November-December 1998

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor's Note: William L. Toffler, MD, and Anita D. Taylor, MAEd, are nationally known predoctoral innovators and family medicine educators. Their column provides a look at teaching/mentoring prematriculation students.

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.

Over the past decade, an increasing number of community-based family physicians have been teaching medical students in their offices. Most of the preceptors have been teaching third- and fourth-year medical students, since more than 75% of US medical schools now have required third- and fourth-year family medicine clerkships.1 More recently, medical schools are including family medicine (among other ambulatory clinical experiences) in the first and second year of medical school.2

Eleven years ago, the Department of Family Medicine at the Oregon Health Sciences University initiated the Summer Observership Program for prematriculation medical students. Entering first-year students are matched with rural family physicians throughout the state. This experience occurs in the 2 weeks prior to the first day of required coursework. This opportunity both exposes students to the discipline of family medicine and allows an intense observation of a family physician’s clinical practice and home life. Participating students and preceptors have expressed enthusiastic endorsement of this program. Students have indicated that the experience allows them to view the basic sciences and future professional activity with a better perspective.

What expectations does a community family physician have when he or she agrees to precept a Summer Observership student? How can the medical school faculty prepare someone for this experience? Based on preceptor feedback, we would like to share some of the aspects that we believe directly contribute to the success of a prematriculation clinical experience.

1. Timing
Theoretically, students might be matched with preceptors at any time from the completion of college coursework until entry into medical school, but scheduling the observership 2 weeks immediately before the beginning of medical school allows students to come together in a 2-day orientation session and then depart to their respective communities. At times, there may be more than one student in a community that has more than one preceptor. As such, participants are given a roster of other family physicians who are in the program so that they can plan joint activities, such as a picnic or hike, with neighbor physicians and their students on days off.

2. Orientation
Students entering medical schools have widely varied backgrounds. Having a 2-day orientation (which includes exposure to some of the basic tools used in a ambulatory setting, as well as core concepts of history taking) ensures that all students have at least some basic understanding of office practice. As part of the orientation, we have learned that it is important to have students who have already participated in the observership share pearls of wisdom and their personal insights. Orientation activities include a panel of students who participated in the past, small-group workshops on interviewing and physical examination skills, and informal time to share hopes and concerns. Preceptors are sent written material that is given to the students in the orientation session.

3. Matching Process

While random matching of students and preceptors might sometimes be sufficient, we believe care needs to be taken to closely match students and physicians wherever possible. Physicians and their families are assured that every effort will be made to have a student who will fit into their lives. Consideration of the individual characteristics of physicians, communities, and even shared interest in activities such as fly fishing, cycling, tennis, or guitar playing can enhance the experience. In addition, some preceptors prefer to be with a specific gender. Some students may have to be close to their own home to cope with specific family needs, such as child care or special schools. We strongly urge the preceptors to discuss their participation in the program with their spouse and children before agreeing to do so. Preceptors are encouraged to include students in as many of their personal and professional activities as is comfortable.

4. Office Welcoming

One of the most important aspects of any student’s experience is the initial greeting on arrival to a practice. Physicians are requested to telephone their assigned student to arrange the time and place of arrival. Since the initial contact person may be the front office staff, preceptors should ensure that all staff are informed of the commitment to host an observership student. As many practices (even in rural areas) are increasingly forming into groups, notification of practice partners is imperative. Involving other partners and staff enhances the student’s sense of belonging and can truly enrich the overall experience. Students will be able to see a variety of practice styles and also have the opportunity to see other aspects of medical care and/or practice management.

5. Professional Roles
As in any teaching situation, the first step is to understand the previous experience and comfort level of the student. Each preceptor is sent a written questionnaire detailing the exposure the student has had to the health professions. In addition, preceptors are urged to discuss the student’s expectations for the observership program, as well as their own expectations. Some of the areas to cover early in the experience include manner of introduction, level of interaction with the patients, office protocols, and opportunities to observe in the hospital operating room. The most successful experiences have featured clear communication among all those involved. Since this is a non-credit program, it is ungraded. However, a form is sent to each preceptor, asking for feedback on the experience. What we often receive are comments on students’ positive or negative behavioral attributes. In addition, students have a comprehensive evaluation form, and their positive comments are shared with the preceptors.

6. Continuity of Relationship
Mentorship relationships that continue throughout medical school and even into residency and practice often result from this brief prematriculation experience. Some preceptors get together with their students when they come to Portland or may meet their students at state American Academy of Family Physicians chapter meetings. Students return to the practice for another experience between their first and second years of medical school or may take an elective in their fourth year. With a strong value on continuity, it is no surprise to find these continuing relationships formed. In fact, despite the large numbers of full-time faculty and possible role models that students will subsequently encounter over the next 4 years, students entering family practice residencies frequently choose their Summer Observership preceptor as their invited mentor for the Annual Family Medicine Student/Mentor Graduation Dinner.

In summary, the Summer Observership Program provides a unique opportunity for learning and exposure to family practice in the community. While family medicine departments around the country have experienced phenomenal increases in the number of opportunities for participation in required medical school curriculum, the observership remains one of the most successful of our teaching endeavors.

The lasting impressions and bonding that sometimes occurs may well relate to the excitement and openness of entering medical students. As such, we believe each of the aforementioned elements needs careful attention to ensure a positive experience.

References:
1. Association of American Medical Colleges. 1997–1998 AAMC curriculum directory. Washington, DC: Association of American Medical Colleges, 1997:12.
2. Fields SA, Toffler WL, Elliot D, Chappelle K. Principles of clinical medicine, Oregon Health Sciences University School of Medicine. Acad Med 1998;73:25-31.

Corresponding Author: Address correspondence to Dr Toffler, Oregon Health Sciences University, Department of Family Medicine, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098. 503-494-6622. Fax: 503-494-4496. E-mail: toffler@ohsu.edu.

Editor's Note: In this column, Jeanne Ferrante, MD, addresses learner contracts in the context of community rotations. Dr Ferrante serves as predoctoral director for the Department of Family Medicine at the University of South Florida in Tampa.

Bob T. is a third-year medical student who is doing his clerkship experience in your office. He has been in an exam room evaluating a new patient complaining of low-back pain for more than 30 minutes. You are wondering what is taking so long and whether you should go into the room. Another patient has arrived, and you decide to see the next patient first. After you have finished with the next patient, you finally see Bob. He begins the precepting encounter with a complete presentation of the patient. Apparently, Bob has done a complete history and physical on the patient. As you sit listening to the presentation, you are thinking, “Get to the point.” You notice that two more patients have been placed in exam rooms to be seen. You finally cut Bob off and tell him you want to concentrate on the low-back pain. You proceed to lecture to him on the causes of low-back pain and the treatment options, as you write out the prescriptions. You then lead Bob back into the patient’s room to examine the patient, explain the diagnosis, and give the patient the instructions and prescriptions.

Precepting medical students can be the most challenging, yet rewarding, form of teaching in family medicine. This teaching encounter was probably frustrating for both the teacher and the student. How could this have been prevented? One way to avoid these uncomfortable encounters is to be proactive and develop a learner contract with a student.

The learner contract is a personal, negotiated agreement between the teacher and the learner that outlines expectations, roles, and responsibilities for the month’s experiences. It can make precepting better for the teacher and the student. Medical students are adult learners who differ in their individual needs, interests, and maturity. Adult learners want to know what they will be learning, what is expected of them, and how they will be evaluated. They learn best when they are motivated and ready to learn, involved in setting goals and deciding on relevant content, and have participated in decisions affecting their learning. A learner contract can help the preceptor and the learner understand and agree on mutually negotiated expectations, roles, and responsibilities. It is an agreement as to what knowledge, skills, and attitudes they will address in their time together and how they will do so. The learner contract will help the preceptor choose certain patients for the student to see and to precept more efficiently and effectively. The learner contract will also include guidelines for the preceptor’s evaluation of the student and the evaluation methods to be used during the month.

The learner contract is a personal, negotiated agreement between the teacher and the learner that outlines expectations, roles, and responsibilities for the month’s experiences. It can make precepting better for the teacher and the student. Medical students are adult learners who differ in their individual needs, interests, and maturity. Adult learners want to know what they will be learning, what is expected of them, and how they will be evaluated. They learn best when they are motivated and ready to learn, involved in setting goals and deciding on relevant content, and have participated in decisions affecting their learning. A learner contract can help the preceptor and the learner understand and agree on mutually negotiated expectations, roles, and responsibilities. It is an agreement as to what knowledge, skills, and attitudes they will address in their time together and how they will do so. The learner contract will help the preceptor choose certain patients for the student to see and to precept more efficiently and effectively. The learner contract will also include guidelines for the preceptor’s evaluation of the student and the evaluation methods to be used during the month. column.4 If learners prefer that the teacher help them think through a problem (collaborative style) while the teacher lectures to them (assertive style), both the teacher and learners may feel frustrated and be less effective. Clarifying this ahead of time can prevent this conflict. The student and you should then each identify two to five specific student learning objectives for the month and strategies to accomplish them. Choose and organize learning strategies, taking into account the time variables, type of skill to be learned, and preferences of the learner. The expectations and goals for the clerkship should be negotiated and clarified by the end of the first week. A written form can be used to construct a learner contract (Figure 1).

Figure 1 Learner Contract Preceptor and student should review: ______A. Other clerkships/clinical experiences student has completed ______B. Student’s medical interests ______C. Clinical skills inventory form ______D. Clerkship educational goals and objectives ______E. Clerkship evaluation forms ______F. Roles for preceptor and student ______G. Evaluation methods Learning Objectives Student goals (to be completed after first full day in preceptor’s office) List two–five learning objectives and specific strategies for accomplishing them. Preceptor goals (to be completed by the end of the first week) List two–five most important areas on which the student should focus and strategies for addressing these areas. Agreement on goals (to be completed by the end of the first week) Student’s summary of performance goals and expectations. Preceptor’s Signature/Date   Student’s Signature/Date Figure is adapted from the Preceptor Education Project. Kansas City, Mo: Society of Teachers of Family Medicine, 1992.

The principles of the learner contract can also be used at the beginning of each teaching session. In the context of a busy medical practice where time is at a premium, a simple, short exchange of needs, content, expectations, and roles before an encounter can ensure a more effective and efficient learning experience. Select patients for the student to see based on the student’s goals and on problems the student has not yet seen. Be educationally specific when you ask the student to evaluate a patient. The student does not need to learn everything on every patient. For example, focus on just the student’s ability to obtain a pertinent history, perform a specific examination, or present an adequate differential diagnosis. This decreases trying to pack too much into each encounter and helps solve the time-demand issues. Students may need to be encouraged to state concisely what they need assistance with. Most of the time, students begin a precepting encounter by giving a complete presentation of the patient with the chief complaint, history of the present illness, past medical history, physical examination, assessment, and plans. After hearing an abundance of information, you are left to decide which aspects of the case to discuss. This may not address the learner’s immediate need. For example, in a patient with low-back pain, after hearing the student’s presentation, you may decide to focus on the pertinent history and physical exam. The student, meanwhile, wants to learn about the treatment modalities for low-back pain. By clearly eliciting the student’s needs, you can precept more effectively.

Communicate your expectations as to the student’s evaluation of the patient and his or her case presentations. The student should clearly understand the desired presentation format and the information that you expect to be included in the oral presentation. Time limitations for the student’s evaluation of the patient and case discussion need to be stated. Roles should be clarified based on the learner’s needs and circumstantial constraints.

A learner contract can be used to promote effective teaching and learning. It can be used at the beginning of a clerkship and ideally at the beginning of each teaching encounter. Most ineffective and uncomfortable teaching encounters are due to the lack of a clear learner contract. Taking a little time with the student at the beginning of the clerkship to discuss and agree on expectations, roles, and ways of communicating with each other can save lots of time and frustrations during the month.

References
1. Pratt D, Magill MK. Educational contracts: a basis of effective clinical teaching, J Med Educ 1983;58:462-7.
2. Society of Teachers of Family Medicine. Preceptor education project. Kansas City, Mo: Society of Teachers of Family Medicine, 1992.
3. Stritter FT, Baker RM, Shahady EJ. Clinical instruction. In: McGaghie WC, Frey JJ, eds. Handbook for the academic physician. New York: Springer-Verlag, 1986. 4. Benzie D. Teaching styles. Fam Med 1998; 30(2):88-9.

Correspondence: Address correspondence to Dr Ferrante, University of South Florida, 12901 Bruce B. Downs Boulevard/MDC 13, Tampa, FL 33612-4742. 813-974-1996. Fax: 813-974-4057. E-mail: jferrant@com1.med.usf.edu.