teaching tips for clinician-teachers

5
PERSPECTIVES Teaching Tips for Clinician-Teachers CATHERINE THOMASSON,MD, WENDY LEVINSON, MD, KEITH ACHESON, PhD, WILEY CHAN, MD, MARY LINDOUIST, DIANE PALAC, MD, GARY YOUNG, MD TEACHING is part of the role of many practicing physi- cians. It begins in the first year of residency with su- pervision of medical students and continues with in- creasing responsibility to the level of full-time participation as faculty members in teaching programs. Few physi- cians have received any formal training in the strategies of tcaching. "See one, do one, teach one" is the maxim that has guided the plunge into teaching assignments. This lack of expertise may lead to frustration for both learners and teachers. This article is a culmination of the efforts of the authors to improve our own clinical teaching skills. We met as "peer consultants" for one to two hours monthly to view and discuss videotapes of teaching encounters from our own work. The excerpts we viewed were brief but were typical of the situations clinician-teachers en- counter. In a climate of support and candor, the group members watched the tapes together and discussed their observations. Direct feedback was encouraged and members often reenacted the exchange to try new strat- egies. After just a few meetings, feedback within the group became more direct and useful regarding specific teaching techniques. The purpose of this article is to inform clinician- teachers about practical and effective strategies for teaching residents, which we discovered in our own faculty development sessions through practice and read- ing.I- ~ Vignettes of typical teaching situations are pre- sented with a discussion of relevant precepts of adult 0 I0 learning theory, - which may be applied to the unique experience of teaching in the medical setting. Our goal is to raise awareness about the process of the educational encounter in order to improve the quality of teaching and ultimately the learner's outcomes. In addition, since practicing new skills is essential, ~, ~ 2 the article includes suggestions of ways clinician-teachers can gain experi- ence with new teaching skills. The first three vignettes Received from Providence Medical Center (CT), the Good Samaritan Hospital & Medical Center (WL), and the Oregon Health Sciences University (WL, ML), Portland, the University of Oregon (KA), Eugene, and Kaiser Pcrmanente (WC) and the Veterans Administration & Med- ical Center (DP), Portland, Oregon; and Highland Hospital (GY), Oak- land, California. Address correspondence and reprint requests to Dr. Thomasson: Department of Medical Education. Providence Medical Center, 4805 NE Glisan, Portland, OR 97213. describe teacher-centered concerns and the last two relate to learner-centered problems. Table 1 summarizes important teaching strategies demonstrated by each of the vignettes. Resident: TOO MUCH TO TEACH This is a 68-year-oM woman who is here today for a routine physical I've followed her for tu,o years and she has multiple prob- lems: stable angiru¢ hypertension, mild renal insufficient., and a recent elevation in her alkaline phosphatase. Her only concern to- day is that her sister has recently had breast cancer diagnosed and she is pret~ upset about that. In many teaching situations both the student and the teacher have their own ideas about what they want to discuss in the limited time available. To set the agenda for the teaching encounter, it is often useful to both address the patient's concerns and identify the learner's goals. It is important to limit the number of topics in each cncountcr. The clinician-teacher's opening question in this set- TABLE 1 Suggested Strategies for Clinical Teaching in One-on-one Settings Set the agenda Place the patient's welfare and concerns foremost Let the learners identify their agendas Limit the number of topics Help structure the process Increase feedback Provide a safe, private environment Focus on direct observation Be descriptive, specific, and nonjudgmental Elicit the learner's areas of concern Provide both positive and negative feedback Base negative feedback on modifiable behaviors Model Go to the bedside together Demonstrate effective data gathering Be explicit about steps in problem solving Deal with emotions Express one's feelings constructively Ask the learner to verbalize his or her feelings when appropriate Support and validate the learner's emotions 349

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Page 1: Teaching tips for clinician-teachers

PERSPECTIVES

Teaching Tips for Clinician-Teachers

CATHERINE THOMASSON, MD, WENDY LEVINSON, MD, KEITH ACHESON, PhD, WILEY CHAN, MD, MARY LINDOUIST, DIANE PALAC, MD, GARY YOUNG, MD

TEACHING is par t of the ro le of many p r a c t i c i n g physi- cians. It beg ins in the first yea r of r e s i d e n c y w i th su- perv is ion of med ica l s tuden ts and con t inues w i th in- creasing responsibil i ty to the level of full-time par t ic ipat ion as faculty m e m b e r s in t each ing p rograms . Few physi- cians have r e c e i v e d any formal t ra in ing in the s t ra teg ies of tcaching. "See one, do one, t each o n e " is the m a x i m that has gu ided the p lunge into t each ing ass ignments . This lack of expe r t i s e may lead to f rus t ra t ion for b o t h learners and teachers .

This ar t ic le is a cu lmina t ion of the efforts of the authors to improve ou r own cl inical t each ing skills. W e met as "pee r consu l tan t s" for one to two hour s m o n t h l y to view and d iscuss v ideo t apes of t each ing e n c o u n t e r s from our o w n work . The e x c e r p t s w e v i e w e d w e r e br ie f but we re typical of the s i tua t ions c l in ic i an - t eachers en- counter . In a c l imate of s u p p o r t and candor , the g roup m e m b e r s w a t c h e d the tapes t o g e t h e r and d i scussed the i r o b s e r v a t i o n s . D i r e c t f e e d b a c k w a s e n c o u r a g e d a n d m ember s of ten r e e n a c t e d the e x c h a n g e to t ry n e w strat- egies. After just a few meet ings , f eedback wi th in the group b e c a m e m o r e d i r ec t and useful r ega rd ing speci f ic teaching techniques .

The p u r p o s e of this a r t ic le is to inform cl inician- teachers abou t p rac t ica l and effect ive s t ra tegies for teaching res idents , w h i c h w e d i s c o v e r e d in ou r o w n faculty d e v e l o p m e n t sess ions t h rough p r a c t i c e and read- ing.I- ~ Vignet tes of typical t each ing s i tua t ions are pre- sen ted wi th a d i scuss ion o f re levan t p r e c e p t s o f adu l t

0 I 0 learning theory, - w h i c h may be app l i ed to the un ique expe r i ence of t each ing in the med ica l set t ing. O u r goal is to raise awareness abou t the p roces s of the educa t iona l e n c o u n t e r in o r d e r to i m p r o v e the qual i ty of t each ing and u l t imate ly the l ea rner ' s ou t comes . In addi t ion , s ince prac t ic ing n e w skills is essential , ~, ~ 2 the ar t ic le inc ludes suggest ions of ways c l in ic ian- teachers can gain exper i - ence wi th new teach ing skills. The first t h r e e v igne t t e s

Received from Providence Medical Center (CT), the Good Samaritan Hospital & Medical Center (WL), and the Oregon Health Sciences University (WL, ML ), Portland, the University of Oregon (KA), Eugene, and Kaiser Pcrmanente (WC) and the Veterans Administration & Med- ical Center (DP), Portland, Oregon; and Highland Hospital (GY), Oak- land, California.

Address correspondence and reprint requests to Dr. Thomasson: Department of Medical Education. Providence Medical Center, 4805 NE Glisan, Portland, OR 97213.

descr ibe t e a c h e r - c e n t e r e d c o n c e r n s and the last two relate to l e a r n e r - c e n t e r e d p rob l ems . Table 1 summar izes impor tan t t each ing s t ra tegies d e m o n s t r a t e d by each of the vignettes.

Resident:

TOO MUCH TO TEACH

This is a 68-year -oM w o m a n w h o is here today f o r a rou t ine p h y s i c a l I 've f o l l o w e d her f o r tu,o years a n d she has m u l t i p l e prob- lems: s table angiru¢ hypertension, m i l d renal i n su f f i c i en t . , a n d a recent e leva t ion in her a l k a l i n e phosphatase . Her o n l y concern to- day is tha t her s is ter has recent ly h a d breast cancer d iagnosed a n d she is p r e t ~ upset a b o u t that.

In many t each ing s i tuat ions bo th the s tuden t and the t eache r have the i r o w n ideas abou t w h a t they wan t to d iscuss in the l imi t ed t ime available. To set the agenda for the t each ing encoun te r , it is of ten useful to bo th address the pa t i en t ' s c o n c e r n s and ident i fy the l ea rne r ' s goals. It is impor t an t to l imit the n u m b e r o f top ics in

each cncoun tc r . The c l in ic ian- teacher ' s o p e n i n g ques t ion in this set-

TABLE 1 Suggested Strategies for Clinical Teaching in One-on-one Settings

Set the agenda Place the patient's welfare and concerns foremost Let the learners identify their agendas Limit the number of topics Help structure the process

Increase feedback Provide a safe, private environment Focus on direct observation Be descriptive, specific, and nonjudgmental Elicit the learner's areas of concern Provide both positive and negative feedback Base negative feedback on modifiable behaviors

Model Go to the bedside together Demonstrate effective data gathering Be explicit about steps in problem solving

Deal with emotions Express one's feelings constructively Ask the learner to verbalize his or her feelings when appropriate Support and validate the learner's emotions

349

Page 2: Teaching tips for clinician-teachers

3S0 Thomasson et al., TEACHING TIPS

t ing might be, "Do you feel comfor t ab l e dea l ing wi th Mrs. X's fear and c o n c e r n abou t b reas t cancer?" After the pa t i en t ' s i m m e d i a t e c o n c e r n s are addressed , the cli- n i c i an - t eacher can f ind ou t wha t he lp the r e s iden t needs in car ing for the pat ient . Research in adul t educa t i on ind ica tes that adul t s learn mos t w h e n they ident i fy for themse lves the p r o b l e m s they n e e d to solve, set pr ior - i t i e s , a n d s e c k t h e a p p r o p r i a t e e d u c a t i o n a l r e - sources.7. ~, i~ Using this p r inc ip le , the c l in ic ian- teacher

might ask, "What are the specif ic ques t ions you have regard ing this pa t i en t ' s ca re today?" The few m o m e n t s of re f lec t ion abou t r e s iden t p r io r i t i es a l low the t each ing conversa t ion to focus on w h a t the r e s iden t needs most .

If all the ques t ions canno t be a n s w e r e d in the t ime available, the c l in ic i an - t eacher might say, "Since the pa- t ient is wait ing, le t ' s make sure w e talk abou t he r renal insufficiency and agree to look up the informat ion abou t the drugs later." After the pa t i en t visit, the t eache r might help the l ea rner seek the answers to his or he r o w n questions using c o m p u t e r searches, library materials, and o the r resources , h e n c e d e v e l o p i n g l i felong skills n e e d e d to keep up wi th med ica l advances. ~s' 16

In add i t ion to the r e s iden t ' s ques t ions abou t the pat ient , the c l in ic i an - t eacher may have specif ic t each ing poin ts he o r she wan t s to discuss. The c l in ic ian- teacher might say, "Since this is Mrs. X's year ly exam, I wan t to r emind you abou t p r e v e n t i v e care. If you feel she needs to c o m e back soon you may wan t to p o s t p o n e any screening." This may be the extent of the teacher 's agenda that can be c o v e r e d in this t each ing e n c o u n t e r to avoid learner over load .

In our expe r i ence , of ten c l in ic ian- teachers have too much to teach and are eager to share all the i r "pear ls of w i s d o m " wi th res idents . It is mos t effect ive to focus on the few main points , s e l e c t e d init ial ly by the stu- dent . t° Research in " l e a r n e r - c e n t e r e d " t each ing envi- r onmen t s has d e m o n s t r a t e d the value of a l lowing stu- dents to s t ruc tu re thc i r o w n learn ing activit ies. Benefits inc lude g rea te r en thus ia sm for the top ic and inc reased abil i ty to solve fu ture p rob l ems , t7' TM In this way, "less teaching" can lead to " m o r e learning."

FEEDBACK

After observing a resident-patient interaction, the teacher states:

Well, t ha t w as a g o o d interview, b u t y o u s h o u l d have i n c l u d e d the w i f e in the interview. She h a d i m p o r t a n t i n f o r m a t i o n to of fer s ince his p r o b l e m was syncope.

This f eedback may be diff icult for the in tern to hear. The in tern may feel de fens ive and, as a conseque nc e , may be less ab le to i n c o r p o r a t e any of the cl inician-

teacher ' s suggest ions. Yet, f e e d b a c k is a necessa ry com- ponen t of learning. ~'~' 2o T h e r e are some impor t an t con- cep t s that can make f e e d b a c k m o r e effect ive and m o r e accep tab le to the learner .

It is impor t an t to r e m e m b c r that r ece iv ing f eedback is anxie ty-provoking. Taking a m o m e n t to assure resi- dents that you u n d e r s t a n d they are ne rvous can help. Next, be expl ic i t abou t y o u r expec ta t ions . Given thei r anxiety, res idents n e e d g u i d a n c e abou t the e x t e n t of the in te rv iew and phys ica l examina t i on you wish t h e m to perform. Stating the ob j ec t i ve s in advance also makes the exe rc i se m o r e focused. 8 2~ For example : "My objec- t ive is to p rov ide f e e d b a c k on y o u r in t e rv iewing skills. This is not a test. I 'm sure t h e r e wi l l be many pos i t ive aspects of you r i n t e rv i ew and poss ib ly a few po in t e r s 1

can offer." Wi th the agenda set, it is op t ima l to c h o o s e an ap-

p rop r i a t e t ime and p lace w h e r e f eedback can o c c u r pri- vately w i t h o u t in te r rup t ion . It is bes t to s tar t w i th pos- it ive f eedback and a l low the re s iden t to ident i fy his or her own strengths. The cl inician-teacher might say, "What s e e m e d to go wel l in y o u r in terview?" This might be fo l lowed by the c l in ic ian- teacher ' s observat ions , such as, "You s ta r ted wi th very o p e n - e n d e d ques t ions and

a l lowed the pa t i en t to tel l his o w n s tory by n o d d i n g and making encourag ing c o m m e n t s . " The i m p o r t a n c e of pos- it ive f eedback canno t be unders ta ted . Tra inees are of ten very self-crit ical and anx ious abou t pe r fo rmance , and of ten focus on the i r def ic iencies . C o m m e n t i n g on the i r s t rengths re in forces p r a c t i c e d skills and increases com- fort levels for r ecep t iv i ty to feedback, t9

After point ing out the strengths, the cl inician-teacher can solici t the l ea rner ' s ideas abou t p r o b l e m s w i th the in te rv iew by asking, "What w o u l d you like to change about the interview?" Most ind iv idua ls are ab le to iden- tify p r o b l e m s themselves . A r e s iden t might say, "I had a hard t ime s taying focused on his ch ie f c o m p l a i n t because he was so vague." The l ea rne r and t e a c he r cou ld discuss a l ternat ive a p p r o a c h e s and even ro le-p lay to p rac t i ce new in te rv iewing techniques .

If the res iden t doe sn ' t ident i fy an impor t an t p rob- lem, such as the n e e d to i nc lude the pa t i en t ' s wife, the c l in ic ian- teacher may p o i n t this ou t by stating, "Some- t imes the pa r tne r p r o v i d e s useful c l in ica l h i s tory in cases of syncope. I n o t i c e d that you add re s sed mos t of you r ques t ions to the pa t ien t r a the r than his wife." In con t ras t to the s t a t emen t above, this p r e s e n t s a n o n j u d g m e n t a l obse rva t ion and suggests an a l te rna t ive in t e rv iew strat- egy. Non judgmen ta l s t a t emen t s are m o r e c o n d u c i v e to

a d iscuss ion than is an e x p e r i e n c e in w h i c h the s tuden t feels embar ra s sed or humi l i a t ed by a p e r c e i v e d defi- c i ency in his o r he r pe r fo rmance . ~9 In addi t ion, f eedback should deal wi th behav io r s tha t can be modif ied.

To review, effect ive f e e d b a c k r equ i r e s a se t t ing that is safe and un in t e r rup ted . A l lowing the s tuden t to iden- tify s t rengths and diff icul t ies e n c o u r a g e s m o r e focused feedback and b e t t e r learning. F e e d b a c k is be t t e r re-

ce ived if it is n o n j u d g m e n t a l and based on d i r ec t ob- servation. The use of specif ic e x a m p l e s and the avoid- ance of genera l iza t ion are also m o r e l ikely to effect

change.

Page 3: Teaching tips for clinician-teachers

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 9 (June), 1994 ;351

WHEN THE TEACHER DOESN'T KNOW

Resident:

Attending:

My p a t i e n t read abou t a baseball p layer whose b lood test f o r Lyme disease was pos- itive a n d he was cured wi th an tibiotics. The p a t i en t savs he has the same s~mptoms and wan t s me to do a blood test f o r Lyme dis- ease. D idn ' t y o u have a lecture abou t Lyme dis- ease f r o m the infectious disease depart- m e n t j u s t last week?

All phys ic ians a re c o n f r o n t e d at t imes wi th pa t i en t care ques t ions for w h i c h they have no i m m e d i a t e an- swer. Cl in ic ian- teachers may feel e m b a r r a s s e d or inad- equate w h e n they canno t p r o v i d e the c o r r e c t r e sponse to s tudents . W h e n t eache r s can admi t the i r lack of k n o w l e d g e d i rec t ly , it a l lows the t e ache r and s tuden t to b e c o m e colearners . The c l in ic ian- teacher may p r o v i d e the f r a m e w o r k by asking ques t ions such as "What d o w e need to k n o w to he lp the pat ient?" and " H o w quick ly do w e n e e d to answer this pa t i en t ' s quest ion?" Then the t eache r and l ea rne r can c o m e to an a g r e e m e n t con- ce rn ing w h a t in fo rmat ion is miss ing and h o w to f ind it.

W h e n the c l in ic ian- teacher doesn ' t k n o w the an- swer, he o r she has an o p p o r t u n i t y to m o d e l ways of ga ther ing p e r t i n e n t data. In the u rgen t b e d s i d e s i tuat ion, a p r o p e r r e s p o n s e might be to page a consul tant . Wi th less t ime res t r i c t ion , a l i t e ra ture search and cr i t ical re- v iew of key r e f e r ences may be m o r e appropriate.~S In this way, the r e s iden t and c l in ic ian- teacher can w o r k t oge the r to organize n e w in format ion and share the thought p r o c e s s e s b e h i n d the c l in ica l dec i s ion-mak ing process .

In te l l ec tua l hones ty in academic m e d i c i n e d e m a n d s that g o o d c l in ic ian- teachers k n o w the i r o w n l imits and are comfo r t ab l e wi th revea l ing those l imits to learners . This p e r s p e c t i v e is in keep ing wi th adul t l ea rn ing theory , w h i c h views the t e ache r as a faci l i ta tor of l ea rn ing ra the r than an e n c y c l o p e d i c sou rce of knowledge . 8

THE UNRECOGNIZED CRITICALLY ILL PATIENT

Resident:

Clinician:

Resident:

Clinician:

I have a pa t i en t to present. He is a middle- aged m a n here f o r his rout ine clinic visit. Currently, he is having chestpain and is short o f breath. His medical p rob lems include di- abetes, hypertension, a n d . . , let me see, oh yes, here's his p rob lem list, degenerative j o i n t disease and pept ic ulcers. His current med- ications are d i l t i a zem . . . . . Excuse me, bu t d id y o u say he is having chest p a i n and shortness o f breath right now? Yes, bu t I th ink his chest p a i n is f r o m ref lux and I" m having the nurse give h i m a GI cock- tail whi le l present the case. I 'm concerned that this p a i n migh t be car- diac Can we move to the bedside together whi le we talk?

Tens ion is inevi tab le w h e n the r e s iden t p r e s e n t s an

acu te ly ill pa t i en t and the c l in ic i an - t eacher suspec t s that the cr i t ica l na tu re of the pa t i en t ' s p r o b l e m was over- looked. The c l in i c i an - t eache r s imul t aneous ly wan t s to d e m o n s t r a t e r e s p e c t for the res ident , p r o v i d e teaching, and evaluate a po t en t i a l l y se r ious ly ill pat ient . In this si tuation, the c l in i c i an - t eache r is a p p r o p r i a t e in inter- rup t ing the r e s iden t ' s p resen ta t ion . A ques t ion such as "What is the w o r s t d iagnos is this c o u l d represen t?" may a l low an assessment of the l ea rner ' s d iagnos t ic reason- ing. If myoca rd ia l i schemia is not i n c l u d e d o r if the exp lana t ion o f w h y it is unl ikely is no t given, the cli- n ic ian- teacher shou ld eva lua te the pa t i en t a long w i th

the r e s iden t at the beds ide . O n c e at the beds ide , the c l in ic ian- teacher may still

assume an obse rve r ' s ro le by stating, "I th ink w e shou ld assume this is myoca rd i a l ischemia. Please go ahead and take care of the pa t i en t as appropr i a t e . " The cl inician- t eache r wil l then have the o p p o r t u n i t y to obse rve the res iden t p rov id ing d i r ec t pa t i en t ca re and wi l l be able to p rov ide f e e d b a c k after the pa t i en t is stable.

Less e x p e r i e n c e d learners , w h o defe r to the teacher , can be ha nd l e d in di f ferent ways. The c l in ic i an - t eacher can out l ine the logical s teps that shou ld be taken and then obse rve the r e s iden t in act ion. Al ternat ive ly , the c l in ic ian- teacher can take ove r and d e m o n s t r a t e the m a n a g e m e n t of uns tab le pa t ien t s for w h o m any de lays in care cou ld be de t r imenta l . In this way, the c l inician- t eache r can m o d e l a p p r o p r i a t e managemen t . 22' 23

Fu r the rmore , it is ve ry i m p o r t a n t to spend t ime after the pa t i en t is s tab i l ized to r e v i e w the t each ing points . The res iden t c o u l d be asked to exp la in the s t ra tegy used

by the c l in ic ian- teacher . Verbal r e f l ec t ion r equ i r e s learn- ers to in tegra te n e w informat ion in the i r o w n words . 2~ Reflection about the p roces s of pa t i en t ca re is a useful t echn ique for conso l ida t ing learn ing and is cha rac te r i s t i c of good p rac t i t i one r s in m e d i c i n e and o t h e r fields, s, 23

In review, it is no t necessar i ly d i s respec t fu l to in- te r rupt housestaff to a t t end to a c r i t ica l ly ill pat ient . Second, m o d e l i n g c o m p l e x m a n a g e m e n t can b e helpful , par t icular ly in u rgen t s i tuat ions. 2~" 22 Las t , a l lowing res- idents to ref lect on the p roc e s s of care a l lows t h e m to incorpora te n e w informat ion.

THE RAMBLING RESIDENT

Resident: Well, I have this . . . urn, 68-year-old m a n who is really a p o o r his torian who had a heart a t tack a b o u t a year ago. His wife brought h i m in today because she said his leg was n u m b yesterday and his face was droopy. He denies that. He is more concerned abou t his p r o b l e m wi th belching al l the time. Oh yeah, his blood pressure is 2 1 0 / 1 1 0 - - h e takes verapamil f o r t h a t . . . .

It is some t imes difficult for a c l in ic ian- teacher to know w h e r e to s tar t w h e n the r e s iden t gives a d i s jo in ted presenta t ion . The r e s iden t ' s d i sorgan iza t ion may lead to

Page 4: Teaching tips for clinician-teachers

352 Thomasson et aL, TF_,ACHSNG TIPS

both inefficient pa t i en t ca re and a t i m e - c o n s u m i n g teaching encoun te r . Teach ing t echn iques wi th a ram- bl ing p r e s e n t e r c o u l d i nc lude respec t fu l ly i n t e r rup t ing the presen ta t ion , summar i z ing the in format ion a l ready given, and a t t end ing to the emo t iona l c o n c e r n s in the

interact ion. Interrupt ion of the case presenta t ion may be needed

to help the res iden t focus o n the main c l in ica l p rob lems . The c l in ic ian- teacher c o u l d s top the p r e sen t a t i on wi th a s ta tement such as "I n e e d to i n t e r rup t for a m o m e n t because I 'm unsure as to wha t y o u r ma jo r c l inical con- cerns are in this case. Cou ld you pause and summar i ze your cl inical impress ions of the case, and y o u r ques- tions?" Some t eache r s may feel that i n t e r rup t i ons are impoli te , bu t if d o n e respec t fu l ly they may e n h a n c e the

learning expe r i ence . Another useful t e c h n i q u e to re focus the " rambl ing

res ident" is to pa raphrase the case: "So you have a pa t i en t with co rona ry ar te ry disease, h y p e r t e n s i o n in p o o r con- trol, and maybe a t rans ien t i s chemic a t tack o r s t roke.

Does that fit w i th y o u r assessment?" This summary dem- onstrates wha t the c l in i c i an - t eache r thinks is impor tan t , and allows the r e s iden t to c o n t i n u e wi th his o r he r o w n thought process . The inabi l i ty to p r io r i t i ze may be a major factor con t r i bu t i ng to the r e s iden t ' s d isorganiza- tion. Summariz ing a l lows the c l in ic ian- teacher to m o d e l case synthesis and p r io r i t y set t ing.

Somet imes a r e s iden t ' s d i so rgan iza t ion may be re- lated to his or he r pe r sona l e m o t i o n a l e x p e r i e n c e . It may be helpful to c h e c k on the res iden t ' s feelings. An open-ended ques t ion such as " H o w are you feel ing as you p resen t this case and w o r k wi th this pa t ien t?" may al low the res iden t to ven t i l a te his o r he r feel ings abou t the interview, the pa t ien t , o r the fact that he o r she has been up all night. This may u n c o v e r an e m o t i o n a l issue that is c rea t ing a ba r r i e r to the pa t i en t ca re o r t each ing

encounter . In addi t ion to the r e s idcn t ' s e m o t i o n a l state, the

c l in ic ian- teacher may e x p e r i e n c e i r r i ta t ion o r f rus t ra t ion with the r ambl ing p re sen ta t i on , and this r e sponse can interfere wi th the t each ing encoun te r . Some t imes cli- n ic ian- teachers d e m o n s t r a t e the i r feel ings nonverba l ly , looking b o r e d o r d o i n g o t h e r p a p e r w o r k du r ing the case presenta t ion . These nonve rba l cues may be i n t e r p r e t e d by the res iden t as nonspec i f i c negat ive feedback, w h i c h intensifies the res ident ' s uncertainty. The cl inician-teacher may wish to label his o r he r f rus t ra t ion by saying, "I feel uncomfor tab le because I d o n ' t k n o w w h a t the pa t i en t ' s main p r o b l e m is o r h o w to be mos t helpful to you." This may he lp to focus the ease p r e s e n t a t i o n and to de l inea t e the ques t ions r e l evan t to the learner .

In review, i n t e r rup t i ons arc some t imes necessa ry and helpful if d o n e in a n o n t h r e a t e n i n g manner . Clini- c ian- teachers can m o d e l c lea r case p r e sen t a t i ons by paraphrasing. A c k n o w l e d g i n g the emo t iona l factors of bo th the r e s iden t and the c l in ic ian- teacher may avoid

p rob lems in c o m m u n i c a t i o n .

STRATEGIES TO IMPROVE TEACHING SKILLS

Deliver ing pa t ien t ca re might be eas ier if it c o u l d be learned d i rec t ly f rom w r i t t e n mater ia ls , bu t t hen it wou ld not be ca l led the "p rac t i ce of med ic ine . " The same can be said of teaching. Medica l e d u c a t o r s mus t prac t ice the "art of teaching." Li terature , w o r k s h o p s , and more ex tens ive courses are avai lable to he lp t eache r s b e c o m e m o r e skilled.*

Within individual r e s idency p rograms , t h e r e is of ten enough in teres t to organize a small g r o u p of c l in ic ian- teachers to discuss and cri t ique teaching skills. Our g roup was formed dur ing a c i t ywide facul ty d e v e l o p m e n t sem- inar. Some m e m b e r s of the g roup fel t the n e e d to i nc lude an expe r t in educat ion . O u r d iscuss ions w e r e fac i l i ta ted by a faculty m e m b e r wi th a d v a n c e d k n o w l e d g e of teach- ing and in te rv iew skills and by a profess iona l educa to r . During the year long process , f e e d b a c k wi th in the g r o u p became more d i r ec t and useful r ega rd ing specif ic teach- ing techniques , and the p e r c e i v e d need for educa t i ona l exper t s d isappeared . Local facul ty d e v e l o p m e n t pro- grams such as this may he lp indiv idual c l in ic ian- teachers enhance their t each ing skills and i m p r o v e the overa l l quality of educa t ion in the inst i tut ion.

CONCLUSION

Teaching m e d i c i n e is an exc i t i ng and s t imula t ing process. Using m o r e effect ive t each ing m e t h o d s wil l en- hance the e x p e r i e n c e for all c o n c e r n e d . Research and expe r i ence in adul t l ea rn ing s h o w that ins t ruc t ion of wel l -mot iva ted learners shou ld p lace m o r e emphas i s on e mpow e r ing them to ident i fy the i r o w n needs and en- abling them to seek answer s m o r e independen t ly .

Good teach ing m e t h o d s wil l i m p r o v e the p roce s s of acquiring, retaining, and a p p r o p r i a t e l y ut i l iz ing the complex skills and k n o w l e d g e n e e d e d for p rac t i ce of

medicine.

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*Two such courses are: 1 ) SGIM National Course: "Task Force on Doctor and Patient." Contact: Penny Williamson, ScD, 4611 Keswich Road, Baltimore, MD 2121 O; phone 1410 ) 889-1550; and 2 ) The Stan- ford Faculty Development Program. Contact: Georgette Stratos, PhD, Stanford Faculty Development Program, 1000 Welch Road, Suite 1, Palo Alto, CA 94304-0146; phone (415) 725-8802.

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ANNOUNCEMENT

The American Board of Allergy and Immunology, the American Board of Internal Medicine,

and the American Board of Pediatrics

Certification in Clinical and Laboratory Immunology

E x a m i n a t i o n date: M o n d a y , O c t o b e r 10, 1 9 9 4 Location: St. Louis, M i s s o u r i Reg i s t r a t ion p e r i o d : t h r o u g h Apr i l 30, 1 9 9 4

C o m p l e t e d a p p l i c a t i o n s m u s t b e r e c e i v e d o n o r b e f o r e t h e c l o s e o f r e g i s t r a t i o n ( p o s t m a r k app l i cab le ) . A n o n r e f u n d a b l e la te f ee wil l app ly to t h o s e a p p l i c a t i o n s r e c e i v e d af ter t h e c l o s e o f r e g i s t r a t i o n a n d p r i o r to t h e c a n c e l l a t i o n d e a d l i n e o f A u g u s t 1, 1994.

Contac t :

H e r b e r t C. M a n s m a n n , Jr., M D E x e c u t i v e S e c r e t a r y

A m e r i c a n B o a r d o f Al le rgy a n d I m m u n o l o g y 3 6 2 4 M a r k e t S t ree t

Ph i l ade lph ia , PA 1 9 1 0 4 - 2 6 7 5 T e l e p h o n e 2 1 5 - 3 4 9 - 9 4 6 6 • FAX 2 1 5 - 2 2 2 - 8 6 6 9