The Microskills of Clinical
Teaching and Learning
Objectives
• Describe characteristics of effective clinical
learning encounters
• Identify, analyze and practice effective
clinical teaching, using the One Minute
Preceptor
Residents as Teachers
• Residents make a major contribution to
student education
• Teaching improves resident learning and
acquisition of knowledge
“to teach is to learn twice”
Miriam Bar-on, MD
Effective Clinical Teachers
& Learners
• Communicate expectations explicitly
• Stimulate interest enthusiastically
• Interact skillfully with patients
• Involve the learner in the teaching process
• Role model desired behaviors
• Give feedback on performance
Irby DM. Ramsey P, Gillmore J, Schad D. Characteristics of effective clinical teachers of ambulatory care medicine.
Acad Med, 1991:66:54-55.
What are the challenges for
teaching in the clinical setting?
• Time
• Time
• Time
Irby DM. What clinical teachers in medicine need to know. Acad Med 1994;69:333-342.
Irby 2000
One-Minute Preceptor
• Validated model for effective and efficient
clinical teaching
• Developed for outpatient clinic but can be used
with learners in any clinical setting
• Promotes the learner’s independence and active
involvement in patient care
• Encourages the teacher to recognize “teachable
moments”
Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family
Medicine Predoctoral meeting, Orlando, FL.
And Best of All…
• Allows for simultaneous care of patients and
learners…
One Minute Preceptor
1. Assess prior knowledge
2. Get a commitment
3. Probe for evidence
4. Give positive feedback
5. Identify and correct mistakes
6. Teach the general rule
7. Encourage reflection and promote self
directed learning
Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers
of Family Medicine Predoctoral meeting, Orlando, FL.
Microskill #1:
Assess Prior Knowledge
• Assess the learner’s knowledge and prior
experience
• Establish goals for the encounter
Microskill #1
Assess Prior Knowledge
• Learners: Would you feel ready to see this
patient?
• Teachers: How might the teacher have
helped the learner in advance of seeing the
patient?
VIDEO
One Minute Preceptor
1. Assess prior knowledge
2. Get a commitment
3. Probe for Evidence
4. Give positive feedback
5. Identify and correct mistakes
6. Teach the general rule
7. Encourage reflection and promote self
directed learning
Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers
of Family Medicine Predoctoral meeting, Orlando, FL.
Microskill #2
Get a Commitment
• What is going on?
• The learner commits
– Can be risky
– The teacher’s goal is to provide a supportive
and safe environment
• Pay attention to tone and body language
Ask The “What?” Question
• What do you think is going on?
– (Differential diagnosis)
• What investigations should be ordered?
– (Diagnostic strategy)
• What is your first choice of medication?
– (Selection of therapy)
• What do you think is probably going to happen?
– (Prognosis)
• What would you like to achieve in this visit or
patient encounter?
– (Management issue)
Microskill #2
Get a Commitment
• How might the teacher have solicited a
commitment from the learner?
VIDEO
What Gets in the Way?
For the Learner:
Difficulty in making a commitment may be
due to ?
What Gets in the Way?
For the Teacher:
Difficulty in making a commitment may be
due to:
–
–
–
–
–
Fear of silence
Fear of being wrong
Knowledge gaps
Fear of being too demanding
Fear of falling behind in patient care
One Minute Preceptor
1. Assess prior knowledge
2. Get a commitment
3. Probe for Evidence
4. Give positive feedback
5. Identify and correct mistakes
6. Teach the general rule
7. Encourage reflection and promote self
directed learning
Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers
of Family Medicine Predoctoral meeting, Orlando, FL.
Microskill #3
Probe for Evidence
• Encourage the learner to think out loud
• Share rationale for commitment
• Why do you think that is so?
• “What if…?” questions allow you to further identify
the learning edge and push to the next level
Microskill #3
Probe for Evidence
• What was done well?
• What could have been done better?
VIDEO
One Minute Preceptor
1. Assess prior knowledge
2. Get a commitment
3. Probe for Evidence
4. Give positive feedback
5. Identify and correct mistakes
6. Teach the general rule
7. Encourage reflection and promote self
directed learning
Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers
of Family Medicine Predoctoral meeting, Orlando, FL.
Microskill #4
Give Positive Feedback
• Reinforce what was done right
• Use language that is specific and behavioral,
not just vague praise
– “You did a good job of considering multiple
diagnoses and prioritizing them”.
– “I noticed how well you considered the patient’s
age and concerns about cost in selecting
medications.”
One Minute Preceptor
1. Assess prior knowledge
2. Get a commitment
3. Probe for Evidence
4. Give positive feedback
5. Identify and correct mistakes
6. Teach the general rule
7. Encourage reflection and promote self
directed learning
Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral
meeting, Orlando, FL.
Microskill #5
Identify and Correct Mistakes
• Correction must be specific and focused
– “That drug is often a good choice but in the
setting of renal failure is contraindicated.”
– “In children who present with diarrhea and
vomiting, assessing the urine output is
essential.”
Microskills #4/#5
Reinforcing and Corrective Feedback
• Was this useful feedback?
• How might the learner have handled the
situation differently?
VIDEO
One Minute Preceptor
1. Assess prior knowledge
2. Get a commitment
3. Probe for Evidence
4. Give positive feedback
5. Identify and correct mistakes
6. Teach the general rule
7. Encourage reflection and promote self
directed learning
Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers
of Family Medicine Predoctoral meeting, Orlando, FL.
Microskill #6
Teach the General Rule
• Choose a rule at the learner’s level
• Consider content areas outside medical
knowledge
– Professionalism
– Communication Skills
– Behavioral and Social Science Domains
Microskill #6
Teach the General Rule
• When I see a patient like this, I think
about…
– “In school age children presenting with headache
I always consider myopia in the differential.”
– “ When I see a rash that I cannot diagnose, I
define it as best as I can and then look it up in….
If we don’t solve the problem by looking at that
reference, we need to call…”
One Minute Preceptor
1. Assess prior knowledge
2. Get a commitment
3. Probe for Evidence
4. Give positive feedback
5. Identify and correct mistakes
6. Teach the general rule
7. Encourage reflection and promote self
directed learning
Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers
of Family Medicine Predoctoral meeting, Orlando, FL.
Microskill #7
Encourage Reflection and SDL
• At the end of your session or at the end of
the patient encounter
– “What do you feel you did well?”
– “What was most challenging?”
– “How did the practice differ from your
expectations?”
– “Did anything surprise you today?”
Microskill #7
Encourage Reflection and SDL
• “What is your next question?”
• “Based on this case I’d like you to
formulate your next question and go to
the literature to answer it…we’ll discuss it
tomorrow.”
• Practice-based learning
Microskills #6/#7
General Rules, Reflection and SDL
• What did the learner do well?
VIDEO
• What did the teacher do well?
Reflective Practice
• In clinical practice
– Reflection on, in, and for action
• In clinical education
– Teach
– Reflect
– Teach some more
One Minute Preceptor
Advantages
• Feedback is embedded
• Allows for improved teaching AND
assessment…
– By questioning you are not only creating a
stimulating learning environment but also
assessing the learner’s knowledge
The 7 Wicroskills of Teaching
What do you know?
Assess prior knowledge
Why is going on?
Get a commitment!
Why do you think that?
Probe for evidence/facts
Warm and Fuzzy
Positive feedback
Whoops!
Identify, correct mistakes
When I see a patient like this
Teach the general rule
What is your next question?
Promote reflection
Acknowledgments
This workshop was developed by:
• Rini Ratan, MD
• Andrew Mutnick, MD
• Lyuba Konopasek, MD
• Sue Bostwick, MD