Reflections from the Liminal Space: Teaching II – In the Clinic

(From the EiC:  This is a three part series that will run consecutively. 

Click here for Part 1.  

Michelle (a Maternal Fetal Medicine specialist), Tim (an intensivist) and Mary (a pediatric gastroenterologist) are just finishing the Royal College diploma in medical education offered at McMaster University.  More details here.) 


By: Michelle Morais  (@dr_mmorais), Tim Karachi (@TKarachi_MD) and Mary Zachos (@maryz777)

Teaching in the out-patient surgical clinic differs significantly from the teaching of procedure-oriented skills of the operating room. Unlike the OR, balancing teaching during a busy clinic offers the unique challenges of managing complex patients under constant time pressure while maintaining quality care, trainee education and billing.  Historically, a 1995 review of the literature reported suboptimal teaching and learning in ambulatory settings, ‘‘characterized by variability, unpredictability, immediacy, and lack of continuity.’’1

Subsequent efforts by clinician educators were aimed at developing novel approaches and strategies to improve time efficient teaching. Irby and Bowen2 suggested a three-stage approach for each teaching encounter consisting of:

  1. Planning: preparing for teaching by planning when and how to teach.
  2. Teaching: using a variety of teaching methods to actively involve the      learners.
  3. Reflecting: evaluating learner’s performance, giving feedback and                             encouraging self-reflection.

Planning: The advantages of advance planning include creating a positive learning climate, establishing expectations, clarifying roles and responsibilities, allocating time for instruction and feedback, and focusing learners on important priorities and tasks.  Another important part of the planning is taking the time to review goals and objectives.  Teachers should solicit learners’ goals, which are the broad statements of what the students will be able to do when they have completed the teaching session.  They should be clearly stated, appropriate, realistic, doable, comprehensive and worthwhile.  Mutual understanding of learners’ goals facilitates feedback regarding progress toward and attainment of them. In contrast, objectives are specific and measurable actions that support the attainment of an associated goal within a time frame. Five basic elements should be included in such objectives: (1) Who will do (2) how much (3) how well (4) of what (5) by when?3

In 1956, Bloom published a framework for categorizing educational objectives, also known as Bloom’s taxonomy.4 Bloom’s taxonomy divides the way people learn into three domains: cognitive, skills and attitudes. The cognitive domain refers to the intellectual capabilities or mental skills. Bloom identified six levels within the cognitive domain: from the lowest level, simple recall of facts, through increasingly more complex levels such as analysis, synthesis and evaluation.

Teaching: A variety of techniques can be used to teach successfully in the clinical environment.5-7 Examples include:

  1. One minute observation (to identify the needs of the learner and target instruction)8
  2. Five Step Microskills or ‘the one-minute preceptor9
  3. Pattern recognition or ‘Aunt Minnie10
  4. Role modeling and “Activated” demonstration” (for early learners or to demonstrate clinical expertise)
  5. SNAPPS (Summarise, Narrow down, Analyse,Probe, Plan) (for encouraging learner self-direction)11

Reflection and Feedback are powerful tools for effective teaching, discussed as well in Surgical Teaching.  In the ambulatory clinic as well, it should be possible to provide feedback on performance by quickly commenting on strengths and making recommendations for improvement. It can also serve as an opportunity to promote self-reflection and independent study.12

Although several models have been developed to increase effectiveness in clinical teaching,5-11 some consider their implementation cumbersome, requiring specific training and time commitment. Yang et al developed an integrated approach to clinical teaching that removes the distinction between patient care and teaching thereby simplifying the relationship between a physician’s clinical and educational duties.13 They propose that the stages of Kolb’s cycle correspond to the elements of the patient care process.14 Concrete experience is gained during history taking, physical examination, and data collection; reflective observation is used during the initial assessment and formation of a differential diagnosis; abstract conceptualization yields a working hypothesis and diagnosis; and active experimentation leads to management and follow-up (see figure).  Instinctive clinical teaching encourages faculty to externalize internal questions to the learner utilizing the clinical experience for both effective teaching that naturally combines subject matter expertise and pedagogical knowledge.15

Reflections from the Liminal Space Pt II_Figure.jpg
Figure: Relationship of Patient Care Activities to Stages of the Experiential Learning Cycle
Numbers (1–4) represent stages of a patient care encounter (a) and their corresponding phase in the experiential learning cycle (b). Capital letters (A–D) represent the internal questions and thought processes that drive each cycle from one stage to the next.


The Denouement

In summary, teaching in a busy, ambulatory clinical environment is possible. Advance planning and adopting time efficient strategies can be helpful in managing the competing demands of providing high quality patient care and effective education. However, it is important to remember that in the clinical environment, not every patient needs to be a pre-planned teaching case. An enthusiastic, adaptable and opportunistic approach based on spontaneously arising  ‘teachable moments’16,17 as well as instinctive teaching13 which mirrors the patient care process can also serve as effective tools for the clinician teacher.



  1.  Irby DM. Teaching and learning in ambulatory care settings: a thematic review of the literature. Acad Med. 1995;70(10):898–931.
  2. Irby D, Bowen J. Time-efficient strategies for learning and performance. Clin Teach 2004;1(1):23–28
  3. Kern D, Thomas P, Hugues M. Curriculum Development for Medical Education. A Six-Step Approach. 2nd edn. Baltimore, MD: Johns Hopkins University Press, 2009.
  4. Bloom BS, Engelhart MD, Furst EJ et al. Taxonomy of Educational Objectives: The Classification of Educational Goals. Handbook I, Cognitive Domain. New York, NY: Longmans Green, 1956.
  5. Irby DM, Wilkerson L. Teaching when time is limited. BMJ 2008(7640); 336:384–387
  6. Jaques D. Teaching small groups. BMJ 2003;326(7387):492–494
  7. Ramani S, Leinster S. AMEE Guide No. 34: teaching in the clinical environment. Med Teach 2008;30(4):347–64.
  8. Kuo A, Irby D, Loeser H. Does direct observation improve medical students’ clerkship experiences? Med Educ 2005;39(5):518.
  9. Neher JO, Gordon KC, Meyer B et al. A five-step “microskills”model of clinical teaching. J Am Board Fam Pract 1992;5(4):419–424
  10. Cunningham A, Blatt S, Fuller P, Weinberger H. The art of precepting: Socrates or Aunt Minnie? Arch Pediatr Adoles Med 1999;153(2):114-6.
  11. Wolpaw T. SNAPPS: a learner-centered model for outpatient education.Acad Med 2003:78(9):893-8.
  12. Hewson M, Little M. Giving feedback in medical education: verification of recommended techniques. J Gen Intern Med 1998;13(2):111-6.
  13. Yang Y, Kim CH, Briones MA, Hilinski JA, Greenwald M.  Instinctive Clinical Teaching: Erasing the Mental Boundary Between Clinical Education and Patient Care to Promote Natural Learning.  J Grad Med Educ 2014 Sep; 6(3): 415–418
  14. Kolb AY, Kolb DA. Learning styles and learning spaces: enhancing experiential learning in higher education. Acad Manage Learn Educ. 2005;4(2):193–212
  15. Shulman LS, Wilson SM. The Wisdom of Practice: Essays on Teaching, Learning, and Learning to Teach. San Francisco, CA: Jossey-Bass; 2004. pp. 219–248
  16. Alguire P,DeWitt D, Pinsky L et al. Teaching in Your Office. Philadelphia, PA: ACP Press, 200
  17. Wiese J. Teaching in the Hospital. Philadelphia, PA: ACP Press, 2010.

Featured image property of the Royal College