Teaching Tools and Giving Feedback

Assessing in Longitudinal Practice 

Students are expected to progress through this two year program as they gain increased competence with history and physical exam skills.  Each preceptor will be asked to intermittently evaluate the students online to assess the students’ progress.  The assessment questions directly reflect the core competencies and are meant to assess the student’s attendance, performance, and successful completion of target objectives.  The evaluations by the preceptors are integrated into the overall grade at the end of most curricular blocks.

Several types of assessments will be used to monitor achievement of learning outcomes of the Longitudinal Practice component of LSI, including attendance, Clinical Preceptor Assessments (CPAs), Direct Observation of Competence, and Student Logs.

Attendance

Attendance will be reported for each Longitudinal Practice session.  Students will be responsible for logging this information.   We understand the need for some flexibility in preceptor scheduling.  If necessary, it is the student’s responsibility to set up a makeup time that is convenient for both the student and the preceptor.

Clinical Preceptor Assessments

Preceptors will be asked to assess student progress by completing an online assessment through Vitals.  Clinical preceptor assessments will allow LP preceptors to report summary observations of important student behaviors in the practice. These are sent approximately three weeks prior to the end of the block in order to have completed forms by assessment week grading. A sample assessment can be viewed here. The first assessment will be completed at the end of Bone and Muscle and then at the end of each block.  In Year 2, a physical exam item will be added to the form. The schedule for the clinical performance assessments is listed below.

Curricular Block and CPA due dates

• Bone and muscle disorders - due: 12/18/2021
• Cardiopulmonary disorders - due: 2/19/2022
• Endocrine and reproductive disorders - due: 4/30/2022
• Neurological disorders - due: 9/24/2022
• GI/Renal disorders - due: 11/19/2022
• Host Defense - due: 2/18/2023

 

Direct Observation of Competence 

Direct Observation of Competence will be used in the practice to assess student performance of key clinical skills with a real patient.  Some of these may be completed by other members of your staff.  Students will have the assessment forms loaded on their iPads and these will be used to complete the assessments.  These are formative only and intended to give students insight on the application of knowledge they are learning in the classroom. 

Student Logs

Student Logs will be used to track the types of patient encounters students experience and the skills they perform during each block.  Students log their completed objectives through PxDx in Vitals. 

Each Curricular Block will end with an Assessment Week OSCE that will measure whether students have become proficient at professional behaviors, communication and patient care skills across cases and contexts. Students will be practicing these skills at the LP sites, while the OSCE is the mechanism for testing their competency. The OSCEs are evaluated by the Longitudinal Group leaders.

We will also request your feedback on the LP Program at the end of Year 1 and Year 2 so we can continue to improve our process and communication. These course evaluations are optional. 

Students will be also asked to complete an evaluation on the preceptor at the end of Year 1 and Year 2.  A sample of the evaluation can be viewed here. We will provide summary information at the end of Year 1 to preceptors, and a complete report at the end of Year 2.

Students Not Meeting Objective Competencies  

If you have any questions or concerns regarding the performance of the student, please contact Diana Bahner.  Most concerns are addressed immediately and do not require intervention.  Occasionally a student may have difficulties that require intervention.  If this occurs, the guidelines of the student handbook for Part One of the LSI curriculum will be followed.

Oral Presentations and Documentation

Many preceptors enjoy helping their students with oral presentation skills and guiding them through the documentation process.  We are incorporating a Direct Observation of Oral Presentation at the end of Year 2 using the same form that will be used in the Med 3 clinical rotations. This year we are encouraging the students to practice documentation with supervision from the Longitudinal Preceptor.  We will be providing instruction and information for the preceptors during the Fall Faculty Development workshop as well as the block instructional email.

• Begin by discussing the learner’s assessment of performance: Obtaining the learners assessment of their performance in accomplishing the relevant goals can help guide the content of feedback given. 
• Well timed and expected: It is most effective when given as soon as possible after the behavior, depending upon the receiver's readiness to hear comments on performance.  If the behavior is distant from the feedback, the receiver is more likely to discount the feedback as inaccurate.  If immediate, denial is more difficult. 
• Descriptive: Feedback should describe the behavior in clear terms and should reflect specific, concrete examples of positive or negative behaviors. "When the patient was discussing her fears about death you quickly moved to another question without stopping to explore her feelings or concerns" is more effective than presenting an interpretation such as "you are afraid to talk about death aren't you?" or a generalization such as “you interrupted the patient all the time.” 
• Positive feedback should be descriptive as well. “Your use of silence when she was crying allowed her to gather her feelings and express her frustrations.” Focus on reporting accurately what was observed in behavioral terms and avoid interrupting or making assumptions about intent. 
• Changeable behavior: Focus on specific action and behavior instead of personality. “Using a transition statement when shifting between topics is helpful” as opposed to “you seemed awkward when changing topics.”  In addition, avoid labeling behaviors as "good" or "bad," "right" or "wrong."   
• Limit the amount of feedback: Comment on one or two important items rather than two major items and four minor items. The feedback will be more effective if the learner can focus on a few specific areas for improvement. 
• Order the content of feedback: When giving both supportive and constructive feedback, it is important to start by giving some of the supportive feedback initially, followed by the constructive feedback. This helps to minimize defensiveness and makes it easier for the learner to hear the constructive feedback. 
• Beneficial to receiver: Feedback should help the learner explore ways in which improve his or her performance. Leaving the session with a plan for improvement is often beneficial. 

Patient empaneling is a unique learning experience for first and second year medical students integrated into Longitudinal Practice (LP) and Longitudinal Group (LG) during Part One of the LSI curriculum.

Students are given a list of broadly-defined symptoms, diagnoses, and sociodemographic and behavioral health issues connected to the Foundational Science concepts they are studying during each block in Part One. During LP, the student and LP preceptor identify patients to empanel who meet at least one of the block requirements on this list. Once identified, the student approaches the patient and requests permission to present their case as a method of learning about their respective symptom, diagnosis, or sociodemographic or behavioral health issue. After permission is obtained, the student uses the Empaneled Patient Form to gather the information needed from the patient and their medical record to present their case in a de-identified fashion. 

During a LG session toward the end of each block, every student is required to bring their completed Empaneled Patient Form to class. The LG facilitator will record that each student has their completed form and invite students to present their empaneled patient to their peers with the understanding that not every symptom, diagnosis, or sociodemographic or behavioral health issue needs to be presented and discussed. With guidance from their LG facilitator, students will discuss the empaneled patient cases and focus on the following questions: 

• How are the chief complaint, signs and symptoms, condition, or situation in the empaneled patient different or similar to the standardized patient or clinical reasoning case discussed in the LG classroom?
• What barriers did the empaneled patient face in obtaining care for their health concern?
  
• In considering your empaneled patient, what would be important for you to remember with future patients?
• How does this symptom, diagnosis, or sociodemographic or behavioral health issue impact the life and overall health of the patient?
  
  

Patient empaneling connects the Foundational Science, Longitudinal Practice, and Longitudinal Group components of the curriculum, and through this experience students are able to

• Apply classroom knowledge and clinical skills to the care of patients with varied symptoms, diagnoses, and sociodemographic and behavioral health issues.
• Demonstrate effective communication of patient cases to health care team members, including attending physicians and peers.
• Compare and contrast presentation, assessment, and management of patients in diverse health care settings.
• Practice population management by following a cohort of patients over time to see how their problems interface with the health care system.

Watch an example of a student discussion about empaneled patients facilitated by Dr. Dan Clinchot, the Vice Dean of Education in the College of Medicine.

Patient Empaneling Requirements - Med 1  

The symptoms, diagnoses and sociodemographic or behavioral health issues for each block are listed below. Students may empanel a patient with any of the listed requirements at any time, even if for presentation in a future block. It is highly recommended that students complete an Empaneled Patient Form at the time a patient is identified and empaneled. Students should keep track of this form, so it can be retrieved to present the empaneled patient during the appropriate block.

Bone and Muscle Disorders block 

• Back pain
• Hip pain
• Knee pain
• Shoulder pain
• Dislocation
• Fibromyalgia
• Fracture
• Gout 
• Juvenile idiopathic arthritis
• Myopathy
• Osteoarthritis
• Rheumatoid arthritis
• Overuse injury
• Behavior change affecting their health
• Injury affecting their quality of life
• Low health literacy

Cardiopulmonary Disorders block

• Chest pain
  
• Cough
  
• Palpitations
  
• Shortness of breath
  
• Wheezing
  
• Asthma
  
• Chronic obstructive pulmonary disease
  
• Congenital heart disease
  
• Coronary artery disease
  
• Cystic fibrosis
  
• Dysrhythmia
  
• Heart failure
  
• Hypertension
  
• Tobacco use or exposure
  
• Difficulty completing activities of daily living 
  
• Obesity affecting their health 

Endocrine and Reproductive Disorders block 

• Abnormal vaginal bleeding
• Breast-related complaints
• Fatigue
• Genital complaints (e.g., discharge, lesions, pain)
• Pregnancy-related concerns/complications
• Sexual dysfunction
• Unintentional weight gain
• Adrenal disorder
• Diabetes mellitus
• Low testosterone
• Osteoporosis
• Polycystic ovarian syndrome
• Thyroid disorder
• Difficulty adhering to a medication regimen 
• High-risk sexual behavior
• Intimate partner violence

Patient Empaneling Requirements – Med 2

Neurological Disorders block

• Dizziness
• Eye complaints (e.g., pain, visual changes)
• Headache
• Memory loss
• Syncope
• Weakness
• Epilepsy
• Neuropathy
• Sleep disorder
• Stroke
• Anxiety
• Depression
• Child and adolescent behavior concerns
• Disability
• Use of Integrative Medicine
• Health literacy-related misunderstanding or error

Gastrointestinal and Renal Disorders block

• Abdominal pain
• Altered bowel habits (e.g., constipation, diarrhea, fecal incontinence)
• Edema
• Infant spitting up
• Jaundice/Hepatitis
• Urinary complaints (e.g., frequency, dysuria, retention, incontinence)
• Unintentional weight loss
• Chronic kidney disease
• Fatty liver disease
• Gastroesophageal reflux disease
• Inflammatory bowel disease
• Irritable bowel syndrome
• Obesity
• Alcohol use disorder
• Psychosocial stressors affecting abdominal pain
• Self-identified as lesbian, gay, bisexual or transgender (how that may or may not affect their care)

Host Defense block

• Fever
• Irritable infant/child
• Joint pain
• Lymphadenopathy
• Pelvic pain
• Rash
• Anemia/Hemoglobinopathy
•  Autoimmune disease
• Bleeding disorder
• Immunodeficiency
• Infectious disease
• Transplantation
• Advance directives 
• Cultural background different from your own 
• Limited English proficiency (LEP) or English as a Second Language (ESL)
• Non-vaccination or under-vaccination or vaccine refusal
  
   

 

Click on the links below to view the videos.

• LG Physical Exam: Bone and Muscle
• LG Physical Exam: Cardiopulmonary
  
• LG Physical Exam: Endo Repro - Thyroid, Diabetic Foot, Pelvic, Breast
  
• LG Physical Exam: GI - Renal
  
• LG Physical Exam: Host Defense -Skin, Lymph Node, Spleen
  
• LG: Physical Exam: Neuro - Sensation
  
• LG Physical Exam: Neuro - Cranial Nerve Exam
  
• LG Physical Exam: Neuro - Motor Exam Strength Testing
  
• LG Physical Exam: Neuro - Cerebellar Function and Gait Testing
  
• LG Physical Exam: Neuro - Accessing Deep Tendon Reflexes

The R.I.M.E. mnemonic created by Dr. Louis Pangaro (1999), provides a framework for describing student progress.  This framework is presented as four      stages: Reporter, Interpreter, Manager and Educator. Each stage requires an integration and progression of knowledge, skills, and attitudes.

Reporter (R)

• Accurately gathers and clearly communicates patient data
• Shows understanding of which data is important
• Has the skills and reliability to perform interview consistently
• Structured Learning

Interpreter (I)

• Integrates data with knowledge base to develop a differential diagnosis
• Identifies and prioritizes basic problems
• Demonstrates analytical and problem-solving skills
• Supported Learning

Manager (M)

• Plans and explores diagnostic and treatment possibilities independently
• Anticipates Outcomes
• Facilitates patient care
• Self-directed learning

Educator (E)

• Can apply knowledge to patient problems
• Consistent knowledge of current literature
• Applies evidence to decision making
• Committed to self-learning and education of the team

Pangaro L. A. (1999). A new vocabulary and other innovations for improving descriptive training evaluations. Acad Med. 74:1203-7.

September-October – Cami Curren, MD

Please remember that the student's clinical experience in your office is invaluable as they learn how to apply their skills to “real” patients. Some of you work in family practices and some are in highly specialized areas such as pediatric or oncology practices. The good news is that the students are just learning how to take a history and the basics of a physical exam. Your willingness to teach and share with them your patients and your skills is greatly appreciated and serves as their introduction to the world of medicine. In the foundational sciences they learn the pathophysiology and anatomy, in group they learn history taking skills, physical exam skills and the art of medicine. Your office, as part of the Longitudinal Practice, serves as the final step for integration of the curriculum into the practice of medicine.

Students should practice normal exams during this part of their career. So, for example, during neurology block they should practice the neurologic exam. So on one patient they can practice the cranial nerves, on another cerebellar testing, etc. The goal is for them to learn how to do a physical exam, not find pathology. The feedback we have received so far about the practices has been overwhelmingly positive! Thanks for all of your efforts.

November 

• Learning to be part of a health care team. After spending time with your MA and getting to know your office staff and the flow of patients, your student will start taking histories and performing physical exams on your patients as suggested by the huddle cards. One way to direct a student to be part of a health care team is to role model the desired traits. So identify ways to work together and show the student ways to contribute to the team.  For example: “It would help me if you would get a good history of present illness from the patient in room 1.  I will join you in about 10 minutes and ask you to summarize what you have heard in a logical and concise way.  This will allow the patient to elaborate and will allow us to efficiently review the story.”  Adapted from: Teaching Medical Students in an Ambulatory Setting, Second Edition.  Cronau, Mack, Curren, Post, Rizer

December

• Teaching Physical Exam skills. One of the goals of the longitudinal preceptorship is to learn and practice physical exam skills.  Steps to help your student learn and practice the physical exam include:

1. Demonstrate proper technique.  Explain when your technique is modified and why (i.e. “due to her weight, this patient cannot stand up and transfer out of her wheelchair, so I will examine her heart and lungs by putting my stethoscope under her shirt as she cannot get on the table and undress.”)
2. Emphasize important aspects of physical exam techniques (i.e. patient positioning)
3. Observe the student performing physical exam skills
4. Give feedback to the student on their exam skills

- Adapted from: Teaching Medical Students in an Ambulatory Setting, Second Edition. Cronau, Mack, Curren, Post, Rizer

January-March 

• Please remember that their clinical experience in your office is invaluable to the students as they learn how to apply their skills to “real” patients. Although your practice may be highly specialized or limited to certain ages of patients, students should be practicing the techniques for a physical exam and therefore normal patients are ideal. The student should independently practice, they do not require your presence, on patients who do not mind a few extra minutes in your office.  For example, this block we would like the students to practice a normal cardiopulmonary examination, in parts or in its entirety, in your practice. Perhaps you can point out a patient who has some “down time” waiting to be seen in your office and who might allow the student to introduce himself and to perform a normal cardiopulmonary examination. Some patients enjoy the experience of interacting with learners or do not mind the additional clinical attention if it does not delay their care or the smooth operation of your office.
• Remember that the students are receiving instruction on specific systems and exam techniques throughout the year, and are able to review material from VITALS which will help them to verify accuracy in these procedures (this is not your responsibility, although the materials are available to you as well if you desire).  We simply appreciate your willingness to make your patients available for learning situations involving LSI students! 

April-June 

Putting it All Together—the Whole Patient Perspective- Cami Curren, MD   

As their first year in a clinical practice environment draws to a close, LP students are becoming expert at taking a basic history, and are moving ahead with practicing the many cardiopulmonary exam skills they have been learning in this block. The time they spend in your office and your guidance and feedback in these areas are invaluable to learners who are developing these skills. 

One of the very real aspects of medical practice that is invisible to the early learner, although it is a common consideration for us daily,  is the behavioral and social aspect of patient care. For some patients, this is as basic as the inability to afford prescribed medications, requiring social work consultation or judicious formulary use on the part of the physician in order to optimize care. For others, cultural beliefs or personal value systems (i.e., distrust in medicine as an organized business or preferences for natural or alternative healing even in the face of lethal illnesses for which successful traditional treatments exist) form obstacles to best care.  Use of substances such as alcohol or cigarettes may undermine successful care delivery and contribute to illness. Poor food choices leading to obesity may have cultural or economic underpinnings.  Poor literacy or English language skills, compounded by embarrassment that prohibits patients from requesting assistance in these areas, make the transmission of self-care and basic disease management instructions problematic for some of our patients.  

Learning to recognize these and other similar problems, and their impact on health care access and delivery, is a skill set that develops over time. Because sensitively acknowledging and addressing social and behavioral issues is an ongoing communication need among health care providers, starting early to verbalize and discuss your approach to these areas as part of the assessment and plan during office visits is very helpful to students.  

When you see patients whose care is affected by behavioral or social concerns, please feel free to discuss care impacts and treatment options that acknowledge these realities with your student. Your guidance in these areas is yet another chance to have a lasting impact in the education of tomorrow’s physicians and will speak volumes to them regarding the need to consider the realities of the individual patient in the practice they have come to know and to respect the most at this time - yours.     

July-August 

• Limiting the number of teaching points: It is easy to become excited with a student who wants to learn.  However, it can be more effective to focus on a few main learning points.  These teaching points will often be general rules that can apply to other situations, or focus on basic knowledge such as a specific physical exam skill.  This strategy results in learning that is more memorable and more easily transferrable to new situations.  - Adapted from: Teaching in Your Office.  A Guide to Instructing Medical Students, and Residents, Second Edition.  ACP Teaching Medicine Series.  Alguire, DeWitt, Pinsky, and Ferenchick.

 

 

 

 

 

 

 

VITALS is the College of Medicine’s Student Information System. This system is used to evaluate the students, preceptors, and program as well as track student completion in certain activities.  Longitudinal Preceptors have instructor accounts in this system in order to evaluate student performance. At designated points in times, you will receive an email notification from the VITALS system with a link to an evaluation of the student(s). The link will take you directly to the evaluation form and you will not need to log in.

Please contact Diana Bahner for any assistance with the website.

Cue:  In getting a diagnostic commitment, or while probing for supporting evidence it becomes clear to you that the learner has either gaps in his knowledge base or is having difficulty interpreting and analyzing the clinical data.

Response: As soon as possible, after the mistake, find an appropriate time and place to correct the error, or help “fill in the gaps.”  Most learners are not entirely off the mark, they just frequently need a little coaxing to help link information in ways effective for problem solving.

Rationale: Mistakes left unattended have a good chance of being repeated.  Learners who are aware of their mistakes and know what to do differently in the future only need to be reinforced.  Learners who are aware of a mistake but are unsure how to avoid the uncomfortable situation in the future are likely to be in a “teachable moment” (eager for tips to get out of or avoid the uncomfortable situation in the future).

Example of a helpful approach: 

• “I agree the patient is probably drug-seeking, but we still need to do a careful history and examination.”

Examples of a non-helpful approach:  

• Avoid vague, judgmental statements.  “You did what!”
• “I can’t believe you ever got into medical school.”

Cue: After presenting the patient to you, the learner either stops to wait for your response or asks your guidance on how to proceed.  In either case, the learner does not offer an opinion on the data presented.

Response: You ask learner to state what she thinks about the information presented.

Rationale:  Asking the learner how she interpreted the data is the first step in diagnosing her learning needs.  In addition, if she has been engaged in processing as well as collecting data and thus problem solving, she will enjoy the collaborative role she feels in sharing this with you.  Alternatively, the learner who has not consciously been engaged in interpretation and analysis of data will now be called upon to do so.

Examples of questions likely to get a commitment: 

• “What do you think is going on with this patient?”
• “Why do you think the patient has not been taking his mediations?”
• “What do you want to do next?”

Examples of questions not likely to get a commitment:

• “Sounds like GERD, don’t you think?”
• “Anything else?”
• “Did you find out which symptom came first?”

Cue: When discussing a case, the learner has committed herself by providing a diagnosis or management plan and looks to you to either confirm the opinion or suggest an alternative. You may or may not agree with the opinion. Your first instinct is to tell the learner outright what you think about the case. Hold back!

Response: Before offering your opinion, ask the learner what information or evidence supports her opinion (diagnosis or management plan).  Alternatively, ask her what other choices she considered and what evidence supported or refuted those other opinions.

Rationale: Learners proceed with problem solving logically from their knowledge base.  Asking them to reveal their thought process (the “why” of it all) allows you to find out what they know as well as how they apply this information and thus to identify gaps in knowledge as well as faculty problem solving skills. Without this information, you may assume they know more or less than they do and risk targeting your instruction inefficiently.

Examples of questions used to probe for supporting evidence: 

• “What were the major findings that led to your conclusions?”
• “What else did you consider?”
• “What else did you consider?”
• What kept you from considering that diagnosis?”

Examples of non-helpful questions: 

• “What are the possible causes of rashes like this?”
• “I don’t think is gout.  Do you have any other ideas?”
• “This seems consistent with biliary colic.  How about an ultrasound?”

Cue: The learner has effectively and efficiently interpreted the clinical data correctly and has demonstrated sound problem solving skills.  They may or may not realize this.

Response: At each opportunity possible take moment to give specific, positive feedback to the learner regarding her problem solving skills.

Rationale: Some good actions, diagnoses, etc., are pure luck, others more deliberate.  In either case, problem-solving skills in learners are not well established and are, therefore, “vulnerable.”  Unless reinforced, competencies may never be firmly established.

Example of a helpful approach: 

• “That was very perceptive of you.  I agree that you would be wise to spend more time evaluating and treating her depression before launching into a significant workup of her various complaints.  In the long run, you will most likely save her unnecessary testing and cost, and hopefully effectively treat a medical problem that has been undiagnosed before.”
• “Your thought process and selection of treatment shows that you have taken into consideration the patient’s financial status as well as his ability to follow a complex treatment regimen.  Your sensitivity to these issues will go a long way to improving his compliance and this diabetic control.”

Examples of a non-helpful approach:  

• General, non-specific praise is not very helpful, e.g. “You are absolutely right. “ That was a wise decision.”  “Nice job.”

Cue: You have ascertained from what the learner revealed that the case has teaching value, i.e. you know something about it that the learner needs or wants to know.

Response: Provide general rules, concepts or considerations – the “take home message.”  Target teaching to the learner’s level of understanding.

Thank out loud; make explicit that which you do implicitly.  Share how you approached the problem and what information was relevant to forming your diagnostic impression and therapeutic plan.

Rationale: Instruction is both memorable and more transferable if it is offered as a general rule, guiding principal or metaphor.

Learners value hearing how experience informs and transforms book knowledge.

Examples of helpful approaches: 

• “If the patient has a soft tissue infection, such as cellulitis, without an area of fluctuance, incision and drainage is not possible.  You have to watch for fluctuance to evolve, and then drain it.”
• “I am less inclined to think this is biliary colic or pancreatitis, as the illness has followed a fairly indolent course, and has been characterized by general, somewhat nonspecific, abdominal discomfort…”

Examples of non-helpful approaches: 

It is not the answer to a problem rather it is your approach to solving the problem that should be stressed. 

• “This patient needs diuresis and then probably should have an ACE Inhibitor started.” 
• “Take it from me, this is not cholecystitis but common variety gastroenteritis.”