“Students slow me down” and “Students take too much time” are common complaints of precepting physicians, and yet some physicians have endless energy for teaching and are able to maintain their clinical productivity. What do these doctors do differently?
We held five professional seminars in 2007 and 2008 to talk with experienced physicians from health education programs across the United States about their precepting experiences. We collected and analyzed the suggestions that emerged in search of common themes. Doing so made it clear that physicians should focus on six areas to be efficient and effective preceptors:
1. Establish a teaching environment
A positive teaching experience begins with an appropriate match between student and preceptor. Make sure the educational programs you work with know your personality and work-style preferences. The programs should also know the makeup of your practice, such as patient population, and the learning experiences you can offer students, such as different types of procedures.
Once the program has matched you with a student, you and your staff will need to address a number of logistical issues.
First, your scheduling template may need to be revised to maximize clinical efficiency and quality teaching. There are several ways you can do this:
Book urgent care visits and complex visits simultaneously. You can conduct one or more brief visits while the student sees a patient with more complex problems.
Block 15 minutes of your schedule in the morning and afternoon to allow time for student review and teaching.
Double-book your first appointment and block your last appointment. This allows you and your student to start seeing patients at the same time, and it provides catch-up time at the end of the day.
At the beginning of each day the student is in the office, review the schedule and consider which patients you would like to include in the student's schedule. Have the staff member rooming the patient ask whether it is OK if a student conducts the visit. Use positive phrasing like, “Your physician is teaching a student. Is it OK if the student sees you first?”
These selections should be based on patient and visit type and the student's educational needs. Some patients take forever even for experienced physicians, so they may not be appropriate for beginning students, but patients who need or desire more in-depth interactions may be ideal for students. Students can help set up appointments for these patients, arrange needed ancillary services and explain their test results.
When possible, plan any follow-up appointments with these patients for a day when the student is in the office. This continuity gives students the opportunity to discover whether treatment plans they helped develop are working. In addition, some patients may appreciate the extra attention and enjoy seeing the student's educational growth.
When selecting patients, also consider what the student is currently learning. Ask, “What are you studying now? We'll try to find a patient with that system issue.”
Ultimately it is important for both preceptor and student to be flexible. Occasionally you may need to ask the student to do other work while you see several patients in a row, because of the nature of the visits or because you need to catch up.
It is also important to provide students with a work-space that includes a desk and a place for personal items. Prior to the student's arrival, arrange for the student to have a computer workstation and access to patient records, including log-in information for electronic health records as needed.
Ask a staff member to orient the student on his or her first day. The student will need to know where to park and be introduced to the staff and the office space. Orientation should include time to attend to administrative details, such as computer training and obtaining a security badge.
2. Communicate with everyone involved
Communication is key to ensuring a successful teaching arrangement. It is essential that you express your expectations and goals to students, their educational program and your fellow clinicians and staff members. Prior to the student's arrival at your practice, the program should describe the student's skill level and explain what it expects the student to learn from the experience in your office.
Students and preceptors should communicate early and frequently regarding expectations, goals, and learning and teaching styles. This saves time and prevents frustration. Soon after the beginning of their rotations, start talking with students about their progress and the extent to which they are meeting their educational goals. Have students keep track of what types of patients they have seen and which procedures and clinical activities they have seen and done, such as taking a patient's history and providing patient education. Ask, “Is there any type of patient we need to have you work with today?” This helps students focus on their goals and helps you focus on meeting their needs. Ask questions that elicit reflection, such as, “What did you learn today?” These discussions could direct future sessions or independent research topics.
Feedback is necessary for evaluation, and it can prevent repetitive, time-wasting mistakes. Be sure to provide students with continuous feedback, and ask them about their experience with questions such as, “Is there a different way that I could teach to help your education?” If you have any concerns about a student's progress or ability, contact the student's educational program immediately.
Because students become part of the clinical team, it is essential that preceptors and students communicate with fellow clinicians and staff members. Preceptors should begin with the attitude that students add value to the practice. This approach will then likely spread to physician partners and clinic staff, and in such an environment, students will be more likely to make significant contributions. Ensuring buy-in from partners and clinic staff will save time for everyone by preventing misunderstandings and duplication of effort. Supportive colleagues can also enhance the student's educational experience. Be sure to let your colleagues know if the student needs experience with certain procedures or diseases. You could say something like, “The student needs more work with diabetic patients. Could you let us know if you see any opportunities for that today?”
3. Tailor your teaching to the student's needs
It is important to adapt your teaching to each student's educational needs, goals and learning style. Doing this boosts the quality of the student's education and helps you to remain efficient. You can assess the student's strengths and weaknesses early on by observing the student's interactions with patients, then adjust your approach as needed based on your findings.
Your teaching method may also be influenced by how much time and how many exam rooms you have. Here are some suggestions for ways the two of you might share patient visits and structure learning opportunities:
Observe the student for an entire patient visit. Create your note while the student takes the history, and ask additional questions or assist with the exam as necessary.
See the patient after the student presents the history to you but before the exam is completed. Assist the student with the exam or demonstrate. Medicare's billing and coding rules permit students to document the review of systems and past, family and social history. A student-documented history of the present illness must be “verified and redocumented” by the preceptor, according to the Centers for Medicare & Medicaid Services' Claims Processing Manual, Chapter 12, Section 100 (see “Medicare's Rules for Student Documentation”).
Take the history while the student listens, and have the student perform the exam while you observe. Then repeat the exam and redocument it as required by the Medicare guidelines.
Have the student observe an entire encounter between you and a patient. This is especially beneficial if you have the opportunity to demonstrate specific interviewing or exam techniques.
Use the classic teaching method if time allows. Have the student see the patient, leave the exam room and present to you, then return together to see the patient. Alternatively, you might have the student present to you in front of the patient. In either case, be sure to give the student time to process the patient's information before presenting. This method can be time-consuming, but it allows the student autonomy that other styles may not achieve. If there are enough exam rooms, you can see other patients while the student is conducting the visit and formulating a plan.
MEDICARE'S RULES FOR STUDENT DOCUMENTATION
Medicare's Claims Processing Manual has this to say about student documentation:
“Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing. Students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. The teaching physician may not refer to a student's documentation of physical exam findings or medical decision making in his or her personal note. If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.”
4. Share teaching responsibilities
Students don't need to spend every minute of the day with you to advance their education. Preceptors, partners, staff, patients and students themselves can all be part of the teaching team. For example, students can learn different exam techniques from your partners, or phlebotomy from ancillary staff. They can also “teach themselves” by building clinical knowledge through independent research. Opportunities like these can enrich the students' experience while enabling you the flexibility you may need to work independently. Here are some additional ways to get other members of the teaching team more involved:
Ask nurses and medical assistants to teach students to administer injections, perform lab tests, obtain ECGs, complete blood draws, etc.
Ask office staff to orient students to the business side of family medicine.
Ask other physicians for help. If they are receptive, you might even consider rotating preceptors daily, weekly or monthly.
Here are some ways to encourage the student to be more involved:
Have the student teach you more about a subject you'd like to study. You could say, “I don't know much about this disease. Would you read up on it and teach me before our next clinic? Be sure to include your resources.”
Know when to answer a student's question and when to have the student find the answer on his or her own. Encourage self-directed learning. Give students examples of what to do when they aren't with you, such as start the next visit, review a chart or look up a question.
Have students create or update patient information resources (e.g., standard one-pagers on common issues). Preceptors can share these student-made resources with patients and future students.
Download six easy-to-use tables that summarize the tips and advice found in each section of this article.
5. Keep observation and teaching encounters brief
Dividing observation and teaching into short, focused time segments helps fit precepting into a busy schedule. Observing student history-taking or exam skills in two- or three-minute segments enables you to assess ability and progress without getting behind on patient care. Teaching can be broken into short, focused interactions as well. Not everything can or should be taught all at once; concepts are often best reinforced with repetition. Students are more likely to benefit from small amounts of information linked directly to patient problems rather than large amounts on general topics. Try these tips:
Don't lecture on every patient visit. In fact, you may not need to lecture on any of them. When you do teach concepts, emphasize key points and avoid lengthy discussions.
Give feedback on individual exam skills. For example, focus only on the student's ear, nose and throat exam for one week.
Teach portions of a procedure over time. For example, have students provide a patient's digital block/lidocaine injection one day and remove another patient's toenail on a different day.
Focus on one aspect of a patient encounter. For example, for a patient who complains of shortness of breath, ask the student to focus on the HPI; for a patient who has asthma, focus on patient education; for a patient with a new rash, focus on the physical exam.
6. Broaden student responsibilities
Expanding students' responsibilities maximizes their educational experience and fully utilizes their skills in patient care. When you think the student is ready to do more, try these ideas:
Have students document their reflections after seeing a patient and summarize learning points.
Ask students to look up answers to patient questions. For example, during a patient visit you might say, “Mrs. Smith, I don't know the answer, so our student will look that up, and we will get back to you this week.” After the student has found the answer and discussed it with you, have the student call the patient or send the answer via e-mail.
Review patient test results and treatment plans with the student, and then have the student call the patient to give test results and follow-up instructions. Chart or complete other paperwork next to the student during the call so that you can verify the accuracy of the message and give feedback as needed.
Have students facilitate ancillary services (make necessary phone calls to the lab, communicate with therapists, etc.).
Have students provide patient education and direct patients through the rest of the office visit while you move on to the next patient.
Have students help improve chart details. Students can sit with patients to review and update medication lists, preventive screening schedules, histories and problem lists. When you see the patient, you should quickly review the student's notes with the patient.
Give students clinical tasks such as administering questionnaires or helping with blood draws.
Have students assist with patient flow by rooming patients and taking vital signs.
As you expand the student's responsibilities, be sure not to repeat tasks you've entrusted him or her to do, unless billing and coding guidelines require it. In such cases, you can confirm and clarify: “Mrs. Smith, my student tells me that your headaches began about one week ago. Is this correct?”
Make sure students contribute to the top of their ability level. The more responsibility a student can take on, the more he or she can contribute to patient care. This makes the student more valuable to you and the clinic, and makes the experience more valuable to the student.
A final note
Some of these suggestions may not apply to every practice setting. Preceptors and practices should consider which strategies work best for them. We hope this article will supply physicians with a pearl or two that will boost their clinical productivity while doing the important work of training future family physicians.