Subha Ramani

AMEE Guide no. 34: teaching in the clinical environment

Teaching in the clinical environment is a demanding, complex and often frustrating task, a task many clinicians assume without adequate preparation or orientation. Twelve roles have previously been described for medical teachers, grouped into six major tasks: (1) the information provider; (2) the role model; (3) the facilitator; (4) the assessor; (5) the curriculum and course planner; and (6) the resource material creator (Harden & Crosby 2000). It is clear that many of these roles require a teacher to be more than a medical expert. In a pure educational setting, teachers may have limited roles, but the clinical teacher often plays many roles simultaneously, switching from one role to another during the same encounter. The large majority of clinical teachers around the world have received rigorous training in medical knowledge and skills but little to none in teaching. As physicians become ever busier in their own clinical practice, being effective teachers becomes more challenging in the context of expanding clinical responsibilities and shrinking time for teaching (Prideaux et al. ). Clinicians on the frontline are often unaware of educational mandates from licensing and accreditation bodies as well as medical schools and postgraduate training programmes and this has major implications for staff training. Institutions need to provide necessary orientation and training for their clinical teachers. This Guide looks at the many challenges for teachers in the clinical environment, application of relevant educational theories to the clinical context and practical teaching tips for clinical teachers. This guide will concentrate on the hospital setting as teaching within the community is the subject of another AMEE guide.

Twelve tips for developing effective mentors

Mentoring is often identified as a crucial step in achieving career success. However, not all medical trainees or educators recognize the value of a mentoring relationship. Since medical educators rarely receive training on the mentoring process, they are often ill equipped to face challenges when taking on major mentoring responsibilities. This article is based on half-day workshops presented at the 11th Ottawa International Conference on Medical Education in Barcelona on 5 July 2004 and the annual meeting of the Association of American Medical Colleges in Boston on 10 November 2004 as well as a review of literature. Thirteen medical faculty participated in the former and 30 in the latter. Most participants held leadership positions at their institutions and mentored trainees as well as supervised mentoring programs. The workshops reviewed skills of mentoring and strategies for designing effective mentoring programs. Participants engaged in brainstorming and interactive discussions to: (a) review different types of mentoring programs; (b) discuss measures of success and failure of mentoring relationships and programs; and (c) examine the influence of gender and cultural differences on mentoring. Participants were also asked to develop an implementation plan for a mentoring program for medical students and faculty. They had to identify student and faculty mentoring needs, and describe methods to recruit mentors as well as institutional reward systems to encourage and support mentoring.

Twelve tips for giving feedback effectively in the clinical environment

Background: Feedback is an essential element of the educational process for clinical trainees. Performance-based feedback enables good habits to be reinforced and faulty ones to be corrected. Despite its importance, most trainees feel that they do not receive adequate feedback and if they do, the process is not effective. Aims and methods: The authors reviewed the literature on feedback and present the following 12 tips for clinical teachers to provide effective feedback to undergraduate and graduate medical trainees. In most of the tips, the focus is the individual teacher in clinical settings, although some of the suggestions are best adopted at the institutional level. Results: Clinical educators will find the tips practical and easy to implement in their day-to-day interactions with learners. The techniques can be applied in settings whether the time for feedback is 5 minutes or 30 minutes. Conclusions: Clinical teachers can improve their skills for giving feedback to learners by using the straightforward and practical tools described in the subsequent sections. Institutions should emphasise the importance of feedback to their clinical educators, provide staff development and implement a mechanism by which the quantity and quality of feedback is monitored.

Whither bedside teaching? A focus-group study of clinical teachers.

Purpose Previous reports document diminishing time spent on bedside teaching, with a shift towards conference rooms and corridors. This study explored facultys perceptions of the barriers to and their strategies for increasing and improving bedside teaching. Method Four focus groups consisting of (1) chief residents, (2) residency program directors, (3) skilled bedside teachers, and (4) a convenience group of other Department of Medicine faculty from the Boston University School of Medicines affiliated hospitals were held in May 1998. Each session lasted 60–90 minutes. Sessions were audiotaped, transcribed, and analyzed using qualitative methods. Results The most significant barriers reported were (1) declining bedside teaching skills; (2) the aura of bedside teaching, a belief that bedside teachers should possess an almost unattainable level of diagnostic skill that creates intense performance pressure; (3) that teaching is not valued; and (4) erosion of teaching ethic. Focus-group participants suggested the following strategies for addressing these barriers: improve bedside teaching skills through faculty training in clinical skills and teaching methods; reassure clinical faculty that they possess more than adequate bedside skills to educate trainees; establish a learning climate that allows teachers to admit their limitations; and address the undervaluing of teaching on a department level with adequate recognition and rewards for teaching efforts. Skilled teachers, in particular, stated that a bedside teaching ethic could be reestablished by emphasizing its importance and challenging learners to think clinically. Conclusions Bedside teaching is regarded as valuable. Some barriers may be overcome by setting realistic faculty expectations, providing incentives for teaching faculty, and establishing ongoing faculty development programs.

Improving bedside teaching: findings from a focus group study of learners.

Purpose Literature reviews indicate that the proportion of clinical educational time devoted to bedside teaching ranges from 8% to 19%. Previous studies regarding this paucity have not adequately examined the perspectives of learners. The authors explored learners’ attitudes toward bedside teaching, perceptions of barriers, and strategies to increase its frequency and effectiveness, as well as whether learners’ stages of training influenced their perspectives. Method Six focus group discussions with fourth-year medical students and first- or second-year internal medicine residents recruited from the Boston University School of Medicine and Residency Program in Internal Medicine were conducted between June 2004 and February 2005. Each 60- to 90-minute discussion was audiotaped, transcribed, and analyzed using qualitative methods. Results Learners believed that bedside teaching is valuable for learning essential clinical skills. They believed it is underutilized and described many barriers to its use: lack of respect for the patient; time constraints; learner autonomy; faculty attitude, knowledge, and skill; and overreliance on technology. Learners suggested a variety of strategies to mitigate barriers: orienting and including the patient; addressing time constraints through flexibility, selectivity, and integration with work; providing learners with reassurance, reinforcing their autonomy, and incorporating them into the teaching process; faculty development; and advocating evidence-based physical diagnosis. Students focused on the physical diagnosis aspects of bedside teaching, whereas views of residents reflected their multifaceted roles as learners, teachers, and managers. Conclusions Bedside teaching is valuable but underutilized. Including the patient, collaborating with learners, faculty development, and promoting a supportive institutional culture can redress several barriers to bedside teaching.

Twelve tips to promote excellence in medical teaching

For medical teachers around the world, teaching duties have expanded beyond the classroom and include teaching small groups, assessment, providing instructional materials beyond the syllabus, problem-based learning, learner-centred teaching, clinical teaching on-the-fly—and the list goes on. Faculty development is essential to train medical faculty in essential educational theory and specific teaching skills as well as to encourage a flexible and learner-centred approach to teaching. Finally, self-reflection and critique of teaching techniques are vital to propel medical schools towards promoting and aiming for uncompromising excellence in medical education. The twelve tips described in this article relating to educating teachers, evaluating teaching and eradicating institutional apathy are simple measures that educational leaders can apply to promote excellence in teaching at their parent institutions. The tips introduce a multi-dimensional approach to improving the overall quality of medical education consisting of measures aimed at individual teachers and those aimed at overhauling the teaching climate at medical institutions.

Gender differences in the treatment of cerebrovascular disease

OBJECTIVE: Previous studies have shown that women receive fewer invasive procedures for the treatment of coronary artery disease than men, but gender differences in cerebrovascular disease have not been well studied. Our objective was to explore differences in the treatment of stroke between men and women.

Twelve tips for excellent physical examination teaching

Background: Physical examination (PEx) skills are declining among medical trainees, yet many institutions are not teaching these systematically and effectively. Many variables contribute to effective teaching: teachers’ confidence in their clinical skills, ability to demonstrate and assess these skills; availability of suitable patients; trainee attitude and fatigue; belief that institutions do not value clinical teachers. Finally, the relevance and significance of a systematic exam must be demonstrated or the teaching degenerates into a ‘show-and-tell’ exercise. Aims: This paper describes twelve practical teaching tips that can be used to promote high quality PEx teaching in 5 minutes or 45 minutes. Teaching tips: (1) Diagnostic hypotheses should guide reflective exam; (2) Teachers with the best clinical skills should be recruited; (3) A longitudinal and systematic curriculum can tailor teaching to multiple learner levels (4) Integration of simulation and bedside teaching can maximise learning; (5) Bedside detective work and games make learning fun; (6) The 6-step approach to teach procedures can be adopted to teach PEx; (7) Clinical teaching at the bedside should be increased; (8) Linking basic sciences to clinical findings will demonstrate relevance; (9) Since assessment drives learning, clinical skills should be systematically assessed; (10) Staff development can target improvement of teachers’ clinical skills for effective teaching; (11) Technology should be used to study utility of clinical signs; (12) Institutions should elevate the importance of clinical skills teaching and recognize and reward teachers. Conclusions: PEx is important in patient-physician interactions, a valuable contributor to accurate clinical diagnosis and can be taught effectively using practical tips. To reverse the trend of deficient clinical skills, precision of clinical findings should be studied and exam manoeuvres that do not contribute to diagnosis discarded; institutions should value clinical skills teaching, appoint and fund core faculty to teach and provide staff development to improve teaching skills.

A pilot study assessing knowledge of clinical signs and physical examination skills in incoming medicine residents.

BACKGROUND Physical exam skills of medical trainees are declining, but most residencies do not offer systematic clinical skills teaching or assessment. OBJECTIVE To assess knowledge of clinical signs and physical exam performance among incoming internal medicine residents. METHOD For this study, 45 incoming residents completed a multiple choice question test to assess knowledge of clinical signs. A random selection of 20 underwent a faculty-observed objective structured clinical examination (OSCE) using patients with abnormal physical findings. Mean percentage scores were computed for the multiple choice question test, overall OSCE, and the 5 individual OSCE systems. RESULTS The mean scores were 58.4% (14.6 of 25; SD 11. 5) for the multiple choice question test and 54.7% (31.7 of 58; SD 11.0) for the overall OSCE. Mean OSCE scores by system were cardiovascular 30.0%, pulmonary 69.2%, abdominal 61.6%, neurologic 67.0%, and musculoskeletal 41.7%. Analysis of variance showed a difference in OSCE system scores (P < .001) with cardiovascular and musculoskeletal scores significantly lower than other systems. CONCLUSION Overall, physical exam knowledge and performance of new residents were unsatisfactory. There appears to be a pressing need for additional clinical skills training during medical school and residency training and we are planning a new clinical skills curriculum to address this deficiency.

Becoming a peer reviewer to medical education journals

Background: Peer reviewing for medical education journals is an art, a privilege, a responsibility and a service to the profession. Writing a review report requires skills and commitment and takes time. Novice reviewers may be interested in participating in this service, but they might lack sufficient knowledge of their role as peer reviewers and the skills needed to conduct a comprehensive and fair review. Aims: The aims of this article are to help novice reviewers in their preparation of manuscript review reports and improve their confidence and skills in their role as reviewers. Methods: We reviewed the literature in this area and applied lessons learned from our experience as peer reviewers. In addition, one of the authors has presented several training workshops for faculty reviewers. Results: Incorporating all the methods described, we have developed a series of simple strategies that medical educators can utilise to perform high-quality reviews of manuscripts. Conclusions: Though the development of skills in reviewing medical education papers is the outcome of continuous practice and experience; the strategies described in this article will be of value to those starting their professional contribution as reviewers and enhance their skills in this area.