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The University of British Columbia
- a place of mind
- Faculty of Medicine
- Department of Family Practice
Introduction | Outline for Preceptors | Skills Relating to Teaching | Resident Interaction
Requirements Related to the Teacher's Office | Encouraged Activities | Benefits to Clinical Teachers
Boundary Issues | References
Introduction
The UBC Department of Family Practice Post Graduate Program welcomes you as a clinical preceptor in the program. We thank you for taking on a critical role in the development of future family physicians. All of us in the Department of Family Practice are teachers in one way or another and we recognize the time, commitment and energy needed to assume this added responsibility.
We expect that, like the rest of us, you will find your involvement with the program enjoyable and fulfilling and your connection with individual residents especially rewarding.
The rest of this document will outline the learning context and structure needed to provide a good community family medicine training experience. It sets out the framework of expectations regarding teaching, and the supports the program can provide to you as you shoulder this important and very valuable work.
Thank you for being prepared to take on this responsibility. We expect your relationship with your residents will be among the most rewarding of your professional life.
This document is a guide to help preceptors understand the expectations and benefits of the Program. We encourage you to refer to this document often.
The objectives of the residency program are available at: www.familymed.ubc.ca/residency/about/policyindex.htm. It is important to understand them.
Preceptors function as role models for their residents. It is an opportunity to present a clear picture of the rewards of family practice.
Preceptors often become mentors for residents. It is helpful to understand the principles of mentoring.
1. Preceptors should understand the patient-centered clinical method (Section 9) and interview, demonstrate this skill to residents and evaluate their residents ability in this area.
2. Preceptors should understand and support the principles of evidence-based medicine (Section 9).
3. The Preceptor should understand the principles of Behavioral Medicine (Section 9) and how these principles relate to their practice. Residents should understand how the principles of behavioral medicine apply to their everyday patient interactions.
4. Residents have an “academic” and a “clinical” curriculum to complete. Residents must be released from clinical duties in order to attend academic sessions scheduled for them.
5. Evaluation is an integral part of resident teaching. Preceptors should evaluate and give regular, face to face, feedback to the resident throughout the rotation (formative evaluation) and at the conclusion of the rotation (summative evaluation).
The preceptor should refer to the “Benchmark Document” to understand the skills expected of and the supervision required for their resident.
The preceptor should employ feedback techniques to promote resident self awareness and improvement.
Evaluations should be completed and signed at the end of each rotation and reviewed with the resident. Evaluations are submitted to the Central Program office on-line using “Web-eval".
1. The clinical Teacher, working with a resident, should define learning objectives for the rotation to maximize the educational experience. The learning objectives should be referred to frequently and for midterm and final evaluations. The preceptor should be sure the resident understands his/her expectations regarding attendance, hours of work, timeliness, dress, duties and obligations.
2. Direct observation is a central tool in the ongoing evaluation of a resident’s progress. Residents should be directly observed on a regular basis, a least once a week. The College of Family Physicians require that resident preceptors record at least 32 observations made over a resident's year of training. ( See Office Visit Evaluation Form 1 under "Evaluation")
Observation may be done with video monitoring, one-way mirrors or in-room viewing.
3. The Clinical Teacher should be aware of the Clinical Practice Audit and Resident Project ( www.familymed.ubc.ca/residency/research/research.htm) that his/her resident is working on.
The preceptor is encouraged to supply the charts for the ”Clinical Practice Audit” from his/her practice and to discuss the results with the resident and explore ways that the Clinical Practice Audit recommendations could be implemented.
While the preceptor has no obligation to directly participate in his/her resident’s Research Project he or she is encouraged to show an interest and give input.
4. The Preceptor is encouraged to role model how a physician can balance work and personal life. The resident should understand how personal issues can affect his or her delivery of patient care. The resident should be shown the positive aspects of life as a family physician.
5. If there are areas of practice such as pediatrics, palliative care or obstetrics, which the resident will not experience in the preceptor’s practice, the resident should be directed to the site director to make alternate arrangements to get this experience elsewhere.
6. The resident will be expected to participate in the preceptor’s on-call activity.
Requirements Related to the Teacher's Office
1. The resident will need a space to see patients, do procedures, do chart work, and consult reference material.
This area may be shared with other doctors or staff and need not be exclusive to the resident. It is important the resident not feel he or she is imposing on others by using this space.
The resident will need to have high-speed internet access available for reference materials, communications and evaluation. The program, in order to encourage this activity, will supply access to this service where possible and contribute to on-going costs.
2. The Preceptor should introduce the resident to his/her colleagues and office staff and orient the resident to the medical and non-medical community.
3. Patients should be made aware that the office is a teaching site and seeing residents is usual. Patients should understand the rationale of having learners in the practice. All patients should be encouraged to interact with the resident. Each teaching site must decide how to deal with patients who are uncomfortable having the resident involved in their care. A suitable sign for the office will be provided by the Department of Family Practice.
4. Residents assigned for an extended period of time should be encouraged to develop a list of patients who they follow. Residents should understand that they must earn the trust of patients to have the privilege of directing their care.
1. The resident should “shadow” their teacher in activities outside the office such as hospital rounds, obstetrical deliveries, hospital meetings and community team meetings.
2. The preceptor is encouraged to participate in practice “SOO” (Simulated Office Oral) exams (participation is expected at some sites). SOOs help to teach patient centred skills. This will help the preceptor evaluate his or her residents and understand the exam process.
3. The Department and Sites periodically organize special events, social retreats, and events that offer increased resident interaction. All preceptors are encouraged to meet new colleagues at these events. Preceptors are encouraged to attend teaching related CME events and clinical faculty Site Rounds organized regularly by each of the Sites.
4. Preceptors are encouraged to hold or be working towards certification in family medicine for the College of Family Physicians.
5. Preceptors are encouraged to join and attend the annual meetings of the Section of Teachers of the College of Family Physicians, held at the Family Medicine Forum each year (see www.cfpc.ca ).
6. Preceptors are encouraged to participate in the resident selection process by assessing applications or conducting interviews.
One of the greatest benefits of teaching is the opportunity to work with enthusiastic young people who can help to invigorate and sustain one’s clinical and academic interest in the practice of medicine.
Other benefits the program offers to preceptors include:
1. A University Clinical Appointment. All preceptors will initially be given the position of “Clinical Instructor”. Further advancement can take place with experience and involvement. See Appendix 1 for Criteria for Advancement. Additional information is available in the Department of Family Practice Academic Ranks, Appointment, Reappointment and Promotion for Clinical Faculty
2. Once you receive your UBC employee number, all preceptors are eligible for a free UBC Interchange e-mail account. For more information on the services available, please call UBC IT Services at 604-822-2441 or visit the website https://web.interchange.ubc.ca/.
3. All Preceptors will be given a UBC library card to access all UBC Library materials and on-line full text journals to which the library subscribes. You can acquire a library card before you receive your UBC employee ID number by going to http://www.library.ubc.ca/home/forms/famprac-form.html
There is a UBC librarian who works with the Department of Family Practice who can help with literature searches.
Using MDConsult as an example, here is how to access databases on UBC library:
Go to: http://www.library.ubc.ca/
Click on "Indexes & Databases"
Scroll down to MD Consult - click and you have access to MD Consult
When accessing the databases off campus, users have to enter in a proxy server to get into the database. The link to the instructions are on the MD Consult page. http://www.library.ubc.ca/home/proxyinfo/
4. Once your appointment is complete and you receive your UBC employee ID number, as a UBC employee, you are eligible to purchase computer software at educational prices.
5. Some UBC sponsored CME events offer reduced rates for UBC faculty.
6. Open access to all electronic clinical resources that are being currently compiled by the family practice residency program.
7. Faculty Development is offered free of charge to all Clinical Faculty. Programs are offered at the site and department level and by the Faculty of Medicine. Skills in teaching, evaluation, working with residents and information technology are offered on a regular basis.
The "Teacher's Toolbox" is an annual one day event offered by the department for new and experienced teachers to improve or solidify their core teaching skills. Arbutus Blooms is a second annual one day event offered to rural preceptors.
Financial support may be available for some faculty development activities outside our department such as taking the facilitator course for the “Small Group Learning Program” or attending the annual Section of Teacher’s meeting at the CFPC FMF.
8. Preceptors have constant “back up” from their Site Directors and Lead Faculty. These people are there to help with any problems. Preceptors are also supported by the Post-graduate Program Director and his or her lead faculty.
Preceptors will receive feedback on teaching on a regular basis
Preceptor’s offices will be visited every one to two years by the Site Director and/or other Lead Faculty members in a supportive role.
Support is available to deal with “the resident in difficulty”. Documentation is available on the Program website with information to help deal with a resident in difficulty. The preceptor is encouraged to contact the Site Director as soon as a problem is identified.
9. Travel Benefits for UBC Clinical Faculty
UBC has travel programs in place which take advantage of the BC Government travel rates and University affiliated rates. See Appendix 2.
Preceptors must understand the relationship between themselves and their learners and be aware or the “power differential”.
Inappropriate influence or conflicts must be avoided.
Examples are listed below. Programs helping teachers to understand boundary issues will be available.
On-call favors, requests or requests for extra work or future locums may be unfair if the resident’s evaluation is not yet completed.
Social interaction with residents is often appropriate but the preceptor must be sure that this does not compromise his or her ability to give appropriate feedback and evaluations.
Any romantic relationship between a preceptor and a student carries a great deal of risk. Teachers should end their student/preceptor relationship before pursuing any other relationship. Preceptors should refer to the UBC Policies #3 and #97 on Conflict of Interest and Exploitation for clarification of these issues.
http://www.universitycounsel.ubc.ca/coi.index.html
A. Patient Centered Clinical Method
Patient centered decision making finds common ground with the patient on which to base a decision. The physician tries to understand the illness from the patient’s perspective as well as the diagnostic perspective. Patient centered decision making implies a moral obligation to share power with the patient. Further reading:
McWhinney's A Textbook of Family Medicine
Patient Centred Medicine by Stewart, Brown, Weston et al
Communicating with Medical Patients by Stewart and Roter
B. Evidence-Based Medicine
The term “evidence-based medicine” (EBM) was coined by a group of medical educators at McMaster in the early 1990’s. Dr. Gordon Guyatt writes: “the goal of evidence-based medicine is to be aware of the evidence on which one’s practice is based, the soundness of the evidence and the strength of inference the evidence permits. Residents are taught to develop an attitude of “enlightened skepticism” toward the application of diagnostic, therapeutic and prognostic technologies in their day-to-day management of patients.” [1]
Practicing EBM requires skills in the following areas:
1. Formulating a focused and answerable clinical question
2. Awareness of important and commonly used sources of medical evidence
3. Searching the medical literature
4. Critical appraisal of the medical literature
5. Basic statistical concepts for family practice
6. Applying the evidence to your patient
7. Evaluation of one’s performance and adherence to evidence
The Evidence-based Working Group at McMaster describes EBM as a distinctive approach to patient care, involving two fundamental principles.
a) Evidence alone is never sufficient to make a clinical decision.
(Clinical decisions also include consideration of benefits and risks of an intervention, inconvenience and costs associated with various management strategies as well as patients values and wishes.)
EVIDENCE + VALUES = CLINICAL DECISION
CLINICAL JUDGMENT /EXPERIENCE [2]
b) EBM relies on a hierarchy of evidence to guide clinical decision making.
Along with good clinical skills and strong interpersonal skills (compassion, listening and communication skills), evidence-based medicine skills are one of three pillars required for high quality patient care. Because of the fundamental importance of EBM skills to clinical practice, the EBM faculty feels that teaching must be regularly integrated into both clinical rotations and the academic curriculum.
UBC Department of Family Practice teachers of EBM at various sites are often also teachers of research methods and informatics. The site faculty at recent retreats (June and October 2002) has clarified the core importance of both informatics and evidence based thinking to research. There is significant overlap between the objectives, learning activities and learning outcomes for research, evidence-based medicine and informatics. The coordinated curriculum in evidence-based medicine, research and informatics will be referred to as the “ERI curriculum”. It is suggested that the following objectives and activities be linked with research/informatics objectives and activities.
C. Behavioural Medicine
What is behavioural medicine? Behavioural medicine provides, first of all, a "whole person" perspective for each patient encounter. This perspective helps the family doctor consider how psychological, social, cultural environmental, employment or educational, legal or even spiritual problems might impact positively and/or negatively on his or her patient's physical health or illness. Equally important, it helps the doctor consider how illness might affect his or her patient's sense of self, sense of hope, relationships and ability to function at work at home and at play. This perspective recognizes the importance of the relationship between doctor and patient, and includes, amongst others things, trust, empathy, time management, problem solving skills and the practice of good self-care for both patient and physician.
Behavioural medicine is also a set of conceptual and behavioural tools for managing specific clinical problems and situations. These tools are used to help patients make the lifestyle and behaviour changes required in order to manage stress, stop smoking, lose weight, control alcohol or substance use, or an eating disorder. These tools also help the family physician do crisis counseling, suicide assessment and management, grief work, and couple or family counseling with a blend of cognitive behavioural therapy (CBT) and prescription medication balanced with empirical evidence and practice wisdom relevant to the patient and his or her circumstances. Some family physicians may use these tools themselves, or refer their patients to psychiatrists, psychologists, social workers or others who will work collaboratively with them to provide the needed help for their patients.
For further discussion of the topic and a review of the evidence see the following WHO report:
World Health Report 2001 "Advances in Behavioural Medicine" http://www.who.int/whr2001/2001/main/en/chapter1/001b2.htm
The following two references provide an overview of the evidence in support of the "whole person perspective" and the different "conceptual and behavioural tools" that can be used to help patients deal make important life style changes.
Lewin, SA; Skea, ZC; Entwistle, V; Zwarenstein, M; Dick J. Interventions for providers to promote a patient-centered approach in clinical consultations. Cochrane Database of Systematic Reviews. 1, 2003.
UK Department of Health, Treatment Choice in Psychological Therapies and Counselling: Evidence Based Clinical Practice Guideline, March 2001. http://www.doh.gov.uk/mentalhealth/treatmentguideline/
For further information or discussion on how to help your resident use behavioural medicine knowledge and skills please feel free to call or email:
Garry D. Grams, PhD
Assistant Professor
Lead Faculty for Behavioural Medicine
UBC Department of Family Practice
Phone: 604-822-5704
email: gdgrams@interchange.ubc.ca
[1] User’s Guides to the Medical Literature: A manual for Evidence –based clinical practice. Edited by Gordon Guyatt and Drummond Rennie. AMA Press. Chicago 2002.
[2] From Ric Arseneau (SPH, Dept of Internal Medicine
Family Practice Residency Office
Suite 300, David Strangway Bldg
5950 University Boulevard
Vancouver, British Columbia,
Canada V6T 1Z3
