This document discusses a teaching curriculum for residents at a Harvard teaching hospital. It covers topics like principles of adult learning, clinical teaching skills, and effective clinical supervision. The goal is to equip residents with the skills needed for successful clinical teaching. It describes qualities of excellent teachers, applying adult learning theories, microskills for teaching, and facilitating self-directed learning.

1. Education is at the heart of patient care.
A teaching hospital of
Harvard Medical School
Resident as Teacher
A core curriculum to equip residents
for successful clinical teaching

2. A teaching hospital of
Harvard Medical School
Key Topics
• Principles of Adult Learning
• Clinical Teaching Skills
• Effective Clinical Supervision
• Providing Effective Feedback
• Leading Small Group Discussions
• Teaching Procedures

3. A teaching hospital of
Harvard Medical School
Learning Objectives:
Resident-as-Teacher Series
• Demonstrate an understanding of adult learning
principles and their application to various clinical
teaching venues
• Recognize common challenges in teaching adult
learners and pose solutions to overcome those
obstacles
• Describe the skills necessary to create learner-
centered experiences that encourage
questioning, discovery and discussion

4. A teaching hospital of
Harvard Medical School
Introduction:
Qualities of Excellent
Clinical Teachers and
Application of Adult Learning
Theories

5. A teaching hospital of
Harvard Medical School
Resident-as-Teacher
• Residents spend 25% of time teaching
• Medical students view residents as
extremely important to their clinical
education
• Many residents do not feel prepared
to teach

6. A teaching hospital of
Harvard Medical School
What qualities have stood out in
exceptional teachers you have
known?

7. A teaching hospital of
Harvard Medical School
Qualities of Excellent Clinical Teachers
• Knowledgeable
• Enthusiastic
• Use questions effectively
• Create safe learning environment
• Give learners responsibility (autonomy)
• Role model professionalism
• Have genuine concern for learner
• Provide meaningful feedback

8. A teaching hospital of
Harvard Medical School
Qualities of Excellent Teaching Attendings
• Preparation
– Know residents (needs assessment)
– Know cases ahead of time (typical vs difficult, educationally
interesting)
• Preplanned curriculum mixed with improvisation
– Read literature in advance
– Prepared materials, mental planning
• Assess residents knowledge while diagnosing
patient’s problem
– Interactive, use of questions
• Limited teaching points Irby, Academic Medicine, 1992

9. A teaching hospital of
Harvard Medical School
Irby, Academic Medicine, 1992

10. A teaching hospital of
Harvard Medical School
Adult Learners Need To:
• Know why they are learning something
• Connect new knowledge to past
experience or prior knowledge
• Actively engage in learning
• Approach learning as problem solving
• See immediate relevance and value
Knowles M, The Adult Learner, 2005

11. A teaching hospital of
Harvard Medical School
Thought Question
• Think of a time, perhaps outside of
medicine, when you learned a new
skill. Describe how the principles of
adult learning applied as you mastered
this skill.

12. A teaching hospital of
Harvard Medical School
Thought Question
• Describe a clinical teacher who had
a positive impact on your learning.
What did he or she do to create a
safe learning environment and
make the experience meaningful for
you?

13. A teaching hospital of
Harvard Medical School
Thought Questions
• What unique roles do residents
play in the medical education of
their peers and students?
• Which of these roles are you
particularly well-suited for or
excited about, and which ones are
you more hesitant to try?

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

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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…”

21. 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?”

22. 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.”

23. 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

24. 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.”

25. 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

26. 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.

27. 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?

28. 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?

29. 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?

30. 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.

31. A teaching hospital of
Harvard Medical School
Effective Clinical Supervision

32. A teaching hospital of
Harvard Medical School
Effective Clinical Supervision
• Provides learners with right mix of
guidance and autonomy
• Varies depending on level of training,
experience, knowledge and skill level
of learner

33. A teaching hospital of
Harvard Medical School
How to Start
• Take a moment at start of rotation or
session to establish learning
environment:
– Share expectations and set goals
– Assess learner’s background, current skill
level and experience.
• Find relevant teachable moment in
each case (“Just-in-time teaching”)

34. A teaching hospital of
Harvard Medical School
5Cs of Clinical Supervision*
• Communication
• Clear Expectations
• Curiosity
• Coaching
• Compassion
Adapted from McKimm J, Swanwick. E-learning for clinical teachers:
Supervision. London, England: London Deanery, 2012.
http://www.faculty.londondeanery.ac.uk/e-learning/supervision

35. A teaching hospital of
Harvard Medical School
Thought Questions
• How do you allow learners to gain
experience while balancing need for
patient safety?
• How is great supervision similar to
good coaching?
• Think about a great supervisor you
have worked with. What did they do
well?

36. A teaching hospital of
Harvard Medical School
Thought Question
Think about the supervisory
responsibilities in that you have had.
• What was the biggest challenge you
faced and how did you deal with it?
• What advice would you have for the
next resident who has this role?

37. A teaching hospital of
Harvard Medical School
Thought Question
Now think about the next supervisory
role you will assume.
• What are you looking forward to
and what will be particularly
challenging?
• How will you prepare for this role?

38. A teaching hospital of
Harvard Medical School
Thought Question
Describe your approach to managing
this situation:
• An intern you are supervising did
not carry out your instructions and a
patient received the wrong
medication.
• What will you say to the intern?

39. A teaching hospital of
Harvard Medical School
Thought Question
• How do you allow your students to
gain independence while assuring
patient safety?

40. A teaching hospital of
Harvard Medical School
Providing Effective Feedback

41. A teaching hospital of
Harvard Medical School
Importance of Feedback
• Receiving specific, relevant feedback is
essential for learning in clinical
environment
• Providing feedback can seem
challenging, but is one of most important
ways to demonstrate interest in learners
• Establish an environment where positive
feedback and suggestions for
improvement are done consistently

42. A teaching hospital of
Harvard Medical School
How to Give Effective Feedback
• Collect information on student’s
performance so you can provide specific
examples of both positive behaviors and
suggestions for improvement
• Balance praise with suggestions for
improvement
• When correcting someone, focus on the
specific behavior, not the individual

43. A teaching hospital of
Harvard Medical School
How to Give Effective Feedback
• Time feedback carefully, assess person’s
ability to receive it
• Explore learner’s own perspective on his
or her performance
• Avoid comparison to other learners
• Follow up with learners frequently for
ongoing discussion and further
questions

44. A teaching hospital of
Harvard Medical School
Example of Feedback
• Instead of
“You have poor hand/eye coordination”
• Try
“Turn your wrist to the left a bit”

45. A teaching hospital of
Harvard Medical School
Thought Questions
• What do you think are challenges to
giving and receiving effective
feedback in the clinical setting?
• What challenges are unique to you
as a resident?

46. A teaching hospital of
Harvard Medical School
Thought Question
• Describe a time when you received
feedback that was very helpful to you.
– What made the experience
beneficial and why?

47. A teaching hospital of
Harvard Medical School
Leading a Small Group
Discussion

48. A teaching hospital of
Harvard Medical School
Small Group Discussions Allow:
• Active learning
• Learner-centered experience
• Reflection
• Peer-to-peer teaching
• Case discussion
• Team based learning

49. A teaching hospital of
Harvard Medical School
Small Group Discussion Techniques
• Set clear expectations for the discussion
– Today we are going to discuss how to deliver
difficult news to a patient.
– I am going to ask you to share with the group
how you were taught to perform your first
procedure.
• Ask about the learners’ interests and needs:
– Are there particular questions or areas that you
want to make sure we discuss today?

50. A teaching hospital of
Harvard Medical School
Small Group Discussion Techniques
• Establish a safe learning environment
– Encourage questions and use learners’ names
– Be willing to say, “I don’t know, let’s look that
up.”
– Think out loud with the group: “When I am
confronted with this issue, I find it helpful to…”
• Encourage learner interactivity and
problem solving

51. A teaching hospital of
Harvard Medical School
Small Group Discussion Techniques
• Ask questions that encourage deeper vs surface
level learning:
– What if the patient was 80 y.o. instead of 20?
– When wouldn’t you choose that course of
treatment?
– Why did you choose that answer and not the
other?
– Explain why we can rule out…

52. A teaching hospital of
Harvard Medical School
Summarize and Close the Discussion
• Ask each group member to name one thing
they learned from the discussion or one
thing they are going to change in their
clinical practice
• Leave time for learners to ask clarifying
questions:
• What are some points you would like me to
cover again next time?

53. A teaching hospital of
Harvard Medical School
A Great Case Discussion...
• Starts w/basics, unfolds in bite-sized pieces
• Avoids focus on lab and imaging data too
early; allows full context of patient’s story
• Includes interesting decision points or
clinical pearls
• Teaches general principles by changing
variables in case
• Encourages a discussion of cost-effective,
value-added care

54. A teaching hospital of
Harvard Medical School
Thought Question
• Discuss the following challenges when
leading a small group discussion:
– A student that won’t participate
– A learner that dominates the discussion
– A particularly quiet group
– Unpredictable tangents in the
conversation

55. A teaching hospital of
Harvard Medical School
Thought Question
• Often your small group will have
residents and students at various
learning levels (e.g. the “one room
school house.”)
– What are strategies to engage all levels
of learners at the table?
– What pitfalls do you need to avoid?

56. A teaching hospital of
Harvard Medical School
Thought Question
• Sometimes a group discussion can
turn into a lecture, or at the opposite
end of the spectrum, dissolve into a
conversation completely off topic.
– What are the most effective strategies to
engage the group in a true discussion on
the topic you wish to teach?

57. A teaching hospital of
Harvard Medical School
Teaching Procedural Skills

58. A teaching hospital of
Harvard Medical School
How to Teach Procedures
• To many, teaching procedures is
one of most rewarding aspects of
clinical education.
• Several key principles:
– start with the basics
– allow opportunity for successful
completion of procedure
– preserve well-being of patient and
student

59. A teaching hospital of
Harvard Medical School
How to Teach Procedures
• Careful preparation is key
• Learn prior experiences of the learner
– Seen one? Tried one? What questions
do you have?
• Review clinical indications and
implications, not only the technical steps
• Review potential complications and how
to minimize them

60. A teaching hospital of
Harvard Medical School
How to Teach Procedures
• Review performance objectives
• Review equipment
• Review anatomy and physiology
• Review technique
• Anticipate questions
• Ensure preparation
– Consider videos, models, diagrams, simulations

61. A teaching hospital of
Harvard Medical School
How to Teach Procedures
• Use a systematic approach – review of
equipment, practice, speak steps aloud
• Always be mindful of patient’s experience
• Give thoughtful corrections as needed
– “Let me show you a helpful trick here”
– “I am going to adjust the position of your
hand”
• Understand when appropriate to take
over procedure

62. A teaching hospital of
Harvard Medical School
How to Teach Procedures
• Debrief after the procedure:
– Be specific and descriptive with
feedback
– Ask learners: What went well, what
did they learn? What questions do
they have?
– Give specific suggestions and an
action plan for improvement

63. A teaching hospital of
Harvard Medical School
Thought Question
Describe a procedure that was initially
challenging for you to master and
think about those that taught you to
perform it.
• What did they say or do that was
helpful or not helpful?
• How do these experiences influence
your own style when teaching a
procedure?

64. A teaching hospital of
Harvard Medical School
Thought Question
Think about the type of procedural
teaching that you do in your specialty.
• What new concept did you learn in
the video that you can apply to that
setting or to a specific procedure?

65. A teaching hospital of
Harvard Medical School
Thought Questions
• What are the biggest challenges
about teaching procedures in your
clinical setting?
• What strategies can you use to
address them?

66. A teaching hospital of
Harvard Medical School
Thought Question
You are in the room with an intern who
is performing a procedure for the first
time. You notice the resident is
struggling with the equipment.
• Describe your approach to assuring the
procedure is done correctly as well as
maintaining the patient’s safety and
comfort during the encounter.