Small Group Teaching
Open Ended Questions
|THE DEMO VERSION DOES NOT FEATURE THE DOCCOM ASSESSMENT QUESTIONS NOR THE LEARNING MANAGEMENT SYSTEM|
|Welcome to DocCom Module 42:
"Effective Clinical Teaching"
by Dennis Novack, MD, Ronald Saizow, MD, Allison Ferris, MD, Burton Landau, PhD
CME Credit is NOT available for this Module.
Allison Ferris MD
|Questions for Reflection:|
Teaching is at the heart of the medical professions.
Much of what we know we have learned from the examples and teachings of our parents, teachers, siblings and friends. When we experience the pleasures of learning, it encourages us to pass along what we have learned to others. Along the way we also learn that teaching is, in many ways, its own reward. Many of us have experienced the gratification of teaching something important to a friend or colleague that makes a difference in their lives. Teaching can be exciting and stimulating when it is going well, connecting us to what we value in our work.
Teaching is core to a doctor’s role. In fact, the origin of the word “doctor” comes from the Latin, “docere,” meaning “to teach.” We teach patients about their diseases and how to care for themselves. If we use effective teaching techniques patient understanding, adherence, and outcomes improve. We teach junior colleagues, who then deliver better patient care.
Indeed, as we progress in medical education, we are expected to teach, and in preparing for teaching sessions, we often learn new material that helps us as much as the learners. It has been estimated that house staff spend 20% of their time teaching. Even these inexperienced teachers impact learners by their role modeling. All clinical teachers must remain cognizant of the impact that their behaviors and attitudes have on learners. We can enhance our effectiveness as teachers and role models by developing certain attitudes, knowledge, skills and self-reflection.
One core goal of clinical teaching focuses on the process of enhancing learners’ clinical reasoning. That's the process of creating a problem synthesis (or one sentence descriptive title), generating hypotheses that are tested through focused data gathering with continuous reassessment of differential diagnoses, establishing the most likely diagnosis (and identifying any must not miss diagnosis), then creating an evaluation strategy to refute or confirm the diagnosis. Exposing every component of the clinical reasoning process is a goal of clinical teaching, in order to identify gaps, correct errors, and promote better refinement of reasoningIf one of the end products of all clinical teaching is to enhance learners’ clinical reasoning, still we do much more than that in our teaching. Through our manner with learners and patients we model professionalism, including respect, kindness, attention to learners’ and patients’ worries and suffering, and using our abilities to not only diagnose and cure, but to understand and promote healing. The best teachers inspire, and pass along their wisdom and art to contribute and to leave something behind – to enhance the lives of current and future patients, families, and communities.
|HOW ATTITUDES AFFECT TEACHING|
Attitudes shape behaviors. Positive attitudes about teaching and about your learners enhance your effectiveness as a teacher.
Attitudes that enhance your teaching include enthusiasm for teaching (1) and patient care, respect for your peers and junior colleagues (2), caring about your learners as people, and concern for their educational needs and for their personal and professional growth. If you believe that your students are basically well-intentioned and trying to do their best, you are more likely to be generous with your praise for their efforts, forgiving of small mistakes and supportive of their stretching their limits. If you believe that your students are lazy and trying to get away with doing as little as possible, don't really care much for what you are teaching, aren't as dedicated as you and your colleagues were, or are not striving for the high standards that are your ideal, you may only see their faults, be stingy with your praise, and generous with your criticism. Positive and negative experiences with teachers help shape our attitudes. For example, some faculty members learned through being "pimped" and humiliated in front of their peers (3), and came to believe that this is an effective way to teach. For most, humiliation inhibits learning.
Moods and affective states affect our attitudes. If you are feeling resentful, angry about your personal or professional situation, unfairly treated by your seniors, not good enough or smart enough, or feeling envious or angry towards certain junior colleagues on your team, these negative emotions will surely inhibit your ability to be an effective teacher. A number of faculty members and house staff are burned out or depressed, causing them to have negative attitudes and to be irritable with others. (4) On the other hand, if you are feeling confident, secure in your knowledge and abilities, and can provide positive energy to your rounds and teaching sessions, these emotions will be infectious and contribute to a positive learning environment.
It can be worthwhile to ponder and discuss these questions: What are your basic attitudes about yourself and towards your peers and junior colleagues? How confident are you in your sense of yourself as someone who can contribute to others and be a role model to junior colleagues? What do you value about being a teacher? How might your emotional state and your attitudes be enhancing or inhibiting your ability to be an effective teacher?
The first step towards improving your effectiveness as a teacher involves self-reflection. Your abilities to teach improve as you grow personally through enhanced self-reflection and self-awareness. It can be helpful to discuss your doubts, fears, concerns and insights with trusted colleagues and friends as a way of promoting your personal growth, as a person and as a teacher. Much has been written in recent years about attending to and improving self-awareness in medical education. Novack, Epstein and their colleagues summarized the issues related to enhancing self-awareness and reflection in medical education and care. (5, 6) Finally, it is worth emphasizing the point about caring for your learners. Peabody (7) famously said that the secret in the care of the patient is in caring for your patient. The same can be said for teaching. If you respect, honor, and care for your learners as individuals, they will know that, forgive small mistakes, and want to learn all the more.
|GUIDELINES FOR EFFECTIVE CLINICAL TEACHING|
Effective clinical teachers understand and employ diverse educational strategies in order to engage and stimulate the intrinsic motivation of their learners.
Novack and colleagues summarized educational principles relevant to teaching medical interviewing (8). In the following section, we describe 10 guidelines that apply to teaching in clinical medical settings.
|1. Define goals and objectives and reach agreement with learners|
|Discussion and development of shared goals and objectives at the beginning of rotations as well as the beginning of individual sessions enhances all learning activities.|
The maxim that if you don't know where you're going it's unlikely you will get there, and you surely will not know if you have arrived, applies to clinical teaching activity. Learners and faculty who share expectations prepare better, stimulate and engage with each other’s needs and can measure progress. In discussion, both learners and teachers may wish to modify objectives or add new ones, according to their learning needs. Interns and residents will learn more in a rotation if they sit down on the first day and agree upon goals, responsibilities, expectations, and what they hope to learn and teach during the rotation. Even when beginning a session to teach a discrete topic, it is helpful to outline the main goals of the session, seek agreement and with your learners, and give them a chance to add other related goals.
|Please click the video-button on the left and watch how a senior resident orients his team members on the first day of a new service.|
|2. Assess and address learners' knowledge and motivation|
|As a rotation or session begins, assess learners’ knowledge, perspectives and feelings, so that you can address misconceptions and fine tune your teaching strategies.|
Address learners’ motivation about a session or rotation to maximize their learning. When learners think they fully understand the topic you are working on, they are unlikely to pay close attention. Some learners may have preconceived notions about your topic area, and close their minds to new learning. Sometimes it is helpful to administer a brief pre-test of knowledge, self-efficacy, and attitudes, to assist learners in becoming better aware of their educational needs.
|3. Teach knowledge and skills sequentially from simple to complex|
|Start with the basics, or review the basics when teaching complex concepts and skills.|
Many concepts and skills that comprise medical practice are quite complex. Students learning the complexities of acute renal failure must first understand acid base balance and the ranges of normal electrolytes. Similarly, skills, including interviewing, physical examination and other procedural skills, rely on learning basic skills first. Members of house staff teams from diverse backgrounds may have had different experiences with learning certain basics. You will often need to assess their familiarity with core concepts and review some basics before teaching advanced topics. Begin your teaching from the level of learner understanding.
|4. When you teach skills, define them and present them as discrete behaviors|
|Clearly describe skills, demonstrate them, and articulate performance standards (anchors).|
Whether you're teaching simple or complex skills, describe orally and in written handouts the behaviors that comprise them. Demonstrate the skills and articulate performance standards (anchors) that allow learners to assess their progress against those standards. Observe learners as they practice, and teach learners to observe each other and give feedback, using the anchors. Showing brief videos of effective skill performance in a medical context can enhance understanding.
|5. Enhance learning of knowledge and skills through repetition and reinforcement|
Present alternative descriptions of key principles and show multiple examples of important or complex skills.
“See one, do one, teach one” is seldom the most effective technique for mastery of skills. Sometimes learners must see complex procedures multiple times before attempting them with expert guidance and repetition until mastery. For behaviors or concepts that are especially important or particularly complex, give multiple examples that shed further light on their utility and execution in varied contexts.
|6. Provide effective feedback|
|Giving feedback shows learners that you are fully engaged, and feedback speeds learning of knowledge and skills.|
When you give feedback to learners and demonstrate that you can both praise success and help them with deficiencies, you show that you value your teaching role. You build trust and relationship, show your willingness to fully engage, and show that you value their success. Your engagement with learners through your feedback thus individualizes and speeds the learning process. Learn feedback principles and be certain to capitalize on the many opportunities presented to you for using feedback as a teaching tool. (9) In addition to formal feedback sessions, feedback can be used within teaching sessions to facilitate learning for the individual and the group. Module 40 presents principles and guidelines and illustrates the process in varied contexts.
|7. Ensure early success|
Ensure that learners can demonstrate knowledge or skill acquisition.
When learners experience success in learning, that success enhances their confidence and motivation to continue learning. Establish goals and objectives that most learners will be able to achieve and demonstrate in that session or within a short time. Organize learning activities that provide opportunities to observe and comment on learner successes, perhaps through quizzes, evoking discussion with good questions, skills practice in role play or other simulation. Whether you are teaching new knowledge or new skills, your honest praise to students for their successful learning increases their self-confidence and enjoyment of learning, as well as their regard for you as a teacher.
|8. Monitor and attend to learners' emotions|
When you respond with empathy to learner expression of reluctance, stress and distress, your sessions can be more effective.
The stresses of medical school and residency training can lead to anxiety and demoralization. These and other negative attitudes and emotions, such as feeling inadequate, guilty or lonely, inhibit learning. Monitor the emotional "temperature" of learners. Sometimes group members will seem somber, or stressed, or be reluctant to answer questions. Some learners, especially in the middle of an internship, may be depressed or burned out. (10) Sometimes you as a teacher may be asking too much of your learners or you may have inadvertently said something that left them confused or upset.
You create an atmosphere that maximizes learning possibilities when learners know you care and that you understand their feelings. If you ignore, put down or make light of learner distress, you add another obstacle to effective learning. If, on the other hand, you inquire about what people are feeling and show your concern and willingness to try to address some of the issues, you can "clear the air," motivating and preparing your learners. Of course you cannot take responsibility for resolving outside situations, but simply acknowledging their significance reassures learners, freeing them up to participate. Sometimes you learn something as simple as that group members are in the middle of major tests, or boards. You further enhance engagement and motivation when you provide encouragement and emotional support in a non-judgmental and empathic fashion.
|9. Encourage interaction, questions, and reflection|
Demonstrating that you value comments, questions and interactions from each learner and among all team members stimulates learning and assimilation of new material.
You set the tone for exciting and stimulating learning on ward rounds or in small group sessions when you invite and value interactions among all group members. Improve group interaction by encouraging questions and comments. Ensure that learners know that all questions are good questions. Acknowledge and praise comments and questions, and use them as springboards for your own questions and comments, as you put them in perspective for the team. Further stimulate discussion by asking provocative questions and encouraging learners to take intellectual risks in proposing diagnostic hypotheses or solutions to problems.Reflection, that is, the consideration of the larger context, the meaning, and the implications of an experience or an action, allows the assimilation and reordering of concepts, skills, knowledge, and values into pre-existing structures. Ask learners to take time to reflect on what they are learning, both in real time and after the session. Encourage individuals to return to the next session and share the insights they attain. Active reflection promotes the professional growth of individuals. (9)
|10. Provide formative and summative evaluations|
Each skillfully conducted evaluative conversation (written or oral) that you conduct with learners motivates and assists them in setting further learning goals
Formative evaluations help learners shape their learning. Summative evaluations communicate students' grades and reveal the knowledge or skills on which they need to continue working. To maximize the benefit of evaluations, schedule them in advance, and assure that your learners share the expectations, goals and objectives of the evaluations. When provided in a constructive and personal but non-judgmental manner, evaluations motivate learners to continue in their pursuit of knowledge and skills. Learners may not share your expectations or goals for a course or rotation, or may become side-tracked by other concerns, so do not omit mid-block or other formative evaluations that can redirect learners’ efforts.
|STAGES OF COMPETENCY DEVELOPMENT: TEACHING LEARNERS WITH DIFFERING EDUCATIONAL LEVELS|
Clinical teaching often involves learners at differing educational levels. Identify learners’ levels and adjust your instructional strategies to meet their needs. (11, 12) Each level requires knowledge, structured experiences, emotional buy-in, reflection on action, role models, and learner-centered instruction for most effective progress toward the next levels.
In this section, we address the differing needs of Novice Learners, Advanced Beginners, and Competent Residents, and discuss appropriate teaching strategies.
For novice learners, highlight key pertinent data from their exams that help distinguish among diagnoses and encourage more intensive study of one or two competing hypotheses about diagnostic or treatment options.
The novice learner on a clinical team has little clinical experience, typically at a second or early third year medical student level. The novice is unable to filter or prioritize data so that synthesis is difficult. Everything seems equally important. With little experience to draw upon, the student performs best when provided rules, such as “when you encounter this, do that,” or “when an adult patient complains of chest pain, always identify cardiovascular risk factors and assess for cardiac causes.”
On their first clinical rotations, novice students typically perform H&Ps using a set of rules or templates. Regardless of the Chief Complaint, they methodically go through each item on the generic template. They have no capacity to focus the information gathering on the basis of a likely differential diagnosis and do not yet comprehend the big picture. When preparing a written H&P, pertinent positives and negatives remain scattered throughout the ROS rather than being discussed in the HPI. Each sign and symptom seems equally relevant. These students still have limited abilities to synthesize the myriad pieces of information into a unified summary. Using learned rules, they link the clinical data to their knowledge of the pathophysiology of disease.
The teacher can employ specific strategies for novice level learners:
For advanced students and interns, require them to formulate differential diagnoses, help them to set priorities, and reinforce the meaning of context to the clinical problems.
The advanced beginner is typified by third and fourth year students through early internship who have experience with many clinical encounters. Advanced beginners use their experience to sort through rules and data to decide what is relevant. They begin to use pattern recognition to solve problems, seeing the big picture and how specific information relates to it. They begin to create their own personalized rules and “maxims” from meaningful prior experiences.
At the beginning of the intern year, when advanced beginners are taking H&Ps, they begin to generate a differential diagnosis that drives data gathering in a more focused direction. Because they are capable of filtering information and focusing on the relevant, they are able to formulate a unified summary of the case. When writing notes, they can abstract the pertinent positives and negatives from the ROS and appropriately incorporate them into the HPI.
Recognizing the advanced beginner on the team, the teacher can employ specific strategies individualized for this competency level:
For increasingly competent residents, balance supervision and autonomy, helping them become aware of the emotional and clinical care consequences both of never asking for help or lacking the confidence to trust their own thinking and decisions.
Competent residents, usually approaching the end of residency, possess a wealth of clinical experience upon which to compare and contrast patient presentations. This provides competent clinicians with a perspective to determine important or ignored elements. They are able to see the big picture, using clinical reasoning tips from analytic to pattern recognition for solving common problems, but complex or uncommon problems require reliance on analytic reasoning. Because supervising residents must decide what plan to choose and when to choose it without being sure, every situation requires coping with uncertainty, which is both frightening and exhausting. It becomes an emotional roller coaster consisting of the pain of mistakes and elation of successes. Self-awareness allows managed emotional involvement, which advances development. Without self-awareness, this roller coaster may produce resistance to risk or responsibility, which leads to stagnation of development.
Competent residents build on many clinical experiences as they near the end of residency, and recognize common illness patterns. They easily see the big picture. Because of their enlarged responsibilities, they see more consequences of their clinical decisions, which results in an emotional buy-in to learning. When they encounter new or unfamiliar problems, they methodically reason through each step of the case, sometimes successfully and sometimes getting stuck. They feel responsible for their decision-making process and are consciously aware of their own roles in contributing to the clinical outcomes.
Recognizing the competent learner on the team, the teacher can employ specific strategies individualized for this competency level:
|ENGAGING LEARNERS AND STIMULATING LEARNING IN CLINICAL TEACHING SETTINGS|
In the following sections we discuss concepts and skills that promote active learning, in groups and with individual learners.
The topics we address in this section are the following:
At each level of training, you will be a role model for junior colleagues. Maximize your effectiveness as a role model by strengthening positive personal qualities, clinical proficiency and teaching expertise.
Young clinicians look to their senior colleagues for inspiration and guidance in all aspects of the practice of medicine. Role models shape those values, attitudes and skills that characterize clinician “professionalism,” as well as students’ career choices.(13) In today’s hectic healthcare environments, excellent role models are harder to find, and many harried clinicians demonstrate distinctly unprofessional values and behaviors. Recent studies of role modeling and the processes of learning through role modeling have identified qualities of excellent role models and key aspects of learning from them.(14)
In one important study, house staff at four hospitals identified 141 clinicians as excellent role models. In contrast to 200 other attendings, the excellent role models were more likely to have attended teaching workshops, to stress the importance of the doctor–patient relationship in their teaching, to teach about the psychosocial aspects of medicine, and to provide in-depth feedback to house staff. They were more likely to say they enjoy clinical teaching, to rate themselves more highly as a role model and to share professional and personal experiences with learners.(13)
According to another recent study (15), some qualities of role models that learners value highly include personal attributes such as compassion, a sense of humor, and integrity, clinical proficiency in diagnosis, effective interaction with patients and families, and skillful teaching such as the ability to explain complex subjects, stimulate thinking and interact in a non-threatening manner. The authors of this study suggest several strategies you might undertake to improve the “role model” aspect of your teaching. These strategies include the following:
|Facilitation skills for small groups|
Medical students, resident clinicians, clinical faculty and others will lead small groups of learners in rounds, case conferences, didactic informational sessions and other settings. We incorporate attitudes, educational principles, and skills into a summary of keys to effective small group teaching.
The areas we include for more intensive review and study are the following:
|Planning learning sessions|
For your assigned and scheduled teaching sessions, develop goals, divide the time into segments and follow your schedule, use more than one teaching strategy, and have a written or digital handout.
Planning improves the quality of learning sessions. Decide on your goals and objectives and write them down. Determine what materials and teaching methods you will use to achieve these goals and objectives. Provide a handout that summarizes essential points and might also serve as an outline for the session. Decide approximately how much time you will allot to each learning objective, and each segment of the session. Develop teaching strategies for each segment and vary teaching methods, not only to keep the session consistently interesting, but also to address varying learning styles of participants. For example, in planning a session around a patient with a particular problem, you might briefly introduce the topic, ask participants for their experiences in dealing with this problem and discuss those, highlight the important information to elicit from patients, do a brief patient interview and exam, discuss these findings and their implications, and then summarize essential learning points, referring to a brief handout or article. When teaching about healthcare relationships and communication skills such as discussion about advance directives, including time for succinct, focused role-plays can be illustrative and engaging.
|Skills for opening and conducting a session|
Always let participants know that you care about their learning. Use words and non-verbal communication to show that you welcome questions and comments. Acknowledge contributions and involve everyone.
First impressions set the tone. When beginning a new group, take a few minutes to introduce yourself and invite each of the participants to do the same. You might ask them about their backgrounds and interests, to say something that nobody knows about them, what they are hoping for in this group, etc. Getting to know participants in a personal way helps set a positive learning climate. Communicate to participants that you care about them and their professional development, and that a key goal for your own work is to foster a stimulating, fun, and safe environment, with their help.
Keep your session learner-centered. In addition to soliciting learners’ feedback on whether the session was learner centered, another gauge is this: if you leave thinking you really showed them how much you know, you may have missed responding to what they really needed to learn.
An additional goal for group leaders is to help participants to share opinions, take intellectual risks and work together. Welcome questions, and invite other group members to respond to them before you do so. Involve the quiet members of the group, ("John, I would be interested in hearing your opinion,") and solicit contrary or minority opinions (“Shireen, from what you’ve said, I expect you might have another opinion on this- if so, would you share it with us?”) Acknowledge each learner’s contribution. Become a patient listener, ask simple questions that help learners refine their thinking, and notice what concerns they are not saying that may be relevant. Share your own insights and experiences only when they will advance the dialogue, never to show that you know the “right answer”.When working with a group of multi-level learners, such as a ward team, you might begin with a basic question and gradually move to advanced questions directed at the senior members. In that way, everyone can participate and know they have contributed to group learning. Observe and comment occasionally on non-verbal expressions of confusion, excitement or disinterest. When someone appears bored or uninterested, you might ask the learner his or her perspective on the issue. Your intervention can provoke useful adjustments to pace, tone, involvement or topic.
|Skills for monitoring the pace and for closing a session|
Be aware of elapsed time, devote time to a summary of the session and involve participants in debriefing your leadership and the session’s effectiveness, and close at the designated time.
Keep one eye on the clock, because interesting discussions that go over the time that you've allotted can limit coverage of additional key topics. Of course, flexibility trumps rigidity in dynamic learning sessions, but you need to take charge, perhaps saying, "This is a fascinating discussion, and we need to move on. Jason, would you look up a review article on this topic and report back tomorrow?”
Remember that every person on the team is as busy and commited as you are, and that closing at the designated time shows that you respect the needs of the team members
As the session approaches closing time, take steps to solidify learning, reach closure, and plan for the next session. Ask participants to summarize the key lessons, and as you listen, paraphrase individual contributions. At times, you might ask each group member to say one thing they learned, or what they might apply in their clinical work in the next week. Identify learning issues for the next session, and if you haven’t done so already, ask a volunteer to look up the answers to questions or to make a brief presentation at the next session. Seek feedback about the session’s learner-centeredness and utility, and inquire about how the group and your leadership could be more effective.
Asking questions helps you understand learners’ level of understanding and their learning needs. Skillful questions stimulate learners’ thinking and motivation to learn more.
Group participants learn best when they are actively engaged in learning. Your questioning skills can be powerful in stimulating learning. When you engage learners in discussion through use of questions that expand their thinking and stimulate problem-solving and critical thinking, you promote active learning. Many obstacles can reduce the effectiveness of otherwise effective questioning strategies.
The following list shows some common barriers to discussion:
The types of questions we include for more intensive review and study are the following:
Excellent sources for these kinds of questions are "The Clinician as Teacher" by N.Whitman and T.L. Schwenk, and "Residents as Teachers: A Guide to Educational Practice, by T.L. Schwenk and N. Whitman(19, 20)
Open-ended questions facilitate discussion, rather than seeking “right” answers, and help you assess learners’ cognitive strategies and ability to generate and test hypotheses.
Open-ended questions possess characteristics that promote active learning. For example, they seldom have “correct” answers, they suggest that people may have differing answers and they require that responders consider more than one factor in developing answers. Additionally, the questioners may have some ideas but is asking for responses they might not have considered. The questioners wish for respondents to “think out loud” rather than parrot the “right” answer.
Asking open questions can help you avoid the normal tendency to show your knowledge, and help learners better grasp complex ideas or concepts. Putting out your own “expert” interpretation too early can suppress thinking and discussion by others. When someone answers, listen attentively and ask others for their input. A good continuer, if discussion seems slow, is to simply reflect back whatever a respondent says, adding something like, “Do I understand you correctly?” or, “Is that what others understood?”
Examples of open-ended questions are the following:
|On rounds, your team sees a patient with HIV admitted for cough and shortness of breath. She has never been on HAART, her last CD4 count was 150, and she takes no medications at home.|
Teacher: “What is the significance of the CD4 count, and why?”
Learner: “A CD4 count less than 200 puts the patient at risk for opportunistic infections such as Pneumocystis pneumonia.”
Teacher: “What if the CD4 count is 250—how does that change your thoughts?”
Learner: “PCP would be unlikely if the CD4 count were that high. Then you would consider the typical organisms that cause CAP—Strep pneumo, H.flu, M.catarrhalis, L.maltophilia. Also, regardless of the CD4 count, I would consider TB in the differential for this patient.”
Teacher: “What do you do next to diagnose this patient’s problem?”
Learner: “I would order a chest x-ray, get a sputum gram stain and culture, sputum for AFB, check her pulse oximetry, and check both her CBC for white cell count and order a CD4 count.”
Use increasingly closed-ended questions to involve learners who may be less facile with higher cognitive strategies, and to help assess the knowledge base of learners.
It may be helpful to build on your questions: start with simple concepts, then ask for further details, gradually leading learners to more complex thinking. This kind of exercise helps learners to expand their thinking.
|Your team later sees an elderly male admitted for dyspnea. He is found to have pulmonary congestion on chest x-ray and has rales on his pulmonary exam.|
Learner: “So, based on the shortness of breath, rales, and pulmonary vascular congestion on x-ray, we are treating this gentleman for CHF exacerbation with diuretics.”
Teacher: “Tell me more about this CHF diagnosis.”
Learner: “Well, the patient has a history of hypertension and coronary artery disease with several MI’s in the past. He likely has a reduced systolic function that led to progressive left heart failure and pulmonary congestion. We should check a 2D Echo to determine his ejection fraction.”
Teacher: “How do you account for this sudden onset of symptoms when he previously had been well?”
Learner: “Well, it could be that he has suffered another MI, perhaps silent, that worsened his systolic function further. If he had a murmur on exam, I would consider worsened valve disease such as mitral regurg that caused this sudden decline. Most likely, though, it has to do with the fact that he admits to not always taking his medications. This makes him more at risk for MI as well as uncontrolled hypertension that may have resulted in this scenario.”
Teacher: “This patient’s medication list—metoprolol, lisinopril, aspirin, simvastatin—help me to understand the rationale behind using these medications.”
Learner: “The statin is for cholesterol lowering, the aspirin is an antiplatelet that helps prevent further MIs, the beta-blocker helps keep heart rate and blood pressure down, and the ACE-inhibitor is for both blood pressure control as well as prevention of cardiac remodeling, a process that occurs after MI and ultimately results in worsened cardiac function.”
|Directed questions help you guide learners’ thinking and stimulate problem-solving. They model how teachers think critically about problems.|
Using directed questions helps learners explore the depths of the situation at hand and understand it more fully. They also begin to imagine the complexity and variety of situations they will likely be called upon to manage that differ slightly from the present one. Examples of directed questions follow:
|The team’s next patient is a 67year old man with a long history of smoking and alcohol abuse who was admitted with dysphagia.|
Teacher: “So this gentleman has a six-month history of progressive dysphagia. What hypotheses help explain his dysphagia?”
Learner: “Well, top on the list is going to be esophageal cancer given his age, his history of both heavy smoking and drinking, and his progressive symptoms. An unknown is whether it would be adenocarcinoma or squamous cell carcinoma. Obviously, he is also at risk for other malignancies, lung especially, but he gives no history of pulmonary symptoms. Other possibilities are neurologic such as myasthenia gravis.”
Teacher: “What do you do next to help diagnosis his problem?”
Learner: “He needs an upper endoscopy.”
Teacher: “How would your differential change if this patient had never smoked or drank?”
Learner: “Well, the malignancies would be lower on the list, I guess. Myasthenia, especially bulbar myasthenia would go higher. I would also add other possibilities such as esophageal webs or rings. I guess I would also wonder about conditions like esophagitis, possibly from reflux or infectious.”
Teacher: “What if our gastroenterology colleagues were all out of town and no one was available to do an endoscopy. Is there a test you could do instead?”
Learner: “Well, you could do a barium swallow to look for masses.”
Teacher: “Even with endoscopy, what questions may remain unanswered for this patient’s diagnosis and prognosis?”
Learner: “Well, obviously, we’d need to wait for the pathology report to come back on any samples that were taken during endoscopy. Also, if it is cancer, we’d need to determine staging with CT Scanning of his chest, abdomen, and pelvis.”
|Please click the video-button on the left and watch an attending clinician teaching a student after seeing a patient together. Which questioning skills did he use? How might he have used different kinds of questioning skills to be more effective in his teaching?|
|Dr. Joseph Boselli and his Interns|
At Hahnemann University Hospital in Philadelphia, Dr. Joseph Boselli is one of the most appreciated teachers.
In this video, Dr. Boselli introduces himself at his first attending rounds of a rotation, and interns comment afterwards on why his teaching is effective.
|TAKING THE TEAM TO THE BEDSIDE|
The complex dynamics of an encounter with a patient along with multiple levels of learners, each with individualized needs, is a challenge requiring attentiveness to respectfulness of both the patient and all learners. Bedside teaching necessitates careful attention to the patient’s comfort and dignity.
Teaching at the patient’s bedside is a powerful opportunity to role model for learners. They can be inspired by your ability to maintain a delicate balance between showing kindness, respect and caring for the patient and attending to team members’ learning needs. They can observe your demeanor and skills as you examine the patient and conduct parallel conversations with patient, family and team members. Further, you observe firsthand the learners’ interactions with the patient and the patient’s family. Physical examination and communication skills can be directly demonstrated, and the key learning points can be based upon data that all team members directly observe and share. (16-18)
Attend to structural elements of a bedside teaching session to maximize the learning benefit. Obtain permission from the patient in advance of the team’s arrival. Engage all team members in establishing both learning goals and a role for each team member to play. When you approach the bedside, introduce each team member and the purpose of your rounds. Attend to the patient’s comfort and to any communication barriers such as pain, privacy, or need to use the bathroom. Attend to all the learners and give them chances to ask questions or appreciate a physical finding, with the patient’s permission. Share some aspects of the “teacher” role with senior team members, both to demonstrate teamwork and to advance their skills. Avoid jargon, and engage the patient beyond the history and physical, perhaps by asking what she thinks about her doctors’ thoughts or what additional ideas she might have.
Monitor the patient’s physical and emotional state, and cut short the session if the patient tires. If someone asks an uncomfortable or inappropriate question for that patient, take the opportunity to assure the patient that she is not required to discuss such an issue in front of the group, and remind her about your commitment to confidentiality. In front of the patient, as you conclude the visit, arrange for a team member to return later to clarify any questions or misunderstandings. Finally, solicit feedback on your teaching and role modeling so as to improve your own skills and jointly examine in more depth the impact of selected aspects of the encounter.
Summary of steps to enhance bedside teaching:
No two sessions are alike. You teach beginners or more advanced learners, and mixed groups. Moods change, crises happen, new information becomes available. Teachers who value their work can continually improve.
The material in this DocCom module is necessarily a summary, and brief. Many easily accessed resources can assist the faculty member who wishes to steadily improve. We recommend the following:
In two excellent articles, Azer, Pinsky and their colleagues summarize the qualities of effective teachers and how they use certain strategies to maximize learning. (21, 22)
Kelley Skeff and his colleagues incorporate many of the concepts we discuss in the Stanford Faculty Development Program (http://sfdc.stanford.edu/). They suggest that teachers enrich their capabilities in key instructional categories. Studies show that Dr. Skeff’s program improves faculty teaching skills and educational outcomes. (23)
The instructional categories are as follows:
The stresses of clinical teaching may evoke inadvertent hurtful interactions with learners and other staff - even to the point of abusing them. Develop awareness of your “hot buttons” and choose to attempt to respond with empathy. Discussions with trusted colleagues and/or counseling may be very helpful.
Celebrate teaching skills that you carry out well, and give yourself credit. You will grow as an educator if you invite, accept and respond to constructive feedback, learn from your mistakes, and reflect on what goes well and what you might change. Do not let “excellent” be the enemy of the good. Modules 2 and 4 address mindfulness, self-reflection and self care, and certain review articles are also helpful. (5, 6)
Clinical education that involves sick and often dying patients, families and other team members is by its nature stressful for learners and teachers. Sometimes you may realize that you left your learners hurt or bewildered, or receive feedback to that effect. Medical students who wish to “know everything” and “care for everyone” are easily hurt. Furthermore, outright abuse of students occurs, (25, 26) and sometimes we are the inadvertent abusers. Under pressure, for example on a busy ward service, we may be short with some learners, pimp others in a harsh and judgmental way, or deride learners’ “wrong” answers. This may have happened to you as a learner, and maybe you learned a lot from being humiliated, or felt it made you “stronger” in some way. You may think some “unmotivated” or “irresponsible” learners deserve such treatment. However, if you find yourself being hard on your learners, pause and take a closer look. Are unrelated problems diminishing your effectiveness with the learner? Sometimes it is in the relationship with you and the learner. Does the learner remind you of someone with whom you have had problems? Which of your “hot buttons” does the learner’s conduct (or lack of it) push, provoking your defensiveness or counterattack?At the very least, take the time to engage a shamed, humiliated, reactive, haughty or “bored” learner in a conversation that might not only clear the air but also enrich the educational experience for both of you. Take a close and frank look at your situation, and check your emotional temperature. Are you stressed, burning out, depressed or angry? Are you short with nurses or other staff members? Are your intimate relationships in trouble? If so, make time to speak with someone you trust and consider seeking counseling from a mental health professional. Few people engaged in clinical teaching escape the need to examine and “rewrite” an emotional story or script at some time or other so that we improve our well-being, balance and teaching interactions.
Clinical teaching presents unique challenges to the educator. Often, both patient and learner require accurate diagnosis and intervention appropriate to the unique needs of each. The goals of clinical teaching focus on exposing the clinical reasoning process in order to assess the learner and improve their skills and knowledge, while insuring quality patient care. Effective teachers continuously improve their knowledge of the principles of education, curriculum development, and teaching techniques, reflect on their attitudes, practice relevant teaching skills, seek, welcome and act on constructive feedback, and cultivate self-awareness about your teaching practices. Clinical teaching at the patient’s bedside is an opportunity for effective role modeling, direct observation of learners in action and demonstration of clinical skills. Bedside teaching in small groups requires planning, facilitation skills, and use of discrete types of questions. Done well, clinical teaching fosters self-reflection and provides necessary feedback to promote self-directed learning which learners may employ for a lifetime of learning.
Define and agree upon final and intermediate goals and objectives
Assess and address learners' knowledge and motivation
Teach knowledge and skills sequentially from simple to complex
If you are teaching skills, define them and present them as discrete behaviors
Repeat and reinforce key knowledge and skills
Provide effective feedback
Ensure early success
Monitor and attend to learners' emotions. Offer encouragement and emotional support
Provide multiple opportunities for interaction, questions, and reflection
Facilitate small group teaching by appropriate use of open-ended, follow-up and directed questions
Monitor and adjust the pace of your teaching so that all key topics are covered
Provide formative and summative evaluations
Identify the developmental level of each learner and adjust to appropriate teaching methods
Remain mindful of the impact your behavior and attitudes have on learners
|APPENDIX: GUIDELINES FOR RESIDENTS|
As part of their doctoring curriculum, we ask interns and residents in the Drexel College of Medicine Internal Medicine program to identify principles that residents can use to enhance the learning environment for interns and medical students. This document shows the principles and strategies that residents have suggested. Residents and staff continously make revisions that have increased the utility of this guide.
Creating an Optimal Learning Environment for your Team
Dennis Novack, MD, Ronald Saizow, MD, Allison Ferris, MD, Burton Landau, PhD
|Dennis Novack M.D., Bill Clark M.D., Ron Saizow M.D.|
|Christof Daetwyler M.D.|
Physicians on Camera:
|Allison Ferris M.D., Joseph Boselli M.D., Eric Vogel M.D.|
Residents on Camera:
|Tobias Zuchelli M.D., Eva Alsheile M.D.,|
Students on Camera:
|Andre Garabedian, Marcy Burns, Hina Lone, Benjamin Raile, Raza Shah, Usman Lone|
Video Director and Producer:
|Christof Daetwyler M.D.|
Video Camera, Light and Sound:
|George Zeiset B.A.|
Video Assoc. Director:
|Dennis Novack M.D.|
|3.0 - 1/13/15 Add Appendix, Revise 5 Microskills video, and Guidelines
2.0 - 2/24/2012 Enhanced with HTML5 code and MP4 videos
1.0 - 11/2/2011
42: Effective Clinical Teaching - by Dennis Novack MD, Ronald Saizow MD, Allison Ferris MD, Burton Landau PhD