Section E

Recommendations for Teaching Strategies
with a Core Curriculum in Pediatrics

Andrew P. Wilking, M.D.

Overview:

The following set of teaching strategies for the core curriculum in pediatrics is, like the curriculum itself, neither prescriptive nor exhaustive.Rather, the set provides a framework and suggested methods for teaching the information presented in the sections: Professional Conduct and Attitudes, Skills and Knowledge in the curriculum.

The set of teaching strategies reflects our recognition that teachers vary in the educational attitudes, skills and knowledge with which they are familiar, practiced and comfortable.Students vary in their learning styles, levels of competence and motivation.The institutions within which the above interact vary in their resources.Other variables influencing the choice of teaching strategies include the number of students participating in the core clerkship at any one time and the number of available teachers, including pediatric faculty, residents and other allied health personnel.Consequently, whenever possible we have provided a number of teaching strategies from which to choose.

Just as the core curriculum defines the Professional Conduct and Attitudes, Skills and Knowledge of pediatrics desirable in our students, it is important to recognize that we teachers have similar standards.There is research in the medical and educational literature which defines the appropriate attitudes, skills and knowledge of medical educators.Some degree of understanding of these, be it intuitive or learned, is necessary to be an effective teacher.To paraphrase William Osler, for a teacher to teach without this understanding is like a doctor practicing medicine without books and like a captain going to sea without charts or navigational instruments.

The teaching strategies applicable to the domains of Professional Conduct and Attitudes, Skills and Knowledge have been divided among the following six steps:

1. Orientation
2. Communication of cognitive materials
3. Demonstration
4. Supervision
5. Feedback and evaluation
6. Initiation of self-directed learning

The sequencing of these steps is intentional but individual steps may be taken out of context and used as necessary.In the recommendations that follow the reader will note that there is some overlap of these steps and indeed the divisions in part theoretical and in part provided as a framework to help guide clerkship directors and other teachers.Certain teaching methods are recommended for several steps because of their general applicability.

Throughout this set of recommendations the word teacher is used generically and may apply to members of pediatric faculty, residents, nurses, or others.It is most important to recognize the valuable role that teachers who are not members of the pediatric faculty play in the education of medical students.Programs which provide teaching skills to all teachers should be encouraged.

Whenever possible we have used examples within the discussion of a teaching method.In addition, a list of references is provided which lists references which we feel will be helpful for the clerkship director and other teachers.These references are meant to be representative but not complete.

1. Orientation:
   
   Orientation is a teaching method with which clerkship directors and other teachers give students a welcome and an introduction while providing them with their responsibilities during the clerkship.A general orientation will be helpful at the beginning of the clerkship and teachers may wish to provide orientations to students as they begin new rotations within the clerkship.We have provided the information and other suggestions which we believe to be part of orientation into three parts and present them below.
   
   Schedule and Atmosphere:
   
   The clerkship director and other teachers should consider writing a schedule and distributing it to all students at the general orientation.Teachers, too, will benefit from having the schedule.This might contain the following information:
• Dates of beginning and ending of clerkship and of included rotations
• Dates of final evaluation
• Locations of different rotations
• Names of teachers for different rotations
• Assignments of students by name to different rotations
• Times and locations of lectures, conferences, grand rounds and other educational programs available to students throughout the clerkship
  
  
In addition to the above, individual teachers may wish to orient students at the beginning of rotations within the clerkship.Such orientation might include the following elements:
• Dates, times and location of rounds and clinics
• Dates, times and location of special conferences and other activities related to the rotation
• Teachers' expectations of the students, such as:
• Number of histories to be obtained and physical exams to be done.
• Number of verbal and written presentations required.
• Attitudes to be demonstrated.
• Skills to be acquired.
• Areas of knowledge to be mastered.
  
  

The clerkship director and other teachers may wish to consider how they will create and maintain a favorable learning atmosphere in which students will feel comfortable, involved and stimulated.Most students who have these feelings will perform better than those who don't.A favorable atmosphere is desirable throughout the clerkship and it is especially important to begin the clerkship and individual rotations within it, by creating this atmosphere.The following are a few behaviors suggested for teachers which will help create and maintain a favorable environment:

• To help students feel comfortable:
• smile, introduce yourself, shake hands, be friendly
• obtain and remember students' names
• ask informal questions which show your interest in students as individuals, such as: 1)where are they from, 2)which clerkships have they already completed, 3)what did they study in college.
• tell them the clerkships is a learning experience for everyone
• remind them that they are intelligent, educated adults with a host of personal experiences, attitudes, skills and knowledge and that their thoughts and ideas will be valued
• admit your limitations in medicine and tell them how you work within them; tell them that everyone has limitations, including students, and they shouldn't be embarrassed by or ashamed of them
  
  
• To involve students:
• call them by name
• make eye contact with them.
• ask for and listen to their thoughts and ideas even if they require constructive feedback
• ask them to perform tasks which are truly useful for them, the medical team or patient
• supervise and evaluate their work and provide them with feedback as frequently as possible
  
  
• To stimulate the student:
• give them assignments which stretch their current abilities without creating anxiety or fear of failure
• present them with unfamiliar ideas and cognitive skills, different attitudes, new knowledge
  
  
Clearly, all of the teaching strategies listed above are appropriate for teachers throughout the clerkship.

Goals and Objectives:

An educational goal describes in general terms an expected result of an educational program.The goal may be phrased so as to apply to the program or to the students in the program.The following are examples of educational goals:

• Acquisition of basic knowledge of growth and development (physical, physiologic, and psychosocial) and of its clinical application from birth through adolescence.
• Develop an understanding of growth and development and their importance in the care of children.
• Develop strategies for health promotion as well as disease and injury.
  
  

A learning objective describes what a student will do, in terms of a specific performance, to demonstrate competency in a particular area of attitudes, skills or knowledge. Learning objectives are usually written by the clerkship director and other teachers and should be provided to all teachers and students.The following are some rationales for providing learning objectives:

• They may provide guidance to teachers in planning an educational process.
• They may provide guidance to allay anxiety in students by identifying areas of particular importance in the large amount of material presented during the clerkship.
• They may provide direction to both teachers and students during the process of evaluation.
  
  

Learning objectives are most successful when they are related to the clerkship's core curriculum, the clinical and other experiences within the clerkship, the evaluation process and when they are provided at the beginning of the clerkship.Clerkship directors can tailor the objectives from the core curriculumto be more specific for use in their individual settings.The following are examples of learning objectives:

• Identify the major differences between human milk and commonly available formulas.
• List immunizations currently recommended from birth through adolescence including adverse side effects and contraindications of each.
• Identify the key concepts used in the clinical evaluation of gestational age and stability at birth(e.g. the Dubowitz exam and the APGAR).Use weight and gestational age to categorize potential clinical problems.
• Describe the specific types of patterns of injury that suggest physical abuse.
  
  

Providing a Rationale: As adult learners, medical students are more likely to participate in an educational program if the rationale or purpose of that program is clear.The clerkship director and other teachers may wish to outline the rationales for the Professional Conduct and Attitudes, Skills and Knowledge Sections in the curriculum and pass these on to the students.It may be worthwhile to provide some rationales at the general orientation at the beginning of the clerkship and also provide rationales for specific instruction within the rotations of the clerkship.Teachers may provide the rationale verbally or in written form and this may be done at any time during an exercise.The following are examples of rationales:

• Knowledge of otitis media is important because it is one of the most common infections in young children and because it has serious potential sequelae.
• The skills required in performing the Ortolani maneuver are important because they will help identify congenital hip dislocation, a problem which, undiscovered, may lead to serious, chronic difficulties.
• The appropriate attitude with which to interview an adolescent is important because individuals in this age group are commonly distrustful of adults and those in authority, but often need advice regarding their potentially unhealthy behavior.
  
  
2. Communication of cognitive material:

For the purpose of this manual, cognitive materials are defined as the science, knowledge and classification of pediatrics. These materials form the basis of all three domains: Professional Conduct and Attitudes, Skills and Knowledge and the rationale for communicating them are that they are intrinsic to the practice of medicine and they are the foundation upon which physicians build their cognitive skills.

Teaching strategies which we believe to be helpful for communicating cognitive materials may be divided between indirect and direct types. Indirect types are those in which the teacher identifies or provides materials but does not directly interact with the students as they use those materials. The following are examples of indirect communication of cognitive materials:

• Identifying or providing:
• individual sections of pediatric textbooks (to assign an entire textbook of general pediatrics will not be helpful).
• specific articles in medical or other literature.
• clerkship curriculum.
• papers or monographs developed in-house for the clerkship.
• videotapes.
  
  

The reference section provides a list of materials which may be helpful in communicating desirable cognitive materials. These lists, divided by domains of Professional Conduct and Attitudes, Skills and Knowledge are suggestions and by no means complete. As in the rest of this paper, they are meant as a guide for clerkship directors and other teachers to use as they wish. These teaching methods may be helpful for communicating the cognitive materials of all three domains.

Direct communication of cognitive materials encompasses teaching strategies in which the teacher and students directly interact. The following are examples of these:

• group conference developed and led by teachers.
• case-based
• subject-based
• interactions on wards and clinics.
• lectures (studies have shown this method is relatively ineffective for communicating cognitive materials which students will retain).
  
  

Ideally, clerkship directors and other teachers will coordinate the goals, learning objectives and curriculum of the clerkship with cognitive materials presented through the above teaching strategies. Specifically, teachers may wish to consider the relevance for students of their own interests and research before presenting them.

Regardless of the chosen teaching method, there are several skills which teachers may find useful in communicating cognitive materials. We have subdivided these into three general categories:

• Skills of organization:
• use of introductions and summaries
• enumerate different points
• make connections between different points
• Skills of clarity:
• use language appropriate for your learners
• be precise
• use examples
• Skills of emphasis:
• be physically and linguistically dramatic
• repeat important points
• use visual aids when appropriate
  
  
3. Demonstration:

Demonstration is a teaching method in which the teacher performs a skill or displays an attitude with the specific intent of showing students how the skill is performed or the attitude manifested correctly. This demonstration may take place within the context of ongoing patient care or in other venues. The rationale for this teaching method is to provide students with an opportunity to observe skills and attitudes in a setting which will allow them to concentrate on their learning as opposed to their performance. In a sense, demonstration is a bridge between the communication of cognitive materials of an area and the supervision of students' performance in that area. As such it gives students a chance to gain confidence in their abilities before practicing them. We believe that demonstration is an especially helpful teaching method for the domains of Professional Conduct and Attitudes and Skill. Demonstration may be indirect or direct. Indirect demonstration is that in which the student has no immediate opportunity to interact with the teacher or the patient and family. The following are examples of indirect demonstration:

• the use of interviewing or examining rooms fitted with one way mirrors
• videotapes of teachers demonstrating specific skills
• computer-assisted learning packages
• audiotapes of pulmonary or cardiac physical findings
  
  

These teaching strategies may be used throughout the clerkship. They are limited by the number of students who may benefit at any one time. On the other hand, audiotapes, videotapes, and computer-assisted learning packages may be used independently by the students.

Direct demonstration may be subdivided further into two teaching methods. The first method is a form of role play in which the teacher and another individual play roles to demonstrate specific skills. Below are a few examples of role play:

• a social worker demonstrates understanding and empathy by interacting with another individual who plays the role of a patient's mother.
• a member of the faculty demonstrates clinical skills while examining his/her own child who plays the role of a patient.
  
  

In the second, traditional method, teachers demonstrate various skills while practicing medicine, i.e. with real patients and their families. This method is an essential part of the core clerkship because it allows the student to directly observe attitudes and skills and to clarify the proper use of these by interacting with the teacher, patient and the patient's family. As this teaching method directly involves the patient, the teacher should ask permission of the patient, explain the process and introduce the student(s) before beginning the demonstration. Below are examples of this form of direct demonstration:

• a resident demonstrates the musculoskeletal examination on a patient to a student or a group of students. The students are encouraged to ask questions about the examination and may try to duplicate parts of the examination themselves.
• a nurse practitioner obtains a social history from an adolescent with a student present, explaining to both the reasons for specific questions as well as a rationale for the interview as a whole. The student may clarify the need for some questions by asking the nurse or clarify answers by asking the adolescent.
  
  

This teaching method may be used throughout the clerkship. The number of students who may participate in a single demonstrated is limited.

Repetition is an important aspect of all teaching methods. Students reasonably may wish to observe some attitudes and skills more than once before they are comfortable practicing them.

While demonstrating is a teaching method with a specific intent, it may also be the behavior which the teacher has not intended to be educational. In other words, teachers may intentionally demonstrate at certain times, but they are constantly being observed and listened to by students and therefore demonstrating without consciously teaching.

The demonstration of Professional Conduct and Attitudes underscores the observation that, practically speaking, those domains exist only in so far as they are manifested by specific skills and activities. Also, the demonstration of these areas, because of their inherent subtleties and complexities and because they are part of every aspect of the teacher's life, can not easily be separated from unintentional impressions made by teachers during routine activities.

Teachers demonstrate cognitive skills by verbally explaining their thought processes. These explanations should follow a sequence which is logical and helpful in identifying and solving clinical problems and in developing a diagnosis and therapeutic plan. Demonstrations of cognitive skills may be useful at any time during the clerkship. Teachers will recognize that these demonstrations may be more helpful to students who are at or near the beginning of their clinical core clerkships (i.e., at the beginning of their third year) than to students further along in their education.

4. Supervision:

Supervision is a teaching method in which the teacher directly observes students performing skills and manifesting attitudes and intervenes to show how their skills may be performed and attitudes manifested differently. It differs from demonstration in that the students, as opposed to the teachers, are the primary performers. The rationale for this teaching method is to provide the students an opportunity to practice their new attitudes and skills while still under the direction of a teacher. We believe supervision to be especially helpful in the two domains: Professional Conduct and Attitudes and Skills.

Supervision, like demonstration, may take place effectively in a host of settings including community clinics, physicians' private offices, subspecialty clinics, hospital rooms, conference rooms, etc. This teaching method may be used at any time during the clerkship with the understanding that it logically follows demonstration.

The supervision of Professional Conduct and Attitudes and Skills is a complex, subtle and constant process which requires that the teacher observe students closely, watching for general appearance, facial expressions, body posture and other physical manifestations and listening to the words, inflections and tones used in speech. Supervision of these manifestations should be practiced in interactions between students and teachers, patients/family, colleagues, allied health personnel and others.

It will be helpful for teachers and students if teachers, while supervising Professional Conduct and Attitudes and Skills, intervene regarding specific student performances as opposed to an expression of the teacher's feelings. Behaviors are of course open to interpretation as are feelings. However, teachers may wish to define, as specifically possible behaviors upon which their feelings are based. There are two main reasons for doing this. First, it may give teachers insight into their own areas of potential bias while identifying the reasons for their feelings. Second, it enables teachers to intervene in ways which are aimed at the student's performance rather than the student's character.

The supervision of clinical skills is perhaps the most important responsibility of the clinical teacher. This teaching method is time-consuming but essential in order to perfect the students' skills in this area. Ideally, during the core clerkship each student should be supervised at least once while practicing all of the clinical skills on a newborn, a school-aged child and an adolescent. Teachers have spent little time traditionally in supervising students obtaining histories and performing physical examinations. Yet these are critical skills which are major parts of the foundation of the practice of medicine, and time must be devoted to their supervision. The supervision of students' presentations is a common practice, occurring on the wards and in the clinics at most schools. With regard to this clinical skill we recommend that teachers supervise both the content and the process of the student's performance. That is, the teacher may wish to intervene to discuss the organization and flow of the information as well as its completeness and accuracy.

Teachers supervise cognitive skills by asking students to explain their thought process verbally. "Thinking out loud" is a valuable practice for students, more especially when this is done in the presence of a teacher who may intervene and provide guidance. Interventions may be made for several reasons including the following:

• The student's thinking:
• is based on cognitive material which is incorrect
• includes assumptions which are not appropriate or reasonable
• includes non sequiturs which lead to faculty conclusions
• identifies clinical problems which are of minor importance, while excluding more important problems
  
  
5. Feedback and evaluation:

Feedback:

Feedback is the process of providing students with information about their performance. The rationale for providing feedback is to improve performance of the student. Feedback may be reinforcing (positive) or constructive (negative) but in practice most teachers find themselves to be most effective when they use some of each. Studies have shown that students are more accepting of constructive feedback if it is preceded by some of the reinforcing type. There are levels of feedback and they may be divided as follows:

• Minimal feedback is provided through facial expressions, (smiles, grimaces), body language (nods or shakes of the head, averting the eyes, etc.) and short expressions ("Good", "I don't agree with you there", etc.).
• Intermediate feedback provides a reason for the teacher's reinforcing or constructive comments. The following are examples of intermediate feedback:
• your presentation was good because of the logic and order which organized the necessary facts.
• your examination generally was good, but I think you need to spend time practicing the musculoskeletal examination.
• Interactive feedback provides the student and teacher an opportunity to exchange their views regarding the student's performance and together develop a plan which will aid the student in the future.
  
  

There are several characteristics of effective feedback among which are:

• Frequency : Like evaluation, feedback may be divided into formative and summative types. Formative feedback should be given as frequently as possible and students are usually eager to receive it. Summative feedback is given only at the end of the clerkship or educational program.
• Timing : Feedback should be given as soon after a student's performance as possible. It may be given individually or in a group setting. The latter is more likely to be successful if the teacher has established a favorable learning atmosphere and if the feedback is applicable to other members of the group.
• Specificity : Feedback should be precise and related to specific performances whenever possible. Students usually respond better to feedback related to their performances than to that which seems to be directed at themselves.
• Interaction : Ideally, some of the feedback provided to a student will take place within the context of an interactive process between teacher and student. It is helpful to inform the student that one is providing feedback. Teachers may wish to start these feedback sessions by asking the student how he/she thinks about their performance to date. The teacher may then respond to the student's observations, provide his/her feedback, and ask for the student's response. Teacher and student together then may develop a plan which the student can use to make any necessary changes in his/her performance.
  
  

Evaluation

Evaluation is the process by which a teacher assesses a student's attitudes, skills and knowledge in a given field. The rationale for evaluation is that it tells the teacher what progress the student has made in gaining competency in these areas. This information may then be used by the teacher to encourage and redirect the student's learning (feedback) and to help the teacher assess the effectiveness of his/her teaching.

Evaluation can be formative or summative. Formative evaluation occurs during the course of the clerkship (or educational program) while summative evaluation occurs near the end of the clerkship. Both forms are of value, though in medical education teachers have tended to emphasize the summative type. The following are teaching strategies which may be helpful in formative or summative evaluation:

• Direct observation is one of the best strategies for evaluating a student's clinical performance. Teachers should observe while students interact with children, families, colleagues, hospital and medical staff; obtain histories; perform physical examinations and present cases. By observing the above, teachers may gain insight into students' attitudes as well as evaluate their skills and knowledge.
• Questioning is another valuable method of evaluating a student's learning. Questions generally fall into two types: close-ended and open-ended. Close-ended questions seek specific information or judgments. The following are examples of close-ended questions:
• What percentage of children with the nephrotic syndrome have minimal change disease?
• What are the findings of your examination of this patient's heart?
• Which personal attitudes influenced your interview of this patient and his mother?
Open-ended questions allow for more general responses. The following are examples of open-ended questions:
• Why do we evaluate the urinary tract of infants with diagnostic images after a urinary tract infection?
• How do you interpret the results of your examination of this patient's heart?
• In what ways did your personal attitudes influence your interview of this patient and mother?

Both types of questioning have their place. However, clinical teachers traditionally have used more close-ended than open-ended questions, while research has shown that open-ended questions are more thought-provoking and promote a more interactive educational environment.

Questions may be divided by levels as well as type. The following are commonly recognized levels of questions:

• Recall questions ask for information pulled directly from memory.
• Analysis/synthesis questions ask students to integrate different pieces of information and to use reasoning and logic.
• Application questions ask students to apply information or understanding to a specific patient.
  All three levels of questions have their place, and all three may be used to evaluate students.
  
  

The following are methods especially helpful for summative evaluation:

• Sets of written, multiple-choice questions are a traditional way of evaluating students at both institutional and national levels. These sets are relatively easy to administer and grade, but have significant limitations. Depending on how these questions are written, they may assess with some accuracy students' knowledge. However, they are less successful in assessing students' attitudes and skills.
• Written essays provide students latitude of expression and are suggested for the evaluation of knowledge, cognitive skills and to some extent, attitude. They are less helpful at assessing clinical skills, and an objective appraisal of essays may be difficult and time-consuming.
• Oral examinations allow students to demonstrate knowledge in a more individual way than written examinations and also have the potential or revealing, intentionally or otherwise, attitudes. Traditional oral examinations are not so good at assessing students' skills. Oral examinations are time-consuming and the results may be difficult to assess.
• Objective Structured Clinical Examinations (O.S.C.E) are a highly recommended method of evaluating attitudes, skills and knowledge. These may be used in innovative ways, as did one clerkship director who employed adolescents from the local high school for performing arts to "act" as adolescents while medical students interviewed them. Additional details regarding these methods can be found in the Evaluation Strategies section.
  
  

In the core clerkship evaluation can be a constant process. Through evaluation we can improve our own performance as well as that of our students during the course of the clerkship.

6. Initiation of self-directed learning:

Self-directed learning is learning based on the student's needs and initiated by the student. The rationale for initiating this process is that, by doing so, teachers enable students to continue to learn after they finish their formal education and training. Further discussion on this subject can be found in the section on student self-directed learning (Section I). The following are several methods with which teachers may initiate self-directed learning:

• Ask students to identify their own goals, needs and interests and how they plan to pursue them.
• Brainstorm with students raising controversy or doubt on a topic, thereby stimulating students to independently pursue more information.
• Explicitly encourage learning beyond that of the planned curriculum and identify and provide opportunities for students to pursue learning.
• Model self-directed learning by using resources such as the medical literature, consultation with experts, and computer-assisted learning.

REFERENCES

Professional Conduct and Attitudes

1. Shelp E, ed. Vitrue and Medicine Dordrecht, Reidel Press. 1985.
2. Pellegrino E, Thomasma D. For the Patient's Good, Oxford University Press, New York. 1988.
3. Works of Hippocrates, "The Physician", "On Decorum", "The Art"

Skills

1. Barness LA, Manual of Pediatric Phyiscal Diagnosis, 6th ed. Mosby Year Book, Philadelphia.
2. Athreya BH, Siverman BK. Pediatric Physical Diagnosis, Appleton-Century- Crofts, Norwalk, CT
3. Cohen B. Atlas of Pediatric Dermatology. Wolfe Pub, London, UK.

Knowledge

1. Textbooks of Pediatrics