CAN CLINICAL TEACHING BE BOTH HIGH QUALITY AND EFFICIENT?

I don't think Cleveland Clinic is alone in attempting to balance high standards for clinical teaching quality and the need for greater clinical productivity. The same way that experienced clinicians seem able to efficiently care for patients without a drop in patient satisfaction or quality of care, so then, experienced clinical teachers seem to be able to "teach" both efficiently and well.

The other day I was observing a clinical teacher with a group of residents and students during rounds. It was quite a sight. I wish I would have had a video camera, because this was a clear example of teaching expertise in action. The attending interacted with everyone on the team, the flow was quick and there did not seem to be a minute wasted as the team moved from room to room. The questions she asked were insightful. She provided quick feedback and was at the same time respectful to the "senior", asking him to "teach" at one point.

So... What is your secret? How do you make time to observe, give feedback, provide focused teaching? If each person that receives this BLOG could share one idea, we would really have something worth saving!

OCTOBER SUMMARY

Dear Teacher’s BLOG Readers:
The responses to the October’s Question, “GLOBAL RATING SCALES: USELESS AS A TOOL FOR IMPROVING PERFORMANCE” were insightful and honest as well as practical. If you have not already read them, I encourage you to go to the OCTOBER Archives and read each one. The following are just a few “pearls” from the list.

There was a consensus that “global ratings” alone do little to assist our learners in improving practice. Some quotes:

• “The student requires a specific notion of what should be improved and therefore numeric value will be useless if there are no specific comments that will provide further feedback and insight”.
• “I agree that a global rating scale number such as "7" alone provides little information to a student about performance. Descriptive feedback is definitely better at elucidating areas of strength and weakness. This type of feedback allows the student to internalize and re-assess their performance with opportunity to adapt to expectations and/or standards.”

Others responded to GRS reliability and the use of data to compare students or residents. Some notes and quotes:

• “Just like with Likert scales, things are given a numerical assessment and each number is exactly the same distance from the other, yet what these numbers mean is not uniform in distance. For example, the distance between what someone would rate a 5 and an 8 on these scales is much smaller than the difference between 1 and 4. In fact I don't even know if 1 exists! This renders the scale even more arbitrary than what is just personal point of view of what an 8 means, etc. This has direct implications on using the numbers in any way - for example averaging and comparing.”
• “…. I think that the information from these GRFs becomes more meaningful when there are a number of raters. In this case, if a student consistently is scroing much lower than his or her peers, (across several stations) then we can intervene with that student and provide targeted input, correction, remediation -- whatever you want to call it. Yet, the students say that they learn the most from the narrative comments that the SP's put on each section of the form, noting what the student did well and what could be improved. I don't think that it's really a question of GRFs vs. narative feedback; we need both as they meet different aims

There are good questions about the value and psychometric properties of Global Rating Scales. A nice short article that addresses the inherent problems with GRS is listed below.
Farrell, S E. (2005) Evaluation of student performance: clinical and professional performance. Academic Emergency Medicine. 12(4): 302e6.

GLOBAL RATING SCALES: USELESS AS A TOOL FOR IMPROVING PERFORMANCE

Probably, all of us can agree that the ACGME Six Core Competencies are important measures of a good physician. They have resonated with medical schools so well that a large number of schools have incorporated these competencies into their expectations for graduates. Who could argue with the concept that we want our graduates to be knowledgeable, clinically proficient, professional, good communicators, lifelong learners, and good stewards of the healthcare system in service to their patients.

The problem, as I see it, is not the competencies, but how we assess them. For the first five years after the introduction of the Competencies, new Global Rating Forms (GRFs) were introduced as the "answer" for assessing the competencies. In this approach, students or residents are assigned a number from a scale, for example, a "5" out of a possible "10" on one of the competencies. The faculty member has "done his/her duty", but how satisfying is the process for our teachers, and what in the world does that student or resident do with that "5".

Our medical school (CCLCM) is a competency-based school that approaches assessment systematically by emphasizing formative narrative feedback organized through a portfolio sytem. Students never are assigned a number, rather they receive narrative feedback about their "strengths" and "areas needing improvement". This seems to be working really well, although, there is a bit of a "learning curve".

So.. what do you think? Are there some strengths to GRFs that I am missing? Have you found ways to make those "numbers" tell a story that leads to improvement? Let us know what you think? Any residents or students reading this link? What do you think?

SEPTEMBER SUMMARY

We had a record “20” responses this month. If you have not already read them, I encourage you to go to the September Archives and read each one. The following are just a few “pearls” from the list.

• 3 or 4 of our responding BLOGGERS mentioned the importance of keeping material new, reading and adding up-to-date information to the “talk”. New findings with their implications for practice can be a great springboard for comparing old with new and many other teaching strategies and stories that go beyond the simple facts
• Another theme was changing from thinking about what and how to teach to thinking about your learners’ needs. What do they need to learn? Where are they now? And What can you offer to help “fill the gap” By focusing on each new groups’ learning needs, you are probably starting at a different place and covering similar material but with the focus not on teaching , but helping the learners succeed.
• Another theme was very practical and focused on extrinsic as well as intrinsic rewards. Extrinsic rewards come from students, one BLOGGER suggested keeping those positive letters and notes from students for a “rainy day” when your motivation needs a boost. Others used feedback as a tool in refining their teaching. Intrinsically reward yourself by communicating with other dedicated teachers.
• Finally, TRY NEW THINGS!!! Get out of your “comfort zone”, go to workshops when offered and learn new approaches to teaching. And most importantly do it with enthusiasm. If you don’t feel enthusiastic, “fake it”, then feed off the students response until you really feel it. Or as one BLOGGER offered, Just say, I’m not on my “A” Game today, let’s go get coffee and do “flash cards”
• My humble addition is to mentor a new teacher on the faculty. No, not that “star” that is a natural, but that highly motivated, limited teaching skill faculty member that really needs you! When I hear that faculty member has gotten great reviews by students, I’ve got a smile on my face a mile wide.
  Hope these suggestions were useful to you!

KEEPING A FRESH PERSPECTIVE ON TEACHING

Let's face it, Teaching is not rewarded in the same way that Clinical Work and Research are in most large academic medical teaching centers. It may be that we simply are not able to measure outcomes in teaching the same way we can in the other two "legs on the academic stool".

Some faculty say, "teaching is its own reward" and I would agree. But how do you keep your teaching "fresh" in the face of all the other demands on your time. This was not the question I had planned for September, but a gifted "early career" teacher stopped me today and asked, "How do they do it! How do some of these guys teach year after year and act like they are teaching this material for the first time? How can I keep my enthusiasm? Sometimes I just feel tired"

So this question is to our faculty who have been doing this for a few years. How do you keep it "fresh" (or appear to)? Any tips you have for keeping your enthusiasm and avoiding burnout would be most welcome. Let's break our record of 10 responses.

AUGUST SUMMARY

The responses to the Augusts’ Question, “Shhhh! Quiet Learner at Work” were insightful as well as practical. We also had our highest response with faculty posting 10 different responses and ideas. If you have not already read them, I encourage you to go to the August Archives and read each one. The following are just a few “pearls” from the list.

• Two of the responders thought that giving quieter students or residents a specific role to play can increase their interaction.
• One responder mentioned assigning a paper, then asking the quieter student to present the next day, another suggested asking them to serve as “teacher”
• In one-to-one teaching it is not as much of a problem since dialog is pretty much mandated. However, if you want to increase students’ one and two word responses, first, ask more open-ended questions and second, make your expectations for depth of response clear.
• One responder suggested killing two birds with one stone by enlisting the “talker or dominant student” to solicit opinions from the quieter student.
• Two responders thought that one needed to consider cultural background as certain cultures regard speaking out as impolite. Again, expectations need to be made clear
• Finally, before labeling the student as quiet and non responsive make sure your own behavior is not intimidating to all but the most aggressive learner.

One thing I might add from years of working with faculty (who can also fall into this category) is to create a “reason for communicating”. Many times the learner themselves prefers to learn through observation and checking the “answer in their head” with those verbalized. They have no personal need to verbalize their understanding. GIVE THEM A REASON!
Hope these suggestions were useful to you!

Shhhh! Quiet Learner at Work

Have you ever spent a week or even a month with a group of students/residents and when it comes time to complete their evaluations you are not at all sure of what they know or don't know. Sure they show up on time and complete their work, but whenever you try to engage them in discussion to see if they really understand, the most you get for your trouble is a short response. You perceive no interest, no passion... It is frustrating!!!!

The dilemma of the "quiet student"!

I've often wondered "Who's problem is it anyway?" Maybe it is just me? The more reflective quiet student or resident seems fairly content handling their learning. Or do we do them a disservice by not challenging them?

How do you all handle "quiet students?" Has anyone found a way of engaging these reluctant participants and getting a good sense of their knowledge and understanding?

Please "comment" if you have an idea.

JULY SUMMARY

The responses to the July’s Question, “When Learners get it Wrong: Handling Incorrect Responses without Intimidating the Learner Discussion” were great examples of the fact that there really isn’t one right way to address any teaching question. The following are just a few “pearls” from the list.

• It is important to build a safe learning environment so that learners are willing to ask and answer questions.


• If the learner is more advanced and seems certain of an incorrect fact, ask a follow-up question concerning their source. If no one has supporting evidence send the individual or group out to find the correct response.


• Look for a “kernel of truth” in the response and work from there.
• For early learners, ask questions in a form that doesn’t require “one right answer”.
• When asking questions, know the difference between “wrong” and “not my way” and respond accordingly.
• Try to avoid “what am I thinking” questions
• Respectfully correct the response and “move on”

What our faculty “bloggers” were telling us on this issue is that their solutions depend on the context. In this case “time” was sometimes a factor. Another factor was “importance of the answer to “good practice”. Another factor was the existing relationship you have with the learner group. Teaching, like medicine and to a lesser degree science, is an "it depends" profession!

WHEN LEARNERS GET IT WRONG

WHEN LEARNERS GET IT WRONG: Handling Incorrect Responses Without Intimidating the Learner and Turning Off Discussion.

When doing observations of teaching in the classroom and clinics, I often pay special attention to how faculty handle incorrect responses. Some teachers use the incorrect response as a springboard for teaching. Others -move on- asking another student or resident to help out. Another group answers the question themselves while still another group (unfortunately) ridicules or makes fun of the incorrect response. While we all can agree that the last strategy is probably not the best, is there one best way to make sure the learner and the rest of the group are clear about the correct answer while not shutting down that learner or the others that are in the group?

What works for you? Is there one best way? Is there clearly a wrong way? Do we worry too much about hurting our learners feelings?

June Summary

The responses to the June Question, “How Do You Effectively Teach Multi Level Learner Groups?” were great examples of expertise in teaching. If you haven’t already read through the comments be sure to click on the Archives for June to read each great idea.
Our faculty came through with 13 excellent suggestions. The following are just a few “pearls” from the list. The advice from the faculty was given primarily in the context of “teaching rounds” :

• Set expectations for teaching rounds. Give each level learner a specific role. Three of our responders suggested giving the student the first question and asking the more senior learners to “build on” the student response. Another approach was to start with the student and a pathophysiology question, then move on to interns for signs and symptoms and differential while saving the management questions for the resident.
• Give opportunities for senior residents to teach. This can be planned (where the senior and the team know that the senior will be “running the show” for a certain number of cases) or impromptu where you ask the senior for their opinion and direct the student questions to them for response. In both instances, give the senior feedback on their teaching

Hopscotch Teaching.. or Teaching to Multi-level Groups

Both clinical and basic science teachers often ask me questions about teaching/facilitating groups composed of learners at different levels. From my observations, I’ve found that it is not uncommon for faculty to conduct hospital teaching rounds where the team is composed of medical students, interns, residents and possibly some fellows. Researchers facilitate conferences and lecture to groups that include graduate students, medical students, fellows, and colleagues. The question is, how do you keep them all engaged and learning?

Have you ever faced this situation before? If so, how did you handle it?

May Summary

Our question for May asked how clinical teachers (especially young teachers) strike the right balance between being considered overly accommodating (pushover) and being considered overly strict (task master).

Our faculty came through with six excellent suggestions. The advice from the faculty was to:

• Set expectations or standards early in the process; this way students and residents will know how to prepare and won’t feel “ambushed”
• Use the ASK-TELL-ASK approach to giving feedback, always starting with the learners’ perspective, using their concerns as a springboard for teaching
• Model the behavior you expect from your learners
  

Two other comments reflected on the difficulties young clinical teachers face as they transition from resident or fellow to attending and develop their own teaching persona. Anecdotally, new faculty have described difficulties especially when joining the faculty at the institution in which they trained, citing evaluating past peers as the most difficult. I reviewed the literature and could find nothing helpful concerning this transition. Perhaps this is an open area for educational research!!

Task Master or Pushover Dilemma

In trying to create a "safe" environment, teachers can over compensate and become so accepting that "anything" seems "ok". In these settings the learners can lose motivation to perform. It is really hard to find just the right balance between being a "task master" and being overly supportive.

Young teachers have often come to me with this dilemma. They in particular feel "singled out" by students and residents as being "too harsh" if they attempt to hold high standards.

Have you shared this experience?, or have some ideas to contribute? Join the discussion. We want to hear from you!