Precepting Students & Residents:Exploring Teaching and Learning

Deanna Kania, PharmD, BCPS, BCACPAmy Hyduk, PharmD, MBA, BCPS

Both, Dr. Kania and Dr. Hyduk have no actual or

potential conflicts of interest in relation to this program or

presentation

Identify opportunities to make site-based learning interesting and interactive for preceptors, students and/or residents

Discuss strategies and unique ways for student learning to improve patient care and experience

Review different student scenarios to gain comfort and appropriate feedback techniques

Objectives

The Preceptor Role

“Modeling the Way”

Introduce to culture & values of the profession

Demonstrating the multidisciplinary team approach to patient care

Instilling knowledge

Coaching, facilitating, reinforcing behaviors & skills

“It is the preceptor who sets the tone of the training program. He accomplishes this by what he does personally, by what he stands for, by the contributions he makes to the profession, by his actions and by his sense of values.”

Am J Hosp Pharm 1967;24:192-203.

Preceptorship

Preceptorship

Preceptors

Manage

LearningStyles

Preceptor

Teaching Styles

Communi-cationStyles

Expectations

Personal Attribute

s

Learning TaxonomiesCognitive Domain(Problem-solving)

Evaluation

Synthesis

Analysis

Application

Comprehension

Knowledge

Evaluate self, evaluate work of others according to objective criteria

Create something new

Select pertinent data on which to base a decision

Use method, theory or principle to solve a new problem

Understand meaning & intent of material; Can restate & describe importance in own words

Recall or recognize ideas or material

The Learning Pyramid

Guide for Instruction by Preceptors.

www.ashp.org

Preceptor’s Role

Facilitating

Coaching

Modeling

Direct Instruction

• Provides some instruction – not the main focus• Readings, guideline review, discussions

Direct Instruction

• Show learner what you would do• Think out loud• Timing is key – prioritization

Modeling

• Working together or separately – dependent on time of year & learner’s progress

• Learner explains back their thought processCoaching

• Working more independently• Later in rotation / learning experience

Facilitating

Preceptor’s Role

Avoid giving “lectures”• Some level of instruction needed, but shouldn’t be

the main focus• Often used as a crutch to cover desired material• Need self-directed learning

Assign readings

Review practice guidelines, protocols w/learner

Guided discussions w/questions & interactive learning techniques to assess understanding

Explain or show “how to” do something

Direct Instruction

Learner observes preceptor

Preceptor “thinks out loud” with learner

Show the “how to’s” in practice

Academics vs. practice examples

Utilize w/patient encounter• Point out controversial issues• Explain rationale• Enhance problem-solving skills in a practice environment

Meet w/learner after the encounter to discuss other points

Modeling

Preceptor begins to take “back seat”

Learner displays a previously modeled task or skill

Learner explains their thought process to preceptor

Preceptor coaches learner before the activity

Preceptor provides “how to” tips for unique scenarios not yet encountered

Preceptor provides timely & specific positive & negative constructive feedback after the activity

Coaching

Preceptor offers an opportunity for learner to practice on their own where appropriate• Develop own clinical decisions• Apply learned problem-solving skills• Perform self-evaluation process

Preceptor assigns learner more complex tasks/patients as learner progresses

Facilitating

The Learning Pyramid

Resident assumes

TPN dosing Service

Resident writes TPN w/preceptor observing;

Resident explains to preceptor his/her recs

Write TPN on patient w/resident observing, explain thought process, resident observes

preceptor communicate w/RN, MD & RD

Review reading materials on nutrition support w/resident, discuss protocol, demonstrate how

to collect lab data in IT systemGuide for Instruction by

Preceptors. www.ashp.org

Preceptor’s Role

Facilitating

Coaching

Modeling

Direct Instruction

The Learning Pyramid

Student provides anticoag

education to pts on own

Student & preceptor review consult for

anticoag education, review pt chart, student

performs teaching to pt while preceptor observes, preceptor

provides feedback after

Preceptor & student review consult for anticoag education, review pt chart, preceptor explains how s/he will tailor education to pt, preceptor teaches pt while student observes

Review guidelines & education materials on anticoag & have interactive topic discussion, discuss various pt

teaching strategies, demonstrate how to document tchgGuide for Instruction by

Preceptors. www.ashp.org

Preceptor’s Role

Facilitating

Coaching

Modeling

Direct Instruction

Matching It All UpStages of Learning

Levels of Cognitive Learning

Appropriate Instructional Methods

Foundation Knowledge & Skills

Knowledge • Assigning readings• Reviewing protocols

Comprehension • Guided discussion• Teach back method

Practical Application

Application • Case presentation• Case-based

teaching• Simulation/role play• Practice-based

teaching

Analysis

Synthesis

Culminating Integration

Evaluation Guide for Instruction by Preceptors. www.ashp.org

Application & Synthesis Teaching Strategies

Create an environment where there is interaction

The ‘teacher’ should be present to “guide” the learning process• Must shift the responsibility for learning

toward the student• ‘Teachers’ should facilitate and serve as a

resource• Help your learners find the “joy” of learning

Teaching Strategies

Educational

traditionChange

Limited time

Learner group size &

resources

Teaching / Learning Barriers

See One – Do One – Teach One (SODOTO) Guided discovery• Use questions to evaluate knowledge

Role Play• Useful for motivational interviewing skills• Physician / pharmacist interactions

Teaching Strategies

Problem solving scenarios or simulations

Learner reflections

Afternoon of sharing• Personal stories• Unique case studies

Think Aloud

Teaching Strategies

Get a commitment• What do you think is going on?

Ask for evidence• What led you to that conclusion?

Teach

Reinforce what was done well

Correct mistakes• Next time, try this

One Minute Preceptor

J Am Board Fam Prac 1992;5:419-24

Summarize history and findings

Narrow the assessment of the problem to 2-3 possibilities

Analyze the assessment

Probe preceptor (ask any questions)

Plan for the patient

Select topic for self-study

SNAPPS Model for Patient Case Discussions

Acad Med 2003 Sep;78(9):893-8

Motivating Students / Residents

Motivating Learners

Give frequent, early, positive

feedback

Assign tasks that are

neither too easy nor too

difficult

Help learners find personal meaning and value in the

material

Create an atmosphere that is open and positive

Help learners feel that they

are valued

Identify the source of poor motivations

Intrinsic versus extrinsic motivation

Discuss behaviors that communicate elusive attitudes• Ex. tardiness = poor attitude

Motivation Challenges

Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015.J Am Pharm Assoc 2012;52(6):897-904

Criteria-based and specific

Listen to their self-assessment• Respect• Empathize/relate

Provide feedback with pos – neg – pos• Be honest

Provide specific examples

Attack the problem not the person

Focus on one or two points at a time

Effective Feedback Strategies

Effective Feedback Strategies

Learner identifies

area(s) for improvement

Learner identifies

specific steps to reach next

goal

Plan is reviewed and

modified

Know yourself as a preceptor

• What type of learner irritates you?

• What characteristics do you value most in

learners?

• What type of learner are you unsure how to

handle?

How to Prevent Problems

Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015

Watch for warning signs• Missed deadlines• Lack of enthusiasm or engagement• Poor professionalism

Appearance Word choice/tone of voice Engagement

• Poor work ethic Late for rounds/clinic/pharmacy service Missing/late assignments Unprepared Insubordinate

• Knowledge base

How to Prevent Problems

Don’t ignore Don’t assume… Discuss and document

How to Prevent Problems

Fam Med 2000;32(4):232-4.

Diagnose the issue

• Knowledge/skill deficit Not taught Not understood Not prepared

• Attitude Doesn’t know what they don’t know Personality issues

• Professionalism

How to Prevent Problems

Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015

Indications for Failing a Learner

Unsafe skill performances

Scrupulous activity

Not meeting rotation / facility

requirements

Poor knowledge

base

Poor communicati

on skills

Document everything!

Communicate• Allow learners to express perspective• Perception vs. reality• Be objective• Paint the picture for what success should look

like• Consider generational differences, stressors,

etc.

How to Handle Poor Learner Performance

Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015.J Am Pharm Assoc 2012;52(6):897-904.

Use motivational interviewing techniques• “Do you mind if we discuss…”• “What I hear you saying is…”• “What I see happening is…”• “What would you like to see different about…”• “May I suggest trying…”• “Here are two suggestions…which would you like to

try…”• “Can I tell you what concerns me about…”

“A patient may be harmed if this continues…” “You may be let go from a position, if this doesn’t

change…”

Communicate

Sobell & Sobell. Motivational Interviewing Strategies and Techniques. 2008. http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf. Accessed March 2015.

How to Handle Poor Learner Performance

Be aware of FERPASeek opinions from

other staff members on-site

Ask for assistance from the College

Development an improvement / action

plan

Document Everythin

g

Work together with learner

Clear and measurable expectations / outcomes

Defined timeline for re-assessment of situation or incomplete assignments

Consequences if expectations / timeline is not met

Signed agreement by both learner and preceptor

Include Experiential office if support is needed

Improvement / Action Plans

Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhA-APPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015.J Am Pharm Assoc 2012;52(6):897-904.

Repeat the rotation• May recommend that this be done elsewhere• Colleges often place the learner with a faculty

member for a repeat rotation, but not always, so you may want to inquire

Repeat part of the rotation

Successfully perform a task that was identified as an area for improvement• Clinical skill• Presentation

Consider alternative career choices

Options for a Failing Learner

Learner Scenarios

You are precepting a learner early in their training on an outpatient rotation block, and it is his third day

You suggest that today would be a great day in hypertension clinic to work on blood pressure assessments

The preceptee replies, “I have done that a ton already and I’m comfortable with it and don’t need any practice.”

What are your concerns? How would you respond? What if this was late in their rotation year?

Case Scenario #1

Your preceptee is on her second week of a rotation She is doing very well on rounds Is completing all patient care activities Documents interventions thoroughly Types complete and excellent progress notes

You notice that she is very inquisitive and challenges you in many discussions, making you feel ‘uneasy’

You notice you are sometimes defensive and short w/ her

At times, she is also outspoken and demanding, even putting an attending physician on edge

How would you handle this situation?

Case Scenario #2

Your learner is on his last clinical rotation

He seems to be progressing well in the first week and is working independently

However, when you do your follow-up, you find Clinical mistakes are occurring All recommendations are not being reviewed w/ a

preceptor Non-patient care work is incomplete

How do you address this problem?

Case Scenario #3

Your learner’s self-evaluation is not consistent with your own at the mid-rotation evaluation He/she feels they are ‘on top of everything’ They display self-confidence despite a mostly lackluster

performance

You meet with them and provide clear documentation of errors and things they can improve upon

They are quite surprised to receive this less than positive feedback

You have heard from previous preceptors that this is a reoccurring problem

How would you handle this situation?

Case Scenario #4

Your preceptee is a stellar learner Excellent knowledge base Great recommendations You feel they could replace you

However, everyday for the first week, she is late to the rotation

She also has shown up late for meetings and has been behind on turning assignments in

You meet with her after week one and reiterate your expectations for timeliness

During week 2, she shows up late 3 of the 5 days and misses another deadline

How do you handle this situation?

Case Scenario #5

It is the April rotation and your preceptee has already signed on to work for community practice upon graduation

You are the preceptor for a critical care rotation

The student is uninterested in your patient population and does not see the value of the information they could obtain from your rotation

How do you handle this situation?

Case Scenario #6

You fail a student learner due to knowledge base deficits• You have multiple objective items documented about the

learner’s deficiencies

You refer the student to the experiential coordinator at the respective college for follow-up

Within 15 minutes, you receive a page from the learner’s mother who demands to know why you are failing her son and wants to know what she can do to fix the situation. She states that clearly you have done something wrong with her child.

How do you respond?

Case Scenario #7

Sweet learner who dresses professionally, is respectful, and is courteous and friendly towards patients

Within the first week, you notice she is struggling clinically• Not able to follow as many patients• Slow in looking up drug information questions • Unprepared in case/topic discussions• States incorrect pharmacy-related information

The learner is putting forth her best effort, is trying very hard, and has recognized that she is struggling

How do you handle this situation at the mid-point evaluation?

How do you handle this situation at the end of the rotation assuming you had a thorough mid-point review?

Case Scenario #8

Precepting Students & Residents:Exploring Teaching and Learning

Deanna Kania, PharmD, BCPS, BCACPkania@purdue.edu

Amy Hyduk, PharmD, MBA, BCPSa-Hyduk@lutheran-hosp.com