Instructional Strategies: Small Group Teaching Daniel Rauch, MD

Disclosure Slide Drs. Gussic, Keller, and Rauch have nothing to disclose. Any real or apparent conflict of interest related to the content of the presentation has been resolved (somewhat amicably). Their presentation will not involve comments or discussion of unapproved or off label, experimental or investigational use of any teaching strategy (although we suggest reckless abandon when trying this at home).

The task faced by the clinical teacher “is unique in the entire realm of teaching. In no other field does the nature of the material demand of the teacher this degree of preparedness without preparation. We suggest that the problem of learning how to teach as a clinician deserves much thoughtful study…” Reichsman F, Browning FE, Hinshaw JR. Observations of undergraduate clinical teaching in action. J Med Educ 1964; 39: “Teaching requires thinking in the midst of action. Yet, is clinical teaching predominantly improvisation or does it involve extensive use of curriculum scripts?” Irby D. How Attending Physicians Make Instructional Decisions when conducting teaching rounds. Acad Med 1992; 67(10):630-8

Exercise 1 Who was your best attending? Why? Who was your worst attending? Why? List your own strengths and weaknesses

What does the literature say? Good attendings: –“a composite of careful listening, limited questioning, use of clarifying rather than probing questions, and use of the student’s presentation and impression as the springboard for subsequent case discussion” Mattern –using a patient-oriented approach Shulman –“…there is no ‘way’...” Ende

Case Presentation Thanks to U. Toronto and Toronto Sick Children for their students and residents

Definitions Example: Attending Rounds Purpose of Attending Rounds –Legal vs Instructive Roles –Attending –Senior –Intern –Student

Sample Definition The priority is education. The second function is to supervise and advise the senior resident as he or she directs the team. The attending is a consultant, available 24/7 to answer questions and facilitate the care of the patients. The attending is not a “super chief resident” who assists in the “micro-management” of the cases. The subtle, but key difference, is that the attending is not expected to make management decisions. Rather, the attending guides the resident’s decision-making.

Sample Roles Senior Resident –Ensure that all new admissions are presented to the attending –Help decide which other cases are worthy of review. –Review the status of each patient with the attending (after teaching rounds). Intern/Subintern –present the new admissions at attending rounds Student –When time permits, present at attending rounds

Small group facilitating Preparation/Agenda Process Reflection/feedback

Preparation/Agenda Day One “Pre-rounding”

Process Adult Learning Principles –Adults prefer to apply what they learn shortly after learning it –Adults prefer learning concepts and principles rather than facts –Adults like to help set their own learning objectives –Adults like to receive feedback

Process It is said that Woodrow Wilson, when teaching at Princeton, would stride into his classroom, greet the class, and then say, “Gentleman, are there any questions?” If no questions were asked then the class would be dismissed, since it was Professor Wilson’s contention that his young scholars had not prepared for class that day. Braughman MD, Bruaghman's Handbook of Humor in Education, West Nyack, NY, Parker, 1974, p.126

Process The 4 questions: –broadening –justifying –hypothetical –alternative Diagnosing the learner

Reflection/Feedback take 5 minutes to think what went right and what went wrong ask for feedback for yourself –from other team members –from another observer

Setting Sitting vs Bedside –“It is a mistake to hold that bedside teaching is necessarily equated to thinking and problem solving. Some undoubtedly is, but so much of it is minilecturing, noneducational chores, and the reflexive ordering of test after test” Eichna, L. Medical School Education: NEJM. 1980; 303:727-34

Content ACGME Competencies Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice

Content Refer back to purpose Teacher centered vs Learner centered Tangential can be OK – refer to competencies

Case Presentation 2

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