Dear Faculty Development Colleagues:

The following workshop materials were developed at an invitational conference on ambulatory education sponsored by the national Center for Medical Education Research at the University of Washington and the University of North Carolina under funding from ealth !ervices and Resources "dministration #ureau for ealth $rofessions and $harmacia%Up&ohn' (ur goal was to provide a new tool for training community preceptors to use a variety of strategies in supervising medical students in the ambulatory setting using a learner)centered approach' We have utili*ed a simulation format for the workshop developed by +inda +esky, M'-', and +u"nn Wilkerson, Ed'-', for preceptor development at arvard Medical !chool .Using /standardi*ed students/ to teach a learner)centered approach to ambulatory precepting' Academic Medicine, 69: 011)012, 30045' These materials are available for your use and can be modified to meet the needs of your individual preceptors' 6f you decide to use the materials, we ask only that you collect participant evaluations of the e7perience using the form attached and share the results with us' 6 am currently developing a pre)post test to assess changes in knowledge about precepting as a result of the workshop' This test is available from us on re8uest' $lease mail results to +u"nn Wilkerson' If you wish to discuss the workshop, please contact LuAnn Wilkerson. Above all else, have fun with the materials and the students. They are wonderful faculty developers! LuAnn Wilkerson, Ed.D. Center for Educational -evelopment 9 Research UC+" !chool of Medicine #o7 0132:: +os "ngeles, C" 0;;01)32:: lwilkerson<mednet'ucla'edu phone= >3; 204)2;3? Richard Sarkin, M.D.

Arrows in the Quiver: Models for Teaching in the Ambulatory Setting

Description (ur roles as teachers are often defined by the environment in which we were primarily trained and now teach )) the hospital' !tudent and resident education has occurred mainly on inpatient wards and as teachers, we have developed

habits and skills for teaching during formal rounds, at the bedside, and in conference room settings' The increased use of ambulatory settings in medical education demands new roles and new skills from us as teachers' "lthough the ambulatory patient encounter offers numerous opportunities to teach, these teachable moments may be lost due to a lack of effective strategies for teaching within the constraints of patient care and restrictions of time' -uring this workshop, we will focus on the identification of learner needs in the ambulatory patient encounter and the development of teaching skills for responding to those needs' The workshop will include simulations in which we will e7plore the teaching opportunities present in the typical ambulatory setting in which you teach' b!ectives

To identify the special challenges and opportunities of teaching in the ambulatory setting' To recogni*e and focus the ambulatory teaching encounter around students needs' To develop a variety of approaches to teaching students during patient care'

"ecommended "eadings ewson M' Clinical Teaching in the "mbulatory !etting' Journal of General Internal Medicine, 7= 2@)?:, 300:' +esky +A 9 #orkan !C' !trategies to 6mprove Teaching in the "mbulatory Medicine !etting' Archives of Internal Medicine, 150= :3>>):3>2, 300;'
This workshop was developed by Richard !arkin, M'-', !UNB #uffalo, and +u"nn Wilkerson, Ed'-', UC+", with the assistance of the other members of the Working Aroup for Caculty -evelopment at the 6cicle Creek "mbulatory Care Education Conference, "ugust :3):4, 300@, +eavenworth, Washington, under funding from R!" #ureau of ealth $rofessions and $harmacia%Up&ohn'

# ST T$AC%A&#$ M M$'TS
!TU= Mr' Evans is a 4; year old white male with a 1)year history of TN who comes in today with a complaint of puffy eyelids 7 : weeks and weight gain' e has no history of recent infection, travel, and change in urination, rash or liver disease' is medications include "ldomet, :1; mg%tid and -ya*ide, 3 8%day' This has not been changes in : years and his #$ has been generally well controlled' e admits to drinking a si7)pack a day' The e7am today reveals his #$ to be 34;%?1' There is not much that is remarkable e7cept for periorbital edema and a

few crackles at the base line' 6 think we ought to do a U%" and check his electrolytes' "TT= -id you document his weightD !TU= 3@: lbs, but there was no baseline on the chart' Mr' Evans thinks heEs gained 31 lbs' "TT= -oes he have foamy urineD !TU= 6 donEt think so' e didnEt mention it' "TT= .!ilently pondering the case5= 6nteresting case' +etEs go see him' !TU= Mr' Evans, this is -r'FFFFFFFFFFFF' "TT= ello, Mr' Evans' -r' FFFFF has told me about your situation' 6 would like to ask you a couple of 8uestions' ave you noticed any foamy urineD $"T= Bou know, doc, 6 thought 6 was losing my mind' 6tEs been foaming up like a head of beer' "TT= -o you have any pain in your sidesD $"T= No, 6 havenEt noticed any' "TT= What medications are you takingD $"T= "ldomet and -ya*ide, like 6 told the doc here' "TT= Nothing elseD $"T= Maybe an occasional aspirin, but thatEs all' "TT= .!ilently e7amining the patient )) face, lungs, heart5= .to the !tudent5 -oes he have pedal edemaD !TU= (h, 6 donEt think that 6 checked that' .E7amines the lower leg'5 "TT= .Crustrated glance5= 6tEs been nice meeting you, Mr' Evans' will be back in to talk to you in Gust a moment' .Walking outside of the room5' Hery interesting case' e could indeed have nephrotic syndrome' +etEs add a liver en*yme test and a H-R+ to his bloods' Why donEt you go back in and let him know about the tests that we want to doD

!TU= .hesitantly5 (I' Case by +inda +esky, M'-', University of 6llinois

# ST T$AC%A&#$ M M$'TS
!tu= #illy !mith is a @)year)old boy who comes to the office today with a complaint of a cough for the past three weeks' e has had a runny nose, but has been acting well and has had no fever' is cough seems to be worse at night' "ctually, for the past two nights, he has gotten up several times because of the cough' is appetite has been normal' is mother has given him some cough medicine, but the cough has not gotten better' (n physical e7am, he looks well and is afebrile' e has a slight runny nose, but the rest of his e7am is normal' is lungs are clear' 6 think he probably needs a chest 7)ray' "tt= "re there any smokers at homeD !tu= Uhhh, 6Em not sure' "tt= -oes anyone in the family have asthmaD !tu= 6 donEt know' 6 guess 6 should have asked about that' "tt= .frustrated glance5 Bes, perhaps you should have' Why donEt we go see him .entering e7am room, student stands in the back5 ello, mom, 6Em -r' FFFFFFFFF' ello, #illy' 6 understand #illy has been coughing 8uite a bit' Mom= Bes, last night he seems to have coughed all night long' "tt= #illy, would you take a deep breath and then blow out as hard as you canD #illy= ('I' "tt= .auscultates as #illy takes a deep breath and blows out5 mmmmm' !ounds like #illy might be whee*ing a bit' Mom= (h' "tt= 6Em going to treat #illy as though he might have asthma with some medicine that he will breathe in' 6 will be back in a moment to e7plain what 6 think is going on and how to use the medicine' !ound ('I', #illyD #illy= ('I'

"tt= .walking outside e7am room5 Bour recommendation for a chest 7)rayD 6 donEt think so' +et me write out a prescription and then we can go talk to the mother and e7plain things' !tu= .hesitantly5 Uhhhh' ('I' Adapted !"ichard #ar$in, M%&%, #'() *uffalo, from a teachin+ case developed ! ,inda ,es$!, M%&%, 'niversit! of Illinois, -hica+o%

ACT()AT$D D$M 'ST"AT( '

*"$C$*T " " #$

b!ective: To assist a third)year medical student in the ambulatory setting to learn by observing your interaction with a patient' Tas+: Bou are a busy clinician in a busy ambulatory setting' This is the first week of an ambulatory rotation for a third)year medical student' Bour student has recently completed a two)month inpatient clerkship in 6nternal Medicine, but has had no ambulatory e7perience' "mong your patients today is Cred Thomas, an 32)year) old patient of yours' Bou have seen Cred once in the past for a school checkup and today he presents with a sore throat' Bou decide that since the student is new to your office that he%she would benefit from observing your interaction with this patient' The simulation begins as you tell your student that he%she will be observing this patient visit' " member of the group will play the role of the patient'

ACT()AT$D D$M 'ST"AT( '

ST,D$'T " #$ b!ective:

To learn from observation of your preceptorEs interaction with a patient' Tas+: Bour role is that of a third)year medical student' Bou are a motivated, enthusiastic student who has had very little e7perience in the ambulatory setting' Bou have recently completed a two)month clerkship in 6nternal Medicine which was totally inpatient based' Bour preceptor will ask you to observe a patient interaction' 6f asked, tell your preceptor that you would be very interested in learning how to take a history from an adolescent' -uring the simulation, when you enter the room with the preceptor, hang back until the preceptor indicates where you should sit or stand and what you should be doing'

ACT()AT$D D$M 'ST"AT( '

"s you observe the interaction, please indicate which of the following is accomplished= Not done $artially done 3' !ets up observation' a5 -etermines studentEs relevant knowledge' b5 6dentifies what student should learn from observation' c5 $rovides clear guidelines for what the student should do during the observation Comments= :' 6ntroduces student to the patient' Comments= >' 6ncludes student in discussions with and e7amination of the patient' Comments= 4' $rovides for a brief discussion of learning -one

points after the observation' Comments= 1' !ets an agenda and opportunity for future learning' Comments=

T-

M(',T$

&S$")AT( '

*"$C$*T " " #$ b!ective: To observe a third)year medical student with a patient for two minutes' Tas+: Bou are a busy clinician in a busy ambulatory setting who is also precepting a third)year medical student' Bou are well aware that medical students are rarely, if ever, observed interacting with patients in ambulatory settings' Cor the past week, your student has been independently performing histories and physical e7aminations on your patients and then presenting you each case' Bou have never actually observed your student taking a history or performing a physical e7amination' Bou have decided that you will now observe two minutes of your student s ne7t encounter with a patient' Bour student is about to see one of your patients, Cred Thomas, a 32)year)old with a sore throat for three days'

T-

M(',T$

&S$")AT( '

ST,D$'T " #$ b!ective: To be observed by a preceptor while your are taking a history or performing a physical e7amination' Tas+: Bou are a third)year medical student doing an ambulatory rotation' Bou have been independently taking histories and performing physical e7aminations and

then presenting each case to your preceptor' None of your interactions with patients have ever been observed by your preceptor' Bour ne7t interaction will be observed by your preceptor for two minutes' Bour patient is Cred Thomas, a 32) year)old with a sore throat for three days' Cor this simulation, you are to follow your preceptorEs lead' 6f asked to take a history, take a history' 6f asked to do a physical e7am, do a physical e7am' !imply, follow your preceptorEs lead'

T-

M(',T$

&S$")AT( '

"s you observe the interaction, please indicate which of the following is accomplished= Not done $artially done 3' -iscusses the purpose of the observation with the student' Comments= :' E7plains to the student how the observation will be conducted' Comments= >' (nce in the room, e7plains or has the student e7plain to patient what will take place' Comments= 4' (bserves student)patient encounter without interrupting' Comments= 1' +eaves patient room without disrupting the student%patient e7change' Comments= @' $rovides feedback to the student based on the observation' Comments= 2' !ets an agenda and opportunity for future learning' Comments= -one

CAS$.&AS$D T$AC%('/
*"$C$*T " " #$ b!ective: To interact with a third)year medical student using a case)based model' Tas+: Bou are a busy preceptor in a busy ambulatory setting' Bou are working with a third)year medical student during his%her ambulatory clerkship' Bour student has Gust taken a history and performed a physical e7amination on one of your patients' Bour student is now ready to present you this case' 6nteract with your student in whatever way you think will be most effective to facilitate the student s learning' Bou will have 1 minutes for this simulation'

CAS$.&AS$D T$AC%('/
ST,D$'T " #$ b!ective: To present a case to your preceptor in an ambulatory setting' Tas+: Bou are a third)year medical student working in your preceptorEs busy ambulatory setting' Bou have Gust taken a history and performed a physical e7amination on one of your preceptorEs patients' Bou will read the following case and then follow your preceptorEs cues' $lease take on the role of a third)year medical student who does not know everything there is to know about this particular case' Cred Thomas is a 32)year)old patient who comes to the office today with a complaint of a sore throat for the past three days' is throat has been getting progressively worse' e took some Tylenol last night for a low grade fever and because his throat hurt' e has been able to drink fluids, but could not eat anything this morning because of the pain' e feels tired and sick now and says that his fever is higher than it was last night' e is a senior at the local high school and says that a couple of kids in his class have had sore throats' e has

not been sick very much in the past' medication'

e has no allergies and takes no

(n physical e7amination, he looks a bit ill' is temperature is 3;3':' is throat looks red, but you didnEt see any e7udate' is anterior cervical nodes are tender' The rest of his e7am was unremarkable' Now stop and wait for your preceptorEs lead'

CAS$.&AS$D T$AC%('/
"s you observe the interaction, please indicate which of the following is accomplished= Not done $artially done 3' Uses 8uestions to= a5 establish the studentEs understanding of the patientEs problem' b5 ask for the most likely diagnosis' c5 ask for a management plan' -one

d5 probe for evidence supporting diagnosis or plan' Comments= :' Clarifies the student%preceptor roles before seeing the patient' Comments= >' 6f the patient is seen, the preceptor includes the student in discussions with and e7amination of the patient' Comments= 4' $rovides constructive feedback on student performance' Comments= 1' !ets an agenda and opportunity for future

learning' Comments=

A"" -S (' T%$ Q,()$"

*AT($'T " #$ b!ective: To simulate the role of a patient as part of an interaction between a preceptor and a third)year medical student in an ambulatory setting' Tas+: Bou are Cred Thomas, a 32)year)old patient who has had a sore throat for > days' Bour throat seems to be getting worse each day' Today you feel tired and are having difficulty swallowing' Bou have been able to drink li8uids, but were not able to eat today because of the pain' Bou began to have a low grade fever last night' Bou took some Tylenol for the pain and fever last night, but your throat hurts worse today and your fever feels like it is a bit higher' 6f someone e7amines you, tell them your throat hurts when you open your mouth' "lso, if your neck is e7amined, tell them it hurts on both sides under your Gaw' $lease feel free to fill in any other details during the simulation that you think a 32)year)old patient might say regarding this visit to the doctor'

M D$#S F " CAS$.&AS$D T$AC%('/ (' T%$ AM&,#AT "0 S$TT('/

There are many models for case)based teaching in the ambulatory setting' The classic case)based encounter between a student and a preceptor may be described as follows= the student is asked to independently perform a history and physical e7amination on a patient and then present the case to the preceptor' What happens ne7tD 6' "sk Two Iey Juestions, ThatEs Enough 3' What do you think is going onD :' Why do you think thatD

66' "sk Two Iey Juestions and a Cew More )) ThatEs More Than Enough 666' Use !ocratic Juestioning 6H' Make a Cocused Teaching $oint H' Teach a Aeneral Rule

H6' Aive a Mini)+ecture

H66' $rovide E7pert Consultation H666' Engage in &oint $roblem !olving 6K' #e a (ne)Minute $receptor .Iay Aordon, #arbara Meyer, M'-', and -avid 6rby, $h'-', University of Washington5 3' Aet a commitment' .What do you think is going onD5 :' $robe for supporting evidence' .Why do you think thatD5 >' Teach general rules' 4' Tell them what they did right and the effect it had' 1' Correct mistakes' K' -elay -iscussion )) ThereEs No Time Right Now, +etEs Ao 6n Together K6' Recommend a Time (ut )) Bou Need to -o !ome Reading K66' Bell When BouEre Ready )) WeEll -iscuss the Case in Cront of the $atient

A"" -S (' T%$ Q,()$": M D$#S F " T$AC%('/ (' T%$ AM&,#AT "0 S$TT('/ T$AC%('/ ' T$S

%andouts for the *articipants: (verview with obGectives' +ost Teachable Moments .choose adult or pediatric version5 "ctivated -emonstration ) $receptor Role Two Minute (bservation ) $receptor Role Case)#ased Teaching ) $receptor Role Models for Case)#ased Teaching in the "mbulatory !etting %andouts to be distributed during the wor+shop by the leader or small group facilitators: Cacilitator Auide .if a small group facilitator model is used, facilitators should have copies of all of the following5 "ctivated -emonstration ) !tudent Role .to student5 "ctivated -emonstration Checklist .3 copy for every participant5 Two Minute (bservation ) !tudent Role .to student5 Two)Minute (bservation Checklist .3 copy for every participant5 Case)#ased Teaching ) !tudent Role .to student5 Case)#ased Teaching Checklist .3 copy for every participant5 $atient Role .same for each simulation5 -or+shop

b!ectives:

To identify the special challenges and opportunities of teaching in the ambulatory setting' To recogni*e and focus the ambulatory teaching encounter around student needs' To develop a variety of approaches to teaching students during the process of patient care'

-or+shop Format:

The workshop begins with the discussion of the case +ost Teachable Moments in either the adult or pediatric version which is intended to loosen up the group and point out the difficulties as well as the opportunities of teaching during patient care' We recommend that you ask for > .adult5 or 4 .pediatric5 volunteers to actually read the parts in the case' This workshop on precepting has as its central component three simulations using the same case to teach in three different ways' There are several formats that can be used for the simulations' Whatever format is used, we recommend doing the simulations in small groups' Each simulation takes appro7imately >; minutes, including the debriefing' The focus is on matching teaching strategies to individual student needs' (ne format for the workshop is to have one workshop leader who divides the large group into small groups of three participants per group' $articipants would then take turns playing the roles of the preceptor, student, and patient' (nce the small groups have completed the first simulation and discussed what happened in their group, the workshop leader would lead a debriefing with the entire group and distribute the checklist before moving back to the small groups and the ne7t simulation' "nother format is to use actual medical students as /standardi*ed students'/ The students are not playing themselves although we think that the scenarios will be ones that will be familiar to them' $articipants can work in groups of >)? with each group having one student who will do all three roles' 6t is preferable if each group has a facilitator but one facilitator can shepherd several groups working in the same room' The facilitator role is described in the accompanying Cacilitator Auide' .The use of students in standardi*ed roles is described in +esky +A and Wilkerson +' Using !tandardi*ed !tudents to Teach a +earner)Centered "pproach to "mbulatory $recepting' Academic Medicine, 69= 011)012, 3004'5 "fter the three simulations have been completed, the workshop can conclude with a summary of the essential precepting skills for teaching around patient cases that have been e7plored in the simulations' The handout, Models for Case) #ased Teaching in the "mbulatory !etting, may be used to suggest additional /arrows in the 8uiver'/

FAC(#(TAT " /,(D$ F " ,S$ -(T% 1STA'DA"D(2$D ST,D$'T1 )$"S( '

A"" -S (' T%$ Q,()$":

M D$#S F " T$AC%('/ (' T%$ AM&,#AT "0 S$TT('/

Bou will be responsible for organi*ing the workshop simulations and facilitating their discussion' The workshop leader should already have reviewed the obGectives of the workshop and done the +ost Teachable Moments case' "s a small group facilitator, you will have several tasks= 3' ave participants introduce themselves :' E7plain the simulation e7ercise and tell them that you will need a volunteer each time to serve as the preceptor' The first simulation, "ctivated -emonstration, is the easiest so it does not pay to delay' Consider this a learning opportunity' The preceptor role for "ctivated -emonstration is in the workshop handout and you should review it before the start of the workshop' >' !et up : chairs away from the small group for the student and the preceptor' "sk the student to take one of the chairs' The student has already seen his%her role but a copy is enclosed in the packet for you' 4' "sk the group to read the preceptor sheet for "ctivated -emonstration' Recruit a volunteer for the role of the preceptor' Bou may need to discuss the precepting assignment if there are 8uestions' 1' Remind the preceptor that he or she has only 3; minutes for this task given the busy nature of the practice .more time is always desirableL this is a minimum5' Watch the time and call stop at minutes even if the simulation is not finished' Bou will have plenty to discuss' @' "sk the preceptor how it went' The person in the hot seat gets to respond firstM 2' (pen up the discussion to the entire group' What else might they have included and whyD What should be a priority if time is limitedD ?' "sk the student for any suggestions' 0' $ass out the "ctivated -emonstration checklist with the comment, /This is a summary of the strategies that we have been discussing' What did we coverD/ Read 8uickly down the sheet and make a few comments on any ideas that were not raised in the simulation and its discussion' 6t has been my e7perience that everything gets raised' Bou might ask that participants individually assess their own use of this teaching format using the form as a summary for this simulation' 3;' Repeat the same process with the other two simulations, Two)Minute (bservation and Case)#ased Teaching' The $receptor Roles are in the participantsE handouts and the Checklists should be handed out as needed'

33' " $atient Role has been included and may be used for any or all of the simulations' Bou will need to recruit a volunteer to play the patient' Bou probably wonEt have time for the preceptor and the student to /see the patient together/ in the Case)#ased Teaching simulation but some preceptors prefer to hear the case with the patient present rather than in the hallway' 6t is usually helpful to talk about recruiting patients to see students during the debriefing on this simulation'

- "3S% * $)A#,AT( ' S%$$T A"" -S (' T%$ Q,()$": M D$#S F " T$AC%('/ (' T%$ AM&,#AT "0 S$TT('/
$lease use the following scale to rate aspects of the workshop= 1 N E7cellent 4 N Hery Aood > N Aood : N Cair 3 N $oor Workshop leaderEs facilitation skills !mall group facilitatorEs skills Juality of the workshop materials WorkshopEs relevant to your needs (verall

>

>

>

1 1

4 4

> >

: :

3 3

workshop effectiveness

What did you find most useful about this workshopD

6dentify one teaching behavior that was discussed in this workshop that you would be willing to try in your own teaching setting'

Comments' -eveloped by Richard !arkin, M'-', !UNB, #uffalo , and +u"nn Wilkerson, Ed'-', UC+" '