Optimizing Outpatient Resident Education Through Precepting Microskills: A Cross-Sectional,Observational Study

Abstract

Objective

Continuity clinics are a cornerstone of family medicine residency. The unpredictable nature of clinic limits the opportunity for formal education during a session. We developed a novel resident-faculty workshop using the ‘One Minute Preceptor’ model to teach five microskills of precepting. This cross-sectional, observational study evaluated the effectiveness of a single resident-faculty workshop in improving implementation of a systematic method of precepting.

Methods

We conducted a 45-minute workshop during a quarterly resident and faculty meeting at a large academic family medicine residency. Faculty members and residents completed pre- and 2-month post-assessments measuring change in the five core precepting microskills over time. Independent T-tests were conducted to assess statistical significance between mean scores related to the core microskills of the pre- and post-group.

Results

Post-intervention, participants were significantly (p<0.05) more likely to ‘get a commitment’ from their learner. The remaining four microskills had numerical improvements in mean scores in the post-intervention assessment but did not achieve statistical significance.

Conclusion

This workshop led to improvement in incorporating one of the five microskills of precepting and showed that a brief educational session can be effective as an educational intervention for outpatient precepting.

Keywords

precepting graduate medical education residency microskills

Introduction

Continuity clinics are a cornerstone of family medicine residency education and a key avenue for residents to receive timely, personalized feedback from experienced faculty preceptors. Clinic can be unpredictable and therefore challenging for residents to efficiently balance patient care, inbasket management, and simultaneously maximize educational opportunities. This can limit the opportunity for formal education during a clinic session. Despite efforts to formalize and improve outpatient education with a variety of interventions, learning needs assessments of our family medicine residents conducted via structured, annual, all-resident feedback sessions continue to identify a need for more robust clinic-based teaching. This finding aligns with the literature, which demonstrates family medicine residents desire high-quality teaching in the outpatient setting with an emphasis on developing clinical knowledge, supporting autonomy and decision making, integrating feedback, and balancing time constraints.¹ Among evidence-based strategies to enhance outpatient education, we identified the ‘One Minute Preceptor’ model as best suited to provide a foundation for our intervention due to its long-standing evidence of efficacy amongst preceptors and learners.^2-5 This precepting method promotes a Socratic method of education while also incorporating brief teaching topics through five key microskills of precepting. The microskills entail getting a commitment, probing for supportive evidence to support a diagnosis, teaching general rules, reinforcing what was done right, and correcting mistakes. The microskills are outlined further with examples in table 1, which demonstrates how this can be implemented in an outpatient precepting session. While research exists on the implementation of the One-Minute Preceptor model, the literature has focused on faculty education workshops or teaching development workshops with residents; to our knowledge, previous studies have not combined residents and faculty in the same session.^3,6 We developed a novel resident-faculty workshop to demonstrate these five microskills of precepting with a focus on a systematic method to implement during outpatient precepting where the clinic setting provides unique time limitations. The authors elected to include residents to provide a pedagogical method for them to implement when working with medical students while also empowering them to promote the systematic framework when precepting with faculty to optimize their education. This cross-sectional, observational study evaluated the effectiveness of a single resident-faculty workshop in improving implementation of a systematic method of precepting.

Table 1.

Microskills Summary⁴

Microskill of Precepting	Summary
1. Get a commitment	Encourage learner to make a commitment to a diagnosis, work-up, or treatment plan. “What do you think is going on with this patient?”
2. Probe for supporting evidence	Assist the learner to understand the thought process that led to the diagnosis or plan. “What were the major findings that led to your diagnosis”
3. Teach general rules	Based on the presentation or the case, a general teaching point or a teaching point to fill in any knowledge gaps can be included.
4. Reinforce what was done right	Reinforce appropriate thought process and decision making with specific examples from resident presentation. Avoid general praise without specific examples.
5. Correct mistakes	Share specific details in a nonjudgemental way to identify the thought process that may have led to an incorrect diagnosis or treatment plan.

Methods

As educational research utilizing standard educational interventions, this was deemed exempt from local Institutional Review Board review, HUM 00242275. The project was conducted within the University of Michigan Family Medicine Residency, a large, university-based training program with continuity clinics in urban and rural settings. Faculty physicians and resident physicians who attended the workshop were included in the study, and those who were not faculty or residents or did not attend at least 40 minutes of the workshop session were excluded. The 45-minute workshop, “Improving Outpatient Resident Education through Precepting: Microskills Workshop” was presented during a structured quarterly resident and faculty meeting in November, 2023. The focus of the workshop was to present and provide guidance on how to implement the five microskills of precepting outlined in Table 1. The workshop entailed a presentation introducing the five microskills with examples. The authors then demonstrated through case-based modelling how to integrate these microskills during a precepting encounter. Following this, the participants were divided into breakout groups and provided an opportunity to practice the microskills. A total of 79 faculty members and residents attended the workshop for at least 40 minutes. Participants were notified of the study at the beginning of the survey including IRB exempt status. Participants were aware they had the option not to proceed with the survey. Written informed consent was not required by our IRB. Faculty members and family medicine residents completed pre- and 2-month post-assessments (see appendix). The analysis was completed on the questions assessing the change in the five core precepting microskills over time. Faculty and resident responses were merged, but not matched, to avoid retaining identifiable participant data. Since the participants were not matched to preserve anonymity, the pre- and post-data were considered two independent samples. Independent T-tests were conducted to assess whether there was a statistically significant difference between mean scores related to the core microskills of the pre- and post-groups (Table 2). Faculty rated their own precepting microskills and residents rated their preceptors, as a group, on each microskill on a five-point Likert scale with 1 being never and 5 being always. Our pre–post educational intervention study was reported in accordance with the SQUIRE 2.0 guidelines to ensure transparent and complete description of the intervention, context, participants, measures, and outcomes (see supplemental file).⁷ In addition, relevant items from the CRISP (Consensus Reporting Items for Studies in Primary Care) guidelines were incorporated to enhance reporting of context, implementation, and applicability in a primary-care–based educational setting.⁸

Table 2.

Microskills Survey Results

	Pre-mean	Post- mean	p-values
I get a commitment from my learner	3.41	3.86	0.02
I probe for supporting evidence from my learner	3.29	3.43	0.864
I teach a general principle for each patient presentation	3.05	3.38	0.471
I give guidance about errors and/or omissions.	3.64	4.00	0.107
I reinforce what was done well with their presentation or patient care.	3.48	3.57	0.862

Statistical Analysis

Participant demographics were calculated using frequency distributions for gender, current role, medical education training, years since terminal degree (faculty only), and year of residency (residents only). None of the demographic variables differed significantly when comparing pre/post means using t-test analysis. To assess differences in the mean scores of the main outcomes (Table 1), independent samples t-tests were used (Table 2). Independent samples t-tests were used since identifiable markers were not obtained for participants’ privacy and were therefore not able to be matched for pre/post data collection.

Results

The pre-intervention group consisted of 59 participants with a total response rate of 75% (n=37 faculty, n=22 residents), and the post-intervention group consisted of 21 participants (n=13 faculty, n=8 residents) (27% response rate). Most of the faculty respondents identified as women having a primarily clinical and educational role in the department. Residents who responded included representation from PGY-1 to PGY-3 years in training. Sample demographics are described in Table 3. Post-intervention, participants were significantly (p<0.05) more likely to ‘get a commitment’ from their learner (Table 2). The remaining 4 microskills (probing for supporting evidence, teaching a general principle, guidance on omissions and errors, and positive reinforcement) had numerical improvements in mean scores in the post-intervention assessment but did not achieve statistical significance (Table 2).

Table 3.

Sample Demographics

	Frequency	Percent
Gender
Woman	39	66.1
Man	15	25.4
Other	1	1.7
Question unanswered	4	6.8
Current Role
Predominantly clinical	16	43.2
Predominantly educational	1	2.7
Predominantly administrative	2	5.4
Predominantly research	0	0
Balanced combination of education and clinical	11	29.7
Other combination of roles	6	16.2
Missing	1	2.7
Advanced Training in Medical Education
Fellowship or equivalent	12	32.4
Advanced degree e.g., masters, PhD	0	0
Postgraduate courses offered in our institution	4	10.8
Postgraduate courses external to our institution	3	8.1
Other	1	2.7
None	16	43.2
Missing	1	2.7
Years Since Terminal Degree (Faculty)
1-5	10	27.0
6-10	8	21.6
>10	18	48.6
Year of Residency
PGY-1	5	22.7
PGY-2	9	40.9
PGY-3	8	36.4

Discussion

Our resident-faculty workshop on the microskills of precepting succeeded in increasing implementation of a systematic method for outpatient precepting. With many competing faculty development topics and limited time within a large academic family medicine department, the authors developed a brief workshop to evaluate if a single, brief intervention can lead to uptake in a systematic method of precepting. We chose a combined forum of faculty and residents not only to provide residents with tools to implement with medical students but to also optimize interactions between residents and preceptors. This allowed the “one-minute preceptor” model to be presented and practiced in the same workshop, with trainees providing real-time feedback to faculty during the session. After the workshop, the 2-month post assessment showed a statistically significant improvement in the microskill of ‘getting a commitment’ from learners. Committing to a diagnosis, workup, or treatment plan allows the learner to develop clinical decision-making skills, gain autonomy, and receive feedback on their plan, leading to a deeper learning experience.⁵ Learners may skip committing to a diagnosis and may directly present the workup/treatment for a condition. For example, obtaining an EKG and ordering a stress test for chest pain, rather than committing to a diagnosis based on supporting clinical evidence. If the learner’s diagnosis was correct, this allows for positive reinforcement, another of the precepting microskills. If the learner’s diagnosis was incorrect, then the preceptor may offer guidance on omissions and errors and teach general principles, two more microskills.

Limitations

This study has the following recognized limitations. As a single center study, our sample size was small and limited to a convenience sample of those individuals who attended our faculty-resident workshop. The follow-up survey response rate was low, and the questionnaire itself was not a validated instrument. Additionally, to avoid identifying data linking participants, statistically assessing samples as independent groups may be more conservative and may have resulted in a loss of power in the process. While our goal was to improve resident perception of their learning in clinic, smaller sample size required combining resident and faculty responses, limiting our interpretation of group-specific results. Finally, our reliance on self-reported survey data is subject to voluntary response and recall biases. No objective data evaluating teaching skills or teaching techniques was collected which may be helpful to include in future follow-up sessions.

Conclusion

Effective teaching during precepting sessions in family medicine continuity clinic is challenging, so we implemented and studied an intervention to improve teaching during precepting. Implementing a faculty-resident workshop on precepting led to improvement in incorporating one of the five microskills of precepting and showed that a single, brief educational session can be effective and can lead to an uptake in a systematic precepting strategy. This study focused on outpatient Family Medicine precepting which offers unique time constraints compared to inpatient education. The incorporation of residents in the same session can help to both teach residents as future educators and to empower them to take ownership of their education by understanding methodology for their preceptors to facilitate their education. Residents were able to provide real-time feedback to their faculty preceptors during a breakout session and practice precepting during the workshop which was another unique component to this workshop. This pilot study shows that a brief intervention can be implemented by other institutions to implement a well-studied, systematic method of precepting.

Based on this pilot study, we are developing a repeat workshop with a stronger focus on group interaction and opportunities for observed precepting and coaching on how to effectively incorporate microskills. We will continue to review our annual residency program evaluation to determine if these precepting methodologic suggestions have improved outpatient education.

Supplemental Material

Supplemental Material - Optimizing Outpatient Resident Education Through Precepting Microskills: A Cross-Sectional, Observational Study

Supplemental Material for Optimizing Outpatient Resident Education Through Precepting Microskills: A Cross-Sectional, Observational Study by Kartik Sidhar, Amy Runyon, Marie Claire O’Dwyer, Leigh Morrison, John Holkeboer, Anna McEvoy, Laura Crespo Albiac, Mercy Adetoye, Jenna Greenberg, Laura Lee, Jessica Barnes, Heidi Joshi, Ananda Sen, Jean Wong in Journal of Medical Education and Curricular Development

Supplemental Material

Supplemental Material - Optimizing Outpatient Resident Education Through Precepting Microskills: A Cross-Sectional, Observational Study

Supplemental Material

Supplemental Material - Optimizing Outpatient Resident Education Through Precepting Microskills: A Cross-Sectional, Observational Study

Footnotes

Acknowledgements

Scott Brown, DO.

ORCID iDs

Kartik Sidhar

John Holkeboer

Ethical Considerations

The authors have no conflicts of interest to declare. This study was determined to be exempt from ongoing IRB review by our institution, HUM 00242275, as it was educational in nature and unlikely to adversely impact student learning or instructor assessment.

Author Contributions

Kartik Sidhar MD: Lead on presentation design, study design, and manuscript preparation.

Amy Runyon, MS: Statistical analysis for pre-post data collection to assess impact of intervention.

Marie Claire O’Dwyer MB BCH BAO: IRB submission, manuscript writing (limitations) and manuscript edits.

Leigh Morrison, MD: Participated in workshop design, survey design, and manuscript writing and editing.

John Holkeboer, BA: Project management team, assisted with writing abstract, manuscript edits, and with coordination between study team and statistics team.

Anna McEvoy MD: Participated in workshop design, implementation, and manuscript writing and editing.

Laura Crespo Albiac MD: Participated in workshop design, implementation, and manuscript writing and editing.

Mercy Adetoye MD: Participated in workshop design, implementation, and manuscript writing and editing.

Jenna Greenberg MD: Participated in workshop design, implementation, and manuscript writing and editing.

Laura Lee MD: Participated in study design and manuscript preparation and editing.

Jessica Barnes MD: Participated in workshop design, implementation, and manuscript writing and editing.

Heidi Joshi PsyD: Participated in manuscript writing and editing.

Ananda Sen PhD: Statistics team lead, assisted with data review and analysis.

Jean Wong MD: Participated in workshop design, implementation, and manuscript writing and editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All work is original in this manuscript and AI was not used in any portion of manuscript generation. The authors have no conflicts of interest.

Author Disclosure

All authors have significantly contributed to the project and manuscript according to ICMJE criteria.

Supplemental Material

Supplemental Material for this article is available online.

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