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Teaching when time is limited

David M Irby and LuAnn Wilkerson

BMJ 2008;336;384-387
doi:10.1136/bmj.39456.727199.AD

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PRACTICE For the full versions of these articles see bmj.com

TEACHING ROUNDS
Teaching when time is limited
David M Irby,1,2 LuAnn Wilkerson3

1 Teaching in small increments of time during the problem at hand—for example, “have you had a
University of California, San
Francisco, CA 94143-0410, USA chance before to do investigations in an elderly patient
2
patient care can provide powerful learning with sudden onset of mental status changes?” or “do
Carnegie Foundation for the
Advancement of Teaching, experiences for trainees. This article you already have a differential diagnosis in mind?”
Stanford, CA 94305, USA
3 explores the ways that clinical teachers Questions that follow the learner’s presentation of
David Geffen School of Medicine
patient findings can guide the teacher’s decisions about
at the University of California,
Los Angeles
might do this in a time efficient way what and how to teach—for example, “what do you
Correspondence to: D M Irby think we should do next?”
irbyd@ucsf.edu Clinical teachers face a daunting challenge of simulta-
neously caring for patients and teaching learners in a Conduct a two-minute observation
BMJ 2008;336:384-7
doi:10.1136/bmj.39456.727199.AD time constrained environment. A cohort study of 179 This time efficient strategy allows the teacher to observe
Dutch medical students (79% of the cohort) during an the learner’s performance instead of making inferences
internal medicine clerkship located at 14 different about the ability of the learner from the case presentation
clinical sites found that the quality of supervision has a alone. The two-minute observation model, which is like
greater impact on clinical competence and knowledge an epidemiologist’s sampling technique, involves the
than does the number of patients seen.1 Even small teacher slipping in and out of the patient encounter
moments of teaching time can offer important learning without intervening, in order to gather more direct
opportunities to trainees by providing them with new information about the learner’s needs for guidance,
insights and skills that they would not acquire from direction, feedback, or enrichment.3 Both teacher and
simply seeing patients on their own.1 learner should agree on the patient encounter that will be
To achieve this combined caring and teaching goal in a used and the aspect of the interaction that will be targeted
time efficient manner, clinical teachers use various for the quick observation—such as establishing patient
strategies to (a) identify the needs of each individual rapport, history taking, physical examination, or patient
learner, (b) teach according to these specific needs, and education. Four elements are needed for this to work
(c) provide feedback on performance.2 This three step effectively:
teaching process can be adapted to the environment in  The teacher must be sure that the learner knows
which the teaching is taking place. Here we describe that the observation is for teaching purposes and
several time efficient strategies in relation to each step in understands how the observation will work;
this process.  The learner will need to explain the process to the
patient so that the teacher can enter and leave the
Step 1: Identify the learner’s needs room without disrupting the encounter;
The time saving rule of thumb is: target, then teach. If  Whenever in the room, the teacher needs to be
the teacher can quickly determine what an individual outside the patient’s visual field and refrain from
learner needs to know, then he or she can focus any participating in any manner;
teaching on those needs, thus saving time by not  Time will be needed for discussion afterwards, to
teaching what the learner already knows or is not ready focus on what was done well, what can be
This series provides an update on for.2 To assess the learner’s level of knowledge quickly, improved, and what type of independent study
practical teaching methods for the teacher needs only two tools: good questions and might be useful.4
busy clinicians who teach. The the ability to listen and observe.
series advisers are Peter Cantillon,
senior lecturer in the department Step 2: Teach rapidly
of general practice at the National Ask questions With the diagnostic tools described above and those
University of Ireland, Galway,
Ireland; and Yvonne Steinert,
Questions are the teacher’s primary diagnostic tool, embedded in several of the following teaching models,
professor of family medicine, can precede or follow the learner’s encounter with the the teacher can teach rapidly during patient care. We
associate dean for faculty patient, and can guide the choice of teaching methods. have selected several teaching models that are
development, and director of the
Centre for Medical Education at Questions asked before a patient encounter can help described in the literature and are advocated by leading
McGill University, Montreal. the teacher to ascertain the learner’s experience with medical educators and which can be used separately.5

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Having several models provides flexibility for adapting and teachers and generally improved learners’ ratings
instruction to the needs of each learner and the of their faculty and resident teaching after they were
constraints of the environment. However, if a clinical observed and given feedback on the basis of the
teacher decides to adopt any of these models, he or she model.6-8 12-14
needs to communicate expectations about what will
happen and why. The Aunt Minnie model
The Aunt Minnie model is designed to promote rapid
The “one-minute preceptor” model pattern recognition among learners in ambulatory
The most widely known and researched teaching settings.15 The name of the model comes from the
method is the “one-minute preceptor model,” (the adage that if the woman across the street walks and
one-minute teaching model).6-13 This method involves dresses like your Aunt Minnie then she probably is
identifying the needs of each individual learner, your Aunt Minnie, even if you can’t see her face. Thus,
teaching, and providing feedback by using a five step after seeing the patient, the learner presents only the
approach: main complaint and the presumptive diagnosis to the
 Get a commitment about what the learner thinks teacher; discussion of the case occurs only after the
is going on with the patient; clinical teacher has independently seen the patient.
 Probe for underlying reasoning or alternative Box 2 gives an example of this model in use.
explanations;
 Teach a general principle; The SNAPPS model
 Provide positive feedback about what the learner The SNAPPS (Summarise, Narrow down, Analyse,
did right; Probe, Plan) model is a learner centred, outpatient
 Correct any errors by making suggestions for model that includes six steps that the learner controls.17
improvement. These steps take place after the learner has seen the
Box 1 gives an example of the model in use. patient.10 17-19 The learner has to:
Research on the one-minute preceptor model has  Summarise briefly the history and findings;
found strong satisfaction with the model by learners  Narrow down the differential to two or three
relevant possibilities;
 Analyse the differential by comparing and con-
Box 1 Example of the one-minute preceptor model trasting the possibilities;
 Probe the clinical teacher by asking questions
The following dialogue took place after a learner’s case presentation of a 3 year old boy who
complained of earache. about uncertainties, difficulties, or alternative
Get a commitment approaches;
 Plan management for the patient’s medical
Teacher: “What do you think is going on?”
problems;
Learner: “I think he has an upper respiratory tract infection, probably an acute bacterial otitis  Select a case related problem for self directed
media.”
learning;
Probe for supporting evidence
This model is appropriate for experienced learners,
Teacher: “What led you to that conclusion?” and encourages them to do most of the work in
Learner: “He has a history of repeated acute otitis media and currently has a fever and a justifying their thinking and exploring what they don’t
painful right ear. In addition, I believe his right ear is red and less mobile.” understand.
Teacher: “What would you like to do for him?”
Learner: “First, I would like you to confirm my findings. If you agree, then we should give him “Activated” demonstrations
some antibiotics. As he doesn’t have any allergies to medications and was successfully When a patient’s problem is unfamiliar to the learner,
treated with amoxicillin in the past, I think amoxicillin is a reasonable choice.” this is the time for the learner to observe the clinical
Teach a general principle teacher at work. However, the learner needs a specific
Teacher: “It does sound like otitis media. The key features of otitis media in the history are assignment to complete while observing (such as
upper respiratory tract symptoms followed by ear pain and increasing fever and irritability. “watch how I ask critical questions about alcoholism
He is also at risk as he has had prior episodes of acute otitis media. In the physical or abuse”) and an understanding of what is expected in
examination, I look for the appearance of the ear drum—including any erythema, terms of participation.3 After the demonstration, the
opacification, and distortion of landmarks with bulging or retraction. Sometimes there will
teacher needs to “activate” the learner by asking him or
be purulent discharge in the external canal if the tympanic membrane has perforated. This
her to describe what was observed. A brief discussion
child would seem to fit these criteria.” The teacher concludes: “With the lack of allergies,
amoxicillin is a logical choice for an antibiotic. I’ll be glad to confirm your ear examination typically ensues in which the rationale for the actions is
findings. Let’s go and see the patient.” examined and independent study is assigned.
Reinforce what was done well
Case presentations at the bedside
Teacher: “You did a good job of putting the history and physical examination findings
together into a coherent whole. The hospital bedside or clinic examination room is a
good location for teaching when the learner is well
Correct errors and/or make recommendations for improvement
prepared to deal with the patient and the discussion is
Teacher: “You might check the Cochrane Collaboration for an evidence based review on otitis
unlikely to frighten or alarm the patient. The learner is
media.”
directed to finish investigating the patient before

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ability to assess their own performance, which is

Box 2 Example of the Aunt Minnie model of ambulatory teaching notoriously inaccurate.23 However, the greatest barrier
This approach focuses on developing rapid pattern recognition16: is an attitude on the part of the teacher that “real
 The learner sees the patient, takes the history, and does the physical examination on the teaching” requires a formal presentation of knowledge
basis of the main complaint; in a conference room, using a whiteboard, and taking
 The learner presents the case to the clinical teacher but only the main complaint (such as lots of time. With this mental model in mind, teachers
“Johnny is 2 months old with a temperature of 40°C and is lying listlessly in his mother’s are understandably reluctant to teach because it slows
arms”) and his or her presumptive diagnosis (“this may be a virus, but we should rule out them down. Yet, the models described here are time
bacteraemia and meningitis”) (30 seconds); efficient and powerful—thus allowing instruction to
 While the learner begins to write up the notes, the clinical teacher sees the patient, occur even when only seconds or minutes exist.
diagnoses the problem, and creates a management plan (5 minutes);
 The teacher then discusses the case with the learner (1-5 minutes) and reviews and signs What’s next?
the medical record (1-2 minutes). Each of these teaching methods helps to diagnose
For this model to work effectively, the learner and the patient need to understand the learning needs and provide targeted instruction and
process, and the teacher must see the patient, know the correct diagnosis, and if uncertain feedback. However, they still take time. Although we
be willing to admit it.15 don’t know exactly how much time is required to create
a powerful learning environment, teaching is clearly
being increasingly squeezed out of most patient care
presenting the case to the teacher in front of the patient. settings. Creating a structure to build in and pay for
The bedside presentation allows the teacher to engage teaching time will become increasingly important.
the learner and the patient in a discussion about any Initial work in this area has centred on documenting
missing information or decisions that need to be made; and rewarding faculty teaching efforts24-26 and creating
encourage the patient to act as a teacher; and use the academies of medical educators to reward and support
opportunity to concurrently teach the learner and distinguished teachers.27 28
inform the patient, thus saving time.20 21
Contributors: Both authors shared in the conceptualisation of the article,
did the literature search, and drafted the article. DMI revised the article
Step 3: Provide feedback after peer review and provided the final version, which had been approved
Feedback is one of the most underused yet powerful by LW.
instructional strategies available and can take less than Competing interests: None declared.
Provenance and peer review: Commissioned; externally peer reviewed.
a minute, and several of the above models build
feedback into the sequence. Feedback provides the
1 Wimmers P, Schmidt H, Splinter T. Influence of clerkship experiences
learner with a description of their strengths and on clinical competence. Med Educ 2006;40:450-8.
recommendations for improvement. The key to feed- 2 Irby D. How attending physicians make instructional decisions when
back is going beyond praise to specific descriptive conducting teaching rounds. Acad Med 1992;67:630-8.
3 Wilkerson L, Sarkin RT. Arrows in the quiver: evaluation of a workshop
comments about a learner’s performance. It can also on ambulatory teaching. Acad Med 1998;73(suppl 10):S67-9.
serve as an opportunity to promote self reflection and 4 Kuo A, Irby D, Loeser H. Does direct observation improve medical
students’ clerkship experiences? Med Educ 2005;39:518.
independent study.22
5 Irby D. Teaching and learning in the ambulatory care setting: a
thematic review of the literature. Acad Med 1995;70:898-931.
Challenges 6 Aagaard E, Teherani A, Irby D. Effectiveness of the one-minute
preceptor model for diagnosing the patient and the learner: proof of
A heavy clinical load can overwhelm any attempt to concept. Acad Med 2004;79:42-9.
use one or more of these teaching methods and can rule 7 Eckstrom E, Homer L, Bowen J. Measuring outcomes of a one-minute
out teaching in the middle of patient care. Another preceptor faculty development workshop. J Gen Intern Med
2006;21:410-4.
challenge is knowing how much to rely on the learner’s 8 Furney S, Orsini A, Orsetti K, Stern D, Gruppen L, Irby D. Teaching the
one-minute preceptor: a randomized controlled trial. J Gen Intern Med
2001;16:620-4.
KEY POINTS 9 Irby D, Aagaard E, Teherani A. Teaching points identified by preceptors
observing the one-minute preceptor and traditional preceptor
In clinical settings, teachers need time efficient methods to help them to assess the learner’s encounters. Acad Med 2004;79:50-5.
10 Lake F, Ryan G. Teaching on the run tips 4: teaching with patients. Med
level of knowledge and skill, teach quickly, and provide feedback on performance. J Australia 2004;181:158-9.
Step 1: Identify the needs of each individual learner by asking questions or by doing a 11 Neher J, Gordon K, Meyer B, Stevens N. A five-step “microskills” model
of clinical teaching. J Am Board Fam Pract 1992;5:419-24.
two-minute observation.
12 Salerno S, O’Malley P, Pangaro L, Wheeler G, Moores L, Jackson J.
Step 2: Select a model for rapid teaching such as: Faculty development seminars based on the one minute preceptor
improve feedback in the ambulatory setting. J Gen Intern Med
 “One-minute preceptor” model (for targeting instruction); 2002;17:779-87.
13 Teherani A, O’Sullivan P, Aagaard E, Morrison E, Irby D. Student
 Aunt Minnie model (for teaching pattern recognition); perceptions of the one minute preceptor and traditional preceptor
models. Med Educ 2007;29:323-7.
 SNAPPS model (for encouraging learner self direction); 14 Regan-Smith M, Hirschmann K, Iobst W. Direct observation of faculty
with feedback: an effective means of improving patient-centered and
 “Activated demonstration” (for making visible the teacher’s clinical expertise); learner-centered teaching skills. Teach Learn Med 2007;19:278-86.
 15 Cunningham A, Blatt S, Fuller P, Weinberger H. The art of precepting:
Case presentations at the bedside (for efficiently engaging the learner and the patient. Socrates or Aunt Minnie? Arch Pediatr Adoles Med 1999;153:114-6.
Step 3: Provide feedback on performance by quickly commenting on strengths and making 16 Schmidt H, Norman G, Boshuizen H. A cognitive perspective on
recommendations for improvement medical expertise: theory and implications. Acad Med
1990;65:611-21.

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17 Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centred model measures of competence: a systematic review. JAMA
for outpatient education. Acad Med 2003;78:893-8. 2006;296:1094-102.
18 Chacko K, Aagaard E, Irby D. Teaching models for outpatient 24 Ruedy J, MacDonald N, MacDougall B. Ten-year experience with
medicine. Clin Teacher 2007;4(2):82-6. mission-based budgeting in the faculty of medicine of Dalhousie
19 Irby D, Bowen J. Time-efficient strategies for learning and University. Acad Med 2003;78:1121-9.
performance. Clin Teacher 2004;1(1):23-8. 25 Stites S, Vansaghi L, Pingleton S, Cox G, Paolo A. Aligning
compensation with education: design and implementation of the
20 Smith AG, Bromberg MB, Singleton JR, Forshew DA. The use of “clinic
educational value unit (EVU) system in an academic internal medicine
room” presentation as an educational tool in the ambulatory care
department. Acad Med 2005;80:1100-6.
setting. Neurology 1999;52:317-20.
26 Watson R, Romrell L. Mission-based budgeting: removing a
21 Usatine RP, Nguyen K, Randall J, Irby DM. Four exemplary preceptors’ graveyard. Acad Med 1999;74:627-40.
strategies for efficient teaching in managed care settings. Acad Med 27 Irby D, Cooke M, Lowenstein D, Richards B. The academy movement: a
1997;72:766-9. structural approach to reinvigorating the educational mission. Acad
22 Hewson M, Little M. Giving feedback in medical education: Med 2004;79:729-36.
verification of recommended techniques. J Gen Intern Med 28 Simpson D, Fincher R, Hafler J, Irby D, Richards B, Rosenfeld G, et al.
1998 13:111-6. Advancing educators and education by defining the components and
23 Davis D, Mazmanian P, Fordis M, van Harrison R, Thorpe K, Perrier L. evidence associated with educational scholarship. Med Educ
Accuracy of physician self-assessment compared with observed 2007;41:1002-9.

RATIONAL IMAGING
Investigating perianal pain of uncertain cause
Rebecca Greenhalgh,1 C Richard Cohen,1 David Burling,2 Stuart Andrew Taylor1,3

1 This article explores the radiological include occult perianal sepsis such as intersphincteric
University College Hospital,
London NW1 2BU abscess (the prevalence of anal fistula in the general
2
St Mark’s Hospital, Harrow
investigations available to diagnose perianal population is about 0.01%1), anal complications of
HA1 3UJ pain of unknown cause, with particular inflammatory bowel disease, and anal cancer. Rarer
3
University College London,
London
reference to perianal sepsis causes include retrorectal developmental cysts, sacrosp-
Correspondence to: S A Taylor
inal tumours, and sacral nerve tumours. Proctalgia fugax
stuart.taylor@uclh.nhs.uk (intermittent severe anal or lower rectal pain of
The patient unknown aetiology) remains a diagnosis of exclusion.
BMJ 2008;336:387-9
doi:10.1136/bmj.39455.393299.AD A 29 year old woman presented with constipation,
constant perianal burning, and pain on defecation. Anal endosonography
Digital rectal examination was uncomfortable with Anal endosonography is a quick, safe, and cheap
induration in the right posterior quadrant, but there technique but requires operator experience. It pro-
was no evidence of anal fissure or skin tag, thrombosed vides detailed, high resolution images of the anal
haemorrhoid, perianal haematoma, anal mass, or sphincter complex and intersphincteric space.
palpable abscess or fistula. Perianal skin sensation Although its main clinical role is in investigating faecal
was normal. incontinence, anal endosonography will usually reveal
the presence of occult intersphincteric abscesses. It
What is the next investigation? may also show anal tumours and developmental cysts,
The aim of further investigation is to identify those particularly if they communicate with the inter-
causes of perianal pain not always detected by direct sphincteric space, but data on its accuracy for these
clinical examination. Commoner causes to consider rarer conditions are limited.

Advantagesand disadvantages ofthe use ofanalendosonographyand magnetic resonance imagingin the investigationofperianal
pain of uncertain cause
Anal endosonography Magnetic resonance imaging
No ionising radiation No ionising radiation
High resolution images of anal sphincter complex Good resolution of anal sphincter complex
Small field of view limits evaluation of tissues and disease Large field of view allows evaluation of tissues and disease processes extending beyond
processes extending beyond anal canal anal canal
This series provides an update on
Examination time around 5 minutes Examination time around 20 minutes
the best use of different imaging
methods for common or important No reported patient safety issues3 Contraindicated in patients with certain metal implants; relatively contraindicated in first
clinical presentations. The series trimester of pregnancy4 5; claustrophobia can prevent scanning
advisers are Fergus Gleeson, Operator dependent Standardised scanning protocol
consultant radiologist, Churchill
Hospital, Oxford, and Kamini Requires specialised ultrasound equipment Requires standard MRI scanner only
Patel, consultant radiologist, Requires insertion of endoanal probe Can be performed without insertion of endoanal coil
Homerton University Hospital,
All statements are supported by evidence, but references are supplied only for the less well established statements.
London.

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