ABC of learning and teaching in medicineLearning and teaching in the clinical environmentJohn Spencer

Clinical teaching—that is, teaching and learning focused on, andusually directly involving, patients and their problems—lies atthe heart of medical education. At undergraduate level, medicalschools strive to give students as much clinical exposure aspossible; they are also increasingly giving students contact withpatients earlier in the course. For postgraduates, “on the job”clinical teaching is the core of their professional development.How can a clinical teacher optimise the teaching and learningopportunities that arise in daily practice?

Strengths, problems, and challengesLearning in the clinical environment has many strengths. It isfocused on real problems in the context of professionalpractice. Learners are motivated by its relevance and throughactive participation. Professional thinking, behaviour, andattitudes are “modelled” by teachers. It is the only setting inwhich the skills of history taking, physical examination, clinicalreasoning, decision making, empathy, and professionalism canbe taught and learnt as an integrated whole. Despite thesepotential strengths, clinical teaching has been much criticisedfor its variability, lack of intellectual challenge, and haphazardnature. In other words, clinical teaching is an educationallysound approach, all too frequently undermined by problems ofimplementation.

The importance of planningMany principles of good teaching, however, can (and should) beincorporated into clinical teaching. One of the most importantis the need for planning. Far from compromising spontaneity,planning provides structure and context for both teacher andstudents, as well as a framework for reflection and evaluation.Preparation is recognised by students as evidence of a goodclinical teacher.

How doctors teachAlmost all doctors are involved in clinical teaching at somepoint in their careers, and most undertake the jobconscientiously and enthusiastically.

However, few receive any formal training in teaching skills,and in the past there has been an assumption that if a personsimply knows a lot about their subject, they will be able to teach

Common problems with clinical teachingx Lack of clear objectives and expectationsx Focus on factual recall rather than on development of problem

solving skills and attitudesx Teaching pitched at the wrong level (usually too high)x Passive observation rather than active participation of learnersx Inadequate supervision and provision of feedbackx Little opportunity for reflection and discussionx “Teaching by humiliation”x Informed consent not sought from patientsx Lack of respect for privacy and dignity of patientsx Lack of congruence or continuity with the rest of the curriculum

Clinical teaching in general practice

Questions to ask yourself when planning a clinical teaching session

Challenges of clinical teachingx Time pressuresx Competing demands—clinical (especially when needs of patients

and students conflict); administrative; researchx Often opportunistic—makes planning more difficultx Increasing numbers of studentsx Fewer patients (shorter hospital stays; patients too ill or frail; more

patients refusing consent)x Often under-resourcedx Clinical environment not “teaching friendly” (for example, hospital

ward)x Rewards and recognition for teachers poor

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it. In reality, of course, although subject expertise is important, itis not sufficient. Effective clinical teachers use several distinct, ifoverlapping, forms of knowledge.

How students learnUnderstanding the learning process will help clinical teachersto be more effective. Several theories are relevant (see firstarticle in the series, 25 January). All start with the premise thatlearning is an active process (and, by inference, that theteacher’s role is to act as facilitator). Cognitive theories arguethat learning involves processing information through interplaybetween existing knowledge and new knowledge. An importantinfluencing factor is what the learner knows already. The qualityof the resulting new knowledge depends not only on“activating” this prior knowledge but also on the degree ofelaboration that takes place. The more elaborate the resultingknowledge, the more easily it will be retrieved, particularly whenlearning takes place in the context in which the knowledge willbe used.

Experiential learningExperiential learning theory holds that learning is often mosteffective when based on experience. Several models have beendescribed, the common feature being a cyclical process linkingconcrete experience with abstract conceptualisation throughreflection and planning. Reflection is standing back andthinking about experience (What did it mean? How does itrelate to previous experience? How did I feel?). Planninginvolves anticipating the application of new theories and skills(What will I do next time?). The experiential learning cycle,which can be entered at any stage, provides a useful frameworkfor planning teaching sessions.

QuestionsQuestions may fulfil many purposes, such as to clarifyunderstanding, to promote curiosity, and to emphasise keypoints. They can be classified as “closed,” “open,” and“clarifying” (or “probing”) questions.

Closed questions invoke relatively low order thinking, oftensimple recall. Indeed, a closed question may elicit no responseat all (for example, because the learner is worried about beingwrong), and the teacher may end up answering their ownquestion.

How to use cognitive learning theory in clinical teachingHelp students to identify what they already knowx “Activate” prior knowledge through brainstorming and briefing

Help students elaborate their knowledgex Provide a bridge between existing and new information—for

example, use of clinical examples, comparisons, analogiesx Debrief the students afterwardsx Promote discussion and reflectionx Provide relevant but variable contexts for the learning

Example of clinical teaching session based on experientiallearning cycleSetting—Six third year medical students doing introductory clinical

skills course based in general practiceTopic—History taking and physical examination of patients with

musculoskeletal problems (with specific focus on rheumatoidarthritis); three patients with good stories and signs recruited fromthe community

The sessionPlanning—Brainstorm for relevant symptoms and signs: this activates

prior knowledge and orientates and provides framework andstructure for the task

Experience—Students interview patients in pairs and do focusedphysical examination under supervision: this provides opportunitiesto implement and practise skills

Reflection—Case presentations and discussion: feedback and discussionprovides opportunities for elaboration of knowledge

Theory—Didactic input from teacher (basic clinical information aboutrheumatoid arthritis): this links practice with theory

Planning— “What have I learned?” and “How will I approach such apatient next time?” Such questions prepare students for the nextencounter and enable evaluation of the session

Effective teaching depends crucially on the teacher’scommunication skills. Two important areas ofcommunication for effective teaching are questioning andgiving explanations. Both are underpinned by attentivelistening (including sensitivity to learners’ verbal andnon-verbal cues). It is important to allow learners toarticulate areas in which they are having difficulties orwhich they wish to know more about

Casebased

"teachingscripts"

Knowledgeaboutthe

learners

Knowledgeabout thesubject

Knowledge aboutlearning and

teaching

Learningcontext

Knowledgeabout

the patient

Various domains of knowledge contribute to the idiosyncratic teachingstrategies (“teaching scripts”) that tutors use in clinical settings

Reflection

Theory

Experience

Planning

Experiential learning cycle: the role of the teacher is to help students tomove round, and complete, the cycle

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In theory, open questions are more likely to promotedeeper thinking, but if they are too broad they may be equallyineffective. The purpose of clarifying and probing questions isself evident.

ExplanationTeaching usually involves a lot of explanation, ranging from the(all too common) short lecture to “thinking aloud.” The latter isa powerful way of “modelling” professional thinking, giving thenovice insight into experts’ clinical reasoning and decisionmaking (not easily articulated in a didactic way). There are closeanalogies between teacher-student and doctor-patientcommunication, and the principles for giving clear explanationsapply. If in doubt, pitch things at a low level and work upwards.As the late Sydney Jacobson, a journalist, said, “Neverunderestimate the person’s intelligence, but don’t overestimatetheir knowledge.” Not only does a good teacher avoid answeringquestions, but he or she also questions answers.

Exploiting teaching opportunitiesMost clinical teaching takes place in the context of busypractice, with time at a premium. Many studies have shown thata disproportionate amount of time in teaching sessions may bespent on regurgitation of facts, with relatively little on checking,probing, and developing understanding. Models for using timemore effectively and efficiently and integrating teaching intoday to day routines have been described. One such, the“one-minute preceptor,” comprises a series of steps, each ofwhich involves an easily performed task, which when combinedform an integrated teaching strategy.

Teaching on the wardsDespite a long and worthy tradition, the hospital ward is not anideal teaching venue. None the less, with preparation andforethought, learning opportunities can be maximised withminimal disruption to staff, patients, and their relatives.

Approaches include teaching on ward rounds (eitherdedicated teaching rounds or during “business” rounds);students seeing patients on their own (or in pairs—students canlearn a lot from each other) then reporting back, with orwithout a follow up visit to the bedside for further discussion;and shadowing, when learning will inevitably be moreopportunistic.

Key issues are careful selection of patients; ensuring wardstaff know what’s happening; briefing patients as well asstudents; using a side room (rather than the bedside) fordiscussions about patients; and ensuring that all relevantinformation (such as records and x ray films) is available.

Teaching in the clinicAlthough teaching during consultations is organisationallyappealing and minimally disruptive, it is limited in what it canachieve if students remain passive observers.

With relatively little impact on the running of a clinic,students can participate more actively. For example, they can be

How to use questionsx Restrict use of closed questions to establishing facts or baseline

knowledge (What? When? How many?)x Use open or clarifying/probing questions in all other circumstances

(What are the options? What if?)x Allow adequate time for students to give a response—don’t speak

too soonx Follow a poor answer with another questionx Resist the temptation to answer learners’ questions—use counter

questions insteadx Statements make good questions—for example, “students

sometimes find this difficult to understand” instead of “Do youunderstand?” (which may be intimidating )

x Be non-confrontational—you don’t need to be threatening to bechallenging

Questions can be sequenced to draw out contributions orbe built on to promote thinking at higher cognitive levelsand to develop new understanding

How to give effective explanationsx Check understanding before you start, as you proceed, and at the

end—non-verbal cues may tell you all you need to know aboutsomeone’s grasp of the topic

x Give information in “bite size” chunksx Put things in a broader context when appropriatex Summarise periodically (“so far, we’ve covered . . .”) and at the end;

asking learners to summarise is a powerful way of checking theirunderstanding

x Reiterate the take home messages; again, asking students will giveyou feedback on what has been learnt (but be prepared for somesurprises)

Teaching during consultations has been much criticisedfor not actively involving learners

Patientencounter(history,

examination, etc)

Teach generalprinciples

("When thathappens, do

this..." )

Get acommitment

("What do youthink is

going on?" )

Help learneridentify and

give guidanceabout omissions

and errors("Although your

suggestionof Y was apossibility,

in a situationlike this, Z ismore likely,because..." )

Probe forunderlyingreasoning("What ledyou to that

conclusion?" )

Reinforce what was done well("Your diagnosis of X was wellsupported by the history..." )

“One-minute preceptor” model

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asked to make specific observations, write down thoughts aboutdifferential diagnosis or further tests, or note any questions—fordiscussion between patients. A more active approach is “hotseating.” Here, the student leads the consultation, or part of it.His or her findings can be checked with the patient, anddiscussion and feedback can take place during or after theencounter. Students, although daunted, find this rewarding. Athird model is when a student sees a patient alone in a separateroom, and is then joined by the tutor. The student then presentstheir findings, and discussion follows. A limitation is that theteacher does not see the student in action. It also inevitablyslows the clinic down, although not as much as might beexpected. In an ideal world it would always be sensible to blockout time in a clinic to accommodate teaching.

The patient’s roleSir William Osler’s dictum that “it is a safe rule to have noteaching without a patient for a text, and the best teaching isthat taught by the patient himself” is well known. Theimportance of learning from the patient has been repeatedlyemphasised. For example, generations of students have beenexhorted to “listen to the patient—he is telling you thediagnosis.” Traditionally, however, a patient’s role has beenessentially passive, the patient acting as interesting teachingmaterial, often no more than a medium through which theteacher teaches. As well as being potentially disrespectful, this isa wasted opportunity. Not only can patients tell their stories andshow physical signs, but they can also give deeper and broaderinsights into their problems. Finally, they can give feedback toboth learners and teacher. Through their interactions withpatients, clinical teachers—knowingly or unknowingly—have apowerful influence on learners as role models.

Drs Gabrielle Greveson and Gail Young gave helpful feedback on earlydrafts.

John Spencer is a general practitioner and professor of medicaleducation in primary health care at the University of Newcastle uponTyne.

The ABC of learning and teaching in medicine is edited by PeterCantillon, senior lecturer in medical informatics and medicaleducation, National University of Ireland, Galway, Republic of Ireland;Linda Hutchinson, director of education and workforce developmentand consultant paediatrician, University Hospital Lewisham; andDiana F Wood, deputy dean for education and consultantendocrinologist, Barts and the London, Queen Mary’s School ofMedicine and Dentistry, Queen Mary, University of London. Theseries will be published as a book in late spring.

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Working effectively and ethically with patientsx Think carefully about which parts of the teaching session require

direct patient contact—is it necessary to have a discussion at thebedside?

x Always obtain consent from patients before the students arrivex Ensure that students respect the confidentiality of all information

relating to the patient, verbal or writtenx Brief the patient before the session—purpose of the teaching

session, level of students’ experience, how the patient is expected toparticipate

x If appropriate, involve the patient in the teaching as much aspossible

x Ask the patient for feedback—about communication and clinicalskills, attitudes, and bedside manner

x Debrief the patient after the session—they may have questions, orsensitive issues may have been raised

Suggested readingx Cox K. Planning bedside teaching. (Parts 1 to 8.) Med J Australia

1993;158:280-2, 355-7, 417-8, 493-5, 571-2, 607-8, 789-90, and159:64-5.

x Parsell G, Bligh J. Recent perspectives on clinical teaching. Med Educ2001;35:409-14.

x Hargreaves DH, Southworth GW, Stanley P, Ward SJ. On-the-joblearning for physicians. London: Royal Society of Medicine, 1997.

Patient

Student

"Sitting in" as observer

Teacher

Patient

Student

Three way consultation

Teacher

Patient

Teacher

"Hot seating"

Student

Seating arrangements for teaching in clinic or surgery

One hundred years ago

A “surgical marvel” at the London Hospital

That modest institution the London Hospital, which does somuch good by stealth and doubtless blushes to find it fame, andwhich has been the scene of so many surgical triumphs, has, if thePall Mall Gazette is to be believed, almost beaten its own record. Aman was “stabbed through the heart” and afterwards “had thepuncture sewn up at the hospital.” The operation, says ourcontemporary, was, though not unique, a very remarkable one.Remarkable indeed it must have been beyond anything in theannals of surgery if the description of it given by the Pall MallGazette is correct. After being informed that “an operation on the

heart is difficult, not only owing to the paramount importance ofthe organ, but because of its deeply-imbedded position in thebody, and in order to do his work the surgeon had to temporarilydisplace the breast, cartilage, ribs, and lungs,” we are further toldthat “it was at first thought that the heart itself would have to beremoved.” Fortunately this formidable contingency was avoided,for, “on washing away the blood clots and raising it a little thepuncture was found.” The man, we are glad to learn, continues toimprove, and we hope that he will live long in undisturbedpossession of the heart which he so nearly lost. (BMJ 1903;i:1332)

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