Precepting 101

Some helpful hints

Better than a thousand days of diligent study is one day with a great teacher." --Japanese proverb

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.

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

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

The Effective Preceptor

Communication Skills

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

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

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

The effective preceptor…

Is open to conflicting ideas and opinions Connects information to broader concepts Communicates clear goals and expectation

The effective preceptor…

Captures learners attention Makes learning fun

Careful Assessment of the Learner

Careful Analysis of the Learner

Accurate assessment of learner’s knowledge, attitudes and skills Uses direct observation of the learner Provides effective feedback Performs fair and thoughtful evaluations

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?”

The Effective Preceptor

Skillful Teaching and Practice

Skillful Teaching and Practice

Provides effective role modeling Demonstrates skillful interactions with patients Presents information with organization and clarity

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 RD’s adjust electrolytes, etc., but this is NOT an entry level skill

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

Motivating the Learner

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.

Motivating the Learner

Many interns are adult learners and internally motivated Allowing interns to direct own learning will help make this transition

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!

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)

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.

How to promote success

Provide an orientation But don’t 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

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 you’re on the phone, etc.) Give your intern responsibility Create an atmosphere for open communication

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

The difficult learner

When the performance does not meet expectations Examples Learner can’t sort out appropriate versus irrelevant information Learner misses important details

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.

Subjective - example

√

Intern has difficulty developing effective working relationships with other disciplines Rather than X Intern is over-bearing and is alienating staff members

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?

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. can’t recognize assumptions, difficulty synthesizing

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

Assessment, continued

Is the learner having difficulty ordering his/her environment?

Time management Inflexible learning style Inefficient learning style

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 don’t meet your expectations?

May be some cultural issues

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

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

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

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

Finally…

Let the internship director know what is going on.

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; 53:808-815.

Stritter, Frank T and Baker, Richard M. Resident preferences for the clinical teaching of ambulatory care. Journal of Medical Education. 1982; 57:33-41.

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.