Precepting 101

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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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Goals

• Discuss characteristics of interns
• Discuss 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

• Communication
• Possesses 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 actions

• Interns 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 learners knowledge,
  attitudes and skills
• Uses direct observation of the learner
• Provides effective feedback
• Performs fair and thoughtful evaluations

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Providing Feedback

• Should 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 RDs adjust electrolytes,
  etc., but this is NOT an entry level skill

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Skillful Teaching and Practice

• Organizes 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 Learner

• Many 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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Strengths

• Are 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 success

• Provide an orientation
• But dont 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 youre on the phone, etc.)
• Give your intern responsibility
• Create an atmosphere for open communication

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Providing effective feedback

• Characteristics of food feedback
• Encourages self assessment
• Includes positives and negatives
• Refers to specific, observed behavior
• Is timely
• Occurs in an appropriate place
• Ends with an action plan

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The difficult learner

• When the performance does not meet expectations
• Examples
• Learner cant sort out appropriate versus
  irrelevant information
• Learner misses important details

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Using the SOAP approach

• Subjective
• 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

• v 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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Objective

• Start by identifying specific behaviors
• Comes late, leaves early
• Provides 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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Assessment

• Are 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
  deficit
• Reasoning - e.g. cant recognize assumptions,
  difficulty synthesizing

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Assessment, continued

• Is there an emotional, attitudinal, or
  personality problem
• i.e. close family member died of cancer, so
  intern has difficulty working with this type of
  patient
• Emotional - e.g. depression, anxiety
• Attitude -e.g. intolerance or lack of motivation
• Personality - e.g. obsessive compulsive, dependent

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Assessment, continued

• Is the learner having difficulty ordering his/her
  environment?
• Time management
• Inflexible learning style
• Inefficient learning style

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Assessment, continued

• Are 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 dont meet your expectations?
• May be some cultural issues

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Plan

• Do 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 - examples

• Knowledge 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 century

• Inappropriate 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 references

• Tumulty, 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
  53808-815.
• Stritter, Frank T and Baker, Richard M. Resident
  preferences for the clinical teaching of
  ambulatory care. Journal of Medical Education.
  1982 5733-41.

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Precepting 101 References

• Skeff, 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.