July-August 1998

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor's Note: This month’s column provides advice for community teachers on the use of the Internet. Richard P. Usatine, MD, is a faculty member, and Ken Lin a third-year medical student, at the UCLA School of 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. 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.



Cool Web Sites for Community Preceptors

Richard P. Usatine, MD; Ken Lin
 

(Fam Med 1998;30(7):475-6.)

Why surf the Web? Is it a wave that is going somewhere productive, or is it a game like playing Nintendo? Maybe it is both. Our children use the computer to play games as they learn that the computer is nothing to be feared. How about the community physician? Many physicians and their patients are using their computers for exploring the Internet and doing MEDLINE searches.

But why should you use the Internet? The benefits occur at many levels: for you, your patients, and your teaching of students. The vast amounts of information on the Internet make it a tremendous resource for obtaining the latest medical information.1 Your patients are using or will be using the Internet to look up their own medical conditions. My patients bring me printouts of searches they have completed on the Internet. Medical students are learning to use medical informatics to investigate medical questions. Your students may serve as a good resource for learning more about the Internet and how to conduct effective MEDLINE searches. Ready access to MEDLINE, the Internet, and other on-line databases will help us manage and access the vast amounts of data to improve our practice of medicine.

What are the most efficient ways to search the Internet? Many search engines (eg, Alta Vista, Infoseek, Excite) are available that can help you find useful sites on the Internet.2 Although it is said that Alta Vista is one of the better search engines for finding medical information on-line, this is not based on rigorous study. Whatever search engine you use, many medical searches will result in thousands of matches. Even after narrowing your search with Boolean logic (and, not, or), you still may have to sort through many useless and irrelevant sites that come up.

A more efficient way to search the Internet is to start with medical sites that have already collected useful links to other sites. The organizations and persons managing these sites have done some screening and evaluation of the many medical sites on the Web. Some of the best sites for community-based teachers of medicine are hosted by the Society of Teachers of Family Medicine, the American Academy of Family Physicians, and the Journal of Family Practice (Table 1). These sites have useful links to other sites and are a good place to begin a search. Organizations like the Centers for Disease Control (CDC), the Agency for Health Care Policy Research (AHCPR), and the National Cancer Institute (NCI) maintain comprehensive and current Web pages.

Some medical schools have created special Web sites for community preceptors. At UCLA, we developed the PreceptorNet Web site as a resource for our faculty and other physicians throughout cyberspace. The Web site includes five main pages accessible from the starting home page: a resources page, news page, preceptor page, search page, and help page. The resources page lists numerous links to the Web sites we have found valuable for medical journals, medical associations, government health agencies, medical references, and computer information. One section is devoted to evidence-based medicine links. We have included a search page or uniform resource locator (URL) for this site (www.medsch.ucla. edu/preceptors). The site is not security protected, so all physicians and educators may use it as a resource.

A “Cool Medical Site of the Week” site lists medical Internet sites that Dr Bil rates as “cool.” One cool site was developed by one of our students and is called the “Auscultation Assistant.” You can use this to review heart sounds and murmurs. (The sounds will be audible with a sound card and speakers.) Some particularly exciting sites have interactive medical cases. We have developed “Interactive Dermatology Cases,” and these can be found at idtu.medsch. ucla.edu/derm. There are also sites that give you the whole text of journal articles on-line. This can save you a trip to the library and help you get information quickly.

There are some great sites for evidence-based medicine (EBM). EBM involves the use of existing evidence from clinical research to inform the practice of medicine. The new challenges to practicing EBM include learning how to efficiently access the vast medical databases available on-line and then how to critically appraise this information. Sites such as the AHCPR site include well-done practice guidelines. It is still important to critically determine potential biases of the persons creating practice guidelines to determine their usefulness.

Wherever you go on-line, be aware that there is little peer review on the Internet. Journals and books get reviewed and printed in a format that is fixed, unlike Web sites, which can change from moment to moment and can be created by anyone with a personal computer. Therefore, if the information is accurate today, there is no guarantee about the accuracy of the information tomorrow. Be aware of the source of the information and the potential biases of the persons or organizations posting the information. Remember to also caution your patients that not everything they find on the Internet is valid medical information. That said, you should be able to count on sites from organizations like the CDC, AHCPR, and NCI for accurate information. Jadad and Gagliardi wrote an excellent review of 47 rating instruments to evaluate health information on the Internet.3 Their conclusion was that it is unclear whether rating instruments should exist in the first place and whether they measure what they claim to measure.

Explore and enjoy the process of searching for information. Share great sites with your patients, students, and colleagues. Feel free to e-mail us at rusatine@ ucla.edu if you find a Web site that you feel should be added to the STFM or PreceptorNet Web site.

After using MEDLINE and the Internet for a while, you may find it easier to throw out those piles of unread journals in your home and office with less feelings of guilt. You will no longer have to rely on your personal files to find up-to-date and clinically useful articles again. You can let the National Library of Medicine and all of the medical sites on the Internet do the cutting, filing, and storing for you.

References
1. Ebell MH. The Internet as a resource for family physicians. Am Fam Physician 1996;53(3):850,855-6.
2. Rathe R. Finding what you need on the Internet. Family Practice Management 1997;4(5):58-69.
3. Jadad A, Gagliardi A. Rating health information on the Internet. JAMA 1998;279: 611-4.

Corresponding Author: Address correspondence to Dr Usatine, UCLA School of Medicine, Family Health Center, 200 Medical Plaza, Suite 220, Los Angeles, CA 90095-1628. 310-825-4651. Fax: 310-206-0181. E-mail: rusatine@ucla.edu.

Table 1

Some Useful and Cool Medical Sites

 

Editor's Note: This month’s column was presented as a plenary session at the 1997 Society of Teachers of Family Medicine Predoctoral Education Conference. Walter L. Larimore, MD, a community preceptor in Kissimmee, Fla, has been honored with the American Academy of Family Physicians Thomas Johnson Award for Teaching and coauthors the American Family Physician series, “Diary From a Week in Practice.”

 

From the Front Lines: Balancing Demands on Time
for Teaching, Productivity, and Family

Walter L. Larimore, MD
 

(Fam Med 1998;30(7):478-9.)

Let me discuss two items with you. One, what do preceptors need? Two, what have the family physicians in our practice learned about improving our learning experiences and our students’ learning experiences?

1. What Does the Preceptor Need?
Several recent articles have helped me distill my thoughts in this area,1-3 and the authors describe preceptors (community-based teachers of family medicine) as needing key and secondary factors: The key factors are the intrinsic rewards (I call this factor satisfaction).
• The teacher believes teaching is worth it.
• The teacher wants to teach.
• The teacher feels a call to give back or return the gift of teaching they were given.

The secondary factors are the extrinsic rewards (I call this factor appreciation) or the “five Rs” of preceptors.
• Revelation: how to teach (on-site is best), how to give feedback, how to evaluate
• Resources to teach: educational tools, supplies, books, articles, MEDLINE, e-mail
• Remuneration for teaching: money or services (CME, on-site consults, locum tenens)
• Reserves: Back-up for problems, problem students
• Recognition/rewards: appointments, certificates/letters, dinners, thanks, feedback from the university (or residency), and feedback from the students (written).

I agree with Kollisch, who said, Physicians teaching in a clerkship should be asked about their needs, and special programs of support should be offered. Furthermore, preceptors’ needs should be solicited, prioritized, and translated into activities that enhance and support their efforts to teach medical students.1 However, do you know what I really needed the most from the predoctoral faculty that sent me students and the teachers who sent me residents? I needed some skills in time management, some skills in prioritization, and some skills in saying no to others and yes to my family and my Lord. Preceptors should be asked about their needs. Preceptors should be offered special support. I have had neither; I would have loved either. My balance would have occurred earlier in my career if it had been offered.

2. How Do We Work With Students?
For us, it’s not about doing so much more than we’re already doing, it’s about doing so much more with what we do—by maximizing time and teamwork. I don’t precept alone. My community precepts, my colleagues precept, my practice precepts, my family precepts. We are a “Southern Baptist precepting opportunity;” we don’t sprinkle them in the faith, we immerse them!

Students live, wake, eat, sleep, practice, round, deliver, home visit, operate, work, and play with us. Students are like most of us, as described in a poem called, “I’d Rather See a Sermon Than Hear One Any Day.”

What are some things my students have taught me to do to become a better and more effective teacher for them? Let me list just a few suggestions.

Intake Interview/Negotiation
Talk with one doctor, nurse, or staff person (but let the other doctors and nurses know).
1) Find out what they know.
2) What do you feel comfortable with?
3) What subjects, what type of patients, what procedures?
4) Find out what and how they want to learn—their preferred learning style (shadow or solo? Patient time versus reading time? Find out what they’ll do. Practice life or personal life? Office hours or night hours? Other specialties, other providers?).
5) Let them know their options for educational experiences in your consultant and colleague network (other specialists [osteopathic family physician, occupational health family phsyician, sports medicine family physician], hospital opportunities [emergency room, surgery, or OB with family physicians], home health, public health [family physician Health Department director], administrative [family physician HMO director], let them know your expectations and weaknesses, and let them know how you will evaluate them.

Orientation
Have orientation preferably before the actual learning visit. The orientation can be with the staff or the doctor or both. We want the students to become quickly comfortable in our learning environment. We want the students to be well matched to our site. We want them to be oriented
1) to office and procedure (nurse staff),
2) to equipment, forms, phone (administrative staff),
3) to what it is like to be a patient,
4) to the town (realtor),
5) to the hospital (administrator), and
6) to where they will stay (family member).

Daily Feedback
Daily feedback goes both ways; it includes the doctor, the nurse, and the student. We always seek feedback and criticism first. Then we give positive feedback, and then we give negative feedback (how to improve/make things easier/tricks of the trade).

Students as Teachers
Ask the student to teach the doctors and/or nurses—at least once.

Exit Interview/Negotiation
1) Share strengths (personal and professional).
2) Share blind spots.
3) Share areas that could/should be improved.

Practice/Patient Flow Changes Are Mandatory
1) Nurses talk at their morning meeting about cases for the student.
2) Doctors arrive a bit early.
3) Spend time with student before patients.
4) Review schedule with nurse and student before patients.
5) Set aside extra time during each half day (one or two 15-minute slots).
6) Every patient should not be seen by every student.
7) Have student carry pad for writing down questions.
8) One take-home point per half day is our goal.
9) After-patient time is limited.

I don’t teach my students about the science of family practice or what it is. I show them what a family physician is and does. That seems to be what they want the most. My teaching and family are only as balanced as my family and my practice are balanced. Therefore, my teaching of balance is a demonstration, not an instruction.

Does it have some costs? Yes. But what that is worthy doesn’t? A balance for you may not be finding those family physicians who can live with teaching but those who can’t live without it and then helping them multiply their satisfaction with what they do. The task for you, as one who wishes to attract and keep quality preceptors for the students in your charge is
1) to identify what the cost is for each of your preceptors, individually,
2) to reduce it (or help to reduce) as much as you can, and
3) balance cost reduction with a healthy dose of the seasoning of appreciation.

Appreciation is the truest and most enjoyable dessert that most family physicians taste. I tasted it when a first-year student called after her rotation with us. Her dad, the chair of OB-GYN at a major university, had taught her that family physicians can’t deliver babies and that nobody should deliver a baby over an intact perineum. She bubbled with glee as she described his face and response as he saw a video of the first delivery she had ever performed, with a family physician, and a 7-lb, 8-oz female infant delivered over the intact perineum of a primiparous mom.

I taste appreciation every Christmas when a former student, now a chair of a department of ophthalmology at a medical university, describes in her Christmas card how much of her success as a specialist is based on what she learned from and about family physicians when with me and how much of her success as a mom and wife is based on what she learned from my family.

There is so much more that I in the town and you in the gown can do together. For the sake of our students, our residents, our community family physicians, and all of our patients, let’s just do it.

References
1. Kollisch DO, Frasier P, Slatt L, Storaasli M. Community preceptors’ views of a required third-year family medicine clerkship. Arch Fam Med 1997;6:25-8.
2. Baldwin LM. Managing clinic time while precepting medical students. In: Paulman P, ed. For the office-based teacher of family medicine. Fam Med 1997;29(1):13.
3. Doyle G, Patricoski CT. Costs of teaching for community teachers of family medicine. In: Paulman P, ed. For the office-based teacher of family medicine). Fam Med 1997;29(1):12-3.
4. Swenson RA. Margin. Colorado Springs, Colo: Navpress, 1992.

Correspondence: Address correspondence to Dr Larimore, Heritage Family Physicians, 825 East Oak Street, Kissimmee, FL 34744. 407-847-9090. Fax: 407-870-7466.