Many of us think of bedside teaching as an effective inpatient teaching technique. In addition, bedside teaching works in the clinic and improves efficiency. A randomized trial evaluated the impact of doing internal medicine continuity clinic “sign-outs” either in the patients’ rooms or entirely in a conference room. There was no difference between groups in: 1) the amount of teaching done by the supervising doctor; 2) whether the attending physician changed the impression or plan; or 3) patient satisfaction. However, patients preferred hearing bedside discussions of their cases to not hearing these discussions. Although 10% of residents reported feeling uncomfortable doing the entire patient presentation in the examination room, the patients felt more comfortable with the interaction in this setting.5
To give the data perspective, I informally surveyed several internal medicine residents at my institution, Duke University Health System, about their subspecialty clinic experiences. These residents indicated they liked independently seeing patients initially and devising preliminary impressions and plans. They value being taught during the patient encounter and having faculty spend time pointing out and practicing physical examination skills particular to rheumatology—all consistent with adult learning theory (adults learn best when addressing a problem in real time). The residents I surveyed universally disliked feeling they were just “tagging along.” They like to be helpful. They do not mind dictating notes when they participate in the visits and help to develop assessments and plans. However, they dislike dictating when they feel their only purpose is to document the visit, especially when they did not even understand the rationale for assessment and treatment decisions.
Efficient Outpatient Teaching Methods, Evaluation and Management Guidelines Overview
The traditional clinical teaching encounter is directed primarily towards patient care, not towards meeting learners’ needs. Traditionally, attendings’ questions serve to clarify clinical data. Teaching occurs as mini-lectures rather than discussion, and the trainee receives little or no feedback on her clinical reasoning skills, perhaps because reasoning skills are not evident in such interactions. Rather, the trainee who appears most competent is the one who best presents data. Unfortunately, such interactions, which neither explore nor reward expressing uncertainty and thinking through diagnostic possibilities, do not promote growth of the trainee as a practitioner.
Fortunately, a few skills can help you both review the data necessary to care for your patients and help you be attentive to the learner’s needs and development of clinical reasoning through effective feedback. One widely referenced outpatient teaching method is the “One-Minute Preceptor” (OMP) model, a learner-centered strategy for efficient teaching.6 The OMP allows discussion of patient data to provide patient care while ensuring that the preceptor–trainee interaction focuses on the thought required to derive clinical conclusions (see Table 2). In this model, the preceptor listens to the trainee’s presentation and then asks the trainee to articulate a diagnosis. The trainee is asked to discuss and support this diagnosis. After this discussion, the preceptor makes a related teaching point then provides positive and constructive feedback on the trainee’s clinical reasoning. Through listening to a trainee justify his or her conclusions, the preceptor can assess the trainee’s clinical abilities. The teaching interaction concludes with constructive feedback on what the trainee did well and what the trainee can improve. When compared to traditional teaching in published studies, the OMP allows preceptors to diagnose patient’s problems equally or better, preceptors can rate students with greater confidence, and preceptors rate OMP encounters as more effective and efficient. Students rate the OMP as a more effective teaching strategy than traditional teaching.7,8
