Preceptors - Frequently Asked Questions

Students participating in the clerkship will already have completed Preparation for Clinical Medicine, and several other rotations.  They should be able to take a focused history and complete a thorough physical exam.  However, the best place to begin is by asking the student what (s)he can do and what (s)he would like to learn to do.

Students appreciate being oriented to a practice.  They like to be told, “This is how we do things here.”  They should watch how preceptors do things just long enough to feel confident that they can fit into the site.  Remember, you won’t know how competent they are until they do something on their own.  Try to schedule a little more time with a patient during the student’s first or second visit to allow you to observe him/her interview and examine the patient.  Immediately show the student how to improve her/his performance to meet your standards.

Most patients sincerely enjoy helping a medical student learn.  In fact, many of them enjoy the extra attention a medical student can provide by taking more time to talk and listen or by looking up answers to their questions.  There are some excellent tips in the Kernan and Goroll article, “A Strategy for Precepting Medical Students in Ambulatory Settings,” in this guide about how to introduce your student to your patients to maximize the possibility of their agreeing to see the student.

Selecting Patients for the Student to Follow:

• Consider who among your patients needs information or extra time communicating
• Select patients of varying ages, races, socioeconomic statuses
• Select patients with both acute and chronic problems
• Select at least one patient whom the student can follow throughout the clerkship

Continuity of Care is the heart and soul of this clerkship.  Therefore, students and preceptors need to make a concerted effort to schedule patients to follow-up with the student.  You will also need to be very imaginative in following patients.  Some follow-up will necessarily occur outside the office, e.g. telephone calls, letters to patients, or home visits.

Suggestions to Help Students Follow Patients:

• Where computerized scheduling occurs, enter the student’s name as “Dr….” so that they can schedule their own patients.
• Encourage students to schedule patients’ follow-up appointments themselves to ensure that they are at a time the student will be in clinic.
• Ask patients if students may phone them at home.
• Tell patients when, where, and how to contact the student.
• Ask patients if the student may visit them at home.
• Have students visit patients in the hospital, nursing home, or Hospice.
• Ask students to get information for patients.
• Have students follow up on lab reports and referrals.

Continuity of Care can extend to a wide range of patients.

Healthcare Requiring Continuity of Care:

• Patients with chronic disease (e.g. HTN, diabetes, asthma, HIV/AIDS, COPD, repeat infections like otitis media, strep or UTIs, eating disorders, obesity) may present management problems (e.g. overuse of antibiotics or pain medications, inability to maintain a diet, drug resistance, lack of compliance).
• Maintaining health in our busy and stressful world is a task in itself.  Students might follow a newborn to watch her development or to be sure that he receives appropriate immunizations.  They might ask what the life of a healthy 7-year old is like?  What ups and downs does a slightly over-weight woman go through in her quest to lose 25 pounds?  How does a middle-aged woman whose mother died of a heart attack decide to take estrogen replacement therapy?  What information does she need?  Is a young businessman engaging in high-risk behavior in terms of his alcohol or drug intake, sleep deprivation or lack of exercise?  What impact are the parental fights having on the 10-year old twins?  All these problems may resolve or worsen over time; all merit medical attention and intervention.
• Caring for a population of patients over time provides another kind of continuity experience.  Issues of screening, disease prevention, and management of illness may need to be treated differently cross-culturally.  Home and work environment as well as family and community support systems are important factors to consider.
• Continuity with a clinical practice and a healthcare system, as they relate to a population of patients or a disease entity, is a valuable experience.  Because students take this clerkship and in-hospital rotations concurrently, they have an excellent opportunity to compare the care of patients in different delivery systems.

Yes and no.  Give some thought to how you can increase the student’s responsibilities over time as (s)he gains competence; but encourage students to learn from the patients they see each week.

Supporting Student-directed Learning:

• Give students autonomy and responsibility for their patients’ care.
• Don’t be afraid to say, “I don’t know; let’s look that up.”
• Encourage patients to ask the student for information.
• Say, “Could you look into that and let us know what you’ve discovered next week.”
• Share but do not assign articles you’ve enjoyed. “Over time, I get busy and don’t schedule in teaching time.”
• Most physicians find that precepting students adds 45-60 minutes to the work day.  The knack is in recognizing the teachable moment.

Teachable Moments:

• Have a one-minute conference in the hallway.
• Teach indirectly:  explain procedures and options to patients in front of students.
• Teach with the patient:  allow the student to present findings in front of the patient and discuss findings with the patient and student together.
• Model difficult encounters or procedures.  Ask the student not to shadow you, but to observe carefully, give you feedback on what worked, and then try it him/herself.
• Talk over an occasional lunch or dinner.

Both students and preceptors will need to be absent from time to time.  Altogether, the student should not miss more than two sessions.  If you do not have a colleague (M.D., nurse practitioner, or other health professional) who could oversee the student’s work, you might suggest that the student use the time to make a home visit, tour the community, read charts, follow up labs, or read about patients (s)he has seen.

You should keep track of the student’s attendance on the website calendar.  It is sometimes confusing when the students have school vacation or a didactic session, so this calendar should help you track attendance.

Expecting absences and planning ahead prevents misunderstandings and problems associated with finding the time to make up for missed sessions at the end of the year.  Therefore, you might ask students when they start, if they know of any planned vacations or away rotations so that you can both sketch out a work plan.  Students are required to arrange with you ahead of time any absences; it is a matter of courtesy as well as professional responsibility.

If a student is absent and has failed to make arrangements, please let us know immediately either by e-mail or telephone.  At no time should you be left wondering when the student will return.

Yes.  Students are supposed to leave their in-hospital rotations in time to be at their clinic sites by 2:00 p.m.  Students are encouraged to arrive at least 30 minutes before the start of clinic to complete charting, make telephone calls, coordinate visits, etc. prior to seeing their first patient at 2:00 p.m.  However, travel time in the bay area can sometimes be unpredictable because of unforeseen traffic delays.  Please be as flexible as possible but make the student understand at what time his/her patients will be waiting to be seen.  If there is a persistent problem that you and the student cannot resolve, please call us for assistance.

Assuming that you and the student have been clear about your expectations of one another and you still are having difficulties, you might want the course director to place the student in another practice.  Before you reach this decision, consider the following:

Procedure for Solving Problems with Students:

• Diagnose the source of the problem.  Discuss it frankly with the student and seek resolution.
• Discuss the problem with the clerkship director, or others who know him/her (e.g. members of your staff).

Although career or employment changes occur rarely, they present a problem in terms of continuity.  The student should move with the preceptor when the preceptor can take his/her patients to the new site or if it is early in the year, so the student can pick up new patients.  If changes occur late in the year, it is difficult for student to maintain continuity with patients and to receive appropriate instruction and evaluation from a new preceptor.  All parties should be alert to the possibility of a new practice having an insufficient number of patients to support teaching.  This is a matter that should be discussed with the clerkship coordinator.