TEACHING METHODS:
PRINCIPLES & PRACTICES
Yvonne Steinert, Ph.D.
Linda Snell, MD, MHPE, FRCPC, FACP
McGill University
How to reference this document:
Steinert. Y., Snell. L., Teaching Methods: Principles & Practice. Train-the-Trainer Program on Professionalism. 2009.
OBJECTIVES
By the end of this session, participants will be able to:
• Outline general principles for teaching and learning
professionalism
• Describe the key concepts of situated learning theory
• Identify principles of adult learning & instructional
design
• Identify teaching methods/tools available in their settings
• Match teaching methods to objectives in their own
settings
SESSION OUTLINE
• A Review of General Principles
• An Overview of Situated Learning Theory
• An Update on Principles of Adult Learning
• Key Concepts of Instructional Design
• An Overview of Teaching & Learning Methods
• Completion of an Action Plan
• Conclusion
THE CHALLENGE …
• How to impart knowledge of professionalism to students
and residents
• How to encourage the behaviors characteristic of the
“good” physician...
WHAT IS NEEDED ?
1. Cognitive base
> teach it explicitly
2. Experiential learning
> provide opportunities on a regular basis
3. Role modeling
> requires knowledge and self-awareness
4. Self-reflection
> provide opportunities through the curriculum
5. Environment
> must be supportive of professional values
THE “BOTTOM LINE”
• Promote an integrated approach
• Define core content & provide conceptual frameworks
• Use multiple teaching & learning strategies
• Enable experiential learning & reflection
• Link evaluation to teaching...
•
•
•
•Methods of instruction may vary with curricular
design and place in the curriculum
•. . .
•BUT …The principles of professionalism should
not vary
FOR DISCUSSION
•
How do you currently teach professionalism?
•
What theoretical frameworks guide your
thinking?
WHAT IS THEORY?
• Theories represent various aspects of reality in an
understandable way.
• Theory simplifies reality by ignoring a large
number of variables (like a map) and often stress
the importance of certain variables by giving them
special names or stressing their importance in
words, figures or formulas.
Adger, 2002
WHY THEORY?
• The particular theory we subscribe to is likely to
dictate how we work.
• An awareness of theoretical frameworks will
allow us to make informed choices about how we
approach teaching and learning
• Without theoretical frameworks to guide our
practice, there is a danger that there will be too
much reliance on intuition or common sense.
There is nothing so practical
as a good theory.
-Lewin, 1951
SITUATED LEARNING THEORY
• Situated learning is based on the notion that
knowledge is contextually situated and fundamentally
influenced by the activity, context, and culture in
which it is used.
• Brown et al, 1989
WHY SITUATED LEARNING?
• It is particularly appropriate to educating professions
that are communities or cultures “joined by intricate,
socially constructed webs of belief”...
• It brings together the cognitive base and experiential
learning needed to facilitate the acquisition of
professionalism
SITUATED LEARNING
• Cognitive Apprenticeship
– Modelling
– Scaffolding
– Coaching
– Fading
• Collaborative Learning
• Reflection
• Practice
• Articulation
MODELLING
• The resident observes, then mimics, the teacher in the
performance of a task.
• Is most effective when teachers make the target processes
visible, often by explicitly showing the resident what to do.
• Enables residents to observe normally invisible processes and
to begin to integrate what occurs with why it happens.
SCAFFOLDING
• Refers to the support teachers give residents in carrying
out a task.
• Can range from almost doing the entire task to giving
occasional hints as to what to do next.
• Supports and simplifies a task as much as necessary to
enable residents to learn
• Facilitates the transfer of what residents already know to
the task at hand.
FADING
• Fading is the notion of slowly removing support... giving the
learner more and more responsibility.
• Fading is a critical step in the trajectory of becoming an
independent practitioner.
COACHING
• Runs through the entire apprenticeship experience
• Involves helping residents while they try to learn or
perform a task
• Includes directing learner attention, providing hints and
feedback, structuring tasks, and providing additional
challenges or problems
• Helps residents to maximize use of their cognitive
resources and knowledge...
COLLABORATIVE LEARNING
• Includes:
– Collective problem-solving;
– Displaying and identifying multiple roles;
– Confronting ineffective strategies and misconceptions;
– Developing collaborative work skills.
REFLECTION
• Reflection IN Action: while performing an act/role,
analyze what is being done
• Reflection ON Action: after performing the act/role,
reflecting on the impact of the action on the patient and
oneself
• Reflection FOR Action: reflecting on what has been
learned for the future
•
-Schön,1983; Lachman & Pawlina, 2006
PRACTICE
• Serves to test, refine, and extend skills into a web of
increasing expertise – in a social context of
collaboration and reflection.
• Enables skills to become deeply rooted and
“automatically” mobilized as needed.
ARTICULATION
• Includes two aspects:
– The concept of articulating or separating out different
component skills in order to learn them more effectively
– Getting students to articulate their knowledge, reasoning, or
problem-solving processes in a specific domain
• Also helps to make learning – and reflection – visible
IN SUMMARY...
• Situated learning is based upon the idea that knowledge is
contextually situated and fundamentally influenced by the
activity, context and culture in which it is used.
• In this model, teachers must assume the role of coach in
addition to that of pedagogue – and they must act as
models for performing tasks.
• At the same time, students become experts and engage in
reciprocal teaching, and the role of apprentice and master
are shared.
INSTRUCTIONAL DESIGN
Topic
Target Audience
Participant Needs
Goals and
Objectives
Evaluation
Content
Teaching
Methods and Aids
PRINCIPLES OF ADULT
LEARNING
• Adults are independent.
• Adults come to learning situations with a variety of
motivations and definite expectations about particular
learning goals and teaching methods.
• Adults demonstrate different learning styles.
• Much of adult learning is “relearning” rather than new
learning.
•
ADULT LEARNING (CONT’D)
• Adult learning often involves changes in attitudes as well as
skills.
• Most adults prefer to learn through experience.
• Incentives for adult learning usually come from within the
individual.
• Feedback is usually more important than tests and evaluations.
•
IN SUMMARY…
• Create a climate of respect and “safety”
• Encourage active participation – in design and
implementation
• Build on experience
• Encourage collaborative inquiry
• Empower participants – to carry out their learning
plans....
LET’S TRY THIS OUT ...
TEACHING AND LEARNING
METHODS
TEACHING AND LEARNING
METHODS
1.
2.
3.
4.
5.
Context
Different methods for different levels?
Strategies / methods
Do all roles have to be taught all the time?
What if resources are limited?
TEACHING AND LEARNING
METHODS
1.
2.
3.
4.
5.
Context
Different methods for different levels?
Strategies / methods
Do all roles have to be taught all the time?
What if resources are limited?
CONTEXT
• Standard of accreditation:
– Curricular content broadly outlined
– Expectation that assessment will occur
• Little guidance re implementation:
– Need to translate general into specific
– Teaching methods that will be effective
• For specialty
• For level of resident
LEARNING ABOUT
PROFESSIONALISM OCCURS…
• Teaching Rounds
• Academic Half Days
• Core Seminars
• Journal Clubs
• Conferences
• Informal discussions
• Self-directed contexts
•…
• Bedside
• Wards
• ER
• Clinics
• OR
• Lab
•…
TEACHING AND LEARNING
METHODS
1.
2.
3.
4.
5.
Context
Different methods for different levels?
Strategies / methods
Do all roles have to be taught all the time?
What if resources are limited?
ADAPT TO LEARNER LEVEL
Medical student
Preclinical
Residency
Clinical
Level of learner
Increasing complexity
Imparting
core
knowledge
Promoting
self-reflection,
application

capacity to personalize
Increasing reflection
TEACHING AND LEARNING
METHODS
1.
2.
3.
4.
5.
Context
Different methods for different levels?
Strategies / methods
Do all roles have to be taught all the time?
What if resources are limited?
‘Miller triangle’
does
shows
knows how
knows
LEARNING PROFESSIONALISM GOALS
Knowledge acquisition
Understanding
Patterning
Participation
Application to practice
Self-evaluation
…
knows how
knows
Harder to evaluate
shows
Harder to teach
does
Strategies for Teaching Professionalism
Report of the CanMEDS Working Groups –
2005
Strategies for Teaching Professionalism
Lectures
Rolemodeling
Guided reflection
& feedback
Simulations
Role play
Bedside
learning
Mentoring
Team
learning
Reading
Workbooks
Encounter
cards
Faculty
Development
Recognition,
ceremonies
Personal
learning projects
Case
discussion
Logbooks
Portfolios
Critical
incidents
Patient stories
Narratives
Group
discussion
Experiential
learning
Vignettes
Web
Video review
Teaching & Learning Methods
•
•
•
•
•
•
•
•
•
•
•
•
Lectures, Interactive Lectures
Directed reading, Web-based learning
Small group discussions
Case discussions / Clinical vignettes
Critical Incidents
Simulation / Role Play / Video review
Experiential Learning
Encounter Cards
Role Modeling
Guided Reflection
Portfolios
Narratives
Knowledge
Acquisition
Understanding
Patterning
Participation
Application
to practice
Selfevaluation
LECTURES,
INTERACTIVE LECTURES
• Excellent for transmitting facts, core knowledge
• Increasing interaction likely improves understanding
and promotes ‘deeper’ learning
• Efficient use of resources
READING, WEB-BASED
• Excellent for transmitting facts, core knowledge
• Using workbooks with question guides, or interacting
on-line may improve understanding
• Efficient use of resources
GROUP DISCUSSIONS
VIGNETTES, CASE DISCUSSION
• Promote understanding and application to practice
• Stimulate reflection, with guided questions
• Cases or vignettes can be ‘paper’, video, Web - based
CASE VIGNETTE EXAMPLE
CASE - A long-time patient of yours requests a note
from you documenting a non-existent illness in order
to recover cancellation penalties from the airlines on a
nonrefundable ticket.
Case
#1
Caring and Compassion
A sympathetic consciousness of another's distress together with a desire to alleviate it.
Insight
Self-awareness; the ability to recognize and understand one's actions, motivations and emotions.
Openness
Willingness to hear, accept, and deal with the views of others without reserve or pretense.
Respect for the Healing
Function
The ability to recognize, elicit and foster the power to heal inherent in each patient.
Respect Patient Dignity
& Autonomy
The commitment to respect and ensure subjective well being and sense of worth in others and
recognizes the patient's personal freedom of choice and right to participate fully in his/her care.
Presence
To be fully present for a patient without distraction and to fully support and accompany the
patient throughout care.
Competence
To master and keep current the knowledge and skills relevant to medical practice.
Commitment
Being obligated or emotionally impelled to act in the best interest of the patient; a pledge given
by way of the Hippocratic oath or its modern equivalent.
Confidentiality
To not divulge patient information without just cause.
Autonomy
The physician’s freedom to make independent decisions in the best interest of the patient and for
the good of society.
Altruism
The unselfish regard for, or devotion to, the welfare of others; placing the needs of the patient
before one's self interest.
Integrity and Honesty
An adherence to a code of moral values; incorruptibility.
Morality and Ethical
Conduct
To act for the public good; conformity to the ideals of right human conduct in dealings with
patients, colleagues, and society.
Trustworthiness
Worthy of trust, reliable.
Responsibility to the
Profession
The commitment to maintain the integrity of the moral and collegial nature of the profession and
to be accountable for one's conduct to the profession.
Self-Regulation
The privilege of setting the standards; being accountable for one's actions and conduct in medical
practice and for the conduct of ones colleagues.
Responsibility to Society
The obligation to use one's expertise for, and to be accountable to, society for those actions, both
personal and of the profession, which relate to the public good.
Case
#2
Case
#3
Case
#4
Case
#5
CRITICAL INCIDENTS
• A discussion, analysis and reflection on a ‘real life’
vignette, of excellent or poor professional behaviors.
• Good to start reflection and self-evaluation
SIMULATION, ROLE PLAY, VIDEO
REVIEW
• ‘Rehearsal in a safe environment’
• Patterning
• Stimulates reflection, with guided questions
SIMULATION, ROLE PLAY:
EXAMPLE
• Standardized patient communication sessions around
ethical issues
• Followed by feedback from SP, tutor-observer and
peer-observers
• Questions to guide reflection and improve skills
ENCOUNTER CARDS
•
•
•
•
Stimulate self-evaluation
Stimulate reflection
Make the implicit explicit
Provide a framework
ENCOUNTER CARDS - EXAMPLE
• P-MEX
• Mini-CEX
• ER shift evaluation and
feedback cards
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Professionalism
Mini-Evaluation
Exercise
P-MEX
Evaluation Forms
Faculty of Medicine
McGill
University
PROFESSIONALISM MINI-EVALUATION EXERCISE
Listened actively to patient
Showed interest in patient as a person
Evaluator:_______________________________________
Student/Resident:________________________________
Recognized and met patient needs
Extended him/herself to meet patient needs
Ensured continuity of patient care
Level: (please check)
3rd yr 4th yr res 1
res 2
res 3
res 4
res 5
Advocated on behalf of a patient
Demonstrated awareness of own limitations
Setting
Ward
Clinic OR
ER
Classroom
Other
Admitted errors/omissions
Solicited feedback
Accepted feedback
Maintained appropriate boundaries
Maintained composure in a difficult situation
Maintained appropriate appearance
Was on time
► Please rate this student’s/ resident’s overall professional
performance during THIS encounter:
UNacceptable
BELow expectations MET expectations
EXCeeded expectations
Completed tasks in a reliable fashion
Addressed own gaps in knowledge / skills
Was available to colleagues
Demonstrated respect for colleagues
► Did you observe a critical event?
(comment required)
no
yes
Avoided derogatory language
Maintained patient confidentiality
Used health resources appropriately
Mini-CEX
EXPERIENTIAL LEARNING
• Includes
• Learning from role models
• Reflection and self evaluation
• ‘Learning by doing’
EXPERIMENTIAL LEARNING –
ROLE MODELING
• Major influence in the creation of a physician
• Affects career choice
• Part of the formal & informal curriculum
• Patterning
• Participation
ROLE MODELS:
WHO ARE THEY?
•...Individuals admired for their ways of being and acting
as professionals.
•Côté & Leclère: Acad Med, 2000
•Role models “must first attempt to reflect core attributes of
physicians.”
•Skeff: NEJM,1998
CHARACTERISTICS OF ROLE
MODELS
Negative
Positive
Clinical Competence
knowledge, skill, reasoning communication
Teaching Skills
explicit about what is modeled, makes time for teaching
respects students’ needs, feedback, encourages reflection
Personal Qualities
compassionate, caring, honesty and integrity, enthusiastic,
interpersonal skills, commitment to excellence, collegial
Cruess, Cruess, Steinert BMJ 2008
STRATEGIES TO IMPROVE ROLE
MODELING
• Demonstrate clinical
• Be aware of the importance
• competence
• Protect time for teaching
• Demonstrate a positive
• of role modeling
• attitude
• Implement a student-centered
• approach
• Facilitate reflection
• possible)
• Encourage dialogue
• Be explicit about what is
• being modeled (when
• Participate in faculty
• development
• Work to improve the
• institutional culture
Cruess, Cruess, Steinert BMJ 2008
EXPERIENTIAL LEARNING –
GUIDED REFLECTION
• Reflection: purposeful thought provoked by learner’s
unease when they recognize that their understanding
is incomplete
Dewey, 1933
• Participation
• Application to practice:
– hands-on, supervised patient care
– mentoring
Linking Reflection
ACTIVE
OBSERVATION
OF ROLE MODEL
& Role Modeling
•
Making the
Unconscious
Conscious
UNCONSCIOUS
INCORPORATION OF
OBSERVED BEHAVIORS
REFLECTION &
ABSTRACTION
ACTIVE EXPLORATION
OF AFFECT AND VALUES
Translating Insights
into Principles and
Action
GENERALIZATION &
BEHAVIOR CHANGE
After Epstein et al, 1998
PORTFOLIOS
• A collection of documents or other media where
reflection, professional attitudes & behaviors are
expressed
• Stimulate reflection
• Stimulate self-evaluation
• Need for review ?
PORTFOLIOS: EXAMPLES
• Might contain:
– Personal notes, reflections, ‘diary’
– Letters to self or others
– Case report examples
– Evaluations
– Letters from patients, supervisors
– Logs
– Professional roles in organizations
– Professionalism education sessions attended,
– Professionalism awards
–
NARRATIVES
• Narrative competence – the ability to absorb, interpret
and act on the stories and plights of others
•
• Stimulate reflection, with guided questions
• Stimulate self-evaluation
R Charron
NARRATIVES: EXAMPLES
Use stories about patients & about own professional
development as a means of learning …
• “When I was a resident ….”
• “I experienced this today in clinic …”
• “Let me tell you about a student I had …”
• “I cared for a patient who had experienced…”
LET’S USE WHAT WE HAVE JUST
LEARNED
TEACHING AND LEARNING
METHODS
1.
2.
3.
4.
5.
Context
Different methods for different levels?
Strategies / methods
Do all roles have to be taught all the time?
What if resources are limited?
DO ALL ROLES HAVE TO BE
TAUGH ALL THE TIME?
THE ‘SLIDING SCALE’ OF CANMEDS
• Not for every rotation
• Not for every objective
• Sometimes one size does not fit all, so identify
– where the competency is best taught, and
– where it is least appropriate to be taught
• Have a rationale for why you teach it
TEACHING AND LEARNING
METHODS
1.
2.
3.
4.
5.
Context
Different methods for different levels?
Strategies / methods
Do all roles have to be taught all the time?
What if resources are limited?
WHEN RESOURCES ARE
LIMITED…
•
•
•
•
Adopt
Adapt
Create
Share
• Don’t forget the learning environment
CONSIDER ALL
TEACHERS …
• Faculty
• Residents
• Other health professionals
• Patients
THE LEARNING ENVIRONMENT
•Be aware of & address
professionalism barriers
•Support, recognize &
reward good
professionalism:
• Time
• Context
• Competing activities
•…
• Ceremonies
• Awards
•
KEY MESSAGES
•
•
•
•
Remember the goal of the
teaching
Identify opportunities for
teaching within your own
context/setting
Match teaching
method/tool to context &
objective
No single method can do
it all
•
•
•
•
It is unnecessary to
teach all roles all the
time
Include other health
professionals
Tie teaching to
assessment
Positively affect the
learning environment
The greatest difficulty in life is to make
knowledge effective, to convert it into
practical wisdom.
• Sir William Osler
ACTION PLAN
• Take a few minutes to reflect on this half-day, and
complete the relevant section of the action plan