Integrating the Learner Into the Busy Office Practice

Acknowledgements

This monograph was developed by the MAHEC Office of Regional Primary Care Education, Asheville, North Carolina. It was developed with support from a HRSA Family Medicine Training Grant. The monograph was provided to our Office of Faculty Development with permission to modify and use in our faculty development program.

Introduction

If one thing is certain in life, it is that your office or clinic is a busy place. Managed care and other changes are making it even busier. At the same time, your office is an increasingly valuable site for training health professionals. With sicker patients in the hospital for shorter stays, and a mandate for medical schools to produce more primary care physicians, learners are spending more of their clinical training in outpatient settings. How can you integrate these learners into your practice while maintaining your sanity and your bottom line?

The best source of practical answers to this question is community-based preceptors like you. The purpose of this monograph is to promote the exchange of these ideas and helpful hints. We will explore five steps that are important in integrating learners into the practice and provide examples from other preceptors' experiences. Some of these ideas may be very helpful for your particular precepting circumstances; others may not. We hope that you find at least a few new suggestions that you can use. As you read this monograph, we encourage you to think about your own tips for teaching learners in a busy practice. The ideas that you provide in the post-test will, with your permission, be shared with other preceptors in future preceptor development activities.

This monograph is geared to experienced and new preceptors of both students and residents. It will:

1. Identify five steps in integrating learners into the office
2. Share time-saving and efficiency-enhancing hints from other preceptors for each of these steps
3. Help you identify and encourage you to share your own helpful hints

Five Steps to Integrating Learners Into the Busy Practice

As you work to integrate learners into your practice, there are five steps to consider: 1) orienting the learner to your practice, 2) encouraging patient acceptance of both your learners and your practice's role as a teaching facility, 3) adapting your patient schedule when working with a learner, 4) keeping the flow going, and 5) finding time to teach. As we go through each of these steps, we will provide hints other preceptors have found helpful in working with learners.

Orientation

The learner usually arrives first thing on a Monday morning to a busy office, often after you have had a busy weekend. Learners and faculty report that without a clear orientation process, it can take as long as two weeks for learners to figure out how to pace themselves, focus their ambulatory care encounters, set priorities for patient visits, write up charts, and present cases (Kurth, Irigoyen, & Schmidt, 1997). Taking the time at the very start of the rotation to instruct learners in these areas will pay off in increased efficiency throughout the rest of the rotation. (For more discussion of the topics to cover in orientation, see the monograph on “Setting Expectations.”)

What does an efficient and effective orientation include?

Establishing a system for orienting learners can help assure that you will cover all the relevant points with each new learner. For example:

• Some preceptors use a checklist to remind them of the topics to cover in orienting the learner to their practice and clarifying expectations of him or her (see example in Appendix A).
• If you have learners regularly, it can ultimately save time to write out these policies, procedures, and expectations, and then answer questions after the learner has reviewed your handout.
• Having learners write down their past experience, which you review in your first meeting with them, is an efficient first step in your assessment of their level and skills (see form in Appendix B).
• Developing 5-7 achievable rotation objectives with the learner can help you focus your teaching for the rest of the rotation. Preceptors who go through this process often write these rotation objectives down and hang them in the clinical area, to make sure other staff are aware of the learner's interests and pull him or her in for relevant cases.

Encouraging others to participate in the orientation process helps lighten your workload and also helps your staff feel invested in the learner's education. For example:

• Your office manager can orient the learner to the office procedures, charting, scheduling, etc.
• Your lab technician can do an OSHA orientation to your office.
• Some offices have learners go through the office as a patient. The learner registers at the front desk and has a seat in the waiting room, is later taken back to an exam room by a nurse and is oriented to the exam room and nursing procedures, goes to the lab and is introduced to the types of tests that are available, and finally stops at the billing window for an orientation to the billing sheet and medical records. (DaRosa, Dunnington, Stearns, Ferenchick, Bowen, & Simpson, 1997).

Finding time to sit down with a learner can be a challenge on a Monday morning.

• The preceptor's detailed orientation need not occur first thing in the morning. After an initial orientation by staff and brief introduction by you, the learner can shadow for part of the morning, allowing time for a more leisurely orientation at lunch.
• One preceptor prefers to meet his learners the evening before their first day of the rotation, when they arrive in town. This arrangement allows more time to meet in a less hectic environment.

A thorough learner orientation sets each rotation off to a good start. It familiarizes the learner with office systems and your expectations in an efficient manner. It helps prevent learner mistakes. While orientation requires some extra time at the start of the rotation, this responsibility can be shared with office staff and there is some room for flexibility as to when the orientation session is scheduled.

Patient Acceptance

Many preceptors who are thinking about having learners become a part of their practice are concerned about how their patients will respond to the presence of the learner. The majority of patients enjoy and benefit from the presence of learners. They like the increased “face time” with a provider. You can take several steps to assure this positive reaction and prevent potential problems with your patients. For example:

• Hang a notice in the waiting room indicating that your practice is a teaching site. Some schools or programs provide a certificate or plaque that indicates your participation. Or, you can develop your own (see Appendix C).
• Your office manager can submit an article for the local newspaper. This is useful for patients and can be fun for the learner.
• The nurse or staff should check with patients to make sure they are willing to be seen by a learner. It is crucial to instruct them on how to ask. Some have been known to ask, “You don't want to see a student, do you?” With a proper introduction, most patients are happy to be seen by a learner. One preceptor introduces the topic by asking the patient, “How would you like to be a teacher today?” NOTE: If possible, avoid asking patients for permission to be seen by learners in front of the learners; this is awkward for students and patients alike.
• Staff can also post a notice in the exam room or vital signs area that a learner is working with the doctor today and the patient should notify the staff if they have any questions or do not want to be seen by the learner.
• Review the schedule at the start of the day with the learner, and indicate which patients would be particularly good for the learner to see and which patients prefer not to be seen by learners. NOTE: Let the learner know in the initial orientation that some patients prefer not to be seen by a learner and that the learner should not take this personally.
• Identify patients with interesting physical findings and let the patient know how useful this is for learners to see or hear. Some patients will point out such a finding with future learners and begin to instruct them on how to examine it.
• One teaching practice emphasizes the patient's role as teacher by having each patient fill out an evaluation of the learner; questions ask about the learner's friendliness, interest in the patient and listening skills, knowledge, overall care, and whether the patient would be willing to be seen by future learners.
• Thank patients for their involvement in teaching the learner.

How patients react to your teaching depends a lot on how you present it to them. Patients are more likely to appreciate your precepting activities if they perceive them as an indication that you are an accomplished clinician, recognized by medical schools for the knowledge you have to share with learners. They are more likely to be open to a learner if they know in advance that they will be seen by the learner and if they see their role as helping teach the learner. They are also more likely to be receptive if they have the extra time to be seen by a learner; patients have more “face time” with a clinician when seen by both the learner and you, but they also have to wait longer while the learner discusses the case with you. With these precautions taken, most practices find that patients readily accept and are interested in helping to train learners.

Scheduling

Research has shown that the presence of a learner in a practice increases the workload by about 45 minutes per day (Vinson, Paden, & Devera-Sales, 1996). Preceptors address this issue in different ways: some see the same number of patients and have a longer work day, others see fewer patients or schedule different kinds of appointments when working with a learner. How do you deal with this?

Scheduling Patients

• Some preceptors block out a number of appointment spots on their schedule (intermittently during the day, or the last two) when they are working with a learner. This can be used as teaching or catch up time.
• Preceptors sometimes include more spots for walk-in acute problem visits on their schedule when they have a learner. These are often more interesting and appropriate for the learner and can often be handled faster than a complex follow up visit or full history and physical.

Scheduling Learner Time

The learner does not have to spend every half-day of his or her rotation with you seeing patients. Most preceptors share the teaching with others in their office. For example:

• Schedule a half-day from time to time for the learner with a practice partner or another practitioner in the community. This can give you a break and some time to catch up. In some offices, practitioners share a learner equally – although one person still needs to be identified as the primary preceptor for purposes of continuity and evaluation.
• Schedule a half-day for the learner to work with a nurse, lab technician, dietitian, and/or front office staff. Learners often report that this exposure enhances their appreciation for the other staff's roles and responsibilities, which is likely to serve the learners well as practitioners.

Schedule other activities for the learner. On some rotations, learners already have community projects or tasks that they are required to do out of the office. Even if these are not required, they may be valuable experiences for the learner. These activities might include:

• Visiting a patient at home. Learners can take as long as they want to work up an extensive patient and family history. This activity can be particularly helpful for new learners, giving them insight into the social context of a patient's illness.
• Accompanying a patient to a sub-specialty consultation visit.
• Spending a half-day with home health, hospice, the health department, or other community agencies you work with and refer patients to.
• Visiting an industrial site may shed light on occupational health issues that arise among your patient population.
• Accompanying you on nursing home rounds, hospital rounds, and/or community health screenings.
• Writing an article on a common or seasonal health topic for the local newspaper.
• Speaking to a community group or students at the local school on a health topic. One community-owned clinic that teaches a high volume of interdisciplinary students has a standing agreement that each student will talk to the local school's fifth grade class about his or her profession and a health topic of his or her choice. The clinic has patient education materials available for students' use in preparing these talks.
• Accompanying you to a hospital medical staff meeting. Learners tend to have only limited exposure to the context in which their clinical care is provided. Attending meetings such as this give them a more three-dimensional view of both your role as a physician and the business administration of medical care.

Learner projects can contribute to the office. Learners can help provide follow-up phone calls for patients, conduct Quality Assurance activities or assess community health concerns, and develop patient education materials for preceptors' use. The trick is to make sure that learner activities both help you do high-priority work and are of interest to the learner. One practice that precepts regularly keeps a list of “Top 10” priority projects which learners choose from. For each project, key steps of the project are outlined and key contact people are identified (Doyle, Burkhardt, Copenhaver, Thach, & Sotak, 1998). Learner activities can include:

• Making follow up phone calls to the patients the learner has seen. This activity helps the learner develop better rapport with patients. This also makes patients more willing to be seen by a learner in the future.
• A literature search conducted on a computer database or at a regional health library. This helps learners develop life-long learning skills as it helps you get pertinent information. Increasingly, learners have access to and training in computerized literature searching. Furthermore, some universities will fax articles free-of-charge to students on community rotations, while it may cost several dollars each to have articles sent to you.
• A chart review, to conduct a Quality Assurance audit for the practice (be sure to set clear guidelines about what the learner should or should not look for in the chart), to identify referral patterns, or to help the learner recognize different manifestations of a common diagnosis.
• A survey of patient satisfaction or patient education needs.
• Development of patient education materials to hand out or post in the waiting room.

Precepting learners tends to lengthen the clinician's workday. Preceptors react to this fact differently: some have longer workdays for the month that they are precepting; some schedule fewer patients or more work-in acute (focused complaint) visits. You can provide periodic breaks for yourself throughout a rotation, while creating meaningful experiences for learners, by scheduling learners to work half-days with your partners and other staff in your office, with other agencies in the community, and in other types of learning activities.

Keeping Things Moving

Keeping things moving along while teaching in a busy practice is a vital and ongoing challenge. What do you do when things bog down and, more importantly, how do you prevent this from happening?

Several measures can help prevent you from getting too far behind in the schedule.

• The learner does not need to see every patient. You can go over the schedule in advance and indicate which patients the learner should see. This allows you to select the most appropriate patients and fit in some time for the learner to write notes and look things up – and time for you to see the rest of the patients.
• Or you can develop a pattern: you see a patient while the learner sees another. After you finish with your patient, you review the learner's patient with him or her. See a third patient while the learner writes his or her note. Then start the cycle again.
• Even if the learner is not seeing all the patients, you can still pull him or her in briefly for interesting findings or appropriate procedures. Encourage your partners to grab the learner from time to time for interesting cases. This can give you a brief break and enhance the learning for the learner.
• Sometimes preceptors slow things down by trying to get too much teaching in between patients. Using focused teaching techniques such as the One Minute Preceptor can make efficient use of the time. Your famous 10-minute talk on “Asymptomatic UTI” might have to wait.
• Some preceptors have learners present cases to them in the exam room, in front of patients. The learner goes in first to conduct a history and physical and then presents as the preceptor conducts his or her own exam. This strategy increases the preceptor's “face time” with the patient, facilitates instant follow up and feedback from the patient, and allows the preceptor to see how the learner interacts with the patient (Ferenchick, Simpson, Blackman, DaRosa, & Dunnington, 1997). When using this strategy, learners should minimize use of medical jargon and should be careful about raising sensitive issues or tentative diagnoses. Some learners will be more comfortable receiving criticism out of the exam room, when they are not in front of patients. (See “Teaching at the Bedside” monograph.)

What do you do if you get way behind schedule?

• It is okay to tell the learner to work on his or her charts or to read up on something until you get your head above water. NOTE: This works best if you have informed the learner in advance that this happens from time to time, so that it is expected and they know to keep themselves occupied while you catch up.
• If you have a slow learner who is taking 45 minutes to see a cold, you can set strict time limits: “You have 15 minutes to get a basic history of the chief complaint and pertinent physical findings. I want you to come out after 15 minutes with whatever you have.” If the learner is not out when you are ready, go in and get him or her.
• One preceptor threatened to charge a slow student a dollar if he were not out of a room by the specified time. Although the preceptor never collected, it added interest and emphasis, and the learner sped up considerably.
• A slow learner was taking copious notes during each encounter, practically transcribing verbatim the words of the patient. The preceptor took paper and pen away to help the learner be more efficient and rely on her memory of the history. Another option is to give a very small note pad to the learner and require that he or she only use one sheet per patient.
• There was a time when precepting advanced licensed learners such as residents in your office did not reduce your efficiency in seeing patients. Recent Medicare regulations require a high level of preceptor supervision and documentation and have put a crimp in this efficiency. As a result, some preceptors have elected to have the residents see only non-Medicare patients. For preceptors with a high proportion of Medicare patients in the practice, it would be helpful to ask the residency program for details on how to provide the necessary supervision and how to document this. This supervision and documentation usually does not take as much time as it would for you to see the patient yourself, but it does add to the time involved, and it is important to do it correctly.

A daily challenge in precepting is setting a sustainable pace of seeing patients and teaching. It will help to tell the learner in the initial orientation how long you expect him or her to spend with each patient and then to go over strategies for being efficient as the need arises. Having backup activities for the learner when things get really behind – and the learner's understanding that this situation will arise periodically – can help you catch up efficiently.

Teaching Time

Precepting is supposed to be about teaching, but sometimes it is difficult to find the time or energy to get much formal teaching in. Recognize that there is a tremendous amount of experiential learning that occurs in your office. At the same time, you want to optimize the formal teaching that you do.

While seeing patients:

• It can help to use techniques designed for the outpatient setting such as the One-Minute Preceptor.
• In responding to a case presentation, briefly highlight one or two things and get back to other aspects of the case later, as time permits.
• Sometimes when you do have a moment for teaching, it is hard to recall pertinent topics. Jotting a note on the border of your patient care schedule or keeping a note card in your pocket can help you keep track of teaching points to make or feedback which you need to share with the learner.
• Likewise, you can encourage the learner to keep a notebook to record questions and issues to discuss at later times.
• Finding time to review:
• Spending a few minutes at the end of the day or half-day reviewing the list of patients seen gives you an opportunity to review or solidify teaching points made earlier in the day.
• Lunch time works well for some preceptors. Discussion of the morning cases over a bag lunch or at the local Burger Barn can serve the dual purpose of nourishing the mind and insuring that you get your lunch. Beware of confidentiality issues if you lunch in public places.
• Travel time to and from hospital rounds can become a routine time for teaching and feedback.
• Other means of providing teaching:
• Many preceptors have the learner review a topic and present it to them the following morning. The topic can be based on a case seen that day or on a patient scheduled for the upcoming day. Set a specific time limit (5 minutes) and format for the presentation, and be sure that you give the learner a chance to present what he or she has reviewed. By having the learner do the research, you save yourself some time and also foster more active learning for the learner.
• For your five or ten most common teaching topics, you might want to collect readings or dictate your talk and keep these materials in a folder that your learner can readily access.
• Reflect on your teaching: ask yourself and your learner what teaching approaches you have used, whether they were effective or not and why, and what – if anything – you might do differently next time. Doing this exercise regularly throughout the rotation (for a few minutes every few days) will help reinforce your good teaching habits and give you time to try alternatives to less successful strategies.

While you can get “bogged down” by trying to integrate too much teaching every day, not setting aside any time for teaching will also result in adverse outcomes. It can help to proactively set aside some time for teaching each day. Focus on brief teaching points as you observe learner-patient encounters and respond to case presentations during the day. And keep notes, or have your learner keep notes, to remind you about longer teaching issues you can cover at the designated teaching time. Encouraging your learner to seek knowledge from other sources as well promotes his or her active learning and relieves you of some teaching time.

Summary

Community-based preceptors are under increasing pressure to both see more patients and teach more learners. Thus efficient and effective means of integrating teaching and patient care are increasingly important. Experienced preceptors have developed a wide variety of ways to integrate learners into their practices. This monograph has sought to promote exchange of preceptors' ideas.

Some of these ideas may work better in your particular precepting circumstances than others. In determining how you might better integrate teaching into your busy office, look at your systems in the following five areas: 1) orienting the learner to the practice, 2) encouraging patient acceptance of both your learners and your practice's role as a teaching facility, 3) adapting your patient schedule when working with a learner, 4) keeping the flow going, and 5) finding time to teach. Use learner feedback and your own observations to enhance these systems.

As community preceptors, you are balancing learner training with patient care. Undertaking these two tasks does not have to result in twice the workload. The challenge – and reward – of community-based precepting is in integrating teaching and patient care in synergistic ways that enhance each task and keep your work stimulating and your workload manageable.

References

DaRosa, D. A., Dunnington, G. L., Stearns, J., Ferenchick, G., Bowen, J. L., & Simpson, D. E. (1997). Ambulatory teaching "lite": Less clinic time, more educationally fulfilling. Academic Medicine. 72, 358-361.

Doyle, D., Burkhardt, E., Copenhaver, J. A., Thach, S., & Sotak, D. (1998). Health profession students as research partners in community-oriented primary care. Journal of Community Health, 23, 337-346.

Ferenchick, G., Simpson, D., Blackman, J., DaRosa, D., & Dunnington, G. (1997). Strategies for efficient and effective teaching in the ambulatory care setting. Academic Medicine, 72, 277-280.

Kurth, R. J., Irigoyen, M., & Schmidt, H. J. (1997). A model to structure student learning in ambulatory care settings. Academic Medicine, 72, 601-606.

Vinson, D. C., Paden, C., & Devera-Sales, A. (1996). Impact of medical student teaching on family physicians' use of time. The Journal of Family Practice, 42, 243-249.

Other Resources

Feins, A., Waterman, M. A., Peters, A. S., & Kim, M. (1996). The teaching matrix: A tool for organizing teaching and promoting professional growth. Academic Medicine, 71, 1200-1203.

Goertzen, J., Steward, M., & Weston, W. (1995). Effective teaching behaviours of rural family medicine preceptors. Canadian Medical Association Journal, 153, 161-168.

Shreve, R. & Kaprielian, V. S. (1998). Independent activities for student learning during community-based rotations. Family Medicine, 30, 408-409.

 

---

---

Top | Monographs | Home

---

Appendix A: Setting Expectations Checklist

Orientation to practice

__Learner work space, reference

materials *

__Dress code: name tag, lab coat? *

__Hours/ days patient care provided *

__Parking, phone system, email *

__Introduce staff, each one's

responsibilities *

__Unique learning opportunities

(clinical activities, patient population,

provider interests)

Orientation to community

__Community characteristics *

__Community resources, arranging

visits to them *

__Where to buy groceries, do laundry *

Overview of rotation

__Relate rotation to learner's career

plans

Introduction to learner

__Rotations completed *

__Experience and skills mastered

__Areas needing work

Expectations of School or Residency

__Course objectives

__Criteria included in evaluation form

Learner Objectives

__Specific knowledge, skills, and

attitudes to develop

__Grade expectations

* Topics that office staff might go over with learners

Preceptor Expectations

Daily routine

__Hours/ days learner in the office

__Learner's level of responsibility and

autonomy in providing patient care

__Hospital rounds, night/weekend call

__Times preceptor is off; what to do

__Amount of reading expected

Office policies

__Directions for writing chart notes,

dictating, writing Rxs, referrals

__How pts selected for learner to see

__Length of time to spend with each pt

__Hospital policies

Values

__Show respect to pts & staff; how?

__Get to know pts?

Preceptor/learner interaction

__Format for case presentations

__Regular time & process for feedback

__Integrate teaching and learning styles

__Learner needs to explain needs

__Criteria to evaluate learner

(“what it takes to get honors”)

__Learner self-evaluation before

discussing preceptor's evaluation

If a problem arises

__Absentee policy, how to notify office

__A contact for questions or problems

__How to reach preceptor in emergency

Rotation objectives

__Requirements based on practice's

unique learning opportunities

__Specific knowledge, skills, attitudes

you notice learner needs to work onAppendix B: Learner Background Form

Learner ___________________________ Preceptor ___________________________

School, Course _____________________ Dates of Rotation _____________________

Personal information (anything that will help the preceptor and practice get to know you a bit):

Previous clinical experience:

Rotations completed: Other clinical experiences you have had:

__ Family Medicine __ Pediatrics

__ Medicine __ Psychiatry

__ OB/GYN __ Surgery

__ Other: __________________

Clinical interests:

Aspects of medicine you have particularly enjoyed or disliked so far, and why:

Career interests at this point:

Special Requests for this Rotation:

Specific topics, skills, or problems you hope to address during this rotation (please describe how your interests might be addressed):

Areas in which you would like specific feedback during the rotation:

Appendix C: Sample Teaching Notice

Thank You!

This practice serves as a teaching site for students at the State University

School of Medicine.

As a patient of this practice,

you are helping educate future doctors in the skills necessary to be

competent and caring physicians.

___________________________

Practice Medical Director

Appendix D: Sample Schedule for a One Month Rotation

Learner: Jesse Banks, 4th year med student at State University Medical School

Preceptor: Jane Long, MD (day off: Wednesday)

Rotation dates: Feb 1-26

Learner interest: Surgery (learner filled out Learner Background form on 1st day)

Project: Prevention: literature review, patient assessment, prepare office protocol and present to practice clinicians (school requirement)

Community activities: Hospice, Health Dept (standard for all learners)

MON	TUES	WED	THURS	FRI	WEEKEND
am	Feb 1 Orient: Office mgr	2 Preceptor	3 Practice partner	4 Project	5 Preceptor	6-7 --
pm	Preceptor	Preceptor	Practice partner	Preceptor	Preceptor	--
am	8 Preceptor	9 Preceptor	10 Practice management: Office mgr, Front office	11 Project	12 Preceptor	13-14 ON CALL: Preceptor
pm	Preceptor	Preceptor	Practice partner	Preceptor	Preceptor, Mid Evaluation	ON CALL: Preceptor
am	15 Off	16 Preceptor	17 Surgeon in town	18 Project	19 Preceptor	20-21 --
pm	1 Hospice	Preceptor	Surgeon in town	Preceptor	Preceptor	--
am	22 8 Health Dept	23 Preceptor	24 Practice partner	25 Project	26 Preceptor	27-28 --
pm	Preceptor	Preceptor	Practice partner	Preceptor	Preceptor, End Evaluation	--

Appendix E: Blank Schedule

Learner: School/Program:

Preceptor: Day off:

Rotation dates:

Learner interest:

Project:

Community activities:

MON	TUES	WED	THURS	FRI	WEEKEND
am
pm
am
pm
am
pm
am
pm