The Six-Step Preceptor
Peter DeBlieux, MD, LSUHSC EM Director of Faculty and Resident Development,
pdebli@lsuhsc.edu
“We are honored not for how tall we stand, but for how often we bend
to help, comfort and teach”- Freemason Quote
Six Steps
I.
A.
B.
C.
D.
E.
F.
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was done correctly
Correct mistakes
Praise again with a plan
Making a commitment to: work-up, diagnosis, or therapeutic plan
II.
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III.
Encourages information processing
Identifies teaching opportunities or not…
No commitment is a lost teaching opportunity-it is your cue to say.
“What do you think is going on?”
“What tests do you think are indicated?”
“What is your goal for this patient encounter?”
Enables the preceptor to assess the resident’s needs as a learner
List other statements or hints for obtaining a commitment
Probe for supporting evidence linked to the commitment
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IV.
Identifies the process that is linked to the commitment
Helps identify what the resident does and does not know
Use nonjudgmental questioning
“What led you to that diagnosis, those diagnostic studies,
those treatment choices?”
“What other diagnosis did you consider and what kept you from those choices?”
Should avoid the sense of “grilling”, thinking out-loud should be encouraged
What are other ways to seek and understand the resident’s thought process
Focus on teaching generalities, avoiding specifics-if possible
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Instruction is more likely to be retained and transferred as a generality, avoiding facts and
linking principles
Avoid idiosyncrasies and anecdotes
Offer critical pathways, consensus statements-utilizing expert sources-look it up together
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V.
“Wrist injury coupled with a normal radiograph should be treated as a possible scaphoid
fracture if snuff box tenderness is present. All soft tissue injuries should be treated with
rest, ice, compressions, elevation, and NSAIDS”
“I have never seen one of these rashes before… Let’s call dermatology or look through
the atlas to figure out what this may be.”
Describe other ways to stress generalized teaching points.
Reinforce what is done correctly- Catch the resident doing something
right
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VI.
To encourage repetition of appropriate actions, praise them
Positive feedback establishes professional self esteem
Be specific-avoid compliments such as “You were great today!” Instead try“I like the way you professionally handled that difficult patient who demanded narcotics
for his contused hand”
“It was to the patient’s benefit that you considered her income and other medications
prior to prescribing antibiotics in managing her acute bronchitis”
“Your documentation of serial neuron exams in this head injured patient paints an
excellent picture”
Describe some ways you can catch residents doing something right in their presentations
or write ups
Correct mistakes
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VII.
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 Public praise and private negative feedback
Immediacy is best and a full story is helpful
Ask the resident to critique their own performance first-an insight gauge
Avoid judgmental generalized statements- “That whole case was handled
like a third year medical student” “You idiot, never-ever care for a patient
in my ED”
Avoid this maneuver at the patient’s bedside-if at all possible
“The patient with crushing chest pain in the monitor cubicle is signing out
AMA after your exam-why?”
“I called you into my office to discuss your heated, public argument with
our consultant-is there a better way to handle such encounters?”
“AHA no longer recommends administration of prophylactic lidocaine to
uncomplicated AMIs-can you think of any reasons for this?”
Praise again with a plan
Complete the feedback sandwich- Praise-Correct-Praise.
Be specific
Get a commitment to reflect or review material that relates to this case later “I want you
to look up the top five causes of…” “When you get home think about how your
interactions with your patient led to success in this case”
Reference: Neher JO, Gordon KC, Meyer B, Stevens N. A Five-Step “Microskills”
Model of Clinical Teaching. J Am Board Fam Pract 1992:5:419-24