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Gordon, Meyer, and Irby
(1995)
The One-Minute preceptor summarizes
five user-friendly techniques that you can put to use in a busy
clinic setting.
Microskill 1: Get a
Commitment
Situation: After presenting a case to you, the student
stops to wait for your response or asks you what to do.
Preceptor: Ask the
student what he or she thinks about the issue. The student's
response will allow you to assess student's knowledge and focus
more precisely on learning needs.
Sample questions:
"What do you think is going on with
this patient?"
"What would you like to
accomplish in this visit?"
"Why do you think the patient
has been non-compliant?"
Microskill 2: Probe for
Supporting Evidence
Situation: The student
has committed to a position in the issue presented and looks to you
to confirm or correct.
Preceptor: Before
giving an opinion, ask the student what evidence supports his or
her opinion.
Alternatively, ask what other
alternatives were considered and how they were rejected in favor of
the student's choice.
Sample
questions:
"What were the major findings that
led to your conclusion?"
"What else did you
consider?" "How did you reject that choice?"
"What are the key features of
his case?"
Microskill 3: Teach General
Rules
Situation: You have
ascertained that there is something about the case which the
student needs or wants to know.
Preceptor: Provide
general rules at the level of the student's understanding. A
generalizable teaching point can be phrased as, "When this happens,
do this…." General rules are more memorable and
transferrable than specific facts.
Example:
"If the patient only has cellulitis,
incision and drainage is not possible. You have to wait until
the area becomes fluctuant to drain it."
"Patients with UTI usually
experience pain with urination, increased frequency and urgency,
and they may have hematuria. The urinalysis should show
bacteria and WBCs, and may also have some RBCs."
Microskill 4: Tell Them
What They Did Right
Situation: The student
has handled a situation effectively.
Preceptor: At the
first opportunity, comment on the specific good work
AND the effect that it had. As
Belasco (1989) wrote, "What gets
measured gets produced; what gets rewarded gets produced
again."
Example:
"You didn't jump into working up her
complaint of abdominal pain, but kept open until the patient
revealed her real agenda. In the long run, you saved yourself
and the patient a lot of time and unnecessary expense by getting to
the heart of her concerns first."
"Obviously, you considered the
patient's finances in your selection of a drug. Your
sensitivity to this will certainly contribute to improving his
compliance."
"Why do you think the patient has
been non-compliant?"
Microskill 5: Correct
Mistakes
Situation: The student
has made mistakes, omissions, or demonstrated distortions or
misunderstandings.
Preceptor: As soon as possible after the mistake, find
an appropriate time and place to discuss what was wrong and how to
correct the error or avoid it in the future. Let the student
critique his or her performance first. The student is likely
to repeat mistakes that go uncorrected.
Example:
"You may be right that this
patient's symptoms are probably due to a viral upper respiratory
Infection. But you can't be sure it isn't otitis media unless
you've examined the ears."
"I agree that the patient is
probably drug-seeking, but we still need to do a careful history
and physical examination."
Apply the One-Minute Preceptor
Microskills to create an alternative strategy to the preceptor's
response in the next situation. Compare your alternative
response to one better alternative found below.
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The Case of the
Painful Ear
Context: A bright,
eager Nurse Practitioner student presents this case to her
preceptor in the Ambulatory clinic.
Student: "I just saw a
4 year old boy in the clinic with a complaint of ear pain and fever
for the past 24 hours. He has a history of prior episodes of
otitis media, usually occurring whenever he has an upper
respiratory tract infection. For the past 2 days, he has had
a runny nose and mild cough. Yesterday he began to
have a low grade fever and complained that his right ear was
hurting. His mother gave him Tylenol last night and again
this morning when he got up. He has no allergies to
medication."
"On physical exam, he appeared in no
acute distress and was alert and cooperative. His temperature
was 38.5 C. His HEENT exam was remarkable for a snotty nose
and I think his right tympanic membrane was red, but I'm not
sure. It looked different from the left one. His
throat was not infected. His neck was supple without
adenopathy. His lungs were clear and his heart had no
murmur. I didn't see any rashes or skin lesions.
Preceptor: "This is
obviously a case of otitis media. Give the child amoxicillin
and send him home."
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Applying One-Minute Preceptor
Microskills To the Case of the Painful Ear
One Alternative
Strategy:
Preceptor: What do you think is going on?
Student: I think he has upper respiratory infection,
probably otitis media.
Preceptor: What led you to that
conclusion?
Student: He has a history of repeated otitis media and
currently has a fever, a painful right ear and a runny
nose.
Preceptor: What would you like to do for him?
Student: First, I would like you to confirm my findings on
the right ear. If you concur about otitis media, then we
should give him some antibiotics. Since he doesn't have any
allergies to medication, I think amoxicillin is a reasonable
choice.
Preceptor: You did a good job of putting the history
and physical exam findings together into a coherent whole. It
does sound as if otitis media is the most likely problem.
There is great variability in ear problems. The key features
of otitis media that I look for in the physical exam are the
appearance and mobility of the ear drum, landmarks, opacity of the
drum, and mucus discharge, and in the history are prior upper
respiratory infections and past problems with the ears. This
child would seem to fit these criteria. With the lack of
allergies, amoxicillin is a logical choice for an antibiotic.
I'll be glad to confirm your ear exam findings. Let's go and
see the patient.
As you read this alternative
response, were you thinking, "But my student doesn't respond like
the student in this ideal situation"? The preceptor-student
relationship is indeed a relationship--you can't conduct it
effectively all by yourself. One of the things the student
needs to learn is how to learn successfully in a
preceptorship. Give the student some examples of the kind of
responses you expect from the student.
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