NASPGHAN/NESTLÉ NUTRITION INSTITUTE · Lauderdale Beach Resort in sunny Ft. Lauderdale, Florida!...
Transcript of NASPGHAN/NESTLÉ NUTRITION INSTITUTE · Lauderdale Beach Resort in sunny Ft. Lauderdale, Florida!...
NASPGHAN/NESTLÉ NUTRITION INSTITUTE
FIRST YEAR PEDIATRIC GASTROENTEROLOGY FELLOWS CONFERENCE
JANUARY 13 – 16, 2011
Course Director: Vicky Ng, MD and Co – Director: Daniel Kamin, MD
1
NASPGHAN/Nestle First Year Pediatric GI Fellows’ Conference
January 13‐ 16, 2011 Dear Pediatric GI Fellows: On behalf of NASPGHAN and the Nestle Nutrition Institute, a warm welcome to The Hilton Fort Lauderdale Beach Resort in sunny Ft. Lauderdale, Florida! We remain thrilled that NASPGHAN and the Nestle Nutrition Institute have continued to partner over the last 9 years to bring together all the 1st Year Fellows of our North American Pediatric GI community. This year, we have a record number of 109 first year fellows, and 15 faculty members! We are most pleased that with each year, the membership of our 1st Year Fellows continues to grow – truly reflecting a positive effect you are having on your profession and future. The goals of this conference are:
1) To help you all develop strategies to get the most out of your fellowship training, with a particular focus on the choice of scholarly activities to pursue during the 2nd and 3rd fellowship training years;
2) To introduce you to the various career paths available in our Profession, and start you thinking about what makes the most sense for you;
3) To encourage a healthful approach to work and life balance, particularly the personal and professional issues that can contribute to burnout during fellowship; and
4) To introduce you all to the larger pediatric GI community. This is also a great opportunity to meet your peers and a rich variety of NASPGHAN faculty. We encourage you to take full advantage of this unique opportunity. Indeed, many of those whom you meet in these three days will become not only future colleagues, but future mentors, collaborators, and life‐long friends. A full agenda has been carefully planned, and we hope the next 3 days will not only be educational and instructive, but will also transmit the enthusiasm of the great faculty who have come together. We hope you take back home with you new ideas, new tools with which to examine them, and the exciting beginnings of a professional network of creative, budding gastroenterologists. So……..get ready for some candid conversations, frolicking fun, and fantastic food! Sincerely,
Vicky Ng, MD José Saavedra, MD
2
2011 FIRST YEAR PEDIATRIC GASTROENTEROLOGY FELLOWS CONFERENCE TABLE OF CONTENTS
Welcome Letter Faculty Listing Program at a Glance Small Group List Choosing a Research Project Manu Sood, MD Designing a Research Project Joshua Friedman, MD Introduction to Research Ethics Daniel Kamin, MD Writing and Presenting an Abstract for a National Meeting Valeria Cohran, MD Breakfast with NASPGHAN and CDHNF Maria Perez, MD and Kathleen Schwarz, MD Getting the Most Out of Your Fellowship Vicky Ng, MD Choosing a Mentor Peter Lee, MD How to Read and Critically Appraise Medical Literature Wallace Crandall, MD Teaching Talk: Dos and Don’ts Michael Narkewicz, MD Finding Balance Susan Gilmour, MD Depression and Burnout in Medical Training Alan Leichtner, MD
3
4
FACULTY Vicky Ng, MD, Director The Hospital for Sick Children Toronto, Ontario [email protected] Daniel Kamin,MD, Co‐ Director Children's Hospital Boston Boston, MA [email protected] Valeria Cohran, MD Children’s Memorial Hospital Chicago, IL vcohran@childrensmemorial .org Wallace Crandall, MD Nationwide Children's Hospital Columbus, OH [email protected] Joshua Friedman, MD The Children's Hospital of Philadelphia Philadelphia, PA [email protected] Susan Gilmour, MD University of Alberta Edmonton, Alberta [email protected] Gregory Kobak, MD Children's Hospital of The King's Daughters Norfolk, VA [email protected] Peter Lee, MD Inova Pediatric Digestive Disease Centre Fairfax, VA [email protected] Alan Leichtner, MD Children’s Hospital Boston Boston, MA [email protected]
Elaine Moustafellos, MD Hackensack University Medical Centre Hackensack, NJ [email protected] Michael Narkewicz, MD The Children's Hospital, Denver Denver, CO [email protected] Maria Perez, MD Nationwide Children's Hospital Columbus, OH [email protected] Pepe Saavedra, MD Nestle Nutrtion Institute Florham Park, NJ [email protected] Kathleen Schwarz, MD Johns Hopkins Children’s Center Baltimore, MD [email protected] Manu Sood, MD Children's Hospital of Wisconsin Milwaukee, WI [email protected]
5
6
Thursday, January 13
16:00 Faculty Briefing Vicky Ng/Daniel Kamin/Alan Leichtner 18:00 Reception 18:30 Dinner ‐ Seating in Groups –Welcome/Opening Remarks Pepe Saavedra/Vicky Ng 19:30 Introductions Faculty Leaders 20:00 GI Quiz Show – “Getting to Know You Exercise”
Greg Kobak/Elaine Moustafellos/Alan Leichtner
21:00 Goodnight!
Friday, January 14
07:30 Breakfast 08:00‐ 12:00 Session 1: Designing and Implementing Research Projects
Moderator – Vicky Ng
08:10 “Choosing a Research Topic” Manu Sood 08:30 “Designing a Research Project” Joshua Friedman 08:50 “Introduction to Research Ethics” Daniel Kamin 09:10 “Writing and Presenting an Abstract for a National Meeting” Valeria Cohran 09:30 Nutrition Break 09:45 Introduction to Clinical Research Exercise Daniel Kamin/Vicky Ng 10:00 Clinical Research Exercise
2011 NASPGHAN First Year Fellows PROGRAM‐AT‐A‐GLANCE
7
12:00 Lunch with Presentations: “So You Think You Can Present?”
Hosts: Vicky Ng/Daniel Kamin Judges: Manu Sood/Valeria Cohran/Joshua Friedman
14:00 Group Picture 14:30 Group Activity: “Sand Castle Building”
18:00 Reception 18:30 Dinner – Self‐Seating/Fellows Choose Tables:
1) Private Practice 2) Scientist Track 3) Educator Track 4) Clinical Investigator/Translational Researcher Track 5) Administrator Track 6) Medicine in Industry
Saturday, January 15
09:00 Breakfast with NASPGHAN & CDHNF Maria Perez and Kathleen Schwarz 10:00‐12:00 Session 2: How to Approach Challenges and Seize Opportunities During Your
Fellowship Moderator – Daniel Kamin 10:05 “Getting the Most Out of Your Fellowship” Vicky Ng 10:25 “Choosing a Mentor” Peter Lee 10:45 “How to Critically Appraise the Literature You Read” Wallace Crandall 11:05 Nutrition Break 11:20 “Giving a Great Teaching Talk”
Michael Narkewicz
8
11:40 “Finding Balance” Susan Gilmour 12:00 “Recognizing Burn Out During Fellowship”
Alan Leichtner 12:15 Lunch
Seating in Small Groups ‐ Discussions with Faculty Leaders 13:45 Free Time Options
1) Sign up for 1:1 Time with Faculty Members OR
2) Activities on Own 18:00 Reception 18:30 Dinner and Awards 21:00 Entertainment Sunday, January 16
07:00 Breakfast 08:00 Fellow Feedback Session/Complete Surveys/ Wrap Up and Closing Remarks Vicky Ng/Daniel Kamin 09:00 Faculty Feedback Session 11:00 Boxed lunches
9
10
Group 1 Gilmour Group 2 Crandall Group 3 Kamin
Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country
Valentino Pamela [email protected] Toronto Canada Newland Catherine [email protected] Chicago IL Awai Hannah [email protected] San Diego CA
Jensen Melissa melissa‐j‐[email protected] Iowa City IA Hourigan Suchitra [email protected] Balitmore MD Burghardt Karolina [email protected] Toronto Canada
Bayardo Ramírez. Laura María [email protected] Guadalajara, Jalisco CP Mexico Neef Haley [email protected] Ann Arbor MI Powers Kerry Jo [email protected] New York NY
Mohanty Prita [email protected] Rochester NY Vittorio Jennifer [email protected] New York NY Van Arsdall Melissa [email protected] Houston TX
Choquette Monique [email protected] Cincinnati OH Mir Sabina [email protected] Sugarland TX Raizner Aileen [email protected] New Haven CT
Vadlamudi Narendra [email protected] Birmingham AL Rodriguez Jorge [email protected] Los Angeles CA Asai Akihiro [email protected] Chicago IL
O'Meara Kevin [email protected] North Bethesda MD Church Peter [email protected] Toronto Canada Hollon Justin [email protected] Ellicott City MD
Ng Kenneth [email protected] Bellaire TX Pant Chaitanya chaitanya‐[email protected] Oklahoma City OK Hashemi Ismaeel [email protected] Ann Arbor MI
Group 4 Kobak Group 5 Narkewicz Group 6 Cohran
Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country
Yeh Ann Ming [email protected] Palo Alto CA Burgis Jennifer [email protected] Palo Alto CA Taketani Tami [email protected] Encinitas CA
Tapia Monge Dora Maria [email protected] Mexico City DF Mexico Gutierrez Glenda Karina [email protected] Delegacion CuahteMexico Gonzalez Berenice [email protected] Mexico City DF Mexico
Salehi Vesta [email protected] New York NY Co Maridine [email protected] Detroit MI Prince Esther [email protected] Brooklyn NY
Soler Dellys [email protected] Pittsburgh PA Jimenez Jennifer [email protected] Swarthmore PA Pham Yen [email protected] Houston TX
Rosen John [email protected] Chicago IL Sukkar Ghassan [email protected] Hamilton Canada Beasley Genie [email protected] Gainesville FL
Zaghloul Hazim [email protected] Royal Oak MI McFerron Brian [email protected] Indianapolis IN Turcotte Jean‐Francois [email protected] Edmonton Canada
Heintz D. Dyer [email protected] Dallas TX Rudolph Bryan [email protected] New York NY DeBosch Brian [email protected] Chesterfield MO
Lee Dale [email protected] Philadelphia PA
Group 7 Ng Group 8 Friedman Group 9 Moustafellos
Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country
Nguyen Vivien [email protected] Los Angeles CA Lau Audrey [email protected] San Francisco CA Vahabnezhad Elaheh [email protected] Los Angeles CA
Bhattacharyya Violina [email protected] Aurora CO Feldman Amy [email protected] Denver CO Memon Zebunnissa [email protected] Buffalo NY
Ambartsumyan Lusine [email protected] Chestnut Hill MA Afzal Amna [email protected] Brookline MA Sevilla Wednesday [email protected] Pittsburgh PA
Joerger Shannon [email protected] St. Louis MO Godínez Hernández Brenda [email protected] Mexico D.F. Mexico Singh Namita [email protected] Seattle WA
Karjoo Sara [email protected] Philadelphia PA Bramlage Kristin [email protected] Cincinnati OH Shouval Dror [email protected] Brookline MA
Bitton Samuel [email protected] New Hyde Park NY Paul Adam [email protected] Balitmore MD Vortia Eugene [email protected] Shaker Heights OH
Carroll Matthew [email protected] Vancouver Canada Elkadri Abdul [email protected] Toronto Canada Carlin Eduardo [email protected] McKinney TX
Infantino Benjamin [email protected] Omaha NE
Group 10 Perez/Schwarz Group 11 Leichtner Group 12 Lee
Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country
Bhardwaj Vrinda [email protected] Los Angeles CA Abell Rebecca [email protected] St. James NY Grzywacz Kelly [email protected] Montreal Canada
Kadzielski Sarah [email protected] Boston MA Kumar Soma [email protected] Columbus OH Rao Meenakshi [email protected] Jamaica Plain MA
Ruiz Navas Patricia [email protected] Medico D.F. Mexico Watson Sheree [email protected] Providence RI Barba Fabiola [email protected] Mexico
Muir Amanda [email protected] Philadelphia PA Lerner Diana [email protected] Milwuakee WI Sheflin‐Findling Shari [email protected] North Woodmere NY
Zacur George [email protected] Cincinnati FL Bayrer James [email protected] San Francisco CA Falaiye Tolulope [email protected] Nashville TN
Aggarwal Arun [email protected] Jackson Heights NY Bodicharla Rajasekha [email protected] Miami FL Ciciora Steven [email protected] Columbus OH
Uko Victor [email protected] Westlake OH Tran Khoa [email protected] Burlington MA Otu‐Nyarko Charles [email protected] River Ridge LA
Gurram Bhaskar [email protected] Milwuakee WI Bitar Anas [email protected] Oklahoma City OK
Group 13 Sood Group 14 Saavedra
Last Name First Name E‐Mail City State/Country Last Name First Name E‐Mail City State/Country
Woo Jennifer [email protected] Boston MA McElhanon Barbara [email protected] Atlanta GA
Valdes Estela [email protected] Guadalajara, Jalisco Mexico Aliaga Mabel [email protected] Mexico D.F. CP Mexico
Moya Diana [email protected] Buffalo NY Sampert Catherine [email protected] Salt Lake City UT
Kassabian Sirvart [email protected] Cleveland Heights OH Albenberg Lindsey [email protected] Philadelphia PA
Saginur Michael [email protected] Edmonton Canada Cameron Russell [email protected] Bronx NY
Middleton Jeremy [email protected] Atlanta GA Khalili Ali [email protected] Cleveland OH
Warolin Joshua [email protected] Nashville TN Wong Gregory [email protected] Houston TX
11
12
How to Choose a Research
ProjectManu R. SoodDirector of Motility & Functional Bowel Disorders ProgramMedical College of Wisconsin, Milwaukee
Goals and Objectives
Goal: Enhance your understanding of what constitutes a good research project and how to go about finding one
Objectives: You should be able to…1. Identify the three critical components of a good
research project2. Know the appropriate steps to take in order to
find a good and successful project.
Why Do Research ?
Opportunity to answer questions
Expectation of the training program
Develop skills in critical thinking which are
always useful
13
Keys Points to Choosing a Research Project
People to help guide you
The research project is of personal interest
Find a defined “do able” project
The project should be worth doing
Balance your ideas and independence with those of others
Decide what area or field you want to focus on
Previous experience
Career goals
Mentor & support
PAST PERFORANCE IS A GOOD
PREDICTOR OF FUTURE SUCCESS
Watch out for the aggressive
salesperson
14
Not Even Your Chief
Never let anyonepressure you intoa research project
What makes a good research project?
First and foremost, it must be interesting
You should learn something of value A technique, methodology, a way of
approaching problems, something you can take with you
It should be productive There should be a reasonable chance of
answering your question and publishing it
Fits your career goal
Pathways
Clinical Research Clinical trials Observational studies
Basic science
Population science
Translational science
15
Choosing a mentor
Remember:
One size does not
fit all1. Meet with possible
mentors, ask questions of others who have worked with them
2. Choose a mentor based on:
a. Past record, first and foremost
b. Potential projects, second
What to do in the first six months of your fellowship
1. Speak to potential research mentors
2. Identify possible projects (2-3 max)
3. Read about the topics and identify what you would enjoy and fits your career goal
4. Clearly define your goals
By the end of first year
After you have chosen a mentor, then…
Develop a research question Do a thorough search of medical literature Identify the edge of knowledge related to that
question and gaps in knowledge Be certain that your question has not already
been answered AND that filling the gaps is important
In other words, if you already knew the answer to your question, would anyone care?
Develop a testable hypothesis
16
Study design
Relevant to Your Career Goals
Stay Focused
How will you be judged
Level of involvement Were you involved in developing the
concept, analyzing data, writing manuscript?
Were you just a data collector?
How productive was it? Did you produce an abstract, manuscript,
present at meetings, etc.
Extent of commitment to research
17
Do’s and Don’ts
Do:
Focus on the mentor
Articulate research question
Literature search
Stay focused, don’t stray
Make sure project is achievable
Don’t:
Choose a mentor just because you like them
Make assumptions
Study something in which your mentor does not have expertise.
Take on a project that is not well developed
Summary
Good research projects are interesting, educational, and productive
The fit with your career goals Identify a mentor first, then the project-
good mentors are invaluable Focus on developing a research question
and then identifying gaps in the knowledge
Be certain that someone will care if you are able to fill that knowledge gap
18
The art and science of asking questions is the source of all knowledge
Thomas Berger
19
20
Designing a Research Project
Joshua R. Friedman, M.D., Ph.D.Assistant Professor of Pediatrics
The Children’s Hospital of PhiladelphiaThe University of Pennsylvania School of Medicine
Overview
• General Research Question
• Hypothesis
• Specific Research Questions
• Study Strategy
Research types
Clinical ResearchClinical
ResearchBasic
ResearchBasic
ResearchTranslational
ResearchTranslational
Research
21
What Makes a Successful Research What Makes a Successful Research Project?Project?
FINER
• Feasible
• Interesting
• Novel
• Ethical
• Relevant
http://www.fmdrl.org/group/index.cfm?event=c.showWikiPage&pageId=473
Feasible
• Is the question answerable?
• Do you have access to all the the materials needed for the study?
• Will you have enough time and money?
• Do you or your mentor have the expertise to complete the study?
22
Interesting
• Are you interested in the study?
• Will others be interested in your results?
Novel
• Has the study been done before?
• Will the study add new information?
Ethical
• Can the study be done in a way that does not subject subjects to excess risks?
23
Relevant
• Will it further medical science?
• Will the results change clinical practice, health policy, or direct new avenues of research?
Overview
• General Research Question
• Hypothesis
• Specific Research Questions
• Study Strategy
General Research QuestionGeneral Research Question
HypothesisHypothesis
Specific Research Questions
Specific Research Questions
Study StrategyStudy Strategy
Research Topic
24
General Research Question
• Derives from the research topic
• Broadly encompassing question
• Allows you to generate a hypothesis
General Research Question Development
• Literature Review
– Identify related research
– Define gaps in current knowledge base
– Avoid redundancy
– Set your research within the proper context
Tip
At the start of your research project, identify “model” articles…use these as guides in the design of your research project.
25
General Research Question Development
• Discuss with Mentor and Other Experts
– Unpublished work
– Recent discussion at meetings
– “Common” knowledge
– General & specialty interest in the field
General Research Question
• Be prepared to justify with published evidence to support
– Why is it a good idea?
– Why is the research worth doing?
• Consider the consequences if the research is positive, negative, or inconclusive
• Will others be interested in this work?
General Research Question
• Expresses curiosity about the relationship between two (or more) phenomena
• Describes a population under study
26
General Research Question
Does drinking coffee improve the procedural skills of pediatric gastroenterology fellows?
General Research Question
HypothesisHypothesis
Specific Research Questions
Specific Research Questions
Study StrategyStudy Strategy
Research Topic
Formulating a Hypothesis
• Formulation of the hypothesis comes after you have had the idea for the research, performed a careful and thorough literature review, and generated a general research question
• Puts the research into focus
• Leads directly to study design
27
What is a Hypothesis?
• A statement derived from the general research question that is used as a basis for argument
• A statement that can be tested
• Essential part of statistical inference
Formulating a Hypothesis
• Use prior evidence
– Clinical observation
– Published literature
– Basic biomedical (mechanistic) understanding
– Preliminary research data
Formulating a Hypothesis
• Good hypotheses
– Make a prediction
– Specify independent and dependent variables
– Specify effects of independent variables on dependent variables
28
Formulating a Hypothesis
• Consists of two competing claims:
– Null hypothesis (H0) ‐ negation of the research question of interest
– Alternative hypothesis (H1) ‐ acceptance of the research question of interest
Null Hypothesis
• Important in statistical testing – receives special consideration
• Must be disproved statistically
• Cannot be rejected unless the evidence against it is sufficiently strong
• Reject H0 in favor of H1 or Do not reject H0
• Never Reject H1 or Accept H1
Hypotheses
Good hypotheses
– Specific
– In advance
– Simple
– Null is stated
Bad hypotheses
– Vague
– After the fact
– Complex
– No clear null
29
Tip
Look down the road; don’t formulate a hypothesis that will lead to a type of research you cannot or do not want to perform.
Hypothesis
Does drinking coffee improve the procedural skills of pediatric gastroenterology fellows?
The amount of coffee consumed prior to performing endoscopy by pediatric GI fellows increases the rate of success of the procedure.
Null Hypothesis
The amount of coffee consumed prior to performing endoscopy by pediatric GI fellows does not increase the rate of success of the procedure.
30
Example
Does drinking coffee improve pediatric GI fellows’ ability to perform endoscopic procedures?
Can beer be considered a clear liquid during a colon preparation?
General Research Question
Hypothesis
Specific Research Questions
Specific Research Questions
Study StrategyStudy Strategy
Research Topic
Specific Research Questions
• What are the specific research questions that need to be answered in order to support or reject the null hypothesis
• Can be answered with: Yes, No, or by a Figure
• Sufficient detail to make the study strategy and analysis obvious
• No more than 3 questions
31
Specific Research Questions
The amount of coffee consumed prior to performing endoscopy by pediatric GI fellows does not correlate with the rate of success of the procedure.
1. Does the volume of coffee consumed affect the success rate of EGD or colonoscopy?
2. Does the length of time the coffee was consumed prior to the proceed have an effect on the rate of success?
General Research Question
Hypothesis
Specific Research Questions
Study StrategyStudy Strategy
Research Topic
Study Strategy
• Specific Research Questions should lead to the study strategy
– observational study vs. interventional Study
• How can the questions be answered?
32
Study Strategy
• Define: Subjects, Interventions, Controls, Outcomes of Relevance
• How can the questions be answered?
Measurement
• Moves the hypothesis from concepts to concrete data
• Define or assign numbers to the concepts under study
• Organizes data collection
Measurement
• Coffee consumption ‐‐ ounces of coffee
• Success rate ‐‐ time of procedure in minues, intubation of the terminal ileum
33
Study Strategy – Statistics
• Consult with a statistician‐ at the outset of the study design process
• Discuss study design
• Types of statistical tests
• Power of study
• Sample size
Study Strategy
• Is the strategy feasible?– Time
– Money
– People
– Equipment
– Patient population– Animal resources
• Consider alternative strategies– List advantages and disadvantages
Study Strategy ‐ Ethics
• Don’t leave ethical considerations as a last step item
• Protection of Participants
• Informed Consent
34
Study Strategy – Formalized Protocol
• Written study plan, detailed
• Without a protocol research can become an unguided exercise in data collection
• Necessary for a study to be replicable
Formalized Protocol
• Background and Rationale
• Hypothesis
• Objectives ‐ Specific Research Questions
• Research Design
• Study Flowsheet/Timeline
• Methods
– Patient Population
– Enrollment criteria
– Recruitment Plan
– Sample Size
– Intervention
– Outcome measurements
– Data Analysis & Statistics
• Human Subjects Protections Consent Procedures
Tip
Have your statistician review the final protocol!
35
Research Study Design
• Iterative process
• Re‐examination at each step of the process
• May need to back track and rework
• May need to abandon project
36
RESEARCH ETHICSDESIGNING AN ETHICAL STUDY
Daniel S. Kamin MDChildren’s Hospital Boston
Division of Gastroenterology and Nutrition
Objectives
• Key Historical Documents• Underlying Ethical Principles• Difference between clinical care and
research• Difference between children and
adults• Heuristic for determining ethical
adequacy of a research study
The Pediatric Dilemma
‘We want children to benefit from the dramatic and accelerating rate of progress in medical care that is fueled by scientific research. At the same time, we do not want to place any children at risk of being harmed by participating in such research, even though their very involvement may be essential to improving the overall medical care of children’
Richard Behrman, IOM 2004
37
Key Documents in Research Ethics
• Nuremberg Code (1949)– informed consent in research
• WHO Declaration of Helsinki (1964)– pediatric research and direct benefit
• Belmont Report (1978)– US gov’t effort to codify the ethical conduct of research
• Subpart D of 45 CFR Part 46 (1983)– US gov’t specific regulations for pediatric research
• IOM review of Subpart D (2004)– clarify meaning of key concepts and optimal procedures for recruitment in pediatric research
Adequate Balance in Pediatrics--Given Limited Autonomy
Special attention to beneficence and justice is necessary because:• autonomy is compromised (at least legally, often ethically)• parents give permission, but this is not the same as consent
Belmont Report:Autonomy
• Greek autos (‘self’) nomos (‘rule’)
• Respect for Autonomy promotes self-rule that is free from controlling interference by others and from certain limitations such as inadequate understanding that limits meaningful choice
• Fundamental tenet: extensive informed consent procedures, independent research subject advocates
38
Consent• The ethical and legal requirements of
consent have two aspects:
Provision of information: Purpose
Methods Demands Risks, inconveniences, discomforts Possible outcomes of the research, and
implications
Exercise of a voluntary choice to participate.
Belmont Report:Beneficence
• Hierarchy of obligation: 1. prevent harm
2. remove harm
3. promote our patient’s or patients’ welfare
• Pediatricians are familiar with the duty to promote the welfare of our patients, sometimes in spite of parents’ wishes
• Children are ‘vulnerable’: necessity for special protections as research subjects
Belmont Report:Justice
• Most complex and philosophically rich concept
• Justice ≅ Fairness• Fairness achieved when equals are treated
equally, and unequals are treated unequally• Problem: how do we gauge equality, and who
does the gauging?• A nice gloss: Research methods should not favor or
disfavor people on the basis of gender, race, class, socioeconomics, religion, sexual orientation, unless that characteristic is a fundamental variable in an otherwise scientifically and ethically valid investigation
39
Autonomy vs Beneficence in Research
28/68 (41%) parents let physician decide if child should participate
% of paren
ts
1. Challenge to achieve pure autonomy 2. Trust in physicians important to parents3. Even greater burden on physicians/scientists/IRBs to protect
a child/children/community from unexpected but unreasonablypredictable harm
Many parents not understand basic elements of the consent
Based on these principles, there are ‘rules’ that guide researchers to construct ethically permissible scientific investigations
40
Clinical care or research?
• Sometimes activity is easily classifiable, sometimes it is not
• Belmont Report– Research: ‘an activity designed to test a
hypothesis, permit conclusions to be drawn, and thereby develop or contribute to generalizable knowledge’
– Practice: ‘interventions that are designed solely to enhance the well-being of an individual patient that have a reasonable expectation of success’
Clinical care or research?
• Why Does it Matter?• When we do research, we have a
conflict of interest– Do what is good for the study– Do what is good for the patient
• Rules and oversight (IRBs) to help prevent the conflict from causing harm, and eroding trust in the system
Children versus Adults
• Adults: risks in proportion to benefits and to the value of the generalizable knowledge: no absolutes and not necessarily about subjects’ own conditions
• Children: protection from more than minimal risk– absolute risk categories(i) expectation of direct benefit to subjects; or
(ii) advancing the general knowledge about subjects’ condition
41
More than minimal risk
• Children participate after (i) adequate assent/permission, but, if (ii) risk more than ‘minimal’– harms must be balanced by prospect for
direct benefit to subjects; or,– harms must represent only minor increase
over minimal risk AND the research ought to yield vital knowledge about subjects’condition
Pediatric Risk CategoriesPediatric Risk Categories
Prospect of direct benefit
No prospect of direct benefit
Commensurate experiences
Vital knowledge re: subjects’ disorder
Risk/benefit is as favorable as alternatives
Risk is justified by the benefits
Minimal riskMinor increase over minimal risk
Greater than minor increase over minimal risk
Risk is justified by the benefits
Risk/benefit is as favorable as alternatives
Risk is not justifiedby the benefits
Not ethically and/orlegally justifiable
Categories refer to sections in Subpart D of 45 CFR 46
Ethical Adequacy in Pediatric Research-A Method
• Each of the Belmont Principles maps (more or less) to particular rules and regulations
• Consider each principle a ‘prism’ through which a protocol must pass
• Beneficence–harms and benefits• Autonomy– considerations for adequate
assent/permissions, avoidance of coercion• Justice–fair access or avoidance of
overrepresentation (intended or unintended)
42
The ModelBeneficence
Respect for Autonomy
Justice
Harms‐ Minimal risk‐Minor increase‐More than minor increaseBenefits‐ Direct benefit ‐ Knowledge about subject condition
Assent‐Developmental sensitivity‐ Attest to respect for developing
autonomy
Permission‐ Parents know what is
best for own children‐ Legal and moral responsibility
Benefits and burdens of research ought to be shared fairly
Prism One - Beneficence
• Minimal Risk Level– Harms/discomforts in proposed research
equivalent to harms/discomforts encountered by healthy children in their daily lives or experienced in routine physical or psychological examinations
– Relate to maturity level of research subjects– Consider duration, magnitude and probabilities
when determining level of risk• Minor Increase over Minimal Risk Level
– Slightly above minimal risk– Standard child is still a healthy child
Examples of Risk Categories
Procedure Risk Category
Minimal Risk Minor Increase More than Minor
Single Venipuncture
X
Chest XR X
DEXA X
LP X
Liver biopsy X
OGTT X
Skin biopsy X
Urine catheterization
X
Source NHRPAC, 2002
43
Prism One- risk evaluation
• Additional Considerations– Observational versus interventional
studies– RDBPCT versus comparison to standard
of care– Relatively healthy, chronically, or
catastrophically ill subjects– DSMBs
Prism Two- Respect for Autonomy
• Assent/permission is a process, not a form• Clarify for children degree of control they will
have over participation decision• Whenever possible, obtaining assent with
– No prospect for direct benefit– more important to have assent and willingness to participate
– Prospect for direct benefit– still important to discuss, even when children do not want to participate
• Need for repeated assent when children reach new developmental milestones over time
Prism Two- Payments
• Agreement to participate in research should not be coerced: unduly influenced by psychological, financial, or other pressures
• Compensation ought to be discussed openly, but not emphasized during the permission/assent process in manner that unduly influences decision-making
• Compensation is good when– Communicates appreciation– Encourages participation for people that would want
to participate but for (financial) hardships assuaged by the compensation
44
Prism Three- Justice
• Consider whether a study encourages under- or overrepresentation on the basis of social categories that are not the subject of the study
• If one is selecting patients based on a vulnerable social category, is this for a medically and scientifically important reason?
• Are there study recruitment methods or compensation strategies that can assuage unwanted under- or overrepresenation?
• International Research- beneficence and justice in action
Summary
• Twenty minute overview of research ethics is not easy
• As a vulnerable group, children garner special protections from harm and assurances of benefit
• Unique to pediatric research is the determinative nature of risk level and subject-focused benefit – nothing more than minimal risk unless particular
pediatric subjects will benefit directly or indirectly
References• Field MJ, Berman RE. Children CoCRI. The Ethical Conduct of Clinical
Research Involving Children. Washington, DC: Institute of Medicine;2004.
• Flotte et al: Recent Developments in the Protection of Pediatric Research Subjects. J Pediatr 2006;149:285-6
• Wilfond, B. Ethical Issues in Pediatric Research: Placebo controlled trials for gastroesophageal reflux. 2002. http://www.fda.gov/ohrms/dockets/ac/02/slides/3870S1_04_Wilfond/
• ‘Special Protections for Children as Research Subjects’, The Office for Human Research Protections, Department of Health and Human Servicers, accessed December 10th, 2010. http://www.hhs.gov/ohrp/children/
• Kopelman, L. ‘Children as Research Subjects: Moral disputes, regulatory guidance, and recent court decisions’. The Mount Sinai Journal of Medicine. 2006. 73: 596-604.
• Ramsey B. Appropriate Compensation of Pediatric Research Participants: Thoughts From an Institute for Medicine Committee. J Peds 2006 149:S15-S9
45
46
1© 2010 Childtren’s Memorial Hospital
Writing and Presenting Abstract for a Writing and Presenting Abstract for a National meetingNational meeting
““Begin with the End in MindBegin with the End in Mind””
Valeria Cohran M.D., M.S,Medical Director of Intestinal Rehabilitation/TransplantChildren’s Memorial Hospital
2© 2010 Childtren’s Memorial Hospital
OUTLINE:OUTLINE:
•• Writing an abstractWriting an abstract
•• (tips and tricks)(tips and tricks)
•• Presenting an Presenting an abstractabstract
3© 2010 Childtren’s Memorial Hospital
LetLet’’s start writing an Abstract!s start writing an Abstract!
Know the rulesKnow the rules–– Can Can notnot be previously presented at another meetingbe previously presented at another meeting–– Can Can notnot be published at time of presentationbe published at time of presentation
Know the deadlinesKnow the deadlines–– Often 5 Often 5 –– 6 months in advance of the meeting6 months in advance of the meeting–– Example: DDW (May) deadline: early DecemberExample: DDW (May) deadline: early December
NASPGHN (Oct) deadline: MayNASPGHN (Oct) deadline: MayAASLD (Oct) deadline: May AASLD (Oct) deadline: May
Know the styleKnow the style–– Read the abstracts from the previous meetingsRead the abstracts from the previous meetings–– Pay attention to font size, formatting, and lengthPay attention to font size, formatting, and length
47
4© 2010 Childtren’s Memorial Hospital
Style: clear and strongStyle: clear and strong!!
You want your abstract to be hardYou want your abstract to be hard--hitting!hitting!––11stst person, active voice:person, active voice:
““We studiedWe studied…”…” ““We observedWe observed…”…”
not not …… ““It was observed thatIt was observed that…”…”
Avoid abbreviations (no more than 2)Avoid abbreviations (no more than 2)
One idea One idea one abstractone abstract
Remember: Good science requires good Remember: Good science requires good writingwriting!!
5© 2010 Childtren’s Memorial Hospital
Abstract : FormatAbstract : Format(always 7 parts)(always 7 parts)
TitleTitleAuthors / InstitutionAuthors / Institution Introduction / BackgroundIntroduction / BackgroundHypothesis / AimHypothesis / AimMethodsMethodsResultsResultsConclusionConclusion
6© 2010 Childtren’s Memorial Hospital
1. Title1. Title
““An accurate promise of the abstractAn accurate promise of the abstract’’s s contentscontents”” D. J. PiersonD. J. Pierson
Most effective when it refers to its overall Most effective when it refers to its overall ““take home messagetake home message”” Ideally: 10 Ideally: 10 –– 12 words12 words
––Easy to understandEasy to understand––No abbreviationsNo abbreviations
Avoid Avoid ““cutecute”” jokes and plays on wordsjokes and plays on words..
48
7© 2010 Childtren’s Memorial Hospital
Limited to the people who actually designed, did, and analyzed the study.Rank order of the relative contributions
1st author (presenter, you!) last author (mentor)Conflict of Interest
2. Authors & Institution2. Authors & Institution
8© 2010 Childtren’s Memorial Hospital
3. Introduction/Background3. Introduction/Background
Answers the question:Answers the question:““Why did you start?Why did you start?””
Provides context for why you Provides context for why you performed the studyperformed the studyAssume readers/reviewers have some Assume readers/reviewers have some
familiarity with subjectfamiliarity with subject Ideally: 1 Ideally: 1 –– 2 sentences2 sentences
9© 2010 Childtren’s Memorial Hospital
4. Hypothesis/Purpose4. Hypothesis/Purpose
Answers the question:Answers the question:
““What was your goal?What was your goal?””
One definitive sentence!One definitive sentence!
Acceptable formats:Acceptable formats:
““We hypothesizedWe hypothesized…”…”
““The aim of this study was The aim of this study was …”…”
““The goal of this studyThe goal of this study……..””
Surprisingly, often omitted!Surprisingly, often omitted!
49
10© 2010 Childtren’s Memorial Hospital
5. Methods5. Methods
Answers the question:Answers the question:
““What did you do?What did you do?””
Can be written before study startedCan be written before study started
This section most often cited by reviewers as reason This section most often cited by reviewers as reason for a rejection!for a rejection!
Concise Concise –– details may be omitteddetails may be omitted
Basic researchBasic research: models, techniques: models, techniquesClinical researchClinical research: subject pop. (N=): subject pop. (N=)retroretro-- or prospective, randomization, controlledor prospective, randomization, controlledStatistical analysis of dataStatistical analysis of data
11© 2010 Childtren’s Memorial Hospital
6. Results6. Results
Answers the question:
“What did you find?”
The phrase “The findings will be presented” is unacceptable!
Need to include real data– * N= and p= values a good idea.
Something is either significant or it is not! – Do not use phrases “trending towards”, “almost
significant”, “different, but not statistically significant”
A table or figure is ok – make sure it:– is not too small– does not duplicate text
12© 2010 Childtren’s Memorial Hospital
7. Conclusion7. Conclusion
Concise statement of why the study’s findings are important
Reasonable and supported by the results
Can include interpretation
Do not:– make more of the data than is deserved– restate results
Optional: If space allows…can include implication statement and/or future direction
50
13© 2010 Childtren’s Memorial Hospital
References:References:
Boice, R. The new Faculty Member. 1992; Jossey-Bass Publishers, San Francisco.
McCabe, LL; McCabe, ERB. How to succeed in academics. Academic Press, Elsevier 2000.
Pierson, DJ. How to write an abstract that will be accepted for presentation at a national meeting. RespCare 49:1206-1212; 2004.
Cole, FL. Writing a research abstract. J Emerg Nurs23:487-90; 1997.
Lister, G. Mentorship: Lessons I wish I learned the first time. Curr Opinion in Pediatrics 16:579-584; 2004.
14© 2010 Childtren’s Memorial Hospital
Art of Oral PresentationArt of Oral Presentation
15© 2010 Childtren’s Memorial Hospital
4 W4 W’’s in Presentings in Presenting
Who?
What?
Where?
When?
51
16© 2010 Childtren’s Memorial Hospital
4 W4 W’’s in Presentings in Presenting
Who?–Know your audience
• Scientists, medical or graduate students, nurses, physicians
–Adult Learning Behaviors• Motivated to learn• Aims must be clear• Audience participation
17© 2010 Childtren’s Memorial Hospital
4 W4 W’’s in Presentings in Presenting
What?
–Research• Hypothesis• Significance/Aims• Methods• Results• Conclusions
18© 2010 Childtren’s Memorial Hospital
4 W4 W’’s in Presentings in Presenting
Where?
–National scientific meeting
–Departmental meeting
–Fellows’ conference
52
19© 2010 Childtren’s Memorial Hospital
4 W4 W’’s in Presentings in Presenting
When?When?
–In the morning–After lunch–During a dinner/lunch session
• Entertaining slide/cartoon• Carefully worded joke
20© 2010 Childtren’s Memorial Hospital
Research Presentations
Research
–Hypothesis–Significance/Aims–Methods–Results–Conclusions
21© 2010 Childtren’s Memorial Hospital
Balistreri, W JPGN vol 35(1):1-4.
53
22© 2010 Childtren’s Memorial Hospital
Principles of PresentingPrinciples of Presenting
Keep it Large and Legible (KILL)Back of the room should be able to read your
slides–6-8 lines of information
Audience reads 500 words/ minuteSpoken word 125 words/minuteSlides
– Consistent – Not Distracting
23© 2010 Childtren’s Memorial Hospital
Principles of PresentingPrinciples of Presenting
KILL means to Keep it Large and Legible
Please keep the text on your slide to the largest font possible so that the people in the back of the
room are able to read your slides.
Please remember that the audience can read faster than you can speak (500 words/min) as
compared to the spoken word (125 words/minute).
Please try to keep your slide back grounds consistent. Also remember it is important that you
choose a background that is non-distracting.
24© 2010 Childtren’s Memorial Hospital
Principles of PresentingPrinciples of Presenting
Keep it Large and Legible (KILL)Back of the room should be able to read your
slides–6-8 lines of information
Audience reads 500 words/ minuteSpoken word 125 words/minuteSlides
– Consistent – Not Distracting
54
25© 2010 Childtren’s Memorial Hospital
PresentationsPresentations
Font (TNR)
Font (TNR bold)
Font (Arial)
Font (Arial bold)Font (Arial Black bold)
Is the Font size the same?Can it be read in the back of the room?
26© 2010 Childtren’s Memorial Hospital
TextText
Concise
Clear
Proofread and Spell-check
Audience reads faster than you speak!
27© 2010 Childtren’s Memorial Hospital
Principles of PresentingPrinciples of Presenting
Slides
–Title each slide–Carefully chosen animation–Pointer use–Explain your graphs/figures–Transition between slides
55
28© 2010 Childtren’s Memorial Hospital
0
200
400
600
800
1000
1200
Intestine + Liver Intestine only
Number of UNOS listing for Number of UNOS listing for ITxITx Oct 1987Oct 1987--Jan Jan 20052005
74.3% vs 25.7%
1159
400
29© 2010 Childtren’s Memorial Hospital
16.9
83.1
46.4
53.6
0
10
20
30
40
50
60
70
80
90
100
%LIL
LIO
<17 yrs, n=1106 >18 yrs, n=453
Differences in Liver Listing Status between Pediatric Differences in Liver Listing Status between Pediatric and Adult Intestinal Transplantand Adult Intestinal Transplant
30© 2010 Childtren’s Memorial Hospital
Waiting List Mortality
light blue = intestine only dark blue= combined liver/intestine
Chungfat et al, Journal of Am Coll Surgery 2007;205:755-761
56
31© 2010 Childtren’s Memorial Hospital
PresentationPresentation
Bold TextFiguresAnimationTransitions between slidesPractice
32© 2010 Childtren’s Memorial Hospital
ConclusionsConclusions
4 W’s of Presenting– Who, What, When, Why
KILL– Keep it Large and Legible
Slides– Must be consistent, – Proof-read, – Transitions
Practice
33© 2010 Childtren’s Memorial Hospital
AcknowledgmentsAcknowledgments
Drew Drew FeranchakFeranchak, M.D., M.D.NestleNASPGHAN
57
58
Breakfast with NASPGHAN and Breakfast with NASPGHAN and CDHNFCDHNF
Kathleen Schwarz, MD Kathleen Schwarz, MD & &
Maria E. Perez, DOMaria E. Perez, DO
North American Society for Pediatric North American Society for Pediatric Gastroenterology, Hepatology, and NutritionGastroenterology, Hepatology, and Nutrition
•• Only society in North America and the Only society in North America and the largest in the world serving the Pediatric largest in the world serving the Pediatric Gastroenterology and Nutrition Gastroenterology and Nutrition communitiescommunities
•• More than 1400 pediatric More than 1400 pediatric gastroenterologists in North Americagastroenterologists in North America
NASPGHAN MissionNASPGHAN Mission
•• Advance understanding of normal development, Advance understanding of normal development, physiology, and pathophysiology of diseases of physiology, and pathophysiology of diseases of the GI tract and liver in childrenthe GI tract and liver in children
•• Improve quality of care by fostering the Improve quality of care by fostering the di i ti f thi k l d th hdi i ti f thi k l d th hdissemination of this knowledge through dissemination of this knowledge through scientific meetingsscientific meetings
•• Professional and public educationProfessional and public education•• Policy developmentPolicy development•• Serve as effective voices for members and the Serve as effective voices for members and the
professionprofession
59
Benefits of MembershipBenefits of Membership
•• Free participation at Free participation at yearly Fellows yearly Fellows ConferencesConferences
•• Reduced registration fees Reduced registration fees for the NASPGHAN for the NASPGHAN
•• Free subscription to the Free subscription to the PedsGI and PedsGIFellows PedsGI and PedsGIFellows Bulletin BoardBulletin Board
•• Access to the MembersAccess to the Members--Only section of the Only section of the o t e S Go t e S G
Annual Meeting, Annual Meeting, Postgraduate course, and Postgraduate course, and other educational other educational offeringsofferings
•• Reduced subscription Reduced subscription rates for rates for JPGNJPGN
•• Free NASPGHAN Free NASPGHAN Quarterly NewsletterQuarterly Newsletter
O y sect o o t eO y sect o o t eNASPGHAN websiteNASPGHAN website
•• Eligibility for research Eligibility for research awards and to apply for awards and to apply for research grants from research grants from CDHNFCDHNF
•• Opportunity to become a Opportunity to become a member of and participate member of and participate in NASPGHAN Committeesin NASPGHAN Committees
NASPGHAN CommitteesNASPGHAN Committees
•• Public Affairs & AdvocacyPublic Affairs & Advocacy•• Awards Awards •• Clinical Care & QualityClinical Care & Quality•• Endoscopy & ProceduresEndoscopy & Procedures•• EthicsEthics
•• Nominations *Nominations *•• NutritionNutrition•• Obesity Task Force Obesity Task Force •• Practitioner’s Task ForcePractitioner’s Task Force•• Professional DevelopmentProfessional Development
•• FellowsFellows•• FinanceFinance•• HepatologyHepatology•• IBDIBD•• InternationalInternational•• MOC Task ForceMOC Task Force•• Neurogastroenterology & Neurogastroenterology &
MotilityMotility
•• Professional EducationProfessional Education•• Public EducationPublic Education•• PublicationsPublications•• ResearchResearch•• Technology *Technology *•• TrainingTraining
Committee Selection ProcessCommittee Selection Process
•• SignSign--up sheets at 1up sheets at 1stst Year Fellows ConferenceYear Fellows Conference•• Sign up for 2 committeesSign up for 2 committees•• Random selection process Random selection process –– two 1two 1stst year fellows year fellows
per committeeper committee•• Those not chosen for a committee, will be given Those not chosen for a committee, will be given
the opportunity to join the Fellows Committeethe opportunity to join the Fellows Committee•• Committee meetings held at DDW and Committee meetings held at DDW and
NASPGHAN annual meetingsNASPGHAN annual meetings
60
NASPGHAN Fellows CommitteeNASPGHAN Fellows Committee
•• Open to Open to allall FellowsFellows•• Educate new fellows about NASPGHANEducate new fellows about NASPGHAN•• Annual reminder regarding the ITEAnnual reminder regarding the ITE
F ll ti t b th DDW d NASPGHANF ll ti t b th DDW d NASPGHAN•• Fellows receptions at both DDW and NASPGHANFellows receptions at both DDW and NASPGHAN•• Responsible for committee selection processResponsible for committee selection process•• Education about the individual Fellows Education about the individual Fellows
ConferencesConferences•• Maintenance of the Fellows section on the Maintenance of the Fellows section on the
NASPGHAN websiteNASPGHAN website
NASPGHAN Fellows CommitteeNASPGHAN Fellows Committee
•• BOARD REVIEWBOARD REVIEW–– Main focus of Fellows Committee over the past Main focus of Fellows Committee over the past
two yearstwo years–– Monthly board review questions via ListServMonthly board review questions via ListServ–– Board Review BookBoard Review Book–– Board Review BookBoard Review Book
•• Approx 90 fellows (past and current)Approx 90 fellows (past and current)•• Senior Editor Senior Editor –– Judith Sondheimer (Georgetown)Judith Sondheimer (Georgetown)•• 13 section editors13 section editors•• Will be published book, available to all Will be published book, available to all
NASPGHAN membersNASPGHAN members•• Funding by NestleFunding by Nestle•• Publisher Publisher –– Castle Connolly Graduate Medical Castle Connolly Graduate Medical
PublishingPublishing
61
62
Getting the Most Out of Your Getting the Most Out of Your FellowshipFellowship
Vicky Lee Ng, MD, FRCPC
Division of Pediatric GI/Hepatology and Nutrition
SickKids Transplant Centre
The Hospital for Sick Children
University of Toronto
January 2011
How can you get the most out of your fellowship?
Goals of Fellowship TrainingGoals of Fellowship Training
• Clinically competent in all aspects of general pediatric GI (identify 1‐2 areas of clinical expertise)
• Learn about research
• Find a job
• Define and start building a career
63
Goals of Fellowship TrainingGoals of Fellowship Training
• Begin to build skill sets and contacts necessary to:– Become a physician‐scientist– Become a clinician educator– Become a clinical expert– Run your own practice– Become a division director/department chair/fellowship director
– Work in industry
Requirements for Board CertificationRequirements for Board Certification
•• Clinical competenceClinical competence
•• Comprehensive core curriculum of scholarly Comprehensive core curriculum of scholarly activitiesactivities
•• Areas of scholarly activity:Areas of scholarly activity:–– Basic, Clinical, Translational researchBasic, Clinical, Translational research–– Health services researchHealth services research–– Quality improvementQuality improvement
–– Bioethics Bioethics –– EducationEducation
–– Public policyPublic policy
Clinical CompetenceClinical Competence
• Throw yourself into your clinical experiences
• See as many patients as you can during your clinical time
• Take every opportunity to do ANY procedure, especially those you’re least comfortable with
64
Clinical CompetenceClinical Competence
• Pay attention to how different people handle similar problems (fussy baby, adolescent with abdominal pain, asymptomatic elevated LFTs)
• Take advantage of “external knowledge” –nurses, nurse practitioners, coordinators, nutritionists, etc.
• Ask lots of questions
Clinical CompetenceClinical Competence• Observe procedures (ERCP, Kasai, IBD surgery, manometry)
• Get as much Pathology and Radiology experience as you can
• Listen to the senior staff talk about the cases that puzzle/interest them
• Read about your patients occasionally– Peer‐reviewed research articles– Review articles– Textbooks
– Google (Scholar)
Choosing an Area of Scholarly ActivityChoosing an Area of Scholarly Activity
65
Choosing a Research ProjectChoosing a Research Project
• Take note/Awareness of basic reactions:
– What kind of questions grab your attention?
– At a conference – what kinds of talks excite you/put you to sleep?
– What kind of papers do you enjoy reading?
Choosing a Research Project, Paul Doughty
Choosing a Research ProjectChoosing a Research Project
•• What do you like to do?What do you like to do?
–– Imagine what youImagine what you’’ll be doing dayll be doing day‐‐toto‐‐day to day to get your dataget your data
Choosing a Research Project, Paul Doughty
How To Choose a Good ProjectHow To Choose a Good Project
• Be informed!! (or hang around people who are)
• Look for gaps in the current knowledge:
–Data are too difficult for more senior people to bother getting
–Lack of the right technique
–Nobody’s gotten around to it yet
Choosing a Research Project, Paul Doughty
66
•• Follow Follow ““hothot”” journals journals –– ee‐‐mail Table of mail Table of ContentsContents
•• Talk to smart people Talk to smart people –– senior staff in your senior staff in your division, people you meet at conferencesdivision, people you meet at conferences
•• Pay attention to cool weird stuff that happens Pay attention to cool weird stuff that happens –– Why??Why??
How To Choose a Good ProjectHow To Choose a Good Project
Choosing a MentorChoosing a Mentor
Coming Up!
It’s time to get a REAL job
67
NASPGHANPeds GI Workforce Survey 2003‐04
USA Canada TotalEmployment Status
University/Academic 56% 87% 58%
Private Practice 23% 5% 22%Hospital or Clinic 16% 8% 16%Pharm or formula company
1% 0 1%
HMO 2% 0 2%Academic Appt
Yes 83% 97% 84%
No 17% 3% 16%Percent who receive a portion of salary from grants
24% 11%
NASPGHANPeds GI Workforce Survey 2003‐04
USA Canada TotalAcademic Track
Adjunct 7% 12% 7%
Clinical 61% 55% 61%Tenure 32% 33% 32%
Proportion Effort
Outpatient GI Clinic 38% 26% 37%
Procedures 13% 9% 13%Inpatient Rounds 15% 18% 15%Research 12% 19% 13%Teaching 5% 7% 5%Admin 7% 10% 7%
Career DevelopmentCareer DevelopmentFinding a jobFinding a job
• Use national meetings as a chance to meet people
• Ask your mentor(s) to introduce you to more senior people
• Use contacts (former fellows, other 1st year fellows) to learn about opportunities
• Become involved in NASPGHAN (bulletin board, website, JPGN, committees)
68
Career DevelopmentCareer Development
• Take time to think about your life/career
• Write down what you want
• Try to find someone to pattern yourself after
• Identify at least one senior person who will talk to you about your career, not just your research
• Share what you’re thinking ‐ people WANT to help you!
Career DevelopmentCareer DevelopmentBasic SkillsBasic Skills
• Learn to manage your time
–Handle paper only once–Do dictations immediately
• Read, Read, Read–Organize and file articles–“Chance favors the prepared mind”
• Write as you go• Sharpen the saw
In the endIn the end……....
• Don’t panic about the future• Take advantage of the expertise that surrounds you
• Be indulgent – choose things that REALLY interest you
• Push yourself• Enjoy the journey
69
ResourcesResources
• http://sciencecareers.sciencemag.org/career_development
• http://www.acphysci.com/aps/app
70
Choosing a MentorChoosing a Mentor
NASPGHAN Fellows ConferenceNASPGHAN Fellows Conference
January 15, 2011January 15, 2011
Peter Lee, MDPeter Lee, MD
INOVA Pediatric Digestive Disease CenterINOVA Pediatric Digestive Disease Center
What is a Mentor ?What is a Mentor ?
What is a Mentor ?What is a Mentor ?
A wise and trusted counselor or teacherA wise and trusted counselor or teacher
Today, Today, mentorshipmentorship refers to a refers to a y,y, ppdevelopmental relationship in which a developmental relationship in which a more experienced person helps a less more experienced person helps a less experienced individuals to develop…… in experienced individuals to develop…… in a spectrum of capacities.a spectrum of capacities.
71
Why do I need a Mentor ?Why do I need a Mentor ?
January is National Mentoring MonthJanuary is National Mentoring Month
I think mentors are important and I don't think anybody makes it in the world without some form of mentorshipmakes it in the world without some form of mentorship. Nobody makes it alone. Nobody has made it alone. And we are all mentors to people even when we don't know it.
Oprah Winfrey
WhoMentoredYou.org
Qualities of a MentorQualities of a Mentor
Knowledgeable, respected, supportive, Knowledgeable, respected, supportive, honest, enthusiastic, encouraginghonest, enthusiastic, encouraging
““Academic ParentAcademic Parent””
A good Mentor A good Mentor teaches, promotes, teaches, promotes, supports and advocates supports and advocates for their Menteefor their Mentee
A good Mentor is A good Mentor is invested invested in their Menteein their Mentee
Qualities of a MentorQualities of a Mentor
A good Mentor A good Mentor teaches:teaches:
Writing skills Writing skills –– abstract submission, grant abstract submission, grant gg ggwritingwriting
Oral presentation skillsOral presentation skills
Critical ThinkingCritical Thinking
Time managementTime management
72
Qualities of a MentorQualities of a Mentor
A good Mentor A good Mentor promotes:promotes:
Is honest with you Is honest with you –– Strengths and WeaknessesStrengths and Weaknessesgg
Guides you and provides constructive criticismGuides you and provides constructive criticism
Encourages you to strive for excellenceEncourages you to strive for excellence
Qualities of a MentorQualities of a Mentor
A good Mentor A good Mentor supports:supports:
Makes time for youMakes time for you
Listens wellListens well
Inspires you (role model)Inspires you (role model)
Dealing with disappointmentDealing with disappointment
Qualities of a MentorQualities of a Mentor
A good Mentor A good Mentor advocates:advocates:
Career Planning and DevelopmentCareer Planning and Developmentg pg p
Provides opportunities Provides opportunities
NetworkingNetworking
73
How do I find one?How do I find one?
Mentor Tree
It may take more than one apple to fill all those needs
How do I Start?How do I Start?
This above all: To thine own self be trueThis above all: To thine own self be true
Polonius to Laertes : Hamlet Act 1, scene 3Polonius to Laertes : Hamlet Act 1, scene 3
Self Reflection: What are my needs?
Short term: Research goals, clinical training
Long Term: Professional and personal development
Where to look?Where to look?
Academic/Research Path:Academic/Research Path:
Mentoring ProgramsMentoring Programs
Lead Investigator (research project), Faculty Lead Investigator (research project), Faculty member, Postmember, Post--doc fellowsdoc fellows
Ask your fellowship director, senior fellows, Ask your fellowship director, senior fellows, other faculty membersother faculty members
74
Where to look?Where to look?
Clinical Educator/Private Practice Path:Clinical Educator/Private Practice Path:
Recent faculty on clinical educator pathwayRecent faculty on clinical educator pathwayy p yy p y
Local/Private practice GI in communityLocal/Private practice GI in community
Fellowship Director, Medical School Faculty, Fellowship Director, Medical School Faculty, Senior FellowsSenior Fellows
How Do I Ask?How Do I Ask?
Be PreparedBe Prepared !! -- Be able to outline your short and Be able to outline your short and long term goals, what will it take to reach these goals long term goals, what will it take to reach these goals and how can your mentor help you to reach these goals and how can your mentor help you to reach these goals -- Personal Mission StatementPersonal Mission Statement
Set up a formal meeting/interview to discuss the Set up a formal meeting/interview to discuss the possibility of mentorshippossibility of mentorship
Be enthusiastic, honest, humbleBe enthusiastic, honest, humble
How Do I Make it Work?How Do I Make it Work?
Recognizing the “Chemistry”Recognizing the “Chemistry” –– Does their style Does their style of teaching, communication match or clash with of teaching, communication match or clash with yours?yours?
Be active not passiveBe active not passive Don’t expect yo rDon’t expect yo r Be active not passiveBe active not passive –– Don t expect your Don t expect your Mentor to setMentor to set--up everythingup everything
Be preparedBe prepared –– have an agenda, send any key have an agenda, send any key information in advanceinformation in advance
75
Multiple Mentors ?Multiple Mentors ?
“the assumption behind mentoring – ‘I’ll tether myself to one person who will take care of me’- is bankrupt. A better way is to build…a personal mosaic of influences, experts and guides.”
For Multiple NeedsFor Multiple Needs
“A” Good Mentor is Hard to Find“A” Good Mentor is Hard to Find
Research NeedsResearch Needs –– Build and develop your Build and develop your critical thinking, research skills, interpretation of critical thinking, research skills, interpretation of the medical literaturethe medical literature
Personal NeedsPersonal Needs –– Balancing work and familyBalancing work and family
Career Planning NeedsCareer Planning Needs –– Teaches you how to Teaches you how to “play the game”, politics of academic medicine, “play the game”, politics of academic medicine, business side of medicinebusiness side of medicine
TakeTake--Home MessagesHome Messages
A mentor is essential to a successful career A mentor is essential to a successful career
Mentees need to be diligent in seeking out these Mentees need to be diligent in seeking out these relationshipsrelationships
Y fi d/ d l l hY fi d/ d l l h You may find/need several mentors along the You may find/need several mentors along the wayway
Maximizing the satisfaction and productivity of Maximizing the satisfaction and productivity of a successful mentora successful mentor--mentee relationship requires mentee relationship requires selfself--awareness, focus, mutual respect, and awareness, focus, mutual respect, and explicit communication about the relationship.explicit communication about the relationship.
76
ReferencesReferences
Sambunjak D, Straus SE, Marusic A. Mentoring in Academic Sambunjak D, Straus SE, Marusic A. Mentoring in Academic Medicine: A Systematic Review. Medicine: A Systematic Review. JAMA 2006;296(9):1103JAMA 2006;296(9):1103--11151115..
Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T.Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T.Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T. Jackson VA, Palepu A, Szalacha L, Caswell C, Carr PL, Inui T. “Having the right chemistry”: A qualitative study of “Having the right chemistry”: A qualitative study of mentoring in academic medicinementoring in academic medicine. Acad Med 2003;78(3):328. Acad Med 2003;78(3):328--34.34.
Rose GL, Rutstalis MR, Schuckit MA. Informal mentoring Rose GL, Rutstalis MR, Schuckit MA. Informal mentoring between faculty and medical students. between faculty and medical students. Acad Med Acad Med 2005;80(4):3442005;80(4):344--348.348.
77
78
How to Read & Critically Appraise Medical Literature
Wallace Crandall, MDNationwide Children’s Hospital
How to Read & Critically Appraise Medical Literature (without a biostatistics degree)
Wallace Crandall, MDNationwide Children’s Hospital
79
Goals
Discuss one approach to becoming comfortable evaluating medical literature
Identify resources to help with this process
Resources
Users Guides to the Medical Literature I. How to Get Started
Getting Started Asking questions that are pertinent and answerable Tracking down articles
Three Questions Are the results of the study valid? What are the results? Will the results help me in caring for my patients?
Oxman AD, Sackett DL, Guyatt GH, JAMA 270(17), Nov 1993
Getting started
Asking questions that are pertinent and answerable More than just “reading” Relevant to your patient
Tracking down articles
Oxman AD, Sackett DL, Guyatt GH, JAMA 270(17), Nov 1993
80
Getting started
Asking questions that are pertinent and answerable “What should I do for my 15 yo IBD patient with
low bone mineral density?” “Should I give him a bisphosphanate?” “Are bisphosphanates effective for low BMD?” “Are bisphosphanates safe and effective in
improving low BMD in adolescents with IBD?”
Oxman AD, Sackett DL, Guyatt GH, JAMA 270(17), Nov 1993
Getting started
Tracking down articles Systematic reviews (eg Cochrane review) Practice Guidelines “High Impact” journals
NEJM 51.2 JAMA 31.7 Gastroenterology 12.5 Am J Gastro 6.1 Pediatrics 4.7 J Peds 4.1 JPGN 2.1
Three Questions(last year it was 10)
Are the results of the study valid? What are the results? Will the results help me in caring for my
patients? You still have to make a decision for your patient,
regardless of the evidence
These are often not “yes/no” answers Specific approach will vary by study type
Oxman AD, Sackett DL, Guyatt GH, JAMA 270(17), Nov 1993
81
Resources
Users Guides to the Medical Literature IIA. How to use an article about therapy or
prevention- Are the results of the study valid
IIB. How to use an article about therapy or prevention- What were the results and will they help me in caring for my patients
Guyatt GH, Sackett DL, Cook DJ JAMA 270(21) Dec1993; Guyatt GH, Sackett DL, Dook DJ JAMA 271(1) Jan 1994
Resources IIIA/B. How to use an article about a diagnostic
test VIIIA/B. How to use a clinical practice guideline XIV. How to decide on the applicability of clinical
trial results to your patient XVI. How to use a treatment recommendation XVII. How to use guidelines and recommendations
about screening How to use an article about quality improvement
(Nov, 2010)
Therapy or Prevention: Are the Results of the Study Valid?
Do results provide an unbiased estimate of treatment effect? Was the question appropriately framed?
Were patients randomized? Were patients, study personnel “blinded”? Were groups similar at start of trial? Were groups treated equally?
Was the evidence appropriately collected and summarized? Were all patients accounted for? Was follow up complete? Were patients analyzed in groups to which they were
randomized?
Guyatt GH, Sackett DL, Cook DJ JAMA 270(21) Dec1993
82
What are the results? How large was the treatment effect?
Point estimate The best estimate of treatment effect (not the actual treatment
effect, just “in the neighborhood”) Absolute risk reduction, relative risk, relative risk reduction, etc
How precise was the estimate of effect? Confidence intervals
“The neighborhood” in which lies the actual treatment effect If crosses “0” or “1”, cant be assured of effectiveness If positive study, examine the low end of CI to consider clinical
significance If negative study, examine upper end of CI to assess for
possible clinical significance. If yes, study failed to exclude an important effect
Guyatt GH, Sackett DL, Dook DJ JAMA 271(1) Jan 1994
Will the results help me in caring for my patients? Can the results be applied to my patient?
Would your patient have been eligible? Is there a compelling reason why results should not be
applied to my patient? Beware of sub-group analysis (“dredging”)
Were all clinically important outcomes considered? Be cautious of “substitute end points” Balance measures
Are likely benefits worth the potential harm and cost? NNT NNH
Guyatt GH, Sackett DL, Dook DJ JAMA 271(1) Jan 1994
Statistics
“He uses statistics as a drunken man useslamp posts – for support rather than forillumination.”
Andrew Lang
83
Understanding What We Read
Healthy 45 yo male undergoes a screening test for a specific cancer Occurs in 1 in 1000 people of his age 99% sensitive (ie only 1% false negative) 98% specific (ie only 2% false positive)
His test comes back positive What is the probability that he has
cancer? PPV 4.7%
Beck-Bornholdt HP, Dubben HH. p<0.05! So what?- What we can learn from the statistician
Interpreting a Positive Clinical Trial
You are reviewing a manuscript of a perfectly designed, well conducted, carefully evaluated study
Results Treatment A is significantly better than
Treatment B, p=0.03
What does this mean?
Beck-Bornholdt HP, Dubben HH. p<0.05! So what?- What we can learn from the statistician?
Sterne JAC, Smith, GD. BMJ 322 Jan 2001.
Interpreting a Positive Clinical Trial
Assumptions: 10% of experimental treatments are better
than standard treatment (fair estimate) Power of 80%
PPV 64% 1/3 of “perfect” studies with positive
results are misleading
Beck-Bornholdt HP, Dubben HH. p<0.05! So what?- What we can learn from the statistician?
Sterne JAC, Smith, GD. BMJ 322 Jan 2001.
84
Sterne JAC, Smith, GD. BMJ 322 Jan 2001.
Sterne JAC, Smith, GD. BMJ 322 Jan 2001.
Sterne JAC, Smith, GD. BMJ 322 Jan 2001.
85
SONIC- Clinical Remission Without Corticosteroids at Week 26
Primary Endpoint
30
44
57
0
20
40
60
80
100
Pro
po
rtio
n o
f P
atie
nts
(%
)
AZA + placebo IFX + placebo IFX+ AZA
p<0.001
p=0.006 p=0.022
51/170 75/169 96/169
Gastroenterology. 2009; 136 (5): Suppl 1. A-116.
Recommendations
Become very good at the fundamentals Regular “exercise”
Then use the excellent available resources to start filling in any “holes”
Be thoughtful, critical, … and realistic
86
Teaching Talk: Dos and Don’ts
Michael Narkewicz MDProfessor of Pediatrics
Hewit Andrews Chair in Pediatric Liver DiseaseFellowship Program Director
Goals
• Outline of Adult Learning
• Tips for a Teaching Talk
• Examples
Understand Adult Learning
• Adults:
– have a specific purpose in mind;
– are voluntary participants in learning;
– require meaning and relevance;
– require active involvement in learning;
– need clear goals and objectives;
– need feedback;
– need to be reflective.
87
Get the Details of Your Talk
• Who is the audience:– Make your talk pertinent to the audience– Parents vs Nursing vs Medical Students vs Residents vs PCPs
• How much time do you have– Major complaint: Talked too long and too fast– 1 slide per minute of your talk
• What are the goals of asking you to talk?– Develop talk goals– Adults need clear goals
Often Helps to Have a CaseAdults Require Meaning and
Relevance • Tips
– Collect images from interesting cases: never know when you may use them
• I have a folder with images from cases (XRays, Endoscopy images, Path images)
– Cases act as a hook to keep interest and shows relevance
Example
• Insert the CT image of the liver tumorPUB MED:24,641 articles, 1645 in children
88
HCC in heart (HBV)
Malignant Thrombus
Define the Goals
• State the Goals up front:
• Maximum Three
• Pancreatitis
– Review definitions
– Understand the evaluation
– Know the management options
Know your subject
• Review the literature for guidelines, reviews
• By definition, most times you will know more than the others.
89
Make the talk interactive
• Set up the talk to allow participation– What would you do next?
– What are the top items on the differential diagnosis?
– How many people would get X?
Some key items not to do
• I know that you can’t see this table but
• Use red and green (color blind issues)
• Put key items in a corner of a slide
Sequence data
90
Sequence Data
• There are 25 key mutations in ferroportin
• The amino acids involved in the mutations are similar between humans and other species including mice and xenopus
• Mutations occur at key parts of the protein in this autosomal dominant
Busy table
Examples of common mutations
• 36 Mutations in Ferroportin
• 10 predicted to cause disease– 5 non classical
• Carrier rate is <1:150 for each
• Many mutations with unknown effect
91
Use arrows and highlights in the talk
Use arrows and highlights in the talk
Keep the focus of the slide in the center
Don’t put the key element on the side or in the corner
Use the right font for the job
18 20 24 28 32 36 40
92
Leave time for Questions
93
94
Twelve tips on teaching the consultant teachers toteach
DAVID WALLUniversity of Birmingham and West Midlands Deanery, Birmingham, UK
Introduction
There has been concern at the standard of clinical teaching
in hospitals in the United Kingdom for some time (Hore,
1976; Parry, 1987; Lowry, 1992) . Teaching by humiliation
and ritual sarcasm, and the demotivating effect this may be
having on junior doctors and medical students have been
described (Metcalfe & Matharu, 1995). Similar problems
exist in North America, where a literature review (Irby,
1995) showed that undergraduate and postgraduate medical
teaching was variable, unpredictable, lacked continuity and
gave virtually no feedback. In Australia, similar problems of
little feedback, poor supervision and haphazard assessment
of junior doctors have also been described (Rotem et al.,
1995), which were worse in large teaching hospitals.
To try to address these issues and improve teaching and
the educational climate in hospitals, the Standing Committee
on Postgraduate Medical and Dental Education (SCOPME)
issued a report on Teaching Hospital Doctors and Dentists to
Teach: Its Role in Creating a B etter Learning Environment
(SCOPME, 1992). Following this publication, there was an
upsurge in the level of professional debate about the need to
improve clinical teaching (Lowry, 1992, 1993). In a review
of current medical education, Coles (1993) concluded that
a change in educational and teaching methods, rather than
a rearrangement of course content, was needed. He drew
attention to the teaching culture, and advocated methods
that re¯ ected the aims and objectives of the curriculum,
and the principles of adult learning, more small-group work,
and problem-based learning. He maintained that it was
imperative that teachers understand the principles of adult
learning, curriculum development, evaluation and assess-
ment.
Several initiatives for `Training the Trainers’ or perhaps
the better named `Teaching the Teachers’ are already in
place (Batstone, 1996). The Universities of Dundee and of
Wales (in Cardiff) have had courses leading to qualifications
in medical education for many years, even before the
SCOPME report was published in 1992. Several Deaneries
and Royal Colleges are now beginning to run courses to
help consultants improve their teaching skills (Biggs et al.,
1994; Peyton, 1996, 1998; and Dennick, 1998). There is an
increasing interest in the need for training in teaching skills.
Some of these courses are short, one- or two-day courses
for the busy consultant. The consultant is now called upon
to be a good educational supervisor for the house officer
(General Medical Council, 1997), to supervise and appraise
the senior house officer (General Medical Council, 1998),
and to assess the learning needs, appraise and assess the
specialist registrar (Department of Health, 1996). Most
consultants have no training in these new skills, so how may
we set up, run and evaluate such courses for the average
busy consultant in our hospitals?
This article contains some advice, based on educational
principles, on research carried out (Wall and McAleer, 1999),
and on experiences in running Teaching theTeachers courses
for consultants in all specialities in the West Midlands over
the last 3 years. This article offers 12 tips for those setting
up and running such courses.
W hat shall we teach? Establishing the curriculum for
your course
Educational planning based on sound principles and increas-
ingly on research evidence will ultimately lead to more effec-
tive and efficient medical education in the future (Bligh,
1999). When planning a curriculum for a course, Harden
(1986) described 10 questions to ask while carrying out this
task. These were related to needs, aims and objectives,
content, organization of content, educational strategies,
teaching methods, assessment, communication of curriculum
details, the educational climate, and progress Ð how to
manage it. Going back to the beginning, Dunn et al. (1985)
described several methods for deriving a curriculum. The
best methods included the Delphi technique (with opinions
from experts), critical incident studies, and behavioural event
analyses with star performers in the area. However, there
may be no need to derive the curriculum from scratch.
Recent research has identi® ed several key themes which
both consultants and junior doctors think are very important
to be taught on such courses (Wall & McAleer, 1999).
These are:
· giving feedback constructively;
· keeping up to date as a teacher;
· building a good educational climate;
· assessing the trainee;
· assessing the trainee’s learning needs;
· practical teaching skills.
These will give a start. However, you may need to focus the
curriculum more towards the particular speciality concerned,
using perhaps a Delphi technique, or interviews with star
performers in that speciality (Dunn, Hamilton and Harden,
1985). For example, urologists may place more emphasis
on teaching practical skills effectively than do psychiatrists.
Remember that effective needs assessment involves teachers,
Cor re sp ondence: D r D avid Wall, D eputy Regional Postg ra duate Dean,
Postgraduate Dean’s office, The M edical School, University of Birmingham,
Edgbaston, Birm ingham B15 2TT, UK. Tel: 0121 414 6892; fax: 0121 414
3155; email: [email protected]
Medical Teacher, Vol. 21, No. 4, 1999
ISSN 0142-159X print/ISSN 1466-187X online/99/040387 ± 06 ½ 1999 Taylor & Francis Ltd 387
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
95
learners and experienced programme planners in a construc-
tive dialogue (Laxdal, 1974).
Tip 1
Establish your curr iculum based on sound
educational principles, and tailor this to the specific
group of consultants on your course.
Setting the learning objectives
Stenhouse (1975), in a major work on curriculum develop-
ment, stressed the importance of curriculum development
resting on the translation of general statements of aims into
much more speci® c and precise behavioural objectives.The
objectives model has considerable power. Objectives have
been described as the ª light and heat in educational
technologyº (Rowntree, 1982). Outcomes of the course
should be stated precisely, and the teaching planned and the
educational experiences offered on the course should ® t in
with these outcomes (Harden et al., 1999).
Therefore the course timetable will state the aims and
the objectives of the course. For example, a practical
teaching-skills course may have a broad aim, and much
more precise behavioural objectives for what the candidate
will be able to do at the end of the course. This could be:
Aim:To give candidates the opportunity to explore
the knowledge and skills of a variety of teaching
methods.
Objectives: At the end of the course the participants
will be able to:
(1) demonstrate the principles of teaching a practical
skills effectively;
(2) demonstrate how to give feedback constructively
and effectively.
(3) and so on.
Tip 2
Set the learning objectives based on the curriculum
in terms of what the candidates will be able to do
at the end of the course. Plan the teaching on your
course around these stated objectives.
The use of active learning methods
Coles (1993) suggested changes to the educational methods
used in medical teaching and learning. He emphasized that
teaching methods must re¯ ect the aims and the objectives
of the curriculum, and that they embody the principles of
adult learning (Brook® eld, 1986). Such methods include
doctors taking more responsibility for their own learning,
with more small-group work, discussions, problem-based
learning, and fewer lectures and formal teaching sessions.
Teachers do need to understand the new relationship
between teacher and learner, with the learners gradually
assuming more control over their education themselves.
Teachers are facilitators of learning, and may be helped by
using small-group workshops on a course to stimulate their
thoughts on effective teaching and learning (Price & Miflin,
1994; Walton, 1997).
In our own courses, we use a mixture of short, 15-minute
keynote talks, small-group work with tasks, plenary sessions,
role plays, and practical teaching exercises. We emphasize
the principles of adult learning (Brook® eld, 1986) very early
on in the course as:
· voluntary participation;
· mutual respect between teacher and learner and among
learners;
· collaboration between teacher and learner and among
learners;
· action and re¯ ection;
· critical re¯ ection;
· nurturing of self-directed adults.
So, candidates on such courses are working to tasks set, to
solving problems, and are actively involved in the course as
a deliberate educational strategy.
Tip 3
Use active learning methods such as small-group
work, role plays, practical exercises and problem
solving, based on the aims and objectives of the
course curriculum, and on the principles of adult
learning.
The educational climate
Many studies have described a poor educational climate in
our hospitals. Such problems have included poor or no
feedback, poor supervision, variable and unpredictable
teaching, lack of continuity, and teaching by humiliation,
shouting and ritual sarcasm (SCOPME, 1992; Metcalfe &
Matharu, 1995; Rotem et al., 1995; Guthrie et al., 1995).
When feedback was given, it often concentrated only on
what was done wrong (Dillner, 1993).
So, we aim to explain in simple terms what the
educational climate is. Many consultants do recognize this,
but will often use other words to describe the concept, such
as `ambience’ , `environment’ or `atmosphere’ . We talk of the
climate in terms of physical, emotional and intellectual
attributes. Many are surprised that the educational climate
can indeed be measured, using a valid and reliable tool, the
Dundee Ready Educational Environment Measure or DREEM
(Roff et al., 1997).
We aim to provide a good educational climate on our
courses. It is important to practise what you preach, and set
up the course in a pleasant setting, with good facilities
(especially enough small rooms for breaking up into small
groups), adequate parking and directions, good communica-
tions, good handout packs, and a fr iendly relaxed
atmosphere. Some humour is important (Ziegler, 1998),
and can make a valuable contribution to the educational
process. It has been shown to reduce stress and anxiety,
build con® dence and reduce boredom. Remember that some
consultants coming on such courses may be ver y
apprehensive, and have not for a long time been in the
learner role, or been in a small-group setting. They should,
it is hoped, go home at the end having enjoyed the day and
had some fun, as well as learned something!
Tip 4
Pay attention to the educational climate of your
course. Practise what you preach, and aim for a
friendly, supportive and non-threatening environ-
ment for teaching and learning. It should be fun.
Giving feedback constructively
This theme was top of the list of 15 educational themes
rated by 441 consultants and junior doctors in the West
D.Wall
388
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
96
Midlands, when asked what should be taught to consultants
on a teaching the teachers course (Wall & McAleer, 1999).
Trainees do complain of lack of feedback, of no feedback at
all, or feedback given negatively, sometimes by humiliation,
sarcasm, sexism and shouting (Metcalfe & Matharu, 1995;
Guthrie et al., 1995; Paice et al., 1997).
Feedback given constructively does improve learning
(Rolfe & McPherson, 1995), and this is true in very many
teaching and learning situations (Black & Wiliam, 1998).
There are methods of giving feedback constructively. The
well-known `Pendleton’s rules’ (Pendleton et al., 1984), and
the `One Minute Teacher’ (Gordon et al., 1996) are two of
these, which we use on our courses and have found to be
valuable. Both depend on giving positive support and
reinforcement for things that were right, and then making
constructive suggestions for correcting mistakes.Very simply,
the One Minute Teacher consists of ® ve micro-skills for
clinical teaching. These are:
· Get a commitment:What is going on?
· Probe for supporting evidence.
· Teach general rules and principles.
· Reinforce what was right.
· Correct mistakes in a constructive way. ª Next time this
happens why not try this instead . . . .º
We teach these early on in our courses, because we use them
in the small-group work and microteaching exercises when
we ask candidates to give constructive feedback to their
peers on their efforts. Sometimes, individuals go straight for
the criticisms, and are then asked to stop and are gently
reminded to go back through the steps of Pendleton’s rules,
and start again. So, as well as teaching about constructive
feedback, we get candidates to give constructive feedback
during the course, and have it given to then by their peers as
well.
Tip 5
Emphasize the crucial importance of g iving
feedback constructively. Use models of giving
feedback to help the candidates do this on the
course, when giving and receiving feedback to and
from each other on activities they all do on the
course.
Teaching of practical skills
Junior doctors value this skill in their teachers very highly,
much more so than do their consultant teachers themselves
(Wall & McAleer, 1999). A simple model of teaching
practical skills is the one used by the Royal College of
Surgeons of England on their `Training theTrainers’ courses
(Peyton, 1996, 1998). The basic elements are the prepara-
tion (set), the procedure itself (dialogue), and the summary
(closure). In teaching the skill in the dialogue, a four-step
model is used:
· The teacher does the procedure at normal speed.
· The teacher does the procedure again, and talks through
it, performing and explaining each step.
· The teacher does it again, with the learner talking through
it and explaining the steps.
· The learner now does the procedure, and talks it through
as well, explaining the steps.
It is very important to give feedback constructively, using
the ideas described in Tip 5 above. Leave time for ques-
tions, and remember to plan the next learning experience at
the end (closure).
We do these exercises in groups of three (trios). Each
candidate is asked to bring to the course all the materials to
give a ® ve-minute teaching session on a practical skill (prefer-
ably not medical). Each person in the group will have a turn
at being a teacher, a learner and an observer in this session,
with feedback given on performance using Pendleton’s rules.
These have been very enjoyable and entertaining sessions.
Complete novices have been able, after 5 minutes of
one-to-one teaching, to perform quite complex tasks, such
as tie a trout ¯ y, put on a turban, tie a bow tie, make a trifle,
play a penny whistle, and prune an apple tree branch! Many
candidates have re¯ ected on these sessions, and have said
that they will go back to their own hospitals and prepare
their teaching much more thoroughly and make sure they
are fully prepared to teach.
In this session it is crucial that everyone brings with
them a practical skill to teach. The exercise is wholly
dependent on this, so we write a reminder, and ring them all
up just before the course starts as well. These measures
usually work!
Tip 6
A practical teaching skills exercise in the course is
very valuable, and does make some good
educational points. Make sure you know all the
steps, and can demonstrate the procedure yourself
® rst. Make sure everyone brings along a practical
skill, and remind them of this before they come.
Role play and appraisal practice
An ancient Chinese proverb gives the following educational
advice:
I hear and I forget
I see and I remember
I do and I understand
When teaching and learning about appraisal and how to
carry out an appraisal with a trainee, we have found that a
combination of a keynote talk, a video demonstrating the
techniques, and some role-play appraisal practice works well.
It is necessary to explain the de® nition and the principles of
good appraisal practice (SCOPME, 1996), its purposes,
and how to use appraisal to deal with problems. The Video
Arts videotape entitled `The Dreaded Appraisal’ is an excel-
lent illustration of both how not to do it, and then how to do
it correctly. It lasts 30 minutes, makes only a few key points,
does this very well, and is entertaining to watch. Finally we
ask candidates to play either an appraiser or an appraisee, in
a small-group setting. Case scenarios have been prepared
beforehand by the organizers to illustrate particular points
(Skelton & Hammond, 1998) and problems that may be
encountered with trainees. They are based on real-life situ-
ations that we have experienced in the past, suitably
anonymized. Some scenarios are applicable to any speciality,
such as the trainee who is very polite to the consultant, but
rude, aggressive and awful to everyone else. Others do need
to be speciality speci® c, so it pays to enlist the help of
colleagues in that speciality in writing and adapting case
scenarios when planning the course.
How are the role play sessions structured? Case scenarios
Twelve tips on teaching teachers to teach
389
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
97
are given out, and candidates divided into groups of three
(trios). In turn, each is asked to be an appraiser, an appraisee
and an observer. Feedback is given using Pendleton’s rules
again (Pendleton et al., 1984). Facilitators watch these
sessions, to help candidates understand the tasks and roles
to be played. It does become very realistic. In a one-hour
session, each of the three candidates will have a turn at
being a consultant appraiser, a trainee being appraised and
an observer, and have done three of the case scenarios.This
is real active learning, and is usually a lot of fun.
Tip 7
Prepare case scenarios carefully, making sure they
are relevant to the candidates’ own experiences.
Explain the purposes of the session carefully
including the giving of feedback to each other
using a method of giving feedback constructively
(such as Pendleton’s rules).
Evidence-based education
Sometimes candidates ask for evidence from the educational
literature to support a concept or statement made on the
course. It is useful therefore to provide a reading list of key
articles and books that interested candidates may look at
afterwards, and some key references to support what you
are going to say on the course. Such key references are
included in the handout pack given out at the beginning of
the course.
We welcome the movement towards evidence-based
medical education, including the new series in Medical
Teacher in 1999 entitled `Best Evidence Medical Educa-
tion’ (Harden, 1998) Much evidence is currently spread
widely over medical education journals, specialist and general
medical journals, and specialist and general education
journals. This makes it very difficult to pull together good
evidence to inform best practice. It will be of great bene® t
to have such evidence available to us.
However, there is good evidence already for some of
what is being done. For example, Rolfe & McPherson (1995)
discussed giving feedback constructively, with the bene® ts
of improved learning outcomes, a deeper approach to
learning , active pursuit o f knowledge and improved
competence at least in the short term. Further evidence in
the same area came from a large review of the educational
literature (Black & Wiliam, 1998), with 250 references
looking at many controlled studies.This review did confirm
that giving feedback constructively did work, and gave
substantive learning gains.
Also, there is evidence that the `student centred ’
curr iculum does have bene ® ts compared with the
`traditional’ curriculum. Studies show no differences in
marks for students on the new curr iculum, despite
widespread differences in curriculum design (Ripkey et al.,
1998). H owever, the `traditional’ students do suffer
disadvantages, with such students showing poorer moral
reasoning skills, less desirable modes of learning, and
increased stress (Bligh, 1999).
So we do need to be familiar with the educational
literature, base our ideas on best educational evidence, and
be able to suggest further reading to candidates in such
areas.
Tip 8
Base your course curriculum on best evidence
medical education. Have your evidence ready for
the topics that will be taught on the course. Ideally
put these references in the handout packs, and
then they are there ready for you to refer to during
the course.
Educational concepts, maps and models
A criticism of educationists, especially by clinical colleagues,
is the supposed use of jargon (Harden, 1998). While this
may be the case, clinical medicine is not without its own
considerable amounts of jargon, which is unintelligible to
others, even doctors in other specialities in medicine!
We aim to present concepts, maps and models which are
as simple as possible, and try to relate these to everyday
situations in medical practice. For example, the educational
cycle may be simpli® ed to four key steps and six key words
as below:
· assess needs;
· set objectives;
· methods;
· assessments.
Much of what we have done is based on this simple model,
as is this paper. Again, the principles of adult learning may
be simpli® ed to a few statements (see above), and the same
may be done for models of giving feedback, and for teaching
a practical skill, as has already been described.
As well as knowing what the model is, we design small-
group activities where candidates do actually use the models
in these activities on the course. This does reinforce the
concepts we are trying to bring to their attention. Thus we
do use structured feedback using Pendleton’s rules, and we
do use practical skills teaching using the model already
described and so on.
We explain simply what assessment, appraisal and evalu-
ation mean. For those who seem to use the terms
interchangeably, sometimes within the same sentence, we
point out that while bilirubin and alkaline phosphatase are
both liver function tests, they are not the same.They cannot
be interchanged, if we want others to understand what we
are talking about. We explain what aims and objectives are,
and illustrate this by looking at a simple First Aid Course. It
is then very clear that the objectives are `what the candidate
may be expected to do at the end of the course’ .
Tip 9
Keep concepts, maps and models as simple as
possible. Illustrate your maps and models with
examples that your course participants can follow
easily, often from clinical situations.
Evaluations
Evaluation of these courses, by the course participants, the
teachers themselves and by the providing organization which
pays for the courses, is an important part of the curriculum
(Harden, 1986).
We give a simple de® nition of evaluation as `measuring
the teaching’ and stress that it is de® nitely not another word
for `assessment’ of the learners. Evaluations may be by the
D.Wall
390
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
98
learners themselves, by the teachers on the course, by peers
(including external bodies such as the Royal Colleges and
the General Medical Council), and by oneself as self-
evaluation and re¯ ection.
We have used a simple one-page A4 size evaluation form
with ideas and questions chosen from an evaluation design
pack (Grant et al., 1993), and from a guide to good assess-
ment practice (Jolly & Grant, 1997). This ® ts in with the
`keep it simple’ philosophy on these courses. In addition,
space is provided for free comments. This has given us
much valuable information and feedback, and has enabled
us to improve courses as a result of these ideas. For example,
the videotape `The Dreaded Appraisal’ was one such idea
that came from a free comment on one of the evaluation
forms.
In addition, even though most people have enjoyed the
course and found it useful, we still need to know if these
ideas are taken back and put into practice. A longer term
follow-up evaluation is very useful here. We have been able
to demonstrate in the West Midlands that consultants did
take these ideas on board, and after 6± 12 months after the
course, had put them into practice in their day-to-day
teaching (Whitehouse, 1997).
All this does take time and effort. Nevertheless it is an
important part of the educational strategy of improving
consultants’ teaching knowledge and skills. There is a need
for more research in this area to be certain that there is a
change occurring as a result of the efforts put in.
Tip 10
Evaluation is an important part of your course.
Keep the evaluation simple, anonymous and easy
to ® ll in. Have some space for free comments on
the form. In addition, do some longer term follow
up to see if ideas have been taken on board and
changes to educational practice made.
W here next? How to keep the momentum going
Much to our delight, many consultants have become
completely enthused by and very keen on learning more
about medical education. For some, this seems to be similar
to the `conversions’ described in the social anthropology
literature (Coffey & Atkinson, 1996).
What can be done to maintain enthusiasm once it has
been generated in the ® rst place? Maybe the consultant
trainers’ group is one way to do this. Whitehouse (1997)
described that after an intensive educational course, a group
of Warwickshire consultant trainers continued to meet
regularly and discuss educational initiatives they have tried,
and derive great bene® t from peer support in such a group.
Rayner et al. (1997) described a similar group of consult-
ants at Birmingham Heartlands Hospital, who continue to
meet after a series of educational courses run by the Staff
Development Unit of the University of Birmingham.
General practitioners will recognize these initiatives as
`trainers’ workshops’ , where trainers meet to discuss ideas,
share problems and successes, and derive peer support for
their role as a teacher from the group.
In addition, many have enrolled for university quali® ca-
tions in medical education. For many years the universities
of Dundee and of Wales (in Cardiff) have run such courses
(Batstone, 1996), and have trained many medical educa-
tors. Their knowledge and skills of medical education are
now increasingly valued (Bligh, 1999). The postgraduate
deans do need to support these initiatives if funds will allow,
and nurture such individuals as extremely valuable
educational resources.
These areas do need further research.What does enthuse
such individuals? Why do they seem to come from some
specialities and not others? Why do the ear, nose and throat
(ENT) surgeons, the paediatricians and the obstetricians
lead the ® eld (in the West Midlands at least) in the numbers
studying for educational quali® cations in medical educa-
tion?
Tip 11
Have a strategy to keep the momentum going.
Capture the enthusiasm of those who develop an
interest in medical education, as they are one of
our most valuable resources for the future.
Research and development
There remains much work to do in this area of medical
education. Researchers are now shedding much welcome
new light on many of the `traditional’ educational practices.
New techniques and new ideas are being introduced to
everyday medical teaching in our hospitals, with evidence to
support such initiatives (Bligh, 1999).
As well as the curriculum content and objectives, the
culture and values (the educational climate) of the institu-
tion are also very important. Research has shown that student
choice of a career in general practice, for example, is
in¯ uenced by the culture of the medical school concerned
being supportive towards general practice (Lambert et al.,
1996).These factors are important and do need researching.
There are still unanswered questions about the
pre-registration year reforms (General Medical Council,
1997), the changes to specialist registrar training (Depart-
ment of Health, 1996), and the very recently published
recommendations for the senior house officer years, The
EarlyYears (General Medical Council, 1998). Some evalua-
tion work is already going on here, but such research does
need to continue, to expand and to be funded adequately.
Tip 12
Research and development is an integral part of
new developments and the new techniques in
medical education. Research should be seen as an
essential part of the overall education strategy of
the teaching-the-consultant-teachers movement,
and supported ® nancially.
Notes on contributor
DAVID WALL FRCP, FRCGP, MMEd is a general practitioner in
Sutton Cold® eld in the West Midlands. He is also deputy regional
postgraduate dean for the University of Birmingham and West
Midlands Deanery. His main interests in medical education are in
curriculum studies, educational needs of GP non-principals and
teaching the consultant teachers.
References
BATSTO NE, G. (1996 ) Training for trainers does exist in Britain,
B ritish Medica l Journal, 312, p. 1301 .
Twelve tips on teaching teachers to teach
391
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
99
BIGGS, J.S.G., AGGER, S.K., DENT , T.H.S., ALLER Y, L.A. & COLES,
C. (1994) Training for medical teachers: a UK survey, Medical
Education , 28, pp. 99 ± 106.
BLACK, P. AND W ILIAM , D. (1998) Assessment and classroom learning,
Assessment in Education, 5, pp. 7± 73.
BLIGH , J. (1999 ) Curriculum design revisited (editorial), Medical
Education, 33, pp. 82 ± 85.
BROOKFIELD, S.D. (1986) Understanding and Facilitating Adult Learning
(Milton Keynes, Open University Press).
CO FFEY, A. & ATKINSON, P. (1996) Making Sense of Qualitative Data
(London, Sage Publications).
COLES, C. (1993) Developing medical education, Postgraduate Medical
Journal, 69, pp. 57 ± 63.
DEN NICK , R. (1998 ) Teaching medical educators to teach: the
structure and participants’ evaluation of the Teaching Improve-
ment Project, Medica l Teacher, 20, pp. 598± 601.
DEPAR TM ENT OF HEA LTH (1996) A Guide to Specialist Registrar
Training (London, Department of Health).
DILLNER , L. (1993) Senior house officers: the lost tribe, British Medical
Journal, 307, pp. 1549 ± 1551.
DUNN , W.R., HAMILTON , D.D. & HARDEN , R.M. (1985 ) Techniques
for identifying competencies needed of doctors, Medical Teacher, 7,
pp. 15± 25.
GRANT , J., EVANS , K., MAY, R., SAVAG E, S. & SAVAG E, R. (1993) An
Evaluation Pack for Education in General Practice (London, Joint
Centre for Education in Medicine).
GENER AL M ED ICAL COUN CIL (1997) The New Doctor (London,
General Medical Council).
GENERAL MEDICAL COUNC IL (1998) The EarlyYears (London, General
Medical Council).
GORDO N, K., M AYER , B. & IRBY, D. (1996) The One Minute Preceptor:
Five Microskills for Clinical Teaching (Seattle, USA, University of
Washington).
GUTHR IE, E.A., BLACK, D., SHAW, C.M., HAMILTON , J., CREED , F.H.
& TO M E N SO N , B. (1995) Embarking on a medical career:
psychological morbidity in ® rst year medical students, Medical
Education , 29, pp. 337± 341.
HARDEN , R.M. (1986) Ten questions to ask when planning a course
or curriculum, Medica l Education, 20, pp. 356± 365.
HARDEN , R.M. (1998) Medical teacher (Editorial), Medica l Teacher,
20, pp. 501± 502.
HARDEN , R.M ., CROSBY, J. & D AVIS, M.H. (1999) Outcome based
education, Medical Teacher, 21 (1), pp 7± 14.
HORE, T. (1976) Teaching the teachers, Anaesthes ia and Intensive
Care, 4, pp. 329 ± 331.
IRBY, D.M. (1995) Teaching and learning in ambulatory care settings:
a thematic review of the literature, Academic Medicine, 70, pp.
898± 931.
JOLLY, B. & GRANT , J. (1997) The Good Assessment Guide. A Practical
Guide to Assessment and Appraisa l for Higher Specialis t Training
(London, Joint Centre for Education in Medicine).
LAMBER T, T., GOLDACRE, M. & PARKH OUSE, J. (1996 ) Career prefer-
ences and their variation by medical school among newly quali® ed
doctors, Health Trends, 28, pp. 135 ± 144.
LAXDAL , O.E. (1974 ) Needs assessment in continuing medical educa-
tion: a practical guide, Journal of Medical Education, 57, pp. 827± 834.
LOW R Y, S. (1992) What’s wrong with medical education in Britain?,
British Medical Journal, 305, pp. 1277 ± 1280 .
LOW R Y, S. (1993) Teaching the teachers, British Medica l Journal, 306,
pp. 127± 130.
METC ALFE, D.H. & M ATHAR U, M. (1995) Students’ perceptions of
good and bad teaching: report of a critical incident study, Medical
Education , 29, pp. 193± 197.
PAICE, E., MOSS, F., WEST, G. & GRANT , J. (1997) Association of a
log book and experiences as a pre-registration house officer:
interview study, British Medical Journal, 314, pp. 213± 215.
PARR Y, K.M. (1987 ) The doctor as teacher, Medical Education, 21,
pp. 512± 520.
PENDLET ON , D., SCHOFIELD, T., TATE , P. & HAVELOC K, P. (1984) The
Consultation: an Approach to Teaching and Learning (Oxford, Oxford
Medical Publications).
PEYTO N, R. (1996 ) College has found strong demand for training
programmes, British Medical Journal, 312, pp. 1301 ± 1302 .
PEYTO N, J.W.R. (1998) Learning and Teaching in Medical Practice
(Rickmansworth, Manticore Europe).
PRICE, D. & M IFLIN, B. (1994 (1)) Teaching the teachers: a new
approach to facilitating learning in student± patient interactions,
Medical Journal of Australia, 161, p. 181.
RAYNER , H., MO R TON , A., M CCULLOCH , R., HEYES, L. & RYAN , J.
(1997) Delivering training in teaching skills to hospital doctors,
Medical Teacher, 19, pp. 209± 211.
RIPKEY, D.R., SWANSO N, D.B. & CASE, S.M. (1998) School to school
differences in Step 1 performance as a fraction of curriculum type
and use of step 1 in promotion/graduation requirements, Academic
Medicine, 73, supplement 10, s91± 93.
ROCHE, A.M ., SANSON-FISHER, R.W. & COCKBUR N, J. (1997) Training
experiences immediately after medical school, Medica l Education,
31, pp. 9± 16.
ROFF , S., M CALEER , S., HARDEN , R.M ., AL-QAH TANI , M., AH MED,
U.A., DEZA, H., GROENEN , G. & PRIMPAR YO N, P. (1997) Develop-
ment and validation of the Dundee Ready Educational Environ-
ment Measure (DREEM), Medical Teacher, 19, pp. 295± 299.
ROLFE, I. & M CPHER SON, J. (1995 ) Formative assessment: How am
I doing?, Lancet, 345, pp. 837± 839.
ROTEM , A., GO DW IN, P. & DU, J. (1995) Learning in hospital settings,
Teaching and Learning in Medicine, 7, pp. 211 ± 217.
ROW NTREE , D. (1982) Educational Technology in Curriculum Develop-
ment, 2nd edn (London, Paul Chapman).
SCOPME (1992) Teaching Hospital Doctors and Dentists to Teach: its
Role in Creating a Better Learning Environment. Proposals for Consulta-
tion ± Full Report (London, Standing Committee on Postgraduate
Medical Education).
SCOPME (1996) Appraising Doctors and Dentists in training (London,
Standing Committee on Postgraduate Medical Education).
SKELTON , J.S. & HAMMOND , P. (1998) Medical narratives and the
teaching of communication in context, Medica l Teacher, 20, pp.
548± 551.
STENH OUSE, N. (1975) An Introduction to Curriculum Research and
Development (Oxford, Heinemann Educational).
WALL, D.W. & M CALEER , S. (1999) Teaching the consultant teachers:
identifying the core content, Medica l Education, 33 (in press).
WALTO N, H.J. (1997) Small Group Methods in Medical Education.
ASME Medica l Education Booklet No. 1, 1997 edition (Edinburgh,
Association for the Study of Medical Education).
WH ITEHO USE, A. (1997) Warwickshire consultants’ Training the
Trainers Course, Postgraduate Medical Journal, 73, pp. 35± 38.
ZIEGLER, J.B. (1998 ) Use of humour in medical teaching, Medical
Education, 20, pp. 341± 348.
D.Wall
392
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
100
2008; 30: 347–364
AMEE GUIDE
AMEE Guide no. 34: Teaching in the clinicalenvironment
SUBHA RAMANI1 & SAM LEINSTER2
1Boston University School of Medicine, USA, 2University of East Anglia, Norwich, UK
Abstract
Teaching in the clinical environment is a demanding, complex and often frustrating task, a task many clinicians assume without
adequate preparation or orientation. Twelve roles have previously been described for medical teachers, grouped into six major
tasks: (1) the information provider; (2) the role model; (3) the facilitator; (4) the assessor; (5) the curriculum and course planner;
and (6) the resource material creator (Harden & Crosby 2000).
It is clear that many of these roles require a teacher to be more than a medical expert. In a pure educational setting, teachers
may have limited roles, but the clinical teacher often plays many roles simultaneously, switching from one role to another during
the same encounter. The large majority of clinical teachers around the world have received rigorous training in medical knowledge
and skills but little to none in teaching. As physicians become ever busier in their own clinical practice, being effective
teachers becomes more challenging in the context of expanding clinical responsibilities and shrinking time for teaching (Prideaux
et al. 2000). Clinicians on the frontline are often unaware of educational mandates from licensing and accreditation bodies as well
as medical schools and postgraduate training programmes and this has major implications for staff training. Institutions need to
provide necessary orientation and training for their clinical teachers. This Guide looks at the many challenges for teachers in the
clinical environment, application of relevant educational theories to the clinical context and practical teaching tips for clinical
teachers. This guide will concentrate on the hospital setting as teaching within the community is the subject of another AMEE
guide.
Introduction
Teaching in the clinical environment is defined as teaching
and learning focused on, and usually directly involving,
patients and their problems (Spencer 2003). The clinical
environment consists of inpatient, hospital outpatient and
community settings, each with their own distinct challenges.
It is in this environment that students learn what it means to
be a real doctor. Skills such as history taking, physical
examination, patient communication and professionalism are
best learned in the clinical setting, medical knowledge is
directly applied to patient care, trainees begin to be
motivated by relevance and self-directed learning takes on
a new meaning (Spencer 2003). Teaching in the clinical
setting often takes place in the course of routine clinical care
where discussion and decision-making take place in real
time. Often the teaching will centre on an analysis of actual
patient care that the student has undertaken. This is the most
common pattern for postgraduate trainees. Undergraduate
students benefit from additional sessions specifically planned
for teaching. These sessions may take place in the ordinary
clinical environment and make use of the patients who are
opportunistically available. They may on the other hand be
highly structured with particular patients brought up espe-
cially for the session.
The word ‘doctor’ is derived from the Latin docere, which
means ‘to teach’ (Shapiro 2001). Clinical teachers have a dual
role in medicine, to provide patient care and to teach
(Prideaux et al. 2000; Irby & Bowen 2004). Though all
doctors are usually well prepared for their clinical roles, few
are trained for their teaching roles (Steinert 2005). Clinical
teachers take their role as teachers of future generations of
doctors seriously and with enthusiasm. Yet, most lack
knowledge of educational principles and teaching strategies
thus may be inadequately prepared for this additional
professional role (Wilkerson & Irby 1998). It has simply
been assumed that professionals who have graduated
from medical schools/colleges and undergone
postgraduate training can automatically start teaching the
day after they graduate. Due to advances in education
such as new methods of teaching and learning, a
more student-centred teaching, competency based assess-
ment and emphasis on professionalism; educators today
are required to have an expanded toolkit of teaching skills
and clinical expertise (Harden & Crosby 2000; Searle et al.
2006).
Correspondence: Dr. Subha Ramani, Boston University School of Medicine, Boston, MA, USA. Tel: 1-617-638-7985; fax: 1-617-638-7905;
email: [email protected]
ISSN 0142–159X print/ISSN 1466–187X online/08/040347–18 � 2008 Informa UK Ltd. 347DOI: 10.1080/01421590802061613
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
101
Clinical teaching overview
What makes a clinical teacher excellent?
Many investigators have examined the qualities that learners
value in their clinical teachers. Irby & Papadakis (2001)
summarized these and list the skills that make a clinical teacher
stand out (see Box 1).
Problems with clinical teaching
John Spencer has listed common problems with clinical
teaching in his article on learning and teaching in the clinical
environment published in the British Medical Journal’s ABC
of learning and teaching in medicine series (Spencer 2003).
The following are examples of such challenges, though by
no means a complete list:
. lack of clear objectives and expectations;
. teaching pitched at the wrong level;
. focus on recall of facts rather than problem solving;
. lack of active participation by learners;
. inadequate direct observation of learners and feedback;
. insufficient time for reflection and discussion;
. lack of congruence with the rest of the curriculum.
Challenges for teachers in the clinical environment
Teaching in the clinical environment comes with its own set
of unique challenges (Spencer 2003); some key ones are listed
in Box 2.
Despite the numerous challenges noted, many clinicians
find practical solutions to overcome them and excel in their
dual role as clinician and teacher. The remainder of this guide
focuses on practical educational strategies that clinicians can
use while teaching in the clinical environment from technical
skills to a scientific and professional approach to their
teaching.
General teaching models for teaching in anyclinical setting
Two models of clinical teaching have been successfully used
in faculty development of clinical teachers. Both models are
behaviour based and can be adapted by clinical teachers to all
clinical settings. The first is the Stanford Faculty Development
model for clinical teaching and the second is the Microskills
of teaching model, also known as the one-minute preceptor.
Practice points
. Clinicians do not become teachers by virtue of their
medical expertise, but a reflective approach to teaching
and professional development can foster excellence in
clinical teaching.
. By using an outcome based approach to teaching and
learning, clinical faculty can progress along the spectrum
of clinical teaching and if they choose to, they can
become truly professional teachers.
. Soliciting feedback on teaching and reflective practice
are key to advancing to the highest level of teaching and
moving from being a technically sound teacher to a
professional and scholarly teacher.
. Staff development can provide clinicians with new
knowledge and skills about teaching and learning. It
can also reinforce or alter attitudes or beliefs about
education.
. Staff development can provide a conceptual framework
for teaching and help clinical teachers adopt and adapt
specific teaching behaviours to real clinical settings and
introduce clinicians to a community of medical educa-
tors interested in furthering clinical teaching and
learning.
. Several models of teaching have been described in this
guide, they are behaviour based and can be easily
adapted to a 5-minute teaching encounter or a one-hour
encounter. These models could also help teachers set
defined objectives for each clinical teaching encounter
and also tailor objectives to individual learners.
. Clinical teachers should attempt to draw a road map of
their career as educators, what their ultimate goals are
(become technically proficient as teachers or researchers
and scholars or develop into educational leaders) and
how they intend to progress and accomplish their goals.
Box 2. Challenges of clinical teaching
. Time constraints
. Work demands – teachers maintain other clinical, research or
administrative responsibilities while being called upon to teach
. Often unpredictable and difficult to prepare for
. Engaging multiple levels of learners (students, house officers etc)
. Patient related challenges: short hospital stays; patients too sick or
unwilling to participate in a teaching encounter
. Lack of incentives and rewards for teaching
. Physical clinical environment not comfortable for teaching
From Focus group discussions of clinical faculty in the Department of
Medicine at Boston University School of Medicine
Box 1. Skills that make a clinical teacher excellent
Excellent clinical teachers:
. share a passion for teaching;
. are clear, organized, accessible, supportive and compassionate;
. are able to establish rapport; provide direction and feedback; exhibit
integrity and respect for others;
. demonstrate clinical competence;
. utilise planning and orienting strategies;
. possess a broad repertoire of teaching methods and scripts;
. engage in self-evaluation and reflection;
. draw upon multiple forms of knowledge, they target their teaching to
the learners’ level of knowledge.
S. Ramani & S. Leinster
348
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
102
Stanford faculty development model forclinical teaching
A popular model for teaching improvement has been the
seven-category framework of analysis developed by the
Stanford Faculty Development Centre. This comprehensive
framework is outlined in the article by Skeff (1988). In
addition, this seven-category framework has been validated
by work at the University of Indiana which resulted in a 26
item questionnaire that can be used to evaluate teaching
(Litzelman et al. 1998). Although it provides a categorical
framework for evaluation and analysis of teaching, the power
of the model is most effectively demonstrated in hands-on
seminars in which faculty are enabled to both understand
and apply this method of analysis to their teaching. This
model described all clinical teaching as fitting into seven key
categories, lists key components under each category and
further describes specific teaching behaviours under each key
component.
The categories are as follows.
(1) Promoting a positive learning climate: The learning
climate is defined as the tone or atmosphere of the
teaching setting including whether it is stimulating, and
whether learners can comfortably identify and address
their limitations. It sets the stage for effective teaching
and learning.
(2) Control of session: This refers to the manner in which
the teaching interaction is focused and paced, as
influenced by the teacher’s leadership style. It reflects
the group dynamics, which affect the efficiency and
focus of each teaching interaction.
(3) Communication of goals: This includes establishment as
well as explicit expression of teachers’ and learners’
expectations for the learners. Setting goals provides a
structure for the teaching process, guides teachers in
planning the teaching and provide a basis for
assessment.
(4) Promoting understanding and retention: Understanding
is the ability to correctly analyse, synthesize and apply
whereas retention is the process of remembering facts
or concepts. This category deals with approaches
teachers can use to explain content being taught and
have learner meaningfully interact with the content,
enabling them to understand and retain it.
(5) Evaluation: It is the process by which the teacher
assesses the learner’s knowledge, skills and attitudes,
based on educational goals previously established. It
allows the teacher to know where the learner is and
helps them plan future teaching as well as assess
effectiveness of teaching. Evaluation can be formative
to assess ongoing learner’s progress towards educa-
tional goals or summative for final assessment to judge
learner’s achievement of goals.
(6) Feedback: Feedback is the process by which the
teacher provides learners with information about their
performance for potential improvement. It provides an
educational loop through which the teacher can guide
learners to use the evaluation of their performance to
reassess attainment of goals.
(7) Promoting self-directed learning: Teachers achieve this
by facilitating learning initiated by learner’s needs,
goals and interests. It stresses the importance of
acquiring skills to equip the learner to continue
learning beyond the time of formal education.
The one-minute preceptor
The ‘Microskills’ of teaching, also called the one minute
preceptor because of the short time available for teaching in
the clinical environment, provides a simple framework for
daily teaching during patient care (Neher et al. 1992). It is most
relevant to teaching postgraduate trainees but the steps also
apply to the longer encounters that are specifically focused on
teaching for undergraduates. These steps can be used to
structure effective short clinical teaching encounters that last
five minutes or less as well as to address problems that arise.
The original microskills model uses a five-step approach.
Step 1. Getting a commitment: The teacher encourages
learners to articulate their opinions on the differential
diagnosis and management rather than giving their own
conclusions and plans. The teacher must create a safe learning
environment so that learners feel safe enough to risk
a commitment – even if it is wrong.
Step 2. Probing for supporting evidence: The teacher
should encourage learners to ‘think out loud’ and give their
rationale for the commitment they have just made to diagnosis,
treatment, or other aspects of the patient’s problem. Teachers
should either validate learners’ commitments or reject them
gently if flawed.
Step 3. Teaching general rules: Teachers can guide learners
to understand how the learning from one patient can be
applied to other situations. The learner is primed for new
information they can apply to a given patient as well as future
patients. If the learner has performed well and the teacher has
nothing to add, this microskill can be skipped.
Step 4. Reinforcing what was done well: It is appropriate to
use this microskill every time the trainee has handled a patient
care situation well. Effective reinforcement should be specific
and behaviour based and not vague. Positive feedback also
builds the trainee’s self-esteem.
Step 5. Correcting mistakes: Negative or constructive
feedback is often avoided by clinical teachers, but this is
vital to ensure good patient care. Encouraging self-assessment
is a good way to have the learners realise their mistakes
themselves and if they have identified their errors, they can be
given positive feedback on their self-reflective capabilities.
If the teacher has to point out mistakes, this must be specific,
timely and based entirely behaviour based.
Applying the Dundee outcomesmodel in clinical teaching
It has been stated that the medical profession needs to think
more seriously about training their teachers and a framework
for developing excellence as a clinical educator is needed
(Hesketh et al. 2001). Harden et al. (1999) had previously
AMEE Guide no. 34: Teaching in the clinical environment
349
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
103
proposed a 3-circle learning outcomes model to classify skills
and abilities that doctors must possess. The Dundee outcomes
model offers a user-friendly approach to communicate
learning outcomes and was adapted to describe outcomes
for medical teachers (Hesketh et al. 2001). We use this model
in describing outcomes expected of a clinical teacher, moving
from technical competencies to meta-competencies within
each circle (Figure 1).
(1) The inner circle refers to the fundamental tasks that
clinical teachers should be able to perform compe-
tently; doing the right thing.
(2) The middle circle represents the teacher’s approach to
clinical teaching with understanding and application of
relevant learning theories; doing the thing right.
(3) The outer circle represents the development of the
individual through a professional approach to teaching
in the clinical environment; the right person doing it.
In applying the three-circle outcomes model for teachers in
the clinical environment we have attempted to keep these
outcomes clear and unambiguous, specific, manageable
and defined at an appropriate level of generality (Harden
et al. 1999) (see Box 3).
Circle one: what the clinicalteacher should be able to do(doing the right thing)
We list the following tasks as essential for teachers in
the clinical environment: time efficient teaching, inpatient
teaching, outpatient teaching, bedside teaching, assessment
of learners in the work setting and giving feedback.
Time efficient teaching
Irby & Bowen (2004) described a 3-step approach for time
efficient teaching in the clinical environment. All three steps
described can be adapted equally well to a one-hour session
as a 10-minute teaching session.
Planning. Advanced planning can achieve the following:
. sharpen expectations;
. clarify roles and responsibilities;
. allocate time for instruction and feedback;
. focus learners on important priorities and tasks.
The planning stage includes communicating expectations to
learners, soliciting learners’ goals, creating a safe and
respectful learning environment, selecting appropriate patients
for the teaching and priming learners about the goals of the
session.
Teaching. Distinguished clinical teachers draw upon a
repertoire of teaching strategies to meet the needs of their
learners and selectively use any or all of the following five
common teaching methods.
. Teaching from clinical cases; combining simple discussions
for novice learners with higher level discussions for more
senior learners
The clinicianas aprofessionalteacher
The clinicalteacher’sapproach toteaching
The basictasks aclinicalteacher mustperform
Adapted from Harden et al. 1999
Figure 1. The Dundee 3-circle outcomes model.
Box 3. Applying the three-circle outcomes model for teachers in the clinical environment
Tasks of a clinical teacher (Doing the right thing) Approach to teaching (Doing the thing right) Teacher as a professional (The right person
doing it)
. Time efficient teaching . Showing enthusiasm for teaching and
towards learners
. Soliciting feedback on teaching
. Inpatient teaching . Understanding learning principles relevant to
clinical teaching
. Self-reflection on teaching strengths and
weaknesses
. Outpatient teaching . Using appropriate teaching strategies for
different levels of learners
. Seeking professional development in
teaching
. Teaching at the bedside . Knowing and applying principles of effective
feedback
. Mentoring and seeking mentoring
. Work based assessment of learners in
clinical settings
. Modelling good, professional behaviour
including evidence based patient care
. Engaging in educational scholarship
. Providing feedback . Grasping the unexpected teaching moment
S. Ramani & S. Leinster
350
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
104
. Using questions to diagnose not only learners’ capacity for
recall but also their analysis, synthesis and application
capabilities
. Using advanced learners to participate in the teaching
. Using illness and teaching scripts. Examples of illness scripts
include knowledge of typical symptoms and physical
findings, predisposing factors that place the patient at
risk and underlying pathophysiology. Teaching scripts
commonly include: key points with illustrations, apprecia-
tion of common errors of learners and effective ways of
creating frameworks for beginners to build their own ‘illness
scripts’.
. Acting as role-models at the bedside or in examination
rooms
Evaluating and reflecting. Observing learners directly is an
important prerequisite for effective feedback. Feedback
should be based on observed behaviours, include positive
and negative feedback and teachers need to promote self-
assessment by learners. These techniques are discussed
in greater depth later.
Inpatient teaching
Ende (1997) wrote that the role of the inpatient teacher is one
of the most challenging in medical education, that of a master,
mentor, supervisor, facilitator, or all of the above. Inpatient
teaching can be chaotic and frustrating, as students of varying
levels of sophistication and interest fight off (or surrender to)
interruptions and urges to sleep, while the attending physician
holds forth on unanticipated topics, and about patients
who may not be available. Despite the various challenges
(see Box 4), he states that inpatient teaching can be riveting
if the teachers follow some basic principles. Teachers should
try to facilitate knowledge acquisition by asking questions that
make learners think and reason rather than recall facts. More
importantly, knowledge should be applied to specific patients
for clinical problem solving. Teachers should have some
knowledge of different learning styles and adapt their teaching
style to different learners. Teachers can set a comfortable and
safe learning environment in which they and the learners
freely ask questions and are prepared to admit their limitations.
Inpatient teams also need to behave as a teaching community
where each member respects the other in order to maximize
their learning. Teachers should learn to challenge their
learners without humiliating them and provide support so
that learning can be furthered. Ende suggests that in
preparation for effective ward teaching, the teachers should
ask themselves a set of questions before each teaching
encounter.
(1) What do you hope to accomplish?
(2) What is your point of view?
(3) How will your learners be engaged?
(4) How will you meet the needs of each learner?
(5) How will rounds be organized?
(6) Are your rounds successful?
(7) How will you make the time?
Although these questions can be applied to any clinical
environment, they are particularly apt for the inpatient
setting where a little mental preparation goes a long way.
Time constraints, varying learner levels, unexpected teaching
moments, presence or absence of the patient can all be
factored in while the teacher attempts to answer these
questions.
Outpatient teaching
Clinical teaching has recently been moving from the wards to
clinics. In recent years, the outpatient clinics have become an
integral venue to teach clinical medicine. With shorter hospital
stays, it has become impossible for trainees to follow and learn
the natural history of a disease from the inpatient environment.
Outpatient settings provide one area where trainees can learn
this, follow the patient over time and become involved in the
psychosocial aspects of patient care (McGee & Irby 1997;
Prideaux et al. 2000). Outpatient clinics are exceedingly busy
and chaotic settings with very short teacher-trainee interactions
(see Box 5). Often, clinical teachers are providing direct
Box 5. Challenges of outpatient teaching
. Busy clinical setting
. Teaching time often short, no time for elaborate teaching
. No control over distribution and organization of time
. Attending to several patients at the same time with multiple learners
. Brief teacher-trainee interactions
. Patient care demands usually take priority and must be addressed
. Multiple patient problems must be addressed simultaneously, so
teachers cannot focus on one problem to teach
. Learning and service take place concurrently
. Organic and psychosocial problems are intertwined
. Diagnostic questions often settled by follow up of empiric treatment
. Teacher should be a guide and facilitator than information provider
Box 4. Challenges of inpatient teaching
1. Difficult to set teaching goals, unanticipated events occur frequently
2. Ward team usually composed of varying levels of learners
3. Patients too sick or unwilling to participate in the teaching encounter
4. Patient stays are too short to follow natural history of disease
5. Teachers could compromise trainee-patient relationship if they
dominate the encounter
6. Trainees and teachers feel insecure about admitting errors in front of
the patient and the rest of the medical team
7. Tendency by many clinical teachers to lecture rather than practise
interactive teaching
8. Engaging all learners simultaneously can be difficult
9. Teachers need to pay close attention to learner fatigue, boredom
and workload
AMEE Guide no. 34: Teaching in the clinical environment
351
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
105
patient care while supervising and trying to teach students and
residents (Neher et al. 1992; McGee & Irby 1997). In a busy
clinic, patients too may not be interested in being participants
of a trainee-teaching encounter. Overall, service requirements
outweigh teaching requirements thus making this an uncon-
trolled teaching setting. Techniques originally described for
effective inpatient teaching do not apply well to outpatient
teaching. The outpatient clinic promises many unique educa-
tional opportunities including more complete observation
of chronic diseases, closer relationships between teachers
and learners, and a more appropriate forum for teaching
preventive medicine, medical interviewing, and psychosocial
aspects of disease (McGee & Irby 1997).
McGee and Irby describe practical tips for efficient teaching
in the outpatient settings and they categorize these steps
as follows.
(1) Prepare for the visit: Orientate learners of the
number of patients to be seen, time to be spent with
each patient and how to present patients succinctly.
(2) Teach during the visit: Ask questions to diagnose the
learner’s knowledge and clinical reasoning, select
a specific teaching point in each case, model good
physician-patient interactions, observe at least in part
learner-patient interactions and provide timely and
specific feedback.
(3) Teach after the visit: Answer questions that arise from
specific patient problems, clarify what learners did not
understand, refer to literature and create reading
assignments.
Wolpaw et al. (2003) describe a model for learner-centred
outpatient precepting where learners are equal if not
the leaders of the teaching interaction. They applied the
mnemonic SNAPPS to this model. The six steps of the SNAPPS
model are described below.
(1) Summarize briefly history and exam findings:
The learner obtains a history, performs an appropriate
examination of a patient, and presents a concise
summary to the supervisor. The summary should
be condensed to relevant information because the
preceptor can readily elicit further details if needed.
(2) Narrow the differential diagnosis: For a new patient
encounter, the learner may present two or three
reasonable diagnostic possibilities. For follow-up or
sick visits, the differential may focus on why
the patient’s disease is active, what therapeutic inter-
ventions might be considered, or relevant preventive
health strategies.
(3) Analyse the differential diagnosis: In this step, the
learner should compare and contrast diagnostic possi-
bilities with evidence of clinical reasoning.
This discussion allows the learner to verbalize his or
her thinking process and can stimulate an interactive
discussion with the preceptor. This discussion also
helps clinical teachers to diagnose the level of their
learners and thus plan further teaching accordingly.
(4) Probe the preceptor by asking questions about
uncertainties, difficulties, or alternative approaches.
This step is the most unique aspect of the learner-
driven model because the learner initiates an educa-
tional discussion by probing the preceptor with
questions rather than waiting for the preceptor to
initiate the probing of the learner. The learner is taught
to utilize the preceptor as a knowledge resource that
can readily be accessed.
(5) Plan management for the patient’s medical issues.
The learner initiates a discussion of patient manage-
ment with the preceptor and must attempt either a brief
management plan or suggest specific interventions.
This step asks for a commitment from the learner,
but encourages him or her to access the preceptor
readily as a rich resource of knowledge and
experience.
(6) Select a case-related issue for self-directed learning.
The learner may identify a learning issue at the end of
the patient presentation or after seeing the patient with
the preceptor. The learner should check with the
preceptor to focus the reading and frame relevant
questions.
Teaching at the bedside
It has been stated that since clinical practice involves the
diagnosis and management of problems in patients, teaching
of clinical medicine should be carried out on real patients with
real problems (Nair et al. 1997). There are many skills that
cannot be taught in a classroom, particularly the humanistic
aspects of medicine (Nair et al. 1997; Ramani 2003)
and require the presence of a patient, real or simulated. The
patient’s bedside, however, appears to be one of the most
challenging settings for clinical teachers. Although many
clinical teachers find this an intimidating mode of teaching
that bares their own deficiencies, they need to realize that all of
them possess a wide range of clinical skills that they can teach
their junior and far less experienced trainees (Ramani et al.
2003). Some common sense strategies combined with faculty
development programmes at individual institutions can over-
come some of this insecurity and promote bedside rounds,
which can be educational and fun for teachers and learners
alike. Teachers’ insecurities can be classified into 2 major
domains (Kroenke 2001):
. Clinical domain: Teachers may feel insecure about their
knowledge being up to date.
. Teaching domain: Teachers often feel intimidated by having
to teach a heterogeneous group of learners who are busy
and frequently sleep deprived.
Twelve practical tips have been described to help ease teacher
discomfort at the bedside and promote effective bedside
teaching (Ramani 2003).
(1) Preparation: Teachers need to familiarise themselves
with the clinical curriculum, attempt to diagnose
different learner levels and improve their own clinical
skills.
S. Ramani & S. Leinster
352
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
106
(2) Planning: Ende (1997) suggests that all clinical
teachers should ask themselves the following questions
prior to a teaching encounter and try to answer them:
a. What do you hope to accomplish?
b. What is your point of view?
c. How will your learners be engaged?
d. How will you meet the needs of each learner?
e. How will rounds be organized?
f. Are your rounds successful?
g. How will you make the time?
(3) Orientation: Teachers should obtain objectives of
learners, assign roles to each of the team members, try
to engage everyone and establish team ground rules.
(4) Introduction: The team of doctors need to be intro-
duced to patients and patients should be oriented about
the nature of the bedside encounter; e.g. Patients need
to be told that the encounter is primarily intended for
teaching and that certain theoretical discussions may
not be applicable to their illness.
(5) Interaction: The clinical teachers should serve as role-
models during their physician-patient interactions and
teach professionalism and a humanistic bedside
manner. In addition, teachers should model team
work and promote positive team interactions including
professional interactions with nursing and other ancil-
lary staff.
(6) Observation: Teachers need not put on a show at the
bedside and dominate the bedside encounter (Kroenke
2001). Observing the trainees’ interaction with the
patient at the bedside can be very illuminating and
these observations can be used to plan future teaching
rounds.
(7) Instruction: Clinical teachers should avoid asking the
trainees impossible questions and ‘read my mind’ types
of questions (LaCombe 1997; Kroenke 2001) and
actively discourage one-upmanship among learners.
Admitting one’s own lack of knowledge might allow
trainees to admit their limitations and ask questions.
Teachers can role model their willingness to learn by
being prepared to learn from trainees.
(8) Summarise: Learners would find it beneficial if teachers
summarize what was taught during that encounter.
Patients also need a summary of the discussion, what
applies and what does not apply to their illness and
management.
(9) Debriefing: Time is needed for learners to ask questions
and teachers to make clarifications and assign further
readings.
(10) Feedback: Teachers can find out from learners what
went well and what did not and give positive and
constructive feedback to learners.
(11) Reflection: Reflections about the bedside encounter
coupled with learner feedback can help teachers plan
the next encounter.
(12) Preparation for the next encounter should begin with
insights from the reflection phase.
Work based assessment of learners in theclinical cenvironment
Assessment plays a major role in the process of medical
education, in the lives of medical students, and in society by
certifying competent physicians who can take care of the
public. Society has the right to know that physicians who
graduate from medical school and subsequent residency-
training programmes are competent and can practise their
profession in a compassionate and skilful manner (Shumway
& Harden 2003). Miller (1990) proposed his now famous
pyramid for assessment of learners’ clinical competence
(Figure 2). At the lowest level of the pyramid is knowledge
Adapted from Miller (1990)
Knows
Application of knowledge:tested by clinical problemsolving etc
Knowledge: testedby written exams
Knows how
Shows how
Does
Demonstration of clinicalskills: tested by OSCE, clinicalexams etc (competency)
Daily patient care:assessed by directobservation in clinicalsettings (Performance)
Figure 2. Miller’s pyramid of assessment.
AMEE Guide no. 34: Teaching in the clinical environment
353
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
107
(knows), followed by competence (knows how), performance
(shows how), and action (does) The clinical environment is
the only venue where the highest level of the pyramid can be
regularly assessed.
Studies have indicated that performance in high stakes
examinations do not accurately reflect what doctors do in
actual patient care (Ram et al. 1999; Rethans et al. 2002).
Patient outcomes are the best measures of quality to assess
learners in the clinical settings (Norcini 2003), but these are
often difficult to ascertain due to factors such as case mix, case
complexity, nature of the clinical team and other intangible
factors. Assessment in the workplace is quite challenging as
patient care takes top priority and teachers have to observe
firsthand what the learners do in their interaction with patients
and yet be vigilant that patient care is of the highest quality.
Performance outcomes. Norcini (2003) states that the princi-
pal measures of performance in the clinical environment
include patient outcomes, process of care and volume of
services doctors provide.
. Patient care outcomes include morbidity and mortality,
physiological outcomes such as blood pressure or diabetes
control, clinical events such as stroke or heart attack and last
but not least patient satisfaction and experience with care.
. Process of care includes such factors as patient screening,
preventive services provided, disease specific measures
such as HbA1C for diabetes, aspirin prescription after a
heart attack etc.
. Patient volume refers to features such as number of hip
replacements performed by orthopaedic surgeons or
cardiac catheterizations performed by cardiologists.
Volume, in general, correlates with skill and patient
morbidity and mortality, but does not always equal high
quality patient care.
Clinical teachers should gain familiarity with an outcomes
based assessment method appropriate to their own environ-
ment (CANMEDS, ACGME, LCME etc.).
Rethans et al. (2002) emphasize that the distinction
between competency-based and performance-based methods
is important and propose a new model, designated the
Cambridge Model, which extends and refines Miller’s pyramid.
It inverts his pyramid, focuses exclusively on the top two tiers,
and identifies performance as a product of competence, the
influences of the individual (e.g. health, relationships), and
the influences of the system (e.g. facilities, practice time). The
model provides a basis for understanding and designing
assessments of practice performance.
Assessment methods. In the clinical environment, faculty can
readily assess any of the performance measures described
above that relate directly to patient care. In these settings,
trainees’ clinical skills can be assessed outside a simulated or
test environment; skills such as patient communication,
physical examination, clinical reasoning, case presentation
and notes, team work, communication with clinical and non-
clinical staff and professionalism. Methods of assessment
include examining case records and notes for evidence of
diagnostic thinking, listening to case presentations, but the
most important method of assessment for clinical teachers
would be direct observation. Without observing trainees at
work and at the bedside, teachers cannot gather accurate data
to provide appropriate feedback.
Giving feedback
In the clinical environment it is vital to provide feedback to
trainees as without feedback their strengths cannot be
reinforced nor can their errors be corrected (Ende 1983). It is
a crucial step in the acquisition of clinical skills, but clinical
teachers either omit to give feedback altogether or the quality
of their feedback does not enlighten the trainees of their
strengths and weaknesses. Omission of feedback can result in
adverse consequences, some of which can be long term
especially relating to patient care. For effective feedback,
teachers need to observe their trainees during their patient
interactions and not base their words on hearsay. Feedback
can be formal or informal, brief and immediate or long and
scheduled, formative during the course of the rotation or
summative at the end of a rotation (Branch & Paranjape 2002).
Why is feedback needed? Feedback is essential for a student
or intern to gain an insight into what they did well or poorly
and the consequences of those actions. If educational goals
had been established ahead of the teaching encounter or
period, feedback is essential to examine accomplishment or
lack thereof of stated goals, re-establish new goals and make
action plans to address them (Ende 1983). It tells the learners
where they are in comparison to where they ought to be and
where they should go. Feedback, when well done, also
promotes self-reflection and self-assessment, which are valu-
able traits for lifelong learning.
Barriers to feedback. One of the biggest hurdles to giving
feedback is lack of direct observation of trainees by teachers
(Ende 1983). Clinical competence cannot be assessed by
written exams, self-report or third party observation, rather this
needs to be observed directly by clinical teachers. Teachers are
also very hesitant to provide negative feedback and frequently
avoid it altogether although this can have adverse conse-
quences on patient care. Trainees, on the other hand, may
view negative feedback as a personal attack. Teachers need to
establish a positive learning environment in which errors are
acknowledged and feedback is expected and accepted.
Frequently, feedback is non-specific and unhelpful to learners,
e.g. ‘good job’, ‘bad patient communication’, etc.
Circle 2: how the clinical teacherapproaches their teaching(doing the thing right)
Showing enthusiasm for teaching andtowards learners
The starting point for any good teacher must be enthusiasm for
the subject being taught. This has to be complemented by
an eagerness to transmit this enthusiasm to others, which
will necessarily result in a positive attitude to learners.
S. Ramani & S. Leinster
354
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
108
Enthusiasm for the subject is usually accompanied by a sound
knowledge of the subject and a desire to learn more about it,
both of which are pre-requisite for successful teaching in
higher education. However, while enthusiasm, knowledge and
a desire to learn more are necessary for successful teaching
they are not sufficient. Teaching is a professional discipline
with its own theoretical background and its own recognised
techniques. A good teacher must have and apply a working
knowledge of both techniques.
Understanding learning principles relevantto clinical teaching
Pedagogy versus androgogy. Much of our approach to
teaching and learning is based on studies in children at
school and is therefore termed pedagogy. The content of
learning is defined by a syllabus and the method of learning is
laid down by a curriculum. Both of these may be developed
by the individual teacher but are likely to have been laid
down by a central authority. The pace of learning is dictated
by the teacher. Knowles (1990) studied adults enrolled
at evening classes in New York and realised that their
approach to learning was different. He coined the term
androgogy to cover this approach. The content of the
student’s studies is dictated by perceived need; the method
of learning is selected by the learner and the pace of learning is
dictated by the learner. From his observations Knowles
derived a set of Principles of Adult Learning which are now
widely regarded as crucial to the design of any course for
adults (Box 6).
Learning theories. Theories of learning may be neurobiolo-
gical or behavioural. From a pragmatic educational viewpoint
the most useful at present are the behavioural theories. These
can be broadly classified as individualistic (based on
psychological approaches) and social constructivist (based
on sociological approaches). While some of the proponents of
each theory will claim that their insights are the only valid
approach, the practical educator can draw lessons from all of
them. It is important to recognise that the theories are
attempting to describe what actually occurs in learning rather
than what ought to occur.
Psychological theories. Learning and memory. There is an
extensive literature on learning and memory. There appears to
be a consensus that different models apply for the learning of
knowledge and the acquisition of skills. Clinical teaching must
deliver both modalities.
The first stage of acquiring knowledge is the activation of
prior knowledge. This is followed by the acquisition of new
knowledge. The new knowledge is incorporated into the
memory through rehearsal which is more effective if it is done
to a third party. The final stage of the learning process is
elaboration. This may take the form of transforming the
information into a different format e.g. summarizing words as a
chart or diagram; comparing and contrasting new information
with old; or drawing inferences and conclusions from the total
information (Bransford et al. 1999). A slightly different
articulation of this process is Schmidt’s Information
Processing Theory which emphasises the link between the
remembering of the new material and the prior knowledge
that has been activated which he describes as encoding
specificity (Schmidt 1983).
The commonest model used to describe the acquisition of
skills is the conscious-competence model. This model is
widely used in management training but no-one is entirely
clear where it originated. Four stages of ability are described,
as described in Box 7.
A fifth stage has been suggested which can be thought of as
reflective competence. It is often the case that the person who
is operating at the level of unconscious competence is unable
to teach others the skill. The person who has reflective
competence is able to perform the task without conscious
thought but can if necessary analyse what they are doing in
order to teach the skill to someone else (Chapman 2007).
Self-determination theory. It is self-evident that students’
learning is affected by their motivation. Williams et al. (1999)
suggest that the nature of the motivation is important.
According to self-determination theory there are two primary
kinds of motivation – controlled and autonomous. Controlled
motivation is brought about by external pressures (other
people’s expectations; rewards and punishments) or by
internalized beliefs about what is expected. In contrast,
autonomous motivation occurs when individuals see the
material to be learnt as intrinsically interesting or important.
Controlled motivation leads to rote-learning with little
Box 6. Principles of adult learning
Adults:
. have a specific purpose in mind;
. are voluntary participants in learning;
. require meaning and relevance;
. require active involvement in learning;
. need clear goals and objectives;
. need feedback;
. need to be reflective.
Knowles (1990)
Box 7. The conscious-competence model
Unconscious incompetence The subject is not aware of the skill in
question
Conscious incompetence The subject is aware of the skill and
recognizes the need to acquire it
Conscious competence The subject has acquired the skill but
needs to focus their attention on its
performance
Unconscious competence The subject has achieved mastery of the
skill and can perform it without
conscious thought; other tasks can
be performed at the same time.
AMEE Guide no. 34: Teaching in the clinical environment
355
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
109
integration of the material into the student’s long term values.
Autonomous motivation, among other benefits, leads to
greater understanding, better performance, and greater feel-
ings of competence. In addition, students who are encouraged
to develop an autonomous approach to learning are more
likely to act in ways that promote the autonomy of their
patients.
Experiential learning. Most informal learning is based on
experience. Kolb (1984) described the process by which this
occurs in his learning cycle. Learning occurs when an
individual reflects on an experience. On the basis of this
reflection, the individual will develop a working theory
(although they may not fully articulate it), which will lead
them to take a certain course of action. That action will result
in a further experience and so the cycle continues with a
steady accumulation of useful knowledge. The cycle can be
entered at any point. For example, an individual may be told
about a theory and take action without having had previous
experience of the particular situation. Different individuals will
have different preferences for the starting point depending on
their learning style (see below).
Sociological theories. Situated learning. Vygotsky, the
Russian educational psychologist, postulated on the basis of
his study of school children that learning was socially
determined and resulted from the interaction of the child
with those around her. He observed that if a child has adult or
peer support she can solve problems that she is incapable of
solving unaided. This difference between aided and unaided
performance he called the zone of proximal development and
suggested that it is here that learning takes place. In other
words, interaction with others is essential to learning
(Vygotsky 1978).
Communities of Practice. Clinical activity usually takes place
in teams. Such teams are important not only for the delivery of
care but for the continuing professional development of the
team members. Functional teams form communities of practice
in which the individual members support one another. It is a
feature of such groups that knowledge and skills are rapidly
disseminated throughout the group. This may be through
formal structures such as seminars but is more likely to be
through the informal day-to-day contact between members.
Lave & Wegner (1991) suggest that learners or apprentices are
legitimate peripheral participants in such groups. Although
they have yet to achieve full membership of the group they are
allowed to take part in the activities of the group and in that
way they also acquire the knowledge that is inherent in the
group. Eventually, they will be absorbed into the group and
accepted as a full member of the group. This transition is often
marked by ceremony such as passing the final examination.
Reflective practice. At first sight, reflective practice might
seem to be an individualistic learning method rather than a
social one. However, Schon (1995) identified that reflection is
much more effective when conducted with a mentor making it
a social activity. He describes two forms of reflection:
reflection in action which takes place during an activity,
and reflection on action which takes place once that action has
been completed. Both are important adjuncts to learning.
Learning styles. It is apparent that different individuals have
different approaches to learning. There have been a variety of
attempts to describe these different approaches or learning
style. Some classifications focus on the cognitive aspects of
learning; some focus on the modalities of learning preferred by
the learners; a third group focus on the outcomes of the
learning.
Cognitive approach – Honey and Mumford Learning Style
Inventory. The Honey and Mumford Learning Style
Inventory is widely used in management training. It is based
on Kolb’s learning cycle and identifies four main learning
styles (Honey & Mumford 1992).
. Pragmatists prefer to learn directly from experience
. Reflectors prefer to learn by reflecting on their experiences
. Theorists prefer to learn by developing explanations and
working theories
. Activists prefer to learn by involvement in activity.
No individual has a single preferred style of learning but each
individual will display the learning styles to differing degrees.
Modalities of learning – visual–auditory–kinaesthetic learning
style. A potentially more useful learning style questionnaire is
the visual–auditory–kinaesthetic (VAK) questionnaire which is
widely used in schools. The emphasis is on the subject’s
preferred modality for acquiring material to be learnt.
. Visual learners prefer material that is delivered through
visual media. This includes written and graphic material but
also electronic visual media.
. Auditory learners prefer the spoken word to visual material.
. Kinaesthetic learners learn best when the learning involves
them in physical activity.
Learners will usually display a mixture of the three learning
styles although one may predominate.
Outcomes of learning – deep/superficial learning. The
desired goal for learning is that the learners should achieve
understanding of the subject. This is called deep learning.
When the amount of material to be learnt is too great, or where
the assessment of the learning is based purely on recall,
learners will display superficial learning. Experienced students
will identify those aspects of the material presented which
need to be understood for future use and those which will
merely need to be recalled for the purposes of assessment.
They will adopt a deep learning approach for the former and a
superficial learning approach for the latter. This combined
approach is described as strategic learning (Newble &
Entwhistle 1986).
The teacher’s goal must be to develop deep learning.
Because students have differing patterns of learning styles,
the material to be learnt must be presented in a variety of
ways. Patient-centred teaching involves all modalities of the
VAK approach as the student will observe the patient, hold
conversations with the patient and the instructor and will
S. Ramani & S. Leinster
356
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
110
carry out physical activity in examining the patient and
carrying out clinical procedures. It is also evident that
patient-centred teaching will give the student experiences
as a result of activities that they undertake. The teacher
needs to encourage reflection on what has taken place
linked to a discussion of the theoretical background to the
case.
Using appropriate learning strategies for differentlevels of learner
Approaches to teaching in the clinical setting will differ
according to the level of the students being taught.
Undergraduates are likely to be taught in sessions specifically
dedicated to this end. Postgraduate trainees may well be
taught in the course of routine service delivery. In any clinical
teaching session it is important that the teacher has clear goals
and objectives for the session. If the teacher is unsure what
they are trying to achieve, the students will not be able to
identify the purpose of the session. This will conflict with the
principles of adult learning.
Motivation is rarely a problem with students in the clinical
setting. Failure to engage with the student is more likely to be a
result of poorly constructed teaching sessions rather than
student motivation. This is often due to the selection of
inappropriate goals for the session.
The purpose of the session will differ depending on the
level of the student. The underlying teaching methods can be
the same. The new undergraduate who is developing the art of
history taking will require different goals from the senior
postgraduate student who is learning the nuances of managing
variants of the same disease. Both can be taught on the same
patient by focusing on different learning tasks. It is not a good
idea to try to teach both at the same time as they have different
goals and objectives.
The session should start with establishing what the student
already knows relevant to the patient’s presentation and this
should include their understanding of the scientific back-
ground as well as the clinical aspects. Failure to establish the
students starting point is another common reason for the
failure of the student to engage in a teaching session. The topic
chosen by the teacher may be too advanced or too elementary
for the group of students being taught. In either case the
student will have difficulties.
The students should be active participants in the session.
Merely telling the students the teacher’s view of the situation
or having them observe the expert in action does not lead
to deep learning. The students should be permitted to carry
out relevant components of the clinical task and then be
engaged in active discussion. In this way the full range of
different learning styles can be accommodated. Dialogue
with the student is an important part of clinical teaching.
Attention should be paid to probing the students’ under-
standing rather than their simple ability to carry out a
mechanical task or recall isolated facts. The questions ‘Why’
and ‘So what’ are an essential part of the clinical teachers
armamentarium. This will encourage the elaboration stage of
learning.
Knowing and applying principles of giving feedback
Feedback should provide the student with the opportunity to
reflect on their performance and its possible consequences. It
can guide the student’s future learning by identifying their
strengths and weaknesses (Sender Liberman et al. 2005). The
principles of giving feedback have been well-rehearsed by a
number of authors. These principles include the use of
mutually agreed upon goals as a guide to the feedback;
addressing specific behaviours not general performance;
reporting on decisions and actions not on one’s interpretation
of the student’s motives; and using language that is non-
evaluative and non-judgemental (Ende 1983). These attri-
butes have been found empirically to be valued by trainees
(Hewson & Little 1998). Feedback may be corrective (when
the student’s performance has been inadequate) or reinfor-
cing (well the student has done well) (Branch & Paranjape
2002). Feedback may be formal or informal. In the clinical
teaching setting timely, informal feedback is highly valued by
the students.
The first requirement of feedback is that the student has a
clear concept of the objective they are trying to attain.
Feedback can then inform how close they have come to
achieving that target and ideally what they need to do
differently in order to achieve the target. Direct observation
of the performance is necessary if feedback is to be effective.
The objective may be a behaviour such as a clinical skill or a
cognitive process such as interpreting a history.
At the simplest level feedback informs the student that
they have either succeeded or failed at the task. This is
common in licensing examinations where the candidate
knows either that they have passed or failed but is not told
why. In the clinical setting it would be more usual for the
student to be told that their performance was inadequate and
then a demonstration given of how it should have been
done. Once again the student is not offered an analysis of
what they did wrong. This approach does not provide the
best opportunity for the student to learn and is more akin to
evaluation than feedback.
Learning is assisted when both the strengths and the
weaknesses of the student’s performance are identified and
discussed. Feedback is not evaluation and therefore should not
use judgemental language or make personal remarks. The
emphasis should be on reporting the observed behaviours and
thinking and should be detailed and specific rather than
general. It is a good technique to start with self-assessment as
many astute learners usually identify their errors and the
teacher can help make plans to correct those errors and
reinforce their strengths. It is often the case that the student’s
judgement of their performance is harsher than the teacher’s
and it is important to reassure the student that they have done
well.
Clinical learning often takes place in a group environment.
In this setting it is helpful to involve the other members of the
group in the informal feedback process. They often have
valuable insights into why their colleague behaved as she did
and, in addition, they will learn the process of constructive
feedback. More formal summative feedback should be given
in private at a mutually agreed time.
AMEE Guide no. 34: Teaching in the clinical environment
357
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
111
Above all feedback should be constructive. This does not
mean that the student’s performance cannot be criticized but
when there are deficiencies the feedback should include
suggestions for making improvements.
Role modelling
An important part of clinical reaching is the development of
the professional role in the students. Both trainees (Brownell &
Cote 2001) and faculty (Wright & Carrese 2002) agree that the
observation of role models is the most important component in
this process. This fits well with the theories of situated learning
and communities of practise discussed previously. If positive
messages are to be transmitted consistently it is essential that
teachers reflect on their own attitudes and behaviours (Kenny
& Mann 2003). Modelling life long learning requires that the
teacher is willing to admit ignorance and prepared to learn
from the students. Good doctor-patient relationships and
evidence based clinical practice are other areas where the
teacher’s behaviour will reinforce (or undesirably contradict)
their formal teaching.
‘Grasping the unexpected teaching moment’
Unpredictability is one of the attractions of clinical practice.
There are occasions when it is better to abandon the carefully
constructed teaching plan and seize the opportunity which
suddenly presents itself. After all, the unexpected will be what
excites you and you are likely to transmit that excitement to
the students. A sound grasp of the theoretical approaches to
teaching are no substitute for enthusiasm for the process of
teaching and for the subject that is being taught.
A key prerequisite for using the unexpected teaching
moment most efficiently is a teacher’s willingness to admit
their errors or limitations, thus allowing learners to admit their
own without an a climate of humiliation.
Circle 3: the clinician as aprofessional teacher (the rightperson doing it)
Even if a teacher can master all the technical competencies
listed in the inner circle, emotional and attitudinal
competencies such as self-awareness, self-regulation, motiva-
tion, empathy and social skills are required to achieve
excellence (Harden et al. 1999).
We list the following as essential circle 3 tasks for
clinical teachers by which they may become the ‘right persons
doing it’.
. Soliciting feedback on teaching
. Self-reflection
. Professional development in teaching
. Mentoring.
Soliciting feedback on teaching
Most clinical teachers go about their business of teaching with
very little feedback on their strengths and weaknesses as a
teacher. Frequently, the only evaluations on their teaching are
from learners and these too may be few and far between.
Some institutions have adopted a coaching or consulting
service for teachers, but these pertain more to classroom
teaching or small group teaching rather than teaching in the
clinical environment. More institutions should adopt a 360-
degree method for evaluating their clinical teachers rather than
depend on incomplete and ineffective evaluations from
learners alone. These may include measures such as learners’
performance and progress as a proxy for teaching impact,
video recording of teaching sessions with reflection and
feedback, teacher self reports, peer observations etc.
In the face of overwhelming expectations at work, clinical
faculty rarely ask for feedback on their teaching from learners
or peers. The clinical environment adds an additional twist by
the all-important focus on patient care and safety. Thus,
frequently the emphasis is on the patient and their manage-
ment and the teaching strategies are all but forgotten. In the
event that a teacher asks their learners for feedback, learners
hesitate to offer it as there may be some anxiety about their
own evaluations by their teachers. Those learners that offer
feedback give non-specific, vague feedback that teachers
cannot readily assimilate or apply in their future teaching
encounters.
Teachers should be encouraged to seek feedback on their
teaching from peers and learners, staff development should
train teachers in efficiently obtaining feedback and last but not
least a teaching consulting or coaching service developed by
institutions for clinical teachers would help improve teaching
skills of individual teachers as well as the institution as
a whole. Trainees too can benefit from coaching and
encouragement on providing useful feedback to their teachers.
Self-reflection
Reflection in medicine has been defined as consideration of
the larger context, the meaning, and the implications of an
experience or action (Branch & Paranjape 2002) and when
used properly allows for the growth of the individual. It has
also been stated that professionals must distinguish themselves
from technicians by awareness of the larger context of their
work using this knowledge for lifelong learning and not
limiting themselves to performing specific tasks (Schon 1987;
1983). One might therefore assume that reflection, so essential
to educating physicians, is even more crucial for clinical
teachers to adopt a professional approach to their teaching,
namely be the right person doing it.
Both phases of reflective practice (Kaufman 2003), reflec-
tion in action which occurs immediately and reflection on
action which occurs later, are readily applicable to clinical
teachers.
Fryer-Edwards et al. (2006) have suggested three key
teaching skills that illustrate learner-centred, reflective
teaching practices and provide a framework for teachers
with both cognitive and affective components. Although
these teaching practices were developed for communication
skills training, they are readily applicable to any clinical
environment.
S. Ramani & S. Leinster
358
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
112
. Identifying a learning edge: Teachers work with learners to
identify their learning edge, which is the place where they
find learning challenging, but not overwhelming.
. Proposing and testing hypotheses: Teachers formulate
hypotheses on issues such as barriers or facilitators to
learning for individual learners, learning needs, emotional
responses to patients or the rest of the team and apply
teaching strategies to test these hypotheses.
. Calibrating learners’ self-assessments: This involved
learners thinking out aloud their self-assessment, values
and beliefs and using these insights to stimulate further
reflection.
Professional development
Medical education has traditionally had little input from trained
educators. In the past, a high level of clinical competence and
experience was considered sufficient to be a good clinician
educator, now it is increasingly recognized that teaching itself
is a skilled profession. The British General Medical Council in
its publication: Tomorrow’s Doctors, includes the following
attributes of a practitioner (General Medical Council 2002).
. Recognition of the obligation to teach others, particularly
doctors in training.
. Recognition that teaching skills are not necessarily innate
but can be learned.
. Recognition that the example of the teacher is the most
powerful influence upon the standards of conduct and
practice of trainees.
Most clinical faculty receive little or no explicit training in how
to teach, or in theories and processes of teaching. Yet, they are
expected to help their trainees master medical knowledge,
clinical skills and acquire a habit of lifelong learning. In the
changing world of medicine, clinical teachers need to perform
time-efficient ambulatory and inpatient teaching, while their
own clinical workload keeps increasing. For teachers to
succeed at their teaching tasks, faculty development is
essential (Wilkerson & Irby 1998). Faculty development also
helps teachers build important professional relationships with
peers and mentors within and outside their institutions and
contribute positively to academic advancement overall
(Morzinski & Fisher 2002).
Summary of professional development programmes.
Common faculty development formats include train the trainer
workshops or seminars, short courses developed by individual
institutions, sabbaticals, part time or full time fellowships,
scholars programmes and educational workshops at confer-
ences (McLeod et al. 1997; Steinert 1993; 2005; Steinert et al.
2006).
Workshops. The prototypical faculty development pro-
gramme is a short, focused series of workshops, most of
which focus on practical teaching skills development and the
educational strategies directly applicable to those teaching
skills. Studies demonstrate that such programmes serve a
variety of purposes including improving attitudes, self-efficacy,
augmenting self-assessed and actual use of specified teaching
concepts; facilitating faculty’s ability to recognize teaching
deficiencies; and increasing knowledge of teaching principles
and teaching ability.
Fellowships. In part-time fellowships, faculty spend limited
time training at another institution and then work on
educational projects at their home institution. Combining the
training with the practical application of knowledge and skills
at home institutions, such fellowships teach the theory and
practice of critical faculty teaching skills. Full-time fellowships
are designed to prepare the fellows to be full-time medical
educators. Although they include teaching skills, they also
emphasize other important educator roles such as educational
research and educational leadership.
Teaching scholars programmes. Innovative formats have
been developed to link workshops into a more comprehensive
programme to target a broader range of outcomes (Gruppen
et al. 2003). As a result, some institutions have designed
teaching- scholars programmes for their faculty. These
programmes are usually a year long and serve as an immersion
experience for clinical educators and most require their
‘fellow’ to complete some educational project. The Teaching
Scholars Programme for Educators in the Health Sciences at
McGill University (Steinert et al. 2003) and the Medical
Education Scholars Programme (MESP) at the University of
Michigan Medical School (Gruppen et al. 2003) were designed
to create leaders in medical education. These programmes
train faculty to provide curriculum design, improved teaching,
educational research, and institutional leadership.
Courses at conferences. Many conferences hosted by pri-
mary care societies as well as conferences organized by
medical education organizations provide a number of courses
which focus on teaching and education. These courses range
from 90 minute courses to all day courses. Examples of such
conferences include the annual conferences of the AAMC,
AMEE, Society of General Internal Medicine, Association of
Teachers of Family Medicine and the Ottawa conferences.
Co-teaching or peer coaching. In this model, paired physi-
cians focus on developing their teaching skills while sharing
the clinical supervision of trainees (Orlander et al. 2000).
Through teaching, debriefing and planning, co-teachers gain
experience in analysing teaching encounters and develop
skills in self-evaluation. Typically, a junior faculty or fellow is
paired with a senior faculty educator who helps the ‘trainee’
teacher reflect on his/her teaching session.
Educational content. The content of staff educational devel-
opment programmes can be classified under the following key
categories.
. Teaching skills: Teaching skills sessions are designed to
help participants identify their own needs with respect to
teaching skills, and then to practice these skills and receive
feedback from colleagues and the faculty (Pololi et al.
2001). Typical topics included in staff educational develop-
ment include: interactive lecturing, small group discussion,
case based teaching, giving effective feedback, promoting a
AMEE Guide no. 34: Teaching in the clinical environment
359
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
113
positive learning climate, communication of goals, evalua-
tion of learners, ambulatory and inpatient teaching and
physician patient communication, learner- centred learning,
teaching evidence based medicine, stimulating self-directed
learning, bedside teaching, etc.
. Educational leadership: This is a higher level of educational
development of staff. Having acquired the basic teaching
skills, some educators go on to become educational leaders.
Examples of topics on the leadership track include:
mentoring skills, curriculum development and reform,
leadership and management of work teams, running
effective meetings, small group leadership, time manage-
ment, instituting change, cost-effectiveness etc.
. Miscellaneous: Additional skills include learning about
instructional technology, using computers in clinical teach-
ing and diversity for the learning environment.
Steinert (2005) has described in depth the reasons and goals of
staff development for clinical teachers and also summarized
types of professional development resources available.
Mentoring
Several literature reports indicate that mentoring is a useful
tool in the academic progression of professionals with many
successful academicians attributing their growth and success at
least partially to their mentoring relationships. It has also been
said that good mentors help their proteges achieve their
professional goals more expeditiously. The medical world has
well-established research mentoring programmes, but formal
mentoring programmes for clinical teachers are scant to non-
existent. Mentors can provide guidance, support or expertise
to clinicians in a variety of settings and can also help teachers
to understand the organisational culture in which they work
and introduce them to invaluable professional networks
(Walker et al. 2002).
Most successful clinical educators have achieved their
success by a trial-and-error approach, seeking multiple senior
educators’ advice and mentoring on their growth as educators
or just talking to their peers. If educating is to be a skilled and
scholarly task, educators need mentoring. The ultimate
evidence of a clinical teacher being a professional would be
if they themselves start mentoring their junior or peer
colleagues who wish to achieve professional success in
teaching.
Engaging in educational scholarship
For clinical teachers to attain the highest level of profession-
alism in education and advance academically as educational
innovators and leaders, scholarship is essential. Education
becomes scholarship when it demonstrates current knowledge
of the field, invites peer review, and involves exploration of
students’ learning. Furthermore, educational work should be
made public, available for peer review and reproduced and
built on by others (Glassick 2000). Glassick also described six
essential criteria of scholarship.
(1) Clear goals
i. The purpose of the work is clearly stated
ii. The goals and objectives are realistic and
achievable
iii. The work addresses an important question or need
(2) Adequate preparation
i. Mastery and understanding of current knowledge
in the field and acquisition of skills to carry out the
work
ii. Identifying and obtaining the resources needed to
complete the work
(3) Appropriate methods
i. Using and applying appropriate methods to
achieve the stated goals
ii. Modification of methods to deal with changing
circumstances
(4) Significant results
i. Achievement of the stated goals and objectives
ii. The work should add to the field and open up
additional areas for further exploration
(5) Effective presentation
i. Using suitable style and organization to present the
work at appropriate venues
ii. Presentation of results with clarity and integrity
(6) Reflective critique
i. The scholar critically evaluates his or her own work
ii. The scholar uses evaluations to improve the quality
of future work
Points for reflection
(1) How can change be sustained – Change in teaching
skills as well as change in attitudes towards teaching?
Other educators have shown that a one-shot approach to
educational development does not sustain change and staff
development should be longitudinal. Moreover, the educa-
tional environment and institutional attitudes towards teaching
need to change in order that teaching skills are considered as
valuable as research skills in academia.
(2) Can improving clinical teaching skills and excellence in
clinical care co-exist? How can teaching initiatives be
reconciled with the demands of service?
Clinicians face increasing pressures in their clinical practice
and the volume of patients they care for keeps increasing.
Time to see patients keeps shrinking and has often been stated
as one of the foremost barriers to clinical teaching.
Departments and institutions must see high quality teaching
as one of their core values; maybe create a core group of
faculty who would be responsible for much of the teaching.
(3) Does improvement in clinical teaching matter to patient
care? If teaching skills improve, what is the impact on
patient management, safety and satisfaction?
This is an area that has not been investigated extensively and is
a difficult area to research. Regardless, unless medical educators
S. Ramani & S. Leinster
360
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
114
demonstrate that improved teaching leads to improved patient
outcomes, the public and other stake holders may not see the
value of allocating dedicated time to teaching.
(4) How should teachers be evaluated – What outcomes
should be measured and who should evaluate them?
Most clinical teachers are evaluated by their trainees, often
irregularly and inconsistently. Frequently trainee evaluations
are subjective and cursory, thereby of little help to teachers
who wish to improve their teaching skills. Trained peers,
acting as coaches, may be one of the more useful ways to
evaluate teaching, but time needs to be set aside for this
coaching model. Microteaching or videotaping of teaching
encounters can be invaluable in allowing self-assessment of
teaching, but can this be carried out in the clinical
environment?
(5) How can institutions and departments elevate the value
of clinical teaching – The hidden curriculum, reward its
teachers and nurture educational leaders?
In the clinical world, research accomplishments are often held
in higher esteem than educational achievements. Expanding
academic tracks, staff development, rewarding teachers and
establishing clear criteria by which educators can be promoted
are possible ways to elevate the value of teaching within
institutions and departments.
(6) Teaching clinical skills, bedside teaching – do they
really matter? Can technology answer all diagnostic
questions?
For better or for worse, technology is here to stay in medicine.
Clinical teachers can model appropriate use of technology
in making the best clinical decisions and teach trainees
the respective value of clinical data and laboratory data in
patient care. Educators can further use technology to
demonstrate the precision of clinical signs, discarding those
that of little value.
(7) How can a clinical teacher set educational
objectives when much of the learning is opportunistic?
How can teachers respond to the unexpected teaching
moments?
Teaching in the clinical environment is beset by frequent
unexpected teaching challenges. Questions arise from patients
or trainees that teachers are unprepared to answer; patient
mood or severity of illness can displace preset teaching
objectives. Setting a positive educational environment where
teachers are willing to admit their limitations, show willingness
to learn from trainees and are prepared to set aside their
teaching objectives while grabbing the unexpected moment
and doing opportunistic teaching are some strategies to
overcome these challenges.
(8) How should teachers inform and orient patients about
the teaching nature of the session – Are patients
benefiting from the teaching?
If physicians are to learn from direct patient care, patients
should be fully engaged in the teaching encounter. Several
reports state that most patients enjoy participating in clinical
teaching. A few common sense strategies can maximise their
impact; introductions, orientation of patients, professionalism,
patient education etc, to name a few.
(9) How can a clinical teacher target their teaching
to multiple levels of learners and keep them all
engaged?
A typical clinical team often consists of multiple levels of
trainees from early students to senior house officers and
beyond. Clinicians are often intimidated by having to engage
all levels during their teaching encounters. Some ways to
achieve this successfully include: giving assignments for
Box 8. Practical strategies to achieve Circle-3 clinical teaching outcomes: The teacher as a professional(the right person doing it)
Teaching objectives
Do you establish teaching goals for different types of clinical encounters?
Did you communicate your teaching goals to the learners?
Did you elicit goals of the learners?
Teaching methods
What teaching methods did you use and were they successful (demonstrating, observing, questioning, role-modelling)?
Do you use the same teaching strategies for all learners or do you change your methods for different learner levels and skills?
Feedback
Did you give feedback?
Did you ask for learners’ feedback on your teaching?
Planning for the next encounter
Have you used reflective critique of your teaching (from self-assessment or peer or learner feedback) to change your teaching methods?
Professional development
Have you attended courses, studied educational literature or held discussions with other teachers to improve your teaching skills?
Are you planning to engage in the scholarship of teaching, study the impact of your interventions?
AMEE Guide no. 34: Teaching in the clinical environment
361
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
115
trainees to prepare ahead of time, allocating specific tasks at
the bedside and using senior trainees to participate in the
teaching.
Quotes for Teaching in the ClinicalEnvironment
Summary: Teaching in the clinical environment is a demand-
ing, complex and often frustrating task, a task many
clinicians assume without adequate preparation or
orientation.
Introduction: Due to advances in education such as new
methods of teaching and learning, a more student-centred
teaching, competency based assessment and emphasis on
professionalism; educators today are required to have an
expanded toolkit of teaching skills and clinical expertise
General Teaching models: Two models of clinical teaching
have been successfully used in faculty development of
clinical teachers. Both models are behaviour based and
can be adapted by clinical teachers to all clinical settings.
Stanford Model: Although it (the Stanford model) provides a
categorical framework for evaluation and analysis of
teaching, the power of the model is most effectively
demonstrated in hands-on seminars in which faculty are
enabled to both understand and apply this method of
analysis to their teaching.
One minute preceptor: The ‘Microskills’ of teaching, also called
the one minute preceptor because of the short time
available for teaching in the clinical environment provides
a simple framework for daily teaching during patient care.
Applying the Dundee model: It has been stated that the
medical profession needs to think more seriously about
training their teachers and a framework for developing
excellence as a clinical educator is needed.
Time efficient teaching: Irby & Bowen (2004) described a
3-step approach for time efficient teaching in the clinical
environment. All three steps described can be adapted
equally well to a one-hour session as a 10-minute teaching
session.
Inpatient teaching: Ende (1997) wrote that the role of the
inpatient teacher is one of the most challenging in medical
education, that of a master, mentor, supervisor, facilitator,
or all of the above.
Outpatient teaching: In recent years, the outpatient clinics
have become an integral venue to teach clinical medicine.
With shorter hospital stays, it has become impossible for
trainees to follow and learn the natural history of a disease
from the inpatient environment.
Teaching at the bedside: It has been stated that since clinical
practice involves the diagnosis and management of
problems in patients, teaching of clinical medicine should
be carried out on real patients with real problems (Nair
et al. 1997).
Work based assessment: Assessment plays a major role in the
process of medical education, in the lives of medical
students, and in society by certifying competent physi-
cians who can take care of the public. Society has the right
to know that physicians who graduate from medical
school and subsequent residency-training programmes are
competent and can practise their profession in a
compassionate and skilful manner.
Giving feedback: It (feedback) is a crucial step in the
acquisition of clinical skills, but clinical teachers either
omit to give feedback altogether or the quality of their
feedback does not enlighten the trainees of their strengths
and weaknesses.
How the teacher approaches their teaching: The starting point
for any good teacher must be enthusiasm for the subject
being taught. This has to be complemented by an
eagerness to transmit this enthusiasm to others, which
will necessarily result in a positive attitude to learners.
Learning and memory: There is an extensive literature on
learning and memory. There appears to be a consensus
that different models apply for the learning of knowledge
and the acquisition of skills. Clinical teaching must deliver
both modalities.
Learning styles: It is apparent that different individuals have
different approaches to learning. There have been a
variety of attempts to describe these different approaches
or learning style. Some classifications focus on the
cognitive aspects of learning; some focus on the mod-
alities of learning preferred by the learners; a third group
focus on the outcomes of the learning.
Knowing and applying feedback: These principles of feedback
include the use of mutually agreed upon goals as a guide
to the feedback; addressing specific behaviours not
general performance; reporting on decisions and actions
not on one’s interpretation of the student’s motives; and
using language that is non-evaluative and non-
judgemental.
Role modelling: An important part of clinical reaching is the
development of the professional role in the students. Both
trainees and faculty) agree that the observation of role
models is the most important component in this process.
Soliciting feedback on teaching: Teachers should be encour-
aged to seek feedback on their teaching from peers and
learners, staff development should train teachers in
efficiently obtaining feedback and last but not least a
teaching consulting or coaching service developed by
institutions for clinical teachers would help improve
teaching skills of individual teachers as well as the
institution as a whole
Workshops: The prototypical faculty development programme
is a short, focused series of workshops, most of which
focus on practical teaching skills development and the
educational strategies directly applicable to those teaching
skills.
Notes on contributors
DR. SUBHA RAMANI, MD, MMEd, MPH is a general internist and medical
educator. She completed Internal Medicine residencies in India and the
United States. She has undergone extensive training in medical education
including the Stanford Faculty Development Programme, the Dundee
Discovery Courses in Medical Education and the Harvard Macy Programme
for Physician Educators and completed a Masters in Medical Education
from the University of Dundee in 2005. Her major areas of interest are
clinical teaching methods, bedside teaching and teaching and assessment
of clinical skills. She is the Director of Clinical Skills development for the
S. Ramani & S. Leinster
362
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
116
Internal Medicine Residency Programme and Associate Professor of
Medicine at the Boston University School of Medicine.
PROFESSOR SAM LEINSTER FRCS (Ed), FRCS (Eng) MD is presently the
Dean of the School of Medicine, Health Policy and Practice, East Anglia
Medical School, and Non-Executive Director and General Surgeon of
Norfolk and Norwich Hospital Trust. He was previously Director of Medical
Studies and Professor of Surgery at the University of Liverpool where he
designed and implemented an acclaimed new curriculum for under-
graduate medicine and he has also established the Breast Unit at the Royal
Liverpool University Hospital. He is involved internationally in many
aspects of medical education and an active member of the Association for
the Study of Medical Education (ASME).
References
Branch WT Jr, Paranjape A. 2002. Feedback and reflection: teaching
methods for clinical settings. Acad Med 77:1185–1188.
Brandsford J, Brown AL, Cocking RR, editors. 1999. How People Learn:
Brain, Mind, Experience and School (Washington, National Academy
Press).
Brownell AK, Cote L. 2001. Senior residents views on the meaning of
professionalism and how they learn about it. Acad Med 76:734–737.
Chapman A. 2007. Conscious competence learning model. Available online
at: http://www.businessballs.com/consciouscompetencelearningmo-
del.htm (accessed 8 October 2007).
Ende J. 1983. Feedback in clinical medical education. Journal of the
American Med Assoc 250:777–781.
Ende J. 1997. What if Osler were one of us? Inpatient teaching today. J Gen
Intern Med 12(Suppl 2):S41–48.
Fryer-Edwards K, Arnold RM, Baile W, Tulsky JA, Petracca F, Back A. 2006.
Reflective teaching practices: an approach to teaching communication
skills in a small-group setting. Acad Med 81:638–644.
Glassick CE. 2000. Boyer’s Expanded Definitions of Scholarship, the
Standards for Assessing Scholarship, and the Elusiveness of the
Scholarship of Teaching. Acad Med 75:877–880.
Gruppen LD, Frohna AZ, Anderson RM, Lowe KD. 2003. Faculty
development for educational leadership and scholarship. Acad Med
78:137–141.
Harden RM, Crosby JR. 2000. AMEE Guide No 20: The good teacher is more
than a lecturer: the twelve roles of the teacher. Med Teach 22:334–347.
Harden RM, Crosby JR, David MH, Friedman M. 1999. AMEE Guide No. 14:
Outcome-based education: Part 5-From competency to meta-compe-
tency: a model for the specification of learning outcomes. Med Teach
21:546–552.
Hesketh EA, Bagnall G, Buckley EG, Friedman M, Goodall E, Harden RM,
Laidlaw JM, Leighton-Beck L, Mckinlay P, Newton R, Oughton R. 2001.
A framework for developing excellence as a clinical educator.
Med Educ 35:555–564.
Hewson GM, Little ML. 1998. Giving feedback in medical education:
verification of recommended techniques. J Gen Intern Med 13:111–116.
Honey P, Mumford A. 1992. The Manual of Learning Styles (Maidenhead,
Peter Honey Publications).
Irby DM, Bowen JL. 2004. Time-efficient strategies for learning and
performance. Clin Teach 1:23–28.
Irby DM, Papadakis M. 2001. Does good clinical teaching really make a
difference? Am J Med 110:231–232.
Kaufman DM. 2003. Applying educational theory in practice. Br Med J
326:213–216.
Kenny NP, Mann KV. 2003. Role modelling in physicians’ professional
formation: reconsidering an essential but untapped educational
strategy. Acad Med 78:1203–1210.
Knowles MS. 1990. The Adult Learner: A neglected species, 4th edn
(Houston, Texas, Gulf Publishing).
Kolb DA. 1984. Experiential Learning: Experience as a Source of Learning
and Development (Chicago, Prentice Hall, Eaglewood Williams Cliffs).
Kroenke K. 2001. Attending rounds revisited. (President’s column). Soc
Gen Intern Med Forum 24:8–9.
LaCombe MA. 1997. On bedside teaching. Ann Intern Med 126:217–220.
Lave J, Wenger E. 1991. Situated Learning: Legitimate Peripheral
Participation (UK, Cambridge University Press).
Litzelman DK, Stratos GA, Marriott DJ, Skeff KM. 1998. Factorial validation
of a widely disseminated educational framework for evaluating clinical
teachers. Acad Med 73:688–695.
McGee SR, Irby DM. 1997. Teaching in the outpatient clinic. Practical tips.
Journal of General Internal Medicine 12(Suppl 2):S34–40.
Mcleod PJ, Steinert Y, Nasmith L, Conochie L. 1997. Faculty development in
Canadian medical schools: a 10-year update. Canadian Medical
Association Journal 156:1419–1423.
Miller G. 1990. The assessment of clinical skills/competence/performance.
Acad Med 65:s63–s67.
Morzinski JA, Fisher JC. 2002. A nationwide study of the influence of faculty
development programs on colleague relationships. Acad Med
77:402–406.
Nair BR, Coughlan JL, Hensley MJ. 1997. Student and patient perspectives
on bedside teaching. Med Educ 31:341–346.
Neher J, gordon KC, Meyer B, Stevens N. 1992. A five-step
‘microskills’ model of clinical teaching. J Am Board Family
Practitoners 5:419–424.
Newble DI, Entwhistle NJ. 1986. Learning styles and
approaches: implications for medical education. Med Educ
20:162–175.
Norcini JJ. 2003. Work based assessment. Br Med J 326:753–755.
Orlander JD, Gupta M, Fincke BG, Manning ME, Hershman W. 2000.
Co-teaching: a faculty development strategy. Med Educ 34:257–265.
Pololi L, Clay MC, Lipkin M JR, Hewson M, Kaplan C, Frankel RM. 2001.
Reflections on integrating theories of adult education into a medical
school faculty development course. Med Teach 23:276–283.
Prideaux D, Alexander H, Bower A, Dacre J, Haist S, Jolly B, Norcine J,
Roberts T, Rothman A, Rowe R, Tallett S. 2000. Clinical teaching:
maintaining an educational role for doctors in the new health care
environment. Med Educ 34:820–826.
Ram P, Grol R, Rethans JJ, Schouten B, Van der Vleuten C, Kester A. 1999.
Assessment of general practitioners by video observation of commu-
nicative and medical performance in daily practice: issues of validity,
reliability and feasibility. Med Educ 33:447–454.
Ramani S. 2003. Twelve tips to improve bedside teaching. Med Teach
25:112–115.
Ramani S, Orlander JD, Strunin L, Barber TW. 2003. Whither bedside
teaching? A focus-group study of clinical teachers. Acad Med
78:384–390.
Rethans JJ, Norcini J, Baron-Maldonado M, Blackmore D, Jolly BC,
Laduca T, Lew S, Page GG, Southgate LH. 2002. The relationship
between competence and performance: implications for assessing
practice performance. Med Educ 36:901–909.
Schmidt HG. 1983. Problem-based learning: rationale and description. Med
Educ 17:11–16.
Schon DA. 1987. Educating the Reflective Practitioner: Toward a New
Design for Teaching and Learning in the Professions (San Francisco,
Jossey-Bass).
Schon DA. 1995. The Reflective Practitioner: How Professionals Think in
Action (New York, Basic Books).
Searle NS, Hatem CJ, Perkowski L, Wilkerson L. 2006. Why Invest in an
Educational Fellowship Program? Academic Medicine 81:936–940.
Sender Liberman A, Liberman M, Steinert Y, McLeod P, Meterissian S. 2005.
Surgery residents and attending surgeons have different perceptions of
feedback. Med Teach 27:470–472.
Shapiro I. 2001. Doctor means teacher. Acad Med 76:711.
Shumway JM, Harden RM. 2003. AMEE Guide No. 25: The assessment of
learning outcomes for the competent and reflective physician. Med
Teach 25:569–584.
Skeff KM. 1988. Enhancing teaching effectiveness and vitality in the
ambulatory setting. J Gen Intern Med 3:S26–S33.
Spencer J. 2003. Learning and teaching in the clinical environment. Br Med
J 326:591–594.
Steinert Y. 1993. Faculty development in family medicine. A reassessment.
Can Fam Phys 39:1917–1922.
Steinert Y. 2005. Staff development for clinical teachers. Clin Teach
2:104–110.
Steinert Y, Mann S, Centeno A, Dolmans D, Spencer J, Gelula M,
Prideaux D. 2006. BEME guide. A systematic review of faculty
AMEE Guide no. 34: Teaching in the clinical environment
363
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
117
development initiatives designed to improve teaching effectiveness
in medical education. BEME Guide No. 8. 28:497–526.
Steinert Y, Nasmith L, McLeod PJ, Conochie L. 2003. A teaching scholars
program to develop leaders in medical education. Acad Med
78:142–149.
Vygotsky LS. 1978. Mind and Society: The Development of Higher Mental
Processes (Cambridge, MA, Harvard University Press).
Walker WO, Kelly PC, Hume RF. 2002. Mentoring for the New Millennium.
Med Educ. Available online at www.med-ed-online.org (accessed
15 August 2007).
Wilkerson L, Irby DM. 1998. Strategies for improving teaching practices: a
comprehensive approach to faculty development. Acad Med
73:387–396.
Williams GC, Saizow RB, Ryan RM. 1999. The importance of
self determination theory for medical education. Acad Med
74:992–995.
Wolpaw TM, Wolpaw DR, Papp KK. 2003. SNAPPS: a learner-centred
model for outpatient education. Acad Med 78:893–898.
Wright SM, Carrese JA. 2002. Excellence in role modelling: insight and
perspectives from the pros. Can J Med 167:638–643.
S. Ramani & S. Leinster
364
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Col
orad
o on
12/
13/1
0Fo
r pe
rson
al u
se o
nly.
118
Balance: Can you have Balance: Can you have it all?it all?
Susan M. Gilmour, Susan M. Gilmour, MScMSc, MD, FRCPC, MD, FRCPCChair, Department of PediatricsChair, Department of Pediatrics
University of AlbertaUniversity of AlbertaStolleryStollery ChildrenChildren’’s Hospitals Hospital
Have it all?Have it all?
YesYes…….but you just can.but you just can’’t have it t have it all at onceall at once……
Balancing What?Balancing What?
CareerCareer PatientsPatients
CoCo--workersworkers
PeersPeers
SupervisorsSupervisors
Relationships/familyRelationships/family
SelfSelf
119
WorkWork--Life Balance: Fact or Life Balance: Fact or Fiction?Fiction?
Imbalance = StressImbalance = Stress
Stress effects both physical and Stress effects both physical and mental health and we become mental health and we become more dissatisfied with our lifemore dissatisfied with our life
Stress results in $10 billion due Stress results in $10 billion due to absenteeism and $14 billion to absenteeism and $14 billion in healthin health--care (Canadian data)care (Canadian data)
““Leave work too early and get Leave work too early and get home too latehome too late””
If you canIf you can’’t stand the heat dont stand the heat don’’t t become a become a soussous chef (chef (……or a or a doctordoctor……) ) GlobeGlobe and Mail,and Mail, December 2010)December 2010)
HealthHealth--care care practionerspractioners have have poorer balancepoorer balance Self neglect/denialSelf neglect/denial
Lack of boundaries between work Lack of boundaries between work and homeand home
Mental healthMental health
Substance abuseSubstance abuse
120
MultiMulti--taskingtasking
DoesnDoesn’’t existt exist Rapid Rapid
succession of succession of single focus single focus taskstasks
Choose your Choose your taskstasks
Say noSay no Be engaged in Be engaged in
the presentthe present
Combating StressCombating Stress
No single formula: Cultivate No single formula: Cultivate habits of personal renewalhabits of personal renewal Emotional selfEmotional self--awarenessawareness
Healthy habitsHealthy habits
Connection with colleaguesConnection with colleagues
Adequate support systemsAdequate support systems
Ability to find meaning in workAbility to find meaning in work
Job SatisfactionJob Satisfaction
DoesnDoesn’’t come from outsourcing t come from outsourcing the rest of your lifethe rest of your life
DoesnDoesn’’t come from financial t come from financial incentivesincentives
Comes from meaningful input Comes from meaningful input (not the same thing as control)(not the same thing as control)
Solving problemsSolving problems……
121
““DonDon’’t worryt worry……be happybe happy””
122
Depression and Burnout in Medical Training
Burnout is a syndrome of emotional exhaustion, depersonalization, and low personal accomplishment. Often, it can lead to decreased effectiveness at work. Burnout is different from depression in that it usually only involves a person’s relationship to work, whereas depression is more global.1
As documented in multiple studies, burnout and depression occur at high rates among house officers across many specialties. In a recent survey study of 123 residents at three pediatric residency programs, 20% of participating residents met criteria for depression, and 74% met criteria for burnout.2
Burnout Emotional exhaustion: - Emotionally drained from work - Depleted at the end of the workday - Tired when you have to face another day of work - You are working too hard on your job - Frustrated with work - As though you are at the end of your rope Depersonalization: - As though you do not have compassion for patients and/or colleagues - More callous toward people as a result of your job - Work seems to be hardening you emotionally - Indifferent about what happens to people at work - Blamed by people at work Low sense of personal accomplishment: - Loss of empathy for others at work - Loss of effectiveness in dealing with the problems of others at work - Loss of energy - Exhausted when you work closely with others - Unsure whether you really accomplish anything worthwhile at work - Loss of ability to remain calm when dealing with emotional problems at work
Depression Major Depression Diagnosis of major depression requires at least five of nine symptoms (must include one of first two) for at least two weeks: - Depressed mood - Markedly diminished pleasure or interest in activities - Significant weight loss or weight gain - Insomnia or excessive sleep - Agitated movements or very slow movement - Fatigue or loss of energy
123
- Feelings of worthlessness or guilt - Impaired concentration and indecisiveness - Thoughts of death or suicide Atypical depression People with atypical depression have some, but not all, of the same features of major depression. They often have prominent physical symptoms, including weight changes and sleep disturbances, especially excessive sleep.
Dysthymia Dysthymia is a chronic, low-grade depression that persists for a long period of time, usually two consecutive years, with no more than two months at a time free of symptoms. The prominent symptoms include an absence of pleasure or interest in activities, low self-esteem, low energy, and poor sleep and concentration.
Accompanying Materials: Bernstein, Mark. Neurosurgical depression. Canadian Medical Association Journal. 2003: 169(9); 943-944. Malach-Pines Short Burnout Measure. Courtesy of the Office of Clinician Support, Children’s Hospital Boston. References: 1. Shanafelt TD et al. Burnout and self-reported care in an internal medicine residency program. Annals of Internal Medicine 2002: 136(5); 358-367. 2. Fahrenkopf, Amy et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ 2008;336:488-91. 3. Sotile, W and Sotile, M. The Resilient Physician. American Medical Association, 2002. 4. Up-To-Date Online, 15.3. Patient Information: Depression in Adults.
124
Office of Clinician Support, Children’s Hospital Boston: A Safe Place to Talk
For Appointments, please call (617) 355-6705
Burnout is a common problem among healthcare givers. You can use the following measure to assess your level of burnout.
Please use the following scale to answer the question: When you think about your work overall, how often do you feel the following?
Nev
er
Alm
ost N
ever
Rar
ely
Som
etim
es
Oft
en
Ver
y O
ften
Alw
ays
1 2 3 4 5 6 7 Tired Disappointed with people Hopeless Trapped Helpless Depressed Physically Weak/Sickly Worthless/Like a Failure Difficulties Sleeping "I've had it"
To calculate your burnout score add up your responses and divide by 10: ________ A score of up to 2.4 indicates low level of burnout; 2.5-3.4 indicates danger of burnout; 3.5-4.4 indicates burnout; 4.5-5.4 indicates serious burnout; a score of 5.5 or higher is suggestive of a need for immediate professional help. Hospitals are complex environments. Taking care of sick patients, especially children, can be very demanding and emotionally draining. Academic pressure, hospital regulations, and differences among staff can also contribute to workplace stress. The Office of Clinician Support is a safe place to talk. Even a few minutes can help reduce your distress. The Office of Clinician Support can be a first step. For appointments, please call 617-355-6705.
Burnout Measure: Short Version (Malach-Pines, 2005)
125
126
tient — and alcoholic — who has lefthospital before completing his treat-ment. They deliver the meds, making atiny inroad into a significant publichealth problem.
Meanwhile, in the Congo, a nurseand logistician from the Netherlandsembark on a 550-km reconnaissancemission to assess the need for a mobileclinic in the “land of the living skele-tons,” a forgotten region near Lolon-golokonga. Peter Rietveld is also tryingto understand the cachexia that afflictsmany inhabitants of the area. Question-ing and observation lead him to suspectan association with endemic river blind-ness — and with abject poverty.
Episode 4, “Borders and Babies” (air-ing Oct. 30 and Nov. 2), features work inSierra Leone and on the border betweenPakistan and Afghanistan. Canadian
nurse Katiana Rivette, in her early daysas head of the maternity ward at Magbu-raka hospital, tries to save a baby whosemother is dying of pre-eclampsia: bothsuccumb. (Was it necessary to show thiswoman’s breasts? Was patient permis-sion obtained? We don’t know.) Thisepisode also features the heart-wrench-ing story of the boy with osteosarcoma.
In Freetown, we catch American Re-becca Golden wrapping up seven yearsas head of the MSF mission in SierraLeone. She admits to being tired — “Iwant to get out from underneath theresponsibility” — but at the same timeshe loves the country and returns to theUS with trepidation.
In Chaman, Afghanistan, BritonVickie Hawkins supervises logistics andmedical care for the thousands ofrefugees streaming across the border.
She also cuts through red tape to get aseriously ill man admitted to hospital.Her frustration simmers, but she can’tshow it. “It’s unstable, volatile, even vi-olent. So, what am I doing here?” sheasks. “I love it!”
This enthusiasm is the thread thatjoins all the MSF staff and volunteersencountered. “A life-changing experi-ence,” says Friend. “I want to change theworld,” says Rivette at the start of herterm. Within a week she’s changed hertune: “I can’t save the world, or SierraLeone, or a village. I’m just here to sharea little bit of my knowledge. For sureI’m going to gain more than I give.”
Lampard aptly sums it up: “At theend of the day, I sleep a little better.”
Barbara SibbaldCMAJ
The Left Atrium
CMAJ • OCT. 28, 2003; 169 (9) 943
Room for a view
Neurosurgical depression
He wakes up soaked in sweat at 3:30am, rescued by consciousness
from a string of nightmares. The firstwas about a new reality show on televi-sion in which all of the male contestantsagreed to have their penises cut off ifthey didn’t win. The victims seemed totolerate the insult with equanimity.
He rolls out of bed, panting withpanic. There is no point in trying tosleep a little longer. It doesn’t take abrain surgeon to understand that thisman has feelings of inadequacy and in-security and is tormented by demons.
He gets dressed, fumbling with hisshirt buttons and the knot in his tie. It’san awkward process: the end of hisdominant thumb is split from the drywinter air and he doesn’t want to re-open it and bloody his clothes. He triesto get downstairs quietly, to avoid wak-ing his wife and daughters, but hischocolate Labrador emerges fromnowhere and trips him up in the dark.Body and briefcase go sprawling. Hisolder dog, a big yellow lab, pads downthe hall to check things out; she licks his
head, sticking her tongue up his nose. This is his laugh for the day. He
pulls himself up, resigned to the blonddog hair now clinging to his meticu-lously kept clothes. He stumbles down-stairs and throws on his coat. The air isfrigid; he feels hisway in the dark tothe car. The enginewon’t be warm untilhe pulls into theparking lot at thehospital. For threehours he answersemails, dictates dis-charge summaries,listens to jazz on theradio, and works on revisions of a man-uscript that he is so proud of and thatthree journals have rejected so far.
He goes downstairs to the coffee barand gets a large regular coffee, his onlymeal of the day. The hospital still has anearly, empty feeling: there’s no one elsein line. At 7:45 a.m. he goes to the oper-ating room. His first patient needs to bedelayed; she has had a sore throat since
yesterday and has started to wheeze. Herelective back surgery was booked amonth ago. He chats with the anesthesi-ologist, who suggests they start with oneof his two other cases — both young,both requiring removal of a brain tu-
mour. The OR nurses,his second family, curseunder their breath be-cause they already hadthe room set up for thelumbar discectomy andhave to rearrange it.
He gets through thetwo tumour surgeriesand the sweet little ladywith the back problem is
deemed fit for surgery after inhalingfrom some puffers. So he gets all threecases done. Much of the surgical day isspent fussing over residents and fellowsto do the surgery as well as he wouldbut in twice the time it would take him.And one of the really good OR nursesis in a manic phase and is exhausting tobe with; he’s usually the only manic onein the OR.
Art
Exp
losi
on
127
Côté cœur
944 JAMC • 28 OCT. 2003; 169 (9)
At the end of the day he makes quickrounds with the residents to make sureall is well: another day of doctors tri-umphing over disease. He ought to feelexhilarated. All of the surgeries havegone well, but he knows that the secondpatient will not graduate from college intwo years; her cancerous brain tumourwill have claimed her by then.
He stumbles back to his office at6:00 p.m. to do paperwork and getshome at 8:30. His dogs greet him en-thusiastically; his wife and daughtersless so. His wife smiles wryly and tossesa meaningful glance toward the girls.Another family supper missed. He sum-mons a loud “Hi” for each of his daugh-ters; they reply with garbled grunts. Hemakes a gin and tonic and after gulpingit in 20 seconds pours a glass of redwine to lubricate the rapid downing ofhis first meal in 24 hours. He has a bathand pours a scotch and takes it with atall glass of water to his study, where heturns on the computer to check emails.He writes a tormented piece like thisone and falls asleep watching television,trying to dream about fishing or being amonster jazz saxophonist. He loves hisfamily and they love him, but every-one’s struggling with the same thing heis. At 3:30 a.m. he wakes up and does itagain.
He’s a little depressed, pal. But hashe figured it out yet?
The next evening he gets a phonecall from one of his daughters, who isout on the town with friends. Shesounds so grown-up, yet so dear andtender — the youngest of three pre-cious daughters, who was born with alarge birth-mark on her upper lip thateventually faded, who had a few febrileseizures as a baby that scared him andhis wife shitless, and who is strugglingwith the things teenagers struggle with.Before he hangs up he tells her howmuch he loves her. Then he sits on theside of the bed and sobs like a baby.
He’s a really depressed man. Whatis he going to do about it?
Mark BernsteinNeurosurgeonToronto Western HospitalToronto, Ont.
Lifeworks
A terrible beauty
“While we may be flesh-colouredon top,” says artist Patricia
Chauncey, “there’s a whole lot morethat’s underneath us that is actuallyshockingly beautiful.”
Chauncey’s textile art pieces vividlyillustrate this idea. Some look likechunks of dinosaur hide, others likemagnifications of animal cells or tissuesamples. One looks like somethingyou’d glimpse in an antismoking ad: athick, textured mat of moist greys,browns and purples. All are potent andorganic, like things excavated from theearth or the human body and exposedto daylight for the first time.
Chauncey has been interested in or-ganic and biological subjects for a longtime, having spent many childhoodhours looking for dinosaur bones in theAlberta badlands. She has used medicalimagery in her work for years, while do-ing art shows, designing and distressingcostumes for the film industry, and rais-ing a family in Vancouver.
Although she had been feeling sickfor years, she was diagnosed with an ag-gressive form of breast cancer only lastyear. “By the time they found the tu-mour in my body it was the size of agrapefruit ... . I had a lymph node thatwas completely replaced by cancer. So, Imoved instantly from not knowing Ihad cancer into metastatic cancer.”Fighting her cancer, she’s come to in-corporate her awareness of her bodyinto her art.
“Since I’ve been diagnosed with can-cer ... I’ve had the opportunity, verydifferently than most people who arehealthy, to see what that looks like. I’veseen what my cells look like, I knowwhat my DNA is like, I know what myskeleton looks like. I've been living upin the library in the cancer clinic. Peo-ple think I’m reading to find out if Ican improve my situation ... . Butwhat’s amazing to me is the visuals ofit. I’m absolutely fascinated by thebeauty of cells, and by how magical theconnection between body parts andeverything is. ... [Cells] are like gar-dens, they’re like little constellations. Imean they’re just absolutely amazing.Sometimes the cells that are pretty arethe ones that are sick.”
These are the images and ideas thatChauncey incorporates into her art. Sheworks in destructive textiles, which in-volves “slashing, cutting, burning, melt-ing and leaving [metal] in the yard torust, and applying different kinds of ma-terials so that the textile takes on a dif-ferent form. You can start with a plaincotton and come out with somethingentirely different, or a plain white pieceof polyester and have something that’svery three dimensional and very carved-up, very mineral-like. It takes on com-pletely different qualities.” Her workalso includes embroidery, dyeing, print-ing and silkscreen techniques. She stud-ied at Capilano College under LeslieRichmond, one of the world’s foremostdestructive textile artists.
Some of her work consists of mem-Patricia Chauncey, 2001. Flesh (detail)
Tim
Hur
ley
128