The Microskills of Clinical

Teaching and Learning

Objectives• Describe characteristics of effective clinical

learning encounters• Identify, analyze and practice effective

clinical teaching, using the One Minute Preceptor

Residents as Teachers• Residents make a major contribution to

student education• Teaching improves resident learning and

acquisition of knowledge

“to teach is to learn twice”Miriam Bar-on, MD

Effective Clinical Teachers

• Communicate expectations explicitly• Stimulate interest enthusiastically• Interact skillfully with patients• Involve the learner in the teaching process• Role model desired behaviors• Give feedback on performance

Irby DM. Ramsey P, Gillmore J, Schad D. Characteristics of effective clinical teachers of ambulatory care medicine. Acad Med, 1991:66:54-55.

& Learners

What are the challenges for teaching in the clinical setting?

• Time• Time• Time

Irby DM. What clinical teachers in medicine need to know. Acad Med 1994;69:333-342.

Irby 2000

One-Minute Preceptor • Validated model for effective and efficient

clinical teaching • Developed for outpatient clinic but can be used

with learners in any clinical setting• Promotes the learner’s independence and active

involvement in patient care• Encourages the teacher to recognize “teachable

moments”

Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

And Best of All…

• Allows for simultaneous care of patients and learners…

One Minute Preceptor1. Assess prior knowledge2. Get a commitment3. Probe for evidence4. Give positive feedback5. Identify and correct mistakes6. Teach the general rule7. Encourage reflection and promote self

directed learning

Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #1: Assess Prior Knowledge

• Assess the learner’s knowledge and prior experience

• Establish goals for the encounter

Microskill #1Assess Prior Knowledge

• Learners: Would you feel ready to see this patient?

• Teachers: How might the teacher have helped the learner in advance of seeing the patient?

VIDEO

One Minute Preceptor1. Assess prior knowledge2. Get a commitment3. Probe for Evidence4. Give positive feedback5. Identify and correct mistakes6. Teach the general rule7. Encourage reflection and promote self

directed learning

Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #2Get a Commitment

• What is going on?• The learner commits

– Can be risky– The teacher’s goal is to provide a supportive

and safe environment• Pay attention to tone and body language

Ask The “What?” Question • What do you think is going on?

– (Differential diagnosis)• What investigations should be ordered?

– (Diagnostic strategy)• What is your first choice of medication?

– (Selection of therapy)• What do you think is probably going to happen?

– (Prognosis)• What would you like to achieve in this visit or

patient encounter? – (Management issue)

Microskill #2Get a Commitment

• How might the teacher have solicited a commitment from the learner?

VIDEO

What Gets in the Way?For the Learner:Difficulty in making a commitment may be

due to ?

What Gets in the Way?

For the Teacher:Difficulty in making a commitment may be

due to:– Fear of silence– Fear of being wrong– Knowledge gaps– Fear of being too demanding– Fear of falling behind in patient care

One Minute Preceptor1. Assess prior knowledge2. Get a commitment3. Probe for Evidence4. Give positive feedback5. Identify and correct mistakes6. Teach the general rule7. Encourage reflection and promote self

directed learning

Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #3Probe for Evidence

• Encourage the learner to think out loud• Share rationale for commitment• Why do you think that is so?• “What if…?” questions allow you to further identify

the learning edge and push to the next level

Microskill #3Probe for Evidence

• What was done well?• What could have been done better?VIDEO

One Minute Preceptor1. Assess prior knowledge2. Get a commitment3. Probe for Evidence4. Give positive feedback5. Identify and correct mistakes6. Teach the general rule7. Encourage reflection and promote self

directed learning

Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #4Give Positive Feedback

• Reinforce what was done right• Use language that is specific and behavioral,

not just vague praise– “You did a good job of considering multiple

diagnoses and prioritizing them”.– “I noticed how well you considered the patient’s

age and concerns about cost in selecting medications.”

One Minute Preceptor1. Assess prior knowledge2. Get a commitment3. Probe for Evidence4. Give positive feedback5. Identify and correct mistakes6. Teach the general rule7. Encourage reflection and promote self

directed learning

Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #5Identify and Correct Mistakes

• Correction must be specific and focused

– “That drug is often a good choice but in the setting of renal failure is contraindicated.”

– “In children who present with diarrhea and vomiting, assessing the urine output is essential.”

Microskills #4/#5Reinforcing and Corrective Feedback

• Was this useful feedback?• How might the learner have handled the

situation differently?VIDEO

One Minute Preceptor1. Assess prior knowledge2. Get a commitment3. Probe for Evidence4. Give positive feedback5. Identify and correct mistakes6. Teach the general rule7. Encourage reflection and promote self

directed learning

Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #6Teach the General Rule

• Choose a rule at the learner’s level• Consider content areas outside medical

knowledge – Professionalism– Communication Skills– Behavioral and Social Science Domains

Microskill #6Teach the General Rule

• When I see a patient like this, I think about…– “In school age children presenting with headache

I always consider myopia in the differential.”

– “ When I see a rash that I cannot diagnose, I define it as best as I can and then look it up in…. If we don’t solve the problem by looking at that reference, we need to call…”

One Minute Preceptor1. Assess prior knowledge2. Get a commitment3. Probe for Evidence4. Give positive feedback5. Identify and correct mistakes6. Teach the general rule7. Encourage reflection and promote self

directed learning

Irby, D. (1997, February). The One-Minute Preceptor. First presented at the annual Society of Teachers of Family Medicine Predoctoral meeting, Orlando, FL.

Microskill #7Encourage Reflection and SDL

• At the end of your session or at the end of the patient encounter– “What do you feel you did well?”– “What was most challenging?” – “How did the practice differ from your

expectations?”– “Did anything surprise you today?”

• “What is your next question?”

• “Based on this case I’d like you to formulate your next question and go to the literature to answer it…we’ll discuss it tomorrow.”

• Practice-based learning

Microskill #7Encourage Reflection and SDL

Microskills #6/#7General Rules, Reflection and SDL

• What did the learner do well?

• What did the teacher do well?VIDEO

Reflective Practice• In clinical practice

– Reflection on, in, and for action• In clinical education

– Teach– Reflect– Teach some more

One Minute Preceptor Advantages

• Feedback is embedded• Allows for improved teaching AND

assessment…– By questioning you are not only creating a

stimulating learning environment but also assessing the learner’s knowledge

What do you know? Assess prior knowledge

Why is going on? Get a commitment!

Why do you think that? Probe for evidence/facts

Warm and Fuzzy Positive feedback

Whoops! Identify, correct mistakes

When I see a patient like this Teach the general rule

What is your next question? Promote reflection

The 7 Wicroskills of Teaching

AcknowledgmentsThis workshop was developed by: • Rini Ratan, MD• Andrew Mutnick, MD• Lyuba Konopasek, MD• Sue Bostwick, MD