precepting 101

Precepting 101

Some helpful hints

Better than a thousand days of diligent study is one day with a

great teacher."

--Japanese proverb

GoalsDiscuss characteristics of internsDiscuss the characteristics of the effective preceptor.Discuss the strengths and limitations of interns.Ways to deal with problem interns.

The Effective Clinician/ The Effective Preceptor

Characteristics of the effective clinicianGood communication skillsCareful assessment of the patientSkillful managementAble to motivate the patient

After Tumulty, 1973

The Effective Clinician/ The Effective Preceptor

Characteristics of the effective preceptorGood communication skillsCareful assessment of the learnerSkillful teaching and practiceAble to motivate the learner

The Effective Preceptor

Communication Skills

The Effective PreceptorCommunication

Possesses and demonstrates broad knowledgeExplains basis for actions and decisions - critical for dietetic internsAnswers learner questions clearly and precisely

Explain the basis for actionsInterns want cut and dry answers in a field where there is often more than one right answerExperienced clinicians automatically by-pass many steps in the decision making process, which need to be made clear to interns

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

The effective preceptor…

Is open to conflicting ideas and opinions

Connects information to broader

concepts

Communicates clear goals and

expectation

The effective preceptor…

Captures learners attention

Makes learning fun

Careful Assessment

of the Learner

Careful Analysis of the Learner

Accurate assessment of learner’s knowledge, attitudes and skillsUses direct observation of the learnerProvides effective feedbackPerforms fair and thoughtful evaluations

Providing FeedbackShould be specific and appropriate

Should honor interns’ effortsCan be useful to have intern self-evaluate - “what do you think went well?”, “what would you do differently?”

The Effective Preceptor

Skillful Teaching and Practice

Skillful Teaching and Practice

Provides effective role modeling

Demonstrates skillful interactions with patients

Presents information with organization and clarity

Remember the preparation is for entry level!

Need to know versus nice to knowExample: need to know - how to calculate basic TPNnice to know - some RD’s adjust electrolytes, etc., but this is NOT an entry level skill

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

Motivating the Learner

Motivating The Learner

Emphasize problem solvingPromote active involvement of learnerDemonstrate enjoyment and enthusiasm for patient care and teachingDevelop a supportive relationship with learner.

Motivating the LearnerMany interns are adult learners and internally motivated

Allowing interns to direct own learning will help make this transition

What can you expect regarding your intern?

Most in distance program have extensive work experienceSome may have familiesMany will have greater financial responsibilitiesThey are highly committed to doing well!

Limitations of interns

May have lots of book learning with limited hands on experienceMay have an untested work ethicMay have difficulty prioritizingMay lack confidence in knowledge and ability (though some may be over-confident)

StrengthsAre generally very enthusiasticOften very idealistic (may be a limitation in some cases)Generally have a good knowledge base but may need to be reminded of that fact.

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 feedbackAsk them to self-assess periodicallyBe focused and enthusiastic

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

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

The difficult learnerWhen the performance does not meet

expectationsExamples

Learner can’t sort out appropriate versus irrelevant informationLearner misses important details

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.

Subjective - example√ Intern has difficulty developing effective

working relationships with other disciplines

Rather than

X Intern is over-bearing and is alienating staff members

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?

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

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

Assessment, continuedIs the learner having difficulty ordering his/her environment?

Time management

Inflexible learning style

Inefficient learning style

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

PlanDo you need further information? Give feedback - be timelyReset your educational goals and objectivesNegotiateCollaborateFocus on interns’ strengthsEstablish plans for follow up

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

Problems for the 21st centuryInappropriate cell phone use - this was addressed during orientationMany distance interns have children, so phone calls often relate to thisInterns should check with preceptor as to when they can check voice mail or return calls

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 rotationcultural issue - did not occur to her to let her preceptor know what was happening

Solution - negotiated later starting time with site

Finally…Let the internship director know what is going on.

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.

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.