Please see Medical Teacher 2001, 23, 6, pp 610-612 for the fulltext version of thispaper.

http://www.tandf.co.uk/journals/tf/0142159x.html

Teaching in the medical setting: balancing teaching styles,learning styles and teaching methods

Lisa Vaughn, Ph.D. and Raymond Baker, M.D.Children’s Hospital Medical CenterDivision of General and Community PediatricsCincinnati, OH, USA

email: lisa.vaughn@chmcc.org

Summary

Effective teaching in medicine requires flexibility, energy, and commitment amidst abusy background of clinical care. Successful medical teaching also requires thatteachers are able to address learner’s needs and understand the variations in learners’styles and approaches. Teachers can accomplish these requirements while creating anoptimal teaching-learning environment by utilizing a variety of teaching methods andteaching styles. If teachers use a variety of teaching methods and styles, learners areexposed to both familiar and unfamiliar ways of learning which provide both comfort andtension during the process ultimately giving learners multiple ways to excel. AsHemesath and colleagues have suggested (1997), new instructional methods arecritical as medical school curricula are changing. Others have mentioned theimportance of using a variety of creative, non-traditional teaching techniques andstrategies in clinical teaching (Handfield-Jones et al., 1993; DaRosa et al., 1997;Wilkerson & Sarkin, 1998). Grasha (1996) suggests using varied teaching styles toaddress the diversity of learner needs. Using a variety of teaching methods and stylesultimately may encourage adaptability and lifelong learning in the teaching-learningprocess. This paper, supplemented by a related website, will provide a conceptualframework and an expanded compendium of teaching styles and teachingmethodologies which can be used in different clinical settings.

The website (www.medicalteacher.org) features descriptions of preceptor-teachingstyles, learning styles, and teaching and learning style “clusters” followed by a detaileddescription of a variety of teaching methods which can be used in the medical setting.

The following tables are not included in the journal published version of the paper:

Table 1: Grasha’s Teaching Styles with description, advantages and disadvantagesTable 2: Grasha’s Learning StylesTable 3. Teaching and Learning Style “Clusters” (Grasha, 1996)Table 4: Teaching Methods

TABLE 1: G

rasha’s Teaching Styles with D

escription, Advantages, Disadvantages

TEACH

ING

STYLED

ESCR

IPTION

ADVAN

TAGE

DISAD

VANTAG

EExpert

Possesses knowledge and expertise;

oversees, guides, and directs learners;gains status through know

ledge; focuses onfacts

Knowledge and inform

ationw

hich preceptor possessesKnow

ledge and information can

be overused and intimidating; m

aynot alw

ays show underlying

thought processesForm

al AuthorityPossesses status am

ong learners becauseof know

ledge and authority/position; follows

“traditions” and standards of medical

practice; focuses on rules and expectationsfor learners; supervises learners closelyw

ith critical eye toward standard practices

and procedures

Focus on clear expectations andacceptable w

ays of doing thingsPotentially rigid and less flexiblew

ays of managing learners and

their concerns

Personal Model

Leads by personal example; suggests

prototypes for appropriate behavior inoffice; show

s learners how to do things;

wants learners to observe and em

ulateapproach

“Hand-on”; em

phasis ondirect observation; em

phasisin follow

ing a role model

(mentor relationship)

May w

ant to “clone” learners inow

n image; learners m

ay feelinadequate cannot live up to;stuck in practice m

ay believeapproach is best w

ay to practicem

edicineFacilitator

Emphasizes personal nature of teaching-

learning relationship; asks questions,explores options w

ith learners; focuses onlearner responsibility, independence, andinitiative

Personal flexibility; Focus onlearner needs and goals;openness to alternatives andoptions

Time consum

ing; sometim

es more

direct approach is needed; canm

ake learner uncomfortable

Delegator

Encourages learner responsibility andinitiative w

hen appropriate; goal is to havelearner function autonom

ously; a “resourceperson”; answ

ers questions and periodicallyreview

s learner progress

Contribute to learners

professional development and

confidence; two-w

ay trust

Learners may not have capability

to function in an autonomous

manner; som

e learners areanxious w

hen not closelysupervised

Adapted from: G

rasha, A.F. (1996). Teaching With Style (p. 154).

Pittsburgh: PA: Alliance Publishers.

TABLE 2.G

rasha’s Learning Styles

LEARN

ING

STYLED

ESCR

IPTION

ADVAN

TAGES

DISAD

VANTAG

ESC

ompetitive

Students learn material to perform

better thanothers, com

pete with other students for rew

ards(grades), like to be the center of attention andreceive recognition for their accom

plishments

Motivates students to

keep up and set goals forlearning.

May turn less com

petitivepeople off; difficult toappreciate and learncollaborative skills.

Collaborative

Students feel they can learn by sharing ideas andtalents; cooperate w

ith teachers and like to work

with others.

Students develop skillsfor w

orking in groups andteam

s.

Students not as well

prepared for handlingcom

petitive people; dependtoo m

uch on others and notalw

ays able to work as w

ellalone.

AvoidantN

ot enthusiastic about learning content; do notparticipate in discussions; uninterested andoverw

helmed by the content to be learned.

Students able to avoidthe tension and anxiety oftaking serious steps tochange their lives; havetim

e to do enjoyable butless productive tasks.

Performance poor; negative

feedback from teachers;

students do not setproductive goals.

ParticipantG

ood citizens in class; enjoy rounds and otherlearning activities and participate actively indiscussions; eager to do as m

uch of thee requiredand optional course requirem

ents as possible.

Students who get the

most out of every

learning experience.

May do too m

uch or putothers’ needs ahead of theirow

n.

Dependent

Show little intellectual curiosity and learn only w

hatis required; view

teacher and peers as sources ofstructure and support; look to authority figures forspecific guidelines on w

hat to do.

Helps students m

anagetheir anxiety and obtainclear directions.

Difficult to develop skills for

exhibiting autonomy and

self-direction as a learner;student does not learn howto deal w

ith uncertainty.Independent

Students like to think for themselves and are

confidant in their learning abilities; prefer to learncontent that they feel is im

portant; prefer to work

alone.

Students develop skillsas self-initiated, self-directed learners.

May becom

e somew

hatdeficient in collaborativeskills; m

ight fail to consultw

ith others or to ask for helpw

hen it is needed.Adapted from

: Grasha, A.F. (1996). Teaching W

ith Style (p. 154). Pittsburgh: PA: Alliance Publishers.

TABLE 3. Teaching and Learning Style “C

lusters” (Grasha, 1996)

PRIM

ARY TEAC

HIN

G STYLE

PRIM

ARY LEAR

NIN

G STYLE

PREFER

RED

TEACH

ING

METH

OD

SExpert/Form

al AuthorityD

ependent, Participant, Com

petitiveD

idactic lectures, technology-based presentations, teacher-centered questioning and discussion

Personal Model/Expert/Form

alAuthority

Participant, Dependent,

Collaborative

Role m

odeling, coaching/guiding students

Facilitator/PersonalM

odel/ExpertC

ollaborative, Participant,Independent

Case-based discussions, concept m

apping, critical thinking,fishbow

l discussions, kineposium, guided reading,

problem-based learning, role plays, student teacher of the

dayD

elegator/Facilitative/ExpertIndependent, C

ollaborative,Participant

Contract teaching, class sym

posium, debate form

ats, small

group discussions, independent study/research, modular

instruction, panel discussions, learning pairs, studentjournals

Adapted from: G

rasha, A.F. (1996). Teaching With Style (p. 154). Pittsburgh: PA: Alliance Publishers.

TABLE 4: Teaching Methods

TeachingM

ethodPossible Setting(s)and SuggestedN

umber of

Learners

Suggested ApproachSam

pleTopics

AbbreviatedC

asePresentation(“Aunt M

innie”)(C

unningham et

al., 1999; Sackett,H

aynes, &Tugw

ell, 1985)

Precepting residentsand m

edicalstudents in a clinicsetting or office (1-4)

Preceptor asks the resident to present the chief complaint and

his/her presumptive diagnosis. W

hile learner records his findingsin the m

edical record, the preceptor evaluates the patient, thendiscusses the case w

ith the learner and signs the chart. Case

discussion may address discrepancies betw

een the learner’sfindings and the preceptors or focus on a relevant teaching pointresulting from

the case.

Based on clinical cases

Bedside

Teaching (Usatine

et al., 1997)

Precepting residentsand m

edicalstudents in a clinicor office setting (1-4)

Preceptor and learner interview and exam

ine the patienttogether, perhaps after the learner has already com

pleted his/herassessm

ent. The preceptor may dem

onstrate a physical findingor focus on a particular teaching point w

ith the learner at thebedside. The patient m

ust be acknowledged as part of the

process – either by explaining the teaching points in non-medical

language during the encounter or imm

ediately afterwards (by

preceptor or learner).

Cardiac auscultation;

knee examination for

effusion;differential diagnosis ofknee effusion

Concept M

apping(C

hastoney et al.,1999; Van N

este-Kenney et al.,1998; Bietz, 1998)

Structured learningtim

e (1 to largegroup)

Allows organization of com

plex material by visually representing

relationships and connections between inform

ation; can be usedto facilitate discussion and solve problem

s. (e.g., evaluation orm

anagement algorithm

, intercepting circles)

ADH

D and co- m

orbidities;evaluation/ m

anagement of

chronic otitis media w

itheffusion

Contract

Teaching(M

ontauk &G

rasha, 1993;G

rasha, 1996;Pratt & M

agill,1983)

Resident/student

taking a specialtyelective.R

esident atbeginning ofcontinuity clinicexperience(1)

Preceptor and learner meet to collaborate on the expectations of

the rotation/research project/continuity clinic experience andtogether develop a plan w

hich might include: tim

etable forselected readings, m

edline search, presentation by resident atrotation conclusion, evaluation process. Process can result inw

ritten document.

Subspeciality rotation;continuity clinic;research elective (outcom

eexpectations)

ElectronicLectures(C

onstantinou etal., 1994)

End of or duringclinic session orunstructuredlearning tim

e(1 to large group)

Prepared by preceptor for self-study or for presentation bypreceptor. R

equires computer availability and learner com

putercapabilities. E.g. Pow

er Point presentations..

Intoeing;otitis m

edia;hypertension

Fishbowl

Medical conference

5-7 learners in inner circle discussing the topic 5-15 minutes.

Medical ethics;

Discussion

(Grasha, 1996)

(10-20)Larger outside circle acting as observers w

ho comm

ent and askquestions after the discussion is over. M

embers of outer circle

may join inner circle.

parenting;difficult patient/fam

ily

Helping Trios

(Grasha, 1996)

End of clinicsession, m

edicalconference,beginning of newrotation(3/group)

Learners individually develop a plan/draft, then collaborate ingroups of three w

ith each participant playing the role of presenter(of his/her plan), consultant, or observer. C

onsultant clarifiesand presents options, observer oversees and com

ments on the

process. After brief discussion, roles change and processrepeated until all participants have played all three roles.

Diagnosis or treatm

ent ofcom

plex patient;planning a conference

Jigsaw G

roups(G

rasha, 1996)C

onference with a

group of medical

students on apediatric clerkshiprotation (10-20 totaldivided into sm

allgroups of 3-5)

The larger group of students is broken up into smaller groups of

3-5. The small groups are assigned a topic and each m

ember of

the group learns 1/3 to 1/5 of the material individually. W

hen thelarger group reassem

bles the following day (or next session), the

small groups m

eet and exchange information so that each

mem

ber of the group learns all the material (assum

ing all of thesm

aller groups had the same assignm

ents). If the smaller

groups were assigned different topics, then a representative from

each of the smaller groups shares the inform

ation learned inhis/her group w

ith the larger group.

In behavioral pediatrics,individual topics m

ightinclude sleep issues,feeding issues, tim

e-outtechnique, and schoolrefusal

Kineposium

(Grasha, 1996)

Conference w

ith agroup of m

edicalstudents on apediatric clerkshiprotation (10-20 totaldivided to 3-5/sm

allgroup)

Learners are divided into small groups of 3-5 m

embers w

ith oneindividual designated as the recorder. The groups discuss theissue for 5-7 m

inutes. Then all mem

bers (except the recorder) ofeach of the groups m

ove on to another group. The recordersum

marizes w

hat the previous group discussed, then leads thenew

mem

bers of the group in a discussion to further clarify theissue. G

roups change 3-4 times. The larger group then

reconvenes and recorders summ

arize their groups’ discussionsw

hile the preceptor notes on a blackboard or overhead major

themes. The preceptor then com

ments on the results.

Physician-assisted suicide;Im

proving the show rate in

continuity clinic;C

omm

unicating with difficult

patients/families

Mini-lecture

(Grasha, 1996;

Gershen, 1978)

Precepting residentsand m

edicalstudents in a clinicor office setting (1-4)

Brief, 2-5 minute m

ini-lecture when need to know

is high. E.g.D

uring a busy clinic session when a learner’s know

ledge baseabout a diagnostic w

ork-up or treatment m

odality is lacking andpatient needs disposition.

Specific medical topics;

Description of a treatm

entm

odality or diagnostic work-

upM

odularInstruction(H

errick et al.,1998)

Medical sem

inar(e.g. Behavioralsem

inar)(U

nlimited)

Developm

ent of individual units that cover major content areas of

a course or seminar. M

odules can be designed for self study orpresentation. M

odule should include goals and objectives,rationale, pre and post-test, teaching m

ethods, deadlines.M

odules may include: case study, reading list, videotape, slides

(e.g. carousel or computer), w

ritten materials, instructions for

small group activities, etc.

Sleep disorders;Feeding problem

s;m

anagement of C

OPD

One-M

inutePreceptor (N

eheret al., 1992;Ferenchick et al.,1997)

Precepting residentsand m

edicalstudents in a clinicsetting or office (1-4)

After the learner presents the case, the preceptor attempts to

determine the diagnosis and assess the learner’s know

ledge inthe area. The preceptor can begin by asking “G

iven thisinform

ation what do you think is going on w

ith this patient?” Inresponse to a proffered diagnosis the preceptor m

ight then ask

Based on clinical cases

“What do you base this diagnosis on?” This m

ay be followed by

a question requiring the learner to synthesize and integrateinform

ation and a further question to broaden the scope of thecase. The preceptor m

ay then focus on a single relevantteaching point and finally provide feedback to the learner.

Role M

odeling(G

rasha, 1996;W

ilkinson, 1989)

Precepting one orm

ore residents andm

edical students ina clinic or officesetting(1-4)

Role m

odeling may occur by direct interaction of the preceptor

with the patient, by m

eans of a videotaped interaction, or by roleplay w

ith preceptor and learner. Preceptor should discuss with

the learner before the interaction what to observe, and w

hat was

observed after the interaction.

Psychosocial history;counseling a parent abouttem

per tantrums;

counseling about smoking

cessation

Role Plays

(Handfield-Jones

et al., 1993;G

rasha, 1996)

End of clinic sessionM

edical conference(4/group)

Preceptor discusses role play rules (perhaps demonstrates w

itha resident or student volunteer) and collaborates w

ith groups ontopics. Lim

it time per role play (3-5 m

inutes), permit tim

e-outsduring role play, and encourage com

ments from

participants andpreceptor at end of each role play.

Temper tantrum

s;tim

e-out technique;exercise and diet

Small G

roupD

iscussion(W

estberg, 1996)

Before or after aclinic session(2-6)

Preceptor should trigger discussion with a question. All group

mem

bers should (be encouraged to) participate. Preceptor may

summ

arize the points made during the discussion and add

his/her own points draw

n from experience.

Adult with drug seeking

behavior;infant w

ith failure to thrive

Socratic method

(Constantinou,

1994)

Precepting residentsand m

edicalstudents in a clinicsetting (1) or leadinga sm

all groupdiscussion (4-8)

Preceptor asks questions of the learner after the casepresentation. Q

uestioning should be non-threatening (non-“pim

ping”) and designed to stretch the learner’s knowledge and

open avenues of learning. E.g. “What are som

e other physicalfindings that one m

ight see in the allergic patient?”; “Do you

know of any O

TC m

edications that might help this patient’s nasal

congestion?”

Based on clinical cases;based on assum

edknow

ledge or assignedreadings

Student Journal(D

aRosa et al.,

1997; Riley-

Doucet & W

ilson,1997;H

ahnemann,

1986)

Resident in private

practice continuitysite(1)

Learner is encouraged to keep a daily or weekly journal of

his/her experiences in a medical situation. This technique

fosters critical and creative thinking about psychosocial aspectsof m

edicine, helps develop writing skills, and provides the learner

and preceptor opportunities to discuss successes, failures, andprogression of the learner’s grow

th.

Death of a patient;

Frustrating families;

difference between inner

city and private population

Student Teacher-of-the-D

ay(G

rasha, 1996)

Medical students on

an inpatient ward

rotation(4-6)

Preceptor develops a list of topics about which the learners

will be responsible for preparing a form

al presentation togive to the other m

embers of the group. Preceptor should

serve as an advisor and resource person, encouraging theuse of hand-outs, visual aids, cases, posters, testquestions, etc. Preceptor then attends all presentationsand encourages open discussion w

ith other groupm

embers.

Specific disease;pharm

acologicm

anagement of a disease

process; logic evaluation ofa disease process

Think-Pair Share(G

rasha, 1996;M

edical conferencew

ith small to

Preceptor raises a question with broad im

plications requiringsom

e thought to develop a response. Preceptor then asks theBarriers to m

edical care;ethical issues;

Nolinske & M

illis,1999)

moderate sized

group of learners(10-20 total dividedinto pairs)

learners to turn to a partner and share ideas and explore thequestion for a few

minutes. Learners then reconvene as a group

and group discussion ensues involving all learners.

curriculum changes

Two-M

inutePapers (G

rasha,1996)

Residents or

medical students in

a medical

conference/discussion(10-20)

Learners are asked to write dow

n in two m

inutes their thoughtsor points of discussion about a controversial topic or im

portantissue that m

ay have resulted from a group discussion.

Responses m

ay then be shared with the group by the individual;

collected and summ

arized by the preceptor for purposes ofdiscussion, or sw

apped with a partner to discuss and present to

the group.

Dealing w

ith non-com

pliance (visits orm

edications);confidentiality issues w

ithH

IV infection

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