In this article, an adaptation of the One Minute Preceptor to teach about social determinants will be proposed. The application of the technique to address a learner’s appreciation of social influencers of health in the life of a patient will be described. Finally the piece will also present examples of how to make teaching points related to these social influencers based on a learner’s level of appreciation of them.
Working with students and residents while on rounds or in clinic, we all find ourselves learning and teaching in a rush. We often need to triage and move quickly to the next challenge, to the next discharge, or in clinic, to the next patient waiting. In moments like these, preceptors often utilize a time-tested technique called the “One Minute Preceptor”1 whereby the “Five Microskills of Teaching” are performed in a compressed time. We diagnose a learner, make a high-yield teaching point tailored to the case and the learner’s knowledge, and give feedback in a short time. To remind us, the typical steps go like the following:
“What do you think is going on?”—get a commitment
- “What led you to that thought?”—probe for thought process
- Teach a principle customized to the learner based on the case so far
- State what the learner had right
- Identify a gap and strategize how to fill it to serve the next patient better
Many faculty development sessions focused on clinical teaching skills in your departments and at regional/national meetings offered the microskills as a foundational approach. In addition, when probing for a thought process in step 2, some of us like to diagnose the learner as a Reporter/Interpreter/Manager/Educator (RIME) for that clinical content—this again is a time-tested rubric we’ve utilized for years.2 Questioning may then be done that not only confirms the learner’s level but also attempts to propel that learner to a higher level.
These techniques are almost exclusively applied to the competencies of medical knowledge and patient care. One Minute Preceptor and RIME are highly useful to assess and teach fund of knowledge, but are less often applied to other core competency targets. With the rest of this piece, let’s apply the five microskills and a diagnostic rubric to another competency and important learner target—that of systems-based practice, and particularly to an appreciation of the Social Determinants of Health (SDOH) in our patients’ lives.
One Minute Preceptor has been applied to SDOH before—at the Society of General Internal Medicine’s National Meeting in Washington DC, May 2019, there were two workshops presenting this application.3, 4 In both, the example of a resident presentation in clinic—whereby a patient affected by a social determinant was unable to adhere to a chronic condition regimen—prompted audience learning and demonstration of the following One Minute Preceptor application:
First announce as the preceptor, “I’d like to take our conversation in a social determinants direction,” then (see the table for suggested preceptor comments at each step):
“What part of the patient’s life might you think is affecting his/her ability to adhere to treatment?”
- “What do you know about the patient that leads you to that assessment?”, “What can we do to help?”
- Teach a principle based on the learner’s level of SDOH appreciation (acknowledger, empathizer, activator, engager)
- Remind the learner of what they had nicely considered
- Make an SDOH related statement that fills a gap in the future
Instead of overlaying the RIME rubric onto One Minute Preceptor for fund of knowledge and patient care, we propose the following for teaching SDOH within the One Minute Preceptor:
Is your learner an acknowledger? Do they realize there is an SDOH issue in the non adherence?
- Is your learner an empathizer? Do they sense and feel the patient’s frustration, rather than categorize the patient as non compliant?
- Is your learner an activator? Do they know resources available in the clinic site or the community that can serve this patient’s situation?
- Has your learner been an engager? Have they already engaged experts and resources in the clinic or the community to help the patient?
To help a preceptor recall this in real time, we might call this the ‘reverse egophany’ (A->E->A->E) of learner SDOH appreciation stages.
An additional consideration for utilizers of this precepting tool would be that in order to close the loop on the SDOH circumstances of a case being presented, one would have to be very familiar with resources in their clinics, divisions, and communities. These may include embedded social workers, a medicolegal partnership, local SDOH themed Web sites to access community resources, links to pantries, links to transportation services, links to shelters and housing assistance, and links to local transportation services. Faculty development across all preceptors in a residency would be key.
And finally, use of this technique can segue to discussions of advocacy for advancing SDOH not just on an individual basis, through the eyes of the learner/patient pair, but also on a broader scale. Enough interactions with learners along these lines may help identify those of our students and residents who may be interested in pursuing local and national advocacy efforts. The use of the SDOH-themed One Minute Preceptor may help move some of our learners toward an unrealized interest and passion.
I hope that clinical teachers will find this a useful adaptation of One Minute Preceptor to call attention to the social determinants of health in our patients’ lives and to the local resources available in our clinic and community settings to assist in their quest for good health.