Principles of Teaching and Learning in Clinical Settings Professor Hossam Hamdy University of...
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Principles of Teaching and Principles of Teaching and Learning in Clinical Learning in Clinical
SettingsSettings
Professor Hossam HamdyProfessor Hossam HamdyUniversity of SharjahUniversity of Sharjah
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AimAim
• What is Clinical Teaching
• Barriers to effective Clinical Teaching
• Strategies to improve Clinical Teaching
• Teaching and learning in different clinical settings
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Clinical TeachingClinical Teaching
There should be no teaching There should be no teaching without the patient for a text and without the patient for a text and the best teaching is often that the best teaching is often that taught by the patient himself taught by the patient himself
(William (William Osler)Osler)
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Triad Interactive Learning in Triad Interactive Learning in the Clinical Contextthe Clinical Context
ContentTeacher Patient
StudentContext
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Teaching with PatientTeaching with Patient
BedsideBedside
Outpatient clinicOutpatient clinic Emergency wardEmergency ward
Day Case Surgery Day Case Surgery
O.RO.R
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Barriers to Effective Clinical Barriers to Effective Clinical TeachingTeaching
Time lack for clinicians.
Insufficient space to teach.
Crowded outpatients.
Increasing number of ‘super-specialist’ clinics.
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Barriers to Effective Clinical Barriers to Effective Clinical Teaching Teaching (cont/-)(cont/-)
Lack of patients and inpatient beds.
Lack of consistency in what is taught.
Lack of organization in what is taught between teachers.
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Barriers to Effective Clinical Barriers to Effective Clinical Teaching Teaching (cont/-)(cont/-)
Teaching is not considered part of service commitment.
Lack of knowledge and skills about teaching methods.
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The Clinical ContextThe Clinical Context
More shift from Hospital setting to More shift from Hospital setting to Ambulatory settings.Ambulatory settings.
Diminish the significance of bedside Diminish the significance of bedside teaching “short length of stay”.teaching “short length of stay”.
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The Clinical ContextThe Clinical Context (cont/-)(cont/-)
Hospital populated with critically ill Hospital populated with critically ill and early post-operative patients.and early post-operative patients.
Early diagnosis – no or little physical Early diagnosis – no or little physical signs.signs.
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Key Clinical CompetenciesKey Clinical Competencies
What are the key clinical competencies What are the key clinical competencies you as a clinical teacher want to ensure you as a clinical teacher want to ensure that the students have accomplishedthat the students have accomplished
Good communication and data Good communication and data gatheringgathering
Decision MakingDecision Making
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Clinical TeachingClinical Teaching
Be available (on time) and approachable.
Introduce yourself and know their names.
Pre select patients/ Ask permission
Ensure respect for patients comfort and dignity
Planning “set”
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Clarify expectations and goals appropriate to the setting, patient problems and student level “prior knowledge”
Clinical TeachingClinical Teaching
Planning “set” (cont/-)(cont/-)
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Teach from clinical cases.Teach from clinical cases.
Go to the bedside or exam roomGo to the bedside or exam room
Use questions to diagnose patient & learners.Use questions to diagnose patient & learners.
Teaching “Dialogue”Teaching “Dialogue”
Clinical TeachingClinical Teaching
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Role modelRole model
Focus the teaching on data gathering by or Focus the teaching on data gathering by or about the patient “critical player” about the patient “critical player”
Promote student clinical reasoning skills..Promote student clinical reasoning skills..
Teaching “Dialogue”Teaching “Dialogue” (cont/-)(cont/-)
Clinical TeachingClinical Teaching
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Context specificity.Context specificity.
Prior knowledge & net-working.Prior knowledge & net-working.
Schemata and script Schemata and script concordance.concordance.
Non-Analytical ReasoningNon-Analytical Reasoning
“Pattern recognition”
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Analytical ReasoningAnalytical Reasoning
Early hypothesis generationEarly hypothesis generation
Testing and re-testing hypothesisTesting and re-testing hypothesis
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Pre-test Pre-test ProbabilityProbability
TESTTEST Post-testPost-test ProbabilityProbability
Analytical ReasoningAnalytical Reasoning
Each question in the history and each physical examination is a diagnostic test.
EBM Approach
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Combined Model of Clinical Combined Model of Clinical Reasoning Reasoning
Patient Presents
Hypotheses Tested
Non-analytic Interactive Analytic
Case Representation
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Increase the student base of Increase the student base of scenarios, scripts and mental images.scenarios, scripts and mental images.
Students should be guided to relate Students should be guided to relate novel experience with past novel experience with past experiences ‘Anchor proto-type in experiences ‘Anchor proto-type in their memory’.their memory’.
Clinical Teaching TipsClinical Teaching Tips
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Clinical Teaching TipsClinical Teaching Tips (cont/-)(cont/-)
Implicit / Tacit Explicit
Key features of disease
Relevant information “focused history & physical exam.”
Model Professional Thinking and Decision Making “Preceptor Thinking Out Loud”
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Clinical Teaching TipsClinical Teaching Tips (cont/-)(cont/-)
Priority in investigations and treatment.
Review diagnostic probabilities and rationale for diagnosis and treatment.
Model Professional Thinking and Decision Making
“Preceptor Thinking Out Loud”
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The One Minute Clinical Preceptor The One Minute Clinical Preceptor Teaching ModelTeaching Model
Diagnose Patient & Learner
Microskill 1: Get a commitmentGet a commitment
What do you think the patient problem is?
Microskill 2: Probe for supportive Probe for supportive evidenceevidence
Reasoning. Why do you
think this is the case?
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The One Minute Clinical The One Minute Clinical Preceptor Preceptor
Microskill 3: Teach general rules & Teach general rules & conceptsconcepts
• When this happens, usually …• Take home message
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Feedback “closure”
Microskill 4: Provide regular, well Provide regular, well timed timed feedback.feedback.
Should be descriptive rather than judgmental.
Reinforces positive behaviors and motivates learner.
Conveys an attitude of concern and interest between instructor and learner.
The One Minute Clinical The One Minute Clinical Preceptor Preceptor
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The one Minute Clinical The one Minute Clinical PrinciplePrinciple
Microskill 5: Correct mistakes and Correct mistakes and promote self promote self
assessment assessment and and self-directed learning.self-directed learning.
Focus on behavior, not individual.
Ask learner for their opinion or perception.
Be straightforward, but respectful.
Feedback “closure”
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Eight Attributes of an Effective Clinical TeacherEight Attributes of an Effective Clinical Teacher(after David Newbie, “A Handbook for Medical Teachers”)(after David Newbie, “A Handbook for Medical Teachers”)
1.1. Encourages active student participation rather than Encourages active student participation rather than passive observationpassive observation
2.2. Emphasis on teaching of applied problem solvingEmphasis on teaching of applied problem solving
3.3. Integrates clinical medicine with basic scienceIntegrates clinical medicine with basic science
4.4. Close observation of students during Close observation of students during interview/examination rather than side-room case interview/examination rather than side-room case presentationpresentation
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Eight Attributes of an Effective Clinical TeacherEight Attributes of an Effective Clinical Teacher(after David Newbie, “A Handbook for Medical Teachers”)(after David Newbie, “A Handbook for Medical Teachers”)
5. Provides adequate opportunity for students to practice 5. Provides adequate opportunity for students to practice skillsskills
6. Provides good role-model for interpersonal 6. Provides good role-model for interpersonal relationships with patientsrelationships with patients
7. Teaching patient-oriented rather than disease-7. Teaching patient-oriented rather than disease-orientatedorientated
8. Demonstrates a positive attitude towards teaching 8. Demonstrates a positive attitude towards teaching
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The Effective Clinical Teacher The Effective Clinical Teacher
Most important being willing to Most important being willing to teach teach
and be enthusiastic about itand be enthusiastic about it
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Thank YouThank You
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COMPARISON BETWEEN COMPARISON BETWEEN HOSPITAL AND COMMUNITY CLINICAL HOSPITAL AND COMMUNITY CLINICAL
TRAININGTRAINING
Hospital Community
Predictable experiences Opportunistic, unpredictable
Disease oriented Illness oriented/relationshipwith patients
Serious, complex, illness Self limiting, prevention, chronic care, psychosocial morbidityMultiple contacts with Single contactpatients
Patient
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COMPARISON BETWEEN COMPARISON BETWEEN HOSPITAL AND COMMUNITY CLINICAL HOSPITAL AND COMMUNITY CLINICAL
TRAININGTRAINING
The LearnerHospital Community
Multiple learners Single learner
Multiple levels Often independent
Member of team
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COMPARISON BETWEEN COMPARISON BETWEEN HOSPITAL AND COMMUNITY CLINICAL HOSPITAL AND COMMUNITY CLINICAL
TRAININGTRAINING
The TeacherHospital Community
High degree of control
Tensions :Competence of assessmentand management
Low control
Tensions :Acceptability to patientcompetence in assessment and management
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Learning in Outpatient Clinic:Learning in Outpatient Clinic:
Focused History & Physical Focused History & Physical ExaminationExamination
Working diagnosisWorking diagnosis Cost-effective investigationCost-effective investigation Selection of management optionsSelection of management options Communication SkillsCommunication Skills
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Tips for Teaching in the Tips for Teaching in the OutpatientOutpatient
Ensure patient comfort and Ensure patient comfort and cooperation. cooperation.
Access the learners’ needs before Access the learners’ needs before patient assignment.patient assignment.
Teach the concept of focused history Teach the concept of focused history and examinationand examination
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Tips for Teaching in the Tips for Teaching in the OutpatientOutpatient (cont/-)(cont/-)
Use higher level questions to promote Use higher level questions to promote development of critical thinking skillsdevelopment of critical thinking skills
Teach good physician-patient Teach good physician-patient interaction skillsinteraction skills
Teach patient education skillsTeach patient education skills
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Teaching in the Operating Teaching in the Operating RoomRoom
Instruction in operative techniquesInstruction in operative techniques
Training in the overall conduct of the Training in the overall conduct of the operationoperation
Discussion of the overall care of the Discussion of the overall care of the patient’s problempatient’s problem
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Teaching in the Operating Room Teaching in the Operating Room (cont/-)(cont/-)
Anatomy, Pathology and Anatomy, Pathology and Pathophysiology.Pathophysiology.
Natural history of disease. Natural history of disease.
Potential postoperative complications Potential postoperative complications and follow-up plansand follow-up plans
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O.R. Highest Rated Teaching O.R. Highest Rated Teaching BehaviorsBehaviors
Demonstrates respect for patientDemonstrates respect for patient
Role models good interaction with Role models good interaction with operating room staffoperating room staff
Allows students to assistAllows students to assist
Writing operative notesWriting operative notes
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O.R. Highest Rated Teaching O.R. Highest Rated Teaching Behaviors Behaviors (cont/-)(cont/-)
Answers questions clearlyAnswers questions clearly
Provides feedback without belittlingProvides feedback without belittling
Remains calm, courteousRemains calm, courteous
Teaches with enthusiasmTeaches with enthusiasm