For outpatient settings, there are several strategies for optimizing both student learning and your own schedule. Initially students may be following you in clinic, observing and taking notes on the patient visit. But as you continue into the term you may try different scheduling schemes and ways to work your student into the flow of the day.
As your student becomes proficient at taking the history and initial physical, you can allow the student to begin the visit and then join in halfway through. Ask the student to report off to you the high points of what they have learned from the patient, who may add clarifications. Then take the lead for the second half of the visit.
Wave scheduling patients
Stagger your patient time slots with student time slots. As you come to know your student, consider scheduling patients for them to initiate off the times that you are beginning a visit.
When you finish with Patient A, your student will be completing the intake information on Patient B and you can move into that room.
Develop a rhythm
The PLAN method allows you to organize the day with the student in an efficient manner:
- Present the daily plan. It helps to have a standard template for assigning patients.
- List expectations. Review with the student which patients they are responsible for and which components of the visit.
- Ask about expectations. Make sure the student understands what they are being asked to do.
- Note exceptions to the plan and potential obstacles.
Overview message to students
- Please ask any and all questions. Know that I don't have all the answers, but will do my best to help you along this clinical journey.
- Please think about and share your goals for the semester. I want to make this a positive learning experience for you. What's your learning style? Has your school given you official learning objectives?
- Plan on choosing 1 to 3 patients per day to do a thorough chart review and present to me, anticipating any needed labs or other orders. My hope is that you'll follow them through the term and get a sense of the continuity of care as well as the workflow of care. I can help you choose patients to get started, if you prefer. If you need more resources, I'm happy to share what I've got, including textbooks. We can plan to start with the non-complex patients for the first month and maybe move into a couple of the more complex patients later in the term.
- Other points: While I expect that you'll be very familiar with a few cases every week, you should/can review as many as you feel comfortable with. You certainly don't need to come into every visit with me every week, especially at the beginning as that won't be super helpful. I do expect that you'll be doing sufficient preparations to be up-to-date on the patient, arrive with questions if something isn't clear to you and eventually be able to lead a visit by the end of the semester. As you likely haven't had this type of rotation, please let me know if things are moving too quickly or too slowly for you.
- 1 to 2 weeks of observation. You should be reviewing charts in the EMR before the clinical day begins to become familiar with patients' history. You should be reviewing routine management. You should write a few SOAP notes for me to review.
- 1 to 2 weeks of choosing 2 to 3 patients per session to lead the visit with me in the room (primarily interviewing patient for chief complaint and history, and then repeating the physical exam after me). You should be documenting in the HPI/CC, ROS and Physical Exam forms.
- By midterm, you should be choosing 2 to 3 patients per day to lead the visit (without me hovering!) which again is primarily chief complaint and history. Then you'll find me, give me a report and we will do the physical examp together. Document in the HPI/CC, ROS and Physical Exam form, and eventually the Assessment/Plan form.
- As the semester progresses, you should be increasing the number of patients you're seeing independently, gradually becoming more independent in physical exams and taking over more of the management plan and education. Continue to document as above, plus writing prescriptions and entering orders for me to review/finalize.
- By the end of the semester, you should be proficient in the patient interview, the physical exam, answering routine questions and developing a routine management plan. I always need to be in the room for physical exams and must sign off on prescriptions, but I expect much of it should be led by you.
As a preceptor, you can use the following techniques to help your students become more efficient in the outpatient setting.
How much time should a student spend? Provide them with timelines—for example:
- 10 minutes to obtain as much history as possible
- 5 minutes to present history, physical examination, diagnosis and plan
Patient assignment and involvement
- Assign the student to familiar patients to make evaluation of the student's accuracy quicker.
- Assign the student to patients who enjoy extra time and attention
- Consider doing case presentations in the examination room so the patient can be involved in clinical teaching.
Practical tips for efficient visits in an outpatient clinic
- Electronically chart in patient room while student does history or physical exam.
- Alternate who does the history and who does the physical exam when seeing a patient together, so student gets practice at both but visits do not become too long
- Student can chart of the previous encounter while preceptor sees the next patient.
- To avoid embarrassing the student, identify a password or nonverbal cue to be used when the student needs help, or when you need to correct them.
Sharing and shaping documentation of encounters
At the beginning of the rotation, consider using documentation to teach. Have the student review some of your patient notes so the student can see what you expect in a note. After the review ask the student what they notice about your documentation. When the student begins to document, you might ask them to go back and look at your notes on similar cases.
The student is often in the room as you document. Take a minute and explain why you are documenting in a particular way. Scribe and teach simultaneously.
Make sure the student knows general guidelines:
- Write notes soon after meeting with the patient, but not in front of the patient.
- Use a professional voice and tone when writing medical documentation, avoiding any slang.
- Use respectful language when documenting symptoms or details.
- Document evidence for judgments and decisions.
When you review the student's notes, make corrections where needed and explain to the student why the changes were needed.
Structuring the clinical assessment to encourage thinking and reasoning
One approach to precepting is to use a structured approach to discussing a patient or differential diagnosis with a student.
A popular method is SNAPPS:
- Summarize the history and physical
- Narrow the differential to 2 or 3 possibilities
- Analyze the differential by compare and contrast
- Probe the preceptor with questions
- Plan management
- Select related issues and follow up with focused readings
Learn more about using the SNAPPS method in Precepting 101: Teaching Strategies and Tips for Success for Preceptors
Managing time and productivity
- Focus the day or week on a specific problem, e.g. hypertension.
- Have the APRN student spend extra time with particularly complex patients.
- Have the APRN student spend extra time with patients needing additional education.
- Have the APRN student prepare in advance to see assigned patients.
Lack of space
- Allow the APRN student to take history in a private non-exam space, then move patient to exam room.
- The preceptor and APRN student can work together, with each taking part of the visit.
Bridging students' clinical reasoning skills
- Challenge the student to relate what they are seeing to pathophysiology.
- Direct the student to resources and evidence-based assigned readings.
- Expect that the student will explore readings on topic and share insights.
Clinical reasoning is a process by which the student integrates the information they have collected and comes to an understanding of the client's problem or situation. Via this understanding they plan and implement an appropriate intervention.
The think aloud method fosters critical thinking and clinical reasoning skills and enhances reflective thinking.
- When you are talking about a decision, think out loud about how you come to think about the issue and the problem-solving process.
- By verbalizing your internal dialogue, you encourage the student to verbalize their own thoughts and rationale for making clinical decisions.
- It is useful to understand how the student is processing information an making decisions.
- Here you are also teaching critical thinking by asking the student to consider all possible factors as they move toward a diagnosis.
- When you are discussing a case, point out patterns in the presentation or response to treatment. Teach the student to recognize patterns.
- Talk about lessons learned in similar cases and ask the student to share similarities as they learn from experience.
1. Get a commitment: focus on one learning point
Encourage students to develop their critical thinking and clinical reasoning skills. Push the student just beyond their comfort zone and encourage them to make a decision about something, be it a diagnosis or a plan.
- Example: "So, tell me what you think is the probable diagnosis with this patient."
2. Probe for supporting evidence
Uncover the basis for the student's decision—was it a guess or was it based on a reasonable foundation of knowledge?
- Example: "What other factors in the HPI support your diagnosis?"
Provide management guidelines—discuss general management guidelines for this incidence.
3. Reinforce what was done well
Positive feedback reinforces desired behaviors, knowledge, skills and attitudes.
- Example: "You covered all the basics in ruling out a competing diagnosis."
4. Give guidance about errors/omissions
Approach the student respectfully while concurrently addressing areas of need/improvement. Without timely feedback, it is difficult to improve. If mistakes are not pointed out, students may never discover that they are making these errors and hence repeat them.
- Example: "I agree that the diagnosis and treatment plan was one way to proceed, but you did not consider..."
5. Teach a general principle
Offer a pearl of wisdom or the general principle you go on in this instance. Students tend to recall guiding principles, and often the individual patient may be a cue to recall a general rule that was taught.
- Example: "Deciding whether or not someone has this diagnosis, you start with..."
Summarize or conclude with next steps, such as a plan for the patient, a reading assignment for the student, a schedule for follow-up, etc.
- How to be an Efficient and Effective Preceptor - Biagioli
- Biagioli FE, Chappelle K. How to be an efficient and effective preceptor. Fam Pract Manag. 2010 May-Jun;17(3):18-21. PMID: 20465189; PMCID: PMC2879074.
- Supporting Nurse Practitioner Preceptor Development - Bazzell
- Bazzell, A. F., & Dains, J. E. (2017). Supporting Nurse Practitioner Preceptor Development. Journal for Nurse Practitioners, 13(8), e375-e382. https://doi.org/10.1016/j.nurpra.2017.04.013
- An Interprofessional Web-Based Resource for Health Professions Preceptors - Kassam
- Kassam R, McLeod E, Kwong M, Tidball G, Collins J, Neufeld L, Drynan D. An interprofessional Web-based resource for health professions preceptors. Am J Pharm Educ. 2012 Nov 12;76(9):168. doi: 10.5688/ajpe769168. PMID: 23193332; PMCID: PMC3508482.
- Precepting 101: Teaching Strategies and Tips for Success for Preceptors - Lazarus
- Lazarus, J. (2016). Precepting 101: teaching strategies and tips for success for preceptors. Journal of midwifery & women’s health, 61(S1), 11-21.
- How to be an Efficient and Effective Preceptor - Biagioli