Teaching Prescription Pad: The One-Minute Preceptor
Session Recorded August 6, 2021

Welcome to this session of the Teaching Prescription Pad, where we learn the prescription for effective teaching from the best clinical teachers. This session is on the One-Minute Preceptor or Microskills. Our expert is Dr. Ken Cheney. Dr. Cheney practices adolescent medicine at Children's Hospital in Des Moines where he teaches medical students and pediatrics, internal medicine, and family medicine residents. I am Jeff Pettit, your moderator for the session. Welcome, Dr. Cheney. 

My first question is, why is this topic important or of interest to you?

I think that it is important to me because it makes me a more effective teacher yet causes me to be more deliberate about what I am going to teach. I think with each patient encounter, I think about what is going to be the main teaching point with that encounter. And I think it causes me to teach one or two specific points and not just give the student or resident a data dump that they are probably not going to remember anyway. I work in the outpatient clinic. If I decide these are going to be the one or two teaching points after each patient, we can reinforce them throughout that half day session. 

Can you briefly describe the steps that are involved in the one-minute preceptor?

Some people call it one-minute; some people call it five minutes. It does not have to take that long; it could take longer. I think of it as kind of a scaffolding for the way I teach, and I think of the five W's. First, ask the learner, “What do you think is going on?” to get a commitment from them. Next, “Why do you think that?” Then, you give them a teaching point. “When you see a red ear in a crying child, that may not always be otitis media.” Next, you tell them what they did Well. “You really steadied that child against their parent when you looked in their ear.” Finally, you tell the student what they could improve on (Whoops). For me, it is just a simple way of going through the whole staffing process where instead of teaching 10 things and everything I know about otitis media, I taught them one or two things that they will probably remember. 

Some teachers, when they use these steps, put the general teaching general policies or procedures and rules and guidelines third. Some teachers put it at the end, it is the last thing. Do you have a preference on which where you put it?

You know, to be honest, I put it in different places, probably each time I do it. I kind of like it in the middle because I think the last ‘W’ about what they can improve on gives them a place to start. “I want you to go and review the American Academy of Pediatrics website for eardrums. They have some really good examples of different eardrums there. And then we can talk more about examining the ear tomorrow.” But I will put the teaching point at the end sometimes to reinforce it as well. But I like to leave with what they can do to keep increasing their knowledge as kind of that last point, the last two steps.

A lot of this has to do with giving the learner feedback. I have observed other teachers, and it seems that those last two steps are the ones that do not always make it into the process. Do you work hard to  make sure you get that feedback into it?

I do. Sometimes I do that by trying to prime the learner for what we are going to focus on in the individual clinical encounter. If it is somebody who, let us say, is coming in with sore eyes symptoms and I say this adolescent may really push for antibiotics, but we know that this most likely is viral. So, I want to really focus on how you help explain this to the family. I think that if you set that teaching point ahead of time, what we are going to focus on, then it is really easy to give the feedback.

Given that you work in so many different environments, is there a better situation to use the one-minute preceptor steps or does it really matter?

I think you can use it anywhere. I think that for me, it is easiest to use in the outpatient setting when people have a simple, straightforward complaint, like a sore throat or an ear. But I use it anywhere. There may be a complex patient that the student presents the history and physical trauma. Then, I will just look at them and say, “what do you think is going on?” Why make my teaching quiet and then give them feedback about it? I think the key thing for me is sometimes we do not get that commitment from the student. They may ramble off three or four things and the differential. Then we say, “yeah, those are great things to think about” to try to get them to commit so that if they commit to a wrong diagnosis, we can give them feedback about how we arrive at a different diagnosis. I think that if you do not make that commitment, then that student says, “oh, yeah, that is what I would have thought, too.” Whereas if you do make a commitment, this is an infected ear, I would give them antibiotics or no, that is not an infected ear. The child is just crying. That causes the student to learn, I think, from that clinical situation.

How long does it take the students to get use to following your steps and routine, and how do they seem to react to when you use it?

I think that it does take a few times and sometimes even in the primary, I will tell them if it is a simple case, like a sore throat, I might say when I come in and we staff in front of the patient, I am going to let you stay the chief complaint and two or three lines, and then I am going to ask you those questions. “What do you think is going on? Why do you think that?” We are going to really focus on that, especially if the history and physical exam is not going to be very complex. It is maybe a little more difficult to use early in the year when learners are just learning to examine the patient or when they are just learning to take the history. But as the year goes on, I think it is easier to use. The learner knows that I am going to ask them for a commitment. If they make their commitment consistently that is not correct, you may be able to help them with their clinical reasoning, which is something that I think is sometimes difficult for students to learn. Why this and not that? So, I really push for that commitment.

What are some of the challenges when you initially try to use the one-minute preceptor or things that pop up after you have been using it for a while?

I think that there is always the chance that you could miss something if you tried to apply it to a complex situation. It is not always that I would walk in the room and say to the student, “what do you think is going on?” if it was a complex patient. If it was a new patient, I would let them present the history and physical. Sometimes, patients will be a little bit startled that you are not going to hear their entire story or do the entire exam before you make the student or learner make a commitment. If that is the case, I just always tell the patient that we are going to start backwards and will come back and hear your story and make sure that all your questions are answered.

As a follow up to the previous question, but does it seem to work better in inpatient or outpatient?

For me, I think it works much better in the outpatient setting because in general, those patients tend to come in for a more focused problem. They may have multiple problems, but we are dealing with one problem on that day. It probably works better for our returning patients than a brand-new patient where you just need more information about the patient's past history, things that you may not know because you have not seen them before. But I know many hospitals who will use it on the inpatient service, maybe not on the first couple of days, but after the patient has been there and everyone is kind of familiar with the history of the patient and family, feel that you listen to them, then you can more focus on what is going on today.

As we finish up here, do you have any final thoughts or suggestions for someone that wants to try or begin using the one-minute preceptor?

I think one of the things is choose the patient. Choose the patient with a very simple complaint.  You may start with just the first couple of parts of it. What do you think is going on? Why make your teaching a point? When you get comfortable with that, then you can add in what are the most important parts, what the learner did well, and what the learner could improve on. There is a time when, for whatever reason, I do not do all five parts of it. But I think to not forget the feedback is probably one of the most important parts. Sometimes you can just work up to that.

Thank you very much for your time and information.

If anyone is interested in more information or has further questions, you can reach us at OCRME-PrescriptPad@uiowa.edu. Feel free to use this email address for any questions or follow up.

The video transcript and podcast will be available on OCRME’s website in the future (https://medicine.uiowa.edu/ocrme/teaching-development/teaching-prescription-pad)