Learners in the Outpatient Setting

Backman by Richard Backman

One of my responsibilities as an academic family physician is educating learners in the clinical setting.  I help them move from classroom theory to real world application of the medical knowledge learners have acquired to implementing that knowledge in caring for patients.  I am very fortunate in that I work with different types of learners that include physician assistant students, medical students, and resident physicians training in family practice. There are several strategies that I employ to optimize the learner’s education and maintain efficiency in my clinical practice. Many of these strategies I have added over the years, but most are summarized from this article in the journal Family Medicine:

1. Define objectives

This can vary widely based on the level of training of the learner and their experience in the clinic setting.  Most learners will need more supervision and direction early in their education and later on gain more independence and require less guidance. Help them define where they are on this continuum, as this will result in greater satisfaction and learning and also help to focus the objectives for the current clinic session.

  1. Limit the number of patients

Our clinic sessions are four hours in length.  I will limit the number of patients seen by an inexperienced learner to one or two patients in that session and increase the number of patients for the more experienced learners to four patients.  When learners are more independent and efficient near the later part of their training, for example 2nd year Physician Assistant Students and 3rd year Family Practice residents, they can see 8 to 10 patients in a session.

  1. Have learners present in front of the patient

For all learners early in their training, I will use the technique of having them collect a history and then present the history to me in front of the patient.  I inform the patient that they are allowed to interrupt or add comments to help clarify the history.  This moves us from a learning dyad to a learning triad and incorporates the patient as a teacher in the visit.  Additionally, all exams or medical decision-making is done with the patient and learner in the exam room allowing more patient centered and patient directed care.  The phrase most applicable is “nothing about me without me”2.

  1. Use the EMR as a tool for documentation, orders, and communication

Technology in healthcare holds great promise for increased connectivity and the ability to share information between providers and patients.  Although some clinics have not adopted electronic medical records (EMRs) that is now increasingly rare.  A 2014 report indicates 69% of primary care providers are using EMRs in their practice. The majority of practices not using an EMR are mainly solo private practitioners. Allowing learners to place orders for laboratory, radiology, or consultation from other services; search for medications; and look at Best Practice Alerts builds confidence and efficiency in the use of an EMR. This is a new skill set we have to teach learners. Many of our learners are digital natives (personally, I am a digital immigrant) and are more savvy and adept with EMRs.

  1. Use point of care evidence based references

Smartphones and EMRs have allowed evidence-based medicine (EBM) into the exam room where we can look up information, treatments, or therapies at point of care. These resources can be used to generate evidence-based questions for learners to research and discuss outside the clinic setting.  I find these resources a valuable addition to the learner’s knowledge and experience.  The information we teach learners and discuss with patients needs to be current and evidenced based.

Here is an example from my office practice using a Physician Assistant student.  I am fortunate enough to work with well-functioning medical assistants. The medical assistants take the patient’s vital signs and then escort them to the examination room and obtain a brief initial history and chief complaint. I usually have three examination rooms. After a patient is put into an exam room, I send the student in to do the history and physical.  The student signs into the record and begins documenting in the chart. I usually see another patient while the student performs the history and physical examination. The student informs the patient that he needs to check with his preceptor and will return soon. Then the student and I enter the room and the student presents the case in front of the patient.  I write information on a whiteboard in the room.  I check in with the patient, clarifying or requesting additional information, and then I perform a problem directed physical again while the student is finishing his or her presentation. Then, I sit down at the EMR and write or review the prescriptions, document in the chart, while meanwhile the student continues to talk to the patient. Then the student or I will print the patient summary and before we leave the room, the patient, the student, and I all talk and recheck the plan.

Medicine is an increasingly complex system and I have learned to incorporate students efficiently into a busy practice.  I hope others will reflect and suggest ways we can efficiently and effectively incorporate learners in the outpatient clinical setting, guiding them on their educational journey.

Richard Backman is an Assistant Professor with the Department of Family and Preventive Medicine at the University of Utah. He is also Medical Director for the University of Utah Physicians Assistant Program.

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