EFFECTIVE CLINICAL TEACHING
Table of Contents
A Message to Preceptors
Information About the Centers for Osteopathic Research and Education (CORE)
Faculty Development Opportunities
10 Most Frequently Asked Questions
· How will my patients react to having a student in my office?
· Will having a student in my office take extra time?
· How do I introduce the student to my patients?
· What do I do if I have a problem with a student in my office?
· How much can I let a student do in my office?
· Does the student have to spend all of his/her time with me?
· I’ll be gone for 3 days while my student is in my office. Can the student work with someone else?
· How do I know what I am supposed to teach the student?
· I’m not sure I know how to teach; how can I prepare?
· How do I handle student-related problems?
· The Preceptor’s Teaching Tasks
· Teaching Strategies
Orienting Students to Your Practice
· Orientation as Foundation
· Suggestions for Orientation
· Menu of Items and Issues for Orienting Students
· Timing and Setting
· Characteristics of Effective Feedback
· Guidelines for Giving Constructive Feedback
· Timing and Setting
· Guidelines for Evaluation
· Evaluating Preceptors
Thank you for your commitment to teaching medical students from the Ohio University College of Osteopathic Medicine as well as students from our affiliated osteopathic medical colleges who participate in the Centers for Osteopathic Research and Education (CORE). Your commitment to excellence as a teacher and role model makes it possible for our students to receive excellent clinical training.
One of the benefits of participating in our teaching program is the continuing medical education (CME) credits you will receive based on the number of weeks spent in the teaching role. The most rewarding benefit, however, is the joy of watching a student develop into a competent and caring physician.
We offer teaching enrichment programs through CORE Faculty Development and invite you to participate. For a complete listing of programs, please visit the Faculty Development website at http://www.oucom.ohiou.edu/fd where you will find additional information about our programs, teaching tips, and links to excellent Internet resources.
If you do not have CORE clinical faculty status with OU-COM and wish to pursue it, you can do so by contacting your CORE Assistant Dean or CORE Administrator.
Thank you for contributing to the success of the CORE teaching program. We trust you will find this Effective Clinical Teaching material helpful as you embark on an exciting educational endeavor.
Information About the Centers for Osteopathic Research and Education
The Centers for Osteopathic Research and Education (CORE) System offers you more opportunity, more structure, and more innovation, all within an infrastructure that makes medical education work. Established in July of 1995, the CORE was officially accredited in 1997 as the country’s first Osteopathic Post-Doctoral Training Institution (OPTI) by the American Osteopathic Association.
The CORE combines the collective strengths of Ohio University College of Osteopathic Medicine (OU-COM), numerous teaching hospitals in Ohio, and an unprecedented affiliation with three osteopathic medical schools: A.T. Still University of Health Sciences (formerly called Kirksville College of Osteopathic Medicine), Des Moines University College of Osteopathic Medicine, and Kansas City University of Medicine and Biosciences.
In our quest to provide excellence in osteopathic training, the CORE provides:
· A statewide consortium featuring unparalleled clerkship, internship, and residency opportunities.
· The finest collection of teaching hospitals in the profession and outstanding clinical faculty.
· Consistent, reliable academic programs.
· State-of-the-art educational technology, including OhioONE, a leading-edge video conferencing system linking Ohio University, CORE hospitals, and medical institutions across America.
· Structured exposure to osteopathic principles and practice.
· A system of Residency Program Advisory Committees (RPAC) that meet regularly for sharing ideas and working systematically toward program improvement.
· Monthly statewide education days for residents.
Faculty Development Opportunities
In the CORE system, there are many opportunities for faculty development that are available to preceptors. There are workshops and seminars on different topics under the domains of faculty development: 1) Education, Instructional Design, Curriculum Development, and Clinical Teaching, 2) Administration, Organization, Leadership, 3) Research, Writing, Scholarly Development, and 4) Personal and Professional Development.
There are also on-line faculty development opportunities via the Faculty Development website. It includes monographs about clinical teaching, curriculum, and other topics with questions for you to answer. Please visit our Faculty Development website at http://www.oucom.ohiou.edu/fd.
We also encourage you to contact either one of the Assistant Directors of Faculty Development to discuss faculty development issues and concerns:
Olivia Ojano Sheehan, Ph.D. Stephen S. Davis, Ph.D.
10 Most Frequently Asked Questions
1) How will my patients react to having a student in my office?
Physicians typically find that serving as a preceptor increases their own credibility and enhances the prestige of their practice in the eyes of patients. Patients usually enjoy being interviewed by and interacting with students - provided they understand that by doing so they are contributing to the student's education. Older patients are often especially appreciative of the opportunity to interact with a young person. Many physicians display plaques in their waiting areas indicating that the practice serves as a precepting site for the OU-COM/CORE System (please contact CORE Faculty Development to request a plaque for your office). They also post announcements and/or pictures of students who are working in their office. It is a good idea to announce the commitment of the practice to teaching medical students in any descriptive brochures or materials. Patients should not be surprised by the presence of a student - many front office staffs routinely inform patients who make appointments of the presence of a student who may be involved in the patient's care. There are of course exceptions to these generalizations, and sometimes "discretion is the better part of valor." The preceptor may find it advisable to avoid student involvement with patients who strongly resist change, who are querulous or contentious, or those who will need to undergo a sensitive or painful examination.
2) Will having a student in my office take extra time?
It depends. Anecdotal comments suggest that a preceptor’s day is lengthened when a student is present in his/her practice, but recent literature suggests that a preceptor’s day is not lengthened when a structured and efficient way to manage the rotation is implemented.
3) How do I introduce the student to my patients?
The student should be treated as a professional by hospital and office personnel at all times. In the clinical setting, when being paged and introduced to patients and their family members, refer to the student as “Student Doctor” followed by the last name so he/she is not misrepresented as a licensed physician.
4) What do I do if I have a problem with a student in my office?
If a serious problem develops with a student who has been assigned to your office immediately call the CORE Office. It is also a good idea to call whenever you have a question or just feel the need for guidance. Call sooner rather than later! “An ounce of prevention is worth a pound of cure.” No question is stupid or out of place.
5) How much can I let a student do in my office?
Base your decisions about the scope of your student’s role on 1) his/her level of training, 2) your assessment of his/her clinical experience (gained during your orientation discussion), and 3) your observations of the student during his/her first few days in your practice. Pre-clinical students are medical novices and probably will not be able to make a physical diagnosis nor recommend medications. They can, however, be very effective in interviewing patients and taking a complete history. They will also gain a great deal by interacting with patients and staff, learning how your practice operates, and bringing their enthusiasm to your practice environment. Third or fourth year students will be much more capable clinically, and should be given a much wider role. Both kinds of students need to be supervised and observed; their roles should be quickly adjusted whenever they - or you - are well outside of your comfort zones. Remember that medical students are adults and prefer active approaches to learning; more often than not, they will quickly lose interest if they are confined to a role of shadowing or observing.
6) Does the student have to spend all of his/her time with me?
Your practice is a rich learning environment, so feel free to assign your student to other staff members. Check with your student after he/she has been with you for a few days or a week and ask if there are areas of the practice they would like to learn more about. A tutorial with your business manager can provide a valuable perspective on the economics of your practice; working for a half day with your receptionist will help the student understand how patients are checked in and scheduled; working with your nursing staff can teach the student how you utilize these valuable colleagues. Take the teaching burden off yourself by enlisting your colleagues in a team teaching effort; ask for their input on what they could teach the student. The student does not have to spend all of the time with you since a CORE student is required to attend a regularly-scheduled didatic program provided by the respective CORE. During the orientation session, ask the student about the respective CORE’s didactic program schedule.
7) I'll be gone for 3 days while my student is in my office. Can the student work with someone else?
As the preceptor, you are responsible for supervising the student, but this responsibility can be delegated briefly to another physician, even one from another specialty. Be sure that your student and your colleague understand their roles and responsibilities. If your absence will involve attending a professional meeting, consider taking the student along.
8) How do I know what I am supposed to teach the student?
The Year 3/Year 4 Manual and other educational resources are available from the CORE Office. In addition, there are three sources of information which you can use to give greater focus to the student's learning: 1) information about the preceptorship sent to you by your student's CORE Office; 2) the evaluation form which you will have to complete on the student at the end of the month; and 3) your orientation discussion with the student. By reading these documents - and by talking to your student - you can work out several goals which meet the student's learning needs. Encourage the student to reflect on and inform you about what he/she thinks he/she needs to learn. Defining personal learning goals may be a new experience for many of your students; it is a valuable ability for them to develop as they approach residency training. It is very useful to write down the student's personal goals. An example for a third year student might be: "Jane Smith will be able to: 1) recognize depression in patients she interviews and ask them appropriate questions; 2) perform a focused musculo‑skeletal examination; and 3) present the patient's history and physical exam findings concisely." Review these goals after the student has been with you for a week or two and set new ones as needed. Also discuss the goals with the student at the end of the month to see if they have been accomplished. This review of goals can serve as a basis for your evaluation of the student.
9) I'm not sure I know how to teach; how can I prepare?
When a physician decides to become a preceptor, he/she usually experiences a feeling of uncertainty and doubt. This reaction is entirely reasonable since the preceptor's role is new and unfamiliar and most physicians have had very little - if any ‑ preparation for teaching. As with any new undertaking these uncertainties quickly resolve with practice. It helps to recall that the Latin root for doctor docere, means to teach, and that as a physician you have a great deal of experience teaching your patients and staff and helping them to acquire new and more productive behaviors. The essence of teaching is to communicate frequently and openly.
For a fuller understanding of how to improve your effectiveness as a preceptor, please consider attending one of the Faculty Development Workshops offered by CORE Faculty Development. Physicians in these workshops examine how to orient medical students to their practice, how to create a productive learning environment, how to give constructive feedback, and how to evaluate the student's performance.
10) How do I handle student-related problems?
In the context used here, a problem exists whenever the performance of a student in your practice does not meet your expectations. Example: a third year student arrives at the hospital at 7:30 am, even though he's been informed that your patient rounds start at 6:30 am.
Most serious problems with students will be prevented if you:
1. Orient the student, providing clear information and clear expectations.
2. Talk frequently with the student and listen carefully to her/his needs and interests.
3. Observe and give feedback to your student.
4. Communicate frequently with the student.
5. Communicate frequently with the student's CORE Office.
Such an approach usually results in problems staying small. In the case of the tardy student mentioned above, it would be important to check with him whether you actually did explain that rounds start at 6:30 am, and if he remembers that time. Such a reminder will usually be sufficient.
If the problem is more complex - if it's not resolved by means of a simple reminder - assess it by asking yourself two questions: 1) Is it real? (or was it just a bad day?) and 2) Is it important? (what would happen if nothing were done?) If you decide the problem is both real and important, look into it further by asking the student about it and by asking colleagues in your office if they perceive the problem as well. As you talk with the student, try to determine if he/she has had this kind of problem in the past.
1. Learning deficiency problem - in which the student cannot perform to expectation even if her life depended on it. In such cases the behavior in question has never been learned, or been learned incompletely or incorrectly. Example: a third year student who is examining a patient's thyroid places her hands on the wrong part of the patient's neck.
Preceptor's response: Take an educational approach with this student. You can check out her understanding of the location of the thyroid, demonstrate
and coach her on how to perform the exam appropriately, and give her clinical
exposure to other patients so that she develops appropriate physical examination skills.
2. Forgotten knowledge problem - in which acceptable knowledge or skill has declined with lack of use. Example: A third year student cannot describe the contraindications of two different anti-depression medications, but remembers that they went over this question in his pharmacology course. Preceptor's response: Your response is again educational. You can recommend readings, give the student more practice interviewing and recommending medications for depressed patients, and hold a follow-up discussion with him later in the month.
3. Knowledge present problem - in which the student can perform appropriately but for some reason does not. Example: your third year student continues to arrive late to the hospital, even after you've reminded him that rounds begin at 6:30 am.
Preceptor's response: More education and more reminders from you will probably not solve this problem. Instead, find out whether there are individual or system factors that are interfering with the student's performance and initiate a process that will resolve them. Whatever you find out ‑ whether the problem is personal or systemic - talk it over straightforwardly with the student and enlist his help in resolving the issue.
(Adapted from: Society of Teachers of Family Medicine Preceptor Education
Physicians who become preceptors soon realize that they are working with extremely bright students. They often cite the stimulation of interacting with their students as one of their principal satisfactions. Medical students are very perceptive and quickly pick up cues from their professors and preceptors, emulating the knowledge, skills, and attitudes of their older colleagues. Thus preceptors, because they typically have more sustained contact (and thus influence) with preceptees than any other medical teachers, discover that they “cannot not” teach.
Whatever behavior the preceptor exhibits in the presence of a student - whether excellent (or poor) patient communication skills, or satisfaction (or cynicism) about practicing medicine - that knowledge or skill or attitude will likely be perceived by the student and taken as a normative. Additionally, because students are medical neophytes, they are often unable to discriminate the many separate elements of a complex interview or procedure. If the preceptor does not identify what he/she is doing - or what is going on during an encounter - the student may not "see" it. The preceptor's teaching task, then, is to insure that what the student learns will contribute to the student's personal and professional growth, rather than unintended and accidental learning.
In order to achieve this kind of intentional learning, the preceptor can utilize the following teaching strategies:
· Recognize and treat students as adults
Our educational system has traditionally been based on the assumption of pedagogy, or the teaching of children. The relatively new field of andragogy, which studies the teaching of adults, has found that in contrast to children,
effective adult learners are very self-directed, want direct involvement with what they are learning, like to apply their new learning quickly, and appreciate a
teacher who serves as a colleague and facilitator. Medical student preceptees are typically from 24 to 40 years of age, and they want direct, "hands-on"
experience with patients rather than shadowing. A recent study found that students give high-ratings to preceptors who "allow students to assume
increasing levels of responsibility" and "provide opportunities to practice both technical and problem solving skills." (1)
· Promote active learning by the students
Since adult learners like to be involved and engaged, one of the attractions of a preceptorship for students is the opportunity for active learning. Students in a
preceptorship no longer have to sit passively in a lecture hall or stand at the back of a large group during rounds; instead they are at the center of the action. To
capitalize on this desire for activity and involvement, assign students a definite role that increases in responsibility as the month goes on. For example, over a month's preceptorship a student might initially be assigned to observe your interactions with patients, subsequently take patient histories, then do physicals, and finally do a complete interview including recommendations for treatment and medications and follow up. To make sure that students fulfill their increasing responsibilities; monitor their activities.
· Create a challenging but supportive learning environment
Make it clear to your students that their responsibilities are real and that you have high standards for their work. Also, make it clear that you know they will often feel uncertain and sometimes make mistakes. Communicate that you know that learning involves taking risks and that students can trust you not to abuse the confidences they share with you.
· Set daily teaching goals
The student's overall learning goals for the month-long preceptorship should be established during the initial orientation. You can refine and refocus these general goals by briefly touching base with the student at the start of each day and defining that day's teaching goals. You might say something like the following to a student: "Jane, I know we decided that this month you'll work on picking up signs and symptoms of depression in patients. Please interview several patients with this in mind today, and report to me on what you've found. After you've seen some patients I'll come into the exam room and you can watch how I talk to the patients about their depression."
· Utilize productive questioning strategies (2)
When distinguished clinical teachers in medicine listen to case presentations during teaching rounds, they first diagnose the patient's problem, then assess the
student’s needs, and finally provide targeted instruction to the student’s point of need. (3) To adapt this to your work with students, consider using the following sequence of questions:
Get a commitment by asking the student questions like "What do you think is going on with the patient?", "What other information do you feel is needed?", and "Why do you think the patient has been non-compliant?" Such an approach is collegial, it engages the student in solving the patient's problem and tends not to cut off communication, which often happens if a preceptor adopts an "expert" role.
Probe for supporting evidence by asking questions like "What were the major findings that led to your conclusion?" and "What else did you consider?" This approach allows you to find out what the student knows and where there may be gaps. In using this approach it is important to avoid grilling the student or conducting an oral examination.
Teach general rules by making comments such as "Patients with cystitis usually experience pain with urination, increased frequency and urgency of urination, and may see blood in their urine."
Tell the student what he/she did right. Say for example, "You didn't jump into solving her presenting problem but stayed open until the patient revealed her real agenda for coming today." Make your comments to the student specific and focused.
Correct mistakes. If possible, after a student makes a mistake, find an appropriate time to discuss what was wrong and how to correct the error in the future. Say for example, "You may be right that the child's symptoms are due to a viral upper respiratory infection, but you can't be sure it isn't otitis media until you've examined the ears." Again, make your comments specific and focused.
A recent study found that this sequence of questioning and instruction is highly efficient and saves the preceptor's time. (4)
· Capitalize on preceptor role modeling
As indicated earlier, students sometimes cannot "see" what you are doing unless you point it out. A good time to utilize this approach is when you are demonstrating physical examination techniques. It will be productive for the student - and educational for the patient - if you "think aloud" as you perform a physical exam by saying things like "I am now going to dorsiflex the ankle…watch how I move the foot up towards the shin…and I find the range of motion normal…now you try the same thing." This approach articulates the examination - or other processes - for the student, and enables him or her to perceive all the steps you take. Be careful that you use this approach only with conditions that are not threatening to the patient, or that you alert the student out of earshot of the patient if there is something that might be alarming.
(1) Biddle WB, Riesenberg LA, Darcy PA. Medical Students’ Perceptions of Desirable Characteristics of Primary Care Teaching Sites. Family Medicine. 1996, 28, 629-33.
(2) Adapted from Gordon K and Meyer B. The One-Minute Preceptor: Microskills of Clinical Teaching. Workshop Handout.
(3) Irby D. How Attending Physicians Make Instructional Decisions When Conducting Teaching Rounds. Academic Medicine. 1992, 67(10), 530-638.
(4) Ferenchick G, Simpson D, Blackmann J, DaRosa D, Dunington G. Strategies for Efficient and Effective Teaching in the Ambulatory Setting. Academic Medicine. 1997, 72(4), 277-280.
Orientation as Foundation
A good student orientation is the foundation for a successful preceptorship experience. On the student's first day in the practice, 15-20 minutes should be set aside to acquaint the student with the preceptor, the practice, and the staff. Orientation can take the form of a conversation in which the student and preceptor get acquainted, explore the student's interests and learning needs, and set clear expectations about the student's involvement in the practice. The preceptor and the student should tour the practice, introduce the student to the staff, and explain how they can assist the student's learning.
It is recommended that the preceptor and student jointly set some specific learning goals during this time, and that they go over the evaluation forms so that both the preceptor and the student know what the evaluation will involve. This time, spent one-on-one, is an investment in the experience that will yield substantial benefits during the student's time in the practice.
An orientation session is important because it provides an opportunity to answer questions and define roles, assess skill levels and experiences, set expectations, and anticipate and head off problems. (Adapted from: Society of Teachers of Family Medicine Preceptor Education Project, 1993)
Some suggestions for an orientation session are the following: welcome the student to the program, create a sense of excitement, present the "big" picture, introduce student to the staff and to each other, and think of orientation as an investment. (From: Westberg, J. & Jason, H. (1993). Collaborative Clinical Education. New York: Springer Pub. Co.)
1. The Student and His/Her Interest
2. The Faculty/Attending
3. Basics of the Environment
4. Office and Staff
5. The Patient
6. Student Responsibilities
7. The Preceptorship
8. Miscellaneous (schedules, phone numbers, contact information)
(Adapted from: Society of Teachers of Family Medicine Preceptor Education Project, 1993)
Providing regular feedback to the student regarding his/her work with you is the most powerful teaching tool a preceptor has. It is also the area most commonly cited as lacking when students and residents evaluate medical faculty.
Quite simply, feedback is the sharing of information about the student's performance. Positive feedback serves to sustain behavior that is appropriate and effective. Negative or corrective feedback serves to change behavior that is inappropriate or ineffective. Thus, the student should receive a mixture of positive and corrective feedback. The feedback should be specific enough that the student understands which behaviors are appropriate and which ones need to be changed. General comments such as "you're doing a really super job!" may be pleasant to give, but do little in the way of teaching. Feedback is most meaningful when it is based on solid data obtained while observing or interacting with the student.
This teaching skill becomes easier with deliberate practice. An experienced preceptor who has worked on developing this skill can incorporate feedback comfortably and quickly into regular interactions with a student.
Feedback is giving specific information about a student's current behavior in order to help him/her either continue the behavior or modify the behavior.
· Provides a basis for maintaining or improving performance
· Provides a forum for assessing needs and planning additional experiences
· Most useful immediately following the experience
· Process established during orientation
· Brief, en‑route encounters
· It is specific and performance based.
· It is descriptive, not labeling.
· It focuses on the behavior, not the student.
· It is based on observations, repeated if possible.
· It begins with "I" statements.
· It balances negative and positive comments.
· It is well timed.
· It is anchored to common goals (for example, the student’s learning or quality patient care).
· It provides for two-way communication, soliciting, and considering the receiver’s input.
· It is brief. (Be alert to signs of resistance).
· It is based on trust, honesty, and concern.
· It is private, particularly if it is negative.
· It is part of your regular teaching process, not an exception to the norm.
· It provides for follow-up.
· All comments should be based upon observable behavior and not assumed motives or intents.
· Positive comments should be made first in order to give the student confidence and gain his/her attention.
· Language should be descriptive of specific behaviors rather than general comments indicating value judgments.
· Feedback should emphasize the sharing of information. There should be opportunities for both parties to contribute.
· Feedback should not be so detailed and broad. It should not "overload" the student.
· Feedback should deal with the behaviors the student can control and change.
· Feedback requires the ability to tolerate a feeling of discomfort.
Timely and systematic evaluation completes the learning cycle. It provides the student with a yardstick by which to compare his/her performance to a predetermined standard. Evaluation is most meaningful when it provides the student with a summary of the information the preceptor has collected through previous observations and which has been shared in earlier feedback sessions.
Plans for handling the evaluation process should be discussed at the beginning of the preceptorship; students have the right to understand "upfront" what will be evaluated and when and how evaluation sessions will take place. We recommend that office‑based teachers give their students a blank copy of the evaluation form at the beginning of the preceptorship, informing them that they will be expected to evaluate themselves by the end of the month. In this way the actual evaluation discussion can center on discrepancies between how the preceptor evaluates the student and the student's self‑evaluation. As with feedback, evaluation skills quickly improve with practice.
Evaluation is the process of making judgments based upon factual information and observations in order to rate, rank, or assess the student's status at a given point.
· To summarize performance for the student and teacher
· To communicate meaningful summary information to other parties
· To provide information for planning future educational experiences
· To identify areas that need revision
· To compare a student's skills to those of others, or to some predetermined standard
· Evaluation sessions should be predetermined and regularly scheduled.
· Evaluation should take place in a protected environment.
· Evaluation should be verbal and written when possible. If verbal only, the one being evaluated should be asked to review his/her understanding of the evaluation.
· Evaluation should be conducted in an unhurried atmosphere. The evaluator should undertake an evaluation only of what he/she can adequately cover in the time available.
· Evaluation must be based on explicit and common goals.
· Evaluation must be based on an atmosphere of trust between students and teachers.
· Students deserve and need to know how they will be evaluated prior to the evaluation session.
· Evaluation should be based on systematic observation recorded over a period of time.
· The one being evaluated should have the opportunity to provide input, not in order to change the evaluation, but to contribute his/her understanding of his/her performance.
· Formal evaluations should be predetermined and regularly scheduled.
· Multiple evaluations are better than single, end-of-experience evaluations. Early input allows for the correction of behavior and directs where the student should focus his/her effort.
In the CORE system, the Evaluation of Student Clinical Performance Form is used by preceptors to evaluate the student’s performance. It is divided into the seven core competencies. Within each competency, specific behaviors are provided as evaluation items. This form needs to be completed by preceptors towards the end of the rotation, discussed with the student, and sent to the respective CORE Office. CORE students from affiliated osteopathic colleges may have a different evaluation form. Please contact your respective CORE Office.
Students who are on rotations evaluate their preceptors. In the CORE system, the Evaluation of Preceptor and Rotation Form (available online in New Innovations) is used by students to evaluate the preceptor. It includes important teaching behaviors that an effective preceptor should exhibit such as “Provides service orientation”, “Accessible”, “Provides clear explanations”, and others. CORE students from affiliated osteopathic colleges may have a different evaluation form. Please contact your respective CORE Office.
*Portions of information on Teaching Skills, Orienting Students To Your Practice, Providing Feedback, Evaluating Students, and Frequently Asked Questions were developed by the Texas Statewide Preceptorship Program. Their willingness to share materials is greatly appreciated.