In a multitude of counselors there is wisdom. We may remember but little of what they said, but we treasure the memory of what they were, for students see their teachers with a penetrating gaze. With the na|$$|Ad|five assurance of youth we knew them, and their brightness is not tarnished by our present certainty that they were not always right in what they taught us or in their methods of teaching - —Robert Marshall, 19551
The question, “What makes a good clinical teacher in medicine?” has been the subject of a considerable body of literature, ranging from essays to empirical studies, and still continues to generate passionate discussion.2,3 Medical education scholars have lamented the numerous threats faced by modern American education and the challenges of turning novices into “informed, curious, compassionate, and moral physician(s).”4
For example, Cooke and her colleagues4 identify as major threats (1) the emphasis of research over teaching, (2) the evolution of research and clinical care into distinct silos creating a dearth of gifted clinician–researchers to teach the students, and (3) economic pressures on faculty to spend more time involved in their clinical duties at the expense of teaching. The transformation of our students requires the engagement of innovative and outstanding clinician–teachers who not only supervise students in their development of technical skills and applied knowledge but also serve as role models of the values and attributes of the profession and of the life of a professional. In 1925, Abraham Flexner5 appealed for excellent clinical teachers, educators who were of “enlightened spirit, seeking stimulus and suggestion.”
Medical schools have tended to let students decide who is a good or excellent teacher through surveys and student-voted teaching awards. All of us believe that there is such a thing as good and poor clinical teaching, even as we believe there are faculty who are good teachers and faculty who are not good teachers.6 But what makes a good clinical teacher in medicine? Only two reviews addressing this question have been done, and both of them have focused entirely on teaching in ambulatory settings.7,8
The answer to this question is important to the field of medical education and to every institution of medical education responsible for creating knowledgeable and compassionate doctors. Therefore, we decided to perform a systematic review of the literature grounded in various forms of inquiry, including the thoughtful essays written early in the 20th century, pertinent to the question, “What makes a good clinical teacher in medicine?”
To build a conceptual framework and formulate our initial question,9 we (G.S. and R.S.) began by discussing our most influential clinical teachers in medicine and their most effective teaching characteristics. We identified five common themes in our descriptions; we referred to the first four as noncognitive and to the last one as cognitive. We defined “noncognitive” characteristics as those involving relationship skills, emotional states, and personality types, and “cognitive” characteristics as those involving perception, memory, judgment, reasoning, and procedural skills. We met to combine and further review our answers:
1. Relationships: A good teacher recognizes that the student–teacher relationship is an educational tool. Teaching becomes a bidirectional exchange. Students appreciate individual attention, and teachers have a role similar to that of a parent. Trust and individual consideration are paramount.
2. Emotional activation: A good teacher has the ability to excite, arouse, and activate his or her students. Although we have all experienced this enthusiasm and responded to it, for now we do not know how it is actually done.
3. Generativity: A good teacher understands that teaching is a giving process which changes as the student grows. The student is allowed a stepwise assumption of responsibility and is given permission to make independent decisions or to perform technical steps of a procedure only when he or she is almost ready. The teacher may be challenging. Expectations may be high.
4. Self-awareness: A good teacher reflects on his or her teaching and is sensitive to feedback. This quality may allow good teachers to adjust quickly to the characteristics of individual students and student groups.
5. Competence: A good teacher is a master of what he or she is trying to teach, and, probably, the student identifies selectively with ways in which the teacher models the doctor–patient relationship.
With this framework in mind, two of us (G.S. and R.S.) independently performed a PubMed search from 1966 to the present, using the terms teaching, medical education, and medical faculty. We found additional relevant articles using the Related Articles function in PubMed and by reviewing referenced articles. We obtained articles published before 1966 by scanning titles listed in Index Medicus under the subheading Medical Education, selecting those titles that seemed relevant to our search, pulling these articles, and reading them in their entirety to determine whether they merited inclusion.
At each stage of the selection process, we (G.S. and R.S.) selected only those articles relevant to the question, “What specific characteristics make a good clinical teacher in medicine?” We defined clinical teaching in medicine using Stritter and Baker’s10 1982 definition: “the teaching/learning interaction between instructor (attending physician) and student (resident) that normally occurs in the proximity of a patient and focuses on either the patient or a clinical phenomenon that concerns a patient or a class of patients. ” Articles were selected only if they included specific characteristics.
Our initial PubMed search and Index Medicus review generated 4,914 relevant titles, 4,060 published before 1966 and 854 published during or after 1966 (Figure 1). With Stritter and Baker’s10 definition of clinical teaching in medicine in mind, we reviewed these titles, culling 153 published before 1966 and 161 published during or after 1966 that included specific teaching characteristics relevant to our initial question, “What specific characteristics make a good clinical teacher in medicine?” We then performed a PubMed Related Articles search and a review of referenced articles on these 161 titles, yielding an additional (approximately) 1,800 unique 1966 or later titles, which we then reviewed and reduced to 131 (eliminating publications that did not specifically describe teacher characteristics), for a total of 292 post-1966 titles. We printed abstracts for each post-1966 title (abstracts were not available for pre-1966 titles). We then reviewed these 292 abstracts and further winnowed them to 154, on the basis of their pertinence to our specific question. We photocopied full articles for the 153 pre-1966 articles and the 154 post-1966 articles, reviewed these articles, and made our final selections, resulting in a total of 68 articles, 26 published before 1966 and 42 published after 1966. We chose abstracts and articles only if they listed specific characteristics of good medical teachers. These characteristics were usually based on either the results of a survey of students/residents or the values or practical wisdom of the author(s). We (G.S. and R.S.) settled disagreements about inclusion by discussion and coming to a consensus. See Figure 2 for a detailed description of the numbers that “overlapped, ” or were chosen simultaneously by each author at each stage of the article-selection process.
We (G.S., E.W., I.H., and R.S.) then independently reviewed these 68 articles with the purpose of identifying themes or patterns in descriptions of characteristics of a good medical teacher, using the method of constant comparative analysis.9 Through discussion, we reached a consensus on clustering all themes into larger categories of characteristics: physician characteristics, teacher characteristics, and human characteristics. We subsequently labeled all themes as cognitive or noncognitive, using the definitions created in our initial framing.
We combined themes whenever possible to create a more concise list, but no themes were outright excluded. For example, we clustered spends time explaining, allows sufficient time for discussion, extensive involvement with students, and accessible into one theme titled Accessible/available to students. Our final list of themes (Appendix 1) contained only positive descriptions because our purpose was to identify criteria for good clinical teaching in medicine. When an article provided a negative description with respect to a criterion, we included it in our analysis and results, but without specifying that it provided a negative opinion about teachers with respect to that criterion. For example, judgmental was translated to nonjudgmental and included within Considers others’ perspectives, viewpoints.
Characteristics of the studies analyzed
The 68 articles identified in our literature search included 26 published before 1966 and 42 published after 1966 (Table 1). Many of these11 reported results of surveys of students, residents, or colleagues, or they12 were essays about the characteristics of the ideal clinical teacher. With one exception,11 the pre-1973 articles were all essays, many of which were transcriptions of addresses given to medical societies.
The post-1973 articles incorporated a wide array of methodologies, including surveys, interviews, and observations of faculty teaching. In those articles, survey results for structured questions were analyzed using descriptive statistics, and the results for open-ended questions were analyzed using qualitative data-analysis methods (Table 1). One article reported correlations between student and faculty opinions of good teaching.12 Three of the 68 articles reported correlations between student opinions about their clinical teachers and student performance.13–15
Sixty-five articles described positive attributes, and three16–18 described negative attributes. All but seven of the essays were written about studies performed primarily within the United States or Canada.*19–22,29,32,77 We were unable to obtain references from before 1909.
Common themes discovered in the studies analyzed
In our review of the 68 selected articles, we identified 480 descriptions of characteristics of a good clinical teacher, and from an all-inclusive list of these characteristics, we identified 49 themes which we clustered into three larger categories of clinical teaching characteristics: physician characteristics, teacher characteristics, and human characteristics (Appendix 1). Out of the 49 themes and 480 descriptions of good clinical teaching, 33 (67%) of these themes and 301 (63%) of these descriptions were classified as noncognitive. Sixteen themes (33%) and 162 descriptions (34%) were described as cognitive. Seventeen descriptions (3%) could not be classified into any specific theme. These were classified as other. We included described characteristics from all 68 studies, regardless of study design or quality.
The most commonly reported themes, with the number of citations and an illustrative quotation, are presented below.
Medical/clinical knowledge (30 citations).
“The provision of biomedical information is often considered both necessary and sufficient to make rounds educationally productive and to improve the clinical skills of the ward team.”23
Clinical and technical skills/ competence, clinical reasoning (28 citations).
“The proficient doctor must be able to do certain procedures and the good teacher knows that the teaching of such simple skills as lumbar puncture, or catheterization, is important.”19
Positive relationships with students and supportive learning environment (27 citations).
“A favorable atmosphere influences learning. This refers not only to the physical environment and the methods used but also to the teacher’s personality and the general climate of the institution.”24
Communication skills (21 citations).
“Excellent listening and speaking skills allow clinical teachers to encourage active participation, establish rapport, answer questions carefully and precisely, and question students in a nonthreatening manner.”22
We identified three separate themes that incorporated enthusiasm: enthusiasm for medicine (categorized as a physician characteristic, 19 references); enthusiasm for teaching/commitment to teaching (teacher characteristic, 18 references); enthusiastic person in general (human characteristic, 14 references): “The most valuable asset to any university is the inspired teacher, the man possessed with that indefinable something which arouses the interest and enthusiasm of the student. Such men are rare in all colleges and all medical schools. How few teachers have the power of making what they say stick in the memory! And how such teachers are prized by the student!”25
Analysis and impressions
It is not surprising that our intuitive, personal assessment of the qualities of good medical teachers produced quite similar results to the themes generated from our search of the literature. The phrasing of our central question, our selection of articles, and our coding process were all influenced by this initial reflection. What surprised us was the dominance of noncognitive characteristics in both explorations: approximately two thirds of the descriptions and themes were classified as noncognitive according to the definitions in our framing exercise. Perhaps what makes a clinical educator truly great depends less on the acquisition of cognitive skills such as medical knowledge and formulating learning objectives, and more on inherent, relationship-based, noncognitive attributes. Whereas cognitive abilities generally involve skills that may be taught and learned, albeit with difficulty, noncognitive abilities represent personal attributes, such as relationship skills, personality types, and emotional states, which are more difficult to develop and teach.
This study suggests that excellent teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students. These activities produce an emotional arousal in the student. Sometimes a relationship is forged between the student and teacher. Sometimes this inspiration arises internally from a personal identification with that teacher. We remember our greatest mentors: we either developed relationships with them or patterned ourselves after them. With ease and aplomb, our teachers performed challenging surgeries, respectfully imparted teaching nuggets to students, and spoke with their patients with compassion, and we wanted to be just like them. Many of our behaviors were similar to those of a child following a parent.
Our intuitive prestatement of the qualities of good teachers did include one important quality which was not as often mentioned in our literature review. This was the quality of self-awareness. The ability to reflect upon one’s teaching skills with the goal of improving teaching was highlighted in only some of the articles.26–32 We were surprised that there were no articles that mentioned such characteristics as aggressive, challenging, or demanding, because some of our favorite teachers exhibited these very characteristics. The literature we reviewed contained positive comments, almost exclusively. The terms aggressive, challenging, or demanding, especially the first and last, may have negative connotations for many, and authors, survey respondents, observers, etc., may have avoided them in seeking to characterize excellent teachers.
We are aware of two previous literature reviews on effective clinical teaching characteristics.7,8 Both focused on ambulatory teaching and included only more recent articles (published after 1980); neither asked our central question, “What makes a good clinical teacher in medicine?” Irby and colleagues8 concluded from their review that excellent teachers are physician role models, effective supervisors, and dynamic, supportive educators. They recommended increasing trainee contact with faculty members. Heidenreich et al7 summarized 11 separate ambulatory teaching characteristics, some similar to ours (e.g., teaching to the learner’s experience, skilled questioning, and giving appropriate feedback). Six of our reviewed articles divided the characteristics of a good clinical teacher in medicine into larger categories that were similar to ours (physician, teacher, and person/human).12,20,33–36 Our study is unique in that it includes essays from the early part of the 20th century, although the majority of the characteristics identified in these early essays were also mentioned in the later articles.
Some characteristics from the post-1970 articles were not mentioned in the earlier essays. For example, provides feedback was only mentioned once in any of the pre-1975 articles. Knowledge about teaching skills was also mentioned rarely in the early essays. The field of medical education started growing in the 1950s and 1960s, and by the early 1970s practices and scholarship grounded in the discipline of education had begun to be influential in medical education. This helps to explain both why surveys, interviews, and observations permeate the literature after then and why these characteristics were not mentioned in the earlier essays. Although we reviewed more pre-1966 titles than post-1966 titles (despite originally identifying more post-1996 titles), this was a function of a liberal review of long lists of pre-1966 titles versus a more selective examination of post-1966 abstracts.
Although we found a multitude of articles addressing our question, the overlap between the two raters (G.S. and R.S.) in the article-selection process was lower than we had expected (Figure 2). We believe this was attributable to the inherent difficulty in finding a concise answer to the question, “What makes a good medical teacher?” Our original list of characteristics was large and unwieldy, but through our coding process, including discussion and reaching consensus, the list was reduced to the present form. We were constantly aware that our backgrounds biased our intuitive classification scheme. Others with different backgrounds might classify the same descriptions into an entirely different framework. This is a natural characteristic of qualitative data analysis. Finally, we found it quite enjoyable reading these articles, especially the pre-1970 essays, because of their eloquence and because they echoed opinions quite similar to the more recent, survey-based reports.
Our findings hold broad implications for teacher selection, promotion, and faculty development programs at U.S. medical schools. What is particularly interesting is that many of the characteristics and attributes we found were noncognitive characteristics rather than the cognitive skills that generally receive so much attention in faculty development programs. This is not surprising, given that clinical teachers must ultimately serve as supportive role models and mentors to trainees in their development of knowledge, skills, attitudes, values, and professionalism. Faculty development programs, although highly variable in their mission, usually focus on traditional cognitive skills such as curriculum design, large-group teaching, and assessment of learners.37 Perhaps these skills become the focus of workshops because they can be worked on and developed in the time frame of a workshop, whereas noncognitive characteristics cannot be easily developed or adapted in a workshop or fellowship context. If a number of noncognitive behaviors are truly important for excellent clinical teaching, as our search suggests, perhaps they should receive greater emphasis in the curriculum of these workshops. Noncognitive behaviors are both measurable and alterable. Most of them, such as personality typology, emotional states, and relationship predispositions, have underlying neural networks which are entering our sphere of understanding.38 It is likely that our findings, such as the importance of supportive relationships between clinical teachers and their students, have implications that should be explored for the training, hiring, and promoting of clinical teachers in medical education as well as other professions.
The identification of 49 different themes mirrors the multifactorial nature of effective teaching, yet it may also indicate limitations in our understanding of what makes a good clinical teacher in medicine. We suspect that the identification of these characteristics is an immature field at best, and we wonder whether the accurate “diagnosis” of good clinical teaching might not be achieved by the continuation of rigorous scholarship. We were surprised by the heterogeneity of methodologies that have been used to answer our central question (See Table 1). We found more opinions than empirical data about good teaching, especially data relating student performance to distinguishable and measurable teaching behaviors.
Four studies of particular importance attempted to correlate student performance with student perception of teaching quality. One used a global rating of teaching.39 The remaining three used measurable teaching behaviors for their correlations,13–15 and although all three demonstrated a positive correlation between some teaching behaviors and student performance, the effect was either small15 or inconsistent across various measures of student performance.13,14 One study correlated students’ evaluations of their first-year clinical teachers with assessment of the same students’ clinical performance by their subsequent clinical teachers.13 The other three relied on student ratings of “good teaching.”14,15,39 The Anderson et al14 study is notable in that students who had previously rated their teachers more positively also had higher OSCE scores.
Many of the opinions used in these four studies were garnered from student evaluations, which are relatively easy and inexpensive to obtain but are, by themselves, hardly objective measures of teaching performance and may depend largely on faculty popularity.35,40 Furthermore, they are also biased by the “halo effect” (student esteem for faculty influences grading), or trait-based evaluation predispositions (higher-performing students rate instructors more highly).41 Clearly, solid evidence supporting a causal relationship between good teaching and student learning is lacking.
New areas for research
Superb teaching is certainly a complex phenomenon. What makes a good teacher is likely different to different students and probably even varies by occasion. Furthermore, teaching depends on multiple dependent factors, such as teacher knowledge, student knowledge, teacher personality, whether the student got a good night’s sleep the night before, whether the teacher got a good night’s sleep before—there probably are hundreds of factors that contribute to good teaching, just as hundreds of factors contribute to complex biologic systems. The human liver operates rather autonomously in most of us, yet its function is dependent on a multitude of very specific variables, not limited to its arterial and venous supply and the various inputs of proteins, carbohydrates, steroids, lipoproteins, and toxic substances. The slightest alteration in these variables can lead to disruptions in hepatic function, which could never be understood without centuries of research that still continues. We argue that the science of medical teaching is a similarly complex system that is also in its infancy. Although it may seem like teaching can never be fully understood, it is imperative that we try, not only to make bad teachers better, but also to maximize the teaching effectiveness of all of us.
Frameworks of clinical teaching in medicine have been rigorously validated, using student, resident, and faculty ratings.42,43 We argue for an expansion of the repertoire of knowledge, skills, and attributes considered in the domain of effective teaching. Some suggestions for research related to this review include investigations related to the following questions:
* Which of these teaching characteristics deserve further study? We recommend the critical examination of those of our themes that have not been previously examined, such as enthusiasm for medicine, forming positive relationships, and integrity, among others. Perhaps they would be best measured through triangulation of multiple measures, including observation, self-reflection, and student evaluations.
* Out of these 49 themes of teaching characteristics, which ones actually influence student learning? Our literature search reveals that students certainly appreciate the personable, patient, and virtuous teacher, but do these qualities help a student acquire the complex skills involved in applying learned knowledge to patient care? We advocate testing on the wards, involving medical students and their teachers, using reliable and valid assessment tools, of the impact of these teaching behaviors on our medical students. Qualitative approaches similar to the one we used in this analysis might be useful for this.
* How do students differ in their response to different teaching characteristics? Perhaps one student might need clearly organized objectives, whereas another might respond to a less organized yet enthusiastic clinical teacher. If students differ in their needs, as we suspect, perhaps they can be explicitly encouraged to prepare differently for learning encounters. Most students intuitively prepare differently, for example, when they know they will be learning from a teacher with superior clinical knowledge.
* How can these teaching behaviors, especially the noncognitive ones, be taught and/or developed? We will need to pursue methodologies for new “teach the teacher” processes aimed at the noncognitive behaviors, ones not previously emphasized in faculty development workshops, as well as research that validates their effectiveness.
In our review of the literature pertinent to the question, “What makes a good clinical teacher in medicine?” we identified more than 400 specific descriptions published over almost a century. These descriptions came from a wide array of methodologies, including essays, surveys, qualitative analyses, and observational studies, but from very few empirical data. We clustered these specific descriptions into 49 themes and then clustered these themes into three broader clinical educator categories—the physician, the teacher, and the human. These categories and themes have broad application in faculty development and student learning.
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* Due to additions made in the proof stage, references 29, 32, and 77 are cited out of order. Cited Here...
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