Medical Teaching in Ambulatory Care, Third Edition [3rd Edition] 9781442662339

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MEDICAL TEACHING IN AMBULATORY CARE Third Edition

A practical, hands-on resource for physicians in all specialties, Medical Teaching in Ambulatory Care is a guide to training medical students and residents in settings such as private practices and hospital clinics. Concise, engaging, and easy to follow, it is an ideal handbook for the busy practitioner looking to upgrade his or her teaching abilities. The authors cover basic education theory, specific teaching skills, strategies for evaluating trainees, and tips on working with challenging learners. Through the adventures of the fictional Dr. Smith, the book provides practical examples that complement each theory, skill, and strategy presented. This new edition has been updated with detailed information on core medical education theories, one-to-one teaching, and structured formats to use when reviewing learners’ interactions with patients. The authors also examine the impact of digital technology on medical education in office-based settings and provide tips on working with the new generation of learners who enjoy – and expect – instant access to information of all kinds. warren rubenstein, md, is a family physician and an associate professor in the Department of Family and Community Medicine at the University of Toronto. yves talbot, md, is a family physician and a professor in the Department of Family and Community Medicine, the Department of Health Policy Management and Evaluation, and the Dalla Lana School of Public Health at the University of Toronto.

warren rubenstein, m.d., is a family physician trained in medical education at the Family Medicine Program, Royal College of General Practitioners of Australia. He is an associate professor in the Department of Family and Community Medicine at the University of Toronto. Since 1978, he has taught medical students and residents in a large dedicated family medicine teaching centre at Mount Sinai Hospital in Toronto. He has presented lectures and workshops focusing on teaching in ambulatory care at conferences and universities worldwide. yves talbot, m.d., is a family physician whose primary work in medical education is with faculty development and global health. He is a professor in, and was recently the director of global health of, the Department of Family and Community Medicine and Health Administration at the University of Toronto. He teaches family medicine at Mount Sinai Hospital in Toronto. He has worked in South America since 1995 and conducts training programs to develop primary care. He has a particular interest in the roles of primary care and health equity.

WARREN RUBENSTEIN, M.D. YVES TALBOT, M.D.

Medical Teaching in Ambulatory Care Third Edition

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

© University of Toronto Press 2013 Toronto Buffalo London www.utppublishing.com Printed in Canada ISBN 978-1-4426-1342-3

Printed on acid-free, 100% post-consumer recycled paper with vegetable-based inks.

Library and Archives Canada Cataloguing in Publication Rubenstein, Warren Medical teaching in ambulatory care / Warren Rubenstein, Yves Talbot. – 3rd ed. Includes bibliographical references and index. ISBN 978-1-4426-1342-3 1. Ambulatory medical care – Study and teaching. II. Title R834.R82 2012

610.71⬘55

I. Talbot, Yves

C2012-907221-4

The University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council. University of Toronto Press acknowledges the financial support of the Government of Canada through the Canada Book Fund for its publishing activities.

To Susan and Jonathan – carpe diem. W.R. To my father, Roland, my wife, Lois, and my sons, Adam and Martin, who are my teachers. Y.T.

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Contents

Acknowledgments ix Introduction

3

1 Learning and Teaching in Ambulatory Care 2 Teaching Skills in Ambulatory Care 3 Setting Up the Clinic for Teaching

25 43

4 Strategies to Use during the Teaching Day 5 Special Learning Situations 6 Evaluation Index 147

129

95

10

68

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Acknowledgments

The authors would like to thank the following people who graciously aided in the evolution of this book: Dr. David Tannenbaum, for the groundwork in chapter 3; Dr. Larry Librach, for the framework of chapter 6; Dr. Brian Goldman, for the first edit of the original manuscript; Dr. Allan Rosenbluth, for the psychiatric profiles in chapter 5; Dr. Richard Tiberius, whose workshops with Dr. Rubenstein provided the basis for chapter 2; Dr. Helen Batty, for advice on educational theory; Astrid Otto, Joanne Permaul, and Rita Shaughnessy, for literature searches; Susan Devins, for getting difficult concepts into plain English; our colleagues at Mount Sinai Hospital Family Medicine Centre, with whom we discussed and developed many of these ideas; and Drs. Wes Fabb, Peter Fleming, Michael Heffernan, and Olle ten Cate, for their guiding light.

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MEDICAL TEACHING IN AMBULATORY CARE

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Introduction

For Whom the Authors Toiled – A Third Time

Since the first publication of Medical Teaching in Ambulatory Care in 1993, primary care physicians and specialists who teach medical students or postgraduate trainees in ambulatory care have used it throughout the world. Historically, learners worked with physicians in dedicated hospital-based teaching centres. More recently, they have begun to work with physicians in community-based locations. This refers to the office, solo or group, where the practitioner is the physician of record for, and provides continuity of care to, the patients. In addition to these community practitioners’ offices, traditional outpatient clinics in teaching hospitals, community hospitals, and local neighbourhood health centres serve as practical classrooms. Learners are also now assigned to ambulatory surgery centres, family planning clinics, urgent care centres, public health offices, and student health services. This book outlines the knowledge and skills you will need as you work with learners. It tells you how, not what, to teach – the approaches you can apply in the context of your specialty for the needs of a particular learner. The goals and content of ambulatory teaching are different across specialties, but the skills to convey that content are universal (Biddle, Siska, & Erney, 1994). As you move from bedside teaching to clinic teaching, this book will give you the tools to make your ambulatory setting an effective educational milieu. Why Ambulatory Care Teaching? Since this book’s first edition, the world-wide paradigm shift from hospital-based patient care to ambulatory care has consolidated (Kuhn, 1970; Bowen et al., 2005). As a result of economic forces and advances in

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health care technology, medical professionals effectively manage many acute illnesses and exacerbations of chronic diseases without hospitalization, and many medical and surgical sub-specialists can now practice almost exclusively in outpatient settings (Green, Fryer, Yawn, Lanier, & Dovey, 2001; Dent, 2003). The case mix on many inpatient services has shifted dramatically. Critically ill patients who require specialized care, patients hospitalized transiently, or patients with extensive pre-admission workups now fill hospital beds. Such patients are rarely suitable for teaching medical students or residents (Prideaux et al., 2000). Four decades ago, training programs recognized that most of the work of family physicians and general practitioners was in office-based settings, while only a fraction was in hospitals. As a result, educators began to develop model training practices in hospitals and use private offices in the surrounding communities (Link & Buchsbaum, 1986). General internal medicine and general paediatrics soon followed suit (Wones et al., 1986). Limited training in other specialties and a call for ambulatory training in the general undergraduate curriculum began (Levy, 1988; GPEP, 1984; Shine, 1986). In 1986, Perkoff alerted the world of medical education to the fact that it was time for learners to work in the settings in which the patients with the problems they needed to learn about could be found (Perkoff, 1986). Over the past twenty years, there has been an explosion of ambulatory care teaching programs (Baum & Axtell, 2005). Almost every discipline conducts an increasing part of its postgraduate training in ambulatory sites. This has particularly affected specialty training, where ambulatory experience for all learners has become mandatory over the past decade. This increased demand for training means there is an increased need for medical and surgical specialists to learn teaching skills for the office and clinic environment (Huh & Goebert, 2010; Brebbia et al., 2008). As well, many undergraduate clinical placements, in both primary care and specialty areas, include ambulatory experience as a a significant component (Lynch, Whitley, Basnight, & Patselas, 1999). More recently, with the evolution of medical schools in which learners are distributed over hundreds of kilometres, introductory undergraduate clinical courses taught in the preclinical years have used ambulatory settings (Karkabi, Castel, Reis, Shvartzman, Vinker, & Lahad, 2010). There has been an endless stream of journal papers, both descriptive and researchbased, about such programs (Bowen et al., 2006; Regan-Smith & Young, 2002; Kilminster & Jolly, 2000; Heidenreich, Lye, Simpson, & Lourich, 2000). There are also several textbooks that provide more detailed pro-

Introduction 5

gram descriptions (see Whitehouse, Roland, & Campion, 1997; Alguire, DeWitt, Pinsky, & Ferenchick, 2008). But where those papers and textbooks talk about the content of ambulatory care programs, this book is a practical how-to guide to teaching in them. From Hospital to Ambulatory Care Teaching Inpatient teaching is quite familiar to all of us. Learners admit patients, either electively or as an emergency. They perform a detailed history and physical, and formulate a differential diagnosis and treatment plan that are shaped by initial discussion with a more senior learner and a more detailed round with an attending physician. Formal teaching, aside from that required to help learners deal with patients whose problems require immediate treatment, is left for later. In the early years of the undergraduate curriculum, learners spend an hour or more at the bedside of a hospitalized patient doing a history and physical. There then follows a lengthy review with teacher and fellow group members beside the captive patient. In ambulatory settings, one-to-one teaching most often occurs directly after a learner sees the patient and simultaneously with patient care. Sometimes, immediate problems are dealt with exclusively. Or, the patient may present for ongoing care of a long-term illness. Ambulatory patients are in the clinical setting for a short period and, because they are not acutely ill, exercise more control over what happens to them. Teachers and learners face significant time pressures – among them, the need to review cases rapidly in order to see patients in a cost-efficient manner (Nadkarni et al., 2011). This book focuses on teaching in this context. Guidebook to Ambulatory Care Teaching We have worked for thirty-five years in ambulatory care teaching and base this book on that experience. We have reflected on what works and what does not, and on which theories are practical and which are not. We have reviewed the explosion in medical education literature on this topic for this third edition and provide key references. This book follows the imaginary Dr. Z.Z. Smith’s personal development as a teacher and the transformation of his multi-specialty clinic, Clinics of Main Street, into a teaching centre. Shortly after establishing his practice, Dr. Smith, a representative of all specialties, finds that learn-

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ers from the local hospital in which he does rounds want to come to his office. Without any previous teacher training, he naturally has difficulty dealing with the daily challenges these learners present. He sets out to see if he can find out more about being a teacher. In chapter 1, we will, with Dr. Smith, explore basic educational theory. He finds theories that provide him with a more formal framework for his teaching rather than his old style of improvising. He discovers theories about reception and discovery learning (contrasting approaches to presenting information), adult learning (a set of guidelines for dealing with mature learners), and competency-based learning (focusing on specifics skills rather than training time). Similar to his work in his clinical practice, he learns about the concept of interprofessional education and its impact on his role as teacher. In chapter 2, we follow Dr. Smith as he investigates specific teaching skills. He discovers that teachers go through a two-step process at each learner encounter before they reach the teaching point. Teachers choose a learner premise (based on their observations of the learner) or a teacher premise (based on their previous experience with learners in general) and then use a specific teaching skill in that circumstance. Dr. Smith discovers a variety of teaching skills within three umbrella categories – telling, asking, and showing – and becomes familiar with when to apply them. In chapter 3, Dr. Smith convinces his colleagues to use the entire clinic as a teaching centre. This process requires preparing the office, the patients, and the staff. He readies the examining rooms for teaching and creates brochures and posters to inform patients about the clinic’s new role. The office staff are involved in the preliminary planning and determines that everyone can enhance the learners’ experience. Finally, the medical staff meets to learn about their teaching role. The steady inflow of learners to the clinic propels the medical staff to develop teaching strategies. In chapter 4, the staff review case discussion, in which they discuss patients’ presenting problems with learners on the spot, and case review, in which they discuss cases later in the day. They consider the advantages and disadvantages of using the patients’ charts for teaching. They also analyse techniques such as role play, didactic presentations, and online learning. One year later, Dr. Smith and his colleagues find they have several difficult learners who tax their teaching abilities. In chapter 5, the staff develop strategies for helping learners with problems in clinical learning, such as poor knowledge bases or clinical judgment difficulty. They seek mechanisms to assist learners who are prejudiced or who avoid

Introduction 7

difficult patients. They devise a system to help other learners who are argumentative or defensive. They also tackle the troublesome matter of learners’ personal problems, such as overconfidence, lying, and unprofessional behaviour. In chapter 6, we discuss evaluation, a three-pronged approach that shows how Dr. Smith evaluates his learners, his teachers, and the clinic’s teaching program. An overview of evaluation theory leads to a sample of rating forms in which learners evaluate the teachers, learners evaluate the office as a teaching centre, and the teachers in turn evaluate the learners. Medical Teaching in Ambulatory Care is a guide to using your office or clinic as an important locus of medical education. It will assist you if you teach either learners at all levels of medical education in core topics, or learners who join you for an elective experience. The future of medical education is in ambulatory care teaching. You can be part of that future right now. Read on!

REFERENCES Alguire, P., DeWitt, D., Pinsky, L., & Ferenchick, G. (2008). Teaching in your office. Philadelphia: ACP Press. Baum, K.D., & Axtell, S. (2005, Mar). Trends in North American medical education. Keio Journal of Medicine, 54(1), 22–28. http://dx.doi.org/10.2302/ kjm.54.22 Medline:15832077 Biddle, B., Siska, K., & Erney, S. (1994). A description of ambulatory teaching in a longitudinal primary care program. Teaching and Learning in Medicine, 6(3), 185–90. http://dx.doi.org/10.1080/10401339409539673 Bowen, J.L., Salerno, S.M., Chamberlain, J.K., Eckstrom, E., Chen, H.L., & Brandenburg, S. (2005, Dec). Changing habits of practice: Transforming internal medicine residency education in ambulatory settings. Journal of General Internal Medicine, 20(12), 1181–87. http://dx.doi.org/10.1111/j.15251497.2005.0248.x Medline:16423112 Bowen, J.L., Clark, J.M., Houston, T.K., Levine, R., Branch, W., Clayton, C.P., et al. (2006, Feb). A national collaboration to disseminate skills for outpatient teaching in internal medicine. Academic Medicine, 81(2), 193–202. http:// dx.doi.org/10.1097/00001888-200602000-00022 Medline:16436586 Brebbia, G., Carcano, G., Boni, L., Dionigi, G.L., Rovera, F., Diurni, M., et al. (2008). To teach and to learn in day surgery: The role of residents. International Journal of Surgery, 6(Suppl 1), S56–S58. http://dx.doi.org/10.1016/j. ijsu.2008.12.017 Medline:19269908

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Dent, J.A. (2003, Jul). Twelve tips for developing a clinical teaching programme in a day surgery unit. Medical Teacher, 25(4), 364–67. http://dx.doi. org/10.1080/0142159031000136806 Medline:12893545 Green, L.A., Fryer, G.E., Jr., Yawn, B.P., Lanier, D., & Dovey, S.M. (2001, Jun). The ecology of medical care revisited. New England Journal of Medicine, 344(26), 2021–25. http://dx.doi.org/10.1056/NEJM200106283442611 Medline:11430334 Heidenreich, C., Lye, P., Simpson, D., & Lourich, M. (2000, Jan). The search for effective and efficient ambulatory teaching methods through the literature. Pediatrics, 105(1 Pt 3), 231–37. Medline:10617728 Huh, J., & Goebert, D.A. (2010, Feb). Diversifying residents’ outpatient psychiatry experience: A contemporary model for academic outpatient psychiatry clinics. Hawaii Medical Journal, 69(2), 37–38. Medline:20358724 Karkabi, K., Castel, O.C., Reis, S., Shvartzman, P., Vinker, S., & Lahad, A. (2010). A shift of amulatory medical education in Israel. Clinical Teacher, 7(2), 126–30. http://dx.doi.org/10.1111/j.1743-498X.2010.00353.x Kilminster, S.M., & Jolly, B.C. (2000, Oct). Effective supervision in clinical practice settings: A literature review. Medical Education, 34(10), 827–40. http:// dx.doi.org/10.1046/j.1365-2923.2000.00758.x Medline:11012933 Kuhn, T.S. (1970). The structure of scientific revolutions. Chicago: The University of Chicago Press. Levy, M. (1988, May). An ambulatory program for surgical residents and medical students. Journal of Medical Education, 63(5), 386–91. Medline:3361590 Link, K., & Buchsbaum, D. (1984, Jun). An agenda for residency training in ambulatory care. Journal of Medical Education, 59(6), 494–500. Medline:6726769 Lynch, D., Whitley, T., Basnight, L., & Patselas, T. (1999). Comparison of ambulatory and inpatient experiences in five specialties. Medical Teacher, 6, 594–96. Nadkarni, M., Reddy, S., Bates, C.K., Fosburgh, B., Babbott, S., & Holmboe, E. (2011, Jan). Ambulatory-based education in internal medicine: Current organization and implications for transformation. Journal of General Internal Medicine, 26(1), 16–20. http://dx.doi.org/10.1007/s11606-010-1437-3 Medline:20628830 Panel on the General Professional Education of the Physician. (1984). Physicians for the twenty-first century: The GPEP report. Journal of Medical Education, 59, 1–208. Perkoff, G.T. (1986, Jan). Teaching clinical medicine in the ambulatory setting: An idea whose time may have finally come. New England Journal of

Introduction 9 Medicine, 314(1), 27–31. http://dx.doi.org/10.1056/NEJM198601023140105 Medline:3940313 Prideaux, D., Alexander, H., Bower, A., Dacre, J., Haist, S., Jolly, B., et al. (2000, Oct). Clinical teaching: Maintaining an educational role for doctors in the new health care environment. Medical Education, 34(10), 820–26. http:// dx.doi.org/10.1046/j.1365-2923.2000.00756.x Medline:11012932 Shine, K.I. (1986, Jan). Innovations in ambulatory-care education. New England Journal of Medicine, 314(1), 52–53. http://dx.doi.org/10.1056/ NEJM198601023140110 Medline:3940317 Whitehouse, C., Roland, M., & Campion, P. (1997). Teaching medicine in the community. Oxford: Oxford University Press. Wones, R., Rouan, G., Brody, T., Bode, R., & Radack, K. (1987, Jun). An ambulatory medical education program for internal medicine residents. Journal of Medical Education, 62(6), 470–46. Medline:3599035

Chapter One

Learning and Teaching in Ambulatory Care

Dr. Z.Z. Smith completed his residency five years ago and began to work with Clinics of Main Street, a large multi-specialty clinic. Like many of his colleagues, he admitted patients to the local community teaching hospital and taught the medical students and residents on a daily basis. Soon, because of his enthusiasm, learners asked if they could see patients with him in his office. Dr. Smith enjoyed teaching and was pleased that learners were interested in working with him. Like some doctors, however, he had no training in teaching and felt his skills were inadequate. He wondered why some teaching sessions were successful and others were not. In addition, when problems arose, he had no concept of how to handle them. He decided to read some education textbooks to find a set of principles to help him improve his learners’ experience and deal with frustrations he encountered as a teacher. Eight subjects attracted his interest: 1 2 3 4 5 6 7 8

Learning Teaching Adult learning Content and process learning Reflection Domains of learning Competency-based education Interprofessional education

The following sections discuss what he discovered about these terms.

Learning and Teaching in Ambulatory Care

11

Learning There are two ways that teachers introduce information to learners (Ausubel, 1968). 1 Reception learning: The teacher presents learners with the entire content of the curriculum its final form. (For example, the teacher hands out a complete set of notes about family planning to medical students at the start of their ambulatory gynaecology rotation.) 2 Discovery learning: Learners use their existing knowledge to explore and ask questions about the content of the curriculum. (For example, instead of handing out a complete set of notes, the teacher holds a seminar at the start of the gynaecology rotation in which students discuss the areas of family planning about which they need to know more and plan how they will find out that information for themselves.) A common example of discovery learning is problem-based learning, which undergraduate medical curricula now use extensively (Wood, 2003). Learners receive a written patient, health-delivery, or research problem as a stimulus and tackle problems in small groups under the supervision of a tutor. (See chapter 4 to learn how you can use problembased learning in your office.) Reception learning saves the teacher time and is an efficient method for presenting large amounts of material (Ausubel, 1968). Discovery learning takes more time for both learner and teacher, but makes education more interesting and challenging. In addition, learners are more likely to remember, able to recall, and likely to apply knowledge they obtain by discovery. It also encourages independent study and the acquisition of learning skills, especially Internet-based knowledge management, that will be useful for continuing education when in practice (Evans, 2001). Teaching While there are differing definitions of teaching, we find the most useful one is teaching as the facilitation of learning. The teacher acts as a guide or helper, not as a giver or spoon-feeder of knowledge (Kaufman, 2010). Learning is a shared process between a teacher and learner and is

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not solely the teacher’s responsibility. The teacher’s role is to challenge learners by alerting them to the problem at hand. This is also known as “creating the need to know.” Learners who recognize the need to know expend more effort to learn; are superior at reformulating new information and applying it to their own setting; better combine new material with existing knowledge to ensure long-term learning; and devote more time to practice and review (Ausubel, 1968). Learners are not always aware of the objectives in the curriculum, and so the teacher should try to make each topic relevant. For example, practice management may be one of the topics of the ambulatory block. A learner may not realize the importance of practice management or even fathom the extent of the topic’s details. A teacher might create the need to know by asking the learner to spend an hour or two at the reception desk talking to patients, answering the telephone, and booking appointments. From this experience, the learner sees the complexities of an office and realizes she has much to learn. She might then be motivated to indicate what she specifically wants to know more about. The result is a captivated learner. It is also part of the teacher’s job to recognize and use teachable moments. The time immediately following an interaction between a learner and patient is a valuable one (Whitman & Magill, 2000). The impact of a teaching point related to a clinical encounter that is fresh in a learner’s mind can make a lasting impression. There are particular special moments, such as following an emotionally charged visit or a challenging diagnostic problem, when long-term learning can be further enhanced. For example, a resident reports that he is seeing Mrs. Jones, who arrived at the office without an appointment because of chest pain. The resident notes from the chart that doctors have seen her several times for chest pain, and each time diagnosed it as chest wall pain. After a brief history, he concludes that the pain is not serious and wants to tell Mrs. Jones to return if it recurs. When you see her, however, you discover that the pain has awakened her almost every night this week. You do an electrocardiogram and see S-T segment elevations in the lateral leads. You send Mrs. Jones to the emergency department at your local hospital. Afterward, you use the moment to talk to the resident about the importance of a thorough history when seeing patients with chest pain. Principles of Adult Learning In grade school, students learn according to the principles of pedagogy.

Learning and Teaching in Ambulatory Care 13

Pedagogy sees the student as dependent, teacher-centred, having little previous knowledge, and ready to learn what she is told. Students learn in this manner throughout most of their schooling experience, including the first years of medical school. However, physicians, like all adults, learn differently (Newman & Peile, 2002). For example, think of a colleague who wants to learn furniture refinishing. He buys a dining room table in poor condition. Instead of having it refinished by a contractor, he decides to save money and do it himself. He reads books and magazines and consults with experts. He works on the table in his spare time, and completes the job himself by trial and error as well as with input from his partner. The table now sits in his dining room. This colleague’s experience highlights several principles of adult learning. 1 He was ready to learn when he perceived a need (he bought the table, it was in bad shape, and it was too expensive to send out to a contractor). 2 He selected his own learning experiences (books and advice rather than a course at a local school). 3 He faced a problem-oriented task (the table’s terrible shape). 4 He applied his new skills and knowledge immediately (he went from books to working on the table). 5 He evaluated his progress (through trial and error, his partner’s comments, and self-evaluation) These are additional principles of adult learning. 1 The learner thrives in a non-threatening environment. 2 The learner strives to use her own reservoir of knowledge and skills to help others. 3 There is respect for the autonomy of the learner. 4 The focus is on the learner, rather than on the teacher or content. The principles of adult learning are known as andragogy (Barer-Stein & Kompf, 2001). Medical learners primarily use pedagogic skills from their previous fifteen years of schooling. Having grown into adulthood, however, they have andragogic expectations. These adults are pedandragogic learners, who possess the expectations of an adult but the learning skills of a child. The ability of learners to define their own objectives, needs, or goals

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– terms that are often used interchangeably – is essential to adult learning. Each term can be defined as a statement of what the learner should be able to do at the end of the course of training (Stagnaro-Green, 2004). Well-defined objectives are helpful to both teacher and learner, so that both are clear on what they are attempting in the educational situation. Learning needs should be very specific, defined in terms of the behaviour of the learner and not the teacher, based on the needs of the learner, and achievable in the time allotted (Lake & Ryan, 2004). For example, the objectives for a third-year student in an ophthalmology office for a one-week rotation might include being able to: • List the differential diagnosis of red eye • Use the ophthalmoscope to identify a cataract • Know the drugs to use to dilate the pupil Formulating objectives is a joint activity for teacher and learner. This learning plan is best as a list based on a combination of the objectives of the course, your previous experience with learners at a similar level of training, and the learner’s own identified needs (Hutchinson, 2003). Medical learners find it difficult to define their own objectives because teachers have always defined them in the past. They also have difficulty defining learning strategies for themselves because the strategies have always been set out in advance. They assume they have little knowledge on their own because teachers have always treated them that way. Learners find contributing and basing their education on knowledge they probably have distressing. They fear receiving progress reports because, in their experience, evaluation has always been a negative experience, rather than a step that assists learning. Finally, they cannot accept teachers as colleagues because they have always seen teachers as authoritarian (Rogers, 1983). Keep this conflict in mind when you plan your teaching. When you try to apply these principles, your learners may not be able to operate at first because they do not yet know how to act as adults. You may need to take the time to explain their role while they unlearn the habits of their previous schooling (Knowles, 1975). This will be time well spent, for they will learn skills they will need as graduate doctors after training. Then, they will be on their own to define gaps in knowledge, keep up with new knowledge, and determine for themselves how they will learn the material (Laidley, Braddock, & Fihn, 2000). There are several ways to apply the principles of adult learning to teaching in your ambulatory setting. For example, when learners first

Learning and Teaching in Ambulatory Care 15

arrive in your office, discuss the areas in which they feel the need for more experience. Help them identify these areas by reviewing their training to date. Explore topics in which they have some special interest. Inquire about knowledge gaps they may have recognized. Present a list of common conditions physicians in your office see, so learners can select cases with which they need more experience (identify a perceived need). Together, you can plan their work schedules, which patients they should see, whom else they might consult to learn about certain topics, and suggested readings (help them select their learning strategies). They can begin seeing patients that day to have clinical experience with some of the identified learning issues (problem solving, immediate application). Then agree to review their performance after a specific period (progress evaluation). Content and Process Learning The following two theories provide complementary approaches to learning. Each chooses the most effective and efficient strategy for the circumstance: Content learning: The teacher presents learners with established facts and knowledge in a prescribed format with predetermined objectives. Elementary schools use this method frequently. The format consists of books, classroom instruction, and tests based on predetermined material. This is the least expensive method of instruction for large groups, when resources or time is limited, or when a large body of material needs to be covered. It is appropriate for learning factual information such as details of symptoms and signs of illness, investigations and treatments, laboratory interpretation, and therapeutics (Biggs, 1973). Process learning: According to this theory, learners gain from what they do (Dewey, 1938). The knowledge and information for learning comes from what happens in the environment in which the learner works, which, along with what teachers and learners do in that environment, can make a lasting impression (McLuhan, 1967; Postman & Weingartner, 1969). The environment, rather than a list of facts, provides the knowledge. For example, you may never have a seminar on the patient record for the learners who rotate through your paediatric office. But in your electronic medical record, there is a profile page that summarizes every patient’s medical problems, immunizations, developmental mile-

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stones, and medications. At each patient encounter, the learner updates – or, for new patients, creates –this profile. As well, the learner sees that your coworkers also complete the profile at each visit and constantly refer to it when first seeing a patient or when seeing a patient on behalf of a colleague away on holiday. Through this experience, the learner recognizes the importance of the use of patient profiles better than they could in a seminar. Thus, process learning is an appropriate method for learning attitudes and skills that cannot be easily transmitted as factual information. Skilled teachers are knowledgeable about both content and process learning and choose one depending on the topic, resources, and learner (Ozolins, Hall, & Peterson, 2008). Reflection Reflection is a helpful theme for teachers of medical learners. When learners rush from one activity to another, they risk mindlessly repeating bad habits and failing to learn from their experiences. Reflection is an ongoing process of evaluating, interpreting, and deliberating that helps build good habits and makes experiences more valuable (Aronson, 2011). Reflective observation involves viewing a new experience through the interpretive lens of prior experience, current readings, and the teacher’s assistance. Seminal thinking about reflection in professionals’ education comes from Schon (1987). In professions that combine academic learning with practical work, certain individuals are identifiably more excellent than the majority. Through a series of empirical studies, Schon finds that these outstanding practitioners consistently reflect on their work in order to continually learn from it. This model of reflection is an ideal for doctors and so is appropriate in medical education. Schon describes the practitioner as working with knowledge in action – the bank of information and skills learned over the years from school, books, journals, and experience. This knowledge is deeply embedded and often used automatically, much like the ability to ride a bike. In medicine, skilled physicians often recognize a particular disease the moment the affected individual walks in the door or describes the first few symptoms. Usually, this knowledge in action gets the doctor through the day. But sometimes, a familiar routine produces an unexpected result or is not enough to correct an error. As Schon states, this “surprise” happens when something fails to meet expectations. In an attempt to preserve constancy of the usual patterns of knowledge, the

Learning and Teaching in Ambulatory Care 17 Figure 1.1. The reflection process

doctor may respond to surprise by brushing it aside and selectively ignoring the signals that produce it. Better yet, the doctor will stop and think (reflection in action), giving rise to an on-the-spot experiment. She will think up and try out new actions, questions, or diagnoses, and observe the result. The experiment, if successful on a few occasions (reflection on action) will then become part of her new knowledge base (Boud, Cressey, & Docherty, 2006.) Schon encourages the teacher to coach learners at each step of the reflection process (see figure 1.1). Knowledge in action: This is the learner’s knowledge base, which you will assess on an ongoing basis as you interact around cases. Where you recognize deficiencies, you should encourage self-directed reading; offer articles, books, or websites available in your office; or assign a learning project. (For more specific ideas, see chapters 2 and 4.) Surprise: Recognize moments in clinical practice when the learner notes variation from the usual. Engage in a dialogue about these clinical problems and how they differ from the norm. Within your specialty, help learners respect the concept of prevalence. Some diagnoses are most common, but awareness of a larger breadth of diagnostic possibilities will prevent premature closure – the tendency to stop asking questions, or to ask questions to make a diagnosis fit. You can create surprise in your teaching by asking, “What if?” For example, “What if this thirty-two year old female with shortness of breath was on oral contraceptives?”

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Reflection in action/experimentation: On recognizing a surprise, encourage the learner to rethink her knowledge base in ways that go beyond the usual rules, facts, and theories. Encourage risk-taking, thinking aloud, and discussing alternative perspectives. Remind the learner of her previous experimentation in similar circumstances. Send her back in with the patient to test a new strategy. Invite learners to keep journals of their insights or questions and discuss them at a later time. Finally, model the reflective process by relating examples from your own patients that day. I saw a young female athlete today with a painful ankle sprain. She was very distraught. I assumed she was in so much pain that I offered additional analgesia. She declined and just cried. I realized that I had missed the point, and I asked her what was upsetting her so much. She told me her injury would cause her to miss the championship tournament, a goal she had been working toward for months.

Domains of Learning A domain of learning is a grouping of educational objectives into a distinctly limited area of knowledge. Grouping objectives means learners and teachers can refer to them with greater precision. Such groupings may help each avoid confusion about what the other has in mind for learning. Through reference to domains of learning, teachers and learners should be able to define better nebulous objectives and discover a wider range of needs for the ambulatory experience. For example, in listing the goals for an elective, the teacher and learners may find that all the goals fall into a certain domain. By thinking about other domains, you could include a broader range of goals. Topics covered in an ambulatory setting fit into one of three domains of learning. 1 Cognitive domain: Objectives that deal with the recall or recognition of factual knowledge (Bloom, Englehart, Furst, Hill, & Krathwohl, 1956), such as: • Differential diagnosis of jaundice • Medical treatment of endometriosis • Pathology of tumours of the kidney 2 Affective domain: Objectives that describe verbal skills, language, attitudes, and values (Krathwohl, Bloom, & Masia, 1964), such as:

Learning and Teaching in Ambulatory Care 19

• Interviewing skills • Interaction with dying patients • Physician’s stress management 3 Psychomotor domain: Objectives that list technical and procedural skills, such as: • Ophthalmoscopy • Skin closure • Nasal packing When teaching a particular topic, it is helpful to know into which domain it fits. A certain teaching skill may be more suited to one domain of learning than another (see chapter 3). Competency-Based Education There are two model approaches to curriculum in medical education: one is based on time and the other is based on the mastery of specific knowledge, skills, and attitudes known as outcomes (Holmboe et al., 2011). Medical education curricula are primarily time-based, with graduation or certification focused on completing the assigned weeks, months, and years (Hodges, 2010). Undergraduate students and postgraduate trainees spend designated time training in various specialties and settings with the expectation that they will, by serendipity or opportunity, acquire the necessary knowledge, skills, professional values, and motivation for their ultimate field of practice. Competency-based education focuses on observable and measurable outcomes that are often mandated by government and consistent with societal expectations or more-defined consumer rights and patient safety (Frank et al., 2010). The emphasis is on the product – on what sort of doctor will be produced – rather than on blocks of time for each topic or specialty. The educational outcomes are clearly and unambiguously specified. Then, the curriculum is developed to guide the learner to these outcomes or competencies (Harden, 2007). Several national organizations have listed competencies to serve as key general attributes or roles of the doctor to be used for curriculum development. The Royal College of Physicians and Surgeons of Canada have created the seven Canadian Medical Education Directions for Specialists, or CanMEDS roles (CanMEDS, 2000; Frank & Danoff, 2007). These roles have been adopted by the Netherlands and other nations

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Table 1.1. General competencies as established by Canadian and American medical education organizations CanMEDS Roles

ACGME Competencies

Medical expert Communicator Collaborator Manager Health advocate Scholar Professional

Patient care Medical knowledge Communication skills Professionalism Practice-based learning Systems-based learning

for their own use (ten Cate & Scheele, 2007). Similarly, the Accreditation Council for Graduate Medical Education in the United States and the General Medical Council in the United Kingdom have similar lists of general competencies (ACGME, 2001; GMC, 2002) (see Table 1.1). As a teacher in ambulatory settings, the principles that underlie competency-based education are an excellent guide. Learners work with you more closely and intensely than they would with supervisors in inpatient hospital experiences. Consistently, you are able to use questions probing their knowledge and clinical reasoning to guide their learning in knowledge-based roles or outcomes. Learners observe you and your colleagues and then apply the skills required as the patient’s advocate, discovering how to manage health care resources or developing scholarly skills for critical appraisal and continuing medical education. You can focus the discussion according to how the learner is progressing in each of the individual outcomes or competencies as specified in your specialty curriculum. For the teacher, the ultimate challenge of competency-based education is to broaden the scope of learning around each patient encounter beyond the clinical details and treatment decisions. For example, a frail seventy-year-old male with congestive heart failure secondary to ischaemic heart disease returns to the outpatient clinic for his first visit after his recent hospitalization. He lives alone and a neighbour brings him to the clinic, where he has been a patient for five years. The student presents the patient’s progress since discharge from the hospital and the current clinical exam. In discussion, you can review the case from several angles: • As the medical expert, you determine the adjustment of the dosage of diuretic medication post hospital discharge;

Learning and Teaching in Ambulatory Care 21

• As the health systems manager, you plan with the student to ask local public health care services to provide assistance so the patient can remain in his home; • As a collaborator with other heath professionals, you ask the student to request a referral to an occupational therapist to ensure the home environment is safe. Interprofessional Education Doctors in ambulatory settings cooperate with professionals from many disciplines in providing preventive, curative, or rehabilitative health care services for patients. The health care providers may work in the same location or collaborate across various settings. Interprofessional describes behaviour that involves working with colleagues from different practice backgrounds and skills to deliver care or services. The providers optimize patient care by drawing on the experience and expertise of all involved. High quality, efficient, and cost-effective care results from effective interprofessional partnerships. However, making those partnerships effective requires learning about the roles, responsibilities, and capabilities of other professionals (Mohanna, Cottrell, Wall, & Chambers, 2011). Interprofessional education occurs when two or more professions learn with, from, and about each other to improve collaboration and the quality of care (CAIPE, 2006). Medical schools may set up formal programs or seminars that involve learners from multiple professions, with significant interaction between participants so that they can learn about and from one another. In ambulatory settings, interprofessional work is embedded in the daily routines of patient care (Hammick, Olckers, & Campion-Smith, 2009). In these situations, learners can gain information about the specific knowledge, skills, and routines of other professions (Price et al., 2009). The teacher can enhance interprofessional education with specific actions. For example: Your student sees a forty-five-year-old Type 2 diabetic patient returning for routine follow-up. In your clinic, you collaborate with a diabetes nurse educator and a certified diabetes dietician, and the patient sees each of you at each visit. The three of you communicate about your interaction and suggestions for care via the electronic medical record. During case discussion with the student (see chapter 4), you ask her to:

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REFERENCES Accreditation Council for Graduate Medical Education. (2001). Outcome project. (http://www.acgme.org). Aronson, L. (2011). Twelve tips for teaching reflection at all levels of medical education. Medical Teacher, 33(3), 200–205. http://dx.doi.org/10.3109/01421 59X.2010.507714 Medline:20874014 Ausubel, D. (1968). Educational psychology - a cognitive view. New York: Holt, Rhinehart. Barer-Stein, T., & Kompf, M. (2001). The craft of teaching adults. Toronto: Irwin Publishing. Biggs, J.B. (1973). Content to process. Australian Journal of Education, 3, 225–38. Bloom, B.S., Englehart, M.D., Furst, E.J., Hill, L.M., & Krathwohl, D.R. (1956). A taxonomy of educational objectives: Handbook 1. The cognitive domain. New York: Longman, Green. Boud, D., Cressey, P., & Docherty, P. (2006). Productive reflection at work: Learning for changing organizations. New York: Routledge. CAIPE (2006). Interprofessional education: A definition. London: Centre for the advancement of interprofessional education. CanMEDS 2000. Extract from the CanMEDS 2000 Project societal needs working group report. Medical Teacher, 22 (6) 549–54. http://dx.doi. org/10.1080/01421590050175505 Medline:21275687 CIPE. (2010). IPE component in a clinical placement. Centre for interprofessional education. University of Toronto. Dewey, J. (1938). Experience and education. New York: Collier Books. Evans, M. (2001). Creating knowledge management skills in primary care

Learning and Teaching in Ambulatory Care 23 residents: A description of a new pathway to evidence-based practice. ACP Journal Club, 135(2), A-11–12. Medline:11571898 Frank, J.R., & Danoff, D. (2007, Sep). The CanMEDS initiative: Implementing an outcomes-based framework of physician competencies. Medical Teacher, 29(7), 642–47. http://dx.doi.org/10.1080/01421590701746983 Medline:18236250 Frank, J.R., Snell, L.S., Cate, O.T., Holmboe, E.S., Carraccio, C., Swing, S.R., et al. (2010). Competency-based medical education: Theory to practice. Medical Teacher, 32(8), 638–45. http://dx.doi.org/10.3109/0142159X.2010.501190 Medline:20662574 General Medical Council. (2002). Tomorrow’s doctors. London: General Medical Council. Hammick, M., Olckers, L., & Campion-Smith, C. (2009, Jan). Learning in interprofessional teams: AMEE Guide no 38. Medical Teacher, 31(1), 1–12. http:// dx.doi.org/10.1080/01421590802585561 Medline:19253148 Harden, R.M. (2007, Sep). Outcome-based education: The ostrich, the peacock and the beaver. Medical Teacher, 29(7), 666–71. http://dx.doi. org/10.1080/01421590701729948 Medline:18236254 Hodges, B.D. (2010, Sep). A tea-steeping or i-Doc model for medical education? Academic Medicine, 85(9 Suppl), S34–44. http://dx.doi.org/10.1097/ ACM.0b013e3181f12f32 Medline:20736582 Holmboe, E.S., Ward, D.S., Reznick, R.K., Katsufrakis, P.J., Leslie, K.M., Patel, V.L. et al. (2011, Apr). Faculty development in assessment: The missing link in competency-based medical education. Academic Medicine, 86(4), 460–67. http://dx.doi.org/10.1097/ACM.0b013e31820cb2a7 Medline:21346509 Hutchinson, L. (2003, Apr). ABC of learning and teaching in medicine: Educational environment. British Medical Journal, 326(7393), 810–12. http:// dx.doi.org/10.1136/bmj.326.7393.810 Medline:12689981 Kaufman, D. (2010). Applying educational theory in practice. In P. Cantillon & D.Wood (Eds.), ABC of learning and teaching in medicine (2nd ed.). London: Blackwell Publishing. Knowles, M. (1975). Self-directed learning: A guide for learners and teachers. Chicago: Follett Publishing. Krathwohl, D.R., Bloom, B.S., & Masia, B. (1964). A taxonomy of educational objectives: Handbook 11. The affective domain. New York: David Mackay. Lake, F.R., & Ryan, G. (2004, May 17). Teaching on the run tips 2: Educational guides for teaching in a clinical setting. Medical Journal of Australia, 180(10), 527–528. Medline:15139832 Laidley, T.L., Braddock, C.H., III, & Fihn, S.D. (2000, Jan). Did I answer your question? Attending physicians’ recognition of residents’ perceived learning

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needs in ambulatory settings. Journal of General Internal Medicine, 15(1), 46–50. http://dx.doi.org/10.1046/j.1525-1497.2000.11318.x Medline:10632833 McLuhan, M. (1967). The medium is the message. New York: Bantam. Mohanna, K., Cottrell, E., Wall, D., & Chambers, R. (2011). Teaching made easy: A manual for health professionals (3rd ed.). Abingdon: Radcliffe Publishing. Newman, P., & Peile, E. (2002, Jul). Valuing learners’ experience and supporting further growth: Educational models to help experienced adult learners in medicine. British Medical Journal, 325(7357), 200–202. http://dx.doi. org/10.1136/bmj.325.7357.200 Medline:12142310 Ozolins, I., Hall, H., & Peterson, R. (2008). The student voice: Recognising the hidden and informal curriculum in medicine. Medical Teacher, 30(6), 606–11. http://dx.doi.org/10.1080/01421590801949933 Medline:18608968 Price, D., Howard, M., Hilts, L., Dolovich, L., McCarthy, L., Walsh, A.E., et al. (2009, Sep). Interprofessional education in academic family medicine teaching units: A functional program and culture. Canadian Family Physician Médecin de Famille Canadien, 55(9), 901–1, e1–e5. Medline:19752260 Postman, N., & Weingartner, C. (1969). Teaching as a subversive activity. New York: Penguin Education. Rogers, C. (1983). Freedom to learn for the 80s. New York: Merrill. Schon, D. (1987). Educating the reflective practitioner. San Francisco: JosseyBass. Stagnaro-Green, A. (2004, Feb). Applying adult learning principles to medical education in the United States. Medical Teacher, 26(1), 79–85. http://dx.doi. org/10.1080/01421590310001642957 Medline:14744700 ten Cate, O., & Scheele, F. (2007, Jun). Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Academic Medicine, 82(6), 542–47. http://dx.doi.org/10.1097/ACM.0b013e31805559c7 Medline:17525536 Whitman, N., & Magill, M. (2000). The teaching moment. In Paulman, P., Susman, J., & Abboud, C. (Eds.), Precepting medical students in the office. Baltimore: The Johns Hopkins University Press. Wood, D.F. (2003, Feb 8). Problem based learning. British Medical Journal, 326(7384), 328–30. http://dx.doi.org/10.1136/bmj.326.7384.328 Medline: 12574050

Chapter Two

Teaching Skills in Ambulatory Care

After reading about theories of learning, Dr. Z.Z. Smith decided he needed to know more about teaching skills. He realized that he tended to teach in a certain way when he had learners in the clinic. He also recognized that, somehow, he had learned his style of teaching; he knew it was not a birthright. After thinking about it, he concluded that he had borrowed the style of his favourite teacher in medical school. It was the style he knew best and was most comfortable with, and it seemed useful for the amount of time available in the office. His colleagues, however, had diverse teaching skills that differed greatly from his. It seemed possible to learn different styles for different situations. He challenged himself to learn more about teaching skills in order to refine the style he used most and adapt new methods to appropriate situations. Here is what he learned from several teaching skills workshops and textbooks. Teaching Steps At every learning encounter, the teacher makes two important decisions even before getting to the teaching point. Often, teachers make these decisions without thinking and instinctually. The first is to choose a learner or teacher premise. The second is to choose a specific teaching skill to use in that circumstance. By understanding these first two steps, you can analyse your usual teaching methods and look at some of the other options available. You can then optimize the approach for a learner in a given situation. Your favourite approach is not necessarily appropriate in every case.

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Step 1 At a teaching encounter, you must choose one of two premises. Choice 1: Using the learner premise, you listen to case presentations from learners or observe each directly with a patient. Based on what you hear or see, you organize and analyse the learners’ knowledge and skills. You then use the outcome of this analysis in combination with your knowledge of the learners’ objectives as a basis for choosing a topic for the teaching encounter or for providing feedback on their performance. Examples: The following are examples of the learner premise. 1 A student in your office at a gastrointestinal clinic presents the patient’s history. You realize that the student does not know the important risk factors for gallbladder disease, and so you discuss them with the entire group after seeing all the patients. 2 You observe that a resident talking to a family about complications of proposed surgery is speaking quickly, using complex medical terms, and not allowing any time for questions. Later, you talk to the resident about your observations and discuss strategies for talking to patients. 3 You assist a resident inserting an intrauterine device. You observe that she fails to check the uterine position before beginning and has trouble with insertion of the sound. You teach her these two specific points by demonstrating them. Choice 2: Using the teacher premise, you listen to a case presentation from a learner. Without considering the knowledge or performance of that specific learner, you choose the topic on which to teach based on the topic of the case, practice experience, and previous encounters with learners at a similar level of training. Examples: The following are examples of the teacher premise. 1 A fourth-year student presents a history of a patient with a peptic ulcer. You know that most students in fourth year do not know much about ulcer treatment, so you proceed to review it. 2 A resident reports to you about several patients she has seen at the preoperative clinic. You ask her to sit in with you during the next patient meeting to observe your method of telling patients about their proposed surgery. 3 A learner tells you there is a patient with a seborrheic keratosis that

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she would like to remove. You tell her to watch you perform the procedure to see how you do it. If you choose to operate from a learner premise, you have begun to apply the principles of adult learning (i.e., teaching about a learner’s particular needs and letting them know how they are progressing). If you choose to operate from a teacher premise, you are using reception learning as your model (i.e., choosing a topic relevant to the clinical situation, often relying on previous experience with learners in similar situations). A skilled teacher deliberately chooses one of premise to make the best of the learning encounter. Use a learner premise with those who are more experienced, who already possess considerable knowledge and need to build on what they have. The learner premise suits confident individuals who want to hear about their performance. Use the teacher premise with novice or more anxious learners, or when time is short and expediency will help get you back on schedule. Step 2 At this point, teachers choose one of three fundamental teaching modes. 1 Telling: Explicit statements to make a teaching point. It is the act of giving information or directing actions. 2 Asking: Some form of questioning to make a teaching point. 3 Showing: Illustrating or explaining the essentials of the topic to be learned in an orderly and detailed way. In many situations, you will switch from one mode to another. For example, you may begin by asking but then shift to telling because of time restraints, lack of knowledge on part of the learner, or questions. In addition, one mode may be more effective in response to some situations than others, particularly if you have chosen one premise over the other. Table 2.1 lists some details about specific teaching skills within each mode. Telling Directive Teaching For learner premise situations, directive teaching is a most helpful skill to master. Three ways of being directive include:

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Table 2.1. Teaching skills Telling

Asking

Showing

Directive Comparison Approval/reproach Confrontation Response

Socratic Inquiry Readiness

Demonstration Role modelling

1 Description: You can make a teaching point by telling learners about their cognitive, affective, or motor performance in some detail. This description lets learners know what they did and leads to a discussion of how to correct the situation. For example, you might say, “When discussing that plan of investigation, you suggested two tests: an abdominal ultrasound and a CT scan. Any comments on your overall plan?” as an alternative to, “You are really over-investigating that patient.” When using description, try to keep your statements: • Value free (not, “That patient hated you,” but, “I noticed that patient was reluctant to answer your questions”); • Specific (not, “You did not do a very good job on that cyst excision,” but, “I saw these particular problematic manoeuvres with that surgery”); • Well timed (not, “You remember that patient last week,” but, “Let me comment on your treatment plan for this last patient”); and • Brief and manageable (not, “Here are the ten problems with that history,” but, “Let me tell you about two points concerning that history of knee pain”) (van de Ridder, Stokking, McGaghie, & ten Cate, 2008). By using description, you present a non-judgmental set of facts from which you can begin your teaching encounter and help learners discover the material (i.e., discovery learning). This style is particularly useful for learners who react defensively to criticism when you present a predetermined conclusion formulated from your observations. It is also useful with learners who lack confidence and might, after hearing your conclusions, become more anxious and have difficulty integrating the information. To encourage learners to learn self-assessment, start by asking them what went well in each patient encounter. In this approach,

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known as Pendleton’s rules, the learner lists what she did well and the teacher describes the positive attributes of the encounter. The teacher then asks the learner what she could improve on and provides constructive comments (Walsh, 2005; Pendleton, Schofield, Havelock, & Tate, 1984). It is just as important to provide learners with descriptions of behaviour, management plans, or procedures that are performed well or correctly (Seehusen & Miser, 2006). Without a mirror, learners create their own images of their progress from incomplete or inaccurate clues. Some successes are pure luck, others are more deliberate, but the learner does not actually know if she has done well. To be firmly established, competencies must be repeatedly rewarded in some fashion (O’Donohue & Ferguson, 2001). Reinforce the correct behaviour so learners remember it. It is helpful to say “well done,” but even more helpful to say “well done” and discuss why. 2 Metaphor: Some teachers use metaphors to colour their interactions with their learners. For example, “You steamrolled that patient at the end of the interview.” Use a metaphor with learners who are having trouble grasping your point or who seem to learn best from visual images. 3 Labelling: Teachers can label an undesirable behaviour, rather than providing a value-free description of it (i.e., an example of reception learning). For instance, you could tell a learner that his recent actions were irresponsible instead of telling him about the behaviours that earned the “irresponsible” label (e.g., “Last night, you could not be reached on two occasions, you missed scrubbing in on the operating room case, and you did not do that blood sugar test which is unacceptable,” rather than saying, “It is important to be easy to reach, on time, and diligent about conducting tests.”). No learner wants to be seen as irresponsible, and so may pay more careful attention to your statement after such a comment. The risk with this method is that, once labelled “irresponsible,” the learner will turn off – he will focus on the label rather than learn from the circumstance. If this happens, ask the learner about his reaction and then discuss the problematic behaviours. The following exchange illustrates this point: teacher: “You have changed topics completely. Are you upset by my calling you irresponsible?” learner: “I certainly am. It is very unfair.”

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teacher: “Let’s talk about what happened last night.”

Use this teaching method when time is short or to emphasize a point. It works best with mature learners. Avoid this strategy, however, with learners who lack self-confidence. Comparison Teachers can make a learner aware of a shortcoming by comparing the learner’s performance against an external authority such as a journal or textbook. The following exchange illustrates this point: learner: “It was impossible to get a history from the patient. He was all over the place and would not give me specific answers.” teacher: “I also find these kinds of patients troubling. But a recent article in the Journal of (Your Specialty) provided some particularly good tips. Let’s talk about them.”

This is an effective and non-threatening way to teach most learners. According to the principles of adult learning, individuals thrive and learn more effectively in a encouraging, collegial environment. In medical settings the physician teacher is automatically an authority figure to learners, and this hierarchy can create anxiety. Establish a collegial atmosphere by transferring the authority from yourself to a book or journal. In addition, statements like, “I also find these kinds of patients troubling,” put learners at ease by helping them realize you share their concerns. The result is a collaborative adult learning environment. Comparison is especially useful for learners who are new to your clinic or who seem anxious in one-on-one situations (Sargeant & Mann, 2010). Approval or Reproach You may choose to make strong statements of approval or reproach about a learner’s behaviour. With such a statement, you emphasize the behaviour you wish to highlight in order to immediately draw attention to the issue. Use this method when time is short and you want to make a point in a brief encounter. For example, “You were entirely undependable during that labour and delivery last night,” or, “You demonstrated a tremendous sense of responsibility when you were readily available to manage that high-risk labour and delivery last night.”

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All learners appreciate the praise inherent in an approval statement. Use statements of reproach sparingly, or they will lose meaning. With new or self-conscious learners, admonishment may evoke feelings of insecurity or defensiveness and so have little effect. Confrontation Confrontation is often frowned on in teaching because learners might interpret it as a put down and lose its impact. But in some instances, when you have tried other techniques and the learner does not seem to understand, a direct forceful statement, followed by discussion, may bring the issue to her attention. Here is an example. learner: “We cannot keep talking about this. I have other people waiting to see me.” teacher: “You keep looking for ways to avoid discussing this issue. It is making me angry,” or, “It seems to me that you want to avoid this situation. What do you think?”

The danger in confrontation is that sometimes learners perceive the encounter as severely critical and they may not be willing to listen. Response In medical teaching, response is a common strategy. When using a learner premise, the teacher recognizes a teaching point and shares it in response to the circumstance. Alternatively, the learner asks a question and the teacher provides a straight answer. In responding, it is important to be brief and concise, even though it may be tempting to pass on as much information and detail as possible at one time. In the ambulatory setting, each case dredges up a deluge of related facts and tips. Choose to share only points that are directly relevant to the learner’s identified objectives. Remember the teachable moment, and base your response on what is immediately related to the patient encounter. Try to exclude items that may be attractive to you because of your personal interests or that are only remotely connected to the case at hand. Some teachers find that, though they have covered something previously, the learner does not remember anything the next time the topic comes up. Unfortunately, learners cannot process information as fast

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as teachers can speak. Research shows that learners have difficulty remembering large bits of information and can only absorb and retain certain amounts in one sitting. Remember to limit the information you provide – learners will have other exposure to a given point and you do not have to cover everything. At the end of your response, to help ensure the learner clearly understood, and will retain, your points, you can ask the following: “Did I confuse you at all?” “Do you have any questions?” “Did I cover too much? “Is it all clear to you?” “Can I repeat anything for you?” Even if the learner requires no further response, these questions provide a momentary break before the next teaching point or before returning to the patient. When responding, you may not be sure if the learner has grasped the material or become lost along the way. Three skills will help in these situations. Checking out: This approach helps you determine the emotional reasons the learner may have missed your point. You verbalize your impression of the learner’s current state of mind and await a response. learner: “That sounds like a good plan for treating this patient’s symptoms, but I think she needs a barium enema before we use that treatment.” teacher: “From this conversation, you seem to be quite anxious about this patient, and I think you may have missed my point about the need for an initial trial of therapy. Any particular reason for this anxiety?” learner: “Yes. The last patient I had like this one, I missed making a diagnosis of colon cancer.”

Paraphrasing: In discussions with learners, you may, periodically, cover a few points in succession and not be quite sure if they clearly understand everything. It is helpful to stop and ask learners to paraphrase your words to see if they understand the teaching point. For example, “I have covered a lot of material in the last few minutes. It might be helpful if you could restate the discussion in your own words, so that we could clear up any confusion.”

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Summarizing: After discussing a few points, it is helpful to summarize as you conclude or before you go on to another topic. This technique helps learners extract the essentials from what may have been a lengthy conversation. To summarize, list the teaching points in a clear, concise manner, covering the essential parts of the exchange and relating them to the learners’ objectives. For example, “The three items we covered about proteinuria are: get a fresh morning specimen, do a microscopic assessment, and then order the twentyfour-hour urine test for total protein.” There is an added benefit to this technique: if the summary is not a faithful reflection of the conversation from the learners’ perspective, they will raise this issue and alert you to any misunderstanding. Asking Socratic Questioning When choosing the asking mode, you may wish to use an indirect manner of questioning. This is a particularly good example of discovery learning, in which teachers guide learners to the information. Mature adult learners thrive on this approach. Known as Socratic questioning, the teacher asks learners a series of questions to gradually increase their awareness of the teaching point. The questions are usually sequenced and progress from general to specific issues. However, this method is more than just asking questions – it is asking questions to encourage independent thinking. The Socratic method helps learners see the logical connection from point to point, explore their existing knowledge, and apply it to novel situations (Oh, 2005). Examples: The following are examples of this method. 1 Learner premise: A student has just seen a case, and her presentation suggests she is unsure about her differential diagnosis of abdominal pain in a twenty-four-year-old woman. You think that you should discuss this topic with her. Some possible questions to ask, in sequence, include the following: “What do you think is this patient’s major problem?” “Where would you start in dealing with this abdominal pain?” “What do you already know about abdominal pain?”

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“What else might help you think of the causes of abdominal pain?” “How might you differentiate the causes of abdominal pain?” “What features of the history in this case help you to pinpoint the diagnosis?” 2 Teacher premise: A resident works in your office every Friday morning. The next patient has been referred because of chronic headaches. Some possible questions to ask include the following: “The next case is one referred for headaches. What are the causes of chronic headaches?” “How might you better group the causes?” “What will help you pinpoint the specific cause?” “How do questions about how the problem has progressed over time help you distinguish between different kinds of headaches?” Avoid a guessing game with the learner. You have a teaching point in mind as you phrase the questions, and so you may inadvertently lead the learner to a very specific point. Learners will pick up on this and try to guess the answers they think you want to hear, rather than the answers they think are correct. Use the Socratic method when there is enough time to allow for a series of questions and responses, such as at lunch, at the end of the day during a chart review, or during a cancelled appointment. Avoid the technique with anxious learners who have a poor knowledge base, since each succeeding question will just raise more panic. Instead, use it with learners who have considerable information on hand and just need guidance to organize what they already know. You should become comfortable with a pause or silence before a learner answers a question. There are several benefits to having a longer amount of time between the question and the response: the learner gives longer responses, volunteers more responses, has more confident answers, and engages in more speculative thinking (Houlden, Collier, & Frid, 1999). Inquiry This method is the one doctors in medical teaching use most. Although the term has a somewhat negative connotation, inquiry means the use

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of a direct series of questions. Each subsequent question will depend on the response to the previous one. You can also find out about the learner’s thinking processes and decision making by using inquiry. Use it when time is short, but asking is better than telling or showing (Benzie, 1998). Inquiry involves finding out what learners know, and so you can use it as part of their evaluation. Based on learners’ objectives, you can also let them know how they are progressing. Remember that every time you ask a series of questions, you automatically evaluate learners’ knowledge by the accuracy and depth of their responses. Let them know what you think. For example, you might say, “That’s excellent. You have a clear and detailed understanding of the treatment of glaucoma.” Or, “As part of your objectives this month, you were going to learn about the laboratory tests for lupus. You seem to have accomplished that. As we discussed this last patient, you were able to tell me exactly which tests to order in this circumstance and why.” Finally, if a learner is struggling, you might say, “You are having difficulty answering questions about this patient’s middle ear problem. Let’s talk about where you might get some more information on this topic.” Unlike Socratic questioning, with moves from the general to the specific, inquiry involves very specific questions with exact answers from the beginning. In addition, Socratic questioning explores the learner’s thinking. Inquiry explores the learner’s knowledge of an answer that you already have in mind. A skilled inquisitor avoids an authoritarian, emphatic series of questions that can intimidate or even freeze learners. Instead, present the questions in a collegial manner and give encouragement as the learner answers. Say that it is acceptable to be wrong and to venture guesses and opinions as part of learning (Schwenk & Whitman, 2005). Ask questions that are: • • • •

Clear Brief (one at a time) Focused Divergent (allow more than one acceptable answer and broad thinking) • Open ended (short answers are insufficient) You can also ask questions to challenge learners at different levels of thinking. The simplest, lower-level questions elicit answers from yes or

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no to a list of facts. A higher level question involves asking the learner to comprehend the knowledge in a novel way. At the highest level, questions require analysis or synthesis, i.e., breaking down knowledge into its components and reformulating the learner’s thinking. The levels of questions and responses include: • Recall: remembering previously learned information • Comprehension: beginning to understand cause and effect • Synthesis: bringing together multiple pieces of information to form a whole • Analysis: breaking down material into its parts and apply to a case • Evaluation: reviewing what was learned (Lake, Vickery, & Ryan, 2005). Begin your questions with words such as clarify, support, defend, justify, correlate, critique, interpret, or predict as you move up the hierarchy of questions. For example, you are reviewing a case you saw with a group of third-year students at your headache clinic. You might ask the following questions: “What are the possible causes of this patient’s headache?” (recall) “Support the most likely diagnosis?” (comprehension) “Clarify how the history fits that diagnosis?” (synthesis) “Compare the clinical features of migraine and tension headache?” (analysis) “From this discussion, justify the use of that medication?’” (evaluation) You can be even more helpful with inquiry by helping learners delve into their memories. Learners probably know most of the information already and simply need help to access it (Elstein, Shulman, & Sprafka, 1978). Adult learners thrive on searching for and discovering learning material themselves. Some learners cannot think of the answer when first asked but nod and say, “Oh, yes,” when the answer becomes apparent. The theory is that most learners possess abundant knowledge, but store and access it in a particular way. Research shows that when learners do not come up with the correct answer, it is rarely because they do not have the answer – instead, they do not have a way to retrieve it from their memories (Bordage, Grant, & Marsden, 1990). Increasing experience is accompanied by increasing access to such knowledge.

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With practice, discussion, and thought, teachers can gradually alter the shape of memorized knowledge until it becomes finely tuned to needs of clinical practice, applicable from case to case, and accessible when needed (Gruppen, 1997). To use this strategy, affirm with learners at the outset that they have the knowledge to find the diagnosis and plan the case’s management. Then, ask questions that explore the learner’s stored memory. Research supports that it is better to guide learners through this process, promoting reflection, than it is to give them the answers (Taylor, Dunn, & Lipsky, 1993). • Prod the learner’s memory by reviewing particular points of the history and physical examination. • Relate this case to previous ones. • Discuss one issue at a time. • Break down each issue, idea, or concept to a less demanding level. Ask the learner to combine pieces of information. • Rephrase your question in different words. Try a “what if” question, such as, “What if the patient were thirty years old instead of fifty?” • Review the previous points by going back over what has just been discussed to attempt to arouse the learner’s memory. • Prompt the learner with simple words or statements that will act as clues to stored memory. • Summarize the process that brought the learner to the answer, right or wrong. Overall, educational researchers and practitioners agree that teachers’ effective use of asking questions promotes learning (Latham, 1997). Readiness When beginning to ask questions, be prepared to deal with blocks in learners’ ability to answer. You must clear such obstructions before learners are ready to move on (Milan, Parish, & Reichgott, 2006). For example, you might say, “Let’s stop for a minute and discuss what seems to be upsetting you so much. I remember that a patient died when you were first on call. That death upset me. I was wondering if it’s upsetting you?” Another problem of readiness is a mismatch between the learner’s developmental level and the message you want to communicate. The

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learner may have to become more sophisticated in the relevant area before she can understand the message. For example, a third-year medical student in your office on an elective would have difficulty appreciating the ethical choices inherent in the investigation of an Alzheimer’s patient with anaemia because she would lack knowledge of differential diagnosis and natural history of the disease. Showing Demonstration It is common in ambulatory care teaching to demonstrate motor skills and even some affective skills to learners. Demonstration is the orderly and detailed illustration or explanation of various procedural or technical skills. When demonstrating a new skill or procedure (Grantcharov & Reznick, 2008), you should: 1 Find out what the learner already knows about the procedure and work from that starting point. There is no use in wasting time teaching existing knowledge and skills. 2 Review the procedure with a diagram or verbally before actually starting to perform it on the patient. Break it down into its easily digestible component parts. 3 Provide a running commentary of what you are doing, describing key steps by deconstructing the procedure. 4 Comment on the variety of approaches for a given situation. 5 Be clear, concise, and brief in your explanation. 6 Check the learner’s comprehension by asking them to describe the steps as you proceed. 7 Review the procedure with the learner after you have completed it, and allow questions. In ambulatory care settings, you will often see patients simultaneously with learner. Remember to call learners to your office when you have a patient with whom you can demonstrate special clinical findings that they might not otherwise experience or that relate to their objectives. You may also use demonstration effectively for teaching about the medical record. Illustrate for learners:

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• Well-organized patient charts with a problem list and flow charts of laboratory tests in either paper or electronic formats; • Concise and accurate documentation of an office visit; • A helpful referral note to a consulting physician; or • A comprehensive consultation report to the referring physician. Demonstrate your reasoning to learners, even in the midst of case decision making. Think out loud. Be reflective and articulate about your thinking process. This allows learners to see how skilled, experienced doctors approach a clinical problem. Role Modelling Role modelling can be defined as facilitating learning by being the example of the attitude or concept to be learned. Role models are persons whose behaviours, personal styles, and specific attributes are emulated by others. As teachers, we act as role models for our learners all the time, whether we like it or not and whether we are aware of it or not. They constantly observe what we do and say and learn from our actions, though such behaviours can be both positive and negative. A role model is a powerful tool, for learners quickly pick up the codes of conduct of the physician and act accordingly (Cruess, Cruess, & Steinert, 2008). Be aware that your interactions and attitudes influence learners. Learners rate teachers who perceive themselves as role models and make use of that role more highly than those who do not (Kenny, Mann, & MacLeod, 2003). Use role modelling as an effective teaching tool through conscious and deliberate behaviours in areas where you need to enhance education. For example, in a second-year course on interviewing, students observed “charismatic role models” taking a history (Siegler, Reaven, Lipinski, & Stocking, 1987). This intervention improved scores on students’ attitudes toward interpersonal skills as well as the doctor-patient relationship. Ambulatory teachers in medicine can especially promote learning through role modelling in the following in three key areas: 1 Professionalism: Professionalism is defined as a collection of attitudes, values, behaviours, and relationships that is essential to the public’s trust in doctors. Professionalism includes altruism, honour, integrity, accountability, advocacy, and self-improvement (Archer,

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Elder, Hustedde, Milam, & Joyce, 2008). Many medical schools establish a didactic structure in pre-clinical years so that students can articulate the cognitive base of professionalism. As well, there is an opportunity in small group reflection to further review, personalize, and internalize their professional identity, changing from novices into skilled professionals (Cruess & Cruess, 2006). In your office or clinic, learners can observe these attributes of professionalism in action. You can promote this learning by role modelling (Loh & Nalliah, 2010): • Intellectual curiosity (talk to your learners about your interests); • Continuing self-education (show learners your reading and conference schedule or how you use online sites for update ); • Sensitivity, respect, and compassion for patients (after you and a learner see a patient together, ask her to reflect on your approach); • Cooperation and mutual respect among specialties (have a learner join you on hospital visits); • Collaboration with and respect for the specific knowledge and skills that other health professionals possess (assign patients to a learner where multiple health professionals work together to provide care); and • Interests in professional associations and community advocacy (take learners along with you to meetings). 2 Practice management: The business aspects of medical practice are not usually taught to learners in their core curriculum. While working in your office, they can begin to learn about this critical part of their careers. Learners can watch your insurance billing routines and grasp issues about time management from you. Invite learners to sit in on a business meeting of your practice group to see behind the scenes of ambulatory care. 3 Lifestyle: When learners arrive at your office or clinic, especially away from academic centres, they become part of your community. You can role model the balance of professional, personal, and family responsibilities by describing your daily routines outside the clinic. You may share your methods to maintain proper nutrition (eat lunch together), discuss when you find time for exercise and your personal interests, or review how you maintain commitments to friends, partners, or children, depending on personal circumstance.

Teaching Skills in Ambulatory Care REFERENCES Archer, R., Elder, W., Hustedde, C., Milam, A., & Joyce, J. (2008). The theory of planned behaviour in medical education: A model for integrating professionalism training. Medical Education, 42(8), 771–77. http://dx.doi. org/10.1111/j.1365-2923.2008.03130.x Medline:18715476 Benzie, D. (1998). Levels of questioning for learners. Family Medicine, 30(1), 12–13. Medline:9460609 Bordage, G., Grant, J., & Marsden, P. (1990). Quantitative assessment of diagnostic ability. Medical Education, 24(5), 413–25. http://dx.doi. org/10.1111/j.1365-2923.1990.tb02650.x Medline:2215294 Cruess, R.L., & Cruess, S.R. (2006). Teaching professionalism: General principles. Medical Teacher, 28(3), 205–208. http://dx.doi.org/10.1080/ 01421590600643653 Medline:16753716 Cruess, S.R., Cruess, R.L., & Steinert, Y. (2008). Role modelling: Making the most of a powerful teaching strategy. British Medical Journal, 336(7646), 718–21. http://dx.doi.org/10.1136/bmj.39503.757847.BE Medline:18369229 Elstein, A., Shulman, L., & Sprafka, S. (1978). Medical problem solving: An analysis of clinical reasoning. Cambridge, MA: Harvard University Press. Grantcharov, T.P., & Reznick, R.K. (2008). Teaching procedural skills. British Medical Journal, 336(7653), 1129–31. http://dx.doi.org/10.1136/ bmj.39517.686956.47 Medline:18483056 Gruppen, L.D. (1997). Implications of cognitive research for ambulatory care education. Academic Medicine, 72(2), 117–20. http://dx.doi. org/10.1097/00001888-199702000-00012 Medline:9040246 Holden, R., Collier, C., & Frid, P. (1999). Questioning in medical education: Enhancing this active teaching tool. Annals of the Royal College of Physicians and Surgeons of Canada, 5, 291–95. Kenny, N.P., Mann, K.V., & MacLeod, H. (2003). Role modeling in physicians’ professional formation: Reconsidering an essential but untapped educational strategy. Academic Medicine, 78(12), 1203–10. http://dx.doi. org/10.1097/00001888-200312000-00002 Medline:14660418 Lake, F.R., Vickery, A.W., & Ryan, G. (2005). Teaching on the run tips 7: Effective use of questions. Medical Journal of Australia, 182(3), 126–27. Medline:15698359 Latham, A. (1997). Asking students the right questions. Educational Leadership, 54, 84–85. Loh, K.Y., & Nalliah, S. (2010). Learning professionalism by role-modelling. Medical Education, 44(11), 1123. http://dx.doi.org/10.1111/j.13652923.2010.03827.x Medline:20963918

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Milan, F.B., Parish, S.J., & Reichgott, M.J. (2006). A model for educational feedback based on clinical communication skills strategies: Beyond the “feedback sandwich.” Teaching and Learning in Medicine, 18(1), 42–47. http:// dx.doi.org/10.1207/s15328015tlm1801_9 Medline:16354139 O’Donohue, W., & Ferguson, K. (2001). The psychology of B.F. Skinner. San Francisco: Sage Publications. Oh, R.C. (2005). The Socratic Method in medicine: The labor of delivering medical truths. Family Medicine, 37(8), 537–39. Medline:16145625 Pendleton, D., Schofield, T., Havelock, P., & Tate, P. (1984). The consultation: An approach to learning and teaching. Oxford: Oxford University Press. Sargeant, J., & Mann, K. (2010). Feedback in medical education: Skills for improving learner performance. In P. Cantillon & D. Wood (Eds.), ABC of learning and teaching in medicine (2nd ed., pp. 29–32). London: Blackwell Publishing. Schwenk, T., & Whitman, N. (2005). Residents as teachers: A guide to educational practice. Salt Lake City: University of Utah School of Medicine. Seehusen, D.A., & Miser, W.F. (2006). Teaching the outstanding medical learner. Family Medicine, 38(10), 731–35. Medline:17075747 Siegler, M., Reaven, N., Lipinski, R., & Stocking, C. (1987). Effect of role-model clinicians on students’ attitudes in a second-year course on introduction to the patient. Journal of Medical Education, 62(11), 935–37. Medline:3681924 Taylor, C.A., Dunn, T.G., & Lipsky, M.S. (1993). Extent to which guided-discovery teaching strategies were used by 20 preceptors in family medicine. Academic Medicine, 68(5), 385–87. http://dx.doi.org/10.1097/00001888199305000-00026 Medline:8484856 Van de Ritter, M., Stokking, K., McGaghie, W., & ten Cate, O. (2008). What is feedback in clinical education? Medical Teacher, 42, 189–97. Walsh, K. (2005). The rules. British Medical Journal, 331(7516), 574. http:// dx.doi.org/10.1136/bmj.331.7516.574

Chapter Three

Setting Up the Clinic for Teaching

Several years after he joined Clinics of Main Street, Dr. Z.Z. Smith became the director. He made an agreement with the local medical school to have senior medical students and residents come to the clinic for their ambulatory training. Thinking back to the meeting he had with his colleagues after the associate dean of the medical school approached him, he recalled that, at first, most were against it. They made comments such as: “We already teach at the hospital. Why do we have to teach in the office, too?” “We had little ambulatory experience when we were training and we seem to be quite capable doctors. The students do not get enough hospital experience as it is, with all those electives and seminar time.” “The learners will just get in the way and slow us down.” “Where will we find enough patients for our clinic groups?” “It will cost us a fortune to have the learners here.” “We really do not have any extra rooms for them to use to see patients.” “Our patients do not want to see learners. They come here to see their doctors.”

Other colleagues, however, supported the idea at once. They said the following: “Ambulatory care medical teaching is the future of medical education.” “We are all committed to and enjoy medical teaching. We just need to reorient our thinking to the ambulatory setting, just as we have reoriented

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Medical Teaching in Ambulatory Care our thinking for patient care from the hospital to the outpatient setting.” “Can you imagine trying to implement the plans for outpatient investigations and treatments we now take for granted twenty years ago?” “Learners should not cost us that much or anything at all. The residents may even make us more efficient and produce some extra income to make up for any shortfall.” “I think there are more empty rooms at certain times of the day than we think there are.” “Our patients are impressed by our teaching credentials. Also, many of them really enjoy talking to learners and feel good about helping them in their education.”

By the end of the meeting, those in favour of ambulatory teaching carried the day. Dr. Smith was charged with the responsibility of organizing the details and reporting back to the group for final approval. Where Will They Work? The next morning Dr. Smith went into the office early, before any patients arrived. He looked around the waiting room and the reception desk and peered into some of the examining rooms. He was frozen by a brief surge of panic. His colleagues were right. Where would learners work? How would a medical school clinic group fit into this office space? He slumped into his chair and pondered the problem. Soon, it struck him that at least a third of the physicians did not come to the office in the morning. Some were in the operating room. Others worked at the hospital doing procedures for part of each day. Dr. Smith decided to ask the office manager to draw up a schedule of exactly when each office and examining room was occupied. The following are our recommended steps for preparing your clinic for learners. Preparing Your Office for Teaching 1 Draw up an office plan or list of all available rooms. Note when they are occupied or empty. This will give you an idea of how many learners you can accommodate and at what times. 2 Try to create blocks of examining rooms learners can use when they are in the office, since they will need to be near the physician with whom they are working. Remember that more junior learners need more time to see patients. Have other rooms available where the

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teaching physician can continue to see patients at the same time. 3 Consider converting one room into an area where physicians can observe learners unobtrusively. There are several inexpensive ways to approach this: a The least expensive method is to purchase an audio recorder and have it sit on the desk where the learner interviews patients. The learner can turn it on for either particular patients or the entire session. b The more expensive method is to prepare a room for direct observation by mounting a video camera with a wide-angle lens in one corner, with a ceiling mounted microphone for sound. (A similar type of camera is used in stores to detect shoplifters.) The wiring can run above the ceiling tiles to almost any room and attach to a standard DVD recorder and a television or computer monitor. (You might use the office coffee room for this.) The entire system can be purchased for $1,000 or less. Most medical schools have funds for such a purchase, which could be made part of the arrangement with the associate dean. 4 Make learners (especially senior ones) feel like part of the office, particularly if they will be there for an extended period. Print some personalized appointment cards for them. Give them each an individual mailbox and telephone message slot, similar to those of the other physicians. In addition, consider adding their names to the list of physicians on your office wall using a sign that is easy to change. Finally, many clinics use electronic medical records. Some clinics have learners record the patient visit using a teacher’s account and opened encounter. However, you can work with your software supplier to give learners individual secure access. This supports each learner as an additional provider in the clinic and makes it easier for them to access patient data, results, and messages. These maneuvers assist staff and patients to integrate these learners as part of your practice and help with continuity of care issues. 5 Remember to use other resources in the community (Richards, 1996). There may not be room in your clinic each day for learners, but this creates an opportunity for them to experience the role of other organizations and health professionals. With little firsthand knowledge about the community, learners have only their own life experiences to draw on when assessing patients’ overall needs. To

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expand that viewpoint, arrange for them to visit (depending on your specialty): Public health units Home care organizations Community mental health services, including those serving specific cultural groups Assisted-living facilities or nursing homes Hospice care Family planning clinics Local pharmacy Home health services, such as those that provide assistive devices and oxygen supply. What Will the Patients Think? As Dr. Smith was finishing his examination of Mr. Parks that day, the patient said, “Thank you so much for helping me with this illness. It’s been so beneficial to have you here throughout. I could not have made it without you.” Dr. Smith had teaching on his mind all day, and so his first thought was, “Could Mr. Parks have coped with having a learner involved in his care?” Would patients leave the practice if learners started coming to the office? Preparing the Patients for Teaching In our experience, many patients look positively on the teaching aspect of a practice. In general, patients are receptive to learners who, they believe, increase the attention they receive (Gress, Flynn, Rubin, & Simonson, 2002). It is unusual for a patient to leave a practice or refuse to attend one solely because learners may be involved in their care. Instead, teaching gives the practice a high profile and, in many circumstances, increases patient satisfaction (Grayson, Klein, Lugo, & Visintainer, 1998; Simon, Peters, Christiansen, & Fletcher, 2000). Patients do not avoid teaching hospitals for fear of learner involvement! The challenge is to prepare patients so they understand the role of a teaching practice and the role of the learner in their care. 1 Proudly emphasize your practice or outpatient clinic as a teaching unit that has a link to the university. Your affiliated medical school

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Figure 3.1. Sample plaque designating a clinic or office as teaching site and declaring its link to the university

or specialty department should present your teaching practice with an impressive-looking plaque to hang in the waiting room, near the front entrance, or next to the list of doctors. See figure 3.1 for an example. 2 Many practices hand out a brochure that outlines the office’s routines as new patients register. As the practice becomes a teaching site, the brochure should include a summary of its teaching activities. See figure 3.2 for an example of information to include to inform patients of the doctors’ teaching roles. 3 Some practices establish a volunteer registry of patients who are particularly interested in helping out with the teaching program

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Figure 3.2. Sample brochure summarizing teaching activities Welcome to the Clinics of Main Street. In this office, the doctors and nurses provide care for patients of all ages involving many branches of medical care. In addition, there is access to all departments and services of the Main Street Hospital. The clinic is affiliated with the University of Main Street. We are involved with teaching new doctors and student doctors from the medical school. For this reason, on some of your visits, you may see a medical student or doctor in training in one of the specialties. Your own physician will always be directly involved in your case. In some circumstances, to assist in our teaching, your visit may be recorded for review with the trainee and your doctor. If you would prefer not to be involved in this teaching program, please notify us. This will in no way diminish the quality of care you receive at the Clinics of Main Street.

(Dent, 2005). This is more important if your practice becomes involved with early medical school teaching of clinical methods, interviewing skills, or other topics where learners require prolonged time with each patient. Two groups of patients may be especially interested in this type of involvement: (a) older patients or isolated individuals who appreciate the opportunity to get out and talk with young people, and (b) patients who recognize the importance of medical education and respond to the chance to be involved in it. Some patients appreciate that their willing participation is as important as any other volunteer community service. Your practice can prepare a special handout to distribute or a poster to put up in the waiting room to advertise the need for volunteers. See figures 3.3 and 3.4 for some examples. 4 When patients call for appointments, most practices find it beneficial to inform them in advance that a learner will be involved in their care. There are, of course, different circumstances depending on the level of the learner’s training. a For undergraduate students who usually work with the doctor, tell patients calling for an appointment that the doctor will have a student from the medical school working with her. The student may see the patient first, but the doctor will also see the patient directly. b For more senior learners who work independently, have patients book appointments specifically with them. Explain the learner’s level of training and the doctor’s teaching role more fully at the office.

Setting up the Clinic for Teaching Figure 3.3. Sample poster advertising the need for volunteers

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Figure 3.4. Sample handout advertising the need for volunteers

VOLUNTEERS ARE REQUIRED FOR TEACHING

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Figure 3.5. Sample sign indicating that direct observation is a part of learning at the teaching site

If some patients are reluctant to be involved with learners, schedule their appointments on a day when learners are not present. It is the authors’ experience that less than 10 per cent of patients express reluctance to be involved with a learner. 5 If direct observation is part of your teaching practice, carefully explain this in the information brochure and have a sign that informs patients about it clearly visible in every room. Figure 3.5 illustrates such a sign. How Will the Office Staff Cope? Dr. Smith had his weekly meeting with the office manager that afternoon, and he approached with trepidation – for good reason. First, he had to calm down the manager and educate her about this new activity and its importance. At length, he persuaded her that the presence of learners would greatly enhance staff morale, add some more prestige to working at the office, and reduce the ancillary staff turnover. The manager agreed to establish a plan to educate the office staff members about their new role.

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Preparing the Office Staff for Teaching 1 All staff must understand the role the office plays as a teaching practice. Do not assume clerical staff, nurses, or other health professionals in your clinic know about medical education and the steps involved in training (Roth et al., 2006). Hold a preliminary meeting for all your staff to explain the following: a The purpose of ambulatory teaching in medicine b The various levels, and expected clinical skills, of the learners who will visit the office c The role learners will play in the practice d The contribution staff members can make to the teaching program e A plan to gather their input and ideas 2 Canvas the office staff for ideas on how best to integrate learners into the office (e.g., appointment bookings, patient flow, follow-up appointments, etc.). This encourages them to play an important role in, and be more tolerant of the complexities of, the teaching practice. 3 Here are examples of how the office staff can enhance the educational experience (Paulman, Susman, & Abboud, 2000): a Medical secretaries can teach proper dictation techniques, charting, and use of office electronic medical records, as well as giving advice on general office supplies and equipment (e.g., where to order supplies, the proper size for stationery and envelopes, etc.). The secretaries can educate learners about preparing referral letters used by primary care physicians or reply letters after completing a consultation, for specialty disciplines. They can highlight the need for a referral letter to indicate the reason for referral, the patient’s ongoing medical conditions and treatments, the tests and results completed to date, and the urgency of the request. They can talk about how the consultant’s reply letter needs to be prepared promptly and not repeat already established details about the patient’s history and background. Referring doctors want information regarding diagnosis, clinical findings, test results, treatment options, and expected outcomes, including risks and benefits and any psychosocial concerns.

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b Receptionists can demonstrate how to schedule appointments; arrange follow-up visits; cope with walk-in patients; make referrals; book hospital beds, operating rooms, and laboratory tests; deal with difficult or demanding patients; and organize time during the daily schedule to respond to telephone calls. c Interprofessional health staff, such as nurses, nurse practitioners, physician assistants, or other health professionals, can play a broad role in the ambulatory training experience. They may teach learners how to perform office procedures (e.g., electrocardiogram or spirometry), manage common clinical problems in your specialty, take a concise history, use community resources, and maintain patient flow. They can educate learners about telephone triage and what conditions can be safely managed over the telephone. Role play is an effective method simulating common telephone situations and allowing learners to practice talking through typical scenarios within your discipline (see chapter 4). These interactions will help learners achieve the goals of interprofessional education described in chapter 1. d Managers and administrators can provide learners, especially those about to enter practice, with the details of setting up and running an office. They can emphasize office design, hiring and training staff, performance appraisal, medical records, accounting and bookkeeping, and dealing with insurance companies and third-party agencies. 4 The office staff has a critical role in integrating learners into the daily practice and shaping the way patients view them. Make sure the staff understands that learners are to be treated as members of the team, not as interlopers or transient observers. Here are a few suggestions: a The staff should direct telephone calls from patients to the learner who saw the patient. b Staff should reaffirm with patients that the learners, though temporary, are an integral part of the office. c Staff should even attempt to contact learners regarding their patients on days when the learner is away from the office, instead of talking to one of the regular physicians. d Ask all staff members in your clinic to invite learners to general staff meetings, other planning meetings, and small group office activities.

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e Ask all staff members to contribute to an orientation list for learners that would include “everything you need to know about our clinic on day one.” Ask staff to periodically update this list based on their experiences with learners. Will the Other Doctors Get Involved? Dr. Smith sat down at the end of day to review his progress. “So far, so good,” he thought to himself. He was certain everyone could manage with the existing physical space. The office staff seemed quite excited and had a plan to educate patients. He was still concerned, however, that his colleagues would be reluctant to climb aboard. After spending time on all this organizing, would they respond to his call to get involved in teaching? Dr. Smith realized he needed a carefully thoughtout plan for the medical staff as well. Preparing the Physicians for Teaching 1 Allow some time for the idea of ambulatory care teaching to register. Most physicians who get involved with ambulatory care teaching have taught previously in a hospital and generally enjoy teaching. To make the transition to ambulatory teaching, it is important to work out organizational kinks so the physicians feel more comfortable about having learners in the office. They need guidance on how to convert the lengthy hospital teaching sessions they may be familiar with into targeted, highly selective, brief encounters. Convene a follow-up meeting to outline the completion of the transition plan. Allow time to receive comments and further suggestions from the teaching physicians. 2 Some physicians wonder how their patients will react to the learners. Some may resent learners’ interference. There should be opportunity to air these concerns at a meeting. Here is an example from our practice that highlights this issue: In our office, there is an active obstetrical practice. Obstetrical training is an important part of our education program (Carroll, 1986). To ensure that learners have an adequate patient load overall, as well as appropriate supervision of their own patients, we implemented a policy assigning each obstetrical couple to a resident and teaching physician. The resident and physician see the patient on alternate visits. This

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applies whether the patient was originally in the physician’s practice or whether she entered the practice as a patient of a resident. At first, some physicians resisted the idea. Some comments included, “Obstetrical patients like to have their own doctor,” “Obstetrical patients are nervous and will never handle having two doctors,” or, “We will lose patients and get no referrals.” The patients, however, adapted well to a system of alternate visits with the staff and residents. They appreciated the time residents spent talking to them, and liked the fact that with two doctors, it was much more likely that someone they knew well would attend their delivery. During the thirty-five years of this joint visit program, we have not lost patients for refusing to participate, our obstetrical volume originally doubled and has remained stable, and we receive even more referrals from other physicians for obstetrical care as knowledge of our excellent academic program spreads. 3 Most physicians are unsure of how and what to teach in an ambulatory setting. They may be comfortable with the content within their specialty, but need to adjust their teaching to the learning opportunities of ambulatory care. If you fall into this category, organize teaching within your specialty with the following in mind: • Prevalence of problems in your specialty seen in the ambulatory setting versus in the hospital setting • Investigation of specific presenting complaints of outpatients • Treatment of common problems of your specialty in the ambulatory setting • Focused history and physical examination • Patient follow-up timing and frequency of laboratory tests • Procedures (investigation and treatment) that can be done in the outpatient setting • Writing consultation or referral letters • Interaction with patients before establishing a firm diagnosis • Preparation of patients for admission to a hospital (e.g., pre-admission testing, preoperative assessment) • Use of community resources and agencies for pre-hospital and post-hospital management (e.g., home care agencies, palliative care services, etc.) • Telephone management • Enhancement of patient compliance

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• Interaction with families • Time factor (a diagnosis is sometimes made over time as a disease develops) • Health maintenance and disease prevention • Interaction with third-party agencies 4 Physicians have two fears as they begin to teach in the ambulatory care setting: loss of income and loss of referrals. Here is a helpful view of these issues: a Adding learners to your practice is probably income neutral. More senior learners bring in extra income as they see additional patients your clinic could not normally handle. However, learners earlier in their training do slow down schedules somewhat. The general positive effect learners have for individual physicians and the office staff far outweighs the income issue. b The status of a physician as a teacher always results in a net gain of referrals. 5 It is important to provide opportunities for physicians to improve their skills as teachers, for we all feel more comfortable doing tasks at which we are more competent. The more comfortable your physicians are in ambulatory teaching, the less they will resist having learners in the office. In our practice, we established the following program to help ourselves learn about teaching. Our group of ten doctors set up a monthly meeting to discuss and learn about topics in education. At first, we met in the evening at 7:30 p.m. for two hours in one of our homes, though we now meet at 6 p.m. over a light dinner in the office conference room. We choose a topic of mutual concern in advance, and one of us presents information about it. Or, we invite a knowledgeable guest to lead a discussion with us. Some of the topics have included: • • • • • •

One-to-one teaching skills Small group teaching skills Adult learning principles Direct observation techniques Learning theories Interaction with families

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We also use our recording facilities in these sessions. We bring DVDs of various learner encounters with patients and discuss ways of teaching the learner in that situation. We record ourselves teaching, replay the scene at meetings, and discuss each others’ performance. These sessions have led us to understand the importance of improving our skills as teachers. Additional Details 1 Block versus longitudinal experiences: There are two approaches to having learners in your office: one is an intensive experience during a short period (block time); the other is multiple brief exposures over longer periods (longitudinal time). In block time, learners spend several weeks, or a month or two, working most of the day at the office. In longitudinal time, learners come to the office for a specified period each week (e.g., one or two mornings or afternoons) over a period as long as a year. The rest of the time, they rotate through other clinical disciplines or hospital wards. Which experience is ideal? Each has its advantages and disadvantages. In block time, learners are committed to a specific teaching site where they become familiar with the setting, its support staff, and its patients. They receive broad exposure to many problems during a short period of time. They quickly become fully integrated into the practice and are available to the patients daily. There are few distractions to draw them away from the office. As the teachers get to know the learners’ strengths and weaknesses, they may give them greater independence in their work and thus extend their learning experience (Hirsh, Ogur, Thibault, & Cox, 2007). The main disadvantage is that learners are unable to observe the natural history of illness and the appropriate follow-up with patients over the long term. Ambulatory block rotations have been successfully used in family medicine, primary care internal medicine, paediatrics, emergency medicine, and gynaecology (Bharel, Jain, & Hollander, 2003). In longitudinal time, the learning experience can be integrated with other rotations. Learners are involved with the clinic during a long period, and so they have the opportunity to follow patients regularly and learn about continuity of care, natural history of illness, and appropriate follow-up intervals. More regular contact with the teacher seems to enhance learning and learner satisfaction (Prislin et al., 1998). The major disadvantage is scheduling: conflicting service needs on inpatient units interfere with learners getting

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to the office. Teachers in many disciplines have successfully used longitudinal time. Medical student electives in early undergraduate years, clerkships in primary care disciplines such as family medicine, paediatrics, and internal medicine, and, more recently, family medicine residency programs have all made extensive use of the longitudinal model (Reust, 2001). Specialty disciplines such as obstetrics and gynaecology, internal medicine, and surgical fields also find this model attractive. 2 Scheduling patients with learners: There are several approaches to booking patients with learners, depending on their stage of training and learning objectives. a Timing: Early in their training, learners take three to four times as long as experienced clinicians to see a patient. In addition, no two learners arrive with the same abilities or experience. Thus, when learners begin working at the office, allow them about an hour for a new patient and thirty minutes for followup visits. As you get a better idea of learners’ skills, and as they gain experience, they will require less time. You may also want to build some extra time into your appointment bookings after every fourth or fifth patient to allow for discussions between patients. A more structured approach to scheduling is the “wave schedule” (Alguire, DeWitt, Pinsky, & Ferenchick, 2008). This schedule begins with the time blocks of your usual schedule, but every second or third patient is asked to come to the office one appointment slot earlier, allowing you and the learner to see patients simultaneously. After your patient is complete, you review the learner’s patient. For example, here is a model schedule using fifteen-minute time blocks: Time

Learner Schedule

Teacher Schedule

8:00 8:15 8:30 8:45 9:00 9:15

Patient A Patient A Records encounter Patient D Patient D Records encounter

Patient B Patient A Patient C Patient E Patient D Patient F

This model allows the teacher to see the same number of patients when a learner is present and can be adapted to whatever is your usual time allocation for appointments.

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b Patient selection: Early in their training, learners need to see more elementary clinical problems within the specialty. As they advance, assign them more challenging cases. If learners are exposed to rare or complicated clinical presentations in early training, they can form false impressions of disease prevalence and text exhaustively as a result. Early exposure to patients with particularly difficult psychosocial issues can be overwhelming and lead learners to feel less confident in their abilities to manage patient care (Dent, 2005). If possible, ask learners to identify their areas of weakness or special interest before they arrive at the clinic. Some teachers like to have this written down in a casual contract that lists each learner’s objectives and methods of assessment (Simon, Davis, Peters, Skeff, & Fletcher, 2003). Direct patients with specific medical problems that may meet the learner’s objectives. Learners should have their own list of patient appointments, and patients should be slotted in according to the needs and skill of each learner. Or, as patients come into the office, you can assign them to learners according to their diagnoses (Simon et al., 2003). Before a learner sees a patient, prime them for the encounter. Priming involves spending a minute or two providing guidance: • If you know the patient, summarize their background and diagnosis. • If the patient is making a follow-up visit, focus on the reason for the encounter. • If the patient is new, define the questions the learner needs to ask. • Tell the learner how much time she should spend on the encounter. c Specific booking: In many ambulatory teaching settings, patients are scheduled specifically to see learners. This is important because learners establish a roster of patients who recognize them as doctors and to whom they can provide continuous care. This may be less of an issue in specialty practices than it is in primary care. Patients may not like seeing learners at first, but some teaching practices have successfully offered earlier appointments to patients who are willing to deal with a learner if they know they will also get to see the teaching physician.

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In a specific booking scenario, you will normally need time for appointments with your patients, teaching, and perhaps seeing learners’ patients. There are many ways to accomplish these tasks, taking into consideration the type of practice (specialty or primary care), personal preference, and each learner’s competence. For example, you book two patients for the same time slot, and leave the next slot open for supervision and teaching. In the third slot, you are booked to see a patient, but the learner has time to do her own work. (This method preserves the total number of patients who would be seen without a learner present and creates dedicated teaching time.) During that time, the learner completes the encounter notes and read related material from textbooks or computers in your office. Learners may also search for relevant journal articles or clinical practice guidelines related to the specific patient they saw. 3 Tracking: It is helpful to log the types of patients learners see and the procedures they perform. This will help learners evaluate their progress and help you prepare for future learners. With this information you can look for specific gaps in learners’ experiences and try to direct the missing types of patients to them. As well, learners may use their logs when applying for hospital privileges upon graduation, if they need to provide documentation of their training experience. There are several tracking methods: a Most clinics use computerized billing systems. Such systems can keep track of what your learners see and do by letting you make a notation in the computer of the learner’s name beside the billing doctor. Each billing entry includes the gender, age, diagnosis, and procedures for each patient. From this data, construct a profile of patients seen by each learner according to diagnosis, age, gender, and the number of procedures performed by the learner. You can determine whether patients return to see a specific learner on more than one occasion or choose to see someone else. You can also measure the learner’s ability to attract new patients. With a simple modification of the software, you can store the number of patients seen, the distribution of patients across diagnostic categories, and the exposure to counselling or psychotherapy. You may compare individual learners against averages for all learners coming to your practice, observe trends from year to year, and monitor the effects of any changes you make in the learners’ program by reviewing practice profiles before and after the changes.

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Figure 3.6. Diagnostic distribution for Resident J.

Figure 3.7. Age-sex distribution for Resident J.

Here are some examples of profiles and their use in a family medicine clinic. In figure 3.6, a resident sees significantly fewer gynaecology and obstetrical patients than the others in his group. In figure 3.7, despite seeing fewer gynaecology and

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obstetrical problems, this resident sees the same age-sex distribution of patients. Present this data to the resident and explore with him reasons for this discrepancy. b Computers can also record patient encounters and procedures performed. Using spreadsheet software on any desktop computer or laptop, learners can enter their patient encounters at a convenient point in the day. You could set up the spreadsheet to list the particular elements of your specialty. Tablet computers provide ready access for learners to record encounters as the day proceeds (Bird, Zarum, & Renzi, 2001; Malan, Haffner, Armstrong, & Satin, 2000). 4 Conflicting work loads: Sometimes the learner might view an ambulatory experience as an add-on to an already busy rotation (e.g., a surgical resident spending two afternoons at a general surgeon’s office in a longitudinal manner while assigned to a general surgery ward). The learner finds there is competition for her services, and might be asked to scrub in at an emergency surgery or to complete a work-up for an acutely ill patient in the emergency department just as the ambulatory clinic begins. Her ward rounds with the attending physician may interfere with time set aside for the office. At other times, a learner will be absent from the office because of oncall work hour restrictions, or the need to catch up on ward work or prepare rounds. Some interruptions are unavoidable, but there are strategies that can minimize them (Warm et al., 2008). The program director must make it clear that ambulatory care time has the same priority as all else and should not be neglected for other work routines. • The learners’ timetable, in cooperation with the dean’s office, must be arranged to ensure adequate coverage for the hospital when learners are scheduled for ambulatory care. • Learners may adopt a buddy system whereby they team up to provide care and replace each other when in the office. • Physicians should work on time management with learners so they can experience the essential skills required for handling the tasks of the busy physician. 5 Continuity of care: In ambulatory care teaching, continuity of care in all specialties is an important learning objective. Continuity of care is defined by a series of interactions that occur over time, where the

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doctor is able to get a better picture of the patient over the course of their life or a specific illness. This includes becoming an identified and trusted source of care for the patient. To use hypertension as an example, considerations for the learner include: longevity of the diagnosis; previous attempted therapies and their success, failure, and side effects; definition of good control; how often to schedule follow-up visits; co-risk factors; how often to order laboratory tests for target organ impact; or medication side effects. There are several potential obstacles to achieving continuity of care. These include the fact that learners are not on-site every day, the rotation may be short, and the patient expects to be seen by the teaching physician (Nadkarni et al., 2011). To help learners achieve this goal, ensure that: • Whenever possible, patients return to the same learner for follow-up. • Learners have a defined roster of patients who remain their responsibility during their ambulatory experience. • The office staff has the capacity to contact learners when they are away from the office in order to handle problems, inform them about abnormal laboratory tests, and get them to return patient telephone calls. Learners should check in daily for phone messages. • The office staff contacts the learner for patient problems, understanding that this is an important educational activity for the learner. Teaching physicians should resist dealing with a patient problem brought to them by the office staff. Encourage staff to take the extra time to contact the learner while re-emphasizing the importance of this extra step for the learner’s education. 6 Patient consent for recording: The extent of consent required from patients varies according to practice setting and individual circumstance. Most teaching practices outline the practice of direct observation in their patient information brochure as well as post a sign in each examination room (see above). In addition, written consent may be required, especially if your clinic keeps any digital recordings past the time of the encounter (see figure 3.8 for a sample consent form). 7 Early undergraduate years: Medical schools are increasingly moving some of the teaching in the first few years of the clinical curriculum from the hospital bedside to the doctor’s office. This includes teach-

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Figure 3.8. Sample digital recording consent form

VIDEO RECORDING CONSENT FORM During your visit, a recording system will be in operation so that a teaching physician may watch from another room. This is for the purpose of education to assist our trainees in learning about interviewing patients. Strict confidentiality will be maintained. The conduct of the visit will be the same as usual and the viewing will not interfere in any way. If you prefer not to be involved, please inform your doctor, who will turn off the system. Your decision not to participate will in no way affect your care at the Clinics of Main Street. I consent to the use of the recording during this visit and for its review afterwards. Date Signature

ing interviewing skills, history taking, and physical examination within a specialty topic. Teachers assign learners a very specific task to undertake with a patient in the clinic: e.g., taking a medical history, practising a lung examination, or learning cranial nerve testing (Dent, J., 2003). Even more creative planning is required to meet the needs of these learners. (Much, of course, depends on the number of learners in each group.) Most medical schools still organize clinical teaching for chunks of pre-scheduled time (e.g., interviewing skills are taught on Tuesday from 2 p.m. to 5 p.m.). You have little flexibility with the schedule, so you need to work with the time allotted. Try to do the following: • Book patients from your volunteer register who have agreed to spend a few hours with learners. • Schedule several follow-up visits with patients who might agree to spend time with a learner as part of their appointment. • Arrange some new patients for that time slot who may agree to see one of the learners voluntarily, especially if they are getting an appointment ahead of their spot on the waiting list.

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• Have the learner work with you during regular office time using a longitudinal model. Assign the learner a specific task of either history taking or physical examination so that she will spend only fifteen to twenty minutes with the patient. Break the teaching into the very small chunks of time that are available between patients, instead of the usual lengthy time at the bedside with a captive patient. • Stagger the time with patients to accommodate room and patient availability (especially when trying to get patients that demonstrate a particular clinical entity). For example, during regular clinic time, there are four learners, two rooms, and two patients. Time

Learner

Location

Patient

1:00

Learner A Learner C and D Learner B Learner C Learner A and B Learner D Teaching time (all)

Room 1 Lunch Room 2 Room 1 Lunch Room 2 Office coffee room

Patient X

2:00

3:00

Patient Y Patient X Patient Y

• Arrange for one or two learners to come to the office during other open time in their schedule when you have rooms or patients available. Then, the learners can use the scheduled clinic time for what they had planned for that open time (e.g., personal study, time off, etc). Alternatively, use the scheduled clinical time for teaching with the entire assigned group of learners, using patients previously seen in the office as the focus for discussion.

REFERENCES Alguire, P., DeWitt, D., Pinsky, L., & Ferenchick, G. (2008). Teaching in your office: A guide to instructing medical students and residents (2nd ed.). Philadelphia: ACP Press. Bird, S.B., Zarum, R.S., & Renzi, F.P. (2001). Emergency medicine resident patient care documentation using a hand-held computerized device. Academic Emergency Medicine, 8(12), 1200–203. http://dx.doi. org/10.1111/j.1553-2712.2001.tb01141.x Medline:11733302 Bharel, M., Jain, S., & Hollander, H. (2003). Comprehensive ambulatory medicine training for categorical internal medicine residents. Journal of

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General Internal Medicine, 18(4), 288–93. http://dx.doi.org/10.1046/j.15251497.2003.20712.x Medline:12709096 Carroll, J.C. (1986). The challenge of teaching obstetrics to family practice residents in a tertiary care hospital. Canadian Family Physician Médecin de Famille Canadien, 32, 2263–65. Medline:21267328 Dent, J.A. (2003). Twelve tips for developing a clinical teaching programme in a day surgery unit. Medical Teacher, 25(4), 364–67. http://dx.doi. org/10.1080/0142159031000136806 Medline:12893545 Dent, J.A. (2005). AMEE Guide No 26: Clinical teaching in ambulatory care settings. Medical Teacher, 27(4), 302–15. http://dx.doi. org/10.1080/01421590500150999 Medline:16024412 Grayson, M.S., Klein, M., Lugo, J., & Visintainer, P. (1998). Benefits and costs to community-based physicians teaching primary care to medical students. Journal of General Internal Medicine, 13(7), 485–88. http://dx.doi. org/10.1046/j.1525-1497.1998.00139.x Medline:9686716 Gress, T.W., Flynn, J.A., Rubin, H.R., Simonson, L., Sisson, S., Thompson, T. et al. (2002). Effect of student involvement on patient perceptions of ambulatory care visits: A randomized controlled trial. Journal of General Internal Medicine, 17(6), 420–27. http://dx.doi.org/10.1046/j.1525-1497.2002.10328.x Medline:12133155 Hirsh, D.A., Ogur, B., Thibault, G.E., & Cox, M. (2007). “Continuity” as an organizing principle for clinical education reform. New England Journal of Medicine, 356(8), 858–66. http://dx.doi.org/10.1056/NEJMsb061660 Medline:17314348 Malan, T.K., Haffner, W.H., Armstrong, A.Y., & Satin, A.J. (2000). Hand-held computer operating system program for collection of resident experience data. Obstetrics and Gynecology, 96(5 Pt 1), 792–94. http://dx.doi. org/10.1016/S0029-7844(00)01015-2 Medline:11042320 Nadkarni, M., Reddy, S., Bates, C.K., Fosburgh, B., Babbott, S., & Holmboe, E. (2011). Ambulatory-based education in internal medicine: Current organization and implications for transformation. Journal of General Internal Medicine, 26(1), 16–20. http://dx.doi.org/10.1007/s11606-010-1437-3 Medline:20628830 Paulman, P., & Susman, J. Abboud, C. (2000). Precepting medical students in the office. Baltimore: Johns Hopkins University Press. Prislin, M.D., Feighny, K.M., Stearns, J.A., Hood, J., Arnold, L., Erney, S. et al. (1998). What students say about learning and teaching in longitudinal ambulatory primary care clerkships: A multi-institutional study. Academic Medicine, 73(6), 680–87. http://dx.doi.org/10.1097/00001888-19980600000015 Medline:9653407

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Richards, R. (1996). Building partnerships. Educating health professionals for the community they serve. San Francisco: Jossey-Boss Publishers. Reust, C.E. (2001). Longitudinal residency training: A survey of family practice residency programs. Family Medicine, 33(10), 740–45. Medline:11730289 Roth, L.M., Severson, R.K., Probst, J.C., Monsur, J.C., Markova, T., Kushner, S.A. et al. (2006). Exploring physician and staff perceptions of the learning environment in ambulatory residency clinics. Family Medicine, 38(3), 177–84. Medline:16518735 Simon, S.R., Peters, A.S., Christiansen, C.L., & Fletcher, R.H. (2000). The effect of medical student teaching on patient satisfaction in a managed care setting. Journal of General Internal Medicine, 15(7), 457–61. http://dx.doi. org/10.1046/j.1525-1497.2000.06409.x Medline:10940131 Simon, S.R., Davis, D., Peters, A.S., Skeff, K.M., & Fletcher, R.H. (2003). How do precepting physicians select patients for teaching medical students in the ambulatory primary care setting? Journal of General Internal Medicine, 18(9), 730–35. http://dx.doi.org/10.1046/j.1525-1497.2003.20838.x Medline:12950482 Warm, E.J., Schauer, D.P., Diers, T., Mathis, B.R., Neirouz, Y., Boex, J.R. et al. (2008). The ambulatory long-block: An accreditation council for graduate medical education (ACGME) educational innovations project (EIP). Journal of General Internal Medicine, 23(7), 921–26. http://dx.doi.org/10.1007/ s11606-008-0588-y Medline:18612718

Chapter Four

Strategies to Use during the Teaching Day

During the weekly medical staff meeting at the Clinics of Main Street, Dr. Brown asked the director about the teaching function: “We now have all these students and residents who work here almost every day, but there does not seem to be much teaching going on. Sure, we talk about the cases they see, but it’s all rather spontaneous and haphazard. How can we make the best use of our teaching time?” Then, Dr. Blue spoke: “Also, there are three obligations that we have to keep in mind: (a) the need for the attending physician to be responsible for care given by learners and the obligation to review the learners’ work; (b) the need to maintain patient flow; and (c) the need to ensure patient satisfaction with high-quality care and continuity with their attending physician.” The director suggested it is difficult to satisfy all of these concerns at the same time. It would be better to have some more time to discuss the various strategies the staff could use in their teaching day to help learners, yet meet these requirements. They set a dinner meeting for the first Tuesday of the next month, and invited the associate dean for medical education, who was very knowledgeable about teaching strategies. Here is a summary of the ideas they generated. Timing A day in the office is always busy for teachers who see patients, answer telephone calls, deal with consultants, refer doctors, or respond to office problems – there is never a dull moment. With lower reimbursement rates over the last decade, there is an additional emphasis on clinical

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Table 4.1. Teaching strategies using patients, charts, and educational techniques Patients

Charts

Educational Techniques

Case discussion Case review Direct observation

Chart review Chart-stimulated recall Criterion chart review

Role play and simulation Short didactic presentation E-learning

productivity in both academic centres and community practices (Ludmerer, 2000). Then, when does teaching fit in? The answer is different for every office and doctor. The important issue is to schedule teaching activities rather than leaving them to chance. In a typical office day, the following are the most opportune moments: 1 In the morning, before the first patient (fifteen to thirty minutes for more concentrated teaching opportunities) 2 Between each patient (a briefer time to review the salient points) 3 At lunch (another chance to spend some relaxed time teaching) 4 When a patient fails to show and there is a gap in the day 5 After the last patient Teaching Strategies Table 4.1 lists various teaching strategies. Use of Patients During the day, as learners see patients, you may use one of the following strategies: case discussion, case review, or direct observation. The following sections explain these strategies. case discussion Description: This strategy is the most common one used in ambulatory care teaching. The learner sees the patient first, and then presents the history, physical, and suggested management to the teacher. The teacher usually asks the learner some clarifying questions and may see the patient to review the findings. Since the discussion occurs between patient visits and usually while the patient is waiting, it is brief and to the point. Thus, you make considerable use of responding and inquiry skills.

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To maintain patient flow, this is a short encounter. For senior learners, a few minutes will usually suffice to clarify some teaching points. For junior learners, five to ten minutes may be required to review the case, see the patient, and highlight some management issues before the patient leaves. Indications: Case discussion is best used with inexperienced learners in situations in which direct observation is unavailable. It is also important in settings in which patients also see the attending physician. It allows for closer control with newer learners and diminishes anxiety because learners know you are available for consultation. Advantages: The following are advantages of case discussion. • Close monitoring of the learner • Fulfilment of the legal obligation to review the patient • Evaluation of learners’ knowledge and decision making by listening to case presentation • Quick suggestions on patient management Limitations: The following are limitations of this strategy. • • • •

Reliance mainly on the learners’ reports of each case Limited to assessment of cognitive domain Restricts the autonomy of learners with more experience More time consuming than case review because each case is discussed between patients Costs: The following items refer to time and resources.

• Economical strategy (i.e., one teacher can supervise two or three learners) • Does not require equipment • Teachers may see patients simultaneously Example: You are the emergency physician on duty. A learner has just finished taking a history on a patient with acute abdominal pain. From listening to his case presentation, you surmise he has focused on a diagnosis of renal colic and ignored the points in the patient’s history about possible gastrointestinal pathology. At this point you tell him about this deficiency in history taking and ask him to report the rest after he has completed his physical examination.

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Tips: The following tips are helpful during case discussion. 1 Keep track of points that come up in the brief discussion between seeing patients for fuller discussion at lunch or later in the day. Carry a small notepad in your pocket to make these notes, or use your smartphone. 2 Remember the teachable moment. 3 Resist the urge to cover everything. Be brief, and do not contribute to the learner falling further behind. This is not the one and only time the learner will see a specific case – make one or two points and leave the rest to another opportunity that you or another teacher will surely find (Heidenreich, Lye, Simpson, & Lourich, 2000). 4 If you would like more structure to your interactions with learners when reviewing a patient, then use the “one-minute preceptor” model (Neher, Gordon, Meyer, & Stevens, 1992). This popular and well-studied model allows you to follow a sequence of questions to focus on the learner’s decision-making process (Aagaard, Teherani & Irby, 2004). After the learner briefly presents the case, use these five steps: • Get a commitment: “What do you think is going on with this patient?” • Probe for supporting evidence: “What were the major findings that led to your diagnosis?” • Teach general rules: From what the learner reveals, offer a teaching point. For example, “If this abscess if fluctuant, then you can drain it.” • Reinforce what was done right: Provide a directive statement describing specific actions the learner performed well. For example, “I see that you kept an open mind until the patient revealed her true agenda.” • Correct mistakes: Use your skills of demonstration or role modelling (see chapter 2) to fill a gap in the learner’s knowledge. For example, “Let me show you how to examine the ears of this young child, because we cannot overlook an otitis media in what you correctly believe is likely a viral respiratory infection” (Grover, 2003). 5 If you wish the learner to conduct the case presentation using a structure to explore clinical reasoning, use the SNAPPS model (Wol-

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paw, Wolpaw, & Papp, 2003; Wolpaw, Papp, & Bordage, 2009). After seeing the patient, the learner discusses the case with you according to these six steps: Summarize: briefly presents the history and findings Narrow: presents two to three relevant diagnoses Analyse: compares and contrasts the diagnostic options Probe: asks specific questions in areas of uncertainty concerning the case Plan: states a suggested management plan Select: chooses an issue or topic from the case for specific additional reading case review Description: In case review, the teacher and learners discuss a larger number of cases at one sitting, such as at lunchtime or the end of the day. The teacher sits down with one or more learners who are working in the office, and asks each to present each patient’s history and physical examination to the group. The teacher then leads a discussion based on the case presented. Many cases can be reviewed without too much discussion, while others merit more careful scrutiny and analysis. Finally, the teacher chooses a topic from one of the cases for more lengthy discussion. These sessions may last from thirty minutes to one hour, depending on the available time (Jaques, 2010). Indications: It is best to use case review in a clinical environment with experienced learners who benefit from more autonomy (i.e., not having to review each case directly after seeing each patient). It is also effective when patient flow does not allow time to discuss each case at the time of the visit. Advantages: The following are advantages of case review. • Fulfils legal obligations of patient review by licensed physician • Increases learner autonomy by maintaining supervision at a distance • Allows more in-depth evaluation of learner’s knowledge base Limitations: The following are limitations of this strategy. • Does not assess physical examination or interviewing skills • Depends on each learner’s account of the encounter • Causes more anxiety for beginning learner

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Costs: The following items refer to time and resources. • Protects income for the practice because teachers can continue to see patients while learners work simultaneously • Requires extra time for a teaching session after seeing patients Example: Over lunch, you and two senior residents working in the clinic sit down in your office to review every patient they saw that morning. They present the cases one by one with only a brief discussion. One resident presents a problem patient with chronic obstructive pulmonary disease. You then all agree to discuss at length the topic of steroid use in chronic lung disease. This discussion lasts for about fifteen minutes, after which you briefly review their remaining cases. Tips: The following tips are helpful during case review. 1 Remember the principles of adult learning and the learner’s personal objectives. At the outset, ask the learners if they have a topic they wish to cover, especially one raised by a case seen that day. Encourage the other learners present, particularly those who are more senior, to contribute to the teaching. 2 Remember to tell learners how well they are functioning (e.g., “That was well managed for the following reasons,” or, “Your understanding of the physiology is excellent.”). You make judgments all the time as learners present cases and discuss topics. Let them know how they are doing. 3 Present some of the cases you saw to add important clinical material and enhance the collegial atmosphere. 4 If it was a rather mundane day and you draw a blank on a good topic for discussion, use the “wheel of fortune.” Take one case of the day, put the diagnosis or presenting complaint at the hub of a wheel drawing, and ask those present to give a related topic to complete each spoke (see figure 4.1). You now have several topics from which to choose. 5 In a case review session, you will use your ability to ask questions most often. Use questions to stimulate discussion rather than to provide information. Use questions that require interpretation rather than factual answers. Rather than saying, “Describe the use of steroids in COPD,” try asking, “How does the idea that steroids reduce inflammation apply to the treatment of COPD?” 6 Be patient when learners do not respond to your question. Be comfortable with silence. It gives time for a learner to reflect on the

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Figure 4.1. Sample “wheel” with presenting complaint at centre and related topics completing each spoke

question, or for peers to help. It also discourages competitiveness to see who can shout out the answer first. 7 Involve all the learners in the group by directing questions to the rest of the group or to each individual: “What do the rest of you think?” or, “Isn’t that similar to what you were saying earlier, Joanne?” (Jaques, 2010). 8 Begin the discussion with a controversial or provocative statement to cause disagreement. A certain degree of surprise or uncertainty arouses curiosity, which is a basic motive to learn. For example, you might say, “From your case of Ms. M., the fifty-year-old patient here today for her periodic health exam, do you agree with the following statement: I believe that all patients should have colonoscopy for colon cancer screening?” direct observation Description: Teachers can directly observe learners by using a video camera or sitting in the consultation room with them. The teacher can actively participate in the encounter by making suggestions to the learner via a telephone intercom. The learner can also check with the teaching physician by stepping out of the room at a prearranged time (e.g., before the physical examination while the patient is undressing). Video technology is more effective for direct observation. You can review the recorded encounter later when more time is available. While watching the recording, the learner can observe her own interviewing

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skills (both verbal and nonverbal) and review her attitudes and feelings about the patient. The two of you can then discuss these and other issues you observe. We use the following equipment in our office. Most suppliers will install the equipment. The total cost was about $1,000: • Black and white surveillance camera with a wide-angle lens, mounted on a supporting bracket (used by stores for loss reduction) • DVD recorder • Twenty-inch video monitor • Pressure Zone Microphone (we placed ours directly in the ceiling, not hanging down from it, by cutting a small hole in the soft tiles). Indications: Direct observation is best for supervising and teaching interviewing skills, physical examinations, organizational skills, clinical reasoning, and attitudes (Hauer, Holmboe, & Kogan, 2011). Advantages: The following are advantages of direct observation. • Fulfils legal obligation for patient supervision as well as teaching about clinical knowledge, decision making, and interviewing • Obviates the need for learners to repeat the details of the history and physical before you discuss management • Provides opportunity, with recording, for learners to see what they have done and draw some of their own conclusions; your points can be seen instead of just described. Limitations: The following are limitations of this strategy. • Time consuming • Increases learners’ anxiety as they know a teacher is watching • The presence of a teacher in the room often interferes with the relationship between learner and patient • Recording requires specific patient consent Costs: The following items refer to time and resources. • Moderate expense for equipment • The process of sitting in with, or remotely observing, learners reduces the number of patients you see • If a session is recorded, you can continue to see patients during

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office hours, but you will need to set time aside to review the tape (this time may be at the expense of other practice activities) Example: A second-year medical student is in your office for her clinical experience in cardiology. You have arranged to see two patients from your volunteer register. As you see some of your follow-up patients, the student interviews these two patients and records the encounters. Afterward, you watch both histories with her. In previous visits to your office, she has had trouble completing histories in a reasonable time. You can both see she is uncertain of the sequence of questions, gets quite confused, and goes in circles around the presenting complaint. You discuss how she might learn to question the patient in a more efficient manner. Tips: The following tips are helpful when using direct observation. 1 You may not know what to look for when you start using direct observation. Figure 4.2 shows a cue sheet that may help guide your observation as well as provide a template for making notes on significant points for comment. This way you can provide specific examples instead of general ones, especially when you do not have recording equipment. 2 If you are using a DVD player, note when interesting interactions happen with the patient. Electronically, bookmark those points of the encounter so you do not have to replay the entire recording. Choose one or two segments to review when only a brief time is available. 3 Remember the skills you use within a learner premise. Use the same skills in direct observation. 4 Watch the encounter from the start. Ask the learner to stop it when he wishes to make a comment or ask a question about an issue of concern. Otherwise, stop the recording occasionally and ask the learner for comments first before you give your opinion. Use of Charts Completing the chart or electronic medical record of the visit is an essential part of each patient encounter. It can also be a valuable aid to teaching in the ambulatory care setting. There are three ways that the chart can become an integral part of your office teaching: chart review, stimulated chart review, and criterion chart review. The following sections explain these strategies.

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Figure 4.2. Direct observation encounter form

DIRECT OBSERVATION ENCOUNTER FORM Name Rating 4 - above level of training 2 - below level of training

Date 3 - satisfactory for level of training 1 - unsatisfactory Score

INTERVIEWING • introduces self • puts patient at ease • open/closed questions • listens well • avoids jargon • clear explanations • diagnosis clarified • allows questions HISTORY • patient’s agenda clarified • non-verbal cues • focused questions • completeness DOCTOR-PATIENT RELATIONSHIP • empathy • support • respect for patient • drapes patient properly Suggestions:

Examples

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chart review Description: This strategy is very similar to case review, but it uses the written or electronic record of the patient’s visit instead of the learner’s verbal report. At lunchtime, the end of the day, or any other convenient block of approximately thirty minutes, you can sit down to review the previous session’s patients. Encounter by encounter, read the learner’s entry of the visit, history and physical, diagnosis, tests ordered, and treatment recommendations. Follow this with discussion on the essentials of completing the patient record as well as any other topic generated by the cases at hand, either from the teacher or learner-based premise. You could also cover basics such as legibility (if applicable), format, length, thoroughness, problem-based summary pages, and the preparation of consultation reporting letters. Indications: Chart review is best used with more senior learners who have worked more or less autonomously during the patient session, but who still require patient review at the end of the session. Alternatively, with junior learners (where you have already reviewed each case before the patient left), this strategy can be used to focus on the teaching about recording the encounter. Advantages: The following are advantages of chart review. • • • • •

Fulfils legal obligations to have a licensed physician review the case Ensures quality of encounter record Is less dependent on learners’ verbal reports Uses case material for discussion and teaching Allows for teaching about the completion of medical records Limitations: The following are disadvantages of this strategy.

• Depends on learners’ written reports of each encounter • Does not assess interviewing or physical examination skills Cost: The following items refer to time and resources. • Interferes little with practice routines • Time must be set aside for teaching after seeing patients Example: A resident is working in the outpatient clinic this month. He has seen his list of patients for the morning and you sit down together to review his cases. You read each encounter and discuss both the case management and also some topics of concern to him that are

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inspired by several of the cases. After completing the charts, it is apparent to you that he did not have a clear, organized format for completing each encounter, even though he seems to get all the important information on the record. The two of you spend the last ten minutes of the thirty-minute session developing a recording system with which he feels comfortable, based on the SOAP (subjective objective assessment plan) format. Tips: The following tips are helpful during case review. 1 Remember the teachable moment. The patient record visually highlights issues on which you can make a lasting impression. 2 The fact that you use the patient’s chart as a teaching stimulator will give the learner a strong message about the importance of medical records. 3 Reviewing medical records is an important tool of the quality assurance programs being developed for ambulatory care settings. By making chart review part of your teaching, learners gain insight into how chart audits can improve health care. chart-stimulated recall Description: Use this strategy in a one-to-one session with a learner working in your office. Choose a time when you have at least thirty minutes. Ask the learner to select several encounters with patients she has seen, and randomly select two patients to cover in the session. Ask her to review and recall the patient encounter, step by step (Schipper & Ross, 2010; Cantillon & Wood, 2010). Use the chart to spur the learner to recall not only what happened with a particular case but also her thinking during the encounter. Ask questions such as the following: “What were you thinking at that point?” “Why did you ask those questions?” “What led you to that conclusion?” “Why did you stop there?” “What other things were you thinking about?” “Did you have a most likely diagnosis at that point?” “Why choose those options?” Do this for each stage of the interview (i.e., history, physical examination, differential diagnosis, severity of illness, aetiology, plan of

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action, and choice of investigation and treatment). At each of these steps, enquire about what the learner was thinking before she moved on. Encourage her to explore her thinking process during the interview and not in retrospect after its completion. Indications: Chart-stimulated recall is used to evaluate and assist learners in understanding and improving their clinical reasoning and decision-making process. It is especially helpful for learners who seem disorganized in patient encounters, have poor time management, are constantly behind, or cannot seem to make a firm decision. Advantages: The following are advantages of chart-stimulated recall. • Powerful strategy for reviewing decision-making processes because the teacher and learner set time aside for it, and focus entirely on thought processes rather than on management issues • The chart helps the learner recall details of what actually occurred Limitations: The following are limitations of this strategy. • A commitment of at least thirty minutes of time. • Requires that additional specific time be set aside after the time already used for routine review of these patients seen during the clinic. • Must be done shortly after the learner sees the patients, probably within forty-eight hours • Initially provokes learner anxiety and requires a lot of trust between learner and teacher Cost: The following items refer to time and resources. • Extra time needs to be set aside in addition to regular patient supervision • This time is at expense of regular practice activities or personal time Example: A final-year medical student, Eric, is doing a required rotation in your office. He sees each patient on his own, and then you join him and see the patient together. Although he gets a good grasp of each patient’s problems, he is very slow. You decide to sit down with him after you have finished seeing all the patients for the day, and ask him to select four interesting encounters from the previous two days and bring them to your office. At the session, you go through chart-stim-

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ulated recall with two of those charts. It becomes apparent that each time Eric sees a patient, he asks more and more questions to confirm the hypothesis that he is formulating in his mind (i.e., he keeps seeking more clues in the decision tree). No wonder he takes so long with each patient. The two of you plan to review the cases again to see where he could have shortened his searching for cues yet still felt comfortable that his hypothesis was confirmed. You also decide that next week, when he presents his cases to you, he will alert you to when in the interview his main hypothesis first came to mind to help him further shorten his search for confirmation. Tips: The following tips are helpful when using chart-stimulated recall. 1 This type of strategy is best when used occasionally and usually not more than once every two weeks. 2 You may use it not only for learners with problems but also for highfunctioning learners to teach them the process of decision making. 3 You can also use this strategy with recordings of the learner’s encounters. While you view the encounter, ask the learner to interrupt at any point to tell you what she was thinking. Question her about her thoughts as you see fit. The recording acts as a potent stimulus to help the learner recall what she was thinking. criterion chart review Description: This is another strategy for reviewing a chart. It differs in that you audit the charts on your own, at your own pace, when you can set aside about fifteen to thirty minutes. Give the results to the learner at a session the following day. A standard checklist acts as a guide to what to look for in the chart. It is an efficient and reliable method for reviewing the learner’s ability to take a complete and comprehensive medical history. You and your colleagues should draw up a checklist of your own. Use one of your evening sessions to discuss what information is most important to gather from the chart and draw up a one-page sheet to use during the chart review. You can type and photocopy it for use by your group members. Going through the process of creating the checklist will help all of you better understand the strategy of criterion chart review. The checklist varies somewhat according to specialty, but there are basic elements to every patient encounter. Figure 4.3 gives an example from our practice.

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Figure 4.3. Criterion chart review form

CRITERION CHART REVIEW FORM Name Rating

Date 3 - exceeds expectations 1 - below expectations

Criterion PRESENTING ISSUE • reason for visit clearly identified • full description of complaint • pertinent negative questions HEALTH REVIEW • current medical problems • medications listed FAMILY HISTORY • details of first degree relatives DIAGNOSIS • main problem identified MANAGEMENT PLAN • appropriate questions • correct treatment • referral option? ORGANIZATION • uses structured format • patient profile page updated LEGIBILITY (PAPER) • clarity of writing

2 - meets expectations 0 - missing from chart Score

Comments

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Indications: Use this strategy to review patients seen by the learners working in your office when there is little time to meet learners during the usual work day. Review the learners’ work on your own in your spare time. Advantages: The following are advantages of criterion chart review. • Fulfils the medical legal requirement for review of patient by licensed physician • Ensures the quality of the medical record • Can be deferred to a time of your choice • Checklist provides stimulus for you to recall specific criticisms • Gives the learner descriptive information about patient management and medical record • Permits senior learners to work autonomously and be evaluated subsequently • Takes less time than direct observation, but you can gather a fair amount of information for teaching Limitations: The following are limitations of this strategy. • Requires more time than other chart review methods because you scrutinize the charts independently and then meet with the learner to summarize your review • Depends largely on the learner’s record of each patient encounter • Does not assess interviewing or physical examination skills Cost: The following items refer to time and resources. • Requires considerable time to prepare a checklist and conduct the actual chart review, but not at the expense of practice income Example: A senior resident is assigned to your specialty group and works independently. At night, you review the charts she has prepared. Using your checklist, you note that she documents everything appropriately and manages all her cases well, but records scant details of patients’ histories and physicals. You note some examples on the checklist and meet with her just before you do hospital rounds the next day to review your findings. Tips: The following tips are helpful during criterion chart review. a Give the blank checklist to the learner when she first starts at your office so she is aware of what you look for when doing a

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criterion chart review. Then it is not a surprise examination but a planned learning experience. b In the ambulatory setting, rounds similar to inpatient attending rounds are difficult to establish. If more than one learner is assigned to your clinic, meet with them for an ambulatory morning report. Use cases drawn from your criterion chart review as a basis for a comprehensive review of one or two topics (Spickard, Hales, & Ellis, 2000). Invite other staff doctors from your clinic to present a case of interest. Use of Educational Techniques Sometimes, patients do not provide the necessary case material for teaching. There are several strategies you may use when time is short that require limited preparation and can focus learning on a particular topic. These strategies are: role play and simulation, short didactic presentation, and e-learning. The following sections explain these strategies. role play and simulation Description: Role play involves acting out a defined character in a mock situation. Individuals take the parts of the doctor and patient and recreate an office visit. Usually, the teacher plays the role of a patient and acts out a particular scene or medical problem while the learner conducts an interview. It is also useful, however, to have the learner play the patient or have learners play both roles if more than one is present. Use actual patient encounters as the material for role playing. When the learner plays the doctor, have her practice different parts of the interview and various approaches to each circumstance. After each segment, share comments from both players about the effectiveness of the approach and their underlying feelings about the role. Role play can be open or structured. Open: The patient role is played following intuition and previous experience with patients. Structured: The player follows a specific script in order to make a very definite learning point. Some medical schools have actors or other interested people rehearse to play clinical scenarios. These people are specially trained to simulate

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a patient in every detail. They can reproduce a problem as if it were their own and present the same physical and emotional picture as an actual patient (Myung et al., 2010) Simulated patients give teachers a consistent, identified patient problem that can be scheduled for a convenient time. These simulated patients can provide unbiased feedback to learners about their own reactions to the interview. Banks of simulated patients are usually developed through the dean’s office of a medical school. They are often included in part of the curriculum for teaching interviewing skills and could be used effectively in an office setting to add some reality to the simulation. You can set role-play teaching aside for a prearranged time (twenty to twenty-five minutes are required).You can also use it spontaneously in the course of an informal case discussion, when a learning point could be best conveyed with this type of simulation. If you have the facility, record the simulation. Indications: Use this strategy to help learners recognize and focus on difficulties in interviewing, history taking, psychotherapy, patient education, or dealing with difficult patients such as those who are angry, flirtatious, or withdrawn. The technique can also be used as preparation for board or licensing examinations (Joyner & Young, 2006). Advantages: The following are advantages of role play. • Interviewing takes place under controlled, safe circumstances. The unplanned and uncontrolled variability of real patients can be eliminated. • Learners can receive an immediate response and try corrective strategies without fear of upsetting patients. • There is not the time pressure of an office schedule. • Learners can experience what it is like to be in the patient’s place and gain valuable insight into their own attitudes. Limitations: The following are limitations of this strategy. • Learners often complain that the simulation is not real and that the artificiality interferes with their usual performance. This response reflects the learner’s anxiety. It is our experience that performance in simulations is remarkably consistent with that in “real” patient encounters. • It can be very anxiety provoking for the teacher to play the role of a particular patient.

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• For the strategy to succeed, the teacher and learner must trust each other. Costs: The following items refer to time and resources. • Time needs to be set aside in addition to regular patient supervision. • lf using simulated patients, you need to coordinate with your medical school to bring actors to the office. Example: You are working with a junior resident in your office this month. Some patients have complained about his communication skills. You note, however, that difficulties arise mainly with your most demanding patients. You set up a time at lunch for a role play session with the resident in which you play a demanding patient. During the role play, it is obvious the resident reacts angrily at the first indication that a patient may be overly demanding. You discuss this reaction with him, the reasons behind it, as well as possible options in dealing with this kind of patient. short didactic presentation Description: Short didactic presentations are a traditional teaching method in medicine. One person presents information to others, typically covering a cognitive area of learning. Either teacher or learner may present a brief topic pertaining to the ambulatory care rotation, usually in response to seeing an interesting or difficult patient. We have found that a ten-minute presentation is sufficient time to provide a concise summary of the material without overloading the learners with unnecessary detail. In our office, these presentations are usually part of a case review session at lunchtime or the end of the workday. Indications: Use this strategy when a learner has a well-defined knowledge gap in a given clinical area. You can also use it to cover any core topics required by the curriculum in your medical school. As learners in ambulatory experiences encounter a variable and random mix of patients, supplemental structured time may be necessary to enhance their breadth of knowledge of common ambulatory problems. This strategy could also be used for teaching about practice management, writing consultation reports to referring physicians, time management in the office, or billing matters. Advantages: The following are advantages of using short didactic presentations.

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• Provokes less anxiety than other methods, for there is time to prepare in advance • Covers topic concisely • Gives learners an opportunity to practice presentation skills and get comment from you • Shows learners how members of a group in practice can help each other keep up to date on knowledge and skills Limitations: The following are limitations of this strategy. • Is useful mainly for cognitive areas of learning • Requires advanced preparation in spare time Costs: The following items refer to time and resources. • Brief addition of time to your regular teaching and supervision of patient care Example: The course director for your specialty asks that you cover six specific common problems with learners at your clinic. You ask your two learners to prepare three topics each and present them at a case review session held twice weekly. Tips: The following tips are helpful during didactic presentations. 1 Use the patients discussed at case review sessions to generate topics for short didactic presentations. Assign a topic or specific reading to a learner and set a mutually agreeable time for its presentation. If the presentation is not part of regularly scheduled rounds, mark it on your calendar; otherwise, you will forget about it. 2 When conducting a short didactic presentation, do the following: • • • •

Break the information down into easily assimilated components. Try to relate the information to previously learned material. Aim for the learners’ current level of knowledge and build on that. Keep the amount of information limited to between three to six units of knowledge.

3 To use a problem-based learning method, provide learners with an actual patient example of a core topic and ask them to build their presentation from that case (Wood, 2003; Azer, 2005).

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4 It is difficult to cover core curriculum topics during the ambulatory experience. One learner may be on vacation, have conflicting inpatient responsibilities, or post night-call and be away from your office just when you have scheduled a core topic discussion. To avoid repetition, store the content of the presentation (in either a wordprocessing document or PowerPoint slides) on a USB device or the office computer. Learners who miss a discussion can then access and review the content at their convenience. You can even use email or cloud-based storage sites (either the medical school’s website or inexpensive file hosting sites) so learners can catch up remotely. e-learning Description: E-learning is learning that uses any type of computerbased technology, but it often refers to the use of online resources or tools (Bostock, 2001). Just as desktop computers, laptops, tablets, and smartphones have transformed the way healthcare is delivered and are widely used in medical schools, teachers in offices and clinics can use technology to enhance learning. As well, electronic medical records are often used in clinics and can specifically impact teaching. Learners access and assimilate information quickly using pre-sorted evidence (e.g., ePocrates, Up-to-Date). Answers to clinical problems or questions are accessible within seconds, allowing learners to both acquire knowledge and apply it immediately within the clinical setting (Murnaghan, Forte, Choy, & Abner, 2011). Indications: Learners use these technologies to quickly answer questions in the cognitive domain that arise from clinical encounters. Also, teachers use web-based sources of patient simulations, cases, and virtual learning to supplement day-to-day instruction (Wong & Lochnan, 2005; Cook et al., 2008). Advantages: The following are the advantages of e-learning: • Learners can fill gaps in their factual knowledge related to the patient encounter before discussing the case, which allows teacher and learner to work on other matters. • Technology is readily available in most offices and clinics. • Many learners come to the office with their own devices, which they are already comfortable using. • Many web-based resources are available to supplement one-to-one teaching in the office or clinic.

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Limitations: The following are limitations of this strategy. • Learners tend to passively use technology as simple portals to information. • Studies show learners retain less knowledge from retrieving passive electronic information than they do from more traditional educational activities (Crelinsten, 2004). • Learners working in your clinic may have variable knowledge of relevant online resources for your specialty. Costs: The following items refer to time and resources: • Many learners possess their own laptops, smartphones, or tablets, and so no expenditure by the clinic is required • Quick access to clinical information and therapeutics may help learners see patients more efficiently. Example: A senior medical student is working with you in the clinic. Despite a solid knowledge base, she presents very disorganized histories to you at case discussion. She often presents the details of a case in a random manner with key information missing. You show her the templates from the electronic health record that provide a systematic approach to the patient and prompt her to ask pertinent questions. There are templates available for the various medical symptoms with which patients present to the clinic. Tips: The following tips are helpful when using e-learning. 1 Suggest learners use resources that encourage “just in time” learning. This is defined as learning that occurs in relation to the patient’s problems in real time within the context of the visit (Morrow & Dobbie, 2010). 2 It is not what you teach or what technology you use, but what the learner, remembers, and applies, that counts (Dror, Schmidt, & O’Connor, 2011). Allow learners to quickly retrieve information using their preferred devices and then use other strategies in this chapter to actively integrate the information into long-term learning (Kho, Henderson, Dressler, & Kripalani, 2006). Facts about diseases, guidelines for prevention, and pharmacotherapy information can be quickly accessed and need not necessarily be taught. But problem

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solving, decision making, and dealing with uncertainty should be your focus with these strategies (Ruiz, Mintzer, & Leipzig, 2006). Show learners the sites and applications appropriate to your specialty. These may include web-based and mobile applications for textbooks, practice guidelines, drug references, medical calculators, and patient education materials (Ellaway & Masters, 2008). Show learners how to use these technologies for continuing medical education. Demonstrate how to access online courses, podcasts, or other virtual learning programs (Baumgart, 2011). Consider using blogs or wikis to provide advanced orientation material to, or communicate with, your learners. This is especially useful if you have learners working with you in a longitudinal curriculum. You may contact learners about cases and other clinical information using these methods when they are not in the office (Sandars, 2006). Medical schools often require learners to complete modules related to assigned topics. As well, your curriculum director may have created other learning modules related to ambulatory care (Cook & Dupras, 2004). Ask your learners to access these sites when the clinic is closed, when patients fail to show, or when you need time for clinic activities that do not involve your learners (Skye, Wimsatt, Master-Hunter, & Locke, 2011).

A Comment on Cost At the conclusion of the dinner meeting to discuss all these teaching strategies, Dr. Brown again had a question: “Sure, we can use all these good educational strategies, but what will they cost us? What are the financial implications of using our practice as an ambulatory care teaching centre? How will it impact our personal time?” Based on the current literature, Dr. Smith was able to report to his colleagues (Bowen & Irby, 2002): • Time saving from learner charting can allow teachers to care for patients and teach without losing valuable practice time (Usatine, Tremoulet, & Irby, 2000) • The teaching physician may see fewer patients when less experienced learners are present. However, senior learners may add to the clinic productivity (Johnson, Shah, Rechner, & King, 2008).

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Figure 4.4. Summary of teaching strategies

TEACHING STRATEGIES SUMMARY STRATEGY

INDICATIONS

ADVANTAGES

LIMITATIONS

COST

case discussion

• new trainee • comments between patients

• close monitoring of trainee

• relies on trainee report

• teacher works at the same time

case review

• senior trainee • when patient flow is rapid

• increased learner autonomy • in-depth knowledge evaluation

• relies on trainee report

• extra time needed after patients are seen

direct observation

• teaching clinical exam, interview skills, attitudes

• no need to repeat encounter • learner may make own conclusions

• learner anxiety • patient consent • time consuming

• extra time for review

chart review

• senior trainee

• not dependent on verbal report

• relies on EMR or paper chart

• time spent later to review

chart stimulated recall

• teaching about decision making

• record is stimulus to recall events

• time consuming

• after patient hours

criterion chart review

• review of learner’s knowledge

• deferred to a convenient time

• relies on trainee record

• time after hours

role play

• teaching of interview skills, attitudes

• controlled situation

• artificial? • anxiety provoking

• extra time needed

short didactic presentation

• learning in a cognitive environment

• covers a topic efficiently

• time to prepare ahead

• added time to teach

e-learning

• quick answers to questions • access to web

• learners are comfortable with computers

• passive use of data

• uses time well

• Physicians spend an average of thirty minutes a day longer in the office when learners are present (Denton, Durning, Hemmer, & Pangaro, 2005), but do this because teaching increases their enjoyment of the practice of medicine and lead to activities that further professional growth, such as increased reading of the medical literature and reviewing the basics of clinical medicine (Boex et al., 2000).

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REFERENCES Aagaard, E., Teherani, A., & Irby, D.M. (2004, Jan). Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: proof of concept. Academic Medicine, 79(1), 42–49. http://dx.doi. org/10.1097/00001888-200401000-00010 Medline:14690996 Azer, S.A. (2005, Dec). Challenges facing PBL tutors: 12 tips for successful group facilitation. Medical Teacher, 27(8), 676–681. http://dx.doi. org/10.1080/01421590500313001 Medline:16451886 Baumgart, D.C. (2011, Jul 25). Smartphones in clinical practice, medical education, and research. Archives of Internal Medicine, 171(14), 1294–1296. http://dx.doi.org/10.1001/archinternmed.2011.320 Medline:21788549 Boex, J.R., Boll, A.A., Franzini, L., Hogan, A.J., Irby, D., Meservey, P.M., & Veloski, J.J. (2000, May). Measuring the costs of primary care education in the ambulatory setting. Academic Medicine, 75(5), 419–425. http://dx.doi. org/10.1097/00001888-200005000-00007 Medline:10824763 Bostock, S. (2011). E-learning and virtual learning environments. In K. Mohanna, E. Cottrell, D. Wall, & R. Chambers (Eds.), Teaching made easy (3rd ed.), 117–24. Abingdon: Radcliffe Publishing. Bowen, J.L., & Irby, D.M. (2002, Jul). Assessing quality and costs of education in the ambulatory setting: a review of the literature. Academic Medicine, 77(7), 621–680. http://dx.doi.org/10.1097/00001888-200207000-00006 Medline:12114139 Cantillon, P., & Wood, D. (2010). Direct observation tools for workplace-based assessment. In P. Cantillon & D. Wood (Eds.), ABC of learning and teaching in medicine (Chapter 12). London: Blackwell Publishing Ltd. Cook, D.A., & Dupras, D.M. (2004, Nov). Teaching on the web: automated online instruction and assessment of residents in an acute care clinic. Medical Teacher, 26(7), 599–603. http://dx.doi.org/10.1080/01421590400004932 Medline:15763848 Cook, D.A., Levinson, A.J., Garside, S., Dupras, D.M., Erwin, P.J., & Montori, V.M. (2008, Sep 10). Internet-based learning in the health professions: a meta-analysis. Journal of the American Medical Association, 300(10), 1181–1196. http://dx.doi.org/10.1001/jama.300.10.1181 Medline:18780847 Crelinsten, G.L. (2004, Mar 4). The intern’s palmomental reflex. New England Journal of Medicine, 350(10), 1059. http://dx.doi.org/10.1056/ NEJM200403043501022 Medline:14999124 Dror, I., Schmidt, P., & O’connor, L. (2011). A cognitive perspective on technology enhanced learning in medical training: great opportunities, pitfalls and challenges. Medical Teacher, 33(4), 291–296. http://dx.doi.org/10.3109/0142 159X.2011.550970 Medline:21456986

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Denton, G.D., Durning, S.J., Hemmer, P.A., & Pangaro, L.N. (2005, Summer). A time and motion study of the effect of ambulatory medical students on the duration of general internal medicine clinics. Teaching and Learning in Medicine, 17(3), 285–289. http://dx.doi.org/10.1207/s15328015tlm1703_15 Medline:16052732 Ellaway, R., & Masters, K. (2008, Jun). AMEE Guide 32: e-Learning in medical education Part 1: Learning, teaching and assessment. Medical Teacher, 30(5), 455–473. http://dx.doi.org/10.1080/01421590802108331 Medline:18576185 Grover, M. (2003, Mar). Teaching general rules during ambulatory education. Family Medicine, 35(3), 160–162. Medline:12670105 Heidenreich, C., Lye, P., Simpson, D., & Lourich, M. (2000, Jan). The search for effective and efficient ambulatory teaching methods through the literature. Pediatrics, 105(1 Pt 3), 231–237. Medline:10617728 Hauer, K.E., Holmboe, E.S., & Kogan, J.R. (2011). Twelve tips for implementing tools for direct observation of medical trainees’ clinical skills during patient encounters. Medical Teacher, 33(1), 27–33. http://dx.doi.org/10.3109 /0142159X.2010.507710 Medline:20874011 Jaques, D. (2010). Teaching small groups. In P. Cantillon & D. Wood (Eds.), ABC of learning and teaching in medicine, 23–28. London: Blackwell Publishing Ltd. Johnson, T., Shah, M., Rechner, J., & King, G. (2008, Jul). Evaluating the effect of resident involvement on physician productivity in an academic general internal medicine practice. Academic Medicine, 83(7), 670–674. http:// dx.doi.org/10.1097/ACM.0b013e3181782c68 Medline:18580086 Joyner, B., & Young, L. (2006, May). Teaching medical students using role play: twelve tips for successful role plays. Medical Teacher, 28(3), 225–229. http:// dx.doi.org/10.1080/01421590600711252 Medline:16753719 Kho, A., Henderson, L.E., Dressler, D.D., & Kripalani, S. (2006, May). Use of handheld computers in medical education. A systematic review. Journal of General Internal Medicine, 21(5), 531–537. http://dx.doi.org/10.1111/j.15251497.2006.00444.x Medline:16704405 Ludmerer, K.M. (2000, Jan 4). Time and medical education. Annals of Internal Medicine, 132(1), 25–28. Medline:10627247 Morrow, J.B., & Dobbie, A. (2010, Jan). Using the electronic health record to enhance student learning. Family Medicine, 42(1), 14–15. Medline: 20063214 Murnaghan, M., Forte, M., Choy, I., & Abner, E. (2011). Innovations in learning in the clinical setting for postgraduate medical education. Members of the Future of Medical Education in Canada Postgraduate Consortium. Myung, S.J., Kang, S.H., Kim, Y.S., Lee, E.B., Shin, J.S., Shin, H.Y., & Park, W.B. (2010). The use of standardized patients to teach medical students clini-

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cal skills in ambulatory care settings. Medical Teacher, 32(11), e467–e470. http://dx.doi.org/10.3109/0142159X.2010.507713 Medline:21039087 Neher, J.O., Gordon, K.C., Meyer, B., & Stevens, N. (1992, Jul-Aug). A five-step “microskills” model of clinical teaching. Journal of the American Board of Family Practice, 5(4), 419–424. Medline:1496899 Ruiz, J.G., Mintzer, M.J., & Leipzig, R.M. (2006, Mar). The impact of E-learning in medical education. Academic Medicine, 81(3), 207–212. http://dx.doi. org/10.1097/00001888-200603000-00002 Medline:16501260 Sandars, J. (2006, Dec). Twelve tips for using blogs and wikis in medical education. Medical Teacher, 28(8), 680–682. http://dx.doi. org/10.1080/01421590601106353 Medline:17594577 Schipper, S., & Ross, S. (2010, Sep). Structured teaching and assessment: a new chart-stimulated recall worksheet for family medicine residents. Canadian Family Physician Médecin de Famille Canadien, 56(9), 958–959, e352–e354. Medline:20841601 Skye, E.P., Wimsatt, L.A., Master-Hunter, T.A., & Locke, A.B. (2011, Mar). Developing online learning modules in a family medicine residency. Family Medicine, 43(3), 185–192. Medline:21380951 Spickard, A., III, Hales, J.B., & Ellis, S. (2000, Feb). Outpatient morning report: a new educational venue. Academic Medicine, 75(2), 197. http://dx.doi. org/10.1097/00001888-200002000-00023 Medline:10693857 Usatine, R.P., Tremoulet, P.T., & Irby, D. (2000, Jun). Time-efficient preceptors in ambulatory care settings. Academic Medicine, 75(6), 639–642. http:// dx.doi.org/10.1097/00001888-200006000-00016 Medline:10875509 Wolpaw, T.M., Wolpaw, D.R., & Papp, K.K. (2003, Sep). SNAPPS: a learnercentered model for outpatient education. Academic Medicine, 78(9), 893–898. http://dx.doi.org/10.1097/00001888-200309000-00010 Medline:14507619 Wolpaw, T., Papp, K.K., & Bordage, G. (2009, Apr). Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial. Academic Medicine, 84(4), 517–524. http://dx.doi. org/10.1097/ACM.0b013e31819a8cbf Medline:19318792 Wong, R.W., & Lochnan, H. (2005, May). Online simulations of ambulatory care for medical residents. Medical Education, 39(5), 527–528. http://dx.doi. org/10.1111/j.1365-2929.2005.02145.x Medline:15842713 Wood, D.F. (2003, Feb 8). Problem based learning. British Medical Journal, 326(7384), 328–330. http://dx.doi.org/10.1136/bmj.326.7384.328 Medline:12574050

Chapter Five

Special Learning Situations

It has been a year now since medical students and residents started coming to Dr. Smith’s group practice. Overall, it has been a positive experience for the staff, and learners’ evaluations of their time in the clinic have been favourable and appreciative. The patients have responded well, and the doctors are becoming more comfortable with the ambulatory care teaching strategies. As one of Dr. Smith’s colleagues said: “When a motivated learner encounters an enthusiastic teacher in a conducive environment, learning seems easy.” As Dr. Smith and his associates have also discovered, however, office procedures do not always run smoothly. Some learners create challenges in the office by interfering with the learning of others or by frustrating the teachers and the rest of the office staff. The doctors have decided to devote today’s evening session to reviewing difficult learning situations in the office over the last year and developing mechanisms to deal with problems in the future. They have invited the director of the department of medical education in the local faculty of medicine to act as a resource. A summary of their conclusions about some general principles follows: 1 Begin to address a problem situation as soon as you recognize it (McGraw & Verma, 2001). 2 Document examples of the problem as they occur so you can be specific with learners when discussing the issue. You will not remember many of them when learners challenge you and ask for specific examples of the problem. 3 Meet with learners and make them aware of your concerns. Obtain their viewpoint and, together, set up a plan for dealing with the problem (Lake & Ryan, 2006).

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4 Each situation is the result of a dynamic between three factors: the learner, the teacher, and the learning environment. Approach the solution by addressing each of these factors. 5 Some problems are related to the learner’s personality. A teacher is not a psychotherapist, and is not expected to diagnose or treat wellestablished traits. If a personality issue seems to play a role in the problem, however, you can at least make the learner aware of it. The dean’s office or curriculum director can then help if more in-depth treatment is a solution. In the meantime, there are some initial strategies that will help you deal with certain personality types when they interfere with learning (Lake & Ryan, 2005). 6 Arrange a follow-up meeting with the learner to monitor progress with the plan of action. 7 You may be able to prevent some problems by understanding and applying principles of learning to your teaching (Steinert, 2008). 8 You will rarely be able to resolve a problem situation completely. In ambulatory care teaching, your encounter with a learner will, in most cases, be only a small fraction of their training time. You can start the process, however, by helping the learner realize the problem and set up an initial plan to work on it while they are with you. 9 If you notice a recurring problem in learners rotating through your ambulatory care teaching centre, consult with the dean’s office or curriculum director. Learners may have established behaviours in their basic training as an unknown consequence of the curriculum. A Summary of Special Learning Situations Dr. Smith’s group compiled a list of problem situations based on their previous encounters with learners. It includes: Clinical Learning Situations • • • •

Difficulties with clinical judgment Poor knowledge base Slow worker Premature closure of inquiry

Patient-Related Situations • Ethnic, racial, or gender biases • Avoidance of difficult patients

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• Inappropriate grooming or dress Teacher-Learner Interactions • • • • • •

Argumentative with teaching staff Defensive about errors or weaknesses Disruptive of group learning Does not respond to questions Noncommittal to management plans Sycophantic toward staff

Personal Issues • • • • • • • • • •

Overconfident as doctor Over-involved with patients Overcommitted Shy with colleagues and staff Laziness Psychiatric problems Lacks self-direction in learning Lies to teaching staff Substance use Lack of professionalism

None of these situations is exclusive to ambulatory care teaching. However, the nature of such teaching, with its intensive one-to-one work, means these problems are often more apparent. They may have more impact on an office routine than a hospital ward, where the team structure helps diffuse the problem and prevents it from affecting patient care. The team may shelter the learner, which can hinder discovering the problem. Your office is an ideal setting to begin the process of change. We will now examine each of these special situations; examine the dynamic between the learner, teacher, and environment; and describe some strategies we have used to help teachers and learners deal with them. Clinical Learning Situations Difficulties with Clinical Judgment Issue: Inability to make appropriate, logical, or correct decisions based on the evidence.

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Presentation: In clinical decision-making, knowledge and experience help physicians choose an appropriate route of action. Learners with poor judgment tend to draw the wrong conclusions based on the available data. Their diagnostic choices do not follow from the clinical information. Their management plans are not sensible and their word selection or approach to patients may be unsuitable (Reamy & Harman, 2006). Example: A final-year medical student is assigned to your office once a week throughout the first term. Her fund of medical knowledge is satisfactory, as are her history-taking skills. On several occasions, however, when the available data points to a major illness, she diagnoses a less serious condition. At other times, she does not ask for help when she needs it. She occasionally misinterprets laboratory results and her recommendations based on those results often do not follow logically. At other times, she dwells inappropriately on several worst-case scenarios and upsets her patients in the process. Considerations: When you encounter a learner with poor judgment, there may be several factors involved: • A poor knowledge base may affect the learner’s ability to draw appropriate conclusions. • Lack of clinical experience may lead the learner down the wrong track. • Anxiety, either from a personal problem or related to pressure from the teacher or the office setting (e.g., a demanding teacher or busy office) can interfere with judgment. (Anxiety interferes with concentration, causing the learner to miss cues or hurry to an incorrect diagnosis.) • Overwork and fatigue cloud judgment by impairing concentration and limiting patience for detail. • Some learners cannot set priorities, have disorganized thoughts, and cannot distinguish serious from trivial conditions. Management: The following strategies are helpful in managing these difficulties. • Discuss concerns with the learner and provide specific examples of the behaviour. • If the learner has poor knowledge, set a learning plan. • If the learner lacks experience, take a little more time to discuss each case as it occurs and highlight clues in the clinical presentation that lead to the diagnosis.

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• Explore the learner’s personal anxieties, or ask about difficulties in working in the current setting. • If fatigue is an issue, review the learner’s work or call schedule with the program director. Sometimes, what the learner really needs is a vacation. • Learners can adjust to weighing clinical evidence by integrating the concepts of prevalence and probabilities. Ask them to rank common disorders first when presenting a differential diagnosis (Rencic, 2011). • Use chart-stimulated recall to help learners weigh clinical evidence by assessing their clinical judgment and providing suggestions for change. Poor Knowledge Base Issue: A learner has insufficient or poor knowledge of the content of medicine for the current level of training. Presentation: The learner is consistently unable to explain standard medical concepts, underlying pathophysiology, or differential diagnoses. Sometimes, the learner cannot elucidate a plan of investigation or has difficulty in outlining options for treatment. The learner may also have an isolated knowledge gap. Example: One of your medical students has completed two weeks of a four-week rotation. The teaching staff comments that, despite “trying hard” and using seemingly reasonable judgment, there are just times when he does not know the tests to order and cannot seem to explain the rationale for his diagnostic choices. In addition, although he knows which drugs to order, he makes errors in prescribing them. Considerations: When you encounter a learner with a poor knowledge base, several factors may be involved. • The learner may not have acquired the specific knowledge during medical school. It may have been poorly taught or skipped altogether. Poor learning habits may have interfered with retaining the information. • Family or personal problems may have taken learners away from school or not allowed them to study. • Social activities or extracurricular school activities may have interfered with reading time. • The learner may have poor organizational skills, retaining just

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enough to pass examinations but not enough to flourish in the clinical setting. • Sometimes the learner has the knowledge, but the teacher does not provide clear questions, or may be quite demanding or overly critical. • The learner may be shy and reluctant to demonstrate actual knowledge. Management: The following strategies are helpful in managing a poor knowledge base. • Check the learner’s past evaluations to identify previous weaknesses in knowledge. An informal conversation with a previous supervisor may be helpful. • Meet with the learner and explore the possibility of personal or emotional conflicts that may have interfered with their medical school experience. If these exist, refer the learner to the appropriate dean’s office to identify opportunities for help. • Set up a plan with the learner to help fill in some knowledge gaps during the ambulatory rotation. The learner should be free to choose a preferred method, be it books, journals, websites, podcasts, update courses, etc. Suggest specific resources such as conferences, courses, or web-based sources. You should hold regular meetings to assess the learner’s progress and modify the plan as necessary. • Encourage the learner to read about a specific problem when it arises in response to cases seen in the office. Some learners may benefit from a problem-oriented textbook or website that focuses on symptom presentation, rather than from a disease-oriented approach. • If, in your discussion, it becomes apparent that the learner knows more than has been evident and has been reluctant to speak up, refer to the section on shyness for suggestions. Slow Worker Issue: A learner seems to spend excessive time with patients and is constantly behind schedule. Presentation: You will recognize this situation when the two of you are always the last ones to leave each day. The learner spends a great deal of time with each patient, not necessarily constructively. Before

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you even realize it, he is way behind in the schedule and often sees patients more than an hour late (Winter & Birnberg, 2002). Example: A final-year medical student is working in your office this month. Each night you leave the office later and later. You always seem to be waiting for the student to finish his last patient. When you observe him at work, he somehow manages to make a short visit into a long one. There are great delays between seeing patients, and you cannot figure out what he is doing. Everything takes him twice as long as any other final-year student in your office. Considerations: When you encounter slow workers, the following may be factors. • Each case usually involves several factors and each needs to be handled individually. Every part of the patient-doctor interaction can be a partial source of delay. The learner may be unable to do a focused history and physical examination, or may talk at great length. Lack of confidence or lack of experience can interfere with decision making and so slow each step along the way. Lack of knowledge of office routines will cause the learner to spend extra time between patients making arrangements for tests, consultations, and so on. • Some learners may be booked with too many patients for their level of training. • The teaching physician may take too much time between cases discussing the management and further delay the learner. Management: The following strategies are helpful in managing slow workers. • With the learner, try to determine where the delays occur. If available, record and review patient sessions to help pinpoint the areas of slowdown. • Remember, the problem is usually multi-factorial, and each problem needs to be handled on an individual basis as follows: • Lack of knowledge of office routines: Ask an office nurse or secretary to give special assistance to the learner to arrange laboratory tests, give injections, or call consultants. • Lengthy explanations: Learners often equate time spent with quality of the interaction. They need to be taught that a brief but clear explanation that leaves an opportunity for the patient to

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ask questions is better than a long-winded conclusion. The best method is to demonstrate this using role-modelling or role play. • Detailed history taking: Each specialty has its own version of a focused history, and learners, especially junior ones, need to be guided in the appropriate questions for a history in your type of ambulatory setting. • Lack of confidence or experience: The learner cannot move on from step to step in the patient encounter because of fear of making an error or missing something. Experience will eventually help, but in the meantime you can demonstrate from your own experience how the concepts of prevalence and likelihood allow you to move from step to step in the patient encounter. • Try booking fewer patients with the learner, and then increase the number booked per session as the learner shows he can handle them in the allotted time. • When appropriate, limit discussion time between patients to the essentials for patient care, and then refer to chapter 4 for additional ideas on other times for teaching. Premature Closure of Inquiry Issue: A learner narrows down the diagnosis prematurely. Presentation: There are two situations in which this issue is evident. First, when a learner takes a history from a patient, she will quickly narrow the series of questions and exclude a wider range of diagnoses. Similarly, in discussion of a differential diagnosis, the learner will present one dominant option with little consideration of a wider differential diagnosis. Example: Via video camera, you are observing a resident who is interviewing an elderly patient who presents with weakness. After a few general questions, the resident begins to ask a series of closed questions that focus on confirming a suspicion of depression. She asks questions in a manner to make the answers fit the diagnosis. She does not ask other questions that might help to rule out other possible causes of weakness. Considerations: Premature closure can result from any of the following. • The learner may have poor interviewing skills. She may not have

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•

• •

•

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learned the concept of listening to the patient, especially if her medical school does not have an interviewing skills course. Some learners use closed questions because they have been taught to take a medical history by following a series of defined questions to narrow down the diagnosis to one possibility. Learners ascertain that the object is to find a single diagnosis, and the teacher may unwittingly reinforce this conclusion. The learner may lack knowledge, not know the appropriate questions to ask, and focus on an area that she knows for greater comfort. The learner may be pressed for time because of a heavy patient load and be anxious to get to a diagnosis quickly. Because of inexperience, she thinks that a series of short, quick questions will get her more rapidly to the diagnosis. Sometimes the learner may be overconfident or insecure, and need to bolster her self-esteem with quick success.

Management: The following strategies are helpful in managing these difficulties with premature closure: • If you have recording equipment, show the learner an example of premature closure. Otherwise, if you have observed, but not recorded, an encounter, repeat the approximate sequence of questions for the learner. Then, using role play, have the learner do the interview again, taking more time to listen to the patient or using open-ended questions that expand the range of diagnostic possibilities. You can repeat this once a week until the learner has a better idea of the problem. • The learner can practise the use of open-ended questions in general, for example, as follows: teacher: A patient presents with abdominal pain. Try to list several questions that you might ask without specifically asking about the pain. learner: Can you tell me more about it? Can you tell me what led up to it? What concerns you about it?

• If the learner’s limited knowledge is blocking the exploration of other options, refer to the previous section for a method to improve knowledge. • If you conclude that overconfidence is an issue, see the section on overconfident learners for help.

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• Ensure the learner is not booked with too many patients for her level of training. • Use every opportunity to ask the learner the widest possible range of differential diagnoses. Consider as well that in ambulatory care, there is often no certain conclusion on diagnosis reached at many visits. • Remember that this is another type of problem for which chart stimulated recall can be used effectively. As the learner talks aloud about the interview, draw her attention to points at which she seemed to come to an early conclusion about the diagnosis and ask her to expand his range of possibilities. Then point out how this new range of possible diagnoses changes the sequence of questions to follow. Patient-Related Situations Ethnic, Racial, or Gender Biases Issue: A learner has a belief or particular bias that affects decision making, patient counselling, or the doctor-patient encounter. Presentation: Belief or bias can interfere with history taking and patient management. There may be biases based on family background or other important life experiences that are a major issue for the learner. There is an overall lack of respect for diversity of race, gender, religion, or sexual orientation. Example: Staff have noticed that a student has difficulty dealing with gay patients. He is obviously very uncomfortable in his interviews. He has difficulty asking about sexual orientation and is fearful of HIV and the risk of patient contact for health care workers. He offers little sympathy to such patients. Considerations: Bias can be related to the following factors. • Biases or prejudices are learned attitudes or behaviours that develop as the child grows. • These beliefs may be acquired from parents, relatives, friends, and school. Management: The following strategies are helpful in managing bias issues. • In ambulatory care, the teacher’s role is to identify learner biases

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that impact on patient care, not to change long-standing beliefs. • Meet with the learner, and provide specific examples of their bias in action. • Discuss the learner’s ethical responsibility toward the patient, and develop strategies to ensure the bias does not interfere with patient care. Avoidance of Difficult Patients Issue: This learner avoids contact with specific groups of patients with whom she does not enjoy working or has trouble handling. Presentation: There are certain groups of patients that learners will often avoid seeing if possible. These include the elderly, people of low socioeconomic status, the unkempt, the difficult historians, and the disabled. Learners may also bypass difficult patients, such as those who are dependent, demanding, or hostile. The learner creates every imaginable reason why she cannot see the patient (e.g., I’m way behind, this is Jan’s patient, etc.). If the learner has to see the patient, she spends as little time with them as possible. Example: A resident in the ambulatory clinic this month has been rude to some of the young teenaged mothers. She often makes derogatory comments about people who lack formal education. Several times, she has left these mothers waiting for long periods while she tended to non-urgent matters on the inpatient unit. You observed her behaviour with them, and noticed she was abrupt, impatient, and inattentive to their concerns about problems with their children. Considerations: When learners avoid difficult patients, a number of factors may be involved. • Most medical learners have middle-class expectations that can interfere with their interactions with other different groups. • Difficult patients evoke emotional negative reactions in doctors that often go unrecognized. The mere sight of the patient’s name on the day list can ruin an afternoon. An office visit or telephone call can leave the doctor frustrated. • Doctors deny these feelings of “hatred” toward these patients and then let their feelings affect future interactions (Groves, 1978). Management: The following strategies are helpful when dealing with learners who avoid certain patients.

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• Use patient profiles for learners to help document their avoidance of a particular group of patients. • To help learners deal with difficult patients, you must alert them to their emotional reaction to them. When discussing such a patient in case review or chart review sessions, ask learners about the feelings that the patient in question provoked (Trowbridge, 2008). Help them realize their reaction is not unique, and that it is proper for them to acknowledge it. Reference literature describing doctors’ common reactions to these types of patients to help learners accept these feelings as normal (Groves, 1978). You can then develop a strategy with the learner for dealing with this patient in the future. This should include the following: • Help the patient clearly identify the problem to be addressed (e.g., “Which problem should we talk about today?”). • Acknowledge the patient’s feelings directly (e.g., “You sound angry today.”). • Identify the source of the feeling (e.g., “Are you angry at anyone in particular?”). • Develop an explicit management plan involving the patient including a channeling of their emotional energy in a positive manner. • If time permits, use role play to practice some of these strategies. Both teacher and learner can play the role of the difficult patient, with the other practicing strategies. Inappropriate Grooming or Dress Issue: Conflicts in learning may arise when a learner’s physical appearance, dress, or personal hygiene distracts from the educational experience. Presentation: The learner may choose to wear casual clothing, such as blue jeans or a T-shirt, which the teaching staff may consider inappropriate for a clinical setting. Sometimes, learners come to ambulatory settings in their blood-covered operating room clothing rather than changing to their regular clothes. Learners might also have apparent hygiene problems such as greasy hair, bad breath, or soiled clothes. Teaching staff often comment on the female learner who wears revealing clothing or the male learner who spends more on clothes than all

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the staff combined. Patients might tell short, young-looking learners, “You look too young to be a doctor.” This may inhibit the establishment of a doctor-patient relationship and affect learning. Example: There is a medical student working once a week in the outpatient department whose personal hygiene leaves much to be desired. His hair is unkempt, he wears the same old white shirt with black jeans every day, and his shirt always hangs out from his pants. He has a pleasant demeanour but resembles the teenaged volunteer worker at the reception desk. Considerations: When issues of inappropriate dress arise, consider the following. • Often the learner is not aware that his dress or appearance is a problem. • The learner may have always dressed a certain way, or may be unable to afford different clothing. • Dress is often a personal statement of belonging to a certain group or an antiestablishment comment. • Outrageous dress may be a method for calling attention to oneself. Alternatively, a learner who wears old clothes or is unkempt and dirty may have little self-respect and so feel no need to dress well. • You may not have clearly outlined the dress code for the clinic to the learner. Management: The following strategies are helpful when dealing with grooming and dress. • Alert the student to the problem, either directly or through a recorded session. Discuss your impression of the learner’s dress, its meaning to the learner, and its potential impact on patient care. • Apply the principles of process learning. The issues of dress and appearance are often set by how the physicians and office staff dress on the job. • It is often simplest to set minimum dress standards, after consultation with the learners’ designated representatives in their respective medical school student organization or resident association. • Encourage young-looking learners to dress more formally to give the impression of an age beyond their appearance.

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Teacher-Learner Interactions Argumentative with Teaching Staff Issue: Discussions with the learner often turn into battles and debates. Presentation: This learner cannot carry on a discussion without getting into a debate or argument with the teaching staff. Even innocuous conversations about patients end up as a battle of words and wills. Example: A senior resident, working with you in the outpatient clinic, is very knowledgeable and a hard worker. She has a tendency, however, to dispute the management of most patients with you. She can be quite stubborn. Her interpretations are not incorrect, but she will stretch a weak point to the limit. You once got into a shouting match with her about the need to admit a patient for intravenous rehydration. She quarrels with the nurses about the completion of laboratory forms and the secretaries about missing charts. Considerations: When you encounter argumentative learners, the following may be factors. • The learner may have a personal upset making her angry, and may transfer her anger to the work setting. She may be angry or concerned about some policy or work matter that she has been unwilling to discuss and is acting out. This is frequently a carryover of adolescent behaviour. • The argumentativeness may actually be a defence mechanism. The learner may fear that needing guidance will lead to dependence and is expressing a conflict between her fear of dependence and need for guidance. • Some arguments stem from a clash in the personalities or work habits of teacher and learner. Management: These suggestions may be helpful when you encounter the argumentative learner. • Arrange a meeting with the learner. Begin by citing specific examples of argumentative behaviour. Next, inquire about any personal problems affecting the learner, or about any office policies or personnel that may be leading to this behaviour. • If you recognize a personality type, try to respond as follows.

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• Give the “rebelling adolescent” some more independence as long as her actions do not affect patient care. • Show the learner who fears dependence the positive learning benefits of careful guidance so they stop viewing it as control. • Offer the angry learner kind understanding, which may decrease her acting out. • After adjusting for the preceding, recognizing and tolerating each other’s obsessions may prevent disagreements. • The above approach provides some immediate solutions during the ambulatory care time. If this is a persistent issue, however, it is appropriate to refer the learner to the dean’s office for advice or professional help. Defensive about Errors or Weaknesses Issue: A learner makes persistent attempts to justify or excuse errors, weaknesses, or gaps in knowledge, each of which remove the problem beyond the learner’s control. Presentation: When you criticize a learner for a specific behaviour, he rationalizes his actions. At the time for evaluation, he explains each negative comment in detail, providing the reason and circumstances that resulted in the behaviour. Most often, such rationalizations blame circumstances, or even others, for the bad outcome. Example: A junior resident has just completed a month on a surgical ambulatory experience. You find him deficient in physical examination skills, knowledge of therapeutics, and charting. The resident explains no one ever observed him do a complete physical examination, only small segments; the knowledge gap in therapeutics resulted because his reading plan was interrupted by a heavy call schedule as a result of other residents’ holidays; and he was booked too heavily and had many late-arriving patients so there was little time for charting. Considerations: When you encounter a defensive learner, several factors may be involved. • The defensive learners lacks skills in self-assessment or reflection. • The learner may have psychosocial problems resulting in low selfesteem. Such a learner may come from a rigid family or conservative education system that tolerates nothing but excellence.

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• A past teacher may have been particularly critical with this learner, forcing him to be defensive. Management: To assist defensive learners, consider the following suggestions. • There is certainly little use in debating each excuse made by a defensive learner. A more constructive approach is to review the learner’s personal goals. This approach improves the learner’s selfassessment skills rather than having to respond to your comments. • Using the concepts of process learning, establish an environment to defuse defensive behaviour by: • Acting in a collegial manner with learners and thus setting a comfortable scene for comments on performance. • Involving learners in discussions with your colleagues on your own cases in which the natural give-and-take is to share information and provide comments on each other’s performance. This will show learners that improving knowledge and skills throughout one’s career is the norm and that learning is enhanced by comments from others. • Refer more difficult concerns such as low self-esteem for further assessment through your dean’s office. Disruptive of Group Learning Issue: A learner interferes with the normal interaction amongst a group of peers during a teaching session by domination or showmanship. Presentation: Short didactic presentations or case reviews are common teaching methods in the ambulatory setting. However, they can be disrupted by an individual who dominates the group by talking at length whether a question has been asked or not. She may ask questions that may or may not be relevant to the situation. She may also disrupt the group with loud laughter or constant jokes. Example: The clinic holds a weekly seminar on management issues with problem cases. Since the arrival of a new first-year resident, the sessions have not met their objectives. In addition, the medical students have begun to complain they are not learning anything at the semi-

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nar and are wasting their time. According to some of the students, the resident presents a case, interspersed with jokes, and then presents a lengthy monologue of her personal opinions on management. As the seminar leader continues to lead the discussion, she interrupts with more picayune questions or jumps into the discussion by answering any question the leader puts to the group. Considerations: When you encounter disruptive learners, the following may be factors. • The dominant speaker may be an outgoing person by nature, think her point may not have been heard or appreciated, or feel she has to compete with others in the group. • Other learners may have an excessive need for power or attention, or may show off to hide a fear of being found out. Management: The following strategies are helpful in dealing with disruptive group members. • Talk privately to the learner who dominates or disrupts the group. She is usually not aware of the issue. • Channel the energy of this individual in a positive manner. This may be accomplished by giving her a definite leadership role in the session. Instruct her to present cases and lead the questioning instead of responding to questions. Often she will thrive in this role, which will eliminate the disruptive element (Jaques, 2010). Does Not Respond to Questions Issue: Lack of spontaneous comments when directly spoken to in a one-to-one situation or in a group discussion. Presentation: This learner does little to enhance group discussions. In a one-to-one setting, he gives you simple, brief answers to your questions and rarely ask questions himself. Example: A resident is one of several learners rotating through the family medicine service. In the daily chart review, he presents his cases in a brief manner. Between patients, when there is case discussion, he does not spontaneously offer any comments. At the weekly seminar, he does not join in the discussion with his colleagues. Considerations: When you encounter the non-responder, the following may apply.

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• The learner may be afraid to reveal gaps in his knowledge. • The learner may know the required information, but not speak much outside the learning situation because of a shy personality or cultural background. • The teacher may be impatient with such a learner or fail to establish a supportive environment in which the learner feels free to talk or finds it permissible to make mistakes. Management: The following strategies are helpful when dealing with non-responders. • Have a private conversation with the learner to try to understand why he is reluctant to participate in discussions. Ask him how both of you might contribute to helping him overcome this inhibition. • Apply the principles of adult learning by setting up a nonthreatening environment, encouraging the learner to use his current reservoir of knowledge, and letting him know when he does something right. • Ask the learner questions that are easy to answer and follow up with more detailed questions to engage him in the conversation. • Avoid questions the learner can answer with a yes or no, and instead ask questions that require a more complete response. • Try to be especially patient and spend a little more time rephrasing questions as you guide the learner to the teaching point. Noncommittal to Management Plans Issue: A learner is unable or unwilling to outline a management plan in clinical situations. Presentation: The learner sees a patient and performs an appropriate assessment. After presenting the history and physical, she does not offer any thoughts on the differential diagnosis nor does she suggest a suitable management plan. Example: A final-year medical student is several months into a weekly longitudinal ambulatory medical experience. She sees her patients and completes a thorough history and physical for each. After she presents a case to you, she awaits direction. In some cases, she offers a differential diagnosis, but then asks, “What should I do now?” Even when you ask her specifically what she would do, she avoids answering.

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Considerations: When you encounter noncommittal learners, the following may be factors. • The learner may have inadequate knowledge of clinical management, despite adequate knowledge of the basics of patient assessment. • The learner may be unwilling to offer a possible management plan for fear of making a mistake and looking “bad.” • The teacher might have established that the office environment is always hurried and that there is little time to fumble around with discussing the management plan. • The teacher may have frequently told the learner what to do after she presents each patient, and thus the learner is programmed to wait for directions. • The teacher may have criticized the learner when she presented management plans and made the learner less willing to take chances as a result. If she is not sure of the correct treatment, she may fear being put to shame. Management: The following strategies are helpful when dealing with noncommittal learners. • In the earlier years of training, learners’ knowledge of the clinical management of the patient lags far behind their patient assessment skills and knowledge of disease. Early on, encourage learners to develop knowledge in patient management. They can do a quick check for information via a smartphone or computer before presenting the case. • Encourage learners by reminding them that such knowledge comes with the experience of seeing patients and reading related journals, texts, and online resources. • If the learner still seems unwilling to suggest management plans, use the skills of inquiry to help the learner bring the patient’s problems together and to explore the learner’s knowledge reservoir in planning the management. • Failing this approach, the learner may lack knowledge. Use chartstimulated recall to get at the learner’s deficiencies and set up a learning plan. • Look at your own method of reviewing patients with the learners and ensure you are supporting learning and not just getting

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through the patient list. It should be acceptable for a learner to make mistakes, to struggle with questions, or to give the wrong answer as a normal part of learning. Sycophantic toward Staff Issue: This learner loves too much. Presentation: The learner tends to be overly attentive and very flattering to the staff. He exhibits constant regard for the teacher’s talents and knowledge and has a fawning, ingratiating approach. The learner’s demeanour is such that you cannot bear much time teaching him, make your encounters as brief as possible, and avoid him if you can. The teacher-learner relationship is seriously interrupted. Example: You work with a family practice resident in your hospitalbased clinic. This student hangs on your every word and is constantly all smiles. He always says, “Dr., this” or “Dr., that.” He tells you that your knowledge of medicine and clinical acumen is excellent twice a day. You feel a need to “brush him aside” because he seems to be “all over you.” Considerations: When you encounter sycophantic learners, the following may be factors. • Such learners may have a need to be liked or protected. They may have difficulty in dealing with authority and cope by being ingratiating. • Sometimes, the learner wants to share the authority’s power by attaching to it. • Others may use flattery to try to hide a poor knowledge base or lack of technical skills. Management: The following strategies are helpful when dealing with this situation. • However difficult it may be, resist the urge to tell the learner to cease the nonsense and stop smiling all the time. This problem is an excellent example of how the relatively brief exposure teachers have with learners in the ambulatory setting makes it difficult to deal with personality issues that can inhibit learning. • In this case, acknowledging the compliment and gently stating that no further commendation is necessary may help you return to a more comfortable interaction with the learner.

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• If you have more time with the learner, gradually explore his feelings about authority to get a better understanding of him and then eventually point out some of this behaviour. Personal Issues Overconfident as Doctor Issue: A learner attempts to function at a level that is inappropriately advanced for her stage of education. Presentation: The learner appears overconfident in her daily work. She tries to function as an experienced doctor beyond her years. Example: A resident on the outpatient surgical clinic rotation works quite rapidly, presenting her cases with assurance. She concludes with her most likely diagnosis and management plan, both of which may be far from correct, and resists considering other diagnoses. She attempts to perform procedures with which she has little experience. Considerations: The following may be factors for the overconfident learner. • This behaviour can be overcompensation or a defence mechanism for deficits the learner is attempting to hide. The learner may have knowledge gaps, poor technical skills, or other deficits she fears will be uncovered, and so she uses overconfidence as a defence mechanism. • Sometimes, the learner has a narcissistic personality. These individuals generally feel good about themselves, are self-centred, and are not empathic or understanding. • Alternatively, you may easily intimidate learners with authority or belittle their knowledge. The learner may compensate for this with overconfident behaviour. Management: The following strategies are helpful when dealing with overconfidence. • When encountering an overconfident learner who does not have the knowledge she purports, monitor her carefully. • Supervise her clinical performance using case discussions, chart audits, or case reviews. Using Socratic questioning, explore her diagnostic plans in detail. When more time is available, chart-stimulated recall will help both of you understand her problem-solving

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method. Gradually, she will become aware of her true level of performance. • If the learner’s knowledge and skills seem adequate for her level of training, you are more likely dealing with a personality type. Use directive teaching to provide clear but firm examples that show the learner she is performing at her level of training but not higher. Direct her energies toward further acquiring knowledge and skills in her search for excellence. As a teacher, you do not have the knowledge, skill, or time to deal with the personality disorder itself. Over-Involvement with Patients Issue: The learner has excessive commitment and feelings of obligation to patients and work responsibilities. Presentation: The patients and their problems become all consuming for the learner. The learner spends inordinate amounts of time with patients. She is emotionally involved with the patient in a way that is more familial than professional. She has a boundary problem, that is, an inability to separate and define the limits of her responsibility to their patients. Example: A junior resident is in your practice for the month. She is always behind schedule with patients, and can easily spend forty-five minutes following up a routine problem. You have observed her in an interview, and noticed she becomes engrossed in the patient’s life beyond what is relevant to the current situation or problem. She seems to be constantly on the telephone organizing details for certain patients. She gives her home telephone number to some families in case they needed assistance during the month. Considerations: When you encounter learners who are over-involved with patients, the following may be factors. • Certain learners cannot define their role as physician and do not understand delegating work to other health professionals. • Some learners equate the total time spent with the patient with an effective outcome, rather than looking at the end result. • Some individuals feel the need to be wanted or depended on by patients. Management: The following strategies are helpful in dealing with over-involvement. • Demonstrate how the learner could achieve the same ends in less

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time by discussing cases in which she seemed to be over-involved. You could use the role-play strategy in this scenario. • During case discussion with the learner, talk about how the various personnel available in the office or health care system can help her achieve the goals she has in mind for the patient. • If you sense the learner is meeting a personal need with this behaviour, use time in case review, when the teaching is less focused on an individual, to discuss the need to separate one’s professional and personal selves. Overcommitted Issue: A learner is preoccupied or involved in work or other activities that interfere with his function or learning on the job. Presentation: This behaviour usually manifests as a general decrease in work performance. The learner may seem fatigued or have low energy, be unable to concentrate on work, and not complete the details of work satisfactorily. At first, you may regard the learner as lazy or unmotivated. The problem, however, may be related to overwork (e.g., too many patients to see, too many rounds to present, involvement in hospital committees, etc.). Working to generate income in a job beyond the learning experience can also cause fatigue and disinterest. Outside interests may compete for his time and attention. Example: A student doing an elective at the clinic arrives late most mornings and often looks quite tired. She has called in to cancel a few appointments without adequate explanation. Several times, she has left early, before all the patients were reviewed. She tells you she commutes a long distance each day because her partner works in the next town. She is actively involved in a dance group that meets several nights a week and she works for a house-call service on weekends. Considerations: When you encounter overcommitted learners, the following may be factors. • These learners are unable to set priorities and manage their time. • They resent the impact of medical life on their outside activities and try to carry a full load of extracurriculars. • They may have to work for additional income to pay off debts or to obtain extra money for discretionary spending. • Teachers sometimes load up learners with additional patients and rounds assignments without knowing their other responsibilities.

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Management: The following strategies are helpful when dealing with this situation. • Meet with the learner and outline the problem, providing specific examples you have kept on file. After getting her perspective on the issue, ask her to prepare a schedule listing all the previous week’s activities. This should include work, educational programs, extracurricular activities, travel time, and personal time. She should account for all the waking hours of the day, including weekends. At the next session, review her schedule with her and discuss its impact on her life and work. Discuss, in general, her life priorities and any time management strategies that can help her achieve her goals. You could refer her to appropriate books, articles, or websites on time management. • In this review, also check to see whether she has been assigned an excessive load of patient or educational tasks. • This scenario is a good example of when to use process learning and role modelling. It is hoped that you and your colleagues have your time management skills in order. In ambulatory care the learner is, in a sense, living with you and your colleagues. (In some smaller towns, learners often do live in doctors’ homes while on rotation from the medical school.) By watching and being part of a well-managed office and personal life, the learner will learn how to arrange her own time successfully. Shy with Colleagues and Staff Issue: A shy learner is reserved, avoids familiarity or contact with colleagues, and tends to work unobtrusively. Presentation: This learner is difficult to get to know. She is quiet and rarely engages in small talk. She volunteers little information about herself and her personal life. She avoids the teaching staff and may be known as a loner. Example: A second-year resident has been coming to the antenatal clinics twice a week for three months. All the staff has commented that she is very shy, and some have described her as cold. She seldom says hello to, or banters with, anyone at the clinic. Little is known of her personal life, and she leaves quickly at the end of work. She rarely makes eye contact when talking to her supervisor. On reviewing her residency file, you find that other evaluations have commented on this shyness.

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When she deals with patients, however, she is quite outgoing, warm, and communicable. Considerations: When you encounter shy learners, the following may be factors. • The shy learner may represent a personality type who has always been that way. • Another type of character is the one who is anxious, often embarrassed, and inhibited. This learner is ruled by anxiety and is fearful of speaking out or having weaknesses discovered, whether real or not. • The learner may interact according to culture or family traditions. • Sometimes, the teaching staff may be so formal and businesslike themselves that teachers and learners do not mix. Management: The following strategies are helpful when dealing with these difficulties. • This is another opportunity for process learning. The teaching staff should try to engage the learner in conversation, make it more obvious that it is acceptable to be friendly and open, and show they have a personal interest in the learner. In a meeting with the learner, express the comments of the staff, explore the learner’s feelings about interactions with teachers, and agree to make more of an effort to be supportive. • If a significant personality problem seems to be interfering with patient care and the learner’s future potential as a doctor, the possibilities for change through psychotherapy should be discussed with the learner, perhaps through the dean’s office. Laziness Issue: The learner lacks enthusiasm and energy for their education and work-related responsibilities. Presentation: The learner shows overall lack of interest in educational activities. He does the bare minimum of work in the office with patients, or out of the office such as hospital visits and on-call coverage. Example: A senior medical student is completing a four-week experience in the ear, nose, and throat outpatient clinic. He spends a great

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deal of time sitting in the lounge and waits to be told he has patients to see. He sees two or three patients per session when other students see five or six. He quickly reviews his cases with the clinic physician and leaves. He does not seem excited about work or his patients. His presentation for rounds is inadequate for his level of training. Considerations: When you encounter lazy learners, the following may be factors. • The learner may have a personality type that demonstrates low energy and low activity. • Otherwise, the learner may have motivation issues. Motivation is the willingness to exert a high level of effort to attain a goal conditioned by one’s ability to satisfy some individual need (Mohana, Cottrell, Wall, & Chambers, 2011). It is the end result of the interaction between the individual and the situation. The learner weighs his conflicting demands and choose, either consciously or subconsciously, to work hard or not. Usually, basic requirements such as sleep and hunger must be satisfied before higher-order ones such as social needs, self-esteem, or learning (Maslow, 1954). An otherwise hard-working learner might skip an excellent seminar related to his particular interest because he is too tired. Conversely, a normally lethargic learner, a computer whiz, might meet with the business manager every week to discuss the office computer system. • Your expectations may be too high, demanding each learner to be as obsessive and hardworking as you are. • In some circumstances, the work load may be excessive and the scheduling inappropriate for the learner’s level of training. Management: The following strategies are helpful when dealing with laziness. • Discuss your expectations for work load and educational activities with the learner and ensure he understands the objectives for the ambulatory care rotation. • Ask the learner what factors may be influencing his motivation. Help him look at the factors affecting personal needs versus demands of the situation. It is a matter of being able to answer the question, “Do I work hard right now? If not, why not?” Ensure that he meets the basic needs for sleep and food, and move on from there.

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• Review the learner’s educational objectives. Discuss his impressions of the work setting (e.g., his level of anxiety or sense of belonging). • Ask about his personal life to see if it might impact his work. Try to help him adjust the variables so he can work harder. Psychiatric Problems Issue: A learner’s apparent behavioural, educational, or work problems are secondary to a more specific psychiatric diagnosis. Presentation: The learner’s overall performance is poor, or perhaps her knowledge level is inferior to that of others. Sometimes the learner appears to be uninvolved or lazy. When you assess the problem, it becomes apparent that the learner has an underlying psychological problem interfering with performance (Yao & Wright, 2001). Example: A junior medical student attends the ambulatory internal medicine clinics. The staff has noticed she has poor knowledge of the content of medicine. She is disorganized and accomplishes less work than her colleagues. She seems to be unenthusiastic and uninvolved. She is not up to date on her patients and their problems, and shows little energy for work. In a meeting with her, you learn she is depressed and that her fiancé recently broke off their marriage plans. Her father died a year ago, and she now cares for her mother, who is also quite depressed. She missed many classes after her father died and knows she has huge gaps in her knowledge. Considerations: When you encounter such as learner, the following may be factors. • Any psychiatric problem can interfere with work performance or learning. Before the learner’s work or knowledge can improve, she has to address the underlying problem. • Often it is difficult for physicians to admit to an emotional problem for the sake of appearing to be functioning well in front of teachers, colleagues, and friends. • The learning environment may contribute to the development of psychological problems. The learner may be isolated in the work setting with little support from her peers. The clinic may be a very competitive atmosphere that places unnecessary pressure on the learner. As well, there may be unusually high expectations placed on the learner, which further increases stress levels.

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Management: The following strategies are helpful when dealing with psychiatric issues. • Meet with the learner to discuss the work problem and introduce the possibility of an emotional problem interfering with work. You are not there to make a diagnosis but to alert the learner to what might be occurring. • Together with the dean’s office or the program director, the learner can approach their own doctor or arrange psychiatric consultation outside of work so that treatment remains fully confidential. Then, set up a learning plan to help fill in the gaps in knowledge and improve clinical areas of performance. Set up a schedule for regular performance reviews. • If necessary, provide time off work for treatment of the psychiatric problem. Lacks Self-Direction in Learning Issue: A learner is unable to change behaviour without specific external guidance. Presentation: In the typical learning situations, this learner depends on the teacher to be a primary source of information and adviser. He is generally unwilling or unable to seek out, independently, sources of new material or people with whom to consult. Such learners want to be “spoon fed” or have everything “given to them on a silver platter.” When you make constructive suggestions, the learner asks for detailed instruction on how to change the identified problem. Example: This month, you are working with a student who is interested in ophthalmology as a career. She attends the offices of all the ophthalmologists on a rotating basis each day. Each of the staff doctors has commented that she asks a lot of detailed questions about each case, rather than exploring answers to these questions on her own. When directed to read a particular article, she never reports back that she has finished it and does not seem to read on her own initiative. She was unable to describe to the chief, who organized her elective, what she wanted to get out of her time in the department. Considerations: When you encounter learners who lack self-direction, the following may be a factor. Most people seem to be born with an innate ability and desire to learn. Picture the infant who constantly explores and learns at an

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incredible rate. Why, then, do so many mature learners arrive at ambulatory teaching centres waiting to be taught rather than eager to explore and learn? Postman and Weingartner suggest traditional school systems undermine this natural drive to learn. As the young child enters the school system, the curriculum is specifically defined and the teacher hands most of the material to the student. Learning is geared to the lowest common denominator in most schools. This continues throughout secondary education and is reinforced by the well-defined curricula of most undergraduate programs. Even in medical schools, instructors hand out notes and students memorize and regurgitate them. Learners no longer know how to be self-directed (Postman & Weingartner, 1969). Management: The following strategies are helpful in dealing with lack of self-direction. • The learner needs to be guided to the skills of self-learning. Use learning plans in which you and the learner agree on objectives and write them down on a list. Review the list so that the objectives are drawn from a combination of cognitive, affective, and psychomotor domains. Both you and the learner should keep a copy. Refer back to this list periodically. • In one-to-one office teaching, teachers should answer learners’ questions in such a way that the learner must find out the answer. Discuss where the learner might find the answer to her question. Establish a time for her to report back to the teacher on how she found the answer and what it was. Lies to Teaching Staff Issue: A learner shows a persistent tendency to create misleading impressions or to overtly deceive staff or patients. Presentation: In its outright form, the learner is dishonest and is discovered. Often, the issue is much subtler. He may act to create an impression that may be far different from reality. He may not be purposefully deceitful, but may stretch or bend the truth. Others may be devious or crafty in their behaviour or reasoning. Example: A third-year medical student is doing a longitudinal elective in the ambulatory day surgery clinic each week. Several times, she stated she had completed certain parts of the physical examination; however, she did not report obvious physical findings, and so had evidently not done it. The clinic manager could not trace a certain

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long-distance call made each week from the office to the same number. The learner denied making these calls until told that the clinic manager called the number, and the party identified the medical learner as the caller. In addition, one of the nurses saw her in the local shopping mall at lunch on a day she called in sick. Considerations: When learners lie, the following may be factors. • One route to understand the person who lies is to look at possible motivating factors. Lying may serve a particular purpose, or it may be an easy way out – all factors that make the lying acceptable to the individual. • Explore a possible lack of guilt. The learner may not have developed a sense of values and thus acts primarily out of self-interest. She may exhibit little empathy and a “who cares?” approach. • At times, both teachers and educational institutions place incredible demands on learners. Sometimes, learners find they need to use deceit to survive. In addition, if teachers establish the perception that learners cannot make mistakes, must know everything, or cannot ask for help, learners will be dishonest. Management: The following strategies are helpful when dealing with lying. • When caught, learners must be informed of the lie or dishonest act by their supervisor. • They should be expected to make amends for any material loss. • There may be extenuating circumstances to explain the dishonesty; otherwise, learners and teachers need to discuss the circumstances that led to such behaviour. • In light of such behaviour, look at the environment created to see if it is open to honesty and positive criticism. Substance Use Issue: The learner uses and abuses both legal and illegal substances for non-therapeutic purposes. Presentation: The learner may exhibit some classic manifestations of substance abuse: irritability, tremors, excessive absence from work, decrease in work performance, smelling of alcohol, or even accidental overdose (Lacasse, 2009). The most common addictions are those prev-

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alent in the general community – alcohol, marijuana, hashish, cocaine, or benzodiazepines. Example: A senior resident has missed at least two gynaecology clinics per week during the last month. He usually calls at about nine in the morning to say he is not feeling well and cannot come to work. Several times, he has not answered his pager when on call. When he is at work, he appears energized and excitable with a somewhat bad temper. Considerations: When you encounter substance abuse, consider this factor. • Learners at all levels of training are subjected to high stress, fatigue, high expectations, fear of failure, and have easy access to legal drugs that they could abuse. Management: The following strategies are helpful when dealing with substance abuse. • If you suspect drug use, you must confront the learner immediately. Then, refer the learner to the dean’s office or program director. • You must establish the learner’s health as a priority. There should be an understanding that, if corrected, training will continue. Make appropriate time off available for treatment, whether it be a certain time each week or an extended leave of weeks or months. • Treatment is best provided in a facility away from the local clinic or hospital to ensure confidentiality. Referral via a local medical association or a learner or medical association hotline will ensure trust and confidentiality. Lack of Professionalism Issue: The learner’s behaviour or attitudes are considered unprofessional by patients, peers, or clinic staff based on societal expectations. Presentation: The learner acts in ways that do not meet the characteristics currently expected of medical providers. Professionalism (see chapter 2) is the basis of medicine’s contract with society. It is those attitudes and behaviours that maintain doctors’ patient interest above self-interest. The learner must maintain integrity and professional competence. The lack of professionalism may appear in various behaviours (Blank, 2002):

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• Lack of altruism where personal priorities take precedence to patient care • Dishonest with patients or unwilling to empower them with adequate information to make informed decisions • Careless about patient confidentiality • No commitment to working collaboratively with peers and other health professionals • Not reliable and responsible to complete all assigned tasks in a timely manner Example: The office staff express concern about a new senior resident at the dermatology clinic who talks about the patients in the lounge and building elevator. She seems more interested in the financial aspects of medicine than in helping patients. She has not been clear about the pros and cons of certain treatments for the psoriatic patients. Considerations: The following factors may lead to unprofessional behaviour: • The learner may not have gained the knowledge of the societal expectations for practicing doctors when progressing from pre-clinical school-based learning to work in an office-based setting. • The learner may not have fully grasped a clear understanding of the exact implications of patient confidentiality. • Your expectations may be too high, demanding each learner to be as obsessive and hardworking as you are. • In some circumstances, the work load may be excessive and the schedule inappropriate for the learner’s level of training. • Personal issues (described above) such as substance abuse, personal situational factors with relationships, grief, or other psychiatric disorders may interfere with the learner’s ability to achieve some of the expected professional behaviours. • A personality disorder, such as narcissism, may impact on office routines. As described above, such individuals are self-centred and are not empathic or understanding. Management: The following strategies are helpful in dealing with lack of professionalism. • Identify the behaviours or attitudes that do not meet the standards for your school and discuss them specifically with the learner. Es-

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tablish specific expectations for the learner’s behaviour or attitude and set an action plan and a time to meet again to review progress. Ask the learner to write a reflective paper including a review of the relevant literature pertinent to the unprofessional conduct. It is important to identify unprofessional conduct. Followup studies confirm that unprofessional behaviour in medical school is associated with doctors’ being disciplined by a medical board (Papadakis, Hodgson, Teherani, & Kohatsu, 2004). In discussions with the learner, ensure that situational or psychiatric issues are not impairing function. Address any such issues first by referral, outlined above. If it is apparent that your expectations for a certain behaviour are beyond the local standard (such as exceeding current work hour limits), discuss a plan with the learner and reassess at a set time. If all other potential causes have been excluded, then a personality disorder may be the issue. As a teacher, you do not have the knowledge nor time to deal with this matter. Check with your curriculum coordinator to see if this non-professional behaviour is repetitive. Then, the medical school resources can be useful to assist this learner. In the interim, while working with you, be clear, directive, and firm about expectations around professional behaviour. Continue to provide information to the learner to ensure he meets those expectations.

REFERENCES Blank, L. (2002, Feb). Medical professionalism in the new millennium: A physicians’ charter. Lancet, 359(9305), 520–22. http://dx.doi.org/10.1016/S01406736(02)07684-5 Medline:11853819 Groves, J.E. (1978, Apr). Taking care of the hateful patient. New England Journal of Medicine, 298(16), 883–87. http://dx.doi.org/10.1056/ NEJM197804202981605 Medline:634331 Jaques, D. (2010). Teaching small groups. In P. Cantillon & D. Wood (Eds.), ABC of Learning and Teaching in Medicine, 23–28. London: Blackwell Publishing Ltd. Lake, F.R., & Ryan, G. (2005, Nov). Teaching on the run tips 11: The junior doctor in difficulty. Medical Journal of Australia, 183(9), 475–76. Medline: 16274350

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Lake, F.R., & Ryan, G. (2006, Apr). Teaching on the run tips 13: Being a good supervisor – preventing problems. Medical Journal of Australia, 184(8), 414–15. Medline:16618243 Lacasse, M. (2009). Educational diagnosis and management of challenging learning situations in medical education. Quebec City: Faculty of Medicine, University of Laval. Maslow, A. (1970). Motivation and personality. New York: Harper & Row. Mohanna, K., Cottrell, E., Wall, D., & Chambers, R. (2011). Teaching made easy (3rd ed.). Abingdon, Oxford: Radcliffe Publishing. McGraw, R., & Verma, S. (2001, Jul). The trainee in difficulty. Canadian Journal of Emergency Medicine, 3(3), 205–208. Medline:17610785 Papadakis, M.A., Hodgson, C.S., Teherani, A., & Kohatsu, N.D. (2004, Mar). Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Academic Medicine, 79(3), 244– 49. http://dx.doi.org/10.1097/00001888-200403000-00011 Medline:14985199 Postman, N., & Weingartner, C. (1969). Teaching as a subversive activity. New York: Penguin Education. Reamy, B.V., & Harman, J.H. (2006, Apr). Residents in trouble: An in-depth assessment of the 25-year experience of a single family medicine residency. Family Medicine, 38(4), 252–57. Medline:16586171 Rencic, J. (2011). Twelve tips for teaching expertise in clinical reasoning. Medical Teacher, 33(11), 887–92. http://dx.doi.org/10.3109/0142159X.2011.558142 Medline:21711217 Steinert, Y. (2008, Jan). The “problem” junior: Whose problem is it? British Medical Journal, 336(7636), 150–53. http://dx.doi.org/10.1136/bmj.39308. 610081.AD Medline:18202068 Trowbridge, R.L. (2008, Jun). Twelve tips for teaching avoidance of diagnostic errors. Medical Teacher, 30(5), 496–500. http://dx.doi. org/10.1080/01421590801965137 Medline:18576188 Winter, R.O., & Birnberg, B. (2002, Mar). Working with impaired residents: Trials, tribulations, and successes. Family Medicine, 34(3), 190–96. Medline:11922534 Yao, D.C., & Wright, S.M. (2001, Jul). The challenge of problem residents. Journal of General Internal Medicine, 16(7), 486–92. http://dx.doi.org/10.1046/ j.1525-1497.2001.016007486.x Medline:11520388

Chapter Six

Evaluation

As the months passed, the medical staff at the Clinics of Main Street became more comfortable with the strategies for teaching learners on a day-to-day basis. Dr. Smith followed the process by periodically asking each of them about their progress. Several of his colleagues mentioned they could benefit from having a system that could summarize and share all the information they gather on daily learner performance. The teachers had amassed considerable data, but had no method for gathering them together and reviewing them for the learners. The staff wanted to pool information from several teachers into one comprehensive report. Dr. Smith also wanted learners to tell him how they thought the doctors performed as teachers and how the clinic staff performed as members of a teaching centre. Although he had obtained informal comments from the learners as they finished their rotations, he wanted a detailed, anonymous system that would be more revealing and helpful. Dr. Smith invited an expert on evaluation from the university’s faculty of education to their next evening meeting to show them how an evaluation system could work in their office. Here is what they covered. What Is Evaluation? Evaluation or assessment is a judgment about how someone’s performance meets defined criteria (Lake & Ryan, 2005). It is the guiding instrument of the learner, teacher, and program director. Just as instruments guide an airplane on its flight path, evaluations inform you if you are on course, if you need midcourse correction, or if you have reached your destination. The destination is predetermined by your medical school’s

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curriculum and enhanced by each learner’s specific goals. Evaluation consists of finding out the extent to which each of these objectives has been attained, and the quality of teaching techniques and teachers (Snell et al., 2000). Evaluation for Learners 1 What to evaluate? Evaluation tools try to measure learners’ habitual and judicious use of communication, knowledge and technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and communities they serve (Epstein, 2007). Determine the following before undertaking your learners’ formal evaluation. a Begin with the course or rotation’s objectives, goals, or competencies as set by the medical school or hospital program. It is important for both the learner and the program to know whether the learner has achieved the knowledge, attitudes, and skills expected during the time allotted in your office or clinic. b Determine each learner’s personal goals as outlined in any plan you established together at the outset (Harborow, 2000). c Evaluate learners’ overall performance for their level of training. Ensure that these parameters have primacy over your particular specialty or an interest on which you might naturally focus. 2 Who are you evaluating? Be clear about learners’ levels of training in order to create appropriate expectations for knowledge and skills. If possible, obtain a summary of learners’ academic backgrounds and performance to date from the hospital or medical school. Obtaining information on learners who have had academic or behavioural difficulties makes it possible to set up special learning objectives. 3 What are the frameworks for evaluation? Evaluation works best for both learner and teacher when optimal performance criteria for the various knowledge and skill levels have been established. Ask if the hospital, medical school, and certifying body have them (Leibrandt, Kukora, & Dent, 2001). If not, develop some for your office and use them as the basis for learner evaluation. Miller’s pyramid, outlined in figure 6.1, is a helpful framework for the clinic teacher in evaluation (Miller, 1990).

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Figure 6.1 Miller’s pyramid

• Knows: At the lowest level of the pyramid, the learner knows the essential information required to carry out professional functions. This level is often evaluated in medical schools with multiplechoice questions. • Knows how: At the next level, the learner knows how to use the knowledge accumulated. This level includes the ability to acquire information from a variety of sources, to analyse and interpret the data, and to translate the findings to rational diagnostic and management plans. This involves an understanding of the facts and is best assessed with simulated case scenarios and modified essay questions.

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• Shows how: Further up the pyramid, the learner shows how to use knowledge. They have to demonstrate knowledge with patients. Evaluation often includes OSCEs (objective structured clinical examinations) and standardized simulated patients. • Does: At the peak of the pyramid, the learner does apply all skills and functions in clinical practice. The shows how and does levels focus on what occurs in practice rather than what happens in an artificial test situation. The ambulatory clinic teacher is in the best position to evaluate these highest levels of the pyramid (Norcini, 2003). 4 When to evaluate? • At the beginning of the rotation: Review the course objectives or competencies with the learner and set up a personal learning plan. Outline the evaluation system your office uses and incorporate additional items from the plan as necessary. Give the learner a copy of your evaluation form. Distribute any lists of performance criteria you have developed. • In the middle: At the midpoint of the rotation or course, complete an interim evaluation with the learner and modify the learning plan based on identified weaknesses. Known as formative evaluation, this step is designed to let the learner know how far she has progressed toward achieving her objectives. It provides benchmarks to orient learners who work with a relatively unstructured body of knowledge. It can reinforce learners’ intrinsic motivation and inspire them to set higher standards for themselves (Ben-David, 2000). The strategies described in chapter 4, such as direct observation and criterion chart review, are other means to evaluate the learner. They enable you to modify learning activities based on identified strengths and weaknesses to date. It is difficult to provide this formative evaluation – other priorities seem to take precedence in a busy clinic. Aim to complete a clinical encounter evaluation form and review it with the learner once a week. The information is based on your review of the learner’s work with a single patient, selected at random. The regular task of completing the form acts as a stimulus for formative evaluation. • At the end: Before the rotation ends, complete the final evalua-

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tion. In this summative evaluation, you make an overall judgment about the learner’s competence, fitness to practice, or qualification for advancement to higher levels of responsibility (Epstein, 2007). This informs the learner as to whether she has achieved her personal objectives as well as those of the medical school for that course. It should identify areas of knowledge and skills the learner needs to improve on, which could be included in the next set of objectives. (Schuwirth & van der Vleuten, 2004) Always meet with learners in person. Do not leave the evaluation in their mailboxes or in the school’s online evaluation system without providing an opportunity to discuss the details. 5 How to evaluate? The following are ways to evaluate learners: • Assessments by supervising clinicians: At your regular staff meetings, set aside some time to evaluate the learners in the office. Have the objectives for each learner’s rotation available, as well as each learning plan. Ask each staff member who has worked with a learner for individual details. Encourage teachers to be objective and provide specific examples, rather than global ratings. Usually one staff member has overall responsibility for the learners. Have this person take notes of the comments and transfer them to the evaluation sheet (Pulito, Donnelly, Plymale, & Mentzer, 2006). • Mini-CEX: Rather than observing a learner-patient interaction from beginning to end, use the mini-CEX (mini-clinical evaluation exercise) to observe the learner for short periods of time with a variety of patients during their assignment to your clinic (Norcini, Blank, Duffy & Fortna, 2003). Ask each of the teachers to observe a focused part of the interview or physical examination and complete a rating form. The observation period is usually limited to ten minutes followed by a brief review with the learner. All clinic teachers can take turns so the burden does not fall on one specific individual. The brief encounter also fits more easily into the hectic clinic pace. The rating forms are accumulated and used in the summative evaluation (Kogan, Holmboe, & Hauer, 2009). Figure 6.2 shows a mini-CEX evaluation form. • 360-degree assessments: Also known as multi-source evaluation, 360-degree assessments are an effective way to gather further information for your learners (Wood, Hassell, Whitehouse, Bul-

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Figure 6.2. Mini-CEX form

Clinics of Main Street MINI-CEX FORM

Date

Name Rating

4-excellent

3-good

Item

2-fair

Score

1-poor

N/A-not applicable

Comments

• History • Physical Examination • Investigation • Patient Education • Prevention • Organization • Presentation • Documentation Teacher’s signature Trainee’s signature lock, & Wall, 2006). The learner herself, or the clinic teacher, asks a number of colleagues, nursing staff, administrative, or other health professionals with whom the learner has worked to complete an assessment form. The colleagues usually rate various aspect of the learner’s work, such as relationship with patients, completion of documentation, interaction with colleagues, and punctuality. Thus, the learner receives information on her work performance from the perspective of her colleagues. 6 Promotion of self-evaluation: Once learners have left formal training programs and entered practice, they must assess their own

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Figure 6.3. Sample learner evaluation form

CLINICS OF MAIN STREET TRAINEE EVALUATION FORM

Name

Date

Rating 4 - above level of training 2 - below level of training

Item • Information gathering

3 - satisfactory for level of training 1 - unsatisfactory

Score

Comments

• Manual skills • Knowledge • Problem solving • Critical thinking • Patient-centred care • Professionalism • Teamwork • Overall assessment

strengths and weaknesses to guide their continuing education. You can enhance this skill by asking learners to complete the evaluation form for themselves before they attend the session when you review the staff comments with them. By looking at themselves and comparing it to what others think, they will get some insight to the accuracy of their self-image (Hodges, Regehr, & Martin, 2001; Ward, Gruppen, & Regehr, 2002). 7 Sample form: When completing the form, remember the guidelines for providing information to learners on their performances (see chapter 2). These principles are as applicable to formal evaluation as to one-on-one situations. Ensure that you conclude the evaluation with some general recommendations to guide the learner’s future education. See figure 6.3 for a sample learner evaluation form.

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Evaluation for Teachers It is important to review and improve your teaching skills periodically. Many teachers have little specific information on their effectiveness. Even the most talented teachers can wonder, “How am I doing?” The most helpful source of information on your present skills is comments from learners working in your office (Cox & Swanson, 2002). An acceptable teacher evaluation process should: • • • • •

Measure what is intended, i.e., teaching performance Document teaching behaviours reliably Be fair to all teachers Maintain learner anonymity Provide adequate information for teachers to improve their skills

You can gather informal impressions of your teaching skills from learners by asking them to comment on their learning experiences. Some learners have the confidence to give you direct comments on your role in their learning. For most learners, however, it is a difficult task, because they fear being disliked or jeopardizing their final evaluations. A less confrontational approach is to have learners complete an anonymous teacher evaluation form, preferably after their final evaluation. How to develop a teacher evaluation form: A standard teacher evaluation form lists several characteristics of teaching, usually in the positive mode, and asks for the learner’s rating and any comments on each point. Your clinic can gather information for its teachers in one of three ways: 1 Many medical schools and training programs have their own version of a system-wide teacher evaluation form that learners complete, often online. The information is then collated and returned to the teacher in summary form. 2 Use pre-existing standardized forms that have been refined and tested for reliability and validity in your clinic. Two examples are: MedIQ (James & Osborne, 1999): An instrument developed to measure instruction activity in ambulatory settings, based on a learner-centred model. It provides information on the teacher’s skills as well as on learning opportunities (James et al., 2001).

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Teacher Encounter Card: This is a small cardboard document designed for ease of use (Kernan, Holmboe, & O’Connor, 2004). It allows learners to rate characteristics of the teacher that are specific to teacher-learner interactions around patient encounters: • Allows the learner to complete the history and physical • Listens to the full results of the encounter • Hears the learner’s assessment and plan before giving their own • Asks questions about the assessment and plan • Completes some observation of patient interviewing • Allows the learner to do the visit closure • Provides constructive comments on learner performance 3 Create a form for your teachers that is specific to your clinic (see figure 6.4 for an example). The attributes evaluated should bear some relationship to the theory your clinic teachers use to guide the daily instruction. In a group meeting, compile a list of criteria that everyone considers important for evaluation. This way, everyone knows what learners will evaluate. When choosing the characteristics, remember that the goal of the form is to help you set a plan for improving your teaching skills by identifying any remediable weaknesses. General categories outlining qualities that are characteristic of good clinic teachers can be your guide: • • • • • • • •

Positive learner-teacher relationship Teacher approachability and availability Enthusiasm to activate the learner Allows learners a stepwise assumption of responsibility Uses a variety of teaching skills and questioning Provides learner-based information that is specific, clear, and timely Establishes non-judgmental, non-threatening learning environment Master of her specialty and positive role model (Sutkin, Wagner, Harris & Schiffer, 2008; Cox & Swanson, 2002). What to do with the information:

• Each teacher should review the forms after the learners complete them.

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Figure 6.4. Teacher evaluation form

CLINICS OF MAIN STREET TEACHER EVALUATION FORM

Name Scoring

Date Agree 5

4

3

2

Disagree 1

• Enthusiastic • Well organized • Available • Uses a variety of teaching skills • Supports independence • Tells the answers directly • Provides clear examples • Non-judgmental • Excellent role model • Sets comfortable space • Uses questions often • Promotes confidence • Personal interest in learner

• Look for ways to learn new teaching skills based on the information, or discuss the forms with the clinic director or curriculum director at the associated hospital or medical school for advice. Options might include: o Self-reflection on a specific teaching behaviour and necessary adjustments, e.g., If a learner writes, “The teacher provides the diagnosis before I have a chance to offer my thoughts,” you might try the “one minute preceptor” model described in chapter 4.

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o Attend teacher development workshops or courses provided by the medical school or at your conferences within your specialty. o Some medical schools offer peer site visits, where colleagues directly observe your teaching and provide written suggestions for change (Regan-Smith, Hirschmann, & Iobst, 2007) o For the adventurous, and if you have the equipment, record an encounter between you and your learner (e.g., during case discussion). View the recording on your own, with a peer colleague, or with your group at a learning session. • As a group, the staff could use the information to plan a teaching skills session at a future meeting at your own clinic (Buchel & Edwards, 2005). Evaluation of Your Clinic as a Teaching Site In the same way you review and improve your teaching skills, you should review and improve your office or clinic function as a teaching site. The most useful information will come from learners who have just completed their learning experiences. It is helpful to determine the factors that make your site work well for learning and those that need improvement (Nadkarni et al., 2011). It is less common for medical schools and training programs to establish their own version of a system-wide teaching site evaluation form that learners complete. The impact of the teaching site is often inferred from the teacher evaluations. However, there are often specific issues to your office or clinic that clearly affect learning (Sisson, Boonyasai, Baker-Genaw, & Silverstein, 2007). You and your colleagues can develop your own form. Use the information below to include aspects that are most relevant or challenging to your particular site. How to develop a teaching site evaluation form: A standard teaching site evaluation form lists characteristics that typically impact learning and asks for the learners’ rating and any comments (Serwint et al., 2004). Use the following general categories and choose the items that are most important for your site. Clinic Characteristics Smooth patient flow Adequate support staff Well-stocked examination rooms

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Readily available examination rooms Sufficient time to assess patients independently Interaction with allied health care providers Use electronic medical record Secure space for personal valuables Patient Characteristics Broad diversity of patients (e.g., age, gender, and socio-economic status) Exposure to a variety of clinical problems relevant to specialty Balance of new consultations and return visits Sufficient patient bookings Educational Characteristics Identifies self as primary care provider (if relevant) Served as patient advocate Received appropriate autonomy Involved in lab result and imaging decisions Longitudinal follow-up of patients Minimal or no interruption from inpatient units Electronic learning resources accessible Teacher readily available Opportunity to learn practice management Variety of learning and teaching strategies Figure 6.5 shows a sample teacher centre evaluation form. What to do with this information: Once the learner’s evaluation is complete, and often after learners have departed, the clinic director should review each form to look for significant trends that require further investigation. The director should present a summary of the comments (both positive and negative) as well as any potentially valuable suggestions at a staff meeting. Methods of improving on weak areas can be formally discussed at an evening clinic session. Pitfalls in Evaluation From our experience, the following are the most common pitfalls in evaluation:

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Figure 6.5. Teaching site evaluation form

CLINICS OF MAIN STREET TEACHING SITE EVALUATION FORM We would appreciate your comments on the learning experience during your time with us. Please complete this form by marking the scale next to each item and write in any specific comments below.

Scoring

Agree 4

Disagree 3

2

1

Experience was appropriate to curriculum Broad diversity of patients Large variety of clinical problems Well stocked examination rooms Adequate assistance from support staff Secure space for my personal items Sufficient patient bookings Balance of new patients and returns Sufficient formal and informal teaching Considerable responsibility for my patients Regular comment of my performance Able to identify as primary physician Received appropriate autonomy Longitudinal follow up of patients Variety of learning and teaching strategies No interruption from inpatient units Worked with allied health Overall, I enjoyed my experience Features that I would continue

Features that I would change and how

1 Failure to evaluate: Learners finish their rotation in your office and leave without receiving any formal evaluation. According to learning theory, learners really want to know how they are progressing, always wonder how the teachers rate their performance, and want that information as soon as possible (Lake, 2005).

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2 Halo effect: The teacher rates everyone at a certain level, usually “good.” Alternatively, the teacher scores all categories on a given learner’s evaluation form with the same mark (e.g., the teacher rates a learner who is particularly good at one task highly in all other areas, or rates a learner who is particularly unreliable poorly in all other areas) because of the spillover effect. Few learners perform exceptionally well or badly in every area. They all have different strengths and weaknesses. Assess each category in and of itself. 3 Teacher biases: The teacher who is biased against learners for whatever reason may allow these prejudices to interfere with an objective assessment (Williams, Klamen, & McGaghie, 2003). Even the teacher’s own clinical skills may impact learners’ ratings (Kogan, Hess, Conforti, & Holmboe, 2010). Be aware of this factor when completing evaluation forms. 4 Reliance on terminal evaluations: View evaluation as an ongoing process that requires interaction with learners at various intervals during their time at your office. One evaluation at the end is helpful, but several evaluations along the way with suggestions for change are much more helpful. 5 Failure to fail: Teachers are reluctant to identify learners who have considerable difficulties. They try to “pass” learners without informing them of their serious misgivings or conveying the information to the medical school or hospital education office. 6 The challenges of direct observation: Direct observation is the beststudied and most suitable method to evaluate learners’ integrated skills in patient care. However, the learner and supervisor have to interrupt their clinical routine to complete this evaluation. This means that neither behaves normally and the time is a feasibility challenge. Multiple evaluators are key to avoid any source of positive or negative bias from the relationships that develop in the close working environment of outpatient clinics. There will also be variance based on the perspective of individual clinical teachers. This can be reduced with training, such as meeting with your colleagues in clinic, watching a recorded encounter, and comparing judgments with standardized schemes (Cantillon & Wood, 2010). 7 Restriction of range: This refers to the tendency to circle the same numerical rating for all attributes on a form, rather than considering and rating each separately. For example, the teacher gives the same score to all the characteristics she evaluates for the sake of efficiency.

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This rating strategy increases the chances of an inaccurate evaluation (Alguire, DeWitt, Pinsky, & Ferenchick, 2008). 8 Relevance of level of training: In all three types evaluation, the learner’s education level has a significant impact. Assess all factors relative to the performance of peer learners at the same stage. For teacher evaluations, the expectation of different learners at various phases of training will impact their impression of the teacher (e.g., novice learners will expect more attention and rank a teacher offering independence much lower than a senior learner might). For teaching site evaluation, those at the beginning compared to nearing the end of training will have diverse expectations (novices want lots of support and care little about billing practices compared to the graduate about to embark on her career (Schultz et al., 2004).

REFERENCES Alguire, P., DeWitt, D., Pinsky, L., & Ferenchick, G. (2008). Teaching in your office. Philadelphia: ACP Press. Ben-David, M.F. (2000). The role of assessment in expanding professional horizons. Medical Teacher, 22(5), 472–477. http://dx.doi. org/10.1080/01421590050110731 Medline:21271959 Buchel, T.L., & Edwards, F.D. (2005, Jan). Characteristics of effective clinical teachers. Family Medicine, 37(1), 30–35. Medline:15619153 Cantillon, P., & Wood, D. (2010). Direct observation tools for workplace-based assessment. ABC of learning and teaching in medicine (2nd ed.). London: Blackwell Publishing Ltd. Cox, S.S., & Swanson, M.S. (2002, Mar). Identification of teaching excellence in operating room and clinic settings. American Journal of Surgery, 183(3), 251– 255. http://dx.doi.org/10.1016/S0002-9610(02)00787-0 Medline:11943121 Epstein, R.M. (2007, Jan 25). Assessment in medical education. New England Journal of Medicine, 356(4), 387–396. http://dx.doi.org/10.1056/NEJMra054784 Medline:17251535 Harborow, P. (2000). Personal learning plan and mentoring. Education for General Practice, 11, s512–14. Hodges, B., Regehr, G., & Martin, D. (2001, Oct). Difficulties in recognizing one’s own incompetence: novice physicians who are unskilled and unaware of it. Academic Medicine, 76(10 Suppl), S87–S89. http://dx.doi. org/10.1097/00001888-200110001-00029 Medline:11597883

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James, P.A., & Osborne, J.W. (1999, Apr). A measure of medical instructional quality in ambulatory settings: the MedIQ. Family Medicine, 31(4), 263–269. Medline:10212768 James, P.A., Kreiter, C.D., Shipengrover, J., Crosson, J., Heaton, C., & Kernan, J. (2001, Oct). A generalizability study of a standardized rating form used to evaluate instructional quality in clinical ambulatory sites. Academic Medicine, 76(10 Suppl), S33–S35. http://dx.doi.org/10.1097/00001888-20011000100012 Medline:11597866 Kernan, W.N., Holmboe, E., & O’Connor, P.G. (2004, Nov). Assessing the teaching behaviors of ambulatory care preceptors. Academic Medicine, 79(11), 1088–1094. http://dx.doi.org/10.1097/00001888-200411000-00017 Medline:15504778 Kogan, J.R., Holmboe, E.S., & Hauer, K.E. (2009, Sep 23). Tools for direct observation and assessment of clinical skills of medical trainees: a systematic review. Journal of the American Medical Association, 302(12), 1316–1326. http://dx.doi.org/10.1001/jama.2009.1365 Medline:19773567 Kogan, J.R., Hess, B.J., Conforti, L.N., & Holmboe, E.S. (2010, Oct). What drives faculty ratings of residents’ clinical skills? The impact of faculty’s own clinical skills. Academic Medicine, 85(10 Suppl), S25–S28. http:// dx.doi.org/10.1097/ACM.0b013e3181ed1aa3 Medline:20881697 Lake, F.R. (2005, Jul 4). Teaching on the run tips 9: in-training assessment. Medical Journal of Australia, 183(1), 33–34. Medline:15992337 Lake, F.R., & Ryan, G. (2005, Jun 6). Teaching on the run tips 8: assessment and appraisal. Medical Journal of Australia, 182(11), 580–581. Medline:15938686 Leibrandt, T.J., Kukora, J.S., & Dent, T.L. (2001, Jul). Integrating educational objectives and the evaluation process in a general surgery residency program. Academic Medicine, 76(7), 748–752. http://dx.doi. org/10.1097/00001888-200107000-00022 Medline:11448835 Miller, G.E. (1990, Sep). The assessment of clinical skills/competence/ performance. Academic Medicine, 65(9 Suppl), S63–S67. http://dx.doi. org/10.1097/00001888-199009000-00045 Medline:2400509 Nadkarni, M., Reddy, S., Bates, C.K., Fosburgh, B., Babbott, S., & Holmboe, E. (2011, Jan). Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors. Journal of General Internal Medicine, 26(1), 16–20. http://dx.doi.org/10.1007/s11606-010-1437-3 Medline:20628830 Norcini, J.J. (2003, Apr 5). Work based assessment. British Medical Jour-

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Index

ACGME Competencies, 20 administrators, 53 adult learning: case review, 73; nonthreatening environments, 112, 137; principles of, 12–15 affective domain, 18–19 ambulatory care, 3–4 ambulatory care training: ambulatory morning reports, 84; continuity of care, 62–3; cost of implementation, 90–1; preparing your office for teaching, 44–6; program increases, 4; reasons for, 43–4; subject selection, 55–6; tracking, 60–2; work loads, 62. See also clinic setup; inpatient teaching analysis, 36 andragogy, 13–14 argumentativeness, 108–9 asking: about, 27; case review, 73–4; chart-stimulated recall, 79–81; inquiry, 34–7, 69, 96; learner premise, 33–4; learners not responding to questions, 111–12; one-minute preceptor model, 71; premature closure of inquiry, 102–3; readiness, 37–8; Socratic

questioning, 33–4, 35; special learning situations, 97; teacher premise, 34 assisted-living facilities, 46 autonomy of learner, 13 bias, 104–5, 142 billing systems, 60 block experiences, 57–8 brief statements, 28, 71 brochures, 47, 48 Canadian Medical Education Directions for Specialists, 19 CanMEDS roles, 19 case discussion: about, 69–72, 91; e-learning, 89; role play and simulations, 85 case presentations: learner premise, 26, 33–4; Socratic questioning, 33–4; teacher premise, 26 case review, 72–4, 91 chart review, 78–9, 91 chart-stimulated recall, 79–81, 91 checking out, 32 clinical learning situations: about, 96; clinical judgment difficulty,

148

Index

97–9; poor knowledge base, 99–100, 103, 115; premature closure of inquiry, 102–4; problems and reflection, 16–18; reasoning and case presentations, 71–2; slow worker, 100–2 clinic setup: block versus longitudinal experiences, 57–8, 65; brochures, 47, 48; communication of office routines, 100; evaluation as teaching site, 139–40; office staff, 51–4; patient preparation, 46–51; phone procedures, 48, 53, 63; physical preparation, 44–6; physician preparation, 54–7; plaques, 47. See also ambulatory care training cognitive domain, 18 collaboration, 40 communication: brief statements, 28, 71; specific statements, 28; valuefree statements, 28, 29; well-timed statements, 28 communities: community advocacy, 40; community-based practitioners, 3; community mental health services, 46; community resources, 45–6, 55 comparison, 30 competency-based curricula, 19–21 comprehension, 36 confidence. See self-confidence confrontation, 31 consent forms, 63–4 content learning, 13 continuity of care, 60–2, 68 cost: ambulatory care training, 90–1; case discussion, 70; case review, 73; chart review, 78; chart-stimulated recall, 80; criterion chart

review, 83; direct observation, 45, 75–6; e-learning, 89; simulations, 86; teaching strategies, 91 criterion chart review, 81–4, 91 cultural groups, 46 curriculum: competency-based curricula, 19–21; time-based curricula, 19 decision making: e-learning, 89; special learning situations, 97–9 defence mechanisms, 108, 115 defensiveness, 109–10 demonstration, 38–9 description, 28–9 didactic presentations, 86–8, 91, 110–11 directive teaching, 27–30 direct observation: direct observation encounter form, 77; evaluation, 133, 142; patient consent, 63–4; premature closure of inquiry, 102, 103; setting up for, 45, 75; teacher evaluation, 139; teaching strategy, 74–6, 77, 91; video technology, 45, 64, 74–5, 102; when unavailable, 70 disabled patients, 105 discovery learning, 11 disease prevention, 56 disruptiveness, 110–11 documentation of problem situations, 95 domains of learning: about, 18; affective domain, 18–19; cognitive domain, 18; psychomotor domain, 19 dress and dress codes, 106–7 elderly patients, 105 e-learning, 88–90, 91

Index ethnic bias, 104–5 evaluation: about, 129–30; adult learners, 13; case review, 73; chart-stimulated recall, 80; clinic teaching site evaluation, 139–40; defensiveness, 109–10; direct observation, 142; evaluation forms, 135–6; evaluation of teachers, 136–9; failure to evaluate, 141; failure to fail, 142; formative, 132; frameworks for, 130–2; halo effect, 142; how to evaluate, 133–4; inquiry, 36; MedIQ, 136; miniCEX, 133, 134; multi-source evaluation, 133–4; obligation of, 68; pitfalls in, 140–3; poor knowledge base, 100; relevance of level of training, 143; restriction of range, 142–3; self-assessment, 28–9, 109, 134–5; self-evaluation, 134–5; shyness with colleagues and staff, 118–19; special learning situations, 95, 97; summative, 133; support for learning from, 13; teacher biases, 142; Teacher Encounter Cards, 137; terminal evaluations, 142; 360-degree assessments, 133– 4; tracking, 60–2; what to evaluate, 130; when to evaluate, 132–3; who is being evaluated, 130 experimentation, 18 failure to fail, 142 families: family planning clinics, 46; interaction with, 56 frameworks for evaluation, 130–2 funding, 45 gender bias, 104–5 grooming, 106–7

149

group learning: asking, 36; case review, 72–4, 91; content learning, 15; criterion chart review, 81–4, 91; disruptiveness in, 110–11; group discussions, 65; inpatient teaching, 5; learner premise, 26; learners not responding to questions, 111–12; problem-based learning, 11; short didactic presentations, 86–8, 91, 110–11 halo effect, 142 health maintenance, 56 home care organizations, 46 home health services, 46 hospice care, 46 hospital admission, 55 hygiene problems, 106–7 immediate application, 13 inappropriate grooming or dress, 106–7 inclusion (of learners), 45 inpatient teaching: about, 5; case mix, 4; compared to ambulatory care training, 20, 84; conflicting scheduling needs of, 57–8, 88, 105, 140–1. See also ambulatory care training inquiry, 34–7, 69, 96 interprofessional education, 21–2 interprofessional health staff, 53 just in time learning, 89 knowledge base, 36–7, 99–100, 103, 115 knowledge-in-action, 16–18 labelling, 29–30

150

Index

laziness, 119–21 learner premise: about, 26; direct observation, 76; learning objectives, 26; Socratic questioning in, 33–4 learning objectives: case review, 73; competency-based education, 19–21; formulation of objectives, 13–15; inquiry, 35; laziness, 121; learner identification of weaknesses and interests, 59; office staff, 52; poor knowledge base, 100; subject selection, 55–6 learning theories: adult learning, 12; content learning, 15; discovery learning, 11; process learning, 15–16, 107; reception learning, 11; special learning situations, 96 legal obligations: consent forms, 63–4; teaching strategies, 68, 70, 72, 75, 78, 83 level of training, 143 lifestyle role modelling, 40 longitudinal experiences, 57–8, 65 lying, 97, 123–4 management plans, 112–14 managers, 53 medical record. See patient records medical secretaries, 52 MedIQ, 136 mental health services, 46 metaphor, 29 Miller’s pyramid, 130–2 mini-CEX, 133, 134 morning reports, 84 motivation, 120 multi-source evaluation, 133–4 noncommittal learners, 112–14

non-threatening environments, 13, 112, 137 not responding to questions, 111–12 nursing homes, 46 obstetrics, 54–5 office setup. See clinic setup office staff: interprofessional health staff, 53; managers and administrators, 53; medical secretaries, 52; preparation for teaching, 51–4; receptionists, 53 one-minute preceptor model, 71 overcommitted learners, 117–18 overconfidence, 97, 103, 115–16 paraphrasing, 32 patients: consent for recording, 63–4; medical histories, 102, 103; overinvolvement with, 97, 116–17; patient compliance, 55; patient flow, 68; patient reactions, 54–5; patient satisfaction, 68; preparation for teaching, 46–51, 53; volunteers, 48–50 patient interactions: appointments, 48; demonstration, 38; learner premise, 26; role modelling, 39, 40; scheduling patients and learners, 58–65 patient logs, 60 patient records: demonstration, 38–9; e-learning, 88; learners, 45; medical secretaries, 52; process learning, 15–16; teaching strategies, 76–84 patient-related learning situations: about, 96–7; avoidance of difficult patients, 105–6; ethnic, racial, or gender bias, 104–5; inappropriate

Index grooming or dress, 106–7; teaching strategies, 69–76 pedagogy, 12–13 pedandragogic learners, 13–14 peer site visits, 139 Pendleton’s rules, 29 perceptions: attitudes towards mistakes, 124; perceived needs, 13 personal issues: argumentativeness, 108–9; lack of professionalism, 125–7; lack of self-direction in learning, 122–3; laziness, 119–21; lying to teaching staff, 123–4; overcommitted learners, 117–18; overconfidence, 115–16; overinvolvement with patients, 116–17; psychiatric problems, 121–2; shyness with colleagues and staff, 118–19; special learning situations, 96, 97; substance abuse, 124–5 pharmacies, 46 phone procedures, 48, 53, 55, 63 physicians: fears of, 56; preparation for teaching, 54–7; self-directed learning, 56–7; syncophantic learners, 97, 114–15; teacher evaluation, 136–9 poor knowledge base, 99–100, 103, 115 practice groups, 40 practice management: curriculum objectives, 12; office staff, 52–3; role-modelling, 40 premature closure of inquiry, 102–3 priming, 59 problem-based learning: adult learning principles, 13; didactic presentations, 87; e-learning, 89; as learning type, 11; reflection, 16–18 problem situations. See special learning situations

151

process learning: learning theories, 13, 15–16, 107; overcommitted learners, 117–18; shyness with colleagues and staff, 119 professional associations, 40 professionalism: definition, 39; lack of professionalism, 97, 125–7; role modelling, 39–40 psychiatric problems, 97, 119, 121–2 psychomotor domain, 19 public health units, 46 questioning: inquiry, 34-7; levels of, 35-6; readiness, 37-8; Socratic, 33-4 racial bias, 104–5 readiness, 37–8 recall, 36 reception learning, 11 referral letters, 52, 55 reflection, 16–18 response, 31–2, 69 restriction of range, 142–3 role modelling: defensiveness, 110; definition, 39; overcommitted learners, 117–18; professionalism, 39–40 role play: case discussion, 85; overinvolvement with patients, 117; teaching strategies, 84–6, 91 selection of patients, 59, 64 self-assessment, 28–9, 109, 134–5 self-confidence: defensiveness, 109; labelling, 30; slow work, 102 self-directed learning: adult learners, 13; e-learning, 90; lack of selfdirection, 122–3; physicians, 56–7; poor knowledge base, 100; role modelling, 40

152

Index

sexual orientation, 104–5 short didactic presentations, 86–8, 91, 110–11 showing: demonstration, 38–9; lifestyle, 40; practice management, 40; role modelling, 39–40; teaching modes, 27, 38–41 shyness, 118–19 simulations, 84–6, 91 skills. See teaching skills SNAPPS model, 71–2 socioeconomic status, 105 Socratic questioning, 33–4, 35 specialist training, 55–8 special learning situations: clinical learning situations, 96, 97–104; documentation, 95; evaluation, 95; factors involved, 96; failure to fail, 142; learning principles, 96; overconfidence, 97, 103; patient-related situations, 96–7, 104–7; personal issues, 97, 115–27; personality factors, 96; recurring problems, 96; teacher-learner interactions, 97, 108–15; timing, 95 specific statements, 28 substance abuse, 97, 124–5 summarizing, 33 surprises, 16–18 synthesis, 36 teachable moments: about, 12; case discussion, 71; chart review, 79; response, 31; Socratic questioning, 34 teacher biases, 142 Teacher Encounter Cards, 137 teacher-learner interaction evaluation, 137 teacher-learner interaction problems:

about, 97; argumentativeness, 108–9; defensiveness, 109–10; disruptiveness, 110–11; noncommittal to management plans, 112–14; not responding to questions, 111–12; sycophantic toward staff, 114–15 teacher premise: about, 26–7; Socratic questioning, 34 teaching modes: asking, 27, 33–8; showing, 27, 38–41; telling, 27–33 teaching skills: about teaching, 11–12; development by teachers, 139; learner premise, 26; physician preparation, 56–7; teacher premise, 26–7; teaching steps, 25–7 teaching strategies: case discussion, 69–72, 91; case review, 72–4, 91; chart review, 78–9, 91; chart-stimulated recall, 79–81, 91; chart use, 75; criterion chart review, 81–4, 91; direct observation, 74–6, 77, 91; e-learning, 88–90, 91; patient interaction, 69–76; role play and simulation, 84–6, 91; short didactic presentations, 86–8, 91, 110–11; timing, 68–9 telling: about, 27; approval or reproach in, 30–1; checking out, 32; comparison, 30; confrontation, 31; description, 28–9; directive teaching, 27–30; labelling, 29–30; metaphor, 29; paraphrasing, 32; response in, 31–2, 69; summarizing, 33 terminal evaluations, 142 360-degree assessments, 133–4 time and timing: evaluation, 132–3; overcommitted learners, 117–18; patient flow, 58, 68; special learning situations, 95, 103; teaching

Index strategies, 68–9, 75; time-based curricula, 19; time factors, 56 tracking, 60 undergraduate training: ambulatory care training, 4, 63–5; competencybased education, 19; informing patients, 48, 64; inpatient training, 5; longitudinal training, 58; problem-based learning, 11; selfdirected learning, 123

153

value-free statements, 28 video technology, 45, 64, 74–5, 102 wave schedule, 58 well-timed statements, 28 work loads: conflicting, 62; overcommitted, 117–18; laziness, 120