Transcript Effective Instructional Practices in Ambulatory Care Settings

Ambulatory Teaching:
Time Efficient and Effective
Strategies
David M. Irby, PhD
University of California
San Francisco
Preview
• Identify constraints on
ambulatory Education
• Describe efficient and
effective teaching strategies
– Planning
– Teaching
– Reflecting
Constraints on Ambulatory Education
• Fast paced and chaotic
environment
• Little teaching, observation
and feedback
• Lack of orientation,
collaborative learning and
reflection
Irby, 1995. Ludmerer, 1999
Recommendations
• Make time for teaching and target to learner needs
– Create opportunity space for teaching
– Develop a repertoire of teaching methods
• Offer opportunities for reflection, collaborative
and independent learning
– Offer ambulatory care conferences
– Promote self-directed and collaborative learning
DaRosa, 1997. Ferenchik, 1997. Heidenreich, 2000. Irby, 1995.
Teacher Reasoning and Action
3. Reflecting
Clinical
Instruction
1. Planning
Orient
Select
Prime
2. Teaching
Planning
• Orient learners to clinic
– Introduce to people,
procedures, resources
– Specify case format
– Solicit learner goals
• Pre-select patients
• Prime learners
Ferenchick, 1997. Kernan, 1997.
Lesky, 1995. McGee, 1997.
Prime Learners
• For patients with a new problem
– What are important causes?
– What are signs, symptoms, risks?
• For patients with a follow-up visit
– What are preventive measures?
– What are complications?
McGee, 1997.
Teacher Reasoning and Action
3. Reflecting
Clinical
Instruction
1. Planning
Orient
Select
Prime
2. Teaching
Model
Observe
1 Min Precept
Teaching with the Patient
• Model reflectively
• Observe and teach
selectively
• Use the One Minute
Preceptor
Cunningham, 1999. Ferenchick, 1997.
McGee, 1997. Usatine, 1997, 2000.
One Minute Preceptor
Teach
3. Provide
positive
feedback
4. Teach
general rules
5. Correct
errors
3.
Discussion
1. Case
Present
2. Inquiry
Diagnose
Patient
•Listen
•Clarify
Diagnose Learner
1. Ask for a
commitment
2. Probe for
underlying reasoning
Neher, 1992.
Five Precepting Microskills
1. Get a
Commitment
Diagnose Learner
2. Probe for
Underlying
Reasoning
5. Correct
Errors
Teach
4. Teach
General
Rules
3. Provide
Positive
Feedback
Teacher Reasoning and Action
3.
Reflecting
Reflect
Learn
Feedback
Clinical
Instruction
1. Planning
Orient
Select
Prime
2. Teaching
Model
Observe
1 Min Precept
Reflection
• Ask questions to
stimulate reflection
– What are your questions?
– What did you learn from
seeing patients today?
– What troubled, surprised,
moved or inspired you
today?
Arseneau, 1995. DaRosa, 1997.
Smith, 1997.
Reflection
• Promote self-directed learning
– What is one thing you want to learn about?
• Encourage self-assessment and share oneminute feedback
– Share a success and a concern or question.
– Specifically, you did well on…
– One recommendation for improvement...
DaRosa, 1997. Ende, 1995. Lesky, 1995.
Neher, 1992. Smith, 1998. Usatine, 2000.
Conclusion
• Prepare learners to be efficient
• Use a repertoire of time-efficient
and effective teaching strategies
• Offer opportunities for reflection,
collaboration and independent
learning
• Have fun
References 1
• Arseneau. Exit Rounds: A Reflection Exercise. Acad Med.
70:684-687, 1995.
• Bland, et al. Faculty Development Special Issue. J. Fam. Med.
29(4):230-293, 1997.
• Cunningham et al. The Art of Precepting: Socrates or Aunt
Minnie? Arch Ped Adolesc Med. 153:114-116, 1999.
• DaRosa, et al. Strategies for Making Ambulatory Teaching Lite:
Less Time and More Fulfilling. Acad. Med. 72(5): 358-361,
1997.
References 2
• Ende et al. Preceptors’ Strategies for Correcting Residents in an
Ambulatory Care Medicine Setting: A Qualitative Analysis. Acad
Med. 70:224-229, 1995.
• Ferenchick, et al. Improving the Efficiency and Effectiveness of
Clinical Preceptors in the Ambulatory Setting. Acad. Med.
72(4):277-280, 1997.
• Heidenreich et al. The Search for Effective and Efficient
Ambulatory Teaching Methods Through the Literature. Ped.
105(1:Suppl):231-237, 2000.
• McGee, Irby. Teaching in the Outpatient Clinic: Practical Tips.
JGIM. 12; April(Suppl 2): S34-S40, 1997.
References 3
• Irby. How Attending Physicians Make Instructional Decisions
When Conducting Teaching Rounds. Acad. Med. 67:630-638,
1992.
• Irby. Teaching and Learning in Ambulatory Care Settings: A
Thematic Review of the Literature. Acad Med. 70:898-931, 1995.
• Kernan, O’Connor. Site Accommodations and Preceptor
Behaviors Valued by Third Year Students in Ambulatory Internal
Medicine Clerkships. Teach Learn Med. 9(2):96-102, 1997.
• Lesky, Hershman. Practical Approaches to a Major Educational
Challenge. Arch Intern Med. 155:897-904, 1995.
References 4
• Ludmerer. Time to Heal. Oxford University Press, 1999.
• McGee, Irby. Teaching in the Outpatient Clinic: Practical Tips.
JGIM. 12:April(Suppl 2):S34-S40, 1997.
• Neher, et al. A Five-step "Microskills" Model of Clinical
Teaching. Journal of the American Board of Family Practice.
5:419-424, 1992.
• Smith, Irby. The Roles of Experience and Reflection in
Ambulatory Care Education. Acad Med. 72:32-35, 1997.
• Smith et al. A Broader Theoretical Model for Feedback in
Ambulatory Care. Advances Health Sci Educ. 3:133-140, 1998.
References 5
• Usatine et al. Four Exemplary Preceptors’ Strategies for Efficient
Teaching in Managed Care Settings. Acad Med. 72:766-769, 1997.
• Usatine et al. Time Efficient Preceptors in Managed Care Settings.
Acad Med. 75:, 2000.