Principles of Teaching and Principles of Teaching and Learning in Clinical Learning in Clinical

SettingsSettings

Professor Hossam HamdyProfessor Hossam HamdyUniversity of SharjahUniversity of Sharjah

AimAim

• What is Clinical Teaching

• Barriers to effective Clinical Teaching

• Strategies to improve Clinical Teaching

• Teaching and learning in different clinical settings

Clinical TeachingClinical Teaching

There should be no teaching There should be no teaching without the patient for a text and without the patient for a text and the best teaching is often that the best teaching is often that taught by the patient himself taught by the patient himself

(William (William Osler)Osler)

Triad Interactive Learning in Triad Interactive Learning in the Clinical Contextthe Clinical Context

ContentTeacher Patient

StudentContext

Teaching with PatientTeaching with Patient

BedsideBedside

Outpatient clinicOutpatient clinic Emergency wardEmergency ward

Day Case Surgery Day Case Surgery

O.RO.R

Barriers to Effective Clinical Barriers to Effective Clinical TeachingTeaching

Time lack for clinicians.

Insufficient space to teach.

Crowded outpatients.

Increasing number of ‘super-specialist’ clinics.

Barriers to Effective Clinical Barriers to Effective Clinical Teaching Teaching (cont/-)(cont/-)

Lack of patients and inpatient beds.

Lack of consistency in what is taught.

Lack of organization in what is taught between teachers.

Barriers to Effective Clinical Barriers to Effective Clinical Teaching Teaching (cont/-)(cont/-)

Teaching is not considered part of service commitment.

Lack of knowledge and skills about teaching methods.

The Clinical ContextThe Clinical Context

More shift from Hospital setting to More shift from Hospital setting to Ambulatory settings.Ambulatory settings.

Diminish the significance of bedside Diminish the significance of bedside teaching “short length of stay”.teaching “short length of stay”.

The Clinical ContextThe Clinical Context (cont/-)(cont/-)

Hospital populated with critically ill Hospital populated with critically ill and early post-operative patients.and early post-operative patients.

Early diagnosis – no or little physical Early diagnosis – no or little physical signs.signs.

Key Clinical CompetenciesKey Clinical Competencies

What are the key clinical competencies What are the key clinical competencies you as a clinical teacher want to ensure you as a clinical teacher want to ensure that the students have accomplishedthat the students have accomplished

Good communication and data Good communication and data gatheringgathering

Decision MakingDecision Making

Clinical TeachingClinical Teaching

Be available (on time) and approachable.

Introduce yourself and know their names.

Pre select patients/ Ask permission

Ensure respect for patients comfort and dignity

Planning “set”

Clarify expectations and goals appropriate to the setting, patient problems and student level “prior knowledge”

Clinical TeachingClinical Teaching

Planning “set” (cont/-)(cont/-)

Teach from clinical cases.Teach from clinical cases.

Go to the bedside or exam roomGo to the bedside or exam room

Use questions to diagnose patient & learners.Use questions to diagnose patient & learners.

Teaching “Dialogue”Teaching “Dialogue”

Clinical TeachingClinical Teaching

Role modelRole model

Focus the teaching on data gathering by or Focus the teaching on data gathering by or about the patient “critical player” about the patient “critical player”

Promote student clinical reasoning skills..Promote student clinical reasoning skills..

Teaching “Dialogue”Teaching “Dialogue” (cont/-)(cont/-)

Clinical TeachingClinical Teaching

Context specificity.Context specificity.

Prior knowledge & net-working.Prior knowledge & net-working.

Schemata and script Schemata and script concordance.concordance.

Non-Analytical ReasoningNon-Analytical Reasoning

“Pattern recognition”

Analytical ReasoningAnalytical Reasoning

Early hypothesis generationEarly hypothesis generation

Testing and re-testing hypothesisTesting and re-testing hypothesis

Pre-test Pre-test ProbabilityProbability

TESTTEST Post-testPost-test ProbabilityProbability

Analytical ReasoningAnalytical Reasoning

Each question in the history and each physical examination is a diagnostic test.

EBM Approach

Combined Model of Clinical Combined Model of Clinical Reasoning Reasoning

Patient Presents

Hypotheses Tested

Non-analytic Interactive Analytic

Case Representation

Increase the student base of Increase the student base of scenarios, scripts and mental images.scenarios, scripts and mental images.

Students should be guided to relate Students should be guided to relate novel experience with past novel experience with past experiences ‘Anchor proto-type in experiences ‘Anchor proto-type in their memory’.their memory’.

Clinical Teaching TipsClinical Teaching Tips

Clinical Teaching TipsClinical Teaching Tips (cont/-)(cont/-)

Implicit / Tacit Explicit

Key features of disease

Relevant information “focused history & physical exam.”

Model Professional Thinking and Decision Making “Preceptor Thinking Out Loud”

Clinical Teaching TipsClinical Teaching Tips (cont/-)(cont/-)

Priority in investigations and treatment.

Review diagnostic probabilities and rationale for diagnosis and treatment.

Model Professional Thinking and Decision Making

“Preceptor Thinking Out Loud”

The One Minute Clinical Preceptor The One Minute Clinical Preceptor Teaching ModelTeaching Model

Diagnose Patient & Learner

Microskill 1: Get a commitmentGet a commitment

What do you think the patient problem is?

Microskill 2: Probe for supportive Probe for supportive evidenceevidence

Reasoning. Why do you

think this is the case?

The One Minute Clinical The One Minute Clinical Preceptor Preceptor

Microskill 3: Teach general rules & Teach general rules & conceptsconcepts

• When this happens, usually …• Take home message

Feedback “closure”

Microskill 4: Provide regular, well Provide regular, well timed timed feedback.feedback.

Should be descriptive rather than judgmental.

Reinforces positive behaviors and motivates learner.

Conveys an attitude of concern and interest between instructor and learner.

The One Minute Clinical The One Minute Clinical Preceptor Preceptor

The one Minute Clinical The one Minute Clinical PrinciplePrinciple

Microskill 5: Correct mistakes and Correct mistakes and promote self promote self

assessment assessment and and self-directed learning.self-directed learning.

Focus on behavior, not individual.

Ask learner for their opinion or perception.

Be straightforward, but respectful.

Feedback “closure”

Eight Attributes of an Effective Clinical TeacherEight Attributes of an Effective Clinical Teacher(after David Newbie, “A Handbook for Medical Teachers”)(after David Newbie, “A Handbook for Medical Teachers”)

1.1. Encourages active student participation rather than Encourages active student participation rather than passive observationpassive observation

2.2. Emphasis on teaching of applied problem solvingEmphasis on teaching of applied problem solving

3.3. Integrates clinical medicine with basic scienceIntegrates clinical medicine with basic science

4.4. Close observation of students during Close observation of students during interview/examination rather than side-room case interview/examination rather than side-room case presentationpresentation

Eight Attributes of an Effective Clinical TeacherEight Attributes of an Effective Clinical Teacher(after David Newbie, “A Handbook for Medical Teachers”)(after David Newbie, “A Handbook for Medical Teachers”)

5. Provides adequate opportunity for students to practice 5. Provides adequate opportunity for students to practice skillsskills

6. Provides good role-model for interpersonal 6. Provides good role-model for interpersonal relationships with patientsrelationships with patients

7. Teaching patient-oriented rather than disease-7. Teaching patient-oriented rather than disease-orientatedorientated

8. Demonstrates a positive attitude towards teaching 8. Demonstrates a positive attitude towards teaching

The Effective Clinical Teacher The Effective Clinical Teacher

Most important being willing to Most important being willing to teach teach

and be enthusiastic about itand be enthusiastic about it

Thank YouThank You

COMPARISON BETWEEN COMPARISON BETWEEN HOSPITAL AND COMMUNITY CLINICAL HOSPITAL AND COMMUNITY CLINICAL

TRAININGTRAINING

Hospital Community

Predictable experiences Opportunistic, unpredictable

Disease oriented Illness oriented/relationshipwith patients

Serious, complex, illness Self limiting, prevention, chronic care, psychosocial morbidityMultiple contacts with Single contactpatients

Patient

COMPARISON BETWEEN COMPARISON BETWEEN HOSPITAL AND COMMUNITY CLINICAL HOSPITAL AND COMMUNITY CLINICAL

TRAININGTRAINING

The LearnerHospital Community

Multiple learners Single learner

Multiple levels Often independent

Member of team

COMPARISON BETWEEN COMPARISON BETWEEN HOSPITAL AND COMMUNITY CLINICAL HOSPITAL AND COMMUNITY CLINICAL

TRAININGTRAINING

The TeacherHospital Community

High degree of control

Tensions :Competence of assessmentand management

Low control

Tensions :Acceptability to patientcompetence in assessment and management

Learning in Outpatient Clinic:Learning in Outpatient Clinic:

Focused History & Physical Focused History & Physical ExaminationExamination

Working diagnosisWorking diagnosis Cost-effective investigationCost-effective investigation Selection of management optionsSelection of management options Communication SkillsCommunication Skills

Tips for Teaching in the Tips for Teaching in the OutpatientOutpatient

Ensure patient comfort and Ensure patient comfort and cooperation. cooperation.

Access the learners’ needs before Access the learners’ needs before patient assignment.patient assignment.

Teach the concept of focused history Teach the concept of focused history and examinationand examination

Tips for Teaching in the Tips for Teaching in the OutpatientOutpatient (cont/-)(cont/-)

Use higher level questions to promote Use higher level questions to promote development of critical thinking skillsdevelopment of critical thinking skills

Teach good physician-patient Teach good physician-patient interaction skillsinteraction skills

Teach patient education skillsTeach patient education skills

Teaching in the Operating Teaching in the Operating RoomRoom

Instruction in operative techniquesInstruction in operative techniques

Training in the overall conduct of the Training in the overall conduct of the operationoperation

Discussion of the overall care of the Discussion of the overall care of the patient’s problempatient’s problem

Teaching in the Operating Room Teaching in the Operating Room (cont/-)(cont/-)

Anatomy, Pathology and Anatomy, Pathology and Pathophysiology.Pathophysiology.

Natural history of disease. Natural history of disease.

Potential postoperative complications Potential postoperative complications and follow-up plansand follow-up plans

O.R. Highest Rated Teaching O.R. Highest Rated Teaching BehaviorsBehaviors

Demonstrates respect for patientDemonstrates respect for patient

Role models good interaction with Role models good interaction with operating room staffoperating room staff

Allows students to assistAllows students to assist

Writing operative notesWriting operative notes

O.R. Highest Rated Teaching O.R. Highest Rated Teaching Behaviors Behaviors (cont/-)(cont/-)

Answers questions clearlyAnswers questions clearly

Provides feedback without belittlingProvides feedback without belittling

Remains calm, courteousRemains calm, courteous

Teaches with enthusiasmTeaches with enthusiasm