precepting 101 some helpful hints. better than a thousand days of diligent study is one day with a...
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Precepting 101
Some helpful hints
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Better than a thousand days of diligent study is one day with a
great teacher."
--Japanese proverb
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GoalsDiscuss characteristics of internsDiscuss the characteristics of the effective preceptor.Discuss the strengths and limitations of interns.Ways to deal with problem interns.
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The Effective Clinician/ The Effective Preceptor
Characteristics of the effective clinician
Good communication skills
Careful assessment of the patient
Skillful management
Able to motivate the patient After Tumulty, 1973
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The Effective Clinician/ The Effective Preceptor
Characteristics of the effective preceptor
Good communication skills
Careful assessment of the learner
Skillful teaching and practice
Able to motivate the learner
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The Effective Preceptor
Communication Skills
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The Effective Preceptor
CommunicationPossesses and demonstrates broad knowledge
Explains basis for actions and decisions - critical for dietetic interns
Answers learner questions clearly and precisely
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Explain the basis for actionsInterns want cut and dry answers in a field where there is often more than one right answer
Experienced clinicians automatically by-pass many steps in the decision making process, which need to be made clear to interns
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Answers learner questions clearly and precisely
Know when intern should look something up themselves or when they need to be given an answer
Fine line between encouraging independence and promoting frustration
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The effective preceptor…
Is open to conflicting ideas and opinions
Connects information to broader
concepts
Communicates clear goals and
expectation
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The effective preceptor…
Captures learners attention
Makes learning fun
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Careful Assessment
of the Learner
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Careful Analysis of the Learner
Accurate assessment of learner’s knowledge, attitudes and skills
Uses direct observation of the learner
Provides effective feedback
Performs fair and thoughtful evaluations
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Providing FeedbackShould be specific and appropriate
Should honor interns’ efforts
Can be useful to have intern self-evaluate - “what do you think went well?”, “what would you do differently?”
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The Effective Preceptor
Skillful Teaching and Practice
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Skillful Teaching and Practice
Provides effective role modeling
Demonstrates skillful interactions with
patients
Presents information with organization
and clarity
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Remember the preparation is for entry level!
Need to know versus nice to know
Example:
need to know - how to calculate basic TPN
nice to know - some RD’s adjust electrolytes, etc., but this is NOT an entry level skill
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Skillful Teaching and PracticeOrganizes and controls learning
experience
Give appropriate responsibility to learner
Balances clinical and teaching
responsibilities
Talk the talk and walk the walk
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Motivating the Learner
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Motivating The Learner
Emphasize problem solving
Promote active involvement of learner
Demonstrate enjoyment and enthusiasm for patient care and teaching
Develop a supportive relationship with learner.
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Motivating the LearnerMany interns are adult learners and internally motivated
Allowing interns to direct own learning will help make this transition
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What can you expect regarding your intern?
Most in distance program have extensive work experience
Some may have families
Many will have greater financial responsibilities
They are highly committed to doing well!
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Limitations of interns
May have lots of book learning with limited hands on experience
May have an untested work ethic
May have difficulty prioritizing
May lack confidence in knowledge and ability (though some may be over-confident)
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StrengthsAre generally very enthusiastic
Often very idealistic (may be a limitation in some cases)
Generally have a good knowledge base but may need to be reminded of that fact.
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How to promote successProvide an orientation
But don’t tell them everything - have them read policy and procedure manual
Make your expectations clear and provide feedback
Ask them to self-assess periodically
Be focused and enthusiastic
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More ways to promote success
Have interns carry note cards to jot down questions throughout the day (or include in their journal)Give them activities to do during down time (while you’re on the phone, etc.)Give your intern responsibilityCreate an atmosphere for open communication
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Providing effective feedbackCharacteristics of food feedback
Encourages self assessmentIncludes positives and negativesRefers to specific, observed behaviorIs timelyOccurs in an appropriate placeEnds with an action plan
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The difficult learnerWhen the performance does not meet
expectations
Examples
Learner can’t sort out appropriate versus irrelevant information
Learner misses important details
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Using the SOAP approachSubjective
What does the intern ‘say’?
Has the situation occurred before?
What do others say?
Describe the problem/difficult behavior - rather than label it.
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Subjective - example
√ Intern has difficulty developing effective working relationships with other disciplines
Rather than
X Intern is over-bearing and is alienating staff members
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ObjectiveStart by identifying specific behaviors
Comes late, leaves earlyProvides incorrect information in chart, to patient, etc.Avoids eye contact during patient interviews
Look for other sources of information - how did intern get this far?
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AssessmentAre your expectations clear?Is there “stuff” going on of which you are not aware?Is there a cognitive problem?
Information processing - e.g.dyslexia, attention deficitReasoning - e.g. can’t recognize assumptions, difficulty synthesizing
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Assessment, continuedIs there an emotional, attitudinal, or personality problem
i.e. close family member died of cancer, so intern has difficulty working with this type of patientEmotional - e.g. depression, anxietyAttitude -e.g. intolerance or lack of motivationPersonality - e.g. obsessive compulsive, dependent
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Assessment, continuedIs the learner having difficulty ordering his/her environment?
Time management
Inflexible learning style
Inefficient learning style
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Assessment, continuedAre the interns’ standards set too low?
Has minimum effort been good enough in the past?
Do they believe they are performing well, when in fact they don’t meet your expectations?
May be some cultural issues
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PlanDo you need further information?
Give feedback - be timely
Reset your educational goals and objectives
Negotiate
Collaborate
Focus on interns’ strengths
Establish plans for follow up
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Plan - examplesKnowledge deficit - provide readings to do outside rotation (or contact director)
Have intern verbally walk through what they are doing so you can see where they fall short
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Problems for the 21st centuryInappropriate cell phone use - this was addressed during orientation
Many distance interns have children, so phone calls often relate to this
Interns should check with preceptor as to when they can check voice mail or return calls
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Make sure you have all the information
Real life situation chronically late intern
renal problem, but MD unable to determine exactly what was going on.
prescribed meds caused drowsiness
concerned about falling asleep while driving to rotation
cultural issue - did not occur to her to let her preceptor know what was happening
Solution - negotiated later starting time with site
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Finally…Let the internship director know what is going on.
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Precepting 101 referencesTumulty, Philip A. The Effective Clinician Philadelphia: W. B. Saunders; 1973.
Irby, D. M.; Ramsey, P. G.; Gillmore, G. M., and Schaad, D. Characteristics of effective clinical teachers of ambulatory care medicine. Acad-Med. 1991 Jan; 66(1):54-5; ISSN: 1040-2446.
Irby, D. M. Clinical teacher effectiveness in medicine. Journal of Medical Education. 1978; 53:808-815.
Stritter, Frank T and Baker, Richard M. Resident preferences for the clinical teaching of ambulatory care. Journal of Medical Education. 1982; 57:33-41.
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Precepting 101 ReferencesSkeff, Kelley M. Enhancing teaching effectiveness and vitality in the ambulatory setting. Journal of General Internal Medicine. 1988; 3(Mar/Apr Supplement):S26-33.
Irby, D. M. What clinical teachers in medicine need to know. Academic Medicine. 1994; 69(5):333-42.
Irby, D, M. Teaching and learning in ambulatory care settings. Academic Medicine. 1995; 70(10):898-931.
Goertzen, J.; Stewart, M., and Weston, W. Effective teaching behaviours of rural family medicine preceptors. Canadian Medical Association Journal. 1995; 153(2):161-8.
Whitman, Neal. Creative Medical Teaching. Salt Lake City: University of Utah School of Medicine; 1990.