SPECIAL: OFFICE-BASED MEDICAL STUDENT TEACHING

Orientation and Priming: Setting the Stage for Learning

Bruce Landres, M.D.

I remember my first outpatient experience as a third year student. There was no preparation for that first visit to the office. I had been told to show up at a certain place and at a certain time for a rotation in Internal Medicine. Upon arriving at the assigned office, I discovered that I was extra baggage. My job was to follow the attending physician around and pick up pearls of wisdom as he saw his patients. I was expected to learn by watching and later modeling his behavior. On the second day of the rotation, I was greeted by my attending and told that I had a patient to work up. I was told to introduce myself, take a detailed history, and discover the patient's medical problems during the course of this interview. Afterwards, I was to perform a full physical exam, write it up, and be prepared to discuss the relevant problems. At no time was I told what to expect or look for or even how to address the patient. In the aftermath, the discussion of the case was a litany of what I did not know.

This initial experience was repeated on multiple occasions on the inpatient ward as well, with the only difference being that I became, over time, wiser in the ways of studentship. Discussions about pathophysiology or differential diagnosis were rare. More commonly the attending would make declarations such as "This is clearly a case of congestive failure. Why don't you read up on it tonight and we can discuss it tomorrow." Sometimes we did, sometimes we didn't.

What was significant was that most attending physicians had no idea of who I was, what I was interested in, what I could and could not do, or my background knowledge and prior experience. My job was to read everything on any given subject with no direction, in the hope of anticipating my attending physi-cian's unspoken questions.

Thirty years later, things have not changed substantially. A national survey of graduating medical students annually conducted by the Association of American Medical Colleges continues to indicate that a large percentage of students, when meeting with their attendings and preceptors, are still frequently left without direction. Nationally, between one fourth and one half of all students entering clerkships have no systematic direction.¹ There is obviously room for improvement.

What can we do to better understand the learning needs of the individual learners that we precept and make clear to them what is expected during the rotation? In this article, I will propose several strategies for making the teaching experience more effective by making it more targeted to the specific needs of the individual student. By assessing each student individually and teaching to that student's strengths and weaknesses appropriately, the process can become more positive and less demeaning. No student should be made to feel as if he or she is excess baggage, and all students should be given a clear understanding of what is to be expected of them on a particular rotation.

Contact the Student Prior to the First Visit

Different doctors have different expectations of their students, and those expectations should be made clear before the student comes to the office for the first time.² The first contact with the student should be made in the week before the preceptorship or rotation begins. A brief telephone call or e-mail by the preceptor to the student can be helpful, to inform the student as to what to wear, what personal medical equipment to bring, where to park, when to arrive, and where to meet on the first day. It is appropriate to have the student come to your office 15 to 30 minutes prior

Table 1: Interest Inventory

to the start of the clinic appointments, to allow the preceptor time to show the student around, make introductions, and assess the student's needs.^2,3 The student should be told this at the time of your first telephone contact. This extra time with the student allows you to begin to know the student and start to understand what his or her needs are.^3,4

It is also useful at this time to ask the student to complete an interest inventory prior to their first day. This information can be brought with them to serve as the basis for the initial discussion.(Table 1) The purpose of gathering this information is to help the preceptor better understand the student's background, prior experience, and interests. It should also be stressed to the student that there are no correct answers in such a questionnaire, and that it is designed to allow the preceptor to provide more individualized teaching.⁴

First Meeting

When the student actually arrives in the office and the preceptor has introduced him or herself, it is an appropriate time to provide a tour and make introduc-tions.^2,3,4 These students will often be on-site for more than ten times during the course of the year. It is obviously important for them to understand the organization and flow of the office.⁴

Insofar as most medical students know little about the business of medicine, showing them the reception area, nursing station, and business office and introducing them to the staff in each division helps them to have an understanding of how an office works. A brief explanation by either the preceptor or a member of the staff as to what is done in each division is also helpful. For example, seeing the medical technicians draw blood, take x-rays, or do electrocardiograms, and then learning how that information gets back to the physician, gives the student a sense of what the patient is undergoing, and of the data flow within the office. It also graphically demonstrates the disparate inputs the doctor gets during the course of the working day. Similar cases can be made for the business office and the front office.^2,3

If there are other physicians in the office, this is also the time to introduce the student to them as well. It should be made clear to the other physicians that the student is in your office to learn, and as such, if there should be any "good" teaching cases, you would appreciate their calling the student in.³ Overall, medicine has always been a collegial profession. This introduction models working together for the greater good, and provides the student with the greatest possible exposure to both patients and pathology. Even a two-minute encounter to demonstrate a physical finding or an interesting facet of a history is a worthwhile teaching exposure for a new medical student.

Introductions having been made, it is also worthwhile to sit down with the student and discuss the nature of the practice.^2,3 Demographics of the patient panel alert the students to the kinds of patient problems and populations with which they will need to become familiar and the special knowledge or skills they will need. For example, a practice with many older patients might involve a greater time investment per patient and more knowledge about clinical pharmacology and the management of chronic problems. A younger patient population may necessitate more discussions on safe sex and substance abuse. Patients with young children may frequently have more upper respiratory infections than those of the same age without children. The student may also be asked about his or her prior experience with select populations during this time as a means of assessing what will be familiar and what will be new.

Information about office flow is also important: how many patients are seen, how long a typical first and return visits are (e.g. 10 minute vs. 15 minutes), what interruptions are allowed, such as telephone or patient emergencies, and how and what is charted. It may even be helpful to show the student a typical chart at this point, to illustrate what is important to record. The preceptor and student can come back to this later after they have seen patients together. However, this provides the student with information as to the pace of activity in your office and by implication, how fast he or she may be expected to work. It also helps the student begin to learn how the preceptor sets priorities and manages work flow.^2,3

By now the student has a limited sense of how the office runs, what kind of patients are seen, how they are seen, and how patient information is recorded. It is now helpful for the preceptor to learn more about the student.

The discussion can begin with a review of the interest inventory previously completed by the student.⁴ It may be helpful to start a file on each student starting with this form. The file will provide a place to make notes on interests and clinical performance to use in feedback and evaluation. In many ways the interest inventory is comparable to a typical medical intake form; one format serves the purpose of

Volume 5, Number 2, Fall 2001

allowing the physician to individualize care while the other format allows the preceptor to individualize teaching. The questions provide information about the student from both personal and educational perspectives. The inventory was specifically designed to achieve a greater understanding of the student as a multi-faceted individual, and not just as a student of medicine. If the student has forgotten to do the Inventory or not brought it in, he or she can take a few minutes to fill it out after the introductions.

The interest inventory should lead naturally into a discussion of prior ambulatory experiences. It may also provide some insight into a student's medical interests, so that teaching can be directed towards those interests. For example, a student interested in dermatology may not see the connection to dermatology in a disease such as bacterial endocarditis. Yet, an appropriate discussion of endocarditis with an emphasis on dermatological findings such as splinter hemorrhages and janeway lesions may provoke a greater interest in the original topic, capture the student's attention, and stimulate him or her to read.

It may also be helpful at this point for the preceptor to provide the student with some of his or her background information such as training, interests, and prior teaching experience. Even some personal information about family, outside activities, and hours worked may open up discussions as to how the practice of medicine allows one to maintain a healthy, balanced lifestyle.

Students often know how they best learn and how they are best supervised. Some may not be able to articulate it in great detail unless they have had a prior experience that really worked for them. However, one positive experience will clearly outshine other lesser encounters. As such, learning from the student what has worked for them in prior situations provides the preceptor with the opportunity to use these methods in his or her own teaching encounters. The student should also be specifically queried as to his or her prior clinical experiences and what has made each a positive or negative experience.

The student should also be asked what his or her expectations and objectives are while working in this setting. For example, is the student looking for a general clinical experience, or an emphasis in diagnostic or therapeutic aspects of medicine? Does he or she want the opportunity to talk to patients and learn better history taking or in observing and treating the full gamut of office based medicine? Are there any specific clinical skills that the student feels he or she will need in this setting?⁵

This discussion provides the preceptor with the initial impression of what the student thinks he or she is able to do. Any objectives articulated by the student at the onset of the rotation can easily be modulated as the year wears on, to best fit the preceptor's impression of the student's changing needs. However, at least at the onset there is a clear direction, and the preceptor can direct teaching at the student's presumed level of expertise.

The student should also be urged to provide feedback to the preceptor as the rotation proceeds, especially as to the match between assigned responsibilities and clinical skills. The ultimate goal is to teach to the student's level, encouraging him or her to provide feedback as the year progresses. This will help to shape the course to the student's changing needs and promote dialogue.²

The preceptor should also inquire at this time as to how the student has been introduced in the past to patients, and how he or she would be most comfortable being introduced. This can help to avoid any awkward situations in which the student and possibly the patient would be made to feel uncomfortable. Referring to the student as "Dr. Jones" is inappropriate, but introductions such as "Mr. Jones, a medical student" or "doctor in training" or "student doctor" help to avoid any embarrassing situations.

The physician should also take some time at this point to discuss the educational objectives of the particular rotation. These are available in the course syllabus, but it is helpful for the student to know what the preceptor understands them to be. The physician should also explain how, over the course of the rotation, the student can expect to meet these objec-tives.^2,6 For example, in Doctoring I, where the students have little patient experience and no pathophysiology prior to coming to the office, the objectives of the course are "to learn the gamut of problems that present to the primary care physician, and to practice interview techniques with an emphasis on the comprehensive social history."

As such, a preceptor may explain that the student will be given the opportunity to both observe his or her interactions with patients as well as perform their own interviews with an emphasis on what he or she is learning in concurrent course work. The concept of the social history assessment could be reviewed at this point, with applicability to a practice setting. In thisway, not only expectations but also goals are laid out in a very direct way and the student will understand what will be expected of him or her.

If there is to be homework or reading done between sessions, the preceptor will need to establish a format for following up on these assignments. Not uncommonly, a student will be asked to do readings on a given disease entity or pharmaceutical therapy encountered in one of their patient visits. If the preceptor can find any opportunity to review what the student has read at the following session, he or she can help to reinforce that knowledge and promote its direct application to patient care.² Insofar as remembering a suggested reading assignment from prior sessions is difficult, it is helpful to note the topic in the student's folder.

In discussing mutual responsibilities, the preceptor needs to ask the student to provide a list of the dates scheduled for their meetings. Guidelines for making up absences on the part of either party need to be clear as well as best ways for contacting one another.

And finally, there should be a discussion of how the student will be evaluated. Many courses are pass/fail but the preceptor's ratings of specific aspects of clinical performance by narrative comments are essential in helping the student to learn from this experience as well as to document accomplishments in the student's academic record. At a minimum, the preceptor will need to describe when and how feedback will be provided throughout the course, what type of effort is required for a passing mark; and how lack of effort will result in a failing grade.^2,3,6

Priming

There is one other aspect of orientation that should be addressed prior to the student's seeing patients. That is the concept of "priming", in which the preceptor sets up each individual patient encounter to guide the student's attention the appropriate medical problems, and to forestall any unforeseen difficulties. Prior to sending a student in to see a patient, it is often helpful to give that student some assistance and direction. Priming can include any of the following, and should occur just prior to each patient encounter in which the student is to be involved:

1. A one-minute thumbnail sketch of a returning patient.

2. A listing of the prior problems of a returning patient.

3. Questions that will allow the student to
   demonstrate his or her readiness to address this particular patient's concerns.
4. Guidance on sensitive areas to avoid with this patient.