Clinical Supervision

Excerpted from Field Guide for the Clinical Preceptor in Ob/Gyn (Marcus, 2007)

Clinical teachers need to set expectations for their students that are appropriate to the setting and to the students’ stage of training:

  • Create opportunities for meaningful involvement in patient care.
  • Take each patient care opportunity to a learning point, rather than necessarily to completeness.
  • Use opportunities to observe the student interact with patients as a basis for feedback. Coordinators have agreed to directly observe every student a minimum of one hour per week.

General Guidelines

Limited but serial patient contacts seem natural to you, however, this approach may be quite different from the student’s experience in other clerkships. You will need to help students focus their work-ups, prioritize problems, and elaborate details down to more succinct ambulatory notes and presentations. Let your students know your expectations of them early in the rotation. The following ideas will help you get started.

  1. Establishing Realistic Expectations
    All students entering this clerkship should be able to collect a biomedical and psychosocial history, including important cultural information, perform an appropriate physical exam, develop a problem list with supportable diagnoses and suggest a management plan that is appropriate to the problem and the patient’s situation.
  2. Reviewing the Clinic Schedule
    Teachers can familiarize students with patients seen in the clinic by reviewing the patient schedule. A brief discussion of each patient helps to establish the student’s prior experience with the problem and its management. From what you know of both the patient and the student, you will determine whether the student will observe you, assist you, precede you, or perhaps, not be involved with the patient. At this time you may give them tips on what to look for, ask about, or what they might read to prepare. Or, you may choose to send them in “cold” to handle a patient.
  3. Getting Patient Consent
    You or your nurse will need to obtain the patients’ consent for having a student involved in their care. Your discretion should help to screen the few situations where it is not appropriate to involve a student. All patients are reassured to know that their “real” doctor will always be supervising their care, participating in the visit and will see them. A good introduction from you or your nurse might be:
    “Susan Brown is a student doctor working with me today. I would appreciate it if she could see you first. I will be in to see you shortly.”
  4. Different Teaching Approaches
    Various clinical situations call for different teaching approaches. Providing the student with “expert” answers or using the Five Microskills discussed below is appropriate when efficiency is a priority. Socratic questions that reveal and guide thought processes are sometimes more satisfying for both the learner and the teacher. Sensitive exploration of students’ feelings about patients or situations help them develop insight and confidence. When you are puzzled, strategizing to find the answer models an essential processing skill in medicine, i.e., recognizing limits and identifying references and resources. One of the most commonly used teaching approaches is the Five Microskills.
    Five Microskills for Clinical Teaching
    Most clinical teaching takes places in the context of busy clinical practice where time is at a premium. When the teacher knows something about the case that the learner needs or wants to know, Five Microskills enable teachers to effectively assess, instruct and give feedback more efficiently. This is just one method of working with learners. Other methods such as Socratic dialog, acting as an expert consultant or joint problem-solving should also be used when appropriate.

    This method has also been called the One Minute Preceptor. The five microskills include:
    1. Get a commitment
    2. Probe for supporting evidence
    3. Teach general rules
    4. Reinforce what was right
    5. Correct mistakes

    Also see Neher, Gordon, Meyer and Stevens. A Five-step “Microskills” Model of Clinical Teaching, Journal of the American Board of Family Practice 1992; 5: 419-424.
  5. Procedures
    Always ask your student to talk through a procedure in detail before he/she is to observe it on a patient. The review will assure both you and the student that they understand why the procedure is being done and what actually will be performed. Students learn by observing and assisting at procedures and, when appropriate, by guided performance of the procedure. When you decide a student is ready to perform a procedure, again talk them through the process which will ensure that he/she is prepared for the responsibility. The dry run also provides you with the chance to embellish the basic steps with tips you’ve learned from experience.
  6. Supervision
    We expect all student encounters with patients to be supervised.
  7. Maximizing Continuity Experiences
    It is difficult to ensure that students experience continuity of care in the very limited time of this clerkship, but it is not impossible. You may suggest that students follow up office visits with phone calls to check progress and adherence. Similarly, hospitalizations can be followed up with home visits to monitor the adjustments of individuals and families to a changed health status. Students should be encouraged to accompany patients to a community service referral, e.g., prenatal class, nutrition consultation, or self-help group. Your nursing and office staff can help schedule return visits when the student will be present (or get the student in another area of the clinic) to see a follow-up patient with you.

Working With Early Third Year Students

The following suggestions may be applicable to any student, but they are especially important for early third year students or students with no previous ambulatory training.

Working with early third year medical students can pose some rewarding challenges.

For many of these students their rotation at your site will be their first clinical exposure to ambulatory medicine. There are definitely ways of making this experience a highly positive and constructive one, as well as one that does not increase the burden on your valuable time.

  1. Orient the new student thoroughly and as soon as possible. Provide a clear written schedule. Consider a brief time for questions at the beginning of the second week. Students often don’t take in all the details in one orientation session.
  2. Utilize other personnel to orient or answer the student’s questions about your site.
  3. Understand what the student already knows. Remember that some of these students have had extensive medical experience as nurses, physicians’ assistants, etc., before coming to medical school. The student may have participated in one or more of our skills sessions for second year students.
  4. Try to determine how this particular student learns best. Learning styles can be very different. Do they like to watch first, or do they prefer to get involved immediately?
  5. Expect early third year students to see fewer patients during each half day, and allow them more time for reading, studying and working on course curricular materials.
  6. Initially allow inexperienced students to observe more extensively than advanced students. Have them observe you in focused encounters and procedures such as pelvic exams, deliveries, and suturing.
  7. Give specific instruction and feedback early in the clerkship to students with little previous experience. This can save you time later. Do this again at their mid-clerkship review.
  8. Think of the site orientation not only as an introduction to your site but also as an introduction to ambulatory medicine. Explain how you deal with patients’ long lists, how you get through a busy clinic session, and how to be efficient at dictating notes.

Information about Your Student

As a physician you would never prescribe or treat a patient before doing a careful assessment of patient needs and resources. As a teacher, information about your student is equally critical to your success. The faculty preceptor should set aside some time at the beginning of the clerkship to get to know the student. Introductory information should be shared with others who will work with the student.

A brief “presentation” on the student will save everyone time, and will help the student feel like a part of the program more quickly. How this introduction is made can take many forms: a capsule introduction at a clinic meeting, a Polaroid snapshot posted on a bulletin board, a spotlight feature in a residency newsletter, and individual introductions to staff. Other clinical supervisors may wish to cover some of this information when first working with the student. A good introduction to the student will help put the student at ease and help you determine what level of responsibility will be appropriate for the student. More important, it will establish a foundation of good communication that can be continued through the rest of the clerkship.

The following categories suggest some useful areas for discussion.

Student Profile

  1. Education: Undergraduate background; clerkships completed to date; ambulatory rotations completed; research interests
  2. Work Experience.
  3. Personal Background: Family and friends in student’s life; significant others
  4. Interests, Hobbies. Avocation/Recreational Interests
  5. Career Goals

What specialty(ies) is the student considering? What post-graduate training is planned? Unresolved career decisions?