SEARCH
Division of Education
for CONTENT

 

EMAIL   PRINT PRINT

RAP

Promoting Excellence in Surgical Care Through Education, Training, and Validation

E-Learning Resource Center

Division of Education > RAP > Previous Articles

Faculty regularly are asking for materials to help their faculty and residents "teach on the fly". The following article by Dr. AnnaMarie Connolly outlines the One Minute Teacher approach along with sample cases that can be used as part of a short teacher development program.

Clinical teaching while you work:
The One Minute Preceptor keeps instruction effective and efficient

AnnaMarie Connolly, MD
Division of Urogynecology/Reconstructive Pelvic Surgery
Department of Obstetrics and Gynecology
University of North Carolina at Chapel Hill, School of Medicine
Chapel Hill, North Carolina

Teaching individual learners in the clinical setting has clear appeal and allows for instruction in the busy office or hospital-based setting where preceptor, attending, and resident teachers deliver patient care. The clear advantages to such teaching include one-on-one time with learners, direct observation, direct patient involvement, and "clinically relevant, real-life" scenarios.1

There are challenges, however, to such instruction. These challenges include the pressures of clinical "productivity,"1 diverse educational settings used for clinical experiences,2 the "unpredictability" of clinical conditions with which patients present, and the difficulty encountered in applying consistent teaching goals or "curricular objectives" in these varied educational settings (ie, clinic office, emergency room, operating room).2,3,4,5 Another important challenge to teaching in the clinical setting is the limited time available with individual patients and/or with individual learners, as students and residents are frequently in the office or clinic with preceptors for short periods of time. 1

Certainly, strategies to facilitate effective and efficient teaching in the clinical setting have been identified. These strategies include planning for learners' interactions with patients in advance of patient visits,1 teaching during interaction with patients--at the bedside or in the exam room, and reflecting with learners on patient care that has already occurred.1,6 Another effective model for teaching in the clinical setting is the "One Minute Preceptor."7

While time may be scarce, the One Minute Preceptor helps to efficiently "shape" educational discussions and enables faculty and resident instructors alike to effectively teach in the clinical setting.7,8 The strengths of the model are that it can be taught in a single one-to two-hour seminar and that the model focuses on a few teaching behaviors that are easy to perform.7 The teacher can "diagnose" the patient as well as the learner and teach the learner by using the following five "microskills":

  1. Getting a commitment
  2. Probing for supporting evidence
  3. Teaching general rules
  4. Reinforcing what was right
  5. Correcting mistakes.7

Getting a commitment
After presenting the case, the learner usually stops to wait for a response or asks for guidance from the teacher. Clinical teachers can take this time to get a commitment and ask the learner what she or he thinks is going on with the patient. A good example of this first microskill of the One Minute Preceptor could be asking the medical student what differential diagnoses s/he might consider after presenting a 21-year-old patient who has just been seen in the emergency department with the complaints of a 24-hour history of nausea and epigastric pain now localizing the to right lower quadrant. Simply telling the student that the patient clearly has either an acute appendicitis or a ruptured ovarian cyst after such a student presentation would be a bad example of getting a commitment and would not facilitate evaluation of the student's clinical reasoning.

Probe for supporting evidence
Before offering an opinion on what is going on with the patient, the clinical teacher can probe the learner for evidence supporting the learner's clinical reasoning. For example, in the above presentation, the teacher can ask for supporting history such as GI and menstrual history. The teacher could probe for supportive surgical history such as whether the patient has had an appendectomy and/or any adnexal surgery. Other supporting evidence the teacher can probe for could include signs such as an elevated temperature, abdominal and pelvic exam findings, pertinent laboratory findings such as white blood cell count and pregnancy test, as well as pertinent imaging such as an abdominal/pelvic CT scan. Alternatively, teachers might ask what other diagnoses were considered and what evidence supported or refuted those diagnoses. A bad example of probing for supportive evidence might include telling the student that a CBC and CT scan were the necessary next steps before the student completes his/her presentation or without asking the student what diagnostic testing and/or imaging s/he thinks would be helpful. Asking learners how they interpret data is the first step in diagnosing their learning needs. Asking them to reveal their thought processes allows teachers both to find out what their learners know and to identify gaps.

Teaching general rules
At this point in the One Minute Preceptor model of instruction, it is time to teach the learner. The teacher reinforces general rules focusing on a single teaching point. Using the above clinical scenario, a good example of teaching general rules could be reinforcing the difficulty with clinically distinguishing amongst acute appendicitis, a ruptured ovarian cyst, or an ectopic, tubal pregnancy. Another good example of teaching general rules in the clinical example would be the importance of ordering a urine or serum pregnancy test in all reproductive-aged women with right lower quadrant pain to rule out a potentially life threatening ectopic pregnancy. A bad example of teaching general rules could include no such discussion of general clinical rules or simply going ahead and ordering an omitted pregnancy test without informing the learner of the importance of this missed diagnostic study. Frequently what is clinically second nature to the teacher (ie, ordering a pregnancy test in this scenario) may be missed by the learner and, as such, these points lend themselves well to the microskill of teaching general rules.

Reinforcing what was correct
The next microskill of the One Minute Preceptor is reinforcing what was correct. This might include reinforcing that the student's history was complete including all necessary elements and that the appropriate focused physical exam was performed in the presence of the clinical teacher. Reinforcing that the student's presentation was focused, well organized, and easy to follow would also be examples of reinforcing what was correct. A poor example of reinforcing what was correct could include no acknowledgment or feedback on the student's history, physical exam, and clinical reasoning.

Correcting mistakes
After reinforcing what the learner reasoned correctly, the teacher then corrects mistakes. Discussing missed laboratory testing such as a missed complete blood count or a pregnancy test in the aforementioned 21-year-old female with right lower quadrant pain would be an example of correcting mistakes or omissions in the student's work-up of the patient. Common errors in students' clinical reasoning include inability to generate plausible hypotheses or differential diagnoses, incorrect interpretation of collected data, too much data collection, and an over-emphasis on positive findings.

Literature supporting the One Minute Preceptor
There are certainly advantages to use of the One Minute Preceptor. The dialogue between students and teachers facilitated by this teaching strategy provides students and teachers with multiple opportunities for active learning and promotes student-teacher communication. For students, the clinical dialogue allows demonstration of clinical knowledge and reasoning skills while facilitating informal feedback sessions. The literature supports that both students and teachers rate the One Minute Preceptor as a more effective model of teaching than traditional precepting.9,10 Furthermore, brief, interactive faculty and resident development workshops, focused on the One Minute Preceptor, have resulted in modest improvements in the quality of faculty feedback delivered in the ambulatory setting11 and resident teaching skills in the inpatient care setting.12 As such, the literature supports the use of the One Minute Preceptor in faculty and resident development workshops designed to enhance teaching skills.11,13,14

The use of role-play with workshop participants taking on roles of "teacher" and "learner" allows for practice with the five microskills of the One Minute Preceptor.13,14 Strategies that facilitate successful use of such role playing to practice the microskills of the One Minute Preceptor include:

  1. The use of pre-selected, clinically relevant case scenarios for role playing and
  2. Overcoming faculty and resident reluctance to participate in role-playing activities by providing scripted scenarios for use during role play.13

The case vignettes included in Appendix A provide workshop leaders and participants with clinically relevant materials for role-play practice of the One Minute Preceptor microskills. To help participants overcome reluctance to participate, specific clinical points for the learner to intentionally omit during the role play session with each case scenario are suggested. This use of intentional omission facilitates additional practice with the microskills of teaching general rules and correcting mistakes.

Summary
In conclusion, the One Minute Preceptor is a powerful teaching strategy that can tangibly facilitate effective and efficient clinical teaching between teachers and learners. This strategy promotes student-teacher communication by allowing students to demonstrate clinical knowledge and reasoning and allowing teachers to diagnose not only the patient but also the learner.1,7-14

References

  1. Ferenchick G, Simpson D, Blackman J, DaRosa D, Dunnington G. Strategies for efficient and effective teaching in the ambulatory care setting. Acad Med. 1997;72:277-280.
  2. Walling AD, Sutton LD, Gold J. Administrative relationships between medical schools and community preceptors. Acad Med. 2001;76:184-7.
  3. Carney PA, Eliassen, MS, Pipas, CF, Genereaux SH, Nierenberg DW. Ambulatory care education: How do academic medical centers, affiliated residency teachings sites, and community-based practices compare? Acad Med. 2004 Jan;79(1):69-77.
  4. McCurdy FA, Sell DM, Beck GL, Kerer K, Larzelere RE, Evans JH. A comparison of clinical pediatric patient encounters in university medical centers and community private practice settings. Ambulatory Pediatrics. 2003;3:12-15
  5. Johnson GA, Pipas L, Newman-Palmer NB, Brown LN. The emergency medicine rotation: a unique experience for medical students. J Emerg Med. 2002 Apr;22(3):307-11.
  6. Smith CS, Irby DM. The role of experience and reflection in ambulatory medical education. Acad Med. 1997;72:32-5.
  7. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching. J Am Board Fam Pract. 1992;5:419-24.
  8. Neher JO, Stevens NG. The One-minute preceptor: Shaping the teaching conversation. Family Medicine. 2003;35(6):391-2.
  9. Teherani A, O'Sullivan P, Aagaard EM, Morrison EH, Irby DM. Student perceptions of the one minute preceptor and traditional preceptor models. Med Teacher. 2007;29:323-7.
  10. Aagaard E, Teherani A, Irby DM. Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: Proof of concept. Acad Med. 2004;79:42-49.
  11. Salerno SM, O'Malley PG, Pangaro LN, Wheeler GA, Moores LK, Jackson JL. Faculty development seminars based on the one-minute preceptor improve feedback in the ambulatory setting. J Gen Intern Med. 2002;17:779-787.
  12. Furney SL, Orsini AN, Orsetti KE, Stern DT, Gruppen LD, Irby DM. Teaching the one-minute preceptor: A randomized controlled trial. J Gen Intern Med. 2001;16:620-624.
  13. Bowen JL, Eckstrom E, Muller M, Janey E. Enhancing the Effectiveness of One-Minute Preceptor Faculty Development Workshops. Teaching and Learning in Med. 18(1), 35-41.
  14. Eckstrom E, Homer L, Bowen JL. Measuring Outcomes of a One-Minute Preceptor Faculty Development Workshop. J Gen Intern Med. 2006; 21:410-414.

Resources for Faculty Development Workshop Leaders

Appendix A
Case Vignettes for Role Playing: Using the One Minute Preceptor

Right lower quadrant pain, reproductive-aged female:

35 yo female, with a 24-hour history of nausea, low grade fever, and epigastric pain now localizing to the right lower quadrant.

Example of a clinical fact for learner to intentionally omit: Leave out ectopic pregnancy from the differential diagnosis and proposed work-up

Urinary Tract Infection:

55 yo male presents with a two-day history of painful urination, hesitancy, and urinary frequency.

Example of a clinical fact for learner to intentionally omit: Leave out urinary stones on the differential diagnosis

Abnormal Bleeding Per Rectum:

62 yo female G3P3 presents with a three-month history of irregular blood noted per rectum.

Example of a clinical fact for learner to intentionally omit: Leave out vaginal source for bleeding on the differential diagnosis

Obesity:

50 yo with a three-month history of weight gain. The patient has had to go up two clothing sizes and is having an increasingly difficult time exercising as a result of knee and back pain. The patient has several family members with a history of diabetes and she is concerned she may develop diabetes herself.

Example of a clinical fact for learner to intentionally omit: Leave out hypothyroidism from the differential diagnosis

 

Online February 26, 2010