New Practitioner and Resident Track
Preceptor Development: From Barriers to Opportunities Christine Ji, PharmD, BCPS Clinical Pharmacist Internal Medicine Massachusetts General Hospital Boston, MA
Speaker Disclosures • Nothing to disclose
Learning Objectives • Identify ways to integrate the four preceptor roles into teaching and solving clinical problem • Develop practical approaches to optimize the precepting time with pharmacy learners • Demonstrate the role of self-reflection to identify and manage preceptor burnout
Define Preceptor Roles
What Makes a Good Preceptor? • Difficult to identify, quantify, and evaluate what makes a good preceptor • Being a good clinician is a necessary • Applying principles of good teaching is a challenge
ASHP Four Preceptor Roles Instructing Modeling Coaching Facilitating http://www.ashpmedia.org/softchalk/softchalk_preceptorroles/softchalk4preceptorroles_print.html. Accessed: April 16, 2019.
Instructing • Teaching of fundamental content • Knowledge that is necessary before skills can be applied • Activities: assigned readings, lectures, and discussions http://www.ashpmedia.org/softchalk/softchalk_preceptorroles/softchalk4preceptorroles_print.html. Accessed: April 16, 2019.
Think-Pair-Share Discuss with a neighbor ways to assess a resident’s baseline knowledge prior to coming to your rotation?
Think-Pair-Share • Assess baseline knowledge • What APPE rotations did the resident have? • What work experience or projects did they have? • Pre-rotation assessment or quiz • Fill in gaps in baseline knowledge
Modeling • Once fundamental knowledge is established, resident is ready to acquire the skills to perform a task • Preceptor demonstrates a skill or process while “thinking out loud” for resident to witness the thoughts and problem solving process • Activities: practice-based observations http://www.ashpmedia.org/softchalk/softchalk_preceptorroles/softchalk4preceptorroles_print.html. Accessed: April 16, 2019.
Practice-Based Observations • Review patient’s chart and treatment plan • Discuss which guidelines or resources you are using • Highlight what labs you are monitoring • Talk about how you are adjusting medication doses • Review any clinical reasoning you are doing
Coaching • Resident has the necessary background knowledge and has observed the preceptor performing the skill or task • Resident performs the skill while being observed • Activities: case-based discussions, simulations • Experience uncertainty • Refine the problem solving skills • Build confidence • Allow for preceptor feedback http://www.ashpmedia.org/softchalk/softchalk_preceptorroles/softchalk4preceptorroles_print.html. Accessed: April 16, 2019.
Case-Based Discussions • MK is a 45 year old male presents to the ED with the chief complaint of a generalized throbbing headache with mild neck pain and stiffness. He has a fever of 102 degrees and is found to have a positive Kernig’s sign and Brudzinski’s sign. The team approaches the pharmacy resident asking for empiric therapy recommendations
Case-Based Discussions • What is on your differential? • No known immune deficiency vs. immunocompromised • Drug penetration to the cerebrospinal fluid • Beta-lactam allergy • Impaired renal function • Adjunctive dexamethasone
Facilitating • Last step! • Resident performs independently once the preceptor and resident are both confident in the ability • Preceptor remains available as needed or for debriefing • Activities: increase complexity of patients or situations, learner self-assessment on performance http://www.ashpmedia.org/softchalk/softchalk_preceptorroles/softchalk4preceptorroles_print.html. Accessed: April 16, 2019.
De-Briefing • Resident independently participates in emergency response • You remain available for questions • Help the resident to assess own performance • Discuss about what went well • Were there any delays in therapy? • What could have been improved? • Encourage to take more complex tasks!
Self-Assessment Question #1 • The resident is beginning their rotation in the ICU. They have reviewed pertinent treatment guidelines and protocols. They are currently observing as you adjust medication doses for patients on renal replacement therapy. Which of the preceptor roles is described in this case? A. Instructing B. Modeling C. Coaching D. Facilitating
Self-Assessment Question #1 • The resident is beginning their rotation in the ICU. They have reviewed pertinent treatment guidelines and protocols. They are currently observing as you adjust medication doses for patients on renal replacement therapy. Which of the preceptor roles is described in this case? A. Instructing B. Modeling C. Coaching D. Facilitating
Identify Barriers and Opportunities
Barriers to Effective Precepting • Heavy clinical workloads • Competing priorities • Increased number of learners • Time constraints • Lack of experience • Poor communication • Preceptor burnout Am J Health-Sys Pharm. 2013;70:1605-8. J Health-Syst Pharm. 2017;74(19):1570-78. Hosp Pharm. 2013;48(3):200-3.
Think-Pair-Share Discuss with a neighbor types of time management barriers to precepting residents you have experienced
Optimize Precepting Time: Overview Assess Prioritize Delegate Communicate Evaluate
Assess • What is the resident’s prior experience in the practice area? • What are the resident’s professional interests and goals? • Set expectations! Am J Health-Syst Pharm. 2012;69(18):1588-99
Prioritize • What activities and goals must be achieved on this rotation vs. later in the residency year? • What patient care activities does the resident need to develop proficiency early in the rotation? Am J Health-Syst Pharm. 2010;67(3):239-43.
Delegate • What activities can the resident do Primary Preceptor independently with instructions? How about with modeling or coaching? Resident • How can layered learning model be Preceptor applied with the resident and student? Student Learner Hosp Pharm. 2017;52(4):266-72.
Communicate • Which patient care responsibility does the resident have to complete each day? each week? by the end of the rotation? • How and when will the resident be evaluated and provided with feedback? Hosp Pharm. 2017;52(4):266-72.
Evaluate • What is the resident’s strengths and areas of improvement? • What activities will be done to minimize the knowledge gaps and become more proficient with the skills in the future? Am J Health-Syst Pharm. 2010;67(3):239-43.
Optimize Precepting Time: Daily • A five step process for clinical teaching • Can be applied during oral presentation, bedside or sit down rounds, or any other One Minute case based discussions Preceptor • Originated in the business literature and has been widely applied to clinical medicine J Gen Intern Med 2001;16:620-624. AcadMed 2004;79:50-55. ACP Press. 2008. pp. 51-73.
One Minute Preceptor • Get a commitment • Probe for supporting evidence • Teach general rules • Reinforce what was done right • Correct mistakes J Gen Intern Med 2001;16:620-624. AcadMed 2004;79:50-55. ACP Press. 2008. pp. 51-73.
Get a Commitment • “What do you think is going on?” • “What do you want to do next?” • Encourage resident’s ownership of the patient case • Not simply gathering information, but processing thoughts • Avoid decision making by preceptor J Gen Intern Med 2001;16:620-624. AcadMed 2004;79:50-55. ACP Press. 2008. pp. 51-73.
Probe for Supporting Evidence • “What led you to that conclusion?” • “What else did you consider?” • Confirm resident used clinical reasoning to arrive at conclusion • Not just “lucky guess” • Identify the learning gap J Gen Intern Med 2001;16:620-624. AcadMed 2004;79:50-55. ACP Press. 2008. pp. 51-73.
Teach General Rules • “Many times when … ” • “In our patient population … ” • This is the teaching point! • Require preceptor to “diagnose” inaccurate or missing information • Apply to current case but try to make generalizable J Gen Intern Med 2001;16:620-624. AcadMed 2004;79:50-55. ACP Press. 2008. pp. 51-73.
Reinforce What was Done Right • “You did an excellent job of … ” • “You were right to continue …” • Be specific! • More than just a simple “good job” • Reinforces good behaviors and encourages to continue J Gen Intern Med 2001;16:620-624. AcadMed 2004;79:50-55. ACP Press. 2008. pp. 51-73.
Correct Mistakes • “Next time this happens, try …” • “Good thoughts, but consider ..” • This is difficult • Consider timing and delivery in a more private setting • Again, be specific! J Gen Intern Med 2001;16:620-624. AcadMed 2004;79:50-55. ACP Press. 2008. pp. 51-73.
One Minute Preceptor Example • AJ is a 63 year old female presents to the ED with the chief complaint of a shortness of breath. She has a 30-pack year smoking history and has past medical history of COPD and hypertension on home lisinopril, HCTZ, and albuterol inhaler. • She received a dose of azithromycin, methylprednisolone, and ipratropium-albuterol nebs in the ED and is now transferred to the floor for further management.
Think-Pair-Share How would you apply one minute preceptor into this case?
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