Resident as Teacher:
Teaching in the Clinical Setting
Resident-As-Teacher Interest Group
The Academy at Harvard Medical School
Agenda
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Residents as Teachers
Adult Learning Theory
Knowing your learners
Setting expectations
Showing respect and enthusiasm
Thinking out loud
Giving specific, prompt feedback
Some Basic Principles
Know your
learners
• Ask about prior education and background
• Become familiar with learner’s goals and objectives
• Give learner clear expectations
Be respectful
and
enthusiastic
• Introduce yourself and share your love of medicine
• Use first names and introduce learner to others
• Be kind when pimping
Think out loud
• Include learner in your thought process
• Probe learners to ensure they follow your reasoning
• Allow learner opportunity to ask clarifying questions
Give specific
real-time
feedback
• Choose right setting/timing for feedback
• Provide positive and constructive SPECIFIC feedback
• Solicit and formally deliver feedback at end of encounter
Residents As Teachers
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LCME mandate
ACGME mandate
Residents spend up to 25% of time teaching (Busari JO,
2002)
Medical students attribute one-third of their knowledge to
teaching from residents (Bing-You RG, 1992)
Residents As Teachers
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Qualities of excellent clinical teachers (Wright, NEJM
1998)
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Spend more than 25% of time teaching (especially beyond
assigned responsibilities)
Stress doctor-patient relationship
Stress psychosocial aspects of medicine
Give more in-depth, specific feedback to learners
Get to know trainees on personal level
Residents As Teachers
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Qualities of excellent clinical teachers
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Prepared, perform needs assessment
Know cases ahead of time
Preplanned curriculum mixed with improvisation
Assess resident’s knowledge while diagnosing patient
Limited teaching points
Adult Learning Theory
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Adult learners bring life experiences and extensive
knowledge to any situation
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Learning happens when new information is linked to prior
knowledge and experience
Knowledge is constructed, not received
For adults, learning is most meaningful when actively
engaged in solving problems
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Learn by answering clarifying questions
“What data or examples support that point of view?”
Know your learners
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Scenario: You are a night float working with a clerkship
student. During an admission for a new diagnosis of
likely MS, you give him an overview of the clinical
features and diagnostic workup. You find out later he
has published on the genetics of MS. How could you
approach this scenario differently?
a) Ask briefly if he is familiar with MS and gauge his level of
knowledge by asking probing questions
b) When first introducing yourself to the resident, ask him about
his background knowledge in neurology
c) Once you learn of his research, stop trying to teach him
d) Ask him how his research informs the case, while explaining
your thought process
Know your learners
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Ask about learner’s background and prior experience
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Educational background
Prior clinical experience
Career plans
Learner’s goals for educational encounter
Become familiar with learner’s other responsibilities
outside of your setting
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Central medical school obligations
Continuity clinic
Clerkship specific didactics and clinics
Know your learners
• Year I (Aug – May)
– Introduction to the
profession
– Basic science courses
– Patient Doctor I
– Epidemiology
– Ethics
– Social medicine
• Year II (Aug – Apr)
– Human systems
– Pharmacology
– Health care policy
– Patient Doctor II
– USMLE Step 1
Know your learners
• Year III (May – Apr)
– Principal Clinical
Experience (PCE)
– Clerkships
– Patient Doctor III
– Primary Care Clinic
• Year IV (May – Jun)
– Required subinternships
– Required clinical
electives
– Other electives
– Residency interviews
– USMLE Step 2
Know your learners
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Who is an HMS Third Year?
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Traditional Student
MD/PHD Student
HST student
Oral Surgery Resident
Visiting (foreign) students
Advanced students
Observers
Third year rotations for most students begin in late April
Know your learners
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Required Third Year (Core) Clerkships
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Medicine – 12 weeks
Surgery – 12 weeks
OB/GYN – 6 weeks
Pediatrics – 6 weeks
Radiology – 4 weeks
Psychiatry – 4 weeks
Neurology – 4 weeks
Know your learners
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Principle Clinical Experience (PCE)
– Student completes all clerkships at one hospital
– Provides structure and community for students
– Weekly student-run case conferences (afternoon)
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Primary Care Clinic (PCC)
– Weekly continuity clinic (Tue or Thu afternoon approx 1-5P)
– Some are off site and require travel time
Students need to be released without guilt for their central
PCE and PCC responsibilities
Set clear expectations
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Educational compact between learner and teacher
Become familiar with clerkship goals and objectives
– Understand clerkship curriculum
– Become familiar with call schedule
– Clarify level of responsibility for students
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Explicitly state your expectations of learner
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Team schedule
Number of admissions
Protocol for assigning and role during procedures
Documentation responsibilities
Patient care responsibilities
Be respectful and enthusiastic
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Scenario: Three new medical students arrive to morning
rounds in the conference room during the middle of a
new case presentation. The senior resident should:
a) Ignore them and hope they go away
b) Interrupt the junior presentation to have a group hug with the
students
c) Pause for brief introductions and then resume case
presentation, with a more complete orientation to team after
rounds
d) Acknowledge the students and suggest that the junior
complete the presentation before formal introductions and
orientation to the team
Be respectful and enthusiastic
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Respect
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Introduce yourself and your background
Learn and use first names
Introduce learners to other providers
Include everyone in team discussions, and speak to all levels
of knowledge
Pimp kindly, but do pimp (engage learners in process rather
than dictating to them)
Invest early by explaining logistics, expectations and then
reinforcing with frequent feedback
Divide tasks among all members of team, including both trivial
and high level
Advocate for learners and back them up
Be respectful and enthusiastic
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Enthusiasm
– Share with learners why you chose your field
– Remind yourself intermittently why you chose to do what you
do
– Find something interesting in every case
– No great teacher was every noted for their apathy to content
or students
– When feeling burned out, tell a peer and/or share with team
your frustrations
– Remember that even when you are not explicitly teaching,
you are actually teaching through role modeling
Think Out Loud
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Scenario: You are paged for the 10th time by the ED
junior to review a consult as the night senior. You have 5
floor consults and a death by cardiac criteria case to
triage in the ICU. The case presented by the ED junior is
straightforward carotid dissection and you tell them to
get an MRA with fat sats, start heparin, and admit to
CMF. How could you teach more effectively in this
context?
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b)
c)
d)
Send them three articles (PDF’s) on dissection
Copy and paste the summary from Up-To-Date to an email
Give them a chalk-talk on ASA vs. anti-coagulation in stroke
Briefly explain your rationale for suspecting dissection, the
imaging modalities that can be used, and the ambiguous
evidence for treatment but your favored approach/reasoning
Think Out Loud
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Include learner in your thought process
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Summarize key aspects of case
Explicitly state guiding principals
Give learner opportunity to ask clarifying questions
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Helps to consolidate principals
Further informs whether they understand key principals
Be open to saying “I don’t know” (“but I will find out for you”)
Think Out Loud
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Probe learner to ensure they follow your reasoning
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Pimping shows interest, keeps students engaged
Allows teacher to identify knowledge gaps
Allows teacher to model sound clinical reasoning
Use first names
Pose questions to group before calling on individual
Avoid “wrong” or aggressive grilling
Rephrase question to lead learner toward “discovering” the
correct answer
Acknowledge effort and challenge
Start junior and work toward more senior learners to avoid
embarrassment
Think Out Loud
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Five types of questions
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Factual: How long has patient had abdominal pain?
Broadening: What are potential causes?
Justifying: What supports your diagnosis?
Hypothetical: What if the patient were immunocompromised,
how would this change your diagnosis?
Alternative: What is the advantage or disadvantage of
watchful waiting vs. endoscopy?
Think Out Loud
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More effective questions
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What major findings lead to your diagnosis?
Is there anything else we should be concerned about?
What were two other diagnoses you considered and why did
you eliminate them?
Less effective questions
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What is the most common symptom associated with this
diagnosis?
What are the three most common causes of this syndrome?
What is the sensitivity of testing for the 2nd and 3rd
diagnoses?
Think Out Loud
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Teaching at bedside
– Prepare – directed questioning and examination
– Practice – seek feedback from experts
– Include patient – no one is more invested in the findings and
they can be an ally in engaging and teaching the learners
– Observe – step back and let the learner take a stab
– Debrief – make sure learners received the information you
intended, discuss what went well and what could be better,
leave time for questions
Think Out Loud
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Teaching on work rounds
– Be flexible – adjust amount and type of teaching to needs of
team and service
– Be explicit – do not assume everyone is following your
thought process; think out loud and verify that learners
understand concepts and decisions
– Role model – every interaction has implications (you are
always being watched!)
– Do it – there is no time like the present; no need for fancy
presentations
Think Out Loud
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Teaching on call
– Set expectations at outset (take first admission, try to see
another one, come with me to ED, etc.)
– Include students in potential learning moments when possible
(paged to see unstable patient on cross-cover)
– Engage student to help with duties they can perform while
learning, making them a part of your team (even if team of
two)
– Confirm history and examination findings, demonstrate
additional findings, review and give feedback on notes
– Role model (always!)
Think Out Loud
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Teaching procedures
– Ask about prior experience (Have you done this before? What
was challenging in the past?)
– Demonstrate (simulation, or live)
– Repeat steps out loud while demonstrating
– Watch trainee and give verbal feedback
– Have trainee teach it back to you
– As learners gets more expertise, provide small tips
Give (High Quality) Feedback
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Scenario: A student on DMD performs at an expected
level, including admitting one admission on call nights,
being reliable with work and notes, and demonstrating a
good knowledge base. You tell him that he did “well” and
there was no specific feedback. He then goes on to
MAS, where his team has a similar impression. At his
exit interview, he is told of his “solid” performance and
later gets an “honors” grade. He wonders how he could
have done better. More effective feedback includes:
a) Specific advice to take on more patients
b) Reviewing specific aspects of the exam to improve
c) Recommending targeted reading on his patients to present to
the team
d) Pointing out specific strengths of his performance
Give (High Quality) Feedback
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Good feedback is…
Give (High Quality) Feedback
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Good feedback is…
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Timely
Respectful
Non-judgmental
Bidirectional
Self-directed
Honest
Positive and constructive
Actionable
SPECIFIC
Give (High Quality) Feedback
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Feedback best deferred to clerkship director
– Inappropriate Dress - Delicate topic
– Mental health - Concerns about depression, substance use
– Serious professionalism issues
Some Basic Principles
Know your
learners
• Ask about prior education and background
• Become familiar with learner’s goals and objectives
• Give learner clear expectations
Be respectful
and
enthusiastic
• Introduce yourself and share your love of medicine
• Use first names and introduce learner to others
• Be kind when pimping
Think out loud
• Include learner in your thought process
• Probe learners to ensure they follow your reasoning
• Allow learner opportunity to ask clarifying questions
Give specific
real-time
feedback
• Choose right setting/timing for feedback
• Provide positive and constructive SPECIFIC feedback
• Solicit and formally deliver feedback at end of encounter