September 1998

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Editor's Note: Editor’s Note: This column addresses a teaching strategy to improve the educational experience for medical students at all levels of training. Christine Taylor, PhD, serves as assistant dean for faculty development at the Medical College of Ohio. Martin S. Lipsky, MD, is professor and chair of the Department of Family Medicine at Northwestern University, and Laurence Bauer, MSW, MEd, is assistant professor at Wright State University.

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.

The education and training of physicians has changed considerably over the past 10 years; medical students enter clinical experiences earlier, and education and training occur more frequently in the ambulatory setting. Training medical students in a busy family physician’s office presents educational challenges for both students and their clinical teachers. Although students report that they enjoy the variety of a family practice schedule, they also relate their difficulty in dealing with the diverse pathology, age groups, and problem types encountered at a family practice office. It appears that the very thing that attracts students to the idea of family practice (variety) often leaves them feeling overwhelmed and frustrated. The medical student is not the only member of the teaching/learning team to encounter frustration. Pressured to increase productivity, our community-based clinical teachers, if they are to teach at all, must use their time wisely and efficiently to balance the needs of their practice with the educational needs of students.

In response to the challenge of teaching early clinical experiences in the most educationally sound and clinically efficient manner, we propose using a teaching strategy described as the “focused half day.” The objective of the focused half-day teaching approach is to provide first- and second-year students with a more structured and manageable learning environment while exploring the unpredictable and often overwhelming variety that is the trademark of the family practice office. At the same time, this strategy offers timesaving benefits to the busy office practitioner.

Focused Half Day
The focused half day uses the half-day patient schedule as an orienting and focusing tool. Students and their preceptors review the patient schedule either the night before or at the beginning of the session and discuss the proposed reason for each patient encounter. Based on the patient list, the student and preceptor pick a teaching issue of the day and choose a limited number of teaching patients that demonstrate that issue. The theme or teaching/learning issue can be based on common disease, type of patients, focused physical exam, a specific procedural skill to be learned, or any issue of interest to the student that can be demonstrated with the patients available. Students are given time before and during office hours for preparation, chart review, and reflection on the teaching issue. This additional planned activity provides the student with an important task to accomplish while the preceptor is engaged elsewhere and reduces the down time students so often complain of when they are participating in longitudinal preceptorships in the first and second year. Skeff et al 1 have suggested that even though the “office setting is more ‘fluid’ and less predictable than the other more traditional learning settings, planning remains a key activity.” In the ambulatory setting, the schedule is the planning structure or “table of contents” for that day’s educational experience.

The focused half-day orienting activities provide a vehicle for the preceptor to structure the clinical experience to the level of the student and to identify themes consistent with course objectives, despite an unpredictable schedule. By incorporating students’ input into selecting themes and patients, focused half-day precepting encourages students to identify needs, stimulates self-directed learning, and encourages student-teacher interaction.2 Students are given the opportunity for mental preparation and reflection, which are important activities for processing and retaining information they have learned.3

Benefits
• The student receives focused teaching on a subject for each day. This allows the student to prepare and feel less overwhelmed and frustrated. Between “teaching patients,” the student has time to review resources and prepare for a conversation with the attending at the end of the half day. The student still sees a variety of patients over the experience and appreciates the complexity of family practice.
• The student and preceptor are able to focus teaching on the competencies—objectives and/or selected common clinical problems identified in their course requirements—and at the same time sample the variety so characteristic of family practice.
• The preceptor can see the non-teaching patients in a more timely fashion while the student is fully engaged in either seeing teaching patients or reading and preparing for the next patient.
• The less-experienced preceptor can also focus on a limited number of teaching issues for the day.

Early Experiences With the Focused Half Day
Students who had the opportunity to interact with a preceptor trained in using the focused half-day approach reported that it was highly effective for learning in the office setting. First-year students viewed these activities as “extremely beneficial;” some viewed them as “essential” to getting anything out of the clinic experience. The students all referred to a mental preparation theme when discussing the activities. Although students had difficulty stating exactly how individual strategies helped them learn, they reported that the “review of schedule” helped trigger their memory for important facts, made them feel more comfortable, prompted them to read and prepare, and helped them formulate better questions during patient interviews.

Physicians who use the focused half-day strategy found it helpful and workable despite practice demands and the unpredictability of adjusted schedules. Physicians reported that the focused half-day strategy helped them to “know where the student was coming from” and enhanced their confidence as teachers. One preceptor commented that imposing structured time for reflection for the student also helped to organize his/her day. All preceptors stated that they would continue to use the focused half-day strategy “in some form” in the future.

In summary, providing structure for students in the form of focused teaching is educationally sound and has proven to be useful for novice learners and a time-efficient strategy for busy community-based clinical faculty.

References
1. Skeff KM, Bowen JL, Irby DM. Protecting time for teaching in the ambulatory care setting. Acad Med 1997;72:694-7.
2. Hannafin MJ. The effects of orienting activities, cueing, and practice on learning of computer-based instruction. Journal of Educational Research 1987;81:48-53.
3. Ausubel DP. The use of the advance organizers in learning and retention of meaningful information. J Educ Psychol 1960; 51:267-72.

Corresponding Author: Address correspondence to Dr Taylor, Medical College of Ohio, Associate Dean for Faculty Development, Raymond H. Mulford Library Building, 3045 Arlington Avenue, Toledo, OH 43614-5805. 419-383-4249. Fax: 419-383-6100. E-mail: ctaylor@.mco.edu.

Editor's Note: In this column, Dan Benzie, MD, provides useful information about dealing with difficult teaching situations. Dr Benzie is associate professor with the Department of Family Medicine at the University of Minnesota-Duluth.

From time to time, we all find ourselves in difficult teaching situations that can make the job uncomfortable. Although most community teaching experiences are positive, there are occasional circumstances where a difficult situation arises or a specific student conflict develops that make us question why we volunteered to teach. There can be problems with: 1) the individual student, 2) the teacher-student interactions or teaching style, 3) relating to the environment, or 4) relating to curricular expectations.

Occasionally, there are situations or individual student problems that cannot be solved in a short clinical rotation or that are beyond our control as teachers. Should this occur, it may be best to work with the university and change the student, the teacher, or the clinical setting. By keeping communication open, however, and involving the student in the problem solving, most conflicts can be resolved and lead to a stronger student-teacher bond.

Student Concerns
Just as with our patients, there are many different student personalities, some of which we are more comfortable with than others.

A student may have a weak knowledge base and not feel comfortable asking or answering questions for fear of not knowing the correct answers. This can also lead to rapid decision making and, at times, poor clinical judgement. A weak knowledge base can also result in the student not asking the patient the appropriate questions or ending the history early for lack of questions to ask.

It is better to know some of the questions than to know all of the answers. — James Thurber

Student-Teacher Interactions
A student’s individual learning style may conflict with your teaching style, and he/she may require more direction or more flexibility than you are accustomed to giving.

However, some conflicts that are identified as personality differences are actually issues of ignorance over expectations between the teacher and learner. Open communication can correct these quickly.

Each student brings with him/her a unique background, with individual learning styles and educational experiences, as well as his/her own ideas on how students should be taught. Students may have personal agendas, including relationships, family conflicts, and career goals that may interfere with learning in the style you would prefer. The student may also present to your office with preconceived biases about certain patient populations. Developing an understanding of your student’s personal life can help you to see through his/her eyes and will help form a better student-teacher relationship.

Office Environment
There will be times when the office is not a comfortable learning environment. This may be a result of overworked physicians, pressure from management to be more productive with patient volume, or too many student commitments. This can result in students feeling like they are a burden on the office and that they’re not contributing to patient care. This may make learning quite difficult.

The curriculum or content that the student or resident is expected to learn can also cause conflicts. At times, you may feel that the information is too basic or too complex for a student at this level, or you may disagree with the goals of the university. The curriculum is designed for large numbers of students and may have to be individualized for a student to achieve the most from his/her rotation.

Occasionally, patients will not want to see a student. Sometimes, this is a result of a personal issue the patient needs to discuss directly with the physician, but often it is more an issue of educating the patients about teaching and about maintaining good communications.

Solutions
The key ingredient to solving conflicts with students in the office is keeping communication open. This will involve assessing, with the student’s input, what the problem is. It will involve mutually agreeing on the solutions and frequent and specific feedback. It is appropriate to consult one of your partners or university colleagues to get another perspective, especially if you feel your rapport with the student is not good.

Helpful Feedback in Interacting With a Difficult Situation1
1) Give specific rather than general feedback. 2) Focus on behavior rather than personality. 3) Share information with students rather than give advice; this allows them to participate in the decision making. 4) Identify problems at the earliest opportunity; don’t let problems build. 5) Address behaviors or areas that can be changed. 6) Get the student’s assessment of the situation and his/her assessment of problem areas before offering your own feedback.

The initial step in solving a problem is to gather as much information as time allows. Consult your office staff, hospital staff, patients, or others the student may have encountered. If it appears there may be an emotional, psychological, or chemical use problem, then it is best to not get further involved—transfer the problem to the student’s university faculty.

If problems are a result of a student’s bias against a particular ethnic group, socioeconomic class, or specific patient population, then this should be brought to the student’s attention and monitored to make sure that this bias is not interfering with patient care. It is unrealistic to expect that you will change a bias during your short time with the student, but it is critical that students have an awareness of their biases and that patient care is not compromised.

If the problem is a student’s limited knowledge base, then a good approach is to begin with the basics and give the student limited responsibilities with frequent feedback. Try to “lengthen the leash” as the student progresses so he/she doesn’t get bored, but continue monitoring his/her progress with frequent questioning and positive feedback. These students should also be given frequent reading assignments and asked about them the following day. This will help them develop appropriate study patterns for the future.

Communications in the office environment can be facilitated by the office staff informing the patients when they arrive that a student is working with the doctor.

The physician can introduce students as part of the team, and students can assure patients that their doctor will be seeing them during the visit. If one physician’s patients are avoiding a student, this can be corrected by having the student work with several physicians at a time, thereby avoiding long wait times while one physician is seeing patients. The student may also interact with those patients on a different level by working with the nurses or midlevel practitioners in the office; patients often perceive this as less threatening.

When the problem is a result of office circumstances that you are unable to change, it may be a good time to share the teaching more evenly around the office, to give the student more library or independent study time or, if possible, to adjust your patient schedule. Remember that the student has other responsibilities, including library study and independent study cases to review. In addition, residents have clinic patients of their own.

A general plan for resolving teaching conflicts should include: 1) Ask if the student has any unresolved issues or specific feelings. 2) Develop a specific plan and timeline. 3) End on a positive note. 4) Give frequent feedback. 5) Don’t hesitate to consult with your colleagues or faculty from the school. Establish good communication. Appropriately assess the student. Review your own teaching methods and the office environment. With these methods, most difficult learning situations can turn into positive experiences for everyone involved, while still maintaining quality patient care.

References
1. Franks R. Difficult teaching situations. Presented at RHS Retreat, University of Minnesota-Duluth School of Medicine; February 22, 1997.

Correspondence: Address correspondence to Dr Benzie, University of Minnesota-Duluth, Department of Family Medicine, 139 Med, 10 University Drive, Duluth, MN 55812. 218-726-7574. Fax: 218-726-6235. E-mail: dbenzie@d.umn.edu.