ATLANTA—Clinicians are often expected to teach others and provide feedback to myriad learners in various settings. Yet in medical schools, residencies and fellowships, a paucity of formal training exists for these activities.
In November, during the 2019 ACR/ARP Annual Meeting session, Doctors’ Toolbox: Learning to Communicate and Teach, presenters discussed methods that make for good teachers and educators in detail, and asked the audience to use these techniques in their daily practices.
Exemplary Educators
Nathan Houchens, MD, FHM, FACP, an assistant professor of internal medicine and assistant program director for the internal medicine residency program at the University of Michigan, Ann Arbor, began the session. He discussed the research he and colleagues performed describing the habits of physicians identified by division chiefs and chairs as exemplary educators. Through interviews with these clinician educators, focus group discussions with their current and former learners, and direct observation of clinical teaching during inpatient rounds, the researchers identified the actions, approaches and behaviors these exemplary educators consistently employed.1
First, these educators foster positive relationships with all team members by building rapport with them, creating a safe and supportive learning environment. This technique includes using icebreaker and open-ended questions to get to know team members. These educators share information about themselves to demonstrate openness, vulnerability and trust, often employing humor or self-deprecation to connect with learners and create a comfortable atmosphere.
These educators also serve as positive role models for patient care by treating patients as partners in their own care. They use patient stories to highlight key teaching points that connect to broader concepts, and demonstrate excellent clinical exam skills and communication techniques to learners. Even seemingly small details, such as helping patients get more comfortable in their hospital beds or assisting patients in putting on their socks after an exam, were regarded as important actions by learners hoping to continue to mature as caring, humanistic physicians-in-training.
Additionally, these educators engaged in coaching and collaboration by facilitating discussions, using effective questioning strategies and tailoring their teaching styles to the different learning levels, strengths and weaknesses of individual learners. In this regard, one learner explained, “[The educators] gauge where your knowledge is and then sort of put themselves in your brain and lead you down the path. … They start slowly, and they leave a trail of bread crumbs for you to follow so that you’re making connections all along the way.”
Dr. Houchens also discussed how educators view their own strengths and weaknesses, as well as how such characteristics as ethnicity, gender and age play a role in how educators present themselves. Example: Although exemplary educators sometimes use self-deprecating humor to connect with learners, this habit may be challenging due to conscious and unconscious biases, which can undermine an educator’s credibility.
When speaking with educators who identified as women and under-represented minorities, many shared stories of being mistaken for a nurse or custodial staff, rather than being seen as a physician. Others shared stories about how an educator’s authority was directly questioned or challenged by learners and patients. These situations can make the prospect of effective teaching challenging. Although there’s no one-size-fits-all solution for every situation, Dr. Houchens implored the audience to use these moments as teaching opportunities. While maintaining good therapeutic relationships with patients, colleagues and learners, individuals should professionally address such situations rather than turn a blind eye.
Feedback
A key part of the educator-learner relationship is also the expression of helpful, effective feedback. During the session, Rachel Levine, MD, MPH, an associate professor of medicine and associate dean for educational faculty development at Johns Hopkins School of Medicine, Baltimore, discussed this topic in detail.
Generally, giving feedback can be challenging, but it’s often more difficult in the context of academic medicine because feedback and assessment can be implicitly or explicitly linked. This context can result in learners worrying that every tidbit of feedback they receive may be reflected in their grades or affect their prospects of entering residency or fellowship programs. Dr. Levine asked the audience to reconceptualize feedback as a dialogue rather than a monologue, allowing context and relationship to be the dominant factors for enabling behavior change. Example: By focusing on the teacher-learner relationship, educators can promote credibility and trust while giving feedback, making it more likely the discussion will be fruitful, elucidating and well received.
Some key fundamentals of feedback discussed by Dr. Levine included basing feedback on direct observation, providing specific and targeted feedback that focuses on learner goals and avoiding providing excessive amounts of feedback in a given session. Also, educators should use non-judgmental language and interpersonal skills, such as active listening, to demonstrate respect and positive regard for all learners.
Many educators are familiar with the feedback sandwich, in which a criticism of a learner is given between positive opening and closing statements. However, this practice has pitfalls. It’s unilateral and does not loop the learner into the discussion. It may have the effect of learners not hearing important parts of the conversation because they are focusing on the criticism they know is coming. Additionally, the feedback may come off as disingenuous. The learner may feel the positive comments were artificial and manufactured to soften the blow of the criticism.
Dr. Levine discussed several alternative methods of feedback, such as ask-tell-ask in which learners are asked to assess their performance. Educators then share specific observations, and ask about and explore the learner’s strategies and goals for improvement, as well as their understanding of the feedback. Finally, educators offer suggestions and resources that may help the learner meet their goals.
The session was highly informative and helpful for many situations. The insights provided by Dr. Houchens and Dr. Levine can easily be applied to a broad range of situations. These two speakers clearly practice what they preach in terms of effectively teaching teachers to be the best they can be.
Jason Liebowitz, MD, completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his MD. He is currently in practice with Arthritis, Rheumatic, & Back Disease Associates, New Jersey.
Reference
- Houchens N, Harrod M, Moody S, Fowler K, Saint S. Techniques and behaviors associated with exemplary inpatient general medicine teaching: An exploratory qualitative study. J Hosp Med. 2017 Jul;12(7):503–509.
