Elevate Your Ambulatory Teaching: Supporting High-Performing Learners

There is a large body of medical education literature that provides critical resources for educators focused on supporting struggling learners. However, we also teach many superstars—medical students and residents who are already exceeding expectations. These learners equally deserve to be challenged, to have their knowledge grow by confronting unfamiliar situations, and to practice new skills. As educators, we need resources and ideas to help us support the learning and growth of our high performers.

As part of our faculty development curriculum for our ambulatory preceptors, we organized strategies to use when teaching the learner who already has mastered the knowledge domains for a particular patient. We used the pharmacy, business, and medical education literature to identify overarching principles (avoid boredom, offer autonomy, provide both positive and constructive feedback, take a collaborative approach).^1-4 However, the limited number of articles available offers a small number of specific suggestions and lacks more detailed resources. We aimed to build on this framework and use our own clinical experience to provide a more extensive list of tangible strategies educators can use. We organized concepts into groups to make them easier to remember (improvise related learning points, individualize your teaching, make the learner the teacher, miscellaneous). We then refined this list through interactive sessions with our experienced clinical faculty. While not comprehensive, the following provides a starting point for those who are searching for ways to challenge these learners.

Improvise Related Learning Points

These strategies aim to challenge learners who have already mastered a particular skill by improvising creative teaching points while taking advantage of the base case.

• Complicate the scenario. What if the patient did not have insurance? What if she was allergic to amoxicillin, or the A1c was actually 10%, or he was traveling out of the country tomorrow?
• Probe the thought process. Ask for their reasoning to ensure they understand the clinical decision making and are not just repeating what they have been taught in the past.
• If/then documentation. Residents often provide coverage for each other’s primary care patients. Clear “if/then” documentation in their clinic notes ensures they are thinking one step ahead to challenge themselves while also making follow-up easier for their colleagues.
• Share interesting cases. If one learner has an exciting case during a clinic day otherwise filled with common presentations, encourage them to share the details with the group.
• Expanding resource horizons. Even if a learner makes a correct treatment decision, there is often an opportunity to refer them to a resource to help guide similar decisions in the future, such as the American College of Radiology Appropriateness Criteria for choosing an imaging study or major society guidelines when treating a nuanced condition.
• Inbasket cases. Learners often request exposure to medical conditions that may not just walk through the door. Having them call patients to review DEXA or PFT results, for example, gives them the opportunity to explain and treat osteoporosis or COPD via telemedicine.

Individualize Your Teaching

The following strategies utilize more involvement from the learner to help adjust your teaching to their needs:

• Ask learner to self-identify learning goals. This often provides an easy opportunity to teach about something you may not have known they wanted to learn about.
• Ask learner to self-identify feedback goals. Learners who are doing well may not get enough specific feedback. Offering feedback options (appreciation, coaching, or evaluation)⁵ allow you to probe what might be most helpful to a particular learner at their current stage.
• Prepare for next stage in career. High-performing learners who are going on to residency programs or fellowships that seem disconnected from their current clinical experience may struggle to find relevance in their work. Knowing about their plans and helping them to recognize why anemia is still relevant in emergency medicine or having the budding cardiologist optimize the patient’s heart failure and save the elbow pain for another visit can keep them engaged and improve learning.

Make the Learner the Teacher

Teaching is a strategy both to reinforce learning points and to learn new material. It is also a challenging skill which many learners, especially residents, will need in their future outpatient practices but will have limited experience practicing in the ambulatory setting during their training.

• Teach thought-process to adjacent learner. If a resident demonstrates advanced knowledge in managing a particular patient, have them turn to a co-resident or student sitting nearby and teach them about the case.
• Have resident teach you. Encourage residents to look up primary literature or society guidelines and then share with you or with other learners in clinic. Alternatively, residents pursuing subspecialty careers often already have significant knowledge in their future subspecialty area ready to share.
• Precept another resident’s scenario. Near-peer precepting offers advanced residents the chance to precept interns in the ambulatory setting, a skill heavily valued and practiced in the inpatient setting but infrequently offered in the ambulatory setting. This provides attendings the opportunity to also give residents feedback on their teaching skills.
• Supervise medical students. Residents are often ideal student preceptors, as they are closest to the medical student experience and remember which teaching techniques are most effective, while simultaneously challenging them to teach to the student’s level.

Miscellaneous

There are many other strategies that do not fall neatly into one of our three main areas, but that can prove invaluable.

• Bask in praise/solidify positive experience. Imposter syndrome is rampant in medical training. Even our most impressive learners can benefit from specific praise. Identify a clinic session in which you highlight the ways they excelled and encourage them to remember that positive experience in the future.
• Direct observation. For high-performing learners, this often may feel unnecessary. But sometimes it can identify unrecognized opportunities for improvement—or even just more opportunities for praise. To help find time for direct observations, options include standardizing it (once/week or month), aiming to do it at the beginning of a session (before things get too busy), focusing on procedures or specific exam skills, or aiming to do just a partial visit.
• Build relationships. Help learners recognize the valuable input of all team members and think about more effective ways to utilize their interdisciplinary team. Encourage them to reach out to social workers or consultants to directly communicate and learn from each other.
• Promoting equity. Encourage the learner to think about ways in which social and structural determinants of health may be impacting the patient’s care and brainstorm potential solutions.
• Panel management. Residents can be encouraged to outreach patients on their panel and try quality improvement interventions to improve their population health metrics.

Teaching high-performing learners is a rewarding and challenging opportunity. Utilizing some of these strategies can help ensure that we continue to support all our learners and help them to excel. Embracing the growth mindset means that we must recognize that we can grow as preceptors, and that even our highest achieving learners still have more they can take away from their training. We hope that this structured and specific list of techniques to use with high-performing learners serves as a resource for preceptors to expand their teaching. This will help us cultivate the next generation of outstanding clinicians, researchers, and teachers.

We would like to acknowledge the incredible General Internal Medicine faculty members at Denver Health whose commitment to ongoing faculty development as well as to helping advance the learning of our amazing residents helped us generate this list.