For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor’s Note: In this column, Samuel LeBaron, MD, PhD, and Erika Schillinger, MD, outline a strategy for improving student education and patient interaction in the office. Drs LeBaron and Schillinger are faculty of the Department of Family Medicine at Stanford University.
I welcome your comments about this feature, which is also published on the STFM Web site at . I also encourage all predoctoral directors to make copies of this feature and distribute it to their preceptors (with the appropriate Family Medicine citation). Send your submissions to Paul Paulman, MD, University of Nebraska Medical Center, Department of Family Medicine, 983075 Nebraska Medical Center, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501. E-mail: ppaulman@unmc.edu. Submissions should be no longer than 3–4 double-spaced pages. References can be used but are not required. Count each table or figure as one page of text.

(Fam Med 2000;32(2):87-8.)

The opportunity for students to take a patient’s history independently and present the patient to their preceptor benefits the student, the preceptor, and the patient. When your student is ready to present the patient to you, consider the advantages of doing this in the exam room in the patient’s presence. This article highlights some advantages of including the patient in the student presentation and describes some techniques to facilitate this format.

Advantages of Presenting the History and Physical in Front of the Patient
There are significant advantages to including the patient in the student presentation.
1) Time Saving
This format usually saves time because the preceptor doesn’t need to confirm or repeat the history. The entire history can be confirmed or corrected by the patient as the student is recounting it.

2) Improved Accuracy
The patient may correct inaccuracies in the history or add additional points that may have been omitted.

3) Improved Student Education
This process is a valuable learning opportunity for the student and provides instant feedback about his/her ability to listen and summarize the history accurately. This process is also a good way for the preceptor to assess the student’s skill at establishing patient rapport. While seeing students in action is valuable to the preceptor, the reciprocal is equally true. When students see their preceptors teaching patients, they may learn to emulate their preceptors as physician educators.

4) Improved Patient Satisfaction
Patient satisfaction is improved when patients are not left waiting alone in the exam room, possibly feeling abandoned, while decisions are being made about their care. The patients feel included as active participants in the discussion, rather than as passive recipients of treatment. When the preceptor and student discuss their differential diagnosis and options for treatment openly in front of their patients—and with the invitation for their participation—patients often comment on how much they enjoy “getting inside the doctor’s head” as they listen to the thought process. Many patients also comment that they feel proud knowing that they are contributing to the development and training of physicians. While the students learn, so do the patients, who, with added insight into their particular disease processes, are more likely to adhere to their treatment regimens.

Exceptions
Some patients present difficult challenges that are best discussed initially in the preceptor’s private office before going into the exam room. Examples include patients who are angry, depressed, grieving, or who have come primarily to discuss complex management issues, such as end-of-life care or a chronic condition.

Students need to be told at the beginning of the rotation that when they encounter such patients, they (and the patients) will usually find it preferable to bring the preceptor into the room as soon as possible.

In such a case, the student may give a brief summary of the circumstances outside of the exam room, and the preceptor and student can then decide how to proceed. In many cases, it will be simpler and more effective for the student to simply observe the remainder of the visit. Occasionally, however, a sensitive and astute student will already have obtained a significant amount of history. In that situation, a few moments outside the room may be helpful to suggest ways for the student to proceed in the most sensitive manner possible.

When the patient does not speak English well, and the preceptor and/or student are not fluent in the patient’s language, there may be a strong inclination to conduct the patient presentation outside the exam room because of a fear of being rude. However, even though the patient may not understand the words, nonverbal behavior still conveys strong messages. Thus, it may be quite meaningful for the patient to simply watch the preceptor and student interact, with an occasional synopsis in the patient’s language of what has been discussed.

Skills
Many students need some preparation to help them maximize the value of presenting in front of the patient.

1) Speak in Real English
Students need to be reminded not to speak in medical jargon when discussing a patient’s medical problems in front of the patient. This is an important and sometimes challenging frame shift for students who have been rotating through inpatient wards and who have worked hard on learning to speak in abbreviations and acronyms.

2) Invite Patient Participation
Patient participation is especially important as a means of correcting, clarifying, or adding to the history obtained by the student. This opportunity to improve the quality of the history is usually felt to be satisfying to both the student and patient. One simple, direct invitation would be for the student to say to the patient, “As I tell the doctor what you have told me, please feel free to correct or add to anything I say, to make sure I’m as accurate as possible.”

3) Use Eye Contact
Remind students to make eye contact at intervals during the presentation. In your role as preceptor, you can model this by looking back and forth between the student and patient during the visit. This acknowledges the patient’s presence and shows an interest in his/her reactions. Patients who do not speak English are often reassured by eye contact, supplemented by a smile and a touch on the patient’s shoulder.

4) Take Control
Ask the student to lead the conversation with the patient. Patients will often interject comments that are directed at the preceptor. It is important for the preceptor not to step in and take over but rather to let the student resume control of the situation by continuing with his/her presentation. The student needs to know that this is your expectation.

5) Treat the Student Like a Colleague as Much as Possible
Some students are understandably reluctant to present in front of a patient when they worry that the preceptor may embarrass them by asking difficult questions or by ignoring the student for the remainder of the visit. Continue to keep the student involved through an ongoing exchange that is collegial, not condescending. It is especially helpful to invite the student to formulate an initial assessment and plan. If you disagree with the student’s conclusion, acknowledge the ideas with respect, while offering your own perspective. If the student is obviously uncertain about how to proceed, there is no need to put him/her on the spot. Instead, you could offer your own ideas and ask the student if that seems reasonable.

Many patients comment that they feel closer to their physician and more confident that their care is of high quality when they are included actively in the teaching of a student doctor. This is a strategy that, in most cases, will be of benefit to all.

Corresponding Author: Address correspondence to Dr LeBaron, Stanford University, Department of Family Medicine, 703 Welch Road, Suite G-1, Palo Alto, CA 94304-1708. 650-725-5339. Fax: 650-723-9692. E-mail: slebaron@ leland.stanford.edu.