A preceptor’s thorough knowledge of a patient’s case before the encounter can pay dividends in terms of control and efficiency during the encounter. This allows the preceptor to guide the learner as needed during the encounter and can inform brief, pre-encounter teaching points (e.g., anatomy review, approach to joint pain).
Asking the learner to review a topic before the start of a clinic session can help shift teaching time outside the clinical encounter. This provides the preceptor with valuable insight into a learner’s zone of proximal development (the conceptual space between what a learner can do independently and what they can do with assistance), which can then guide the preceptor’s educational efforts during the encounter. Pre-teaching also encourages immediate practical application of theoretical knowledge and sets learners up for success, which naturally builds enthusiasm for the subject.
During the Encounter
Perhaps the most important aspect of teaching during a patient encounter is the maintenance of learner engagement and active learning. In the traditional setup in which a learner evaluates the patient independently and then presents to the preceptor, we often use the One-Minute Preceptor (OMP) model to guide the teaching encounter (see Table 2), although a number of other frameworks have been proposed.6
Although it is tempting to evaluate the learner’s knowledge based on their presentation alone, getting a commitment and probing for supportive evidence can help more precisely identify knowledge gaps and direct time-efficient teaching. Identifying the knowledge gap or zone of proximal development through clarifying questions is critical to making teaching effective and time efficient. After all, the goal is not for preceptors to teach but for learners to learn.
Table 2: One-Minute Preceptor Model
| Steps | Description | Examples |
|---|---|---|
| Get a commitment to a diagnosis or differential diagnosis | Getting a commitment makes the teaching more engaging and personal. It draws on the ALT tenet of optimized learning in situations that are problem-based. | “You’ve nicely summarized the case of an 81-year-old woman with a history of rheumatoid arthritis presenting with acute monoarthritis. What are your leading considerations in this case?” |
| Probe for supporting evidence | This step helps the preceptor understand the thought process behind the answer in the first step and gives insight into their knowledge and clinical reasoning. | “What elements make you think gout is most likely?” “What do you think about the possibility of septic arthritis?” |
| Reinforce what was done well | Positive reinforcement increases the likelihood that the learner will repeat positive skills/behaviors (which they may not have recognized themselves) in future encounters. It also helps create a positive learning environment. | “Your hypothesis-driven physical exam was excellent and helped prioritize the differential diagnosis.” |
| Give guidance on errors and omissions | Identification of errors and omissions provides important opportunities for targeted education. | “Her lack of fever does not have a high negative predictive value for septic arthritis, which is an important consideration because of its associated morbidity/mortality—your plan for an arthrocentesis will help us further evaluate for this possibility.” |
| Teach a general principle | Junior learners are not rheumatologists, so it is especially important to connect clinical encounters to more broadly applicable principles. | “It is common in rheumatology and other specialties that work with immunosuppressed patients to encounter a patient whose use of immunosuppressive medications both predisposes them to infection and makes their presentation with infection more subtle.” |
When time is particularly short, preceptors can teach effectively simply by thinking out loud about the case. Further, some teaching can be aimed at both the patient and the learner at the same time to increase efficiency. As discussed earlier, we try to increase relevance of the teaching by linking it to the learner’s anticipated specialty, aspects that are applicable to all specialties (e.g., clinical reasoning) or other, broader learning objectives (e.g., knowledge important for the shelf exam).
Junior learners in subspecialty settings often shadow their preceptors. The main limitation of shadowing is the passive role the learner often assumes, which does not take advantage of ALT principles. However, shadowing can be an effective learning modality when the trainee assumes the role of an active learner. We use the term active apprenticeship when describing this model.
We try to achieve learner engagement in the active apprenticeship model through three steps.7 First, we engage the learner by familiarizing them with the patient and making learning relevant. This can be done by asking the learner to read about the patient before the encounter or giving them a brief patient history, often accompanied by a question to further enhance engagement and promote critical thinking (e.g., “This 36-year-old woman presented with eight weeks of pain, swelling and morning stiffness in the wrists, metacarpophalangeal joints, proximal interphalangeal joints and knees without other symptoms. What laboratory tests would you order?”). We often simplify the case description depending on the learner level and our teaching objectives.
Second, when time allows, we ask the learner to perform a part of the history or physical exam. This presents an important opportunity to observe the learner in a time-efficient manner, which subsequently enables the preceptor to provide specific feedback. While observing, the preceptor can write the visit note. Alternatively, asking the learner several questions that pertain to the patient history or exam, or teaching briefly during the visit, can also be considered.
Third, and most important, we set the expectation that at the end of the encounter we will discuss the learner’s opinion about the diagnosis or management decisions encountered in the visit. In our experience, this expectation is crucial to maintaining learner engagement even if the learner does not take an active role in the visit itself. We typically step out of the exam room to discuss the learner’s thoughts to limit the hesitation they may have in sharing their thoughts in front of the patient. We then use elements of the OMP model to structure the discussion. We have found that although these discussions take only a few minutes, they have a significant positive impact on learning and engagement.
It should be noted that the type of questions used in teaching affects their impact. Using higher order questions according to Bloom’s Taxonomy framework (see Table 3) is most effective at identifying knowledge and reasoning gaps and fostering student engagement.8,9 Finally, junior learners have much to learn and it can be tempting to teach many concepts in an encounter. Our general goal is to teach fewer concepts but to do so in an active manner while staying on time and moving additional teaching to the pre- or post-encounter periods.
