On the Job Teaching
Vinod Patel
Bernadette O’Hare
Clinical Teaching is a bit
like…
Discovering the
Tomb of
Tut’ankhamun…
Everyday!
In a way ?!
Medical Education
From Theory to Practice
Teachers , Facilitators &
Teaching
Environment
Modified David M Kaufman 2003
Curriculum
Student
Outcome
Teaching
methods
Assessmen
t methods
Clinical
Settings
Knowledge
Learning
Experience
Attitudes
Best Clinical
Practices
Improved
patient
outcome
Skills
Clinical
Skills
Communication
Skills
Current
or Future
Patients
Aim.
• To help you to improve your service
based teaching.
Objectives.
• To agree the particular strengths of OTJ
teaching.
• To identify barriers to OTJ Teaching and
some solutions
• To learn and share basic OTJ tools for
everyday use.
Format of the session.
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Strengths and Weaknesses analysis
Tools of teaching OTJ
Bit of Philosophy
Logbook Mention
Concluding Discussion
“The best teaching is that taught by the
patient ….”
From Ed Peile
“Learn to see, learn to hear, learn
to feel, learn to smell, and know
that by practice alone can you
become expert. Medicine is
learned by the bedside and not in
the classroom. Let not your
conceptions of the manifestations
of disease come from words heard
in the lecture room or read from the
book. See, and then reason and
compare and control. But see first.”
[ William Osler 1919]
Bedside teaching dying
out?
•
75% of clinical teaching at the bedside 1964
Reichman F et al (1964) J Med Educ 39: 147-63
•
16% in 1978 (USA)
Collins GF et al (1978) J Med Educ 53: 429-31
•
“Still less” 1997
LaCombe MA (1997) Annals Internal Medicine 126: 217-220
•
Teachers and Learners think 15 – 30%
appropriate
Kroenke et al 1997
From Ed Peile
Opportunities
• Teaching Clinical Observation
• Teaching Ethics / Values-based Medicine
• Teaching Problem-solving/Evidence-based
Medicine
• Teaching Communication Skills
• Teaching Professionalism
From Ed Peile
Why are some sessions not good?
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Sessions not involving patient!
Repetition
“Inappropriate for bedside…”
Trying to cover too much / too long
No valuable feedback
“Too dogmatic, authoritative, and
downright degrading”
Langrish J, Informal Oxford Student Survey 2003
From Ed Peile
What do students find awkward
about bedside teaching?
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Consent / reluctant patient
Dignity
Introductions
What can be said in front of the patient?
What does the patient already know?
From Ed Peile
The patient perspective
• 77% of patients enjoy bedside teaching*
• 83% of patients did not find bedside teaching
provoked any anxiety*
• 99% in OPD do not mind having students in
OPD (Medicine, Surgery n=100)
*Nair BR et al (1997) Med Educ 31:341-346
On the Job Teaching
The SWOT Analysis!
Please conduct a SWOT analysis of Teaching
OTJ
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Strengths
Group A: Please focus on Ward Rounds
Weaknesses
Opportunities
Group B: Please focus on Clinics
Threats and Barriers
Group C: Please focus on Theatre work
Group D: Your peculiar work place
Why is bedside teaching more
difficult than it used to be ?
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Patients spend less time in hospital
The patients in hospital are often too ill
Patients are more empowered – may refuse
More tests and investigations means patients
are not available (relatives!)
• Many more psychosocial problems – not just
physical signs
Elements of Effective
Learning and Teaching
General principles of effective learning and teaching
which apply to any learning encounter:
1. Discover what the trainee wants to learn
2. Discover what the trainee needs to learn
3. Negotiate the content, methods and priorities of the
session
4. Use appropriate methods and techniques
5. Plans for further learning
6. Example of good practice that reinforces learning
7. Establish a relationship with the trainee
8. Evaluate the teaching.
On the Job Teaching
Shared Tips for Teaching 1
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List of cases that students must see
Asking student s to following up points from previous
learning
Giving students responsibility for a few patients
Opportunities to use students as resources
Ensure students shadow a range of professionals
Availability of list
Use of the full theatre staff
“Dual specialty” teaching
On the Job Teaching
Shared Tips for Teaching 2
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Saltatory teaching (Nodes of Ranvier)
Time management
Promote Education as culture
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Teaching on the Job
On-the Job Training for Physicians:
DH Hargreaves et al 1997. RSM
“Teaching without needs
assessment” is like………..
treatment
before
diagnosis
Johari window model
© Alan Chapman 2003 www.businessballs.com
Teacher
Knows
Knows
Does not
Know
No Point
Teaching
Be
Taught?
Teach
Cannot
Teach!
Student
Does not
Know
This!
Important Clinical Competencies:
Need to be taught with competency assessment
Johari
concept
in Education
Questioning strategies to extend
student thinking
• Provide thinking time (at least 5 seconds after ?)
• Think-pair-share (Pose a question, ask them to talk in
pairs, then share)
• Follow-up questions (with the same student)
• Withhold judgement
• Ask for a summary of what has been learnt so far
• Play Devil’s Advocate
• Invite a contradictory response
• Get the students to ask the questions
Socratic questioning
Principles
• “Teacher as midwife, helping the student
to give birth to her own ideas”
• Questions are used as a way of approaching
truth through the use of reason in a shared
enquiry.
• Teacher professes ignorance (in reality to
hold back knowledge temporarily) in order to
provoke, motivate and facilitate the thinking of
students
Socratic questioning
Techniques
• Questions that seek clarification
– Can you explain that?
• Questions that probe reasons and evidence
– Why do you think that?
• Questions that explore alternative views
– What would be alternative explanations…in a different
setting?
• Questions that test implications
– What follows from what you say? What is the
management plan?
• Questions about questions/discussion
– Do you have a question about that?
– Who can summarise so far?
Knowledge Failure
Type 1 Knowledge Failure
• The student simply does not
know!
Type 2 Knowledge Failure
• The student knows but cannot access
Waterhouse Friderichsen
Syndrome
Low BP
Septicaemia
Septicaemia
Low Platelets
Purpura
Isolated
Facts
Purpura
Clinical
Knowledge
Knowledge Failure
Type 1 Knowledge Failure
• The student simply does not
know!
Type 2 Knowledge Failure
• The student knows but cannot access
Hiatus Hernia
Hiatus Hernia
Saint’s Triad
Diverticulosis
Diverticulosis
? Another condition
Isolated
Facts
Gallstones
Clinical
Knowledge
The One Minute Teacher
Five microskills for clinical teaching
Model recognises that most clinical teaching takes place when
busy.
Five microskills: assess, instruct, and give feedback more
efficiently.
1. Get a commitment
– What do you think is going on here?
Asking the trainee how they interpreted the “situation” is the first
step in diagnosing their learning needs.
2. Probe for supporting evidence
– What led you to that conclusion?
Ask the trainee for their evidence before offering your opinion.
Allows you to find out about what they know and identify where
they have gaps.
Five microskills for clinical teaching
3.
Teach general rules and principles
– When this happens, do this…
Instruction will be remembered better if in the form of a general rule
or principle.
4.
Reinforce what was right
– Specifically, you did an excellent job of…
Skills in learners that are not well established need to be reinforced.
5.
Correct mistakes
– Next time this happens try this instead…
Mistakes which are left unattended have a good chance of being
repeated.
The One Minute Preceptor: Five Microskills for Clinical Teaching.
K Gordon, B Meyer, D Irby, D Wall 1997
Pendleton's Rules (of feedback)
• Student: First discuss what went well.
– Ask: what did you do well?
• Teacher: then discusses what went well.
– State: what went well
• Student: What could have been better and and
recommendations for change.
– Ask: how would you have done it better?
• Teacher: discusses what could have been better
and recommendations for change.
– State: how could it have gone better
– Allow further discussion!
How to encourage active participation
rather than passive observation
Need to engage all students all of the time
1. allocate roles to each student and then to bedside
2. Share history taking and examination between
students, one can do presenting complaint another
social history, one to do general exam. Another the
specific system.
3. Specific roles such as Student A will state
observations to the House Officer and Student B will
locate and study the Drug Chart
4. The Nodes of Ranvier Idea !?
History Outline
Total 10 Minutes
Referral details:
GP, A & E, Self, OPD
Introduction
Wash Hands!
Details about one system
and other details eg risks
History of Presenting
Complaint
“Open”
3-4 Minutes
History of Presenting
Complaint
“Open/Closed”
Past Medical History
Social + Family History
2-3 Minutes
Drugs and Allergies
Systemic Review
2-3 Minutes
Cardiovascular, Respiratory, Gastro-intestinal
Central Nervous System, Other
Ideas + Concerns + Expectations
2-3 Minutes
Examination Outline
General Observations
• End of Bed
• Specific: BP, Pulse rate, Temp
Introduction
General Examination
Hands, Pulse, Neck, tongue, lymph-nodes
Systemic Examination
CVS, RS, Abdo, CNS, other
Clinical Conclusion
Approaches to
Clinical Diagnosis
?
3 Different Models of arriving at a
Clinical Diagnosis
Full systematic history and examination:
Hypothetico-deductive reasoning:
Pattern Recognition:
3 Philosophical
Approaches to Clinical
Diagnosis
• Plato (427 BC- 347 BC): "forms" to describe the true
essence of material objects in the world
• A chair is not defined by what we see but rather by its
nature or "chair-ness."
• An object is therefore defined by its closeness to the
idea or form of what it means to be a chair.
• Thus a tree stump, possessing the qualities of a
elevated object conducive to humans sitting on it, has a
quality of chair-ness and has the form of a chair.
• This idea of the form exists in a quasi-heavenly realm
that can only be understood by the mind.
3 Philosophical
Approaches to Clinical
Diagnosis
• Plato: The idea and application of the theory of forms is
best illustrated in the allegory of the cave.
• Story: prisoners are restrained and are looking at the
wall of the cave. They are able to see the distorted
shadows of things that are going by but not the actual
things themselves.
• So: the material things we perceive are shadows while
the thing producing the shadow is the true form.
• Most people never break free from the prison of their
own perceptions to grasp the reality of the forms. Those
that do are the truly wise and learned that Plato would
have us rise to the level of philosopher kings.
3 Philosophical
Approaches to Clinical
Diagnosis
• Hegel (1770-1831): The triad thesis, antithesis,
synthesis describes some philosophy of Hegel
• The triad is usually described in the following way:
 The thesis is an intellectual proposition.
 The anti-thesis is simply the negation of the thesis, a
reaction to the proposition.
 The synthesis solves the conflict between the thesis
and antithesis by reconciling their common truths
and forming a new thesis, starting the process over.
3 Philosophical
Approaches to Clinical
Diagnosis
• Hegel: The triad thesis,
antithesis, synthesis is
often used to describe the
philosophy of Hegel
3 Philosophical
Approaches to Clinical
Diagnosis
• Husserl (1859-1938): A philosophy or method of inquiry
based on the premise that reality consists of objects and
events as they are perceived or understood in human
consciousness and not of anything independent of
human consciousness.
3 Philosophical
Approaches to Clinical
Diagnosis
• Husserl (1859-1938): A philosophy or method of inquiry
based on the premise that reality consists of objects and
events as they are perceived or understood in human
consciousness and not of anything independent of
human consciousness.
{n}
3 More Philosophical
Approaches to Clinical
Diagnosis
• Bayes’ Theorem (1701-1761): Probability theory theorem
with two distinct interpretations. It expresses how a subjective
degree of belief should rationally change to account for evidence.
• Until the last half of the 20th century, Bayes’theorem was largely
rejected by the mathematics community as unscientific.
• However, it is now widely accepted.
• .
3 More Philosophical
Approaches to Clinical
Diagnosis
• Bayes Theorem: Probability theory theorem with two distinct
interpretations.
• Wikipedia example: Suppose someone told you they had a nice
conversation with someone on the train. Not knowing anything else
about this conversation, the probability that they were speaking to a
woman is 50%. Now suppose they also told you that this person had
long hair. It is now more likely they were speaking to a woman, since
most long-haired people are women. Bayes' theorem can be used to
calculate the probability that the person is a woman.
3 More Philosophical
Approaches to Clinical
Diagnosis
• Bayes Theorem: Probability theory theorem with two distinct
interpretations.
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W represent the event that the conversation was held with a woman, and L denote the event that
the conversation was held with a long-haired person. It can be assumed that women constitute
half the population for this example. So, not knowing anything else, the probability that W occurs
is P(W) = 0.5.
Known that 75% of women have long hair, which we denote as P(L|W) = 0.75. (read: the
probability of event L given event W is 0.75).
But 30% of men have long hair, or P(L|M) = 0.30, where M is the complimentary event of of W,
i.e., the event that the conversation was held with a man (assuming that every human is either a
man or a woman).
Our goal is to calculate the probability that the conversation was held with a woman, given the fact
that the person had long hair, or, in our notation, P(W|L).
The numeric answer can be obtained by substituting the above values into this formula. This
yields i.e., the probability that the conversation was held with a woman, given that the person had
long hair, is about 71%.
3 More Philosophical
Approaches to Clinical
Diagnosis
• Daniel Kahneman (1934-): 2002 Nobel Prize Economic Science.
• Prospect theory is a behavioral economic theory that describes the
way people chose between alternatives that involve risk
• Probabilities of outcomes are usually known.
• The theory states that people make decisions based on the potential
value of losses and gains rather than the final outcome
3 More Philosophical
Approaches to Clinical
Diagnosis
• Daniel Kahneman (1934-): 2002 Nobel Prize Economic Science.
• The theory states that people make decisions based on the potential
value of losses and gains rather than the final outcome
• People evaluate these losses and gains using certain heuristics (or
simple rules and concepts)
• It tries to model real-life choices, rather than theoretical best
decisions (eg computer)
3 More Philosophical
Approaches to Clinical
Diagnosis
• Hanuman: Hindu Myth BC:
Lakshmana is severely wounded during the battle against Ravana,
Hanuman is sent to fetch the Sanjivani, a powerful life-restoring herb,
from the Himalayas
These are he specific instructions of the physician called Sushena who
stated that Lakshmana would perish if untreated by daybreak
3 More Philosophical
Approaches to Clinical
Diagnosis
• Hanuman: Hindu Myth BC:
Lakshmana is severely wounded during the battle against Ravana,
Hanuman is sent to fetch the Sanjivani herb, from the Himalayas
On reaching the mountain he cannot identify the exact herb so he lifts
the entire mountain
Although attacked on the way (friendly fire), the mountain is delivered
to the battlefield in Lanka.
Sushena then identifies and administers the herb, and Laksmana lives
Personal Approaches to Clinical Diagnosis
Difficult to teach but essential clinical skill
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Plato
Hanuman
Bayes
Hegel
Husserl
Kahneman
Your Method?
Presentation Outline:
The 4 Point Presentation
General Findings
On Examination the patient was comfortable
Important Positive Findings
My main findings were jaundice and
an enlarged liver that was hard and nodular
Important “Negative” Findings
However, there was no ascites
Clinical Conclusion
These findings would be consistent with malignancy
Teaching on the Job
On-the Job Training for Physicians:
DH Hargreaves et al 1997. RSM
Teaching on the Job
•COPD Patient OSCE
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history taking
examination
discussion of differential diagnosis
writing the prescription chart
explanation of treatment
reviewing the chest x-ray
sharing bad news
written clinical communication
discussion with colleagues and carers
– At the end of each task the learner is encouraged to reflect and then
provided with constructive feedback on the clinical and communication task.
Clinical and Communication Skills:
•Clinical Skills teaching:examination, treatment
planning, safe prescribing, procedures
(venepuncture, suturing, CPR)1
•Communication Skills: aim to develop effective
(clear and sensitive) communication with
patients, carers and colleagues.
General Medical Council (2002) Tomorrow’s doctors. London.
Clinical Investigations
Clinical Skills and Communication Skills
Two strands can be
taught together!
Clinical and Communication Skills
Relationship with patient, History, Examination, Problem Solving and Management
Clinical Skills (g,h)
• Work out drug dosage and record the
outcome accurately.
• Write safe prescriptions for different types
of drugs.
Communication Skills
• Explain drugs action
• Side effects
Clinical Decision Making
Clinician’s expertise
based on clinical skills and
circumstances
Evidence based
recommendations
Patient
preferences
Knowledge based
Clinical Work Observed
ACAT, CbD, CeX,
OSLER
Does
Shows how
OSCE
Short Answer-Reasoning
Knows how
Written Exams
Knows
MCQ
Miller GE (1990) Acad Med (Suppl) 65 : S63
Clinical Teaching Resource:
•Guidelines
•Clinical Evidence
•? PDA/Computer
•Simulation models
•Textbooks
•X-rays, test results
•Pictures
A Clinical Skills Trolley
What’s good about OTJT?
• Arises from everyday work, so has the right
content.
• Work constantly reveals our “learning needs”.
• The “Situational learning” principle.
• Great for modelling (skills, consultation etc)
What’s good about OTJT?
• Great for role modelling of best
behaviours, esp humanistic and “life
long learning”
• Allows teaching of all domains;
knowledge, skills and attitudes.
• Opportunity to get the right “hidden
curriculum”.
What’s good about OTJT?
• Allows checking of “real” not “professed”
knowledge, beliefs and actions.
• Often provides the benefits of small group
teaching, eg group input, interactive, team
supporting, one to one, targeted teaching
points.
• Allows assessment of performance, not just
competence. (see Miller)
What’s good about OTJT?
• Regularly varied and lively environment
eg on the ward round, stimulates minds.
• Opportunities for team based learning.
• Can be entirely trainee dictated, esp
when on the hoof, eg: “what did you find
trickiest on take last night?”, or “what
shall we talk about?”
On the Job Teaching
•Evidence from RCTs
that interactive
continuing medical
education is effective
in positively changing
clinical performance12
12. Davis D et al Do conferences, workshops, round and other traditional continuing education activities
change physician behaviour or health care outcomes? JAMA 1999 Sep 1; 282:867-74.
Education Quote 10
“To study the phenomena of disease
without books is to sail an uncharted
sea.
“Whilst to study books without patients
is not to go to sea at all”
William Osler (1849-1919)
The Kolb Cycle
The Experiential Learning Cycle
Theorising
Reflection
New Actions
Experience
“Every interaction can be a mini educational
cycle”
Andrew Whitehouse
Summary
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Organised, short sessions
Patient and students briefed
“Comfortable” environment
Clear focussed learning objective
Use the patient and the environment
Use the “tools”
Feedback on performance
Subsequent discussion and reflections
Physicians learning - the human
dimension
In becoming physicians, students pass through three initial phases:
1. Gaining technical competence in dealing with disease.
– This is the principal preoccupation at medical school. Students
are immersed in the biological sciences and quickly learn the
value system of the medical establishment: The primary task of
medicine is the recognition and treatment of disease. Everything
else - communication, psychological, social, and environmental
factors - become peripheral. One result of this arrangement is
the deterioration of students' ability to communicate effectively
with patients as they progress through medical school
Physicians learning - the human
dimension
2. Developing a professional identity.
– This phase usually is begun during clinical
clerkship and completed during residency
training. It is only when students work as part of
the clinical team and have responsibility for
patient care that they begin to feel like doctors.
The metamorphosis is dramatic; students usually
become comfortable with their strengths and
limitations, develop a clearer sense of their
professional roles, and refine their ability to
appraise critically their own performance
Physicians learning - the human
dimension
3.
Learning to heal.
–
During this phase, physicians learn to be instruments of
healing, accepting with humility and wisdom the power to
heal bestowed upon them by their patients. This phase
takes at least 5 to 10 years and is not accomplished by all
physicians.It is important to note that learning to be a
healer continues after formal education is completed. The
seeds are planted during the training period, but only grow
and develop as physicians experience the power of the
healing relationship in practice.
Physicians learning - the human
dimension
4. Healing: The Professional Stage
– It has been one of the most basic errors of the modern era in
medicine to believe that patients cured of their diseases
(cancer removed, coronary arteries opened, infection
resolved, walking again, talking again, or back home again)
are also healed; are whole again. Through the [doctorpatient] relationship it is possible, given the awareness of the
necessity, the acceptance of the moral responsibility, the
understanding of the problem and mastery of the skills, to
heal the sick; to make whole the cured, to bring the
chronically ill back within the fold, to relieve suffering, and to
lift the burdens of illness.
Patient-centered medicine: transforming the clinical method. Moira Stewart et al, Sage. 1995 pp 120-131
Characteristics of the competent
trainer
• Teaching knowledge
– understand basic teaching methods and be able
to apply this knowledge
• Teaching skills
– to give good feedback observation skills
analysis skills to foster reflection in the trainee
Characteristics of the competent
trainer
• Teaching attitude
– giving latitude to the trainee having respect for
trainee having an interest in the trainee being
available for consultation individualized
teaching approach
• Personality traits
– enthusiasm
– flexibility
– patience
– self-insight
Boendermakera, Schulinga, et al. Family Practice 2000 Vol. 17, No. 6,
547-553
What makes a good
teaching session?
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Small groups
Interesting signs / classical case
Focussed area for teaching
Observed examination with feedback
Combined with theory and case
discussion
Langrish J, Informal Oxford Student Survey 2003