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Name of Preceptor: ______Dates worked with preceptor. From: To:

Frequency of Contact: ______

1 contact = 1 day/night on clinical service.

For the following, enter a rating (1 to 5) for each domain in the column on the far right.

Where the domain is not applicable and/or not observed or you have no data, enter N/A.

SCHOLARLY ACTIVITY: A). Teaching Skills

DOMAIN / 1 = Unsatisfactory / 2 = Needs Improvement / 3 = Satisfactory / 4 = Good / 5 = Excellent / Rating
Teaching Attitude / Lacks enthusiasm. Rarely teaches. / Occasionally teaches.
Minimal encouragement. / Teaches when requested. / Stimulates intellectual curiosity, and motivates self-directed learning. / Exemplary. Always enthusiastic and considers teaching a priority
Delivery of Teaching / Information not imparted in relevant manner. / Information presented in unclear manner. Discussion disorganized. / Adequate organization and presentation. / Information/discussions during rounds and other encounters presented/led in organized manner. Encourages participation. / Clear, concise, logical, organized. Is open to and provides opportunity for discussion and questioning. Makes learning exciting and fun.
Content of Teaching / Unclear, limited or not appropriate for level of learner. / Relevance of information often not clear and often not directed at level of learner. / Appropriate emphasis on relevant and important information.
Teaching directed to learner’s needs. / Emphasizes conceptual understanding and problem solving. Enables learner to acquire new knowledge. Content interesting, practical, relevant, accurate, up to date, evidence-based. Motivated to assist learner. / Makes difficult concepts easy to understand. Presents divergent viewpoints for contrast/comparison. Poses problems for learner to solve and emphasizes what is important. Enables learner to sequentially integrate prior and new knowledge.
Clinical Skills Teaching / Seldom takes to bedside to review clinical findings / Sub-optimal quality of bedside teaching / Adequate quality of bedside teaching. Stresses precision and accuracy. / High quality. Emphasizes clinical skill development with integration of pathogenesis, basic science and bio-ethics in clinical decision making. / Exemplary.
Encourages development of critical decision making skills in preparation for independent practice.

SCHOLARLY ACTIVITY: B). Evaluation

DOMAIN / 1 = Unsatisfactory / 2 = Needs Improvement / 3 = Satisfactory / 4 = Good / 5 = Excellent / Rating
Feedback frequency / Almost never / Infrequent (< 1/week)
or inappropriate / Adequate
( x 1 / week) / Frequent and regularly
( x 2 per week) / As often as appropriate and usually
> x 2/week with immediate feedback.
Feedback Content / Too sparse/general / Non-specific
Somewhat sparse / Adequate amount and detail / Very helpful with constructive details. / Extremely helpful, provides guidance with focus on key issues. Invites self-critique after observed performance.
Feedback Delivery / Too harsh.
Belittling. / Harsh. / Appropriate. / Sensitive and helpful. / Very helpful and attentive to key issues.
COLLABORATOR / COMMUNICATOR
DOMAIN / 1 = Unsatisfactory / 2 = Needs Improvement / 3 = Satisfactory / 4 = Good / 5 = Excellent / Rating
Level of Responsibility / Makes learner feel redundant or insecure. / Did not delegate adequately or provide graded responsibility (appropriate for level of training and patient acuity). / Appropriate patient load and complexity for level of training. / Learner felt responsible for care while receiving adequate support and backup. / Learner felt respected. Decisions made by team supported and respected.
Backup for learner / Hard to get hold of. Not there when needed. / Learner not always secure with backup. / Adequate. Learner not insecure. / Makes learner feel very secure with dependable availability for patient care issues. / Exemplary. Invariably ready to help, advise and step in when necessary.
Use of Consultants / Very poor. Extreme over use or under use. / Some over or under use. / Generally appropriate. / Careful use of consultants. Clear question generally specified. / Exemplary use. Clear question always specified.
Health Care Team
(Learners, RNs, RRTs, others) / Unresponsive to concerns of other team members. / Less than optimally responsive to concerns. / Responds appropriately when concerns raised. / Seeks out issues from other team members. Responds quickly and effectively. / Very sensitive response to concerns of other team members. Facilitates their involvement.

MANAGER

DOMAIN / 1 = Unsatisfactory / 2 = Needs Improvement / 3 = Satisfactory / 4 = Good / 5 = Excellent / Rating
Use of investigations and treatment / No discussion of appropriateness of Invx/Mx. / Limited discussion. / Appropriate. / Discusses relevance, appropriateness and costs incurred by the healthcare system of Invx./ Mx. strategies. / Demonstrates discusses appropriateness and costs incurred by the health care system of Invx./ Mx. strategies.
Punctuality / Frequently late. / Occasionally late. / Almost always on time.

ADVOCACY

DOMAIN / 1 = Unsatisfactory / 2 = Needs Improvement / 3 = Satisfactory / 4 = Good / 5 = Excellent / Rating
Health Care Promotion / Rarely identifies nor reviews prevention strategies. / Recognizes opportunities when preventive counseling could be offered. / Identifies important determinants affecting health of patients [poverty (socioeconomic), psychosocial and cultural]. / Actively involves learners, patients, families and allied health care professionals.
Family Centered Care / Rarely mention. / Very infrequent emphasis. / Responds appropriately. / Emphasizes role physicians’ play within a multidisciplinary team. / Actively involves patients and families and promotes family centered care.

MEDICAL EXPERT

DOMAIN / 1 = Unsatisfactory / 2 = Needs Improvement / 3 = Satisfactory / 4 = Good / 5 = Excellent / Rating
Application of Knowledge / Seldom cites evidence to support clinical decisions. Does not integrate basic science with clinical knowledge. / Conveys an impression of gaps in knowledge. Often fails to substantiate decisions with evidence. / Overall appropriate and adequate. Usually substantiates decisions with evidence. / Demonstrates a good understanding of basic scientific principles and integrates these well with clinical knowledge. Aware of methodological issues. Substantiates decisions. / Displays mastery of subject matter. Always substantiates decisions and integrates basic science with evidence based clinical knowledge relevant to solving common clinical problems. Acknowledges limitations of evidence.
Clinical Decision Maker / Unsure, hesitant and does not instill confidence in learner. / Inconsistent. Often fails to substantiate decisions with evidence. / Adequate and generally competent. / Accurate, efficient, focussed and logical. Instills confidence in learner. / Highly proficient. Displays and imparts a sense of mastery with a well-honed ability to critically appraise, diagnose and manage patient problems and emergencies.
Procedural Skills / No guidance provided to learner. / Inconsistently assists learner in attaining proficiency at procedural task. / Adequate assistance provided and appropriate method demonstrated. / Proficient. Assists and demonstrates how to perform task.
Emphasizes how to minimize risk and discomfort to patient. / Displays mastery performing and teaching how to perform task.

PROFESSIONAL

DOMAIN / 1 = Unsatisfactory / 2 = Needs Improvement / 3 = Satisfactory / 4 = Good / 5 = Excellent / Rating
Inter-personal
Ability / Inappropriately disparaging or intimidating. / Inconsistent behavior that detracts from learning environment. / Appropriate professional interaction. / Develops positive relationship, has a genuine interest and is aware of learner’s needs and difficulties. / Outstanding. Superior teacher-learner relationship.
Ethical Issues / Consistent lack of awareness. / Variable awareness. / Appropriate awareness of ethical issues. / Consistent awareness of ethical issues. Facilitates education in ethical reasoning and problem-solving. / Displays enthusiasm when discussing and teaching around ethical issues.
Patient Care / Unaware of issues. Does not know patients adequately. / On occasion, does not know patients adequately. / Always knows patients adequately. / Excellent knowledge and awareness of all patients’ issues. / Provides exemplary care. Serves as a role model that learner can aspire to emulate.
Empathy and Compassion / Openly disparaging or indifferent to patients. / Not sensitive. On occasion disparaging or indifferent. / Sensitive. Clearly concerned about patients’ well-being. / Very sensitive and concerned. Excellent rapport with patients/families. / Striking concern and sensitivity to patients/families and their needs. A true role model to emulate.

OVERALL EFFECTIVENESS OF TEACHING - please circle a rating for the preceptor. * please note that this is a 7 pt. scale.

1 / 2 / 3 / 4 / 5 / 6 / 7

Poor Fair Good Excellent

Comments: If indicating 1 (poor) / 2 (needs improvement) or “5 (excellent) please support this rating with comments/examples.
What are this preceptor’s strengths?
What could this preceptor do to improve his/her teaching effectiveness?

Was evaluation given ½ way through the rotation?

Was final thorough evaluation given face to face?

Prepared by Dr. Christina Grant and Edited by Cynthia Cupido, February 2011

Adapted with permission from the Department of Pediatrics, Calgary