Improving the Improving the Quality of Clinical Quality of Clinical

PreceptorsPreceptorsPractical Applications for Bench Practical Applications for Bench

Teaching Teaching

Donald D. Simpson, Ph.D., M.P.H., CT(ASCP)CMDonald D. Simpson, Ph.D., M.P.H., CT(ASCP)CM

University of Arkansas for Medical SciencesUniversity of Arkansas for Medical Sciences

Little Rock, ARLittle Rock, AR

24 February 201124 February 2011

Don SimpsonDon Simpsonsimpsondonald@uams.edu

(501) 686-5776(501) 686-5776

““My method (is) to My method (is) to leadlead my students by hand to the my students by hand to thepractice practice of medicine, taking them every day to of medicine, taking them every day to seeseepatients in the public hospital, that they may patients in the public hospital, that they may hearhear

thethepatients' symptoms and patients' symptoms and seesee their physical findings. their physical findings.Then I Then I questionquestion the students as to what they have the students as to what they have

notednotedin the patients and about their in the patients and about their thoughts and thoughts and

perceptionsperceptionsregarding the regarding the causecause of the illness and the of the illness and the principles principles

ofoftreatmenttreatment””

Dr. Franciscus de la Boe Sylvius, 17th century Dr. Franciscus de la Boe Sylvius, 17th century professorprofessor

of medicine at the University of Leyden, Netherlandsof medicine at the University of Leyden, Netherlands

What “Makes”What “Makes”An Effective An Effective

TeacherTeacher

Effective Teachers . . .Effective Teachers . . .

• Demonstrates respect for the learnerDemonstrates respect for the learner• Challenges the learner to thinkChallenges the learner to think• Encourages learners to focus on Encourages learners to focus on

things they can use immediately, things they can use immediately, practice and take responsibilitypractice and take responsibility

• Know the difference between Know the difference between “Gremlins” and “Gnomes”“Gremlins” and “Gnomes”

G.N.O.M.E.G.N.O.M.E.

• GG – goals (often silent) – goals (often silent) • NN – needs (learner’s deficit in relation – needs (learner’s deficit in relation

to goals)to goals)• OO – objectives (‘E’ in GNOME informs – objectives (‘E’ in GNOME informs

about ‘O’) about ‘O’) • MM – methods (must be compatible – methods (must be compatible

with objectives)with objectives)• EE – evaluation (feedback and – evaluation (feedback and

judgment)judgment)

RationaleRationale

What is your teaching What is your teaching mission statement?mission statement?

Example: Example: “I intend to teach the learner the differential diagnoses (in my “I intend to teach the learner the differential diagnoses (in my

content area) from clinical cases, such that they can content area) from clinical cases, such that they can demonstrate this reasoning strategy when seeing patients in demonstrate this reasoning strategy when seeing patients in

the clinic”the clinic”

Relatively short; easily communicated; memorable; and Relatively short; easily communicated; memorable; and frequently revisitedfrequently revisited

“The unexamined life is not worth living”“The unexamined life is not worth living” - Socrates- Socrates

Habits are Habit-Habits are Habit-FormingForming

Training Training MYMY ReplacementReplacement

Workforce Workforce ShortageShortage

43% of laboratories 43% of laboratories report difficulties report difficulties hiring personnelhiring personnel

~~25% of workforce (73,000 ) will retire 25% of workforce (73,000 ) will retire in next 10 yearsin next 10 years

Shortage will exacerbate as baby Shortage will exacerbate as baby boomers retire and more people utilize boomers retire and more people utilize the health care systemthe health care system

Only 2 laboratorians enter the field for Only 2 laboratorians enter the field for every 7 that retireevery 7 that retire

Median age = 48 Median age = 48 yearsyears

National OutlookNational Outlook

• BLS projects 13,700 new Medical BLS projects 13,700 new Medical Laboratory professionals will be needed Laboratory professionals will be needed per yearper year

• CLS/CLT employment is expected to grow CLS/CLT employment is expected to grow by 14% by 2016, which is faster than the by 14% by 2016, which is faster than the average for all occupationsaverage for all occupations– The number of openings is expected to The number of openings is expected to

continue to exceed the number of job seekerscontinue to exceed the number of job seekers– Most jobs will continue to be in hospitals, but Most jobs will continue to be in hospitals, but

employment will grow faster in other settings employment will grow faster in other settings (medical and diagnostic laboratories, offices (medical and diagnostic laboratories, offices of physicians, and all other ambulatory health of physicians, and all other ambulatory health care services)care services)

* * data from the Bureau of Labor data from the Bureau of Labor StatisticsStatistics

Graduate Graduate ShortfallShortfall

# graduates needed/yr = # graduates needed/yr = 13,700*13,700*

# graduating/yr = # graduating/yr = 4,4454,445

yearly shortfall = yearly shortfall = 9,2009,200* * data from the Bureau of Labor data from the Bureau of Labor

StatisticsStatistics

In 2005In 2005National Accrediting National Accrediting Agency for Clinical Agency for Clinical Laboratory Science Laboratory Science (NAACLS) summarized:(NAACLS) summarized:

Cost to Train a CLS StudentCost to Train a CLS Student

• Student rotations are 19 – 26 weeksStudent rotations are 19 – 26 weeks• On average there is a 50% On average there is a 50%

productivity impact for the trainer productivity impact for the trainer in a hospital setting.in a hospital setting.

• Assuming a CLS salary for trainer Assuming a CLS salary for trainer = $50,000= $50,000

• Other miscellaneous costs may be Other miscellaneous costs may be minimalminimal

Clinical Rotation Cost Clinical Rotation Cost to Educate a CLS to Educate a CLS

StudentStudent•Hospital Setting Cost Hospital Setting Cost

Analysis:Analysis:– Train for 26 weeks or 1/2 year = 0.5 Train for 26 weeks or 1/2 year = 0.5

FTEFTE– 0.5 FTE @ 50% productivity loss = 0.5 FTE @ 50% productivity loss =

0.25 FTE in dedicated training time0.25 FTE in dedicated training time– 0.25 FTE x $50,000 = $12,500 to train 0.25 FTE x $50,000 = $12,500 to train

CLS student CLS student

Cost to Recruit New Cost to Recruit New EmployeeEmployee

• Most HR departments factor 1 to 1.5 times Most HR departments factor 1 to 1.5 times the employee’s annual salarythe employee’s annual salary

• This includes direct and indirect costs for:This includes direct and indirect costs for:– Processing the termination, payout of benefitsProcessing the termination, payout of benefits– Review and authorization to replace vacated Review and authorization to replace vacated

positionposition– Job posting and advertisingJob posting and advertising– InterviewsInterviews– Processing the hired applicant (Health Service Processing the hired applicant (Health Service

and screening)and screening)– Orientation and TrainingOrientation and Training

• Assuming an annual salary of $50,000, Assuming an annual salary of $50,000, replacement cost will range from $50,000 – replacement cost will range from $50,000 – 75,00075,000

SHRM Metrics Staffing ReportSHRM Metrics Staffing Reporthttp://www.shrm.org/metrics/library/http://www.shrm.org/metrics/library/

Math MattersMath Matters

• Assumptions:Assumptions:– Training CLS student for complete Training CLS student for complete

internshipinternship– Using internship of about 19 - 26 Using internship of about 19 - 26

weeksweeks– Using conservative estimate of 1 year Using conservative estimate of 1 year

salary to replacesalary to replace

• Break-even point is to hire 1 Break-even point is to hire 1 student for every 4 trained ! ! !student for every 4 trained ! ! !

% of Students Hired% of Students HiredInstitutionInstitution Trained (08/10)Trained (08/10) Hired Hired

(08/10)(08/10)AA 14 14 22% 22%BB 3 3 0% 0%

CC 4 4 25% 25%DD 8 8 25% 25%EE 3 3 33% 33%FF 7 7 71% 71%GG 4 4 25% 25%HH 1 1 0% 0% II 5 5 20% 20%JJ 5 5 20% 20%KK 2 2 0% 0%

Cost to Train Non-Cost to Train Non-traditional path Employee traditional path Employee

to be Eligible for to be Eligible for CertificationCertification

• Minimum 4 months of training for one Minimum 4 months of training for one clinical areaclinical area

• Total of 1 year training for a CLS Total of 1 year training for a CLS Generalist equivalentGeneralist equivalent

• Productivity loss is much higher due to Productivity loss is much higher due to lack of educational background (75%)lack of educational background (75%)

• 1 FTE x $50,000 x .75 = $37,500 to train 1 1 FTE x $50,000 x .75 = $37,500 to train 1 new employeenew employee– Plus salary cost of that individual - $35,000Plus salary cost of that individual - $35,000– Total = $72,500Total = $72,500

Value to EmployerValue to Employer

• Having students helps keep procedures Having students helps keep procedures up to date and easy to followup to date and easy to follow

• Patient safetyPatient safety• Keeps existing employees “sharp” on Keeps existing employees “sharp” on

their skills, knowledge, and behaviorstheir skills, knowledge, and behaviors– Follow and explain proceduresFollow and explain procedures– Utilize best practice or standard work Utilize best practice or standard work

practicespractices– Model proper behaviors for customer service, Model proper behaviors for customer service,

etc.etc.

• Ability to “pre-screen” before hiring (i.e., Ability to “pre-screen” before hiring (i.e., 4 – 5 month interview period4 – 5 month interview period

Value to EmployerValue to Employer

• ““Many of our students stay on and Many of our students stay on and become valuable employees”become valuable employees”

• ““They may one day become employees They may one day become employees in our facility and by training the in our facility and by training the students we are re-training ourselves students we are re-training ourselves and learning along with them”and learning along with them”

• ““We were all students at one point in We were all students at one point in our careers and we want the students our careers and we want the students to become good practitioners who will to become good practitioners who will care for us some day”care for us some day”

The ChallengeThe Challenge

Consider the value to your Consider the value to your organization to provide organization to provide

additional clinical additional clinical laboratory rotation laboratory rotation

opportunitiesopportunities

UAMS MT ProgramUAMS MT Program TracksTracks 20082008 20092009

20102010

2+22+2 1212 1111 77

Fast-Track Fast-Track 55 99 1313

DistanceDistance 99 77 1111

Part-TimePart-Time 22 11 11

MLT-MTMLT-MT 77 44 1313

BOC Pass RateBOC Pass Rate 78%78% 80% 80% 90%90%

AttritionAttrition 18%18% 20% 20% 18%18%

MethodologyMethodology

The Five P’s of Effective The Five P’s of Effective TeachingTeaching

•PPreparationreparation•PPerceptionserceptions•PProfessionalismrofessionalism•PPresentationresentation•PParticipationarticipation

PreparationPreparation

• Determine the need of studentsDetermine the need of students• Integrate previous learning into Integrate previous learning into

present lessonpresent lesson• Determine the educational level Determine the educational level

of the studentsof the students• Assemble teaching accessoriesAssemble teaching accessories

PerceptionsPerceptions

• Student and preceptorStudent and preceptor• Integration of one’s ideas during Integration of one’s ideas during

teachingteaching• Positively reinforce the practice Positively reinforce the practice

of medicineof medicine• Attitudes are easily conveyedAttitudes are easily conveyed

ProfessionalismProfessionalism

• Appearance (clean lab coat)Appearance (clean lab coat)• DemeanorDemeanor

– Polite without being overly friendlyPolite without being overly friendly

• Preceptor is addressed as Dr., Preceptor is addressed as Dr., Mr., Ms., etc.Mr., Ms., etc.

• Know students nameKnow students name

PresentationPresentation

• Competing student interest and Competing student interest and materialmaterial

• Focus on student attentionFocus on student attention• Positive learning environmentPositive learning environment• Three points (presented at first Three points (presented at first

meeting):meeting):– What you are going to doWhat you are going to do– How you are going to do itHow you are going to do it– What the students are expected to doWhat the students are expected to do

ParticipationParticipation• Bilateral participationBilateral participation• Eye contactEye contact• Questions=feedbackQuestions=feedback• Questions=fact finding missionQuestions=fact finding mission• Orient learners to lessonOrient learners to lesson• Review past materialReview past material• Reflect on learningReflect on learning• OK to say “I don’t know”OK to say “I don’t know”• Give feedback to learners oftenGive feedback to learners often• Praise is important to the group and Praise is important to the group and

individualindividual

ConclusionConclusion

• Reflect on the five P’s and make Reflect on the five P’s and make adjustments for the next adjustments for the next teaching experienceteaching experience– PreparePrepare early early– Discuss your pDiscuss your perceptionserceptions– Be Be professionalprofessional– Design your Design your presentationpresentation– Allow bilateral Allow bilateral participationparticipation

Teaching in the Clinical Teaching in the Clinical SettingSetting

In-depth LecturesIn-depth LecturesSeminarsSeminarsFormal Educational Formal Educational

SessionsSessionsExtensive DiscussionExtensive Discussion

Efficient and effective bench teaching Efficient and effective bench teaching requires that both the student and requires that both the student and preceptor accept the limitations of the preceptor accept the limitations of the settingsetting

Example: in an outpatient ambulatory Example: in an outpatient ambulatory care setting - extensive discussions of care setting - extensive discussions of differential diagnoses, pathophysiology differential diagnoses, pathophysiology and psychosocial problems are not and psychosocial problems are not possible nor necessarily desirablepossible nor necessarily desirable

• Demonstrate enthusiasmDemonstrate enthusiasm• Give meaningful (“authentic”) Give meaningful (“authentic”)

responsibilityresponsibility• Possess credible clinical skillsPossess credible clinical skills

Pitfalls in clinical case-based Pitfalls in clinical case-based teachingteaching

• ““Taking over” the caseTaking over” the case• Inappropriate lecturesInappropriate lectures• Insufficient “wait-time”Insufficient “wait-time”

- 3 – 5 second wait to answer your questions- 3 – 5 second wait to answer your questions

• Pre-programmed answersPre-programmed answers

- What do you think is going on? Could it be an - What do you think is going on? Could it be an ulcer?ulcer?

Pitfalls continued…Pitfalls continued…• Rapid rewardRapid reward

- Effectively ends the student’s thinking - Effectively ends the student’s thinking processprocess

• Pushing past abilityPushing past ability- Persisting in carrying the students - Persisting in carrying the students beyond their understanding of what is beyond their understanding of what is being askedbeing asked

The “One-Minute Preceptor”The “One-Minute Preceptor”

1. Get a commitment1. Get a commitment

2. Probe for supporting evidence2. Probe for supporting evidence

3. Tell them what they did right3. Tell them what they did right

4. Teach general rules4. Teach general rules- Take each encounter to a learning - Take each encounter to a learning pointpoint

5. Provide feedback (correct errors)5. Provide feedback (correct errors)A. PositiveA. PositiveB. CorrectiveB. Corrective

““One-Minute Preceptor” One-Minute Preceptor” MicroskillsMicroskills

• Get commitment Get commitment ((AssessAssess))– ““What do you think is going on?”What do you think is going on?”

• Probe for rationale Probe for rationale ((AssessAssess))– ““What led you to that conclusion?”What led you to that conclusion?”

• Reinforce what was correct Reinforce what was correct ((FeedbackFeedback))– ““You did an excellent job of…”You did an excellent job of…”

• Teach general rules Teach general rules ((InstructInstruct))– ““When this happens, do this…”When this happens, do this…”

• Correct mistakes Correct mistakes ((FeedbackFeedback))– ““Next time this happens, try this…”Next time this happens, try this…”

““One-Minute Preceptor” QuizOne-Minute Preceptor” Quiz

1. Get a _______________________1. Get a _______________________

2. Probe for ___________________2. Probe for ___________________

3. Tell them ___________________3. Tell them ___________________

4. ____________ general rules4. ____________ general rules

5. _____________ errors 5. _____________ errors

““Trainees do not perform required skills Trainees do not perform required skills incorrectly on purpose…errors in performance incorrectly on purpose…errors in performance are typically the result of insufficient feedback”are typically the result of insufficient feedback”

““They (errors) are seldom the result of They (errors) are seldom the result of insufficient interest or caring”insufficient interest or caring”

Microskills of the One-Minute Preceptor (W. Fred Miser, M.D.)Microskills of the One-Minute Preceptor (W. Fred Miser, M.D.)

Q:Q:Information you provide to learners Information you provide to learners

aboutabouttheir clinical performance that is their clinical performance that is

intendedintendedto guide their future to guide their future clinical performanceclinical performance

A:A:What is What is feedbackfeedback

The Feedback SandwichThe Feedback Sandwich

What was done “right”What was done “right”

What needs improvementWhat needs improvement

What to do next timeWhat to do next time

Feedback ChecklistFeedback Checklist

Make sure learner is readyMake sure learner is ready Give it soon and oftenGive it soon and often Link to goalsLink to goals Be specific & non-judgmentalBe specific & non-judgmental Give positive and constructive commentsGive positive and constructive comments Suggest correct performanceSuggest correct performance Don’t give too muchDon’t give too much Make sure feedback is understoodMake sure feedback is understood Follow up your feedbackFollow up your feedback Expect learners to develop skills in self-Expect learners to develop skills in self-

evaluationevaluation

Case StudyCase StudyUAMS ExampleUAMS Example

Advantages to Serving Advantages to Serving as Clinical Internship Siteas Clinical Internship Site

• Source of potential employeesSource of potential employees• Keeps staff current on theoryKeeps staff current on theory• Reputation of facilityReputation of facility• Increase job satisfaction and self Increase job satisfaction and self

esteem of staffesteem of staff• Professional responsibilityProfessional responsibility

DisadvantagesDisadvantages

• Use more suppliesUse more supplies• Increase in daily dutiesIncrease in daily duties

– Already overworked professionalsAlready overworked professionals

• Staff resistance – not all are Staff resistance – not all are teachersteachers

Making Internships Making Internships Successful Successful

• Make students feel welcomeMake students feel welcome• Reassure students as they progressReassure students as they progress• Keep the roles of instructor and Keep the roles of instructor and

student well definedstudent well defined• Selector instructors who have Selector instructors who have

patience, positive attitude, and patience, positive attitude, and want want to teachto teach

• An Orientation on the first dayAn Orientation on the first day– Cover safety regulationsCover safety regulations– Lab/hospital regulationsLab/hospital regulations– Dress codeDress code– ExpectationsExpectations– Exam dates Exam dates – Introduction to staffIntroduction to staff

CLS/MT Program will ProvideCLS/MT Program will Provide

• Support to clinical rotation siteSupport to clinical rotation site• Student internship manualStudent internship manual

– Evaluation formsEvaluation forms– Learning ObjectiveLearning Objective– Complete with study questions for Complete with study questions for

each discipline and answer keyseach discipline and answer keys– List of Required testsList of Required tests

• ExamsExams

Schedules & Schedules & ExpectationsExpectations

• Provide each site with a schedule Provide each site with a schedule template to help schedule weekly template to help schedule weekly activities for student activities for student

• Date of departmental practical Date of departmental practical examexam– This should be established by This should be established by

teaching techteaching tech

• Dates for internship examsDates for internship exams

Grades for Each CourseGrades for Each Course• Needed from clinical rotationNeeded from clinical rotation

– Practical exam – be consistent for Practical exam – be consistent for each studenteach student

• Practical exam Practical exam – Use controls, patient samples Use controls, patient samples – Save/freeze serum with interesting Save/freeze serum with interesting

resultsresults– Can use photos, CD images, etc…Can use photos, CD images, etc…

• UAMS facultyUAMS faculty– May need to support preceptors in May need to support preceptors in

the design of practical examsthe design of practical exams

Practical ExamPractical Exam

• Objectively assess a technical Objectively assess a technical performanceperformance

• Use worksheetsUse worksheets• Students should interpret and Students should interpret and

assessassess• Can grade on oral responses or Can grade on oral responses or

observationsobservations

Practical Practical Exam . . .continuedExam . . .continued

• Example of Course GradeExample of Course Grade– Exam for the department Exam for the department = 30%= 30%– Laboratory practicalsLaboratory practicals = 45%= 45%– Performance evaluation Performance evaluation = 25%= 25%

• Be sure to review evaluation with Be sure to review evaluation with each student and have them sign each student and have them sign all forms (feedback and all forms (feedback and DOCUMENTATION)DOCUMENTATION)

Students LikeStudents Like

• Helpful, enthusiastic and pleasant Helpful, enthusiastic and pleasant techs techs

• When their questions are well When their questions are well receivedreceived

• When they are treated with respectWhen they are treated with respect• They receive praise when they do They receive praise when they do

wellwell• When they need help, receive When they need help, receive

patient and kind guidancepatient and kind guidance

What Students DO NOT What Students DO NOT LikeLike

• Being called “the Student”Being called “the Student”• Having nothing to doHaving nothing to do• Reading procedure manuals for Reading procedure manuals for

extended periodsextended periods• Being left alone in an areaBeing left alone in an area• Not knowing expectationsNot knowing expectations• Inconsistency with proceduresInconsistency with procedures

Bench TeachingBench Teaching• Teach concepts, problems solving and Teach concepts, problems solving and

principles along with specific proceduresprinciples along with specific procedures• Encourage student to carry a small Encourage student to carry a small

notebook to jot things downnotebook to jot things down• Demo a test and then let a student Demo a test and then let a student

perform the test using a manual and you perform the test using a manual and you watchwatch

• Principle of test is very important and Principle of test is very important and necessary for trouble shootingnecessary for trouble shooting

• Students learn basic procedures on Students learn basic procedures on campus, but we cannot simulate a real campus, but we cannot simulate a real lab environmentlab environment

• Be consistent Be consistent

Bench TeachingBench Teaching

• Keep students informed of progressKeep students informed of progress• Teaching a new procedureTeaching a new procedure

– Demo, go slowly repeat and emphasize Demo, go slowly repeat and emphasize key pointskey points

– Read procedure including principleRead procedure including principle– Watch student perform the new testWatch student perform the new test– Check results Check results

• Students performs work Students performs work independentlyindependently

Students NEED to Students NEED to Perform TestPerform Test

• We RememberWe Remember– 20% of what we hear20% of what we hear– 30% of what we see30% of what we see– 50% of what we see and hear50% of what we see and hear– 70% of what we participate in or say70% of what we participate in or say– 90% of what we say and do90% of what we say and do

– Learning has not occurred unless Learning has not occurred unless learners change their behavior as a learners change their behavior as a result of what we doresult of what we do

Students Doing Patient Students Doing Patient Work?Work?

• When (completed rotation and When (completed rotation and passed)passed)

• If (there is time; after teaching)If (there is time; after teaching)• You must be comfortable with You must be comfortable with

decisiondecision• Does not need to be the same for Does not need to be the same for

each studenteach student• Verify results Verify results

If Problems AriseIf Problems Arise

• Questions we can’t answerQuestions we can’t answer• Work with supervisor for minor Work with supervisor for minor

problemsproblems• Unresolved problems contact the Unresolved problems contact the

Department of Laboratory Department of Laboratory SciencesSciences

References:References:• Bennett, A., Thompson, N., Holladay, B., Bugbee, A., & Bennett, A., Thompson, N., Holladay, B., Bugbee, A., &

Steward. ASCP wage and vacancy survey of U. S. medical Steward. ASCP wage and vacancy survey of U. S. medical laboratories. 2009laboratories. 2009

• Passiment, K. Update on the laboratory workforce-Passiment, K. Update on the laboratory workforce-shortage crisis. Washington Report. March:2006; shortage crisis. Washington Report. March:2006; www.mlo-online.com

• Irby, D. How attending physicians make instructional Irby, D. How attending physicians make instructional decisions when conducting teaching rounds. decisions when conducting teaching rounds. Academic Academic MedicineMedicine, 1992;67(10):630-638, 1992;67(10):630-638

• Gordon, J. ABC of learning and teaching in medicine: Gordon, J. ABC of learning and teaching in medicine: One-to-one teaching and feedback. One-to-one teaching and feedback. British Medical British Medical Journal,Journal, 2003;326:543-545 2003;326:543-545

Acknowledgements:Acknowledgements:• Mark Quirk, Ed.D.Mark Quirk, Ed.D.• Tatum Langford Korin, Ed.D.Tatum Langford Korin, Ed.D.• W. Fred Miser, M.D.W. Fred Miser, M.D.