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For the Office-based Teacher of Family MedicineApril 2000, Vol. 32, No. 4 Paul M. Paulman, MD Feature Editor Editor’s Note: Jeffrey A. Stearns, MD, of the Department
of Family Medicine at the University of Wisconsin, Milwaukee;
and Karla Hemesath, PhD, and Richard A. Londo, MD, of the Department
of Family Medicine at the University of Illinois at Rockford,
examine a key part of student orientation in this column. Preventing the Difficult Learning SituationJohn P. Langlois, MD; Sarah Thach, MPH The old adage, “An ounce of prevention is worth a pound of cure” is as true in clinical teaching as it is in clinical medicine. It is generally much more efficient (and pleasant) to prevent a problem than to manage the negative impact once it has occurred. In medicine and in clinical education, there are three levels of prevention: primary, secondary, and tertiary. In primary prevention, the goal is to keep the problem from occurring. Secondary prevention is the early detection of an issue and decisive action to minimize or eliminate the effects. Tertiary prevention is the management of an existing problem to minimize its negative impact. Each level of prevention has its own characteristics and strengths (Table 1). Primary Prevention As the preceptor, you should know the school’s expectations for the learning experience. Some programs allow the preceptor a large degree of latitude in structuring the rotation. Others may have extremely specific learning objectives. You should know the specific expectations before agreeing to teach the rotation and then review them with the learner at the beginning of the rotation. A detailed orientation for the learner is critical and should include your specific expectations to him or her. What time does he or she need to arrive? What are the night call and weekend expectations? What format do you prefer for notes and presentations? What is your dress code? These and other issues of value to you should be specifically addressed with the learner from the beginning. A clear understanding of your expectations and goals can help the learner adapt to your environment and avoid significant problems. Learners also bring their own expectations to a rotation or learning experience. They may expect a certain level of responsibility or be counting on clinical experiences that are not available in your practice situation. Detecting any mismatches early can allow you to inform learners or negotiate options before problems develop. By the same token, knowing the learners’ individual desires, goals, and expectations will help you make their rotations more successful experiences for them. Even if a good orientation and discussion occur at the beginning of the rotation, new or unanticipated issues can develop once the rotation is underway. A formal opportunity to sit down together halfway through the rotation creates an opportunity to reassess and refine goals and expectations for both the preceptor and the learner and can set the stage for an even smoother second half of the experience. Secondary Prevention Secondary prevention depends on maintaining an awareness that things can go wrong. Community-based teachers of health professionals are often optimists in dealing with their learners. They have come to expect high-quality learners with whom they are able to interact in a positive and pleasant way. As a result, early warning signs of difficult interactions are often ignored, downplayed, or attributed to a bad day or other circumstances. It is crucial for the teacher to pay close attention to these hunches or feelings that things may not be quite right. Additional clues can come from the comments or opinions of staff or partners. Every red flag (or even yellow flag!) should be evaluated, just as attention should be paid to every abnormal Pap smear. Not all will reveal an underlying serious problem, but serious problems can be missed if these warning signs are not viewed as potential indicators of significant issues. Do not use the wait-and-see approach as the only way to manage potential issues. A delay of 1 week may lead to further delay, and, before long, the problem has grown, or it is near the end of the experience, and there is not time to intervene. In the community educational setting, the preceptor must examine and address potential issues as early as possible due to the limited time of contact. Plan to institute an organized assessment of a potential problem situation early. (A future column will address “Managing the Difficult Learning Situation.”) The earlier the preceptor begins looking critically at the situation, the more likely it is that an intervention will succeed. Not all situations require an immediate full assessment. When a problem appears minor, the preceptor can give the learner specific feedback on the issue and then watch carefully to see whether that feedback is acted on. The following example may illustrate this: A third-year medical student is beginning a clerkship in your office. During the first week you have noted that the learner takes a much longer time to evaluate patients than previous students have taken. It is early in the third year, and the student has had one clinical experience in the hospital setting only. You arrange a feedback session where you review the learner’s performance with specific examples and give specific suggestions and instruction in time management with patients. You then closely monitor the learner’s performance for the next 2 days.
The above is a screening test. You have identified a problem behavior and have made a simple intervention to determine if this problem exists. The key step is the follow-up: monitoring closely for a limited time. If there is no longer a problem, then only continued monitoring is needed. If the problem behavior continues, a careful assessment needs to be made as soon as possible. Note that this is quite a different strategy from the wait-and-see strategy; a brief active intervention is made, and a brief period of close observation follows. The chance of problem issues slipping through undetected is minimized. The judicious use of quality feedback and close follow-up is invaluable. Tertiary Prevention Avoid the temptation to say, “Well, I’ll just stick this out. There are only a couple of weeks left.” This does nothing to alleviate the negative impact of the problem on you, your staff, and patients, and it does not help the learner. If you have been trying the tricks and techniques that you know and are still not making any headway, then it is time to get help. It is important not to give a passing grade if you do not feel the learner has earned it. One of the characteristics of a profession and a professional is self-governance. Preceptors have a duty to address important concerns and keep from passing along learners who may not serve the profession well. Calling the course director notifies the program of your concerns and can help you determine an appropriate course of action. Some grade choices, such as “low pass” or “incomplete,” will require follow-up of educational issues or concerns by the program or school. Give the grade that is earned so that the learner’s performance and abilities are accurately reflected. Prevention: A Summary Corresponding Author: Address correspondence
to Dr Langlois, MAHEC Family Practice Residency, 118 W.T. Weaver
Boulevard, Asheville, NC 28804. 828-258-0670. Fax: 828-257-4738. |
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