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Imagine the crisp starched fabric and the bright reflection of the afternoon sun as you run your index finger over the embroidered writing, “M.D.” This is the moment you have been waiting for: Donning your long white coat, punctuated by those two beautifully embroidered letters. You are now a doctor.
Your long medical school training -- including hours of observing interns, residents, and attendings -- has finally paid off. You can now diagnose and treat patients, prescribe medications, run family meetings, and perform procedures and surgeries. But, do you know how to teach your new students?
Despite the hours spent gaining medical knowledge and skills training, chances are that little time was spent preparing you to teach. Yet, on day one you will be expected to do just that. So, how do you prepare for this role? In this blog post, we review high-yield skills and behaviors of effective clinical teachers.
Think about your time in medical school: Which teachers were you drawn to? Who kept your attention the longest? Where did you learn the most and how did you retain that information? Chances are your best teachers were the ones who facilitated your learning, rather than simply lectured, and kept you engaged through activities or small group discussion. As you embark on your new role as teacher, keep in mind the following key concepts about teaching adults:
The Five-Step "Microskills" Model of Clinical Teaching is a helpful guide to facilitate development of practical clinical teaching. The five microskills (get a commitment, probe for supporting evidence, teach general rules, reinforce what was done right, and correct mistakes) are explained below:
Example: “John, what do you think is going on in this patient?”
“How do you put this patient’s history and exam together?”
Example: Imagine you are a resident supervising two interns and two medical students in the hospital. Your team is admitting a young woman with chest pain and shortness of breath. You want to teach about the workup and management of pulmonary embolisms. How do you think about teaching this topic?
Topic: Approach to and Treatment of Pulmonary Embolism (PE)
Goals: The goal of this session is to learn about PE and explore the workup and management of an inpatient with symptoms suggestive of PE.
Learning Objectives: After this session, participant will be able to:
Mins Allotted |
Activity |
2 |
Case Review — 30-yo-woman G1P1 admitted with chest pain and SOB |
5 |
Get Commitment Probe for supporting evidence Group discussion regarding thought process and approach to workup and management |
10 |
Teach General Rules
|
3 |
Summarize and Debrief (Correct mistakes and reinforce what was done right)
|
“What are five risk factors for developing a pulmonary embolism?”
“Why do you think this young woman has a pulmonary embolism?”
“What is the treatment of choice for a pulmonary embolism?”
“How does your thought process change if this is a 60-year-old man with a smoking history?”
While helpful in identifying specific knowledge points, “what” questions generally result in brief answers that are either right or wrong. Learners are hesitant to answer “what” questions because they fear being wrong in front of you or their peers. “How” and “why” questions allow a learner to reason through a problem and you to better understand their thought process. In addition, “how” and “why” questions provide you with the opportunity to guide the learner to the correct answer by redirecting them through further inquiry. In doing so, you allow the learner to identify their own knowledge gaps (a concept called cognitive dissonance).
Furthermore, “how” and “why” questions help the learner to progress up Bloom’s Taxonomy of Learning Domains, moving from simply remembering facts, a low level proficiency, to applying and analyzing the data, a much higher skill level that enhances understanding and retention.
Ask the right questions to guide a learner up proficiency levels.
This microskill is the cornerstone of your teaching encounter. Everything you have done thus far leads to this moment:
You laid the groundwork by creating a safe learning environment.
You obtained a commitment from your learner.
By rooting the teaching in clinical care, you engaged the learner through relevance to daily practice.
By probing for evidence, you expanded the thinking of the learner, generated cognitive dissonance, and assessed the learner’s level of understanding.
As a result, you undoubtedly uncovered gaps in medical knowledge or thought process.
Now you can use this gap to advance the learner’s understanding.
Example: “For patients who have a confirmed diagnosis of pulmonary embolism, the length of anticoagulation is dependent on whether the embolism was provoked.”
“Patients with pulmonary embolism usually describe sharp chest pain which is worse with inspiration. The physical exam is often notable for tachycardia and rapid shallow breathing.”
Example: “I am glad you considered alternative causes of this patient’s chest pain, it is important that we do not anchor too early on a diagnosis for risk of missing an alternate etiology.”
Example: “I observed that you rolled your eyes and crossed your arms when we discussed myocardial infarction as a possible cause of this patient’s chest pain.” In contrast to:
“You were not happy when we discussed…”
Two common clinical teaching scenarios are bedside teaching and teaching medical procedures teaching. Both rely on similar elements as clinical teaching.
Bedside Teaching: You may be concerned or anxious about bedside teaching and how you will be able to impart knowledge. Consider some of the following myths and facts about bedside teaching as you start incorporating teaching in your role as a resident.
Myth |
Fact* |
Takes too long |
Bedside rounding does not take any longer than walk rounding |
Patients feel uncomfortable |
Patients prefer bedside rounding. Patients report:
|
Not educationally valuable |
Allows observer to assess (diagnose) the learner Provides opportunity for skill development Allows directly observed feedback Allows role-modeling behaviors |
Although you may not realize it, you teach through all your words and actions. Lead by example; learners are constantly watching your behavior and learning from you. In fact, they are likely to learn more by observing you than from your prepared content (educators call this the “hidden curriculum”).
Instill the behaviors you want learners to emulate by modeling those behaviors effectively. Always be thoughtful of your words and actions in front of learners. Avoid derogatory comments about patients or other services. Maintain a positive attitude, even in the face of challenges. Maintain calm and confidence in the midst of busy call days and sick patients. Describe your own actions to highlight subtle behaviors you hope to teach.
Example: “Why do you think I pulled up a chair and sat at the bedside with the patient when discussing the need for anticoagulation…?”
Ask for feedback from your learners and always debrief with your team. Doing so instills a culture of self-reflection and ongoing improvement. Ask for input on your teaching and finish the day by working on team dynamics.
Example: “What is going well?” “What can we do better?“
“Are your learning goals being met?” “How can I better meet your learning goals?”
Teaching is one of the great joys of medicine and a highlight during hectic days of patient care. Have fun teaching; there is no substitute for enthusiasm. Be innovative, try novel techniques, and think outside the box. Solicit feedback from your learners and continue to refine those techniques. Find what works for you. You will be most successful when you are comfortable and excited to teach; don’t force things and doesn’t worry about being like someone else.
Finally, go to “the balcony” by observing others teach and ask yourself what works and what doesn’t. What engages me or bores me and why? Identify specific skills, behaviors, and techniques and incorporate them into your own practice.
Dr. Christopher Smith is a general internist in the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center and an Associate Professor of Medicine at Harvard Medical School. Dr. Smith completed the Rabkin Fellowship in Medical Education at the Shapiro Institute for Education and Research and Harvard Medical School. He is the Director of the Internal Medicine Residency Program at BIDMC, and the Director of the Clinician Educator Track for residents.
Dr. Daniel Ricotta is an academic hospitalist at Beth Israel Deaconess Medical Center and Instructor in Medicine at Harvard Medical School. Dr. Ricotta is currently a Rabkin Fellow in Medical Education at the Shapiro Institute for Education and Research and Harvard Medical School.