Teaching Prescription Pad: Priming the Learner
Session Recorded September 22, 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 Priming the Learner. Our expert is Dr. Kelly Skelly. Dr. Skelly predominantly does clinical teaching and works with providers on patient provider communication. She likes to set goals with learners to make sure they get something out of each patient interaction and is always looking for ways to make certain that this is possible. I am Jeff Pettit, your moderator for the session. Welcome, Dr Skelly.

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

Priming the learner is one of the best ways for me to make sure that learners learn when I am working with them in a busy clinical setting. I do clinical teaching in a very busy clinic. If I do not remember to plan for the learning part, then I do not always leave knowing that I accomplished some learning with the learner. By priming, I make certain that I make the most of the situation if I plan ahead. 

Can you explain what is meant by priming the learner?

Really, it is looking at the situation and preparing and then setting expectations for the clinical setting to make certain that we have learning. 

When can you use priming the learner? Are there certain situations or is it every time that you work with learners?

Every time you work with learners. Every time you remember.

How do you use it typically?

I start with orientation. First, I orient the learner to who I am. I introduce myself and explain the setting where I am practicing and what is going on and what the expectations of my morning are for me. First, I orient the learner to me then I orient myself to the learner. So I ask the learner about prior experiences they have in a clinical setting, something like mine and with my patient population, so that I sort of know what they are bringing to the table. They are oriented to me; I am oriented to them. 

Then I orient them to the situation—sort of where I work, the team that I work with, the facilities that I am working in, what the workflow is like, what the patient population is like either that day or in general, and what my expectations are for the learner. For example, I always like to staff clinic visits in front of the patient with my learners, and that is something a little bit different. I want to make sure that my learner knows that about my situation. 

Then, I like to orient to the learning environment, which is a little different than the clinical environment. The learning environment is the one that I have to keep reminding myself of it. I love the fact that we are going to be doing learning. I need to make sure that it is safe. I need to make sure that they feel safe. I need to acknowledge that I do not know everything, that there may be issues worth looking things up. I need to invite input from the learner so that they feel comfortable sharing and participating. I need to make sure that they understand I will never embarrass them in front of a patient or punish them for a wrong answer or shame them or anything like that. I need to make certain that they know that I hope they ask questions and that we have a discussion. If they have concerns or recognize the mistake I am making, that this is a two-way street for us both learning all the time and that it is going to be a safe environment and I will give feedback, but I will do it privately. I always want them to feel safe.

Once we are all oriented, learn to be more alert to the clinical environment, to the learning environment, that is hopefully safe, then the last major piece at the beginning is to establish learning goals. We have to do that every single time. If we establish goals that when we leave, we can certainly be the goal and if we can assess that. I let the learner identify a learning opportunity every single time to address their goals. If I do it right, it is the first time. Often a learner may not have goals, but if they know the expectation that every time, I am going to ask them their goals for the learning, they will start to get good at that. Then we have better success. Once they have got a goal, I help them look at the setting to see what opportunities they have to address their goals. I also, hopefully, have some skills to identify opportunities to address circumstances as well. Maybe my patient population have some interesting social determinants of health, or it might be a migrant family that cannot get to the office because they do not have a car or something like that that would allow us to address the interest in social determinants of health. Maybe my patient population has some sort of disease processes. Today, we are seeing a lot of patients with diabetes and we can look at that as a disease process or at clinical challenges associated with that. Or instead, maybe we have got some physical exam findings. We have got a Parkinson's tremor in this patient that we could show them or a big thyroid or history taking challenges like agenda setting. This is a really talkative patient. You are going to see it. So, this is a good one for us to practice our agenda, setting, and that type of thing. Looking at the learner opportunities to address their goals, is the next step as part of Priming the Learner?

A couple of tips that I use along that way. I do like to think out loud as we meet the goals so that we recognize when I have it tied together nicely. “The patient responded really great to your agenda setting” or, you know, “oh, that patient hits with a doorknob concerned about their chest pain.” If we would have an agenda set that we maybe caught that. What do you think about that? That encourages curiosity of the learner. So, all of these things sort of tie together to let us if we prime the learner and plan what we are going to do, we are better able to identify it, learning opportunities, make certain that we are doing that. 

So, it sounds like you used priming first. The first step, basically, is to get the learner to say what they want to learn so that you can focus on that part of it. If they do not, you can come back with suggestions, looking at clinical scheduling, looking at types of illnesses, anything along those lines to help them figure out, let us focus on that and not every aspect of medicine.

Yes. Sometimes it is just one simple thing, but if we do that, at least we leave the day and we know that there is one simple thing. I guess the final key piece is that we do have to close the loop. We have to debrief at the end to make sure that our priming and goal setting was effective. It sort of reinforces those goals and lessons. 

I have heard from some faculty and clinical teachers that they can also use priming with regard to feedback. So, before you go into a situation, you tell them I am priming you, this is what I am going to give you feedback on, have you tried that?

Both directions. So, it works for me to say I am going to give you feedback on this, or one of the things that you are responsible for is doing a good presentation. So, when we leave the site, this is a great chance for me to watch you. And I will give you specific feedback about that and to have any particular concerns about that or had at the time. That is really nice. It also works—this is an added bonus—but it also works for me to prime the learner and that this is a really difficult situation. I am going to try and talk to them about something complex. I would like feedback, and it is an opportunity for faculty to get feedback as well if we prime them the right way, because we are able to do that as well.

When you do the orientation part, how long does it typically take you to do an orientation? And do you do it all in one complete package or do you break it up?

Great question. So, if it is the very first time you are with the learner, it takes a little bit longer than other times. Sometimes we dive in and I promise to orient them later and I will say, “so come right in with me on this patient and after we leave, we will talk a little bit more about things that because timing requires that.” But in general, the introducing yourself to some degree, letting them introduce themselves and then showing them the situation and making the learning environment key, all four of  those pieces have to happen pretty early on in the process. So I try and make it a goal that if I do not do it immediately, I say we are going to do this in just a couple of minutes and then make sure that happens before I really feel like it is a safe learning environment for learning to happen. If you work with a learner over time, your point also is well taken in that if you work with a learner over time, you can do different pieces of it each time and you do not have to go through all of it every time. 

So early on with the new learners, when you try to do priming the learner, how do they react? How do they deal with it since it is probably their first time in a clinical setting?

That is a great question. The first time in the clinical setting they look at it with relief, I think, because for many of our clinical learners, the most terrifying part is to go to a new setting, find the setting, make sure they get there safely and know where they are supposed to be. So, they are just happy to know what the expectations are, and this is part of that. If it is instead, maybe I will call them some of our more experienced learners. They still, it never goes away—the wondering of what the expectations are. And so I think they appreciate it. And then they can really focus on what it is that they are trying to get out of the experience if we prime them correctly and it opens up the opportunities for them to benefit from the situation. 

Are there any challenges or any side effects of learning how to use priming the learner?

You know, you alluded to it—it is time. Time is always the thing. So just remembering to use it. Probably the biggest frustration with learning is if we do not remember to use it and then we are frustrated with our learner because it is unclear what we are trying to get out of the process or what our expectations are or what we are going to get feedback on. So just remembering the biggest, biggest challenge, I think, and then the time and remembering that we can do it gradually, bits and pieces gradually, as long as we get it done. 

I understand or I hear that you do not have to prime every patient, every situation, every time—pick and choose.

You know, there is so much to learn and so little time.

So, with the priming the learner, it sounds like it is an efficient way to get teaching across to them. It is an efficient way to set up feedback. And it is also somewhat of an efficient way to find out what the learner wants to focus on. So as a teacher, you are not trying to set the agenda or come across with all the topics and all the areas. Does that sound right? 

That is absolutely right.

So our last question then is that you have any final words of wisdom or thoughts related to others that might want to try priming the learner?

I think I had two thoughts. One is, it was fun to think about this; it is always fun to think about all teaching. It is fun to take the time to think about it, because I you remember to do it more and my favorite part about it, it all lumps into when I get to the end of the day and I think about the experience of teaching, I often have that panicked feeling of did we learn anything at all? So, if I bring that to the forefront of every teaching experience and say, gosh, what are our expectations? It is much easier at the end of the day to say, did we learn anything at all? Because it is explicit and that just helps me sleep better at night. 

Well, we want to thank Dr. Skelly for her time and for your information related to priming the learner. For additional information, if you have questions or would like follow-up information, you are welcome to use the email address you see on the screen: OCRME-PrescriptPad@uiowa.edu. I will respond and get the information back to you as soon as I can.

We will also have all of the interviews on our website: https://medicine.uiowa.edu/ocrme/teaching-prescription-pad. Along with each interview, there will also be a podcast that can be downloaded and a transcript of each of the presentations.

So, again, thank you, Dr. Skelly, for your time being with us. And we hope that you will be a future teacher and some other topics of interest. For the audience, thank you for joining us and I hope you see some of our other interviews in the future.