April 1998

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor's Note: Neal Whitman, EdD, and Michael Magill, MD, are well-known family medicine educators and have published a number of works about the education of medical students in the clinical setting. In this month’s column, they address a practical issue for our community-based teachers of family medicine. I welcome your comments about this feature, and I also encourage all predoctoral directors to make copies of this feature in its entirety and distribute it to their preceptors. Send your submissions to Paul Paulman, MD, University of Nebraska, Department of Family Medicine, 600 South 42nd Street, Box 983075, Omaha, NE 68198-3075. 402-559-6818. Fax: 402-559-6501. E-mail: ppaulman@mail.unmc.edu.

Objective One—Identify Benefits and Challenges
In response to a brainstorming question, participants identified several benefits of teaching to the practitioner, including the opportunity to reevaluate their own values, beliefs, and attitudes and to learn from teaching others. Also, participants welcomed the opportunity to put their own slant on medical education and to teach tomorrow’s doctors. In addition, they like giving something back to medical education and helping future colleagues. With regard to the challenges of teaching, the participants expressed concern that teaching had a negative impact on their productivity and income and was a big time commitment. Also, they were concerned that local hospitals do not always understand the role of a medical student and that Medicare adds the restriction that the preceptor has to see the same patient seen by a resident. In addition, participants raised the issue that some students resist learning in an active role and that some patients did not like being seen by a student.

Objective Two—Describe and Use Three Tools for Effective Teaching Educational
Contracting According to Pratt and Magill:1

An educational contract is a negotiated agreement between a teacher and a learner. It addresses four elements: needs, expectations, roles, and content. Contracts should develop and evolve via explicit negotiation between the teacher and the learner.

Participants suggested that it was educationally effective to consider not just the content of what to teach but also the process of how to teach. They commented that learning the student’s agenda demonstrates openness and provides a starting point for discussion. In addition, they noted that educational contracting can save time because you do not have to teach what learners already know.

Active Learning
According to Rubenstein and Talbot:2

Learning is a shared process between teacher and learner and not just the responsibility of the teacher. The teacher’s role is to challenge the trainee by alerting him/her to the problem at hand. This is also known as ‘creating the need to know.’

Participants suggested that it was educationally effective to guide learners through the medical process, allow them to make a diagnosis, suggest several competing hypotheses, test these hypotheses, and evaluate the results. They emphasized the importance of making it safe for students and residents to give a wrong answer and to admit what they do not know. Feedback According to a survey of family practice residents, Lewis et al3 found that “The residents wanted personal feedback, eg, ‘How am I doing?’ and ‘What areas can I improve?’” Participants suggested that giving feedback was educationally effective because feedback reinforces positive behavior and provides guidance to improving behavior. In addition, it provides the opportunity to correct problems early on so that these do not become bigger problems.

Objective Three—Experiment With Strategies
Participants identified teaching problems they had encountered in the past and role-played these scenarios, generating several strategies that could be effective. For example, one participant role-played a resident who wanted to limit the preceptor’s help to looking at the possible fracture of a patient’s big toe. Yet, the preceptor’s larger concern was that this was a diabetic patient who had not been seen in 5 years. Participants suggested several strategies, including asking the resident what his plan was for a follow-up visit. The group also discussed how to help learners get past their need to “prove” themselves worthy. Suggestions included the preceptor modeling the learner’s role by revealing gaps in knowledge. In addition, the group brainstormed needs from a resident’s point of view. For example, a resident may simply need to know, “Does he or she like me?” or “Am I worthy of becoming a doctor?”

Evaluation and Future Needs
Participants reported that, for the most part, they achieved the workshop objectives. As a result of the workshop, they reported plans to ask more about their learners’ needs, to establish more formal contracts with students and residents, and to formalize the feedback process with routine feedback sessions. Overall, they rated the presenters’ capacities to meet their needs and expectations as “excellent” or “exemplary.” In particular, they like the role-playing of their own teaching problems. In terms of future needs, participants expressed interest in opportunities to hear from former residents, to listen to a student panel, and to learn additional teaching tips (for example, how to use nonverbal cues to communicate with a student or resident in front of a patient). As reported by Ullian and Stritter,4 faculty development workshops and seminars can be developed to meet the needs of any group of local faculty and can take into account the unique context of the participants. Our experience, as reported here, is consistent with their conclusion that short-term learning experiences can be effective in training primary care faculty members in community practices. We encourage you to ask for and attend faculty development workshops aimed at office-based teachers.

References
1. Pratt D, Magill MK. Educational contracts: a basis for effective clinical teaching. J Med Educ 1983;59(6):452-67.
2. Rubenstein W, Talbot Y. Medical teaching in ambulatory care: a practical guide. New York: Springer Publishing Co, 1992:3.
3. Lewis BS, Montes SD, Nicholas RA. Resident and faculty perceptions of criteria for evaluating residents’ performances in the ambulatory setting. Acad Med 1996;71(7): 793-4.
4. Ullian JA, Stritter FT. Types of faculty development programs. Fam Med 1997; 29(4):237-41.

Correspondence: Address correspondence to Dr Whitman, Department of Family and Preventive Medicine, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132-001. 801-581-7234. Fax: 801-581-2759. E-mail: whitman@msscc.med.utah.edu.