A Naturopathic Clinical Algorithm
An Adaptation of the “5-Clinical Microskills Model”
for Naturopathic Practice
Rich Barrett ND
Paul Kalnins ND, LAc
Dickson Thom DDS, ND
Plan

Rich Barrett presents the 5 Microskills model

Dick Thom and Jeremy Mikolai will role play a clinical preceptor
encounter

Paul Kalnins will present a naturopathic version of the 5
microskills

Dick Thom and Jeremy Mikolai will continue their role play
The Problem

Clinical teaching is challenging
◦ We have to diagnose and treat our patients
◦ We typically do this through an intermediary, a medical
student or resident.
◦ We also have to diagnose and teach these learners
 New information
 and clinical reasoning
Clinical teaching skills are not innate

The thorough examination of clinical teaching by
Koen and Vivian identified five major modes and 18
micro skills in effective clinical teaching

John Neher and colleagues at the University of
Washington in collaboration with Koen pared these to
Five “microskills”
Advantages of the 5 Microskills

Focuses the consultation on the decision-making process used
by the medical student

Reveals the fund of knowledge available to the student

Designed to be efficient: most encounters take about five
minutes

Can vary according to the complexity of the case and the needs
of the student
The 5 Microskills
1.
2.
3.
4.
5.
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was done right
Correct mistakes
First Microskill:
Get a commitment

Student presents the history, physical findings and any labs
available

Early in the consultation they should be encouraged to make a
commitment to a diagnosis, workup, or therapeutic plan

Gives student more responsibility for patient care

Encourages them to process and analyze information gathered
from the encounter
Get a commitment

Failure to commit may indicate a student has not processed
the information, is afraid to expose a weakness, or is
dependent on the thinking of others

It is critical that the environment be supportive to promote
intellectual honesty

It’s better before the learner to be incorrect, than not
commit. Being wrong is a learning opportunity
Get a commitment

The cue for this microskill occurs when the student presents
the facts of the case, and then pauses, waiting for
interpretation from the attending physician

Resist the urge to fill in the verbal blank!

Instead ask:
◦ What do you think is going on with this patient?
◦ What laboratory tests do you think are indicated?
Second Microskill:
Probe for supporting evidence

Find out what evidence supports this commitment

“ What were the major findings that led to your diagnosis?”

What other diagnoses did you consider? What kept you from
that choice?

By having the student “think out loud” the preceptor can
identify what the student knows and does not know
Third Microskill:
Teach general rules

This step allows the teacher to generate and communicate a
general teaching point resulting from the case

A teaching point will be apparent from their omissions or
mistakes

Instruction is more memorable and more transferable to other
cases when it is offered as a general rule
Fourth Microskill:
Reinforce what was done right

Rewards competence

Builds professional self-esteem

Caveat: Avoid general praise which reinforces no particular
behavior i.e. “ You did a good job”

Both praise and criticism need to be as specific as possible
Fifth Microskill: Correct mistakes

Do this last

Choose the appropriate time and place

Vague, judgmental statements such as “This case was badly
mismanaged” are not helpful or appropriate

It is generally a good idea to ask the student to critique
their own performance first

Suggest outside reading or other learning
Studies supporting the use of the
five-step multiskills model:
Aagard, Salerno, Furney, Jones, Tehernani

Faculty rated Microskills more efficient

Increased likelihood of the correct diagnosis

Twice as much higher order verbal feedback

Higher quality and quantity written feedback

Students were more motivated to do outside reading
Case Example using the Five-Step Microskills
with a Resident at the NCNM Clinic

40 Year Old White Female

CC: Gas/bloating, constipation, right
upper quadrant pain, hyperlipidemia
The 5 Microskills
1.
2.
3.
4.
5.
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was done right
Correct mistakes
Biomedical 5-Clinical Microskills Model
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Advantages for Clinical Training

Engages the student in the thinking and decision processes

Attempt is made at gathering the best available evidence

Builds a student’s confidence

Fosters a genuine collaborative approach between all members of a patient’s treatment team
Disadvantages for Naturopathic Medicine

Approach is based on the biomedical disease model:


Once diagnosis is made, treatment protocols are often established
Not reflective of naturopathic approach to preventative care and wellness (naturopathic wellness model)

Naturopathic treatments often based on factors independent of the disease diagnosis
What is the Naturopathic Approach to Patient Care?
Benedict Lust ND, DO, MD (1872-1945)
 Founded naturopathic medicine (~1902) & first naturopathic medical school
 Roots in European “Nature Cure” movement
 Amalgamated many medical traditions & techniques:
Hydrotherapy
Physical medicine
Herbal medicine
Homeopathy
Diet therapy
Core Concepts of Naturopathy
 First do no harm
 Respect the Vis medicatrix naturae
 Identify & treat the causes
 Doctor as teacher
 Treat the whole person
 Prevention
Vis medicatrix naturae, “Healing power of nature”
 Self-regulatory mechanisms in the organism
 Modern interpretation: milieu interieur (Bernard, 1985), homeostasis (Cannon, 1930’s)
 Role of psycho-neuro-endocrine-immune system
Naturopathic practice: identify & remove factors inhibiting the Vis medicatrix
 Restore homeostasis
What is the Naturopathic Approach to Patient Care?
A Functional Approach to Illness
History
Physical
Tests
Biomedical Assessment/Diagnosis
Migraine with Aura
Biomedical Treatment
Diet/lifestyle/exercise
Medications
Triptans
 NSAIDS
 Ergot derivatives
 Beta-blockers
 Calcium channel blockers
 Antidepressants
 Antiseizure medications
 Etc.
Naturopathic Assessment/Diagnosis
Naturopathic Treatment
Hepatic-Biliary
General Support
 Dietary changes
 Lifestyle/exercise
 Stress reduction
 Self-care techniques
 Poor liver phase I & II detoxification?
 Cholestasis?
Digestive
 Pro-inflammatory diet/food triggers?
 Food allergies/sensitivities?
 Integrity of intestinal mucosa?
Nervous-Endocrine
 HPA-axis/cortisol dysregulation?
 Poor clearance of estrogen metabolites?
 Poor methylation processes?
 Lack of neurotransmitter clearance?
Cardio-Circulatory
 Endothelial dysfunction?
 Cardiovascular inflammation?
Renal
 Poor renal elimination of metabolites?
 Subtle acid-base balance shifts?
Structural
 Head/neck structural or soft-tissue issues?
Specific Support
 Botanical medicine
 Homeopathic medicine
 Essential fatty acids
 Vitamins/minerals
 Etc.
Physical Support
 Physical medicine
 NMT
 Acupuncture
 Other modalities
Other Support
 Counseling
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
Gather History
Physical Exam
Pre-Assessment
Biomedical Assessment
Define context of care
What is your biomedical diagnosis?
15-25 minutes
10-15 minutes
Naturopathic Assessment
What is your functional diagnosis?
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Treatment
What is your treatment plan?
10-15 minutes
Follow-up
What are your follow-up and/or
referral recommendations?
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What is your Pre-Assessment?

Is this case today acute or chronic?

Does the patient have a primary care physician?

Are there financial limitations that must be considered?

What is the patient willing to do?
◦ Are they really interested in naturopathic treatment?
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What is your Biomedical Assessment?

What is your biomedical diagnosis?
◦ Working diagnosis?
◦ Important differentials to rule out?
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
◦ Need for urgent referral or biomedical treatment?
◦ What labs and/or imaging would you like to obtain?

What are the current standards of care for your diagnosis?
◦ Consult practice guidelines
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What is your Naturopathic Assessment?
Will vary by practitioner

Typological assessment
◦
◦

Temperament, miasm, constitution
Blood type, body type, etc.
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Organ-gland-systems assessment
◦ Functional assessment
◦ Renal, GI/hepato-biliary, Respiratory, Endocrine, Heart-circulation, Nervous, etc.

Pattern differentiation
◦ Tissue state/terrain: Hot/cold, dry/damp, etc.
◦ Homeopathic patterns assessment
◦ Chinese medicine pattern differentiation

Other
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What is your Treatment Plan?

Basic support
◦
◦
◦
◦
◦

Vitamin/mineral therapy
Essential fatty acids, probiotics, etc.
Herbal medicine
Glandulars
Homeopathic support
Bio-identical hormone therapy
Specific support: Physical Modalities
◦
◦
◦
◦
◦
Diet recommendations
Lifestyle, exercise
Stress reduction
Home hydrotherapy
Other
Specific Support: Natural Remedies
◦
◦
◦
◦
◦
◦


Other modalities
◦
◦
◦

Constitutional hydrotherapy
Physical medicine, NMT
Acupuncture
Ultrasound, cold laser, TENS, microcurrent, etc.
Massage
Counseling
Biofeedback/neurofeedback
Other
Biomedical Support
◦
◦
◦
Prescription medications
Surgery
Other
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
What are your Follow-up Recommendations?

Has patient understood their diagnosis?
◦ Important things they need to look out for?

Has patient understood the treatment plan?
◦ Ask the patient if they think they can manage this plan

When do you want the patient to return?
◦ Acute cases


Check in by phone in 24-48 hours
Follow-up in office in 1 week
◦ Chronic cases

Follow-up in office in 4 weeks
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Naturopathic Clinical Algorithm
Application of the One-Minute Preceptor Model to Naturopathic Medicine
Gather History
Physical Exam
Pre-Assessment
Biomedical Assessment
Define context of care
What is your biomedical diagnosis?
15-25 minutes
10-15 minutes
Naturopathic Assessment
What is your functional diagnosis?
Get a commitment
Probe for supporting evidence
Teach general rules
Reinforce what was right
Correct mistakes
Treatment
What is your treatment plan?
10-15 minutes
Follow-up
What are your follow-up and/or
referral recommendations?
Citations
Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching.
J Am Board Fam Pract. 1992 Jul-Aug;5(4):419-24.
Jones K, Reis S. Learning through vulnerability: a mentor-mentee experience. Ann Fam Med.
2010 Nov-Dec;8(6):552-5.
Aagaard E, Teherani A, Irby DM. Effectiveness of the one-minute preceptor model for
diagnosing the patient and the learner: proof of concept. Acad Med. 2004 Jan;79(1):42-9.
Teherani A, O'Sullivan P, Aagaard EM, Morrison EH, Irby DM. Student perceptions of the one
minute preceptor and traditional preceptor models. Med Teach. 2007 May;29(4):323-7.
Salerno SM, O'Malley PG, Pangaro LN, Wheeler GA, Moores LK, Jackson JL. Faculty
development seminars based on the one-minute preceptor improve feedback in the
ambulatory setting. J Gen Intern Med. 2002 Oct;17(10):779-87.
Salerno SM, Jackson JL, O'Malley PG. Interactive faculty development seminars improve the
quality of written feedback in ambulatory teaching. J Gen Intern Med. 2003
Oct;18(10):831-4.
Furney SL, Orsini AN, Orsetti KE, Stern DT, Gruppen LD, Irby DM. Teaching the one-minute
preceptor. A randomized controlled trial. J Gen Intern Med. 2001 Sep;16(9):620-4.
Zeff J. The process of healing: a unifying theory of naturopathic medicine. J Naturopath Med
1997;1:122-126.