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26 Practical Didactic, Bedside, andOce 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 identied 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 denes a good clinical teacher in medicine, Sutkin etal. identied 49 themes that could be grouped into three major characteris­tics, physician, teacher, and humanistic (Table 26.1) [17]. The majority of the identied 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 Specic 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’ reective 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 reective Is altruistic
Adapted from Sutkin etal. [17]
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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 reected 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 specic 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 difcult 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 efcient 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, dened 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 claries the [resi­dent’s] awareness of their developing competencies, enhances their self-efcacy 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-
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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 (Table26.2). 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 reective physician [23]. Their answers will help provide insight into their ability to self-reect 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 specic and concrete, focusing on specic 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 signicant 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 specic 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 specics—not just “great job” but review specic behaviors. Providing positive feedback on what resi­dents are doing correctly helps build condence 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
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“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 identied—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 reect on what went well, what to change next time and what new strategies they will adapt for future sessions [23].
Large Group Teaching: Delivering aDynamic Presentation
Presenting a lecture is often one of the rst things to come to mind when discussing teaching to a large group, usually dened as 25 or more participants. The lecture has been the primary method of college and university instruction for more than 500years [2628], 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 3years 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 30–45minutes 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-
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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 12–15minutes [26, 37]. After 20minutes 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 briey 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.
Specic 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 3–5sec­onds 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 1–2minutes 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 inection. 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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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 1–2minutes 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
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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 5seconds 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 magnied 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 intheHospital 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 ofce, 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 reects 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 23hours per week minimum is needed to accomplish the tasks of inpatient attending [41].
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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—denitely 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, identies 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 modi­ed Delphi process, Zulman and colleagues identied 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, andOce Teaching Skills
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lished, allows for teaching the entire team. Assigning spe­cic 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 reect 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 identied 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 etal. [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 conicts.
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
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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 difcult 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.
Justication Soliciting reasons and underlying
understanding.
Clarication 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 efcient, effective, and results in better knowledge recall [10]. In contrast, asking a series of difcult 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 intheOce
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 3years to transform from recently graduated medical students to family physicians capable of full-spectrum auton­omous family medicine care. The teaching environment in the ofce is quite different than that of the hospital ward (Table 26.5). Teaching in the ofce has many benets. Residents will be learning and caring for conditions they will encounter in their future practice. The ofce 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 ofce 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 ofce learning environment
Features Hospital setting Ofce setting Patients Often have well-
dened 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