Graffam, Ben PhD; Bowers, Lori MD; Keene, Karen N. MA
There are continual calls for more effective teaching in medical education.1–5 Evidence shows medical schools generally teach clinical skills inadequately.6–11 Bedside teaching is in decline,11 and personalized instruction has been nearly dismissed in the age of electronic teaching.6
Although medical educators often perceive teaching as simply transferring knowledge between minds,1–5 researchers in cognitive science and education have contradicted this view12–16 and have produced models of effective instruction. Such instructional models help instructors
* identify purpose or area of concentration,17,18
* clarify assumptions about the teaching/learning process,17,19 and
* guide and define patterns for learning experiences.17,20–22
These models embody theories about the nature and needs of learners and the effectiveness of teaching/learning methods.20,22–24 For example, Gagne’s25 model for transforming gifts into talents informs teachers who work with gifted learners not only about how to conceptualize giftedness, but also about how to design learning experiences that draw out those gifts. By framing developmental processes that connect natural learning abilities (i.e., intellectual, creative, and others) to systematically developed outcomes (i.e., academic, arts, technology, and others), Gagne shows how a learner’s interpersonal skills connect with environmental characteristics and create both positive and negative learning impacts. Then Gagne models a dynamic process for working with gifted learners by outlining how teachers use conscious intention to attain specific learning goals.
Such models are common in education, and educators call on them when teaching challenges shift and their teaching skills prove to be less effective with new learning groups.
In preparation for the study described below, we sought to discover the availability of instructional models for clinical educators. We searched PubMed, Web of Science, and ERIC using the following terms and variations: medical education, medical school, faculty, teaching, pedagogy, instruction, model, framework, and matrix. Although some models appeared,26–35 none spoke directly to teaching behaviors during clinical instruction. Expanding our search, we explored conference papers, dissertations, grant reports, government and technical reports, and similar sources, including the National Library of Medicine’s Gateway, ProQuest Dissertations and Theses, CRISP, Lexis-Nexis, NTIS, GrayLit Network, USASearch, PapersFirst, ProceedingsFirst, Google, and Google Scholar. Again, we found no models addressing behaviors of teaching practice in clinical education.
One model that our search uncovered addresses relevant knowledge needed by medical instructors.29 Using interview and observation of six distinguished clinicians, this model indicates that clinical educators need broad knowledge of patients, medicine, learners, case-based teaching, and “general principles of teaching.” It makes a strong argument for what instructors must know, but it doesn’t describe what they must do.
Another model depicts curricular revisions allowing students to receive yearlong mentoring while following patients through health care interventions.27 Like the previous model, this one describes what a curriculum must provide, not the instructional skills that enhance those opportunities.
A third explores how to uncover good clinical teaching.33 Yet, this model addresses the development of competent observers, not the nature of good teaching. Citing direct observation as the best way to understand clinical teaching, Beckman found that clinicians’ diagnostic training overrode their teaching evaluation skills.33 The author provided training, but clinician–observers found it difficult to assess pedagogy. This makes sense because clinicians are trained to diagnose and treat, not to evaluate teaching. Like the other two models, it doesn’t illuminate teaching practice.
A paucity of instructional models means clinical instructors have little guidance to build learning environments needed by medical students. These environments develop through intentional teaching practices of instructors, practices that can be modeled and learned.36,37
Our purpose was to discover, define, and describe the teaching behaviors of a set of clinical instructors. Then, once those behaviors were understood, we would build a model of clinical instruction for medical education. This model would introduce a method of guided reflection for clinicians, who, generally lacking pedagogical training, teach as they were taught.1,32
Guiding the development of our model were three significant education texts: Palmer’s The Courage to Teach,38 Lowman’s Mastering the Techniques of Teaching,36 and Gardner’s The Unschooled Mind.39 Each describes behaviors of good teaching while simultaneously presenting concepts teachers call on to do good work.
Most clinicians want to be good teachers. Our sense is that many would benefit from clearer understandings of positive teaching behaviors so that they would be better able to reflect on and guide the growth of their teaching skills.
Seeking first to discover and define what clinicians do while teaching, the primary observer (B.G.) spent more than 100 hours of direct participant observation of clinical teaching during the months of January, February, June, and July of 2007 at the University of South Florida College of Medicine’s (USFCOM) medical clinic (January and February) and at Tampa General Hospital (TGH) during morning rounds (June and July). Both sites are training centers for USFCOM students.
Participant observation explores the lived experience of people in particular tasks and has a highly regarded record in anthropological research.40 It is an essential method for researchers hoping to build relationships with those being studied and not merely gather data from them.41 A participant observer does not just observe but also interacts with those from whom the data are gathered.42 Often, partnerships are formed. For this reason, it was the right vehicle for our research because we hoped to uncover a system and then find ways to influence that system.
In our study, the primary observer had already built relationships with 11 of the clinicians, and this helped in the data-gathering process. In participant observation, it is important that the observers and participants have a positive working relationship, so that as data are interpreted, insights can be shared.40,41
We chose January and February because they allowed access to clinicians working with students who had already participated in several rotations. Some teaching behaviors (e.g., how well an instructor has incorporated various strategies by the middle of the academic year) might be easier to spot in those months. June and July were selected because they are the first two months of rotations, and we could explore what we gleaned in January and February as we made our observations in those months.
Sixteen clinicians (eight at both sites) were observed individually on two separate occasions. Sessions lasted three to four hours.
We recruited clinicians in two ways. Those at TGH were assigned by their internal medicine and pediatrics clerkship directors. Six were internists, and two were pediatricians. Clinicians at USFCOM volunteered to be observed through a joint recommendation from the directors of family medicine and from the primary care and special populations clerkship. Five were family physicians, and three were pediatricians. The clinicians had a range of teaching experience, with three in their first year of teaching and four having more than 15 years of teaching experience.
The primary observer for this study is an educator, with degrees in secondary (BS), gifted (MA), and special (PhD) education, as well as more than 20 years of classroom teaching, both in public schools and university settings. As the education specialist at USFCOM, he observes through a lens that sits outside the physician’s paradigm, unencumbered by thoughts of diagnosis and/or treatment plan, thereby addressing the concern raised by Beckman33 (i.e., that clinicians’ diagnostic training overrode their teaching evaluation skills). He completed full Health Insurance Portability and Accountability Act training for this project. Considering the no-risk nature of the research, the IRB process was waived.
B.G. observed all clinicians’ interactions during the sessions, including time with students, time with colleagues, and time with patients. Observations occurred during morning rounds at TGH and in both morning and afternoon sessions at USFCOM. During observations, B.G. wrote notes on behaviors, attitudes, strategies, conversations, and other details in the learning environment. He also conducted interviews with physicians and students during and after sessions. These interviews were unscripted, probing the intent and attitudes about experiences in the learning environment.
B.G. transcribed the observational data into brief narratives. When two sessions for any one clinician were completed, these narratives were sent to that clinician, as a type of member checking.43 Member checking is a process where researchers and participants share insights on the observations and interpretations. When the process is seen in similar terms and outcomes, data are strengthened.
Consider, for example, the statement, “Upon entering the exam room, the clinician dominated the encounter and did not let the student address the concerns raised about the patient in the conference room.” Through member checks, the clinician might inform observers that “in a very similar case yesterday, the student addressed a patient, but today, in order to expedite the patient encounter, that opportunity was omitted.” This can make observers aware of teaching practices that were not observed.
As the discovery and definition processes evolved, a concurrent process of developing a model emerged. To enhance this development, a coding process43,44 was applied to the narratives to illuminate attitudes, ideas, and teaching practices of these clinicians. Coding organized the interpretation of behaviors, and, with guidance from the education texts, we identified the following seven teaching behaviors that helped us distill the five core behaviors and two ancillary behaviors of our model: converse, model, engage, empower, structure, measure, and conceptualize. Although these labels are common educational terms, they emerged clearly during analysis of our data. (These terms are explained in the following section and in List 1).
Some behaviors were observed in every clinician. All 16 clinicians asked questions and shared reciprocal conversations with students. All modeled many behaviors, though this was generally focused on how to palpate or how to use a certain device, not on how to think about the relationship of symptoms to diagnoses. All assigned academic work to be done away from the clinical setting. These behaviors were labeled, respectively, converse, model, and engage.
Other practices were part of some instructors’ tool kits but missing from others. Seven clinicians challenged their students in hypothetical cases while conversing about the patient: “What if this patient were 20 years younger and male? How might that alter your decision?” Sometimes, this occurred in the patient’s presence. Although this might be classified as converse, the challenge elevates cognitive interaction, and we labeled it engage.
Five clinicians watched their students work with patients in the exam room, and 11 had their students watch as they worked. Whereas the second practice is clearly model, we labeled the first empower because it gave students opportunities to practice physician skills while under the eye of an expert.
Two clinicians who empowered students did so through specific tasks: “When we get back with Mr. Patel, I want you to take him through the importance of his physical therapy regimen” or “I think you should give Ms. Johnson a full understanding of her labs, so that she gets a better sense of our concern.” This allowed opportunities to provide very specific feedback on student performance.
Empower, by our definition, occurred only in the clinical setting; no ward instructor empowered a student during bedside teaching at the hospital. All ward instructors modeled physician behaviors at the bedside; none observed their students working with the patient.
Four clinicians gave instructions similar to “This week, I want you to eliminate unnecessary elements of the history when you report to me and just get to the positive pertinents that frame a treatment plan” or “Today, tell me only the top three ideas in your differential. I may ask you to expand, but I want you to think critically before presenting them to me.” Five other clinicians sat with their students at the start of each learning situation and shared information about the patients for that day. In these brief sessions, the clinicians gave some specific challenges to each student, thereby framing the learning of that day.
These were labeled structure because they demonstrated clinicians’ understanding that learning objectives and outcomes change over time. How learners are taught in week one of rotation one should be different from how they are taught in week one of rotation three. In other words, structuring recognizes individual student needs within the context of the particular teaching environment so that students receive instruction based on those needs.
Six clinicians provided feedback to their students. We have mentioned two clinicians who empowered students with specific tasks and then gave specific feedback. More often, feedback occurred in general statements like “Nice job” or “You’ve got a good mind for diagnosing.” This element was labeled measure.
Eight clinicians spoke extensively with B.G. about their teaching repertoire. Five of these described, unprompted, what a patient/student encounter should be. Three mentioned intentional teaching interactions and the relationships that are built through teaching. The other eight shared no specific or general information about teaching.
These conversations were labeled conceptualize. Working from a cognitive frame of teaching methods is central to developing good teaching skills. Different from structure, which focuses on the immediate learning environment, this behavior builds from a deeper understanding of the role teachers play in their students’ lives. It is as much a sense of identity as it is a practice.36
A Model of Clinical Instruction
During our observations, certain behaviors and conversational topics became key indicators for the five core behaviors (discussed below) of the developing model. The five were chosen because they are observable in the interactions that occur between instructor and student. The other two serve either as a foundation to practice (conceptualize) or as a result of practice (empower). Because our sessions occurred in two different parts of the year, we used the behaviors of the volunteer participants in January and February to build expectations into our observations in June and July.
Teaching as practice
Combining observations and interpretations, our model describes the clinician’s teaching practice as made up of five core behaviors: converse, engage, measure, model, and structure (see Figure 1). Clinical teaching skills are manifest in these behaviors. Through quality modeling, in-depth conversations, proper engagement, and authentic measuring, significant learning experiences are created.
The core behaviors interact dynamically: interventions in one area influence interventions in another. When a clinician structures a learning environment, the kind of conversations and feedback shared with a student will change. Similarly, when a student is empowered, the nature of the learning engagement is altered. Within our model all behaviors are in constant interaction. No one behavior is the specific goal of instruction; rather, clinicians should combine multiple behaviors in their immediate practice.
As with all models, ours works as a guide for reflective and comparative practice.45–50 Clinicians can juxtapose their teaching practice with the characteristics presented in the model. List 2 provides an explanatory structure and set of guiding questions for the clinician to reflect on teaching. Considering these questions before, during, and after teaching engagements should help a clinician focus on pedagogical practice. It should help engender professional growth and development as a teacher.
Teaching as conceptualizing
As Figure 1 shows, the behaviors of teaching sit atop clinicians’ conceptualizations of teaching: how they perceive and define their work drives their practice. Clinicians who used teaching methods intentionally generally created better learning environments. Some clinicians in our study spoke of their love for teaching. Others described why they engaged students as they did.
Considering the background of clinician educators, clinicians can probably give detailed descriptions of their philosophy of patient care but not of their philosophy of teaching. For example, many clinicians pointed out their belief in relationship-centered care. Many shared stories where this philosophy availed them to details and information making the diagnostic process more effective.
However, those same clinicians may not be as comfortable centering their teaching through similar relationships. They don’t see that good teaching places the student at the center of learning. In our view, a relationship-centered philosophy allowed good clinicians to glean significant information that helped them instruct their students more effectively.
For intentional teaching to become paramount in teaching practice, and for the five core behaviors to become more understood, it is important for clinicians to make their pedagogy explicit. We found that instructors who spoke about their teaching philosophy were more effective as instructors.
Teaching as empowerment
The core behavior of empower sits atop teaching practice (see Figure 1). When clinicians perform the core behaviors with a high degree of purpose, empowerment occurs. For example, clinicians who structured their learning though intentional engagement and who gave regular and specific feedback found it valuable to let their students engage the patient in their presence. It was a better way to observe how well the student was doing. The act of empowering comes from the collective quality of the teaching practices at the core of our model.
Better clinical teaching empowers students to be decision makers, to build relationships with patients, and to think with autonomy in the exam room. Such empowerment is born of the clinicians’ philosophies and practices.
Discussion and Conclusions
Basing our model on the teaching practices we observed creates a starting place for building a better clinical teacher. Juxtaposing clinicians who do and do not understand the importance of structuring the learning environment, or of engaging the student with hypothetical extensions of the case being discussed, allowed us to see that a model that describes the behaviors of good practice can be of great benefit to the teaching clinician.
It was surprising to observe that clinicians who shared the same conference room and could have shared their teaching practices did not always do so. It was also surprising that clinicians rounding on the same ward had widely diverse styles of interacting with students. Although we are not proposing that teaching practices be standardized, we do feel that the implementation of a model of clinical instruction, along the lines of ours but refined via more research and trial runs, could help clinicians discern the strengths and weaknesses of their own teaching and, thereby, improve clinical teaching overall.
A significant body of work extols the importance of reflection within education, including the training of medical students.34–39,45–50 Just as physicians must reflect on the way they have diagnosed and treated patients, teachers need to reflect on the ways they have enriched students’ learning experiences.50 Not to be reflective is a professional shortcoming for both teachers and physicians.
Physicians generally know how to reflect on their medical practice, but they may not have equal insights into their teaching practice. Having a model for guiding professional self-reflection offers great potential for clinical instruction. It places an understandable framework in the hands of instructors who commonly have no pedagogic vocabulary.1
Although this model has yet to be applied broadly in medical education, it is now providing guidelines for informal assessment of clinical and ward instruction at USFCOM. As such, it is expanding the conversation and perceptions about clinical teaching. Moreover, it seems to be increasing the opportunities for students working hospital wards to engage more directly with patients while in the presence of their clinician. Three clinicians in the study have commented that they now appoint a student to initiate the patient encounter each time the clinicians enter the exam room. In the shadow of the literature that has been critical of clinical teaching over the years,1–11 this is a step in a positive direction.
We hope that others will put the model into practice in their own clinical and ward teaching. Then, as is the case with models, it can be adapted and enhanced so that more instructors are affected by it, and it can be refined and improved to make it even more effective. Models should be living, breathing guides for those who use them. Over time, the conversations and practices the model may engender might just refocus the nature of clinical teaching.
Special thanks to Dr. Maria Cannarozzi, Dr. Kira Zwygart, and Dr. Jamie Brownlee for allowing observations of their clinical staff. And thanks to Lara Westphal for the visual design of the model.
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