May 1999

For the Office-based Teacher of Family Medicine

Paul M. Paulman, MD
Feature Editor

Example is not the main thing in influencing others. It is the only thing.
	- Albert Schweitzer1

An increasing number of medical schools are offering generalist clinical experiences to students during the first 2 (preclinical) years of medical school. These experiences are enthusiastically received by students, since they offer reality checks and opportunities to apply newly acquired medical knowledge and practice evolving clinical skills during the traditional basic science years. Preceptors or community-based teaching physicians may provide these students with their first intimate experiences of doctoring. As physician teachers, preceptors serve as role models, clinical instructors, evaluators, and mentors for preclinical students.2 Each of these functions is reviewed below.

Role Model
Medical students observe and emulate physician role models to develop their own standards for appropriate physician behavior.3 From hand washing to conducting interviews and physical examinations, students notice the nuances of physician behaviors toward patients, staff, and colleagues. Many of these behaviors will be incorporated into the students’ professional identity. Witnessing nonjudgmental interviewing and cultural competence, as well as the application of medical science to patient problems, allows students to appreciate the importance of integrating the art and science of medicine in the delivery of high-quality patient care. Physician role models may convey powerful messages that are difficult to cover in the formal medical school curriculum. How does the physician cultivate the doctor-patient relationship, respond to patient emotion, convey empathy, or motivate patients to change behavior? How does the physician use his/her knowledge of the unique qualities of the patient, family, and community to improve health? When is physician self-disclosure useful in patient care? How do physicians address the problems of uninsured patients in their practice? To what extent is the physician involved in the community? How do physicians manage time in busy clinical practice and balance their professional and personal lives? Generalist physicians can dispel the myths that portray them as triage physicians who manage only simple problems by demonstrating the complexity and skills required for the delivery of comprehensive primary care.4

Clinical Instructor
Preclinical teachers initiate students to a new and unfamiliar medical culture with particular customs, language, and procedures. What you teach a preclinical student is quite different from what you emphasize to a third- or fourth-year student. Introducing the student to the way you understand patients and their problems by thinking out loud will help demystify the black box of clinical decision making and allow the student to begin to think like a doctor. Helping students decipher medical lingo and abbreviations may be necessary as they master a new vocabulary. Keep your clinical teaching simple. Focusing on the basics of history and physical exam is a good way to begin. To avoid falling behind in patient schedules, most preceptors first have preclinical students observe and later participate in the physical exam. Carefully consider which patients are most appropriate, since students can be overwhelmed by their first clinical experiences. Students may not feel empowered to say no when they feel unprepared for a particular learning opportunity. Use caution when involving students in procedures or sensitive exams of the breasts or genitalia until they have received appropriate training. Remembering your own early patient encounters may be of help in deciding what to emphasize and teach. As students gain confidence and skills, they may be ready to complete preliminary interviews and focused exams alone. All history and physical findings should be confirmed. An experienced physician’s methods of interviewing and observation often reveal critical patient information easily missed by the student. In addition, patients may more readily reveal sensitive information to a well-known primary care physician than to a student in training.

Evaluator
Students rely on clinical teachers to provide feedback on their performance. At this early stage, when a student is developing new skills, it is important to concentrate on providing specific positive feedback for work well done. “I liked the way you made good eye contact and were gentle in unwrapping the patient’s wound” is more useful than “Good job.” Constructive feedback should be tailored to help students understand their learning needs: “You may need to review the anatomy of the shoulder to conduct a good physical exam and understand rotator cuff injuries.” Students should understand that the preclinical environment is a safe place in which they will learn by experience and inquiry. This will allow them to comfortably disclose uncertainties or learning needs. Repeated questioning or pimping is rarely conducive to learning. Early in a career, this style can be particularly demoralizing and should be avoided. Most preclinical experiences have limited goals, and the final student evaluation may consist of a brief discussion/narrative with suggestions for improvement.

Mentor
If the student is assigned to your clinic for a longitudinal clinical experience, you have the opportunity to get to know the student in depth. With this long-term relationship, you may come to know the student better than any other faculty member. You may be able to provide assistance as the student formulates professional identity and goals. Being supportive during the difficult transition to medical school can help bolster the student’s much-needed self-confidence. If you suspect that the student is experiencing serious problems, suggest professional guidance—avoid becoming the student’s therapist. If you are comfortable doing so, disclosing information about how you balance your personal and professional life may be greatly appreciated by students. Consider inviting the student to your home for informal socializing and the opportunity to meet family and friends. Enthusiasm for teaching and your clinical practice is important in making the student’s first clinical experience a positive one.

Summary
Preclinical preceptors have an opportunity to imprint students with good clinical work habits, professionalism, and excitement for medical education. While attention to the multiple roles of the preclinical preceptor can add responsibilities to a busy physician’s day, the chance to influence the development of future physicians is deeply gratifying.

Corresponding Author: Address correspondence to Dr Haq, University of Wisconsin, Department of Family Medicine, 777 South Mills Street, Madison, WI 53715. 608-263-6546. Fax: 608-263-5813. E-mail: chaq@fammed.wisc.edu.

References

1. Schweitzer A. The world of Albert Schweitzer. New York: Harper and Brothers, 1995.
2. Whitman N, Schwenk T. Preceptors as teachers: a guide to clinical teaching. Salt Lake City: University of Utah School of Medicine, Department of Family and Preventive Medicine, 1984/1995.
3. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994; 69(11): 861-71.
4. Cassell EJ. Doctoring: the nature of primary care medicine. New York: Oxford University Press Inc, 1997.