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Department of Family Medicine
Teaching Effectiveness

A. Background & Planning to Precept (or Attend)

1. I am a teacher or am going to teach—what are my goals?

• Have learners who want to learn
• Provide information that is helpful
• See progress
• Care for patients
• Survive!

2. What specific knowledge and skills can I teach?

What do I think? What specific knowledge and skills will this student / resident be able to learn from me? Write down two or three:

These have been suggested:

3. What are the characteristics of an ideal (effective) teacher?

I have had a lot of experience as a student. Two or three characteristics of excellent teachers I have had (or wish I'd had) include the following:  (write them down)

These have been suggested:

Effective Teachers
Personal Characteristics	With Students	With Patients
Is Trustworthy Is Enthusiastic Is Energetic Is Responsible Keeps promises, agreements Sets a good example Models appropriate behavior Stimulates interest Has knowledge and presents it with clarity Relates well Interpersonally Attributes success to effort and failure to lack of effort Enjoys patient care and teaching Others?	Demonstrates clinical & professional competence Shows interpersonal regard for learner Shows respect Shows commitment to student growth and improvement Is responsive to questions Explains things well Is personable and approachable Is concerned about students' needs Provides clear feedback Displays high expectations Supports asking questions Respects students' authority Nurtures self-directed learning Has good supervisory skills Builds students' confidence Involves students in learning process Communicates expectations for performance Emphasizes improvement rather than competition Others?	Has concern for patients Demonstrates caring Shows respect Possesses clinical credibility Demonstrates clinical & professional competence Interacts skillfully with patients Others?

B. The Role of Observation in Clinical Precepting & Attending

1. What are the benefits of direct observation in clinical teaching?

• Communicates to the student / resident that I care about him / her, and am interested in his / her development

• Enables me to establish a baseline for each student / resident in terms of abilities, comfort level with patients, etc.

• Emphasizes to the patient that having a student / resident in the practice is important

• Enables me to assess the student's / resident's abilities in certain areas (interviewing style, history-taking technique, and organization of the physical exam)

• Prevents the "halo effect" (attribution of only positive judgments about a new student's or resident's abilities). Enables me to specify strengths and weaknesses rather than make global judgments.

• Reminds me that evaluation is not my only job as a teacher.

2. How can I better learn what the student needs to learn?

• Assess a student's clinical skills (interviewing style, history taking, physical exam technique and organization)

• Distinguish specific parts of the encounter (opening, engagement, empathy, enlistment, education, elicitation of presenting problem, background history, physical exam, explanation of treatment or management, and closure)

• Observe student / resident in hallway interactions with others

• Look for specific behaviors regarding the process of the visit (putting patient at ease, communicating clearly, listening attentively, responding to patient's issues, organizing information flow, specific techniques of exam)

• Separate the content issues (full description of presenting problems, patient's expectations, psychosocial context, relevant history, appropriate exam, concise-clear directions, provision for follow-up)

• Notice how the student / resident communicates attitudes (body language, voice, pace, touch, spoken words, etc.)

• Witness effect of interaction on patient

• Prepare for feedback (organize, prioritize, and balance examples of positive and negative items prior to providing feedback)

• Question: "How may I help you?" ," What is your question?"

• Listen: be silent, rephrase, reflect

• Build a relationship that is professional and open (get to know your learners, share personal thoughts and stories, be assessable)

• Use written questionnaires that allow for self assessment (must be communicated before encounter)

• Examine previous evaluations, test scores, etc.

3. How can I learn to observe better?

• Focus on a few specific activities at the beginning

• Watch actively (describe what I am seeing before giving feedback)

• Listen actively (non-judgmentally paraphrase what I heard)

• Be observed (ask the student / resident to observe me, then describe what I did and how I did it, e.g.: "in the next three patient encounters watch how I bring closure to the encounter")

C. Teaching Skills (Principles, Roles, Methods)

1. What are some principles of adult learning?

Unlike teaching children, teaching adults addresses (and capitalizes on) a number of adult needs and characteristics:

• Normal maturation involves movement from dependency to self-directedness

• Teachers are responsible for nurturing this movement

• Adults have deep desire to be self-directing, except in particular, temporary situations

Role of Learner's Experience

• Adults accumulate a rich reservoir of experience that is a resource for learning

• Adults attach more meaning to learning gained from experience (i.e. doing) than from passive learning (being lectured to)

• Primary adult education techniques are experiential (lab experiments, discussion, problem-solving cases, simulation exercises, field experience, etc.)

Readiness to Learn

• Adults are ready to learn something when they experience a need to solve a real-life problem

• Teachers create conditions and provide procedures to help learners discover their "needs to know"

• Learning is organized by life application and sequenced by learner's readiness to learn (is there a present problem I can't solve until I learn something new?)

Orientation to Learning

• Adults see learning as a process of developing competence

• Adults want to be able to apply what they learn

• Learning should be organized around competencies

• Adults are performance-centered in their orientation to learning

2. How do I vary my precepting / attending role based on a student's or resident's needs?

Effective teaching is targeted at the level of professional development of the learner. As the learner's professional development moves from "novice" to "mature", the teacher's instructional style and method moves from more "dependent" to more "independent"

(Stritter's "Learning Vector")

Click for a larger image

3. What are the objectives I need to address in teaching?

Knowledge

• (Addresses a need for information, corrects misinformation, helps student better organize the information)

• Situation: Student examines patient with strep throat

• Behavior: Student will identify diagnostic signs indicative of the patient's condition and describe these signs

• Acceptance level: Attending/preceptor is satisfied with student's description

Attitude

• (Addresses a need for more confident decision-making, dependence/independence on attending, and intervenes with value/personality conflict)

• Situation: Student interviews an obese indigent female patient

• Behavior: Student will exhibit sensitivity to the personal problems the condition creates for the patient and her family

• Acceptance level: Attending / preceptor is satisfied with student's interaction

Skill

• (Addresses a need for development of skill and proficiency at skill)

• Situation: Student observes a pediatric exam by the attending/preceptor

• Behavior: Student will be able to perform the same procedure

• Acceptance level: Attending / preceptor is satisfied with student's performance

4. What methods can I use to reach these objectives?

• Mini-Lecture

• Questioning (narrow and broad)

• Demonstrating procedures

• Role modeling

• Observation & feedback

• Sharing of reasoning process (thinking aloud)

• Facilitating learner's self-evaluation and determination of new learning goals

5. What are some tips for Efficient Instruction?

The Five micro skills model

Get a commitment:

• Diagnosis, treatment, work up

• Collaborative, supportive, honest

• Attempt to assess clinical judgment

• Cue–presentation stops

• Response—ask a question with the word " you " in it

• Limit further questions

• Goal– to learn what is or is not known

• Cue–resident looks for confirmation

• Get evidence, evaluate alternatives

• Avoid passing judgment

• "What else did you consider?" (think out loud)

• Low risk

Teach general rules

• Identify specific teaching point

• Teach at learner's level

• If you don't know, then teach how to find the answer

• General rules are transferable

• If no gaps exist, skip this step

Reinforce what was done right

• Reinforce specific behavior

• Avoid general praise

• Timing is key

• Try to get student/resident to identify the problem

• Be specific

• "Not the best " is better than " bad "

• Focus on correctable behavior

More Tips

• State clearly that your time is limited–set limits to encounters (e.g. "I can meet with you now for 10 minutes–you can have five minutes to ask me questions, then I need to give you some feedback on the patient we saw together this afternoon.")

• Make assignments that are specific and time limited (e.g. "Go in, get as much history as you can in 10 minutes, and then come out and present it to me" or "I'd like you to examine this patient's abdomen for five minutes, then I'll come in and we'll discuss your findings.")

• Have students carry a notebook to record their questions during the day (follow up with them daily for 15-20 minutes)

• Honor your appointments with students and make them brief (keep your promises to discuss things when you said you would)

• Ask students to read about the problems of several patients they have seen during the day (be specific about where they can locate information and set the expectation that the next morning I will ask them to give me a ten minute oral presentation about only one of the problems they've prepared).

• Be realistic about how much I attempt to teach (teach what I judge the student needs and what s/he has expressed interest in).

• Expose students to my busy schedule (make sure they attend noon conferences, hospital committees, etc. with me)

• Conduct discussions/tutorials as I walk or drive around with the student

• Jot down patient care pearls that arise in conversation and on teaching rounds (share these with the student at the end of the month, quarter, etc.)

• Use other staff in my office to teach the student (group partners, nurses, business managers, receptionists)

D. The Role of Feedback in Clinical Precepting & Attending

1. What is constructive feedback?

Feedback is the control of a system by reinserting into the system the results of its performance. If these results are merely used as numerical data for criticism of the system and its regulation, we have the simple feedback of the control engineer. If, however, the information which proceeds backwards from the performance is able to change the general method and pattern of the performance, we have a process which may very well be called learning." (Ended, 1983).

Constructive feedback is provision of information by the teacher to the student about the performance without judgment about quality.

Feedback levels (students will have an easier time accepting lower levels)

• What I heard or saw the student do (recounting with no interpretation)

• What my personal reaction is to what the student did (not judgment)

• What my prediction is as to likely outcomes of the student's action (judgment based on my experience)

2. How can I make my feedback constructive for the student or resident?

• Use the lowest level of feedback possible

• Provide feedback as soon as possible after the performance or action

• Describe the behavior of the student, not the person of the student

• Set the stage for feedback by:

  • Developing a relaxed, supportive atmosphere

  • Outlining a brief agenda for the feedback session

  • Considering the time frame

  • Comparing your assessment with the student's, sharing information

  • Discussing specific issues

  • Maintaining focus

  • Balancing "good" and "bad" items of performance (do not make a general brief statement of the "good" followed by "but" and then get very specific about the "bad")

  • Limiting amount of information to that which the student can use

  • Checking for clear communication

  • Checking for degree of agreement with other teachers

  • Establishing follow-up plans

  • Summarizing

E. Evaluation (Guidelines and Strategies)

1. What are some guidelines I can use to evaluate my student's work?

Evaluation is the process of making judgments based on factual information and observations in order to rate, rank, or assess an individual's status at a given point.

It is helpful to orient the student to the evaluation process at the beginning of the learning experience (by explaining clearly the expectations for learning and the evaluation process), at pre-set points in time during the learning experience (with reference to the prior evaluation at each new one), and at the end of the learning experience (the final evaluation).

Do not impulsively schedule an evaluation to blow off steam at the student. Rather, write down the problem and discuss it with the student at the next pre-scheduled evaluation or, if necessary, privately at an agreed upon feedback time with the student. At this meeting, use the feedback guidelines suggested.

Purposes of Evaluation

• To summarize performance at a given point in time.

• To provide information for planning future educational experiences.

• To communicate summary information to other parties.

Guidelines for the Final Evaluation (include those for giving feedback)

• Evaluation should be based on a systematic observation recorded over a period of time.

• Evaluation should emphasize both changes in behavior (improvement) and progress toward a goal.

• Evaluation should be both verbal and written whenever possible. If only verbal evaluations are given, those being evaluated should be asked to review their understanding of the evaluation.

• Evaluation should be conducted in an unhurried atmosphere. The evaluator should undertake an evaluation of only what can adequately be covered in the available time.

• The individual being evaluated should have the opportunity to provide input.

• Evaluation should fulfill due process procedures

• Dictate student "progress note" at end of day or when procedures occur

• Use log books

• Review student's written record (e.g. progress notes written by student at beginning, middle, and end of learning experience)

• Consider periodic video and/or audio recording of student's case presentations

• Use computer printout of student's "patient profile"

• Use 3 X 5 cards for "teaching file"

F. Handling Problems

Problems exist when there is a difference between the learner’s performance and my expectation.

Identifying a Problem

• The desired task should be defined clearly (if not, the student does not know what to do)

• The expectation should be defined clearly (if not the student does not know the level at which s/he must perform)

• Any differences between the clearly defined task and expectation must be identified and carefully analyzed

First, try to prevent them from happening in the first place.

Preventing a Problem

• Use effective management strategies

• Regularly use observation and feedback

• Regularly have student self-assess his/her experience

If, despite all your prevention efforts, they still occur, assess, diagnose and respond to the problems.

• If it is a real problem (or just a bad day)

• If it is important

• What would happen if nothing were done about it

• If the problem is in the eye of the beholder (is it mine or my student’s?)

If the problem is real and important, check it out. Ask the student

Do others see it? Has it happened before?

Diagnose the problem

Determine if the problem is because of a learning deficiency (the absence or incomplete development of a behavior, or an incorrectly taught or learned behavior). Here, a student couldn’t do it if his/her life depended on it. If this is the case:

Respond to the Problem

• Educate the learner

• Develop learning experiences

• Help the learner understand reasons for change

• Replace incorrect skills or behaviors

Determine if the problem is because of forgotten knowledge (knowledge or skill was once acceptable but has declined because of lack of use and passage of time). Here, a student could do it at one time. If this is the case:

Respond to the Problem

• Educate the learner

• Provide opportunities for the learner to practice

• Provide opportunities for the learner to review/refresh

• Provide opportunities for the learner to maintain

Determine if the problem is truly a result of lack of knowledge or skill. (This is a performance rather than an educational problem). Here, a student could do it if s/he wanted to. If this is the case:

Respond to the Problem

• Understand that education is not the solution

• Determine if there is a barrier to performance

• Determine if there is secondary gain for not performing

• Determine specific causes through analysis

• Determine if there are systemic or idiosyncratic (attitudinal) causes (these may be hidden and powerful)

Systems Problems

• Fix them

• Avoid them in the future

• Provide feedback to those in charge

• Involve others in problem-solving

Attitudinal Causes of Problems (Prevention is the best strategy)

• Give clear definitions of expectations

• Employ learner contract

• Give regular feedback and evaluations

• Make sure other possible causes have been checked out

• Deal with it early 

• Employ effective listening and feedback skills

• Develop confrontation techniques

• Identify and clarify differences

• Be direct

• Diffuse anger

• Have a mutually agreed upon action plan

• Schedule reassessment

• Consult/refer to others

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Note: The material contained herein is a combination of original text and information quoted and/or modified from: Society of Teachers of Family Medicine (1992). The Preceptor Education Project Workshop

Neher, J.O., Gordon, K.C., Meyer, B., Stevens, N. (1992). A five-step "microskills" model of clinical teaching. Journal of the American Board of Family Practice, 5:419-424.

Research and Faculty Development  |  Department of Family Medicine
 Medical College of Georgia

Please email comments, suggestions or questions to:
Stan Sulkowski, ssulkowski@mcg.edu.

January 10, 2008