Five Microskills for Clinical Teaching

Most clinical teaching takes place in the context of busy clinical practice where time is at a premium. Microskills enable teachers to effectively assess, instruct, and give feedback more efficiently.

Five Microskills:

  1. Get a commitment - What do you think is going on?
  2. Probe for supporting evidence - What led you to that conclusion?
  3. Teach general rules - When this happens, so does this....
  4. Reinforce what was right - Specifically, you did an excellent job of..
  5. Correct mistakes - Next time this happens, try this....

Microskill 1: Get a commitment

Cue:
After presenting the facts of a case to you, the learner either stops to wait or your response or asks your guidance on how to proceed.

Preceptor:
Instead, you ask the learner to state what s/he thinks about the issues presented by the data.

Rationale:
Asking learners how they interpret the data is the first step in diagnosing their learning needs. Without adequate information on the learner's knowledge, teaching might be misdirected and unhelpful.

Examples:
"What do you think is going on with this patient?"
"What would you like to accomplish in this visit?"
"Why do you think the patient has been non-compliant?"

Microskill 2: Probe for supporting evidence

Cue:
When discussing a case, the learner has committed him/herself on the problem presented and looks to you to either confirm the opinion or suggest an alternative.

Preceptor:
Before offering your opinion, ask the learner for the evidence that s/he feels supports her/his opinion. A corollary approach is to ask what other choices were considered and what evidence supported or refined those alternatives.

Rationale:
Asking them to reveal their thought process allows you both to find out what they know and to identify where there are gaps.

Examples:
"What were the major findings that led to your conclusions?"
"What else did you consider? What kept you from that choice?"

Microskills 3: Teach general rules

Cue:
You have ascertained that you know something about the case which the learner needs or wants to know.

Preceptor:
Provide general rules, concepts or considerations, and target them to the learner's level of understanding. A general teaching point can be phrased as: "When this happens, do this..."

Rationale:
Instruction is both more memorable and more transferable if it is offered as a general rule, guiding principal or a metaphor.

Examples:
"If the patient only has cellulitis, incision and drainage is not possible. You have to wait until the area becomes fluctuant to drain it."

"Patients with UTI usually experience pain with urination, increased frequency and urgency, and they may have hematuria. The urinalysis should show bacteria and WBCs, and may also have some RBCs."

Microskill 4: Tell them what they did right

Cue:
The learner has handled a situation in a very effective manner.

Preceptor:
Take the first chance you find to comment on: 1) the specific good work and 2) the effect it had.

Rationale:
Skills in learners that are not well established need to be reinforced.

Examples:
"You didn't jump into working up her complaint of abdominal pain, but kept open until the patient revealed her real agenda. In the long run, you saved yourself and the patient a lot of time and unnecessary expense by getting to the heart of her concerns first."

"Obviously you considered the patient's finances in your selection of a drug. Your sensitivity to this will certainly contribute to improving his compliance."

Microskill 5: Correct mistakes

Cue:
The learner's work has demonstrated mistakes (omissions, distortions, or misunderstandings).

Preceptor:
As soon after the mistake as possible, find an appropriate time and place to discuss what was wrong and how to avoid or correct the error in the future. Allow the learner a chance to critique his/her performance first.

Rationale:
Mistakes left unattended have a good chance of being repeated.

Examples:
"You may be right that this child's symptoms are probably due to a viral upper respiratory infection. But you can't be sure it isn't otitis media unless you've examined the ears."

"I agree that the patient is probably drug-seeking, but we still need to do a careful history and physical examination."

Used with the permission of: Kay Gordon, MA; Barbara Meyer, MD, MPH; and David Irby, PhD, University of Washington.