The educational experience in the outpatient clinic is an important part of a fellow’s education since fellowship graduates can spend a significant amount of time in the ambulatory setting. Despite this, pulmonary and critical care medicine (PCCM) training occurs largely in the inpatient setting, with only approximately 7% of total fellowship training dedicated to ambulatory settings(1). Because such a small amount of training time is spent in the outpatient setting, it is of paramount importance to optimize the educational experience during ambulatory rotations in fellowship.
One strategy to improve the educational experience in the outpatient clinic is to restructure clinic precepting to optimize learning and skill development for fellows. In a traditional precepting encounter, a large portion of time is spent on presentation of the history, physical exam, and data, while less time is dedicated to discussion and/or teaching of clinical reasoning(2). While traditional precepting models may be appropriate for novice learners, this style may not be optimal for fellow-level learners who are already proficient in gathering and reporting information, and who would benefit more from honing higher-level synthesis and decision-making skills. Using a more active precepting model that emphasizes learner-driven objectives, focusing on diagnostic and/or management discussions between the preceptor and fellow can maximize education without extending the time spent on precepting. Below we will review options for implementing active fellowship precepting models, provide strategies for implementation within your institution, and share lessons learned from our experience.
Existing Precepting Models
Finding time for teaching in a precepting encounter is certainly not a new problem in ambulatory medical education. Several precepting models have previously been developed and implemented in medical school, residency, and fellowship settings, aiming to narrow the focus of the encounter and maximize educational time. Three active precepting models include the ‘One-Minute Preceptor/5 Microskills’ model, the SNAPPS model, and the STEP-UP model.
The One-Minute Preceptor model is a five-step model in which the preceptor takes an active role in the encounter. In this model, the preceptor prompts the learner for a clinical decision as well as evidence supporting the commitment made. Then, the preceptor offers feedback, reinforcing what was done well while providing clarification on areas of ambiguity(3). This model can be adapted to multiple settings, but it works best in a relatively straightforward encounter (eg, a patient with a past medical history of COPD and heart failure presenting with acute dyspnea and cough, where the learner makes an assessment and recommends further diagnostic testing and treatment.) The preceptor drives and sets the learning objectives, making this model more suited to less-experienced learners.
Unlike in the ‘One-Minute Preceptor’ model, in the SNAPPS precepting model, the learner takes the active role in the educational encounter. In this model, after summarizing the case and presenting the differential diagnosis, the learner identifies questions on which the preceptor should weigh in (eg, “How often do you see this diagnosis without [common feature]”,) before presenting a plan. The final step in the model asks the learner to identify an area for further learning, thereby engendering self-directed learning both during and after the encounter(4). The SNAPPS model is well-suited for advanced level learners who are able to identify areas for focus and learning. However, this model does mirror the traditional case presentation model, so the precepting encounter may still be lengthy.
More recently, the learner-driven STEP-UP precepting model was developed specifically for fellow-level learners, to improve their educational experience. The STEP-UP model prioritizes the assessment and management portions of a traditional presentation. It calls for the learner to lead the discussion and identify their own learning goals, with opportunities for the preceptor to clarify any areas of uncertainty. This model is designed to focus the precepting interaction on development of higher-level reasoning and management skills, and it allows for flexibility based on the complexity of the patient case and the needs of the learner (2).
In summary, the One-Minute Preceptor, SNAPPS and STEP-UP models all provide a structured approach to ensure efficient patient care and learning in ambulatory precepting encounters. The One-Minute Preceptor model may have some limited applications for fellowship learners, such as to ensure that learning occurs even on “routine” or less complex patient encounters. The SNAPPS and STEP-UP models are both learner-driven models which may have wider applications for fellow learners. Ideally, a precepting model can be selected according to fellow or faculty comfort and complexity of the patient. For example, in new, complex patient presentations, a traditional SOAP (Subjective, Objective, Assessment, Plan) presentation may be utilized. For more straightforward patient presentations and/or established patients, SNAPPS or STEP-UP model may be used.
A How-To Guide for Implementing a Precepting Model in Your Fellowship Clinic
We detail steps below to implement a learner-driven precepting model into your fellowship ambulatory clinic, based on our personal experience. Perhaps the hardest aspect of implementing a novel precepting model is encouraging initial uptake (by both fellows and faculty) and sustaining use of the precepting model. Fellows are likely most familiar with the traditional SOAP format of presentation, so both familiarity and comfort may lead to slow implementation of a new model. Further, faculty members may be unfamiliar with learner-driven models, feel uncomfortable using abbreviated models when they either are unaware of or don’t know the skillset of the trainee, or perceive a lack of control in the encounter.
Given these potential sources of resistance, it is imperative to establish early buy-in and engagement from both the faculty and fellows, along with dedicated training and implementation support.
Consider engaging key stakeholders to assess current precepting practices through informal meetings, focus groups, and/or surveys. In our experience, both faculty and fellows recognized the need to improve the precepting process and therefore were invested in making improvements.(2) Discussing the perceived barriers and ideas for overcoming barriers is a critical step to ensure successful implementation of a new precepting model. For example, one of the perceived barriers to employing learner-driven precepting models was concern that the change would increase precepting time and worsen delays in clinic. Aware of this concern, we were able to collect data both on the current practices and in pilot phases using the STEP-UP model, to reassure both fellows and faculty that the use of these models would not add time to precepting encounters. Highlighting shared perceptions and openness to improvement between faculty and fellow groups can help build fellow and faculty engagement and encourage openness to potential changes.
Train Fellows and Faculty
Time needs to be allotted to train both fellows and faculty when and how to use novel precepting models. We used time already allocated to fellow learning to ensure engagement, and we saw our biggest jumps in adoption of the model as we onboarded new fellows to our outpatient clinic processes. For fellow training, we developed a workshop-style session where we reviewed the prior data collected, presented justification for the implementation of the novel model, and gave time for hands-on practice.
Faculty training is also required, although one advantage of learner-driven models is that the training of faculty can be primarily focused on the justification and explanation of the model. We used time in our regular administrative meetings for faculty training, in addition to providing self-directed asynchronous material for faculty education.
Remind Fellows and Faculty
To encourage sustained use of the model, we recommend designating a faculty member to champion the initiative, such as a program director, assistant program director, or clinic director. In addition to providing training to incoming fellows, the faculty champion can remind fellows and preceptors throughout the year both in real-time clinic encounters as well as through nudges in emails, informational materials, and signage posted in precepting spaces. Success of the new approach will require iterative adjustments to adapt to the structure and culture of your fellowship program and to address evolving challenges.
Although it may seem daunting, adopting learner-driven precepting paradigms for outpatient clinic can enrich ambulatory training for fellows, addressing a critical need given the condensed nature of outpatient experience in PCCM fellowship.
- Kassutto SM, Dine CJ, Kreider M, Shah RJ. Changing the Ambulatory Training Paradigm. Design and Implementation of an Outpatient Pulmonology Fellowship Curriculum. Ann Am Thorac Soc. 2016;13(4):540-544. doi:10.1513/AnnalsATS.201601-009PS
- Clancy CB, Heath JK, Nandiwada DR, Aizenberg D, Kassutto S. Development and Implementation of a Novel Learner-driven Precepting Model for Pulmonary Fellowship. Sch. 2020;1(2):161-169. doi:10.34197/ats-scholar.2019-0011IN
- Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419-424.
- Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: A Learner-centered Model for Outpatient Education. Acad Med. 2003;78(9):893-898.