Facilitating After-Clinic Teaching Conferences

(accompanying PowerPointŇ presentation)

CDR John R. Holman, MC,USN

(edited for web page by CDR DL Hufford, MC, USN, 03 JUL 99)

Faculty Development Fellowship

Madigan Army Medical Center

Goal:

  1. Define the goals and learning objectives for after-clinic conferences.

Learning Objectives:

  1. Discuss in small groups the use of collaborative teaching and case-based teaching in after-clinic conference sessions.
  2. In small groups write a goal and 1 to 3 achievement-based objectives for after-clinic conference.
  3. In a large group, share your goals and objectives.
  4. In a large group, develop methods of applying the biopsychosocial model in after-clinic conference.

Introduction:

            Traditional medical education has focused on the patient who is admitted to the hospital and cared for by a team of physicians and students of various levels of training and experience. With the increased emphasis on ambulatory care, mainly for economic reasons, medical education has also shifted to the outpatient setting . However, due to time constraints and the high ratio of learners to teachers, the learning techniques used with inpatient teaching may not be applicable in the ambulatory setting . Important techniques for teaching and learning in the ambulatory care setting include:

For this session, we will concentrate on case-based teaching and collaborative learning as it applies to the after-clinic conference.

After-Clinic Conference:

            After an extensive review of the medical and educational literature, there are no articles that discuss after-clinic conferences (ACC) and their purpose for learning in the ambulatory setting. Three articles discussed an "ambulatory morning report" where the clinic attending reviews the encounter sheets from residents’ clinics in the afternoon and prepares a brief teaching session for the next morning after the resident/student presents the patients’ history and physical exam findings. The possible goals for ACC may include time for reflection on challenging patient encounters, case-based teaching for ambulatory medical problems, collaborative learning among students, residents, fellows and faculty, and incorporation of the biopsychosocial model in ambulatory care. In conclusion, ACC can be whatever we decide it should be. However, I believe each learning session we engage in should have clear goals and achievement-based objectives. This includes ACC!

Case-Based Teaching:

            Case presentations offer preceptors and learners a key opportunity for teaching and learning. What is the optimal environment to conduct this type of teaching? In our busy clinic, residents typically present to the preceptor in the attending room, discuss the possible diagnoses, review treatment options, and decide on a plan together. The resident returns to the patient to relay the information decided upon. The preceptor infrequently interviews or examines the patient, due to time constraints. This may limit educational effectiveness. Having the learner’s case presentation in the examination room increases the preceptor’s "face time’ with the patient, reinforces the learners role, and facilitates almost instantaneous feedback from the patient. The preceptor may also have the opportunity to observe the learner’s "real-time" performance and provide immediate feedback after the patient encounter. Can this type of preceptor-learner interaction take place in our clinic? I believe so, if the preceptors want it to. The preceptor would have to leave the "safety" of the attending office and listen to case presentations while in the examination room with the patients and learners present.

            Case-based teaching can also be used in the ACC. However, there is often very little or no time for clinic attendings to prepare for these teaching sessions. If the preceptor cannot provide the learners with the latest recommendations from the literature, what do they teach? The teacher must rely heavily on very focused teaching and preexisting teaching scripts 7. Clinical teachers develop teaching scripts. These are action-oriented instructional knowledge developed through repetitive teaching of the same illness or medical content. Teaching scripts are content specific and include general goals for instruction, key teaching points, representations of the content, knowledge of learners’ difficulties, and knowledge of how to help learners overcome these difficulties. Since the number of primary problems seen in clinic is relatively limited (10-20) teaching scripts may develop rather rapidly. However, the repertoire of options within the scripts maybe rather limited. In conclusion, the most effective case-based teaching occurs when the preceptor has a teaching script already developed for a common ambulatory care problem.

Collaborative Learning:

            One of the major differences between education in the inpatient setting and education in the outpatient setting is the lack of team learning in the ambulatory care clinic. Most of the interactions are between the learner and the patient, and then between the learner and the attending physician. The limitations of this one-on-one teaching model may be overcome with supplemental collaborative learning opportunities such as ambulatory morning report or ACC. These venues offer an opportunity for social learning in the context of caring for ambulatory patients 4 5 6. The content to be learned during these sessions should offer a spiraling approach to patient problems—beginning with common complaints and moving toward more complicated illnesses. Medical students need to understand common illnesses in enough depth to develop strong prototypes or key features of a disease. Interns need a focus on rapid diagnosis and management of both common and complex cases. Senior residents need the challenge of complex and unusual cases to stimulate their interest and continued growth.

            Collaborative learning in ACC may also be accomplished using small groups of students, house officers and faculty distributed equally. The "team" can then be asked to tackle a case presentation and provide a differential diagnosis, evaluation and treatment plan. Differences in plans can be discussed as a large group when each small group reviews their recommendations.

Conclusions:

            ACC can be an excellent forum for two important formats for ambulatory teaching—case-based teaching and collaborative learning. However, ACC can involve other types of ambulatory education. The critical element is to decide what is the goal of ACC. It is very important to have a goal and achievement-based objectives for each learning session in medical education. This information can serve as an outline for both learners and teachers for their experiences in ACC and may help improve the learning that occurs there. ACC can remain informal and unstructured. The faculty should decide what they want ACC to be and develop goals and objectives to accomplish this.

Bibliography:

1. Stagnaro-Green A, Packman C, Baker E, Elnicki DM. Ambulatory education: expanding undergraduate experience in medical education. A CDIM commentary. Am J Med 1995;99:111-115.

2. Cope DW, Sherman S, Robbins AS. Restructuring VA ambulatory care and medical education: The PACE model of primary care. Acad Med 1996:71(7):761-771.

3. Irby DM. Teaching and learning in ambulatory care settings: a thematic review of the literature. Acad Med 1995;70(10):898-931.

4. Malone ML, Jackson TC. Educational characteristics of ambulatory morning report. J Gen Intern Med 1993;8:512-514.

5. Paccione GA, Cohen E, Schwartz CE. From forms to focus. A new teaching model in ambulatory medicine. Arch Intern Med 1984;149:2407-2411.

6. Wartman SA, O’Sullivan PS, Cyr MG. Ambulatory-based residency education: improving the congruence of teaching, learning and patient care. Ann Intern Med 1992;116:1071-1075.

7. Irby DM. How attending physicians make instructional decisions when conducting teaching rounds. Acad Med 1992;67:630-638.

8. Ferenchick G, Simpson D, Blackman J, Darosa D, Dunnington G. Strategies for efficient and effective teaching in the ambulatory care setting. Acad Med 1997;72:277-280.

9. Irby DM. What clinical teachers in medicine need to know. Acad Med 1994;2-69:333-342.

10. Gruppen LD, Wisdom K, Anderson DS, Woolliscroft JO. Assessing the consistency and educational benefits of students’ clinical experiences during an ambulatory care internal medicine rotation. Acad Med 1993;68:674-680.

11. Lowdermilk D, McGaghie WC. Resident learning in ambulatory care: skill adaptation and faculty supervision. Qualitative Health Res 1991;1:1089-1093.

12. Perkoff GT. Teaching clinical medicine in the ambulatory setting—An idea whose time may have finally come. N Engl J Med 1986;314:27-31.

 

Addendum:

Quick Reference for Participants

After-Clinic Conference (ACC)

Goals:

  1. Teach the family practice approach in the outpatient setting
  2. Impart accurate medical information
  3. Explore the biopsychosocial model in outpatient medicine
  4. Provide a consistent direction for the after-clinic conference learning environment.
  5. Develop collaborative problem-solving skills in the outpatient setting.

Objectives:

The clinic attending will:

  1. Be present when after-clinic conference starts.
  2. State the goal for the case discussion from the start. Include biopsychosocial aspects of care whenever possible.
  3. Function as a moderator for the group discussion.
  4. Teach common ambulatory care problems using teaching scripts.
  5. Disseminate medical data to all ACC attendees
  6. Start and finish on time.
  7. Model obtaining pertinent medical information.

The family practice residents and medical students will:

  1. Be present when ACC starts. All residents and students are encouraged to participate in ACC. Those in clinic during the morning and afternoon are REQUIRED. Allowances will be made for providers involved in direct patient care or on other rotations.
  2. Primarily present patients with common ambulatory care problems for discussion.
  3. Present patients with unusual problems secondarily.
  4. Use a focused presentation style in the SOAP format.
  5. Commit to a diagnosis, a differential and a treatment or evaluation plan at the end of the presentation.
  6. Participate in discussions regarding the evaluation and management of patients in the ambulatory setting.

The family practice staff will:

  1. Have the option of attending ACC. All staff are welcome, however, only the clinic attending staff for both the morning and afternoon are REQUIRED.
  2. Allow the attending staff to moderate the discussion.
  3. Permit medical students and residents to be the primary participants in the discussion, especially for common ambulatory medical problems.
  4. Volunteer general information regarding the evaluation and management of patients as needed to facilitate discussion.
  5. Share knowledge freely for patients with challenging or unusual problems.
  6. Incorporate the biopsychosocial model into patient care discussions.
  7. Pull together patient, time and financial issues into discussion.
  8. Retrieve current journal articles pertinent to ACC discussions for attendees as needed.
  9. Triage provider will take over remaining clinic and precepting duties to free attending to be present at ACC.
  10. Present cases if needing assistance with management.

 

Educational Strategies

  1. Use case-based teaching for general principles of ambulatory medicine.
  2. Use collaborative teaching for challenging and unusual outpatient presentations.
  3. Faculty will develop teaching scripts for common ambulatory problems.
  4. Obtain a personal computer with Internet access for the attending room and conference room to perform literature searches and obtain pertinent medical information.
  5. Teach the "One-Minute Preceptor" to faculty to help residents and students commit to a diagnosis and differential.
  6. Teach focused patient presentations to residents and students.

Evaluation Strategies

  1. Include assessment of ACC on staff, resident and student evaluation forms.
  2. Entertain informal feedback at anytime on ACC.
  3. Monitor attendance by residents and students at ACC.
  4. The Chief, Department of Family Practice iterates that this is a requirement for a satisfactory OER.

 

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