Faculty of one: How to teach a future doctor while still tending your patients

Office-based physicians now play an increasingly important role in medical education.

By Myrle Croasdale — Posted March 14, 2005

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With more medical schools wanting their students to learn from physicians in a practice setting, more doctors than ever have the opportunity to pass on what they know to the next generation.

But it's one thing to answer the occasional question from a young doctor in training when you happen to be at a hospital or at a dinner. It's another thing when you realize you have an eager, wide-eyed student trailing your every move, and that you're expected to show that student everything you know while still being responsible for a full patient load and keeping your practice financially afloat. Oh, and to do that for little or no extra pay.

"It's getting harder to get people because of the pressure people are under," said David Kern, MD, MPH, co-director of general internal medicine at Johns Hopkins Bayview Medical Center. "Working for HMOs or even for yourself, if you are in a nonprocedural specialty, there's increased productivity pressure."

So should you tell the local medical school "no thanks" when it comes calling?

Not necessarily. There are resources out there to help doctors learn how to balance teaching and practicing medicine. As far as remuneration, even if you're not getting paid in dollars, they say, becoming a preceptor has its own rewards.

Andrew Albritton, MD, associate dean for curriculum at the Medical College of Georgia in Augusta, said despite the lack of monetary reward, teaching students is worth it.

"I work with two second-year students, and they heard their first S3 gallop," said Dr. Albritton, who also recruits and trains physicians for the school's branch campus in rural southwest Georgia, which relies heavily on clinical rotations in community-based offices. "They were so enthusiastic. It reminds me why I went into medical school in the first place."

Why medical schools want you

Thousands of doctors already volunteer. Patrick Alguire, MD, director of education and career development for the American College of Physicians, said a recent ACP survey showed that 50% of members reported they'd taught in their office in the last year and another 30% had taught in the last 10. If this is representative of physicians as a whole, he said, that's a lot of volunteering. But demand still surpasses supply.

The demand is driven by medical schools' realization that most of their students will end up working in an office-based practice, and they should have some idea of the cases they will see there and the environment they'll be working in.

As enticements, some schools give volunteer faculty a small stipend. Others give access to their medical library and Internet services. But concern about a loss of productivity frequently comes up in talks to prospective preceptors. Dr. Alguire said most private physicians find teaching costs them time instead of money, about 30 minutes to an hour per half-day of teaching.

"Generally they just work harder to overcome the productivity issue," he said.

Samuel Durso, MD, clinical director of geriatrics at Johns Hopkins School of Medicine and author of a teaching column for community-based physicians, said there are a variety of scheduling techniques to keep the day moving along. At his clinic, he'll have two exam rooms going. He'll see one patient with the medical student, who will have a focused objective such as taking some part of the history or performing a specific part of the exam. He'll leave for 15 minutes to see his other patient. When he returns, the student gives the patient's history or demonstrates the exam.

"I'll listen to the history or repeat the exam with the student watching," he said. "The bottom line is you can stagger those visits so you are seeing patients, and then you're seeing a patient with the learner where you are just confirming their work."

Part of keeping up productivity is making sure, when it comes to the medical students, that the patients are informed and office staff is prepared.

Doctors can do a lot to help make patients feel comfortable with students, said Dr. Albritton, who is helping to develop a Medical College of Georgia branch campus that would rely almost entirely on community-based faculty. He suggests they think through how the students will introduce themselves. For example, will they be called medical students or physicians in training?

His other pointers include: Get the office staff up to speed on how having medical students in the office will work. Ask the staff to let patients know there are students in the practice, and mention this in the practice brochure. And clearly tell patients that they have a choice whether the medical student is part of their exam or not.

However, sensitivity is required.

"You have to think about your practice and your patient's experience," Dr. Durso said. "I can't say this is the right thing for everybody in every circumstance. ... My own practical experience ... is that most of the time patients are flattered to be part of the teaching experience. When it is explained what their contribution to this is, most will jump at the chance."

The nitty gritty

Once the office staff is prepped and the patients informed, the actual teaching begins. A model popularly used today is the one-minute preceptor model, detailed in "Five-Step 'Microskills' Model of Clinical Teaching," Journal of the American Board of Family Practice, July-August 1992. The five "microskills" of the model are: get a commitment; probe for supporting evidence; teach general rules; reinforce what was done right; and correct mistakes.

Researchers found clinicians got an equal or better impression of the patient using this model, had greater self-confidence in rating students, and rated the encounter as more effective and efficient than when using traditional teaching techniques, according to the study "Effectiveness of the One-Minute Preceptor Model for Diagnosing the Patient and the Learner: Proof of Concept," Academic Medicine, January 2004.

For new teachers, Dr. Kern recommends physicians think about verbalizing their thought processes. "Think out loud about what you are doing," he said. "Most experienced physicians have talents that are intrinsic, but a new learner doesn't know [these thought processes] yet."

Students will learn a lot indirectly from, and can be inspired by, your own enthusiasm. Two years ago, the Medical College of Georgia started a community-based rotation in obstetrics and gynecology. The year before, six students declared an interest in ob-gyn as a career. This year, 15 have. "They see the true practice of obstetrics and gynecology," Dr. Albritton said. "It really helps students in their career choices."

Show me how

The teaching model demonstrated to Dr. Albritton's community faculty looks like this: At the beginning of the day, the physician asks the student what skills he or she wants to work on, with the explanation that at the end of the day they'll sit down together, with the student reporting back on two things learned. Then the doctor will give feedback on the day's performance.

Telling a student you're giving feedback is vital. "When I first started out on faculty, students would say I never gave feedback," Dr. Albritton said. "Well, I wasn't labeling it as feedback."

Knowing at what level to teach is also important. Dr. Durso said ideally the program director provides information on the curriculum and teaching objectives. However, if this doesn't happen, the students have most likely been apprised of their learning objectives and will share them as well as their personal goals.

Dr. Durso's teaching model is similar to the one Dr. Albritton uses. He suggests preceptors start out the day reviewing objectives that will be addressed, informing the student that other learning will also occur during the session, and telling the student that he or she will be debriefed at the end and will be expected to share one or two things he or she got out of the clinic.

If the student wanted to become more proficient at a knee exam, Dr. Durso would go over that before starting to see patients, then make sure at the end of the day that the student had done others on their own.

"I've found with learners it's very important to make sure they acknowledge they've met certain objectives, especially subtle objectives," he said. "They don't always understand they met the objective. So you do this in the debriefing. Usually, I find the learners are satisfied because they've pretty much written their own prescription. Really, this is learner-driven."

Before giving feedback, Dr. Kern said he often asks students to evaluate themselves. For example, recently he had a student from a more traditional medical culture who was very cognitive in her approach and disorganized and nervous when presenting in front of patients.

"At one point in giving a history she became discombobulated and frustrated," he said. "She was being too hard on herself. We told her we were her coaches and were not there to grade her initially, we wanted to help. This took a little tension off, and her presentations have remarkably improved."

Giving negative feedback or constructive criticism is probably the toughest part of teaching. But it has to be done.

"Giving feedback is a little frightening at times," Dr. Durso said. "The truth of the matter is that giving feedback is surprisingly easy and well-received. Studies show that medical learners really crave it. If preceptors get dinged by students, it's for not giving enough feedback."

Dr. Durso is confident those who take on teaching will find that the rewards outweigh the challenges. Recently, he was the attending physician for a team of students and residents who reviewed the history of a patient with a lot of somatic complaints, he said, which resulted in a long list of possible causes.

"She was an older woman and [it] was helpful to hold the patient's hand," he said. "The healing touch seemed appropriate. I was listening to her social history, which suggested that her real problem was anxiety and depression. Several times ... her eyes looked slightly reddish, like tears.

"I asked her what was really worrying her. She burst into tears. She'd been depressed and didn't have the courage to tell anyone about it. She was extremely upset about something that had happened in her social history.

"So when the team went out, we looked at the technique of asking an open-ended question. It was really heartening to me, from resident to medical student. They all acknowledged they'd learned a new approach to taking a history -- using the healing touch, asking a simple question and being quiet, the power of just letting the question sit. Every one of them said they'd never forget how to use that technique. And I walked away feeling I had made a difference."

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Constructive feedback

Telling someone they've done a poor job is uncomfortable, but there are ways to ease the tension.

David Kern, MD, MPH, co-director of general internal medicine at Johns Hopkins Bayview Medical Center offers these tips for dealing with performance issues.

Before the meeting:

  • Tell the learner what the meeting is about and ask him or her to prepare if needed.
  • Don't meet when you are still angry. Assess your own biases beforehand, anticipating how you're likely react to the individual.
  • Set reasonable goals for the meeting and the specific points you want to convey.
  • Decide what you'll do if the individual fails to respond.
  • Practice saying what you want to say. How you say it does make a difference.

To open the meeting:

  • Build rapport and state the purpose of the meeting; acknowledge any awkwardness or discomfort.
  • State the performance issue.

If the individual acknowledges the problem:

  • Define and analyze the problem together and come up with solutions, then decide on future actions and follow-up.
  • Assess the individual's acceptance of the problem. Summarize the meeting, and document it.

If the individual doesn't acknowledge there's a problem:

  • Check your own emotional reactions, acknowledge the learner's perspective and emotions, and state your own perspective.
  • State your expectations and decide on future actions and follow-up, before summarizing the meeting and documenting it.

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External links

Teaching in Your Office: A Guide to Instructing Medical Students and Residents, American College of Physicians (link)

"Can Precepting Add Value to an Office-based Practice?" Advanced Studies in Medicine, an online newsletter from Johns Hopkins University School of Medicine, May 2003, in pdf (link)

"Outcomes of a National Faculty Development Program in Teaching Skills Prospective Follow-up of 110 Internal Medicine Faculty Development Teams," Journal of General Internal Medicine, December 2004 (link)

"Effectiveness of the One-Minute Preceptor Model for Diagnosing the Patient and the Learner: Proof of Concept," abstract, Academic Medicine, January 2004 (link)

"Five-Step 'Microskills' Model of Clinical Teaching" Journal of the American Board of Family Practice, abstract, July-August 1992 (link)

Society of Teachers of Family Medicine (link)

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