Practice Teaching Rounds

Teaching when time is limited

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39456.727199.AD (Published 14 February 2008) Cite this as: BMJ 2008;336:384
  1. David M Irby, vice dean for education and professor of medicine, and senior scholar 12,
  2. LuAnn Wilkerson, senior associate dean for medical education, and professor of medicine3
  1. 1University of California, San Francisco, CA 94143-0410, USA
  2. 2Carnegie Foundation for the Advancement of Teaching, Stanford, CA 94305, USA
  3. 3David Geffen School of Medicine at the University of California, Los Angeles
  1. Correspondence to: D M Irby irbyd{at}ucsf.edu

    Teaching in small increments of time during patient care can provide powerful learning experiences for trainees. This article explores the ways that clinical teachers might do this in a time efficient way

    Clinical teachers face a daunting challenge of simultaneously caring for patients and teaching learners in a time constrained environment. A cohort study of 179 Dutch medical students (79% of the cohort) during an internal medicine clerkship located at 14 different clinical sites found that the quality of supervision has a greater impact on clinical competence and knowledge than does the number of patients seen.1 Even small moments of teaching time can offer important learning opportunities to trainees by providing them with new insights and skills that they would not acquire from simply seeing patients on their own.1

    To achieve this combined caring and teaching goal in a time efficient manner, clinical teachers use various strategies to (a) identify the needs of each individual learner, (b) teach according to these specific needs, and (c) provide feedback on performance.2 This three step teaching process can be adapted to the environment in which the teaching is taking place. Here we describe several time efficient strategies in relation to each step in this process.

    Step 1: Identify the learner’s needs

    The time saving rule of thumb is: target, then teach. If the teacher can quickly determine what an individual learner needs to know, then he or she can focus any teaching on those needs, thus saving time by not teaching what the learner already knows or is not ready for.2 To assess the learner’s level of knowledge quickly, the teacher needs only two tools: good questions and the ability to listen and observe.

    Ask questions

    Questions are the teacher’s primary diagnostic tool, can precede or follow the learner’s encounter with the patient, and can guide the choice of teaching methods. Questions asked before a patient encounter can help the teacher to ascertain the learner’s experience with the problem at hand—for example, “have you had a chance before to do investigations in an elderly patient with sudden onset of mental status changes?” or “do you already have a differential diagnosis in mind?” Questions that follow the learner’s presentation of patient findings can guide the teacher’s decisions about what and how to teach—for example, “what do you think we should do next?”

    Conduct a two-minute observation

    This time efficient strategy allows the teacher to observe the learner’s performance instead of making inferences about the ability of the learner from the case presentation alone. The two-minute observation model, which is like an epidemiologist’s sampling technique, involves the teacher slipping in and out of the patient encounter without intervening, in order to gather more direct information about the learner’s needs for guidance, direction, feedback, or enrichment.3 Both teacher and learner should agree on the patient encounter that will be used and the aspect of the interaction that will be targeted for the quick observation—such as establishing patient rapport, history taking, physical examination, or patient education. Four elements are needed for this to work effectively:

    • The teacher must be sure that the learner knows that the observation is for teaching purposes and understands how the observation will work;

    • The learner will need to explain the process to the patient so that the teacher can enter and leave the room without disrupting the encounter;

    • Whenever in the room, the teacher needs to be outside the patient’s visual field and refrain from participating in any manner;

    • Time will be needed for discussion afterwards, to focus on what was done well, what can be improved, and what type of independent study might be useful.4

    Step 2: Teach rapidly

    With the diagnostic tools described above and those embedded in several of the following teaching models, the teacher can teach rapidly during patient care. We have selected several teaching models that are described in the literature and are advocated by leading medical educators and which can be used separately.5 Having several models provides flexibility for adapting instruction to the needs of each learner and the constraints of the environment. However, if a clinical teacher decides to adopt any of these models, he or she needs to communicate expectations about what will happen and why.

    The “one-minute preceptor” model

    The most widely known and researched teaching method is the “one-minute preceptor model,” (the one-minute teaching model).6 7 8 9 10 11 12 13 This method involves identifying the needs of each individual learner, teaching, and providing feedback by using a five step approach:

    • Get a commitment about what the learner thinks is going on with the patient;

    • Probe for underlying reasoning or alternative explanations;

    • Teach a general principle;

    • Provide positive feedback about what the learner did right;

    • Correct any errors by making suggestions for improvement.

    Box 1 gives an example of the model in use.

    Research on the one-minute preceptor model has found strong satisfaction with the model by learners and teachers and generally improved learners’ ratings of their faculty and resident teaching after they were observed and given feedback on the basis of the model.6 7 8 12 13 14

    Box 1 Example of the one-minute preceptor model

    The following dialogue took place after a learner’s case presentation of a 3 year old boy who complained of earache.

    Get a commitment
    • Teacher: “What do you think is going on?”

    • Learner: “I think he has an upper respiratory tract infection, probably an acute bacterial otitis media.”

    Probe for supporting evidence
    • Teacher: “What led you to that conclusion?”

    • Learner: “He has a history of repeated acute otitis media and currently has a fever and a painful right ear. In addition, I believe his right ear is red and less mobile.”

    • Teacher: “What would you like to do for him?”

    • Learner: “First, I would like you to confirm my findings. If you agree, then we should give him some antibiotics. As he doesn’t have any allergies to medications and was successfully treated with amoxicillin in the past, I think amoxicillin is a reasonable choice.”

    Teach a general principle
    • Teacher: “It does sound like otitis media. The key features of otitis media in the history are upper respiratory tract symptoms followed by ear pain and increasing fever and irritability. He is also at risk as he has had prior episodes of acute otitis media. In the physical examination, I look for the appearance of the ear drum—including any erythema, opacification, and distortion of landmarks with bulging or retraction. Sometimes there will be purulent discharge in the external canal if the tympanic membrane has perforated. This child would seem to fit these criteria.” The teacher concludes: “With the lack of allergies, amoxicillin is a logical choice for an antibiotic. I’ll be glad to confirm your ear examination findings. Let’s go and see the patient.”

    Reinforce what was done well
    • Teacher: “You did a good job of putting the history and physical examination findings together into a coherent whole.

    Correct errors and/or make recommendations for improvement
    • Teacher: “You might check the Cochrane Collaboration for an evidence based review on otitis media.”

    The Aunt Minnie model

    The Aunt Minnie model is designed to promote rapid pattern recognition among learners in ambulatory settings.15 The name of the model comes from the adage that if the woman across the street walks and dresses like your Aunt Minnie then she probably is your Aunt Minnie, even if you can’t see her face. Thus, after seeing the patient, the learner presents only the main complaint and the presumptive diagnosis to the teacher; discussion of the case occurs only after the clinical teacher has independently seen the patient. Box 2 gives an example of this model in use.

    Box 2 Example of the Aunt Minnie model of ambulatory teaching

    This approach focuses on developing rapid pattern recognition16:

    • The learner sees the patient, takes the history, and does the physical examination on the basis of the main complaint;

    • The learner presents the case to the clinical teacher but only the main complaint (such as “Johnny is 2 months old with a temperature of 40°C and is lying listlessly in his mother’s arms”) and his or her presumptive diagnosis (“this may be a virus, but we should rule out bacteraemia and meningitis”) (30 seconds);

    • While the learner begins to write up the notes, the clinical teacher sees the patient, diagnoses the problem, and creates a management plan (5 minutes);

    • The teacher then discusses the case with the learner (1-5 minutes) and reviews and signs the medical record (1-2 minutes).

    For this model to work effectively, the learner and the patient need to understand the process, and the teacher must see the patient, know the correct diagnosis, and if uncertain be willing to admit it.15

    The SNAPPS model

    The SNAPPS (Summarise, Narrow down, Analyse, Probe, Plan) model is a learner centred, outpatient model that includes six steps that the learner controls.17 These steps take place after the learner has seen the patient.10 17 18 19 The learner has to:

    • Summarise briefly the history and findings;

    • Narrow down the differential to two or three relevant possibilities;

    • Analyse the differential by comparing and contrasting the possibilities;

    • Probe the clinical teacher by asking questions about uncertainties, difficulties, or alternative approaches;

    • Plan management for the patient’s medical problems;

    • Select a case related problem for self directed learning;

    This model is appropriate for experienced learners, and encourages them to do most of the work in justifying their thinking and exploring what they don’t understand.

    “Activated” demonstrations

    When a patient’s problem is unfamiliar to the learner, this is the time for the learner to observe the clinical teacher at work. However, the learner needs a specific assignment to complete while observing (such as “watch how I ask critical questions about alcoholism or abuse”) and an understanding of what is expected in terms of participation.3 After the demonstration, the teacher needs to “activate” the learner by asking him or her to describe what was observed. A brief discussion typically ensues in which the rationale for the actions is examined and independent study is assigned.

    Case presentations at the bedside

    The hospital bedside or clinic examination room is a good location for teaching when the learner is well prepared to deal with the patient and the discussion is unlikely to frighten or alarm the patient. The learner is directed to finish investigating the patient before presenting the case to the teacher in front of the patient. The bedside presentation allows the teacher to engage the learner and the patient in a discussion about any missing information or decisions that need to be made; encourage the patient to act as a teacher; and use the opportunity to concurrently teach the learner and inform the patient, thus saving time.20 21

    Step 3: Provide feedback

    Feedback is one of the most underused yet powerful instructional strategies available and can take less than a minute, and several of the above models build feedback into the sequence. Feedback provides the learner with a description of their strengths and recommendations for improvement. The key to feedback is going beyond praise to specific descriptive comments about a learner’s performance. It can also serve as an opportunity to promote self reflection and independent study.22

    Challenges

    A heavy clinical load can overwhelm any attempt to use one or more of these teaching methods and can rule out teaching in the middle of patient care. Another challenge is knowing how much to rely on the learner’s ability to assess their own performance, which is notoriously inaccurate.23 However, the greatest barrier is an attitude on the part of the teacher that “real teaching” requires a formal presentation of knowledge in a conference room, using a whiteboard, and taking lots of time. With this mental model in mind, teachers are understandably reluctant to teach because it slows them down. Yet, the models described here are time efficient and powerful—thus allowing instruction to occur even when only seconds or minutes exist.

    What’s next?

    Each of these teaching methods helps to diagnose learning needs and provide targeted instruction and feedback. However, they still take time. Although we don’t know exactly how much time is required to create a powerful learning environment, teaching is clearly being increasingly squeezed out of most patient care settings. Creating a structure to build in and pay for teaching time will become increasingly important. Initial work in this area has centred on documenting and rewarding faculty teaching efforts24 25 26 and creating academies of medical educators to reward and support distinguished teachers.27 28

    Key points

    In clinical settings, teachers need time efficient methods to help them to assess the learner’s level of knowledge and skill, teach quickly, and provide feedback on performance.

    • Step 1: Identify the needs of each individual learner by asking questions or by doing a two-minute observation.

    • Step 2: Select a model for rapid teaching such as:

      • “One-minute preceptor” model (for targeting instruction);

      • Aunt Minnie model (for teaching pattern recognition);

      • SNAPPS model (for encouraging learner self direction);

      • “Activated demonstration” (for making visible the teacher’s clinical expertise);

      • Case presentations at the bedside (for efficiently engaging the learner and the patient.

    • Step 3: Provide feedback on performance by quickly commenting on strengths and making recommendations for improvement

    Footnotes

    • This series provides an update on practical teaching methods for busy clinicians who teach. The series advisers are Peter Cantillon, senior lecturer in the department of general practice at the National University of Ireland, Galway, Ireland; and Yvonne Steinert, professor of family medicine, associate dean for faculty development, and director of the Centre for Medical Education at McGill University, Montreal.

    • Contributors:Both authors shared in the conceptualisation of the article, did the literature search, and drafted the article. DMI revised the article after peer review and provided the final version, which had been approved by LW.

    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; externally peer reviewed.

    References