The Five Microskills: A Model to Enhance the Clinical Teaching Encounter Jonathan D. Ference, PharmD, BCPS; Allen R. Last, MD, MPH; Stephen A. Wilson, MD, MPH; Lee M. Vogel MD; Deborah A. Spring, MD The Clinical Teaching Encounter Traditional Model Microskills Direct attention toward patient care issues Get a commitment from learner Ask low level questions Probe for supporting evidence Give mini lecture Teach general rules Provide little feedback Reinforce what was done correctly Correct mistakes Get a Commitment • Discovery phase: allows learner to create formulation of the clinical situation and encourages collaborative role in problem solving • Failure to commit: learner has not processed information, reluctant to expose weaknesses, dependent on others à indicates a teachable moment • Cues to engage: o “What do you think is going on with this patient?” o “What do you think are the medication-‐related problems with this patient?” o “What do you think are the learning outcomes of this encounter?” Probe for Supporting Evidence • Diagnosis phase: allows preceptor to determine any underlying deficits and further identifies critical thinking skills • Helps learner reflect upon the process • Cues: “Think out loud” vs. “Grilling” o “What were you trying to do here?” o “Explain to me how you reached your conclusion?” o “What evidence helped you make that choice?” Teach General Rules • Teaching will flow from the first two steps • More memorable and transferable: application for broad patient populations • Principles: o “The best available evidence demonstrates…..” o “Deciding whether someone needs to be treated in the hospital for pneumonia is challenging. Fortunately there are some criteria that have been tested which help…” o “Given this patient’s renal function, standard antibiotic dosing is not appropriate. The best reference to find the information is…” The Society of Teachers of Family Medicine rd 43 Annual Spring Conference Vancouver, British Columbia
Reinforce what was done correctly • Helps learner absorb and retain • Occurs when: o A consequence is presented dependent on a behavior or response o The behavior becomes more likely to reoccur because and only because the consequence is understood as dependent on the same behavior • Key concept in behavior analysis: o “When recommending that medication, you appropriately considered the patient’s age and renal function. That will certainly decrease the risk of the patient falling because of oversedation.” o “Obviously, you considered the patient’s finances in you selection of therapy. Your sensitivity to this will certainly contribute to improving compliance.” Correct Mistakes • Presents opportunity for self-‐assessment à uncorrected mistakes are often repeated • Requires tact to be effective: time, place, conscious effort to wait • Frame as “not best” or “less than optimal”: include suggestion for the future o “I agree that the patient is probably drug-‐seeking, but we still need to wait for a careful history and physical exam.” o “Next time a patient becomes angry during the encounter, try this…” o “I agree that the patient’s cholesterol needs to be addressed, but achieving glycemic control first will decrease their length of stay…” Creative Exercises • Two Minute Analysis: on a blank sheet of paper, pose a specific or open-‐ended question and allow two minutes for a response • Most Clear/Least Clear Point: similar to 2-‐minute analysis, reveals overall understanding of materials and directs teaching efforts • Daily Journal: May be helpful with learners that struggle with self-‐insight Useful Resources • Neher JO, Gordon KC, Meyer B, Stevens N. A five-‐step “microskills” model of clinical teaching. J Am Board Fam Pract 1992;5:419-‐24. • Parrott S, Dobbie A, Chumley H, Tysinger JW. Evidence-‐based office teaching-‐The five-‐step microskills model of clinical teaching. Fam Med 2006;38:164-‐7. • Molodsky E. Clinical teacher training: Maximizing the ‘ad hoc’ teaching encounter. Aust Fam Physician 20072007;12:1044-‐46. Contact Information Stephen A. Wilson:
[email protected] Allen R. Last:
[email protected] Jonathan D. Ference:
[email protected] Lee M. Vogel MD:
[email protected] Deborah A. Spring:
[email protected] The Society of Teachers of Family Medicine rd 43 Annual Spring Conference Vancouver, British Columbia