conquering clinical precepting: 1 minute at a time...background of 5 microskills • also known as...
TRANSCRIPT
1
Conquering Clinical Precepting:
1 minute at a time
Sarah Krahe Dombrowski, PharmD, BCACP
Geisinger
2
Objectives
1) List and describe the 5 microskills for clinical
teaching
2) Utilize appropriate microskills in 1 minute when
presented with precepting cases
3
Precepting Example
You currently have a pharmacy student with you on your
rotation. It is September and this is their first clinical
rotation as a resident.
You send the student into patient room to gather H&P.
Student comes back and presents you with the following
information…
4
Precepting Example
Patient is 59 yo female who presents to the physician practice with a
cough that started about 2 weeks ago. Consistent throughout the
day. Doesn’t recall any recent illness such as cold or URI. Nothing
really makes it better or worse. Cough is non-productive.
History negative for GERD, HF, recent illness.
Med list:
Metformin 1000mg BID
Lisinopril 40mg daily
Atorvastatin 10mg daily
MVI daily
5
Precepting Challenges
• Time
• Workflow
• Time
• Challenging learners (residents, students, etc)
• Low performing learners
• High achieving learners
• Time?!
6
Background of 5 Microskills
• Also known as the “One Minute Preceptor”
• Introduced in 1992 in Family Medicine
• Ideal for clinical teaching when teaching time is limited
(busy clinic, acute care rounds, etc)
• Traditional ambulatory clinical setting:
• Learner spends 50% of the time describing case
• Preceptor asks questions for 25% of the time
• Preceptor discusses case for 25% of time
7
5 Microskills
Get a commitment
Probe for supporting evidence
Teach a general principle
Reinforce what is right
Correct mistakes
8
5 Microskills
9
Get a Commitment
When to use: Learner presents the facts of the case to the
preceptor and then waits for response.
Possible preceptor responses:
1. Tell learner what is going on in the case
2. Ask learner for more information
3. Ask learner what they think is going on or to propose a hypothesis
Examples:
“What do you think is going on with this patient?”
“Why do you think this patient was put on this medication?”
“What do you want to do next?”
10
5 Microskills
Commitment: ACE-induced cough
Probe for supporting evidence
Teach a general principle
Reinforce what is right
Correct mistakes
11
Probe for Supporting Evidence
When: Once learner has stated his/her opinion and is waiting for
you to tell them whether or not you agree.
Possible preceptor responses:
1. Tell learner they are right/wrong
2. Tell learner what you think is going on
3. Take learner’s opinion at face value (especially tempting when right)
4. Ask learner for evidence of their opinion
Examples:
“What led you to that conclusion?”
“Why do you think that?”
“What else did you consider?”
12
5 Microskills
Commitment: ACE-induced cough
Evidence: dry cough. no GERD, HF, or illness. No
aggravating/remitting factors.
Teach a general principle
Reinforce what is right
Correct mistakes
13
Teach a General Principle
When: After “diagnosing” the learner and you have identified what they
need or want to know
Possible preceptor next steps:
1. Tell the learner about this specific case
2. Teach the learner about a principle you already picked for today
3. Select a specific principle or rule related to this case
Examples:
Poor: “You should probably switch patient’s lisinopril to losartan.”
Better: “Cough can be associated with ACE inhibitors regardless of start
date of the medication. ARBs do not have this side effect associated with them
and would be a safe alternative for the patient.”
14
5 Microskills
Commitment: ACE-induced cough
Evidence: dry cough. no GERD, HF, or illness. No
aggravating/remitting factors.
General Rule: ACE cough can start at any time and ARBs do
not have this side effect
Reinforce what is right
Correct mistakes
15
Reinforce What Was Right
When: After the learner has handled the case well and identified
appropriate learning points
Possible preceptor next steps:
1. Tell the learner they did a great job
2. Move on to another topic/case
3. Pick out a specific thing the learner did well and discuss the impact it
had
Examples:
Poor: “Great job today!” or “It is clear you’re very smart!”
Better: “It was good how you used open ended questions when asking the patient
about their medication adherence and now we are able to better help the patient take her
medications.” or “It was obviously that you had researched the topic that we discussed
yesterday and were able to select the appropriate drug therapy for the patient today.”
16
5 Microskills
Commitment: ACE-induced cough
Evidence: dry cough. no GERD, HF, or illness. No
aggravating/remitting factors.
General Rule: ACE cough can start at any time and ARBs do
not have this side effect
Right: History was thorough and applicable to patient
problem
Correct mistakes
17
Correct Mistakes
When: The learner’s presentation/work has demonstrated
mistakes or misunderstandings that will impact patient care
Possible preceptor next steps:
1. Tell the learner they are unprepared and send them off to do more
research
2. Tell the learner about their mistake immediately in front of everyone
3. Wait until the end of the day (or rotation) to list all mistakes made
4. Identify a mistake(s) as soon as possible at appropriate time and place
• Let learner self-critique first
Examples:
“How do you think that went?”
“What do you think you could have improved?”
18
5 Microskills
Commitment: ACE-induced cough
Evidence: dry cough. no GERD, HF, or illness. No
aggravating/remitting factors.
General Rule: ACE cough can start at any time and ARBs do
not have this side effect
Right: History was thorough and applicable to patient
problem
Mistake: Didn’t ask the patient about compliance to
medications
19
Examples from your experience?
20
Thought questions
How would your responses/experience change if you were
working with an IPPE vs APPE student? Pharmacy
resident? Medical resident?
What happens if everything is wrong?!
How do I fit all my learning points in if I can only teach one
thing?
21
Conclusions
Pick one or two microskills out of the 5 for each clinical
teaching period
Don’t try to teach 20 concepts in one interaction
Be specific in giving feedback
Clinical teaching doesn’t have to take all of your time! –
this should take less than 1 minute
22
References
1. Neher JO, Gordon K, Meyer BB. A Five-step "Microskills"
Model of Clinical Teaching. J. Am Board of Fam Prac. 5:419-
424, 1992.
2. Five Clinical Microskills. University of Alabama at Birmingham
School of Medicine.
https://www.uab.edu/medicine/home/residents-
fellows/current/cert/five-clinical-microskills
3. Gordon K and Meyer B. (updated by Greer T). Five Microskills
for Clinical Teaching. University of Washington.
https://depts.washington.edu/fammed/files/FiveMicroskillsforCli
nicalTeaching.pdf
