Goal
Residents will be able to effectively integrate the 5 microskills of clinical teaching into the daily clinical routine.
Objectives
At the end of the session, the learner will be able to:Identify the 5 clinical microskills Describe rationale for each of the microskillsDemonstrate the technique for each of the microskills
What You are Working With . . .
Your considerable medical knowledge Your desire to be an effective teacher Your uncertainty about what you may
need to teach Your uncertainty how to best teach a
topic Your limited time = Challenge to fit
teaching into your daily routine
What You Already Do …
Much of clinical teaching is discussing a patient Student/Intern interviews & examines
patient Presents to preceptor (i.e., YOU) Make clinical decisions
Diagnosis, tests to order, treatment
On average, this takes approximately 10-minutes
Example
Student: "I just examined a 26 year-old female, with dysuria for the past few days. She has never had a urinary tract infection. She denies abdominal pain, fever or seeing blood in her urine. She thinks her last menstrual period was a couple of weeks ago. I don’t know if she is sexually active. I wasn’t sure if I was supposed to ask those kinds of questions.”
Example
Student: "On exam, she looked well. She was afebrile and the rest of her vital signs were O.K. Her lungs were clear and her heart was regular without any murmurs. Her abdomen was soft and not tender and I didn’t think her spleen or liver were enlarged. That’s all I examined."
Example
Preceptor : "Get a urine and write for Cipro.”
In this example, the student was not given an opportunity to learn or really think rather, the student was simply told what to do.
Five Microskills of Teaching
1. Obtain a commitment2. Probe for supporting evidence3. Teach general rules4. Reinforce what was right5. Correct mistakes
Neher JO, Gordon KC, Meyer B, Stevens N. A five- step "microskills" model of clinical teaching. Journal of the American Board of Family Practice 1992; 5:419 -424.
No. 1: Obtain a Commitment
When the case is presented to you ask the learner what they think
Example Questions LIKELY to Get a Commitment:
“What do you . . .think is going on with this patient?”want to do next in the work-up?”want to accomplish during this hospitalization?”
No. 1: Obtain a Commitment
Commitment on ANY clinical decision . . . What other diagnoses would you consider? What lab tests do you think we should get? How should we treat this patient? What antibiotic do you want to use? Do you think the patient needs to be
hospitalized? Based on the history, what parts of the
physical exam should we focus on?
No. 1: Obtain a Commitment
Example questions NOT LIKELY to get a commitment:
“Sounds like pneumonia, don’t you think?”
“Anything else?” “Did you find out which symptoms
came first?”
No. 2: Probe for Supporting Evidence
When discussing the case, before offering your opinion, ask learners for evidence supporting their opinion
Helpful approaches:“What were the major findings that led to your conclusions?”“What else did you consider?”“What did you rule out that choice?”
No. 2: Probe for Supporting Evidence
Non-helpful approaches: “What are the possible causes of the
elevated temperatures?” “I don’t think this is good. Do you have
any other ideas?” “This seems to be a classic case of . . .” “What do you know about her last
admit?”
No. 3: Teach General Rules
Learner’s responses reveal that he/she need to know something.Provide general rules, concept, etc at learner’s level of understanding.
Helpful approaches:“If patient only has . . . then . . . is not possible.”Patients with . . . usually experience pain w/ . . . The labs should show . . .”
No. 3: Teach General Rules
Non-helpful approaches: “This patient needs . . . now. Don’t
start the . . . until tomorrow. “I’m convinced that to
diagnose . . . you need a . . . “
No. 4: Reinforce What They Did Right
Learner has handled the situation well Comment on the SPECIFIC good
work and effect it had
Helpful approach: “You did a very thorough job
evaluating the patient’s abdominal complaints. Identifying the . . . was critical in making the diagnosis.”
No. 4: Reinforce What They Did Right
Non-helpful approaches: “You are absolutely right. That was
a wise decision.” “Nice job taking care of those
patients today.”
No. 5: Correct Mistakes
Learner has demonstrated mistakes Find appropriate time and place to
discuss ASAP. First allow learner to own
performance. You then detail negative effect &
correction needed.
No. 5: Correct Mistakes
Helpful approach: “I agree the patient is probably drug
seeking, but we still need to do a careful H&P before we make any recommendation.”
Non-helpful approaches: “You did what?” “I can’t believe you ever got into medical
school!”
Microskill Demonstration
Teaching Scenarios
Videos from the University of California, Irvine’s BEST Program: Copyright © 2003-2006 The Regents of the University of California. All rights reserved.
Microskills of Teaching
1. Obtain a commitment2. Probe for supporting evidence3. Teach general rules4. Reinforce what was right5. Correct mistakes
Neher JO, Gordon KC, Meyer B, Stevens N. A five- step "microskills" model of clinical teaching. Journal of the American Board of Family Practice 1992; 5:419 -424.
Example
Student: "I just examined a 26 year-old female, with dysuria for the past few days. She has never had a urinary tract infection. She denies abdominal pain, fever or seeing blood in her urine. She thinks her last menstrual period was a couple of weeks ago. I don’t know if she is sexually active. I wasn’t sure if I was supposed to ask those kinds of questions.”
Example
Student: "On exam, she looked well. She was afebrile and the rest of her vital signs were O.K. Her lungs were clear and her heart was regular without any murmurs. Her abdomen was soft and not tender and I didn’t think her spleen or liver were enlarged. That’s all I examined.“
Based on what you just learned about microskills, what would be a better question to ask?
1. Get a Commitment
Preceptor: "What do you think is her problem?"
Student: "I am concerned that it might be a urinary tract infection."
2. Probe for Understanding Preceptor: "What do you see here that
might indicate a urinary tract infection?”
Student: "She has pain on urination but not much of a problem with frequency or urgency of urination. I thought UTIs had other symptoms like that.”
Preceptor: “What else could she have?”
3-5. Teach General Rules, Provide Positive Feedback, Correct Errors
Preceptor: "You identified the most probable concern in this case but you need to complete the physical exam and get a sexual history. Without more information, we can’t be sure of what we have."
3-5. Teach General Rules, Provide Positive Feedback, Correct Errors
Preceptor: "Do you want me to model how to take a sexual history and do a pelvic examination or would you like me to observe you do them?“
Student: "I would really appreciate your demonstrating how to do them.“
Preceptor: “Okay, let’s go and see the patient."
Key Points
Your teaching time is limited Make the most of the time you
have Incorporate it into what you do
everyday Microskills enable you to effectively
assess, instruct, and give feedback more efficiently
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