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- •Preface
- •References
- •Contents
- •Author Biographies
- •About the Series Editors
- •Family Medicine Advocacy Summit
- •Robert Graham Center Workforce Studies
- •HealthLandscape
- •Residency Resources
- •Medical Education Policy Development
- •Residency Program Solutions
- •Residency Leadership Summit
- •Chief Resident Leadership Development Program
- •Educational Resources
- •Continuing Medical Education (CME) Tracking
- •Graduate Medical Education Awards
- •Summary
- •References
- •AAFP Structure
- •AAFP Governance
- •Workforce Mission
- •AAFP Workforce Advocacy
- •Residency Redesign
- •References
- •Osteopathic Recognition Requirements
- •Osteopathic Recognition Program Essential Personnel
- •Osteopathic Faculty
- •Osteopathic Recognition Resident Requirements
- •Osteopathic Educational Program Core Competencies
- •Osteopathic Program Evaluation
- •References
- •Reference
- •5: Association of Family Medicine Administration and the Key Role of the Residency Program Coordinator
- •Appendix 1
- •References
- •References
- •Membership Categories within NAPCRG
- •The AAFP Robert Graham Center
- •AAFP National Research Network (NRN)
- •Family Physicians Inquiry Network (FPIN)
- •The Family Medicine Physician-Scientist Pathway (PSP) Program
- •NAPCRG Grant Generating Project
- •Building Research Capacity (BRC)
- •Conclusion
- •References
- •Reference
- •9: Family Medicine Residency Accreditation
- •Why Accreditation Matters
- •ACGME Organizational Structure
- •The Family Medicine Review Committee (RCFM)
- •The Clinical Learning Environment Review (CLER)
- •The Site Visit
- •Initial Accreditation Period
- •Subspecialty Fellowship Application
- •The Annual Program Review
- •The Next Accreditation System Annual Review Process
- •Accreditation Data System (ADS)
- •Citations
- •Accreditation Status
- •Program Requirement Development
- •Competency-Based Medical Education (CBME)
- •References
- •10: Graduate Medical Education Funding
- •Introduction
- •Residency Operating Costs
- •Medicare GME Funding
- •Residency Caps
- •Rural Track Programs
- •Inpatient Prospective Payment System (IPPS) Subtype Hospitals
- •Rural Referral Centers
- •Sole Community Hospitals
- •Medicare-Dependent Hospital
- •Medicaid GME Funding
- •Teaching Health Center Funding
- •Veteran’s Administration GME
- •Children’s Hospital GME (CHGME)
- •State Line Item Funding
- •Hospital Supplemental Funding
- •Patient Care Revenue
- •Philanthropy
- •Conclusions
- •References
- •Introduction
- •Informed Self-Assessment
- •Faculty Development
- •Summary
- •References
- •12: Core Competencies, Milestones, and Entrustable Professional Activities
- •Entrustable Professional Activities
- •Entrustment
- •Pearls
- •Pitfalls
- •References
- •Objectives
- •Educational Strategies
- •Implementation
- •13: A Practical Approach to Curriculum Development
- •Introduction
- •Cognitive Learning Theory
- •Behavioral Learning Theory
- •Humanistic Learning Theory
- •Goals
- •Conclusion
- •References
- •Introduction
- •Preparation Phase
- •Information Technology Systems
- •Medical Student Rotations
- •Interview Season
- •Application Screening
- •Interview Day
- •Second Looks
- •Postinterview Communication
- •Ranking
- •Using R3®
- •Match® Week
- •SOAP®
- •Conclusion
- •References
- •Preboarding
- •Planning New Resident Integration
- •Baseline Assessment
- •Individual Learning Plan
- •Integration Components
- •Longitudinal Integration
- •Learner/Residency/Institutional Goal Alignment
- •Conclusion
- •References
- •Introduction
- •History
- •Residency Application
- •Conclusion
- •References
- •References
- •Introduction
- •Identifying Performance Issues
- •Medical Knowledge
- •Patient Care
- •Interpersonal Skills/Communication
- •Professionalism
- •Systems-Based Practice
- •Remediation
- •Medical Knowledge
- •Patient Care
- •Interpersonal Skills/Communication
- •Professionalism
- •Systems-Based Practice
- •Conclusions
- •References
- •19: Faculty Recruitment: Best Practices
- •Background
- •Seeking Out Suitable Candidates: Recruitment Methods
- •Unique Challenges: Faculty Who Are New Residency Graduates
- •Concluding Thoughts: Always Recruit!
- •References
- •20: Faculty Performance
- •Faculty Performance Concerns
- •Appendix 1: Sample Family Medicine Residency Program Director Job Description
- •Job Summary
- •Educational Delivery
- •Evaluation
- •Administration
- •Appendix 2: Sample Family Medicine Residency Core Faculty Job Description
- •Job Summary
- •References
- •21: Faculty Development
- •Introduction
- •Clinical Skills
- •Scholarly Work
- •Tasks that Family Medicine Residency Faculty Perform
- •Role Modeling
- •Faculty Peer Support
- •Teaching
- •Training Courses
- •Workshops
- •Learning by Doing
- •Self-Directed Learning
- •Career Development
- •Organizational Resources
- •References
- •Introduction
- •Promoting Loving Accountability
- •Clinical Setting
- •Curriculum
- •Social Connection
- •Assessment
- •Vision Forward
- •Handling Microaggressions
- •Financial Investment
- •References
- •Building Trust
- •Positionality
- •Set the Stage
- •Normalize Not Knowing
- •Probing, Not Prodding
- •Accurate
- •Addressing Implicit Bias
- •Micro-Level
- •Macro-Level
- •Conclusion
- •References
- •Introduction
- •Background
- •Risk Factors
- •Stigma
- •FSMB Recommendations Regarding Licensing Questions
- •Physician Health Programs (PHP)
- •Individual-Level Actions
- •Conclusion
- •References
- •References
- •The Clinical Learning Environment
- •Feedback
- •References
- •27: Teaching Maternal Health Care
- •ACGME Requirements
- •Obstetric Family Medicine Faculty Shortage
- •Maternity Care Curricular Elements
- •Preconception Care
- •Prenatal Care
- •Immunizations
- •Common Conditions Which Complicate Pregnancy
- •Breastfeeding
- •Intimate Partner Violence (IPV)
- •Substance Use
- •Food Insecurity
- •Inpatient Obstetrical Care
- •References
- •Introduction
- •Family Medicine Residency Advocacy Curricular Development
- •Evaluation
- •Conclusion
- •References
- •Faculty Leadership
- •Resident Leadership
- •Patient Satisfaction
- •Professional Conduct
- •Ethical Considerations
- •Curriculum Development
- •The Hidden Curriculum
- •Conclusion
- •Context Matters
- •References
- •30: Teaching Behavioral Science
- •Introduction
- •Core Mental Health Topics
- •Patient-Centered Communication Skills
- •Contextual Care
- •Integrated Behavioral Health Care
- •Master Adaptive Learner
- •Clinic-Based Learning
- •Classroom-Based Learning
- •Interprofessional Education
- •Balint Groups
- •Conclusion
- •Appendix 1: Sample Behavioral Health Rotation (Myerholtz 2023)
- •References
- •31: Teaching Evidence-Based Medicine
- •Introduction
- •Longitudinal Deep Dives
- •Journal Club
- •Family Physicians Inquiries Network
- •Case-Based Learning
- •Day-to-Day Integration
- •Curriculum Development Tips Summary
- •Institutional Involvement
- •Summary
- •References
- •32: Teaching Practice Management
- •Background
- •Current Curriculum
- •Activities
- •Quality Improvement Project
- •Virtual Practice Instructions
- •Presenters
- •Topics Covered
- •References
- •Overview
- •Why Training Is Needed
- •Stressing Communication
- •Balint Group
- •Putting It All Together
- •References
- •Introduction
- •Broad Scope
- •Primary Contact
- •Emerging Technology
- •Rural Generalism
- •Public Health Advocate
- •Rural Practice Systems
- •References
- •Introduction
- •Basic Logistics
- •Operational Considerations
- •Billing Requirements
- •Additional Funding Considerations
- •Engaged Leadership
- •The FMC-Residency Partnership
- •Scheduling
- •Data-Driven Improvement
- •Empanelment
- •Panel Weighting
- •Panel Transitions
- •Team-Based Care
- •Population Management
- •References
- •Introduction
- •Personnel Management
- •Meeting Management
- •Communication Management
- •References
- •37: Managing Change in Family Medicine Residency Programs
- •Introduction
- •What Is Change Management?
- •Change Management Case Study
- •Kotter Model
- •Step 1: Create Urgency
- •Step 4: Communicate Buy-In
- •WIFM Worksheet
- •Step 5: Empower Others
- •Step 6: Generate Quick Wins
- •Step 7: Consolidate Gains
- •Conclusion
- •References
- •Negotiating Styles
- •Collaboration
- •Summary
- •References
- •Anticipating Task Cycles
- •Residency
- •Home Life
- •Seize Control
- •Delegate
- •Delegate Residency Chores
- •Delegate Domestic Chores
- •Exercise
- •Lunch
- •Organizing
- •Summary
- •References
- •Introduction
- •References
- •Introduction
- •Anticipate Common Disasters
- •Learn About Your Regional Emergency Infrastructure
- •Learn Your Organization’s Command Center Structures
- •Here Are Some Alternative Care Site Scenarios That May Arise
- •Regional Emergency Infrastructure
- •Managing Your Program During Disaster
- •Community Recovery
- •Consolidate Your Learning
- •Author Background
- •References
- •Conclusion

26 Practical Didactic, Bedside, andOce Teaching Skills
269
They interact skillfully with students and residents.
Outstanding teachers provide clinical supervision, demonstrate excellent clinical skills, and role model professional
characteristics.
In a study of recognized outstanding teachers in the ambulatory setting, Irby and colleagues identied the following
characteristics that best predicted overall teaching effectiveness [15]. The most important characteristics of the best
teachers were they possessed broad knowledge of medicine,
seemed to enjoy teaching and providing patient care, were
enthusiastic, demonstrated caring concern for patients, were
personable and approachable, and showed respect for others.
In addition, the best teachers involved the resident in the
learning process, communicated expectations for performance, respected the autonomy of the residents, and nurtured self-directed learning. Gjerde and Coble in a study of
family medicine clinical faculty found that effective clinical
teachers demonstrated three broad areas of teaching skills:
(1) two-way communication, (2) creating an environment
that facilitates learning, and (3) providing feedback [16].
In their exhaustive literature search of what denes a
good clinical teacher in medicine, Sutkin etal. identied 49
themes that could be grouped into three major characteristics, physician, teacher, and humanistic (Table 26.1) [17].
The majority of the identied characteristics were “noncognitive” and the most commonly reported themes were
medical and clinical knowledge, clinical and technical skills/
competence and clinical reasoning, positive relationships
with students and supportive learning environment, communication skills, and enthusiasm.
Role Modeling Faculty serve as professional role models
and mentors to residents. Role modeling is a powerful teaching technique and should be purposeful and demonstrate the
knowledge, skills, attitudes, and ethical behaviors that residents should acquire [1]. Through role modeling faculty
must also demonstrate exemplary professional characteristics such as showing genuine concern for patients, recognizing their own limitations, showing respect for others, taking
responsibility, and avoiding arrogance [1]. Outstanding
teachers show enthusiasm for the practice of medicine and
for teaching. They are dynamic, energetic, and show pleasure in teaching [5].
Clinical Competence Outstanding physicians must demonstrate clinical competence in patient care. They must show
the residents their approach to patient care through effective
history taking, performing physical examinations, knowing
the current advances in family medicine, and demonstrating
decision-making skills [1]. Clinical competency extends into
the faculty’s role of clinical supervisor, ensuring safe, effective, and quality care is provided by residents. This supervi-
Table 26.1 Characteristics of “excellent” clinical educators
General
characteristics Specic traits
Physician Demonstrates medical/clinical knowledge
Demonstrates clinical and technical skills/
competence, clinical reasoning
Shows enthusiasm for medicine
Models a close doctor-patient relationship
Exhibits professionalism
Is scholarly
Values teamwork and has good collegial skills
Is experienced
Demonstrates skills in leadership and/or
administration
Accepts uncertainty in medicine
Teacher Maintains positive relationships with residents and
a supportive learning environment
Demonstrates enthusiasm for teaching
Is accessible/available to residents
Provides effective explanations, answers to
questions, and demonstrations
Provides feedback and formative assessment
Is organized and communicates objectives
Demonstrates knowledge of teaching skills,
methods, principles and their application
Stimulates residents’ interest in learning and/or
subject
Encourages residents’ active involvement in clinical
work
Provides individual attention to residents
Demonstrates commitment to improvement of
teaching
Actively involves residents
Demonstrates resident assessment/evaluation skills
Uses questioning skills
Stimulates residents’ reective practice and
assessment
Teaches professionalism
Is dynamic, enthusiastic, and engaging
Emphasizes observation
Human Has communication skills
Acts as positive role model
Is an enthusiastic person in general
Is personable
Is compassionate and empathetic
Respects others
Displays integrity/honesty
Has wisdom, intelligence, common sense and good
judgment
Appreciates culture and different cultural
backgrounds
Considers others’ perspectives and viewpoints
Is patient
Balances professional and personal life
Is perceived as a virtuous person and a globally
good person
Maintains health, appearance and hygiene
Is modest and humble
Has a good sense of humor
Is responsible and conscientious
Is imaginative
Has self-insight, self-knowledge, and is reective
Is altruistic
Adapted from Sutkin etal. [17]

270
W. F. Miser
sion also involves setting clear expectations and structuring
time for both work and learning.
Teaching Styles Teaching styles are principles, strategies,
and behaviors adapted by faculty to enable residents’ learning [18]. They are reected in how faculty present themselves to residents, transfer learning material, interact and
engage with residents, and manage learning tasks. Although
there are various recognized teaching styles, four are commonly used, especially in one-to-one interactions. The
Expert Consultant style is used when the faculty covey
expert knowledge to the resident in response to a specic
question. This is the traditional teacher-oriented form. An
example is when a resident asks the faculty for the dose of a
certain medication and the faculty responds with the dosage.
This style is useful when a simple answer can be given and
time is of the essence.
The Socratic style is used when the faculty explores the
resident’s knowledge through thoughtful questioning. The
faculty has a predetermined goal of what the resident should
learn. This style is often regarded as the preferred style but is
more time-intensive. An example is when the resident asks
for the dose of a certain medication and the faculty member
replies with a series of thoughtful questions such as asking
why that certain medication was chosen, whether are there
other options that might be less expensive but just as effective, etc.
The Collaborative style is used when the resident asks a
question the faculty member may not know and the resident
and faculty member mutually pursue the answer. This is a
good opportunity for the attending to demonstrative how
they seek answers in a time-effective manner using evidencebased tools. The Counseling style is when the faculty member explores intra- and interpersonal issues in a difcult
patient encounter. Instead of focusing on a disease or treatment, the attending provides support to the resident and
advice on how to manage similar issues in the future.
No one teaching style is best and the choice depends upon
the resident and the situation. Each encounter, however,
should have one goal for the learner to learn, and each
encounter should employ at least one of these teaching styles.
It is best to match the teaching style with the level of the
learner. First-year residents most often at the beginning need
the expert style while more senior residents may need to be
stimulated with the Socratic approach.
Feedback
Regardless of the clinical setting, a crucial skill all faculty
need to master is the ability to provide feedback to residents
[19]. Feedback to residents on their skills and abilities is
essential for efcient and effective learning so they “reach
their maximum potential.” [1, 20] Residents crave feedback
but often complain they do not receive enough feedback on
their performance, as if they are in a “feedback vacuum.” [1]
Feedback can be complex but is essential to learning in medicine [21].
Rocket engineers in the 1940s appreciated the concept of
feedback, dened as information a system uses to make
adjustments in reaching a predetermined goal [22]. As the
rocket hurdles toward the moon, there is constant feedback
between NASA and the rocket. If the rocket is off course,
feedback is given to correct the heading to put the rocket
back on course. If the rocket is on course, feedback is given
to the rocket to continue its course. The ultimate goal is to
have the rocket land safely at its destination. Likewise, as
residents care for patients they need to know what corrective
actions need to take place so they achieve the goal of graduating with the skills for autonomous practice. If they do
something right, residents need to know what they did right
so they can continue that behavior.
Feedback is distinct from evaluation. Feedback is formative, descriptive, and neutral and presents information on
behaviors and actions, with the goal of guiding future performance. Feedback is best when given continually. Evaluation
on the other hand is summative and presents judgment. There
is a place for both in clinical education. Positive feedback,
with the aim of having the resident continue a certain behavior, should not be looked upon as a compliment, the purpose
of which is to make the resident feel good. Negative feedback, with the goal of improving performance, should not be
perceived as criticism, the purpose of which is to make someone feel bad. All feedback should be constructive. “Helpful
feedback is a supportive conversation that claries the [resident’s] awareness of their developing competencies, enhances
their self-efcacy for making progress, challenges them to set
objectives for improvement, and facilitates their development
of strategies to enable that improvement to occur.” [21]
Before providing feedback these ve questions should be
considered. Are my perceptions accurate? Sometimes it is
useful to ask others if they have noticed a similar behavior.
Ask who is the best source for delivering the message. This
person should have the technical skills to evaluate the resident’s performance, have observed the behavior rst-hand,
and have developed a relationship of trust with the resident.
Are the motives genuine? Feedback should only be given to
convey information, not as a means of control, of putting
someone in their place, or of expressing aggression. Ensure
that one is genuinely trying to help the resident, not simply
serving one’s own needs. Is the resident ready to listen, or
will they be blindsided? If a resident is not in a mood or position to listen, they may respond in anger or dismiss the comments. Finally, what is the best setting? Supportive feedback
is often welcome when other colleagues are present, but cor-

26 Practical Didactic, Bedside, andOce Teaching Skills
271
rective feedback should be given privately whenever possible. Feedback should never jeopardize a resident’s
relationship with patients or colleagues.
For feedback to be effective the learning environment
should be safe, respectful, and nonjudgmental [23]. The resident needs to feel safe and understand that the faculty member is working as an ally and has their best interest at heart.
A resident’s trust in the faculty is important for the feedback
to be well received [24]. The learning environment needs to
be one in which feedback is the norm and not the exception.
“Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved
empirically or not at all.” [22]
Although feedback is best when given continually, it is
most effective when it doesn’t come as a surprise [19]. It is
best at the beginning of residency to set the tone that feedback will frequently be given with the purpose to help residents improve their skills. Reinforcing this at the beginning
of each year and at the beginning of each rotation will help
frame feedback in a positive light. Also, knowing how each
resident prefers to receive their feedback helps tailor how
and when it is given.
Several tips exist for feedback to be effective (Table26.2).
When giving feedback it is often helpful to begin by asking
the resident how they thought they did with a particular
patient care encounter or procedure. Inviting the resident to
self-assess helps promote the development of a reective
physician [23]. Their answers will help provide insight into
their ability to self-reect and self-assess their performance.
After they answer, follow-up questions could be, “What
aspects did you think went well?” and “What aspects could
Table 26.2 Tips for effective feedback
Establish a safe, respectful, nonjudgmental learning environment
Provide feedback with care and intention to always help the resident
grow
Be a good listener and observer, being aware of the resident’s verbal
and nonverbal responses
Ensure the resident is ready to receive the feedback
Base feedback on personal observations and not hearsay
Be specic and concrete, focusing on specic actions and behaviors
that can be changed
Avoid general praise or criticism
Feedback should be brief and concise—too much at one time can be
overwhelming
Focus the feedback on the action or behavior, not the resident
Feedback should be timely, given when the resident is receptive and
the action/behavior is recent; avoid feedback when the resident is
tired or stressed, especially after a signicant bad outcome has
occurred (wait for emotions to settle)
Clarify the resident understands the feedback and then follow up the
feedback with an action plan to monitor and assist the resident
Adapted from Kaprielian and Gradison [19], Ramani and Krackov [23]
and Ende [22]
be improved?” [19]. Their answers will help lay the platform
for further discussion and feedback.
Feedback should always be given to the resident with the
utmost care, with the intention of helping the resident grow.
Feedback should be specic rather than general, with a focus
on actions or behaviors the resident can change. Frustration
occurs when a resident is reminded of a shortcoming in
which they have no control. A resident and their personal
traits should not be the focus of the feedback [19]. It is best
to avoid “you” or “your” when providing feedback, although
this can be challenging. Feedback focused on the individual
and potentially threatening to self-esteem is unlikely to be
effective [21].
The “feedback sandwich” (telling the residents what they
did well, then what was not the best, followed by what they
did well) needs to be sincere. Don’t sandwich negative feedback in between too many accolades or the person may not
hear the critique. Evidence is lacking that this approach is
effective [21].
Feedback should be timely, occurring as soon as possible
after the action or behavior has occurred. It is best given
when the resident is receptive. If a resident is overly fatigued
or stressed, especially after a major critical event such as a
patient’s bad outcome, it is often best to wait for emotions to
calm. During this time it is more important to support the
needs of the resident. Otherwise, feedback is most meaningful if given as soon as it is appropriate to do so. Waiting until
the end of a rotation to provide feedback from items at the
beginning of the rotation is not helpful as it does not provide
an opportunity to remediate the behavior during that
rotation.
Feedback should be brief and concise—giving too much
at one time may be overwhelming and not well received. A
single critique is more easily received than several at once.
Faculty should ensure the resident understands the feedback
given and then follow up with a plan to monitor and assist the
resident. Feedback should be balanced—it is just as important to “catch someone doing right” than always focusing on
the negative. Immediate praise after observing commendable
behavior will reinforce goals and expectations and help
maintain behavior. Positive feedback should be given often
and promptly with specics—not just “great job” but review
specic behaviors. Providing positive feedback on what residents are doing correctly helps build condence in their
skills and creates a better learning environment [23].
Feedback should be based on personal observation and
rst-hand data, not hearsay [22, 23]. Residents tend to discount feedback if they do not believe feedback is based on
rst-hand observation [25].
Faculty should own the feedback that is given, using “I”
statements (e.g., “I interpret your lack of not seeing the
patient that you don’t care about them. Please correct me if
my perception is wrong.”). When in a group it is often best to

272
W. F. Miser
“praise in public” without embarrassing the resident. If a
mistake has occurred, it is just as important to point that out
in the group so that others do not think the action or behavior
was okay. However, when correcting mistakes in a group, do
so in a manner in which a resident does not personally feel
identied—focus on the issue and not the resident. When
possible, respect the resident’s privacy, especially if the feedback is corrective.
Finally, faculty should ask for resident feedback. Being
receptive to hearing residents’ opinions and suggestions will
show residents that feedback both ways is important [19].
Faculty should reect on what went well, what to change
next time and what new strategies they will adapt for future
sessions [23].
Large Group Teaching: Delivering aDynamic
Presentation
Presenting a lecture is often one of the rst things to come to
mind when discussing teaching to a large group, usually
dened as 25 or more participants. The lecture has been the
primary method of college and university instruction for
more than 500years [26–28], yet it has been much aligned as
too boring, ineffective, pointless, old-fashioned, and obsolete [29]. Educator Hamilton Holt once described the lecture
as “that mysterious process by means of which the contents
of the professor’s notebooks are transferred by means of the
fountain pen to the pages of the student’s notebooks without
passing through the minds of either.” [8]
Lectures do have strengths if performed correctly [28].
Typically lectures can cover more material in a shorter time,
can be recorded and transcribed, and can be given to a large
audience which assures uniformity of information. They can
provide new and meaningful insights not captured in readings or the internet. They can pull information together from
a variety of sources and summarize results. The best lectures
will stimulate enthusiasm for the topic and encourage critical
thinking. Weaknesses are lectures do not account for individual differences among the audience members, offer little
opportunity to judge audience understanding, heavily rely on
participants’ note taking skills and memory, demand sustained listening, and can limit active learner participation.
The Pyramid of Learning proposed by the National
Training Laboratories for Applied Behavioral Science suggests that students remember only 5% of what they hear in a
lecture, 10% of what they read, 20% from a lecture that
includes audiovisual aids, 30% of a demonstration, 50% of
what they discuss in a group, 75% of what they practice by
doing, and 90% of what they teach others. Although recent
criticism has questioned the science behind this pyramid, it
does point out that the more the resident is involved in the
learning process the greater their retention rate of presented
material [30, 31]. It also points out that lectures without getting the resident actively involved results in very little retention of material [32]. Application and interaction increase
resident engagement and knowledge retention [8].
If included in residents’ education, lectures must be wellprepared, clearly organized, and energetically delivered [26].
They must be focused and relatively short in duration [33]. It
is important to take into account the principles of adult learning when planning lectures to the residents [8]. A Chinese
proverb illustrates this point: “Tell me, and I forget. Show
me, and I remember. Involve me, and I understand.” [34] The
best lectures will involve the residents in active learning by
including various methods to be covered in this section.
Interactive lecturing involves combining engaging presentations with carefully selected active learning methods [29]. If
lectures are to actively engage residents they must be done in
an environment safe from judgment or embarrassment [33].
Planning is the rst step in providing an outstanding
interactive lecture. Start by answering the 5 W’s—who is the
audience?; what is the goal for this lecture?; where will it be
given?; when will it occur?; and why am I giving this talk?
“As a result of this lecture, what do I want the residents to do,
to know, to feel, to remember?” Writing an impact statement
will help focus the method and content for the lecture.
Delineate proper boundaries and be clear about the conclusions the residents should take away from the presentation
[35]. Select content that is essential, needed, and important
[34]. Unless there is time, avoid material that may be interesting and “nice to know” but not essential. Include rules and
pearls and exclude the chaff [36].
A major problem is that most lecturers try to cram in too
much material in their given time frame, resulting in not nishing on time and causing confusion and frustration among
the residents. It is essential to never go over the allotted time
for the lecture. Identify the participants in the audience—
will there be a mixture of medical students and all 3years of
residents with various levels of knowledge, experience and
interests? If so, more planning is required to ensure the lecture includes important material for all. Tailor material to the
level of knowledge of the audience. Provide a common
ground and then expand. Finally, the format and location of
the lecture is important—will it be in a huge auditorium or in
a smaller classroom?
It is important to keep in mind what residents perceive as
being effective lectures. Generally they prefer topics that are
clinically relevant, practical, and readily applicable to patient
care [33]. They want lectures that have three to ve clearly
stated learning points in a shorter time period, typically
30–45minutes in length [33]. The most useful lectures are
those centered on clinical cases and questions, with an
emphasis on clinical reasoning.
When organizing the presentation, there are three necessary components—the introduction, the body, and the con-

26 Practical Didactic, Bedside, andOce Teaching Skills
273
clusion. The introduction is the engine of the train—it
requires a lot of energy, is very powerful, but often is missing. It is important that the introduction captures the attention of the audience. Do something so that the audience
wants to listen to what will be said. Examples can include a
dramatic story, case vignette, or stimulating question.
Explain why the material to be covered is important to them.
The introduction should include a preview and road map of
the main points that will be covered. If this lecture is a continuation of a previous lecture, review the major points from
what had previously been covered. The introduction should
create an atmosphere for learning. Some lecturers nd it
helpful to state the conclusion at the beginning. The best
learning occurs when the lecturer tells the audience the main
points of the presentation, then present those main points,
then conclude by restating them. “Tell them what you’re
going to say, say it, and tell them what you said.” [36]
The body of the talk is the “meat” of the lecture. It is key
to keep the body organized and logically owing. A clear and
organized instruction is related to improvements in deep
learning and higher-order thinking skills [29]. Typically
there should be no more than three to ve major points,
depending on the length of the presentation [35]. Progression
should be logical. Each main point should have three to ve
subpoints neatly packaged to illustrate the main point.
The attention span for most adults begins to wane after
12–15minutes [26, 37]. After 20minutes lectures become
less effective [8]. This may be even shorter in a generation
accustomed to YouTube and TikTok videos. As such, the presentation should be varied every 15 minutes to maintain
attention. Ideally this should involve the residents in the
audience. Techniques that can be used to vary this presentation can include having the residents break into small groups
of two to ve and present questions to address or cases and
vignettes to solve. Using this technique obviously shortens
the time allowed for the amount of material the lecturer can
present, but is important for learning.
The conclusion is the end of the presentation and should
decisively wrap up the lecture in a powerful way. At this time
the lecturer should review briey the major points discussed
with a few take away points. It is also important in the conclusion to create bridges for further learning. Ending the talk
with a “thank you” lets the audience know that you are done.
If time permits, allowing for questions is a good time to clarify any issues that arise during the lecture.
Specic Techniques for the Dynamic Lecture Even the
best prepared lectures may be boring. One must realize that
“lecturing is a mixture of art and science, that the podium is
part stage and part research bench, and that the lecturer must
capture not only the audience’s intellect, but their imagination and interest as well.” [36] Effort must be put into the
presentation to make it dynamic and memorable.
After preparing for the lecture, it is important to rehearse
the presentation, at least mentally. Arrive early to become
familiar with the room and if used, audiovisual equipment,
ensuring it works properly. Start on time—being late is unacceptable to the audience. Be prepared for Murphy’s Law
(anything that can go wrong will go wrong at the worst time).
Avoid making presentations totally dependent on slides and
have a backup plan in case a catastrophe occurs.
During the lecture use demonstrations, if appropriate,
anecdotes to make a point, and metaphors to enhance residents’ learning. If questions are to be asked by the lecturer
during the presentation, it is important to use them effectively. Ask one question at a time and wait at least 3–5seconds for an answer. This time may feel awkward but it does
take time for the residents to think about the question. One
technique is to silently count to 10 while waiting for an
answer [34]. Calling on a resident to answer is okay as long
as the environment is safe in case the resident answers the
question incorrectly. One method to engage and to check
comprehension without putting anyone on the spot is to use
a digital application using clickers or cellphones—results
can then be displayed on a screen [27].
The rst 1–2minutes of the presentation set the stage for
the remainder of the talk. Begin the presentation with a cordial, friendly greeting. Look as if you are glad to be with
them. Exhibit enthusiasm and speak loud enough so that
those in the back row will have no problem hearing. Stand
erect, don’t lean on the podium if present, and make eye contact with the audience. Begin the presentation with some
ground rules such as “we will have time at the end for questions so please hold them until then.” As a general rule, usually questions are best held during the close of the presentation
[36]. Premature questions interrupt the ow, and often are
answered later in the talk.
Smile and look as if you are pleased to be there presenting
this material. Sweeping eye contact from the left to the right
and front to the back of the audience during the presentation
helps connect with all members in the audience. One technique is to divide the room into quadrants and look at each
person in the quadrant before moving to the next quadrant.
Avoid monotone speech and use movements and gestures.
The larger the group, the larger the hand gestures and voice
inection. As noted, always keep within the allotted time
limit. Relax and enjoy the performance. Beware of and avoid
annoying mannerisms such as frequent clearing of the throat,
frequent use of “umms,” swinging a laser pointer, if used, at
the screen or circling a word with it, looking at only one section of the audience for the entire lecture, and playing with
keys or change in a pocket.
Even polished speakers experience some nervousness
when they present. Some individuals may be anxious to the
point they may want to take a mild sedative or beta-blocker
prior to the talk. However, it is important to know the effect

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W. F. Miser
that medication may take prior to the talk to avoid unwanted
effects. Some anxiety is helpful as it provides motivation and
energy for the presentation. Being prepared is the best
defense against nervousness. Knowing the content well and
being familiar with the setup of the room and the equipment
to be used during the presentation helps relieve anxiety.
Use of Audiovisual Aids Residents will retain more from a
lecture that includes the use of audiovisual aids. The purposes
of audiovisual aids are to complement the presentation,
emphasize important points, reinforce key concepts, stimulate the residents’ senses, and enhance the clarity of the presentation. Audiovisual aids should enhance the spoken word,
but not be the talk itself. Avoid reading from the slides. If
used, audiovisual aids should be done carefully as poorly
done aids can distract. The four “Rs” of audiovisual aids is
that they should be [1] readable (legible, visible to everyone,
appropriate format for the size of the group and room), [2]
reliable (choose the least complicated aid that will do the job
effectively, don’t build the entire presentation around them in
the event they fail), [3] relevant (pertinent to the topic being
presented), and [4] repetitious (support the presentation,
stress important points and summarize key concepts). It is
best to not use an aid if it requires a lengthy explanation or an
apology.
With smaller audiences, writing on a whiteboard or ipchart can be useful as audiovisual aids, especially when
working through a patient scenario and wanting resident participation. The main advantages of using a whiteboard is that
it is readily available, inexpensive, encourages spontaneity,
material can be easily changed or updated, it is highly
dependable, and if done properly involves the residents in the
learning process. Disadvantages of using a whiteboard is that
there is no permanent record of the material presented, it is
not very portable, it limits the size of the audience, and if
used improperly, places the instructor’s back to the audience.
If used, writing must be legible and the presenter must be
careful to not talk while facing the board.
Flip charts have the same advantages as the whiteboard,
plus it may provide a more permanent record. Disadvantages
include limited writing space, any changes can be messy, and
limits are placed on the size of the audience. The same precautions exist for ip charts—writing must be legible by all
participants and the presenter should avoid talking while facing the board. If large amounts of material are to be recorded,
having an assistant do the writing can be advantageous.
With today’s technology, the use of presentation software
such as PowerPoint has become the most used audiovisual
aid for providing lectures. Prepared PowerPoint slides are
one of the best media for large rooms or audiences, are portable, and references can easily be made back to previous
material. Videos can be embedded within the presentation.
Disadvantages to the use of slides are they require projection
equipment and often the room must be darkened for maximum effectiveness. To counter the latter, using a white or
light background with dark lettering may allow the lights to
remain on. If used, slides should only be used to reinforce or
highlight key concepts and not be the talk itself. Action slides
which contain pictures should only be left on long enough to
provide maximum effectiveness while word slides can be left
on substantially longer.
The number of slides to be used during the presentation
depends upon the complexity of the material and the presenter.
Normally using one slide per 1–2minutes is a rough guide; too
many more may be distracting [29]. The usual rule is “less is
more” meaning that slides should be minimalist in design.
Limit each slide to one main idea. Subdivide complex information into several slides and successively disclose the content. Keep slides simple and bold. Normally sans serif fonts
such as Helvetica and Arial are easier to read. Use a larger type
size for the title and smaller type sizes for the rest of the words.
The size of the font should easily be legible from the back of
the room. Use upper and lower case and avoid full sentences
(unless using a quotation). Simple bullet points help organize
the slide. Use key words with no more than six to eight words
each line and ve to seven lines per slide. Leave adequate
spaces between words and use double line spacing.
Normally colors used in the slide should be consistent and
pleasing to the eye. Changing the background frequently can
be distracting. Keep headings in one color and the body of
text in another. One well received standard color combination is to use a dark background, such as dark blue, with light
lettering (such as white or yellow). However this color combination often requires the lights to be lowered in the room
for maximum effect. An effective color combination that
allows the lights to remain on is a white background with
black or dark gray lettering. For those who are color blind, a
black/white or blue/white color combination is best.
Embedding a picture highlighting the material can be effective as long as it reinforces the main point of the slide.
If a word chart is used, each line in the table should have
one thought. Keep the chart simple by limiting it to no more
than six words per line and six lines per slide. Limit type
styles to two and don’t try to tell everything with the chart. If
a pie chart is used, limit the number of slices to no more than
six if possible. Ideally the largest slice should be in the 12
o’clock position and data should read clockwise in descending sizes. Slices should be tagged logically, either on the
slice or outside of the slice with an arrow pointing to the
slice. Judiciously use tilted and three-dimensional pies as
they may distort the data.
Graph charts should use different line weights, heaviest
for data, medium for horizontal and vertical axes, and lightest for grid lines. If possible limit the number of lines to four.
When presenting bar and column charts, arrange the data so

26 Practical Didactic, Bedside, andOce Teaching Skills
275
bars are in ascending or descending order, using the minimum number of bars to present the information. If using
three-dimensional bars, drop the shadow below the top of the
bar rather than above it.
Typically the slide should be understood within 5seconds
of presentation. Items which promote this is keeping the slide
elements consistent, using the same type of balance on the
slides throughout the presentation, and using images subtly
and sparingly in combination with text and chart slides. It is
important to check spelling and numbers for accuracy as any
potential errors are magnied for the audience. Avoid overcrowding the slide and making “ugly” slides. One should
never have to apologize for a slide—it is better just not to
include it in the presentation. Busy slides should be deleted
[36]. Before using a slide ask these questions: is the slide
appropriate? accurate? legible? comprehensible? well executed? interesting? memorable? brief? If the answer is no to
more than two of these it is best to discard the slide.
Flipping the Classroom An educational approach to more
actively involve participants in the material to be covered in
the lecture is known as the “ipped classroom.” [38] This
method involves providing residents with reading material, a
video or podcast to review prior to the session, which then
allows the lecture time to be used for small group, active
learning exercises such as working through case vignettes.
Those that use this technique nd that it improves resident
self-direction and encourages residents to take responsibility
for their own education [38]. The ipped classroom improves
knowledge acquisition and retention compared to the standard lecture format [39]. However, this approach requires the
residents to be self-motivated and to actually review the
assigned materials. The pre-lecture activities support lower
levels of learner cognitive work (e.g., knowledge and comprehension) while the in-class activities are used to facilitate
higher levels (e.g., application and analysis) [38].
Small Group Teaching: Team Rounding
intheHospital Setting
While discussing medical education in 1867, Oliver Wendell
Holmes stated, “The most essential part of a student’s
instruction is obtained, as I believe, not in the lecture room
but at the bedside.” [40] In this section we will cover techniques useful in clinical teaching in small groups consisting
of four to 16 individuals. We will focus on teaching rounds in
a hospital setting, but these techniques are also useful in
leading effective small group discussions in the ofce, journal club, and other settings. A small group atmosphere facilitates learning in all three domains—cognitive knowledge,
affective knowledge, and motor skills.
Role of the Family Medicine Attending In most residency
programs an inpatient team consists of six learners with a
mixture of junior and senior medical students, all 3-year
groups of residents, and a FM faculty member, known as the
attending. The attending is responsible for the care of the
patients admitted to their service, ensuring patient safety and
quality care is provided. The attending is also responsible for
clinical teaching to the medical students and residents on the
team. When not physically present on the ward, the senior
resident assumes the leadership and teaching of the team, but
the attending is still responsible to ensure an appropriate
management plan is in place.
Before assuming the role as inpatient attending, it is
important to ask several questions to help guide the teaching.
Ende recommended the following questions to ponder [41].
What do I want to accomplish as attending and what are my
vision and goals? This provides a system for self-assessment
and to develop a road map for daily instructional decisions.
What is my point of view and what aspects of medicine will
I emphasize? Possibilities include evidence-based medicine,
clinical epidemiology, physical diagnosis, quality and cost of
care, social aspects of care, etc. How much will my residents
be engaged in rounds, especially if some may be sleep
deprived? Rounds should be lively, interactive and fun and
“no one should be hurt, no one should dominate, and everyone should learn.” [41] How will I meet the needs of each
learner? It is important to set time at the beginning to get to
know each student and resident on the service to understand
their strengths and challenges.
There is not just one perfect way to conduct rounds. What
will be done depends upon the skill and knowledge level of
the residents and the complexity and number of patients on
the service. Irby described the phases of instructional reasoning and actions of distinguished attendings on inpatient
rounds [42]. Planning occurs prior to rounds—determining
what will be emphasized during teaching. During rounds the
attending diagnoses the patient’s conditions and the resident’s understanding of those conditions. It is during this
time the attending thinks interactively and teaches. After
rounds the attending reects on went well and what could be
improved during the next rounds. How will you organize
teaching rounds? Decide how much time will be sitting
together around a table to discuss the patients and how much
time will be spent visiting the patients at their bedside.
Decide if you will round together on all patients, or select a
few patients in which maximum teaching at the bedside can
occur. Regardless the attending must see every patient, either
as a team or individually. How will you nd the time to
accomplish this? Availability is key as studies suggest that at
least 23hours per week minimum is needed to accomplish
the tasks of inpatient attending [41].

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W. F. Miser
To maximize patient safety and clinical education, it is
important for the attending to set goals and expectations for
the team at the beginning of the rotation. This can include
providing excellent, safe, and quality patient care, assessing
personal learning needs, clinical teaching of the team, supervising and evaluating team members, supporting team
morale, and promoting team identity and unity—denitely a
tall order. The attending needs to accept all patients, see each
patient daily, understand the patients’ issues, orders, lab and
imaging results, and decide when the patient is to be discharged for further care in the ambulatory setting.
When setting expectations for the team, the attending
should clarify when to be called by the residents. There
should be enough supervision to oversee patient care issues
and know when potential problems are developing but also
allow the residents to manage the care so they learn. Residents
should also know they can ask for help at any time and are
not expected to ounder with seeking their own solutions.
Midway through the rotation the attending should meet with
the team to discuss how things are going and to review any
problems or changes that should be made.
The attending should discuss the goals of meeting as a
team and whether it will be once or twice a day. The purpose
of this rounding is to establish team identity and discuss each
hospitalized patient’s care. Although this can be done around
a table, the best learning occurs when seeing patient together
at the bedside. This helps exchange information on the
patient with direct patient contact, identies new and unresolved patient issues, reinforces group teaching, expands the
opportunity to role model and teach, and involves patients in
their own care. Role modeling is essential as students and
residents can see how the attending approaches patients at
the bedside through communication, shared-decision making, patient examination skills, and professionalism [43].
Seeing the patient at the bedside (“bedside rounds”) provides a great learning opportunity for the residents and
should be done as frequently as possible, even if they can be
time consuming [44]. Unfortunately, residents report
decreasing teaching time with patients, resulting in a decline
in clinical skills [43]. Decreasing time at the bedside negatively impacts the patient-physician relationship.
When making bedside rounds with the team, the number
of students and residents around the bedside should be limited to no more than six—this allows for demonstration of
clinical and interpersonal skills without overwhelming the
patient [45]. When beginning, brief the patient about what is
to occur and obtain consent for the teaching encounter.
Involving the patient in the teaching improves the patient’s
experience and provides some feeling of pride they are contributing to the residents’ education. At the bedside symptoms are elicited, physical signs are demonstrated, and
patients better understand their condition. It is probably best
to discuss differential diagnosis outside of the room, but dis-
cussing management plans at the bedside helps inform the
patient. It is important to never criticize or embarrass the
residents in front of the patient. Any corrective feedback
should be done outside the examination room. There should
be no surprises and everyone on the team should know what
can and cannot be discussed. For example, if the patient has
a recent diagnosis of cancer and does not yet know, discuss
how this will be revealed to the patient.
During the session avoid interruptions. Pagers and other distractions can degrade the learning experience and annoy
patients. If possible, include nurses in the bedside session to
help minimize interruptions and promote the concept of a team
approach to medical care. Tailor the session to the allotted time.
Involve all members and let everyone know their input is valued. Avoid medical jargon so the patient fully understands what
is being discussed. The patient should feel like a participant,
not a disease on display. After the session, consolidate the
information obtained and plan a course of action.
If family is present, asking the patient whether they can
stay during these rounds is important. If given permission,
involving the family improves satisfaction and teaches skills
of communication [44]. A simple ground rule is that everyone, including the patient and family, should feel better after
bedside rounds to be considered successful [44]. Bedside
rounds should be fun and instructive, not adversarial.
Garabaldi and Russell offer four strategies to improve
bedside teaching: (1) be present with patients and the residents, (2) practice evidence-based physical diagnosis, (3) use
point-of-care technology, and (4) provide feedback to residents [43]. Through a systematic literature review and modied Delphi process, Zulman and colleagues identied ve
recommended practices to foster presence and meaningful
connections with patients [46]. Prepare with intention—be
familiar with the patient prior to entering the room. This can
be done with the team by reviewing the chart together.
Understanding the patient’s life circumstances and “back
story” is helpful. Listen intently and completely—sit down
on a chair, lean forward, and position to listen. Sitting
increases patient estimates of visit length. Avoid interrupting
the patient, especially at the beginning, when they tell their
“story.” Agree on what matters—nd out what is most
important to the patient to develop shared priorities. Connect
with the patient’s story—consider the circumstances that
impact the patient’s health and acknowledge their efforts and
celebrate success. Explore emotional cues—notice and validate the patient’s verbal and nonverbal emotional cues to
become a trusted partner.
Modeling and incorporating these ve practices into bedside rounds demonstrates a method of connecting with each
patient. Bedside teaching will be enhanced by demonstrating
targeted physical examination and use of point-of-care technology such as ultrasound and digital stethoscope. Providing
real-time feedback, following guidelines previously estab-

26 Practical Didactic, Bedside, andOce Teaching Skills
277
lished, allows for teaching the entire team. Assigning specic tasks for each resident when they are at the patient’s
bedside, such as observing certain signs or demonstrating a
certain physical exam, followed by discussion with the team,
improves active participation.
At the time a patient is being discharged from the hospital, it is a good practice to reect on the care that was delivered, what was done well, what could have been improved,
and what was learned from caring for this patient [47].
Houchens and colleagues identied three key strategies
used by exemplary faculty in inpatient teaching: (1) foster
positive relationships, (2) patient-centered teaching, and (3)
collaboration and coaching (Table 26.3) [48]. Establishing
rapport and successful relationships with team members is
the cornerstones of excellent teaching [17]. Key features of
excellent attendings include enthusiasm, showing interest in
Table 26.3 Exemplary teaching techniques for inpatient attendings
Key strategy Examples
Foster Positive
Relationships
Patient-Centered
Teaching
Collaboration and
Coaching
Adapted from Houchens etal. [48]
Get to know each team member and address
them by rst name
Use appropriate humor to make rounds more
informal and enjoyable
Let team members present without interrupting
Be a member of the team instead of a “leader
of the team”
Be humble
Encourage the view that mistakes are critical
for learning and use your own past mistakes to
illustrate teaching
Admit when you do not know something and
show how you intend to nd the answer
Include other health professionals, such as
nurses, pharmacists, etc., in team discussion,
giving them full respect and seek their valuable
insights into the patients’ care
Prepare for rounds by reviewing medical
records, anticipating potential stumbling points,
identifying key teaching points, and identifying
items for the team members to study
Conduct rounds in a timely manner and
manage time well
Build rapport with patients and demonstrate
good patient-centered care
Plan for the patient’s future after discharge and
encourage the team to start thinking about the
patient’s discharge at the time of admission.
Engage team members in discussions about a
few key points—emphasize thinking process
over content knowledge
Through the Socratic method of questioning,
ask team members to explain their answers and
how they arrived at their conclusion
Share clinical reasoning with the team
members to help build analytical frameworks
Recognize differences in team members’
learning levels and adapt conversations
accordingly. Engage all team members in the
learning process.
residents and patients, being knowledgeable and helpful in
managing challenging patients and problems, actively involving residents, running balanced rounds, working with residents outside of rounds, acknowledging the resident’s role as
team leader and manager, and providing and receiving feedback easily. In a qualitative study of distinguished clinical
teachers, Irby noted these eight common principles: (1)
actively involve learners and ask lots of questions, (2) capture
attention and have fun, (3) connect the case to broader concepts, (4) go to the bedside, (5) meet individual needs of the
learners, (6) be practical and relevant, (7) be selective and
realistic, focusing on a few important teaching points per
case, and (8) provide feedback and evaluation [13].
Small Group Discussion The discussion that occurs on
daily rounds can be one of the most powerful learning experiences for students and residents. If done correctly, small
group discussion can provide immediate feedback about the
resident’s knowledge level and helps identify areas for
further teaching. Small group discussions can develop
higher- order cognitive skills, form or change attitudes, and
encourage active participation by all learners.
Steps in leading small group discussions include preparing for the discussion, starting the discussion, managing the
group process, and concluding the discussion. In preparing
for the discussion, the attending can notify the team that they
will be covering a particular patient care issue the following
morning. This will allow time for the attending or senior
resident to nd an article for the team to read prior to the
discussion to ensure a common ground. The topic for discussion should be relatively clear and limited enough to focus
the residents’ attention. Centering the discussion around a
patient’s care on the team will help make the topic relevant.
Settle on one to two key points to teach at the bedside
encounter.
Create the expectation of participation and arrange seating so it is easy for everyone to see each other. When getting
the discussion started, the attending can focus on the patient’s
issues, state objectives and create an agenda for the discussion. A climate of mutual respect will put the students and
residents at ease so they may more likely participate in the
discussion. The attending’s primary role in a discussion is to
act as a facilitator, encouraging active participation, keeping
the group on task, clarify and mediate when needed, and to
summarize at the conclusion of the discussion. Facilitative
behaviors include listening and observing, allowing for
silence (for learners’ thinking), requesting examples, recognizing contributions, testing consensus, and dealing with
conicts.
Asking thought provoking questions is an essential skill
in leading small group discussions. The two basic types of
questions are convergent (e.g., “What is the best antibiotic

278
W. F. Miser
Table 26.4 Types of questions used in small group discussions
Types of questions Examples
Knowledge “What are the known major risk factors for
coronary artery disease?”
Application “Proper diet and exercise are often difcult for
patients with diabetes mellitus. What does that
tell us?”
Problem solving “An elderly woman with type 2 diabetes
mellitus on metformin develops pneumonia.
Would you continue or stop the metformin?
Please justify your answer.”
Attitudes and values “Should family physicians assist in euthanasia
of terminally ill patients?”
Prompting Leading the resident to the correct answer by
questions containing hints to the desired
response.
Justication Soliciting reasons and underlying
understanding.
Clarication Asking for a restatement of an incomplete or
poorly organized response.
Extension Encouraging the resident to elaborate on a
correct response.
Redirection Taking a question from a resident and
redirecting it to another resident or the group
for a response.
choice for this patient with sepsis?”) and divergent (e.g.,
“What right does this patient have in refusing medical treatment?”). There are also several levels of questions, as outlined in Table 26.4. Using these types of questions can
generate good discussion among members of the group.
The Socratic method of questioning incorporates a
thoughtful line of questioning that carefully leads the resident to the answer and effectively develops critical thinking
skills [49]. The use of probing questions as a teaching method
is efcient, effective, and results in better knowledge recall
[10]. In contrast, asking a series of difcult questions, known
as “pimping”, with the sole purpose of embarrassing the resident and showing the superior knowledge of the faculty, is to
be avoided [50]. The main distinction between Socratic
teaching and pimping is in the perception of “psychological
safety.” [51] Socratic teaching holds residents accountable
for learning without resorting to humiliation or
intimidation.
If questions are asked, phrase them clearly so the resident
doesn’t have to guess what is asked. Avoid “read my mind”
questions [10]. Low-level questions can be used to assess
knowledge while high-level questions assess problemsolving skills. Ask one question at a time and allow ample
time for an answer. Being patient is important as often time
is needed to generate good discussion. Ensure good eye contact is maintained with each member of the group. Be sensi-
tive to the residents’ feelings and challenge but do not
threaten. More than likely there will be a mixture of extroverts and introverts in the group. It is important to manage
the “talkers” by calling or redirecting questions to the
“non-talkers.”
One-on-One Teaching: Ambulatory
Precepting intheOce
The Accreditation Council for Graduate Medical Education
(ACGME) Family Medicine Residency Review Committee
considers the family medicine practice as the “foundation for
resident education in family medicine.” [52] It is here that
family medicine residents, under the tutelage and supervision of experienced family medicine clinicians known as
preceptors, develop their skills, knowledge, and attitudes
over 3years to transform from recently graduated medical
students to family physicians capable of full-spectrum autonomous family medicine care. The teaching environment in
the ofce is quite different than that of the hospital ward
(Table 26.5). Teaching in the ofce has many benets.
Residents will be learning and caring for conditions they will
encounter in their future practice. The ofce is where the
majority of medicine is practiced in the United States.
Residents are able to more completely observe the impact of
chronic diseases over time. With continuity residents can
learn how knowing their patients allows for better quality of
care. There often is a closer relationship between the resident
and the preceptor. Finally, the ofce is the more appropriate
forum for teaching good communication skills, the psychosocial aspects of disease, and preventive medicine.
Table 26.5 Comparison of hospital and ofce learning environment
Features Hospital setting Ofce setting
Patients Often have well-
dened acute problems
Problems addressed
tend to be limited in
number
Time Usually can address
many aspects without
time pressure
Teaching Can often prepare
teaching points ahead
of time
Often come with a mixture of
acute and chronic problems
Problems often have unclear
presentations
Preventive health care needs to
be addressed
Multiple psychosocial issues
need addressed
Decisions often made without
complete information
Often do not have time to read
and prepare ahead of
discussion
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