Working with the Difficult Clinical Learner

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Working with the Difficult Clinical Learner

• Luke H. Mortensen, PhD, FAHA
• Des Moines University

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Why Do You Teach ?

• It is possible to store the mind with a million
  facts and still be entirely uneducated.
• -Alec Bourne
• Education is the ability to listen to almost
  anything without losing your temper.
• -Robert Frost
• The whole art of teaching is in awakening the
  natural curiosity of a young mind.
• -Anatole France

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Whats Available at DMU?

• Cutting-edge technology
• METI and Laerdal Human Patient Simulators
• Reevaluation of students and clerkship clinical
  faculty
• Computer-savvy students and faculty
• Integration of technology into all courses
• Medical Informatics Infrastructure
• Useful, appropriate and effective communication
  (electronic and direct) between central campus
  and all rotation sites

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Medical Informatics

• Introduction to the DMU Portal, e-Library and PDA
  Resources
• Access to the DMU Faculty Development Web-site
• Locating and Accessing Full Journal Articles at
  the DMU e-Library
• Evidence-Based Practice Resources
• Pub-Med Searching
• Drug Resources
• Disease Resources/References and Full Texts
• PDA Texts, References (ePocrates, etc.),
  Calculators and Quick Decision e-Books
• Differential Diagnosis Tools
• Patient Education Resources

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DMU Faculty Development Website
www.dmu.edu
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Faculty Development at DMU

• What is Available (publicly available, structured
  modules, podcasts, RSS feeds, videos, etc.)
• Evaluation of Learners
• The Art of Conversation and Conflict Management
• Leadership and Negotiation Skills in the Clinical
  Setting
• Career Goals/Management for Medical School
  Faculty
• Understanding a Competency-Based Curriculum
• Assessing and Evaluating Competency
• Academic Medicine and Medical Education Research
• Technology and Teaching Effectiveness
• Cultural Competency in the Clinical Setting
• Teaching Medical Students Effectively/Providing
  Feedback
• Working with the Difficult Medical Student

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The One Minute PreceptorTime-Efficient
Teaching in a Busy Clinical Practice

• Teaching the 5-Microskills

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The One Minute Preceptor
10 Minutes of Teaching Time

• The average teaching encounter takes 10 min
• 6 min for the learner to present the case
• 3 min for the preceptor to ask questions and
  clarify information
• 1 min of discussion and teaching time
• One Minute Preceptor model may take more than a
  minute but provides a structure to help maximize
  the teaching time of the encounter

3 Minutes
Questioning
1 Minute
Discussion
Presentation
6 Minutes
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The 5-Step Microskills Method

• The One Minute Preceptor strategy is based on
  five steps that build upon each other
• Get a Commitment
• Probe for Supporting Evidence
• Reinforce What Was Done Well
• Give Guidance About Errors or Omissions
• Teach a General Principle

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Step 1 Get a Commitment

• What do you think is going on?
• What do think the plan should be?
• How should this case be followed up?
• Why?
• It invests the learner further into the case
• Encourages learner to process beyond their
  current comfort level and problem solve
• Allows you to assess their problem-solving skills

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Step 2 Probe for Supporting Evidence

• Explore the basis of the learners opinion and
  what they have committed to in Step 1
• What factors support your diagnosis?
• Why did you choose that treatment?
• Why?
• Was it a lucky guess or was it a well-reasoned
  and logical answer?
• Helps you to assess the learners
• knowledge base
• thinking process
• clinical reasoning skills

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Step 3 Reinforce What Was Done Well

• Skills and positive behaviors need repeated
  reinforcement to become firmly established
• Provide the learner some positive feedback
• Increase the likelihood that these behaviors will
  be incorporated into future clinical encounters
• Describe specific behaviors and likely outcomes
• Good job! is too vague
• Example I liked that your differential took
  into account the patients age, recent exposures
  and symptoms is reinforcing positive feedback

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Step 4 Guide Errors and Omissions

• Correct the learners mistakes avoiding negative
  labels such as bad or poor
• Learner less likely to feel judged
• Learner more likely to see criticism as
  constructive
• Describe specifically what was wrong, what the
  consequence might be, and how to correct it for
  the future
• Example During the ear exam the patient seemed
  uncomfortable. Lets go over holding the
  otoscope.

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Step 5 Teach a General Principle

• An important and challenging task for any learner
  is to take new information from one encounter and
  generalize it to others
• Manifestation of symptoms
• Treatment options
• Available resources and references
• Why? Allows learning to be more easily
  transferred to other situations
• Example Remember 10-15 people are carriers of
  strep, which can lead to false positive strep
  tests.

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Conclusion Step

• Wrap up the teaching session with directions to
  the learner about what may be necessary to
  resolve the case
• Why?...
• Time management is critical
• Signals the end of the interaction so that the
  learner may move on to the next encounter
• Directs remainder of the encounter
• ExampleLets go back in the room and Ill show
  you how to get a good throat swab. Tell me when
  we have the results, and Ill watch you go over
  the treatment plan.

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Example Teacher-Learner Encounter

• The One Minute Preceptor strategy is based on
  five steps that build upon each other
• Get a Commitment
• Probe for Supporting Evidence
• Reinforce What Was Done Well
• Give Guidance About Errors or Omissions
• Teach a General Principle

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Difficult Learner

• Hard to define
• but you know one when you see one!
• a continuum of struggling ? failing
• deficiencies in one or more areas
• insufficient knowledge
• poor clinical judgment/reasoning skills
• poor communication/interpersonal skills
• professionalism
• inefficient use of time

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Objective Structured Educational Experience

• The OSEE is a simulation of the difficult
  learner as a formative experience for clinical
  teaching
• There exist many useful taxonomies for both the
  difficult learner and teaching approaches in
  this exercise, we will focus on the interactive
  features of the student-preceptor encounter
• As such, this isnt about doing teaching wrongly
  or rightly, but to help us reflect on what we are
  doing as educator-clinicians and teaching efficacy

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The Scenario

• The agenda for today is to start with a volunteer
  from the audience who will precept our
  difficult learner.
• The student
• A fourth-year undergraduate medical student
• Has just had a 15-minute patient encounter
• The volunteer
• Will act as the attending in a clinical
  environment in which students or residents are
  seeing patients
• Will debrief the student-patient encounter

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Observation

• Following the encounter, we will open the
  discussion to these areas
• The Encounter
• The teaching-learning interaction
• Formative Assessment
• Feedback for the preceptor
• Appreciative Inquiry
• Objective is NOT to correct but to explore
  reasons for choices made

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The Teacher-Learner Encounter

• Observation of

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Debriefing the Encounter

• What did we just see?
• Discuss a key point in the interaction that you
  felt was remarkable.
• How would you characterize the learner?
• How would you describe the teacher?
• How did the preceptor teach this learner?

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Debriefing the Encounter

• Did the preceptor fall into the learners trap by
  providing answers to all questions asked?
• Did the preceptor placate the learner?
• What kind of teacher does this learner need?
• What do you think the student learned?
• What does this learner need from this teacher?
• How much time did they take?
• How much time do they need?

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Formative Assessment

• Debriefing the faculty member
• Feedback for the teacher
• DMU resources available for clinical educators
• Appreciative Inquiry
• What was this encounter like for the preceptor?
• Why did they make the choices they made?
• Would they change anything?
• What would follow-up with this learner include?
• What were your expectations?
• How do you formally evaluate this learner?
• How is the learner remediated?

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Bibliography

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Remediation References

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Remediation References (cont.)

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  or unacceptable mark in any category. Students
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