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CHICAGO—Teaching in the inpatient setting can be a tall task, hindered by a lack of time, an unpredictable environment and a variety of learners encountered at different levels. But a few techniques—based mainly on understanding who your students are and how they prefer to learn—can make a big difference, an expert said at the 2018 ACR/ARHP Annual Meeting.
With podium lecturing on the wane, learners want structure, support and community, engagement, discussion and feedback, particularly when in the swirl of the hospital, said Eli Miloslavsky, MD, assistant professor of medicine at Harvard Medical School in Boston.
A must, he said, is creating an informal “learning contract,” not just for establishing what the student is expecting to learn, but to create a plan for the flow of rounds and to assign roles that keep everyone engaged. If a fellow is presenting a case, for example, a student or resident might be assigned the task of observing a relevant finding, making a problem list or starting the differential diagnosis, while a fellow could be asked to propose the workup and assign probabilities to diagnoses to the other team members, Dr. Miloslavsky said.
Creating the right support system and a sense of community with learners, he said, depends in part on curiosity—“curiosity about your learners as people, curiosity about your learners as learners, curiosity about the patients and curiosity about our diseases.”
“I think [curiosity] as a faculty member is kind of critical to make your learners curious,” Dr. Miloslavsky said. “We’re not curious enough as teachers about what’s going on in front of us.”
Another aspect of promoting a positive learning environment while effectively assessing learners is asking open-ended questions, such as how to choose between therapies or interpret a certain case feature. Such questions can give teachers an idea about the learner’s gaps, which they can then try to fill.
“It’s hard asking these questions in a way that’s most effective, but I think it’s a key, key skill,” he said.
Teaching the primary team as a consultant is also an important aspect of inpatient teaching. Even short encounters can prove useful, Dr. Miloslavsky said, but they must be properly couched and structured. Just a simple, “I’d like to do a little bit of teaching, do you have three minutes?” can serve as a kind of “mini learning contract” and lay the groundwork for real learning to take place, he said.
‘The more they understand this, the more they understand how to work up joint disease.’ —Dr. O’Rourke
Connect with Your Learners
Jay Mehta, MD, MS, clinical director of rheumatology at the Children’s Hospital of Philadelphia, said he learned many years ago when he received early reviews of his own teaching style that he wasn’t connecting enough with students and residents. They had individual needs, and he was too boilerplate. In addition, they wanted feedback, but he was too busy to give it.
“If you’re not spending time thinking about the stage the learner is [in], you’re wasting your time and the learner’s time,” Dr. Mehta said.
With the “one-minute preceptor” model he uses to teach in the clinic, he helps build a bridge to his learners.1 The first step is to “get a commitment” from learners using the patient’s data, for example, asking, “What do you think is going on?”
Next, Dr. Mehta said, “probe for supporting evidence,” asking, “Why do you think this?” Here you should avoid telling the resident or student their initial thought was right or wrong.
Then, “teach general rules,” which he does using pearls; that is, by frequently weaving in “high-yield” teaching points rather than overloading learners with less relevant points.
“We all have a desire when we’re first starting out to show how much we know,” Dr. Mehta said. “[But] learners prefer we keep it simple.”
After that, tell them what they did right, using specifics rather than just saying, “Great job.”
Finally, correct their mistakes while remaining as judgment free as possible and focusing on improving learners’ knowledge and skills. If the feedback might be sensitive in the moment, it’s okay to wait a bit before talking about it, he said.
“This step is often the most critical,” Dr. Mehta said. “You want the learner to come away with an idea of what they might do better next time.”
Teaching in Private Practice
Teaching in private practice involves special considerations, said Kenneth O’Rourke, MD, of Rheumatology Associates in Portland, Maine. Although a patient visiting an academic medical center probably expects a trainee might be involved in their care, they don’t necessarily expect it at a private office visit. It’s therefore a good idea to “prime the patient,” with a word from the staff when the patient gets to the exam room, Dr. O’Rourke said, and even with small placards on tables in the waiting area.
Private rheumatology practices that choose to teach must contend with shorter and shorter rotations, and most learners will not have rheumatology as their end goal. Therefore, clinicians should tailor their education accordingly, not trying to teach too much in a short time.
But, Dr. O’Rourke said, “You still want impart to any trainee some component of rheumatic disease care. … They’ll need it no matter what they go into.”
A good approach: “Reduce the cognitive load” for the trainee before they go in to see a patient by offering a vignette, he said. Tell them, for example, “Mrs. Smith has long-time rheumatoid arthritis and is in clinical remission on such and such medication, and we will want to ask about symptoms including fatigue and stiffness and drug side effects.”
“You’re sort of framing that patient’s vignette for them,” Dr. O’Rourke said, “and unbeknownst to them, you’ve given them a 30-second, 45-second talk on rheumatoid arthritis.”
He added, “The most important thing I think residents need to get out of any rotation with us is to do a better exam.” Three questions—in the joint or not, inflammatory or non-inflammatory, and distribution pattern—remain essential.
“The more they understand this, the more they understand how to work up joint disease,” Dr. O’Rourke said. “And this repetition builds and builds and they develop an ‘illness script’ centered around these kinds of questions for the kinds of diseases we see.”
Thomas R. Collins is a freelance writer living in South Florida.
References
- Neher J, Gordon K, Meyer B, et al. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992 Jul-Aug;5(4):419–424.
