May 1998

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor's Note: This month’s column features two articles by two different, experienced family medicine educators. Our first author, Eugene Orientale, Jr, MD, associate professor of family medicine at the University of Connecticut, shares his top 10 teaching tips for community teachers. Dr Orientale has served as an predoctoral director, is an active preceptor for residents and medical students, and is a recognized authority on rural student preceptorships. 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.

(Fam Med 1998; 30(5):326-7.)

For most physicians, embarking on teaching is much like parenting. It is a job that we perform with little preparation or experience. Like parenting, on-the-job training ultimately gives us the experience we need to become more proficient. I am often reminded of this fact by my wife, who teaches special education. Her preparation at the undergraduate and graduate levels gave her the skills necessary to perform her job as a teacher. On the other hand, few physician educators receive any formal education in teaching. As a result, despite the best of intentions, physicians will commit many blunders in their attempts to educate both students and residents. No brief article on medical education in private practice can do justice to the challenge of this task. However, after practicing in a residency environment for the past 7 years, I have made some observations. I have assembled these into a “Top 10 List” of dos and don’ts for working with physicians in training.

1. Be a Role Model and Mentor
Contrary to the words of National Basketball Association athlete Charles Barkley, whether he likes it or not, he is a role model. We are also role models. As physicians, our actions and lifestyles will speak louder than our words. Students and residents observe how we conduct ourselves both personally and professionally. What we do in our spare time, what we value, and how we conduct our personal lives conveys subtle but important messages to our physicians in training.

2. Teach Learning
“What we should seek to instill in our colleagues is not so much learning as the spirit of learning” (Woodrow Wilson). It is well worth remembering that little of the factual knowledge we convey to our pupils is actually retained. Thus, if we can convey enthusiasm for the process of learning—the thought, research, and investigation—then we have met an important educational objective. The process of how we learn as physicians eclipses and surpasses the content of any factual data.

3. Care for Patients
It has been said that the secret in caring for patients is in caring for the patient. Our ability to listen and convey empathy, as well as our behind-the-scenes gestures and comments, are observed and scrutinized by our pupils. If we expect our learners to demonstrate empathy, we must first demonstrate it.

4. Avoid Salesmanship
As family physician educators, we are often placed in the dual role of instructor and recruiter. My experience with more than 300 volunteer clinical faculty who participate as instructors for medical students tells me that we pursue our role with zeal. Many of us have little doubt that more family physicians could help solve the current US health care crisis. Unfortunately, our enthusiasm is often misperceived as overzealousness. The students we seek to attract to our profession are often repelled by our uniqueness. As a result, we should teach more and recruit less. It is easy to forget that bright young medical students can make reasonable decisions if they are given objective data and some reasonable guidance. We must refrain from trying to make our pupils into family physicians. Rather, by demonstrating how we practice the art and science of medicine, we reveal that our specialty has a legitimate place within the context of health care delivery and that it represents an attractive career decision.

5. Take a Team Approach
In a busy day of clinical practice, teaching a student or resident can seem like more of a burden than a joy. But it need not be this way. By adopting a proactive and constructive team approach to instruction, a medical student or resident can easily be incorporated into a busy ambulatory and inpatient practice. After carefully assessing a learner’s educational level, a learner can be reasonably incorporated into one’s everyday routine. A second- or third-year medical student can take a patient’s history and perform a physical examination. A fourth-year medical student can pre-round on hospital inpatients. And, a resident can often function at the level of a junior colleague. By taking a team approach, an instructor makes a conscious decision to share clinical responsibilities with the student. This certainly makes learning most enjoyable for all involved.

6. Listen to the Student
Recent medical studies indicate that physicians typically interrupt their patients before they speak a mere 20 seconds, often hardly enough time to convey their history and chief complaint. Similarly, we often don’t critically listen to our learners. How often do we get personal information and educational background information on our students? The typical answer is “not often enough.” To write the best educational prescription of goals and objectives for our students, the instructor must obtain both subjective and objective data from the pupil. Listen critically to students, and their actions and words will tell you what they need to learn the most.

7. Provide Constructive Feedback
We are our own worst critics. There is a natural tendency for each of us to see our glass as half empty rather than half full. By providing constructive feedback to our learners, our criticisms and praise will be more easily assimilated. My experience indicates that the more constructive the feedback, the more likely that the learning objective will be obtained.

8. Challenge the Learner
We sometimes forget that medical students and resident physicians are among the best students in our country. These elite learners have risen to their level of education because of their aptitude for learning. Thus, it behooves us to challenge the learner. Family practice provides us an endless array of learning opportunities every day, in both clinical diagnosis and therapy. Our challenge is to invite participation in our everyday diagnostic and therapeutic dilemmas.

9. Make Time—Don’t Be Too Busy
Many of us are always in a rush. Perhaps it is due to our compulsive personalities. Sometimes, our pace is dictated by our hectic schedules and the demands of clinical practice. More often than not, it is a combination of both. A good teacher will find the time to meet the needs of his or her students. In doing so, the teacher acknowledges the importance of learning and validates students’ interests and needs. The converse is also true. If one is constantly putting off questions and dismissing students’ concerns, the educational process is quickly derailed.

10. Challenge Yourself
When I first began teaching medical residents, I would review the office and inpatient schedule to mentally prepare myself for those with whom I would be working. Admittedly, I would breathe a sigh of relief when I found myself assigned to the finer residents! With time and experience, I became more confident in my teaching role, and now I find myself actually cherishing the opportunity to work with any of the residents, because each represents a unique and interesting challenge; no two learners are alike. I find it challenging to constantly adapt my teaching style to better suit the needs of my pupils. Consequently, teaching has become much more rewarding.

I don’t want to imply that simply by following these 10 tips that you will excel as a teacher, but I do hope that these concepts will become part of your teaching style. Teaching is a little like playing golf; you can only become good at it with a lot of hard work. I believe that family physicians make excellent teachers because they are intrinsically motivated to teach. After all, teaching our patients is one of our primary clinical objectives. Good luck in your next teaching role!

Correspondence: Address correspondence to Dr Orientale, University of Connecticut, Asylum Hill Family Practice Center, 99 Woodland St, Hartford, CT 06105-1207. 860-714-6738. Fax: 860-714-8079. E-mail: orientale@pol.net.

Editor’s Note: Rick Ricer, MD, contributed this second article, which clarifies some of the commonly used language surrounding physician-medical student interaction. Dr Ricer is predoctoral director at the University of Cincinnati’s Department of Family Medicine.

(Fam Med 1998; 30(5):328.)

Preceptor, mentor, and role model are three of the most common terms used to describe interactions that family physicians may have with medical students. The terms, at time, can be confusing. The tasks and responsibilities of each of these can be quite different; however, one family physician can be expected to fill all these roles at the same time or different roles at different times.

A role model is an example, someone whose behaviors, personal styles, or specific attributes are emulated by others. This is usually a passive role. Role models can be positive or negative. Role models do not have to be known personally by those trying to emulate their behaviors.1 The role model’s behaviors are an ideal after which the students can pattern their own behavior.

A preceptor is more of a clinical teacher. Usually, a practicing family physician does this real-world teaching in his/her office as part of a formal course of instruction with implied or written goals and objectives. The family physician is usually a preceptor for a brief, finite period of time, such as a 1- or 2-month rotation. The preceptor is concerned with enhancing the clinical competency of students2 or the teaching and learning aspect of their professional development.3

A mentor is more of a coach or trusted counselor and usually has prolonged contact with a student over many months or years but not necessarily in any formal course or formal evaluation. Mentoring is a more personal process that combines role modeling, apprenticeship, and nurturing.4 One definition of mentorship is an intense, often multifaceted process in which an experienced family physician serves not only as teacher, sponsor, and advisor to a student but provides for the personal growth of the student as well and derives personal growth from the process.5 There are many opportunities at every medical school for clinical preceptors, mentors, and role models. Some schools have a formal process where a practicing physician can mentor a student over a period of years. Perhaps the most recognized precepting opportunity is the 1- or 2-month family medicine clerkship offered in the third or fourth year of medical school. This is a formal course with goals, objectives, and formal evaluations.

There are also many other opportunities for precepting and role modeling throughout the medical school curriculum. Examples include courses in medical interviewing, doctor-patient relationship, ethics, medical humanities, introduction to clinical practice, physical diagnosis, clinical externships, research externships, and other elective rotations.

The courses can have confusing names. In some medical schools, the third- and fourth-year rotations are called clerkships, and a rotation done in a community office is termed a preceptorship. Regardless of what these activities are called, they are taught by preceptors.

Some of the best role models, preceptors, and mentors are the community-based practicing family physicians who are not paid faculty of the medical schools. Most departments of family medicine could not complete their functions without the assistance of the community-based practicing family physicians. Please get involved in medical student teaching. Your efforts will be greatly appreciated and are most rewarding.

References
1. Shapiro EC, Hasseltine FP, Rowe MP. Moving up: role models, mentors, and the “patron system.” Sloan Manage Rev 1978;spring:51-8.
2. Ricer RE. Definition of a preceptor. Ohio Family Physician News 1993; Dec 9.
3. Armitage P, Burnard P. Mentors or preceptors? Narrowing the theory-practice gap. Nurse Education Today 1991;11:225-9.
4. Davidhizar RE. Mentoring in doctoral education. J Adv Nurs 1988;13:775-81.
5. Ricer RE, Fox BC, Miller KE. Mentoring for medical students interested in family practice. Fam Med 1995;27(2):98-103.

Correspondence: Address correspondence to Dr Ricer, University of Cincinnati, Dept of Family Medicine, Predoctoral Medical Education, PO Box 670582, Cincinnati OH 45267-0582. 513-558-4066. Fax: 513-558-3440. E-mail: rick.ricer@uc.edu.