The One-Minute Preceptor Method for Clinical Teaching
6-7 Minutes
Author: Julpohng Vilai, MD
Purpose
To familiarize clinical educators with a the One-Minute Preceptor, a simple and effective strategy for clinical teaching that can be used with learners in a variety of clinical settings.
Learning Objective
1. Recall the five steps of the One-Minute Preceptor method.
2. Describe the purpose of each step of the One-Minute Precepor method.
3. Describe one example of how the one-minute preceptor can be employed.
With increasing duties and responsibilities, clinicians not only frequently lack the time necessary for teaching but often must also actively advocate for it.(1) This is certainly nothing new; in order to address the challenges to effective teaching for the busy clinician in 1992, Neher et al introduced the “Five-Step ‘Microskills’ Model of Clinical Teaching”.(2) Since then, this approach – now more commonly known as the One-Minute Preceptor method – has been extensively tested and widely utilized.(3-6)
Here we will explore each step and illustrate the method with a practical example.
Situation: A third-year medical student near the end of her Pediatrics rotation presents a patient to you while the family waits in the exam room.
Learner: Zoey Smalls is a 4-year-old female who is brought in by her mother. Zoey presents with mom a 2-day history of fever and sore throat. She has not had a cough or much congestion, but mom is concerned because her voice sounds hoarse and she is drooling. She has not wanted to eat but is still drinking and urinating normally and has no sick contacts. On exam, she is febrile to 101.5 and is ill-appearing. She has left tonsillar hypertrophy with exudate and bilateral tender anterior cervical lymphadenopathy.
Step One: Get a Commitment
At this point, the preceptor could choose several educational pathways. Let’s follow the One-Step Preceptor method, which asks us to get a commitment.
Preceptor: What do you think is going on?
Learner: I think she probably has strep throat.
Given that learners present patients differently and at varying levels of skill and complexity, appropriate questions to ask will depend on factors such as the educator’s objectives, the learner’s existing knowledge and experience, and the clinical setting.
Alternative questions might be some variation of:
What do you think we should do next?
What laboratory tests or imaging studies should we get?
What else might be going on?
Do you think this patient needs to be hospitalized?
Importantly, instead of gathering additional data, the questions used in this approach encourage clinical reasoning and increase commitment to the patient and their condition. A “correct” answer is an opportunity to reinforce a particular skill; an “incorrect” answer is a teaching moment which may have a greater impact as we tend to learn from our mistakes. Additionally, this strategy allows insight into the learner’s thought processes and reasoning skills. Teaching may be adjusted to the learner’s level of knowledge, e.g., one might ask a medical student about additional history and physical findings, whereas a resident may be expected to discuss possible management plans.
Step Two: Probe for Supporting Evidence
Now that the learner has committed to a possible diagnosis, the next step is to assess the learner’s reasoning in greater detail by probing for supporting evidence.
Preceptor: Why do you think she has strep throat?
Learner: She has all the Centor criteria: fever, absence of cough, exudative tonsillar hypertrophy, and anterior cervical lymphadenopathy.
This skill allows the educator to distinguish a “lucky guess” from a well-reasoned response. One should resist the urge to offer immediate confirmation or judgment, instead allowing the learner to demonstrate the rationale for their answer.
Questions that can elicit useful responses might include:
What parts of the history and physical exam point toward that?
Why did you choose that diagnosis?
Why did you ask that history or perform that exam?
Why did you think the patient should be hospitalized?
Step Three: Teach General Rules
Once the learner reveals her line of reasoning, it’s time to use this opportunity to teach general rules.
Preceptor: Okay, strep throat is possible, but what about her drooling? When someone has fever, sore throat, hoarseness, drooling, and looks sick, we also must think about peritonsillar or retropharyngeal abscesses. One helpful distinguishing sign could be uvular deviation to one side. Did you see that?
Learner: I didn’t specifically look for that, but I did notice that her left tonsil was much bigger than the other one, and she was breathing kind of loudly and seemed distressed.
Preceptor: Other things to think about would be, if she had a strawberry tongue and sandpaper rash, you might consider scarlet fever. If she had 5 days of high fever, especially with conjunctivitis, mucous membrane involvement, swelling of the hands and feet, and a rash, you might think about Kawasaki disease.
Assuming you have a positive rapid strep test, you return to the exam room with the student. On your exam, she is acutely ill and in moderate distress. You think it is best to refer her to the Emergency Department for further management and to rule out abscess.
Brief and targeted teaching pearls can be very helpful to a learner. Even if there is no specific medical fact or generalization to share, strategies on searching for additional information or facilitating admission to the hospital could be useful.
Step Four: Reinforce What Was Done Right
After explaining to the family that they should proceed to the ED, you debrief with your medical student and reinforce what was done right.
Preceptor: Your presentation was organized well. You clearly synthesized pertinent aspects of your history of present illness and focused physical exam, and your diagnosis of strep throat was well supported by your data.
A learner’s ability to improve depends on constructive feedback. Simply telling the learner, “that was a great presentation” adds very little helpful information. Instead, comments should include specific behaviors, skills, or attitudes the preceptor wishes to highlight. This can help to reinforce positive elements that will be translated to subsequent patient encounters.
Step Five: Correct Mistakes
Once you have reinforced what she did well, you can correct mistakes, moving into a discussion of what could have been done differently.
Preceptor: In your presentation you told me the temperature but did not mention other vitals. Following a SOAP format, we would typically expect the objective section to include full vitals, especially oxygen saturation in this case as her markedly enlarged tonsil could lead to airway obstruction. You also mentioned that she was ill-appearing; I would have gone further to say that she was toxic-appearing. This can help you recognize when someone is very ill and needs a higher level of care.
Perhaps even more important than hearing what was done well, a learner should understand areas of weakness. It may be helpful to avoid terms such as “bad” or “poor,” opting instead for expressions such as “not best”, “it is preferred,” or “I might have done it this way”. This can improve your ability to get the point across without a negative value judgment or learner defensiveness. Another aim is that comments should be specific to the situation, identifying specific behaviors that could be improved upon going forward.
Learner feedback has been covered elsewhere, but it is helpful to strike a balance between positive and negative feedback. The natural tendency to focus on the positive may preclude critical opportunities for improvement, while perseverating on criticism may drive the learner toward self-doubt, imposter-syndrome, and detachment.
Conclusion
The One-Minute Preceptor method can be especially helpful for clinicians with more labor-intensive workflows and limited teaching time, and it can be utilized in a variety of clinical settings. Furthermore, these “microskills” can be dynamic rather than discrete sequential steps; elements may be rearranged or employed in a different order that is more appropriate for a particular educational situation. While inherently emphasizing brevity and simplicity, this approach can be a powerful clinical teaching tool.■
References
(1) Ludmerer K. Time and Medical Education. Ann of Internal Med. 2000;132(1):25-8.
(2) Neher J, Gordon K, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Bd Fam Pract. 1992;5:419-24.
(3) Aagaard E, Teherani A, Irby D. Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: proof of concept. Acad Med. 2004;79:42-9.
(4) Eckstrom E, Homer L, Bowen J. Measuring outcomes of a one-minute preceptor faculty development workshop. J Gen Intern Med. 2006;21:410-4.
(5) Furney S, Orsini A, Oresetti K, Stern D, Gruppen L, Irby D. Teaching the one-minute preceptor: a randomized controlled trial. J Gen Intern Med. 2001;16:620-4.
(6) Gatewood E, De Gagne JC. The one-minute preceptor model: A systematic review. J Am Assoc Nurse Pract. 2019;31(1):46-57. doi:10.1097/JXX.0000000000000099