Teaching Skills
The Preceptor's Teaching Tasks
Physicians who become preceptors soon realize that they're working with extremely bright learners, and 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 or 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.
Teaching Strategies
In order to achieve this kind of intentional learning, the preceptor can utilize the following teaching strategies:
- Recognizing and treating 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)
- Promoting 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 which 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.
- Creating 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, but also that you know they will often feel uncertain and sometimes make mistakes. Communicate that you know that learning involves taking risks and that the student can trust you not to abuse the confidences they share with you.
- Setting daily teaching goals
The student's overall learning goals for the month-long preceptorship should be established during the initial orientation discussion, as has been discussed elsewhere in this guide. You can refine and refocus these general goals by touching base very briefly 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."
- Utilizing 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 learner's needs, and finally provide targeted instruction to the learner'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 kept open until the patient revealed her real agenda for coming today." Make your comments to the student specific and focused.
- Correct mistakes. As soon 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 was highly efficient and saved the preceptor's time.(4)
Capitalizing on preceptor role modeling
As indicated earlier, students sometimes can't "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. Medial 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, Blackmanm J, DaRosa D, Dunington G. Strategies for Efficient and Effective Teaching in the Ambulatory Setting. Academic Medicine. 1997, 72(4), 277-280.
*Portions of information on Important Teaching Skills, Orientation, Feedback, Evaluation, and Frequently Asked Questions were developed by theTexas Statewide Preceptorship Program. Their willingness to share materials is greatly appreciated.