The One-Minute Preceptor
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The One-Minute Preceptor method consists of a number of skills that are employed in a stepwise fashion at the end of the learner's presentation (See Table 1.) Each step is an individual teaching technique or tool, but when combined, they form an integrated strategy for instruction in the health care setting.
|Table 1 : The One-Minute Preceptor Method|
|1||· Get a Commitment|
|2||· Probe for Supporting Evidence|
|3||· Reinforce What Was Done Well|
|4||· Give Guidance About Errors and Omissions|
|5||· Teach General Principles|
Consider a common situation for precepting encounters, especially with less advanced students. The student's presentation is rather unorganized, verbose, and after completion, the student looks hopefully to the preceptor for guidance in making sense out of the clinical data. As a preceptor, it can be difficult to try to decide what direction to take with the student at this point, and very often, the response of the preceptor is to provide all of the answers and to move on. Although providing the answers immediately would save a little time, it does not necessarily help to develop the student's clinical reasoning abilities.
The One-Minute Preceptor method provides an approach for your teaching encounters. It is not meant to replace other teaching approaches you have found to be successful. However, being able to utilize this approach will broaden your teaching repertoire and it will provide you with and additional instructional strategy to utilize with your students.
Let us explore each of the six steps.........
STEP ONE: Get A Commitment
After the learner has finished his/her preliminary presentation, the One-Minute Preceptor method suggests that you "get a commitment" from the learner. In other words, ask the learner to verbally commit to an aspect of the case. The act of having the learner state a commitment does a number of things: 1) it puts the learner in an active role, 2) it asks the learner to start thinking for him/herself instead of immediately looking to an outside person for the answer, and 3) it helps the teaching encounter become more personal because the learner's perspective is being requested in an explicit manner. In addition, this teaching method shows respect for the learner and fosters an adult learning style or "andragogy."
Consider an encounter where the student presents the history and physical, and then stops, waiting for the preceptor to take the lead. An appropriate question from the preceptor at this point might be: "What do you think is going on with this patient?" This approach encourages the learner to further process the information they have gathered. You obtain important information on the learner's clinical reasoning ability and the learner is given a higher sense of involvement and responsibility in the care of the patient. If the answer is "correct," you have the opportunity to reinforce the learner. If the response is "incorrect," you have identified an important teaching opportunity. In addition, the impact of this teaching opportunity is likely to be greater because it is tied to a clinical case that directly relates to the student at that point in time.
Not all learners will stop at the same point in their presentation, but you can still get a commitment. Additional examples of questions you could ask the learner to "get a commitment" are:
"What other diagnoses would you consider in this setting?"
"What laboratory tests do you think we should get?"
"How do you think we should treat this patient?"
"Do you think this patient needs to be hospitalized?"
"Based on the history you obtained, what parts of the physical should we focus on?"
By selecting an appropriate question, you can encourage learners at any stage in their training to expand their current skills and abilities.
Note: The questions you use to get a commitment from the learner do not need to simply gather further data about the case. The goal is to gain insight into the learner's reasoning abilities. In addition, the line of questioning that you choose is critical to the teaching encounter. It not only helps you assess the learner's knowledge and skill level, it also serves as a model of your clinical reasoning process.
STEP TWO: Probe For Supporting Evidence
Now that you have a commitment from the learner, it is important to explore the basis for his/her opinion. The educational setting often rewards a lucky guess to the same degree as a well-reasoned, logical answer. In the clinical setting, it is important to determine that the student has an adequate basis for his/her answer and to encourage an appropriate reasoning process. By the same token, it is important to identify the "lucky guess" and to demonstrate the use of appropriate supporting evidence.
Once the learner has made his/her commitment and looks to you for confirmation, it is a good idea to try to resist the urge to pass immediate judgment on the response . Instead, ask a question that seeks to understand the student's rationale for the answer. The question you ask will depend on how the student has responded to your request for a commitment.
Some sample questions you could ask are:
"What factors in the history and physical support your diagnosis?"
"What factors made you choose that particular medication?"
"Why do you feel this patient should be hospitalized?"
"Why would it be important to do that part of the physical in this situation?"
There are significant benefits to using Step Two. You are able to immediately gauge the strength of evidence upon which the student's commitment was made. In addition, faulty inferences or conclusions may become apparent and can be corrected. This step enables you to assess the learner's clinical reasoning and assists the learner in improving this skill.
STEP THREE: Reinforce What Was Done Well
In order for the learner to improve, it is important to identify what he/she did well. The simple statement, "That was a good presentation" is not sufficient. The learner has no idea "what" about the presentation was good. It is important for you to include specific behaviors in your reinforcing comments to the student.
"Your diagnosis of 'probable pneumonia' was well supported by your history and physical. You clearly integrated the patient's history and your physical findings in making that assessment."
"Your presentation was well organized. You outlined the chief complain, followed by a detailed history of present illness. You included appropriate additional medical history and medications, and finished with a focused physical exam."
STEP FOUR: Give Guidance About Errors and Omissions
Just as it is important for the learner to hear what he/she did well, it is also important to tell them what areas need improvement. Although this step is often the hardest for many of us, it fosters continuing growth and improved performance by identifying areas of relative weakness. In framing your comments, it is helpful to avoid extreme terms such as "bad" or "poor." Instead, focus your comments on specific behaviors that the learner can change or modify in the future. Include guidance on alternative actions or behaviors the student could use in future situations.
For more information on providing feedback to students, refer to Module 3.
STEP FIVE: Teach A General Principle
One of the key but challenging tasks for the learner is to take information and data gained from an individual learning situation and to accurately and correctly generalize it to other situations. There may be a tendency to over generalize - to conclude that all patients in a similar clinical situation may behave in the same way or require the exact same treatment. Or, the learner may be unable to identify an important general principle that can indeed be applied effectively in the future. Brief teaching that is specifically focused to the encounter can be very effective. Even if you do not have a specific medical fact to share, information regarding strategies to search for additional information, process information, or information that relates to hospital admission can be useful to the learner.
Here are some examples of general principles:
"Smokers are more likely than non-smokers to be infected with gram-negative organisms. This is one situation where you may need to broaden your antibiotic coverage to be sure to cover these more resistant organisms."
"Deciding whether someone needs to be treated in the hospital for pneumonia is challenging. Fortunately, there are some criteria that have been tested which help........"
"In looking for information on what antibiotics to choose for a disease, I have found it more useful to use an up-to-date handbook rather than a textbook, which may be several years out-of-date."
Because of time limitations, it probably will not be practical to conduct a major teaching session at that point in time. However, a statement or two that outline a relevant and practical teaching point can have a significant impact on the learner.
STEP SIX: Conclusion
Time management is a critical component to clinical teaching. This final step serves the very important function of ending the teaching interaction and defining what the role of the learner will be in the next events. It sometimes is easy for a teaching encounter to last much longer than anticipated, with negative effects on the remainder of the patient care schedule. It is helpful if you are aware of time and not rely on the student to limit or end the interaction.
After the teaching encounter, the roles of the preceptor (you) and the learner may need to be defined. In some cases, you may wish to be the observer while the student performs the physical or reviews the treatment plan with the patient. In other cases, you may wish to go into the patient's exam room to confirm the student's physical findings and then review the case with the patient yourself. Explaining to the student what the next steps will be and what their role should be will facilitate the care of the patient and the functioning of the learner.
"OK, now we'll go back in the room and I'll repeat the lung exam and talk to the patient. After that, I would like you to help the nurse get a peak flow, a pulse ox, and a CBC. When we've gotten all of those results, let me know and we can make a final decision about our treatment plan and whether we need to hospitalize this patient."
The teaching encounter is smoothly concluded and the roles and expectations for each person are made clear, ultimately facilitating learning and optimizing patient care.