Teaching the one-minute preceptor. A randomized controlled trial.

OBJECTIVE: The One-Minute Preceptor (OMP) model of faculty development is used widely to improve teaching, but its effect on teaching behavior has not been assessed. We aim to evaluate the effect of this intervention on residents' teaching skills. DESIGN: Randomized controlled trial. SETTING: Inpatient teaching services at both a tertiary care hospital and a Veterans Administration Medical Center affiliated with a University Medical Center. PARTICIPANTS: Participants included 57 second- and third-year internal medicine residents that were randomized to the intervention group (n = 28) or to the control group (n = 29). INTERVENTION: The intervention was a 1-hour session incorporating lecture, group discussion, and role-play. MEASUREMENTS AND MAIN RESULTS: Primary outcome measures were resident self-report and learner ratings of resident performance of the OMP teaching behaviors. Residents assigned to the intervention group reported statistically significant changes in all behaviors (P <.05). Eighty-seven percent of residents rated the intervention as "useful or very useful" on a 1-5 point scale with a mean of 4.28. Student ratings of teacher performance showed improvements in all skills except "Teaching General Rules." Learners of the residents in the intervention group reported increased motivation to do outside reading when compared to learners of the control residents. Ratings of overall teaching effectiveness were not significantly different between the 2 groups. CONCLUSIONS: The OMP model is a brief and easy-to-administer intervention that provides modest improvements in residents' teaching skills.

Insights from outstanding rural internal medicine residency rotations at the University of Washington.

PURPOSE: Despite being well suited to provide the breadth of care needed in rural areas, few general internists become rural physicians. Little formal rural residency training is available and no formal curricula exist. For over 25 years the University of Washington School of Medicine has provided elective WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) rural residency rotations to expose residents to the rewards and challenges of rural practice. This study identified the characteristics of outstanding rural residency rotations. METHOD: The key preceptors at three outstanding rural residency sites were interviewed about their experiences, teaching strategies, and opinions about curriculum. Their responses were categorized. Seven university-based residents and eight training at WWAMI sites recorded and rated the value of over 1,500 learning encounters. RESULTS: The preceptors agreed that outstanding rotations were led by enthusiastic preceptors who served as role models for excellence. These preceptors provided residents with meaningful responsibilities and emphasized independent decision making based on the history and physical examination. They stressed supervised independence and self-directed learning with frequent structured feedback for residents. The residents rated the learning value of patient encounters in rural locations significantly higher than that of those in university clinics. CONCLUSIONS: Exceptional rural residency experiences involve excellent role models who provide meaningful responsibility and emphasize core skills using a learner-centered approach. Rural training experiences should be supported, and the suggestions of outstanding preceptors should be used to develop and disseminate a curriculum that will better prepare residents for rural practice.

Teaching compassion and respect. Attending physicians' responses to problematic behaviors.

OBJECTIVE: To describe how and why attending physicians respond to learner behaviors that indicate negative attitudes toward patients. SETTING: Inpatient general internal medicine service of a university-affiliated public hospital. PARTICIPANTS: Four ward teams, each including an attending physician, a senior medicine resident, two interns, and up to three medical students. DESIGN: Teams were studied using participant observation of rounds (160 hours); in-depth semistructured interviews (n = 23); a structured task involving thinking aloud (n = 4, attending physicians); and patient chart review. Codes, themes, and hypotheses were identified from transcripts and field notes, and iteratively tested by blinded within-case and cross-case comparisons. MAIN RESULTS: Attending physicians identified three categories of potentially problematic behaviors: showing disrespect for patients, cutting corners, and outright hostility or rudeness. Attending physicians were rarely observed to respond to these problematic behaviors. When they did, they favored passive nonverbal gestures such as rigid posture, failing to smile, or remaining silent. Verbal responses included three techniques that avoided blaming learners: humor, referring to learners' self-interest, and medicalizing interpersonal issues. Attending physicians did not explicitly discuss attitudes, refer to moral or professional norms, "lay down the law," or call attention to their modeling, and rarely gave behavior-specific feedback. Reasons for not responding included lack of opportunity to observe interactions, sympathy for learner stress, and the unpleasantness, perceived ineffectiveness, and lack of professional reward for giving negative feedback. CONCLUSIONS: Because of uncertainty about appropriateness and effectiveness, attending physicians were reluctant to respond to perceived disrespect, uncaring, or hostility toward patients by members of their medical team. They tended to avoid, rationalize, or medicalize these behaviors, and to respond in ways that avoided moral language, did not address underlying attitudes, and left room for face-saving reinterpretations. Although these oblique techniques are sympathetically motivated, learners in stressful clinical environments may misinterpret, undervalue, or entirely fail to notice such subtle feedback.

Education in ambulatory settings: developing valid measures of educational outcomes, and other research priorities.

Efforts to redesign education in ambulatory settings are hampered by a lack of rigorous and coherent research on the learning process in these settings and the desired outcomes of the educational experiences. The authors present 13 priority research topics and 51 important research questions concerning education in ambulatory settings that were defined by a distinguished group of medical educators, clinicians, and policymakers who attended an invitational conference on education in ambulatory settings in 1996. The need to establish valid and reliable measures of quality and outcomes of educational programs and instructional interventions stood out as the major prerequisite for conducting research on education in ambulatory settings. Issues of theory building, research priorities, and research design are discussed, and policy recommendations are made for the development of valid measures of educational outcomes. The creation of a "Medical Education Outcomes Commission" is proposed to act as a repository for measures and instruments, and to provide the field with mechanism to validate instruments and uniform recommendations to conduct studies of quality. The authors urge funding agencies with missions that support medical education to invest in basic research on the outcomes of education in ambulatory settings.

Strategies for improving teaching practices: a comprehensive approach to faculty development.

Medical school faculty members are being asked to assume new academic duties for which they have received no formal training. These include time-efficient ambulatory care teaching, case-based tutorials, and new computer-based instructional programs. In order to succeed at these new teaching tasks, faculty development is essential. It is a tool for improving the educational vitality of academic institutions through attention to the competencies needed by individual teachers, and to the institutional policies required to promote academic excellence. Over the past three decades, strategies to improve teaching have been influenced by the prevailing theories of learning and research on instruction, which are described. Research on these strategies suggests that workshops and students' ratings of instruction, coupled with consultation and intensive fellowships, are effective strategies for changing teachers' actions. A comprehensive faculty development program should be built upon (1) professional development (new faculty members should be oriented to the university and to their various faculty roles); (2) instructional development (all faculty members should have access to teaching-improvement workshops, peer coaching, mentoring, and/or consultations); (3) leadership development (academic programs depend upon effective leaders and well-designed curricula; these leaders should develop the skills of scholarship to effectively evaluate and advance medical education); (4) organizational development (empowering faculty members to excel in their roles as educators requires organizational policies and procedures that encourage and reward teaching and continual learning). Comprehensive faculty development, which is more important today than ever before, empowers faculty members to excel as educators and to create vibrant academic communities that value teaching and learning.

Precollege enrichment programs intended to increase the representation of minorities in medicine.

The authors reviewed the literature published from 1966 to 1996 to identify enrichment programs for underrepresented minority precollege students sponsored by medical schools and affiliated programs, finding 19 articles describing 27 programs. The authors categorized the reported programs according to the components they contained. Most programs contained more than one component type. Twenty-four programs had an academic enhancement component. Two thirds had a motivational component to encourage students to consider medical and other health careers. Two programs set up mentoring relationship between students and health professionals. There were four research apprenticeships and three academic partnerships between medical schools and local school districts. Twelve of the 27 programs were evaluated in the literature. Eight evaluations focused on identifying the numbers of students who continued their education into college and professional schools. Five programs reported participant satisfaction or identified other short-term outcomes such as gains on standardized tests. While the percentage of participants completing college and entering health care careers is impressive, the authors do not believe that the educational success of participants can be attributed to involvement in these programs. The authors recommend ways to improve the quality and interpretability of enrichment program evaluations. Evaluators should adopt common terminology for activities and outcomes. Participants' economic and educational disadvantages should be described. Programs' theoretical underpinnings should be identified and related to evaluation. Measures should include immediate effects as well as long-term outcomes. Where possible, data from comparison groups should be reported to support conclusions. Adequate funding needs to be available to design and complete reasonable evaluations.

Development and psychometric properties of the Washington Primary Care Interest Inventory.

PURPOSE: To describe the development of the Washington Primary Care Interest Inventory (WPCII), which was designed to assess attitudes toward what constitutes appropriate psychosocial concerns for visiting a family physician, and to demonstrate the relationship between these attitudes and specialty selection in matriculating medical students. METHOD: Five entering classes of medical students (1990 to 1995, without 1992) at the University of Washington were administered the WPCII during orientation. Reliability, factor, and predictive validity analyses were performed to measure the utility of the WPCII. RESULTS: Factor analysis revealed three interpretable factors to underlie the WPCII: stressors, physical complaints, and familial complaints. Scales developed from these factors correlated with students' early career preferences and showed significant differences across students who were selected under different interviewing formats. Differences between the sexes were found for both specific items and scales. CONCLUSION: The WPCII is a reliable and valid measure of attitudes toward the appropriateness of family physicians' treating psychosocial complaints. These attitudes have implications for the selection of medical students, curriculum development, assessment, and health education research.

"If at first you don't succeed": using failure to improve teaching.

The authors surveyed a group of distinguished clinical teachers regarding episodes of failure that had subsequently led to improvements in their teaching. Specifically, they examined how these teachers had used reflection on failed approaches as a tool for experiential learning. The respondents believed that failures were as important as successes in learning to be a good teacher. Using qualitative content analysis of the respondents' comments, the authors identified eight common types of failure associated with each of the three phases of teaching: planning, teaching, and reflection. Common failures associated with the planning stage were misjudging learners, lack of preparation, presenting too much content, lack of purpose, and difficulties with audiovisuals. The primary failure associated with actual teaching was inflexibly using a single teaching method. In the reflection phase, respondents said they most often realized that they had made one of two common errors: selecting the wrong teaching strategy or incorrectly implementing a sound strategy. For each identified failure, the respondents made recommendations for improvement. The deliberative process that had guided planning, teaching, and reflecting had helped all of them transform past failures into successes.

Four exemplary preceptors' strategies for efficient teaching in managed care settings.

To identify time-efficient and educationally effective methods for teaching in ambulatory care and managed care settings, the authors studied four exemplary preceptors who taught family medicine clerks in managed care clinics. They interviewed all four preceptors and observed three of them. All of these preceptors claimed to practice more efficiently with students than without them. Analysis of 33 patients encounters involving students revealed that each of the five students observed spent an average of 12.0 minutes conducting a history and physical examination, 2.2 minutes presenting the case to the preceptor, 7.9 minutes observing the preceptor reviewing and/or repeating the examination with the patient, and 1.8 minutes receiving direct instruction and feedback from the preceptor. The total time per patient encounter was 23.7 minutes, 11.7 minutes of which directly involved the preceptor. The authors then compared these 33 encounters with encounters involving the preceptors alone; these encounters took an average of 10.6 minutes of the preceptors' time. The 1.1-minute difference between the amount of time preceptors spent in encounters involving students and the amount of time they spent in encounters on their own was not statistically significant as measured by t-test (p < .05). However, in calculating this time difference, possible time saved by students' assistance with charting was not accounted for. In interviews the preceptors identified three major instructional strategies for time-efficient teaching; planning and preparing; teaching with patients; and charting, giving feedback, and reflecting. Students described these preceptors as enthusiastic teachers and good role models; however, they also felt that their first two years of education had not prepared them for seeing patients in fast-paced ambulatory care settings. The challenge for medical schools is to better prepare both students and preceptors for learning and teaching in productivity driven ambulatory care and managed care environments.

Protecting time for teaching in the ambulatory care setting.

The current drive for efficient clinical teaching threatens the educational mission of academic medical centers. With pressures to increase clinical productivity, protected time and compensation for teaching have become scarce resources for clinical teachers in all settings. Although it may yield new approaches to education, the push for efficiency may ultimately result in insufficient time for teaching and may cause some clinical preceptors to stop teaching completely. Further, it may lead to the illusion that comprehensive teaching truly requires little time. Since the future of American health care depends upon the provision of high-quality clinical education to young physicians, this situation presents a potential national crisis. In this article, the authors discuss the complex nature of teaching, its time requirements, and the special challenges of teaching in outpatient settings. To avoid overemphasizing efficiency to the detriment of education they recommend adhering to two principles: (1) academic medical centers are educational as well as training institutions, and therefore should provide a broad-based education as well as training in clinical skills; and (2) the clinical teaching process is complex and adequate time must be provided for its many phases, including planning, instructing, and reflecting. Finally, the authors make recommendations for ensuring the delivery of high-quality education in ambulatory care settings.

A study of medical students' specialty-choice pathways: trying on possible selves.

PURPOSE: To describe the decision-making processes reported by graduating medical students in choosing primary care (PC) or non-primary-care (NPC) specialties. METHOD: Members of the University of Washington School of Medicine's graduating class of 1995 were invited to participate in focus groups. Six specialty-choice pathways were defined based on a previously administered survey of recalled preferences at matriculation and stated choice at the time of the National Resident Matching Program. Students were assigned to focus groups based on specialty-choice pathway. Transcribed discussions and summaries were thematically coded and analyzed using grounded theory and quantitative comparisons. RESULTS: Of 157 students, 140 (89%) completed the initial survey, and 133 (85%) provided enough information to be classified by pathway. In all, 47 students participated in the focus group discussions. The PC students cited PC orientation, diversity of patients and activities, role models and mentors, interaction with patients, and overall medical school culture as having influenced their choice. The NPC students cited lifestyle, controllable hours, opportunities to do procedures, therapeutic urgency and effect, active tempo, exciting settings, and intellectual challenge. Role models influenced PC career choice much more than NPC career choice, and often served to refute negative stereotypes. The sense of personal fit between themselves and specialties was important to the students in all groups, but differed in emphasis according to career-choice pathways. Those whose preferences did not change experienced a confirmation of pre-existing beliefs, while those who switched specialty areas developed a sense of fit through the inclusion or elimination of different practice aspects. Those who switched specialty areas reported more negative influences and misunderstanding of their initially preferred specialties. CONCLUSION: The process of specialty choice can be described usefully as a socially constructed process of "trying on possible selves" (i.e., projecting oneself into hypothetical career and personal roles). This may explain role models' exceptional influence in disproving negative stereotypes. Medical students' choices can best be facilitated by recognizing their needs to gain knowledge not only about specialty content, but also about practitioners' lives and the students' own present and possible selves.

Future directions for research on faculty development.

BACKGROUND AND OBJECTIVES: Based on prior research and current public policy needs, this article identifies five areas that should receive priority in future research on faculty development: 1) To conduct research, greater clarity is needed about the components, competencies, and strategies of faculty development. 2) A stronger link needs to be created between assessment and outcomes of faculty development programs. 3) As faculty roles and career paths change, greater understanding of the nature of professional development is needed. Strategies for promoting teaching, research, and leadership skills require further study. 4) Organizational culture and structure require greater description and illumination as contributors to organizational vitality. 5) Information and instructional technology offer new opportunities for faculty development, but research is needed to determine appropriate uses. Since research takes place in a broader context of societal needs and resources, we conclude with public policy recommendations. We strongly recommend that government, foundations, and universities work together to support fundamental research on faculty development.