2. Teaching Strategies for the Ambulatory Setting

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affective preceptor series teaching
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strategies for the ambulatory setting
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we know that you have a busy schedule in
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the office and sometimes having a
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learner just seems like something else
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added to your to-do list so in this
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video we will review a teaching strategy
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called the 5 micro skills model this has
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been shown to be both highly educational
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for the learner and quite effective for
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the preceptor
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what is the five-step micro skills model
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this model was developed in the early
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1990s by Nayer and colleagues it creates
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a framework for teaching medical
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students in the outpatient setting the
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micro skills are designed to promote
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independent thinking on the part of the
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student while allowing an opportunity
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for constructive feedback how does it
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work the preceptor uses a series of five
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questions in the context of a patient
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visit to encourage the student to think
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like a doctor therefore the student can
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develop a rationale for the assessment
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come up with a differential diagnosis
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when appropriate and think of the next
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steps in the patient workup the
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questions also lead the preceptor to
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provide formative feedback teach briefly
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about the patient’s problem and gently
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correct any mistakes made by the student
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how to use micro scale when precepting a
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student patient encounter
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micro skills work well when precepting
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in the outpatient setting ideally the
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student has seen the patient
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independently and returns to the
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preceptor to present the history and any
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physical exam maneuvers that have been
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performed the 5 micro skills are one get
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a commitment
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to probe for supporting evidence
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three teach a general rule
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for reinforce what was done right
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five correct mistakes
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the preceptor can then use the following
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questions to guide the students thinking
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get a commitment arguably this is one of
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the most important micro skills the
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preceptor asks an open-ended question to
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get the student to commit to a
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differential diagnosis or assessment of
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the patient’s problem for example what
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do you think is going on with this
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patient this simple question moves the
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student from reporting patient data to
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interpreting that data and making a
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commitment to consider different
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diagnoses or steps in the workup in
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order to determine the final
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differential diagnosis
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probe for supporting evidence after the
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student has made a commitment to discuss
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thoughts about possible diagnosis the
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preceptor asks the student to explain
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the rationale behind his or her
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differential the preceptor challenges
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the student to explain the reasoning
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what items in the history or physical
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exam made the student consider the
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differential diagnosis and the next step
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in the workup such questions guide the
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student to think about moving from
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reporting to interpreting data during
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the discussion the preceptor may
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evaluate the depth of the students
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critical reasoning and fund of knowledge
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teach a general rule after the student
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has had the opportunity to develop an
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assessment backed up by verbalized
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reasoning the preceptor may take a
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moment to do some targeted teaching
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about the specifics of the patient’s
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problem in general this teaching is
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brief and designed to communicate one
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specific point derived from the case
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reinforce what was done right a commonly
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neglected aspect of teaching medical
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students is the delivery of useful
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feedback the fourth micro skill focuses
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on giving positive feedback on any or
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all aspects of the patient encounter
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positive feedback may touch on the
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students interaction with the patient
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the quality of oral presentation the
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ability to develop an assessment or the
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students reasoning process students
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strongly desire feedback and this micro
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skill formalizes the feedback component
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correct mistakes the flipside of
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positive feedback correcting mistakes
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involves gentle delivery of constructive
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criticism and often points the way for
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students to pursue self-directed
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learning the preceptor clarifies
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misunderstandings about parts of the
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patient case and urges the student to
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identify knowledge and reasoning gaps so
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here’s an example of how the micro
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skills are used in the context of a case
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so in summary this is a 22 year old
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g-zero with a high fever and abdominal
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pain
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what do you think could be going on with
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her I think she has pelvic inflammatory
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disease what makes you think she has PID
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she has complaints of abdominal pain and
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fever that’s associated with cervical
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motion tenderness and abdominal
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peritoneal signs excellent reasoning
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could anything else be going on it is
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less likely that she could have
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appendicitis or pyelonephritis what are
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the next steps for this patient we
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should get a white count and send her
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home with antibiotics I agree that we
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should obtain a white count
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assess for gonorrhea or chlamydia and
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probably also an ultrasound to rule out
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an abscess although you are correct in
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thinking about antibiotics due to her
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high fever and peritoneal signs we
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should consider inpatient treatment with
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IV antibiotics we should also check a
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pregnancy test in all our reproductive
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age patients please look up decision
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making about outpatient verse inpatient
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treatment of PID
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both direct and indirect evidence
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support the effectiveness of this
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teaching model direct evidence indicates
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that traditional precepting places more
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focus on correct diagnosis and treatment
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of the patient whereas the microscope
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model leads to a higher degree of
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student participation in decision-making
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it also fosters the process of the
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student moving from reporter to
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interpreter while maintaining excellent
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quality of patient care preceptors cite
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several advantages of the microscale
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model they feel that they do a better
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job in identifying level of clinical
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skills and give better more useful
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feedback than with a traditional model
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students rate preceptors is better and
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often say that they motivate them to
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read independently when probed for the
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rationale behind diagnosis and
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management decisions students may
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develop a stronger need to know
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motivating them to pursue outside study
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[Music]
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using these microscopes students may
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derive a high quality of learning
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experience and the preceptor should
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experience minimal impact on his or her
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productivity
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[Music]