Clinical Teaching

Learning and teaching in the clinical environment

Clinical teaching-that is, teaching and learning focused on, and usually directly involving, patients and their problems-lies at the heart of medical education. At undergraduate level, medical schools strive to give students as much clinical exposure as possible; they are also increasingly giving students contact with patients earlier in the course. For postgraduates, "on the job" clinical teaching is the core of their professional development. How can a clinical teacher optimise the teaching and learning opportunities that arise in daily practice?

Strengths, problems, and challenges
Learning in the clinical environment has many strengths. It is focused on real problems in the context of professional practice. Learners are motivated by its relevance and through active participation. Professional thinking, behavior, and attitudes are "modelled" by teachers. It is the only setting in which the skills of history taking, physical examination, clinical reasoning, decision making, empathy, and professionalism can be taught and learnt as an integrated whole. Despite these potential strengths, clinical teaching has been much criticised for its variability, lack of intellectual challenge, and haphazard nature. In other words, clinical teaching is an educationally sound approach, all too frequently undermined by problems of implementation.

Common problems with clinical teaching

Lack of clear objectives and expectations
Focus on factual recall rather than on development of problem solving skills and attitudes
Teaching pitched at the wrong level (usually too high)
Passive observation rather than active participation of learners
Inadequate supervision and provision of feedback
Little opportunity for reflection and discussion
"Teaching by humiliation"
Informed consent not sought from patients
Lack of respect for privacy and dignity of patients
Lack of congruence or continuity with the rest of the curriculum

Challenges of clinical teaching

Time pressures
Competing demands-clinical (especially when needs of patients and students conflict); administrative; research
Often opportunistic-makes planning more difficult
Increasing numbers of students
Fewer patients (shorter hospital stays; patients too ill or frail; more patients refusing consent)
Often under-resourced
Clinical environment not "teaching friendly" (for example, hospital ward)
Rewards and recognition for teachers poor

The importance of planning
Many principles of good teaching, however, can (and should) be incorporated into clinical teaching. One of the most important is the need for planning. Far from compromising spontaneity, planning provides structure and context for teacher and students, as well as a framework for reflection and evaluation. Preparation is recognised by students as evidence of a good clinical teacher.

How Doctors Teach
Almost all doctors are involved in clinical teaching at some point in their careers, and most undertake the job conscientiously and enthusiastically.
However, few receive any formal training in teaching skills, and in the past there has been an assumption that if a person simply knows a lot about their subject, they will be able to teach it. In reality, of course, although subject expertise is important, it is not sufficient. Effective clinical teachers use several distinct, if overlapping, forms of knowledge.

How Students learn
Understanding the learning process will help clinical teachers to be more effective. All start with the premise that learning is an active process (and, by inference that the teacher's role is to act as facilitator). Cognitive theories argue that learning involves processing information through interplay between existing knowledge and new knowledge. An important influencing factor is what the learner knows already. The quality of the resulting new knowledge depends not only on "activating" this prior knowledge but also on the degree of elaboration that takes place. The more elaborate the resulting knowledge, the more easily it will be retrieved, particularly when learning takes place in the context in which the knowledge will be used.

How to use cognitive learning theory in clinical teaching
Help students to identify what they already know
"Activate" prior knowledge through brainstorming and briefing

Help students elaborate their knowledge

Provide a bridge between existing and new informationfor example, use of clinical examples, comparisons, analogies
Debrief the students afterwards
Promote discussion and reflection
Provide relevant but variable contexts for the learning

Example of clinical teaching session based on experiential learning cycle
SettingSix third year medical students doing introductory clinical skills course based in general practice
TopicHistory taking and physical examination of patients with musculoskeletal problems (with specific focus on rheumatoid arthritis); three patients with good stories and signs recruited from the community

The session
Planning-Brainstorm for relevant symptoms and signs: this activates prior knowledge and orientates and provides framework and structure for the task
Experience-Students interview patients in pairs and do focused physical examination under supervision: this provides opportunities to implement and practise skills
Reflection-Case presentations and discussion: feedback and discussion provides opportunities for elaboration of knowledge
Theory-Didactic input from teacher (basic clinical information about rheumatoid arthritis): this links practice with theory
Planning- "What have I learned?" and "How will I approach such a patient next time?" Such questions prepare students for the next encounter and enable evaluation of the sessionTeaching in the clinic
Although teaching during consultations is organisationally appealing and minimally disruptive, it is limited in what it can achieve if students remain passive observers.

Teaching during consultations has been much criticised for not actively involving learners
With relatively little impact on the running of a clinic, students can participate more actively. For example, they can be asked to make specific observations, write down thoughts about differential diagnosis or further tests, or note any questions-for discussion between patients. A more active approach is "hot seating." Here, the student leads the consultation, or part of it. His or her findings can be checked with the patient, and discussion and feedback can take place during or after the encounter. Students, although daunted, find this rewarding. A third model is when a student sees a patient alone in a separate room, and is then joined by the tutor. The student then presents their findings, and discussion follows. A limitation is that the teacher does not see the student in action. It also inevitably slows the clinic down, although not as much as might be expected. In an ideal world it would always be sensible to block out time in a clinic to accommodate teaching

Teaching on the wards
Despite a long and worthy tradition, the hospital ward is not an ideal teaching venue. None the less, with preparation and forethought, learning opportunities can be maximised with minimal disruption to staff, patients, and their relatives.
Approaches include teaching on ward rounds (either dedicated teaching rounds or during "business" rounds); students seeing patients on their own (or in pairs-students can learn a lot from each other) then reporting back, with or without a follow up visit to the bedside for further discussion; and shadowing, when learning will inevitably be more opportunistic.
Key issues are careful selection of patients; ensuring ward staff know what's happening; briefing patients as well as students; using a side room (rather than the bedside) for discussions about patients; and ensuring that all relevant information (such as records and x ray films) is available.

The patient's role
The importance of learning from the patient has been repeatedly emphasised. For example, generations of students have been exhorted to "listen to the patient-he is telling you the diagnosis." Traditionally, however, a patient's role has been essentially passive, the patient acting as interesting teaching material, often no more than a medium through which the teacher teaches. As well as being potentially disrespectful, this is a wasted opportunity. Not only can patients tell their stories and show physical signs, but they can also give deeper and broader insights into their problems. Finally, they can give feedback to both learners and teacher. Through their interactions with patients, clinical teachers-knowingly or unknowingly-have a powerful influence on learners as role models. Working effectively and ethically with patients

Think carefully about which parts of the teaching session require direct patient contact-is it necessary to have a discussion at the bedside?
Always obtain consent from patients before the students arrive
Ensure that students respect the confidentiality of all information relating to the patient, verbal or written
Brief the patient before the session-purpose of the teaching session, level of students' experience, how the patient is expected to participate
If appropriate, involve the patient in the teaching as much as possible
Ask the patient for feedback-about communication and clinical skills, attitudes, and bedside manner
Debrief the patient after the session-they may have questions, or sensitive issues may have been raised