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Teaching Strategies Excerpted and adapted below are challenges and strategies identified by our preceptors, with input offered by students, as well. We will update this site with new information on a periodic basis.
Ask the student to provide a C.V. or brief biographical sheet before the first session; provide the student with copy of your own C.V. as well. This is a way to quickly learn a little more about each other. I arrange an initial meeting with the student on the day of the first session (before patients are scheduled) or at a separate time. This allows us to meet, discuss expectations and plans for the preceptorship and have an orientation to the office, staff, charts, managed care and procedures. I introduce the student to key personnel in my office (advice nurse, triage nurse) and arrange for them to interview or work with one of them for part of the session. Introduce the student to a willing patient in the waiting room and have the student accompany the patient through their visit, from check-in to curb-side departure. This provides a view of office functioning from the patient's perspective.
How can I determine what first year students want most from the time they spend with us in our offices? At the beginning of the preceptorship ask the student what their personal goals are. Ask at each session: what is the main thing they would like to address that day? Think of it as taking a brief history from the student: What is their chief concern?
How can I focus my teaching at the appropriate level for the student? I sometimes assume students know more (or less) than they do. I ask the students, acknowledging to them I am unfamiliar with their on-campus course work and their experience level. For example, "Have you taken a focused history before? Do you feel ready to do this today?" "What parts of the exam would you most like help with?" "Are you expected to be learning differential diagnoses at this stage?" I ask students what they see as their strengths and the areas they most need to improve.
What are some ways I can help patients accept the student’s role in my practice? We post a letter in the waiting room in advance of the preceptorship,
announcing the student’s participation and including a photo and
brief biographical description. Patients really like this! They anticipate
the student’s arrival and even request to be included in student
sessions. For preceptors who see children: Always ask both parent and child for permission to include the student. Introduce the student to the child, as well as to the parent. Say, for example, "She's going to school also. She's in medical school studying to be a doctor." Children identify with the student and respond enthusiastically, excited to be helping the student learn. Parents are protective of their children being examined by people they do not know, especially if the child is apprehensive about medical exams. Also, children like to know what to expect during a visit. Some (especially toddlers and early teens) may be upset by sudden change in routine and be wary of a stranger. I use the family's trust in me to help bridge apprehension, sometimes sharing my belief that for medical education, children should not be expected to participate in unwanted experiences from which they derive no direct benefit. Their experiences should be positive. Good teaching will model how to put the child's needs first.
How do I handle the patient who does not want to be seen by a student? My patients are rarely reluctant to be seen by a student, but when that happens I respect their decision and find an alternate activity for the student (such as doing vital signs with the triage nurse, interviewing a waiting patient, observing at the front desk). This is well accepted by staff, students and patients and avoids needless anxiety.
I arrange for the student to experience office activities specific to children, such as accompanying a child through height, weight, vision and hearing screenings or the administration of immunizations. I also suggest they use the time to become familiar with the immunization, safety and other handouts we use.
How do I help students who are reluctant to be alone with a patient or have trouble getting started on their own? Students are usually eager to spend time with patients but can be shy about getting started. A student says: "Students are often nervous! Once they get in front of the patient, family, or preceptor all the history questions and exam ideas quickly leave their brains." I set the student up for success by giving them and the patient a structured task to complete, one that is useful to me and the patient. Example: Taking a focused history in one area (nutrition history, occupational history, medication review). Provide students with wording for questions likely to produce useful information with minimal further direction. Examples: "Tell me about your child. Let's go through a typical 24-hour day." "Dr. X suggested we review all your medications, exactly how you're taking them and how they affect you." Or, "Tell me about your school (or work). What do you like best? Least? How would you change your school (or job) if you could?"
Some students have no experience with children and really don't know how to begin. I select parents and children who I know will be comfortable with the student and who will help things along. When possible, I match the student with a child/family who shares an interest in areas of the student's expertise, such as computers or sports.
Sometimes it is difficult to find a patient appropriate for the educational objectives outlined for a particular week. What can I do? Identify what your practice best exemplifies within the content of the stated objectives; find creative ways to bring this out. Before each session quickly review student’s objectives and priorities and course objectives for that session. Review the appointment schedule and think creatively about how objectives might be addressed with the scheduled patients. Help the student identify related content from other patient visits. For example, if the assignment is to take a history of a sensitive subject (abuse, sexual history, etc.) and this does not work out, identify themes of privacy, confidentiality, discussing difficult subjects, etc.
How can I give the student the expected “hands-on” experience while keeping up with patient care? Initially see patients together; model interviewing for the student. Next sit in and back the student up as he/she interviews patient. Begin with focused histories of presenting concern or specific symptoms. Later have student do independent focused histories with selected patients. Whenever possible select areas for which the student has received training in on-campus sessions. Ask the student about what he/she has learned thus far. Demonstrate a complete physical examination with student. Review exam skills by narrating as you do your examinations. Have student do parts of the PE along with you, focusing on areas in which they have had training. When the student feels ready and you feel they’re ready, have the student do their own examination as far as they are able. Student response: It's great to do physical exam skills with the preceptor at the same time (i.e., "in tandem"). This helps solidify skills while not taking too much time.
Sibling visits are great, especially twins! We do tandem exams on two children side-by-side on the exam table, then switch sides. I show the exam techniques to the children and parents while teaching the student. Everyone has a great time. I enlist the student's assistance when an active sibling is present. Many children enjoy volunteering for "pretend" exams. It's a great experience for the student to interact directly with young children and gives the parent and me time for an uninterrupted discussion.
My first-year students expect to have some time alone with patients. How can I do this when they lack experience, I lack the required additional space and time, and many patients also have time constraints? While patients are waiting to be seen, I introduce the student and
suggest an appropriate activity, such as taking a history in one area
only (example: presenting concern). When I enter the room, I have the
student and patient summarize the information. We, then, complete the
history and physical together, with the student sharing selected parts
of the exam.
Many teens really enjoy talking with medical students. I'll have the student meet with a teenager waiting to be seen by me, suggesting a relevant topic for them to discuss (nutrition, sports, school, etc.). However, I must be prepared to respond to any unexpected information the student elicits--some teens really open up to a medical student. How can I provide feedback to the student? Providing negative feedback is especially difficult for me. If you like the way a student has phrased a question, obtained a medical history or some useful clinical information, tell them. And, tell them in a way that helps them generalize the concept to other interactions. For example: "I like the way you reinforced things for the family by writing them down." Provide feedback in terms of where the student is and where they are going, not in terms of deficiencies. Objectively describe something they have done successfully and what the next step is. Example: "You're holding the otoscope correctly, positioning it well and are finding the tympanic membrane. Next you can begin to identify what you're seeing and practice describing your findings to me."
My first student had never held a baby. Getting the student less anxious around children was my first goal, so I tried to provide positive feedback for anything the student did that was at all successful. One example: "Your making funny faces to entertain the child while I did the ear exam was really helpful. You're discovering how useful distraction can be in calming a young child." Eliciting differential diagnoses and plans from beginning students is difficult. Students seem unsure of the appropriate format for presentations and write-ups. From the Office of Community Based Education (OCBE): The primary learning in these areas occurs in on-campus courses. The preceptorships provide the opportunity to further develop these areas. Begin where your student is, ask to see the format they are using and help them work with this. Complete presentations, differential diagnoses and plans can be overwhelming to the beginning student and unworkable in a busy office setting. Help students practice components of these rather than trying to do it all. Students will integrate the components with time. For example, have a student describe one normal finding, one presenting problem, or name the components of a plan (further evaluation, medications, etc.) while you provide most of the specifics.
How can I find out what my student is learning on-campus teaching sessions? I'd like to be able to provide some interesting clinical correlations in preceptorship. The OCBE website has a link to the medical students' schedules. This link will connect you to the calendar that outlines the material that students are studying at any given time. The link is available on OCBE's home webpage by clicking on "Medical Student Schedule" link available below the LeftHandNavigation toolbar.
Pediatricians ask: The students have so few pediatric sessions and many have little or no experience with children. What can we teach them in this limited time? What can they best learn in our offices? Most students will not become pediatricians but may well have interactions with children as patients regardless of the specialty they enter. Consider what all physicians need to know when they see children. Most important is understanding the fundamental importance of development; it underlies everything we do. To model this approach, teach selected aspects well, rather than trying to cover it all. The student can generalize and will understand that similar content exists for all aspects of pediatric care. Preceptors at workshops have identified the following themes:
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