Enrichment Program








Rural Physician Action Plan

 

Steps in the One-Minute Preceptor method

  • Get a Commitment -Ask a question such as "what do you think is going on with this patient?" to get the learner to decide on the patient's key issue|
  • Probe for Supporting Evidence -Was the answer based on evidence or just a lucky guess
  • Give Feedback -Reinforce what was done well & give guidance about errors
  • Teach a General Principle - What can be learned and applied to other cases
  • Conclusion -See if the learner needs further clarification or help and clearly end the teaching session

An example of applying the one-minute preceptor method:

A medical student in your office sees a patient and is reporting to you his findings. He tells you:

The patient is female 67-year-old 30-pack year smoker complaining of fever (oral temp 38.5°C), shortness of breath and cough. She has mild COPD. She began to feel sick about two days ago, more winded with a productive cough. This morning she had chills. She has no significant chest pain. Her medications include HCTZ for high blood pressure and an inhaler. Upon physical exam, her wheezing can be heard without a stethoscope and her HEENT are normal, and chest exam reveals decreased sounds to the right middle lobe.

After this explanation the student waits for your comments. Applying the one-minute preceptor you get a commitment . Ask her, "What do you think is going on with this patient?" Depending on where the learner ends you can ask one of the following questions:

"What is another possible diagnosis?"
"How should we treat this patient?"

In this case the student tells you he suspects the patient has community-acquired pneumonia, and that a chest x-ray would be useful to confirm this diagnosis.

Now you can probe for supporting evidence by asking more questions to deduce the learner's reasoning. Ask open-ended questions such as:

" What factors support your diagnosis?"
"Why did you choose that medication or test?"

This question will allow you to determine if the diagnosis or whatever aspect of the case you are focusing on is based on evidence or a lucky guess. This step is probing for clinical reasoning.

In this case the student provides the differential diagnosis he used to make his conclusions.   

Now it is time to provide feedback .   There is an entire section on this site on giving feedback to refer to. Try to include both positive and negative feedback, this helps the learner to improve for next time, continuing what was done right and correcting the errors and omissions. In this case you might comment on correct application of the differential diagnosis and the efficient history and physical exam. You might mention that it is important to know the correct drugs to use in clinical practice.

Finally you can briefly teach a general principle . Generalize the case or an aspect of the case to other situations. This need not be a medical fact but a how to communicate with this type of patient or other non-medical tips for how to be a good physician. In this case you might discuss:

"Gram negative organisms are more common in smokers than in non-smokers and ensuring adequate antibiotic coverage is important"
"This handbook is relevant to bacteria in our region and is up to date, you might want to look at it for determining proper drug use"

The conclusion ends the teaching interaction and it is important to do so before the conversation lingers too long. A good way to conclude the interaction is to state the next step such as "now I will watch you do the physical exam" or "you can go in and tell the patient what your diagnosis is and explain your treatment plan". This type of clear instructions allows the day to proceed at a reasonable pace.

Are there problems with case based teaching?

Although it is widely used and is considered one of the teaching methods of choice, cased based teaching is not without its problems. There are 5 key errors that are commonly made by the physician preceptor.

Taking over the case -This is the most common error. It usually oc curs when the learner answers a question incorrectly. Rather than asking why the preceptor immediately gives the correct answer and this stops the learning opportunity.

Not allowing sufficient wait time -This is closely related to taking over the case and occurs if the learner is taking a few seconds to decide on an answer to a questions the preceptor immediately jumps in and answers the question. This discourages the learner from answering questions or thinking before answering a question.

Giving lectures -When they are not warranted does not encourage learning in the student.   Use the one-minute preceptor model, provide one general tip that will not take up too much of your time and will be retained by your learner.

Asking questions that lead to a particular answer - These are not useful in assessing the reasoning used by a learner. A poor question to ask is "Does this case seem like pneumonia to you?"   A better question to ask is "what do you think is going on with this patient?"   This allows the learner's reasoning to be observed.

Pushing a learner too hard- This can occur with any type of teaching, but if you push too hard the learning experience has ended. When a question is answered, put yourself in the learner's position. How much does the learner know about this diagnosis or treatments? If you jump ahead of the learner's cognitive level they can't grasp what you are trying to teach them.  

   Possible Pitfalls:

  • Taking over the case
  • Not allowing sufficient wait time
  • Giving lectures Asking questions that lead to a particular answer Pushing the learner too hard
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How do I teach a new skill?

There are three basic steps to teaching a procedural skill: cognitive, guided practice and independent practice. The cognitive step involves explaining the procedure, then demonstrating it and having the learner articulate an understanding of the procedure. The guided practice step involves reviewing the procedure, observing the learner perform the procedure and providing feedback . The learner should then practice the procedure with supervision. The final step involves independent practice by the learner but with the preceptor available for feedback.

University of British Columbia Office for faculty development. 2004. Teaching skills for community based preceptors.

   Quick Tips:

  • When giving feedback there are 4 things to say:
    • Continue
    • Do More  
    • Do Less
    • Stop
  • Ask the learner what behaviour they would like feedback on

   Possible Pitfalls:

  • Giving feedback too long after the event
  • Giving all positive or all negative feedback is not helpful
  • Non-specific feedback (e.g. "That was great")
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1 Hawkins & Sohet. Supervisions in the helping professions . 1989. Open University Press, USA

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