Principles of Teaching and Learning in Clinical Settings Professor Hossam Hamdy University of Sharjah

Aim What is Clinical Teaching Barriers to effective Clinical Teaching Strategies to improve Clinical Teaching Teaching and learning in different clinical settings

Clinical Teaching There should be no teaching without the patient for a text and the best teaching is often that taught by the patient himself (William Osler)

Triad Interactive Learning in the Clinical Context Content TeacherPatient Student Context

Teaching with Patient  Bedside  Outpatient clinic  Emergency ward  Day Case Surgery  O.R

Barriers to Effective Clinical Teaching  Time lack for clinicians.  Insufficient space to teach.  Crowded outpatients.  Increasing number of ‘ super-specialist ’ clinics.

Barriers to Effective Clinical Teaching (cont/-)  Lack of patients and inpatient beds.  Lack of consistency in what is taught.  Lack of organization in what is taught between teachers.

Barriers to Effective Clinical Teaching (cont/-)  Teaching is not considered part of service commitment.  Lack of knowledge and skills about teaching methods.

The Clinical Context  More shift from Hospital setting to Ambulatory settings.  Diminish the significance of bedside teaching “short length of stay”.

The Clinical Context (cont/-)  Hospital populated with critically ill and early post-operative patients.  Early diagnosis – no or little physical signs.

Key Clinical Competencies  What are the key clinical competencies you as a clinical teacher want to ensure that the students have accomplished  Good communication and data gathering  Decision Making

Clinical Teaching  Be available (on time) and approachable.  Introduce yourself and know their names.  Pre select patients/ Ask permission  Ensure respect for patients comfort and dignity Planning “set”

  Clarify expectations and goals appropriate to the setting, patient problems and student level “ prior knowledge ” Clinical Teaching (cont/-) Planning “set” (cont/-)

 Teach from clinical cases.  Go to the bedside or exam room  Use questions to diagnose patient & learners. Teaching “Dialogue” Clinical Teaching

 Role model  Focus the teaching on data gathering by or about the patient “critical player”  Promote student clinical reasoning skills.. Teaching “Dialogue” (cont/-) Clinical Teaching

 Context specificity.  Prior knowledge & net-working.  Schemata and script concordance. Non-Analytical Reasoning “ Pattern recognition ”

Analytical Reasoning  Early hypothesis generation  Testing and re-testing hypothesis

Pre-test Probability TEST Post-test Probability Analytical Reasoning Each question in the history and each physical examination is a diagnostic test. EBM Approach

Combined Model of Clinical Reasoning Patient Presents Hypotheses Tested Non-analytic Interactive Analytic Case Representation

 Increase the student base of scenarios, scripts and mental images.  Students should be guided to relate novel experience with past experiences ‘Anchor proto-type in their memory’. Clinical Teaching Tips

Clinical Teaching Tips (cont/-)  Implicit / Tacit  Explicit  Key features of disease  Relevant information “ focused history & physical exam. ” Model Professional Thinking and Decision Making “ Preceptor Thinking Out Loud ”

Clinical Teaching Tips (cont/-)  Priority in investigations and treatment.  Review diagnostic probabilities and rationale for diagnosis and treatment. Model Professional Thinking and Decision Making “ Preceptor Thinking Out Loud ”

The One Minute Clinical Preceptor Teaching Model Diagnose Patient & Learner Get a commitment Microskill 1: Get a commitment What do you think the patient problem is? Probe for supportive evidence Microskill 2: Probe for supportive evidence Reasoning. Why do you think this is the case?

The One Minute Clinical Preceptor Teach general rules & concepts Microskill 3: Teach general rules & concepts When this happens, usually … Take home message

Feedback “closure” Provide regular, well timed feedback. Microskill 4: Provide regular, well timed 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 Preceptor

The one Minute Clinical Principle Correct mistakes and promote self assessment and self-directed learning. Microskill 5: Correct mistakes and promote self assessment and self-directed learning.  Focus on behavior, not individual.  Ask learner for their opinion or perception.  Be straightforward, but respectful. Feedback “closure”

Eight Attributes of an Effective Clinical Teacher (after David Newbie, “A Handbook for Medical Teachers”) 1. Encourages active student participation rather than passive observation 2. Emphasis on teaching of applied problem solving 3. Integrates clinical medicine with basic science 4. Close observation of students during interview/examination rather than side-room case presentation

Eight Attributes of an Effective Clinical Teacher (after David Newbie, “A Handbook for Medical Teachers”) 5. Provides adequate opportunity for students to practice skills 6. Provides good role-model for interpersonal relationships with patients 7. Teaching patient-oriented rather than disease- orientated 8. Demonstrates a positive attitude towards teaching

The Effective Clinical Teacher Most important being willing to teach and be enthusiastic about it

Thank You

COMPARISON BETWEEN HOSPITAL AND COMMUNITY CLINICAL TRAINING HospitalCommunity Predictable experiencesOpportunistic, unpredictable Disease orientedIllness oriented/relationship with patients Serious, complex, illnessSelf limiting, prevention, chronic care, psychosocial morbidity Multiple contacts withSingle contact patients Patient

COMPARISON BETWEEN HOSPITAL AND COMMUNITY CLINICAL TRAINING The Learner HospitalCommunity Multiple learnersSingle learner Multiple levelsOften independent Member of team

COMPARISON BETWEEN HOSPITAL AND COMMUNITY CLINICAL TRAINING The Teacher HospitalCommunity High degree of control Tensions : Competence of assessment and management Low control Tensions : Acceptability to patient competence in assessment and management

Learning in Outpatient Clinic:  Focused History & Physical Examination  Working diagnosis  Cost-effective investigation  Selection of management options  Communication Skills

Tips for Teaching in the Outpatient  Ensure patient comfort and cooperation.  Access the learners’ needs before patient assignment.  Teach the concept of focused history and examination

Tips for Teaching in the Outpatient (cont/-) Tips for Teaching in the Outpatient (cont/-)  Use higher level questions to promote development of critical thinking skills  Teach good physician-patient interaction skills  Teach patient education skills

Teaching in the Operating Room  Instruction in operative techniques  Training in the overall conduct of the operation  Discussion of the overall care of the patient’s problem

Teaching in the Operating Room (cont/-)  Anatomy, Pathology and Pathophysiology.  Natural history of disease.  Potential postoperative complications and follow-up plans

O.R. Highest Rated Teaching Behaviors  Demonstrates respect for patient  Role models good interaction with operating room staff  Allows students to assist  Writing operative notes

O.R. Highest Rated Teaching Behaviors (cont/-)  Answers questions clearly  Provides feedback without belittling  Remains calm, courteous  Teaches with enthusiasm