Learning and Teaching in Clinical Encounters
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Introduction
"Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from a book. See, and then reason and compare and control. But see first." William Osler
- dlp: anchor prototypes.
Cognitive Learning theory has much to offer the clinical learning process. Deliberate practice can be used to help students activate their prior knowledge through brainstorming and briefing. Subsequent to this, help students elaborate their knowledge by providing a bridge between existing and new information. This can be done using examples, comparisons, analogies. Afterwards, solidify learning by debriefing, and promoting discussion and reflection. Provide variable contexts for learning, as long as they are relevant, to maximize connectivity.
Clinincal teachers have various aspects of personality:
- style of presenting: enthusiastic/boring, charismatic/anxious, etc
- professional: knowledgeable, diligent, high expecations vs lack of commitment
- personal: loyal, supportive, patient, flexible, intuitive, persuasive, intimidating vs humiliating, authoritarian, arrogant, dogmatic, bigot
Outpatient Education
During clinic-based education, as opposed to hospital-based education, the learner normally completes a clinical encounter to the best of their ability and then seeks out the teacher. As such, there is some rationale that the learner should effectively prepare for the learning encounter. The SNAPPS model is a very effective tool to guide this dialogue, and is described here.
Orientation
It is very important to orient a learner when they first begin a clinical rotation. This helps set the tone for time together, and also provides reassurance.
Set expectations on time, rounding, charting, dictations. Provide these clearly.
Discuss models of assessment, including:
Establish goals. Review objectives provided by the program, assess where the learner is situated regarding these goals, and ask the learner what they would like to gain from the experience together.
Show them around. Introduce to important places and people.
General Logistics
Clinical work is demanding, and often does not leave much time for clinical teaching. Some opportunities that may work better include:
- before patients
- beween patients
- over lunch
- when there is a cancellation or a patient does not show
- after the last patient
Selecting Patients
It can be challenging to select patients for outpatient encounters. It is especially difficult to arrange for longitudinal exposure.
There are concerns about patient fatigue and negative effects on the patient-doctor relationship.
Both learners and preceptors acknowlege the value of selecting approprtiate patients.
Preceptors choose appear to make selections based on the following (Simon et al, 2003):
- time and efficiency, ensuring the schedule continues to move
- educational value, attempting to select 'interesting' patients for learners, and trying to balance acute and chronic complaints
- influence on the patient-doctor relationship
Before the Encounter
Briefing the learner before an encounter can be effective in increasing time efficiency and maximizing learning. This is especially important for junior learners, who require parameters regarding their role and responsibility during the encounter.
Learners have a large body of abstract knowledge they can draw upon, and briefing before an encounter can help activate the appropriate stored knowledge - a concept termed 'elaboration'. Where needed, the expert can also assist in the development of this knowledge base that can be effectively accessed in the future (Miflin and Price, 1997).
Briefing can help allay anxiety and build confidence for the learner to push the boundaries of their abilities in taking histories and doing physical exams. This is especially important if the patient is known to have a condition that could cause stress or embarassment.
Priming is a brief orientation of the learner to the patient and the task, immediately before the interaction.
Elements of priming can be described using the acronym TAPP:
Task: define the task and the amount of time required to complete it
Attending role: when you will reconnect, and how
Patient: briefly discuss patient issues/chief complaint
Product: what student is expected to produce by the end of the encounter. be consistent!
As clinical experience improves, the briefing can change to reflect this heightened ability.
Case Discussion
Depending on the amount of time available, the time immediately after an encounter can be extremely beneficial regarding solidification of concepts and learning of new ones. This may or may not see the preceptor also seeing the patient.
One-minute Preceptor
- get a committment
- question for reasoning
- provide feedback on what
went well - correct errors
- teach general rules
While there are a number of approaches that may be used, one popular approach in North America and beyond is the One-minute preceptor, also known as the 'Microskills' model. The one-minute preceptor is a five step approach to assist the learner in identifying and learning around key concepts (Neher et al, 1992). It is designed to be rapid and efficient, and can be learned in 1-2 hours. The steps are outlined below:
Get a commitment: The learner should quickly outline a diagnosis or management plan. This ownership of the patient's situation encourages deeper processing. As necessary, ask questions that allow for specific probing:
- differential diagnosis
- diagnostic strategy
- selection of therapy
- prognosis
- management issue
While questions of these sorts can be helpful, it is important not to rapidly question the learner in an effort to understand and solve the situation.
If the learner does not demonstrate a committment, it suggests poor data gathering or interpretation skills, or anxiety about being wrong. This should be explored.
Question for reasoning: Building upon the commitment, the preceptor should help both learner and teacher understand the cognitive processes used. The teacher should not, however, immediately approve of or denounce the decision. Instead, it can be useful to ask what else was considered, and why these choices were rejected. The teacher should listen carefully for teaching points, as described below.
Provide feedback on what was done well: During the interaction, watch carefully for knowledge, behaviours, or approaches that should be reinforced, and provide appropriate feedback. Endeavour to be as specific as possible.
Correct errors and make suggestions: As appropriate, given the setting and timing, describe gaps in the learner's approach or knowledge. Again, be as specific as possible. For more information on providing feedback, see here.
Teach general rules, or take home points: As appropriate, provide a brief teaching that supplements the learner's performance. Use general principles that are transferrable.
This model depends on effective data-gathering, and as such, if the clinical skills of the learner are not sufficiently developed, the preceptor will still need to evaluate the patient themself.
Questioning
Questions can be extremely helpful. They assess learner knowledge and knowledge needs, promote clinical reasoning, encourage reflection. However, if used poorly, they can be very intimidating and off-putting.
To effectively ask questions, be safe, friendly, and encouraging, promote thinking and problem-solving by focusing on what learner doesn't know. 'I don't know' needs to be a safe sentence.
Use closed questions to establish facts or learner's knowledge, then move into open, probing questions. With increasing complexity, questions can assess facts, comprehension, synthesis, analysis, and evaluation.
Allow for sufficient time for a response; don't jump in too soon!
If the learner responds poorly, follow with another question. Similarly, if a learner asks a question, respond again with a question.
Again, questions can be viewed as confrontational or uncomfortable. Instead of asking 'do you understand'? say 'many people find this topic difficult to understand' and wait for their response.
Teaching in Front of Patient
Can be very positive, but needs to be done carefully. Think about what discussions, if any, belong at the nedside. ALways obtain patient consent before the students arrive.
Ensure students respect confidentiality.
Prime students beforehand (see above)
Ask patient for feedback, then debrief afterwards.
Introduce everyone there.
Ask patient if they have questions, and follow up with them after.
Benefits
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Drawbacks
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Case Review
Case review can be done after the patient has left. Sessions can include a number of learners, and typically cover a number of patients. This is often carried out with more senior learners who have a greater level of autonomy.
Patients are normally covered quickly, though a small number of cases can be used to guide deeper discussion and teaching. In this case, the SNAPPS model should be used.
In order to be collegial, and to add to the discussion, cases the preceptor saw that day may also be discussed.
In mediating discussion with a group, ensure all learners contribute.
Adding controversial opinions to the discussion can help stimulation conversation.
Resources and References
Miflin BM, Price DA. 1997. Briefinf students before seeing patients. Medical Teacher. 19(2):143.
Neher JO, Gordon KC, Meyer B, Stevens N. 1992. A Five-Step "Microskills" Model of Clinical Teaching. CJABFP 5(4):419-424.
Simon SR et al. 2003. How do precepting physicians select patients for teaching medical students in the ambulatory primary care setting? J Gen Intern Med. 18(9):730-5.
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