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?
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Teaching on rounds in the hospital is one of the most challenging situations. I usually have students + interns + residents, all in one group. Besides the different levels of training, there are additional issues. Some of them are post- call (read sleep deprived, not interested in learning) some are in “this is not my patient” mode; medical emergencies, beepers ringing, balancing between work and learning; all make for a chaotic situation.
I don’t know if I have an answer but some techniques/tips that have worked on occasion:
1. Tell the team that after the case is presented, each of them will have a task. The student will summarize the case very briefly, the intern will come up with a short differential for the presenting problem and the resident will provide a plan for sorting through the differential. This keeps everyone involved in the case presentation and in the following discussion
2. If time does not permit an educational discussion during rounds, assign each team member to search for answers to a clinical question and report back to the team the next day. Thus in a patient with shortness of breath and hypoxemia, you could ask the medical student to read up on the 5 mechanisms of hypoxemia, the intern to report back on the typical ABGs seen in Acute PE and how to use ABGs in eliminate hypoventilation as a cause of hypoxemia, and the resident to look up the how the pre test probability affects the interpretation of V/Q scans in PE and thus impacts on which test to order. Make sure you make time to follow up on these the next day!
3. If a particular trainee needs some targeted education that is best provided immediately, assign the other members of the team to some tasks while you do this… thus ask one member to place an order for a test, and the other member to call in a consult or look up some lab results. Thus “work” gets done while providing appropriate education.
4. When asking questions, LOOK AT the student first, then the intern and then the resident.
5. Sometimes we worry too much about the level of training – what every trainee needs to see are examples of good history taking and examination and how that can impact decision making. Just do the right thing for the patient, think aloud during this and each trainee will take away something useful!
It is a necessity of medical education that faculty be able to address and teach students, residents and fellows who are in different stages of training.
It is very useful to have group teaching sessions where the faculty member probes each individual at his/her appropriate level of training. Having students at a higher PGY level participate to guide the discussion is also useful.
Assigining tasks to different members of the team is also helpful. Each one can present a portion of a case, problem etc. and the depth of conversation can begin superificially and progress to higher levels of inquiry.
One key feature of this type of education is to engage everyone and have each learn and teach one another.
If during the educational process, one individual is not able to keep up with the discussion, then alternative arrangements will have to be made. This can include more one on one involvement with higher PGY level trainees, with or without the faculty member present.
Teaching is a difficult process and we learn everyday on how to individualize teaching that suits the needs of the involved student.
One technique I use when there are different levels of learners is to set up the expectation that students always get first dibs to answer the questions asked, interns next, then residents, and finally fellows, similar to Dr. Mehta's point #4. This strategy allows everyone in the group to contribute what they know and frequently builds on the clinical question, highlighting important symptoms to recognize, bringing in differential diagnosis, reviewing treatment options and discussing actual management of the patient's problem. It can be very surprising and enlightening what knowledge and insight different learners bring to the table.
With some of the students or junior residents, I'll encourage them to discuss what they've seen previously and how it relates to the case or problem at hand. Almost everyone has a prior experience to share.
I would add to Neil's excellent suggestions that as one moves from medical student to intern to resident the teacher can ask the more advanced trainee to add or expand to the preceding answer such as additional signs and symptoms of an illness, other diagnositic criteria for a condition or additional first line or second line treatments and the rationale for them. This often gives trainees a sense of a comprehensive answer and at times fosters dialogue/sharing between trainees of all levels.
Giving "educational prescriptions" for one of the trainees or the whole group to search out answers to questions they dont know and present briefly the next day can close the loop.
Several excellent comments. I'll mention one additional strategy. I will sometimes offer a supervising resident a chance to "direct" a short bedside teaching exercise if they are interested in working on their teaching skills as part of the rotation. The resident and I will plan this in advance. As attending I will announce to the team that the resident is going to take the lead on a bedside interaction. I will "observe" the interaction and meet with the resident shortly after to debrief the experience. This can be especially useful for the senior resident planning on an academic career whose knowledge base is quite strong. The team can take advantage of this knowledge base and the resident receives feedback in an area not usually focused on in resident education.
One way I like to keep everyone involved is by starting with a focus on basic pathophysiology and expanding from there. The students have the most recent experience with this. When moving to the higher level learners, ask them to add information about typical symptoms and management decisions, then have the more senior team member contribute with broader management options and some information about evidence for decisions if available.
When at the bedside, I consider the person who is presenting the case (student or intern almost all of the time) to be the "doctor" for that patient and most of the questioning about their thought process and plan of care is directed toward them with questions and expectations being set according to level of training. If questions cannot be answered I usually send it as a toss up to the rest of the group.
I also actively engage the residents throughout asking their opinions, and to comment on the case to transition to higher level appreciation of the case and to give them a chance to teach on the fly as well.
You have to really control these expectations early as the residents will usually jump in immediately when they feel the presentation, or representation is going awry and the original presentor gets overshadowed and the chance to really probe their thought process is lost.
For a more lecture type discussion, I think it is very difficult to taylor a lecture to that degree of learner ability. It would be up to the person presenting to know what his intended audience is and then inform the audience up front as the the level of skill assumed.
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