This document will become one of many chapters in a text book on education in the health professions to be published by Oxford University Press. All of the chapters in the textbook will follow a Problem-based Learning (PBL) format dictated by the editors and used by these authors.
As learners progress from early health professions education to the clinical learning environment, there is a need for high-quality instruction from their clinical preceptors to foster the application of knowledge to patient care. The busy clinical environment poses challenges to both learners and educators as there is a time constraint to meet both the learner’s and patient’s needs. The One-Minute Preceptor is an easily-learned clinical teaching tool that features five microskills initiated by the educator: getting a commitment from the learner, probing for supporting evidence, teaching a general rule, reinforcing what was done right, and correcting mistakes. This model has been well-studied. It effectively and efficiently imparts high-quality education to the learner without compromising patient care. It is a preferred modality by learners and preceptors alike. Although the original intent was for use in the ambulatory care setting while working with a learner one-on-one, it can be adapted in a variety of settings. There are also several factors that can facilitate the model’s success, including educator adaptability and focusing on the principles of effective feedback.
One-Minute preceptor, clinical education, teaching model, efficient teaching, effective teaching, feedback
- Identify strengths, weaknesses and situations to utilize the “One-Minute Preceptor” model
- Define and utilize the 5 steps of the One-Minute Preceptor
- Adapt the model for various learning environments and groups of learners
- Identify barriers to using the “One-Minute Preceptor” model and strategies for resolving them.
Maria is a medical student just starting her clerkship year and has been assigned to the pediatric endocrine clinic for a week. She arrives at the front desk and recognizes the waiting room is already full. She is greeted and brought back to wait in the team room.
How is learning in the clinical environment different than her previous, pre-clerkship medical school experience?
How can she best meet her learning needs while fitting into the flow of her assigned clinic?
Dr. Wright, Maria’s assigned preceptor, walks through the clinic door to see a full waiting room. The clinic receptionist greets him saying, “your medical student Maria is here and she is sitting in the team room.” Dr. Wright had forgotten this was the first day of the clerkship.
How can Dr. Wright best meet the medical needs of his patients, keep up with his schedule and still provide the student with a meaningful educational experience?
Is there a proven format that can help?
Following introductions, Dr. Wright quickly shows Maria around the clinic and describes the schedule and his expectations. When asked about her learning goals, Maria was unsure of how to respond.
How will Maria learn what she is capable of and where she falls short?
How will Dr. Wright observe Maria’s work enough to learn about her abilities and knowledge gaps?
How will Dr. Wright find time in the busy clinic to provide effective feedback safely?
Dr. Wright enters the first patient’s room with Maria and makes introductions. He then leaves Maria to obtain a history and physical exam.
How can Dr. Wright learn about Maria’s questioning and exam skills without being there?
How can Dr. Wright ensure that Maria’s questioning and exam follow a hypothesis-driven progression?
Maria presents her findings to Dr. Wright when he finishes up with a patient. She pauses looking to Dr. Wright for next steps. Dr. Wright quietly notes to himself that he is already late for his next patient, but wants to provide clinical teaching to Maria.
How is Dr. Wright able to teach and keep up with his clinical schedule?
How does Dr. Wright provide efficient disease-specific teaching to meet Maria’s needs?
Maria feels stressed recognizing that Dr. Wright is busy. She is also worried that she is not performing well enough. There is so much new here in the clinic!
What are the components of effective feedback?
Can effective feedback be provided in a busy clinic?
The clinical environment introduces educational challenges distinct from those in classroom-based health professions education. In the latter, a more structured environment, there are many teaching modalities to facilitate knowledge acquisition: team-, case- and problem-based learning, simulation, classroom teaching and self-study. Additionally, during that time, a student’s education is the primary focus of the teaching faculty and their performance is reported directly as a score on a summative assessment. As students become integrated into the clinical environment, their emerging knowledge and skills are stretched with the real-world complexity of clinical applications. For example, students need to balance the disease-based knowledge obtained through their reading with actual patient symptoms to construct a prioritized differential diagnosis and a patient-specific management plan. In the clinical setting, faculty need to create a fruitful and safe educational environment while concurrently administering exceptional patient care. Teaching modalities leaned on heavily in early health professions education are less congruent with the environment of clinical practice. The assessments students receive can be more subjective and based on short interactions.
To be feasible, models of teaching need to adapt to this environment. To be useful to the instructor, the model must somehow provide insight into both the patient’s illness and the learner’s abilities, be easy to utilize and fit within the tight time-constraints required of increasing patient volumes. To be beneficial to the learner, the model should allow for autonomy in a psychologically safe environment, provide direct teaching that improves an area of weakness, and impart honest feedback. There have been multiple models published to overcome these challenges and maximize learning (SNAPPS, concept mapping and One-Minute-Preceptor).1 Each approach has different strengths and weaknesses. Based on a broad evidence-base detailing its efficiency, efficacy, learner- and preceptor-preference, and its adaptability for multiple health professions and settings, we will delve into the specifics of the One-Minute Preceptor model.1,2
The five-step “microskills” model of clinical teaching, known more commonly as the “One-Minute Preceptor” was first formally described in the Journal of the American Board of Family Practice in 1992 by Neher et al.3 This clinical teaching method earned its name due to its emphasis on providing a brief teaching moment within the context of a busy clinical setting. The model was originally created by senior educators at the University of Washington to provide less experienced family practice preceptors an educational framework to improve their teaching. It was originally presented within the University of Washington Family Practice Network Faculty Development Fellowship curriculum and at other regional and national meetings. Since the 1990s, use of the One-Minute Preceptor has spread across various disciplines as an effective approach to clinical teaching.
The five microskills are simple teaching behaviors focused on optimizing learning when time is limited.3 The model is best initiated by the clinical preceptor after the learner has seen a patient and presented details about the case. The preceptor then encourages the learner to develop their own conclusions about the patient from the information they have gathered. The preceptor then identifies gaps in the learner’s knowledge and provides specific teaching and feedback to fill those gaps. This approach is different than traditional models in which the preceptor asks a series of clarifying questions, mostly to aid the preceptor in correctly diagnosing the patient.3
The first microskill is to “get a commitment from the learner”.3 This entails asking the learner to commit to a certain aspect of the patient’s case. For example, after the learner presents the patient the preceptor may ask, “What do you think is the most likely diagnosis?” or “What laboratory tests would you like to order?”. This encourages the learner to make a decision and demonstrate their level of knowledge.
The second microskill is to “probe for supporting evidence”.3 After the learner makes a commitment, this step allows the supervising clinician to better understand the learner’s thought process and identify knowledge gaps. The preceptor may ask, “What aspects of the patient’s history support your diagnosis?” or “How did you select those laboratory tests?”.
The third microskill is to “teach a general rule” that ideally helps fill a knowledge gap identified in the first two steps.3 This is meant to be a brief teaching pearl about one aspect of the patient’s case. For example, the preceptor may highlight physical exam findings that support the most likely diagnosis or discuss an additional laboratory test that could help narrow the differential diagnosis.
The fourth microskill begins the feedback portion of the model and “reinforces what was done right”.3 Feedback should always be specific, timely, and focused on behaviors.4,5
The fifth microskill “corrects mistakes”.3 This should be done after allowing the learner to assess their own performance first. Educators are also encouraged to provide context while giving feedback, highlighting the positive impact of the learner’s behaviors and how to correct any errors that took place. The five microskills are meant to be a brief set of teaching tools to provide relevant teaching points and feedback in a few quick minutes.
There are many process-oriented strengths of the One-Minute Preceptor model that explain its widespread use. First, this model improves upon more traditional approaches in that it not only focuses on the learner but also has the benefit of facilitating correct diagnosis of the patient.6 The first two steps delve into the learner’s knowledge base, thought process, and potential gaps so that the later steps can provide teaching and feedback that are specific to the learner’s needs in that moment. It has also been shown that teaching is more disease-specific rather than generic when using this model.7 Educators are more likely to provide teaching points that are focused on differential diagnoses, patient evaluation, and disease progression than more general topics, such as approaches to history taking or presentation skills.7 This higher level of teaching can focus on the learner’s decision-making process and clinical reasoning ability, which are essential skills for optimal patient care.3,8 Another process-oriented strength of the model is its efficiency. In addition to the teaching being high-yield and learner-centered, it is also quick to work through and is viewed by preceptors and residents as more effective and efficient.6,9 The model is also easy for preceptors to learn in just an hour or two3. Receiving training in the One-Minute Preceptor model also increases the preceptors’ self-efficacy as an educator and increases the likelihood that they will choose to precept in the future.10 Finally, feedback is often lacking in more traditional teaching encounters, which can leave the learner unsure of their performance and where they should focus their learning. By integrating feedback into the model, the One-Minute Preceptor model has improved the quality and specificity of feedback, even in busy clinical environments.11
As with any teaching process, there are limitations and weaknesses of the One-Minute Preceptor model. The premise of the model relies on good information gathering from the learner and an ability to convey this information to the preceptor. This may be challenging for more junior learners. As it is a preceptor-driven model, faculty development and practice are necessary for success. Also, more junior educators such as residents may feel less comfortable teaching general rules due to lack of confidence or limitations in their own knowledge base.12 Due to its focus on efficiency, the general rule that is taught must be limited and succinct and the preceptor may need to omit other key learning points.
There have been many studies on the outcomes (i.e. impact and efficacy) of the One-Minute Preceptor model since its inception. There is evidence to support that this teaching method benefits educators, students, and patients alike. Clinician educators find the model to be more effective and efficient than traditional models.6 They also indicate higher confidence in their ability to rate learners and tend to rate learner performance more favorably than with more classic methodology.6 The One-Minute Preceptor is also useful in everyday teaching practice, with faculty in the original study indicating that they used the five microskills in 90% of their teaching encounters and all found it a least somewhat helpful.3 Learners also favor this model to more traditional approaches.13 Medical students rate resident teaching skills higher after the resident has received training in One-Minute Preceptor.12 Learners are also more likely to be included in the decision-making process when this model is used as compared to more traditional models.13 Learners also benefit from increased feedback. With this teaching model, they receive higher quality feedback in that it is specific and includes constructive comments in addition to positive ones.11 One common barrier to effective clinical teaching is that it takes time away from the patient, but One-Minute Preceptor aims for efficiency and leaves time for quality medical care. There is also evidence to show that patients are more likely to be diagnosed correctly when One-Minute Preceptor is used versus more traditional models.6
The original intent of the One-Minute Preceptor was to assist clinician educators in the ambulatory clinical setting. This is an ideal environment as learners are often presenting patients to their preceptor one-on-one. This setting provides an opportunity for preceptors to tailor teaching to the individual learner’s needs. Furthermore, there are often high patient volumes in the ambulatory setting with limited time per patient, making quick clinical teaching models necessary for work flow. The model does function best in the context of patient care rather than in the classroom setting, as the basis for starting this approach is a learner’s presentation of an actual patient’s case. It also may be challenging at the patient’s bedside as the teaching is tailored to the learner’s level of understanding rather than the patient’s. Despite its initial application in the ambulatory setting, One-Minute preceptor has been used effectively in other clinical and educational environments. It has been adapted and implemented to teach multiple learners on the inpatient wards.14 After a learner presents a patient on rounds, the clinician educator can then ask the learner to make a commitment to the diagnosis. If the learner struggles at this step, the same question can then be posed to a more senior learner on rounds. General rules and feedback can be delivered quickly during rounds as well. With multiple learners, it may be effective to alter step three (“teach a general rule”) and highlight several general rules, more basic learning points for junior learners and more complex ones for senior learners. As the clinical setting is often unpredictable, altering the model to fit the scenario can be beneficial. One environment which might require some adaptation for the One-Minute Preceptor model to be successful is a high-acuity setting, like the emergency department. Since presentations may happen at the bedside, learners should be counseled ahead of time on what discussions are appropriate to have in front of patients.15 Learners should also be encouraged to circle back to their preceptor to complete the model if an interruption arises. Another adaptation might be that learners make a commitment on the patient’s most acute problem rather than completing a full assessment as there might not be appropriate time during very critical and pressing scenarios.16 To further aid feasibility, preceptors might opt not to use all the steps in every encounter or to alter their exact order.17 In some instances, only a few of the steps may apply. This allows for widespread use of the model in a variety of situations, even while teaching procedures.
Table 1. One-Minute Preceptor User’s Guide 2, 3, 4, 17, 18
|Step 1. Getting a commitment|
|• Goal: The resident should internally process the information they gathered to create an assessment of the situation.3 Learners can be asked to commit to primary or alternative diagnoses, next diagnostic step or potential therapies.18|
|• Approaches to initiate step: This step is usually initiated following the learner presentation. This questioning can evolve through longitudinal experiences with the same learner.|
• “What do you think is the most likely diagnosis for this patient?2”
• “What do you think is going on with this patient?3”
• “I like you’re thinking that this might be pneumonia, what other diagnoses are you considering?2”
• “What laboratory tests do you feel are indicated?3”
• “What would you do for this patient if I weren’t here?” (to decrease pressure of “the ideal” answer)18
|• Learner deficit identified: Failing to commit could indicate difficulty processing the information, fear of exposing a weakness or dependence on the opinions of others.3 Alternatively, the learner might not have integrated some relevant information they had gathered, which could suggest lack of content knowledge.2,17|
|• Possible remedy for identified learner deficit: Assuming a safe environment, this identified mistake in processing is a teaching opportunity.3 The next step will help elucidate if that teaching point should focus on the learner’s processing, a knowledge deficit, or the need for hypothesis-driven data gathering.|
|Facilitators for success:|
• Create a safe and supportive environment to allow the learner to feel comfortable being vulnerable to make a commitment instead of more safely staying quiet.3
• If necessary for patient care, preceptors can ask a few brief clarifying questions. This should be limited at this stage, as too much questioning highlights the preceptor’s thought process rather than the learner’s.3 These questions are more appropriate later in the process.
• Learners should be gently pushed to make a commitment just beyond their level of comfort.18
|Step 2. Probing for supporting evidence|
|Goal: Help learners reflect on their reasoning to identify process or knowledge gaps.17|
|Approaches to initiate step: Open-ended questions aimed at having the learner identify information used to arrive at their commitment:|
• “Why do you think that is the most likely diagnosis?2”
• “What were the major findings that led to your diagnosis?3“
• “Did you consider any other diagnoses based on the patient’s presentation and exam?2”
• “How did you rule those things out?17”
• “Why did you choose that particular medication?17“
|Learner deficit identified: Probing allows clear evaluation of learner’s knowledge and clinical reasoning and identification of gaps and deficits.|
|Possible remedy for identified learner deficit: Any deficits (either knowledge or reasoning) identified in this step can serve as content for the next step, “teaching a general rule”.17|
|Facilitators for success:|
• Preceptors should avoid passing judgement or talking and teaching immediately.3 By listening and learning which facts support the learner’s commitment, the teaching point can be tailored to the learner. This decreases the likelihood of general teaching that might repeat areas the learner already knows.3
• Maintain a supportive environment.
|Step 3. Teaching a general rule|
|Goal: Preceptor shares expertise with a relevant and succinct learning point based on what the preceptor learned about the learner’s knowledge and deficits.3|
|Approaches to initiate step: Direct statements work well:|
• “There was a recent journal article indicating that children with otitis media do not necessarily require antibiotics, unless they meet certain criteria…”
• “In elderly people with confusion, it is important to ask about recent medication changes.”
• “Following an uncomplicated vaginal delivery, our standard of care is a follow-up contact within 3-weeks.”
|Facilitators for success:|
• This step can be skipped if the resident has performed well, and no gaps are obvious, or if more information is needed for a decision.3 The saved time can be spent gathering additional information with the patient.
• Generalizable and succinct “take-home” teaching points relevant to the patient are preferred to complete lectures or descriptions of preceptor preferences.3,17 Topics can include disease-specific features, patient-specific management decisions, or areas for follow-up.18
• If during the probing step, you identify larger knowledge gaps it might be more appropriate to assign more comprehensive reading or plan a slightly longer discussion for a later time.18
|Step 4. Reinforcing what the learner did well|
|Goal: Recognize, validate and encourage certain behaviors. Appropriately build learner confidence.3|
|Approaches to initiate step: A timely, direct, specific statement that is based on the behavior directly observed by the preceptor is ideal.4, 17 Asking the learner what they felt they did well is an effective place to start.18|
• “I was impressed with how you obtained a thorough social history on our patient and noted that smoke exposure at home may be exacerbating her asthma.”
|Facilitators for success:|
• Aim for specific statements which are more helpful than general praise.3 Brief positive statements can be integrated into the questions from the preceding steps as well.17 (During “probing for evidence”: “Asking about travel history was a great thought, what was your motivation?”)
|Step 5. Correcting mistakes|
|Goal: Tactfully improve learner performance.3|
|Approaches to initiate step: A timely, direct, specific statement is helpful.4 Asking the learner where they feel they could improve can help the preceptor start the conversation starting from where the learner feels they are.3,4,18|
• “A thorough skin exam is important in every patient. Noting his Janeway lesions may have brought endocarditis to the list of his potential diagnoses.”
|Facilitators for success:|
• Maintain a collaborative and psychologically safe environment.4 “Focus on the decision, not the decion-maker.4” Finding the right moment and setting for this part is helpful for success.3,4 The most effective feedback occurs in quiet, relaxed areas soon after the observed performance.3,4 This can be challenging as the clinical environment is unpredictable and often fairly public.
• Asking students ahead of time how and when they want to receive feedback can be very helpful.18
• Very specific feedback for areas of improvement is more actionable and measurable than general criticism.4 Concrete improvement suggestions can move this delicate conversation in a positive direction; general criticism can impair the supportive and trusting environment.
• Faculty development efforts can be helpful for successful implementation.
Multiple Choice Questions:
- Which of the following is NOT a step in the One-Minute Preceptor model?
A. Correct mistakes
B. Get a commitment
C. Provide five teaching points
D. Teach a general rule
- Which of the following are benefits of the One-Minute Preceptor model?
A. Increases quality of feedback to learner
B. Improves efficiency and effectiveness of clinical teaching
C. Provides disease-specific, rather than generic teaching
D. All of the above
- How can the One-Minute Preceptor model be adapted in the emergency department setting?
A. Prioritize all five steps of the model over patient care
B. Get a commitment on the patient’s most urgent clinical issue
C. Encourage the patient to provide feedback instead of the clinician educator
D. Skip teaching a general rule since time is limited
- Which of the following is the best way to come up with the general rule to teach?
A. Teach a knowledge gap identified in step two (“probing for supporting evidence”)
B. Teach a general rule that the learner already knows to reinforce it
C. Teach the general rule that you know the most about
D. Teach a general rule that pertains to the next patient that the learner will see
- Pierce C, Corral J, Aagaard EM, Harnke B, Irby DM, Stickrath C. A BEME realist synthesis review of the effectiveness of teaching strategies used in the clinical setting on the development of clinical skills among health professionals: BEME guide no. 61. Med Teach. 2020; 42(6): 604-615.
- Gatewood E, DeGagne JC. The one-minute preceptor model: a systematic review. JAANP. 2019; 31(1): 46-57.
- Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Prac. 1992; 5(4): 419–424.
- Ende J. Feedback in clinical medical education. JAMA. 1983; 250: 777-81.
- Kelly E, Richards JB. Medical education: giving feedback to doctors in training. BMJ. 2019; 366-370.
- Aagaard EM, Teherani A, Irby DM. Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: proof of concept. Acad Med. 2004; 79(1): 42–49.
- Irby DM, Aagaard E, Teherani A. Teaching points identified by preceptors observing one-minute preceptor and traditional preceptor encounters. Acad Med. 2004; 79(1): 50–55.
- Richards JB, Hayes MM, Schwartzstein RM. Teaching clinical reasoning and critical thinking: from cognitive theory to practical application. Chest. 2020; 158(4): 1617-1628.
- Arya V, Gehlawat VK, Verma A, Kaushik JS. Perception of one-minute preceptor (OMP) model as a teaching framework among pediatric postgraduate residents: A feedback survey. Indian Journal of Pediatrics. 2018; 85: 598.
- Miura M, Daub K, Hensley P. The one-minute preceptor model for nurse practitioners: a pilot study of a preceptor training program. JAANP. 2020; 32: 809-816.
- Salerno SM, O’Malley PG, Pangaro LN, Wheeler G. A, Moores LK, Jackson JL. Faculty development seminars based on the one-minute preceptor improve feedback in the ambulatory setting. Journal of General Internal Medicine. 2002; 17: 779–787.
- Furney SL, Orsini AN, Orsetti KE, Stern DT, Gruppen LD, Irby DM. Teaching the one-minute preceptor: a randomized control trial. J Gen Intern Med. 2001; 16: 620-624.
- Teherani A, O’Sullivan P, Aagaard EM, Morrison EH, Irby DM. Student perceptions of the one-minute preceptor and traditional preceptor models. Med Teach. 2007; 29(4): 323–327.
- Pascoe JM, Nixon J, Lang VJ. Maximizing teaching on the wards: review and application of the One-Minute Preceptor and SNAPPS models. J Hosp Med. 2015; 10(2): 125–130.
- Farrell SE, Hopson LR, Wolff M, Hemphill RR, Santen SA. What’s the evidence: a review of the One-Minute Preceptor Model of clinical teaching and implications for teaching in the emergency department. J Emerg Med. 2016; 51(3): 278–283.
- Sokol, K. Modifying the one-minute preceptor model for use in the emergency department with a critically ill patient. J Emerg Med. 2017; 52: 368–369.
- Lockspeiser TM, Kaul P. Applying the one-minute preceptor model to pediatric and adolescent gynecology education. Journal of Pediatric and Adolescent Gynecology. 2015; 28: 74–77.
- Neher JO, Stevens NG. The one-minute preceptor: shaping the teaching conversation. Fam Med. 2003; 35(6): 391-393