|The One-Minute Preceptor|
SPECIAL: OFFICE-BASED MEDICAL STUDENT TEACHING
The One-Minute Preceptor
Harvey S. Raskind, M.D.
Many challenges confront the office-based clinician when teaching medical students or residents. None creates more problems than that of the efficient use of time. The clinician must attempt to effectively teach these residents and students while running a busy practice. With this time factor in mind, a number of different teaching models have been established to assist the preceptor in performing their teaching duties.
Many teaching models are available that offer different methods for observing and evaluating the learner. Each model follows a different pathway but the desired end result is the same: the effective teaching of ambulatory care medicine. There is no right or wrong way to observe or evaluate the learner. One must choose the most suitable method. Over years of teaching, many preceptors have combined different models or developed their own model.
We have completed a full circle in community-based teaching from Hippocrates to the present time. Community practice was the forum for medical education until the development of academic centers in the nineteenth century. William Osler recognized that this shift away from experienced practitioners to formal teaching centers was not good for teaching, and he expressed strong reservations about it. Today, medical education is shifting back to the community base. A base that is rewarding for the student, resident, preceptor, and patient. All are benefiting from the careful attention, critical thinking, and high standards of care associated with this re-emergence of commu-nity-based teaching.1
Preceptors may be tempted to give lectures instead of conducting discussions. The teaching process should be dynamic with active participation in the lesson from the learner as much as possible. With bilateral participation, learning occurs for both the preceptor and the student/resident.2
Because medical knowledge is immense and constantly changing, medical students and residents must acquire and remember a tremendous number of details, making memory processes critical. Learning theories indicate that a cognitive approach, through case presentations and real situations, reinforce these memory processes.3 Research in ambulatory care learning has also shown that learners must be given significant roles in patient care with helpful feedback from the preceptors.4
These theories have led to the development of three stages for teaching clinical medicine: planning, teaching, and reflecting. Planning deals with orientation, patient selection, and priming the learner. Teaching is concerned with thinking interactively and diagnosing both the patient and learner. Reflecting involves evaluation of the learner as well as an assessment of the implementation and success of the teaching methods.5
The One-Minute Preceptor emphasizes these learning and teaching concepts.6 The model demonstrates how to teach effectively in short periods of time. By utilizing the One-Minute Preceptor, the preceptor will be able to quickly evaluate the case then take the most appropriate course of action for the patient and learner.7
Albert Schweitzer once said, "Example is not the main thing in influencing others. It is the only thing."8 Learning from experience/example involves a cycle of having a concrete experience (e.g., an encounter with a patient), reflecting on that experience as it unfolds, formulating conceptualizations and generalizations from the experience, and testing them in new situations. That is the basic idea of the One-Minute Preceptor.9 Five microskills form the basis of the One-Minute Preceptor.6 These skills enable the preceptor to analyze the case and the learner then take appropriate action to teach the learner. The microskills are:
Get a commitment: "What do you think is going on?"
When the learner presents the case, he/she may either wait for a response or ask for guidance on how to proceed. At this time, ask the learner to state what he/she thinks about the case. "What do you think is going on with this patient?" "What do you want to do?" Asking the learners how they interpret the data is the first step in diagnosing the learner's needs. Withoutadequate information on the learner's knowledge, teaching might be misdirected and not beneficial.10
Probe for supporting evidence: "What led you to that conclusion?"
Once the learner has committed to a conclusion, he/she may ask for your confirmation or suggestion to an alternative. Before offering your opinion, ask the learner for evidence that supports their conclusion. "What were the major findings that led to your diagnosis?" "What else did you consider?" By asking the learner to reveal their thought processes, both the preceptor and learner can find out what the learner knows then determine the gaps in the learner's knowledge.10 The preceptor should ask basic, obvious questions, and allow the learner to answer, learn to wait. Ask only one question at a time, and ask open ended questions.
Teach general rules: "When this happens, do this."
Provide general rules, concepts or considerations, and target them to the learner's level of understanding. Instruction is both more memorable and transferable if it is offered as a general rule.6 For example, "The key features of this illness are…" "The natural progression of this disease is…" "Patients with cystitis usually experience pain with urination, increased frequency, and urgency. The urinalysis should show bacteria, white cells, and may also have some red cells."
Reinforce what was done: "Specifically, you did an excellent job of…"
Tell them what they did right. Take the first chance to comment on the specific good work and the effect it had.10 Positive feedback helps build the learner's self-confidence. Both praise and criticism need to be as specific as possible.2 With positive feedback, questions arise that allow the student to seek answers. This self-directed learning is the most lasting of all experiences. For example, "Your choice of medication was excellent. That antibiotic covers most of the organisms that we are concerned about."
Correct mistakes: "Next time this happens, try this."
As soon after the mistake as possible, find an appropriate time and place to discuss what was done wrong, and how to avoid or correct the error in the future. Correcting mistakes was placed last because many people put this microskill first. Correcting mistakes is very important, but it is only one part of the teaching encounter, and it requires tact to be effective.6 Unattended mistakes have a good chance of being repeated. We learn best from our mistakes. For example, "You could be right that the patient's symptoms are due to an URI, but without looking at the ears you could easily overlook an otitis media."
Teaching general rules, reinforcing what was done correctly, and correcting mistakes can be done in any order as long as correcting mistakes is done without embarrassing the learner (e.g., in front of the patient). Asking the learner to self-critique may decrease the tension in correcting mistakes.10
In order for the One-Minute Preceptor to work effectively, the preceptor must probe for a commitment and supporting evidence. The preceptor must also reinforce what was done correctly and teach according to the learner's needs following their presentation. The preceptor should try not to lecture. He/she should give adequate feedback and most importantly, ascertain what the learner knows about the case. We cannot do any form of teaching without determining the learner's needs. The first two microskills are the most effective tools in the preceptor's teaching experience. These microskills help determine the learner's deficiencies and offer direction on how teaching should proceed.
As community-based teaching becomes a greater proportion of the undergraduate experience, there has been a need for the development of newer teaching methods. Innovations such as the One-Minute Preceptor model have provided new challenges for both the teacher and the learner in promoting active learning and effective educational experience.11 Employing this model in the ambulatory care setting will allow preceptors to satisfy those objectives. Students that participate in office based experiences value learning the process of patient care as much as, or possibly more than, mastering core content.12 Excellent one-on-one teaching in a clinical setting requires two major items. First, medical educators must understand the special communication skills that create effective teaching. Second, medical administrators must support the faculty development programs needed to foster excellent teaching. Fortunately for the medical faculty here at UCLA, we have had full support of the medical administration. William Osler and Albert Schweitzer would be proud.