Foundations of Great Clinical Teaching:

Moving From Theory to Practice

September 19th, 2013

Stephen Pinney MD MEd FRCSCSt. Mary’s Medical Center

San Francisco CA

Faculty/Presenter Disclosure

• Faculty: Stephen Pinney MD Med FRCSC

• Relationships with commercial interests:– Grants/Research Support: None– Speakers Bureau/Honoraria: None– Consulting Fees: BC Ministry of Health– Other: Owner: www.footeducation.com

ObjectivesUpon completion of the teaching session the learners

will be able to:1. Describe eight adult education principles that can

be used to foster learning among medical students and residents.

2. Describe the concept of active learning.3. Identify the relationship between evaluation and

learning.4. Understand the role of program planning in

fostering learning.

Questions?

• Describe an example of excellent teaching?

• What is an example of an accepted medical or surgical principle?

• How did you actually learn your discipline?

This weekend I taught my dog how to speak English

???

I thought you said you taught your dog how to speak English!

I did teach him English!!………. But, I didn’t say that he learned!

Educational Principle #1

What is learned is more important than what is taught!

Educational Principle #1

What is learned is more important than what is taught!

A. What is taught is not necessarily what is learned.

B. Teaching is much more than just telling.

Educational Principle #1

What is learned is more important than what is taught!

Example:You spend considerable time explaining a concept to a medical student. Two weeks later, as you watch him respond to someone else’s question, you realize he had no real understanding of the concept you discussed.

Educational Principle #1What is learned is more important than what is taught!

Background:• Students will not necessarily learn everything that is

“taught”• Emphasis should be on what is actually learned• Reasons:

– Don’t actually understand– Learn, but forget– Too tired or distracted– Already know

Educational Principle #1

What is learned is more important than what is taught!

Implications:• Be alert to what you residents are actually learning• Probe for understanding with non-threatening

questions• Teach concepts, not just facts• Revisit important concepts• Be cognizant of their learning environment

Educational Principle #1

What is learned is more important than what is taught!

Teaching = Facilitation of Learning(one definition)

Educational Principle #2

Residents learn best within their zone of development.

Educational Principle #2 Residents learn best within their

zone of development.

A. Involve students at a level appropriate to their knowledge and ability.

B. Adapt your knowledge to the student’s ‘zone of development’.

Educational Principle #2

Residents learn best within their zone of development.

Example:

You are lecturing to the second year medical students on a topic you believe is very basic. After ten minutes, many students have a glazed look in their eyes and it is clear they don’t understand most of what you are saying.

Educational Principle #2

Residents learn best within their zone of development.

Background• Every student brings prior knowledge (and skills) to each

learning endeavor• Prior knowledge can vary widely among students• Teaching should begin at the learner’s “zone of proximal

development” (intersection between what they know and understand and what they do not yet know or understand)

Educational Principle #2

Residents learn best within their zone of development.

Implications:• Probe for knowledge gaps and misconceptions

with non-threatening questions Focus your teaching at the level of your learner’s

zone of development.

Educational Principle #3

Foster ”active,” rather than

“passive”, learning.

Educational Principle #3

Foster “active,” rather than passive, “learning”

A. ‘Active’ means engaged in the work, intellectually and physically.

B. Too much observation and too little engagement => less learning.

Educational Principle #3

Foster “active,” rather than passive, “learning”

Example:Your student mentions that he does not learn much during Grand Rounds presentations, especially when he is post call and the lights are dimmed.

Educational Principle #3Foster “active,” rather than passive, “learning”

Background:• Learning is more intense when the learner’s mind is

actively engaged• Experiences which actively engage the learner in the

process produce deeper learning• Basis of education strategies such as Problem-based

learning

Educational Principle #3

Foster “active,” rather than passive, “learning”

Implications:• Create learning environments where your resident’s

mind’s are active• Encourage your residents to find study activities that

require mental and physical activity

8 Guiding Educational Principles1. What is learned is more important than what

is taught.2. Start where the learner ‘is’ and work within

their zone of development. 3. Foster active, rather than passive, learning.

Educational Principle #4

Cognitive overload interferes with learning

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Apple windlemon Apricot

Rain sheep Sunshine

Goat snow

Educational Principle #4

Cognitive overload interferes with short term learning.

A. Short term memory is limited to 7 +/- 2 discrete bits of information.

B. A few key points can be anchors for several other points.

Educational Principle #4

Cognitive overload interferes with learning.

Example:It is difficult to remember a long distance telephone number unless you employ a memory strategy.

Quiz Answers??

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HenCowSheepGoat

BananaAppleLemonApricot

WindRainSunshineSnow

Educational Concept #4

Cognitive overload interferes with learning.

Background:• Typical human retains only 7+/-2 bits of discrete

information in short-term memory• To retain more the brain employs various cognitive

strategies (Chunking, rehearsal)• Highly effective cognitive strategies can be learned

Educational Principle #4Cognitive overload interferes with learning.

Implications:• When teaching, present new information in a clearly

organized manner.• Teaching “in context” allows the learner to tie the

new information to the realities of the context.• Don’t overload learners; sometimes ‘less is more’.• Question your residents on their learning methods.

How do they intend to retain the information they have learned today?

Education Principle #5

Embarrassment and threat diminish learning

Educational Principle #5

Embarrassment and threat diminish learning.

A. Excessive anxiety reduces ability to process information.

B. When working with different levels of learners, question “up the ladder”.

Educational Principle #5

Embarrassment and threat diminish learning.

Example:A student who is embarrassed in morning rounds is unable to adequately answer a question you are sure she knows.

Educational Principle #5

Embarrassment and threat diminish learning. Background:• Emotions and cognition are interactive• Learning requires a receptive mind• A negative environment can undermine our ability to

process, synthesize, and retain information• Higher learning expectations should be accompanied

by greater learning supports until the student masters the material

• Performance assessment and feedback should include both effort and achievement

Educational Principle #5Embarrassment and threat diminish

learning. Implications:• Students learn better in a positive learning

environment• Make the learning environment positive and

non-threatening for students while still challenging them to push themselves to their limits

• Give them a few moments to gather their thoughts

• There may be a fine line between trying to evaluate what they know, and intimidation

• Demeaning or embarrassing students is never justified

Educational Principle #6

Program planning is critical to effective teaching and learning.

Educational Principle #6

Program planning is critical to effective teaching and learning.

A. Get the big picture, listen to the entire orchestra.

B. Know how each learning episode relates to the overall program.

Educational Principle #6Program planning is critical to effective

teaching and learning.Examples:

Junior residents are complaining they are not learning much during the arthroplasty/oncology rotation. Clinical workload and work hours do not allow adequate time for reading, and the case complexity is beyond their level of training.

Educational Principle #6

Program planning is critical to effective teaching and learning.

Background:• The learning experience that a student has should

not be left to chance. • Teachers can control many variables that will

effect a student’s learning

Educational Principle #6Program planning is critical to effective teaching

and learning.• Rotation specific objectives?• Establishing expectations for

– clinic presence, – operative experience?

• Reading list?• Formative and summative feedback?• Student feedback

Educational Principle #6Program planning is critical to effective

teaching and learning.Implications:• Think about the learning environment from the

resident’s point-of-view. • Identify barriers to learning that your students

face and attempt to resolve them.• Individualized rotation specific objectives• Not only provide feedback, but obtain feedback

on your rotation and your teaching methods from your students.

8 Guiding Educational Principles

1. What is learned is more important than what is taught.

2. Start where the learner ‘is’ and work within their zone of development. 

3. Foster active, rather than passive, learning.

4. Cognitive overload interferes with learning.5. Embarrassment and threat diminish learning.6. Program planning is critical to teaching and

learning.

Educational Principle #7

Students learn from a hidden curriculum

Educational Principle #7

Residents Learn from a hidden curriculum.

A. You are not your student’s only “teacher”.

B. What you do teaches more than what you say.

Educational Principle #7Residents Learn from a hidden curriculum.

Example:Many find it difficult to teach professionalism. Yet professionalism is modeled more by what we do than what we say. It is often taught more by the tone of our voice than the choice of our words.

If someone is watching, we are teaching. How do we speak to nursing, support staff? How do we refer to care provided by other physicians?

Educational Principle #7

Residents Learn from a hidden curriculum.

Background:• Students observe how things are done – a lot of

learning occurs via an apprenticeship mode• Learning is socially situated, things are done a certain

“way” and students become enculturated to this way• What we do and how we act is probably more

important than what we say.

Educational Principle #7

Residents Learn from a hidden curriculum.Implications:• You’re a role model. Avoid “negative” behavior and

actions.• Create a work environment that your residents will

want to emulate.• Many others serve as important “teachers” of

informal student learning• The hidden curriculum is hidden from you, but not

from the students

Educational Principle #8

Perception of assessment and accountability drives learning.

Educational Principle #8

Perception of assessment and accountability drives learning.

A. Smart learners figure out the assessment scheme and work accordingly

B. Students choose the most efficient route to the perceived evaluation.

Educational Principle #8

Perception of assessment and accountability drives learning.

Example:One of your students spends a disproportionate amount of time studying old Exam questions. You do not believe she is doing enough reading around the various cases she is currently seeing.

Educational Principle #8

Perception of assessment and accountability drives learning.

Background:• Students are motivated by personal and

practical goals. (What do I need to learn and do to succeed?)

• They will choose the most effective route to achieve these goals

• Perception of how they perceive they will be evaluated often drives learning

Educational Principle #8Perception of assessment and accountability drives learning.

Implications:• Think carefully about what you want your

students to know and to do.• Make your expectations clear to your students. • Clearly outline how you intend to evaluate them.• Carry out the evaluation method you describe.• Be consistent and fair in your evaluations.

8 Guiding Educational Principles1. What is learned is more important than

what is taught.2. Start where the learner ‘is’ and work within their

zone of development. 3. Foster active, rather than passive, learning.

1. Cognitive overload interferes with learning.2. Embarrassment and threat diminish learning.3. Program planning is critical to teaching and

learning.

1. Students learn from a hidden curriculum.2. Students’ perceptions of assessment and

accountability drive their learning.

ObjectivesUpon completion of the teaching session the learners will be

able to:1. Reframe “teaching” to focus on the goal of facilitating

learning.2. Describe eight adult education principles that can be used

to foster learning among medical students and residents.3. Describe the concept of active learning.4. Identify the relationship between evaluation and

learning.5. Understand the role of program planning in fostering

learning.

Questions?