Practical (but evidence-based) Clinical Teaching That Doesn’t Suck

(A bit of context… this post also serves as the “show notes” for a presentation I gave at the Social Media and Critical Care conference, Chicago, 2015)

Clinical (aka bedside) teaching is at the heart of health professions education.  When William Osler dragged medical students out of the lecture theatre and back to the wards of Johns Hopkins, he helped return medical education to its roots.  As we enter this new era of competency-based medical education, the centrality of clinical teaching is of even greater emphasis.

So, as administrative, academic and clinical pressures mount, how do Clinician Educators effectively and efficiently teach in the clinical environment? We’ve discussed this previously on the ICE blog.  Today’s post expands on the idea further.

Teaching Models:

There is certainly evidence to guide us.  Two prominent systematic reviews, one by Irby, the other by Heidenreich et al. suggest common approaches.

The One Minute Preceptor by Nehrer provides this framework.

  1. Get a Commitment
  2. Probe for Supporting Evidence
  3. Reinforce What Was Done Well
  4. Give Guidance About Errors and Omissions
  5. Teach a General Principle

Specific to emergency medicine is the ED STAT (Emergency Department Strategies for Teaching Anytime) model.

The Model: EDSTAT!

Expectations
Diagnose the learner
Set-up
Teach
Assess and give feedback
Teacher Always

The first two elements – Expectations and Diagnosis need to happen early in a shift, particularly if you have never worked with the learner before.

Expectations

– Orient the learner
– Your expectations
– Learner’s expectations

Expectations help to establish a priori the roles for both you and the learner.

Diagnose

– Demographics
– Observed needs
– Perceived needs

Diagnosing the learner’s educational needs will help you improve efficiency and effectiveness in your teaching.

The next four elements occur continually spiral with every clinical encounter you discuss with the learner.

Set-up

– Organizing learning
– Clear tasks
-‘Priming’

Prior to sending a learner to see a patient, establish the process for case presentation, timeframe, and the potential teaching issues to be discussed (often based on a quick review of the medical record).

Teach

– Tagged
– Targeted
– Tailored

In a busy emergency department, teaching need not resemble a traditional lecture or seminar.  Rather, if you tag as “teaching” the numerous brief conversations you have with your learner, you (and the learner) will be amazed at how much teaching occurs.  In my busy Emergency Department, I routinely limit my teaching to 90 second discussions.  Rather than talking about everything I know about an ECG, I choose to target a single point.  This allows regular teaching to be incorporated into the hectic pace of emergency medicine practice.  Finally, choose your teaching points strategically.  Tailor your teaching based on the educational diagnosis of your learner.

Assess and Feedback

– Observe
*multi source
*backstage)

– Trending
– “Rhetorical coaching”

Incorporating observations from other health professionals (e.g. nurses, respiratory therapists, paramedics etc.) or as you listen from the other side of a curtain or watch from the doorway (i.e. backstage)  can help improve the targeted, tailored teaching you offer to your learners.  “Rhetorical coaching” is simply an alternate way to frame feedback. The term is intended to indicate that teachers should intentionally insert themselves into the clinical practice of their learners. (e.g. “ Let me coach you on…).  It also suggests that coaches should be persuasive and make a strong argument for a change in practice.  Of course, “rhetorical coaching” follows all of the hallmarks of feedback, including:

  • choosing a small, specific item to discuss;
  • linking the discussion to observed behaviour;
  • initiating the discussion close in time to the behaviour; and
  • providing concrete, actionable next steps.

For a classic reference on feedback, check this out. For an opinion leader on the topic, check this and this out.

Teacher Always

– Wear gloves
– Conscious conscience
– Reflect in/on action

 

Finally, as teachers, we need to put on gloves and go to the bedside with our learners.  We must intentional in modeling best practices (consciously conscience) as the most powerful teaching we do rarely requires words.  Of course, as suggested by Schon, we need to reflect (aloud for our learners) in the moment and after the moment as we model best practices.

Teaching Mistakes – Learn from the Experts

Of course, even with the benefits of these teaching frameworks, we will mistakes.  The point of presenting these common errors is not to dishearten Clinician Educators with the significant challenge of efficient and effective clinical teaching.  Rather, it is to identify ahead of time, issues that can cause you trouble.

Based on the work of Bandiera et al and Thurger et al, here are things you want to avoid.

The Top 10…

10. Not listening to the learner
9. Excluding learners from interesting cases
8. Making assumptions about competence level
7. Lack of interest in learners
6. Refusing to say: “I don’t know”
5. Inappropriate autonomy
4. Lack of honest feedback
3. Teaching at an inappropriate level
2. Criticism and intimidation

#1 Teaching Mistake:
Failing to bring out the teachable moment

Bonus
As a bonus to ICE blog followers, a number of teaching scripts (i.e. brief, structured learning points for use with learners who frequently rotate through your service) have been created for open access use.  (After June 23) search #teachingscript #SMACCUS for a teaching script you might want to adopt.

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