RAP Article
Foreword
Featured Article:
Clinical teaching while you
work: The One Minute
Preceptor keeps instruction
effective and efficient
AnnaMarie Connolly, MD
• Previous Articles
Faculty regularly are asking for materials to help their faculty and reside
"teach on the fly". The following article by Dr. AnnaMarie Connolly outli
the One Minute Teacher approach along with sample cases that can be u
part of a short teacher development program.
Clinical teaching while you work:
The One Minute Preceptor keeps instruction effective and efficient
AnnaMarie Connolly, MD
Division of Urogynecology/Reconstructive Pelvic Surgery
Department of Obstetrics and Gynecology
University of North Carolina at Chapel Hill, School of Medicine
Chapel Hill, North Carolina
ACS Presentations
(Resident Work Hours
Issues):
ACGME Program
Requirements
Teaching individual learners in the clinical setting has clear appeal and allows
instruction in the busy office or hospital-based setting where preceptor, atten
and resident teachers deliver patient care. The clear advantages to such teach
include one-on-one time with learners, direct observation, direct patient
involvement, and "clinically relevant, real-life" scenarios.1
RRC Procedures for
Granting Duty Hour
Exceptions
There are challenges, however, to such instruction. These challenges include
pressures of clinical "productivity,"1 diverse educational settings used for clini
experiences,2 the "unpredictability" of clinical conditions with which patients p
and the difficulty encountered in applying consistent teaching goals or "curric
objectives" in these varied educational settings (ie, clinic office, emergency ro
operating room).2,3,4,5 Another important challenge to teaching in the clinical
is the limited time available with individual patients and/or with individual lea
as students and residents are frequently in the office or clinic with preceptors
short periods of time. 1
Certainly, strategies to facilitate effective and efficient teaching in the clinical
have been identified. These strategies include planning for learners' interactio
patients in advance of patient visits,1 teaching during interaction with patients
the bedside or in the exam room, and reflecting with learners on patient care
has already occurred.1,6 Another effective model for teaching in the clinical se
the "One Minute Preceptor."7
While time may be scarce, the One Minute Preceptor helps to efficiently "shap
educational discussions and enables faculty and resident instructors alike to
effectively teach in the clinical setting.7,8 The strengths of the model are that
be taught in a single one-to two-hour seminar and that the model focuses on
teaching behaviors that are easy to perform.7 The teacher can "diagnose" the
patient as well as the learner and teach the learner by using the following fiv
"microskills":
1.
2.
3.
4.
5.
Getting a commitment
Probing for supporting evidence
Teaching general rules
Reinforcing what was right
Correcting mistakes.7
Getting a commitment
After presenting the case, the learner usually stops to wait for a response or a
guidance from the teacher. Clinical teachers can take this time to get a comm
and ask the learner what she or he thinks is going on with the patient. A good
example of this first microskill of the One Minute Preceptor could be asking th
medical student what differential diagnoses s/he might consider after present
21-year-old patient who has just been seen in the emergency department wit
complaints of a 24-hour history of nausea and epigastric pain now localizing t
right lower quadrant. Simply telling the student that the patient clearly has ei
acute appendicitis or a ruptured ovarian cyst after such a student presentatio
would be a bad example of getting a commitment and would not facilitate eva
of the student's clinical reasoning.
Probe for supporting evidence
Before offering an opinion on what is going on with the patient, the clinical te
can probe the learner for evidence supporting the learner's clinical reaso
For example, in the above presentation, the teacher can ask for supporting hi
such as GI and menstrual history. The teacher could probe for supportive sur
history such as whether the patient has had an appendectomy and/or any adn
surgery. Other supporting evidence the teacher can probe for could include si
such as an elevated temperature, abdominal and pelvic exam findings, pertin
laboratory findings such as white blood cell count and pregnancy test, as well
pertinent imaging such as an abdominal/pelvic CT scan. Alternatively, teacher
might ask what other diagnoses were considered and what evidence supporte
refuted those diagnoses. A bad example of probing for supportive evidence m
include telling the student that a CBC and CT scan were the necessary next st
before the student completes his/her presentation or without asking the stude
what diagnostic testing and/or imaging s/he thinks would be helpful. Asking le
how they interpret data is the first step in diagnosing their learning needs. As
them to reveal their thought processes allows teachers both to find out what
learners know and to identify gaps.
Teaching general rules
At this point in the One Minute Preceptor model of instruction, it is time to tea
learner. The teacher reinforces general rules focusing on a single teaching poi
Using the above clinical scenario, a good example of teaching general rules
be reinforcing the difficulty with clinically distinguishing amongst acute appen
a ruptured ovarian cyst, or an ectopic, tubal pregnancy. Another good examp
teaching general rules in the clinical example would be the importance of orde
urine or serum pregnancy test in all reproductive-aged women with right lowe
quadrant pain to rule out a potentially life threatening ectopic pregnancy. A b
example of teaching general rules could include no such discussion of general
rules or simply going ahead and ordering an omitted pregnancy test without
informing the learner of the importance of this missed diagnostic study. Frequ
what is clinically second nature to the teacher (ie, ordering a pregnancy test i
scenario) may be missed by the learner and, as such, these points lend them
well to the microskill of teaching general rules.
Reinforcing what was correct
The next microskill of the One Minute Preceptor is reinforcing what was cor
This might include reinforcing that the student's history was complete includin
necessary elements and that the appropriate focused physical exam was perf
in the presence of the clinical teacher. Reinforcing that the student's presenta
was focused, well organized, and easy to follow would also be examples of
reinforcing what was correct. A poor example of reinforcing what was correct
include no acknowledgment or feedback on the student's history, physical exa
and clinical reasoning.
Correcting mistakes
After reinforcing what the learner reasoned correctly, the teacher then
correc
mistakes. Discussing missed laboratory testing such as a missed complete blo
count or a pregnancy test in the aforementioned 21-year-old female with righ
quadrant pain would be an example of correcting mistakes or omissions in the
student's work-up of the patient. Common errors in students' clinical reasonin
include inability to generate plausible hypotheses or differential diagnoses, inc
interpretation of collected data, too much data collection, and an over-empha
positive findings.
Literature supporting the One Minute Preceptor
There are certainly advantages to use of the One Minute Preceptor. The dialog
between students and teachers facilitated by this teaching strategy provides
students and teachers with multiple opportunities for active learning and prom
student-teacher communication. For students, the clinical dialogue allows
demonstration of clinical knowledge and reasoning skills while facilitating info
feedback sessions. The literature supports that both students and teachers ra
One Minute Preceptor as a more effective model of teaching than traditional
precepting.9,10 Furthermore, brief, interactive faculty and resident developme
workshops, focused on the One Minute Preceptor, have resulted in modest
improvements in the quality of faculty feedback delivered in the ambulatory
setting11 and resident teaching skills in the inpatient care setting.12 As such, t
literature supports the use of the One Minute Preceptor in faculty and residen
development workshops designed to enhance teaching skills.11,13,14
The use of role-play with workshop participants taking on roles of "teacher" a
"learner" allows for practice with the five microskills of the One Minute
Preceptor.13,14 Strategies that facilitate successful use of such role playing to
practice the microskills of the One Minute Preceptor include:
1. The use of pre-selected, clinically relevant case scenarios for role play
and
2. Overcoming faculty and resident reluctance to participate in role-play
activities by providing scripted scenarios for use during role play.13
The case vignettes included in Appendix A provide workshop leaders and
participants with clinically relevant materials for role-play practice of the One
Preceptor microskills. To help participants overcome reluctance to participate,
specific clinical points for the learner to intentionally omit during the role pla
session with each case scenario are suggested. This use of intentional omissio
facilitates additional practice with the microskills of teaching general rules a
correcting mistakes.
Summary
In conclusion, the One Minute Preceptor is a powerful teaching strategy that c
tangibly facilitate effective and efficient clinical teaching between teachers an
learners. This strategy promotes student-teacher communication by allowing
students to demonstrate clinical knowledge and reasoning and allowing teach
diagnose not only the patient but also the learner.1,7-14
References
1. Ferenchick G, Simpson D, Blackman J, DaRosa D, Dunnington G. Stra
for efficient and effective teaching in the ambulatory care setting. Aca
Med. 1997;72:277-280.
2. Walling AD, Sutton LD, Gold J. Administrative relationships between m
schools and community preceptors. Acad Med. 2001;76:184-7.
3. Carney PA, Eliassen, MS, Pipas, CF, Genereaux SH, Nierenberg DW.
Ambulatory care education: How do academic medical centers, affiliat
residency teachings sites, and community-based practices compare?
Med. 2004 Jan;79(1):69-77.
4. McCurdy FA, Sell DM, Beck GL, Kerer K, Larzelere RE, Evans JH. A
comparison of clinical pediatric patient encounters in university medic
centers and community private practice settings. Ambulatory Pediat
2003;3:12-15
5. Johnson GA, Pipas L, Newman-Palmer NB, Brown LN. The emergency
medicine rotation: a unique experience for medical students. J Emerg
2002 Apr;22(3):307-11.
6. Smith CS, Irby DM. The role of experience and reflection in ambulator
medical education. Acad Med. 1997;72:32-5.
7. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" m
clinical teaching. J Am Board Fam Pract. 1992;5:419-24.
8. Neher JO, Stevens NG. The One-minute preceptor: Shaping the teach
conversation. Family Medicine. 2003;35(6):391-2.
9. Teherani A, O'Sullivan P, Aagaard EM, Morrison EH, Irby DM. Student
perceptions of the one minute preceptor and traditional preceptor mo
Med Teacher. 2007;29:323-7.
10. Aagaard E, Teherani A, Irby DM. Effectiveness of the one-minute prec
model for diagnosing the patient and the learner: Proof of concept. A
Med. 2004;79:42-49.
11. Salerno SM, O'Malley PG, Pangaro LN, Wheeler GA, Moores LK, Jackso
Faculty development seminars based on the one-minute preceptor im
feedback in the ambulatory setting. J Gen Intern Med. 2002;17:779
12. Furney SL, Orsini AN, Orsetti KE, Stern DT, Gruppen LD, Irby DM. Tea
the one-minute preceptor: A randomized controlled trial. J Gen Inter
2001;16:620-624.
13. Bowen JL, Eckstrom E, Muller M, Janey E. Enhancing the Effectiveness
One-Minute Preceptor Faculty Development Workshops. Teaching an
Learning in Med. 18(1), 35-41.
14. Eckstrom E, Homer L, Bowen JL. Measuring Outcomes of a One-Minut
Preceptor Faculty Development Workshop. J Gen Intern Med. 2006;
21:410-414.
Resources for Faculty Development Workshop Leaders
Appendix A
Case Vignettes for Role Playing: Using the One Minute Preceptor
Right lower quadrant pain, reproductive-aged female:
35 yo female, with a 24-hour history of nausea, low grade fever, and epigastr
now localizing to the right lower quadrant.
Example of a clinical fact for learner to intentionally omit: Leave out ect
pregnancy from the differential diagnosis and proposed work-up
Urinary Tract Infection:
55 yo male presents with a two-day history of painful urination, hesitancy, an
urinary frequency.
Example of a clinical fact for learner to intentionally omit: Leave out uri
stones on the differential diagnosis
Abnormal Bleeding Per Rectum:
62 yo female G3P3 presents with a three-month history of irregular blood not
rectum.
Example of a clinical fact for learner to intentionally omit: Leave out vag
source for bleeding on the differential diagnosis
Obesity:
50 yo with a three-month history of weight gain. The patient has had to go up
clothing sizes and is having an increasingly difficult time exercising as a resul
knee and back pain. The patient has several family members with a history of
diabetes and she is concerned she may develop diabetes herself.
Example of a clinical fact for learner to intentionally omit: Leave out
hypothyroidism from the differential diagnosis
Online February 26, 2010
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