The

 Five  Microskills:  A  Model  to  Enhance  the  Clinical  Teaching  Encounter  

 
Jonathan  D.  Ference,  PharmD,  BCPS;    Allen  R.  Last,  MD,  MPH;  Stephen  A.  Wilson,  MD,  MPH;  Lee  M.  
Vogel  MD;  Deborah  A.  Spring,  MD  

The  Clinical  Teaching  Encounter    

 
Traditional  Model   Microskills  
Direct  attention  toward  patient  care  issues   Get  a  commitment  from  learner  
Ask  low  level  questions   Probe  for  supporting  evidence    
Give  mini  lecture     Teach  general  rules  
Provide  little  feedback   Reinforce  what    was  done  correctly    
  Correct  mistakes    
 
Get  a  Commitment  
• Discovery  phase:  allows  learner  to  create  formulation  of  the  clinical  situation  and  encourages  
collaborative  role  in  problem  solving  
• Failure  to  commit:  learner  has  not  processed  information,  reluctant  to  expose  weaknesses,  
dependent  on  others  à    indicates  a  teachable  moment    
• Cues  to  engage:    
o “What  do  you  think  is  going  on  with  this  patient?”  
o “What  do  you  think  are  the  medication-­‐related  problems  with  this  patient?”  
o “What  do  you  think  are  the  learning  outcomes  of  this  encounter?”  
 
Probe  for  Supporting  Evidence    
• Diagnosis  phase:  allows  preceptor  to  determine  any  underlying  deficits  and  further  identifies  
critical  thinking  skills  
• Helps  learner  reflect  upon  the  process  
•  Cues:  “Think  out  loud”  vs.  “Grilling”  
o “What  were  you  trying  to  do  here?”  
o “Explain  to  me  how  you  reached  your  conclusion?”  
o “What  evidence  helped  you  make  that  choice?”  
 
Teach  General  Rules  
• Teaching  will  flow  from  the  first  two  steps  
• More  memorable  and  transferable:  application  for  broad  patient  populations  
• Principles:  
o “The  best  available  evidence  demonstrates…..”  
o “Deciding  whether  someone  needs  to  be  treated  in  the  hospital  for  pneumonia  is  
challenging.    Fortunately  there  are  some  criteria  that  have  been  tested  which  help…”  
o “Given  this  patient’s  renal  function,  standard  antibiotic  dosing  is  not  appropriate.    The  
best  reference  to  find  the  information  is…”  

 
 
 
The  Society  of  Teachers  of  Family  Medicine    
rd
43  Annual  Spring  Conference  
Vancouver,  British  Columbia      
 
  
Reinforce  what  was  done  correctly    
• Helps  learner  absorb  and  retain  
• Occurs  when:  
o A  consequence  is  presented  dependent  on  a  behavior  or  response  
o The  behavior  becomes  more  likely  to  reoccur  because  and  only  because  the  
consequence  is  understood  as  dependent  on  the  same  behavior  
• Key  concept  in  behavior  analysis:  
o “When  recommending  that  medication,  you  appropriately  considered  the  patient’s  age  
and  renal  function.    That  will  certainly  decrease  the  risk  of  the  patient  falling  because  of  
oversedation.”    
o “Obviously,  you  considered  the  patient’s  finances  in  you  selection  of  therapy.    Your  
sensitivity  to  this  will  certainly  contribute  to  improving  compliance.”  

Correct  Mistakes  
• Presents  opportunity  for  self-­‐assessment  à  uncorrected  mistakes  are  often  repeated  
• Requires  tact  to  be  effective:  time,  place,  conscious  effort  to  wait  
• Frame  as  “not  best”  or  “less  than  optimal”:  include  suggestion  for  the  future  
o “I  agree  that  the  patient  is  probably  drug-­‐seeking,  but  we  still  need  to  wait  for  a  careful  
history  and  physical  exam.”  
o “Next  time  a  patient  becomes  angry  during  the  encounter,  try  this…”  
o “I  agree  that  the  patient’s  cholesterol  needs  to  be  addressed,  but  achieving  glycemic  
control  first  will  decrease  their  length  of  stay…”  

Creative  Exercises  
• Two  Minute  Analysis:  on  a  blank  sheet  of  paper,  pose  a  specific  or  open-­‐ended  question  and  
allow  two  minutes  for  a  response  
• Most  Clear/Least  Clear  Point:  similar  to  2-­‐minute  analysis,  reveals  overall  understanding  of  
materials  and  directs  teaching  efforts  
• Daily  Journal:  May  be  helpful  with  learners  that  struggle  with  self-­‐insight    
 
Useful  Resources  
• Neher  JO,  Gordon  KC,  Meyer  B,  Stevens  N.  A  five-­‐step  “microskills”  model  of  clinical  teaching.  J  
Am  Board  Fam  Pract  1992;5:419-­‐24.  
• Parrott  S,  Dobbie  A,  Chumley  H,  Tysinger  JW.  Evidence-­‐based  office  teaching-­‐The  five-­‐step  
microskills  model  of  clinical  teaching.  Fam  Med  2006;38:164-­‐7.  
• Molodsky  E.  Clinical  teacher  training:  Maximizing  the  ‘ad  hoc’  teaching  encounter.  Aust  Fam  
Physician  20072007;12:1044-­‐46.  
 
Contact  Information  
Stephen  A.  Wilson:  wilsons2@upmc.edu  
Allen  R.  Last:  allen.last@fammed.wisc.edu    
Jonathan  D.  Ference:  jonathan.ference@wilkes.edu    
Lee  M.  Vogel  MD:  Lee.Vogel@FAMMED.WISC.ED    
Deborah  A.  Spring:  dspring@wvhcs.org    

The  Society  of  Teachers  of  Family  Medicine    

rd
43  Annual  Spring  Conference  
Vancouver,  British  Columbia