Teaching tips for clinician-teachers - Duke University

PERSPECTIVES

Teaching Tips for Clinician-Teachers

CATHERINE THOMASSON,MD, WENDYLEVINSON, MD, KEITH ACHESON, PhD, WILEYCHAN, MD, MARY LINDOUIST,DIANE PALAC, MD, GARYYOUNG, MD

TEACHING is p a r t o f t h e r o l e o f m a n y p r a c t i c i n g physicians. It begins in the first year of residency with supervision of medical students and continues with increasing responsibility to the level of full-time participation as faculty members in teaching programs. Few physicians have received any formal training in the strategies of tcaching. "See one, do one, teach one" is the maxim that has guided the plunge into teaching assignments. This lack of expertise may lead to frustration for both learners and teachers.

This article is a culmination of the efforts of the authors to improve our own clinical teaching skills. We met as "peer consultants" for one to two hours monthly to view and discuss videotapes of teaching encounters from our own work. The excerpts we viewed were brief but were typical of the situations clinician-teachers encounter. In a climate of support and candor, the group members watched the tapes together and discussed their observations. Direct feedback was encouraged and members often reenacted the exchange to try new strategies. After just a few meetings, feedback within the group became more direct and useful regarding specific teaching techniques.

The purpose of this article is to inform clinicianteachers about practical and effective strategies for teaching residents, which we discovered in our own faculty development sessions through practice and reading.I- ~ Vignettes of typical teaching situations are presented with a discussion of relevant precepts of adult learning theory,0 - I0 which may be applied to the unique experience of teaching in the medical setting. Our goal is to raise awareness about the process of the educational encounter in order to improve the quality of teaching and ultimately the learner's outcomes. In addition, since p r a c t i c i n g n e w skills is essential, ~, ~2 t h e a r t i c l e i n c l u d e s suggestions of ways clinician-teachers can gain experience with new teaching skills. The first three vignettes

Received from Providence Medical Center (CT), the Good Samaritan Hospital & Medical Center (WL), and the Oregon Health Sciences University (WL, ML), Portland, the University of Oregon (KA), Eugene, and Kaiser Pcrmanente (WC) and the Veterans Administration & Medical Center (DP), Portland, Oregon; and Highland Hospital (GY), Oakland, California.

Address correspondence and reprint requests to Dr. Thomasson: Department of Medical Education. Providence Medical Center, 4805 NE Glisan, Portland, OR 97213.

describe teacher-centered concerns and the last two relate to learner-centered problems. Table 1 summarizes important teaching strategies demonstrated by each of the vignettes.

TOO MUCH TO TEACH

Resident:

This is a 68-year-oM woman who is here today for a routine physical I've followed her for tu,o years and she has multiple problems: stable angiru? hypertension, mild renal insufficient., and a recent elevation in her alkaline phosphatase. Her only concern today is that her sister has recently had breast cancer diagnosed and she ispret~ upset about that.

In many teaching situations both the student and the teacher have their own ideas about what they want to discuss in the limited time available. To set the agenda for the teaching encounter, it is often useful to both address the patient's concerns and identify the learner's goals. It is important to limit the number of topics in each cncountcr.

The clinician-teacher's opening question in this set-

TABLE 1

Suggested Strategies for Clinical Teaching in One-on-one Settings

Set the agenda Place the patient's welfare and concerns foremost Let the learners identify their agendas Limit the number of topics Help structure the process

Increase feedback Provide a safe, private environment Focus on direct observation Be descriptive, specific, and nonjudgmental Elicit the learner's areas of concern Provide both positive and negative feedback Base negative feedback on modifiable behaviors

Model Go to the bedside together Demonstrate effective data gathering Be explicit about steps in problem solving

Deal with emotions Express one's feelings constructively Ask the learner to verbalize his or her feelings when appropriate Support and validate the learner's emotions

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ting might be, "Do you feel comfortable dealing with Mrs. X's fear and concern about breast cancer?" After the patient's immediate concerns are addressed, the clinician-teacher can find out what help the resident needs in caring for the patient. Research in adult education indicates that adults learn most when they identify for themselves the problems they need to solve, set priorities, and seck the appropriate educational resources.7. ~, i~ Using this p r i n c i p l e , the c l i n i c i a n - t e a c h e r might ask, "What are the specific questions you have regarding this patient's care today?" The few moments of reflection about resident priorities allow the teaching conversation to focus on what the resident needs most.

If all the questions cannot be answered in the time available, the clinician-teacher might say, "Since the patient is waiting, let's make sure we talk about her renal insufficiency and agree to look up the information about the drugs later." After the patient visit, the teacher might help the learner seek the answers to his or her own questions using computer searches, library materials, and other resources, hence developing lifelong skills needed to k e e p u p w i t h m e d i c a l advances. ~s' 16

In addition to the resident's questions about the patient, the clinician-teacher may have specific teaching points he or she wants to discuss. The clinician-teacher might say, "Since this is Mrs. X's yearly exam, I want to remind you about preventive care. If you feel she needs to come back soon you may want to postpone any screening." This may be the extent of the teacher's agenda that can be covered in this teaching encounter to avoid learner overload.

In our experience, often clinician-teachers have too much to teach and are eager to share all their "pearls of wisdom" with residents. It is most effective to focus on the few main points, selected initially by the student. t? Research in "learner-centered" teaching environments has demonstrated the value of allowing students to structure thcir own learning activities. Benefits include greater enthusiasm for the topic and increased ability to solve f u t u r e p r o b l e m s , t7' TM In this way, "less teaching" can lead to "more learning."

FEEDBACK

After observing a resident-patient interaction, the teacher states:

Well, that was a good interview, but you should have included the wife in the interview. She had important information to offer since his problem was syncope.

This feedback may be difficult for the intern to hear. The intern may feel defensive and, as a consequence, may be less able to incorporate any of the clinicianteacher's suggestions. Yet, feedback is a necessary comp o n e n t o f learning. ~'~'2o T h e r e are s o m e i m p o r t a n t concepts that can make feedback more effective and more acceptable to the learner.

It is important to remembcr that receiving feedback is anxiety-provoking. Taking a moment to assure residents that you understand they are nervous can help. Next, be explicit about your expectations. Given their anxiety, residents need guidance about the extent of the interview and physical examination you wish them to perform. Stating the objectives in advance also makes the e x e r c i s e m o r e focused. 8 2~ For e x a m p l e : "My o b j e c tive is to provide feedback on your interviewing skills. This is not a test. I'm sure there will be many positive aspects of your interview and possibly a few pointers 1 can offer."

With the agenda set, it is optimal to choose an appropriate time and place where feedback can occur privately without interruption. It is best to start with positive feedback and allow the resident to identify his or her own strengths. The clinician-teacher might say, "What seemed to go well in your interview?" This might be followed by the clinician-teacher's observations, such as, "You started with very open-ended questions and allowed the patient to tell his own story by nodding and making encouraging comments." The importance of positive feedback cannot be understated. Trainees are often very self-critical and anxious about performance, and often focus on their deficiencies. Commenting on their strengths reinforces practiced skills and increases comfort levels for r e c e p t i v i t y to feedback, t9

After pointing out the strengths, the clinician-teacher can solicit the learner's ideas about problems with the interview by asking, "What would you like to change about the interview?" Most individuals are able to identify problems themselves. A resident might say, "I had a hard time staying focused on his chief complaint because he was so vague." The learner and teacher could discuss alternative approaches and even role-play to practice new interviewing techniques.

If the resident doesn't identify an important problem, such as the need to include the patient's wife, the clinician-teacher may point this out by stating, "Sometimes the partner provides useful clinical history in cases of syncope. I noticed that you addressed most of your questions to the patient rather than his wife." In contrast to the statement above, this presents a nonjudgmental observation and suggests an alternative interview strategy. Nonjudgmental statements are more conducive to a discussion than is an experience in which the student feels embarrassed or humiliated by a perceived defic i e n c y in his o r h e r p e r f o r m a n c e . ~9In addition, f e e d b a c k should deal with behaviors that can be modified.

To review, effective feedback requires a setting that is safe and uninterrupted. Allowing the student to identify strengths and difficulties encourages more focused feedback and better learning. Feedback is better received if it is nonjudgmental and based on direct observation. The use of specific examples and the avoidance of generalization are also more likely to effect change.

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WHEN THE TEACHER DOESN'T KNOW

Resident: Attending:

My patient read about a baseball player whose blood testfor Lyme disease was positive and he was cured with an tibiotics. The patient savs he has the same s~mptoms and wants me to do a blood test for Lyme disease. Didn't you have a lecture about Lyme disease from the infectious disease department just last week?

All physicians are confronted at times with patient care questions for which they have no immediate answer. Clinician-teachers may feel embarrassed or inadequate when they cannot provide the correct response to students. When teachers can admit their lack of knowledge directly, it allows the teacher and student to become colearners. The clinician-teacher may provide the framework by asking questions such as "What do we need to know to help the patient?" and "How quickly do we need to answer this patient's question?" Then the teacher and learner can come to an agreement concerning what information is missing and how to find it.

When the clinician-teacher doesn't know the answer, he or she has an opportunity to model ways of gathering pertinent data. In the urgent bedside situation, a proper response might be to page a consultant. With less time restriction, a literature search and critical review of key references may be more appropriate.~S In this way, the resident and clinician-teacher can work together to organize new information and share the thought processes behind the clinical decision-making process.

Intellectual honesty in academic medicine demands that good clinician-teachers know their own limits and are comfortable with revealing those limits to learners. This perspective is in keeping with adult learning theory, which views the teacher as a facilitator of learning rather than an encyclopedic source of knowledge. 8

THE UNRECOGNIZED CRITICALLY ILL PATIENT

Resident: I have a patient to present. He is a middleaged man here for his routine clinic visit. Currently, he is having chestpain and is short of breath. His medical problems include diabetes, hypertension, a n d . . , let m e see, oh yes, here's his problem list, degenerative j o i n t disease and peptic ulcers. His current medications are diltiazem .....

Clinician: Excuse me, but did you say he is having chest pain and shortness of breath right now?

Resident: Yes, but I think his chest p a i n is f r o m reflux a n d I"m h a v i n g the nurse give h i m a GI cocktail while l present the case.

Clinician: I'm concerned that this pain might be cardiac Can we move to the bedside together while we talk?

Tension is inevitable when the resident presents an

acutely ill patient and the clinician-teacher suspects that the critical nature of the patient's problem was overlooked. The clinician-teacher simultaneously wants to demonstrate respect for the resident, provide teaching, and evaluate a potentially seriously ill patient. In this situation, the clinician-teacher is appropriate in interrupting the resident's presentation. A question such as "What is the worst diagnosis this could represent?" may allow an assessment of the learner's diagnostic reasoning. If myocardial ischemia is not included or if the explanation of why it is unlikely is not given, the clinician-teacher should evaluate the patient along with the resident at the bedside.

Once at the bedside, the clinician-teacher may still assume an observer's role by stating, "I think we should assume this is myocardial ischemia. Please go ahead and take care of the patient as appropriate." The clinicianteacher will then have the opportunity to observe the resident providing direct patient care and will be able to provide feedback after the patient is stable.

Less experienced learners, who defer to the teacher, can be handled in different ways. The clinician-teacher can outline the logical steps that should be taken and then observe the resident in action. Alternatively, the clinician-teacher can take over and demonstrate the management of unstable patients for whom any delays in care could be detrimental. In this way, the cliniciant e a c h e r can m o d e l a p p r o p r i a t e m a n a g e m e n t . 22' 23

Furthermore, it is very important to spend time after the patient is stabilized to review the teaching points. The resident could be asked to explain the strategy used by the clinician-teacher. Verbal reflection requires learners to i n t e g r a t e n e w i n f o r m a t i o n in t h e i r o w n w o r d s . 2~ Reflection about the process of patient care is a useful technique for consolidating learning and is characteristic of g o o d p r a c t i t i o n e r s in m e d i c i n e and o t h e r fields, s, 23

In review, it is not necessarily disrespectful to interrupt housestaff to attend to a critically ill patient. Second, modeling complex management can be helpful, particularly in u r g e n t situations. 2~"22 Last, a l l o w i n g residents to reflect on the process of care allows them to incorporate new information.

THE RAMBLING RESIDENT

Resident:

Well, I have this ... urn, 68-year-old m a n who is really a poor historian who had a heart attack about a year ago. His wife brought him in today because she said his leg was numb yesterday and his face was droopy. He denies that. He is more concerned about his problem with belching all the time. Oh yeah, his blood pressure is 210/110--he takes verapamil for that....

It is sometimes difficult for a clinician-teacher to know where to start when the resident gives a disjointed presentation. The resident's disorganization may lead to

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both inefficient patient care and a time-consuming teaching encounter. Teaching techniques with a rambling presenter could include respectfully interrupting the presentation, summarizing the information already given, and attending to the emotional concerns in the interaction.

Interruption of the case presentation may be needed to help the resident focus on the main clinical problems. The clinician-teacher could stop the presentation with a statement such as "I need to interrupt for a moment because I'm unsure as to what your major clinical concerns are in this case. Could you pause and summarize your clinical impressions of the case, and your questions?" Some teachers may feel that interruptions are impolite, but if done respectfully they may enhance the learning experience.

Another useful technique to refocus the "rambling resident" is to paraphrase the case: "So you have a patient with coronary artery disease, hypertension in poor control, and maybe a transient ischemic attack or stroke. Does that fit with your assessment?" This summary demonstrates what the clinician-teacher thinks is important, and allows the resident to continue with his or her own thought process. The inability to prioritize may be a major factor contributing to the resident's disorganization. Summarizing allows the clinician-teacher to model case synthesis and priority setting.

Sometimes a resident's disorganization may be related to his or her personal emotional experience. It may be helpful to check on the resident's feelings. An open-ended question such as "How are you feeling as you present this case and work with this patient?" may allow the resident to ventilate his or her feelings about the interview, the patient, or the fact that he or she has been up all night. This may uncover an emotional issue that is creating a barrier to the patient care or teaching encounter.

In addition to the residcnt's emotional state, the clinician-teacher may experience irritation or frustration with the rambling presentation, and this response can interfere with the teaching encounter. Sometimes clinician-teachers demonstrate their feelings nonverbally, looking bored or doing other paperwork during the case presentation. These nonverbal cues may be interpreted by the resident as nonspecific negative feedback, which intensifies the resident's uncertainty. The clinician-teacher may wish to label his or her frustration by saying, "I feel uncomfortable because I don't know what the patient's main problem is or how to be most helpful to you." This may help to focus the ease presentation and to delineate the questions relevant to the learner.

In review, interruptions arc sometimes necessary and helpful if done in a nonthreatening manner. Clinician-teachers can model clear case presentations by paraphrasing. Acknowledging the emotional factors of both the resident and the clinician-teacher may avoid problems in communication.

STRATEGIES TO IMPROVE TEACHING SKILLS

Delivering patient care might be easier if it could be learned directly from written materials, but then it would not be called the "practice of medicine." The same can be said of teaching. Medical educators must practice the "art of teaching." Literature, workshops, and more extensive courses are available to help teachers become more skilled.*

Within individual residency programs, there is often enough interest to organize a small group of clinicianteachers to discuss and critique teaching skills. Our group was formed during a citywide faculty development seminar. Some members of the group felt the need to include an expert in education. Our discussions were facilitated by a faculty member with advanced knowledge of teaching and interview skills and by a professional educator. During the yearlong process, feedback within the group became more direct and useful regarding specific teaching techniques, and the perceived need for educational experts disappeared. Local faculty development programs such as this may help individual clinician-teachers enhance their teaching skills and improve the overall quality of education in the institution.

CONCLUSION

Teaching medicine is an exciting and stimulating process. Using more effective teaching methods will enhance the experience for all concerned. Research and experience in adult learning show that instruction of well-motivated learners should place more emphasis on empowering them to identify their own needs and enabling them to seek answers more independently.

Good teaching methods will improve the process of acquiring, retaining, and appropriately utilizing the complex skills and knowledge needed for practice of medicine.

REFERENCES

1. Acheson KA, Gall MD. Techniques in the clinical supervision of teachers. In: Clinical Supervision and Effective Teaching, 3rd ed. New York: Longman, 1992.

2. Hewson MG. Clinical teaching in the ambulatory setting. J Gen Intern Med. 1992;7:76-82.

3. Skeff KM. Enhancing teaching effectiveness and vitality in the ambulatory setting. J Gen Intern Med. 1988;3(M/A suppl): $26-$33.

4. Kroenke K~Attending rounds: guidelines for teaching on the wards. J Gen Intern Med. 1992;7:68-75.

5. Irby DM. How attending physicians make instructional decisions when conducting teaching rounds. Acad Mcd. 1992;67:630-8.

6. Mezirow J. Making meaning: the dynamics of learning. In: Trans-

*Two such courses are: 1) SGIM National Course: "Task Force on Doctor and Patient." Contact: Penny Williamson, ScD, 4611 Keswich Road, Baltimore, MD 2121O;phone 1410 ) 889-1550; and 2 ) The Stanford Faculty Development Program. Contact: Georgette Stratos, PhD, Stanford Faculty Development Program, 1000 Welch Road, Suite 1, Palo Alto, CA 94304-0146; phone (415) 725-8802.

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formative Dimensions of Adult Learning. San Francisco: JosseyBass, 1991. 7. Knowles MS. The m o d e r n practice of adult education: from pedagogy to andragogy. New York: Cambridge, The Adult Education Company, 1975. 8. Brookfield SD: The facilitator's role in adult learning. In: Brookfieid SD. Understanding and Facilitating Adult Learning. San Francisco: Jossey Bass, 1986. 9. Brookfietd SD. Self-directed learning: a critical review of research. In: Brookfield SD (ed). Self-directed Learning: From Theory to Practice. New Direction for Continuing Education, 25th ed. San Francisco: Jossey-Bass, 1985;5-16. 10. Knowles MS. Self-directed Learning: A Guide for Learners and Teachers. New York: Cambridge, The Adult Education Company, 1975. 11. Brown JS, Collins A, Dugiud P. Situated cognition and the culture of learning. Educ Res. 1989;Jan/Feb:32-42. 12. Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective on medical expertise: theory and implications. Acad Med. 1990;65: 611-21.

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