Cue:
After presenting the facts of a case to you, the learner either stops to wait for your response or asks your guidance on how to proceed. In either case, the learner does not offer an opinion on the data presented. If you recognize the patient's problem, your immediate response is to want to tell the learner the answer.

Preceptor Response:
Instead, you ask the learner to state what she/he thinks about the issue presented by the data. Issues may include coming up with more data, proposing a hypothesis or plan, developing a management plan, figuring out why the patient is noncompliant, deciding on whom to consult, etc.

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. When encouraged to offer their suggestions, learners not only feel more of the responsibility for patient care but enjoy a more collaborative role in the resolution of the problem.

Examples

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

Non-Examples

It is not offering your own opinion.
"This is obviously a case of pneumonia."

It is not asking for more data nor is it Socratically leading them to the right answer.
"Anything else?"
"Did you find out which symptom came first?" 

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. You may or may not agree with the opinion and your instinct is to tell them outright what you think about the case.

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

Rationale:
Learners proceed with problem solving logically from their knowledge and database. Asking them to reveal their thought processes allows you both to find out what they know and to identify where there are gaps. Without this information, you may assume they know more or less than they do and risk targeting your instruction inefficiently.

Examples

"What were the major findings that led to your conclusion?"
"What else did you consider? What kept you from that choice?"
"What are the key features of this case?"
"What questions are arising in your mind?"

Non-Examples

It is not list-making or an oral examination/grilling about the problem.
"What are the possible causes of congestive heart failure?"
It is not a judgment on the student's thinking.
"I don't think this is infectious mono. Don't you have any other ideas?"
It is not your own opinion on the case.

"This seems like a classic case of ... "
It is not asking for more data about the case than was presented initially.
"What do you know about her previous childbirth?"

Cue:
You have ascertained from what the learner revealed that the case has teaching value; i.e. you know something about it which the learner needs to or wants to know.

Preceptor Response:
Provide general rules, concepts or considerations, and target them to the learner's level of understanding. A generalized 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 or a guiding metaphor. Learners value approaches that are stated as more standardized approaches for a class of problems or as key features of a particular diagnosis.

Targeting your instruction minimizes the risk of misjudging the learner's sophistication on the topic - resulting in either insulting or losing him/her, and wasting both of your time.

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 cystitis usually experience pain with urination, increased frequency and urgency of urination, and they may see blood in the urine. The urinalysis should show bacteria and white blood cells, and may also have some RBCs."

Non-Example

It is not the answer to a problem (although this may also be needed), rather it is an approach to solving.
"In this case, it's a good idea to soak the affected area to relieve the tenderness rather than lancing it."
It is not an unsupported, idiosyncratic approach.
"I'm convinced the best treatment for diarrhea with salmonella enteritis is still a liquid or soft diet."

Cue:
The learner has handled a situation in a very effective manner that resulted in helping you, patients or other colleagues. She/he may or may not realize that the action was effective and had a positive impact on others.

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

Rationale:
Some good actions are pure luck, others are more deliberate. In either case, skills in learners are not well established and are, therefore, "vulnerable." Unless reinforced, competencies may never be firmly established.

Examples

"You didn't jump into solving her presenting problem but kept open until the patient revealed her real agenda for coming in today. 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/her compliance."
"Thanks for volunteering for the selection committee. Now I don't have to pick someone and wonder about their commitment to the job."

Non-Examples

It is not general praise.
"You are absolutely right. That was a wise decision."
"You did that IV preparation very well."

Cue:
The learner's work has demonstrated mistakes (omission, distortions or misunderstanding) that have or will have an impact on the patient's care, the team's functioning or the learner's own effectiveness.

Preceptor Response:
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. By allowing the person the first chance to discuss what was wrong and what could be done differently in the future, you are in a better position to assess both their knowledge and standards.

Learners who are aware of their mistakes and know what to do differently in the future need only to be reinforced. Learners who are aware of their mistakes but unsure of how to avoid the situation in the future are very likely to be in a "teachable moment" (they are eager for and appreciate tips that will help them get out of or avoid the uncomfortable situation in the future).

Learners who are unaware that they made a mistake or are unwilling to admit the error are more troublesome. Obviously they have not seen that their action has an undesirable consequence. In order to maximize learning for them, detailing the negative effect as well as the correction are both essential for effective feedback.

Example

"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."

Non-Example

Avoid vague, judgmental statements.
"You did what?"