Inconvenient truths about effective clinical teaching

Student Perceptions of Effective Simulation Instructor Teaching

SUMMARY STATEMENT

Twenty-three focus groups were held with 183 first-year medical students to assess student perceptions of effective simulation instructors during preclinical training in a medical school. Qualitative descriptive analysis guided the interpretation of focus group data. Students identified 6 areas of knowledge (schedule, student learning goals, session scenario, tasks and checklists, technique, and session purpose); 5 effective instructor skill categories (setting up the learning environment, teaching at the appropriate level, teaching technique, providing deeper context, and giving effective feedback); and 8 positive instructor attributes (enthusiasm, engaged, prepared, knowledgeable, patient, relational, transparent, and calm) instructors should have. Each category of instructor attributes, skills, and knowledge was also described in detail providing illustrative examples of what effective instruction would look like in practice from the students' perspective. Recommendations for instructor faculty development methods and topics/goals are given.

Design and First Impressions of a Small Private Online Course in Clinical Workplace Learning: Questionnaire and Interview Study

BACKGROUND

Clinical workplace learning takes place in a dynamic and complex learning environment that is designated as a site for patient care and education. Challenges in clinical training can be overcome by implementing blended learning, as it offers flexible learning programs suitable for student-centered learning, web-based collaboration, and peer learning.

OBJECTIVE

The aim of this study is to evaluate the Small Private Online Course (SPOC) by interns' first impressions and satisfaction measures (N=20) on using the SPOC. This study describes the design process of a SPOC from a theoretical and practical perspective and how it has been integrated into a clinical internship in internal medicine.

METHODS

The design of the SPOC was based on general theoretical principles that learning should be constructive, contextual, collaborative, and self-regulated, and the self-determination theory to stimulate intrinsic motivation. Interns' impressions and level of satisfaction were evaluated with a web-based questionnaire and group interview.

RESULTS

Interns thought the web-based learning environment to be a useful and accessible alternative to improve knowledge and skills. Peer learning and web-based collaboration through peer interaction was perceived as less effective, as student feedback was felt inferior to teacher feedback. The interns would prefer more flexibility within the course, which could improve self-regulated learning and autonomy.

CONCLUSIONS

The evaluation shows that the SPOC is a useful and accessible addition to the clinical learning environment, providing an alternative opportunity to improve knowledge and skills. Further research is needed to improve web-based collaboration and interaction in our course.

Predictors of effective clinical teaching - nursing educators' perspective

BACKGROUND

The clinical teaching is the core component of the nursing curriculum, the alarming pandemic rates brought uncertainty to clinical teaching, weighing the safety of patients, students, and faculty, which demanded essential modification in clinical teaching and resulted in challenges in relation to effective response to clinical teaching requirements. This study aimed to assess the effective clinical teaching from the nurse educators' perspective during the remote teaching that followed the COVID-19 pandemic.

METHODS

This study is a national Web-based descriptive study. Participants were recruited from five major Nursing Colleges in Oman. Descriptive and inferential as well as multiple linear regression analyses were conducted.

RESULTS

A total of 127 nurse educators completed the survey with mean age of 43.9 (SD = 6.9) years. The overall effective clinical teaching score was 54.4 (SD = 10.9) which is considered acceptable, although the nurse educators in Oman reported the highest score on the safety dimension of the effective clinical teaching. Furthermore, females, doctoral prepared nurse educators, and those who acted as preceptors reported higher effective clinical teaching levels compared to their counterparts. The regression analysis showed that age, gender, and attending infection control training are significant predictors of effective clinical teaching.

CONCLUSION

The paradigm shift in clinical teaching requires adequate measures including identification and appropriate training of clinical instructors and preceptors to meet clinical teaching demands in remote teaching. It is also important to take actions that promote and maintain the safety prioritization in bedside clinical teaching. These measures might positively impact on the nursing education process.

The Cardiovascular Physical Examination - Is It Still Relevant?

Advances in technology have reshaped the practice of medicine. These changes have greatly benefited our patients. However, in the setting of these advances, the importance of basic clinical tools is more pertinent than ever. Despite the growing reliance on technology, the physical exam remains valuable and cost effective, often enabling the well-trained clinician to arrive at the diagnosis, rapidly and accurately. The physical exam must not become a relic of a distant past. We aim to investigate current competency and proficiency, proposals for change in teaching curriculums, and the relationship with technology such as hand-held echocardiography. A skillful exam provides both emotional and intellectual satisfaction. It may be a lost art but it is well worth the effort to restore.

Mentors' perspectives on strengths and weaknesses of a novel clinical mentorship programme in Rwanda: a qualitative study

OBJECTIVES

To identify mentors' perspectives on strengths and weaknesses of the Training, Support and Access Model for Maternal, Newborn and Child Health (TSAM-MNCH) clinical mentorship programme in Rwandan district hospitals. Understanding the perspectives of mentors involved in this programme can aid in the improvement of its implementation.

DESIGN

The study used a qualitative approach with in-depth interviews.

SETTING

Mentors of TSAM-MNCH clinical mentorship programme mentoring health professionals at district hospitals of Rwanda.

PARTICIPANTS

14 TSAM mentors who had at least completed six mentorship visits on a regular basis in three selected district hospitals.

RESULTS

Mentors' accounts demonstrated an appreciation of the two mentoring structures which are interprofessional collaboration and training. These structures are highlighted as the strengths of the mentoring programme and they play a significant role in the successful implementation of the mentorship model. Inconsistency of mentoring activities and lack of resources emerged as major weaknesses of the clinical mentorship programme which could hinder the effectiveness of the mentoring scheme.

CONCLUSION

The findings of this study highlight the strengths and weaknesses perceived by mentors of the TSAM-MNCH clinical mentorship programme, providing insights that can be used to improve its implementation. The study represents unique TSAM-MNCH structural settings, but its findings shed light on Rwandan health system issues that need to be further addressed to ensure better quality of care for mothers, newborns and children.

Dynamic Tensions Following New Pedagogy in Undergraduate Medical Education

The authors draw on their many decades of combined experience with medical students, observing their maturation into practice in widely differing contexts, to reaffirm some of the essential goals of medical education. They briefly review curricular changes in medical education over the past 100 years, then focus on the dynamic tension in undergraduate medical education (UME) resulting from new pedagogy. Specifically, these tensions arise from the differing trajectories and directions of the 3 traditional pillars of academic medicine: clinical excellence, state-of-the-art education, and cutting-edge research. The authors highlight the role of generalism as an essential foundation of UME, as well as the dilemma of a shrinking cadre of medical students choosing a generalist career path. To address challenges stemming from pedagogical changes, the authors offer 4 observations. First, a more condensed approach to faculty development may be to ensure that bringing teachers up to speed on the new curriculum is not excessively burdensome. Second would be a more gradual introduction of the proposed changes. Third, some discussion about medical education pedagogy and curricular development ought to have a place in UME to prepare the next generation of physicians for ongoing changes in accreditation and in approaches to education. Finally, more appropriate funding of medical education would alleviate some of the burden and anxiety by acknowledging its nonmaterial value.

Family-Centered Rounds: Past, Present, and Future

Bedside rounds have evolved concurrently with hospitalist medicine and patient-centered care. Family-centered rounds are the foundation of effective communication in the in-patient pediatric setting. Participant perspectives (family members, patients, nurses, faculty, and trainees) on family-centered rounds differ and goals may not always align. Further, the practical components of how rounds are conducted varies and have continued opportunities for improvement. This article summarizes the most recent experience with rounds in an attempt to identify unified and effective strategies moving forward.

Family medicine training in Africa: Views of clinical trainers and trainees

Background

This article reports on the findings of a workshop held at the joint 5th World Organisation of Family Doctors (WONCA) Africa and 20th National Family Practitioners Conference in Tshwane, South Africa, in 2017. Postgraduate training for family medicine in Africa takes place in the clinical workspace at the bedside or next to the patient in the clinic, district hospital or regional hospital. Direct supervisor observation, exchange of reflection and feedback, and learning conversations between the supervisor and the registrar are central to learning and assessment processes.

Objectives

The aim of the workshop was to understand how family medicine registrars (postgraduate trainees in family medicine) in Africa learn in the workplace.

Methods

Thirty-five trainers and registrars from nine African countries, the United Kingdom, United States and Sweden participated. South Africa was represented by the universities of Cape Town, Limpopo, Pretoria, Sefako Makgatho, Stellenbosch, Walter Sisulu and Witwatersrand.

Results

Six major themes were identified: (1) context is critical, (2) learning style of the registrar and (teaching style) of the supervisor, (3) learning portfolio is utilised, (4) interactions between registrar and supervisor, (5) giving and receiving feedback and (6) the competence of the supervisor.

Conclusion

The training of family physicians across Africa shares many common themes. However, there are also big differences among the various countries and even programmes within countries. The way forward would include exploring the local contextual enablers that influence the learning conversations between trainees and their supervisors. Family medicine training institutions and organisations (such as WONCA Africa and the South African Academy of Family Physicians) have a critical role to play in supporting trainees and trainers towards developing local competencies which facilitate learning in the clinical workplace dominated by service delivery pressures.

Education Research: Positive effect of scheduled faculty modeling on clerkship student bedside skills exposure and learning

Objective:

To evaluate the effect of scheduled bedside skills modeling for third-year medical students on their neurology clerkship.

Methods:

During the 2012–2014 academic years, 56 third-year medical students participated in a curricular pilot program involving a scheduled bedside skills modeling experience during the first week of their neurology clerkship, whereas 131 students underwent the typical rotation. The experience consisted of observing a faculty member conduct a comprehensive encounter on a new outpatient. To promote active learning, students were provided an observation guide to document questions and observations. An anonymous survey was conducted at the end of each clerkship block assessing student exposure to bedside skills modeling. Using qualitative thematic analysis, observation guide statements were transcribed and coded into emergent learning themes.

Results:

A total of 57.4% (95% confidence interval [CI] 43.3%–71.5%) of students in the modeling group reported observing both a comprehensive history and neurologic examination vs 37.5% (95% CI 28.2%–46.8%) in the nonmodeling groups (p = 0.023). A total of 253 observation statements were transcribed and coded from the observation guides. The most common learning themes included (1) strategies for performing a neurologic examination, (2) techniques for eliciting a neurologic history, and (3) importance of detail and thoroughness of the history and examination.

Conclusions:

Our study demonstrated that there was a significant increase in structured observation by students of neurologic bedside skills with the inclusion of a scheduled modeling experience, and we provide a qualitative description of the most common learning themes associated with this experience.

Producing Competent Doctors - The Art and Science of Teaching Clinical Skills

For a doctor to provide medical care with competence, he must not only have knowledge but must also be able to translate that knowledge into action. It is his competence in clinical skills that will enable him to practice safely and effectively in the real world. To ensure acquisition of clinical skills, medical teachers must adopt teaching methods that prioritise observation, practice, feedback; and more practice. We try to elucidate the meaning of clinical skills, the challenges inherent in clinical skills training in India, training models that have shown success in practice and can be adopted in the Indian context, and various techniques to enhance skill-training, including the giving of feedback, which is a critically important component of skills development.

Enhancing the Clinical Reasoning Skills of Postgraduate Students in Internal Medicine Through Medical Nonfiction and Nonmedical Fiction Extracurricular Books

OBJECTIVE

To improve the clinical reasoning skills of postgraduate students in internal medicine through 2 kinds of extracurricular books: medical nonfiction and nonmedical fiction.

METHODS

Clinical reasoning is difficult to define, understand, observe, teach, and measure. This is an educational innovation under an experimental framework based on a cognitive intervention grounded in constructivist and cognitivist theories. This study was conducted from June 1, 2014, through May 31, 2015. It was a pre-post, randomized, controlled, prospective, mixed-methods, small-group study. The intervention was through medical nonfiction and nonmedical fiction books. The process was structured to ensure that the students would read the material in phases and reflect on them. Clinical reasoning (pretests and posttests) was quantitatively assessed using the Diagnostic Thinking Inventory (DTI) and clinical reasoning exercises (CREs) and their assessment using a rubric. A qualitative design was used, and face-to-face semistructured interviews were conducted.

RESULTS

Posttest total scores (DTI=188.92; CREs=53.92) were higher for the study group after the intervention compared with its own pretest scores (DTI=165.25; CREs=41.17) and with the pretest (DTI=159.27; CRE=40.73) and posttest (DTI=166.91; CREs=41.18) scores of the control group. Interviews with the study group confirmed that the intervention was acceptable and useful in daily practice.

CONCLUSION

We introduced, evaluated, and proved an approach to teaching-learning clinical reasoning based on the assumption that the clinical reasoning skills of postgraduate students in internal medicine can be enhanced through 2 kinds of extracurricular books and that fun as well as interest will enhance learning. This study is not only about teaching-learning clinical reasoning but also about the humanities in medical education.

Intraoperative questioning to advance higher-order thinking

BACKGROUND

The type of question asked elicits a particular response. The purpose of this study was to determine what types and levels of questions were asked in the operating room. These insights are important for understanding how questions are used to advance learners.

METHODS

12 laparoscopic cholecystectomy operations were observed and recorded at a single institution. Intraoperative questions asked by faculty were transcribed for all cases. Using revised Bloom's taxonomy, questions were classified into one of 5 levels: (1) remembering, (2) understanding, (3) applying, (4) analyzing, (5) evaluating.

RESULTS

141 questions were asked by faculty and ranged from 0 to 34 questions per case. Classification of questions showed there were 43 remembering, 29 understanding, 47 applying, 13 analyzing, and 8 evaluating questions asked.

CONCLUSIONS

Questioning was predominately classified at lower-order and mid-level thinking skills (120/141). Integrating intraoperative questions at higher-order levels has the potential to guide trainees into progressively complex thinking and decision making.

Making the Most of Five Minutes: The Clinical Teaching Moment

Clinical educators face the challenge of simultaneously caring for patients and teaching learners, often with an unpredictable caseload and learners of varied abilities. They also often have little control over the organization of their time. Effective clinical teaching must encourage student participation, problem solving, integration of basic and clinical knowledge, and deliberate practice. Close supervision and timely feedback are also essential. Just as one develops an effective lecture through training and practice, clinical teaching effectiveness may also be improved by using specific skills to teach in small increments. The purpose of this paper is to identify potential teachable moments and to describe efficient instructional methods to use in the clinical setting under time constraints. These techniques include asking better questions, performing focused observations, thinking aloud, and modeling reflection. Different frameworks for teaching encounters during case presentations can be selected according to learner ability and available time. These methods include modeling and deconstructing the concrete experience; guiding the thinking and reflecting process; and providing the setting and opportunity for active practice. Use of these educational strategies encourages the learner to acquire knowledge, clinical reasoning, and technical skills, and also values, attitudes, and professional judgment.

Teaching: aligning faculty member and resident perceptions

PURPOSE

This study sought to examine and address concerns received from residents regarding their perception of the length of time faculty members devoted to intraoperative teaching.

METHOD

Faculty members and residents were surveyed on their perceptions of intraoperative teaching. The survey was evaluated using descriptive methods. A disparity was noted between faculty member and resident perceptions of time devoted to intraoperative teaching. To better understand the disparity, a series of focus groups to discuss the survey results were held with both faculty members and residents. To address the disparity, a teaching tool was developed using the keywords of the American Board of Anesthesiology's in-training examination. Faculty members and residents used this tool in the intraoperative environment for 2 months. After 2 months, faculty members and residents were surveyed to see whether a change in perception took place. The use of the teaching tool was continued. Faculty members and residents were surveyed after 1 year of continued use to assess usage and satisfaction with the tool.

RESULTS

The pre-intervention survey yielded responses from 29.6 per cent (n = 64) of the teaching faculty members and 29.2 per cent (n = 24) of the residents. The post-intervention survey yielded responses from 64 per cent of the faculty members and 62.5 per cent of the residents. After implementation of the tool, an improved alignment of resident and faculty member perceptions of the time faculty members spent teaching intraoperatively was observed. The majority of faculty members and residents reported continued use and satisfaction with the keyword tool after 1 year of use.

DISCUSSION

This experience revealed the importance of making simple, pragmatic changes to improve resident perceptions of intraoperative teaching time.

Educating the clinical trainer: professional gain for the trainee? A controlled intervention study in general practice

The aim of this study was to establish whether a 'teach-the-trainer' course leads to improvements in, firstly, the knowledge and attitude of clinical trainers and their trainees, and, secondly, the role model behaviour of the clinical trainers. A controlled intervention study was performed with GP trainers and GP trainees from four training institutes in the Netherlands. Clinical trainers in the two intervention institutes received two 3-h training sessions on weight management, focusing on knowledge and attitudes towards obesity, and on conveying the correct professional competency as a positive role model for trainees. This was measured using questionnaires on knowledge, attitude, and role model behaviour (the role model apperception tool; RoMAT). GP trainers showed an increase in knowledge and several characteristics could be identified as being related to positive role model behaviour. A small correlation was found between the trainer's score on the RoMAT and the attitude of the trainee. A teach-the-trainer course in which knowledge, attitudes, and role modelling are integrated proved to be a first step toward improving the knowledge of clinical trainers, but did not result in a measurably better professional outcome for the trainee, maybe due to a more objective level of assessment.

Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators

BACKGROUND

Clinical reasoning is fundamental to all forms of professional health practice, however it is also difficult to teach and learn because it is complex, tacit, and effectively invisible for students. In this paper we present an approach for teaching clinical reasoning based on making expert thinking visible and accessible to students.

METHODS

Twenty-one experienced allied health clinical educators from three tertiary Australian hospitals attended up to seven action research discussion sessions, where they developed a tentative heuristic of their own clinical reasoning, trialled it with students, evaluated if it helped their students to reason clinically, and then refined it so the heuristic was targeted to developing each student's reasoning skills. Data included participants' written descriptions of the thinking routines they developed and trialed with their students and the transcribed action research discussion sessions. Content analysis was used to summarise this data and categorise themes about teaching and learning clinical reasoning.

RESULTS

Two overriding themes emerged from participants' reports about using the 'making thinking visible approach'. The first was a specific focus by participating educators on students' understanding of the reasoning process and the second was heightened awareness of personal teaching styles and approaches to teaching clinical reasoning.

CONCLUSIONS

We suggest that the making thinking visible approach has potential to assist educators to become more reflective about their clinical reasoning teaching and acts as a scaffold to assist them to articulate their own expert reasoning and for students to access and use.

How can students' diagnostic competence benefit most from practice with clinical cases? The effects of structured reflection on future diagnosis of the same and novel diseases

PURPOSE

To develop diagnostic competence, students should practice with many examples of clinical problems to build rich mental representations of diseases. How to enhance learning from practice remains unknown. This study investigated the effects of reflection on cases compared with generating a single or differential diagnosis.

METHOD

In 2012, during the learning phase, 110 fourth-year medical students diagnosed four cases of two criterion diseases under three different experimental conditions: structured reflection, single-diagnosis, or differential-diagnosis. One week later, they diagnosed two novel exemplars of each criterion disease and four cases of new diseases that were not among the cases of the learning phase but were plausible alternative diagnoses.

RESULTS

Diagnostic performance did not differ among the groups in the learning phase. One week later, the reflection group obtained higher mean diagnostic accuracy scores (range: 0-1) than the other groups when diagnosing new exemplars of criterion diseases (reflection: 0.67; single-diagnosis: 0.36, P < .001; differential-diagnosis: 0.51, P = .014) and cases of new diseases (reflection: 0.44; single-diagnosis: 0.32, P = .010; differential-diagnosis: 0.33, P = .015). No difference was found between the single-diagnosis and the differential-diagnosis conditions.

CONCLUSIONS

Structured reflection while practicing with cases enhanced learning of diagnosis both of the diseases practiced and of their alternative diagnoses, suggesting that reflection not only enriched mental representations of diseases practiced relative to more conventional approaches to clinical learning but also influenced the representations of adjacent but different diseases. Structured reflection seems a useful addition to the existing clinical teaching methods.

Challenges and responsibilities of clinical teachers in the workplace: an ethnographic approach

This study aimed to explore the complex role of the clinical teacher in the workplace, with a view to identifying effective teaching practices. An ethnographic case-study approach was taken, including participant observations and semi-structured interviews with three participants that were selected from two participating veterinary institutions. The clinical teacher has several responsibilities, such as establishing a rapport with learners and maximizing the use of case-based learning opportunities to provide instruction and support to individual learners in a safe but challenging environment. Associated difficulties include balancing the competing demands of students' learning needs and patients' welfare, as well as maximizing the learning opportunities within available case material. Participants in this study demonstrated a reflective approach, adjusting their teaching approach "in action" and "on action" as appropriate.

The national portfolio of learning for postgraduate family medicine training in South Africa: experiences of registrars and supervisors in clinical practice

BACKGROUND

In South Africa the submission of a portfolio of learning has become a national requirement for assessment of family medicine training. A national portfolio has been developed, validated and implemented. The aim of this study was to explore registrars' and supervisors' experience regarding the portfolio's educational impact, acceptability, and perceived usefulness for assessment of competence.

METHODS

Semi-structured interviews were conducted with 17 purposively selected registrars and supervisors from all eight South African training programmes.

RESULTS

The portfolio primarily had an educational impact through making explicit the expectations of registrars and supervisors in the workplace. This impact was tempered by a lack of engagement in the process by registrars and supervisors who also lacked essential skills in reflection, feedback and assessment. The acceptability of the portfolio was limited by service delivery demands, incongruence between the clinical context and educational requirements, design of the logbook and easy availability of the associated tools. The use of the portfolio for formative assessment was strongly supported and appreciated, but was not always happening and in some cases registrars had even organised peer assessment. Respondents were unclear as to how the portfolio would be used for summative assessment.

CONCLUSIONS

The learning portfolio had a significant educational impact in shaping work-place based supervision and training and providing formative assessment. Its acceptability and usefulness as a learning tool should increase over time as supervisors and registrars become more competent in its use. There is a need to clarify how it will be used in summative assessment.

Qualities of an effective teacher: what do medical teachers think?

BACKGROUND

Effective teaching in medicine is essential to produce good quality doctors. A number of studies have attempted to identify the characteristics of an effective teacher. However, most of literature regarding an effective medical teacher includes student ratings or expert opinions. Furthermore, interdisciplinary studies for the same are even fewer. We did a cross-sectional study of the characteristics of effective teachers from their own perspective across medicine and dentistry disciplines.

METHODS

A questionnaire comprising of 24 statements relating to perceived qualities of effective teachers was prepared and used. The study population included the faculty of medicine and dentistry at the institution. Respondents were asked to mark their response to each statement based on a 5-point Likert scale ranging from strongly disagree to strongly agree. These statements were grouped these into four main subgroups, viz. Class room behaviour/instructional delivery, interaction with students, personal qualities and professional development, and analysed with respect to discipline, cultural background, gender and teaching experience using SPSS v 13.0. For bivariate analysis, t-test and one way ANOVA were used. Multiple linear regression for multivariate analysis was used to control confounding variables.

RESULTS

The top three desirable qualities of an effective teacher in our study were knowledge of subject, enthusiasm and communication skills. Faculty with longer teaching experienced ranked classroom behaviour/instructional delivery higher than their less experienced counterparts. There was no difference of perspectives based on cultural background, gender or discipline (medicine and dentistry).

CONCLUSION

This study found that the faculty perspectives were similar, regardless of the discipline, gender and cultural background. Furthermore, on review of literature similar findings are seen in studies done in allied medical and non-medical fields. These findings support common teacher training programs for the teachers of all disciplines, rather than having separate training programs exclusively for medical teachers. Logistically, this would make it much easier to arrange such programs in universities or colleges with different faculties or disciplines.

The national portfolio for postgraduate family medicine training in South Africa: a descriptive study of acceptability, educational impact, and usefulness for assessment

BACKGROUND

Since 2007 a portfolio of learning has become a requirement for assessment of postgraduate family medicine training by the Colleges of Medicine of South Africa. A uniform portfolio of learning has been developed and content validity established among the eight postgraduate programmes. The aim of this study was to investigate the portfolio's acceptability, educational impact, and perceived usefulness for assessment of competence.

METHODS

Two structured questionnaires of 35 closed and open-ended questions were delivered to 53 family physician supervisors and 48 registrars who had used the portfolio. Categorical and nominal/ordinal data were analysed using simple descriptive statistics. The open-ended questions were analysed with ATLAS.ti software.

RESULTS

Half of registrars did not find the portfolio clear, practical or feasible. Workshops on portfolio use, learning, and supervision were supported, and brief dedicated time daily for reflection and writing. Most supervisors felt the portfolio reflected an accurate picture of learning, but just over half of registrars agreed. While the portfolio helped with reflection on learning, participants were less convinced about how it helped them plan further learning. Supervisors graded most rotations, suggesting understanding the summative aspect, while only 61% of registrars reflected on rotations, suggesting the formative aspects are not yet optimally utilised. Poor feedback, the need for protected academic time, and pressure of service delivery impacting negatively on learning.

CONCLUSION

This first introduction of a national portfolio for postgraduate training in family medicine in South Africa faces challenges similar to those in other countries. Acceptability of the portfolio relates to a clear purpose and guide, flexible format with tools available in the workplace, and appreciating the changing educational environment from university-based to national assessments. The role of the supervisor in direct observations of the registrar and dedicated educational meetings, giving feedback and support, cannot be overemphasized.

Characteristics of effective clinical teachers identified by dental students: a qualitative study

This qualitative research study identified criteria for clinical teacher quality preferences as perceived by dental students. Third and fourth year dental students at New York University College of Dentistry were given a two question, open-ended survey asking what qualities they liked most and least in a clinical teacher. Responses were collected until data saturation was achieved. A total of 157 respondents provided a total of 995 written comments. Descriptive words within the responses were coded and grouped into key words, according to similar relationships, and further refined into 17 defined categories. Three core themes, Character, Competence and Communication, emerged from these 17 categories, which were validated according to specific references found in the existing educational literature. 'Character' comprised nine of the 17 defined categories: (caring, motivation, empathy, patience, professionalism, available, fairness, happiness, patient-centred) and yielded 59.1% of total student responses; 'Competence' consisted of five categories: knowledgeable, expertise, efficient, skilful, effective (29.2%); and 'Communication' represented the remaining three categories: feedback, approachable and interpersonal communication (11.7%). Positive and negative responses related to the defined category of caring were cited by 59.2% of all students. Motivation was the next highest category, cited by 45.9% of students. Non-cognitive attributes, especially those in the Character theme, comprised the majority of student comments. Because students' perceptions are so critical to understanding clinical teaching effectiveness in dental education, these findings can be used to develop assessments to measure clinical teaching effectiveness, to create criteria for the hiring and promotion of clinical faculty and to plan faculty development programming.

A time-motion study of inpatient rounds using a family-centered rounds model

OBJECTIVE

Family-centered rounds (FCR) have become increasingly prevalent in pediatric hospital settings. The objective of our study was to describe time use and discrete events during pediatric inpatient rounds by using a FCR model.

METHODS

We conducted a prospective observational study at Children's National Medical Center between September 2010 and February 2011. Investigators directly observed rounds on hospitalist and neurology services. Events were timed, and key features were recorded by using a Microsoft Access-based program. Associations with increased time spent during rounds were determined by using regression analyses.

RESULTS

One hundred fifty-nine rounding encounters were observed. Rounds lasted 7.9 minutes on average per patient. An average of 1.3 minutes was spent between patients during rounds. Eighty-six (54%) encounters occurred outside the patient's room, 3% of the time because of the family's request. Infectious isolation was associated with rounds occurring outside the room (P<.0001). Participation of the parent, location of rounds inside or outside the patient's room, most teaching behaviors, and interruptions were not significantly associated with increased time spent during rounds. Teaching physical examination techniques by allowing multiple trainees to examine the patient was associated with increased rounding time (P= .02).

CONCLUSIONS

The majority of rounds occurred outside the patient's room, yet rarely at the parent's request. Patients on infectious isolation were more likely to have rounds occur outside the patient's room. Neither parental participation nor most teaching behaviors were associated with increased time spent on rounds. These findings will enrich the evidence base needed to establish FCR best practices.

The nature of excellent clinicians at an academic health science center: a qualitative study

PURPOSE

To understand the nature of excellent clinicians at an academic health science center by exploring how and why excellent clinicians achieve high performance.

METHOD

From 2008 to 2010, the authors conducted a qualitative study using a grounded theory approach. Members of the Clinical Advisory Committee in the Department of Pediatrics at the University of Toronto nominated peers whom they saw as excellent clinicians. The authors then conducted in-depth interviews with the most frequently nominated clinicians. They audio-recorded and transcribed the interviews and coded the transcripts to identify emergent themes.

RESULTS

From interviews with 13 peer-nominated, excellent clinicians, a model emerged. Dominant themes fell into three categories: (1) core philosophy, (2) deliberate activities, and (3) everyday practice. Excellent clinicians are driven by a core philosophy defined by high intrinsic motivation and passion for patient care and humility. They refine their clinical skills through two deliberate activities-reflective clinical practice and scholarship. Their high performance in everyday practice is characterized by clinical skills and cognitive ability, people skills, engagement, and adaptability.

CONCLUSIONS

A rich theory emerged explaining how excellent clinicians, driven by a core philosophy and engaged in deliberate activities, achieve high performance in everyday practice. This theory of the nature of excellent clinicians provides a holistic perspective of individual performance, informs medical education, supports faculty career development, and promotes clinical excellence in the culture of academic medicine.

Advances in clinical education: a model for infectious disease training for mid-level practitioners in Uganda

Advances in health professional education have been slow to materialize in many developing countries over the past half-century, contributing to a widening gap in quality of care compared to developed countries. Recent calls for reform in global health professional education have stressed, among other priorities, the need for approaches that strengthen clinical reasoning skills. While the development of these skills is critical to enhance health systems, little research has been carried out on the effectiveness of applying these strategies in the context of severe human resource shortages and complex disease presentations. Integrated Infectious Disease Capacity Building Evaluation (IDCAP) based at the Infectious Diseases Institute at Makerere University created a training program using current best practices in clinical education to support the development of complex reasoning skills among clinicians in rural Uganda. Over a period of 9 months, the program integrated classroom and clinic-based training approaches and measured indicators of success with particular reference to common infectious diseases. This article describes in detail the IDCAP approach to integrating advances in health professional education theory in the context of an overburdened, inadequately resourced primary health care system; results from the evaluation are expected in 2012.

Reflection as a strategy to foster medical students' acquisition of diagnostic competence

OBJECTIVES

Developing diagnostic competence in students is a major goal of medical education, but there is little empirical evidence on instructional strategies that foster the acquisition of this competence. The aim of this study was to investigate the effects of structured reflection compared with the generation of immediate or differential diagnosis while practising with clinical cases on learning clinical diagnosis.

METHODS

This was a three-phase experimental study. During a learning phase, 46 Year 4 students diagnosed six clinical cases under different experimental conditions: structured reflection, immediate diagnosis, or differential diagnosis. This was followed by an immediate test and a delayed test administered 1 week later. Each test consisted of diagnosing four different cases of diseases presented in the learning phase. Performance in diagnosing these new cases was used as a measure of learning.

RESULTS

Repeated-measures analysis of variance on the mean diagnostic accuracy scores (range: 0-1) showed a significant interaction between performance moment (i.e. performance in the learning phase and on each test) and instructions followed during the learning phase (p=0.003). Follow-up analyses of this interaction showed that diagnostic performance did not differ between conditions in the learning phase. On the immediate test, scores in the reflection condition (mean=0.48, 95% confidence interval [CI] 0.38-0.58) were significantly lower than scores in the differential diagnosis condition (mean=0.62, 95% CI 0.54-0.70; p=0.012) and marginally lower than those in the immediate diagnosis condition (mean=0.61, 95% CI 0.52-0.70; p=0.04). One week later, however, scores in the reflection condition (mean=0.66, 95% CI 0.56-0.76) significantly outperformed those in the other conditions (differential diagnosis: mean=0.48, 95% CI 0.37-0.58 [p<0.01]; immediate diagnosis: mean=0.52, 95% CI 0.43-0.60 [p=0.01]). Comparisons within experimental conditions showed that performance from the immediate to the delayed test decreased in the immediate and differential diagnosis conditions (immediate diagnosis: p=0.042; differential diagnosis: p=0.012), but increased in the reflection condition (p=0.003).

CONCLUSIONS

Structured reflection while practising with cases appears to foster the learning of clinical knowledge more effectively than the generation of immediate or differential diagnoses and therefore seems to be an effective instructional approach to developing diagnostic competence in students.

Who will be the faculty of the future? Results of a 5-year study growing educators using an immersive third postgraduate year (PGY-3) faculty development mini-fellowship

BACKGROUND

Residency education requires large numbers of skilled teaching faculty. Potential faculty can often be identified during residency training.

AIMS

Employ a 4-week immersive faculty development mini-fellowship to enhance the teaching skills of selected PGY-3 residents and study outcomes over 5 years.

METHODS

PGY-3 residents were competitively selected and completed the 4-week curriculum to increase skills in precepting, small group teaching, large group teaching, learner feedback/assessment, academic career development, and research.

RESULTS

Fifteen residents completed the mini-fellowship over the 5-year study period. The curriculum was rated highly by the residents with mean ratings of curriculum components ranging from 4.5 to 4.9 on a 5-point scale. Eight residents (53%) were selected for faculty positions compared to a usual selection rate of 11%. Compared to new faculty without mini-fellowship completion, program directors rated the residents completing the mini-fellowship as better prepared to perform learner feedback (4.1 vs. 3.0, p ≤ 0.01) and to understand the conduct of research (3.6 vs. 2.5 p ≤ 0.01).

CONCLUSIONS

This study demonstrates short-term success at growing faculty with enhanced teaching skills during residency. While long-term retention in academic medicine cannot be predicted, this program represents one method to mitigate shortages of qualified junior residency faculty.

The educational attributes and responsibilities of effective medical educators

Of the many roles that the academic-educator may fulfill, that of teacher is particularly challenging. Building on prior recommendations from the literature, this article identifies the skill set of teachers across the medical education continuum-characteristics of attitude and attributes, knowledge, and pedagogic skills that permit effective teaching to be linked with effective learning and understanding. This examination which characterizes teachers' attitudes, knowledge, and skills serves to reemphasize the centrality of teaching within medical education, provides direction for faculty and institutions alike in the discharge of academic responsibilities, and makes educational accountability clear. This listing of teacher attitudes and responsibilities was vetted in 2009 by medical education leaders from across North America during a national conference on faculty development.A set of recommendations concerning faculty development issues for medical teachers is offered. The recommendations are intended to establish an academic culture in medical education that values and rewards-academically and fiscally-those centrally committed to the role of teacher. The challenges of defining skills, developing and funding programs, and ongoing evaluation must be faced to achieve success in teaching throughout medical education, now and in the future. Faculty members, fellow learners, and patients deserve no less.

Making the most of teaching at the chairside

This study examines the chairside as an opportunity for teaching and learning. It sets out to understand how students learn in the dental clinic so that they can better be supported in their clinical learning. The study draws on current theories of learning to establish a rationale for effective chairside teaching. Current theories highlight the active role of learners in 'constructing' their own knowledge of a field, and emphasise the importance of active learning and reflection in this process. The study is practical in nature. It weaves evidence from empirical studies of medical and dental clinical teaching, as well as 'best practice tips' from the literature, with theory to suggest a strategy for effective teaching in the clinical context. The study concludes with a caveat, warning that effective clinical teaching requires an investment in time.

Teaching for clinical reasoning - helping students make the conceptual links

BACKGROUND

Dental educators complain that students struggle to apply what they have learnt theoretically in the clinical context. This paper is premised on the assumption that there is a relationship between conceptual thinking and clinical reasoning.

AIMS

The paper provides a theoretical framework for understanding the relationship between conceptual learning and clinical reasoning.

METHOD

A review of current literature is used to explain the way in which conceptual understanding influences clinical reasoning and the transfer of theoretical understandings to the clinical context.

RESULTS

The paper argues that the connections made between concepts are what is significant about conceptual understanding. From this point of departure the paper describes teaching strategies that facilitate the kinds of learning opportunities that students need in order to develop conceptual understanding and to be able to transfer knowledge from theoretical to clinical contexts. Along with a variety of teaching strategies, the value of concept maps is discussed. The paper provides a framework for understanding the difficulties that students have in developing conceptual networks appropriate for later clinical reasoning.

CONCLUSION

In explaining how students learn for clinical application, the paper provides a theoretical framework that can inform how dental educators facilitate the conceptual learning, and later clinical reasoning, of their students.

Integrating teaching into the busy resident schedule: a learner-centered approach to raise efficiency (L-CARE) in clinical teaching

BACKGROUND

Clinical teachers are sometimes challenged by residents who seem too busy to concentrate on their learning. In such situations, teachers must be aware to diagnose underlying problems in learners and to effectively help them maximize learning while minimizing time and energy requirements.

OBJECTIVE

To develop a learner-centered model to improve efficiency of clinical teaching.

METHODS

We reviewed the literature on educational diagnosis, self-directed learning, and effective/efficient teaching to put together a new model.

RESULTS

The Learner-Centered Approach to Raise Efficiency (L-CARE) in Clinical Teaching is inspired from the well-known patient-centered clinical method. Using the L-CARE in clinical teaching involves: (1) addressing the learners' feelings regarding their environment as well as patient care and study issues, which provides a good learning climate facilitating educational diagnosis and management of issues that could impair learning; (2) establishing a learning contract (expectations); (3) sharing resources and strategies (ideas) that should be effective without wasting time or energy; (4) self-assessment and constructive feedback (impact). These steps are grounded in self-directed learning theory to improve motivation and ensure that learners concentrate on their own needs to promote learning efficiency.

CONCLUSION

The L-CARE model integrates educational diagnosis principles, self-directed learning theory, and efficient teaching strategies to improve efficiency of clinical teaching.

Basic science right, not basic science lite: medical education at a crossroad

This perspective is a counterpoint to Dr. Brass' article, Basic biomedical sciences and the future of medical education: implications for internal medicine. The authors review development of the US medical education system as an introduction to a discussion of Dr. Brass' perspectives. The authors agree that sound scientific foundations and skill in critical thinking are important and that effective educational strategies to improve foundational science education should be implemented. Unfortunately, many students do not perceive the relevance of basic science education to clinical practice.The authors cite areas of disagreement. They believe it is unlikely that the importance of basic sciences will be diminished by contemporary directions in medical education and planned modifications of USMLE. Graduates' diminished interest in internal medicine is unlikely from changes in basic science education.Thoughtful changes in education provide the opportunity to improve understanding of fundamental sciences, the process of scientific inquiry, and translation of that knowledge to clinical practice.

Impact of a pre-clinical clinical skills curriculum on student performance in third-year clerkships

BACKGROUND

Research on the outcomes of pre-clinical curricula for clinical skills development is needed to assess their influence on medical student performance in clerkships.

OBJECTIVE

To better understand the impact of a clinical-skills curriculum in the pre-clinical setting on student performance.

DESIGN

We conducted a non-randomized, retrospective, pre-post review of student performance evaluations from 3rd-year clerkships, before and after implementation of a clinical-skills curriculum, the Colleges (2001-2007).

MAIN RESULTS

Comparisons of clerkship performance data revealed statistically significant differences favoring the post-Colleges group in the Internal Medicine clerkship for 9 of 12 clinical-skills domains, including Technical Communication Skills (p < 0.023, effect size 0.16), Procedural Skills (p < 0.031, effect size 0.17), Communication Skills (p < 0.003, effect size 0.21), Patient Relationships (p < 0.003, effect size 0.21), Professional Relationships (p < 0.021, effect size 0.17), Educational Attitudes (p < 0.001, effect size 0.24), Initiative and Interest (p < 0.032, effect size 0.15), Attendance and Participation (p < 0.007, effect size 0.19), and Dependability (p < 0.008, effect size 0.19). Statistically significant differences were identified favoring the post-Colleges group in technical communication skills for three of six basic clerkships (Internal Medicine, Surgery, and Pediatrics).

CONCLUSIONS

Implementation of a pre-clinical fundamental skills curriculum appears to be associated with improved clerkship performance in the 3rd year of medical school, particularly in the Internal Medicine clerkship. Similar curricula, focused on teaching clinical skills in small groups at the bedside with personalized mentoring from faculty members, may improve student performance. Continued efforts are needed to understand how to best prepare students for clinical clerkships and how to evaluate outcomes of similar pre-clinical skills programs.

Effective teaching and learning on the wards: easier said than done?

OBJECTIVES

The aim of this study was to evaluate the teaching and learning during a clinical placement, and to draw lessons from the findings to inform medical educators about more efficient and effective ways of teaching and learning.

METHODS

This study involved students and teachers from a final year clinical placement on a graduate-entry medical programme. Questionnaires, focus groups, unstructured observation and structured observation using time sampling were used to elicit student and clinician perceptions of various learning opportunities.

RESULTS

Analysis revealed positive perceptions of the variety of different learning opportunities available to final year students undertaking a clinical rotation, as well as a high degree of congruency between student and clinician perceptions of these. Questionnaire data indicated that both groups valued hands-on learning and a broad knowledge base. Analysis of observation variables revealed a dominance of passive and low-level cognitive actions across learning sessions, particularly (and counter-intuitively) during bedside teaching.

DISCUSSION

This study highlighted a number of strengths and weaknesses in the clinical teaching that took place during these rotations. In particular, it highlighted congruency between student and teacher perceptions of good teaching and learning. At the same time, it flagged a potential disjunct between student and teacher expectations (or understandings) of various learning opportunities, and revealed a much broader disconnection between what is most valued and what is easiest to deliver in the clinical context. The results emphasise the need for quality rather than quantity, contextual blended learning, protected teaching time, the valuing of close student-teacher interaction and faculty development.

Unintentional failure to assess for experience in senior undergraduate OSCE scoring

CONTEXT

One goal of undergraduate assessment is to test students' (future) performance. In the area of skills testing, the objective structured clinical examination (OSCE) has been of great value as a tool with which to test a number of skills in a limited time, with bias reduction and improved reliability. But can OSCEs measure undergraduate internship expertise in basic clinical skills?

METHODS

Undergraduate students (n = 32) were given a questionnaire listing 182 basic clinical skills. We asked them to score the number of times they had performed each skill during their internships (a 12-month period in Year 6). We assessed the students at the end of Year 5 (before the start of their internships) and again at the start of Year 7 (undergraduate training takes 7 years in Belgium, with internships during Year 6), using a 14-station OSCE assessing basic clinical skills. Global ratings were used to score performance. The relationship between internship experience and the OSCE Year 7 score was analysed using a linear regression model, controlling for variation in OSCE scores from Year 5. A multi-level analysis was performed considering students as level-1 units and stations as level-2 units.

RESULTS

Year 7 OSCE scores (post-internships) were not affected by the number of times that students practised basic medical skills during their internships.

DISCUSSION

Scores on OSCEs do not seem to reflect clinical expertise acquired during internships. Other more integrated assessment methods may prove to be more valid for testing final undergraduate skills levels.

A clinical nutrition course to improve pharmacy students' skills and confidence in counseling patients

OBJECTIVE

To create, implement, and evaluate a PharmD course on primary care nutrition.

DESIGN

A 2-credit hour elective course was offered to second- and third-year pharmacy students. It was informed by the Socratic method using a minimum number of formal lecture presentations and featured problem-based learning exercises, case-based scenarios, and scientific literature to fuel informed debate. A single group posttest design with a retrospective pretest was used to assess students' self-efficacy.

ASSESSMENT

There was a significant overall improvement in students' self-efficacy in their ability to practice primary care nutrition.

CONCLUSION

Completion of a nutrition course improved students' confidence in providing primary care nutrition and empowered them to speak more comfortably about the role of nutrition in the prevention of chronic diseases.

Recently published papers: more about EGDT, experimental therapies and some inconvenient truths

This issue's recently published papers concentrates on early goal directed therapy, starting with new data from the original study through to new studies that may have a major bearing on the treatment of septic shock in years to come. A timely reminder about talking, walking and teaching clinical medicine completes the roundup.