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The Art of Precepting: Socrates Or Aunt Minnie?

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The Art of Precepting: Socrates Or Aunt Minnie? COMMENTARY The Art of Precepting Socrates or Aunt Minnie? Allan S. Cunningham, MD; Steven D. Blatt, MD; Paul G. Fuller, MD; Howard L. Weinberger, MD s clinicians and as teachers we are asked to be efficient and effective. In pediatric out- patient departments, this sometimes seems like a tall order, especially when trainees are lined up to present cases. They expect excellent teaching and families expect ex- cellent care for their children. A Aunt Minnie, even if you cannot identify Editor’s Note: I think that Socrates would really like Aunt Min- her face. nie and vice versa. I doubt that you could get to Aunt Minnie with- Consider the 2-year-old boy with a fe- out having experienced Socrates, but Socrates becomes obsolete ver and a runny nose who is playing hap- in a harried setting—which is no place for teaching beginners. For pily on his mother’s lap. He probably has them, I’d try a Socrates sandwich on Aunt Minnie, ie, begin with a upper respiratory tract infection. The 2- Aunt Minnie, switch to Socrates, and then back to Aunt Minnie. month-old infant with a temperature of Hold the mayo. 40°C lying listlessly in his mother’s arms Catherine D. DeAngelis, MD may have a virus, but you had better ex- clude bacteremia and meningitis. Finally, consider the 5-year old girl who looks well but has had stomach aches “around the Tradition has given us the Socratic method: belly button” for a month. She probably has the trainee performs a complete medical his- functional abdominal pain. These are com- tory and physical examination and pre- mon patterns that are quickly recognized sents the case with all details to a precep- by experienced clinicians. tor. The trainee then lists the diagnostic How does this apply to our trainees possibilities and the 2 engage in a discus- and the medical care we help them to pro- sion of the pros and cons of each diagno- vide? It has modified the method we have sis. Facets of the history and examination used lately for precepting in our outpa- are discussed and there is a process of elimi- tient department. For example, we often nation until the most likely diagnosis is cho- have trainees give only the chief com- sen. The method is thorough but time con- plaint and their presumptive diagnosis suming. In the past, the preceptor may not when presenting a case (30 seconds). actually have seen the patient. While the trainee begins the write up, the We have reconsidered the tradi- preceptor evaluates the patient (5 min- tional method. To Socrates we have added utes), discusses the case with the trainee another model to help guide our teach- (1-5 minutes), and reviews and signs the ing. Her name is Aunt Minnie. medical record (1-2 minutes). After Sackett et al, we have dubbed this PATTERN RECOGNITION technique “the Aunt Minnie method” and found that it works. It works with third- Aunt Minnie is the name facetiously given year medical students, third-year pediat- by Sackett et al and others1-3 to pattern rec- ric residents, and everyone in between. We ognition: If the lady across the street walks have not measured its effectiveness or polled like your Aunt Minnie and dresses like trainees for their opinions. Most of them your Aunt Minnie, she probably is your seem to like it, although many are sur- prised the first time they are asked for a di- From the Department of Pediatrics, State University of New York Health Science agnosis prior to a recitation of the com- Center, Syracuse. plete history and physical examination. ARCH PEDIATR ADOLESC MED/ VOL 153, FEB 1999 114 ©1999 American Medical Association. All rights reserved. Downloaded From: http://archpedi.jamanetwork.com/ by a UNIV OF MINN LIBRARIES User on 05/26/2016 Evasions and verbal circumlocu- diagnostic problems early in their ordinary the problem is. It is against tions are common as they think out careers. Neufeld et al8 showed that a background of the ordinary that loud, running down a list of diag- students have the facility for clini- good clinicians recognize what is ex- noses before committing them- cal reasoning (listing and exclud- traordinary, “...those pieces of in- selves. But, with persistence, it does ing diagnostic possibilities) on ar- formation that are odd or discor- not take long before they come to the rival at medical school. Diagnostic dant and ring warning bells to say preceptor prepared with a diagnosis accuracy is learned with the acqui- things may not be what they seem.”4 and the data to support it. Usually sition of knowledge and experience. Illingworth said it another way: they are right and their competence Higgins9 suggests that this occurs “Know the normal, or else....”10 can be confirmed. When they are when students are exposed to real Aunt Minnie is an efficient way to wrong we matter-of-factly give them clinical problems, make their own di- get trainees to know the common the correct diagnosis and the clini- agnoses, and have them confirmed or and the normal. When appropri- cal features that support it. This is the denied by experienced clinicians. ate, we can always turn to Socrates. way they learn. Traditionalists—including us— RESERVATIONS FEEDBACK AND EVALUATION may be uneasy about what seems to ABOUT AUNT MINNIE be superficial treatment of patients Trainees should have some means and trainees. Perhaps McCormick Clinicians, including us, embrace of knowing whether they are acquir- will put them at ease: “...thedi- Aunt Minnie with varying degrees of ing the appropriate clinical skills. agnostic process is simple, straight- enthusiasm. Traditionalists won- Traditionally, faculty preceptors are forward, and in need of demystifi- der if trainees under their tutelage supposed to have facilitated this by cation.”4 He pokes some fun at the will fail to learn how to do a com- means of timely feedback in the form traditional workup and empha- plete history and physical examina- of written and oral evaluations and sizes that most diagnoses occur by tion. They worry that trainees will grades. Ende11 has drawn on the simple recognition based on a few make snap judgments. They fret that fields of personnel management and facts from a quick history and physi- skill in differential diagnosis will fail education to provide clinical teach- cal examination. No need for an ex- to develop. Perhaps the best re- ers with guidelines for providing haustive history and detailed exami- sponse to these concerns is that Aunt feedback to trainees: (1) teacher and nation followed by Socratic dialogue. Minnie—rapid pattern recogni- trainee are colleagues and allies; (2) He further suggests that the com- tion—is the method most experi- feedback is an impersonal process di- pulsive workup can do more harm enced clinicians themselves use most rected to the clinical tasks at hand; than good by inhibiting communi- of the time. Occasionally a brief his- and (3) feedback is given routinely cation. Davies,5 Leaper et al,6 and tory and physical examination fails and promptly. their colleagues suggest that the to yield a working diagnosis. On Aunt Minnie seems well lengthy, stereotyped workup may ac- these occasions the clinician must adapted to these principles. Her fo- tually reduce diagnostic accuracy by start again, ask some more ques- cus is always on the patients and diverting clinicians with extrane- tions, and listen more carefully. The their families. The job at hand is to ous information. Sackett et al be- same process can be taught to train- reach the correct diagnosis. Feed- lieve that “...medical students ees, who learn that initial impres- back is immediate. Most of the chil- should be taught how to do a com- sions may be incorrect and that they dren seen in our clinic have com- plete history and physical but must sometimes must return to other mon problems and in most instances also be taught never to do one.”1 components of the history and trainees have working diagnoses that Campbell7 believes in the So- physical examination. Gradually are readily confirmed by the precep- cratic approach to teaching diagno- they build a diagnostic repertoire by tors. When the preceptors disagree sis, but in practice his suggestions seeing patients, reading, and dis- (usually regarding the examination are similar to McCormick’s and cussing cases with colleagues. of tympanic membranes) they give Sackett’s: do not overdo the history In the interest of broadening their diagnosis and compare notes and physical; focus the physical ex- their experience trainees often place with the trainees. There is immedi- amination on the problem at hand a premium on “good teaching cases,” ate reinforcement when trainees are instead of performing a lengthy rou- meaning patients with rare or com- correct and immediate correction tine; do not overdo the write up. He plex illnesses. Bob Meechan, MD, when they are not. also emphasizes the importance of former director of the University of We are still learning how to use open communication and tells us to Oregon Pediatric Clinic, liked to say, Aunt Minnie, but one of the pleas- listen to the patient. Finally, he ac- “Every case is a good teaching case.” ant surprises has been the matter- knowledges that gamesmanship, He usually said it when the resi- of-fact quality of the feedback pro- professional status, and defensive dents were grumbling about end- cess. Trainees are less likely to feel medicine are at fault for long, mind- less well-child check ups, upper res- they have been interrogated or sub- less workups. piratory tract infections, etc. The jected to personal criticism.
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