Transcript Precepting Students & Residents: Exploring Teaching and

Precepting Students & Residents:
Exploring Teaching and Learning
Deanna Kania, PharmD, BCPS, BCACP
Amy Hyduk, PharmD, MBA, BCPS
Both, Dr. Kania and Dr. Hyduk have
no actual or potential conflicts of
interest in relation to this program
or presentation
Objectives
 Identify opportunities to make site-based learning
interesting and interactive for preceptors, students and/or
residents
 Discuss strategies and unique ways for student learning to
improve patient care and experience
 Review different student scenarios to gain comfort and
appropriate feedback techniques
The Preceptor Role
“Modeling the Way”
Introduce to culture &
values of the profession
Instilling knowledge
Coaching, facilitating,
reinforcing behaviors &
skills
Demonstrating the
multidisciplinary team
approach to patient care
Preceptorship
“It is the preceptor who sets the tone of the training
program. He accomplishes this by what he does
personally, by what he stands for, by the contributions
he makes to the profession,
by his actions and by his
sense of values.”
Am J Hosp Pharm 1967;24:192-203.
Preceptorship
Learning
Styles
Personal
Attributes
Preceptors
Manage
Expectations
Preceptor
Teaching
Styles
Communication
Styles
Learning Taxonomies
Cognitive Domain
(Problem-solving)
Evaluation
Synthesis
Evaluate self, evaluate work of others according to
objective criteria
Create something new
Analysis
Select pertinent data on which to base a decision
Application
Use method, theory or principle to solve a new problem
Comprehension Understand meaning & intent of material; Can restate &
describe importance in own words
Knowledge
Recall or recognize ideas or material
The Learning Pyramid
Preceptor’s Role
Culminating
Integration
Facilitating
Coaching
Practical Application
Modeling
Foundation Skills & Knowledge
Direct Instruction
Guide for Instruction by
Preceptors. www.ashp.org
Preceptor’s Role
Direct
Instruction
•Provides some instruction – not the main focus
•Readings, guideline review, discussions
Modeling
•Show learner what you would do
•Think out loud
•Timing is key – prioritization
Coaching
•Working together or separately – dependent on time of
year & learner’s progress
•Learner explains back their thought process
Facilitating
•Working more independently
•Later in rotation / learning experience
Direct Instruction
 Avoid giving “lectures”
• Some level of instruction needed, but shouldn’t be the main
focus
• Often used as a crutch to cover desired material
• Need self-directed learning
 Assign readings
 Review practice guidelines, protocols w/learner
 Guided discussions w/questions & interactive learning
techniques to assess understanding
 Explain or show “how to” do something
Modeling
 Learner observes preceptor
 Preceptor “thinks out loud” with learner
 Show the “how to’s” in practice
 Academics vs. practice examples
 Utilize w/patient encounter
• Point out controversial issues
• Explain rationale
• Enhance problem-solving skills in a practice environment
 Meet w/learner after the encounter to discuss other points
Coaching
 Preceptor begins to take “back seat”
 Learner displays a previously modeled task or skill
 Learner explains their thought process to preceptor
 Preceptor coaches learner before the activity
 Preceptor provides “how to” tips for unique scenarios not
yet encountered
 Preceptor provides timely & specific positive & negative
constructive feedback after the activity
Facilitating
 Preceptor offers an opportunity for learner to practice
on their own where appropriate
• Develop own clinical decisions
• Apply learned problem-solving skills
• Perform self-evaluation process
 Preceptor assigns learner more complex
tasks/patients as learner progresses
The Learning Pyramid
Preceptor’s Role
Resident
assumes
TPN dosing
Service
Facilitating
Resident writes TPN
w/preceptor observing;
Resident explains to
preceptor his/her recs
Coaching
Write TPN on patient w/resident observing,
explain thought process, resident observes
preceptor communicate w/RN, MD & RD
Modeling
Review reading materials on nutrition support
w/resident, discuss protocol, demonstrate how
to collect lab data in IT system
Direct Instruction
Guide for Instruction by Preceptors.
www.ashp.org
The Learning Pyramid
Preceptor’s Role
Student
provides
anticoag
education to pts
on own
Student & preceptor
review consult for
anticoag education,
review pt chart, student
performs teaching to pt while
preceptor observes, preceptor
provides feedback after
Preceptor & student review consult for
anticoag education, review pt chart, preceptor
explains how s/he will tailor education to pt,
preceptor teaches pt while student observes
Review guidelines & education materials on anticoag
& have interactive topic discussion, discuss various pt
teaching strategies, demonstrate how to document tchg
Facilitating
Coaching
Modeling
Direct Instruction
Guide for Instruction by Preceptors.
www.ashp.org
Matching It All Up
Stages of
Learning
Levels of Cognitive
Learning
Appropriate Instructional
Methods
Foundation
Knowledge &
Skills
Knowledge
•Assigning readings
•Reviewing protocols
Comprehension
•Guided discussion
•Teach back method
Practical
Application
Application
•Case presentation
•Case-based teaching
•Simulation/role play
•Practice-based teaching
Analysis
Synthesis
Culminating
Integration
Evaluation
Guide for Instruction by Preceptors.
www.ashp.org
Application & Synthesis
Teaching Strategies
Teaching Strategies
 Create an environment where there is interaction
 The ‘teacher’ should be present to “guide” the
learning process
• Must shift the responsibility for learning toward the
student
• ‘Teachers’ should facilitate and serve as a resource
• Help your learners find the “joy” of learning
Teaching / Learning Barriers
Educational
tradition
Change
Limited
time
Learner
group size
& resources
Teaching Strategies
 See One – Do One – Teach One (SODOTO)
 Guided discovery
• Use questions to evaluate knowledge
 Role Play
• Useful for motivational interviewing skills
• Physician / pharmacist interactions
Teaching Strategies
 Problem solving scenarios or simulations
 Learner reflections
 Afternoon of sharing
• Personal stories
• Unique case studies
 Think Aloud
One Minute Preceptor
 Get a commitment
• What do you think is going on?
 Ask for evidence
• What led you to that conclusion?
 Teach
 Reinforce what was done well
 Correct mistakes
• Next time, try this
J Am Board Fam Prac 1992;5:419-24
SNAPPS Model for Patient Case
Discussions
 Summarize history and findings
 Narrow the assessment of the problem to 2-3
possibilities
 Analyze the assessment
 Probe preceptor (ask any questions)
 Plan for the patient
 Select topic for self-study
Acad Med 2003 Sep;78(9):893-8
Motivating Students / Residents
Motivating Learners
Give frequent,
early, positive
feedback
Help learners
feel that they
are valued
Create an
atmosphere that
is open and
positive
Assign tasks that
are neither too
easy nor too
difficult
Help learners
find personal
meaning and
value in the
material
Motivation Challenges
 Identify the source of poor motivations
 Intrinsic versus extrinsic motivation
 Discuss behaviors that communicate elusive
attitudes
• Ex. tardiness = poor attitude
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhAAPPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015.
J Am Pharm Assoc 2012;52(6):897-904
Effective Feedback Strategies
 Criteria-based and specific
 Listen to their self-assessment
• Respect
• Empathize/relate
 Provide feedback with pos – neg – pos
• Be honest
 Provide specific examples
 Attack the problem not the person
 Focus on one or two points at a time
Effective Feedback Strategies
Learner
identifies
area(s) for
improvement
Learner
identifies
specific steps to
reach next goal
Plan is reviewed
and modified
How to Prevent Problems
 Know yourself as a preceptor
• What type of learner irritates you?
• What characteristics do you value most in learners?
• What type of learner are you unsure how to handle?
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhAAPPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015
How to Prevent Problems
 Watch for warning signs
• Missed deadlines
• Lack of enthusiasm or engagement
• Poor professionalism
 Appearance
 Word choice/tone of voice
 Engagement
• Poor work ethic
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Late for rounds/clinic/pharmacy service
Missing/late assignments
Unprepared
Insubordinate
• Knowledge base
How to Prevent Problems
 Don’t ignore
 Don’t assume…
 Discuss and document
Fam Med 2000;32(4):232-4.
How to Prevent Problems
 Diagnose the issue
• Knowledge/skill deficit
 Not taught
 Not understood
 Not prepared
• Attitude
 Doesn’t know what they don’t know
 Personality issues
• Professionalism
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhAAPPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015
Indications for Failing a Learner
Unsafe skill
performances
Scrupulous
activity
Poor knowledge
base
Not meeting
rotation / facility
requirements
Poor
communication
skills
How to Handle Poor
Learner Performance
 Document everything!
 Communicate
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Allow learners to express perspective
Perception vs. reality
Be objective
Paint the picture for what success should look like
Consider generational differences, stressors, etc.
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhAAPPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015.
J Am Pharm Assoc 2012;52(6):897-904.
Communicate
 Use motivational interviewing techniques
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“Do you mind if we discuss…”
“What I hear you saying is…”
“What I see happening is…”
“What would you like to see different about…”
“May I suggest trying…”
“Here are two suggestions…which would you like to try…”
“Can I tell you what concerns me about…”
 “A patient may be harmed if this continues…”
 “You may be let go from a position, if this doesn’t change…”
Sobell & Sobell. Motivational Interviewing Strategies and Techniques. 2008.
http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf. Accessed March 2015.
How to Handle Poor
Learner Performance
Be aware of FERPA
Seek opinions from other
staff members on-site
Document
Everything
Ask for assistance from
the College
Development an
improvement / action plan
Improvement / Action Plans
 Work together with learner
 Clear and measurable expectations / outcomes
 Defined timeline for re-assessment of situation or
incomplete assignments
 Consequences if expectations / timeline is not met
 Signed agreement by both learner and preceptor
 Include Experiential office if support is needed
Precepting Challenges. http://www.pharmacist.com/sites/default/files/files/APhAAPPM%20Preceptor%20SIG%20Webinar%20Slides%20040213.pdf. Accessed March 2015.
J Am Pharm Assoc 2012;52(6):897-904.
Options for a Failing Learner
 Repeat the rotation
• May recommend that this be done elsewhere
• Colleges often place the learner with a faculty member for a
repeat rotation, but not always, so you may want to inquire
 Repeat part of the rotation
 Successfully perform a task that was identified as an area
for improvement
• Clinical skill
• Presentation
 Consider alternative career choices
Learner Scenarios
Case Scenario #1
 You are precepting a learner early in their training on an
outpatient rotation block, and it is his third day
 You suggest that today would be a great day in hypertension
clinic to work on blood pressure assessments
 The preceptee replies, “I have done that a ton already and I’m
comfortable with it and don’t need any practice.”
 What are your concerns? How would you respond? What if this
was late in their rotation year?
Case Scenario #2
 Your preceptee is on her second week of a rotation
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She is doing very well on rounds
Is completing all patient care activities
Documents interventions thoroughly
Types complete and excellent progress notes
 You notice that she is very inquisitive and challenges you in
many discussions, making you feel ‘uneasy’
 You notice you are sometimes defensive and short w/ her
 At times, she is also outspoken and demanding, even putting
an attending physician on edge
 How would you handle this situation?
Case Scenario #3
 Your learner is on his last clinical rotation
 He seems to be progressing well in the first week and is
working independently
 However, when you do your follow-up, you find
 Clinical mistakes are occurring
 All recommendations are not being reviewed w/ a preceptor
 Non-patient care work is incomplete
 How do you address this problem?
Case Scenario #4
 Your learner’s self-evaluation is not consistent with your own at the
mid-rotation evaluation
 He/she feels they are ‘on top of everything’
 They display self-confidence despite a mostly lackluster performance
 You meet with them and provide clear documentation of errors and
things they can improve upon
 They are quite surprised to receive this less than positive feedback
 You have heard from previous preceptors that this is a reoccurring
problem
 How would you handle this situation?
Case Scenario #5
 Your preceptee is a stellar learner
 Excellent knowledge base
 Great recommendations
 You feel they could replace you
 However, everyday for the first week, she is late to the rotation
 She also has shown up late for meetings and has been behind on
turning assignments in
 You meet with her after week one and reiterate your expectations
for timeliness
 During week 2, she shows up late 3 of the 5 days and misses
another deadline
 How do you handle this situation?
Case Scenario #6
 It is the April rotation and your preceptee has already
signed on to work for community practice upon
graduation
 You are the preceptor for a critical care rotation
 The student is uninterested in your patient population
and does not see the value of the information they could
obtain from your rotation
 How do you handle this situation?
Case Scenario #7
 You fail a student learner due to knowledge base deficits
• You have multiple objective items documented about the learner’s
deficiencies
 You refer the student to the experiential coordinator at the
respective college for follow-up
 Within 15 minutes, you receive a page from the learner’s mother
who demands to know why you are failing her son and wants to
know what she can do to fix the situation. She states that clearly
you have done something wrong with her child.
 How do you respond?
Case Scenario #8
 Sweet learner who dresses professionally, is respectful, and is courteous
and friendly towards patients
 Within the first week, you notice she is struggling clinically
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Not able to follow as many patients
Slow in looking up drug information questions
Unprepared in case/topic discussions
States incorrect pharmacy-related information
 The learner is putting forth her best effort, is trying very hard, and has
recognized that she is struggling
 How do you handle this situation at the mid-point evaluation?
 How do you handle this situation at the end of the rotation assuming you
had a thorough mid-point review?
Precepting Students & Residents:
Exploring Teaching and Learning
Deanna Kania, PharmD, BCPS, BCACP
[email protected]
Amy Hyduk, PharmD, MBA, BCPS
[email protected]