July 23, 2015
Bern Master’s Program
How Clinical Teachers Develop Skills to
Attend to Different Level Learners
H. Carrie Chen, MD, MSEd
Professor of Clinical Pediatrics
University of California San Francisco
School of Medicine
Expectations of Clinical Teachers
Clinical teachers need to
support clinical learning
and developmental progression
of
a wide range of individual
learners
Context
• Unpredictable, opportunistic nature of clinical learning
• Need to engage multiple-level learners
Ramani & Leinster 2008
Jenny, the New Faculty Member
Learning in the Clinical Setting
• Apprenticeship model
– Learning situated in workplace
– Learning triggered by engagement in work activities
– Learners learn everything necessary for job by doing
(Billett 2001, Collins 2005)
• Learning through
participation
Variation Towards More Structured Learning
• Structured learning with feedback, regular assessments,
portfolios, etc
• Cognitive apprenticeship model (Collins 2005)
– Promotes development of cognitive skills needed for
complex practice
– Learner tasks based on learning needs rather than
just workplace needs
Two Apprenticeship Models
Learning
Learner
task
Teaching
emphasis
Apprenticeship
Cognitive
Apprenticeship
Opportunistic
Deliberate
Workplace needs
Learning
considerations
Knowledge & skills
Cognitive skills
Knowledge & skill
application
Collins A. The Cambridge Handbook of the Learning Sciences. 2005.
Cognitive Apprenticeships
• 4 dimensions
– Content required for expertise
– Sociology/social characteristics affecting learning
– Methods (teaching strategies to promote learning)
– Sequence
of learning activitiesArticulation
(curricular design)
Coaching
Scaffolding
Reflection
Modeling
Exploration
Collins A. The Cambridge Handbook of the Learning Sciences. 2005.
Supported Participation
• Deliberate matching of activities to learner needs
• Key to learning in the workplace (Billett 2002, Dornan et al. 2007)
• Experts argue (Billett 2002, Dornan et al. 2007, Dornan et al. 2014, Teunissen
et al. 2007)
– Curriculum leaders need to developmentally
sequence learning activities
– Teachers need to enable learner participation in
workplace activities appropriate to the learner’s level
of development
Challenges
• “Different learners can learn from same patient if
teachers choose different teaching goals and focus on
different learning activities” (Ramani & Leinster 2008)
– Not sure how teachers accomplish this
• Most commonly identified problems (Spencer 2003)
– Teaching pitched at wrong developmental level
– Lack of learner participation in workplace activities
Excellent Clinical Teaching
• Studies on teachers (Buchel & Edwards 2005, Fluit et al. 2010, Irby 1995,
Sutkin et al. 2008)
– Teacher characteristics (knowledge, enthusiasm,
good role model)
– General skills (feedback, communication)
– Not on teacher’s role in choosing opportunities for
effective learning
• Studies on teaching practices (Stalmeijer et al. 2009, Stalmeijer et al.
2013, Taylor & Care 1999, Woolley & Jarvis 2007)
– Teaching strategies (articulation, coaching, etc)
– Not on engaging different level learners in the
workplace
Faculty Development
• Majority of offerings (Steinert et al. 2006)
– Via skill-specific workshops
– Focus on general skills and teaching strategies
– For broad application to any level learner
Purpose
To determine how excellent clinical teachers:
1. Approach selection of developmentally
appropriate clinical learning experiences for
learners
2. Develop the skills to address the teaching
challenge of working with different level
learners
Study Team
• Pat O’Sullivan, EdD
• Arianne Teherani, PhD
• Shannon Fogh, MD
• Brent Kobashi, MD
• Olle ten Cate, PhD
Methods
• Qualitative interview study using a constructive grounded
theory approach
• Purposive sampling to select interviewees who were
– Identified as excellent teachers (AME membership)
– Practicing physicians
– Taught learners of multiple levels in clinical settings
• Specifically sampled from procedural and nonprocedural specialties, and range of inpatient and
outpatient settings
Faculty Interviews
• Semi-structured interviews
– Conducted between Jan 2012 and March 2013
– Averaged 30 minutes (range 15 – 50 min)
– Audio-recorded, transcribed, and de-identified
• Asked 3 questions
– Approach to teaching different level learners
– Development of current approach
– Perceived role in promoting learners’ developmental
progression
Data Analysis
Initial open coding
(6 random transcripts, 3 authors)
Compared codes, reconciled differences
Codebook for thematic analysis
All transcripts coded (open and axial)
(independently by 2 authors)
Discrepancies reconciled
Saturation reached within sample
Additional Analyses
• Additional analyses
– Frequency of codes
– Co-occurrence of codes
– Stratification of codes by years of teaching
experience
• Final organization of themes using sensitizing concepts
– Cognitive apprenticeships & curricular sequencing
– Workplace learning
– Cognitive load
Results
• 46 clinical teachers invited
– 20 responded
– 19 agreed to participate, 1 declined
• All 19 interviewed
– Averaged 18 years of teaching (range 6 – 33 years)
– All taught students and residents
– Approx 1/3 also taught fellows
Demographics
Participants
n = 19
Specialty
Procedural (anesthesia, ob/gyn, surgery, surgical sub)
Non-procedural (FCM, med, peds, psych, subspecialty)
5 (26%)
14 (74%)
Clinical setting*
Outpatient clinic or emergency room
Inpatient ward, nursery, or nursing home
Intensive care unit or operating room
13 (68%)
13 (68%)
5 (26%)
Location
County hospital
Tertiary care hospital
Veteran’s hospital
4 (21%)
9 (47%)
6 (32%)
Themes Identified
• 6 Themes
• Related to two categories
– Teaching practice
– Skills development
Teaching Practice – 3 Themes
Selection
of Learning
Activities
Sequencing
of Learning
Experiences
Teacher
Responsibilities
Teaching Practice
1. Sequencing of Learning Experiences
• All described deliberate ordering/sequencing of learning
experiences
• No teachers relied on curricular sequencing alone
• Increasing years of experience associated with more
descriptions of sequencing practice
• Sequenced using 3 factors
– Content (general to specific, learning hierarchies)
– Complexity
– Expectations (increasing responsibility & autonomy)
2. Selection of Learning Activities
• Chose learning activities
– Initially by learner level (average competency)
– Later by individual level (assessed needs)
– More individualized with longitudinal relationships
• Choices influenced by
– Curricular goals/objectives
– Learner goals
– Faculty goals
– Developmental considerations
3. Teacher Responsibilities
Clinical Teacher
Promote learner
development
Learners
Ensure
patient
safety
Patients
Skills Development – 3 Themes
Developmental
Trajectory
of Clinical
Teachers
Teacher
Agency &
Work-Based
Learning
Clinical
Confidence
& Teaching
Skills
Skills Development
1. Teacher Agency & Work-Based Learning
of Teaching Strategies
• Faculty as learners
– Transformed workplace experiences into personal
development opportunities
– Used on-the-job experience and trial & error
– Accessed peers and education, departmental &
professional communities
• Greater years of teaching experience associated with
informal development of skills via workplace experiences
On-the-Job Experiences
“The main purpose of those meetings is to bring
preceptors together to discuss how a [learner] is
doing…but…that provides faculty development
because faculty are talking together about where
the [learner] is now and what the next step would
be for them to develop”
“We often precept in a room with multiple learners
and preceptors at the same time…You’ll hear
other people – sometimes more experienced
people…precepting other learners. I think that’s
actually the best source of education of all.”
2. Developmental Trajectory of Clinical
Teachers
• All described developmental progression in clinical
teaching
– Teacher- to learner-centered
– Expert to facilitator/ collaborator
• Requested ongoing personal development
– Teaching scripts
– Developmental trajectory with benchmarks
Evolution of Teacher
“When I first started teaching, it was inevitable…to
focus on the content…Now…it’s my process of
teaching that I focus on – will this session be
interactive…will the environment be good if I set it
up this way – so I think more about my teaching
process now than I do about content.”
3. Interplay Between Clinical Confidence and
Teaching Skills
• Evolution of teaching abilities and confidence described
in association with increased
– Clinical experience
– Clinical confidence
• Increased clinical confidence translated into increased
learner-centeredness
– Willingness to be flexible, accommodating individual
learner needs
– Allowed learners to drive teaching interaction
– Placed more trust in learner abilities
Trust in Self and Learner
“[I was] very anxious about things that could go
wrong…one of the transformative things is that
[surgeries] became…so routine that the anxiety
component was removed…I kind of had been
through almost every complication that could
occur and I kind of knew what to do…that’s
helped me to be calmer and to tolerate more
sluggish progress on the part of the [learner]
because I know that I can get them out of this,
and as long as they’re not doing anything
dangerous, I can roll with it a little bit.”
Summary
• Clinical teaching can be deliberative despite lack of
control over patient cases
• Excellent teachers used sequencing to structure/match
learning opportunities to different learner levels
• Teachers developed these skills through informal workbased experiences
• Teaching practices
– Followed a developmental trajectory toward learnercenteredness
– And teaching confidence co-evolved with clinical
experience and confidence
Implications for Preparing Teachers
• Need faculty development
– Address working with learners at different levels and
their differing needs
– Include intentional focus on sequencing as a key
teaching strategy
– Clarify/ emphasize teacher’s role in learners’
developmental progression
Implications for Faculty Development
• Consider work-based learning
– Encourage faculty agency
– Build faculty development support into the workplace
• Effective programs (Steinert et al. 2006, O’Sullivan & Irby 2011, Steinert
2012)
– Employ elements of experiencial learning, feedback,
collegial relationships
– Attend to context, workplace community, lived
experience of faculty
Implications for Faculty Development
• Consider developmental trajectory
– Sequence faculty training
– Different benchmarks for different teaching
competencies
– Use teaching scripts
• Consider cognitive load
– Pattern of new vs experienced teachers
– Account for faculty’s development as clinician
Acknowledgements
• Members of the UCSF Academy of Medical Educators
who participated in this study
• Funding from
– Association of American Medical Colleges (AAMC)
Western Group on Educational Affairs (WGEA)
– UCSF Academy of Medical Educators
Questions
Carrie.Chen@ucsf.edu