Santa Rosa Family
Medicine Residency ProgramMedicine Residency ProgramJune 7, 2011June 7, 2011
Session OutlineSession Outline BackgroundBackground Introduction to the One-Minute Preceptor Introduction to the One-Minute Preceptor
ModelModel One-Minute Preceptor PracticeOne-Minute Preceptor Practice Introduction to feedback and the Brief Introduction to feedback and the Brief
Structured Clinical Observation (BSCO)Structured Clinical Observation (BSCO) BSCO practiceBSCO practice RIME FrameworkRIME Framework
Challenges with Clinical Challenges with Clinical TeachingTeaching
Time pressuresTime pressures Competing demands - clinicalCompeting demands - clinical Often opportunistic - makes planning Often opportunistic - makes planning
challengingchallenging Lack of rewards/recognition for teachersLack of rewards/recognition for teachers Patient acceptance of learnersPatient acceptance of learners
Time Time Average duration of ambulatory Average duration of ambulatory
teaching encounter - 4-10 teaching encounter - 4-10 minutesminutes11
JacksonJackson22
50 ambulatory encounters50 ambulatory encounters 75% of time spent discussing 75% of time spent discussing
patient case/mgmtpatient case/mgmt 30 seconds for feedback30 seconds for feedback
1. Irby DM. Acad Med 1995.2. Jackson JL. Teach Learn Med 2002.
One-Minute PreceptorOne-Minute Preceptor Teaching model initially developed for use Teaching model initially developed for use
in the outpatient settingin the outpatient setting33
Involves 5 steps:Involves 5 steps: Get a commitmentGet a commitment Probe for supporting evidenceProbe for supporting evidence Teach general rulesTeach general rules Reinforce what was done rightReinforce what was done right Correct mistakesCorrect mistakes
3. Neher et al. JABFP 1992.
OMP: Step 1OMP: Step 1 Get a commitment from the learnerGet a commitment from the learner
Ask the learner what he/she thinks about the Ask the learner what he/she thinks about the casecase
Get a commitment to a diagnosis, work-up, Get a commitment to a diagnosis, work-up, treatmenttreatment
OMP: Step 2OMP: Step 2 Probe for supporting evidenceProbe for supporting evidence
Ask the learner for evidence that supports Ask the learner for evidence that supports his/her opinionhis/her opinion
Allows you to identify where there are gaps in Allows you to identify where there are gaps in knowledgeknowledge
OMP: Step 3OMP: Step 3 Teach general rules Teach general rules
Provide general rules/concepts that are Provide general rules/concepts that are targeted to the learner’s level of targeted to the learner’s level of understandingunderstanding
If there is no new information to be added, If there is no new information to be added, you can skip this stepyou can skip this step
OMP: Step 4OMP: Step 4
Reinforce what was done rightReinforce what was done right Reinforcing correct behavior helps the Reinforcing correct behavior helps the
behavior become firmly establishedbehavior become firmly established Comments should focus on specific behaviors Comments should focus on specific behaviors
rather than general praiserather than general praise
OMP: Step 5OMP: Step 5 Correct mistakesCorrect mistakes
As soon after mistake as possible, find an As soon after mistake as possible, find an appropriate time to discussappropriate time to discuss
If possible, allow the learner to critique his/her If possible, allow the learner to critique his/her performance firstperformance first
OMP: Step 6?OMP: Step 6? Encourage self-directed learningEncourage self-directed learning
OMP ClipOMP Clip
OMP: The EvidenceOMP: The Evidence OMP faculty training associated with an OMP faculty training associated with an
increase in specific feedback in increase in specific feedback in ambulatory encountersambulatory encounters44
Videotaped teaching encounters: OMP vs Videotaped teaching encounters: OMP vs TraditionalTraditional Faculty perceive that they are better able to Faculty perceive that they are better able to
assess student skills and are more confident assess student skills and are more confident in their ratings with OMP modelin their ratings with OMP model55
Students preferred OMP model for quality of Students preferred OMP model for quality of feedback it providesfeedback it provides66
4. Salerno S. J Gen Int Med 2002.5. Aagaard E. Acad Med 2004.6. Teherani A. Med Teach 2007.
OMP PracticeOMP Practice
Other teaching models…Other teaching models… SNAPPS ModelSNAPPS Model77
SSummarize findingsummarize findings NNarrow the DDxarrow the DDx AAnalyze the differentialnalyze the differential PProbe the preceptor about uncertaintiesrobe the preceptor about uncertainties PPlan managementlan management SSelect case related issues for self-studyelect case related issues for self-study
Has been shown to facilitate expression of Has been shown to facilitate expression of clinical reasoning and uncertaintyclinical reasoning and uncertainty88
7. Wolpaw et al. Acad Med 2003 8. Wolpaw et al. Acad Med 2009
FeedbackFeedback Information on the student’s performance Information on the student’s performance
given given for the purpose of improving future for the purpose of improving future performanceperformance
Analogous to coachingAnalogous to coaching Key step in the acquisition of clinical skillsKey step in the acquisition of clinical skills Medical students and residents Medical students and residents
dissatisfied with the amount and quality dissatisfied with the amount and quality of feedbackof feedback
The ChallengeThe Challenge Limited opportunities for observationLimited opportunities for observation Lack of specificity of feedbackLack of specificity of feedback
Tips for Giving FeedbackTips for Giving Feedback Immediate Immediate Self-reflection firstSelf-reflection first Both positive and correctiveBoth positive and corrective Focus on behavior - not personFocus on behavior - not person Specific, not generalSpecific, not general Amount limited to what the student can Amount limited to what the student can
incorporate (not too much!)incorporate (not too much!) Check to ensure clear communicationCheck to ensure clear communication
Brief Structured Clinical Brief Structured Clinical Observation (BSCO)Observation (BSCO)
Tool for brief, real-time feedbackTool for brief, real-time feedback Attending enters patient room during patient Attending enters patient room during patient
encounterencounter Watches silentlyWatches silently Leaves when 3 feedback points obtainedLeaves when 3 feedback points obtained
Feedback discussed that dayFeedback discussed that day
BSCO PracticeBSCO Practice
BSCO TipsBSCO Tips Orient student and patientOrient student and patient Consider asking student for observation Consider asking student for observation
focusfocus Carefully position yourself in the room; try Carefully position yourself in the room; try
to remain silentto remain silent Consider times when you are required to Consider times when you are required to
be in the roombe in the room
RIME FrameworkRIME Framework
((OObserver) bserver) RReporter eporter
IInterpreter nterpreter MManageranagerEEducatorducator
Pangaro Acad Med 1999.
OBSERVEROBSERVER - - struggling to report accuratelystruggling to report accuratelyREPORTERREPORTER Works professionally with patients, staff, colleagues; Works professionally with patients, staff, colleagues;
complete, reliable, accurate; gathers info, clearly complete, reliable, accurate; gathers info, clearly communicates with proper termscommunicates with proper terms
Understands pathophysiologyUnderstands pathophysiology Answers “What” questions. Answers “What” questions. INTERPRETERINTERPRETER Identifies, prioritizes problems Identifies, prioritizes problems Offers 2 or 3 Offers 2 or 3 reasonablereasonable possibilities with reasons applied possibilities with reasons applied
to the patient. (Students do not have to be “right”) to the patient. (Students do not have to be “right”) Answers "Why" questions. Answers "Why" questions.
MANAGERMANAGER Selects among options Selects among options withwith the patient the patient Proactive rather than simply reactiveProactive rather than simply reactive Plans should be Plans should be reasonable,reasonable, include test options, include test options,
student’s preferences, merits of therapies student’s preferences, merits of therapies Answers “How" questions. Answers “How" questions. EDUCATOREDUCATOR Identifies questions that can't be answered from Identifies questions that can't be answered from
textbooks textbooks Cites evidence on relevant new therapies, tests Cites evidence on relevant new therapies, tests Active in educating self, colleagues, and patientsActive in educating self, colleagues, and patients
SummarySummary Orient learner to goals/expectationsOrient learner to goals/expectations Choose a tool for clinical teaching (?OMP)Choose a tool for clinical teaching (?OMP) Incorporate frequent observation and Incorporate frequent observation and
feedback (?BSCO)feedback (?BSCO) Think about your learner’s skill level and Think about your learner’s skill level and
what the next steps are in their what the next steps are in their development as a physiciandevelopment as a physician