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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: HOW - How To
- Sprache: Englisch
How to Teach in Clinical Settings is a practical guide to support all doctors wishing to develop their skills in clinical teaching and supervision.
It provides hands on strategies to address common problems such as giving critical feedback effectively and teaching mixed-level groups. It gives guidance on the particular challenges of teaching in clinical settings including the need to manage teaching with service provision, to engage patients, motivate students, and to judge the balance of support and independence appropriate for each trainee.
How to Teach in Clinical Settings is invaluable for all doctors involved in teaching and training at any stage of their career. It is also useful and accessible to medical students who increasingly need to consider and develop their own teaching skills as part of their career progression.
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Seitenzahl: 191
Veröffentlichungsjahr: 2013
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Table of Contents
Title Page
Copyright
Acknowledgements
Introduction
Reference
Chapter 1: Creating an effective learning environment
Practical ways to create an environment conducive to learning
Design of clinical placements
The teaching climate
What makes a good clinical teacher?
Involving patients in teaching
Involving other disciplines in teaching
Some principles of effective clinical teaching
Useful strategies for clinical teaching
Five tips for clinical teaching which do not take time or money
References
Chapter 2: Teaching in clinical contexts
Teaching on ward rounds
Handover meetings, board rounds and bench rounds
Bedside teaching
Teaching in clinics
Teaching the interpretation of images/specimens
Teaching in theatre
Teaching practical skills
On-call/remote teaching
Teaching patients
Teaching other disciplines
Further reading on clinical teaching
References
Chapter 3: Workplace-based assessment and feedback
The workplace-based assessments/supervised learning events
Giving feedback
Further reading on assessment and feedback
References
Chapter 4: Common problems in clinical teaching
Balancing teaching and service demands
Pitching teaching at the right level
Dealing with complaints and clinical incidents
Ad hoc teaching
Teaching people at different levels together
Teaching older or more experienced colleagues
Engaging the quiet or reluctant learner
The difficult consultation
Teaching multiple students
Teaching trainees with no interest in your speciality
References
Chapter 5: Next steps
Developing as a teacher
Evaluating your teaching
Useful resources
Appendix
Index
This edition first published 2014 © 2014 by John Wiley & Sons, Ltd.
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Library of Congress Cataloging-in-Publication Data
Seabrook, Mary, 1960- author.
How to teach in clinical settings / Mary Seabrook.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-118-62093-9 (pbk.)
I. Title.
[DNLM: 1. Education, Medical. 2. Teaching— methods. 3. Clinical Competence. 4. Learning. W 18]
R834.5
610.71— dc23
2013029215
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover design by Meaden Creative
Acknowledgements
Thanks to the following people who have assisted with providing examples, reviewing draft material or other support:
Special thanks to Helen Graham and Rachael Morris-Jones for inspiring me.
Introduction
Traditionally, learning to become a doctor has been an apprenticeship, with students and junior doctors working alongside practising clinicians and gradually taking on more responsibility for patient care. In recent years, the nature of the apprenticeship has changed: in many places, the master–apprentice relationship has become less prominent and junior doctors now work within wider teams of colleagues. At the same time, there has been an increased formalisation of training with the development of curricula that specify what is expected at each stage. There has also been more emphasis on providing regular, structured teaching, which tends to take place away from immediate clinical demands.
Nothing, however, can replace the centrality of ‘on-the-job’ learning because assessing and managing patients requires so much more than can ever be taught in a lecture theatre. Over 100 years ago, William Osler said that
To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all [1].
In a clinical environment, people, often unconsciously, take in the sights, smells, sounds, the way in which the team works and decisions are made—multiple facets and subtle nuances of practice that can only be learnt on the job. Doctors often call this ‘learning by osmosis’ and, although much can be learnt in this way, learning can be greatly enhanced by good supervision.
Individual supervisors can make a real difference, but face conflicting demands as clinical environments have become increasingly pressurised. Greater bureaucracy, busier clinics, less time with patients and targets focused on clinical work rather than education, all make finding time for teaching challenging.
This book aims to help medical teachers/supervisors at whatever stage—from students to consultants—to explore different ways in which to help others learn. It is designed primarily as a practical manual, providing examples of hands-on strategies that can be used in daily supervision and teaching. These have been gathered from first-hand observation or reports of effective teaching provided by students and doctors. The content is underpinned by educational theory and evidence, but references and theoretical explanations are kept to a minimum as there are many existing books that cover this material (see Further Reading sections).
The book is divided into five chapters:
Not everything will be relevant to everyone, but there should be something for all. Some suggestions may seem idealistic, but the contexts in which doctors teach vary enormously, so select what is appropriate to your context. The book was written for doctors in hospital and community trusts, but some sections may also be relevant to general practitioners or other disciplines.
Some ideas or information relate specifically to students (undergraduates), others to trainees (postgraduates) and some to both (learners). Teachers and supervisors refer to those in a teaching or supervisory role, whatever their level of seniority.
Each chapter has a number of sections containing some or all of the following:
This book is designed as a resource for teachers to dip into for ideas and inspiration—hopefully helping to expand their repertoire of approaches and understanding of effective teaching and learning.
Reference
[1] Osler W. Aequanimitas: with other addresses to medical students, nurses and practitioners of medicine. Philadelphia: P. Blakiston's Son & Co; 1906. p. 220.
Chapter 1
Creating an effective learning environment
The clinical environment can be an exciting and, at the same time, daunting place in which to learn. Students entering clinical placements have to adjust to learning in a work environment, where, unlike at school or college, their learning is not the organisation's primary goal. They are usually enthused by the prospect of clinical work but feel that they lack a genuine role or place in the team. They may need help to learn how to gain access to patients and find learning opportunities.
So what determines how much people learn in workplace settings such as hospitals and general practices?
A study of learning at work found three main factors (Table 1.1).
Table 1.1 Main factors affecting learning at work [1]
Factor
Examples
1. Characteristics of the learner
Confidence, motivation, capability, prior knowledge(This is probably the most important factor, accounting for about 50% of variance in learning.) [2]
2. The immediate work culture
Level of challenge and responsibility, quality of supervision/management, emotional support, learning climate, pressures and priorities
3. The broader context
The career structure, appraisal systems, working hours, training policies
Depending on your role, you may be able to impact on different areas. Most people find it quite easy to teach a motivated, competent and appropriately confident student or trainee. However, what if a trainee appears uninterested or lacking basic clinical skills? Someone in a pastoral role such as an educational supervisor or a personal tutor could address areas such as a learner's confidence and motivation. They might also help learners to set goals for developing their clinical skills, with teachers at all levels providing opportunities for practice and feedback.
Someone with a more strategic role such as a course organiser or training programme director may have some influence on the broader context, for example, ensuring that learners have adequate time for private study in their timetable.
Those supervising learners on a daily basis (often students or trainees at the next level up) will probably have most influence on their immediate conditions of work, such as the climate for learning and the type of work in which they are engaged. These aspects (which are addressed in the next two sections) are important, and sometimes underestimated, although not by Albert Einstein, who is reported to have said
I never teach my pupils; I only attempt to provide the conditions in which they can learn [3].
Factors identified by medical students as influencing the effectiveness of placements at a large teaching hospital are shown in Table 1.2. Trainees mention similar helpful characteristics: a study of resident medical officers in Australia identified eight elements of a placement contributing to professional development (Table 1.3).
Table 1.2 Medical students' experiences of clinical placements [6]
What students found helpful
What students found difficult
Feeling valued within the team
Feeling in the way
Being made to feel useful
Being ignored
Having a forum to discuss their ideas where they will not be laughed at
Being talked over and not having things explained to them
Friendly, accessible and approachable staff
Not being able to contribute to patient care
Staff who want to teach
A pattern of teachers being late or cancelling planned teaching
Lots of practical experience and exposure
Hanging around waiting for opportunities
Doctors being interested in what they are doing
Lack of induction—learning by getting things wrong
Expectations being made explicit
Table 1.3 Elements of the clinical environment perceived by trainees as contributing to learning
Element
Description
Autonomy
Responsibility for patient care
Supervision
Guidance and direction from senior medical colleagues
Social support
Being accepted, recognised and valued within the team
Workload
Balance between service and professional development
Role clarity
Clarity of expectations about what should be done and achieved
Variety
Diversification of the work
Orientation to learning and teaching
Emphasis on learning and development and availability of learning activities
Orientation to general practice
Attention given to learning requirements relevant to general practice
Adapted from [8] with permission from Taylor & Francis Ltd.
Both studies highlight the importance of clear expectations, opportunities for practical experience and the exercise of responsibility. They also agree on the need for a social climate in which learners feel accepted and valued. These findings are supported by a major review of educational research which found that expert teachers respect students, both as learners and as people, showing care and commitment for them [2]. The optimal educational climate is described as one ‘where error is welcomed, where student questioning is high, where engagement is the norm’ [2].
In a clinical context, error would not be welcomed, but it is safer for patients if the climate is sufficiently open that learners are not afraid to ask questions or admit mistakes or weaknesses [9, 10]. It is easy for senior doctors to forget how scary they can seem to those lower down the hierarchy! At the same time, a culture of high expectations is important, with teachers demonstrating high standards themselves and expecting the same of their learners [11].
Practical ways to create an environment conducive to learning
Aim for a combination of challenge (setting goals and tasks which are demanding but achievable) and support (providing advice, encouragement and feedback to enable goals to be met). Practical things you can do include the following.
Before students/trainees arrive
Send a welcome letter/e-mail to let them know where and when to come and what to bring.
You may want to suggest how they could prepare for their placement, for example, relevant reading.
On arrival
During the placement
introduce them to patients from whom they can learn;
be aware of curricular requirements (Box 1.3);
provide feedback and open discussion of cases in which they are involved;
periodically check how they are getting on and any problems they are having;
provide a structured teaching programme covering common diseases/problems, with arrangements to cover clinical duties so that they can attend;
give sufficient time for ward-based teaching;
include them in team social events;
adapt your teaching to the differing levels and needs of individuals;
recognise when they are struggling and provide support—personal or professional.
These strategies should help newcomers to settle in and start to learn quickly and effectively.
Design of clinical placements
This section is most relevant to teachers who are in a position to influence students' or trainees' timetables.
Most learning at work arises not from formal teaching but from the challenges posed by the work itself, such as solving problems and interacting with colleagues and patients [1].
In an apprenticeship, the development of expertise depends primarily on the quantity and quality of learning opportunities inherent in the work. So the type and scope of work in which learners are engaged and the level of responsibility they assume are important.
Learners will naturally increase their expertise fastest in relation to the conditions and stages of care that they see most commonly. So a useful question to ask about any placement is
Are the types and numbers of patients to which trainees are exposed, and the stages at which they are involved, in line with the objectives of their training?
Placements are not always well matched to the stage of the learner, for example,
Students or junior trainees are sometimes placed in highly specialised teams—opportunities which may be better suited to specialist trainees.
Trainees may be busy on the wards, learning a lot about day-to-day management of patients but missing opportunities to learn about diagnosis, surgical interventions or long-term management.
These situations often occur because of service pressures, difficulty in finding placements or the increasingly specialised nature of health care. It is often argued that trainees will learn generic skills such as history taking or examination skills, although the evidence suggests that such skills are not easily transferable from one situation to another [12]. For example, taking histories from patients with anorexia does not prepare you for taking histories from patients with anaemia or even with another psychiatric condition because they rely on different underpinning knowledge bases.
