Setting Expectations

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

For the community preceptor, teaching is not a full-time job. When there are long periods of time between precepted rotations, it can take a few days to get back into the routine of teaching. Yet those first days of a rotation are critical for helping a learner adapt to a new practice environment and a new preceptor.

Developing a system for orienting and clarifying expectations with a learner can help each rotation get off to a good start. While the first day of a rotation (usually Monday) is almost always hectic, taking the time to orient the learner on that first day saves the preceptor time and energy the rest of the rotation by preventing learner mistakes and unintended transgressions of office norms. A systematic orientation also helps a preceptor tailor the rotation to different learners' particular needs. And it provides a framework for giving learners feedback and evaluating them.

In this monograph, we will explore the four steps of setting expectations: 1) orienting learners to the logistics of the practice and rotation, 2) setting expectations of the learner's performance, 3) selecting mutually-agreeable rotation objectives, and 4) providing feedback about whether they are meeting the set expectations. We will present several tools that preceptors can immediately use with learners, including: a checklist of orientation topics and expectations to discuss with learners, a timeline of activities, and tools to gather and share information about a learner's background and rotation objectives.

This monograph is geared to experienced and new preceptors alike. By the end you will be able to:

  1. Go through the process of setting expectations with a learner.
  2. Share specific tasks in this process with others in your office.
  3. Identify your own expectations of a learner on a given rotation.

An Example

Throughout this monograph we will demonstrate the different steps of setting expectations with an example learner.

It is Tuesday evening and you are catching up on paperwork. On your calendar you see that you have a third-year medical student coming Monday for a four-week rotation, Lisa Jones.

Several months ago, the arrival of your last student coincided with a particularly busy morning at the hospital. You were delayed getting into the office and the student spent an hour reading magazines in the waiting room. You were pleased with his clinical skills, but as you filled out his evaluation form at the end of the rotation, you realized you had not observed him in some of the categories listed on the form. When you asked for his feedback about the rotation, you were surprised to hear he had wanted learn more about managing chronic back pain; this request would have been easy to meet had you known his interest.

You want to prevent some of these surprises with the upcoming rotation. What will help assure that it gets off to a good start?

Orientation

Before learners can focus on learning objectives and developing clinical skills, they need to know their way around your office. Where can they leave their belongings? How do they use the phone? A systematic orientation helps learners promptly answer these initial questions so that they can focus on the main purpose of the rotation.

In the orientation, a learner needs to learn about the practice, the community served by the practice, and the rotation. At the same time, a preceptor needs to determine the learner's past experience and current skill level (Table 1).

Table I: Orientation Topics

Introduction to the Practice

Introduction to the Community

Overview of the Rotation

Introduction to the Learner

Introduction to Practice

Learners need a tour of the practice that includes instructions for basic office systems, resources available for the learner, introductions to the staff they will be working with, and some characteristics of the practice and the population it serves.

Introduction to Community

Orienting learners to the community served by the practice and resources in the community can help them better understand trends in the patient population and the context of individual patients' health concerns. For example, your learner might be likely to see many repetitive-motion injuries because of the chicken-processing plant down the road. If the closest battered women's shelter is two hours away; he or she might have to learn about alternative resources for patients experiencing domestic violence.

It is also helpful to tell the learner where the nearest grocery store, ATM or bank, and Laundromat are, and explain the most direct routes from learner housing to the practice and to the hospital.

Overview of Rotation

Addressing the objectives of this rotation in the greater context of the learner's career goals is similarly important. It may not be obvious to a learner how an internal medicine rotation is relevant given her intended specialty of child psychiatry. Helping learners find relevance can enhance their enthusiasm for the rotation and their motivation.

Introduction to Learner

While learners are adapting to the practice, the preceptor is getting to know the learners. A one-page form can help learners outline their background, identify the rotations they have completed, and describe their interests – in general, clinically speaking, and specific to the rotation (DaRosa, Dunnington, Stearns, Ferenchick, Bowen, & Simpson, 1997; Society of Teachers of Family Medicine, 1992). Figure 1 shows such a form that has been completed by Lisa Jones, the third-year student mentioned in the example above. A blank form is provided in Appendix A.

Figure 1: Learner Background

Learner Lisa Jones Age 26 Mike Smith

Course Internal Medicine clerkship Dates of Rotation February 1 –26

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

I have an MPH in Maternal and Child Health and worked for a year doing WIC education at a health department in Washington state before starting med school. My grandparents live in this county (I'm staying with them) and have been coming to your partner, Dr. Jones, for years.

Medical interests:

Aspects of medicine you like the most, and why:

I like interacting with patients and being able to address their needs. I also like the challenge of developing a good differential diagnosis.

Aspects of medicine you like the least, and why:

I'm daunted by the business side of medicine – can you really go into private practice anymore with managed care and all the different insurance companies & HMOs?

Career interests at this point:

I'm thinking about pediatrics.

Clinical background:

Rotations completed:

X

X

Other types of clinical/ ambulatory care experience you've had:

I was with a family physician for the 2-week rotation during our first year.

Special Requests:

Indicate any special topics, skills, or problems you hope to address during this rotation, and describe how your special interests might be addressed:

I want to get better at focused histories. I'd like more hands-on experience with procedures like suturing and giving shots. I'm also interested in learning more about the clinic at the homeless shelter in town – I'd be interested in spending a day there if that could be arranged.

Indicate any special areas on which you would like to receive direct feedback during this rotation:

History-taking, differential diagnosis, how to be more efficient in presenting cases.

The learner's skills, attitudes, and level of knowledge can best be assessed in the first few days of the rotation by observing the learner working with a patient directly (either in person, or less intrusively, through video monitoring). Learners' case presentations also provide some of this information in their omissions or additions of extraneous information.

Orienting Efficiently

One strategy for efficiently covering these various topics is to enlist the aid of your staff in orienting learners. Who in your office might best give a tour of the facility, introduce staff and their various roles, and show the learner how to use the phone? Do you have patients that might enjoy showing a learner around the community? The more these orientation responsibilities are shared, the less work for you and the more aware and invested your office staff and community members are in the learner's education.

Introducing the learner to the practice can start before the learner arrives. Some preceptors choose to send in advance a “site description” of their practice that includes the name, address, and phone number of the

practice; providers' names; a paragraph describing the mission, patients served, and procedures done at the practice; directions to the practice; and instructions regarding who to report to on the first day of the rotation and at what time.

Example

Tuesday evening you put up a note to staff on the kitchen refrigerator with Lisa Jones' name, school, and rotation dates. Wednesday morning you ask your office manager to orient Lisa on the first morning of the rotation and to prepare a “learner background” form (Figure 1) for Lisa to complete. When the student arrives at 8:30 Monday morning, the office manager gives her a tour and introduces her to staff. She gives Lisa a patient brochure that lists your office hours and clinical services and a copy of an article that the local paper did on your practice a few years ago. Lisa then completes the “learner background” form.

Once Lisa fills out the form, the office manager brings her back to your office. You introduce yourself and explain the plan for the rest of the day: she will shadow you this morning, and then see patients and present to you this afternoon. After you finish seeing patients this evening, probably about 6:00, you two will sit down and talk about your expectations and objectives for the rotation.

CLARIFYING EXPECTATIONS

Once the learner knows the way around the practice and you have developed a sense of his or her level, it is time to clarify expectations of learner performance. While many components of the learner orientation can be delegated to other staff in the office, it is important that the learner discuss expectations directly with the primary preceptor. You are responsible for guiding his or her clinical education and for completing the evaluation.

You may want to discuss these expectations with the learner at lunch or in the evening of the first day of the rotation. To make sure that you have adequate time to talk with the learner (45 minutes to an hour), you can have this meeting put on your schedule a few weeks in advance.

There are three parties whose expectations are relevant for your learner's rotation: those of the school or residency, the learner, and you (Table 2).

The clearer you can be in discussing expectations of learners, the more likely they are to meet them -- and the easier it is to hold them accountable if they fall short of the expectations.

The School or Residency

The school or residency's expectations are laid out in its course curriculum objectives, which the course director usually sends preceptors before the rotation starts. The course curriculum will likely tell you what knowledge and skills the learner is expected to develop, and whether the learner is expected to conduct community outreach or a research project in

Table 2: Clarifying Expectations

School or Residency Expectations

Learner Objectives

Preceptor Expectations

addition to the clinical work. Some curriculum objectives are more specific than others. You may want to seek clarification with the course director. Sometimes there are more curriculum objectives than is feasible to accomplish in one rotation; in these cases, it may be useful to select four or five objectives that are particularly appropriate to your practice.

While the curriculum objectives outline the content of the rotation, the evaluation form clarifies the school's expectations of the learner's performance. Is the learner expected to show mastery in a particular skill or merely be introduced to it? This information guides your daily choices about which patients the learner should see and what level of autonomy to give him or her.

Also be familiar with the school's expectations of you, the preceptor. On some types of rotations, preceptors assign the learners' grades; on many, course directors determine the grade based on preceptors' comments and completion of the evaluation form. Are you expected to assign a grade?

The Learner

It helps you to know what knowledge, skills, or attitudes the learner wants to develop or further hone during this rotation. To the extent that learners take an active part in defining their learning objectives, they may be more likely to recognize the rotation's relevance to their needs and be more motivated. At the same time if the learner has an unrealistic expectation for the rotation, such as performing advanced procedures on his or her first rotation, now is the time to recognize it and help the learner identify more realistic objectives.

Another motivating factor for learners is the rotation grade. What kind of grade is your learner trying for? You can clarify what performance level you expect for an honors grade versus a high pass or for the various categories listed on the evaluation form.

Your Expectations

You have many expectations about how learners will act. Spend some time thinking about the unique learning opportunities available at your practice and what your expectations are of the learner. Below are some guidelines for topics to cover.

Learners need to know when they are expected in the office, whether they will have evening and weekend call, and what sorts of activities are expected beyond seeing patients in the practice. Let learners know if they are expected to round with you at the hospital before going to the practice each morning, and who they should spend time with on your days off or when you are out of the office. They also need to know how much responsibility they will have in seeing patients. Furthermore, learners needs instruction on your office policies, such as whether they should dictate chart notes or write them, and how long they are expected to spend with each patient.

Perhaps less readily identified are the expectations you have regarding the values and attitudes a learner will demonstrate. For example, you might tell a learner that is it important to you that he or she addresses patients' perceived needs as well as identified clinical needs. Or you might tell learners they are expected to try to get to know the patients beyond their clinical problems. In what ways do you expect learners to show patients and staff respect?

Included in this discussion should be your expectations of the preceptor/ learner interaction. When presenting cases, you may prefer that learners go through all of the history and physical exam findings, or that they skip negative findings (depending on their skill level). Explain when you plan to give learners feedback about their performance: during case presentations, at the end of the day, and/or in weekly reviews. Describe your mid-term evaluation process.

During this discussion you can describe your precepting style and ask about their learning style. Do you tend to engage in respectful pimping or prefer to give assignments for learners to report the next day? Do they learn best by watching first or doing, by being quizzed or researching? By discussing your styles, you can help map out strategies for communicating more effectively throughout the rotation (see monograph on “Teaching Styles and Learning Styles”).

Go over with the learner what he or she should do if a problem arises. Review the school or residency's absentee policy and identify to contact if the learner is going to be absent. The learner may also want to know how to reach you in an emergency.

Finally, you might discuss with the learner any particular expectations that are unique to you as a preceptor because of your experience, interests, or community setting – clinical or otherwise – that go beyond the school or residency's expectations. For example, if you treat a lot of patients with chronic back pain, you could decide that all learners at your practice will learn about chronic back pain management. Or perhaps you handle a lot of workers' compensation cases and could share your knowledge of workers' comp rules. You may be active in the local medical society or heavily involved in a hospital merger; you could bring learners to these meetings. If your practice emphasizes quality assurance, you could require each learner to conduct a chart audit and report the results at a provider meeting. These expectations, along with the initial orientation topics, are outlined as a checklist in Appendix B.

Rotation Objectives

Once you have discussed your various expectations with the learner, it is time to set specific rotation objectives. This step may occur immediately after discussing expectations on the first day of the rotation. Or you may opt to wait one or two days to get a better sense of the learner's skills and so that the learner thinks more about his or her own objectives. In either case, it is important that time be set aside to determine the rotation objectives with the learner, just as you took time to clarify expectations together.

The rotation objectives should be limited in number (more than 5-7 will be hard to accomplish), should reflect the expectations of the school, learner and you, and should be mutually agreeable to you and the learner. They can include clinical knowledge, skills, and attitudes that the learner is expected to develop, and should include specific strategies for meeting each objective. Writing these objectives down can help you and the learner keep track of them (Society of Teachers of Family Medicine, 1992). Some preceptors prefer a less formal verbal agreement on the objectives. Figure 2 shows medical student Lisa Jones' objectives. A blank form is provided in Appendix C.

When you have identified clinical objectives for the rotation, it is helpful to share them with other staff (Figure 3 and Appendix D). If receptionists, nurses, and your partners know what the learner's interests are, they can include the learner when patients with a particular chief complaint are on the day's schedule.

Figure 2: Rotation Objectives

Learner Lisa Jones Preceptor Mike Smith

Course Internal Medicine clerkship Dates of Rotation February 1-26

Together we have identified the following specific objectives for this rotation:

Example

In your first day with Lisa, you notice that she spends a long time in the room with each patient, even when the chief complaints are relatively straightforward. She also tends to ramble as she presents cases and needs some work on her differential diagnoses. These were rotation objectives she mentioned on her “learner background” form as well, and they make sense given where she is in her clinical training. An area of weakness that she has not mentioned but that you want her to work on, is presenting an assessment and plan after she presents a patient's subjective and objective. You want to encourage her to be more proactive in resolving cases and not wait for your assessment.

Together, you develop six rotation objectives (Figure 2) that draw on your observations and on her priorities, as outlined on the “learner background” form.

Figure 3: Learner Request for Clinical Experience

Learner Lisa Jones Preceptor Mike Smith

Course Internal Medicine clerkship Dates of Rotation February 1-26

To: Receptionists, Nursing Staff, Providers

This learner would like to have more exposure and hands-on experience in the following areas during this rotation. Please make a special effort to involve the learner in these activities:

Follow Through: Feedback About Meeting Expectations

By clarifying expectations and developing mutually agreeable rotation objectives, you have created a “road map” for the learner's education.

Over the course of the rotation, you will need to refer back to this map to make sure you are still on track. Setting expectations accomplishes little if it is not combined with feedback to the learner about whether he or she is meeting those expectations (see module on “Giving Feedback”).

Is the learner being exposed to the clinical experiences needed on this rotation? It may be necessary to remind staff about incorporating the learner for specific clinical cases.

Is the learner meeting your expectations? Refer to the expectations and rotation objectives as you give feedback to the learner both in response to case presentations and as you debrief at the end of the day. If the learner is not meeting your expectations, you need to let him or her know early on, so that there is ample time to modify behavior before your evaluation is completed.

Some preceptors choose to conduct a “mid-rotation evaluation”, a 30-minute exercise in which they fill out the evaluation form based on the learner's performance thus far and then go over it with the learner. This mid-rotation evaluation is usually not a part of the final grade and is not sent to the school or residency. It serves to show learners your assessment of their performance so far and to identify areas they need to work on for the rest of the rotation. Having learners assess themselves first using the same form will help involve them in the process, and it provides a good lead-in for your assessment. The ensuing discussion should include a plan for addressing the areas that the learner needs to work on (see module on “Evaluation”).

At this point you may need to rethink the rotation objectives if they have proven to be unrealistic or if you have identified other areas that are a higher priority to address. In this case it is important to make sure the learner and you are both clear about any changes and have planned strategies for achieving the new objectives.

A final 45-minute debriefing session or “exit interview” provides a great opportunity to both give and get feedback. First and foremost on learners' minds is their grade. If you have initially stated clear expectations for the rotation, developed mutually agreeable rotation objectives, and then given learners consistent feedback about their performance in relation to those objectives throughout the rotation, your end-rotation evaluation of their performance should come as no surprise.

As you sit down with the learner to discuss the evaluation, once again refer to the expectations you had outlined and the rotation objectives you had both agreed to. The more you can objectively compare a learner's performance to mutually agreed-upon goals, the easier it is to justify your assessment.

In this same session, you may want to get feedback from the learner about the orientation process and your expectations. What in the orientation helped the learner feel situated in the practice? What new or different topics might be included in future orientation sessions? Were your expectations realistic for this level of learner? Did the learner identify other unstated expectations of yours that should be made explicit with future learners? It can be helpful to have learners write down their suggestions at the end of the session or to take notes during this session.

The learners' feedback is important input in an assessment of the orientation process. Share this feedback with the relevant staff and encourage their assessment as well. Also review your own observations about orientation and your expectations. Together, these three perspectives will help you identify any needed changes in the process of orientation and setting expectations.

Example

At your mid-rotation evaluation of Lisa, you tell her that she is presenting cases much better: she is regularly presenting assessments and plans, and her presentations are more succinct. You note that she is still spending too long on each patient's history and physical, and you two brainstorm how to be more efficient in that regard. You also raise your concern that she is not reading as much as you expect, and you give her specific suggestions about selecting reading topics.

Your final evaluation reflects her improvements in efficiency seeing patients and her increased reading in the second half of the rotation. As you debrief about the rotation overall, she suggests that you encourage future learners to present to you based on their reading; she thinks this will help motivate learners to do the amount of reading you expect. You think this might be an individual style preference, but say you will keep her suggestion in mind with the next learner.

After talking with staff and thinking yourself about what to do differently next time, you ask the office manager to develop a packet of materials that she will give each learner on the first morning of the rotation. This packet will include a site description, a practice brochure, a copy of the newspaper article, and the “learner background” form. She will have the student fill out the learner background form that morning, in preparation for your meeting that day. You also ask that the last patient slot before lunch on the first and last days of the rotation be blocked out so that you will have time to orient and debrief with the student.

A Timeline

The following timeline (Table 3) outlines actions for orient learners, clearly communicating expectations, selecting rotation objectives, and giving feedback about whether expectations and objectives are being met.

Summary

Setting expectations for the learner's performance during a rotation is critical to get the rotation off to a good start. Setting expectations saves time and energy in correcting unintended mistakes, helps the preceptor tailor rotation objectives to learners' particular needs, and provides a framework for giving feedback and evaluating learners.

In this monograph, we have presented four steps of setting expectations: orienting learners to the logistics of a practice and rotation, setting expectations of their performance, selecting mutually-agreed upon rotation

objectives, and providing feedback about whether they are meeting the expectations and rotation objectives. Orientation includes introducing the learner to the practice, the community it serves, and the rotation and assessing the learner's knowledge and skill level. Preceptors need to clarify the school or residency's, learner's, and their own expectations. Preceptors should be prepared to explain their expectations regarding the learner's daily routine, office policies, values, preceptor/learner interaction, what to do if a problem arises, and unique learning opportunities at the practice. Providing feedback to learners throughout their rotation about whether they are meeting expectations is critical.

Table 3: Timeline of Activities

Before the Learner Arrives

As the Learner Arrives

During the Rotation

At the End of the Rotation

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.

Society of Teachers of Family Medicine. (1992). Organization & planning. Preceptor education project. Kansas City, MO: Society of Teachers of Family Medicine.

OTHER RESOURCES

Lesky, L.G., & Hershman, W.Y. (1995). Practical approaches to a major educational challenge: Training students in the ambulatory setting. Archives of Internal Medicine, 155: 897-904.

Olson, A. (1996). The “nuts and bolts” of a successful student experience in the office. Workshop presented at the COMSEP Annual Meeting, St. Petersburg Beach, FA, March 1996. http://www.med.uci.edu/~comsep/workshop/office.html

Steele, D.J. (1997). Orienting medical students in community-based teaching sites. Family Medicine, 29, (9): 614-5.

Tresolini, C.P., & Stritter, F.T. (1996). Setting the stage: Learning environment and goals. The expert preceptor: A curriculum guide for community faculty development in the health professions. Chapel Hill, NC: Office of Educational Development, School of Medicine, University of North Carolina at Chapel Hill.

Weinholtz, D. & Edwards, J. (1992). Teaching During Rounds: A Handbook for Attending Physicians and Residents. Baltimore: The Johns Hopkins Press.

Appendix A: 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 B: Setting Expectations Checklist

 

I. General Orientation

Introduction to practice

__Learner work space, references
__Dress code: name tag, lab coat
__Hours/ days patient care provided
__Parking, phone system, and mail
__Introduce staff & responsibilities
__Unique learning opportunities (clinical activities, patient population, provider interests)

Introduction to community

__Community characteristics
__Community resources, arranging visits to them
__Where to buy groceries, do laundry, etc.

Overview of rotation

__Relate rotation to learner's career plans

Introduction to learner

__Rotations completed
__Experience and skills mastered
__Areas needing work

II. Clarifying Expectations

Expectations of School or Residency

__Course objectives
__Criteria included in evaluation form

Learner Objectives

__Specific knowledge, skills, and attitudes to develop
__Grade expectations

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
__Which patients learner should see
__How long to spend with each patient
__Hospital policies

Values:

__Show patients & staff respect (how?)
_ Other:

Preceptor/learner interaction:

__Format for case presentations
__Regular time & process for feedback
__Integrating teaching & learning styles
__Learner must explain own needs
__How you evaluate learner (“what it takes to get an honors grade”)

If a problem arises:

__Absentee policy, how to notify office
__A contact for questions or problems
__How to reach preceptor in emergency

Rotation Objectives:

__Required activities based on practice's unique opportunities (i.e. learn to manage chronic back pain, conduct chart audit, etc.)
__Specific knowledge, skills, attitudes you notice learner needs to work on

Appendix C: Rotation Objectives

* This form is to be completed in the first week of the rotation and then referred back to during mid-rotation and end-rotation evaluations. Both the preceptor and the learner should be given a copy.

Learner _______________________ Preceptor ______________________________

School, Course __________________ Dates of Rotation _______________________

The learner and preceptor agree to the following specific objectives for this rotation (regarding learner's knowledge, skills, or attitudes; specific procedures, type exams, clinical problems, psychosocial issues; etc). Strategies for meeting these objectives include:

Appendix D:

Learner Request For Clinical Experiences

* Post in a prominent place in the clinical area or distribute copies to staff.

Learner _______________________ Preceptor __________________________

School ___________________ Year _____ Rotation Dates _____________________

Course _____________________________

To: Receptionists, Nursing Staff, Providers

This learner would like to have more exposure and hands-on experience in the following areas during this rotation. Please make a special effort to involve the learner in these activities:

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