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“Students slow me down” and “Students take too much time” are common complaints of precepting physicians, and yet some physicians have endless energy for teaching and are able to maintain their clinical productivity. What do these doctors do differently?
We held five professional seminars in 2007 and 2008 to talk with experienced physicians from health education programs across the United States about their precepting experiences. We collected and analyzed the suggestions that emerged in search of common themes. Doing so made it clear that physicians should focus on six areas to be efficient and effective preceptors.
A positive teaching experience begins with an appropriate match between student and preceptor. Make sure the educational programs you work with know your personality and work-style preferences. The programs should also know the makeup of your practice, such as patient population, and the learning experiences you can offer students, such as different types of procedures.
Once the program has matched you with a student, you and your staff will need to address a number of logistical issues.
First, your scheduling template may need to be revised to maximize clinical efficiency and quality teaching. There are several ways you can do this:
At the beginning of each day the student is in the office, review the schedule and consider which patients you would like to include in the student’s schedule. Have the staff member rooming the patient ask whether it is OK if a student conducts the visit. Use positive phrasing like, “Your physician is teaching a student. Is it OK if the student sees you first?”
These selections should be based on patient and visit type and the student’s educational needs. Some patients take forever even for preceptors, so they may not be appropriate for beginning students, but patients who need or desire more in-depth interactions may be ideal for students. Students can help set up appointments for these patients, arrange needed ancillary services and explain their test results.
When possible, plan any follow-up appointments with these patients for a day when the student is in the office. This continuity gives students the opportunity to discover whether treatment plans they helped develop are working. In addition, some patients may appreciate the extra attention and enjoy seeing the student’s educational growth.
When selecting patients, you should also consider what the student is currently learning. Ask, “What are you studying now? We’ll try to find a patient with that system issue.”
Ultimately it is important for both preceptor and student to be flexible. Occasionally you may need to ask the student to do other work while you see several patients in a row, because of the nature of the visits or because you need to catch up.
It is also important to provide students with a work-space that includes a desk and a place for personal items. Prior to the student’s arrival, arrange for the student to have a computer workstation and access to patient records, including log-in information for electronic health records as needed.
Ask a staff member to orient the student on his or her first day. The student will need to know where to park and be introduced to the staff and the office space. Orientation should include time to attend to administrative details, such as computer training and obtaining a security badge.
Communication is key to ensuring a successful teaching arrangement. It is essential that you express your expectations and goals to students, their educational program and your fellow clinicians and staff members. Prior to the student’s arrival at your practice, the program should describe the student’s skill level and explain what it expects the student to learn from the experience in your office.
Students and preceptors should communicate early and frequently regarding expectations, goals, and learning and teaching styles. This saves time and prevents frustration. Soon after the beginning of the rotation, start talking with students about their progress and the extent to which they are meeting their educational goals. Have students keep track of what types of patients they have seen and which procedures and clinical activities they have seen and done, such as taking a patient’s history and providing patient education. You should ask, “Is there any type of patient we need to have you work with today?” This helps students focus on their goals and helps you focus on meeting their needs. Ask questions that elicit reflection, such as, “What did you learn today?” These discussions could direct future sessions or independent research topics.
Feedback is necessary for evaluation, and it can prevent repetitive, time-wasting mistakes. Be sure to provide students with continuous feedback, and ask them about their experience with questions such as, “Is there a different way that I could teach to help your education?” Preceptors who have any concerns about students should immediately contact the student’s educational program.
Because students become part of the clinical team, it is essential that preceptors and students communicate with fellow clinicians and staff members. Preceptors should begin with the attitude that students add value to the practice. This approach will then likely spread to physician partners and clinic staff, and students will be more likely to make significant contributions. Ensuring buy-in from partners and clinic staff will save time for everyone by preventing misunderstandings and duplication of effort. Supportive colleagues can also enhance the student’s educational experience. Be sure to let your colleagues know if the student needs experience with certain procedures or diseases. You could say something like, “The student needs more work with diabetic patients. Could you let us know if you see any opportunities for that today?”
It is important to adapt your teaching to each student’s educational needs, goals and learning style. Doing this boosts the quality of the student’s education and helps you to remain efficient. You should assess the student’s strengths and weaknesses early on by observing the student’s interactions with patients. Then adjust your approach as needed based on your findings.
Your teaching method may also be influenced by how much time and how many exam rooms you have. Here are some suggestions for ways the two of you might share patient visits and structure learning opportunities:
First, make your practice a teaching environment. Altering your appointment template will help you accomplish this.
Communicate with all parties involved to help ensure success.
Tailor how you teach according to the student’s educational goals, needs and learning style.
Students don’t need to spend every minute of the day with you to advance their education. Preceptors, partners, staff, patients and students themselves can all be part of the teaching team. For example, students can learn different exam techniques from your partners, or phlebotomy from ancillary staff. They can also “teach themselves” by building clinical knowledge through independent research. Opportunities like these can enrich the students’ experience while enabling you the flexibility you may need to work independently. Here are some additional ways to get other members of the teaching team more involved:
Dividing observation and teaching into short, focused time segments helps fit precepting into a busy schedule. Observing student history-taking or exam skills in two- or three-minute segments enables you to assess ability and progress without getting behind on patient care. Teaching can be broken into short, focused interactions as well. Not everything can or should be taught all at once; concepts are often best reinforced with repetition. Students are more likely to benefit from small amounts of information linked directly to patient problems rather than large amounts on general topics. Try these tips:
Expanding students’ responsibilities maximizes their educational experience and fully utilizes their skills in patient care. When you think the student is ready to do more, try these ideas:
As you expand the student’s responsibilities, be sure not to repeat tasks you’ve entrusted him or her to do, unless billing and coding guidelines require it. In such cases, you can confirm and clarify: “Mrs. Smith, my student tells me that your headaches began about one week ago. Is this correct?”
Make sure students contribute to the top of their ability level. The more responsibility a student can take on, the more he or she can contribute to patient care. This makes the student more valuable to you and the clinic, and makes the experience more valuable to the student.
Some of these suggestions may not apply to every practice setting. Preceptors and practices should consider which strategies work best for them. We hope this article will supply physicians with a pearl or two that will boost their clinical productivity while doing the important work of training future family physicians.
Ask members of your staff and other physicians to help you teach the student.
Keep teaching and observation segments short and focused.
Expanding students’ responsibilities fully utilizes their skills in patient care.
Follow these guidelines when working with students.
“Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing. Students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note. If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.”
Check out the online version of this article at http://www.aafp.org/fpm/2010/0500/p18 where you’ll find printable tables in a handy format that contain much of the helpful tips and advice found in the article.
Author disclosure: nothing to disclose.
Send comments to gro.pfaa@tidempf.