An Approach to Ambulatory Clinical teaching for clients

-Many of you will have worked with 3rd and 4th year students
– The term clerks is not universal.
-JURSI’s at the University of Saskatchewan Junior undergraduate rotating student interview.
-A few years ago the JURSI year was extended and is now more than 15 months long. This has had many positive benefits but it does mean JURSI’s are less experienced in clinical situations than previous; especially in the early portion of the JURSI we do refer to senior and junior year JURSI’s of the history on physical examination.
THE APPROACH (PERRR)
(1) Planning
-The teacher and the JURSI meet prior to the patient encounter to discuss.
-Comfort zone of the JURSI.
-What does the JURSI have to get out of the encounter(s).
-What agent of the Hx/Px/Dx management does the JURSI feel comfortable with?
-What aspects do they feel they need help with?
A plan is developed to concentrate on 1-2 areas by mutual agreement with the next few patients.
(2) Encounter
– The JURSI sees the patient (on their own), or the teacher and JURSI go see the patient together.
Usually the JURSI feels more comfortable with the teacher; especially early in the year.
(3) Reporting
– The JURSI reports on the encounter with the patient. The information should include Hx/Px exam, different diagnosis and management. There should also be a few minutes to view what was in the plan.
(4) Review
– The teacher and JURSI review with the patient their thoughts and possible management.
– It would also be the time to review aspects of the history of physical examination.
(5) Reflect
– The teacher and JURSI reflect the encounter
– The teacher would ask the JURSI on aspects:
-how they feel it went
-what they did well
-what could they have done
– If any further review required.
Plans for the next patient or two

Teaching the Hidden Curriculum

Today I’m going to talk about seven methods that you can use as a clinical teacher to assist students to learn the hidden curriculum – in other words the skills and attitudes we expect doctors to demonstrate, but in most cases don’t teach and don’t assess as part of the medical curriculum. Some of the methods you will already be familiar with, others will be easily implemented, some will be more difficult to implement, but all of them will help reveal the hidden curriculum to medical students.
I’d like to begin this session by telling you a story about why I keep returning to my family doctor even though his practice is so busy that I’ve waited weeks for an appointment.
Several years age, my daughter was diagnosed with a serious illness and as he was telling her about the diagnosis, without a break in his eye contact with her, he laid his hand on my shoulder. That brief contact told me that even though his focus had to be on my daughter, he knew that I was in pain as well. Without a word, he had conveyed his empathy.
Empathy, professionalism, multicultural sensitivity, communication, team work, office management are just a few of the skills that we expect graduates to have when they become physicians. So let’s look at how we teach these skills and attitudes.
1. Consciously Role Modeling
Role modeling is a standard expectation but conscious role modeling requires daily thought about what part of professionalism you are going to demonstrate today. At the same time each day think about not demonstrating the dehumanizing of patients and staff.
2. Use Deliberate Reflection
What aspect of professionalism are students not being exposed to in your teaching? Maybe its patient advocacy, maybe its teamwork; how can you rectify that missing element? Have a coffee with the student and ask them what they think makes a good doctor.
3. Tell the Stories
Provide students with an opportunity to explore doctors’ impact on patients’ lives. If you don’t have time or are uncomfortable with storytelling, provide them with opportunities to watch movies like Wit or The Doctor, or read excerpts from books such as the Tennis Partner, The Vagina Monologues or The Spirit Catches You and You Fall Down.
4. Provide Humanistic Problems
Humanistic problems include questions such as “How difficult is it for this diabetic to eat properly?” or “Are their cultural implications to the patient accepting this treatment?” which provides students with opportunities to explore cultural and economic reasons behind non-compliance.
5. Involve Your Patients
Select one or two of your regular patients and ask them ahead of time if they would be willing to work with one of your students directly including giving the student feedback on how they did. In some cases, you might want to arrange a home visit or informal discussion time for the student to explore a fuller picture of the patient’s viewpoint.
6. Involve Your Staff
Medical students have in some cases been isolated from other medical practitioners and haven’t had the opportunity to explore interdisciplinary teams or other aspects of medical management. Your staff is a good starting point. Ask them to teach the student a specific skill, and then ask them to provide feedback on how the student interacted with them as professionals, either to you or directly to the student.
7. Involve Your Community
Provide your students with a project that explores larger community issues such as “How healthy is this community?”, “What resources are available for handling bereavement issues?” or “What resources are available for patients who have chronic pain?” Projects of this kind allow the students to meet other professionals while at the same time increasing their knowledge.
Thank you for participating in today’s broadcast. I hope these seven methods will prove useful in your practice. Please feel free to contact me directly or participate in the comments section of my Blog.