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These two principles can help you translate learning theory into effective practical teaching. Keep your teaching relevant and take advantage of
small “teachable moments” frequently.
Tips for Teaching that Won’t Slow you Down (Too Much)
While every clinical setting could be described as busy, the inpatient setting
usually adds acuity and increased severity of a patient’s illness to the equation, making the time pressures uniquely challenging to the hospitalist
physician.
9
Below are some teaching techniques that can help you maximize
teaching for your learners despite the pressures of time, and take advantage
of the teaching opportunities on the wards (see also Table 2).
7,9–13
Teaching Different Levels of Learners
Teaching different levels of learners simultaneously is the classic model
of inpatient teaching. It is also one that can prove to be the most daunting
to faculty who are eagerly trying to ensure that all learners on the team are
engaged and actively learning. Some of the methods that your best clinical teachers used are undoubtedly those recommended in the literature.
9,11,13,14
While considering the following options, try using more than
one method. While it may be easier and more comfortable using one
teaching method, changing teaching formats keeps you and your learners
more engaged, and reaches different types of learners.
Suggestions:
1. Explain how you will be conducting rounds and your expectations.
For example:
• Everyone will be involved so that we’re all contributing and
learning from each other.
• I’ll be asking lots of questions and it’s ok to be wrong, but I expect
you to try to reason through the questions or think about how to
find the answer.
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Teaching Tips and Pearls
Table 2. Tips for Teaching with Limited Time
Teaching Technique Actions Example
Orient your learners on 1. Explain the daily schedule
• Are there any particular
Day 1 and establish 2. Introduce team to each topics that we should
goals (Saves other, nurses, etc. focus on this month?
time later) 3. Clarify your expectations for • What types of experiences
rounds, presentations, write-ups have been most useful
4. Ask learners for to you in attending rounds
their goals (bedside rounds, review
5. Share your learning goals of radiology studies, etc?
Create a productive 1. Introduce yourself and others
learning environment 2. Use learners’ names
(i.e. A stimulating 3. Encourage participation
learning setting where (invite learner’s opinions and
learners feel questions, ask
Do you have any questions
comfortable to verbalize questions, praise independent about our session
their ideas and thinking, state your desire yesterday?
knowledge gaps) for participation)
4. Engage your learners/
audience: Speak clearly,
make eye contact, use
I also had trouble
an animated voice, avoid learning to diagnose
sitting/standing in one place acid-base problems. Let
5. Acknowledge your me show you what
own limitations helped me.
Create interest in 1. Show enthusiasm for Acid-base problems are my
the topic your topic and learners favorite topic to teach —
a. Why do you like it? they affect almost every
b. Why did you choose patient in the hospital and
to teach it? figuring out the problems
c. How is it relevant is fun once you understand
to them? the basics.
Center the teaching 1. Take time to diagnose your Jen, since you’re
around the learner’s learner before you teach going into OB/Gyn, you
needs 2. Choose topics that will undoubtedly see
are relevant to the patients with heart
learner’s experience, failure. Let’s focus on the
interests and physical exam findings
knowledge gaps today.
(Continued )
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L. Coplit
Table 2 (Continued )
Teaching Technique Actions Example
Let others help you teach 1. Use consultants’ expertise
Mike, why don’t you look
(include teaching about how up the diagnostic criteria
to ask a clinical question) for SLE, and Maria, can
2. Ask all learners on you look up the recent
the team to teach article on early vs. late
3. Search the literature initiation of dialysis on
as a team during patient survival to help us
a teaching session decide whether we should
call renal before
discharging your patient?
Use modeling to 1. Demonstrate a physical I want you to watch
demonstrate skills exam skills how I break bad news
2. Demonstrate to this patient and let’s
communication skills, talk afterwards about
history taking, or what you observed
patient counseling skills and how it went.
3. Demonstrate procedural
skills
4. Demonstrate written
communication skills
(note writing, consult
writing)
Verbalize your thought 1. Think out loud to explain
I’m debating whether this
process your reasoning process patient needs a cardiac
for diagnostic or catheterization or continued
treatment decisions medical management.
2. Include the alternatives His angina is stable and
that you are considering relatively well controlled
and why you are on meds, but the stress
excluding them test suggests the area
of ischemia is larger.
Let’s call cardiology to
evaluate him for a cath.
(Continued )
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Teaching Tips and Pearls
Table 2. (Continued )
Teaching Technique Actions Example
Create Teaching Scripts 1. Mini-lectures
(5–10 min) on the most
common topics (Anemia,
hyponatremia, acute
renal failure, etc)
2. Focus on diagnosis
or management
3. Use them as a teachable
moment when it’s
relevant to a patient’s
case
Extend the case 1. Ask “What if…” questions
• What if the patient’s
2. Illustrate how the creatinine was 3
context changes instead of 1?
the diagnostic possibilities • What if the patient was
and teaches clinical 60 instead of 20?
reasoning • What if you start
3. Helpful for sign out treatment and the
rounds with housestaff patient starts seizing?
because it can help • What will you do if
predict potential the patient spikes a
unrecognized outcomes fever tonight? Why?
Ask higher level 1. Requires your learners
(reasoning) questions to analyze data and
apply information,
unlike a recall (pimping/
factual) question
2. Allows you to evaluate
• Why do you think this
your learners clinical patient has jaundice?
reasoning skills • Why did you rule
3. Demonstrates to learners out hepatitis?
the types of questions • How do you treat heart
to be asking themselves failure in a patient with
aortic stenosis?
(Continued )
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L. Coplit
Table 2. (Continued )
Teaching Technique Actions Example
Teach and role model 1. Address the hidden
other important curriculum
topics that impact The customs and unspoken
learners and patients actions that learners
experience
2. Functioning on the wards
Time management, use of
technology, relationships with
other healthcare providers
3. Professionalism
Your responsibilities to
patients and colleagues, and
your attitudes and behaviors
4. Empathy
5. Effective use of the
literature
6. Communication skills, including
oral and written presentations
• Explain how you will ask questions and who is responsible for
answering the questions.
• Stop me if you have any questions.
2. Ask level appropriate questions to all — Start with the most junior learners (differential diagnosis, pathophysiology) and increase the “clinical
difficulty” of the questions with each level of learner (advanced differential diagnosis for interns and management, advanced management and
recent literature for residents). If a senior learner is not able to answer a
question, avoid allowing a more junior learner to attempt it because this
may embarrass the resident and affect group dynamics.
3. Consider aiming high — Target your teaching to the intern and resident
level which allows more junior learners to see what they will eventually
be expected to know, but allow junior learners to ask clarifying questions.
4. Have them teach each other — Vary how often, how much, and who
will teach.
5. Make the resident your “teaching assistant” — Many are very up to
date on recent literature and subspecialty medicine.
6. Let the team work together to guide the discussion — Generate a list
of problems/learning issues from a case presentation and allow the
team to decide which you will discuss.
7. When the team is separated (such as post-call), take advantage of that
time and dedicate some teaching to the level of learners left on the team.
8. Remember that everyone needs to learn and review the basics — The
most common medical conditions, physical findings, diagnosis and
treatment. The techniques above can help to ensure active learning for
all, but don’t hesitate to teach “bread and butter” medicine.
The Microskills of Clinical Teaching
The Microskills of Clinical Teaching is a practical, well studied, well
known, learner-centered teaching model designed for time-limited clinical teaching settings.
15–17
It is also called the One Minute Preceptor referring to the ability of the attending to use five short steps to facilitate a
quick, yet effective teaching encounter. It is most useful after a case presentation and allows the teacher to evaluate the learner’s level and knowledge, teach important concepts, and provide meaningful feedback to
learners.
Example of the Microskills in Action
A medicine resident covering medical consults presents a patient to the
medicine consultation attending:
Mrs. M. is a 62-year-old woman with diabetes and hypertension who is
post-op day #3 from a right fem-pop bypass. Her nurse called me at 7 am
today because she was complaining of heartburn. She said that she felt
burning and pressure in her lower chest for an hour and did have some
nausea. She doesn’t have any cardiac history, has a history of GERD, and
had some relief with Maalox. Her BP was a little elevated at 145/90, HR
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Teaching Tips and Pearls
85, and the rest of her vitals were normal. Her exam was unremarkable
and her ECG was unchanged. Her labs are pending.
1. Get a Commitment
Attending: What do you think is going on?
Resident: I think it’s probably GERD, but I’m not sure.
2. Probe for Supporting Evidence
Attending: What led you to that conclusion?
Resident: She said that this feels similar to her usual heartburn
which is the most compelling piece of history to me and her ECG is
unchanged.
Attending: Do you feel comfortable ruling out a cardiac cause of her pain?
Resident: That is next on my differential. As I said, her ECG is unchanged
but she has LVH and some flipped t waves at baseline. Her pre-op stress
test was unremarkable, but it wasn’t diagnostic because she’s on a beta
blocker. She has a family history of CAD and she is diabetic, so I realize
that she can have an atypical presentation, but I still think this is GERD.
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L. Coplit
Case
Presentation
Evaluate Your Learner
1. Get a commitment
2. Probe for supporting
evidence (reasoning)
Teach
3. Teach General
Rules
4. Reinforce what
was right
5. Correct Mistakes
3. Teach General Rules (Focus on one to two general concepts that can
be applied to other patients in the future)
Attending: You’re probably right, but I’m concerned about her risk fac-
tors. Each time I create a differential diagnosis, I try to include the most
likely and the most concerning possibilities. The fact that she has known
vascular disease means that we can assume she also has CAD, so she is at
a fairly high risk of having perioperative ischemia after vascular surgery.
I think our suspicion is high enough to at least warrant checking her cardiac enzymes and a follow-up ECG.
4. Reinforce What was Right
Attending: You did an excellent job of distilling a complicated case into a
succinct and logical presentation, and you used all of the information to
create a reasonable differential diagnosis.
5. Correct Mistakes
Attending: The next time you see a patient with postoperative chest pain,
especially after vascular surgery, remember to have a low threshold for
working up and treating ischemia.
Pearls for Giving Meaningful Feedback with Less Stress
Regardless of whether evaluations of learners need to be formally documented, feedback is an essential part of teaching that cannot be separated
from the learning process. Feedback provides learners with direction,
helps them assess whether they are meeting their goals, and provides them
with the benefit of your wealth of experience and knowledge to help them
achieve their educational goals.
6,18,19
Faculty often forget or avoid giving
necessary negative/corrective feedback because it can be time consuming
and unpleasant, but there are several guidelines for giving feedback that
can make the process more comfortable for the teacher, and more useful
for the learner.
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Teaching Tips and Pearls
Guidelines for Effective Feedback:
1. Commit to a specific date and time to give global feedback with each
team of housestaff/students (e.g. one attending rounds at the midpoint and the end).
2. Let your learners know what to expect at the beginning of the rotation:
Your goals — You will be basing your feedback upon these goals.
Relevance of feedback — Feedback will help them reach their
goals and everyone has room for improvement.
Your role — To work with them and help them improve (you are
their ally).
Their role — To assess their own performance, ask for help, dis-
cuss their assessment at your formal feedback sessions, and possibly give you feedback.
3. Be specific — Effective feedback explains to the learner what he/she
is doing right and what needs improvement.
Examples of Specific Feedback
It seems that you’re having difficulty with organization during the
day which is keeping you here late each night.
Your write-ups are excellent because they are well organized,
your HPI tells a logical story and your assessment explains your
thought process.
I’m concerned about your attitude towards the nurses because
you often make negative comments about them to your interns.
I’ve noticed that the chief complaints in your write-ups often
don’t address the actual symptoms of the patient at presentation,
but rather focus on the first thing the patient says — for instance,
for Mr. P who presented with complaints of dizziness and your
chief complaint was “my cardiologist told me to come in.” It may
require using a bit of interpretation. We’ll work on this for the
next few patients you see until it makes sense.
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L. Coplit
• Use the feedback sandwich if it makes you more comfortable (posi-
tive, negative positive OR positive negative, action plan), but make
sure your message is not lost in the sandwich.
• Ally with your learners:
I want you to be successful and we’ll work on this together.
How can I best help you achieve this?
• Have the learner create a plan for improvement — Ask the learners
how you can help them improve but have a plan ready in case they
need your help.
For the next week, lets go over your “To Do List” together right
after rounds. The first two days I’ll help you prioritize your list,
then you will take over and we’ll touch base at the end of each day.
Making Time for Teaching
The most helpful approach is to remember that great teaching occurs in
small moments and can be woven into the fabric of your clinical responsibilities. However, it can also be very helpful to plan out protected time
for teaching.
Suggestions:
• Plan time for teaching that is sacred (Nothing but a patient emergency
will cut it short or interrupt it). Examples:
Attending rounds
5 minutes at the beginning of work rounds
5 minutes at the end of work rounds
End of the day (around 4 pm)
20 minutes on “no admit” days for clinical skill teaching at the
bedside
Once a week at lunchtime for everyone on the team to present the
topics they researched that week.
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Teaching Tips and Pearls