Module 1 Presentation - Clinical Teaching Skills

1. A teaching hospital of
Harvard Medical School
Clinical Teaching Skills

2. A teaching hospital of
Harvard Medical School
Characteristics of Effective
Clinical Teachers
• Agree upon and share expectations
• Are enthusiastic, stimulate curiosity
• Demonstrate clinical skills
• Involve learners in the educational
process
• Role model desired behaviors
Irby et al, Academic Medicine, 1991

3. A teaching hospital of
Harvard Medical School
Microskills of Teaching
• Get a commitment
– Learner outlines his diagnosis or
management plan
• Probe for supporting evidence
– Question the learner about reasoning
• Teach general rules
– Provide take home points
• Reinforce what was right
– Provide positive feedback
• Correct mistakes
– Suggest what could be improved
Modified from: Neher, Gordon, Meyer,
Stevens. J Am Board Fam Prac., 1992
Lake FR, Ryan G. MJA, 2004.

4. A teaching hospital of
Harvard Medical School
Get a Commitment
• Active participation in the learning
process
• Learner has more responsible for
patient care
“Thinking and problem-solving occur not when
answering a question posed by a teacher, but when
attempting to solve a problem important to the
learner.” - John Dewey

5. A teaching hospital of
Harvard Medical School
Probe for Supporting Evidence
• Helps learner engage in clinical reasoning
– Learners asked to think out loud
• Allows the preceptor to identify knowledge
gaps and model clinical reasoning
– “What major findings led 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?”
• Uncovers surface vs deeper learning

6. A teaching hospital of
Harvard Medical School
Ask the Right Question
Five types of questions:
1. Factual – When did the patient’s abdominal pain
start?
2. Broadening – What are other potential causes of
this patient’s abdominal pain?
3. Justifying – What supports your diagnosis?
4. Hypothetical – If the patient were immuno-
compromised, how would this change your
diagnosis?
5. Alternative – What would be the advantage or
disadvantage of PPI and watchful waiting vs.
endoscopy?
From Whitman and Schwenk, In Alguire et al. Teaching in Your Office, 2001

7. A teaching hospital of
Harvard Medical School
Promote Thinking and Problem Solving
• Create supportive environment
• Model critical thinking
• Pose question and pause for > 4 seconds
• Involve all learners in problem solving
• If learners hesitate or do not answer, ask
them to go back to the basics and think
out loud with you:
“This is a complex case. Let’s go back
to what we learned yesterday…”

8. A teaching hospital of
Harvard Medical School
Teach General Rules
• Limit key points
• Evidence-based
• Link knowledge to similar cases
• Extend teaching— Use “What if?”
“Why?” and “How” questions:
o“What if the patient had renal dysfunction?”
o“Why do you think the infection progressed so rapidly?”
o“How does this patient’s chest pain compare to the patient
yesterday who was having an MI?”

9. A teaching hospital of
Harvard Medical School
Reinforce What Was Right
• Builds confidence and increases motivation
• Promotes nascent skills
• Facilitates ability to give negative feedback
• Instead of:
– “Strong work” or “Nice job”
– Try: “By keeping a broad differential and
analyzing all of the data available you were
able to make the correct diagnosis.”

10. A teaching hospital of
Harvard Medical School
Correct Mistakes
• Appropriate time and place
• Allow learner to critique own performance
• Reinforce positives and be kind
• Avoid vague and judgmental language
• Describe what went wrong and how to
correct it
• Ask how you can be helpful

11. A teaching hospital of
Harvard Medical School
Focused and Specific Feedback
• Instead of “Good job.”
o “You took a very complete history. Next
time, try to wait a bit after you ask a
question to give the patient more time to
answer.”
• Instead of “You seemed rushed.”
o “You evaluated that patient very quickly.
Next time try sitting down in a chair next
to the patient when you talk to him.”

12. A teaching hospital of
Harvard Medical School
Facilitate Self-Directed Learning
•Have student identify learning points
•Encourage learner to reflect on
his/her patients and identify areas
for improvement or learning
•Help learner identify a clinical
question and resources to answer it
•Specify time to follow-up

13. A teaching hospital of
Harvard Medical School
Thought Question
Think about some of the best clinical
teaching you have experienced.
•What did you appreciate about the
experience?
•Name two specific methods you
would like to adopt in your own
teaching.

14. A teaching hospital of
Harvard Medical School
Thought Questions
•Sometimes a busy workload and
patient care responsibilities can
make it more challenging to engage
learners.
•What are some effective ways to fit
in teaching when you are very busy?

15. A teaching hospital of
Harvard Medical School
Thought Question
The scenario in the video takes place
in an outpatient clinic.
•How might the micro-skills of
teaching be adapted to other clinical
venues such as the inpatient wards,
labor and delivery, a reading room,
the emergency department, or
operating room?

16. A teaching hospital of
Harvard Medical School
Thought Question
•Describe what you can do at the
start of any teaching encounter to
emphasize a learner-centered
approach?

17. A teaching hospital of
Harvard Medical School
Thought Question
Often you will have the opportunity to
teach in the presence of a patient.
•Describe important considerations
when including the patient in your
bedside teaching.