Strategies for Efficient Office Precepting

For the Office-based Teacher of Family Medicine

William Huang, MD
Feature Editor

Editor’s Note: In this month’s column, Alison Dobbie, MD; James Tysinger, PhD; and Joshua Freeman,
MD, give practical tips to help the office-based preceptor efficiently teach students during busy patient
care sessions. Drs Dobbie and Freeman are faculty members of the University of Kansas School of
Medicine and Dr Tysinger is a faculty member of the University of Texas Health Science Center at San
Antonio.
I welcome your comments about this feature, which is also published on the STFM Web site at
www.stfm.org. I also encourage all predoctoral directors to make copies of this feature and distribute it
to their preceptors (with the appropriate Family Medicine citation). Send your submissions to
williamh@bcm.tmc.edu. William Huang, MD, Baylor College of Medicine, Department of Family and
Community Medicine, 3701 Kirby, Suite 600, Houston, TX 77098-3915. 713-798-6271. Fax: 713-798-
7789. Submissions should be no longer than 3.4 double-spaced pages. References can be used but
are not required. Count each table or figure as one page of text.

Strategies for Efficient Office Precepting
Alison E. Dobbie, MD; James W. Tysinger, PhD; Joshua Freeman, MD

http://www.stfm.org/fmhub/fm2005/April/Alison239.pdf

Many family physicians teach because
they enjoy the personal satisfaction
of working with students
and want to share their enthusiasm
for family medicine while contributing
to the education of the next
generation of physicians.1,2 However,
most office-based teachers are
unpaid volunteers,3 and evidence
indicates that time spent teaching
can lengthen the preceptors’ working
day3-5 and/or decrease their
clinical productivity.3 Fortunately,
preceptors can use several strategies
to minimize the added tasks of
teaching while optimizing students’
educational experience. Preceptors

(Fam Med 2005;37(4):239-41.)


who use these strategies have reported
practicing more efficiently
with a student than without one.6 In
this article, we summarize some
practical strategies for efficient office-
based teaching that are likely
to be highly valued by preceptors
and students.
Planning and Preparing
Agree on Daily Goals
The vast amount of potential
learning material in each session
can overwhelm both teacher and
student. To better manage this learning
material, spend 1 or 2 minutes
before each session agreeing on
mini-learning goals that relate to the
clerkship objectives and are achievable
that day. For example, it may
be too time-consuming to observe
a student conduct a complete physical
exam, but it is practical to observe
and give feedback on two abdominal
exams in one session and

ensure that the student has mastered
this part of the physical exam.
Achieving such mini goals over several
sessions results in an impressive
amount of clinical observation,
teaching, and feedback.
Limit the Number of Patients
That Your Student Sees
Seeing too many patients often
prevents students from reflecting on
how the clinical experience aids
their learning. Depending on the
number of clerkships completed,
the clerkship’s goals, and the patients’
clinical complexity, thirdyear
students should see between
three and six patients for each 4-
hour session.
Encourage “Just
in Time” Learning
Between patients, students
should review content related to the
patients they see. For example, after

seeing a child with a sore throat,
students can use their handheld
computers or the Internet to look up
the risk factors for strep throat and
determine the sensitivity and specificity
of the “rapid strep” test. This
“just in time” learning, especially
when combined with formulating
clinical questions, encourages students
to seek and use evidencebased
medicine. Such integration of
evidence-based medicine into practice
has been reported as one of the
top three factors students associate
with effective teaching.7

Debrief and Plan
for the Next Session
At the end of each session, it is
efficient to spend a few minutes
debriefing on the teaching session,
reviewing how well the student met
the mini goals, agreeing on any
homework, and planning for the
next session.

Maximizing Learning
Efficiency

Limit Presentation Time
Students must learn to give a focused
2–3 minute patient presentation
that includes pertinent positive
and negative findings and their assessment
and plan. Students consistently
report the opportunity to formulate
assessments and plans as
one of the top factors associated
with high-quality clinical teaching.8

Use the Five Clinical
Teaching Microskills

Most preceptors are familiar with
the five microskills of clinical
teaching9 but may not use them because
they think that completing all
steps after every patient is too timeconsuming.
However, all five
microskills do not need to be completed
for every patient. For example,
if a patient presents with a
sprained ankle, the preceptor can
use the microskill “teach general
rules” in discussing and demonstrating
a proper ankle exam and
use the microskills “reinforce what
was done right” and “correct mistakes”
in giving the student feedback
about his/her actual exam of
the patient’s ankle. For other
sprained ankle issues such as understanding
why an X ray was or was
not ordered, the teacher can direct
the student to find the Ottawa ankle
rules as “just in time” learning between
patients and discuss their
application in more detail later.

Make Feedback Routine

Giving feedback challenges most
preceptors because they see it as
time-consuming and fear it may
upset the student. Yet students report
receiving high-quality feedback
as one of the top two factors
associated with excellent clinical
teaching.8 Feedback that is based on
observation, consistent, fair, routine,
and given in a spirit of unconditional
positive regard will be accepted
and appreciated. For example,
while observing the student
perform an abdominal exam, a preceptor
might say, “You correctly
palpated all four quadrants superficially
and deeply, but you forgot to
observe and listen first! Remember:
always observe the abdomen first,
listen to it second, and then palpate
it.”

Teaching With Patients
Develop a Cadre
of “Teaching Patients”

Every physician has patients who
have interesting stories to share. If
these patients have conditions that
add to students’ learning, both student
and patient usually enjoy
spending extra time together. Such
regular “teaching patients” can become
familiar with students and
may even learn to evaluate them
and give informal feedback on students’
performance. Such patient
feedback is particularly powerful
for students.

Seize Unexpected
Learning Opportunities

Besides planning in advance
which patients the student will see,
one should seize unexpected learning
opportunities. For example,
where a patient has a newly discovered
goiter or heart murmur, the student
may be briefly introduced to
the patient simply to experience the
abnormal sign.

Hear Presentations
in the Exam Room

When all parties are comfortable
and the clinical problem is suitable,
it is efficient and mutually satisfying
to have the student present his/
her findings and for the preceptor
to teach in the patient’s presence.
Patients can then give immediate
feedback on the accuracy and completeness
of the student’s presentation.

Using Service Learning
Use the Students for
Administrative Tasks

Many non-clinical tasks can aid
student learning. For example, students
can learn a great deal by performing
administrative tasks under
the preceptor’s guidance and supervision.
These tasks may include filling
out lab requests, writing referrals,
updating problem lists, and
doing telephone callbacks.

Let Students Write Notes

Writing notes aids students’
learning and helps students present
the patient’s issues to the preceptor
in an efficient and organized manner.
According to Health Care Financing
Administration documentation
guidelines, only a small portion
of a student’s note is billable,
and the preceptor must still write or
dictate a note and personally document
major aspects of the patient
visit.10 However, preceptors can still
save time by using the student’s
note as a guide when dictating or
writing their own note. In one study,
students’ notes saved preceptors 3.3
minutes of charting time per patient.
11

Use Students to Teach Patients

Students learn a great deal by
teaching patients about such topics
as smoking cessation and weight
loss. Teaching patients sharpens
students’ communication and negotiation
skills and makes them aware
of the many reasons patients don’t
comply with medical advice.

Conclusions

Using these simple strategies can
help office-based teachers improve
the teaching experience for themselves
and their students. Devoting
a few minutes each day to these
activities can maximize the teaching
session’s efficiency and minimize
extra work for the preceptor.