Professor of Medicine, Duke University School of Medicine
I have been asked at times what a typical day looks like for a learner in the office, and I thought I would jot down some of the logistics that pertain to having a learner work with us in our clinic.
Whenever a learner is starting, I try my best to meet at least 15 minutes before my first patient arrives. I orient the student to our workspace and introduce them to the staff helping us for that session. I ask the learner about a specific goal for the session, and I share my expectations about what we might be able to accomplish. I also try to estimate how much time they might have with a particular patient in order to reduce confusion. I look at my schedule with the student and plan which patients might be instructive for them to see.
I almost always urge my students to see a patient before me, so they can obtain a history and perform some of the salient parts of the physical examination before I come into the room. I give the students about 15 to 20 minutes to do this work, but the time varies depending on my schedule. When they are ready, I ask the student to present the story to me in the room so I can confirm details with the patient and family. We then examine the patient together to confirm (or exclude) any findings on the physical exam the student noted.
After the exam, I stay in the room with the student and the patient; and together we discuss the assessment of the patient and determine a plan for what tests might be needed or what medications require adjustment. When finished, we leave the room together. I then debrief the session and ask if the learner has questions. If there are areas of confusion, or more time is necessary, we postpone the debrief until the end of the session.
If a student is moderately proficient as regards to the interview and examination of the patient, then I ask the student to work on a note to document what we found. Be careful when it comes to note writing! This is not easy for most students, and it takes time for them to do this. Early on, I might ask them to write just one note in a half-day, just to let them begin to practice this work. Over time, I expect most accomplished students to be able to write two to three notes in a half day. I try not to ask them to write more; otherwise, they become scribes, and that is not the intention of the exercise or the rotation.
When possible, I look for at least one interaction in the half-day that might be challenging in some way. For instance, yesterday, my nurse practitioner student watched me interact with a patient who was losing weight and had an abnormal abdominal CT. I explained the scan to the patient and family, and began to talk about some ominous diagnoses that could explain the findings. I believe this is one of the very few times when having students shadow us is worthwhile; they learn when we are challenged or have to have a difficult conversation. I try not to have students just observe me. That’s boring for them and not an effective way for them to learn.
If I am going to do a procedure, I ask the student to help me. They usually are quite fond of being involved in procedures, and I have found most patients very supportive of students’ involvement as well.
Midway through a work session, I find I often need a break, and I try to give the students a break too, either to use the restroom or to check their cell phone. If I grab a snack, I may grab them one as well. It’s amazing how helpful a granola bar can be midway through a shift! For that matter, I try to share some nutrition with my rooming staff as well.
As a result of the pandemic, I usually have one or two video or telephone visits in a half day. Especially if a learner has not been involved in some of these visits, I introduce them to this new twist that affects our normal workflow. With some guidance, I have found students are more than happy to call our patients waiting to connect with us for a video/telephone visit. They can present the case to us after obtaining a history beforehand, and they can help write these notes as well.
Toward the end of a half-day session, we are all a bit tired and ready to wrap things up. I try hard to not involve the learner in the last patient of the day. For whatever reason (probably fatigue!), I find it challenging to just finish that last visit and to do it well, so I try not to throw in teaching into that mix.
Oftentimes, when we are done with patients, I touch base with the learner. I ask them what went well and what they think they should work on for the next session. They usually know their own areas of weakness, and this can be a relatively easy time to give them some corrective feedback. At the end, I also will share observations about their work, and then I try to inspire them to read about a focused topic that pertains to something we saw that day.
I wish I could say I did all these things with each learner for each session, but that would not be true. But what is accurate is that these are some of the goals and intentions I have when I work with learners in the office. I would love to hear about some of your best practices for teaching and will happily share them across the network for others to try.
Thanks again for all the teaching that occurs in your practice. We likely will have more than 160 different learners come to our clinics this next year. Your hard work and commitment to teaching is hugely appreciated by them and by Duke Health.