Principles of Teaching and Learning in Clinical Settings

Principles of Teaching and Principles of Teaching and Learning in Clinical Learning in Clinical

SettingsSettings

Professor Hossam HamdyProfessor Hossam HamdyUniversity of SharjahUniversity of Sharjah

AimAim

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

clinical settings

Clinical TeachingClinical Teaching

There should be no teaching without There should be no teaching without the patient for a text and the best the patient for a text and the best teaching is often that taught by the teaching is often that taught by the patient himself patient himself

(William (William Osler)Osler)

Triad Interactive Learning in Triad Interactive Learning in the Clinical Contextthe Clinical Context

ContentTeacher Patient

StudentContext

Teaching with PatientTeaching with Patient Bedside “Different from ward rounds”Bedside “Different from ward rounds”

Outpatient clinicOutpatient clinic Emergency wardEmergency ward

Day Care Surgery Day Care Surgery

O.RO.R

Barriers to Effective Clinical Barriers to Effective Clinical Teaching – A global ConcernTeaching – A global Concern

Time lack for clinicians. Insufficient space to teach. Crowded outpatients. Increasing number of ‘super-

specialist’ clinics.

Barriers to Effective Clinical Barriers to Effective Clinical Teaching Teaching (cont/-)(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 Barriers to Effective Clinical Teaching Teaching (cont/-)(cont/-)

Teaching is not considered part of service commitment.

Lack of knowledge and skills about teaching methods.

The Clinical ContextThe Clinical Context

More shift from Hospital setting to More shift from Hospital setting to Ambulatory settings.Ambulatory settings.

Diminish the significance of bedside Diminish the significance of bedside teaching “short length of stay”.teaching “short length of stay”.

The Clinical ContextThe Clinical Context (cont/-)(cont/-)

Hospital populated with critically ill and Hospital populated with critically ill and early post-operative patients.early post-operative patients.

Early diagnosis – no or little physical signs.Early diagnosis – no or little physical signs.

Key Clinical CompetenciesKey Clinical Competencies What are the key clinical competencies What are the key clinical competencies

you as a clinical teacher want to ensure you as a clinical teacher want to ensure that the students have accomplishedthat the students have accomplished

Good communication and data gathering Good communication and data gathering (history and physical examination (history and physical examination

Clinical reasoningClinical reasoning

Decision Making, investigation and Decision Making, investigation and treatment treatment

Clinical TeachingClinical 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 TeachingClinical Teaching Planning “set” (cont/-)(cont/-)

Teach from clinical cases.Teach from clinical cases. Go to the bedside or exam roomGo to the bedside or exam room Use questions to diagnose patient & Use questions to diagnose patient & learners.learners.

Teaching “Dialogue”Teaching “Dialogue”

Clinical TeachingClinical Teaching

Role modelRole model Focus the teaching on data gathering by or Focus the teaching on data gathering by or about the patient “critical player” about the patient “critical player” Promote student clinical reasoning Promote student clinical reasoning skills..skills..

Teaching “Dialogue”Teaching “Dialogue” (cont/-)(cont/-)

Clinical TeachingClinical Teaching

Context specificity.Context specificity.

Prior knowledge & net-working.Prior knowledge & net-working.

Schemata and script concordance.Schemata and script concordance.

Non-Analytical ReasoningNon-Analytical Reasoning “Pattern recognition”

Analytical ReasoningAnalytical Reasoning

Cues form c/o – duration Cues form c/o – duration Early hypothesis generationEarly hypothesis generation Testing and re-testing hypothesisTesting and re-testing hypothesis Ranking and re-ranking hypothesis Ranking and re-ranking hypothesis

Pre-test Pre-test ProbabilityProbability

TESTTEST Post-testPost-test ProbabilityProbability

Clinical ReasoningClinical Reasoning

Each question in the history and each physical examination is a diagnostic test.

EBM Approach

Combined Model of Clinical Combined Model of Clinical Reasoning Reasoning

Patient Presents

Hypotheses Tested

Non-analytic Interactive Analytic

Case Representation

Increase the student base of Increase the student base of scenarios, scripts and mental images.scenarios, scripts and mental images.

Students should be guided to relate Students should be guided to relate novel experience with past novel experience with past experiences ‘Anchor proto-type in experiences ‘Anchor proto-type in their memory’.their memory’.

Clinical Teaching TipsClinical Teaching Tips

Clinical Teaching TipsClinical Teaching Tips (cont/-)(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 TipsClinical Teaching Tips (cont/-)(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 The One Minute Clinical Preceptor Teaching ModelTeaching Model

Diagnose Patient & Learner

Microskill 1: Get a commitmentGet a commitmentWhat do you think the patient problem is?

Microskill 2: Probe for supportive Probe for supportive evidenceevidence

Reasoning. Why do you think this is the case?

The One Minute Clinical The One Minute Clinical Preceptor Preceptor

Microskill 3: Teach general rules & Teach general rules & conceptsconcepts

When this happens, usually … Take home message

Feedback “closure”

Microskill 4: Provide regular, well timed Provide regular, well timed feedback.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 The One Minute Clinical Preceptor Preceptor

The one Minute Clinical The one Minute Clinical PrinciplePrinciple

Microskill 5: Correct mistakes and Correct mistakes and promote self promote self

assessment assessment and and self-directed learning.self-directed learning.

Focus on behavior, not individual.

Ask learner for their opinion or perception. Be straightforward, but respectful.

Feedback “closure”

The Effective Clinical Teacher The Effective Clinical Teacher (D. Newbie)(D. Newbie)

1.1. Encourages active student participation rather Encourages active student participation rather than passive observationthan passive observation

2.2. Emphasis on teaching of applied problem solvingEmphasis on teaching of applied problem solving

3.3. Integrates clinical medicine with basic scienceIntegrates clinical medicine with basic science

4.4. Close observation of students during Close observation of students during interview/examination rather than side-room case interview/examination rather than side-room case presentationpresentation

The Effective Clinical Teacher (D. Newbie)The Effective Clinical Teacher (D. Newbie)

5. Provides adequate opportunity for students to practice 5. Provides adequate opportunity for students to practice skillsskills

6. Provides good role-model for interpersonal 6. Provides good role-model for interpersonal relationships with patientsrelationships with patients

7. Teaching patient-oriented rather than disease-7. Teaching patient-oriented rather than disease-orientatedorientated

8. Demonstrates a positive attitude towards teaching 8. Demonstrates a positive attitude towards teaching

The Effective Clinical Teacher The Effective Clinical Teacher

Most important being willing to teach Most important being willing to teach and be enthusiastic about itand be enthusiastic about it

Thank YouThank You