“I Don’t Have Time For Students”“I Don’t Have Time For Students”I Don t Have Time For StudentsI Don t Have Time For StudentsShowing Preceptors How to Be more Showing Preceptors How to Be more

Efficient with StudentsEfficient with StudentsOregon Health & Science UniversityOregon Health & Science University

Frances Biagioli, M.D., Frances Biagioli, M.D., biagioli@ohsu.edubiagioli@ohsu.eduAssociate Professor OHSU Family MedicineAssociate Professor OHSU Family MedicineAssociate Professor, OHSU Family MedicineAssociate Professor, OHSU Family Medicine

Claire E. Hull, MHS, PAClaire E. Hull, MHS, PA--C C –– Clinical CoordinatorClinical CoordinatorOHSU Physician Assistant ProgramOHSU Physician Assistant Program

ObjectivesObjectivesObjectivesObjectives

Identify the most common causes ofIdentify the most common causes ofIdentify the most common causes of Identify the most common causes of running behind with students.running behind with students.Identify concrete solutions to thoseIdentify concrete solutions to thoseIdentify concrete solutions to those Identify concrete solutions to those causes.causes.Create tools for clinical preceptors so theyCreate tools for clinical preceptors so theyCreate tools for clinical preceptors so they Create tools for clinical preceptors so they can become more efficient teachers. can become more efficient teachers. Create scripts and to use when recruitingCreate scripts and to use when recruitingCreate scripts and to use when recruiting Create scripts and to use when recruiting clinical preceptors to respond to the clinical preceptors to respond to the comment: “I don’t have time for a student.”comment: “I don’t have time for a student.”

Barriers to the Recruitment and Barriers to the Recruitment and f Cf CRetention of Clinical PreceptorsRetention of Clinical Preceptors

Preceptor PerceptionsPreceptor Perceptions–– Patient population not accepting of studentsPatient population not accepting of studentsp p p gp p p g–– Lack of teaching experienceLack of teaching experience–– Decreased productivityDecreased productivityp yp y–– Not enough time to teachNot enough time to teach

When a preceptor has a student what areWhen a preceptor has a student what areWhen a preceptor has a student , what are When a preceptor has a student , what are the barriers to running on time and thus the barriers to running on time and thus maintaining productivity?maintaining productivity?maintaining productivity?maintaining productivity?

We are here to discuss solutionsWe are here to discuss solutionsWe are here to discuss solutionsWe are here to discuss solutions

Remind Preceptors of the BenefitsRemind Preceptors of the BenefitsRemind Preceptors of the BenefitsRemind Preceptors of the BenefitsShow them how others succeedShow them how others succeedP id t ith t h lP id t ith t h lProvide preceptors with resources to help Provide preceptors with resources to help them succeed.them succeed.

Benefits for Clinical PreceptorsBenefits for Clinical PreceptorsBenefits for Clinical PreceptorsBenefits for Clinical Preceptors

Increased enjoyment of clinical practiceIncreased enjoyment of clinical practiceIncreased enjoyment of clinical practiceIncreased enjoyment of clinical practiceSense of giving back to the professionSense of giving back to the professionDecreased sense of professional isolationDecreased sense of professional isolationDecreased sense of professional isolationDecreased sense of professional isolationSatisfaction in being a role model for Satisfaction in being a role model for studentsstudentsstudentsstudentsAdjunct or volunteer faculty appointmentsAdjunct or volunteer faculty appointmentsCME f t hiCME f t hiCME for teachingCME for teachingTeaching improves own skillsTeaching improves own skills

“I’m Too Busy to Take a Student”“I’m Too Busy to Take a Student”I m Too Busy to Take a StudentI m Too Busy to Take a Student

Classic teaching method used is anClassic teaching method used is anClassic teaching method used is an Classic teaching method used is an inefficient and ineffective way of teaching inefficient and ineffective way of teaching an learningan learningan learningan learning

ItIt ii ibl f t t b ff tiibl f t t b ff tiIt It isis possible for preceptors to be effective possible for preceptors to be effective educators while maintaining high clinical educators while maintaining high clinical

d ti itd ti itproductivityproductivity

OHSU Faculty Teaching Hours vs. OHSU Faculty Teaching Hours vs. Productivity RVU/clinicProductivity RVU/clinic

600

Productivity RVU/clinicProductivity RVU/clinicClinical Teaching Hours RVU/clinic

500

300

400

200

300

20

100 10

0A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA

0

Strategies UsedStrategies Used**Strategies UsedStrategies UsedOrient students to the practice settingOrient students to the practice settingp gp gClarify expectations to studentsClarify expectations to studentsSchedule patients in such a way that maximizes Schedule patients in such a way that maximizes p yp yteaching and productivityteaching and productivityProvide frequent and immediate constructive Provide frequent and immediate constructive f db k t t d tf db k t t d tfeedback to studentsfeedback to studentsShare students with other practice partnersShare students with other practice partners

*Seim HC and Johnson OG. Clinical Preceptors: Tips for Effective *Seim HC and Johnson OG. Clinical Preceptors: Tips for Effective Teaching with Minimal Downtime. Teaching with Minimal Downtime. Fam MedFam Med1999; 31(8):5381999; 31(8):538--9.9.

Practice Tips from Productive Practice Tips from Productive O S CO S COHSU Clinical PreceptorsOHSU Clinical Preceptors

See one Do One Teach OneSee one Do One Teach OneSee one, Do One, Teach OneSee one, Do One, Teach OneFaculty is busy while student is Faculty is busy while student is –– while while student is in one room faculty is seeingstudent is in one room faculty is seeingstudent is in one room faculty is seeing student is in one room faculty is seeing one, two, or three other patients.one, two, or three other patients.D ’t t t d t tiD ’t t t d t ti ththDon’t repeat student questions Don’t repeat student questions –– rather, rather, summarize and clarify history.summarize and clarify history.Student is Value Added Team Member: Student is Value Added Team Member: patient education, vitals, assist with getting patient education, vitals, assist with getting patient ancillary servicespatient ancillary services

SMALL GROUPSMALL GROUPQQDiscussionDiscussion QuestionsQuestions

Do you have clinical preceptors that seem Do you have clinical preceptors that seem to have an endless capacity for students?to have an endless capacity for students?to have an endless capacity for students?to have an endless capacity for students?–– What types of things do those preceptors do What types of things do those preceptors do

differently?differently?differently?differently?

Wh t d ti l t i l th dWh t d ti l t i l th dWhat educational materials or methods What educational materials or methods exist to help preceptors be more efficient?exist to help preceptors be more efficient?

Discussion Key PointsDiscussion Key PointsDiscussion Key PointsDiscussion Key PointsGood communication is criticalGood communication is critical!!–– Orient student to the practice on first dayOrient student to the practice on first day–– Set clear goals and expectations; refine and update Set clear goals and expectations; refine and update

goals as rotation progressesgoals as rotation progressesgoals as rotation progressesgoals as rotation progresses–– Provide feedback that is immediate and constructiveProvide feedback that is immediate and constructive

Quality not QuantityQuality not QuantityQuality not QuantityQuality not Quantity–– The quality of the patient encounter (having the The quality of the patient encounter (having the

student follow one patient thoroughly, look something student follow one patient thoroughly, look something up and order their labs) and the teaching point isup and order their labs) and the teaching point isup, and order their labs) and the teaching point is up, and order their labs) and the teaching point is more important than the number of patients the more important than the number of patients the student is seeing. If the student is seeing nearly every student is seeing. If the student is seeing nearly every patient with youpatient with you that is too muchthat is too muchpatient with you patient with you –– that is too much. that is too much.

Discussion Key PointsDiscussion Key PointsDiscussion Key PointsDiscussion Key PointsObservation is importantObservation is important!!pp–– ObserveObserve H&Ps and other skills H&Ps and other skills over timeover time with multiple with multiple

patients patients –– don’t observe an entire physical all the don’t observe an entire physical all the timetimetime. time.

–– Don’t need to observe from start to finish all the time. Don’t need to observe from start to finish all the time. Choose which components of the patient encounter to Choose which components of the patient encounter to b b d ti t’ di l bl db b d ti t’ di l bl dobserve based on patient’s medical problem and observe based on patient’s medical problem and

student’s skill levelstudent’s skill level–– Have student keep track of what skills have been Have student keep track of what skills have been

observed (HPI, P.E., procedures, patient education, observed (HPI, P.E., procedures, patient education, etc). Communicate with student about what skills still etc). Communicate with student about what skills still need to be observed and plan accordingly.need to be observed and plan accordingly.

Discussion Key PointsDiscussion Key PointsDiscussion Key PointsDiscussion Key PointsMix up the type of teaching you doMix up the type of teaching you do. . p yp g yp yp g y–– The classic teaching method of having the student The classic teaching method of having the student

see the pt, come out and present the case, then the see the pt, come out and present the case, then the two of you going back in can be very inefficienttwo of you going back in can be very inefficienttwo of you going back in can be very inefficient.two of you going back in can be very inefficient.

–– Sometimes you can go in and observe the student “I Sometimes you can go in and observe the student “I am going to be a fly on the wall” (and write your notes am going to be a fly on the wall” (and write your notes

hil th d thi )hil th d thi )while they do everything). while they do everything). –– Sometimes go in after they do the history. Sometimes go in after they do the history. –– Sometimes you do the history and they do the Sometimes you do the history and they do the y y yy y y

physical (you repeat what is needed). physical (you repeat what is needed). –– Sometimes just have them observe you.Sometimes just have them observe you.

Time ManagementTime ManagementTime ManagementTime ManagementBegin clinic on time! Begin clinic on time! ggDouble book patientsDouble book patients such that the student can see one such that the student can see one patient and the preceptor sees the other patient; patient and the preceptor sees the other patient; maintains productivitymaintains productivitymaintains productivitymaintains productivitySet time deadlines for studentsSet time deadlines for students: : (“You have 10 minutes (“You have 10 minutes to see this patient”)to see this patient”)T kT k A th t d t i bt i i th hi tA th t d t i bt i i th hi tTeamworkTeamwork: As the student is obtaining the history or : As the student is obtaining the history or performing the exam, the preceptor can enter the performing the exam, the preceptor can enter the information into the electronic medical record (or visa information into the electronic medical record (or visa

))versa)versa)Not necessary to repeatNot necessary to repeat the entire HPI and PE obtained the entire HPI and PE obtained by the student, just summarize with the patient what you by the student, just summarize with the patient what you y j p yy j p yheard and add any clarifying statements.heard and add any clarifying statements.

Time ManagementTime ManagementTime ManagementTime ManagementPlan aheadPlan ahead: Look at your schedule and pre: Look at your schedule and pre--y py pselect the patients the student will see… some select the patients the student will see… some patients you know will take forever. patients you know will take forever. Utilize the student fullyUtilize the student fully::Utilize the student fullyUtilize the student fully: : –– Don’t repeat unnecessary items that you know Don’t repeat unnecessary items that you know

student does well, just clarify. student does well, just clarify. Have students look up questions that the patientsHave students look up questions that the patients–– Have students look up questions that the patients Have students look up questions that the patients have and after they discuss it with you call patients have and after they discuss it with you call patients back. back. Have students call patients with results after youHave students call patients with results after you–– Have students call patients with results after you Have students call patients with results after you discuss them with the student. discuss them with the student.

–– Have the student call specialists and help facilitate Have the student call specialists and help facilitate care with ancillary servicescare with ancillary servicescare with ancillary services. care with ancillary services.

Time ManagementTime ManagementTime ManagementTime ManagementShare the teaching responsibilitiesShare the teaching responsibilities::

Sh t hi ith ti tSh t hi ith ti t–– Share teaching with practice partnersShare teaching with practice partners–– Utilize nurses, medical assistants, lab Utilize nurses, medical assistants, lab

assistants to teach students in how to giveassistants to teach students in how to giveassistants to teach students in how to give assistants to teach students in how to give injections, perform lab tests, obtain an EKG, injections, perform lab tests, obtain an EKG, practice blood draws, etc.practice blood draws, etc.

–– The office manager, billing specialist, The office manager, billing specialist, scheduler, can teach the student about the scheduler, can teach the student about the business side of clinical practicebusiness side of clinical practicebusiness side of clinical practicebusiness side of clinical practice

–– If you have more than one student they can If you have more than one student they can teach each otherteach each otherteach each otherteach each other

Time ManagementTime ManagementUse a StepUse a Step--Wise Approach to TeachingWise Approach to Teaching–– Have student focus on Have student focus on oneone aspect of a patient aspect of a patient

enco nter rather than a comprehensi e approachenco nter rather than a comprehensi e approachencounter rather than a comprehensive approach encounter rather than a comprehensive approach with with eacheach patient.patient.

–– ExampleExample: For patient “A” who complains of shortness : For patient “A” who complains of shortness of breath the student should focus on the HPI onlyof breath the student should focus on the HPI onlyof breath, the student should focus on the HPI only. of breath, the student should focus on the HPI only. For patient “B” with asthma, the student should focus For patient “B” with asthma, the student should focus on patient education. For patient “C” who developed on patient education. For patient “C” who developed a new rash the student should focus on the physicala new rash the student should focus on the physicala new rash, the student should focus on the physical a new rash, the student should focus on the physical exam.exam.

–– ExampleExample: Instead of allowing the student to perform : Instead of allowing the student to perform an entire procedure have him/her perform the digitalan entire procedure have him/her perform the digitalan entire procedure have him/her perform the digital an entire procedure have him/her perform the digital block/lidocaine injection the first time, and the next block/lidocaine injection the first time, and the next time remove the toenail.time remove the toenail.

–– Emphasize key teaching points only; lengthy Emphasize key teaching points only; lengthy p y g p y; g yp y g p y; g ydiscussions usually not necessary. discussions usually not necessary.

Create the Right EnvironmentCreate the Right EnvironmentCreate the Right EnvironmentCreate the Right Environment

Patients are more accepting of students if theyPatients are more accepting of students if theyPatients are more accepting of students if they Patients are more accepting of students if they are are incorporated into the practiceincorporated into the practice setting on a setting on a regular basisregular basisTh t ’Th t ’ i f t hii f t hi ill hill hThe preceptor’s The preceptor’s passion for teachingpassion for teaching will have a will have a positive effect on the students, staff, and positive effect on the students, staff, and patientspatientsppDo students need Do students need training to access the EMRtraining to access the EMRsystem? How/when will this be done?system? How/when will this be done?Consider theConsider the physical aspect of the clinicphysical aspect of the clinic::Consider the Consider the physical aspect of the clinicphysical aspect of the clinic::–– Is there a place for the student to work?Is there a place for the student to work?–– Are there enough exam rooms?Are there enough exam rooms?

ResourcesResourcesThe OneThe One--Minute PreceptorMinute PreceptorThe OneThe One--Minute Preceptor Minute Preceptor

A strategy for instruction in the health care A strategy for instruction in the health care gygysetting that consists of the following steps:setting that consists of the following steps:–– Get a commitment from the studentGet a commitment from the student–– Probe for supporting evidenceProbe for supporting evidence–– Reinforce what was done well Reinforce what was done well –– be specificbe specific–– Give guidance about errors and omissionsGive guidance about errors and omissions–– Teach a general principleTeach a general principle–– ConclusionConclusion

Neher J O Gordon K C et al (1992) A fiveNeher J O Gordon K C et al (1992) A five step "microskills“ model of clinicalstep "microskills“ model of clinicalNeher, J. O., Gordon K. C. et al. (1992). A fiveNeher, J. O., Gordon K. C. et al. (1992). A five--step microskills model of clinical step microskills model of clinical teaching Journal of the American Board of Family Practice, 5, 419teaching Journal of the American Board of Family Practice, 5, 419--424 424

ResourcesResourcesPreceptor Education ProjectPreceptor Education Project

Sheets K and Garret E CoSheets K and Garret E Co--directorsdirectorsSheets K and Garret E., CoSheets K and Garret E., Co directors. directors. Preceptor Education Project: Facilitator’s Preceptor Education Project: Facilitator’s Guide 2Guide 2ndnd edition Society of Teachers ofedition Society of Teachers ofGuide, 2Guide, 2 edition. Society of Teachers of edition. Society of Teachers of Family Medicine. 1999. Available to order Family Medicine. 1999. Available to order atat http://stfm org/bookstorehttp://stfm org/bookstoreat at http://stfm.org/bookstorehttp://stfm.org/bookstore

ReferencesReferencesReferencesReferences1. Zayas TT. Qualities of Effective Preceptors pf Physician Assistant 1. Zayas TT. Qualities of Effective Preceptors pf Physician Assistant StudentsStudents Perspective on Physician Assistant EducationPerspective on Physician Assistant Education 1999;10(1):71999;10(1):7 1111Students. Students. Perspective on Physician Assistant EducationPerspective on Physician Assistant Education 1999;10(1):71999;10(1):7--11.11.

2. Seim HC and Johnson OG. Clinical Preceptors: Tips for Effective 2. Seim HC and Johnson OG. Clinical Preceptors: Tips for Effective Teaching with Minimal Downtime. Teaching with Minimal Downtime. Fam MedFam Med1999; 31(8):5381999; 31(8):538--9.9.

3. McKee MD, Steiner3. McKee MD, Steiner--Grossman P, et al. Quality of student learning and Grossman P, et al. Quality of student learning and preceptors productivity in urban community health centers. preceptors productivity in urban community health centers. Family MedicineFamily Medicine1998;30(2):1081998;30(2):108--12.12.

4. Salerno SM, O’Malley PG et al. Faculty development seminars based on 4. Salerno SM, O’Malley PG et al. Faculty development seminars based on the onethe one--minute preceptor improve feedback in the ambulatory setting. minute preceptor improve feedback in the ambulatory setting. J J Gen Intern MedGen Intern Med 2002; 17:7792002; 17:779--787.787.

5. Skeff KM, Stratos GA, et al. Clinical teaching improvement: past and 5. Skeff KM, Stratos GA, et al. Clinical teaching improvement: past and future for faculty development. future for faculty development. Fam MedFam Med 1997;29(4):2521997;29(4):252--7.7.

6. York NL, DaRosa DA, et al. Patients’ attitudes toward the involvement of 6. York NL, DaRosa DA, et al. Patients’ attitudes toward the involvement of medical students in their care. medical students in their care. Am J SurgAm J Surg 1995;169:4211995;169:421--3.3.

ReferencesReferencesReferencesReferences7. O’Malley PG, Omori DM et al. A prospective study to assess the effect of 7. O’Malley PG, Omori DM et al. A prospective study to assess the effect of ambulatory teaching on patient satisfactionambulatory teaching on patient satisfaction Acad MedAcad Med 1997; 72:10151997; 72:1015--77ambulatory teaching on patient satisfaction. ambulatory teaching on patient satisfaction. Acad MedAcad Med 1997; 72:10151997; 72:1015 7.7.

8. Gress TW, Flynn JA et al. Effect of student involvement on patient 8. Gress TW, Flynn JA et al. Effect of student involvement on patient perceptions of ambulatory care visits. perceptions of ambulatory care visits. J Gen Intern MedJ Gen Intern Med 2002; 17: 4202002; 17: 420--427.427.

9. Simon SR, Peters AS, et al. Effect of medical student teaching on patient 9. Simon SR, Peters AS, et al. Effect of medical student teaching on patient satisfaction in a managed care setting. satisfaction in a managed care setting. J Gen Intern MedJ Gen Intern Med 2000; 15:5472000; 15:547--561.561.

10. Neher JO, Gordon KC, et al. A five10. Neher JO, Gordon KC, et al. A five--step “micro skills” model of clinical step “micro skills” model of clinical teaching. J Am Board of Family Practice 1992; 5:419teaching. J Am Board of Family Practice 1992; 5:419--424.424.

11. Sheets K and Garret E., Co11. Sheets K and Garret E., Co--directors. Preceptor Education Project: directors. Preceptor Education Project: Facilitator’s Guide, 2Facilitator’s Guide, 2ndnd edition. Society of Teachers of Family Medicine. edition. Society of Teachers of Family Medicine. 1999. Available to order at 1999. Available to order at http://stfm.org/bookstorehttp://stfm.org/bookstore

http://www.oucom.ohio.edu/fd/monographshttp://www.oucom.ohio.edu/fd/monographshttp://stfm.orghttp://stfm.org